Nursing Care and Treatment Plan for Respiratory Insufficiency

Extract

[...] ? Absence of fever. ? No palpitations. ? No dizziness, weakness, or cyanosis. ? Fatigue ? DRS : No spontaneous respiratory difficulty has been reported. ? Dyspnea : The patient experiences difficulty breathing only during physical exertion. ? DPN and orthopnea : The patient does not present with chest pain or difficulty breathing in a lying down position. - Duration: The episodes of shortness of breath last approximately 5 to 6 minutes. [...]

[...] In improvement or deterioration and why? What are the clinical manifestations to monitor? Are there other monitoring to be done? What are the possible complications? Is there a follow-up to be done? Are there interventions to be done?) NT-proBNP 900 ng/L) 2024-06-20 1185 2024-10-05 909 2024-10-16 2221 Respiratory insufficiency and pulmonary fibrosis : The presence of elevated NT-proBNP (2221 ng/L on 2024-10-16) may be a sign of worsening heart failure, often observed in patients with chronic respiratory disorders such as pulmonary fibrosis. [...]

[...] Mobilization and management of dyspnea Objectif partially achieved, as the patient was able to mobilize once with success. However, desaturation occurred during the effort, which limited the second mobilization. 3. Vital Sign Management and Infection Control Objective Achieved, vital signs are stable, no fever detected. The CRP remains elevated at 163.7 mg/L, indicating a systemic inflammation, but without an observed urgent clinical worsening 4. Fluid monitoring and management of hyponatremia (SIADH) Objective achieved, as the fluid restriction was respected with a limitation to 1.5 litres/day, However, strict monitoring of urine output must be maintained to follow the evolution of the fluid balance (Lasix, Sodium Chloride 0.9% Injectable Bag at night, sodium). [...]

[...] - Assessment of fluid balance : Compare fluid intake and urine output to assess daily fluid balance and adjust interventions accordingly. - Clinical monitoring of hyponatremia : Assess the patient for clinical signs of hyponatremia (confusion, nausea, muscle weakness) and inform the doctor in case of significant changes. - Patient Education : Explain to the patient the importance of limiting fluid intake to control hyponatremia and prevent complications. - Documentation : Record the patient's urine output, fluid intake, and any observations regarding the patient's condition (hyponatremia symptoms) in the nursing file. [...]

[...] Consider adjusting treatments to support immune function. Grade: A B C D E F NURSING THERAPEUTIC PLAN (PTI) Name: R Sex: M Age: 67 years Chamber: STATISTICS OF THE ASSESSMENT Date Hour No Problem or priority need D Initials RESOLVED/SATISFIED Professionals/ Services concerned Date Hour Initials 24-10-17 8h 1 Dyspnea: desaturation O2/Hypoxia Doctor, Physiotherapist 24-10-17 8h 2 Pulmonary infection Pulmonologist 24-10-17 8h 3 Hyponatremia Nephrologist 24-10-17 8h 4 Hyperglycemia Nutritionist 24-10-17 8h 5 Insomnia Psychologist 24-10-17 8h 6 Mobility Ergotherapist/Physiotherapist 24-10-17 8h Date Hour No Nursing Directive D Initials CEASED/COMPLETED Date Time Initials 24-10-17 8h 1 Evaluate saturation at 8 adjust flow. [...]