CRITICAL THINKING SUMMARY

Student Amanda Mathy Client Dx Altered Mental Status & Visual Changes Age 58 Allergies Ativan, codeine, penicillin, Vicodin,
morphine, shellfish
The MEDICAL DIAGNOSIS that brought the client to the hospital is:
Acute on Chronic Hypercapnic Respiratory Failure
PATHOPHYSIOLOGY of diagnosed disease: (From text)
-Respiratory failure syndrome in which the respiratory system falls in one or both of its gas exchange functions: oxygenation
and carbon dioxide elimination.
-Hypercapnic respiratory failure (type 2) is characterized by a PaCO2 higher than 50 mmHg; hypoxemia is common

SYMPTOMS typically seen with this diagnosis include (as identified in your text):
Headache, confusion, lethargy, flushed skin, hand flaps, shortness of breath, rapid breathing, high blood pressure, panic, convulsions,
muscle twitching, disorientation, hypertension
CLIENTS SYMPTOMS of the diagnosed disease include:
Headache, lethargy, shortness of breath, panic/anxiety, disorientation, confusion, high blood pressure
NUTRITIONAL ASSESSMENT:
Height (actual or estimated) 158 cm, 62.2 in Weight (actual or estimated) 45 kg, 99 lbs
Estimate Ideal Body Weight ( Male: 105lb + 6 lb/inch > 5. Female: 100lb + 5lb/inch > 5) 110 lbs
Does this client have characteristics of a well-nourished person? Yes _____ No x
Patients albumin level is low (3.2) and total protein level is 6.0 (normal) meaning there is not enough protein being taken in or there
is a loss of protein during a period of illness. The patients BMI is 18 and is underweight for ideal body weight. The patient also has
poor nutritional intake because of intubation and general weakness.
PSYCHOSOCIAL STAGE OF DEVELOPMENT
What is the clients developmental stage?
Generativity vs. Stagnation
Has he/she met the necessary accomplishments? Yes No x
Explain
Patient is in stagnation, which refers to the failure to find a way to contribute. The patient feels very disconnected and uninvolved with
her family and community as a whole. She does not feel successful because she is so young and is leaving her mother, husband, and
son without putting on her mark. Patient seems depressed and is not ready for death yet. Once extubated, patient states I have nothing
else to offer anyone or anything. She feels very unproductive and uninvolved because she is unable to move around and perform
ADLs, instead she lays in bed all day.
How is this illness affecting the clients ability to meet these necessary accomplishments?
Patient is unable to stay social and active in the community with her friends and family. Prior to this sickness, she was able to drive to
see her son, make dinner, go to Grand Rapids on lunch dates with friends and other activities; however, the sickness has affected
her body emotionally and physically. Patient is stuck lying in bed all day and not allowing her to stay independent with
performing ADLs.

STRESS MANAGEMENT: Identify coping mechanisms used by this client during stress.
Patient tended to use smoking as a coping mechanism before her illness. She now uses therapeutic touch with her family, friends, and
staff. She likes to hold hands, rub hands, and hug quite frequently. She also likes to watch TV, especially reality TV, because she likes
to focus on other peoples lives.
NURSING DIAGNOSIS/OBJECTIVES/INTERVENTIONS
Indicate below the 2 priority nursing diagnosis that is most relevant for your client.
#1 NURSING DIAGNOSIS (problem r/t)
Ineffective breathing pattern related to decreased lung compliance as evidenced by dyspnea, tachypnea, and abnormal ABGs
DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
Tachypnea, low pCO2, HCO3, high pO2, decreased vital capacity, pursed-lip breathing, decreased minute ventilation, decreased
inspiratory and expiratory pressure.
OBJECTIVE/CLIENT OUTCOME for this diagnosis:
Patient will exhibit signs of adequate perfusion; ABGs will be within normal baseline limits; client with exhibit signs of effective
breathing pattern; client with have adequate tissue perfusion
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:
1.

Monitor head of bed elevation at least 30 degrees

2.

Monitor ABGs for changes; monitor pulse oximetry for oxygen saturation and notify if under 90% or normal for baseline

3.

Monitor ECG changes in cardiac rhythm or dysrhythmias

#2 NURSING DIAGNOSIS (problem r/t)

Impaired gas exchange r/t loss of effective lung surface
DEFINING CHARACTERISTICS (S/S) that support this diagnosis:

OBJECTIVE/CLIENT OUTCOME for this diagnosis:

Patient will experience adequate O2, CO2 exchange by usual mental status, unlabored respirations at 12-20 per minute, oximetry
results within normal range, and blood gases within normal range
NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:
1.

Assess for signs and symptoms of impaired gas exchange: restlessness, irritability, confusion, somnolence, tachypnea,
dyspnea, decreased oximetry results

2.

Perform actions to improve pulmonary blood flow (anticoagulants)

3.

Maintain client on bed rest to reduce oxygen demands during acute respiratory distress; increase activity as ordered

COMPLICATIONS:
If this clients condition were to worsen, what would be the most likely reason and why?
One complication would be shock (SIRS)
How would you know this is happening?
Symptoms of this would be a fever, increased white blood cell count, tachypnea, tachycardia, hypotensive possibly, and chills.
What will you do if this happens?

First, I would assess the patient. Then I would call the physician, so he could prescribe antibiotics. As the nurse, I would treat the fever
by giving an anti-pyretic (Tylenol). I would also put cold rags, or icepacks on the patient to cool her down.

EVALUATION:
Was the patient able to achieve the objectives identified on the first clinical day? yes
If no, list new objectives.
Did you choose the appropriate nursing diagnosis on the first clinical day? yes
If no, list nursing diagnosis that would have been more appropriate.
Were the interventions appropriate? yes no n/o
If no, list more appropriate interventions.

no

no

n/o

PHYSICIAN PRESCRIBED MEDICATIONS AND INTERVENTIONS

MEDS/IVS/TX/DIET
(Include dose, route,
frequency)

REASON PRESCRIBED
(Drug Classification
What is it treating?)

NURSING IMPLICATIONS
FROM TEXT
(Checking for adverse reactions,
preparation & administration
concerns)

aspirin; 81 mg, 1 tab, PO,

routine

Antipyretic, nonopioid
analgesics; treating fever and
pain

Side effects: GI bleeding,

anemia, dyspepsia, nausea,
abdominal pain, tinnitus
May increase risk of bleeding

PATIENT DATA FROM

YOUR ASSESSMENT
(What data is important to know
before & after giving)
-monitor for tinnitus, headache,
hyperventilation, agitation,
mental confusion, lethargy,
sweating, diarrhea = toxicity
overdose
-monitor hepatic function

Docusate-senna; 1 tab, PO,

bid

Stimulant laxatives; stool

softeners; treat and prevent
constipation from lying in bed

Side effects; rashes, nausea,

vomiting, diarrhea, dehydration,
urine discoloration, electrolyte
imbalances

-assess fever and pain before and

after
Assess for abdominal distention,
usual pattern for bowel function

Medication does stimulate

intestinal peristalsis
famotidine; 20 mg=2 mL IV
push, subQ, every 8 hours

Antiulcer agent; histamine h2

antagonists; treating patients
GERD

Side effects: arrhythmias,

confusion, dizziness, pain at site,
anemia, neutropenia,
constipation, diarrhea, nausea

Monitor CBC with differential

periodically during therapy,
assess for epigastric or
abdominal pain or frank/occult
blood

Administer with meals or

immediately afterwords
LevoFLAXACIN; 750
mg=150 mg, IVPB, daily
NOW
Ipratropium 0.5 mg=2.5 ML
NEB every 4 hours

Anti-infective,
fluoroquinolones; treats
infection (respiratory tract
infection or pneumonia)

Side effects: seizures, anxiety,

confusion, depression, vaginitis,
hyperglycemia, nausea,
abdominal pain

Bronchodilator,
anticholinergic; treated COPD

Side effects: dizziness, sore

throat, blurred vision, cough,
hypotension, rash, GI irritation,
nausea
Do not exceed 12 doses within
24 hours

Assess for infection, observes

patient for signs/symptoms of
anaphylaxis shock, monitor
bowel function, assess for rash
periodically
Assess for allergy to atropine,
assess respiratory status,
Administer bronchodilator first,
then ipratropium, then
corticosteroids; wait 5 minutes
in-between
Take missed doses as soon as
possible; rinse mouth after, give
good oral hygiene, minimize dry
mouth by gum

Analysis of Diagnostic Tests

DIRECTIONS:
1.

List all diagnostic and laboratory tests pertinent to the patient's medical diagnosis or medical treatments (i.e. medications)
and provide the patient values for each test. Explain why they are pertinent for this patient.

2.

List any screening diagnostic and laboratory tests that are not within normal limits. Explain why these tests are increased
or decreased in relation to your patient's medical condition.

WBC

Diagnostic/Lab Test
16.57 (h)

Patient Values

Analysis of Values
Patient has infection; pneumonia

RBC

2.58 (L)

Patient, with COPD, has chronic anemia

HCT

26.3(L)

Patient, with COPD, has chronic anemia

8.3(L)

Patient, with COPD, has chronic anemia

96.4

Patient has infection; pneumonia

108

Patient has Diabetes Mellitus

27 (L)

Patient has COPD

16(L)

Patient has COPD

164 (H)

Nurse increased FiO2

HGB
Neutrophils
Glucose
pCO2
HCO3
PO2

Narrative Charting Sample