YOUNGSTOWN STATE UNIVERSITY Student: Lauren Hardt

Department of Nursing Date of Care: February 6, 2020 Nursing 4840L Clinical

Data Base Nurse’s Name: Christine

Pt’s Initials: A.C. Date admitted: 2/04/2020 Height: 5ft. 10in.

Room #25 DNR status: Full Code Adm. Weight: 270 lb 9 oz.
Age: 61 Isolation type: None
Sex: Male Allergies: PCN; Doxycycline

Diagnosis (es): Acute Respiratory Failure with Hypoxia; Pneumonia; Septic Shock

Reason for Admission/Events Leading to Current Hospitalization:

(Include reason patient is still in Unit > 2 days if appropriate)

Patient was previously seen in the ED for pneumonia. Patient was then at work when he had sudden
SOB, he was intubated in the field. The patient was diagnosed with Acute Respiratory Failure open
arrival to the ED along with worsening pneumonia. Patient was then transferred to ICU due to the
continued need for continuous ventilation.
Pertinent History of Illnesses/Surgery:

Type 2 Diabetes; Peritoneal Abscess; Perirectal Abscess; Sepsis; Hypertension; Hyperlipidemia

Day of Care (ranges): Vent Settings:

T 36.8– 37
ETT (size/lip-line) – 8mm/27
BP 90/52 – 124/74 Vent: Mode: Assist Control
MAP 67 - 100 Rate: 16
HR 54- 83 FiO2: 40%
RR 16-17 TV: 500
PEEP: 10
SPO2 (range) 95-99

Revised 8/16 lrcalcagni & cmshields Page 1

Neurological: Skin:
LOC: RASS -1 Temp: Warm
Orientation: Nods appropriately, Follows commands Mucous membranes: pink and dry
Ordered Sedation: Propofol Wounds: None, ecchymosis on arms
Opens Eyes: Spontaneous Color: Appropriate for ethnicity
GCS: 11 Turgor: Slight Tenting

Pupils: Brisk movement, 2 mm; PERRLA

Speech: UTA due to ETT
Tongue: pink, moist, midline
Face Symmetry: symmetrical

Cardiovascular:
Rhythm: Normal Sinus Rhythm
JVD or Cyanosis: None
Pulse: Regular
Cap Refill: <3 seconds
Heart Sounds: S1 and S2

Peripheral Vascular:
Pulses: Palpable Radial: Bilateral +2 Pedal: Bilateral +1 Post Tibial: Bilateral +1
Edema: Yes Location: General Edema Degree: +1, non-pitting

Respiratory:
Breath Sounds: Diminished breath sounds bilaterally; crackles present in RLL
Sputum: small, thick, tan
Cough: Yes, productive
Musculoskeletal:
GI:
Diet: OG tube Upper Extremities:
Bowel Sounds: Hypoactive x4 Movement: Follows commands; normal
Stool: None on shift, incontinent flexion and extension
TF (type/rate): Diabetic 15mL/hr Strength: Strong, moves against gravity
Abdomen: soft, distended Sensation: Full
FMS: Present
GU: Lower Extremities:
Urine: Yellow and clear Movement: Follows commands; normal
Genital Irritation: None flexion and extension
Amount: 30mL/hr Strength: Strong, moves against gravity
Catheter Type: Foley Sensation: Full
Dialysis: Right Femoral

Continuous IV Drips: IV Drips must also be looked up & included on Med Sheet

Medication Concentration Rate Site Line

Propofol 5 mcg/ml 14.4 mL/hr Right Arm Triple Lumen
Fentanyl 20 mcg/kg/min 7.5 mL/hr Right Arm Triple Lumen

Intake/Output/Weight:
24 hr. Intake: 2770 mL
24 hr. Output: 1982 mL
Cumulative Fluid Balance (prior day): -788

6 hr. Intake: 600 mL

6 hr Output: 345 mL

Daily Wt (today): 122.4 kg (prior day): 122.9 kg

Pain/Pain Management:
CPOT: 0; Preformed during a sedation vacation

ABG Analysis:

ABG’s: pH PCO2 PO2 HCO3 Interpretation

Admission
7.18 65.3 133.1 24 Uncompensated respiratory acidosis
Date: 2/4
Day prior
7.37 37.8 71.3 21.7 Compensated Metabolic acidosis
Date: 2/5
Day of care
7.42 35.7 64.1 22.7 Normal
Date: 2/6

Diagnostic Test: Results:

Chest X-Ray 2/5: Mild cardiomegaly; Central congestive change; Right lobe infiltrate
2/6: Improving CHF
Other pertinent 2/5: CTA of the Chest with Contrast: No embolism; Cardiomegaly with coronary
diagnostic tests artery calcification with patchy bilateral infiltrates and effusions likely CHF

Normal Admission Day Day of

Reason for Abnormal
Lab Test Values prior care
Value
Date 2/4 2/5 2/6
Na+ 136-145 142 142 142
B MP

K+ 3.5-5.5 4.5 4.0 3.3 Malnutrition

Cl- 96-106 109 109 109 Dehydration

CO2 23-30 22 21 20
Glucose 70-110 242 154 93
BUN 6-20 11 15 17
 Creatinine .6-1.2 0.9 1.0 1.2

Calcium * 9.8-10.4 8.8 8.5 8.8

Albumin 3.5-5.2 4.3 ______ ______
CMP (+ BMP)

Total protein 6.4-8.3 5.5 ______ ______ Malnutrition

ALP (Alk Phos) 25-100 56 ______ ______

ALT/SGPT 0-32 28 ______ ______

AST/SGOT 14-20 33 ______ ______

Total Bilirubin 0-1.2 0.6 ______ ______

Magnesium 1.8-2.6 1.2 1.9 1.6 Malnutrition

El

Phosphate 2.7-4.5 3.8 3.9 4.1

Cholesterol 140-400 ______ ______ ______
Lipid

Triglycerides <150 ______ ______ ______

RBC 4.2-5.4 6.06 5.73 5.46

CBC

Hgb 14-17.4 16.1 15.0 14.6

Hct 42-52% 52.9% 50.1% 47.1%

Platelets 140-400 201 190 177

WBC 3.2-10 4.5 4.4 4.3 Infection
neutrophils 43-80% 48.6% 52.7% 60.4%
lymphocytes 20-42% 39.0% 34% 28.9%
monocytes 2-12% 8.4% 8.5% 8.5%
eosinophils 0-6% 2.9% 2.1% 1.6%

basophils 0-2% 0.9% 0.7% 0.4%

PT 11-13 10.3 ______ ______

Coag

INR 1-1.5 0.9 ______ ______

HPTT/PTT 18-28 28.8 ______ ______

CK 38-174 ______ ______ ______

Cardiac

CK MB 0-4.3 ______ ______ ______

Troponin <.04 ______ ______ ______

B-type natriuretic peptide (BNP) <100 1,724 ______ ______ Increase in CO; Sepsis

Lactate 0.5-2.2 1.2 1.4 ______

Other

Ammonia ______ ______ ______

 GFR >60 >60 >60 >60

* Calcium part of BMP in some facilities

ECG Interpretation:
Post 6 second ECG strip here or on back (no identifiers ). Interpret using 8 step method .

ECG Analysis: 2. R-R Interval Regular: Yes

1. Rate: 80 4. PR Interval: .18 Constant: Yes
3. P wave present: Yes
6. QRS Interval: .08
5. P precedes each QRS: Yes
8. ECG Interpretation: Normal Sinus Rhythm
7. QT Interval: .4
__________________________________________________________________________

Pathophysiology of primary diagnosis &/or surgery:

Pneumonia- An infection of the lungs that may be caused by bacteria, viruses, or fungi. Infection
causes the lungs alveoli to become inflamed and fill up with fluid. This makes it hard for the Oxygen to
get into the bloodstream.

Book used & page no. Medscape

Psychosocial Considerations:
Intubation puts this patient at risk for anxiety, depression, and hopelessness. Son, mother, and wife
take turn visiting with the patient. Pt does not have a history of smoking, drinking, or illegal drug use.

Pertinent subjective and objective data for the following:

Health Maintenance (Use of Alcohol, Tobacco, Drugs): Pt is currently not using any substances.
Activity/Exercise: Self Care Ability (eating, bathing, transferring, tolerance to activity): Pt is currently
unable to preform ADL’s due to orders of bedrest and propofol.
Sleep-Rest: Pt has been having extended periods of rest, with breaks from rest during sedation
vacations.
Cognitive-Perceptual (mental status, ability to communicate, language barriers, comprehension,
anxiety, interactive skills, hearing, vision, memory): ETT
Role Relationship (marital status, occupation, employment status, support system, family concerns):
Married; On leave from work; Children are older and are now apart of the larger support system.
Value/Belief (religion, spiritual needs): Catholic
Medications

Allergies: _PNC; and Doxycycline____________________________________________

Times Due 0900 2300 Continuous Continuous

Brand Name Protonix Maxipime Diprivan Fentanyl

Generic Name Pantoprazole Cefepime Propofol Sublimaze

Dose 40mg/10mL 2g 5.3mL/hr 50mcg/hr

Route/How to IV Push 2 IV:12.5ml/h IV IV; 10ml/hr

Administer minutes r Titration w/ RASS

Classification Antiulcer (PPI) Antibiotic General anesthetic Opiod

Action Diminishes acid in Inhibits the 3rd and Induction and Analgesia and
gastric lumen Final stage of the maintenance of sedation
bacterial wall anesthesia
synthesis

Reason Pt Prevent ulcers Pt is suffering from Sedation Pain management

Receiving and VAP Pneumonia and sedation

Contra Hypersensitivity Hypersensitivity to Egg allergy MAOI within last 14

PCN days
Myasthenia gravis
MAJOR Hyperglycemia, Fever; Colitis Bradycardia, Cardiac Arrest;
Adverse/ hypomagnesemia Eosinophils; N/V/D hypotension, apnea Circulatory
Side Effects Depression;
Respiratory
Depression
Nursing Assess for Do the C & C before Assess respiratory Monitor Vital Signs
Implications epigastric pain therapy status, BP, and Monitor Respiratory
pulse continuously Status
Change IV tubing
q12
Pt/Family Avoid alcohol and S&Sof Superinfection May decrease Signs and
Teaching NSAID’s No breast feeding mental recall Symptoms of an
Overdose
 Medications

# Key Problem/ND # Key Problems/ND # Key Problem/ND

1 Ineffective Airway 2 Impaired Gas 3 Impaired
Clearance Exchange Spontaneous
Ventilation
Data: Data:
Crackles in RLL Diminished Lung sounds Data:
Diminished breath Ventilator Inability to maintain
sounds FiO2 40% airway
Excessive secretions PEEP 10 On Assist Control
ETT that requires q1h Confusion Ventilator
suctioning pH- 7.18, PCO2-65.3, TV 500
Ineffective cough PO2-133.1, HCO3-24 FiO2 40
Performist (formoterol) Uncompensated Rate 16
Respiratory Acidosis PEEP 10
# Key Problem/ND: # Key Problem/ND
8 Risk for Anxiety Reason For Needing Health Care 4 Risk for Infection
(Medical Dx/ Surgery)
Data: Data:
Intubated Acute Respiratory Failure due to Compromised host
Sedated Pneumonia defenses- Type 2
Confusion Septicemia Diabetic
Restrained 61 yo Male, Full Code WBC- 4.3
Consistent Noise Weight Loss
Interrupted Rest Key Assessments: VS d/t Nutritional Deficit
Altered Communication Hemodynamic instability; Intubated
Perfusion; Focus on Respiratory. Yellowish Secretions

# Key Problem/ND
7 Risk for Impaired Skin
Integrity # Key Problem/ND # Key Problem/ND
6 Imbalanced Nutrition: 5 Deficient Fluid Volume
Data: Less Than Body
Fluid Imbalances Requirements Data:
Nutritional Deficit Dry Mucous Membrane
Weight loss Data: Dry Skin
Infection WBC 4.3 NPO Weakness
Skin color changes Chloride: 109 Increased Urine
(ecchymosis) Total Protein: 5.5 Concentration
Dry skin Potassium: 3.3 Fever
Magnesium: 1.6
 Problem #1: Ineffective Airway Clearance
General Goal: Increased airway clearance
Predicted Behavioral Outcome Objective (s):
The patient will have thinner secretions on this shift.

Interventions
1. Assess airway for patency
2. Auscultate lung sounds
3. Suction PRN
4. Administer breathing treatments
5. Oral care q2 hours
6. Elevate HOB to 30º
Rationales
Patent, ETT in place
Crackles in RLL, diminished bilaterally
Thick, tan secretions
Thinner secretions, Lung sounds clearer
Mouth care tolerated well
SpO2 99%

Evaluation of outcomes objectives:

Met. Secretions thinner and smaller with last suctioning.

Problem #2: Impaired Gas Exchange

General Goal: Increased gas exchange

Predicted Behavioral Outcome Objective (s):

The patient will have normal ABG’s on this shift.

Interventions
1. Assess lung sounds
2. Assess ABG’s
3. Assess Chest XR
4. Elevated HOB 30 degrees
5. Assess level of consciousness
6. Continuously monitor SpO2
Rationales
Crackles in the RLL; Diminished breath sounds
pH – 7.54, PCO2 – 34, HCO3 – 28.5
Right lobe infiltrates
SpO2 99%
Follows commands, nods appropriately
Mechanical ventilation SpO2 100%

Evaluation of outcomes objectives:

Met; pH-7.42 PCO2-35.7 PO2-64.1 HCO3- 22.7

Problem #3: Impaired Spontaneous Ventilation

General Goal: Will achieve spontaneous ventilation

Predicted Behavioral Outcome Objective (s):

The patient’s SpO2 will remain > 92% on this shift.
Interventions
1. Assess ETT Placement
2. Assess ventilator settings
3. Suction PRN
4. Auscultate lung sounds
5. Assess ABG’s
6. Assess capillary refill
7. Assess for cyanosis
Rationales
Bilateral chest expansion present; no movement of
ETT
FiO2 40%, TV 500, PEEP 10, RR 16
Large amount of thick, tan sputum
Crackles in RLL, diminished bilaterally
pH – 7.42, PCO2 – 65.3, HCO3 – 24.0
<3 seconds
No cyanosis present

Evaluation of outcomes objectives:

Met. Patient’s SpO2 remained at 100% due to mechanical ventilation.

Problem #4: Risk for Infection

General Goal: Patient remains free of infection, as evidenced by normal vital signs and
absence of signs and symptoms of infection.

Predicted Behavioral Outcome Objective (s):

Adequate vital sign readings and absence of symptoms.
Interventions Rationales
1. Assess blood glucose readings Glucose: 93 - 242
2. Evaluate WBC count WBC- 4.3
3. Assess Weight Loss Wt. 122.9 kg to 122.4
4. Assess for redness, swelling, and inc. Pt is not currently showing signs of skin changes
pain
5. Assess vital signs Temp- 36.8-27, Map- 67-100, HR- 54-83, RR- 16-17
6. Assess for adventitious heart sounds S1 and S2 present, no adventitious
Evaluation of outcomes objectives:
Not met. Pt WBC are low, lost weight, and diabetes is uncontrolled.

Problem #5: Deficient Fluid Volume

General Goal: Patient is normovolemic

Predicted Behavioral Outcome Objective (s):

Vital sign readings specifically Bp and HR
Interventions Rationales
1. Assess Bp and HR BP: 90/52-124/74(low for someone with HTN); HR 54-83
2. Assess mucous membranes Membranes are dry
 3. Assess skin turgor Skin is dry and shows mild tenting
4. Assess Pts LOC Pt follows commands and on RASS -1
5. Assess Urine Colo Urine is clear and yellow
6. Assess I&O Intake 600 mL, Output 345 mL

Evaluation of outcomes objectives:

Met. Patient’s BP and HR along with other assessments are WNL

Problem #6: Imbalanced Nutrition: Less Than Body Requirements

General Goal: Improved nutritional status

Predicted Behavioral Outcome Objective (s):

The patient will tolerate tube feeding at 40 mL/hour with residual <100 mL on this shift.
Interventions Rationales
1. Assess GI status Active bowel sounds, no BM on shift
2. Assess OG placement PRN Placement correct per abdominal XR
3. Assess residual q4 hours Residual 20 mL
4. Administer Protonix No signs of ulcer formation
5. Assess stool characteristics No BM this shift
6. Daily weights 122.4 kg today

Evaluation of outcomes objectives:

Met. Residual 20mL.

Problem #7: Risk for Impaired Skin Integrity

General Goal: Patient skin remains intact

Predicted Behavioral Outcome Objective (s):

Skin will not show reddened areas or symptoms of skin breakdown
Interventions Rationales
1. Initial skin assessment Baseline assessment had no signs of breakdown.
2. Q2h turns Prevent breakdown on bony prominences
3. Assess pt sensation Pt nods when asked if they can feel extremities
4. Braden Scale Score of 11; High Risk
5. ROM During sedation vacation ROM was Full
6. Foley and FMS Pt remained dry
 Evaluation of outcomes objectives:
Met. Pt is yet to have any reddened or open areas

P roblem #8 : Anxiety
General Goal: Decreased anxiety
Predicted Behavioral Outcome Objective(s):
Patient demonstrates decreased tension through facial expressions and gestures.

Interventions
1. Promote family visitation
2. Thoroughly explain procedures
3. Use therapeutic communication
4. Lessen sensory stimuli
5. Administer Propofol per order
6. Provide sedation vacations
Rationales
3 family members during this shift
Nods with understanding
Visibly lowered anxiety
Alarm volume lowered, clustering care
RASS -1
Patient can take a break from sedation

Evaluation of outcomes objectives:

Met. Patient is less tense during assessment and suctioning.

Research Article Information

Reference:
Joseph-Belfort, A. (2009). A brief report of student research: protocol versus nursing practice: sedation
vacation in a surgical intensive care unit. Dimensions of Critical Care Nursing : DCCN, 28(2), 81–82.
https://eps.cc.ysu.edu:2144/10.1097/DCC.0b013e318195d5d6

Link: https://eps.cc.ysu.edu:8443/login?url=https://search.ebscohost.com/login.aspx?
direct=true&AuthType=ip,uid&db=mnh&AN=19225320&site=ehost-live&scope=site