Question

A patient in respiratory distress is admitted to the Intensive care Unit with Pneumococcal Pneumonia. The nurse receives the following report:

S Patient admitted to ICU 2 hours ago with pneumococcal pneumonia

B History of Chronic Obstructive Lung Disease Lung Cancer Diabetes Type II

A Temperature 38.7 Heart rate of 80 beats per minute Respiratory rate of 40 breaths per minute Blood Pressure 80/40 White blood cell count (WBC) of 15,000 cells/mm3 Oxygen saturation 78%. PaCO2 of 60 mmHG Blood Glucose 800 mg/dL Na of 120 millimoles per liter UOP less than 30 cc per hour

R Blood cultures, Sputum culture and Urine Culture The patient is intubated and placed on Mechanical Ventilation. Ventilator Settings: Assist Control Tidal Volume: 450 cc Rate: 14 PEEP: 5 cmH2O O2: 100% Questions: 1. Identify 3 Nursing Diagnoses. Describe the best practices that the nurse will incorporate into the collaborative plan of care for each of the Nursing Diagnoses. ( 6) 2. Identify and describe the outcomes for each of the Nursing Diagnoses. (3) 3. Identify and describe the risks for this patient including decompensation. (3)

Answer 1

1.Nursing diagnosis and the best practices are

• Impaired gas exchange related to infection as evidenced by tachypnea,hypoxia,increased PaCo2 level secondary to COPD
  • Administer oxygen to increase the oxygen level
  • Mechanical ventilation to support breathing
  • Monitor vital signs, to know the status and progress of the patient's condition
  • Administer antibiotics as per order to treat infection
  • Administer corticosteroids to reduce inflammation, bronchodilators to dilates bronchial walls.
  • Monitor GCS to assess patient's level of consciousness due to hypercapnia
• Decreased cardiac output related to decreased oxygenation as evidenced by decreased oxygen saturation, confusion,hypotension
  • Administer intravenous fluid to raise the blood pressure
  • Monitor vital signs ,to get baseline data and plan for care
  • Elevate the lower limbs to improve circulation
  • Use of compression stocking
  • Administer vasopressor as per order to improve vasoconstriction and increase the blood pressure
  • Monitor intake and output to prevent fluid overload or under load  
  • Correct hyponatremia with NaCl to relieve confusion
• Impaired blood glucose level related to metabolic changes as evidenced by increased blood sugar level
  • Monitor blood glucose level every hourly until normal or as per order
  • Administer insulin therapy to reduce the blood sugar level
  • Watch the patient for any signs of ketoacidosis and treat accordingly because this is possible in very high sugar levels
  • Monitor patient's level of consciousness due to high level of glucose in the body

The risk for involved for the patient are

• Infection (ventilator associated pneumonia) ,due to weak immunity
• Sepsis due to acid base changes
• Cardiac failure due to impaired cardiac function,renal failure as the UOP is less than 30 ml /hr,respiratory failure dur to hypercapnea, hypoxia
• Coma
• Sepsis
• Death