Contributing factors involved in this hospitalization such as

lifestyle, PMH, FH,

Pulmonary Infarction Pt had a Right Nephrectomy for a renal mass on April Acute Kidney Injury in the setting of PE
4, 2016 ; Pt admitted for dehydration and
hypotension. Original diagnosis was pneumonia. Pt
had a V/Q scan which determined multiple clots
throughout the right lung.
Other Hx: BPH, HTN, Hyperlipidemia
Medications for this condition
Medications for this condition PE led to infarc Kidney function (name, route, dose, action)
(name, route, dose, action) which causes lung impaired due to
tissue to die from lack hypotension and Normal saline, IV, 150 mL/hr,
6L of O2 through nasal cannula, to of perfusion dehydration hydration
improve O2 saturations
RATE CHANGE at 0900:
Normal saline, IV, 75mL/hr,
hydration

(P.C., 69/M)
Pulmonary Medications for this condition (name, route,
Pertinent Physical Examination findings: Embolus dose, action)
Pt had diminished lung sounds on the right side: upper,
middle, and lower. Pt was very tachypnic breathing Heparin, IV, 16 units or 14.6 mL/hr,
~30-40 breaths per minute. Pt also desat into the 80s anticoagulant.
with minimal exertion. Pt also had left sided flank pain
Pathograph of this condition (Lewis, 551)
that would surge with movement making the Pt very
anxious to move and take deep breaths. Pulmonary Embolism is the blockage of
pulmonary arteries by a thrombus, fat or air
embolus, or tissue tumor. Emboli are Psychosocial / Spiritual issues and needs
mobile clots that generally do not stop He has strong family support, wife and 4
Priority Nursing Diagnosis (3 parts) moving until they lodge at a narrowed part children. All very attentive and assisting with
Measurable outcome w/ timeframe: Impaired gas exchange related of the circulatory system. household needs. Pt also has a strong spiritual
to altered blood flow to alveoli or to major portions of the lung as support system in his church. Many visitors
evidenced by profound dyspnea, restlessness, and apprehension. The from his church sharing scripture and prayer.
client will display resolution of symptoms of respiratory distress
within three days. Recent laboratory/diagnostic tests results with significance (i.e. why are
Nursing interventions you used with rationales: they high/low?)
1) Increase fluid intake to at least 1,500 to 2,000 mL/day, within Anticipated patient teaching required 4/20 4/21
cardiac limits; Dehydration increases blood viscosity and venous Anticoagulant therapy MD Creatinine 4.05 (high) 2.84 (high) - Improved
stasis, predisposing to thrombus formation. (Doenges, 2013) informed Pt that he would require BUN 95 (high) 58 (high) - Improved
2) Administer pharmacological measures: heparin sodium via
some type of anticoagulant therapy Calcium 7.9 (low) 8.2 (low)
continuous IV infusion; Heparin may be used initially because it is
for 6 months to a year. Food Albumin 2.5 (low) 2.2 (low)
prompt, predictable, antagonistic action on thrombin, preventing
further clot formation. (Doenges, 2013) interaction. Compliance.
3) Administration of morphine sulfate; Pt reported pain, given to Safety Education r/t bleeding risks; Creatinine and BUN are high due to the AKI. Improving the
control pain and also helps with anxiety and improves work of Pts hydration status has improved those lab values. The low
electric razor, soft toothbrush, etc.
breathing, maximizing gas exchange. (Doenges, 2013) calcium and albumin levels are also most likely a result of the
Clustering activities during acute kidney insult. 1
Evaluation: Pt was on day 2 of this hospital admission. Pts phase due to Pt exhaustion. aPPT was also frequently monitored, levels were high from the
symptoms had not resolved by the end of my shift. Goal not yet heparin therapy. 62.7; 63.4; 61.2
met.
 Guide for Reflection
Guide for Reflection Using Tanners (2006) Clinical Judgment Model

Program Thread:

Communication and Collaboration

I had a great last day in the ICU. My nurse was super supportive of my involvement with the patient. It was
one of the first times this semester I felt like I was working autonomously. The first time was when Dr. Apostle
was rounding. My nurse was busy with her other patient, so I was alone answering his questions before he went
into assess the patient. I appreciated that he asked me questions and my opinion about his care. What caught me
off guard was when he asked me if he should put in for a PT consult. I automatically said yes because this
patient needs to start moving and building up strength. I followed that with the assessment finding that his
oxygen would desat upon exertion. Then we went in to talk to the patient and discussed PT starting out by
simply sitting up in a chair. The patient was excited and saw the PT order as another sign of improvement in his
condition. The next time I felt like an independent thinker was when the patient had an acute pain attack from
repositioning in bed. His son came out of the room to get me. I went in and asked about the patients pain,
location, described the pain, and rated it on a pain scale. The patient who had not complained of any pain all day
was now at a 99 out of 10. I looked up his PRN orders and he did have an order for morphine. My nurse was
still busy with her other patient, I was able to find my instructor who confirmed the PRN morphine was a good
idea. The morphine was administered and the patient was able to get quick relief, which also lowered his
anxiety, and he was able to take a good nap. By lunchtime, I was feeling very nursey.
Communication was very important for this family. The patients wife was a momma bear according to
the patient. She wanted to be in the know, as all wives do. By the time she arrived to the hospital, the patient had
already talked to three doctors; the nephrologist, the pulmonologist, and a hospitalist (I believe). The patient
restated what the physicians had said. She was much calmer than she had been since all the news was good from
each doctor. After about an hour, she started thinking of other questions for the doctor. Since Dr. Apostle was
still on the floor, I asked him to come back to speak to the wife and he gladly came over and talked to her.
I felt like it was a great day for open communication and collaboration with the nurses and the doctors. It
was also a good day to address the concerns of my patient and family. We were able to talk about the issues and
address the problem or seek the appropriate information. I have a strong appreciation for the work in the ICU
and the collaboration and teamwork in that setting.

Nielsen, A., Stragnell, S., & Jester P (2007). Guide for reflection using the Clinical Judgment
Model. Journal of Nursing Education, 46(11), p. 513-516.

2
 Resources

Doenges, M., Moorhouse, M. F., & Murr, A. (2013). Nursing care plans: Guidelines for
individualizing client care across the life span.(8th ed.). Philadelphia, PA: F.A. Davis
Company.

Lewis, S. M., Dirksen, S. R., Heitkemper, M. M., Bucher, L., & Camera, I. (2014).
Medical-surgical nursing: Assessment and management of clinical problems (9th
ed.). St. Louis, MO: Elsevier, Mosby.