I.

FOUNDATION UNIVERSITY MISSION, VISION & LIFE PURPOSE

Mission
To enhance and promote a climate of excellence relevant to the challenges of the times, where individuals are committed to the pursuit of
new knowledge and life-long learning in service of society.

Vision
To be a dynamic, progressive school that cultivates effective learning, generates creative ideas, responds to societal needs and offers equal
opportunity for all.

Life Purpose
To educate and develop individuals to become productive, creative, useful and responsible citizens of society.

Core Values
• Excellence
• Commitment
• Integrity
• Service

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II. CENTRAL OBJECTIVE

This case study aims to identify and determine the general health problems and needs of emergency care of patient with Respiratory arrest.
This paper is also intended to provide a better understanding of the disease process based on the patient’s health history and as a reference for
future nursing students.

Specific Objectives
At the end of the discussion, the learners will be able to:
• obtain the needed information of the client base on its demographic data completely but not surpassing the patient’s privacy;
• identify the findings of the physical assessment accurately;
• comprehensively understand the anatomy and physiology of systems involved in the disease condition;
• trace the pathophysiology of the disease condition comprehensively;
• identify both medical and nursing intervention, satisfactorily;
• identify the different emergency interventions with their rationale towards the patient;
• comprehend the nursing theory applicable to the care of the patient;
• determine the three priority nursing diagnoses comprehensively;
• formulate effective nursing care plans towards the care of the client critically; and
• evaluate the case presentation by asking relevant questions

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 ACKNOWLEDGEMENT

The goal of nursing education in Foundation University College of Nursing is to provide quality and competent education, honing its student to
be well rounded in all the aspects of life, namely physically, emotionally, intellectually, socially and spiritually. Our exposure to the clinical setting
would not only entail experiential learning but also are employing our critical learning skills in order to render care effectively yet exercising the use
of resources economically most especially in the institution we are being exposed. For the whole duration of our ER rotation we were able to
appreciate the different works and nursing responsibilities.
First and foremost, I would like to give thanks to God, for giving opportunities, for the guidance, for the strength and unconditional love that
keeps them going.

I would like to emphasize the warmest accommodation of the Negros Oriental Provincial Hospital-Emergency Room, the staff and personnel
who have been so supportive and helpful in meeting the needs about certain information regarding the patient’s status.

To Dean Marlene Rosejie Sontillano, RN, RM, MN and Foundation University College of Nursing for the opportunity to integrate knowledge
learned from the four walls of the classroom to the field they are assigned.

To our parents, for the financial, emotional and moral support, this motivates and encourages us to work and study harder.

To the patient and the significant others, for allowing us take up their time to interview, for being cooperative, responsive and answering the
questions related to the patient’s condition. Without their cooperation the researcher’s will not be able to collect exact and reliable data.
Lastly, I would like to express our sincere gratitude to Mr. Peter Orlino for being the adviser of this study, for his patience, motivation, time
and his expertise and supplemented ideas in addition to our gained knowledge.

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 III. INTORDUCTION

Respiratory failure is a sudden and life-threatening deterioration of the gas exchange function of the lung and indicates failure of the lungs to
provide adequate oxygenation or ventilation for the blood. Respiratory failure can be acute (short term) or chronic (ongoing). Acute respiratory
failure can develop quickly and may require emergency treatment while chronic respiratory failure develops more slowly and lasts longer (Black,
2005).

The signs and symptoms of respiratory failure depends on its underlying cause and the levels of oxygen and carbon dioxide in the blood.
A low oxygen level in the blood can cause shortness of breath and air hunger. If the level of oxygen is very low, it also can cause a bluish color on
the skin, lips, and fingernails. A high carbon dioxide level can cause rapid breathing and confusion (Black, 2005)

Pneumonia, on the other hand, is a common illness which occurs in all age groups, and is a leading cause of death among the elderly and
people who are chronically ill. Vaccines to prevent certain types of pneumonia are available and the prognosis for an individual depends on the type
of pneumonia, the appropriate treatment, any complications, and the person's underlying health. Pneumonia occurs in which the alveoli
(microscopic air-filled sacs of the lung responsible for absorbing oxygen from the atmosphere) become inflamed and flooded with fluid. This can
result from a variety of causes, including infection with bacteria, viruses, fungi, or parasites. It may also occur from chemical or physical injury to the
lungs, or indirectly due to another medical illness, such as lung cancer or alcohol abuse (Smeltzer, 2004)

Typical symptoms associated with pneumonia include cough, chest pain, fever, and difficulty in breathing. Diagnostic tools include x-rays and
examination of the sputum. Treatment depends on the cause of pneumonia; community-acquired or bacterial pneumonia is treated with antibiotics.

In the case of my patient, she was admitted on August 20, 2017. She was diagnosed with a respiratory failure associated with community-
acquired pneumonia. 1 month PTA, patient admitted at NOPH due to nausea and vomiting. Patient complaint of cough for almost a month, 5days
PTA, shortness of breath, cough and fever and few hours PTA, patient complaint of dyspnea with which she sought for consultation and then
admission.

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IV. DEMOGRAPHIC DATA

Name: E. B.
Address: Yupisan, Pamplona
Birthdate: March 16
Attending Physician: Dr. Bomediano, Jenellie Faith T. MD
Sex: Female
Age: 58y/o
Date of Admission: 7-20-17, 05:45 AM

Nationality: Filipino
Civil Status: Married
Religion: Roman Catholic

Chief Complaint: Few hours PTA, patient complaint if dyspnea with which she sought for consultation and then admission.

HPI:
1 month PTA, patient admitted at NOPH due to nausea and vomiting
Patient complaint of cough for almost a month
5days PTA, shortness of breath, cough and fever
Few hours PTA, patient complaint of dyspnea with which she sought for consultation and then admission

General Impression: Received patient lying in bed with O2 cannula and 1L PNSS inserted at the right metacarpal vein regulated at 10gtts/min.
Patient is experiencing dyspnea, cold clammy skin and capillary refill of >4 seconds. He is still oriented to time and place and able to communicate
properly.

Final Diagnosis: Respiratory failure secondary to Community-acquired Pneumonia

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V. DEVELOPMETAL TASK

Erik Erikson’s Psychosocial Theory

Age: Late Adulthood, Beyond 50
Ego Integrity vs. Despair

The important event in this stage is productivity. According to Erikson, he said that as we grow older and become senior citizens we tend to
slow down our productivity and ex life as retired person. It is during this time that we contemplate our accomplishments and are able to develop
integrity if we see ourselves as leading a successful life. If we see our life as unproductive, or feel that we did not accomplish our life goals, we
become dissatisfied with life and develop despair, often leading to depression and hopelessness (McCrae, 2002).

The final developmental task is retrospection: people look back on their lives and accomplishments. They develop feelings of contentment and
integrity if they believe that they have led a happy, productive life. They may instead develop a sense of despair if they look back on a life of
disappointments and unachieved goals (McCrae, 2002).

This stage can occur out of the sequence when an individual feels they are near the end of their life (such as when receiving a terminal
disease diagnosis) (McCrae, 2002).

Elements for a positive Outcome:

Success in this stage will lead to the virtue of wisdom. Wisdom enables a person to look back on their life with a sense of closure and
completeness, and also accept death without fear. This may be in response to retirement, the death of a spouse or closure friends, or may simply
result from changing social roles. No matter what cause, this sense of mortality precipitates the final life crisis. The final life crisis manifest itself as a
review of the individual is life-cancer (McAdams, 2001).

Elements for a negative outcome:

Despair is the result of the negative resolution or lack of resolution of the final life crisis. This negative resolution manifests itself as a fear of
death, a sense that life is too short, and depression. Despair is the last dystonic element in Erikson’s Theory (McAdams, 2001).

6
Correlation:

In this stage it explains that as a person we grow older and become senior citizens, it tends to slow down the productivity and explore life as
a retired person. It is during this time that they contemplate their accomplishments and can develop integrity if they see there selves as a leading
successful life. If in this stage we see our lives as unproductive, feel guilty about our past or feel that we did not accomplish our life goals, we
become dissatisfied with our life.
Patient was able to meet the task. She is now contented with her family right now, their relationship with each other is very fine. She always
makes sure that her children receive fair treatment. Although she is unemployed and as works as a housewife, she expresses content that her family
was able to maintain a balance in both economic and emotional balance. In relation to the task, she has already achieved a sense of integrity which
she fully accepts herself and coming to terms with retirement. Accepting responsibility for your life and being able to undo the past and achieve
satisfaction with self is essential.

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VI. ANATOMY AND PHYSIOLOGY

A. Integumentary System

THE SKIN

Skin Structure

The skin is made up of two layers, the epidermis and the dermis. The epidermis, the upper

or outer layer of the skin, is a tough, waterproof, protective layer. The dermis, or inner layer, is

thicker than the epidermis and gives the skin its strength and elasticity. The two layers of the

skin are anchored to one another by a thin but complex layer of tissue, known as the basement

membrane. Below the dermis is the subcutaneous layer, a layer of tissue composed of protein

fibers and adipose tissue. Although not part of the skin itself, the subcutaneous layer contains Figure 1

glands and other skin structures, as well as sensory receptors involved in the sense of touch. (Seeley, 2007)

THE EPIDERMIS

8
 About 90 percent of the cells in the epidermis are keratinocytes which produce a tough, fibrous protein called keratin. This protein is the main

structural protein of the epidermis, and it provides many of the skin’s protective properties. Keratinocytes in the epidermis are arranged in layers,

with the youngest cells in the lower layers and the oldest cells in the upper layers. The old keratinocytes at the surface of the skin constantly

slough off. Meanwhile, cells in the lower layers of the epidermis divide continually, producing new keratinocytes to replace those that have

sloughed off. As keratinocytes push up through the layers of the epidermis, they age and, in the process, produce keratin. By the time the cells

reach the uppermost layer of the epidermis, they are dead and completely filled with the tough protein. Healthy epidermis replaces itself in a

neatly orchestrated way every month.

Like all epithelial cell tissues, the epidermis is avascular meaning has no blood supply of its own. This explains why skin does not bleed when

shaving.

Scattered among the keratinocytes in the epidermis are melanocytes, cells that produce a dark pigment called melanin. This pigment gives

color to the skin and protects it from the sun’s ultraviolet rays. Scattered among the keratinocytes in the epidermis are melanocytes, cells that

produce a dark pigment called melanin. This pigment gives color to the skin and protects it from the sun’s ultraviolet rays. (Bailey, 2017)

THE DERMIS

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 The dermis is the lower layer of the skin which is richly supplied with blood vessels and sensory nerve endings. The dermis also contains

relatively few cells compared to the epidermis instead; it is made up mainly of fibrous proteins and other large molecules. The main structural

component of the dermis is a protein called collagen. Bundles of collagen molecules pack together throughout the dermis, about three-fourths of

the dry weight of skin. Collagen is also responsible for the skin’s strength. Another protein in the dermis is elastin, which is the main component

of elastic fibers. These protein bundles give skin its elasticity and the ability to return to its original shape after stretching. Collagen and elastin

are produced by cells called fibroblasts, which are found scattered throughout the dermis.

The upper part of the dermis is known as the papillary layer. It is characterized by dermal papillae, tiny, fingerlike projections of tissue that

indent into the epidermis above. The lower layer of the dermis is called the reticular layer. It is made primarily of coarse collagen and elastic

fibers. Skin appendages such as glands and hair follicles are often anchored in the reticular layer of the dermis.

b. THE HAIR

Hair Structure

Hair is a distinguishing characteristic of mammals, a group of vertebrates that includes humans. It is composed

primarily of keratin. The protein is packed into dead keratinocytes, much like those found in the upper layers of

the epidermis. The dead keratinocytes fuse together to form the hair. The portion of the hair above the skin is

known as the shaft, while that below the surface of the skin is known as the root. Each hair grows from its own
Figure 2
10
follicle, an indentation of the epidermis. At the base of the follicle is the bulb, which contains cells that give rise to the keratinocytes that make up

the hair, as well as blood vessels that nourish the growing hair.

Each hair follicle also contains the arrector pili, a muscle that contracts in response to cold, fright, and other emotions. The color of hair is due

to melanin, produced by melanocytes in the bulb of the hair follicle and then incorporated into the keratinocytes that form the hair. Dark hair

contains true melanin like that found in the skin, while blond and red hair result from types of melanin that contain sulfur and iron. Hair goes gray

when melanocytes age and lose the enzyme necessary to produce melanin. White hair occurs when air bubbles become incorporated into the

growing hair. The texture of hair results from the shape of the hair shaft.

c. THE NAILS

The Nail Structure

The nails are made of hard, keratin-filled epidermal cells. They protect the ends of the digits from

injury, help us grasp small objects, and enable us to scratch. The part of the nail that is visible is called the

nail body, and the portion of the nail body that extends past the end of the digit is called the free edge. Most Figure 3

of the nail body appears pink because of blood flowing in the tissue underneath, but at the base of the body is a pale, semicircular area called the

lunula. This area appears white due to an underlying thick layer of epidermis that does not contain blood vessels. The part of the nail that is buried

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under the skin is called the root. Nails grow as epidermal cells below the nail root and transform into hard nail cells that accumulate at the base of

the nail, pushing the rest of the nail forward. (Bailey, 2017)

B. Respiratory System

Organs that deliver oxygen to the circulatory system for transport to all body cells happen in the respiratory system. Oxygen is essential for cells

to function. In addition to supplying oxygen, the respiratory system aids in removing of carbon dioxide, preventing the toxin buildup of waste

products in body tissues. The respiratory system carries out its life-sustaining activities. If the respiratory system’s tasks are interrupted for more

than a few minutes, serious, irreversible damage to tissues occurs, followed by the failure of all body systems, and ultimately, death.

Other than carbon dioxide and oxygen functions, the respiratory system helps regulate the balance of acid and base in tissues which is crucial

in normal functioning of cells. It protects the body against disease-causing organisms and toxic substances inhaled with air. The respiratory system

also houses the cells that detect smell, and assists n the production of sounds for speech. (Zimmermann, 2016)

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Figure 4
Nose

The uppermost portion of the human respiratory system, the nose is a hollow air passage that functions

in breathing and in the sense of smell. The nasal cavity moistens and warms incoming air, while small hairs and

mucus filter out harmful particles and microorganisms.

Pharynx

Pharynx is a short, funnel-shaped tube about 13 cm or 5 in long that transports air to the larynx.

Air leaves the nasal passages and flows to the pharynx. Like the nasal passages, the pharynx is lined with a protective mucous membrane and

ciliated cells that remove impurities from the air. The pharynx houses the tonsils, lymphatic tissues that contain white blood cells. The disease-

causing organisms that escape the hairs, cilia, and mucus of the nasal passages and pharynx are attacked by the white blood cells. The tonsils are

strategically located to prevent these organisms from moving further into the body. One tonsil, called the adenoids, is found high in the rear wall of

the pharynx. A pair of tonsils, the palatine tonsils, is located at the back of the pharynx on either side of the tongue. Another pair, the lingual tonsils,

is found deep in the pharynx at the base of the tongue. In their battles with disease-causing organisms, the tonsils sometimes become swollen with

infection. When the adenoids are swollen, they block the flow of air from the nasal passages to the pharynx, and a person breathes through the

mouth.

Larynx

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 Air moves from the pharynx to the larynx, a structure about 5 cm or 2 in long located approximately in the middle of the neck. Several layers

of cartilage, a tough and flexible tissue, comprise most of the larynx. It plays a primary role in producing sound; it prevents food and fluid from

entering the air passage which cause choking; and its mucous membranes and cilia-bearing cells help filter air. The cilia in the larynx trap airborne

particles up toward the pharynx to be swallowed. Food and fluids from the pharynx usually are prevented from entering the larynx by the epiglottis.

When a person is breathing, the epiglottis is held in a vertical position, like an open trap door. When a person swallows, a reflex causes the larynx

and the epiglottis to move toward each other, forming a protective seal, and food and fluids are routed to the esophagus. Food, fluid, or other

substances in the larynx initiate a cough reflex as the body attempts to clear the larynx of the obstruction. If the cough reflex does not work, a

person can choke a life-threatening situation. (Seeley, 2007)

Trachea, Bronchi and Bronchioles

Air passes from the larynx into the trachea, a tube about 12 to 15 cm long located just below the larynx. The trachea is formed of 15 to 20 C-

shaped rings of cartilage. The cartilage rings hold the trachea open, enabling air to pass freely at all times.

The base of the trachea is located a little below where the neck meets the trunk of the body. Here the trachea branches into two tubes, the

left and right bronchi, which deliver air to the left and right lungs, respectively. Within the lungs, the bronchi branch into smaller tubes called

bronchioles. The trachea, bronchi, and the first few bronchioles contribute to the cleansing function of the respiratory system.

Human Lungs

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 In humans the lungs occupy a large portion of the chest cavity from the collarbone down to the diaphragm.

The right lung is divided into three lobes while the left lung, has two lobes. The two branches of the trachea,

called bronchi, subdivide within the lobes into smaller and smaller air vessels known as bronchioles. Bronchioles

terminate in alveoli. When the alveoli inflate with inhaled air, oxygen diffuses into the blood in the capillaries to be

pumped by the heart to the tissues of the body. At the same time carbon dioxide diffuses out of the blood into the
Figure 5
lungs, where it is exhaled. (Zimmermann, 2016)

Alveoli

The bronchioles divide many more times in the lungs to create an impressive tree with smaller branches. These branches dead-end into tiny

air sacs called alveoli. The alveoli deliver oxygen to the circulatory system and remove carbon dioxide.

Interspersed among the alveoli are numerous macrophages, large white blood cells that patrol the alveoli and remove foreign substances that

have not been filtered out earlier. The macrophages are the last line of defense of the respiratory system where their presence helps ensure that the

alveoli are protected from infection so that they can carry out their vital role.

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 The alveoli number about 150 million per lung and comprise most of the lung tissue. Alveoli resemble tiny, collapsed balloons with thin elastic

walls that expand as air flows into them and collapse when the air is exhaled.

Since the concentration of oxygen is much higher in the alveoli than in the capillaries, the oxygen diffuses from the alveoli to the capillaries.

The oxygen flows through the capillaries to larger vessels, which carry the oxygenated blood to the heart, where it is pumped to the rest of the

body. (Zimmermann, 2016)

C. Cardiovascular System

The cardiovascular system consists of the heart, which is an anatomical pump, with its intricate conduits (arteries,

veins, and capillaries) that traverse the whole human body carrying blood. The blood contains oxygen, nutrients, wastes,

and immune and other functional cells that help provide for homeostasis and basic functions of human cells and organs.

(Buddiga, 2014)

a. Location and Size

Figure 6
The size and weight of the heart give few hints of its incredible strength. It is said to be that the size of the heart is the

same as the size of the fist. The hollow coned-shaped heart weighs less than a pound. It is located at the bony thorax and flanked on each side by

16
the lungs. The apex of the heart is directed toward the left hip and rests on the diaphragm at the level of the 5 th intercostal space. The base of the

heart is broader where the great vessels of the body emerge, points toward the right shoulder and lies beneath the second rib.

The human heart has four chambers. The upper two chambers, the right and left atria, are receiving chambers for blood. The atria are

sometimes known as auricles. They collect blood that pours in from veins, blood vessels that return blood to the heart. The heart’s lower two

chambers, the right and left ventricles, are the powerful pumping chambers. The ventricles propel blood into arteries, blood vessels that carry blood

away from the heart.

b. Structure

The human heart has four chambers. The upper two chambers, the right and left atria, are receiving chambers for blood. The atria are

sometimes known as auricles. They collect blood that pours in from veins, blood vessels that return blood to the heart. The heart’s lower two

chambers, the right and left ventricles, are the powerful pumping chambers. The ventricles propel blood into arteries, blood vessels that carry blood

away from the heart.

Four valves within the heart help prevent blood from flowing backward in the heart. The valves open easily in the direction of blood flow, but

when blood pushes against the valves in the opposite direction, the valves close. Two of the valves are located between the atria and ventricles, and

are known as atrioventricular valves. The right atrioventricular valve is formed from three flaps of tissue and is called the tricuspid valve, while the

left atrioventricular valve has two flaps and is called the bicuspid or mitral valve. The other two valves are located between the ventricles and

17
arteries. They are called semi lunar valves because they each consist of three half-moon-shaped flaps of tissue. The right semi lunar valve, between

the right ventricle and pulmonary artery, is also called the pulmonary valve. The left semi lunar valve, between the left ventricle and aorta, is also

called the aortic valve.

c. Functions

The heart must also be able to respond to changes in the body’s demand for oxygen. The heart works very differently during sleep than in the

middle of a 5-kilometer run. In addition, the heart and the rest of the circulatory system can respond almost instantaneously to constantly shifting

situations, when a person stands up or lies down or when a person is faced with a potentially dangerous situation.

d. Cardiac Cycle

The right and left halves of the heart are separate; they both contract in unison, producing a single heartbeat. The sequence of events from

the beginning of one heartbeat to the beginning of the next is called the cardiac cycle. Two phases of the cardiac cycle are systole and diastole.

During the systolic phase, the atria contract first, followed by contraction of the ventricles. This sequential contraction ensures efficient movement of

blood from atria to ventricles and then into the arteries. If the atria and ventricles contracted simultaneously, the heart would not be able to move as

much blood with each beat. While diastole on the other hand is when the heart’s chambers are relaxed, and systole, when the chambers contract to

move blood. (Zimmermann, 2016)

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VII. REVIEW OF RELATED LITERATURE

Respiratory Failure

Respiratory failure is not a disease per se but a consequence of the problems that interfere with the ability to breathe. The term refers to the
inability to perform adequately the fundamental functions of respiration: to deliver oxygen to the blood and to eliminate carbon dioxide from it.
Respiratory failure has many causes and can come on abruptly (acute respiratory failure) when the underlying cause progresses rapidly or slowly
(chronic respiratory failure) when it is associated over months or even years with a progressive underlying process. Typically, respiratory failure
initially affects the ability either to take up oxygen (referred to as oxygenation failure) or to eliminate carbon dioxide (referred to as ventilatory
failure). Eventually, both functions cease when the respiratory failure becomes severe enough. This chapter will focus mainly on ventilatory failure;
oxygenation failure is discussed in more detail in which examines the acute respiratory distress syndrome (ARDS).

Epidemiology, prevalence, and economic burden because so many underlying causes contribute to it, respiratory failure is a common and
major cause of illness and death. It is the main cause of death from pneumonia and chronic obstructive pulmonary disease (COPD), which together
comprise the third-leading cause of death in the United States today. It is also the main cause of death in many neuromuscular diseases, such as
Lou Gehrig disease (amyotrophic lateral sclerosis or ALS), because these diseases weaken the respiratory muscles, rendering them incapable of
sustaining breathing. Epidemiologic studies suggest that respiratory failure will become more common as the population ages, increasing by as much
as 80 percent in the next 20 years. Because respiratory failure is such a common cause of illness and death, the cost to society in terms of lost
productivity and shortened lives is enormous. However, it is hard to quantify because the cause of death is more likely to be listed as pneumonia,
COPD, or another underlying condition, rather than respiratory failure. Pathophysiology, causes: genetic, environment, microbes In patients with

19
neuromuscular disease, breathing first becomes a problem during sleep, when breathing normally slows and the weak respiratory muscles cannot
keep up with the need to eliminate carbon dioxide. The rising carbon dioxide affects the acid–base balance of the body, and, in extreme cases, it
could cause coma or even death (Anon, 2017).

Community-Acquired Pneumonia

Community-acquired pneumonia (CAP) is one of the most common infectious diseases addressed by clinicians and is an important cause of
mortality and morbidity worldwide. Numerous pathogens can cause CAP. Typical bacterial pathogens that cause CAP include S pneumoniae, H
influenzae, and M catarrhalis.

The epidemiology of CAP is unclear because few population-based statistics on the condition alone are available. The Centers for Disease
Control and Prevention (CDC) combines pneumonia with influenza when collecting data on morbidity and mortality, although they do not combine
them when collecting hospital discharge data. In 2001, influenza and pneumonia combined were the seventh leading causes of death in the United
States, down from sixth in previous years, and represented an age-adjusted death rate of 21.8 per 100,000 patients. Death rates from CAP increase
with the presence of comorbidity and increased age; the condition affects persons of any race or sex equally. The decrease in death rates from
pneumonia and influenza are largely attributed to vaccines for vulnerable populations.

Pneumonia is an inflammation or infection of the lungs that causes them to function abnormally. Pneumonia can be classified as typical or atypical,
although the clinical presentations are often similar. Several symptoms commonly present in patients with pneumonia.

TYPES OF CAP

Typical pneumonia usually is caused by bacteria such as Streptococcus pneumoniae. Atypical pneumonia usually is caused by the influenza virus,
mycoplasma, chlamydia, legionella, adenovirus, or other unidentified microorganism. The patient’s age is the main differentiating factor between

20
typical and atypical pneumonia; young adults are more prone to atypical causes, 5,6 and very young and older persons are more predisposed to typical
causes.

SYMPTOMS

Common clinical symptoms of CAP include cough, fever, chills, fatigue, dyspnea, rigors, and pleuritic chest pain. Depending on the pathogen, a
patient’s cough may be persistent and dry, or it may produce sputum. Other presentations may include headache and myalgia. Certain etiologies,
such as legionella, also may produce gastrointestinal symptoms (Baer, 2017).

21
VIII. Medical Management

A. Laboratory Exams

Laboratory Exams Result Normal Values Correlation/Implication

My patient has a high hgb level to
Hemoglobin 18.0 (H) 12-14 gm% compensate for chronically low
blood oxygen level due to poor
lung function.
Hematocrit 51.9 (H) 37-44 % My patient has high hct level
because the cells are dehydrated
due to low blood oxygen level of
the body.
RBC 6.04 (H) 3.5-4.5 M/cumm My patient has high RBC level to
compensate for low oxygen level
of the body.

Differential Count

WBC Count 24.0 (H) 4.0-10.0 T/cumm An increase in WBC count to my

patient was due to presence of
bacteria or virus in her lungs.
Neutrophil Seg 91 (H) 50-70 %
Patient neutrophils was high due
to presence of bacterial infection
in her lungs.

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Lymphocyte 4 (L) 20-40 %
Patient’s lymphocyte was because
it may indicate that the body’s
ability to repel infections is
weakened
Monocyte 4 1-6 %

Eosinophil 0 1-4 %

Basophil 0 0-0.5 %

Platelet Count 275 150-400 T/cumm

23
PATHOPHYSIOLOGY

PREDISPOSING FACTOR PRECIPITATING FACTOR

- Gender (Female) - Environment acquired
- Age (58 y/o) - Cigarette smoking

Entrance of bacteria in airways

Material propelled into alveolar system

Adherence to alveolar macrophages exposure of call

wall component (bacterial invasion to lungs)

Acute inflammatory response

Vasodilation and increase blood flow Airway Construction

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 Increase capillary permeability narrowing of air passage

Alveolar capillary leakage Decrease O2 intake

Fluid Leakage to pleural space

Anaerobic metabolism
S/S: Pleural effusion
- Persistent cough S/S:
- dyspnea - 45cpm
Decreased lung contraction Alveolar collapse Hyperventilation retained
- SOB

Lung collapse
Respiratory acidosis

Lungs no longer able to function in

gas exchange
Nursing DX:

> Ineffective airway clearance related to thick sputum

S/S: secondary to pneumonia
- Bluish in color of Low oxygen delivered to blood
nails > Impaired gas exchange related to bronchospasm
- Cold clammy skin
> Ineffective Breathing Pattern related to an
Heart will put extra strain to inflammatory process secondary to ARI with pneumonia
compensate for the imbalance

Pumps more hard than normal 25

 Sudden cessation of heart activity

C. Treatment Modalities
Cardiac Arrest
Date Doctor’s Order Rationale
To provide specific medical care based on
7/20 Admit to medicine – CCU perceived needs
To have ethical considerations and also to
Severe consent
protect patient’s freedom to make healthcare
decisions.

NPO due to dyspnea To avoid aspiration

Start IVF with PLNSS to For fluid and electrolyte replacement therapy in
Right @ 10gtts
conditions where water and sodium losses are
in isotonic proportion.
Medication: Inhaled salbutamol is also used to prevent
1. Salbutamol I neb x 3dose now then asthma attacks caused by exercise. It works by
relaxing the muscles in the walls of the small
airways in the lungs. This helps to open up the
airways and make breathing easier.

2. Hydrocortisone 25mg IVTT then It reduces the actions of chemicals in the body
100mg IVTT q 6hr that cause inflammation, redness, and swelling.

3. Meropenem I gm IVTT now is used to treat a wide variety of bacterial

infections. This medication is known as a

26
 carbapenem-type antibiotic. It works by
stopping the growth of bacteria.

4. Diazepam 5mg IVTT now

is used to treat anxiety disorders, alcohol
withdrawal symptoms, or muscle spasms.
Diazepam is sometimes used with other
Dopamine IVTT medications to treat seizures.
10:40 AM May help correct low blood pressure due to low
systemic vascular resistance.
Epinephrine 1amp IVTT then 5mins
!0:55AM
Acts quickly to improve breathing, stimulate the
heart, raise a dropping blood pressure, reverse
hives, and reduce swelling of the face, lips, and
throat.
ECG Lead
A test that checks for problems with the
electrical activity of your heart. An EKG shows
the heart's electrical activity as line tracings on
Do CPR paper.

A combination of chest compressions and

rescue breathing (mouth-to-mouth
resuscitation). If someone isn't circulating blood
or breathing adequately, CPR can restore
True of death
circulation of oxygen-rich blood to the brain.
11:15AM
A doctor at the hospital will give a medical
certificate that shows the cause of death.

27
D. DRUG STUDY

Drug Order Drug Study

Salbutamol I neb x 3dose now then
Generic name: salbutamol
Brand name: Proventil, Vospira ER, Accuneb, Ventodisk, Ventolin
Pregnancy Category: C
Drug Classes: Bronchodilator, Adrenergics
Therapeutic action:
It relaxes the smooth muscles of the bronchioles allowing maximum
passage of air. It decreases intracellular calcium which will relax the
smooth muscles of the lungs by mobilizing kinase through activation of
cyclic-3’5’-adenosine monophosphate (cAMP).
Indications:
Quick relief of bronchospasm induced through both exercise and
physiological alterations.
To control and prevent reversible airway obstruction caused by bronchial
asthma, chronic obstructive pulmonary diseases such as emphysema and
chronic bronchitis as well as other obstructive pulmonary diseases.
Inhalation: treatment of acute attacks of bronchospasm
Unlabeled use: Adjunct in treating moderate to severe hyperkalemia in
dialysis patients; seems to lower potassium concentrations when inhaled
by patients on hemodialysis
Contraindications and cautions:
Hypersensitivity to salbutamol

28

Hydrocortisone 25mg IVTT then 100mg IVTT q 6h
Tachyarrhythmias and tachycardia caused by digitalis intoxication
Patients with degenerative heart diseases
Use cautiously with patients who have diabetes as this can aggravate
diabetes and ketoacidosis
Use cautiously in elderly because they are more sensitive to CNS effects
Side Effects and Adverse Reactions:
CNS: Restlessness, apprehension, anxiety, fear, CNS stimulation, vertigo,
headache, weakness, tremors, drowsiness
CV: Cardiac arrhythmias, palpitations, tachycardia
Dermatologic: Sweating, pallor, flushing
GI: Nausea, vomiting, heartburn, unusual or bad taste in the mouth
Respiratory: Respiratory difficulties, pulmonary edema, coughing,
bronchospasm, paradoxical airway resistance with repeated, excessive
use of inhalation preparations
Nursing Responsibilities:
>Check and verify with doctor’s order and Kardex.
>Observe rights in medication administration such as giving the right
drug to the right patient using the right route and at the right time.
>Monitor ECG, serum electrolytes and thyroid function test results.
>Administer accurately because adverse reactions and tolerance might
occur.
>Raise side rails up because client might be restless and drowsy because
of this drug.
Generic Name: Hydrocortisone
Trade Name: Cortef, Solu-Cortef
Classification: Adrenal cortical steroid, Corticosteroid, Glucocorticoid
Mechanism Of Action: Enters target cells and binds to cytoplasmic
receptor; initiates many complex reactions that are responsible for its
anti-inflammatory, Immunosuppressive(glucocorticoid), and salt-retaining
(mineralocorticoid)actions. Some actions maybe undesirable, depending
29
on drug use.
Indication: Replacement the rapyin adrenal cortical insufficiency-
Allergic states –severe or incapacitating allergic conditions- Hematologic
disorders- Ulcerative colitis.
Contraindication: Concentrations
- Allergy to any component of the drug- Fungal infections- Amebiasis-
Hepatitis B- Vaccinia or varicella- Antibiotic-resistant infections-
Immunosuppression
Precaution-
Kidney disease- Liver disease- Cirrhosis- Hypothyroidism- Ulcerative
colitis with impending perforation- Diverticulitis- Recent GI surgery-
Active or latent peptic ulcer - Inflammatory bowel disease- Hypertension-
Heart failure- Thrombo embolictendencies- Osteoporosis- Convulsive
disorders- Metastatic carcinoma- Diabetes mellitus- TB- Lactation.
Adverse Reaction: CNS: Vertigo, headache, paresthesias, insomnia,
seizures, psychosis
CV:
Hypotension, shock, HPN and heart failure secondary to fluid retention,
thromboembolism, thrombophlebitis, fat embolism, cardiac arrhythmias
Dermatologic:
Thin, fragile skin, petechiae, ecchymoses, purpura, striae, subcutaneous
fat atrophy
EENT: Cataracts, glaucoma, increased IOP
Endocrine: Amenorrhea, irregular menstruation, growth retardation,
decreased carbohydrate tolerance and DM, cushingoid state, HPA
suppression systemic ,hyperglycemia
GI: Peptic or esophageal ulcer, pancreatitis, abdominal distention,
nausea, vomiting, increased appetite and weight gain
Nursing Responsibilities:
Before
- Assess for contraindications.- Assess body weight, skin color, V/S,
urinalysis, serum electrolytes, X-rays, CBC.- Arrange for increased dosage

30
 when patient is subject to unusual stress.- Do not give live vaccines with
immunosuppressive doses of hydrocortisone.- Observe the 15 rights of
drug administration.
During
- Give daily before 9am to mimic normal peak diurnal corticosteroid
levels.- Space multiple doses evenly throughout the day.- Use minimal
doses for minimal duration to minimize adverse effects.- Do not give IM
injections if patient has thrombocytopenic purpura.- Taper doses when
discontinuing high-dose or long-term therapy
Brand Name: Truphylline
Pregnancy Category C
Drug classes: Bronchodilator, Xanthine
Therapeutic actions: Relaxes bronchial smooth muscle, causing
Aminophylline 125 IVTT
bronchodilation and increasing vital capacity, which has been impaired by
bronchospasm and air trapping; in higher concentrations, it also inhibits
the release of slow-reacting substance of anaphylaxis (SRS-A) and
histamine.
Indications: Symptomatic relief or prevention of bronchial asthma and
reversible bronchospasm associated with chronic bronchitis and
emphysema
Unlabeled uses: respiratory stimulant in Cheyne-Stokes respiration;
treatment of apnea and bradycardia in premature babies
Contraindications: Contraindicated with hypersensitivity to any
xanthine or to ethylene diamine, peptic ulcer, active gastritis; rectal or
colonic irritation or infection (use rectal preparations).
Adverse effects: Irritability (especially children); restlessness, dizziness,
muscle twitching, convulsions, severe depression, stammering speech;
abnormal behavior characterized by withdrawal, mutism, and
unresponsiveness alternating with hyperactive periods, Palpitations, sinus
tachycardia, ventricular tachycardia, life-threatening ventricular
arrhythmias, circulatory failure, Loss of appetite, hematemesis.
Nursing considerations:

31
 · Administer to pregnant patients only when clearly needed--neonatal
tachycardia, jitteriness, and withdrawal apnea observed when mothers
received xanthines up until delivery.
· Caution patient not to chew or crush enteric-coated timed-release
forms.
· Give immediate-release, liquid dosage forms with food if GI effects
occur.
· Do not give timed-release forms with food; these should be given on an
empty stomach 1 hr before or 2 hr after meals.
· Maintain adequate hydration.
· Monitor results of serum theophylline levels carefully, and arrange for
reduced dosage if serum levels exceed therapeutic range of 10–20
mcg/mL.
Meropenem I gm IVTT now Generic Name: Meropenem
Brand Name: Merrem
Classification: Anti-infective; carbapenem antibiotic
Indication: Prescribed for bacterial infections like skin and skin
structure infections, bacterial meningitis, serious no socomiali nfections
like septicaemia, febrile neutropenia, intra-abdominal and pelvic
infections. The medication inhibits cell wall synthesis in bacteria, and
thereby leading to cell death.
Contraindication: Contraindicated with hypersensitivity to carbapenem
antibiotics
Adverse Reaction: allergic reaction (difficulty breathing; closing of the
throat; swelling of the lips, tongue, or face; or hives)
seizures;
severe or watery diarrhea;
a skin rash;
unusual tiredness or weakness; or
unusual bleeding or bruising

32
 Nursing Responsibilities:
Assessment & DrugEffects
-Lab tests: Perform C&S tests prior to therapy. Monitor periodically liver
and kidney function.
- Determine history of hypersensitivity reactions to other beta-lactams,
cephalosporins, penicillins, or other drugs.
- Discontinue drug and immediately report S&S of hypersensitivity (see
Appendix F).
- Report S&S of superinfection or pseudo membranous colitis (see
Appendix F).
- Monitor for seizures especially in older adults and those with renal in
sufficiency.

Generic Name: diazepam

Diazepam 5mg IVTT now Brand Names: Valium
Pregnancy Category D
Controlled Substance C-IV
Drug classes: Benzodiazepine, Anxiolytic, Antiepileptic, Skeletal muscle
relaxant (centrally acting)
Therapeutic actions:
Exact mechanisms of action not understood; acts mainly at the limbic
system and reticular formation; may act in spinal cord and at supraspinal
sites to produce skeletal muscle relaxation; potentiates the effects of
GABA, an inhibitory neurotransmitter; anxiolytic effects occur at doses
well below those necessary to cause sedation, ataxia; has little effect on
cortical function.
Indications:
Management of anxiety disorders or for short-term relief of symptoms of
anxiety
Acute alcohol withdrawal; may be useful in symptomatic relief of acute
agitation, tremor, delirium tremens, hallucinosis
Muscle relaxant: Adjunct for relief of reflex skeletal muscle spasm due to

33
local pathology (inflammation of muscles or joints) or secondary to
trauma;spasticity caused by upper motor neuron disorders (cerebral
palsy and paraplegia); athetosis, stiff-man syndrome
Contraindications and cautions:
Contraindicated with hypersensitivity to benzodiazepines; psychoses,
acute narrow-angle glaucoma, shock, coma, acute alcoholic intoxication;
pregnancy (cleft lip or palate, inguinal hernia, cardiac defects,
microcephaly, pyloric stenosis when used in first trimester; neonatal
withdrawal syndrome reported in newborns); lactation.
Adverse effects:
CNS: Transient, mild drowsiness initially; sedation, depression, lethargy,
apathy, fatigue, light-headedness, disorientation, restlessness,
confusion,crying, delirium, headache, slurred speech, dysarthria, stupor,
rigidity, tremor,
dystonia, vertigo, euphoria, nervousness, difficulty in concentration, vivid
dreams, psychomotor retardation, extrapyramidal symptoms; mild
paradoxical excitatory reactions, during first 2 wk of treatment, visual
and auditory disturbances, diplopia, nystagmus, depressed hearing, nasal
congestion
CV: Bradycardia, tachycardia, CV collapse, hypertension and hypotension,
palpitations, edema.
Nursing Responsibilities:
Assessment
History: Hypersensitivity to benzodiazepines; psychoses, acute narrow-
angle glaucoma, shock, coma, acute alcoholic intoxication; elderly or
debilitated patients; impaired liver or renal function; pregnancy, lactation
Physical: Weight; skin color, lesions; orientation, affect, reflexes, sensory
nerve function, ophthalmologic examination; P, BP; R, adventitious
sounds; bowel sounds, normal output, liver evaluation; normal output;
LFTs, renal function tests, CBC
Interventions
WARNING: Do not administer intra-arterially; may produce arteriospasm,

34
 gangrene.[/sws_red_box]
Change from IV therapy to oral therapy as soon as possible.
Do not use small veins (dorsum of hand or wrist) for IV injection.
Reduce dose of opioid analgesics with IV diazepam; dose should be
reduced by at least one-third or eliminated.
Carefully monitor P, BP, respiration during IV administration.

Dopamine Generic Name: Dopamine

Brand Name:
Classification: AUTONOMIC NERVOUS SYSTEM AGENT
Therapeutic Action: Naturally occurring neurotransmitter and
immediate precursor of norepinephrine. Major cardiovascular effects
produced by direct action on alpha- and beta-adrenergic receptors and
on specific dopaminergic receptors in mesenteric and renal vascular
beds.
Indication: Acute heart failure
Contraindication: Pheochromocytoma, uncorrected tachyarrhythmias,
ventricular fibrillation. Hypersensitivity.
Adverse Effects: nausea, vomiting, tachycardia, ectopic beats,
palpitation, anginalpain, hypotension, vasoconstriction, bradycardia,
hypertension, dyspnoea, headache, widened QRS complexes, azotaemia
Nursing Responsibilities:
- Monitor vital signs , and ECG during infusion, watch for dsyarrythmias
and ischemia also monitor, PCWP,CVP, CO2, and urinary output
- Monitor for possible adverse reaction
- Assess for heart failure: dsypnea, neck vain distention,
- Assess for oxygenation and perfusion deficit

35
IX. NURSING MANAGEMENT

A. Nursing History

Chief Complaint: Few hours PTA, patient complaint if dyspnea with which she sought for consultation and then admission.

General Impression: Received patient lying in bed with O2 cannula and 1L PNSS inserted at the right metacarpal vein regulated at 10gtts/min.
Patient is experiencing dyspnea, cold clammy skin and capillary refill of >4 seconds. He is still oriented to time and place and able to communicate
properly.

HPI:
1 month PTA, patient admitted at NOPH due to nausea and vomiting
Patient complaint of cough for almost a month
5days PTA, shortness of breath, cough and fever
Few hours PTA, patient complaint if dyspnea with which she sought for consultation and then admission

Past Health History: Patient is hypertensive with followed drug maintenance (Lopicard).

Patient was admitted last month due to dizziness and vomiting

Psychosocial History:

36
 The patient displays good intimate relationship with her family. She also maintains a good relationship and interaction with her neighbors and

friends. She does not commonly engage in neighborhood or barangay activities as verbalized by the SO.

Environmental History:

Patient is currently residing at Yupisan, Pamplona, Negros Oriental. Their community is nice and a bit of a crowded place. Their surrounding

environment is averagely clean but still is conducive for living. Their house is made of wood and located away from the highway with surrounding

various trees.

Spiritual History:

Patient was baptized as a Roman Catholic as well as her family and children. She was raised by her family as God-fearing and religious person. She

usually goes to church on Seldom. No signs of any religious practices or beliefs were implemented throughout the course of her care and recovery as

verbalized by the So.

37
B. GENOGRAM

with Genogram

HPN Heart
Attack HPN HPN

Unknown

LEGEND

HPN

- Female Patient

38
 - Male

- Deceased

C. PHYSICAL ASSESSMENT

System Normal Finding PA Findings

INTEGUMENTARY Skin: Skin:

Inspection: Fair in color unexposed skin is Inspection: Bluish in color due to low oxygen in

more lighter than exposed skin. In the the body, absence of rashes on skin, moist skin,

body, absence of rashes on skin, moist low skin turgor and cold clammy skin

skin, good skin turgor and warm to touch

Palpation: No lesions, lumps and nodules Palpation: No lesions, lumps and nodules present

Nails:

Nails: Pale in color, smooth, normal angle, capillary

Pinkish in color, smooth, normal angle, refill is 3-4 sec.

capillary refill is 1-2 sec. Hair:

39
 Hair: Inspection: Dry, well distributed, dark brown

Inspection: Dry, well distributed, light color but slightly presence of white hair

brown in color Palpation: Absence of lumps, nodules and

Palpation: Absence of lumps, nodules and masses

masses

RESPIRATORY Anterior Chest Anterior Chest

Inspection: Symmetrical in shape, Inspection: Symmetrical in shape, absence of

absence of any deformities, any deformities,

Posterior Chest: Posterior Chest:

Inspection: Symmetrical in shape, absence Inspection: Symmetrical in shape, absence of any

of any deformities, absence of rashes at deformities, absence of rashes at the back

the back

Palpation: Absence of nodules, lumps and Palpation: Absence of nodules, lumps and
masses masses

Percussion: Resonant on both lung lobes Percussion: Dull on both lung lobes
Auscultation: No presence of rales and Auscultation: Presence of rales and crackles on
crackles on the lower lung the lower lung

40
CARDIOVASCULAR Inspection:
- Noted positive carotid pulsations.
- Jugular venous wave undulated, easily
obliterated.
- Carotids not affected by respirations,
jugulars are.
- Carotids not affected by position, jugulars
normally only visible when client is supine.
Palpation:
- Rhythm: Regular
- Amplitude: Strong or pulses may normally
be seen in high-output states such as
exercise.
- Contour: Smooth upstroke with smooth,
less acute descent.
- Symmetry: Pulses equal.
- Elasticity: Carotid soft and pliable.
Percussion:
- Dullness at third, fourth, and fifth
intercostal spaces to left of sternum at
midclavicular line.
- Negative bruits.
- Negative carotid bruit is associated with
high-output states.
Inspection:
- Negative carotid pulsations.
- Jugular venous wave undulated, easily
obliterated.
- Carotids not affected by respirations, jugulars
are.
- Carotids not affected by position, jugulars
normally only visible when client is supine.
Palpation:
- Rhythm: Irregular (Arrythmia)
- Amplitude: Strong, more than normal
- Contour: Smooth upstroke with smooth, less
acute descent.
- Symmetry: Pulses unequal.
- Elasticity: Carotid soft and pliable.
Percussion:
- Dullness at third, fourth, and fifth intercostal
spaces to left of sternum at midclavicular line.
- Negative bruits.
- Positive carotid bruit is associated with high-
output states.
- Negative venous hum
41
 - Negative venous hum Auscultation:
Auscultation: - Irregular heartbeat noted
- Regular heartbeat noted - presence of wheezing

D. NURSING THEORY

Dorothea E. Orem’s self-nursing deficit theory

Dorothea Elizabeth Orem numbers among the first American nursing care theoreticians. Born in Baltimore, Maryland, Orem obtained her first
nursing diploma in Washington, D.C. in the thirties. In the following period she worked as a private and hospital nurse and teacher. From 1040 to
1949 she was the director of the nursing school at Provincial Hospital in Detroit. This was followed by positions in the health departments of Indiana
and Washington, D.C. In 1959 she became an assistant professor at catholic University of America. There she developed her concept of nursing and
self-nursing. In 1970 Orem established her own consulting firm and wrote her book “Nursing: Concepts of Practice”. She retired in 1984 and has
been living in Savannah, Georgia since then. Orem divides her self-nursing deficit theory into three sub-theories: the theory of self-nursing, the
theory of self-nursing deficit and the theory of nursing systems (Orem, 1991).

Self-nursing is a form of target-oriented behavior that people learn in order to sustain their lives, health and well-being. Adults take care of
themselves; infants, children, the ill, the elderly and the disabled need limited assistance or complete support in exercising self-help (Orem, 1991)

In a case history talk the self-nursing requirements and self-nursing competence are determined, the situation-related problems of the patient are
ascertained and the appropriate self-nursing needs are defined. Supportive measures are developed based on the determination of the self-nursing
deficit. The measures are implemented while taking into account existing standards and patient-related documentation (Orem, 1991)

Finally, with respect to the actions of the nursing staff Orem makes a distinction between different nursing systems, competent and professional
handling of which is learned during training. Depending on the situative self-nursing needs, completely compensatory, partially compensatory or
education-supporting systems are applied. Self-care is a universal requirement for sustaining and enhancing life and health. Competence in self-care
determines quality of life and has an impact on longevity. Nurses assist clients to achieve competence in self-care.

42
Health education (an example of a self-care service) informs, motivates and helps people adopt healthful life styles. Self-care: “activities initiated or
performed by an individual, family, or community to achieve, maintain or promote maximum health” (Steiger & Lipson, 1985. Self-care Nursing:
(Theory and Practice.) Self-care is ongoing and a competence which is in continual development (Taylor, (2006).

Nursing Implication

In the theory Self-Care Deficit, it deliberately states that adults deliberately learn and perform actions to direct their survival, quality of life,

and well-being. Self-Care Deficit theory states that nursing is required because of the inability to perform self-care as the result of limitations. In the

case of our patient after the operation, our client was unable to do things by his own.

She is dependent to his significant other and to the nurses. The activity of daily living is altered and cannot render an independent self-care.

She has limitations involving usual activities since he still feels malaise due to his condition and post-operation. So our nursing goal was to assist him

in retaining his strength and helping him attain independence to promote total self-care.

43
E. GORDON’S FUNCTIONAL HEALTH PATTERN

USUAL PATTERN INITIAL PATTERN

I. HEALTH PERCEPCION / MANAGEMENT

- Health during the past few years was good but patient is hypertensive - General health at thid time is poor.
followed by maintenance of medication. - Patient is experiencing dyspnea.
- Admitted last month due to dizziness and vomiting. - Vital Signs: Undefined
- Had experienced cough and colds in the past year - Patient is in O2 (nasal cannula)
- Had good appetite - Cold clammy skin when touch
- Takes OTC drugs when having fever or slight illness - Gasping Air upon assessment.
- Presence of crackles in both lungs upon auscultation
- Gasping air
- Cold clammy skin
- Coughing
- Cyanosis
- Laboratory Exams Result
Hemoglobin
18.0 (H)
Hematocrit 51.9 (H)
RBC 6.04 (H)

44
 WBC Count
24.0 (H)
Neutrophil Seg 91 (H)
Lymphocyte 4 (L)
II. NUTRITIONAL METABOLIC PATTERN

- Patient appetite was good for the past 3months. - NPO

- Patients eats 3 meals a day.
- Usual daily intake: 1 or ½ cup of rice, 1 cup porridge, vegetables, fish,
meat.
- Patient drinks water 7 or 8 glasses a day.
- Sometimes 1 cup of coffee a day
- No problem in swallowing

III. ELIMINATION PATTERN

Urine - Patient with foley-bag catheter
- Light yellow in color; pungent odor
- Urinates a maximum of 5 or 6 times a day
Bowel
- Defecates at least once a day
- Stool is light brown in color
Skin
- Slight perspiration
- No unusual odor
IV. ACTIVITY – EXERCISE PATTERN

- Walking and doing household chores like sweeping and washing are
considered to be her morning exercises before she goes to work
- Patient is admitted due to dyspnea

45
- Energy is sufficient enough for doing her daily activities at home - Bed rest
- Patient usually experience dizziness when blood pressure rises.

V. SLEEP – REST PATTERN

Onset: 8pm
Awakening:4am or 5am usually
Experiences nightmares; causing sleep interruptions - Patient haven’t slept well due to her condition.
Hours of sleep:
- No use of sleeping aids
- No sleeping problems
- Feels rested after sleep

VI. COGNITIVE PERCEPTUAL PATTERN

Highest educational attainment:

- Elementary Graduate
- No hearing problem or hearing aids used
- Can retain information
- No memory changes - Patient can’t talk clearly due to her condition
- Her easiest way to learn and understand things is through listening as
stated by SO

VII. SELF – PERCEPTION / SELF – CONCEPT PATTERN

- Described by SO as a strict yet generous mother

- Described by SO as religious
- Feels good about herself
- She is worried every time she finds out about having an illness as

46
stated by SO
- ‘Ganahan ming ma okay pa si mama, basun og maayo pani siya. Karun
rajud ni siya nag in ani mam’ as verbalized by the SO.

VIII. ROLE RELATIONSHIP PATTERN

- She lives with her family

- Decision making is done by the couple
- Has no difficulties in relating with her family
- Has close friends in their barangay
- Experienced having little misunderstanding and conflicts but was solved
easily

- Almost all of the family member is their beside the patient during the
ER.
IX. SEXUALITY REPRODUCTIVE PATTERN

- Menarche
- 13 years old

X. COPING STRESS TOLERANCE PATTERN

- SO stated that her way of coping is very helpful and is usually

successful and will help her relieve her stress
- SO stated that in handling problems, she prays and seeks advices and - Menarche
comfort from her children - 13 years old

XI. VALUE BELIEF PATTERN

47
- Patient goes to church seldom along with her family - Family members still hoping for the recovery for the patient.
- Prays every day before and after bed time
- Religion: Roman Catholic
- SO stated that in facing problems in life, her only solution to it is to
pray and have faith in the Lord

- Family members are praying and hoping for the patient.

F. SUMMARY OF NURSING DIAGNOSES

Priority Nursing Diagnosis

1. Ineffective airway clearance related to thick sputum secondary to pneumonia

48
2. Impaired gas exchange related to bronchospasm

3. Ineffective Breathing Pattern related to an inflammatory process secondary to ARI with pneumonia

Other Applicable Nursing Diagnosis

4. Self-care Deficit

5. Anxiety related to hospitalization

G. NURSING CARE PLAN

Cues Nursing Diagnosis Objectives Intervention Rationale Evaluation

49
Subjective: Ineffective airway After 5 hours nursing 1. Monitor V/S Serve as a baseline
“Galisod siyag clearance related to intervention patient data.
ginhawa” as verbalized thick sputum must be able to: 2. Auscultation of
by the SO secondary to Lung Sound Note adventitious
“Gi pulmonya man gud pneumonia - absence of rales breath sounds
siya nya wala namo - expectorate clear 3. Change position
kapaliti og tambal’ as secretions q2H Facilitate drainage
verbalized by the SO - minimize cough .
- stable V/S 4. Keep environment Prevent any triggering
free from allergens. factor for cough.

5. Increased fluid to at To liquefy secretions

least 2000ml/day.

Objective: 6. Perform postural Enhance drainage to

Gasping air drainage and different segment of
Cold clammy skin percussion the lungs.
Coughing
7. Promote chest
7. Elevate head of bed expansion

Facilitate liquefaction
8. Assist with and removal of
nebulization treatment secretions

Cues Nursing Diagnosis Objectives Intervention Rationale Evaluation

50
Subjective: Ineffective airway After 5 hours nursing 1. Monitor V/S Serve as a baseline
“Galisod siyag clearance related to intervention patient data.
ginhawa” as verbalized thick sputum must be able to: 2. Auscultation of
by the SO secondary to ARI with Lung Sound Note adventitious
“Gi pulmonya man gud pneumonia - Absence of rales breath sounds
siya nya wala namo - Expectorate clear 3. Change position
kapaliti og tambal’ as secretions q2H Facilitate drainage
verbalized by the SO - Minimize cough .
- Stable V/S 4. Keep environment Prevent any triggering
free from allergens. factor for cough.

5. Increased fluid to at To liquefy secretions

least 2000ml/day.
Objective:
Gasping air 6. Perform postural Enhance drainage to
Cold clammy skin drainage and different segment of
Coughing percussion the lungs.
Cyanosis
7. Promote chest
7. Elevate head of bed expansion

Facilitate liquefaction
8. Assist with and removal of
nebulization treatment secretions

51
 Cues Nursing Diagnosis Objectives Intervention Rationale Evaluation
Subjective: Impaired gas After 5 hours nursing 1. Monitor cardiac To note any changes
“Kutas kaayo siya unya exchange related to intervention patient rhythm.
maglisod siya bronchospasm must be able to:
ginahawa” as 2. Encourage frequent To promote optimal
verbalized by the SO - Absence of dyspnea position changes chest expansion
“Gi pulmonya man gud - Absence of irritability breathing exercises.
siya nya wala namo
kapaliti og tambal’ as 3. Monitor adequate This will liquefy
verbalized by the SO fluid intake secretions

4. Encourage adequate Helps limit oxygen

rest consumptions.

5. Elevate head of bed Promote chest

expansion.
Objective:
Gasping air 6. Promote To decrease irritability
Cold clammy skin calm/restful
Coughing environment
Cyanosis Cyanosis in nail bed
7. Note for color of may occur
skin and mucus

8. Oxygen Therapy To maintain PsCo2

above 60mmhg
> To facilitate bronco
secretions

52
 Cues Nursing Diagnosis Objectives Intervention Rationale Evaluation
Subjective: Ineffective Breathing After 5 hours nursing 1. Assess RR, depth & - Reveals rate & type
“Kutas kaayo siya unya Pattern related to an intervention patient chest expansion, of respirations.
maglisod siya inflammatory process must be able to: noting respiratory
ginahawa” as secondary to effort.
verbalized by the SO ARI with pneumonia - Client demonstrates - Provides indication of
“Gi pulmonya man gud breath sounds 2. Assess breath patent airways and
siya nya wala namo clearing. sounds by reveals crackles &
kapaliti og tambal’ as - Client demonstrates auscultation. wheezes.
verbalized by the SO less use of accessory
“Usahay mo gahi o muscles. - Facilititates chest
humok kayo iyang - Client manifests a expansion &
ubo” as verbalized by decrease in dyspnea, 3. Elevate head of bed respiratory efficiency
the SO. cyanosis & sputum at least 30 degrees, by reducing pressure
production. check position of abdominal organs in
frequently to ensure diaphragm.
child maintains
position. Removes secretions
Objective: that would otherwise
Presence of crackles 4. Suction sputum obstruct pt’s airway
upon auscultation and/ or secretions as and impair breathing.
Gasping air needed. Teach parents
Cold clammy skin to use bulb syringe to
Coughing suction; allow return
Cyanosis demonstration. Maximizes respiratory
effort & may reduce
5. Administer work of breathing.
supplemental oxygen.

IX. ANNOTATED READINGS

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Summary:

54
 Acute exacerbations of chronic obstructive pulmonary disease describe the phenomenon of sudden worsening in airway function and
respiratory symptoms in patients with COPD. These exacerbations can range from self-limited diseases of episodes of florid respiratory failure
requiring mechanical ventilation. The average patient of COPD experiences two such episodes annually, and they account for significant consumption
of health care resources. Although bacterial infections are the most common causes of COPD, viral infections and environmental stresses are also
implied. COPD episodes can be triggered or complicated by other comorbidities, such as heart disease other lung diseases or systemic processes.
Pharmacologic management includes bronchodilators, corticosteroids, and antibiotics in most patients. Oxygen physical therapy, mucolytics, and
airway clearance devices may be useful in selected patients.
These require limiting ventilation. Although mild episodes of COPD are generally reversible, more severe forms of respiratory failure are
associated with substantial mortality and a prolonged period of disability in survivors.

Reaction:

For the reaction, COPD is the most prevalent problem that effect mostly elderly people. The mai symptom of COPD is shortness of breath,
production of cough with sputum. The main cause of occurrence of this disease is cigarette smoking. History taking and physical examination is
beneficial in excluding all the differential diagnosis. Through spirometry diagnosis of COPD can be made. Pharmacology is helpful in controlling the
further spread of disease but medication does not provide efficient result in long term care.

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Summary:

56
 NP is an uncommon but increasingly recognized severe complication of pneumonia in previously healthy young children. The major pathogens
are S. pneumoniae and S. aureus and the diagnosis should be considered when, despite appropriate antibiotics, the child remains febrile and unwell
with persistent signs of respiratory distress and pneumonia. Most will have a PPE, empyema and/or BPF that has not improved despite chest
drainage or
surgical intervention. The diagnosis is confirmed by chest imaging, usually by a CT scan or sonography, while treatment requires prolonged IV
antibiotics, which can be changed to oral medication for an additional 10–14 days, once the child is afebrile and clinically stable. Ideally, surgical
intervention is kept to a minimum, but this is not always possible if there are mass effects from gas and fluid in the pleural cavity or pulmonary
gangrene leading to massive hemoptysis, uncontrolled sepsis, or difficulties with assisted ventilation. Nevertheless, despite its severity, mortality in
children is uncommon; the children improve clinically within a couple of months, radiographic changes are largely resolved after 5–6 months, and
only a minority are left with mildly impaired lung function. Important targets for future research include identifying host–pathogen interactions
leading to disease, improving the microbiologic diagnostic gap, optimizing medical and surgical management, and ultimately preventing this severe
complication of pediatric pneumonia.

Reaction:
In this article it is important to consider that our understanding of NP is limited to individual case reports or small case series, and treatment
data from randomized-controlled trials are lacking. Furthermore, case series are retrospective and usually confined to single centers. Consequently,
these studies may not be representative of patients in other locations, especially when allowing for temporal changes in pathogen behaviour and
differences in immunization schedules and antibiotic prescribing practices.

X. CONCLUSION

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 The ER Rotation experience has given me profound meanings to the greatest challenges encountered. It gave me the opportunity to see life’s

miseries and the continuous battle each client and their respective families have to face along with the health care team to surpass varied or deals.

The exposure has been a humbling experience for able to extend the care the simplest but best way I can.

This case study has given the researchers a unique understanding of the client and her condition. The time spent in caring for the patient has

left each one with a sense of matchless experience. The nurse-patient interactions have shed new light on how individuals with this certain disease

conditions live their lives; and how I, as student nurse, have learned to be more grateful for the lives that we live and to appreciate the simple joys

that life offers each one of us.

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XI. BIBLIOGRAPHY

A. BOOKS

Black, Joyce, Hawk, Jane. (2005) Medical – Surgical Nursing: Clinical Management for Positive Outcome. 7th ed. Elsevier (Singapore) PTE LTD pp. 420, Vol. 1

Elaine N. Marieb. (2005) Essentials of Human Anatomy and Physiology 6th ed. Pearsons Education Asia pte. Ltd.

Kozier (2004) Fundamentals of Nursing: Concepts, Process and Practice. 7th ed. Pearsons Education South Asia Pte. Ltd.

Smeltzer and Bare (2004) Medical and Surgical Nursing 10th ed. Lippincott Williams and Wilkins Vol. 2

B. WEBSITE

Anon, (2017). [online] Available at: https://www.thoracic.org/patients/patient-resources/breathing-in-america/resources/chapter-20-respiratory-

failure.pdf [Accessed 31 Jul. 2017]

Anon, (2017). [online] Available at: http://www.resmedjournal.com/article/S0954-6111(03)00297-X/pdf [Accessed 2 Aug. 2017]

Anon, (2017). [online] Available at: http://www.annemergmed.com/article/S0196-0644(15)00379-0/pdf [Accessed 2 Aug. 2017]

Anon, (2017). [online] Available at: https://www.thoracic.org/professionals/clinical-resources/critical-care/clinical-education/mechanical-

ventilation/respiratory-failure-mechanical-ventilation.pdf [Accessed 2 Aug. 2017]

Budduga, (2014). [online] Available at: http://emedicine.medscape.com/article/1948510-overview [Accessed on 3 Aug. 2017]

myVMC. (2017). Respiratory failure (types I and II) | myVMC. [online] Available at: https://www.myvmc.com/diseases/respiratory-failure-types-i-and-ii/
[Accessed 2 Aug. 2017]

Zimmermann, (2016). [online] Available at: https://www.livescience.com/22486-circulatory-system.html [Accessed on 3 Aug. 2017]

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