Art Christian M.

Ramos BSN 4 - 3

Diagnosis: Muscle Paresis, s/t Motor Neuro Disease, Spinal Cord Injury, Epidural Abcess July 10, 2013 Patient: X
Diagnosis Ineffective Airway Clearance related to accumulation of mucous secretion secondary to Spinal Cord Injury as manifested by: Mucous secretion in the Endotrache al tube. (+) wheezing and crackes on left lobe of the lung noted upon auscultation Inference The presence of a foreign microorganism triggers the B lymphocyte to produce antibodies that are specific to that antigen. These antibodies then attach to mast cells in the lungs. The mast cells with the antibody attaches to the antigen and begins to degranulate. This degranulation causes the release of certain chemical mediators, namely, histamine, bradykinin, prostaglandin, and leukotriene. These chemical mediators cause bronchospasm leading to bronchoconstriction, increased vascular permeability leading to fluid leakage from the lung vasculature and increased mucus production. These lead to swelling of the bronchi, mucus buildup that plugs the airway and decreased bronchial diameter. This causes an Planning After 8 hours of effective nursing intervention, patient will manifest: Maintain and improve airway clearance by decrease in secretion Manifest decrease in wheezing and crackles upon auscultation Vital Signs within Normal Limits. Interventions Auscultate breath sounds q 4. Rationale Breath sounds are normally clear or scattered fine crackles at bases, which clear with deep breathing. The presence of coarse crackles during late inspiration indicates fluid in the airway; wheezing indicates an airway obstruction. Normal respiratory rate for an adult without dyspnea is 12 to 16. With secretions in the airway, the respiratory rate will increase. Normal blood gas values are a PO2 of 80 to 100 mm Hg and a PCO2 of 35 to 45 mm Hg. An oxygen saturation of less than 90% indicates problems with oxygenation. Hypoxemia can result from Evaluation after 8 hours of effective nursing intervention, patient manifested: Improved airway clearance and decrease accumulation of secretion by suctioning and repositioning methods Decreased crackles and wheezes noted upon auscultation Lates vital signs taken @ 9pm, 7/9/13: Temp = 37.7C BP= 110/60 RR = 28A PR= 91 O2Sat = 95%

Assessment Subjective: N/A due to patient can only mouth words when asked or when she needs something. Objective:

Received Sleeping but arousable c Nasogastric tube intact and patent for feeding(NPO temporarily) c endotracheal tube @ 22mm leveled connected to Mechanical Ventilatior c settings @ : Fi02 = 40% TV = 400ml IFR = 55 BUR = 16 18 AC mode c IVF 1L PNSS leveled @ 720cc, infusing @ 80cc/hr. c foley catheter

Monitor respiratory patterns, including rate, depth, and effort.

Monitor blood gas values and pulse oxygen saturation levels as available.

Position client to optimize respiration

Art Christian M. Ramos BSN 4 - 3

Diagnosis: Muscle Paresis, s/t Motor Neuro Disease, Spinal Cord Injury, Epidural Abcess July 10, 2013 Patient: X
increased airway resistance and a constricted pathway for air. Air cannot pass effectively and this manifests as a whistling sound. Coughing is a way to expel the obstruction (mucus plug) while dyspnea is a manifestation of the increased airway resistance. Irritant during inhalation due to microbial agents Inflammatory Responses Tissue Injury ventilationperfusion mismatches secondary to respiratory secretions. (e.g., head of bed elevated 45 degrees and repositioned at least every 2 hours). An upright position allows for maximal air exchange and lung expansion; lying flat causes abdominal organs to shift toward the chest, which crowds the lungs and makes it more difficult to breathe. Studies have shown that in mechanically ventilated clients receiving enteral feedings, there is a decreased incidence of nosocomial pneumonia if the client is positioned at a 45-degree semirecumbent position as opposed to a supine position

received connected to urine bag noted c yellowish output with adequate amount. c bed sore grade 2 on the lumbar area c estimate 8 10 long c 2 more bed sore grade 3 approximately 1 2 in diameter (+) edema with grade 2 pitting Noted c distended abdomen Hypotonic bowel sound noted upon auscultation Initial Vital signs taken @ 3pm, 7/9/13: T= 39.6C, BP = 100/50 mm/HG RR= 32 A cpm, PR 98 bpm, O2 Sat = 93%

Vascular Responses

Increaseproduction of secretions

Airway constriction

Dyspnea

Art Christian M. Ramos BSN 4 - 3

Diagnosis: Muscle Paresis, s/t Motor Neuro Disease, Spinal Cord Injury, Epidural Abcess July 10, 2013 Patient: X
Maintain a semiFowler's position with a lateral position (with a 10- to 15degree elevation and "good lung down") , Gravity and hydrostatic pressure allow the dependent lung to become better ventilated and perfused, which increases oxygenation Normal sputum is clear or gray and minimal; abnormal sputum is green, yellow, or bloody; malodorous; and often copious. To clear or remove mucous secretion of the patient but in a very limited manner of time to prevent patient from hypoxia. Oral care freshens the mouth after respiratory secretions have been expectorated. Research is promising on the use of chlorhexidine oral

Observe sputum, noting color, odor, and volume.

Suctioning of secretion per oral/ Endotracheal tube

Provide oral care every 4 hours.

Art Christian M. Ramos BSN 4 - 3

Diagnosis: Muscle Paresis, s/t Motor Neuro Disease, Spinal Cord Injury, Epidural Abcess July 10, 2013 Patient: X
rinses after oral care to reduce bacteria, and possibly reduce the incidence of nosocomial pneumonia Body movement helps mobilize secretions. The supine position and immobility have been shown to predispose postoperative clients to pneumonia Oxygen has been shown to correct hypoxemia, which can be caused by retained respiratory secretions. To treat or prevent bronchospasms and facilitate expectoration of mucus and airway clearance. Used to reduce colonization or prophylactic treatment for localized infection process.

Turn client from side to side at least every 2 hours.

Administer oxygen as ordered.

Administer Salbutamol + Ipratropium nebulizer

Q8Administer Meropenem 1gm IV Q8

Art Christian M. Ramos BSN 4 - 3

Diagnosis: Muscle Paresis, s/t Motor Neuro Disease, Spinal Cord Injury, Epidural Abcess July 10, 2013 Patient: X