Client Diagnosis: Shortness of breath, hypoxia

Assessment

Nursing Diagnosis (NANDA approved):

Nursing Diagnosis: Deficient Knowledger/t: emotional state affecting learningA.E.B.: questioning members of the health care teamComplete Nursing Diagnosis Statement:

Client Centered Outcome: Pt. will describe rationale for treatment/therapy

Planning / Implementation

Interventions:

1. Consider the pts. ability to learn (eg; mental acuity, ability to see and year, existing pain, emotional readiness, motivation, and previous knowledge.)

A. Rationale: Learning readiness changes over time based on situational, physical and emotional challenges. The nurse assumes the role of authority, guide, motivator, mentor, and consultant depending on the learning readiness of the pt. (Ackley, pg. 504)

2. Assess personal context and meaning of illness (eg., perceived changes in lifestyle, financial concerns, cultural patterns.)

A. Rationale: Improved symptom management and pt. satisfaction were noted as a result of interventions that focused on the needs of the pt and the meaning and perspective of their illness. (Ackley, pg. 505)

3. Repeat and reinforce information during several brief sessions.

A. Rationale: At times, the energy level of pts. may be diminished. Brief sessions focus attention on essential information. Older pts. benefit from repeated follow up sessons. (Ackley, pg. 506)

4. Use verbal and non-verbal therapeautic communication approaches including active listening to encourage pt. to ask questions to gain the knowledge they are seeking

A. Rationale: A nurses communication skills contributes to the well being of pts. and minimizes psychosocial problems. (Ackley, pg. 262)

Evaluation

Evaluation of Client Centered Outcome:

Assessment

Nursing Diagnosis (NANDA approved):

Nursing Diagnosis: Ineffective Breathing Patternr/t: hypoxiaA.E.B.: shortness of breath

Complete Nursing Diagnosis Statement:

Client Centered Outcome: Pt. O2 saturation will remain > 95 during shift.

Planning / Implementation

Interventions:

1. Auscultate breath sounds every 1 – 2 hours. Listen for diminished breath sounds, crackles and wheezes.

A. Rationale: The presence of crackles and wheezes may alert the nurse to airway obstruction, which may lead to or exacerbate existing hypoxia. (Ackley, pg. 375)

2. Monitor the client’s behavior and mental status for the onset of restlessness, agitation confusion, and (in the later stages) lethargy.

A. Rationale: Changes in behavior and mental status can be an early sign of impaired gas exchange. (Ackley, pg. 175)

3. Monitor O2 sat continuosly using pulse oximetry.

A. Rationale: An oxygen saturation of < 90% indicates significant oxygenation problems. . Pulse oximetry is a useful tool for tracking and/or readjusting or supplementing oxygen. (Ackley, pg. 375)

4. Note use of accessory muscles, nasal flaring, retractions, irritability, confusion or lethargy.

A. Rationale These symptos signal increasing respiratory signal increasing respiratory difficulty and increasing hypoxia (Ackley, pg. 176)

Evaluation

Evaluation of Client Centered Outcome:Goal partially met. Pts. O2 was 95 for most of the shift, but did go down to 94 at times.

Diagnostic Test/Lab Test

Normal Value Pt. Value/ Implications of

value

Nursing Considerations/ Why this test was needed for patient

Glucose 70 - 110PV: 236 - 419

Imp: blood sugar high and not well controlled

NC: Monitor bg frequently and as per providers orders. Assess for signs of hypoglycemia such as increased thirst, vision changes, polyuria, or changes in cognition.

Why: To administer proper dose of insulin to pt.

Neutrophils 40 - 60 PV: 85

Imp: Value is high – pt. could be developing or trying to stave off an infection.

NC: Assess frequently for fever, normal breath sounds, weakness and fatigue and other signs of infection.

Why: To determine if her SOB may be caused by an infection.

Lymphocyte 20 - 40PV: 0.8

Imp: Steroid use is affecting the low level – indicates

NC: Trend values by looking at lab values every time they are drawn to determine if value is improving.

Why: To assess the pts. immune

immune system compromised. This puts pt. at risk for infection

function and ability to fight off infection.

Echocardiogram Structures all functioning appropriately with no abnormalies present

PV: All views within normal limits – nothing of significance to note

Imp: Ruled out heart structures causing the pts. symptoms

NC: assure pt. study is painless. Position pt. appropriately for study to be performed accurately.

Why: To determine if structure and function of the heart is within normal limits – to rule out structural deficiencies causing SOB and hypoxia pt. is experiencing

EKG Normal Sinus Rhythm

PV: Premature Ventricular Contractons

Imp: abnormal finding that must be investigated and treated.

NC: Ensure leads are placed appropriately to ensure accurate reading., and that skin is clean and dry so electrodes stay in place.

Why: To assess electrical current function and any abnormalies.

Patient Teaching Plan

Knowledge Deficit r/t Pt. educational

Need

Patient/Resident Specific Teaching

Content: Include Specific

Instructions Given and Method of

Instructions

Patient/Resident Strengths to

Learning

Patient/Resident Barriers to Learning

Evaluation of Patient/Resident

Learning

Medication Dose & Route

Therapeutic Use and Side Effects

Nursing Considerations & Why was this medication

given to the patient/resident?

Insulin Detemir

20 units q hs

TU: lowers bg by moving glucose into the cells

SE: hypoglycemia

NC: Insulin needs can increase in a hospitalized pt

Why: To keep bg levels within normal limits

Aspirin 81 mg q dayTU: propholactic use to as a blood thinner

SE: seizures, coma, GI bleeding,thrombocytopenia, neutropenia, leukopenia

NC: Monitor AST, ALT bilirubin, Bun, creatnine, biliburbin. Also I & O

Why: Propholactically to decrease chance of MI

Simvastatin 20 mg q hsTU: reduces cholesterol synthesis

SE: Liver dysfucntion, pancreatitis, myositis, rhabdomyolysis

NC: Liver dysfucntion, pancreatitis, myositis, rhabdomyolysis

Why: treatment for hypercholesterolemia

Gabapentin 200 mg tid po

TU: Neuropathic pain

SE: diplopia, leukopenia

NC: Assess for signs of infection such as fever, redness or swelling d/t risk of leukopenia, assess for mental status changes

Why: Diabetic nerve pain

Lovenox40 mg q 24 hours sq

TU: Anti-coagulant, prevention of DVT’s

SE: bleeding, fever, edema

NC: Assess for signs of bleeding, teach pt. to report any unusual bleeding or bruising immediately – skin assessment important

Why: Venous stasis d/t immobility

Magnesium Oxide

400 mg tid po

TU: Increases osmotic pressure, drawing fluid into colon

SE: flaccid paralysis, circulatory collapse

NC: Assess I & O, monitor for signs of mag toxicity such as thirst, confusion, decrease in reflexes

Why: Arrhythmias

Allopurinol 100 mg q poTU: reduces uric acid

SE: thrombocytopenia, anemia, leukopenia, bone marrow suppression

NC:

Why: Prophalactic tx of gout