NURSING DX NURSING DX
Ineffective Breathing Pattern r/t inability to expand lungs fully, presence of fluid in pleural Ineffective Health Maintenance r/t lack of knowledge regarding diagnoses, demonstrated lack of
cavity, inflammatory response (asthma and COPD), and pain from thoracentesis and JP drain adaptive health promoting behaviors, language barrier AEB refusal of medications, pt reaching into
exchange AEB requesting to be put back on the nasal cannulas, shallow, rapid breathing, his attends and then putting his hand out to grab an item, inability to focus when nurse is
tachycardia, anxiousness, abnormal rate, inability to use the Incentive Spirometer appropriately. instructing or looking away when nurse is attempting to discuss.
OUTCOMES: Breath sounds will be present in all lung fields within 48 hours. OUTCOMES: Patient will verbalize importance of adhering to highest priority medications prior to
INTERVENTIONS DX INTERVENTIONS
*Nurse will (check 02 sat) and provide oxygen via cannula if client appears to be Pancreatitis *Nurse will offer the highest priority medications earlier in the day with explanations done in
having difficulty breathing, checking on him q 30 minutes, or will ask him to always with Spanish stating their importance if client refuses. Rationale is that some cirrhosis patients can get a
call for the nurse if he wants to be put on the oxygen. Rationale is that the patient developing little out of control or “unreasonable” towards the later evening and night. So, by offering the
understands that he has breathing difficulties and he also just had a thoracentesis and pseudocyst teaching and highest priority meds earlier in the day, this favors compliance.
JP drain exchange and so won’t want to inhale or exhale forcefully because of the *Nurse will educate the family about patient’s current medications. Rationale is that they are very
pain. involved with the patient’s care and thus it is important that they understand the different
*Nurse will position patient in high or semi-fowler’s position at least every 2 hours. medications purposes so that they can encourage the patient to comply with the therapeutic
Rationale is to facilitate normal lung expansion which can improve respiratory status. regiment after discharge.
*Nurse will encourage the client to use the incentive spirometer q2h or ad lib. SECONDARY DX *Nurse will discuss behaviors that the client wishes to remain unchanged by current diagnosis.
Rationale is that patient is immobile and quite weak, thus needs to intentionally Cirrhosis Rationale is that the client has personally meaningful or valuable behaviors that need to be
practice deep breathing to prevent atelectasis or stasis of secretions within the lungs COPD addressed, understood, and preserved. In this way, the nurse will know what behaviors the patient
because this can cause diminished lung function. Pleural effusion is willing to change to improve health status and what medications will be most beneficial to
compensate for those behaviors left unchanged.
MEDICATIONS PATHOPHYSIOLOGY PT HEALTH HISTORY
Bacitracin-neomycin-polymyxin (triple --Pancreatitis: (acute inflammatory process of the pancreas, with many possible etiologies. For my patient’s history of 60s, hispanic, Spanish-speaking, married male with
antibiotic) 3.5-400-500 ointment: for drinking, cirrhosis, having gallstones removed at one time, it seems that alcoholism and biliary tract disease. The long history of alcohol use (quit about 3 years ago),
insertion site of JP drain. damage occurs after the pancreatic enzymes are activated. The pancreas produces trypsinogen, an inactive proteolytic tobacco 40 years (quit), cirrhosis of the liver,
Cholestryramine(questran) packet 4 grams: enzyme that usually gets released into the small intestine through the pancreatic duct, and then activated into trypsin by asthma, COPD, and HTN. Pt also has hx of CAD
to promote clearance of cholesterol (pt has enterokinase. The pancreas also has trypsin inhibitors (also present in plasma) that would inactivate any trypsin that is with prior infarction by echocardiogram, benign
hyperlipidemia and HTN) inadvertently produced. In pancreatitis, either through blockage of the duct, perhaps by gallstones, there is activated prostatic hypertrophy with urinary retention, and
Digoxin (Lanoxin) tablet 0.125mg PO daily trypsin, which begin to digest the pancreatic tissues and then activate other proteolytic enzymes like elastase and degenerative joint disease which is illustrated by
to increase contractility of heart muscle (pt phospholipase A. These two enzymes autodigest the pancreas and actually cause hemorrhage (elastase destroys the his musculoskeletal impairment. Iron study during
had prior MI) elastic fibers of blood vessels) and fat necrosis (phsopholipase A). It is not known how exactly the mechanism works a prior admit, when the pt was admited with ETOH
Fat Emulsion (Liposyn, intralipid) 20% inj with chronic alcoholism but alcohol does cause digestive enzymes to be release sooner than normal within the withdrawal, showed elevated ferritin (1205) which
250 mL: to provide nutrition because pt is on pancreas and it also created permeability of the smaller ducts that move enzymes around in the pancreas, which allows would occur with cirrhosis and iron is 32 with iron
clear liquid diet and has chronic malnutrition the leakage of juices into healthy tissues, which then become damaged. Also, excessive alcohol consumption can binding capacity of 184 and percent sat of 17.
from cirrhosis, pancreatitis, and poor diet. cause protein plugs( precursor to small stones) that can block part of the pancreatic duct. Also, in pancreatitis, due to Upon exam, light touch and pinprick sensations are
Fluticasone-salmetrol (Advair Diskus) 250- its inflammatory nature and autodigestion of pancreatic tissues, the endocrine cells called Islets of Langerhans become diminished below the knees. Patient is
50mcg/dose BID: for management of asthma damaged, therefore, the production and secretion of insulin, glucagons, and somatostatin is inhibited. This will malnourished upon appearance (prealbumin was 8).
symptoms interfere with the ability to maintain normal blood sugar levels, which is why this patient needs insulin and is on the
Lorazepam (Ativan) 2mg/mL inj 1 mg q6h sliding scale.
PRN: for anxiety and agitation (mostly --Pseudocyst: This is a cavity that can be surrounding the pancreas or continuous with the pancreas. It is filled with
when he was going through detox) necrotized tissues and liquid secretions (plasma, pancreatic enzymes, and inflammatory exudates). As fluid escapes PRESENTATION
Metoprolol (Lopressor) tablet 25mg BID: from it, the serosal surface of the pancreas becomes inflamed and then granulation tissue forms and encapsulates the Pt presented (about 2 weeks before I gave
Management of HTN exudate. These can rupture and then the treatment is an anastomosis between the pancreatic duct and the jejunum to care)with fever, nausea, vomiting, abdominal pain
Oxycodone (Roxicodone) 1mg/ml solution drain it. that would not go away for two days. Dx was
5-10mg: for pain from thoracentesis and JP --Pleural Effusion: It is reasonable to assume the cause of this was because the pancreatic pseudocyst was spreading to pancreatitis with biliary origin and progressive
drain exchange neighboring tissues and eventually managed to being damaging the left lung, which is why it was nearly collapsed. symptoms of sepsis. Underwent ERCP with
TPN solution 1000mL Q24 hour IV: for When the infectious fluid seeped into the pleural space, the immune response is of course to send WBCs to fight the removal of stones, complicated by aspiration and
nutrition invading cells. This did not really work for this patient because his JP drain was not functioning and so the ongoing sepsis. Patient also pulled his Dobhoff
Insulin regular human (Novolin) SQ sliding anymes/exudates/secretions were not draining, but they were accumulating in the abdominal cavity. tube so currently has no NG tube and is drinking
scale (high dose) 100units/ml Q6h: --Cirrhosis: This is probably what began the pancreatitis in my patient. Stemming from chronic alcohol use in this fluids but needs help because has a shaky hold. CT
management of blood sugar because patient case, the damaging effects cause a replacement of healthy liver tissue with fibrotic scar tissue and also nodules, which showed Left lobe pleural effusion, so underwent
has diabetes mellitus type II progresses ultimately to liver failure. Ascites is a common complication and has a poor prognosis. Some other issues thoracentesis (this was the day that I provided care)
are hepatic encephalopathy due to high ammonia and other nitrogenous substances that can’t be cleared by the liver and also had his JP drain exchanged for a bigger
anymore and are carried to the brain, affecting cerebral functioning, causing unresponsiveness, forgetfulness, or sized drain (16 French pigtail drain) because the
difficulty concentrating. Cirrhosis can also cause dysfunction with the immune system, which can lead to infection. CT showed that the catheter was transversing the
--COPD: With the long history of smoking and also having asthma, this patient had a lot of fibrotic tissue built up in stomach and was twisted This was why it was not
his lungs, so even in a semi-healthy state his lungs do not function up to standards. So, with an infectious process draining and probably caused the pleural effusion
involved his alveoli simply become congested and suffocated from the exudate. and sepsis.