Section 1

• Introduction

The case patient is called Joy Smith. Her body weight is 88kgs. Her past medical history shows that she has already been diagnosed with hypertension, atherosclerosis, and osteoarthritis. Besides, her surgical history shows that she had a left total knee replacement in 2010. In 2009, a percutaneous coronary intervention was done. Lastly, a stent on the left anterior descending artery was done in 1989. Currently, the patient lives with her husband, and they are stable enough to perform activities of daily living. However, today Joy woke up today at 4:30am, and her husband noticed that she had chills, looked confused, and agitated. According to her husband, John, she has had symptoms such as agitation, confusion, loss of appetite, fatigue, and spending more time in bed for the past 3 days. Following these changes, her husband brought to the emergency department at 5:30 am. Vitals signs were measured, and she had a respiratory rate of 26 breaths per minute, SPO2 of 94% on room air, blood pressure of 95/55 mmHg, and her body temperature was 38.5 centigrade. More so, Joy stated that she had a stinging sensation on urination. The table below shows her current medications.

Table 1: Current medication

Medication	Dose	Route	Frequency	Indication
Carvedilol	50mg	PO	BD	Used to treat hypertension
Aspirin	100mg	PO	Daily (Morning)	Used to treat pain and inflammation, e.g. osteoarthritis
Lipitor	40mg	PO	Nocte	Associated with atherosclerosis
Panadol Osteo	2 tablets	PO	TDS	Pain associated with arthritis

 

Section 2: Collect Cues

            In this case, abnormal values are highlighted in red while normal values have been cites.

Table 2: A-G assessment conducted at 0600hrs

A-G	Assessment and observation	Normal values
Airway	·       Accessory muscles used on inspiration ·       Airway patent
Breathing	·       Respiratory rate (RR) – 27 breaths per minute (bpm) ·       SpO2% – 93% on room air ·       Breathless ·       On Auscultation, there was decreased air entry in both bases	·       RR: 12-20 breaths per minute (bpm) (Bellchambers, 2015) ·       SpO2%: 95-100% (Bellchambers, 2015).
Circulation	·       Pulse – 116 beats per minute (bpm) – weak and regular   ·       Blood pressure (BP) – 90/55 mmHg   ·       Nil cyanosis peripherally or centrally.     ·       Venous blood gas (VBG) results: §  pH = 7.36 §  pCO2 = 43 mmHg §  pO2 = 40 mmHg §  Hb= 115 g/l §  K+ = 4.3 mmol/L §  Na+ = 143 mmol/L §  HCO3 = 25 mmol/L §  BE = 1.5 mmol/L §  Lactate = 3 mmol/L	·       Pulse: 60-100 beats per minute (Bellchambers, 2015) ·       BP: 120/80mmHg is considered normal. Blood pressure below 90/60 mmHg is considered hypotensive (Paliadelis, 2015). ·       pH = 7.35-7.45 ·       pCO2 = 35 – 45 mmHg ·       pO2 = 28 – 48 mmHg ·       Hb = 121 to 150 g/L ·       K+ = 3.5 to 5 mmol/L ·       Na+ = 135 to 145 mmol/L ·       HCO3 = 21 – 28 mmol/L ·       BE = -2 to 3 mmol/L ·       Lactate = 0 to 2 mmol/L
Disability	·       Nil slurred speech, talking in full sentences ·       Glasgow Coma Scale (GCS) 14 (Eyes=4, Verbal=4, Motor=6) ·       AVPU – alert and disoriented ·       Pain – 3/10 when passing urine	·       GCS: 15 (reference)     ·       Pain: 3/10 is mild to moderate pain (Applegarth, 2015)
Exposure	·       IV access right arm ·       Temperature (T) – 38.3ºc	·       T: 36 – 38ºc, a reading above 38ºc is considered hyperthermia (Bellchambers, 2015).
Fluids	·       Decreased skin turgor observed
Glucose	·       Venous blood test results: §  Glucose (Gluc) = 9.0 mmol/L	·       Gluc: 4-8 mmol/L (Marini et al., 2017)

 

Section 3

1. Process Information

Interpret

Firstly, Joy’s respiratory rate was 27 breaths per minute. Any breathing that is higher than 20 breaths per minute is referred to as tachypnea (Bellchambers, 2015). Tachypnea, breathlessness and the use of accessory muscles on breathing indicates respiratory distress (Bolzani et al., 2017). Besides, Joy showed signs of a slight reduction in oxygen saturation. Her SPO2 measured 93%, yet the normal range is 95-100% (Vold, Aasebø, Wilsgaard & Melbye, 2015). Since she has no comorbidities that could reduce her oxygen saturation, the reduction is due to low oxygen in tissues (Stratton, 2019). Her pulse was 116 beats per minute indicating that she was in a tachycardic state. Such a weak pulse show decreased cardiac output (Lowry, 2015). Furthermore, the patient was suffering from hypotension due to the reduced blood pressure which was 90/55 mmHg (Paliadelis, 2015). She had hypertension, and such a low blood pressure indicated that her condition was worse. Also, the patient had abnormal values of pO₂, hemoglobin and lactate as shown in the table in section 2. According to the Clinical Excellence Commission (2014), elevated levels of serum lactate indicate sepsis.

Moreover, the pain of the patient was 3/10 based on the pain scale meaning that it was mild (Applegarth, 2015). However, pain on urination indicated that she had a urinary tract infection (MFMER, 2019). Joy was also conscious but disoriented based on the measurement of 14 on the Glasgow coma scale (Slater, 2015). In most cases, disorientation results from dehydration, hyperglycemia, reduced oxygen supply, fever, and sepsis (Pisani, 2019). The high fever of 38.3ºc is a response to infection ((healthdirect, 2019). Excessive fluid loss through fever and dehydration led to a decrease in skin turgor (Royal Children’s Hospital, 2019). According to Walker (2015), older adults have less sensation for thirsty, and so they take less water. As such, Joy might be subjected to the same. Lastly, Joy’s blood glucose level is higher than normal, 9 mmol/L (Diabetes Australia, 2015).

 

 

Discriminate, Relate, and Infer

Firstly, the high fever experienced by Joy may be due to the inflammatory response by her immune system to fight invading microorganisms through the production of neutrophils (Gatzonis, 2017). Besides, dysuria is as a result of the urinary tract infection which may progress to the kidneys (Borg, Dwyer & Goldsworthy, 2017). In most cases, the Glasgow coma scale of 14 is common among people diagnosed with a urinary tract infection (Lee, 2019). Commonly, sepsis is a response to infection. It is defined as the addition of SIRS to the suspected infection (Gatzonis, 2017). There is a standard SIRS criteria which includes temperature >38, HR >90, and RR >20 (Zhao, Lin, Jiang, Mao, & Li, 2016). Also, serum lactate elevation shows that the sepsis is turning into septic shock (Clinical Excellence Commission, 2014). Finally, patients with sepsis have elevated blood glucose levels (Daniels, Inada-Kim, Saifuddin, Nutbeam & Berry, 2018).

In general, sepsis can lead to multiple symptoms including fever, tachycardia, mild hypotension, hypovolemia, low oxygen supply on blood, and lastly, a decrease in Hb (Song et al., 2019). In short, the presenting symptoms are related to sepsis, and so the patient’s major condition is sepsis.

Match

            Hypertension is related to overweight, and it can lead to atherosclerosis. In atherosclerosis, plaques occupy arteries blocking smooth flow of blood. Thus, the patient takes Lipitor to reduce plaques in arteries. On relating the patient’s symptoms to her past medical history, it is clear that the symptoms are as a result of osteoarthritis, which is characterized by inflammation, fever, and sepsis.

 

 

Predict

            In case sepsis is not treated appropriately it may turn to septic shock which is severe enough to cause death.

Section 4

Identify Critical Problems

• Impaired gas exchange related to poor tissue perfusion found in sepsis evidenced by the oxygen saturation of 93%, low Hb, breathlessness, and use of accessory muscles on breathing.
• Risk infection related to the stinging sensation of urination and sepsis evidenced by temperature 38.3ºc, respiratory rate of 27bpm and heart rate of 117bpm.
• Deficient fluid volume related to dehydration, inadequate fluid intake, and sepsis evidenced by blood pressure of 90/55mmHg, rapid heart rate of 115 bpm, hypotension, and decreased skin turgor

Section 5

Interventions

Problem 1: Gaseous Exchange

Intervention 1: Administer Oxygen

            Supplemental oxygen will be administered to the patient immediately after she is administered on the bed. Oxygen flow is efficient if the patient is placed in a stable position. Since the patient is suffering from acute respiratory failure characterized by breathlessness, use of accessory muscles to breath, a slide decrease in peripheral capillary oxygen saturation, a simple method of artificial gaseous exchange will be used (Bolzani et al., 2017). As such, a nasal cannula will be used to transfer oxygen from the oxygen cylinder to the patient. This will progress until the patient starts breathing normally or when the SPO2 returns to normal.

Intervention 2: Position the patient in Fowler/semi-Fowler’s position and elevate legs

            Fowler/semi-Fowler’s position is preferred for obese patients who are suffering from acute respiratory distress. Also, patients who are obese are put in this position to prevent obstruction of the artificial airways. Furthermore, the position prevents upward displacement of the diaphragm. Therefore, the patient can comfortably breathe without using accessory muscles. As such, Joy will be laid in the hospital bed in semi-fowlers to ensure that adequate gaseous exchange occurs to enhance breathing. She will have to remain in this position until she returns to the usual breathing. Secondly, helping the patient to lie on the hospital bed with her legs elevated promotes tissue perfusion. As a result, free circulation of blood in veins will be guaranteed, and this will as well reduce hypoxemia which results due to ineffective tissue perfusion. Thus, elevating legs enables blood containing oxygen to flow to all parts of the body. In this regard, Joy’s legs will be elevated once she has been directed to lie on the bed in an appropriate fowlers/semi-fowlers position.

Problem 2: Infection

Intervention 1: Do tests to determine the culture of infections

            To determine the cultures of infection for Joy, blood tests will be done in the laboratory. Full blood count will be done to determine changes in white blood cells count. Usually, patients with bacterial infections show elevated white blood cells and neutrophils. Also, elevated creatinine protein as well shows the presence of bacterial infections (Lee, 2019). Thus, such tests will be done before any type of treatment is initiated to come up with the necessary treatment. In this case, symptoms of sepsis such as fever are noticeable, and so it is apparent that the patient is suffering from bacterial infections. Thus, the bacterial tests are aimed to determine specific bacteria that is responsible for the infection.

Intervention 2: Administer antibiotics

Based on the symptoms identified while assessing Joy Smith, it is clear that she has a risk for sepsis. As such, the best intervention is to administer antibiotics which will act as prophylaxis or an actual treatment of the underlying bacterial conditions. Antibiotics such as ceftriaxone, azithromycin, vancomycin, ciprofloxacin, and piperacillin-tazobactam will be administered. Since the severity of sepsis in Joy’s case has not been confirmed, oral antibiotics will be administered to her so that she can take them while at home or when she is still in the hospital. The patient will be taking the prescribed antibiotics while health care personnel will play the role of monitoring for any change in symptoms. In case the sepsis gets worse, intravenous antibiotics will be started. The goal is to ensure that Joy recovers from the disease.

Problem 3: Hypovolemia

Intervention 1: Administer fluids of Normal Saline

            As shown before, adults have a problem with taking fluids due to the reduced sensation of thirst. To avoid extreme cases of hypovolemia, intravenous fluids such as normal saline will be administered to her with an approximate of 1 litre for every eight hours. Excess fluids are not recommended for her since she is suffering from hypertension. Apart from the intravenous administration of normal saline, the patient will be advised to feed on foods and fluids that can help her to regain fluid balance (Walker, 2015). This will be done when the patient is conscious again. The patient will as well be advised to take oral fluids, including water. While doing this, nurses will be observing for positive changes in her body.

Intervention 2: Monitor Input and Output

            In this case, Joy Smith will be monitored closely, especially when put on intravenous floods. While monitoring fluid input measuring the amount administered in litres, the output will also be measured by measuring urine output. Thus, urine catheters will be fixed before administering the first load of fluids. After that, the output of urine measured from the catheter will be subtracted from the total input, and this will determine the next step take in ensuring that the patient does not suffer from hypovolemia (Royal Children’s Hospital, 2019).

Section 6

Rationales

Problem 1: Gaseous Exchange

The Rationale for administering oxygen

Oxygen is administered to ensure that the patient recovers hypoxia and to improve tissue perfusion. Besides, administering oxygen through nasal cannula prevents Joy Smith from experiencing forced breathing using accessory muscles. Also, symptoms such as breathlessness will be prevented since there is enough supply of oxygen (Bolzani et al., 2017). Most importantly, peripheral capillary oxygen saturation will return to the normal range due to the supply of enough oxygen.

The rationale for positioning the patient in Fowler’s position and elevating legs

            Positioning the patient in a Fowler’s position enhances effective breathing as it allows the diaphragm to stay in its position during inhalation and exhalation. Also, the patient will not use much energy while breathing as the intercostal muscles while be put in action instead of accessory muscles. On the other hand, elevating the patient’s legs allows blood to flow through all veins in the body, and this improves tissues perfusion and prevents hypoxia.

 

Problem 2: Infection

The Rationale for carrying culture tests

            Culture tests are meant to identify the causative agents for the suspected infection. For proper treatment, specific microorganisms need to be isolated in the lab. For example, performing a blood culture can reveal some bacteria in the blood sample, meaning that the patient’s blood is infected with. After that, appropriate measures will be taken to treat the infection. More so, carrying out a complete blood count will enable nurses to determine the severity of the infection based on the white blood cell and neutrophils count. As a result, they will be able to formulate the best management plan for the patient.

The Rationale for administering antibiotics

            In the case of Joy Smith, administering antibiotics is aimed at treating bacterial infections. Presence of fever shows that she is either suffering from sepsis, or she is at risk of infection (Lee, 2019). Besides, antibiotics can act as a prophylaxis to prevent an impending bacterial infection. As such, administering antibiotics is necessary to ensure a positive outcome for the patient.

Problem 3: Hypovolemia

The Rationale for administering fluids of normal saline

            Hypovolemia shows that Joy Smith is experiencing body fluid imbalance. Thus, administering normal saline, which is an isotonic solution that enables her to regain from dehydration and hypovolemia. As a result, the skin turgor will return to normal since there is an adequate supply of fluids to her body. Therefore, nurses have to intervene adequately to be sure of positive outcomes.

 

 

The Rationale for monitoring input and output

While giving intravenous fluids to the patient, nurses should as well monitor for input and output to ensure that the fluids being administered do not exceed normal levels. Joy has a history of hypertension, and so excessive fluid intake will increase blood pressure, resulting in edema and other effects of hypervolemia. Therefore, nurses should measure input and output continuously to ensure that there is fluid balance all the time.

Section 7: Outcomes Evaluation

            Evaluation of outcomes involves relating the interventions to the status of the patient thereafter. Several interventions have been planned for the patient as discussed before. Thus, outcomes should as well be evaluated to determine the viability of the interventions.

Outcomes of Administering Oxygen

            Before putting the patient on oxygen, SPO2 was 93% which is slightly below the normal ranger. After intervening the patient is expected to regain normal SPO2 of between 95-100%. Besides, the patient will be expected to regain normal breathing with a heart rate ranging at 12-20 breaths per minute. Lastly, the patient will be expected to breathe normally without involving accessory muscles.

Outcomes of Administering Antibiotics

            As shown before, antibiotics treat and prevent bacterial infections. Hence, the patient will be expected to be free of bacterial infections. Symptoms such as fever and sepsis are expected to vanish as a result of the administered antibiotics.

Outcomes of Administering Fluids

Initially, the patient had symptoms of hypovolemia including hypotension, reduced blood pressure, and dehydration. Therefore, changes are expected after administering intravenous fluids such as normal saline. For example, the blood pressure which was 99/55 mmHg should go back to the normal range of about 120/70 mmHg.

Outcomes of Monitoring Input and Output

The reason for monitoring input and output is to ensure that there is a fluid balance to avoid administering too much or too little fluids. Since the case patient is a diagnosed hypertensive patient, administering too much raises blood pressure to extreme levels and leads to massive edema. As such, it is expected that the patient will regain a normal body fluid volume.

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