AZUSA PACIFIC UNIVERSITY

SCHOOL OF NURSING

GNRS 588: ADVANCED NURSING CARE FOR ADULTS

COMPREHENSIVE CARE PLAN #: _1_

Student: Donna Le

Professor: Steve Lehr

Date of Care: 06/08/2016

Date of Submission: 07/06/2016

Admitting Diagnosis: Lower back pain (ICU Admission due to sepsis, respiratory distress, and ALOC)

Secondary Diagnosis:

Pulmonary fibrosis, DM II, hyperlipidemia, gout, CKD III, Diabetic nephropathy, history of obstructive sleep

apnea, lumbar pain, dehydration, lumbar compression fracture, intractable pain, pulmonary mass, lung mass, and

liver mass.

Patient’s Hospital Course (refer to progress notes):

A 79 years old female with past medical history of DM II, history of CKD III, pulmonary fibrosis, and diabetic

nephropathy. Patient presented to the ER with history of 4 weeks of lower back pain. She denied any weakness in

her lower extremity or bowel or urine incontinence. She denied fever or chills. She had a CT scan of the lumbar

area and CT scan of the abdomen and it showed liver masses as well as a fracture in the lumbar area more

specifically an L1 compression fracture noted 60% loss of vertebral body. Therefore, she was admitted to the

hospital for further investigation and care. On 06/03/2016 she had an episode of respiratory failure, and an ETT

was inserted for the patient to be able to breath by using the ventilator. Patient was sedated since then and still on

sedation medication.

Prioritized To Do List (refer to patient’s orders): 1. Provide comfort measures for the patient.

2. Explain to the family the prognosis of the disease and patient’s care needs at the end-of-life.

3. Provide support for the family.

4. Maintain patient clean and administer medications.

Diagnostic tests and procedures

Tests (Date completed) Results

Liver biopsy (06/02/2016)

Chest X-ray (06/01/2016)

Chest CT (06/01/2016)

Abdomen CT (06/07/2016)

Liver mass (cancerous cells)

Oral intubation for checking of replacement. In addition, the heart is

enlarged. Aorta is calcified. There is mild diffuse interstitial edema

suggestive of mild CHF and small bilateral pleural effusions.

Underlying L. basilar infiltrates vs. atelectasis cannot be excluded. No

pneumothorax. There are degenerative changes of the thoracic spine.

Sub pleural partially visualized soft tissue density mass along the

right lower lobe posterior basal segment measuring up to 3.7 X 2 cm

is noted. There is mild pleural thickening and small pleural effusion

suggest with mild cardiomegaly. Hepatomegaly with multiple slightly

hypodense hepatic masses measuring up to 4.8cm long the L. hepatic

lobe and 4.5 cm long the R. upper lobe in suggestive of metastatic

disease.

Abnormal / Pertinent Lab Values

Test Range Value at

Admissio

n

06/1/2016

Recent

value

06/7/201

Why this test was ordered and what is the

significance of the value?

WBC 4.8-10.8 K/mm3 12.8 H 12.1 H Patient has an infection UTI. The WBC are

increasing due to infection.

RBC 4.2-5.4 M/mm3 3.94 L 2.82 L Patient is not drinking and eating regularly. Poor

diet. Need to check RBC regularly to prevent

anemia.

HGB 12.0-16.0 gm/dl 11.7 L 8.4 L HGB is necessary for oxygen delivery and tissue

perfusion. Patient has heart and lungs problems.

Neutrophils 42.2-75.2% 79.2 H 83.1 H Patient immune system is fighting the infection.

Na 136-145 mmol/L 134 L 135 L Electrolyte balance needs to be followed since the

patient is on antihypertensive medication.

K 3.5-5.1 mmol/L 3.4 L 2.9 L Electrolyte balance needs to be followed since the

patient is on antihypertensive medication. This

can cause dysrhythmias.

BUN 7-18 mg/dl 19 H 20 H Patient has UTI, CKD III, and taking

medications. Kidney function needs to be

followed up to prevent further complications.

GLU 74-106 mg/dl 127 H 453 H Patient has DM II and Kidney problems.

AST 15-37 U/L 74 H 2313 H Patient has cancerous cells in the liver.

ALT 12-78 U/L 67 N 379 H Patient has cancerous cells in the liver.

Malarkey, L., & McMorrow, M. (2012). Nursing Guide to Laboratory and Diagnostic Tests. Missouri: Saunders.

Vital Signs 0800 1200 160

0

IV Fluids

Noninvasive Blood

Pressure (NIBP)

115/59 130/7

0

125

/70 Type Rate/ Site

KCl

RUA/PICC

Mean Arterial

Blood Pressure

(MAP)

72 90 88

Pulse Rate 80 79 77

Respiration Rate

(RR)

20 20 20

% O2 Saturation

(SpO2)

96% 96% 95

%

Temperature 98.5 F 99.0

F

98.

5 F

Normal Saline

PICC

150 ml/hr Hemodynamic

Monitoring N/A

0800 0900 100

0

Arterial Blood

Pressure (ABP)

Central Venus

Pressure (CVP)

Pulmonary Artery

Pressure (PAP)

Propofol (Diprivan)

PICC (Drip)

Pulmonary Artery

Occlusion Pressure

(PAOP)

19.7 ml/hr

Cardiac Index

Levophed

Levofloxacin

PICC (Drip)

16 mcg/ml

7.5 ml/hr

PICC

100 ml/hr

Cardiac Output

(CO)

Other

Intracranial

Pressure (ICP)

N/A

Blood Glucose

(POC)

210

Pain Level 0

Intake

Oral Enteral IV TOTAL

Shift

Total

0 200 2967.6 3167.6

Output Urine

output

BM Emesis Total

Shift

Total

1620 0 0 1620

PLACE ECG STRIP HERE SORRY, I COULD NOT PRINT OUT THE EKG TRIP.

HR Rhythm P wave PR QRS P:Q ratio ST segment T-wave Q-T Ectopy

Interpretation:

Complete Head-To-Toe Assessment

General

Survey

Physical

Appearance:

Patient is sedated and in bed. Patient is on ventilator. No signs of pain or distress on

the face. Patient basically on life support with ETT at 7.5 teeth and 23 cm.

Mood: It is hard to tell since the patient is under the effects of sedation.

Signs of

Acute

Distress:

No signs apparent on the face. Patient is on life support and comfort measure.

Orientation Altered level of consciousness.

Neurologi

c

Speech Cannot determine patient is under the effects of sedation.

Pupil (L) PERRLA (both eye lids are closed, Nurse had to open and point light in order to

assess).

Pupil (R) PERRLA (both eye lids are closed, Nurse had to open and point light in order to

assess).

GCS score It was not used since the patient is under the effects of the sedation. There is another

scale used called RASS.

Abnormal

Muscles

Location

:

N/A

Strength

:

N/A

Pain

Assessmen

t

Provocation/

palliation

No sign or repots of pain.

Quality No sign or repots of pain.

Region/

Radiation

No sign or repots of pain.

Severity No sign or repots of pain.

Time However, the patient showed signs of pain when she was extubated of the ETT.

Pulmonar

y

Oxygenation ☐ Room Air ☐ Device :Ventilator Flow rate: 0.5 L/min

Respiration Quality: not labored with the assistance of the ventilator.

Rate: 20 breaths per minute

Rhythm: Regular with the assistance of the machine.

R. Lung Clear lung sounds in the two upper lobes, kind of diminished breath sounds in the

lower lobe.

L. Lung Clear lung sound in the upper lobe, and diminished or low breath sound in the lower

lobe.

Cardio-

vascular

Capillary

Refill

More than 3 sec.

Skin Color/

Temp

WNL skin is pale, warm, and clammy.

Apical Pulse Present 2+

Heart Sounds S1 and S1 were located and heard.

Peripheral

Pulses

Weak in the pedal. 2+ in the wrist and AC.

Gastro-

intestinal

Oral Mucosa Not pink, pale, but moist.

Tongue Pale not fully pink.

Abdomen Tender to touch at the upper right quadrant. Distend and there is wound related to

biopsy over the liver area. The wound is covered with clean cloths. Hernia obese.

Bowel sounds were present in all four quadrants.

Nutrition Well-nourished and she weighs 61.8 Kg

Tube Feeding Current Rate: ____0_______ Goal Rate: ___N/A__________

Residuals: _______Less than 50 ml_Type: ☐ N/A ☐ NGT ☐ PEG ☐ J-tube

Bowel

Sounds

Bowel

Movement

Last BM date: ____06/07/2016____

Genito-

urinary

Urination Patient has a Foley.

Urine Color Yellow (more dark).

Urine Cloudy.

Character

Urine (ml) 1620 ml

Urinary

Catheter

Insertion date: 06/05/2016.

Skin

(wounds)

Skin Color Pale and match patient’s ethnical group.

Skin

Integrity

Intact, hematoma due to blood draws on the upper L. arm under the cuff pressure.

Wound/

Ostomy

Wound due to biopsy of the liver on the upper right quadrant. No signs of bleeding

or infection.

Insertion

Site(s)

2 IV lines in the R. hand and L. wrist that patent but not in use currently. Patient has

a PICC line in the upper Right arm with three lumens. The PICC line is the main

source for medication.

IV

Assessment

Patent IV and intact skin at the location of the insertion and surroundings.

IV Fluids Normal saline, Propofol (Diprivan), KCl, antibiotics.

Musculo-

skeletal

Describe

abnormalities

:

There was not any abnormality noticed, beside what was reported about the vertebra

fracture in the lumbar area. Patient is sedated and limited assessment was done in this

system.

Psychosocial Assessment

Psychosocial

History

Marital status Married

Education level College level

Social resources Family

Spiritual

resources

God family, and church

Occupation Retired

Employment N/A

Smoking Quit 10 years ago

Alcohol Occasional on events

Recreational

Drugs

Never

Spiritual Assessment

Spiritual

Integrity 1) Look: (Signs of Meaning, Relationships, Hope and Joy)

Spiritual

Distress

Presence of….. Provide checkmark in either box for each criteria Absence

of….

X Family, friends, visitors, wedding ring, photographs

Cards, letters, phone calls, flowers, pets X

Attention to personal care and appearance X

Work, projects, hobbies, music, books, tapes X

Newspapers, magazines, television, radio X

Special dress, prayer cap, head scarf, cross X

Articles of faith, pictures, statues, rosary, star X

Books of faith, Bible, Koran, Torah prayers X

Smiles, motivation, coping skills, healthy lifestyle X

Uses the observations listed above to begin your Spiritual Assessment

Acknowledge and inquire about photographs, cards, flowers, visitors

Acknowledge and inquire about hobbies, books, television/newspaper content

Acknowledge strength and inquire about profession

Acknowledge and inquire about articles of faith & religious preference

Acknowledge and inquire about mood (physical and psychological)

With your client as your guide, and after a sense of trust and connectedness have been established, continue

with the assessment. Phrase your questions and indirect statement in ways that convey your genuineness,

style, and comfort.

I would like to hear more about your life and/or your family. N/A

When you return home, will there be someone available to help you? N/A

What brings you joy, makes you happy, or makes you laugh? N/A

What has brought you the greatest sense of pride and accomplishment to date?N/A

What is your next goal? N/A

What give you such strength? N/A

Who do you turn to in tough times? N/A

Would you like me to pray for you or with you? N/A

Spiritual

Integrity

Listen: (Actively listen for signs of meaning, relationships, hope,

and joy) Spiritual Distress

Pt verbalizes... **Provide checkmark in each box that is applicable Pt verbalizes…

Sense of purpose and meaning

My life has no meaning

Source of pride & accomplishment Guilt, if only….I should have

Source of joy & happiness Sense of sadness and despair

Future Goals and desires Lack of motivation

Hope and Courage Hopelessness “What is the use?”

Interest in world & concern for others Lack of concern for others

Personal Strengths Powerlessness I am useless.

Connection to others Loneliness and isolation

Connection to a higher source Helplessness, anxiety, fear

Religious affiliation “This is not fair. Why me?”

Request for special diets, clergy “Why am I being punished?”

Appreciation for nature Apathy

Ability to adapt to changes Inflexibility

2. Nursing Diagnosis: Analyze the data, and if appropriate, select one of the following nursing diagnoses.

Potential for Enhanced Spiritual Well-Being

Spiritual Distress

Hopelessness

Other

3. Plan: Develop a short-term goal and a long term goal for your client.

ST Goal: The Client will have friends and family surrounding her all through the day.

LT Goal: The Client will die in peace and with minimal physical suffering

4. Interventions: Identify the specific nursing interventions you will use with your client and her family.

Be present.

Establish a therapeutic relationship conveying respect, warmth, empathy and genuineness

Active listening.

Assist client to identify strengths, supports, and interconnections.

Instill hope.

Use of touch, if client is comfortable with closeness.

Provide an environment conductive to reflection, prayer, and spiritual growth.

Provide an environment conductive to client’s beliefs (food, ceremonies.)

Provide religious articles as requested.

Support client in search for meaning and purpose in life, illness, and death

Support client in search for a relationship with a higher power.

Pray with the client.

Pray for the client.

Promote private time with people who are significant in client’s life.

Be available and approachable to assist client with meeting spiritual needs, and making spiritual choices.

Collaborate with chaplain or spiritual leader.

Other:

Other:

5. Evaluation: Evaluate the client’s progress towards the goals.

(Note: Each person’s spirituality is highly variable, individual, and ever changing!)

ST Goal: Patient had her family coming in and saying their goodbyes.

LT Goal: Patient did not show prolonged signs of distress or pain.

SCHEDULED MEDICATIONS AND PRN MEDICATION GIVEN

Generic Name : Lidocaine Trade Name : Lidoderm

Classification : Antidysrhythmic, local

anesthetic

Dose: I patch Route: Topical Frequency/ Rate: One patch Daily

Pt. Specific Indications: Ventricular dysthymias, patient has lower back pain.

Mechanism of Action: Increase electrical stimulation threshold of ventricle and His-purkinje system, which stabilize

cardiac membrane and decrease automaticity.

Contraindications: Hypersensitivity to amides, severe heart block, and supraventricular dysrhythmias.

Side Effects: seizures, heart block, cardiovascular

collapse, arrest.

Adverse Effects: methomeglobinemia, respiratory

depression.

Patient Family Education: teach the family reason for use of medication and expected results.

Generic Name : pantoprazole Trade Name : Protonix

Classification : proton pump inhibitor Dose: 40mg Route: PO Frequency/ Rate: Qday

Pt. Specific Indications: patient has oral feeding tube. In order to decrease stomach acidity and protect the stomach

from ulceration.

Mechanism of Action: Suppresses gastric secretion by inhibiting hydrogen/potassium ATPase enzyme system in the

gastric parietal cells, characterized as gastric acid pump inhibitor, since it blocks the final step of acid production

Contraindications: hypersensitivity.

Side Effects: headache, insomnia, asthenia, fatigue,

malaise, somnolence, diarrhea, abdominal pain,

flatulence, pancreatitis, weight changes, rash, weight

gain/loss.

Adverse Effects: hyponatremia, rhabdomyolysis,

pneumonia, anaphylaxis, Stevens-Johnson syndrome.

Patient Family Education: advise to report severe diarrhea. Advise to avoid hazardous activities and advise that

hyperglycemic might occur. Advise to avoid alcohol and aspirin.

Generic Name : Fluoxetine Trade Name : Prozac

Classification : Antidepressant Dose: 40mg Route: PO Frequency/ Rate: Qday

Pt. Specific Indications: Patient needs to stay calm as long as she is intubated.

Mechanism of Action: inhibits CNS neuron uptake of serotonin but not of norepinenephrin.

Contraindications: hypersensitivity

Side Effects: seizures, hemorrhage, angioedema,

bradycardia.

Adverse Effects: Steven-Johnson syndrome, MI,

thrombophlebitis. Flu-like symptoms.

Patient Family Education: advise patient not to discontinue medication, advise patient to take gum or sugar less

candy for dry mouth, advise patient to avoid activities such as driving when taking medication.

Generic Name : baclofen Trade Name : Gablofen

Classification : Skeletal muscle relaxant Dose: 20mg Route: PO Frequency/ Rate: BID

Pt. Specific Indications: patient needs to be sedated.

Mechanism of Action: inhibits synaptic responses in CNS by stimulating the GABA receptor subtype, which

decrease neurotransmitters function, decreasing frequency and severity of muscle spasms.

Contraindications: hypersensitivity

Side Effects: seizures, cardiovascular collapse, dyspnea,

N/V

Adverse Effects: weakness, fatigue, tinnitus, nasal

congestion, blurred vision.

Patient Family Education: not to take with alcohol, report any adverse effects.

Lehne, R. (2013). Pharmacology for Nursing Care. Missouri: Saunders

Present History and Relevant Past History

A 79 years-old female with past medical history of DM II, history of CKD III, pulmonary fibrosis, and

diabetic nephropathy. Presented to the ER with history of 4 weeks of lower back pain. She came in 06/01/2016

because she was not able to walk because of the severity of her lower back pain. She denied any weakness in

her lower extremity or bowel or urine incontinence. She denied fever or chills. She had a CT scan of the

lumbar area and CT scan of the abdomen and it showed liver masses as well as a fracture in the lumbar area

more specifically an L1 compression fracture noted 60% loss of vertebral body. Therefore, she was admitted

to the hospital for further investigation and care. On 06/03/2016, she had an episode of respiratory failure, and

an ETT was inserted for the patient to be able to breath by using the ventilator. Patient was sedated since then

and still on sedation medication.

Pathophysiology of Admitting Diagnosis

The pathophysiology of this patient here is for Cancer stage IV, and it spread from lungs to liver and

other organs. A minority of patients present with local symptoms related to their primary tumor, but most

present with either nonspecific systemic or metastatic symptoms. Many lung cancers occur in central airways

and may lead to post-obstructive pneumonia; lymph node enlargement also may occur. Hemoptysis is the

presenting symptom in those patients. The pathogenesis of lung cancer is like other cancers, beginning with

carcinogen-induced initiation events, followed by a long period of promotion and progression in a multistep

process. Cigarette smoke both initiates and promotes carcinogenesis. The initiation event happens early on, as

evidenced by similar genetic mutations between current and former smokers. Smoking thus causes a “field

effect” on the lung epithelium, providing a large population of initiated cells and increasing the chance of

transformation. Continued smoke exposure allows additional mutations to accumulate due to promotion by

chronic irritation and promoters in cigarette smoke. The time delay between smoking onset and cancer onset is

typically long, requiring 20-25 years for cancer formation. Cancer risk decreases after smoking cessation, but

existing initiated cells may progress if another carcinogen carries on the process. SCLC and NSCLC are

treated differently because they originate from different cells, (ii) undergo different pathogenesis processes,

and (iii) accumulate different genetic mutations. SCLC often mutations in MYC, BCL2, c-KIT, p53, and RB,

while NSCLC often has mutations in EGFR, KRAS, CD44, and p16. These are all either tumor suppressor

genes or oncogenes. Stage IV non-small cell lung cancer (NSCLC) is the most advanced form of the disease.

In stage IV, the cancer has metastasized, or spread, beyond the lungs into other areas of the body (Huether &

McCance, 2012); (Lewis et al, 2014).

PATIENT’S PLAN OF CARE:

The patient’s initial wish was not to be on life support; DNR. In this patient situation, she had terminal

diagnosis that will inhibit her from going back to where she was before being admitted. The most important

care that can be provided to this patient is spiritual and end of life care. Support her family and provide

comfort measures for the patient in order to die without suffering. Provide spiritual care through offering

prayer for her with the family, call in a Chaplin, providing quiet and safe environment. Give time for the

family to come and say their goodbyes. Be sensitive and not judgmental. Pain medication to relief her pain and

die peacefully.

LIST 4 NURSING DIAGNOSIS IN ORDER OF HIGHEST PRIORITY

1) Pain r/t difficulty breathing on her own when she was extubated as evidenced by patient agitation and

distress.

2) Death anxiety r/t unresolved issues relating to death and dying as evidenced by verbal statement from

patient’s family.

3) Ineffective breathing pattern r/t compromised cardiac output and pulmonary function as evidenced by

patient has ventilator assistance.

4) Risk for decreased cardiac tissue perfusion: risk factor: possible dysrhythmias r/t low potassium levels as

evidenced by low potassium level of 2.9.

- Nursing Diagnosis #1: Pain r/t difficulty breathing on her own when she was extubated as evidenced by

patient agitation and distress.

Related assessment: Patient looked agitated and in distress. Patient was sighing every time the pain

medication wears off. Patient has back fracture, lung and liver cancer. Increased respiration rate to 35 breaths

per minute.

Related Tests and labs: N/A. but we can check lactic acid level that increase irritability and cause heart

muscle ache.

Relevant Medications: Pain medication including morphine.

- Intervention and Rationale:

1. Administer pain medication in order to keep the patient from feeling pain and die without suffering. Pain is

associated with actual tissue injury such as cancer. A multidisciplinary approach in palliative care of the dying

patient improves the outcomes in the end-of-life care.

2. Provide comfort measures such as nasal cannula oxygenation, fowler’s position. In order to ease breathing

as much as possible and reduce pain.

3. Handle the patient body gently. Caregivers must be patient and gentle especially the client has fracture in

the lower back. This would reduce the chances of further complication and reduce pain related to that area.

Outcome Parameters: The patient will be painless until she passes away.

Evaluation: The patient did not feel pain for long time between the pain medication doses; however, the shift

was over before she passes away.

- Nursing Diagnosis #2: Death anxiety r/t unresolved issues relating to death and dying as evidenced by

verbal statement from patient’s family.

Related assessment: Her two sons and husband, who is the stepfather, seemed in disagreement at the

beginning about withdraw life support. There was tension in the room when the three of them around in the

same room. Patient was holding her older son hand when was withdrawn off life support machines.

Related Tests and labs: N/A.

Relevant Medications: N/A.

- Intervention and Rationale:

1. Teach the family of the patient to talk, hug, and kiss the patient even that she has altered orientation. This

will reduce her fear of the strange place and feels safe by feeling the presence of people she knows.

2. Assess the client and family for fears related to death and losing someone special. Acknowledging and

responding to these fears is the core of end-of-life palliative care.

3. Offer prayers for the patient and family. Inform the family of the available Chaplin services at the

hospital. Patient and family believe in higher power; God, and believe that this will give inner peace to the

patient.

Outcome Parameters: Patient’s family will ask for Chaplin and prayer for the comfort of the patient before

the death of the patient.

Evaluation: Family requested a Chaplin and accepted the prayer offer for the patient peace of heart, mind,

and spirit before the end of the shift.

Ackley, B., & Ladwig, G. (2014). Nursing Diagnosis Handbook. Missouri: Mosby.

References

Ackley, B.J & Ladwig, G.B. (2014). Guide to nursing diagnoses. Nursing diagnosis handbook. Missouri: Mosby.

Huether, S., & McCance, K. (2012). Understanding Pathophysiology. Missouri: Mosby.

Lehne, R. (2013). Pharmacology for Nursing Care. Missouri: Saunders.

Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-Surgical Nursing. Missouri: Mosby.

Malarkey, L., & McMorrow, M. (2012). Nursing Guide to Laboratory and Diagnostic Tests. Missouri: Saunders.

References

Ackley, B., & Ladwig, G. (2014). Nursing Diagnosis Handbook. Missouri: Mosby.

Huether, S., & McCance, K. (2012). Understanding Pathophysiology. Missouri: Mosby.

Lehne, R. (2013). Pharmacology for Nursing Care. Missouri: Saunders.

Lewis, S., Dirksen, S., Heitkemper, M., & Bucher, L. (2014). Medical-Surgical Nursing. Missouri: Mosby.

Malarkey, L., & McMorrow, M. (2012). Nursing Guide to Laboratory and Diagnostic Tests. Missouri: Saunders.