De La Salle Health Sciences Institute

College of Nursing
Nursing Case Plan

ACUTE RESPIRATORY

FAILURE TYPE II, CAP HR

Submitted by:
Alexander B. Lee
Submitted to:
Dr. Rommel Salazar
 De La Salle Health Sciences Institute
College of Nursing
Nursing Case Plan

Patient Name: P.T.R Age: 74 y/o Sex: M CS: Married

Medical Diagnosis: Acute Respiratory Failure Type II, CAP HR
Attending Physician: Dr. Feliciano

I. Chief Complaint/ Other Complaints:

Ø Difficulty of Breathing

II. Nursing History

1 week prior to admission, the pt. experienced productive cough with yellowish
secretions and difficulty of breathing. He took his regular medications but the
symptoms persisted. Hours before the admission the client experienced worsening of
his difficulty of breathing resulting to his consultation to UMC Emergency
Department.

The pt. was diagnosed with COPD in 2002. He had no history of HTN, DM or renal
disease. He has no allergies in foods or medications and he is compliant in taking his
regular medications for COPD. The pt. is a known smoker and an alcohol drinker but
he stopped in 2007.

III. Pathophysiology

COPD/Severe Asthma
CNS Injury (SCI, CVA)
Myasthenia Gravis
Obesity Hypo-
Ventilatory Syndrome
Drug Overdose

Decreased inspiratory muscle

strength

Ineffective cough and disordered

swallowing, thoracic impairment
 Microatelectasis and decreased
pulmonary distensability
Physical
Exam
Pulse
Increased work in breathing
oximetry
ABG
Rapid breathing, Chest X-ray
Confusion, Inspiratory muscle fatigue
Difficulty of
Breathing, Anxiety,
restlessness, Alveolar hypoventilation
Profuse Sweating

Hypercapnia
Respiratory Acidosis

Acute Respiratory
Failure Type II

Legend:

Sequence of Events Signs of symptoms Laboratory/Diagnostics Risk Factors

 IV. Laboratory/Diagnostic Procedures
Procedure/Date Actual Normal Interpretation Nursing Implications
Finding Finding
Hematology Low hematocrit and Pre:
11-10-17 RBC count may -Explain procedure
indicate blood loss or to pt.
Hemoglobin 139 130 – 180 maybe caused by -Encourage to avoid
Hematocrit 0.39 L 0.40 – 0.50 conditions like chronic stress if possible
WBC Count 12.4 H 4.0 – 10.0 kidney disease, anemia. -Explain that slight
RBC Count 4.3 L 4.5 – 6.2 High WBC, Segmenters pain may be felt
DIFFERENTIAL count may indicate an when skin is
COUNT infection, a disease in punctured
Segmenters 0.87 H 0.55 – 0.65 the bone marrow or an Intra:
Lymphocytes 0.0.8 L 0.25 – 0.35 immune system -Instruct pt. to
Eosinophils 0.01 L 0.02 – 0.04 disorder cooperate
Basophils 0.00 0.00 – 0.01 Low Lymphocyte and -Observe standard
Monocytes 0.04 0.03 – 0.06 Eosinophils count are precautions
Platelet count 176 150 – 400 usually not significant -Identify pt. and
INDICES label the specimen
MCV 90 80 – 96 with the client’s
MCH 30.3 27 – 31 name
MCHC 337 320 – 360 Post:
RDW 14.1 11 -17 -Transport specimen
to the lab.
-Monitor puncture
site for hematoma
formation
-Record &
Document

V. Medications and Treatment

BN/GN Indication/ S/E and A/R Nursing Responsibilities
Dosage/Frequency/ Contraindication
Route
Fluimucil Indication: Tx of Bronchospasm >Monitor effectiveness of
600 mg/OD/PO respiratory affections Angioedema therapy and adverse/allergic
characterized by thick Rashes effects
and viscous Pruritus >Instruct the patient about
hypersecretions Nausea and the appropriate use and
Contraindication: Vomiting adverse effects to report
Severe HTN, CAD and Fever
hypersensitivity to the Sweating
drug
Coralan - Indication: Used to Atrial Fibrillation, >Advise patient to avoid
Ivabradine decrease heart rate Bradycardia, HTN, taking grapefruit juice during
25 mg/BID/PO Contraindication: Sinus Arrest therapy; may increase risk of
Acute decompensated side effects.
HF, BP <90/50 mmHg,
Heart rate <60 bm, >May be teratogenic. Advise
severe hepatic female patient to use
impairment effective contraception
during therapy and to notify
health care professional if
pregnancy is planned or
suspected or if breast
feeding.

Trimetazidine Indication: For tx of Dizziness, >May cause dizziness and

35 mg/BID/PO Angina Pectoris headache, drowsiness, if affected, do
Contraindications: abdominal pain, not drive or operate
Patients with dyspepsia, machinery.
Parkinson’s Disease, diarrhoea, nausea,
tremors and severe vomiting, pruritus, >May be teratogenic. Advise
renal impairment rash, urticaria, female patient to use
asthenia. Rarely, effective contraception
tachycardia, during therapy and to notify
palpitations, health care professional if
extrasystoles, pregnancy is planned or
orthostatic suspected or if breast
hypotension, feeding.
arterial
hypotension,
flushing.

Atorvastatin- Indication: Reduction Headache, >Tell patient to take drug at

Lipitor of risk of stroke and Flaatulence, the same time each day to
40mg/ODHS/PO heart attack in type II Diarrhea, Nausea maintain its effects
Diabetes, CAD, reduce and Vomiting, >Instruct patient to takea
risks of MI Anorexaia, missed dose as soon as
Contraindications: Angioedema, Chest possible. >Advise patient to
Hypersensitivity, active pain, Allergy notify physician immediately
liver disease, if he develops unexplained
pregnancy, lactation muscle pain, tenderness or
weakness.
Azithromycin- Indication: Treatment Mild to moderate >Culture site of infection
Zithromax of lower respiratory nausea, vomiting, before therapy.
500mg/OD/PO infections: Acute abdominal pain, >Administer on an empty
bacterial exacerbations dyspepsia, stomach 1 hr before or 2–3 hr
of COPD, community- flatulence, diarrhea, after meals. Food affects the
acquired pneumonia. cramping; absorption of this drug.
Contraindications: angioedema, >Take the full course
Hypersensitivity, use cholestatic prescribed. Do not take with
cautiously with jaundice; dizziness, antacids. Tablets and oral
gonorrhea or syphilis, headache, vertigo, suspension can be taken with
hepatic or renal somnolence; or without food.
impairment transient elevations
of liver enzyme
values.

Procedure/Date Indication Nursing Responsibilities

Intravenous Insertion >For hydration and prevent Pre:
(10-9-17) electrolyte imbalance >Verify doctor’s order
>Explain procedure to pt.
Intra:
>Observe standard precautions
>Regulate drops/min
Post:
>Monitor intake and output
>WOF bleeding/infection
>Check for backflow
>Record & Document
Nasogastric Tube Insertion >provides access to the stomach Pre:
(10-10-17) for diagnostic and therapeutic >Verify doctor’s order
purposes >Explain procedure to pt.
Intra:
>Position the pt. sitting up and well
supported
>Measure distance to which the
tube is to be passed.
>Lubricate the tube and insert to
the patent nostril.
>Secure the tube.
Post:
>Confirm the position of tube
>Record & Document
Endotracheal Tube Insertion >For patients who is unable to Pre:
(10-9-17) maintain airway patency and >Attach patient to a pulse oximeter
fails to ventilate or oxygenate for monitoring.
 >Prepare the laryngoscope and
blades.
Intra:
>Position pt.
>Assist physician during insertion
> Fix tube in place partially using a
tape, to ensure that the tube is
steady
Post:
>Check the pulse oximeter
>Attach pt. to mech. Vent.
>Record & Document

VI. Nursing Priorities

Priority Problem Date Resolved
1 Impaired Gas Exchange 10-13-17
2 Risk for Infection 10-13-17

VII. Discharge Plans

Content Strategy
Medication Compliance >Instruct client to take
medications with or after meals
>Advise the client to avoid
skipping dose and continue
taking the drugs prescribed
Exercise Improve ambulation w/ >Encourage to increase
assistance frequency of exercise
>Advise the client to ambulate
slowly and carefully as soon as
she can
Treatment Follow doctor’s order >Advise client to continue the
treatment regimen that is
prescribed by his doctor
Hygiene Proper Self-Care >Give health teaching on proper
hygiene and its benefits
Out-Patient Check up Follow-up Check-up should be >Encourage to have a follow up
attended checkup to maintain health and
prevent complications
Diet High Protein and vitamin Diet >Encourage the client to eat
health foods rich in protein and
vitamins
>Provided health teaching about
the importance of protein and
vitamins to the body
 Nursing Care Plan
Cues Diagnosis Long Term Short Term Intervention Rationale Evaluation
>received Impaired After 2 Within the >Assess and record >Useful in >Goal met
client Gas weeks, the shift, the pt. respiratory rate, evaluating the
awake, Exchange pt. will will be able depth. Note use of degree of
conscious r/t altered demonstrate to accessory muscles, respiratory
and oxygen improved participate pursed-lip distress or
coherent supply s/t ventilation in treatment breathing, inability chronicity of the
with NGT acute and regimen to speak or disease process.
inserted respiratory adequate within his converse.
through his failure oxygenation level of
left nostril, of tissues ability. >Elevate head of >Oxygen delivery
ET tube evidenced bed, assist patient to may be improved
connected by normal assume position to by upright
to range of ease work of position
mechanical ABGs and breathing. Include and breathing
ventilator, the pt. periods of time exercises to
IV Fluid would be in prone position as decrease airway
infused free from tolerated. Encourage collapse,
through his symptoms deep-slow or dyspnea, and
left of pursed-lip breathing work of
metacarpal respiratory as individually breathing.
vein and distress. needed or tolerated.
IFC.
Objective: >Evaluate level of >During severe,
(+) activity tolerance. acute or
Presence of Provide calm, quiet refractory
yellowish environment. Limit respiratory
to whitish patient’s activity or distress, patient
secretions encourage bed or may be totally
during chair rest during unable to perform
suctioning acute phase. basic self-care
activities because
of hypoxemia and
dyspnea. Rest
interspersed with
care activities
remains an
important part of
treatment
regimen
Cues Diagnosis Long Term Short Term Intervention Rationale Evaluation
>received client Risk for infection After a Within the >Practiced >to avoid >Goal met
awake, r/t site of week, the shift, the pt. standard and transmission or
conscious and organism client will will be able contact spread of
coherent with invasion s/t be free to precaution pathogens to
NGT inserted presence of from any determine when handling patient
through his left invasive lines infection. the the pt.
nostril, ET tube different
connected to ways on >Advised >reduce the
mechanical how relatives to transmission of
ventilator, IV infections minimize pathogens
Fluid infused are visitation and
through his left transmitted also taught
metacarpal vein them some
and IFC. precautions
when
attending their
relative.

>Provided >to give the pt.

health and his relatives
education to awareness and
the client and prevent
his relative infection
about the
transmission
of infection