For the purpose of privacy and confidentiality, the real name of the patient in this Case Study is withheld and she will referred as “Mommy Dionisia” throughout the entire document. Mommy Dionisia is a 45 year old female and currently residing in Brgy Estrada, Capaz, Tarlac with her husband and her four children. She was admitted at the Intensive Care Unit of Central Luzon Doctors’ hospital on July 27,2010 with a chief complaint of difficulty of breathing. She was then diagnosed having an acute respiratory failure secondary to asthma. Asthma is a chronic inflammatory disease of the airways that causes airway hyperresponsiveness, mucosal edema and mucous production. This inflammation ultimately leads to recurrent episodes of asthma symptoms such as cough, chest tightness, wheezing and dyspnea. A patient with asthma may develop an exacerbation or infection that causes additional deterioration of gas exchange which can lead to acute respiratory failure. Acute respiratory failure(ARF) is defined as a decreased in atrial oxygen tension(PaO2) to less than 50 mmHg (hypoxemia) and increase atrial carbon dioxide tension(PaCO2) to greater than 50 mmHg(hypercapnia), with an atrial Ph of less than 7.35. A patient with acute respiratory failure may manifest shortness of breath, shortness of breath on exertion, syncope, dyspnoea, chest pain, tachycardia, tachypnoea, fatigue and weight loss.
II. OBJECTIVES At the end of the exposure, the student nurse will be able to: 1 2 3 1. Establish rapport and gain trust and cooperation of the patient and the immediate 2. Perform necessary & thorough physical assessment using the cephalocaudal approach; family members. collect complete medical, socio-cultural, and family history related to the client’s current health condition. 1 2 3. Analyze and prioritize problems based from the gathered pertinent data to formulate 4. Plan the appropriate nursing interventions to address client’s health problems & needs. correct nursing diagnoses The interventions should provide not only the well being of the patient but also with her social, emotional and mental welfare. 3 1 2 5. Implement the planned nursing interventions to meet the desired outcomes and help 6. Impart useful health teachings to the client and immediate family members to prevent 7. Acquire knowledge and responsibilities regarding Acute Respiratory failure and the improve client’s condition further development or recurrence of the client’s condition and other related complications possible complication that may occur or manifest in the patient.
By that time she can still do her activities of daily living.II. Nursing Health History A
A. C. Chief Complaint Mommy Dionisia sought consultation to the hospital due to difficulty of breathing.
A. History of Present Illness Three days prior to admission Mommy Dionisia is experiencing difficulty of breathing which is rapidly relieved when she nebulized at their home. Paediatric illness Mumps ______ Pertusis________ HPN _______
Religion: Iglesia ni Cristo
. Few hours before the admission she again experienced difficulty of breathing after riding a bicycle.2010 Care Unit (ICU) Age: 45 Sex: Female C/S: Married Examiner: Dra. Demographic data Patient Name: Mrs. Tuquero B. D.. Dionisia Date admission: Ward: Intensive Room no: 8 July 27. She tried to nebulize but still the difficulty that she is experiencing is aggravating. Past Medical History (prior to admission and onset of illness) a. That was then her husband decided to bring her to the hospital to seek for medical management.
she doesn’t experienced dysmenorrhea. She’s practicing natural method of family planning (withdrawal).Measles
Heart Disease _______ Hepatitis Others _______ ______
Chicken Pox ___√___Pneumonia______ Rubella ______ Tuberculosis_____
b. Obstetrics Mommy Dionisia had her first menstruation (menarche) when she was 13years old. According to her. d. f. She has a regular monthly period that lasts for 3-5 days. e. Immunization/Tests BCG DPT FLU _____ _____ _____ Hepa B Measles ____ _____ Pneumonia _____ OPV Tetanus toxoid _____
c. Hospitalization According to the patient she has no previous hospitalization. Gravida: 3 TPALM: Gravida= 4 Term = 4 Para = 4 Abortion = 0 Live birth = 4 Multiple = 0 g. Transfusions Mommy Dionisia has not yet undergone any blood transfusions. Medication
. Injuries Mommy Dionisia had no injuries.
b. Residence Mommy Dionisia and her family currently reside in Brgy. Family History Age 80 76 50 45 43 38 Family Member Father Mother Sister Mommy Dionisia Sister Brother Health Status Unhealthy Unhealthy Healthy Unhealthy Healthy Unhealthy Living or deceased Deceased Deceased Living Living Living Living Diseases Present in the Family Heart Disease Hypertenson None A. kapampangan. Pangasinan Educational Attainment: High School Ethnic Background: Ilocano (undergraduate) Position in the Family: mother Language: Ilocano. Estrada. Capaz. She and her family have been living in Capaz for 21 years. None None
E.F. Their house is constructed with sawali and wood and stands at the middle rice fields.
D. tagalog a.
h. they do have ceiling and adequate light source. the space is adequate enough for them.R. According to her. Sawali is more dominant.Before seeking help from health care professionals she nebulized first with a medicine suggested by her neighbour (Pulmo Inhalants). Social and Personal History Date of Birth: November 14. Occupation
. Allergies She had reported not having any allergies to either food groups or drugs.1965 Birthplace: Rosales. Tarlac.
Usually she sleeps at around 7-8 in the evening. Habits Mommy Dionisia spends her time doing household chores and attending the needs of her animals by cleaning their pen and feeding them. She spends her free time by watching television. Financial Mommy Dionisia’s family supports their daily needs through their savings from selling animals and rice. But when she was still single she worked in a factory of coffee in manila.
F. g. c. Infact her favorite is Pinakbet and bangus. Brief Description of Average Day Mommy Dionisia usually wakes up as early as 4 in the morning. Physical Activity/Exercise Household chores and cleaning the pig pen daily were usually her form of exercise. d. Review of Systems
Put check on significant (abnormal) findings
Weight loss √Weakness
Weight gain Night sweats
. Diet She eats three meals a day. She then starts doing household chores and cleaning the pigpen. She also find time to chat with her neighbours and watch television at the afternoon. e.Mommy Dionisia is raising animals such as pigs and chickens for four years now. She prefer to eat vegetables and fish and occasionally she eats meat and meat products. f.
Itch Excessive Tearing
Vision Loss Eye Glasses
Blurring Contact Lenses
Notes: The above deviations from normal were not present in the patient.Notes :Shows weakness and fatigue.
Notes: The above deviations from normal were not present in the patient.
Itch Lesions BurnsDrainage
Bruising Blisters Scars
Notes: Upon performing inspection. no skin abnormality found.
Throat & Mouth
Notes: The above deviations from normal were not present in the patient.
√Chest pain PND
√Dyspnea on Exertion Others: ___________
Notes: She declared difficulty when breathing and it was also observed by the presence of nasal flaring .
√Cough √Dysnea Breast:
√Pain on respiration
Sputum:___________________ Lumps Pain Bleeding Discharge
Notes: Laboured breathing was observed.She also complain chest pain at the right side with a pain scale of 5/10.Obstruction
Notes: The above deviations from normal were not present in the patient. GIT
Dysuria Dribbling Menarche: 13y/o
Nocturia Hematuria LMP: July 5.2010.2010
Retention Flank Pain Cycles: 3-5 days
Notes: The patient had her menarche when she was 13 years old with regular 3-5-day cyclemenstruation and her last menstrual period happened last July 5.Food Intolerance Vomiting Constipation
Heartburn Pain: Change in BM
Nausea Bloating Melena
Jaundice Excessive Gas
Notes: The above deviations from normal were not present in the patient.
Joint Pains Stiffness
Varicose Veins Deformities: none
Notes: There is a grade 1 edema at both legs.
dusting their house. washing dishes. Sleep-Rest Pattern VI. Sexuality-Reproductive Pattern
Before Hospitalization According to Mommy Dionisia. She does not have any known allergies to any foods or drugs. She considered her household chores as her daily exercise. She’ used to sleep during the afternoon.
Mental Health Status
Notes: The patient is mildly anxious as a result of thinking to her children at home. and cleaning the pen of her animals. Health Perception-Health Management Pattern II. usually wakes up at 4:00 in the morning. cooking. Nutritional-Metabolic Pattern
. She was oriented to time.
B. She’s fond of eating vegetables and fish and occasionally eat meat.√Headaches Numbness Paresis
Dizziness Tingling Paralysis
Memory Loss Seizures
Notes:The patient complains headache 4/10. Activity-Exercise Pattern
V. Cognitive-Perceptual Pattern VII. She weighed 48 kg. She was able to communicate well and can comprehend and accommodate questions. Nursing Health History
Category I. and defecates daily usually every morning. Elimination Pattern IV. place and person. She was sexually active and has 4 children. . She voids normally. She retires at around 7-8 pm. activities included were washing clothes. a person without an illness is considered healthy.
irritability and mild anxiety associated with her complaints of difficulty of breathing and chest pain. appeared weak. Ilocano and Kapampangan. She is mildly anxious yet attentive and cooperative when asked. looks tired and sleepy. Value-Belief Pattern
She was very optimistic in life.VIII. with easy fatigue ability noted. Body Make-Up: mesomorph Communication Pattern: The patient speaks calmly in Filipino. as evidenced by her consulting a doctor. she will be completely cured. She believes in scientifically accepted and traditional healing. Her speech is even and moderately paced with appropriate words in a calm and understandable voice.
C. Bruises: none Rashes: none Scars:none Blisters: none Ecchymosis: none Burns: none
. She is oriented to time. Skin Integrity Color: brown complexion Turgor: normal skin turgor with instant recoil of 2-3 seconds. Weight: 48 kg. places and persons. PHYSICAL ASSESSMENT
General Survey Overall Physical Appearance: Mommy Dionisia is mesomorph. She also believe that with the help of GOD. Signs of physical discomfort have been noticed such as facial grimace. Height: 5’1. Coping-Stress Tolerance Pattern
IX. She took medications to relieve her difficulty of breathing and performed her usual activities as not to feel that she’s sick.
smooth and moist.:5/10.Eyes Sclera: white Pupils: round and equal.moderate Body Position/Alignment √Supine Fowlers Semi-Fowlers PR: 76bpm RR: 24bcpm TEMP: 36.
Respiratory Easy breathing Vital Signs BP: 140/80 mmhg P.S.6 ⁰C Capillary refill: 1-2 sec √In Distress No Distress
Alignment √Appropriate Inappropriate Others: can change position according to desire Mental Acuity √Oriented Disoriented Sensory/Motor Restrictions Amputation Fracture Deformity: none Gait Paresis Hearing Disorders √Coherent Incoherent √Appropriately responsive Inappropriately responsive
Speech: even and moderately paced Emotional Status Euphoric Distressed Apprehensive Angry/Hostile √Anxiety(mild)
Medically Imposed Restrictions CBR w/out BRP: √ Sexual activity: Other Health Related Patterns CBR w/ BRP: OOB-Chair: Restricted ambulation:
. responsive to light Cornea: transparent.
. 2-3 seconds. Moist.6 oC. SCALP Technique Inspection Palpation Inspection Key findings Hair is black and well distributed. Returns immediately to its normal position when pinched. scars were evident in the left posterior arm. Absence of any infestation. Smooth and even. Within normal temperature of 36. Technique Inspection Inspection Palpation Palpation Palpation Palpation Palpation Key Findings Brown complexion and Absence of lesion. 9:00am 1. HAIR Area/Feature to assess Color and Distribution Texture and Oiliness Infestation 3. no tenting noted. SKIN Area/ Feature to assess Color Lesions Moisture Temperature Texture Mobility and Turgor 2. Fine texture and smooth to touch. PHYSICAL EXAMINATION Conducted last July 30. 2010.√Fatigue √Coughing
Environment Room temp: Lighting: √Adequate √Adequate Inadequate Inadequate
Activities Of Daily Living Can perform: Feeding Dressing Brushing teeth Bathing Combing Transfering
There is no obvious deformity seen in the external eye structures. Masses. Technique Inspection Palpation Key findings Symmetrical. SKULL Area/Feature to assess Shape and symmetry Contour.Area/Feature to assess Technique Scaliness and scars Inspection Tenderness. EYES Area/Feature to assess Technique External feature Inspection Eyebrows. Smooth. The pupils and iris are also symmetrical. edema or deformities. Has a normal pupillary reaction: constrict with a near object and dilate with a distant object.
. No tender areas. pupils. FACE Area/Feature to assess Facial Feature Edema and Masses 6. iris and sclera. masses. EARS Area/Feature to assess Technique Key findings Key findings With eye bags noted.
4. tenderness and lumps. Lesions. Absence of lesion. Eyebrows are symmetrical. Technique Inspection Inspection Palpation Key findings Proportion to the gross body structure. Depression and Tenderness 5. smooth and intact. with white sclera Has a normal pupillary reaction: constrict with light and dilate in darkness. for reaction to Inspection light Inspection for accommodation for convergence Inspection 7. Has a normal convergence. masses
Key findings No scars and scaliness. non-tender and free from masses and depression. Palpation lumps.
smooth and free from lesions and pain. Technique Inspection Inspection Inspection Inspection Inspection Inspection Key findings Pinkish in color. MOUTH AND PHARYNX Area/Feature to assess Lips Gums Teeth Tongue Palate Tonsils 10. No pain felt upon palpation.
NOSE AND SINUSES Technique Inspection and Palpation Inspection Palpation Key findings Located symmetrically. NECK Area/Feature to assess Technique Symmetry and Inspection and Masculature Palpation Lymph nodes Palpation Key findings The patient’s neck is mobile and proportion to the gross body structure. proportion to the face. There is absence of neck vein engorgement. Dorsal and ventral surface are both smooth and mobile. Mucosa is pink without swelling. Firm. inflammation. and is without swelling. There is absence of swelling. There is no pain or discomfort felt upon palpating the frontal and maxillary sinuses. The numbers whispered to both ears with one ear occluded at a time were heard clearly. Presence of nasal flaring .The nasal bridge is aligned. or scars. The lymph nodes are normal in size and shape. quite dry but no ulcers present. Palates are concave and pink. there is absence of cerumen or any discharge. Soft palate is smooth and hard palate has ridges. bleeding. Pinkish.
. smooth and moist. lesion or masses. Gums are pink.
8. or bleeding. Tonsils are symmetrical and there is no swelling. masses. Complete teeth.
Area/Feature to assess Nose
Nasal cavities Nasal sinuses
9.External and internal Inspection ear Palpation Auditory acuity Inspection
Symmetrical with upper attachment at eye corner level.
THORAX AND LUNGS A. UPPER and LOWER EXTREMITIES Area/Feature to assess Extremities Technique Inspection palpation Key findings and Peripheral pulses were strong and palpable. with normoactive bowel sound. Technique Inspection Auscultation Key findings Thorax rises and falls in unison with respiratory cycle. Smooth and no tenderness noted. With wheezes upon inspiration
14. Rhythm Sound 12. Extremities are proportion to the gross body
. ANTERIOR THORAX Area/Feature to assess Symmetry. PMI was located on the 4th to 5th intercostal space left midclavicular line or the apical area.11. clear.
B. POSTERIOR THORAX Area/Feature to assess Lesions Breath sounds Technique Palpation Auscultation Key findings Posterior thorax is free from tenderness and lesion. Gurgling sounds were heard over the abdomen. Technique Auscultation Auscultation Auscultation Key findings No murmur. 76 cardiac cycle/min. With wheezes upon inspiration. ABDOMEN Area/Feature to assess Technique General appearance of Inspection the abdomen Sound Auscultation Percussion Tenderness Palpation Key findings The 4 quadrants and 9 regions were correctly identified No evidence of linea nigra and stretchmarks. HEART Area/Feature to assess Heart sound Point of maximal impulse(PMI) Heart beat 13. The abdomen has a dull sound while the liver has a dull sound also.
. Radial pulse rate at 76 bpm. Peripheral IV access at right arm with no signs of phlebitis and infiltration.But with grade 1 edema in both legs.
15. shape and texture Capillary refill Lesion Technique Inspection Palpation Palpation Inspection Inspection Key findings and Transparent. normal in color and mobile. smooth and convex with a 160˚ nail bed angle. GENITAL:
Area/ feature to assess
16.structure. All body parts are present. and 1-2 sec. NAILS Area/Feature to assess Color.
Anatomy and Physiology
chronic obstructive pulmonary diseases.The respiratory system consists of all the organs involved in breathing. cough. larynx. Common respiratory symptoms include breathlessness. The respiratory system does two very important things: it brings oxygen into our bodies. oxygen is brought into the bloodstream and carbon dioxide is pushed from the blood out into the air. trachea. There. in very small air sacs called alveoli. it makes it harder for us to get the oxygen we need and to get rid of the waste product carbon dioxide. which is a waste product of cellular function. and chest pain. The nose. larynx. bronchi and lungs. trachea and bronchi all work like a system of pipes through which the air is funneled down into our lungs. pharynx. These include the nose. pharynx. and it helps us get rid of carbon dioxide.
The Upper Airway and Trachea
. When something goes wrong with part of the respiratory system. which we need for our cells to live and function properly. such as an infection like pneumonia.
air comes down the trachea and through the bronchi into the alveoli.
. it travels down your throat through the larynx (or voicebox) and into the trachea (or windpipe) before entering your lungs. cone-shaped organs which take up most of the space in our chests. which we need for our cells to live and function properly. because the heart takes up some of the space in the left side of our chest. Covering each alveolus is a whole network of little blood vessel called capillaries. We each have two lungs. It also helps to moisten and warm the air before it reaches your lungs. The right lung has three lobes but the left lung has only two. In this way. called ‘bronchopulmonary segments’.
These are pyramidal-shaped areas which are also separated from each other by membranes. From there. air enters your body through your nose or mouth. This fresh air has lots of oxygen in it.When you breathe in. These are divided up into ‘lobes’.
How they work Air enters your lungs through a system of pipes called the bronchi. until they eventually form little thin-walled air sacs or bubbles. which are very small branches of the pulmonary arteries. a left lung and a right lung. So. and to help us get rid of carbon dioxide. or big sections of tissue separated by ‘fissures’ or dividers. so that oxygen and carbon dioxide can move (or diffuse) between them. you bring in to your body the oxygen that you need to live. The Lungs
Structure The lungs are paired. These pipes start from the bottom of the trachea as the left and right bronchi and branch many times throughout the lungs. Traveling in the opposite direction is carbon dioxide. and get rid of the waste product carbon dioxide. All these structures act to funnel fresh air down from the outside world into your body. The alveoli are where the important work of gas exchange takes place between the air and your blood. which crosses from the blood in the capillaries into the air in the alveoli and is then breathed out. There are about 10 of them in each lung. and some of this oxygen will travel across the walls of the alveoli into your bloodstream. along with the heart. It is important that the air in the alveoli and the blood in the capillaries are very close together. known as the alveoli. The upper airway is important because it must always stay open for you to be able to breathe. The lungs can also be divided up into even smaller portions. Each segment receives its own blood supply and air supply. which is a waste product. Their role is to take oxygen into the body. when you breathe in.
The lungs are very vascular organs. The newly oxygen-rich blood then travels back through the paired pulmonary veins into the left side of your heart. They carry blood which is low in oxygen and high in carbon dioxide into your lungs so that the carbon dioxide can be blown off. come directly from the right side of your heart. and more oxygen can be absorbed into the bloodstream. which supply the lungs. This is because the pulmonary arteries. From there. meaning they receive a very large blood supply. it is pumped all around your body to supply oxygen to cells and organs
33 12.E.5 6.08 x 10ˆ3/uL 3.7 – 5.56 – 6.9 321.98 – 10.3.9%
Impression Increase Normal Normal Normal Decrease Decrease Increase Normal Increase Decrease Decrease Normal Normal Normal
.1 – 44.5 0.54 x 10ˆ3/uL 0.16 65.24 – 0. 2010 Test Ph PCO2 PO2 HCO3 B.1 – 1.18 – 3.4 – 0.22 x 10ˆ3/uL 11.47 1.2 1. 2010 Test
time: 3:35 pm Results 10.7 4.35 – 7.7g/dL 34. Significance: time: 3:35 pm Results 7.2 mEq/ L 95 – 100 % Impression Increase Decrease Increase Increase Increase Normal
Routine blood count Date: July 27.36 x 10ˆ3/uL 0.51.04 x 10ˆ3/uL
neutro% lympho% mono% eo% baso% netro# lympho# Mono# Eo# baso# RBC Hemoglobin Hematocrit Significance:
34.8 27.3 9.8 0.4 99.58 29.13 x 10ˆ3/uL 1. O2 sat.9 Normal range
3.1 19.7 – 12.68 2.2 – 15.0 – 71.93 – 5.Laboratory findings Atrial blood gas Date: july 27.1 – 0.74 x 10ˆ3/uL 0.1 0.8 24.8 0.8 Normal range 7.45 35 – 45 mmHg 80 – 100 mmHg 22 – 26 mEq/ L + / .0 4.0 6.01 0.8 37.0 0.
8 – 5. 2010 Chest Pa – basic Radiologic findings: The lung fields are clear.2 μ mol/L 53-106 μ mol/L Impression Normal Normal
Chest X.Ray Date: July 27.0 mmol/L 95 – 103 mEq/ L Decrease Normal Increase Result 3.9-8. 2010 Test BUN Creatinine Electrolytes Sodium Potassium Chloride Significance: 1.72 time: 3:35pm Normal range 2.Blood chemistry Date: July 27. The rest of visualized chest structures are unremarkable.36 3.5 136 – 142 mmol/L 3.53 104. Impression: normal chest findings Significance time: 3:00 pm
.5 70. heart is not enlarged. The diaphragm and costophrenic sulci are intact.
. every 12 hours combivent every 1 hour after four dose then every four hours. to hook plain Lactated Ringer Solution 1L x 20 gtts/min and 5% Dextrose in Water 250 cc x 31 gtts/min. 12 lead ECG and Chest X ray. The doctor ordered CBC . ciphrofloxacin 400 mg. kalium durule 1 tab TID. The doctor also ordered to feed the patient at 1800 kCal of osteorized food every four hours and delay O2 saturation after 2 hours.Medical Management Upon admission at the ICU of Central Luzon Doctors’ Hospital with a chief complaint of difficulty of breathing and later accompanied by headache and chestpain. hydrocortisone 100 mg IV every 8 hours. to have nebulization every 6 hours and hook aminophyliine drip to 10 gtts/min to give omeprazole 20 mmg IV OD. meptin 50 g 1 tab twice a day and ketorolac 30 mg 1 amp IVP PRN after negative skin test.
The student-nurse were able to perform thorough physical assessment on the client and formulated nursing diagnosis based on the gathered data. And the student nurse was able to impart useful health teachings to the client to be able to perform self-care. From this exposure. the student nurse have acquired knowledge regarding Acute Respiratory Failure (ARF). prevent recurrence of the disease and also included her diet and the importance of taking her medications. implemented the nursing interventions and evaluated if goals were met.
. The patient’s condition has been improved as evidenced by improvement of her breathing pattern and decrease chest pain from pain scale of 5/10 to 2/10.
To the health care team. They must be responsible enough to create awareness program for care and management for all the Filipino people. They must observe and always remember to keep in line with their duties towards patient and significant others. the student nurse would like to recommend and share some pointers on how to deal with different diseases like Acute Respiratory Failure. Thus.RECOMMENDATION With this study. To the community and the family. that they must be sufficient coordinate with the government and the health care team regarding promotion of health and prevention of disease. they should righteously implementing basic and ideal procedures regardless of the health care facilities where they belong. To the government. the student nurse was able to gain more knowledge and wider view and perspective of the complication of Acute Respiratory Failure.
. primarily they should allocate sufficient budget to sustain and provide better facilities.
Irritants bind to antibody molecule(IgE) attached in mast cells and basophils Capillary dilation Edema of airway Broncho constriction Airflow limitation Cough Dyspnea Wheezes Chest tightness Inadequate gas exchange
Contraction of bronchial smooth muscle
Increased mucous production
Decreased inhalation of oxygen
Decreased exhalation of carbon dioxide
Cyanosis Restlessn ess Confusion Headach e Tachycar dia
Acute respiratory failure
.Pathology and Physiology
Causal factor: • Exposure to indoor and outdoor allergens Occupational
Contributing factor: • • • Respiratory infection Airway pollution Active/ passive smoking