I.

INTRODUCTION

A. Background of the Study

Since World War I, it has been recognized that some patients with
nonthoracic injuries, severe pancreatitis, massive transfusion, sepsis, and
other conditions develop respiratory distress, diffuse lung infiltrates, and
respiratory failure, sometimes after a delay of hours to days. Ashbaugh et al
described 12 such patients in 1967, using the term “adult respiratory distress
syndrome” to describe this condition.
The term, “Acute Respiratory Distress Syndrome (ARDS)” was first used
in 1967 to describe a distinct clinical entity characterized by acute
abnormality of both lungs..
Despite substantial progress in understanding the pathophysiology,
ARDS remains a major clinical problem, and mortality is still as high as 40 -
46%. Rarely, the cause of ARDS is brought about by chest trauma or injury,
which extends to the damage of some lung tissue particularly the pleural
cavity resulting to hemothorax. Hemothorax is the presence of blood in the
pleural space. The source of blood may be the chest wall, lung parenchyma,
heart or great blood vessels.
Hemothorax is usually a consequence of blunt or penetrating trauma.
Much less commonly, it may be a complication of disease, may be
iatrogenically induced, or may develop spontaneously.
Prompt identification and treatment of traumatic hemothorax is an
essential part of the care of the injured patient. The upright chest radiograph
is the ideal primary diagnostic study in the evaluation of hemothorax.
Cross-sectional studies demonstrate that patients with ARDS represent
approximately 5% of hospitalized, mechanically ventilated patients.
Approximately one-third of patients with initially mild ARDS will later progress
to moderate or severe disease; identification of factors associated with
progression of mild ARDS requires further study. The incidence of ARDS
varies widely. For example, estimates from prospective US cohort studies

1
using the American- European Consensus Conference on ARDS’ definition
range from 64.21 to 78.91 cases/100,000 person-years, whereas estimates
from Northern Europe (17 cases/100,000), Spain (7.2 cases/100,000), and
Australia/New Zealand (34 cases/100,000) have shown substantially lower
rates. Reasons for the large variation in ARDS incidence are unclear, and
may include major differences in demographics and healthcare delivery
systems.
The National Heart, Lung and Blood Institute data base from Population
Estimates based upon US Census Bureau, International Data Base, 2004
revealed that Philippines with a total population of 86,241,697 had 47,559
cases in a year.
In the past 5 years, Victoriano Luna Medical Center came up with a total
prevalence of 35 cases of ARDS brought about by preexisting medical
condition like pneumonia. Gunshot injury at chest area causing hemothorax
leading to ARDS has been a unique case as there was a low survival rate for
such condition.
The case was chosen for the reason that the patient had displayed
better prognosis along the course of stay in Surgical Intensive Care Unit.
Studies presented that there is a low survival rate for such condition but the
response of the subject to the treatment was satisfyingly noted and was stable
prior to transfer to Ward 4D and eventually, got discharged from the hospital.
Also, the investigator finds the case interesting and very beneficial to be
shared to colleagues due to the intricacy of the case.

2
 A. Objectives of the Case Study

General Objective:
To conduct a comprehensive case study of client with Acute
Respiratory Distress Syndrome secondary to hemothorax secondary to
Gunshot injury.

Specific Objectives:
At the end of case presentation, the presenter will be able to:
1. Obtain a comprehensive nursing history and conduct physical
assessment using the standards of nursing health history taking
and a head-to-toe approach in physical assessment.
2. Discuss the anatomy and physiology of the affected body organ
and formulate a schematic diagram showing an in-depth
understanding of the disease process.
3. Present significant laboratory and diagnostic findings that are
directly affected in relation to the disease process.
4. Formulate an individual nursing care plan that focuses on high
quality nursing interventions and provides holistic care to the
patient.
5. Render a discharge home care plan that will ensure continuous
and effective medical and nursing care management to the
patient.

B. Significance of the Study

This case study would be valuable to the following:

Patient - enhance the collaboration and commitment of the patient to

the healthcare management through better understanding of the disease
process, medications and subsequently enhance compliance.

3
 Significant others – would gain knowledge and understand their
patient’s condition for them to be able to provide necessary assistance to their
patient.

Nurses – to be able to synthesize complete and efficient nursing care

plan and its implementation to patients experiencing the same case.

Allied Healthcare Professionals - to be able to provide competent

and efficient care and management to patients experiencing Acute
Respiratory Distress syndrome caused by Hemothorax.

Nursing Education and Training - this study would be a source of

information or be as a reference for future investigators who will focus on this
particular case.

C. Scope and Limitation

The scope of the study is limited upon the admission from Emergency
Room on 04 0100H March 2018 up to patient’s trans-out on 17 1000H March
2018 to Ward 4D for a total of 14 hospitalization days at Surgical Intensive
Care Unit, Victoriano Luna Medical Center, Armed Forces of the Philippines
Health Service Command.
The sources of information were the significant others, medical
records, and members of the health care team. Other pertinent data were
taken from books and articles from the internet as well as the Subjective and
Objective Data noted from the patient.

4
 II. PROFILE, HISTORY AND PHYSICAL EXAMINATION

A. Patient’s Profile
Name: CC
Rank: Civilian - Pure
Sex: Male
Age: 44 years old
Address: Upper Bathala, Barangay Sampaloc, Tanay Rizal
Citizenship: Filipino
Date of Birth: 08 October 1973
Place of Birth: Masbate
Religion: Islam
Civil Status: Married
Date of Admission: 04 0100H March 2018 at Surgical Intensive Care
Unit, VLGH.
Date of Trans-Out to Ward 4D: 17 1000H March 2018
Chief Complaint: Gunshot Wound
NOI: Gunshot Wound
TOI: 1810H
POI: Sampaloc, Tanay Rizal
DOI: 03 March 2018
Date of Discharge: 21 1200H March 2018

Admitting Diagnosis (03 March 2018)

T/C Intraabdominal Injury, Penetrating Chest Injury secondary to
Gunshot Injury; 1) POEN: Proximal 3rd Anterior Aspect Arm, Right; POEX:
Proximal 3rd Anteromedial Aspect Arm, Right (Thru and Thru); 2) POEN: 4 th
Intercostal Space Anterior Axillary Line; POEX: None with Retained Metallic
Foreign Body

5
 Revised Diagnosis (04 March 2018)
Hemothorax secondary to Gunshot Wound 4th Intercostal Space
Anterior Axillary Line, Right (POEN) with Thru and Thru Proximal 3 rd;
Anterolateral Aspect Arm Right (POEX); Alcohol Intoxication

Revised Diagnosis (06 March 2018)

Acute Respiratory Distress Syndrome secondary to Hemothorax, Right
secondary to Gunshot Wound 4th Intercostal Space Anteromedial Axillary
Line, Right (POEN) with Thru and Thru Proximal 3rd Anterolateral Aspect,
Arm, Right (POEN) Proximal 3rd Anteromedial Aspect, Arm, Right (POEX)

B. Socio-Demographic Characteristics

CC is second among three (3) siblings and a 3rd year Highschool

Undergraduate. He speaks, read and write Bisaya, Filipino and English.
Currently, he is a construction worker residing at Upper Bathala, Barangay
Sampaloc, Tanay, Rizal having three (3) biological offspring and four (4) step
children which is an extended type of family. They live in a semi-concrete
bungalow house with two (2) bedrooms and a comfort room. Their source of
water comes from a local water supply in their barangay. His partner is a
fulltime housewife, thus, CC is the sole provider of the family with a daily
compensation of P350.00.

C. History of Present Illness

On 03 March 2018, CC was invited by his friends for some drinks and had
some heated conversation with them in between. On or about 1810H on their
way home, he got into another argument with one of his drunk friend,
subsequently, his friend got annoyed and shot CC on his right arm. CC was
then immediately rushed to the nearest hospital which is Camp Capinpin
Station Hospital. Wherein upon arrival, he was intubated with 7.0tube at
22cm depth. An improvised Chest Tube Thoracostomy was inserted using a

6
nasogastric tube with an initial output of 630cc. An intravenous line was also
inserted with gauge 18 IV cannula at left hand and hooked to PNSS 1L as
fast drip then regulated to run for 8 hours. He was then referred to our
institution for further evaluation and management. Upon arrival at our
Department of Emergency Medicine (DEM), CC was awake and responsive
with GCS 11 (E4V1M6) per stretcher accompanied NOD. Vital signs were
taken as follows: T = 36.9 degrees Celsius, PR = 115 bpm, RR = 25 cpm, BP
= 100/60 mmHg, O2Sat = 93%. Pertinent laboratories and diagnostic
procedures were done. during assessment, it was found out that his ET was
out thus reintubation was done by the Anesthesia Service with 7.0 tube at 21
cm depth. Improvised CTT was replaced and connected to a water sealed
bottle with sanguinous output hence admitted to Surgical Intensive Care Unit
with admitting diagnosis of T/C Intraabdominal Injury, Penetrating Chest
Injury secondary to Gunshot Injury 1) POEN: Proximal 3 rd Anterior Aspect,
Arm, Right; POEX: Proximal 3rd Anteromedial Aspect, Arm, Right (Thru and
Thru); 2) Point of Reentry: 4th Intercostal Anterior Axillary Line; POEX: None
with Retained Metallic Foreign Body.

D. Past Health History

CC verbalized that he has allergy to crabs and shrimps. He claimed that
he haven’t had hospitalizations due to any illness and considered this as his
first (1st) hospitalization. Common illness that he encountered was cough and
colds. He also claimed that he had a complete immunization when he was a
child.

7
 Gordon’s Functional Health Patterns

1. Health Perception-Health Management Pattern

According to CC, health is a state of being free from diseases and able
to perform daily tasks with ease. He expressed that his general health is not
100% in good shape but he and his family rarely get sick; usually cough and
colds and they would self- medicate using herbal medicines like Lagundi and
not so often Biogesic for fever. He mentioned that he’s not healthy at the
moment due to his current medical condition; he accepts his illness and is
amenable to the therapeutic regimen prescribed by the physician. He added
that it was his first time to get hospitalized.

2. Nutritional-Metabolic Pattern
CC is a Muslim thus he is restricted to swine and other pork products
other than said, he has no dietary restrictions except to crabs and shrimps
since he allergic to it. He eats three times a day and his typical meals were
composed of 2 viands: meat or fish and vegetable and 1 cup of rice every
meal with snacks in between meals. He limits his intake of soda and sweets.
His fluid intake amounts to 8-10 glasses per day prior to confinement. He likes
to drink Gin or Brandy consuming 1-2 bottles per day or more if with his
friends. His current weight is 64 kg; his height is 170 cm with a BMI 22.7,
interpreted as normal.

3. Elimination Pattern
Prior to hospitalization, CC has regular bowel movement of 1 to 2 times
a day with brown formed stool and urinates about 7-8 times amounting to
2000ml daily. As claimed, he doesn’t have any difficulty in defecating and
urinating. During confinement, he passes formed stool every other day. His
urinary elimination pattern is facilitated by the indwelling foley catheter
connected to the urine bag, with adequate output amounting to 1500-2000ml
in a 24-hour basis or 60 to 80 ml per hour.

8
4. Activity Exercise Pattern
CC had an active lifestyle since he works as a construction worker.
He’s able to perform activities of daily living independently. His work lasts 12
hours a day. During confinement, CC was on complete bed rest without
bathroom privileges. CC has limited physical activities; passive range of
motion exercises was done on affected and non-affected limbs. His form of
recreational activities was surfing the internet for current events using his
phone and using social media applications like Facebook.

5. Sleep - Rest Pattern

CC verbalized that his sleep is adequate; he sleeps at 2100H and
wakes up at 0500H. He has no time for noon nap due to his busy schedule.
CC uttered that he doesn’t have difficulty in sleeping nor takes medication to
aid sleep. During confinement, he mentioned that he can’t have continuous
sleep due to his condition and hourly monitoring which he understood.
According to CC, his sleep usually lasts about 4-5 hours daily.

6. Cognitive - Perceptual Pattern

CC’s highest educational attainment was 3rd year high school. He does
not use eye glasses to aid in reading. He has no difficulty in hearing. His long-
term memory is excellent as he was able to recall past events from the time
he transferred residence to Tanay Rizal, short-term memory by being able to
state the chronologic events upon hospitalization. He is able to speak, write,
and read Tagalog, English and Bisaya. He was observed to be attentive to the
investigator’s queries and able to respond immediately.

7. Self-Perception and Self-Concept Pattern

CC mentioned that the presence of wound on his arm and beside his
right rib might affect his ability to perform daily tasks and work as a
construction worker. But he is positive and hopeful that the removal of the
retained metallic foreign body will improve his condition. He perceives his

9
illness a problem but just accepts it and cooperates with the treatment
regimen prescribed by the physician.

8. Role - Relationship Pattern

CC is separated with his first wife and their two (2) children are under
his custody. He has a new partner for three (3) years and he verbalized that
he has no problem with his new family. His children go to school. CC stated
that being a father to his children, he needs to work harder to sustain the
needs of his family; he needs to earn more to feed and send them to school.
He added that he has a good relationship with their neighbours and co-
workers as they are reliable whenever he needs help in some difficult
situations. During hospitalization, his children visited to look over him. His
church peers also visited him and offered help.

9. Sexuality and Reproductive Pattern

CC was circumcised when he was 11 years old and engaged to sexual
activity when he was 18 years old. He has two children from his first wife and
one with his present partner; and 4 step children. CC has never used
contraceptives during coitus.

10. Coping-Stress Tolerance Pattern

CC verbalized that he and his family didn’t encountered serious
problems so far; though he just earn a minimum wage for them it is enough to
sustain their daily needs. He mentioned that whenever they have problems,
they would talk about it and come up with a solution. Whenever he gets
tensed, he makes sure to keep calm and relax; this helps him think well.

11. Value-Belief Pattern

CC goes to the mosque with his family and prays regularly. He was a
Roman Catholic 13 years ago and just converted to Islam. He considers Allah
as the center of their lives. He always prays for guidance whenever they are
in trouble. CC reported that they follow some superstitious beliefs that were

10
imposed by their elders like no sweeping and no cutting of nails during the
night.

E. Physical Assessment
The assessment was done on 05 2100H March 2018 at Surgical Intensive
Care Unit.

GENERAL APPEARANCE:
Well groomed, dressed with hospital uniform, medium built, and no body odor.

LEVEL OF CONSCIOUSNESS
Conscious, alert and coherent, GCS 11, (E4M6V1)

VITAL SIGNS AND ANTHROPOMETRIC MEASUREMENTS:

T: 38.7°C
HR: 120 bpm
RR: 28 cpm (Assisted)
BP: 100/60 mmHg
O2 Saturation: 80%
HT: 170 cm
WT: 64 kgs
BMI: 22.7 – Normal

SKIN
No jaundice or cyanosis noted. Skin turgor is normal. Appears smooth, warm
and dry skin noted; uniform in color, temperature is within normal limit.
Wound present at right arm anterior and posterior with a size about
3mm, with dressing, dry and intact. Wound present with a size of 3mm at
anterior axillary line with dressing dry and intact. Redness and swelling
noted around affected site.
Pale nail beds, clean and well-trimmed

11
HEAD/NECK
Head is round, normocephalic and symmetrical. Hair is thick, black in color,
and evenly distributed. No infection or infestation noted. No jugular vein
distention, lymph nodes are not tender upon palpation.

EYES
Pale palpebral conjunctiva, anicteric sclerae, pupils are equally round and
reactive to light and accommodation (PERRLA).

EARS
Auricles are symmetrical, not tender, no discharges, aligned to lateral canthus
of eyes, same color with the skin. CC has no difficulty of hearing during the
assessment.

NOSE
Symmetrical nasolabial fold; septum in midline, no tenderness upon palpation.
CC has no difficulty identifying odors, no secretions noted. NGT inserted at
right nasal opening.

MOUTH
No dryness, pinkish and moist lips and oral mucosa. No dentures noted,
complete set of teeth upper and lower jaw. No halitosis noted. Tongue in the
midline, no lesions, and no fasciculation noted. Endotracheal Tube inserted
and connected to mechanical ventilator with the following settings: AC
Mode, BUR- 20, FiO2- 100%, Presence of mouth guard.

CHEST/LUNGS
Symmetrical chest, clear breath sounds. Decreased breath sounds on right
lung field. Unequal chest rise. Presence of wound on anterior axillary
line, right; with dressing dry and intact. Presence of CTT at anterior

12
axillary line, right with sutures and dressing, soaked with blood about 3
cm in diameter.

HEART
Tachycardic with Pulse Rate of 120 bpm, no abnormal sound

ABDOMEN
Flat, normoactive bowel sounds, soft, non-tender, unblemished skin, uniform
in color. Non-distended

GENITALS
Presence of Indwelling Foley Catheter connected to urine bag, with
adequate output. Urine output of about 3000 ml per day, light to yellow color.

UPPER AND LOWER EXTREMITIES:

Full equal pulses on both lower and upper extremities, with punctured
wound proximal 3rd anteromedial and anterolateral aspect arm, right. No
edema, no cyanosis. With on-going D5LR 1 litre to run for 8 hours at 41-42
drops per minute rate at left arm with IV cannula gauge 18.

13
 III. CLINICAL DISCUSSION

A. Anatomy and Physiology

Respiratory System – The Lungs

The lungs are paired cone-shaped organ in the thoracic cavity. The two
lungs, which contain all the components of the bronchial tree beyond the
primary bronchi, occupy most of the space in the thoracic cavity. The lungs
are soft and spongy because they are mostly air spaces surrounded by the
alveolar cells and elastic connective tissue. They are separated from each
other by the
mediastinum, which
contains the heart.
Each lung is roughly
cone shaped, rests
on the diaphragm,
and extends upward
just above the
midpoint of the
clavicle. The only
point of attachment
for each lung is at
the hilum, or root, on the medial side. This is where the bronchi, blood
vessels, lymphatics, and nerves enter the lungs. The right lung is shorter, is
broader, and has a greater volume than the left lung. It is divided into three
lobes (superior, middle, and inferior) by two fissures. Each lobe is supplied by
one of the secondary (lobar) bronchi. The lobes are further subdivided into
bronchopulmonary segments by connective tissue septa that are not visible
on the surface. Because each segment has its own bronchus and blood
supply, which do not cross the septa, a segment can be surgically removed
with relatively little damage to the rest of the lung. The left lung is longer and
narrower than the right lung. It has an indentation, called the cardiac notch, on

14
its medial surface for the apex of the heart. The left lung is divided into two
lobes by a single fissure. Each lung is enclosed by a double-layered serous
membrane, called the pleura. The visceral pleura is firmly attached to the
surface of the lung. At the hilum, the visceral pleura is continuous with the
parietal pleura that
lines the wall of the
thorax. The small
space between the
visceral and parietal
pleurae is the
pleural cavity. It
contains a thin film
of serous fluid that
is produced by the
pleura. The fluid
acts as a lubricant to reduce friction as the two layers slide against each
other, and it helps to hold the two layers together as the lungs inflate and
deflate. Surface tension of the pleural fluid also leads to close apposition of
the lung surfaces with the chest wall. This allows for the greater inflation of the
alveoli during breathing. The pleural cavity transmits movements of the rib
muscle to the lungs, particularly during heavy breathing. During inhalation, the
external intercostals contract, as does the diaphragm. This causes the
expansion of the chest wall that increases the volume of the lungs. A negative
pressure is thus created
and inhalation occurs.

Physiology of the
Respiratory System
The major function
of the respiratory system
is to supply the body with

15
oxygen and to dispose of carbon dioxide.
During pulmonary respiration or simply termed as breathing, the air
moves into and out of the lungs so that gases in the air sacs are continuously
refreshed. The gas exchange between pulmonary blood and alveoli must take
place and this is called external respiration, while internal respiration is the
gas exchange at the systemic capillaries made between the tissue cells and
the blood. The respiratory gas transport is the travel of oxygen and carbon
dioxide from the lung to the tissue cells in the blood stream.

Mechanics of Ventilation
Pulmonary ventilation is commonly referred to as breathing. It is the
process of air flowing
into the lungs during
inspiration (inhalation)
and out of the lungs
during expiration
(exhalation). Air flows
because of pressure
differences between the
atmosphere and the
gases inside the lungs.
One of the fundamental properties of gases is Boyle’s law, which states that
at constant temperature, when the volume of a gas increases the pressure
decreases; conversely, when the volume decreases the pressure increases.
This is stated in equation form as P1V1 = P2V2, where P represents
pressure and V represents volume. A gas expands to fill a given container,
and when it expands (volume increases) the pressure of the gas decreases.
In ventilation, the containers are the atmosphere, the lungs, and the pleural
cavity. Ventilation depends on changes in pressures and volumes within the
containers.

16
Pressures in Pulmonary Ventilation
Air, like other gases, flows from a region with higher pressure to a region
with lower pressure. Muscular breathing movements and recoil of elastic
tissues create the changes in pressure that result in ventilation. Pulmonary
ventilation involves three different pressures: atmospheric pressure,
intrapulmonary (intraalveolar) pressure, and intrapleural pressure.
Atmospheric pressure is the pressure of the air outside the body. At sea
level, this pressure is normally 760 mm Hg. Intrapulmonary pressure, also
called intraalveolar pressure, is the pressure inside the alveoli of the lungs.
When the lungs are at rest, between breaths, this pressure equals
atmospheric pressure.
The intrapulmonary
pressure varies as the
thoracic cavity changes
size with each breath,
and it is responsible for
air moving into and out of
the lungs. When
intrapulmonary pressure
is less than atmospheric
pressure, air flows into
the lungs. When it is
greater than atmospheric pressure, air flows out of the lungs.
Intrapleural pressure is the pressure within the pleural cavity, between the
visceral and parietal pleurae. This pressure also changes with each breath,
but under normal conditions it is slightly less than both the atmospheric
pressure and the intrapulmonary pressure. It represents a partial vacuum or
negative pressure and is an important factor in keeping the lungs inflated.
Because the pressure inside the lungs is greater than the intrapleural
pressure, the lungs always expand to fill the space and press against the
thoracic wall. If the intrapleural pressure becomes greater than the
intrapulmonary pressure, the lungs collapse and are non-functional.

17
 B. Pathophysiology

ARDS is associated with diffuse alveolar damage and lung capillary

endothelial injury. Early ARDS is characterized by an increase in the
permeability of the alveolar-capillary barrier, leading to an influx of fluid into
the alveoli. The alveolar-capillary barrier is formed by the microvascular
endothelium and the epithelial lining of the alveoli. Hence, a variety of insults
resulting in damage either to the vascular endothelium or to the alveolar
epithelium could result in ARDS.
Trauma (gunshot) caused a punctured wound on the thoracic cavity
leading to bleeding. The bullet travelled from proximal 3 rd anterolateral Aspect
Arm Right, went through and through and exited at proximal 3 rd anteromedial
aspect arm right and punctured the thoracic cavity at 4 th intercostal space
anterior axillary line. The trauma caused hemothorax, which is the
accumulation of blood in the pleural cavity.
The bleeding caused lung and chest congestion leading to increased
intrapleural pressure as manifested by acute pain with a pain scale of 10/10;
CC experienced difficulty of breathing; pallor in nail bed and palpebral
conjunctiva was noted; decreased breath sound was heard on affected area.
He also experienced tachycardia with a heart rate of 120 bpm and the blood
pressure dropped to 90/60mmHg.The lungs doesn’t have enough room to
expand precipitated to alveolar epithelial cell damage.
The main site of injury may be focused on either the vascular endothelium
or the alveolar epithelium. Two types of alveolar epithelial cells exist.
Type I cells, which make up 90% of the alveolar epithelium, are injured
easily. Damage to type I cells result in increased capillary permeability and
the influx of protein-rich fluid into the alveolar space. Injury to the alveolar
lining cells also promotes pulmonary edema formation. Type II alveolar
epithelial cells are relatively more resistant to injury. However, type II cells
have several important functions, including the production of surfactant, ion
transport, and proliferation and differentiation into type l cells after cellular
injury. Damage to type II cells results in decreased production of surfactant

18
with resultant decreased compliance and alveolar collapse. This may also
result in decreased in surfactant production. The depletion of surfactant
production results in decreased alveolar compliance and recoil and further
lead to decreased lung compliance with a significant effect of impaired gas
exchange then eventually leads to ARDS. Signs and symptoms like
tachycardia, hypotension, decreased O2 saturation are evident and this will
be confirmed thru the results of the diagnostic work ups done like elevated pH
as shown in ABG, presence of infiltrates in the lung fields. Moreover, trauma
to the chest that violates the lungs may activate the release of vasoactive
substance which are potent agent influencing the increase and decrease of
blood pressure and/or heart rate through its vasoactivity- vascular activity in
the blood vessels. This action promotes bronchoconstriction which will disrupt
the airway passage causing decreased O2 entrance in the alveoli leading to
impairment in gas exchange just as how the effect causing the
alveolopapillary membrane becoming permeable where outward migration of
blood cells and fluids from capillaries happen. The effect of this is pulmonary
edema leading to impairment in gas exchange.
The cause of ARDS on CC’s case is not the most common type which is
trauma. Sensible set of managements were also uniquely applied to prolong
the life of CC.
Medical management includes early prophylaxis like administration of anti-
tetanus immunoglobulin and tetanus toxoid through intramuscular route.
Intravenous fluid therapy was also enforced since bleeding is present and it’s
a route for IV drug administration. Antibiotics in loading dose should
commence. The lung compliance of CC was insufficient, thus artificial
ventilation should be initiated. CC was intubated and connected to mechanical
ventilator. To correct low haemoglobin count, blood transfusion was given and
close monitoring to bleeding parameters and measures to control bleeding
should be considered. Surgical management includes the insertion of chest
tube/chest tube thoracostomy to vacate the blood and fluid accumulated in the
pleural cavity and responsible in the removal of the retained metallic foreign
body at patient’s chest. As part of the health care team, the nurses’

19
responsibilities are mainly on close assessment and monitoring of patient’s
condition. We should check for the vital signs, record and refer abnormal
findings. Wound care must be done aseptically to prevent infection. Provide
bundles of care which includes the use of proton pump inhibitor to prevent
gastric upset, use of oral antiseptic agent to prevent descending infection, bed
turning and positioning including head of bed elevation to promote pulmonary
drainage and formation of decubitus ulcer and suctioning of ET and oral
secretions to clear airway. Good response to the set management may result
to good prognosis and quality of life is maintained.
On the other hand, poor management may lead to further bleeding,
resulting to hypovolemic shock and eventually death.

20
 Schematic Diagram Modifiable:
Environmental
Gunshot Age
Lifestyle

Punctured wound at right upper arm (thru POEN: Proximal 3rd Anterolateral
Aspect Arm Right
and thru) to right chest wall POEX: Proximal Anteromedial
Aspect Arm Right
POEN: 4th Intercostal Space
Complete Blood Anterior Axillary Line
Count Hemothorax
Hgb – 80
Hct – 0.24
RBC – 2.84 Lung/Chest Congestion
Release of Vasoactive
Manifestations: substance (serotonin,
Acute Pain (Pain Scale- Increased Intrapleural histamine, bradykinin)
10/10), Difficulty of
Breathing, Tachycardia- pressure
PR-120bpm,
Hypotension-BP-
90/60mmHg,
Pale nail bed and Alveolar Epithelial Cell damage Bronchoconstriction Increased
palpebral conjunctiva, Alveolocapillar
decreased breath sounds y membrance
on affected area
permeability

Type I Cell Damage: Type II Cell Damage:

Decreased Airway
Increase in entry of Decreased Surfactant
Passage
fluid in the aveoli Production Outward
migration of
blood cells and
fluids from
capillaries
Decreased O2
Decreased Alveolar Compliance and entrance to
Recoil alveoli

Pulmonary
Decreased Lung Compliance Edema

Impairment in Gas Exchange

Diagnostics: Signs and Symptoms:

Chest X-ray Acute onset
ARDS Lung infiltrates
ABG
No evidence of left atrial pressure

- next -

21
 - continuation -

With Management Without Management

Medical Nursing Surgical

Management: Management: Management:

 Early  Assess ABC’s  Chest Tube

 Assess wound Hemorrhage
Prophylaxis Thoracostomy
 Antibiotics tissue involved.
 Removal of
 Clean and dress
 Anti- Tetanus RMFB.
wound aseptically
 Fluid  Monitor/Follow up
Therapy/Hydrati laboratory results.
on  Closely Monitor
 Intubation Vital Signs
 Mechanical  Adherence to
infection control
Ventilation
 Suctioned ET and
 Measures to oral secretions as Hypovolemic
control bleeding necessary Shock
 Blood  Placed on
moderate high
transfusion. back rest position
 Diet/nutrition

Wound Healing and drainage of blood

from pleural cavity

Good
Prognosis

Discharged Death

22
 C. Course in the Ward

Date of Admission – 03 March 2018

At 2245H, CC was brought to V. Luna Medical Center. with chief
complaint of Gunshot Wound. With Endotracheal tube size 7 with depth of
22cm on continuous ambubagging, GCS 10 (E3V1M6). With improvised
Chest Tube Thoracostomy using a Nasogastric tube. With ongoing D5LR 1L x
8 hours at left hand, patent and infusing well and PNSS as fast drip.. Vital
signs taken and recorder as follows: T = 36.9 degrees Celsius, PR = 115
beats per minute, RR = 25 cycles per minute, BP = 100/60 mmHG, O2Sat =
93%. During assessment it was found out that his ET was out thus at 2255H,
CC was given Diazepam 5mg TIV by ER NOD as ordered. At 2300H, he was
reintubated by Dr. U via direct laryngoscopy by 7.0 tube at a depth of 21 cm
and was hooked to the mechanical ventilator with the following settings: AC
mode, VT = 360, BUR = 20, FiO2 = 50%. He was maintained on Nothing per
Orem and hooked to D5LR 1L to run for 8 hours. Side drip of Midazolam
15mg in 247 cc PNSS to run at 31 cc/hr. Another IV access was inserted with
G18 at right hand and hooked to PNSS 1L to run as fast drip. Pertinent
laboratories were done including: ABG, Creatinine, CBC w/ PC, PT, PTT,
Blood Typing, Electrolytes (Na, K, Ca, Cl, Mg), BUN, Crea, AST, ALT. 12
Lead ECG was also done. At 2310H, CTT was replaced by Dr. T and
connected to a water sealed bottle with sanguineous output. Diagnostic
procedures were also done including Chest Xray APL, Shoulder APL Arm
Right, Abdominal Flat Plate Xray, and WAB CT Scan with Triple Contrast.
Patient started on medications including: ATS 4500 IU ANST, Tetanus Toxoid
0.5ml IM was also given. Omeprazole 40mg TIV OD, Tranexamic Acid 1000
mg TIV as loading dose then 500mg TIV every 8 hours, Vitamin K 1 amp TIV
now given then every 8 hours. Cefuroxime 1.5gm TIV as loading dose ANST
then 750mg TIV every 8 hours. Skin tests were done and were evaluated by
the PGI on Duty prior to administration. At 0115H, CC got agitated and his
endotracheal got dislodged thus reintubation was done using a 7.5 tube at 22

23
cm depth. At 0130H insertion of nasogastric tube on his right nostril and
indwelling foley catheter connected to urine bag was done. Urine sample was
sent for urinalysis. ER NOD then coordinated patient’s admission to Surgical
Intensive Care Unit under the service of LTSG R / CPT J & team with the
diagnosis of T/C Intraabdominal Injury, Penetrating Chest injury secondary to
Gunshot Injury; 1) POEN: Proximal 3rd Anterior Aspect Arm, Right; POEX:
Proximal 3rd Anteromedial Aspect Arm, Right (Thru and Thru); 2) PoReentry:
4th Intercostal Space Anterior Axillary Line; POEX: None with retained metallic
foreign body. At 0300H, CC was transported to SICU via stretcher
accompanied by wardman, PGI on duty and relatives. CC was received
drowsy, GCS 11 (E4V1M6) with Endotracheal tube on continuous
ambubagging. With ongoing D5LR 1L to run for 8 hours at left arm patent and
infusing well with side drip of Midazolam 15mg in 247cc PNSS to run for 31
cc/hr and heplock on right arm patent. He has an NGT inserted at right nasal
opening connected to a bedside bottle with 300cc output. With CTT to water
sealed bottle at 300ml level with sanguinous output and good fluctuation. With
IFC to urine bag with tea-colored output at 100ml level. Transferred patient to
bed safely and comfortably. Vital signs taken as follows: T = 37.8 degrees
Celsius, PR = 88 bpm, RR = 24 cpm, BP = 140/80 mmHg and O2Sat = 100
%. Hooked to MechVent with the same settings as above. Paracetamol
300mg TIV given as ordered at 0330H. Tepid sponge bath rendered.
Regulated IVF as ordered. Maintained on NPO. Positioned CC on moderate
high back rest. Oriented significant others regarding SICU staff and ward
rules/regulations. Monitored vital signs, intake and output hourly and
recorded.

04 March 2018 - 1st Hospital Day at SICU

CC’s neurologic status was GCS 11 (E4V1M6), with Endotracheal tube
to mechanical ventilator with the following settings; AC mode, TV- 360, BUR-
20, FiO2- 80%. With CTT to water sealed bottle at 400cc level with
sanguineous output. With ongoing D5LR 1Lx8hrs at 41-42 gtts/min at left
hand and a side drip of Midazolam drip of: Midazolam 15mg in PNSS 247cc

24
to run at 30-31milliliter per hour rate. At 0924H, CC was cleared from GS
standpoint and then referred to Thoracocardiovascular Service for transfer of
service. Seen by Dr. V at 1000H a TCVS resident with revised dx of
Hemothorax secondary to gunshot wound 4th ICS AAL, right (POEN) with t/t
Proximal 3rd, anterolateral aspect arm, right (POEX); Alcohol Intoxication; with
orders made and carried out. CC was maintained on NPO. Cefuroxime was
discontinued and was shifted to ampicillin sulbactam 3gms TIV ANST as
loading dose and 1.5 gms TIV every 8 hours. Additional medication ordered
such as Fluimucil 200mg/sachet, 1 sachet in 150 mL water every 8 hours per
NGT and Combivent nebulization every 8 Hrs. CC was also scheduled for
chest xray AP/L at 1850H.
At 1200H, CC was referred to neurosurgery for evaluation of possible
spinal cord injury. At 1300H, CC was maintained on NPO except medications
and to secure 2 units PRBC properly typed and cross-matched. He was also
seen by the neurosurgery team and according to them, there was no
neurosurgical intervention needed at the time of assessment and ordered to
correct anemia of the patient. Continuously monitored vital signs, intake and
output every 1 hour and recorded. No untoward events happened. Total 24
hour intake was 4078 ml while output was 3480 ml. BP ranges between 100-
110/70-80 mmHg, afebrile for the whole 24hours, PR- 63-83bpm with O2 sat
of 100%. ABG was done 1 hour after FiO2 was reached. CC started NGT
feeding of 2100 cal/day in 6 equally-divided feedings. CC was still intubated
therefore suctioning of oral and endotracheal tube secretions was done
regularly to clear airway. CC was also placed on moderate high back rest
position to promote pulmonary drainage.

05 March 2018 – 2nd Hospital Day at SICU

CC’s new neurologic status was GCS11 (E4M6V1), with
mechanical ventilator settings with the same settings. CTT level noted at 850
mL, serosanguineous output. With ongoing D5LR 1L x 8hrs and a side drip of
Midazolam 15mg in 247 cc PNSS at 31cc/hr at right at left arm, patent and
infusing well. Vital signs were taken and recorded. Positioned on moderate

25
high back rest. Suctioned oral and ET secretions regularly. Due medications
given as ordered. ABG was done at 0600H, result was referred to resident on
duty. At 1915H, patient was seen and examined by Dr. V made and carried
out. FiO2 was decremented by 10% every hour to reach 40% but to maintain
O2sat greater than or equal to 98%. CC was started on NGT feeding
amounting 2,100kcal per day divided into 6 equal feedings. Initial feeding was
done amounting 50cc. Shifted ampicillin sulbactam to Levofloxacin 750mg TIV
once a day and started on Azithromycin 500mg/tab, 1 tab OD for 5 dyas. At
2100H, CC had episodes of desaturation with O2 saturation of 80%, he was
tachycardic. Vital signs were taken and recorded as follows: Temperature-
37.7°C; Pulse Rate- 120 bpm; Respiratory Rate- 20 cpm (Assisted); Blood
Pressure- 90/60mmHg; O2 Saturation- 80%. ECG taken as ordered. He’s still
GCS 11 (E4M6V5) With CTT output of 600ml in 24 hour period. He was
referred to Department of Emergence Medicine- Internal Medicine for
hypotension and persistent tachycardia, and Pulmonary Service for co-
management.FiO2 was increased back to 90% as ordered. He was seen by
Dr. S from Pulmonary Service and Tramadol 50mg TIV every 8 hours, and
Chlorhexidine oral swab thrice a day was initiated. Still on IVF of D5LR with
revised infusion rate from 8 hours to 16 hours at 21-22 drops per minute. CTT
has positive fluctuation. At 0400H, Updated Mechanical Ventilator setting:
SIMV Mode, TV- 350, BUR- 20, FiO2- 90%. CBC revealed that hemoglobin
was just 80gms/L. Requested 2 units of PRBC from blood bank as ordered.
Reinserted Intravenous access using Gauge 18 in preparation for Blood
transfusion on left arm.

06 March 2018 – 3rd Hospital Day at SICU

CC was seen, examined and vital signs taken with the ff: BP – 100/20
mmHg, CR – 87bpm, RR – 22cpm, O2Sat 100%. GCS 11 (E4 M6 V1) with
mechanical ventilator setting of: AC mode, TV – 350, FiO2 – 90%, BUR – 20.
Maintained on NPO except medications. CTT was patent with good fluctuation
and tight air entry. With IVF of D5LR for 16 hours at 21-22 drops per minute.
At 0800H, started to decrease FiO2 by decrements of 10% every hour to

26
reach 40%. No desaturations noted, CC was able to tolerate decrease in
FiO2. At 1300H, with orders to transfuse 1 unit PRBC PTXM. Followed up
availability of requested blood at Blood Bank. Repeat ABG was taken at
1400H. At 1500H, CC was agitated and had episodes of desaturation.
Endotracheal tube got dislodged and was reintubated care of anesthesia
service with 7.5 tube at a depth of 21 cm. Chest X-ray was done post
intubation with initial result showing ET was in place. Mechanical ventilator
setting was revised post reintubation to the following settings: AC Mode, TV-
400, BUR- 20, Fio2- 40%. At 2050H, hooked 1 unit Packed Red Blood Cell
was transfused after properly typed, screened and cross-matched. Pre-blood
transfusion vital signs were also taken as follows: Temperature: 37.2°C, Pulse
Rate of 88, Respiratory Rate of 20 (Assisted), Blood Pressure of
120/70mmHg. Pre BT meds of Paracetamol 300mg TIV and
Diphenhydramine 50mg TIV given at 2020H. Monitored vital signs every 15
mins for the 1st 1 hour then every 30 minutes for the 2nd hour and every hour
afterwards. CC’s diagnosis was revised to Acute Respiratory Distress
Syndrome secondary to Hemothorax, Right secondary to Gunshot Wound 4 th
ICS AAL, Right (POEN) with T/T Proximal 3rd, Anterolateral Aspect, Arm,
Right (POEN) Proximal 3rd Anteromedial Aspect, Arm, Right (POEX). At
0100H, above blood transfusion was consumed and terminated. No blood
transfusion reaction noted.

07 March 2018 – 4th Hospital Day at SICU

CC was awake, not in distress. Vital signs were taken and recorded as
follows: Temperature- 37.7°C; Pulse Rate- 110 bpm; Respiratory Rate- 20
(Assisted); Blood Pressure- 110/70mmHg; O2 Saturation- 99%. Maintained
on ET to Mech Vent with the following setting: AC Mode, TV- 400, BUR- 20,
Fio2- 40%. With CTT output of 300cc in 24 hour basis. Continued IVF of
D5LR for 16 hours at 21-22 drops per minute. Heard clear breath sounds on
both lung fields upon auscultation but CC was tachycardic, and was having
thick whitish phlegm. Regular suctioning of oral and endotracheal tube was
done. ABG result in and seen by Dr. S with order to decrease FiO2 to 30% to

27
wean CC from mech vent. She also ordered to discontinue Midazolam 2mg
IV, to start Tramadol 25mg TIV rescue dose PRN severe pain initiated.
Started NGT feeding with OF at 2100 calories per day to be given in 6 equally
divided feedings. Correction of anemia was still on going. Followed up request
of remaining 1 unit of PRBC from the blood bank as ordered.

08 March 2018 – 5th Hospital Day at SICU

CC has episodes of desaturation was noted whenever agitated. With
clear breath sounds upon auscultation. Vital signs were taken and recorded
as follows: Temperature- 37.6°C; Pulse Rate- 80 bpm; Respiratory Rate- 20;
Blood Pressure- 110/80mmHg; O2 Saturation- 91%. CTT output was 250ml in
24 hour report. Subcutaneous emphysema was improving and crepitus noted
upon palpation. Pulmonary service ordered to decrease FiO2 to 30%. Revised
Mechanical Ventilator setting to: SIMV Mode, TV 400, BUR 16, FiO2 30%,
PSV 16. Hooked water-sealed bottle to Thoracic Pump to correct
subcutaneous emphysema as ordered. Dr. V ordered to discontinue
Midazolam Drip. Followed up with blood bank for availability of requested
blood product. CC had elevated body temperature of 38.5°C in the afternoon.
Rendered tepid sponge bath. Due Paracetamol 300mg given as ordered.

09 March 2018 – 6th Hospital Day at SICU

CC was alert, conscious and not in respiratory distress. Vital signs
were taken and recorded as follows: Temperature- 37.5°C; Pulse Rate- 85
bpm; Respiratory Rate- 20; Blood Pressure- 110/80mmHg; O2 Saturation-
99%. CTT output was 250ml in 24 hour report. ABG done in the morning and
referred to resident on duty. Pulmonary Service ordered to revise Mechanical
Ventilator setting as follows: SIMV Mode, TV- 400, BUR- 16, FiO2- 30%, PS-
16. Continued NGT feeding observing strict aspiration precaution.

10 March 2018 – 7th Hospital Day at SICU

On 7th hospital day, vital signs were taken and recorded as follows:
Temperature- 37.7°C; Pulse Rate- 80 bpm; Respiratory Rate- 20; Blood

28
Pressure- 120/80mmHg; O2 Saturation- 99%. There was no episode of
desaturation noted. Pulmonary Service ordered to revise Mechanical
Ventilator setting to: SIMV Mode, TV- 400, BUR- 14, FiO2- 14%, PS- 14. CTT
output was closely monitored and recorded with output of 220ml in 24 hour
report. Still with good fluctuation. Assisted in wound care and dressing
change.

11 March 2018 – 8th Hospital Day at SICU

CC was on close monitoring. Revised Mechanical Ventilator setting
especially BUR and PSV by decrements of 2 every 2 hours to reach BUR of
8cpm, and PSV of 8 cmH20 was done. CC now has developed pain
tolerance. No episodes of desaturation noted. Withdrew 1 unit of PRBC from
blood and transfused after properly type, screened and cross-matched. Initial
vital signs are as follows: Temperature- 36.9°C, Pulse Rate- 88, Respiratory
Rate- 20, BP- 110/70mmHg. Post BT reactions not noted. Repeat CBC post-
BT was sent.

12 March 2018 – 9th Hospital Day at SICU

CC was not in respiratory distress. Vital signs were taken and recorded
as follows: Temperature- 37.2°C; Pulse Rate- 80 bpm; Respiratory Rate- 20;
Blood Pressure- 120/80mmHg; O2 Saturation- 99%. CTT output was 10ml.
Multivitamins + Ferrous Sulfate OD per NGT initiated. In the afternoon at
around 1800H, CC was shifted from Mechanical Ventilator to T-piece at 6
liters per minute, continuous. ABG taken after 1 hour with result showing
normal findings: pH-7.41, pCO2 – 35, paO2- 90.6, HCO3- 22, BE- -1.5,
O2Sat- 98.9%. No signs of difficulty of breathing and desaturation noted. CC
was able to tolerate weaning process. Post-BT CBC result is in.

13 March 2018 – 10th Hospital Day at SICU

On 10th hospital day, CC was awake and not in distress, with no
episodes of desaturation, difficulty breathing, chest pain, or fever. Vital signs
were taken and documented as follows: Temperature- 37.5°C; Pulse Rate- 86

29
bpm; Respiratory Rate- 20; Blood Pressure- 110/70mmHg; O2 Saturation-
98%. CTT ouput was 10ml. CC tolerated weaning process. Pulmonary
Service ordered extubation. Hydrocortisone 100mg TIV given as order prior to
extubation. CC got extubated in the afternoon at 1700H. Placed CC on
moderate high back rest postion. Salbutamol Nebule given and Chest
Physiotherapy rendered post- extubation. Hooked to O2 support via nasal
cannula at 1-2 liters per minute. Pulmo Service signed out of care. ABG sent
after 1 hour post extubation. ET tip GS/CS sent to laboratory. No signs of
desaturation noted.

14 March 2018 – 11th Hospital Day at SICU

On 10th hospital day, patient was awake, not in distress and has
tolerated extubation well. Vital signs were taken and documented as follows:
Temperature- 37.5°C; Pulse Rate- 85 bpm; Respiratory Rate- 20; Blood
Pressure- 110/80mmHg; O2 Saturation- 98%. There was no CTT ouput.
Maintained on O2 support via nasal cannula at 1-2 liters per minute. Started
regular diet as tolerated. IVF was discontinued. Levofloxacin shifted to
500mg/tab once a day for 2 days. Placed on moderate high back rest position.
Encouraged to do deep breathing exercises.

15 March 2018 – 12th Hospital Day at SICU

On 12th hospital day, CC was not in respiratory distress, conscious and
coherent. Vital signs were taken and documented as follows: Temperature-
37.5°C; Pulse Rate- 86 bpm; Respiratory Rate- 20; Blood Pressure-
110/70mmHg; O2 Saturation- 98%. Tranexamic Acid, Vitamin K discontinued.
Assisted in the removal of CTT. CTT tip was collected and sent out to the
laboratory for Chest Tube GS. Advised CC to increase fluid intake and do
deep breathing exercises.

16 March 2018 – 13th Hospital Day at SICU

CC was on diet as tolerated, was encouraged to increase oral fluid
intake. Vital signs were taken and documented as follows: Temperature-

30
 36.9°C; Pulse Rate- 80 bpm; Respiratory Rate- 20; Blood Pressure-
120/70mmHg; O2 Saturation- 98%. Fluimucil 200mg / sachet dissolved in
150ml water given. Due nebulization of Combivent done. Still on antibiotic
therapy of Levofloxacin 500mg/tab once a day. Chest tube GS result was in
and seen by Dr. V, no microorganisms found.

17 March 2018 – 14th Hospital Dat at SICU

It’s the 4th day post- extubation day and 2nd day post CTT removal of
CC. Vital signs were taken and documented as follows: Temperature- 36.8°C;
Pulse Rate- 85 bpm; Respiratory Rate- 20; Blood Pressure- 110/80mmHg; O2
Saturation- 98%. Seen and examined by Dr. V with Trans- out orders made to
transfer CC to Ward 4D. The retained foreign metallic body at the back of CC
will also be removed as Dr. V ordered to secure minor set and Prolene 3.0.
CC was properly endorsed to nurse of duty at Ward 4D and was transported
at 1000H accompanied by ward man, intern on duty and relatives.

D. Laboratory and Diagnostic Procedures

Complete Blood Count

RESULTS
Reference
TEST
Values 05 06 07 10 11 12 16
March March March March March March March
Hemoglobin 120-160 gms/L 80 85 94 100 110 115 118
Hematocrit 0.37-0.43 0.24 0.21 0.24 0.30 0.32 0.33 0.36
RBC Count 4.0-5.4 X1012/L 2.80 2.49 2.79 3.32 3.49 3.55 3.73
WBC Count 4.0-10.0 x109/L 13.44 10.7 12.7 8.4 8.7 8.6 9.68
Segmenters 0.55-0.65 0.82 0.87 0.61 0.65 0.64 0.64 0.65
Lymphocytes 0.25-0.35 0.14 0.07 0.28 0.25 0.25 0.28 0.30
Eosinophils 0.02-0.04 0.00 0.00 0.02 0.02 0.02 0.02 0.02
Monocytes 0.03-0.06 0.04 0.09 0.08 0.06 0.06 0.06 0.06
Basophils 0.00-0.01 0.00 0.00 0.01 0.01 0.00 0.00 0.00
MCV 80-100 86.4 85 85 85 85 86 90
MCH 26-32 28.6 27 27 26 26 27.5 28.4

31
 MCHC 32-36 33 32 32 32 33 33 33
RDW 11-15 14 13.43 13.06 13.11 13.22 13.16 14
Platelet Count 130-400 x109/L 181 130 185 226 233 248 390

Analysis and Interpretation:

Decreased Hemoglobin, Hematocrit and RBC levels are possible

indication of anemia due to blood loss secondary to gunshot injury.

An increase in WBC with increased in segmenters, monocytes,

eosinophils may indicate an acute infection, inflammation and trauma. While
decreased in lymphocytes may also suggest infection.

Arterial Blood Gas

REFERENCE RESULTS
TEST VALUES
04 05 06 07 08 09 10 11 12 13
Mar Mar Mar Mar Mar Mar Mar Mar Mar Mar
7.34
pH 7.35 - 7.45 7.37 7.42 7.38 7.41 7.43 7.37 7.41 7.43 7.4
7
35 - 45
PCO2 28.6 53.8 38.5 42.1 34.5 32.6 36.9 26.4 38.3 38.1
mmHg
80 -100 167. 112. 111. 130. 108.
PaO2 51.2 95.7 91.7 89 97.4
mmHg 3 7 8 3 9
22 - 26
HCO3 15.7 31 25.1 24.9 19.9 21.9 21.8 16.4 25.7 24.8
mEq/L
BE (-2) - (+2) -8 4.7 1.5 0.2 -2.9 -0.7 -2.3 -2 2 1.3
84.6 98.1 97.2 96.5 97.4 98.6
SaO2 95 – 100% 99% 97% 98% 98%
% % % % % %
100
FiO2 80% 40% 40% 40% 30% 30% 30% 60% 40%
%

Analysis and Interpretation:

CC was experiencing Compensated Metabolic Acidosis due to

impaired gas exchange dated 04 March 2018.

Bleeding Parameters

32
 REFERENCE RESULTS
VALUES
06 March
PT 10.6-13.6 secs 10.6 secs
APTT 25.3- 32.3 secs 25.5 secs
% ACTIVITY 74-94% 93.0%
INR 0.87

Analysis and Interpretation: CC has normal bleeding parameters result which

is a positive indication that he might not have further bleeding due to gunshot
injury.

Serum Electrolyte

REFERENCE RESULTS
ELECTROLYTE
VALUES
06 March 10 March
Sodium 136- 142 139 137
Potassium 3.80- 5.00 3.9 3.8
Chloride 95- 103 107 108

Analysis and Interpretation: Increased Sodium and Chloride is brought about

by fluid loss.

Urinalysis

NORMAL VALUE RESULTS

Color Yellow-amber Light Yellow

Transparency Slightly Turbid Slight Tubid

SP Gravity 1.015-1.025 1.015

Reaction 4.8-7.0 5.0

33
 Sugar Negative Negative

Protein Negative Negative

RBC 0-1/HPF 0-1/HPF

Pus Cells 0-2/HPF 0-2/HPF

Epithelial Cells FEW FEW

Mucus Threads FEW FEW

Amorphous Urates FEW FEW

Analysis and Interpretation: Normal Findings

ET GS/CS

Result: No microorganism found.

CTT Tip GS/CS

Result: No microorganism found.

Chest X-ray

Result: Presence of patch infiltrates in right lung fields.

34
 E. Drug Study

Action & Nursing

Name Of Drug Adverse Effects
Indications Responsibilities
Tetanus Actions:  CNS: headache  Observed the 12
Toxoid 0.5ml promotes active  CV: tachycardia, rights for medication.
IM immunity by hypotension,  Assessed injection
inducing flushing site for swelling and
Drug production of  EENT: rhinorrhea tenderness.
classification: tetanus  Resp:  Assessed respiratory
Vaccines, antitoxins. bronchospasm, status; breath
Antisera and chest tightness sounds, breathing
Immunologicals Indications:  Skin: erythema, patterns,
Presence of induration, nodule characteristic of
punctured (at injection site) secretions.
wound on right pruritus, urticarial  Assessed for allergic
arm and  Hypersensitivity reactions to the drug.
thoracic cavity. reactions  Monitored for
nausea and
vomiting.
 Advised patient to
avoid activities that
requires alertness
because of the
drowsiness caused
by the drug.

Action & Nursing

Name Of Drug Adverse Effects
Indications Responsibilities
Anti-Tetanus Actions:  CNS: headache  Observed the 12
Serum 4500 IU Tetnaus  CV: tachycardia, rights for medication.
IM antitoxin hypotension,  Assessed injection
(-) ANST neutralizes the flushing site for swelling and
toxin produced  EENT: rhinorrhea tenderness.
Drug by Clostridium  Resp:  Assessed respiratory
classification: tetani. bronchospasm, status; breath
Immunizing chest tightness sounds, breathing
Agent - Passive Indications:  Skin: erythema, patterns,
Presence of induration, nodule characteristic of
punctured (at injection site) secretions.
wound on right pruritus, urticarial  Assessed for allergic
arm and chest  Hypersensitivity reactions to the drug.
wall. reactions  Monitored for
nausea and
vomiting.

35
  Advised patient to
avoid activities that
requires alertness
because of the
drowsiness caused
by the drug.

Action & Nursing

Name Of Drug Adverse Effects
Indications Responsibilities
Tranexamic Actions:  CNS: severe  Observed the 12
Acid 500 mg/ Inhibits the headache, rights for medication.
amp 1 amp action of confusion  Checked patency of
every 8 hours. plasmin  CV: vasodilation, IV line prior to
(finronolysin) tachycardia, administration.
Drug the hypotension  Assessed
classification: antifibrinolytic  EENT: swelling of hemodynamic status
Antifibrinolytic agent reduces mouth, lips, face and bleeding
Agent, excessive and tongue, vision parameters.
Antihemorrhagi breakdown of changes  Watched out for
c fibrin and effect  Resp: dyspnea, severe bleeding.
physiological coughing up  Assessed respiratory
hemostasis. blood, chest pain, status; breath
shortness of sounds, breathing
Indications: breath patterns,
Used for prompt  Skin: rash, characteristic of
and effective pruritus, urticarial secretions.
control of  Hypersensitivity  Assessed for allergic
hemorrhage in reactions reactions to the drug.
promoting  Monitored for
hemostasis in nausea and
traumatic injury. vomiting.
 Advised patient to
avoid activities that
requires alertness
because of the
drowsiness caused
by the drug.

Action & Nursing

Name Of Drug Adverse Effects
Indications Responsibilities
Vitamin K 1 Actions: Is  CNS: drowsiness  Observed the 12
amp TIV every used in  CV: vasodilation, rights for medication.
8 hours. prophylaxis and tachycardia,  Checked patency of
treatment of hypotension IV line prior to
Drug hemorrhagic  EENT: rhinorrhea administration.

36
classification: disease.it  Resp:  Assessed respiratory
Antifibrinolytic promotes liver bronchospasm, status; breath
Agent formation of chest tightness, sounds, breathing
clotting factors increased patterns,
II, VII, IX and X secretions characteristic of
 GI: nausea and secretions.
Indications: CC vomiting  Assessed for allergic
is bleeding  Skin: rash, reactions to the drug.
manifested by pruritus, urticarial  Monitored for
bloody output in  Hypersensitivity nausea and
CTT water reactions vomiting.
sealed bottle.  Advised patient to
avoid activities that
requires alertness
because of the
drowsiness caused
by the drug.

Action & Nursing

Name Of Drug Adverse Effects
Indications Responsibilities
Combivent 1 Actions:  CNS: drowsiness  Observed the 12
nebule every 8 hydrolyzes  CV: vasodilation, rights for medication.
hours. disulfide bonds tachycardia,  Assessed respiratory
in mucus, which hypertension status; breath
Drug breaks down the  EENT: rhinorrhea sounds, breathing
classification: mucus into  Resp: patterns,
Mucolytic thinner units bronchospasm, characteristic of
which are easier chest tightness, secretions.
to expectorate. increased  Assessed for allergic
secretions reactions to the drug.
Indications: CC  GI: nausea and  Monitored for
had thick vomiting nausea and
viscous whitish  Skin: rash, vomiting.
phlegm while pruritus, fever,  Advised patient to
intubated and sweating avoid activities that
hooked to  Hypersensitivity requires alertness
Mechanical reactions because of the
Ventilator. drowsiness caused
by the drug.

Action & Nursing

Name Of Drug Adverse Effects
Indications Responsibilities
Fluimucil 200 Actions:  CNS: drowsiness  Elevated bed to 80-
mg/ sachet in hydrolyzes  CV: vasodilation, 90 degrees before
150ml water disulfide bonds tachycardia, administration of

37
every 8 hours in mucus, which hypertension drug per NGT.
per NGT. breaks down the  EENT: rhinorrhea  Checked placement
mucus into  Resp: of NGT prior to
Drug thinner units bronchospasm, administration of
classification: which are easier chest tightness, drug.
Mucolytic to expectorate. increased  Assessed respiratory
secretions status; breath
Indications: CC  GI: nausea and sounds, breathing
had thick vomiting patterns,
viscous whitish  Skin: rash, characteristic of
phlegm while pruritus, fever, secretions.
intubated and sweating  Assessed for allergic
hooked to  Hypersensitivity reactions to the drug.
Mechanical reactions  Monitored for
Ventilator. nausea and
vomiting.
 Advised patient to
avoid activities that
requires alertness
because of the
drowsiness caused
by the drug.

Action & Nursing

Name Of Drug Adverse Effects
Indications Responsibilities
Paracetamol Actions:  CNS: drowsiness  Observed the 12
300mg TIV Thought to  CV: vasodilation, rights for medication.
every 4 hours produce tachycardia,  Checked patency of
Round-the- analgesia by hypotension IV line prior to
clock. blocking  EENT: rhinorrhea administration.
generation of  Resp:  Assessed respiratory
Drug pain impulses, bronchospasm, status; breath
classification: probably by chest tightness, sounds, breathing
Antipyretic/ inhibiting increased patterns,
Analgesic prostaglandin secretions characteristic of
synthesis in the  GI: nausea and secretions.
CNS or the vomiting  Assessed for allergic
synthesis or  Skin: rash, reactions to the drug.
action of other pruritus, urticarial  Monitored for
substances that  Hypersensitivity nausea and
sensitize pain reactions vomiting.
receptors to  Advised patient to
mechanical or avoid activities that
chemical requires alertness
stimulation. It is because of the
thought to drowsiness caused

38
 relieve fever by by the drug.
central action in
the
hypothalamic
heat regulating
center.

Indications: CC
has CTT and
wound on his
right arm and
had episodes of
elevated body
temperature.
Also, as a
prophylaxis for
BT as ordered.

Action & Nursing

Name Of Drug Adverse Effects
Indications Responsibilities
Tramadol Actions: Binds  CNS: dizziness,  Observed the 12
50mg TIV to mu-opioid vertigo, headache, rights for medication
every 8 hours receptors. confusion, seizure administration.
Inhibits reuptake  CV: tachycardia,  Checked patency of
Drug of serotonin and hypotension IV line prior to
classification: norepinephrine  EENT: dry mouth administration.
Analgesics in the CNS.  GI: nausea and  Assessed
vomiting, respiratory status;
Indications: CC constipation, breath sounds,
has wound on flatulence breathing patterns,
the arm and  Skin: sweating, characteristic of
right chest rash, pruritus, secretions.
which he pallor  Assess bowel
complains acute  Hypersensitivity function routinely,
pain. Acute pain reactions minimize
was also felt on constipation.
CTT insertion  Assessed for allergic
site on post reactions to the
removal of CTT. drug.
 Monitored for
nausea and
vomiting.
 Advised patient to
avoid activities that
requires alertness
because of the

39
 drowsiness caused
by the drug.

Action & Nursing

Name Of Drug Adverse Effects
Indications Responsibilities
Midazolam Actions: Is a  CNS: physical and  Observed the 12
1. Drip of short-acting psychological rights for
Midazolam benzodiazepine. dependence with medication.
15mg + It exerts sedative withdrawal  Checked patency of
PNSS 247 and hypnotic, symptoms, IV line prior to
ml TIV at muscle relaxant, headache, administration.
30- anxiolytic and oversedation,  Assess level of
31milliliter anticonvulsant reduced alertness sedation and level of
per hour actions. The confusion, consciousness
rate. anesthetic action euphoria, throughout and for
2. Bolus of may be due to hallucinations, 2-6 hours following
Midazolam the occupation dizziness administration.
2mg TIV for of the  CV: heart rate  Continuously
restlessnes benzodiazepine changes, monitor blood
s. and GABA hypotension pressure, respiration
Drug receptors  Respi: increased and pulse during IV
classification: leading to In tidal volume administration.
Sedative membrane and respiration  Oxygen and
hyperpolarization rate, apnea, resuscitative
and neuronal laryngospasm, equipment should
inhibition, and bronchospasm be immediately
further interfering  GI: nausea and available.
with the reuptake vomiting  Assessed for allergic
of GABA at the  Skin: rash, reactions to the
synapses. pruritus, urticarial drug.
Indications: CC
was intubated
and was
restless,
sedative is
indicated
whenever CC
gets agitated.

Action & Nursing

Name Of Drug Adverse Effects
Indications Responsibilities
Omeprazole Actions:  CNS: dizziness,  Observed the 12
40mg TIV once Gastric acid- headache rights for medication.
a day. pump inhibitor,  CV: vasodilation,  Checked patency of

40
 suppresses tachycardia, IV line prior to
Drug gastric secretion hypotension administration.
classification: by specific  EENT: dry mouth,  Assessed for allergic
Proton Pump inhibition of the  GI: nausea and reactions to the
Inhibitor hydrogen- vomiting, diarrhea, drug.
potassium ATP acid regurgitation,  Monitored for
as enzyme taste perversion, nausea and
system at the abdominal pain vomiting.
secretory  Skin: rash,  Advised patient to
surface if the pruritus, urticarial avoid activities that
gastric parietal  Muculoskeletal: requires alertness
cells; blocks the weakness, because of the
final step of acid myalgia dizziness and
production.  Hypersensitivity muscle weakness
reactions caused by the drug.
Indications: CC
was placed on
NPO while
intubated for a
couple of days.
Also, CC is
connected to
mechanical
ventilator which
is a gastric
irritant, thus PPI
is indicated.\\

Action & Nursing

Name Of Drug Adverse Effects
Indications Responsibilities
Levofloxacin Actions: Inhibit  CNS: seizures  Observed the 12
750mg/vial TIV the enzyme  CV: hypotension rights for medication.
once a day DNA gyrase in  Resp:  Checked patency of
susceptible bronchospasm, IV line prior to
Drug gram-negative chest tightness, administration.
classification: and gram- increased  Assessed vital. signs
Antibiotic positive aerobic secretions especially blood
and anaerobic  GI: pressure.
bacteria, pseudomembrano  Assessed for allergic
interfering with us colitis reactions to the
bacterial DNA  Skin: rash, drug.
synthesis. pruritus, urticarial  Monitored for severe
 Hypersensitivity diarrhea which may
Indications: reactions. indicate
Choice of pseudomembranous
antibiotic colitis.
therapy for CC

41
 by Infectious
Disease Service
as per Blood
CS.

Action & Nursing

Name Of Drug Adverse Effects
Indications Responsibilities
Azithromycin Actions: Blocks  CNS: dizziness,  Observed the 12
500/tab once a transpeptidation drowsiness, rights for medication.
day for 5 days by binding to headache, vertigo,  Elevated bed to 80-
per NGT 50s ribosomal  GI: mild to 90 degrees before
subunit of moderate nausea administration of
Drug susceptible and vomiting and drug per NGT.
classification: microorganisms abdominal pain,  Checked placement
Antibiotic, and disrupting dyspepsia, of NGT prior to
Macrolide RNA-dependent flatulence, administration of
protein diarrhea drug.
synthesis at the  Skin: rash,  Assessed for allergic
chain of pruritus, urticarial reactions to the drug.
elongation step.  Hypersensitivity  Monitored for
reactions nausea and
Indications: CC vomiting.
has punctured  Advised patient to
wound thus, avoid activities that
infection is requires alertness
prevented. because of the
drowsiness caused
by the drug.

Name Of Drug Action & Adverse Effects Nursing

Indications Responsibilities
Cefuroxime Actions: Stop or  CNS: headache  Observed the 12
1.5mg TIV (-) slow the growth of  EENT: mouth rights for
ANST as bacterial cells by ulcer medication.
loading dose preventing bacteria  GI: diarrhea,  Checked patency
then 750mg from forming the nausea and of IV line prior to
TIV every 8 cell wall that vomiting, administration.
hours surrounds each cell abdominal pain  Assessed for
wall.  Skin: rash, allergic reactions
Drug pruritus, urticarial to the drug.
classification: Indications:  Hypersensitivity  Monitored for
Semisynthetic Choice of antibiotic reactions nausea and
Cephalosporin therapy for CC by vomiting.
Antibiotic Infectious Disease

42
 Service as per
Blood CS.

Name Of Drug Action & Adverse Effects Nursing

Indications Responsibilities
Ampicillin Actions:  CNS: drowsiness  Observed the 12
Sulbactam Penetrate gram-  CV: vasodilation, rights for medication.
3grams TIV (-) positive and tachycardia,  Checked patency of
ANST as some gram hypotension IV line prior to
loading dose negative  EENT: rhinorrhea administration.
then 1.5 grams bacteria. Acts  Resp:  Assessed respiratory
TIV every 8 as irreversible bronchospasm, status; breath
hours. inhibitor of the chest tightness, sounds, breathing
enzyme increased patterns,
Drug transpeptidase secretions characteristic of
classification: which is needed  GI: nausea and secretions.
Antibioytic to make cell vomiting  Assessed for allergic
wall.  Skin: rash, reactions to the drug.
Indications: pruritus, urticarial  Monitored for
Choice of  Hypersensitivity nausea and
Antibiotic reactions vomiting.
therapy for CC  Advised patient to
by Infectious avoid activities that
Disease Service requires alertness
as per Blood because of the
CS. drowsiness caused
by the drug.

Action & Nursing

Name Of Drug Adverse Effects
Indications Responsibilities
Chlorhexidine Actions:  EENT:  Assessed respiratory
Oral Swab TID bacteriostatic tooth/tongue status; breath
and bactericidal, staining, increases sounds, breathing
Drug kills by tartar, patterns,
classification: disrupting the mouth/throat characteristic of
Antiseptic cell membrane. irritation, dry secretions.
Agent mouth, altered  Assessed for allergic
Indications: CC taste perception reactions to the drug.
is intubated and  Respi: trouble
hooked to breathing
mechanical  Skin: rash,
ventilator. pruritus, urticarial
Mouth care is  Hypersensitivity
needed for reactions
mechanically

43
 ventilated
patient to
prevent VAP.

Name Of Drug Action & Adverse Effects Nursing

Indications Responsibilities
Diphenhydram Actions:  CNS: dizziness,  Observed 12 rights
ine 25mg TIV Significant drowsiness of medication.
pre-Blood anticholinergic  CV: vasodilation,  Checked patency of
Transfusion activity; tachycardia, IV line prior to
competes for hypotension administration.
Drug H1-receptor  EENT: dry mouth ,  Assessed for allergic
classification: sites on effector nose and throat, reactions to the drug.
Antihistamine cells thus rhinorrhea  Monitored for
blocking  Resp:, chest nausea and
histamine tightness vomiting.
release  GI: constipation,  Advised patient to
Diarrhea, nausea avoid activities that
Indications: CC and vomiting, loss requires alertness
will have blood of appetite because of the
transfusion, thus  Skin: rash, drowsiness caused
prophylaxis is pruritus, urticarial by the drug.
needed pre-BT  Hypersensitivity
as ordered. reactions

44
 IV. Nursing Management

A. Problem List

Problem Date Identified Date Resolved

Impaired Gas 13 March 2018

05 March 2018
Exchange (Date Extubated)
Fluid Volume Deficit 05 March 2018 07 March 2018
Impaired Skin
05 March 2018 Still resolving
Integrity

B. Long Term Objective

Upon discharge CC and with the help of his significant others will be
able to attain optimum level of physiologic functioning and will be able to
comply and adapt to his illness and treatment in order to improve his quality of
life.

45
C. Nursing Care Plan

1. Impaired Gas Exchange

Nursing Diagnosis Objectives Intervention Evaluation

05 2100H March 2018 After 7-8 Hours of Independent After 7-8 hours of
nursing  Assessed respiratory nursing
Impaired gas exchange related to decreased interventions CC will status(rate, depth, effort, interventions
pulmonary perfusion secondary Hemothorax maintain optimal gas oxygen saturation) objectives were
exchange as  Placed on moderate high met:
Subjective: evidenced by: back rest position.  Oxygen
“Sir, nahihirapan siyang huminga” as  Oxygen  Maintained mechanical saturation of
verbalized by the significant others saturation with ventilator settings as 98%
in normal range ordered.  BP-110/70
Objective: (95-100%).  Suctioned ET and oral mmHg
 ABG with in secretions as necessary  PR- 90 BPM
(+) ET to Mech Vent with the following settings: normal range  Provide bundles of care to  RR- 20 BPM
AC Mode, TV - 360,BUR- 20 FiO2- 50% (pH 7.35-7.45) mechanically ventilated (Assisted)
O2 Sat 80% patient as follows:  ABG with in
BP- 100/60 mmHg - Proper Handwashing normal range
PR- 120 BPM - Maintained Bed elevated at 35- pH 7.42, PCO2
RR- 28 BPM (Assisted) 45 degrees 38.5, PaO2
-Daily sedation vacation and 112.7, HCO3-
Laboratory results: daily assessment to wean 24.1, Sa02 of
ABG SaO2 is 84.6%, PaO2 is 51.2, PCO2 is - DVT prophylaxis 98.1%
53.8, HCO3 is 31, PH is 7.37 - Stress Ulcer Prophylaxis ( Bed
Compensated Metabolic Acidosis Turning)

46
 -Subglottic secretion drainage
(Suctioning)
- Daily mouth care with
chlorhexidine
Dependent
 Combivent 1 Nebule given
 Fluimucil 200mg/sachet
every 8 hours given
administered as ordered
 Referred to Pulmonary
Service for co-management.

Collaborative
 Referral to Pulmonary
Laboratory for prompt
availability of ABG result

47
 2. Fluid Volume Deficit

Nursing Diagnosis Objectives Intervention Evaluation

05 0700H March 2018 After 8 hours of Independent After 8 hours of
nursing  Monitored vital signs; compare with nursing
Fluid volume deficit related to moderate blood interventions CC will normal or previous readings. interventions,
loss secondary to Gun Shot Injury. manifest:  Monitored intake and output. objectives were
 Balanced intake  Encouraged elevation of lower partially met as
Subjective: “Marami na sir and lumabas jan and output level. extremities. evidenced by.
sa container na dugo simula kaninang  Improved  Maintain and accurately regulate IV
madaling araw, sir,”as verbalized by the complete blood Fluids to compensate with fluid loss.  24-hour Intake
significant others. count result to  Review laboratory results. of 3244ml
normal value 24-hour
Objective: (Hemoglobin - Dependent Output of
 With bloody output in the water sealed 120-160 gms/L;  Requested 2 units of PRBC from the 1570ml with
bottle connected to CTT with an output of Hematocrit- blood bank for possible blood CTT output
450 ml in 24 hour report 0.37-0.43) transfusion as ordered. of 250 mL
 Pale palpebral conjunctiva  BP-  Transfused 1 unit of PRBC properly  Hemoglobin -
 Pale nail beds 110/70mmHg typed, screen and cross-matched as 100 gms/L;
 PR- 120 bpm  PR- 80-100 bpm ordered; with side drip of PNSS Hematocrit-
 BP- 100/60mmHg 1000 mL x KVO 0.30
 24- hour Intake- 2500ml  BP of
24- hour Output- 3800ml Collaborative 110/70mmHg
 Referral to Laboratory for blood  PR- 86 bpm
Laboratory Result: typing, screening and cross-
Hemoglobin- 80 gms/L; matching of blood.
Hematocrit – 0.24  Referral to Blood bank for possible
donors of blood.

48
3. Impaired Skin Integrity

Nursing Diagnosis Objectives Intervention Evaluation

05 0900H March 2018 After 8 hours of Independent After 8 hours of

nursing care  Assessed skin integrity and wound nursing care
Impaired skin integrity related to tissue trauma interventions, CC for bleeding, discoloration and intervention,
secondary to gunshot injury. will be able to discharges. objective was
display improvement  Provided wound care aseptically. partially met.
Objective: in wound healing as  Encouraged proper hygiene and CC was able to
 With wound on: 1. Anterolateral and evidenced by: hand washing. display
Anteromedial of right arm (thru and thru)  Encouraged to eat foods rich in improvement in
about 3mm in size; 2. Anterior axillary line,  Intact skin or Vitamin A,C, protein and zinc for wound healing as
with dressing dry and intact; minimized faster wound healing. evidenced by:
 Swelling and redness noted around the presence of  Instructed to report signs of infection
-wound dressing
affected site. wound swelling such as discoloration and foul appeared dry and
 With CTT on anteromedial axillary line  Absence of discharges. intact
secured with sutures, dressing soaked with redness and -minimized
blood about 3cm in diameter. erythema. Dependent erythema
 No signs of  Administered Levofloxacin -Wound still about
bleeding. 500mg/tab once a day. 3mm in size
 Administered cefuroxime 750mg TIV -No signs of
(-) ANST every 8 hours bleeding noted.

Collaborative
 Referral to IDS for evaluation of
antibiotic therapy.

49
D. Discharge Plan (METHODS)
To be able to improve the quality of life and fully recover, CC must
learn to adjust his lifestyle and increase his compliance with the drug regimen
before he can totally resume working. Due to this need the nurse, members of
the health care team, the patient and the significant other formulated a
discharge plan.

MEDICATIONS
Handed and explained to the patient the following home medications.
 Acorbic Acid 1 tab Once a day for 7 days
 Ferrous Sulfate 1 tab Once a day for 7 days
 Levofloxacin 500mg 1 tab three times a day for 7 days
 Salbutamol 1 nebule as necessary for thick mucus.
Emphasized the importance of strict adherence to medications and the
possible effects of neglecting the scheduled frequency and time of taking the
said medications.
Included the significant others in following the prescribed time for the
patient’s medications.

EXERCISE
 Encouraged to perform stretching exercises and walking as tolerated.
 Educated that the best time to exercise is during morning 0600H-0800H
because at this time CC will have more energy. Also to provide adequate
rest in between activity.
 Encouraged to perform activities of daily living gradually with
independence and eventually may go back to work.

TREATMENT
 Advised to practice aseptic technique in rendering wound care as follows:
1. Practice proper handwashing before and after wound care
2. Carefully loosen the tape from your skin.

48
 3. Use a clean (not sterile) medical glove to pull of the old
dressing.
4. Use of sterile gloves and apply appropriate solution such as
alcohol and iodine solution on the wound via cotton.
5. Apply dry dressing (sterile gauze) and secure via micropore tape
as appropriate
 Instructed to perform chest physiotherapy and deep breathing exercises
after nebulization.

HEALTH TEACHINGS
 Educated and emphasized the importance of hand washing to prevent
cross-contamination and infection.
 Rendered home education about proper Environmental sanitation such as
proper disposal of dressing and other infectious wastes.
 Instructed to seek for medical advice whenever signs of infection on
incision site are present like redness, swelling, presence of pus, warm to
touch and tenderness.

OUTPATIENT
 May visit the nearest medical facility for complaints of pain on incision site
and point of entry site at anterior axillary line.
 Follow-up consultation at GS/ TCVS OPD one week after discharge. ( 28
March 2018)

DIET
 Advised to eat protein rich foods, fruits and vegetables to facilitate faster
wound healing as shown in Chapter VII- Appendix Table 1.
 Suggested a three-day meal plan as shown in Chapter VII- Appendix
Table 2.

49
 Encouraged to increase oral fluid intake of 10-12 glasses daily to maintain
hydration of the cells in the body and to compensate fluid loss during
heavy activities.

SPIRITUAL
 Advised that he may continue to go to the mosque to pray and ask spiritual
guidance from Allah.
 Encouraged to mingle with relatives, friends and church peers to enhance
support.
SEXUAL
 Educated that he may return to usual sexual patterns as tolerated.

50
 V. CONCLUSION

Acute respiratory distress syndrome is a multifaceted type of condition.

Researches revealed that the percentage of survival is so minimal that if a
patient gets over it, he might have acquired further symptoms and the
recovery will last for 2 years or more, but not in the case of my patient.
With the joint effort of the medical practitioners, CC was able to
recuperate. The medical, surgical and nursing management were so effective
that in 14 days of stay in Surgical Intensive Care Unit, CC was transferred to
Ward 4D and eventually went home. The health care team continuously
monitored CC and gave proper treatment which he positively responded to.
As an ICU nurse, it is my vital responsibility to closely monitor the vital signs,
intake and output of the patient, competently perform nursing procedures and
the follow up laboratory workups done to check patient’s condition in a daily
basis.
The case study helped the investigator to broaden the knowledge and
skills about the case, most especially the assessment skills according to
nursing standard. I have gained so much information about the case. I was
able to identify nursing problems that are associated with condition and were
able to apply what were written in nursing books. This case made me more
efficient and competent in providing quality and comprehensive care to
patients with the said condition.

The author believes that through this study, there will be learning,
enhancement of knowledge, skills and development of right attitude towards
providing quality care to patients having acute respiratory distress syndrome.

51
 VI. BIBLIOGRAPHY

 PRINCIPLES OF ANATOMY AND PHYSIOLOGY

14TH EDITION
Gerard J. Tortora/ Bryan Derrickson

 CARSON THE ANATOMY AND PHYSIOLOGY LEARNING SYSTEM 4TH

EDTION 2011
Edith Applegate, MS

 BRUNNER AND SUDDARTH TEXTBOOK OF MEDICAL SURGICAL

NURSING
12TH EDITION
 https://emedicine.medscape.com/article/2047916-overview#a4

 https://www.mayoclinic.org/diseases-conditions/ards/symptoms-
causes/syc-20355576

 https://www.mayoclinic.org/diseases-conditions/ards/diagnosis-
treatment/drc-20355581

 https://patient.info/doctor/gunshot-injuries

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3953859/

 https://patient.info/doctor/gunshot-injuries

52
 VII. APPENDICES

Table 1
Examples of Foods Needed for Wound Healing

PROTEINS VITAMIN A VITAMIN C ZINC

Meat, eggs, Dark green leafy Citrus fruits and Cereals, red
cheese, milk, vegetables, orange juices, tomatoes, meat and
yogurt, dried or yellow peppers, potatoes, seafoods
beans, nuts vegetables, dairy spinach, cabbage
products, liver

Table 2
Three Days Dietary Plan
BREAKFAST LUNCH DINNER
1 piece banana 1 cup of rice 1 cup rice
1 cup rice 1 pc orange 1 cup ginisang munggo
1 pc boiled egg 1 cup spinach with beef
1 pc 1 pc steamed fish 1 glass of kalamansi
juice
1 cup champorado with 1 cup rice 1 cup rice
dilis 1 cup ginataang kalabasa 1 cup camote tops
1 glass of milk 1 cup fried fish 1 pc steamed fish
1 pc orange 1 glass kalamansi juice 1 glass lemon juice
1 bowl arroz caldo with 1 cup rice 1 cup rice
chicken 1 cup sautéed munggo 1 pc fried tofu
1 piece apple sprout 1 cup mixed vegetables
1 glass ginger ale 1 piece fried chicken 1 glass kalamansi juice
1 glass orange juice

53