EENT CASE

Diagnosis: Septic Shock, Pneumonia in pre

immunocompromised host, Oropharyngeal CA stage IV

Submitted to: Submitted to:

Mr. Neil Ganchero, RN, MN Mr. Paul John Jalover, RN
MN210 instructor Mrs. Michelle Lynn Lee, RN
Nursing Rationale Nursing Rationale Evaluation
Diagnosis Intervention
Ineffective airway Normally the lungs are 1. Placed in upright 1. An upright position Goal met.
clearance related to free from secretions. position ( if tolerated, provides for better
increased secretions Pneumonia bacteria are the head of the bed at lung expansion and After immediate
secondary to invading the lung 45 degree). Instruct improved air intervention, patient was
tracheostomy as evidence parenchyma thus, the patient to assist in exchange. Position able to breath normally
by excessive mucus producing inflammatory changing the position changes mobilize as manifested by
production and difficulty process. And these every 2 hours. secretions. decreased respiratory
of breathing. responses leading to rate from 30 breaths per
filling of the alveolar sacs 2. Instill 0.5cc PNSS into minute to 22 breaths per
2. This will help
with exudates leading to tracheostomy tube minute and patient O 2
stimulate coughing
Subjective: consolidation. The airway sat remained > 95%.
up of mucus and
is narrowed thus wheezes
add moisture to the
“ na budlayan c misis mag is being heard. Difficulty
mucucs
ginhawa ky kadamo sang of breathing in some
membranes.
iya plemas,” as verbalized cases.
by folk.
3. Suctioning is
3. Suctioned secretions
indicated when
as needed
patients are unable
Objective:
to remove
secretions from the
-RR: 30bpm
airway by coughing
-CR: 110bpm
because of
-O2 sat: 91%
weakness, thick
-BP: 170/90 mmhg
mucus plug, or
-restlessness
excessive or
-diaphoresis
tenacious mucus
-hypoxemia
production. It can
-hypoxia
also stimulate a
-pallor
cough.
-dyspnea
Nursing
Diagnosis
The patient will maintain
clear, open airways, as
evidenced by normal
breath sounds, normal
rate and depth of
respiration, and ability to
cough up secretions.
Rationale Nursing Rationale Evaluation
Intervention
4. Instruct the patient to 4. These measures
deep breathe improve lung capacity
adequately, to cough andgas exchange.
effectively. Coughing is the most
effective way to remove
most secretions.
5. Maintain humidified 5. Increasing the
oxygen as prescibed. humidity of inspired air
will reduce the viscosity
of secretions and
facilitate removal.
Nursing
Diagnosis
Impaired gas exchange Excess or deficit in
related to collection of oxygenation and carbon
mucus in airways as dioxide elimination at the
evidenced by difficulty in alveolar-capillary
breathing. membrane.
Objective:
-respiratory rate: 30bpm
-cardiac rate: 120bpm
-BP 170/90 mmhg
-O2 sat of 90%
-capillary refill of 2-3
seconds
-paleness of the skin
-irritability
-dyspnea
Client will maintain
optimal gas exchange as
evidenced by
arterial blood gasses
(ABGs) within the client’s
normal range, oxygen
saturation of 90% or
greater, alert response
mentation or no further
reduction in the level of
consciousness, and
relaxed breathing.
Rationale Nursing Rationale Evaluation
Intervention
1. Placed in upright 1. An upright position Goal met.
position ( if tolerated, provides for better
the head of the bed at lung expansion and After immediate nursing
45 degree). Instruct improved air intervention, the goal
the patient to assist in exchange. Position was met as evidenced by
changing the position changes moilize O2 sat of 95%, cardiac
every 2 hours. secretions. rate of 90bpm, BP of 130/
80 mmhg, absence of
2. Monitor vital signs 2. To obtain baseline dysnea.
including O2
saturation. 3. Bronchodilator +
mucolytics increases
3. Nebulized as ordered patient’s secretion.
(ipratropium salbutamol
+ ambroxol 1cc) 4. Suctioning is indicated
when patients are unable
4. Suctioned secretions as to remove secretions
needed from the airway by
coughing because of
weakness, thick mucus
plug, or excessive or
tenacious mucus
production. It can also
stimulate a cough.
5. Assess for changes in 5. Increased
the level of restlessness, confusion
consciousness. and/or irritability are
early indicators of
insufficient oxygenation
of the brain and require
further interventions.
Nursing Rationale Nursing Intervention Rationale
Diagnosis
6. Assess for changes in the
client’s HR and temperature.
7. Auscultate lung sounds,
noting any areas of decreased
ventilation or the presence of
adventitious sounds.
8. Monitor arterial blood
gasses and oxygen saturation.
Evaluation
6. Tachycardia is associated
with the increased work of
breathing or hypoxia. Fever
may develop in response to
retained secretions or
atelectasis.
7. Changes in lung sounds may
reveal the cause of impaired
gas exchange.
8. Pulse oximetry is a useful
tool to detect early changes in
oxygen saturation. Oxygen
saturation should be kept at
90% or greater. Increasing
PaCo2 and decreasing PaO2are
signs of hypoxemia and
respiratory acidosis.
Nursing
Diagnosis
Active infection related to
surgical incision of
tracheostomy as
evidenced by redness and
presence of purulent
discharges around the
stoma site.
Objective:
-Temperature 38.1
-Swelling at stoma site
-Redness at stoma site
-Skin warm to touch
Patients remains free of
infection, as evidenced by
normal body
temperature, normal
white blood cell count,
negative cultures, normal
vital signs.
Rationale
Infection is the invasion
of an organism’s body
tissues by disease-causing
agents, their
multiplication, and the
reaction of host tissues to
the infectious agents and
the toxins they produce.
Nursing Rationale Evaluation
Intervention
1. Institute airways 1. Accumulation of Goal met.
suctioning as needed. secretions provides a
medium for bacterial After 8 hours of nursing
growth. intervention, patient was
free from signs of
2. Provide tracheostomy 2. Good hygiene and infection as evidenced by
care prevention of temperature of 37.1 from
infection 38.1 and absence of
redness around the
3. Assess skin integrity 3. This is a common site stoma site.
under the tracheal for infection and skin
ties. breakdown.
4. Observe the stoma for 4. Observe the stoma for
erythema, color, erythema, color,
exudates, and exudates, and
crusting lesions. If crusting lesions. If
present, culture the present, culture the
stoma and notify the stoma and notify the
physician. physician.
5. Observe the patient’s 5. Increased amounts of
secretions for color, sputum and colored
consistency, quantity, or odorous secretions
and odor. may indicate
infection.
6. Monitor sputum
cultures and 6. Identification of the
sensitivities. infecting
microorganism is
important to
determine antibiotic
coverage.