INTENSIVE CARE UNIT CASE
STUDY:
ICU G
PREPARED BY:
ABABA, NICOLE
AGUM, PHILIP
ANDRADE, CHERY
ASCORA, MELARIE
AYCARDO, ALEXANDRA
BARSANA, AHSLY
BUENVIAJE, FAITH
CAGUIMBAL, YRAMENRI
BSN 2 SECTION 2
FEBRUARY 23rd, 2023
DEMOGRAPHIC DATA (HILARY)
Name: Pedro P.
Birthdate: July 22, 1946
Age: 76 years old
Sex: Male
Address: 22 Visitacion Street, San Joaquin, Pasig City
Civil Status: Widow
Religion: Roman Catholic
Nationality: Filipino
Room Number: ICU G
Diagnosis: Pneumonia r/o ACS
Attending Physician: Dr. Mariecris Mercado
Date of Admission: February 8, 2023
Chief Complaint: Body Weakness and Difficulty of Breathing
NURSING ASSESSMENT (MIRANG)
Level of consciousness:
The patient is still conscious he knows the date, including the year and the day. He knows his
name, age and where he is and the day he was confined and admitted to ICU.
Skin:
(+) bruises, redness, edema, and lesions.
Head:
(+) his head is symmetrical, no lesions, no scars.
Eyes:
His eyes are equal and its color is a bit yellow.
Mouth:
(+) pallor, lingering of mandible, dry
Nose:
(+) dry, symmetrical
(-) malformations, discoloration, swelling
Chest/ Lungs:
PR: 84
(+) redness at his chest
Abdomen:
(+) Soft, symmetric, and non-tender without distention.
Pain score:
The patient verbalizes that his body is weak and he rates his weakness 7, 1 is the lowest and
10 is the highest.
Stool:
x3, yellowish, watery
Extremities:
(+) edema, dark color, dry
(+) impaired right arm and right leg
GORDON’S FUNCTIONAL PATTERN (Ababa)
Activity of Before Hospitalization During Hospitalization
Daily Living
1. Nutrition Has a very good appetizer; Eats 3x/day with difficulty
eats 2-3 cups of rice per meal. swallowing.
Eat 3x/day and sometimes Drinks approximately 30 ml of
even eat biscuits for snacks. water/day.
Drinks approximately 6 cups of After a week of being hospitalized
water. the physician advice put the
patient into NGT feeding.
2. Urinates without difficulty and Urinates more frequently.
Elimination experiences no pain when
voiding. Voids 3-4x/day.
Urine is light amber in color, is Stool is light yellow to light brown
aromatic, and adequate in color, liquid in consistency with
amount. blood.
Voids 5-6x/day.
Delegates once every morning
without pain and difficulty.
Stool is light brown to brown in
color , semi solid in
consistency, soft and tubular.
3. Exercise Sits on the chair most of the Lying in bed most of the time.
time while watching TV.
Can’t perform ROM (Range of
Doesn’t have time to exercise Motion) exercise because he
and considered walking experiences DOB (difficulty of
around the village as an breathing).
exercise.
Can’t perform ADL (activities of
daily living).
4. Hygiene Bathes once everyday , Never taken a full bath since he
shampoos hair and cleanses was hospitalized.
the body with soap and towel.
Daily regimen includes using a
Brushes teeth 2x/day. towel with soap to wipe clean the
body parts.
Gets fingernails cleaned and
trimmed. Hair hasn't been washed since
the first day of hospitalization.
Change clothes everyday.
Nails are not cut but clean and
Comb hair everyday. reddish.
5. Drink alcoholic beverages Does not drink alcoholic
Substance sometimes. beverages since he was
Use hospitalized.
Does not use any form of
recreational drugs. Does not use any form of
recreational drugs.
6. Sleep and Usually sleeps at around 8 or The patient can sleep easily.
Rest 9 pm and wakes up 7 to 7:30
am. Wake up for vital signs.
Describe sleep as complete Describe sleep as incomplete and
and started feeling relaxed feels tired even after waking up.
after waking up.
Sleeps lightly and is easily
Sleep soundly and describe awakened by disturbance in the
sleep as deep. environment.
Wake up in the middle of the
night to urinate but can easily
go back to sleep.
7. Sexual Inactive sex life. Inactive sex life.
Activity
NURSING DIAGNOSIS (FAITH & YRA)
● Ineffective breathing pattern related to excessive lung fluid as evidenced by shortness of
breathing.
● Risk for aspiration related to impaired swallowing of fluids and solid foods.
● Decreased Activity Tolerance related to general weakness due to respiratory muscle
fatigue as evidenced by exertional dyspnea.
● Ineffective Airway Clearance related to pleuritic pain as evidenced by ineffective
cough.
DISEASE OF THE PATIENT (ALEX)
Community Acquired Pneumonia is the disease of the patient. According to Sanjay Sethi,
MD from University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Community
Acquired Pneumonia or CAP is an infection of the lungs that often affects either healthy or
immunocompromised individuals who are not hospital patients and have not had regular
exposure to the health care system. It is one of the most prevalent infectious illnesses and a
significant contributor to mortality and morbidity globally. Community Acquired Pneumonia is
brought on by a variety of microorganisms, including bacteria, fungi, parasites and viruses. The
precise bacteria that causes pneumonia is typically not known. But, based on the patient’s age
and other characteristics, such as if they have other illnesses, the doctors can easily determine
which microorganisms are most likely to be the cause of the pneumonia.
There are 4 most common bacterial causes of Community Acquired Pneumonia, these are
the following; Streptococcus pneumoniae, Haemophilus influenzae, Chlamydophila pneumoniae
and Mycoplasma pneumoniae. First is Streptococcus pneumoniae, it is a bacteria that causes
pneumococcal disease and commonly found in the respiratory tract of those people who are
healthy, especially children. Second, Haemophilus influenzae may occur in adults but is more
common among children. Though, children are now immunized against H. Influenzae so it
became less common to children. Third, Chlamydophila pneumoniae often results in a mild form
of pneumonia that can be treated at home. Lastly, Mycoplasma pneumoniae is most common in
older children and adults younger than 40 years old, particularly those who reside in crowded
areas. It is rarely severe and the symptoms can last for weeks and even in months.
People who smoke, have weak immune systems & have health problems like diabetes,
cancer etc., have other lung problems such as Chronic Obstructive Pulmonary Disease (COPD),
kidney failure and heavy alcohol use are all at risk for Community-Acquired Pneumonia.
Symptoms of Community Acquired Pneumonia often develop quickly such as coughing, fever,
chills, chest pain when breathing or coughing, shortness of breath, have upper abdomen pain
with nausea, vomiting or diarrhea, have fast heartbeat & breathing rate and there are certain
sound coming from lungs on lung exam.
( source/s:)
“Community-Acquired Pneumonia - Lung and Airway Disorders.” Merck Manuals Consumer
Version,
www.merckmanuals.com/home/lung-and-airway-disorders/pneumonia/community-acquired-pne
umonia.
Lutfiyya, M. Nawal, et al. “Diagnosis and Treatment of Community-Acquired Pneumonia.”
American Family Physician, vol. 73, no. 3, 1 Feb. 2006, pp. 442–450,
www.aafp.org/pubs/afp/issues/2006/0201/p442.html#:~:text=to%20 typical%20 causes.-.
HISTORY OF THE PATIENT (PHILIP)
a. Biographic
Patient Pineda, 76 years old, currently resides at Visitacion San Joaquin, Pasig City. He was
born July 22, 1946. His religious affiliation is Roman Catholic. The patient was admitted at Tricity
Medical Center with a chief complaint of Difficulty of Breathing and Shortness of breathing.
b. Reason for Seeking Health Care
Patient Pineda seeks medical attention with the following chief complaint; Difficulty of
Breathing and Body Weakness.
c. Present Medical History
Patient Pineda was brought to Tricity Medical Center because he complained of Difficulty
Breathing and body weakness. He received medicines for his maintenance such as Cilostazol
500 mg, Citicoline 500 mg, and Atorvastatin 10 mg. He also experienced a 1-week history of
on-and-off episodes of Shortness of Breath for a few hours pre-still with Difficulty of Breathing.
d. Past Medical History
Patient Pineda experienced Hypertension, allergies and Neurocirculatory Asthenia (NCA). In
October 2002, he also experienced Chronic Obstructive Pulmonary Disease (COPD) and a
history of Stroke in 2009. Last year, October 22, 2022, patient Pedro was infected by COVID-19.
He received these following medications, Tiotropium + Olodaterol Nac, Azithromycin, Isoniazid +
Rifampicin Fixcom and N- Acetyl cysteine 600 mg during his last consultation.
Diagnosis (Barsana)
Diagnostic Criteria for Pneumonia:
Presence of at least 4 of the following 6 signs:
Chest pain when breathing or coughing. ✓
Loss of appetite, low energy, and fatigue. ✓
Confusion, especially in older people. ✓
Lower than normal body temperature
Cough, which may produce phlegm. ✓
Diarrhea ✓
Hematology: February 12, 2023
Normal Laboratory Result
RBC 4.7 - 6.1 3
Hgb 13.8 - 17.2 9.3
Hct 41 - 50 27
WBC 4.5 _ 11 9.7
Basophil 0.5 - 1 1
Segmenter 35% - 75% 84
Lymphocyte 20% - 40% 7
monocyte 2% - 10% 5
Platelet Count 150 - 450 216
Creatinine 0.7mg/dL - 1.3 mg/dL 6.30
Sodium 135mEq/L and 145 mEq/L 148.3
Potassium 3.6mmol/L - 5.2 mmol/L 2.45
Chloride 96mmol/L - 106 mmol/L 114.0
Magnesium 1.7mg/dL - 2.2 mg/dL 1.87
Troponin I 0ng/mL and 0.04 ng/mL 1.13 ng/ml
Blue - Low than the normal range
Red - High than the normal range
Black - Normal
X-ray Findings
Based on Chest X ray finding was diagnosed having Pneumonia. X-ray shows an area of
lung inflammation indicating the presence of pneumonia. There are also pleural effusions that
show an excess of fluid in the pleural cavity.
Drug Study (Andrade)
Trimetazidine
Classification : fatty acid oxidation inhibitors.
Desired Effect: It helps metabolize fatty acids, which helps your body use oxygen. The drug
allows for more blood flow to your heart and limits quick changes in your blood pressure. This
can help lessen chest pain from blocked blood vessels. It can also improve overall performance
in someone with a heart-related disease.
Side Effects: Most common side reactions Nausea, vomiting
Abdominal pain, indigestion
Diarrhea
Dizziness
Headache
Feeling weak
Rashes
Nursing Interventions:
Treating angina.
The nurse should instruct the patient to stop all activities and sit or rest in bed in a semi-Fowler’s
position when they experience angina, and administer nitroglycerin sublingually.
Reducing anxiety.
Exploring implications that the diagnosis has for the patient and providing information about the
illness, its treatment, and methods of preventing its progression are important nursing
interventions.
Preventing pain.
The nurse reviews the assessment findings, identifies the level of activity that causes the
patient’s pain, and plans the patient’s activities accordingly.
Decreasing oxygen demand.
Balancing activity and rest is an important aspect of the educational plan for the patient and
family.
Nebivolol
Classifications
- Beta- Blocker
Desired effects
- It works by relaxing blood vessels and slowing heart rate to improve blood flow and
decrease blood pressure.
Side effects
- Headache
- Dizziness
- Swelling in you legs
- Slow heartbeats
- Tiredness
Nursing interventions
- Monitor BP, ECG, and pulse prior to and periodically during therapy.
- Monitor intake and output ratios and daily weights.
- Advise to take bystolic every day exactly as your doctor tells you. Do not suddenly stop
taking bystolic. You could have chest pain or a heart attack.
- To minimize orthostatic hypotension, patient should move slowly when assuming a more
upright position.
- Establish aerobic exercise workloads that account for the effects of beta blockers on heart
rate. Some heart rate guidelines may not be appropriate because beta blockers typically
decrease maximal HR by 20–30 bpm. Use other guidelines such as rating of perceived
exertion (RPE, modified Borg scale) to determine exercise workloads.
Cilostazol
Classification
antiplatelet agent and vasodilator
Desired Effect
improves the flow of blood through the blood vessels. It is used to reduce leg pain caused
by poor circulation (intermittent claudication). Cilostazol makes it possible to walk farther
before having to rest because of leg pain.
Side Effects
CNS: headache, dizziness.
CV: palpitations, tachycardia.
GI: diarrhea.
Nursing Interventions
Implement therapeutic exercises and ambulation activities to augment the effects of drug
therapy and promote increased walking distance. Patients should attempt to walk as long as
possible after the onset of leg pain, and progressively increase the time spent walking
before stopping due to claudication.
Because of the risk of tachycardia and other arrhythmias, use caution during aerobic
exercise and other forms of therapeutic exercise. Assess exercise tolerance frequently
(blood pressure, heart rate, fatigue levels), and terminate exercise immediately if any
untoward responses occur
Instruct the patient to take cilostazol on an empty stomach, exactly as directed.
Advise the patient to avoid grapefruit juice during therapy.
May cause dizziness. Caution patients to avoid driving or other activities requiring alert-ness
until response to medication is known.
Advise the patient to avoid smoking. Nicotine constricts blood vessels.
Ceticoline
Classifications
- Proton- pump inhibitor
Desired effects
- enhance cellular communication by increasing levels of neurotransmitters.
Side effects
- Fleeting and discrete hypotension effect
- Increased parasympathetic effects
- Hypotension
- Itching or hives
- Swelling in face or hands
- Chest tightness
- Tingling in mouth and throat
- Headache
- Nausea
- Diarrhea
- Blurred Vision
Nursing interventions
- Instruct the patient to take the medication as prescribed.
- Teach the patient that citicoline may be taken with or without food.
- Monitor for adverse effects; instruct the patient to report immediately if he/she develops
chest tightness, tingling in mouth and throat, headache, diarrhea and blurring of vision.
- Contact the physician immediately if allergic reactions such as hives, rash, or itching,
swelling in your face or hands, mouth or throat, chest tightness or trouble breathing are
experienced.
- Citicoline therapy should be started within 24 hours of a stroke. The physician will
prescribe the correct dosage and the length of time it should be taken for a medical
condition
Atorvastatin
Classification:
HMG-CoA reductase inhibitors, or statins.
SIDE EFFECTS:
Chest tightness
cough
difficulty with swallowing
dizziness
fast heartbeat
fever
hives, itching, skin rash
muscle cramps, pain, stiffness, swelling, or weakness
puffiness or swelling of the eyelids or around the eyes, face, lips, or tongue
unusual tiredness or weakness.
DESIRED EFFECTS:
Help with a proper diet to lower cholesterol and triglyceride (fats) levels in the blood. This
medicine may help prevent medical problems (eg, chest pain, heart attack, or stroke) that
are caused by fats clogging the blood vessels.
Nursing intervention:
-Determine the goal of therapy in starting atorvastatin.
-Monitor serum lipid levels regularly.
-Evaluate the patient’s response to atorvastatin.
-For muscle pain, administer pain medications as ordered
Implement safety and fall precautions as atorvastatin may affect concentration, alertness,
and vision
Immediately report EKG changes, yellowish discoloration to the skin, muscle weakness, or
unusual bleeding
Administer at bedtime
