NCM 109 MIDTERM

At the end of the lecture, the students will be able to: Many of us have hundreds of things on our minds at any
1. Determine and describe common child’s condition and illness involving moment, often struggling to keep track of everything we need to do.
alterations in:
But fortunately, there's one important thing we don't have to worry
a. Oxygenation
b. Fluid and Electrolytes & Acid -Based Balanced about remembering: breathing.
c. Inflammatory & Immunologic response
2. Care of the child at risk, acute and chronic and with life threatening When you breathe, you transport oxygen to the body's cells
conditions to keep them working and clear your system of the carbon dioxide that
this work generates.
TOPIC

A. Alterations in oxygenation Breathing, in other words, keeps the body alive. So, how do
• Oxygen Ventilation Problems we accomplish this crucial and complex task without even thinking
a. Upper respiratory tract infection about it? The answer lies in our body's respiratory system. Like any
b. Lower respiratory tract infection machinery, it consists of specialized components, and requires a
• Oxygen Transport Problems
trigger to start functioning. Here, the components are the structures
• Oxygen Perfusion Problems
B. Alteration in Fluid and Electrocytes & Acid-Base Balance
and tissues making up the lungs, as well as the various other
C. Alteration with infectious, Inflammatory and Immunologic Response respiratory organs connected to them.

And to get this machine moving, we need the AUTONOMIC

REVIEW OF ANATOMY & PHYSIOLOGY NERVOUS SYSTEM, our brain's unconscious control center for the
vital functions.

As the body prepares to take in oxygen-rich air, this system

TWO DIVISION: sends a signal to the muscles around your lungs, flattening the
diaphragm and contracting the intercostal muscles between your ribs
to create more space for the lungs to expand. Air then wooshes into
your nose and mouth, through your trachea, and into the bronchi that
split at the trachea's base, with one entering each lung. Like tree
branches, these small tubes divide into thousands of tinier passages
called bronchioles. It's tempting to think of the lungs as huge
balloons, but instead of being hollow, they're actually spongy inside,
with the bronchioles running throughout the parenchyma tissue.

At the end of each bronchiole is a little air sack called an

alveolus, wrapped in capillaries full of red blood cells containing
FUNCTIONS OF THE LUNGS special proteins called hemoglobin. The air you've breathed in fills
1. Gas Exchange these sacks, causing the lungs to inflate.
2. Metabolic function
Here is where the vital exchange occurs. At this point, the
3. Regulation of acid base balance
capillaries are packed with carbon dioxide, and the air sacks are full of
4. Pulmonary defense
oxygen. But due to the BASIC PROCESS OF DIFFUSION, the
MUSCLES molecules of each gas want to move to a place where there's a lower
1. Diaphragm 2. Intercostal muscles concentration of their kind.

So as oxygen crosses over to the capillaries, the

hemoglobin grabs it up, while the carbon dioxide is unloaded into the
lungs. The oxygen-rich hemoglobin is then transported throughout the
body via the bloodstream. But what do our lungs do with all that
carbon dioxide? Exhale it, of course. The autonomic nervous system
kicks in again, causing the diaphragm to ball up, and the intercostal
muscles to relax, making the chest cavities smaller and forcing the
lungs to compress. The carbon dioxide-rich air is expelled, and the

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 NCM 109 MIDTERM
cycle begins again. So that's how these spongy organs keep our Cyanosis is a blue skin color you can usually see it around your
bodies efficiently supplied with air. baby's lips chest and stomach this blue color means that the oxygen
level in the blood may be too low. Cyanosis may mean there is a
Lungs inhale and exhale between 15 and 25 times a minute, problem with the baby's lungs or heart
which amounts to an incredible 10,000 liters of air each day. That's a
lot of work, but don't sweat it. Your lungs and your autonomic nervous Jaundice is an overall yellow skin color it happens when a substance
system have got it covered. called bilirubin builds up in the blood. Most babies have some
jaundice that appears more than 24 hours after birth
@: https://www.youtube.com/watch?v=8NUxvJS-
_0k&ab_channel=CrashCourse If left untreated severe or long-lasting jaundice may cause
brain damage.
It's important to check your baby for these signs of distress.
GENERAL ASSESSMENT
Immediately contact a member of your health care team if
1. History taking you notice any of these warning signs
• Biographic and Demographic
• Past health history
• Present history PALPATION
• Family health history
Purposes/importance
• Chief Complaint
1. confirm observed abnormalities, such as swellings and
deformations
2. Physical assessment and examinations (IPPA)
2. identify areas of tenderness or lymph nodal enlargement
• Subjective data
3. document the position of the trachea; to assess respiratory
• Objective data
excursions
INSPECTION 4. detect changes in the transmission of voice sounds through
the chest.
A. Chest
o Size, symmetry movement PERCUSSION
o Infancy shape is almost circular
 It involves listening to the volume and pitch of percussion
o < 6-7 year respiratory movement primarily abdominal or
notes across the chest to identify underlying pathology
diaphragmatic
Types of percussion note:
B. Respirations ❖ RESONANT
o Rate, rhythm, depth, Quality, Effort ❖ DULLNESS
o >60 /min in small children - significant respiratory distress ❖ STONY DULLNESS
❖ HYPER-RESONANCE AUSCULTATION
C. Retraction
D. Effort AUSCULTATION
o Grunting
A. Listen comparing one areas to the other
o Flaring
→ Equality of breath sounds
INFANT DISTRESS WARNING SIGNS → Diminished
→ Poor air exchange
Infant distress
 means your baby is having difficulties, knowing what to look B. Abnormal breath sounds
for will help you know if your baby is in distress. → Rales
 Your baby may have breathing problems such as → Rhonchi
retractions, grunting and apnea. → Wheezing
→ Crackles
SYMPTOMS OF BREATHING PROBLEMS: → Grunting
✓ Retractions- are unusual breathing movements with each
ADVENTITIOUS BREATH SOUNDS
breath your baby's chest muscles pull in the skin around the
bones. A. Stridor
✓ Grunting- is a noisy breathing sound your baby may grunt to  is a continuous high-pitched, crowing sound head
cut air in the lungs. Grunting may sound like snoring or predominately on inspiration
singing.  the cause of the sound is generally the partial obstruction of
✓ Apnea is a condition in which your baby pauses breathing the larynx or trachea.
for 15 to 20 seconds, then continues breathing. you may  It may be heard in conditions such as croup and foreign
notice changes in your baby skin two common findings are body obstruction
conditions known as cyanosis and jaundice.  it's typically loud as over the anterior neck as air moves
turbulently over partially obstructed upper airway.

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 NCM 109 MIDTERM

B. Wheeze
 sound of a wheeze is a high pitch continuous musical sound
 This is caused by air passing through an obstructed narrow
airway.
 The classic wheeze may be referred to as a sibilant wheeze
 This refers to the high pitch whistle like sound

Alternatively, what we often refer to as rhonchi is the “sonorous

wheeze” which refers to a deep, low-pitched rumbling or coarse
sound as air moves through tracheal/bronchial passages in the
presence of mucus or respiratory secretions.
GENERAL CLINICAL MANIFESTATIONS
 It is commonly heard in the lungs during expiration.
 It may be heard an asthma, emphysema and chronic UPPER RESPIRATORY TRACT INFECTIONS (URTI)
bronchitis.
✓ Sneezing
C. Crackles ✓ Chills
 are also known as alveolar rales. ✓ Headache
 The sound crackles create a fine, short, high-pitched, ✓ Sore Throat
intermittent crackling sounds. ✓ Airborne Infection
 The cause of crackles can be from air passing through fluid, ✓ Cough
pus or mucus. ✓ Cold
 It is commonly heard in the bases of the lung lobes during ✓ Backache
inspiration. ✓ Snot
 Crackles can be further categorized as coarse or fine
DIAGNOSTIC/ LABORATORY TESTS (URTI)
Coarse crackles sound quality is low pitched and moist, maybe her
✓ Throat Swab/Culture
pulmonary oedema and bronchitis
✓ Rapid Strep Test
Fine crackles sound qualities like hair rubbing near the ear and ✓ Nasal Swab
maybe heard in congestive heart failure and pulmonary fibrosis. ✓ Blood Tests
✓ Chest X-Ray
D. Pleural rub ✓ Nasopharyngeal Aspirate Or Wash
 The Pleural rub sound results from the movement of ✓ Computed Tomography (Ct)
inflamed pleural surfaces against one another during chest ✓ Allergy Testing
wall movement.
 The sound quality is considered a harsh grating or creaking. DIAGNOSTIC/LABORATORY TESTS LOWER RESPIRATORY
 Potential causes include tuberculosis and pneumonia. TRACT INFECTIONS (LRTI)
 It is best heard in the lower anterior lungs and lateral chest
Pulmonary Function Test
during both inspiration and expiration.
Pulse Oximetry
@:https://www.youtube.com/watch?v=ObZFU3YUqyE&ab_channel= Arterial Blood Gas TEST (ABG)
Ausmed Radiography: Chest x-ray (CXR)
MRI
OTHER ASSESSMENTS CT and PET scan
Sputum Studies
 Other Vital signs: Temperature Bronchoscopy
 Febrile state increases oxygen consumption Spirometry

 Fluid Needs NURSING MANAGEMENT

 Vomiting/diarrhea are commonly associated with
respiratory illness 1. Sore throat (Pharyngitis)
 Increase respiratory efforts, increased fluid losses with ✓ Warm saltwater gargles
decreased oral intake—requires an increase in fluid ✓ Pain relief medications such as acetaminophen or ibuprofen
need as prescribed
 Color ✓ Throat lozenges or throat sprays for symptomatic relief
 Mucous membranes ✓ Adequate hydration
 Nail Beds
 Skin–cyanosis and jaundice 2. Cough
✓ Cough suppressants for dry, non-productive coughs
✓ Hydration
✓ Proper positioning for comfort and ease of breathing

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3. Sneezing CAUSES:
✓ Proper sneezing etiquette (into a tissue or elbow) • Rhinoviruses
✓ Use tissues and hand hygiene supplies • Enteroviruses
• Parainfluenza
4. Hoarseness or loss of voice • Adenoviruses
✓ Vocal rest
✓ Warm, non-caffeinated beverages to soothe the throat
✓ Throat lozenges or sprays for temporary relief
✓ Avoid irritants such as smoking or exposure to dry air

5. Runny nose (Rhinorrhea)

✓ Saline nasal irrigation to help clear mucus
✓ Antihistamines or decongestants for relief

6. Nasal congestion
✓ Steam inhalation to help relieve congestion
✓ Saline nasal sprays or drops to moisturize and clear nasal
passages
✓ Elevate head
✓ Decongestants

7. Fatigue
✓ Adequate rest and sleep
✓ Rest periods in between activities

IMPORTANT POINTS TO REMEMBER

Differences between Children and Adults Respiratory System
1. Chest / respiratory system → Obligate nasal
breathers >6wks
2. Short neck → smaller, narrower airways — more PREVENTION OF COMMON COLDS
susceptible to airway obstruction and resp. Distress
• Always Wash Hands
3. Tongue is larger in proportion to the mouth → more likely to
• Avoid Crowded Place
obstruct airway in unconscious child
• Eat Healthy Foods
4. Smaller lung capacity and underdeveloped intercostal • Avoid Smoking
muscles, poor chest musculature → less pulmonary • Sleep Well/ Sleep Early
reserved, lung damage
5. Children rely on diaphragm breathing → high risk for resp. II. SINUSITIS
Failure if the diaphragm is unable to contract  Or RHINOSINUSITIS
 An inflammation or swelling of the tissue lining of the
ALTERATIONS IN OXYGENATION UPPER RESPIRATORY sinuses
TRACT INFECTIONS  Bacterial infection. Infection, allergies, or structural issues.
✓ Common colds/ Nasopharyngitis  Acute or chronic
✓ Sinusitis  Approximately 5% of URI are complicated with acute
✓ Tonsillitis / Pharyngitis sinusitis
✓ Laryngitis
✓ Influenza
✓ Otitis media
✓ Croup

I. COMMON COLDS/NASOPHARYNGITIS
 A viral URI
 Spread through contaminated air or from person-to-person
contact (direct contact)
 Affect children of all ages
 Higher incidence among daycare attendees and school
aged children

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MEDICAL MANAGEMENT

❖ Antibiotics
❖ Pain Relievers
❖ Throat Lozenges
❖ Rest And Hydration
❖ Warm Saltwater Gargle
❖ Humidifier
MEDICAL MANAGEMENT ❖ Steroid Medications
❖ Surgery (Tonsillectomy)
❖ Antibiotics
❖ Nasal Corticosteroids DIAGNOSTIC TESTS
❖ Decongestants
❖ Throat Swab/ Culture
❖ Saline Nasal Irrigation
❖ Rapid Antigen Test
❖ CBC
III. TONSILLITIS
 Commonly caused by viral or bacterial infections
IV. PHARYNGITIS
 Most frequent bacterial cause is Streptococcus pyogenes,
 Inflammation of the pharynx
aka group A streptococcus
 Other viruses that can cause tonsillitis include: CAUSES:
✓ Adenovirus • Viral infections
✓ Parainfluenza virus • Bacterial infections: group A streptococcus
✓ Influenza virus • Environmental factors
✓ Epstein- Barr virus • Allergies
 Highly contagious and can spread through respiratory • Other causes
droplets from coughing, sneezing, or direct contact with an
infected person

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• Anatomical factor
• Environment factor
• Age
• Allergies
• Virus

SYMPTOMS:
• Ear Pain
• Fever
• Rubbing or Tugging Ear
• Headache
• Trouble Sleeping At Night
V. INFLUENZA • Nausea /vomiting
 A highly contagious airborne disease caused by influenza A • Loss of Balance
or influenza B virus • Loss of Appetite
 An acute febrile illness with variable degrees of systemic • Pus /Fluids
symptoms • Hearing Impairment

MODE OF TRANSMISSION

• Direct contact
• Unhygienic food preparation
• Aerosol transmission
• Contact with contaminated objects

SYMPTOMS OF FLU:

• Headache
• Weakness
• Fever
• Cough
• Muscle Ache
• Chest Discomfort

DIAGNOSTIC TESTS

• Viral Cultures
• Rapid Influenza Diagnostic Tests (RIDTS)

VII. CROUP
NURSING INTERVENTION  Often referred to as laryngotracheobronchitis
The primary nursing goal: relief of symptoms and prevention of  Is a common childhood respiratory condition characterized
secondary infection by inflammation and swelling of the upper airway, larynx
(voice box) and trachea (windpipe).
1. Instruct patient to have rest
 Can be caused by the following: Viral Infection
2. Advise patient to stay hydrated
Anatomical Factors
3. Encourage patients to gargle with oral antiseptic sol.
Seasonal Variability
MEDICAL MANAGEMENT:
OVERVIEW:
1. Antiviral medications
 Viral Upper Respiratory Tract Infection (URTI) that typically
2. Analgesics and antipyretics
affects babies and children 6 months and 6 years.
PREVENTION:  Most common pathogen: Parainfluenza Virus (75%)
 The infection affects the larynx, trachea and bronchi.
1. Inactivated  Swelling and inflammation in these areas makes it
2. Live Attenuated difficult to breathe.
 Mild Croup typically resolves within 48 hours.
VI. OTITIS MEDIA
 Is an infection or inflammation of the middle ear. SIGNS AND SYMPTOMS:

CAUSES: • Fever
• Bacteria • Labored breathing
• Eustachian tube dysfunction • 3 Classical Features: Barking Cough, Stridor, Hoarse voice

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• Flu like symptoms (Temperature, Coryza) 3. Cough, Production of Mucus, Fatigue, Slight Fever,
• In moderate to severe cases, upper airway obstruction can Shortness of Breath and Chest Discomfort
cause respiratory distress

TREATMENT:

• All patients receive Oxygen support and oral

dexamethasone (0.15mg/kg)
• Admit moderate to severe cases and further management
includes nebulized epinephrine and senior support
• If mild and not deteriorating after dexamethasone, then
home with strict safety netting advice and low threshold
to seek medical attention again.

NURSING INTERVENTION:

1. Encourage oral fluid intake

2. Advise to drink hot tea and honey
VIII. BRONCHITIS
3. Quit smoking
 Is a self-limiting inflammation of the bronchi in the lower
4. Avoid secondhand smoke
respiratory tract.
5. Wash hands often
CLINICAL FEATURES: 6. Use of humidifier

 Chest Pain ---------------------------- END ----------------------------

 Cough
 Fever WEEK 1: ACUTE RESPIRATORY DISTRESS & ASTHMA
 Color of Sputum: white
 Difficulty of breathing Case Scenario:
 Cyanosis
Sarah, a 4-year-old girl from a suburban area, is brought to the
 Tachycardia
emergency department by her parents due to severe breathing
TYPES OF BRONCHITIS: difficulty, a worsening cough, and noticeable fatigue. She has been
experiencing flu-like symptoms and a high-grade fever for the past
1. Acute Bronchitis week, accompanied by a decreased appetite which made her parents
 Recover after a few days or week
worried because she lost some weight. Additionally, Sarah has a
 Cause by viral infections, air pollution, dust, inhalation of history of mild asthma, which has been well-managed with
chemicals, smoking, chronic sinusitis, and asthma.
occasional use of an inhaler during cold seasons. Concerned about
her recent respiratory distress, Sarah’s parents also express worries
2. Chronic Bronchitis
about the air quality in their neighborhood due to nearby industrial
 An ongoing cough that lasts for several months and comes activities, which they fear may have contributed to her condition.
back two or more consecutive years
Upon arrival at the hospital, the doctor conducts an initial
 Causes: Chronic exposure to smoke
assessment, noting Sarah’s rapid breathing, decreased oxygen
Cigarette smoking saturation, and the presence of crackles in her lung sounds. With
Exposure to pollutants
Sarah already diagnosed with Pediatric Acute Respiratory Distress
BRONCHITIS SYMPTOMS: Syndrome (PARDS) and presenting cyanosis, the medical team plans
1. Normal Bronchial Tube to conduct further assessments, including a physical examination,
2. Inflamed Bronchial Tube chest X-rays, and blood tests, to confirm the diagnosis. Since being
diagnosed with PARDS, Sarah will require admission to the pediatric

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intensive care unit for close monitoring and supportive care, which
could involve oxygen therapy, mechanical ventilation, and addressing
any underlying infections or inflammatory processes contributing to
her respiratory distress. The hospital offers resources such as
counseling services and educational materials to support the family
through this challenging time, providing them with information about
PARDS, potential treatment plans, and the importance of adherence
to prescribed medications, while also addressing their concerns PATHOPHYSIOLOGY:
about environmental factors impacting Sarah’s health.
NCM 109 MIDTERM
❖ Environmental factors: Air pollution or exposure to
secondhand smoke may have contributed to Sarah’s
condition.
❖ Medication: Sarah’s medication may have contributed to
her condition, but further information is needed to
determine its role.

ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)

→ It is a life-threatening lung condition.

→ It is a form of breathing failure that can occur in very ill or
severely injured people.
→ It is not a specific disease.
→ It starts with swelling of tissue in the lungs and build up of
fluid in the tiny air sacs that transfer oxygen to the
bloodstream. This leads to LOW BLOOD OXYGEN LEVELS.
→ ARDS is similar infant respiratory distress syndrome, but the
causes and treatments are different.
→ ARDS can develop in anyone over the age of one year old.
→ Also known as ADULT RESPIRATORY DISTRESS
SYNDROME, RESPIRATORY DISTRESS SYNDROME

TYPES:

• Type 1 respiratory failure occurs when the respiratory

system cannot adequately provide oxygen to the body,
leading to hypoxemia.
• Type 2 respiratory failure occurs when the respiratory
system cannot adequately remove carbon dioxide from the
body, leading to hypercapnia.

ASSESSMENT:

✓ Chest auscultation and looking for signs of lack of oxygen,

such as blue-tinged nails or lips.
✓ Vital Signs: Respiratory rate,
Cardiac output,
Pulse oximetry

CAUSES: Inhalation of Viral Pathogen/Exposure to Environmental Factors:

1. Flu-like symptoms and a high-grade fever, accompanied by a
decreased appetite.
2. Possible history of mild asthma.
3. Environmental factors such as air pollution or exposure to
secondhand smoke.
4. Possible contributions from her medication.
RISK FACTORS:
❖ Age: Sarah is only 4 years old and may be at higher risk for
ARDS due to her young age.
❖ Medical history: Sarah has a history of mild asthma, which
can increase her risk for ARDS when she is sick with
respiratory illnesses such as the flu.
Sarah experiences flu-like symptoms and high-grade fever, possibly
due to viral infection. Her parents express concerns about
environmental factors such as nearby industrial activities affecting air
quality.
Viral Replication and Activation of Inflammatory Response: the
viral pathogen replicates in the respiratory tract, triggering an
inflammatory response.
Airway Inflammation and Edema Formation: Inflammatory
mediators cause inflammation and swelling in the airways, leading to
difficulty in breathing.
Bronchiolar Inflammation: Inflammation extends to the bronchioles,
further obstructing airflow.

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Alveolar Damage/Leakage: Inflammatory processes result in  A ventilator is a machine used to open airspaces that have
damage to the alveoli, causing leakage of fluids and proteins into the shut down and help with the work of breathing. The
alveolar space. ventilator is connected to the patient through a mask on the
face or a tube inserted into the windpipe.
Surfactant Dysfunction: Alveolar damage impairs the production and
function of surfactant, leading to increased surface tension in the Indications: Respiratory Failure
alveoli.
Duration of therapy: ARDS patients may require ventilation for
Impaired Gas Exchange: Surfactant dysfunction and alveolar long periods of time. On average this is seven to 14 days.
damage compromise the exchange of oxygen and carbon dioxide.
Side Effects: Immobility
Pulmonary Vasoconstriction: Hypoxemia triggers vasoconstriction in Bedsores
the pulmonary vasculature, redirecting blood flow to better- Blood clots
oxygenated areas of the lung. Weak muscles

Pulmonary Hypertension: Prolonged vasoconstriction leads to
increased pulmonary arterial pressure, contributing to respiratory
distress.
Respiratory Distress Syndrome (PARDS): The combination of
airway inflammation, alveolar damage, surfactant dysfunction,
impaired gas exchange, pulmonary vasoconstriction, and
hypertension results in pediatric acute respiratory distress syndrome.
Sedation and medications to prevent movement
➢ To relieve shortness of breath and prevent agitation, the
ARDS patient usually needs sedation. Sometimes added
medications called paralytics are needed up front to help
the patient adjust to the ventilator. These medications have
significant side effects and their risks and benefits must be
continuously monitored.

Clinical Manifestations: Sarah presents with symptoms such as
cyanosis, tachypnea, and crackles upon physical examination.
Supportive Care: Sarah requires admission to the pediatric intensive
care unit for close monitoring and supportive care, including
mechanical ventilation, oxygen therapy, or addressing underlying
causes such as infections or inflammatory processes.
SIGNS AND SYMPTOMS:
2. Extra-Corporeal Membrane Oxygenation (Ecmo)
 Extracorporeal membrane oxygenation is an extracorporeal
technique of providing prolonged cardiac and respiratory
support to persons whose heart and lungs are unable to
provide an adequate amount of oxygen, gas exchange or
blood supply to sustain life.
 The use of ECMO has expanded rapidly to support both
pediatric and adult respiratory failure.

✓ Severe Breathing Difficulty Duration of therapy: ECMO therapy may be needed for several
✓ Worsening Cough days to weeks, but in some cases, it can extend to several weeks
✓ Noticeable Fatigue or even months if necessary for the patient’s recovery.
✓ Flu-like Symptoms Indication: Severe ARDS
✓ Decreased Oxygen Saturation
✓ Presence of Crackles in Lung Contraindication: High pressure ventilation or high FIO2
✓ Cyanosis requirements for more than 7 days.

DIAGNOSTIC TESTS: 3. Adrenergic Agonist Agents

 Adrenergic agonist agents are used to increase cardiac
1. Chest X-ray: to measure fluid in the lungs. output and improve hemodynamics induced by various
2. Echocardiogram: an ultrasound of the heart to evaluate mechanism including elevated mean airway pressures from
heart function. mechanical ventilation, sedation, multi organ failure etc.
3. Electrocardiogram (EKG): to measure the heart’s electrical These agents should be administered via central line.
activity.
4. Pulse oximetry: a fingertip sensor for constant monitoring Side effect: Tachycardia
of oxygen levels. Palpitation
5. Computed tomography (CT) scan: to provide more Nervousness
detailed information about the lungs. Tremors
Headache
LABORATORY TESTS: Dizziness
1. Blood test: to measure oxygen levels in the blood and Nausea and vomiting
determine the severity of ARDS. Sweating
Insomnia
MEDICAL & SURGICAL MANAGEMENT:

1. Ventilator 1. Dobutamine
 All patients with ARDS will require extra oxygen. Oxygen  Indicated during the early stage of septic shock-induced
alone is usually not enough, and high levels of oxygen can ARDS.
also injure the lung.
Route & Usual dosage: IV, (Injectable site) 12.5mg/mL

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Contraindication: For patient with ARDS if no septic shock tadalafil, vardenafil, and avanafil, as they may result in severe
induced then it is contraindicated. hypotension.

Side effect: Irregular Heartbeat, Chest pain, Shortness of breath Side Effects: Headaches, Nausea, Diarrhea

2. Dopamine Route of administration: Oral tablets, injection form, and topical

 In the lungs, dopamine modulates respiratory functions ointment.
through carotid bodies and modulates pulmonary blood
vessel tone, alveolar liquids, and bronchial exchange, and Usual Dose:
possibly participates in the regulation of airways diameter. • Infusion solution, in D5W: 20mg/100mL,
40mg/200mL
Route & Usual Dosage: IV, infusion solution, in D5W: • Injectable solution: 1mg/mL
80mg/100mL, 160mg/100mL, 320mg/100mL

Indication: Dopamine may be considered in patients with acute 6. Corticosteroids

respiratory distress syndrome (ARDS) who exhibit signs of  Corticosteroids have anti-inflammatory and
hemodynamic instability or cardiovascular compromise. May be immunosuppressive properties. They cause profound and
indicated in ARDS patients if they present with: varied metabolic effects, and they modify the body’s
immune response to diverse stimuli.
Contraindication: Hypersensitivity
Contraindications:
Side effects: Dyspnea
• Hypersensitivity to any component of the formulation
3. Epinephrine
• Concurrent administration of live or live-attenuated
 By acting on alpha receptors, it constricts blood vessels to
vaccines (when using immunosuppressive dosages)
help maintain blood pressure and heart function. Through
• Systemic fungal infection
its action on beta receptors, it relaxes the smooth muscle in
the airways of lungs to help relieve shortness of breath and • Osteoporosis
wheezing • Uncontrolled hyperglycemia
• Diabetes mellitus
Side effects: Dyspnea & Pulmunary edema • Glaucoma
• Joint infection
Route & Usual dose: IV, 0.1mg/mL (1mg/10mL) 1mg/mL
• Ucontrolled hypertension
4. Nitric Oxide • Herpes simplex keratitis
 Inhaled nitric oxide (iNO) has been suggested as a therapy • Varicella infection
for PARDS. It is well recognized as a potent and effective • Peptic ulcer disease
pulmonary vasodilator as it relaxes vascular smooth • Congestive heart failure
muscle. • Viral or bacterial infections not controlled by anti-
infectives
Contraindications: Contraindicated in the traetment of
neonates known to be dependet on right-to-left shunting of Side Effects:
blood.
• Osteoporosis, fractures, and osteonecrosis
Side Effects: Methomoglobinemia • Adrenal suppression
Hypotension • Cushingoid features
Withdrawal • Diabetes and hyperglycemia
Pulmonary edema • Myopathy
Route of Administration: Inhalation • Glaucoma and cataracts
• Psychiatric disturbance
Recommended dose: 20 ppm • Immunosuppression
• Cardiovascular adverse effects
Duration of therapy: 14 days or until the underlying oxygen
• Gastrointestinal adverse effects
desaturation has resolved
• Dermatologic adverse effects
5. Phosphodiesterase Enzyme Inhibitors • Growth suppression
 Phosphodiesterase inhibitors are medications that cause
blood vessels to relax and widen, improving circulation and Route of Administration: Parenteral, oral, inhaled, topical,
lowering blood pressure. That makes them useful for injected (intramuscular, intraarticular, intralesional,
treating a wide range of medical conditions intradermal, etc.), and rectal.
 Milrinone is commonly used phosphodiesterase inhibitor. 7. Surfactants
Contraindications: Hypersensitivity is an absolute  Rescue treatment of infants who have RDS.
contraindication to all phosphodiesterase inhibitors. Nitrites are  Prophylactic treatment of infants at high risk for
contraindicated to use alongside PDE-5 inhibitors: sildenafil, development of RDS (birth weight of <1, 350g, birth

10 | P a g e

weight >1, 350g who have evidence of respiratory
immaturity).
Contraindications: Because lung surfactants are used as
emergency drugs in newborn, there are no contraindications.
Side Effects:
• Cardiovascular: Patent ductus arteriosus, bradycardia,
intraventricular hemorrhage, hypotension.
• Respiratory: Pneumothorax, pulmonary air leak,
pulmonary hemorrhage, apnea.
• Systemic: Sepsis, infection.
Route of Administration: Endotracheal Instillation
Usual Dose: Typical doses of intratracheal surfactant in
premature infants are 100 mg/kg body weight.
NURSING DIAGNOSIS:
❖ Ineffective airway clearance related to airway spasms as
evidenced by the presence of adventitious breath sounds
(i.e. crackles).
❖ Ineffective breathing pattern related to increase rate and
decreased depth of respiration.
❖ Impaired gas exchange related to ventilation imbalance
associated with decreased pulmonary blood flow resulting
from decreased cardiac output.
❖ Imbalanced nutrition: less than body requirements related
to inadequate interest in food as evidenced by weight loss.
NURSING INTERVENTIONS:
1. Ineffective Airway Clearance
 Assist the patient to an optimal upright position.
 Administer supplemental oxygen as ordered.
 Encourage the client to cough and deep breathe.
 Administer medications as ordered.
 Encourage adequate fluid intake, if not contraindicated.
 For acute conditions, anticipate interventions such as
bronchoscopy or intubation.
2. Ineffective breathing pattern
 Monitor respiratory rate, depth, and pattern regularly.
 Provide a calm and comforting environment to reduce
anxiety and respiratory distress.
 Encourage relaxation techniques such as deep breathing
exercises or blowing bubbles to promote optimal breathing
patterns.
 Administer prescribed medications (e.g., bronchodilators)
to alleviate respiratory distress if indicated.
 Educate caregivers on signs of respiratory distress and
when to seek medical attention.
3. Impaired gas exchange
 Monitor oxygen saturation levels and respiratory status
closely.
 Position the child for optimal respiratory function, such as
elevating the head of the bed.
 Administer supplemental oxygen as prescribed to maintain
adequate oxygenation.
11 | P a g e
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 Assist with activities of daily living to conserve energy and
decrease oxygen demand.
 Collaborate with the healthcare team to address the
underlying cardiac condition and optimize cardiac output.
4. Imbalanced nutrition
 Offer small, frequent meals and snacks that are high in
calories and nutrients.
 Provide favorite foods and snacks to encourage intake.
 Create a positive mealtime environment, free from
distractions and stressors.
 Encourage and support the child during meals, praising
efforts and progress.
PATIENT EDUCATION:
1. Explain the cause, signs and symptoms of ARDS and the
importance of promptly reporting any changes to the
healthcare provider.
2. Educate the child and their family on avoiding exposure to
respiratory infections and not smoking around the child.
3. Highlight strict medication adherence to home
medications and involve significant others in following the
prescribed medication schedule. If antibiotics are
prescribed, instruct the family to continue giving them as
directed by the healthcare provider.
4. Encourage the child to engage in regular physical activity
within their capabilities to improve lung function and overall
well-being.
5. Encourage increased oral fluid intake of 10-12 glasses
daily to maintain hydration and compensate for fluid loss
during activities.
6. Emphasize the importance of maintaining a healthy and
balanced diet, including protein-rich foods, fruits, and
vegetables, to support overall health and recovery.
7. Explain the need for regular follow-up check-ups to
monitor progress, assess lung function, and adjust the
treatment plan if necessary.
8. Encourage frequent handwashing, proper respiratory
hygiene, and avoiding close contact with individuals who
have respiratory illnesses.
9. Encourage social interaction with relatives, friends, and
church peers to enhance support during the recovery
process.
10. Highlight importance of age-appropriate vaccinations,
such as influenza and pneumococcal vaccines, to reduce
the risk of respiratory infections.
MEDICAL TERMS USED:
Hypercapnia: This is a condition where the carbon dioxide (CO2) in
the blood is at a high level. It can be caused by inadequate removal of
CO2 from the body.
Hypersensitivity: This is a body's reaction that is overly sensitive to a
particular thing or substance. It can result in symptoms such as
itching, swelling, or difficulty breathing.
Cyanosis: This is the presence of a bluish color or insufficient oxygen
in the blood. It can be a sign of inadequate heart function or breathing
problems.

Bronchoscopy: This is a medical procedure where the examination of
the airways and lungs is done using a special instrument called a
bronchoscope.
Adventitious breath sounds: These are unusual sounds heard during
breathing. They may result from problems in the airways or lungs,
such as breathing difficulties or swelling.
Crackles: These are small, popping sounds heard in the lungs when
there are patches of fluid or swelling in the airways.
ABG analysis: This is the analysis of gases in the blood, including
oxygen levels, carbon dioxide, and pH. It is used to measure lung and
breathing function.
PARDS: This is the acronym for Pediatric Acute Respiratory Distress
Syndrome. It is a severe breathing failure condition in children, often
caused by infections, inflammation, or lung problems.
Mild asthma: This is a condition of asthma where the symptoms are
not very severe or frequent. It is often associated with episodic
breathing difficulties, coughing, and chest tightness.
---------------------------- END ----------------------------
Case Scenario:
A 12-year-old girl with a history of asthma presented to the
emergency department with a three-day history of increased work of
breathing, coughing, and wheezing. She reported no clear trigger for
her respiratory symptoms, although she had noted some symptoms
of a mild upper respiratory tract infection. With this episode, the
patient had been using a short-acting bronchodilator more frequently
than she had in the past, without the expected resolution of
symptoms.
On the day of presentation, the patient awoke feeling ‘suffocated’
and her mother noted her lips to be blue. In the emergency
department, her oxygen saturation was 85% and her respiratory rate
was 40 breaths/min. She had significantly increased work of breathing
and poor air entry bilaterally to both lung bases, with wheezing in the
upper lung zones.
ASTHMA
 is a chronic disease in which the bronchial airways in the
lungs become narrowed and swollen, making it difficult to
breathe. There are different types, such as childhood, adult-
onset, seasonal, and workplace-related asthma
ASSESSMENT: The patient presents with acute exacerbation of
asthma, characterized by increased work of breathing, cough, wheezing,
and poor air entry bilaterally. The presence of blue lips indicates severe
hypoxemia, further confirmed by the low oxygen saturation of 85%.
CAUSE: Various factors, including respiratory infections, allergens,
cold air, or irritants can trigger asthma exacerbations. In this case, the
patient's symptoms appear to have been precipitated by a mild upper
respiratory tract infection, leading to worsening asthma symptoms.
RISK FACTORS:
• Family history of Asthma
• Respiratory conditions
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Risk factors for asthma (General):
• Allergies
• Airway infections
• Family history of asthma
• Obesity
• Smoking
• Breathing in cold air
• Environmental exposure
• Occupational exposures
PATHOPHYSIOLOGY
The conduction zone of the airways is from the nose to the bronchial.
It is where the air is warmed and moistened before going to the
Respiratory Zone where gasses are exchanged in the alveoli. It is the
conducting zone particularly the bronchi and bronchioles that are
greatly affected in asthma. Multiple layers in the bronchus include the
lumen where air is present, a mucus layer to help protect against
foreign particles, the epithelial cells, lamina propria, and smooth
muscle cells.
The First Phase of an asthma exacerbation is the early
phase which happens in the first few minutes. In asthma, there’s an
excess of T-Helper cells which is also present in allergic dermatitis
known as eczema, and allergic rhinitis known as hay fever. The trigger
factor is taken up by an antigen-presenting cell typically a dendritic
cell and shown to the T-Helper cell. In asthmatic patients, these
TH2 cells produce cytokines in response including IL-4, IL-5, and IL-
13. IL-4 and IL-13 cause that plasma cells to release IgE. An Ige will
then activate Mast Cells to release Granules in a process known as
Degranulation. These granules include Histamine, Leukotriene, and
Prostaglandins.
In immunology, this is called a TYPE 1 HYPERSENSITIVITY
REACTION. The release of these molecules leads to the contraction
of the smooth muscle layer in the airways known as Bronchospasm,
and Increased Production of Mucous, and also Edema. These three
lead to a narrower airway which produces asthma symptoms. IL-5
leads to activation of Eosinophils which then releases more
Cytokinesis and Leukotriene. The release of all of these
inflammatory mediators leads to more inflammatory cells being
recruited from the blood over the next few hours known as

Chemotaxis and further production of inflammatory mediators giving
the Second Phase of Exacerbation termed as the LATE RESPONSE
The pathological process is thought to begin with exposure
to a specific trigger. This can be inhalation of an irritant such as cold
air or an allergen, which then due to bronchial hypersensitivity leads
to airway inflammation. Airflow limitation in asthma is recurrent and
caused by a variety of changes in the airway. These include:
Bronchoconstriction, the dominant physiological event leading to
clinical symptoms is airway narrowing and a subsequent interference
with airflow. In acute exacerbations of asthma, bronchial smooth
muscle contraction (bronchoconstriction) occurs quickly to narrow
the airways in response to exposure to a variety of stimuli including
allergens or irritants.
As the disease becomes more persistent and inflammation
more progressive, other factors limit airflow including Hypersecretion
of mucus. This can be observed pathologically as an increase in
intracellular mucins (‘mucous metaplasia’) or an increase in mucus in
the airway lumen. Excessive luminal mucus may become impacted
and lead to airway closure. The other pathological process that
causes it is Inflammatory Cell Infiltration. Histopathological studies in
asthmatic patients have established that asthma is a process
involving both central and peripheral airways. This process includes
cellular changes i.e. infiltration of the airway wall by inflammatory
cells, and structural changes, i.e. thickening of all components of the
airway wall. The result of all of these will be narrow breathing
passages which means making it hard to breathe. It will manifest
signs such as wheezing, coughing, shortness of breath (dyspnea), and
tightness in the chest.
SIGNS
✓ The patient woke up feeling suffocated
✓ Lips turned into blue (cyanotic)
✓ Oxygen saturation: 85%
✓ Respiratory rate: 40 bpm
SYMPTOMS
✓ Chest tightness
✓ Coughing especially at night/morning
✓ Shortness of breath or gasping for air
✓ Wheezing, which causes a whistling sound
✓ Personal history: eczema or allergic rhinitis
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✓ Other nonspecific symptoms in infants or young children
may be a history of recurrent bronchitis, bronchiolitis, or
pneumonia; a persistent cough with colds; and/or recurrent
croup or chest rattling.
DIAGNOSTICS TEST
1. Spirometry - Diagnoses and monitors certain lung
conditions by measuring how much air the patient can
breathe throughout in one forced breath.
2. Peak flow meter - a peak flow meter or, rarely, a small
electronic portable spirometer is a handheld device that
measures how fast a person can blow air out of the lungs.
Asthma causes patients to not be able to blow air out fast
because their airways are narrowed, so a low measurement
with this device suggests problems are occurring with your
child's asthma.
3. Fractional exhaled nitric oxide (FeNO) tests - measure
how much nitric oxide is in the patient’s breath. High levels
of nitric oxide may mean that the airways in your lungs are
inflamed, which can make it hard to breathe.
4. Allergy skin - A test that can tell the doctor which allergens,
such as pet dander, pollen and mold, or dust mites cause a
reaction in your body when you are around these
substances. The doctor may do these tests if they have a
history of allergies.
LABORATORY TEST
1. Blood tests - The doctor may order blood tests to check on
the patient’s immune system. The checking of levels of
white blood cells called eosinophils and an antibody called
immunoglobulin E (IgE.) High levels may be a sign of severe
Asthma
Medical Management
 High-flow oxygen therapy delivered via nasal cannula
(HFNC) has proven safe and beneficial for respiratory
support with sufficient airway humidity. To maintain
sufficient tissue oxygenation, avoid hypoxemia-induced
problems, and sustain respiratory function, it is crucial to
administer supplemental oxygen to keep oxygen saturation
over 90% during asthma exacerbations. Supplemental
oxygen reduces the effort required to breathe during asthma
flare-ups, lowers the chance of respiratory exhaustion, and
improves oxygen delivery to critical organs, thereby lowering
the risk of serious side effects like cardiac arrhythmias,
myocardial ischemia, and respiratory failure. To stabilize
patients, improve their overall oxygen supply-demand
balance, and enable successful bronchodilator therapy, it is
vital to maintain oxygen saturation levels over 95%.
 Albuterol (Short-acting bronchodilators) via nebulization
or metered-dose inhaler (MDI) with spacer is vital for
immediate relief by inducing bronchodilation through beta-2
adrenergic receptor activation, easing airflow obstruction.
Nebulization allows rapid delivery of high doses, crucial in
acute scenarios, while MDIs with spacers provide
convenient outpatient treatment.
 Oral prednisone or intravenous methylprednisolone
(systemic corticosteroids) are essential for reducing airway
inflammation, mitigating mucosal swelling, and inhibiting
inflammatory cell influx, especially in an emergency. This

dual approach addresses both bronchospasm and
inflammation, ensuring symptom alleviation and preventing
relapse, with oral prednisone suitable for outpatient care
and intravenous methylprednisolone for severe cases.
Nursing Diagnosis and Nursing Interventions
1. Ineffective Airway clearance related to increased mucus
production and bronchoconstriction as evidenced by Increased
work of breathing, cough, wheezing, and Poor air entry bilaterally.
Nursing Interventions:
 Instruct the client to expectoration of sputum, and if needed
suction.
 Instruct the parent/guardian to reduce environmental
pollutants that can cause reaction to the client
 Encourage to limit the number of indoor pets that can cause
allergy reactions
 Encourage the client to increase fluid intake
 Instruct the patient to stay away from straining physical
activities
2. Impaired Gas Exchange related to ventilation-perfusion
imbalance as evidenced by oxygen saturation of 85% and
increased respiratory rate.
Nursing Interventions
 Elevate the head of the bed and assist the client in
assuming a position that eases the work breathing of the
client.
 Encourage the patient to do breathing exercises.
 Encourage the patient to increase fluid intake
3. Anxiety related to acute exacerbation of Asthma as evidenced by
feeling suffocated Blue lips and increased respiratory rate.
Nursing Interventions:
 Provide comfort measures;
 Create an open space for the patient. That can relieve their
anxiety
 Encourage the patient to do breathing exercises; pursed-lip
breathing
 Encourage the patient to let the parent/guardian stay with
the client for the patient’s reassurance due to anxiety
Patients Education
Patient education for children aged 0-12 is necessary so that at a
young age they can have early health awareness. Our patient has
encountered a lot of triggers and symptoms. Which this could have
been easily avoided had the 12-year-old girl been fully aware. It is duty
the duty of the nurse to educate the patient about the right thing to do.
This is especially important as even if they are young they can
understand the triggers and recognize symptoms in which they can
follow their schedule of medication, manage their lifestyle, as well as
reduce their anxiety.
With that, they can be empowered to deal with asthma, despite their
age. Which this can lead to improved asthma control, reduced
healthcare costs, and even live a better quality of life.
Here are the things that a nurse should do to educate their patients
with asthma:
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• Educate patient regarding symptoms of asthma through
the Asthma Symptom Guide
• Teach patients to reduce exposure to the different
triggers of asthma so they can narrow down what triggered
their asthma ( from Cold air, Pollen, Molds, Infection,
Medicine, etc.)
• Allow the patient to learn how to use asthma medicines
correctly (Albuterol, Inhaled or Oral Corticosteroids,
Inhalers, Spacers, etc.)
• Teaching them that diet influences their symptoms ( Eat
plenty of fruits and vegetables, Avoid allergy-triggering foods,
Take in vitamin D, etc.)
• Teach parents how to manage asthma
• Teach parents how to make an asthma action plan as
well as an asthma diary
• Other kinds of care that the patient or parents can do (hand
washing, exercise, etc.)
• Always have a follow-up check-up
MEDICAL TERMS USED:
Bronchoconstriction- in relation to asthma, it is the tightening of
muscles in reaction to certain things.
Bronchodilator- a type of drug that causes small airways in the lungs
to open up.
Exacerbation- a worsening. In medicine, exacerbation may refer to an
increase in the severity of a disease or its signs and symptoms.
FeNO testing- a test that measures the levels of nitric oxide in your
breath.
Hypoxemia- is a low level of oxygen in the blood.
Inflammatory Cell Infiltration- the ability of cells to infiltrate
neighboring tissues and cause inflammation.
Oxygen Saturation- is a measure of how much hemoglobin is
currently bound to oxygen compared to how much hemoglobin
remains unbound.
Peak flow meter- a handheld device that measures how well air
moves out of your lungs.
Spirometry- the most common type of pulmonary function or
breathing test.
T-Helper cells- are a type of immune cell. When they sense an
infection, they activate other immune cells to fight it
---------------------------- END ----------------------------
WEEK 2: RHD & KAWASAKI DISEASE
Case Scenario:
Anna is a 10-year-old girl who was brought to the hospital
by her mother with fever, chest pain, and difficulty breathing. She
has a history of sore throat two weeks ago, which was treated with
home remedies. She lives in a rural area with poor sanitation and
limited access to health care.
On arrival, her vital signs were BP 140/90 mmHg, HR 130
bpm, RR 32 bpm, SpO2 88% on room air, Temp 39°C. She looked
pale and tired. She had a loud holosystolic murmur at the apex of
the heart, and crackles in both lung bases. She had mild swelling in
her ankles. She had erythema marginatum, a rash with red edges
and clear centers, on her chest and arms.
 NCM 109 MIDTERM
Her laboratory tests showed elevated levels of CRP, ESR,
WBC, troponin, and CK. Her blood culture was positive for
Streptococcus pyogenes. Her EKG showed sinus tachycardia, left
atrial enlargement, and ST segment elevation in leads V1-V6. Her
chest x-ray showed cardiomegaly and pulmonary congestion. Her
echocardiogram showed severe mitral valve stenosis and
regurgitation, and mild aortic valve regurgitation.

She was diagnosed with rheumatic heart disease, acute

pericarditis, and heart failure. She was given intravenous antibiotics,
anti-inflammatory drugs, diuretics, vasodilators, inotropic drugs,
anticoagulants, antiarrhythmic drugs, and oxygen therapy. She was
scheduled for surgical intervention to repair or replace her
damaged valves, and to relieve her pericardial tamponade.

RHEUMATIC HEART DISEASE

 is a condition in which the heart valves have been

permanently damaged by RHEUMATIC FEVER.
 The heart valve damage may start shortly after untreated
or under-treated streptococcal infection such as strep
throat or scarlet fever.
 An immune response causes an inflammatory condition in
the body which can result in on-going valve damage.
 It also causes inflammation throughout the body, including
in the heart. If untreated, the inflammation can lead to
permanent heart valve damage and serious health
problems.

TYPES
1. Valvular Heart Disease - Valvular heart disease is when
any valve in the heart has damage or is diseased.
2. Pericarditis -Pericarditis is swelling and irritation ofthe thin,
saclike tissue surrounding the heart (pericardium).
Pericarditis often causes sharp chest pain.
3. Endocarditis -Endocarditis is a life-threatening
inflammation of the inner lining of the heart's chambers and
valves. This lining is called the endocardium.
4. Heart Block -Heart block is a condition where the heart
beats more slowly or with an abnormal rhythm. It's caused
by a problem with the electrical pulses that control how
your heart beats.
ASSESSMENT/CAUSES/RISK FACTORS
Assessments findings:
✓ Fever ✓ Erythema
✓ Chest pain ✓ Rash
✓ Loud holosystolic ✓ Positive
✓ murmur ✓ streptococcal
✓ Crackles in both lungs ✓ culture
✓ Mild swelling
Causes:
✓ Difficult
✓ Breathing
✓ Sore throat
✓ Poor Sanitation

15 | P a g e

Risk Factors:
✓ Limited Access to Healthcare
✓ Poor Living Conditions
✓ Age
✓ Delayed Diagnosis and Treatment
PATHOPHYSIOLOGY
SIGNS/SYMPTOMS:
✓ FEVER - Individuals with Rheumatic Heart Disease may be
more susceptible to infections, including recurrent
streptococcal infections, which can lead to fever and Fever
can also arise if Rheumatic Heart Disease leads to
complications such as infective endocarditis, an infection of
the heart valves or inner lining of the heart chambers.
✓ CHEST PAIN - The heart valves can be inflamed and
become scarred overtime. This can result in narrowing or
leaking of the heart valve making it harder for the heart to
function normally additionally the inflammatory processes
associated with rheumatic heart disease may contribute to
chest pain.
✓ SWELLING ANKLES - In rheumatic heart disease, swelling
ankles can occur due to fluid retention, a condition known
as edema. This happens when the heart's ability to pump
blood effectively is compromised, leading to fluid buildup in
the body, particularly in the lower extremities like the ankles.
✓ ERYTHEMA MARGINATUM - Erythema marginatum is a
cutaneous finding associated with acute rheumatic fever.
16 | P a g e
NCM 109 MIDTERM
The lesions typically develop 7 days to months after the
onset of the streptococcal pharyngitis or, rarely,
streptococcal skin infections.
✓ HOLOSYSTOLIC LOUD MURMUR - A heart valve that
doesn't close correctly can cause a holosystolic murmur. If
a valve doesn't close completely, blood can slide backward
to the place where it just left. This "leaky valve"
✓ FATIGUE - This caused by the reduced cardiac output can
result in fatigue and weakness due to inadequate delivery of
oxygen and nutrients to the body’s tissue and organ. Also
having Rheumatic Heart Disease can also take a toll on
mental and emotional well-being, leading to feelings of
fatigue and lethargy.
✓ SHORTNESS OF BREATH - Rheumatic heart disease often
leads to damage and scarring of the heart valves,
particularly the mitral and aortic valves. As the disease
progresses, these damaged valves may become stenotic
(narrowed) or in sufficient (leaky), impairing the heart’s
ability to efficiently pump blood. This can result in fluid
buildup in the lungs, leading to shortness of breath,
especially during physical exertion or when lying
flat(orthopnea).
DIAGNOSTICS/ LABORATORY TESTS
 Physical Examination
 Blood Test: blood culture was positive for Streptococcus
pyogenes.
 Electrocardiogram findings: sinus tachycardia, left atrial
enlargement, ST segment elevation in leads V1-V6.
 Chest x-ray: cardiomegaly, pulmonary congestion.
 Echocardiogram: severe mitral valve stenosis and
regurgitation, mild aortic valve regurgitation.
MEDICAL/SURGICAL MANAGEMENT
Medical
→ Healthcare provider may prescribe these medications:
• Intravenous Antibiotic
• Antiarrhythmic drugs
• Diuretics
• Anti-inflammatory
• medicine
• Anticoagulants
• Vasodilators
• Inotropic drugs
• Oxygen therapy
Surgical
→ Mitral Valve repair- in severe cases of RHD, surgery is done
to replace or repair a badly damaged valve, in this case—the
mitral valve.
PATIENT EDUCATION
• It is recommended to be on bed rest for 2 to 12 weeks,
based on how serious the patient’s illness is.
• After treatment, the patient may still need to take medicine
(prophylactic antibiotics) to make sure the infection does
not come back.
• They need to keep their teeth and gums clean. They should
also have regular dental exams with preventive antibiotics.
• The patient will need to have regular exams to check on
their heart. They may also have repeat diagnostic tests of
the heart.
• Some patients need surgery to fix orreplace damaged heart
valves.

Nursing Diagnosis and Nursing Interventions
1. Hyperthermia related to bacterial infection as evidenced by
temperature of 39.9 degree celsius
Nursing Intervention:
• Monitor vital signs (BP, RR, CR)
• Monitor and record all sources of fluid loss
• Observe the child for signs of discomfort, such as
restlessness or irritability, and assess the level of pain
associated with the fever.
• Promote cool environment
• Perform tepid sponge bath
• Maintain bedrest
• Encourage fluid intake
• Provide high-calorie diet
• Administer medication as indicated
• Provide client safety
2. Decrease cardiac output related to mitral valve stenosis.
Nursing Intervention:
• Monitor vital signs frequently
• Keep client on bed or chair rest in a position of comfort
• Assess and monitor for client reports of chest pain.
• Review signs of impending failure/shock changes in heart
sounds.
• Provide a quiet environment
• Administer medication as indicated
3. Impaired gas exchange related to pulmonary congestion
and decrease saturation
Nursing Intervention:
• Elevate the head of the bed and position the client
appropriately.
• Monitor the respiratory rate and oxygen saturation
• Encourage deep breathing and coughing exercises
• Monitor adequate fluid intake
• Encourage adequate rest and limit activities
• Administer medication as indicated.
---------------------------- END ----------------------------
Case Scenario:
A 3-year-old boy named Alex is brought to the pediatric
clinic by his concerned parents. They noticed that Alex had a high
fever persisting for the past five days, accompanied by a rash on his
trunk and swollen lymph nodes in his neck. Alex is also irritable and
complaining of a sore throat.
Upon further examination, the pediatrician observes that
Alex has redness in both of his eyes, known as bilateral
conjunctivitis. His lips appear red and cracked, and his tongue has a
"strawberry-like" appearance with prominent red bumps.
Based on Alex's symptoms and physical examination
findings, the pediatrician suspects Kawasaki disease and orders
additional tests, including blood work and an echocardiogram to
assess heart function.
KAWASAKI DISEASE
 is an illness that causes inflammation (swelling and
redness) in blood vessels throughout the body.
17 | P a g e
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 It happens in three phases, and a lasting fever usually is the
first sign. The condition most often affects kids younger than
5 years old.
TYPES OF KAWASAKI DISEASE:
1. Complete or Classic Kawasaki Disease (KD)
→ It refers to the full spectrum of the disease
characterized by a specific set of clinical criteria. To be
diagnosed with complete KD, a patient must exhibit a
fever lasting at least 5 days along with four or five
classic clinical signs.
2. Incomplete Kawasaki Disease (KD)
→ It refers to a variant of the condition where patients
present with some, but not all, of the classic clinical
signs required for a definitive diagnosis of complete KD.
→ The diagnosis of incomplete KD is challenging as
patients exhibit a fever lasting at least 5 days but have
fewer than four classic KD clinical signs.
ASSESSMENT/CAUSES/RISK FACTORS
CAUSES: Unknown
RISK FACTOR: Kawasaki disease mostly affects children younger
than 5. Boys are slightly more likely than girls to develop Kawasaki
disease. Ethnicity, Kawasaki disease is more common in people of
Asian or Pacific Island descent
ASSESSMENT: Classic (typical) Kawasaki disease is diagnosed
based on the presence of fever lasting five or more days,
accompanied by four out of five findings: bilateral conjunctival, oral
changes such as cracked and erythematous lips and strawberry
tongue, cervical lymphadenopathy, extremity changes such as
erythema or palm and sole desquamation and polymorphous rash.
PATHOPHYSIOLOGY
SIGNS/SYMPTOMS:
✓ Fever: persistent high fever lasting more than 5 days is a key
symptom.
✓ Rash: a red rash may appear, often on the trunk and genital
area.
✓ Swollen hands and feet: swelling and redness in the hands
and feet, sometimes with peeling skin.
✓ Red Eyes: conjunctivitis (red eyes) without discharge is
common.
✓ Swollen lymph nodes: enlarged lymph nodes, especially in
the neck area.
✓ irritated mouth and lips: red, swollen, and sometimes
cracked lips; a "strawberry tongue" appearance.
✓ Joint Pain: joint pain and inflammation, often affecting the
larger joints
 NCM 109 MIDTERM
BASED ON SCENARIO 3. Risk for Impaired Tissue Integrity related to Kawasaki disease as
✓ High Fever: persisting for more than five days. evidenced by the presence of a rash on the trunk, redness and
✓ Rash: present on the trunk. cracking of the lips, and the "strawberry-like" appearance of the
✓ Swollen lymph nodes: in the neck. tongue with prominent red bumps. (Domain 11: Safety/
✓ Bilateral Conjunctivitis: redness in both eyes. Protection)
✓ Irritability: alex's behavior is indicative of discomfort. Monitor Intake and Output. Closely monitor intake and output, and
✓ Sore Throat: complaints of a sore throat. monitor hydration status by checking skin turgor, weight, urinary
✓ Red And Cracked Lips: observable on examination. output, specific gravity, and presence of tears.
✓ "Strawberry-Like" Tongue: tongue with a prominent red,
bumpy appearance.
PATIENT EDUCATION
DIAGNOSTICS/ LABORATORY TESTS • Explain to the parents the need for additional test, such as
Diagnostic Test Echocardiogram.
 Echocardiogram Explain to report if fever or rash comes back.
• Do not give the child any other medicines without
Laboratory Test
• checking with the doctor.
 CBC • If aspirin causes an upset stomach, give it withcrackers,
 Urinalysis bread, or another bland food.
 Liver Function Test
• Treat dry lips with Vaseline and dry skin with unscented
 Electrolyte Panel
lotions or creams.
 C-Reactive Protein (CRP) and Erythrocyte Sedimentation
• Encourage adequate intake of fluid, limit sugary foods, limit
Rate (ESR)
intake of Sodium.
MEDICAL/SURGICAL MANAGEMENT • Keep the child from rough play, especially if he or she is
The medical management of Kawasaki disease typically involves: taking aspirin.
• Have the child rest when he or she is tired.
1. Intravenous immunoglobulin (IVIG) therapy to reduce
• Administer medication as indicated.
inflammation and prevent coronary artery
complications.
2. High-dose aspirin therapy to reduce fever and
inflammation, although its use may vary depending on
the stage of the disease and the presence of coronary
artery abnormalities.
3. Close monitoring of cardiac function with
echocardiograms to detect any coronary artery
abnormalities.
4. Symptomatic treatment for fever, sore throat, and
other symptoms.
5. Follow-up care to monitor recovery and assess any
long-term effects on cardiac health.
Treatment may vary depending on the severity of the disease and
individual patient factors, so it's important for Alex's pediatrician to
closely monitor his condition and adjust treatment as needed.

Nursing Diagnosis and Nursing Interventions

1. Acute Pain related to sore throat and irritable behavior secondary
to Kawasaki disease as evidenced by the child's complaints of a
sore throat, irritability, and presence of redness and swelling in
the throat area. (Domain 12: Comfort)
Provide Oral Care. Offer cool liquids (ice chips and ice pops); progress
to soft, bland foods; and give mouth care every 1 to 4 hours with
special mouth swabs; use soft toothbrush only after healing has
occurred.
2. Risk for Infection related to compromised immune system
secondary to Kawasaki disease as evidenced by the child's
persistent fever, swollen lymph nodes, and presence of redness
and swelling in the eyes, lips, and tongue. (Domain 11: Safety/
Protection)
Cardiac monitoring and assessment. Take vital signs as directed by
conditions; assess for signs of mycocarditis (tachycardia, gallop
rhythm, chest pain); and monitor for heart failure.

---------------------------- END ----------------------------

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WEEK 3: TYPE 1 DM & SLE
Case Scenario:
Lalisa, a 12-yrs.-old girl, was admitted to the emergency room. She
appeared tired, and slightly dehydrated. Her mother complains that
her child has been experiencing excessive thirst, frequent urination,
and unintentional weight loss for about 5kg in the past 2 weeks.
The following data were obtained:
VITAL SIGNS: Temperature = 37.5C, Pulse = 100 bpm, RR= 20 bpm,
BP = 120/80mmhg, Height = 150cm (4'11), Weight = 45kgs(99 lbs)
NCM 109 MIDTERM
level of 99 mg/dL or lower is normal, 100 to 125 mg/dL
indicates prediabetes, and 126 mg/dL or higher indicates
diabetes.
o Microalbuminuria test - a urine test that measures the
amount of albumin in your urine.
o Albumin - a protein that your body uses for cell growth and
to help repair tissues.
o Lipid profile blood test - measures The total amount of
cholesterol in your blood (total cholesterol) the level of
HDL-cholesterol (high-density cholesterol, often called
'good cholesterol') the level of LDL-cholesterol (low-density
cholesterol, often called 'bad' cholesterol).

LABORATORY/DIAGNOSTIC TEST RESULTS: ASSESSMENT/CAUSES/RISK FACTORS

Blood Glucose Level = 350mg/dl ASSESSMENT
Hemoglobin A1c = 9.5% SUBJECTIVE: Drinking excessive amounts of fluids, weight
Lost about 5 kg(11 lbs) over the past few weeks, Frequent
Urinalysis = Positive for Ketones
Urination day and night.
OBJECTIVE:
DIAGNOSIS: Type 1 Diabetes Mellitus, based on clinical presentation, o Height: 150cm (4’11")
hyperglycemia, and positive ketones o Weight: 45 kg (99 lbs)
o Hemoglobin A1c level 9.5%
o Blood Glucose: 350 mg /dl (HYPERGLYCEMIA)
Diabetes mellitus (DM) - is a chronic metabolic disorder caused by o Urinalysis: Positive for KETONES
an absolute or relative deficiency of insulin, an anabolic hormone. o VITAL SIGN: Temperature: 37.5 °C
Pulse: 100 bpm
TYPE 1 DIABETES MELLITUS RR: 20 bpm
Bp: 120/ 80 mmHg
 (also known as insulin-dependent diabetes mellitus (IDDM) CAUSES
and juvenile diabetes mellitus) is a chronic illness
Type 1 diabetes is caused by the immune system mistakenly
characterized by the body’s inability to produce insulin due
destroying pancreatic insulin-producing cells, resulting in a shortage
to the autoimmune destruction of the beta cells in the
of insulin. The actual reason is unknown, however it is thought that
pancreas.
there is a substantial hereditary component. Risks vary according to
family history, with both parents being at a higher risk. Viruses and
DEFINITION: environmental pollutants can both cause immune system assaults.
o Insulin is produced by the beta cells of the islets of
Langerhans located in the pancreas, and the absence,
RISK FACTOR
destruction, or other loss of these cells results in type 1
diabetes (insulin-dependent diabetes mellitus [IDDM]). • Family History
o Hyperglycemia is the technical term for high blood glucose • Geography
(blood sugar). High blood glucose happens when the body • Age
has too little insulin or when the body can't use insulin • Genetics
properly.
o Ketosis is a metabolic state that occurs when your body
PATHOPHYSIOLOGY
burns fat for energy instead of glucose called ketones,
which it can use for fuel.
o Hemoglobin is the protein contained in red blood cells
responsible for delivering oxygen to the tissues.
o Hemoglobin A1C or HbA1c test—is a simple blood test
that measures your average blood sugar levels over the past
3 months. Normal range: 4.2-5.6%
o Fingerstick glucose test - a “finger stick check” where one
pricks their fingertip with a small needle called a lancet to
produce a blood drop, then places the drop against the test
strip in the glucose meter, and the meter shows the blood
sugar level within seconds.
o Urine Dipstick Test - a thin, plastic stick with strips of
chemicals on it placed into the urine (pee) sample. Then, its
chemical patches will change color if the sample contains
SIGNS/SYMPTOMS:
things like white blood cells, protein, or glucose.
o Fasting Blood Sugar Test - This measures your blood sugar ✓ tired/fatigue
after an overnight fast (not eating). A fasting blood sugar ✓ slightly dehydrated

19 | P a g e

✓ excessive thirst
✓ frequent urination
✓ unintentional weight loss for about 5kg in the past 2 weeks.
✓ hyperglycemia
✓ positive ketones
DIAGNOSTICS/ LABORATORY TESTS
 Fasting blood sugar test
 Urine dipstick test
 Fingerstick glucose test
 Hemoglobin A1C
 Lipid profile
 Microalbuminuria
MEDICAL/SURGICAL MANAGEMENT
• Insulin Aspart. Rapid-acting insulin; insulin aspart is
approved by the FDA for use in children aged >2 y with type
1 DM for SC daily injections and for SC continuous infusion
by external insulin pump; onset of action is 10-30 minutes,
peak activity is 1-2 h, and duration of action is 3-6 h.
• Insulin glulisine. Rapid-acting insulin; (aged 4-17 y) with
type 1 DM; onset of action is 20-30 minutes, peak activity is
1 h, and duration of action is 5 h.
• Insulin glulisine. Rapid-acting insulin; only lispro U-100 is
approved by the FDA to improve glycemic control in children
aged >3 y with type 1 DM; onset of action is 10-30 minutes,
peak activity is 1-2 h, and duration of action is 2-4 h.
• Insulin degludec. Ultra-long-acting insulin; insulin
degludec is approved by the FDA to improve glycemic
control in pediatric patients aged >1 y with type 1 or type 2
DM; it usually takes 3-4 days for insulin degludec to reach
steady state, peak plasma time is 9 h and the durations of
action is at least 42 h.
• Regular insulin. Short-acting insulin. Novolin R has been
approved by the FDA to improve glycemic control in
pediatric patients aged 2-18 y with type 1 DM; Humulin R is
indicated to improve glycemic control in pediatric patients
with diabetes mellitus requiring more than 200 units of
insulin per day.
• Insulin NPH. Intermediate-acting insulin; it is indicated to
improve glycemic control in pediatric patients with type 1
diabetes mellitus; onset of action is 3-4 h, peak effect is in
8-14 h, and usual duration of action is 16-24 h.
• Insulin glargine. Long-acting insulin; the safety and
effectiveness of glargine U-100 have been established in
pediatric patients (6-15 y) with type 1 DM.
• Insulin detemir. Long-acting insulin. Insulin detemir is
indicated for once- or twice-daily SC administration for the
treatment of pediatric patients (aged 6-17 years) with type 1
DM; onset of action is 3-4 h, peak activity is 6-8 h, and
duration of action ranges from 5.7 h (low dose) to 23.2 h
(high dose).
Nursing Diagnosis and Nursing Interventions
1. Risk for infection related to elevated glucose levels.
• Instruct on the use of glucometers or other equipment.
• Encourage the patient to maintain a blood glucose log.
• Monitor for any signs of hypoglycemia.
• Strict infection control protocols must be followed, which
involves regular hand hygiene, using sterile dressing
changes, and taking prescribed antibiotics in a timely
manner. By adhering to these measures, nurses can prevent
and manage infections effectively.
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NCM 109 MIDTERM
2. Imbalanced nutrition: less than body requirements related to
insufficient caloric intake to meet growth and development
needs and the inability of the body to use nutrients.
• Collaborate with a dietitian to create a personalized meal
plan that meets the patient’s nutritional requirements and
includes nutrient-dense foods.
• Educate them on portion control, meal timing, and healthy
food choices.
• Regular monitoring of nutritional status and weight, and
addressing any adherence barriers.
3. Deficient knowledge related to appropriate exercise and activity.
• Identify the learner: the client, family, significant other, or
caregiver.
• Assess the client’s emotional readiness.
• Assess the client’s physical readiness for learning.
• Assess the ability to learn or perform desired health-related
care.
• Evaluate the comprehension of the patient regarding
physical activity and detect any deficiencies in knowledge.
Customized learning sessions can be arranged to enlighten
the patient on the advantages of exercise, suitable forms
and levels of physical activities.
PATIENT EDUCATION
• Assess the parent’s and child’s understanding of disease
and ability to perform procedures and care, for educational
level and learning capacity, and for developmental level.
• Provide a quiet, comfortable environment; allow time for
teaching small amounts at a time and for reinforcement,
demonstrations, and return demonstration; start educating
one day following diagnosis and limit sessions to 30 to 60
minutes.
• Include as many family members in teaching sessions as
possible.
• Teach about the cause of disease, disease process, and
pathology; use pamphlets and other aids appropriate for the
age of the child and the level of comprehension of parents.
• Healthy eating habits consisting of nutrient-rich and high-
quality foods are recommended
---------------------------- END ----------------------------
Case Scenario:
Princess, age 12, has been diagnosed with Systemic Lupus
Erythematosus. She has a family history of SLE and the signs and
symptoms manifested after she got a sunburn. It included facial rash,
join pains, chest pains, and sensitivity to sunlight. She also has protein
in her urine indicating a kidney abnormality. Her ANA test also came
back positive which indicates SLE.
SYSTEMATIC LUPUS ERYTHEMATOSUS
 is an autoimmune illness. The most common type of lupus
is SLE.
Normally, the body's immune system defends itself by producing
antibodies to fend off various threats. These may consist of bacteria,
viruses, and other foreign microorganisms. An abnormal immune
system produces antibodies that target healthy tissue in lupus.
Inflammation and pain result from this. The skin, joints, kidneys, brain,
and other organs can all be impacted by lupus.

TYPES OF SYSTEMIC LUPUS ERYTHEMATOSUS:
1. Systemic lupus erythematosus (SLE)
➢ is the most common kind of lupus. If SLE manifests in
childhood. It is referred to as childhood-onset SLE, or cSLE
➢ 10-20 percent of SLE cases start in childhood.
➢ Most adult SLE cases start between the ages of 15 and
44.cerat. Cras suscipit est at mauris.
2. Cutaneous lupus erythematosus (CLE)
➢ is the term for lupus that solely affects the skin, which is
less prevalent.
➢ Three categories of CLE exist:
o Discoid – also known as Chronic cutaneous lupus
erythematosus
o Subacute - is a nonscarring, non–atrophy- producing,
photosensitive dermatosis.
o Acute - is the most common form of cutaneous lesions
of lupus
THE TWO RAREST FORMS OF LUPUS ARE
• Drug-Induced Lupus
➢ is an autoimmune condition in which exposure to drugs
causes the development of manifestations similar to
systemic lupus erythematosus (SLE).
➢ is an example of an environmental trigger that causes lupus
to develop in a genetically susceptible person.
• Neonatal Lupus
➢ is an autoimmune condition that causes prenatal and
neonatal illness by the passive transmission of
autoantibodies from the mother to the fetus.
➢ The two main symptoms are cutaneous and cardiac
abnormalities.
ASSESSMENT
Signs/Symptoms:
✓ facial rash
✓ joint pain
✓ chest pain
✓ sensitivity to sunlight
21 | P a g e
NCM 109 MIDTERM
CAUSES
• The causes of SLE are unknown, but are believed to be
linked to environmental, genetic, and hormonal factors.
• SLE, often known as systemic lupus erythematosus, is an
autoimmune disease.
→ The immune system malfunctions in autoimmune
illnesses like lupus and others. It generates
autoantibodies that mistakenly attack the body's own
healthy tissues and cells.
→ These autoantibodies can cause organ harm by
inducing inflammation. In addition to sex hormones, a
variety of environmental factors such as nutrition,
stress, exposure to toxins, sunshine, and virus
infections can also cause this complex condition.
CAN SLE BE HEREDITARY?
SLE tends to run in families even if the exact mode of inheritance is
mostly unclear. The majority of people do not inherit SLE but may
inherit a gene mutation that either increases or decreases the
disorder's risk. Not every SLE patient has a gene mutation that
increases their likelihood of developing the disease, and not every
person who carries such a variant will exhibit symptoms.
RISK FACTOR
In genetically susceptible people, there are various external factors
that can trigger symptoms. These are the common risk factors that
princess acquired or may acquire:
- Sunlight (UVB) is considered a definite SLE trigger.
- Colds and other infections
- Fatigue
- Stress
- Smoking (possibly secondhand smoke)
- Viruses (i.e. Epstein-Barr virus (EBV))
- Chemicals (i.e. crystalline silica) and some prescription
medicines (hydralazine, methyldopa, penicillamine,
minocycline, and others)
Other Risk Factors:
Gender
Women make up around 90% of lupus patients, and the majority are
diagnosed in their 20s and 30s, when they are most fertile. Before
becoming 18 and after turning 50, men are more likely to have lupus.
Race and Ethnicity
Compared to white women, African American women are three to
four times more likely to have SLE. In addition, compared to whites,
African Americans and Hispanics have higher illness severity. Women
who identify as Asian or Native American are also more vulnerable to
the illness.
Age
Most people develop SLE between the ages of 15 to 44. About 15% of
patients experience the onset of symptoms before age 18.
PATHOPHYSIOLOGY
SLE is an extremely unpredictable disease since it is
marked by extended periods of subclinical activity mixed with periods
of remission and exacerbation(flares). Nearly every organ in the body
may be impacted, especially during a flare-up. The primary organs
affected in milder forms of the disease are the joints and skin. More
organs are harmed in the moderate versions, but the severe form—

which affects the heart and kidneys—is what makes this disease so
deadly. Since renal involvement affects between 30% and 50% of
these patients and is typically detected in the early stages of the
illness, organ damage must be prevented as this condition is clinically
silent.
SLE is usually caused by the disturbance or malfunction of
the immune system. Numerous immune system abnormalities,
including those involving B cells, T cells, and monocytic lineage cells,
are associated with SLE. These abnormalities lead to the activation of
polyclonal B cells, an increase in the number of cells that produce
antibodies, hypergammaglobulinemia, the creation of autoantibodies,
and the formation of immunological complexes. It seems that a final
common pathway is likely to involve excessive and unchecked T cell
assistance in the differentiation and activation of autoantibody-
forming B cells.
Systemic autoimmune illness may be brought on by or
made worse by a number of circumstances, and polyclonal B-cell
activation may also bring on autoimmune disease on its own.
Polyclonal gammopathy, also known as hypergammaglobulinemia, is
the term used to describe the overproduction of multiple
immunoglobulin classes by plasma cells and is commonly associated
with autoimmune disorders and malignancies.
SIGNS/SYMPTOMS:
Common
- Fatigue, Skin rashes, Fever, and pain or Swelling in the joints.
Other Signs and Symptoms Manifested by patient:
- Chest pain, Protein in urine, Sensitivity to sunlight.
SIGNS:
• Skin rashes - In cutaneous lupus, the immune system
targets skin cells, causing inflammation that leads to red,
thick, and often scaly rashes and sores that may burn or itch.
• Protein in Urine - Lupus nephritis occurs when lupus
autoantibodies affect parts of the kidneys that filter out
waste.
• Fever - fever in SLE is due to activation of the monocyte-
macrophage system in the body, which releases a large
number of leukocyte pyrogens and produces prostaglandin
E2, eventually causing dysfunction of the body temperature
regulation center.
22 | P a g e
NCM 109 MIDTERM
SYMPTOMS:
• Fatigue - Any time the body is experiencing excess
inflammation, such as during a lupus flare, the body will feel
more tired.
• Pain or Swelling in the joints - patient body's immune
system attacks your own tissues as though they were
foreign. This can lead to pain, swelling, and damage to
organs such as the kidneys.
• Chest pain - Lupus can trigger inflammation in the lining of
the lungs. This causes chest pain when breathing deeply.
• Sensitivity to sunlight - A patient with lupus may also have
skin cells that are more sensitive to sun-induced damage.
Their body may not be able to clear the dead skin cells away
effectively
DIAGNOSTICS/ LABORATORY TESTS
1. BLOOD TEST
Antinuclear Antibody Tests
- The presence of antibodies that target the body's cells is an
indicator for systemic lupus erythematosus and is
measured by this test. Almost everyone that has active
lupus have ANA.
- -It's crucial to understand that a positive ANA doesn't
always indicate lupus because healthy individuals might
also have positive results. An ANA test result that is positive
could point to other autoimmune diseases.
Anti-Double-Stranded DNA Antibody Tests
- Lupus patients frequently carry an antibody in their blood
called anti-double-stranded DNA, or anti-dsDNA.
- The material that comprises the body's genetic code,
double-stranded DNA, is the target of this antibody. Anti-
dsDNA autoantibodies may increase with increased lupus
activity, suggesting a higher risk of lupus nephritis and
subsequent kidney failure.
2. URINE TEST/URINALYSIS
- An examination of a sample of your urine may show
an increased protein level or red blood cells in the
urine, which may occur if lupus has affected your
kidneys.
MEDICAL/SURGICAL MANAGEMENT
Corticosteroids - (prednisone) to manage inflammation.
Hydroxychloroquine- an anti-malaria drug used to manage
symptoms and prevent disease flares.
Immunosuppressants such as azathioprine,
mycophenolate mofetil, methotrexate and
cyclophosphamide.
Pain relievers such as ibuprofen or naproxen
Calcium and Vitamin D supplements to prevent
osteoporosis which is a possible side effect of long-term
use of corticosteroids.
 NCM 109 MIDTERM

Nursing Diagnosis and Nursing Interventions

1. Impaired skin integrity related to sunlight exposure.
- Encourage adequate nutrition and hydration
- Instruct the client and parent to clean, dry, and moisturize
intact skin; use warm water, especially over bony
prominences; use unscented lotion; use mild shampoo
- Instruct the client and guardian to avoid contact with harsh
chemicals and to wear appropriate protective gloves as
needed. Avoid hair dye, permanent solution, and curl
relaxers.
- Recommend prophylactic pressure relieving devices (e.g.
mattress, elbow pads)
2. Acute chest pain related to inflammation of the linings of the
lungs (Pleurisy).
- Administer medication as ordered by the physician.
- Encourage breathing exercises to open airways, reduce pain
and relieve anxiety.
- Encourage the use of incentive spirometers if necessary as
it may be beneficial.
3. Acute pain related to inflammation of the linings of the joints
(Arthritis).
- Encourage the use of ambulation aids when pain is related
to weight bearing
- Encourage the client to assume and anatomically position
with all joints, suggest that the client uses a small flat pillow
under the head and not use a knee patch or pillow to prop
the knee
- Remind the client and parent to avoid prolonged periods of
inactivity
- Encourage the client to perform ROM exercises after the
shower or bath, two repetitions per joint.

PATIENT EDUCATION
 Understanding SLE: Explain SLE simply as the body
attacking itself, not catching it from others.
 Triggers: Talk about how sun and stress make symptoms
worse and teach sun protection.
 Symptom Management: Educate on managing pain with
rest, exercise, and medication as prescribed.
 Skin Care: Share tips for managing rashes and sun
protection for skin.
 Kidney Health: Discuss protein in urine, regular check-ups,
and following doctor's advice.
 Medication Adherence: Stress taking meds as prescribed,
mentioning side effects and communication.
 Emotional Support: Offer resources for feelings and
encourage family communication.
 School and Activities: Discuss balancing school, activities,
and self- care.
 Family Support: Include family in learning and supporting
her.
 Emergency Plan: Create a plan for flare-ups, knowing when
to seek help.
 Maintain a balanced and Healthy Diet
 Avoid exposure to secondhand tobacco smoke.
 Engage in regular light to moderate exercise to help joints
flexible.

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