BRONCHIECTAS IS

I. INTRODUCTION
“Look to your health; and if you have it, praise God and value it next to conscience; for health is the second blessing that we mortals are capable of, a blessing money can't buy. “ --Izaak Walton

The quote expresses the thought that health is wealth; that good health is equal to having everything in the world. It states that health is the best thing God could give us. We should be thankful for it, live it well, and most of all be contented of what we have for it is a blessing more important than money. Achieving good health is a way of thanking Him in return of giving us this life. As discussed in this case study, a nun, a servant of God, was diagnosed with Bronchiectasis. But, as most people would do, she did not blame nor asked God why, and instead thanked Him for such a blessing. Bronchiectasis is a disease that causes localized, irreversible dilation of part of the bronchial tree. It is classified as an obstructive lung disease, along with bronchitis and cystic fibrosis. Involved bronchi are dilated, inflamed, and easily collapsible, resulting in airflow obstruction and impaired clearance of secretions. Bronchiectasis is associated with a wide range of disorders, but it usually results from necrotizing bacterial infections, such as infections caused by the Staphylococcus or Klebsiella species or Bordetella pertussis. Rene Theophile Hyacinthe Laënnec, the man who invented the stethoscope, used his creation to first discover bronchiectasis in 1819. The disease was researched in greater detail by Sir William Osler in the late 1800s; in fact, it is suspected that Osler actually died of complications from undiagnosed bronchiectasis. There are both congenital and acquired causes of bronchiectasis. Kartagener syndrome, which affects the mobility of cilia in the lungs, aids in the development of the disease. Another common genetic cause is cystic fibrosis, in which a small number of patients develop severe localized bronchiectasis. Young's syndrome, which is clinically similar to cystic fibrosis, is thought to significantly contribute to the development of bronchiectasis. This is due to the occurrence of chronic, sinopulmonary infections. Patients with alpha 1-antitrypsin deficiency have been found to be particularly susceptible to

bronchiectasis, for unknown reasons. Other less-common congenital causes include primary immunodeficiencies, due to the weakened or nonexistent immune system response to severe, recurrent infections that commonly affect the lung. Acquired bronchiectasis occurs more frequently, with one of the biggest causes being tuberculosis. Endobronchial tuberculosis commonly leads to bronchiectasis, either from bronchial stenosis or secondary traction from fibrosis. An especially common cause of the disease in children is acquired immune deficiency syndrome, stemming from the human immunodeficiency virus. This disease predisposes patients to a variety of pulmonary ailments, such as pneumonia and other opportunistic infection. Bronchiectasis can sometimes be an unusual complication of inflammatory bowel disease, especially ulcerative colitis. It can occur in Crohn's disease as well, but does so less frequently. Bronchiectasis in this situation usually stems from various allergic responses to inhaled fungus spores. Recent evidence has shown an increased risk of bronchiectasis in patients with rheumatoid arthritis who smoke. One study stated a tenfold increased prevalence of the disease in this cohort. Still, it is unclear as to whether or not cigarette smoke is a specific primary cause of bronchiectasis. Other acquired causes of bronchiectasis involving environmental exposures include respiratory infections, obstructions, inhalation and aspiration of ammonia and other toxic gases, pulmonary aspiration, alcoholism, heroin (drug use), and various allergies. Death and mortality statistics for Bronchiectasis: Deaths from Bronchiectasis: 970 deaths (NHLBI 1999) Death rate extrapolations for USA for Bronchiectasis: 969 per year, 80 per month, 18 per week, 2 per day, 0 per hour, 0 per minute, 0 per second. Note: this extrapolation calculation uses the deaths statistic: 970 deaths (NHLBI 1999) Hospitalizations for Bronchiectasis: 6,000 (NHLBI 1999) The following are statistics from various sources about hospitalizations and Bronchiectasis: 0.06% (7,605) of hospital consultant episodes were for bronchiectasis in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)

78% of hospital consultant episodes for bronchiectasis required hospital admission in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03) • 39% of hospital consultant episodes for bronchiectasis were for men in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03) • 61% of hospital consultant episodes for bronchiectasis were for women in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03) • 54% of hospital consultant episodes for bronchiectasis required emergency hospital admission in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03) • 10.5 days was the mean length of stay in hospitals for bronchiectasis in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03) • 8 days was the median length of stay in hospitals for bronchiectasis in England 200203 (Hospital Episode Statistics, Department of Health, England, 2002-03) • 60 was the mean age of patients hospitalised for bronchiectasis in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03) • 37% of hospital consultant episodes for bronchiectasis occurred in 15-59 year olds in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03) • 22% of hospital consultant episodes for bronchiectasis occurred in people over 75 in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03) • 16% of hospital consultant episodes for bronchiectasis were single day episodes in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03) • 0.09% (48,984) of hospital bed days were for bronchiectasis in England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)

Objectives:

These are set goals or criteria that will enable the health care provider (student nurses) as well as the client (patient) to identify basic importance of the study in the interaction process. A. Nurse Centered After 2 days of student nurse-patient interaction, the nurse will be able:  To build therapeutic relationship between the client and health care provider as well as with the significant others and health care team.  To enhance knowledge and understanding pertinent to the client’s health condition, disease process, management, intervention and treatment modalities.

 To provide quality nursing care by setting specific goals and appropriate nursing intervention which are essential to the client’s condition  To identify health problems and needs of the client that will be the basis of further assessment and evaluation in the understanding of the disease process  To supplement health teachings to the client especially factors that will contribute to the continuity of care. B. Patient Centered After 2 days of student nurse-patient interaction, the client will be able:  To understand clearly the disease process (bronchiectasis) its causes, effect, management, treatment and possible prevention.  To appreciate and apply the health teachings given by the health care provider for the betterment of his condition.  To participate in the course of care and initiate change by modifying one’s behavior and lifestyle that may further aggravate his condition.  To acknowledge the importance of proper monitoring of health status by regularly consulting to health care providers regarding their health condition

II. Personal history

NURSING HISTORY

Mrs. Minnie Mouse is currently 61 years old and is a Filipino. She was born on September 12, 1943 at Gapan, Nueva Ecija and grew in Quezon City. She got married at the age of 29 to Mr. Mickey Mouse. She gave birth to three boys namely: Mr. Road Runner, who is married and has three children as of the moment; Mr. Donald Duck, who became a monk; and Mr. Taz, who became a priest; in chronological order. At the age of 35 and her children being: eldest, 6 years old; second eldest, 4 years old; and the youngest at 2, together with her husband, they entered the monastery in Mabalacat, The St. Benedictine Monastery as a family. Since then, they have been living at 168 Monastery Road San Isidro, Magalang. She got admitted last February 17, 2009 with a chief complaint of cough and a clinical impression of Bronchiectasis, Dilated Cardiomyopathy.

Mrs. Minnie together with her family works for the monastery. There, Mr. and Mrs. Mickey Mouse are no longer husband and wife but are brothers and sisters instead. They work for their food by planting vegetables. They literally plant what they eat. Their everyday expenses are being taken care of by the monastery’s director. They just work and serve the Lord, wholeheartedly. They are given allowances but she saves them for future needs. Help and donations from kind hearted people also keep the monastery strong. She finished grade school and high school in Quezon City and took Bachelor of Science in Education major in science at St. Joseph’s College. Then she took up her Masterals in Ateneo and University of the Philippines specifically AB mastery in Mathematics and Physics. She taught in La Salle and then UP for 8 years. After that, she got married and few years later they entered the monastery as a family. Mrs. Minnie’s family members are all Catholics. In fact, she is actually a nun, only a married one; and her husband is a brother who is also working at the said monastery. Mrs. Minnie stated that she believes in the effects herbal medicines have. In fact, they plant their own herbal medicines in their monastery. However, she does not believe in the so-called “albularyos”, for her everything happens with a purpose and that it is in accordance to God’s will. She also said that she would rather rush to the nearest hospital than seek help with these “albularyos”. In fact, they have their own health care practitioner in their monastery where in severe cases; they would go to Makati Medical Center, where he was also working, for better treatment and latest facilities.

FAMILY-HEALTH ILLNESS HISTORY

Mr. Beast
(Died at the age of 70 due to liver cancer)

Mrs. Belle
(Died at the age of 75 due to cancer of the ovaries)

Cinde rella
Died due to cancer of the ovary

Auror a
Died due to cancer of the colon

Ariel
Currently living in Switzerla nd

Mrs. Minnie Mouse
61 years old (Has arthritis, osteoporosis , but no hereditary disease)

Mr. Mickey Mouse
(No current illness, no hereditary disease known)

Snow White
(Forgot cause of death)

Aladd in
Died due to liver cancer

Jasmi ne
71 years old Living with Mrs. Minnie mouse

Legend: Pts. Father Pts. Mother Pts. Siblings Pts. Husband Pts. children

Mr. Road Runner
30 years old (No hereditary disease known)

Mr. Donald Duck
28 years old (No hereditary disease known)

Mr. Taz
26 years old (No hereditary disease known)

Schematic Diagram of the Disney Family

HISTORY OF PAST ILLNESS Mrs. Minnie Mouse was a menopause baby which made her sickly since childhood. She was frequently being infected with cough, colds and fever. In April 1, 2005, she was diagnosed to have Bronchiectasis, a condition wherein the bronchioles are inflamed and are not functioning very well. She was not aware of this and the only one that noticed that there was something wrong with the way she coughed was the resident doctor of their monastery. The doctor talked to her and said that they should go to Makati Medical Center, where he is also working, to clarify the condition. A computed tomography or CT scan and a Chest X-ray confirmed the diagnosis. She was prescribed antibiotics then, medications that are quite similar to those with Tuberculosis. She took these medications until 2007. Due to the extent of her condition, she already knew its definition and some treatments that were given to her. From then on she was being confined once or twice a year. In February 07, 2008, she was confined because of Pneumonia and a fungal infection. The doctor prescribed cyclic medications after being discharged. Every six weeks she returned and the doctor would give her another pack of medications. Arthritis and osteoporosis made her weaker since these conditions are associated with weakening of the bones and joints. HISTORY OF PRESENT ILLNESS During the first week of February this 2009, she had massive edema in the upper and lower extremities. She was rushed to AMC and was given medications. Fortunately, this was solved and she was discharged early. According to her, the doctor said that the edema was due to the poor pumping action of the heart which made them suspect Congestive Heart Failure, so they did a chest x-ray. But they found out that she had a congenital hole in her heart. Dilated cardiomyopathy was then diagnosed. During the first days of the second week, she experienced coughing, fever, stabbing pain, weakness and fatigue. On February 17, 2009, she was rushed and admitted to Angeles Medical Center at exactly at 4:37 pm. Her chief complaint was cough and she was diagnosed with Bronchiectasis, Dilated Cardiomyopathy. Several laboratory procedures were done and it was identified that she had another fungal infection and pneumonia.

III. Physical Assessment ( IPPACephalocaudal Approach) ASSESSMENT UPON ADMISSION: February 17, 2009 The patient was conscious, wheel chair borne, afebrile, with pale palpebral conjunctiva, anicteric sclerae, with crackles and rales,BLF, no wheezes, tachycardic, (+) murmur, flat, NABS, soft full equal pulses. FIRST NURSE-PATIENT INTERACTION: February 20, 2009 General appearance Mrs. Minnie was seen lying on bed and was alert and conscious. She was wearing a cream blouse with black vest and a below-the-knee length skirt. The patient was neatly groomed. Vital signs taken as follows: At 08:00 am T: 36.4 °C P: 82 beats per minute R: 23 breaths per minute BP: 130/60 mmHg At 10:00 am T: 36.2 °C P: 82 beats per minute R: 25 breaths per minute BP: 130/70 mmHg At 12:00 pm T: 36.2 °C P: 83 bets per minute R: 26 breaths per minute BP: 130/70 mmHg

SKIN: • No lesions observed • Slow skin turgor (3-4 seconds) due to old age • Poor capillary refill (3-4 seconds) • Skin is moist and warm • Greenish discoloration on IV site related to IV administration HEENT: Head • Symmetrical to face • Hair is thin and quite moist, black with minimal white hair strands • Even distribution of hair • No nits and dandruff observed Eyes • Palpebral fissures are equal when eyes are open • Pale palpebral conjunctiva • Anicteric sclera • Can open eyelids when pressure is applied • Patient is near-sighted Ears • Pinna is pale pink in color • External canal is clean • No discharge noted

• Right ear cannot hear ticking of watch’s hands • Left ear can clearly hear ticking of watch’s hands Nose • No discharge seen • Can breath with one nostril occluded Tongue and mouth • Sore on the end of lower lip • 9 upper teeth, 9 lower teeth present, all natural • Pale pink gums • No breath odor NECK: • Thyroid muscle moved upon swallowing • Can move chin when pressure is applied • Can move shoulder when pressure is applied • Lymph nodes are not palpable LUNGS: • Rales and Crackles on both lung fields upon auscultation • Uses accessory muscles • Increased Respiratory rate of 26 breaths per minute • Difficulty of breathing reported GUT: • Regular bowel movement (once in two days as stated by patient) • No urinary incontinence MUSCULOSKELETAL: • Cyanosis and clubbing of fingers • No edema • Muscle weakness specifically on lower extremities • Can ambulate with assistance SECOND NURSE-PATIENT INTERACTION: February 21, 2009 General appearance Seen on bed sitting, finished eating breakfast. She was well-groomed. And she wears a floral blouse with gray vest and a below-the-knee length floral skirt. Vital signs taken as follows: At 08:00 am T: 35.5 °C P: 73 beats per minute R: 19 breathe per minute BP: 130/60 mmHg SKIN: • Poor capillary refill (3-4 seconds) • Greenish discoloration still present on IV site related to IV administration

HEAD: Head • Hair is quite moist Eyes • Pale palpebral conjunctiva • Deep eye bags noted Ears • Right ear cannot hear ticking of watch’s hand • Left ear can clearly hear ticking of watch’s hand Tongue and mouth • Sore on right lower lip • Pale pink gums LUNGS • Crackles on Right lung field upon auscultation • Uses accessory muscles. MUSCULOSKELETAL: Cyanosis and clubbing of fingers • Muscle weakness specifically on lower extremities • Can ambulate with assistance

IV.

DIAGNOSTIC AND LABORATORY PROCEDURE Diagnostic / Laboratory Procedure Indications or Purpose Date ordered Date results were released Date ordered 02/17/09 Date results were released 02/17/09 Results Normal values (units used in the hospital) Normal lung fields, cardiac size, mediastinal structures, thoracic spine, ribs and diaphragm. Analysis and Interpretation of Results

Chest X-ray

This study yields information about the pulmonary, cardiac, and skeletal systems. It is used to evaluate known or suspected pulmonary disorders, chest trauma, cardiovascular disorders, and skeletal disorders.

There is no significant interval change in the Koch’s infiltrates on both lung fields and the bronchiectatic changes on the right mid and lower lung fields and the left upper lobe compared with the 1/20/09 chest radiograph. The heart is minimally enlarged with left ventricular form. The aortic knob is calcified. The diaphragm, sulci and ribs are intact.

The patient has chronic Koch’s infection with bronchiectatic Changes. Bilateral lung fields, radiographically stable since the 1/20/09 chest radiograph. Mild cardiomegaly, left ventricular form. Atheromatous aorta. Dextroscoliosis, thoracic spine.

Nursing Responsibilities: Prepare your patient • Inform the patient about the purpose of the procedure, various positions to assume, and the need to hold his or her breath.

• Inform the patient that the procedure takes 5 to 10 minutes. • There are no food or fluid restrictions. • Inform the patient that no pain is associated with the study. Perform procedure • Instruct the patient to remove clothing and metallic objects from the waist up. • Give the patient a gown and robe to wear. • Remove any wires connected to electrodes, if allowed. • Place patient in a standing, sitting, or recumbent position in front of the x-ray film holder. • Have the patient place hands on hips, extend neck, and position shoulders forward. • Position the chest with the left side against the film holder for a lateral view. • Instruct the patient to inhale deeply, to hold his or her breath while the x-ray is taken, and then exhale after the film is taken. Care after the test • Inform the patient of the possible need for additional chest x-rays to evaluate progression of the disease process or determine the need for a change in therapy. • Determine if the patient or family members have any further questions or concerns. • A physician sends a written report to the ordering health care provider, who discusses results with the patient. Diagnostic / Laboratory Procedure Indications or Purpose HEMATOLOGY Date Results ordered Date results were released Date 41.0 % ordered 02/17/09 Date results were released 02/17/09 Normal values (units used in the hospital) Male: 40.0-54.0% Female: 37.0-47.0% Analysis and Interpretation of Results

Hematocrit

This blood test evaluates blood loss, anemia, blood replacement therapy, and fluid balance, and screens red blood cell status.

The patient’s hematocrit is within normal values which mean that the concentration of red bloods cells is normal.

Nursing Responsibilities Prepare your patient • Explain that this test helps evaluate if there are enough red blood cells in the blood, or if there is too much or too little water in the body. Perform procedure Collect 7 mL of venous blood in a lavender-top tube.

Alternately, collect the sample in a heparinized capillary tube (red-banded tube) and seal on or both ends after collection. Care after test • Observe the patient for signs and symptoms of anemia including pallor, tachycardia, dyspnea, chest pain, and fatigue. Severe anemia may produce these symptoms from tissue hypoxia • Encourage rest periods for patient experiencing fatigue related to anemia. • Evaluate patient’s ability to perform activities of daily living. • Discuss with patient or family the significance of hematocrit levels. For example, extreme increases in red blood cells may trigger a stroke in some individuals. Acute dehydration can start a sickling crisis. Diagnostic / Laboratory Procedure Indications or Purpose Date ordered Date results were released Date ordered 02/17/09 Date results were released 02/17/09 Results Normal values (units used in the hospital) Male: 14-18 g/dL Female: 12-16 g/dL Analysis and Interpretation of Results

Hemoglobin

This test evaluates blood loss, erythropoietic ability, anemia, and response to therapy. The hemoglobin level is directly related to the red blood cell count (RBC).

12.5 g/dL

The patient’s hemoglobin is within normal values which mean that the ability of red blood cells to carry oxygen and carbon dioxide to and from tissues is normal.

Nursing Responsibilities Prepare your client Explain that this test measures a part of the blood that carries oxygen. Perform procedure • Collect 5-7 mL of venous blood in a lavender-top tube. • Alternately, a fingerstick or heel-stick method may be used to collect venous blood in a heparinized capillary tube. Care after test • Observe the patient for signs and symptoms of anemia including pallor, dyspnea, chest pain, and fatigue. • Encourage rest periods for patient experiencing fatigue related to anemia. • Evaluate patient ability to perform activities of daily living.

• If a low hemoglobin level indicates the possibility of blood loss or anemia, instruct the patient or family that further testing will be necessary to identify the cause of the condition to treatment. Diagnostic / Laboratory Procedure Indications or Purpose Date ordered Date results were released Date ordered 02/17/09 Date results were released 02/17/09 Results Normal values (units used in the hospital) 141-440 Analysis and Interpretation of Results

Platelet count

This blood test evaluates platelet production and assesses the effects of cancer treatment on platelet numbers. The platelet’s size and shaper are noted. Platelets are nonnucleated, round or oval, flattened diskshaped structures that are vital to the formation of a hemostatic plug in vascular injury. This is the most important screening tests of platelet function.

274

The patient’s platelet count is within normal range which means that there is adequate coagulating function.

Nursing Responsibilities Prepare your patient • Explain that this test helps assess the blood’s ability to clot Perform procedure • Collect 7 mL of venous blood in a lavender-top tube. • Apply pressure or a pressure dressing to the venipuncture site. Care after test • Hold pressure ate the venipuncture site for 5 minutes to prevent hematoma formation. • Assess patient for unusual bruising or prolonged bleeding from venipuncture site. Delayed clotting is a complication of severely impaired clotting. • Test all body secretions including stool, gastrointestinal aspirate, and tracheal aspirate for occult blood. Closely inspect mucous membranes for bleeding.

• Teach the patient and family members about bleeding, precautions including using a soft-bristled toothbrush, using a electric razors, avoiding constipation, avoiding picking their nose, and avoiding constricting clothing. • Teach the patient and family the signs and symptoms of bleeding including petechiae (small purplish spots on the skin), bruising, and blood in the urine or stool, vaginal bleeding, and bleeding from any other sites. Diagnostic / Laboratory Procedure Indications or Purpose Date ordered Date results were released Date ordered 02/17/09 Date results were released 02/17/09 Results Normal values (units used in the hospital) 4.3-10.0 Analysis and Interpretation of Results

White blood cell

This blood test evaluates a number of conditions and differentiates causes of alterations in the total white blood cell (WBC) count including inflammation, infection, tissue necrosis, and or leukemic neoplasia. The differential white cell count identifies the five specific types of white blood cells present in the blood. These five cell types reflect the integrity of the patient’s immune system.

13.8

The patient has increased levels of WBC (leukocytosis) which indicate infections, inflammation, stress or hemorrhage.

Lymphocyte/ This test is used Monocytes to evaluate the patient’s response (%) to treatment, the prognosis, and (x10/1) bleeding disorders. As well as infection.

Date ordered 02/17/09 18 Date results were released 02/17/09 Date ordered 02/17/09 Date results were released 02/17/09 28.0-48.0

The patient is compromised because of immunodeficiency. So this type of WBC is decreased.

2.5

1.2-5.3

Granulocyte (%) (x10/1)

This test evaluates prognosis, response to treatment and bleeding disorder.

82 11.3

44.2-80.2 2.0-8.8

The immune system of the patient may be poor or an overwhelming infection is present.

Nursing Responsibilities Prepare your patient • Explain to your patient that this test helps to assess the body’s ability to fight infection, to tell the difference between an infection and an allergy, or to find problems with the way bone marrow makes blood cells. • Instruct your patient to avoid strenuous physical activity for 24 hours prior to testing, if possible. Perform procedure • Collect 7 mL of venous blood in a lavender-top tube. • Gently invert the collection tube several times immediately after collection to mix the sample with the anticoagulant in the tube. Care after test • If WBC differential indicates an infection, assess patient responses to antimicrobials. Interventions will include assessment of vital signs, focused physical assessment of body systems affected, administration and maintenance of fluids, monitoring intake and output, and assistance with activities of daily living as required. • If WBC differential indicates an allergic or inflammatory response, monitor the client’s response to therapies. Inflammatory responses may worsen or involve more than one body system. Monitor the patient for worsening of the inflammatory condition, particularly respiratory compromise. • When decreased bone marrow activity is demonstrated on the WBC differential, instruct your patient about the importance of obtaining immunizations that may provide some level of protection (pneumococcal vaccine, flu vaccine, hepatitis B vaccine). Also instruct the patient and family about the importance of avoiding individuals with acute

illnesses and upper respiratory infections. If the patient lives with young children, it is important to maintain the immunization schedule of these children to prevent unnecessary exposure of the client to infections. • When an allergic or inflammatory condition is identified, explore possible interventions for preventions for prevention of recurrences with the patient and family. • Explain the similarities and differences in treatment and management of parasitic, viral, and bacterial illnesses to the patient and family. Discuss routes of transmission to help the patient and family identify means of limiting exposure of others. BLOOD CHEMISTRY Diagnostic / Laboratory Procedure Indications or Purpose Date ordered Date results were released This group of tests Date is used assess ordered condition such as 02/17/09 asthma, chronic obstructive pulmonary disease Date (COPD), results embolism. Blood were gas analysis is released used to evaluate 02/17/09 respiratory function and provide a measure for determining acid-base balance. Respiratory, renal, and cardiovascular system functions are integrated in order to maintain normal acid-base balance. Results Normal values (units used in the hospital) 7.35-7.45 mmHg 35-45 mmHg 80-100 mmHg 22-26 mEq/L ±2 mEq/L (97%) Analysis and Interpretation of Results

Arterial blood gas

pH: 7.491 pCO²: 34.3 PO²: 89.3 HCO³: 25.6 O² Sat: 2.8 B.E: 97.4

The patient has a high pH level, a low pCO² level, and a normal HCO³ which means that the patient is experiencing respiratory alkalosis. A high O² sat and B.E. level was also noted. The patient may have fever, hyperventilation and excessive artificial ventilation.

Nursing Responsibilities Prepare your patient • Obtain a history of the patient’s complaints, including known allergies

• Obtain a history of the patient’s cardiovascular and respiratory systems, any bleeding disorders, and results of tests and procedures previously performed, especially bleeding time, clotting time, complete blood count, and prothrombin time. • Obtain a list of medications the patient is taking including anticoagulant therapy. It is recommended that use of these medications be discontinued 14 days before dental or surgical procedures. • Note any recent procedures that can interfere with test results • There are no food, fluid, or medication restrictions unless by medical direction. • Note the patient’s temperature. Perform procedure • Direct the patient to breathe normally and to avoid unnecessary movement. Care after test • Pressure should be applied to the puncture site for at least 5 minutes in the unanticoagulated patient and for at least 15 minutes in the case of a patient receiving anticoagulant therapy. Observe puncture site for bleeding or hematoma formation. Apply pressure bandage. • Observe the patient for signs and symptoms of respiratory acidosis, such as dyspnea, headache, tachycardia, pallor, diaphoresis, apprehension, drowsiness, coma, hypertension, or disorientation. • Teach the patient breathing exercises to assist with the appropriate exchange of oxygen and carbon dioxide. • Administer oxygen, if appropriate. • Observe the patient for signs or symptoms of respiratory alkalosis such as tachypnea, restlessness, agitation, tetany, numbness, seizures, muscle cramps, dizziness, or tingling fingertip. • Instruct patient to breathe deeply and slowly; performing this type of breathing exercise into a paper bag decreases hyperventilation and quickly helps the patient’s breathing return to normal. Diagnostic / Laboratory Procedure Indications or Purpose Date ordered Date results were released Date ordered 02/17/09 Date results were released 02/17/09 Results Normal values (units used in the hospital) 3.5-5.1 mEq/L Analysis and Interpretation of Results

Potassium

These serum and urine tests evaluate fluid and electrolyte balances and identify renal dysfunction. Potassium is critical to neuromuscular

5.1 mEq/L

The patient has normal level of potassium which means that there is normal osmotic pressure and cardiac and neuromuscular electrical conduction.

function, specifically skeletal and cardiac muscle activity. Nursing Responsibilities Prepare your patient • Explain that the test is helpful in identifying chemical imbalances, specifically potassium. Perform procedure SERUM • Collect 5-10 mL of venous blood in a red-top or green-top tube. • Collect blood form the arm opposite an intravenous infusion of electrolyte solution. • Do not allow patient to pump the arm with a tourniquet in place. URINE • Use a clean 3-L container and no preservative. • Carefully collect a 24-hour urine sample. • Keep the collection container on ice or refrigerated during the collection period. Care after test • Monitor for signs and symptoms of hypokalemia including weakness, paralysis, hyporeflexia, ileus, dizziness, thirst, increased sensitivity to digoxin and cardiac dysrhythmias. • Monitor for signs and symptoms of hyperkalemia including weakness, paralysis, irritability, nausea and vomiting, intestinal colic, and diarrhea. • Monitor intake and output. • Monitor vital signs every 4 hours and note changes in blood pressure and pulse. • Teach patient and family that potassium is found in most foods. Cereals, dried peas and beans, fresh vegetables, fresh or dried fruits, bananas, orange juice, nuts, fresh fish are excellent sources. • Teach patient to avoid laxative or diuretic abuse.

Diagnostic / Laboratory Procedure

Indications or Purpose

Sodium

These serum and urine tests for sodium levels evaluate fluid and electrolyte balance as well as renal or adrenal disorders. Sodium is the main cation of the extracellular fluid and is a critical factor in acid-base balance and the water balance between blood and body tissues.

Date ordered Date results were released Date ordered 02/17/09 Date results were released 02/17/09

Results

Normal values (units used in the hospital) 135-145 mEq/L

Analysis and Interpretation of Results

137 mEq/L

The patient’s sodium level is within normal values which means there is water balance and extracellular fluid replacement is functioning.

Nursing Responsibilities Prepare your patient • Explain that this test is helpful in evaluating the balance of chemicals in the body, particularly sodium. Explain how sodium balance is regulated by the kidneys and two glands near the kidneys called the adrenals. Perform procedure SERUM • Collect 5-7 mL of venous blood in a red-top tube. • Avoid collecting blood near a vein where saline or electrolyte solutions are infusing. URINE • Collect 24-hour urine specimen without preservatives. • Keep specimen refrigerated or on ice during the collection period. • Instruct the client that all urine voided in the next 24-hour period must be added to the collection container. Care after test • Monitor intake and output. Report urine output less than 30 mL/hour in adults, less than 1 mL per kg body weight per hour in infant and children. • Monitor urine specific gravity every 8 hours and as indicated. • Monitor vital signs every 4 hours and note changes in blood pressure and pulse. • Weigh daily; assure the clothing, time of day, and scales are consistent. • Assess breathing sounds every 4 hours for presence of rales.

• Assess for dependent edema in ankles or sacral area. • Monitor for signs and symptoms of hyponatremia including fatigue, weakness, confusion, stupor, anorexia, apprehension, headache, nausea and vomiting, diarrhea and abdominal pain. • Monitor for signs and symptoms of hypernatremia including dry mucous membranes, fever, sweating, increased thirst, oliguria, flushed skin, agitation, restlessness, and decreased reflexes. • Teach patient to avoid or increase dietary sodium depending on diet prescription. High-sodium foods include bacon, ham, cheese, celery, pickles, and tomato juice. Diagnostic / Laboratory Procedure Indications or Purpose Date ordered Date results were released Date ordered 02/17/09 Date results were released 02/17/09 Results Normal values (units used in the hospital) 76-111 mg/dL Analysis and Interpretation of Results

GLUCOSE: Random Blood Sugar

This blood test detects alterations in glucose metabolism, and is most often used as a random screen for glucose level or when a patient is unconscious for unknown reasons. It may also help diagnose diabetes mellitus or evaluate the control of this disease.

102 mg/dL

The patient’s glucose is within normal values which mean that randomly collected blood from the patient yields a normal level of sugar.

Nursing Responsibilities Prepare your patient • Explain that this test is to measures the amount of sugar in the bloodstream and is often used to look for any sign of sugar diabetes (diabetes mellitus). • Do not give insulin, oral antidiabetic agents or food until after the blood is drawn. • There is no period of fasting for this random analysis of blood glucose. Perform procedure • Perform a venipuncture and collect 5 cc of blood into a red-top or green-top tube. • Patient or staff may instead use a bedside glucometer after obtaining a sample from a fingerstick. Follow the manufacturer’s directions for usage. Care after test

• Administer any medications withheld for this test. • Resume patient’s normal diet immediately to prevent hypoglycemia. • Assess for symptoms such as nausea, light-headedness, hunger, and tremors, which may signify hypoglycemia. • If the blood glucose is extremely low, administer a source of carbohydrates by offering crackers, orange juice, or other high-carbohydrate foods to patient who has no alteration in level of consciousness • Inform the patient and family that continued elevated blood glucose levels may indicate sugar diabetes (diabetes mellitus). • Begin or reinforce diabetic teaching as indicated. • Encourage patient to self-monitor blood glucose. • Encourage patient and family to join diabetes support groups.

Diagnostic / Laboratory Procedure

Indications or Purpose

2D Echocardiogram And Color Doppler

This ultrasonic test diagnoses abnormalities in anatomy and valvular function within the heart. As in other ultrasound tests, sound waves are bounced off the heart using a transducer to image the heart in motion as well as its valves and vessels. While Color Flow Doppler is used primarily to diagnose arterial and venous disease as ell as anatomical abnormalities in vessels, vascular grafts, and the heart.

Date ordered Date results were released Date ordered 02/17/09 Date results were released 02/18/09

Results

Normal values (units used in the hospital) Normal appearance in the size, position, structure, and movements of the heart valves visualized and recored in a combination of ultrasound modes; and normal heart muscle walls of both ventricles and left atrium, with adequate blood filling. Established walues for the measurement of heart activities obtained by the study may vary by physician and institution.

Analysis and Interpretation of Results

1. LV size with hyperthropie d wall (concentric LVH) with adequate contractility and systolic function with Doppler evidence of impaired LV relaxation. 2. LA, RA, RV, MPA and aortic root dimension. 3. Thickened aortic valve cusps with no restriction of motion with aortic annular calcification noted (aortic sclerosis). 4. Thickened mitral valve leafted with no restriction of motion with mitral annular calcification noted (mitral sclerosis). 5. Structurally normal tricuspid and pulmonic valves. 6. No intracardiac thrombus or pericardial effusion noted. 7. There is a

Some of the valves of the patient’s heart are thickened which may indicate mitral valve prolapse, valvular stenosis, ventricular dysfunction, pericardial effusion, valvular insuffiency or regurgitation.

Nursing Responsibilities Prepare your patient • Inform the patient that the procedure assesses heart function • Inform the patient that the procedure is performed in a special department by a technologist and takes approximately 30 to 60 minutes, and that there is no risk of radiation form the study. • Obtain a list of medication the patient is taking. Perform procedure • Place the patient in a supine position on a flat table with foam wedges to help maintain position and immobilization. Ask the patient to lie very still during the procedure because movement will produce unclear images. Care after test • Cleanse the patient’s skin of remaining gel or mineral oil. • Instruct the patient to resume normal activity and diet unless otherwise indicated. • Encourage family and significant others to learn cardiopulmonary resuscitation.

Diagnostic / Laboratory Procedure

Indications or Purpose

GLUCOSE: Fasting Blood Sugar

This blood test detects alterations in glucose metabolism, most often to diagnose diabetes mellitus or help evaluate the control of this disease. The blood glucose will fluctuate depending upon the patient’s activity level and length of time form the last meal.

Date ordered Date results were released Date ordered 02/17/09 Date results were released 02/18/09

Results

Normal values (units used in the hospital) 76-111 mg/dL

Analysis and Interpretation of Results

122.08 mg/dL

The patient’s blood after fasting for 8-12 hours may indicate diabetes mellitus, hypokalemia, pancreatitis or chronic liver disease. But results may be increased by intravenous infusions, stress or medications such as beta-

Fasting blood glucose is used as a baseline measurement, as it is not influenced by dietary intake as a variable factor.

blockers.

Nursing Responsibilities Prepare your patient • Explain that this test is used to determine blood levels of sugar. • Ensure that the patient fasts from food for 8-12 hours before the test. They may drink water. • Do not give their insulin/antidiabetic agents until the blood is drawn. Confer with the primary care provider if symptoms of hyperglycemia develop during the period that insulin is withheld. Perform procedure • Collect 5 mL of venous blood into red (for plasma level) or green-top (for whole blood) tube. • Although this test is usually done using venous blood, it may also be performed on capillary blood using a glucometer and reagent strips. If so, follow specific directions for the particular brand of machine and reagent strips. Care after test • Administer medications previously withheld for testing purposes. • Ensure the patient receives food promptly in accordance with the ordered diet. • Observe for signs and symptoms of hypoglycemia such as diaphoresis, palpitations, tachycardia, and changes in the level of consciousness. • Observe for signs and symptoms of hyperglycemia such as thirst, increased urination, hunger, mental status change, and fruity or acetone breath. • Monitor fluid and electrolyte status. • Teach patient or family to self-monitor their blood sugar if appropriate. • Teach signs and symptoms of hypoglycemia including nausea, light-headedness, hunger, and shakes. • Teach patient and family to administer orange juice, hard candy, or another suitable source of quick sugar for these symptoms if the patient’s level of consciousness is unimpaired.

Diagnostic / Laboratory Procedure

Indications or Purpose

Blood Urea Nitrogen

This test measures renal function and hydration. Urea, the end product of protein and amino acid metabolism in the liver, enters the blood and passes to the kidneys for excretion. The blood urea nitrogen is, therefore, an indicator of both the metabolic function of the liver and the excretory function of the kidney.

Date ordered Date results were released Date ordered 02/17/09 Date results were released 02/18/09

Results

Normal values (units used in the hospital) 7-21 mg/dL

Analysis and Interpretation of Results

13.8 mg/dL

The result is within the normal values which mean that the liver and kidneys of the patient are functioning normally.

Nursing Responsibilities Prepare your patient • Explain that this test is helpful in discovering any problem is the kidney. • The most accurate BUN testing occurs when food, fluids, or medications have been restricted for 8 hours. Perform procedure • Collect 5 mL of venous blood in a red-top tube. Care after test • Assess for dehydration by noting poor skin turgor, increased pulse and respiration, dry mucous membrane, and decreased urine output. Encourage an increased oral intake unless contraindicated. • Monitor for lethargy, confusion, and change in mental status. Provide necessary safety precaution. • Monitor for signs and symptoms of uremia including nausea, vomiting, stupor, peripheral edema, decreased urine output, dyspnea, jugular vein distention, and weight gain. • Compare BUN to serum creatinine. Elevations in both strongly suggest renal disease. • Observe for signs and symptoms of anemia, as an elevated BUN is associated with decreased red blood cells.

• Observe for signs and symptoms of gastrointestinal bleeding, which is associated with an elevated BUN. • Teach patient and family regarding specific dietary prescription. In renal failure, the most common diet prescription is low protein, high calorie, low sodium, and low potassium. • Teach patient the importance of maintaining fluid restriction when indicated. • Instruct patient to report evidence of any anemia (weakness, shortness of breath, palpitations) or bleeding. • Teach the patient the purpose, action, and side effects of any prescribed medications. Diagnostic / Laboratory Procedure Indications or Purpose Date ordered Date results were released This blood test is Date essential in the ordered evaluation of renal 02/17/09 function. Creatinine is constantly Date excreted by the results kidneys. were released 02/18/09 Results Normal values (units used in the hospital) 0.5-1.69 mg/dL Analysis and Interpretation of Results

Creatinine

1.0 mg/dL

The result is within normal values which mean that the patient’s kidneys are functioning normally.

Nursing responsibilities Prepare your patient • Explain that this test is important to help understand how well the kidneys are working. Perform procedure • Collect 5-7 mL of venous blood in a red-top tube. Care after test • Assess fluid and nutritional status of patient for clues of renal impairment and other diseases causing changes in creatinine levels. • Continuously monitor fluid through daily weights and intake and output recordings. • Initiate safety precautions such as night lights for uremic patient (creatinine greater than 7 mg/dL), because cognitive function may be impaired. • For patient with oliguria, carefully assess for cardiac dysrhythmias because hyperkalemia as common. • If the patient is in end-stage renal failure, explain that eating large amounts of fish, meat, and poultry can increase serum creatinine levels.

Diagnostic / Laboratory Procedure

Indications or Purpose

Uric acid

Date ordered Date results were released This blood test Date evaluates a variety ordered of condition 02/17/09 where there is excessive production and Date destruction of results cells, identifies were patients at risk for released renal calculi, and 02/18/09 evaluates the severity of toxemia of pregnancy. Most uric acid produced daily is excreted by the kidneys, with a small amount excreted in the stool.

Results

Normal values (units used in the hospital) Female: 2.5-7.0 mg/dL

Analysis and Interpretation of Results

4.5 mg/dL

The result is within the normal values which mean that the patient’s uric acid is normally produced and excreted by the kidneys.

Nursing Responsibilities Prepare your patient • Explain that this test is performed to look for gout, kidney problems, or other conditions where tissues may be damaged. • Instruct the patient to fast for 8 hours before the test, if appropriate. (Check with the laboratory as this requirement varies.) Perform procedure • Collect 5-7 mL of venous blood in a red-top tube. Care after test • Increase fluid intake, unless contraindicated, to prevent formation of renal stones if hyperuricemia is suspected. • If hyperuricemia is present, check the urine pH. • Instruct patient with high uric acid levels to avoid foods high in purines such as organ meats, sardines, scallops, anchovies, broth, mincemeat, shellfish, legumes, mushrooms, and spinach. • Advise the patient to decrease or eliminate alcoholic intake, since ethanol causes renal retention of urate.

• Teach the patient, if appropriate, about drugs that are used to treat an acute attack of gout such as colchicine and indomethacin and maintenance drugs such as probenecid, sufinpyrazone, or allopurinol. • Advise the patient with hyperuricemia to maintain a liberal fluid intake to decrease the risk of renal stone formation. Diagnostic / Laboratory Procedure Indications or Purpose Date ordered Date results were released Date ordered 02/17/09 Date results were released 02/18/09 Results Normal values (units used in the hospital) 5-40 mg/dL Analysis and Interpretation of Results

SGOT/AST

This blood test helps determine the extent of damage to the liver, heart or musculoskeletal system. This test is often performed in conjunction with the alanine aminotransferase (ALT) test. Both AST and ALT are enzymes found mainly in liver, heart, and skeletal muscle tissue; only small amount are found in kidney tissue.

8 mg/dL

The result is within normal values. This test is part of the liver profile which means that the patient’s liver is functioning normally.

Nursing Responsibilities Prepare your patient • Explain that this test is important to help understand either how well the liver is functioning or to help diagnose a heart attack. • Do not administer intramuscular injections prior to drawing the blood sample for AST to be sure results are not altered by muscular trauma. Perform procedure • Collect 7-10 cc of venous blood in a red-top tube. • Unless otherwise ordered or indicated, draw serial samples at the same time each say. • Handle the sample gently to avoid hemolysis. Care after test

• Assess patient for unusual bruising or prolonged bleeding from venipuncture site. Delayed clotting is a complication of severely impaired liver function. • Assess for skin and sclera of eyes for jaundice and note findings. Protect the skin form damage due to pressure or friction. • Assess for occult gastrointestinal bleeding with routine stool guaise testing. Esophageal varices and mucosal bleeding are complications of liver disease. • Instruct the patient and family to report any jaundice-yellow discoloration of skin or whites of the eyes. • For patient with severely impaired liver function, instruct patient and family to report unusual or increased bruising and tarry stools. Instruct them to use electric razors and nonskid shoes to avoid falls and injuries. Diagnostic / Laboratory Procedure Indications or Purpose Date ordered Date results were released Date ordered 02/17/09 Date results were released 02/18/09 Results Normal values (units used in the hospital) Color: Pale, strawcolored to ambercolored Analysis and Interpretation of Results

Urinalysis

This test screens for abnormalities within the urinary system as well as for systemic problems that may manifest symptoms through the urinary tract. Abnormalities in any finding warrant further related testing and investigation.

Color: Yellow Specific Gravity: 1.030 Sugar: + 1 Appearance: Slightly turbid Reaction: pH 6.0 Albumin: (-) Pus cells: 4-8 Led cells: 3-5 Epithelial cells: Rare Amorphous urates: Rare

Yellow in color may indicate concentration of urine. The appearance of the urine may Appearance: indicate the clear to presence of white slightly blood cells, pus, hazy or uric acid. A positive result in Glucose: sugar may (-); indicate severe <0.5 g/24 stress, or hours hypothalamic dysfunction. pH: 4.5-8.0 pH and specific gravity are Specific within normal gravity: values. Led cells, 1.003-1.035 pus cells, epithelial cells, Epithelial and amorphous cells: Few urates are within their values as well.

Nursing Responsibilities

Prepare your patient • Explain that this test is to look for problems with urine and the organs that help form it. • Advise the client to wash the perineal area prior to collecting the specimen to avoid contamination with vaginal secretions or stool. • Inform the patient that a specimen from the first morning urination is preferred since it is usually concentrated and more likely to reveal abnormalities and formed substances. • Describe the procedure for collecting a clean-catch or midstream specimen if indicated. Perform procedure • Collect approximately 50 mL of urine, freshly voided into a clean, dry container. A fresh specimen may be taken from a urinary catheter according to agency policy. • Collect a clean-catch or midstream specimen if the specimen is likely to be contaminated by vaginal discharge, bleeding, or feces. Care after test • Note the appearance of the specimen and document this according to policy. • Review the specimen collection process with the patient to rule out contamination with other substances. • Assess the patient for signs and symptoms of urinary tract infection such as dysuria, urgency, and frequency. • Teach women the importance of emptying the bladder at least every 4-6 hours to prevent stasis of urine. Also, advise them to void immediately after intercourse. • Advise women to shower rather than tub bathe, especially with bubble bath, due to the irritation to the urethra. • If antibiotics are prescribed, stress the importance of taking all the medication, even after symptoms have disappeared.

Diagnostic / Laboratory Procedure

Indications or Purpose

Gram Stain AFB stain KOH preparation

It is used to classify bacteria as either grampositive or gramnegative based upon their ability to retain the crystal violet stain following

Date ordered Date results were released Date ordered 02/18/09 Date results were released

Results

Normal values Analysis and (units used in Interpretation of the hospital) Results

Gram (+) bacilli: Few Gram (-) bacilli: Few Fungal elements: Moderate

Gram stain: A normal result means no bacteria were seen in the sample. The sputum is clear, thin, and odorless.

Few gram positive and gram negative bacteria were seen and more of fungal elements. Fungal infection was then identified.

decolorization. In 02/18/09 addition, the Gram stain provides vital diagnostic information, aids in the selection of culture media, and dictates initial selection of antibiotics for treatment and antimicrobial susceptibility testing.The Gram stain is used to detect the presence of bacteria, yeast, and other cells in direct smears prepared from swabs, aspirates, secretions, etc. from any part of the body where infection is suspected. Acid fast bacilli (AFB) stain is helpful in rapid identification of bacterial infection so that therapy can be initiated in a timely manner. Potassium Hydroxide (KOH) preparation is used to identify fungal infection.

Yeast cells: Rare Pus cells: 48/HPF Epithelial cells: 24/HPF AFB stain: No acid fast bacilli seen KOH preparation: Positive for fungal elements

AFB stain: Negative for acid-fast bacilli. KOH preparation: A normal, or negative, KOH test shows no fungi (no dermatophytes or yeast).

Nursing Responsibilities Prepare your patient • Obtain a history of the patient’s complaints, including a list of known allergens.

• Obtain a history of the patient’s gastrointestinal, genitourinary, immune, reproductive, and respiratory system, as well as results of previously performed tests and procedures. • There are no food, fluid, or medication restrictions unless by medical direction. • Review the procedure with the patient. • The time it takes to collect a proper specimen varies according to the patient’s level of cooperation as well as the specimen collection site. Perform procedure • Label the specimen, and promptly transport it to the laboratory. Care after test • Instruct the patient to resume usual diet and medication as directed by the health care practitioner. • Instruct the patient to perform mouth care after the specimen has been obtained (for sputum specimens). • Note the color, consistency, and volume of the specimen collected. • Evaluate test results in relation to the patient’s symptoms and other tests performed. Related laboratory tests include bacterial and viral cultures.

Diagnostic / Laboratory Procedure

Indications or Purpose

Total protein

This blood test helps diagnose hepatic, gastrointestinal, and renal disease; protein abnormalities; cancer; and blood dyscrasias. This test measures serum albumin and globulins, which are the

Date ordered Date results were released Date ordered 02/18/09 Date results were released 02/19/09

Results

Normal values (units used in the hospital) 58-80g/L

Analysis and Interpretation of Results

52 g/L

There is marked decrease in protein of patient which may indicate malabsorption syndromes, malnutrition, hypervolemia, hepatic dysfunction, or hyperthyroidism.

body’s major blood proteins.

Albumin

Albumin is formed in the liver and comprises 50%-60% of the total serum protein. Its primary function is to maintain serum colloid osmotic pressure.

Date ordered 02/18/09 Date results were released 02/19/09

21 g/L

35-60 g/L

Globulin

The globulin molecules are much larger than the albumin molecules.

Date ordered 02/18/09 Date results were released 02/19/09

31 g/L

18-32 g/L

The albumin of the patient is significantly decreased; this may indicate malnutrition, severe malabsorption, third space loss, diffuse liver disease, or intestinal obstruction. The result is within the normal range.

A/G ratio

The albumin to globulin ratio is useful in the evaluation of liver and kidney disease. It assesses nutritional status of hospitalized patients, especially geriatric patients.

Date ordered 02/18/09 Date results were released 02/19/09

0.67 g/L

1.1-2.5 g/L

There was a marked decrease in albumin to globulin ratio which may indicate malabsorption and malnutrition.

Nursing Responsibilities Prepare your patient • Explain that the test is important to help check nutritional status, liver and kidney function, water balance, and to diagnose some diseases. • Instruct the patient that foods high in fat content should be avoided for 24 hours before the test. Perform procedure • Collect 5-7 mL of venous blood in a red-top tube. • Note patient’s activity level before the sampling on the laboratory slip. Care after test • Observe for signs and symptoms of abnormalities in blood protein such as recurring infections, peripheral edema, hepatomegaly, brittle hair, decreased body weight, and dehydration. • Evaluate other diagnostic tests such as the serum protein electophoresis, urine protein, hematocrit, hemoglobin, red blood cell count, calcium, bilirubin, antibodies, plasma protein S, and or immunoelectrophoresis. • If the test results indicate a protein deficiency, encourage the increased consumption of protein-rich foods, such as meat products, eggs, cheese, and beans. • Teach patient and family to notify staff of edema, weight gain, and shortness of breath, all signs of fluid retention into tissue spaces.

V.

THE PATIENT AND HIS ILLNESS

The Human Respiratory System
This system includes the lungs, pathways connecting them to the outside environment, and structures in the chest involved with moving air in and out of the lungs.

Air enters the body through the nose, is warmed, filtered, and passed through the nasal cavity. Air passes the pharynx (which has the epiglottis that prevents food from entering the trachea).The upper part of the trachea contains the larynx. The vocal cords are two bands of tissue that extend across the opening of the larynx. After passing the larynx, the air moves into the bronchi that carry air in and out of the lungs.

Bronchi are reinforced to prevent their collapse and are lined with ciliated epithelium and mucus-producing cells. Bronchi branch into smaller and smaller tubes known as bronchioles. Bronchioles terminate in grape-like sac clusters known as alveoli. Alveoli are surrounded by a network of thin-walled capillaries. Only about 0.2 µm separate the alveoli from the capillaries due to the extremely thin walls of both

structures. The lungs are large, lobed, paired organs in the chest (also known as the thoracic cavity). Thin sheets of epithelium (pleura) separate the inside of the chest

cavity from the outer surface of the lungs. The bottom of the thoracic cavity is formed by the diaphragm. Ventilation is the mechanics of breathing in and out. When you inhale, muscles in the chest wall contract, lifting the ribs and pulling them, outward. The diaphragm at this time moves downward enlarging the chest cavity. Reduced air pressure in the lungs causes air to enter the lungs. Exhaling reverses theses steps.

The Alveoli and Gas Exchange Diffusion is the movement of materials from a higher to a lower concentration. The differences between oxygen and

carbon dioxide concentrations are measured by partial pressures. The greater the difference in partial pressure the greater the rate of diffusion. Respiratory pigments increase the oxygencarrying capacity of the blood. Humans have the red-colored pigment hemoglobin as their respiratory pigment. Hemoglobin increases the oxygen-carrying capacity of the blood between 65 and 70 times. Each red blood cell has about 250 million hemoglobin molecules, and each milliliter of blood contains 1.25 X 1015 hemoglobin molecules. Oxygen concentration in cells is low (when leaving the lungs blood is 97% saturated with oxygen), so oxygen diffuses from the blood to the cells when it reaches the capillaries. Carbon dioxide concentration in metabolically active cells is much greater than in capillaries, so carbon dioxide diffuses from the cells into the capillaries. Water in the blood combines with carbon dioxide to form bicarbonate. This removes the carbon dioxide from the blood so

diffusion of even more carbon dioxide from the cells into the capillaries continues yet still manages to "package" the carbon dioxide for eventual passage out of the body. In the alveoli capillaries, bicarbonate combines with a hydrogen ion (proton) to form carbonic acid, which breaks down into carbon dioxide and water. The carbon dioxide then diffuses into the alveoli and out of the body with the next exhalation. Control of Respiration Muscular contraction and relaxation controls the rate of expansion and constriction of the lungs. These muscles are stimulated by nerves that carry messages from the part of the brain that controls breathing, the medulla. Two systems control breathing: an automatic response and a voluntary response. Both are involved in holding your breath. Although the automatic breathing regulation system allows you to breathe while you sleep, it sometimes malfunctions. Apnea involves stoppage of breathing for as long as 10 seconds, in some individuals as often as 300 times per night. This failure to respond to elevated blood levels of carbon dioxide may result from viral infections of the brain, tumors, or it may develop spontaneously. A malfunction of the breathing centers in newborns may result in SIDS (sudden infant death syndrome). As altitude increases, atmospheric pressure decreases. Above 10,000 feet decreased oxygen pressures causes loading of oxygen into hemoglobin to drop off, leading to lowered oxygen levels in the blood. The result can be mountain sickness (nausea and loss of appetite). Mountain sickness does not result from oxygen starvation but rather from the loss of carbon dioxide due to increased breathing in order to obtain more oxygen.

BOOK-BASED PATHOPHYSIOLOGY Schematic Diagram

Bronchiec

Predisposing Factors:  Recurrent Upper & Lower respiratory infections in early childhood  Measles  Influenza  Tuberculosis  Immunodeficiency disorders  Diffused airway injury  Airway obstruction  Immunodeficiency

Precipitating Factors:  Congenital disease such as cystic fibrosis (Genetic Disorder)  Idiopathic causes

Productive cough (purulent sputum)

Pulmonary infections damaging the bronchial walls

Inflammation of the bronchial walls

Airway obstruction (dyspnea) Abnormal breath sounds (rales & crackles upon auscultation)

Loss of supporting structures of the bronchi Permanent distention and distortion of bronchial walls

Impaired mucociliary clearance

Dilated bronchial tubes amounts to lung abscess

Retention of secretions and subsequent obstruction affects peribronchial tissues

Hemoptysis

Excessive exudates drains freely through the bronchus

Inflammatory scarring / fibrosis of bronchus replace the functioning of lung tissue A segment or lobe of lung collapse (bronchiectasis)

Respiratory insufficiency

Respiratory insufficiency

Reduced vital capacity

Decreased ventilation

Increased ratio of residual volume to total lung capacity

Ventilation – perfusion imbalance

Hypoxemia

Cyanosis (clubbing of fingers)

 Synthesis of the disease The inflammatory process associated with frequent pulmonary infections damages the bronchial wall, causing a loss of its supporting structure and resulting in thick sputum that ultimately obstructs the bronchi. The walls become permanently distended and distorted, impairing mucociliary clearance. The inflammation and infection extend to the peribronchial tissues; in the case of saccular bronchiectasis, each dilated tube virtually amounts to a lung abscess, the exudates of which drains freely through the bronchus. Bronchiectasis is usually localized, affecting a segment or lobe of a lung, most frequently the lower lobes. The retention of secretions and subsequent obstruction ultimately cause the alveoli distal to the obstruction to collapse (atelectasis). Inflammatory scarring or fibrosis replaces functioning lung tissue. In time, the patient develops respiratory insufficiency with reduced vital capacity, decreased ventilation, and an increased ratio of residual volume to total lung capacity. There is impairment in the matching of ventilation to perfusion (ventilation-perfusion imbalance) and hypoxemia.  Predisposing / Precipitating factors Bronchiectasis may be caused by a variety of conditions, including pulmonary infections and obstruction of the bronchus diffuse airway injury; genetic disorder (e.g, cystic fibrosis); and abnormal host defense (e.g, humoral immunodeficiency). A

person may be predisposed to bronchiectasis (history of recurrent infections, measles influenza, tuberculosis, and immunodeficiency disorders).  Signs and symptoms Clinical manifestations includes chronic cough and production of copius purulent sputum, which has a quality of “layering out” into three layers on standing a frothy top layer, a middle clear layer, and a dense particulate bottom layer. Hemoptysis, clubbing of fingers, and repeated episodes of pulmonary infections are also manifested.

CLIENT-BASED PATHOPHYSIOLOGY Schematic Diagram

Bronchiec
Predisposing Factors:  Recurrent Upper & Lower respiratory infections in early childhood  Recurrent Pneumonia Precipitating Factors:  Weak immune system  Idiopathic causes

Pulmonary infections damaging the bronchial walls Productive cough (purulent sputum) February 17, 2009 Stabbing chest pain Upon coughing in February 17, 2009 Abnormal breath sounds (rales & crackles upon auscultation) Rales in February 17, 2009; crackles on both lung fields in February 20 & 21 2009

Inflammation of the bronchial walls

Loss of supporting structures of the bronchi Permanent distention and distortion of bronchial walls

Impaired mucociliary clearance

Dilated bronchial tubes amounts to lung abscess

Retention of secretions and subsequent obstruction affects peribronchial tissues

Hemoptysis April 2005 and February 2008

Excessive exudates drains freely through the bronchus

Inflammatory scarring / fibrosis of bronchus replace the functioning of lung tissue A segment or lobe of lung collapse (bronchiectasis) First diagnosed on April 01, 2005 February 17, 2008 confined due to the cough with the same diagnosis

Respiratory insufficiency

Respiratory insufficiency

Decreased ventilation

Ventilation – perfusion imbalance Cyanosis (clubbing of fingers) February 07, 2007 And at P.E. as of February 20, 2009

Synthesis of the Disease a. Predisposing / Precipitating Factors The patient was born with a weak immune system since childhood. She experienced recurrent upper and lower respiratory infections such as cough, colds, and fever. Mild but frequent infections which weakened her respiratory tract. She also had pneumonia before and now to infections of it, one after the other. b. Signs and Symptoms with rationale noting the specific dates During the childhood of the patient she was frequently infected with mild illnesses such as cough, fever, and colds. She was born weak and frail. In April 1, 2005, she was diagnosed with Bronchiectasis by their doctor in the monastery. He noticed the way Ms. Minnie cough and he told her to go to his clinic. Several tests ere done afterwards, and the diagnosis was confirmed. She then started taking medicines for this disease which lasted until 2007. Along with these, clubbing fo fingers was also noted. The symptoms subside but the illness was not cured, it was noncurable but not progressive, stated by the patient. In February 07, 2008, she was diagnosed with pneumonia and a fungal infection. After being discharged she was given cyclic medicines for 6 weeks. First week of February, 2009, she was confined due to massive edema on her upper and lower extremities. She was given treatment and was discharged few days after.

February 17, 2009, she experienced chronic cough and weakness. And another fungal infection and pneumonia were diagnosed. VI. THE PATIENT AND HIS CARE

A. IVFs, BT, NGT feeding, Nebulization, TPN, Oxygen Therapy, etc. Medical General Indications / Date Ordered, Client’s Management Description Purpose Date Performed, Response to Date Changed Treatment or D/C Intravenous D5 NR 1L x 15 5 % Dextrose Date ordered: The fluid was fluid (IVF) gtts/min in Balance 02/17/09 administered Multiple Date performed: with no adverse Replacement 02/17/09 reaction at first Solution At 05:00 pm on the right arm (D5NR): When Date Changed: but after administered 02/19/09 approximately D5 NM 1L x 15 intravenously, Date ordered: 1-2 hours of IV Ionosol T and infusion (as gtts/min 02/18/09 5% Dextrose Date performed: stated by the Injection patient) the fluid 02/19/09 provides a Date Changed: stopped source of water, dropping. The 02/20/09 electrolytes, and nurse on duty D5 NR 1L x 15 Date ordered: carbohydrate. was notified and gtts/min 02/19/09 The solution she tried to Date performed: was originally reinsert the 02/20/09 designed as a needle but an Date Changed: pediatric artery was 02/21/09 fluid/electrolyte accidentally D5 NM 1L x 15 replacement Date ordered: pricked and it gtts/min 02/20/09 formula, became swollen. Date performed: It was providing 02/21/09 nearly equal transferred to At 7pm amounts of the left arm. sodium, Blood potassium, and coagulated again chloride; and so it was phosphate and inserted on the lactate are also left arm again. present, along For the third with dextrose. fluid, it was administered 5 % Dextrose again on the in Balance right arm after Multiple the swelling had

Maintenance Solution (D5NM): When administered intravenously, Normosol-M and 5% Dextrose Injection provides water and electrolytes (with dextrose as a readily available source of carbohydrate) for maintenance of daily fluid and electrolyte requirements, plus minimal carbohydrate calories. Nursing Responsibilities Prepare your patient • Countercheck doctors order to IVF solution on hand. • Check the expiration date. • Check for clarity of the fluid. • Explain the procedure to the patient. • Check for the condition and size of the vein. • Record things done and note patient’s response. Perform procedure • Perform peripheral venipuncture. • Regulate according to doctors order. • Observe for adverse reactions e.g. Swelling, obstruction. • Record patient’s response. Care after test • Check for doctor’s order for discontinuing order or fluid to follow. • Monitor IVF regulation as well as patency. • Check for any swelling at the venipuncture site. B. Drugs

ceased. No further adverse reaction was observed afterwards.

Generic Name and Brand Name

General Action

GENERIC NAME: Hydrocortisone Sodium succinate BRAND NAME: Solu-Cortef DOSE, ROUTE, FREQUENCY: 100mg IV Q6°

Decreases inflammation, mainly by stabilizing leukocyte lysosomal membranes; suppresses immune response; stimulates bone marrow; and influences protein, fat, and carbohydrate metabolism.

Indication or Purpose why medication is given for the particular disease condition or signs and symptoms It is indicated for severe inflammation, adrenal sufficiency. It is a corticosteroid hormone which increases

Date Ordered, Date Started, Date Changed or D/C

Client’s Response to the medication with actual side effects

Date ordered: 02/17/09 Date started: 02/17/09

There were no adverse reactions experienced by the patient e.g. hypersensitivity, bruising, hypokalemia.

Nursing Responsibilities Prior administration • Always observe the 10 rights for medication administration. • Determine whether patient is sensitive to other corticosteroids. • For better results and less toxicity, give a once-daily dose in morning. During administration • Alert: only hydrocortisone sodium phosphate and sodium succinate can be given I.V. • Always adjust to lowest effective dose. • Monitor patient’s weight, blood pressure, and electrolyte level. • Inspect patient’s skin for petechiae. • Gradually reduce dosage after long-term therapy. Care after administration • Teach patient signs and symptoms of early adrenal insufficiency: fatigue, muscle weakness, shortness of breath, dizziness, and fainting. • Warn patient about easy bruising. Generic Name and Brand Name General Action Indication or Purpose why medication is Date Ordered, Date Started, Date Changed Client’s Response to the medication with

GENERIC NAME: Montelukast sodium BRAND NAME: Kastair DOSE, ROUTE, FREQUENCY: 100mg TAB BID

Selective, competitive leukotrienereceptor antagonist that reduces early and late-phase bronchoconstriction from antigen challenge.

given for the particular disease condition or signs and symptoms It is indicated for asthma, allergic rhinitis or bronchial asthma.

or D/C

actual side effects

Date ordered: 02/17/09 Date started: 02/17/09

There were no adverse reactions experienced by the patient e.g. dental pain, dyspepsia, abdominal pain, and rash.

Nursing Responsibilities Prior administration • Always observe the 10 rights for medication administration. • Assess patient’s underlying condition and monitor patient for effectiveness. • Drug isn’t indicated for use in patients with acute asthmatic attacks, status asthmaticus, or as monotherapy for management of exercise-induced bronchospasm. • Oral granules may be given without regard to meals. During administration • Inform the patient about the indication and action of the medication. Care after administration • Tell caregiver not to open packet until ready to use and after opening, to give the full dose within 15 minutes. Tell her that if she’s mixing the drug with food, not to store excess for future use and to discard the unused portion. • Advise patient to take drug daily, even if asymptomatic, and to contact his prescriber if asthma isn’t well controlled. • Advise patient with known aspirin sensitivity to continue to avoid using aspirin and NSAIDs during drug therapy. Generic Name and Brand Name General Action Indication or Purpose why medication is given for the particular Date Ordered, Date Started, Date Changed or D/C Client’s Response to the medication with actual side effects

GENERIC NAME: Hydroxyzine Dihydrochloride BRAND NAME: Iterax DOSE, ROUTE, FREQUENCY: 25mg TAB BID

Suppresses activity in certain essential regions of the subcortical area of the CNS.

disease condition or signs and symptoms It is indicated to reduce anxiety of patient.

Date ordered: 02/17/09 Date started: 02/17/09

The patient stated that she feels relaxed when this medication is given to her.

Nursing Responsibilities Prior administration • Always observe the 10 rights for medication administration. • If patient takes other CNS drugs, observe for over sedation. • Elderly patients may be more sensitive to adverse anticholinergic effects; monitor these patients for dizziness, excessive sedation, confusion, hypotension, and syncope. During administration • Inform patient about indication and action of the medication. Care after administration • Warn patient to avoid hazardous activities that require alertness and good coordination until effects of drug are known. • Tell patient to avoid alcohol while taking drug. • Advise patient to use sugarless hard candy or gum to relieve dry mouth

Generic Name and Brand Name

General Action

Indication or Purpose why medication is given for the particular disease condition or signs and symptoms

Date Ordered, Date Started, Date Changed or D/C

Client’s Response to the medication with actual side effects

GENERIC NAME: Meropenem Trihydrate BRAND NAME: Meronem DOSE, ROUTE, FREQUENCY: 1g IV Q12°

Inhibits cellwall synthesis in bacteria. Readily penetrates cell wall of most gram-positive and –negative bacteria to reach penicillinbinding protein targets.

It is indicated for the treatment of fungal infection.

Date ordered: 02/17/09 Date started: 02/17/09

There were no adverse reactions experienced by the patient e.g. headache, pain, vomiting, anemia, and constipation.

Nursing Responsibilities Prior administration • Always observe the 10 rights for medication administration. • Obtain specimen for culture and sensitivity test before giving. Begin therapy awaiting test results. • If seizures occur during therapy, stop infusion and notify physician. Dosage adjustment may be needed. During administration • Monitor patient for signs and symptoms of superinfection. Drug may cause overgrowth of nonsusceptible bacteria or fungi. • Monitor patient’s fluid balance and weight carefully Care after administration • Instruct patient to report adverse reactions or signs and symptoms of superinfection. • Advise patient to report loose stools to physician.

Generic Name and Brand Name

General Action

GENERIC

Mucolytic that

Indication or Purpose why medication is given for the particular disease condition or signs and symptoms It is indicated

Date Ordered, Date Started, Date Changed or D/C

Client’s Response to the medication with actual side effects

Date ordered:

The patient

NAME: Acetylcysteine BRAND NAME: Fluimucil DOSE, ROUTE, FREQUENCY: 600mg TAB dissolve in 50mL water TID

reduces the viscosity of pulmonary secretions by splitting disulfide linkages between mucoprotein molecular complexes. Also, restores liver stores of glutathione to treat acetaminophen toxicity.

for adjunct therapy for abnormal viscid or thickened mucous secretions.

02/17/09 Date started: 02/17/09

expectorated yellowish mucous secretions after administration of medication.

Nursing Responsibilities Prior administration • Always observe the 10 rights for medication administration. • Drug smells strongly of sulfur. Mixing oral form with juice or cola improves its taste. • Monitor cough type and frequency. During administration • Use fresh oral dilution within 1 hour. • Dilute oral dose (used for acetaminophen overdose) with cola, fruit juice, or water. Care after administration • Warn patient that drug may have a foul taste or smell that may be distressing. • For maximum effect, instruct patient to cough to clear his airway before aerosol administration.

Generic Name and Brand Name

General Action

GENERIC NAME:

It is a supplement for

Indication or Purpose why medication is given for the particular disease condition or signs and symptoms Underweight due to lack of

Date Ordered, Date Started, Date Changed or D/C

Client’s Response to the medication with actual side effects

Date ordered: 02/19/09

There were no adverse

Pizotifen hydrogen maleate BRAND NAME: Mosegor Vita TAB BID Q12°

deficiency of vitamin B. It is also an appetite enhancer.

appetite associated w/ vitamin B deficiency secondary to impaired dietary intake or absorption; old age when prevention of deficiency of Bgroup vitamin is indicated.

Date started: 02/19/09

reactions experienced by the patient e.g. headache, pain, vomiting, anemia, and constipation.

Nursing Responsibilities Prior administration • Always observe the 10 rights for medication administration. • Explain to the patient the indication and action of the medication. • Counter check doctor’s order with drug on hand. During administration • Instruct the patient to take the medication with or without meals; taken best before meals to improve appetite. Care after administration • Observe for any side effects.

Generic Name and Brand Name

General Action

GENERIC NAME: Voriconazole

It inhibits the cytochrome P450-dependent

Indication or Purpose why medication is given for the particular disease condition or signs and symptoms It is an antiinfective specifically

Date Ordered, Date Started, Date Changed or D/C

Client’s Response to the medication with actual side effects

Date ordered: 02/19/09 Date started:

There were no adverse reactions

BRAND NAME: Vfend 200mg/vial IV

synthesis of ergosterol, a vital component of fungal cell membranes.

anti-fungal indicated for the patient’

02/19/09

experienced by the patient e.g. fever, headache, hypokalemia, chills, and pruritus.

Nursing Responsibilities Prior administration • Always observe the 10 rights for medication administration. • Monitor liver function test results at start of and during therapy. Monitor patients who develop abnormal liver function test results for more severe hepatic injury. If patient develops signs and symptoms of liver disease, drug may need to be stopped. During administration • Inform the patient about the indication and action of the medication. • Monitor renal function during treatment. For patients with creatinine clearance less than 50 ml/minute, give the oral form. Care after administration • Tell patient to avoid strong, direct sunlight during therapy. • Tell patient to discard any unused portion of suspension after 14 days. C. Diet Type of diet General Action Indication or Purpose Indicated for patients unable to consume a regular diet and patients wild mild G.I. problems. It was with aspiration precaution so as to avoid airway obstruction like that of a regular diet. Date Ordered, Date Started, Date Changed or D/C Date ordered: 02/17/09 Date started: 02/17/09 Client’s Response and/or reaction to diet Since the patient was oriented and understands needed interventions, she followed meticulously with the doctors prescriptions. Food that is prepared by the hospital is likely consumed. And she was told to notify the staff nurses if aspiration occurs.

Soft diet with aspiration precaution

This type of diet is often used during transition from liquid diet to regular or general diets. Whole foods low in fiber and only lightly seasoned foods are used. Food supplements or between meals snack may be used if needed to add Kcalories. Aspiration

precaution is indicated to avoid incidents of airway obstruction which may be cause harmful effects to the patient. Nursing Responsibilities Prior • Verify doctor’s order. • Explain the diet prescribed to the patient. • Identify foods that are allowed to be taken by the patient such as fluids, meat that are tender in consistency, milk, and fruits such as banana. During • Ensure that the patient strictly follow the diet. After • Tell the patient to report immediately if any aspiration occurs. D. ACTIVITY Type of General exercise description Keep rested An activity where strenuous activities should be avoided. Bed rest should be implemented but with assisted bathroom privilege Indication or Purpose Indicated to avoid fatigue and difficulty of breathing and to promote expansion of lungs. Date Ordered, Date Started, Date Changed or D/C Date ordered: 02/18/09 Date started: 02/18/09 Client’s Response and/or reaction to activity For two days NPI, patient was seen lying on bed. This means that the patient complied with the doctor’s order. The patient also had limited to no visitors giving her lots of time to rest. Mrs. Minnie asks assistance whenever she needs to go to the bathroom.

Nursing Responsibilities

Prior • Check doctor’s order for any other considerations needed. • Explain the activity to the patient. • Explain why it is important and what it could improve in her condition. During • Assess patient’s present condition. • Reinforce information as appropriate. After • Note patient’s response to activity. • Tell the patient to report immediately if difficulty in breathing, weakness, or fatigue persists.

VII.

NURSING CARE PLAN Objectives After 8 hours of nursing intervention, the patient will be able to expectorate secretions to maintain/achieve a patent airway. Nursing Interventions • Elevate head of bed/change position every two hours Rationale • To take advantage of gravity, decreasing pressure in the diaphragm • To maximize effort of inhalation • Hydration can help liquefy viscous secretions thus improving secretion clearance • To report changes in color and amount to determine if medical Evaluation The patient expectorated yellowish sputum/phlegm of about 60 ml within 4 hours and demonstrated behavior of following health teachings.

INEFFECTIVE AIRWAY CLEARANCE Assessment Nursing Scientific Diagnosis Explanation Subjective: Ineffective Bronchiectasis is “There is cough airway clearance a chronic with minimal related to irreversible secretions.” retained dilation of the secretions as bronchi and Objective evidenced by bronchioles. patient productive and Such dilation of manifested: ineffective the bronchial cough. walls causes • RR of 26 brpm disruption of • Use of normal air accessory pressure in the muscles bronchial tubes, • Productive causing airflow cough obstruction and • Yellowish pooling of secretions of sputum inside the approximatey dilated areas 30 mL within 3 instead of being hours pushed upwards. • Crackles Unable to auscultated on expectorate both lung fields secretions this • Dryness of now leads to mouth ineffective • No adventitious airway clearance. bowel sound

• Encourage deepbreathing and coughing exercises • Encourage increase of fluid intake at least 2 L/day

• Provided information about necessity of raising and expectorating secretions vs.

noted

swallowing them • Obtain and refer specimen to laboratory as ordered • Administered expectorants / bronchodilators as ordered such as:  Solu-Cortef 100mg IV at 8 am;  Montekulast Na 10mg TAB at 8 am;  Fluimucil 600mg dissolved in 50 ml water at 8 am and 1 pm.

intervention may be needed • To determine if therapy is effective • To metabolize secretions

INEFFECTIVE BREATHING PATTERN

Assessment Subjective: “I use the oxygen only when I’m having difficulty in breathing”. Objective: patient manifested: • RR of 26 • Deep shallow breathing • Use of accessory muscles • Minimal difficulty of breathing

Nursing Diagnosis Ineffective breathing pattern related to respiratory muscle fatigue as evidenced by use of accessory muscles and an RR of 26 brpm.

Scientific Explanation Repeated episodes of pulmonary infection stressed great risk to the respiratory muscles which leads to this bronchiectasis. With those frequent infections, muscles that are necessary for normal respiratory functions are weakened. Retained secretions also add to the condition which obstructs airway leading to ineffective breathing pattern.

Objectives

After 4 hours of nursing intervention, the patient will be able to verbalize ways to maintain comfort or relief • Administer from difficulty of oxygen at lowest breathing. concentration indicated • Elevate HOB or have patient sit up in bed as appropriate

Nursing Interventions • Auscultate breath sounds

Rationale • To evaluate presence / character of breath sounds/ secretions • For management of underlying pulmonary condition • To promote physiological / psychological ease of maximum inspiration • To correct hyperventilatio n • To limit level of anxiety • To promote relief from difficulty of breathing

Evaluation The patient verbalized ways of achieving comfort and ways to perform to have an effective respiratory pattern.

• Have patient breathe into a paper bag, if appropriate • Maintain calm attitude while dealing with patient and S.O • Assist patient in the use of relaxation technique such as deep breathing, • Stress the importance of good posture and effective use of accessory muscles

• To maximize respiratory effort

IMPAIRED GAS EXCHANGE

Assessment

Nursing Diagnosis

Scientific Explanation There are many millions of alveoli in each lung, and these are the areas responsible for gaseous exchange. In Bronchiectasis, the retention of the secretions in the bronchial walls will affect the peribronchial tissues, lung functioning will be replace thus a collapse in a lobe or segment of the lung will cause respiratory insufficiency. The small blood vessels in the lungs (capillaries) become leaky, and proteinrich fluid seeps into the alveoli. This results in a less functional area for oxygen-carbon dioxide exchange (ventilationperfusion imbalance). The patient becomes relatively oxygen deprived, while retaining potentially damaging carbon dioxide. The patient breathes faster and faster, in an effort to

Nursing Planning After 2hours of nursing intervention, the patient will be able to improved ventilation, oxygenation, and participate in treatment regimen. Interventi ons • Assess patient's condition. Monitored V/S and recorded. • Observe color of skin and nail beds. • Rationale To have a baseline data. To determine manifestations of respiratory distress. Evaluation Patient participated in treatment regimen provided and improved ventilation and oxygenation as evidenced by absence of signs and symptoms of respiratory distress.

Subjective: Ø Objective •Dyspnea •Shortness of breath •Cyanosis (pale palpebral conjunctiva, poor capillary refill) •Use of accessory muscles in breathing •Productive cough with yellowish sputum noted. •Limited movements and needs assistance in repositioning •RR=26bpm •Body temperature of 36.2ºC •PR-83bpm •BP130/70mmHg

Impaired gas exchange RT altered oxygen supply as evidenced by dyspnea, SOB, and cyanosis secondary to bronchiectasis.

• To note presence of peripheral cyanosis indicating systemic hypoxemia. • To reveal presence of pulmonary congestions and indicate the need for further evaluation. •Restlessnes s, irritation, confusion may reflect hypoxemia/ decreased cerebral oxygenation •To promote relaxation and aid in expectoratio n of

• Auscultate breath sounds

•Assess mental status.

•Perform back rub

KNOWLEDGE DEFICIT

Assessment

Nursing Diagnosis

Scientific Explanation The patient’s previous inexperience with hospitalization will cause an insufficient knowledge in the patient as well as the significant others.

Planning After 1 hour of presentation and discussion of the disease, the patient will: Verbalize understanding of condition, prognosis, and complications. Verbalize understanding of therapeutic regimen and participate in treatment program. Correctly perform activities of selfcare.

Nursing Interventions • Review pathology, prognosis, and future expectations. •

Rationale Promotes understanding of current situation and importance of cooperating with treatment.

Evaluatio n Patient verbalized understanding of appropriate interventions with regards to the disease. Participated with the discussion and performed her activities regarding self care.

Subjective: “I don’t know how I got this disease ”

Knowledge deficit regarding condition, Objective: treatment and self care related • Request for information by to lack of frequent asking exposure to her condition as about the manifested by disease frequent asking, • Confusion of confusion, and how the signs and symptoms statement of misconception develop. about the • Statement of misconception disease entity.

• Discuss debilitating aspects of disease, length of convalescence, and recovery expectations.

• To provide information that can enhance coping and help reduce anxiety and excessive concern. • To prevent recurrence of pneumonia cause patient is still at high risk even after discharge. • Encourage patient’s compliance with treatment and rationalization of the medicines give. • Increase natural

• Stress importance of continuing effective coughing/deep breathing exercises.

• Discuss the reason for the treatment and complications if untreated.

• Outline steps to enhance general

FATIGUE

Assessment

Nursing Diagnosis

Scientific Explanation In Bronchiectasis, mucous production is constant and accumulates in the brochial tree specifically the bronchioles. Retained secretions obstruct the air pathway causing difficulty in breathing. The body compensates by increasing the respiratory rate, this now can lead to sleep disturbance. Sleep is vital for cells to regenerate, especially for a hospitalized person; therefore it results to weakness and fatigue.

Planning After 4 hours of nursing intervention, the patient will demonstrate behaviours of effective coping mechanism.

Nursing Interventions • Determine degree of sleep disturbance

Rationale • Fatigue can be a consequence of, and/or exacerbated by, sleep deprivation • To maximize participation

Evaluatio n The patient demonstrated behaviours of effective coping mechanism.

Subjective: “I was not able to sleep last night.” Objective: Patient manifested: • Difficulty of breathing • RR of 26brpm • Use of accessory muscles • Deep eye bags

Fatigue related to difficulty of breathing and sleep deprivation

• Plan interventions to allow individually adequate rest periods. Schedule activities for periods when patient has the most energy. • Monitor vital signs specially respiration rate • Provide quiet environment, cool room and decrease sensory stimuli • Encourage patient to restrict activity and rest in bed as much as possible

• Respiration is typically elevated even if at rest • Reduces stimuli that may aggravate agitation and fatigue • To help counteract effects of increased metabolism • To promote lung expansion • Presence of anemia/hypoxe mia reduces

• Elevate head of bed as appropriate • Provide supplemental oxygen, as indicated

VIII. TOPIC: TIME ALLOTMENT: VENUE:

DISCHARGE PLAN

Promoting Home Health Care, Self-Based Care 30 minutes Angeles Medical Center—Executive Room 226 (Bedside)

OBJECTIVE

CONTENT

TIME ALLOTMENT
30 minutes

TEACHING STRATEGIES

EVALUATION

At the end of discussion Presentation of Disease Factors contributing to the the patient shall have: development of the • Determine the good effects of health promotion and disease prevention through home and community-based care. • Understand the disease entity and its prevention. • Improve and Disease Health Promotion in Older Adults • • Self Care Home

Discussion Question and Answer • INTRODUCTION  Ask the patient what is her knowledge about the disease.  Discussion of the Presentation of the disease (Bronchiectasis)  factors contributing to the development of the disease • MOTIVATION

At the end of discussion: • The patient was able to participate by asking questions and answering the questions of the student nurse. • Patient was able to understand the disease and how to prevent its occurrence. • Patient was able to know some tips for Home Health Care and

Health Care Patterns of Healthy eating and Healthy activity that promotes general wellbeing.

maintain the patient’s quality of life. • Act correctly on how to protect their body through selfcare and management teachings. • The patient can able to spread the information given to them by telling her family member’s especially older adults and encourage them to practice the same activities to promote general

Ask who among the

Self Care at the same time practice the teaching given.

family had the disease, what are their home treatments, and how do they do to prevent the recurrence of the disease. • GENERALIZATION  Good effects of Healthy eating and Healthy activity particularly older adults promote health and wellness. • CLOSURE  Ask the patient what did she learned from the health teaching given.

well-being.

IX. LEARNING DERIVED FROM THE STUDY The core purpose of this study is to have a deep comprehension about certain diseases and to build a better understanding pertinent to those clients committed to our care. In scenarios they are most vulnerable and susceptible to certain changes that we could somehow supplement them with our own understanding and knowledge, hence a two-wayprocess is the ultimate outcome. Truth of the matter is it is not limited on the superficial understanding that student nurses or health care providers on the process of studying patient’s condition will gain benefit with the course of action. But it is within the process that, patients gain something from it for the reason that one of our job description is to aid them health related teaching that will promote a better health condition for them. Furthermore, it is not only bounded with information that we may employ but being there with them at their most downfall moment will at least give them the support that they may need. Something not so great but for them, that little thing makes a difference. First hand information and experience is the best way to understand things and that is the main reflection upon the completion of the study. Patient’s with complicated pathology of disease and with idiopathic cause are sometimes so interesting to the point that you search and explore even beyond your own limitation just to give an exact, current and suited information to our client for us to identify ourselves as effective health care provider. For the reason that we did something for them, that we fulfill our purpose. As a final analysis, everyday is a new experience and everyday is an opportunity to gain something. It’s an advantage on our part that now we experience actual cases that we could refer on to, we can surpass our own endeavor by utilizing and maximizing every opportunity. One of the great opportunities is to complete an actual case study. Through this case study, we should be able to learn and understand the disease Bronchiectasis and therefore give us knowledge in proper management, prevention and treatment. As a student nurse, it is very important to know many things including the said disease condition. After the hardships of completing our case study, a reward of selffulfillment and credential to our knowledge and skills has been added to us being student nurses as well as professionals in the near future. REFERENCE: Gadaeke, M. K..1996. Laboratory and diagnostic test handbook. Addison-Wesley Publishing Company Inc. Malarkey, L. M..et al. 2005. Nursing guide to laboratory and diagnostic test. St. Louis Missouri, El Sevier Inc. Grodner, M. et al. 2004. Foundations and clinical applications of nutrition: a nursing approach. 3rd edition. Mosby, Inc. Deaths from Bronchiectasis: 970 deaths (NHLBI 1999) Retrieved March 4, 2009 form the world wide web,
http://www.wrongdiagnosis.com/b/bronchiectasis/stats.htm

Johnson, J.Y.2008. Textbook of Medical-surgical nursing. 11th edition. Lippincott Williams & Wilkins

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