Question:
Bilateral legs still intact, no redness or ooze and plaster from Paris intact for the left distal.
Wound site on left hip still intact- no serous excudate ooze, or redness.
The right upper thigh wound has some haemoserous fluid. It is being dressed reinforced. A patient who was noted to be in theatre today will undergo a washout.
[Input] Compound calcium lactate at 200m1ihr via IVC.
Site patent with no reddening or serous ooze.
[Output] It was noted that Ms Foley is in a positive liquid balance.
Daily weight: She is now at 83.5kgs. This is a significant difference from her previous daily weight of S0kgs.
She continued to state that she has had “bad dreams” overnight.
She has the sensation of being suffocated until she sits up IriERN Harmon).
10/08/2017 0800 – Nursing addendum Theatre nurses called Ms Foley to inform them that they are available.
She was lying flat on the bed and struggling for breath when she was called to her aid.
She says she is’scared’ and is somewhat apprehensive.
It is said that she has a strange sensation that she describes as ‘an impending doom’.
These vital signs were taken and include a pulse of 120bpm and regular, BP 10150, RR 34 and Sa02 92% in RA.
Her lips have begun to turn blue and her nails are becoming cyanotic.
She remains dizzy and thirsty for air.
She is now coughing.
Answer to Question: SNUG102 Nursing As A Profession
Nursing care plans are complex. They must be able to identify the problem and provide appropriate interventions.
This is made easier by several clinical assessment tools, which indicate if there has been an improvement in the patient’s condition.
A standardised and evidenced-based holistic treatment plan can be created based upon this evaluation (Ackley Ladwig & Makic, 2016).
This report discusses all aspects of care planning. We will be analyzing the case scenario Ms Martha Foley (35) with risk of pulmonary oedema.
The patient’s condition is analysed using an observation and HHHS fluid balanced chart.
Based on this chart’s assessment, a care plan for the patient’s recovery is developed. This plan includes evidence-based arguments and support.
The report provides details about Mrs. Foley’s inter-professional care plan.
Part 1
Observation Chart and Interpretation
Mr Martha Foley was injured in a motor vehicle accident and has been admitted to the emergency department with multiple fractures of his legs.
Here are the following details:Table: Fluid Balance Chart (HSSS)
Time
Oral/enteric intakeIV fluids
mls/ IN
ProgramUrine/mls
12:00:00 AMNBMcompound
Total
1:00:00 AM
sodium200
Input100
2:00:00 AM
Intake200
3:00:00 PM1000mls200
4:00:00 AM200
5:00:00 AM200
6:00:00 AM200
7:00 AM200
8:00AM200
9:00 AM
10:00 am
11:00 AM
12:00:00 PM
1:00PM
2:00 PM
3:00:00 PM
4:00:00 PM
5:00:00PM
6:00 PM
7:00 pm
8:00 PM
9:00 PM
10:00:00PM
11:00:00PM
12:00:00 AM
Total intake1600
Total100
Output
Current Balance
Posiitve 1500mls
The Pevious Balance
Positive 1900mlsCumulative Balance
Positive 3400mls
Table 2: Observation Chart
2/10 pain
Shortness of breath and greater work of respiration up to 25 rpm per minute
With the use of four pillows, oxygen saturation has returned to 95%.
Vital sign progressing to hypotension with tachycardia
No pus or redness around wounds
Ms. Foley suffers from dyspoenic symptoms and cyanosis.
Ms Foley has done a vital sign assessment and it is clear that her vital signs fluctuate regularly.
Her breathing problems have been severed by multiple trips to the theatre for ankle and fracture treatment.
Fluctuations in the respiratory rate can cause shortness, dyspnea, and even tachycardia.
This led to her needing ar.
This was also caused by pulmonary oedema (an accumulation of fluids within the tissues and spaces between the lungs that causes gas exchange problem and respiratory dysfunction in patients) (Vadasz, Sznajder 2017,).
Nursing intervention is essential in this area.
The second is the management of patient’s orientation and pain, wound site on her hip, fluid imbalance, sleep, and emotional issues.
Pathophysiological knowledge related to the Scenario
Most commonly, pulmonary hemorhage is caused by an increase in the capillary pressure secondary to an increase of pulmonary vein pressure.
An increase in the capillary hydrostatic pressure secondary to an increased level of pulmonary vein pressure can lead to pulmonary oedema.
Inamasu, et al. 2012: Increased pulmonary Capillary Pressure decreased plasma oncotic tension and increased negative interstitial (so that the pressure in the lungs was lower).
Pulmonary dysfunction can lead to acute and chronic respiratory distress.
This can be due to either the left-ventricular systolic dysfunction or the diastolic dysfunction.
Hypertension, pulmonary fluid overload and renal arterial stiffness can all lead to acute pulmonary swelling.
Because of the lack of an elevated pulmonary calf pressure, the alveolar space in the lungs becomes clogged up with fluids (Vandse-et al. (2012)).
As you can see, Ms. Foley was diagnosed with severe pulmonary oedema in the report. She was involved with both a serious car accident as well as a tree collision.
Serious accidents may cause severe pulmonary embolism, leading to pulmonary collapse.
Research has shown that chronic lung injury can result in thickening and swelling of the capillary wall. This is due to the release or interleukins.
When the lung expands, the microvessels get stretched, which damages the endothelial tissue.
MS Foley was also reported to be a smoker.
Researchers have found that people who smoke are more likely to develop pulmonary edema.
Ms. Foley’s signs and symptoms match the general symptoms of pulmonary oedema.
Nursing Care Plan
These are the nursing requirements for Ms. Foley.
Nursing Intervention: Gas Exchange, Respiratory Failure and Management of Patients
Nursing action
Ms Foley needs to be assessed by a nurse every 30 minutes to determine if she is able manage her lung function.
This will enable you to take immediate action if your breathing rate becomes difficult.
Fowler’s position can be used to induce relaxation in the patient.
Nurses can ask patients to slow their breathing if hyperventilating. They can also teach them breathing techniques to increase strength, activity tolerance and endurance (Valenza et. al. 2014).
A severe case of cough may also result in a reduced respiratory exchange. In such cases, it will be crucial to show the patient how to use effective breathing techniques.Rationale:
Ms. Foley, who was in the hospital following a car accident, is at high risk of developing pulmonary oedema from the damage to her lungs.
The accumulation of fluid in the lungs can lead to reduced gas exchange. Therefore, improving patients’ respiratory function is an important nursing intervention.
It is also possible to improve the condition of patients (Kubota, et al. 2017).
The patient’s oxygenation rate will be increased by being upright or prone.
Placement of the patient in a fowlers position has another advantage: it increases patient’s tolerance to enteral feedings (Richard, Lefebvre 2011).Evaluation:
Normal breathing rate and pulse rates of patients should be stable to indicate an improvement in patient’s ability to breathe.
In this case, oxygen saturation will increase and may be stopped.
Nursing Intervention: Manage Fluids, Nutrition Intake and Medications
Nursing action
Ms. Foley is an avid smoker and must stop smoking to avoid additional complications.
A nurse should give diuretics as a way to lower the fluid buildup in the lungs.
To reduce the symptoms caused by pulmonary edema, other fluids must be balanced.
A nurse should also monitor fluid levels in patients to ensure that there is no excess urine.Rationale:
Foley is one of the most important patients to stop smoking. It increases the chances of mucus formation, damages to the bronchial walls, reduces oxygen availability, and can cause mucus buildup (Varol et. al. 2015).
Ms. Foley’s past medical history of congenital hearts failure meant that fluid management was particularly important.
This is why fluid overload can have adverse consequences for patients with congenital heart failure.
While diuretics are the primary treatment for fluid imbalance, it is vital to monitor any fluid or enteral intake.
Patients suffering from heart failure experience high rates of peripheral edema due to reduced renal perfusion. (Kelm; Al. 2015).Evaluation:
On the basis of stable weight and balanced intake, the effectiveness of the intervention can also be assessed.
The nurse may also be able to assess the sounds of the lungs.
Assessment of patients’ weight relative to nutritional status is another way to determine whether fluid intake is maintained or balanced.
Nursing Intervention: Management of Wounds and Pain in Patient
Nursing actions
Be sure to monitor the drainage, size, depth, smell, and odour of any wounds
Regular dressings and infection prevention are important to preserve the integrity wounds
Analyze the characteristics of pain
Assess patient’s vital signs for hypertension or tachycardia.
It is important to determine the root cause of any discomfort in each patient.
Other comfort measures that can be taken by patientsRationale:
Ms. Foley was recently treated for pain after a hip resection.
An important indicator for pain management is the assessment of vital signs. This gives an indication about patient’s level and degree of discomfort (Ross 2017.
Certain comfort measures, including oral care, relaxation techniques, position changes and posture change can reduce stress and anxiety. (Mahler 2017).Evaluation:
An indicator of pain management success is stable vital signs, and decreases in patient discomfort.Oxygen Requirements:
The case study supports the idea that Ms. Foley was suffering respiratory distress.
She was suffering from shortness in breath and greater breathing (WOB), and her respiratory rate was increasing up to 25Rpm. Her oxygen saturation is falling to 80%.
The ABCs should be used for the initial treatment of pulmonary embolism. This is the airway, breathing, circulatory and circulation.
A face mask, non-invasive pressure ventilation, mechanical ventilation and intubation are all possible methods for oxygen delivery (Lenglett et. al., 2012).
Low oxygen saturation levels below 80% mean that the oxygen in your blood is too low to penetrate red blood cell walls.
Intubation or mechanical ventilation are possible in cases of persistent hypoxemia.
A patient suffering from severe pulmonary oedema will need non-invasive pressure supporting ventilation.
Intra-aortic balloon therapy can be used to increase coronary blood flow.
According to Matthay, Ware, & Zimmerman (2012), the woman was dyspnoeic, and she was in desperate need for air.
The bronchodialators can be used to treat dyspnea.
To reduce swelling in your lungs, you can use steroids.
Subcutaneous injections may be used to administer broncodialators (Lenglett and colleagues, 2012).
Dyspnea can be treated with albuterol Sulphate or ipratropium Bromide.Part 2: Interprofessional Model Of Care:
Interprofessional care is the use of different professionals to care for one patient.
The medical history, appropriate investigations, as well as a medical exam are required to diagnose pulmonary embolism.
The case history shows clearly that Ms Foley was in severe respiratory distress. Specialized clinicians should be able to focus on treating her respiratory problems.
Pulmonary oedema treatment should begin with oxygen (Thille, et al. 2013). Medications like Preload reducers.
The usual treatment is to maintain blood pressure with afterload or morphines (Davison, et al. (2012)).
These standards are what registered nurses must follow:
She must be able to critically evaluate and analyse nursing practice.
You can see that she suffered from respiratory distress throughout her illness.
The patient should be administered oxygen according to her condition.
To increase lung capacity, the patient should be in a fowler-like position (Morrowet al. (2012)).
Nurses should participate in therapeutics as well as professional relationships.
Conduct an assessment
A registered nurse should examine the patient carefully and assess any deterioration.
Monitoring vital signs should take place every 15 to 30-minutes (Morrow et. al., 2012).
You might be interested in specific nursing plans.
A registered nurse should advise the patient to stick to the prescribed medication.
Should explain all details to Ms Foley and her family.
Be sure to focus on the early signs that fluid upload is occurring.
You should provide support mental to the patient. Otherwise, it can lead to the deterioration or worsening of the condition.
Be sure to check all medications.
If it is not properly treated, acute pulmonary embolism can result in death and/or morbidity.
Current treatment of pulmonary obstruction focuses not only upon the treatment of symptoms but also on preventing the condition from becoming severe (Villar-Kacmarek and Guerin 2014).
Recent studies have shown that pharmacological therapy has not greatly improved the high mortality and morbidity rates.
Patients with acute pulmonary swelling require holistic treatment.Conclusion:
Ms Foley’s case analysis clearly identifies the risk and complications associated with pulmonary hypertension.
Because she was a former smoker, and had suffered injuries in a car accident, her risk of developing pulmonary hypertension was high.
Both her vital sign assessment, clinical presentation, and clinical presentation showed that there were complications associated with pulmonary embolism such as impaired gas exchange and poor breath rate.
Therefore, the nursing care plan was primarily focused on improving patient’s breathing rate, fluid uptake, and managing pain and integrity.
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