D.Z. , a 65-year-old adult male, is admitted to a medical floor for aggravation of his chronic clogging pneumonic disease ( COPD ; emphysema ) . He has a past medical history of high blood pressure, which has been good controlled by Enalapril ( Vasotec ) for the past 6 old ages. He has had pneumonia annually for the past 3 old ages, and has been a 2-pack-a-day tobacco user for 38 old ages. He appears as a cachectic adult male who is sing trouble take a breathing at remainder. He reports cough productive of thick yellow-green phlegm. D.Z. seems cranky and dying ; he complains of kiping ill and states that recently feels tired most of the clip. His critical marks ( VS ) are 162/84, 124, 36, 102 F, SaO2 88 % . His acknowledging diagnosing is an acute aggravation of chronic emphysema.
CHART VIEWPhysician’s OrdersDiet as toleratedOut of bed with aidOxygen ( O2 ) to keep Sa O2 of 90 %IV of D5W 1/n NS with 20KCl meq/L to run at 50 ml/hrContinuous ECG monitoringPneumonic map trials ( PFT’s ) in AMArterial blood gases ( ABGs ) in AMComplete blood count with differential and Na+ /K+ nowBasic metabolic panel ( BMP ) now and fasting in AMChest X ray ( CXR ) on admit and QAMSputum civilization now ( obtain civilization prior to get downing anbiotics ) Albuterol 2.5 mg plus ipratropium 250 mcg atomizer intervention STAT Incentive Spirometery Q10x’s per hr while awake
1. Explain the pathophysiology of emphysema.Abnormal lasting expansion of lung infinites distal to terminal bronchioles accompanied by devastation of walls without obvious fibrosis. This leads to worsen in alveolar surface country available for gas exchange. Loss of alveoli leads to airflow restriction in 2 ways: foremost, loss of the alvoelar walls consequences in a lessening in elastic kick ( leads to airflow restriction ) . Second, loss of the alveolar supporting construction leads to airway narrowing, which further bounds airflow.
2. Are D.Z.’s critical marks and SaO2 allow? If non, explicate why. critical marks ( VS ) are 162/84, 124, 36, 102 F, SaO2 88 % .Tachypnea and tachycardia indicates organic structure is holding problem oxygenizing tissues. SaO2 88 % is excessively low. Orders are to administrate O2 as needed to maintain it & gt ; 90 % HTN: portion of the COPD tract is pneumonic high blood pressure, which so leads to cor pulmonale ( R ventricular hypertrophy ) These critical marks are expected for an aggravation, but non needfully “appropriate” ( we would wish to see oxygen Saturdaies above 90 % , normal HR, RR, BP )
3. Describe a program for implementing these physician’s orders. Administer O via rhinal cannula to acquire SaO2 & gt ; 90 % and set on continous ECG monitoring Call for lab draw for the followers:Basic metabolic panel now and fasting in AMComplete blood count with diff and Na+/K+ABGSputum civilization nowPneumonic map trial ( pre-albuterol )Albuterol 2.5 milligram plus ipratropium 250 mcg atomizer intervention STAT IV of D5W 1/NS with 20KCl meq/L to run at 50ml/hr ( set up IV while nebulizer traveling ) Pulmonary funciton trial ( pre-albuterol )Chest X ray QAMCan hold breakfast as tolerated. Wait ~30 proceedingss before Incentive Spirometry.
4. Identify three independent nursing actions you would seek to better D.Z.’s oxygenation. Administer low flow O ( humidified ) ( rhinal cannula )Sit vertical ( tripod ; high Fowlers if tripod non tolerated )Incentive spirometryAtomizer interventions as perscribedTurn, cough, deep breathe
LABS are as follows:WBC-15RBC-10Hgb-37Hct-57Na+-126K+ -5.2
5. Based on these consequences, prioritise your following actions.Precedence 1: Potassium highName supplier to discourse stoping IV fluids with 20KCl and perchance adding water pill ( since BP besides high ) Monitor EKGPrecedence 2: WBC highName supplier to discourse culture+sensitivity and possible antibiotics Low NaExpectd with high K, so if we decrease K ( exp alteration IV fluids ) so we can anticipate sodium elimination to decelerate down. Hct high ( this is expected with COPD—body’s response to low O ) Hb high ( this is expected with COPD—body’s response to low O ) RBC count ( this is expected with COPD—body’s response to low O )
6. Give an explantaion ( principle ) for all unnatural consequencesSee above
CHART VIEWMedication Administration RecordMethylprednisolone ( Solu-Medrol ) 125 milligram IVP q8hDoxycycline ( Doryx ) 100 milligram PO q12h for~ 10 yearssAzithromycin ( Zithromax ) 500 milligram IVPB q24h for~ 2 yearss so 500 milligrams PO for~ 7 yearss Fluticasone/salmeterol ( Advair ) 100/50 mcg 2 whiffs commandHeparin 4000 units subcut q12hEnalapril ( Vasotec ) 10mg PO Q AMAlbuterol 2.5 mg/ipratropium 250 mcg atomizer intervention q6hour
7. Bespeak the expected result for D.Z. that is associated with each of the medicines he is having. Methylprednisolone ( Solu-Medrol ) 125 milligram IVP q8hSystemic corticoidDecreases rednessDoxycycline ( Doryx ) 100 milligram PO q12h for~ 10 yearssAntibiotic to handle infectionAzithromycin ( Zithromax ) 500 milligram IVPB q24h for~ 2 yearss so 500 milligrams PO for~ 7 yearss Antibiotic to handle infectionFluticasone/salmeterol ( Advair ) 100/50 mcg 2 whiffs commandCorticosteroid/long moving bronchodilatorAnti-inflammatory and dilation of bronchioles to help in take a breathing. Heparin 4000 units subcut q12hMost patients admitted to hospital will be put on Lipo-Hepin due to immobility-related DVT Pt. besides has high RBC counts?makes blood more syrupyEnalapril ( Vasotec ) 10mg PO Q AMACE inhibitor to handle hypertention ( he is antecedently on this ) Albuterol 2.5 mg/ipratropium 250 mcg atomizer intervention q6hour Beta 2 agonist/anticholinergicBeta 2 agonist reduces bronchospasm ( side consequence of tachycardia ) ( for bronhiles—the little air passages ) Anticholinergic act as bronchodilators—for bronchial tube ( big air passages )
8. Since D.Z. is on Zithromax ( Zithromax ) , what nursing actions need to be added to the program of attention? Select all that apply.a. Monitor IV site for redness or extravasationthis is standard patternb. Assess liver map surveies and hematoidin degreesit’s hepatotoxic, so yes.c. Obtain a hearing trial prior to originating therapymay do irreversible sensorineural hearing lossd. Carefully dilute the medicine in the proper sum of solutionAzithromycin is a drug that needs to be reconstituded/diluted. Either pharmaceutics or the RN will make this, depending on installation protocol e. Place D.Z. on consumption and end productthis is standard patternf. Administer the medicine over one-half hrno. should be given at lower limit over 1 hr
LABS are back- Basic Metabolic Panel ( BMP )Albumin: 4.5 g/dLnormal: 3.5-5.5 g/dLAlkaline phosphatase: 125 IU/Lnormalnormal: 44-147 IU/LALT ( alanine transaminase ) : 30 IU/Lnormal: 10-40 IU/LAST ( aspartate transaminase ) : 29 IU/Lnormal 10-40 IU/LBUN ( blood urea N ) : 22 mg/dLhighnormal: 7-20 mg/dLCalcium: 8.6 mg/dLnormal: 8.5-10.2 mg/dLChloride: 96 mmol/Lnormal: 95-105 mmol/LCO2 ( C dioxide ) : 22 mmol/Lnormal=20-29 mmol/LCreatinine: 1.6 mg/dL **highnormal: 0.6-1.2 mg/dL ( males )0.5-1.1 mg/dL ( females )Glucose trial: 110 mg/dL
9. Bases on the above lab consequences, describe ( prioritise ) your following actions and supply your principle for your actions. Name provider—kidney map trials indicated because high creatinine and BUN Continue to supervise ALT and AST ( higher side of normal )
Continue to supervise glucose ( on high side, but expected with medicines )
10. D.Z is ordered heparin 4000 units hypodermic q12 hour. The undermentioned phial is available. How many millilitres will D.Z. have? Shade in the dosage on the tuberculin syringe. This is 5000 units/1mL. we want 4000 units: ( 4000/5000 ) = .8mL
11. What are two of the most common side effects of bronchodilators? TachycardiaAll right shudders
13. D.Z. provinces he gets really hungry but after eating even a few bites he loses his appetency. What might be some of the grounds for his sudden loss of appetency? Identify four schemes that might better his thermal consumption. Increased work of take a breathing hwile eating causes him to lose appetency. Eat soft nutrients that are easy to get down, thick soups. Colds nutrients might assist you experience less full ( smoothies, milk shakes ) . Clear air passages prior to eating. Frozen nutrients so you don’t have to use energy prepping repasts. High protein, high Calorie nutrients in smaller sums frequently throughout twenty-four hours.
14. List six other educational subjects that you need to research with D.Z. Smoking surceaseDiet?want to increase weight.Incentive spirometry at placeHand washing/infection bar ( avoid sick people, crowds ) InoculationsFollow-up assignmentsMedication regimine ( complete antibiotic class. Teach about MDI etc. )
15. What other wellness attention professional would likely be involved in D.Z.’s interventions and how? DieticianPhysical therapist/occupational healerPulmonologistPsychologistRespiratory healer
CASE STUDY PROGRESSD.Z.’s married woman attacks you in the hallway and says, “I don’t know what to make. My hubby used to be so active before he retired 6 months ago. Since so he’s lost 35 lbs. He is afraid to take a bath, and it takes him hours to dress—that’s if he gets dressed at all. He has gone downhill so fast that it scares me. He’s afraid to make anything for himself. He wants me in the room with him all the clip, but if I try to speak with him, he snarls and does things to annoy me. I have to maintain working. His medical measures are run outing all of our nest eggs, and I have to be able to back up myself when he’s gone. You know, sometimes I go to work merely to acquire off from the house and his changeless demands. He calls me several times a twenty-four hours inquiring me to come place, but I can’t travel place. You may non believe I’m much of a married woman, but rather candidly, I don’t want to come place any longer. I merely don’t cognize what to do.” 16. How would you react to her statement? What Resources are available to them? Listen and don’t justice
Offer supportProvide resources for household therapyAsk about extra support/care for hubby. ( supply low cost aid options ) Resources for fiscal support for medical supplies/therapies.
17. List 2 other intervention options or patients with advanced emphysema/COPD and briefly describe what each option entails. Ginkgo biloba: a Chinese herb that may beef up lungs. Add to diet. Sulfur: used to cut down redness, mucous secretion and increase O2 flow. Surgery ( but non used on aged ) —bullectomy ( remotion of the big blister ( the dead infinite ) from the lungs )
