Pulmonary Congestion Secondary To ESRD Secondary To Cardiorenal Syndrome in Respiratory Failure Type I

University of Makati
College of Allied Health Studies

J. P. Rizal Extension, West Rembo, Makati City
A Case of a Thirty Years Old Male Diagnosed with Pulmonary Congestion

secondary to ESRD secondary to Cardiorenal Syndrome in
Respiratory Failure Type I
A Case Presentation Submitted in Partial Fulfillment of the

Requirements of Related Learning Experience
Submitted by:
Eclarino, Giselle C.
Ferrer, Jeffrey Z.
Filomeno, Pamela Shiermaine D.
September 26, 2014
I.
INTRODUCTION
Pulmonary congestion is a distention of blood vessels in the lungs and filling of the alveoli with
blood. The fluid collects in the tiny air spaces known as the alveoli, the place where oxygen and
carbon dioxide is exchanged. Once the alveoli become filled with fluid, gas exchange is
impaired, resulting in symptoms of pulmonary edema such as anxiety, restlessness, shortness of
breath, wheezing, excessive sweating, cough and the coughing up of bloody sputum.
Most often caused by heart failure, pulmonary congestion may also occur as a result of
pneumonia or other infections, drug overdose, exposure to high altitudes, kidney failure or shock
due to excessive bleeding.
In pulmonary congestion, the heart works harder to push blood through the body. This puts
added pressure on the small blood vessels of the lungs. In order to relieve this growing pressure,
the vessels release fluid into the lungs.
Ordinarily, the lungs are responsible for taking oxygen from the air that you breathe and
putting that oxygen into the bloodstream. However, if the lungs are filled with fluid, they cannot
properly perform that task. In cases of pulmonary congestion, the lungs cannot put oxygen into
the bloodstream, and the rest of the body is deprived of oxygen.
There are two basic types of pulmonary congestion. One is cardogenic edema which the
fluid backs up from a weakened heart. Pulmonary pressure increases, and this fluid is forced into
the parychemal tissue lining the bronchi and alveoli. The other is termed noncardogenic
pulmonary edema which the heart did not cause the pulmonary edema. There is a simple
pneumonic to remember all the disorders that fit into this category: NOT CARDIAC. As noted:
Near drowning
Oxygen therapy
Transfusion or Trauma
CNS disorder
ARDS, aspiration or altitude sickness
Renal disorder or resuscitation
Drugs
Inhaled toxins
Allergic alveolitis
Contrast or contusion
Pulmonary congestion that develops suddenly, is a medical emergency requiring immediate

care. Although pulmonary congestion can sometimes prove fatal, the outlook improves when you
receive prompt treatment for pulmonary congestion along with treatment for the underlying
problem. Treatment for pulmonary congestion varies depending on the cause but generally
includes supplemental oxygen and medications.
http://www.britannica.com/EBchecked/topic/351528/lung-congestion
II.
OBJECTIVES
GENERAL OBJECTIVE:
The case study aims to acquire information about Pulmonary Congestion secondary
to ESRD secondary to Cardiorenal Syndrome in Respiratory Failure Type I and to apply such
knowledge for optimum level of nursing care practice.
SPECIFIC OBJECTIVE:
To assess the condition of the patient by establishing rapport, gather all vital information
and determine clients past and present health history.
To formulate an accurate nursing care plan for patient with Pulmonary Congestion
secondary to ESRD secondary to Cardiorenal Syndrome in Respiratory Failure Type I.
To know the different signs and symptoms, manifestations and other things connected to
the condition to help the health care providers to diagnose the real condition properly.
To apply intervention and lessen the anxiety that the clients feels on.
To evaluate patients condition after treatment.
III. NURSING HISTORY

BIOGRAPHICAL DATA
Name
: Patient X
Age
: 30
Gender
: Male
Address
: Pitogo, Makati
Nationality
: Filipino
Religion
: Roman Catholic
Birthdate
: May 5, 1984
Hospital
: Ospital ng Makati
Date of Admission
: September 9, 2014 10:11 pm
Date of Interview
: September 22, 2014 10:30 am
Source of information : Patient

Chief Complaint: Difficulty of Breathing
HISTORY OF PRESENT ILLNESS:

On the year 2009, Patient used to work as an OFW in a chemical waste factory in
Taiwan. He is healthy and doing well until he decided to go home in the Philippines to have a
vacation in mid-2010. Patient experienced intermittent cough for about 6 months until he decided
to seek medical attention. He was admitted at San Lazaro Hospital and diagnosed to have
Pneumonia. Patient was confined and treated for a month.
On January 2011, Patient experienced sudden onset of difficulty of breathing and he seek
consultation at Philippine Heart Center. He was then diagnosed with Rheumatic Heart Disease
and was prescribed with medications such as Enalapril and Warfarin but the patient was noncompliant to the medication therapy.
4
Last March 2014, he went again to Philippine Heart Center because he experienced
decreased in urine output for almost 3 days and edema, he was then referred to National Kidney
and Transplant Institute because his problem has nothing to do with cardiovascular system
anymore. Patient undergone IJ catheter insertion in his left side of the neck and was scheduled
for hemodialysis two times a week.
Last July 2014, he was admitted to Ospital ng Makati because his IJ catheter was clogged
and infected. At July 15, at the same day he was then scheduled for removal and reinsertion of IJ
catheter to his right side of his neck. Patient was compliant to hemodialysis two times a week.
Few days prior to admission, patient was at his friends home and experienced difficulty
of breathing and suddenly became unconscious. He was rushed to Ospital ng Makati-Emergency
Room via ambulance. After 24 hours he was transferred to Intensive Care Unit for continuous
care and further monitoring.
PAST MEDICAL HISTORY:

Patient has no known allergy. He was a smoker since he was 14 years old and an
alcoholic drinker. He used to consume prohibited drugs but stopped when he was diagnosed with
Rheumatic Heart Disease in 2011. Patient X is not hypertensive and diabetic.
FAMILY GENOGRAM
MOTHER
FATHER
BROTHER
BROTHER
BROTHER
PATIENT X
BROTHER
Legends:
Hypertension
ESRD
Rheumatic Heart Disease
III. GORDONS FUNCTIONAL HEALTH PATTERN
FUNCTION HEALTH
PATTERN
I.
BEFORE HOSPITALIZATION
and
INTERPRETATION
HOSPITALIZATION
According to the patient, he is
Health
Perception
DURING
According to the patient, after climbing
Health three flight of stairs he suddenly felt
Managemen
difficulty in breathing, nauseated and
t Pattern
excessive sweating.
not in a good state and he is Ineffective health maintenance

uncomfortable
of
the related
ineffective
individual
environment. He wants to go coping

back to his normal daily life
because he cant stand the fact Nurses Pocket Guide Edition 12
that he is staying in the hospital.
The patient states that he consumes 1-2

II.
He consumed of what
the
Nutrition
cup of rice every meal. Before he was doctors order a diet for him. He
and
hospitalized, he had good appetite and had drinks 5-8 glasses of water.
Metabolic
no problem in swallowing food. He drinks Diet : LSLF Diet
Pattern
at least 5-8 glasses of water a day. He Weight: 64 kilograms
Readiness for enhanced nutrition.

Nurses Pocket Guide Edition 12
states that he and his family usually eat Height: 173 cm

fish, vegetables and meat. He consumed BMI: 21.4 (Normal)
10 sticks per day. He started smoking at

the age of 14. He drinks any kind of
alcohol beverages every day.
Weight: 64 kilograms
Height: 173 cm
III.
Elimination
pattern
He defecates once or twice a day.
According to the patient, he
Feces
doesnt
Activity and
difficulty
in
- Color: Yellowish
defecating. He has difficulty in
- Texture: Semi formed
urinating.
Readiness for enhanced urinary

elimination
He has some difficulty in urinating.

Urine
Urine
IV.
feel
- Color: Yellow
- Color: Red Orange
- Consistency: Cloudy
- Consistency: Concentrated
- Odor: Foul Odor
- Odor: Foul Smell
- Amount: 30cc/hour
During hospitalization, according Activity Intolerance related to
exercise
According to the patient, his daily routine to him, he can only perform secondary
pattern
composed of exercise such as playing minimal movements because of process.
underlying
disease
basketball, walks and strolls around his unfamiliar environment.
neighbourhood, reads newspaper and

listens to the radio.
V.
Cognitiveperceptual
pattern
He is assertive all throughout the

There is no evident problem on his five interview. He is focused on what
vital senses.
Sleeppattern
In addition to
that, he answers us clearly.
According to the patient, before he was

VI.
we are talking.
rest hospitalized he had difficulties falling

asleep at night and has a maximum of four
hours of sleep a day.
During hospitalization, he cant

sleep well because theres a time
that the nurse is awakening him
in giving medication and getting
vital signs.
Disturbed
Sensory
Perception
related to altered status of sense

organ.
Disturbed sleep pattern related to

interruptions for therapeutics.
The
VII.
Selfperception,
Self-concept
pattern.
patient
stated
that
his
According to the patient, he considered character of silent is still the

himself an introvert. He stated that he is same. He stated that he is feeling Situational
low
self
esteem
quite popular in their barangay. His temper depressed and loses hope but he related to social role changes.
is only test when his wife doesnt listen to knows he can surpass this trial
him.
and can go home. He worries Nurses Pocket Guide Edition 12

about the hospital billing and he
feels he is a burden to his family
According to the patient, he is lives with

VIII. Role
relationship
pattern
his son and wife. He stated that most of

his relatives have financial problems. He
was once an OFW and now he is suffering
from an illness. He decided to go home to
due to financial issues.
IX.
According to the patient, now

that he is admitted in the hospital
his mother are the one taking
good care of him. His mother
admits that they are having a
hard time whos the one to look
Family
process
related to situational transition or

crises in economic.
out for him in the hospital.
Sexuality-
Ineffective sexual pattern related
reproductive
pattern.
Interrupted
He has an active sexual lifestyle.
There would be a changes

regarding to his condition.
to lack of significant other.
10
According to the client, when he is

X.
Coping
stressed, he usually turns to God through
stress
praying. In the past 2 years he was
tolerance
depressed because he is in and out of the
pattern
hospital and worries about his financial
According to the patient, he cant

manage stress properly because
he is thinking of different things.
Ineffective
coping
related
to
inadequate resources available.

issues.
According to the patient, he is Roman The patient states that he believes

XI.
Value-belief
Catholic. He goes to church every in God and he knows he can
pattern
Sunday. He puts God at the center of his surpass it. And he can attend the
life.
Sunday mass when he recovers.
Readiness for spiritual well being

11
IV. REVIEW OF SYSTEMS
EENT
Masakit tuwing nagagalaw yung tubo sa leeg ko
Integumentary System
No Significant finding.
Respiratory System
Minsan nararamdaman kong mabigat ang dibdib

ko
Madali lang akong hingalin at hapuin
Gastrointestinal System
No Significant Finding.
Muscoskeletal System
Mabilis akong mapagod
Genitourinary System
May kasamang dugo ang ihi ko

Nahihirapan din akong makadumi
Neurologic System
Paminsan-minsan nakakaramdam ako ng

pagkahilo
Nahihirapan akong makatulog
12
V.
PHYSICAL ASSESSMENT
Date: September 23, 2014

Time: 10:30 AM
General survey:
The patient is awake, conscious and coherent; patient is also cooperative. Upon
interview, patient appears pale and weak. The initial vital signs were taken as follows:
Height:
Weight:
BMI:
Temperature:
Heart Rate:
Respiratory Rate:
Blood Pressure:
5'7
53 kg
18 - underweight
36.6
79
25
110/70
Organ/ System
Technique
Skin
Hair
Actual Findings
Inspection
Normal
Findings
Color: Pinkish
Palpation
Moisture: Moist
moist
Normal
Texture: Smooth
smooth
Normal
Skin pinch goes

back within 2-3
secs.
Skin pinch goes

back within 2-3
secs.
Normal
Warm to touch
Color: Black
warm
Color: Black
Normal
Normal
Capillary Refill:
2-3 secs
Brittle and dry

Capillary Refill:
2 secs
Normal
Symmetrical
facial feature
Eye lids:
(-) lesion
Symmetrical
facial feature
Eye lids:
(-) lesion
Inspection
Head
Inspection
Eyes
Inspection
Interpretation
Color: Grayish
Abnormal: May
and presence of
indicate side
hyperpigmentation effect of
hemodialysis.
Normal
Normal
13
Ears
Nose
(-)redness
(-) periorbital
edema
(-)redness
(-) periorbital
edema
Normal
Normal
Normal visual
acuity
Normal visual
acuity
Normal
Conjunctiva:
Pinkish in color
Conjuctiva:
Pale Whitish
Sclerae: white or
buffy
Sclerae: yellowish
Abnormal: May
indicate
increased
bilirubin in the
blood
Eyelids:
(-) Masses
Normal
(-) discharges
(-) discharges
Normal
(-) lesions
(-) lesions
Normal
(-) nodules
(-) nodules
Normal
(-) redness
(-) redness
Normal
Symmetrically
aligned
Symmetrically
aligned
Normal
(-) discharge
(-) discharge
Normal
(-) flaring of
nares
(-) flaring of nares
Normal
Palpation
Eyelids:
(-) Masses
Inspection
Symmetry
Inspection
Abnormal: May
indicate reduced
blood flow or a
decreased
number of red
blood cells.
(+) contraption
(-) contraption
Abnormal: Due
to the presence
of O2 therapy 3
14
lpm via nasal

cannula.
Mouth
Inspection
Lips
Color: Pinkish
Lips
Color: Pinkish
Normal
(-) lesions
(-) lesions
Normal
(-) scars/
incisions
(-) scars/ incisions
Normal.
(+) dry mouth

(-) dry mouth
Abnormal: Due
to the side effect
of hemodialysis
(-) lumps
Palpation
(-) lumps
Normal
(-) mass
(-) mass
Tongue:
Color: Pink red
Normal
Tongue:
Color: Pink red
Normal
(-) lesions
(-) lesions
Normal
(-) thrush
(-) thrush
Normal
Gums:
Gums:
Color: Pink Red
Color: Pink
Red
Neck
Normal
Oral Mucosa:
Color: dark red
Oral Mucosa:
Color: Pinkish
(+) Moisture
Normal
(+) Moisture
(-) lesions
Normal
(-) lesions
(-) odor
Normal
Inspection
(-) odor
Symmetrically
aligned
Palpation
(-) scars
Normal
Not symmetrically Abnormal: Due
aligned
to the presence
of intrajugular
catheter for
hemodialysis.
(-) scars
Normal
(-) mass
15
(-) mass
Normal
(-) swelling
(-) swelling
Normal
(+) contraption
(-) contraption
Abnormal: Due
to the presence
of intrajugular
catheter for
hemodialysis.
Respiratory
System
Chest /Thorax/
Lungs
Inspection
Palpation
Auscultation
Heart
Inspection
(+) symmetrical
expansion with
respiration
(+) symmetrical
expansion with
respiration
Normal
(-) retraction
(-) retraction
Normal
(+) smooth
(+) smooth
Normal
(+) warm
(+) warm
Normal
(+) dry
(+) dry
Normal
(-) mass
(-) mass
Normal
(+) normal
breath sounds
(-) normal breath

sounds
Abnormal:
Presence of
wheezing.
(-) adventitious
sound
(+) adventitious
sound
Abnormal:
Presence of
wheezing.
(-) visible PMI
(-) visible PMI
Normal
(+) regular
rhythm
(+) regular rhythm
Normal
(-) thrills
(-) thrills
Normal
(-)murmurs
Auscultation
(-) murmurs
Normal
16
Extremities
Inspection
Palpation
Upper
Extremities
Upper
Extremities
(-) pallor
(+) pallor
Abnormal: May
indicate reduce
amount of
oxyhemoglobin
in skin or
mucuos
membrane.
(-) rashes
(-) rashes
Normal
(-) bruise
(-) bruise
Normal
(-) contraption
(+) contraption
Abnormal: left
hand due to
heplock
(-) swelling
(+) swelling at the

right arm
Abnormal:
(-) edema
(-) edema
Normal
(+) Radial and

Brachial Pulses
(+) Radial and

Brachial Pulses
Normal
(+) warm to
touch
(+) warm to touch
Normal
Lower
Extremities
Lower
Extremities
(+) pallor
Inspection
(-) pallor
Abnormal: May
indicate reduce
amount of
oxyhemoglobin
in skin or
mucuos
membrane.
(-) rashes
(-) rashes
Normal
(-) bruise
(-) bruise
Normal
(-) swelling
17
(-) swelling
Normal
(-) edema
(-) edema
Palpation
Abdomen
Inspection
Normal
(+) popliteal,
(+) popliteal,
posterior tibial,
posterior tibial,
and dorsalispedis
and dorsalispedis pulses
pulses
Normal
Symmetrical
Symmetrical
Normal
(+) globular
shape
(-) globular shape
Abnormal:
abdomen is
distended due to
presence of
current condition
ESRD
(-) masses
(-) masses
Normal
(-) lesions
(-) lesions
Genitalia
Inspection
(-) discharges
Normal
(-) discharges
Normal
18
VI. COURSE IN THE WARD

DATE & SHIFT
September 21, 2014

2PM
11PM
DOCTORS ORDER
NURSING
RESPONSIBILITIES
PT REACTION/
EVALUATION
Maintain present Mechanical

Ventilator Settings
-Check ventilator settings and

mode
-Clients mechanical ventilator

was monitored and in correct
settings
For repeat ABG and possible

extubation if results are
acceptable
-Inform the patient and relatives

regarding the order; informed
them about the possible
extubation
-Client and his relatives have

knowledge about the order
Suction secretions q2
-Elevate head of bed when

suctioning
-Clients secretion was lessened
Ensure q2 bed turning
-Position and turned the patient

every 2 hours
-Client didnt acquire bed sore
CBG monitoring BID, refer if

<80 or >200mg/dL
-Instruct patient to have CBG

monitoring first before taking
meals.
-Client understands the

importance of taking of CBG
before meals.
Continue present management
-Monitor vital signs and

perform bedside care.
-Client was monitored and

checked thoroughly.
-Done bedside care at the end of

the shift
Continue giving medications
-Administer medications with

the right dosage, route and
-Client received medication

accordingly.
19
frequency, and without adding

injury to the patient.
September 22, 2014

6-2pm
Refer accordingly
-Refer to the physician if there

are any alterations.
For hemodialysis
-Monitor patient. Vital signs

taken and recorded
-Client was ready for

hemodialysis
-Informed the patient and his

relative about the procedure
-Client understand the

importance of the order
-Monitor and assess the patient.

Vital signs taken and recorded
-Client was ready for extubation
-Feeding was not given due to

extubation
-Client was not fed
-Hooked to oxygen 3LPM via

nasal cannula
-Client maintained oxygen


checked thoroughly.

the shift

importance of the order.
For extubation; once extubated

oxygenate the patient
Continuous present
management
20
September 23, 2014

6-2pm
For removal of NGT and Soft

Diet
-Instruct client regarding the

removal of the tube
-Client was informed regarding

the procedure
-Instruct client to try eating

jellyace to know if hes ready
for soft diet
-Client diet was changed to Soft

Diet


checked thoroughly.

the shift

importance of the order.
Continue giving medications
-Administer medications with

the right dosage, route and
frequency, and without adding
injury to the patient.
-Client received medication

accordingly.
Refer accordingly
-Refer to the physician if there

are any alterations.
Continuous present
management
21
VIII. DIAGNOSTICS
ARTERIAL BLOOD GAS
Date: Sept 9, 2014
Reference Value:
pH
7.054
7.350 7.450
pCO2
9.9
mmHg
35.00 45.00
pO2
75.0
mmHg
80.00 100.00
HCO3
2.7
mmol/L
B.E.
-27.7
mmol/L
Sat. O2
28.8
Total CO2
3.0
Interpretation: Metabolic Acidosis
ARTERIAL BLOOD GAS

Date: Sept 10, 2014
Reference Value:
7.350 7.450
pH
7.445 N
pCO2
26.1
mmHg
35.00 45.00
pO2
121.5
mmHg
80.00 100.00
HCO3
17.6
mmol/L
B.E.
6.5
mmol/L
Sat. O2
98.6
Total CO2
18.4
Interpretation: Metabolic Alkalosis
22
ARTERIAL BLOOD GAS

Date: Sept 11, 2014
Reference Value:
pH
7.486
7.350 7.450
pCO2
22.2
mmHg
35.00 45.00
pO2
95.8 N
mmHg
80.00 100.00
HCO3
20.7
mmol/L
B.E.
- 7.0
mmol/L
Sat. O2
97.9
Total CO2
17.1
ARTERIAL BLOOD GAS

Date: Sept 14, 2014
Reference Value:
pH
7.514
7.350 7.450
pCO2
23.1
mmHg
35.00 45.00
pO2
109.9
mmHg
80.00 100.00
HCO3
22.3
mmol/L
B.E.
- 4.9
mmol/L
Sat. O2
98.5
Total CO2
18.9
Interpretation: Respiratory Alkalosis
23
ARTERIAL BLOOD GAS

Date: Sept 17, 2014
Reference Value:
pH
7.515
7.350 7.450
pCO2
23.8
mmHg
35.00 45.00
pO2
53.9
mmHg
80.00 100.00
HCO3
22.6
mmol/L
B.E.
- 4.1
mmol/L
Sat. O2
91.7
Total CO2
19.5
ARTERIAL BLOOD GAS

Date: Sept 18, 2014
Reference Value:
7.350 7.450
pH
7.440 N
pCO2
23.0
mmHg
35.00 45.00
pO2
156.0
mmHg
80.00 100.00
HCO3
19.2
mmol/L
B.E.
- 8.9
mmol/L
Sat. O2
99.1
Total CO2
15.9
24
ARTERIAL BLOOD GAS

Date: Sept 19, 2014
Reference Value:
pH
7.484
7.350 7.450
pCO2
24.1
mmHg
35.00 45.00
pO2
136.0
mmHg
80.00 100.00
HCO3
21.5
mmol/L
B.E.
- 5.7
mmol/L
Sat. O2
98.9
Total CO2
18.5
ARTERIAL BLOOD GAS

Date: Sept 20, 2014
Reference Value:
7.350 7.450
pH
7.442 N
pCO2
20.8
mmHg
35.00 45.00
pO2
147.2
mmHg
80.00 100.00
HCO3
18.4
mmol/L
B.E.
- 10.2
mmol/L
Sat. O2
99.0
Total CO2
19.5

25
ARTERIAL BLOOD GAS

Date: Sept 21, 2014
Reference Value:
pH
7.451
7.350 7.450
pCO2
27.0
mmHg
35.00 45.00
pO2
130.5
mmHg
80.00 100.00
HCO3
21.3
mmol/L
B.E.
- 5.6
mmol/L
Sat. O2
98.8
Total CO2
19.2
ARTERIAL BLOOD GAS

Date: Sept 22, 2014
Reference Value:
7.350 7.450
pH
7.440 N
pCO2
30.2
mmHg
35.00 45.00
pO2
141.4
mmHg
80.00 100.00
HCO3
22.1
mmol/L
B.E.
- 4.1
mmol/L
Sat. O2
98.9
Total CO2
20.9

CLINICAL CHEMISTRY
Date: Sept 9, 2014
Result (S.I.)
Unit Range Result (conv) Unit Range
Troponin I NEGATIVE
26
CHEMISTRY SECTION
Test Name
Result
(09/10/14
Result
1.02
Result
Result
(09/17/14
(09/21/14
0.96
1.07
1.02
(09/11/14) (09/14/14
)
IONIZED
Result
1.15
CALCIUM
(iCA)
1.23
1.03
1.47
1.12 1.32
Decrease; Low total of calcium is caused
mmol/L
bylow blood protein levels that result from
1.31
alcoholism
0.66 1.07
Increase; usually the result of an excretion
mmol/L
problem in patients with kidney failure
PHOSPORUS
Increase; Low levels of phosphorus is a

0.81 1.45
BUN/CREA
Interpretation and Analysis
0.97
MAGNESIUM
4.37
Normal values
11.35
12.4
13.7
10.4
result of kidney failure
mmol/L
UREL/BUN
Increase; It suggest impaired kidney

-
224
267
332
357
function
2.1 7.1 mmol/L
CREATININE
Increase; it suggest impaired kidney

PANEL 3
139
128
133
130
SODIUM (Na)
45.0 104.0
umol/L
3.2
3.6
3.7
3.7
POTASSIUM
(K)
function
Decrease; due to sodium loss from

-
101
91
95
136 145 mmol/L
conditions such as kidney diseases

27
Decrease; Low level of potassium may be

3.5 5.1 mmol/L
CHLORIDE (Cl)
PANEL 11
90
268
caused by certain drugs such as

corticosteroids
98 107 mmol/L
Decrease; hypochloremia is caused by
SGOT/AST
chronic lung diseases causing respiratory
SGPT/ALT
acidosis
0 40 U/L
0 41 U/L
Increase; Very high levels of ALT and AST

(more than 10 times normal) are usually due
to acute hepatitis, sometimes due to
a viral infection.
28
HEMATOLOGY
Component
Hemoglobin
Result
Result
Result
Normal
(09/09/14)
(09/20/14)
(09/11/14)
values
14.0
12.1
14-18g/l
Decreased Hb is caused by Kidney failuresevere

and chronic kidney diseases lead to decreased
production of erythropoietin, a hormone produced
by the kidneys that stimulates RBC production by
the bone marrow
http://labtestsonline.org/understanding/analytes/he
moglobin/tab/test#what
Hematocrit
0.43
0.40
0.40-0.54
Normal
WBC
33.8
25.9
4-11 x 109
Normal
g/l
RBC
5.0
4.5
5.0-6.4
Decreased Hb is caused by Kidney failuresevere

and chronic kidney diseases lead to decreased
production of erythropoietin, a hormone produced
by the kidneys that stimulates RBC production by
the bone marrow
http://labtestsonline.org/understanding/analytes/rbc
/tab/test#what
Differential
count
29
Eosinophils
0.01
0.09
0.02-0.04
Decreased in result is usually not medically

significant. Numbers are usually low in the blood
Increased in numbers are usually because of
asthma, allergy, drug reactions and infections.
http://labtestsonline.org/understanding/analytes/co
mpletebloodcount/tab/test#what
Neutrophil
Segme
0.84
0.75
0.50-0.70
Increased may indicate presence of infection and

inflammation and reaction to drugs
nters
http://labtestsonline.org/understanding/analytes/cbc
/tab/test/
Lymph
0.11
0.13
0.20-0.40
Decreased may due to certain bacterial infection

http://labtestsonline.org/understanding/analytes/cbc
ocytes
/tab/test/
Monoc
0.04
0.03
0.02-0.05
Normal
410
88
150-450 x
Decreased may be caused by certain drugs, such as

acetaminophen, quinidine, sulfa drugs, digoxin,
vancomycin, valium, and nitroglycerine, are just a
few that have been associated with drug-induced
decreased platelet counts.
ytes
Platele
t count
109 g/l
http://labtestsonline.org/understanding/analytes/pla
30
telet/tab/test#what
Prothrombin
40.1 secs
Time
10.4 14.0
A prolonged PT means that the blood is taking too
seconds
long to form a clot. This may be caused by

conditions such as liver disease, vitamin K
deficiency, or a coagulation factor deficiency.
http://labtestsonline.org/understanding/analytes/pt/t
ab/test#what
% Activity
13.6 %
73 127 %
A prolonged PT means that the blood is taking too

long to form a clot. This may be caused by
conditions such as liver disease, vitamin K
deficiency, or a coagulation factor deficiency.
http://labtestsonline.org/understanding/analytes/pt/t
ab/test#what
INR
3.44
0.88 1.21
For some who have a high risk of clot formation, the

INR needs to be higher - about 2.5 to 3.5. The
doctor will use the INR to adjust a person's drug
dosage to get the PT into the desired range that is
right for the person and their condition.
http://labtestsonline.org/understanding/analytes/pt/ta
b/test#what
31
Activated PTT
83.4 secs
30.4 41.2
A prolonged PTT means that clotting is taking
seconds
longer to occur than expected and may be due to

anticoagulant drugs such as heparin
http://labtestsonline.org/understanding/analytes/apt
t/tab/test#what
HEMATOLOGY
Component
Hemoglobin
Result
Result
Normal
(09/14/14)
(09/17/14)
values
12.1
12.5
14-18g/l
Decreased Hb is caused by Kidney failuresevere and

chronic kidney diseases lead to decreased production
of erythropoietin, a hormone produced by the kidneys that stimulates
RBC production by the bone marrow
http://labtestsonline.org/understanding/analytes/hemoglobin/tab/test
#what
Hematocrit
0.39
0.40
0.40-0.54
Decreased is caused by decreased production of hemoglobin,

chronic bleeding, and chronic inflammatory diseases
http://labtestsonline.org/understanding/analytes/hematocrit/tab/test#
what
WBC
24.5
23.1
4-11 x 109
Normal
g/l
32
RBC
4.5
4.6
5.0-6.4
0.09
0.11
0.02-0.04
Normal
Differential
count
Eosinophils
Decreased in result is usually not medically significant. Numbers

are usually low in the blood
Increased in numbers are usually because of asthma, allergy, drug
reactions and infections.
http://labtestsonline.org/understanding/analytes/completebloodcount/
tab/test#what
Neutrophil
Segme
0.75
0.59
0.50-0.70
Increased may indicate presence of infection and inflammation and

reaction to drugs
nters
http://labtestsonline.org/understanding/analytes/cbc/tab/test/
Lymph
0.13
0.19
0.20-0.40
ocytes
Monoc
ytes
Decreased may due to certain bacterial infection
0.03
0.11
0.02-0.05
Increased is maybe due to presence of infection or chronic

inflammatory disease
33
Platele
105
182
150-450 x
109 g/l
t count
Decreased may be caused by certain drugs, such as acetaminophen,

quinidine, sulfa drugs, digoxin, vancomycin, valium, and
nitroglycerine, are just a few that have been associated with druginduced decreased platelet counts.
http://labtestsonline.org/understanding/analytes/platelet/tab/test#wha
t
Prothrombin
18.3 secs
16.2 secs
Time
10.4 14.0
A prolonged PT means that the blood is taking too long to form a
seconds
clot. This may be caused by conditions such as liver disease, vitamin

K deficiency, or a coagulation factor deficiency.
http://labtestsonline.org/understanding/analytes/pt/tab/test#what
% Activity
13.6 %
73 127 %
A prolonged PT means that the blood is taking too long to form a

clot. This may be caused by conditions such as liver disease, vitamin
K deficiency, or a coagulation factor deficiency.
INR
3.44
0.88 1.21
For some who have a high risk of clot formation, the INR needs to be
higher - about 2.5 to 3.5. The doctor will use the INR to adjust a
person's drug dosage to get the PT into the desired range that is right
for the person and their condition.
Activated PTT
83.4 secs
30.4 41.2
A prolonged PTT means that clotting is taking longer to occur than
seconds
expected and may be due to anticoagulant drugs such as heparin

http://labtestsonline.org/understanding/analytes/aptt/tab/test#what
34
MICROBIOLOGY
CULTURE AND SENSITIVITY
Date: Sept 15, 2014
Specimen: BLOOD 2 SITES

Organisms: COAGULASE NEGATIVE STAPHYLOCOCCI
ANTIMICROBIAL SUCEPTIBILITY
ANTIBIOTIC
Erythromycin 15 ug (E)
Tetracycline 30 ug (TE)
RESISTANT INTERMEDIATE SENSITIVE

x
x
35
VII.
Differential Diagnosis
SIGNS AND
SYMPTOMS
PULMONARY
CONGESTION
PLEURAL
EFFUSION
PNUEMONIA
Presence of Fluid in
the lungs
Shortness of Breath
Sharp Chest Pain
Cough
Difficulty Breathing
Nasal Congestion
Fever
Chest Tightness
Weakness
Fluid Retention
36
VIII. Anatomy of the Respiratory System
Nose and Nasal Cavity

The nose and nasal cavity form the main external opening for the respiratory system and are the
first section of the bodys airwaythe respiratory tract through which air moves. The nose is a
structure of the face made of cartilage, bone, muscle, and skin that supports and protects the
anterior portion of the nasal cavity. The nasal cavity is a hollow space within the nose and skull
that is lined with hairs and mucus membrane. The function of the nasal cavity is to warm,
moisturize, and filter air entering the body before it reaches the lungs. Hairs and mucus lining the
nasal cavity help to trap dust, mold, pollen and other environmental contaminants before they
can reach the inner portions of the body. Air exiting the body through the nose returns moisture
and heat to the nasal cavity before being exhaled into the environment.
Mouth
The mouth, also known as the oral cavity, is the secondary external opening for the respiratory
tract. Most normal breathing takes place through the nasal cavity, but the oral cavity can be used
to supplement or replace the nasal cavitys functions when needed. Because the pathway of air
entering the body from the mouth is shorter than the pathway for air entering from the nose, the
mouth does not warm and moisturize the air entering the lungs as well as the nose performs this
function. The mouth also lacks the hairs and sticky mucus that filter air passing through the nasal
cavity. The one advantage of breathing through the mouth is that its shorter distance and larger
diameter allows more air to quickly enter the body.
37
Pharynx
The pharynx, also known as the throat, is a muscular funnel that extends from the posterior end
of the nasal cavity to the superior end of the esophagus and larynx. The pharynx is divided into
3 regions: the nasopharynx, oropharynx, and laryngopharynx. The nasopharynx is the superior
region of the pharynx found in the posterior of the nasal cavity. Inhaled air from the nasal cavity
passes into the nasopharynx and descends through the oropharynx, located in the posterior of the
oral cavity. Air inhaled through the oral cavity enters the pharynx at the oropharynx. The
inhaled air then descends into the laryngopharynx, where it is diverted into the opening of the
larynx by the epiglottis. The epiglottis is a flap of elastic cartilage that acts as a switch between
the trachea and the esophagus. Because the pharynx is also used to swallow food, the epiglottis
ensures that air passes into the trachea by covering the opening to the esophagus. During the
process of swallowing, the epiglottis moves to cover the trachea to ensure that food enters the
esophagus and to prevent choking.
Larynx
The larynx, also known as the voice box, is a short section of the airway that connects the
laryngopharynx and the trachea. The larynx is located in the anterior portion of the neck, just
inferior to the hyoid bone and superior to the trachea. Several cartilage structures make up the
larynx and give it its structure. The epiglottis is one of the cartilage pieces of the larynx and
serves as the cover of the larynx during swallowing. Inferior to the epiglottis is the thyroid
cartilage, which is often referred to as the Adams apple as it is most commonly enlarged and
visible in adult males. The thyroid holds open the anterior end of the larynx and protects the
vocal folds. Inferior to the thyroid cartilage is the ring-shaped cricoid cartilage which holds the
larynx open and supports its posterior end. In addition to cartilage, the larynx contains special
structures known as vocal folds, which allow the body to produce the sounds of speech and
singing. The vocal folds are folds of mucous membrane that vibrate to produce vocal sounds.
The tension and vibration speed of the vocal folds can be changed to change the pitch that they
produce.
Trachea
The trachea, or windpipe, is a 5-inch long tube made of C-shaped hyaline cartilage rings lined
with pseudostratified ciliated columnar epithelium. The trachea connects the larynx to the
bronchi and allows air to pass through the neck and into the thorax. The rings of cartilage making
up the trachea allow it to remain open to air at all times. The open end of the cartilage rings faces
posteriorly toward the esophagus, allowing the esophagus to expand into the space occupied by
the trachea to accommodate masses of food moving through the esophagus.
The main function of the trachea is to provide a clear airway for air to enter and exit the lungs. In
addition, the epithelium lining the trachea produces mucus that traps dust and other contaminants
and prevents it from reaching the lungs. Cilia on the surface of the epithelial cells move the
38
mucus superiorly toward the pharynx where it can be swallowed and digested in the
gastrointestinal tract.
Bronchi and Bronchioles
At the inferior end of the trachea, the airway splits into left and right branches known as the
primary bronchi. The left and right bronchi run into each lung before branching off into smaller
secondary bronchi. The secondary bronchi carry air into the lobes of the lungs2 in the left lung
and 3 in the right lung. The secondary bronchi in turn split into many smaller tertiary bronchi
within each lobe. The tertiary bronchi split into many smaller bronchioles that spread throughout
the lungs. Each bronchiole further splits into many smaller branches less than a millimeter in
diameter called terminal bronchioles. Finally, the millions of tiny terminal bronchioles conduct
air to the alveoli of the lungs.
As the airway splits into the tree-like branches of the bronchi and bronchioles, the structure of
the walls of the airway begins to change. The primary bronchi contain many C-shaped cartilage
rings that firmly hold the airway open and give the bronchi a cross-sectional shape like a
flattened circle or a letter D. As the bronchi branch into secondary and tertiary bronchi, the
cartilage becomes more widely spaced and more smooth muscle and elastin protein is found in
the walls. The bronchioles differ from the structure of the bronchi in that they do not contain any
cartilage at all. The presence of smooth muscles and elastin allow the smaller bronchi and
bronchioles to be more flexible and contractile.
The main function of the bronchi and bronchioles is to carry air from the trachea into the lungs.
Smooth muscle tissue in their walls helps to regulate airflow into the lungs. When greater
volumes of air are required by the body, such as during exercise, the smooth muscle relaxes to
dilate the bronchi and bronchioles. The dilated airway provides less resistance to airflow and
allows more air to pass into and out of the lungs. The smooth muscle fibers are able to contract
during rest to prevent hyperventilation. The bronchi and bronchioles also use the mucus and cilia
of their epithelial lining to trap and move dust and other contaminants away from the lungs.
Lungs
The lungs are a pair of large, spongy organs found in the thorax lateral to the heart and superior
to the diaphragm. Each lung is surrounded by a pleural membrane that provides the lung with
space to expand as well as a negative pressure space relative to the bodys exterior. The negative
pressure allows the lungs to passively fill with air as they relax. The left and right lungs are
slightly different in size and shape due to the heart pointing to the left side of the body. The left
lung is therefore slightly smaller than the right lung and is made up of 2 lobes while the right
lung has 3 lobes.
The interior of the lungs is made up of spongy tissues containing many capillaries and around 30
million tiny sacs known as alveoli. The alveoli are cup-shaped structures found at the end of the
terminal bronchioles and surrounded by capillaries. The alveoli are lined with thin simple
39
squamous epithelium that allows air entering the alveoli to exchange its gases with the blood
passing through the capillaries.
Muscles of Respiration
Surrounding the lungs are sets of muscles that are able to cause air to be inhaled or exhaled from
the lungs. The principal muscle of respiration in the human body is the diaphragm, a thin sheet of
skeletal muscle that forms the floor of the thorax. When the diaphragm contracts, it moves
inferiorly a few inches into the abdominal cavity, expanding the space within the thoracic cavity
and pulling air into the lungs. Relaxation of the diaphragm allows air to flow back out the lungs
during exhalation.
Between the ribs are many small intercostal muscles that assist the diaphragm with expanding
and compressing the lungs. These muscles are divided into 2 groups: the internal intercostal
muscles and the external intercostal muscles. The internal intercostal muscles are the deeper set
of muscles and depress the ribs to compress the thoracic cavity and force air to be exhaled from
the lungs. The external intercostals are found superficial to the internal intercostals and function
to elevate the ribs, expanding the volume of the thoracic cavity and causing air to be inhaled into
the lungs.
http://www.innerbody.com/anatomy/respiratory
40
IX. SURGICAL MANAGEMENT
PROCEDURE DONE/ TO BE DONE
NURSING RESPONSIBILITIES
Insertion of Intrajugular Catheter

in the left side
March 2014
Take baseline vital sign..

The nurse maintaining safest and aseptic
environment
Prepare all the instruments and supplies
needed for insertion of IJ catheter.
Position the client.
Observe aseptic technique, avoid
contamination of the catheter.
Immediate Care
The nurse is responsible for taking and
recording the blood pressure every 4 hours
Nurses are also responsible for monitoring
and taking the temperature every 4 hours.
Inspect the wound every 30 minutes to
monitor for sign of infection.
After 24 hours:
Continue monitoring the blood pressure,
41
respiratory and pulse rates every 4 hours.

Assess the dressing for presence of
discharges.
Assess for change of dressing.
Ambulation is encouraged.
48 hours:
Monitor incision for infection risks.
Make sure that the wound is properly
dressed.
PROCEDURE DONE/ TO BE DONE
NURSING RESPONSIBILITIES
Reinsertion of Intrajugular
Catheter in the right side.
March 2014
Take baseline vital sign..

The nurse maintaining safest and aseptic
environment
Prepare all the instruments and supplies
needed for insertion of IJ catheter.
Position the client.
Observe aseptic technique, avoid
contamination of the catheter.
Immediate Care
42
The nurse is responsible for taking and

recording the blood pressure every 4 hours
Nurses are also responsible for monitoring
and taking the temperature every 4 hours.
Inspect the wound every 30 minutes to
monitor for sign of infection.
After 24 hours:
Continue monitoring the blood pressure,
respiratory and pulse rates every 4 hours.
Assess the dressing for presence of
discharges.
Assess for change of dressing.
Ambulation is encouraged.
48 hours:
Monitor incision for infection risks.
Make sure that the wound is properly
dressed.
43
X.
Drug Study
DRUG
DOSAGE
Generic
Name:
Pantoprazole
40mg, IV,
OD while
on NPO
Brand Name:
Protonix
CLASSIFICATION MECHANISM
OF ACTION
Pharmacologic:
Action:
Proton pump
Gastric Acid
inhibitor
pump inhibitor
Therapeutic:
-used to control
gastric acidity ,
regulate
gastrointestinal
motility.
Reduces gastric
acid secretion
Increases
gastric mucus
and bicarbonate
production
Creating
protective
coating on
gastric mucosa
INDICATION
Treatment for
duodenal and
gastric ulcer.
SIDE EFFECT
Side Effect:
CNS: dizziness,
headache
CV: chest pain
EENT: rhinitis
GI: vomiting,
diarrhea, abdominal
pain, dyspepsia
Metabolic:
hyperglycemia
Skin: rash, pruritus
Other: injection
site reactionrug
NURSING
CONSIDERATION
-Assess history for
any allergy to proton
pump inhibitor.
-Maintain supportive
treatment as
appropriate for
underlying problem.
-Provide additional
comfort measures to
alleviate discomfort
from GI effects and
headache.
Contraindication:
-Hypersensitivity to
drug
Blocks the final

step of acid
production.
44
DRUG
DOSAGE
Generic
Name:
Paracetamol
300 mg
TIV Q4,
prn for
fever
Brand Name:
Aeknil
OF ACTION
Pharmacologic:
For Fever:
Synthetic NonFever reduction
Opioid pmay result from
aminophenol
vasodilation
derivative
Therapeutic:
Analgesic,
Antipyretics
Increased
peripheral
blood flow in
hypothalamus
Dissipates heat
and lowers
body
temperature.
For Pain:
Pain relief may
result from
inhibition of
prostaglandin
synthesis in
CNS
INDICATION
SIDE EFFECT
Relief of mildto-moderate
pain; treatment
of fever
Side Effect:
Hematologic:
thrombocytopenia,
haemolytic anemia,
neutropenia,
leukopenia,
pancytopenia
Hepatic: jaundice,
hepatotoxicity
Metabolic:
hypoglycemic coma
Skin: rash, urticaria
Other:
hypersensitivity
reactions (such as
fever)
NURSING
CONSIDERATION
-Assess history for
any allergy to proton
pump inhibitor.
-Maintain supportive
treatment as
appropriate for
underlying problem.
-Provide additional
comfort measures to
alleviate discomfort
from GI effects and
headache.
Contraindication:
drug
Subsequent
blockage of
pain impulses.
45
DRUG
DOSAGE
500 mg
Generic
TIV OD
Name:
Vancomycin
every 3
Hydrochloride days
Brand Name:
Vancocin
OF ACTION
Binds the
Pharmacologic:
Tricyclic
bacterial cell
glycopeptide
wall
Therapeutic:
Anti-infective
Inhibiting cell
wall synthesis
Causing
secondary
damage to
bacterial
membrane
.
INDICATION
SIDE EFFECT
Severe, lifethreatening
infections
caused by
susceptible
strains of
methicillinresistant
staphylococci.
Side Effect:
CV: hypotension,
cardiac arrest,
vascular
EENT: permanent
hearing loss,
ototoxicity, tinnitus
GI: vomiting,
nausea,
pseudmembranenous
colitis
GU: nephrotoxicity,
severe uremia
Hematologic:
eosinophilia,
leukopenia,
neutropenia
Respiratory:
wheezing, dyspnea
Skin: red man
syndromerash,
pruritus, necrosis,
urticaria
Other: chills,fever,
thrombophlebitis
Contraindication:
drug
NURSING
CONSIDERATION
-Monitor closely for
signs and symptoms
of hypersensitivity
reactions, including
anaphylaxis.
-Assess BUN and
creatinine levels
every 2 days, or
daily in patients with
unstable renal
function.
-Monitor urine
output daily. Weigh
patient at least
weekly.
-Check I.V. site
often for phlebitis.
-Monitor CBC.
Watch for signs and
symptoms of blood
dyscrasias.
-Closely monitor
respiratory status.
46
DRUG
DOSAGE
Generic
Name:
Enoxaparin
Sodium
2000 units
SQ
Brand
Name:
Lovenox 3
OF ACTION
Pharmacologic:
Action:
Low-molecule
weight heparin
Inhibits
thrombus and
clot formation
Therapeutic:
Anticoagulant
by blocking
factor Xa and
factor IIa
Inhibition
accelerates
formation of
antithrombin
III-Thrombin
complex
Deactiviting
thrombin and
preventing
conversion of
fibrinogen to
fibrin
INDICATION
Prevention of
ischemic
complications
of unstable
angina or non
Q wave MI
SIDE EFFECT
Side Effect:
CNS: dizziness,
headache, insomnia,
confusion, CVA
CV: chest pain,
edema, heart failure
GI: vomiting,
nausea, constipation
Metabolic:
hyperkalemia
GU: urinary
retention
Hematologic:
anemia,
thrombocytopenia,
hemorhage
Skin: rash, pruritus,
bruising, urticaria
Other: fever, pain,
irritation, or
erythema at
injection site
Contraindication:
drug, heparin,
sulphites, benzyl
alcohol, or pork
products
-Active major
NURSING
CONSIDERATION
-Monitor CBC and
platelet counts.
Watch for signs and
symptoms of
bleeding and
bruising.
-Monitor fluid intake
and output. Watch
for fluid retention
and edema.
-If patient will selfadminister drug,
teach proper
injection technique.
-Teach patient safety
measures to avoid
bruising or bleeding.
-Advise patient to
weigh himself
regularly ad report
gains.
-As appropriate,
review all other
significant and life
threatening adverse
47
bleeding
reactions and
interactions,
especially those
related to the drugs,
tests and herbs
mentioned above.
48
XI.
CUES
Subjective:
nahihirapan
akong
huminga
Objective:
-Nasal flaring
Nursing Care Plan

DIAGNOSIS
Impaired gas
exchange
related
ventilation
perfusion
imbalance
INFERENCE
Short term:
After 3-4 of nursing
interventions the
patient will
demonstrate improve
ventilation and
adequate
oxygenation of
Amount of blood tissues by HBGs
ejected from the within clients
left ventricle
normal limits.
diminishes
Perfusion
myocardium is
impaired with
left ventricular
failure
-Difficulty of
breathing
-RR: 25 cpm
-O2 Sat.: 92
PLANING
Hypostatic
pressure builds
in the pulmonary
venous system
-weakness
Results-filled
alveoli and
pulmonary
congestion
Long term:
After 8 hours of
nursing intervention
the client will
participate in
treatment regimen
(e.g. breathing
exercises, effective
coughing, use of
oxygen) within level
of ability/ situation.
NURSING
INTEVENTIONS
Independent:
-Elevate head of bed
patient
RATIONALE
-To maintain airway.

-To reduce secretions.
-Suction patient.
-Encourage frequent
deep breathing/
coughing exercises.
-Auscultate breath
sounds noting crackles,
wheezes.
Dependent:
-Administer oxygen
therapy via face mask
or nasal cannula as
orderd by the
physician.
-Provides optimal chest

expansion and drainage
secretions.
-Reveals presence of
pulmonary congestion/
collection of secretion,
indicating for further
intervention.
-To improve gas

exchange.
EVALUATION
Short term:
After 3-4 of
nursing
interventions the
patient
demonstrated
improved
ventilation and
adequate
oxygenation of
tissues by HBGs
within clients
normal limits.
Long term:
After 8 hours of
nursing
intervention the
client
participated in
treatment
regimen (e.g.
breathing
exercises,
effective
coughing, use of
oxygen) within
level of ability.
49
CUES
NURSING
DIAGNOSIS
Objective:
-Weakness
Risk for
-With dry and Infection
intact dressing
in the IJ
catheter.
-
INFERENCE
ESRD
Intrajugular
catheterization
for hemodialysis
Surgical Incision
Open skin and

presence of
catheter
Risk for
Infection
GOAL
NURSING
INTERVENTION
RATIONALE
EVALUATION
Short term:
Short term:
Independent:
After 1-2 hours of

nursing
interventions, the
patient will be able
to identify and
demonstrate
interventions to
prevent or reduce
risk of infection.
Establish patients
rapport
To gain trust and

cooperation of the
patient
Monitor and record

vital signs
To obtain baseline data
Proper hand washing

technique
To avoid cross
contamination
After 1-2 hrs of

Nursing
Intervention
clients
understand the
importance of
interventions to
prevent
infection.
Long term:
Instruct on proper
wound care
Prevention for infection
Long term:
After 1 day of
nursing
interventions, the
patient will achieve
timely wound
healing and be free
from signs and
symptoms of
infection.
Inspect the wound for

swelling, unusual
drainage, odor redness,
or separation of the
suture lines.
Dependent:
taking antibiotics as
prescribed by a
physician
After 1 day of
Wound infection are
Nursing
accompanied by signs of Intervention
inflammation and a
Clients wound
delay in healing
is free from signs
and symptoms of
infection.
To prevent infection
50
ASSESSMENT
S: Mabilis ako
mapagod,
madali akong
hingalin at
hapuin.
O:
>conscious and
coherent
>pale skin
>RR: 22 cpm
NURSING
DIAGNOSIS
Activity
intolerance
related to
imbalance
between oxygen
supply and
demand
INFERRENCE
PLANNING
After 8 hours of
Accumulation of
effective nursing
fluids in the lungs intervention
patient will
Pulmonary edema demonstrate
measurable/prog
Pulmonary
ressive increase
congestion
in tolerance for
activity with
Excessive fatigue heart rate/rhythm
within normal
Activity
limits and skin
Intolerance
warm, pink and
dry
NURSING
INTERVENTION
Independent:
-Encourage bed rest
initially
-Instruct client to
avoid increasing
abdominal pressure
-Review signs and

symptoms
reflecting
intolerance
Dependent:
-Monitor response
to supplemental
oxygenation and
medicines
Collaborative:
-Refer to cardiac
rehabilitation
program
RATIONALE
EVALUATIO
N
-reduces
myocardial
workload/oxygen
consumption
After 8 hours
of effective
nursing
intervention
patient
-Activities that
demonstrated
require holding of measurable/pr
breath and bearing ogressive
down can result in increase in
bradycardia and
tolerance for
increased in BP
activity with
-May indicate need heart
for changes in
rate/rhythm
exercise regimen
within normal
limits
-Skin is warm,
pinkish and
dry
-Provides
continous
support/additional
supervision and
51
participation in
recovery and
wellness process
52
XII.
DISCHARGE PLAN
Medication
Advice the patient, as well as the significant others that medication should be taken as
prescribed by the physician.
Explain the mechanism of action of each medication regimen and the information
regarding side effects of the medications.
Stress the importance of compliance to prescribed medications and complete the full
course of the medication therapy.
Exercise
Encourage the client to resume tolerable daily activities which aides in achieving and
maintaining an optimum level of wellness and health.
Encourage patient to have rest, rest rejuvenates your body and mind it also regulates your
mood.
Treatment
Encourage the patient to go hospital as soon as possible if untoward symptoms are

observed and cant be relieved by medications.
Continue medication as prescribed by the physician
Instruct client to go for hemodialysis every 3 days per week.
Health Teaching
Instruct the patient to eat nutritious food as long as she can tolerate chewing and maintain
soft diet.
53
Teach client deep breathing exercises to improve gas exchange.
Emphasize the importance of hygiene and hand washing to prevent infection. Instruct
client to take extra precaution to prevent injuries that may cause prolong wound healing.
Instruct patient to maintain hygiene at all times.
Instruct client to weigh himself daily to monitor if you gain or loose weight.
Instruct client to limit alcohol intake and to avoid smoking.
OPD
Advice client to have a follow up check-up with his attending physician.
Emphasize the importance and benefits of following the scheduled dates of checkup.
Diet
Eat a well balanced diet.
Instruct client to have a low salt l low fat diet.
Advise patient to avoid eating junk foods and limit the consumption of sugar to avoid
diabetes.
Weight: 53kg
Height: 57 ft
Desired Body Weight (DBW)
DBW = 5x12 = 60+7 x 2.54

= 170.18 100 = 70.18 7.018
Total Energy Requirement
TER = DBW/ weight of patient x activity

TER = 63 x 35 = 2205kcal
= 63.162 = 63kg
BMI =
DBW = 63 kg
53kg
((1.70) (1.70))2
= 18.33 or 18
BMI = 18-------- Underweight
54
CHO= 2205kcal x .60 = 1323kcal 4

= 330grams
PRO= 2205kcal x .15 = 330.75kcal 4
= 85 grams
Fat
= 2205kcal x .25 = 551.25kcal 9

= 60 grams
Spiritual
Encourage the client to keep praying, believing and visiting to their church.
Help restore the patients feelings of independence and set realistic goals.
55
XIII. EVALUATION
Through that assessment and data gathering, certain problems and needs at the client
were identified. Nursing care plan was established to improve clients status and recovery.
Information and health teaching not only to the client who are suffering from this condition
but also to the people who are interested to be aware in different conditions were imparted
which lead to increase clients/ people awareness and knowledge with regards to her
condition. The student nurse gained additional information about Pulmonary Congestion
secondary to ESRD secondary to Cardiorenal Syndrome in Respiratory Failure Type I
including diagnostic examination, medical management needed and as well as the factors
affecting the condition which may help the group and different people in handling properly
this kind of condition that the student nurse may possible encounter again.
56

Pulmonary Congestion Secondary To ESRD Secondary To Cardiorenal Syndrome in Respiratory Failure Type I

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Pulmonary Congestion Secondary To ESRD Secondary To Cardiorenal Syndrome in Respiratory Failure Type I

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University of Makati

College of Allied Health Studies

A Case of a Thirty Years Old Male Diagnosed with Pulmonary Congestion

A Case Presentation Submitted in Partial Fulfillment of the

September 26, 2014

Pulmonary congestion that develops suddenly, is a medical emergency requiring immediate

To evaluate patients condition after treatment.

III. NURSING HISTORY

: September 9, 2014 10:11 pm

: September 22, 2014 10:30 am

Source of information : Patient

HISTORY OF PRESENT ILLNESS:

PAST MEDICAL HISTORY:

III. GORDONS FUNCTIONAL HEALTH PATTERN

According to the patient, after climbing

Health three flight of stairs he suddenly felt

difficulty in breathing, nauseated and

not in a good state and he is Ineffective health maintenance

environment. He wants to go coping

The patient states that he consumes 1-2

no problem in swallowing food. He drinks Diet : LSLF Diet

at least 5-8 glasses of water a day. He Weight: 64 kilograms

Readiness for enhanced nutrition.

states that he and his family usually eat Height: 173 cm

10 sticks per day. He started smoking at

He defecates once or twice a day.

According to the patient, he

defecating. He has difficulty in

- Texture: Semi formed

Readiness for enhanced urinary

He has some difficulty in urinating.

- Color: Red Orange

- Odor: Foul Odor

- Odor: Foul Smell

Nurses Pocket Guide Edition 12

During hospitalization, according Activity Intolerance related to

composed of exercise such as playing minimal movements because of process.

basketball, walks and strolls around his unfamiliar environment.

Nurses Pocket Guide Edition 12

neighbourhood, reads newspaper and

He is assertive all throughout the

that, he answers us clearly.

According to the patient, before he was

rest hospitalized he had difficulties falling

During hospitalization, he cant

related to altered status of sense

Disturbed sleep pattern related to

According to the patient, he considered character of silent is still the

and can go home. He worries Nurses Pocket Guide Edition 12

According to the patient, he is lives with

his son and wife. He stated that most of

According to the patient, now

related to situational transition or

out for him in the hospital.

Ineffective sexual pattern related

He has an active sexual lifestyle.

There would be a changes

to lack of significant other.

Nurses Pocket Guide Edition 12

According to the client, when he is

stressed, he usually turns to God through

praying. In the past 2 years he was

depressed because he is in and out of the