5 patient and his care

V. THE PATIENT AND HIS CAREA. Medical Management a. Intravenous FluidsIntravenous Fluid/RegulationsDate StartedDate ModifiedDate ConsumedGeneral DescriptionIndication(s) or PurposesPatients Response to the Treatment

# 1 Plain Normal Saline Solution (0.90%)1 Liter

(80 mL/hour)Approximately 27 macrodrops per minute with drop factor of 20 drops per mL

Date Started:February 12, 2015Hooked Outside

Date ConsumedFebruary 13, 20154 AM

Normal saline solution is a solution of common salt in distilled water, of strength of 0.9 per cent. It is called normal saline because the percentage of salt resembles that of the crystalloids in the blood plasma. Another way of stating this is to say that normal saline is isotonic. An isotonic solution is less irritating to the body cells.

It is generally the most compatible fluid for many medications that are needed to be incorporated to IVF for intravenous administration, because of its tonicity and stability. The said fluid is generally used among patients that need fluid replacement as a result of a decrease in blood volume; hence it is often called as the universal blood volume expander. PNSS is isotonic with Osmolality of 308 with no caloric and dextrose content, therefore a good source of fluid for patients having blood sugar level problem especially those with Diabetes Mellitus. Patient Xs blood sugar level was already elevated. This type of fluid would restrict excessive glucose to the patient which may worsen hyperglycemia. The physicians initially started an Intravenous line with such solution as this type of solution is the most compatible with most medications. This is a safe solution to be started in the given situation.

The patient responded well to the treatment without any abnormal signs and symptoms observed. There was no hypotensive and hypoglycemic episode noted. The vein was maintained open as an access to intravenous medications.

#2 5% Dextrose in Lactated Ringers Solution

80 mL per hourApproximately 27 macrodrops per minute with drop factor of 20 drops per mL

Date StartedFebruary 13, 20154 AM

Date terminatedFebruary 14, 20156 AM D5 LRS is a hypertonic solutions. This type of solution has an effective osmolarity greater than the body fluids. This pulls the fluid into the vascular by osmosis resulting in an increase vascular volume. It raises intravascular osmotic pressure and provides fluid, electrolytes and calories for energy.This solution useful for daily maintenance of body fluids and nutrition, and for rehydration. It contains electrolytes including, Sodium, Potassium, Calcium, and chloride. This also contains Lactate and Dextrose that could serve as a source of energy. This type of solution was given to Patient X as a nutritional aid and to increase plasma volume as the patient is highly at risk for dehydration. It is also used to maintain the intravenous line open for administration of medications. The Patient did not manifest any signs of dehydration which is great indication that the patient responded well to the treatment. His lined also remained patent and intravenous medication were given accordingly.

#3-7 5% Dextrose in Normosol-M

Date StartedFebruary 13, 20154 AM

Date terminatedFebruary 18, 20158 PMIt is a hypotonic solution which makes the cells shrink composes of water and carbohydrates as source of energy and both cations and amino acids.. It is one of the intravenous solutions containing high amount of potassium D5NM is indicated for parenteral maintenance of routine daily fluid and electrolyte requirements with minimal carbohydrate calories from dextrose.

This type of solution was indicated for Patient X as his potassium level upon admission was 3.91 mmol/L which means that he has a normal potassium level, but also almost at the borderline low (3.5mmol/L) This type of intravenous fluid could actually help prevent hypokalemia.The patient did not become show any signs and symptoms of hypokalemia and hypoglycaemia. His intravenous lines were also maintained open as a route for administering intravenous medications.

Nursing Responsibilities for starting and maintaining an Intravenous siteBefore: Verify prescriptions for IV therapy Check solution label and identify patient Explain procedure to the patient Carry out hand hygiene and put on disposable non-latex gloves Apply a tourniquet 4-6 inches above the sites apply identify a suitable vein Choose site. Use distal veins of hands and arms first Raise bed for comfortable working height and position for patient and adjust lighting

During: Explain to the patient what you are going to do, why it is necessary, and how he can cooperate Question the patient carefully about sensitivity to latex, use blood pressure cuff rather than latex tourniquet if there is sensitivity Apply a new tourniquet for each patient and palpate for a pulse distal to the tourniquet With hand not holding the venous access devise, steady patients arm and use finger to pull skin taut Hold needle bevel up and at 5-25 degree angle, depending on the depth of vein If backflow of blood is visible, straighten angle and advance needle. Additional steps for catheter is inserted over the needle: Hold needle hub, and slide catheter over the needle and vein Remove while pressing lightly on the skin over the catheter tip Release tourniquet and attach infusion tubing: open clamp enough to allow drip Cover and tape the small loop of IV tubing onto the dressing Calculate infusion rate and regulate flow of infusion After: Document date and time therapy initiated Monitor vital signs Check the level of the IV as per hospital policy Tape the IV lines Dress and label the venipuncture according to the hospital policy Instruct the patient to inform the health care professionals should there be any swelling or redness on insertion site which may be a sign for dislodged IV line Regularly check regulation of IVF.

b. Oxygen Treatment Type of Oxygen DeliverySettings% or LPMDate StartedDate ModifiedDate DiscontinuedGeneral DescriptionsPatient IndicationPatients Response to the Treatment

Mechanical Ventilator

AC MODE; BUR; 25;VT; 200;PEEP 4FIO2-70%





CPAPFiO2-60%PEEP- 4

AC MODE;BUR; 15;VT; 200;PEEP 4FIO2-60%

CPAPFiO2-60%PEEP- 4 AC MODE; BUR; 15;VT; 200;PEEP 4FIO2-60%

CPAPFiO2-60%PEEP- 4

Date StartedFebruary 12, 201412:55 PM

Date ModifiedFebruary12, 20156 PM

Date ModifiedFebruary 12, 20159 PM

Date ModifiedFebruary 13, 201512 AM

Date ModifiedFebruary 13, 20153 AM

Date ModifiedFebruary13, 20156 AM-12 PM Increments and Decrements of 30 minutes*See Figure 5.1

Date ModifiedFebruary13, 201512 PM 12 AM Increments and Decrements of 1 Hour*See Figure 5.1

Date ModifiedFebruary14, 201512 AMContinuous*See Figure 5.1

The delivery of oxygen to the bodys cells is a process that depends upon the interplay of the pulmonary, hematologic, and cardiovascular systems. Specifically, the processes involved include ventilation, alveolar gas exchange, oxygen transport and delivery, and cellular respiration (Delaune, 2010).

Mechanical ventilation is the use of a mechanical device (machine) to inflate and deflate the lungs. Mechanical ventilation provides the force needed to deliver air to the lungs in a patient whose own ventilator abilities are diminished or lost (Bach, 2015).

The indication of oxygen support to the patient is only to promote rest to the patient and to aid in increasing the oxygen delivery to the body of the patient as the patients respiratory muscles are affected by his condition in which the muscles are too weak to provide adequate ventilation to the patient.The patient responded very well to the treatment as he did not develop any signs of respiratory distress during the hospital stay as evidenced by a decrease in oxygen saturation based from the cardiac monitor. Moreover, there was no hypoxemic event noted. The patient also complained of throat discomfort because of the endotracheal tube inserted

The patient was also able to tolerate the weaning process hence the patient was eventually extubated and removed from ventilator support.

Face Mask at 6 LPM

Date Started February 14, 20157 AM 7:30 AM Face masks that cover the clients nose and mouth may be used for oxygen inhalation. Exhalation ports at the side of the mask allow exhaled carbon dioxide to escape. The patient utilized a simple face mask which delivers oxygen concentration from 40-60% at Liter flows of 5 to 8 LPM, respectively (Kozier, 2010). Since the patient was newly extubated, the patient would still be needing oxygen support. The physician ordered an oxygenation support via face mask after the patient was extubated to assess the patients need for higher or lower oxygen concentration delivery. The patient showed no sign of respiratory distress after he was extubated since his oxygen saturation did not decrease (97-100%). He was also uncomfortable with the oxygen mask, hence, after 30 minutes of face mask, the physician ordered to shift the mask to a simpler oxygen delivery system i.e. nasal cannula.

O2 Via Nasal Cannula at 2 LPMDate StartedFebruary14, 20157:30 AM 12 PM

Date DiscontinuedFebruary 17, 201512 PM (Shifted to PRN Basis)The nasal cannula (nasal prongs) is the most common and inexpensive device used to administer oxygen. The nasal cannula is easy to apply and does not interfere with the clients ability to eat or talk. It is relatively comfortable, permits some freedom of movement and is well tolerated by the client. It delivers a relatively low concentration of oxygen (24 to 45 %) at flow rates of 2-6 LPM (Kozier, 2010). Patient Xs myasthenic crisis has already been resolved. His respiratory muscles are no longer weak; hence he can breathe on his own with no mechanical support. This type of oxygen delivery system only serves as a support in the event that the patients oxygen demand increases. A room air contains 21% of oxygen while the patients setting for oxygen delivery is set at only 27% (2LPM) Patient X did not like the nasal cannula as he would always say that it is as if he is breathing gasoline. He would remove it at his own convenience, but there were no noted signs of respiratory distress even if the patient has no oxygen support. The physician then ordered to remove the nasal cannula and give oxygen support in cases that he would be under respiratory distress.

MECHANICAL VENTILATOR WEANING PROCESS

TimeMechanical Ventilator Setting

6 AM 6:30 AMCPAP (30 minutes)

6: 30 AM 8 AMMechanical Ventilator (1.5 Hours)

8 AM 9 AMCPAP (1 hour)

9 AM 10 AMMechanical Ventilator (1 Hour)

10 AM 11: 30 AMCPAP (1.5 Hours)

11: 30 AM 12 PMMechanical Ventilator (30 minutes)

12 PM 1 PMCPAP (1 Hour)

1 PM 4 PM Mechanical Ventilator (3 Hours)

4 PM 6 PMCPAP (2 Hours)

6 PM 8 PMMechanical Ventilator (2 Hours)

8 PM 11 PMCPAP (3 Hours)

11 PM 12 AMMechanical Ventilator (1 Hour)

12 AM 6 AMCPAP(Continuous)

Figure 5.1 Mechanical Ventilator Weaning Process

Nursing Responsibilities for Mechanical Ventilator:Before:1. Check and verify doctors order.2. Check and assemble the equipment.3. Position the client into the sniffing position.4. Pre-oxygenate the client with 100% Oxygen to provide apneic or distressed clients with reserve while attempting to intubate by ambubagging the patient.During:1. Assist in the insertion of the endotracheal tube.2. Stay with the client and provide support during the insertion.3. Do not allow more than 30 seconds to any intubation attempt.4. If intubation is unsuccessful, ventilate client with 100 % oxygen for 3-5 minutes before a reattempt.After:1. Secure the endotracheal tube with tapes.2. Ensure that the tube is properly stabilized.3. Suction secretions as necessary4. Monitor the client.5. Document properly.

Nursing Responsibilities for Face Mask:Before:1. Wash hands/hand hygiene.2. Verify the prescribing practitioners order.3. Explain procedure and hazards to the client.4. Remind clients who smoke of the reasons for not smoking while oxygen is in use.5. If using humidity, fill humidifier to fill line with distilled water and close container.6. Attach humidifier to oxygen flow meter7. Check faulty electrical wirings and other possible sources of ignition as oxygen is a combustible gas.8. Insert humidifier and flow meter into oxygen source in wall or portable unit.

During:1. Place the face mask by guiding the mask toward the clients face, and apply it from the nose downward.2. Fit the mask contours of the clients face (the mask should mold to the face so that very little oxygen escapes into the eyes or around cheeks and chin.3. Secure the elastic band around the clients head so that the mask is comfortable but snug. 4. Pad the band behind the ears and over the bony prominences to precent irritation from the mask. 5. Make sure to use the right size to the patient to avoid unnecessary discomfort from using a very small or very large masks. Secure the mask by placing the After:1. Check for proper flow rate every 4 hours and when the client returns from procedures.2. Add humidifier if not already in place. 3. Monitor vital signs, oxygen saturation, and client condition every 48 hours (or as indicated or ordered) for signs and symptoms of hypoxia. 4. Wean client from oxygen as soon as possible using standard protocols.

Nursing Responsibilities for Face Mask and Nasal Cannula: Before:1. Wash hands/hand hygiene.2. Verify the prescribing practitioners order.3. Explain procedure and hazards to the client.4. Remind clients who smoke of the reasons for not smoking while O2 is in use.5. If using humidity, fill humidifier to fill line with distilled water and close container.6. Attach humidifier to oxygen flow meter7. Check faulty electrical wirings and other possible sources of ignition as O2 is a combustible gas.8. Insert humidifier and flow meter into oxygen source in wall or portable unit.

During:1. Attach the oxygen tubing and nasal cannula to the flow meter and turn it on to the prescribed flow rate.2. Check for bubbling in the humidifier.3. For nasal cannula, place the nasal prongs in the clients nostrils. Secure the cannula in place by adjusting the tubing around the clients ears and using the slip ring to stabilize it under the clients chin.After:1. Check for proper flow rate every 4 hours and when the client returns from procedures.2. Assess clients nostrils every 8 hours. If the client complains of dryness or has signs of irritation, use sterile lubricant to keep mucous membranes moist. 3. Add humidifier if not already in place. 4. Monitor vital signs, oxygen saturation, and client condition every 48 hours (or as indicated or ordered) for signs and symptoms of hypoxia. 5. Wean client from oxygen as soon as possible using standard protocols.

d. Drugs (In Alphabetical Order)

Name of DrugsGeneric and (Brand Name)Stock DoseType of OrderDate OrderedDate Modified Date DiscontinuedRoute of Administration DosageFrequency of administrationGeneral ActionFunctional classificationMechanism of actionGeneral Indication

Patient IndicationClients response to the medication with actual side effects

acetylcysteine

(Fluimucil)

10%/3mL ampule

STANDING ORDERDate OrderedFebruary 12, 201512:55 PM

Nebulization10%/3mL/AmpuleEvery 12 HoursMucolytic

N-acetyl-L-cysteine (NAC), active ingredient of Fluimucil, exerts an intensive mucolytic-fluidifying action on mucous and mucopurulent secretions, by depolymerizing the mucoproteic complexes and the nucleic acids which confer viscosity to the vitreous and purulent component of the sputum and of the secretions. These features make Acetylcysteine (Fluimucil) particularly suitable for the treatment of acute and chronic affections of the respiratory system, characterized by thick, viscous, and mucopurulent secretions.Treatment of respiratory affections characterized by thick and viscous hypersecretions: acute bronchitis, chronic bronchitis and its exacerbations; pulmonary emphysema, mucoviscidosis and bronchieactasis.

The prescription of Fluimucil to Patient X is due to his thick Endotracheal secretions. Loosening up the patients tracheal secretions will aid in proper oxygenation of the patient. Thick secretions could lead to blockage of the airway of the patient. The patients secretion did not become thicker and the patient did not experience oxygen desaturation that may have resulted from ineffective airway clearance due to thick tracheal secretions. Therefore, the desired effect of the drug to the patient was achieved.

Nursing Responsibilities:Before:1. Check the doctors order2. Check the drug labels and appearance.3. Check for the expiration date4. Check the right dosage, route, and time of administration.5. Inquire if the patient has taken a meal prior to administration as the drug may induce coughing reflex and should therefore cause gag and aspiration. Nebulization should be given 15 minutes before eating or at least 30 minutes after feeding.6. Explain to the patient the purpose of the drug.7. Assess for bleeding tendencies of the patient as one of the side effect of the drug may cause stomach ulceration.During:1. Observe proper medical asepsis.2. Aspirate the drug from the ampule using a syringe and a needle.3. Pour the drug into the nebulization set and tightly close the the set.4. In intubated patients, connect the nebulization set to the mechanical ventilator tubing. The port of connection may differ from one set of tubing to another. Contact respiratory therapy for assistance5. For patients with no special tubes, instruct the patient to inhale through the nebulization sets mouthpiece and exhale through the nostril during nebulization.

After:1. Monitor for the patients reaction to the drug specifically the amount and characteristic of the expelled mucus.2. Perform chest physiotherapy to loosen up thickened phlegm3. Document the findings.4. Document the procedure in the patients chart.



Cefepime(Axera)1gram/ IV

SELF-TERMINATING ORDERDate OrderedFebruary 12, 201512:55 PM

Intravenous1 Gram

OD for 7 daysAntibiotic

Fourth Generation Cephalosporin

Cephalosporins exert bactericidal activity by interfering with bacterial cell wall synthesis and inhibiting cross-linking of the peptidoglycan. The cephalosporins are also thought to play a role in the activation of bacterical cell autolysins which may contribute to bacterial cell lysis.Its spectrum of activity includes most strains of bacterial pathogens responsible for respiratory and urinary tract, infections, including Susceptible organismsBacteroides spp, Enterobacter spp, Escherichia coli, Haemophilus influenzae, Klebsiella spp, Proteus mirabilis, Pseudomonas spp, Staphylococcus aureus, Streptococcus pyogenes

This medication was indicated for Patient X as he was also diagnosed with Community Acquired Pneumonia. The most common cause of such infection is Streptococcus pneumoniae which is susceptible to the antibiotic.The patient was not allergic to the drug, hence no allergic reaction was noted upon administration of the said treatment.It was very interesting to note a great positive influence of the drug to the WBC count of the patient as it decreased to of 18.63 X 109/ L from 41.71 X 109/ L in a span of 7 days of taking the medication. This only implies that the infection is already resolving and that the pathogenic microorganism that is causing the infection is susceptible to the antibiotic.

Nursing Responsibilities:

Before:1. Check the doctors order2. Check the drug labels and appearance.3. Check for the expiration date4. Check the right dosage, route, and time of administration.5. Assess the patients allergy to any drugs that may be associated with the components of cefepime including cephalosporin antibiotic (eg, cephalexin), penicillin antibiotic (eg, amoxicillin) or another beta-lactam antibiotic (eg, imipenem). 6. Observe Drug to drug interaction. Cefepime reacts with Aminoglycosides (eg, gentamicin) or diuretics (eg, furosemide) and increases risk of toxic effects on the kidneys.7. Use aseptic technique.8. Explain to the patient the purpose of the drug.During:1. Observe proper medical asepsis.2. Dilute the powdered drug using 8.8 mL of sterile water for injection to make 10 mL.3. Incorporate the diluted drug to at least 40 mL of D5% Water or Plain Normal Saline Solution.4. Infuse the drug for 30 minutes to 1 hour.5. Regulate the infusion accordingly.

After:1. Monitor for the patients reaction to the drug.2. Document the findings.3. Document the procedure in the patients chart.4. Observe for infection resolution to the physician and correlate with the laboratory results. Relay findings to the physician.



Sulfamethoxazole + TrimethoprimCo-trimoxazole

(Bactrim)

400mg/80mg/5mLSTANDING ORDER

Date OrderedFebruary 16, 20154:45 PM

Oral7mLEvery 12 HoursAntibiotic

SulfonamideDihydrofolate reductase inhibitor

Sulfonamides are structural analogs of para-aminobenzoic acid (PABA) and competitively inhibit a bacterial enzyme, dihydropteroate synthetase, that is responsible for incorporation of PABA into dihydrofolic acid, the immediate precursor of folic acid. This blocks the synthesis of dihydrofolic acid and decreases the amount of metabolically active tetrahydrofolic acid, a cofactor for the synthesis of purines, thymidine, and DNA.

Susceptible bacteria are those that must synthesize folic acid. Mammalian cells require preformed folic acid and cannot synthesize it. The action of sulfonamides is antagonized by PABA and its derivatives (e.g., procaine and tetracaine) and by the presence of pus or tissue breakdown products, which provide the necessary components for bacterial growth.

Trimethoprim:

Trimethoprim is a bacteriostatic lipophilic weak base structurally related to pyrimethamine. It binds to and reversibly inhibits the bacterial enzyme dihydrofolate reductase, selectively blocking conversion of dihydrofolic acid to its functional form, tetrahydrofolic acid. This depletes folate, an essential cofactor in the biosynthesis of nucleic acids, resulting in interference with bacterial nucleic acid and protein production. Bacterial dihydrofolate reductase is approximately 50,000 to 100,000 times more tightly bound by trimethoprim than is the corresponding mammalian enzyme.

Trimethoprim exerts its effect at a step in the folate biosynthesis immediately subsequent to the one at which sulfonamides exert their effect. When trimethoprim is administered concurrently with sulfonamides, synergism occurs, which is attributed to inhibition of tetrahydrofolate production at 2 sequential steps in its biosynthesis.Sulfonamides, such as sulfadiazine and sulfamethoxazole, used together with trimethoprim, produce synergistic antibacterial activity. {14}{156} Sulfadiazine and sulfamethoxazole have equal antibacterial properties, covering the same spectrum of activity. These sulfonamides, in combination with trimethoprim, are active in vitro against many gram-positive and gram-negative aerobic organisms. They have minimal activity against anaerobic bacteria. Susceptible gram-positive organisms include many Staphylococcus aureus , including some methicillin-resistant strains, S. saprophyticus , some group A beta-hemolytic streptococci, Streptococcus agalactiae , and most but not all strains of S. pneumoniae . Gram-negative organisms that are susceptible include Escherichia coli, many Klebsiella species, Citrobacter diversus and C. fruendii , Enterobacter species, Salmonella species, Shigella species, Haemophilus influenzae , including some ampicillin-resistant strains, H. ducreyi , Morganella morganii , Proteus vulgaris and P. mirabilis , and some Serratia species. Sulfonamide and trimethoprim combinations also have activity against Acinetobacter species, Pneumocystis carinii, Providencia rettgeri , P. stuarti , Aeromonas , Brucella , and Yersinia species. They are also usually active against Neisseria meningitidis , Branhamella (Moraxella) catarrhalis , and some, but not all, N. gonorrhoeae . Pseudomonas aeruginosa is usually resistant, but P. cepacia and P. maltophilia may be sensitive.The most common side effect of the drug includes blood dyscrasia by affectating the major blood components such as platelets, hemoglobin and white blood cell. On the third and last determination of the patient complete blood count, the only abnormal finding was the White Blood Cell count which is elevated. This elevation is due to the presence of infection, specifically pneumonia. In this case, the WBC count is already decreasing (18.63 X 109/ L) from its severely elevated baseline (41.71 X 109/L). This is highly suggestive of resolving infection whereas the current pathogenic microorganism is susceptible to the current antibiotic treatment being given.

Nursing Responsibilities:Before:1. Check the doctors order2. Check the drug labels and appearance.3. Check for the expiration date4. Check the right dosage, route, and time of administration.5. Assess the patients allergy for the drug components found in other drugs including furosemide, thiazide diuretics, sulfonylureas, or carbonic anhydrase inhibitors. Patients sensitive to sulfites may have an allergic reaction to Bactrim I.V. since it contains sodium metabisulfite.6. Explain to the patient the purpose of the drug.During:1. Shake the bottle before opening.2. Pour the oral suspension to the measuring cup at eye level to prevent error of parallax.3. Make sure that the meniscus reaches the level of desired dosage.4. Let the child take the drug himself to promote self-reliance.

After:5. Monitor for the patients reaction to the drug. 6. Document the findings.7. Document the procedure in the patients chart.8. Observe proper storage of drug. Make sure to place the drug in a light sensitive container as the suspension is light sensitive.

Name of DrugGeneric(Brand)Stock DoseDate Ordered, Taken, Modified and DiscontinuedRoute of Administration Dosage and frequency of administrationGeneral ActionFunctional classificationMechanism of actionGeneral Indication/ Patient IndicationClients response to the medication with actual side effects

ipratropium bromide + albuterol sulfate(Duavent)21mcg + 120mcg/ nebule

STATDate orderedFebruary 14, 201411 PM

Inhalation via nebulization

2 nebules after extubation

AnticholinergicBronchodilator

Anticholinergic blocks the Ach receptors to prevent bronchoconstriction. This may indirectly cause bronchodilation.

Selectively stimulates beta-2 adrenergic receptors, relaxing airway smooth muscles.Management of reversible bronchospasm associated obstructive airway disease. Patient with chronic obstructive pulmonary and who requires 2nd bronchodilator.

It was prescribed to Patient X as an adjunct treatment for his mucolytic for him to be able to expectorate his sputum more effectively. It was also given to the patient to prevent possible bronchospasm that may worsen the patients condition after extubation. The patient responded well with the treatment as the patients respiratory condition did not worsen and the patient did not experience untoward and allergic reaction with the drug. He was also able to expectorate his sputum during and after nebulization. No respiratory distress was noted after administration of the drug.

Nursing Responsibilities:Before:1. Check the doctors order2. Check the drug labels and appearance.3. Check for the expiration date4. Check the right dosage, route, and time of administration.5. Incorporate the drug with 2ml sterile NSS6. Explain to the patient the purpose of the drug.

During:1. Observe proper medical asepsis.2. Administer the drug before any feeding.3. Use one container of solution or mix the exact amount of solution using the dropper provided for each dose.4. Place the inhalation solution in the medicine reservoir or nebulizer cup on the machine.5. Connect the nebulizer to the face mask or mouthpiece.6. Use the face mask or mouthpiece to breathe in the medicine.7. Use the nebulizer for about 5 to 15 minutes, or until the medicine in the nebulizer cup is gone.

After:1. Monitor for the patients reaction to the drug.2. Suction patients endotracheal tube as necessary.3. Document the findings.4. Document the procedure in the patients chart.5. Observe proper storage of drug.



methylprednisolone

(Solu-Medrol)

500mg/vial

STANDING ORDER


Date ModifiedFebruary 13, 20157PM

Intravenous

500mg/IV OD at 6 AM

60mg/IVOD at 6 AMHormoneCorticosteroidGlucocorticoid

Immunosuppresant

Enters target cells and binds to intracellular corticosteroid receptors, initiating many complex reactions that depresses formation, release, and activity of endogenous mediators of inflammation, including prostaglandins, kinins, histamine, liposomal enzymes, and complement system. Modifies body's immune response.

Short-term management of various inflammatory and allergic disorders, such as rheumatoid arthritis, collagen diseases (eg SLE), dermatologic diseases (eg, pemphigus), status asthmaticus, and autoimmune disorders (eg, MS)

Patient X is experiencing an exacerbation of his condition which is autoimmune in nature. Therefore Patient X may benefit from medically inducing immunosuppressionThere was a great improvement in the condition of the patient after the administration of the loading dose as evidenced by improvement in the respiratory status and increase in the sensorium and muscle strength of the patient. Furthermore, the patient also tolerated the ventilator weaning process which is highly suggestive of the improvement in respiratory muscle power.

Also, Patient X did not experience any additional infection that may have been due to the drugs immunosuppressive effects.

Nursing Responsibilities:Before:1. Check the doctors order2. Check the drug labels and appearance.3. Check for the expiration date4. Check the right dosage, route, and time of administration. Corticosteroids are preferably administered in the morning to mimic the normal peak corticosteroid levels. 5. Make sure that the patient will not receive and live vaccines before and after administering the drug.6. Assess for bleeding tendencies of the patient as one of the side effect of the drug may cause stomach ulceration.7. Explain to the patient the purpose of the drug.During:1. Observe proper medical asepsis.2. Dilute the by incorporating the diluent to the powdered drug. 3. Mix the solution to another diluent with at least 50 mL of preferred solution (plain NSS or D5% Water).4. Infuse the drug at least 30 minutes, but no more than 2 hours.

After:1. Monitor for the patients reaction to the drug specifically for improvement of the muscle strengths.2. Maintain protective isolation as the patient is highly at risk of acquiring infection due to induced immunosuppression by limiting visitors, maintaining asepsis in suctioning and providing care and observing proper frequent hand washing both of the caregiver and patient.3. Document the findings.4. Document the procedure in the patients chart.5. Instruct patient to report presence of gastric upset or abdominal pain.6. Observe proper storage of drug.

Name of DrugGeneric(Brand)Stock DoseType of orderDate Ordered, Modified and DiscontinuedRoute of Administration Dosage and frequency of administrationGeneral ActionFunctional classificationMechanism of actionIndicationInitial ReactionsClients response to the medication with actual side effects

Omerprazole

(Omevex)

40mg/vial

February 12, 201412:55 PM

IV

20mg/IV

OD

Proton pump inhibitor

Antisecretory Drug

Gastic acid-pump inhibitor; Suppresses gastric acid secretion by specific inhibition of the hydrogen potassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the final step of acid productionMaintenance for healing of erosive esophagitis, treatment of duodenal ulcer and prophylaxis treatment for patients who are taking drugs that may be corrosive to the gastric lining.

For Patient X, the medication was prescribed as a prophylactic drug for any drug that may aggravate gastric upset such as the use of corticosteroids. The patient was able to meet the desired effects of the drug as there was no GI bleeding and the patient did not experience any abdominal pain due to hyperacidity and use of corticosteroid.

Nursing Responsibilities:Before:1. Check the doctors order2. Check the drug labels and appearance.3. Check for the expiration date4. Check the right dosage, route, and time of administration.5. Use aseptic technique.6. Explain to the patient the purpose of the drug.During:1. Observe proper medical asepsis.2. Dilute the IV preparation only with Plain NSS as the drug may be unstable when used with other diluents.3. Administer the drug before meals4. Administer oral drug while the patient is in upright or sitting position to avoid aspiration.After:1. Monitor for the patients reaction to the drug.2. Monitor Patients bowel movement3. Document the findings.4. Document the procedure in the patients chart.5. Observe proper storage of drug and this drug should be administered within 8 hours after dilution.

Name of DrugGeneric(Brand)Stock DoseType of orderDate Ordered, Modified and DiscontinuedRoute of Administration Dosage and frequency of administrationGeneral ActionFunctional classificationMechanism of actionIndicationInitial ReactionsClients response to the medication with actual side effects

pyridostigmine

(Mestinon)

10 mg/ paper tablets


Oral/OGT

30 mg

Q 5 Hours

parasympathomimeticAntisecretory

AcetyCholinesterase Inhibitor

Pyridostigmine inhibits acetylcholinesterase in the synaptic cleft, thus slowing down the hydrolysis of acetylcholine. It is a quaternary carbamate inhibitor of cholinesterase that does not cross the bloodbrain barrier which carbamylates about 30% of peripheral cholinesterase enzyme. The carbamylated enzyme eventually regenerates by natural hydrolysis and excess ACh levels revert to normal.This drug is used in treating myasthenia gravis. Pyridostigmine is a cholinesterase inhibitor. It works by improving nerve impulses in muscles so that the muscles are better able to work.

Patient Xs condition involves affectation of the neuromuscular junction transmission (NMT). This drug decreases catabolism of acetycholine as patient may benefit from the increase in concentration of Acetycholine in the synaptic cleft to improve NMT thereby increasing muscle strength. The patient responded well on the treatment as his myasthenic crisis was resolved. Moreover, the patient did not show any exacerbation of the disease process as he was still maintained on this regimen even after he was extubated.

Nursing Responsibilities:Before:1. Check the doctors order2. Check the drug labels and appearance.3. Check for the expiration date4. Check the right dosage, route, and time of administration. This drug usually needs to be well distributed according to the patients activity in the day to prevent fluctuation of muscle strength in a day. 5. Explain to the patient the purpose of the drug.During:1. It is highly suggested that the patient should take the drug at least 30 minutes prior to his meal, to improve muscle strength that would help the patient masticate and swallow his food. 2. Encourage water intake after administration unless otherwise contraindicated.

After:1. Monitor for the patients reaction to the drug specifically muscle strength. 2. Document the findings.3. Document the procedure in the patients chart.4. Instruct patient to report excessive salivation, hyperactive bowel and frequent urination. 5. Note for presence of adverse and life threatening reactions from the drug including cholinergic crisis in which the patient may manifest sudden onset of severe muscle weakness.6. Observe proper storage of drug.



salbutamol

(Asmalin)

2.5mg/2.5mL nebule

STANDING ORDERDate OrderedFebruary 12, 201512:55 PM

Date ModifiedFebruary 13, 20155AM

Nebulization2.5mg Q4 Hours

2.5mgQ 6 HoursSympathomimetic

Bronchodilator

Salbutamol stimulates 2 adrenergic receptors which are predominant receptors in bronchial smooth muscle of the lung. Stimulation of 2 receptors leads to the activation of enzyme adenyl cyclase that form cyclic AMP (adenosine-mono-phosphate) from ATP (adenosine-tri-phosphate). This high level of cyclic AMP relaxes bronchial smooth muscle and decreases airway resistance by lowering intracellular ionic calcium concentrations. Salbutamol relaxes the smooth muscles of airways, from trachea to terminal bronchioles. Bronchospasm with reversible obstructive airway diseases

Salbutamol is indicated for the preventation or treatment of bronchospasm with reversible obstructive airway diseases such as Bronchial asthma, Chronic obstructive pulmonary disease (COPD) which includes chronic bronchitis and emphysema, exercise-induced bronchospasm.Any other situations known to induce bronchospasm.

A bronchodilator is indicated to Patient X because he is intubated. Bronchial irritation may occur because of the presence of a foreign object in the airway. This may cause bronchospasm. This nebulization serves as a prophylaxis for such occurrences. There were no recorded events of bronchospasm. Patient X did no longer suffer from respiratory distress. This indicates that the drug was effective in preventing bronchospasm.

He did not experience tachycardia, which is a very common side effect of the drug because of its sympathomimetic action.

Nursing Responsibilities:Before:1. Check the doctors order2. Check the drug labels and appearance.3. Check for the expiration date4. Check the right dosage, route, and time of administration. This drug should be given at least 30 minutes before or after feeding as this may stimulate gag reflex. 5. Inquire if the patient has taken a meal prior to administration as the drug may cause nausea/6. Explain to the patient the purpose of the drug.

During:1. Observe proper medical asepsis.2. Use one container of solution or mix the exact amount of solution using the dropper provided for each dose.3. Place the inhalation solution in the medicine reservoir or nebulizer cup on the machine.4. Connect the nebulizer to the face mask or mouthpiece.5. Use the face mask or mouthpiece to breathe in the medicine.6. Use the nebulizer for about 5 to 15 minutes, or until the medicine in the nebulizer cup is gone.

After:1. Clean all the parts of the nebulizer after each use.2. Monitor for the patients reaction to the drug specifically for the most common side effects including tachycardia. 3. Document the findings.4. Document the procedure in the patients chart.5. Instruct patient to report presence palpitations6. Observe proper storage of drug.

Name of DrugsGeneric and (Brand Name)Stock DoseDate Ordered, Taken, Modified and DiscontinuedRoute of Administration Dosage and frequency of administrationGeneral ActionFunctional classificationMechanism of actionGeneral Indication and Patient IndicationClients response to the medication with actual side effects

Prednisone(Pred)

30mg/tablet

SELF-TERMINATING ORDER

Date OrderedFebruary 18, 20148 AM

Oral

30mg/tab 2 tabletsAfter breakfast for 7 days

Glucocorticoid

Immunisuppressant

Glucocorticoids such as Prednisolone can inhibit leukocyte infiltration at the site of inflammation, interfere with mediators of inflammatory response, and suppress humoral immune responses. The antiinflammatory actions of glucocorticoids are thought to involve phospholipase A2 inhibitory proteins, lipocortins, which control the biosynthesis of potent mediators of inflammation such as prostaglandins and leukotrienes. Prednisolone reduces inflammatory reaction by limiting the capillary dilatation and permeability of the vascular structures. These compounds restrict the accumulation of polymorphonuclear leukocytes and macrophages and reduce the release of vasoactive kinins. Recent research suggests that corticosteroids may inhibit the release of arachidonic acid from phospholipids, thereby reducing the formation of prostaglandins. Prednisolone is a glucocorticoid receptor agonist. On binding, the corticoreceptor-ligand complex translocates itself into the cell nucleus, where it binds to many glucocorticoid response elements (GRE) in the promoter region of the target genes. The DNA bound receptor then interacts with basic transcription factors, causing an increase or decrease in expression of specific target genes, including suppression of IL2 (interleukin 2) expression.For the treatment of primary or secondary adrenocortical insufficiency, such as congenital adrenal hyperplasia, thyroiditis. Also used to treat psoriatic arthritis, rheumatoid arthritis, ankylosing spondylitis, bursitis, acute gouty arthritis and epicondylitis. Also indicated for treatment of systemic lupus erythematosus, pemphigus and acute rhematic carditis. Can be used in the treatment of leukemias, lymphomas, thrombocytopenia purpura and autoimmune hemolytic anemia. Can be used to treat celiac disease, insulin resistance, ulcerative colitis and liver disorders.

Patient X was given such medication as the one of the side effect of the drug i.e. Immunosuppression is desired in the present autoimmune condition of the patient. The initial treatment by the patient last December 2013 can be considered effective as the patients exacerbation was managed, but the present treatment of immunosuppression in the current case of the patient cannot be well evaluated as the duration of the treatment was not completed during the confinement.

Nursing Responsibilities:Before:1. Check the doctors order2. Check the drug labels and appearance.3. Check for the expiration date4. Check the right dosage, route, and time of administration.5. Explain to the patient the purpose of the drug.6. Assess for any contraindications for the administration of the drug such as elevated blood sugar level, congestion and fluid overload. During:8. Ensure that the patient is sitting upright while taking the drug to avoid aspiration9. Administer the drug around 9-10 in the morning to mimic the natural release of glucocorticoids of the body.After:1. Monitor for the patients reaction to the drug.2. Coordinate with the physicians any adverse reaction to the drug such as 1. Hyperglycemia2. Blurring of vision3. Breathing problems4. Weight gain5. Frequent infection3. Document the findings.4. .Document the procedure in the patients chart.5. Observe proper storage of drug.

b.3 Diet

Type of DietDate Ordered, Date StartedDate ChangedGeneral DescriptionIndication or PurposesSpecific Foods TakenClients response and/or reaction to the diet

Oro-Gastric Tube Feeding with*See Figure 5.2 for Nutritional Information


Date StartedFebruary 12, 20156 PM

Date ChangedFebruary 14, 20157 AM

PediaSure Milk provides balanced nutrition for a child's growth and development. PediaSure is clinically proven nutrition to help kids grow based on studies conducted among children at risk for malnutrition. Each formulation provides 7g protein and 25 vitamins and minerals. PediaSure is gluten-free, kosher, and halal, as well as suitable for children with lactose intolerance. Patient X is place on tube feeding since the patient is on ventilator and cannot swallow foods per orem due to risk of aspiration.

PediaSure Plus Milk Formulation(Vanilla Flavor)

120 cc every 2 hoursi.e.120 kcal/feedingor 1440kcal/day

No allergic response and no residual or vomiting was noted.

Based on observation by the nurse-researcher, the patients diet was sufficient as the patient did not experience starvation. No abdominal discomfort, diarrhea and constipation that may be associated with the use of milk formula noted. Given all these at hand, it can be concluded that the patient responded well with the treatment.

Soft DietDate OrderedFebruary 14, 20157 AM

Date StartedFebruary 14, 20158 PM

Date ChangedFebruary 14, 201512 PM

Soft diet includes food that are generally thicker in consistency and more solid than liquid diet which includes mashed food, oatmeal, and porridge.Patient X was intubated which may have affected his ability to swallow. His tolerant of taking food per orem was being assessed prior to taking a full diet. Patient X was newly extubated and his OGT was also removed at the very same time last February 14, 2015 at 7 AM. In relation to this, Patient X should not immediately be given solid food to prevent aspiration. Oatmeal and Milk (PediaSure Plus). The patient was able to swallow his foods without experiencing any gag reflex during the process that couldve led to aspiration. The patient did not like the fact that he could only eat soft foods and so he demanded to eat solid food like fried chicken from Jollibee.

Full DietDate ChangedFebruary 14, 201512 PM


DAT, Diet as Tolerated. This particular diet is only given when client can now tolerate any food he desires that is nutritious, if this will not lead to any complications.This diet was indicated for the patient as there is no contraindication of any dietary consideration in the case presented by the patient. He also needs to regain his weight and so the patient is encouraged to eat more foods according to his demand to improve his nutritional status. February 14, 2015Lunch:Jollibee Fried Chicken and SpaghettiSnack: PediaSure 120 mL and hotdog sandwichDinnerPeach mango pie and creamy macaroni soup

February 15, 2015Breakfast:Egg, porridge, BearBrand Milk and ToastLunch:Chicken Barbecue, Chopsuey and RiceSnack:SkippedDinner:Jollibee creamy macaroni soup

February 16, 2015

Breakfast:Ham and Cheese Sandwich with PediaSure 120mL

Snack:Skyflakes crackers and orange juice

Lunch:Beef with Broccoli and RiceSnack:SkippedDinner:Mashed Potato and SamosaFebruary 17, 2015Breakfast:Jollibee macaroni soup and pineapple juice

Snack:Jollibee Tuna Pie and BearBrand Sterilized Milk

Lunch:Mang Inasal Chicken and Fried Rice

Snack:Cupcake and Pediasure 120mL

Dinner:Champorado (Chocolate Porridge) and Pediasure 120 mL

February 18, 2015

Breakfast:Jollibee Fried Chicken and Spaghetti and chocolate drink

Lunch:Tuna Mayo Sandwich and Pineapple Juice

Snack:Spaghetti and BearBrand Sterilized Milk The patient tolerated his normal diet with no episode of aspiration, nausea and vomiting. His appetite was also normal and he did not experience anorexia and he was able to finish the food that was served to him. He did not experience dysphagia and odynophagia during his meals. He is very fond of eating meals from his favourite fast-food chain, Jollibee, hence he is always fed with take-out meals per demand.

Nursing Consideration in assisting the patient in eatingBefore:1. Verify doctors order for the specific diet indicated for the patient2. Before bringing the meal tray into the room, ask whether the client needs to void to have a bowel movement.3. Provide hygiene measures before serving the meal tray4. Position client in a comfortable position5. Ask about the clients eating habits and the foods he prefers to eat first. Ask what help is needed. For instance, in Patient Xs condition, he may benefit with light meals during night time where his swallowing is impaired by the weakness of his muscles.6. Make sure the food are given at the right temperatureDuring:1. Provide assistance if the client is unable to handle eating or to open containers and packages.2. Provide adequate time for the client who has difficulty chewing or swallowing. Make sure that someone is in the room while the client is eating.After:1. Document the type of and amount of food taken at each meal.2. Remove the tray after the meal, and provide hygiene measures.

Nursing Responsibilities for OGT insertion and FeedingBefore:

1. Explain and discuss the procedure with the patient. 2. Arrange a signal by which the patient can communicate if he/she wants the nurse to stop e.g. by raising his/her hand. 3. Assist the patient to sit in a semi-upright position in the bed or chair. Support the patients head with pillows. Note: The head should not be tilted backwards or forwards.4. Put on Plastic apron, wash hands and put on gloves 5. Mark the distance with tape which the tube is to be passed by measuring the distance on the tube from the patients ear lobe to the bridge of the nose plus the distance from the bridge of the nose to the bottom of the xiphisternum.

During:

1. Check the patients nostrils are patent by asking him/her to sniff with one nostril closed. Repeat with the other nostril. 2. Lubricate about 15-20 cm of the tube with a thin coat of lubricating jelly that has been placed on a topical swab. 3. Insert the proximal end of the tube into the clearer nostril and slide it backwards and inwards along the floor of the nose to the nasopharynx. If an obstruction is felt, withdraw the tube and try again in a slightly different direction or use the other nostril. 4. Advance the tube through the pharynx as the patient swallows until the tapemarked tube reaches the point of entry into the external nares. If the patient shows signs of distress, e.g. gasping or cyanosis, remove the tube immediately.5. When feeding the patient, check patency by auscultating a gurgling sound from the patient stomachs after pushing air to the NGT tube using a Toomey or Bulb Syringe. Place the patient at least in semi-fowlers position prior to feeding. Flush the tube with 30mL of water if not contraindicated. Proceed with feeding. Flush with water before giving diluted pulverized medications. Flush the tube again with water. Make sure to close the NGT to avoid unnecessary residuals.

After:1. Secure the tube to the nostril with hypoallergenic adherent dressing tape An adhesive patch (if available) will secure the tube to the cheek. 2. Check the position of the tube to confirm that it is in the stomach by using the following methods: 3. Aspirating 2 ml of stomach contents and testing this with pH indicator strips. A pH of between 1 and 5.5 is reliable confirmation that the tube is not in the lung, however it does not confirm gastric placement as there is a small chance the tube tip may sit in the oesophagus where it carries a higher risk of aspiration. If this is a concern, the patient should proceed to x-ray in order to confirm position. Where pH readings fall between 5 and 6 it is recommended that a second competent person checks the reading or retests. 4. Once position has been confirmed, a spigot or drainage bag can be place into the distal end of the tube.

b.3 Activity / Exercise

Type of ActivityDate OrderedDate StartedDate ChangedGeneral DescriptionGeneral Description/Indication/ Patient IndicationClients response to the activity

Complete Bed Rest with no bathroom privilegesDate OrderedFebruary 12, 201512:55 PMDate StartedFebruary 12, 201512:55 PMDate ChangedFebruary 14, 201512 PM

Bed rest is a therapeutic intervention that achieves several objectives including the following:1. Provide rest for clients who are exhausted2. Decreases the bodys oxygen consumption3. Reduces pain and discomfort

A complete bed rest was indicated for Patient X for the purpose of providing rest as he is physically exhausted and he is too weak to function since the patients oxygen supply is decreased and his muscles are weak.

Although he was only prescribed with complete bed rest, his nurses initiated to perform active-passive range of motion exercises.He was tolerant of the complete bed rest and did not complain of inactivity. There was no noted adverse effect of prolonged bed rest as the patient did not show any signs of muscle dystrophy and bed sores. He is able to turn himself side to side and active range of motion exercises were also encouraged. The patient was bathed in bed as he is not allowed to travel to bathroom.

Complete Bed Rest with bathroom privileges Date OrderedFebruary 14, 201512 PMDate StartedFebruary 14, 201512 PM

This type of activity is similar to the activity mentioned above, but the patient is now allowed to use the bathroom to defecate, urinate and take a shower. Patient X was given the privilege to have bathroom trips as he was already extubated, he is no longer under respiratory distress and he was finally able to regain his muscle strength.The patient was able to take trip to the bathroom to meet his elimination and hygienic needs without any difficulty and without any noted signs dyspnea. He did not experience

Nursing Responsibilities for Complete Bed Rest:Before:1. Verify doctors order2. Educated the client regarding the prescribed activity like Type of activity Indication of activity Limitations of the activity How he can cooperate with the prescribed activity How the activity would benefit him with his current conditionDuring:1. Assist the patient in a comfortable position2. Assist the patient with other activities3. Make sure that the patient is always in comfortable position4. Assist the client with AROM exercises to prevent adverse effects of inactivity.After: 1. Monitor how much activity the patient exerts2. Monitor the patients reaction and compliance to the activity3. Document findings in the patients chart.

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B. NURSING MANAGEMENT1. NURSING CARE PLANSDuring the course of Patient Xs hospitalization, there were 10 Nursing Diagnoses identified and intervened accordingly by the nurse/s on duty. The following Nursing Diagnoses were prioritized from the cross principles of Airway, Breathing and Circulation (ABCs) and Abraham Maslows Hierarchy of Needs,

PriorityNursing Diagnoses

1Impaired spontaneous ventilation

2Ineffective airway clearance

3Impaired gas exchange

4Risk for Aspiration

5Ineffective protection

6Impaired physical mobility

7Disturbed sleep pattern

8Imbalanced nutrition: less than body requirements

9Impaired verbal communication

10Readiness for Enhanced Health Maintenance

Figure 5.3 Prioritization of Nursing Diagnoses.

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Problem Number 1: Impaired Spontaneous Ventilation

AssessmentNursing diagnosisScientific explanationObjectivesNursing interventionsRationaleExpected outcome

Subjective cues:Patient nodded when his mother asked if he is having difficulty of breathing.

Objective cues:

The patient manifested:

1. Decreased arterial oxygen saturation (83%)2. Tachycardia (117bpm)3. Dyspnea4. Tachypnea (29cpm)5. Decrease in sensorium (GCS 7 i.e. E2V1M4)

The patient may manifest:

1. Apprehension2. Use of accessory muscles for respiration3. Increase restlessness4. Cyanosis5. Increase partial pressure of arterial carbon dioxide6. Decrease partial pressure of arterial oxygen7. ApneaImpaired Spontaneous Ventilation related to decrease in respiratory muscle strength as evidenced by dyspnea secondary to Myasthenic Crisis

Myasthenia Gravis is a disease in which voluntary muscles are affected and becomes weak. Acetylcholine, a neurotransmitter, is the primary signal from the neuron that triggers muscle contraction through the receptors present in the outer layer of the muscles. In Myasthenia Gravis, these receptors are rapidly destroyed by an autoantibody; hence they are decreased in number. The decrease in the receptor leads to decrease muscle contraction. When a patient with Myasthenia Gravis is in crisis, there is severe weakening of muscles including respiratory muscles. This results to ineffective control of spontaneous ventilation. The decrease in ventilation causes a decrease inhalation of oxygen and the oxygen demand of the body is not met. Chemoreceptors found in the carotid body detects high levels of carbon dioxide as it is also not properly expelled through decrease in ventilation. This chemical changes is converted to action potential that is sent to the midbrain, a part of the brain that controls breathing. In an effort to increase the needed oxygen and expel excessive toxic carbon dioxide, the midbrain would increase respiratory effort hence the increase in respiration per minute, and activate stretch receptors which eventually leads to release of catecholamine that increases the heart rate. Short term:

After two hours of nursing interventions, The patient will not show progression of respiratory distress as evidenced by hemodynamic stability and proportionate oxygen demand and supply

Long term:

After 2-3 days of nursing interventions, The patient will have proper spontaneous ventilation

1. Monitor / document characteristics of Respiratory status, including rate and depth of respiration, chest excursion and symmetry,presence of cyanosis, use of accessory muscles for respiration, effectiveness of cough,suctioning demands, sputum characteristics and oxygen levels.

2. Assess the need for an artificial airway and prepare in assisting in case there is a need to intubate the patient.

3. Assess the patient and their relatives knowledge of mechanical ventilation to promote cooperation and understanding.

4. Inform the patient, other health care members and family members about signs and symptoms of complications, such as atelectasis, fluid overload, respiratory infection, and tension pneumothorax.

5.Perform aseptic technique in performing artificial airway care to the patient.

6.Wean the patient from ventilator support as soon as possible.

7.Suction secretions gently as necessary.

8.Encourage deep Breathing Exercises.

9.Allow bed mobility and turn patients side to side at least every 2 hours.

10.Evaluate patients response to treatment. 1. In patients with impaired spontaneous ventilation, the patient is not able to meet the oxygen demand of the body. The current respiratory status will suggest improvement or deterioration of the patients current status.

2. Patients who cannot control their ventilation whether temporarily or permanently, would highly benefit from artificial airway in order to promote proper tissue oxygenation via mechanical ventilation.

3.Artificial airways can be easily removed and therefore can impose great risks in the patients ventilation. Self-extubation is common in the health care settings. Patients who do not understand the need for mechanical ventilation would tend to cooperate less than those who are knowledgeable. 4.Immediate reporting of complications will ensure early intervention for respiratory distress.

5. Infection if very common among patients with artificial airway, whether they already have an on-going infection or not, asepsis should always be observed to prevent concurrent or promoting infection.

6.Prolonged ventilator support and artificial airways increases the risk for infection other respiratory complications including respiratory muscle atrophy. Endotracheal and nasopharyngeal airways are prone to mucus block if prolonged for more than 7 days. Reintubation may be an option.

7.Vigorous, prolonged, frequent and improper suctioning can traumatize the patients airway wich can cause complications such as infection, bleeding and blockage from clots of blood.

8.Performing deep breathing exercises even when mechanically ventilated would help prevent respiratory muscle atrophy.

9.Prolonged immobility can cause or compound pneumonia as it can cause stasis of pulmonary secretions.

10.Mechanical ventilation may not be sufficient to promote proper spontaneous ventilation. Assess for the underlying cause and coordinate with other health care members to address the problem. Short term:

The patient shall not have shown progression of respiratory distress as evidenced by hemodynamic stability and proportionate oxygen demand and supply

Long term:

The patient shall have proper spontaneous ventilation

Problem Number 2: Ineffective Airway ClearanceAssessmentNursing diagnosisScientific explanationObjectivesNursing interventionsRationaleExpected outcome

Subjective cues:

The patient may verbalize:

1.Progressive dyspnea2.Headache3.Dizziness

Objective cues:

The patient manifested:

1.Crackles heard on both lung fields2.Productive cough3.Shortness of breath4.Weakness5.Thick endotracheal mucous secretions6.Tachypnea (29bpm)7.Tachycardia (117cpm)8.Decrease in Oxygen Saturation (83%)

The patient may manifest:1.Pale fingernail beds2.Pale palpebral conjunctiva3.Restlessness4.Irritability5.CyanosisIneffective Airway Clearance related to increased mucus production as evidenced by effective productive cough secondary to pneumoniaWith ineffective ventilation process and medically induced immunosuppression the patient is at risk for respiratory infection. Respiratory tract infections are caused by an invasion of micro-organisms on the trachea - bronchial tract of the patient. These microorganisms cause inflammatory reactions thereby increasing the production and secretion of mucous. These mucous secretions accumulated on his trachea - bronchial tract thereby reducing the diameter of the bronchial lumen. With this, there was then a decrease in airflow to and from his lungs. Ineffective airway clearance results from the inability to expectorate the said retained secretions. In addition to this, the problem also occurs as a result of the patients pulmonary congestion. Because of this congestion, the airway is thereby blocked thus the normal entry of oxygen and exit of carbon Dioxide is denied.Short term:

After four hours of nursing interventions, the patient will be able to maintain airway patency as evidenced by absence of signs and symptoms of respiratory distress.

Long term:

After four days of nursing interventions, the patient will be able to demonstrate absence of congestion with clear breath sounds, respirations noiseless and improved oxygen exchange as evidenced by absence of cyanosis or any signs of respiratory distress.

1.Assess patients condition including vital signs.

2. Assess rate / depth of respirations and chest movement.

3. Auscultate lung fields noting areas of decreased / absent airflow and adventitious breath sounds.

4. Elevate head of bed, change position frequently.

5. Assist patient with frequent deep-breathing exercises. Demonstrate / help patient learn to perform activity such as splinting chest and effective coughing while in upright position.

6.Suction secretions as indicated.

7.Provide adequate fluid intake.

8. Administer medications such as bronchodilators as indicated and ordered.

9. Monitor serial chest X-rays, ABGs, and pulse oximetry readings as ordered.

1. Assessing the patients condition and vital signs will give the health care providers baseline data for the planning and implementation of nursing interventions.

2. Tachypnea, shallow respirations and asymmetric chest movement are frequently present because of discomfort of moving chest wall and / or fluid in the lungs.

3. Decreased airflow occurs in areas consolidated with fluid. Bronchial breath sounds can also occur in consolidated areas. Crackles, rhonchi and wheezes are heard on inspiration and / or expiration in response to fluid accumulation, thick secretions and airway spasm.

4. Lowers diaphragm, promoting chest expansion, aeration of lung segments, mobilization and expectoration of secretions.

5. Deep breathing facilitates maximum expansion of the lungs / smaller airways. Coughing is a natural self-cleaning mechanism, assisting the cilia to maintain patent airways. Splinting reduces discomfort, and an upright position favors deeper, more forceful cough effort.

6.Stimulates cough or mechanically clears airway in patient who is unable to do so because of ineffective cough.

7.Fluids, especially aid in mobilization and expectoration of secretions. Facilitates liquefaction and removal of secretions.

8. Aids in reduction of bronchospasm and mobilization of secretions. congestion.

9.Follows progress and effects of disease process / therapeutic regimen. And facilitates necessary alterations in therapy.Short term:

The patient shall have maintained airway patency as evidenced by absence of signs and symptoms of respiratory distress.

Long term:

The patient shallhave demonstrated absence of congestion with breath sounds clear, respirations noiseless and improved oxygen exchange as evidenced by absence of cyanosis or any signs of respiratory distress.

Problem Number 3: Impaired Gas ExchangeAssessmentNursing diagnosisScientific explanationObjectivesNursing interventionsRationaleExpected outcome

Subjective cues:

The Patient verbalized shortness of breath and dyspnea prior to admission

Objective cues:

The patient manifested:1.Decrease in oxygen saturation (83%)2.Crackles on both lung fields 3.Productive Cough4.Shortness of breath5.Weakness6.Decrease in sensorium GCS 7(E2V1M4)7.Dyspnea8Tachycardia (130bpm)9.Tachypnea (53cpm)

The patient may manifest:

1.Tissue injury2.Hypercapnia3.Respiratory Acidosis

Impaired Gas Exchange related to decrease in ventilator effort and mechanical blockage (mucus)evidenced by decrease in oxygen saturation of 83% secondary to Myasthenia Gravis and PneumoniaThe patient experienced dyspnea with the presence of trachea - bronchial secretions. His respiratory efforts were also diminished because of the respiratory muscle weakness. Although he was tachypneic, his breathing was shallow. He was unable to maintain a patent airway. Thus, hypoxia started to set in. With this, he was hooked under mechanical ventilation to provide his tissues with the adequate oxygenation and ventilation.Short term:

After four hours of nursing interventions, the patient will be able to maintain improved ventilation and oxygenation of tissues as evidenced by ABGs / pulse oximetry within patients normal ranges and free of symptoms of respiratory distress.

Long term:

After two days of nursing interventions, the patient will be able to manifest signs of normal gas exchange as evidence by absence of dyspnea, tachypnea, cyanosis, restlessness, irritability, and normal pulse oximetry results.

1.Assess respiratory status for rate, depth and ease of effort at rest or with exertion, inspiratory/expiratory ratio.

2. Observe for presence of cyanosis and mottling; monitor ABGs for ventilation /perfusion problems.

3. Monitor for mental status changes, deterioration in level of consciousness, restlessness, irritability or increased fatigue.

4. Assess for nausea and vomiting.

5. Position in semi- or high-Fowlers position.

6. Prepare for intubation and placement on mechanical ventilation as ordered.

7. Prepare patient for placement on mechanical ventilation and intubation procedures as ordered.

8. Instruct patient and family members with regards to all procedures, placement on ventilator, what to expect and methods to communicate.

9. Assist with intubation of patient; auscultate all lung fields for breath sounds.

10. Pre-oxygenate patient and auscultate for bilateral breath sounds and observe for symmetric chest expansion.

11. Utilize low pressure endo-tracheal intubation.

12. Maintain airway, secure tube with tape of other securing device.

13. Obtain chest X-ray after ETT is inserted and after 24 hours, as per doctors order.

14. If ETT is placed orally, daily changes from side to side of mouth should be routinely performed. Perform oral care every 4 fours and as necessary.

15. Suction secretions as needed making sure to Pre-oxygenate the patient before during and after procedure.

16. Monitor ventilator settings at least every 2-4 hours and as necessary.

17. Observe for temperature of ventilator circuitry; drain tubing away from the patient as warranted.

18. Monitor airway cuff for leakage, noting amount of air volume in cuff and cuff pressures at least every 4-8 hours.

19. Auscultate for adventitious breath sounds, subcutaneous emphysema or localized wheezing.

20. Monitor ventilatory pressure wave forms and notify physician of significant abnormalities.

21. Observe breathing patterns and note if patient has spontaneous breaths in addition to ventilatory breaths.

22. Assess for cuff leakage and change/notify physician for change of airway.

23. Instruct patient and family members regarding equipments and alarms. Ensure that patient understands that he will not be able to speak, but will have nurse available at all times.

24. Instruct patient and family members regarding weaning procedures.

25. Monitor ABGs for trend and change ventilator setting as ordered.

26. Monitor lab work, such as Hemoglobin and Hematocrit, electrolytes and so forth, as ordered.

27. Obtain chest X-ray every day and as necessary while the patient is intubated, as ordered.

1. Changes in respiratory pattern or patency of airway may result in gas exchange imbalances.

2. Cyanosis results from decreases in oxygenated haemoglobin in the blood and this reduction leads to hypoxia. Reading of 90 % on pulse oximeter correlates with pO2 of 60, depending on the patients pH, temperature and other factors.

3.Hypoxia affects all body systems and mental changes can result from decreased oxygen to brain tissues.

4. May indicate effects of hypoxia on gastrointestinal system.

5.Promotes breathing and lung expansion to enhance gas distribution.

6. Placement on mechanical ventilator will maintain adequate oxygenation and perfusion. 7. Provides know-ledge and decreases fear. Emergent nature of the problem may negate the ability to do pre-procedure teaching but should be done as soon as possible. Instruct patient and family members if time warrants for placement on mechanical ventilation.

8. Patient may be anxious and fight the ventilator requiring sedation to achieve adequate ventilation.Promotes knowledge and reduces fear. May promote cooperation.

9. Placement of an artificial airway is required for mechanical ventilation support.

10. Prolonged difficulty in placement of the tube may result in hypoxia. If symmetric chest expansion is not observed, or if breath sounds cannot be heard bilaterally, this may indicate improper placement of the tube into the right main bronchus or esophagus, and correction of this problem must be addressed promptly.

11. High pressure cuffed tubes may promote tracheal necrosis or result in tracheal fistula.

12. Artificial airways may become occluded by mucous or other secretory fluids, may develop a cuff leak resulting in inability to maintain pressures sufficient for ventilation, or may migrate to a position whereby adequate oxygenation is impaired. Tubes should be adequately secured to prevent movement, loss of airway, and tracheal damage.

13. Radiographic confirmation of tube placement is mandatory; the tube should be 2-3 cm above the carina.

14. Prevents tissue necrosis from pressure of tube against teeth, lips, and other tissues. Oral tubes promote saliva formation, cause nausea and vomiting if movement of tube stimulates retching, and prevent the patient from closing his mouth without biting down on the tube.

15. Suctioning is required to remove secretions because the patient is unable to do so, on his own.

16. Ventilator settings are adjusted based on the disease process and patients condition to maintain optimal oxygenation and ventilation while the patient is unable to do so on his own.

17. Intubation bypasses the bodys natural warming/ humidifying action, and requires increase temperature and moisturizing of the delivered oxygen.

18. Proper cuff inflation is done with the least amount of air to ensure a minimal leak with maintenance of adequate ventilatory pressures and tidal volume.

19. May indicate migration of airway tube. Movement from trachea into tissue may cause mediastinal of subcutaneous emphysema and / or pneumothorax.

20. Airway pressure tracing can identify asynchronous respiratory status between patient and ventilator, patients effort and work of breathing, and auto PEEP identification in order to promptly correct disadvantageous situations.

21. Increased or decreased ventilation may be experienced by ventilator patients who may try to compensate by competing with ventilatory breaths.

22. Cuffs which have leaks that enable a patient to have the ability to speak, in which air may be felt at the nose and / or mouth, changing pressure with ventilation, and / or decreased exhaled volumes require change in order to maintain adequate oxygenation and ventilation.

23. Provides knowledge to facilitate compliance and decrease anxiety.

24. Progressive but slow weaning helps the patient to adjust to the increase in work of breathing.

25. Maintains adequate oxygenation and acid-base balance.

26. Decreases in Hemoglobin and Hematocrit reflect a decrease in the oxygen-carrying capability of the blood. Abnormal electrolytes may result in cardiac dysrhythmias, which increase the workload on the cardiac and pulmonary systems.

27. Facilitates recognition of tube migration, atelectatic changes, presence of pneumothorax, or other significant changes.

Short term:

The patient shall have demonstrated improved ventilation and oxygenation of tissues as evidenced by ABGs / pulse oximetry within patients normal ranges and free of symptoms of respiratory distress.

Long term:

The patient shall have manifested signs of normal gas exchange as evidence by absence of dyspnea, tachypnea, cyanosis, restlessness, irritability, and normal pulse oximetry results.

Problem Number 4: Risk for Aspiration


Subjective cues:

The patient verbalized:Nandito na naman po yung hirap po akong lumunok kahpag gabi na po

(I am having difficulty in swallowing again, especially at night)

The Patient may verbalize:1.Odynophagia2.Shortness of Breath

Objective cues:

The patient may manifest1. Choking by widening of eyes and protrusion of tongue2.Hypoxia3. Dyspnea4.Vomiting5.Dizziness6. Panicked and distressed behaviour.7.Inability to talk in complete sentences or at full volume.8.Frantic coughing.9.Unusual breathing sounds, such as wheezing or whistling.10.Clutching at the throat.11.Watery eyes.12.Red face.Risk for aspiration related to decrease in muscle strength (bulbar weakness)Secondary to Myasthenia GravisIn patients with Myasthenia Gravis, there is weakening of muscles that are evident most especially on the latter part of the patients day. This weakening of muscles is because of ineffective neuromuscular junction transmission of Acetylcholine that is autoimmune mediated. Affected muscles usually include the bulbar muscle which is responsible for swallowing. With the weakened swallowing reflex, there is a great risk for aspiration. Short Term:

After four hours of nursing intervention the patient and relative will be able to identify causative/risk factors of aspiration and demonstrate and verbalize understanding of how to prevent patient aspiration.

Long Term:

After 2 days of nursing intervention the patient will be able to decrease risk of aspiration with the help of proper assessment and early intervention,1.Assess patients ability to swallow

2.Assess the underlying cause of patients inability to swallow

3.Mealtimes should coincide with the peak effects ofAnticholines-terase medication ex: Pyridostigmine bromide(Mestinon)

4.Coordinate with the hospital nutritionist to address dietary modifications

5.Feed the patient with the head of bed elevated.

6.Offer small frequent feeding instead of heavy meals

7. Assess for vomiting and activity intolerance

8.Maintain operational suction equipment at hand

9. Notify the physician or other health care provider immediately of noted decrease in cough and/or gag reflexes, or difficulty in swallowing.

10. Offer foods with consistency that patient can swallow. Use thickening agents as appropriate. Cut foods into small pieces.

11. Encourage patient to chew thoroughly and eat slowly during meals. Instruct patient not to talk while eating.

12, Maintain upright position for 30 to 45 minutes after feeding.

13. Provide oral care after meals.1. This should serve as a baseline knowledge for the caregiver. The extent of swallowing defects will direct nursing education and interventions.

2.This should give the nurse the idea on what intervention/s to provide

3.In Myasthenic patients, the maximum plasma concentration of acetylcholines-terase inhibitors are usually about 1-2 hours. Therefore it should be given at least an hour before eating their meals.

4.If weakness of muscles occur at night, the patient should eat more easily masticated and light meals during dinner and heavy meals should be served in the morning when the patient regain his strength.

5.To prevent aspiration by minimizing the risk of reflux

6.This will allow some time for rest in the part of the patient that would promote regaining muscle strength.

7. Predisposes to aspiration of contents of reflux which is precipitated by factors associated with feeding

8.This should be placed at bedside for immediate intervention in case aspiration occurs.

9. Early intervention protects the patient's airways and prevents aspiration.

10.Semisolid foods like pudding are most easily swallowed. Liquids and thin foods like creamed soups are most difficult for patients with dysphagia.11.Facilitates easier swallowing of foods. Eating while taking may increase the risk for aspiration due to opening of the epiglottis.

12. The upright position facilitates the gravitational flow of food or fluid through the alimentary tract. If the head of bed cannot be elevated because of patient's condition, use a right side-lying position after feedings to facilitate passage of stomach contents into the duodenum.

13. To remove residuals and to reduce pocketing of food that can be later aspirated.Short term:

The patient shall have demonstrated improved ventilation and oxygenation of tissues as evidenced by ABGs / pulse oximetry within patients normal ranges and free of symptoms of respiratory distress.

Long term:

The patient shall have manifested signs of normal gas exchange as evidence by absence of dyspnea, tachypnea, cyanosis, restlessness, irritability, and normal pulse oximetry results.

Problem Number 5: Ineffective Protection


Subjective cues:

The Patient may verbalize:1. Perceived changes in body temperature

Objective cues:

The patient manifested :

1. Leukocytosis Day 141.71x109/LDay 321.83x109/LDay 718.63 x109/L

2.NeutrophiliaDay 10.73Day 30.78Day 70.823. Secondary Thrombocytosis Day 1535 x 109/LDay 3577 x 109/LDay 7536 x 109/L

4. Increase in mucous secretion production5.Bilateral lung fields crackles6.Persistent productive cough

The patient may manifest :

1. Hyperthermia2. Wheezes3. Chills4. Nasal CongestionIneffective protections related to impaired secondary protective mechanismas evidenced by leucocytosis secondary to medically induced immune-suppression (Prednisone intake) Therapeutic immunosuppression is usually indicated among patients with autoimmune disorders. Prednisolone is a synthetic glucocorticoid that is given among patients with autoimmune disorders such as Myasthenia Gravis. Prednisolone acts in the feedback mechanism of the immune system which turns the immune system down. Glucocorticoids cause their effects by binding to the glucocorticoid receptor (GR). The activated GR complex, in turn, up-regulates the expression of anti-inflammatory proteins in the nucleus (a process known as transactivation) and represses the expression of proinflammatory proteins in the cytosol by preventing the translocation of other transcription factors from the cytosol into the nucleus (Rhen, 2013). Given all these at hand, the patient is at risk for infection including pneumonia, which is the second leading cause of morbidity in the Philippines in the year 2010 (Department of Health, 2010)Short Term :

After three hours of nursing interventions, the patient and relatives would be able to identify techniques and participate on preventing further infection by examples of proper frequent hand washing, aseptic technique and limiting visitors.

Long Term:

After 7 days of nursing interventions, the patient will resolve on-going infection and will remain free from other infection/s as evidenced by normal white blood cell counts. 1.Monitor and record vital signs and observe signs of infection such as increased body temperature

2.Promote adequate rest/exercise periods.

3. Note and report laboratory values(e.g., white blood cell count and differential, serum protein, serum albumin, and cultures).

3.Use strategies to prevent infection transmission including disinfecting/washing hands before and after client contact and wearing protective isolation mask or face mask

4. Teach the patient and significant others about the nature of this disorder and the need for therapeutic immunosupression

5.Observe for localized sign of infection at insertion sites of invasive lines.

6.Review environmental factors.

7. Administer prophylactic and therapeutic antibiotics as ordered and note response.1. Increase in body temperature may indicate presence of severe infection in the case of the patient who are therapeutically immunocompromised.

2.Aqeuate rest allows preservation of oxygen that is needed by other body parts to fight off pathogenic microorganisms.

3.Temperature elevation may occur (if not masked by corticosteroids or anti-inflammatory drugs) because of various factors, e.g., chemotherapy side effects, disease process, or infection. Early identification of infectious process enables appropriate therapy to be started promptly.

3. Protects patient from sources of infection, such as visitors and staffs who may spread their on-going infection.

4.Comprehension and understanding of the disease process will help the patient and their relatives to be compliant with the need for therapeutic immunosuppression despite its adverse effects .

5.Immuno-compromised patients usually does not show any signs of inflammation as their inflammatory response is deactivated. IV lines should be changed within 72 hours after insertion to prevent infection.

6.The environment plays a great role in preventing infection among patients. auxiliary should be coordinated to promote clean and safe environment for the immuno-compromised patient.

7. Physicians usually order antibiotics to cover for the most common pathogenic microorganisms. Assessment for improvement or development of patient signs and symptoms should be coordinated to the physician to assess effectiveness of treatment.Short Term :

The patient and relatives shall have identified techniques and participated on preventing further infection by examples of proper frequent hand washing, aseptic technique and limiting visitors.

Long Term:

The patients on-going infection shall have been resolved and he shall have remained free from other infection/s as evidenced by normal white blood cell counts.

Problem Number 6: Impaired Physical Mobility*Functional Level of Classification IV: Dependentdoes not participate in activityAssessmentNursing diagnosisScientific explanationObjectivesNursing interventionsRationaleExpected outcome

Subjective cues:

The Patient verbalized:Nodding when the nurse asked if he is reluctant to move because of presence of discomfort in his throat when the endotracheal tube is mobilized and he might accidentally remove his endotracheal tube.

The patient may verbalize:1.Numbness of immobilized extremities

Objective cues:

The patient manifested :1. Reluctance to attempt movement2. Limited range of motion (ROM)3. Imposed restrictions of movement

The patient may manifest:1.Decreased muscle endurance, strength, control, or mass.2.Signs and symptoms of deep vein thrombosis3.Bed sores4.Progression of pneumonia5.Constipation

Impaired Physical Mobility related to throat discomfort from mobilization of endotracheal tube as evidenced by Reluctance to attempt movement The endotracheal tube is a foreign body that triggers the nociceptors in the throat of the patient. These nociceptors trigger pain response in which the patient feels as discomfort. Patient Xs movement is then limited because he does not want to feel this discomfort because of the mobilization of the endotracheal tube. Hence, Patient X does not want to participate in activities that would involve bed mobility. Prolonged immobility causes stasis of blood in areas with pressure including the sacral and other bony prominences, this leads to pressure sore. The stasis of blood can also cause decrease in circulation of nerves in the area leading to numbness. Moreover, proteins in the muscle are catabolized and wasted away leading to muscle atrophy and weakness.Short Term :

After four hours of nursing interventions, the patient and relatives would be able to identify techniques and participate on activities that could promote bed mobility including active range of motion exercises.

Long Term:

After three days of nursing interventions, the patient not show any adverse signs and symptoms of prolonged immobility as evidenced by no motor deficits. 1. Assess for impediments to mobility

2. Assess patient's ability to perform ADLs effectively and safely on a daily basis

3. Assess patient or caregivers knowledge of immobility and its implications.

4. Assess for developing thrombophlebitis (calf pain, Homans' sign, redness, localized swelling, and rise in temperature).

5. Assess skin integrity. Check for signs of redness, tissue ischemia (especially over ears, shoulders, elbows, sacrum, hips, heels, ankles, and toes).

6. Assess elimination status (usual pattern, present patterns, signs of constipation).

7. Encourage and facilitate early ambulation and other ADLs when possible. Assist with each initial change: dangling, sitting in chair, ambulation.

8. Provide positive reinforcement during activity.

9. Allow patient to perform tasks at his or her own rate. Do not rush patient. Encourage independent activity as able and safe.

10. Keep side rails up and bed in low position.

11. Turn and position every 2 hours, or as needed.

12. Perform passive or active assistive ROM exercises to all extremities

13. Encourage coughing and deep-breathing exercises. 1. Identifying the specific cause guides design of optimal treatment plan.

2.Restricted movement affects the ability to perform most ADLs.

3. Even patients who are temporarily immobile are at risk for some of the effects of im

5 patient and his care

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