REMEDIOS TRINIDAD ROMULADEZ MEDICAL FOUNDATION INC.

COLLEGE OF NURSING

ACTIVITY 3
NCM 112 RLE
Case scenario related to clients with Lower Respiratory problems

Mr. Budoy 55 years old, a 10 wheeler driver, normotensive, nondiabetic, & smoker was rush to the
nearest hospital and admitted due to worsening of cough associated with tightness all over the chest,
with profuse expectoration of mucoid sputum, and difficulty of breathing more markedly during
moderate to severe exertion.
Initially, cough was present during cold season only and persisted for 2 to 3 months. For the last 3
months, the same signs & symptom were present throughout the day and night, more markedly in the
morning and also on exposure to cold and dust. The patient also complains of occasional tightness all
over the chest, which worsen upon coughing. He also complains of difficulty in breathing, more
markedly during moderate to severe exertion but relieved by taking rest.
There is no history of chest pain, hemoptysis, and paroxysmal nocturnal dyspnea. He does not have any
history of fever, swelling of the ankle or weight loss. His bowel and bladder habits are normal.
Two years ago, he was admitted in the hospital due to severe attack of cough and breathlessness. He
smokes 30 sticks a day for last 35 years. All the family members are in good health. No such illness in
family.
Upon Examination in the Emergency Room
General examination
  The patient is emaciated
  Central cyanosis present
  No anemia, jaundice, edema, clubbing, koilonychia or leukonychia
  No lymphadenopathy or thyromegaly
  Pulse: 125/bpm, high volume
 B.P: 110/80 mm Hg
 O2 sat- 89%
 Capillary refill- 3 sec.
 Respiratory rate: 28cpm
Systemic examination .
Respiratory system
 Inspection:
 Shape of the chest: Normal
 Movement of the chest: Bilaterally restricted
 Intercostal space: Appears full.
Palpation: 
 Trachea: Central
 Apex beat: in the left 5th intercostal space in the midclavicular line, normal in character
 Chest expansion: Reduced
 Vocal fremitus: Normal.
Percussion:
 Percussion note: Normal resonance
 Area of liver dullness: In the right 5th ICS in midclavicular line
 Area of cardiac dullness: Impaired
Auscultation:
 Breath sounds: Vesicular with prolonged expiration
 Added sounds: Plenty of rhonchi, in both lung fields, present in both inspiration and expiration
Below are the treatment modalities and management for the patient:

DATE/TIME DOCTORS ORDER REMARKS

Oct. 8, 2020  Please admit to Medical Ward
2:00PM  Secure consent for care & mgt
BP-110/80 mmHg  TPR q4h & record
PR- 125 bpm  DAT with SAP
RR- 28 cpm  Problem: Productive cough associated with chest
O2 Sat- 89% tightness & difficulty of breathing.
 Diagnostics: CBC,plt, blood chem, CXR, ABG
analysis, & pulmonary function studies.
 IVF: PNSS 1L regulated at 20gtts/min.
 O2 inhalation via face mask at 8L/min
 Medications:
1. Hydrocortisone 200 mg IVTT now, then q 4h
2. Rapid Salbutamol + ipratropium nebulization 1
neb alternated with Budesonide 1 neb q 20 min x
3 cycles, then reassess (each nebule diluted with
1cc of sterile water/PNSS)
 Place on moderate high back rest.
 Monitor O2 saturation.
 Suction secretions as needed
 Monitor I & O q shift.
 Pls. relay lab & diagnostics results once available.
 For close watch.
 Refer accordingly.

Laboratory & Diagnostics Results

CBC Result (Oct. 8, 2020 @ 3:00PM)

CBC Results
WBC 8000/ul
RBC 4.8 million/ul
Hgb 20 g/dl
Hct 56%
WBC Differential
Neutrophils 60%
Lymphocytes 35%
Monocytes 5%
Eosinophils 4%
Basophils 1%
Platelet Count 200,000/mm3

Blood Chem Result: (Oct. 8, 2020 @ 3:00PM)

Blood Chemistry Results

FBS 110mg/dL
BUN 20 mg/dL
Creatinine 1 mg/dL
Sodium 139 mEq/L
Potassium 4.0 mEq/L
Chloride 102 mEq/L
Calcium 9 mg/dL
Pulmonary Function Test Result (Oct. 8, 2020 @ 3:00PM)

VC- 52 mL/kg
FEV- 73%
RV- 128%
TLC- 118%

ABG analysis result (Oct. 8, 2020 @ 3:00PM)

Pao2- 50 mmHg
PaCO2- 50 mmHg
pH- 7.30
O2 Sat- 89%
HCO3- 29 mmol/L

X-ray Result (Oct. 8, 2020 @ 4:00PM)

Impression: Enlarged heart with a flattened diaphragm. Consolidation in the lung fields is observable.

DATE/TIME DOCTORS ORDER REMARKS

Oct. 8, 2020  IVF to follow: PNSS 1L at 20gtts/min
4:30PM  Medications:
1. Taper Hydrocortisone 200mg IVTT to g6h
2. Taper Salbutamol+Ipratropium
nebulization to q6h and Budesonide
nebulization to q12h
3. Start Aminophylline drip: D5W 500cc+ 2
ampules Aminophylline 250mg/amp to
run for 24 hours.
4. Start Ceftriaxone 2gms IV OD ANST ( )
5. Azithromycin 500mg tab I tab OD
6. Slowly taper O2 sideflow bu1 lpm until 6
lpm maintaining O2 sat at >95%
Oct. 9, 2020  Cont. DAT with SAP
8am  IVF: PNSS 1L at 20gtts/min
BP-110/80 mmHg  Medications:
PR- 105 bpm 1. Further taper hydrocortisone 200mg IVTT to
RR- 23cpm q8h.
O2 Sat- 95% 2. Taper Salbutamol+Ipratropium nebulization
Capillary refill- 2 to q8h.
sec. 3. Aminophylline drip to consume.
4. Shift facemask to nasal cannula and
maintain 3 lpm, maintaining O2 sat at 95%-
98%
5. Continue other meds.
6. Suction secretions as needed.
7. Refer
 Oct. 10, 2020  Cont. DAT with SAP
9am  IVF to consume then attach to heplock.
BP-110/80 mmHg  Medication:
PR- 100 bpm 1. Discontinue Hydrocortisone
RR- 20cpm 2. Start Prednisone 20mg tab TID pc
O2 Sat- 97% 3. Cont. other meds.
Capillary refill- 2 4. Discontinue O2 inhalation, may resume if
sec. with episodes of desaturation <95%
(-) rhonchi 5. Refer
Oct. 11, 2020  May Go Home
9am  Terminate heplock
BP-110/80 mmHg  Home Medication:
PR- 100 bpm 1. Prednisone 20mg tab TID to complete 5
RR- 20cpm days.
O2 Sat- 99% 2. Salbutamol + Ipratropium 25/250mcg MDI 2
Capillary refill- 2 puffs BID.
sec. 3. Tiotropium 18 mcg cap inhaled OD at HS
(-) rhonchi  For spirometric studies as OPD
 Follow-up after 1 week.

Questions:

1. Identify factors that have contributed to the health condition of the patient.
2. Based on the given scenario, identify the priority signs and symptoms.
3. Interpret the laboratory and diagnostics results with clinical significance.
4. Using a concept map, explain the pathophysiology of the specific condition integrating
the diagnostic/laboratory results and possible medical managements. (Note: Submit
also a narrative pathophysiology explaining the concept map).
5. Based on the treatment modalities prescribed by the physician, make a pharmacological
study of the specific medications.
6. Based on the priority problems of the client’s condition, Formulate 5 priority nursing
care plan.
7. Make a discharge planning to prevent the reoccurrence of the disease.