Riyadh Colleges Of
Dentistry And Pharmacy
Riyadh, Kingdom of Saudi Arabia
Case Study
Marwah Abdulaziz
Alabdulsalam
43320209
Objectives
Case Study
A 71 year old female patient presented with sense
of difficulty in breathing & decrease conscious
level of 1 day duration but no fever . ABG done in
ER found that the PCO2 of 140 & the patient was
immediately intubated & ventilated . Patient is
known to have respiratory failure , COPD ,
diabetes mellitus & hypertension .
2. Baseline Data
Patient Initial :
(M.M)
Age:
71 years old
Birth date:
24 June 1941
Gender:
Female
Marital Status:
Married
Educational Level:
Primary
Nationality:
Saudi
Occupation:
Housewife
Date of Admission:
2 April 2014
2. Baseline Date
Chief complaints:
Difficult of breathing
Diagnosis:
chronic respiratory failure
COPD (Chronic obstructive pulmonary disease)
DM (Diabetes Mellitus)
HTN (Hypertension)
Anatomy and Physiology
The respiratory system
is situated in the thorax,
and is responsible for
gaseous exchange
between the circulatory
system and the outside
world
Anatomy and Physiology
. Air is taken in via the
upper airways (the nasal
cavity, pharynx and
larynx) through the lower
airways (trachea, primary
bronchi and bronchial
tree) and into the small
bronchioles and alveoli
within the lung tissue.
Health History
a. Present Health History:
(+)DM, (+) HTN, COPD
b. Past Health History:
NON
c. Family and Social History:
(+) DM
Nursing Assessment
Review of System
Vital Sign
Blood Pressure 150/81
Temperature 37.0
Heart Rate 15
Pulse Rate 85
O2 Saturation 98
Pain 3-4
Weight 40
Height 160
Blood Sugar Level 226
General Appearance
Head : Normal
Neck : Pain with movement
Breast :Normal
Unwell
Lethargic
Calm
Nutrition
Type of diet : low fat
soft diabetic high protein
Appetite : poor
Musculoskeletal
Motor : paralysis
Range of motion: limited
Balance and gait : Unsteady
Strength/Hands grasps: Equal
Strength/Leg Muscles: Weak
-Weakness/paralysis: Lift and Right
Skin
Color (Normal)
Temperature (Warm)
Neurologic
(Glasgow Coma Scale)
GCS 15/15
Eye Opening: 6
Verbal Response: 5
Motor: 4
EENT (Eyes,Ears,Nose and Throat)
EYES
Color of sclera (white )
size of eyes pupils ( 3 mm )
Visual Acuity (cataract)
Presence of tears (no)
EARS
shape and position: symmetric
Color: same as facial skin
EENT (Eyes,Ears,Nose and Throat)
NOSE
shape and position: symmetric
Color: same as facial skin
THROAT & MOUTN
Palate (hard)
Size of Tonsils (normal size)
Bleeding gums
Dryness
Cardiovascular
Heart Sounds (Normal)
Color (Normal)
Capillary Refill Time: 3 seconds
Presence of edema (no)
PULSE
Rhythm: Regular
Strength: Normal
Rate: Normal
Respiratory
Respiratory Rate: Normal
Shortness of breath (yes)
Difficulty of Breathing (yes)
Sounds: Normal
Cough : Non
Mode of breathing : Mechanical Ventilator
Air way: Tracheostomy
Gastro Intestinal Tract
Feeding: (oral )
Elimination:
Frequency: 2
Consistency : Watery , black
Shape of Abdomen: Flat
Bowel Sounds : hyperactive
Gastro Urinary Tract
Urinary Pattern: Incontinence
Foley catheter : (yes)
Urine Output per 8 hrs :465 ml
Hydration Status:
Intake = 1300
Output=1430
Laboratory Result
test
Result
Normal
WBC
7.8
4-11
Hgb
83
120-150
HCT
0.239
0.36-0.46
MCV
75.4
83-101
MPV
6.8
6.5-11.6
RDW
16.4
11.6-14
Pathophysiology
Respiratory failure is a condition in which not
enough oxygen passes from your lungs into your
blood. body's organs, such as your heart and brain,
need oxygen-rich blood to work well.
Respiratory failure also can occur if your lungs can't
properly remove carbon dioxide (a waste gas) from
blood.
Drug Analysis
Drug Analysis
Name of Medications
uses
Side Effects
Band Name:
Inj Clexane
It is used to stop blood
clots forming within the
blood vessels.
1. Pain and irritation at
the injection site.
Generic Name:
Enoxaparin sodium
Dosage:
30 Mg
Frequency:
Daily
Routes:
P.O
2. Major bleeding
(hemorragie).
3. Blood clots in the
spinal cord.
4. Decrease in the
number of platelets in
the blood.
Drug Analysis
Name of Medications
uses
Side Effects
Band Name:
Protonix
decreases the amount of
acid produced in the
stomach.
1. severe stomach pain,
nausea, vomiting, and
weight loss.
Generic Name:
pantoprazole
Dosage:
40 Mg
Frequency:
Daily
Routes:
P.O
2. diarrhea that is watery
or bloody.
3. kidney problems.
4. headache.
5. Fever.
Drug Analysis
Name of Medications
uses
Side Effects
Band Name:
Amlodipine besylate
treat high blood pressure
(hypertension)
1. Headache.
Generic Name:
Cap-amlor
2. Dizziness,
drowsiness.
3. tired feeling.
Dosage:
5 Mg
Frequency:
Daily
Routes:
P.O
4. stomach pain.
5. flushing .
Drug Analysis
Name of Medications
uses
Band Name:
Atrovent HFA
relaxes muscles in the
airways and increases air
flow to the lungs.
Generic Name:
ipratropium inhalation
Dosage:
250 Mg
Frequency:
8 Hrs
Routes:
Tracheostomy
Atrovent is used to
prevent bronchospasm,
or narrowing airways in
the lungs, in people with
bronchitis, or COPD
(chronic obstructive
pulmonary disease).
Side Effects
1. headache, dizziness;
2. stuffy nose, sinus
pain, dry mouth,
cough, hoarseness.
3. Nausea .
4. back pain; or fever,
chills, body aches, flu
symptoms.
Drug Analysis
Name of Medications
uses
Side Effects
Band Name:
laxative manufactured
Generic Name:
Movicol
Helps to have a
comfortable bowel
movement.
1. Anal discomfort.
2. Borborygmi.
3. Diarrhoea.
Dosage:
1 sachet
Frequency:
two times a day.
Routes:
P.O
4. distension of the
stomach.
5. Stomach pain.
6. Vomiting.
nursing responsibilities
1- Ensure that you are giving Medications to:
The correct patient. The Correct dose. The correct
time. The correct route.
2- Ensure that there is a written order from the doctor.
3- Ensure that the patient is NOT allergic to any
Medications .
4- Know the drug- drug interactions.
nursing responsibilities
5- Assess the patient after giving the medication
for any reaction, let the dr. decide what is it
( Allergy?).
6- Document all the above.
Nursing Care Plan
Assessment
SUBJECTIVE:
(I do not breathe well)
as verbalized by the patient.
OBJECTIVE:
Request for information.
Inaccurate follow through of instructions.
V/S taken as follows:
T: 37.0
P: 85
R: 15
BP: 150/81
Nursing Diagnosis
Ineffective Airway Clearance r/t tracheobronchial
obstruction
Difficulty of breathing related to:
1.
Altered O2 supply
2.
Altered blood flow.
Altered oxygen-carrying capacity
of blood
3.
Goal
Long Term Goal:
Patient will maintain a patent airway.
Short Term Goal:
Patients lungs sounds will be clear to auscultate.
Patient will be free of dyspnea.
Patient will demonstrate correct coughing and deep
breathing techniques.
Intervention
Assess airway for patency by asking the patient to state
his name.
Assess respiratory quality, rate, depth, effort and pattern.
Monitor arterial blood gases (ABGs).
Administer supplemental oxygen.
Suction as needed.
Change patient's position every 2 hours.
Intervention
Encourage deep breathing, using incentive
spirometer as indicated.
Assess changes in vital signs.
Position patient to facilitate ventilation/perfusion
matching. Use upright, high Fowler's position
whenever possible.
Administer medications as prescribed.
Evaluation
Patients lungs sounds are clear to auscultation
throughout all lobes.
Patient is receiving oxygen. SaO2 via pulse oximetry is 90
100%.
Patient is normotensive with heart rate 60 100 bpm.
Patient is free of signs of distress.
Discharge Care Plan
Medication:
Confirm that the patient
understands the reason for the
medication.
Explain the medication to other
people so they can help with
administration and provide
reminders.
Exercise Environment
Physiotherapy should be started as
soon as possible. It will help to improve
blood circulation and relax muscles.
Range of motion exercise refers to
activity aimed at improving movement
of a specific joint
Practice relaxation or slow, deep
breathing.
Diet :
Decrease the salt in your diet.
Eat healthy foods low fat
soft diabetic high protein
Health Teaching:
Monitor your blood pressure at home.
Manage stress.
Don't smoke.
Thank
You