Case study on acute respiratory failure

3.  Respiratory Failure is a broad, non specific clinical
diagnosis indicating that the respiratory system is unable
to supply the O2 necessary to maintain metabolism or
cannot eliminate sufficient CO2.
 The group has chosen the case due to the urge to learn
more and be familiar with said disease. After caring for said
patient we have chosen to present it because carries with it
a colossal amount of new learning and along with it the
experiences faced by the two members of the group who
handled the client. It is beneficial to study the case because
of the complications that arose and thus it provokes critical
thinking. This study also help us to develop our skills when
it comes to palliative care.
 This study includes the three-days we handled the patient.

4.  Respiratory failure is a syndrome in which the
respiratory system fails in one or both of its gas
exchange functions. That is oxygenation and carbon
dioxide elimination.
 In practice, respiratory failure is defined as:
-PaO2 value of less than 6o mmHg while breathing air
-PaCO2 of more than 50 mmHg

5.  Acute exacerbation of asthma
 Pulmonary embolism
 Pulmonary edema
 Acute respiratory distress syndrome
 Pneumonia
 Acute epiglottitis
 Cardiogenic pulmonary edema
 Pulmonary trauma
 Inhalation injury (with toxic fumes or gases including
chlorine, smoke, carbon monoxide, hydrogen sulfide)

6.  Upper/lower airway obstruction (e.g., foreign bodies,
retropharyngeal abscess, epiglottitis, and swelling as a
result of acute allergy or anaphylaxis)
 Pneumothorax
 Chronic lung disease (e.g., chronic obstructive
pulmonary disease, cystic fibrosis, pulmonary fibrosis,
chronic interstitial lung disease)
 Bronchiectasis
 Alveolar abnormalities (e.g., emphysema, Goodpasture
syndrome, Wegener granulomatosis)
 Chest wall abnormalities (e.g., kyphoscoliosis)
 Malignancy
 Decompensated congestive cardiac failure
 Collagen vascular disease.

7.  Respiratory failure is a syndrome of inadequate gas
exchange due to dysfunction of one or both essential
components of the respiratory system:
-Chest wall (including pleura and diaphragm)
-Airways
-Alveolar- capillary units
-Pulmonary circulation
-Nerve supply to respiratory organs
-CNS or Brain Stem

8.  Type I or Hypoxemic (PaO2 <60 mmHg): Failure of
oxygen exchange
 Type II or Hypercapnic (PaCO2 >45 mmHG): Failure to
exchange or remove carbon dioxide
 Type III Respiratory Failure: Perioperative Respiratory
Failure
 Type IV Respiratory Failure: Shock

9.  It is characterized by a PaO2 of <60 mmHg
 Most common form of respiratory failure, and it can be
associated with virtually acute diseases of the lung
which generally involve fluid filling or collapse of
alveolar units.
 Examples: Pulmonary edema, PNEUMONIA, and
pulmonary hemorrhage

11.  Major Function:
1. Pulmonary Ventilation
2. External Respiration
3. Transport of
respiratory gases
4. Internal respiration

12.  The respiratory system
is responsible for gaseous
exchange between the
circulatory system and
the outside world. It is
situated in the thorax
 Division of Respiratory
Tract
 Upper Respiratory Tract
 Lower Respiratory Tract

13.  Nose - partially filters air before entering the lungs
 Pharynx - receive the air from the external
environment and filter, warm, and humidify it before
it reaches the lungs.
 Larynx - regulates the opening into the lower
respiratory system and produces speech sounds.
 Trachea and Bronchi - maintain an open airway to
the lungs

14.  Lungs - occurs exchange of gases between alveolar
sacs and the blood in pulmonary capillaries.
 Lobes of lungs
 Left lung – 2 lobes
 Right lung – 3 lobes

15. Nose
Nasopharynx
Oropharynx
Laryngopharynx
Larynx
Trachea
Bronchi
Lungs (Alveoli)
Environment

17. Precipitating Factor:
FALL
Non-modifiable Factor:
Age: 86 years old
Prolonged immobility
And supine position
Decrease gag
And swallowing reflex
Aspiration
Fluid/foreign body
May enter the lungs
Moisture promotes
Bacterial invasion/colonization
Altered lung defense
mechanism
Decrease cough effectiveness
Impaired mucocilliary function
Impaired macrophages functionAspiration pneumonia
Impaired
Gas exchange
Increased airway
closure
Decrease
Ventilatory-perfusion
ratio
Hypoxemia
Acute
Respiratory
Failure

19.  Tachycardia
 Impaired functioning of the heart and blood vessels
 Inadequate blood circulation to the parts of the body
 Appears sleepy and confused
 Cyanosis
 Drowsiness and malfunctioning of the brain and heart
 Lethargy and shortness of breath
 Impaired mental functioning

20.  Pneumonia:
-cough
-sputum production
-chest pain

21.  ABG
 Quantifies level of gas exchange abnormality
 Identifies type and chronicity of respiratory failure
 COMPLETE BLOOD COUNT
 Anemia may cause cardiogenic pulmonary edema
 Leukocytosis, or leukopenia suggestive of infection
 MICROBIOLOGY
 Respiratory cultures: sputum/tracheal aspirate
 Blood, urine, body fluid (e.g. pleural) cultures

22.  PULMONARY FUNCTION TEST/BEDSIDE
SPIROMETRY
 Identify obstruction, restriction
 May be difficult to perform if critically ill
 BRONCHOSCOPY
 Obtain biopsies
 Bronchoscopy may not be safe in the critically ill

23.  CHEST RADIOGRAPHY
 Identify chest wall, pleural and lung parenchymal with
opacities present
 ELECTROCARDIOGRAM
 Identify arrythmias, ischemia, ventricular dysfunction
 ECHOCARDIOGRAM
 Identify right and left ventricular dysfunction

25. Test Result Normal value Interpretation
Albumin 2.4 g/dl 3.5-5.0 Hemorrhage
A/G ratio .8 1.5-2.5 Over production
of globulins in
condition like
multiple myeloma
Total protein 5.4 g/dl .6-.8 Hemoconcentratio
n
Globulin 3.0 g/dl 1.7-3.3 NV
January 24, 2013

26. ABG (January 24, 2013)
Test Result Normal value Interpretation
pH 7.31 7.35-7.45 Uremia, DKA,
hemorrhage,
nephritis
pCO2 30 35-45 Respiratory alkalosis
pO2 77 85-95 Anemia, cardiac or
pulmonary disease
HCO3 15.6 22-26

27. January 22, 2013
Test Result Normal value Interpretation
BUN 45 mg/dl 7-18 Excessive protein
catabolism
CR-S 1.3 mg/dl .42-1.09

28. January 18, 2013 (CBC)
Test Result Normal value Interpretation
WBC 17.41 4-10 Possible infection
Hemoglobin 113 120-160 Decrease in various
anemias, and with
excessive fluid
intake
Hematocrit 0.33 0.37-0.47 Severe anemias

29. Clinical history : Fall
Impressions: chronic ischemic changes in the bilateral
periventricular frontal white matter regions likely due
to microvascular atherosclerosis as related diffuse
cerebral atrophic changes. No evidence of skull
fracture, intracerebral or extra axial hemorrhage.

30.  January 7, 2013 (X-ray)
Impression:
>pneumonia Right lung base
>atheromatous aorta
>Degenerative osseous changes of thoracic spine

31.  Mechanical Ventilator
 Emergency treatment follows the principles of
cardiopulmonary resuscitation
 Endotracheal intubation may be required
 Respiratory stimulants such as doxapram may be used
 Bronchodilators
 Positive airway pressure, diuretics, vasodilators
 O2 therapy

32.  Cardiac or respiratory arrest
 Tachypnea or bradypnea with respiratory fatigue
 Acute respiratory acidosis
 Hypoxemia (when PaO2 could not be maintained
above 60 mmHG)
 Inability to clear secretions with impaired gas
exchange or excessive respiratory work

34. Brand
name
Generic
name
Classific
ation
Indicati
on
Contrai
ndicatio
n
Adverse
reaction
Packagi
ng
Nsg.
Respons
ibilities
Combive
nt
Salbutam
ol
Anti-
asthmati
c and
COPD
prep
Manage
ment of
reversible
bronchos
pasm
assoc
with
obstructi
ve airway
dse.
Hypertro
phic
obstructi
ve
cardiomy
opathy,
tachyarry
thmia, hx.
Of
hypersen
sitivity to
soya
Fine
tremor of
skeletal
muscle,
palpitatio
ns,
headache,
dizziness,
dryness
of mouth
Vial:
2.5ml
q6 hrs
>Monitor
VS esp.
RR
>Check
the
pattern
and
rhythm
>Don’t
leave
patient
alone
Omepro
n
omepraz
ole
Antacid,
anti-
reflux
agent
and anti-
ulcerant
Gastric
ulcers,
GERD,
symptom
atic
GERD
w/o
esophage
al lesions
Constipa
tion,
flatulenc
e, nausea,
vomiting,
acid
regurgita
tion,
abdomin
Vial : 40
mg
40 mg IV
OD
>Given
with
meals
>watch
for the
side
effects

35. Brand
name
Generic
name
Classific
ation
Indicati
on
Contrai
ndicatio
n
Adverse
reaction
Packagi
ng
Nsg.
Respons
ibilities
Fluimucil Acetylcys
teine
Cough
and cold
prep
Acute
and
chronic
respirato
ry tract
infection
s with
abundant
mucus
secretion
s
Phenylke
tonurius
Rarely
urticaria,
bronchos
pasm,
nausea,
vomiting
Tab
600mg
600 mg 1
tab in 30
cc water
BID
>Monitor
respirato
ry rate,
pattern
and
rhythm,
>Assess if
patient is
positive
in cough
and cold
Aeknil Paraceta
mol
Analgesic Pyrexia
of
unknown
origin,
fever and
pain
associate
d with
common
URTI
Anemia,
cardiac
and
hepatic
disease
Hematol
ogical,
skin and
other
allergic
reaction
Amp:
150mg/m
l
1 amp q4
hours
prn for
fever
>monitor
temperat
ure of the
patient
from
time to
time
>check
for
chilling

36. Brand
name
Generic
name
Classific
ation
Indicati
on
Contrai
ndicatio
n
Adverse
reaction
Packagi
ng
Nsg.
Respons
iblilities
Solucorte
f
Hydrocor
tisone Na
succinate
Corticost
eroid
hormone
Endocrin
e,
hematolo
gic,
rheumati
c and
collagen
disorder
Systemic
fungal
infection,
lactation
Fluid and
electrolyt
e
disturban
ce,
impaired
wound
healing,
thin
fragile
skin,
muscle
weakness
Vial:
100mg x
2ml
100mg IV
q6 hours
>Monitor
BP
>monitor
electrolyt
e levels
>check
patient’s
skin if
there’s
wound

37. Brand
name
Generic
name
Classific
ation
Indicati
on
Contrai
ndicatio
n
Adverse
reaction
Packagi
ng
Nsg.
Respons
ibilities
Choliner
v
Citicoline
Na
Anti-
convulsa
nt
Cerebrov
ascular
d/o
including
ischemic
stroke,
parkinso
nism and
head
injury
Parasym
pathetic
hyperton
ia
Stomach
pain,
diarrhea,
hypotens
ion,
tachycard
ia
Tab: 500
mg
>Check
the VS
>watch
for
adverse
reaction
Heraclen
e
Dibencoz
ide
Appetite
enhancer
Convales
cence
from
acute
infection,
faulty
nutrition
in older
people
Hypersen
sitivity to
drug,
children
<12 y/o
Rarely
dizziness,
dry
mouth,
nausea,
constipat
ion
Cap:
1 mg
1 cap OD
>monitor
appetite
of
patient

38. Brand
name
Generic
name
Classific
ation
Indicatii
on
Contrai
ndicatio
n
Adverse
reaction
Packagi
ng
Nsg.
Resposi
bilities
Dalacin C Clindamy
cin
Antibioti
c
Infection
s caused
by
susceptib
le
anaerobi
c or gram
+
bacteria:
upper
and
lower
respirato
ry tract
Hypersen
sitivity to
clindamy
cin or
lincomyci
n
Diarrhea
occasion
ally with
acute
colitis,
abdomin
al pain,
GI upsets,
skin
reactions
Cap:
150mg
300 mg
300 mg 1
cap TID
>check
for
hypersen
sitivity to
drug
>ask for
history of
GI
disease
Asomex Amlodipi
ne
Calcium
antagonis
t
For pt. at
increased
CV risk
due to
the
presence
of HTN
Active
liver dse,
Flushing,
fatigue,
edema,
dizziness
headache,
abdomin
al pain
Tab 5mg
5mg 1 tab
OD
>monitor
VS esp.
BP and
HR
>watch
out for
known

39. Brand
name
Generic
name
Classific
ation
Indicati
on
Contrai
ndicatio
n
Adverse
reaction
Packagi
ng
Nsg.
Respons
ibilities
Tergecef Cefixime Antibioti
c
Acute
bronchiti
s,
bronchio
ectasis
with
infection,
pneumon
ia
Hypersen
sitivity to
cephalos
phorins,
penicillin
s
Hypersen
sitivity
reactions,
GI effects,
CNS
effects,
hematolo
gic d/o
Cap:
100mg
200mg
1 cap
200mg
>WOF
Hypersen
sitivity
reaction
>monitor
results of
blood
test esp.
Hgb level
Tazocin Piperacill
in Na
Tazobact
am
Penicillin Tx. Of
infection
LRT
Hypersen
sitivity to
penicillin,
cephalos
phorin
N/V, rash,
leukopen
ia,
neutrope
nia,
thrombo
cytopeni
a,
pruritus
and
hypotens
ion
Vial: 4.5
gm
2.25gm
4.5 gm IV
q8 hours
>monitor
VS esp.
temp
>review
result of
CBC esp.
WBC
level

41.  Patient’s Name: Patient JBP
 Address: Brgy. Bayanihan, Dolores Quezon
 Age: 86 years old
 Gender: Female
 Civil status: Single
 Date of Admission: Jan. 7, 2013
 Date of Discharge: Jan. 28, 2013
 Admitting impression: T/C CVA infarct
 Final Diagnosis: Cardiopulmonary Arrest secondary to
ACUTE RESPIRATORY FAILURE secondary to Pneumonia,
high risk and severe malnutrition
 Initial Vital Signs: BP: 90/60; CR: 106 bpm; RR: 22 bpm; T:
38.6
 Physical Assessment: Patient is conscious but appears to be
weak, immobile and with loss of appetite.

42.  Chief Complaint: Fall
 History of Present Illness: the patient is in the
bathroom when she slipped and fell.
 Past Medical History:
 Childhood illness: occasional fever and cold
 Adult illness: none
 Immunization: incomplete. The relative couldn’t
remember which vaccine but she knew the patient
hadn’t had all the vaccines.
 Allergies: no known allergy

44.  Health perception Pattern
 According to her caregiver when it comes to health the
client isn’t very much concerned. She said that due to
her old age the client rarely verbalizes concerns other
than physical symptoms such as occasional backache.
 Nutrition/Metabolic Pattern
 The client’s meal on daily basis consist of rice, vegetables
and soup because she had difficulty in mastication. A
few months prior to confinement the pt. was only able to
eat three spoons every meal.
 Elimination Pattern
 Had regular bowel movement (at least once a day) and
urinated at least four times per day.

45.  Activity/Exercise Pattern
 The patient doesn’t usually exercise. She sometimes
roam around the yard or sit and watch the TV.
 Self-Perception Pattern
 (Could not be assessed because the patient cannot speak
due to ET tube during interview)
 Sleep/Rest Pattern
 According to her caregiver the client only gets to sleep at
least 3-4 hours.
 Cognitive/Perceptual Pattern
 The client tends to be forgetful due to her age said the
relative. She had diminished sense of hearing and
vision.

46.  Role/Relationship
 The patient is a spinster but she lives with her sister and
her sister’s family. Her brother-in-law, nephews and
nieces are the ones taking care of her.
 Coping/Stress
 When under stressed the client only rest and talks to her
sister about her problem, said her niece.
 Values/Belief
 She’s a catholic and used to go to church every Sunday
for Mass. Doesn’t consult any faith healers or albularyo.

47.  Vices: doesn’t drink/ smoke
 Travel: She was from Visayas and came to Quezon to
live with her sister
 Occupation: no job; stays at home
 Social Affiliation: none

50.  Received patient on bed awake, hooked to a
mechanical ventilator and pulse oxymeter.
 Vital signs: BP: 120/70; PR: 104; RR: 20; T: 36; O2 sat:
100%
 With IVF: PNSS IL x 24

51.  General status: Conscious but weak in appearance
 Skin: with dry, scaly and sagging skin; poor skin
turgor; no wound or irritation noted
 Hair: evenly distributed but thinning gray-white hair,
dry
 Head: normocephalic, no lesions noted.
 Eyes: opens spontaneously, white and clear sclera, pale
conjunctiva, (+) PERRLA, no discharge seen

52.  Ears: no discharges noted, symmetrical, with a few
cerumen seen
 Nose: with NGT on
 Mouth and Pharynx: with ET tube on; dry lips, with
greenish-yellowish dried secretions on tongue
 Neck: with palpable lymph nodes
 Thorax and Lungs: symmetrical lung expansion, with
crackles on both lung fields upon auscultation, RR: 20;
no tenderness noted upon palpation. With blood
tinged yellowish secretions

53.  Cardiovascular: BP: 120/70, PR: 104 bpm; no murmurs
heard
 Abdomen: flat, with bourborygmi sound heard, no
tenderness noted, with patent NGT upon auscultation
 Genitals/Rectum and Anus: patent, urinary meatus
slightly lower than normal; with foley catheter

54.  Nutrition/Metabolic: receives food via NGT: 210 cc +
30 cc with medication + 30 cc of water with fluimucil +
30 cc (flushing) given twice in 6-2 shift = 560 cc
 Elimination: Defecated @ 12:00nn (brown soft
consistency of stool) Foley catheter inserted; Urine
output for Jan. 23: 300 cc
 Activity/Exercise: confined to bed; turned every 2
hours

55.  Sleep/rest: 3-4 hours of sleep at night; in the morning
gets a few minutes of sleep (at least 15-30 minutes),
easily awaken
 Cognitive/Perceptual: GCS= 10 (eye opening: 4; motor
response: 5 verbal response:1) Nods when asked
question
 Role/Relationship: her niece is the one constantly
present in the room with her
 Coping/Stress: ET tube puts a stress on her and she
tries to remove it that’s why safety straps were tied on
her fingers

56. Day 1

57. Assessment Diagnosis Planning Interventio
n
Rationale Evaluation
Objective;
>With ET
tube
>with blood
tinged
yellowish
secretions
>Hooked to
MV
>RR: 20
>PR: 104
>Decrease
PO2
>Increase
PCO2
>With
crackles on
both lung
fields
Impaired
spontaneous
ventilation
related to
hypermetabo
lic state
After a series
of nursing
intervention
the patient’s
respiratory
pattern will
be
reestablished
and
maintained
via respirator
with absence
of signs of
hypoxia such
as normal
level of
oxygen
saturation
and no
cyanosis
Assess
patient:
>spontaneou
s respiratory
pattern,
noting rate,
depth,
rhythm,
symmetry of
chest
movement,
use of
accessory
muscles
>Auscultate
breath
sounds
noting for
adventitious
breath
sounds
To measure
work of
breathing
To determine
presence and
degree of
hypoxemia and
hypercapnia
resulting in
impaired
ventilation
Goal met
Patient
didn’t
exhibit
signs of
hypoxia and
respiratory
rate
maintained
in normal
levels RR:
20
O2 sat:
100%

58. Assessment Diagnosis Planning Intervention Rationale Evaluati
on
Objective;
>With ET
tube
>with blood
tinged
yellowish
secretions
>Hooked to
MV
>RR: 20
>PR: 104
>Decrease
PO2
>Increase
PCO2
>With
crackles on
both lung
fields
Impaired
spontaneous
ventilation
related to
hypermetabo
lic state
After a series
of nursing
intervention
the patient’s
respiratory
patter will be
reestablished
and
maintained
via respirator
with absence
of signs of
hypoxia such
as normal
level of
oxygen
saturation
and no
cyanosis
>Review results
of ABG
Other
diagnostic and
laboratory tests
>Assist with
implementation
of ventilatory
support, as
indicated
>Observe
overall
breathing
pattern
>Count client’s
RR for 1 full
minute
>to assess
presence and
degree of
respiratory
insufficiency
>to support
compromised
ventilation
>For baseline
data

59. Assessment Diagno
sis
Planning Intervention Rationale Evaluatio
n
Objective;
>With ET
tube
>with blood
tinged
yellowish
secretions
>Hooked to
MV
>RR: 20
>PR: 104
>Decrease
PO2
>Increase
PCO2
>With
crackles on
both lung
fields
Impaire
d
spontan
eous
ventilati
on
related
to
hyperme
tabolic
state
After a series
of nursing
intervention
the patient’s
respiratory
patter will
be
reestablishe
d and
maintained
via
respirator
with
absence of
signs of
hypoxia
such as
normal level
of oxygen
saturation
and no
cyanosis
>Check tubings for
obstruction, drain
tubings as
indicated and avoid
draining towards
client or back into
the reservoir
>Check ventilator
alarms for proper
functioning
>Assess ventilator
setting routinely
>Note inspired
humidity and
temperature;
maintain hydration
>suction as needed
>To prevent
contamination
and bacterial
growth
To liquify
secretions
facilitating
removal
To clear
secretion and
maintain
airway

60. Assessment Diagnosis Planning Interventio
n
Rationale Evaluation
Objective;
>With ET
tube
>with blood
tinged
yellowish
secretions
>Hooked to
MV
>RR: 20
>PR: 104
>Decrease
PO2
>Increase
PCO2
>With
crackles on
both lung
fields
Impaired
spontaneous
ventilation
related to
hypermetabo
lic state
After a series
of nursing
intervention
the patient’s
respiratory
pattern will
be
reestablished
and
maintained
via respirator
with absence
of signs of
hypoxia such
as normal
level of
oxygen
saturation
and no
cyanosis
>Monitor
vital signs
and record it
>Place in
high-fowler’s
position
>Monitor IV
fluids and
regulate
accordingly
>Give NGT
feeding
>Change
soiled linens
and turn
client every 2
hours
>Administer
medications
as ordered
>For baseline
data and
assessment
>For
maximal
lung
expansion
>To prevent
fluid
overload
>To meet
nutritional
needs
>To promote
comfort to
the client
and protect
skin integrity
Goal met
Patient didn’t
exhibit signs
of hypoxia
and
respiratory
rate
maintained
in normal
levels RR: 20
O2 sat: 100%

62.  General status: Conscious but weak in appearance
 Skin: with dry, scaly and sagging skin; poor skin
turgor; no wound or irritation noted
 Hair: evenly distributed but thinning gray-white hair,
dry
 Head: normocephalic, no lesions noted.
 Eyes: opens spontaneously, white and clear sclera, pale
conjunctiva, (+) PERRLA, no discharge seen

63.  Ears: no discharges noted, symmetrical, with a few
cerumen seen
 Nose: with NGT on
 Mouth and Pharynx: with ET tube on; dry lips, with
greenish-yellowish dried secretions on tongue
 Neck: with palpable lymph nodes
 Thorax and Lungs: symmetrical lung expansion, with
crackles on both lung fields upon auscultation, RR: 22;
no tenderness noted upon palpation

64.  Cardiovascular: BP: 120/80, PR: 95 bpm; no murmurs
heard
 Abdomen: flat, with bourborygmi sound heard, no
tenderness noted, with patent NGT upon auscultation
 Genitals/Rectum and Anus: patent, urinary meatus
slightly lower than normal; with foley catheter

65.  Nutrition/Metabolic: receives food via NGT: 210cc + 30
cc with medication + 30 cc of water with fluimucil + 30
cc (flushing) given twice in 6-2 shift = 560 cc
 Elimination: Defecated once during 6-2 shift; urine
output the whole day: 610cc
 Activity/Exercise: confined to bed; turned every 2
hours

66.  Sleep/rest: 3-4 hours of sleep at night; in the morning
gets a few minutes of sleep (at least 15-30 minutes),
easily awaken
 Cognitive/Perceptual: GCS= 10 (eye opening: 4; motor
response: 5 verbal response:1)
 Role/Relationship: both nephew and niece were
present in the room
 Coping/Stress: ET tube puts a stress on her and she
tries to remove it that’s why safety straps were tied on
her fingers

67. Day 2

68. Assessment Diagnosi
s
Planning Intervention Rationale Evaluation
Objective:
>Physical
immobilizatio
n
>Poor skin
turgor
>Dry, scaly
and saggy
Risk for
impaired
skin
integrity
related to
immobilit
y
After a
series of
nursing
interventio
n the
patient’s
skin
integrity
will be
maintained
and free
from skin
tear
>Assess skin
routinely, note:
moisture, color
and elasticity
>Handle patient
gently
>Inspect skin
surfaces and
pressure points
routinely
>Observe for
reddened or
blanched areas
or skin rashes
and institute tx
immediately
>To identify
particular
vulnerability
>To prevent
injury such
as bruising or
skin tear on
client
>To prevent
development
of pressure
sores
Goal Met
Patient didn’t
acquire any
skin tear and
skin integrity
was
maintained

69. Assessment Diagnosi
s
Planning Intervention Rationale Evaluation
Objective:
>Physical
immobilizatio
n
>Poor skin
turgor
>Dry, scaly
and saggy
Risk for
impaired
skin
integrity
related to
immobilit
y
After a
series of
nursing
interventio
n the
patient’s
skin
integrity
will be
maintained
and free
from skin
tear
>Maintain
meticulous skin
hygiene,
lubricate skin
with lotion or
emollient
(moisturizer) as
indicated
>Change
position in bed
on a regular
schedule
>Massage bony
prominences and
use proper
positioning,
turning and
lifting
techniques when
moving client
>Keep
bedclothes dry
>To maintain
skin integrity
and keep
skin moist
>To prevent
bed sores
>To provide
protection to

71.  General status: Lethargic
 Skin: with dry, scaly and sagging skin; poor skin
turgor; no wound or irritation noted
 Hair: evenly distributed but thinning gray-white hair,
dry
 Head: normocephalic, no lesions noted.
 Eyes: white and clear sclera, pale conjunctiva, no
discharge seen

72.  Ears: no discharges noted, symmetrical, with a few
cerumen seen
 Nose: with NGT on
 Mouth and Pharynx: with ET tube on; dry lips, with
greenish-yellowish dried secretions on tongue
 Neck: with palpable lymph nodes
 Thorax and Lungs: symmetrical lung expansion, with
crackles on both lung fields upon auscultation, RR: 21;
no tenderness noted upon palpation

73.  Cardiovascular: BP: , PR: bpm; no murmurs heard
 Abdomen: flat, with bourborygmi sound heard, no
tenderness noted
 Genitals/Rectum and Anus: patent, urinary meatus
slightly lower than normal; with foley catheter

74.  Nutrition/Metabolic: receives food via NGT. With
intake of 510 total feeding with meds.
 Elimination: With no bowel movement within 6-2
shift. With 400 cc urine output.
 Activity/Exercise: confined to bed; turned every 2
hours

75.  Sleep/rest: 3-4 hours of sleep at night; in the morning gets
a few minutes of sleep (at least 15-30 minutes), easily
awaken
 Cognitive/Perceptual: GCS=8 (Eye opening to verbal
response=3, Motor Response=4, Verbal Response=1)
 Role/Relationship: both nephew and niece were present in
the room. They reports of feeling of tired, frustrated, has
family conflict, looks impatient and has insufficient
finances.
 Coping/Stress: ET tube puts a stress on her and she tries to
remove it that’s why safety straps were tied on her fingers

76. Day 3

77. ASSESSMENT DIAGNOSI
S
PLANNING INTERVENT
IONS
RATIONALE EVALUATIO
N
SUBJECTIVE:
“Wala na po
talaga kmi
pagkukunan,”
as verbalized
by the
caregiver
OBJECTIVE:
>Caregiver
status:
-fatigue
-frustration
-family
conflict
-looks
impatient
Caregiver
Role
Restrain r/t
insufficient
finances
After series
of nursing
interventions
the client
along with
her caregiver
will identify
resources
within self to
deal with the
situation.
>Nurse
patient
interaction
>Facilitate
family
conference,
as
appropriate
>Provide
appropriate
references
and
encourage
discussion of
information
>Never leave
and stay with
the client
and the
relatives
>to gain trust
and rapport
>To share
information
and develop
plan for
involvement
in care
activities
>To enhance
spiritual
aspects
>To provide
emotional
support
After series
of nursing
interventions,
goal met, the
client along
with the
caregiver will
identify
resources
within self to
deal with the
situation.

78. ASSESSMENT DIAGNOSI
S
PLANNING INTERVENT
IONS
RATIONALE EVALUATIO
N
>Encourage
verbalization
of feelings
>Provide the
pros and
cons for
possible
extubating
the patient
>provide the
caregiver
time to
decide and
sit silently
with the
client
>Inform AP
of decision
>To
acknowledge
concerns and
problems
faced by the
caregiver
>To present
reality and
show options
available
>To provide
some form of
support