Quezon Medical Mission Group Hospital and Health Services Cooperative Roeder Max R. Pangramuyen CI -Mrs. Melena V.

. Quintos Related Learning Experience BSN IV SLSU Group 7

CASE NARRATIVE Intensive Care Unit is a special area which caters mostly critically ill patients. It is different from other ward in a sense that holistic approach, urgent interventions, keen observation, critical thinking and judgment is brought to higher level. This week we only had one day to be exposed in ICU, but still I grabbed every minute of it to gain learning and took opportunity to enhance my nursing knowledge, skills, and attitude in caring critical patient.

I handled patient on ICU C, Mrs. Adelaida Ambas, a 62 year old female, born on November 19,1944, Roman Catholic, widowed woman, with chief complaint upon

admission of difficulty of breathing. He was admitted last August 6, 2013 at around 4:35pm under the service of Dr. Jao and with co management of Dr. Enriquez and Dr. Guzman, initial diagnosis was Bronchial Asthma in Acute Exacerbation t/c pneumonia, she had allergies with sea foods and poultry products, and diet as tolerated with strict aspiration was ordered.

Prior to admission the client was on her home and had an asthma attack, she was brought to QMMG-HHHS and admitted to NS1 room 211. Different examination were ordered and she was hooked with D5NM 1L x KVO. GCS by that time was 15, and no other complaints other than difficulty of breathing. Result of CBC was within normal levels and ABGs result were as follows pH 7.26, pCO 2 64.8, pO2 63.5, HCO3 28.5, and O2 sat 88.3% which indicates respiratory acidosis partially compensating. Upon history taking, the S.O. said that the patient already had been hospitalized several times due to her asthma attacks and these was the most severe when she was brought to ICU. The patient also had scoliosis which can be the cause of her back pain and shortness of breath due to compression of the lungs.

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Quezon Medical Mission Group Hospital and Health Services Cooperative August 8, 2013 the pt coughed with blood, and the breathing became most severe. Tranexamic Acid 500mg IV a haemostatic was given.

August 09, 2013 the patient was inserted with foley catheter (change q 3-5 days) upon the request of the relative, still with hemoptysis and Dr. Guzman marked her with upper gastrointestinal bleeding (UGIB) and ordered to have general liquid diet. Based on ECG, officially read by Dr. Enriquez, the pt had cardiac dysrhythmia secondary to electrolyte imbalance, hyponatremia. Digoxin 0.25mg 1 tab OD an inotropic drug, and NaCl 1 tab TID as a treatment for sodium depletion was given.

Then on August 10, 2013 the pt was transferred to ICU, hooked with endotracheal tube, connected to mechanical ventilator, nasogastric tube was inserted and osteorized feeding low fat 1400 kcal divided into 6 equal feedings was started. Mechanical ventilator was set up with FlO2 80%, TV 350L, and BUR 16bpm. Result of electrolyte levels revealed that sodium level was 135mg/dl and potassium was 5.31mg/dl which were both on normal levels.

On August 14, 2013, the pt had positive tymphanitic abdomen, complaints epigastric pain, with residual on nasogastric tube and it was connected to urine bag. The patient also had negative bowel movement since admission and Dr. Enriquez noted that the pt has Ileus 20 to hypokalemia (decrease in potassium levels decrease the contraction of smooth muscle of the intestines thus decreasing/stops the bowel movement). Anti ulcer drug, proton pumps inhibitor- Omeprazole 40mg IV now and Domperidone 10mg 1tab TID (once with diet) indicated for dyspeptic symptoms associated with GERD were given. Lactulose 30cc ODHS (hold if with LBM), a laxative that produces an osmotic effect in colon and promotes peristalsis was also given.

On August 17, 2013 the pt again had bloody secretions on ET, and was restarted with hemostatic treatment, an antihemmorrhagic and anti fibrinolytic - Hemostan 500mg IVq8.

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Quezon Medical Mission Group Hospital and Health Services Cooperative August 20, 2013 was the first and last time when I handled the patient. Upon assessment I noted that the patient was on her 12th Bottle of D5NM 1L X KVO inserted at her right cephalic vein, NGT was inserted at left nostril, she also was still hooked at endotracheal tube connected to mechanical ventilator with the following set up Fl0 2 50%, BUR 12bpm, PFR 80, TV 350L, sensitivity 2.0, PSV15cmH20, and foley catheter connected to urine bag draining yellowish to dark yellow urine moderate in amount. The pt. had negative bowel movement since Aug. 16, reports back pain due to history of scoliosis and due to prolonged lying (because it was her 15th day of hospitalization) and it was also noted that she had slight redness on her back, frequent turning and Fastum gel an non steroidal anti-inflammatory drugs was applied at her back BID.

Urinalysis result shows risk for urinary tract infection. It was yellowish to dark yellow in color, slightly turbid, acidic, with trace of albumin, with RBC 10/hpf, pus cells 48/hpf, rare crystal A. urates and epithelial cells and had few bacteria. The catheter was frequently changed 3-5 days to prevent further urinary tract infection. Meropenem (Merop) a miscellaneous anti-infectives which destroys bacteria causing urinary infection was started last Aug. 9.

CBC results were as follows Hgb 143mg/dl, Hct 0.43, RBC10^12, WBC 9.6 10^g/L, Platelet count 160g/L, which were within normal levels. The patient was assisted on doing range of motions exercises and had rest periods in between activities.

ABGs results on August 20 were as follows: pH 7.495, pCO2 58.4, pO2 89, HCO3 44.6, and O2 sat 97% which indicates metabolic acidosis partially compensating. Based on assessment, the pt had wheezing sounds upon auscultation, uses accessory muscles when breathing, respiratory rate was 15bpm, and complaints of difficulty of breathing. Medication such as hydrocortisone 100mg IV q60, a corticosteroid that decreases inflammation mainly by stabilizing leukocyte lysosomal membranes, Ceterizine diHCl (Alnix) 20mg 1 tab ODHS a symptomatic relief of allergic rhinitis, meropenem (Merop) a miscellaneous anti-infectives which destroys bacteria causing formation of secretions and Burinex 1mg 1tab OD loop diuretic that inhibits sodium Case Narrative Page 10

Quezon Medical Mission Group Hospital and Health Services Cooperative chloride reabsorption at the ascending loop of henle was given to remove fluids in the lungs (pulmonary edema). Sodium level was 135.5mmol and Potassium was 3.52mmol, continuous treatment with NaCl 1 tab BID and Kalium Durule 2 tabs TID were given due to diuretic and low levels of electrolytes. Respiratory therapies also gave combivent neb q60 and Flixotide neb q120, bronchodilators for better breathing pattern; chest physiotheraphy, postural drainage, and suctioning were done to remove the secretions. Before I left the set up of mechanical ventilator was changed and the pt was started to wean with, had GCS score of 11/15, performed breathing exercises, and used less effort when breathing.

By the time I handled this patient, I was able to do things such as assesses level of consciousness and complaints of pain, monitor client vital signs q30 (which a little bit lighter due to cardiac monitor), noting intake and output, assisting the staff nurses when suctioning, frequently turn patient and assess for redness on her back, and NGT feeding (which became easier and faster because I already mastered it last time). I also came to realization that therapeutic approach, keen observation; careful monitoring and frequently informing the doctors the clients status and result of diagnostic examinations were crucial points to be practice as an ICU nurse.

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