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Medical Case Study: Analysis of a Patient with Multiple Health Issues, Cheat Sheet of Nursing

A comprehensive medical case study of a patient with multiple health issues, including copd, cardiovascular complications, and metabolic acidosis. It provides a detailed analysis of the patient's symptoms, vital signs, and laboratory results, highlighting the potential causes and implications of each finding. The document also outlines the patient's current treatment plan and the rationale behind each intervention. This case study is valuable for healthcare professionals and students seeking to understand the complexities of managing patients with multiple chronic conditions.

Typology: Cheat Sheet

2024/2025

Uploaded on 02/17/2025

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LB/DW/CB revised 3/30/23
Clinical Judgement Plan
Luz Angel
West Coast University
Professor Frederick Perez, MSN, APRN, PHN, CEN, CHEP, FNP-C
Date: 02/15/2025
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LB/DW/CB revised 3/30/

Clinical Judgement Plan

Luz Angel

West Coast University

Professor Frederick Perez, MSN, APRN, PHN, CEN, CHEP, FNP-C

Date: 02/15/

History of Present Illness (HPI)

The patient arrived in the ER with complaints of shortness of breath and increased urination. Upon initial assessment, the patient was alert and oriented x3, with a blood pressure of 76/47, a pulse of 50, and an oxygen saturation of 93%. The patient denied any pain and had a temperature of 36.9°C. Labs and further evaluation led to a diagnosis of acidosis, urinary tract infection (UTI), and shortness of breath. The clinical presentation suggests a possible systemic response to infection, with significant hypotension and bradycardia likely contributing to the patient’s symptoms. The patient has a significant medical history, including coronary artery disease (CAD), triple coronary bypass surgery, hypercapnia, respiratory acidemia, chronic obstructive pulmonary disease (COPD), and hypercholesterolemia. Given her history of CAD and triple coronary bypass, the acute presentation raises concern for a cardiovascular component, particularly due to the noted hypotension and bradycardia. Additionally, the patient’s history of respiratory acidemia and COPD, combined with active smoking (2 packs per day), further complicates her condition, suggesting that underlying chronic respiratory issues may be contributing to her current symptoms of shortness of breath. The patient was started on IV fluids and antibiotics to address the UTI, with close monitoring of vitals, including blood pressure, pulse, and oxygenation. Upon further assessment during the shift, the patient remained alert and oriented x3, though she complained of mild pain (3/10). She appeared to be experiencing hallucinations, stating that everyone was smoking, and she needed a smoke as well. The patient became increasingly agitated, and while initially coherent, she showed signs of forgetfulness. On auscultation, wheezing and crackles were noted, and heart sounds were diminished with a murmur detected. No signs of jugular venous distention (JVD) were observed. The patient’s skin appeared fragile and pale for her ethnicity but was warm to the touch. No labs or consults are pending, and there is currently no plan for discharge.

Pathophysiology of Admitting Dx (minimum of 3-5) (Cite References)

For each disease identified, describe pathophysiology, and any potential complications & cite source.

Shortness of Breath: Shortness of breath occurs when the lungs can’t provide enough oxygen to the body. In this patient, her COPD (chronic obstructive pulmonary disease) makes breathing difficult because her airways are damaged and inflamed. Smoking over the years has worsened her condition. Additionally, acidosis and hypotension contribute by reducing oxygen delivery to the body and causing difficulty in breathing, making it harder for her to catch her breath (Zheng et al., 2002). UTI : A UTI happens when bacteria infect the urinary tract. This patient’s low blood pressure (hypotension) and CAD (coronary artery disease) may reduce kidney function, making her more vulnerable to infections. Her history of smoking also weakens her immune system, increasing her risk. The infection can worsen due to poor kidney function from inadequate blood flow (Harding et al., 2023). Acidosis: Acidosis occurs when the body’s pH balance becomes too acidic. In this case, COPD causes respiratory acidosis by preventing the lungs from removing enough carbon dioxide. Her kidneys may also struggle with metabolic acidosis due to the UTI and inflammation, leading to an excess of acid in the blood. Both issues cause her body to become too acidic, making it harder for her to breathe and maintain balance (Zheng et al., 2002).

Pathophysiology of Medical History (minimum of 3-5)

For each disease identified, describe pathophysiology, and any potential complications & cite source.

Coronary Arteries Disease w/out Angina pectoris: Coronary artery disease (CAD) occurs when the arteries that supply blood to the heart become narrowed or blocked by plaque buildup. This limits the heart's ability to get the oxygen-rich blood it needs to function properly. While the patient doesn’t currently have angina (chest pain), her CAD can still lead to complications like heart failure or arrhythmias, especially if blood flow to the heart is compromised. Though unrelated to her current diagnosis, CAD can contribute to hypotension and poor oxygenation, making it harder for her to recover from the acute symptoms of shortness of breath and infection. Potential complications could include worsening heart failure or heart attack in the future if the condition progresses (Bai et al., 2022). Hypercapnia: Hypercapnia happens when there is too much carbon dioxide (CO2) in the blood, often due to an impaired ability to breathe out CO2. This is common in people with COPD because the damaged lungs can't properly exchange gases. For this patient, hypercapnia is directly related to her COPD and contributes to respiratory acidosis. As CO2 builds up, the body becomes more acidic, which can worsen her shortness of breath and fatigue. The condition can lead to confusion, decreased oxygen levels, and even respiratory failure if not treated. It's important to address her breathing difficulties to help her get rid of excess CO and avoid complications (Bai et al., 2022). COPD: COPD is a lung condition that makes it difficult to breathe, usually caused by long-term smoking or exposure to irritants. Over time, it causes damage to the lungs, leading to narrowing of the airways and destruction of the lung tissue. For this patient, COPD is a major reason behind her shortness of breath and respiratory acidemia. Her chronic smoking has made her lungs even more vulnerable, and she is struggling to clear out CO2 properly. This can lead to hypoxia (low oxygen levels) and increased carbon dioxide levels in her blood, which makes it even harder for her to breathe. Potential complications include acute respiratory failure , worsening of her COPD symptoms, and pneumonia, which could further strain her body’s ability to fight the current infection (Akwe et al., 2020). Hypercholesterinemia: Hypercholesterolemia means having high levels of cholesterol in the blood, which can cause plaque to build up in the arteries, narrowing them and making it harder for blood to flow. In this patient, while hypercholesterolemia is unrelated to her current diagnoses of UTI, acidosis, and shortness of breath, it still poses a risk for future cardiovascular issues. If left unchecked, it can lead to atherosclerosis, where the blood vessels harden, increasing the risk of heart attacks or strokes. For this patient, managing cholesterol levels is important to prevent further cardiovascular complications (Mormone et al., 2024).

Surgical History

For each procedure identified, define & describe it; include year of procedure & cite source.

Triple Coronary bypass: This surgery is done when multiple coronary arteries are blocked or narrowed. It uses healthy blood vessels from other parts of the body (like the saphenous vein or internal mammary artery) to bypass the blocked areas, allowing for better blood flow to the heart. It's usually recommended for people with severe coronary artery disease to ease symptoms like chest pain or shortness of breath. When it’s called a "triple bypass," it means three arteries are bypassed (Patel et al., 2024).

Social History

SMOKING/ CIGARETTE/ TOBACCO/ E-CIGARETTE /MARIJUANA USE ALCOHOL/ ELICIT DRUG USE

Smoker: Since 9 years old (59 years). Lives with family: Son, daughter in-Law and 2 grandchildren.

Chief Complaint SOB & Increased Urine Frequency

Admitting Diagnosis SOB, UTI, & Acidosis

Patient Information (1)

Name: F.P

Age: 68

Gender: Female

Code Status: Full

DPOA: None

Living Will: None

Allergies: Aggrenox (Reaction not noted), Chantin

(Reaction not noted), Midrin (Reaction not noted),

Percocet (SOB), Sulfa Drugs (Reaction not noted)

Date:02/15/

Student Name: Luz Angel

Instructor: Fredrick

Erickson’s Developmental Stage Related to pt. & Cite References (1) The patient is a 68-year-old female and is most likely in the ego integrity versus despair stage of Erikson’s developmental theory. This stage begins around age 65 and continues through the end of life (Jones & Waite-Stupiansky, 2022).

In this stage, individuals reflect on their lives and, depending on how they perceive their past, either achieve ego integrity or experience despair. If the patient feels her life has been fulfilling and meaningful, she will likely experience ego integrity, characterized by pride in her accomplishments and a sense of peace. However, if she feels regretful or perceives her life as incomplete, she may experience despair, feeling dissatisfied or bitter about missed opportunities (Jones & Waite-Stupiansky, 2022).

Given her age and health history, the patient may be reflecting on her life and evaluating her relationships and achievements, such as her role as a mother. Based on her chronic health conditions and current emotional state, I believe the patient may be leaning toward the despair side of this stage. She may have feelings of regret or frustration related to her health and life choices, particularly if she feels that time is running out to resolve them. Her relationship with her son, along with her ongoing health issues, may be central to her emotional state and how she processes this stage. Therefore, providing emotional support and encouraging reflection on any unresolved regrets could help her find a sense of closure and peace (Jones & Waite-Stupiansky, 2022).

Identify and explain abnormal findings related to Patient’s disease process

Test Normal Pt labs Explanation of Abnormal

WBC 4.40-11 17.2 The elevated WBC indicates an infection, likely related to the urinary tract infection (UTI) the patient is currently dealing with. The body’s immune system is responding to the infection, causing an increase in white blood cells to fight off the bacteria (Hu et al., 2020). Hgb 14.0- 16.0 12.4 The patient's low hemoglobin (Hgb) suggests mild anemia, which can reduce oxygen-carrying capacity in the blood. Given her COPD, this could exacerbate her shortness of breath as less oxygen is available for the body's tissues, potentially worsening her respiratory distress. While not directly related to the UTI, anemia can compound the challenges of managing her current symptoms (Plant et al., 2021). Hct 36-42 39.5 Normal Platelets 150-450 210 Normal Na+ 135-145 143 Normal K+ 3.5-5.0 5.10 The elevated potassium could be indicative of metabolic acidosis, which is consistent with the patient’s respiratory acidosis and current shortness of breath. The kidneys are unable to effectively balance the potassium and other electrolytes due to renal dysfunction or the acid-base imbalance caused by the infection (Plant et al., 2021). This needs to be monitored carefully to avoid dangerous arrhythmias.

Chloride 95-110 100 Normal Co2 23-29 49 The elevated CO2 level suggests respiratory acidosis, which is a direct consequence of the patient’s COPD. The lungs are unable to effectively expel CO2, leading to its accumulation in the bloodstream, which further worsens her shortness of breath. This abnormality is directly related to her chronic obstructive pulmonary disease and contributes to her current state of acidosis (Plant et al., 2021). Creatinine 0.6-1.3 0.64 Normal Blood Glucose 76-106 169 The elevated blood glucose level is likely due to stress-induced hyperglycemia, which can occur during acute illnesses. The patient is under significant physiological stress from her infection and acidosis, which can lead to an increase in blood glucose levels. This is also significant because the patient is on insulin therapy, suggesting that her diabetes may be poorly controlled in this acute phase (Hu et al., 2022). BUN 8.0-30.0 32 The elevated BUN could be a sign of dehydration or kidney strain, both of which can happen when the body is dealing with low blood pressure or an infection. In this patient's case, her UTI and low blood pressure may be putting extra pressure on her kidneys, making them work harder than usual. This suggests her kidneys might not be functioning as well as they should, and they need to be closely monitored to prevent further complications (Hu et al., 2022). Ca+ 8.5 – 10.5 9.90 Normal Imaging:

CT normal normal Pelvis w/out contrast ECG abnormal abnormal The abnormal ECG findings, showing atrial flutter and ectopic tachycardia, are likely linked to her heart history, including triple bypass surgery. These irregular heartbeats are common after heart surgery and can increase her risk of stroke. Her low blood pressure and slow heart rate may make managing these heart rhythms even more challenging (Harding et al, 2023). CXR abnormal abnormal The degenerative changes in her bones are probably due to age and limited movement from her chronic conditions like COPD. This can lead to musculoskeletal pain and make it harder for her to move or recover, especially with her current hospitalization and health struggles (Harding et al, 2023).

Vital Signs

Pulse: 50(monitor) Her pulse of 50 could be due to her medications like amiodarone and diltiazem, which slow the heart rate. Also, her low blood pressure and breathing issues from COPD might be contributing, as the body tries to adjust. It's important to monitor her closely to ensure her heart rate doesn't drop too low (Harding et al, 2023).

Pulse: 130(monitor) A pulse of 130 is elevated, likely due to infection (such as the UTI) or stress from her current health issues. It could also be a response to low blood pressure as her body tries to compensate by increasing heart rate to maintain circulation (Harding et al, 2023).

Temp 36.9(oral) Normal Temp: 36.7 (oral) A mild fever is normal in response to infection, like the UTI. The temperature is slightly lower than the typical fever seen with infections, but still within a range that could suggest the body is fighting off an infection (Harding et al, 2023). Resp: 20 (monitor) Normal Resp: 30(monitor) An elevated respiratory rate is common in infection and respiratory distress, especially given her COPD and acidosis. It’s her body trying to get more oxygen as her lungs are struggling to work efficiently (Harding et al, 2023). BP: 76/47 (monitor) -This low blood pressure is likely due to a combination of factors, including the infection (UTI), possible fluid imbalance, and her heart's compromised function from her cardiac history. It also could be worsened by hypoperfusion to vital organs due to her hypotension (Harding et al, 2023).

BP : 92/64(monitor)- This blood pressure is slightly elevated compared to her previous reading and could be related to the body’s stress response to the infection or fluid imbalance. It may also be impacted by kidney dysfunction, possibly due to her UTI or medications affecting fluid balance (Harding et al, 2023). Sp02: 93% (room air)-This could be due to problems with the patient's lungs, heart, or how the patient's body is using oxygen in result of the toxic metabolic encephalopathy (Harding et al, 2023).

Sp02: 90% (room air) This could be due to problems with the patient's lungs, heart, or how the patient's body is using oxygen in result of the toxic metabolic encephalopathy (Harding et al, 2023).

Pain: 0 (0-10 pain scale) Pain: 5 (0-10 pain scale)

Cultural considerations, ethnicity, occupation, religion, family support, insurance. Cultural Considerations : White/European- patient will be evaluated for food preferences so it can be adjusted for her recommended l ow-sodium, heart-healthy diet. Religion: None Spiritual Considerations : None patient denies spiritual considerations Occupation : Retired Sales Family Support: Lives with her son, patient and family will be educated on support groups, medication adherence, and home safety. Insurance: Family Choice with Cal Optima (PPO)

Medical Management and Collaborative Plan

Cardiology: Rational: Given the patient’s heart history, including her triple bypass surgery and current symptoms of low blood pressure and slow heart rate, a cardiologist is needed to keep a close eye on her heart function. Her heart is under stress right now, and we need to make sure her heart rate and blood pressure are managed appropriately to prevent any further problems (Gajdacs et al., 2021). The cardiologist will help adjust her medications like Amiodarone or Diltiazem to help her heart pump efficiently and reduce the chances of any cardiovascular complications, such as heart failure (Gajdacs et al., 2021). Social Worker: Rational: The social worker plays a key role in supporting the patient and her family. They’ll provide emotional support, help them understand what’s going on with her care, and assist with any practical matters that come up during her hospitalization (Harding et al., 2023). They’ll also work with the family on discharge planning, making sure they have the right support at home, whether it’s coordinating home healthcare or connecting them with community resources like support groups. The social worker will be there to help the family through the emotional and logistical challenges of caring for a loved one with multiple health issues (Harding et al., 2023). Raspatory Therapy: Rational: Because the patient has COPD and is struggling with shortness of breath, respiratory therapy is crucial. Respiratory therapists are the experts in helping patients breathe easier. They’ll make sure her oxygen levels are good, help her manage her medications like Albuterol, and provide treatments to improve airflow and lung function. With her respiratory acidemia, it's vital to make sure her lungs are working well and that she’s getting the oxygen she needs to recover (Harding et al., 2023). Physical Therapist: Rational: The patient’s body is weak from her heart history, respiratory issues, and hospital stay, so physical therapy will help her regain strength. The physical therapist will focus on gentle exercises to help improve her ability to move, build strength, and get back to doing things on her own. They’ll also help prevent falls and reduce the risk of other complications like pressure sores, which can happen when a patient isn’t able to move much. Physical therapy will make sure that when she leaves the hospital, she’s in the best possible shape to take care of herself at home. Urology: Rational: The patient’s urinary tract infection and increased urination may be contributing to her low blood pressure and overall weakness. The urologist will ensure the infection is properly treated and check for any underlying urinary issues that could complicate her recovery. Given her heart history and the medications she’s on, monitoring her kidney function is also important to avoid additional complications (Harding et al., 2023).

Cardiovascular

  • ECG: Abnormal, showing ectopic atrial tachycardia and possible atrial flutter (Harding et al, 2023).
  • Concern for arrhythmia, which may be contributing to the bradycardia and hypotension, warranting careful monitoring and potential treatment to stabilize heart rhythm (Harding et al, 2023).
  • Blood Pressure: 76/47: Likely due to infection (sepsis), dehydration, and possible cardiovascular compromise, which may be exacerbated by her history of heart disease and current acidosis (Harding et al, 2023).
  • Heart Rate: 50 bpm (bradycardia), likely influenced by the arrhythmia (Harding et al, 2023).
  • BUN (32): Elevated, could indicate renal involvement or dehydration secondary to hypotension and infection. Monitor closely for kidney function (Harding et al, 2023).
  • Hgb (12.4): Slightly low, but within acceptable range. May need close monitoring if there is ongoing blood loss or fluid shifts (Harding et al, 2023).
  • WBC (17.2): Elevated (normal range: 4.4-11), indicating an infection—likely urinary tract infection (UTI), possibly with a systemic inflammatory response (sepsis) (Harding et al, 2023).
  • Skin: Normal temp/ color for ethnicity
  • Cap refill: >3 no bilateral edema
  • Heart Sounds: Diminished/murmur present in S1 & S
  • Lower entreaties pulse: L4+/ R4+ • Upper extremities pulse: L4+/R4+
  • No signs of JVD

Musculoskeletal

  • MORSE fall score of 35 likely due to her age and current diagnosis which can lead to increased risk of injury from falls, fractures, or head trauma (Harding et al, 2023).
  • Unsteady gait - due to the effects of acidosis on motor control and possible weakness which can lead to increased likelihood of falls, fractures, and accidents (Harding et al, 2023).
  • Muscle weakness - likely due to immobility and deconditioning from extended hospitalization which can lead to reduced mobility, increased dependence on caregivers, difficulty performing daily activities (Harding et al, 2023).
  • Poor coordination - may be due to acidosis affecting neuromuscular function which can lead to difficulty with self-care activities, risk of falls, and further immobility (Harding et al, 2023).
  • Educate Fall Prevention-patient is falling risk due to possible seizures due to her acidosis, and weakness. If fall prevention strategies are not implemented, the patient may experience a fall, which could lead to injury or hospitalization (Harding et al, 2023).
  • Fall protocol in place: Bed alarm- due to weakness; without the fall protocol, there could be a delayed response to a fall, increasing the risk of injury (Harding et al, 2023).

Respiratory

  • CXR: Abnormal, showing degenerative disease of visual osseous structure. This finding could be indicative of chronic lung disease or musculoskeletal changes due to long-term COPD or smoking. It may complicate respiratory function, but no acute pulmonary findings were noted (Harding et al, 2023).
  • CO2 (49): Elevated, indicative of respiratory acidosis. Likely related to COPD and hypercapnia, suggesting insufficient ventilation and CO2 retention. Requires close monitoring and potential respiratory support (Harding et al, 2023).
  • Oxygen saturation: 93% but watch for potential decline due to respiratory distress or failure (Harding et al, 2023).
  • CO2 (49): Elevated, indicating metabolic acidosis or respiratory acidosis, contributing to the patient's shortness of breath and possible confusion (Harding et al, 2023).
  • Wheezing/crackles upon auscultation: both in inhalation and expiration more than likely due to her COPD as well as possible infection or fluid buildup present (Harding et al, 2023).
  • Diminished Lung Sounds: more than likely due to her history of COPD due to narrowed airways and difficulty exhaling fully (Harding et al, 2023).
  • Respiratory Rate of 30- elevated due to respiratory distress, likely from COPD exacerbation and respiratory acidosis (Harding et al, 2023).
  • SOB: Present, likely exacerbated by COPD and acidosis. The lungs are struggling to clear CO2, contributing to the patient’s difficulty breathing (Harding et al, 2023).
  • SpO2: 90%: indicating mild hypoxia. Given the patient’s COPD and possible respiratory acidosis, oxygenation is compromised, necessitating close monitoring and possible supplemental oxygen (Harding et al, 2023).
  • Cough: Present, likely productive, which could be due to COPD or infection (e.g., UTI with systemic effects) (Harding et al, 2023).
  • Normal Gag reflux
  • Suction as needed: Likely due to her increased secretion from her past medical history of COPD, infection and smoking (Harding et al, 2023).

Neurological

  • Ox
  • Confusion- due to the Acidosis which can lead to increased risk of falls, difficulty following treatment orders, worsened mental status, and increased care giver burden (Harding et al, 2023).
  • Hallucinations- Due to the Acidosis which can lead to anxiety, disorientation leading to unsafe behaviors, risk of agitation, and delayed diagnosis and treatment if hallucinations are mistaken for other causes (Harding et al, 2023).
  • Poor memory- Due to the Acidosis which can lead to poor compliance with treatments, increased confusion, risk of self-harm, and impaired communication with caregivers (Harding et al, 2023).
  • Agitation- due poor coping mechanisms which Can lead to physical harm, difficulty following medical advice, impaired relationships with healthcare providers, and worsening anxiety (Harding et al, 2023).
  • Coordination: well
  • PERRLA: ERAR
  • GCS score: 12 which can lead to neurological deterioration, need for intubation, loss of consciousness, and delayed intervention if score decreases (Harding et al, 2023).
  • Gait: balance unsteady due to acidosis which an lead to increased fall risk, decreased mobility, fatigue, and need for physical therapy (Harding et al, 2023).
  • Cranial nerve V: Intact

Psychosocial

  • Confusion - potentially caused by acidosis or infection affecting cognitive function leading to impaired decision-making and awareness (Harding et al, 2023).
  • Agitation - likely due to metabolic disturbances or psychological stress from hospitalization (Harding et al, 2023).
  • Hallucinations - could be secondary to hypercapnia, acidosis, or infection-related confusion leading to distorted perceptions (Harding et al, 2023).
  • Poor memory - possibly a result of acidosis or metabolic changes affecting brain function (Harding et al, 2023).
  • Emotional Impact: Agitation, and Anxiety-due to confusion from the acidosis, and infection (Harding et al, 2023).
  • Despair-due to poor coping skills leading to feelings of hopelessness and difficulty managing stress (Harding et al, 2023).
  • Impaired coping mechanisms- anxiety, and agitation from confusion, acidosis, and infection, affecting the ability to manage stress effectively (Harding et al, 2023).
  • Spiritual support: None

Patient Education while in patient :

The patient was educated on the importance of following a low-sodium, heart-healthy diet due to her history of heart disease and high blood pressure. She was encouraged

to eat more fresh fruits, vegetables, whole grains, and lean proteins, while cutting back on salty foods like processed snacks and canned soups. Staying hydrated,

monitoring her blood pressure, and maintaining a healthy weight were also emphasized to support her heart health and prevent further complications.

Discharge Planning/Education home needs

Educated the patient on the importance of medication adherence for their current prescriptions including Albuterol, Amiodarone, Ceftriaxone, Diltiazem, Doxycycline, Ascorbic

Acid, Cholecalciferol, Divalproex, Lovenox, Gabapentin, Insulin, Methylprednisolone, Acetaminophen, and Hydrocodone. The patient was informed/advised to contact their

pharmacy or healthcare provider if they have any questions or concerns regarding side effects or medication adjustments. The patient was also advised on blood glucose monitoring

due to the use of Insulin, and to continue following up with Cardiology for arrhythmia management and Respiratory Therapy for COPD. Additionally, the patient was educated on

maintaining a low-sodium, heart-healthy diet to support both cardiac and respiratory health, as well as ensuring proper hydration and completing the full course of antibiotics for

UTI management. The patient was referred to Physical Therapy to address mobility, muscle weakness, and balance issues, with a rehabilitation plan to improve functional

abilities and prevent falls. They were also referred to a Social Worker to assess home safety and coordinate equipment needs, such as a walker and shower chair, and to provide

support for community resources and emotional support. A fall prevention plan was discussed, including removing hazards from walkways, installing grab bars, and ensuring home

accessibility. The patient was informed of emergency symptoms to watch for and instructed on seeking medical attention if necessary.

Observation Interpreting Responding

Assessment Analysis Planning Implement

Recognizing Cue

- Coughing while eating - Copious secretions - PRN Suction - Shortness of breath - Oxygen saturation of 93% - History of COPD - Respiratory acidemia - Mental Status - Bradycardia (50) - Hypotension (76/47) - History of (CAD) - History of Triple Coronary Bypass - Aspiration Precautions - History of Smoking ( years) - Elevated BUN (32) - Increased WBC count (17.2) - Hypotension (76/47) - Elevated blood glucose (169) - Temp: 36.9 C - Increased Urination - History of smoking - Elevated CO2 levels (49) - History of COPD - Confusion - Hallucinations - Poor memory - Agitation - GCS score: - Mental Status changes - Reported pain score of 5.

Analyzing Cues

1.Airway due to Shortness of breath , Low Oxygen saturation of 93% which could be a sign of respiratory distress or inadequate ventilation which can further exacerbate respiratory issues. The patient has a history of COPD and respiratory acidemia , which increases her risk of airway obstruction or worsening respiratory function as well as leading to a buildup of CO2 in the bloodstream and worsening the patient’s mental status and cardiovascular stability.

2.Infection due to Increased WBC of 17.2, indicating an active infection likely from the UTI, which can lead to a systemic inflammatory response. The patient's hypotension of 76/47 and elevated BUN of 32 are concerning for possible sepsis, which could cause further vasodilation, worsening hypotension, and multi- organ dysfunction. If left untreated, this could progress to septic shock and acute kidney injury, potentially leading to a decline in cognitive function and overall stability

3.Altered Mental Status due to elevated CO2 levels of 49, indicating respiratory acidosis, which can impair neurological function and lead to confusion or agitation. The patient’s hypotension (76/47) and bradycardia (50 bpm) suggest decreased perfusion to the brain, which can result in cognitive changes or lethargy. These combined factors increase the risk of delirium or coma if not managed, along with a higher potential for falls and further deterioration in the patient’s overall condition.

Prioritize Hypotheses

1. I will assess the patient's airway, including oxygen saturation, respiratory rate, and lung sounds. By ensuring the patient is receiving adequate ventilation, I can detect any signs of respiratory distress or obstruction, allowing me to act promptly to prevent further complications such as hypoxia, respiratory failure, or worsening of her mental status.

2. I will assess the patient's infection status by monitoring her vital signs, including temperature, blood pressure, and white blood cell count. By ensuring early recognition of any signs of sepsis or systemic infection, such as elevated WBC, hypotension, or elevated BUN, I can intervene promptly with appropriate antibiotic therapy and fluid resuscitation to prevent further complications, including septic shock or multi-organ failure.

3. I will assess the patient's neurological status by monitoring her mental clarity, including orientation, level of consciousness, and cognitive function. By closely evaluating her CO2 levels and ensuring her oxygenation status is optimal, I can address any contributing factors like respiratory acidosis or hypoperfusion to prevent further cognitive decline, delirium, or potential coma, which could worsen her overall condition.

SMART Goals

1 .Patient will maintain oxygen saturation levels above 94% and exhibit normal respiratory rate and lung sounds by the end of my shift, indicating adequate ventilation and no signs of respiratory distress.

- Assess patient's oxygen saturation regularly (Harding et al., 2023). - Administer supplemental oxygen as prescribed to maintain oxygen saturation levels above 94% (Harding et al., 2023). - Auscultate patient's lung sounds every shift to monitor for any changes in breath sounds (Harding et al., 2023). - Monitor respiratory rate and pattern frequently to detect any signs of respiratory distress or increased work of breathing (Harding et al., 2023). - Provide bronchodilators as scheduled or PRN to improve airflow and reduce bronchospasm (Harding et al., 2023). - Encourage deep breathing and use of incentive spirometer every shift to promote lung expansion and prevent atelectasis (Harding et al., 2023). - Perform a daily physical assessment, including respiratory status and vital signs, to detect any signs of deterioration in the patient’s respiratory function (Harding et al., 2023). - Monitor for signs of respiratory distress such as accessory muscle use or cyanosis and notify the healthcare provider if condition worsens (Harding et al., 2023). - Collaborate with Respiratory Therapy to evaluate the patient's condition and provide additional respiratory support if necessary (Harding et al., 2023).

Take Action

  • Assess patient's oxygen.
  • Monitor respiratory rate and pattern.
  • Administer supplemental oxygen.
  • Auscultate patient's lung sounds.
  • Provide bronchodilators.
  • Monitor for signs of respiratory distress such as accessory muscle use or cyanosis.
  • Encourage deep breathing and use of incentive spirometer.
  • Perform a daily physical assessment, including respiratory status and vital signs.
  • Collaborate with Respiratory Therapy to evaluate the patient’s condition.
  • Assess temperature regularly.
  • Administer antibiotics as prescribed for UTI.
  • Monitor WBC count and other labs.
  • Monitor vital signs, especially blood pressure and heart rate.
  • Provide fluid resuscitation as ordered.
  • Assess for signs of sepsis.
  • Administer antipyretics for fever control if ordered.
  • Collaborate with the healthcare team to adjust treatment plan if needed.
  • Provide patient education on infection control and hygiene practices.
  • Frequently assess mental status and confusion.
  • Monitor vital signs, especially blood pressure and oxygen.
  • Administer medications for underlying issues like acidosis.
  • Ensure a safe environment to prevent falls.
  • Offer reassurance and cognitive support.

Prioritize Hypotheses (^) SMART Goals

  • Administer medications as prescribed to correct respiratory acidosis and promote optimal oxygenation, which can positively impact mental clarity (Plant et al., 2021).
  • Track vital signs, particularly blood pressure and heart rate, to ensure proper brain perfusion and prevent cognitive decline (Gajdacs et al., 2021).
  • Provide reassurance and orientation frequently to help the patient stay mentally engaged and reduce confusion (Harding et al., 2023).
  • Reassess mental status after interventions and consult with the healthcare provider if confusion persists or worsens (Hu et al., 2022). 4. Patient will report a pain level of 3 or less on the 0-10 pain scale by the end of the shift, indicating improved comfort and reduced discomfort.
  • Assess the patient's pain level every shift and after any interventions using the 0- pain scale (Harding et al., 2023).
  • Administer prescribed analgesics as needed and monitor for effectiveness (Harding et al., 2023).
  • Evaluate any sources of pain, including respiratory discomfort or infection, and address accordingly (Harding et al., 2023).
  • Encourage the use of non- pharmacological pain management strategies, such as deep breathing or relaxation techniques, to complement medication (Harding et al., 2023).
  • Collaborate with the healthcare team to adjust pain management plan as needed to maintain adequate comfort levels (Harding et al., 2023).
  • Reassess pain after each intervention to ensure that the patient’s comfort is improving (Harding et al., 2023).

Recognizing Cue (^) Analyzing Cues Take Action

Evaluation: Eval #1: The goal was not met; the patient’s oxygen saturation decreased to 90% during my shift. I will increase the supplemental oxygen to help raise the oxygen saturation back above 94%. I will also notify the healthcare provider for further intervention and continue to monitor the patient's respiratory status closely. Eval #2: The goal was met; the patient received all prescribed antibiotics on schedule without any adverse reactions. Eval #3: The goal was met; the patient’s safety was maintained, and no falls or injuries occurred due to altered mental status during my shift. Eval #4: The goal was met; the patient demonstrated an improved pain level after receiving appropriate interventions throughout my shift.

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