Republic of the Philippines

CAVITE STATE UNIVERSITY

DON SEVERINO DE LAS ALAS CAMPUS Indang, Cavite

College of Nursing

Competency appraisal I
(Situational analysis)
Submitted by: Isurea, Melody Ann R. IVBSN1

Submitted to: Mr. Joinito C. Ofracio, RN

Instructor, Competency Appraisal I

26 July 2012

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Situation: Mr. Douglas McDougal, a 67 y/o is admitted to ICCU for close monitoring due to difficulty of breathing. He is a known case of COPD with emphysema and CHF. He is on O2 therapy @ 2L/min via nasal canula and is attached to a cardiac monitor. His O2 saturation of 87%, after an hour of admission he went to a respiratory arrest and was intubated and was attached to a mechanical ventilator @ 100% O2 setting. He is on Dobutamine 10mg side drip 250mL D5W @ 10gtts/min, Cefuroxime 750mg IV q6h, Lasix 20mg IV OD and with D5NS 1L @ 31gtts/min. Diet was withhold. He has an indwelling foley catheter for accurate measurement of I&O.
1. As an RN using the nursing process, how will you prioritize your nursing care to Mr. McDougal from the time of admission to your unit? Also, make your nursing assessment on Mr. McDougals prognosis on the ICU. Answer: A number of tools or guidelines can be used to prioritize the care that will be rendered to the said patient. This includes the Maslows Hierarchy of needs and ABC. During the assessment, the difficulty of breathing as the chief complaint of the patient should be prioritized since it is considered as impairment in the airway as well as a physiologic need. From the time of admission, interventions that will enhance the respiratory status of the patient should be in top of the priority, his O2 saturation should be closely monitored because there is a risk for it to decline due to the inability of the patient to efficiently breath because of his underlying condition. Positioning the patient in Semi-Fowlers could also help to attain maximum level of diaphragmatic expansion, thus improving the quality of breath of the patient. Assessment For COPD Emphysema Cough due to increase secretion and irritation Dyspnea on exertion Chest pain Sputum production

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 Adventitious breath sounds e.g. wheezing, crackles, stridor and bronchi Pursed lip breathing Tends to assume upright leaning position Alteration in level of consciousness Alteration in skin color (pallor to cyanosis) Alteration in skin temperature (cold to touch) Voice changes Decreased metabolism (weakness, fatigue, anorexia, weight loss) Alteration in thoracic anatomy (Barrel chest) Clubbing of fingers Polycythemia Hyperinflation of lungs in CXR Respiratory acidosis Hypoxemia Decreased vital capacity Assessment for CHF Dyspnea Paroxysmal Nocturnal Dyspnea Orthopnea Rales/Crackles Moist cough Blood tinge frothy sputum Wheezing (Cardiac Asthma) Dizziness Syncope Fatigue Weakness Anorexia

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 Hypokalemia (Increase level of aldosterone) Clubbing of fingers Polycythemia S3s4 heart sounds, pulsus alternans Elevated PCWP

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Assessment Possible Subjective Cues

Nursing Diagnosis

Background Knowledge

Planning After rendering 30 minutes of nursing care, the patient is expected to have the following desirable outcomes Goals: Short term

Implementation Intervention During the 30 minutes of nursing care, the following interventions were done by the nurse: Independent: 1. Noted presence of medical condition s that contributes to impairment in gas exchange. 1.Underlying condition such as COPD, emphysema and left sided CHF affects the ability of the patients respiratory system to effectively exchange gases in the alveolar level Rationale

Evaluation After rendering 30 minutes of nursing care, goal was not met; patients condition progressed into a respiratory distress.

Impaired gas exchange related to ventilation Objective perfusion Cues: inequality secondary to - (+) DOB SOB COPD and - (+) use of emphysema as manifested accessory muscle in by difficulty of breathing breathing - (+) pursed-lip breathing (+) non productive cough (+) pale mucosal membrane and palpebral conjunctiva - Level IV in Gordons Functional Level Classification (Dyspnea and

Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane Due to the presence of over distended, non-functional alveoli in case of emphysema, it results in loss of aerating surface thus decreasing the perfusion and ventilation rate leading to imbalance O2 supply and demand

1. demonstrate improved ventilation and adequate oxygenation of tissues by ABGs within 2. Assessed RR, depth, of accessory the clients use muscles, pursed lip normal limits breathing, and areas of pallor/cyanosis. Long Term

2.Provides comparative baseline information about needed education or intervention.

3.Maintained on 3. To facilitate 1. absence of moderate high back rest movement of symptoms of position diaphragm thus respiratory improving respiratory
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Fatigue at rest -on O2 therapy at 2l/min - 87% O2 Sat - CXR revealed accumulation of mucus in right lobe of the lungs diagnosed with emphysema and COPD, CHF

distress. 2. eradicate aggravating factors of his condition Dependent:

effort and respiration

effective

1. Vital sign changes 1. Monitored vital signs may indicate q15 and recorded as complication of ordered. condition 2. May indicate to 2. I&O monitored and response pharmacological recorded qshift as therapy. ordered.

To promote 3. Maintained on O2 3. therapy limiting to 1- adequate oxygenation 2L/min via nasal canula yet considering a low level oxygen because of inability to expel carbon dioxide due to underlying condition 4. in case of emergency, necessary 4. ensured availability of equipments will be proper emergency readily available. equipment, including ET/tracheostomy set and suction catheters
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appropriate for age. 5. to determine oxygenation and level cardiac of carbon dioxide pulse retention

5. evaluated monitor or oximeter

1. to make self aware in the use of the said 1. updated knowledge equipment, in cases of e.g. in the use of mechanical emergency respiratory distress ventilator settings Collaborative:

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ASSESSMENT

NURSING DIAGNOSIS

BACKGROUND KNOWLEDGE

PLANNING

IMPLEMENTATION

EVALUATION

Short- term Goals: Objective Data: The patient manifested: - (+) episodes of adventitous breath sound (crackles) on the basilar area of the lungs - dyspnea -orthopnea along side with tachypnea - rapid and shallow breathing -restlessness -pinkish to pale palpebral conjunctiva -yellowish and viscid secretions Ineffective Airway clearance related to exudation of fluid in the distended nonfunctional alveoli extending to the pleural cavity secondary to COPD, Emphysema and CHF as manifested by difficulty of breathing. Ineffective airway clearance is the inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. After 8 hours of nursing intervention, the patient will be able to: 1. Demonstrate behaviors to improve or maintain clear airway. 2. Demonstrate reduction of congestion of breath from a respiration rate Long-term Goals: After 2- 3 days of nursing interventions the patient will be able to: 1. Expectorate secretions readily. 2. Maintain airway

Interventions During the 3-day shift, the following interventions were done by the student nurse: Independent: 1. Auscultated the lungs for crackles, consolidation and pleural friction rub. 2. Assessed characteristics of secretions: quantity, consistency, color, and odor.

Rationale

Short -term Goals: After 8 hours of nursing intervention, the goal was met

1. To determine the adequacy of gas exchange and extent of airways obstructed with secretions.

2. Because presence of infection is suspected when secretions are thick, yellow or rust in color and foul smelling. 3. To facilitate optimal breathing and better lung expansion.

3. Assisted in position of comfort either orthopneic position or moderate high

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patency.

back rest.

4. Encouraged to have good oral care such as brushing and gargling with warm water.

4. This helps remove the unpleasant taste of the sputum and prevent infection.

5. Performed and 5. For easy secretion instructed expulsion and to chestmaximize effort of physiotherapy the lungs. and deepbreathing and coughing exercises. 6. To prevent allergic 6. Keep the reactions that may environment cause bronchial allergen free irritation. according to the individual needs. Dependent: 1. To have baseline Dependent: data of the 1. Vital signs condition of the taken and patient. recorded every 4 hours. 2. May indicate response to 2. I & O pharmacological 9|Page

monitored and recorded every 4 hours.

therapy like Acetylcysteine, a mucolytic and to monitor balance between patients fluid intake and bodys excretory function in the output. 3. This facilitates fast recovery

3. Administered meds per doctors order 4. Monitored O2 inhalation via mechanical ventilation

5. monitor o2 saturation

4. To promote ample amount of oxygenation supporting normal gas exchange in the patients alveolar sacs this by then will be delivered to body cells. 5. To prevent complications of the condition such as respiratory acidosis

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Name Generic Name: Cefuroxime

Indication Lower respiratory tract infections, PNA due to S. pneumoniae , H. influenza (including ampicillin resistant strain)

Action Secondgeneration cephalosporin that inhibits cell-wall synthesis, promoting osmotic instability; usually bactericidal

Contraindication Contraindicated in patients hypersensitive to drug or other cephalosporins.

Side effects

Drug interaction

Nursing management -Obtain specimen for culture and sensitivity tests giving first dose. Therapy may begin pending results. - use IV route for severe life threatening infections such as septicemia or in poor-risk clients esp. in presence of shock

Classification: Cephalosporin, second generation

Brand Name: Ceftin ApoCefuroxime Zinacef

diarrhea that is Drug-drug: watery or bloody; Aminoglycosides: fever, chills, body May cause aches, flu symptoms; synergistic effect against some chest pain, fast or strains of pounding P.aeruginosa and heartbeats; Enterobacteriaceae species. Monitor unusual bleeding; patient. blood in urine; Probenecid: High seizure (convulsions); doses (1 g or 2 g daily) may enhance pale or yellowed hepatic clearance skin, dark colored of ceftriaxone and urine, fever, shorten its half-life. confusion or Avoid using weakness; together. jaundice (yellowing of the skin or eyes); Pregnancy fever, sore throat, category: B and headache with a severe blistering, peeling, and red skinrash; skin rash, bruising, severe tingling,

Dosage: 750mg IV q6h

-slowly inject drug over 3-5 minutes or give risk in tubing of other IV solutions -drug may be added to 0.9% NaCl, D5W, or D10W, D5/0.45% or
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numbness, pain, muscle weakness; increased thirst, loss of appetite, swelling, weight gain, feeling short of breath; or painful or difficult urination, urinating less than usual or not at all.

0.9% NaCl and M/6 sodium lactate injection. -protect from light, drug may darken without affecting potency -do not administer with aminoglycosides -Absorption of cefuroxime axetil is enhanced by food

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Name Generic Name:

Indication

Action Directly stimulates beta-1 receptors in the heart, increasing cardiac function, CO, and SV with minor effects on HR

Contraindication Idiopathic hypertropic subaortic stenosis. Previous hypersensitivity in dobutamine

Side effects Marked increased in HR, BP, ventricular ectopic activity, premature ventricular beats, hypotension, nausea, headache, SOB

Drug interaction

Nursing management

When parenteral Dobutamine therapy is Hydrochloride needed for support in the short term treatment of Classification: cardiac Symphatomimetic, decompensation Direct-acting on adults secondary to depressed contractility Brand Name: resulting from Dobutamine HCl organic heart disease or Dosage: cardiac surgical 10 mcg side drip procedure 250ml D5W @ 10gtts/min

Bretylium1.IV reconstitute possible according to potentiation of manufacturers vasopressor direction, takes action, place in two arrhythmias stages. 2.solution is diluted further Guanethidineaccording to (+) increase clients fluid pressor needs. response, severe 3.may hypotension refrigerate the more concentrated solution for 48 Halogenated hours or store hydrocarbon at room temp anestheticsfor 6hours possible sensitization of 4. drug is the incompatible myocardium, with alkaline serious solutions. Do arrythmias not give with agents sodium bisulfate.

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Name

Indication

Action

Contraindication

Side effects

Drug interaction

Nursing management

Generic Name: Furosemide

Classification: Diuretic, loop

Edema associated with CHF, nephritic syndrome, hepatic cirrhosis and ascites. Acute pulmonary edema.

Brand Name: Lasix Dosage: 20 mg IV OD

Inhibits sodium reabsorption in the proximal and distal tubules as well as the ascending loop of Henle, this results in the excretion of NA, Cl, and to a lesser degree, K and bicarbonate ions. The resulting urine is more acidic

Never use with ethacrynic acid. Anuria, hypersensitivity to drug, severe renal disease assoc. with azotemia and oliguria, hepatic coma, assoc. with electrolyte depletion

Jaundice, tinnitus, hearing impairement, hypotension, water/electrolyte depletion, pancreatitis, abdominal pain, dizziness, anemia

Charcoal1.Give 2-4 days decrease a week. absorption of food drug in the GI 2. decreases tract bioavailability Clofibrateand ultimately enhanced the degree of diuretic effect dieresis Hydantoinsdecreased diuretic effect 3. observe for ototoxicity

4. assess signs Propanololof vascular increase plasma thrombosis and propanolol embolism level. 5. monitor BP, weight, edema, breath sounds, i&o, electrolytes uric acid, CO2, hypokalemia 6. observe for dehydration and circulatory collapse
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3. Why is he given the above medications? Dobutamine- Since the patient is suffering from congestive heart failure, his heart cannot compensate to the needs or demands of his body. This drug takes it action by Directly stimulating beta-1 receptors in the heart, increasing cardiac function, CO, and SV with minor effects on HR. with increase cardiac function, his O2 sat and oxygen demand will be compensated. Lasix- There is an excess accumulation of fluid as a symptom of congestive heart failure. As a diuretic, lasix excretes sodium and chloride, thus preventing excessive accumulation of fluid in the interstitial space. Cefuroxime- as an antibiotic, it prevents the further invasion of microorganism in the respiratory tract of the client since there is already an excessive mucus production in the alveolar level of the client, there is a greater risk in acquiring infection. 4. Interpret his ABG results. pH 7.21, PaCO2 60 mmHG, HCO3 24 mEq/ L. Blood pH- below normal acidosis paCO2- Above normal respiratory acidosis HCO3- normal Normal Degree of compensation- paCO2 HIGH ; HCO3 NORMAL uncompensated Interpretation : UNCOMPENSATED RESPIRATORY ACIDOSIS 5. Differentiate COPD to emphysema and give the predisposing factors of each disease. COPD or chronic obstructive pulmonary disease is a disease state characterized by airflow limitation that is not fully reversible. It may include diseases that cause airflow obstruction. Currently, it is the fourth leading cause of mortality and 12 th leading cause of disability in the United States. People with COPD commonly became symptomatic during the middle adult years, and the incidence of the disease increases with age.
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In COPD, the airflow limitation is both progressive and associated with abnormal inflammatory response of the lungs to noxious particles or gases. The inflammatory response occurs throughout the airways, parenchyma, and pulmonary vasculature. Because of the chronic inflammation and the bodys attempts to repair it, narrowing occursin the small peripheral airways. Over time, this injury-and-repair process causes scar tissue formation and narrowing of the airway lumen. In addition to inflammation, processes related to imbalances of proteinases and antiproteinases in the lung may be responsible for airflow limitation. Predisposing factors exposure to tobacco smoke (80%-90% of COPD cases) passive smoking occupational exposure ambient air pollution genetic abnormalities including deficiency of alpha1-antitrypsin, an enzyme inhibitor that normally counteracts the destruction of lung tissue by certain other enzymes Emphysema In emphysema, impaired gas oxygen and carbon dioxide exchange results from the destruction of the walls of overdistended alveoli. Emphysema is a pathologic term that describes an abnormal distention of the airspace beyond the terminal bronchioles, with destruction of the walls of the alveoli. It is the end stage of a process that has progressed slowly for many years. As the walls of the alveoli are destroyed, (a process accelerated by recurrent infections) the alveolar surface area in direct contact with the pulmonary capillary continually decreases, causing in an increase in dead space and impaired oxygen diffusion leading to hypoxemia. In the later stage of the disease, carbon dioxide elimination is impaired resulting in increased carbon dioxide tension in arterial blood (hypercapnia) and respiratory acidosis. As the alveolar walls continue to break down, the pulmonary capillary blood flow is increased, forcing the right ventricle to maintain higher blood pressure in the pulmonary artery. For this reason, right sided heart failure (cor pulmonale) is one of the complications of emphysema.

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Predisposing factors cigarette smoking heredity plasma protein abnormality aging process References: Brunners Medical-surgical Nursing Udan Medical Surgical Nursing Concepts and Clinical Application

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