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I.

INTRODUCTION

For the purpose of privacy and confidentiality, the real name of the patient in this Case Study is withheld and she will referred as Mommy Dionisia throughout the entire document. Mommy Dionisia is a 45 year old female and currently residing in Brgy Estrada, Capaz, Tarlac with her husband and her four children. She was admitted at the Intensive Care Unit of Central Luzon Doctors hospital on July 27,2010 with a chief complaint of difficulty of breathing. She was then diagnosed having an acute respiratory failure secondary to asthma. Asthma is a chronic inflammatory disease of the airways that causes airway hyperresponsiveness, mucosal edema and mucous production. This inflammation ultimately leads to recurrent episodes of asthma symptoms such as cough, chest tightness, wheezing and dyspnea. A patient with asthma may develop an exacerbation or infection that causes additional deterioration of gas exchange which can lead to acute respiratory failure. Acute respiratory failure(ARF) is defined as a decreased in atrial oxygen tension(PaO2) to less than 50 mmHg (hypoxemia) and increase atrial carbon dioxide tension(PaCO2) to greater than 50 mmHg(hypercapnia), with an atrial Ph of less than 7.35. A patient with acute respiratory failure may manifest shortness of breath, shortness of breath on exertion, syncope, dyspnoea, chest pain, tachycardia, tachypnoea, fatigue and weight loss.

II. OBJECTIVES At the end of the exposure, the student nurse will be able to: 1 2 3 1. Establish rapport and gain trust and cooperation of the patient and the immediate 2. Perform necessary & thorough physical assessment using the cephalocaudal approach; family members. collect complete medical, socio-cultural, and family history related to the clients current health condition. 1 2 3. Analyze and prioritize problems based from the gathered pertinent data to formulate 4. Plan the appropriate nursing interventions to address clients health problems & needs. correct nursing diagnoses The interventions should provide not only the well being of the patient but also with her social, emotional and mental welfare. 3 1 2 5. Implement the planned nursing interventions to meet the desired outcomes and help 6. Impart useful health teachings to the client and immediate family members to prevent 7. Acquire knowledge and responsibilities regarding Acute Respiratory failure and the improve clients condition further development or recurrence of the clients condition and other related complications possible complication that may occur or manifest in the patient.

II.

NURSING PROCESS

A. Nursing Health History A

A. Demographic data Patient Name: Mrs. Dionisia Date admission: Ward: Intensive Room no: 8 July 27,2010 Care Unit (ICU) Age: 45 Sex: Female C/S: Married Examiner: Dra. Tuquero B. Chief Complaint Mommy Dionisia sought consultation to the hospital due to difficulty of breathing.. C. History of Present Illness Three days prior to admission Mommy Dionisia is experiencing difficulty of breathing which is rapidly relieved when she nebulized at their home. By that time she can still do her activities of daily living. Few hours before the admission she again experienced difficulty of breathing after riding a bicycle. She tried to nebulize but still the difficulty that she is experiencing is aggravating. That was then her husband decided to bring her to the hospital to seek for medical management. D. Past Medical History (prior to admission and onset of illness) a. Paediatric illness Mumps ______ Pertusis________ HPN _______

Religion: Iglesia ni Cristo

Measles

______ Rheumatic______

Heart Disease _______ Hepatitis Others _______ ______

Chicken Pox ______Pneumonia______ Rubella ______ Tuberculosis_____

b. Immunization/Tests BCG DPT FLU _____ _____ _____ Hepa B Measles ____ _____ Pneumonia _____ OPV Tetanus toxoid _____

others:

c. Hospitalization According to the patient she has no previous hospitalization. d. Injuries Mommy Dionisia had no injuries. e. Transfusions Mommy Dionisia has not yet undergone any blood transfusions. f. Obstetrics Mommy Dionisia had her first menstruation (menarche) when she was 13years old. She has a regular monthly period that lasts for 3-5 days. According to her, she doesnt experienced dysmenorrhea. Shes practicing natural method of family planning (withdrawal). Gravida: 3 TPALM: Gravida= 4 Term = 4 Para = 4 Abortion = 0 Live birth = 4 Multiple = 0 g. Medication

Before seeking help from health care professionals she nebulized first with a medicine suggested by her neighbour (Pulmo Inhalants).

h. Allergies She had reported not having any allergies to either food groups or drugs.

D. Family History Age 80 76 50 45 43 38 Family Member Father Mother Sister Mommy Dionisia Sister Brother Health Status Unhealthy Unhealthy Healthy Unhealthy Healthy Unhealthy Living or deceased Deceased Deceased Living Living Living Living Diseases Present in the Family Heart Disease Hypertenson None A.R.F. None None

E. Social and Personal History Date of Birth: November 14,1965 Birthplace: Rosales, Pangasinan Educational Attainment: High School Ethnic Background: Ilocano (undergraduate) Position in the Family: mother Language: Ilocano, kapampangan, tagalog a. Residence Mommy Dionisia and her family currently reside in Brgy. Estrada, Capaz, Tarlac. Their house is constructed with sawali and wood and stands at the middle rice fields. Sawali is more dominant, they do have ceiling and adequate light source. According to her, the space is adequate enough for them. She and her family have been living in Capaz for 21 years. b. Occupation

Mommy Dionisia is raising animals such as pigs and chickens for four years now. But when she was still single she worked in a factory of coffee in manila. c. Financial Mommy Dionisias family supports their daily needs through their savings from selling animals and rice. d. Habits Mommy Dionisia spends her time doing household chores and attending the needs of her animals by cleaning their pen and feeding them. She spends her free time by watching television. e. Diet She eats three meals a day. She prefer to eat vegetables and fish and occasionally she eats meat and meat products. Infact her favorite is Pinakbet and bangus. f. Physical Activity/Exercise Household chores and cleaning the pig pen daily were usually her form of exercise. g. Brief Description of Average Day Mommy Dionisia usually wakes up as early as 4 in the morning. She then starts doing household chores and cleaning the pigpen. She also find time to chat with her neighbours and watch television at the afternoon. Usually she sleeps at around 7-8 in the evening.

F. Review of Systems

Put check on significant (abnormal) findings

General Description

Weight loss Weakness

Weight gain Night sweats

Anorexia

Fatigue

Notes :Shows weakness and fatigue.

Skin

Itch Lesions BurnsDrainage

Bruising Blisters Scars

Rash Ecchymoses

Bleeding

Notes: Upon performing inspection, no skin abnormality found.

Eyes

Pain Diplopia

Itch Excessive Tearing

Vision Loss Eye Glasses

Blurring Contact Lenses

Notes: The above deviations from normal were not present in the patient.

Ears

Pain

Discharge

Tinnitus

Hearing loss

Notes: The above deviations from normal were not present in the patient.

Nose

Obstruction

Epistaxis

Discharges

Notes: The above deviations from normal were not present in the patient.

Throat & Mouth

Sore throat

Bleeding gums

Tooth Ache

Tooth Decay

Notes: The above deviations from normal were not present in the patient.

Chest

Cough Dysnea Breast:

Hemoptysis

Wheeze

Pain on respiration

Sputum:___________________ Lumps Pain Bleeding Discharge

Notes: Laboured breathing was observed.

CVS

Chest pain PND

Palpitation Orthopnea

Dyspnea on Exertion Others: ___________

Edema

Notes: She declared difficulty when breathing and it was also observed by the presence of nasal flaring .She also complain chest pain at the right side with a pain scale of 5/10. GIT

Food Intolerance Vomiting Constipation

Heartburn Pain: Change in BM

Nausea Bloating Melena

Jaundice Excessive Gas

Notes: The above deviations from normal were not present in the patient.

GU

Dysuria Dribbling Menarche: 13y/o

Nocturia Hematuria LMP: July 5,2010

Retention Flank Pain Cycles: 3-5 days

Polyuria

Notes: The patient had her menarche when she was 13 years old with regular 3-5-day cyclemenstruation and her last menstrual period happened last July 5,2010.

Extremities

Joint Pains Stiffness

Varicose Veins Deformities: none

Claudication

Edema

Notes: There is a grade 1 edema at both legs.

NEURO

Headaches Numbness Paresis

Dizziness Tingling Paralysis

Memory Loss Seizures

Fainting

Others:_______________________

Notes:The patient complains headache 4/10.

Mental Health Status

Anxiety (mild)

Depression

Insomnia

Sexual Problems

Fear

Notes: The patient is mildly anxious as a result of thinking to her children at home.

B. Nursing Health History

Category I. Health Perception-Health Management Pattern II. Nutritional-Metabolic Pattern

III. Elimination Pattern IV. Activity-Exercise Pattern

V. Sleep-Rest Pattern VI. Cognitive-Perceptual Pattern VII. Sexuality-Reproductive Pattern

Before Hospitalization According to Mommy Dionisia, a person without an illness is considered healthy. She does not have any known allergies to any foods or drugs. Shes fond of eating vegetables and fish and occasionally eat meat. She weighed 48 kg. She voids normally, and defecates daily usually every morning. She considered her household chores as her daily exercise, activities included were washing clothes, dusting their house, washing dishes, cooking, and cleaning the pen of her animals. She retires at around 7-8 pm, usually wakes up at 4:00 in the morning. She used to sleep during the afternoon, . She was oriented to time, place and person. She was able to communicate well and can comprehend and accommodate questions. She was sexually active and has 4 children.

VIII. Coping-Stress Tolerance Pattern

IX. Value-Belief Pattern

She was very optimistic in life. She took medications to relieve her difficulty of breathing and performed her usual activities as not to feel that shes sick. She believes in scientifically accepted and traditional healing, as evidenced by her consulting a doctor. She also believe that with the help of GOD, she will be completely cured.

C. PHYSICAL ASSESSMENT

General Survey Overall Physical Appearance: Mommy Dionisia is mesomorph, appeared weak, with easy fatigue ability noted, looks tired and sleepy. Signs of physical discomfort have been noticed such as facial grimace, irritability and mild anxiety associated with her complaints of difficulty of breathing and chest pain. She is oriented to time, places and persons. She is mildly anxious yet attentive and cooperative when asked. Her speech is even and moderately paced with appropriate words in a calm and understandable voice. Height: 51. Weight: 48 kg. Body Make-Up: mesomorph Communication Pattern: The patient speaks calmly in Filipino, Ilocano and Kapampangan. Skin Integrity Color: brown complexion Turgor: normal skin turgor with instant recoil of 2-3 seconds. Bruises: none Rashes: none Scars:none Blisters: none Ecchymosis: none Burns: none

Eyes Sclera: white Pupils: round and equal, responsive to light Cornea: transparent, smooth and moist.

Respiratory Easy breathing Vital Signs BP: 140/80 mmhg P.S.:5/10;moderate Body Position/Alignment Supine Fowlers Semi-Fowlers PR: 76bpm RR: 24bcpm TEMP: 36.6 C Capillary refill: 1-2 sec In Distress No Distress

Alignment Appropriate Inappropriate Others: can change position according to desire Mental Acuity Oriented Disoriented Sensory/Motor Restrictions Amputation Fracture Deformity: none Gait Paresis Hearing Disorders Coherent Incoherent Appropriately responsive Inappropriately responsive

Speech: even and moderately paced Emotional Status Euphoric Distressed Apprehensive Angry/Hostile Anxiety(mild)

Medically Imposed Restrictions CBR w/out BRP: Sexual activity: Other Health Related Patterns CBR w/ BRP: OOB-Chair: Restricted ambulation:

Fatigue Coughing

Restlessness Dyspnea

Weakness Dizziness

Insomnia Pain

Environment Room temp: Lighting: Adequate Adequate Inadequate Inadequate

Activities Of Daily Living Can perform: Feeding Dressing Brushing teeth Bathing Combing Transfering

D. PHYSICAL EXAMINATION Conducted last July 30, 2010; 9:00am 1. SKIN Area/ Feature to assess Color Lesions Moisture Temperature Texture Mobility and Turgor 2. HAIR Area/Feature to assess Color and Distribution Texture and Oiliness Infestation 3. SCALP Technique Inspection Palpation Inspection Key findings Hair is black and well distributed. Fine texture and smooth to touch. Absence of any infestation. Technique Inspection Inspection Palpation Palpation Palpation Palpation Palpation Key Findings Brown complexion and Absence of lesion; scars were evident in the left posterior arm. Moist. Within normal temperature of 36.6 oC. Smooth and even. Returns immediately to its normal position when pinched, no tenting noted, 2-3 seconds.

Area/Feature to assess Technique Scaliness and scars Inspection Tenderness, Lesions, Palpation lumps, masses

Key findings No scars and scaliness. Absence of lesion, tenderness and lumps; smooth and intact.

4. SKULL Area/Feature to assess Shape and symmetry Contour, Masses, Depression and Tenderness 5. FACE Area/Feature to assess Facial Feature Edema and Masses 6. EYES Area/Feature to assess Technique External feature Inspection Eyebrows, pupils, iris and sclera. for reaction to Inspection light Inspection for accommodation for convergence Inspection 7. EARS Area/Feature to assess Technique Key findings Key findings With eye bags noted. Eyebrows are symmetrical. The pupils and iris are also symmetrical. There is no obvious deformity seen in the external eye structures, with white sclera Has a normal pupillary reaction: constrict with light and dilate in darkness. Has a normal pupillary reaction: constrict with a near object and dilate with a distant object. Has a normal convergence. Technique Inspection Inspection Palpation Key findings Proportion to the gross body structure. No tender areas, masses, edema or deformities. Technique Inspection Palpation Key findings Symmetrical. Smooth, non-tender and free from masses and depression.

External and internal Inspection ear Palpation Auditory acuity Inspection

Symmetrical with upper attachment at eye corner level, there is absence of cerumen or any discharge. Firm, smooth and free from lesions and pain. The numbers whispered to both ears with one ear occluded at a time were heard clearly.

8.

NOSE AND SINUSES Technique Inspection and Palpation Inspection Palpation Key findings Located symmetrically, proportion to the face.The nasal bridge is aligned, and is without swelling, bleeding, lesion or masses. Presence of nasal flaring . Mucosa is pink without swelling. There is no pain or discomfort felt upon palpating the frontal and maxillary sinuses.

Area/Feature to assess Nose

Nasal cavities Nasal sinuses

9. MOUTH AND PHARYNX Area/Feature to assess Lips Gums Teeth Tongue Palate Tonsils 10. NECK Area/Feature to assess Technique Symmetry and Inspection and Masculature Palpation Lymph nodes Palpation Key findings The patients neck is mobile and proportion to the gross body structure. There is absence of neck vein engorgement, masses, or scars. The lymph nodes are normal in size and shape. No pain felt upon palpation. Technique Inspection Inspection Inspection Inspection Inspection Inspection Key findings Pinkish in color, quite dry but no ulcers present. Gums are pink, smooth and moist. There is absence of swelling, inflammation, or bleeding. Complete teeth. Pinkish. Dorsal and ventral surface are both smooth and mobile. Palates are concave and pink. Soft palate is smooth and hard palate has ridges. Tonsils are symmetrical and there is no swelling.

11. THORAX AND LUNGS A. POSTERIOR THORAX Area/Feature to assess Lesions Breath sounds Technique Palpation Auscultation Key findings Posterior thorax is free from tenderness and lesion. With wheezes upon inspiration.

B. ANTERIOR THORAX Area/Feature to assess Symmetry, Rhythm Sound 12. HEART Area/Feature to assess Heart sound Point of maximal impulse(PMI) Heart beat 13. ABDOMEN Area/Feature to assess Technique General appearance of Inspection the abdomen Sound Auscultation Percussion Tenderness Palpation Key findings The 4 quadrants and 9 regions were correctly identified No evidence of linea nigra and stretchmarks. Gurgling sounds were heard over the abdomen, with normoactive bowel sound. The abdomen has a dull sound while the liver has a dull sound also. Smooth and no tenderness noted. Technique Auscultation Auscultation Auscultation Key findings No murmur, clear. PMI was located on the 4th to 5th intercostal space left midclavicular line or the apical area. 76 cardiac cycle/min. Technique Inspection Auscultation Key findings Thorax rises and falls in unison with respiratory cycle. With wheezes upon inspiration

14. UPPER and LOWER EXTREMITIES Area/Feature to assess Extremities Technique Inspection palpation Key findings and Peripheral pulses were strong and palpable. Extremities are proportion to the gross body

structure, normal in color and mobile.But with grade 1 edema in both legs. All body parts are present. Peripheral IV access at right arm with no signs of phlebitis and infiltration. Radial pulse rate at 76 bpm.

15. GENITAL:

Area/ feature to assess

Technique

Key findings

16. NAILS Area/Feature to assess Color, shape and texture Capillary refill Lesion Technique Inspection Palpation Palpation Inspection Inspection Key findings and Transparent, smooth and convex with a 160 nail bed angle. and 1-2 sec. No lesion

Anatomy and Physiology

The respiratory system consists of all the organs involved in breathing. These include the nose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two very important things: it brings oxygen into our bodies, which we need for our cells to live and function properly; and it helps us get rid of carbon dioxide, which is a waste product of cellular function. The nose, pharynx, larynx, trachea and bronchi all work like a system of pipes through which the air is funneled down into our lungs. There, in very small air sacs called alveoli, oxygen is brought into the bloodstream and carbon dioxide is pushed from the blood out into the air. When something goes wrong with part of the respiratory system, such as an infection like pneumonia, chronic obstructive pulmonary diseases, it makes it harder for us to get the oxygen we need and to get rid of the waste product carbon dioxide. Common respiratory symptoms include breathlessness, cough, and chest pain.

The Upper Airway and Trachea

When you breathe in, air enters your body through your nose or mouth. From there, it travels down your throat through the larynx (or voicebox) and into the trachea (or windpipe) before entering your lungs. All these structures act to funnel fresh air down from the outside world into your body. The upper airway is important because it must always stay open for you to be able to breathe. It also helps to moisten and warm the air before it reaches your lungs. The Lungs

Structure The lungs are paired, cone-shaped organs which take up most of the space in our chests, along with the heart. Their role is to take oxygen into the body, which we need for our cells to live and function properly, and to help us get rid of carbon dioxide, which is a waste product. We each have two lungs, a left lung and a right lung. These are divided up into lobes, or big sections of tissue separated by fissures or dividers. The right lung has three lobes but the left lung has only two, because the heart takes up some of the space in the left side of our chest. The lungs can also be divided up into even smaller portions, called bronchopulmonary segments.

These are pyramidal-shaped areas which are also separated from each other by membranes. There are about 10 of them in each lung. Each segment receives its own blood supply and air supply.

How they work Air enters your lungs through a system of pipes called the bronchi. These pipes start from the bottom of the trachea as the left and right bronchi and branch many times throughout the lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are where the important work of gas exchange takes place between the air and your blood. Covering each alveolus is a whole network of little blood vessel called capillaries, which are very small branches of the pulmonary arteries. It is important that the air in the alveoli and the blood in the capillaries are very close together, so that oxygen and carbon dioxide can move (or diffuse) between them. So, when you breathe in, air comes down the trachea and through the bronchi into the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel across the walls of the alveoli into your bloodstream. Traveling in the opposite direction is carbon dioxide, which crosses from the blood in the capillaries into the air in the alveoli and is then breathed out. In this way, you bring in to your body the oxygen that you need to live, and get rid of the waste product carbon dioxide.

Blood Supply

The lungs are very vascular organs, meaning they receive a very large blood supply. This is because the pulmonary arteries, which supply the lungs, come directly from the right side of your heart. They carry blood which is low in oxygen and high in carbon dioxide into your lungs so that the carbon dioxide can be blown off, and more oxygen can be absorbed into the bloodstream. The newly oxygen-rich blood then travels back through the paired pulmonary veins into the left side of your heart. From there, it is pumped all around your body to supply oxygen to cells and organs

Laboratory findings Atrial blood gas Date: july 27, 2010 Test Ph PCO2 PO2 HCO3 B.E. O2 sat. Significance: time: 3:35 pm Results 7.58 29.9 321.8 27.5 6.4 99.8 Normal range 7.35 7.45 35 45 mmHg 80 100 mmHg 22 26 mEq/ L + / - 2 mEq/ L 95 100 % Impression Increase Decrease Increase Increase Increase Normal

Routine blood count Date: July 27, 2010 Test


WBC

time: 3:35 pm Results 10.16 65.8 24.3 9.8 0.1 0.0 6.68 2.47 1.0 0.01 0.0 4.33 12.8 37.9 Normal range
3.98 10.04 x 103/uL

neutro% lympho% mono% eo% baso% netro# lympho# Mono# Eo# baso# RBC Hemoglobin Hematocrit Significance:

34.0 71.1 19.3- 51.7 4.7 12.5 0.7 5.8 0.1 1.2 1.56 6.13 x 103/uL 1.18 3.74 x 103/uL 0.24 0.36 x 103/uL 0.4 0.54 x 103/uL 0.1 0.08 x 103/uL 3.93 5.22 x 103/uL 11.2 15.7g/dL 34.1 44.9%

Impression Increase Normal Normal Normal Decrease Decrease Increase Normal Increase Decrease Decrease Normal Normal Normal

Blood chemistry Date: July 27, 2010 Test BUN Creatinine Electrolytes Sodium Potassium Chloride Significance: 1.36 3.53 104.5 136 142 mmol/L 3.8 5.0 mmol/L 95 103 mEq/ L Decrease Normal Increase Result 3.5 70.72 time: 3:35pm Normal range 2.9-8.2 mol/L 53-106 mol/L Impression Normal Normal

Chest X- Ray Date: July 27, 2010 Chest Pa basic Radiologic findings: The lung fields are clear, heart is not enlarged. The diaphragm and costophrenic sulci are intact. The rest of visualized chest structures are unremarkable. Impression: normal chest findings Significance time: 3:00 pm

Medical Management Upon admission at the ICU of Central Luzon Doctors Hospital with a chief complaint of difficulty of breathing and later accompanied by headache and chestpain. The doctor ordered CBC , 12 lead ECG and Chest X ray, to hook plain Lactated Ringer Solution 1L x 20 gtts/min and 5% Dextrose in Water 250 cc x 31 gtts/min, to have nebulization every 6 hours and hook aminophyliine drip to 10 gtts/min to give omeprazole 20 mmg IV OD, hydrocortisone 100 mg IV every 8 hours, ciphrofloxacin 400 mg. every 12 hours combivent every 1 hour after four dose then every four hours, kalium durule 1 tab TID, meptin 50 g 1 tab twice a day and ketorolac 30 mg 1 amp IVP PRN after negative skin test. The doctor also ordered to feed the patient at 1800 kCal of osteorized food every four hours and delay O2 saturation after 2 hours.

Nursing management

EVALUATION

The student-nurse were able to perform thorough physical assessment on the client and formulated nursing diagnosis based on the gathered data, implemented the nursing interventions and evaluated if goals were met. From this exposure, the student nurse have acquired knowledge regarding Acute Respiratory Failure (ARF). And the student nurse was able to impart useful health teachings to the client to be able to perform self-care, prevent recurrence of the disease and also included her diet and the importance of taking her medications. The patients condition has been improved as evidenced by improvement of her breathing pattern and decrease chest pain from pain scale of 5/10 to 2/10.

RECOMMENDATION With this study, the student nurse was able to gain more knowledge and wider view and perspective of the complication of Acute Respiratory Failure. Thus, the student nurse would like to recommend and share some pointers on how to deal with different diseases like Acute Respiratory Failure. To the government, primarily they should allocate sufficient budget to sustain and provide better facilities. They must be responsible enough to create awareness program for care and management for all the Filipino people. To the health care team, they should righteously implementing basic and ideal procedures regardless of the health care facilities where they belong. They must observe and always remember to keep in line with their duties towards patient and significant others. To the community and the family, that they must be sufficient coordinate with the government and the health care team regarding promotion of health and prevention of disease.

Pathology and Physiology

Causal factor: Exposure to indoor and outdoor allergens Occupational

Contributing factor: Respiratory infection Airway pollution Active/ passive smoking

Allergens/. Irritants bind to antibody molecule(IgE) attached in mast cells and basophils Capillary dilation Edema of airway Broncho constriction Airflow limitation Cough Dyspnea Wheezes Chest tightness Inadequate gas exchange

Contraction of bronchial smooth muscle

Increased mucous production

Decreased inhalation of oxygen

Decreased exhalation of carbon dioxide

hypoxemia

hypercapnia

Cyanosis Restlessn ess Confusion Headach e Tachycar dia

Acute respiratory failure