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AZUSA PACIFIC UNIVERSITY
SCHOOL OF NURSING
GNRS 588: ADVANCED NURSING CARE FOR ADULTS
COMPREHENSIVE CARE PLAN #: ____2____
Student: Antonia Y Perez
Instructor: Professor Padilla
Date of Care: 03/22/2024
Date of Submission: 04/05/2024
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ARDS Management: Pharmacological and Nursing Interventions, Schemes and Mind Maps of Nursing
A focused overview of a 39-year-old male's ICU management, emphasizing pharmacological interventions and nursing priorities. It covers his history, spiritual assessment, and medications like fentanyl, precedex, and propofol, detailing their mechanisms, side effects, and nursing implications. Nursing diagnoses related to impaired gas exchange and skin integrity risk are outlined, including assessments, goals, and interventions. Useful for medical and nursing students understanding critical care management and pharmacological interventions in ARDS patients. It offers insights into assessment, medication administration, and tailored nursing care plans, emphasizing continuous monitoring, patient education, and interdisciplinary collaboration.
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AZUSA PACIFIC UNIVERSITY
SCHOOL OF NURSING
GNRS 588: ADVANCED NURSING CARE FOR ADULTS
COMPREHENSIVE CARE PLAN #: ____2____
Student: Antonia Y Perez
Instructor: Professor Padilla
Date of Care: 03/22/
Date of Submission: 04/05/
Nursing Clinical Worksheet
Student Name: Antonia Y Perez Date: 03/22/ Patient Initials: J.G Age: 39 Sex: M Isolation and Type: Standard Code Status: Full Weight: 118.2 kg Admit Date: 03/10/ Allergies: NKA Diet: NPO Fall Risk: Yes RASS: - Braden Score: 12 Activity: Unable to ambulate currently placed on Bed-Rest. LOC: Sedated & Unresponsive Admitting Diagnosis/Chief Complaint (if present in ED): 39 yr old presents hypothermic, with acute respiratory distress, methamphetamine intoxication, and agitation.
ASSESSMENT DATA:
1. History of Present Problem: (notes: begin with what brought the patient to the hospital, what has been done since admission, plan for what is coming up next + discharge planning if appropriate)
Initial Note: Patient is a 39 year-old-male with no known pertinent past medical history presented in ED on
03/10/2024 hypothermic and unresponsive, patient was noted to have UDS positive for TSH/meth upon arrival.
During stay patients’ agitation worsened, requiring intubation. Over the course of his stay in the intensive care unit,
patient has had multiple attempts to wean off the ventilator but has required persistent mechanical ventilation
secondary to agitation. Workup also concerning for multifocal pneumonia, and ARDs. Patient currently
intubated/sedated. On chest x-ray today, findings persistent with atelectasis and categories of ARDS.
3/22: Patient evaluated bedside, remains intubated/sedated on fentanyl/Precedex/propofol secondary to increased
agitation and hypoxemia. Improved ventilator settings. Will continue monitor for daily weaning. Family aware that
tracheostomy may be indicated.
2. Past Medical History No known past medical history What is the relationship of your patient’s past medical history (PMH) and current medications? Which medications treat which conditions? PMH Home Medications Pharm. Classification Expected Outcome 1. none applicable 2. 3.
BEGINNING OF PATIENT CARE:
Doc Flowsheet Data Vital Signs 0800 1200 1600 Ventilator Settings IV Fluids/Drips Noninvasive Blood Pressure (NIBP) 134/59 135/64 140/ Mode: Press-Reg Type Rate/ Site Sodium Chloride 3 ml RTQ6H Mean Arterial Blood Pressure (MAP) Pulse Rate 59 60 60
General Survey Physical Appearance: Patient is un-groomed, in hospital gown. Hair is evenly distributed. symmetrical facial features and even tone of skin. Mood: Intubated and sedated unable to present any affect. Signs of Acute Distress: No current signs of acute distress due to high sedation. Neurologic Orientation Sedated/Intubated -5 RASS unarousable no response to voice or physical simulation. Speech Unable to assess speech due to being mechanically intubated. Pupil (L) Pupils upon eyelids being manually opened are equal round and reactive to light. Dilates at 2mm Pupil (R) Pupils upon eyelids being manually opened are equal round and reactive to light. Dilates at 2mm GCS score GCS: Can not be fully tested due to intubation, verbal responses not acquired. Abnormal Muscles Location: Muscle tone, deep tendon reflexes not assessable due to sedation and intubation. Strength: Range of motion not accessible due to sedation and intubation. Pain Assessment P rovocation/ palliation NONE unable to attain due to high sedation levels. Q uality NONE unable to attain due to high sedation levels. R egion/ Radiation NONE unable to attain due to high sedation levels. S everity NONE unable to attain due to high sedation levels. T ime NONE unable to attain due to high sedation levels.
Pulmonary Oxygenation Room Air XDevice Mechanical Ventilator & Intubation Respiration Quality/Rhythm : Poor requiring support of press-reg on mechanical ventilation Rate: 17 with assistance Set: 14 FiO2: 50 TV: 480 PEEP: 14 R. Lung Decreased air entry heard on auscultation of the right lung due to consolidation or atelectasis, consistent with multifocal pneumonia and ARDS. L. Lung Decreased air entry heard on auscultation of the right lung due to consolidation or atelectasis, consistent with multifocal pneumonia and ARDS. Cardio- vascular Capillary Refill Normal > Skin Color/ Temp Light pink warm to touch Apical Pulse Present 2+ Heart Sounds No extra sounds or murmurs s1 and s2 audible Peripheral Pulses
Gastro- intestinal Oral Mucosa Moist and pink Tongue Normal color no signs of thrush Abdomen Warm and dry no superficial findings no organomegaly presents Nutrition Currently NPO until further instruction due to vomiting last night but previously on TPN Tube Feeding X OG Tube further info not available because patient vomited last night and was stopped on tube feedings. Bowel Sounds Normoactive Bowel Movement Last BM date: 03/20/ Genito- Urination Condom catheter Urine Color Clear
**Spiritual Assessment DUE to patients high sedation and intubation these answers were primarily assessed through mother and father at bedside. Spiritual Integrity
- Look: (Signs of Meaning, Relationships, Hope and Joy) Spiritual Distress Presence of….. Provide checkmark in either box for each criteria Absence of…. X** Family, friends, visitors, wedding ring, photographs X Cards, letters, phone calls, flowers, pets Attention to personal care and appearance X Work, projects, hobbies, music, books, tapes X Newspapers, magazines, television, radio X Special dress, prayer cap, head scarf, cross X Articles of faith, pictures, statues, rosary, star X Books of faith, Bible, Koran, Torah prayers X Smiles, motivation, coping skills, healthy lifestyle X Uses the observations listed above to begin your Spiritual Assessment Acknowledge and inquire about photographs, cards, flowers, visitors Patient mother and father is at bedside and are only primary Spanish speakers. No pictures or cards present at bedside. Acknowledge and inquire about hobbies, books, television/newspaper content Patient had no hobbies. Acknowledge strength and inquire about profession Patient had no profession. Acknowledge and inquire about articles of faith & religious preference Patients parents stated he was atheist. Acknowledge and inquire about mood (physical and psychological) Patient is not in good spirits prior to being intubated. With your client as your guide, and after a sense of trust and connectedness have been established, continue with the assessment. Phrase your questions and indirect statement in ways that convey your genuineness, style, and comfort. I would like to hear more about your life and/or your family. Unable to answer due to sedation/intubation. When you return home, will there be someone available to help you? Unable to answer due to sedation/intubation. What brings you joy, makes you happy, or makes you laugh? Unable to answer due to sedation/intubation What has brought you the greatest sense of pride and accomplishment to date? Unable to answer due to sedation/intubation
What is your next goal? Unable to answer due to sedation/intubation What give you such strength? Unable to answer due to sedation/intubation Who do you turn to in tough times? Unable to answer due to sedation/intubation Would you like me to pray for you or with you? Unable to answer due to sedation/intubation. **Spiritual Integrity Listen: (Actively listen for signs of meaning, relationships, hope, and joy) Patient unable to verbalize this and did not have good bond with parents for them to know. Spiritual Distress Pt verbalizes... Provide checkmark in each box that is applicable Pt verbalizes… Sense of purpose and meaning My life has no meaning Source of pride & accomplishment Guilt, if only….I should have Source of joy & happiness Sense of sadness and despair Future Goals and desires Lack of motivation Hope and Courage Hopelessness “What is the use?” Interest in world & concern for others Lack of concern for others Personal Strengths Powerlessness I am useless. Connection to others Loneliness and isolation Connection to a higher source Helplessness, anxiety, fear Religious affiliation “This is not fair. Why me?” Request for special diets, clergy “Why am I being punished?” Appreciation for nature Apathy Ability to adapt to changes Inflexibility
2. Nursing Diagnosis: Analyze the data, and if appropriate, select one of the following nursing diagnoses. X Potential for Enhanced Spiritual Well-Being Spiritual Distress Hopelessness Other 3. Plan: Develop a short-term goal and a long term goal for your client. (This is subject to the patient waking up.)
LT Goal: The patient will look into attending a rehabilitation center for substance abuse to better his person. **This Client Spiritual Assessment Tool (CSAT) was adapted from: Hoffert, D., Henshaw, C., & Mvududu, N. (2007). Enhancing the ability of nursing students to perform a spiritual assessment. Nurse Educator , 32 (2), 66-72. What vital sign data are relevant that must be recognized as clinically significant? Relevant Vital Sign/Assessment Data: Clinical Significance: 1.Blood Pressure (MAP) MAP: 84, 86, 90 NORMAL RANGE: 65-
- Heart rate HR: 59, 60, 61
- Oxygen saturation O2 on RA: 98, 98,
- Neurological status RASS: -
- Since the patient is critically ill and intubated, it is important to ensure he is receiving adequate organ perfusion.
- It is a vital indictor of cardiovascular function and can let us know if there is any other underlying conditions.
- Important that the brain is receiving adequate amounts of oxygen for recovery of the injury to the lungs.
- monitoring their RASS is crucial to evaluate the patient’s potential for weaning off intubation and recovery.
RADIOLOGY REPORTS AND LAB VALUES:
What diagnostic and lab results are relevant that must be recognized as clinically significant for the nurse? Relevant Results: (Date) Clinical Significance: X-ray Chest x-ray persistent extensive opacification right mid upper lung. Lower lung due to combination of small pleural effusion associated with right lower lobe atelectasis. Left Patchy airspace disease/pneumonia CT Scan None MRI/Ultrasound none Other: None What lab results are relevant that must be recognized as clinically significant to the nurse? Lab Order(s): (Normal Range) Current Values: (N/H/L) N = Normal H = High L = Low Previous Values: N/H/L) N = Normal H = High L = Low Clinical Significance of Lab Values: What body/system function are we monitoring with each test and what is the significance of the value? Are there any trends (improved, worsened, stable)? Complete for each lab value even if it is normal and/or stable. Complete Blood Count (date) (date) WBC 18.9 (H) 22.9 (H) 4.5-11 (H) the immune system is compromised with infection of pneumonia Hgb 7.6 (L) 7.4 (L) 12-16 (L) due to the use of methamphetamine causing induced hemolysis
Hct 24.4 (L) 23.8 (L) 35-46 (L) due to the use of methamphetamine causing induced hemolysis Platelets 481 (H) 452 (H) 150-450 WNL ensure patient is clotting appropriately. Neutrophils 71.7 (H) 46.7 (N) 40-70 Slightly beginning to elevate potentially meaning they are not able to regulate immune system. Worsening infection. Basic Metabolic Panel Sodium 148 (H) 146 (H) 135-145 Slightly elevated Potassium 5.2 (H) 4.9 (N) 3.5- 5.2 Slightly elevating potentially from high potassium or medications like propofol can cause this. Glucose 115 (H) 105 (N) 70-110 becoming slightly elevated can be due to stress response BUN 46 (H) 48 (H) 7-20 (H) could indicate AKI due to various factors such as methamphetamine-induced rhabdomyolysis or nephrotoxicity. Creatinine 0.950 (N) 1.010 (N) 0.5-1.4 WNL Calcium 9.9 (N) 9.1 (N) 8.5-10.5 WNL Other Labs: ABGs PH 7. (H)
CO2 45.
(N)
HCO
32.0 (H)
LAB LEVELS REFERENCE: (Urden, Stacy, & Lough, 2014) Scheduled Medications and PRN Medication Given (please also include all saline flushes and IVFs) Generic Name : Albuterol Trade Name : IPRATR/ Ablute Classification : bronchodilator Dose: 3ml (^) Route: NEB Frequency/ Rate: RTQ6H Pt. Specific Indications: used to relieve bronchospasm Mechanism of Action: stimulates beta 2 adrenergic receptor in lungs, leading to relaxation of bronchial smooth muscles and widening of airways (Skidmore-Roth, 2022). Contraindications: hypersensitivity to albuterol Side Effects: headache, tremor, nervousness Adverse Effects: paradoxical bronchospasms, arrythmias Patient Family Education: Take medication as prescribed and do not stop unless told by healthcare provider. Nursing implications/actions: monitor respiratory status, heart rate and blood pressure before and after administration. Follow dosing schedule Generic Name : Furosemide Trade Name : Lasix Classification : loop diuretic Dose: 40mg Route: IV Frequency/ Rate: Daily Pt. Specific Indications: used to treat edema associated with kidney disorders or liver disease Mechanism of Action: inhibits sodium and chloride reabsorption in the kidneys, leading to increased urine production and fluid loss (Skidmore-Roth, 2022). Contraindications: Anuria, severe electrolyte depletion Side Effects: hypokalemia, dehydration Adverse Effects: hyponatremia, renal dysfunction
Patient Family Education: inform the patient about potential changes in heart rate and blood pressure Nursing implications/actions: monitor heart rate and blood pressure Generic Name : Fentanyl Citrate Trade Name : Fentanyl Classification : opioid analgesic Dose: 100ml Route: IV Frequency/ Rate: Titrate Pt. Specific Indications: used for pain management Mechanism of Action: binds to mu-opioid receptors in the CNS, inhibiting pain transmission and perception (Skidmore-Roth, 2022). Contraindications: hypersensitivity to fentanyl, severe asthma Side Effects: nausea, constipation, sedation Adverse Effects: hypotension, bradycardia Patient Family Education: educate on respiratory depression with high doses in opioid Nursing implications/actions: monitor respiratory status, if needed administer naloxone as an antidote for opioid overdose if needed Generic Name : Propofol Trade Name : Diprivan Classification : anesthetic/sedative Dose: 100ml Route: IV Frequency/ Rate: ASDIR Pt. Specific Indications: used for induction and maintenance of anesthesia, sedation for mechanically ventilated patients Mechanism of Action: enhances the inhibitory effects of GABA neurotransmitter (Skidmore-Roth, 2022). Contraindications: hypersensitivity to propofol, egg or soy bean oil Side Effects: hypotension, respiratory depression Adverse Effects: potentially rhabdomyolysis, cardiac failure Patient Family Education: inform patients about potential side effects, Nursing implications/actions: Generic Name : Heparin Trade Name : Heparin Sodium Classification : anticoagulant Dose: 5, units Route: Sub Q Frequency/ Rate: Q8H Pt. Specific Indications: prevent deep vein thrombosis and PE Mechanism of Action: binds to antithrombin III enhancing its ability to inhibit clotting factors like thrombin and factor Xa (Skidmore- Roth, 2022). Contraindications: hypersensitivity to heparin, active bleeding Side Effects: bleeding, bruising Adverse Effects: heparin induced thrombocytopenia Patient Family Education: educate on signs of bleeding, easy bruising and monitoring patient Nursing implications/actions: therapeutic PTT at 1.5-2.5, monitor for signs of thrombocytopenia Generic Name : Glucagon Trade Name : Glucagon
Classification : hyperglycemic agent Dose: 1gram (^) Route: 1mg Frequency/ Rate: ASDIR IV Pt. Specific Indications: treats hypoglycemia Mechanism of Action: stimulates glycogenesis and gluconeogenesis in the liver leading to increase in blood glucose levels (Skidmore- Roth, 2022). Contraindications: hypersensitivity to glucagon Side Effects: nausea, vomiting Adverse Effects: rare but allergic reactions or hyperglycemia Patient Family Education: educate on the signs and symptoms of hypoglycemia and how this is for emergency use only. Nursing implications/actions: take blood glucose checks regularly and monitor for s/s of hypoglycemia.
BEGINNING OF CLINICAL REASONING:
CLINICAL REASONING: Pathophysiology of Admitting Diagnosis (Describe pathophysiology, treatments and plan as you would explain it to the patient. Tie in the patient’s medications to their condition as well and why they’re taking it) I made this explanation based upon how I explained it to the patients parents in Spanish since he is in critical condition and can not understand his condition yet. Currently your son’s body is having respiratory dysfunction due to multifocal pneumonia, and ARDs. These conditions lead to decreased oxygen levels in his blood, making it difficult for his body to get the appropriate oxygen it needs to help his tissues and organs to function properly. Your son is experiencing ARDs, where his lungs are inflamed and becoming filled with fluid making it harder to breathe, alongside pneumonia which is an infection in his lungs adding further complications. To help those respiratory complications he is receiving mechanical ventilation while being sedated on medications like propofol, fentanyl and dexmedetomidine to help protect his lungs from further damage and help preserve any energy his body needs to promote healing. We are also managing his pain and discomfort with Gabapentin, and chlordiazepoxide to address those anxious symptoms he presented throughout this process with prior to the sedation. We are also managing any excess fluid he may be retaining with furosemide and albuterol to help open his airways. If you have any further questions we are here to help! NURSING CARE PRIORITIZATION: List 4 Nursing Diagnoses In Order of Highest Priority (Based on your patient’s specific needs, identify three nursing diagnosis and rank them in order of importance; be sure to include at least one physiologic and one psychosocial diagnosis) (1) impaired gas exchange related to pneumonia, ARDs, and atelectasis as evidence by hypoxemia requiring mechanical ventilation despite adjustments in ventilator settings, persistent atelectasis on chest x-ray and ongoing need for sedation to maintain oxygenation. (2) ineffective airway clearance related to mechanical ventilation and sedation evidence by continued presence of atelectasis on chest x-ray despite interventions aimed at improving ventilation. (3) risk for infection related to compromised respiratory function secondary to pneumonia, and ARDs as evidenced by pneumonia on imaging studies, ongoing mechanical ventilation, and immunocompromised status due to critical illness.
- NSG DX #2: Risk for impaired skin integrity related to prolonged immobility and sedation as evidenced by the need for continuous sedation to manage agitation, prolonged mechanical ventilation necessitating immobilization and potential for pressure injuries from positioning during prolonged critical care management. (a) NURSING ASSESSMENT a. Related Assessments: Regular skin assessments for signs of pressure injury development, like redness, warmth, swelling, and breakdown b. Related Risk Factors: Prolonged immobilization, sedation c. Relevant History: documenting all pressure injuries daily (b) SHORT TERM GOAL: Patient will maintain intact skin integrity during the hospital stay with no pressure injuries developing. (c) INTERVENTIONS AND RATIONALES a. Intervention #1: Create a turning schedule to ensure the patient is repositioned at least every two hours. i. Rationale: The regular repositioning helps redistribute pressure, reliving areas of regular sustained pressure and reducing risk of pressure injuries. b. Intervention #2: Utilizing pressure relieve devices like cushions and heel protectors. i. Rationale: These assistive devices can help minimize the pressure on bony parts, reducing the risk of pressure ulcer formation. c. Intervention #3: Keeping skin hygiene up to par by keeping the skin clean and dry and using the right skin care products, avoiding any sheets or things rubbing against patient when handling. i. Rationale: Keeping the patient’s skin dry, helps reduce moisture related skin breakdown. (d) LONG TERM GOAL: The patient will maintain intact skin integrity up until discharge from the hospital, with no pressure injuries. (e) INTERVENTIONS AND RATIONALES a. Intervention #1: Educating the patients family on the importance of repositioning this patient, using cushions to relieve pressure, and inspecting his skin. i. Rationale: Patient and family education helps them become more aware and help the patient in long-term care if remains immobilized. b. Intervention #2: Working with the healthcare team to develop a plan for when the patient recovers to have mobilization and rehabilitation. i. Rationale: This plan will help prevent future complications and reduce pressure injuries. c. Intervention #3: Arrange for follow up care and support services upon discharge with home health to help with skin assessments and ADLs. i. Rationale: Continued monitoring and support after discharge are essential for maintaining skin integrity and preventing pressure injuries outside the hospital. (f) EVALUATIONS a. Short term goal: Patient maintains intact skin integrity without the development of new pressure injuries during their hospital stay. b. Long term goal: Upon discharge the patient demonstrates intact skin integrity and no pressure injuries present and family is aware of the importance of skin care and prevention strategies. What is the worst possible/most likely complication to anticipate based on the primary problem? The worse possible complication that could happen based on this patient pneumonia, ARDS, and prolonged immobilization is sepsis. Which could even go into septic shock because of his already known respiratory failure. What nursing assessments will identify this complication EARLY if it develops?
Constant monitoring of the patients vital signs, including temperature, heart rate, blood pressure, respiratory rate and oxygen saturation. Monitoring their WBCs which are already elevating and C-reactive protein levels, and ABGs to detect signs of this infection spreading. What nursing interventions will you initiate if this complication develops? I will immediately start them on the appropriate antibiotic therapy as prescribed, providing fluid resuscitation and vasopressor therapy if needed hemodynamically. Looking towards making sure they don’t go into MODs as well. Taking the right precautions like gowning up and hand hygiene. SHIFT RESPONSE EVALUATIONS: All physicians’ orders have been implemented that are listed under medical management. Evaluate the response of your patient to nursing and medical interventions during your shift.
- Has the status or your patient improved or not as expected to this point?
- It has not improved which is to be expected because the patient had a significant amount of damage to their lungs when they decided to self-extubate themselves upon sedation vacation during their initial hospital stay.
- Do your nursing plans/goals and interventions need to be modified in any way after this evaluation assessment? Explain:
- Just need to start monitoring for infection because his WBCs were starting to become elevated during the shift and that is not a good sign, but it can be expected because of his status and the pneumonia the patient has. Just begin implementing contact precautions because they are not yet installed. Continue to monitor those respirations because as of right now they are diminished and watching the ventilator settings. Working with the RT will be very crucial to this patient’s improvement.
- What will be the most important discharge/education priorities you will reinforce with their medical condition to prevent future readmission with the same problem? Explain:
- The most important in the long process this patient has to recovery will include rehabilitation to learn to walk again after being immobilized for so long, to learn how to eat nutritious foods, and substance abuse management. It will have to be a complete lifestyle modification and health care team of professionals that work to collaborate with this patient. Ranging from a mental therapist, nutritionist, social worker, physical therapist, and respiratory therapist.