Nursing Care Plan


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Medical Diagnoses: Impaired Gas Exchange, Ventilation-perfusion inequality 

Assessment

Nursing DX/Clinical Problem

Client Goals/Desired Outcomes/Objectives

Nursing Interventions/Actions/Orders and Rationale

*I

Evaluation

Goals

Interventions

Subjective:

Client reported no trouble breathing, but that she did not intend to leave room until dinner.

   

Objective:

Client sat in her wheelchair the entire shift.  Did not seem to have labored breathing.


Problem

Impaired gas exchange

Long Term:

Maintain client comfort by assessing ease of breathing every 4 hrs.  Client will report minimal discomfort in breathing efforts.

Nursing student will make hourly rounds to ensure that client’s nasal cannula is in proper position.  Nursing student will assess client’s breathing throughout shift per facility policy (Perry & Potter p.652).

X

Client reported that she was breathing “rather easily” when asked how her breathing was at that time compared to other times.

Nursing student checked client’s O2 saturation which was 95% with 3L O2.  Nursing student then readjusted client’s nasal cannula and checked saturation levels 15 min. after intervention.  Saturation reached 95%.

R/T

Ventilation-perfusion inequality

Short Term:

Client’s O2 saturation will remain higher than 90% throughout the shift. 

Nursing student will use pulse/oximeter to check client’s O2 saturation 2x during the shift.  Nursing student will “verify that supplemental oxygen delivery system” is properly in place (Perry & Potter p. 652).  

X

Client’s saturation levels were 95% at first check of shift.

Nursing student checked O2 saturation levels again near end of shift.  Saturation was 94% at final check.

AEB

Client’s dependence on supplemental oxygen.

   

*I = Implementation.  Check those interventions/actions/orders that were implemented

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Demographic Information

Health History

Care Prescriptions

Age: xx

Chronic Health Conditions & Previous Health Problems:

Diet: NCS

Gender: F

Race: xxx

COPD, IBS, chronic diarrhea

›  G tube

› NG tube 

   

Code Status: DNR                              

Weight: 137.0

Height: 5’3”

   

   

Activity:    Sarita Lift

Reason for Admission [residents own words]:

   

“Oh, I don’t know. Couldn’t take care of myself anymore, I guess.”

   

   

   

   

   

   


Medical Complications:

I & O:  X voiding   › Foley catheter  

        

Medical Diagnosis [medical terms]:

Depression, end stage COPD, dementia, PVD, HTN, IBS, OA, ETOH/tobacco abuse, chronic diarrhea, diet-controlled DM, rt shoulder pain, mildly elevated troponins.

Tobacco use

immobility

Wound Care:

N/A

   

   

› drains (Type, Location, Drainage from]

   

   

   

Pulmonary care:

Date of admission: xxxxxx

   

  Nursing Diagnoses (3, prioritized)

Impaired gas exchange r/t ventilation-perfusion inequality as evidenced by client’s dependence on supplemental oxygen.

   

Impaired social interaction r/t social isolation because of oxygen use, activity intolerance as evidenced by resident claiming that she never goes to social activities because she requires oxygen all day, everday.

   

   

Risk for Disuse syndrome: Risk factor: immobilization.

    X O2   _2_ L/min  via   X N/C     › mask   

Previous Surgeries                 When? N/A

   

    › IS q ___ hrs.     › MDI  

   

   

   

    Med. › albuterol › atrovent 

            › other _____________

Allergies: sulfa, latex

   

Glucometer:      › ac & hs

   

   

                       › sliding scale insulin

   

   

Other:

Discharge Plan/ Long Term Goals

   

   

   

Treat pain

   

   

   


Describe pathophysiology of primary illnesses

   

COPD is increased resistance to airflow, loss of elastic recoil and decreased expiratory flow rate.

   

HTN results from consistent elevation of systemic arterial blood pressure.

   

   

Medications

Name/Dose

Why does resident receive?

Major Side Effects

Nursing Implications


Acetaminophen

RP  Tylenol

500mg tab POevery 4 hours as needed 

As needed for temperature greater than 101degrees Fahrenheit or pain

Hepatotoxicity

Monitor for S&S of hepatotoxicity even with moderate does, especially in individuals with poor nutrition or who have ingested alcohol over prolonged periods. Poisoning from accidental ingestion or suicide attempts.

Bisacodyl

RP Dulcolax

Insert 1 Suppository in rectum 

As needed for constipation

No systemic effects reported. Mild cramping and fluid electrolyte disturbances.

Evaluate periodically the patient’s needs for continued use of drug; bisacodyl usually produces 1 or 2 soft stools daily.


Senna Plus

RP Senokot

Give  PO   times daily 
 

As needed for constipation

Abdominal cramping and loss in water and electrolytes

Reduce dose in patients with considerable abdominal cramping


Albuterol

RP Proventil

1 dosette with Ipratropium Bromide twice daily 
 

For COPD



Hypersensitivity reaction CNS: tremor anxiety nervousness restlessness convulsions and weakness

CV: palpitations, HTN

Monitor therapeutic effectiveness which is indicated by significant subjective improvement in pulmonary function within 60-90 days after drug admin. Watch for S&S of fine tremors in fingers, which may interfere with precision handwork. Also look for tachycardia and GI symptoms those report immediately to physician.  Give periodic ABGs, pulmonary functions and pulse oximetry.


Artificial tears

Instill 1 drop 4times a day  

For dryness

Severe eye pain or vision impairment

Monitor for severe eye pain or visual impairment and stop giving drops immediate if they occur.

Asacol

400mg tab

PO twice daily

DO NOT CRUSH

For GI

Sensitivity reaction shown in skin, rash purities alopecia, Interstial nephiritis

DO NOT CRUSH. Monitor carefully urinalysis, BUN and  creatinine, especially in patients with preexisting kidney disease. The kidney is the major target organ for toxicity. Assess for S&S of allergic type reactions e.g. hives itching wheezing anaphylaxis. Expect response  to therapy within 3-21 days.

Caltrate

Calcium with vitamin D

600mg tab

1 tab PO daily

For supplement

Constipation or laxative effect, acid rebound. Hypocalcaemia with alkalosis, metastatic calcinosis, hypercalciuria, hypomagnesemia, hypophosphatemia.

Note number and consistency of stools. If constipation problem inform physician may be given with magnesium antacid. Determine serum and urine calcium weekly in patients receiving prolonged therapy and in patients with renal dysfunction. Record amelioration of symptoms of hypocalcaemia. Observe for S&S of hypocalcaemia in patients receiving frequency or high doses.

Cozaar

50mg tab

1 tab PO at bedtime

For HTN. Hold if BP less than 130/70

Dizziness Insomnia, Myalgia, back or leg pain. Nasal congestion, cough, Upper respiratory infection, sinusitis.

Monitor BP at drug trough(prior to a scheduled dose) Monitor drug effectiveness, especially in African Americans. Monitor CBC, electrolytes, liver and kidney function with long term therapy.

Cyanocobalamin

1000mcg/1mL vial injection IM

6th of every month

For dementia

Anaphylactic shock, sudden death. Peripheral vascular thrombosis (she has PVD should she take this med?)

Monitor potassium levels risk for hyokalemia and sudden death. Monitor vital signs in patient, look for S&S of pulmonary edema.

Folic Acid

1 mg tab

1 tab PO once daily

For dementia

fever, general weakness or discomfort, reddened skin, shortness of breath, skin rash or itching, and wheezing

Monitor for hypersensitivity to folic acid.

Mucinex DM 600

130 mg tab

Give 1 tab PO every twelve hours

COPD

Nausea and Drowsiness

DO NOT CRUSH. Persistent cough may indicate a serious condition requiring further diagnostic work. Notify physician if high fever rash or headache develops.

Namenda

5 mg tab

1 tab PO at bedtime

For dementia

Fatigue pain flu like symptoms, peripheral edema. TIA, ataxia, vertigo

Monitor respiratory and CV status, especially with preexisting heart disease. Assess for and report S&S of focal neurological deficits. DO periodic Hct and  Hgh, serum sodium, alkaline phosphatase and  blood glucose.

Paroxetine

20mg tab

Give 1 tab PO daily

Depression



Postural Hypotension, Urinary hesitancy, Isolated reports of elevated liver enzymes. Headache, weakness, sedation, dizziness, insomnia, nausea, constipation, diarrhea, dry mouth, sweating, male ejaculatory disturbance.

Monitor for worsening of depression or emergencies of suicidal ideation. Monitor for adverse effects which include headache, weakness, sedation, dizziness, insomnia, nausea, constipation, diarrhea, dry mouth, and sweating, male ejaculatory disturbance. Monitor older adults for fluid imbalances. Monitor for suicidal ideation. Monitor for significant weight loss.

Seroquel

25 mg tab

Give 2 tab 50 mg Po at bedtime

For Dementia with psychosis.

Asthenia, fever, hyertonia, dysarthria, flu syndrome, weight gain, peripheral edema.

Monitor for changes in behavior that indicate suicidality. Reassess need to continued treatment periodically. Withhold drug and immediately report S&S of tardive dyskinesia or neuroleptic malignant syndrome. Monitor ECG especially if have known cardiovascular disease.

   

Your Assessment of Resident

Pertinent Lab/Diagnostic Test Results and date of exam: no recent lab tests

   

   

   

VS:

   

Neuro / Musculoskeletal Activity: At time of assessment (1345), client was seated in wheelchair watching television. Claimed to have moved to wheelchair from recliner during visit from son.  Reported no desire to leave room until dinner.  Client is fully dependent for help with ADLs and requires Sarita lift for transfers.

   

Skin : Damp, smooth. Bilateral tenting on dorsal side of hands. Consistent white color. No visible lesions.

   

   

Cardiac: S1, S2 audible in all 5 five cardiac areas.  No abnormal heart sounds. Regular heart rate.

   

   

Pulmonary:  Reported breathing “rather easily” as compared with other days. Exhalation through pursed lips. Receiving 3L O2 through N/C. Wheezing heard in bilateral lower quadrants.

   

   

GI / Nutritional Status: Reported eating 75% lunch.  No BM since 10/29/08.

   

   

GU/Reproductive:  Incontinent, but aware when wet.

   

   

Psychosocial: Alert/oriented to place and time. Pleasant demeanor. Reported being “happy” after son visited. Sat in wheelchair watching television until dinner.



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