WINE LIST - Hotel Brighton

Running head: CASE STUDY BH
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Case Study: BH
Nursing Care of Adults-NURS 30030
Constance Contreras
Kent State University at Stark
CASE STUDY: BH
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Data Collection
Client Profile
B.H. is a 58 year old male with the admitting diagnosis of acute exacerbation of chronic
obstructive pulmonary disease (COPD) and hypoxia. He came to the emergency room due to
increasing dyspnea. COPD is a combination of chronic obstructive bronchitis, emphysema, and
asthma. He has a history of scoliosis, schizophrenia, schizoaffective disorder with paranoia and
depression. The pathophysiology for chronic obstructive bronchitis is the result of bronchial
inflammation that leads to increased mucous production, chronic cough, and scarring of the
bronchial lining. In chronic obstructive bronchitis, there is an increase in the size and number of
submucous glands in the large bronchi, increasing mucus production. There is also increased
number of goblet cells, which produce, mucous also. There is also a resulting impairment of
ciliary function reducing excess mucous clearance. The mucous primarily affects the larger
airways but eventually affects all areas. The thickened, uncleared mucous along with the
inflammation of the bronchi affect expiration of CO; thus causing collapse of the airways and air
trapping in the lower portions of the lung. The patient with chronic obstructive bronchitis
typically presents as stocky build, pursed lip breathing, a productive cough, decreased tolerance
of exercise, shortness of breath, wheezing, and prolonged expiration. As the disease progresses,
more profuse amounts of sputum are produced and lung infections become increasingly
common. The client will also present with chronic hypoxemia and hypercapnia. Orthopneic
breathing in the tripod position is characteristic of COB sufferers. The pace they ambulate and
their gait is determined by their breathing. Frequent rest periods are generally required to
breathe. The pathophysiology of emphysema is a destruction of alveolar walls, resulting in
permanent overdistention of the air sacs. Due to the lack of elasticity in the alveolar walls, the
CASE STUDY: BH
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air passages are obstructed. Expiration is impaired due to wall destruction, partial airway
collapse, and loss of elasticity. As these passages collapse, dead space forms in pockets leading
to decreased gas exchange surface area. There is less functional air space for gas exchange
therefore increasing breathing workload. Emphysema also causes destruction of the pulmonary
capillaries making oxygen perfusion and ventilation even more decreased. The client with
emphysema presents with progressive dyspnea on exertion, which over time converts to
generalized dyspnea at rest. The AP diameter of the chest tends to be enlarged. ABG values can
be normal until later stages when compensated respiratory acidosis is seen. Some clients have an
enlarged heart with right ventricular lift. The ECG may show right heart strain and some right
axis deviation. Other manifestations can include cyanosis around the lips, pitting peripheral
edema, or neck vein distention. Scoliosis is the lateral curvature of the spine at any area.
Generally, scoliosis occurs in preadolescents and adolescents, equally in boys and girls. Black
and Hawk (2009) state that “adult scoliosis may be the progression of a childhood condition that
was undiagnosed or untreated when the person was still growing. It can also be caused by
degenerative changes in the spine” (p. 497). Spinal curvature greater than 40-45 degrees can
cause cardiopulmonary problems and pain; however, curvatures of less than 20 degrees do not
require treatment in the skeletally mature client. Schizophrenia is a mental disorder, more
clearly defined as a “psychosis characterized by delusions, hallucinations, apathy, and a ‘split’
between thought and emotion” (Coon & Mitterer, 2011, p S23). Schizophrenic symptoms tend
be related to “selective attention” (p. 557). The client may seem to be overwhelmed by a
cluttering of thoughts, sensations, images, and feelings at once. It appears they have a hard time
focusing on one item of information at time. The causes of schizophrenia are undetermined but
are thought to be one or all of the following: environmental, heredity, and brain chemistry. Signs
CASE STUDY: BH
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and symptoms of schizophrenia include but are not limited to delusions, hallucinations, abnormal
thoughts, blunted or inappropriate emotions, apathy. Schizoaffective disorder with paranoia and
depression is a mental disorder that causes both a loss of contact with reality and mood
problems. Its cause is unknown but thought to be caused by brain chemistry and some experts
do not separate this disorder from schizophrenia. Symptoms can include delusions, disorganized
speech, visual or auditory hallucinations, lack of concern with hygiene, mania or depression,
sleeping problems, hopelessness, social isolation, etc.
Assessment Data
For assessment data, please refer to Table 1.
ALLERGIES: PCN
VITALS: 141/97, 20R, 84P, 97.1˚F, 90%O2 RA at rest.
Pt weighed 85.7kg and height of 71 inches upon admission. A BMI of 26.3. Hx of
smoking 1.5-2ppd for approximately 40 years; pt now states smokes 1ppd. Pt admits
occasionally ETOH. BH stated he came to the hospital after having cold symptoms that lasted
for about one week and progressive shortness of breath for one week. He does not use O 2
therapy at home. Pt ambulated in the hallway on a portable pulse oximeter and after one minute
had a pulse ox reading of 84% on RA. At two minutes, BH stopped to take a break and look at
some hallway art. We continued for one more minute and returned to his room. Pt c/o dyspnea
and the need to rest. His pulse ox reading was 87% on room air. He was visibly short of breath
and audibly wheezing. He was not on oxygen therapy in the room because he was being
evaluated for home O2 therapy. Pt takes numerous medications for his multiple diagnoses refer
to Table 3 for further details. Pt had abnormal laboratory test results on multiple days refer to
CASE STUDY: BH
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Table 2 for further details. Pt underwent a chest radiograph, ECG, and an arterial blood gas. For
results, refer to Table 2-1.
Table 1 Assessment data
Neurological
A&Ox3,
No trouble communicating, speech clear.
No HOH, No visual trouble. PERRLA 3mm brisk.
Emotions
Affect appropriate, wanting to go home and not stay in hospital.
Integument
Warm, Dry, Pink, intact. Clubbing present on fingertips. Mucus membranes
moist.
IV 20G R forearm heplock, without redness/swelling.
RRR, Cap Refill <3sec, no edema present, pedal and radial pulses palpable
strong +2/+2
Cardiovascular
Respiratory
Bladder
Dyspnea, audible wheezing. Lung sounds diminished and wheezes bilaterally
anteriorly and posterior More diminished in lower lobes. O2 sats continuous
pulse ox ranging 87-90% RA at rest.
Productive cough with sputum.
Continent, voiding without difficulty
Bowel
Abdomen distended and round, Bowel sounds active in all 4 quadrants, passing
flatulence, last BM 9/23, no c/o abdominal pressure, appetite good.
Musculoskeletal
MAE AROM, gait steady, hand grasps strong and equal bilaterally. Foot
push/pull strong and equal bilaterally. Denies any pain in legs. Activity is up
as tolerates.
Regular diet, no restrictions.
Diet
CASE STUDY: BH
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Lab Values/Diagnostic Tests
For laboratory values, please refer to Table 2. For diagnostic test results, please
refer to Table 2-1.
Table 2 Lab Values and Results
Tests
Patient’s
low/high
Range
9/23
9/24
RBC
5.40
5.11
4.6-6.0
Hgb
17.9
16.6
13.518g/dL
Hct
51.5
49.2
40-54%
Platelets
157
159
150-400
WBC
6.4
6.5
4.5-10
Neutrophils
(Segs)
5.8
6.0
2.5-7.0
Blood Serum
Glucose
106
144
FBS 70110
Abnormal
Results
CBC
WBC
Normal
Range
Reason
CHEM
This could be due to what and when the pt ate
and when the BS was drawn.
PPBS
<140
BUN
7
9
5-25
Creatinine
0.641
0.636
0.51.5mg/dL
BUN/Creat
Ratio
11
14
Avg 15:1
Calcium
8.7
8.4
ABG Hgb
--
911mg/dL
Heparin use decreases Calcium serum levels
18.6
13.5-18
This is slightly elevated. COPD can cause an
elevated level; as well as
dehydration/hemoconcentration
pH
7.41
7.35-745
pCO2
41.4
35-45
pO2
60
75-100
ABG
Pt is COPD sufferer and has impaired gas
exchange. In addition, pt is not oxygenating
CASE STUDY: BH
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effectively due to acute exacerbation of disease
process.
BiCarb
25.4
24-28
Base Excess
0.7
-2 to +2
NC O2 Sat
ABG
86.2
>92%
Pt is suffering from acute exacerbation of
COPD.
Note: Normal ranges were obtained Prentice Hall Handbook of Laboratory and Diagnostic Tests
with Nursing Implications, 6th edition, LeFever Kee, J. 2009, Prentice Hall.
Table 2-1 Diagnostic Test Results
PROCEDURE
RESULT
Portable Chest X-Ray (9/23)
PE is identified. Note is made that inferior
most aspect of right costophrenic angle has
been omitted from field of view.
No acute C.P. process
Streptococcus pneumonia
Gram (pos)
Gram (neg)
Moderate WBCs
Normal sinus
Septal infarct
Inferior infarct
Abnormal ECG
T-wave inversion now evident on inferior leads
Sputum Culture (9/23)
ECG
Medication Information
Medications
Albuterol MDI
Pt Dosage
Dose, route
Classification
2 puffs q4h/q2h
PRN INH
Preg (C)
INH 2 puffs q15min
before exercising or
2 puffs q4h or PRN
ROUTE: MDI INH
Bronchodilator,
adrenergic β2agonist,sympathomi
meometic
Mechanism of Action
Causes bronchodilation
by action on B2 receptors
by increasing levels of
cAMP, which relaxes
smooth muscle; produces
bronchodilation, CNS,
cardiac stimulation, as
well as increased dieresis
and gastric acid secretion;
longer acting than
isoproterenol
Indications for use
Patient Reason for
Use
Prevention of
exercise-induced
asthma, acute
bronchospasm,
bronchitis,
emphysema,
Bronchiectasis, or
other reversible
airway obstruction
Pt has COPD
Possible side effects
Tremors, anxiety
insomnia, HA,
palpitations,
tachycardia, angina,
hypo/hypertension, dry
nose, heartburn, N&V,
cough, wheezing,
dyspnea, flushing,
sweating
CASE STUDY: BH
ipratropium bromide
INH
0.5mg q4h/q2h
PRN, (INH)
ROUTE: INH, SOL,
NEB, Intranasal
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Inhibits interaction of
acetylcholine at receptor
sites on the bronchial
smooth muscle, resulting
in decreased cGMP and
bronchodilation
COPD, rhinorrhea
in children 6-11yr
(nasal spray)
Fluticasone: decreases
inflammation by
inhibiting mast cells,
macrophages, and
leukotrienes; antiinflammatory, and
vasoconstrictor properties
Salmeterol: Causes
bronchodilation by action
on B2 receptors by
increasing levels of
cAMP, which relaxes
smooth muscle with very
little effect on HR,
maintains improvement
in FEV from 3-12hr;
prevents nocturnal
asthma symptoms
Corticosteroid,
bronchodilator
Inhibits synthesis of
prostaglandins in body
tissues by inhibiting at
least 2 cyclooxygenase
isoenzymes-(COX-1),
(COX-2); may inhibit
chemotaxis, may alter
lymphocyte activity,
decrease proinflammatory
cytokine activity, and
may inhibit neutrophil
aggregation. These
effects may contribute to
its anti-inflammatory
activity
Pain, fever,
inflammatory
disease,
dysmenorrhea,
osteoarthritis, RA,
vascular headache,
cystic fibrosis
acts by inhibiting the
action of serotonin (5HT); has shown little
potential for abuse, a
Mgmt and short
term relief of
generalized anxiety
disorders
Pt has COPD
anticholinergic,
bronchodilator,
synthetic
quaternarary
ammonium
compound
Advair 250/50
(fluticasone 250mcg;
salmeterol 50 mcg)
Preg (C)
1 puff BID
Treatment of asthma
in patients ≥12 years:
1 inhalation of
ADVAIR DISKUS
twice daily
ROUTE: INH
Corticosteroid,
bronchodilator
Ibuprofen
400mg PO BID with
meals
Normal dosage: 300800mg PO q6h for
pain; 100-200mg PO
q4-6h PRN; not to
exceed 3200mg/day
ROUTE: PO
NSAIDs
Buspar (busPIRone)
15mg BID
PO 5mg tid; may
increase by 5my/day
Pt has COPD
CNS: Anxiety,
dizziness, HA,
nervousness
CV: Palpitation
EENT: Dry mouth,
blurred vision
GI: N&V, cramps
INTEG: rash
RESP: cough,
worsening of symptoms,
bronchospasms**
Candida albicans
infection, pneumonia,
immunosuppression,
hypercorticism, adrenal
suppression, growth
effects, glaucoma,
cataracts
NSAIDs increase risk of
CV thrombotic events,
MI and stroke; stomach
irritation
Pt has COPD,
inflammatory
response and
occasional pain
CNS: Dizziness,
headache, depression,
stimulation, insomnia,
nervousness, light-
CASE STUDY: BH
q2-3 days, max
60mg/day
ROUTE: PO
9
good choice in substance
abuse
Pt has dx of
schizoaffective d/o
with paranoia and
depression
Antianxiety, sedative
Azaspirodecanedione
heparin
5000units SC q8h
Prophylaxis
DVT/PE: Adults SC
5000units q8-12h
ROUTE: SC
Anticoagulant,
antithrombotic
UNLABELED
USES:
Autism
Prevents conversion of
fibrinogen to fibrin and
prothrombin to thrombin
by enhancing inhibitory
effects of antithrombin III
Prevention of DVT,
PE, MI, open heart
surgery,
disseminated
intravascular
clotting syndrome,
a-fib with
embolizations, as an
anticoagulant in
transfusion and
dialysis procedures,
prevention of
DVT/PE, to
maintain patency of
indwelling
venipuncture
devices; dx and tx
of DIC
Pt is majority
bedridden due to
condition, DVT/PE
prophylaxis
headedness, numbness,
paresthesia,
incoordination,
nightmares, tremors,
excitements, involuntary
movements, confusion,
akathesia, hostility
CV: Tachycardia,
palpitations,
hypo/hypertension
EENT: Sore throat,
tinnitus, blurred vision,
nasal congestion; red,
itching eyes, change in
taste, smell
GI: Nausea, dry mouth,
diarrhea, constipation,
flatulence, increased
appetite, rectal bleeding
GU: Frequency,
hesitancy, menstrual
irregularity, change in
libido
INTEG: Rash, edema,
pruritus, alopecia, dry
skin
MISC: Sweating,
fatigue, weight gain,
fever
MS: Pain, weakness,
muscle cramps, spasms
RESP:
Hyperventilation, chest
congestion, SOB
Fever, chills, HA,
hematuria**,
hemorrhage**,
thrombocytopenia**,
anemia**, rash,
dermatitis, urticaria,
pruritus, delayed
transient alopecia,
cutaneous necrosis
(SC), anaphylaxis**
CASE STUDY: BH
Levaquin
(levofloxacin)
10
500mg PO q daily
AC
Adult: 500mg q24h x
7 days (acute
bacterial
exacerbation of
chronic bronchitis)
Interferes with
conversion of
intermediate DNA
fragments into highmolecular weight DNA in
bacteria; DNA gyrase
inhibitor; inhibits
topoisomerase IV
ROUTE: PO/IV
Anti-infective,
fluoroquinolone
Acute sinusitis,
acute chronic
bronchitis,
communityacquired
pneumonia,
uncomplicated skin
infections,
complicated UTI,
cellulitis, PID,
prostatitis, postexposure inh
anthrax, acute
pyelonephritis
caused by Strep
pneumoniae, H.
influenzae, H.
parainfluenzae, M.
catarrhalis, E. coli,
S. marcescens, K.
pneumoniae, C.
pneumoniae, L.
pneumophilia, M.
pneumoniae, E.
faecalis, S.
epidermidis, S.
pyogenes
HA, dizziness,
insomnia, anxiety,
seizures**,
encephalopathy,
paresthesia, chest pain,
palpitations,
vasodilation, QT
prolongation, dry
mouth, visual
impairment, N&V,
flatulence, diarrhea,
abdominal pain,
pseudomembranous
colitis**,
hepatotoxicity**,
eosinophilia, rash,
pruritus, pneumonitis,
tendonitis
Pt has positive
sputum culture for
Strep pneumoniae,
gram + and gram –
flora.
Nicoderm TD
(nicotine patch)
21mg TD qdaily
21mg/day x 4-8 wk;
14mg/day x 2-4 wk;
7mg/day x 2-4wk
ROUTE:
Transdermal patch
Haldol (haloperidol)
5mg PO BID
Adult 0.5-5mg bid or
tid initially
depending on
severity of condition;
dose increased to
desired dose, max
100mg/day
Agonist at nicotinic
receptors in peripheral,
CNS systems; acts at
sympathetic ganglia, on
chemoreceptors of aorta
carotid bodies; also
affects
adrenalin=releasing
catecholamines
Deter cigarette
smoking
Depresses cerebral
cortex, hypothalamus,
limbic system, which
control activity and
aggression; blocks
neurotransmission
produced by dopamine at
synapse; exhibits strong
α-adrenergic,
anticholinergic blocking
action; mechanism for
antipsychotic effects
Psychotic disorders,
control of tics,
vocal utterances in
Tourettes, ST tx of
hyperactive children
showing excessive
motor activity,
prolonged
parenteral tx in
chronic
schizophrenia,
organic mental
Pt a smoker with
COPD
Dizziness, vertigo,
insomnia, HA,
confusion, seizures,
depression, euphoria,
numbness, tinnitus,
strange dreams,
dysrhythmias,
tachycardia,
palpitations, edema,
flushing, HTN, jaw
ache, N&V, indigestion,
diarrhea, abdominal
pain
EPS,
seizures***neuroleptic
malignant syndrome**,
confusion, orthostatic
hypertension, HTN
cardiac arrest**, ECG
changes, tachycardia**,
QT prolongation**,
sudden death**, blurred
vision, glaucoma, dry
eyes, dry mouth N&V,
diarrhea, constipation,
CASE STUDY: BH
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unclear
syndrome with
psychotic features,
hiccups (ST),
emergency sedation
of severely agitated
or delirious pt.
ileus**, hepatitis**,
rash, urinary retention,
gynecomastia,
impotence, dyspnea,
respiratory depression**
risk for death
(dementia)**
Pt has dx of
schizophrenia,
schizoaffective d/o
with paranoia and
depression
mirtazapine
(Remeron)
60mg hs
PO 15mgday hs,
maintenance to
continue for 6mo
titrate up to
45mg/day
ROUTE: PO
Blocks reuptake of
norepinephrine, serotonin
into nerve endings,
increasing action of
norepinephrine, serotonin
in nerve cells, antagonist
of central α2-receptors,
blocks histamine
receptors
Depression,
dysthymic d/o,
bipolar disorderdepressed, agitated
depression
Increases the amounts of
serotonin and
norepinephrine, natural
substances in the brain
that help maintain mental
balance.
Treats depression.
Blockade of central
acetylcholine receptors
Parkinson’s
symptoms, EPS
associated with
neuroleptic
products, acute
dystonic reactions,
hypersalivation
Antidepressant,
tetracyclic
Pristiq
(desvenlafaxine
succx)
100mg PO qdaily
ROUTE: PO
Antidepressant,
SNRI
benztropine mesylate
1mg PO BID
Adult: 1-2mg/day tid
Cholinergic blocker,
antiparkinson’s
agent, tertiary amine
Pt has dx of
schizophrenia,
schizoaffective d/o
with paranoia and
depression
Pt has dx of
schizophrenia,
schizoaffective d/o
with paranoia and
depression
Unsure of why pt
takes this. Possibly
Dizziness, drowsiness,
confusion, HA, anxiety,
tremors, stimulation,
weakness, nightmares,
EPS, increased
psychiatric symptoms,
seizures**, orthostatic
hypotension, ECG
changes, tachycardia,
HTN**, palpitations,
blurred vision, tinnitus,
mydriasis, diarrhea, dry
mouth, N&V, paralytic
ileus**, urinary
retention, acute renal
failure, rash, urticaria,
sweating, pruritus.
Constipation, loss of
appetite, dry mouth,
dizziness, extreme
tiredness, unusual
dreams, yawning,
sweating, uncontrollable
shaking of a part of the
body, pain, burning,
numbness, or tingling in
part of the body,
enlarged pupils (black
circles in the centers of
the eyes), blurred
vision, changes in
sexual desire or ability,
difficulty urinating
Anxiety, restlessness,
irritability, delusions,
hallucinations, HA,
sedation, depression,
incoherence, confusion,
palpitations,
tachycardia,
hypotension,
Bradycardia, blurred
vision, photophobia,
CASE STUDY: BH
prednisone
12
60mg PO with meals
5-60mg/day or
divided bid or qid
ROUTE: PO
Corticosteroid,
intermediate-acting
glucocorticoid
100mg TID
Tessalon
perles(benzonatate)
due to other
medications
producing EPS side
effects.
dilated pupils, difficulty
swallowing, dry eyes,
N&V, rash urticaria,
increased temperature,
flushing, numbness of
fingers, muscular
weakness, cramping
Decreases inflammation
by suppression of
migration of
polymorphonuclear
leukocytes, fibroblasts,
reversal to increase
capillary permeability,
and lysomal stabilization,
minimal
mineralocorticoid activity
Severe
inflammation,
immunosuppression
, neoplasms, MS,
collagen disorders,
dermatologic
disorders.
Depression, flushing,
sweating, HA, mood
changes, HTN,
circulatory collapse**,
embolism**,
tachycardia**, fungal
infections, increased
IOP, blurred vision,
nausea, abdominal
distention, acne, poor
wound healing,
hyperglycemia
Not listed in resource.
Non-productive
cough.
100mg up to TID,
max 600mg/day
Pt suffering from
acute exacerbation
of COPD, antiinflammatory
response required.
N/A
Pt has cough result
from infection and
COPD
ROUTE: PO
Antitussive, nonopioid
Humalog(lispro)
sliding scale SC qid
ROUTE: SC
Rapid acting insulin
Antidiabetic,
pancreatic hormone
Modified structures
of endogenous
human insulin
Decreases blood glucose;
by transport of glucose
into cells and the
conversion of glucose to
glycogen, indirectly
increases blood pyruvate
and lactate, decreases
phosphate and potassium
Analysis Planning Intervention Documentation
Nursing Care Plan
Type 1 DM, Type 2
DM, gestational
diabetes, insulin
lispro may be used
in combo with
sulfonlyureas in
children >3y
Pt has had repeat
elevated blood
glucose levels.
EENT: blurred vision,
dry mouth
INTEG: flushing, rash,
urticaria, warmth,
lipodystrophy,
lipohypertrophy,
swelling, redness
META: hypoglycemia,
rebound hyperglycemia
MISC: peripheral edema
CASE STUDY: BH
13
Nursing Diagnosis #1: Activity intolerance related to inadequate oxygenation AEB dyspnea,
oxygen saturation <90% at rest on RA and as low as 84% RA during ambulation.
Short-Term Goal: BH will demonstrate energy conservation techniques to improve activity
tolerance during ambulation q 4 hours.
Long-Term Goal: Pt will demonstrate improved activity tolerance by maintaining a realistic
activity level as evidenced by less complaint of dyspnea on exertion by the monthly follow up
appointment.
Interventions:
1. Monitor severity of dyspnea and O2 sats with and following activity
a. Rationale: activity increases the demand for oxygen, and the inability to meet
the demand may result in dyspnea and desaturation. (Black, J.M., & Hawk ,
J.H., 2009).
2. Stop or slow any activity that leads to significant change in respiratory rate, failure of
pulse to return to near resting rate within 3 minutes of activity, and/or changes in
mental status.
a. Rationale: significant changes in respiratory, cardiac, or circulatory status
signal activity intolerance (Sandland, Morgan, & Singh, 2008).
3. Maintain supplemental oxygen therapy as needed during activity.
a. Rationale: supplemental oxygen helps alleviate exercise-induced hypoxemia,
thus improving activity tolerance (Sandland, Morgan, & Singh, 2008).
4. Schedule activity after respiratory treatment.
CASE STUDY: BH
14
a. Rationale: Lung function is maximized during peak periods of medication and
drug effect (Black, J.M., & Hawk , J.H., 2009).
5. Assist the client in scheduling a gradual increase in daily activities and exercise.
a. Rationale: gradual increases in physical activity improve respiratory and
cardiac conditioning, improving activity tolerance (Black, J.M., & Hawk ,
J.H., 2009).
6. Advise client to avoid conditions that increases oxygen demand, like smoking,
temperature extremes, excess weight, and stress.
a. Rationale: These factors increase peripheral vascular resistance, which
increases cardiac workload and oxygen requirements (Black, J.M., & Hawk ,
J.H., 2009).
7. Instruct the client on energy conservation techniques, like pacing activities
throughout the day, interspersed with adequate rest periods, and alternating high
energy and low energy tasks.
a. Rationale: Conservation techniques allow the client to accomplish more tasks
with a limited energy supply (Black, J.M., & Hawk , J.H., 2009).
8. Teach the client to use pursed-lip and diaphragmatic breathing techniques during
activities.
a. Rationale: Breathing retraining ensures maximal use of available respiratory
function. Purse lip breathing leaves PEEP in the lungs and helps keep airways
open (Black, J.M., & Hawk , J.H., 2009).
Evaluation: Pt ambulated in the hallway for 2 minutes; he rested after 1 minute of ambulation
due to increased dyspnea. He continued for 1 minute more of ambulation, then returned to his
CASE STUDY: BH
15
room to rest. STG was met. LTG not met, will take longer in meeting this goal. Home O 2
therapy recommended due to amount of dyspnea and desaturation upon exertion.
Nursing Diagnosis #2: Impaired gas exchange r/t decreased ventilation AEB wheezing,
diminished lung sounds, O2 sats >90% RA at rest.
Short-Term Goal: Pt will maintain adequate gas exchange as evidenced by ABG (pH within
normal limits, PaO2 equal to or greater than 60mmHg) in 24 hours.
Long-Term Goal: Pt will maintain his pulse ox at >92% at rest on room air.
Interventions:
1. Regularly monitor client’s RR, pattern, pulse ox, ABG results, and manifestations of
hypoxia or hypercapnia. Report any significant changes or a lack of response promptly
a. Rationale: Prompt recognition of deteriorating respiratory function can reduce
potentially lethal outcomes (Black, J.M., & Hawk , J.H., 2009).
2. Administer low flow O2 (1-3L/min on 24%-31%FiO2) s needed via NC or high-flow
Venturi mask.
a. Rationale: oxygen corrects existing hypoxemia (Black, J.M., & Hawk , J.H.,
2009).
3. Assist the client into the high Fowler position.
a. Rationale: The upright position allows full lung excursion and enhances air
exchange (Black, J.M., & Hawk , J.H., 2009).
4. Administer bronchodilators, if ordered. Monitor for side effects.
CASE STUDY: BH
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a. Rationale: Bronchodilators relax bronchial smooth muscle facilitating airflow.
Common side effects include tremor, tachycardia, and other cardiac dysrhythmias.
(Black, J.M., & Hawk , J.H., 2009).
5. Use caution when administering opioids, sedatives, and tranquilizers.
a. Rationale: These medications are respiratory depressants and can further impair
ventilation (Black, J.M., & Hawk , J.H., 2009).
Evaluation: Pt’s ABG values met the criteria, his PaO2 was 60mmHg and his ABG pH was 7.41.
These should be redrawn and analyzed again. However, his LTG was not met; his O2 sats on
room air at rest were never greater than 90%.
Evidence-Based Practice/Nursing Research Article
Please refer to attached article.
CASE STUDY: BH
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References
Black, J.M., & Hawk , J.H. (2009). Medical-Surgical Nursing: Clinical Management for Positive
Outcomes (8th ed.). St. Louis: Saunders Elsevier.
Coon, D., & Mitterer, J. O. (2011). Psychology. Mason: Cengage Learning.
LeFever Kee, J. (2009). Prentice hall handbook of laboratory and diagnostic tests with nursing
implications (6 ed.). upper saddle river: Pearson Prentice Hall.
Roth-Skidmore, L. (2011). Mosby's nursing drug reference (24 ed.). St. Louis: Elsevier Mosby.
Sandland, C. J., Morgan, M. D., & Singh, S. J. (2008). Patterns of domestic activity and
ambulatory oxygen usage in COPD. CHEST , 134 (4), 753-760.
Wilkinson, J. M., & Ahern, N. R. (2009). Prentice Hall nursing diagnosis handbook (9 ed.).
New Jersey: Pearson Prentice Hall.
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