Riyadh Colleges Of

Dentistry And Pharmacy

Riyadh, Kingdom of Saudi Arabia

Case Study
Marwah Abdulaziz
Alabdulsalam
43320209

Objectives

Case Study
A 71 year old female patient presented with sense

of difficulty in breathing & decrease conscious

level of 1 day duration but no fever . ABG done in
ER found that the PCO2 of 140 & the patient was
immediately intubated & ventilated . Patient is
known to have respiratory failure , COPD ,
diabetes mellitus & hypertension .

2. Baseline Data
Patient Initial :

(M.M)

Age:

71 years old

Birth date:

24 June 1941

Gender:

Female

Marital Status:

Married

Educational Level:

Primary

Nationality:

Saudi

Occupation:

Housewife

Date of Admission:

2 April 2014

2. Baseline Date
Chief complaints:

Difficult of breathing
Diagnosis:

chronic respiratory failure

COPD (Chronic obstructive pulmonary disease)
DM (Diabetes Mellitus)
HTN (Hypertension)

Anatomy and Physiology

The respiratory system

is situated in the thorax,

and is responsible for
gaseous exchange
between the circulatory
system and the outside
world

Anatomy and Physiology

. Air is taken in via the

upper airways (the nasal

cavity, pharynx and
larynx) through the lower
airways (trachea, primary
bronchi and bronchial
tree) and into the small
bronchioles and alveoli
within the lung tissue.

Health History
a. Present Health History:
(+)DM, (+) HTN, COPD
b. Past Health History:
NON
c. Family and Social History:
(+) DM

Nursing Assessment
Review of System

Vital Sign
Blood Pressure 150/81
Temperature 37.0
Heart Rate 15
Pulse Rate 85
O2 Saturation 98
Pain 3-4
Weight 40
Height 160
Blood Sugar Level 226

General Appearance
Head : Normal
Neck : Pain with movement
Breast :Normal
Unwell
Lethargic
Calm

Nutrition
Type of diet : low fat
soft diabetic high protein
Appetite : poor

Musculoskeletal
Motor : paralysis
Range of motion: limited
Balance and gait : Unsteady
Strength/Hands grasps: Equal
Strength/Leg Muscles: Weak

-Weakness/paralysis: Lift and Right

Skin
Color (Normal)
Temperature (Warm)

Neurologic
(Glasgow Coma Scale)
GCS 15/15
Eye Opening: 6
Verbal Response: 5
Motor: 4

EENT (Eyes,Ears,Nose and Throat)

EYES
Color of sclera (white )
size of eyes pupils ( 3 mm )
Visual Acuity (cataract)
Presence of tears (no)

EARS
shape and position: symmetric
Color: same as facial skin

EENT (Eyes,Ears,Nose and Throat)

NOSE
shape and position: symmetric
Color: same as facial skin

THROAT & MOUTN

Palate (hard)
Size of Tonsils (normal size)
Bleeding gums
Dryness

Cardiovascular
Heart Sounds (Normal)
Color (Normal)
Capillary Refill Time: 3 seconds
Presence of edema (no)
PULSE
Rhythm: Regular
Strength: Normal
Rate: Normal

Respiratory
Respiratory Rate: Normal
Shortness of breath (yes)
Difficulty of Breathing (yes)
Sounds: Normal
Cough : Non
Mode of breathing : Mechanical Ventilator
Air way: Tracheostomy

Gastro Intestinal Tract

Feeding: (oral )

Elimination:

Frequency: 2
Consistency : Watery , black
Shape of Abdomen: Flat
Bowel Sounds : hyperactive

Gastro Urinary Tract

Urinary Pattern: Incontinence
Foley catheter : (yes)
Urine Output per 8 hrs :465 ml
Hydration Status:
Intake = 1300
Output=1430

Laboratory Result
test

Result

Normal

WBC

7.8

4-11

Hgb

83

120-150

HCT

0.239

0.36-0.46

MCV

75.4

83-101

MPV

6.8

6.5-11.6

RDW

16.4

11.6-14

Pathophysiology
Respiratory failure is a condition in which not

enough oxygen passes from your lungs into your

blood. body's organs, such as your heart and brain,
need oxygen-rich blood to work well.
Respiratory failure also can occur if your lungs can't

properly remove carbon dioxide (a waste gas) from

blood.

Drug Analysis

Drug Analysis
Name of Medications

uses

Side Effects

Band Name:
Inj Clexane

It is used to stop blood

clots forming within the
blood vessels.

1. Pain and irritation at

the injection site.

Generic Name:
Enoxaparin sodium
Dosage:
30 Mg
Frequency:
Daily
Routes:
P.O

2. Major bleeding
(hemorragie).
3. Blood clots in the
spinal cord.
4. Decrease in the
number of platelets in
the blood.

Drug Analysis
Name of Medications

uses

Side Effects

Band Name:
Protonix

decreases the amount of

acid produced in the
stomach.

1. severe stomach pain,

nausea, vomiting, and
weight loss.

Generic Name:
pantoprazole
Dosage:
40 Mg
Frequency:
Daily
Routes:
P.O

2. diarrhea that is watery

or bloody.
3. kidney problems.
4. headache.
5. Fever.

Drug Analysis
Name of Medications

uses

Side Effects

Band Name:
Amlodipine besylate

treat high blood pressure

(hypertension)

1. Headache.

Generic Name:
Cap-amlor

2. Dizziness,
drowsiness.
3. tired feeling.

Dosage:
5 Mg
Frequency:
Daily
Routes:
P.O

4. stomach pain.
5. flushing .

Drug Analysis
Name of Medications

uses

Band Name:
Atrovent HFA

relaxes muscles in the

airways and increases air
flow to the lungs.

Generic Name:
ipratropium inhalation
Dosage:
250 Mg
Frequency:
8 Hrs
Routes:
Tracheostomy

Atrovent is used to
prevent bronchospasm,
or narrowing airways in
the lungs, in people with
bronchitis, or COPD
(chronic obstructive
pulmonary disease).

Side Effects

1. headache, dizziness;
2. stuffy nose, sinus
pain, dry mouth,
cough, hoarseness.
3. Nausea .
4. back pain; or fever,
chills, body aches, flu
symptoms.

Drug Analysis
Name of Medications

uses

Side Effects

Band Name:
laxative manufactured
Generic Name:
Movicol

Helps to have a
comfortable bowel
movement.

1. Anal discomfort.
2. Borborygmi.
3. Diarrhoea.

Dosage:
1 sachet
Frequency:
two times a day.
Routes:
P.O

4. distension of the
stomach.
5. Stomach pain.
6. Vomiting.

nursing responsibilities
1- Ensure that you are giving Medications to:
The correct patient. The Correct dose. The correct
time. The correct route.
2- Ensure that there is a written order from the doctor.
3- Ensure that the patient is NOT allergic to any
Medications .
4- Know the drug- drug interactions.

nursing responsibilities
5- Assess the patient after giving the medication
for any reaction, let the dr. decide what is it
( Allergy?).
6- Document all the above.

Nursing Care Plan

Assessment
SUBJECTIVE:
(I do not breathe well)
as verbalized by the patient.
OBJECTIVE:
Request for information.
Inaccurate follow through of instructions.
V/S taken as follows:
T: 37.0
P: 85
R: 15
BP: 150/81

Nursing Diagnosis
Ineffective Airway Clearance r/t tracheobronchial

obstruction

Difficulty of breathing related to:

1.

Altered O2 supply

2.

Altered blood flow.

Altered oxygen-carrying capacity

of blood

3.

Goal
Long Term Goal:
Patient will maintain a patent airway.
Short Term Goal:
Patients lungs sounds will be clear to auscultate.
Patient will be free of dyspnea.
Patient will demonstrate correct coughing and deep

breathing techniques.

Intervention
Assess airway for patency by asking the patient to state

his name.
Assess respiratory quality, rate, depth, effort and pattern.
Monitor arterial blood gases (ABGs).
Administer supplemental oxygen.
Suction as needed.
Change patient's position every 2 hours.

Intervention
Encourage deep breathing, using incentive

spirometer as indicated.
Assess changes in vital signs.
Position patient to facilitate ventilation/perfusion

matching. Use upright, high Fowler's position

whenever possible.
Administer medications as prescribed.

Evaluation
Patients lungs sounds are clear to auscultation

throughout all lobes.

Patient is receiving oxygen. SaO2 via pulse oximetry is 90

100%.
Patient is normotensive with heart rate 60 100 bpm.
Patient is free of signs of distress.

Discharge Care Plan

Medication:
Confirm that the patient

understands the reason for the

medication.
Explain the medication to other

people so they can help with

administration and provide
reminders.

Exercise Environment
Physiotherapy should be started as

soon as possible. It will help to improve

blood circulation and relax muscles.
Range of motion exercise refers to

activity aimed at improving movement

of a specific joint
Practice relaxation or slow, deep

breathing.

 Diet :
Decrease the salt in your diet.
Eat healthy foods low fat

soft diabetic high protein

Health Teaching:
Monitor your blood pressure at home.
Manage stress.
Don't smoke.

Thank
You