Fundamentals of Nursing Care Plan

 
Fundamentals of Nursing Care Plan



Client Data:




Initials: P.B.
Age: 80 years
Gender: Female


Weight:
Height:
Race/Ethnicity: Caucasian


Diet: Heart-healthy diet
Religion: Baptist
Language Spoken: English


Allergies: 

Latex

Aspirin

Sulfadiazine

Adhesive bandage
Marital Status: Married
Code Status: Full code


Past Surgeries: N/A
Consults:   

 
Social Habits: 

Occasional alcohol intake (once or twice per week)

Non-smoker


Vital Signs:






B/P:
P:
R: 
T:
SAO2 sat: 

 


153/74
67
18
97.4
99%












 Present History: Admitting Medical Diagnosis:

 	
Why the client is in the hospital:

Respiratory failure
Admitting Diagnosis Information:
The patient presents with dizziness, difficulty breathing, shortness of breath, and chest tightness.
Definition/Etiology/Pathophysiology:
Respiratory failure occurs when the respiratory system cannot efficiently eliminate carbon dioxide or conduct oxygenation. Respiratory failure is hypercapnic (type Ⅱ) or hypoxemic (type Ⅰ) respiratory failure. Respiratory failure is further described as chronic or acute, depending on the symptoms duration.

Etiology of hypercapnic respiratory failure includes drug overdose, asthma, pulmonary edema, tetanus, cervical cordotomy, poliomyelitis, a chronic obstructive pulmonary disorder, polyneuropathy, porphyria, obesity hypoventilation, acute respiratory distress syndrome, primary muscle disorders, poisonings, myxedema, myasthenia gravis, and primary alveolar hypoventilation. Pneumothorax, bronchiectasis, a chronic obstructive pulmonary disorder, kyphoscoliosis, pneumoconiosis, pneumonia, asthma, pulmonary fibrosis, fat embolism syndrome, obesity, cyanotic congenital heart disease, pulmonary edema, and granulomatous lung disease cause hypoxemic respiratory failure.

Respiratory failure occurs through an abnormality in the central nervous system, alveoli, airways, chest wall, peripheral nervous system, and respiratory muscles. Respiratory failure occurs when there is a malfunction in transporting oxygen to tissues, removing carbon dioxide from the alveoli from blood, and transporting oxygen across the alveoli.
Clinical Manifestations/Signs and Symptoms:
The clinical manifestations of respiratory failure depend on the type of respiratory failure and the underlying disease. Patients diagnosed with respiratory distress present with dyspnea, cyanosis, hypoxemia, tachycardia, hypercapnia, pulmonary hypertension, tachypnea, and neurological manifestations such as anxiety, seizures, and restlessness. Patients with hypercapnic respiratory failure have a PaCO2 of more than 50 mmHg, while those with hypoxemic respiratory failure present with a normal PaCO2 and a PaO2 of less than 60 mmHg. Respiratory failure presents with acute respiratory distress syndrome with sepsis, lung compliance of 40 mL/cm water, pulmonary capillary wedge pressure less than 18 mmHg, and three or 4-quadrant alveolar flooding. Acute respiratory failure presents with several complications. Gastrointestinal complications include gastric distention, diarrhea, bleeding, and pneumoperitoneum, while nutritional complications include malnutrition. Lastly, cardiovascular complications of acute respiratory failure include endocarditis and myocardial infarction. P.B. presents with dizziness, difficulty breathing, shortness of breath, and chest tightness, which are symptoms experienced in respiratory distress.
Medical Management:
Management of hypoxemia focuses on correcting hypoxemia, mechanical ventilation, and patient monitoring. Mechanical ventilation is done to decrease PaCO2 and increase PaO2. Medical management done for P.B. focuses on treating and managing the underlying disease, atrial fibrillation. Amiodarone, atorvastatin, and apixaban are prescribed to control atrial fibrillation. P.B. is administered in the ICU, where oxygen is administered.
Past History/Secondary Diagnosis:
Atrial fibrillation
Definition/Etiology/Pathophysiology:
Atrial fibrillation is an arrhythmia with a rapid and irregular heart rate. Atrial fibrillation commonly leads to the formation of clots in the heart, increasing a patient’s risk of heart failure and stroke. Atrial fibrillation is caused by inflammation such as pericarditis, substance abuse, advancing age, hemodynamic stress such as left ventricular dysfunction, endocrine disorders such as hyperthyroidism, genetics, neurologic disorders such as stroke, atrial ischemia and non-cardiovascular, respiratory causes such as pneumonia. The risk of Atrial fibrillation is higher in individuals above 60 years.

Atrial fibrillation occurs through contractile, electrical, and structural remodeling. The signals in the heart’s upper chambers are uncontrolled, causing the chambers to quiver. Signals transmitted through the ventricles bombard the arterioventricular node, causing irregular and fast heart rhythms (Nesheiwat et al., 2022).
Clinical Manifestations/Signs and Symptoms:
Patients diagnosed with atrial fibrillation usually present with weakness, fatigue, palpitations, lightheadedness, decreased tolerance to physical activity, shortness of breath, and chest pain. P.B. experiences shortness of breath and chest tightness, which are seen in atrial fibrillation. P.B. has respiratory failure, which occurs due to atrial fibrillation (Nesheiwat et al., 2022).
Medical Management
Management of atrial fibrillation focuses on anticoagulation and heart rate control (Nesheiwat et al., 2022). In addition, the treatment plan selection depends on the presenting symptoms and severity. Atrial fibrillation in P.B. is managed using apixaban, atorvastatin, and amiodarone