NCM 110 - RLE CASE PRESENTATION

Submitted by:

➢ Christine Cosip
➢ Phebe Dela Cruz
➢ Zarah Dela Cruz
➢ Ma. Crystel Delotina
➢ Merlden Andrea Gonzales

8/16/18

I. Objectives:

During 3- 4 hours of case presentation, the post graduate nurses of Dr. Pablo O.

Torre Memorial Hospital will be able to:

1. Review the anatomy and physiology of the Respiratory system specifically

the bronchial tree and the lungs.

2. Identify the subjective data collected from the patient and significant others

while gathering the nursing history.

3. Identify the deviations from normal using the IPPA to elicit the objective

data while performing the nursing assessment.

4. State the normal values and interpret findings with significant deviations in

the diagnostics examinations.

5. Trace the pathophysiology of acute respiratory failure secondary to COPD

in acute exacerbation.
 6. Formulate appropriate nursing care plans using the nursing process as the

framework of care.

7. Tabulate drugs given to the patient according to content, action,

mechanism of action, indication, contraindication, adverse effects and

nursing considerations.

8. Appreciate the nursing process and the role of a nurse in caring for a

patient’s holistic needs with acute respiratory failure secondary to COPD in

acute exacerbation.

I. Anatomy and Physiology

RESPIRATORY SYSTEM
FUNCTIONS:

· Responsible for olfaction.

· Filtration, warming and humidification of inspired air.

· Produce sounds for vocalization.

· Responsible for gas exchange.

· Helps regulate blood pH.

DIVISIONS OF RESPIRATORY TRACT

 Upper Respiratory Tract

1. Nose - serves as a passageway for air to pass to and from the lungs. It
filters impurities and humidifies and warms the air as it is inhaled.

2. Sinuses - serve as a resonating chamber in speech

- help regulate the temperature and humidity of the air you inhale

- they are a common site of infection

1. frontal
2. ethmoid
3. sphenoid
4. maxillary

3. Pharynx (throat) - a tubelike structure that delivers air from your mouth

and nose to the trachea. It is divided into three regions: nasal, oral, and

laryngeal

4. Larynx (voice box) - is a cartilaginous epithelium-lined organ that

connects the pharynx and the trachea; common site for tumor growth,

especially for smokers and alcoholic drinkers

Lower Respiratory Tract - The lower respiratory tract consists of the lungs,

which contain the bronchial and alveolar structures needed for gas exchange.

· Trachea – a tubular passageway for air that is about 12 cm long and

2.5 cm in diameter located in the anterior portion of the esophagus.

• Left Bronchus

• Right Bronchus – more vertical, because of its anatomical position usually

gets a solid particle whenever there is a solid particle

• Carina- above the bronchus, tip of endotracheal tube when patient is

intubated

· Primary Bronchi – serves as a passageway of air to the right and left

 lung.

· Secondary and Tertiary Bronchi – subdivisions of the main bronchi and

spread in an inverted tree-like formation.

· Terminal Bronchioles – the last airway of the conducting system.

· Acinus – composed of respiratory bronchioles, alveolar ducts, alveolar

sac and alveoli.

· Lungs – soft paired cone-shaped organs that are essential for breathing.
 The right lung is divided into 3 lobes: superior, middle and inferior lobe. It is

composed of 10 bronchopulmonary segments. While the left lung is divided only

into superior and inferior lobe and it has only 8 bronchopulmonary segments.

These structures facilitate effective postural drainage.

· Alveoli – are grape-like clusters that are responsible for the exchange

of oxygen and carbon dioxide. It is the functional unit of the lungs

where gas exchange happens.

TYPES OF CELL IN THE ALVEOLI

❖ Type I Pneumocyte – composed of simple squamous epithelium that forms

 the lining of the alveolar wall.

❖ Type2 Pneumocyte – normally round or cuboidal where free surfaces

contains microvilli and responsible for the production of alveolar fluids

“surfactant”.

· Pleura

A doubled-layer membrane that covers the lungs and the inside of the

thoracic cavities.

The Parietal Pleura and Visceral Pleura. Between them is called the
Pleural Space which contains Pleural Fluids (surfactant) that prevents friction

between 2 pleurae.

DEFENSES OF THE RESPIRATORY SYSTEM

➢ Mucociliary transport

➢ Alveolar clearance

➢ Reflexes of the airways

Lung Volumes

✓ Tidal Volume – volume of air inhaled and exhaled with each breath. (500

ml)

✓ Inspiratory Reserve Volume – maximum volume of air that can be inhaled

after a normal inhalation. (3000 ml)

✓ Expiratory Reserve Volume – volume of air that can be exhaled after a

normal exhalation. (1200 ml)

✓ Residual Volume – volime of air remaining in the lungs after a maximum

 exhalation. (1200 ml)

Lung Capacities

▪ Vital Capacity – the maximum volume of air exhaled from the point of

maximum inspiration.

▪ Inspiratory Capacity – the maximum volume of air inhaled after normal

expiration.

▪ Functional Residual Capacity – volume of air remaining in the lungs after a

normal expiration.

▪ Total Lung Capacity – volume of air in the lungs after a maximum

inspiration.

Muscles of breathing
· Quiet Breathing

✓ Diaphragm Muscle

✓ External Intercostal Muscles

· Forced Breathing

(Inhalation)

✓ Sternocleidomastoid

✓ Scalene

✓ Pectoral

✓ Trapezius

(Exhalation)

✓ Internal Intercostal Muscles

✓ Abdominal Muscles
As the diaphragm contracts and moves downward, the pectoralis minor and

intercostal muscles pull the rib cage outward. The chest cavity expands, and air

rushes into the lungs through the trachea to fill the resulting vacuum. When the

diaphragm relaxes to its normal, upwardly curving position, the lungs contract,

and air is forced out.

II. Assessment

A. Nursing Health History

a) Biographic Data:

i. Client’s Name : Patient A.B.

ii. Address: not stated

iii. Age: 54 years old

iv. Birth Date: not stated

v. Birth Place: not stated

 vi. Marital Status: Married

vii.Nationality: not stated

viii. Religion: not stated

ix. Educational Attainment: not stated

x. Occupation: Sales Representative for a National Medical

Company

xi. Health Care Financing :

xii.Usual Source of Medical Care: Medical doctors

xiii. Date and Time of Admission:

xiv. Attending Physician:

Source of information:

b) Chief Complaint : Difficulty of Breathing

Admitting Impression: Chronic Obstructive Pulmonary Disease,

Community Acquired Pneumonia

Principal Diagnosis: Acute Respiratory Failure secondary to Chronic

Obstructive Pulmonary Disease in acute exacerbation, Community

Acquired Pneumonia

c) History of Present Illness

When the nurse-in-charge observed a frequent, nonproductive

cough, she questioned Patient A.B. about it. The patient claimed it was
 simply a tickle in his throat that came about every morning due to an

allergic rhinits. Because it is already afternoon and the cough remained,

the nurse made a note for the physician to check into the cough when he

examined the patient.

The physician found nothing remarkable on Patient A.B’s physical

examination, even though he listened to the patient's chest to assess the

cough. As a precaution, however, he ordered a chest x-ray and some

routine lab work.

Three days later, the results of the exams were returned. The chest

film showed an infiltrate in the patient's right lower lobe. Laboratory work

showed mild anemia with a hemoglobin of 10.0 and hematocrit of 31.

The next day at the clinic, the physician explained the results and

showed Patient A.B. the x-rays. He said that while he suspected lung

cancer, he hoped he was wrong. A definitive diagnosis required further

testing. The physician ordered sputum for cytology, an MRI of the chest,

and scheduled a bronchoscopy with biopsy for later in the week.

The MRI showed a peripheral lung tumor. Based on the lung scan,

the physician believed the mass was likely cancer, but he also wished to

get a consult from a thoracic surgeon and obtain a biopsy to determine

exactly what they were dealing with.

Laboratories:

· Chest X-ray- infiltrated in the right lower lobe

· Laboratory work- Hemoglobin of 10.0 and hct of 31

· Cytology and immunohistochemistry- cytokeratin 7 positive, cytokeratin 20
negative

· MRI- shows peripheral lung tumor

· CT scan- revealed a 3cm mass located in the right upper lobe

· Bronchoscopy

The biopsy was scheduled for the following day but on that evening the
patient’s wife, sounding frantic, called the physician. She related that
patient A.B complains of severe abdominal pain.and that she had called an
emergency response team. By the time the ambulance had arrived, her
husband refused to go with them.The paramedics insisted that the family
physician be contacted immediately. Per the physician's instructions,
Patient A.B. was driven to the emergency room at the nearest hospital.

Patient A.B., who carried the diagnosis of probable adenocarcinoma of the right
lung with liver metastasis. While on the hospital Patient A.B experience a
dyspnea, wheezing, bronchospasm, cough, fatigue and pleural effusion which
are common respiratory symptoms of advance cancer. Lung cancer spreading to
the liver resulting to his nausea, fatigue, bloating and jaundice. Vital signs was
taken and recorded , T- 36.3 , P – 127 bpm , R- 22 breaths per minute , BP 100-
70 mmhg .

The attending physician ordered, on NPO and for administration of oxygen at

2L per minute, IV to start D5LR 1L @ 120 cc/hour , corticosteroids
(dexamethasone 4mg OD), breathing exercises with effective cough instruction
and bronchodilators (albuterol 90mcg/inh) followed by a chest physiotherapy
techniques with comprehensive evaluation. Antibiotics (azithromycin 500mg
OD for 7 days), NSAIDS (ibuprofen 400mg every 4hours PRN for pain). Blood
transfusion of 2PRBC compatible blood type and properly cross matched.
Chemotherapy drugs include (carboplatin, cisplatin, etoposide, gemcitabine and
paclitaxel). Palliative therapy may include radiation therapy to shrink the tumor
to provide pain relief.

d) History of Past Illness

Patient A.B. is a man, 54 years of age, who worked as a sales

representative for a national medical company. He traveled by car over a

 wide area and spent a great deal of his time driving and smoking. The

patient was first seen at his physician's office for a routine physical check-

up.

When he met the physician for the first time in September, he

denied any major complaints and stated that he was there for a routine

check-up. His medical history revealed no major illness or injuries, apart

from an appendectomy at 14 years of age. Past medical history is

negative for hypertension, diabetes respiratory disease or heart disease.

His family history is negative for lung cancer and no known drug allergies.

He admitted he had smoked two packs of cigarettes every day for the last

forty years.

e) Family Health History

Hereditary Diseases Paternal Maternal

Hypertension (+) (-)

Diabetes Mellitus (-) (-)

Cancer (-) (-)

Asthma (-) (-)

f) Lifestyle

Mr. Fredricksen was a smoker, consuming 2-3 packs/day for 28

years. He started smoking at the age of 25. He occasionally drinks

alcoholic beverages usually after work with his co-workers and drinks

coffee everyday during breakfast. Mr. Fredricksen eats 3 meals a day and
prefers pork. He spends his free time resting at home and also enjoys

biking. During Sundays, he, along with his family, enjoys strolling at the

mall and eating out after hearing mass.

His work is one of the factors in his illness. Most of the time, he is

exposed with chemicals and fertilizers and also exposes him under the

heat of the sun, without protection. Hence, he is prone to respiratory

diseases. He also loved eating salty foods like dried fish, dried squid,

shrimp paste and mostly sea foods.

Mr. Fredricksen is a productive worker and professor. As described

by his wife, he knows how to value and schedule his time every day. He

loved his job and it suits him well. He worked as the Head of the

Department of Agriculture in Pulupandan. He garnered his position

through hard work and as an experienced agriculturist by working in the

fields for almost 15 years, and also as a professor of Agriculture in La

Carlota City College. As he and his wife would always say, “It’s all for the

benefit of our children”. Three of his children are now working abroad, a

daughter working as a nurse in Texas, a son as a nurse in Singapore and

another son as an engineer in New York.

Mr. Fredricksen lived an outgoing lifestyle when he was working. He

was always on the go and he was very active. He played various kinds of

sports but biking was his favorite for he loves traveling. According to Mrs.

Fredricksen, biking is the only thing that relived the stress he encounters

at work. He was very conscious of how he looks, that’s why he stayed

active and exercises whenever he gets a chance.

But when he retired, he was most of the time at home. Exercise was
 never on his priorities, he became lazy and inactive as stated by his wife.

According to her, Mr. Fredricksen’s unproductiveness seemed to have

altered his active view in life. After 28 years of smoking, his vices caught

up to him. That’s when his chronic illness came in.

g) Social Data

Mr. Fredricksen is a cheerful and very charismatic person. He has a

good personality, always kind to the people around him and always the

positive one in the room. Being friendly in nature is his asset. He always

smiles that it seemed that he has no problem and ailments at all. “The

calm one” as his wife stated, because he would always avoid arguments

and violence which is entirely opposite to his wife’s rage or aggressive

personality.

He never forgets a face, that after his transfer from the ICU to a

private room 469 (Station 12) that we came by to visit him, he

remembered all of us who took care of him in the ICU. He loves

interacting with different kinds of people with different attributes and

definitely sociable. Unfortunately, he was intubated and verbal interactions

were absent, prompting him to use a pen and paper as well as gestures to

convey things in his mind.

Mr. Fredricksen is a religious person and is active in their

community. He always sees to it that they hear mass every Sunday with

his family. He is also a pro-active leader, that’s why he was head of the

department of agriculture in Pulupandan. He knows how train and to

encourage people to work especially in doing the tasks properly. He is

 very patient and understanding, not only to his family but to the people

around him such as his co-workers, subordinates and students.

Mr. Fredricksen met his wife, a guidance counselor from La Carlota,

Negros Occidental, at Davao while she was on vacation. They dated for

about 5 years and decided to get married and move to Negros Occidental

to raise their family. They have 4 children; 3 boys and 1 girl. All are

professionals now. But their eldest son succeeded his father’s work in the

same field.

He graduated from Mindanao State University with a Bachelor’s

Degree in Agriculture. After graduating from his degree, he worked in the

field of Agriculture and made his way of being the head of the department

of Agriculture 20 years ago. He then retired upon reaching the age of 60.

h) Psychologic Data

Mr. Fredricksen is really one of a kind. He is optimistic when

problems arise. He is a calm person and doesn’t like confrontation. But

when he retired, some of those traits changed. He became grumpy,

irritable and always in the bad mood. He often gets mad of simple things

and errors. As stated by his wife, these were possibly brought about by

his chronic illness and by being so unproductive and bored for he was

once so used to working coped by smoking, drinking and biking when he

was still young and able. He had also viewed his ailments as a barrier to

his freedom, limiting his activities that he used to do before. With all these

burdens carried on his back, he just diverts his attention to his

grandchildren reminding him the value of family and bonds. According to

 Mrs. Fredricksen, he is still seen happy at times despite his condition,

seeing the family he raised and his fast growing grandchildren who were

always reminded by Mr. Fredricksen not to smoke nor drink to have a

wince free life and not to end up like him having an irreversible condition

brought about by reversible decisions that even he wished to change with

his regretful and “it’s too late” state.

B. Physical Assessment

a.) Baseline Data

Baseline data was gathered in the Intensive Care Unit of Dr. Pablo O. Torre

Memorial Hospital. The data was taken on June 21, 2010 (2-10 shift) as part of

the group’s initial assessment. Physical assessment was done continuously

throughout the shift.

Vital Signs

TIME BP CR RR T Urine Output

3PM 130/80 103 22 36.6 180

4PM 130/80 109 24 36.2 210

5PM 130/90 110 29 36.2 120

6PM 130/80 111 22 37 170

7PM 130/90 114 21 36.5 100

8PM 130/90 110 22 36.4 120

9PM 130/80 106 18 36.2 200

10PM 130/90 108 24 36.8 90

Highest 130/90 111 29 37 210

Lowest 130/80 103 18 36.2 90

b.) Overall Appearance of the Client

The patient could be described as thin, with bony shoulders, flat chest and

stomach, and delicate extremities. He is generally clean and considers grooming

very important as he shows interest and cooperates during bed bath. Posture,

gait, and balance cannot be assessed as he is on complete bed rest, with tubes

attached to him. The patient’s appearance is congruent to his age.

During the time of assessment, the patient can only perform activities of daily

living with assistance. Either his wife or his son assists him in his activities

considering he is intubated and can only make gestures and facial expressions,

or write on a piece of paper to convey his messages. The patient is able to

perform active range of motion exercises but with weakness. He would always

follow instructions given by the nurse without question. The patient lies on the

hospital bed in a Semi-Fowler’s position as this is the position he is most

comfortable with. He is also able turn himself to his sides anytime. The patient

has endotracheal tube at the right side of the mouth and is attached to a

mechanical ventilator with a tidal volume of 350, FI02 of 40%, and a back-up rate

of 14 cycles per minute. During the shift, weaning is done but is usually

interrupted as the patient experiences difficulty of breathing. Setup is at SIMV

(Synchronized Intermittent Mandatory Ventilation) mode for 20 minutes and A/C

(Assist/Control) mode for 40 minutes. He has a nasogastric tube for feeding and

administration of medications. He is also attached to a bedside monitor with pulse

oximeter that shows 98% of oxygen saturation. The intravenous fluid bottle #5 is

1 liter of plain normal saline solution running at a rate of 20cc/hour with a

remaining solution of 260 cc, via drip meter. The patient has a foley catheter that
is attached to a drainage bag with an initial output of 150cc of straw colored urine.

Urine output is adequate throughout the entire shift.

c.) Cephalocaudal Assessment

1. Skin

· Skin is noted to be medium brown in color; only a slight darkening is noted

in comparison to unexposed areas of the body (chest, abdomen, back, and

thighs)

· No unusual odor noted

· No presence of wounds but minor abrasions can be seen at the right elbow

· Hematomas noted on inner aspect of both arms

· Wrinkles noted on dorsal surface of hands

· Skin is smooth but slightly dry; no scaling or flaking noted

· Moles (melanocytic nevi) are noted on the face

· Skin is cool to touch; temperature of 36.2 ⁰C

· Good skin turgor is noted, with skin returning immediately after pinching

· No areas of itchiness, pain or tenderness on the extremities and trunk

· Scalp is white in color; no lesions noted; no tenderness palpated

2. Hair

· Hair had been dyed black three months ago but newly-grown hair is white
 in color

· Hair on the patient’s head is thin, coarse, and straight; evenly distributed; a

little oily

· No hairs cover the patients trunk and extremities; sparse hairs noted on

the axilla

· Scalp is intact and free of lesions

· No tics or lice noted during inspection of hair and scalp

3. Head

· The shape of the head is round; size is proportional to body’s size

· Wrinkles noted all around the face

· Facial expression is consistent and appropriate; symmetrical in features

and movement

· Facial contour and structures are smooth with no unexpected bulges and

nodules

▪ Neurologic Examination

▪ Awareness of self and environment is observed; oriented to

time, place, and person

▪ LOC: awake but weakness is noted

▪ Glasgow Coma Scale = 11 (E4,V1,M6)

 ▪ Speech cannot be assessed as the patient is intubated; patient

responds to simple questions with nods, universal signs and

hand gestures

▪ Sounds and voices of people can be easily heard by the patient

without difficulty

▪ Eyes

▪ Patient can clearly see and read; colors are correctly identified;

no prescription glasses have been used

▪ Eyelashes are present and curving outward; infestation or

crusting not noted

▪ Eyelids cover ½ of upper iris and in contact with eyeball; no

lesions noted

▪ Swelling, redness, and drainage not noted

▪ Sclera is smooth and white in color with slight redness

▪ Pupils are equally round and reactive to light accommodation;

both measure 3 millimeters, both pupils are equal in size

▪ Ears

▪ All landmarks are complete and well-formed

▪ Auricles are paler than face and symmetrical

 ▪ Lesions and lumps and tenderness not noted

▪ Responds to normal tone and volume of voice of the nurse

▪ Flaky cerumen is present on outer part of both ears

▪ Nose

▪ Shape is symmetrical and in midline

▪ Nares are patent

▪ Internal mucosa is moist with clear, scant mucus; no perforations

and lesions seen

▪ Tenderness not noted

▪ Mouth

▪ Lips are dry and pale pink; fissure noted on the right corner of

the lips

▪ Oral mucosa and gums are intact, pale pink in color; pain and

inflammation not noted

▪ All 16 pairs of teeth are missing (dentures were removed during

ICU admission)

▪ Tongue is pink and moist, with accumulation of saliva on the

surface; free from lesions and nodules

4. Neck

· Neck is symmetrical; no lesions and masses palpated

· Patient is able to perform active range of motion exercises on the neck

· Lymph nodes are nonpalpable

· Jugular vein is not distended; carotid pulse can be checked

5. Thorax and Lungs

· Thorax, ribs, clavicles and intercostals spaces are symmetrical

· Lesions and tenderness not noted; hair is absent

· Chest expansion is symmetrical

· Respiratory rate is increased at 24 cycles per minute; deep and irregular

breathing pattern

· Rales and wheezes heard upon inhalation and expiration, respectively

· Cough is noted but patient cannot effectively expectorate secretions due to

the presence of an endotracheal tube; suctioning is needed to get

rid of the secretions; secretions are noted to be thick and whitish to

yellowish in color

· Nipples are everted, elastic, and nontender

· Orthopneic; requiring 2 pillows or to be positioned in a Semi-Fowler’s

 position to breathe well

6. Circulation

▪ Heart

▪ Apical pulse is palpated at the left midclavicular line at the 5th

intercostal space

▪ Heart rate is increased at 109 beats per minute

▪ No abnormal heart sounds noted during auscultation

▪ Oxygen saturation of 98% during assessment

▪ Extremities

▪ Radial pulse is assessed with a rate of 106 beats per minute,

graded +2

▪ Blood pressure of 130/80 mmHg taken at the left arm in a Semi-

Fowler’s position

▪ Edema not noted on extremities

 ▪ Nails

▪ Nailbeds are pinkish

▪ Nails are untrimmed but no grime can be found under the nails

▪ Edges of nails are round, with no visible splitting

▪ Capillary refill time test done on thumbs, index fingers and big

toes, all with a result of less than 2 seconds

7. Abdomen

· Abdomen is soft and intact without any lesions or masses

· Skin is dry; no wrinkles present

· Umbilicus is inverted and at the midline

· Contour is flat; distention not noted

· Normoactive bowel sounds of 10-15 per minute auscultated on all

quadrants

8. Musculoskeletal

· Muscle mass is symmetrical on both sides

· Decreased muscle strength; on Lovett’s Scale for Grading Muscle

Strength, a rating of 3/5 = active motion against gravity

· Able to move all extremities and perform active range of motion exercises
 but with slight weakness

· Able to turn from side to side on his own

[Pick the date]

Diagnostics and Laboratory Tests

LABORATORY TEST: CLINICAL CHEMISTRY

Name: Mr. Carl Fredricksen
Result validated: 0615/18 2:31 am

TEST NORMAL ACTUAL IMPLICATION/CAUSE

VALUE VALUE
POTASSIUM 3.50-5.50 3.43 DECREASED
mmol/L
SODIUM 136.00-145.00 127 DECREASED
mmol
CREATININE 0.8-1.50 mg/dl 1.86 INCREASED

GLUCOSE 215 mg/dl INCREASED

RBS

DEPARTMENT OF RADIOLOGY

Name: Mr. Carl Fredricksen

Result validated: 07/15/18

CHEST PA OR AP (CONVENTIONAL)

Radiologic findings:
Chest AP supine after May 4, 2007 shows bilateral pulmonary hyperinflation.

Both Costophrenic sulci are minimally blunted most likely due to pleural

thickening. Pulmonary vascular pattern is within normal limits. Atherosclerotic

aorta again noted.

Heart is not enlarged. Tip of endotracheal tube is seen in place about 5 cms

above the carina, Mid thoracic spine levoscoliosis is noted. The rest of the chest

structures are unremarkable.

Remarks:

- bilateral pulmonary hyperaeration may have been due to asthma or other

chronic obstructive pulmonary disease

- minimal bilateral pleural thickening, both lung bases

-atherosclerotic aorta

- mid thoracic spine levoscoliosis

URINALYSIS

Name: Mr. Carl Fredricksen Result validated: 07/15/18

Physical

Color Pale Straw

Reaction pH 6.5

Transparency Hazy

Specific gravity 1.010

 Chemical

Albumin 3+

Sugar Trace

Microscopic

Pus cells 1-2 HPF

RBC 124-128 HPF
Bacteria FEW/ HPF

Epithelium

Squamous FEW/LPF
Renal OCCASIONAL/LPF

LABORATORY TEST: GRAM STAINING SPECTRUM

Name: Mr. Carl Fredricksen Result validated: 07/16/18 07:28 am

 Specimen: sputum

PUS CELLS MORE THAN 25/ LPF

EPITHELIAL CELLS LESS THAN 1/LPF
GRAM NEGATIVE BACILLI MODERATE
GRAM POSITIVE COCCI(in pairs, in FEW
cluster)

ECG RESULT

Result validated: 07/16/18

Heart Rate: 129 bpm

PR Interval: 118 ms

QRS Duration: 104 ms

QT/QT: 330/486 ms

Sinus Tachycardia (HR: 100-130)

Low Voltage (limb leak)

Prolonged QT

Axis may be incorrect due to low voltage

LABORATORY TEST: SERUM POTASSIUM AND SODIUM

Name: Mr. Carl Fredricksen Result validated: 06/17/10 7:04 am

TESTS ACTUAL VALUE NORMAL VALUE IMPLICATION

POTASSIUM 3.09 3.50-5.50 mmol DECREASED

SODIUM 132 136.00-145.00 mmol DECREASED

LABORATORY TEST: CULTURE AND SENSITIVITY

Name: Mr. Carl Fredricksen Result validated: 07/18/18

Organism: ---

Sensitivity test:

Remarks: final report: no respiratory pathogen isolated

LABORATORY TEST: SERUM POTASSIUM AND CREATININE

Name: Mr. Carl Fredricksen Result validated: 07/19/18

TESTS ACTUAL NORMAL IMPLICATION/CAUSE

VALUE VALUE
POTASSIUM 3.15 3.50-5.50 mmol DECREASED
CREATININE 2.16 0.80-1.50 mg/dl INCREASED

LABORATORY TEST: COMPLETE BLOOD COUNT

Name: Mr. Carl Fredricksen

Result validated: 07/19/18 7:57 am

Specimen: BLOOD

TEST ACTUAL NORMAL IMPLICATION/CAUSE

VALUE VALUE
HEMOGLOBIN 138 125.00-170.00 NORMAL
g/L

HEMATOCRIT 0.43 0.40-0.54 NORMAL

RBC COUNT 4.269 4.00-5.50 x 10 NORMAL
^12/L
WBC COUNT 13.5 5.00-10.00 X INCREASED
10 ^ 9/L
DIFFERENTIAL COUNT

NEUTROPHIL 0.90 0.50-0.70 INCREASED

LYMPHOCYTE 0.02 0.20-0.40 DECREASED

EOSINOPHIL 0.00 0.00-0.05 NORMAL

MONOCYTES 0.08 0.00-0.09 NORMAL

BASOPHIL 0.00 0.00-0.01 NORMAL

MCH 32.40 26.00-34.00 NORMAL
MCHC 32.50 32.00-38.00 NORMAL
g/ml
MCV 99.80 82.00-98.00 fl INCREASED
RDW – CV 13.5 11.00-16.00 % NORMAL
P – LCR 25.2 15.00-35.00 % NORMAL
PDW 9.6 9.00-14.00 fl NORMAL
LABORATORY TEST: CLINICAL CHEMISTRY

Name: Mr. Carl Fredricksen Result validated: 07/24/18

TEST ACTUAL NORMAL IMPLICATION/CAUSE

VALUE VALUE
POTASSIUM 2.86 3.50-5.50 DECREASED
mmol/L
BUN 57.98 7.00-17.09 INCREASED
mg/dl
CREATININE 1.53 0.80-1.50 mg/dl INCREASED

GLUCOSE FBS 96.36 74.55-107.27 NORMAL

mg/dl
 ARTERIAL BLOOD GAS

NORMAL 06/14/10 06/14/10 06/15/16 06/16/10

VALUES

ABG @ ER Others: face Others: mech Others:

mask at 8 lpm vent AC mode mechanical
Others: nasal ventilator
cannula at 2 lpm

Ph 7.22 7.21 7.41 7.33

(7.35 – 7.45)

PCO2 60 79.00 58 54

(35-45
mmHg)

PO2 78 151.00 77 69

(80-100
mmHg)

HC03 29 26.2 32.8 26

(22-26 meq /
L)

O2 sat 86% 99% 95% 92 %

(95-100%)

Interpretation: Interpretation: Interpretation: Interpretation:

Respiratory Resp. acidosis Resp. acidosis Respiratory

acidosis with acidosis
overcorrected Compensated
Uncompensated hypoxemia at with uncorrected Uncompensated
with uncorrected 52% Fio2 hypoxemia at with uncorrected
hypoxemia at 40 60% Fio2 hypoxemia at 40
% Fio2 % Fio2

Cause Impaired gas Impaired gas

exchange exchange
 COMPARISON OF THE DIAGNOSTIC RESULTS

POTASSIUM

DATE ACTUAL VALUE NORMAL VALUE

06/15 3.43 3.50-5.50 mmol/L
06/17 3.09
06/19 3.15
06/24 2.86

SODIUM

DATE ACTUAL VALUE NORMAL VALUE

06/15 127 136.00-145.00 mmol
06/17 132

CREATININE

DATE ACTUAL VALUE NORMAL VALUE

06/15 1.86 0.8-1.50 mg/dl
06/19 2.16
06/24 1.53
 V. Pathophysiology

Predisposing Factors: Precipitating Factor:

 54 years old 
 Male

Pathological changes in the airway Inflammation of the airway

epithelium

Pulmonary defence mechanism Infiltration of inflammatory cells and

compromise release of cytokines

Continuous bronchial irritation and

Slowing down of Impaired mucociliary inflammation
alveolar macrophages function and movement

Hypertrophy of mucosal Bronchial swelling

glands, hyperplasia of
goblet cells

Bacterial colonization
Hypersecretion of mucus Decreased airway size

Gram staining result

(06/16/10): Moderate gram
Pulmonary negative bacilli, Few gram Irritant Thick Mucus plug
Infection positive cocci, in pairs and receptor tenaciou formation
stimulation s
yellowis
h
Cough
Release of multiple
inflammatory Complete blood count Airway obstruction
mediators (06/19/10): Increased WBC of
13.5 ^g/L Increased Neutrophil

Alveolocapillary
membrane damage

Increased airway resistance Air trapping

Infectious debris and exudates
filling at acini and terminal
bronchioles
Rales Wheezes CXR
ausculatated ausculatated (06/15/10):
Loss of surface Decreased Lung
Bilateral
area for gas Compliance
pulmonary
exchange
hyperaerati

Hypoventilation Carbon dioxide

retention
 Precipitating Factors:
· Strenuous activity

· Stress

· Exertion

Oxygen utilization

Glycolysis

Energy release and consumption made

possible by hydrolysis of ATP to ADP

ATP is generated by citric acid cycle

and oxidative phosphorylation

Release of Carbon Dioxide as

by product

Excitation of chemoreceptors
Increased carbon dioxide
in the arterial blood Increased respiratory rate
of 29 cycles per minute

Hypercapnia Vasodilation

ABG result (06/16/10):

Respiratory acidosis uncompensated
with uncorrected hypoxemia at 40%
FiO2 Hypotension of 80/palpatory
Ph: 7.33; PaCO2: 54; PaO2: 69; mmhg upon admission
HCO3: 26
 Hypoventilation
(Due to decreased lung compliance, increased airway Carbon dioxide
resistance, loss of surface area for gas exchange and air retention (due to air
trapping) trapping)

Inability to maintain adequate alveolar

ventilation

Increased work of breathing

Use of accessory Nasal flaring Supraclavicular and

muscles (upon (upon intercostal retractions (upo
admission) admission)

Ventilation – perfusion mismatch

Hypoxemia

Tissue hypoxia

Weakness: graded 3 Skin cool to touch Dyspnea 2 pillow

(scale for muscle with a temp. of orthopnea
strength) 36.2
Problem list:

1. Impaired gas exchange related to ventilation perfusion imbalance (adequate blood flow

to pulmonary alveoli but inadequate movement of air in and out of lungs) as evidenced

by chest x-ray result dated, 6/15/18 shows bilateral pulmonary hyperinflation. (June 21,

2018)

2. Ineffective airway clearance related to retained thick whitish to yellowish secretions as

evidenced by rales and wheezes upon auscultation of the anterior chest wall. (June 21,

2010)

3. Infection related to pulmonary defense mechanism compromise as evidenced by gram

staining spectrum result dated, 6/16/10: presence of moderate gram negative bacilli and

few positive cocci in pairs and in clusters. (June 21, 2018)

4. Activity intolerance related to weakness as evidenced by Lovett’s scale of 3/5. (June 21,

2018)

5. Impaired oral mucous membrane related to presence of ET tubes as evidenced by a

fissure on the right corner of lips. (June 21, 2018)

6. High risk for aspiration related to the presence of Endotracheal Tube & Nasogastric

Tube. (June 21, 2018)