CRITICAL THINKING SUMMARY

Student: Katie VanderVelde

Client Dx: Rheumatoid Arthritis Age: 81

Allergies: methotrexate, naproxen, oats, plaquenil sulfate
The MEDICAL DIAGNOSIS that brought the client to the hospital is:
Interstitial lung disease
PATHOPHYSIOLOGY of diagnosed disease: (From text)
The interstitium is the area between the capillaries and the alveolar space. In the normal state, this
space allows close apposition of gas and capillaries with minimal connective tissue matrix,
fibroblasts, and inflammatory cells such as macrophages. The interstitium supports the delicate
relation between the alveoli and capillaries, allowing efficient gas exchange. When responding to
any injury, whether from a specific exposure, an autoimmune-mediated inflammation from a
systemic connective tissue disease (rheumatoid arthritis), or unknown injury, the lung must respond
to the damage and repair itself. If the exposure persists or if the repair process is imperfect, the lung
may be permanently damaged, with increased interstitial tissue replacing the normal capillaries,
alveoli, and healthy interstitium (Chapman, 2010).
SYMPTOMS typically seen with this diagnosis include (as identified in your text):
Dyspnea
Nonproductive cough
Sputum production
Hemoptysis
Wheezing (Chapman, 2010)
CLIENTS SYMPTOMS of the diagnosed disease include:
Temperature of 38.6
HR in 150s-160s
Respiratory Rate of 26
Atrial fibrillation
Shortness of breath
No sputum production
Peripheral edema
NUTRITIONAL ASSESSMENT:
Height (actual or estimated): 157.42 cm Weight (actual or estimated): 84.5 kg

Estimate Ideal Body Weight (Male: 105lb + 6 lb/inch > 5. Female: 100lb + 5lb/inch > 5): 46 is the
ideal body weight for patient

Does this client have characteristics of a well-nourished person? Yes __X___ No _____
Explain your answer.
Patients skin is not dry, hair is shiny and not falling out. Her nails are non-brittle and she is not
skin and bone. Her lips are not cracked and smooth.


PSYCHOSOCIAL STAGE OF DEVELOPMENT

What is the clients developmental stage?
Ego integrity vs. despair

Has he/she met the necessary accomplishments? Yes __X__ No _____
Explain. Patient and husband are in a good standing relationship. Husband comes in each morning
to do devotionals with the patient even though she is on a ventilator. Husband also talks amount
their sons and daughters and how he is proud of them. They are also involved with the church and
the church has been praying for the patient consistently. (Eriksons Psychosocial Stages Summary
Chart, n.d.).

How is this illness affecting the clients ability to meet these necessary accomplishments?
Patient was actively involved with the church and her family, however now she is unconscious and
mostly asleep. She is not arousable and grimaces to pain. Her inability to communicate and breath
on her own may can be a problem with her development stage. However, her husband has been
talking to her which is very important.

Stress Management: Identify coping mechanisms used by this client during stress.

Explained to patient the care given even though she was unconscious.
Held patients hand during wound care.
Spoke in a calming voice when in the room.
NURSING DIAGNOSIS/OBJECTIVES/INTERVENTIONS
Indicate below the 2 priority nursing diagnoses that are most relevant for your client.
#1 NURSING DIAGNOSIS (problem r/t)
Impaired gas exchange r/t to ventilation-perfusion mismatching.
DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
Somnolence
Inability to move secretions
Hypercapnia
Hypoxia

OBJECTIVE/CLIENT OUTCOME for this diagnosis:
Patient improves gas exchange as evidenced by normal ABGs and alert responsive mentation and
further reduction in mental status by 09/30/14.

NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:

1. Monitor effects of position changes on oxygenation (SaO2, ABGs, SvO2, and end tidal
CO2).

2. Monitor arterial blood gases (ABGs) and note changes.



3. Assess for signs and symptoms of hypoxemia: tachycardia, restlessness, diaphoresis.

4. Assess lung sounds, noting areas of decreased ventilation and the presence of adventitious
sounds.

(Galanes, 2012)

#2 NURSING DIAGNOSIS (problem r/t)
Ineffective airway clearance r/t increased airway resistance associated with edema of the bronchial
mucosa and pressure on the airways resulting from engorgement of the pulmonary vessels.
DEFINING CHARACTERISTICS (S/S) that support this diagnosis:
Somnolence
Diminished breath sounds
Abnormal blood gases
Significant decrease in oximetry results

OBJECTIVE/CLIENT OUTCOME for this diagnosis:
The client will experience adequate respiratory function as evidenced by usual or improved breath
sounds, usual mental status, and blood gases within normal range by 09/30/14.

NURSING INTERVENTIONS that will assist the client to resolve the above identified diagnosis:

1. Administer the following medications if ordered: diuretics to decrease fluid accumulation in
the lungs or morphine sulfate to decrease pulmonary vascular congestion in acute
pulmonary edema.
2. Perform actions to promote removal of pulmonary secretions like humidifing inspired air as
ordered to keep secretions thin.
3. Help client to change positions, turn, and perform ROM exercises.
(Nurses Diagnosis: Impaired, 2012)








COMPLICATIONS:
If this clients condition were to worsen, what would be the most likely reason and why?
Worsening heart and lung failure resulting in unresolved hypoxia.

How would you know this is happening?
Patient is pale
Decreased p02
Labored breathing
Decreased BP

What will you do if this happens?
Call the health care provider
Raise head of bed
Prepare for intubation
Administer medication to help cardiac fixation


Evaluation:
Was the patient able to achieve the objectives identified on the first clinical day? Yes

Did you choose the appropriate nursing diagnosis on the first clinical day? Yes

Were the interventions appropriate? Yes



PHYSICIAN PRESCRIBED MEDICATIONS AND INTERVENTIONS

MEDS/IVs/TX/DIET
(Include dose, route,
frequency)
REASON
PRESCRIBED
(Drug Classification,
What is it treating?)
NURSING
IMPLICATIONS
FROM TEXT
(Checking for adverse
reactions, preparation
& administration
concerns)
CLIENT DATA FROM
YOUR ASSESSMENT
(What data is
important to know
before & after giving)
diltiazem
30mg=1 tab
once daily
Calcium channel blocker
Decreases heart rate
Can cause severe
hypotension
Check blood pressure and
apical pulse before giving
Adverse reactions include
dizziness and swelling
Can cause dermatitis.
Patient has cellulitis on
right leg.
Used because
unresponsive to
metropolol.
Albuterol
2 puffs
Once daily
Adreceptor agonist
Helps with inflammation
and breathing
Prevents asthma attacks
Can decrease immune
system-avoid people who
are sick
If allergic to milk
proteins medication
should be avoided.
Higher doses should be
watched with
arrhythmias.
Patient is 81 and can
decrease immune system
Watch out for infection
and use all standard
precautions.
Patient experiencing
Atrial fibrillation.
Ascorbic acid Vitamin C
Important for connective
tissue
Drink plenty of liquids Patient has interstitial
lung disease
ERTApenem Antibiotic
Fights cellulitis
Powder is mixed with
liquid.
Given slowly at least for
30 minutes.
Antibiotic given for
cellulitis on right leg.
Furosemide Loop diuretic
Help with fluid overload
and hypervolemia
Can cause hyperkalemia Can cause tachycardia.
Patient experiencing
Atrial fibrillation.
Heparin Anticoagulant
Blood thinner
Increased bleeding over
age 60
Thrombocytopenia can
occur.
Skin necrosis may occur
in the wound (cellulitis)
on right leg.
Prednisone Corticosteroid
Synthetic anti-
inflammatory
May mask signs of
infection
Patient is 81 and can
decrease immune system
Watch out for infection
and use all standard
precautions.
Used for inflammation in


lungs.
Metropolol
25 mg BID
Beta 1 selective
adrenergic receptor
antagonist
Can cause severe
hypotension.
Dyspnea is a side effect.
Decreases BP in patient
because of Atrial
fibrillation. Patient was
given Cardizem because
patient was unresponsive
to metropolol.
(National Library of Medicine - PubMed Health, n.d.)


Analysis of Diagnostic Tests

DIRECTIONS:

1. List all diagnostic and laboratory tests pertinent to the patient's medical diagnosis or
medical treatments (i.e. medications) and provide the patient values for each test. Explain
why they are pertinent for this patient.

2. List any screening diagnostic and laboratory tests that are not within normal limits.
Explain why these tests are increased or decreased in relation to your patient's medical
condition.

Diagnostic/Lab Test Patient Values Analysis of Values
MRI of spine and head

(-) no acute infarction Atrial fibrillation and irregular
rate and rhythm so MRI was
given. Lumbar puncture was
done
Cardiac monitor

Heart rate in the 150s Atrial fibrillation. Metrolol
25mg BID for rate controlled.
Will restart heparin when Hb
stabilizes.
Troponin T 0.054 H Increased troponins likely due
to respiratory failure.
WBC

9.6 L Antibiotics still need to be
given.
Hgb


91 L The low level is primarily due
to her acute anemia.
Hb


6.7 L The low level is primarily due
to her acute anemia. 2 units of
PRBCs was given.

DR chest-single view

No new acute
cardiopulmonary process
identified
Decreased lung sounds in
bases. Intubated and bronched
40% so a DR chest-single view
was taken. PEEP is at 5















References

Eriksons Psychosocial Stages Summary Chart. (n.d.). Retrieved March 31, 2014, from
http://psychology.about.com/library/bl_psychosocial_summary.htm
Chapman, J. (2010).Interstitial lung disease. The Cleveland Clinic Foundation. Retrieved from
http://www.clevelandclinicmeded.com/medicalpubs/diseasemanagement/pulmonary/inter
stitial-lung-disease/
Nurses Diagnosis: Impaired respiratory function. (2012). Saunders. Retrieved from
http://www1.us.elsevierhealth.com/SIMON/Ulrich/Constructor/diagnoses.cfm?did=130
Galanes, S. (2012). Gas exchange, impaired: Ventilation or perfusion imbalance. Mosbys Guide
to Nursing Practice (3
rd
ed). Retrieved from
http://www1.us.elsevierhealth.com/MERLIN/Gulanick/archive/Constructor/gulanick23.ht
ml
National Library of Medicine - PubMed Health. (n.d.). Retrieved March 31, 2014,
fromhttp://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0010993/?report=details#warnin
g