ACUTE RESPIRATORY FAILURE

SECONDARY TO COMMUNITY ACQUIRED PNEUMONIA

Presented by: BSN 4A group 1 Anas, Ann Pauline de Vera, Gazzel Del Rosario, Pamela Janine Fuentes, Mary Dominica Guballa, Guianne Mishael Imperio, Aryanne Fay Jacinto, Kendrick Ferr Jahiron, Nashraifar Jalos, Marian

Objective of the study To be able to describe and explain ARF, together with the risk factors contributing to the occurrence of the condition. Review the anatomy and physiology of the organ involved Correlate the results in the laboratory and diagnostic procedure done with the patient. Enumerate the different medication for the patients disease condition, their indications and specific nursing responsibilities before, during, and after medications administration. To be able to perform accurate assessment and identify the priority needs and health problems in order to make considerably related nursing care plans based on the patients course during the treatment.

Introduction The lungs are elastic structures enclosed in the thoracic cage, which is an air tight container with distensible walls. Ventilation requires movement of the walls of the thoracic cage and the diaphragm. The effect of these movements is alternately to increase and decrease the capacity of the chest. Inspiration occurs during the first third of the respiratory cycle, expiration during the later 2/3. The inspiration normally requires energy; the expiratory phase is normally passive, requiring very little energy. Acute respiratory failure is a sudden and life threatening deterioration of the gas exchange function of the lungs to provide adequate oxygenation, or ventilation for the blood. Risk factors include pulmonary dysfunction such as COPD , pneumonia, and asthma.

Incidence of Acute Respiratory Failure In the Philippines, eight out of the ten leading causes of morbidity or illness can be attributed to infectious diseases. Illnesses related to the respiratory system such as acute respiratory infection, pneumonia and bronchitis. These in turn affects 1,203 Filipinos out of 100,000 population enduring Acute Respiratory Failure per day.

Biographical data Name: Mr. EC Age: 84 yrs/old Height: 58 Civil Status: Married Nationality: Filipino Religion: Catholic Weight: 60 kgs. Gender: Male

Date of birth: Nov. 20, 1929 Address: Quezon City Insurance coverage: Philhealth member

Date of admission: September 16,2013

Admitting physician: Dr. XY

Reason for seeking Health Care/chief complain/s:

Difficulty of breathing History of present illness: Mr. CE is a 84 y/o retired veteran from Quezon City who was admitted at VMMC last September 16,2013 due to difficulty of breathing. It all started two weeks prior to admission when the patients family observed him having a progressive coughing events, the patients family advised him to sought consult but the patient stated he was ok. As days passed, the coughing events continued to progress which was later accompanied by other signs and symptoms such as fever and difficulty of breathing, which made them rush the patient to the emergency department of VMMC for consult.

Perception of Health Status:

As stated by his daughter, they considered their father not a healthy person due to his condition and subsequent confinement to the Pulmonary ICU., yet she is expecting that his father will recover from his condition with the help of health care providers attending to his needs. Previous Illness/Hospitalizations/Surgeries:
Diabetes Mellitus and Hypertension diagnosed last 2003 Cataract surgery OU last 2007 at VMMC

Allergies:
Patient has no known allergies to food and medication.

Family medical history:

Disease

Mother

Father

Diabetes mellitus
Hypertension

(+)
(-)

(-)
(+)

Bronchial asthma
Heart disease

(-)
(-)

(-)
(-)

Chronic lung disease

(-)

(-)

Home medications/Alternative medicines:

Home medications of patient are glipizide 5mg/tab for his diabetes, which he takes once a day in the morning, another medication is Lozartan 50 mg, for the patients hypertension, which he takes once a day as well. Patients family states that they have not seen the patient drinking herbal medicine or any other drug aside from those that are prescribed.

Developmental Stage and Psychosocial Developmental Task: Late Adulthood (65 years up to death) Integrity VS. Despair
It is during this time that people contemplate their accomplishments and are able to develop integrity if they see themselves as leading a successful life. If they see their lives as unproductive, feel guilt about their pasts, or feel that they did not accomplish their life goals, they become dissatisfied with life and develop despair, often leading to depression and hopelessness. Our patient, Mr. CE is a 84 y/o senior citizen of Quezon City. Her daughter recalled her father slowing down on his productivity when he reached 60, and it was then when he explored life as a retired person after many years of hard work serving the military.

Patients daughter warmly tells his fathers stories and looked back on his fathers life including both of his fathers successes and losses, as her father was able to send her to school and managed to made her finish a professional course of business administration. She as well stated that his father demonstrates acceptance of failures in life, when patient s daughter verbalized having the first born son of his father died. She as well tell stories about his fathers aging, in which she said his father never had a dull time due to being active to their community and church groups .Patients daughter expresses that his father during his well times demonstrate feelings of contentment and integrity as he believe that even though his life is not perfect, he had led a happy, productive life not just for himself but also for his family.

Psychosexual Stage: Genital Stage (puberty up to death)

The final stage of psychosexual development focuses through the lessons learned during the previous stages, with the genitals as the primary focus of pleasure. Patient was able to have a lifetime partner, get married and have 1 alive child. Patients daughter recalled that his father exhibits realization of the psychosexual stage through maturity, and enhancement of life through his group affiliations, engaging in various activities, and by sustaining a happy aging life, as psychosexual development doesnt just speak about creating new life (reproduction) but also about intellectual and artistic creativity. The patients daughter expressed as well that his father was able to learn how to add something constructive to life and society by assuming the responsibilities of the late adult not just within his family but as well in the community where his father lives in by being active to their community and church groups. Where in earlier stages, the focus was solely on individual needs, individual maturity is one of the focus during this stage. The patients daughter as well expressed that his father was able to show interest in the welfare of others through participating in various charitable works and managed to become well-balanced, warm and caring and establish a balance between the various life areas.

Cognitive Stage: Formal Operational Stage The formal operational stage begins at approximately age twelve to and lasts into adulthood. Deductive reasoning, and systematic planning also emerge at this stage. During interview, the patients daughter recalled that even though at old age, his father was able to think about abstract concepts and demonstrates logical thought , and as well as application of advanced reasoning and logical processes to social and ideological matters. Another cognition demonstrated by patient according to his daughter is that his fathers thinking tends to become multidimensional, rather than limited to a single issue as his father see things through more complicated lenses due to its different life experiences as a military man, husband, father, and member of the community. Spiritual Stage: "Conjunctive" faith A person in this stage acknowledges paradox and transcendence, relating reality behind the symbols of inherited systems or spiritual belief. Patients daughter stated that his father lives his life realizing that there is a lot of truth to be found and that life was full of mystery. She stated that her father sees life as a mystery and often returns to sacred stories and gospels by attending mass and in serving their church. She as well verbalizes importance of God and talking to God as being one of his fathers source of strength and guidance.

Environmental history:
Patient currently lives in Quezon City, along the main road of the said city, in the same place where he was born and raised by his parents. His daughter stated that they stays in a house with 2 bedrooms, which are occupied by his mother and father and the other one was occupied by her and her husband and kids. The house was originally from her grandparents which his father inherited when his parents died.

Ancestors of the patient and both her deceased parents were all from Quezon City. The patients daughter states that even his father is in the late adulthood, patients daughter states that his father follows no ethnic belief with regards to treating his illness. Patients daughter as well denies his fathers use of herbal medicines or other alternatives aside from the maintenance medications prescribed by her physician.

Psychosocial History:
The patients daughter stated that his father started smoking when he was 20 years old and in recent 4 decades, smokes approximately 1 pack per day and drinks alcohol (beer) occasionally, consuming 2-3 bottles per session, 1-2 times a month. She also stated no knowledge of his father using prohibited drugs.

Gordons Pattern of Functioning

Before Hospitalization

During Hospitalization Analysis

Health Perception/ health management

Significant others stated that Patients prescribed Having an illness creates patient home medications are medications are physical and emotional Glipizide for his diabetes, and Piperacillin tazobactam, distress to client because Lozartan for his hypertension. Lozartan, and they considered the Patients family declares non- Glipizide. disease on entity which is observance of patient drinking socially herbal medicine or drug aside unacceptable.(Medical from those that are prescribed Surgical, Brunner p.1265) His daughter stated that he only seeks medical attention when the condition worsens.

His daughter stated that patient Patients prescribed diet eats 3 times a day. He is fond of is Low Salt Low Fat Nutritional/M eating salty foods like tuyo, tinapa (LSLF). He has NGT, his etabolic and fish sauce with tomatoes and diet contains Management onions .He likes caffeinated 1800kcal/day drinks such as soda (coke 8 oz 180cc for osterized once a day) and 2 cups of coffee. feeding, 60cc water for He also eats vegetables and flushing every 2 hours. meat and have snacks composed of bread or biscuits. Patient as well consumes 4-5 glasses of water a day.

An individuals health status greatly affects eating habits and nutritional status. (Medical Surgical, Brunner p.1176)

Elimination Pattern

Significant others stated that before hospitalization patient usually voids 3 to 4 times a day. Urine is light yellow in color and no complaints of pain when voiding.

Patient was in foley Defecation and catheter. voiding patterns vary His urine output is at different stages of 60-80 cc per hour. life, circumstances Urine is turbid, of diet, fluid intake yellow in color. and output, activity, lifestyle, medications He defecates once and medical a day consuming 1 procedures and He defecates every 2 diaper. disease also affect days. Stool is brown in elimination. (Medical color and well formed. Surgical, Brunner p.71)

Activity and Exercise

Patients daughter He was maintained stated that he felt a in a High-Fowlers decrease in energy due position. Able to to aging process. move body during Patients normal routine passive ROM was staying at their exercises. home and walks 10 minutes within their area with his daughter every morning.

Elderly people have a decreased ability to rapidly move air in and out of the lungs. They require additional rest after prolonged or vigorous activity. (MS Brunner and Suddarths p. 495)

Sleep and Rest

Patients daughter stated that he has usual sleeps - at night for 4-5 hours, waking up early, having short naps of approximately 1 hour in the afternoon and feels rested right after sleeping.

Cognitive and perceptual

Older adults require as much as sleep as younger people. Older people are more likely to awaken because of factors such as noise, pain and nocturia. (MS Brunner and Suddarths p.207) Patients daughter stated that The only sense that is Auditory changes begin the patient has decreased active to the patient is to be noticed at older visual acuity (400 both eyes). hearing. The patient adults. (MS Brunner p. Patients memory was intact response to verbal 209) and mentation was stimuli (moan), appropriate to time, place and response to pain (eye person. opening).

Patients daughter verbalized that patient was asleep most of the time and just opens his eyes whenever painful stimuli is received.

NO DATA Self-perception AVAILABLE

NO DATA AVAILABLE

no data obtained-the patient is always asleep / semiconscious, with Endotracheal tube and hooked to mechanical ventilator

Role Relationship

He has a good relationship with his wife and daughter in terms of decision making. patient as well has harmonious relationship with his siblings, siblings family and within their neighborhood.

According to the patients daughter, his family is always there to support him in all aspect of his needs. Her daughter stated that their relatives let him feel extra care by visiting in the hospital .

Giving extra care and attention help the patient manage the problems in living more effectively and develop unused or underused opportunity more fully, help client become better at helping themselves in their recovery. (MS by Brunner, pg 429)

Coping no data obtained-the stress/tolerance patient is always asleep, with Endotracheal tube and hooked on mechanical ventilator

Value/Belief

The relative of the patient Patient wasnt able stated that the patient is a to go to church or Catholic and even with perform his prayers lifes challenges. Patients secondary to daughter states his semiconscious fathers achievement of condition. satisfaction in life and observance of his father praying every night and entrust himself and his children to God.

Ideas, goals, perception and spiritual beliefs influence ones choices and decisions, enhance feeling of connectedness to God and promote total health of mind, body, and spirit. (MS Brunner , 12th edition p.39)

Physical Assessment: General appearance: the patient is an elderly, thin built, wearing light clothing (hospital gown), semiconscious, responds to verbal stimulus.
Body parts Skin Actual findings Patients skin is warm to touch and had dry, sagging skin. Analysis The blood supply changes with ages, vessels, capillary loops decreasing number and size, resulting diminished supply in the skin, causing change, loss of resiliency and wrinkling and sagging of the skin (MS, Brunner & suddarth pg 1664).

Pale skin color noted on peripheral extremities

In patients with areas of localized skin paleness, suspect impaired arterial circulation or inadequate oxygen delivery to the affected extremity. (Assessment reference for nurses, Lippincot William & Wilkins, 2007)

Eyes

Symmetrical, pupils equally round but minimally slow to react to light. Patient used reading glasses.

Pupils dilate and constrict slowly and less completely because of increased stiffness of the muscle of the iris Many elders wear corrective lenses; they are most likely to have hyperopia. Visual changes are due to loss of elasticity and transparency of the lens (Kozier pg 554).

Ears

Auricle is symmetrical, uniform in color, no pain/tenderness upon palpation, hears well spoken words and responds to it.

Patient with normal hearing can respond to verbal stimulus (MS, Brunner & suddarth pg 1804).

Thorax and lungs

Prominent rib cage noted. Presence of crackles, heard over base and middle lung lobes. Patients RR is 28 cycles per minute, assisted by mechanical ventilator.

Loss of lean muscle mass in the thorax makes bony prominence of the ribcage evident. Presence of crackles suggests retained secretions in the lungs (MS, Brunner & suddarth pg 559).

Extremities

Extremities warm, skin less resilient and sagging, no edema noted. Patient was able to perform passive ROM.

Lessening of blood supply causes skin to become less resilient and sagging. Performing ROM exercises enhances circulation. (MS, Brunner & suddarth pg 1664)

Chest Xray September 16, 2013 Lung lobes Right lung Evaluation Reticulonodular infiltrates with areas of haziness from the apex to the base

Left lung

Apex is clear. Reticulonodular density from 3rd ICS down to the base

Impression: Pneumonia, bilateral

DIAGNOSTIC/LABORATORY EXAMINATIONS: SEPTEMBER 16, 2013

CBC
WBC Segmenter

Results
13.2 0.86

Normal Values
5-10x10/L 0.60-0.70

Interpretation
elevated., indicates infection Slightly elevated, indicated infection Low, decrease immune response Low indicates anemia Normal Normal

Lymphocyte

0.13

0.20-0.40 140-180/L 0.40-0.51 150-450x10/L

Hgb Hct Platelet

103 0.42 325

Blood Chemistry September 16, 2013

Glucose cholesterol Triglycerides Na 8.2 2.3 0.6 141 3.6-6.3 0-5.9 0-2.2 135-156 High, indicates diabetes mellitus (brunner suddarth) Normal Normal Normal and

K
HDL

5.0
0.6

3.6-5.5
0.8-2.0

Normal
Low, lower in patient with increase risk of coronary artery disease. Normal High, indicates hepatocellular damage

LDL SGPT

1.0 40u/L

1.7-4.8 0-36

SGOT
Albumin Glycosylated hgb

103u/L
24g/L 5.4

0-31
34-50 6.2-8.3

High, indicate hepatocellular damage

Low, Indicate hepatocellular damage Low; indicate adequate maintainance of blood glucose levels over the previous months.

Urine Analysis Sept.17,2013

Color Transparency Specific Gravity

PH Albumin Sugar

Dark yellow

Turbid 1.020 5 2 Positive

Interpretation Indicates infection Normal

Normal Indicates renalcomplication from diabetes mellitus Indicates renal compensation to eliminate excess glucose in the blood Indicates renal compensation to eliminate excess acid in the blood Indicates infection

Acetone
Pus

Positive
>100/HPI

ABG September 17, 2013

Normal values pH pCo2 pO2 HCO3 7.35-7.45 35-45mmhg 80-100mmhg 22-26mmol/L Result 7.32 50mmhg 59mmhg 18.80mmol/L Interpretation Low, indicates acidosis High, indicates accumulation of carbon dioxide in the blood Low, indicates decreased oxygen levels in the blood Low, indicates noncompensation of the Sodium bicarbonate buffer Low, indicates non optimal tissue oxygen supply

SpO2

95-100%

87%

Impression: Respiratory Acidosis

MEDICAL DIAGNOSIS:

Acute respiratory failure secondary to community acquired pneumonia

ANATOMY AND
PHYSIOLOGY

The cells of the body derive the energy they need from the oxidation of carbohydrates, fats, and proteins. As any type of combustion, this process requires oxygen. However, as a result of oxidation in the body tissues, carbon dioxide is produced and must be removed from the cells to prevent the build-up of acid waste products. The respiratory system performs this function by facilitating life sustaining processes such as oxygen transport, respiration, ventilation, and gas exchange.

A gradual decline in respiratory function begins in early to middle adulthood and affects the structure and function of the respiratory system. The vital capacity of the lungs and strength of respiratory muscles peak between 20-25 years of age and decreases thereafter. With aging and changes occur in the alveoli that reduce the surface area available for the exchange of O2 and CO2. Alveoli begins to lose its elasticity, theres loss of chest wall mobility, restricting the tidal flow air. These changes result in a decreased diffusion capacity for O2 with increasing age, producing lower O2 levels in the elderlys arterial circulation.

PATHOPHYSIOLOGY

Modifiable: DM, alcohol, smoking, environmental exposure to S. pneumoniae

Non-modifiable: Age, environment, decline of immune system

Compromised lung defense mechanism Acquisition and colony multiplication os S pneumoniae Activation of bodys inflammatory response against infection

Spreading trough out the respiratory tract including the bronchioles and alveoli
Edema and exudate formation within the tracheobronchial tree and alveoli these inflammatory infiltrates causes reduced lung volumes and altered ventilatory pattern Impaired ventilation-perfusion Impaired gas exchange Hypoxemia
Tachypnea, dyspnea, orthopnea, rust colored ,blood tinged sputum

Release of pyrogens

Fever, flushed and warm skin

Loss of spontaneous breathing

Acute respiratory failure

Nursing diagnosis: Impaired airway clearance related to copious tracheobronchial secretions secondary to impaired respiratory functions. Hyperthermia related to release of pyrogens from inflammatory immune response secondary to infectious process in the lungs. Ineffective peripheral tissue perfusion related to compromised respiratory function as evidenced by oxygen saturation of 87% and capillary refill of 4 seconds.

NURSING CARE PLAN:

Assessment
Objective cues: Tachypnea (RR28) Crackles over middle and base of lung lobes Assisted ventilation Presence of tenacious secretions on ET tubes Oxygen saturation of 87%

Nsg. Diagnosis Planning

Impaired airway clearance related to copious tracheobronchial secretions secondary to impaired respiratory functions. Analysis: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway Within 8 hours of nursing intervention the patient will demonstrate improved airway patency as evidenced by adequate SPO2 from 87% to 95% and clear breath sounds.

Nsg. Intervention
1.Assessed patients lung field.

Rationale
1.To established baseline data(nurses pocket guide 11 edition pg 81)

Evaluation

2.Provided adequate humidification.

3.Properly positioned

patient from side to side.

4.Perform chest percussion and postural drainage.

After 8 hours of nursing intervention the patient 2.To loosen secretions and demonstrated promote expectoration. improved (nurses pocket guide 11 airway patency edition pg 82) as evidenced by 3.To prevent stagnation of SPO2 of 95% pulmonary secretions. and diminished (nurses pocket guide 11 crackles over edition pg 82) middle and based of lungs 4.To loosen and diameter. mobilized.(nurses pocket guide 11 edition pg 82)

5.Assisted patient in nebulization.

5.To loosen secretions and widens airway. (nurses pocket guide 11 edition pg 82)

6.Perform endotracheal suctioning.

6.To effectively remove secretions. (nurses pocket guide 11 edition pg 82)

7.Properly regulated IVF of PNSS 1L at 33gtts/min.

7.To maintain patients

hydration. (nurses pocket guide 11 edition pg 82)

Assessment Nsg. Diagnosis Planning Nsg. Intervention

Objective cues: Hyperthermia related to release of pyrogens from inflammatory immune response secondary to infectious process in the lungs. Within 1 hour of nursing interventi on the patients will decrease from 38.2 C to 37.5*C 1.Assessed patients temperature together with patients clothing and environment condition.

Rationale
1.To establish baseline data and note any contributory factors causing patients hyperthermia(nursing pocket guide 11 edition pg 440) 2.To promote cooling of body surface and promotion of comfort. (nursing pocket guide 11 edition pg 441) 3.To promote comfort and decrease any external contributory to bodys heat formation. (nursing pocket guide 11 edition pg 441)

Evaluation
After1 hour of nursing intervention patients temperature decreased from 38.2 to 37.5C

Skin warm to touch

Flushed skin

Temperatu re 38.2*C
WBC

2.Rendered continuous tepid sponge bath and hygiene care.

Segmenter =0.86 slightly elevated indicate infection

Analysis:
Body temperature elevated above normal range. 3.Changed patients linens and provided patient dry and light clothing.

4.Properly regulated patients IVF of PNNS 1L at 33 gtts/min.

4.To promote hydration. (nursing pocket guide 11 edition pg 441)

5.Adminnistered paracetamol 500 mg via NGT feeding as ordered.

5.Pharmacologic method in decreasing fever.

Assessment
Objective cues:

Nursing diagnosis

Planning
Within the shift the patient will:

Nursing intervention

Rationale

Evaluation
Within the shift the patients:

Ineffective peripheral O2 sat 87% tissue perfusion related to Capillary refill of 4 compromised seconds. respiratory function as Pale skin color of evidenced by the peripheral O2 saturation extremities of 87%.

1. Changed patient position To promote peripheral in timed intervals every two circulation and limit hours. complication associated with poor O2 saturation perfusion.(nurses pocket level will guide 12 edition page improve from 612). 87% to 92%. 2. Perform passive Range To promote peripheral of motion exercises to all circulation.(nurses extremities. pocket guide 12 edition page 612). 3. Administer fluids as ordered To promote optimal blood flow and organ perfusion and function.( nurses pocket guide 12 edition page 612).

O2 saturation level had improved from 87% to 92%.

4. Ensure adequate oxygen To provide optimal supply are maintained at 6 support for the patients LPM. respiratory function in terms of oxygenation

NAME OF THE MECHANISM DRUG OF ACTION

DOSAGE

INDICATION

CONTRAINDICATI ON

ADVERSE EFFECT

NURSING CONSIDERATIONS

Piperacillin Tazobactam Pharma. Class: antiinfectives

Inhibits 300mg TIV cell wall every 8 synthesis, hours promoting osmotic instability causing cell death

Lower respiratory tract infection

Hypersensitivit Rash Perform skin y to drug Hives testing before the Urticaria drug therapy. Diarrhea Advise patients Anaphylaxi family to report if s diarrhea, rashes, Stomatitis itching, or inflammation of mouth are noticed.

Losartan

Selectively blocks Pharma. angiotensin Class: II as well as Antithe release hypertensi of ve aldosterone resulting in decrease blood pressure

50mg/tab Hypert Hypersensitivity OD via ension to the drug and Nasogast hypotension ric tube

Hypotensio Monitor patient n closely for any Dizziness situation that may Rash lead to a sudden Urticaria decrease in blood Abdominal pressure secondary to Pain decrease in blood Constipatio pressure. n Provide adequate fluids if not contraindicated to prevent constipation. Advise family to report if any rash is noticed. Instruct the family to turn and move the client slowly.

Name of Drug
Ipratropium bromide Classification: Anticholinergic Bronchodilator

Mechanism Dosag Indication Contraindicatio Advers Nursing of action e n e Effect considerations

Anticholinergic, 1 neb per chemically administr related to ation, BID atropine, which blocks vagally mediated reflexes by antagonizing the action of acetylcholine. Causes bronchodilation and inhibits secretion from serous and seromucous glands lining the nasal mucosa. Bronchodilat Hypersensitivity to or for atropine maintenance treatment of bronchospas m. Dizziness, headache, fatigue, nausea, GI distress, dry mouth. *Use nebulizer mouthpieceinstead of facemask to avoid blurred vision or aggravation of narrowangle glaucoma. *Ensure adequate hydration:control environment (temperature) to prevent hyperpyrexia *Teach family proper use of inhaler.

Glipizide Stimulates functioning B-cells to release insulin.

5mg/tab Type 2 OD via Diabetes Nasogastri mellitus c tube

Hypersensit ivity to sulfonylure as and Diabetic ketoacidosi s

Dizziness Hypoglyce mia Leukopeni a Thromboc ytopenia Cholestatic jaundice Rash Urticaria

Instruct patients family that drug is given on a continued basis. Give drug in the am to prevent hypoglycaemia at night. Instruct family and other health care team to move the patient slowly. Provide feeding on time and adequately to prevent hypoglycemic episodes.

Nurses progress notes: September 17, 2013

F- Ineffective airway clearance

D- Received patient rested in bed, semiconscious, responsive to verbal stimuli, skin warm to touch, hooked on mechanical ventilator. Patient demonstrates intercostal and supraclavicular retractions, labored breathing, crackles heard over middle and bases of lungs upon auscultation. A- initial VS taken within the shift, as of 3pm T-37.5, PR-103bpm, RR- 3bpm, spO287%, BP-130/90mmHg, ensured proper oxygen humidification, performed chest tapping and postural drainage, suctioned ET tube. R- Patients Vital Signs gradually improved having a PR-100bpm, RR-25, spO295%, BP- 130/80mmHg, diminished crackles over the middle and bases of the lungs noted. Patient is well rested.

Nurses progress notes:

September 18, 2013

F- Hyperthermia

D- Received patient rested in bed, semiconscious, responsive to verbal stimulus, skin flushed and warm to touch, hooked on mechanical ventilator.
A- Initial VS taken within the shift, as of 3pm T-38.5, PR-103bpm, RR- 30bpm, spO287%, BP-130/90mmHg, ensured proper regulation of IV fluid (.9% NSS), proper oxygen humidification, performed continuous tepid sponge bath, ensured dry and light clothing administered paracetamol, 500mg through NG tube as prescribed.

R- Patients fever subsided, VS gradually improved having T-37.3 from T-38.5, PR100bpm, RR-25, spO2-92%, BP-130/80mmHg, patients skin no longer flushed and warm to touch, demonstrates adequate sweating, safe and well rested.

DISCHARGE PLAN
Medication:

Cefuroxime 500mg/tab twice a day 8am and 6pm

Advise patient to take the drug with food to decrease Gastrointestinal distress such as abdominal pain. Advise patient about importance of compliance to drug regimen. Advise patient that if signs of hypersensitivity occurs such as rash difficulty breathing, immediately stop taking the drug and consult medical attention. Advise patient about importance of compliance to drug regimen. Advise patient to avoid sudden rising or rapid turning from one position to another to avoid orthostatic hypotension. Advise patient to avoid driving or operating any hazardous machineries to avoid accident. Advise patient about importance of compliance to drug regimen. Advise patient not to discontinue taking the drug without the advise of the doctor. Advise patient to avoid alcohol while having taking this drug. Advise patient to seek the advice of the nurse or physician if fever, sore throat or unusual bleeding occurs.

Losartan 50mg/tab every morning after breakfast.

Glipizide 5mg/tab every morning after breakfast.

Exercise: Advise patient and family the importance exercise. Instruct significant others to perform it more. Ex.: once a day 8:00am passive ROM exercises at least 10mins twice a day Demonstrate to the family examples of passive ROM such as flexion, extension, internal and external rotation, abduction and adduction. Treatment:

Cefuroxime twice a day; give as scheduled to maintain proper blood levels. Losartan administer in morning; take drug without regard to meals; do not stop taking this drug without consulting primary care provider. Glipizide take in the morning to prevent hypoglycemic reactions at night; caution patient to avoid OTC medication unless approved by the health care provider.

Health Teaching: Advise patient to gradually stop smoking and its risk to health and wellbeing. Advise the patient to refrain from drinking alcohol. Advise the patient and family to avoid stress as much as possible and instruct relaxation techniques. Advise the patient to adhere to proper medication regimens of Cefuroxime, Losartan, and Glipizide. Follow low salt low fat diet and diabetic diet. Advise the patient to perform exercise within tolerable limits Outpatient: Instruct patient relatives to have the patient checked in the Outpatient department two weeks after discharge and have consultation on nearest health center on a regular basis to effectively monitor health.

Diet:

Instruct patient and significant others to adhere on low salt low fat diet and diabetic Advise the patient to avoid canned and preserved foods Advise the patient to avoid drinking caffeinated drinks (soda, tea, coffee) Advise the patient to Limit foods high in sugar (less carbohydrates) Encourage family support on patients diet by having meal plans conducive to patient.
Spiritual: Continue to pray everyday Seek guidance to our almighty God Bible readings to promote spiritual well-being and enhance feeling family of connectedness with God.