7 T ‘Impaired Gas Exchange -Nimbex to decrease 02 demand on vital organs -Epoprostenol continuous + ‘through vent (nebulization) Partially comp. resp. acidosis -ABG upon admission- pH: 7.26, CO2: 68, HCO3: 30 -Dx of pneumonia -ETT/ OG/Ventilator: A/C, PEEP = 30, Fi02 = 80%, TV = 300ml, Rate = 35, -Rotoprone bed utilized Pulmonary fibrosis/ARDS Bilateral DVT and PE’s a Decreased Cardiac Output -Levophed 2m contin -Fsmolol 3imV/ar contin “MAP “BP: 103-57 -Dx of acute kidney injury ‘minimal urine output during shift (415ml) -Hypoactive bowel sounds x -Nimbex (paralytic) ordered to decrease 02 demand = Pneumonia = +Rhinovius “Levaquin Q48H ordered ~-Maxipime Q12H ordered “Temporature range 99.1- 100.9 day of eae -WBC 300 (lobular ‘pneumonia; glucose = 211 ‘Reason for Needin; Health Care: Acute Respiratory Distress ‘Syndrome (due to rhinovirus) 7B y.o. Female NKA — Full code Key assessment: Respiratory Jamie Giambattista 1 a ‘Excess Fluid Volume rit Acute Renal Failure -Frothy pink sputum CXR: possible pleural effusion -24hr fluid bal = +1259m1 -Creatinine = 13; BUN = 80 “Mg = 27; K = 638; Na= 132 -BNP = 1975 (CHF) -RBC = 2.85; Hab= 89; Het = 27.1 (hemodilution) Bilateral lower extremity 3+ pitting edema; facial edema; periorbital edema present (patient prone) “CYP = 17mmHg -Fcho showing severe pulm, HTN Imbalanced Nutrition: ‘Less than body ‘requirements Pertinent lab values ‘Albums Total protein Patient NPO TF via OG tube: 10mi/nr -Long term bedrest 4 6 Impaired Verbal 7 Impaired Skin Integrity (o Ineffective Family § ‘Communication -Rotoprone bed being utilized Coping Imm ETT tube at -Intubated/sedated/paralyzed (ETT, Husband unaware of all 22cqn lip line Propofol, Peredex. Nimbex) details of wife's current “Sedated -Diaphoretic patient status “Paralyzed -Multiple IV lines: CVC triple lumen -Overall uncertain diagnosis -Rotoprone bed R subclavian, arterial line L radial, Husband not on board with “Facial edema CVC triple lumen R femoral palliative care after recent -Drv oral mucosa -Micotin powder Q12H b/w pt folds PEA -Q2H ms: -Self-adhesive dressings applied 10 ankles, anterior foot, entire abdomen, under breasts, and on upper chest to protect and prevent further breakdown while prone eo P. Scllugte}, Concept Mapping: A Critical Thinking Approach, Davis, 2002\ g - Jamie Giambattista 2 Problem # 1: Impaired Gas Exchange General Goal: Increased Gas Exchange Predicted Behavioral Outcome Objective: The patient will maintain an SPO2 of >95% with, signs of improvement (ABGs trending back to normal limits) on the day of care. ‘Nursing Interventions 1. Assess breath sounds Q2H Patient Responses 1, Bilateral U lobes = clear, symmetrical Bilateral L lobes = diminished, symmetrical 2. Monitor SPO2 2. SPO2 remains 98-100% while prone = 3. Check ABGs | 3. 9/9: pH. 7.26, CO2: 68, HCO3: 30 eo LAT 6 ‘9/14: pCR) CO2: 60.4, HCO3: 2736p VY 7 (partially comp. resp. acidosis for both) 4, Review chest x-rays _/ 49/13: mild bibasilar consolidation, possible pleural effusions, no pneumothorax 5. Monitor ventilator settings 5. AIC, PEEP: 30, FiO2: 80%, TV: 300, R: 35 Patient continues to sat 98% during shift 6. Administer Solu-Medrol 40mg IV Q6H 6. Breath sounds clear bilaterally 7. Maintain patient prone and in Trendelenburg) 7. Patient continues to sat 98% during shift 8. Suction/mouth care PRN 8. Oral mucosa dry; pink frothy sputum present 4 Clessi—- ‘Sga Peet Evaluation of outcome objectives: Patient continued to sat 98% and ABGs showing a trend tee “MET Problem #2: Decreased Cardiac Output, General Goal: Maintain Stable MAP Predicted Behavioral Outcome Objective: The patient will maintain a MAP of >65 on the day of care. ‘Nursing Interventions Patient Responses 1. Check echocardiogram results 1. 9/10: severely dilated R ventricle, moderate tricuspid regurgitation, severe pulm, HTN Smale LeveHV-runningtoRfemFEC AP=71 ‘Wave dampened; arterial line positional BP; 103/57, MAP: 71, P: 79, RR: 35, T: 99.1 412-4mi*hr-was rumning-tntil heparin was DIC p77 2. Titrate Levophed 16mg/250m! per order (2. 3. Maintain arterial line 3 4. Monitor vital signs 4 gat wv, o 5. Titrate heparin 25,000U/250ml per order 5. e fo 6 Monitor aPTT values 6 (07 7. Titeate Nimbex 20mg/100ml per order 7 8. Check ECG or patient 8 overall due to +GIB (gastrointestinal bleed) 9/13: 66.7 (HIGH), 9/14: 22.4 (WNL) Ps 6-2mb¢he-Nimbex running to Rfenr TEE, BIS, gs") 9e-!* conincs tobe nanned cad ~ #2 *iapoe Patient in NSR, with HR <100 Evaluation of outcome objectives: MAP averagi help of the paralytic and Levophed, (MET) P. Schuster, Concept Mapping: A Critical Thinking ing at 79 during my shift today, with the ik Approach, Davis, 2002.snahce! OF Jamie Giambatisia 3 WA Problem #3:Jatection- Hyperthermia F 7eckion General Goal: Improve the Status of Current Underlying Infection(s) Predicted Behavioral Outcome Objective: The patient will maintain a temperature of <100 and WBC <10,000 on the day of care ‘Nursing Interventions Patient Responses 1. Monitor WBC levels 1. 9/13: 34,800, 9/14: 37,300 (trending upwards) 2. Asses for REEDA (S/S infection) 2. Skin warm with ecchymosis; 3+ pitting edema BLE; breakdown on skinfolds 3. Obtain temperature Q4H 3. Temperature range during si=99.1-1009 4-Administer antibiotics as ordered 4 i FS0mg/TSOml QaRH @-1OOmIthr Zlob Lesagom er eoipios Maxipime 2a TVPB ¢ eT prior day 7AM agave 5. Assess clarity of urine output 5. Sediment noted in urine output 6. Utilize Chlorhexadine in mouth care kit 6. VAP-protocol; patient’s lung sounds are clear (VA? Retecad\, bilaterally; sputum collected during suctioning was pink and frothy 7. Disinfect IV hubs prior to any medications 7/8: NoREEDA noted during assessment, ongoing temperature and elevated WBC count 8. Good hand hygeine prior to patient care Evaluation of outcome objectives: Patient’s temperature ranged from.99.1@100,9 during, ‘my shift, WBC continued to be elevated (37,300). (PARTIALLY-MET; CONTINUE) eee? wey Problem #4: Excess Fluid HA Oe General Goal: Fluid Volume Balance oma OY Predicted Behavioral Outcome Objective: The patient will have a 6-hour net 1/0 within 100ml on the day of care. ‘Nursing Interventions Patient Responses 1. Monitor electrolytes (*Na/K*) 1. Na= 132, K=6.8 (AKI and fluid overload) 2. Assess BP and overall edema 2. BP: 103/57, Edema: 3+ pitting edema go bilateral lower extremes, facial edema; bilateral periorbital edema 3. Assess urine color, quantity, clarity 3. Total 6-hour output = 415 ml; concentrated yellow, sediment present 4, Administer Albumin 25g 1V Q6H 4. 9/14 albumin levels = 3.4 (improving) 5, Monitor 1/0’s of patient 5. 24 hour /O net = +1259ml 6. Assess lung sounds for fluid overload 6. Lung sounds clear bilaterally 7. Monitor serum calcium levels 7. 9/13: 78, 9/14: 8.5 (Albumin administered) Evaluation of outcome objectives: Patient’s net VO during my 6-hour shift was +44ml (= 459ml, O = 415 ml) (MET) P, Schuster, Concept Mapping: A Critical Thinking Approach, Davis, 2002