BSCN 3605 - Clinical Judgement Concept Map by Francisca Greaves

Client Profile

franciscagreaves — 2024-05-25 04:40:40 UTC

Initials: JD Cared for on Day: May 14/15 Admission Age: 81 Gender: Female Code Status: No CPR Diagnosis: Hydronephrosis with obstructing calculi

Client History: Disuse osteoporosis, hypertention, cognitive impairment, subarachnoid hemorrhage, hypothyroidism, alcohol abuse, dyslipidemia, GERD, obstructive uropathy, renal calculi, anxiety, arthritis

Client Medications:

Acetaminophen 325-650 - PRN Q4H Betamethasone Valerate 0.1% Cream - 2x daily Citalopram 20mg - daily Glucose Tablet 16g - daily Haloperidol Injection 0.5mg IM - PRN Q4H

Heparin 5000u/0.5ml SC - Q12H HYDROmorphone 0.5mg - PRN Q3H Levothyroxine 50mcg - daily Lidocaine 20mg Injection SC - daily

Melatonin 6mg - nightly Midodrine 10mg - Q8H Multivitamin 1 tablet - daily Sulfamethoxazole-trimethoprim 80mg - Q12H

TraZODone 50mg - nightly TraZODone 50mg PRN - nighty TraZODone 12.5-25mg PRN - Q6H for agitation

Cue Rationale

franciscagreaves — 2024-05-25 04:40:59 UTC

Following the ABCs of medical care, shortness of breath puts the client at risk of poor hypoperfusion. Poor urine output may result from poor intake; however, it may also result from renal hypoperfusion. Additionally, increased client stress and decreased intake put client at high risk for hospital acquired infections and complications.

Patient Signs/Symptoms

franciscagreaves — 2024-05-27 16:37:15 UTC

Cough (weak, productive)

Bilateral coarse crackles

Dyspnea (RR 23, SpO2 80 RA)

Tachypnea

Applicable Lab Findings

franciscagreaves — 2024-05-27 16:37:30 UTC

Multifocal pneumonia

Right pleural effusion

Small left pleural effusion

Diagnostic Tests/Findings

franciscagreaves — 2024-05-27 16:37:53 UTC

Covid swab (pending)

Chest X-ray

Patient Risk Factors

franciscagreaves — 2024-05-27 18:03:44 UTC

Dysphagia

Cognitive impairment

Indwelling catheter

Full feeding support

Nephrostophy tube (left)

Poor intake

Analyze Cues

franciscagreaves — 2024-05-27 18:04:40 UTC

With the client history dysphagia (requiring thickened fluids and pureed foods) and full dependence with feeding, client is at high risk for aspiration. This is aggravated by client cognitive impairment which results in them biting down on the spoon when being fed (which results in further concerns when swallowing), their inability to follow direction and their inability to produce a cough as a protective factor.

Discussion of Analysis of Cues

franciscagreaves — 2024-05-27 18:04:45 UTC

Cues, signs and symptoms led me and my nurse to contact the doctor to delay discharge (which was planned on this day) and request diagnostic tests (x-ray and Covid swab) due to suspected aspiration pneumonia. Client was put on supplemental oxygen (initially 2L NP and overnight changed to 4L NRB) and on continuous pulse oximetry. Additionally, client was put on droplet precautions.

Recognize Cues

franciscagreaves — 2024-05-27 18:04:52 UTC

Shortness of breath

Use of accessory muscles

Shallow breathing

Dysphagia

Cognitive/Neurological Impairment

Poor urine output

Inability to follow direction/commands

Impaired cough reflex

Disease Process and Trajectory of Illness

franciscagreaves — 2024-05-27 21:20:59 UTC

Major Disease Process/Problem: Pneumonia (Hospital Acquired) Etiology/Causes: Aspiration

Definition: Bacterial infection of the lungs resulting in acute inflammation of the lung parenchyma resulting from aspirated material (in this case food entering the trachea and lungs).

Disease Progression:

Increased SOB

Tachypnea (compensatory)

Increased O2 demands (current 91% on 4L NRB)

Acute lung injury

Acute respiratory distress syndrome

Respiratory failure

Client Factors or Co-mobidities that Affect Disease:

Cognitive impairment - client is unable to follow commands or understand treatment and repeatedly removes mask, dropping SpO2

Client Psychosocial Considerations (if any) Which May Impact Outcome:

Client cannot be supported in current living condition (LTC)

Children of client spoke to doctor on two occasions to revise treatment plan. Initially client was changed from "no CPR" to "DNR/DNI" overnight and finally all care was withdrawn (including antibiotics) and palliative/symptomatic care only to be provided with RN to pronounce.

Client stress due to hospital stay

Nursing Priorities

franciscagreaves — 2024-05-27 21:56:44 UTC

Impaired Breathing/Gas Exchange ➡

Risk for Sepsis ➡.

Nursing Interventions

franciscagreaves — 2024-05-27 21:57:56 UTC

1a. Provide supplemental oxygen to keep O2 above 92%

1b. Complete vitals and respiratory assessment (lung sounds, SpO2, RR, HR, BP, temperature) and provide update to PHP, requesting orders for diagnosis and subsequent treatment

1c. Monitor VS regularly and SpO2 continuously

1d. Collaborate with respiratory therapist and SLP to provide client with breathing support and proper feeding/administration of medications.

2a. Administer antibiotics (Piperacillin / Tazobactam) as per orders following confirmation of diagnosis

2b. Encourage fluids to maintain adequate hydration and perfusion

2c. Monitor/screen for sepsis and complications using SIRS/QSOFA criteria

2d. Monitor vital signs and lab results

Potential Complications

franciscagreaves — 2024-05-27 21:58:31 UTC

Acute Respiratory Distress Syndrome (ARDS)

Increased SOB/dyspnea

Low oxygenation (SpO2 <92%)

Tachypnea (>20 RR/min)

Wet lung sounds

Septic Shock

Hypotension with poor perfusion (cap refil >3, reduced peripheral pulses)

Tachypnea (>22 RR/min)

Altered mental status (GCS ≦ 13)

Tachycardia (>90 HR/min)

Leukocytosis (>12,000)

Hyperpyrexia (>38℃)

Lactic Acidosis

References

franciscagreaves — 2024-05-27 22:20:16 UTC

Eisenmann, N. (2021). An innovative clinical concept map to promote clinical judgement in students. Journal of Nursing Education, 60(3), 143-149.

Habib, S. (2021///Sep/Oct). Aspiration Pneumonia. Medsurg Nursing, 30(5), 342-343. https://ezproxy.humber.ca/login?url=https://www.proquest.com/scholarly-journals/aspiration-pneumonia/docview/2581886363/se-2

Kaukonen, K.-M., Bailey, M., Pilcher, D., Cooper, D. J., & Bellomo, R. (2015). Systemic Inflammatory Response Syndrome Criteria in Defining Severe Sepsis. The New England Journal of Medicine, 372(17), 1629–1638. https://doi.org/10.1056/NEJMoa1415236

Lewis, S. M., Tyerman, J., & Cobbett, S. L. (2023). Lewis’s Medical-surgical nursing in Canada : Assessment and management of clinical problems (Fifth edition.). Elsevier.

Potter, P.A., Perry, A.G., Stockert, P., Hall, A., Astle, B.J. & Duggleby, W. (2019). Canadian fundamentals of nursing (6th ed.). Elsevier, Canada.