Critical thinking: Infection Mr.

Richmond, age 76, resides in an extended care facility where you work the afternoon shift. Mr. Richmond is generally able to care for himself with minimal assistance. He has been withdrawn and more immobile the past week. As you enter his room today, he is restless, and his answers to your questions are not clear. Vital signs: BP 154/90, P 98, R 24, T 99. Lung sounds: diminished bases with bilateral crackles.

1. What additional assessment data do you collect? I will collect the following: *Presence of dyspnea and chest pain *Respiratory depth and pattern *Skin color (pallor, cyanosis) *Past pulmonary diagnoses *History of smoking *Family history of chronic lung disease *Assessment of cognitive function, orientation to time and place, language skills, hearing and visual abilities. *Sleep pattern disturbances *Determination of abilities to perform functional activities of daily living (ADL) 2. What do you think is happening to Mr. Richmond? The respiratory infection triggered the condition that is called delirium. Delirium can be caused by physical illness, it is abrupt in onset and is commonly due to an underlying medical condition. Older adults are more vulnerable to occasional episodes of delirium, than the other age groups. This condition is reversible with treatment of the underlying cause. 3. What typical signs for an elderly client is Mr. Richmond displaying for his possible condition? Mr. Richmond is displaying signs typical for his age as following: *Pneumonia in the older adult may present with confusion. *Fever and cough may be absent. *Decrease in the mucus transport, therefore, there is decreased clearance of mucus. *Disorientation due to possible delirium.

4. What nursing diagnoses might apply to Mr. Richmond? a. Ineffective airway clearance related to pulmonary infection as evidenced by abnormal lung sounds and increased respiratory rate. b. Acute confusion related to delirium and age over 60 as evidenced by increased restlessness and misperceptions. 5. Develop an expected outcome and plan for Mr. Richmond. Expected

outcomes: a. Within 24 hours the client will state that breathing is easier. b. Within 48 hours the client will maintain maximum degree of orientation and self-care within level of ability. c. By day 4 of treatment client`s lungs will be clear to auscultation. Nursing actions: a. Monitor vital signs and respiratory status, including auscultation every 2 hours. b. Follow ABG levels/SaO2 to determine oxygen need and response to oxygen therapy. c. Administer oxygen at concentration to maintain PaO2 at acceptable level. d. Administer an antibiotic as ordered. e. Assist client to assume semi-Fowler to high Fowler position and reposition frequently. f. Instruct client in coughing and deep breathing. g. Encourage fluid intake. h. Administer benzodiazepines and neuroleptics as ordered i. Gradually increase client`s activity level, assisting client out of bed to the chair. j. Assist client with activities of daily living (dressing, bathing, and grooming). Provide slow step-by-step instructions for the client when providing hygiene. k. Teach measures to prevent pulmonary infection-avoid crowds during cold and flu season, wash hands frequently , report early signs of infection. 6. How will you evaluate your plan? *After 24 hours client will report a decrease of difficulty breathing. *After 48 hours I expect client`s vital signs to be within normal ranges. *I will expect a decrease in using accessory muscles during breathing *I will notice if my client demonstrates decreased anxiety, answers questions correctly and is oriented in time and place. *I will schedule client`s hygiene activities in morning and evening as per client`s usual routine. Client will be able to participate in washing hands, face and brushing teeth.

2. Medications that relieve pain are called analgesics. damage causes acute pain. to provide the same pain relief tolerance has occurred.

3. Tissue 4. When more and more drug is needed

5. Fear is the sense of threat to self image that may accompany pain. 6. Endorphines are endogenous pain relievers that work in the central nervous system. 7. If a client is physically depended on a drug, symptoms will occur when the drug is stopped abruptly. 8. A client who is addicted to a drug craves the drug for effects other than pain relief. 9. refers to a drug dose that is limited by side effects. 10. Central pain is associated with injury to nervous system. 11. The term used to refer to narcotic analgesics is opioids. 12. An alternative medication or treatment works with an analgesic to make it work better. 13. PCA is treatment that is controlled by the patient. 14. Some clients appear to be addicted because they are undermedicated and therefore constantly ask for medication. This is called pseudoaddiction. 15. A placebo is an inactive substance that should never be used to treat pain.

Mr. Lewis is a 59-year-old gentleman admitted for exacerbated emphysema and chronic lung disease. He has been on corticosteroids for 10 years to reduce inflammation in his lungs. As a result, he has developed osteoporosis and compression fractures, leaving him with constant back pain. He has a long smoking history and has been unable to quit. 1. A. how would you rate the pain you are feeling? B. How long have you been experiencing and when did the pain start?

C. Have you felt this pain before? If so, what measures do you take to relieve it? How effective were these measures? D. What happened right before? E. Where is the pain centered? 2. Usually, when our body feels pain there is an increase in vital signs, such as blood pressure, pulse, and respiration. 3. Since Tylenol No. 3 is less powerful than morphine, the ordered amount may not be enough Mr. Lewis may need more of this medication. 4. Mr. Lewis has a right to medication and as his nurse I am obliged to fulfill that right so long as I

follow the 5 rights to medication administration: 1) Right Patient. 2) Right Route 3) Right Dose. 4) Right Time 5) Right Medication. 5. Side effects of morphine include: Constipation; dizziness; drowsiness; headache; lightheadedness; nausea; restless mood; sweating; vomiting, irregular heart beats, stomach pains, shortness of breath, respiratory depression. 6. Checking vital signs Monitoring the clients appetite The patient may also ambulate more and engage in more activities. The patient may also experience constipation. 7. If administered as an extended release, the highest dosage is 600 mg equally divided over 8 to 12 hours 8. This is called breakthrough pain. Repositioning, guided imagery, and meditation, deep breathing exercises. 9. You request a consultation at the pain clinic for Mr. Lewis. The pain specialist recommends a Duragesic patch. The RN applies the patch and tells you to hold the morphine. What concerns do you have about the patch? About the RNs instructions? - Duragesic patches are contraindicated for patients who have trouble breathing. Therefore, my concerns with the patch would be that because Mr. Lewis already has respiratory problems (exacerbated emphysema and chronic lung disease), and is a long time smoker he may enter respiratory distress. - I would be concerned with the RNs instructions because it may take a long time for the patch to have release its therapeutic effect---withholding the morphine may exacerbate the patients pain. 10. What are some nondrug strategies that you can teach Mr. Lewis to help him deal with his pain? - Mr. Lewis may use many non-pharmacologic measures to manage his pain. - Stress management is important in managing pain as stress exacerbates pain. - He may also try heat and cold applications, ROM exercises and ambulating, distraction and diversion (ie: television, games, arts & crafts), deep relaxation techniques, and looking into support groups where he would be able to discuss what he is feeling with a group of people who would be more understanding of the pain since they may have some of the same ailments he has.