A nurse is taking care of an 85-year-old woman in a hospital based skilled nursing facility. In report, the nurse is told the patient has not been breathing well for the past 2 days. She has been lethargic, her skin is warm and dry, and she has a decreased urine output. The following laboratory findings were returned from the laboratory immediately after morning report: Address the following: 3 pages

Introduction

This case involves an 85-year-old woman who is exhibiting signs of respiratory distress and altered urine output. The nurse must analyze the patient’s symptoms and laboratory findings to determine the underlying cause of these abnormalities. This paper will address the nurse’s responsibilities in assessing the patient’s condition, interpreting the laboratory results, and providing appropriate interventions for the patient’s health.

Assessment of the Patient’s Condition

As a nurse, it is crucial to conduct a thorough assessment of the patient’s condition. In this case, the nurse is informed that the patient has been experiencing breathing difficulties for the past two days and is now lethargic. The nurse also notices that the patient’s skin is warm and dry, and there is a decrease in urine output. These findings suggest a potential problem with the patient’s respiratory and renal systems.

Interpretation of Laboratory Findings

Upon receiving the laboratory results, the nurse must carefully analyze the findings to gain further insights into the patient’s condition. The specific laboratory tests performed in this case are not mentioned, but based on the symptoms presented, it is essential to consider tests related to respiratory and renal function.

One possible test to consider is a complete blood count (CBC) to assess for any signs of infection or anemia. If there is an infection, it could explain the patient’s lethargy and increased respiratory effort. Anemia, on the other hand, may contribute to the reduced oxygen-carrying capacity of the blood, leading to respiratory distress.

Another relevant test to consider is a basic metabolic panel (BMP). A BMP provides information about the patient’s electrolyte levels, kidney function, and acid-base balance. Abnormalities in these parameters can indicate renal dysfunction, which would align with the patient’s decreased urine output.

Additionally, a chest X-ray may be useful in evaluating the patient’s respiratory status. It can help identify potential underlying causes of respiratory distress, such as pneumonia, pulmonary edema, or chronic obstructive pulmonary disease (COPD).

Interventions and Treatments

Based on the assessment findings and laboratory results, the nurse should develop a plan of care to address the patient’s respiratory distress and reduced urine output. The primary goal is to stabilize the patient’s condition while determining the underlying cause.

One crucial intervention for respiratory distress is providing supplemental oxygen. The nurse should assess the patient’s oxygen saturation levels and administer oxygen as needed to maintain oxygenation within the target range. This intervention can help improve the patient’s breathing and alleviate symptoms of hypoxia.

If the patient’s laboratory findings indicate an infection, initiating antibiotic therapy may be necessary. The choice of antibiotics should be guided by the suspected source of infection and the patient’s individual factors such as allergies and renal function. The nurse should closely monitor the patient’s response to antibiotic therapy and assess for any signs of adverse reactions.

In addition to addressing the respiratory issues, it is crucial to manage the patient’s renal dysfunction. The nurse should ensure adequate hydration by encouraging the patient to drink fluids or administering intravenous fluids if necessary. Close monitoring of urine output and renal function is necessary to assess the effectiveness of interventions and identify any worsening of kidney function.

Furthermore, the nurse should collaborate with the healthcare team to conduct a comprehensive assessment of the patient’s underlying conditions and co-morbidities. This assessment can help identify any factors contributing to the current presentation and guide further management strategies.

Conclusion

In conclusion, this case highlights the importance of a nurse’s role in assessing and managing a patient with respiratory distress and reduced urine output. By conducting a thorough assessment, interpreting laboratory findings, and implementing appropriate interventions, the nurse can contribute to stabilizing the patient’s condition and identifying the underlying cause. Timely interventions and close monitoring are crucial in managing the patient’s respiratory and renal dysfunction effectively.