icu presentation

7/30/2019 Icu Presentation

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Submitted by:Dannica V. Nofuente

Submitted to:Mr. Jeffrey Solitario RN


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BACKGROUND OF THE STUDYCommunity-acquired pneumonia (CAP) isone of several diseases in which individuals who

have not recently been hospitalized develop an

infection of the lungs (pneumonia). CAP is acommon illness and can affect people of all

ages. CAP often causes problems like difficulty

in breathing, fever, chest pains, and a cough.

CAP occurs because the areas of the lung

which absorb oxygen (alveoli) from the

atmosphere become filled with fluid and cannot

work effectively.


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CAP occurs throughout the world and is a leadingcause of illness and death. Causes of CAP includebacteria, viruses, fungi, and parasites. CAP can bediagnosed by symptoms and physical examination

alone, though x-rays, examination of the sputum,and other tests are often used. Individuals withCAP sometimes require treatment in a hospital.CAP is primarily treated with antibiotic

medication. Some forms of CAP can be preventedby vaccination.


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Symptoms of CAP commonly include:

dyspnea coughing that produces greenish or yellow

sputum a high fever that may be accompanied withsweating, chills, and uncontrollable shaking sharp or stabbing chest pain

rapid, shallow breathing that is oftenpainful


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Less common symptoms include:

the coughing up of blood (hemoptysis) headaches (including migraine headaches)

loss of appetite excessive fatigue blueness of the skin (cyanosis) nausea

vomiting diarrhea joint pain (arthralgia) muscle aches (myalgia)


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The manifestations of pneumonia, like those for manyconditions, might not be typical in older people. Theymight instead experience:

new or worsening confusion hypothermia falls*


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Cause

There are over a hundred microorganisms which can

cause CAP. The most common types of

microorganisms are different among different groups of

people. Newborn infants, children, and adults are atrisk for different spectrums of disease causing

microorganisms. In addition, adults with chronic

illnesses, who live in certain parts of the world, who

reside in nursing homes, who have recently been

treated with antibiotics, or who are alcoholics are at riskfor unique infections. Even when aggressive measures

are taken, a definite cause for pneumonia is only

identified in half the cases.


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Adults

The full spectrum of microorganisms is responsible for CAP in

adults. Several important groups of organisms are more common

among people with certain risk factors. Identifying people at risk for

these organisms is important for appropriate treatment. Viruses

Viruses cause 20% of CAP cases. The most common

viruses are influenza, parainfluenza, respiratory syncytial

virus, metapneumovirus, and adenovirus. Less common

viruses causing significant illness include chicken pox,

SARS, avian flu, and hantavirus.[6]


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Atypical organisms

The most common bacterial causes ofpneumonia are the so-called atypical

bacteria Mycoplasma pneumoniae andChlamydophila pneumoniae. Legionellapneumophila is considered atypical but isless common. Atypical organisms are more

difficult to grow, respond to differentantibiotics, and were discovered morerecently than the typical bacteria discoveredin the early twentieth century.


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Streptococcus pneumoniae

Streptococcus pneumoniae is a common bacterial cause ofCAP (most common cause in UK). Prior to the developmentof antibiotics and vaccination, it was a leading cause ofdeath. Traditionally highly sensitive to penicillin, during the

1970s resistance to multiple antibiotics began to develop.Current strains of "drug resistant Streptococcuspneumoniae" or DRSP are common, accounting for twentypercent of all Streptococcus pneumoniae infections. Adults

with risk factors for DRSP including being older than 65,having exposure to children in day care, having alcoholism orother severe underlying disease, or recent treatment withantibiotics should initially be treated with antibioticseffective against DRSP.[7]
http://en.wikipedia.org/wiki/Community-acquired_pneumoniahttp://en.wikipedia.org/wiki/Community-acquired_pneumonia


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Hemophilus influenzae

Hemophilus influenzae is anothercommon bacterial cause of CAP. Firstdiscovered in 1892, it was initiallybelieved to be the cause of influenzabecause it commonly causes CAP in

people who have suffered recent lungdamage from viral pneumonia.


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Enteric Gram negative bacteria

The enteric Gram negative bacteria suchas Escherichia coli and Klebsiellapneumoniae are a group of bacteria thattypically live in the human intestines.

Adults with risk factors for infectionincluding residence in a nursing home,

serious heart and lung disease, and recentantibiotic use should initially be treatedwith antibiotics effective against EntericGram negative bacteria.


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Pseudomonas aeruginosa

Pseudomonas aeruginosa is anuncommon cause of CAP but is a

particularly difficult bacteria to treat.Individuals who are malnourished, havea lung disease called bronchiectasis, areon corticosteroids, or have recently had

strong antibiotics for a week or moreshould initially be treated withantibiotics effective againstPseudomonas aeruginosa.[8]


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Risk factors

Obstruction

When part of the airway (bronchi) leading to the alveoli is

obstructed, the lung is not able to clear fluid when it

accumulates. This can lead to infection of the fluidresulting in CAP. One cause of obstruction, especially in

young children, is inhalation of a foreign object such as a

marble or toy. The object is lodged in the small airways

and pneumonia can form in the trapped areas of lung.Another cause of obstruction is lung cancer, which can

grow into the airways block the flow of air.


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Lung disease

People with underlying lung disease are more likely

to develop CAP. Diseases such as emphysema or

habits such as smoking result in more frequent and

more severe bouts of CAP. In children, recurrentepisodes of CAP may be the first clue to diseases

such as cystic fibrosis or pulmonary sequestration.

Immune problems

People who have immune system problems are more

likely to get CAP. People who have AIDS are much

more likely to develop CAP.


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Diagnosis

Physical examination by a health provider may reveal fever, an

increased respiratory rate (tachypnea), low blood pressure

(hypotension), a fast heart rate (tachycardia), and/or changes in the

amount of oxygen in the blood. Feeling the way the chest expands

(palpation) and tapping the chest wall (percussion) to identify dull

areas which do not resonate can identify areas of the lung which are

stiff and full of fluid (consolidated). Examination of the lungs with the

aid of a stethoscope can reveal several things. A lack of normal

breath sounds or the presence of crackling sounds (rales) when the

lungs are listened to (auscultated) can also indicate consolidation.

Increased vibration of the chest when speaking (tactile fremitus) andincreased volume of whispered speech during auscultation of the

chest can also reveal consolidation.


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X-rays of the chest, examination of the blood and sputum for infectiousmicroorganisms, and blood tests are commonly used to diagnose individuals

with suspected CAP based upon symptoms and physical examination.. pulseoximeter. analysis of arterial blood gas may be required to accuratelydetermine the amount of oxygen in the blood. Complete blood count (CBC),a blood test, may reveal extra white blood cells, indicating an infection.Chest x-rays and chest computed tomography (CT) can reveal areas ofopacity (seen as white) which represent consolidation.

Main symptoms of infectious pneumonia

Several tests can be performed to identify the cause of an individual's CAP.Blood cultures can be drawn to isolate any bacteria or fungi in the bloodstream. Sputum Gram's stain and culture can also reveal the causativemicroorganism. In more severe cases, a procedure wherein a flexible scope ispassed through the mouth into the lungs (bronchoscopy) can be used tocollect fluid for culture. Special tests can be performed if an uncommonmicroorganism is suspected (such as testing the urine for Legionella antigenwhen Legionnaires' disease is a concern).


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Treatment

CAP is treated by administering an antibiotic which is effective in

killing the offending microorganism as well as managing any

complications of the infection. remembered when choosing the initial

antibiotics (called empiric therapy). Typically this is a macrolide

antibiotic such as azithromycin orclarithromycin although a

fluoroquinolone such as levofloxacin can substitute. Doxycycline is

now the antibiotic of choice in the UK for complete coverage of the

atypical bacteria. This is due to increased levels of clostridium difficile

seen in hospital patients being linked to the increased use of

clarithromycin.

Complications

Despite appropriate antibiotic therapy, severe complications can

result from CAP, including: sepsis, respiratory failure,pleural effusion

and empyema, abscess,
http://en.wikipedia.org/wiki/Empiricismhttp://en.wikipedia.org/wiki/Azithromycinhttp://en.wikipedia.org/wiki/Clarithromycinhttp://en.wikipedia.org/wiki/Fluoroquinolonehttp://en.wikipedia.org/wiki/Levofloxacinhttp://en.wikipedia.org/wiki/Doxycyclinehttp://en.wikipedia.org/wiki/Clarithromycinhttp://en.wikipedia.org/wiki/Clarithromycinhttp://en.wikipedia.org/wiki/Doxycyclinehttp://en.wikipedia.org/wiki/Levofloxacinhttp://en.wikipedia.org/wiki/Fluoroquinolonehttp://en.wikipedia.org/wiki/Clarithromycinhttp://en.wikipedia.org/wiki/Azithromycinhttp://en.wikipedia.org/wiki/Empiricism


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Epidemiology

CAP is a common illness in all parts of the world. It is a major cause

of death among all age groups. In children, the majority of deaths

occur in the newborn period, with over two million worldwide deaths

a year. In fact, the WHO estimates that one in three newborn infantdeaths are due to pneumonia.Mortality decreases with age until late

adulthood; elderly individuals are particularly at risk for CAP and

associated mortality.

More cases of CAP occur during winter months than during other

times of the year. CAP occurs more commonly in males thanfemales and in blacks than Caucasians. Individuals with underlying

illnesses such asAlzheimer's disease, cystic fibrosis, emphysema,

tobacco smoking, alcoholism, orimmune system problems are at

increased risk for pneumonia.
http://en.wikipedia.org/wiki/Alzheimer's_diseasehttp://en.wikipedia.org/wiki/Cystic_fibrosishttp://en.wikipedia.org/wiki/Emphysemahttp://en.wikipedia.org/wiki/Tobacco_smokinghttp://en.wikipedia.org/wiki/Alcoholismhttp://en.wikipedia.org/wiki/Immunosuppressionhttp://en.wikipedia.org/wiki/Immunosuppressionhttp://en.wikipedia.org/wiki/Alcoholismhttp://en.wikipedia.org/wiki/Tobacco_smokinghttp://en.wikipedia.org/wiki/Emphysemahttp://en.wikipedia.org/wiki/Cystic_fibrosishttp://en.wikipedia.org/wiki/Alzheimer's_disease


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Prevention

Smoking cessation is important not only for treatment of any

underlying lung disease, but also because cigarette smoke interferes

with many of the body's natural defenses against CAP.

Vaccination is important in both children and adults. Vaccinationsagainst Haemophilus influenzae and Streptococcus pneumoniae in

the first year of life have greatly reduced their role in CAP in children.

A vaccine against Streptococcus pneumoniae is also available for

adults and is currently recommended for all healthy individuals older

than 65 and any adults with emphysema, congestive heart failure,diabetes mellitus, cirrhosis of the liver, alcoholism, cerebrospinal fluid

leaks, or who do not have a spleen. A repeat vaccination may also be

required after five or ten years.
http://en.wikipedia.org/wiki/Smoking_cessationhttp://en.wikipedia.org/wiki/Vaccinationhttp://en.wikipedia.org/wiki/Haemophilus_influenzaehttp://en.wikipedia.org/wiki/Streptococcus_pneumoniaehttp://en.wikipedia.org/wiki/Streptococcus_pneumoniaehttp://en.wikipedia.org/wiki/Emphysemahttp://en.wikipedia.org/wiki/Congestive_heart_failurehttp://en.wikipedia.org/wiki/Diabetes_mellitushttp://en.wikipedia.org/wiki/Cirrhosishttp://en.wikipedia.org/wiki/Liverhttp://en.wikipedia.org/wiki/Alcoholismhttp://en.wikipedia.org/wiki/Cerebrospinal_fluidhttp://en.wikipedia.org/wiki/Aspleniahttp://en.wikipedia.org/wiki/Aspleniahttp://en.wikipedia.org/wiki/Cerebrospinal_fluidhttp://en.wikipedia.org/wiki/Alcoholismhttp://en.wikipedia.org/wiki/Liverhttp://en.wikipedia.org/wiki/Cirrhosishttp://en.wikipedia.org/wiki/Diabetes_mellitushttp://en.wikipedia.org/wiki/Congestive_heart_failurehttp://en.wikipedia.org/wiki/Emphysemahttp://en.wikipedia.org/wiki/Streptococcus_pneumoniaehttp://en.wikipedia.org/wiki/Streptococcus_pneumoniaehttp://en.wikipedia.org/wiki/Streptococcus_pneumoniaehttp://en.wikipedia.org/wiki/Streptococcus_pneumoniaehttp://en.wikipedia.org/wiki/Haemophilus_influenzaehttp://en.wikipedia.org/wiki/Haemophilus_influenzaehttp://en.wikipedia.org/wiki/Haemophilus_influenzaehttp://en.wikipedia.org/wiki/Vaccinationhttp://en.wikipedia.org/wiki/Smoking_cessation


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Influenza vaccines should be given yearly to the sameindividuals as receive vaccination againstStreptococcus pneumoniae. In addition, health care

workers, nursing home residents, and pregnantwomen should receive the vaccine. When an influenzaoutbreak is occurring, medications such asamantadine, rimantadine, zanamivir, and oseltamivir

have been shown to prevent cases of influenza
http://en.wikipedia.org/wiki/Influenzahttp://en.wikipedia.org/wiki/Streptococcus_pneumoniaehttp://en.wikipedia.org/wiki/Amantadinehttp://en.wikipedia.org/wiki/Rimantadinehttp://en.wikipedia.org/wiki/Zanamivirhttp://en.wikipedia.org/wiki/Oseltamivirhttp://en.wikipedia.org/wiki/Oseltamivirhttp://en.wikipedia.org/wiki/Zanamivirhttp://en.wikipedia.org/wiki/Rimantadinehttp://en.wikipedia.org/wiki/Amantadinehttp://en.wikipedia.org/wiki/Streptococcus_pneumoniaehttp://en.wikipedia.org/wiki/Streptococcus_pneumoniaehttp://en.wikipedia.org/wiki/Influenza


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Name: R.A

Gender: Male

Age: 80 yrs old

Address: Martinez St. Antipolo City.

Religion: Roman Catholic

Occupation: None

Nationality: Filipino

Chief Complaint: Difficulty of Breathing

Admitting Diagnosis:

Date and Time of Admission:

To consider Community Acquired

Pneumonia

November 6, 2012 at 10:00am

Date/Time of Assessment: November 6, 2012 at 10:30am

PATIENTS PROFILECase #: 12-4660


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NURSING HISTORY

Chief Complaint:Nahihirapan akong humingaas verbalized by the client.

Present Health History:

3 days Prior to admission, November 2, 2012. Mr. R.A had cough according to

him he doesnt take any medication to relieve then November 6, 2012 at around 7:00am he

experience difficulty of breathing and difficulty expelling the phlegm again he doesnt take

any medication at around 7:30 when he cannot manage his condition he decided to seek

medical help at Unciano Medical Center via tricycle accompanied by his helper At theemergency room, vital signs taken Blood Pressure of 150/90mmHG, respiratory rate of 28

cpm, pulse rate of 115 bpm and body temperature 36.3C, and oxygene saturation of 78%.

He was seen and examined by Dr. Luzano MD, henced advised him to be admitted to

Intensive Care Unit Chest xray with PAL, ECG, CBC with PC, Blood Chemistry

examination were ordered. An IVF of PNSS 1Lx KVO inserted in his right cephalic vein

with Oxygen inhalation via face mask 10L/mins given. Dr. Luzano ordered medication

Cefuroxime 750mg TIV q8, Aspirin 80mg 1 tab OD, Clopidogrel 75mg 1 tab OD, Arixtra2,5mg SC, OD, Hydrocortisone 50mg TIV, Captopril 25mg tab q12, Nitrogylcerin

(Transdermal Patch) 5mg/patch, OD Q16, Pantoloc 40mg TIV OD, Aldactone 50mg/tab

q12, Combivent neb + 1cc Mucosulvan + 1cc PNSS Q6.dmission. At around 10:00am, he

was endorsed to ICU accompanied by his helper and nurse in charge.


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History of Past Illness:

He had an Hypertension with a maintenance of

Amlodipine 5mg/tab he stop taking medication on August 2012

and also he had a pneumonia on August 2012 and treated it with

Cefuroxime and natremycin.

Heredo-Familial History:According to Mr. R.A, his grandfather had a history of

asthma and both his parents had a history of hypertension.

Socio Economic:

According to Mr. R.A, his wife died and he have a 1 son.according to him, his son works in America and had a good

relationship to his son they have communication through

telephone and also he stated that his son is responsible for his

needs and hospitalization. He stay in his house together with his

helper he only watch TV and listening sounds.


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ASSESMENT

General SurveyMr. R.A is in a respiratory distress, he is cooperative, conscious and coherent.

When I asked him some question he can answer it, he is oriented to time, place and person

with a Glasgow Coma Scale of 15/15 and looks thin.

Vital SignsBP-120/70mmHG

PR-120bpm

RR-26cpm

Temp. 36.3C

O2 Saturation- 78%Skin

His skin is warm, appears thin, dry and flaky, white in color, and no edema. Poor

skin turgor .

Headsymmetrical, hair evenly distributed, thin hair no infection or infestation.

EyesThe color of his eyes are black, pink conjunctiva, anicteric sclera

Earssymmetrical, no gross abnormalities and tenderness. Have slightly hearing deficit.

NoseSymmetrically in line, septum in midline position, flaring of nares

MouthDry oral mucosa, slightly dry and pale lips, have dentures, tongue moves freely, no

tenderness, decrease gag reflex


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Respiratory

Symmetrical chest expansion, presence of adventitiousbreath sounds crakles and wheezes on both lung fields, deep and

rapid breathing and use of accessory muscles, non productive

cough with a presence of rusty sputum.

Breast and Axilla

Symmetrical and equal in size, no masses, redness,

edema or any localized discoloration.

Cardiovascular

Rapid and bounding pulse, slightly pale nail beds, CRT in 3

seconds.


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Neurologic

No language deficit, he can speak clearly, he is oriented to

time, place and person, he has a Glasgow coma scale of 15/15, eye

opening score of 4 because he has a spontaneous eye movement,

motor response score of 6 because he can obey command when I

asked him to lift his leg he able to follow it vice versa to the other

extremities, verbal response of 5 because he is oriented when Iasked him some question he can answer it. pupils are equal at 3mm

equally round and reactive to light and accommodation.

GastroIntestinal

Flat, soft, not tender, normoactive bowel sounds-12, no

bruit.


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Genito-Urinary

He wear diaper according to him, he urinate 1

time, according to him, the color of his urine is light

yellow, he defecated 1 time.

Musculoskeletal

Muscle size is equal size in both sides of the

body, muscle and tendons no contractures, no tremors,

poor muscle tone, uncoordinated movements, skeletonfor structures no deformities, tenderness or swelling,

crepitation or nodules. Theres a limited range of

motion.


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ANATONY OF PHYSIOLOGY OF RESPIRATORY SYSTEM


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The respiratory system (orventilatory system) is thebiological system of an organism that introducesrespiratory gases to the interior and performs gasexchange. In humans and other mammals, the

anatomical features of the respiratory system includeairways, lungs, and the respiratory muscles. Moleculesofoxygen and carbon dioxide are passively exchanged,bydiffusion, between the gaseous external environment

and the blood. This exchange process occurs in thealveolar region of the lungs.
http://en.wikipedia.org/wiki/Gas_exchangehttp://en.wikipedia.org/wiki/Gas_exchangehttp://en.wikipedia.org/wiki/Humanhttp://en.wikipedia.org/wiki/Mammalhttp://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Moleculehttp://en.wikipedia.org/wiki/Oxygenhttp://en.wikipedia.org/wiki/Carbon_dioxidehttp://en.wikipedia.org/wiki/Diffusionhttp://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Bloodhttp://en.wikipedia.org/wiki/Diffusionhttp://en.wikipedia.org/wiki/Carbon_dioxidehttp://en.wikipedia.org/wiki/Oxygenhttp://en.wikipedia.org/wiki/Moleculehttp://en.wikipedia.org/wiki/Lunghttp://en.wikipedia.org/wiki/Mammalhttp://en.wikipedia.org/wiki/Humanhttp://en.wikipedia.org/wiki/Gas_exchangehttp://en.wikipedia.org/wiki/Gas_exchange


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Lower Respiratory Tract

Lungs:The lungs primary function is gas exchange. Oxygen is delivered to

the tissue and carbon dioxide is removed from the tissues. Breathing

is an automatic, rhythmic mechanical process, which delivers O2 to

the tissues and removes CO2 from the tissues.

Bronchi and Bronchioles:there are several division of the bronchia within each lobe of the lung.

First is the lobar bronchi it is divided into segmental bronchi.Segmental bronchi then divided into subsegmental bronchi. These

bronchi are surrounded by connective nervetissue that contain

arteries, lyphatics and nerves. The bronchioles contain submucosal

glands, which produces that covers the inside lining of the airways.

The bronchi and the bronchioles are also lined with cells that have

surface covered with cilia. These cilia create a constant whippingmotion that propels mucus and foreign substances away from the

lungs. The bronchioles then branch into terminal bronchioles,which do not have mucus gland or cilia. Terminal bronchioles thenbecome respiratory bronchioles, which are considered the transitional

passageway between conducting airways and the gas exchange

airway.


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