Client -in-ContextStoryX1OPT Model of Clinical ReasoningOutcome StatePresent StateDecision Making (interventions)Judgments:TestingExit Framing:Reflective JournalingCue Logic:Keystone Issue:Pesut & Herman, 1999 1.Outcome met:Pt ambulated 6 ft will occupational therapist before discharge and did not report any shortness of breath.2.Outcome not met: Adventitious sounds were still heard on auscultation of the right upper lobes.3.Outcome not met: Unable to determine due to inability to obtain lab test/results.4.Outcome met: Pt no longer needed the aid of a nasal cannula after ambulating and before discharge.5.Outcome not met: Unable to obtain respiratory rate at the end of shift.1.Pt will deny shortness of breath after ambulating 6 ft. before discharge.2.No adventitious sounds will be heard upon auscultation of the lungs by discharge.3.CO2 will increase to a level greater than 20 before the end of shift.4. A nasal cannula will no longer be needed and spontaneous breathing of room air will be achieved by discharge.5. Respiratory rate will decrease to around 13-15 bpm before the end of shift.1.Shortness of Breath2.Pleural friction auscultated in right upper lung lobes.3.Decreased CO2 of 19.4.Nasal cannula used as needed at 2L/min.5.Higher-level respiratory rate of 17 bpm.-Decreased Cardiac Output-Ineffective Breathing Pattern-Impaired Gas Exchange-Excess Fluid Volume-Risk for Infection-Pruritis-Ineffective Tissue Perfusion (Cardiopulmonary, Gastrointestinal, & Renal)-Activity Intolerance-Impaired Spontaneous VentilationImpaired Gas ExchangePt XYZ is a 59 YO white female with an admitting diagnosis of Flash Pulmonary Edema. She was admitted on 8/27/12 to the ED and transferred to the ICU. She had previously been admitted 3 wks prior with complaints of SOB. Previous medical history includes: Stage IV Chronic Kidney Disease, Type II Diabetes Mellitus, GERD, Hyperlipidemia, high chlolesterol, and periotoneal carcinomatosis. She is considered to be developmentally delayed due to microcephaly in infancy. Past surgical procedures include: laparotomy and debridement in May ’09, 6 cycles of Gemzar and Avastin, T&A, D&C, and a hysterectomy in May ’09. VS: T-98.5, P-120, BP-169/99, O2 sat-98%. Known allergy is to penicillin. Client BG ambulates with assistance and consumes a consistent-carb diet. She has a nasal cannula, prn, at 2L/min. Blood glucose is monitored ac and hs. Currently on Contact Level I Precautions r/t MRSA. A catheter is located in her R chest wall. A portacath is in her L upperarm and a 22-gauge Saline well is in her R forearm. She is currently on 24-hr urine I&0. Abnormal lab values: WBC-11.5 H, RBC-3.39 L, HGB-10.2 L, HCT-32.2 L, MCHC 32.7 L, RDW-18.1 H, Platelets-103 L, Glucose-119 H, BUN-26 H, Creatinine-3.8, Sodium-131 L. Medications: Ceftriaxone, Novolin R; Toprol XL, Protonix ; Hydralazine HCl Ondasetron HCl;, Promethazine. VS q4h, O2 sat, Cardio, Pulmonary, & Renal Assessments, 24h urine collection, blood glucose monitoring ac & hs, BUN/creatinine ratio, urea, sodium, potassium, C-reactive protein, CBC, PT, aPTT, BNP, xray, ABG’s, ECG, walking distanceAnswer here59 YO white female admitted with flash pulmonary edema. Catheter in R chest wall. Portacath in L upperarm. 22-gauge Saline well in R forearm. Pt is thin, wears glasses, and is appropriately dressed and groomed. Pt lies in Semi-Fowler’s position in bed and is able to ambulate with assist to bedside commode. Her shelf is lined with stuffed animals and a get well card. She also has a “Get Well” balloon and a case filled with candy on her bedside table. Pt gets confused easily, but is able to communicate with others and her speech is understandable with slight slurring present. She remains alert, awake, and pleasant and enjoys talking to visitors.2Decision Making (Interventions) Rationale1.2.3.4.5.References3“Determine severity of dyspnea using a rating scale such as the modified Borgscale, rating dyspnea 0 (best) to 100 (worst), or the Medical Research CouncilDyspnea Scale” (Ackley & Ladwig, 2008, 188).“Perform acupressure at true accupoints to improve breathing pattern and oxygenation and aid in the movement ofsecretions and fluid out of the lungs”(Lin, Lin-Chang, 2004, 257).“Support the client in using pursed-lip and controlled breathing techniques”(Ackley & Ladwig, 2008, 189).“If the client ahs adult respiratory distress syndrome or difficulty maintainingoxygenation, consider positioning the client prone with the upper thorax andpelvis supported, allowing the abdomen to protrude. Monitor oxygen saturationand turn back to supine position if desaturation occurs” (Ackley & Ladwig, 2008,388).“Note pattern of respiration. If client is dyspneic, note what seems to cause thedyspnea, the way in which the client deals with the condition, and how thedyspnea resolves or gets worse. Note amount of anxiety associated with dyspnea”(Ackley & Ladwig, 2008, 188)“In a study in an emergency room, the modified Borg scale correlated well with clinical measurements of respiratory function and was found helpful by both clients and nurses. Another study comparing dyspnea scales in clients with COPD found that the Medical Research Council Dyspnea Scale most effectively measured breathlessness in this client group” (Ackley & Ladwig, 2008, 188).“The ‘Celestial Chimney’ acupoint can aid diffusion in the lung, calm panting, suppress coughs, transform phlegm, clear and liquefy material in the throat, transport qi and stop vomiting”(Lin, Lin-Chang, 2004, 257)“Pursed-lip breathing is effective in decreasing breathlessness” (Ackley & Ladwig). “Oxygenation levels have been shown to improve in the prone position, probably because of decreased shunting and better perfusion to the lungs” (Ackley & Ladwig, 2008, 388).“A normal respiratory pattern is regular in a healthy adult. To assess dyspnea, it is important to consider all of its dimensions, including antecedents, mediators, reactions, and outcomes” (Ackley & Ladwig, 2008, 188).Ackley, B. J. & Ladwig, G. B. (2008). Nursing diagnosis handbook: An evidence-based guide to planning care (8th ed.). St. Louis, Missouri: Mosby Elsevier.Wu, H. S., Wu, S. C., Lin, J. G., & Lin, L. C. (2004). Journal of advanced nursing: Effectiveness of acupressure in improving dyspneain chronic obstructive pulmonary disease, 45(3). Blackwell Publishing