ACUTE RESPIRATORY FAILURE SECONDARY TO COMMUNITY

ACQUIRED PNEUMONIAPresented by:

BSN 4A group 1 Anas, Ann Paulinede Vera, GazzelDel Rosario, Pamela JanineFuentes, Mary DominicaGuballa, Guianne MishaelImperio, Aryanne FayJacinto, Kendrick FerrJahiron, NashraifarJalos, Marian

Objective of the study

To be able to describe and explain ARF, together with the risk factors contributing to the occurrence of the condition.

Review the anatomy and physiology of the organ involved Correlate the results in the laboratory and diagnostic

procedure done with the patient. Enumerate the different medication for the patient’s

disease condition, their indications and specific nursing responsibilities before, during, and after medications administration.

To be able to perform accurate assessment and identify the priority needs and health problems in order to make considerably related nursing care plans based on the patients course during the treatment.

Introduction

The lungs are elastic structures enclosed in the thoracic cage, which is an air tight container with distensible walls. Ventilation requires movement of the walls of the thoracic cage and the diaphragm. The effect of these movements is alternately to increase and decrease the capacity of the chest. Inspiration occurs during the first third of the respiratory cycle, expiration during the later 2/3. The inspiration normally requires energy; the expiratory phase is normally passive, requiring very little energy.

Acute respiratory failure is a sudden and life threatening deterioration of the gas exchange function of the lungs to provide adequate oxygenation, or ventilation for the blood. Risk factors include pulmonary dysfunction such as COPD , pneumonia, and asthma.

Incidence of Acute Respiratory Failure

In the Philippines, eight out of the ten leading causes of morbidity or illness can be attributed to infectious diseases. Illnesses related to the respiratory system such as acute respiratory infection, pneumonia and bronchitis. These in turn affects 1,203 Filipinos out of 100,000 population enduring Acute Respiratory Failure per day.

Biographical data

Name: Mr. EC Nationality: Filipino

Age: 84 yrs/old Religion: Catholic

Height: 5’8” Weight: 60 kgs. Civil Status: Married Gender: Male

Date of birth: Nov. 20, 1929 Address: Quezon City Insurance coverage: Philhealth member

Date of admission: September 16,2013

Admitting physician: Dr. XY

Reason for seeking Health Care/chief complain/s:

Difficulty of breathing

History of present illness:

Mr. CE is a 84 y/o retired veteran from Quezon City who was admitted at VMMC last September 16,2013 due to difficulty of breathing. It all started two weeks prior to admission when the patient’s family observed him having a progressive coughing events, the patient’s family advised him to sought consult but the patient stated he was ok. As days passed, the coughing events continued to progress which was later accompanied by other signs and symptoms such as fever and difficulty of breathing, which made them rush the patient to the emergency department of VMMC for consult.

Previous Illness/Hospitalizations/Surgeries:

Diabetes Mellitus and Hypertension diagnosed last 2003 Cataract surgery OU last 2007 at VMMC

Allergies:

Patient has no known allergies to food and medication.

Perception of Health Status:

As stated by his daughter, they considered their father not a healthy person due to his condition and subsequent confinement to the Pulmonary ICU., yet she is expecting that his father will recover from his condition with the help of health care providers attending to his needs.

Family medical history:

Disease Mother Father

Diabetes mellitus (+) (-)

Hypertension (-) (+)

Bronchial asthma (-) (-)

Heart disease (-) (-)

Chronic lung disease

(-) (-)

Home medications/Alternative medicines:

Home medications of patient are glipizide 5mg/tab for his diabetes, which he takes once a day in the morning, another medication is Lozartan 50 mg, for the patient’s hypertension, which he takes once a day as well. Patient’s family states that they have not seen the patient drinking herbal medicine or any other drug aside from those that are prescribed.

 

Developmental Stage and Psychosocial Developmental Task: Late Adulthood (65 years up to death) Integrity VS. Despair

It is during this time that people contemplate their accomplishments and are able to develop integrity if they see themselves as leading a successful life. If they see their lives as unproductive, feel guilt about their pasts, or feel that they did not accomplish their life goals, they become dissatisfied with life and develop despair, often leading to depression and hopelessness.Our patient, Mr. CE is a 84 y/o senior citizen of Quezon City. Her daughter recalled her father slowing down on his productivity when he reached 60, and it was then when he explored life as a retired person after many years of hard work serving the military.

Patient’s daughter warmly tells his father’s stories and looked back on his father’s life including both of his father’s successes and losses, as her father was able to send her to school and managed to made her finish a professional course of business administration. She as well stated that his father demonstrates acceptance of failures in life, when patient ‘s daughter verbalized having the first born son of his father died. She as well tell stories about his father’s aging, in which she said his father never had a dull time due to being active to their community and church groups .Patient’s daughter expresses that his father during his well times demonstrate feelings of contentment and integrity as he believe that even though his life is not perfect, he had led a happy, productive life not just for himself but also for his family.

Psychosexual Stage: Genital Stage (puberty up to death)

The final stage of psychosexual development focuses through the lessons learned during the previous stages, with the genitals as the primary focus of pleasure.

Patient was able to have a lifetime partner, get married and have 1 alive child. Patient’s daughter recalled that his father exhibits realization of the psychosexual stage through maturity, and enhancement of life through his group affiliations, engaging in various activities, and by sustaining a happy aging life, as psychosexual development doesn’t just speak about creating new life (reproduction) but also about intellectual and artistic creativity. The patient’s daughter expressed as well that his father was able to learn how to add something constructive to life and society by assuming the responsibilities of the late adult not just within his family but as well in the community where his father lives in by being active to their community and church groups.

Where in earlier stages, the focus was solely on individual needs, individual maturity is one of the focus during this stage. The patient’s daughter as well expressed that his father was able to show interest in the welfare of others through participating in various charitable works and managed to become well-balanced, warm and caring and establish a balance between the various life areas.

Cognitive Stage: Formal Operational StageThe formal operational stage begins at approximately age twelve to and lasts

into adulthood. Deductive reasoning, and systematic planning also emerge at this stage.

During interview, the patient’s daughter recalled that even though at old age, his father was able to think about abstract concepts and demonstrates logical thought , and as well as application of advanced reasoning and logical processes to social and ideological matters.  Another cognition demonstrated by patient according to his daughter is that his father’s thinking tends to become multidimensional, rather than limited to a single issue as his father see things through more complicated lenses due to its different life experiences as a military man, husband, father, and member of the community. Spiritual Stage: "Conjunctive" faith

A person in this stage acknowledges paradox and transcendence, relating reality behind the symbols of inherited systems or spiritual belief.

Patient’s daughter stated that his father lives his life realizing that there is a lot of truth to be found and that life was full of mystery. She stated that her father sees life as a mystery and often returns to sacred stories and gospels by attending mass and in serving their church.  She as well verbalizes importance of God and talking to God as being one of his father’s source of strength and guidance.

Environmental history:

Patient currently lives in Quezon City, along the main road of the said city, in the same place where he was born and raised by his parents. His daughter stated that they stays in a house with 2 bedrooms, which are occupied by his mother and father and the other one was occupied by her and her husband and kids. The house was originally from her grandparents which his father inherited when his parents died.

Ancestors of the patient and both her deceased parents were all from Quezon City. The patient’s daughter states that even his father is in the late adulthood, patient’s daughter states that his father follows no ethnic belief with regards to treating his illness. Patient’s daughter as well denies his father’s use of herbal medicines or other alternatives aside from the maintenance medications prescribed by her physician.

Psychosocial History:

The patient’s daughter stated that his father started smoking when he was 20 years old and in recent 4 decades, smokes approximately 1 pack per day and drinks alcohol (beer) occasionally, consuming 2-3 bottles per session, 1-2 times a month. She also stated no knowledge of his father using prohibited drugs.

Gordon’s Pattern of Functioning

Before Hospitalization During Hospitalization

Analysis

  Health Perception/ health management

Significant others stated that patient home medications are Glipizide for his diabetes, and Lozartan for his hypertension. Patient’s family declares non-observance of patient drinking herbal medicine or drug aside from those that are prescribed

His daughter stated that he only seeks medical attention when the condition worsens.

Patient’s prescribed medications are Piperacillin tazobactam, Lozartan, and Glipizide.   

Having an illness creates physical and emotional distress to client because they considered the disease on entity which is socially unacceptable.(Medical Surgical, Brunner p.1265)

  Nutritional/Metabolic Management

His daughter stated that patient eats 3 times a day. He is fond of eating salty foods like tuyo, tinapa and fish sauce with tomatoes and onions .He likes caffeinated drinks such as soda (coke 8 oz once a day) and 2 cups of coffee. He also eats vegetables and meat and have snacks composed of bread or biscuits. Patient as well consumes 4-5 glasses of water a day.  

Patient’s prescribed diet is Low Salt Low Fat (LSLF). He has NGT, his diet contains 1800kcal/day180cc for osterized feeding, 60cc water for flushing every 2 hours.   

An individual’s health status greatly affects eating habits and nutritional status. (Medical Surgical, Brunner p.1176)

  Elimination Pattern         

Significant others stated that before hospitalization patient usually voids 3 to 4 times a day. Urine is light yellow in color and no complaints of pain when voiding.  He defecates every 2 days. Stool is brown in color and well formed.

Patient was in foley catheter. His urine output is 60-80 cc per hour. Urine is turbid, yellow in color. He defecates once a day consuming 1 diaper. 

Defecation and voiding patterns vary at different stages of life, circumstances of diet, fluid intake and output, activity, lifestyle, medications and medical procedures and disease also affect elimination. (Medical Surgical, Brunner p.71)

 Activity and Exercise

Patient’s daughter stated that he felt a decrease in energy due to aging process. Patient‘s normal routine was staying at their home and walks 10 minutes within their area with his daughter every morning.

He was maintained in a High-Fowler’s position. Able to move body during passive ROM exercises.

Elderly people have a decreased ability to rapidly move air in and out of the lungs. They require additional rest after prolonged or vigorous activity. (MS Brunner and Suddarths p. 495)

  Sleep and Rest

Patient’s daughter stated that he has usual sleeps - at night for 4-5 hours, waking up early, having short naps of approximately 1 ½ hour in the afternoon and feels rested right after sleeping.

Patient’s daughter verbalized that patient was asleep most of the time and just opens his eyes whenever painful stimuli is received.

Older adults require as much as sleep as younger people. Older people are more likely to awaken because of factors such as noise, pain and nocturia. (MS Brunner and Suddarths p.207)

 Cognitive and perceptual

Patient’s daughter stated that the patient has decreased visual acuity (400 both eyes). Patients’ memory was intact and mentation was appropriate to time, place and person.

The only sense that is active to the patient is hearing. The patient response to verbal stimuli (moan), response to pain (eye opening).

Auditory changes begin to be noticed at older adults. (MS Brunner p. 209)      

 Self-perception       

NO DATA AVAILABLE

NO DATA AVAILABLE

 no data obtained-the patient is always asleep / semiconscious, with Endotracheal tube and hooked to mechanical ventilator

 Role Relationship

He has a good relationship with his wife and daughter in terms of decision making.  patient as well has harmonious relationship with his siblings, sibling’s family and within their neighborhood.

According to the patient’s daughter, his family is always there to support him in all aspect of his needs. Her daughter stated that their relatives let him feel extra care by visiting in the hospital . 

Giving extra care and attention help the patient manage the problems in living more effectively and develop unused or underused opportunity more fully, help client become better at helping themselves in their recovery. (MS by Brunner, pg 429)  

 Coping stress/tolerance

 no data obtained-the patient is always asleep, with Endotracheal tube and hooked on mechanical ventilator

 Value/Belief

The relative of the patient stated that the patient is a Catholic and even with life’s challenges. Patient’s daughter states his father’s achievement of satisfaction in life and observance of his father praying every night and entrust himself and his children to God.

Patient wasn’t able to go to church or perform his prayers secondary to semiconscious condition.

Ideas, goals, perception and spiritual beliefs influence one’s choices and decisions, enhance feeling of connectedness to God and promote total health of mind, body, and spirit. (MS Brunner , 12th edition p.39)

Body parts Actual findings Analysis

Skin Patient’s skin is warm to touch and had dry, sagging skin.

The blood supply changes with ages, vessels, capillary loops decreasing number and size, resulting diminished supply in the skin, causing change, loss of resiliency and wrinkling and sagging of the skin(MS, Brunner & suddarth pg 1664).

Pale skin color noted on peripheral extremities In patients with areas of localized skin paleness, suspect impaired arterial circulation or inadequate oxygen delivery to the affected extremity. (Assessment reference for nurses, Lippincot William & Wilkins, 2007)

Physical Assessment:

General appearance: the patient is an elderly, thin built, wearing light clothing (hospital gown), semiconscious, responds to verbal stimulus.

Eyes Symmetrical, pupils equally round but minimally slow to react to light.Patient used reading glasses.

Pupils dilate and constrict slowly and less completely because of increased stiffness of the muscle of the iris Many elders wear corrective lenses; they are most likely to have hyperopia. Visual changes are due to loss of elasticity and transparency of the lens (Kozier pg 554).

Ears Auricle is symmetrical, uniform in color, no pain/tenderness upon palpation, hears well spoken words and responds to it.

Patient with normal hearing can respond to verbal stimulus (MS, Brunner & suddarth pg 1804).

Thorax and lungs

Prominent rib cage noted. Presence of crackles, heard over base and middle lung lobes. Patient’s RR is 28 cycles per minute, assisted by mechanical ventilator.

Loss of lean muscle mass in the thorax makes bony prominence of the ribcage evident. Presence of crackles suggests retained secretions in the lungs (MS, Brunner & suddarth pg 559).

Extremities Extremities warm, skin less resilient and sagging, no edema noted. Patient was able to perform passive ROM.

Lessening of blood supply causes skin to become less resilient and sagging. Performing ROM exercises enhances circulation. (MS, Brunner & suddarth pg 1664)

Chest Xray September 16, 2013

Lung lobes Evaluation

Right lung Reticulonodular infiltrates with areas of haziness from the apex to the base

Left lung Apex is clear. Reticulonodular density from 3rd ICS down to the base

Impression: Pneumonia, bilateral

DIAGNOSTIC/LABORATORY EXAMINATIONS: SEPTEMBER 16, 2013

CBC Results Normal Values Interpretation

WBC 13.2 5-10x10⁹/L elevated., indicates infection

Segmenter 0.86 0.60-0.70 Slightly elevated, indicated infection

Lymphocyte

0.13 0.20-0.40 Low, decrease immune response

Hgb 103 140-180⁹/L Low indicates anemia

Hct 0.42 0.40-0.51 Normal

Platelet 325 150-450x10⁹/L Normal

Glucose 8.2 3.6-6.3 High, indicates diabetes mellitus (brunner and suddarth)

cholesterol 2.3 0-5.9 Normal

Triglycerides 0.6 0-2.2 Normal

Na 141 135-156 Normal

K 5.0 3.6-5.5 Normal

HDL 0.6 0.8-2.0 Low, lower in patient with increase risk of coronary artery disease.

LDL 1.0 1.7-4.8 Normal

SGPT 40u/L 0-36 High, indicates hepatocellular damage

SGOT 103u/L 0-31 High, indicate hepatocellular damage

Albumin 24g/L 34-50 Low, Indicate hepatocellular damage

Glycosylated hgb

5.4 6.2-8.3 Low; indicate adequate maintainance of blood glucose levels over the previous months.

Blood Chemistry September 16, 2013

Urine Analysis Sept.17,2013

Color Dark yellow Interpretation

Transparency Turbid Indicates infection

Specific Gravity 1.020 Normal

PH 5 Normal

Albumin ⁺2 Indicates renalcomplication from diabetes mellitus

Sugar Positive Indicates renal compensation to eliminate excess glucose in the

blood

Acetone Positive Indicates renal compensation to eliminate excess acid in the blood

Pus >100/HPI Indicates infection

Normal values

Result Interpretation

pH 7.35-7.45 7.32 Low, indicates acidosis

pCo2 35-45mmhg 50mmhg High, indicates accumulation of carbon dioxide in the

blood

pO2 80-100mmhg 59mmhg Low, indicates decreased oxygen levels in the blood

HCO3 22-26mmol/L 18.80mmol/L Low, indicates non-compensation of the Sodium

bicarbonate buffer

SpO2 95-100% 87% Low, indicates non optimal tissue oxygen supply

ABG September 17, 2013

Impression: Respiratory Acidosis

MEDICAL DIAGNOSIS:

Acute respiratory failure secondary to community

acquired pneumonia

ANATOMY AND PHYSIOLOGY

The cells of the body derive the energy they need from the oxidation of carbohydrates, fats, and proteins. As any type of combustion, this process requires oxygen. However, as a result of oxidation in the body tissues, carbon dioxide is produced and must be removed from the cells to prevent the build-up of acid waste products. The respiratory system performs this function by facilitating life sustaining processes such as oxygen transport, respiration, ventilation, and gas exchange.

 

A gradual decline in respiratory function begins in early to middle adulthood and affects the structure and function of the respiratory system. The vital capacity of the lungs and strength of respiratory muscles peak between 20-25 years of age and decreases thereafter. With aging and changes occur in the alveoli that reduce the surface area available for the exchange of O2 and CO2. Alveoli begins to lose its elasticity, there’s loss of chest wall mobility, restricting the tidal flow air. These changes result in a decreased diffusion capacity for O2 with increasing age, producing lower O2 levels in the elderly’s arterial circulation.

PATHOPHYSIOLOGY

Modifiable:

DM, alcohol, smoking, environmental exposure to S. pneumoniae

Non-modifiable:

Age, environment, decline of immune system

Compromised lung defense mechanism

Acquisition and colony multiplication os S pneumoniae

Spreading trough out the respiratory tract including the bronchioles and alveoli

Edema and exudate formation within the tracheobronchial tree and alveoli

Tachypnea, dyspnea, orthopnea, rust colored ,blood tinged sputum

these inflammatory infiltrates causes reduced lung volumes and altered ventilatory pattern

Impaired ventilation-perfusion

Impaired gas exchange

Hypoxemia

Acute respiratory failure

Activation of body’s inflammatory

response against infection

Release of pyrogens

Fever, flushed and warm skin

Loss of spontaneous breathing

Nursing diagnosis:

Impaired airway clearance related to copious tracheobronchial secretions secondary to impaired respiratory functions.

Hyperthermia related to release of pyrogens from inflammatory immune response secondary to infectious process in the lungs.

Ineffective peripheral tissue perfusion related to compromised respiratory function as evidenced by oxygen saturation of 87% and capillary refill of 4 seconds.

NURSING CARE PLAN:

Assessment Nsg. Diagnosis Planning Nsg. Intervention Rationale Evaluation

Objective cues:

Tachypnea (RR-28)

Crackles over middle and base of lung lobes

Assisted ventilation

Presence of tenacious secretions on ET tubes

Oxygen saturation of 87%

Impaired airway clearance related to copious tracheobronchial secretions secondary to impaired respiratory functions.

Analysis:

Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway

Within 8 hours of nursing intervention the patient will demonstrate improved airway patency as evidenced by adequate SPO2 from 87% to 95% and clear breath sounds.

1.Assessed patient’s lung field.

2.Provided adequate humidification.

3.Properly positioned patient from side to side.

4.Perform chest percussion and postural drainage.

1.To established baseline data(nurses pocket guide 11 edition pg 81)

 2.To loosen secretions and promote expectoration. (nurses pocket guide 11 edition pg 82)

 3.To prevent stagnation of pulmonary secretions. (nurses pocket guide 11 edition pg 82)

4.To loosen and mobilized.(nurses pocket guide 11 edition pg 82)

 

After 8 hours of nursing intervention the patient demonstrated improved airway patency as evidenced by SPO2 of 95% and diminished crackles over middle and based of lungs diameter.

5.Assisted patient in nebulization.

 

 

6.Perform endotracheal suctioning.

 

7.Properly regulated IVF of PNSS 1L at 33gtts/min.

5.To loosen secretions and widens airway. (nurses pocket guide 11 edition pg 82)

6.To effectively remove secretions. (nurses pocket guide 11 edition pg 82)

 

7.To maintain patient’s hydration. (nurses pocket guide 11 edition pg 82)

Assessment Nsg. Diagnosis Planning Nsg. Intervention Rationale Evaluation

Objective cues:

Skin warm to touch

Flushed skin

Temperature 38.2*C

WBC

 

Segmenter =0.86 slightly elevated indicate infection

Hyperthermia related to release of pyrogens from inflammatory immune response secondary to infectious process in the lungs.

 

Analysis:

Body temperature elevated above normal range.

Within 1 hour of nursing intervention the patients will decrease from 38.2 C to 37.5*C

1.Assessed patient’s temperature together with patients clothing and environment condition.

2.Rendered continuous tepid sponge bath and hygiene care.

3.Changed patient’s linens and provided patient dry and light clothing.

1.To establish baseline data and note any contributory factors causing patient’s hyperthermia(nursing pocket guide 11 edition pg 440)

2.To promote cooling of body surface and promotion of comfort. (nursing pocket guide 11 edition pg 441)

3.To promote comfort and decrease any external contributory to body’s heat formation. (nursing pocket guide 11 edition pg 441)

After1 hour of nursing intervention patient’s temperature decreased from 38.2 to 37.5C

4.Properly regulated patients IVF of PNNS 1L at 33 gtts/min.

 

5.Adminnistered paracetamol 500 mg via NGT feeding as ordered.

4.To promote hydration. (nursing pocket guide 11 edition pg 441)

5.Pharmacologic method in decreasing fever.

Assessment Nursing diagnosis

Planning Nursing intervention Rationale Evaluation

Objective cues: O2 sat 87%

Capillary refill of 4 seconds.

Pale skin color of the peripheral extremities

Ineffective peripheral tissue perfusion related to compromised respiratory function as evidenced by O2 saturation of 87%.

Within the shift the patient will:

  

O2 saturation level will

improve from 87% to 92%.

  

1. Changed patient position in timed intervals every two hours.  

 2. Perform passive Range of motion exercises to all extremities. 

3. Administer fluids as ordered

4. Ensure adequate oxygen supply are maintained at 6 LPM.

To promote peripheral circulation and limit complication associated with poor perfusion.(nurses pocket guide 12 edition page 612).

  To promote peripheral

circulation.(nurses pocket guide 12 edition page 612).

  To promote optimal

blood flow and organ perfusion and function.( nurses pocket guide 12 edition page 612).

To provide optimal support for the patient’s respiratory function in terms of oxygenation

Within the shift the patient’s:

  

O2 saturation level had

improved from 87% to 92%.

  

NAME OF THE DRUG

MECHANISM OF

ACTION

DOSAGE INDICATION CONTRAINDICATION

ADVERSE EFFECT

NURSING CONSIDERATIONS

Piperacillin Tazobactam Pharma. Class: anti-infectives

Inhibits cell wall synthesis, promoting osmotic instability causing cell death

300mg TIV every 8 hours

Lower respiratory tract infection

Hypersensitivity to drug

Rash Hives Urticaria Diarrhea Anaphyla

xis Stomatitis

Perform skin testing before the drug therapy.

Advise patient’s family to report if diarrhea, rashes, itching, or inflammation of mouth are noticed.

Losartan Pharma. Class: Anti-hypertensive

Selectively blocks angiotensin II as well as the release of aldosterone resulting in decrease blood pressure

50mg/tab OD via Nasogastric tube

Hypertension

Hypersensitivity to the drug and hypotension

Hypotension

Dizziness Rash Urticaria Abdomina

l Pain Constipati

on

Monitor patient closely for any situation that may lead to a sudden decrease in blood pressure secondary to decrease in blood pressure.

Provide adequate fluids if not contraindicated to prevent constipation.

Advise family to report if any rash is noticed.

Instruct the family to turn and move the client slowly.

Name of Drug

Mechanism of action

Dosage

Indication

Contraindication

Adverse Effect

Nursing considerations

Ipratropium bromideClassification:AnticholinergicBronchodilator

Anticholinergic, chemically related to atropine, which blocks vagally mediated reflexes by antagonizing the action of acetylcholine. Causes bronchodilation and inhibits secretion from serous and seromucous glands lining the nasal mucosa.

1 neb per administration, BID

Bronchodilator for maintenance treatment of bronchospasm.

Hypersensitivity to atropine

Dizziness, headache, fatigue, nausea, GI distress, dry mouth.

*Use nebulizer mouthpieceinstead of facemask to avoid blurred vision or aggravation of narrow-angle glaucoma.*Ensure adequate hydration:control environment (temperature) to prevent hyperpyrexia*Teach family proper use of inhaler.

Glipizide Stimulates functioning B-cells to release insulin.

5mg/tab OD via Nasogastric tube

Type 2 Diabetes mellitus

Hypersensitivity to sulfonylureas and Diabetic ketoacidosis

Dizziness Hypoglyc

emia Leukopen

ia Thrombo

cytopenia Cholestat

ic jaundice

Rash Urticaria

Instruct patient’s family that drug is given on a continued basis.

Give drug in the am to prevent hypoglycaemia at night.

Instruct family and other health care team to move the patient slowly.

Provide feeding on time and adequately to prevent hypoglycemic episodes.

 

Nurse’s progress notes:

September 17, 2013

F- Ineffective airway clearance

D- Received patient rested in bed, semiconscious, responsive to verbal stimuli, skin warm to touch, hooked on mechanical ventilator. Patient demonstrates intercostal and supraclavicular retractions, labored breathing, crackles heard over middle and bases of lungs upon auscultation.

A- initial VS taken within the shift, as of 3pm T-37.5, PR-103bpm, RR- 3bpm, spO2-87%, BP-130/90mmHg, ensured proper oxygen humidification, performed chest tapping and postural drainage, suctioned ET tube.

R- Patient’s Vital Signs gradually improved having a PR-100bpm, RR-25, spO2-95%, BP- 130/80mmHg, diminished crackles over the middle and bases of the lungs noted. Patient is well rested.

Nurse’s progress notes:

September 18, 2013

F- Hyperthermia

D- Received patient rested in bed, semiconscious, responsive to verbal stimulus, skin flushed and warm to touch, hooked on mechanical ventilator.

A- Initial VS taken within the shift, as of 3pm T-38.5, PR-103bpm, RR- 30bpm, spO2-87%, BP-130/90mmHg, ensured proper regulation of IV fluid (.9% NSS), proper oxygen humidification, performed continuous tepid sponge bath, ensured dry and light clothing administered paracetamol, 500mg through NG tube as prescribed.

R- Patients’ fever subsided, VS gradually improved having T-37.3 from T-38.5, PR-100bpm, RR-25, spO2-92%, BP-130/80mmHg, patient’s skin no longer flushed and warm to touch, demonstrates adequate sweating, safe and well rested.

DISCHARGE PLAN

Medication: Cefuroxime 500mg/tab twice a day 8am and 6pm

Advise patient to take the drug with food to decrease Gastrointestinal distress such as abdominal pain. Advise patient about importance of compliance to drug regimen. Advise patient that if signs of hypersensitivity occurs such as rash difficulty breathing, immediately stop

taking the drug and consult medical attention. Losartan 50mg/tab every morning after breakfast.

Advise patient about importance of compliance to drug regimen. Advise patient to avoid sudden rising or rapid turning from one position to another to avoid orthostatic

hypotension. Advise patient to avoid driving or operating any hazardous machineries to avoid accident.

Glipizide 5mg/tab every morning after breakfast. Advise patient about importance of compliance to drug regimen. Advise patient not to discontinue taking the drug without the advise of the doctor. Advise patient to avoid alcohol while having taking this drug. Advise patient to seek the advice of the nurse or physician if fever, sore throat or unusual bleeding

occurs.

Exercise:

Advise patient and family the importance exercise. Instruct significant others to perform it more. Ex.: once a day 8:00am passive

ROM exercises at least 10mins twice a day Demonstrate to the family examples of passive ROM such as flexion,

extension, internal and external rotation, abduction and adduction.

Treatment:

Cefuroxime – twice a day; give as scheduled to maintain proper blood levels. Losartan – administer in morning; take drug without regard to meals; do not

stop taking this drug without consulting primary care provider. Glipizide – take in the morning to prevent hypoglycemic reactions at night;

caution patient to avoid OTC medication unless approved by the health care provider.

Health Teaching:

- Advise patient to gradually stop smoking and its risk to health and well-being.

- Advise the patient to refrain from drinking alcohol.- Advise the patient and family to avoid stress as much as possible and

instruct relaxation techniques.- Advise the patient to adhere to proper medication regimens of

Cefuroxime, Losartan, and Glipizide.- Follow low salt low fat diet and diabetic diet.- Advise the patient to perform exercise within tolerable limits

Outpatient:

- Instruct patient relatives to have the patient checked in the Outpatient department two weeks after discharge and have consultation on nearest health center on a regular basis to effectively monitor health.

Diet:

• Instruct patient and significant others to adhere on low salt low fat diet and diabetic

• Advise the patient to avoid canned and preserved foods• Advise the patient to avoid drinking caffeinated drinks (soda, tea, coffee)• Advise the patient to Limit foods high in sugar (less carbohydrates)• Encourage family support on patient’s diet by having meal plans

conducive to patient.

Spiritual:

•Continue to pray everyday •Seek guidance to our almighty God•Bible readings to promote spiritual well-being and enhance feeling family of connectedness with God.