Posted: September 16th, 2024
Patient Case Study: Respiratory Distress Management
Patient Case Study: Respiratory Distress Management.
Respiratory distress is a critical condition requiring immediate medical attention. This paper presents a fictional case study of a patient admitted to the hospital on September 5th for respiratory distress. The focus is on the patient’s medication administration record (MAR), clinical assessments, and management strategies. The aim is to provide a comprehensive overview of the therapeutic interventions and nursing considerations involved in treating respiratory distress.
Medication Administration Record (MAR)
Medication 1: Albuterol (Proventil)
Class: Bronchodilator (Therapeutic), Beta-2 Agonist (Pharmacologic)
Indications: Used to relieve bronchospasm in conditions such as asthma and COPD.
Dose/Route/Frequency: 2.5 mg via nebulizer every 4-6 hours as needed.
Contraindications: Hypersensitivity to albuterol.
Nursing Considerations: Monitor respiratory status and lung sounds before and after administration. Assess for paradoxical bronchospasm. Educate the patient on proper inhalation technique.
Side Effects: Tremors, nervousness, tachycardia.
Patient Teaching: Instruct on the importance of adhering to prescribed doses and recognizing signs of worsening symptoms.
Medication 2: Prednisone
Class: Corticosteroid (Therapeutic), Glucocorticoid (Pharmacologic)
Indications: Reduces inflammation in respiratory conditions.
Dose/Route/Frequency: 40 mg orally once daily.
Contraindications: Systemic fungal infections, hypersensitivity.
Nursing Considerations: Monitor blood glucose levels, especially in diabetic patients. Assess for signs of infection. Taper dose gradually to avoid adrenal insufficiency.
Side Effects: Hyperglycemia, increased risk of infection, mood changes.
Patient Teaching: Advise on potential side effects and the importance of not abruptly discontinuing the medication.
Medication 3: Furosemide (Lasix)
Class: Diuretic (Therapeutic), Loop Diuretic (Pharmacologic)
Indications: Manages fluid overload in heart failure or pulmonary edema.
Dose/Route/Frequency: 40 mg IV once daily.
Contraindications: Anuria, hypersensitivity to sulfonamides.
Nursing Considerations: Monitor electrolytes, particularly potassium. Assess fluid status and daily weights. Watch for signs of dehydration.
Side Effects: Hypokalemia, dehydration, hypotension.
Patient Teaching: Encourage potassium-rich foods and report any signs of electrolyte imbalance.
Medication 4: Ceftriaxone (Rocephin)
Class: Antibiotic (Therapeutic), Cephalosporin (Pharmacologic)
Indications: Treats bacterial infections potentially causing respiratory distress.
Dose/Route/Frequency: 1 g IV every 24 hours.
Contraindications: Hypersensitivity to cephalosporins.
Nursing Considerations: Monitor for signs of allergic reaction. Assess renal function. Ensure culture and sensitivity tests are performed.
Side Effects: Diarrhea, rash, elevated liver enzymes.
Patient Teaching: Complete the full course of antibiotics even if symptoms improve.
Medication 5: Enoxaparin (Lovenox)
Class: Anticoagulant (Therapeutic), Low Molecular Weight Heparin (Pharmacologic)
Indications: Prevents thromboembolic events in immobilized patients.
Dose/Route/Frequency: 40 mg subcutaneously once daily.
Contraindications: Active bleeding, heparin-induced thrombocytopenia.
Nursing Considerations: Monitor for signs of bleeding. Check platelet counts regularly. Educate on proper injection technique.
Side Effects: Bleeding, anemia, thrombocytopenia.
Patient Teaching: Report any unusual bleeding or bruising.
Clinical Assessment and Management
Patient Information
Room: 101
Patient/Age/Sex: John Doe, 65, Male
Attending & Consults: Dr. Smith, Pulmonology
Allergies: Penicillin
Admit Date: September 5th
Isolation & Organism: None
Code Status: Full Code
Primary Diagnoses
Acute respiratory distress syndrome (ARDS)
Chronic obstructive pulmonary disease (COPD)
Chief Complaint and History of Present Illness
The patient presented with severe shortness of breath, wheezing, and cyanosis. Symptoms began acutely two days prior to admission, with a history of COPD exacerbations.
Past Medical and Surgical History
Medical: COPD, hypertension, type 2 diabetes.
Surgical: Appendectomy at age 30.
Neurological and Psychological Assessment
GCS: 15
Primary Language: English
Mood/Behavior: Anxious but cooperative.
Laboratory and Diagnostic Data
GFR: 60 mL/min
HgbA1C: 7.5%
BNP: 150 pg/mL
ABG: pH 7.35, pCO2 50 mmHg, HCO3 28 mEq/L, pO2 60 mmHg
Respiratory Assessment
O2 Delivery: 4 LPM via nasal cannula
O2 Sat Trends: 88-92%
Lung Sounds: Bilateral wheezing, diminished bases.
Plan of Care
Priority Problem #1: Impaired Gas Exchange
Assessment Data: Low oxygen saturation, wheezing, cyanosis.
S.M.A.R.T. Goal: Improve oxygen saturation to above 92% within 24 hours.
Interventions:
Assess/Monitor: Continuous pulse oximetry, ABG analysis every 6 hours.
Manage: Administer bronchodilators and corticosteroids as prescribed.
Educate: Teach breathing exercises and the importance of medication adherence.
Evaluation: Goal met if oxygen saturation improves.
Priority Problem #2: Risk for Infection
Assessment Data: Recent antibiotic initiation, COPD history.
S.M.A.R.T. Goal: Prevent infection during hospital stay.
Interventions:
Assess/Monitor: Monitor WBC count and temperature daily.
Manage: Administer antibiotics as prescribed, maintain aseptic technique.
Educate: Importance of hand hygiene and completing antibiotics.
Evaluation: Goal met if no signs of infection develop.
Priority Problem #3: Fluid Volume Overload
Assessment Data: Edema, elevated BNP.
S.M.A.R.T. Goal: Reduce edema and maintain stable weight.
Interventions:
Assess/Monitor: Daily weights, intake and output.
Manage: Administer diuretics, restrict fluid intake as ordered.
Educate: Importance of fluid restriction and monitoring weight.
Evaluation: Goal met if edema decreases and weight stabilizes.
Conclusion
Effective management of respiratory distress involves a multidisciplinary approach, focusing on medication administration, continuous monitoring, and patient education. By addressing the primary problems of impaired gas exchange, infection risk, and fluid overload, healthcare providers can improve patient outcomes and enhance quality of care.
References
Global Initiative for Chronic Obstructive Lung Disease. (2023). Global strategy for the diagnosis, management, and prevention of COPD. Retrieved from GOLD website
National Heart, Lung, and Blood Institute. (2022). Acute respiratory distress syndrome. Retrieved from NHLBI website
American Thoracic Society. (2021). Guidelines for the management of COPD. American Journal of Respiratory and Critical Care Medicine, 203(1), 24-56.
Mayo Clinic. (2020). Prednisone: Uses, side effects, and precautions. Retrieved from Mayo Clinic website
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The patient is in the hospital for a respiratory destress he came in September 5th. all the information you need you can come up with. patient is fictional so you can put whatever you like. if it doesn’t apply to the patient you don’t have to fill it in. Include 5 medications in the MAR you only need to put there 5 medication.
Medication
(Generic & Brand Names) Class
(Therapeutic & Pharmacologic) Indications
(Why is pt. taking this drug?) Dose
Route Frequency Contraindications Nursing Considerations Side Effects Pt. Teaching
Medication
(Generic & Brand Names) Class
(Therapeutic & Pharmacologic) Indications
(Why is pt. taking this drug?) Dose
Route Frequency Contraindications Nursing Considerations Side Effects Pt. Teaching
Room Patient/Age/Sex Attending & consults Allergies Admit date Isolation & organism Code status
Primary diagnoses
CC/HPI
Past medical hx
Past surgical hx
Neuro/Psych GCS
Primary language Eyes _____
Level of consciousness Verbal _____
Orientation & follow commands Motor _____
Mood/behavior Total _____
Pupils
Muscle strength: LUE _____ / RUE _____ / LLE _____ / RLE _____
Labs BGM frequency _____ / 07 _____ 11 _____ 17 _____ 21 _____
GFR ________ HgbA1C ________
Troponin ________ Lactate ________
BNP ________ Procal ________
CK ________ CRP ________
D-dimer ________ ESR ________
Fibrinogen ________ Amylase ________
Ammonia ________ Lipase ________
UA _________________________________
Cultures ___________________________
____________________________________
Cardiac Echo EF _____ %
Heart rate trends
Tele rhythm trends
SBP/MAP trends & goal parameters
Temp trends & method/fevers & Tmax
Pulses: L rad _____ / R rad _____ / L ped _____ / R ped _____
Edema & grading
[ ] Pacemaker / [ ] AICD
Respiratory IS [ ] & trends/max _____ ml
Lung sounds & work of breathing/rhythm
O2 delivery _____ @ _____ LPM / _____%
O2 sat trends
Secretion amt & character/suction method
Chest tube(s) output & character
ABG date _____: pH _____ / pCO2 _____ / HCO3 _____ / pO2 _____
GI Lt NG / Rt NG taped @ _____ cm / PEG
Continent/incontinent Suction __________ / Output _____ ml
Last BM & character Current TF rate @ _____ ml/hr
Bowel sounds TF goal rate _____ ml/hr
Abdomen appearance & palpation TF max residual _____ ml
Diet/TF formula
Rectal tube/colostomy output & character
Fluid restriction _____ ml/day
Diagnostics/Imaging 12-lead ECG
XR
CT
MRI
Ultrasound
EEG
GU Foley insert date _____ Indication __________
Continent/incontinent Last bladder scan _____ ml @ _____
Voiding method Last I&O cath _____ ml @ _____
Shift/hourly urine output
Urine character
HD sched __________ & last HD amt removed _____ ml
Specialty: Advanced Med/Surg
Neuro/Psych – Richmond Agitation-Sedation Scale
RASS
Cardiac – Hemodynamics
PA cath @ _____ cm
CI _____ / SvO2 _____ / CVP _____ / PAP _____ / SVR _____
Respiratory – Artificial airway & mechanical ventilation
ETT size _____ taped @ _____ cm @ teeth / gum / lip
Trach brand __________ & size _____
Vent mode ____________
Rate _____ VT/PS _____
FiO2 _____% PEEP _____
GI – Enteral tube
OG taped @ _____ cm
Musculoskeletal/Safety & Mobility [ ] SCDs [ ] VTE ppx meds
Pain & scale utilized
Assistive devices
Level of assist
Calls for assist/safety concerns
Restraint type & location
Sitter/tele-sitter
Rehab consults: [ ] PT [ ] OT [ ] SLP
Skin & Drains/Tubes
Pressure injuries/wounds
Wound tx/dressings output & character
Drains/tubes output & character
Wound care consult [ ]
OTOs/PRNs given & time last given To-do/Follow-up/Notes
IV Lines
Continuous IV Drips
Hct
Hgb
WBC Plt
Na Cl BUN
Glu
K CO2(HCO3) Cr
Bili
AST ALT
PT
aPTT
INR
Phos
Ca Mag
Alk
Phos
Alb
Shift Notes Vitals 08/20 12/00 16/04
07/19 08/20 09/21 10/22
Temp &
source
HR &
rhythm
11/23 12/00 13/01 14/02
BP & MAP
Resp
rate
15/03 16/04 17/05 18/06
SpO2 &
delivery
method
Pain &
pain
scale
used
Medication Administration Record – provide 5 most critical/priority medications
Generic & trade name Pharm class Dose Route Freq Indication(s) r/t patient Common SEs/ADEs (at least 3) Nursing considerations (at least 3)
Plan of Care (Clinical Judgment Plan)
Priority problem #1 [hypothesis]:
Pertinent assessment data [cues]:
S.M.A.R.T. goal/outcome #1 [solution]:
Interventions with frequency & rationale [actions]:
Assess/monitor:
Manage:
Educate:
Evaluation [evaluate]: Met / Not met
Recommendations (If goal/outcome not met):
Priority problem #2 [hypothesis]:
Pertinent assessment data [cues]:
S.M.A.R.T. goal/outcome #2 [solution]:
Interventions with frequency & rationale [actions]:
Assess/monitor:
Manage:
Educate:
Evaluation [evaluate]: Met / Not met
Recommendations (If goal/outcome not met):
Priority problem #3 [hypothesis]:
Pertinent assessment data [cues]:
S.M.A.R.T. goal/outcome #3 [solution]:
Interventions with frequency & rationale [actions]:
Assess/monitor:
Manage:
Educate:
Evaluation [evaluate]: Met / Not met
Recommendations (If goal/outcome not met):