Medical diagnosis: EXPLAIN PATHOPHYSIOLOGY AND INCLUDE STRUCTURAL FUNCTIONAL CHANGES THAT THE DISEASE CAUSES:

Pneumonia- Infection in the lungs. Usually due to bacteria, viruses, or other pathogenic organisms. Most patients with pneumonia have cough, SOB, and fever, although these symptoms are not universal. Diagnosed by chest x-ray, sputum, pulse ox, ABG’s, CBC, blood cultures. Prevention is the Pneumococcal vaccine.

Resp. Failure- One or both gas exchange functions are inadequate. (interferes with O2 transfer into the blood. Monitor ABG’s and pulse Ox. Dyspnea- Shortness of breath

Explain significance of operative procedure, lab data, and/or special diagnostic test or procedures:

2/15 Chest: Portable view of the chest shows persistent bilateral pulmonary infiltrates with no significant change from 2/7. No obvious new infiltrates are seen.

2/21 Portable chest: Limited funal (frontal?) view due to significant pt’s rotation. The visualized lung fields are clear. Tracheostomy tube is in good position.

1/29/2005 : Pre-op diagnosis:dysphagia for peg placement, 24 french mic GT tube placement. Essentially formal (normal) upper endoscopy.

Operation:esophogastoduodenoscopy with percutaneous endoscopic gastrostomy tube placement.

WBC: 8.4 N, RBC: 2.97 L, HGB: 9.0 L, HCT: 26.1 L

Instructor’s comments: Stephanie, You did a WONDERFUL job with this NCP. Your nursing dx is accurately stated for the pt, SCA/SCD’s are relevant and come from assessment. Goal reflects successful resolution/teaching of problem, interventions treat the problem, rationales are scientific and reflect reason for implementing the intervention, evaluation reflects your ability to implement the int as well as the pt response. Very nicely done!! Sca/scd’s=4, dx=4, goal=4, ints=4, rationales=4, evals=4, total=4=1JJ%!! CP

ASSESSMENT

Universal Self

Care Requisites: Water

NURSING DIAGNOSIS

Problem, Etiology, Symptoms

GOALS

PLANNING

INTERVENTIONS

SCIENTIFIC RATIONALES

EVALUATION

Self Care Agency (SCA):

No edema, skin warm and dry,

WBC 8.4 N, ABG PH 7.411, RR 16bpm, tracheostomy in place, ventilator A/C 15, PEEP 5, TV 450, O2 40%, ½ NS @ 20cc/hr, pulmocare feeding (GT) @ 30cc/hr. ½ NS IV infusing @20cc/hr, HOB semifowler’s position. Peripheral pulses present with Doppler.

The SCA/SCD’ in regard to the tube feeding do not really relate to ineffective tissue perfusion. (see rationale #9)

Should include BP and Pulse

Self Care Deficit (SCD)

SCD’s:

Not oriented, confused, bed rest, GT, NPO, pale conjunctiva, poor skin turgor,

Decreased ROM, abnormal chest X-ray (pulmonary infiltrates), HGB 9.0 L, HCT 26.1 L, ABG results PO2 74.0 L, PCO2 51.2 H, language barrier, pt removes ventilator, non productive cough.

Nursing agency:

Wholly compensatory

Partially compensatory

Supportive-educative

P: Risk for ineffective tissue perfusion. (arterial, venous, and peripheral)

E: Related to impaired transport of oxygen across alveolar and or capillary membrane, exchange problems; interruption of venous flow; mechanical reduction of venous and arterial blood flow, decreased hemoglobin in the blood

GOOD DIAGNOSIS

While in the hospital Pt will demonstrate adequate tissue perfusion as evidenced by palpable peripheral pulses, warm and dry skin, adequate urinary output, and absence of respiratory distress. Improved lab values (hgb and hct)

YOUR INTERVENTIONS ARE COMPREHENSIVE, EVEN BETTER, ALL YOUR RATIONALES PROVIDE THE REASON FOR HOW THE INTS TREAT INEFFECTIVE TISSUE PERFUSION-VERY IMPRESSIVE!!

AND

YOUR INTS ADDRESS BOTH VENOUS AND ARTERIAL OBSTRUCTION! NICE

Monitor peripheral pulses. If there is new onset of loss of pulses with bluish, purple or black areas and extreme pain, notify the physician immediately.QS

Do not elevate the legs above the level of the heart.

Keep the client warm and have the client wear socks and shoes or slippers while mobile. Do not apply heat.

Pay meticulous attention to foot care. Refer to a podiatrist if the client has a foot or nail abnormality.

Note skin color and feel the temperature of the skin. .QS

Check capillary refill.

Note skin texture and the presence of hair, ulcers, or gangrenous areas on the legs or feet.

Assess for pain in the extremities, noting severity, quality, timing and exacerbating and alleviating factors. Differentiate venous from arterial disease.

Assess client’s nutritional status, paying close attention to obesity, hyperlipidimia, and malnutrition. Refer to a dietician if appropriate.

Observe for signs of DVT, including pain, tenderness, or swelling in the calf and thigh, and redness in the involved extremity.

Measure urine output hourly.

12. Perform toe-up and point-flex exercises.

(Ackley Nursing Diagnosis Handbook, pg 990-995)

These are symptoms of arterial obstruction that can result in loss of a limb if not immediately reversed.

With arterial insufficiency, leg elevation decreases arterial blood supply to the legs.

Keep extremities warm to maintain vasodilation and blood supply. Heat application can easily damage ischemic tissue.

Ischemic feet are very vulnerable to injury; meticulous foot care prevents further injury.

Skin pallor or mottling, cool or cold skin temperature, or an absent pulse can signal arterial obstruction, which is an emergency that requires immediate intervention. Rubar indicates dilated or damaged vessels. Brownish discoloration of the skin indicates chronic venous insufficiency.

Nailbeds usually return to a pinkish color within 2-3 seconds after nailbed compression.

Thin, shiny, dry skin with hair loss; brittle nails, and gangrene or ulcerations on toes and anterior surfaces of the feet are seen the clients with arterial insufficiency.

In clients with venous insuff. The pain lesions with elevation of the lefs and exercise. In clients with arterial insuff. The pain increases with elevation of the legs and exercise. Some clients have both arterial and venous insuff. Arterial is associated with pain when walking that is relieved by rest. Clients with severe arterial disease have foot pain while at rest.

Malnutrition contributes to anemia, which further compounds the lack of oxygenation to tissues. GOOD, now that you have given me a rationale that supports monitoring nutrition as it relates to tissue perfusion, your tube feeding SCA/SCD’s are acceptable!

Thrombosis with clot formation usually first detected as swelling of the involved leg and then as pain. Leg measurement discrepancies of more than 2 cm warrant further investigation.

An output below 30ml/hr may indicate deficient fluid vol., which can result decreased oxygen delivery and organ system failure.

Exercise helps to increase venous return, build up collateral circulation, and strengthen the calf muscle pumps.

Pedal pulses checked and present with use of Doppler. Pulses decreased and weak.

Pt’s bed was positioned: HOB semi fowlers position. FOB (foot of bed not elevated)

Pt wearing socks. New pair applied with AM care.

Pt’s feet were checked. No foot or nail abnormality noted.

Pt’s skin warm and dry to the touch and intact no cyanosis.

Pt’s capillary refill was checked and was WNL (between 2-3seconds). (SCA)

Pt’s skin texture was dry and smooth with no ulcers or gangrenous areas on legs or feet.

Not able to assess.

9. Pt receiving pulmocare feeding (GT) @ 30cc/hr.

No pain, tenderness, redness, or swelling noted on lower extremities.

Pt has foley cath. Within a 4-hour time period foley had collected approximately 50 ml of dark amber urine (SCD). RN aware.

Pt unable to follow request to perform exercises. (not implemented)