Explore in detail, two of the actual or potential patient problems identified in assessment 1
review the patient care plan submitted in assessment 1 and select two of the identified patient problems (Impaired gas exchange related to bilateral crackles in the lungs as manifested by shortness of breath, Activity intolerance related to impaired gas exchange as evidenced by difficulty of breathing). For these two problems students are to provide an evidence based plan of care.
Day 1 of admission
Mr Peter Lars is a 62 year old male who presented to the Hospital Emergency Department with chest pain and shortness of breath. Mr Lars was brought in by his wife and was triaged at 1000hrs. He stated that he was running late for work and was racing to get himself ready, when he experienced the onset of these symptoms. He tried to continue to get himself to work, however the symptoms continued for over an hour and his wife insisted he go to hospital.
Mr Lars has an extensive medical history. He was diagnosed with and commenced treatment for type 2 diabetes 16 years ago, which has been managed with oral medications. Mr Lars has established peripheral vascular disease (PVD) and symptomatic neuropathy, both complications of his diabetes. Other medical history includes angina, hypertension and dyslipidaemia, which are generally well controlled with antihypertensive and hypolipidaemic agents.
Mr Lars is an ex-smoker and non-drinker, and has no known allergies. He had an Acute Myocardial Infarction (AMI) in 2010 for which he had a coronary angioplasty and stents. Mr Lars is currently under the care of a cardiologist, Dr Blair.
Mr Lars is also very anxious about the fact that he is having more time off work. His wife has stated that she fears if he has another hospital admission, his employer will ask him to retire. She says this is placing a lot of stress on Peter and she has noticed a recent decline with his health over the past 4-5 months. Mr and Mrs Lars have three adult children, who all live in the Sydney Metropolitan area and see them regularly.
Admission Data (ED):
The condition of Mr Lars on admission included the following:
HR 125 BPM (sinus tachycardia)
BP Sitting: 126/68 standing: 118/58
Resps. 28 BPM non-productive cough; pt. speaking in incomplete sentences
O2 Sats. 91% RA this increased to 95% with O2 6L/min via the NRB
LOC Alert and orientated to person slightly confused with time and place GCS 14/15; complains of feeling light headed when getting up quickly.
Pupils Equal and reactive to light
Pain 4/10 focused left upper chest area – reduced with O2 administration
In emergency oxygen therapy was continued. A comprehensive respiratory assessment showed that Mr. Lars had coarse crackles bilaterally in the bases of his lungs. It was also noted that Mr. Lars had oedema in both ankles. An IDC with hourly urine measure bag was inserted and IV Lasix was given. After the administration of the Lasix, 200mls of urine was drained via the IDC. BiPAP was considered, however Mr. Lars was found to be improving and therefore was continued on oxygen therapy (O2 6L/min via NRB). Decision made to admit and he has been scheduled for an echocardiogram later today.
Handover Emergency Department to Ward 1A:
This is Mr Peter Lars, a 62 year old male who was brought into Hospital ED by his wife after experiencing SOB and chest pains at home this morning. On arrival he was tachycardic, however in sinus rhythm. He was still experiencing SOB and was only able to speak in incomplete sentences. Further assessment revealed bilateral crackles in the lung bases and oedema in both ankles. We commenced O2 therapy via the NRB, administered IV Frusemide and inserted an IDC with hourly urine measure bag. The IDC has drained 400mls of clear urine so far. Mr Lars is now reporting to be more comfortable. His chest pain has subsided and his WOB has reduced. He has a provisional diagnosis of CCF and is for an echo later today. Under the care of Dr Giles
Condition on Arrival to the ward:
HR 100 BPM (NSR)
BP Sitting: 130/70 standing: 120/60
Resps. 22 BPM non-productive cough;
O2 Sats. 96% with O2 6L/min via the NRB (drops rapidly to 88% on air)
LOC Alert and orientated GCS 15/15; complains of feeling light headed when getting up quickly.
Pupils Equal and reactive to light
Pain 1/10 focused left upper chest area – reduced with O2 administration
Lungs Bilateral Coarse Crackles