5 Patient and His Care

V.
THE PATIENT AND HIS CARE

A. Medical Management
a. Intravenous Fluids
Intravenous
Fluid/
Regulations
# 1 Plain Normal
Saline Solution
(0.90%)
1 Liter
(80 mL/hour)
Approximately 27
macrodrops per
minute with drop
factor of 20 drops
per mL
Date Started
Date Modified
Date Consumed
Date Started:
February 12, 2015
Hooked Outside
Date Consumed
February 13, 2015
4 AM
General
Description
Normal
saline
solution is a solution
of common salt in
distilled water, of
strength of 0.9 per
cent. It is called
normal
saline
because
the
percentage of salt
resembles that of
the crystalloids in
the blood plasma.
Another
way
of
stating this is to say
that normal saline is
isotonic. An isotonic
solution
is
less
irritating to the body
cells.
Indication(s) or Purposes
The said fluid is generally used among

patients that need fluid replacement as a
result of a decrease in blood volume;
hence it is often called as the universal
blood volume expander.
PNSS is isotonic with Osmolality of 308
with no caloric and dextrose content,
therefore a good source of fluid for
patients having blood sugar level problem
especially those with Diabetes Mellitus.
Patient Xs blood sugar level was already
elevated. This type of fluid would restrict
excessive glucose to the patient which
may worsen hyperglycemia.
Patients
Response to the
Treatment
The
patient
responded well to
the
treatment
without
any
abnormal
signs
and
symptoms
observed. There
was
no
hypotensive and
hypoglycemic
episode
noted.
The vein was
maintained open
as an access to
intravenous
medications.
The physicians initially started an

Intravenous line with such solution as this
type of solution is the most compatible
It is generally the with most medications. This is a safe
most
compatible solution to be started in the given
fluid
for
many situation.
medications that are
needed
to
be
85
#2 5% Dextrose
in Lactated
Ringers Solution
Date Started
February 13, 2015
4 AM
80 mL per hour
Approximately 27
macrodrops per
minute with drop
factor of 20 drops
per mL
Date terminated
February 14, 2015
6 AM
#3-7 5% Dextrose
in Normosol-M
Date Started
February 13, 2015
4 AM
Date terminated
February 18, 2015
8 PM
incorporated to IVF
for
intravenous
administration,
because
of
its
tonicity and stability.
D5
LRS
is
a
hypertonic solutions.
This type of solution
has an effective
osmolarity greater
than the body fluids.
This pulls the fluid
into the vascular by
osmosis resulting in
an
increase
vascular volume. It
raises intravascular
osmotic
pressure
and provides fluid,
electrolytes
and
calories for energy.
It is a hypotonic
solution
which
makes the cells
shrink composes of
water
and
carbohydrates
as
source of energy
and both cations
and amino acids.. It
is
one
of
the
intravenous
solutions containing
high
amount
of
potassium
This solution useful for daily maintenance

of body fluids and nutrition, and for
rehydration. It contains electrolytes
including, Sodium, Potassium, Calcium,
and chloride. This also contains Lactate
and Dextrose that could serve as a
source of energy.
This type of solution was given to Patient
X as a nutritional aid and to increase
plasma volume as the patient is highly at
risk for dehydration. It is also used to
maintain the intravenous line open for
administration of medications.
D5NM is indicated for parenteral

maintenance of routine daily fluid and
electrolyte requirements with minimal
carbohydrate calories from dextrose.
This type of solution was indicated for

Patient X as his potassium level upon
admission was 3.91 mmol/L which means
that he has a normal potassium level, but
also almost at the borderline low
(3.5mmol/L) This type of intravenous fluid
The Patient did

not manifest any
signs
of
dehydration which
is great indication
that the patient
responded well to
the treatment. His
lined
also
remained patent
and intravenous
medication were
given accordingly.
The patient did

not become show
any signs and
symptoms of
hypokalemia and
hypoglycaemia.
His intravenous
lines were also
maintained open
as a route for
administering
intravenous
medications.
86
could actually help prevent hypokalemia.
Nursing Responsibilities for starting and maintaining an Intravenous site

Before:
Verify prescriptions for IV therapy
Check solution label and identify patient
Explain procedure to the patient
Carry out hand hygiene and put on disposable non-latex gloves
Apply a tourniquet 4-6 inches above the sites apply identify a suitable vein
Choose site. Use distal veins of hands and arms first
Raise bed for comfortable working height and position for patient and adjust lighting
During:
Explain to the patient what you are going to do, why it is necessary, and how he can cooperate
Question the patient carefully about sensitivity to latex, use blood pressure cuff rather than latex tourniquet if there is
sensitivity
Apply a new tourniquet for each patient and palpate for a pulse distal to the tourniquet
With hand not holding the venous access devise, steady patients arm and use finger to pull skin taut
Hold needle bevel up and at 5-25 degree angle, depending on the depth of vein
If backflow of blood is visible, straighten angle and advance needle. Additional steps for catheter is inserted over the needle:
Hold needle hub, and slide catheter over the needle and vein
87
Remove while pressing lightly on the skin over the catheter tip
Release tourniquet and attach infusion tubing: open clamp enough to allow drip
Cover and tape the small loop of IV tubing onto the dressing
Calculate infusion rate and regulate flow of infusion
After:
Document date and time therapy initiated
Monitor vital signs
Check the level of the IV as per hospital policy
Tape the IV lines
Dress and label the venipuncture according to the hospital policy
Instruct the patient to inform the health care professionals should there be any swelling or redness on insertion site which
may be a sign for dislodged IV line
Regularly check regulation of IVF.
88
b. Oxygen Treatment
Type of Oxygen
Delivery
Settings
% or LPM
Mechanical
Ventilator
Date Started
Date Modified
Date Discontinued
AC MODE;
BUR; 25;
VT; 200;
PEEP 4
FIO2-70%
Date Started
February 12, 2014
12:55 PM
AC MODE;
BUR; 25;
VT; 200;
PEEP 4
FIO2-65%
Date Modified
February12, 2015
6 PM
AC MODE;
BUR; 25;
VT; 200;
PEEP 4
FIO2-60%
Date Modified
February 12, 2015
9 PM
AC MODE;
BUR; 18;
VT; 200;
PEEP 4
FIO2-60%
Date Modified
February 13, 2015
12 AM
AC MODE;
BUR; 15;
VT; 200;
Date Modified
February 13, 2015
3 AM
General Descriptions
Patient Indication
The delivery of oxygen

to the bodys cells is a
process that depends
upon the interplay of the
pulmonary, hematologic,
and
cardiovascular
systems.
Specifically,
the processes involved
include
ventilation,
alveolar gas exchange,
oxygen transport and
delivery, and cellular
respiration
(Delaune,
2010).
The indication of oxygen

support to the patient is
only to promote rest to the
patient and to aid in
increasing
the
oxygen
delivery to the body of the
patient as the patients
respiratory muscles are
affected by his condition in
which the muscles are too
weak to provide adequate
ventilation to the patient.
Mechanical ventilation is
the use of a mechanical
device (machine) to
inflate and deflate the
lungs.
Mechanical
ventilation provides the
force needed to deliver
air to the lungs in a
patient
whose
own
ventilator abilities are
diminished or lost (Bach,
2015).
Patients Response to the

Treatment
The patient responded very
well to the treatment as he
did not develop any signs
of
respiratory
distress
during the hospital stay as
evidenced by a decrease in
oxygen saturation based
from the cardiac monitor.
Moreover, there was no
hypoxemic event noted.
The
patient
also
complained
of
throat
discomfort because of the
endotracheal tube inserted
The patient was also able
to tolerate the weaning
process hence the patient
was eventually extubated
and
removed
from
ventilator support.
89
PEEP 4
FIO2-60%
CPAP
FiO2-60%
PEEP- 4
AC MODE;
BUR; 15;
VT; 200;
PEEP 4
FIO2-60%
CPAP
FiO2-60%
PEEP- 4
AC MODE;
BUR; 15;
VT; 200;
PEEP 4
FIO2-60%
CPAP
FiO2-60%
PEEP- 4
Date Modified
February13, 2015
6 AM-12 PM
Increments and
Decrements of 30
minutes
*See Figure 5.1
Date Modified
February13, 2015
12 PM 12 AM
Increments and
Decrements of
1 Hour
*See Figure 5.1
Date Modified
February14, 2015
12 AM
Continuous
*See Figure 5.1
90
Face Mask at
6 LPM
Date Started
February 14, 2015
7 AM 7:30 AM
O2 Via Nasal
Cannula at
2 LPM
Date Started
February14, 2015
7:30 AM 12 PM
Date Discontinued
February 17, 2015
12 PM
(Shifted to PRN
Basis)
Face masks that cover

the clients nose and
mouth may be used for
oxygen
inhalation.
Exhalation ports at the
side of the mask allow
exhaled carbon dioxide
to escape. The patient
utilized a simple face
mask which delivers
oxygen
concentration
from 40-60% at Liter
flows of 5 to 8 LPM,
respectively
(Kozier,
2010).
The
nasal
cannula
(nasal prongs) is the
most
common
and
inexpensive device used
to administer oxygen.
The nasal cannula is
easy to apply and does
not interfere with the
clients ability to eat or
talk. It is relatively
comfortable,
permits
some
freedom
of
movement and is well
tolerated by the client. It
delivers a relatively low
concentration of oxygen
(24 to 45 %) at flow
rates of 2-6 LPM
(Kozier, 2010).
Since the patient was newly

extubated,
the
patient
would still be needing
oxygen
support.
The
physician
ordered
an
oxygenation support via
face mask after the patient
was extubated to assess
the patients need for higher
or
lower
oxygen
concentration delivery.
The patient showed no sign

of respiratory distress after
he was extubated since his
oxygen saturation did not
decrease (97-100%). He
was also uncomfortable
with the oxygen mask,
hence, after 30 minutes of
face mask, the physician
ordered to shift the mask to
a simpler oxygen delivery
system i.e. nasal cannula.
Patient Xs myasthenic
crisis has already been
resolved. His respiratory
muscles are no longer
weak; hence he can
breathe on his own with no
mechanical support. This
type of oxygen delivery
system only serves as a
support in the event that the
patients oxygen demand
increases. A room air
contains 21% of oxygen
while the patients setting
for oxygen delivery is set at
only 27% (2LPM)
Patient X did not like the

nasal cannula as he would
always say that it is as if he
is breathing gasoline. He
would remove it at his own
convenience, but there
were no noted signs of
respiratory distress even if
the patient has no oxygen
support. The physician then
ordered to remove the
nasal cannula and give
oxygen support in cases
that he would be under
respiratory distress.
91
Time
6 AM 6:30 AM
6: 30 AM 8 AM
8 AM 9 AM
9 AM 10 AM
10 AM 11: 30 AM
11: 30 AM 12 PM
12 PM 1 PM
1 PM 4 PM
4 PM 6 PM
6 PM 8 PM
8 PM 11 PM
11 PM 12 AM
12 AM 6 AM
MECHANICAL VENTILATOR WEANING PROCESS

Mechanical Ventilator Setting
CPAP (30 minutes)
Mechanical Ventilator (1.5 Hours)
CPAP (1 hour)
Mechanical Ventilator (1 Hour)
CPAP (1.5 Hours)
Mechanical Ventilator (30 minutes)
CPAP (1 Hour)
Mechanical Ventilator (3 Hours)
CPAP (2 Hours)
Mechanical Ventilator (2 Hours)
CPAP (3 Hours)
Mechanical Ventilator (1 Hour)
CPAP(Continuous)
Figure 5.1 Mechanical Ventilator Weaning Process
Nursing Responsibilities for Mechanical Ventilator:

Before:
1. Check and verify doctors order.
2. Check and assemble the equipment.
3. Position the client into the sniffing position.
4. Pre-oxygenate the client with 100% Oxygen to provide apneic or distressed clients with reserve while attempting to intubate
by ambubagging the patient.
During:
92
1. Assist in the insertion of the endotracheal tube.

2. Stay with the client and provide support during the insertion.
3. Do not allow more than 30 seconds to any intubation attempt.
4. If intubation is unsuccessful, ventilate client with 100 % oxygen for 3-5 minutes before a reattempt.
After:
1. Secure the endotracheal tube with tapes.
2. Ensure that the tube is properly stabilized.
3. Suction secretions as necessary
4. Monitor the client.
5. Document properly.
Nursing Responsibilities for Face Mask:
Before:
1. Wash hands/hand hygiene.
2. Verify the prescribing practitioners order.
3. Explain procedure and hazards to the client.
4. Remind clients who smoke of the reasons for not smoking while oxygen is in use.
5. If using humidity, fill humidifier to fill line with distilled water and close container.
6. Attach humidifier to oxygen flow meter
7. Check faulty electrical wirings and other possible sources of ignition as oxygen is a combustible gas.
8. Insert humidifier and flow meter into oxygen source in wall or portable unit.
During:
1. Place the face mask by guiding the mask toward the clients face, and apply it from the nose downward.
93
2.
Fit the mask contours of the clients face (the mask should mold to the face so that very little oxygen escapes into the eyes or
around cheeks and chin.
3.
Secure the elastic band around the clients head so that the mask is comfortable but snug.
4. Pad the band behind the ears and over the bony prominences to precent irritation from the mask.
5. Make sure to use the right size to the patient to avoid unnecessary discomfort from using a very small or very large masks.
Secure the mask by placing the
After:
1. Check for proper flow rate every 4 hours and when the client returns from procedures.
2. Add humidifier if not already in place.
3. Monitor vital signs, oxygen saturation, and client condition every 48 hours (or as indicated or ordered) for signs and
symptoms of hypoxia.
4. Wean client from oxygen as soon as possible using standard protocols.
Nursing Responsibilities for Face Mask and Nasal Cannula:
Before:
1. Wash hands/hand hygiene.
2. Verify the prescribing practitioners order.
3. Explain procedure and hazards to the client.
4. Remind clients who smoke of the reasons for not smoking while O2 is in use.
5. If using humidity, fill humidifier to fill line with distilled water and close container.
6. Attach humidifier to oxygen flow meter
7. Check faulty electrical wirings and other possible sources of ignition as O2 is a combustible gas.
8. Insert humidifier and flow meter into oxygen source in wall or portable unit.
94
During:
1. Attach the oxygen tubing and nasal cannula to the flow meter and turn it on to the prescribed flow rate.
2. Check for bubbling in the humidifier.
3. For nasal cannula, place the nasal prongs in the clients nostrils. Secure the cannula in place by adjusting the tubing around
the clients ears and using the slip ring to stabilize it under the clients chin.
After:
1. Check for proper flow rate every 4 hours and when the client returns from procedures.
2. Assess clients nostrils every 8 hours. If the client complains of dryness or has signs of irritation, use sterile lubricant to keep
mucous membranes moist.
3. Add humidifier if not already in place.
4. Monitor vital signs, oxygen saturation, and client condition every 48 hours (or as indicated or ordered) for signs and
symptoms of hypoxia.
5. Wean client from oxygen as soon as possible using standard protocols.
95
d. Drugs (In Alphabetical Order)
Name of Drugs
Generic and
(Brand Name)
Stock Dose
Type of Order
acetylcysteine
(Fluimucil)
Date Ordered
Date Modified
Date Discontinued
Date Ordered
February 12, 2015
12:55 PM
Route of
Administration
Dosage
Frequency of
administration
Nebulization
10%/3mL/Ampule
Every 12 Hours
10%/3mL ampule
STANDING
ORDER
General Action
Functional
classification
Mechanism of
action
Mucolytic
N-acetyl-Lcysteine (NAC),
active ingredient of
Fluimucil, exerts
an intensive
mucolyticfluidifying action
on mucous and
mucopurulent
secretions, by
depolymerizing the
mucoproteic
complexes and the
nucleic acids
which confer
viscosity to the
vitreous and
purulent
component of the
sputum and of the
secretions. These
features make
Acetylcysteine
(Fluimucil)
particularly
suitable for the
General
Indication
Patient Indication
Treatment of
respiratory
affections
characterized by
thick and viscous
hypersecretions:
acute bronchitis,
chronic bronchitis
and its
exacerbations;
pulmonary
emphysema,
mucoviscidosis
and
bronchieactasis.
Clients response to the

medication with actual
side effects
The patients secretion did
not become thicker and
the
patient
did
not
experience
oxygen
desaturation that may
have
resulted
from
ineffective
airway
clearance due to thick
tracheal
secretions.
Therefore, the desired
effect of the drug to the
patient was achieved.
The prescription of
Fluimucil to
Patient X is due to
his thick
Endotracheal
secretions.
Loosening up the
patients tracheal
secretions will aid
in proper
oxygenation of the
patient. Thick
96
treatment of acute
and chronic
affections of the
respiratory system,
characterized by
thick, viscous, and
mucopurulent
secretions.
secretions could
lead to blockage
of the airway of
the patient.
Nursing Responsibilities:
Before:
1. Check the doctors order
2. Check the drug labels and appearance.
3. Check for the expiration date
4. Check the right dosage, route, and time of administration.
5. Inquire if the patient has taken a meal prior to administration as the drug may induce coughing reflex and should therefore
cause gag and aspiration. Nebulization should be given 15 minutes before eating or at least 30 minutes after feeding.
6. Explain to the patient the purpose of the drug.
7. Assess for bleeding tendencies of the patient as one of the side effect of the drug may cause stomach ulceration.
During:
1. Observe proper medical asepsis.
2. Aspirate the drug from the ampule using a syringe and a needle.
3. Pour the drug into the nebulization set and tightly close the the set.
4. In intubated patients, connect the nebulization set to the mechanical ventilator tubing. The port of connection may differ from
one set of tubing to another. Contact respiratory therapy for assistance
97
5. For patients with no special tubes, instruct the patient to inhale through the nebulization sets mouthpiece and exhale through
the nostril during nebulization.
After:
1. Monitor for the patients reaction to the drug specifically the amount and characteristic of the expelled mucus.
2. Perform chest physiotherapy to loosen up thickened phlegm
3. Document the findings.
4. Document the procedure in the patients chart.
Name of Drugs
Generic and
(Brand Name)
Stock Dose
Type of Order
Date Ordered
Date Modified
Date Discontinued
Cefepime
(Axera)
1gram/ IV
Date Ordered
February 12, 2015
12:55 PM
Route of
Administration
Dosage
Frequency of
administration
Intravenous
1 Gram
OD for 7 days
SELFTERMINATING
ORDER
General Action
Functional
classification
Mechanism of
action
Antibiotic
Fourth Generation
Cephalosporin
Cephalosporins
exert bactericidal
activity by
interfering with
bacterial cell wall
synthesis and
inhibiting crosslinking of the
peptidoglycan. The
cephalosporins are
also thought to
General
Indication
Patient Indication
Its spectrum of
activity includes
most strains of
bacterial
pathogens
responsible for
respiratory and
urinary tract,
infections,
including
Susceptible
organisms
Bacteroides spp,
Enterobacter spp,
Escherichia coli,
Haemophilus

side effects
The patient was not
allergic to the drug, hence
no allergic reaction was
noted upon administration
of the said treatment.
It was very interesting to
note a great positive
influence of the drug to
the WBC count of the
patient as it decreased to
of 18.63 X 109/ L from
41.71 X 109/ L in a span of
7 days of taking the
medication. This only
implies that the infection is
already resolving and that
98
play a role in the

activation of
bacterical cell
autolysins which
may contribute to
bacterial cell lysis.
influenzae,
Klebsiella spp,
Proteus mirabilis,
Pseudomonas
spp,
Staphylococcus
aureus,
Streptococcus
pyogenes
the pathogenic
microorganism that is
causing the infection is
susceptible to the
antibiotic.
This medication
was indicated for
Patient X as he
was also
diagnosed with
Community
Acquired
Pneumonia. The
most common
cause of such
infection is
Streptococcus
pneumoniae which
is susceptible to
the antibiotic.
Before:
99

5. Assess the patients allergy to any drugs that may be associated with the components of cefepime including cephalosporin
antibiotic (eg, cephalexin), penicillin antibiotic (eg, amoxicillin) or another beta-lactam antibiotic (eg, imipenem).
6. Observe Drug to drug interaction. Cefepime reacts with Aminoglycosides (eg, gentamicin) or diuretics (eg, furosemide) and
increases risk of toxic effects on the kidneys.
7. Use aseptic technique.
During:
2. Dilute the powdered drug using 8.8 mL of sterile water for injection to make 10 mL.
3. Incorporate the diluted drug to at least 40 mL of D5% Water or Plain Normal Saline Solution.
4. Infuse the drug for 30 minutes to 1 hour.
5.
Regulate the infusion accordingly.
After:
1. Monitor for the patients reaction to the drug.
4. Observe for infection resolution to the physician and correlate with the laboratory results. Relay findings to the physician.
100
Name of Drugs
Generic and
(Brand Name)
Stock Dose
Type of Order
Date Ordered
Date Modified
Date Discontinued
Route of
Administration
Dosage
Frequency of
administration
Sulfamethoxazole
Date Ordered
Oral
+ Trimethoprim
February 16, 2015
7mL
Co-trimoxazole
4:45 PM
Every 12 Hours
(Bactrim)
400mg/80mg/5mL
STANDING
ORDER
General Action
Functional
classification
Mechanism of
action
Antibiotic
Sulfonamide
Dihydrofolate
reductase inhibitor
Sulfonamides are
structural analogs
of paraaminobenzoic acid
(PABA) and
competitively
inhibit a bacterial
enzyme,
dihydropteroate
synthetase, that is
responsible for
incorporation of
PABA into
dihydrofolic acid,
the immediate
precursor of folic
acid. This blocks
the synthesis of
dihydrofolic acid
and decreases the
amount of
metabolically
active
tetrahydrofolic
acid, a cofactor for
General
Indication
Patient Indication
Sulfonamides,
such as
sulfadiazine and
sulfamethoxazole,
used together with
trimethoprim,
produce
synergistic
antibacterial
activity. {14}{156}
Sulfadiazine and
sulfamethoxazole
have equal
antibacterial
properties,
covering the same
spectrum of
activity. These
sulfonamides, in
combination with
trimethoprim, are
active in vitro
against many
gram-positive and
gram-negative
aerobic
organisms. They
have minimal
activity against
anaerobic
bacteria.

side effects
The most common side
effect of the drug includes
blood dyscrasia by
affectating the major
blood components such
as platelets, hemoglobin
and white blood cell. On
the third and last
determination of the
patient complete blood
count, the only abnormal
finding was the White
Blood Cell count which is
elevated. This elevation is
due to the presence of
infection, specifically
pneumonia. In this case,
the WBC count is already
decreasing (18.63 X 109/
L) from its severely
elevated baseline (41.71
X 109/L). This is highly
suggestive of resolving
infection whereas the
current pathogenic
microorganism is
susceptible to the current
antibiotic treatment being
given.
101
the synthesis of
purines, thymidine,
and DNA.
Susceptible
bacteria are those
that must
synthesize folic
acid. Mammalian
cells require
preformed folic
acid and cannot
synthesize it. The
action of
sulfonamides is
antagonized by
PABA and its
derivatives (e.g.,
procaine and
tetracaine) and by
the presence of
pus or tissue
breakdown
products, which
provide the
necessary
components for
bacterial growth.
Trimethoprim:
Trimethoprim is a
bacteriostatic
lipophilic weak
Susceptible grampositive organisms

include many
Staphylococcus
aureus , including
some methicillinresistant strains,
S. saprophyticus ,
some group A
beta-hemolytic
streptococci,
Streptococcus
agalactiae , and
most but not all
strains of S.
pneumoniae .
Gram-negative
organisms that are
susceptible
include
Escherichia coli,
many Klebsiella
species,
Citrobacter
diversus and C.
fruendii ,
Enterobacter
species,
Salmonella
species, Shigella
species,
Haemophilus
influenzae ,
including some
ampicillin-resistant
strains, H.
102
base structurally
related to
pyrimethamine. It
binds to and
reversibly inhibits
the bacterial
enzyme
dihydrofolate
reductase,
selectively
blocking
conversion of
dihydrofolic acid to
its functional form,
tetrahydrofolic
acid. This
depletes folate, an
essential cofactor
in the biosynthesis
of nucleic acids,
resulting in
interference with
bacterial nucleic
acid and protein
production.
Bacterial
dihydrofolate
reductase is
approximately
50,000 to 100,000
times more tightly
bound by
trimethoprim than
is the
corresponding
mammalian
ducreyi ,
Morganella
morganii , Proteus
vulgaris and P.
mirabilis , and
some Serratia
species.
Sulfonamide and
trimethoprim
combinations also
have activity
against
Acinetobacter
species,
Pneumocystis
carinii,
Providencia
rettgeri , P. stuarti ,
Aeromonas ,
Brucella , and
Yersinia species.
They are also
usually active
against Neisseria
meningitidis ,
Branhamella
(Moraxella)
catarrhalis , and
some, but not all,
N. gonorrhoeae .
Pseudomonas
aeruginosa is
usually resistant,
but P. cepacia and
P. maltophilia may
be sensitive.
103
enzyme.
Trimethoprim
exerts its effect at
a step in the folate
biosynthesis
immediately
subsequent to the
one at which
sulfonamides exert
their effect. When
trimethoprim is
administered
concurrently with
sulfonamides,
synergism occurs,
which is attributed
to inhibition of
tetrahydrofolate
production at 2
sequential steps in
its biosynthesis.
Before:
104
5. Assess the patients allergy for the drug components found in other drugs including furosemide, thiazide diuretics,
sulfonylureas, or carbonic anhydrase inhibitors. Patients sensitive to sulfites may have an allergic reaction to Bactrim I.V.
since it contains sodium metabisulfite.
During:
1. Shake the bottle before opening.
2. Pour the oral suspension to the measuring cup at eye level to prevent error of parallax.
3. Make sure that the meniscus reaches the level of desired dosage.
4. Let the child take the drug himself to promote self-reliance.
After:
8. Observe proper storage of drug. Make sure to place the drug in a light sensitive container as the suspension is light sensitive.
105
Name of Drug
Generic
(Brand)
Stock Dose
Date Ordered,
Taken, Modified
and Discontinued
ipratropium bromide
+
albuterol sulfate
(Duavent)
21mcg + 120mcg/
nebule
Date ordered
February 14, 2014
11 PM
STAT
Route of
Administration
Dosage and
frequency of
administration
Inhalation
via
nebulization
General Action
Functional
classification
Mechanism of
action
Anticholinergic
Bronchodilator
2 nebules
extubation
Anticholinergic
blocks
the
Ach
receptors to prevent
bronchoconstriction.
This may indirectly
cause
bronchodilation.
after
Selectively
stimulates
beta-2
adrenergic
receptors, relaxing
airway
smooth
muscles.
General
Indication/
Patient Indication
Clients response
to the medication
with actual side
effects
Management
of
reversible
bronchospasm
associated
obstructive airway
disease.
Patient
with
chronic
obstructive
pulmonary and who
requires
2nd
bronchodilator.
The
patient
responded well with
the treatment as the
patients respiratory
condition did not
worsen and the
patient
did
not
experience
untoward
and
allergic
reaction
with the drug. He
was also able to
expectorate
his
sputum during and
after nebulization.
No
respiratory
distress was noted
after administration
of the drug.
It was prescribed to
Patient X as an
adjunct
treatment
for his mucolytic for
him to be able to
expectorate
his
sputum
more
effectively. It was
also given to the
patient to prevent
possible
bronchospasm that
may worsen the
patients condition
after extubation.
Before:
106

5. Incorporate the drug with 2ml sterile NSS
During:
2. Administer the drug before any feeding.
3. Use one container of solution or mix the exact amount of solution using the dropper provided for each dose.
4. Place the inhalation solution in the medicine reservoir or nebulizer cup on the machine.
5. Connect the nebulizer to the face mask or mouthpiece.
6. Use the face mask or mouthpiece to breathe in the medicine.
7. Use the nebulizer for about 5 to 15 minutes, or until the medicine in the nebulizer cup is gone.
After:
2. Suction patients endotracheal tube as necessary.
5. Observe proper storage of drug.
107
Name of Drugs
Generic and
(Brand Name)
Stock Dose
Type of Order
Date Ordered
Date Modified
Date
Discontinued
methylprednisolon
e
(Solu-Medrol)
Intravenous
Date Ordered
February 12, 2015
12:55 PM
500mg/vial
STANDING
ORDER
Route of
Administration
Dosage
Frequency of
administration
Date Modified
February 13, 2015
7PM
General Action
Functional
classification
Mechanism of
action
Hormone
Corticosteroid
Glucocorticoid
500mg/IV
OD at 6 AM
60mg/IV
OD at 6 AM
Immunosuppresan
t
Enters target cells
and binds to
intracellular
corticosteroid
receptors, initiating
many complex
reactions that
depresses
formation, release,
and activity of
endogenous
mediators of
inflammation,
including
prostaglandins,
kinins, histamine,
liposomal
enzymes, and
complement
system. Modifies
body's immune
response.
General Indication
Patient Indication
Short-term
management
of
various
inflammatory
and
allergic disorders,
such as rheumatoid
arthritis,
collagen
diseases (eg SLE),
dermatologic
diseases
(eg,
pemphigus), status
asthmaticus,
and
autoimmune
disorders (eg, MS)
Patient
X
is
experiencing
an
exacerbation of his
condition which is
autoimmune
in
nature. Therefore
Patient
X
may
benefit
from
medically inducing
immunosuppressio
n
Clients response to
the medication with
actual side effects
There was a great
improvement
in
the
condition of the patient
after the administration
of the loading dose as
evidenced
by
improvement
in
the
respiratory status and
increase
in
the
sensorium and muscle
strength of the patient.
Furthermore, the patient
also
tolerated
the
ventilator
weaning
process which is highly
suggestive
of
the
improvement
in
respiratory
muscle
power.
Also, Patient X did not
experience
any
additional infection that
may have been due to
the
drugs
immunosuppressive
effects.
108
Before:
4. Check the right dosage, route, and time of administration. Corticosteroids are preferably administered in the morning to mimic
the normal peak corticosteroid levels.
5. Make sure that the patient will not receive and live vaccines before and after administering the drug.
6. Assess for bleeding tendencies of the patient as one of the side effect of the drug may cause stomach ulceration.
During:
2. Dilute the by incorporating the diluent to the powdered drug.
3. Mix the solution to another diluent with at least 50 mL of preferred solution (plain NSS or D5% Water).
4. Infuse the drug at least 30 minutes, but no more than 2 hours.
After:
1. Monitor for the patients reaction to the drug specifically for improvement of the muscle strengths.
2. Maintain protective isolation as the patient is highly at risk of acquiring infection due to induced immunosuppression by
limiting visitors, maintaining asepsis in suctioning and providing care and observing proper frequent hand washing both of the
caregiver and patient.
109

5. Instruct patient to report presence of gastric upset or abdominal pain.
Name of Drug
Generic
(Brand)
Stock Dose
Type of order
Omerprazole
Date Ordered,
Modified and
Discontinued
February 12, 2014
12:55 PM
Route of
Administration
Dosage and
frequency of
administration
IV
(Omevex)
20mg/IV
40mg/vial
OD
General Action
Functional
classification
Mechanism of
action
Proton
pump
inhibitor
Indication
Initial Reactions
Maintenance
for
healing of erosive
esophagitis,
Antisecretory Drug
treatment
of
duodenal ulcer and
Gastic acid-pump prophylaxis
inhibitor;
treatment
for
Suppresses gastric patients who are
acid secretion by taking drugs that
specific inhibition of may be corrosive to
the
hydrogen the gastric lining.
potassium ATPase
enzyme system at For Patient X, the
the
secretory medication
was
surface
of
the prescribed as a
gastric
parietal prophylactic
drug
cells; blocks the for any drug that
final step of acid may
aggravate
production
gastric upset such
as the use of
corticosteroids.
Clients response
to the medication
with actual side
effects
The patient was
able to meet the
desired effects of
the drug as there
was no GI bleeding
and the patient did
not experience any
abdominal pain due
to hyperacidity and
use
of
corticosteroid.
110
Before:
5. Use aseptic technique.
During:
2. Dilute the IV preparation only with Plain NSS as the drug may be unstable when used with other diluents.
3. Administer the drug before meals
4. Administer oral drug while the patient is in upright or sitting position to avoid aspiration.
After:
2. Monitor Patients bowel movement
5. Observe proper storage of drug and this drug should be administered within 8 hours after dilution.
111
Name of Drug
Generic
(Brand)
Stock Dose
Type of order
pyridostigmine
Date Ordered,
Modified and
Discontinued
February 12, 2014
12:55 PM
Route of
Administration
Dosage and
frequency of
administration
Oral/OGT
(Mestinon)
30 mg
10 mg/ paper
tablets
Q 5 Hours
General Action
Functional
classification
Mechanism of
action
parasympathomimeti
c
Antisecretory
AcetyCholinesterase
Inhibitor
Pyridostigmine
inhibits
acetylcholinesterase
in the synaptic cleft,
thus slowing down
the
hydrolysis
of
acetylcholine. It is a
quaternary
carbamate inhibitor of
cholinesterase
that
does not cross the
bloodbrain
barrier
which carbamylates
about
30%
of
peripheral
cholinesterase
enzyme.
The
carbamylated
enzyme
eventually
regenerates
by
natural hydrolysis and
Indication
Initial Reactions
Clients response
to the medication
with actual side
effects
This drug is used in

treating myasthenia
gravis.
Pyridostigmine is a
cholinesterase
inhibitor. It works by
improving
nerve
impulses
in
muscles so that the
muscles are better
able to work.
The
patient
responded well on
the treatment as his
myasthenic crisis
was
resolved.
Moreover,
the
patient
did
not
show
any
exacerbation of the
disease process as
he
was
still
maintained on this
regimen even after
he was extubated.
Patient
Xs
condition involves
affectation of the
neuromuscular
junction
transmission
(NMT). This drug
decreases
catabolism
of
acetycholine
as
patient may benefit
from the increase in
concentration
of
Acetycholine in the
synaptic cleft to
improve
NMT
112
excess ACh levels

revert to normal.
thereby increasing
muscle strength.
Before:
4. Check the right dosage, route, and time of administration. This drug usually needs to be well distributed according to the
patients activity in the day to prevent fluctuation of muscle strength in a day.
During:
1. It is highly suggested that the patient should take the drug at least 30 minutes prior to his meal, to improve muscle strength
that would help the patient masticate and swallow his food.
2. Encourage water intake after administration unless otherwise contraindicated.
After:
1. Monitor for the patients reaction to the drug specifically muscle strength.
4. Instruct patient to report excessive salivation, hyperactive bowel and frequent urination.
5. Note for presence of adverse and life threatening reactions from the drug including cholinergic crisis in which the patient may
manifest sudden onset of severe muscle weakness.
113
Name of Drugs
Generic and
(Brand Name)
Stock Dose
Type of Order
salbutamol
(Asmalin)
Date Ordered
Date Modified
Date Discontinued
Date Ordered
February 12, 2015
12:55 PM
Route of
Administration
Dosage
Frequency of
administration
General Action
Functional
classification
Mechanism of
action
Nebulization
Sympathomimetic
2.5mg
Bronchodilator
Q4 Hours
2.5mg/2.5mL
nebule
STANDING
ORDER
Date Modified
February 13, 2015
5AM
2.5mg
Q 6 Hours
Salbutamol
stimulates 2
adrenergic
receptors which
are predominant
receptors in
bronchial smooth
muscle of the lung.
Stimulation of 2
receptors leads to
the activation of
enzyme adenyl
cyclase that form
cyclic AMP
(adenosine-monophosphate) from
ATP (adenosinetri-phosphate).
This high level of
cyclic AMP relaxes
bronchial smooth
muscle and
decreases airway
resistance by
lowering
General
Indication
Patient Indication
Bronchospasm
with
reversible
obstructive airway
diseases
Salbutamol
is
indicated for the
preventation
or
treatment
of
bronchospasm
with
reversible
obstructive airway
diseases such as
Bronchial asthma,
Chronic
obstructive
pulmonary
disease (COPD)
which
includes
chronic bronchitis
and emphysema,
exercise-induced
bronchospasm.
Any
other
situations known
to
induce
bronchospasm.

side effects
There were no recorded
events of bronchospasm.
Patient X did no longer
suffer from respiratory
distress. This indicates
that the drug was effective
in
preventing
bronchospasm.
He did not experience
tachycardia, which is a
very common side effect
of the drug because of its
sympathomimetic action.
A bronchodilator is
114
intracellular ionic
calcium
concentrations.
Salbutamol
relaxes the smooth
muscles of
airways, from
trachea to terminal
bronchioles.
indicated
to
Patient X because
he is intubated.
Bronchial irritation
may
occur
because of the
presence of a
foreign object in
the airway. This
may
cause
bronchospasm.
This nebulization
serves
as
a
prophylaxis
for
such occurrences.
115
Before:
4. Check the right dosage, route, and time of administration. This drug should be given at least 30 minutes before or after
feeding as this may stimulate gag reflex.
5. Inquire if the patient has taken a meal prior to administration as the drug may cause nausea/
During:
2. Use one container of solution or mix the exact amount of solution using the dropper provided for each dose.
3. Place the inhalation solution in the medicine reservoir or nebulizer cup on the machine.
4. Connect the nebulizer to the face mask or mouthpiece.
5. Use the face mask or mouthpiece to breathe in the medicine.
6. Use the nebulizer for about 5 to 15 minutes, or until the medicine in the nebulizer cup is gone.
After:
1. Clean all the parts of the nebulizer after each use.
2. Monitor for the patients reaction to the drug specifically for the most common side effects including tachycardia.
116
5. Instruct patient to report presence palpitations

117
Name of Drugs
Generic and
(Brand Name)
Stock Dose
Date Ordered,
Taken, Modified
and
Discontinued
Prednisone
(Pred)
Route of
Administration
Dosage and
frequency of
administration
Oral
Immunisuppressan
t
30mg/tablet
SELFTERMINATING
ORDER
General Action
Functional
classification
Mechanism of
action
Glucocorticoid
Date Ordered
February 18, 2014
8 AM
30mg/tab 2 tablets
After breakfast for
7 days
Glucocorticoids
such
as
Prednisolone can
inhibit
leukocyte
infiltration at the
site
of
inflammation,
interfere
with
mediators
of
inflammatory
response,
and
suppress humoral
immune
responses.
The
antiinflammatory
actions
of
glucocorticoids are
thought to involve
phospholipase A2
inhibitory proteins,
lipocortins, which
control
the
biosynthesis
of
General Indication
and Patient
Indication
Clients response
to the medication
with actual side
effects
For the treatment

of
primary
or
secondary
adrenocortical
insufficiency, such
as
congenital
adrenal
hyperplasia,
thyroiditis.
Also
used
to
treat
psoriatic arthritis,
rheumatoid
arthritis, ankylosing
spondylitis, bursitis,
acute gouty arthritis
and epicondylitis.
Also indicated for
treatment
of
systemic
lupus
erythematosus,
pemphigus
and
acute
rhematic
carditis. Can be
used
in
the
treatment
of
leukemias,
lymphomas,
thrombocytopenia
The
initial
treatment by the
patient
last
December
2013
can be considered
effective as the
patients
exacerbation was
managed, but the
present treatment
of
immunosuppressio
n in the current
case of the patient
cannot be well
evaluated as the
duration of the
treatment was not
completed during
the confinement.
118
potent mediators
of
inflammation
such
as
prostaglandins and
leukotrienes.
Prednisolone
reduces
inflammatory
reaction by limiting
the
capillary
dilatation
and
permeability of the
vascular
structures. These
compounds restrict
the accumulation
of
polymorphonuclear
leukocytes
and
macrophages and
reduce the release
of
vasoactive
kinins.
Recent
research suggests
that corticosteroids
may inhibit the
release
of
arachidonic
acid
from
phospholipids,
thereby reducing
the formation of
prostaglandins.
Prednisolone is a
glucocorticoid
receptor agonist.
purpura
and
autoimmune
hemolytic anemia.
Can be used to
treat
celiac
disease,
insulin
resistance,
ulcerative
colitis
and liver disorders.
Patient
X
was
given
such
medication as the
one of the side
effect of the drug
i.e.
Immunosuppressio
n is desired in the
present
autoimmune
condition of the
patient.
119
On binding, the
corticoreceptorligand
complex
translocates itself
into
the
cell
nucleus, where it
binds to many
glucocorticoid
response elements
(GRE)
in
the
promoter region of
the target genes.
The DNA bound
receptor
then
interacts with basic
transcription
factors, causing an
increase
or
decrease
in
expression
of
specific
target
genes,
including
suppression of IL2
(interleukin
2)
expression.
Before:
120

6. Assess for any contraindications for the administration of the drug such as elevated blood sugar level, congestion and fluid
overload.
During:
8. Ensure that the patient is sitting upright while taking the drug to avoid aspiration
9. Administer the drug around 9-10 in the morning to mimic the natural release of glucocorticoids of the body.
After:
2. Coordinate with the physicians any adverse reaction to the drug such as
1.
2.
3.
4.
5.
Hyperglycemia
Blurring of vision
Breathing problems
Weight gain
Frequent infection

4. .Document the procedure in the patients chart.
121
122
b.3 Diet
Type of Diet
Oro-Gastric Tube
Date Ordered,
Date Started
Date Changed
Date Ordered
Feeding with
February 12,
*See Figure 5.2
2015
for Nutritional
12:55 PM
Information
Date Started
General
Description
PediaSure
Indication or
Purposes
Milk
provides balanced Patient X is place on

nutrition
for
a tube feeding since the
Specific
Foods
Taken
PediaSure
Plus Milk
Formulation
child's growth and
patient is on ventilator
(Vanilla
development.
and cannot swallow
Flavor)
PediaSure
is
proven
foods per orem due to

risk of aspiration.
Clients response
and/or reaction to the
diet
No allergic response
and
residual
or
vomiting was noted.

Based on observation
by
the
nurse-
researcher,
the
February 12,
clinically
2015
nutrition
6 PM
kids grow based
i.e.
sufficient as the patient
on
120
did
to
help
studies
120 cc every
no
2 hours
conducted among
kcal/feeding
Date Changed
children at risk for
or
February 14,
malnutrition. Each
1440kcal/day
2015
formulation
7 AM
provides
protein
and
vitamins
gluten-free,
not
diet
was
experience
starvation.
No
abdominal discomfort,
diarrhea
and
constipation that may

7g
be associated with the
25
use of milk formula
and
noted. Given all these
minerals.
PediaSure
patients
at hand, it can be
is
concluded
that
the
patient responded well
123
kosher, and halal,
with the treatment.
as well as suitable
for
children
with
lactose
Soft Diet
Date Ordered
intolerance.
Soft diet includes
February 14,
food
2015
7 AM
that
are
Patient
was
Oatmeal and
The patient was able to
Milk
swallow
his
foods
generally thicker in
intubated which may
(PediaSure
without
consistency
and
have
Plus).
any gag reflex during
than
ability to swallow. His
the
which
tolerant of taking food
couldve
more
solid
liquid diet
affected
his
experiencing
process
that
led
to
2015
mashed per orem was being

food, oatmeal, and assessed prior to
taking a full diet.
porridge.
8 PM
Patient X was newly
foods
extubated
his
demanded to eat solid
also
food like fried chicken
Date Started
February 14,
includes
OGT
Date Changed
February 14,
and
was
removed at the very

same
time
aspiration. The patient

did not like the fact that
he could only eat soft
and
so
he
from Jollibee.
last
2015
February 14, 2015 at
12 PM
7 AM. In relation to
this, Patient X should
not
immediately
be
given solid food to

prevent aspiration.
124
Full Diet
Date Changed
February 14,
2015
12 PM
DAT,
February 14,
The patient tolerated
2015
his normal diet with no
Lunch:
episode of aspiration,
Jollibee Fried
nausea and vomiting.
now contraindication of any Chicken and

tolerate any food dietary consideration Spaghetti
he desires that is in the case presented Snack:
His appetite was also
Tolerated.
particular
2015
12:30 PM
as
This
diet
is
only given when

client
February 14,
Diet
This
diet
indicated
was
for
the
patient as there is no
can
normal and he did not

experience
anorexia
this
by the patient. He also
PediaSure
and he was able to
will not lead to any
needs to regain his
120 mL and
finish the food that was
complications.
weight
nutritious,
if
and
so
the
hotdog
served to him.
patient is encouraged
sandwich
He did not experience
to
foods
Dinner
dysphagia
his
Peach
odynophagia during his
improve
mango
eat
more
according
demand
to
to
his nutritional status.
and
pie
and
meals. He is very fond
creamy of eating meals from
macaroni
his favourite fast-food
soup
chain, Jollibee, hence

he is always fed with
February 15,
take-out
2015
demand.
meals
per
Breakfast:
Egg,
porridge,
BearBrand
125
Milk
and
Toast
Lunch:
Chicken
Barbecue,
Chopsuey
and Rice
Snack:
Skipped
Dinner:
Jollibee
creamy
macaroni
soup
February 16,
2015
Breakfast:
Ham
and
Cheese
Sandwich
with
PediaSure
126
120mL
Snack:
Skyflakes
crackers and
orange juice
Lunch:
Beef
with
Broccoli and
Rice
Snack:
Skipped
Dinner:
Mashed
Potato
and
Samosa
February 17,
2015
Breakfast:
Jollibee
macaroni
soup
and
pineapple
127
juice
Snack:
Jollibee Tuna
Pie
and
BearBrand
Sterilized
Milk
Lunch:
Mang Inasal
Chicken and
Fried Rice
Snack:
Cupcake and
Pediasure
120mL
Dinner:
Champorado
(Chocolate
Porridge)
and
128
Pediasure
120 mL
February 18,
2015
Breakfast:
Jollibee Fried
Chicken and
Spaghetti
and
chocolate
drink
Lunch:
Tuna
Mayo
Sandwich
and
Pineapple
Juice
Snack:
Spaghetti
and
129
BearBrand
Sterilized
Milk
130
Nursing Consideration in assisting the patient in eating

Before:
1. Verify doctors order for the specific diet indicated for the patient
2. Before bringing the meal tray into the room, ask whether the client needs to void to have a bowel movement.
3. Provide hygiene measures before serving the meal tray
4. Position client in a comfortable position
5. Ask about the clients eating habits and the foods he prefers to eat first. Ask what help is needed. For instance, in Patient Xs
condition, he may benefit with light meals during night time where his swallowing is impaired by the weakness of his muscles.
6. Make sure the food are given at the right temperature
During:
1. Provide assistance if the client is unable to handle eating or to open containers and packages.
2. Provide adequate time for the client who has difficulty chewing or swallowing. Make sure that someone is in the room while
the client is eating.
After:
1. Document the type of and amount of food taken at each meal.
2. Remove the tray after the meal, and provide hygiene measures.
131
Nursing Responsibilities for OGT insertion and Feeding

Before:
1. Explain and discuss the procedure with the patient.

2. Arrange a signal by which the patient can communicate if he/she wants the nurse to stop e.g. by raising his/her hand.
3. Assist the patient to sit in a semi-upright position in the bed or chair. Support the patients head with pillows. Note: The head
should not be tilted backwards or forwards.
4. Put on Plastic apron, wash hands and put on gloves
5. Mark the distance with tape which the tube is to be passed by measuring the distance on the tube from the patients ear lobe
to the bridge of the nose plus the distance from the bridge of the nose to the bottom of the xiphisternum.
During:
1. Check the patients nostrils are patent by asking him/her to sniff with one nostril closed. Repeat with the other nostril.
2. Lubricate about 15-20 cm of the tube with a thin coat of lubricating jelly that has been placed on a topical swab.
3. Insert the proximal end of the tube into the clearer nostril and slide it backwards and inwards along the floor of the nose to the
nasopharynx. If an obstruction is felt, withdraw the tube and try again in a slightly different direction or use the other nostril.
4. Advance the tube through the pharynx as the patient swallows until the tapemarked tube reaches the point of entry into the
external nares. If the patient shows signs of distress, e.g. gasping or cyanosis, remove the tube immediately.
5. When feeding the patient, check patency by auscultating a gurgling sound from the patient stomachs after pushing air to the
NGT tube using a Toomey or Bulb Syringe. Place the patient at least in semi-fowlers position prior to feeding. Flush the tube
132
with 30mL of water if not contraindicated. Proceed with feeding. Flush with water before giving diluted pulverized medications.
Flush the tube again with water. Make sure to close the NGT to avoid unnecessary residuals.
After:
1. Secure the tube to the nostril with hypoallergenic adherent dressing tape An adhesive patch (if available) will secure the tube
to the cheek.
2. Check the position of the tube to confirm that it is in the stomach by using the following methods:
3. Aspirating 2 ml of stomach contents and testing this with pH indicator strips. A pH of between 1 and 5.5 is reliable
confirmation that the tube is not in the lung, however it does not confirm gastric placement as there is a small chance the tube
tip may sit in the oesophagus where it carries a higher risk of aspiration. If this is a concern, the patient should proceed to xray in order to confirm position. Where pH readings fall between 5 and 6 it is recommended that a second competent person
checks the reading or retests.
4. Once position has been confirmed, a spigot or drainage bag can be place into the distal end of the tube.
b.3 Activity / Exercise

Type of Activity
Date Ordered
General Description
General
Date Started
Description/Indicat
activity
Date Changed
ion/
Complete Bed
Date Ordered
Bed rest is a therapeutic
Patient Indication
A complete bed
He was tolerant of the
Rest with no
February 12,
intervention that
rest was indicated
complete bed rest and did

133
bathroom
2015
privileges
12:55 PM
Date Started
achieves several
for Patient X for
not complain of inactivity.
objectives including the
the purpose of
There was no noted
following:
providing rest as
adverse effect of
February 12,
1. Provide rest for clients
he is physically
prolonged bed rest as the
2015
who are exhausted

2. Decreases the bodys
exhausted and he
patient did not show any
is too weak to
signs of muscle dystrophy
function since the
and bed sores. He is able
patients oxygen
to turn himself side to side
supply is
and active range of motion
decreased and his
exercises were also
muscles are
encouraged. The patient
weak.
was bathed in bed as he is
12:55 PM
Date Changed
February 14,
oxygen consumption
3. Reduces pain and
discomfort
2015
12 PM
not allowed to travel to

Although he was
bathroom.
only prescribed
with complete
bed rest, his
nurses initiated to
perform activepassive range of
Complete Bed Rest
Date Ordered
This type of activity is similar
motion exercises.
Patient X was given
with bathroom
February 14,
to
mentioned
the privilege to have
trip to the bathroom to meet
privileges
2015
above, but the patient is now
bathroom trips as he
his elimination and hygienic
allowed to use the bathroom
was
needs without any difficulty
the
activity
already
The patient was able to take
134
12 PM
Date Started
to defecate, urinate and take
extubated, he is no
and without any noted signs
a shower.
longer
dyspnea.
February 14,
respiratory
under
distress
2015
and he was finally
12 PM
able to regain his
He
did
not
experience
muscle strength.
Nursing Responsibilities for Complete Bed Rest:

Before:
1. Verify doctors order
2. Educated the client regarding the prescribed activity like
Type of activity
Indication of activity
Limitations of the activity
How he can cooperate with the prescribed activity
How the activity would benefit him with his current condition
During:
1. Assist the patient in a comfortable position
135
2. Assist the patient with other activities

3. Make sure that the patient is always in comfortable position
4. Assist the client with AROM exercises to prevent adverse effects of inactivity.
After:
1. Monitor how much activity the patient exerts
2. Monitor the patients reaction and compliance to the activity
3. Document findings in the patients chart.
136
B. NURSING MANAGEMENT
1. NURSING CARE PLANS
During the course of Patient Xs hospitalization, there were 10 Nursing
Diagnoses identified and intervened accordingly by the nurse/s on duty. The
following Nursing Diagnoses were prioritized from the cross principles of Airway,
Breathing and Circulation (ABCs) and Abraham Maslows Hierarchy of Needs,
Priority
1
2
3
4
5
6
7
Nursing Diagnoses
Impaired spontaneous ventilation
Ineffective airway clearance
Impaired gas exchange
Risk for Aspiration
Ineffective protection
Impaired physical mobility
Disturbed sleep pattern
Imbalanced nutrition: less than body
8
9
10
requirements
Impaired verbal communication
Readiness for Enhanced Health Maintenance
Figure 5.3 Prioritization of Nursing Diagnoses.
149
Problem Number 1: Impaired Spontaneous Ventilation
Assessment
Subjective cues:
Patient nodded
when his mother
asked if he is
having difficulty of
breathing.
Objective cues:
The patient
manifested:
Decreased arterial
oxygen saturation
(83%)
Tachycardia
(117bpm)
Dyspnea
Tachypnea (29cpm)
Decrease in
sensorium (GCS 7
i.e. E2V1M4)
The patient may
manifest:
Nursing
diagnosis
Scientific
explanation
Impaired
Spontaneous
Ventilation
related to
decrease in
respiratory
muscle
strength as
evidenced by
dyspnea
secondary to
Myasthenic
Crisis
Myasthenia
Gravis
is
a
disease in which
voluntary
muscles
are
affected
and
becomes weak.
Acetylcholine, a
neurotransmitter
, is the primary
signal from the
neuron
that
triggers muscle
contraction
through
the
receptors
present in the
outer layer of
the muscles. In
Myasthenia
Gravis,
these
receptors
are
rapidly
destroyed by an
autoantibody;
hence they are
decreased
in
Objectives
Short term:
Nursing
interventions
1.
Monitor
/
document
After two hours characteristics of
of
nursing Respiratory
interventions,
status, including
The patient will rate and depth of
not
show respiration, chest
progression of excursion
and
respiratory
symmetry,
distress
as presence
of
evidenced by cyanosis, use of
hemodynamic
accessory
stability
and muscles
for
proportionate
respiration,
oxygen
effectiveness of
demand
and cough,
supply
suctioning
demands,
Long term:
sputum
characteristics
After 2-3 days and
oxygen
of
nursing levels.
interventions,
The patient will 2. Assess the
have
proper need
for
an
spontaneous
artificial
airway
ventilation
and prepare in
Rationale
1. In patients with
impaired
spontaneous
ventilation,
the
patient is not able
to
meet
the
oxygen demand
of the body. The
current
respiratory status
will
suggest
improvement or
deterioration
of
the
patients
current status.
Expected
outcome
Short term:
The
patient
shall not have
shown
progression of
respiratory
distress
as
evidenced by
hemodynamic
stability
and
proportionate
oxygen
demand and
supply
Long term:
2. Patients who
cannot
control
their
ventilation
whether
The
patient
shall
have
proper
spontaneous
ventilation
150
Apprehension
Use of accessory
muscles for
respiration
Increase
restlessness
Cyanosis
Increase partial
pressure of arterial
carbon dioxide
Decrease partial
pressure of arterial
oxygen
Apnea
number.
The
decrease in the
receptor leads
to
decrease
muscle
contraction.
When a patient
with Myasthenia
Gravis is
in
crisis, there is
severe
weakening
of
muscles
including
respiratory
muscles.
This
results
to
ineffective
control
of
spontaneous
ventilation. The
decrease
in
ventilation
causes
a
decrease
inhalation
of
oxygen and the
oxygen demand
of the body is
not
met.
Chemoreceptor
s found in the
carotid
body
detects
high
assisting in case
there is a need to
intubate
the
patient.
temporarily
or
permanently,
would
highly
benefit
from
artificial airway in
order to promote
proper
tissue
oxygenation via
mechanical
ventilation.
3. Assess the
patient and their
relatives
knowledge
of
mechanical
ventilation
to
promote
cooperation and
understanding.
3.Artificial airways
can be easily
removed
and
therefore
can
impose
great
risks
in
the
patients
ventilation. Selfextubation
is
common in the
health
care
settings. Patients
who
do
not
understand
the
need
for
mechanical
ventilation would
tend to cooperate
less than those
who
are
knowledgeable.
4. Inform the
patient,
other
4.Immediate
151
levels of carbon
dioxide as it is
also
not
properly
expelled
through
decrease
in
ventilation. This
chemical
changes
is
converted
to
action potential
that is sent to
the midbrain, a
part of the brain
that
controls
breathing. In an
effort
to
increase
the
needed oxygen
and
expel
excessive toxic
carbon dioxide,
the
midbrain
would increase
respiratory effort
hence
the
increase
in
respiration per
minute,
and
activate stretch
receptors which
eventually leads
to release of
health
care
members
and
family members
about signs and
symptoms
of
complications,
such
as
atelectasis, fluid
overload,
respiratory
infection,
and
tension
pneumothorax.
5.Perform aseptic
technique
in
performing
artificial
airway
care
to
the
patient.
6.Wean
the
patient
from
ventilator support
as
soon
as
possible.
reporting
of
complications will
ensure
early
intervention
for
respiratory
distress.
5. Infection if very
common among
patients
with
artificial
airway,
whether
they
already have an
on-going infection
or not, asepsis
should always be
observed
to
prevent
concurrent
or
promoting
infection.
6.Prolonged
ventilator support
and
artificial
airways increases
152
catecholamine
that increases
the heart rate.
the
risk
for
infection
other
respiratory
complications
including
respiratory
muscle atrophy.
Endotracheal and
nasopharyngeal
airways are prone
to mucus block if
prolonged
for
more than 7 days.
Reintubation may
be an option.
7.Suction
secretions gently 7.Vigorous,
as necessary.
prolonged,
frequent
and
improper
suctioning
can
traumatize
the
patients
airway
wich can cause
complications
such as infection,
bleeding
and
blockage
from
clots of blood.
8.Encourage
deep Breathing 8.Performing
Exercises.
deep
breathing
exercises
even
when
153
mechanically
ventilated would
help
prevent
respiratory
muscle atrophy.
9.Allow
bed
mobility and turn
patients side to
side
at
least
every 2 hours.
10.Evaluate
patients
response
treatment.
to
9.Prolonged
immobility
can
cause
or
compound
pneumonia as it
can cause stasis
of
pulmonary
secretions.
10.Mechanical
ventilation
may
not be sufficient to
promote
proper
spontaneous
ventilation.
Assess for the
underlying cause
and
coordinate
with other health
care members to
address
the
problem.
154
Problem Number 2: Ineffective Airway Clearance

Assessment
Subjective cues:
The patient may
verbalize:
1.Progressive
dyspnea
2.Headache
3.Dizziness
Objective cues:
The patient
manifested:
1.Crackles heard on
both lung fields
2.Productive cough
3.Shortness of breath
4.Weakness
5.Thick endotracheal
mucous secretions
6.Tachypnea
(29bpm)
7.Tachycardia
(117cpm)
8.Decrease in
Oxygen Saturation
Nursing
diagnosis
Scientific
explanation
Ineffective
Airway
Clearance
related to
increased
mucus
production
as evidenced
by effective
productive
cough
secondary to
pneumonia
With
ineffective
ventilation process
and
medically
induced
immunosuppressio
n the patient is at
risk for respiratory
infection.
Respiratory
tract
infections
are
caused
by
an
invasion of microorganisms on the
trachea - bronchial
tract of the patient.
These
microorganisms
cause inflammatory
reactions thereby
increasing
the
production
and
secretion
of
mucous.
These
mucous secretions
accumulated on his
trachea - bronchial
tract
thereby
reducing
the
Objectives
Short term:
After
four
hours
of
nursing
interventions,
the patient will
be able to
maintain
airway
patency
as
evidenced by
absence
of
signs
and
symptoms of
respiratory
distress.
Nursing
interventions
1.Assess
patients
condition
including
signs.
1. Assessing the
patients
condition
and
vital vital signs will
give the health
care
providers
baseline data for
the planning and
implementation
of
nursing
interventions.
2. Assess rate /
depth
of
respirations and
chest
movement.
Long term:
After
four
days
of
nursing
interventions,
the patient will
be able to
demonstrate
absence
of
Rationale
3.
Auscultate
lung fields noting
areas
of
2.
Tachypnea,
shallow
respirations and
asymmetric chest
movement
are
frequently
present because
of discomfort of
moving
chest
wall and / or fluid
in the lungs.
3.
Decreased
airflow occurs in
areas
consolidated with
Expected
outcome
Short term:
The
patient
shall
have
maintained
airway
patency
as
evidenced by
absence
of
signs
and
symptoms of
respiratory
distress.
Long term:
The
patient
shallhave
demonstrated
absence
of
congestion
with
breath
sounds clear,
respirations
noiseless and
155
(83%)
The patient may
manifest:
1.Pale fingernail
beds
2.Pale palpebral
conjunctiva
3.Restlessness
4.Irritability
5.Cyanosis
diameter of the
bronchial
lumen.
With this, there was
then a decrease in
airflow to and from
his
lungs.
Ineffective airway
clearance results
from the inability to
expectorate
the
said
retained
secretions.
In
addition to this, the
problem
also
occurs as a result
of the patients
pulmonary
congestion.
Because of this
congestion,
the
airway is thereby
blocked thus the
normal entry of
oxygen and exit of
carbon Dioxide is
denied.
congestion
with
clear
breath
sounds,
respirations
noiseless and
improved
oxygen
exchange as
evidenced by
absence
of
cyanosis
or
any signs of
respiratory
distress.
decreased
/
absent
airflow
and adventitious
breath sounds.
4. Elevate head
of bed, change
position
frequently.
5. Assist patient
with
frequent
deep-breathing
exercises.
Demonstrate
/
help
patient
learn to perform
fluid.
Bronchial
breath
sounds
can also occur in
consolidated
areas. Crackles,
rhonchi
and
wheezes
are
heard
on
inspiration and /
or expiration in
response to fluid
accumulation,
thick secretions
and
airway
spasm.
improved
oxygen
exchange
evidenced
absence
cyanosis
any signs
respiratory
distress.
as
by
of
or
of
4.
Lowers
diaphragm,
promoting chest
expansion,
aeration of lung
segments,
mobilization and
expectoration of
secretions.
5.
Deep
breathing
facilitates
maximum
expansion of the
lungs / smaller
airways.
Coughing is a
156
activity such as
splinting chest
and
effective
coughing while
in
upright
position.
6.Suction
secretions
indicated.
7.Provide
adequate
intake.
as
natural
selfcleaning
mechanism,
assisting the cilia
to
maintain
patent airways.
Splinting reduces
discomfort, and
an
upright
position
favors
deeper,
more
forceful
cough
effort.
6.Stimulates
cough
or
mechanically
clears airway in
patient who is
unable to do so
because
of
ineffective cough.
7.Fluids,
especially aid in
fluid mobilization and
expectoration of
secretions.
Facilitates
liquefaction and
removal
of
secretions.
157
8.
Administer
medications
such
as
bronchodilators
as indicated and
ordered.
9. Monitor serial
chest
X-rays,
ABGs, and pulse
oximetry
readings
as
ordered.
8.
Aids
in
reduction
of
bronchospasm
and mobilization
of
secretions.
congestion.
9.Follows
progress
and
effects of disease
process
/
therapeutic
regimen.
And
facilitates
necessary
alterations
in
therapy.
158
Problem Number 3: Impaired Gas Exchange

Assessment
Subjective cues:
The Patient
verbalized shortness
of breath and
dyspnea prior to
admission
Objective cues:
The patient
manifested:
1.Decrease in
oxygen saturation
(83%)
2.Crackles on both
lung fields
3.Productive Cough
4.Shortness of
breath
5.Weakness
6.Decrease in
sensorium GCS
7(E2V1M4)
7.Dyspnea
8Tachycardia
Nursing
diagnosis
Scientific
explanation
Impaired
Gas
Exchange
related to
decrease in
ventilator
effort and
mechanical
blockage
(mucus)
evidenced
by decrease
in oxygen
saturation of
83%
secondary
to
Myasthenia
Gravis and
Pneumonia
The
patient
experienced
dyspnea with the
presence
of
trachea - bronchial
secretions.
His
respiratory efforts
were
also
diminished
because of the
respiratory muscle
weakness.
Although he was
tachypneic,
his
breathing
was
shallow. He was
unable to maintain
a patent airway.
Thus,
hypoxia
started to set in.
With this, he was
hooked
under
mechanical
ventilation
to
provide his tissues
with the adequate
oxygenation and
ventilation.
Objectives
Short term:
After
four
hours
of
nursing
interventions,
the
patient
will be able to
maintain
improved
ventilation
and
oxygenation
of tissues as
evidenced by
ABGs / pulse
oximetry
within
patients
normal
ranges and
free
of
symptoms of
respiratory
distress.
Long term:
Nursing
interventions
Rationale
1.Assess respiratory
status
for
rate,
depth and ease of
effort at rest or with
exertion,
inspiratory/expirator
y ratio.
1. Changes in
respiratory
pattern
or
patency
of
airway
may
result in gas
exchange
imbalances.
2.
Observe
for
presence
of
cyanosis
and
mottling;
monitor
ABGs for ventilation
/perfusion problems.
2.
Cyanosis
results
from
decreases
in
oxygenated
haemoglobin in
the blood and
this
reduction
leads to hypoxia.
Reading of 90 %
on
pulse
oximeter
correlates with
pO2
of
60,
depending
on
the patients pH,
temperature and
other factors.
Expected
outcome
Short term:
The patient
shall
have
demonstrate
d improved
ventilation
and
oxygenation
of tissues as
evidenced by
ABGs / pulse
oximetry
within
patients
normal
ranges and
free
of
symptoms of
respiratory
distress.
Long term:
159
(130bpm)
9.Tachypnea
(53cpm)
The patient may
manifest:
1.Tissue injury
2.Hypercapnia
3.Respiratory
Acidosis
After
two
days
of
nursing
interventions,
the
patient
will be able to
manifest
signs
of
normal
gas
exchange as
evidence by
absence
of
dyspnea,
tachypnea,
cyanosis,
restlessness,
irritability, and
normal pulse
oximetry
results.
3.
Monitor
for
mental
status
changes,
deterioration in level
of consciousness,
restlessness,
irritability
or
increased fatigue.
4.
Assess
nausea
vomiting.
3.Hypoxia
affects all body
systems
and
mental changes
can result from
decreased
oxygen to brain
tissues.
4. May indicate
effects
of
for hypoxia
on
and gastrointestinal
system.
The patient
shall
have
manifested
signs
of
normal gas
exchange as
evidence by
absence of
dyspnea,
tachypnea,
cyanosis,
restlessness,
irritability,
and normal
pulse
oximetry
results.
5.Promotes
breathing
and
5. Position in semi- lung expansion
or
high-Fowlers to enhance gas
position.
distribution.
6. Placement on
mechanical
6.
Prepare
for ventilator
will
intubation
and maintain
placement
on adequate
mechanical
oxygenation and
ventilation
as perfusion
ordered.
.
7.
Provides
know-ledge and
7. Prepare patient decreases fear.
160
for placement on
mechanical
ventilation
and
intubation
procedures
as
ordered.
8. Instruct patient
and family members
with regards to all
procedures,
placement
on
ventilator, what to
expect and methods
to communicate.
9.
Assist
with
Emergent nature
of the problem
may negate the
ability to do preprocedure
teaching
but
should be done
as
soon
as
possible. Instruct
patient
and
family members
if time warrants
for placement on
mechanical
ventilation.
8. Patient may
be anxious and
fight
the
ventilator
requiring
sedation
to
achieve
adequate
ventilation.
Promotes
knowledge and
reduces
fear.
May
promote
cooperation.
9. Placement of
an
artificial
airway
is
161
intubation of patient;
auscultate all lung
fields for breath
sounds.
required
mechanical
ventilation
support.
for
10.
Prolonged
difficulty
in
10. Pre-oxygenate placement of the
patient
and tube may result
auscultate
for in hypoxia. If
bilateral
breath symmetric chest
sounds and observe expansion is not
for symmetric chest observed, or if
expansion.
breath sounds
cannot be heard
bilaterally,
this
may
indicate
improper
placement of the
tube into the
right
main
bronchus
or
esophagus, and
correction of this
problem must be
addressed
promptly.
11.
Utilize
low
pressure
endotracheal intubation.
11.
High
pressure cuffed
tubes
may
promote tracheal
necrosis
or
result in tracheal
162
fistula.
12.
Artificial
airways
may
12. Maintain airway, become
secure tube with occluded
by
tape
of
other mucous or other
securing device.
secretory fluids,
may develop a
cuff
leak
resulting
in
inability
to
maintain
pressures
sufficient
for
ventilation,
or
may migrate to a
position whereby
adequate
oxygenation is
impaired. Tubes
should
be
adequately
secured
to
prevent
movement, loss
of airway, and
tracheal
damage.
13. Obtain chest Xray after ETT is
13.
Radiographic
confirmation of
tube placement
163
inserted and after

24 hours, as per
doctors order.
14. If ETT is placed

orally, daily changes
from side to side of
mouth should be
routinely performed.
Perform oral care
every 4 fours and as
necessary.
15.
Suction
secretions
as
needed making sure
to
Pre-oxygenate
the patient before
during and after
procedure.
is
mandatory;
the tube should
be 2-3 cm above
the carina.
14.
Prevents
tissue necrosis
from pressure of
tube
against
teeth, lips, and
other
tissues.
Oral
tubes
promote saliva
formation, cause
nausea
and
vomiting
if
movement
of
tube stimulates
retching,
and
prevent
the
patient
from
closing
his
mouth
without
biting down on
the tube.
15. Suctioning is
required
to
remove
secretions
because
the
patient is unable
to do so, on his
own.
164
16.
Monitor
ventilator settings at
least
every
2-4
hours
and
as
necessary.
17. Observe for

temperature
of
ventilator circuitry;
drain tubing away
from the patient as
warranted.
18. Monitor airway

cuff for leakage,
noting amount of air
volume in cuff and
cuff pressures at
least
every
4-8
16.
Ventilator
settings
are
adjusted based
on the disease
process
and
patients
condition
to
maintain optimal
oxygenation and
ventilation while
the patient is
unable to do so
on his own.
17.
Intubation
bypasses
the
bodys
natural
warming/
humidifying
action,
and
requires
increase
temperature and
moisturizing of
the
delivered
oxygen.
18. Proper cuff
inflation is done
with the least
amount of air to
ensure
a
minimal
leak
165
hours.
19. Auscultate for

adventitious breath
sounds,
subcutaneous
emphysema
or
localized wheezing.
20.
Monitor
ventilatory pressure
wave forms and
notify physician of
significant
abnormalities.
with
maintenance of
adequate
ventilatory
pressures and
tidal volume.
19. May indicate
migration
of
airway
tube.
Movement from
trachea
into
tissue
may
cause
mediastinal
of
subcutaneous
emphysema and
/
or
pneumothorax.
20.
Airway
pressure tracing
can
identify
asynchronous
respiratory
status between
patient
and
ventilator,
patients
effort
and work of
breathing, and
auto
PEEP
identification in
order
to
166
21.
Observe
breathing patterns
and note if patient
has
spontaneous
breaths in addition
to
ventilatory
breaths.
promptly correct
disadvantageou
s situations.
21. Increased or
decreased
ventilation may
be experienced
by
ventilator
patients
who
may
try
to
compensate by
competing with
ventilatory
breaths.
22. Assess for cuff

leakage
and
change/notify
22. Cuffs which
physician
for have leaks that
change of airway.
enable a patient
to
have
the
ability to speak,
in which air may
be felt at the
nose and / or
mouth, changing
pressure
with
ventilation, and /
or
decreased
exhaled volumes
require change
in
order
to
maintain
adequate
oxygenation and
167
23. Instruct patient

and family members
regarding
equipments
and
alarms. Ensure that
patient understands
that he will not be
able to speak, but
will
have
nurse
available
at
all
times.
24. Instruct patient
and family members
regarding weaning
procedures.
25. Monitor ABGs

for
trend
and
change
ventilator
setting as ordered.
26.
Monitor
lab
work,
such
as
Hemoglobin
and
Hematocrit,
electrolytes and so
forth, as ordered.
ventilation.
23.
Provides
knowledge
to
facilitate
compliance and
decrease
anxiety.
24. Progressive
but
slow
weaning helps
the patient to
adjust to the
increase in work
of breathing.
25.
Maintains
adequate
oxygenation and
acid-base
balance.
26. Decreases in
Hemoglobin and
Hematocrit
reflect
a
decrease in the
oxygen-carrying
168
27. Obtain chest Xray every day and

as necessary while
the
patient
is
intubated,
as
ordered.
capability of the
blood. Abnormal
electrolytes may
result in cardiac
dysrhythmias,
which increase
the workload on
the cardiac and
pulmonary
systems.
27.
Facilitates
recognition
of
tube migration,
atelectatic
changes,
presence
of
pneumothorax,
or
other
significant
changes.
169
Problem Number 4: Risk for Aspiration
Assessment
Subjective cues:
The patient
verbalized:
Nandito na naman
po yung hirap po
akong lumunok
kahpag gabi na po
(I am having difficulty
in swallowing again,
especially at night)
The Patient may
verbalize:
1.Odynophagia
2.Shortness of
Breath
Objective cues:
The patient may
manifest
1. Choking by
widening of eyes and
protrusion of tongue
Nursing
diagnosis
Scientific
explanation
Risk for
aspiration
related to
decrease in
muscle
strength
(bulbar
weakness)
Secondary to
Myasthenia
Gravis
In patients with
Myasthenia Gravis,
there is weakening
of muscles that are
evident
most
especially on the
latter part of the
patients day. This
weakening
of
muscles is because
of
ineffective
neuromuscular
junction
transmission
of
Acetylcholine that
is
autoimmune
mediated. Affected
muscles
usually
include the bulbar
muscle which is
responsible
for
swallowing.
With
the
weakened
swallowing reflex,
there is a great risk
for aspiration.
Objectives
Short Term:
After
four
hours
of
nursing
intervention
the
patient
and
relative
will be able to
identify
causative/risk
factors
of
aspiration and
demonstrate
and verbalize
understanding
of how to
prevent
patient
aspiration.
Long Term:
After 2 days
of
nursing
intervention
the patient will
Nursing
interventions
Rationale
1.Assess
1. This should
patients ability serve
as
a
to swallow
baseline
knowledge
for
the
caregiver.
The extent of
swallowing
defects will direct
nursing
education
and
interventions.
2.Assess
the
underlying
2.This
should
cause
of give the nurse
patients inability the idea on what
to swallow
intervention/s to
provide
3.Mealtimes
should coincide 3.In Myasthenic
with the peak patients,
the
effects of
maximum
Anticholinesplasma
terase
concentration of
medication ex: acetylcholinesPyridostigmine
terase inhibitors
bromide
are usually about
(Mestinon)
1-2
hours.
Expected
outcome
Short term:
The
patient
shall
have
demonstrated
improved
ventilation
and
oxygenation
of tissues as
evidenced by
ABGs / pulse
oximetry
within
patients
normal
ranges
and
free
of
symptoms of
respiratory
distress.
Long term:
170
2.Hypoxia
3. Dyspnea
4.Vomiting
5.Dizziness
6. Panicked and
distressed behaviour.
7.Inability to talk in
complete sentences
or at full volume.
8.Frantic coughing.
9.Unusual breathing
sounds, such as
wheezing or
whistling.
10.Clutching at the
throat.
11.Watery eyes.
12.Red face.
be able to
decrease risk
of aspiration
with the help
of
proper
assessment
and
early
intervention,
Therefore
it
should be given
at least an hour
before
eating
their meals.
4.Coordinate
with the hospital
nutritionist
to 4.If weakness of
address dietary muscles occur at
modifications
night, the patient
should eat more
easily masticated
and light meals
during dinner and
heavy
meals
should be served
in the morning
when the patient
regain
his
5.Feed
the strength.
patient with the
head of bed 5.To
prevent
elevated.
aspiration
by
minimizing
the
6.Offer
small risk of reflux
frequent feeding
instead of heavy 6.This will allow
meals
some time for
rest in the part of
the patient that
would
promote
regaining muscle
7. Assess for strength.
vomiting
and
activity
7. Predisposes to
The
patient
shall
have
manifested
signs
of
normal
gas
exchange as
evidence by
absence
of
dyspnea,
tachypnea,
cyanosis,
restlessness,
irritability, and
normal pulse
oximetry
results.
171
intolerance
8.Maintain
operational
suction
equipment
hand
aspiration
of
contents of reflux
which
is
precipitated
by
factors
associated with
feeding
at
9. Notify the
physician
or
other health care
provider
immediately of
noted decrease
in cough and/or
gag reflexes, or
difficulty
in
swallowing.
10. Offer foods
with consistency
that patient can
swallow.
Use thickening
agents
as
appropriate. Cut
foods into small
pieces.
8.This should be
placed
at
bedside
for
immediate
intervention
in
case aspiration
occurs.
9.
Early
intervention
protects
the
patient's airways
and
prevents
aspiration.
10.Semisolid
foods
like
pudding are most
easily swallowed.
Liquids and thin
foods
like
creamed soups
172
11. Encourage
patient to chew
thoroughly and
eat slowly during
meals. Instruct
patient not to
talk while eating.
12,
Maintain
upright position
for 30 to 45
minutes
after
feeding.
13. Provide oral

care after meals.
are most difficult

for patients with
dysphagia.
11.Facilitates
easier
swallowing
of
foods.
Eating
while taking may
increase the risk
for aspiration due
to opening of the
epiglottis.
12. The upright
position
facilitates
the
gravitational flow
of food or fluid
through
the
alimentary tract.
If the head of bed
cannot
be
elevated
because
of
patient's
condition, use a
right
side-lying
position
after
feedings
to
facilitate passage
of
stomach
contents into the
duodenum.
173
13. To remove
residuals and to
reduce pocketing
of food that can
be
later
aspirated.
Problem Number 5: Ineffective Protection
Assessment
Subjective cues:
The Patient may
verbalize:
1. Perceived
changes in body
temperature
Objective cues:
The patient
manifested :
1. Leukocytosis
Day 1
41.71x109/L
Day 3
Nursing
diagnosis
Scientific
explanation
Objectives
Nursing
interventions
Rationale
Expected
outcome
Ineffective
protections
related to
impaired
secondary
protective
mechanism
as
evidenced
by
leucocytosi
s
secondary
to medically
induced
immunesuppressio
n
Therapeutic
immunosuppressio
n
is
usually
indicated
among
patients
with
autoimmune
disorders.
Prednisolone is a
synthetic
glucocorticoid that
is given among
patients
with
autoimmune
disorders such as
Myasthenia Gravis.
Prednisolone acts
in the feedback
mechanism of the
Short Term :
1.Monitor
and
record vital signs
and observe signs
of infection such as
increased
body
temperature
1. Increase in body
temperature
may
indicate presence of
severe infection in
the case of the
patient
who
are
therapeutically
immunocompromised
.
Short Term :
After three
hours of
nursing
interventions
, the patient
and relatives
would be
able to
identify
techniques
and
participate
on
preventing
further
infection by
2.Promote
adequate
rest/exercise
periods.
3. Note and report

laboratory
2.Aqeuate rest allows

preservation
of
oxygen
that
is
needed by other
body parts to fight off
pathogenic
microorganisms.
The patient
and relatives
shall have
identified
techniques
and
participated
on
preventing
further
infection by
examples of
proper
frequent
hand
washing,
174
21.83x109/L
Day 7
18.63 x109/L
2.Neutrophilia
Day 1
0.73
Day 3
0.78
Day 7
0.82
3. Secondary
Thrombocytosis
Day 1
535 x 109/L
Day 3
577 x 109/L
Day 7
536 x 109/L
4. Increase in
mucous secretion
production
5.Bilateral lung
fields crackles
6.Persistent
productive cough
The patient may
manifest :
1. Hyperthermia
2. Wheezes
3. Chills
(Prednison
e intake)
immune
system
which turns the
immune
system
down.
Glucocorticoids
cause their effects
by binding to the
glucocorticoid
receptor (GR). The
activated
GR
complex, in turn,
up-regulates
the
expression of antiinflammatory
proteins
in
the
nucleus (a process
known
as
transactivation) and
represses
the
expression
of
proinflammatory
proteins
in
the
cytosol
by
preventing
the
translocation
of
other transcription
factors from the
cytosol into the
nucleus
(Rhen,
2013). Given all
these at hand, the
patient is at risk for
infection including
pneumonia, which
examples of
proper
frequent
hand
washing,
aseptic
technique
and limiting
visitors.
values(e.g., white
blood cell count
and
differential,
serum
protein,
serum
albumin,
and cultures).
Long Term:
After 7 days
of nursing
interventions
, the patient
will resolve
on-going
infection and
will remain
free from
other
infection/s
as
evidenced
by normal
white blood
cell counts.
3.Use strategies to
prevent
infection
transmission
including
disinfecting/washin
g hands before and
after client contact
and
wearing
protective isolation
mask or face mask
4. Teach the patient
and
significant
others about the
nature
of
this
disorder and the
need
for
therapeutic
immunosupression
3.Temperature
elevation may occur
(if not masked by
corticosteroids
or
anti-inflammatory
drugs) because of
various factors, e.g.,
chemotherapy side
effects,
disease
process, or infection.
Early identification of
infectious
process
enables appropriate
therapy to be started
promptly.
3. Protects patient
from
sources
of
infection, such as
visitors and staffs
who may spread their
on-going infection.
aseptic
technique
and limiting
visitors.
Long Term:
The patients
on-going
infection
shall have
been
resolved and
he shall have
remained
free from
other
infection/s as
evidenced by
normal white
blood cell
counts.
4.Comprehension
and understanding of
the disease process
will help the patient
and their relatives to
be compliant with the
175
4. Nasal
Congestion
is
the
second
leading cause of
morbidity in the
Philippines in the
year
2010
(Department
of
Health, 2010)
need for therapeutic

immunosuppression
despite its adverse
effects .
5.Observe
for
localized sign of
infection
at
insertion sites of
invasive lines.
6.Review
environmental
factors.
7.
Administer
prophylactic
and
therapeutic
antibiotics
as
ordered and note
response.
5.Immunocompromised
patients usually does
not show any signs of
inflammation as their
inflammatory
response
is
deactivated. IV lines
should be changed
within 72 hours after
insertion to prevent
infection.
6.The
environment
plays a great role in
preventing infection
among
patients.
auxiliary should be
coordinated
to
promote clean and
safe environment for
the
immunocompromised patient.
7. Physicians usually
order antibiotics to
cover for the most
common pathogenic
microorganisms.
176
Assessment
for
improvement
or
development
of
patient signs and
symptoms should be
coordinated to the
physician to assess
effectiveness
of
treatment.
177
Problem Number 6: Impaired Physical Mobility

*Functional Level of Classification IV: Dependentdoes not participate in activity
Assessment
Subjective cues:
The Patient
verbalized:
Nodding when
the nurse asked if
he is reluctant to
move because of
presence of
discomfort in his
throat when the
endotracheal
tube is mobilized
and he might
accidentally
remove his
endotracheal
tube.
The patient may
verbalize:
1.Numbness of
immobilized
extremities
Objective cues:
Nursing
diagnosis
Scientific
explanation
Objectives
Impaired
Physical
Mobility
related to
throat
discomfort
from
mobilization
of
endotrachea
l tube as
evidenced
by
Reluctance
to attempt
movement
The endotracheal
tube is a foreign
body that triggers
the nociceptors in
the throat of the
patient.
These
nociceptors trigger
pain response in
which the patient
feels as discomfort.
Patient
Xs
movement is then
limited because he
does not want to
feel this discomfort
because of the
mobilization of the
endotracheal tube.
Hence, Patient X
does not want to
participate
in
activities that would
involve
bed
mobility. Prolonged
immobility causes
stasis of blood in
Short Term :
After four
hours of
nursing
interventions
, the patient
and relatives
would be
able to
identify
techniques
and
participate
on activities
that could
promote bed
mobility
including
active range
of motion
exercises.
Nursing
interventions
1.
Assess
impediments
mobility
for
to
2. Assess patient's
ability to perform
ADLs effectively
and safely on a
daily basis
3. Assess patient or
caregivers
knowledge
of
immobility and its
implications.
Long Term:
After three
4.
Assess
developing
Rationale
Expected
outcome
1. Identifying the
specific
cause
guides design of
optimal
treatment
plan.
Short Term :
The patient
and relatives
shall have
identified
2.Restricted
techniques
movement affects the and
ability to perform participated
most ADLs.
on activities
that could
promote bed
3. Even patients who mobility
are
temporarily including
immobile are at risk active range
for some of the of motion
effects of immobility, exercises.
such
as
skin
breakdown, muscle
weakness,
thrombophlebitis,
constipation,
pneumonia,
and
depression).
Long Term:
for
4.Bed
rest
or
The patients
178
The patient
manifested :
1. Reluctance to
attempt
movement
2. Limited range
of motion
(ROM)
3. Imposed
restrictions of
movement
The patient may
manifest:
1.Decreased
muscle
endurance,
strength, control,
or mass.
2.Signs and
symptoms of
deep vein
thrombosis
3.Bed sores
4.Progression of
pneumonia
5.Constipation
areas with pressure

including the sacral
and other bony
prominences, this
leads to pressure
sore. The stasis of
blood can also
cause decrease in
circulation
of
nerves in the area
leading
to
numbness.
Moreover, proteins
in the muscle are
catabolized
and
wasted
away
leading to muscle
atrophy
and
weakness.
days of
nursing
interventions
, the patient
not show
any adverse
signs and
symptoms of
prolonged
immobility as
evidenced
by no motor
deficits.
thrombophlebitis
immobility promotes
(calf pain, Homans' clot formation.
sign,
redness,
localized swelling,
and
rise
in
temperature).
5.
Assess
skin
integrity. Check for
signs of redness,
tissue
ischemia
(especially
over
ears,
shoulders,
elbows,
sacrum,
hips, heels, ankles,
and toes).
5.Blood stasis occurs

in
prolonged
immobility and causes
bed sores.
on-going
infection
shall not
have shown
any adverse
signs and
symptoms of
prolonged
immobility
as
evidenced
by no motor
deficits.
6.
Assess
elimination
status
(usual
pattern, 6.
Immobility
present
patterns, promotes
signs
of constipation.
constipation).
7. Encourage and
facilitate
early
ambulation
and
other ADLs when
possible. Assist with
each initial change:
dangling, sitting in
chair, ambulation.
7. The longer the

patient
remains
immobile the greater
the level of debilitation
that will occur.
8. Provide positive
179
reinforcement
during activity.
8. Patients may be
reluctant to move or
initiate new activity
from
a
fear
of
9. Allow patient to discomfort.
perform tasks at his
or her own rate. Do 9. Hospital workers
not rush patient. and family caregivers
Encourage
are often in a hurry
independent activity and do more for
as able and safe.
patients than needed,
thereby
slowing
patient's recovery and
reducing his or her
10. Keep side rails self-esteem.
up and bed in low
position.
10. To promote safe
environment.
11.
Turn
and
position every 2
hours,
or
as 11.
To
optimize
needed.
circulation
to
all
tissues and to relieve
pressure.
12. Perform passive
or active assistive 12.
To
promote
ROM exercises to increased
venous
all extremities
return,
prevent
stiffness, and maintain
muscle strength and
endurance.
13.
Encourage
coughing and deep- 13. To prevent build-
180
breathing exercises. up of secretions.

Problem Number 7: Disturbed Sleep Pattern
Assessment
Subjective cues:
The Patient
verbalized:
Nahihirapan po
akong matulog
kapag gabi dito
kasi laging
kumakatok yung
mga ate at kuya
tapos may
ilalagay sila sa
kilikili ko, pati po
nung may tubo
ako nung nasa
kabilang kwarto
ako mas lalo po
akong hirap kasi
nakakatakot
gumalaw dahil
sa tubo at mas
madalas din po
akong gisingin.
I am having
Nursing
diagnosis
Scientific
explanation
Disturbed
Sleep
Pattern
related to
excessive
stimulation
as
evidenced
by
verbalizatio
n of
interrupted
sleep
Sleep is required
to provide energy
for physical and
mental activities.
Such disruptions
may result in both
subjective distress
and
apparent
impairment
in
functional abilities.
Sleep patterns can
be affected by
environment,
especially
in
hospital
critical
care units. These
patients
experience sleep
disturbance
secondary to the
noisy,
bright
environment, and
frequent
monitoring
and
treatments. Such
Objectives
Nursing
interventions
Short Term : 1.
Assess
past
patterns of sleep in
After four
normal
environment:
hours of
amount,
bedtime
nursing
rituals, depth, length,
interventions positions, aids, and
, the patient, interfering agents.
relatives,
and health
2. Assess patient's
care
perception of cause of
providers
sleep difficulty and
would be
possible
relief
able to
measures to facilitate
identify and treatment.
address the
problem by 3. Document nursing
techniques
or
caregiver
that would
observations
of
promote
sleeping and wakeful
sleep and
behaviors.
Record
rest in the
number of sleep hours.
part of the
Note physical (e.g.,
patient.
noise,
pain
or
discomfort,
urinary
Long Term: frequency)
and/or
Rationale
Expected
outcome
1. Sleep patterns are

unique
to
each
individual.
Short Term :
2.
Knowing
the
specific
etiologic
factor
will
guide
appropriate therapy
3. Often, the patient's

perception of the
problem may differ
from
objective
evaluation.
The patient,
relatives,
and health
care
providers
shall have
identified
and
addressed
the problem
by
techniques
that would
promote
sleep and
rest in the
part of the
patient.
Long Term:
181
difficulty time
sleeping
especially at
night because
the nurses
always knock on
the door to check
my temperature.
I find it more
difficult to sleep
when I was still
in the Intensive
Care Unit as
they would wake
me up more
frequently than
here in the
regular room
because I had a
tube in my mouth
and I am afraid
to move.
The patient may
verbalize:
1.Feeling of
weakness during
daytime
2. Verbal
complaints of not
feeling rested
Objective cues:
sleep disturbance
is a significant
stressor in the
intensive care unit
(ICU) and can
affect
recovery
(Gulanick, 2013).
With less rest,
there is frequent
movement
of
muscles that could
exhaust
acetylcholine in the
neuromuscular
junction in the
case
of
Myasthenic
patients.
This
leads to persistent
weakening
of
muscles leading to
myasthenic
symptoms even in
the
morning.
Exacerbation
of
the
disease
condition or crisis
can also occur due
to lack of rest.
After two
days of
nursing
interventions
, the patient
will be able
to restore his
normal
sleeping
pattern.
psychological
(e.g.,
fear,
anxiety)
circumstances
that
interrupt sleep.
4. In both the hospital
and
home
care
4. Evaluate timing or setting, patients may
effects of medications be
following
that can disrupt sleep. medication schedules
that
require
awakening in the
early morning hours.
Attention to changes
in the schedule or
changes to once a
day medication may
solve the problem.
5. Instruct patient to
follow as consistent a
daily
schedule
for
retiring and arising as
possible.
The patient
shall have
restored his
normal
sleeping
pattern..
5. This promotes
regulation
of
the
circadian rhythm, and
reduces the energy
required
for
adaptation
to
changes.
6. Though hunger
can also keep one
6. Instruct to avoid awake,
gastric
heavy meals, alcohol, digestion
and
caffeine, or smoking stimulation
from
before retiring.
caffeine and nicotine
can disturb sleep.
7. For patients may
182
The patient
manifested :
1. Interrupted
sleep
2. Awakening
earlier or later
than desired
3. Restlessness
4. Irritability
The patient may
manifest
1. Dozing
2.Yawning
3.Altered mental
status
4.Difficulty in
arousal
5.Change in
activity level
6.Altered facial
expression (e.g.,
blank look,
fatigued
appearance)
7.Loss of
appetite
8.Worsening of
Myasthenic
symptoms in the
morning.
7. Instruct to avoid need to void during

large fluid intake before the night.
bedtime.
8. To reduce stress
8. Increase daytime and promote sleep.
physical activities as
indicated
9.
Napping
can
9. Discourage pattern disrupt normal sleep
of daytime naps unless patterns.
However
deemed necessary to the elderly do better
meet
sleep with frequent naps
requirements or if part during the day to
of one's usual pattern. counter their shorter
night
time
sleep
schedule.
10. Suggest use of 10. Which contains
soporifics such as milk. L-tryptophan
that
facilitates sleep.
11. Provide nursing 11. To promote rest.
aids (e.g., back rub,
bedtime care, pain
relief,
comfortable
position,
relaxation
techniques).
12. Organize nursing 12.
To
promote
care
minimal interruption
in sleep or rest..
a.Move patient to room
farther from the nursing
183
station if noise is a
contributing factor.
b.Post a "Do not
disturb" sign on the
door.
c.Eliminate
nonessential
nursing
activities.
d.Prepare patient for
necessary anticipated
interruptions/disruption
s
184
Problem Number 8: Imbalance Nutrition: Less then body requirements

Assessment
Nursing
diagnosis
Scientific
explanation
Subjective cues:
Imbalance
Nutrition:
Less than
Body
Requirements
related to
Unwillingness and
inability to
ingest food
as
evidenced
by BMI of
18.2 kg/m2
Adequate nutrition
is necessary to
meet the body's
demands.
Myasthenia Gravis
is a disorder that
causes decrease in
muscle
strength.
Bulbar muscle that
is present in the
throat
and
is
responsible
for
swallowing
is
commonly affected
in
Myasthenia
Gravis leading to
dysphagia that is
sometimes
perceived
as
odynophagia. This
symptoms
are
usually the reason
for anorexia among
patients
with
Myasthenia Gravis
The Patient
verbalized:
Lagi po akong
nawawalan ng
ganang kumain
kapag
nararamdaman
ko na po na
mahirap akong
lumunok kahit
laway lang
(I always tend to
lose my appetite
especially when I
am having a
difficult time in
swallowing)
The patient
manifested
1.Loss of appetite
2.Decrease in
food and oral
intake
The patient may
Objectives
Nursing
interventions
Short Term : 1. Document actual

weight;
do
not
After four
estimate.
hours of
nursing
interventions
, the patient, 2. Obtain nutritional
relatives,
history;
include
and health
family,
significant
care
others, or caregiver
providers
in assessment.
would be
able to
3.Determine
identify and etiologic factors for
address the reduced nutritional
problem by intake.
implementin
g techniques 4.
Monitor
or
that would
explore
attitudes
promote
toward eating and
increase in
food.
caloric
intake
through
dietary
modification
to
5.
Encourage
adequately
patient participation
Rationale
Expected
outcome
1. Patients may be
unaware
of
their
actual
weight
or
weight loss due to
estimating weight.
Short Term :
patient,
relatives,
and health
care
2. Patient's perception providers
of actual intake may shall have
differ.
identified
and
addressed
the problem
3. Proper assessment by
guides intervention.
implementin
g techniques
that would
promote
4.
Many increase in
psychological,
caloric intake
psychosocial,
and through
cultural
factors dietary
determine the type, modification
amount,
and to
appropriateness
of adequately
food consumed.
meet the
metabolic
5. Determination of requirement
type, amount, and s of the
185
manifest
1.Dizziness and
light-headedness
2. Feeling weak
3. Moody
4.Depresed
5.Anxious
meet the
metabolic
requirement
s of the
patient and
improve
patients
appetite
in recording food pattern of food or fluid

intake using a daily intake as facilitated by
log.
accurate
documentation
by
patient or caregiver as
the intake occurs;
memory is insufficient.
Long Term:
6. Weigh
weekly.
After four to
seven days
of nursing
interventions
the patient
will be able
to tolerate
dietary
modification
as
evidenced
by
improvement
of his body
mass index.
6. During aggressive
patient nutritional
support,
patient can gain up to
0.5 lbs per day.
7. Consult dietician
for
further
assessment
and
recommendations
regarding
food
preferences
and
nutritional support.
8.
Establish
appropriate
shortand
long-range
goals.
7. Dieticians have a
greater understanding
of the nutritional value
of foods and may be
helpful in assessing
specific
foods
favourable
to
the
patients condition. In
the case of the patient
heavy meals should
be
given
during
daytime
and
light
mealsshould
be
served at night
patient and
improve
patients
appetite.
Long Term:
The patient
shall have
tolerated
dietary
modification
as
evidenced
by
improvement
of his body
mass index.
8. Depending on the
etiologic factors of the
problem, improvement
in nutritional status
may take a long time.
Without realistic short-
186
term goals to provide

tangible
rewards,
patients may lose
interest in addressing
this problem.
9. Suggest ways to
assist patient with
meals as needed:
ensure a pleasant
environment,
facilitate
proper
position,
and
provide good oral
hygiene
and
dentition.
9. HOB elevated 30
degrees
aids
in
swallowing
and
reduces
risk
of
aspiration.
10. Attention to the

10.
Provide social
aspects
of
companionship
eating is important in
during mealtime.
both the hospital and
home setting.
11.
Encourage
family to bring food
from
home
as
appropriate.
11.
Patients
with
specific
ethnic,
religious preferences,
or restrictions may not
be able to eat hospital
foods.
12. May decrease

12.
Discourage appetite and may lead
beverages that are to early satiety.
caffeinated
or
carbonated.
187
Problem Number 9: Impaired Verbal Communication

Assessment
Subjective cues:
The Patient
verbalized:
Pag gabi po
dun ako hirap
magsalita. Kaya
ko pong sabihin
pero yung dila
ko at bibig ko
parang ayaw
sumunod sakin.
Tapos lagi po
nila akong hindi
naiintindihan
kunwari po may
gusto akong
sabihin kaya
tinatawanan po
nila ako lagi sabi
nila ngo-ngo
ako. Kaya po
hindi ako nalang
ako nagsasalita
(I usually have
Nursing
diagnosis
Scientific
explanation
Impaired
Verbal
Communication
related to
decrease in
muscle
strength as
evidenced
by slurring
of speech
secondary
to
Myasthenia
Gravis
Human speech is
produced by using
the muscles of
the throat, jaw,
palate,
tongue,
and lips to shape
the
sound generated
by the voice box
into consonants
and vowels. When
the muscles of the
lungs, vocal
tract, throat or
mouth are affected
in
Myasthenia
Gravis, there are
symptoms
of
voice, speech, and
swallowing
problems.
Voice
problems
seen
in
Myasthenia Gravis
include
vocal
fatigue
Objectives
Short Term :
Nursing
interventions
Rationale
1.Assess conditions
or situations that
may hinder the
patient's ability to
use language, such
as the following:
Orofacial/maxillary
problems
1. Understanding the
cause of impairment
will guide the nurses
intervention.
After two
hours of
nursing
interventions,
the patient
and relatives
would be able
to accept the 2.
Assess
for
patients
presence
and
incapacitation history of dyspnea.
to speak at a
given time by
understanding
that the
problem is
part of the
disease
process.
Long Term:
2. Patients who are

experiencing
breathing problems
may reduce or cease
verbal
communication that
may complicate their
respiratory efforts. In
Myasthenia
Gravis
this may suggest
impending crisis.
3. Assess energy 3. Fatigue and/or

level.
shortness of breath
After two days
can
make
of nursing
communication
interventions
difficult or impossible.
Expected
outcome
Short Term:
The patient
and relatives
Shall accepted
the patients
incapacitation
to speak at a
given time by
understanding
that the
problem is
part of the
disease
process.
Long Term:
The patient
shall have
utilized forms
of
communicatio
188
difficulty in
articulation at
night. I feels like
I can say it, but
my tongue and
mouth wont do
it. They (siblings)
would
misunderstood
what I want to
say) so theyll
laugh and insult
because I sound
like I am
speaking
nasally. So I just
do not talk
sometimes.)
The patient
manifested
1. Difficulty
vocalizing words
especially during
night time
(Dysarthria).
2.Slight slurring
of speech
2.Dysphagia
(voice wears out

over the day or
with prolonged
speaking tasks),
difficulty controlling
pitch, or a
monotone
voice
(lack of ability to
change
vocal
pitch).
The voice problem
can stem from
poor
breath
support or from
weakness causing
the vocal folds not
to move
properly. Speech
disturbances
include
a
hypernasal
voice or slurred
speech
(dysarthria).
Dysarthria is
more
frequently
seen in younger
patients diagnosed
with
Myasthenia
Gravis, whereas
dysphonia is more
often seen in
elderly men with
Myasthenia
the patient will

be able to use
a form of
communicatio
n to get needs
met and to
relate
effectively with
persons and
his or her
environment.
4. Assist the patient

in
seeking
an
evaluation of their
home and work
setting
4. To evaluate the
need for assistive
devices,
talking
computers, telephone
typing
device,
interpreters,
and
others. In the case of
the patient, his iPad
is a very useful tool.
n to get needs
met and to
relate
effectively with
persons and
his or her
environment
5. Place important 5. Place important

objects within reach objects within reach
6. Listen attentively
when
patient
attempts
to
communicate.
Clarify
your
understanding
of
the
patient's
communication with
the patient or an
interpreter.
6.Paying attention to
the
patient
will
increase the patients
self-worth
and
esteem.
7. Keep distractions
such as television
and radio at a
minimum
when
talking to patient
7. Keep distractions
such as television
and radio at a
minimum
when
talking to patient
8. Give the patient 8. It may be difficult

ample
time
to for
patients
to
respond
respond
under
189
Gravis. Typically,
the
symptoms
appear
and/or worsen with
continuing
or
extended speech
(ORourke, 2013).
pressure; they may

need extra time to
organize responses,
find the correct word,
or regain muscle
strength
in
myasthenic cases.
9. Praise patient's
accomplishments.
Acknowledge his or
her frustrations.
9. The inability to
communicate
enhances a patient's
sense of isolation and
may promote a sense
of helplessness.
10.
Use
short
sentences and ask
only one question
at a time.
10.This will allow

patient to give short
answers.
Patients
with
Myasthenia
Gravis
tend
to
exhaust their speech
muscles when talking
too long.
11.
Encourage
family
member/caregiver
to talk to patient
even though patient
may not respond.
11.
Decreases
patient's sense of
isolation and may
assist in recovery
from aphasia.
12.
Encourage 12. Communication
patient to socialize should
be
with family and encouraged despite
190
friends.
impairment
Problem Number 10: Readiness for Enhanced Health Maintenance

Assessment
Subjective cues:
The Patient
verbalized:
Kuya, kung
umuwi na po
kami paano po
yung gamot ko?
Pupunta po kayo
samin?
(Nurse, what if I
am to be
discharged from
this hospital, who
will be giving my
medications?
Will visit me at
home to give it to
me?)
The patient
manifested
1. Inquisitive
behaviour
Nursing
diagnosis
Scientific
explanation
Readiness
for
Enhanced
Health
Maintenanc
e related to
forthcoming
discharge
as
evidenced
by healthseeking
behaviours.
Positive
attitude
towards recovery
and rehabilitation
of a patient is
usually manifested
once
relief
of
symptoms
is
experienced or if
discharge
from
facility is near.
Patients with such
attitude
usually
present
an
inquiring outlook
with regards to
homecare
and
other
health
seeking
behaviours
like
medical
management and
allowable diet. The
patient, in this
case
presented
interest
in
his
Objectives
Short Term
After an hour
of nursing
interventions,
the patient
and relatives
will be able to
verbalize
understandin
g on home
care
practices,
home
medication
regimen,
positive
lifestyle and
dietary
changes and
importance of
follow-up
check ups
Long Term
Nursing
interventions
1.Assess
current
condition
Rationale
patient 1. To establish initial

health assessment with the
shift that would serve
as comparison during
evaluation
2.
Monitor
and 2.
To
establish
record vital signs
baseline data
3. Verify and review 3.
This
helps
discharge orders
ascertain
if
all
treatments,
medications,
and
other
important
information
are
complete
and
appropriate to the
patients need.
4. Prepare a home
management
4. Providing a patient
instruction sheet
with a guide helps
produce
a
solid
compliance
with
home care orders
5. Construc home
Expected
outcome
Short Term
The patient
and relatives
shall have
verbalized
understandin
g on home
care
practices,
home
medication
regimen,
positive
lifestyle and
dietary
changes and
importance of
follow-up
check ups
Long Term
191
focused on home
care and home
medical regimen
The patient may
manifest:
1.Appearance of
increased vigor
2.Openness to
health teachings
from health care
team
medication.
After a day of
nursing
intervention,
the patient
and relative
would be able
to make the
positive
health
changes in
indicated by
health
education
provided by
the nurse as
evidenced by
consistent
follow up with
their doctors
appointments
and religious
intake of
prescribed
drugs.
instruction in
mans term
lay- 5. This helps the

patient gain better
understanding
with
medical regimen this
a
more
accurate
continuation of care at
home
6. Educate patient
and relatives with5. This helps patient
certain actions of achieve a more
medications
and therapeutic level for
special
medication to be
consideration
for taken at home
taking
certain
medications
with
specified
instructions.
7. Provide time for
patient and relatives
to raise queries or
clarifications
regarding
previously provided
teachings
and
evaluate
understanding.
7.
This
helps
determine a correct
continuation of the
hospital provided care
once the patient is
sent home.
The patient
and relatives
shall have
made positive
health
changes as
indicated in
health
education
provided by
the nurse as
evidenced by
consistent
follow up with
their doctors
appointments
and religious
intake of
prescribed
drugs.
192
ACTUAL SOAPIERs
1st Nurse and Patient Interaction
February 12, 2015
10 PM 6 AM shift
Patient X was lying supine on a bed at moderate high back rest at 30 o angle
wearing a hospital gown with Glasgow Coma Scale of 11 (E4V1M6) i.e. spontaneous
eye opening, intubated, hence cannot produce verbal output and obeys verbal command
such as raising extremities with no difficulties. With endotracheal tube hooked to
mechanical ventilator with the following settings: Assist Control Mode; Tidal Volume at
200 ml; Positive End Expiratory Pressure at 4 cm H 2O; Fraction of Inspired Oxygen at
60%; Back Up Rate at 25 cycles per minute with thick yellowish-clear secretions in
moderate amount. With bilateral crackles on both lung fields upon auscultation.
With on-going IVF of #1 Plain Normal Saline Solution at 27 drops per minute (81 ml per
hour) infusing well over the right cephalic vein with Neoflon gauge 24 with no signs of
inflammation and infiltration. With mild ptosis over the left eye. With patent and intact
oro-gastric tube upon auscultation. With muscle strength of 5/5 on all extremities. Patient
appeared uncomfortable moving in bed because of the fear of mobilizing the
endotracheal tube, but not restless; With pinkish palpebral conjunctiva and good skin
turgor. Patient is complaining of throat discomfort. Patient X was normotensive
(100/70mmHg), normothermic (36.5oC), and with tachycardic episode (117 beats per
minute), with tachypneic episodes (29 cycles per minute). The patient nodded
when asked if he is having difficult time breathing at times witn no Oxygen
Desaturation Noted (100%)
1st Nursing Problem:
Impaired Spontaneous Ventilation
Subjective cues: Patient nodded when his mother asked if he is having difficulty of
breathing at home
Objective cues: Tachypneic (29 cycles per minute). The patient nodded when asked if
he is having difficult time breathing at times.
Assessment: Impaired Spontaneous Ventilation related to decrease in respiratory
muscle strength as evidenced by dyspnea secondary to Myasthenia Gravis.
Plan: After two hours of nursing interventions, The patient will not show progression of
respiratory distress as evidenced by hemodynamic stability and proportionate oxygen
demand and supply
Interventions:
193
1. Monitored and recorded vital signs and intake and output every hour
2. Document characteristics of respiratory status, including rate and depth of respiration,
chest excursion and symmetry, presence of cyanosis, use of accessory muscles for
respiration, effectiveness of cough, suctioning demands, sputum characteristics and
oxygen levels.
3. Assessed for progression of dyspnea and its systemic effects including changes in
vital signs and deteriorating sensorium.
4. Assessed the patient and their relatives knowledge of mechanical ventilation to
promote cooperation and understanding.
5. Performed aseptic technique in performing artificial airway care to the patient such as
suctioning.
6. Assisted respiratory therapist and physicians in weaning the patient from ventilator
support.
7. Encouraged deep breathing exercises to increase respiratory muscle strength and
prevent muscle atrophy.
8. Allowed bed mobility and turned patients side to side at least every 2 hours to prevent
statis of pulmonary secretions and promote pulmonary hygiene.
9. Administered acetylcholinesterase inhibitors as ordered to promote regaining strength
of patients muscles.
Evaluation: Goal Met. The patient did not show progression of respiratory distress as
evidenced by hemodynamic stability and proportionate oxygen demand and supply
2nd Nursing Problem:
Ineffective Airway Clearance
Subjective cues: None
Objective cues: Thick yellowish-clear secretions in moderate amount. Bilateral crackles
on both lung fields upon auscultation. Tachypneic (29 cycles per minute). The patient
nodded when asked if he is having difficult time breathing at times.
Assessment: Ineffective Airway Clearance related to increased mucus production as
evidenced by effective productive cough secondary to pneumonia.
Plan: After four hours of nursing interventions, the patient will be able to maintain airway
patency as evidenced by absence of signs and symptoms of respiratory distress.
Interventions:
1. Assessed patients condition including vital signs.
2. Assessed rate / depth of respirations and chest movement.
3. Auscultated lung fields noting areas of decreased / absent airflow and adventitious
breath sounds to monitor progression of pulmonary condition.
4. Elevated head of bed to promote lung expansion
5. Changed position frequently to promote airway drainage.
5. Assisted patient with frequent deep-breathing exercises to allow mobilization of
pulmonary secretions.
6. Suctioned secretions gently as indicated to promote coughing and expulsion of
sputum.
7. Provided adequate fluid intake to liquefy thickened secretions.
8. Performed chest physiotherapy before and after nebulization to promote loosening of
secretions.
194
9. Administered medications such as bronchodilators as indicated and ordered.

10. Monitored serial chest X-rays, ABGs, and pulse oximetry readings as ordered.
EVALUATION: Goal met. The patient maintained airway patency as evidenced by
absence of signs and symptoms of respiratory distress.
2nd Nurse and Patient Interaction
February 13, 2015
10 PM 6 AM shift
Patient X was lying supine on a bed at moderate high back rest at 45 o angle wearing a
hospital gown with Glasgow Coma Scale of 11 (E4V1M6) i.e. spontaneous eye opening,
intubated, hence cannot produce verbal output and obeys verbal command such as
raising extremities with no difficulties. With endotracheal tube hooked to mechanical
ventilator with the following settings: Continuous Positive Airway Pressure; Positive End
Expiratory Pressure at 4 cm H2O; Fraction of Inspired Oxygen at 70%; with thick
yellowish-clear secretions in moderate amount. With bilateral crackles on both
lung fields upon auscultation. With on-going IVF of #2 5% Dextrose in Lactated
Ringers Solution 1 Liter at 27 drops per minute (81 ml per hour) infusing well over the
right cephalic vein with Neoflon gauge 24 with no signs of inflammation and infiltration.
With patent and intact oro-gastric tube upon auscultation. With mild ptosis over the left
eye. With pinkish palpebral conjunctiva and good skin turgor. With muscle strength of 5/5
on all extremities. Patient still appeared uncomfortable moving in bed because of the
fear of mobilizing the endotracheal tube, but not restless; Patient is complaining of
throat discomfort. Patient X was normotensive (110/70mmHg), normothermic (36.4 oC),
and with sinus heart rhythm 87 beats per minute), eupneic (19 cycles per minute) with no
oxygen desaturation (98%). The patient nodded when the nurse asked if he is
reluctant to move because of presence of discomfort in his throat when the
endotracheal tube is mobilized and he might accidentally remove his endotracheal
tube.

Impaired Physical Mobility
Subjective cues: Nodding when the nurse asked if he is reluctant to move because of
presence of discomfort in his throat when the endotracheal tube is mobilized and he
might accidentally remove his endotracheal tube.
Objective cues: Appeared uncomfortable moving in bed because of the fear of
mobilizing the endotracheal tube.
195
Assessment: Impaired Physical Mobility related to throat discomfort from mobilization of

endotracheal tube as evidenced by reluctance to attempt movement.
Plan: The patient and relatives would be able to identify techniques and participate on
activities that could promote bed mobility including active range of motion exercises.
Interventions:
1. Assessed for impediments to mobility to guide effective plans
2. Assisted patient in performing ADLs especially with his elimination to minimize
discomfort brought about by the endotracheal tube.
3. Explained to the patient and relatives the importance of frequent changed in
position such as proper pulmonary drainage, prevention of muscle atrophy that
could worsen the patients muscle weakness and avoidance of bed sores.
4. Assessed for development of prolonged immobilization like thrombophlebitis (calf
pain, Homans' sign, redness, localized swelling, and rise in temperature).
5. Assessed skin integrity for possibilities of bed sores. Checked for signs of
redness, tissue ischemia (especially over ears, shoulders, elbows, sacrum, hips,
heels, ankles, and toes).
6. Assessed elimination status to know the normal patients pattern.
7. Encouraged and facilitate early ambulation after extubation and other ADLs when
possible. Assisted with each initial change: dangling, sitting in chair, ambulation.
8. Allowed patient to perform tasks at his or her own rate to encourage
independence.
9. Kept side rails up and bed in low position to promote a safety environment
10. Turned and positioned every 2 hours, or as needed with assistance with the
endotracheal tube to which the patients concern for discomfort is focused.
11. Performed passive or active assistive ROM exercises to all extremities to regain
muscle strength and prevent atrophy.
12. Encouraged coughing and deep-breathing exercises to promote expelling of
pulmonary secretions.
EVALUATION: Goal met.
The patient and relatives identified techniques and
participated on activities that could promote bed mobility including active range of motion
exercises.
196
197
3rd Nurse and Patient Interaction

February 14, 2015
10 PM 6 AM shift
Patient X was lying supine on a bed moderate high back rest at 45 o wearing a
hospital gown, conscious and coherent. With on-going IVF of #3 5% Dextrose in
Normosol M 1 Liter at 27 drops per minute (81 ml per hour) infusing well over the left
dorsal metacarpal vein with Venflon gauge 22 with no signs and symptoms of
inflammation and infiltration. With mild ptosis over the left eye. With pinkish palpebral
conjunctiva and good skin turgor. With muscle strength of 5/5 on all extremities. Patient
X was normotensive (110/70mmHg), normothermic (36.4oC), and with sinus heart rhythm
87 beats per minute), eupneic (19 cycles per minute). Patient is complaining of
dysphagia that is more prominent at night which causes him to lose his appetite.

Risk For Aspiration
Subjective cues: Nandito na naman po yung hirap po akong lumunok kahpag gabi na
po
(I am having difficulty in swallowing again, especially at night)
Objective cues: (+) Dysphagia
Assessment: Risk for aspiration related to decrease in muscle strength (bulbar
weakness) Secondary to Myasthenia Gravis
Plan: After four hours of nursing intervention the patient and relative will be able to
identify causative/risk factors of aspiration and demonstrate and verbalize understanding
of how to prevent patient aspiration.
Interventions:
198
1. Assessed the underlying cause of patients inability to swallow to serve as guide

for interventions to be implemented.
2. Coordinated mealtimes with the peak effects of Anticholines-terase medication
bulbar muscle strength for swallowing 3.
3. Coordinated with the hospital nutritionist to address dietary modifications by
providing light and soft meals at night where muscle strength for swallowing is
usually diminished.
4. Fed the patient with the head of bed elevated to minimize chances of reflux.
5. Offered small frequent feeding instead of heavy meals to allow time for patient to
regain his muscle strength
6. Maintained operational suction equipment at bedside in case aspiration occurs
7. Offered foods with consistency that patient can swallow by cutting foods into
small pieces.
8. Encouraged patient to chew thoroughly and eat slowly during meals. Instructed
patient not to talk while eating.
9. Maintained upright position for 30 to 45 minutes after feeding to prevent reflux.
Head and neck was also tilted forward slightly to facilitate elevation of the larynx
and posterior movement of the tongue
10. Provided oral care after meal to remove residuals and to reduce pocketing that
can later be aspirated.
EVALUATION: Goal met. The patient and relative were able to identify causative/risk
factors of aspiration and demonstrate and verbalize understanding of how to prevent
patient aspiration.
199
4th Nurse and Patient Interaction

February 18, 2015
6 AM 2 PM shift
Patient X was sitting on bed wearing a hospital gown, conscious and coherent.
With on-going IVF of #8 5% Dextrose in Normosol M 1 Liter at 27 drops per minute (81
ml per hour) infusing well over the right dorsal metacarpal vein with Venflon gauge 22
infusing well with no signs and symptoms of inflammation and phlebitis. No ptosis noted.
With pinkish palpebral conjunctiva and good skin turgor. No muscle weakness noted. (-)
Dysphagia. (-) Ptosis. Patient X was normotensive (100/70mmHg), normothermic
(36.3oC), and with sinus heart rhythm 88 beats per minute), eupneic (25 cycles per
minute).
Readiness for Enhanced Health Maintenance
Subjective cues: Kuya, kung umuwi na po kami paano po yung gamot ko? Pupunta po
kayo samin?
(Nurse, what if I am to be discharged from this hospital, who will be giving my
medications? Will visit me at home to give it to me?)
Objective cues: The patient is inquisitive of his discharge.
Assessment: Readiness for Enhanced Health Maintenance related to forthcoming
discharge as evidenced by health-seeking behaviours
Plan: After an hour of nursing interventions, the patient and relatives will be able to
verbalize understanding on home care practices, home medication regimen, positive
lifestyle and dietary changes and importance of follow-up check-ups.
Interventions:
1. Assessed patient current health condition
200
2. Monitored and recorded vital signs

3. Verified and reviewed discharge orders
4. Prepared a home management instruction sheet
5. Constructed home instruction in lay-mans term
6. Educated patient and relatives with certain actions of medications and special
consideration for taking certain medications with specified instructions.
7. Provide time for patient and relatives to raise queries or clarifications regarding
previously provided teachings and evaluate understanding.
EVALUATION: Goal met. The patient and relatives were able to verbalize
understanding on home care practices, home medication regimen, positive lifestyle and
dietary changes and importance of follow-up check-ups.
201

5 Patient and His Care

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

5 Patient and His Care

Uploaded by

Copyright:

Available Formats

V.

THE PATIENT AND HIS CARE

The said fluid is generally used among

The physicians initially started an

This solution useful for daily maintenance

D5NM is indicated for parenteral

This type of solution was indicated for

The Patient did

The patient did

could actually help prevent hypokalemia.

Nursing Responsibilities for starting and maintaining an Intravenous site

Verify prescriptions for IV therapy

Check solution label and identify patient

Explain procedure to the patient

Carry out hand hygiene and put on disposable non-latex gloves

Choose site. Use distal veins of hands and arms first

Calculate infusion rate and regulate flow of infusion

Document date and time therapy initiated

Monitor vital signs

Check the level of the IV as per hospital policy

Tape the IV lines

Dress and label the venipuncture according to the hospital policy

Regularly check regulation of IVF.

The delivery of oxygen

The indication of oxygen

Patients Response to the

Face masks that cover

Since the patient was newly

The patient showed no sign

Patient X did not like the

MECHANICAL VENTILATOR WEANING PROCESS

Figure 5.1 Mechanical Ventilator Weaning Process

Nursing Responsibilities for Mechanical Ventilator:

1. Assist in the insertion of the endotracheal tube.

d. Drugs (In Alphabetical Order)

Clients response to the

Clients response to the

play a role in the

3. Check for the expiration date

Regulate the infusion accordingly.

February 16, 2015

Clients response to the

Susceptible grampositive organisms

1. Check the doctors order

3. Document the findings.

This drug is used in

excess ACh levels

Clients response to the

5. Instruct patient to report presence palpitations

For the treatment

5. Explain to the patient the purpose of the drug.

3. Document the findings.

*See Figure 5.2

provides balanced Patient X is place on

child's growth and

and cannot swallow

foods per orem due to

vomiting was noted.

kids grow based

sufficient as the patient

children at risk for

constipation that may

be associated with the

use of milk formula