Foundation Concepts care nurses maintain

1. Foundation Concepts professional competence based

A. Definition of terms on a broad base of knowledge
B. Scope of Critical Care Practice and experience through
C. Advocacy: Access to Social Care Services continuous education and
D. Critical Care Body of Knowledge evidence-based research.
2. Nursing Process in the Critical Care Unit • With advances in sophisticated
A. Assessment biomedical technology and knowledge,
B. Analysis/ Nursing Diagnosis critical care nurses are able to
C. Planning continuously monitor and observe
D. Implementation of Care of Clients patients for physiological changes to
E. Client Education confront problems proactively and to
F. Evaluation of the Outcome of Care assist patients to achieve and maintain
G. Reporting and Documentation of Care an optimum level of functioning or a
peaceful death.
1. Definition of terms III. Acutely ill patients
I. Critical Care Unit • patients who developed a disease/
• a place in the hospital where illness with an abrupt onset and,
the most seriously ill patients usually, a short course.
are cared for by specially IV. Critically ill patients
trained staff • it has the highest • patients who are at high risk for actual
density of healthcare providers or potential life-threatening health
per square foot in the hospital. problems
• It is also defined by high • Those who are more critically ill require
technology and complex care. more intensive and vigilant nursing
• ICU patients are the sickest care.
patients. They are those with V. Hemodynamic Monitoring
the most severe disease of one • a mainstay in the care of critically ill
or more organ-systems. patients
• Patients who require any of the • involves using invasive and non-invasive
following are best cared for in methods to provide information about
an ICU setting: pump effectiveness, vascular capacity,
• frequent monitoring; blood volume and tissue perfusion
• special monitoring devices; • The precise data obtained from
• special medications and hemodynamic monitoring helps to
technology to support and identify the type and severity of shock
sustain normal bodily functions. (cardiogenic, hypovolemic, distributive,
II. Critical Care Nurse or obstructive).
• In collaboration with other • When paired with clinical evaluation,
health care team members, hemodynamic monitoring is helpful in
critical care nurses provide high guiding the administration of fluids, in
level of patient care which selecting and titrating vasoactive drugs,
includes patient and family and in deciding when mechanical
education, health promotion support might be necessary to treat
and rehabilitation. refractory shock.
• At the forefront of critical care • It allows for evaluation of the
science and technology, critical effectiveness of treatment in real time.
VI. Invasive Management care to an equally qualified critical care
VII. Polypharmacy Management nurse.
• regular use of at least five medications • Intercede for patients who cannot speak
common in older adults and younger at- for themselves in situations that require
risk populations and increases the risk immediate attention.
of adverse medical outcomes. • Monitor and safeguard the quality of care
that the patient receives.
B. Scope of Critical Care Practice • Act as a liaison between the patient and
1. Development of Critical Care Nursing the patient’s family and other health care
Practice, Education and Professional professionals.
Activities in the Philippines b. Expanded-Role Nursing Position
• The scope is defined by the dynamic • interacts with critical care patients,
interaction of the: families, and the health care team.
• Nurse case managers work closely with
Critical Care Environment the care providers to ensure appropriate,
timely care and services and to promote
Critical Care Nurse continuity of care from one setting to
Critically Ill Patient another.
• Other nurse clinicians, such as patient
• Constant intensive assessment, timely educators, cardiac rehabilitation specialists,
critical care interventions and physician office nurses, and infection
continuous evaluation of management control specialists, also contribute to the
through multidisciplinary efforts are care.
required to restore stability, prevent • The specific types of expanded-role
complications and achieve optimal nursing positions are determined by
health. patient needs and individual organizational
• Palliative care should be instituted to resources.
alleviate pain and sufferings of the III. ICU Nurse as a Patient’s Advocate
patient and family in situations where • Acts in the best interest of the patient.
death is imminent. • Monitors and safeguards the quality of
II. Critical Care Nursing Roles care which the patient receives.
a. Critical Care Nurse Role Responsibilities a. End of Life Care
• Respect and support the right of the • The primary purpose of admission of
patient or patient’s designated surrogate to patients to a critical care unit is to
autonomy and informed decision making. provide aggressive, life-saving
• Intervene when the best interest of the treatment. The death of a patient is
patient is in question. generally regarded as a failure.
• Help the patient obtain necessary care. • Because the culture emphasizes
• Respect the values, beliefs, and rights of saving lives, the language that describes
the patient. the end of life employs negative terms,
• Provide education and support help to such as “forgoing life-sustaining
the patient or patient’s designated treatments,” “do not resuscitate
surrogate to make decisions. (DNR),” and “withdrawal of life
• Represent the patient in accordance with support.”
the patient’s choices. • Sometimes the phrase withdrawal of
• Support the decisions of the patient or care is used, which can cause families to
patient’s designated surrogate or transfer think there will be no comfort measures
or assistance provided after a decision
 is made to discontinue mechanical d. ADVANCE CARE PLANNING
ventilation and other life-sustaining • Planning for decisions to be made at a
treatments. later date if one is deemed incompetent
• In reality, treatment options are is a difficult process, but this knowledge
usually explained in rapid technical helps the family members left to make
language, followed by a frightening the treatment decisions.
question, “Do you want us to keep • Communication of the patient’s
going?” or “Tell us what you want us to wishes between primary care providers
do.” and intensivists is critical. If patients
• This heavy burden placed on loved have stated desires, they should be
ones means they must choose between communicated when patients are
treatment options, one of which may transferred out of the critical care unit.
result in loss of their loved one. If the patient has not specified his or
• Critical care nurses are often the i ers her preferences, that information also is
of medical information and how it important and should be
applies to personal preferences and communicated to new health care
values. providers; the level of care patients
• The ability to respond realistically in desire should be offered as appropriate.
accordance with the listener’s values • Families and care providers should be
and culture is a learned skill. informed if patients decline aggressive
• Fortunately, many resources are care, so their families will not be left
available to further develop the with difficult decisions in emergency
necessary skills to better support situations.
patients and families through a critical V. Palliative Care for Critically ill
care unit admission to discharge. • Patients who are identified as being
b. ADVANCE DIRECTIVES near the end of life require aggressive
• A.k.a. a living will, or a health care care for their symptom management,
power of attorney intended to ensure provided by a team of health
that patients received the care they professionals.
desired at end of life, their enactment • The most relevant clinical goal is to
has been less than desired palliate these unpleasant situations by
c. PHYSICIAN ORDERS FOR LIFE assessing for them and implementing
SUSTAINING TREATMENT (POLST) appropriate interventions.
• POLST forms are medical orders that a. PAIN MANAGEMENT
are honored across all treatment • many critical care patients are not
settings and are especially important to conscious; assessment of pain and
emergency responders in the other symptoms becomes more
community difficult.
• completed by the patient and • Gélinas and colleagues
physician in the presence of a serious recommended using signs of body
chronic illness and should be movements, neuromuscular signs,
incorporated into medical orders upon facial expressions, or responses to
admission to the hospital or skilled physical examination for pain
nursing facility. assessment in patients with altered
• POLST forms are more easily read consciousness.
than an advance directive in that the • Nonopioid medications - first-line
format is one of check boxes with approach
specific directions.
 • followed by adding an opioid for • dyspnea, nausea and vomiting, edema and
additional analgesia when relief is pulmonary edema, anxiety and delirium,
not obtained. Because opioids metabolic derangements, skin integrity, and
provide sedation, anxiolysis, and anemia and hemorrhage.
analgesia, they are particularly c. DYSPNEA
beneficial in the ventilated patient. • best managed with close evaluation of the
• Morphine - medication of choice, patient and the use of opioids, sedatives, and
and there is no upper limit in nonpharmacologic interventions (oxygen,
dosing. positioning, and increased ambient air flow).
• In nonventilated patients - • Morphine - reduces anxiety and muscle
sedation may cause respiratory tension and increases pulmonary vasodilatation
depression, and nonopioids or but is not effective when inhaled.
specific anesthetic agents may be • Benzodiazepines - may be used in patients
more appropriate. who are not able to take opioids or for whom
• In the sedated ventilated patient, the respiratory effects are minimal.
especially those receiving • Benzodiazepines and opioids - should be
neuromuscular blocking titrated to effect.
medications, there is no systematic, • Treatment efforts should be aimed at the
reliable method to determine patient’s expression of dyspnea rather than at
presence or degree of pain. respiratory rates or oxygen levels.
• The absence of the usual clinical d. NAUSEA AND VOMITING
indicators of pain, such as grimacing • common and should be treated with
or guarding, makes it a challenge to antiemetics.
determine whether pain is present. • The cause of nausea and vomiting may be
• Titration of intravenous infusions intestinal obstruction.
to achieve maximum effect with • Treatment for decompression may be
minimum sedation is an inexact uncomfortable in dying patients, and its use
science. should be weighed using a benefit-to-burden
• Sedation/ agitation scales are one ratio.
method of monitoring the e. FEVER AND INFECTION
effectiveness of medications but • necessitate assessment of the benefits of
are not performed continuously continuing antibiotics so as not to prolong the
with frequent titration, such as dying process.
during surgery. • Management of the fever with antipyretics
• Potential pain sources include may be appropriate for the patient’s comfort,
prone position, endotracheal tube, but other methods such as ice or hypothermia
wounds, and immobility, and blankets should be balanced against the
should necessitate preventive amount of distress the patient may experience.
analgesia administration. f. EDEMA
• Critical care nurses should assume • may cause discomfort, and diuretics may be
pain is present in the immobile effective if kidney function is intact.
patient and administer routine • Dialysis is not warranted at the end of life.
analgesics to prevent suffering. • The use of fluids may contribute to the edema
b. SYMPTOM MANAGEMENT when kidney function is impaired, and the body
• Campbell, in her book chapter titled “Usual is slowing its functions.
Care Requirements for the Patient Who Is Near g. ANXIETY
Death,” listed the following symptoms as • should be assessed verbally, if possible, or by
necessary parts of the assessment: changes in vital signs or restlessness.
• Benzodiazepines, especially midazolam with • Two hospice nurses have described a
its rapid onset and short half-life, are frequently phenomenon of near-death awareness.
used. • The same behaviors may be seen in conscious
• Minimizing noxious sounds and playing a critical care patients near death.
patient’s favorite music may help to soothe • Having an awareness of the phenomenon
anxiety. enables more careful assessment of behaviors
h. DELIRIUM that may be interpreted as delirium, acid-base
• commonly observed in the critically ill and in imbalance, or other metabolic derangements.
those approaching death. • These behaviors include communicating with
• Haloperidol is recommended as useful, and someone who is not alive, preparing for travel,
restraints should be avoided. describing a place they can see, or even
• In a review of the available literature, Kehl knowing when death will occur.
concluded that despite the recommendations of • Family members may find these behaviors
most study authors to use neuroleptic disturbing but find comfort in understanding
medications as a treatment for restlessness, the phenomenon and in sharing these
several studies demonstrated the effectiveness experiences with their loved one.
of other medications, such as benzodiazepines VIII. FAMILY MEETINGS
(notably midazolam and lorazepam) or • Although family meetings should be held
phenothiazines, alone or in combination. within 72 hours of an admission, they are
V. METABOLIC DERANGEMENT frequently held to formulate a decision to
• Treatments for metabolic derangements, skin withdraw life support.
problems, anemia, and hemorrhage should be • Lilly and colleagues found that an earlier
tempered with concerns for the patient’s meeting led to shorter critical care unit stays for
comfort. patients who eventually died and allowed them
• Only interventions promoting comfort should earlier access to palliative care.
be performed. • These results held up in a 4-year evaluation of
• Patients do not necessarily feel better “when this intervention, and they found that they were
the laboratory values are right.” providing advanced life support to patients with
VI. PROVIDING COMFORT the potential to survive and an earlier
• The nursing interventions at end of life should withdrawal when ineffective.
focus on the provision of comfort care as an
active, desirable, and important service. C. Advocacy: Access to Social Care Services
• Unnecessary checks of vital signs, laboratory • Philippine Health Insurance Corporation (PHIC)
work, and any treatment that does not promote • Department of Health (DOH)
comfort should be avoided. • Department of Social Welfare and
• Positioning the patient who is actively dying Development (DSWD)
has as its purpose only comfort, not the • Philippine Amusement and Gaming
schedule to promote skin integrity. Corporation (PAGCOR)
• Coordinating this care with the many • Philippine Sweepstakes Charity Office (PCSO)
members of the critical care team is important • Philippine Health Insurance Corporation (PHIC)
to ensure consistency across disciplines and • Department of Health (DOH)
across shifts. • Department of Social Welfare and
• When symptom management is not Development (DSWD)
successful in ensuring comfort, the services of • Programs:
the pain team or the palliative care service may a. Assistance to Individuals in Crisis
be required. Situation (AICS)
VII. NEAR-DEATH AWARENESS • AICS is part of the DSWD’s protective
services for the poor, marginalized and
 vulnerable/ disadvantaged individuals. assistance to individuals/ beneficiaries
• medical assistance: assistance to help amounting to P20.37 million and
shoulder hospitalization expenses, financial grants to Local Government
purchase of medicines, and other Units, Non-government organizations,
treatment and other medical expenses. and other government agencies and
cases with chronic illnesses may be individual beneficiaries amounting to
provided with PhilHealth insurance P30.45 million.
coverage, in coordination with the DOH. • Philippine Sweepstakes Charity Office (PCSO)
they will no longer be entitled to in- • It is the program for the provision of
patient financial assistance, except by assistance to male and female
the philhealth. individuals with health-related
b. Lingap at Gabay Para sa may sakit/ problems seeking financial help, which
Lingap sa Masa: is embedded on the premise of
• envisioned as the program that will augmenting their funds, in partnership
implement the president’s directive to with government and private hospitals,
provide free medicines, prosthetics, health facilities, medicine retailers and
medical and assistive devices, medical other partners.
supplies, medical implants, laboratory/ • Requests Covered:
diagnostic/ radiology procedure, • Confinement
chemotherapy and dialysis, medical • Chemotherapy
assistance to indigents and to needy • Dialysis (Hemo/ PD/
government workers. the amount of 1 Erythropoietin)
Billion Pesos has been committed to the • Medicines (Hemophilia and Post-
program to be sources from the transplant)
president’s socio-civic projects fund of
the president. D. Critical Care Body of Knowledge
• Philippine Amusement and Gaming a. Critical Care Competencies
Corporation (PAGCOR) • The competence of critical care nurses
• PAGCOR supports the promotion of together with established nursing standards
key health-related programs of the and the identified core competencies for
government by providing financial registered nurses will result to excellence in
assistance to state-run hospitals. critical care nursing practice.
• Apart from that, PAGCOR also • This three-pronged holistic framework
donated P350 million funding to ensures quality performance through an
Southern Philippines Medical Center adherence to nursing standards, the application
(SPMC) for the procurement of Linear of competencies, and the integration of
Accelerator Machine, an apparatus appropriate nursing model/s into the care
used for cancer treatment, aside from delivery process.
chemotherapy. SPMC also received • To achieve safe and quality client-centered
P184 million from PAGCOR in 2018, for care, nurses working in the critical care units
the purchase of medical equipment that are envisioned to adopt not only the stated core
will cater to women and newborn’s competencies of registered nurses but also the
sensitive health conditions. specific competencies stipulated in the
• Aside from helping state-run following eleven major key responsibility areas:
hospitals, PAGCOR continues to help • Safe and Quality Nursing Care (CCNAPI page
less-privileged citizens through 10)
providing financial support. In 2020, the I. Management of Resources
agency granted financial medical II. Legal Responsibilities
 I. Fulfilling legal responsibilities iii. Evaluating own nursing
and acting as patient advocate. practice and knowledge to
Description: The critical care enhance personal skills.
nurse functions in accordance The critical care burse
with common law, ordinance assesses self-awareness of
and regulations influencing his/her own professional
nursing practice. competence continuously
III. Ethico-Moral Responsibilities and independently;
I. Practicing ethico-moral maintains up-to-date
standards of the nursing nursing knowledge to keep
profession. abreast of nursing trends
Description: The critical care and nursing standards in
nurse demonstrates the specialty practice.
appropriate application of VI. Communication
knowledge in nursing practice, i. Communicates with
which complies with the code individual patient and/or
with professional conduct, groups with other
principles of autonomy, members of the health
beneficence and justice. She/He care team. The critical care
also accepts personal nurse takes initiative to
responsibility for one’s own communicate with the
professional judgement and individual and/or groups
actions as well as consequence and with other members of
of one’s behavior. the health team to facilitate
IV. Collaboration and Teamwork care and management of
V. Personal and Professional the patients.
Development VII. Health Education
i. Facilitating the i. Provides appropriate
development of nursing health education based on
knowledge in clinical comprehensive learning
setting. The critical care needs of the patient and
nurse takes initiative to family. Description. The
support or conduct critical care nurse makes
activities, which promote thorough assessment of the
the advancement of nursing learning needs of the
knowledge. patient and family for the
ii. Promoting the professional provision of health
image of ICU nurse. The education to assist the
critical care nurse acts in patient and family towards
manner that maintains a productive life.
active ongoing involvement VIII. Quality Improvement
in activities related to the i. Proactive in the
nursing profession such as implementation of the
ICU conference, workshop changes as a consequence
and course; and promotes of the quality
the professional image of improvement initiatives.
nursing.
 Description: The critical care nurse address the patient’s identified learning
demonstrates positive attitudes needs.
towards a change for improvement. • The assessment is an important first step
IX. Research to providing need-targeted patient and
i. Supports a positive climate family education.
for research within the • It begins on admission and continues until
practice. The critical care the patient is discharged.
nurse maintains currency of • A formal, comprehensive, initial education
knowledge and practice assessment produces valuable information;
based on relevant research however, it can take the nurse hours to
findings. complete.
X. Record Management • The nurse must focus the initial and
i. Ensures that written subsequent education assessments on
information conforms to identifying gaps in knowledge related to the
legal and ethical patient’s current health-altering situation.
framework. The critical • Learning needs can be defined as gaps
care nurse maintains between what the learner knows and what
accurate and updated the learner needs to know, such as survival
documentation for the care skills, coping skills, and ability to make a
the critically ill patients. care decision.
b. Professional Organizations • Identification of actual and perceived
• In the Philippines, the Professional learning needs directs the health care team
Regulation Commission – Board of Nursing to provide need-targeted education.
(PRC-BON) is committed to provide need- • Need targeted or need-to-know education
driven, effective and efficient specialty is directed at helping the learner to become
nursing care services of high standard and familiar with the current situation.
at international level within the obtainable • Educational needs of the patient and
resources. family can be categorized as:
• To respond to this mission and ➢ information only (environment,
commitment, a PRC-BON Working Group in visitation hours, get questions
Developing the Nursing Specialty answered);
Framework was formed sometime in 1996 ➢ informed decision making (treatment
to take on the task of setting the process- plan, informed consent); or
based framework and guidelines for ➢ self-management (recognition of
specialty nursing services. problems and how to respond)
• Working Group members comprise clinical • Patient education to be included in the
nurse practitioners, nurse educators and education plan should address the plan of
nurse managers. care, health practices and safety, safe and
effective use of medications, nutrition
interventions, safe and effective use of
medical equipment or supplies, pain, and
habilitation or rehabilitation needs.
2. Nursing Process in the Critical Care Unit • Learning needs may change from day to
Assessment day, shift to shift, or minute to minute.
• According to The Joint Commission, Educational needs are influenced by how
education provided should be appropriate the patient, or the family perceives or
to the patient’s condition and should interprets the critical illness.
• Perceptions of experiences vary from gaps rather than assume knowledge by
person to person, even if two people are obtaining a yes-or-no response.
involved in the same event. • These types of questions also assist the
• This intense internal feeling affects the patient and family to tell their story of the
desire to learn and understanding of the illness and communicate their perceptions
current situation. Satisfaction with the of the experience, allowing the adult
learning encounter is often judged to be learner to feel respected and involved in
positive if the nurse meets the expected the treatment process.
learning needs of the patient and family. • Questions that elicit a yes-or-no response
• Congruency between nurse-identified close off communication and do not provide
needs and patient-identified needs brings an interactive teaching learning session.
about more positive learning experiences • Generally, with practice and effort, it can
and encourages the learner to seek further be determined what educational
information. The nurse must actively listen, information is needed in a brief period
maintain eye contact, seek clarification, and without much disruption in the routine care
pay attention to verbal and nonverbal cues of the patient.
from the patient and the family to gather • Patients and families are
relevant information concerning perceived multidimensional. Even with good
learning needs. The nurse should seek to questioning skills, the nurse cannot assess
first understand the learning need from the many aspects of the learner during the
patient’s point of view and then seek to be initial contact or even during the hospital
understood. stay.
• Strategic questioning provides an avenue a. Subjective Data
for the nurse to determine whether the • Information that is provided verbally
patient or family has any misconceptions by the patient is called subjective data.
about the environment, their illness, self- Symptoms are subjective data.
management skills, or the medication Subjective data are often placed in
schedule. quotes, such as “I have a headache” or
• Health care providers use the term “I feel out of breath.” You must listen
noncompliant to describe a patient or carefully to the patient and understand
family members who do not modify that only the patient truly knows how
behaviors to the meet the demands of the he or she feels.
prescribed treatment regimen, such as • When collecting subjective data,
following the rules of a low-fat diet or begin with the patient’s main concern.
medication dosing. However, the problem Focus on the reason the patient is
behind noncompliance may not be a seeking health care. The question,
conscious desire to defy the treatment plan “What happened that made you decide
but instead be a misunderstanding of the to come to the hospital (clinic, office)?”
importance of the medication or how to can be helpful.
take the medication. • Once the patient has identified the
• The technique of asking open-ended main concern, further questioning can
questions (“Can you tell me what you know elicit more pertinent information. Use
about your medication?”) can elicit more the letters of the “WHAT’S UP?”
information about the patient’s knowledge questioning format to remember
base than asking closed-ended questions questions to ask the patient (Box 1.1
(“You know this is your water pill, right?”). What’s Up? Guide to Symptom
Open-ended questions provide the nurse an Assessment). Asking the right questions
opportunity to assess actual knowledge
 can help you obtain better data with • Completing a physical examination and
which to make the best decisions. reviewing current patient data
• Next, obtain a patient history. This is • Subjective data
done by asking the patient and family • Objective data
questions about the patient’s past and Diagnosis
present health problems, including • The issue on which the nursing care
specific questions about each body plan is based. The nursing diagnosis is
system, family health problems, and the clinical judgement regarding the
risk factors for health problems. The patient’s response to actual or possible
patient’s medical record may also be medical problems. It is based on the
consulted for background history assessment.
information. Planning and Outcomes
• In addition to assessment related to Are detailed in the nursing care plan by:
physiological functioning, ask the • Assigning priorities, if the patient has
patient about personal habits that multiple musing diagnoses
relate to health, such as exercise, diet, • Setting short-and-long-term goals that
and the presence of stressors, per are patient oriented and measurable
institutional assessment guidelines. • Including assessment and diagnosis
Finally, assess the patient’s family role, details
support systems, and cultural and • Stating appropriate nursing
spiritual beliefs. interventions and corresponding
b. Objective Data medical orders
• Objective data are pieces of factual • Utilizing a standardized or
information obtained through physical computerized care plan or clinical
assessment and diagnostic tests and are pathway as a guideline, if appropriate
observable or knowable through the Implementation
five senses. Objective data are
• The performance of nursing care
sometimes called signs.
according to the care plan by
• Note that these are all observable or
• Documenting the care provided to the
measurable by a nurse and do not
patient properly
require explanation by the patient.
• Performing treatment in a way that
• Objective data are gathered through
minimizes complications and life-
physical assessment. Inspection,
threatening issues
palpation, percussion, and auscultation
• Involving patients, families, caregivers,
techniques are used to collect objective
and the other members of the
data (Fig. 1.2). Give special attention to
healthcare team as their abilities and
areas that the patient has identified as
patient safety allow
potential problems.
Evaluation
c. Physical Assessment
d. Diagnostic Studies/ Procedures • The process of evaluating the status of
the patient and the effectiveness of the
ADD ONS: treatment. The plan of care may be
Assessment modified if warranted
Documentation
• Interviewing the patient and/or family
members • A nurse must remember of the nursing
process, liability, safety and patient care
• Reviewing medical past history and
when documenting. It is always
records
 necessary to “save” or store, the the teaching-learning encounter, interventions
information after inputting in properly to meet that outcome, and appropriate
• A critical care nurse must be aware that teaching strategies
despite all the technology employed in • Research and accepted national guidelines or
the ICU, the rule, “if it was not standards can be used to assist the practitioner
documented, it was not done” still in developing an evidence-based plan for
holds true education.
Analysis/ Nursing Diagnosis • Examples of organizations that offer
• Once data have been collected, the LPN/LVN education standards are the American
assists the RN to compare the findings with Association of Critical Care Nurses,
what is considered “normal.” American Heart Association Guidelines
• Data are then grouped, or clustered, into sets for Practice, and the Society of Critical
of related information that identify problems. Care Medicine.
• According to the North American Nursing • It can be used in daily practice and can
Diagnosis Association (NANDA), a nursing be found in two books: Nursing
diagnosis is a clinical judgment about individual, Interventions Classification (NIC) and
family, or community response to actual or Nursing Outcomes Classification (NOC).
potential health problems or life processes. These evidence-based interventions
• Nursing diagnoses are standardized labels that and outcomes assist the nurse in
make an identified problem understandable to providing consistent outcomes and
all nurses. Nursing diagnoses are the foundation interventions from nurse to nurse, shift
used to select interventions to achieve a to shift, and discipline to discipline.
desired outcome. a. Planning for health Promotion
• A list of NANDA-approved nursing diagnoses b. Planning for health restoration and
can be found in Appendix A of this book. maintenance
• Nursing actions are either independent or
collaborative. Independent nursing actions can Implementation of Care of Clients
be initiated by the nurse a. Independent Nursing Care
Planning • Physiologic Care
• Education must be ongoing, interactive, and • Psychosocial Care
consistent with the patient’s plan of care and • Spiritual Care
education level. b. Interdependent Care
• The nurse must analyze information gathered • Pharmacological Therapeutics
from the assessment to prioritize the • Complementary and Alternative
educational needs of the patient and family. Therapies
• The nursing diagnosis for deficient knowledge • Nutritional and Diet Therapy
and accompanying interventions can be applied • Surgical Interventions
to any situation. • Immunologic Therapy
• The nurse must also consider the patient’s
physical and emotional status when setting Client Education
education priorities. Ability, willingness, and • Patient education is a process that includes
readiness to learn are factors that impair the purposeful delivery of health-related
acceptance of new information and add to the information to promote changes in behavior
complexity of teaching-learning encounter. that will optimize health practices and assist the
• These factors should be recognized by the individual in attaining new skills for living.
nurse before implementation of teaching. • The bedside nurse must incorporate the
• The written teaching plan should identify the abundant educational needs of the patient or
learning need, goals or expected outcome of family into the education plan and be aware of
the requirements of regulatory agencies and interaction, including the level of learner
the legalities of documenting the teaching interest in the session, willingness to learn the
learning encounter. content, and level of participation during the
• Studies have documented that quality encounter.
education shortens hospital length of stay, • Evaluation should be completed at the end of
reduces readmission rates, and improves self- each teaching-learning encounter.
care management skills. Complications • This allows the nurse to immediately present
associated with the physiologic stress response positive and constructive feedback to the
may be prevented if the patient or family patient and family, as well as revise the
perceives the education encounter as positive. education plan to accommodate ongoing
Positive encounters decrease the stress learning needs.
response, relieve anxiety, promote individual • It is also important to assess the response to
growth and development, and increase patient teaching and determine whether follow-up
and family satisfaction. education is required.
• The following are examples of positive • Techniques such as verbalization of
outcomes associated with a structured information, return demonstration, and
teaching-learning process. physiologic measurement are common
• Clarification of patients’ understanding evaluation methods to determine the
and perceptions of their chronic illness effectiveness of a teaching-learning encounter
and care decisions • Evaluation of knowledge retention can be
• Improved health outcomes relative to completed by verbally questioning the learner.
self-management techniques, such as This method is known as teach-back. Teach-
symptom management back is an interactive process that assists the
• Promotion of informed decision making nurse in determining whether the learner has
and control over the situation retained the information taught. The nurse may
• Diminished emotional stress associated ask the patient if he or she is able to list signs
with an unfamiliar environment and and symptoms of heart failure. Verbal
unknown prognosis questioning should occur immediately after the
• Improved adaptation to stressful teaching event and throughout the
situations hospitalization to assess knowledge retention.
• Improved satisfaction with the care For example, the physician orders a new
received medication for the patient today, and the nurse
• Improved relationship with the health educates that patient on the effects and side
care team effects; the next day, the nurse may assess
• Promotion of self-concept retention by asking the patient if he or she
remembers the reason for taking the new
Evaluation of the Outcome of Care medication. Common items that patients and
• Evaluation is the final component in the families are asked to verbalize are reportable
patient and family education process. signs and symptoms, how to manage symptoms
• The intent of evaluation is to determine the at home, when to take medication, how often
effectiveness of the educational interventions. the medication should be taken, and who to call
• The nurse must use his or her clinical for questions or concerns.
judgment and knowledge of adult-learning • Changes in attitude, beliefs, or lifestyle are
principles to determine how well the learner often difficult to evaluate, because learners can
has met the expected outcomes and objectives. say they have changed their attitude when
• The evaluation process is continual and actually they have not. In this learning domain,
assesses the entire teaching-learning the nurse must use his or her detective skills to
assess whether the individual has accepted the
prescribed treatment plan and modified Reporting and Documentation of Care
behavior accordingly. Sometimes, the best way • Documentation of education is necessary to
to evaluate a change in attitude is by communicate educational efforts to members
observation and verbal questioning. An example of the health care team, patients and families,
is a patient who has been asked to comply with and regulatory agencies.
a low-cholesterol diet; a food diary the patient • The nurse should recognize that informal
has kept as requested provides some evidence teaching at the bedside is education.
about what the patient has eaten. A wealth of • It is important to record any information given
information can also be obtained from the to the patient on formal documents approved
family concerning the patient’s exhibited for use by each health care institution.
changes • In most institutions, formal education records
• Physiologic evidence of the effectiveness of are used to document education rendered by
education can also be measured. Indicators practitioners of any discipline involved in the
such as blood cholesterol levels, blood pressure, care of a particular patient and family.
heart rate, blood sugars, and weight can lead • These forms are communication tools used to
the practitioner to the conclusion that the indicate progress in the teaching-learning
patient and family may be having difficulties process from shift to shift, day to day, and
understanding or following through with the discipline to discipline.
identified plan of care. • Documentation should include education
• Adults generally want to comply with new from admission to discharge on topics ranging
expectations but often cannot for various from orientation to the environment to
reasons, such as a lack of money for acquisition of self-management skills for home
medications or an inability to understand what care
is expected of them. These barriers must be • What Should Be Documented?
explored and included in the education plan. • The complexity of information, demand by
• Observation and return demonstration is the governing agencies, lawsuits, and the sheer
evaluation of choice for the skills-learning volume of patients in and out of a unit are
domain. For the patient and family members to driving nurses to provide quality documentation
be “checked off” on a particular skill, they of the education encounter.
should be able to perform it independently, • Documentation of the teaching-learning
using the nurse only as a resource for questions. process is multifaceted.
Endotracheal suctioning, placing condom • The documentation form should “tell the
catheters, and performing dressing changes are story” of the education encounter from
examples of common tasks that patients and assessment to evaluation.
families may be asked to learn. Because of the • Documentation of the education assessment
increasingly complex care that patients require should include learning preferences; factors
at home after discharge, these skills may be the that impair ability, readiness, and willingness to
entire focus of teaching before discharge. Not learn; and actual or perceived learning needs.
every teaching moment is a success, and the • Information should be recorded on the
nurse need not feel guilty or like a failure when interaction, material taught, supplemental
the learner has not achieved the desired materials distributed, response to the
objective. Revisiting and revising the goals and education, achievement of outcome, and any
objectives during the teaching learning session follow-up education or resources needed
may be necessary to meet the ever-changing
needs of the patient or family.
RESPONSES TO ALTERATIONS/PROBLEMS AND Sputum- when patient produces sputum, ask
ITS PATHOPHYSIOLOGIC BASIS IN LIFE- him to estimate the amount produced in
THREATENING CONDITIONS, ACUTELY ILL teaspoons or some other common
/MULTI-ORGAN PROBLEMS, HIGH ACUITY, measurement. Also ask him these questions:
AND EMERGENCY SITUATIONS • At what time of day do you cough most
often?
Physical Assessment 1 • What’s the color and consistency of the
SUBJECTIVE DATA CURRENT HEALTH STATUS sputum?
• FOCUS ON THE CLIENTS PRESENTING • If sputum is a chronic problem, has it
PROBLEM EXPLORE THE ONSET LOCATION, changed recently? If so, how?
DURATION, CHARACTER AGGRAVATING
ALLEVIATING FACTORS RADIATION (IF Wheezing- If the patient has a wheezing, ask
RELEVANT) these questions:
➢ Older adults: respiratory disease • At what time of day does wheezing
changes occur?
➢ Vaccines • What makes you sneeze?
➢ Current medical status • Do you sneeze loudly that enough for
➢ Family history other to hear it?
➢ Smoking history • What helps stop your wheezing?
➢ Duration
➢ Location Chest pain- occurs from a respiratory problem
➢ Setting usually results from pleural inflammation,
➢ Severity inflammation of the costochondral junctions,
➢ Time of day soreness of chest muscles because of coughing,
➢ Associated symptoms or indigestion. Less common causes of pain
➢ Aggravating factors include rib or vertebral fractions caused by
➢ Environmental exposure coughing or osteoporosis. If the patient has
➢ Alleviating factors chest pain, ask him these questions:
➢ Past history • Where is the pain exactly?
• What does it feel like? Is it sharp,
WHAT WILL YOU ASK? burning, or aching?
Orthopnea- patient with orthopnea (shortness
• Does it move to another area?
of breath when lying down) tends to sleep with
• How long does it last?
his upper body elevated. Ask this patient how
• What causes it to occur or makes it
many pillows he uses. The answer describes the
better?
severity of orthopnea. For instance, a patient
• Do you have associated symptoms, such
who uses 3 pillows can be said to have “3 pillow
as shortness of breath or nausea and
orthopnea”
vomiting?
When Cough- ask the patient with a cough
PAST HEALTH HISTORY
these questions:
-IDENTIFICATION OF PREVIOUS HEALTH
• When did the cough start?
PROBLEMS
• If the cough is chronic, has it changed
-CHILDHOOD ILNESS
recently? If so, how?
-IMMUNIZATION
• What makes the cough better?
-SMOKING HISTORY
• What makes it worse? -ALCOHOL HISTORY
• What medications are you taking?
Family history 2. COSTAL ANGLE- the angel between the
-Ask the patient if anyone in his family has had ribs and the sternum at the point
cancer, diabetes, sickle cell anemia, heart immediately above the xiphoid process.
disease, or a chronic illness, such as asthma or • Should be less than 90 degrees in
emphysema. Be sure to determine whether the an adult
patient lives with anyone who has an infectious 3. BREATHING RATE AND PATTERN- count
disease, such as influenza or tuberculosis (TB), his respirations for a full minute longer
COVID. if you note abnormalities.
• Normal adult respiratory rate and
Lifestyle patterns frequency and should be quiet.
-The patient’s history should also include
information about lifestyle, community, and
other environmental factors that might affect
his respiratory status or how he deals with
respiratory problems. Most importantly, ask the
patient if he smokes; if he does, ask when he
started and how many cigarettes he smokes per
day. Also ask about interpersonal relationships,
mental status, stress management, and coping
style

How to solve packs of cigarettes consumed

every year:
Formula:
No. of cigarettes smoked per day x no. of years
smoked = no of pack year
20 4. CYANOSIS- which occurs when
Example: oxygenation to the tissues is poor, is a
➢ Smokes 40 cigarettes per day for 30 late sign of hypoxemia.
years • The most reliable place to check for
cyanosis is the tongue and mucous
40 x 30 = 60 packs per year membranes of the mouth.
20 5. CLUBBING- a possible sign of long
hypoxia.
OBJECTIVE DATA (IPPA) • A fingernail is normally enters the
Inspection skin at an angel of less than 180
Palpation degrees. When clubbing occurs, the
Percussion angel is greater than or equal to
Auscultation 180 degrees.

INSPECTION PALPATION
1. CHEST SYMMETRY- both sides of the 1. CREPITUS- indicates subcutaneous air
chest should be equal at rest and the chest, an abnormal condition.
expand equally as the patient inhales. Crepitus feels like puff-rice cereal
The diameter of the chest from front to crackling under the skin and indicates
back should be half the width of the that air is leaking from the airways or
chest. lungs.
2. PAIN – if the patient complains of chest PERCUSSION
pain, check for painful areas on the 1. PERCUSSING THE CHEST
chest wall. 2. PERCUSSING THE DIAPHRAGM
• Painful costochondral joints are
typically located at the Percussion sounds:
midclavicular line or next to the 1. Flat- short, soft, high-pitched,
sternum. extremely dull, found over the thigh
• Rib or vertebral fractures will be 2. Dull- medium in intensity and pitch,
quite painful over sore muscles. moderate length, thud like, found over
3. FREMITUS the liver
• What to do? 3. Resonant- loud, long low-pitch, hollow
Check for tactile fremitus 4. Hyperresonant- very loud, low-pitch,
by lightly placing your open found over the stomach
palms on the both sides of 5. Tympanic- loud, high-pitch, moderate
the patient’s back, as length, musical, drum like, found over a
shown, without touching puffed-out cheek
his back with your fingers.
Ask the patient to repeat AUSCULTATION
the phrase “ninety-nine” NORMAL BREATH SOUNDS
loudly enough to produce 1. VOCAL FREMITUS- is a sound produce
palpable vibrations. Then by chest vibrations as the patient
palpate the front of the speaks
chest using the same hand 2. Bronchophony- ask the patient to say
positions. “ninety- nine” or “blue moon”. Over
• What the results mean? lung tissue, the words sound muffled. In
Vibrations that feel more bronchophony, the words sound
intense on one side than unusually loud over consolidated areas.
the other indicates tissue 3. Egophony- ask the patient to say “E”.
consolidation on the side. Over lung tissue, the words sound
• Lung consolidation occurs muffled. In egophony, it will sound like
when the air that usually the letter A over consolidated lung
fills the small airways in tissue.
your lungs is replaced with 4. Whispered pectoriloguy- ask the
something else. Depending patient to whisper “1,2,3”. Over normal
on the cause, the air may lung tissue, the numbers will be almost
be replaced with a fluid indistinguishable. In whispered
such or no vibrations in the pectoriliguy, the numbers will be loud
upper posterior thorax may and clear over consolidated lung tissue.
indicate bronchial
obstruction or a fluid filled
space.
4. CHEST WALL EXPANSION- as the
patient inhales deeply, watch your
thumbs. They should be separate
simultaneously and equally, to a
distance several centimeters away from
the sternum.
 Nursing considerations:
• Blood for an ABG analysis should be drawn
from an arterial line if the patient has one.
• The brachial, radial, or femoral arteries can be
used.
• After the sample is obtained, apply pressure
to the puncture site for 5 minutes and tape a
gauze pad firmly in place.
• Regularly monitor the site for bleeding, and
check the arm for signs of complications, such
Common Diagnostic Assessments as swelling, discoloration, pain, numbness, and
A. Non-Invasive tingling.
1. Pulse Oximetry or SPO2 • Make sure you note on the slip whether the
▪ continuously monitoring patient is breathing room air or oxygen. If
the oxygen saturation of oxygen, document the number of liters.
hemoglobin (SaO2). • If the patient is receiving mechanical
▪ A probe or sensor is ventilation, document the fraction of inspired
attached to the fingertip, oxygen. Also include the patient’s temperature
forehead, earlobe, or on the slip; results may be corrected if the
bridge of the nose. patient has a fever or hypothermia.
▪ Normal Value: 95-100%
Special Considerations
✓ Place the probe or clip over the finger
or other intended sensor site so that
the light beams and sensors are
opposite each other
✓ Protect the transducer from exposure
to strong light.
✓ Check the transducer site frequently to
make sure the device is in place and
examine the skin for abrasion and
circulatory impairment.
✓ Rotate the transducer at least every 4
hours to avoid skin irritation.
✓ If oximetry has been performed
properly, the saturation readings are 2. Pulmonary Capillary Wedge
usually within 2% of ABG values pressure- PCWP is the left atrial
B. INVASIVE pressure measurement obtained by
1. Arterial Blood Gas- assessing the the passing of a catheter from the
ability of the lungs to provide right side of the heart into the
adequate oxygen and remove pulmonary artery, wedging it into a
carbon dioxide, which reflects small pulmonary branch
ventilation, and the ability of the • Measures PCWP by using “Swan-
kidneys to reabsorb or excrete Ganz Catheter”
bicarbonate ions to maintain 3. Pleural Fluid analysis- Pleural Fluid
normal body pH, which reflects is a liquid present in the space
metabolic states. between the chest wall and the
outer lining of lungs (PLEURA).
• Pleural fluid analysis is done to fibrosis, pneumonia, emphysema,
identify the reason of pleural and lung cancer.
effusion
• Normal Result: a volume less than Nursing Diagnosis
20 milliliters of yellowish, clear ✔ Ineffective Airway Clearance related
serous fluid to Excessive and Tenacious Secretions
• Abnormal Result: Pleural fluid with ✔ Impaired Gas Exchange related to
reddish color, Pleural fluid with a Activity Intolerance
thick and cloudy appearance ✔ Anxiety related to Breathlessness
4. Pulmonary Angiography- ✔ Powerlessness related to Feelings of
Pulmonary angiography involves an Loss of Control
x-ray examination of the pulmonary ✔ High Risk for Ineffective Therapeutic
vessels after intravenous (IV) Regimen Management related to Lack
administration of a radiopaque dye. of Knowledge
• A catheter is inserted into the
femoral, brachial, or jugular vein Conditions with altered ventilator Functions
and threaded through the heart to 1. Chronic Obstructive Pulmonary
the pulmonary artery, where the Disease (COPD)-) is a common lung
dye is injected disease. Having COPD makes it hard to
5. Ventilation-Perfusion scan (V/Q breathe.
scan)- This procedure is used • progressive respiratory disease
clinically to measure the integrity of characterized by the combination of
the pulmonary vessels relative to signs and symptoms of emphysema
blood flow and to evaluate blood and bronchitis. It is a common
flow abnormalities. disease, affecting tens of millions of
• A V/Q lung scan use a low-risk people and causing significant
radioactive substance that can be numbers of deaths globally.
traced by a special type of scanner • There are two main forms of
obtaining a scan of the chest to COPD:
detect radiation. ➢ Chronic bronchitis also known
• The isotope particles pass through as blue bloaters, which involves
the right side of the heart and are a long-term cough with mucus
distributed into the lungs in ▪ Excessive mucus
proportion to the regional blood production with
flow, making it possible to trace and productive cough and
measure blood perfusion through impaired ciliary
the lung. function which
• The patient takes a deep breath of a decreased mucus
mixture of oxygen and radioactive clearance
gas, which diffuses throughout the ▪ “Smoker cough”
lungs. Repeated lung
• A scan is performed to detect inflammation damages
ventilation abnormalities in patients the lungs causing a
who have regional differences in scarring of the airway
ventilation. ➢ Emphysema also known as
• It may be helpful in the diagnosis of pink puffers, which involves
bronchitis, asthma, inflammatory damage to the lungs over time
 ▪ Destruction of alveolar
walls resulting in
decreased elastic recoil
of lungs
Types
1. Panacinar-involves
alveoli and extends to the
central bronchioles
2. Centriacinar- Affects the
bronchioles in the central
part of the respiratory
lobules
Management
▪ SMOKING CESSATION
▪ BRONCHODILATORS
▪ OXYGEN
Nursing Responsibilities
• Urge the patient to stop smoking and to avoid
other respiratory irritants.
• Explain that bronchodilators alleviate
bronchospasm and enhance mucociliary
clearance of secretions.
• Familiarize the patient with prescribed
bronchodilators. Teach or reinforce the correct
method of using an inhaler.
Risk Factors • To strengthen the muscles of respiration,
✔ Smoking -80-90% teach the patient to take slow, deep breaths
and exhale through pursed lips.
✔ Air pollution
• Teach the patient how to cough effectively to
✔ Exposure to industrial chemical
help mobilize secretions. If secretions are thick,
✔ Deficiency of enzyme alpha-antitrypsin urge the patient to maintain adequate
hydration.
DIAGNOSTIC • If the patient will continue oxygen therapy at
• Pulse Oximeter home, teach him how to use the equipment
• Chest Xray correctly.
• ABG • administer 1 to 2 liters of low-flow oxygen
• Spirometry because of carbon dioxide retention.
• Pulmonary Function test
• CT scan PULMONARY EMBOLISM- is a life-threatening
• Alpha 1-antitypsin screening levels –TISSUE disorder typically caused by blood clots in the
DAMAGE - elastas lungs.
- Blood clots that form in the deep veins
of the legs and embolize to the lungs
can cause a pulmonary infarction where
emboli mechanically obstruct the
pulmonary vessels, cutting off the blood
supply to sections of the lung
CLINICAL MANIFESTATION • Sometimes heparin therapy is initiated
• dyspnea for no apparent reason. even before a diagnosis of PE is made.
• gasping for breath and appear anxious. • Oxygen is administered as ordered. ▪
• Tachycardia, tachypnea, and cough may Intubation and mechanical ventilation
be present. may be required in some cases.
• Auscultation may reveal crackles or a • Warfarin sodium (Coumadin), an oral
friction rub. anticoagulant, is used for at least 3 to 6
• If lung infarction has occurred, months following PE to prevent
hemoptysis and pleuritic chest pain may recurrence.
also be present. • Warfarin therapy can be initiated 2 to 3
• Some patients have no symptoms at all. days after the initiation of heparin
DIAGNOSTIC TEST therapy.
- chest Xray • Because it has a slow onset of action, it
- lung scan may require several days for the full
- CT angiography anticoagulant effect to occur.
- ECG (RULE OUT MI) • The patient will be on both
- ABG anticoagulants for a time.
- pco2 pao2 decreased • Warfarin therapy is monitored regularly
- ELEVATED D-DIMER with prothrombin time (PT) and
Medical-Surgical Management international normalized ratio (INR).
• The body naturally dissolves clots in 7 • If clots are a recurring problem, a filter
to 10 days. However, if the embolism is may be placed into the inferior vena
large, a thrombolytic agent might be cava via the jugular or femoral vein.
used. These agents, such as • In patients with life-threatening
streptokinase, urokinase, reteplase and symptoms, a surgical embolectomy can
tissue plasminogen activator (t-PA), be performed. This is a rare procedure
dissolve clots and are very effective. that is reserved for emergency
However, they must be used within 4 to situations
6 hours of the clot’s occurrence and are Nursing Responsibilities
associated with a risk for hemorrhage. • Monitor coagulation studies and report
• If a thrombolytic agent is not used, results to the physician. Anticoagulant
treatment is aimed at preventing therapy may be adjusted as often as
extension of the clot and the formation every 6 hours based on laboratory
of additional clots. results.
• Heparin, a potent anticoagulant • Protect the patient from injury so that
medication, is administered via excessive bleeding does not occur.
continuous intravenous infusion. • Encourage the patient to wear shoes or
• Sometimes an intermittent IV or slippers when ambulating to protect
subcutaneous route is used. from injury.
• Heparin is never given intramuscularly • Teach patient to use a soft toothbrush
because of the risk of hematoma and an electric razor to prevent injury.
development. • Avoid use of IM injections. IM injection
• Clotting studies (partial thromboplastin can result in hematoma in an
time [PTT]) is monitored and anticoagulated patient.
maintained at 1.5 to 2 times the control • Instruct the patient to report any signs
value. of bleeding, such as hematuria or easy
bruising.
 • Bleeding may be associated with • Complications that can result from
excessively prolonged clotting and may ARDS include heart failure,
require a change in anticoagulant pneumothorax related to mechanical
dosing or administration of an antidote ventilation, infection, and disseminated
intravascular coagulation
ACUTE RESPIRATORY DISTRESS diagnostics
SYNDROME(ARDS)- ARDS closely resembles • Brain natriuretic peptide
severe pulmonary edema. results from • Echocardiography
increased permeability of the alveolocapillary • Pulmonary artery catherization
membrane. The acute phase of ARDS is marked Medical-surgical management
by a rapid onset of severe dyspnea that usually • An ECG is done to rule out a cardiac-
occurs less than 72 hours after the precipitating related cause.
event • The patient with ARDS is cared for in an
ETIOLOGY intensive care unit.
• sepsis. • Treatment begins with oxygen therapy
• Pneumonia that is adjusted based on repeated ABG
• Trauma results.
• Shock • Intubation and mechanical ventilation
• narcotic overdose are necessary in most cases, with the
• inhalation of irritants, burns use of positive end-expiratory pressure
• pancreatitis (rare) (PEEP) to keep the airways open.
• Each of these causes begins a chain of • Diuretics may be used to reduce
events leading to alveolocapillary pulmonary edema, but care must be
damage and noncardiac pulmonary taken to prevent fluid depletion.
edema (pulmonary edema that is not • IV fluids are administered if blood
caused by heart failure). pressure or urine output is low.
• ARDS usually affects patients without a • A pulmonary artery catheter may be
previous history of lung disease. used to monitor hemodynamic status. If
Clinical Manifestation infection is the underlying cause,
• Initially the patient may experience antibiotics are administered.
dyspnea and an increase in respiratory • Parenteral nutrition may be given to
rate. Respiratory alkalosis results from maintain nutritional status while the
hyperventilation. patient is acutely ill.
• Fine inspiratory crackles may be • Positioning the patient with the less
auscultated. involved lung in the dependent position
• As the condition worsens, breathing (“good lung down”) allows the better
becomes more rapid and labored and lung to be well perfused with blood and
the patient becomes cyanotic. may increase PaO2
• The patient is no longer able to • Prone positioning has also been shown
oxygenate the blood and get rid of to increase oxygenation in patients with
carbon dioxide, and respiratory ARDS
acidosis occurs. Nursing Responsibilities
• Oxygen therapy does not reverse the 1. Record intake and output of fluid:
hypoxemia. Monitor for signs of renal insufficiency
• If ARDS is not reversed, eventually or failure (decrease in urinary output
hypoxemia leads to decreased cardiac less than 30 ml/h) and monitor BUN
output, shock, and death. and Creatinine.
 2. Monitor for possible fluid overload— • Carefully assess the patient and report
more fluid going in than coming out. significant findings to the physician
Patient may end up in heart failure, immediately.
compounding the fluid building up in • It is easy to mistakenly treat symptoms
the lungs. of agitation or confusion with sedatives,
3. Weigh the patient daily—inability to which will speed the onset of
handle excess fluids, causing third respiratory failure.
spacing of fluids into interstitial spaces, • Oxygen therapy via nasal cannula or
increasing weight and causing edema. mask is provided.
4. Change position at least every 2 hours • If the patient has a chronically high
to prevent pressure build-up, causing PaCO2, oxygen is administered at a flow
skin breakdown. rate of 1 to 2 L to prevent interference
5. Avoid overexerting the patient during with the hypoxic drive.
treatment—patient will tire easily and • Antibiotics or other treatments are
will have problems with increased ordered to correct the underlying cause
oxygen demands. Also provide rest of the failure.
periods during activities. • Bronchodilators promote ventilation
6. Explain to the patient: and secretion removal.
a) The importance of doing coughing • The patient is instructed to cough and
and deep-breathing exercises— deep breathe if able.
after coming off the ventilator the • Suctioning is indicated if the patient is
patient needs to move adequate air unable to cough effectively.
in and out of the lungs. Coughing • Mechanical ventilation via
helps to rid the lungs of any endoctracheal tube or noninvasive
remaining fluid. positive pressure ventilation (NIPPV)
b) How to identify the signs of may be required.
respiratory distress, any sign that
• Before invasive ventilation is initiated, it
symptoms may be returning:
is important to check the patient ’s
shortness of breath, coughing,
advance directives
wheezing, rapid breathing,
Nursing Responsibilities
cyanosis, restlessness, or anxiety
1. Assess the patient’s degree of dyspnea
on a scale of 0 to 10 if the patient is
RESPIRATORY FAILURE- Respiratory failure is a
able to participate.
sudden and life-threatening deterioration of the
2. Respiratory rate, effort, and use of
gas exchange function of the lung and indicates
accessory muscles are noted.
failure of the lungs to provide adequate
3. Monitor:
oxygenation or ventilation for the blood.
a) Arterial blood gases and oxygen
CLINICAL MANIFESTATION
saturation values
• The patient with impending respiratory b) The presence of cyanosis
failure may become restless, confused, c) Mental status, including
agitated, or sleepy. restlessness, confusion, and
• Arterial blood gases show decreasing level of consciousness, is also
PaO2 and pH and increasing PaCO2, assessed, because reduced
which lead to respiratory acidosis. oxygenation can produce
• The patient is cyanotic and dyspneic, central nervous system (CNS)
and respiratory rate becomes rapid and symptoms.
deep in an effort to blow off excess CO2
MEDICAL SURGICAL MANAGEMENT
 d) Symptoms of the underlying 2. Residence in a nursing home or
cause of respiratory i. If the longterm care facility
cause is infectious, sputum 3. Antibiotic therapy,
amount and color, chemotherapy, or wound care
temperature, and white blood within 30 days of current
cell counts are monitored. infection
e) All assessment findings should 4. Hemodialysis treatment at a
be compared with earlier data. hospital or clinic
f) Even subtle changes in the 5. Home infusion therapy or home
assessment findings can be wound care
significant and should be 6. Family member with infection
reported due to multidrug-resistant
bacteria
PNEUMONIA- Pneumonia is an acute infection 4. VAP- A type of HAP that develops ≥48
of the lung parenchyma that commonly impairs hours after endotracheal tube
gas exchange intubation ventilator-associated
- Pneumonitis pneumonia (VAP) it develops in patients
- Pneumonia is caused by an infecting who are intubated and mechanically
pathogen (bacterial or viral) or by a ventilated. The endotracheal tube
chemical or other irritant (such as keeps the glottis open, so secretions
aspirated material). can be aspirated into the lungs –
Classifications: microaspiration
1. Community Acquired Pneumonia Pathogenesis of VAP
(CAP)- Occurs in the community setting ▪ Aspiration
or <48 hours of admission ▪ Intubation procedure
- Hospitalization depends on the severity ▪ Biofilm formation
(CAP-LR, MR, HR) ▪ Contaminated
- S. pneumoniae - 60 yrs marker secretions
- H. influenzae - older adults ▪ Contaminated
- M. pneumoniae - MOT: contact with respiratory equipment
respiratory droplets 5. Opportunistic viruses- Seen in clients
- Primarily interstitial but may eventually with very poor immune systems:
result to bronchopneumonia malnutrition, HIV/AIDS, transplant
- Viruses is common for infants and clients receiving steroids, cancer clients.
children 6. Aspiration Pneumonia- Entry of foreign
2. HAP (Nosocomial)- Occurs 48 hours or substances into the lower airway.
more after admission Exposure to Most common - aspiration of bacteria that
potential bacteria from other sources normally reside in the upper airways Can occur
Intervention-related factors Overuse both in the community and hospital
and misuse of antimicrobial agents Other sources: gastric contents, chemical
3. HCAP- Pneumonia occurring contents, irritating gases
hospitalized patient in a non- with CLINICAL MANIFESTATION
extensive health care contact with one ▪ Fever
or more of the following: ▪ Pleuritic pain
1. Hospitalization for ≥2 days in an ▪ Myalgia
acute care facility within 90 ▪ Rash
days of infection ▪ Sputum
▪ production
 ▪ Increased tactile fremitus 7. Monitor pulse oximetry
▪ Marked tachypnea Respiratory 8. Monitor and record color, consistency,
distress and amount of sputum.
▪ Blood-tinged sputum 9. Provide a high-calorie, high-protein diet
▪ Loss of appetite with small frequent meals.
▪ Orthopnea 10. Encourage fluids, up to 3 L/day, to thin
DIAGNOSTIC TEST secretions unless contraindicated.
▪ Chest 11. Provide a balance of rest and activity,
▪ Xray increasing activity gradually
▪ Sputum GS/CS 12. Administer antibiotics as prescribed.
▪ Bronchoscopy 13. Administer antipyretics,
▪ Pulse oximeter bronchodilators, mucolytic agents, and
▪ ABG expectorants as prescribed.
MEDICAL MANAGEMENT 14. Prevent the spread of infection by hand
▪ Pharmacologic washing and the proper disposal of
▪ Therapy Antibiotic (C/S) secretions.
▪ IV then Oral 15. notify the HCP if chills, fever, dyspnea,
▪ Increase OFI hemoptysis, or increased fatigue occurs
▪ Nebulizer 16. To receive a pneumococcal vaccine as
▪ Bronchodilator recommended by the Health Care
▪ Antipyretic Provide
▪ Supportive Treatment
▪ Pulse Oximetry & ABG Coronavirus disease (COVID-19)- Coronavirus
▪ Oxygen Supplement disease (COVID-19) is an infectious disease
▪ Endotracheal Intubation caused by a newly discovered coronavirus
▪ Mechanical Ventilator called SARS-CoV-2.
DETERMINATION THRU SPUTUM - First learned this virus on December 31,
1. Strepto - rust-colored sputum 2019 following a report of a cluster of
2. Pseudomonas, haemophilus, viral pneumonia in Wuhan, People’
pneumococcal - green sputum Republic of China.
3. Klebsiella - red currant jelly sputum - The transmission of infection: droplets.
4. Anaerobic - foul-smelling or bad tasting - Fecal–oral route is possible.
sputum - The median incubation period of
Nursing Responsibilities COVID-19 is 5.2 days; most patients will
1. Administer oxygen as prescribed. develop symptoms in 11.5 to 15.5 days.
2. Monitor for labored respirations, - Therefore, it has been recommended to
cyanosis, and cold and clammy skin. quarantine those exposed to infection
3. Encourage coughing and deep for 14 days.
breathing and use of the incentive Clinical Manifestations:
spirometer. The MOST COMMON SYMPTOMS OF
4. Place the client in a semi-Fowler’s COVID-19
position to facilitate breathing and lung - Fever
expansion. - Dry cough
5. Change the client’s position frequently - Fatigue
and ambulate as tolerated to mobilize Symptoms of severe COVID‐19 disease include:
secretions and Provide CPT. - Shortness of breath
6. Perform nasotracheal suctioning if the - Loss of appetite
client is unable to clear secretions. - Confusion
 - Persistent pain or pressure in the chest b) Cross-reactivity with other
- High temperature (above 38 °C). human coronaviruses may
Other less common symptoms are: occur.
- Irritability c) The serology test is particularly
- Confusion useful:
- Reduced consciousness (sometimes I. when the viral test is
associated with seizures) not available.
- Anxiety, Depression, Sleep disorders II. Using the serology test
- More severe and rare neurological together with the
complications such as strokes, brain clinical picture could
inflammation, delirium and nerve guide in decision
damage making.
OTHER SYMPTOMPSARE LESS COMMON III. Patients with late
- Loss of taste or smell disease complications
- Nasal congestion and their physicians
- Conjunctivitis (also known as red eyes) need to make
- Sore throat immediate decisions
- Headache (the viral test takes
- Muscle or joint pain more time to get the
- Different types of skin rash results).
- Nausea or vomiting d) In some patients, virus
- Diarrhea shedding is reduced, making
- Chills or dizziness. RT-qPCR results falsely
MEDICAL MANAGEMENT negative.
1. Viral testing: e) The serology test can detect
a) performed by the RT-qPCR test, IgM and IgG antibodies against
used for qualitative detection of SARS-CoV-2 in serum, plasma
the nucleic acid for SARS-CoV-2. and whole blood
b) Swabs are usually taken from f) Rapid antigen testing is a
nasal, nasopharyngeal, monoclonal antibody test
oropharyngeal, sputum or against the SARS-CoV-2
lower respiratory tract aspirates nucleocapsid protein (N).
or wash. g) This protein is abnormally
c) Positive tests indicate the expressed in infected cells.
presence of SARS-CoV-2 RNA, h) Monoclonal antibodies are
and together with the clinical specifically directed against
picture support the diagnosis. nucleocapsid protein, and by
d) Negative test results do not using enzyme-linked
preclude SARS-CoV-2 infection, immunosorbent assay, it is
and shall be interpreted in light possible to detect SARS-CoV-2.
of the clinical picture and 3. Ultrasonography
epidemiologic information a. Whole-body point-of-care
2. Serology testing: ultrasonography has been provided to
a) The test can assess prior COVID-19 patients. Ultrasonography is
exposure to virus and cannot be considered an essential modality to
used in the diagnosis of current guide treatment in patients with
infection. cardiorespiratory failure. Current
recommendations are to extend its use
 to multisystem and whole-body - MERS-CoV likely came from an animal
ultrasonography: thoracic, cardiac, source in the Arabian Peninsula and
abdomen and deep venous thrombosis humans
4. Chest computed tomographic scan - In addition to humans, MERS-CoV has
a. Earlier studies during the outbreak in been found in camels in several
China suggested that patients with and countries. It is possible that some
without SARS-CoV-2 can be people became infected after having
differentiated by chest computed contact with camels.
tomographic imaging, together with - MERS-CoV, like other coronaviruses, is
clinical presentation and the presence thought to spread from an infected
of pneumonia. person’s respiratory secretions, such as
Nursing Management through coughing. However, the precise
1. Wash your hands regularly with soap ways the virus spreads are not currently
and water, or clean them with alcohol- well understood. MERS-CoV has spread
based hand rub. from ill people to others through close
2. Maintain at least 1 metre distance contact, such as caring for or living with
between you and people coughing or an infected person.
sneezing. Clinical Manifestation
3. Avoid touching your face. ➢ The symptoms of MERS start to appear
4. Cover your mouth and nose when about 5 or 6 days after a person is
coughing or sneezing. exposed, but can range from 2 to 14
5. Stay home if you feel unwell. days.
6. Refrain from smoking and other ➢ Most people confirmed to have MERS-
activities that weaken the lungs. CoV infection have had severe
7. Practice physical distancing by avoiding respiratory illness with symptoms of:
unnecessary travel and staying away • fever
from large groups of people. • cough
• shortness of breath
Middle East respiratory syndrome coronavirus, • Some people also had diarrhea
or MERS‐CoV- Middle East Respiratory and nausea/vomiting.
Syndrome (MERS) is an illness caused by a virus ➢ Some laboratory-confirmed cases of
(more specifically, a coronavirus) called Middle MERS-CoV infection are reported as
East Respiratory Syndrome Coronavirus (MERS- asymptomatic, meaning that they do
CoV). Most MERS patients developed severe not have any clinical symptoms, yet
respiratory illness with symptoms of fever, they are positive for MERS-CoV
cough and shortness of breath. About 3 or 4 out infection following a laboratory test.
of every 10 patients reported with MERS have Most of these asymptomatic cases have
died. been detected following aggressive
- Through first reported in Saudi Arabia, contact tracing of a laboratory-
it was later identified that the first confirmed case.
known cases of MERS occurred in Diagnostic test
Jordan in April 2012. • rRT-PCR assay
- A large MERS outbreak occurred in the • Serology
Republic of South Korea linked to a • Chest Xray
traveler from the Arabian Peninsula in Medical surgical management
2015 1. No vaccine or specific treatment is
currently available, although several
 MERS-CoV specific vaccines and 4. Avoid close contact with sick
treatments are in development. individuals, such as kissing, sharing
Treatment is supportive and based on cups, or sharing eating utensils.
the patient’s clinical condition. 5. Clean and disinfect frequently touched
2. As a general precaution, anyone visiting surfaces, such as toys and doorknobs
farms, markets, barns, or other places
where dromedary camels and other Severe Acute Respiratory Syndrome (SARS)
animals are present should practice - Severe acute respiratory syndrome
general hygiene measures, including (SARS) is a viral respiratory disease
regular hand washing before and after caused by a SARS-associated
touching animals and avoiding contact coronavirus.
with sick animals. - It was first identified at the end of
3. The consumption of raw or February 2003 during an outbreak that
undercooked animal products, including emerged in China and spread to 4 other
milk and meat, carries a high risk of countries
infection that can cause disease in - SARS is an airborne virus and can
humans. Animal products that are spread through small droplets of saliva
processed appropriately through in a similar way to the cold and
cooking or pasteurization are safe for influenza.
consumption but should also be - The incubation period of SARS is usually
handled with care to avoid cross 2-7 days but may be as long as 10 days
contamination with uncooked foods. CLINICAL MANIFESTATION
Camel meat and camel milk are • The first symptom of the illness is
nutritious products that can continue to generally fever (>38°C), which is often
be consumed after pasteurization, high, and sometimes associated with
cooking or other heat treatments. chills and rigors.
4. Transmission of the virus has occurred • It may also be accompanied by other
in health care facilities in several symptoms including headache, malaise,
countries, including transmission from and muscle pain.
patients to health care providers and • At the onset of illness, some cases have
transmission between patients before mild respiratory symptoms.
MERS-CoV was diagnosed. It is not • Typically, rash and neurologic or
always possible to identify patients with gastrointestinal findings are absent,
MERS‐CoV early or without testing although a few patients have reported
because symptoms and other clinical diarrhea during the early febrile stage.
features may be non‐specific • After 3-7 days, a lower respiratory
NURSING RESPONSIBILITIES phase begins with the onset of a dry,
1. Wash hands often with soap and water non-productive cough or dyspnea
for 20 seconds; if water and soap are (shortness of breath) that may be
not available, use an alcohol-based accompanied by, or progress to,
hand sanitizer. hypoxemia (low blood oxygen levels).
2. Practice respiratory etiquette. Cover • In 10–20% of cases, the respiratory
nose and mouth with a tissue or the illness is severe enough to require
inner elbow when coughing or intubation and mechanical ventilation.
sneezing. • Chest radiographs may be normal
3. Avoid touching eyes, nose, and mouth throughout the course of illness, though
with unwashed hands. not for all patients.
 • The white blood cell count is often from the heart to the lungs become
decreased early in the disease, and narrowed as a result of changes in the
many people have low platelet counts lining and smooth muscle of the vessels.
at the peak of the disease. - The result is elevated pressure in the
Medical-Surgical Management pulmonary arteries, causing the right
• There is no cure or vaccine for SARS and ventricle to work harder to push blood
treatment should be supportive and into them. Eventually the right ventricle
based on the patient’s symptoms. fails (cor pulmonale).
• Controlling outbreaks relies on - The reason for these vascular changes is
containment measures including: not known. Primary PAH is more
▪ prompt detection of cases common in women between ages 20
through good surveillance and 40 and has a hereditary tendency.
networks and including an early Clinical Manifestations
warning system; • Dyspnea
▪ isolation of suspected of • Fatigue
probable cases; • Crackles
▪ tracing to identify both the • Decreased breath sounds
source of the infection and • Peripheal edema
contacts of those who are sick • Distended jugular veins
and may be at risk of • Angina may result from right
contracting the virus; ventricular ischemia
▪ quarantine of suspected Medical Surgical Management
contacts for 10 days; 1. No cure is available for pulmonary
▪ exit screening for outgoing hypertension except for lung or heart-
passengers from areas with lung transplant.
recent local transmission by 2. In secondary pulmonary hypertension,
asking questions and the underlying disorder is treated.
temperature measurement; 3. Supportive care includes a low-sodium
and disinfection of aircraft and diet and diuretics to reduce blood
cruise vessels having SARS cases volume (and therefore pressure),
on board using WHO guidelines. oxygen, and cardiac monitoring.
NURSING MANAGEMENT 4. Vasodilators such as calcium channel
1. Personal preventive measures to blockers or angiotensin-converting
prevent spread of the virus include enzyme (ACE) inhibitors may be used to
frequent hand washing using soap or reduce pulmonary artery pressure.
alcohol-based disinfectants. 5. Warfarin may be used to prevent
2. For those with a high risk of contracting clotting.
the disease, such as health care 6. Epoprostenol (Flolan) is a vasodilator
workers, use of personal protective that may reverse some of the vascular
equipment, including a mask, goggles changes and prolong survival, but has
and an apron is mandatory. 3 many serious side effects, and must be
3. Whenever possible, household contacts continuously administered IV via an
should also wear a mask implanted pump.
7. Bosentan (Tracleer) is a new oral drug
Pulmonary Arterial Hypertension that blocks endothelin, a substance that
- Primary pulmonary arterial causes blood vessels to constrict.
hypertension (PAH) occurs when the
arteries that carry deoxygenated blood
 8. Silfenadil (Viagra) is being tested for the pleural space through a breach of
possible use in PAH. either the parietal or visceral pleura.
Nursing Management Most commonly, this occurs as air
1. Nursing care is collaborative and enters the pleural space through the
focuses primarily on patient rupture of a bleb or a bronchopleural
assessment. fistula
2. Fowler’s or high-Fowler’s position may TENSION PNEUMOTHERAX
help reduce dyspnea, and rest and - A tension pneumothorax occurs when
comfort measures are helpful in air is drawn into the pleural space from
treating fatigue and anxiety a lacerated lung or through a small
3. Nursing care is collaborative and opening or wound in the chest wall
focuses primarily on patient TRAUMATIC PNEUMOTHERAX
assessment. - A traumatic pneumothorax occurs
4. Fowler’s or high-Fowler’s position may when air escapes from a laceration in
help reduce dyspnea, and rest and the lung itself and enters the pleural
comfort measures are helpful in space or from a wound in the chest
treating fatigue and anxiety. wall. It may result from blunt trauma
(e.g., rib fractures), penetrating chest or
PNEUMOTHORAX abdominal trauma (e.g., stab wounds or
- air or gas accumulates between the gunshot wounds), or diaphragmatic
parietal and visceral pleurae, causing tears.
the lungs to collapse. Accumulation of Open Pneumothorax
atmospheric air in the pleural space, - If air can enter and escape through the
which results in a rise in intra thoracic opening in the pleural space, it is
pressure and reduced vital capacity. considered an open pneumothorax.
CLINICAL MANIFESTATION Close pneumothorax
• SUDDEN PLEURITIC PAIN - If air collects in the space and is unable
• TACHYPNEA to escape, a closed pneumothorax
• ANXIOUXS exists.
• DYSPNEA (AIR HUNGER) Hemothorax
• USE OF ACCESORY MUSCLE - The term hemothorax refers to the
• CYANOSIS presence of blood in the pleural space.
• TACHYCARDIA - This can occur with or without
• PROFUSE DIAPHORESIS accompanying pneumothorax
• ASSYMETRICAL CHEST WALL (hemopneumothorax) and is often the
EXPANSION result of traumatic injury.
DIAGNOSTIC Nursing Responsibilities
1. Apply a nonporous dressing over an
• CHEST XRAY
open chest wound
• ABG
2. Monitor Vital signs for indications of
MANAGEMENT
shock or increasing respiratory distress
• THORACENTESIS
3. Administer oxygen as prescribed
• CHEST TUBE DRAINAGE
4. Place the client in a fowler’s position
• THORACOTOMY 5. Prepare for chest tube placement which
• PAIN RELIEVER will remain in place until the lung has
SIMPLE PNEUMOTHORAX expanded fully
- A simple, or spontaneous, 6. If chest tube is in place, encourage the
pneumothorax occurs when air enters patient to cough and breathe deeply at
 least once per hour to promote lung - naga loose ug 20% ug body fluids
expansion. - distribution kay abnormal distribution
7. In the patient undergoing chest tube or inadequate supply sa body
drainage, watch for continuing air
leakage (bubbling) in the water-seal Distributive – the blood should decrease
chamber. This indicates the lung defect the blood flow to small vessels but in this
has failed to close and may require case, the blood flow to the small vessels is
surgery. increased which leads to abnormal
8. Observe for increasing subcutaneous distribution and this will lead to inadequate
emphysema by checking around the supply of blood in the body especially in the
neck or at the tube insertion site for extremities
crackling beneath the skin. Obstructive – blocks in the area = located
9. If the patient is on a ventilator, be alert in the heart itself – great vessels or inside
for any difficulty in breathing in time the heart
with the ventilator as you monitor its
gauges for pressure increases. - Blocks the area kay problem sa
10. Change dressings around the chest tube heart affected ang hemodynamic sa
insertion site as needed and as per your pt.
facility’s policy.
11. Don’t reposition or dislodge the tube; if Respiratory failure- deterioration of the
the tube does dislodge, immediately lungs caused by acidity
place a petroleum gauze dressing over Two types of respiratory failure
the opening to prevent rapid lung
collapse. 1. Decrease oxygen or hypooxemic -
12. Observe the chest tube site for leakage, cause of fluids in lungs like water,
and note the amount and color of pus or blood caused by injury
drainage. 2. Over carbon dioxide or hypercapnia
- The carbon dioxide cannot go out of
the body
ADDITIONAL NOTES: - It is caused by obstruction in the
Symptoms of morphine toxicity lungs either COPD or asthma
1. Depressed CNS
2. Low respiratory rate
3. Pinpoint eyes
4. Deep tendon reflex
Antidote
Naloxone administered thru IM and IV which
blocks the effects of opioids given every 5
mins, 3 times 2-4mg
Cardiogenic – cannot pump the blood
properly which will cause problem in the
heart
Hypovolemic – less volume – 20 percent
loss of body fluids = hypovolemic