Care Plan 2 – Critical Care

Student: Evelina Balzhyk Date: 2.4.2020.

Course: NSG-430CC/Critical Care Instructor: Sheila Arnberger

Clincial Site: Banner Del Webb Medical Center Client Identifier: DV Age: 63

Reason for Admission:

DV was admitted into the ED on 1.24.2020. According to the patient report, DV experienced shortness of breath and chest pain. Patient also
states that he fell two days ago and “hurt his chest on the right”. The patient was transferred to PCU on 1.25.2020 due to a

Medical Diagnoses: Clinical Manifestation(s):

The patient was diagnosed with COPD exacerbation and pneumonia.
COPD exacerbation is worsening or a “flare up” of COPD symptoms. The
cause of the exacerbation may be infection, but it is not always known.
Inflammation or irritating substances cause the lung to react in
inflammation which “makes the airways narrow from muscle tightness,
swelling, and mucus” (Lareau, Moseson, & Slatore, 2018). Woresening of
usual signs and symptoms of exacerbation include breathlessness,
increased cough in severity and frequency, and change of amount and
color of sputum in the cough (Lareau, Moseson, & Slatore, 2018). Risk
factors of COPD exacerbation include tobacco smoke, dusts, and
chemicals. Pneumonia is defined as an infection of the lung parenchyma.
Pneumonia is an umbrella term for various syndromes caused by
organisms resulting in different manifestations. The etiology of
pneumonia can be community-based, hospital-based, and ventilator
associated (Jain & Bhardwaj, 2019). Defense machanisms which are
compromised in the pathogenesis of pneumonia include: impaired
Clinical manifestations which DV is experiencing from the COPD
exacerbation are cough, breathlessness, and fatigue. Potential
clinical manifestations which DV could expereince from the COPD
exacerbation are low oxygen saturation levels and waking up with a
headache, which is an indicator for high carbon dioxide levels
(Lareau, Moseson, & Slatore, 2018).
Pneumonia clinical manifestations which DV is experiencing are
chest pain, cough, and dyspnea. Potential clinical manifestations
are tachypnea, tachycardia, fever, and crackles (Jain & Bhardwaj,
2019).
Some of the clinical manifestations which DV is experiencing may
be similar for both COPD exacerbation and pneumonia.

© 2018. Grand Canyon University. All Rights Reserved. Rev 2.17.18

mucociliary clearance in cigarette smokers, impaired cough reflex in
comatose patients, and accumulation of secretions in patients with cystic
fibrosis or bronchial obstruction (Jain & Bhardwaj, 2019). Risk factors
for pneumonia include weakened immune system, being on a ventilator,
chronic diseases such as asthma or COPD, and smoking.

Assessment Data

Subjective Data: Patient states his pain is 6/10 and says, “it’s in my right chest side”. Patient also says that he has had discoloration in his feet
“for years, it’s because of the Beurger’s”.
VS: taken on 2.4.2020 at 0800 Labs: Diagnostics:
T : 36.3 C RBC (4.2-5.4): 4.19 The patient has 1.24.2020 at 1727
(L) pneumonia and
BP: 135/75 Chest PA and lateral X ray
COPD which could
HR: 60 bpm indicate a low red Impression: right base consolidation, internal since
blood cell count. 11.22.2019, favored to reflect atelectasis or aspiration.
RR: 20 bpm
Left lung base scarring. Intact pacemaker.
O2 Sat: 94% on 4 L/min Glucose (<100): 140 This patient has HTN,
with nasal cannula. (H) and is obese. DV is
also experienceing
Pain: 6/10 on a scale of 0 to 10 anxiety with this
pain. hospital stay. This
VS: taken on 2.4.2020 at 1400 explains why the
blood glucose would
T: 36.4 C be elevated.
BP: 136/83 BUN (7-20): 33 (H) This patient
HR: 18 bpm congestive heart
failure. This would
RR: 18 bpm
explain why the BUN
O2 Sat: 94% on 4 L/min level is increased.
with nasal cannula.
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Pain: 6/10 on a scale of 0 to 10 Mch (27-33): 26.3 (L) DV has shortness of
pain scale. breath due to COPD
and pneumonia, this
would explain why
Mch is lowered.
Mchc (33.4-35.5): DV has shortness of
30.3 (L) breath due to COPD
and pneumonia, this
would explain why
Mch is lowered.
RDW CV (12.2- An elevated RDW
16.1): 16.6 (H) level could be caused
by low RBCs in the
blood, this is what
DV presents with.
RDW SD (11.8-14.5): An elevated RDW
15.2 (H) level could be caused
by low RBCs in the
blood, this is what
DV presents with.
(Lewis, S. L., Bucher,
L., Heitkemper, M.
M., & Harding, M.,
2017).

Assessment: Orders:
History: DV has history of COPD, HTN, CHF, Beurger’s disease,  Consent for Blood transfusion
anxiety  Continuous pulse oximetry

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Neuro: The patient is alert and oriented x4. Pupils are 3 mm bilaterally  Vital signs per protocol
and are regular bilaterally. PR’s glasgow coma score is 15.  Continuous cardiac monitoring
Communication and behavior are appropriate and cooperative.  Fall risk protocol
Respiratory: Lung sounds are present and clear in all lobes bilaterally.  Ambulation
Patient has a cough, no sputum. Respirations are 20 bpm on 4 L of O2  Monitor I&Os, patient is on diuretic
via nasal cannula.  Continuous O2 via nasal cannula
 Continuous O2 saturation
Cardiac: Normal S1 and S2 sounds. Patient has a pacemaker, V-paced
 Manage pain
rhythm. Rhythm is 60 bpm. No edema is present in lower extremities.
Radial +2 bilaterally, slightly diminished. Dorsalis pulses were not  Regular skin assessment in lower extremities, apply cream
found by me (Doppler was not used). Capillary refill is less than 2
seconds, nail beds are pink.
GI: Bowel sounds are present. Abdomen is soft and non distended.
GU: Patient voids appropriately, uses urinal. Output of 515 ml. Last
BM was 3 days ago.
Muscoloskeletal: No joint swelling noted on all joints, no compression
devices or compression stockings. Patient ambulated to restroom, weak
gait.
Integumentary: Skin turgor is normal. Color is appropriate for
ethnicity. Skin is dry and warm (except for lower extremities). Lower
extremities have discoloration, bluish tint. Skin feels cold to touch in
feet.
Lines: Patient has an IV in the left AC; line is patent, no erythema or
swelling noted.
Diet: Patient is on heart healthy diet. Low sodium.

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 Medications
ALLERGIES: Trazadone, Gabapentin
Name Dose Route Frequenc Indication/Therapeutic
y Effect
acetylcysteine 1 ml inhalation QID This medication is
indicated for management
of conditions associated
with thick viscid mucous
secretions (mucolytic).
Patient has pneumonia
and this medication helps
with the mucus secretions
in the lungs.
Albuterol 3 ml inhalation QID Used as a bronchodilator
to control and prevent
reversible airway
obstruction caused
by asthma or COPD. DV
has as exacerbation of
COPD.
Benzonatate 1 cap PO TID This medication
Anesthetizes cough or
stretch receptors in vagal
nerve afferent fibers found
Adverse Effects Nursing
Considerations
Drowsiness, vasodilation, Assess respiratory
tachycardia, hypotension, function (lung
bronchospasm sounds, dyspnea)
and color,
amount, and
consistency of
secretions before
and immediately
following treatment
to determine
effectiveness of
therapy
Nervousness, restlessness, Assess lung sounds,
tremor, HA, chest pain, pulse, and BP
palpitations, nausea, before
vomiting, tremor. administration and
during peak of
medication. Note
amount, color, and
character of sputum
produced
HA, mild dizziness, Instruct patient to
constipation, GI upset, take exactly as
chest numbness, chilly directed. If a dose is
sensation missed, take as
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 in lungs, soon as possible
pleura, and respiratory unless almost time
passages. The patient has for next dose. Do
a cough, the cough is not double doses.
decreased with this Instruct patient to
medication. cough effectively:
Sit upright and take
several deep breaths
before attempting to
cough. Do not chew
capsules.
Furosemide 40 mg PO QID Medication in indicated Blurred vision, dizziness, Assess fluid status.
for patients with heart headache, vertigo, Monitor BP.
failure and HTN, that is hypovolemia, metabolic Monitor daily
what DV uses this alkalosis, hearing loss, weight, intake and
medication for. tinnitus, dehydration, output ratios,
hypokalemia, amount and
hypocalcemia location of edema,
lung sounds, skin
turgor, and mucous
membranes. Notify
health
care profe ssional if
thirst, dry mouth,
lethargy, weakness,
hypotension, or
oliguria
occurs.
(Vallerand, A. H., Sanoski, (Vallerand, A. H.,
C. A., & Deglin, J. H., Sanoski, C. A., &
2017). Deglin, J. H.,
2017).
Nursing Diagnoses and Plan of Care

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 Goal
Client or family focused.
Priority Nursing Diagnosis
Impaired gas exchange related to decreased functional lung tissue as evidenced by oxygen level of 94% on 4 L of oxygen.
This has been selected as the priority diagnosis because activity intolerance is a concern for physical needs which is the first tier in Maslow’s
Hierarchy of Needs.
Patient maintains optimal
gas exchange as evidenced gas exchange as
by oximetry results above
94%.
Expected Outcome
Measurable, time-specific,
reasonable, and attainable.
Patient maintains optimal 1.) Assess the lungs for
evidenced by oximetry
results above 94% by time presence of adventitious
of discharge.
Intervention(s)
Nursing or interprofessional
interventions.
areas of decreased
ventilation and auscultate
sounds.
2.) Monitor patient’s
behavior and mental status
for onset of restlessness,
agitation, confusion, and (in existing hypoxia.
the late stages) extreme
lethargy.
3.) Monitor oxygen
saturation continuously,
using pulse oximeter.
(Ralph, S. S., Taylor, C. M., changes may occur with
& Phelps, L. L., 2017).
Rationale Evaluation
Provide reason why Was goal met? Revise
intervention is the plan of care
indicated/therapeutic. according the client’s
Provide references. response to current plan
of care.
1.) Any irregularity of 1.) The goal was met
breath sounds may disclose because the patient was
the cause of impaired gas auscultated and had no
exchange. Presence of adventitious sounds
crackles and wheezes may upon auscultation,
alert the nurse to an airway bilaterally.
obstruction, which may 2.) The goal was met,
lead to or exacerbate patient’s behavior and
mental status were
Diminished breath sounds monitored and patient
are linked with poor had appropriate
ventilation. behavior.
2.) Changes in behavior 3.) The goal was, patient
and mental status can be has continuous pulse
early signs of impaired gas oxymeter.
exchange. Cognitive
chronic hypoxia.
3.) Pulse oximetry is a
useful tool to detect
changes in oxygenation.
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 An oxygen saturation of
<90% (normal: 95% to
100%) or a partial pressure
of oxygen of <80 (normal:
80 to 100) indicates
significant oxygenation
problems.
(Ralph, S. S., Taylor, C.
M., & Phelps, L. L., 2017).
Secondary Nursing Diagnosis:
Chronic pain related to Beurger’s disease as evidenced by complaint of 6 on a pain scale fo 0 out of 10.

This has been selected as the secondary diagnosis because pain is a concern for physical needs which is the first tier in Maslow’s Hierarchy of
Needs.
Patient will help develop a Patient will help develop a 1. Assess patient’s signs 1. Assessment allows for 1. Goal was met. Patient’s
plan for pain control. plan for pain control by and symptoms of pain, and care plan modification, as signs and symptoms were
time of discharge. administer pain needed. assessed and appropriate
medication, as prescribed. 2. Although pain is medication was provided.
Monitor and record the subjective, when using the 2. Goal was met, a pain
medication’s effectiveness scale you can compare the scale was used to assess
and adverse effects. patient’s perception of and compare the pain
2. Use a pain scale when pain from one assessment levels.
assessing pain. to another. 3. Goal was met, a
3. Consider the services of 3. Patients who remain psychiatric professional
psychiatric mental health helpless, unmotivated, was contacted and a
professionals to help uncooperative, and realistic plan was
patient and staff members manipulative are self- established.
establish a realistic plan to destructive. Underlying
resolve the problem. causes should be explored
(Ralph, S. S., Taylor, C. (Ralph, S. S., Taylor, C.
M., & Phelps, L. L., M., & Phelps, L. L.,
2017). 2017).
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Definition of Client-Centered Care: Care that is unique to the age/developmental stage, gender, race, ethnicity, socio-economic
status, cultural and spiritual preferences of the individual and focused on providing safe, evidence based care for the achievement of
quality client outcomes.”

Jain, Vardhmaan. “Pneumonia Pathology.” StatPearls [Internet]., U.S. National Library of Medicine, 29 Dec. 2019,

www.ncbi.nlm.nih.gov/books/NBK526116/.

Lareau, S., Moseson, E., & Slatore, C. (2018). Exacerbation of COPD. Retrieved February 7, 2020, retrieved from

https://www.thoracic.org/patients/patient-resources/resources/copd-exacerbation-ecopd.pdf

Lewis, S. L., Bucher, L., Heitkemper, M. M., & Harding, M. (2017). Medical-Surgical Nursing: Assessment and Management of

Clinical Problems (10th ed.). St. Louis, MO: Elsevier.

Ralph, S. S., Taylor, C. M., & Phelps, L. L. (2017). Nursing diagnosis reference manual. (10th ed.). Philadelphia: Wolters Kluwer

Health/Lippincott Williams & Wilkins.

Vallerand, A. H., Sanoski, C. A., & Deglin, J. H. (2017). Davis's Drug Guide for Nurses (15th ed.). St. Louis, MO: Elsevier