Resp: Impaired Gas Exchange r/t pneumonia Pt. is intubated and mechanically ventilated w/ settings: Vt=500, R=10, FiO2=50%, PEEP=5 Upon auscultation coarse rhonchi heard in all lobes, Respiratory rate: 14, O2sat 95%. Chest X-ray revealed “worsening of rt. bilateral opacities and cardiomyopathy.” ABG on pH 7.38, PCO2 35, PO2 95, HCO3=20 metabolic acidosis uncompensated. Breathing treatment of Albuterol and atrovent given Q4H. Suction Q2H/PRN, care Q2H, ETT 26cm at holster taped to the right lip Goals: No aspiration, ETT maintained in place, O2 sat remain >95%, PO2 remains , HCO3 Increases to 22-26, PCO2 remains 35-45, pH CV: Fluid overload r/t CHF Pt. HR cont. monitored: Atrial fibrillation, HR 110. Pt. on 17cc/hr via PICC line. On auscultation clear S1S2 heard w/ an irregular rhythm. Radial and pedal pulses +2. Pitting 2+ edema in Bilateral lower ext. Cap. Refill <3 secs. Labs: Albumin: 1.6, Mg 2.7, Tropoinin 0.09, BNP 657 Monitor I&O due to Albumin levels. Intake Greater than output by 800 cc. CVP= 12, pt. Watch K+ levels. K+: 4.0. Echo showed EF 30-35%. Hgb 11.3, Hct 23.8, Pt given 2 units of blood now Hgb 17.9, Hct BP 168/61. Goals: Hgb remains >12, Hct increases to >37, K levels remain >5, Albumin levels >5, BNP <100, Resolution of Atrial Fibrillation, HR <100, CVP <6 Skin: Altered skin integrity rr/t immobility Pt. immobile on vent, On assessment skin was warm, dry with small blanch able area on sacrum area. Yeast Rash on groin area. Skin turgor elastic. PICC line On rt. Upper arm. Low albumin level of 1.6. Elevate arms. Turn Q2H. Lotion PRN. Goals: no sign of infection, no worsening of perineal Or groin areas, no further breakdown, GI: Risk for aspiration r/t ETT Assessment revealed active bowel sounds in all Quadrants, abdomen soft, flat, last BM NG Tube in Rt. Nare placed in the ICU Check Placement. Tube feedings, check BS Q4H, Check Residuals Q4H, Pt. receiving Prevacid. Clostiridum difficile found in stool. pt receiving PO vancomyocin IV Flagyl. Contact precautions. WBC count on = 18 Pt. receiving pancreatlipase due to chronic pancreatitis. Goals: No aspiration, WBC under <10, bowel sounds Remain active, NG tube remains in place, C. diff no longer found in stool Psychosocial: Anxiety r/t decreased health 24 y.o. granddaughter is the patients only living family, living will in 2009 stating does not want ventilator, Granddaughter has power of attorney and is scared grandmother will pass. Goals: Meet coping needs of granddaughter, Support patient decisions, Meet cultural/ Spiritual needs of patient and granddaughter. Make pt. comfortable Medical Diagnosis: Resp. insufficiency, pneumonia Nursing Diagnosis: Impaired gas exchange r/t pneumonia, CHF, fluid overload Past Medical History: CHF, Pancreatitis, HTN, Pulm. HTN,CAD, GERD, Osteoarthritis, depression Present Illness: 69 y.o. female presented to ER on lethargic with labored breathing. ABG revealed ph 7.27 PO2 76 PCO2 72. Diagnosed with pneumonia and respiratory failure. Pt. admitted to ICU. Pt now has arrhythmias and has been intubated. Positive culture for C. diff. Neuro: Altered Mental Status r/t failure to Thrive. Weak motor function, weak grips, Unable to assess orientation, decreased LOC, Responds to tactile stimuli, Assess orientation and neurological system every hour. Goals: Improved LOC, strong grips GU: Risk for infection r/t foley, possible sepsis Foley catheter output <30 cc, clear yellow urine, imbalance of I&O, Labs: BUN 17, Creatinine 0.4, Goals: No evidence of UTI, WBC 30 cc/hr, BUN remains <20, Creatinine remains <1.1.