Case Presentation

Nursing History

I. VITAL INFORMATION
Clients name: Mr. E. V. Age: 53 years old Gender: Male Civil status: Single Religion: Roman Catholic Nationality: Filipino Address: Tabuc Suba, Barotac Nuevo Iloilo Birth date: January 21, 1958 Birth place: Barotac Nuevo, Iloilo City Educational attainment: Bachelor of Science in Marine Transportation John B. Lacson Maritime University (Villa) (no need)College Graduate Occupation: Jeepney Driver Chief complain/s: Difficulty of Breathing Date and time of admission to ER: July 2, 2011 at 5:00 AM Mode of transportation upon admission: Stretcher Accompanied by: Mr. E. J ( Cousin) , Mrs. C. J. ( Cousin-in-law) Mental/emotional status upon admission: disoriented

Admission vital signs: T: 36.5c RR:35 breaths/min CR: 92 beats/ min BP:130/70mmHg Medical diagnosis: Acute Respiratory Failure secondary to Pulmonary edema secondary to Chronic Kidney Disease vs Left Ventricular Dysfunction; CAP-HR (plus working diagnosis) Attending physicians/doctors: Dr. A. Dr. S Dr. Barrameda, Dr. Franco, Dr. Alava , Dr. Sirilan(all physicians and subspecialties) Number and dates (previous) hospital admission: St. Paul Hospital due to Chronic Kidney Disease (August 2009) Ward/unit, bed and room number: MICU Bed 12 Food or drug allergy: None Source of information: (identify sources) Mrs. T. B. (Cousin) Secondary Ms. C. B. (Niece) - Secondary Chart Secondary Height: 58 Weight: 92 kg. was not able to weigh patient Home access number: unavailable Person to be contact in case of an emergency: (including number) Significant other/ or responsible party for the client: Mrs. C.J Ethnic background/ race: Filipino Native language: karay-a, Hiligaynon

II. History of Present Illness

The ff. information was claimed by mrs EV: 1 month prior to admission, Mr. E. V. started to have gradual cough characterized by yellowish, sticky sputum, difficult to expectorate associated with back pain. (mrs ev complained to mr ev) Cough alleviated by taking medication (medication unrecalled as claimed by Mrs. T. B.); Back pain alleviated by body massage Hilot twice or once a week. Cough aggravated by smoking, air pollution, and damp clothing (sweaty clothes) when driving the jeepney; back pain is aggravated by long hours of driving. Client consulted his niece Dr. Belo, Pediatrician and was given medications (unrecalled). Medications did not take effect due to aggravating factors. Patient was advised to reduce cigarette smoking and was able to comply (reduced from 1x 20s pack a day to 8-10 sticks). (not chronological) A day before the admission, Mr. E. V. came home from work with (onset )of fever taken as 37.8 via axilla ( as stated by Mrs. T. B) which was relieved by self medication 1 doze of Paracetamol 500mg; 3:00 A.M of July 2,2011 Mr. E.V has difficulty of breathing characterized by fainting and hoarseness .(hoarseness of voice)

10 hours prior to admission, patient had onset of 2 episodes of vomiting previously eaten food, whitish, approximately 180 cc per vomit. 5 hours prior to admission, Mr. E. V. was brought to Hospital at Barotac Nuevo due difficulty of breathing accompanied by Mrs. C. J. ( Cousin-in-law). What happened in barotac (see referral sheet). Medications, etc. 4:00 A.M(1hr prior to) family brought Mr. E.V at St. Pauls Hospital because of lack of facilities (not enough facilities) such ventilator at the District Hospital to support the patient. 5:00 A.M patient came at Emergency Room disoriented ,in stretcher. Vital signs were taken as follows: Temperature of 36.5C, Respiratory Rate of 35 breaths/ min, Cardiac Rate of 92 beats/min, Blood Pressure of 130/70 mmHg. Patient at E.R, IV of PNSS 1L was attached and run for 60 cc/hr.(state iv given at district hospital) Laboratories were taken such as CBC, UA and Blood Chemistry. At the same day patient was brought to the Medical ICU Following days: further observation for complications and improvements(not included) July 5,2011 patient was received by the student nurses in coma state: in bed, wearing a hospital gown ; in semi-fowlers position with indwelling catheter for urine output; IV catheter attached of jugular vein explain the use of catheter ; IV line of PNSS 1L with incorporation of Dopamine 250c add rate: c; with Endotracheal tube attached to ventilator. Lacking actual progression of symptoms

III. Past Medical History

Health is deteriorating(define) as perceived by the family(specific) due to chronic kidney disease. Experienced childhood illnesses such as fever, cough, chicken pox, measles, flu and mumps (as claimed by). Whenever client was ill, his parents would bring him to a traditional healer, would be given Paracetamol for fever, boiled Lagundi for cough; which afforded relief. Havent received any immunization because vaccines were not available during his childhood and didnt bother to go to a Physician to get vaccinated because he believed he doesnt need it. Was diagnosed to have Diabetes Mellitus Type 2 (where diagnosed and who) unrecalled10 years ago. Insulin was given as maintenance for 2 years but stopped and asked to replace it to Metformin due to financial constraint.as claimed by was

 In 2006, Mr. E. V. was diagnosed to have Pulmonary Tuberculosis .Completed treatment for PTB (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol, Streptomycin) for six months, effective without side effects and adverse reaction. In August 2009 he was admitted at St. Paul Hospital due UTI secondary to Chronic Kidney Disease. Stayed at the hospital for two weeks; unrecalled medications and treatment. Discharged with problem unresolved but on maintenance for CKD(stage?) and was advised to have a check up every month. Was unable to comply due to laziness(change) and claimed to be busy at work as claimed by mrs. TB. No history of falls, surgery, blood transfusion, or psychiatric illness. No known allergies to food, drugs or other substances.(as claimed)

IV. Lifestyle
The following information was claimed by the patients family members: Independent with routine activities of daily living and instrumental activities of daily living. Considers walking for 15-20 minutes in their backyard everyday before going to work as a form of exercise.as claimed by Has sleeping problem or changes in sleeping pattern due to cough and difficulty of breathing(degree of DOB) ; sleeps in a side-lying position with one pillow supporting the head and neck, from 9 pm until 5 am. Does not take any sleeping aides. Has good appetite, consumes 100% of meal which usually consists 1 cup of rice, fish or pork with soft drinks every lunch even though it is restricted. Dental caries on upper and lower molars, no reported visits to a dentist. Has a mouth sore on left side of the tongue and soft palate which caused him problem with eating and chewing.patient on OTF Able to consume only 5-6 glasses per day. Drinking water is supplied by a deep well.

as claimed Weighs 92 (same unit lbs) kg prior to admission, weight loss of 10-20 lb for the past six months due to decrease intake of rice. -as claimed by Has difficulty in urinating, voids 2-3 times in a day because he holds his need to void especially when hes driving, slightly hazy yellow urine, approximately 100-150 cc per void. Defecates once a day to a brown stool, well formed. Bowel or bladder continent (diagnosis) - Patient started smoking since he was in third year high school. Consumes 1 pack of cigarette per day (Camel 20's) but reduced it to 8-12 sticks Per day since he had a check up to Dr. Belo. Denies consumption of alcohol. -Denies uses of eye glasses for reading and daily activities.

-PRN medication Catapres 7mcg/tab for Hypertension, Nexium 40mg IVTT, Ng H2O3 1/2 amp IV (25ml), Atorvastatin (Lipitor) 80 mg 1/2 tab, Piperacilin Tazobactam 4.5g IV, Mg SO4 1g IV now. Compliant with maintenance medication of ValproiC Acid (Depacon) 500 mg IV Once a ay, Lansprazole 50 mg/tab 1 tab once a day, Lactulose 30cc once a day at half strength, Furosemide 20mg IV every 8 hours, Bactidol Oral Swab three times a day, Nasal Cannula 1 neb Combivent every 6 hours, Diazepam 5mg IV for Frank Seizure IV, Piacetam 1 tab three times a day, Citicoline 1gm/tab 1 tab every 12 hours, Piperacilin Tazopactam (Vigocid) 2.25gm IV every 12 hours, Clonazepam (Rivofil) 2mg/tab 1/2 tab twice a day, Lactulose 30cc once a day at half-strenght, NaHCO3 1 tab four times a day, Fondaparinux (Drixta) 2.5 mg SQ once a day. - Haven't complied to his follow up check up after his hospitalization 2 years ago due to laziness and financial constrainat; visits Dr. Belo during illness (e.g. Cough, Fever). -Denies illicit drug use.

V. Family History
Paragraph form -Mrs. E.R 60 -sister diabetic Mr. E.V - brother diabetic Ms. G.V 49- sister diabetic (deceased) Mr. A.V 60 -father has lung cancer(deceased) Mrs. S.V 70 -grandmother has lung cancer (deceased) -no known rare family genetic condition -Diabetes on both sides of the family -Lung cancer on father's side of the family

VI. Personal and Social History

-Graduated at John B. Lacson Foundation as Bachelor in Science in Marine Transportation. -Lives in a rural area with environmental hazards such as smoke from using charcoal when cooking, air pollution upon -driving his jeepey -Extended family type lives with Mr. (cousin) and his family, which is headed by Mr. E. -Employed as a jeepney driver with an income of 6,000-7,000. Income is enough for his basic needs; missed five days of work due to hospitalization. Helps with the financial concerns of his nephews. (to take into consideration the economic viability of the patient) -Goes to mass every Sunday together with his cousin and his cousins family. -sexual activity data unavailable due patient's unconscious state. have no knowledge of patients sexual activity) -is not involved in any social organizations -enjoys watching basketball games during leisure time

VII. Stressors
PHYSIOLOGIC (OBJECTIVE) Data not gathered due to comatose state of the patient. PSYCHOLOGIC(SUBJECTIVE) Data not gathered due to comatose state of patient.

Health Assessment

 Clients name: _Mr. Edgar Violata___ Bed # _12_ Clients chief complaints: Difficulty of Breathing Medical Impression: Acute Respiratory Failure type 1 secondary to pulmonary edema secondary to CKD vs left ventricular dysfunction; CAP-HR; Working Diagnosis: Acute Symptomatic Seizure probably secondary to hypoxic encephalopathy secondary to Cardiac Arrest

General Survey: Date: 7-6-11 Time: 10:30 am Received this medium-built,54 year-old Filipino male; in bed, semi-fowlers position; comatose; brown skin color; no lesions; in hospital gown; no unpleasant body odor; proportionate body built; edematous kung din nga part; (no response upon verbal or tactile stimulatio); endotracheal and nasogastric tube present and (patent); with urinary catheter, draining to a light yellow urine; with (IVF of PNSS 1L X 40 cc/hr with sidedripof Dopamine 250 ml) , through IJ catheter infused at right jugular vein; .

FUNCTIONAL AREA

FINDINGS With RR of 27 breaths per minute, deep and labored; presence of endotracheal tube, oxygen at 10LPM; Oxygen saturation is at 99%; upon auscultation, wheezing sound and crackles were heard on the left and right lung fields With pulse rate of 109bpm, grade 1 pulses on the radial pulse; Intrajugular catheter for hemodialysis;inserted with pitting edema graded as +1 on both the upper and lower extremities; soles and palms are light pink in color ; capillary refill takes 6 seconds on the fingernails and 7 seconds on the toenails; pulse oximetry is attached to the right middle finger; left index finger is bluish in color;

RESPIRATORY

CIRCULATORY

On semi-fowlers position; comatose; REST AND COMFORT ELIMINATION Presence of indwelling catheter; with an hourly urine output ranging from 20-30cc; urine is light yellow in color; wearing an adult diaper ; LAST BOWEL MOVEMENT WAS ____ With GCS of 3; with Endotracheal tube; no eye opening; no response; pupillary size of 2; PERRLA; gag / corneal reflex. No response upon stimulation; MOTOR

NEUROLOGIC

FUNCTIONAL AREA

REMARKS

Non responsive to stimuli; SENSORY/ SPECIAL SENSES On OTF 1200 calories per day in 800cc volume divided in 6 feedings; decrease in weight 10lbs

NUTRITION

THERMOREGULATORY

With temperature of 37.4 C via axillary route; upper and lower extremities are cold;
Dry lips, dry tongue with presence of lesion on left lower aspect of the tongue; presence of mustache and beard; fingernails and toenails are untrimmed and dirty ;minimal hair on the upper and lower extremities. not responsive.

INTEGUMENTARY

MENTAL/ EMOTIONAL Grossly male; circumcised; brown in color; pubic hair is coarse; catheter in place;

REPRODUCTIVE: MALE: FEMALE:

Laboratories and Diagnostic Tests

COMPLETE BLOOD COUNT (CBC) PURPOSE: To aid in detection of anemias; to determine hydration status; evaluate patients response to treatment; part of routine hospital admission. SPECIMEN: Blood DRAW DATE AND TIME:7/6/11 5:10am DO NOT DIAGNOSE;
PARAMETERS White Blood Cell (WBC) Red Blood Cell (RBC) NORMAL VALUES 4.5-11.0X10^q/L 4.5-5.9X10^q/L RESULTS 17.9x10^q/L 3.02X10^q/L SIGNIFICANCE Increased in WBC suggests infection. Decreased in RBC may indicate abnormal destruction of RBC production, lack of substances needed for RBC production. Decreased in Hemoglobin may indicate anemia, erythropoietin deficiency, deficiencies of iron, overhydration. Decreased in Hct indicates that cells are microcytic, presence of kidney failure. Normal Normal Normal

Hemoglobin(Hgb)

13.0-17.0g/dL

8.4g/dL

Hematocrit(Hct)

40.0-54.0%

25.3%

MCH MCH Mean Corpuscle Hemoglobin Concentration (MCHC) Red Cell Distribution Width (RCDW)

80-96 cu.u 27-33uug 32-36 g/dL

84 cu.u 27.9uug 33.3 g/dL

11-16%

14.6%

Normal

DIFFERENTIAL COUNT
PARAMETERS NORMAL VALUES RESULTS SIGNIFICANCE

Stabs Segmenters

0-7% 50-70%

6% 91%

Normal Increased due to infection. WHAT KIND OF INFECTION Indicates infection Normal

Lymphocytes Monocytes

20-45% 0-8%

2% 1%

INACCURATE(include all)
Component or Lab. test Urinalysis Reaction Amorphous Urates Clinical Chemistry Uric Acid Creatinine Total Protein Albumin Globulin A/G Ratio Potassium Normal values Date/ Result 7/3/10 5.0 Few

0.52
902.47 5.2 L 2.0L 3.2 0.6 4.0

Chest Xray Date taken: 7/3/10 Results: -Endotracheal tube is seen with the tip at the level of T5 vertebra -Nasogastric tube is seen within the gastric shadow -Internal jugular catheter is seen in the right hemothorax with the tip at the level of 7th posterior rib Significance Chest X-ray determines the location, position, and condition of respiratory organ found in the thoracic cavity area. Can be used as basis for diagnosis of respiratory illnesses such as respiratory failure, pulmonary edema and or presence of mucous in the lungs.

ACUTE RESPIRATORY FAILURE

PREDISPOSING FACTORS MODIFIABLE ASmoking BHaving back massage every week CDamp clothing (sweaty clothes) NON-MODIFIABLE A. Air pollution B. allergens

PRECIPITATING FACTORS: 1Airway obstruction due to increase mucous secretion. 2Reduction of oxygen supply in tissues. 3Low level of oxygen and excess carbon dioxide in blood. 4Impaired diffusion that results to pulmonary edema and respiratory distress syndrome. As evidenced by 5Weakness or paralysis of respiratory muscle. 6Impaired matching of ventilation and perfusion. 7Metabolic factor laboratories

Clinical lung injury

Write all factors and indicate thru legends to emphasize which factors is evident to patient Start with the source of problem DM causes CKD START WITH PNEUMONIA

Alveolar epithelial damage

Endothelial damage

Platelet aggregation

Complement (C5a) activation

Type II pneumocyte damage Release of neutrophil chemotactic factor

Bacterial endotoxin

Macrophage mobilization

Decreased surfactant production

Neutrophil aggregation and release of mediators: Oxygen radicals Proteolytic enzymes Arachidonic Acid metabolites PAF

Release of cytokines (TNF,IL-1)

Vasoconstriction Alveolocapillary membrane permeability Cough Crackles Hypoxia dyspnea Decreased flow to selected areas Exudation of fluid, protein, RBCS into interstitium

V/Q mismatching impaired lung compliance Pulmonary edema and hemorrhage with severe impairment of alvelolar ventilation Right-to-left shunt hyaline membrane formation, and finally fibrosis

Acute respiratory failure

Positioning patient with proper body alignment for optimal chest excursion Institute suctioning via ET as necessary Administer mouth care to limit bacterial growth Maintains patients personal hygiene, nutrition to increase natural defense Oxygen administration

RECOVERY

DEATH

LEGEND:

-Shows continuous process

- complications that may arise -signs and symptoms - Interventions

Problem List

PROBLEM NOT THE SAME CUES FOR ALL PROBLEMS CUES SHOULD COME FROM PA OR LABORATORY 1. Ineffective airway clearance as manifested by: a. Thick mucus secretions b. Changes in rate and depth of respiration c. Adventitious breath sounds heard upon auscultation 2. Impaired spontaneous ventilation as manifested by: a. (Tachycardia (with cardiac rate of of 109bpm)) b. Tachypnea (with RR of 27 breaths per minute) c. Decrease in level of consciousness 3. Impaired Gas Exchange as manifested by: a. Collection of mucus in airways b. Tachycardia (with cardiac rate of 109bpm) c. Tachypnea (with RR of 27 breaths per minute) d. Functional decline with or without fever 4. Potential for infection Risk factors: a. Suctioning of airway b. Endotracheal intubation

DATE SIGNATURE IDENTIFIED July 6,2011

DATE RESOLVED

SIGNATURE

July 6,2011

July 6,2011

July 6,2011

Nursing Care Plan

Cues (Subj. / Obj.) Objective: Diminished or adventitious breath sounds (crackles, wheezes) Cough, ineffective or absent; sputum Deep and labored breathing

Nursing Diagnosis

Plan of Care (Goals) The patient will demonstrate absence/ reduction of congestion with breath sounds clear, respirations noiseless, and improved oxygen exchange.

Interventions

Rationale

Evaluation

Ineffective airway clearance may be related to increased sputum production as manifested by wheezing and crackles heard upon auscultation, changes in rate and depth of respirations

Independent: Assessment Assist with appropriate testing (pulmonary function/ sleep studies) Assess rate/ depth of respirations and chest movement. Monitor for signs of respiratory failure.

Auscultate lung fields, noting areas of decreased/ absent air flow and adventitious breath sounds.

Independent: Assessment To identify causative/precipitating factors. Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of discomfort of moving chest wall and/or fluid in lung. Decreased airflow occurs in areas consolidated with fluid. Bronchial breath sounds (normal over bronchus) can also occur in consolidated areas. Crackles, ronchi, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasm/ obstruction.

Cues (Subj. / Obj.)

Nursing Diagnosis

Plan of Care (Goals)

Interventions

Rationale

Evaluation

Objective: Diminished or adventitious breath sounds (crackles, wheezes) Cough, ineffective or absent; sputum Deep and labored breathing

Therapeutic: Ineffective airway clearance may be related to increased sputum production as manifested by wheezing and crackles heard upon auscultation, changes in rate and depth of respirations The patient will demonstrate absence/ reduction of congestion with breath sounds clear, respirations noiseless, and improved oxygen exchange. Give expectorants/ bronchodilators as ordered: 1 LNC 1 neb Combivent Q 6

Therapeutic To expel mucous and dilate the airways. Albuterol: Produces bronchodilation by relaxing bronchial smooth muscle through beta-2 receptor stimulation. Ipratropium: Antagonizes action of acetylcholine on bronchial smooth muscle in lungs, causing bronchodilation. Keeping the head elevated lowers the diaphragm, promoting chest expansion, aeration of lung segments, and mobilization and expectoration of secretions to keep the airway clear. Stimulates cough or mechanically clears airway in client who is unable to do so because of ineffective cough or decreased level of consciousness. Health Teaching: To prevent aspiration into the lungs

Elevate head of the bed, change position frequently. Suction as indicated Health teaching: Discourage use of oilbased products around nose

Cues (Subj. / Obj.) Objective: Increased heart rate Decreased cooperation

Nursing Diagnosis

Plan of Care (Goals) Independent:

Interventions

Rationale Independent: Assessment: To determine clients future capabilities, ventilation needs, and most appropriate type of ventilatory support. To measure work of breathing. May indicate improper placement of ET tube, development of barotrauma. Therapeutic: To avoid contamination/ providing medium for growth of bacteria. To check for developing complications/ equipment problems. To alleviate dyspnea and facilitate oxygenation. Promotes relaxation decreasing energy/oxygen requirements. Health Teaching: Reduces fear of unknown.

Evaluation

Impaired spontaneous ventilation may be related to respiratory center depression, possibly evidenced by; Changes in rate and depth of respirations Increased work of breathing Tachypnea

Reestablish/main tain effective respiratory pattern via ventilator with the absence of retractions/ use of accessory muscles or other signs of hypoxia; and with ABG/SaO2 within acceptable range.

Assessment: Investigate etiology of respiratory failure. Assess spontaneous respiratory pattern, noting rate, depth, rhythm, symmetry of chest movement, use of accessory muscles. Note changes in chest symmetry. Therapeutic: Check tubing for obstruction. Monitor airway pressure Elevate head of bed Provide quiet environment, calm approach, and undivided attention of the nurse. Health Teaching Explain weaning activities/techniques, individual plan and expectations.

Cues (Subj. / Obj.)

Nursing Diagnosis

Plan of Care (Goals)

Interventions

Rationale

Evaluation

Objective: Diminished or adventitious breath sounds (crackles, wheezes) Cough, ineffective or absent; sputum Deep and labored breathing

Collaboration: Ineffective airway clearance may be related to increased sputum production as manifested by wheezing and crackles heard upon auscultation, changes in rate and depth of respirations The patient will demonstrate absence/ reduction of congestion with breath sounds clear, respirations noiseless, and improved oxygen exchange. Assessment: Monitor serial chest xrays, ABGs, pulse oxymetry readings.

Therapeutic Assist with/monitor effects of nebulizer treatments and other respiratory physiotherapy; e.g. incentive spirometry, IPPB, percussion, postural drainage. Perform treatments between meals and limit fluids when appropriate. Administer medications as indicated: mucolytics, expectorants, bronchodilators, analgesics. Provide supplemental fluids; e.g. IV, humidified oxygen and room humidification.

Collaboration: Assessment Follows progress and effects of disease process/ therapeutic regimen, and facilitates necessary alterations in therapy. Therapeutic Facilitates liquefaction and removal of secretions. Postural drainage may not be effective in interstitial pneumonias or those causing alveolar exudates/ destruction. Coordination of treatments/schedules and oral intake reduces likelihood of vomiting with coughing and expectorations. Aids in reduction of brochospasm and mobilization of secretions. Analgesics are given to improve cough effort by reducing discomfort, but should be used cautiously because they can decrease cough effort/ decrease respirations. Fluids are required to replace losses (including insensible) and aid in mobilization of secretions. Note: Some studies indicate that room humidification has been found to provide minimal benefit and is thought to increase the risk of transmitting infection.

Nursing Diagnosis 1.

Plan of Care (Goals) Potential for Within 8 hours of infection nursing and Risk factors: medical a. Suctioni intervention, the ng of patient will be airway able to avoid the transmission of b. Endotrac infection using heal proper infection intubatio control. n

Interventions INDEPENDENT Assessment: 1. Assess for potential sites of infection: urinary or IV line. 2. Monitor temperature 3. Note signs of localized or systemic infection; report promptly. SUCH AS

Rationale

Evaluation

Infection must be monitored closely because there is a tendency for development of infection with ARF. Infection increases the mortality associated with ARF, especially in older clients. Because of a decreased immune response, an elevated temperature Therapeutic: may not be present with infection. 1. Provide meticulous skin care. Infection is the leading cause of 2. Use aseptic technique during catheter care death in ARF. Skin is the first line of defense and suctioning. 3. Protect the patient from exposure to other against infection. Skin that is clean, dry, and free of prolonged pressure is infected people. resistant to breakdown and possible Health Teaching infection. COLLABORATIVE This decreases risk for infection. Assessment: Visitors, family members, and other 1. Monitor white blood cell (WBC) count. patients with obvious infections pose 2. If infection is suspected, obtain specimens an infection risk to the patient in of blood, urine, and sputum for culture and renal failure who may be immune sensitivity, as prescribed. compromised. Therapeutic: The patients WBC count will increase in the presence of infection. 1. If infection is present, administer Identifying the source of the antibiotics, as prescribed. infection is necessary to plan appropriate therapy. Health Teaching: Treatment of any infection with antibiotics is necessary to prevent further complications associated with Infections.

Nursing Diagnosis

Plan of Care

Interventions

Rationale

Evaluation

1.

a. b.

c.

(Goals) Impaired Gas Within 8 hours Exchange related to of nursing and ventilation perfusion medical imbalance and intervention, the alveolar-capillary patient will be membrane changes able to as manifested by: improved Collection of mucus in ventilation and airways adequate Tachycardia (with oxygenation of cardiac rate of tissues by ABGs 109bpm) within clients Tachypnea (with RR of normal limits 27 breaths per and absence of minute) of distress. Functional decline with or without fever

d.

INDEPENDENT Assessment: 1. Assess for abnormal heart and lung sounds, along with rate, rhythm, and depth of respirations every hour. 2. Monitor blood pressure and pulse; note dysrhythmias and irregularities. 3. Monitor oxygen saturation and ABGs. Therapeutic: 1. Keep environment allergen/pollutant free. Health Teaching COLLABORATIVE Assessment: Therapeutic: 1. Give oxygen (9LPM) as indicated by patient symptoms, oxygen saturation, and ABGs. 2. Assist the patient in assuming a semiFowlers position. Health Teaching:

Helps to detect the presence of pulmonary congestion that may occur with renal failure patients due to fluid volume excess, as the diseased kidneys are unable to excrete water. Heart rate increases as a compensatory mechanism to increase the effectiveness of the heart in handling the excess fluid. Provides information regarding hearts ability to perfuse distal tissues with oxygenated blood. To reduce irritant effect of dust and chemicals on airways. Makes more oxygen available for gas exchange, assisting to alleviate signs of hypoxia. Allows for better chest expansion, thereby improving pulmonary capacity.

Discharge Plan

Discharge plan
Client may be discharge from MICU bed 12 of St. Pauls Hospital Iloilo, if the following criteria are met: Vital signs are stable and within the normal range. Medication such as catapress (for hypertension),Citicoline (for severe signs and symptoms of Cerebrovascular Disease), Diazepam (for muscle spasm), Valproic acid (for seizure), Fondaparinux (prophylaxis for deep vein thrombosis) regimen are completed and started. Food and fluid intake are appropriate for client weight

 Patient will be able to perform active exercise starting from non-strenuous activities to activities that he can tolerate such as flexion and extension of upper and lower extremities. Able to perform ADLs such as clothing, eating, bathing and toileting. Diet: food low in salt and fats such as vegetables, lean meat and fish. Patients significant others will be able to understand the discharge instructions especially when patient experience the recurrence of seizure, difficulty of breathing and chest pain.

 Instruct patient to monitor blood glucose regularly though CBG(capillary blood glucose) monitoring. Advice patient to minimize smoking from 1 pack a day to 8 to10 sticks a day.

END