Question

The Client:  #35467

GH is an 82 year old male widow with three grown children.  One daughter lives nearby, the other two live in different provinces. Mr. H is Japanese and has only lived in Canada for the past two years.  He is financially stable and has a close relationship with his children. This is his first experience with the Canadian health care system.

The Diagnosis

The client’s admitting diagnosis is: exacerbation of COPD (chronic obstructive pulmonary disease), CAD (coronary artery disease), diabetes and possible small bowel obstruction.

History:

Mr. H has been diabetic for 15 years and has been reasonably well managed with diet and Insulin although meeting his dietary needs has been a challenge since arriving in Canada.  He has had COPD for the past 5 years and CAD for 10 years.  He smokes 1 package of cigarettes per day and has done so for the past 65 years.  He has had frequent problems with constipation over the last 2 years and has been treated with suppositories and Fleet Enema’s PRN.  He has significant vision loss due to diabetic retinopathy.  He has never had surgery before and is quite concerned about this possibility.  He speaks English very poorly and cannot read English at all.  His daughter acts as his translator on a regular basis but does not have Power of Attorney for personal care.

Admission Findings:

When he arrives from the emergency department you find a frail, elderly man who is short of breath and repeatedly pointing to his abdomen and grimacing. He walks with a pronounced limp on the left side. He appears anxious and is unable to answer most of your questions due to the language barrier.  He appears to be in considerable physical and emotional distress. His vital signs are:  T – 38.6  P – 102  BP – 186/98 R – 24   O2 sat 88 on room air.  He is well groomed but appears reluctant to allow you to remove his clothing so that you can get him settled in bed.  He keeps pointing to the phone but can’t explain what he wants you to do. He attempts to light a cigarette and doesn’t seem to understand that he can’t smoke in hospital.  When you remove his shoes you find that his great left toe appears gangrenous and his nails are badly ingrown on both feet.  

Doctor’s Orders:

Bed rest with bathroom privileges – A1                            Deep breathing and coughing exercises q4h

Foot care nurse to see                                                  Abdominal ultrasound today                                                       

Stool for Culture and sensitivity                                    Fleet enema PRN                                  

NPO                                                                             Dietician to see

Vital signs q4h                                                              Abdominal x-ray today

Diabetic Clinic nurse to see                                              Intake and output q8h              

Oxygen at 2L/min via NP PRN                                       Contact Translation Services to see asap

Bedside glucometer ac and hs                                       1500 calorie diabetic diet

Care Plan

                    

Student Name ________________________                                                                                                                 Date_____________________________

Nursing Diagnosis	Assessment data that supports the nursing diagnosis	Plan/Goal(s)	Interventions
1. _________________________ 2.	___________________________________________	_________________________	________________________________

Answer 1

1. Ineffective gas exchange related to bronchospasm as evidenced by emotional distress and saturation level of 88 %.

Assessment

On admission, the patient has shortness of breath and are in emotional distress, oxygen saturation was 88 %.

Plan

• respiratory distress of the patient will improve.
• the patient will take part in the treatment regimen.

Interventions

• Assess respiratory rate and use of accessory muscles or pursed-lip breathing or any difficulty to talk due to breathing difficulty.- provides a baseline data
• make the patient in a semi-fowlers position and encourage pursed lip breathing- upright position encourages lung expansion and breathing exercises like pursed-lip breathing reduce the chance to alveolar collapse and laboured breathing.
• assess skin colour and auscultate for breath sounds- cyanosis indicates hypoxemia and type of breath sounds indicates an actual problem (wheezing- bronchospasm, crackles- interstitial fluid)
• provide health education about the lifestyle changes - to increase coping with treatment.

2. Acute pain related to bowel obstruction as evidenced by grimacing while pointing towards the abdomen.

assessment

patient has the blood pressure of 186/98, frequently pointing towards the abdomen and grimacing.

goals

the patient will verbalise decrease of pain as evidenced by decrease in blood pressure to a normal range.

interventions

• assess pain using the pain scale, location, duration and frequency - to know baseline data.
• encourage short, relaxation exercise - to redirect the concentration from pain
• Provide emotional support and a soothing environment by playing music if interested- to distract patient attention.
• administer pain medication as per doctors order.