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BRONCHIECTAS

IS
I. INTRODUCTION

“Look to your health; and if you have it, praise God and value it next to conscience; for
health is the second blessing that we mortals are capable of, a blessing money can't buy. “

--Izaak Walton

The quote expresses the thought that health is wealth; that good health is equal to
having everything in the world. It states that health is the best thing God could give us. We
should be thankful for it, live it well, and most of all be contented of what we have for it is a
blessing more important than money. Achieving good health is a way of thanking Him in
return of giving us this life. As discussed in this case study, a nun, a servant of God, was
diagnosed with Bronchiectasis. But, as most people would do, she did not blame nor asked
God why, and instead thanked Him for such a blessing.

Bronchiectasis is a disease that causes localized, irreversible dilation of part of the


bronchial tree. It is classified as an obstructive lung disease, along with bronchitis and cystic
fibrosis. Involved bronchi are dilated, inflamed, and easily collapsible, resulting in airflow
obstruction and impaired clearance of secretions. Bronchiectasis is associated with a wide
range of disorders, but it usually results from necrotizing bacterial infections, such as
infections caused by the Staphylococcus or Klebsiella species or Bordetella pertussis.

Rene Theophile Hyacinthe Laënnec, the man who invented the stethoscope, used his
creation to first discover bronchiectasis in 1819. The disease was researched in greater detail
by Sir William Osler in the late 1800s; in fact, it is suspected that Osler actually died of
complications from undiagnosed bronchiectasis.

There are both congenital and acquired causes of bronchiectasis. Kartagener


syndrome, which affects the mobility of cilia in the lungs, aids in the development of the
disease. Another common genetic cause is cystic fibrosis, in which a small number of
patients develop severe localized bronchiectasis. Young's syndrome, which is clinically
similar to cystic fibrosis, is thought to significantly contribute to the development of
bronchiectasis. This is due to the occurrence of chronic, sinopulmonary infections. Patients
with alpha 1-antitrypsin deficiency have been found to be particularly susceptible to
bronchiectasis, for unknown reasons. Other less-common congenital causes include primary
immunodeficiencies, due to the weakened or nonexistent immune system response to severe,
recurrent infections that commonly affect the lung.

Acquired bronchiectasis occurs more frequently, with one of the biggest causes being
tuberculosis. Endobronchial tuberculosis commonly leads to bronchiectasis, either from
bronchial stenosis or secondary traction from fibrosis. An especially common cause of the
disease in children is acquired immune deficiency syndrome, stemming from the human
immunodeficiency virus. This disease predisposes patients to a variety of pulmonary
ailments, such as pneumonia and other opportunistic infection. Bronchiectasis can sometimes
be an unusual complication of inflammatory bowel disease, especially ulcerative colitis. It
can occur in Crohn's disease as well, but does so less frequently. Bronchiectasis in this
situation usually stems from various allergic responses to inhaled fungus spores. Recent
evidence has shown an increased risk of bronchiectasis in patients with rheumatoid arthritis
who smoke. One study stated a tenfold increased prevalence of the disease in this cohort.
Still, it is unclear as to whether or not cigarette smoke is a specific primary cause of
bronchiectasis.

Other acquired causes of bronchiectasis involving environmental exposures include


respiratory infections, obstructions, inhalation and aspiration of ammonia and other toxic
gases, pulmonary aspiration, alcoholism, heroin (drug use), and various allergies.

Death and mortality statistics for Bronchiectasis:

Deaths from Bronchiectasis: 970 deaths (NHLBI 1999)


Death rate extrapolations for USA for Bronchiectasis: 969 per year, 80 per month, 18
per week, 2 per day, 0 per hour, 0 per minute, 0 per second. Note: this extrapolation
calculation uses the deaths statistic: 970 deaths (NHLBI 1999)
Hospitalizations for Bronchiectasis: 6,000 (NHLBI 1999)
The following are statistics from various sources about hospitalizations and Bronchiectasis:
• 0.06% (7,605) of hospital consultant episodes were for bronchiectasis in England
2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 78% of hospital consultant episodes for bronchiectasis required hospital admission in
England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 39% of hospital consultant episodes for bronchiectasis were for men in England
2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 61% of hospital consultant episodes for bronchiectasis were for women in England
2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 54% of hospital consultant episodes for bronchiectasis required emergency hospital
admission in England 2002-03 (Hospital Episode Statistics, Department of Health, England,
2002-03)
• 10.5 days was the mean length of stay in hospitals for bronchiectasis in England
2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 8 days was the median length of stay in hospitals for bronchiectasis in England 2002-
03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 60 was the mean age of patients hospitalised for bronchiectasis in England 2002-03
(Hospital Episode Statistics, Department of Health, England, 2002-03)
• 37% of hospital consultant episodes for bronchiectasis occurred in 15-59 year olds in
England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 22% of hospital consultant episodes for bronchiectasis occurred in people over 75 in
England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 16% of hospital consultant episodes for bronchiectasis were single day episodes in
England 2002-03 (Hospital Episode Statistics, Department of Health, England, 2002-03)
• 0.09% (48,984) of hospital bed days were for bronchiectasis in England 2002-03
(Hospital Episode Statistics, Department of Health, England, 2002-03)

Objectives:
These are set goals or criteria that will enable the health care provider (student nurses)
as well as the client (patient) to identify basic importance of the study in the interaction
process.
A. Nurse Centered
After 2 days of student nurse-patient interaction, the nurse will be able:
 To build therapeutic relationship between the client and health care provider as
well as with the significant others and health care team.
 To enhance knowledge and understanding pertinent to the client’s health
condition, disease process, management, intervention and treatment modalities.
 To provide quality nursing care by setting specific goals and appropriate nursing
intervention which are essential to the client’s condition
 To identify health problems and needs of the client that will be the basis of further
assessment and evaluation in the understanding of the disease process
 To supplement health teachings to the client especially factors that will contribute
to the continuity of care.
B. Patient Centered
After 2 days of student nurse-patient interaction, the client will be able:
 To understand clearly the disease process (bronchiectasis) its causes, effect,
management, treatment and possible prevention.
 To appreciate and apply the health teachings given by the health care provider
for the betterment of his condition.
 To participate in the course of care and initiate change by modifying one’s
behavior and lifestyle that may further aggravate his condition.
 To acknowledge the importance of proper monitoring of health status by
regularly consulting to health care providers regarding their health condition

II. NURSING HISTORY

Personal history

Mrs. Minnie Mouse is currently 61 years old and is a Filipino. She was born on
September 12, 1943 at Gapan, Nueva Ecija and grew in Quezon City. She got married at
the age of 29 to Mr. Mickey Mouse. She gave birth to three boys namely: Mr. Road
Runner, who is married and has three children as of the moment; Mr. Donald Duck, who
became a monk; and Mr. Taz, who became a priest; in chronological order. At the age of
35 and her children being: eldest, 6 years old; second eldest, 4 years old; and the
youngest at 2, together with her husband, they entered the monastery in Mabalacat, The
St. Benedictine Monastery as a family. Since then, they have been living at 168
Monastery Road San Isidro, Magalang.
She got admitted last February 17, 2009 with a chief complaint of cough and a
clinical impression of Bronchiectasis, Dilated Cardiomyopathy.
Mrs. Minnie together with her family works for the monastery. There, Mr. and Mrs.
Mickey Mouse are no longer husband and wife but are brothers and sisters instead. They
work for their food by planting vegetables. They literally plant what they eat. Their
everyday expenses are being taken care of by the monastery’s director. They just work
and serve the Lord, wholeheartedly. They are given allowances but she saves them for
future needs. Help and donations from kind hearted people also keep the monastery
strong.
She finished grade school and high school in Quezon City and took Bachelor of
Science in Education major in science at St. Joseph’s College. Then she took up her
Masterals in Ateneo and University of the Philippines specifically AB mastery in
Mathematics and Physics. She taught in La Salle and then UP for 8 years. After that, she
got married and few years later they entered the monastery as a family.
Mrs. Minnie’s family members are all Catholics. In fact, she is actually a nun, only a
married one; and her husband is a brother who is also working at the said monastery.
Mrs. Minnie stated that she believes in the effects herbal medicines have. In fact, they
plant their own herbal medicines in their monastery. However, she does not believe in the
so-called “albularyos”, for her everything happens with a purpose and that it is in
accordance to God’s will. She also said that she would rather rush to the nearest hospital
than seek help with these “albularyos”. In fact, they have their own health care
practitioner in their monastery where in severe cases; they would go to Makati Medical
Center, where he was also working, for better treatment and latest facilities.
FAMILY-HEALTH ILLNESS HISTORY

Mr. Beast Mrs. Belle


(Died at the age (Died at the age of 75
of 70 due to liver due to cancer of the
cancer) ovaries)

Mrs.
Cinde Auror Minnie
Ariel Mr.
rella a Currently Mouse
Died due Died due 61 years old
Mickey
living in
to cancer to cancer Switzerla Mouse
of the of the nd (Has (No current
ovary colon arthritis, illness, no
osteoporosis hereditary
Snow Aladd , but no disease
hereditary known)
White in
disease)
(Forgot Died due Jasmi
cause of to liver
death) cancer
ne
71 years
old
Living
with
Legend: Mrs.
Minnie
Pts. Father mouse

Pts. Mother
Mr.
Mr. Road Mr. Taz
Donald 26 years old
Pts. Siblings Runner Duck (No
30 years old 28 years old hereditary
(No hereditary (No hereditary
Pts. Husband disease
disease known) disease known) known)

Pts. children
Schematic Diagram of the Disney Family
HISTORY OF PAST ILLNESS
Mrs. Minnie Mouse was a menopause baby which made her sickly since childhood.
She was frequently being infected with cough, colds and fever. In April 1, 2005, she was
diagnosed to have Bronchiectasis, a condition wherein the bronchioles are inflamed and are
not functioning very well. She was not aware of this and the only one that noticed that there
was something wrong with the way she coughed was the resident doctor of their monastery.
The doctor talked to her and said that they should go to Makati Medical Center, where he is
also working, to clarify the condition. A computed tomography or CT scan and a Chest X-ray
confirmed the diagnosis. She was prescribed antibiotics then, medications that are quite
similar to those with Tuberculosis. She took these medications until 2007. Due to the extent
of her condition, she already knew its definition and some treatments that were given to her.
From then on she was being confined once or twice a year. In February 07, 2008, she was
confined because of Pneumonia and a fungal infection. The doctor prescribed cyclic
medications after being discharged. Every six weeks she returned and the doctor would give
her another pack of medications. Arthritis and osteoporosis made her weaker since these
conditions are associated with weakening of the bones and joints.

HISTORY OF PRESENT ILLNESS


During the first week of February this 2009, she had massive edema in the upper and
lower extremities. She was rushed to AMC and was given medications. Fortunately, this was
solved and she was discharged early. According to her, the doctor said that the edema was
due to the poor pumping action of the heart which made them suspect Congestive Heart
Failure, so they did a chest x-ray. But they found out that she had a congenital hole in her
heart. Dilated cardiomyopathy was then diagnosed. During the first days of the second week,
she experienced coughing, fever, stabbing pain, weakness and fatigue. On February 17, 2009,
she was rushed and admitted to Angeles Medical Center at exactly at 4:37 pm. Her chief
complaint was cough and she was diagnosed with Bronchiectasis, Dilated Cardiomyopathy.
Several laboratory procedures were done and it was identified that she had another fungal
infection and pneumonia.
III. Physical Assessment ( IPPA-
Cephalocaudal Approach)

ASSESSMENT UPON ADMISSION:


February 17, 2009
The patient was conscious, wheel chair borne, afebrile, with pale palpebral
conjunctiva, anicteric sclerae, with crackles and rales,BLF, no wheezes, tachycardic, (+)
murmur, flat, NABS, soft full equal pulses.

FIRST NURSE-PATIENT INTERACTION:


February 20, 2009
General appearance
Mrs. Minnie was seen lying on bed and was alert and conscious. She was wearing a
cream blouse with black vest and a below-the-knee length skirt. The patient was neatly
groomed.

Vital signs taken as follows:


At 08:00 am At 10:00 am At 12:00 pm
T: 36.4 °C T: 36.2 °C T: 36.2 °C
P: 82 beats per minute P: 82 beats per minute P: 83 bets per minute
R: 23 breaths per minute R: 25 breaths per minute R: 26 breaths per minute
BP: 130/60 mmHg BP: 130/70 mmHg BP: 130/70 mmHg

SKIN:
• No lesions observed
• Slow skin turgor (3-4 seconds) due to old age
• Poor capillary refill (3-4 seconds)
• Skin is moist and warm
• Greenish discoloration on IV site related to IV administration
HEENT:
Head
• Symmetrical to face
• Hair is thin and quite moist, black with minimal white hair strands
• Even distribution of hair
• No nits and dandruff observed
Eyes
• Palpebral fissures are equal when eyes are open
• Pale palpebral conjunctiva
• Anicteric sclera
• Can open eyelids when pressure is applied
• Patient is near-sighted
Ears
• Pinna is pale pink in color
• External canal is clean
• No discharge noted
• Right ear cannot hear ticking of watch’s hands
• Left ear can clearly hear ticking of watch’s hands
Nose
• No discharge seen
• Can breath with one nostril occluded
Tongue and mouth
• Sore on the end of lower lip
• 9 upper teeth, 9 lower teeth present, all natural
• Pale pink gums
• No breath odor
NECK:
• Thyroid muscle moved upon swallowing
• Can move chin when pressure is applied
• Can move shoulder when pressure is applied
• Lymph nodes are not palpable
LUNGS:
• Rales and Crackles on both lung fields upon auscultation
• Uses accessory muscles
• Increased Respiratory rate of 26 breaths per minute
• Difficulty of breathing reported
GUT:
• Regular bowel movement (once in two days as stated by patient)
• No urinary incontinence
MUSCULOSKELETAL:
• Cyanosis and clubbing of fingers
• No edema
• Muscle weakness specifically on lower extremities
• Can ambulate with assistance

SECOND NURSE-PATIENT INTERACTION:


February 21, 2009
General appearance
Seen on bed sitting, finished eating breakfast. She was well-groomed. And she wears
a floral blouse with gray vest and a below-the-knee length floral skirt.
Vital signs taken as follows:
At 08:00 am
T: 35.5 °C
P: 73 beats per minute
R: 19 breathe per minute
BP: 130/60 mmHg

SKIN:
• Poor capillary refill (3-4 seconds)
• Greenish discoloration still present on IV site related to IV administration
HEAD:
Head
• Hair is quite moist
Eyes
• Pale palpebral conjunctiva
• Deep eye bags noted
Ears
• Right ear cannot hear ticking of watch’s hand
• Left ear can clearly hear ticking of watch’s hand
Tongue and mouth
• Sore on right lower lip
• Pale pink gums
LUNGS
• Crackles on Right lung field upon auscultation
• Uses accessory muscles.
MUSCULOSKELETAL:
• Cyanosis and clubbing of fingers
• Muscle weakness specifically on lower extremities
• Can ambulate with assistance
IV. DIAGNOSTIC AND LABORATORY PROCEDURE

Diagnostic / Indications or Date Results Normal Analysis and


Laboratory Purpose ordered values Interpretation of
Procedure Date (units used Results
results in the
were hospital)
released
Chest X-ray This study yields Date There is no Normal The patient has
information about ordered significant lung fields, chronic Koch’s
the pulmonary, 02/17/09 interval cardiac infection with
cardiac, and change in the size, bronchiectatic
skeletal systems. Koch’s mediastinal Changes.
It is used to Date infiltrates on structures, Bilateral lung
evaluate known or results both lung thoracic fields,
suspected were fields and the spine, ribs radiographically
pulmonary released bronchiectatic and stable since the
disorders, chest 02/17/09 changes on the diaphragm. 1/20/09 chest
trauma, right mid and radiograph.
cardiovascular lower lung Mild
disorders, and fields and the cardiomegaly,
skeletal disorders. left upper lobe left ventricular
compared with form.
the 1/20/09 Atheromatous
chest aorta.
radiograph. Dextroscoliosis,
The heart is thoracic spine.
minimally
enlarged with
left ventricular
form.
The aortic
knob is
calcified.
The
diaphragm,
sulci and ribs
are intact.

Nursing Responsibilities:
Prepare your patient
• Inform the patient about the purpose of the procedure, various positions to assume,
and the need to hold his or her breath.
• Inform the patient that the procedure takes 5 to 10 minutes.
• There are no food or fluid restrictions.
• Inform the patient that no pain is associated with the study.
Perform procedure
• Instruct the patient to remove clothing and metallic objects from the waist up.
• Give the patient a gown and robe to wear.
• Remove any wires connected to electrodes, if allowed.
• Place patient in a standing, sitting, or recumbent position in front of the x-ray film
holder.
• Have the patient place hands on hips, extend neck, and position shoulders forward.
• Position the chest with the left side against the film holder for a lateral view.
• Instruct the patient to inhale deeply, to hold his or her breath while the x-ray is taken,
and then exhale after the film is taken.
Care after the test
• Inform the patient of the possible need for additional chest x-rays to evaluate
progression of the disease process or determine the need for a change in therapy.
• Determine if the patient or family members have any further questions or concerns.
• A physician sends a written report to the ordering health care provider, who discusses
results with the patient.

HEMATOLOGY
Diagnostic / Indications or Date Results Normal Analysis and
Laboratory Purpose ordered values Interpretation of
Procedure Date (units used Results
results in the
were hospital)
released
Hematocrit This blood test Date 41.0 % Male: The patient’s
evaluates blood ordered 40.0-54.0% hematocrit is
loss, anemia, 02/17/09 within normal
blood replacement Female: values which
therapy, and fluid 37.0-47.0% mean that the
balance, and Date concentration of
screens red blood results red bloods cells
cell status. were is normal.
released
02/17/09

Nursing Responsibilities
Prepare your patient
• Explain that this test helps evaluate if there are enough red blood cells in the blood, or
if there is too much or too little water in the body.
Perform procedure
• Collect 7 mL of venous blood in a lavender-top tube.
• Alternately, collect the sample in a heparinized capillary tube (red-banded tube) and seal on
or both ends after collection.

Care after test


• Observe the patient for signs and symptoms of anemia including pallor, tachycardia,
dyspnea, chest pain, and fatigue. Severe anemia may produce these symptoms from tissue
hypoxia
• Encourage rest periods for patient experiencing fatigue related to anemia.
• Evaluate patient’s ability to perform activities of daily living.
• Discuss with patient or family the significance of hematocrit levels. For example,
extreme increases in red blood cells may trigger a stroke in some individuals. Acute
dehydration can start a sickling crisis.

Diagnostic / Indications or Date Results Normal Analysis and


Laboratory Purpose ordered values Interpretation of
Procedure Date (units used Results
results in the
were hospital)
released
Hemoglobin This test evaluates Date 12.5 g/dL Male: The patient’s
blood loss, ordered 14-18 g/dL hemoglobin is
erythropoietic 02/17/09 Female: within normal
ability, anemia, 12-16 g/dL values which
and response to mean that the
therapy. The Date ability of red
hemoglobin level results blood cells to
is directly related were carry oxygen and
to the red blood released carbon dioxide to
cell count (RBC). 02/17/09 and from tissues
is normal.

Nursing Responsibilities
Prepare your client
• Explain that this test measures a part of the blood that carries oxygen.
Perform procedure
• Collect 5-7 mL of venous blood in a lavender-top tube.
• Alternately, a fingerstick or heel-stick method may be used to collect venous blood in
a heparinized capillary tube.
Care after test
• Observe the patient for signs and symptoms of anemia including pallor, dyspnea, chest
pain, and fatigue.
• Encourage rest periods for patient experiencing fatigue related to anemia.
• Evaluate patient ability to perform activities of daily living.
• If a low hemoglobin level indicates the possibility of blood loss or anemia, instruct the
patient or family that further testing will be necessary to identify the cause of the
condition to treatment.

Diagnostic / Indications or Date Results Normal Analysis and


Laboratory Purpose ordered values Interpretation of
Procedure Date (units used Results
results in the
were hospital)
released
Platelet This blood test Date 274 141-440 The patient’s
count evaluates platelet ordered platelet count is
production and 02/17/09 within normal
assesses the range which
effects of cancer means that there
treatment on Date is adequate
platelet numbers. results coagulating
The platelet’s size were function.
and shaper are released
noted. Platelets 02/17/09
are nonnucleated,
round or oval,
flattened disk-
shaped structures
that are vital to the
formation of a
hemostatic plug in
vascular injury.
This is the most
important
screening tests of
platelet function.

Nursing Responsibilities
Prepare your patient
• Explain that this test helps assess the blood’s ability to clot
Perform procedure
• Collect 7 mL of venous blood in a lavender-top tube.
• Apply pressure or a pressure dressing to the venipuncture site.
Care after test
• Hold pressure ate the venipuncture site for 5 minutes to prevent hematoma formation.
• Assess patient for unusual bruising or prolonged bleeding from venipuncture site.
Delayed clotting is a complication of severely impaired clotting.
• Test all body secretions including stool, gastrointestinal aspirate, and tracheal aspirate
for occult blood. Closely inspect mucous membranes for bleeding.
• Teach the patient and family members about bleeding, precautions including using a
soft-bristled toothbrush, using a electric razors, avoiding constipation, avoiding picking
their nose, and avoiding constricting clothing.
• Teach the patient and family the signs and symptoms of bleeding including petechiae
(small purplish spots on the skin), bruising, and blood in the urine or stool, vaginal
bleeding, and bleeding from any other sites.

Diagnostic / Indications or Date Results Normal Analysis and


Laboratory Purpose ordered values Interpretation of
Procedure Date (units used Results
results in the
were hospital)
released
White blood This blood test Date 13.8 4.3-10.0 The patient has
cell evaluates a ordered increased levels of
number of 02/17/09 WBC
conditions and (leukocytosis)
differentiates which indicate
causes of Date infections,
alterations in the results inflammation,
total white blood were stress or
cell (WBC) count released hemorrhage.
including 02/17/09
inflammation,
infection, tissue
necrosis, and or
leukemic
neoplasia. The
differential white
cell count
identifies the five
specific types of
white blood cells
present in the
blood. These five
cell types reflect
the integrity of
the patient’s
immune system.
Lymphocyte/ This test is used Date The patient is
Monocytes to evaluate the ordered compromised
patient’s response 02/17/09 because of
(%) to treatment, the 18 28.0-48.0 immunodeficiency.
prognosis, and So this type of
(x10/1) bleeding Date WBC is decreased.
disorders. As well results
as infection. were 2.5 1.2-5.3
released
02/17/09
Granulocyte This test Date The immune
evaluates ordered system of the
(%) prognosis, 02/17/09 82 44.2-80.2 patient may be
response to poor or an
(x10/1) treatment and overwhelming
bleeding disorder. Date 11.3 2.0-8.8 infection is present.
results
were
released
02/17/09

Nursing Responsibilities
Prepare your patient
• Explain to your patient that this test helps to assess the body’s ability to fight
infection, to tell the difference between an infection and an allergy, or to find problems
with the way bone marrow makes blood cells.
• Instruct your patient to avoid strenuous physical activity for 24 hours prior to testing,
if possible.
Perform procedure
• Collect 7 mL of venous blood in a lavender-top tube.
• Gently invert the collection tube several times immediately after collection to mix the
sample with the anticoagulant in the tube.
Care after test
• If WBC differential indicates an infection, assess patient responses to antimicrobials.
Interventions will include assessment of vital signs, focused physical assessment of body
systems affected, administration and maintenance of fluids, monitoring intake and output,
and assistance with activities of daily living as required.
• If WBC differential indicates an allergic or inflammatory response, monitor the
client’s response to therapies. Inflammatory responses may worsen or involve more than
one body system. Monitor the patient for worsening of the inflammatory condition,
particularly respiratory compromise.
• When decreased bone marrow activity is demonstrated on the WBC differential,
instruct your patient about the importance of obtaining immunizations that may provide
some level of protection (pneumococcal vaccine, flu vaccine, hepatitis B vaccine). Also
instruct the patient and family about the importance of avoiding individuals with acute
illnesses and upper respiratory infections. If the patient lives with young children, it is
important to maintain the immunization schedule of these children to prevent
unnecessary exposure of the client to infections.
• When an allergic or inflammatory condition is identified, explore possible
interventions for preventions for prevention of recurrences with the patient and family.
• Explain the similarities and differences in treatment and management of parasitic,
viral, and bacterial illnesses to the patient and family. Discuss routes of transmission to
help the patient and family identify means of limiting exposure of others.

BLOOD CHEMISTRY

Diagnostic / Indications or Date Results Normal Analysis and


Laboratory Purpose ordered values Interpretation of
Procedure Date (units used Results
results in the
were hospital)
released
Arterial This group of tests Date pH: 7.491 7.35-7.45 The patient has a
blood gas is used assess ordered mmHg high pH level, a
condition such as 02/17/09 low pCO² level,
asthma, chronic pCO²: 34.3 35-45 and a normal
obstructive mmHg HCO³ which
pulmonary disease Date means that the
(COPD), results PO²: 89.3 80-100 patient is
embolism. Blood were mmHg experiencing
gas analysis is released respiratory
used to evaluate 02/17/09 HCO³: 25.6 22-26 alkalosis. A high
respiratory mEq/L O² sat and B.E.
function and level was also
provide a measure O² Sat: 2.8 ±2 mEq/L noted. The
for determining patient may have
acid-base balance. B.E: 97.4 (97%) fever,
Respiratory, renal, hyperventilation
and and excessive
cardiovascular artificial
system functions ventilation.
are integrated in
order to maintain
normal acid-base
balance.

Nursing Responsibilities
Prepare your patient
• Obtain a history of the patient’s complaints, including known allergies
• Obtain a history of the patient’s cardiovascular and respiratory systems, any bleeding
disorders, and results of tests and procedures previously performed, especially bleeding
time, clotting time, complete blood count, and prothrombin time.
• Obtain a list of medications the patient is taking including anticoagulant therapy. It is
recommended that use of these medications be discontinued 14 days before dental or
surgical procedures.
• Note any recent procedures that can interfere with test results
• There are no food, fluid, or medication restrictions unless by medical direction.
• Note the patient’s temperature.
Perform procedure
• Direct the patient to breathe normally and to avoid unnecessary movement.
Care after test
• Pressure should be applied to the puncture site for at least 5 minutes in the
unanticoagulated patient and for at least 15 minutes in the case of a patient receiving
anticoagulant therapy. Observe puncture site for bleeding or hematoma formation. Apply
pressure bandage.
• Observe the patient for signs and symptoms of respiratory acidosis, such as dyspnea,
headache, tachycardia, pallor, diaphoresis, apprehension, drowsiness, coma,
hypertension, or disorientation.
• Teach the patient breathing exercises to assist with the appropriate exchange of
oxygen and carbon dioxide.
• Administer oxygen, if appropriate.
• Observe the patient for signs or symptoms of respiratory alkalosis such as tachypnea,
restlessness, agitation, tetany, numbness, seizures, muscle cramps, dizziness, or tingling
fingertip.
• Instruct patient to breathe deeply and slowly; performing this type of breathing
exercise into a paper bag decreases hyperventilation and quickly helps the patient’s
breathing return to normal.

Diagnostic / Indications or Date Results Normal Analysis and


Laboratory Purpose ordered values Interpretation of
Procedure Date (units used Results
results in the
were hospital)
released
Potassium These serum and Date 5.1 mEq/L 3.5-5.1 The patient has
urine tests ordered mEq/L normal level of
evaluate fluid and 02/17/09 potassium which
electrolyte means that there
balances and is normal
identify renal Date osmotic pressure
dysfunction. results and cardiac and
Potassium is were neuromuscular
critical to released electrical
neuromuscular 02/17/09 conduction.
function,
specifically
skeletal and
cardiac muscle
activity.

Nursing Responsibilities
Prepare your patient
• Explain that the test is helpful in identifying chemical imbalances, specifically potassium.
Perform procedure
SERUM
• Collect 5-10 mL of venous blood in a red-top or green-top tube.
• Collect blood form the arm opposite an intravenous infusion of electrolyte solution.
• Do not allow patient to pump the arm with a tourniquet in place.
URINE
• Use a clean 3-L container and no preservative.
• Carefully collect a 24-hour urine sample.
• Keep the collection container on ice or refrigerated during the collection period.
Care after test
• Monitor for signs and symptoms of hypokalemia including weakness, paralysis,
hyporeflexia, ileus, dizziness, thirst, increased sensitivity to digoxin and cardiac
dysrhythmias.
• Monitor for signs and symptoms of hyperkalemia including weakness, paralysis,
irritability, nausea and vomiting, intestinal colic, and diarrhea.
• Monitor intake and output.
• Monitor vital signs every 4 hours and note changes in blood pressure and pulse.
• Teach patient and family that potassium is found in most foods. Cereals, dried peas
and beans, fresh vegetables, fresh or dried fruits, bananas, orange juice, nuts, fresh fish
are excellent sources.
• Teach patient to avoid laxative or diuretic abuse.
Diagnostic / Indications or Date Results Normal Analysis and
Laboratory Purpose ordered values Interpretation of
Procedure Date (units used Results
results in the
were hospital)
released
Sodium These serum and Date 137 mEq/L 135-145 The patient’s
urine tests for ordered mEq/L sodium level is
sodium levels 02/17/09 within normal
evaluate fluid and values which
electrolyte means there is
balance as well as Date water balance
renal or adrenal results and extracellular
disorders. Sodium were fluid replacement
is the main cation released is functioning.
of the 02/17/09
extracellular fluid
and is a critical
factor in acid-base
balance and the
water balance
between blood
and body tissues.

Nursing Responsibilities
Prepare your patient
• Explain that this test is helpful in evaluating the balance of chemicals in the body,
particularly sodium. Explain how sodium balance is regulated by the kidneys and two
glands near the kidneys called the adrenals.
Perform procedure
SERUM
• Collect 5-7 mL of venous blood in a red-top tube.
• Avoid collecting blood near a vein where saline or electrolyte solutions are infusing.
URINE
• Collect 24-hour urine specimen without preservatives.
• Keep specimen refrigerated or on ice during the collection period.
• Instruct the client that all urine voided in the next 24-hour period must be added to the
collection container.
Care after test
• Monitor intake and output. Report urine output less than 30 mL/hour in adults, less
than 1 mL per kg body weight per hour in infant and children.
• Monitor urine specific gravity every 8 hours and as indicated.
• Monitor vital signs every 4 hours and note changes in blood pressure and pulse.
• Weigh daily; assure the clothing, time of day, and scales are consistent.
• Assess breathing sounds every 4 hours for presence of rales.
• Assess for dependent edema in ankles or sacral area.
• Monitor for signs and symptoms of hyponatremia including fatigue, weakness,
confusion, stupor, anorexia, apprehension, headache, nausea and vomiting, diarrhea and
abdominal pain.
• Monitor for signs and symptoms of hypernatremia including dry mucous membranes,
fever, sweating, increased thirst, oliguria, flushed skin, agitation, restlessness, and
decreased reflexes.
• Teach patient to avoid or increase dietary sodium depending on diet prescription.
High-sodium foods include bacon, ham, cheese, celery, pickles, and tomato juice.

Diagnostic / Indications or Date Results Normal Analysis and


Laboratory Purpose ordered values Interpretation of
Procedure Date (units used Results
results in the
were hospital)
released
GLUCOSE: This blood test Date 102 mg/dL 76-111 The patient’s
Random detects alterations ordered mg/dL glucose is within
Blood Sugar in glucose 02/17/09 normal values
metabolism, and which mean that
is most often used randomly
as a random Date collected blood
screen for glucose results from the patient
level or when a were yields a normal
patient is released level of sugar.
unconscious for 02/17/09
unknown reasons.
It may also help
diagnose diabetes
mellitus or
evaluate the
control of this
disease.

Nursing Responsibilities
Prepare your patient
• Explain that this test is to measures the amount of sugar in the bloodstream and is
often used to look for any sign of sugar diabetes (diabetes mellitus).
• Do not give insulin, oral antidiabetic agents or food until after the blood is drawn.
• There is no period of fasting for this random analysis of blood glucose.
Perform procedure
• Perform a venipuncture and collect 5 cc of blood into a red-top or green-top tube.
• Patient or staff may instead use a bedside glucometer after obtaining a sample from a
fingerstick. Follow the manufacturer’s directions for usage.
Care after test
• Administer any medications withheld for this test.
• Resume patient’s normal diet immediately to prevent hypoglycemia.
• Assess for symptoms such as nausea, light-headedness, hunger, and tremors, which
may signify hypoglycemia.
• If the blood glucose is extremely low, administer a source of carbohydrates by
offering crackers, orange juice, or other high-carbohydrate foods to patient who has no
alteration in level of consciousness
• Inform the patient and family that continued elevated blood glucose levels may
indicate sugar diabetes (diabetes mellitus).
• Begin or reinforce diabetic teaching as indicated.
• Encourage patient to self-monitor blood glucose.
• Encourage patient and family to join diabetes support groups.
Diagnostic / Indications or Date Results Normal Analysis and
Laboratory Purpose ordered values (units Interpretation
Procedure Date used in the of Results
results hospital)
were
released
2D This ultrasonic Date 1. LV size Normal Some of the
Echocardiogram test diagnoses ordered with appearance valves of the
And Color abnormalities 02/17/09 hyperthropie in the size, patient’s heart
Doppler in anatomy and d wall position, are thickened
valvular (concentric structure, which may
function within Date LVH) with and indicate mitral
the heart. As in results adequate movements valve prolapse,
other were contractility of the heart valvular
ultrasound released and systolic valves stenosis,
tests, sound 02/18/09 function with visualized ventricular
waves are Doppler and recored dysfunction,
bounced off the evidence of in a pericardial
heart using a impaired LV combination effusion,
transducer to relaxation. of ultrasound valvular
image the heart 2. LA, RA, modes; and insuffiency or
in motion as RV, MPA normal heart regurgitation.
well as its and aortic muscle walls
valves and root of both
vessels. dimension. ventricles
While Color 3. Thickened and left
Flow Doppler aortic valve atrium, with
is used cusps with adequate
primarily to no restriction blood filling.
diagnose of motion Established
arterial and with aortic walues for
venous disease annular the
as ell as calcification measurement
anatomical noted (aortic of heart
abnormalities sclerosis). activities
in vessels, 4. Thickened obtained by
vascular grafts, mitral valve the study
and the heart. leafted with may vary by
no restriction physician
of motion and
with mitral institution.
annular
calcification
noted (mitral
sclerosis).
5. Structurally
normal
tricuspid and
pulmonic
valves.
6. No
intracardiac
thrombus or
pericardial
effusion
noted.
7. There is a
Nursing Responsibilities
Prepare your patient
• Inform the patient that the procedure assesses heart function
• Inform the patient that the procedure is performed in a special department by a
technologist and takes approximately 30 to 60 minutes, and that there is no risk of
radiation form the study.
• Obtain a list of medication the patient is taking.
Perform procedure
• Place the patient in a supine position on a flat table with foam wedges to help
maintain position and immobilization. Ask the patient to lie very still during the
procedure because movement will produce unclear images.
Care after test
• Cleanse the patient’s skin of remaining gel or mineral oil.
• Instruct the patient to resume normal activity and diet unless otherwise indicated.
• Encourage family and significant others to learn cardiopulmonary resuscitation.

Diagnostic / Indications or Date Results Normal Analysis and


Laboratory Purpose ordered values Interpretation of
Procedure Date (units used Results
results in the
were hospital)
released
GLUCOSE: This blood test Date 122.08 mg/dL 76-111 The patient’s
Fasting detects alterations ordered mg/dL blood after
Blood Sugar in glucose 02/17/09 fasting for 8-12
metabolism, most hours may
often to diagnose indicate diabetes
diabetes mellitus Date mellitus,
or help evaluate results hypokalemia,
the control of this were pancreatitis or
disease. The blood released chronic liver
glucose will 02/18/09 disease. But
fluctuate results may be
depending upon increased by
the patient’s intravenous
activity level and infusions, stress
length of time or medications
form the last meal. such as beta-
Fasting blood blockers.
glucose is used as
a baseline
measurement, as it
is not influenced
by dietary intake
as a variable
factor.

Nursing Responsibilities
Prepare your patient
• Explain that this test is used to determine blood levels of sugar.
• Ensure that the patient fasts from food for 8-12 hours before the test. They may drink
water.
• Do not give their insulin/antidiabetic agents until the blood is drawn. Confer with the
primary care provider if symptoms of hyperglycemia develop during the period that
insulin is withheld.
Perform procedure
• Collect 5 mL of venous blood into red (for plasma level) or green-top (for whole
blood) tube.
• Although this test is usually done using venous blood, it may also be performed on
capillary blood using a glucometer and reagent strips. If so, follow specific directions for
the particular brand of machine and reagent strips.
Care after test
• Administer medications previously withheld for testing purposes.
• Ensure the patient receives food promptly in accordance with the ordered diet.
• Observe for signs and symptoms of hypoglycemia such as diaphoresis, palpitations,
tachycardia, and changes in the level of consciousness.
• Observe for signs and symptoms of hyperglycemia such as thirst, increased urination,
hunger, mental status change, and fruity or acetone breath.
• Monitor fluid and electrolyte status.
• Teach patient or family to self-monitor their blood sugar if appropriate.
• Teach signs and symptoms of hypoglycemia including nausea, light-headedness,
hunger, and shakes.
• Teach patient and family to administer orange juice, hard candy, or another suitable
source of quick sugar for these symptoms if the patient’s level of consciousness is
unimpaired.
Diagnostic / Indications or Date Results Normal Analysis and
Laboratory Purpose ordered values Interpretation of
Procedure Date (units used Results
results in the
were hospital)
released
Blood Urea This test measures Date 13.8 mg/dL 7-21 mg/dL The result is
Nitrogen renal function and ordered within the normal
hydration. Urea, 02/17/09 values which
the end product of mean that the
protein and amino liver and kidneys
acid metabolism Date of the patient are
in the liver, enters results functioning
the blood and were normally.
passes to the released
kidneys for 02/18/09
excretion. The
blood urea
nitrogen is,
therefore, an
indicator of both
the metabolic
function of the
liver and the
excretory function
of the kidney.

Nursing Responsibilities
Prepare your patient
• Explain that this test is helpful in discovering any problem is the kidney.
• The most accurate BUN testing occurs when food, fluids, or medications have been
restricted for 8 hours.
Perform procedure
• Collect 5 mL of venous blood in a red-top tube.
Care after test
• Assess for dehydration by noting poor skin turgor, increased pulse and respiration,
dry mucous membrane, and decreased urine output. Encourage an increased oral intake
unless contraindicated.
• Monitor for lethargy, confusion, and change in mental status. Provide necessary
safety precaution.
• Monitor for signs and symptoms of uremia including nausea, vomiting, stupor,
peripheral edema, decreased urine output, dyspnea, jugular vein distention, and weight
gain.
• Compare BUN to serum creatinine. Elevations in both strongly suggest renal disease.
• Observe for signs and symptoms of anemia, as an elevated BUN is associated with
decreased red blood cells.
• Observe for signs and symptoms of gastrointestinal bleeding, which is associated with
an elevated BUN.
• Teach patient and family regarding specific dietary prescription. In renal failure, the
most common diet prescription is low protein, high calorie, low sodium, and low
potassium.
• Teach patient the importance of maintaining fluid restriction when indicated.
• Instruct patient to report evidence of any anemia (weakness, shortness of breath,
palpitations) or bleeding.
• Teach the patient the purpose, action, and side effects of any prescribed medications.

Diagnostic / Indications or Date Results Normal Analysis and


Laboratory Purpose ordered values Interpretation of
Procedure Date (units used Results
results in the
were hospital)
released
Creatinine This blood test is Date 1.0 mg/dL 0.5-1.69 The result is
essential in the ordered mg/dL within normal
evaluation of renal 02/17/09 values which
function. mean that the
Creatinine is patient’s kidneys
constantly Date are functioning
excreted by the results normally.
kidneys. were
released
02/18/09

Nursing responsibilities
Prepare your patient
• Explain that this test is important to help understand how well the kidneys are
working.
Perform procedure
• Collect 5-7 mL of venous blood in a red-top tube.
Care after test
• Assess fluid and nutritional status of patient for clues of renal impairment and other
diseases causing changes in creatinine levels.
• Continuously monitor fluid through daily weights and intake and output recordings.
• Initiate safety precautions such as night lights for uremic patient (creatinine greater
than 7 mg/dL), because cognitive function may be impaired.
• For patient with oliguria, carefully assess for cardiac dysrhythmias because
hyperkalemia as common.
• If the patient is in end-stage renal failure, explain that eating large amounts of fish,
meat, and poultry can increase serum creatinine levels.
Diagnostic / Indications or Date Results Normal Analysis and
Laboratory Purpose ordered values Interpretation of
Procedure Date (units used Results
results in the
were hospital)
released
Uric acid This blood test Date 4.5 mg/dL Female: The result is
evaluates a variety ordered 2.5-7.0 within the normal
of condition 02/17/09 mg/dL values which
where there is mean that the
excessive patient’s uric
production and Date acid is normally
destruction of results produced and
cells, identifies were excreted by the
patients at risk for released kidneys.
renal calculi, and 02/18/09
evaluates the
severity of
toxemia of
pregnancy. Most
uric acid produced
daily is excreted
by the kidneys,
with a small
amount excreted
in the stool.

Nursing Responsibilities
Prepare your patient
• Explain that this test is performed to look for gout, kidney problems, or other
conditions where tissues may be damaged.
• Instruct the patient to fast for 8 hours before the test, if appropriate. (Check with the
laboratory as this requirement varies.)
Perform procedure
• Collect 5-7 mL of venous blood in a red-top tube.
Care after test
• Increase fluid intake, unless contraindicated, to prevent formation of renal stones if
hyperuricemia is suspected.
• If hyperuricemia is present, check the urine pH.
• Instruct patient with high uric acid levels to avoid foods high in purines such as organ
meats, sardines, scallops, anchovies, broth, mincemeat, shellfish, legumes, mushrooms,
and spinach.
• Advise the patient to decrease or eliminate alcoholic intake, since ethanol causes
renal retention of urate.
• Teach the patient, if appropriate, about drugs that are used to treat an acute attack of
gout such as colchicine and indomethacin and maintenance drugs such as probenecid,
sufinpyrazone, or allopurinol.
• Advise the patient with hyperuricemia to maintain a liberal fluid intake to decrease
the risk of renal stone formation.

Diagnostic / Indications or Date Results Normal Analysis and


Laboratory Purpose ordered values Interpretation of
Procedure Date (units used Results
results in the
were hospital)
released
SGOT/AST This blood test Date 8 mg/dL 5-40 mg/dL The result is
helps determine ordered within normal
the extent of 02/17/09 values. This test
damage to the is part of the liver
liver, heart or profile which
musculoskeletal Date means that the
system. This test results patient’s liver is
is often performed were functioning
in conjunction released normally.
with the alanine 02/18/09
aminotransferase
(ALT) test. Both
AST and ALT are
enzymes found
mainly in liver,
heart, and skeletal
muscle tissue;
only small amount
are found in
kidney tissue.

Nursing Responsibilities
Prepare your patient
• Explain that this test is important to help understand either how well the liver is
functioning or to help diagnose a heart attack.
• Do not administer intramuscular injections prior to drawing the blood sample for AST
to be sure results are not altered by muscular trauma.
Perform procedure
• Collect 7-10 cc of venous blood in a red-top tube.
• Unless otherwise ordered or indicated, draw serial samples at the same time each say.
• Handle the sample gently to avoid hemolysis.
Care after test
• Assess patient for unusual bruising or prolonged bleeding from venipuncture site.
Delayed clotting is a complication of severely impaired liver function.
• Assess for skin and sclera of eyes for jaundice and note findings. Protect the skin
form damage due to pressure or friction.
• Assess for occult gastrointestinal bleeding with routine stool guaise testing.
Esophageal varices and mucosal bleeding are complications of liver disease.
• Instruct the patient and family to report any jaundice-yellow discoloration of skin or
whites of the eyes.
• For patient with severely impaired liver function, instruct patient and family to report
unusual or increased bruising and tarry stools. Instruct them to use electric razors and
nonskid shoes to avoid falls and injuries.

Diagnostic / Indications or Date Results Normal Analysis and


Laboratory Purpose ordered values Interpretation of
Procedure Date (units used Results
results in the
were hospital)
released
Urinalysis This test screens Date Color: Yellow Color: Pale,Yellow in color
for abnormalities ordered straw- may indicate
within the urinary 02/17/09 Specific colored to concentration of
system as well as Gravity: 1.030 amber- urine. The
for systemic colored appearance of the
problems that may Date Sugar: + 1 urine may
manifest results Appearance: indicate the
symptoms were Appearance: clear to presence of white
through the released Slightly turbid slightly blood cells, pus,
urinary tract. 02/18/09 hazy or uric acid. A
Abnormalities in Reaction: pH positive result in
any finding 6.0 Glucose: sugar may
warrant further (-); indicate severe
related testing and Albumin: (-) <0.5 g/24 stress, or
investigation. hours hypothalamic
Pus cells: 4-8 dysfunction.
Led cells: 3-5 pH: 4.5-8.0 pH and specific
gravity are
Epithelial Specific within normal
cells: Rare gravity: values. Led cells,
1.003-1.035 pus cells,
Amorphous epithelial cells,
urates: Rare Epithelial and amorphous
cells: Few urates are within
their values as
well.

Nursing Responsibilities
Prepare your patient
• Explain that this test is to look for problems with urine and the organs that help form
it.
• Advise the client to wash the perineal area prior to collecting the specimen to avoid
contamination with vaginal secretions or stool.
• Inform the patient that a specimen from the first morning urination is preferred since
it is usually concentrated and more likely to reveal abnormalities and formed substances.
• Describe the procedure for collecting a clean-catch or midstream specimen if
indicated.

Perform procedure
• Collect approximately 50 mL of urine, freshly voided into a clean, dry container. A
fresh specimen may be taken from a urinary catheter according to agency policy.
• Collect a clean-catch or midstream specimen if the specimen is likely to be
contaminated by vaginal discharge, bleeding, or feces.
Care after test
• Note the appearance of the specimen and document this according to policy.
• Review the specimen collection process with the patient to rule out contamination
with other substances.
• Assess the patient for signs and symptoms of urinary tract infection such as dysuria,
urgency, and frequency.
• Teach women the importance of emptying the bladder at least every 4-6 hours to
prevent stasis of urine. Also, advise them to void immediately after intercourse.
• Advise women to shower rather than tub bathe, especially with bubble bath, due to
the irritation to the urethra.
• If antibiotics are prescribed, stress the importance of taking all the medication, even
after symptoms have disappeared.

Diagnostic / Indications or Date Results Normal values Analysis and


Laboratory Purpose ordered (units used in Interpretation of
Procedure Date the hospital) Results
results
were
released
Gram Stain It is used to Date Gram (+) Gram stain: Few gram
classify bacteria ordered bacilli: Few A normal positive and
AFB stain as either gram- 02/18/09 result means gram negative
positive or gram- Gram (-) no bacteria bacteria were
KOH negative based bacilli: Few were seen in seen and more of
preparation upon their ability Date the sample. fungal elements.
to retain the results Fungal The sputum is Fungal infection
crystal violet were elements: clear, thin, was then
stain following released Moderate and odorless. identified.
decolorization. In 02/18/09
addition, the Yeast cells: AFB stain:
Gram stain Rare Negative for
provides vital acid-fast
diagnostic Pus cells: 4- bacilli.
information, aids 8/HPF
in the selection of
culture media, Epithelial KOH
and dictates cells: 2- preparation:
initial selection of 4/HPF A normal, or
antibiotics for negative,
treatment and AFB stain: KOH test
antimicrobial No acid fast shows no
susceptibility bacilli seen fungi (no
testing.The Gram dermatophytes
stain is used to KOH or yeast).
detect the preparation:
presence of Positive for
bacteria, yeast, fungal
and other cells in elements
direct smears
prepared from
swabs, aspirates,
secretions, etc.
from any part of
the body where
infection is
suspected. Acid
fast bacilli (AFB)
stain is helpful in
rapid
identification of
bacterial infection
so that therapy
can be initiated in
a timely manner.
Potassium
Hydroxide
(KOH)
preparation is
used to identify
fungal infection.

Nursing Responsibilities
Prepare your patient
• Obtain a history of the patient’s complaints, including a list of known allergens.
• Obtain a history of the patient’s gastrointestinal, genitourinary, immune,
reproductive, and respiratory system, as well as results of previously performed tests and
procedures.
• There are no food, fluid, or medication restrictions unless by medical direction.
• Review the procedure with the patient.
• The time it takes to collect a proper specimen varies according to the patient’s level
of cooperation as well as the specimen collection site.
Perform procedure
• Label the specimen, and promptly transport it to the laboratory.
Care after test
• Instruct the patient to resume usual diet and medication as directed by the health care
practitioner.
• Instruct the patient to perform mouth care after the specimen has been obtained (for
sputum specimens).
• Note the color, consistency, and volume of the specimen collected.
• Evaluate test results in relation to the patient’s symptoms and other tests performed.
Related laboratory tests include bacterial and viral cultures.

Diagnostic / Indications or Date Results Normal Analysis and


Laboratory Purpose ordered values Interpretation of
Procedure Date (units used Results
results in the
were hospital)
released
Total This blood test Date 52 g/L 58-80g/L There is marked
protein helps diagnose ordered decrease in
hepatic, 02/18/09 protein of patient
gastrointestinal, which may
and renal disease; indicate
protein Date malabsorption
abnormalities; results syndromes,
cancer; and blood were malnutrition,
dyscrasias. This released hypervolemia,
test measures 02/19/09 hepatic
serum albumin dysfunction, or
and globulins, hyperthyroidism.
which are the
body’s major
blood proteins.

Albumin Albumin is Date 21 g/L 35-60 g/L The albumin of


formed in the liver ordered the patient is
and comprises 02/18/09 significantly
50%-60% of the decreased; this
total serum may indicate
protein. Its Date malnutrition,
primary function results severe
is to maintain were malabsorption,
serum colloid released third space loss,
osmotic pressure. 02/19/09 diffuse liver
disease, or
intestinal
obstruction.
Globulin The globulin Date 31 g/L 18-32 g/L The result is
molecules are ordered within the normal
much larger than 02/18/09 range.
the albumin
molecules.
Date
results
were
released
02/19/09
A/G ratio The albumin to Date 0.67 g/L 1.1-2.5 g/L There was a
globulin ratio is ordered marked decrease
useful in the 02/18/09 in albumin to
evaluation of liver globulin ratio
and kidney which may
disease. It Date indicate
assesses results malabsorption
nutritional status were and malnutrition.
of hospitalized released
patients, 02/19/09
especially
geriatric patients.
Nursing Responsibilities
Prepare your patient
• Explain that the test is important to help check nutritional status, liver and kidney
function, water balance, and to diagnose some diseases.
• Instruct the patient that foods high in fat content should be avoided for 24 hours
before the test.
Perform procedure
• Collect 5-7 mL of venous blood in a red-top tube.
• Note patient’s activity level before the sampling on the laboratory slip.
Care after test
• Observe for signs and symptoms of abnormalities in blood protein such as recurring
infections, peripheral edema, hepatomegaly, brittle hair, decreased body weight, and
dehydration.
• Evaluate other diagnostic tests such as the serum protein electophoresis, urine protein,
hematocrit, hemoglobin, red blood cell count, calcium, bilirubin, antibodies, plasma
protein S, and or immunoelectrophoresis.
• If the test results indicate a protein deficiency, encourage the increased consumption
of protein-rich foods, such as meat products, eggs, cheese, and beans.
• Teach patient and family to notify staff of edema, weight gain, and shortness of
breath, all signs of fluid retention into tissue spaces.

V. THE PATIENT AND HIS ILLNESS

The Human Respiratory System

This system includes the lungs, pathways connecting them to the outside environment, and
structures in the chest involved with moving air in and out of the lungs.
Air enters the body through the
nose, is warmed, filtered, and passed
through the nasal cavity. Air passes the
pharynx (which has the epiglottis that
prevents food from entering the
trachea).The upper part of the trachea
contains the larynx. The vocal cords are
two bands of tissue that extend across the
opening of the larynx. After passing the
larynx, the air moves into the bronchi that
carry air in and out of the lungs.

Bronchi are reinforced to prevent


their collapse and are lined with ciliated
epithelium and mucus-producing cells.
Bronchi branch into smaller and smaller
tubes known as bronchioles. Bronchioles
terminate in grape-like sac clusters known as
alveoli. Alveoli are surrounded by a network
of thin-walled capillaries. Only about 0.2
µm separate the alveoli from the capillaries
due to the extremely thin walls of both

structures.

The lungs are large, lobed, paired organs


in the chest (also known as the thoracic
cavity). Thin sheets of epithelium
(pleura) separate the inside of the chest
cavity from the outer surface of the lungs. The bottom of the thoracic cavity is formed by the
diaphragm.

Ventilation is the mechanics of breathing in and out. When you inhale, muscles in the chest
wall contract, lifting the ribs and pulling them, outward. The diaphragm at this time moves
downward enlarging the chest cavity. Reduced air pressure in the lungs causes air to enter the
lungs. Exhaling reverses theses steps.

The Alveoli and Gas Exchange

Diffusion is the movement of materials


from a higher to a lower concentration.
The differences between oxygen and

carbon dioxide concentrations are measured


by partial pressures. The greater the
difference in partial pressure the greater the
rate of diffusion.

Respiratory pigments increase the oxygen-


carrying capacity of the blood. Humans have
the red-colored pigment hemoglobin as their
respiratory pigment. Hemoglobin increases
the oxygen-carrying capacity of the blood between 65 and 70 times. Each red blood cell has
about 250 million hemoglobin molecules, and each milliliter of blood contains 1.25 X 1015
hemoglobin molecules. Oxygen concentration in cells is low (when leaving the lungs blood is
97% saturated with oxygen), so oxygen diffuses from the blood to the cells when it reaches
the capillaries.

Carbon dioxide concentration in metabolically active cells is much greater than in capillaries,
so carbon dioxide diffuses from the cells into the capillaries. Water in the blood combines
with carbon dioxide to form bicarbonate. This removes the carbon dioxide from the blood so
diffusion of even more carbon dioxide from the cells into the capillaries continues yet still
manages to "package" the carbon dioxide for eventual passage out of the body.

In the alveoli capillaries, bicarbonate combines with a hydrogen ion (proton) to form
carbonic acid, which breaks down into carbon dioxide and water. The carbon dioxide then
diffuses into the alveoli and out of the body with the next exhalation.

Control of Respiration

Muscular contraction and relaxation controls the rate of expansion and constriction of the
lungs. These muscles are stimulated by nerves that carry messages from the part of the brain
that controls breathing, the medulla. Two systems control breathing: an automatic response
and a voluntary response. Both are involved in holding your breath.

Although the automatic breathing regulation system allows you to breathe while you sleep, it
sometimes malfunctions. Apnea involves stoppage of breathing for as long as 10 seconds, in
some individuals as often as 300 times per night. This failure to respond to elevated blood
levels of carbon dioxide may result from viral infections of the brain, tumors, or it may
develop spontaneously. A malfunction of the breathing centers in newborns may result in
SIDS (sudden infant death syndrome).

As altitude increases, atmospheric pressure decreases. Above 10,000 feet decreased oxygen
pressures causes loading of oxygen into hemoglobin to drop off, leading to lowered oxygen
levels in the blood. The result can be mountain sickness (nausea and loss of appetite).
Mountain sickness does not result from oxygen starvation but rather from the loss of carbon
dioxide due to increased breathing in order to obtain more oxygen.

BOOK-BASED PATHOPHYSIOLOGY
 Schematic Diagram

Bronchiec
Predisposing Factors: Precipitating Factors:
 Recurrent Upper & Lower respiratory  Congenital disease such
infections in early childhood as cystic fibrosis (Genetic
 Measles Disorder)
 Influenza  Idiopathic causes
 Tuberculosis
 Immunodeficiency disorders
 Diffused airway injury
 Airway obstruction
 Immunodeficiency

Pulmonary infections damaging the


bronchial walls
Productive
cough
(purulent
sputum) Inflammation of the bronchial walls

Airway
obstruction Loss of supporting structures of the
(dyspnea) bronchi

Abnormal breath Permanent distention and distortion of


sounds (rales & bronchial walls
crackles upon
auscultation)

Impaired mucociliary
clearance

Dilated bronchial tubes Retention of secretions and


amounts to lung abscess subsequent obstruction affects
peribronchial tissues

Excessive exudates
Hemoptysis drains freely through the Inflammatory scarring / fibrosis of
bronchus bronchus replace the functioning
of lung tissue

A segment or lobe of
lung collapse
(bronchiectasis)
Respiratory
insufficiency

Respiratory
insufficiency

Reduced vital Decreased Increased ratio of


capacity ventilation residual volume to
total lung capacity

Ventilation – perfusion
imbalance

Hypoxemia Cyanosis (clubbing of


fingers)

 Synthesis of the disease


The inflammatory process associated with frequent pulmonary infections damages
the bronchial wall, causing a loss of its supporting structure and resulting in thick
sputum that ultimately obstructs the bronchi. The walls become permanently distended
and distorted, impairing mucociliary clearance. The inflammation and infection extend
to the peribronchial tissues; in the case of saccular bronchiectasis, each dilated tube
virtually amounts to a lung abscess, the exudates of which drains freely through the
bronchus. Bronchiectasis is usually localized, affecting a segment or lobe of a lung,
most frequently the lower lobes.
The retention of secretions and subsequent obstruction ultimately cause the alveoli
distal to the obstruction to collapse (atelectasis). Inflammatory scarring or fibrosis
replaces functioning lung tissue. In time, the patient develops respiratory insufficiency
with reduced vital capacity, decreased ventilation, and an increased ratio of residual
volume to total lung capacity. There is impairment in the matching of ventilation to
perfusion (ventilation-perfusion imbalance) and hypoxemia.

 Predisposing / Precipitating factors


Bronchiectasis may be caused by a variety of conditions, including pulmonary
infections and obstruction of the bronchus diffuse airway injury; genetic disorder (e.g,
cystic fibrosis); and abnormal host defense (e.g, humoral immunodeficiency). A
person may be predisposed to bronchiectasis (history of recurrent infections, measles
influenza, tuberculosis, and immunodeficiency disorders).

 Signs and symptoms


Clinical manifestations includes chronic cough and production of copius purulent
sputum, which has a quality of “layering out” into three layers on standing a frothy top
layer, a middle clear layer, and a dense particulate bottom layer. Hemoptysis, clubbing
of fingers, and repeated episodes of pulmonary infections are also manifested.

CLIENT-BASED PATHOPHYSIOLOGY
 Schematic Diagram

Bronchiec

Predisposing Factors: Precipitating Factors:


 Recurrent Upper & Lower  Weak immune system
respiratory infections in early  Idiopathic causes
childhood
 Recurrent Pneumonia
Pulmonary infections damaging the
bronchial walls

Productive cough
(purulent sputum)
February 17, 2009 Inflammation of the bronchial walls

Stabbing chest pain


Upon coughing in Loss of supporting structures of the
February 17, 2009 bronchi

Abnormal breath Permanent distention and distortion of


sounds (rales & bronchial walls
crackles upon
auscultation)

Rales in February 17, Impaired mucociliary


2009; crackles on both clearance
lung fields in February
20 & 21 2009

Dilated bronchial tubes Retention of secretions and


amounts to lung abscess subsequent obstruction affects
peribronchial tissues

Excessive exudates
Hemoptysis drains freely through the Inflammatory scarring / fibrosis of
April 2005 and bronchus bronchus replace the functioning
February 2008 of lung
A segment tissue
or lobe of lung
collapse (bronchiectasis)

First diagnosed on April


01, 2005
February 17, 2008
confined due to the cough
with the same diagnosis
Respiratory
insufficiency

Respiratory
insufficiency

Decreased
ventilation

Ventilation – perfusion
imbalance
Cyanosis (clubbing of fingers)
February 07, 2007
And at P.E. as of February 20, 2009

 Synthesis of the Disease


a. Predisposing / Precipitating Factors
The patient was born with a weak immune system since childhood. She experienced
recurrent upper and lower respiratory infections such as cough, colds, and fever. Mild but
frequent infections which weakened her respiratory tract. She also had pneumonia before
and now to infections of it, one after the other.

b. Signs and Symptoms with rationale noting the specific dates


During the childhood of the patient she was frequently infected with mild illnesses
such as cough, fever, and colds. She was born weak and frail.
In April 1, 2005, she was diagnosed with Bronchiectasis by their doctor in the
monastery. He noticed the way Ms. Minnie cough and he told her to go to his clinic.
Several tests ere done afterwards, and the diagnosis was confirmed. She then started
taking medicines for this disease which lasted until 2007. Along with these, clubbing fo
fingers was also noted. The symptoms subside but the illness was not cured, it was non-
curable but not progressive, stated by the patient. In February 07, 2008, she was
diagnosed with pneumonia and a fungal infection. After being discharged she was given
cyclic medicines for 6 weeks.
First week of February, 2009, she was confined due to massive edema on her upper
and lower extremities. She was given treatment and was discharged few days after.
February 17, 2009, she experienced chronic cough and weakness. And another fungal
infection and pneumonia were diagnosed.

VI. THE PATIENT AND HIS CARE

A. IVFs, BT, NGT feeding, Nebulization, TPN, Oxygen Therapy, etc.


Medical General Indications / Date Ordered, Client’s
Management Description Purpose Date Performed, Response to
Date Changed Treatment
or D/C
Intravenous D5 NR 1L x 15 5 % Dextrose Date ordered: The fluid was
fluid (IVF) gtts/min in Balance 02/17/09 administered
Multiple Date performed: with no adverse
Replacement 02/17/09 reaction at first
Solution At 05:00 pm on the right arm
(D5NR): When Date Changed: but after
administered 02/19/09 approximately
D5 NM 1L x 15 intravenously, Date ordered: 1-2 hours of IV
gtts/min Ionosol T and 02/18/09 infusion (as
5% Dextrose Date performed: stated by the
Injection 02/19/09 patient) the fluid
provides a Date Changed: stopped
source of water, 02/20/09 dropping. The
electrolytes, and nurse on duty
D5 NR 1L x 15 Date ordered:
carbohydrate. was notified and
gtts/min 02/19/09
The solution she tried to
Date performed:
was originally reinsert the
02/20/09
designed as a needle but an
Date Changed:
pediatric artery was
02/21/09
fluid/electrolyte accidentally
D5 NM 1L x 15 replacement Date ordered: pricked and it
gtts/min formula, 02/20/09 became swollen.
providing Date performed: It was
nearly equal 02/21/09 transferred to
amounts of At 7pm the left arm.
sodium, Blood
potassium, and coagulated again
chloride; and so it was
phosphate and inserted on the
lactate are also left arm again.
present, along For the third
with dextrose. fluid, it was
administered
5 % Dextrose again on the
in Balance right arm after
Multiple the swelling had
Maintenance ceased. No
Solution further adverse
(D5NM): reaction was
When observed
administered afterwards.
intravenously,
Normosol-M
and 5%
Dextrose
Injection
provides water
and electrolytes
(with dextrose
as a readily
available source
of
carbohydrate)
for maintenance
of daily fluid
and electrolyte
requirements,
plus minimal
carbohydrate
calories.

Nursing Responsibilities
Prepare your patient
• Countercheck doctors order to IVF solution on hand.
• Check the expiration date.
• Check for clarity of the fluid.
• Explain the procedure to the patient.
• Check for the condition and size of the vein.
• Record things done and note patient’s response.
Perform procedure
• Perform peripheral venipuncture.
• Regulate according to doctors order.
• Observe for adverse reactions e.g. Swelling, obstruction.
• Record patient’s response.
Care after test
• Check for doctor’s order for discontinuing order or fluid to follow.
• Monitor IVF regulation as well as patency.
• Check for any swelling at the venipuncture site.

B. Drugs
Generic Name General Action Indication or Date Ordered, Client’s
and Brand Purpose why Date Started, Response to the
Name medication is Date Changed medication with
given for the or D/C actual side
particular effects
disease
condition or
signs and
symptoms
GENERIC Decreases It is indicated Date ordered: There were no
NAME: inflammation, for severe 02/17/09 adverse
Hydrocortisone mainly by inflammation, Date started: reactions
Sodium stabilizing adrenal 02/17/09 experienced by
succinate leukocyte sufficiency. the patient e.g.
lysosomal It is a hypersensitivity,
membranes; corticosteroid bruising,
BRAND suppresses hormone which hypokalemia.
NAME: immune increases
Solu-Cortef response;
stimulates bone
DOSE, marrow; and
ROUTE, influences
FREQUENCY: protein, fat, and
100mg IV Q6° carbohydrate
metabolism.

Nursing Responsibilities
Prior administration
• Always observe the 10 rights for medication administration.
• Determine whether patient is sensitive to other corticosteroids.
• For better results and less toxicity, give a once-daily dose in morning.
During administration
• Alert: only hydrocortisone sodium phosphate and sodium succinate can be given I.V.
• Always adjust to lowest effective dose.
• Monitor patient’s weight, blood pressure, and electrolyte level.
• Inspect patient’s skin for petechiae.
• Gradually reduce dosage after long-term therapy.
Care after administration
• Teach patient signs and symptoms of early adrenal insufficiency: fatigue, muscle
weakness, shortness of breath, dizziness, and fainting.
• Warn patient about easy bruising.

Generic Name General Action Indication or Date Ordered, Client’s


and Brand Purpose why Date Started, Response to the
Name medication is Date Changed medication with
given for the or D/C actual side
particular effects
disease
condition or
signs and
symptoms
GENERIC Selective, It is indicated Date ordered: There were no
NAME: competitive for asthma, 02/17/09 adverse
Montelukast leukotriene- allergic rhinitis Date started: reactions
sodium receptor antagonist or bronchial 02/17/09 experienced by
that reduces early asthma. the patient e.g.
and late-phase dental pain,
BRAND bronchoconstriction dyspepsia,
NAME: from antigen abdominal pain,
Kastair challenge. and rash.

DOSE,
ROUTE,
FREQUENCY:
100mg TAB
BID

Nursing Responsibilities
Prior administration
• Always observe the 10 rights for medication administration.
• Assess patient’s underlying condition and monitor patient for effectiveness.
• Drug isn’t indicated for use in patients with acute asthmatic attacks, status asthmaticus, or
as monotherapy for management of exercise-induced bronchospasm.
• Oral granules may be given without regard to meals.
During administration
• Inform the patient about the indication and action of the medication.
Care after administration
• Tell caregiver not to open packet until ready to use and after opening, to give the full
dose within 15 minutes. Tell her that if she’s mixing the drug with food, not to store
excess for future use and to discard the unused portion.
• Advise patient to take drug daily, even if asymptomatic, and to contact his prescriber
if asthma isn’t well controlled.
• Advise patient with known aspirin sensitivity to continue to avoid using aspirin and
NSAIDs during drug therapy.

Generic Name General Action Indication or Date Ordered, Client’s


and Brand Name Purpose why Date Started, Response to the
medication is Date Changed medication with
given for the or D/C actual side
particular effects
disease
condition or
signs and
symptoms
GENERIC Suppresses It is indicated to Date ordered: The patient
NAME: activity in reduce anxiety 02/17/09 stated that she
Hydroxyzine certain essential of patient. Date started: feels relaxed
Dihydrochloride regions of the 02/17/09 when this
subcortical area medication is
of the CNS. given to her.
BRAND NAME:
Iterax

DOSE, ROUTE,
FREQUENCY:
25mg TAB BID

Nursing Responsibilities
Prior administration
• Always observe the 10 rights for medication administration.
• If patient takes other CNS drugs, observe for over sedation.
• Elderly patients may be more sensitive to adverse anticholinergic effects; monitor
these patients for dizziness, excessive sedation, confusion, hypotension, and syncope.
During administration
• Inform patient about indication and action of the medication.
Care after administration
• Warn patient to avoid hazardous activities that require alertness and good
coordination until effects of drug are known.
• Tell patient to avoid alcohol while taking drug.
• Advise patient to use sugarless hard candy or gum to relieve dry mouth

Generic Name General Action Indication or Date Ordered, Client’s


and Brand Purpose why Date Started, Response to the
Name medication is Date Changed medication with
given for the or D/C actual side
particular effects
disease
condition or
signs and
symptoms
GENERIC Inhibits cell- It is indicated Date ordered: There were no
NAME: wall synthesis for the 02/17/09 adverse
Meropenem in bacteria. treatment of Date started: reactions
Trihydrate Readily fungal infection. 02/17/09 experienced by
penetrates cell the patient e.g.
wall of most headache, pain,
BRAND gram-positive vomiting,
NAME: and –negative anemia, and
Meronem bacteria to reach constipation.
penicillin-
DOSE, binding protein
ROUTE, targets.
FREQUENCY:
1g IV Q12°

Nursing Responsibilities
Prior administration
• Always observe the 10 rights for medication administration.
• Obtain specimen for culture and sensitivity test before giving. Begin therapy awaiting
test results.
• If seizures occur during therapy, stop infusion and notify physician. Dosage
adjustment may be needed.
During administration
• Monitor patient for signs and symptoms of superinfection. Drug may cause
overgrowth of nonsusceptible bacteria or fungi.
• Monitor patient’s fluid balance and weight carefully
Care after administration
• Instruct patient to report adverse reactions or signs and symptoms of superinfection.
• Advise patient to report loose stools to physician.

Generic Name General Action Indication or Date Ordered, Client’s


and Brand Purpose why Date Started, Response to the
Name medication is Date Changed medication with
given for the or D/C actual side
particular effects
disease
condition or
signs and
symptoms
GENERIC Mucolytic that It is indicated Date ordered: The patient
NAME: reduces the for adjunct 02/17/09 expectorated
Acetylcysteine viscosity of therapy for Date started: yellowish
pulmonary abnormal viscid 02/17/09 mucous
secretions by or thickened secretions after
BRAND splitting mucous administration
NAME: disulfide secretions. of medication.
Fluimucil linkages
between
DOSE, mucoprotein
ROUTE, molecular
FREQUENCY: complexes.
600mg TAB Also, restores
dissolve in liver stores of
50mL water glutathione to
TID treat
acetaminophen
toxicity.

Nursing Responsibilities
Prior administration
• Always observe the 10 rights for medication administration.
• Drug smells strongly of sulfur. Mixing oral form with juice or cola improves its taste.
• Monitor cough type and frequency.
During administration
• Use fresh oral dilution within 1 hour.
• Dilute oral dose (used for acetaminophen overdose) with cola, fruit juice, or water.
Care after administration
• Warn patient that drug may have a foul taste or smell that may be distressing.
• For maximum effect, instruct patient to cough to clear his airway before aerosol
administration.

Generic Name General Action Indication or Date Ordered, Client’s


and Brand Purpose why Date Started, Response to the
Name medication is Date Changed medication with
given for the or D/C actual side
particular effects
disease
condition or
signs and
symptoms
GENERIC It is a Underweight Date ordered: There were no
NAME: supplement for due to lack of 02/19/09 adverse
Pizotifen deficiency of appetite Date started: reactions
hydrogen vitamin B. It is associated w/ 02/19/09 experienced by
maleate also an appetite vitamin B the patient e.g.
enhancer. deficiency headache, pain,
secondary to vomiting,
BRAND impaired dietary anemia, and
NAME: intake or constipation.
Mosegor Vita absorption; old
age when
TAB BID Q12° prevention of
deficiency of B-
group vitamin is
indicated.

Nursing Responsibilities
Prior administration
• Always observe the 10 rights for medication administration.
• Explain to the patient the indication and action of the medication.
• Counter check doctor’s order with drug on hand.
During administration
• Instruct the patient to take the medication with or without meals; taken best before meals
to improve appetite.
Care after administration
• Observe for any side effects.

Generic Name General Action Indication or Date Ordered, Client’s


and Brand Purpose why Date Started, Response to the
Name medication is Date Changed medication with
given for the or D/C actual side
particular effects
disease
condition or
signs and
symptoms
GENERIC It inhibits the It is an anti- Date ordered: There were no
NAME: cytochrome P- infective 02/19/09 adverse
Voriconazole 450-dependent specifically Date started: reactions
synthesis of anti-fungal 02/19/09 experienced by
ergosterol, a indicated for the the patient e.g.
BRAND vital component patient’ fever, headache,
NAME: of fungal cell hypokalemia,
Vfend membranes. chills, and
pruritus.
200mg/vial IV

Nursing Responsibilities
Prior administration
• Always observe the 10 rights for medication administration.
• Monitor liver function test results at start of and during therapy. Monitor patients who
develop abnormal liver function test results for more severe hepatic injury. If patient
develops signs and symptoms of liver disease, drug may need to be stopped.
During administration
• Inform the patient about the indication and action of the medication.
• Monitor renal function during treatment. For patients with creatinine clearance less than
50 ml/minute, give the oral form.
Care after administration
• Tell patient to avoid strong, direct sunlight during therapy.
• Tell patient to discard any unused portion of suspension after 14 days.

C. Diet
Type of diet General Action Indication or Date Ordered, Client’s
Purpose Date Started, Response and/or
Date Changed reaction to diet
or D/C
Soft diet with This type of diet Indicated for Date ordered: Since the patient
aspiration is often used patients unable 02/17/09 was oriented and
precaution during to consume a Date started: understands
transition from regular diet and 02/17/09 needed
liquid diet to patients wild interventions,
regular or mild G.I. she followed
general diets. problems. It meticulously
Whole foods was with with the doctors
low in fiber and aspiration prescriptions.
only lightly precaution so as Food that is
seasoned foods to avoid airway prepared by the
are used. Food obstruction like hospital is likely
supplements or that of a regular consumed. And
between meals diet. she was told to
snack may be notify the staff
used if needed nurses if
to add aspiration
Kcalories. occurs.
Aspiration
precaution is
indicated to
avoid incidents
of airway
obstruction
which may be
cause harmful
effects to the
patient.

Nursing Responsibilities
Prior
• Verify doctor’s order.
• Explain the diet prescribed to the patient.
• Identify foods that are allowed to be taken by the patient such as fluids, meat that are
tender in consistency, milk, and fruits such as banana.
During
• Ensure that the patient strictly follow the diet.
After
• Tell the patient to report immediately if any aspiration occurs.

D. ACTIVITY
Type of General Indication or Date Ordered, Client’s
exercise description Purpose Date Started, Response and/or
Date Changed reaction to
or D/C activity
Keep rested An activity Indicated to Date ordered: For two days
where strenuous avoid fatigue 02/18/09 NPI, patient was
activities should and difficulty of Date started: seen lying on
be avoided. Bed breathing and to 02/18/09 bed. This means
rest should be promote that the patient
implemented expansion of complied with
but with lungs. the doctor’s
assisted order. The
bathroom patient also had
privilege limited to no
visitors giving
her lots of time
to rest. Mrs.
Minnie asks
assistance
whenever she
needs to go to
the bathroom.

Nursing Responsibilities
Prior
• Check doctor’s order for any other considerations needed.
• Explain the activity to the patient.
• Explain why it is important and what it could improve in her condition.
During
• Assess patient’s present condition.
• Reinforce information as appropriate.
After
• Note patient’s response to activity.
• Tell the patient to report immediately if difficulty in breathing, weakness, or fatigue
persists.
VII. NURSING CARE PLAN

INEFFECTIVE AIRWAY CLEARANCE


Assessment Nursing Scientific Objectives Nursing Rationale Evaluation
Diagnosis Explanation Interventions
Subjective: Ineffective Bronchiectasis is After 8 hours of • Elevate head of • To take The patient
“There is cough airway clearance a chronic nursing bed/change advantage of expectorated
with minimal related to irreversible intervention, the position every gravity, yellowish
secretions.” retained dilation of the patient will be two hours decreasing sputum/phlegm
secretions as bronchi and able to pressure in the of about 60 ml
Objective evidenced by bronchioles. expectorate diaphragm within 4 hours
patient productive and Such dilation of secretions to and demonstrated
manifested: ineffective the bronchial maintain/achieve • Encourage deep- • To maximize behavior of
• RR of 26 brpm cough. walls causes a patent airway. breathing and effort of following health
• Use of disruption of coughing inhalation teachings.
accessory normal air exercises
muscles pressure in the
• Productive bronchial tubes, • Encourage • Hydration can
cough causing airflow increase of fluid help liquefy
• Yellowish obstruction and intake at least 2 viscous
secretions of pooling of L/day secretions thus
approximatey sputum inside the improving
30 mL within 3 dilated areas secretion
hours instead of being clearance
• Crackles pushed upwards.
auscultated on Unable to • Provided • To report
both lung fields expectorate information changes in
secretions this about necessity color and
• Dryness of
now leads to of raising and amount to
mouth
ineffective expectorating determine if
• No adventitious airway clearance.
bowel sound secretions vs. medical
noted swallowing them intervention
may be needed
• Obtain and refer • To determine
specimen to if therapy is
laboratory as effective
ordered

• Administered • To metabolize
expectorants / secretions
bronchodilators
as ordered such
as:
 Solu-Cortef
100mg IV at 8
am;
 Montekulast
Na 10mg TAB
at 8 am;
 Fluimucil
600mg
dissolved in 50
ml water at 8
am and 1 pm.
INEFFECTIVE BREATHING PATTERN
Assessment Nursing Scientific Objectives Nursing Rationale Evaluation
Diagnosis Explanation Interventions
Subjective: Ineffective Repeated After 4 hours of • Auscultate • To evaluate The patient
“I use the breathing pattern episodes of nursing breath sounds presence / verbalized ways
oxygen only related to pulmonary intervention, the character of of achieving
when I’m having respiratory infection stressed patient will be breath sounds/ comfort and ways
difficulty in muscle fatigue as great risk to the able to verbalize secretions to perform to
breathing”. evidenced by use respiratory ways to maintain have an effective
of accessory muscles which comfort or relief • Administer • For respiratory
Objective: muscles and an leads to this from difficulty of oxygen at lowest management pattern.
patient RR of 26 brpm. bronchiectasis. breathing. concentration of underlying
manifested: With those indicated pulmonary
• RR of 26 frequent condition
• Deep shallow infections,
breathing muscles that are • Elevate HOB or • To promote
• Use of necessary for have patient sit physiological /
accessory normal up in bed as psychological
muscles respiratory appropriate ease of
• Minimal functions are maximum
difficulty of weakened. inspiration
breathing Retained
secretions also • Have patient • To correct
add to the breathe into a hyperventilatio
condition which paper bag, if n
obstructs airway appropriate
leading to
ineffective • Maintain calm • To limit level
breathing pattern. attitude while of anxiety
dealing with
patient and S.O
• Assist patient in • To promote
the use of relief from
relaxation difficulty of
technique such breathing
as deep
breathing,

• Stress the • To maximize


importance of respiratory
good posture and effort
effective use of
accessory
muscles
IMPAIRED GAS EXCHANGE
Nursing
Assessment Nursing Scientific
Planning Interventi Rationale Evaluation
Diagnosis Explanation
ons
Subjective: Ø Impaired gas There are many After 2hours of • Assess • To have a Patient
exchange RT millions of alveoli in nursing patient's baseline data. participated in
Objective altered oxygen each lung, and these intervention, the condition. To determine treatment
•Dyspnea supply as are the areas patient will be Monitored V/S manifestations regimen
•Shortness of evidenced by responsible for able to improved and recorded. of respiratory provided and
breath dyspnea, SOB, gaseous exchange. In ventilation, distress. improved
•Cyanosis (pale and cyanosis Bronchiectasis, the oxygenation, and ventilation and
palpebral secondary to retention of the participate in • Observe color • To note oxygenation as
conjunctiva, bronchiectasis. secretions in the treatment of skin and presence of evidenced by
poor capillary bronchial walls will regimen. nail beds. peripheral absence of signs
refill) affect the cyanosis and symptoms of
•Use of peribronchial tissues, indicating respiratory
accessory lung functioning will systemic distress.
muscles in be replace thus a hypoxemia.
breathing collapse in a lobe or
•Productive segment of the lung • Auscultate • To reveal
cough with will cause breath sounds presence of
yellowish respiratory pulmonary
sputum noted. insufficiency. The congestions and
small blood vessels indicate the
•Limited
in the lungs need for further
movements and
(capillaries) become evaluation.
needs assistance
leaky, and protein-
in repositioning
rich fluid seeps into •Assess mental •Restlessnes
•RR=26bpm the alveoli. This
•Body status. s, irritation,
results in a less confusion
temperature of functional area for
36.2ºC may reflect
oxygen-carbon hypoxemia/
•PR-83bpm dioxide exchange decreased
•BP- (ventilation- cerebral
130/70mmHg perfusion oxygenation
imbalance). The
patient becomes
relatively oxygen •Perform back •To
deprived, while rub promote
retaining potentially relaxation
damaging carbon and aid in
dioxide. The patient expectoratio
breathes faster and n of
faster, in an effort to
KNOWLEDGE DEFICIT
Assessment
Nursing Scientific Nursing Evaluatio
Planning Rationale
Diagnosis Explanation Interventions n

Subjective: Knowledge The patient’s After 1 hour of • Review pathology, • Promotes Patient
“I don’t know how I deficit previous presentation and prognosis, and understanding verbalized
got this disease ” regarding inexperience with discussion of the future expectations. of current understanding
condition, hospitalization will disease, the patient situation and of appropriate
Objective: treatment and cause an insufficient will: importance of interventions
• Request for self care related knowledge in the cooperating with regards
information by to lack of patient as well as the Verbalize with to the disease.
frequent asking exposure to her significant others. understanding of treatment. Participated
about the condition as condition, with the
disease manifested by prognosis, and • Discuss debilitating • To provide discussion
• Confusion of frequent asking, complications. aspects of disease, information and
how the signs confusion, and length of that can performed her
and symptoms statement of Verbalize convalescence, and enhance activities
develop. misconception understanding of recovery coping and regarding self
• Statement of about the therapeutic expectations. help reduce care.
misconception disease entity. regimen and anxiety and
participate in excessive
treatment concern.
program.
• Stress importance • To prevent
Correctly perform of continuing recurrence of
activities of self- effective pneumonia
care. coughing/deep cause patient
breathing exercises. is still at high
risk even after
discharge.

• Discuss the reason • Encourage


for the treatment patient’s
and complications compliance
if untreated. with treatment
and
rationalization
of the
medicines
give.

• Outline steps to • Increase


enhance general natural
FATIGUE
Assessment
Nursing Scientific Nursing Evaluatio
Planning Rationale
Diagnosis Explanation Interventions n

Subjective: Fatigue related In Bronchiectasis, After 4 hours of • Determine degree of • Fatigue can be The patient
“I was not able to to difficulty of mucous production nursing sleep disturbance a consequence demonstrated
sleep last night.” breathing and is constant and intervention, the of, and/or behaviours of
sleep accumulates in the patient will exacerbated by, effective
Objective: deprivation brochial tree demonstrate sleep coping
Patient manifested: specifically the behaviours of deprivation mechanism.
• Difficulty of bronchioles. effective coping
breathing Retained secretions mechanism. • Plan interventions to • To maximize
• RR of obstruct the air allow individually participation
26brpm pathway causing adequate rest
• Use of difficulty in periods. Schedule
accessory breathing. The body activities for periods
muscles compensates by when patient has the
• Deep eye increasing the most energy.
bags respiratory rate, this
now can lead to • Monitor vital signs • Respiration is
sleep disturbance. specially respiration typically
Sleep is vital for rate elevated even
cells to regenerate, if at rest
especially for a
hospitalized person; • Provide quiet • Reduces
therefore it results to environment, cool stimuli that
weakness and room and decrease may aggravate
fatigue. sensory stimuli agitation and
fatigue

• Encourage patient to • To help


restrict activity and counteract
rest in bed as much effects of
as possible increased
metabolism

• Elevate head of bed • To promote


as appropriate lung expansion

• Provide • Presence of
supplemental anemia/hypoxe
oxygen, as indicated mia reduces
VIII. DISCHARGE PLAN

TOPIC: Promoting Home Health Care, Self-Based Care


TIME ALLOTMENT: 30 minutes
VENUE: Angeles Medical Center—Executive Room 226 (Bedside)

OBJECTIVE CONTENT TIME TEACHING STRATEGIES EVALUATION


ALLOTMENT

At the end of discussion Presentation of Disease 30 minutes Discussion At the end of discussion:

the patient shall have: Factors contributing to the Question and Answer • The patient was able to
development of the participate by asking

• Determine the Disease • INTRODUCTION questions and

good effects of health Health Promotion in Older  Ask the patient what is answering the

promotion and Adults her knowledge about the questions of the student

disease prevention • Self Care disease. nurse.

through home and • Home  Discussion of the • Patient was able to


community-based Health Care disease (Bronchiectasis) understand the disease
care. Patterns of Healthy eating  Presentation of the and how to prevent its

• Understand the and Healthy activity that factors contributing to the occurrence.

disease entity and its promotes general well- development of the disease • Patient was able to
prevention. being. know some tips for

• Improve and • MOTIVATION Home Health Care and


maintain the  Ask who among the Self Care at the same
patient’s quality of family had the disease, what time practice the
life. are their home treatments, and teaching given.
• Act correctly on how do they do to prevent the
how to protect their recurrence of the disease.
body through self-
care and • GENERALIZATION
management  Good effects of Healthy
teachings. eating and Healthy activity
• The patient can able particularly older adults
to spread the promote health and wellness.
information given
to them by telling • CLOSURE
her family  Ask the patient what did
member’s she learned from the health
especially older teaching given.
adults and
encourage them to
practice the same
activities to
promote general
well-being.
IX. LEARNING DERIVED FROM THE STUDY

The core purpose of this study is to have a deep comprehension about certain diseases
and to build a better understanding pertinent to those clients committed to our care. In
scenarios they are most vulnerable and susceptible to certain changes that we could
somehow supplement them with our own understanding and knowledge, hence a two-way-
process is the ultimate outcome. Truth of the matter is it is not limited on the superficial
understanding that student nurses or health care providers on the process of studying
patient’s condition will gain benefit with the course of action. But it is within the process
that, patients gain something from it for the reason that one of our job description is to aid
them health related teaching that will promote a better health condition for them.
Furthermore, it is not only bounded with information that we may employ but being there
with them at their most downfall moment will at least give them the support that they may
need. Something not so great but for them, that little thing makes a difference.

First hand information and experience is the best way to understand things and that is
the main reflection upon the completion of the study. Patient’s with complicated pathology
of disease and with idiopathic cause are sometimes so interesting to the point that you
search and explore even beyond your own limitation just to give an exact, current and
suited information to our client for us to identify ourselves as effective health care provider.
For the reason that we did something for them, that we fulfill our purpose.

As a final analysis, everyday is a new experience and everyday is an opportunity to


gain something. It’s an advantage on our part that now we experience actual cases that we
could refer on to, we can surpass our own endeavor by utilizing and maximizing every
opportunity. One of the great opportunities is to complete an actual case study.

Through this case study, we should be able to learn and understand the disease
Bronchiectasis and therefore give us knowledge in proper management, prevention and
treatment. As a student nurse, it is very important to know many things including the said
disease condition. After the hardships of completing our case study, a reward of self-
fulfillment and credential to our knowledge and skills has been added to us being student
nurses as well as professionals in the near future.

REFERENCE:

Gadaeke, M. K..1996. Laboratory and diagnostic test handbook. Addison-Wesley


Publishing Company Inc.
Malarkey, L. M..et al. 2005. Nursing guide to laboratory and diagnostic test. St. Louis
Missouri, El Sevier Inc.
Grodner, M. et al. 2004. Foundations and clinical applications of nutrition: a nursing
approach. 3rd edition. Mosby, Inc.
Deaths from Bronchiectasis: 970 deaths (NHLBI 1999)
Retrieved March 4, 2009 form the world wide web,
http://www.wrongdiagnosis.com/b/bronchiectasis/stats.htm
Johnson, J.Y.2008. Textbook of Medical-surgical nursing. 11th edition. Lippincott Williams
& Wilkins