XI.

RESPIRATORY THERAPY CARE PLAN

The respiratory therapy care plan (RTCP) provides the written plan or description of
treatment that the patient will receive. The plan is based on a careful patient interview, physical
assessment, diagnostic results, and treatment modalities available. The RTCP includes goals,
rationale, significance, and a description of how care will be assessed. Following a careful
patient assessment, the care plan is developed, modified, and evaluated.

A. Respiratory Therapy Care Plan #1

TABLE 11-1

RT Care Plan #1 Patient Data

Name : Patient JD Date : 3/18/2022

Age : 4 years old Time : 7:00 am

Diagnosis : Kawasaki Disease Secondary to Acute

Respiratory Distress Syndrome from Community
Sex : Male Acquired Pneumonia

Unit : PICU Ward, Room #324 Physician : Del Rosario, RTRP, MD

Subjective: Patient is intubated.

Objective:

TABLE 11-2

Baseline Vital Signs Reflected on Cardiac Monitor, 03/18/2022

Taken at 8:11 am Reference Value

Temperature : ↑ 37.5°C (ax.) 36.1-37.2°C (ax.)

Pulse Rate : ↑ 105 bpm 70-90 bpm

Respiratory Rate : ↑ 39/min 22-34/min

Blood Pressure : ↑ 115/85 mmHg 80/50 mmHg - 110/80 mmHg

Heart Rate : ↑ 100 bpm 70-90 bpm

SpO2 : 94% 95%-100%

Impression:VS reveal increased temperature, PR, RR, BP, HR; and low SpO2
Implication:Patient is febrile, tachypneic, tachycardic, and hypertensive
 Glasgow Coma Scale and Level of Consciousness, 03/18/2022, 8:16 am
Eye Opening : 3 (to speech)
GCS Score : 8
Verbal Response: 1 (intubated)

Motor Response : 4 (localizes pain) LOC : Obtunded

Impression:Severe brain injury (8), patient is easily aroused with minimal stimuli

Current MV Set Up, 03/18/2022, 8:20 am

Patient’s Height:3’3” (100.9 inches/39.72 cm)

Patient’s IBW:6.6 lbs. (62 kg); Patient’s BSA:1.53 m2

Mode : SIMV -VC f : 16/min I:E: 1:2

FiO2: 100% VE : 2 L/min I time : 0.75s

VT : 130 mL Flow : 6 L/min PEEP : 5

Baseline ABG from the Current MV Set Up at 100% FiO2, 11/05/2021

ABG Taken at 8:22 am Reference Values

pH : ↓ 7.30 7.35-7.39

PaCO2 : ↑ 55 mmHg 45-55 mmHg

PaO2 : ↓ 57 mmHg 70-80 mmHg

HCO3- : 22 mEq/L >26 mEq/L

SaO2 : ↓ 80% 88-92%

Impression: Uncompensated Respiratory Acidosis with Uncorrected hypoxemia

Implication:A low pH level shows acidemia with an increase in pCO2 is called respiratory
acidosis. The slight reduction of HCO3 is the effect of the hydration reaction. Oxygen
desaturation occurs when the body is experiencing low blood oxygen concentration support
at 100% FiO2.

Cephalocaudal Assessment:
Head
Upon inspection, the patient’s head is spherical, normocephalic, and symmetrical, with
frontal, parietal, and occipital prominences upon examination. No swelling and birthmarks were
observed. The features and movements of the face are symmetrical, and no hair infestations
and no nodules or masses palpated.
Upon palpation, there were no nodules and depressions in the head and face.

Eyes
Upon inspection, the eyes of the patient were symmetrical with no discolorations.
There is symmetry in both eyes without opacities in the red reflex test. Eyebrows are
symmetrical, evenly distributed, and moved equally. Eyelashes are equally distributed and
curled slightly outward. Eyelids close symmetrically. Both were dark brown, isochoric, and pupils
are equal, round, and brisk upon light accommodation. Both sclera and conjunctiva were clear
and anicteric. Palpebral conjunctiva is pale with no nodules Upon palpation, no edema or
tenderness noted.
Ears
Upon inspection, auricles are symmetrical and aligned with the outer canthus of the
eye. Ears are the same color as facial skin. Upon palpation, there is no swelling, lumps, or
tenderness noted. The pinna recoils after it is folded.

Nose
Upon inspection, the nose was symmetrical, straight, midline, and moist. The septum
was in the middle and the turbinates project into the nasal passages. There was sufficient room
for the nasal passages. There was no presence of discharge or flaring.
Upon light palpation, there were no tenderness and lesions.

Mouth
Upon inspection, the lips are dry and have no presence of discoloration. A nasogastric
tube of 5.0 mm inner diameter at level 17 cm was inserted in the patient’s mouth. The buccal
cavity there has no ulceration, nodules, swelling and discoloration noted. The uvula is in the
midline. The maxilla and mandible are symmetrical. There is a presence of swollen white
coating in the tongue with red lumps. Upon palpating the palate, there were no submucosal and
mucosal clefts noted.
Neck
Upon inspection, the neck appeared symmetric and sore throat was present. Trachea
is in midline. And there is a use of the accessory muscles such as sternocleidomastoid and
supraclavicular due to the difficulty of breathing. Upon palpation, there is a presence of swollen
lymph nodes and pain around the neck was noted. The clavicles are intact and no swelling was
noted.

Thorax and Lungs

Upon inspecting the chest, it appears cylindrical and symmetrical, with the sternum no
protrusion nor depression.Visible indentations between the ribs resulting in intercostal and
subcostal retractions were present. Upon palpating the chest, no masses nor swelling are
present. Upon auscultating the lungs, crackles and dull sound is present. Upon auscultating the
heart, there were no irregular heart rhythms and the point of maximal impulse is at the 5 th ICS,
LMCL.

Abdomen
Upon inspection, the abdomen of the patient is symmetrical, round, and has no lesions.
No visible vascular pattern or lesions. Color is uniform all throughout the abdomen.

Upon auscultation, normal bowel sounds are heard.

Upon percussion, there is no tymphany over the stomach and gas-filled bowels, no
dullness over the liver and spleen.
Upon palpation, the abdomen was soft to touch, no areas of tenderness found in all
four abdominal quadrants and abdominal respirations were observed. No evidence of
abdominal distention.

Upper Extremities
Upon inspection, the upper extremities appeared to be equal in size. There are five
fingers on each hand with a normal palmar crease. The capillary refill time is greater than 3 with
good skin turgor but there is presence of rashes, dryness, and irritation. A pulse oximeter is
attached at the right middle finger with a reading of 96%. An indwelling vascular line was
inserted on the right brachial artery for A-line access.

Upon palpation, no edema or swelling is present. A 22-gauge IV line of 0.9 normal

saline was inserted in the right dorsal metacarpal vein secured with an IV board and tape.

Lower Extremities
 Upon inspection, both lower extremities appeared to be equal in size. There are five
toes on each foot and there is presence of rashes, irritation, and dryness. No digital clubbing
noted. Rashes are present on patient’s diaper area.
Upon palpation, there are no peripheral edema, lumps and any deformities noted. The
skin of the feet was warm when touched.

TABLE 11-3

Complete Blood Count Result for Infection Evaluation, 03/18/2022 Received at 9:30 am

CBC Result Received at 10:15 am Reference Value

HGB : 10.4 g/dL 10.2-15.2 g/dL

HCT : 38 % 36-46%

RBC : N 5.03 x106/uL 4.00-5.20 x 106/uL

MCH : N 28 pg 23-31 pg

MCHC : N 33% 32-36%

MCV : N 81 fl 78-94 fl

WBC : ↑ 20.2 x 103/uL 5.0-17.0 x 103/uL

Lymph : ↑ 12.5 x 103/uL 1.5-11.1 x 103/uL

Mono : 2.0 x 103/uL 0.1-1.15 x 103/uL

Eos : ↑ 0.8 x 103/uL 0.0-0.7 x 103/uL

Bas : ↑ 0.4 x 103/uL 0.0-0.3 x 103/uL

PLT : ↓ 145 x 103/uL 150-450 x 103/uL

Impression: All WBC components are increased.

Implication: increased WBC reveals presence of infection

Chest Radiography Result, 03/18/2022,

CXR Result Received at 10:29 am Reference Image (AP view)

Impression:

A. There is an increase in radiodensity. Lungs become whiter (increased opacity),

enlarged heart, diaphragm is flattened, and retrosternal air is increased.
B. Normal chest radiograph of a healthy child. Both lungs are clear and expanded.
Implication: Bilateral Alveolar Infiltrates due to Consolidation

12-Lead EKG Result, 03/18/2022

EKG Result Received at 10:51 am

 Impression:Increased heart rate and close R-R intervals in leads V2- V6
Implication: EKG result showed sinus tachycardia with regular ventricular rate.

Warm, Cream and Febrile Test Result, 03/18/2022 ; 11:00 am

Warm = Fever for > 5 days ✓

C = Conjunctivitis without exudate ✓

R = Rash ✓

E = Edema or erythema of hands or feet, followed by

A = Adenopathy, often unilateral, cervical node > 1.5 cm ✓

M = Mucosal erythema, fissures or crusting of lips or strawberry tongue ✓

E = Enanthem of mucosal membranes ✓

B = Bulbar conjunctivitis

R = Rash, Erythematous, Polymorphous, ✓

 I = Internal Organ involvement: Coronary Abdominal, Pneumonitis, Hepatitis,

E = Extremity, Changes, Initial Edema, and Erythema, Desquamation, Nail

Changes

Impression: The patient is experiencing high fever for more than five days, a presence of
rash, mucosal erythema, fissures or crusting of lips or strawberry tongue, enanthem of
mucosal membranes and erythematous polymorphous rash.
Implication: The patient is positive for Kawasaki disease (presence of at least five days of
high fever and presence of six other criteria).

C-Reactive Protein Test 03/18/2022 ; 11:00 am

Date of Submission: 03/14/2022 Reference value

Result: 5mg/L <3.0mg/L

Impression: The C-reactive protein is elevated.

Implication: A presence of infection leading to acute inflammation

Analysis: Impaired Gas Exchange related to Alveolar Consolidation secondary to Kawasaki

Disease from Community-Acquired Pneumonia to ARDS as evidenced by Uncompensated
Respiratory Acidosis with Uncorrected Hypoxemia.

Planning:At the end of our 8-hour shift, the patient’s Impaired gas exchange will be improved
as evidenced by the following:
a) Gradual improvement in vital signs as evidenced by:
· Drop in body temperature from 37.5°C to range of 36.5-37.5°C
· Decline in pulse rate from 105 bpm to range of 70-90 bpm
· Decline in heart rate from 100 bpm to range of 70-90 bpm
· Decline in spontaneous respiratory rate from 35/min to range of 12-20/min
· Decrease in blood pressure from 115/85 mmHg to range of 80/50 mmHg - 110-80
mmHg
· Improvement in oxygen saturation from 94% to range of 88-92%
 b) Gradual improvement in ABG values to chronic stable state and improved
oxygenation as evidenced by:
· pH of 7.30 increasing to acidotic normal range of 7.35-7.45;
· Increase in PaO2 from 75 mmHg to range of 80-100 mmHg
· Gradually decrease PaCO2 from 55 mmHg to range of 35-45 mmHg
c) Increase in sputum production as evidenced by more frequent suctioning and
disappearance of adventitious breath sounds upon chest auscultation

Intervention:

TABLE 11-4

Dependent Interventions and Rationale

Obtaining arterial blood gas via an indwelling vascular line is

ABG Extraction via A- essential to monitor the patient's acid-base status and oxygenation
line Access status frequently. ABG contains vital information on whether to
maintain/escalate FiO2 requirements.

Chest radiography should be ordered to assess the progression of

Chest Radiography
infiltrates.

Electrocardiogram EKG should be ordered to assess the patient’s cardiac status and
Monitoring regularity of heart rhythm.

Normal saline solution (0.9% NaCl) or NSS is a crystalloid fluid

Administer NSS administered intravenously. It is used to clear pulmonary
secretions, hydration, and electrolyte disturbances.

Penicillin, a narrow-spectrum antibiotic given 60 mg in q 4 hours

IV Antibiotic Therapy intravenously, is administered to treat infection caused by
Streptococcus pneumoniae.

Provide liquid using

To avoid dryness and soreness of the lips and may also aid to
cotton balls or ice
lubricate the lips.
chips.
 This is to improve ventilation and oxygenation status of Patient JD.
The initial MV set-up calculations are the following:
Adjusted MV Set-Up
as per Doctor’s Order
1. Calculate the patient’s IBW

2. Calculate the patient’s BSA in square meters

ℎeigℎt ( cm ) xweigℎt (kg)

BSA (m 2) = sq. root
3600

100.9 ( cm ) x 16.7(kg)
BSA (m 2) = sq. root o f
3600

BSA (m 2) = 0.468 / 0.47 m 2

3. Initial Tidal Volume

V t = IBW x 6 mL/ kg

V t = 16.7 x 6 mL/kg = 100 ml

4. Estimated Frequency

3.5 xBSA 3.5 x 0.47

f¿ = = 16 /min
Vt 0.100

5. Minute Ventilation

V e = f (V t ) = 16 (100) = 2 L/min

6. Flow rate

Flow = V e x Sum of I:E

Flow = 2 L/min x 3 = 6L/min

7. I time

I time = Time for breath (I ratio) / (Sum of I:E ratio)

Time for each breath = 60 /16 = 3.75s

I time: 3.75 s / 3 = 0.75s

8. Tubing loss, corrected tidal volume, and static compliance

Tubing loss = (PIP – PEEP) x (TCF = 3 ml/cmh20)

Tubing loss = (28 cmH20 - 5 cmH20) x 3 ml/cmH20

Tubing Loss = 69 mL

Corrected V t = Expired V t – Tubing loss

Corrected V t = 100 mL – 69 mL

Corrected V t = 31 mL

CorrectedTidalVolume
C stat =
Pplat − PEEP

31 mL
C stat =
25 cmH 20 −5 cmH 20

C stat = 1.5 mL / cmH20

9. Dynamic Compliance

CorrectedTidalVolume
C DYN =
PIP − PEEP

31 mL
C DYN =
28 cmH 20 −5 cmH 20

C DYN = 1.3 mL/cmH20

10. Mean Airway Pressure

FxItime
MAP❑= ( PIP − PEEP ) + PEEP
60

16 x 0.75
MAP❑= ( 28 −5 )+5
60

MAP = 6.6 cmH20

Independent Interventions and Rationale

Vital signs monitoring is essential to evaluate improvement in a

patient’s RR, SpO2, BP, and other VS parameters and to monitor
Vital Signs Monitoring the therapeutic response for the prompt detection of delayed
recovery or adverse events. Check the patient’s vital signs every 4
hours.

Establish patient and

To gain patient and watcher’s trust and comfort. Understanding
watcher’s rapport.
expected events and sensations can help eliminate anxiety
Explain all procedures
associated with the unknown.
and treatments.

Auscultation of Breath To check for the presence of secretions, bronchospasm, or any

Sounds lung abnormalities.

Obtaining GCS and assessing LOC are important to monitor the

GCS/LOC Assessment
neurological status of the patient.

Ensuring the patency of A-line ensures safety against infection and

A-line Patency
inadvertent bleeding on the indwelling site.

Frequent Drainage Water accumulated in the water trap attached from the corrugated
and Disinfection of tube should be drained frequently to reduce the likelihood and
Water Trap transmission of infection.

CPT is done after nebulization to mobilize the loosen secretions

Chest Physiotherapy
into the central airways.

To maintain a patent airway and improve oxygenation by the

Endotracheal
facilitation of mucous secretion removal and pooling of saliva in the
Suctioning
mouth and back of throat.

Chlorhexidine oral care done by RTs should be performed following

the infection-reduction protocol to reduce risk of an infection
Patient Oral Care
recurrence. Oral hygiene also prevents stagnation of saliva that
promotes proliferation of bacteria.

Assessing the endotracheal tube patency and integrity are essential

ET Tube Care to effectively deliver supplemental O2 to the patient. Monitor the
endotracheal tube prevent the patient from aspiration.

Pulse oximetry is essential to monitor oxygen saturation and

Pulse Oximetry
desaturation of the patient.
 Do patient monitoring
To ensure proper ventilation function and check for patient-
and ventilator checks
ventilator issues.
every 4 hours.

Check cuff inflation

every 4-8 hours or To protect against accidental changes that may occur with the
whenever the cuff is controls.
deflated or inflated.

Assist patient
repositioning in semi- To help diaphragmatic expansion and maximal effectiveness of
fowler’s position as medications to the basilar areas of the lungs.
tolerated.

Evaluation:
Goal partially met as evidenced by:

TABLE 11-5

Summary of Vital Sign Values Throughout the 8-hr Shift, 03/18/2022

Parameters 8:11 am 11:53 am 2:45 pm Reference Value

Temperature 37.5°C (ax.) 37.2°C (ax.) 37.0°C (ax.) 36.5-37.5°C (ax.)

Pulse Rate 105 bpm 100 bpm 102 bpm 60-100 bpm

Respiratory Rate 32/min 30/min 29/min 12-20/min

125/90
Blood Pressure 120/80 mmHg 119/75 mmHg 120/80 mmHg
mmHg

Heart Rate 100 bpm 95 bpm 97 bpm 60-100 bpm

SpO2 90% 96% 95% 88-92%

✓ Drop in body temperature from 37.52°C to 37.0°C

✓ Decrease in blood pressure from 125/90 mmHg to 119/75 mmhm
Summary of ABG Values Throughout the 8-hr Shift, 03/18/2022

Parameters 8:22 am 11:46 am 2:39 pm Reference Value

 pH 7.30 7.33 7.34 7.35-7.45

PaCO2 55 mmHg 60 mmHg 62 mmHg 35-45 mmHg

PaO2 78 mmHg 80 mmHg 87 mmHg 80-100 mmHg

HCO3- 22 mEq/L 24 mEq/L 25 mEq/L 22-26 mEq/L

SaO2 94% 94% 95% 90-95%

✓ Improvement in PaO2 from 78 mmHg to 87 mmHg

Goals were not fully met as heart and pulse rates were still elevated at 116 bpm;
spontaneous RR still elevated at 26/min; blood pressure still elevated at 141/90; and pH still
unstable at acidotic value of 7.29 (acute ventilatory failure).

Recommendation:
1. Continue mechanical ventilation.
R:Mechanical ventilation should be continued until the acid base is stabilized.
2. Continue to administer Penicillin G:
R:Continue administer antibiotics as per doctor’s order to help reduce and rule out the
presence of bacterial growth that may cause further complications.
3. Evaluate the response of the patient to the prescribed medications.
R:To assess if the medication is effective to the patient.
4. Continue administer aspirin as needed:
R:To reduce the presence of onset myocarditis and coronary arteritis and down-
regulation of inflammation.

5. Observe C-reactive protein result.

R:To check the status of the patient if inflammation is still present and how well the anti-
inflammatory medications are working.
6. Observe ABG results.
R:To assess if the patient is responding to the mechanical ventilation set-up and the
effectiveness of the treatment.
7. Administer chest physiotherapy by postural drainage and percussion.
 R: To eliminate inflammatory exudates and tracheobronchial secretions, remove airway
obstructions, reduce airway resistance, enhance gas exchange and reduce the work of
breathing.
8. Monitor A-line patency:
R:This avoids the likelihood of inadvertent bleeding, infection, and pre-analytic errors in
ABG samples.
9. Continue and maintain ET tube integrity:
R:Monitoring ETT integrity ensures effective delivery of O2 to the patient.
10. Request for CBC:
R:To monitor patient’s blood count and assess effectiveness of IV antibiotics.
11. Request for a new chest radiograph:
R:To monitor progression of obstruction and monitor cardiac abnormalities.
12. Change patient’s position in a prone position.
R:Turning the patient prone improves perfusion to less damaged parts of the lungs,
improves V/Q matching, and decreases intrapulmonary shunting.
13. Notify the extracorporeal membrane oxygenation (ECMO) team.
R:Notifying the ECMO team is advised when the patient cannot tolerate invasive
mechanical ventilator support.

RTCP 2

A. Respiratory Therapy Care Plan #2

 TABLE

RT Care Plan #2 Patient Data

Name: Patient Weight: 16.7 kg

J.D

Age: 4 years old Date: March 20,2022

Sex: Male Time: 7:30 a.m

Unit: PICU Diagnosis: Acute Respiratory Distress secondary to Kawasaki Disease

Height: 100.9 cm Physician: Dr. Del Rosario, MD

Subjective: The patient is intubated.

Objective
TABLE

Baseline Vital Signs Reflected on Cardiac Monitor, 03/20/2022

Taken at 7:45 a.m Reference Value

Temperature: 37.2 °C 36.1-37.2 °C

Pulse Rate : 100 bpm 70-90bpm

Respiratory Rate: 37 breaths 22-34 breaths per minute

per minute

Blood Pressure: 100/85mmHg 80/50 mmHg- 110/80 mmHg

Pulse Pressure: 15 mmHg 40-60 mmHg

Heart Rate: 103 bpm 70-90 bpm

SaO2: 95 % 95-100%

Impression : The vital signs still show an increase of RR, HR, PR and BP. The temperature
is within normal range.
Implication : Patient is afebrile, tachycardic and hypertensive.

Glasgow Coma Scale Level of Consciousness, 02/20/2022 8:15 a.m

Eye opening: 4 (spontaneous) GCS SCORE: 10

Verbal Response: 1
(Intubated) LOC: Lethargic
Motor Response: 5 (localizes
pain)

Impression: Moderate Brain Injury (10), patient is drowsy, sleeps a lot and easily aroused
with minimal stimuli.

Current MV Set up, 03/22/1011, 7:45 a.m

Patient’s Height : 3’3 ft (109 cm)

Patient’s IBW : 6.6 lbs (3kgs)
Patient’s BSA : 0.47

Mode : F : 16/min I: E : 1:2

SIMV- Volume Control

Fio2 : 1.0 Ve : 2/min I time : 0.75 s

Vt : 130 Flow : 6L/min PEEP : 3 cmH20

mL

Pplat : 25 MAP : 6.4 cmH2O PIP :28 cmH2O

cmh2O

Cdyn : 2mL/ Cstat :2.75 mL/cmH2O

cmH2O

Baseline ABG from the current MV Set Up at 80 % FiO2, 03/22/2022

ABG taken at 8:25 a.m Reference Value

pH : 7.50 7.35-7.45

PaCO2 : 50 mmHg 35-45 mmHg

Pao2 : 80 mmHg 80-100 %

HC03 : 27 mEq/L 22-26 mEq/L

SpO2 : 95 % 95-100 %

Impression: The patient’s pH, PaCO2 and HCO3 is above normal and Sao2 is 95 %.

Implication: Partially Compensated Respiratory Acidosis

Cephalocaudal Assessment

Head
Upon Inspection, the patient’s head is spherical, normocephalic, and symmetrical, with
frontal, parietal, and occipital prominences upon examination. No swelling and birthmarks were
observed. The features and movements of the face are symmetrical, and no hair infestations.
 Upon palpation, no nodules or masses palpated.

Eyes
Upon Inspection, the eyes of the patient were symmetrical with no discolorations but
discharges were noted due to runny nose. There is symmetry in both eyes without opacities in
the red reflex test. Eyebrows are symmetrical, evenly distributed, and moved equally. Eyelashes
are equally distributed and curled slightly outward. Eyelids close symmetrically. Both were dark
brown, isochoric, and pupils are equal, round, and brisk upon light accommodation. Both sclera
and conjunctiva were clear and anicteric.
Upon palpation, no edema or tenderness noted.

Ears
Upon Inspection, auricles are symmetrical and aligned with the outer canthus of the
eye. Ears are the same color as facial skin.
Upon palpation, there is no swelling, lumps, or tenderness noted. The pinna recoils
after it is folded.

Nose
Upon Inspection, the nose is uniform in color, nasal septum is intact and in midline and
no engorgement of maxillary sinuses. Nasal flaring is observed. The patient hooked in the
mechvent via nasotracheal tube with an inner diameter of 5mm at level 17 cm.

Upon palpation, maxillary and frontal sinuses are not tender.

Mouth
Upon inspection, the lips are dry and have no presence of discoloration . The buccal
cavity there is no ulceration, nodules, swelling and discoloration noted. Uvula is midline, maxilla
and mandible fit together well and open at equal angles and there is minimal salivation. There is
a presence of swollen white coating in the tongue with red lumps.
Upon Palpation, there were no submucosal and mucosal clefts noted.

Neck
Upon inspection, the neck appeared symmetric and sore throat was present. Trachea
is in midline. And there is a use of the accessory muscles such as sternocleidomastoid and
supraclavicular due to the difficulty of breathing.
Upon palpation, there is a presence of swollen lymph nodes and pain around the neck
was noted. The clavicles are intact and no swelling was noted

Thorax and lungs

Upon inspection, it appears cylindrical and symmetrical, with the sternum no protrusion
nor depression.Visible indentations between the ribs resulting in intercostal and subcostal
retractions were present.
Upon palpating the chest, no masses nor swelling are present.
 Upon auscultatIon, crackles and dull sounds are present. Upon auscultating the heart,
there were no irregular heart rhythms and the point of maximal impulse is at the 5th ICS, LMCL.

Abdomen
Upon inspection, the abdomen was dome shaped.
Upon auscultation, normal bowel sounds are heard
Upon percussion, there is no tympany over the stomach and gas-filled bowels, no
dullness over the liver and spleen.
Upon palpation, the abdomen was soft to touch and abdominal respirations were
observed. No evidence of abdominal distention.

Upper Extremities
Upon inspection, The upper extremities appeared to be equal in size. There are five
fingers on each hand with a normal palmar crease. The capillary refill time is greater than 3 with
good skin turgor but there is presence of rashes, dryness and irritation. A pulse oximeter is
attached in the right middle finger of the patient.

Upon palpation, no edema or swelling is present. A 22-gauge IV line of 0.9 normal

saline was inserted in the right dorsal metacarpal vein secured with an IV board and tape. A
pulse oximeter is attached at the right index finger with a reading of 95%.

Lower Extremities,
Upon inspection, both lower extremities appeared to be equal in size. There are five
toes on each foot but there is presence of rashes specifically in the diaper area, irritation and
dryness. No digital clubbing noted.

Upon palpation, there are no peripheral edema, lumps and any deformities noted. The
skin of the feet was warm when touched.

Genitalia

Upon inspection, a catheter is inserted for urination.

X. DIAGNOSTICS

There is no specific diagnostic test in diagnosing Kawasaki disease, however the

physician will perform physical examination and order some actual diagnostic test to help in
diagnosing the disease (Mayo Clinic, 2022).

A. Actual Diagnostic Tests

 Actual diagnostic tests for acute respiratory distress leading to Kawasaki disease are tools
that are helpful for the following reasons: (1) to help diagnose Kawasaki disease, (2) to know
what the bacteria is causing the infection (3) monitor the progression of the disease process
along the course of ongoing treatment. To confirm the diagnosis of ARDS leading to Kawasaki
disease, actual diagnostic tests and procedures include Warm CREAM and FEBRILE
Mnemonics for KD Criteria, Berlin Diagnostic Criteria for Respiratory Distress, Arterial blood gas
(ABG), Complete Blood Count (CBC), Sputum test, Chest Radiograph (X-ray), Erythrocyte
Sedimentation Rate (ESR), C- Reactive Protein (CRP).

Warm CREAM and FEBRILE Mnemonics for KD Criteria

Warm CREAM and FEBRILE Mnemonics for KD Criteria is a tool used to diagnose
Kawasaki disease. It is a series of symptoms present in the patient's body. The symptoms
include fever which is the most consistent presentation seen in patients with Kawasaki disease.
Also found in the criteria are conjunctival injection with photophobia, which is also correlated
with uveitis present in about 65% of the patients. When these symptoms are present
sequentially, it will indicate the diagnosis of KD. Furthermore, a diagnosis of KD should be made
in the acute phase of the disease (Modesti & Plewa, 2021). The table summarizes the result of
Patient J.D.'s Warm CREAM and FEBRILE criteria, which can be found in the respiratory care
plan.

Table 9-1

Warm CREAM and FEBRILE ,03/18/2022, Inspection at 07:45 a.m.

Warm = Fever for > 5 days Ö

C = Conjunctivitis without exudate Ö

R = Rash Ö

E = Edema or erythema of hands or feet, followed by desquamation

and nail changes
 A = Adenopathy, often unilateral, cervical node > 1.5 cm

M = Mucosal erythema, fissures or crusting of lips or strawberry Ö

tongue

F = Fever for > 5 days Ö

E = Enanthem of mucosal membranes Ö

B = Bulbar conjunctivitis

R = Rash, erythematous, polymorphous Ö

I = Internal organ involvement: coronary, abdominal, pneumonitis,

hepatitis, orchitis

E = Extremity changes, initial edema, and erythema, desquamation,

nail changes

Impression: The patient is experiencing high fever for more than five days, a
presence of rash, mucosal erythema, fissures or crusting of lips or strawberry
tongue, enanthem of mucosal membranes and erythematous polymorphous rash.

Implication: The patient is positive for Kawasaki disease (presence of at least five
days of high fever and presence of six other criteria).

Berlin Diagnostic Criteria for Acute Respiratory Distress Syndrome

The ARDS diagnosis is based on the acute onset and bilateral lung infiltrates of non-
cardiac origin on chest- ray and moderate to severe impairment of oxygenation (Haskwel,2020).
To know the severity of ARDS berlins test is used as a diagnostic criterion (Des Jardins &
Burton, 2016). This criterion is classified as mild, moderate, and severe ARDS. Patients with a
PaO2/FiO2 ratio of 200-300 are considered mild ARDS, those with PaO 2/FiO2 100-199 are
deemed moderate ARDS, and those with <100 are considered to have severe ARDS. Patient
J.D is hooked in mechanical ventilator with an FiO 2 of 100 % and PaCo2 of 78 mmHg which
shows a PaO2/FiO2 ratio of 76 mmHg leading to Patient J.D to have a severe acute respiratory
distress syndrome.

Sputum Culture

A sputum culture, also called a sputum test, is a painless test to study what bacteria or
fungi might be growing in the lungs and causing sputum production. This test lets the patient
cough up profoundly and spits any phlegm from the patient's lungs into the container provided.
After that, it will be delivered to the laboratory, which is also placed in a special dish for culture.
After that, it will be cultured for 2-3 days (Gill, 2018). The result of a sputum test is primarily
reported as normal(negative) or abnormal (positive). A normal or negative result indicates that
there are no harmful germs in the sputum of the patients. On the other hand, a positive result
indicates the presence of bacteria or fungi in the patient's sputum (Testing.com, 2020). The
table shows the sputum analysis of Patient J.D found in the respiratory therapy care plan.

Table 9-2

Sputum Culture Result for Pathogen Identification, 03/18/2022, 8:00 a.m.

Sample Collection Date: 03/14/2022

Pathogen: Streptococcus pneumoniae

Sputum Color/Consistency: Yellow,
Purulent

Complete Blood Count

 A complete blood count is a test used to measures several components and features of
the blood. This is to evaluate for any range of disorders, including anemia, infection, and
leukemia (Mayo Clinic, 2020). A CBC is done by drawing a blood from a vein (Sullivan,2018).

In patient with Kawasaki disease there is leukocytosis which often marked with increase in
immature cells, mild normocytic anemia, thrombocytosis (≥ 450,000/mcL [≥ 450,000 × 10 9/L]) in the
2nd or 3rd week of illness (Raab,2021).

Table 9-3

Complete Blood Count (CBC) Result for Infection Evaluation, 03/18/2022

CBC Result Received at 9:30 a.m. Reference Range

Hemoglobin : ↑9.98 g/dL 10.2-15.2

Hematocrit : ¯30% 36-46

RBC : ↑5.03 X 1012/L 4.00-5.20

MCH : N 24 pg 23-31

MCHC : N 35 g/dL 32-36

MCV : N 90 fL 78-94

WBC : ↑20.2 X 109/L 5.0-17.0

Neutrophil : ↑11.4 X 109/L 1.5-11.0

Basophil : ↑0.4 X 103/L 0.0-0.3

Eosinophils : ↑ 0.8 X 103/L 0.0-0.7

Lymphocytes : ↑1.2 X 109/L 1.5-11.1

Monocytes :↑2.0 X 109/L 0.1-1.9

Monocytes :↑2.0 X 109/L 0.1-1.9

Platelet :¯ 145 X 109/L 150-450

Impression: All WBC components are increased indicative of presence of infection.

Implication: CBC reveals presence of infection.

Complete Blood Count Result for Infection Evaluation, 03/20/2022

CBC Result Received at 10:00 a.m Reference Value

Hemoglobin : N 10.5 g/dL 10.2-15.2

Hematocrit : ¯34 % 36-46

RBC :↑5.15 X 1012/L 4.00-5.20

MCH : N 26.3pg 23-31

MCHC : N 35.10 g/dL 32-36

MCV : N 91 fL 78-94
WBC : ↑21.0X 109/L 5.0-17.0

Neutrophil : ↑11.3 X 109/L 1.5-11.0

Basophil : ↑1 X 103/L 0.0-0.3

Eosinophils : ↑ 0. X 103/L 0.0-0.7

Lymphocytes : ↑11.2 X 109/L 1.5-11.1

Monocytes : ↑6 X 109/L 0.1-1.9

Platelet : N 147 X 109/L 150-450

Impression: All WBC components were elevated.

Implication: Infection were present.

Complete Blood Count Result for Infection Evaluation, 03/22/2022

CBC Result Received at 10:00 a.m Reference Value

Hemoglobin : N 12.8 g/dL 10.2-15.2

Hematocrit : N 42% 36-46

RBC : N 4.50 x106/uL 4.00-5.20

MCH : N 25 pg 23-31
MCHC : N 33% 32-36

MCV : N 81 fl 78-94 fL

WBC : ↑ 18.5 x 103/uL 5.0-17.0

Neutrophil : ↑ 13 x 103/uL 1.5-11.0

Basophil : ↑ 0.5 103/uL 0.0-0.3

Eosinophil : 0.1-1.9

Monocytes : ↑ 1.2 103/uL 0.1-1.9

Lymphocytes : ↑ 12 103/uL 1.5-11.1

Platelet : N 200 X 109/L 150-450

Impression: WBC components were elevated.

Implication: Increased WBC indicates that there is a presence of infection.

Electrocardiogram

An electrocardiogram is a non-invasive procedure used to detect the heart's rhythm. This

is done by placing electrodes at certain spots on the chest, arms, and legs. Then the electrodes
are connected to an ECG machine by lead wires. Then the electrical of the heart is measured,
interpreted, and printed out (John Hopkins, 2020).

An electrocardiogram is a test done for patients with Kawasaki disease to rule out
different heart problems such as ventricular dysfunction and arrhythmias due to myocarditis.
Furthermore, in the acute phase of Kawasaki disease, prolonged PR interval and nonspecific
ST changes, t-wave changes, and increased q/r changes (Gibson,2018). The table shows the
electrocardiogram of Patient J.D that can be found in respiratory therapy care plan.

Table 9-4

ECG Result, 03/18/2022

ECG Result Received at 8:00 a.m.

Impression: Increase heart rate of 125bpm and fast R-R interval

Implication: Sinus Tachycardia

ECG Result, 03/20/2022

ECG Result Received at 9:45 a.m.

Impression: Persisting T wave inversion in V2

Implication: Rate has slowed, axis is normal, and QRS width has begun to normalize

ECG Result, 03/22/2022

ECG Result Received at 8:06 a.m.

Impression: Rate: 100 bpm P waves: Upright and Regular QRS: 0.04 sec

Rhythm: Regular P-R interval: 0.16 sec

Implication: Sinus Tachycardia

Table 9-5

Chest Radiograph (AP Views) Baseline Results

Impression: Taken on 03/18,2022, The AP Impression:Increased Opacity due to
view shows that there is an increase in bilateral alveolar infiltrates
radiodensity. Lungs become whiter
(increased opacity), enlarged heart,
diaphragm is flattened, and retrosternal air is
increased.
Implication: Bilateral infiltrates
Implication: Increased Opacity due to consistent with acute respiratory
bilateral alveolar infiltrates due acute distress syndrome
respiratory distress syndrome
Impression: Chest radiograph shows confluent airspace opacity in the right and
upper lobe of the right lung and patchy infiltrates with air bronchogram indicating
consolidation or accumulation of secretions in the lung parenchyma.

Arterial Blood Gas

An arterial blood gas analysis (ABG) measures the balance of oxygen and carbon
dioxide in your blood to see how well your lungs are working. It also measures the acid-base
balance in the blood (URMC, 2019) An arterial blood gas (ABG) test measures the oxygen and
carbon dioxide levels in your blood as well your blood's pH balance. The sample is taken from
an artery, not a vein, and healthcare providers typically order it in certain emergency situations.
This test is used to determine the acid-base balance of the patient. Furthermore, this test will
also help in ruling in the diagnosis.
Table 9-5

STAT ABG on Initial MV Set-Up at 100 FiO2

ABG Taken at 8:45 a.m

PARAMETERS Result Reference Value

pH ¯7.30 7.35-7.45

PaCO2 ↑55 mmHg 35-45 mmHg

PaO2 ↑75 mmHg 80-100 mmHg

HCO3 N 22 mEq/L 22-26 mEq/L

SaO2 ¯94% 90-95%

Impression: A low pH level shows acidemia with an increase in pCO2 is called

respiratory acidosis. The slight reduction of HCO3 is the effect of the hydration reaction.
Oxygen desaturation occurs when the body is experiencing low blood oxygen
concentration.

Implication: Uncompensated Respiratory Acidosis with uncorrected Hypoxemia

Post-Hooking ABG from the Current MV Set-up at 100 % FiO2, 03/18/2022

ABG Taken 9:15 a.m.

PARAMETERS Result Reference Value

pH ¯7.30 7.35-7.45

PaCO2 ↑55 mmHg 35-45 mmHg

PaO2 ¯78 mmHg 80-100 mmHg

HCO3 N 22 mEq/L 22-26 mEq/L

SaO2 N 95 % 95-100%

Impression: The pH, HCO3, and PaCO2 are elevated. The PaO2 is also below the
normal range.

Implication: Partially Compensated Respiratory Acidosis.

ABG from Adjusted MV Set-up at 80 % FiO2, 03/20/2022

PARAMETERS Result Reference Value

pH ↑7.50 7.35-7.45

PaCO2 ↑50 mmHg 35-45 mmHg

PaO2 ¯79 mmHg 80-100 mmHg

HCO3 N 27 mEq/L 22-26 mEq/L

SaO2 N 95 % 90-95%

Impression: The patient’s pH, PaCO2 and HCO3 is above normal and Sao2 is 95 %.

Implication: Partially Compensated Respiratory Acidosis with uncorrected hypoxemia

ABG from Current MV Set-up, 03/22/2022, Taken at 8:05 a.m.

PARAMETERS Result Reference Value

pH ↓7.26 7.35-7.45

PaCO2 ↑ 65 mmHg 35-45 mmHg

PaO2 ↓60 mmHg 80-100 mmHg

HCO3 N 23 mEq/L 22-26 mEq/L

SaO2 N 96 % 90-95%

Impression: Uncompensated Respiratory Acidosis with Uncorrected Hypoxemia

Implication: Patient’s acidosis is uncompensated, and the primary problem is in the

ventilation side.

Erythrocyte Sedimentation Rate

Erythrocyte Sedimentation Rate or also called as sedimentation rate test or sed rate test,
it does not diagnose any condition but help medical professionals to determine inflammation
and what further may be needed. An ESR test measures the rate at which your red blood cells
(RBCs) fall to the bottom of a test tube. The blood sample for this test is measured over the
course of hour. Furthermore, if a patient has an acute infection or chronic inflammation it can
increase the RBCs which causes the blood to settle quicker (Goodwin, 2021).

In Kawasaki disease the patient typically shows >40 mm/hr. When patient receives IVIG
therapy and ESR are elevated it indicates positive for Kawasaki disease (The Royal’s Children
Hospital Melbourne, 2021). Table shows Patient J.D ESR test after 1 hour of IVIG which can be
found in the respiratory therapy care plan.

Table 9-6

ESR TEST, 03/18/2022, taken at 10:00 a.m.

ESR : 60 mm/hr

Impression: The RBCs settle quicker in the bottom of the test tube and ESR test is greater than
40 mm/hr.

Implication: Patient has inflammation caused by Kawasaki disease.

C-reactive

A c-reactive protein test measures the level of c-reactive protein (CRP) in your blood.
CRP is a protein made by your liver. It's sent into your bloodstream in response to inflammation.
Inflammation is your body's way of protecting your tissues if you've been injured or have an
infection. It can cause pain, redness, and swelling in the injured or affected area. Some
autoimmune disorders and chronic diseases can also cause inflammation. A health care
professional will take a blood sample from a vein in your arm, using a small needle. After the
needle is inserted, a small amount of blood will be collected into a test tube or vial. (Medline
plus, 2021)

In general, high serum CRP levels are expected in KD. Therefore, in patients presenting
with incomplete KD that does not fulfill the diagnostic criteria, a CRP serum level > 3 mg/dL is
used as a criterion to confirm KD.

Table 9-7

C-Reactive Protein Test

Date of Submission: 03/18/2022 Date of Release: 03/18/2022

Result : 5 mg/L

Impression: The C-reactive protein is elevated.

Implication: A presence of infection leading to acute inflammation.

C-reactive Protein Test

Date of Submission: 03/202022 Date of Release: 03/20/2022

Result : 10 mg/L

C-reactive Protein Test

Date of Submission: 03/22/2022 Date of Release: 03/22/2022

Result : 5 mg/L

Impression: The c-reactive protein is elevated.

Implication: Increased C-reactive protein indicates there is a presence of inflammation.

B. Possible Diagnostic Tests

Renal function Test

Kidney function tests are urine or blood tests that evaluate how well your kidneys are
working. Most of these tests measure glomerular filtration rate (GFR). GFR assesses how
efficiently your kidneys clear waste from your system. (Cleveland Clinic, 2021)

This test is a measure of how well the kidneys are removing wastes and excess fluid
from the blood. It is calculated from the serum creatinine level using age and gender. The
normal value for GFR is 90 or above. A GFR below 60 is a sign that the kidneys are not working
properly. Once the GFR decreases below 15, one is at high risk for needing treatment for kidney
failure, such as dialysis or a kidney transplant. (Kidney Org, 2021)

Kawasaki disease (KD) is a systemic vasculitis and can develop multiple organ injuries
including kidney and urinary tract involvement. Because KD is a systemic vasculitis, multiple
organ involvement can develop, including coronary artery lesions (CALs), carditis, arthritis,
hepatitis, central nervous system (CNS) disease, KD shock syndrome (KDSS), muscle
involvement, hyponatremia and kidney and urinary tract involvement.

Liver enzymes Test

This test is used to measure the level of alkaline phosphatase (an enzyme) in the blood.
Alkaline phosphatase is found in many tissues, with the highest concentrations in the liver,
biliary tract, and bone. This test may be performed to assess liver functioning and to find liver
lesions that may cause biliary obstruction, such as tumors or abscesses. (Hopkins, 2020)

The blood sample for liver function tests is usually taken from a vein in your arm. The main risk
associated with blood tests is soreness or bruising at the site of the blood draw. Most people
don't have serious reactions to having blood drawn (Mayo Clinic, 2021)

Elevated liver enzymes in children are often found during a routine blood test. Elevated liver
enzymes are a warning sign of possible liver damage, irritation or inflammation. Elevated liver
enzymes are usually due to common conditions that are easily treated or resolve on their own.

Albumin Test

Albumin is a protein made by the liver. A serum albumin test measures the amount of
this protein in the clear liquid portion of the blood. Albumin can also be measured in the urine.
Blood is drawn from a vein (venipuncture), usually from the inside of the elbow or the back of
the hand. Serum albumin levels are a useful predictor of IVIG resistance in patients with KD.

Hypoalbuminemia may be present and correlates with a more severe and prolonged
disease course. Hyperbilirubinemia and elevated liver enzymes can be caused by hepatic
congestion, which in turn can lead to obstructive jaundice as well as gallbladder hydrops.

Analysis: Ineffective breathing pattern related to airway obstruction secondary to kawasaki

diseases from CAP complicated to ARDS as evidenced by high C-reactive test result and
elevated WBC.

Planning: At the end of the 8-hour shift, the patient’s ineffective breathing pattern will improve
as evidenced by the following:

a.)Gradual improvement in vital signs as evidenced by:

 ● Decline in respiratory rate from 30/min to range of 22-34/min
● Decline in heart rate from 103 bpm to range of 70-90 bpm
● Decrease in pulse rate from 100 bpm to range of 70-90 bpm
● Drop in blood pressure from 100/85 mmHg to range of 80/50 - 110/80 mmHg
● Gradual improvement in oxygen saturation from 95% to range of 95%-100%

b.) Gradual improvement of ABG values from partially compensated respiratory acidosis
to normal value and improved oxygenation as evidence by:
● pH of 7.50 to normal level of 7.35-7.45
● PaCO2 of 50 mmHg to 35-35 mmHg
● HCO3 of 27 mmHg to 22-28 mEq/L
● Increased in PaO2 from 79 mmHg to 80-100 mmHg

c.) Absence of inflammation from elevated wbc, rbc and c-reactive protein to normal
level.

Intervention:
TABLE

Dependent Interventions with Rationale

Complete Blood Count

Chest X-Ray Chest radiographs should be monitored to know

the severity of the infiltrates.

Electrocardiogram Monitoring To help diagnose and monitor conditions

affecting the heart. It can be used to investigate
symptoms of a possible heart problem, such as
chest pain, palpitations (suddenly noticeable
heartbeats), dizziness and shortness of breath.

Administer medication as ordered by the

physician.
It is given in a single dose to treat and reduce
● IV immunoglobulin inflammation and thereby lessen the duration of
fever.

● Aspirin It is an anti-inflammatory drug that is given to

reduce inflammation.

● Ventolin Ventolin increases airflow and relieves acute

shortness of breath while also preventing
exercise-induced bronchospasms by relaxing
smooth muscle in the bronchial tubes.

● Sarafem Is an antidepressant medication which can also

 help to relieve the anxiety of the patient.

● Budesonide Indicated for patients requiring oral corticosteroid

therapy

Adjusted Mechvent Set-up as per This is to improve ventilation, oxygenation and to

Doctor’s order stabilize the acid base balance of the patient.
The initial MV set-up calculations are the
following:

1. Calculate the patient’s IBW

BSA () = 0.468 / 0.47

2. Initial Tidal Volume

= IBW x 6 mL/ kg

= 16.7 x 6 mL/kg = 100 ml

3. Estimated frequency

f = = 16 /min

4. Minute Ventilation

= f () = 16 (100) = 2 L/min

5. Flow rate

Flow = x Sum of I:E

Flow = 2 L/min x 3 = 6L/min

6. I time

I time = Time for breath (I ratio) / (Sum of I:E

ratio)

Time for each breath = 60 /16 = 3.75s

I time: 3.75 s / 3 = 0.75s

7. Flow rate
 Flow = x Sum of I:E

Flow = 2 L/min x 3 = 6L/min

8. I time

I time = Time for breath (I ratio) / (Sum of I:E

ratio)

Time for each breath = 60 /16 = 3.75s

I time: 3.75 s / 3 = 0.75s

9. Tubing loss, corrected tidal volume,

and static compliance

Tubing loss = (PIP – PEEP) x (TCF = 3

ml/cmh20)

Tubing loss = (28 cmH20 - 5 cmH20) x 3

ml/cmH20

Tubing Loss = 69 mL

Corrected = Expired – Tubing loss

Corrected = 100 mL – 69 mL

Corrected = 31 mL

= 1.5 mL / cmH20

9. Dynamic Compliance

= 1.3 mL/cmH20

10. Mean Airway Pressure

= 6.6 cmH20
Independent Interventions with Rationale

Cardiac monitoring and assessment Take vital signs as directed by conditions;

assess for signs of myocarditis (tachycardia,
gallop rhythm, chest pain); and monitor for heart
failure.

Monitor patient’s response to oxygen Check the patient for any signs of anxiety and
therapy. agitation. When the patient is positively or
negatively responding to the therapy, assess if
there is a need to titrate equipment for delivery

Monitor temperature every 4 hours; Kawasaki disease initially begins with a high
every 2 hours if elevated. fever (102° to 104°F) for 5 or more days in
duration.

Provide adequate rest periods. Bed rest decreases metabolic demands and
oxygen consumption.

Elevate the head of the bed Head elevation helps improve the expansion of
the lungs, enabling the patient to breathe more
effectively.

Assess the characteristics of pain Pain is usually sharp or stabbing and gets worse
especially in association with respiratory with deep breathing and coughing. It can result
cycle in shallow respirations, further impairing
breathing pattern.

Evaluation

Goal Partially met as evidenced by:

Summary of Vital Signs Values throughout the 8hr Shift, 03/22/2022

Parameters 8:00 a.m 10:00 a.m 2:00 p.m Reference

Value

Temperature 37.2 °C 37.1 °C 36.9 °C 36.1-37.2 °C

Pulse Rate 100 bpm 95 bpm 90bpm 70-90bpm

Respiratory 37 breaths/min 32 breaths/min 30 breaths/min 22-34 breaths

Rate per minute
Blood Pressure 100/85 mmHg 81/80 mmHg 75/80 mmHg 80/50 mmHg-
110/80 mmHg

Heart Rate 103 bpm 98 bpm 93 bpm 70-90bpm

SaO2 95% 96 % 95% 95-100 %

● Drop in body temperature from 37.2 °C to 36.9 °C

● Improvement of Oxygenation Saturation from 95 % to 96 %

Summary of ABG Values Throughout the 8 hr Shift, 03/22/2022

Parameters 8:25 a.m 11:25 a.m 2:25 a.m Reference

Value

pH 7.50 7.51 7.49 7.35-7.45

PaCO2 50 mmHg 49 mmHg 48 mmHg 35-45 mmHg

PaO2 79 mmHG 80 mmHg 82 mmHg 80-100mmHg

HCO3 27 mEq/L 26 mEq/L 25 mEq/L 22-26 mEq/L

SaO2 95 % 96% 96% 95-100%

● Improvement of PaO2 from 79 mmHg to 82 mmHg

C reactive Test Result

X- Patient’s C-reactive protein is still elevated ( 6 mg/L).

X-Patient’s WBC is still elevated.

Recommendation

1. Continue monitoring vital signs every 2 hours .

R: To obtain vital signs status of the patient.
2. Continue monitoring ABG
R: To know the acid-base status of the patient.
3. Do handwashing before and after in contact with the patient.
R: Handwashing helps to deter the spread of microorganisms.
4. Provide supplemental care to the patient.
R: Adequate rest is vital for faster recovery of the patient
5. Administer chest physiotherapy by postural drainage and percussion.
R: To eliminate inflammatory exudates and tracheobronchial secretions, remove airway
obstructions, reduce airway resistance, enhance gas exchange and reduce the work of
breathing of the patient.
6. Continut to clean and disinfect mechanical ventilator equipment.
 R: To prevent nosocomial infection that can worsen a patient's condition.
7. Change the patient in a prone position.
R: Turning the patient prone improves perfusion to less damaged parts of the lungs,
improves V/Q matching, and decreases intrapulmonary shunting.
8. Notify the extracorporeal membrane oxygenation (ECMO) team.
R: Notifying the ECMO team is advised when the patient cannot tolerate invasive
mechanical ventilator support.
9. Evaluate the response of the patient to the prescribed medications.
R: To assess if the medication is effective to the patient.
10. Request for another chest radiograph.
R: To monitor the patient’s condition if the improvement associated with ARDS
11. Request for CBC test.
R: To monitor the WBC of the patient..
12. Continue to administer antibiotics.
R: Continue administer antibiotics as per doctor’s order to help reduce and rule out the
presence of bacterial growth that may cause further complications.
13. Request and Monitor C-Reactive Protein level.
R: To know if there is still inflammation.
14. Continue to administer aspirin as per physicians order.
R: To reduce and eliminate inflammation.
15. Adjust Mechvent set-up as physician’s order.
R: To normalize the acid-base balance of the patient.
Respiratory Therapy Care Plan #3

TABLE 3-1
RT Care Plan #1 Patient Data
Name : JD
Weight : 16.7 kg
Age :4 Date : 03/22/2022
Sex : Male
Time : 8:05 AM
Unit : PICU Diagnosis : Kawasaki Disease Secondary to ARDS from
CAP
Height : 100.9 cm Physician : Dr. del Rosario

Subjective: The patient is sleeping and receives NCPAP.

Objective:
TABLE 3-2
Baseline Vital Signs Upon Assessment, 03/22/2022
Taken at 8:05 AM Reference Value
Temperature : ↑ 37.5 °C (ax.) 36.1-37.2°C (ax.)
Pulse Rate : ↑ 105 bpm 70-90 bpm
Respiratory Rate : ↑ 40 /min 22-34/min
Blood Pressure : ↑ 112/84 mmHg 80/50 mmHg – 110/80 mmHg
Heart Rate : ↑ 100 bpm 70-90 bpm
SpO2 : N 96 % 95-100%
Impression: VS reveal increased temperature, PR, RR, BP, HR; and normal SaO2
Implication: Patient is febrile, tachycardic, tachypneic, and hypertensive
Pediatric GCS and Level of Consciousness, 03/22/2022, 8:05 AM
Eye Opening : 4 (Spontaneous)
GCS Score : 10
Verbal Response : 1 (Intubated)
Motor Response : 5 (Moves to localized pain) LOC : Obtunded
Impression: Moderate brain injury (10), patient is intubated but responds minimally to
stimuli such as through shaking or asking questions.
ABG on Current NCPAP Set-up, 03/22/2022, 8:05 AM
ABG Taken at 8:05 AM Reference Values
pH : ↓ 7.27 7.35-7.45
PaCO2 : ↑ 65 mmHg 35-45 mmHg
PaO2 : ↓ 60 mmHg 80-100 mmHg
-
HCO3 : N 23 mEq/L 22-26 mEq/L
SaO2 : N 96 % 95-100%
Impression: Uncompensated Respiratory Acidosis with Uncorrected Hypoxemia
Implication: Patient’s acidosis is uncompensated, and the primary problem is in the
ventilation side.

TABLE 3-3
Current NCPAP Set Up, 03/22/2022, 8:05 AM
FiO2 : .60 Flow : 10 L/min Pressure : 5 cm H2O

Cephalocaudal Assessment on 8:06 AM

Head
 Upon Inspection, the patient’s head is spherical, normocephalic, and symmetrical, with
frontal, parietal, and occipital prominences upon examination. No swelling and birthmarks were
observed. The features and movements of the face are symmetrical, and no hair infestations.
Upon palpation, no nodules or masses palpated.
Eyes
Upon Inspection, the eyes of the patient were symmetrical with red discoloration and
discharges were noted due to runny nose. There is symmetry in both eyes without opacities in
the red reflex test. Eyebrows are symmetrical, evenly distributed, and moved equally. Eyelashes
are equally distributed and curled slightly outward. Eyelids close symmetrically. Both were dark
brown, isochoric, and pupils are equal, round, and brisk upon light accommodation. Both sclera
and conjunctiva were clear and anicteric.
Upon palpation, no edema or tenderness noted.
Ears
Upon Inspection, auricles are symmetrical and aligned with the outer canthus of the
eye. Ears are the same color as facial skin.
Upon palpation, there is no swelling, lumps, or tenderness noted. The pinna recoils
after it is folded.
Nose
Upon Inspection, the nose is uniform in color, nasal septum is intact and in midline and
no engorgement of maxillary sinuses. Nasal flaring is observed. The patient is in continuous
supplementation of oxygen with 0.6 FiO2 via nasal CPAP of 5 cm H2O and 5 L/min.
Upon palpation, maxillary and frontal sinuses are not tender.
Mouth
Upon inspection, the lips are dry and have no presence of discoloration. The buccal
cavity there is no ulceration, nodules, swelling, and discoloration noted. Uvula is midline, maxilla
and mandible fit together well and open at equal angles and there is minimal salivation. There is
a presence of swollen white coating in the tongue with red lumps.
Upon Palpation, there were no submucosal and mucosal clefts noted.
Neck
Upon inspection, the neck appeared symmetric and sore throat was present. Trachea
is in midline and there is a use of the accessory muscles such as sternocleidomastoid and
supraclavicular due to the difficulty of breathing.
Upon palpation, there is a presence of swollen lymph nodes and pain around the neck
was noted. The clavicles are intact, and no swelling was noted
Thorax and lungs
Upon inspection, it appears cylindrical and symmetrical, with the sternum no protrusion
nor depression. Visible indentations between the ribs resulting in intercostal and subcostal
retractions were present. The electrodes placed at various spots on the thoracic area connected
to a cardiac monitor to detect electrical activity of the heart through the skin.
Upon palpating the chest, no masses nor swelling were present.
Upon percussion, dull thuds were heard over the chest.
Upon auscultating the lungs, crackles and dull sound is present. There were no
irregular heart rhythms, and the point of maximal impulse is at the 5 th ICS, LMCL upon
auscultating patient’s chest area.
Abdomen
Upon inspection, the abdomen of the patient is symmetrical, round, and has no lesions.
No visible vascular pattern or lesions. Color is uniform all throughout the abdomen.

Upon auscultation, normal bowel sounds are heard.

Upon percussion, there is no tympany over the stomach and gas-filled bowels, no
dullness over the liver and spleen.
Upon palpation, the abdomen was soft to touch, no areas of tenderness found in all
four abdominal quadrants and abdominal respirations were observed. No evidence of
abdominal distention.
Upper Extremities
Upon inspection, the upper extremities appeared to be equal in size. There are five
fingers on each hand with a normal palmar crease. The capillary refill time is greater than 3 with
good skin turgor but there is presence of rashes, dryness, and irritation. A 22-gauge IV line of
0.9 normal saline was inserted in the right dorsal metacarpal vein secured with an IV board and
tape. A pulse oximeter is attached at the right middle finger with a reading of 96%. An indwelling
vascular line was inserted on the right brachial artery for A-line access.
Upon palpation, no edema or swelling is present.
Lower Extremities
Upon inspection, both lower extremities appeared to be equal in size. No digital
clubbing noted. There are five toes on each foot and there is presence of rashes, irritation, and
dryness on patient’s diaper area.
Upon palpation, there are no peripheral edema, lumps and any deformities noted. The
skin of the feet was warm when touched.
Genitalia
Upon Inspection, a catheter was inserted on for urination.

TABLE 3-4
Complete Blood Count Result for Infection Evaluation, 03/22/2022
CBC Result Received at 8:30 AM Reference Value
HGB : N 12.8 g/dL 10.2-15.2 g/dL
HCT : N 42% 36-46%
6
RBC : N 4.50 x10 /uL 4.0-5.20 x 106/uL
MCH : N 25 pg 23-31 pg
MCHC : N 33% 32-36%
MCV : N 81 fl 78-94 fl
3
WBC : ↑ 18.5 x 10 /uL 5.0-17.0 x 103/uL
Neutro : ↑ 13 x 103/uL 1.5-11.0 x 103/uL
Lymp : ↑ 12 103/uL 1.5-11.1 x 103/uL
Mono : ↑ 1.2 103/uL 0.1-1.15 x 103/uL
3
Eo : ↑ 0.9 10 /uL 0.0-0.7 x 103/uL
Baso : ↑ 0.5 103/uL 0.0-0.3 x 103/uL
PLT : ↓ 140 x 103/uL 150-450 x 103/uL
Impression: WBC components were elevated.
Implication: Increased WBC indicates that there is a presence of infection.
Chest Radiography Result, 03/22/2022
CXR Result Received at 1:15 pm Reference Image (AP view)

A B
Impression:
A) Chest radiograph shows confluent airspace opacity in the right and upper
lobe of the lungs and patchy infiltrates with air bronchogram indicating
consolidation or accumulation of secretions in the lung parenchyma.
B) Normal chest radiograph of a healthy child. Both lungs are clear and
expanded. No suspicious pulmonary opacities and no focal features of
consolidation.
Implication: Consolidated lungs because of accumulated secretions from infection.
C-Reactive Protein Test Result, 03/22/2022
C-Reactive Protein Test Taken at 8:08 AM
Result : 4 mg L
 Impression : C-reactive protein is elevated
Implication : Increased C-reactive protein indicates there is a presence of inflammation.
ECG Result, 03/22/2022
ECG Taken at 8:06 AM

Impression:
Rate : 100 bpm P waves : Upright and Regular QRS : 0.04 sec
Rhythm : Regular P-R interval : 0.16 sec

Implication: Sinus Tacycardia

Analysis: Ineffective airway clearance related to consolidated airway secondary to Kawasaki

disease from CAP complicated to ARDS as evidenced by presence of crackles upon
auscultation, opacity, and infiltrates in the upper right lobe of the lungs as seen in the chest x-
ray, tachypnea, and patient’s use of accessory muscles.

Planning: At the end of our 8-hour shift, the patient’s ineffective airway clearance will be
improved as evidenced by the following:
a) Gradual improvement in vital signs as evidenced by:
 Drop in body temperature from 37.5°C to range of 36.1-37.2°C
 Improvement in heart and pulse rates from 100 bpm to range of 70-90 bpm
 Improvement in spontaneous respiratory rate from 40/min to range of 22-34/min
 Decrease in blood pressure from 112/84 to range of 80/50 mmHg – 110/80 mm Hg
b) Gradual improvement in ABG values as evidenced by:
 pH of 7.27 increasing to the range of 7.40-7.45.
 Decline in PaCO2 from 65 mm Hg to the range of 50-55 mm Hg.
 Improvement in PaO2 from 60 mmHg to the range of 70-80 mm Hg.
c) Free signs of respiratory distress as evidenced by:
 Reduce crackling sounds upon auscultation
  Without using of accessory muscles
 Ease of hyperventilation
Intervention:
Intervention:
TABLE 3-5
Dependent Interventions and Rationale
Perform ABG
To monitor the patient’s blood gas values
Extraction
Chest radiography should be ordered to assess lung field
Chest Radiography
consistency and monitor any heart structure abnormalities.
C- Reactive Protein To monitor the level of c-reactive protein in patient’s blood
Test and to look out for presence of inflammation.
Electrocardiogram Electrocardiogram is ordered to monitor the heart electrical
Monitoring activity of the patient and to assess any heart disease.
Administer
It is given in a single dose to treat and reduce inflammation
Immunoglobulin via
and thereby lessen the duration of fever.
IV as ordered by the
physician
Administer anti-
inflammatory drug It is an anti-inflammatory drug that is given to reduce
(Aspirin) as ordered inflammation.
by the physician
Administer anti-
Ventolin increases airflow and relieves acute shortness of
bronchodilator
breath while also preventing bronchospasms by relaxing
(Ventolin) as ordered
smooth muscle in the bronchial tubes.
by the physician
Administer anti-
Is an antidepressant medication which can also help to
antidepressant
relieve the anxiety of the patient
(Sarafem) as ordered
by the physician
This is to improve the acid-base status of the patient. The
following NCPAP adjustments were made during the 8-
Lung Expansion hour shift:
Therapy via NCPAP
New Pressure = 6 cm H2O

Independent Interventions and Rationale

Take vital signs as directed by conditions; assess for signs
Vital Signs
of myocarditis (tachycardia, gallop rhythm, chest pain); and
Monitoring
monitor for heart failure.
Auscultation of To check for the presence of secretions, crackles,
Breath Sounds bronchospasm, or any lung abnormalities.
Establish patient and
watcher’s rapport and To gain patient and watcher’s trust and comfort.
explain all the Information can help alleviate anxiety associated with the
procedures and disease.
treatments.
Check the patient for any signs of anxiety and agitation.
Monitor patient’s
When the patient is positively or negatively responding to
response to oxygen
the therapy, assess if there is a need to titrate equipment
therapy
for delivery
Monitor temperature
Kawasaki disease initially begins with a high fever (102° to
every 4 hours; every
104°F) for 5 or more days in duration.
2 hours if elevated
Monitor respiratory Respiratory rate and rhythm changes are early signs of
rate, depth, and impending respiratory distress. Tachypnea is a typical
Evaluation:
Goals are partially met as evidenced by:
TABLE 3-6
Summary of Vital Sign Values Throughout the 8-hr Shift, 12/13/2021
8:05 AM 9:00 AM 12:00 PM 3:00 PM Reference
(Post-VS Value
after
Parameters
NCPAP
adjustment
)
37.5°C 37.4°C (ax.) 37.2°C 37°C (ax.) 36.5-37.5°C
Temperature
(ax.) (ax.) (ax.)
Pulse Rate 105 bpm 101 bpm 98 bpm 95 bpm 70-90/bpm
Respiratory Rate 40/min 40/min 38/min 36/min 22-34/min
112/84 112/75 110/70 106/66 80/50 mmHg –
Blood Pressure
110/80 mmHg
Heart Rate 100 bpm 96 bpm 93 bpm 90 bpm 79-90 bpm
SpO2 96% 96% 96% 97% 95-100%
 Drop in body temperature from 37.5°C to 37°C
 Gradual improvement in heart and pulse rates from 100 bpm to 94 bpm
 Gradual improvement in respiratory rate from 40/min to 36/min
 Gradual improvement in blood pressure from 135/93 to 115/70
Summary of ABG Values Throughout the 8-hr Shift, 12/13/2021
8:05 AM 9:00 AM 12:00 PM 3: 00 PM Reference
(Post-ABG Value
after
Parameters
NCPAP
adjustment
)
pH 7.27 7.28 7.33 7.35 7.35-7.45
PaCO2 65 mmHg 63 mmHg 58 mmHg 55 mmHg 35-45 mmHg
PaO2 60 mmHg 65 mmHg 72 mmHg 80 mmHg 80-100 mmHg
HCO3- 23 mEq/L 23 mEq/L 24 mEq/L 24 mEq/L 22-26 mEq/L
SaO2 96% 96% 96% 97% 95-100%
 Gradual increase in pH from 7.27 to 7.35
 Gradual decrease in PaCO2 from 65 mmHg to 55 mmHg
 Gradual increase in Pa O2 from 60 mm Hg to 80 mm Hg
Implication: Uncompensated Respiratory Acidosis with Corrected Hypoxemia
Free of Signs of Respiratory Distress
 Reduced crackling sounds upon auscultation
 Visible and decrease use of accessory muscles
Recommendation:
1. Continue monitoring the patient's vital signs:
R: Used as baseline data to assess the response of the patient towards the given
treatment and intervention.
2. Continue to assess ABG and the patient's oxygenation status:
R: To monitor the oxygenation and acid-base status of the patient.
3. Perform frequent hand hygiene/medical handwashing:
R: This deters the spread of microorganisms and decreases the transmission of infection
in the ICU.
4. Continue administration of IV TPN:
R: Patient is reliant on TPN to sustain bodily nutrient requirements especially when the
patient cannot receive feeding PO.
5. Perform suctioning as needed:
R: To clear out secretion and help maintain patent airway.
6. Continue frequent disinfection of ventilator equipment:
R: To prevent nosocomial infection and transmission of infection to the patient.
7. Continue and maintain nasotracheal tube integrity:
R: Monitoring nasotracheal tube integrity ensures effective delivery of O2 to the patient.
8. Request for a new chest radiograph:
R: To monitor the cardiopulmonary status of the patient.
9. Request for a new CRP
R: To monitor presence of inflammation.
10. Request for CBC
R: To monitor WBC.
11. Continue to administer the prescribed medications
R: Patient’s status is improving. Continuing the medications may aid for a faster
recovery.
12. Continue NCPAP set-up [ Flow: 10 L/min Pressure: 6 cm H2O FiO2: .60]:
R: Mechanical ventilation should be continued until acid-base status is stabilized to
chronic state.
13. Wean FiO2 and Pressure as per doctor’s order:
R: Weaning the FiO2 and PEEP is indicated since normoxemia is achieved and to avoid
oxygen toxicity and complications.