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Concept Mapping Nursing diagnosis: Impaired gas exchange pertaining to medical diagnosis of coughing, COPD and pneumonia and smoking history.

M.B., 56 years old, male Admitting diagnosis: Tachycardia, Palpitations, COPD, CHF, A. fibrillation, Pneumonia

Nursing diagnosis: Excess fluid volume pertaining to medical diagnosis of congestive heart failure and atrial fibrillation.

Vital signs: HR:122bmp, BP:106/66, SpO2: 84%-91% depending on pt. use of oxygen. Subjective: Patient reports shortness of breath. Patient reports no pain Objective: Tachycardia, palpitations, COPD, shortness of breath, HR is elevated, normal but shallow respiration, crackles present on the posterior chest. Spo2 between 84%-91% depending on patient use of Oxygen. Oxygen through nasal cannula is set up to 3L, patient is very uncompliant with the use. Skin is warm, dry, pale. Patient has both lower leg edema +1. Patient claims no pain, is conscious, oriented x 4 but very restless. During coughing attack patient turns pale to cyanotic.

Patient’s better compliance with oxygen therapy, that will result in better breathing and gas exchange improvement. SpO2 above 90% within next 24 hours

Patient will be educated and started on low sodium diet and fluid restriction (less than 1500ml). Maintain oxygen above 90%. Swelling will go down within next 24 hours

Vital signs: HR: 122bmp, BP: 106/66, SpO2: 84%-91% depending on pt. use of oxygen. Signs: Fast breathing, shortness of breath, water retention in both lower extremities Objective: Tachycardia, palpitations, shortness of breath, anxiety. Skin is warm, dry and pale. Erythema on both lower extremities, edema +1. Patient is very anxious, claims no pain nor other medical problems.

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Place patient in optimal position for ventilation. Continue oxygen therapy as prescribed, attempt to maintain SpO2 above 90% Assist with coughing and suction if needed. Provide education on proper use of oxygen and importance of compliance. Provide education on importance of smoking cessation.

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Patient will undergo trans esophageal echocardiogram with cardioversion to restore regular sinus rhythm. Educate patient on monitoring weight on daily basis and notify his doctor if he gains more than 3 lb within 24 hrs. Educate patient to measure input and output. Instruct patient to take diuretics. Instruct patient on importance of low sodium consumption. Educate patient how to use inhalers.

Evaluation of Interventions/Outcomes: Patient underwent trans esophageal echocardiogram to restore normal sinus rhythm. Lower extremity edema slowly improving. Patient oxygen level is within normal limits as for a COPD patient. Patient is compliant with low sodium diet. MB is stable and will de discharge today.

Pathophysiology: COPD- chronic pulmonary obstructive disease is a group of common chronic respiratory disorders that are characterized by progressive tissue degeneration and obstruction in the airways of the lungs. COPD causes irreversible and progressive damage to the lungs, respiratory failure may result due to severe hypoxia or hypercapnia. In many patient COPD leads to cor pulmonale, right-sided congestive heart failure due to lung disease History of smoking has significant impact on lungs and COPD Patient received education on his disease, smoking cessation and use of inhalers to help with his breathing and cardiac issues. COPD is a debilitating disease but with good care, smart life choices and use of prescribed medicine patient can have a good quality of life.

Miscellaneous: Allergies: None Patient was stressed and revealed common signs of anxiety that could have been side effects of few of his drugs, smoking cessation or alcohol withdrawal. Patient cooperated well and was willing to take all assessment. Patient discharge depends on an echocardiogram report scheduled for this afternoon.

Medication

Albuterol

Dose, Route & Frequency Nebulizer solution 2.5 mg 4 x day

Amiodarone

P.O. 400 mg 3 x day

Classification Adrenergic Beta2agonist, sympathomimetic, bronchodilator Antidysrhythmic (class III)

Purpose / Mechanism of Action Causes bronchodilation by action on Beta2(pulmonary) receptors.

Significant Side Effects / Adverse Reactions CNS: tremors, anxiety, restlessness. RESP: paradoxical bronchospasm.

Prolong duration of action potential. Increases PR and QT intervals, decreases sinus rate, decreases peripheral vascular

CV: sinus arrest, CHF, dysrhythmias, SA node dysfunction, AV block GI: hepatotoxicity INTEG: toxic epidermal necrolysis, pancreatitis

Nursing Implications Evaluate lungs sounds, heart rate and rhythm, B/P.

Evaluate vital signs, electrolytes. Pulmonary and CNS function.

resistance.

Azithromycin

Ceftriaxone

Digoxin

VS Fluticasone

IV in 250 cc 0.9NS 500mg 1 x day

Anti-infective Macrolides

Suppresses protein synthesis in gramnegative bacteria, broad spectrum.

Injection 1Gm 1x day

Anti-infectivescephalosporin derivates

Inhibits cell wall synthesis by binding to essential penicillinbinding protein

P.O. 250 mg 1 x day

Cardiac glycosides, inotropic antidysrhythmic

Inhaler 100-25 mcg 1 puff x day

Corticosteroid, long acting beta2-adrenergic agonist

Inhibits sodium/potassium ATPase pump to increase cardiac output, increases force of contractions, decreases heart rate, decreases AV conduction speed. Decreases inflammation in inhibiting mast cells, anti-inflammatory, vasoconstrictor properties relax bronchial smooth muscle.

REPS: pulmonary fibrosis/toxicity, ARDS. Black Box warning for pulmonary toxicity, hepatotoxicity and cardiac dysrhythmias CV: QT prolongation, torsades de pointes GI: hepatotoxicity, cholestatic jaundice, pseudomembranous colitis SYST: Angioedema, Stevens-Johnson syndrome, toxic epidermal necrolysis CNS: seizures CV: phlebitis, bradycardia GI: pseudomembranous colitis HEMA: thrombocytopenia, neutropenia INTEG: anaphylaxis GU: renal failure CV: Dysrhythmias, AV block

Black box warning: Asthma related deaths. MISC: angioedema, ChurgStrauss syndrome, anaphylaxis, adrenal insufficiency (high doses) RESP: bronchospasm

Evaluate vital signs, electrolytes. Aware of QT prolongation, skin reactions, pseudomembranous colitis and superinfection. Assess: hypersensitivity, anaphylaxis, pseudomembranous colitis Monitor: BUN, creatinine Evaluate apical pulse before each dose (...