Case study: Mr. Patrick Cowley resident of Shady Acres Continuing Care Centre arrived at Emergency.

Case study:

Mr. Patrick Cowley resident of Shady Acres Continuing Care Centre arrived at Emergency.He complains of increased cough over the past three weeks and fever for 48 hours. The doctor queries pneumonia and last shift reported an increased temperature and blood work confirms an increased WBC count. Previous nurse gave Tylenol 20 minutes ago for his temperature. Mr. Cowley receives intermittent HDC for hydration. The doctor has started him on corticosteroids. This is also day 3 with no bowel movement and Mr. Cowley requires a bowel routine as ordered by doctor.

PATHOLOGY: Dehydration, Pneumonia, Dementia

Initial Vital Signs: BP: 145/95 mmHg; Pulse (radial): 100bpm strong/regular; Resp Rate: 20 unlabored/regular; Temp (oral): 38.5 Celsius; SpO2: 92% on RA; Pain rated: 0/10.

Post Vital Signs (after all treatment):

BP: 135/85 mmHg; Pulse (radial): 85bpm strong/regular; Resp Rate: 18 unlaboured/regular; Temp (oral): 37.5 Celsius; SpO2: 95% on RA; Pain rated 0/10. Fleet enema was effective.

NURSING PROCESS ORGANIZATION PLAN FORM -

PRIORITY NURSING DIAGNOSIS:

CLIENT-CENTRED OUTCOME RELATED TO PRIORITY DIAGNOSIS (Using SMART

Criteria):

NURSING INTERVENTIONS RELATED TO PRIORITY DIAGNOSIS

• Identify one intervention related to nursing care.

• Identify one intervention related to medication administration.

• Identify one intervention related to teaching.

Evaluate effectiveness of the three nursing Interventions: (1. 2. 3.)

Medication Research for oral medication ( For Morphine)

1. Medication Name (Generic and Trade name):

2. Purpose:

3. Safe Dose: (show rationale)

• Nursing Assessment (related to medication)

Admission Orders:

• Vital Signs Routine • Methylprednisolone 150mg IM STAT once then doctor to reassess in AM • Dulcolax Suppository 10 mg PR if no bowel movement times 3 days Fleet Enema PR one time if suppository ineffective

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• HDC Normal Saline at 50ml per hour.• Patient to do 5 repetitions of Deep Breathing and Coughing 3 times a day • Monitor Intake and Output every shift • Tylenol 325-650mg PO every 4 hours PRN • Lorazepam 2-4 mg sublingually at bedtime PRN

Answer & Explanation Nursing Diagnosis

• Ineffective Airway Clearance

Related Factors

The following are the common related factors for the nursing diagnosis Ineffective Airway

Clearance related to pneumonia:

• Tracheal bronchial inflammation, edema formation, increased sputum production

• Pleuritic pain

• Decreased energy, fatigue

• Aspiration

Defining Characteristics

Here are the common assessment cues that could serve as defining characteristics or "as evidenced by" for ineffective airway clearance secondary to pneumonia.

• Changes in rate, depth of respirations

• Abnormal breath sounds (rhonchi, bronchial lung sounds, egophony)

• Use of accessory muscles

• Dyspnea, tachypnea

• Cough, effective or ineffective; with/without sputum production

• Cyanosis

• Decreased breath sounds over affected lung areas

• Ineffective cough

• Purulent sputum

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• Hypoxemia

• Infiltrates seen on chest x-ray film

CLIENT-CENTRED OUTCOME RELATED TO PRIORITY DIAGNOSIS (Using SMART

Criteria):

• After 2 to 3 hours of nursing intervention Patient will identify/demonstrate behaviors to achieve airway clearance.

• After 3 to 4 hours of nursing intervention Patient will display/maintain patent airway with breath sounds clearing; absence of dyspnea, cyanosis, as evidenced by keeping a patent airway and effectively clearing secretions.

NURSING INTERVENTIONS RELATED TO PRIORITY DIAGNOSIS

• Identify one intervention related to nursing care.

Elevate head of bed, change position frequently.

Rationale:

Doing so would lower the diaphragm and promote chest expansion, aeration of lung segments, mobilization and expectoration of secretions.

Maintain adequate hydration by forcing fluids to at least 3000 mL/day unless contraindicated (e.g., heart failure).

Rationale:

Offer warm, rather than cold, fluids.Fluids, especially warm liquids, aid in mobilization and expectoration of secretions. Fluids help maintain hydration and increases ciliary action to remove secretions and reduces the viscosity of secretions. Thinner secretions are easier to cough out.

• Identify one intervention related to medication administration.

There is evidence that acute administration of corticosteroids decreases the inflammatory response and might decrease mortality in severe pneumonia. This has been shown in one small randomised controlled study, terminated prematurely due to 0% mortality in the intervention arm.Reference

https://erj.ersjournals.com/content/32/2/259

Intervention:

Corticosteroids can increase blood glucose, so close monitoring of blood sugar and higher doses of diabetes medications may be needed.

• Identify one intervention related to teaching.

Teach and assist patient with proper deep-breathing exercises. Demonstrate proper

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splinting of chest and effective coughing while in upright position. Encourage him to do so often.

Patients should be advised that corticosteroids are not used to treat an acute asthma attack. They can cause immunosuppression and suppress signs of infection.Corticosteroids can also cause an increase in blood glucose levels. Patients may experience weight gain, swelling, increased fatigue, bruising, and behavioral changes.These occurrences should be reported to one's healthcare provider.

Evaluate effectiveness of the three nursing Interventions: (1. 2. 3.)

• Assess cough effectiveness and productivityCoughing is the most effective way to remove

secretions. Pneumonia may cause thick and tenacious secretions to patients

• Used to rapidly control severe or incapacitating allergic or respiratory conditions, to

reduce inflammation.Auscultate lung fields, noting areas of decreased or absent airflow and adventitious breath sounds: crackles, wheezes.Decreased airflow occurs in areas with consolidated fluid.Bronchial breath sounds can also occur in these consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasms and obstruction.

• Deep breathing exercises facilitates maximum expansion of the lungs and smaller

airways, and improves the productivity of cough.

Coughing is a reflex and a natural self-cleaning mechanism that assists the cilia to maintain patent airways. It is the most helpful way to remove most secretions.

Splinting reduces chest discomfort and an upright position favors deeper and more forceful cough effort making it more effective

Medication Research for oral medication ( For Morphine)

• Medication Name (Generic and Trade name):

Morphine US Brand Name • AVINza • Kadian • Kadian ER • Morphabond • MS Contin • Oramorph SR • Roxanol • Roxanol-T

• Purpose:

Morphine tablet is used to relieve short-term (acute) or long-term (chronic) moderate to severe pain. The extended-release capsule and extended-release tablet are used to treat