Thursday, February 23, 2006

A DiVa's Perfect Care Plan

Since I was up and all, I thought I would post a copy of the care plan that I got a perfect score on. I wish I could be as optimistic about the test I took yesterday.

P.M. is a 72 year old Caucasian female that was under the care of the student on February 12th 2006. Her growth and development stage at the time of assessment is Stage 8: Ego Integrity vs. Despair. She presented to the Emergency Department on February 10th 2006 after tripping on a rug in her home. P.M. was admitted to the hospital when the x-ray films revealed an internal fracture of the right femur. An open reduction internal fracture repair was performed under general anesthesia on February 11th 2006. In the PACU, the patient was extubated and administered dilaudid and morphine for pain. During this time she became hypotensive and experienced an episode of respiratory distress that resulted in her admittance to the medical intensive care unit.

Medical History includes:
Breast Cancer, emphysema, osteoarthritis, rheumatic fever, hypertension, chronic obstructive pulmonary disease (COPD), hypercholesterolemia, mastectomy of the left breast, left and right carotid endarectomy

Nursing Diagnosis and Evidenced-Based Nursing Interventions

Ineffective gas exchange and respiratory distress related to chronic obstructive pulmonary disease as evidenced by low oxygen saturation, high anxiety and verbal complaint.

1. Patient will maintain a pulse ox rating within acceptable range. (92-93)

2. Patient will use the Bipap and venti-mask periodically during hospitalization and resume using the portable oxygen and nasal cannula prior to transfer to a regular floor

3. The patient’s lab values will reflect a normal Ph balance with regard to respiratory performance

4. The patient will report a decrease in respiratory effort

5. The patient will have an absence of adventitious breath sounds

Interventions and Scientific Rationales

- The patient will be given medications as ordered to improve respiratory performance

Rationale: The patient is ordered various medications to help improve respiratory performance. One such medication is Solumedrol. According to the evidence, high-dose prednisolone successfully reduces the inflammatory process in COPD. Side effects include gastric toxicity, fluid retention hyperglycemia and oral candidiasis. These side effects should be monitored carefully, and to prevent adverse effects, corticosteroids should be titrated down to the minimally effective dose after starting with a high dose to treat inflammation, (Jantarakupt and Porock, 2005, Pg. 789)

- The patient’s anxiety should be addressed immediately to prevent the increase of respiratory distress. This includes pharmacological interventions and non-pharmacological interventions such as relaxation/pursed lip breathing and guided imagery.

Rationales: The patient was prescribed various medications to address anxiety. The following paragraphs discuss the scientific evidence that support the pharmacological interventions utilized for this patient.

“Benzodiazepines do not have direct effects on the lungs, but their sedative action is very helpful in reducing anxiety that may induce or exacerbate dyspnea (Quinn, 1999; Rousseau). Because dyspnea intensity is believed to be highly correlated with anxiety (Bruera, Schmitz, Pither, Neumann, & Hanson, 2000), sedatives or anxiolytic drugs may lessen the distress associated with dyspnea). Benzodiazepines may cause excessive sedation, impair thinking, and cause respiratory distress (Cohen et al., 1991; Cowcher & Hanks, 1990). Nurses should monitor the side effects carefully, especially in older adults and in patients with poor kidney or liver function (Macklon, Barton, James, & Rawlins, 1980).” (Jantarakupt and Porock, 2005 Pg. 791)

“Pursed-lip and diaphragmatic breathing have been found to have beneficial results for dyspneic patients, including reduced respiratory rate and control of dyspnea. In addition, pursed-lip and diaphragmatic breathing decrease functional residual capacity, increase respiratory muscle recruitment during inspiration and expiration, reduce the work of the diaphragm, increase tidal volume and alveolar ventilation, improve the ability to perform effective coughing, and improve blood gases (Breslin, 1992; Coppola & Wood, 2001; Sexton, 1990; Vitacca, Clini, Bianchi, & Ambrosino, 1998). The mechanism for breathing techniques for reducing dyspnea can be explained by physiologic changes during performance of breathing. Deep inhalation through the nose followed by slow exhalation through pursed lips increases lung expansion, and decreased time with the airway constricted improves gas exchange in the lungs. When patients perform proper diaphragmatic breathing, abdominal muscle contraction moves the diaphragm downward, providing more space for lung expansion and, therefore, increased gas exchange in the lungs. The physiologic explanation is sufficient to encourage patients with dyspnea to learn and practice the techniques. Because this is such a simple and cost-effective strategy for reducing dyspnea, nurses should teach and encourage patients to practice breathing techniques.” (Jantarakupt and Porock, 2005 Pg. 791-792)

Non-Pharmacological Treatment was used in the care of PM. We utilized relaxation breathing and guided imagery. PM responded positively to light massage of the forehead and guided imagery. In thinking open thoughts and visualizing an open airway, the patient became calmer and showed decreased respiratory effort. The evidence that supports such activities is embodied in the following paragraph:

“Relaxation techniques, including controlled breathing, may help patients control dyspnea and decrease anxiety, thus stopping the vicious cycle of anxiety and dyspnea (Cowcher & Hanks, 1990; Wickham, 1998). Complete muscular relaxation is associated with decreased oxygen consumption, decreased carbon dioxide production, and decreased respiratory rate (Sexton, 1990).” (Jantarakupt and Porock, 2005 Pg. 793)

If the interventions are effective, the patient’s respiratory condition will improve and she will be able to breathe effectively with only a nasal cannula at 3 liters. Since she has impaired lung compliance and directives that prevent intubation/ventilator use one must exercise care and prudence in institution of aggressive treatment.


Jantarakupt, P., Porock D., (2005). Dyspnea management in lung cancer: applying the evidence from chronic obstructive pulmonary disease. ONCOLOGY NURSING FORUM, 32. Retrieved Feb 14, 2006, from EBSCO Host.

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