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Brief Background: 60 year old accountant, admitted 2 days ago to tele for increasing SOB, DOE.

Assessment Problem
Statement
Goals Actions Eval/Reform
Vital signs and significant
history:
T= 100.2 P= 102
and irregular R 30, BP=
142/89 %sat= 85 on 4
liters O2/minute.
History of COPD
Resp. failure x1 in
2013
100 pack/year
history of smoking.
Quit 2 weeks ago
Body habitus:
Wasted, thin,
listless
Observations: CV
Sleeps with HOB
JVD @ 45
o

Monitor= NSR
with frequent PACs
Pretibial edema
No appetite
Gained 2 pounds
Impaired
oxygenation
RT
Chronic alveolar
hypoventilation
(2
o
to COPD) and
V/Q mismatch
AEB
Hypercarbia,
hypercapnea,
refractory
hypoxia










Within 24
hours:
temp will
remain 99
o
or
below and
WBCs will
trend toward
normal.
Maintain
%sat above 90
on 4 L/min O
2

Will
tolerate walking
to BR using
(supplemental
oxygen) w/out
drop in %sat
and c/o dyspnea




Collaborative actions:
Continuous cardiac
monitoring
D5NS @ 75 ml/h
O
2
6L/min
Methylprednisolone
125 mg IV q6h
Moxifloxacin 400 mg
IV q24h
Respiratory protocol
(RT) q6h and prn.
Nursing actions:
Group nursing
activities
VS q4h and prn
Bubbler with O
2

Hourly rounding
Personal belongings
call light at hand
Up with oxygen and
2 person assist




Note:
To make the
CRT more
readable,
the
problems,
goals and
actions that
complement
each other
are color
coded








since admission
Plethoric
appearance, ruddy
Observations: Pulmonary
DOE (up in chair
OK but becomes very
SOB when ambulated to
door of room and back.
Sits tripod
position
Using abd. muscles
to exhale against
pursed lips.
SCM muscles and
traps to breath in.
Barrel chest
Wet cough
productive of yellow
sputum
Physical Assessment:
Harsh breath
sounds, coarse rales in
bases, with bronchial
breath sounds, wheezes
throughout.
S1/S2 (possible S3?)
Risk for
decreased
cardiac tissue
perfusion (and/or
oxygenation)
RT
Pulmonary
hypertension
AEB
PACs, EKG
findings,
Prominent
pulmonary
vasculature on
CXR










Prior to
discharge
patient will list
5 improvements
in physical
activity taught
in pulmonary
rehab.
Patient will
explain the
effect of Long-
term-oxygen-
therapy (LTOT)
in preserving
heart function
and reducing
mortality rates
in COPD
Will
ambulate 50 to
nurses station
and back x3
per day
(walker, 1 man
assist, O
2
tank)
Flu and pneumonia
vaccine per protocol
Request PT consult
to begin increasing
strength in upper
extremities
Consult OT for
adaptive tools to perform
ADLs with less energy
expenditure

Ambulate 5 minutes
3x/day
Work with patient
to walk while using pursed
lip breathing (w/out
breath holding)
Anxiety with
walking accompany
patient offering
encouragement
Instruct pt. to use
albuterol inhaler prior to
walking
Using repeat

























Hypoactive bowel
sounds, no tenderness
to palpation.
Labs (Chemistries)
Na
+
145, K
+
4.4, Cl
-
105,
HCO
3
-
48, BUN 28,
Creatinine 1.5
Albumin 3.1, Ca
2+
8,
ALT 63, AST 58,
Heme
Hgb 19, Hct 58,
WBC 18.1, Neutrophils
81%, Platelets 305,000
ABGs on admission
PaO
2
55, PaCO
2
59, pH
7.35, %sat 85 on
4L/min
Diagnostics
CXR: Flattened
diaphragms,
hyperlucent lung fields
but bilateral
consolidation in bases.
Prominent pulmonary
arteries
EKG: Right axis

























Articulate
importance of
yearly flu shot
Will
identify
situations that
provoke
yearning for
cigarette and
two methods to
stay tobacco
free.













demonstration, teach pt
to monitor heart rate and
stay below 80% of max
for age. (220-age in
years)
Provide patient and
spouse with information
about institutions
outpatient pulmonary
rehab services.

Teach airway clearance
techniques
(demonstration & repeat
demonstration)
Huff coughing
Vibratory end-
expiratory pressure
devices (Lung Flute or
Acapella)
Explain importance
of adequate hydration




























deviation, right atrial
and ventricular strain.
Interview:
No appetite,
stomach roiled by
prednisone
Food too much
work. Get SOB during
meal. Food gets cold
Lives and sleeps in
Barco-lounger.
Can do ADLs even
though dyspneic
(eating, hygiene,
clothing self) but is
dependent upon wife
for all IADLs
(shopping, cooking,
banking, etc.)
Describes his life
as worthless.
Only thing Im
good for is sitting in my
recliner.
Life characterized
Risk for impaired
nutrition
RT
Stomach
irritation of
steroids and
extreme dyspnea
AEB
food too much
work, stomach
roiled and thin,
wasted body
habitus




Impaired self-
esteem
RT
severe handicaps
AEB
worthless life

Patient will
consume 1800
calories low Na
+

low fat soft
diet daily
Patient
and wife will
list favorite
foods that are
easily
masticated.
Pt. will
make an
appointment to
see dentist.


By 0830
daily pt. will
make decisions
about his care
goals for the
day (times for
walks, frequent
feedings, etc.)
Dietary consult to
select easily masticated
foods of high nutritional
value
More finger foods
(notify kitchen)
Small frequent
feedings (6 meals)
Assist patients wife
in recipe selections







Plan schedule of
care with patient in AM
Keep patient
informed of any changes
that become necessary
Plan visit with
representative from
Pulmonary Rehab services

















Pt. states he
is more
likely to
smoke when
he is bored.



by boredom except
when he coughs so bad
he cant catch his
breath which replaces
boredom with panic.
By time of
discharge pt
will describe
likely outcomes
of pulmonary
rehab
http://www.nhlbi.nih.gov/
health/health-
topics/topics/pulreh/
Discuss support
groups through American
Lung Association