Its getting harder

and harder to
breathe.
Acute Respiratory Failure secondary to Chonic
Obstructive Pulmonary Disease, Community
Acquired Pneumonia Moderate Risk Cardiac
Dysrhythmia (!AC" #rom $lectrolyte %mbalance,
Coronary Artery Disease,
&eni'n Prostatic (yperplasia
Objectives

General Objective:

This case study aims to identify and

discuss the health problems
associated ith acute respiratory
failure! chronic obstructive
coronary disease and cardiac
dysrhythmia and render nursing
care and management to a patient
ith such condition.
Objectives
"peci#c Objectives:
To understand the disease process and recogni$e
the ris% factors! clinical manifestations!
&anagement and potential complications of
patient ith multiple diseases
To formulate an individuali$ed plan of care to the
patient.
To establish appropriate health teachings for the
promotion of health and prevention of the
disease.
To develop con#dence and competency in
providing safe and 'uality nursing care to
patients ith such condition.
Case )tudy
Proper
Personal Data*

+, year old

male

-ido-er

Roman Catholic

a retired businessman takin' a vacation in the

Philippines, #rom the .)/

(t 0 123 cm

4t 0 33 k'

&M% 0 ,5/6

)moker 0 7 packs per day but stopped

last March ,51,

Occasional Drinker

Chie# complaint* easy #ati'ability

and shortness o# breath/

Medical (istory
Present (istory*

%n the mornin' prior to admission to !MC,

patient e8perienced di9culty o# breathin'
-hile -atchin' in a cock :'ht, he -as brou'ht
to a hospital nearby and -as
intubated/
(e -as 'iven hydrocortisone
,35m', and terbutaline 5/3 m'
subcutaneously #or , doses, 75
minutes apart and Combivent
7 doses, 15 minutes apart and
-as subsequently trans#erred
in !MC/
Medical (istory
Past (istory

!hyroid Disease 0 ,511

(ypertension 0 ,511

&eni'n prostatic hyperplasia 0

December ,511

Coronary artery disease 0

December ,511

;on )mall Cell <un' Cancer

)tatus post <obectomy 0

)eptember ,511 = .)A

$mphysema 0 February ,51,

)tatus post e8cision o# mali'nant

lun' tumor 0 March ,51,

)tatus post chemotherapy o# 2

cycles Carboplatin 0 March ,51,
Medical (istory
Family

(ypertension

Diabetes
Assessment 0 April ,5, ,51,
%nitial ital )i'ns

!emperature 0 72
de'rees celcius

(eart Rate 0 63
beats per minute

Respiratory Rate 0
,7 breaths per
minute

&lood Pressure 0
122>+?
(ead to toe

;eurolo'ical

$ye response 0 ?
spontaneous

erbal response 0 1
presence o# $! tube

Motor respose 0 2
obeys commands

@C) 0 11>13
Assessment 0 April ,5, ,51,

isual>Auditory
)pontaneous movement
o# le#t eye -ith pupillary
siAe o# positive ,B7mm
Ri'ht eye, :8ed
;o auditory impairment

Mouth>Dentures
;o dentures
4ith presence o# $!
tube at ,1 lip level

Aller'ies
;o kno-n aller'ies

Pulmonary

4ith mechanical
ventilator
AC ,1
F%5, 73C
! ?,5
&.R 12
Peep 3

Presence o# ronchi >

rales

Presence o# -heeAes
Assessment 0 April ,5, ,51,

Cardiovascular
Re'ular pulses
Re'ular rhythm
;o chest pain noted
;o peripheral edema
Peripheral pulses palpable
Musculoskeletal
Moves all e8tremities
;o -eakness noted

%nte'umentary
&raden )cale )core 0
13>,7
@astrointestinal
)o#t abdomen, non
tender, non distended
Presence o# bo-el sounds
;o &M #or , days
4ith presence o#
;aso'astric !ube
@enitourinal
&ladder distended
Continent
4ith presence o# a
condom catheter
Cloudy urine output
Functional abilities

&raden )cale
)ensory perception 0 ?
no impairment
Moisture 0 7
occasionally moist
Activity 0 1 bedrest
Mobility 0 7 sli'htly
limited
;utrition 0 , probably
inadequate
Friction and )hear 0 ,
potential problem
13 0 At risk
Risk #or #all assessment
(istory o# #allin' -ithin 7
months 0 5
)econdary dia'nosis 0 13
Ambulatory aid 0 5
%>(eplock 0 ,5
@ait>!rans#errin' 0 15
?3 0 lo- risk #or #allin'
Functional assessment
&ed Mobility B
@roomin' 0 8
Ambulation 0 8
Cranial nerves 0 not
applicable
Course in the -ard
Day 1 0 ?>1D>,51, B 6*35 pm
Patient -as admitted to the $R
under the service o# Dr/& and
-as re#erred to Dr/!/
ital si'ns and % E O
monitorin' #or every hour/
For his diet, he -as ordered OF
o# 1255 Fcal in 2 equal
#eedin's/
For his laboratory test, he -as
ordered #or C&C, ;a, F,
Creatinine, .A, $!A @)>@),
!rop ! !)(, F!?, A<!, Chest GB
ray, A&@, 1,B <ead $C@/
%F -as Plain ;ormal )aline
)olution 1< #or 6 hours
(is medicines -ere*
For'ram , 'rams % every ,? hours
AAith 1 tab once a day
(ydrocortisone 155 m' % every 6
hours
Combivent 1 nebule every 2 hours
Acetylcysteine 255 m'>tab
dissolved in H 'lass o# -ater once
a day
%mdur 75 m'>tab once a day
<isinopril 3 m'>tab once a day
Pravastatin ,5m'>tab once a day
!amsulosin 5/? mc'>tab once a day
Finasteride 3m'>tab once a day
Aspirin 65 m'>tab once a day
Course in the -ard
D*55 pm
Falium Durule 1 durule 7
times a day #or 7 doses
Pantoloc ?5m'>tab once a
day/
15*,5 pm
A&@s in AM
trans#er to C side %C.
nebuliAation and
hydrocortisone be
continued #or no-
head elevation 73 de'rees
C&@ monitorin' preBmeals
every 6 hours
revised #eedin' via enteral
pump -ith 15 ml Iushin'
MidaAolam 1m' % #or
di9culty o# sleepin'
11*55 pm
Decrease F%5, to 25C
Course in the -ard
4/20/2012
1,*55 mn
Decrease F%5, to ?5C

6*55 am
Diet o# 1255 Fcal>day Prosure 65'm
protein to be delivered at a rate o# 37
ml>hour 1/,2*1 dilution

6*?3 am
Mechanical ventilator settin's
decrease F%5, to 73C AC Mode !
?,5ml RR 12>min P$$P 3
Do8o#ylline ?55 m'>tab , times a day
<evodropopirine 15 ml 7 times a day
Montelukast 15 m'>tab once a day
secure previous dia'nostic results
done on the patient
11*55 am
% Iuid to #ollo- -as P;))
1< #or 6 hours
Continue Falium Durule
every 6 hours/

7*75 pm
PeriBolimel 1/? Fcal to run
#or ,? hours
decrease %F to FO once on
PeriBolimel
bed turnin' to sides every ,
hours/

Course in the -ard
3*55pm
Mr/ $<$ e8perienced di9culty
o# breathin' )!A! dose o#*
hydrocortisone 155 m' %
nebuliAation o# combivent
MidaAolam 3m' %
)hi#ted Combivent to
)albutamol K , ml o# normal
saline solution every ? hours
and as needed #or dyspnea
%ncreased (ydrocortisone to
155 m' % every 2 hours
%ntermittent strai'ht
catheteriAation every 6 hours
6*?3 pm
)trai'ht catheteriAation at 15 pm
&lood -orks o# serum potassium and
creatinine at 3 am
MethimaAole 3m'>tab once a day
)!A! dose o# %sordil 3m'>tab #or increased
&P
15*75pm
)!A! dose Morphine 1m' %
#or 1, <ead $C@,
blood-orks o# !roponin %, CF at 1*75am
)albutamol -as decreased to every 6
hours/
(R slidin' scale*
'reater than 165 m'>dl L , units
subcutaneously
'reater than ,,5 L ? units
subcutaneously
Course in the -ard
4/21/12
7*,5 am
Medicine service su''ested #oley
catheter insertion once sur'ery
service consents/
)!A! dose o# <actulose 75 ml,
then once a day at bedtime

2*35am
Cle8ane 5/2 ml subcutaneously
once a day
Clopido'rel +3m'>tab once a day
&lood -orks o# P!, P!!

+*75am
Medicine service su''ested
cardiolo'y re#erral
,d echo at bedside
6*55am
re#erred to Dr/P #or cardiolo'y
mana'ement
)albutamol -as discontinued, shi#ted
to Combivent 1 nebule K ,ml nss
every 2 hours and as needed #or
dyspnea
Chest GBray is scheduled #or the
#ollo-in' day
For $!A @)>C)
D*55am
)tart -ith beta blockers
)u''est salmeterol

D*?5am
Carvedilol once ok -ith cardio service
Maintain mechanical ventilator
settin's

Course in the -ard
15*55am
(old lisinopril #or no-
Olmesartan ?5 m'>tab once a day
%soket drip B D5ml P;)) K 15m'
%sordil 8 15 ml>hr, titrate to
maintain )&P M1?5
%vabradine 3m'>tab no-, then ,8
a day
4ill not start beta blockers #or
no-

11*55am
Discontinue Pravastatin
)tart <ipitor 65 m'>tab once a day
Cle8ane 5/2 ml subcutaneously
every 1, hours
(old imdur -hile on isoket drip
!rop ! and 1, lead $C@ at , pm
Amlodipine 3m'>tab once a day
<ast dose o# kalium durule
For <ipid Pro:le
1,*55nn
Aspirin 65 m'>tab once a day
Clopido'rel +3m'>tab once a day
For PC% on Monday ?>,7>1, 0 15 am
Re#er to cardiac rehab c>o Dr/&

,*55pm
Dr/ & #or anesthesia
Dr/ $ #or cardiac rehab
Course in the -ard
4/22/12
6*75am
Additional amlodipine 3m' this am
%soket drip to consume
)tart %mdur 25m'>tab once a day
PreBcatheteriAation orders
P;)) 1< 8 65ml>hour
Diphenhydramine 35 m' per
orem
%n#orm cath lab
%n#orm cardio #ello-

1,*55nn
)ave ri'ht radial artery
(old levopront #or no-
Fluimucil 255m'>tab in H 'lass ,8 a
day
3*55pm
AntiBhypertensive medication at
?>,7>1, 3am via ;@!
6*35pm
C&@ every ? hours -hile on ;PO
Maintain (R slidin' scale

D*13pm
Amlodipine K Olmesartan
(!-ynsta" 65>15 >tab once a day in
AM
;icardipine 1 m' % push no-
Restart isoket drip 15 m' isordil K
D5ml P;)) >m'>hr #or )&P 8 1?5
mm('
Course in the -ard
4/23/12
,*75am
;icardipine , m' % no-
+*55am
De#er coBmana'ement -ith Dr/A
6*55am
Combivent nebuliAation every 2
hours
Continue % hydrocortisone
Dr/ ! to cover
6*75am
;icardipine 1 m' % push no-
15*55am
Patient is under'oin' PC%

11*55am
Post CatheteriAation orders*
$levate not more than 75 de'rees
Re#er #or &P less than D5 (R less
than 35
Resume diet
Replace -ith the same %F every 6
hours
Replace -ith !R band -ith &andBAid
in AM
!R band release at ?pm
%soket drip ,5m' in 65ml P;)) 8 ?5
ml>hour (6m'>hour" then titrate to
maintain )&P less than or equal to
1?5
Course in the -ard
11*75am
!o %C.
For urine ;@A<
For creatinine ?>,?>1, am
%nclude C&C
Clopido'rel +3m'>tab , times a
day
CilostaAol 35m' >tab , times a
day
Aspirin 65m'>tab once a day
Cle8ane 5/2 ml , times a day
(old %mdur
Continue !-ynsta
Add Methyldopa ,35 m' > tab ,
times a day
P;)) 1< 8 6 hours
3*55pm

!eraAocin ((ytrin" ,
m'>tab once a day
4/24/12

6*55am

Decrease %F to ?5
ml>hour

;icardipine drip ,5m' K

65ml P;)) 8 15 cc>hour

%ncrease methyldopa to
355m' , times a day
Course in the -ard
6*75am

For %ca, M', ;a, F and CF

enAymes no-

Combivent 7 doses no-

(ydrocortisone 155m'>%
no-

MidaAolam , m'>% no-

CPR no-

De:brillate -ith ,55

Noules biphasic

Amiodarone 15m'>%
no-

C&C to blood-orks

(old #eedin' #or no-

For 1, lead $C@

For A&@

MidaAolam 7m'>%
no-

(old isoket and

nicardipine drip

Amiodarone 255m' K
,35ml D3 4ater 8 ,?
hours
Course in the -ard
D*,5am
Ma'nesium )ul#ate 1 'ram K D5 ml
D3 4ater #or 1 hour
Dolcet 1 tablet no-
(old ivabradine
(old methyldopa

15*55am
Potassium Chloride 15 meqs K D5 ml
o# P;)) #or 7 cycles
7 tabs o# Falium durule per ;@! no-
Falium durule , tabs every 6 hours
#or 7 doses
@ive , tabs o# Falium durule at 3 pm
Repeat potassium at 2 pm toni'ht
%ncrease combivent nebuliAation to
every ? hours #or no-
,*55pm

<ano8in 5/3 m' % no-

7*15pm
Decrease nebuliAation to
every 2 hours

)tandby nicardipine drip

#or )&PO135

3*?3pm
De#er cardiac rehab until
hemodynamically stable
Course in the -ard
2*75pm
(ydrocortisone 35 m' % every 6
hours
Discontinue do8o#ylline
Ce#tria8one #or + days
+*75pm
Potassium 15 meqs K D5 ml
P;)) 8 1 hour #or , cycles
Repeat potassium ?>,3>1, AM

11*55pm
@ive nicardipine 1m'>ml no-
Dolcet 1 tab every 6 hours #or
pain as needed
Course in the -ard
4/25/12
2*?3am
Potassium Chloride drip 15 meqs K
D5ml ;)) #or 1 hour #or 7 cycles/
%F to #ollo- P;)) 1< 8 ?5 ml>hour
+*75am
%mdur 75 m' once a day
!itrate nicardipine drip
%ncrease Falium Durule , tabs every 2
hours #or ? doses, 'ive , durules no-
Aldactone ,3 m'>tab every 1, hours
#or , doses
For potassium and ma'nesium
?>,2>1, am
Dolcet 1 tab no-/
Amiodarone drip to consume
then start Amiodarone
,55m'>tab 7 times a day
)hi#t %F to Plain <actated
Rin'ers K ?5meqs FC< 8 ?5
ml>hour
Decrease Cle8ane 5/2 ml
subcutaneous once a day
startin' ?>,+>1,
Cold compress to le#t hand 78
a day until s-ellin' resolves
D*55am
Consume dose o#
Acetylcysteine then
discontinue
;PO #or no-
)uction secretions thorou'hly
Revise dose o# (ytrin to
3m'>tab once a day/ @ive 1
st

dose no-
Course in the -ard
11*55am

;o obNection to
-eanin'

Re#er to cardiac rehab

%vabradine +/3' t-ice

a day

)@P! to ne8t
blood-orks

Dolcet 1 tablet every

6 hours as needed #or
pain
1*,5pm

Fentanyl ,3 m'>% no-

,*75pm

Post e8tubation B (ook

to O, at 1 lpm via nasal
cannula

May have 'eneral liquid

diet toni'ht -ith strict
aspiration precaution

Medical mana'ement
<aboratory
?>1D>,51,
$!A @)>C)

;ormal Flora
?>1D>,51,
Chest GBRay
%mpression*
Post sur'ical chan'es in the
ri'ht upper lobe and hilium
Mild tracheal narro-in' ,
may also be due to post
sur'ical chan'es
Probable nodule, le#t
!ortous and atherosclerotic
aorta
C! correlation is su''ested
and clinically -arranted
Medical mana'ement
<aboratory
()*+),-*,
.hemistry / (:01 pm
Test Result
SGPT Within normal range
Creatinine Within normal range
Sodium Within normal range
Potassium Within normal range
Medical mana'ement
<aboratory
()*+),-*,
.omplete 2lood .ount / (:01 pm
Test Result Normal Range Interpretation
Hemoglobin 131 g/L 13 ! 1"#
$lood loss and bone marro%
suppression redu&e total R$C
&ount and there'ore lo%er total
hemoglobin &ontent(
Hemato&rit #(3) (*# ! (*
+e&reased hemato&rit indi&ates
anemia- su&h as that &aused b.
iron de'i&ien&. or other
de'i&ien&ies(
R$C *(1 /1#011/L *(2# 3 2(1#
4 de&reased number o' R$Cs
results 'rom eithera&ute
or&hroni&blood loss( 4&ute
blood loss is a rapid depletion o'
blood 5olume( Chroni& blood loss
stems 'rom 5arious &onditions
that o'ten results in some 'orm
o' ananemia(
6ean Corpolar
hgb
31 1" ! 31
7le5ated 6CH is asso&iated %ith
ma&ro&.ti& anemia-
H.perlipidemia ma. gi5e a 'alse
ele5ation o' the 6CH
R+W 1(1 11( 3 1*(
R+W test results are o'ten used
together %ith
mean &orpus&ular 5olume86C9:
results to 'igure out %hat the
&ause o' the anemia might be
Medical mana'ement
<aboratory
"pecial .hemistry / 3:14
pm
Test Result
Troponin T Negati5e
Medical mana'ement
<aboratory
(),-),-*,
5rinalysis / *,:*4 am
Test Result Normal Range Interpretation
Color .ello% amber
Rea&tion (#
7r.thro&.tes Positi5e 8;;;:
It ma. beidiopathi&and/or
benign- or it &an be asign
that there is a<idne. stone
or atumorin the
urinar. tra&t8<idne.s-
ureters-urinar. bladder-
prostate- andurethra:-
ranging 'rom tri5ial to
lethal(
Protein Positi5e 8;;:
Possible %ith renal anomal.
Medical mana'ement
<aboratory
(),-),-*,
5rinalysis / *,:*4 am
Test Result Normal Range Interpretation
Glu&ose Positi5e 8;;:
Sin&e blood glu&ose is high
probabl. it &onne&ted to
ele5ated blood glu&ose
Leu&o&.tes Positi5e 8;:
4 positi5e leu<o&.te esterase test
results 'rom the presen&e o'
%hite blood &ells either as %hole
&ells or as destro.ed &ells(
R$C 12/ul #!11
Hematuria is the presen&e o' abnormal
numbers o' red &ells in urine due to an.
o' se5eral possible &auses- e(g(
glomerular damage- tumors %hi&h erode
the urinar. tra&t an.%here along its
length- <idne. trauma- urinar. tra&t
stones- renal in'ar&ts- a&ute tubular
ne&rosis- upper and lo%er urinar. tra&t
in'e&tions- nephroto/ins- and ph.si&al
stress 8li<e a &onta&t sport- or long
distan&e running 'or e/ample:( Red &ells
ma. also &ontaminate the urine 'rom
trauma produ&ed b. bladder
&atheri=ation(
Medical mana'ement
<aboratory
(),-),-*,
5rinalysis / *,:*4 am
Test Result Normal Range Interpretation
W$C 33/ul #!11
P.uria re'ers to abnormal
numbers o' leu<o&.tes 8%hite
&ells: that ma. appear %ith
in'e&tion in either the upper or
lo%er urinar. tra&t or %ith a&ute
glomerulonephritis(
7pithelial 33/L #!11
S>uamous epithelial &ells 'rom
the s<in sur'a&e or 'rom the
outer urethra &an appear in
urine( The. represent possible
&ontamination o' the spe&imen
%ith s<in ba&teria(
Medical mana'ement
<aboratory
(),-),-*,
62G / 0:0+ am
Test Result Normal Range Interpretation
PH "(3"? "(3 ! "(*
PaCo1 3(1 3 ! * mmHg @n&ompensated
PaA1 1""(" ?# 3 1## mmHg 6etaboli&
Standard
$i&arbonate
1#(" 11 3 1" mmol/l 4&idosis
A1 saturation !3(1 # ; (1
$ase 7/&ess ))(1B CD ) B
Medical mana'ement
<aboratory
(),*),-*,
"pecial .hemistry 7 (:(- am
Test Result Normal Range Interpretation
CE Total 2#"(# 3# ! 1##
It indi&ates the a&ti5it. o'
the 66- 6$- and $$
isoen=.mes
CE 3 6$ *1(# # ! 1*
CE!6$ is &onsidered the
ben&hmar< 'or &ardia&
mar<ers o' m.o&ardial
inFur.
CE 3 66 22(# 3# ! 1"2
CE ! 66 e/plains tissue
inFur. and ma. be ele5ated
as earl. as one hour a'ter
m.o&ardial inFur.- though it
ma. also be ele5ated due
to s<eletal mus&le trauma(
Medical mana'ement
<aboratory
(),*),-*,
.hemistry 7 (:(- am
Test Result
Potassium Within normal range
Creatinine Within normal range
(),*),-*,
"pecial .hemistry 7 (:(- am
Test Result %nterpretation
Troponin I Positi5e indi&ate a person has
had a signi'i&ant
m.o&ardial inFur.
Medical mana'ement
<aboratory
(),*),-*,
"pecial .hemistry / *:0+ pm
Test Result Normal Range Interpretation
Troponin T #(12 ng/ml #(1 ng/ml
8onsetG 3!* hrs-
pea<G
1#!1* hrs-
return to
normalG 1#!1*
da.s:
High ris<
m.o&ardial
damage has
been dete&ted
Medical mana'ement
<aboratory
(),*)*,
"pecial .hemistry / *:0+ pm
Test Result Normal Range Interpretation
CE Total **1(# 3# ! 1##
It indi&ates the a&ti5it. o' the
66- 6$- and $$ isoen=.mes
CE 3 6$ **(# # ! 1*
CE!6$ is &onsidered the
ben&hmar< 'or &ardia&
mar<ers o' m.o&ardial inFur.
CE 3 66 3)"(# 3# ! 1"2
CE ! 66 e/plains tissue inFur.
and ma. be ele5ated as earl.
as one hour a'ter m.o&ardial
inFur.- though it ma. also be
ele5ated due to s<eletal
mus&le trauma(
Medical mana'ement
<aboratory
(),*),-*,
.hemistry 7**:-0 pm
Test Result
Cholesterol Within normal range
L+L Cholesterol Within normal range
H+L Cholesterol Within normal range
Trigl.&erides Within normal range
9L+L Within normal range
Medical mana'ement
<aboratory
?>,,>,51,
Chest GBRay
%mpression*
Post sur'ical chan'es in the ri'ht upper lobe
and hilium
Mild tracheal narro-in' , may also be due to
post sur'ical chan'es
Consider pulmonary nodule versus en #ace,
le#t
Atherosclerotic aorta
Medical mana'ement
<aboratory
(),(),-*,
.hemistry / (am
Test Result Normal Range Interpretation
Creatinine (2 u6ol/L 21 3 11 +e&rease in serum
&reatinine is seen
in &onditions
&hara&teri=ed b.
mus&le %asting
@rine NG4L 11() # 3 131("# +e5iation ma.
indi&ate
a&ute <idne. inFur
.
Medical mana'ement
<aboratory
(),(),-*,
.omplete 2lood .ount 7 + am
Test Result Normal Range Interpretation
Hemoglobin 111 g/L 13 ! 1"#
$lood loss and bone
marro% suppression
redu&e total R$C &ount
and there'ore lo%er
total hemoglobin
&ontent(
Hemato&rit #(3* (*# ! (*
+e&reased hemato&rit
indi&atesanemia- su&h
as that &aused b. iron
de'i&ien&. or other
de'i&ien&ies(
Medical mana'ement
<aboratory
(),(),-*,
.omplete 2lood .ount 7 + am
Test Result Normal Range Interpretation
R$C 3(2 /1#011/L *(2# 3 2(1#
4 de&reased number o'
R$Cs results 'rom
eithera&ute
or&hroni&blood loss( 4&ute
blood loss is a rapid
depletion o' blood 5olume(
Chroni& blood loss stems
'rom 5arious &onditions
that o'ten results in some
'orm o' ananemia(
Neutrophil ( (2 ! (22
Neutropeniama. be
parado/i&all. seen in
&ertain in'e&tions-
in&luding 5iral illnesses(
Ather &auses in&lude
aplasti& anemia and
th.roid disorders
Medical mana'ement
<aboratory
(),(),-*,
.omplete 2lood .ount 7 + am
Test Result Normal Range Interpretation
L.mpho&.te (#) (11!*#
It is also seen in
a&ute in'e&tions-
%ith administration
o' &orti&osteroids(
7osinophil # #(*
7osinopeniais seen
in the earl. phase o'
a&ute insults- su&h
as sho&<- maFor
p.ogeni& in'e&tions-
trauma- surger.-
et&( +rugs produ&ing
eosinopenia in&lude
&orti&osteroids(
Medical mana'ement
<aboratory
(),()*,
"pecial .hemistry / + am
Test Result Normal Range Interpretation
CE Total 11*(# 3# ! 1##
It indi&ates the a&ti5it. o'
the 66- 6$- and $$
isoen=.mes
CE 3 6$ *)(# # ! 1*
CE!6$ is &onsidered the
ben&hmar< 'or &ardia&
mar<ers o' m.o&ardial
inFur.
CE 3 66 "(# 3# 3 1"2
CE ! 66 e/plains tissue
inFur. and ma. be ele5ated
as earl. as one hour a'ter
m.o&ardial inFur.- though it
ma. also be ele5ated due
to s<eletal mus&le trauma(
Medical mana'ement
<aboratory
(),()*,
"pecial .hemistry / + am
Test Result Normal Range Interpretation
6agnesium (?" (22 3 1(#" Within normal
range
Sodium 1*2 13 3 1*
In&reasein serum sodium is seen in
&onditions %ith %ater loss in e/&ess o'
salt loss- as in pro'use s%eating- se5ere
diarrhea or 5omiting- pol.uria and
inade>uate %ater inta<e( +rugs &ausing
ele5ated sodium in&lude steroids %ith
mineralo&orti&oid a&ti5it.- and
meth.ldopa
Potassium 1(? 3( 3 (1
+e&reasein serum potassium is seen
usuall. in states &hara&teri=ed b.
e/&essE;loss- su&h as in 5omiting-
diarrhea- &ertain renal tubular
de'e&ts(Redistribution h.po<alemia is
seen in glu&ose/insulin therap.- al<alosis(
+rugs &ausing h.po<alemia in&lude
&orti&osteroids- diureti&s(
Medical mana'ement
<aboratory
(),(),-*,
62G / + am
Test Result Normal Range Interpretation
PH "(*#1 "(3 ! "(*
PaCo1 *#() 3 ! * mmHg Normal
PaA1 123(1 ?# 3 1## mmHg
Standard
$i&arbonate
1(3 11 3 1" mmol/l
A1 saturation 1(1 # ; (1
$ase 7/&ess ))(1B CD ) B
Medical mana'ement
<aboratory
(),(),-*,
.hemistry / 4pm
Test Result Normal Range Interpretation
Potassium 3(1# 3( 3 (1
+e&reasein serum
potassium is seen
usuall. in states
&hara&teri=ed b.
e/&essE;loss- su&h as
in 5omiting- diarrhea-
&ertain renal tubular
de'e&ts(Redistribution
h.po<alemia is seen in
glu&ose/insulin therap.-
al<alosis( +rugs &ausing
h.po<alemia in&lude
&orti&osteroids-
diureti&s(
Medical mana'ement
<aboratory
(),0),-*,
.hemistry / 0am
Test Result Normal Range Interpretation
Potassium 3(# 3( 3 (1
+e&reasein serum
potassium is seen
usuall. in states
&hara&teri=ed b.
e/&essE;loss- su&h as
in 5omiting- diarrhea-
&ertain renal tubular
de'e&ts(Redistribution
h.po<alemia is seen in
glu&ose/insulin therap.-
al<alosis( +rugs &ausing
h.po<alemia in&lude
&orti&osteroids-
diureti&s(
Medical mana'ement
<aboratory
(),4),-*,
.hemistry 70 am
Test Result
Potassium Within normal range
6agnesium Within normal range
Medical mana'ement
<aboratory
(),4),-*,
.hemistry
Test Result Normal Range Interpretation
SGPT 12? # !
4 number o' &onditions &an
&ause damage to li5er
&ells- resulting in an
in&rease in 4LT le5els( The
test is most use'ul in
dete&ting damage due to
hepatitisand drugs or other
substan&es to/i& to the
li5er( 4LT- ho%e5er- is not
entirel. spe&i'i& 'or the
li5er- and mild to
moderatel. in&reased
le5els ma. also be seen in
&onditions a''e&ting other
parts o' the bod.(
+iagnosti&s
4/19/2012
CBC
Na
K
Creatinine
UA
ETA GS/GS
TSH
FT4
ALT
Trop T
Chest Xra!
ABG
12 Lea" ECG
CBG
4/20/2012
#otassi$%
Creatinine
12 Lea" ECG
Troponin &
CK
4/21/2012
#T
#TT
2" E'ho
ETA GS/CS
4/22/2012
Chest Xra!
+iagnosti&s
4/2(/2012
#C&
CBC
Urine NGAL
4/24/2012
Crea
&'a
)*
Na
K
CK en+!%es
CBC
ABG
12 Lea" ECG
,epeat K at
-p%
4/2./2012
K
SG#T
Treatment
?>1D>,51,
Patient -as initially dia'nosed as acute respiratory #ailure
probably secondary to COPD in acute e8acerbation/
)tarted -ith P;)) 1< 8 6 hours
;@! -as inserted
laboratory blood tests -ere requested
)tarted on antibiotics, steroids bronchodilators alon' -ith
antihypertensive medications, 'astric protectant, electrolytes
and medications #or his &P(
started on continuous #eedin'
C&@ monitorin' -as started
dru' #or di9culty o# sleepin' -as also ordered
!here -as also constant chan'in' o# the mechanical ventilator
settin's/
Treatment
?>,5>,51,
PatientPs diet -as revised
Mechanical ventilator settin's -ere a'ain adNusted
AntiBasthma medications started
$lectrolyte supplement -as continued
)tarted on parenteral nutrition
Ordered #or bed turnin'
At 3 pm he e8perienced di9culty o# breathin'* steroids and
bronchodilators -ere ordered alon' -ith antiBa'itation meds
)teroid dose -as also increased to every 2 hours #rm every 6
hours/
%ntermittent strai'ht catheteriAation every 6 hours -as ordered #or
bladder distension/
!he patient complained o# chest pain and -as ordered pain meds
and 1, lead $C@
Cardiac enAymes at 1 am
&ronchodilator -as decreased to every 6 hours and a (R slidin'
scale -as started/
Treatment
?>,1>,51,
!he medicine service su''ested #oley catheteriAation i# ok -ith
sur'ery service
)!A! dose o# la8ative -as 'iven
)tarted on lo-BmolecularB-ei'ht heparin and blood thinners
&lood-orks #or bleedin' and clottin' time -as ordered
Medicine ordered cardio re#erral since patient does not have a
consistent blood pressure
,D echo at bedside -as also done
!he bronchodilator -as chan'ed to another
PatientPs settin' o# the mechanical ventilator -as maintained
)tarted on oral and % antihypertensive medications
)hi#ted antiBlipids to another and increased the dose o# the lo-B
molecularB-ei'ht heparin
Ordered #or $C@ and lipid pro:le
)cheduled #or PC% on the ,7
rd/

Treatment
?>,,>,51,

PreBcatheteriAation orders -ere 'iven

%nstructed to save radial artery

AntiBtussive medication -as discontinued and -as

'iven a mucolytic

%nstructed to take his antihypertensive medication at 3

am

C&@ monitorin' -ill be every ? hours -hile on ;PO

Revised , antihypertensive medication into a

combination dru'

Restarted on % antihypertensive medication due to

unstable &Ps
Treatment
?>,7>,51,

Patient -as ordered an % push o# an

antihypertensive medication due to unstable
&P at , am, another dose at 6 am

At 15 am PC% -as done to the patient

PostBcatheteriAation orders -ere 'iven

Diet -as resumed and a double concentration

o# % antihypertensive -as started

(is medication doses -ere adNusted

Another medication #or his &P( -as added

Treatment

?>,?>,51,

Decreased %F to ?5 ml per hour

;icardipine drip -as ordered

At 6*75 am, patientPs &P -ere risin' and then he

became pulseless, he has ventricular tachycardia

CPR and de:brillation -as done

&ronchodilator 7 doses -ere ordered

A&@, $C@ and blood-orks to check #or electrolyte

imbalance -ere ordered

;ebuliAation -as increased to every ? hours

Amiodarone in#usion -as started

ordered #or ma'nesium to run #or 1 hour a#ter

blood-orks collection
Treatment

4hen the results arrived, he -as ordered #or #ast

potassium correction

(e -as 'iven pain meds #or his complain

At , pm, nebuliAation -as decreased to every 2

hours

Cardiac rehab re#erral -as temporarily de#erred

For repeat potassium at 2 pm, and since the result

-as lo-, he -as a'ain ordered #or potassium
correction/

Pain meds -as ordered to every 6 hours

Repeat potassium in the AM -as ordered

Treatment

?>,3>,51,

Potassium levels -ere still lo-

Another potassium correction order -as 'iven

Oral potassium -as also ordered

Amiodarone -as shi#ted to oral

Revised the dosa'e #or his &P( meds

(e -as ordered ;PO prior to -eanin'

;o obNection to -eanin' -as noted

)ubsequently -eaned #rom mechanical ventilation

(e tolerated the -eanin' process

(ooked to 5, via nasal cannula/

Anatomy and Physiolo'y
4N4TA6H 4N+ PHHSIALAGHG
The respirator. s.stem &onsists o' all the organs in5ol5ed in breathing(
These in&lude the nose- phar.n/- lar.n/- tra&hea- bron&hi and lungs(
The respirator. s.stem does t%o 5er. important thingsG it brings o/.gen
into our bodies- %hi&h %e need 'or our &ells to li5e and 'un&tion
properl.I and it helps us get rid o' &arbon dio/ide- %hi&h is a %aste
produ&t o' &ellular 'un&tion( The nose- phar.n/- lar.n/- tra&hea and
bron&hi all %or< li<e a s.stem o' pipes through %hi&h the air is 'unneled
do%n into our lungs( There- in 5er. small air sa&s &alled al5eoli- o/.gen
is brought into the bloodstream and &arbon dio/ide is pushed 'rom the
blood out into the air( When something goes %rong %ith part o' the
respirator. s.stem- su&h as an in'e&tion li<e pneumonia- &hroni&
obstru&ti5e pulmonar. diseases- it ma<es it harder 'or us to get the
o/.gen %e need and to get rid o' the %aste produ&t &arbon dio/ide(
Common respirator. s.mptoms in&lude breathlessness- &ough- and &hest
pain(
Anatomy and Physiolo'y
Anatomy and Physiolo'y
The Upper Air/a! an" Tra'hea

When .ou breathe in- air enters .our bod. through

.our nose or mouth( Jrom there- it tra5els do%n
.our throat through the lar.n/ 8or 5oi&ebo/: and
into the tra&hea 8or %indpipe: be'ore entering
.our lungs( 4ll these stru&tures a&t to 'unnel 'resh
air do%n 'rom the outside %orld into .our bod.(
The upper air%a. is important be&ause it must
al%a.s sta. open 'or .ou to be able to breathe( It
also helps to moisten and %arm the air be'ore it
rea&hes .our lungs(
Anatomy and Physiolo'y
The L$n*s
Stru&ture
The lungs are paired- &one!shaped organs %hi&h ta<e up most o' the
spa&e in our &hests- along %ith the heart( Their role is to ta<e
o/.gen into the bod.- %hi&h %e need 'or our &ells to li5e and
'un&tion properl.- and to help us get rid o' &arbon dio/ide- %hi&h is
a %aste produ&t( We ea&h ha5e t%o lungs- a le't lung and a right
lung( These are di5ided up into KlobesL- or big se&tions o' tissue
separated b. K'issuresL or di5iders( The right lung has three lobes
but the le't lung has onl. t%o- be&ause the heart ta<es up some o'
the spa&e in the le't side o' our &hest( The lungs &an also be di5ided
up into e5en smaller portions- &alled Kbron&hopulmonar. segmentsL(
These are p.ramidal!shaped areas %hi&h are also separated 'rom
ea&h other b. membranes( There are about 1# o' them in ea&h lung(
7a&h segment re&ei5es its o%n blood suppl. and air suppl.(
Anatomy and Physiolo'y
Anatomy and Physiolo'y
CAP+ 97RS@S H74LTHH L@NG
Ho% the. %or<
4ir enters .our lungs through a s.stem o' pipes &alled the bron&hi( These
pipes start 'rom the bottom o' the tra&hea as the le't and right bron&hi and
bran&h man. times throughout the lungs- until the. e5entuall. 'orm little
thin!%alled air sa&s or bubbles- <no%n as the al5eoli( The al5eoli are %here
the important %or< o' gas e/&hange ta<es pla&e bet%een the air and .our
blood( Co5ering ea&h al5eolus is a %hole net%or< o' little blood 5essel &alled
&apillaries- %hi&h are 5er. small bran&hes o' the pulmonar. arteries( It is
important that the air in the al5eoli and the blood in the &apillaries are 5er.
&lose together- so that o/.gen and &arbon dio/ide &an mo5e 8or di''use:
bet%een them( So- %hen .ou breathe in- air &omes do%n the tra&hea and
through the bron&hi into the al5eoli( This 'resh air has lots o' o/.gen in it-
and some o' this o/.gen %ill tra5el a&ross the %alls o' the al5eoli into .our
bloodstream( Tra5eling in the opposite dire&tion is &arbon dio/ide- %hi&h
&rosses 'rom the blood in the &apillaries into the air in the al5eoli and is then
breathed out( In this %a.- .ou bring in to .our bod. the o/.gen that .ou need
to li5e- and get rid o' the %aste produ&t &arbon dio/ide(
Anatomy and Physiolo'y
Anatomy and Physiolo'y
&lood )upply

!he lun's are very vascular or'ans, meanin' they

receive a very lar'e blood supply/ !his is because
the pulmonary arteries, -hich supply the lun's,
come directly #rom the ri'ht side o# your heart/
!hey carry blood -hich is lo- in o8y'en and hi'h
in carbon dio8ide into your lun's so that the
carbon dio8ide can be blo-n oQ, and more o8y'en
can be absorbed into the bloodstream/ !he ne-ly
o8y'enBrich blood then travels back throu'h the
paired pulmonary veins into the le#t side o# your
heart/ From there, it is pumped all around your
body to supply o8y'en to cells and or'ans/
Anatomy and Physiolo'y

The 8or% of 2reathing

!he Pleurae

!he lun's are covered by smooth membranes that

-e call pleurae/ !he pleurae have t-o layers, a
RvisceralP layer -hich sticks closely to the outside
sur#ace o# your lun's, and a RparietalP layer -hich
lines the inside o# your chest -all (ribca'e"/ !he
pleurae are important because they help you
breathe in and out smoothly, -ithout any #riction/

!hey also make sure that -hen your ribca'e

e8pands on breathin' in, your lun's e8pand as
-ell to :ll the e8tra space/
Anatomy and Physiolo'y
The 8or% of 2reathing
!he Diaphra'm and %ntercostal Muscles
4hen you breathe in (inspiration", your muscles need to -ork
to :ll your lun's -ith air/ !he diaphra'm, a lar'e, sheetBlike
muscle -hich stretches across your chest under the ribca'e,
does much o# this -ork/ At rest, it is shaped like a dome
curvin' up into your chest/ 4hen you breathe in, the
diaphra'm contracts and Iattens out, e8pandin' the space in
your chest and dra-in' air into your lun's/ Other muscles,
includin' the muscles bet-een your ribs (the intercostal
muscles" also help by movin' your ribca'e in and out/
&reathin' out (e8piration" does not normally require your
muscles to -ork/ !his is because your lun's are very elastic,
and -hen your muscles rela8 at the end o# inspiration your
lun's simply recoil back into their restin' position, pushin'
the air out as they 'o/
;ursin' Care
Plan
ASSESS)ENT 0&AGN1S&S #LANN&NG &NTE,2ENT&1N ASSESS)ENT
SubFe&ti5eG
Patient points
at mouth 'or
su&tioning
AbFe&ti5eG
Patient has a
endotra&heal
tube &onne&ted
to a me&hani&al
5entilator
Presen&e o'
&opious and
thi&< se&retions
+iagnosed %ith
pneumonia-
moderate ris<
With harsh
ron&hi and rales
RR 3 12 breaths
per minute
Ine''e&ti5e
air%a.
&learan&e
related to
in&reased
mu&us
produ&tion- due
to
bron&hopulmon
ar. in'e&tion
Short termG
4'ter * hours o'
nursing
inter5ention-
the amount o'
&opious
se&retions
%ould de&rease
and no
desaturations
%ill o&&ur
Long termG
4'ter 1 %ee< o'
nursing
inter5ention-
patient %ould
ha5e &lear
breath sounds
6onitor
respirator.
rate
4us&ultate
breath
sounds
In5estigate
'or
restlessness-
d.spnea and
signs o'
&.anosis
7le5ate head
o' the bed
'or 3#!*
minutes
7n&ourage
&oughing and
deep
breathing
4'ter * hoursG
No
desaturation
s noted 'or
the %hole
shi't(
Lessened
se&retions
RR D 1#
breaths per
minute
4'ter 1 %ee<G
6inimal
rales and
ron&hi
&ompared to
admission
ASSESS)ENT 0&AGN1S&S #LANN&NG &NTE,2ENT&1N ASSESS)ENT
SubFe&ti5eG
Patient points
at mouth 'or
su&tioning
AbFe&ti5eG
Patient has a
endotra&heal
tube &onne&ted
to a me&hani&al
5entilator
Presen&e o'
&opious and
thi&< se&retions
+iagnosed %ith
pneumonia-
moderate ris<
With harsh
ron&hi and rales
RR 3 12 breaths
per minute
Ine''e&ti5e
air%a.
&learan&e
related to
in&reased
mu&us
produ&tion- due
to
bron&hopulmon
ar. in'e&tion
Short termG
4'ter * hours o'
nursing
inter5ention-
the amount o'
&opious
se&retions
%ould de&rease
and no
desaturations
%ill o&&ur
Long termG
4'ter 1 %ee< o'
nursing
inter5ention-
patient %ould
ha5e &lear
breath sounds
Su&tion
endotra&heal
tube and oral
and nasal
a&ti5ities as
needed- note
'or amount-
&olor and
&onsisten&.
o' se&retions
6onitor 'orn
7T tube
pla&ement
Reposition
patient e5er.
1 hours
4'ter * hoursG
No
desaturation
s noted 'or
the %hole
shi't(
Lessened
se&retions
RR D 1#
breaths per
minute
4'ter 1 %ee<G
6inimal
rales and
ron&hi
&ompared to
admission
ASSESS)ENT 0&AGN1S&S #LANN&NG &NTE,2ENT&1N ASSESS)ENT
SubFe&ti5eG
Patient points
at mouth 'or
su&tioning
AbFe&ti5eG
Patient has a
endotra&heal
tube &onne&ted
to a me&hani&al
5entilator
Presen&e o'
&opious and
thi&< se&retions
+iagnosed %ith
pneumonia-
moderate ris<
With harsh
ron&hi and rales
RR 3 12 breaths
per minute
Ine''e&ti5e
air%a.
&learan&e
related to
in&reased
mu&us
produ&tion- due
to
bron&hopulmon
ar. in'e&tion
Short termG
4'ter * hours o'
nursing
inter5ention-
the amount o'
&opious
se&retions
%ould de&rease
and no
desaturations
%ill o&&ur
Long termG
4'ter 1 %ee< o'
nursing
inter5ention-
patient %ould
ha5e &lear
breath sounds
6onitor
pulse
o/imetr.
and 4$Gs
as ordered
6aintain on
me&hani&al
5entilation
Nebuli=a!
tion as
ordered
4ntibioti&s
as ordered
4'ter * hoursG
No
desaturation
s noted 'or
the %hole
shi't(
Lessened
se&retions
RR D 1#
breaths per
minute
4'ter 1 %ee<G
6inimal
rales and
ron&hi
&ompared to
admission
ASSESS)ENT 0&AGN1S&S #LANN&NG &NTE,2ENT&1N ASSESS)ENT
AbFe&ti5eG
Patient has a
endotra&heal
tube
&onne&ted to
a me&hani&al
5entilator
Presen&e o'
&opious and
thi&<
se&retions
RR 3 12
breaths per
minute
Patient is
diagnosed
%ith
pneumonia-
moderate ris<
4$G sho%s
un&ompensate
d metaboli&
a&idosis
Impaired
gas
e/&hange
related to
retained
se&retions
and
in'e&tious
pro&ess
Short termG
4'ter ? hours
o' nursing
inter5ention-
no d.spnea
%ill o&&ur
Long termG
4'ter 1 da. o'
nursing
inter5ention-
patientLs 4$G
%ill be normal
4us&ultate
lung 'ield
e5er. ?
hours to
assess 'or
altered
breath
sounds and
noting areas
o' de&reased
or absent
5entilation
Note depth
o'
respiration-
presen&e o'
d.spnea
4ssess the
le5els o'
&on&iousness
4'ter ? hours
No d.spnea
noted 'or
the %hole
shi't(
Lessened
se&retions
RR D 1#
breaths per
minute
4'ter 1 da.
4$Gs
normal
ASSESS)ENT 0&AGN1S&S #LANN&NG &NTE,2ENT&1N ASSESS)ENT
AbFe&ti5eG
Patient has a
endotra&heal
tube
&onne&ted to
a me&hani&al
5entilator
Presen&e o'
&opious and
thi&<
se&retions
RR 3 12
breaths per
minute
Patient is
diagnosed
%ith
pneumonia-
moderate ris<
4$G sho%s
un&ompensate
d metaboli&
a&idosis
Impaired
gas
e/&hange
related to
retained
se&retions
and
in'e&tious
pro&ess
Short termG
4'ter ? hours
o' nursing
inter5ention-
no d.spnea
%ill o&&ur
Long termG
4'ter 1 da. o'
nursing
inter5ention-
patientLs 4$G
%ill be normal
In5estigate
'or reports
o' &hest pain
7le5ate head
o' bed
Su&tion
air%a. as
needed using
sterile
te&hni>ue
4llo%
ade>uate
rest periods
in bet%een
a&ti5ities
7n&ourage
deep
breathing
e/er&ises
4'ter ? hours
No d.spnea
noted 'or
the %hole
shi't(
Lessened
se&retions
RR D 1#
breaths per
minute
4'ter 1 da.
4$Gs
normal
ASSESS)ENT 0&AGN1S&S #LANN&NG &NTE,2ENT&1N ASSESS)ENT
AbFe&ti5eG
Patient has a
endotra&heal
tube
&onne&ted to
a me&hani&al
5entilator
Presen&e o'
&opious and
thi&<
se&retions
RR 3 12
breaths per
minute
Patient is
diagnosed
%ith
pneumonia-
moderate ris<
4$G sho%s
un&ompensate
d metaboli&
a&idosis
Impaired
gas
e/&hange
related to
retained
se&retions
and
in'e&tious
pro&ess
Short termG
4'ter ? hours
o' nursing
inter5ention-
no d.spnea
%ill o&&ur
Long termG
4'ter 1 da. o'
nursing
inter5ention-
patientLs 4$G
%ill be normal
7n&ourage
turning 'rom
side to side
6onitor 4$Gs
and pulse
o/imetr.
Pro5ide %ith
&hest
ph.siothera!
p.
Pro5ide
humidi'ied
supplemen!
tal o/.gen
b.
maitaining
on
me&hani&al
5entilator
4'ter ? hours
No d.spnea
noted 'or
the %hole
shi't(
Lessened
se&retions
RR D 1#
breaths per
minute
4'ter 1 da.
4$Gs
normal
ASSESS)ENT 0&AGN1S&S #LANN&NG &NTE,2ENT&1N ASSESS)ENT
AbFe&ti5eG
Patient has a
endotra&heal
tube
&onne&ted to
a me&hani&al
5entilator
Presen&e o'
&opious and
thi&<
se&retions
RR 3 12
breaths per
minute
Patient is
diagnosed
%ith
pneumonia-
moderate ris<
4$G sho%s
un&ompensate
d metaboli&
a&idosis
Impaired
gas
e/&hange
related to
retained
se&retions
and
in'e&tious
pro&ess
Short termG
4'ter ? hours
o' nursing
inter5ention-
no d.spnea
%ill o&&ur
Long termG
4'ter 1 da. o'
nursing
inter5ention-
patientLs 4$G
%ill be normal
4dminister
medi&ations
as ordered
su&h as
bron&hodi!
lators-
antibioti&s-
antitussi5es-
antiasthma
et&(
75aluate the
e''e&ti5e!
ness o'
nebuli=ation
4'ter ? hours
No d.spnea
noted 'or
the %hole
shi't(
Lessened
se&retions
RR D 1#
breaths per
minute
4'ter 1 da.
4$Gs
normal
ASSESS)ENT 0&AGN1S&S #LANN&NG &NTE,2ENT&1N ASSESS)ENT
AbFe&ti5eG
H.potension
o' ?#/2#
Potassium
le5el o' 1(?
Patient is
diagnosed to
be
h.pertensi5e
Patient is
diagnosed to
be h.perlipi!
demi&
In&reased
blood sugar
With histor. o'
d.sr.thmias
Restless
Jrom
ta&h.&ardia to
pulselessness
Ine''e&ti5e
&ardiopulmo!
nar. tissue
per'usion
related to
ele&tri&al
alterations o'
the heartLs
rate- rh.thm
and
&ondu&tion
se&ondar. to
ele&trol.te
imbalan&e
Short termG
4'ter 1 hour o'
nursing
inter5ention-
patient %ill be
re5i5ed and 5ital
signs %ould be at
a normal range
Long termG
4'ter 1 da. o'
nursing
inter5ention-
patientLs
ele&trol.tes %ill
be in a normal
le5el and ha5e
de&reased
're>uen&. o'
d.sr.thmia
6onitor 5ital
signs- &ardia&
rate/rh.thm-
do&ument 'or
d.srrh.thmias
$e read. /
assist in
Cardiopul!
monar.
resusitation
6onitor
ele&trol.te
le5els
4'ter 1 hour
9ital signs
T!32- RR!
1*- PR!""-
$P 1/?"
Patient %as
re5i5ed(
4'ter 1 da.
Potassium
le5el 3 3(#
ASSESS)ENT 0&AGN1S&S #LANN&NG &NTE,2ENT&1N ASSESS)ENT
AbFe&ti5eG
H.potension
o' ?#/2#
Potassium
le5el o' 1(?
Patient is
diagnosed to
be
h.pertensi5e
Patient is
diagnosed to
be h.perlipi!
demi&
In&reased
blood sugar
With histor. o'
d.sr.thmias
Restless
Jrom
ta&h.&ardia to
pulselessness
Ine''e&ti5e
&ardiopulmo!
nar. tissue
per'usion
related to
ele&tri&al
alterations o'
the heartLs
rate- rh.thm
and
&ondu&tion
se&ondar. to
ele&trol.te
imbalan&e
Short termG
4'ter 1 hour o'
nursing
inter5ention-
patient %ill be
re5i5ed and 5ital
signs %ould be at
a normal range
Long termG
4'ter 1 da. o'
nursing
inter5ention-
patientLs
ele&trol.tes %ill
be in a normal
le5el and ha5e
de&reased
're>uen&. o'
d.sr.thmia
4dminister
Jluids and
ele&trol.tes
as indi&ated
4dminister
medi&ations
as ordered
6aintain on
me&hani&al
5entilation
4'ter 1 hour
9ital signs
T!32- RR!
1*- PR!""-
$P 1/?"
Patient %as
re5i5ed(
4'ter 1 da.
Potassium
le5el 3 3(#
ASSESS)ENT 0&AGN1S&S #LANN&NG &NTE,2ENT&1N ASSESS)ENT
SubFe&ti5eG
Patient
points to
&hest- %hen
as<ed i' it is
pain'ul- he
replied .es
Pain S&ore o'
"/1#
AbFe&ti5eG
Pain
appeared
a'ter &ode
With 'a&ial
grima&e
Restlessness
4&ute
pain
related to
&ardiopul!
monar.
resus&ita!
tion(
Short termG
4'ter 1 hour o'
nursing
inter5ention-
patientLs pain
le5el %ill be
less than *
Long termG
4'ter 1 shi'ts
o' nursing
inter5ention-
patientLs pain
%ill be
relie5ed
+o&ument
lo&ation and
intensit. o'
pain
In5estigate
&hanges in
pain
&hara&teristi
&s
Promote
general
&om'ort
measures
su&h as ba&<
rubbing-
deep
breathing
e/er&ises
and
5isuali=ation
Pain
le5el
a'ter 1
hour
*/1#
Pain
le5el
a'ter 1
shi'ts
/1#
ASSESS)ENT 0&AGN1S&S #LANN&NG &NTE,2ENT&1N ASSESS)ENT
SubFe&ti5eG
Patient
points to
&hest- %hen
as<ed i' it is
pain'ul- he
replied .es
Pain S&ore o'
"/1#
AbFe&ti5eG
Pain
appeared
a'ter &ode
With 'a&ial
grima&e
Restlessness
4&ute
pain
related to
&ardiopul!
monar.
resus&ita!
tion(
Short termG
4'ter 1 hour o'
nursing
inter5ention-
patientLs pain
le5el %ill be
less than *
Long termG
4'ter 1 shi'ts
o' nursing
inter5ention-
patientLs pain
%ill be
relie5ed
In5estigate
'or reports
o' poor
lo&ali=e pain
unrelie5ed
b. analgesi&s
4dminister
medi&ations
su&h as
+ol&et
Re'er to pain
management
Pain
le5el
a'ter 1
hour
*/1#
Pain
le5el
a'ter 1
shi'ts
/1#