A Grand Case Presentation

Presented to the Faculty of St. Lukes College of Nursing

In Partial Fulfillment of the Requirements

In Related Learning Experience for the

Degree of Bachelor of Science in Nursing

Submitted to:
Dr. Marilyn Buhat

Submitted by:
Steffi Shanice M. Muriel

March 13, 2017 CCU5

P> Risk for Cardiopulmonary Distress
D> Received patient awake; GCS 15); with foley catheter and DObutamine drip

1.4cc/hr

- PR= 85bpm RR= 26bpm BP 116/45 mmHg

A> - Assessed overall condition

- Monitored vital signs and I & O hourly
- Assisted patient in doing activities of daily living
- Decreased O2 to 1Lpm
- Discontinued Dobutamine Drip
- Due medications was administered as ordered
R> PR=74, BP 90/40, RR=21
*same patient*
P> Hypotension
D> After the discontinuation of DOBUtamine, noted patients SBP of 80s-90s mmHg
A> - Informed CFOD Bumatay regarding status of the patient
- Hooked Dobutamine drip @ 2mcg/kg/min
- Titrated inotropes accordingly
D> No distress noted; for transfer to progressive care unit.

March 14, 2017 CCU10 R.

P> Risk for Cardiopulmonary Distress
D> Patient tracheostomy hooked to mechanical ventilator on SIMV mode; GCS 8 (E2
V1 M5); with Right IJ, PR= 88 RR= 22 BP= 151/73, Atrial
A> - Assessed general condition
- Monitored vital signs hourly
- Repositioned patient every 2 hours
- Suctioned gently as necessary
- For Hemodialysis today
- Watch out for bradypnea
- Administered medications as ordered
R> PR= 84 RR= 23 O2Sat= 97% BP= 145/66
March 15, 2017 CCU10
 P> Risk for Cardiopulmonary Distress
D> Patient tracheostomy hooked to mechanical ventilator on SIMV mode TV 380
BUR 6 PS 14 PEEP 5 FiO2 35; GCS 7 (E2 V1 M4);, PR=71 RR= 20 BP= 148/61 O2sat=
99%
A> - Assessed overall condition and status
- Monitored vital signs hourly
- Repositioned patient every 2 hours
- Suctioned gently as necessary
- CBG taken and recorded
- Watch out for any signs and symptoms of distress
- Due medications was given as ordered
R> PR= 92 RR= 26 O2Sat= 96% BP= 161/72

ASSESSME NURSING PLANNING INTERVENTION EVALUATI

NT DIAGNOS ON
IS
Subjective: Decrease Independent: Goal met.
N/A d cardiac Short term:
output Monitored vital signs VS as
Objective: altered After 2 hours of every hour. follows:
contratility nursing
- BP: intervention, the Monitored cardiac BP=
82/50mm patient will be rhythm continuously. 100/80
Hg able to display PR=
Assessed urine
- HR: 78 bpm vital signs 82bpm
- Urine output hourly.
stability. RR=
Output: 17bpm
Decreased stimuli
30cc/hr Long term: O2sat 99%
and provide quiet
- Skin cold to
After 2 days of environment.
touch
- Weak nursing
Maintained
peripheral intervention, the
surveillance for signs
pulse patient will have
of decreased tissue
improved cardiac
perfusion and
output as
acidosis.
evidenced by
having vital signs
within normal Dependent:
 range for
patient; palpable Administered
peripheral Dobutamine 1.4cc/hr
pulses. as ordered by the
physician.

ASSESSME NURSING PLANNING INTERVENTION EVALUATI

NT DIAGNOS ON
IS
Subjective: Impaired Independent: Goal not
N/A skin Long term: -Assess skin daily. Take met.
integrity photographs if
Objective: related to After 3 days of necessary.
-Grade 3-4 immobility nursing
intervention, the - Assess bony
pressure and poor prominences,
ulcer on circulation patient will be
able to manifest perineum, and
sacral area. dependent and pruritic
-Dry skin on signs of healing
and reduction of areas for pallor,
upper and redness, and
lower pressure ulcers.
breakdown.
extremities
-Position client properly
every 2 hours; use
pressure-reducing or
pressure-relieving
devices
-Apply prescribed
dressing such as
hydrocolloid dressing.

-Observe sterile
technique in doing
procedure.
-Provide adequate
nutritional and
hydration.

-Prevent overexposure
to moisture such as
from urine or
persipiration.

Dependent:
-Administer prescribed
 antibiotics

- Administer prescribed
Glucocorticoid
(prednisone) for
inflammation

ASSESSMEN NURSING PLANNING INTERVENTION EVALUATI

T DIAGNOSIS ON
Subjective: Decreased Independent: Goal not
N/A cardiac Long term: met.
output Monitored vital
Objective: altered After 3 days of signs every hour.
PR= 92 cardiac nursing
RR= 26 electrical intervention, the Monitored cardiac
O2Sat= 96% conduction patient will have rhythm
BP= 161/72 as improved continuously.
ECG: Atrial evidenced cardiac output
as evidenced by Assessed urine
Fibrillation by atrial
having vital output hourly.
Weak fibrillation
peripheral signs within
Maintain optimal
pulses normal range
fluid balance.
No urine for patient;
output palpable Maintain
Skin cold to peripheral hemodynamics at
touch pulses. normal levels.

Provide nutritional
supplement.

Dependent:
-Administer
Cordarone as
ordered.