Patient Project- Jared Johnson PDF

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KEISER UNIVERSITY – Port Saint Lucie Campus BSN NUR2032C Care Management I Daily Care Plan Student name: Gabriella Squillace Patient: Jared Johnson Age: 10

Sex:

Male

Current date: 11/02/2021 Race: African American

ADMISSION DIAGNOSIS: Acute asthma exacerbation

PERTINENT PREVIOUS MEDICAL HISTORY (PMI): Moderate persistent asthma

Chief Complaint: (Subjective) He is experiencing chest tightness and shortness of breath.

PATHOPHYSIOLOGY/POTENTIAL COMPLICATIONS: Mr. Johnson was admitted to the hospital with acute asthma exacerbation. This illness is described as a “chronic disorder of the airways that cause episodes of airway obstruction, bronchial hyperresponsiveness, airway inflammation, and, in some cases airway remodeling” (Norris, 2020). Risk factors for developing asthma in children are genetic disposition of IgE mediated response to allergens and “exposure to environmental tobacco smoke” (Norris, 2020). Asthma in children is characterized by wheezing and chest tightness. Complications of this illness includes: “theophylline toxicity, lactic acidosis, electrolyte disturbances, myopathy and anoxemic brain injury” (Papiris et al, 2002). More severe complications include: “pneumothorax, pneumomediastinum, subcutaneous emphysema, barotrauma, and ventilator-assisted pneumonia” (Papiris et al, 2002).

VITALS SIGNS: (Objective) Vitals: T: 99.9 F/ 37.7 C (Oral) P: 120 RR: 30 BP: 114/78 O2 sat: 90% on Room Air

PAIN/LOCATION/SCALE 0-10: (Subjective) PQRST: “Pain worsens when tries to take a deep breath. He feels better when allowed to sit upright on the gurney. He is experiencing constant tightness across the anterior chest with the pain level at 8/10”

ASSESSMENT/OBJECTIVE DATA General Appearance: 5/2019 pg. 1

KEISER UNIVERSITY – Port Saint Lucie Campus BSN NUR2032C Care Management I He has dark circles under his eyes and his color is ashen, appears anxious, and is under moderate respiratory distress. Sitting upright on gurney. Only able to speak in short sentences due to breathlessness. He uses his accessory muscles to breath and has moderate intercostal and substernal retractions with increased respiratory rate. Cardiac: Pale, warm & moist at forehead, no edema, heart sounds regular with no abnormal beats, pulse strong, equal with palpation at radial/pedal/post-tibial landmarks Resp: Breath sounds with inspiratory and expiratory wheezing and prolonged expiration. Has tight-sounding nonproductive cough, decreased breath sounds in right base Neuro: Alert & Oriented x4 GI: Abdomen soft/non-tender, bowel sounds audible through auscultation in all four quadrants GU: Voiding without difficulty, urine clear/yellow Skin: Skin integrity intact, moist on forehead Psychosocial: (Subjective) Lives with mother, maternal grandmother, sister. Housing is an older development in the inner city. He is a good student and is in 5th grade. He misses school 2-3x/year for asthma. Both Jared and his mother deny tobacco smoke at their home.

Lab Data (List Basic Chemistry, CBC, pertinent labs, abnormal labs) Patient Initials: Lab Test Purpose of Test for this Normal Value Patient Results Patient 5/2019 pg. 2

Reason for Abnormal labs

KEISER UNIVERSITY – Port Saint Lucie Campus BSN NUR2032C Care Management I WBC

CBC

4.5-11.0 mm3

10.0 mm3

Normal

Neutrophil %

CBC

55%

42-72%

Normal

Hgb

CBC

12-16 g/dL

14.1 g/dL

Normal

Platelets

CBC

350 10^3/ul

Normal

Sodium (Na+)

Basic Metabolic Panel – assess electrolyte balance Basic Metabolic Panel assess electrolyte balance Basic Metabolic Panel – evaluate disorder of carbohydrate metabolism Basic Metabolic Panel – assess kidney function

150-450 x 10^3/ul 135-145 mEq/L

138 mEq/L

Normal

3.5-5.0 mEq/L

3.7 mEq/L

Normal

70-110 mg/dL

80 mg/dL

Normal

0.6-1.2 mg/dL

0.6 mg/dL

Normal

Potassium (K+)

Glucose

Creatinine

MED

Albuterol Sulfate Indication: Prevent bronchospasm

5/2019 pg. 3

DOSE

2 puff q4h PRN

ROUTE

INH (inhaled)

CLASS

SIDE EFFECTS

Bronchodilator Bronchospasm, angina, hypotension, pulmonary edema

NURSING RESPONSIBILITIES/IMPLICATIONS

Administer pressurized inhalations of albuterol during second half of inspiration, when airways are open wider and aerosol distribution is more effective

KEISER UNIVERSITY – Port Saint Lucie Campus BSN NUR2032C Care Management I Amoxicillin Trihydrate

250 mg BID

PO

Antibiotic

Seizures, C. diff, hepatic dysfunction, leukopenia

Expect to start therapy before culture and sensitivity test results are known

220 mg QD

PO

Nutritional supplement

Hypotension, hemolysis, dyspnea, wheezing

Know that the maximize absorption, iron salts should be given 1 hour before or 2 hours after meals. If GI irritation occurs, give with or just after meals.

2 puff BID

INH

Antiasthmatic

Bronchospasm, Closely monitor a child’s growth pattern; budesonide may pancreatitis, rectal bleeding, stunt growth benign intracranial hypertension

Indication: Treatment for a variety of bacterial infections Ferrous Sulfate Indication: treat iron deficiency anemia

Pulmicort (Budesonide) Indication: Maintenance of asthma

PRIORITIZED NURSING DIAGNOSES (1): Ineffective airway clearance r/t dyspnea and alteration in respiratory pattern AEB patient complaining of “chest tightness and shortness of breath”, decreased breath sounds in right base, with an spO2 of 90% RA, and wheezing

Goal: Patient will demonstrate effective coughing and clear breath sounds by the end of hospital stay.

PRIORITY INTERVENTIONS 5/2019 pg. 4

RATIONALE

KEISER UNIVERSITY – Port Saint Lucie Campus BSN NUR2032C Care Management I 1. Help the client deep breath and perform controlled coughing. Have the client inhale deeply, hold breath for several seconds, and cough two or three times with mouth open while tightening the upper abdominal muscles

1. Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective (Gosselink et al, 2008).

2. Auscultate lung sounds every 1-4 hours.

2. In severe exacerbations, lung sounds may be diminished or distant with air trapping (Bickley & Szilagyi, 2017).

3. Administer medications such as bronchodilators, or inhaled steroids as ordered.

3. Bronchodilators decrease airway resistance improve the efficiency of respiratory movements, improve exercise tolerance and can reduce symptoms of dyspnea on exertion (O’Donell et al, 2014).

EVALUATION of GOAL 1: Goal met, patient demonstrated effective coughing and clear breath sounds.

PRIORITIZED NURSING DIAGNOSES (2): Acute pain r/t self-report of intensity using standardized pain scale AEB patient reports pain “8/10”

Goal: Patient will identify pain level as 4 or under by the end of intervention

PRIORITY INTERVENTIONS

5/2019 pg. 5

RATIONALE

KEISER UNIVERSITY – Port Saint Lucie Campus BSN NUR2032C Care Management I 1. Assess for the presence of pain using valid and 1. Scales that depict faces at various levels of pain reliable pain scale based on age, cognitive development, intensity are commonly used in young children and have been shown to be reliable and valid in children as young and the child’s ability to provide self-report. as 3 years old (Tobias, 2014). 2. Implement or request orders to implement pain management interventions to achieve a satisfactory level of comfort.

2. Reducing pain and pain management is related to increased quality of life.

3. As with adults, use nonpharmacologic analgesic interventions to supplement pharmacologic interventions in pediatric clients.

3. Pain and distress in children were significantly reduced using live music therapy (Sundar et al, 2016)

EVALUATION of GOAL 2: Goal met, patient identified pain level of 2.

PRIORITIZED NURSING DIAGNOSES (3): Anxiety r/t alteration in respiratory pattern and distress AEB appearing anxious, only able to speak in short sentences, and increased respiratory rate.

Goal: Patient will have vital signs and reflect baseline or decreased sympathetic stimulation by the end of intervention.

PRIORITY INTERVENTIONS 1. Assess the client’s level of anxiety and physical reactions to anxiety. (e.g., tachycardia, tachypnea, irritability, restlessness).

5/2019 pg. 6

RATIONALE 1.Barley & Lawson (2016) stated in their study of health psychology’s effect on common mental disorders that for nurses to deliver holistic care, they must be alert to the possibility that the patient may be undergoing psychological anxiety and then use appropriate

KEISER UNIVERSITY – Port Saint Lucie Campus BSN NUR2032C Care Management I communication skills to identify and manage the issue.

2. Teach the client to visualize or fantasize about the absence of anxiety or pain, successful experience of the situation, resolution of conflict, or outcome of the procedure

2. Guided imagery has been shown to augment comfort and can be used as a psychosupportive intervention (Satija & Bhatnagar, 2017).

3. Having awareness about symptoms of anxiety may reduce panic.

3. Teach the client/family symptoms of anxiety.

EVALUATION of Goal 3: Goal met, patient had vital signs meet the baseline and had decreased sympathetic stimulation.

References Barley, E., & Lawson, V. (2016). Using health psychology to help patients: Common mental disorders, and psychological distress. British Journal of Nursing, 25(17), 966-974. Bickley, L. S., & Szalagyi, P. (2017). Bate’s guide to physical examination (12th ed.). Philadelphia, PA: Lippincott, Williams and Wilkins. Gosselink, R., Bott, J., Johnson, M., Dean, E., Nava, S., Norrenberg, M., Schönhofer, B., Stiller, K., van de Leur, H., Vincent, J.L. (2008). Physiotherapy for adult patients with critical illness: recommendations of the European Respiratory Society and European Society of Intensive Care Medicine Task Force on Physiotherapy for Critically Ill Patients. Intensive Care Med, 34(7), 1188-1199. Norris, N.L., & Tuan, R. L. (2020). Porth’s Essentials of Pathophysiology (5th ed.). Philadelphia, PA: Wolters Kluwer | Lippincott, Williams and Wilkins. 5/2019 pg. 7

KEISER UNIVERSITY – Port Saint Lucie Campus BSN NUR2032C Care Management I O’Donnell, D., Webb, K., & Mahler, D. (2014). Effect of bronchodilators and inhaled corticosteroids on dyspnea in chronic obstructive pulmonary disease. In D.A. Mahler & D.E. O’Donnell (Eds.), Dyspnea mechanisms, measurements and management. Boca Raton, FL: CRC Press Taylor & Francis Group. Papiris, S., Kotanidou, A., Malagari, K., & Roussos, C. (2002). Clinical review: severe asthma. Critical care (London, England), 6(1), 30–44. Satija, A., & Bhatnagar, S. (2017). Complementary Therapies for Symptom Management in Cancer Patients. Indian journal of palliative care, 23(4), 468–479. Sundar, S., Ramesh, B., Dixit, P. B., Venkatesh, S., Das, P., & Gunasekaran, D. (2016). Live Music Therapy as an Active Focus of Attention for Pain and Behavioral Symptoms of Distress During Pediatric Immunization. Clinical pediatrics, 55(8), 745–748. Tobias J. D. (2014). Acute pain management in infants and children-Part 1: Pain pathways, pain assessment, and outpatient pain management. Pediatric annals, 43(7), e163–e168.

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