Patient: Cecilla Alcantara The patient has had an enlarging R parotid mass for the past four months

The patient has had an enlarging R parotid mass for the past four months without
Age/sex: 77/female consult. She is also a diagnosed hypertensive of 4 years, maintained on amlodipine with poor
Mdx: ARF from new onset VAP on top of HAP compliance.
Septic shock, resolved, from new onset VAP
Parotid mass, R malignancy
Anteriar cranial fossa meningioma Family history
HF FCIII The patient has a family history of hypertension. She does not have a family history of
Anemia of inflammation cancer or diabetes.
Acquired coagulopathy from sepsis
Chronic CVD infarct, pons, L corona radiate, R putamen
s/p THBSO Functional health pattern
The client has not engaged in illicit drug use, or in any vices such as alcohol-drinking
and cigarette use.

NURSING HEALTH HISTORY nutritional and metabolic pattern
The patient currently is being fed via NGT tube with feeding of 312cc of osterized
History of present illness: feeding (CHO, CHON, FAT) with _____________kcal per feeding. She currently does not have
any IVF fluid replacement.
1 month PTA to Ward 1, the patient was admitted into Ward 10 under ORL service and
Rad Onco for a parotidectomy (was having an enlarging mass on R cheek). Upon the earliest CT elimination pattern
sna performed on the patient (1/6/17), it was seen that the patient has a right pre-auricular mass
exhibiting extensions and associated right ototympanic mastoiditis, anterior parafacial
meningioma, subacute infarct on left parietal corona radiate and cerebrovascular volume loss.

On 1/8/17, the patient had started to complain of difficulty of breath and had increasing activity/exercise pattern
Troponin I trends (indicative of congestive heart failure?) and was subsequently intubated. It was The patient is seen to have some degree of control of her movements such as being
during this time that she had a new onset HAP with hypotensive episodes and was managed as able to withdraw her extremities in response to pain, lifting of head and chewing. In the hospital,
septic shock. On 1/10/17 she was assessed to have acute respiratory failure from HAP, severe she is immobile on bed and is totally dependent on all activities.
sepsis from HAP, heart failure FC II-III with persisting malignant parotid mass.
Her performance for activities during hospitalization are as follows:
From 1/13 1/18 weaning was done but blood tinged secretions were noted (suggestive
of pulmonary embolism, enoxaparin was ordered). It was then the patient was referred transfer to Activity of daily living Score
MICU. In MICU (1/20-1/28) the patient was seen to be hemodynamically stable and tolerated
CPAP. Cranial MRI was done and it was seen that her R parotid mass has extensions to the Feeding 0
mastication space with abscess formation in necrotic neoplasm. Bathing 0
Toileting 0
On 2/3, she was then sent to the OR for tracheostomy then was subsequently
Cooking 0
transferred to Ward 1 post-OR. The treatment goals as of the present are to 1.) wean patient to
General mobility 0
room air 2.) resolve HAP & VAP 3.)plan start of chemotherapy for malignant parotid mass.
Bed mobility 0
Significant medical history Dressing 0
Shopping 0
Home maintenance 0
SN Ma. Eliza Patrice d.B. VerzosaN121.1Ward 1
 Legend: Level 4: Full self-care R.R.: 26
Level 3: Use of device O2 saturation: 98% on O2 support
Level 2: Requires assistance skin
Level 1: Requires assistance and/or device Skin tone: brown; (-) pallor
Level 0: Dependent (-) jaundice, flushing, cyanosis, pettechiae, varices
Dry, rough, flaky skin with warm, non-clammy temperature
sleep-rest pattern With generalized edema
The patient is observed to have intermittent sleep-wake cycles and displays eye-opening Water-filled blebs on both feet
to light tapping and name-calling. (-) Skin tenting

cognitive perceptual pattern

. As of assessment, the patient is able to open eyes and respond to visual threat as well head
as turn head to voice. She is also observed to withdraw from pain such as finger pricking. She is Asymmetrical facial features, with tennis ball-sized mass (parotid), described as inflamed
seen to respond to simple yes or no questions. and necrotic
Hair: fine, dark brown, short (-) alopecia
role relationship pattern Scalp: (-) dandruff, lice, lesions, nits, tenderness
The patient currently is not being taken care of by any of her family members and only
by volunteers composed mainly of her fellow church group, hence very little health history has eyes
been attained. The patient has two sons, one of which is a pastor. Iris color: brown; symmetrical features (-) preorbital edema, (-) sunken eyelids
pale conjunctiva, (-) lesions, tearing and discharge
self-perception/self-concept pattern anicteric sclera
Cannot be assessed at present time. Smooth, clear cornea and lens
Pupils equally rounded, quick reaction to light (2mm on both pupils) and equal reaction
value-belief pattern to accommodation
The patient is Christian Baptist. Convergence not assessed
(+) dolls eye
ears
L ear normoset
PHYSICAL ASSESSMENT R ear affected by parotid mass, slightly necrotized and enlarged
general survey asymmetrical pinnae, L springs back upon manipulation
Mobile (disorganized movement) on bed, with regard to person, and looks according to Watch tick test Not assessed
age, ectomorphic Rinne Not assessed
Eyes open to name-calling and light tapping (orientation cannot be assessed), able to Weber Not assessed
follow commands such as opening of eyes (E4VtM6) nose
With clean hair and hygiene Symmetrical nasolabial fold
With heplock on R cephalic vein Septum midline
With NGT level 60 pale mucosa, (-) swelling, lesions
With tracheostomy to oxygen mask, with O2 at 3-4 LPM mouth
vital signs pinkish lips with dryness and cracking, (+) pallor (-) cyanosis
Temp: 37c tongue not assessed
B.P.: 120/90 mmHg (supine, on L arm) Gums: (-) bleeding, tenderness, lesions (+) pallor
H.R.: 115 incomplete set of teeth

SN Ma. Eliza Patrice d.B. VerzosaN121.1Ward 1

pharynx Muscle tone grade not assessed
with gag reflex neuro
neck Cranial nerve assessment summary:
Trachea in midline I Olfactory Not assessed
(-) neck rigidity and masses II Optic Not assessed
non-palpable thyroid III Oculomotor pupils quickly reactive to light
non-palpable lymph nodes IV Trochlear (+) corneal reflex and (+) visual threat
lungs with spontaneous EOM
RR 26/min, regular with no respiratory distress V Trigeminal (+) teeth clenching and chewing
Inspiration-expiration ratio: 1:2 (+) blink reflex
APL ratio: 1:2, symmetrical Able to localize pain
Symmetrical chest expansion VI Abducens Spontaneous EOM
(+) crackles bilateral lung fields
VII Facial Equal eye closure
heart
symmetrical facial features
Precordial area flat (-) lifts, thrills, tenderness
VIII Acoustic Not assessed
PMI @ 5th ICS, LMCL; with rate of 70 bpm
IX Glossopharyngeal Some degree of tongue movement
Distinct, bounding heart sounds
(-) murmurs on apical area X Vagus (-) gag reflex, symmetry not assessed
S1>S2 @ apex, S2>S1 @ base XI Accessory Neck ROM not assessed
abdomen XII Hypoglossal With some tongue movement (withdrawal to sensation)
Flat and soft abdomen
(-) visible pulsations or peristaltic movements
DRUG STUDY
Skin: umbilicus midline, dry skin
(-) striae, scars, rashes MEDICATIO DRUG STUDY
Bowel sounds present at 2/minute N ORDER
(-) muscle guarding
Meropenem Classifications: ANTIINFECTIVE; CARBAPENEM ANTIBIOTIC
(-) shifting dullness and fluid wave
1gm q8H IV Effective against both gram-positive and gram-negative bacteria. High
back and extremities
(-) ST resistance to most bacterial beta-lactamases. Do not use to treat
peripheral pulses:
methicillin-resistant Staphylococci(MRSA).
Pule strength grading R L PREPARE: Direct: Reconstitute the 500-mg or 1-g vial, respectively, by
Carotid 2 2 adding 10 or 20 mL sterile water for injection to yield approximately 50
Radial 2 2 mg/mL. Shake to dissolve and let stand until clear. IV Infusion: Further
Brachial 2 2 dilute in 50100 mL of D5W, NS, or D5/NS.
Femoral 2 2 IV Infusion: Give over 1530 min.
Popliteal 2 2 Omeprazole Classifications: gastrointestinal agent; proton pump inhibitor
Dorsalis pedis 2 2 40mg/cap 1 Suppresses gastric acid secretion relieving gastrointestinal distress and
cap OD / promoting ulcer healing.
pale nail beds (-) cyanosis, inflammation NGT TX: Duodenal and gastric ulcer. Gastroesophageal reflux disease including
(-) nail clubbing; <2 seconds capillary refill observed severe erosive esophagitis (4 to 8 wk treatment). In combination with
(-) joint swelling, tenderness, redness clarithromycin to treat duodenal ulcers associated with Helicobacter pylori.
With grade 2 sacral decubitus ulcer Give before food, preferably breakfast; capsules must be
muscle size equal bilaterally on both lower and upper extremities swallowed whole (do not open, chew, or crush).

SN Ma. Eliza Patrice d.B. VerzosaN121.1Ward 1

 Note: Antacids may be administered with omeprazole.

PRN Classifications: AUTONOMIC NERVOUS SYSTEM DIAGNOSTICS

Salbutamol AGENT; BETA-ADRENERGIC AGONIST
HEMATOLOGY
Q8h (SYMPATHOMIMETIC); BRONCHODILATOR (RESPIRATORY SMOOTH
Patients Values
MUSCLE RELAXANT)
Reference Date
Bronchodilation decreases airway resistance, facilitates mucus drainage, and
increases vital capacity.
Adult: PO 24 mg 34 times/d, 48 mg sustained release 2 4-11x109/L WBC
times/d Inhaled 12 inhalations q46h 4-6 x 1012/L RBC
Classifications:SKIN AND MUCOUS MEMBRANE 120-180g/L Hgb
AGENT;MUCOLYTIC;ANTIDOTE 37-54% HCT
Adjuvant therapy in patients with abnormal, viscid, or inspissated mucous 80-100 fL MCV
secretions in acute and chronic bronchopulmonary diseases, and in 27-31 pg MCH
pulmonary complications of cystic fibrosis and surgery, tracheostomy, and 320-360 g/L MCHC
atelectasis. Also used in diagnostic bronchial studies and as an antidote for 11-16% RDW-CV
acute acetaminophen poisoning. 150-450 PLT
0.5-0.7 Neut%
Classifications: AUTONOMIC NERVOUS SYSTEM 0.2-0.5 Lymph%
AGENT; BETA-ADRENERGIC AGONIST 0.02-0.09 Mono%
(SYMPATHOMIMETIC); BRONCHODILATOR (RESPIRATORY SMOOTH 0-0.06 Eo%
MUSCLE RELAXANT) 0-0.02 Baso%
Bronchodilation decreases airway resistance, facilitates mucus drainage, and
increases vital capacity.
Adult: PO 24 mg 34 times/d, 48 mg sustained release 2
times/d Inhaled 12 inhalations q46h ARTERIAL BLOOD GASES
Classifications: ANTIINFECTIVE; TETRACYCLINE ANTIBIOTIC Patients Values
Treatment of mucopurulent cervicitis, granuloma inguinale, lymphogranuloma Reference Date
venereum, proctitis, bronchitis, lower respiratory tract infections caused
by Mycoplasma pneumoniae, Rickettsial infections, chlamydial infections,
7.35-7.45 pH
non-gonococcal urethritis, chlamydial conjunctivitis, plague, brucellosis,
35-45 pCO2
bartonellosis, tularemia, UTI, and prostatitis; acne vulgaris, gonorrhea,
cholera, meningococcal carrier state, 90-100 pO2
Oral 22-28 HCO3
Shake suspension well before administration. TCO2
Oral therapy is the preferred route; institute as soon as possible. [-2,2] SBE
Check expiration date. Outdated tetracycline can cause severe >95% O2 sat;
adverse effect FiO2
Silver Classifications: ANTIINFECTIVE; SULFONAMIDE Temp; Hb
sufodiazene Broad antimicrobial activity including many gram-negative and gram-positive
over SDU BID bacteria and yeast.

SN Ma. Eliza Patrice d.B. VerzosaN121.1Ward 1

 BLOOD/SERUM CHEMISTRY
Patients Values Color
Reference Date Transparency
1.016-1.022 Specific
4.1-6.1 Glucose gravity
3.2-8 BUN <17 mmol/L Bilirubin
53-133 u Crea <5 mmol/L Urobilinogen
135-145 Na Negative Ketone
3.5-5.0 K <2.8 mmol/L Glucose
99-110 Cl <0.3 g/L Albumin
2.12-2.52 Ca <5 erys/uL Blood
0.7-1.05 Mg
4.6-6.5 pH
0.9-1.55 Phosphat
Negative Nitrite
e
64-83 g/L T. Protein <25 leukos/uL Leukocytes
38-51 g/L Albumin 0-9/uL RBC
23-35 g/L Globulin 0-22/uL WBC
0-34 U/L AST 0-13/uL Sq. Epithelial
(SGOT) Cell
0-330 U/L ALT 0-220/uL Bacteria
(SGPT) 0-13/uL Mucus thread
36-92 mmol/L Alk Phos
0-17.1 Total bili
mmol/L
0-3.42 Dir bili PROTHROMBIN
mmol/L Patients Values
3.4-13.7 Ind bili Reference Date
mmol/L
0.13-0.44 Urate 12-15 PT
mmol/L reference
1-63 U/L Amylase 12-15 sec PT time
23-300 U/L Lipase PT%
1.0 PT INR
APTT Ref
30-40 sec APTT Time
AUTOMATED URINALYSIS 12-15 PT
Patients Values reference
Reference 12-15 seconds PT time
Date

SN Ma. Eliza Patrice d.B. VerzosaN121.1Ward 1


NOC: Vital Signs NIC: Respiratory Monitoring
Status (c) Monitor for signs of acidbase imbalance:
NOC: Electrolyte & ABG analysis: pH<7.35, PaCO >48 mm Hg (ABG analysis
NURSING CARE PLANS (in decreasing priority)
AcidBase helps evaluate gas exchange in the lungs.)
Collaborative Problem: Risk for complications of respiratory dysfunction Balance (i) Monitor vital signs.
With initial hypoxia and hypercapnia, blood pressure (BP),
Subsuming: Ineffective airway clearance
heart rate, and respiratory rate all rise. As the hypoxia
Ineffective breathing pattern
and/or hypercapnia becomes more severe, BP may drop,
Impaired gas exchange
heart rate tends to continue to be rapid with arrhythmias,
Impaired spontaneous ventilation
and respiratory failure may ensue with the patient unable t
Cues
maintain the rapid respiratory rate.
With tracheostomy to O2 2-3 (lpm), half inflated cuff
(i) Assess for use of accessory muscles (scalene and
Intolerant to room air, desaturated to 92% off O2 support
sternocleidomastoid).
With productive cough, greenish blood-tinged sputum
Work of breathing increases greatly as lung compliance
vital signs
decreases. As moving air in and out of the lungs becomes
Temp: 37c
more and more difficult, the breathing pattern alters to
B.P.: 120/90 mmHg (supine, on L arm)
include use of accessory muscles to increase chest
H.R.: 115
excursion to facilitate effective breathing.
R.R.: 26
(c) Use pulse oximetry to monitor O2 saturation and pulse rate
O2 saturation: 98% on O2 support
continuously.
Inspiration-expiration ratio: 1:2
Pulse oximetry is a useful tool to detect changes in
APL ratio: 1:2, symmetrical
oxygenation. O2 saturation should be maintained at 90% or
symmetrical chest expansion
greater
presence of crackles in bilateral lung fields
Assess skin, nail beds, and mucous membranes for pallor or cyanosis.
with _____________ as evidenced by ABG:
Cool, pale skin may be secondary to a compensatory
pH
vasoconstrictive response to hypoxemia. As oxygenation
pCO2 and perfusion become impaired, peripheral tissues becom
PO2 cyanotic. For cyanosis to be present, 5 g of hemoglobin
must be desaturated.
HCO3

BE
O2sat NOC: Respiratory NIC: Oxygen Therapy
Status: Airway NIC: Artificial Airway Management
With tracheal aspirate (Jan 13) of klebsiella
Patency, (i) Monitor oxygen setup settings, and patient response to therapy at
Diagnosed with VAP (A. Baumanni & S. Maltophilia) on top of HAP (MRSA &
Gas Exchange, least hourly.
Klebsiella)
Ventilation Ensures correct functioning of equipment.
With CXR (2/2) with ventriculonodular infiltrates in R mid base
(c) Maintain oxygen administration device as ordered, attempting to
NOC: Mechanical maintain O2 saturation at 90% or greater.
Goal: The patient will not have any complications of respiratory dysfunction such as
Ventilation Check tubing for obstruction (kinking or accumulations of
hypoxemia, respiratory alkalosis and acidosis, and sepsis from hospital/ventilator-acquired
Response: Adult water)
pneumonia.
Monitor inspiratory and expiratory ratio
Objectives: Interventions and Rationales:
SN Ma. Eliza Patrice d.B. VerzosaN121.1Ward 1
 Note inspired humidity and temperature; maintain hydration monitor subsequent improvement of infection or
to liquefy secretions facilitating removal. exacerbation
Note changes in chest symmetry. This may indicate ensure adequate nutrition and hydration status
improper placements of tube and development of instruct significant others to observe handwashing technique
barotrauma. in entering and leaving the room
To provide for adequate oxygenation monitor labs for indicators of improvement or worsening of
(i) Provide adequate hydration. Monitor and document intake and infection severity
output at least every shift, total every 24 hours. Monitor for signs and symptoms of septic shock:
Avoids fluid-volume deficit, assists in liquefying secretion Altered body temperature (>38C or<36C)
and prevents development of pulmonary edema. Hypotension (/90, >90/60 mm Hg (MAP [mean arterial
(i) disturb and remove condensed water in t-piece tubing away from pressure] >70) (CVP >11)
patient Decreased level of consciousness
condensate increases airway pressure readings and may Weak, rapid pulse
accidentally enter the patients airways Rapid, shallow respirations or CO2<32
(i) Turn every 2 hours. Perform chest physiotherapy every 2 (Diminishing oxygen saturation as seen by pulse oximetry)
hours Cold, clammy skin
pulmonary clapping loosens secretions and lessens tenac Oliguria (urine output <5 mL/kg/h)
to airways (Septic shock is a systemic inflammatory response
(i) Position the patient with proper body alignment for optimal syndrome[SIRS] associated with infection because of
breathing pattern. microorganisms resulting in hypotension and perfusion
If not contraindicated, a sitting position allows adequate abnormalities despite fluid resuscitation or vasopressors.)
diaphragmatic and lung excursion and chest expansion.
(c) Administer medications (e.g., bronchodilator, mucolytics, Evaluation:
and expectorants) as prescribed Ventilator settings:
promotes air circulation ABG results: _____________________
(i) Using gentle suctioning if necessary PH__________ _____________________
(Suctioning is effective only at the tracheal level.) PO2 ________ _____________________
(i) Assess sputum for quantity, color, consistency, and odor. PCO2________ ______________________
These may be indicative of an etiology for the alteration in HCO3 _______ _____________________
breathing pattern. ABG imbalance? ________
(i) Administer supplemental oxygen before and after suctioning. Suctioning:
(This measure helps prevent decreased PO2 as a result of Vital signs: time secretion
suctioning.) HR: ____________
(i) provide oral hygiene RR: ____________
Oral hygiene clears away dried secretions and freshens SPO2: ___________
the mouth. Oil-based products may obstruct breathing Temp:
NOC: infection passages.
severity Respiratory status: Chest physiotherapy (time)
NIC: Infection control Chest symmetry: _________ ___________________
(i) maintain strict aseptic technique in handling the patient and in Lung expansion: ________ ____________________
preparing medications I:E_______________
collaborative care with use of prescribed antibiotic Breath sounds: _________ Oral hygiene & time

SN Ma. Eliza Patrice d.B. VerzosaN121.1Ward 1

Respi distress: __________ Using: ________________ not use circumferential wrapping. Avoid extreme flexion of the hips and
knees.
This Inhibits venous drainage , which increases cerebrovascu
congestion and intracranial pressure)
Impaired Bed Mobility Flexion increases thoracic pressure, which inhibits jugular
Subsuming: Risk for disuse syndrome NOC: venous drainage, increasing ICP)
Self-care deficit
Risk for aspiration Maintain a quiet, calm environment. Schedule several lengthy periods of
Cues uninterrupted rest. Cluster necessary procedures to minimize interruptions.
vital signs These measures promote rest and decrease in stimulation
Temp: 37c
B.P.: 120/90 mmHg (supine, on L arm)
(i) Elevate head of bed to 30 degrees, and keep head in neutral alignment.
H.R.: 115
implement measures to promote sleep (e.g. elevate head of bed and
R.R.: 26
support arms on pillows to facilitate breathing, maintain oxygen
O2 saturation: 98% on O2 support
GCS of E4VtM6 therapy during sleep, discourage intake of fluids high in caffeine in the
With sacral decubitus ulcer, grade 2 extending to subcutaneous layer evening, reduce environmental stimuli.
With generalized edema (i) Assess for developing thrombophlebitis (redness, localized swelling,
With rough, dry and flaky skin and rise in temperature).
Immobile on bed Bed rest or immobility promotes clot formation.
Goal:.The patient will be free of complications of prolonged bed rest (i) Maintain limbs in functional alignment (e.g., with pillows)
To prevent unnecessary contractures, flexion, and tightness.
Objectives: Interventions and Rationales:
(i) Assess skin integrity. Check for signs of redness, tissue ischemia

(especially over ears, shoulders, elbows, sacrum, hips, heels, ankles, and
(i) Assess neurologic status as follows: LOC per Glasgow coma scale,
toes).
pupil size, symmetry, reaction to light, extraocular movement, tone,
Development of pressure sources provide an entry way for
reflexes, and Babinski
infection
Deteriorating neurological signs indicate increased cerebral

damage.
NIC: Exercise Therapy: Joint Mobility

NIC: Exercise Promotion: Stretching
(i) Elevate head of bed to 30 degrees, and keep head in neutral alignment.
i) Perform passive or active assistive ROM exercises to all extremities
To decrease in venous outflow and prevent possible increase
To promote increased venous return, prevent stiffness, and maintain
ICP.
muscle strength and endurance.

(c) Maintain physical and emotional rest, as in the following:
(i) Avoid vagal stimulation by eliciting gag reflex, or by prolonged
Restrict activity
suctioning time. Limit suctioning to 10 seconds at a time. Hyperoxygenate
before suctioning. Also, administer laxative to prevent eliciting of valsalva
maneuver. o To reduce O2 demands.
Vagal nerve stimulation can further increase bradycardia.
Provide quiet, relaxed environment.
(i) Avoid carotid massage, neck flexion or extreme rotation. If intubated, do

SN Ma. Eliza Patrice d.B. VerzosaN121.1Ward 1

 o Emotional stress increases cardiac demands. (i) Assess for developing thrombophlebitis (redness, localized swelling,
and rise in temperature).
Organize nursing and medical care Bed rest or immobility promotes clot formation.

o To allow rest periods.
(i) Auscultate bowel sounds to evaluate bowel motility.
Decreased gastrointestinal motility increases the risk of aspirat
because food or fluids accumulate in the stomach.
(i) Assess pulmonary status for clinical evidence of aspiration. Auscultate
breath sounds for development of crackles and/or rhonchi.
Aspiration of small amounts can occur without coughing or
sudden onset of respiratory distress, especially in patients wit
decreased levels of consciousness.
(c) In patients with endotracheal or tracheostomy tubes, monitor the
effectiveness of the cuff.
An ineffective cuff can increase the risk of aspiration
(i) Assess skin integrity. Check for signs of redness, tissue ischemia
(especially over ears, shoulders, elbows, sacrum, hips, heels, ankles, and
toes).
Development of pressure sources provide an entry way for
infection.
(i) Maintain limbs in functional alignment (e.g., with pillows)
To prevent unnecessary contractures, flexion, and tightness.
(i) Perform passive or active assistive ROM exercises to all extremities
To promote increased venous return, prevent stiffness, and maintain
muscle strength and endurance.
Evaluation

(i) Position patients who have a decreased level of consciousness on their

side.
To protect the airway. Proper positioning can decrease the ris
of aspiration. Comatose patients need frequent turning to
facilitate drainage of secretions.

(i) Check placement before feeding.

A displaced tube may erroneously deliver tube feeding into th
airway.

(i) Check residuals before feeding. Hold feedings if residuals are high and
notify the physician.
High amounts of residual (greater than 50% of previous hour's
intake) indicates delayed gastric emptying and can cause
distention of the stomach leading to reflux emesis.

(i) Maintain upright position for 30 to 45 minutes after feeding.

The upright position facilitates the gravitational flow of food o
fluid through the alimentary tract.

SN Ma. Eliza Patrice d.B. VerzosaN121.1Ward 1

 PROGRESS NOTES
FEB 8, 2017 - WEDNESDAY

Collaborative Problem: Risk for complications of respiratory dysfunction

Subsuming: Ineffective airway clearance
Ineffective breathing pattern
Impaired gas exchange
Impaired spontaneous ventilation
The patient is maintained on oxygen mask to tracheostomy. The patient has an
increased respiratory rate and 98-99% O2 saturation with oxygen support. Without
oxygen support, however, O2 saturation decreases to 95%. The patient has active
cough reflexes but cannot expectorate independently. She has greenish blood tinged
sputum upon suctioning. She is maintained on suctioning PRN. Bibasal crackles are
heard on both lung fields prior to suctioning and evaluation after suctioning has
shown decrease in adventitious lung sounds. Tracheostomy care and chest
pulmophysiotherapy has been rendered. Tracheostomy was received intact, with
balloon deflated and reinflated to 6ml.

Impaired Bed Mobility

Subsuming: Risk for disuse syndrome
Self-care deficit
Risk for aspiration
The patient has a GCS of E4VtM6. She is able to move her upper extremities in
response to pain but has little to no movement in her lower extermities. Her skin is
described to be dry, rough and flaky as a result of her generalized edema which has
begun to resolve. She is seen to have water-filled blebs on both feet, some of which
have burst and have been dressed with gauze. She is seen to have a grade 2 sacral
decubitus ulcer (reddish and skin peeling) which is dressed with SSD and was
aerated for 1 hour. Turning every 2 hours was maintained.

SN Ma. Eliza Patrice d.B. VerzosaN121.1Ward 1