cardio pulmonary arrest secondary to status asthmaticus (1) (1)

7/27/2019 Cardio Pulmonary Arrest Secondary to Status Asthmaticus (1) (1)

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NETP Batch 12 Group 3



Patient’s Profile

History of Present Illness

Family History

Social History



Patient’s Profile Patient’s Name: V.S.

Age: 77 years old

Sex: Male Religion: Catholic

Admission Date: January 29, 2013

Ward/Room number: CCU- 2 /CCU-7



History of Present Illness

Chief Complaint: difficulty of breathing* Aggravating factors: sudden change of weather

* Relieving factors: high back rest, puff/ inhaler



Past Medical History Last Hospitalization: year 2008

Medical problems or illness: fever, common coughand colds,

Medications:Blopress Plus 16mg/tab Amlodipine ( Amvasc ) 5mg

Ipratropium Bromide (Duavent puff)

Allergies: none



Social History ( + ) smoker : 50 packed years

Non-alcoholic, non user of other prohibited drugs.

Status: Married Occupation: retired P.E teacher

Support: children, sibling (brother)

Activity: Sedentary Lifestyle



Family History

( - ) Cancer ( - ) CVA

( - ) TB ( + ) Respiratory Dse.

( - ) DM

( - ) Hemophilia ( - ) Kidney Disease

( - ) Mental and Nervous Disease

( + ) Hypertension

( - ) Allergy



Genogram

Legend: Male with no known disease With AsthmaFemale with no known disease With Parkinson’s diseaseDeceased (Bronchopneumonia); Deceased (uncontrolled fever) With Hypertension



Cephalocaudal Assessment



Data FindingsLevel of consciousness;

Glasgow coma scale (GCS)

Stuporous, GCS -

3(E1V1M1)

Functional level

classification

Level 4

Vital signs Temperature- 36.4Respiratory rate- 17

breaths/minute

Pulse rate- 95beats/minute

Blood pressure- 120/70

Oxygenation level O2 sat- 94%

Contraptions Mechanical ventilator,

cardioscope, NGT

General Physical Assessment



Inspection andPalpation

Findings

Generalized color Light brown

Temperature, moisture and

turgor

Warm and moist, good skin

turgor

Edema Grade 2 pitting edema onupper extremities

Grade 1 bipedal edema on

lower extremities

Swelling and erythema on

venous cut down

Skin lesion Venous cut down- palpable,

elevated, circumscribed (2-

3mm)

Geriatric variation Senile lentigines

Physical Examination

SKIN



Inspection andPalpation

Findings

Nails (color, texture, shape) Light pink, smooth nailbed,

160° nailbase

Capillary refill 3-5 seconds




Inspection and

Palpation

Findings

Size and shape Symmetrical, round

Hair (color, amount) Black with some grey hairs,

minimal hair loss

Scalp texture, presence of

lesions

(+) dandruff, (-) nits, tinea

capitis, no lesions or

masses

Face symmetry Slightly asymmetric

Temporal artery Palpable, strong andregular


HEAD



Inspection Findings

Eyelids and eyelashes Intact, no signs of ptosis,

entropion or ectropion

Eyeballs Non protruding

Conjunctiva (bulbar and

palpebral)

Bulbar (clear, moist, smooth

with tiny vessels visible)

Palpebral ( pink, no

discharges)

Pupils Equal in size (2-3mm);

sluggish reaction

Sclera Anicteric sclerae

Lens opacity arcus senilis

Visual acuity, movement of

extraoccular muscles

Not possible to assess


EYES



Inspection Findings

External ears Equal size, pinnae

symmetrical;

Auditory canal Minimal flaky cerumen


EARS




NOSE

Inspection Findings

External nose Symmetic, septum at

midline, nasogastric tube at

right nares, redness on both

nares, no alar flaring

Discharges, exudates,lesions

Minimal disharges, noexudates and lesions

Palpation Findings

External nose firmness No mass or enlargement on

maxillary, frontal and

temporal sinuses




MOUTH, THROAT AND

NECK

Inspection Findings

Mouth Remains open, drooling

whitish secretions,

endotracheal tube (7.5mm

at 22 cm depth)

Lips (color and consistency) Pink and dried

Tongue (texture) No drying or fissures

Trachea midline

Palpate Findings

Neck Symmetric, no bulgingmasses

Muscle strength Poor on passive range of

motion rating to 2

Jugular vein No distention

Lymph nodes No swelling andenlargement



Inspection Findings

Mechanical ventilator Assist control mode; FiO2-

30%, tidal volume-500ml,backup rate- 14

Respiration Relaxed, eupneic

Sternum Midline; slight prominent, no

sternal retractions and chest

indrawingsPalpation Findings

Vocal fremitus Not possible to assess

Chest expansion symmetric

Percussion Findings

Lung sound Hyperresonance

Auscultation Findings

Breath sounds bronchial

Adventitious sounds Coarse crackling sound;wheezes

THORACIC AND LUNGS



Inspection Findings

Breast Symmetrical; no masses,

discharges

Palpation FindingsPoint of Maximum Impulse Left midclavicular line 5th

intercoastal space


Heart sounds 95beats/minute, regular, not

weak or thready Audible S1 and S2

CHEST AND HEART



Peripheral Pulses Findings

Carotid artery Regular; equal not bounding,85beats per minute

Radial and ulnar Bilaterally palpable

Femoral pulse Bilaterally palpable

Dorsalis pedis Bilaterally palpable

Posterior tibial pulse Bilaterally palpable

Popliteal pulse Bilaterally palpable

PERIPHERAL VASCULAR

ASSESSMENT



Inspection Findings

Integrity, contour, symmetry No rashes or lesions, round,no distention, symmetric

Umbilicus Sunken, located centrally


Bowel sounds Irregular, 5-15 times per

minute

Vascular sounds No bruits, venous hum and

friction rub

Percussion FindingsPercussion tones Generalized tympany

ABDOMEN



Inspection Findings

Pubic hair Normal in distribution

Testes Equal in size

Penis No discharges

Inguinal area Dark and dried lichenificationof skin

Anal area 2x1 fissure with minimal

drainage

Stool Minimum to moderate pastybrown

Diaper change frequency 4-5 times/day soaked with

moderate yellowish urine

GENITALIA



MUSCULOSKELETAL

Palpation Findings

Muscle strength and tone Bilaterally weak, upper and

lower extremities contract

on passive range of motion

Muscle strength scale Grade 1Muscle size Muscle atrophy on left lower

extremity

Joint structure No nodules and swelling

Inspection Findings

Irregularities Spasm, jerky movements on

lower extremities



NEUROLOGIC ASSESSMENT

Cranial Nerves Findings

I (olfactory) --------------

II (optic) --------------

III (occulomotor) --------------

IV (trochlear) ---------------

V (trigeminal) Sensory function- blinks bilaterally

VI (abducens) Pupils are equal, round and reactive to

light. Accommodation not possible to

assess

VII (facial) --------------

VIII (acoustic) --------------

IX (glossopharyngeal) -------------

X (vagus) ------------

XI (accessory) -------------

XII (hypogloassal) -----------



NEUROLOGIC ASSESSMENT

Reflexes Findings

Biceps reflex Contracted; grade 1

Brachioradialis Elbow flexed with slight pronation of

forearm; grade 1

Triceps Barely extension of elbow; grade 1

Patellar Slight extension of knees; grade1

Achilles Plantar flexion; grade 1

Babinski Dorsiflexion of toe with involuntary

jerky movements; grade 4

Ankle clonus Foot stayed dorsiflexed

Kernig’s sign Not possible to assess

Brudzinki’s sign Not possible to assess

Brainstem reflexes Intact yawning, hiccups and blink

reflex



Cardio Pulmonary Arrest Secondary to Status Asthmaticus ; Acute respiratory distress SyndromeSecondary to Hypoxic Encephalopathy ; COPDIAE

r/o Pulmonary Embolism



Cardio Pulmonary Arrest Secondary to Status Asthmaticus ; Acute respiratory distress

Syndrome Secondary to Hypoxic Encephalopathy ; COPDIAE r/o Pulmonary Embolism

Pathophysiology

Precipitating Factor:

smoker (50 pack

years)

Bronchospasm

Bronchial Inflammation

Predisposing Factor:

• Male

• weather

• Age (77 y/o)

• Increase in wbc• Increase segmenters

Mucus hypersecretion

Airflow obstruction

Mucousal Edema

• Wheezing• Increase RR

• Productive cough• Whitish sputum

• crackles

• Wheezing

• Increase RR



(Status asthmaticus)

Progressive asthma

Lung inflammation

Cell lysis and cell death

Air Trapping

Alveolar Injury

Inflammatory in the capillary

side

Increase secretion production in

alveoliBronchoconstriction

• Crackles

Respiratory acidosis

Decrease Respiratory

exchange

Capillary leak in basement

membrane

• Increase in wbc



Scarring of basement

membrane

Pulmonary Edema

Inflammatory Vasodilation

Decrease lung

compliance

Decrease surfactant

production

Cell Damage (type II

cells)

Membrane fibrosis

Decrease diffusion

capacity

Systemic O2 supply decrease

hypoxia



Decrease O2 perfusion in the

brain

Decrease pons function

Damage on the brainstem

Hypoxic encephalopathy

Coronary artery

hypoperfusionRenal hypoperfusion

• Syncope

Acute respiratory distress

Cardiopulmonary Arrest

(ventricular fibrillation)

Decrease electrical

conductivity

Decrease myocardialperfusion

Uncordinated myocardial

contraction

Thrombus formation

Dislodging of the thrombus

Occlusion of the embolus

Blood stasis in the ventricles

• Coma

• Stupor

Pulmonary embolism

• ↑ creatinine

• (+) albumin



Cardiopulmonary Arrest

Problem:

(-) BP, CR, SpO2

Epinephrine 1 mg/IV x 4 doses given Ventricular fibrillation Defibrillation @ 200J

(+) Bp = 180/90 mmHg, CR = 130 bpm, (+)pulse

Na bicarbonate and Atropine given.



Hypertension Problem:

2nd day post arrest=BP = 200/100 mmHg

Nicardipine 1 mg/IV given

BP rechecked = 200/110 mmHgNicardipine drip(10 mg + 95 cc

PNSS x 10cc/hr)

BP = 120/80 mmHg, tapering of

2cc/hr started.

BP = 100-110/60 mmHg,

Nicardipine drip clamped.



Maintenance drugs: Simvastatin(Cholestad),

Candesartan(Blopress), Carvedilol (Cardipress),

Clonidine(Catapress), Amlodipine(Norvasc),Candesartan + HTCZ(Blopress plus).



Hypotension

Problem:

Day 25: (+) 2 episodes of hypotension

BP = 80/50 mmHg

FD: 200 cc PNSS

Anti-hypertensive drugs ON HOLD

Day 41: BP = 80/40 mmHg

FD: 100 cc PNSS



Hypokalemia

Problem

Day 4: Serum K level = 3.30 mmol/L

Kalium durule 1 tab TID x 3 doses given

Incorporate 20 meqs KCl to present IVF

Day 20: Serum K level = 2.0 mmol/L

Kalium durule 1 tab TID x 4 dosesKCl drip: 95 cc + 10 meqs KCl x 6 doses started



Ineffective Airway Clearance Problem

- Day 1: Positive tight airway

- hooked to PEEP, ET 7.5 cm, level 22- A/C Mode, FiO2 = 100%, BUR = 16, TV = 450

- Inline Nebulization

- FiO2 was tapered

- Day 9: Possible clogged ET

- Patient reintubated



- Day 22: ET partially clogged

- Day 36 and 81: Patient reintubated

RR: 24-34 bpm

wheezes on expiratory

Abdominal breathing

Desaturation of 86- 90%

Tight airway



Seizures Problem

- Day 1: Episodes of 2 seizures

- Diazepam given- Day 2: Diazepam shifted to Rivotril

- Day 63: Patient referred back to Dr. Fe Bacsal

- Keppra was given

- Day 65: EEG result: showed severe diffuseencephalopathy without focal slowing orepileptiform discharges



Arrhythmia Problem

- Day 19: Frequent trigeminal PVC

- Day 22: Non sustained ventricular tachycardia-Lidocaine 50 mg/ IV given



ThrombosisCXR results:

Arteriosclerotic cardiovascular disease withprominent left ventricle. (1/29/13)

Heart remains enlarged with atherosclerosis in thethoracic aorta. (2/8/13)

Heart remains enlarged with prominent left

ventricle and atherosclerosis in the thoracic aorta.(2/15/13)

Atheromatous aorta is again noted. (3/6/13)



Suggested D- dimer (4/5/13)

D- dimer result- 4 ug/ml (4/6/13)

Anti- embolic stockings were ordered

Clexane was given

Vessel Due F was given

Thrombocil was started



Low Total Protein, Albumin,

and Globulin (TPAG)•Blood chemistry showed low TPAG count

Total protein- 57 g/L (4/10/13)

Albumin- 24 g/L (3/27/13)

23 g/L (4/10/13)

28 g/L (5/9/13)

Globulin- 34 g/L (4/10/13)



20 % Albumin + 20 mg Lasix was given

6-8 egg whites were included in the OF



Hypoalbuminemia

Blood chemistry result : AlbuminNormal value: 38-54 g/ L

(3/27/13)- 24

(4/10/13)- 23

(5/9/13)- 25



Hypoprotenemia

Blood chemistry result: Total proteinNormal value:62-80 g/L

(3/13/13): 54

(4/10/13): 57



Fever and Infection Problem:

(+) recurrence of Fever

( 37.8-39 C ) Aeknil & Paracetemol (tab) was given

(+) infection

Prolong use of Foley Catheter

Chest Xray Result

Urine Culture and Sensitivity



Ineffective Airway Clearance

Impaired Skin Integrity

Impaired physical mobility



NURSING DIAGNOSIS



• (+) crackles on both lung fields are heard early

in inspiration

•(+) wheezes on both lungs upon expiration

•drooling of saliva (moderate loose whitishsecretions

Objectives



•With ET at 20 cm level, Fr. 7.5 connected tomechanical ventilator in AC mode, FIO2 at 30%, BUR

= 14, TV= 500, SPO2 of 94%

•Chest X-ray: (+) lung atelectasis



Short Term Goal:

After 1 hour of effective nursing intervention,the client will exhibit an improvement in

respiration as manifested by:

A. SPO2 of >95%

B. Minimal crackles on both lung fields



After 2 weeks of nursing intervention theclient will be able to maintain patent airway

as evidence by:

A. SPO2 of 99-100%

B. Independence from O2 and ventilator

support

C. Absence of adventitious breath sounds

such as crackles and wheezes



1. Monitor vital signs, chest movement, amount,

color of the sputum, breath sounds2. Elevate head of bed.

3. Turn side to side and do back tapping every 2

hours

4. Provide good oral care

INDEPENDENT:



1. USN ventolin given as ordered

2. USN with Flixotide Given as ordered

3. Acetylcysteine (Fluimucil) 600mg/tab viaNGT given as ordered



INTERDEPENDENT:

• Suctioned secretions as ordered and as needed

via ET; with (-) resistance, obtaining moderate

to large amount of loose whitish secretions and

via oral route obtaining moderate loose whitish

secretions



EVALUATION Short term Goal:

Goal Met.

After 1 hour of effective nursing intervention theclient was able to exhibit an improvement in

respiration as manifested by:

a. SPO2 of 98%b. Minimal crackles on both lungs after suctioning



Impaired Skin Integrity related to altered

metabolic state secondary to low albumin

level

NURSING DIAGNOSIS:



ASSESSMENT:

• Disrupted Skin on the previous cut down located on the right brachialpart of the arm

• 2x1 fissures on the anal area• (+) erythema• (+) Grade 1 bipedal edema on both extremities• (+) Grade 2 Pitting edema on upper extremities• Hypoalbuminemia

3/27/13- 24 4/10/13- 23 5/9/13- 25



GOAL/ OBJECTIVES:

SHORT TERM GOAL: After 30 minutes of nursing intervention, the patient’s relatives will be able to demonstrateunderstanding and skills in wound care as manifested by:

OBJECTIVES:

1.Proper and accurate assessment on wound. (Color, Depth, length)

2. Demonstrate proper hygiene (handwashing, PPE’s) during wound care

LONG TERM GOAL:

After 1 week of nursing intervention the patient will be able to display healing of skin lesions asevidenced by:

1. (-) erythema

2. Minimal to no swelling

3. Minimal to no bipedal edema on both extremities.

4. From grade 2 to grade 1 pitting edema on upper extremities.



NURSING INTERVENTION:

INDEPENDENT:

• Demonstrate proper wound care to the care givers of the patient

• Discuss the ways on how to prevent recurring of infection and worsening of theinjury.

• Assess site of skin impairment and determine etiology

• Note skin color, texture and turgor. Assess areas of least pigmentation for colorchanges.

• Monitor site of skin impairment at least once every shift for color changes.(redness, swelling, warmth, pain of other signs of infection.)

• Measure length, width, depth of wounds.

• Monitor client's skin care practices, noting type of soap or other cleansing agentsused temperature of water, and frequency of skin cleansing



•Follow body substance isolation precautions; use clean gloves when cleaning the woundsof the patient

• Turn patient every 2 hours or as needed.

• Determine nutritional status and potential delayed healing points.

INTERDEPENDENT:

• Apply wound ointments such as calmoseptine and bactroban as doctor’s ordered.



EVALUATION:

SHORT TERM GOAL:

After 30 minutes of nursing intervention the patient’s goal are met asevidenced by:

• Proper and accurate assessment on wound.

• Demonstrated Proper hygiene (handwashing, wearing gloves) during woundcare



LONG TERM GOAL:

After 1 week of nursing intervention the patient’s goal is partially met asevidenced by:

Goal Met 2/4

• (-) erythema

• (-) swelling

• Grade 2 pitting edema on upper extremities

• Grade 1 Bipedal edema on both extremities



Impaired Physical Mobility related to

ventilator dependency

NURSING DIAGNOSIS:



Objective:

• With ET at 22 cm level, Fr. 7.5 connected to mechanicalventilar with AC mode, FIO2 at 30% ,

BUR = 14, TV =500, SPO2 of 94%

• Functional Level Classification: 4

•Glasgow Coma Scale of 3

•EEG result :

- Severe diffuse encephalopathy



• (+) Babinski reflex

• (+) Myoclonic jerk

• Crackles on both lung fields (inspiration)

• Pitting edema Grade 2

•Bipedal edema Grade 1



•Muscle strength Grade 1

•Musle tone: Bilaterally weak

(upper and lower extremities)



Impaired physical mobility related to

cerebral hypoxia secondary to

ventilator dependency



After 3 weeks of nursing intervention, the client will have an

optimal position of function and display no further signs of deterioration as evidenced by :

•Absence of contractures and footdrop

•Hip in internal rotation

•Absence of pressure ulcers/ skin breakdown

•Pitting edema decreased to grade 1

•Absence of bipedal edema



Independent:

1. Ascertain that dependent client is placed in best bedsituation.

2. Assess for developing signs of thrombophlebitis.

3. Assess skin integrity.

4. Monitor input and output record and nutritionalpattern



5. Assess elimination status .

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

7. Turn, position and suction every 2 hours.

8. Maintain limbs in functional alignment.

9. Perform passive ROM exercises to all extremities.



Collaborative :

1. Consult with physical/ occupational therapist as

needed.



After 3 weeks of nursing intervention, the client’s goals are

partially met (2 out of 6) as evidenced by :

•Flaccid arms and legs

•Hip in internal rotation

•Presence of 2x1 anal fissure

•Pitting edema grade 2

•Bipedal edema grade 1



Thank You!

cardio pulmonary arrest secondary to status asthmaticus (1) (1)

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