Case Study On Kawasaki DSX

Case Study On Kawasaki Disease Secondary to Acute Respiratory Distress Syndrome
from Community Acquired Pneumonia
In Partial Fulfillment of the Requirements

in RT126 – Clinical Education 2
GENERAL RESPIRATORY CARE

ROTATION
Submitted to:
Aljessa L. Sebastian, RN, RTRP
Clinical Instructor
Submitted by:
Charlene Mae A. Cesar Joshua Emmanuel G. Queng
Flora Mae P. Concordo Yenz Grae R. Quiamco
Cybil Margareth A. Espino Shaina Mae P. Rodriguez
Mark Luigi M. Lazaro Samir E. Sangki
Rafael L. Maluag Marvin Z. Taasin
Elea Kyla Reneth A. Medrano Algene Dave L. Tabinas
Karina Isabel C. Perales Love D. Villanueva
Anne Lexcee V. Pimentel
Date Submitted:
March 29, 2022
TABLE OF CONTENTS
Page No.
Cover Page ………………………………………………………………………… i
I. INTRODUCTION 1
II. OBJECTIVES 3
III. DEFINITION OF DIAGNOSIS 4
IV. PERSONAL DATA 5
Biographical Data ……………………………………………………... 5
Clinical Data …………………………………………….……………... 5
V. PATIENT HISTORY 6
Past Health History ……………………………………………………. 6
Present Health History ……………………………………………….. 7
Genogram ……………………………………………………………… 8
Genogram Narrative …………………………………………………... 8
VI. ASSESSMENT 10
Physical ………………………………………………………………… 10
Reflex …………………………………………………………………… 13
Developmental Task ………………………………………………….. 15
VII. ANATOMY AND PHYSIOLOGY 17
Respiratory System …………………………………………………... 17
Cardiovascular System ………………………………………………. 27
Circulatory System …………………………………….………...……. 27
Lymphatic System …………………………….………………………. 27
VIII. PATHOPHYSIOLOGY 32
Symptomatology ………………………………………………………. 32
Factors …………………………………………………………………. 34
Pathophysiology Diagram ……………………………………………. 36
Pathophysiology Narrative …………………………………………… 39
IX. DIAGNOSTICS 43
Actual Diagnostic Tests ………………………………………………. 43
Other Possible Diagnostic Tests …………………………………….. 51
X. DRUG STUDY 53
XI. RESPIRATORY THERAPY CARE PLAN 67
Respiratory Therapy Care Plan 1 …………………………………… 67
XII. PULMONARY REHABILITATION 94
XIII. PROGNOSIS 98
XIV. REFERENCES 99
2
I. INTRODUCTION
One of the pulmonary department areas of rotation in Clinical Education 2 is the
General Respiratory Care (GRC). It refers to a wide range of specializing in the care of
patients regardless of age which covers the general fundamentals of respiratory care
procedures. The respiratory therapy interns spend 8 hours a day from 7:00 am to 3:00
pm of the first and third weeks of the month and 3:00 pm to 11:00 pm of second and
fourth weeks of the month; Monday to Friday to give optimum respiratory care and
comfort to their patients. The interns perform respiratory care procedures on patients
under the supervision of a licensed Respiratory Therapist. These respiratory care
procedures include taking vital signs, routine patient monitoring, oxygen therapy,
aerosol drug therapy, lung expansion therapy, and airway clearance therapy.
Also known as mucocutaneous lymph node syndrome, Kawasaki disease (KD) is

a rare, febrile disease that most commonly affects young children, causing inflammation
or swelling of the blood vessels throughout the body. It is frequently considered to be a
harmless, self-limiting sickness, but has now been discovered to cause aneurysms and
other cardiac issues, and it can be fatal. A rare disease of unknown etiology, KD is
believed to to be related in genetics since the disorder is more common in the Asian
descent, Japanese to be specific. The Centers for Disease Control and Prevention
(2020) emphasized that the disease was first described in Japan by Tomisaku
Kawasaki in 1967, and the first cases outside of Japan were reported in Hawaii in 1976.
The clinical signs include fever, rash, irritation and redness of the whites of the eyes,
swollen lymph glands in the neck, and irritation and inflammation of the mouth, lips, and
throat.
Globally, the epidemiology of kawasaki disease varies significantly among those

industrial countries (Elakabawi et al., 2020). In connection to this, the western and
northern countries’ incidence of kawasaki disease ranges from 5-22 cases per 100,000
children under 5 years old. However, Asian countries like Japan, Taiwan, and Korea
have reported more than 10 times higher than western countries (Elakabawi et al.,
2020). In the Philippines, there was no data present from the last 6 years, however, a
study from a single hospital from the past 10 years (2005 -2006), with total respondents
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of 788 multiethnics, revealed that 4 out of 44 Filipinos were diagnosed with Kawasaki
disease (Skochko, 2016). In Manila City, the incidence of cardiac involvement in
patients with Kawasaki disease among children admitted at the Philippine General
Hospital is 59% with 41% having coronary artery dilatation (Caguit et al., 2020).
This case is conducted with the following implications: For RT education, this
case will provide additional and relevant knowledge about kawasaki disease caused by
genetics following respiratory infection, including its presenting signs and symptoms,
diagnosis, and management. It will also allow us to provide complete, clear, concise,
and accurate health teachings to the patient’s family. When RT students gain sufficient
knowledge, this will give a positive reflection on our clinical skills and experience. For
RT practice, this case analysis will broaden and enhance our skills in dealing with
patients who have kawasaki disease by implementing interventions which will help
patients meet their needs. Therefore, better delivery of care will aid in faster recovery of
clients to reach optimal functioning. Lastly, this case can further benefit the field of RT
research by serving as a guide to perform further studies, review more articles, and
concepts. Moreover, this can be a reference for future research in elevating the
standards and fundamentals of respiratory care. Researchers in the future may also be
motivated about the study and urge them to know more about this rare, febrile disease
in pediatrics.
II. OBJECTIVES
A. General Objectives
Our general objective for this case is to better understand the RT theories and
put them into practice, which will harness our skill in formulating preventive measures
and effective treatments that will help keep our patient from deteriorating and build their
sense of initiative in such a way that respiratory complications can be prevented. We,
the Group 8 interns, are confident that by the end of our General Respiratory Care
rotation, the final output of our case will enhance our knowledge and shape our
perspective on how to provide care for patients with this rare medical condition.
B. Specific Objectives
We specifically aim to:
A. Construct a brief introduction about kawasaki disease and its distribution in
global, national, and the local setting.
B. State implications of the study to RT education, practice, and research.
C. Develop objectives that are specific, measurable, attainable, realistic, and time-
bound to guide the development of this case study.
D. Explain the definition of diagnosis in simple and scientific manner.
E. Create patient data biographically and medically.
F. Describe the patient’s past and present health history.
G. Design a genogram and present a narrative.
H. Devise a thorough physical assessment and developmental evaluation.
I. Review the anatomy/physiology of the systems affected by the disease process.
J. Discuss the symptomatology and predisposing/precipitating factors involved.
K. Illustrate the pathophysiology of the disease process in diagrammatic way.
L. Break down the actual and other possible diagnostic tests.
M. Discuss all the medications administered to the patient through drug studies.
N. Formulate RT care plans directed toward the improvement of the patient's status.
O. State the importance of pulmonary rehabilitation and how it can optimize the
patient's health progress upon discharge.
P. Assess the prognosis of our patient's condition.
III. DEFINITION OF DIAGNOSIS
Defining kawasaki disease will be useful in understanding the next sections of
this case. This is also helpful when readers do not have a basic background about this
rare disorder. The following have their methods of describing kawasaki disease:
Hedrich et al. (2018) simply defined kawasaki disease (KD) as an acute-onset

systemic vasculitis of medium-sized vessels that mostly affects the infant and toddler
population. Globally, it is the most common form of childhood primary vasculitis.
Delayed diagnosis and treatment results in coronary artery aneurysms in up to 25% of
all affected individuals. The name KD goes back to the detailed description of 50
children experiencing this form of vasculitis by Tomakisu Kawasaki in Japan, 1967.
Generally, inflammatory changes to arterial vessels of all body regions can be present,
however, coronary arteries are most commonly affected.
Langford and Fauci (2018) defined kawasaki disease as an acute, febrile,

multisystem disease of children. Some 80% of cases occur prior to the age of 5, with
the peak incidence occurring at ≤2 years. KD has three principal stages of the disease
process: acute, subacute, and convalescent. The acute phase consists of an abrupt
onset of high fever that lasts 1-2 weeks but can last up to 3-4 weeks if left untreated.
The subacute phase begins when the fever subsides and lasts into weeks 4-6 of the
disease course. The convalescent phase is when the clinical signs of the illness cease,
which is typically within 3 months from the initial onset of the disease.
Rife and Gedalia (2020) defined KD as a disease of unknown etiology. However,

the presence of familial clusters and increased incidence in Asian populations indicate
the presence of a genetic component. Several additional findings support a genetic
component to KD susceptibility, including the concordance risk in identical twins at 13%,
increased incidence of KD in children whose parents have a history of KD, and higher
occurrence of KD in siblings of affected patients. KD may be caused primarily by
genetics, the disease onset can also be facilitated by environmental and infectious
triggers.
IV. PERSONAL DATA
The personal data is any information relating to an identified or identifiable
natural person. This covers any information that could lead to the direct identification of
the patient. The personal data consists of biographical and clinical data, which are
obtained with full consent for this case study.
A. Biographical Data
Personal Name : JD
Age :4
Sex : Male
Race : Asian
Date of Birth :
Height : 100.9 cm (1.009 m)
Weight : 16.7 kg (36.8 lbs.)
BMI : 16.40 kg/m2
Occupation : N/A
Religion : Roman Catholic

Home Address : Obrero, Davao City
B. Clinical Data
Chief Complaint :
Admitting Diagnosis : Kawasaki Disease of unknown etiology
Admission Date : March 14, 2022
Time Admitted : 4:00 AM
Place of Admission :
Room Number : #324, PICU Ward
Attending Physician : Dr. Del Rosario
Final Diagnosis : Kawasaki Disease secondary to Acute Respiratory
Distress Syndrome from Community Acquired
Pneumonia
V. PATIENT HISTORY
This section will comprehensively discuss the components of a patient history:
past health history, present health history, and genogram or the McGoldrick–Gerson
study, which will help picture the patient’s family relationships and medical history
followed by a narrative explanation regarding the genogram.
A. Past Health History

Patient JD, a 4-year old male, was born healthy in full-term weighing about 3 kg
through vaginal delivery. In terms of the patient’s vaccination history, the patient was a
recipient of basic infant vaccines, except for the hepatitis B vaccine. The patient already
received 3 out of 4 doses of the polio vaccine at schedules of 2 months of age, 4
months, and 9 months, respectively. For the diphtheria, tetanus, and whooping cough
(DTaP), the schedules were followed as per the recommendation of his physician. The
patient’s diet included fruits, vegetables, and meat and was not allergic to any food,
beverage, nor any medication.
In terms of the patient’s hospitalization history, the patient was never admitted
and did not have any medical condition nor did he undergo any surgery. A one-time
clinic appointment with the patient was made with Dr. Gallardo, according to the
guardian’s statement. For the patient’s illness history, Patient JD usually experiences
fever and did not experience having chickenpox, rheumatic fever, or had any heart
complications in his younger years. He usually experiences colds once or twice a year
as per the guardian’s estimation. In terms of the social history, the patient, living
together with his 3 siblings and parents, are living in a smoke-free environment. The
patient’s mother was a stay-at-home housewife while the father was working in an
office, considering the guardian’s occupational history.
B. Present Health History
1 day prior to admission, Patient JD had an onset rash on some areas of his
body, mostly on the genital or diaper area. He had a high fever lasting for several days
and complained about the lumps in his neck.
Hours prior to admission, the patient’s mother sought medical attention and
Patient JD was admitted in the emergency room by wheelchair. An hour later at exactly
4:00 AM of March 14, 2022, the patient’s mother complained about an uncertain pain
that Patient JD was experiencing, may be due to the enlarged lymph node in his neck
area, high continuous fever, or the rash in his genital area. The patient appeared to be
in distress and hyperventilating. Upon physical assessment, the patient’s lips were
chappy and dry, eye conjunctiva was red, tongue was swollen with evidence of white
coating and red lumps, and sore throat. Upon chest auscultation, crackles and bronchial
breath sounds were heard.
The patient’s vital signs upon admission were the following: Temperature of
38.7°C; PR and HR of 115 bpm; RR of 32/min; BP of 140/100; and SpO 2 of 95%. His
GCS score was 14 (Eye response [4], verbal response [5], motor response [5]) and was
awake and conscious but not fully oriented. The physician ordered for the following
diagnostic tests including arterial blood gas, complete blood count, chest X-Ray, and
electrocardiogram. The results of the tests were as follows:
TABLE 5-2
ABG on Room Air, 03/14/2022

ABG Taken at 4:10 am Reference Values
pH : ↑ 7.55 7.35-7.45
PaCO2 : ↓ 30 mmHg 35-45 mmHg
PaO2 : ↓ 65 mmHg 80-100 mmHg
-
HCO3 : ↑ 32 mEq/L 22-26 mEq/L
SaO2 : N 95% 95-100%
Impression: Partially compensated respiratory alkalosis with mild hypoxemia
Implication: ABG of Patient JD is partially compensated and hypoxemia is mild on
room air.
Complete Blood Count Results, 03/14/2022
Taken at 6 am, Received at 8:30 am Reference Values (4-7 years old)
HGB : ↑ 179 102-152 g/L
HCT : ↓ 0.45 36-46 %
RBC : N 4.50 4.00-5.20 x10/L
WBC : N 13.22 5.0-17.0
Neut : ↑ 60 1.5-11.0
Lymph : ↑ 47 1.5-11.1
Mono :↑6 0.1-1.9
Baso :↑1 0.0-0.3
PLT : N 200 150-450
MCH : N 26.32 23-31 pg
MCHC : N 35.10 32-36 g/dL
MCV : N 82.22 78-94 fl
Impression: The patient's WBC components are elevated.
Implication: An elevated value of those parameters shows a sign of infection caused
by acute infections.
PA Chest X-Ray Result, 03/14/2022
Taken at 6:15 am, Received at 9:02 am Reference View (PA)
(A) (B)
Impression: (A) The patient's chest x-ray showed a presence of bilateral chest
infiltrates having a “ground-glass appearance” (B) normal CXR film.
Implication: The impression is supportive of ARDS diagnosis.
12-Lead EKG Result, 03/14/2022, Taken at 6:25 am, Received at 6:33 am
Impression: Normal ventricular rate, normal R-R intervals, normal axis evaluation.
Implication: Normal EKG findings.
Dr. Del Rosario ordered to administer the patient q4h of plasma gob via IV for the
fever and Ventolin via nebulization for airway clearance. The physician also requested
bacterial culture. An oxygen therapy of 2 LPM via nasal cannula was also administered
to the patient.
C. Genogram
PATERNAL SIDE MATERNAL SIDE
GRANDFATHER GRANDFATHER
GRANDMOTHER GRANDMOTHER
Age: 79 Age: 81
Age: 76 Age: 79
FATHER
Age: 38 MOTHER
Age: 37
BROTHER PATIENT JD
Age: 10 SISTER Age: 4
Age: 7
Legend:
= Male = Deceased = Hypertensive
= Female = Diabetic = Has Kawasaki disease
D. Genogram Narrative
Basic laws of inheritance are important in understanding patterns of disease
transmission. If a family is affected by a disease, an accurate family history will be
important to establish a pattern of transmission (“Genetic Alliance”, 2010).
Starting with the paternal side, the patient’s grandfather, age 79, and the
grandmother, age 76, were both hypertensive with the former being the only diabetic.
Both grandparents are still alive. Knowing the history of hypertension, there is a higher
chance of passing down hypertension to the patient’s father due to genetics.
Meanwhile, the father was both hypertensive and diabetic.
For the maternal side of the patient, the patient’s grandfather is deceased at the
age of 81 and had a history of hypertension and diabetes. The patient’s grandmother
was also hypertensive and diabetic at the age of 79. The patient’s mother was
hypertensive but not diabetic.
Kawasaki disease (KD) is characterized as an acute systemic vascular disease

that affects mostly the medium sized and small vessels. It is generally self-limited and
the highest incidence occurs in children under five years of age (Ramphul et al., 2018).
The patient’s brother was also hypertensive, with her sister having no known existing
disease. Patient JD was hypertensive, and is now being affected by Kawasaki disease.
This febrile disease may be idiopathic (unknown etiology), but the influence of genetics
may still apply in order to trace the onset of the disorder, especially when the disease is
precipitated by an existing respiratory infection.
VI. ASSESSMENT
A careful attention to the patient’s subjective information and objective
information obtained during the assessment will contribute to positive outcomes
(Teegardin, 2020). This section will discuss the physical assessment done to the patient
in cephalocaudal pattern including the reflexes and developmental evaluation which is
helpful to track the developmental progress of the patient.
A. Physical (03/18/2022)
General Survey: Patient Livander, a 34-year-old male with a mesomorphic body
type and a height of 5’5” (65 inches), was transferred to Adult ICU 2, Room #7 on the
night of November 4 and was intubated by the physician as the patient was in
impending failure. At exactly 8:07 am of November 5, the patient was febrile,
tachypneic, and was exhibiting signs of peripheral cyanosis. A 5-point electrode system
connected to a cardiac monitor was attached to the patient’s anterior chest and multiple
IV access were on the patient’s upper extremities. Baseline vital signs, GCS/LOC
assessment, current MV set-up, and baseline ABG on 100% FiO2 were the following:
TABLE 6-1
Baseline Vital Signs Reflected on Cardiac Monitor, 11/05/2021
Taken at 8:11 am Reference Value
Temperature : ↑ 38.2°C (ax.) 36.5-37.5°C (ax.)
Pulse Rate : ↑ 137 bpm 60-100 bpm
Respiratory Rate : ↑ 35/min 12-20/min
Blood Pressure : ↑ 145/95 mmHg 120/80 mmHg
Heart Rate : ↑ 138 bpm 60-100 bpm
SaO2 : ↓ 80% 88-92%
Glasgow Coma Scale and Level of Consciousness, 11/05/2021, 8:16 am
Eye Opening : 3 (to speech)
GCS Score : 8
Verbal Response : 1 (intubated)
Motor Response : 4 (localizes pain) LOC : Obtunded
Current MV Set Up, 11/05/2021, 8:20 am
Patient’s Height: 5’5” (65 inches/165.1 cm)
Patient’s IBW: 136 lbs. (62 kg); Patient’s BSA: 1.53 m2
Mode : VA/C f : 12/min I:E : 1:4
FiO2 : 100% VE : 5 L/min I time : 0.67 s
VT : 410 ml Flow : 40 L/min PEEP : 0
Baseline ABG from the Current MV Set Up at 100% FiO2, 11/05/2021
ABG Taken at 8:22 am Chronic Stable ABG Reference Values
pH : ↓ 7.23 7.38 7.35-7.39
PaCO2 : ↑ 78 mmHg 55 mmHg 45-55 mmHg
PaO2 : ↓ 57 mmHg 78 mmHg 70-80 mmHg
-
HCO3 : ↑ 41 mEq/L 37 mEq/L >26 mEq/L
SaO2 : ↓ 80% 90% 88-92%
Cephalocaudal Assessment:
Head
Upon inspection, the head was rounded, normocephalic, and symmetrical with
prominent frontal, parietal, and occipital ridges and prominences. The symmetry of facial
features and motions were evident. There were no hair infestations.
Upon palpation, there were no nodules and depressions in the head and face.
Eyes
Upon inspection, the bulbar conjunctiva appeared transparent with few
capillaries evident. The sclera appeared white. The palpebral conjunctiva appeared
shiny, smooth and pink. There was no edema or tearing of the lacrimal gland. Cornea
was transparent, smooth and shiny and the details of the iris were visible. The pupils of
the eyes were PERRLA, black in color, and equal in size. The iris was flat and round.
Ears
Upon inspection, the color was the same as the facial skin, with no lesions and
discharges. It was symmetrical, aligned with the outer canthus of eye. The eardrums of
the patient were intact with cerumen.
Upon palpation, the auricles were mobile, firm, and not tender.
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 mouth was inserted with a 7.5-mm ID endotracheal tube
taped on the right side of the mouth using a medical plaster to hold the ET tube in place,
with occasional evidences of green and sweet-smelling secretions. The lips of the
patient were slightly pale, symmetric, and had a dry texture. There were no discoloration
of the teeth enamels and no retraction of gums.
Neck
Upon inspection, the neck muscles were equal in size with no evidence of neck
vein distention.
Upon palpation, lymph nodes were not palpable and trachea was in the midline.
Thorax and Lungs

Upon inspection, the anterior chest was attached to a cardiac monitor via a 5-
point electrode system. The anteroposterior chest diameter was slightly increased. The
spine was vertically aligned. Both shoulders were of the same height. The costal angle
has been expanded.
Upon palpation, the front and posterior chest were warm and intact, with no
discomfort or lumps.
Upon percussion, a hyperresonant note was noted.
Upon auscultation, bilateral wheezing and fine crackles were heard, as well as
diminished breath and heart sounds.
Abdomen
Upon inspection, the abdomen had an unblemished skin, symmetric contour,
with no discernible vascular pattern. The abdomen appeared soft and bloated.
Upon auscultation, normal bowel sounds were heard.
Upon percussion, tympany over the stomach and epigastric area while dullness
over the liver were noted.
Upon palpation, the abdomen was non-tender in all four abdominal quadrants.
Upper Extremities
Upon inspection, a 24-gauge IV cannula was inserted at the cephalic vein of the
right arm for TPN of amino acid/dextrose solution and IV antibiotics at the metacarpal
vein of the left arm. An indwelling vascular line was inserted on the left radial artery. The
upper extremities were symmetrical in size and length and had no presence of a bone
deformity. Acrocyanosis was noted.
Upon palpation, the muscles were not palpable with the absence of tremors.
Bones and joints were non-tender. Capillary refill time was <2 seconds.
Lower Extremities
Upon inspection, thighs and legs were symmetrical in size and length with the
same skin color. There was no presence of a bone deformity. Acrocyanosis was noted.
B. Reflex (03/18/2022)
The presence and strength of a reflex is an important sign of nervous system
development and function. Healthcare providers check reflexes to determine if the brain
and nervous system are working well.
TABLE 6-2
Cranial Nerve Reflexes and Rationale

Reflexes Present Rationale
Patient’s pupils constrict upon assessment using
Pupillary light reflex 
pen light confirming the presence of this reflex.
Patient’s eyes should move inward or converge
Accommodation
✔ while focusing on the pencil that moves towards
reflex
the nose. Patient is able to cooperate.
Jaw jerk reflex  Tapping the patient’s chin while the mouth is
relaxed and partially open or closed should not
elicit a reflex, thus, confirming its absence
(normal).
By lightly stroking the patient’s eye with a penlight, the
Corneal reflex /
 patient protects his eyes by the rapid closure of his
Blink reflex
eyelid.
Tapping the patient’s forehead (between eyebrows
and nose) should not elicit sustained blinking
Glabellar reflex 
throughout the duration of test indicating absence
of the reflex (normal).
Patient confirms the presence of this reflex as he
Vestibulo-ocular
can still follow images even as his head is turned
reflex
sideways. Patient is unable to cooperate.
The patient should exhibit this reflex when stroking
Gag reflex  the tongue with tongue depressor causing
constriction of the throat.
Myotatic Reflexes and Rationale
The patient was instructed to hold a pen, and he
Grasping reflex 
held the ballpen with his fingers in a grasp.
A light tap to the patient’s patellar tendon should
Patellar reflex /
 elicit extension of the lower leg while seated with
Knee-jerk reflex
lower legs hanging.
Patient’s dorsiflexed foot responded with
Ankle jerk reflex /
 plantarflexion immediately after tapping the
Achilles reflex
Achilles tendon with a tendon hammer.
When his sole is stroked by the end of the pen, the
Babinski Reflex /
 big toe moves upward, which shows a positive
Plantar reflex
response.
Walking / Stepping reflex  The patient can walk from the age of one.
C. Developmental Task
Developmental tasks provide information on the developmental milestones that
an individual has reached, aiding in choosing the best course of action to take in order
to reach additional milestones. The results of developmental tests can also be used to
determine the level of progress made following an intervention, and both clinicians and
researchers frequently utilize these tasks to make this determination.
Erik Erikson’s Eight Stages of Development
Psychologist Erik Erikson developed his eight stages of development to explain
how people mature. Erik Erikson’s theory of psychosocial development provides a
framework through which we may examine a person’s growth throughout a lifetime.
Initiative vs. Guilt

Erik Erikson’s theory of psychosocial development includes the third stage of
development, initiative vs. guilt. This stage occurs between 3 and 5 years old in
preschoolers. Patient JD, age 4, is in this stage, where preschoolers are increasingly
focused on doing things themselves and establish their own goals. When caregivers
nurture a preschooler, there would be tendencies at this level. Children comprehend
how to make decisions and plan for the future. They can grow into adults who can follow
their ambitions. When preschoolers are criticized for being assertive, they may feel guilt
for pursuing their desires. Controlling caregivers may teach children to follow another’s
lead rather than starting their plans.
Patient JD has achieved the prior stages before the initiative vs. guilt stage and
has developed a sense that the world is trustworthy and that they can act
independently. He needs to try things on his own and explore his abilities. By doing this,
he can develop ambition and direction. That sense has led him to trust the people
around him, specifically his parents, to look on the positive side of life.
Robert Havighurst’s Developmental Task Theory

Many theorists are responsible for contributing to the developmental task theory,
and one of them is Robert Havighurst, who elaborated a most systematic and extensive
manner of developmental evaluation. The central assertion of Havighurst’s theory is that
development is continuous throughout an individual’s entire lifespan, occurring in
stages. He stated that an individual moves from one step to another by successfully
resolving problems or performance of specific developmental tasks.
TABLE 6-3
Developmental Tasks of Early Childhood from Havighurst’s Developmental Task Theory
Tasks of Early Adulthood Met/Unmet Rationale
Learning to walk Met Patient JD knew how to walk at an early
age of his childhood and was able to
balance himself independently.
At the age of 1, he was able to take solid
Learning to take solid
Met foods but was very picky and hard to feed
foods
when eating some greens.
Patient JD was able to talk, saying his first
Learning to talk Met word, “mama” and has limited vocabulary
for his age.
In controlling the elimination of body
Learning to control the
wastes, Patient JD is sometimes unable to
elimination of body Unmet
control the timing of his body waste
wastes
elimination.
As he grew, Patient JD started socializing
and interacting with other people, while
Learning sex differences
Met playing and mingling with them. He
and sexual modesty
perceived and understood the difference
between sexes and sexual modesty.
Forming concepts and
learning language to Patient JD is still unable to attain this task.
Unmet Imagination is vivid, and the line between
describe social and
real and imaginary is often indistinct.
physical reality
Patient JD is now capable of attaining this
task, as his vocabulary and pronunciation
Getting ready to read Met
continues to expand, and he can read
some basic simple terms.
VII. ANATOMY AND PHYSIOLOGY
This section will comprehensively discuss the body systems involved and
affected in Kawasaki disease secondary to ARDS, and how they function in a normal
anatomy. Most of the respiratory system information are based from Fishman and
Rodriguez (2019).
A. Respiratory System
The primary function of the respiratory system is the continuous absorption of
oxygen and the excretion of carbon dioxide. This exchange between the gas of the
atmosphere and blood is termed external respiration. This process supports internal
respiration, which is the exchange of gases between blood and tissues. To carry out
external respiration, the system brings gas into close proximity with the flowing blood in
the pulmonary circulatory system. This close “match” of gas and blood across a large
but extremely thin blood-gas barrier membrane enables efficient gas exchange to occur
via simple diffusion. The respiratory system includes the upper airways, chest wall,
respiratory muscles, lower airways, pulmonary blood vessels, support nerves, and
lymphatics.
Nasal Cavity and Sinuses
The surface of the nasal cavity is covered with epithelia. The anterior portion is
covered with stratified squamous cells and possesses hair follicles and hair. Within the
skull bones and around the nasal cavity are the sinuses. These hollow spaces are
named for the bones in which they are found. The sinuses are lined with a mucous
membrane and drain into the nasal cavity through numerous ducts.
Oral Cavity
The mucosal surfaces of the oral cavity provide humidification and warming of
inspired air. These surfaces are much less efficient than the nose. Saliva is produced by
major and minor salivary glands. Saliva functions primarily as a wetting and digestive
agent for food but provides some humidification of inspired gas. The oral cavity ends at
a double web on each side, called the palatine folds. The palatine tonsils sit between
these folds on each side. The palatine tonsils are vascularized lymphoid tissues that
play an immunologic role, especially in childhood.
Pharynx
The posterior portion of the nasal and oral cavities opens into a region called the
pharynx. The entire pharynx is lined with stratified squamous epithelium. The pharynx is
subdivided into the nasopharynx, oropharynx, and hypopharynx, or laryngopharynx. The
nasopharynx lies at the posterior end of the nasal cavity and extends to the tip of the
uvula. The oropharynx has a similar function, except it is located at the posterior part of
the oral cavity. Once the air goes into the laryngopharynx, a structure called the
epiglottis will divert in into the larynx.
Larynx
Also known as the voice box, the larynx is located within the anterior aspect of
the neck, anterior to the inferior portion of the pharynx and superior to the trachea. Its
primary function is to protect the lower airway by closing abruptly upon mechanical
stimulation, thereby halting respiration and preventing the entry of foreign matter into
the airway. Other functions of the larynx include the production of sound (phonation),
coughing, the Valsalva maneuver, control of ventilation, and acting as a sensory organ.
The larynx is composed of three large, unpaired cartilages (cricoid, thyroid,
epiglottis); three pairs of smaller cartilages (arytenoids, corniculates, cuneiform); and a
number of intrinsic muscles. The hyoid bone, while technically not part of the larynx,
provides muscular attachments from above that aid in laryngeal motion.
Trachea
Also known as the windpipe, the trachea extends from its connection to the
cricoid cartilage down through the neck and into the thorax to the articulation point
between the manubrium and body of the sternum (angle of Louis). At this point, it
divides into two main stem bronchi. The windpipe is a tube of 12 cm length connecting
the larynx to the principal bronchi that lead to the lungs. The main functions of the
trachea comprise air flow into the lungs, mucociliary clearance, and humidification and
warming of air.
Bronchi and Bronchioles

The bronchi are the airways that lead from the trachea into the lungs and then
branch off into progressively smaller structures until they reach the alveoli, the tiny sacs
that allow for the exchange of oxygen and carbon dioxide in the lungs. While the bronchi
function primarily as passageways for air, they also play a role in immune function. A
number of different medical conditions can affect the bronchi, including bronchitis and
asthma.
Each lung is composed of smaller units called lobes. Fissures separate these
lobes from each other. The right lung consists of three lobes: the superior, middle, and
inferior lobes. The left lung consists of two lobes: the superior and inferior lobes. A
bronchopulmonary segment is a division of a lobe, and each lobe houses multiple
bronchopulmonary segments. Each segment receives air from its own tertiary bronchus
and is supplied with blood by its own artery. Some diseases of the lungs typically affect
one or more bronchopulmonary segments, and in some cases, the diseased segments
can be surgically removed with little influence on neighboring segments. A pulmonary
lobule is a subdivision formed as the bronchi branch into bronchioles. Each lobule
receives its own large bronchiole that has multiple branches. An interlobular septum is a
wall, composed of connective tissue, which separates lobules from one another.
Alveoli
Alveoli are microscopic balloon-shaped structures located at the end of the
respiratory tree. They expand during inhalation, taking in oxygen, and shrink during
exhalation, expelling carbon dioxide. These tiny air sacs are the site where gas
exchange between inspired air and the blood takes place. A variety of factors, many of
which are currently under research, determine the size and shape of individual alveoli.
In the distal airways, a state of balance exists between the forces acting to deflate the
lungs and the ones trying to keep them inflated.
Histology of the Airway Wall

All of the conducting airways from the trachea to the bronchioles have walls that
are constructed of three layers: an inner layer that forms a mucous membrane called
the mucosa, which is primarily composed of epithelia; a submucosa composed of
connective tissue, bronchial glands, and smooth fibers that wrap around the airway; and
an outer covering of connective tissue called the adventitia. The cartilaginous rings and
plates found in larger airways are located in the adventitia. The mucosa is composed of
many different types of specialized epithelial cells that sit on top of a basement
membrane. The most common type of epithelia are the numerous pseudostratified,
ciliated, columnar epithelia. The junctions, especially the tight junctions, play an
important role in the maintenance of fluid and electrolyte transport across the mucous
membrane. These junctions prevent the movement of fluids and electrolytes between
the apical surface and basal surfaces of the airway. Disturbances in this transport like
will lead to mucus transport abnormalities.
Pleura of the Lungs

Each lung is enclosed within a cavity that is surrounded by the pleura. The pleura
is a serous membrane that surrounds the lung. The right and left pleurae, which enclose
the right and left lungs, respectively, are separated by the mediastinum. The pleurae
consist of two layers. The visceral pleura is the layer that is superficial to the lungs, and
extends into and lines the lung fissures. In contrast, the parietal pleura is the outer layer
that connects to the thoracic wall, the mediastinum, and the diaphragm. The visceral
and parietal pleurae connect to each other at the hilum. The pleural cavity is the space
between the visceral and parietal layers.
The pleurae perform two major functions: they produce pleural fluid and create
cavities that separate the major organs. Pleural fluid is secreted by mesothelial cells
from both pleural layers and acts to lubricate their surfaces. This lubrication reduces
friction between the two layers to prevent trauma during breathing, and creates surface
tension that helps maintain the position of the lungs against the thoracic wall.
Lungs
The lungs have an apex and a base and are subdivided by fissures into lobes.
The lobes are subdivided further into bronchopulmonary segments. Each segment is
supplied with gas from a single segmental bronchus. Controversy exists over the exact
number of segments; some anatomists accept that each lung has 10 segments,
whereas others maintain that the right has 10 and the left has 8.
Blood Supply
The major function of the lungs is to perform gas exchange, which requires blood
from the pulmonary circulation. This blood supply contains deoxygenated blood and
travels to the lungs where erythrocytes, also known as red blood cells, pick up oxygen
to be transported to tissues throughout the body. The pulmonary artery is an artery that
arises from the pulmonary trunk and carries deoxygenated, arterial blood to the alveoli.
The pulmonary artery branches multiple times as it follows the bronchi, and each branch
becomes progressively smaller in diameter.
Nervous Innervation
Dilation and constriction of the airway are achieved through nervous control by
the parasympathetic and sympathetic nervous systems. The parasympathetic system
causes bronchoconstriction, whereas the sympathetic nervous system stimulates
bronchodilation. Reflexes such as coughing, and the ability of the lungs to regulate
oxygen and carbon dioxide levels, also result from this autonomic nervous system
control. Sensory nerve fibers arise from the vagus nerve, and from the second to fifth
thoracic ganglia. The pulmonary plexus is a region on the lung root formed by the
entrance of the nerves at the hilum. The nerves then follow the bronchi in the lungs and
branch to innervate muscle fibers, glands, and blood vessels.
Pulmonary Ventilation
Pulmonary ventilation is the main process by which air flows in and out of the
lungs. This is through contraction of muscles like the diaphragm, as well as through
negative pressure that is being accomplished by the pleural membrane covering the
lungs. When the lungs are sealed completely, they remain at a certain pressure that is
slightly lower than the pressure of the lungs at rest. Because of this, the air fills the
lungs until there is no more pressure difference. To this point, if necessary, additional air
can be inhaled by contracting the diaphragm and the intercostal muscles. During
exhalation, the muscles will relax and this reverses the pressure on the outside of the
lungs that forces the air to escape until both pressures equalize again.
External Respiration
External respiration is the exchange of gases between the air filling of the alveoli
and the blood in the capillaries surrounding the walls of the alveoli. Air entering the
lungs from the atmosphere has a higher PaO2 and a lower PaCO2 than does the blood
in the capillaries.
Internal Respiration
Internal respiration is the exchange of gases between the blood in the capillaries
and the tissues in the body. Capillary blood has a higher partial pressure of oxygen and
a lower partial pressure of carbon dioxide than the tissues through which it passes.
Transportation of Gases
The two major respiratory gases, oxygen and carbon dioxide are transported
through the body in the blood. Hemoglobin is an important transport molecule found in
red blood cells that carries almost 99% oxygen in the blood. When the partial pressure
of carbon dioxide is high in the tissues, the enzyme carbonic anhydrase catalyzes a
reaction between carbon dioxide and water to from carbonic acid.
Homeostatic Control of Respiration

Under normal resting conditions, the body maintains a quiet breathing rate and
depth called Eupnea. Eupnea is maintained until the body’s demand for oxygen and
production of carbon dioxide rises due to greater exertion. Autonomic chemoreceptors
in the body monitor the partial pressures of oxygen and carbon dioxide in the blood and
send signals to the respiratory center of the brain stem. The respiratory center then
adjusts the rate and depth of breathing to return the blood to its normal level of gas
partial pressures.
B. Cardiovascular System
Located between the lungs in the middle of the chest, the heart pumps blood
through the network of arteries and veins known as the cardiovascular system. It
pushes blood to the body’s organs, tissues and cells. Blood delivers oxygen and
nutrients to every cell and removes carbon dioxide and other waste products made by
those cells. Blood is carried from the heart to the rest of the body through a complex
network of arteries, arterioles, and capillaries. Blood is returned to the heart through
venules and veins. Most information of the cardiovascular system is based from the
Texas Heart Institute (2019) and University of Minnesota (2019).
Vena Cava
Vena cava Is a short, but large diameter vein located in the anterior right superior
mediastinum. The SVC is one of the 2 large veins by which blood is returned from the
body to the right side of the heart. After circulating through the body systemically, the
deoxygenated blood returns to the right atrium of the heart through either the SVC,
which drains the upper body or the inferior vena cava (IVC) that drains everything below
the diaphragm.
Right Atrium
It is positioned in the upper region of the right side of the heart. It consists of the
sinus venosus and the right atrial appendage and contains the sinoatrial node. The right
ventricle receives deoxygenated blood from the body.
Right Ventricle
It extends from the right atrium to the apex of the heart; it forms the major portion
of the anterior surface of the heart. Pumps deoxygenated blood from the body to the
lungs.
Pulmonary Artery
The pulmonary arteries carry deoxygenated blood from the right ventricle into the
alveolar capillaries of the lungs to unload carbon dioxide and take up oxygen. These are
the only arteries that carry deoxygenated blood and are considered arteries because
they carry blood away from the heart. The short, wide vessel branches into the left and
right pulmonary arteries that deliver deoxygenated blood to the respective lungs. Blood
first passes through the pulmonary valve as it is ejected into the pulmonary arteries.
Pulmonary Vein
The pulmonary veins carry oxygenated blood from the lungs to the left atrium of
the heart. Despite carrying oxygenated blood, this great vessel is still considered a vein
because it carries blood towards the heart. Four pulmonary veins enter the left atrium.
The right pulmonary veins pass behind the right atrium and superior vena cava while
the left pass in front of the descending thoracic aorta. The pulmonary arteries and veins
are both considered part of pulmonary circulation.
Left Atrium
Situated above the left ventricle; blood enters via the pulmonary veins and exits
through the mitral valve. Drains/pumps oxygenated blood from the lungs into the left
ventricle.
Left Ventricle
Located in a posterior and lateral location relative to the right ventricle. The right
ventricle forms the apex of the heart. Pumps oxygenated blood from lungs to body.
Aorta
Anterior to trachea and esophagus, on bifurcation of the pulmonary artery. Origin
of the great vessel.
Coronary Artery
The coronary system is composed of arteries, arterioles, capillaries, venules, and
veins. The coronary arteries originate as the right and left main coronary arteries which
exit the ascending aorta just above the aortic valve (coronary Ostia). These two
branches subdivide and course over the surface of the heart (epicardium) as they
traverse away from the aorta. These arteries divide into progressively smaller branches
that then progress inward to penetrate the epicardium and supply blood to the
transmural myocardium. Coronary arteries eventually branch into arterioles. Arterioles
then branch into innumerable capillaries through which blood will begin its flow back to
the cardiac chambers. The coronary arteries supply blood to the myocardium (heart
tissue) itself: e.g., coronary capillaries deliver oxygenated blood (nutrients) to all of the
heart’s cells.
C. Circulatory System
System that transports nutrients, respiratory gases, and metabolic products
throughout a living organism, permitting integration among the various tissues. The
process of circulation includes the intake of metabolic materials, the conveyance of
these materials throughout the organism, and the return of harmful by-products to the
environment. Most of the information is based from Tortora (2014).
Pulmonary Circulation
Pulmonary circulation is the movement of blood from the heart to the lungs for
oxygenation, then back to the heart again. Oxygen-depleted blood from the body leaves
the systemic circulation when it enters the right atrium through the superior and inferior
venae cavae. The blood is then pumped through the tricuspid valve into the right
ventricle. From the right ventricle, blood is pumped through the pulmonary valve and
into the pulmonary artery. The pulmonary artery splits into the right and left pulmonary
arteries and travel to each lung.
At the lungs, the blood travels through capillary beds on the alveoli where gas
exchange occurs, removing carbon dioxide and adding oxygen to the blood. Gas
exchange occurs due to gas partial pressure gradients across the alveoli of the lungs
and the capillaries interwoven in the alveoli. The oxygenated blood then leaves the
lungs through pulmonary veins, which returns it to the left atrium, completing the
pulmonary circuit. As the pulmonary circuit ends, the systemic circuit begins.
Pathway of Pulmonary Circulation

From the right atrium, the deoxygenated blood is pumped through the tricuspid
valve into the right ventricle. Then this blood pumped from the right ventricle through the
pulmonary valve and into the pulmonary trunk of the pulmonary artery and travels
through the lungs where carbon dioxide is released and oxygen is picked up during
respiration. Arteries are further divided into very fine capillaries which are extremely
thin-walled. Then the pulmonary vein returns oxygenated blood to the left atrium of the
heart.
Right Atrium
Receives deoxygenated blood from the superior and inferior vena cavae, and
from the coronary veins. It pumps this blood through the right atrioventricular orifice
(guarded by the tricuspid valve) into the right ventricle. In the anatomical position, the
right atrium forms the right border of the heart.
Tricuspid Valve
Its role is to make sure blood flows in a forward direction from the right atrium to
the ventricle and is located between the right atrium (top chamber) and right ventricle
(bottom chamber).
Right Ventricle
Right ventricle is the chamber within the heart that is responsible for pumping
oxygen-depleted blood to the lungs and is located in the lower right portion of the heart
below the right atrium.
Pulmonary Valve
The pulmonary valve normally acts like a one-way door from the heart's right
ventricle to the lungs. Blood flows from the right ventricle through the pulmonary valve
to the pulmonary artery and then into the lungs, where it picks up oxygen to deliver to
your body.
Pulmonary Artery
The main pulmonary artery, also called the pulmonary trunk, is a vessel that
emerges from the heart. It divides into the left and right pulmonary arteries, which carry
blood with relatively low oxygen content and high carbon dioxide content into the lungs.
Pulmonary Capillaries
Red blood cells are filled with oxygen at the level of the pulmonary capillaries.
They are the junction between the small arteries and veins of the pulmonary circulation.
It is at that microscopic site that ‘’respiration” really occurs. The pulmonary capillaries
are the junction points between the pulmonary arteries and the pulmonary veins. They
are microscopic vessels in which red blood cells pass in single file.
One can compare the blood circulation of the human body to the plumbing
network of a house. It brings water to all the required sites. Once used, the waste water
returns to the sewers by the drains.
The human body has a plumbing system made up of arteries, veins and
capillaries. Blood is brought to the organs by the arteries, and the use of this blood by
the cells occurs at the level of the smallest vessels: the capillaries.
A Multitude of Small Air Sacs

The lungs are composed of more than 300 million of small air sacs called alveoli.
They have a very thin wall covered with pulmonary capillaries. Alveoli have a diameter
of 0.2 mm.
The capillaries are tiny blood vessels that act as perforated drains which prevent
blood cells from leaving the circulation, but which allow fluids from the blood to escape
and to return to the circulation. Under normal conditions, the movement of fluids is
balanced and there is no accumulation of water in the lungs. The thin layer of cells lining
the interior of the alveoli is covered by this fluid, which creates the contact between the
capillary and alveoli cells. This is what makes the exchange of oxygen and carbon
dioxide (CO2) possible. The oxygen that gets into the lungs during inspiration moves
from the alveoli to the capillaries. In the opposite direction, carbon dioxide (CO 2) moves
from the capillaries to the alveoli and it is eliminated during expiration.
Systemic Circulation
The systemic circulation provides the functional blood supply to all body tissue. It
carries oxygen and nutrients to the cells and picks up carbon dioxide and waste
products. Systemic circulation carries oxygenated blood from the left ventricle, through
the arteries, to the capillaries in the tissues of the body. From the tissue capillaries, the
deoxygenated blood returns through a system of veins to the right atrium of the heart.
Aorta
Largest artery in the body, carries oxygen-rich blood from the left ventricle of the
heart to other parts of the body, originating from the left ventricle and descending to the
abdominal region, where it bifurcates into the common iliac arteries at the level of the
fourth lumbar vertebra; arteries originating from the aorta distribute blood to virtually all
tissues of the body.
Ascending Aorta
Initial portion of the aorta, rising superiorly from the left ventricle for a distance of
approximately 5 cm. The ascending aorta rises up from the heart and is about 2 inches
long. The coronary arteries branch off the ascending aorta to supply the heart with
blood.
Aortic Arch
Graceful arc to the left that connects the ascending aorta to the descending
aorta; ends at the intervertebral disk between the fourth and fifth thoracic vertebrae. The
aortic arch curves over the heart, giving rise to branches that bring blood to the head,
neck, and arms.
Descending Aorta
Portion of the aorta that continues inferiorly past the end of the aortic arch;
subdivided into the thoracic aorta and the abdominal aorta.
Thoracic Aorta
Travels down through the chest. Its small branches supply blood to the ribs and
some chest structures. Portion of the descending aorta superior to the aortic hiatus.
Abdominal Aorta
Begins at the diaphragm, splitting to become the paired iliac arteries in the lower
abdomen. Most of the major organs receive blood from branches of the abdominal
aorta. Portion of the aorta inferior to the aortic hiatus and superior to the common iliac
arteries.
Capillaries in the Body

Small, thin blood vessels that connect the arteries and the veins. Their thin walls
allow oxygen, nutrients, carbon dioxide and waste products to pass to and from the
tissue cells.
Vena Cava
A large vein that carries blood to the heart from other areas of the body. The
vena cava has two parts: the superior vena cava and the inferior vena cava. The
superior vena cava carries blood from the head, neck, arms, and chest. The inferior
vena cava carries blood from the legs, feet, and organs in the abdomen and pelvis. The
vena cava is the largest vein in the body.
B. Lymphatic System
Since limited stage SCLC radiates to nearby structures of the lungs like lymph
nodes, the lymphatic system is affected and involved. This system is a network of
tissues, vessels and organs that work together to move a colorless, watery fluid called
lymph back into the circulatory system. Most information is based from Tortora (2014).
The lymphatic system assists in circulating body fluids and helps defend the body
against disease-causing agents. After interstitial fluid passes into lymphatic vessels, it is
called lymph. The significant difference between interstitial fluid and lymph is location:
Interstitial fluid is found between cells, and lymph is located within lymphatic vessels
and lymphatic tissue. Lymphatic tissue is a specialized form of reticular connective
tissue that contains large numbers of lymphocytes. Two types of lymphocytes
participate in adaptive immune responses: B cells and T cells. Lymphatic vessels drain
excess interstitial fluid from tissue spaces and return it to the blood. This function
closely links it with the cardiovascular system. In fact, without this function, the
maintenance of circulating blood volume would not be possible. Lymphatic tissue
initiates individual responses directed against particular microbes or abnormal cells.
Lymphatic Vessels and Lymph Circulation
Lymphatic vessels begin as lymphatic capillaries. These capillaries, which are
located in the spaces between cells, are closed at one end. Just as blood capillaries
converge to form venules and then veins, lymphatic capillaries unite to form larger
lymphatic vessels, which resemble small veins in structure but have thinner walls and
more valves.
At intervals along the lymphatic vessels, lymph flows through lymph nodes,
encapsulated bean-shaped organs consisting of masses of B cells and T cells. In the
skin, lymphatic vessels lie in the subcutaneous tissue and generally follow the same
route as veins; lymphatic vessels of the viscera generally follow arteries, forming
plexuses (networks) around them. Tissues that lack lymphatic capillaries include
avascular tissues (such as cartilage, the epidermis, and the eye's cornea), the central
nervous system, portions of the spleen, and red bone marrow.
Lymphatic Capillaries
Lymphatic capillaries have more excellent permeability than blood capillaries and
thus can absorb large molecules such as proteins and lipids. Lymphatic capillaries are
also slightly larger in diameter than blood capillaries and have a unique one-way
structure that permits interstitial fluid to flow into them but not out. The ends of
endothelial cells that make up the wall of a lymphatic capillary overlap. When pressure
is more significant in the interstitial fluid than in lymph, the cells separate slightly, like
opening a one-way swinging door, and interstitial fluid enters the lymphatic capillary.
When pressure is more significant inside the lymphatic capillary, the cells adhere more
closely, and lymph cannot escape back into the interstitial fluid. The pressure is relieved
as lymph moves further down the lymphatic capillary.
Attached to the lymphatic capillaries are anchoring filaments, which contain
elastic fibers. They extend out from the lymphatic capillary, connecting lymphatic
endothelial cells to surrounding tissues. When excess interstitial fluid accumulates and
causes tissue swelling, the anchoring filaments are pulled, making the openings
between cells even more prominent so that more liquid can flow into the lymphatic
capillary.
Lymph Trunks and Ducts

As lymphatic vessels exit lymph nodes in a particular body region, they unite to
form lymph trunks. The main trunks are the lumbar, intestinal, bronchomediastinal,
subclavian, and jugular trunks. The lumbar trunks drain lymph from the lower limbs, the
wall, and viscera of the pelvis, the kidneys, the adrenal glands, and the abdominal wall.
The intestinal trunk drains lymph from the stomach, intestines, pancreas, spleen, and
part of the liver. The bronchomediastinal trunks drain lymph from the thoracic wall, lung,
and heart. The subclavian trunks drain the upper limbs. The jugular trunks drain the
head and neck.
Lymph passes from lymph trunks into two main channels, the thoracic duct and
the right lymphatic duct, then empties into venous blood. The thoracic (left lymphatic)
duct is about 38–45 cm (15–18 in.) long and begins as a dilation called the cisterna chyli
anterior to the second lumbar vertebra. The thoracic duct is the central duct for the
return of lymph to blood. The cisterna chyli receives lymph from the right and left lumbar
trunks and from the intestinal trunk. The thoracic duct also receives lymph from the left
jugular, left subclavian, and left bronchomediastinal trunks in the neck. Therefore, the
thoracic duct receives lymph from the left side of the head, neck, chest, the left upper
limb, and the entire body inferior to the ribs. In turn, the thoracic duct drains lymph into
venous blood at the junction of the left internal jugular and left subclavian veins.
The right lymphatic duct is about 1.2 cm (0.5 in.) long and receives lymph from
the right jugular, right subclavian, and right bronchomediastinal trunks. Thus, the right
lymphatic duct receives lymph from the upper right side of the body. From the right
lymphatic duct, lymph drains into venous blood at the right internal jugular and right
subclavian veins.
Lymphatic Organs and Tissue

The widely distributed lymphatic organs and tissues are classified into two
groups based on their functions. Primary lymphatic organs are the sites where stem
cells divide and become immunocompetent, capable of mounting an immune response.
The primary lymphatic organs are the red bone marrow (in flat bones and the
epiphyses of long bones of adults) and the thymus. Pluripotent stem cells in the red
bone marrow give rise to mature, immunocompetent B cells and pre-T cells. The pre-T
cells, in turn, migrate to the thymus, where they become immunocompetent T cells. The
secondary lymphatic organs and tissues are the sites where most immune responses
occur. They include lymph nodes, the spleen, and lymphatic nodules (follicles). The
thymus, lymph nodes, and spleen are considered organs because a connective tissue
capsule surrounds each; lymphatic nodules, in contrast, are not considered organs
because they lack a capsule.
Thymus
The thymus is a bilobed organ located in the mediastinum between the sternum
and the aorta. An enveloping layer of connective tissue holds the two lobes closely
together, but a connective tissue capsule separates the two. Extensions of the capsule,
called trabeculae, penetrate inward and divide each lobe into lobules.
Each thymic lobule consists of a profoundly staining outer cortex and a lighter-
staining central medulla. The cortex comprises large numbers of T cells and scattered
dendritic cells, epithelial cells, and macrophages. Immature T cells (pre-T cells) migrate
from red bone marrow to the thymus cortex, where they proliferate and mature.
Dendritic cells, which are derived from monocytes (so named because they have long,
branched projections that resemble the dendrites of a neuron), assist the maturation
process. Because of its high content of lymphoid tissue and a rich blood supply, the
thymus has a reddish appearance in a living body. However, with age, fatty infiltrations
replace the lymphoid tissue, and the thymus takes on more of the yellowish color of the
invading fat, giving the false impression of reduced size.
However, the actual size of the thymus, defined by its connective tissue capsule,
does not change. In infants, the thymus has a mass of about 70 g (2.3 oz). It is after
puberty that adipose and areolar connective tissue begins to replace the thymic tissue.
By the time a person reaches maturity, the functional portion of the gland is reduced
considerably, and in old age, the operating part may weigh only 3 g (0.1 oz). Before the
thymus atrophies, it populates the secondary lymphatic organs and tissues with T cells.
However, some T cells proliferate in the thymus throughout an individual's lifetime, but
this number decreases with age.
Lymph Nodes
Located along lymphatic vessels are about 600 bean-shaped lymph nodes. They
are scattered throughout the body, both superficially and deep, and usually occur in
groups. Large groups of lymph nodes are present near the mammary glands and in the
axillae and groin. Lymph nodes are 1–25 mm (0.04–1 in.) long and, like the thymus, are
covered by a capsule of dense connective tissue that extends into the node. The
capsular extensions called trabeculae, divide the node into compartments, provide
support, and provide a route for blood vessels into the interior of a node. Internal to the
capsule is a supporting network of reticular fibers and fibroblasts. The capsule,
trabeculae, reticular fibers, and fibroblasts constitute a lymph node's stroma (supporting
framework of connective tissue). The parenchyma (functioning part) of a lymph node is
divided into a superficial cortex and a deep medulla. The cortex consists of an outer
cortex and an inner cortex. Within the outer cortex are egg-shaped aggregates of B
cells called lymphatic nodules (follicles). A lymphatic nodule consisting chiefly of B cells
is called a primary lymphatic nodule.
Lymph nodes function as a type of filter. As lymph enters one end of a lymph
node, foreign substances are trapped by the reticular fibers within the sinuses of the
node. Then macrophages destroy some foreign substances by phagocytosis, while
lymphocytes destroy others by immune responses. The filtered lymph then leaves the
other end of the lymph node. Since many afferent lymphatic vessels bring lymph into a
lymph node and only one or two efferent lymphatic vessels transport lymph out of a
lymph node, the slow flow of lymph within the lymph nodes allows additional time for
lymph to be filtered. Additionally, all lymph flows through multiple lymph nodes on its
path through the lymph vessels. This exposes the lymph to numerous filtering events
before returning to the blood.
Spleen
The oval spleen is the enormous single mass of lymphatic tissue in the body,
measuring about 12 cm (5 in.) in length. It is located in the left hypochondriac region
between the stomach and diaphragm. The superior surface of the spleen is smooth and
convex and conforms to the concave surface of the diaphragm. Like lymph nodes, the
spleen has a hilum. Through it pass the splenic artery, splenic vein, and efferent
lymphatic vessels.
A capsule of dense connective tissue surrounds the spleen and is covered in turn
by a serous membrane, the visceral peritoneum. Trabeculae extend inward from the
capsule. The capsule plus trabeculae, reticular fibers, and fibroblasts constitutes the
stroma of the spleen; the parenchyma of the spleen consists of two different kinds of
tissue called white pulp and red pulp.
White pulp is lymphatic tissue primarily composed of lymphocytes and
macrophages arranged around branches of the splenic artery called central arteries.
The red pulp consists of blood-filled venous sinuses and cords of splenic tissue called
splenic cords of Billroth's cords. Splenic cords consist of red blood cells, macrophages,
lymphocytes, plasma cells, and granulocytes. Veins are closely associated with the red
pulp.
Blood flowing into the spleen through the splenic artery enters the central arteries
of the white pulp. B cells and T cells carry out immune functions within the white pulp,
similar to lymph nodes, while spleen macrophages destroy blood-borne pathogens by
phagocytosis. Within the red pulp, the spleen performs three functions related to blood
cells: (1) removal by macrophages of ruptured, worn out, or defective blood cells and
platelets; (2) storage of platelets, up to one-third of the body's supply; and (3) production
of blood cells (hemopoiesis) during fetal life.
Lymphatic Nodules
Lymphatic nodules (follicles) are egg-shaped masses of lymphatic tissue that are
not surrounded by a capsule. Because they are scattered throughout the lamina propria
(connective tissue) of mucous membranes lining the gastrointestinal, urinary, and
reproductive tracts and the respiratory airways, lymphatic nodules in these areas are
also referred to as mucosa-associated lymphatic tissue (MALT).
Although many lymphatic nodules are small and solitary, some occur in multiple
large aggregations in specific body parts. Among these are the tonsils in the pharyngeal
region. Usually, five tonsils form a ring at the junction of the oral cavity and oropharynx
and the intersection of the nasal cavity and nasopharynx. The tonsils are strategically
positioned to participate in immune responses against inhaled or ingested foreign
substances. The single pharyngeal tonsil or adenoid is embedded in the posterior wall
of the nasopharynx. The two palatine tonsils lie at the posterior region of the oral cavity,
one on either side.
VIII. PATHOPHYSIOLOGY
This section will discuss the disordered physiological processes associated with
Kawasaki disease secondary to ARDS from community-acquired pneumonia.
Symptomatology and the predisposing and precipitating factors specific for this case will
be identified as well as the complete pathophysiology of the disease presented in
diagram and narrative way.
A. Symptomatology
All signs and symptoms found below are associated with Kawasaki disease.
Included are those findings seen in Patient JD:
High Fever. It is a temporary increase in an individual’s temperature. It is the

body’s natural response if an infection or something unusual is present in the body
(Mayo Clinic, 2020). Patient JD experienced high fever as it is the first sign manifested
if a patient has or suspected of Kawasaki disease.
Rash on genital area/diaper area. Rash is an area of irritated or swollen skin

and it can be red, itchy, painful, and irritating. Rash is a response of a body and a sign
of many different medical conditions that may be caused by irritating substances or
allergies (Medline Plus, 2022). Rashes appear all over the body particularly and usually
on the groin or diaper area is one of the symptoms that present in Kawasaki disease
and Patient JD personally experienced.
Neck lymph node enlargement. Swollen or enlarged lymph nodes usually

occurs as a response from an infection (Mayo Clinic, 2021). Patient JD experienced
swelling of lymph node particularly on the neck area as one of the symptoms of
Kawasaki disease.
Conjunctivitis. It is an inflammation on the conjunctiva or the transparent

membrane that lines the eyelid or cover the white part of the eyeball; and the pinkish or
reddish appearance of the white area of the eyes is caused by the inflammation of the
small red blood vessels in the conjunctiva. Inflammation can be caused by infection
from bacteria or virus or allergies (Mayo Clinic, 2020). Extremely red eyes without a
thick discharge is one of the symptoms of Kawasaki disease which Patient JD
personally manifested.
Swollen “strawberry” tongue. Strawberry tongue is a term refers to a tongue

that is swollen, bumpy, bright red, and resembling a strawberry. This usually occurs as
a symptom of a medical condition such as Kawasaki disease (Holland, 2018).
Sore throat. It is an irritation, pain, or scratchiness of the throat and often

worsens when an individual swallow. It is often caused by a viral infection (Mayo Clinic,
2021).
Shortness of breath. Difficulty in breathing is defined as an intense air hunger,

difficulty in breathing, breathlessness, or a feeling of suffocation (Mayo Clinic, 2020).
Patient JD experienced shortness of breath as consolidation blocks the airways making
it difficult for the patient to breathe.
Crackles. It is defined as an adventitious lung sound that can be heard upon

auscultation of the chest; the sound produced is due to the air passing over retained
secretions or the sudden opening of the collapsed airways (Kahn, 2019).
B. Factors
TABLE 8-1
Predisposing and Precipitating Factors Causing Kawasaki Disease Secondary to

ARDS from CAP with Rationale
Predisposing Factor Present Rationale
Kawasaki disease is a rare illness and is commonly
affecting children ages 0 to 5, but it can sometimes
affect children until the age of 13 (Cedars Sinai,
Age 
2022). Moreover, ARDS can occur in people of
many ages; however, the incidence increases with
advancing age (Harman, 2020).
Gender  Kawasaki disease appears more frequently and
usually affects the male population than the female
by a ratio of approximately 1.5 to 1 (National
Organization for Rare Diseases, 2009).
Children of any race or ethnic group can get
Kawasaki disease, but it is more common in
Race 
children whose family is from East Asia or Asian
ancestry (Mayo Clinic, 2021).
The children who develop Kawasaki disease may
be genetically predisposed to it. This means the
genes they inherit from their parents may make
them more likely to get the condition (NHS, 2021).
In recent years, there have been studies that have
Genetics 
shown certain genetic markers (such as HLA-B51
and HLA-Bw22j2 serotypes, chemokine receptor
gene-cluster CCR2-CCR5 haplotypes, and
FCGR3A polymorphism of the IgG receptor IIIa)
show a predisposition to the disease.
Precipitating Factor Present Rationale
Recent epidemiological studies have focused on
some potential environmental risk factors for
Kawasaki disease. Recently, a study examined the
Environmental  association between Kawasaki disease onset and
triggers
exposure to specific air pollutants such as carbon
monoxide, nitrogen oxide, ozone, and sulfate oxide
(Lin et al., 2017).
Some researchers suggest that Kawasaki disease
may be caused by certain toxic substances called
bacterial “superantigens” that are produced by
particular types of bacteria, such as streptococci or
staphylococci. They indicate that such
Infectious triggers  superantigens may trigger an exaggerated response
of the immune system, resulting in infiltration of
blood vessel walls with certain white blood cells,
associated blood vessel inflammation (vasculitis),
and cardiovascular damage (National Organization
for Rare Diseases, 2009).
A person who is obese or has a higher body mass
index (BMI) is particularly at risk of developing
Weight ARDS. However, the aforementioned statement is
likely associated with longer lengths of stay but not
ARDS mortality (De Jong, 2019).
Exposure or the act of cigarette smoking may
contribute to the development of ARDS through an
abnormal response of an increased alveolar-
Tobacco smoking
capillary membrane permeability, exaggerated
inflammation, increased epithelial injury and
endothelial dysfunction (Lu et al., 2018).
Chronic consumption of large amounts of alcohol
Alcohol drinking may significantly contribute to one being able to
develop ARDS (Simou et al., 2017).
ARDS is a condition that causes fluid to pool in tiny
air sacs in the lungs that may be due to the leaks
Severe bleeding coming from the blood vessels, disabling oxygen to
be delivered properly as these sacs were not filled
with enough air (Miller, 2020).
Patients with severe trauma have a significantly
high chance of developing ARDS, wherein an
Trauma estimated 10% to 30% of critically ill trauma patients
have developed the said condition (Jabaudon et al.,
2019).
Sepsis is the most common cause for ARDS. This
blood poisoning mechanism is the body’s deadly
Sepsis
response to infection, killing and disabling
multitudinous lives (Sepsis Alliance, 2021).
Illicit use of drugs can lead to several respiratory
problems. The use of cocaine can cause severe
respiratory complications. In addition to that, opioid
Drug overdose overdose has been implicated as a cause of ARDS
as it causes breathing to slow, obstruct air from
entering the lungs, or induce severe bronchospasm
(National Institute on Drug Abuse, 2020).
Pulmonary consequences of fat embolism
syndrome (FES) includes ARDS, the initial
Fat embolism
manifestation of FES that appears within 24 hours
after the traumatic insult (Bulauitan, 2018).
Pancreatitis Most cases of pancreatitis would often present
severe stomach pain and dehydration. Sometimes,
a severe inflammation can cause complications
inside and outside of the pancreas. Inflammatory
chemicals are secreted in the bloodstream that may
reach the lungs. In consequence, the patient may
experience an inflammatory reaction within the
lungs, such as ARDS (Brady, 2019).
C. Pathophysiology Diagram
Legend:
Diagnostic Test Manifestation Management
Predisposing Factors:
 Age
Precipitating Factors:
 Gender
 Environmental triggers
 Race
 Infectious triggers (bacterial infection)
 Genetics
GENETICS FOLLOWING RESPIRATORY INFECTION

(Main etiology of Kawasaki Disease)
Community social contact (droplets spread through coughing/sneezing)
Typical community acquired pneumonia CAP confirmed through bacterial

c culture exam (Streptococcus
(streptococcal pneumonia) pneumoniae positive)
Oral Antibiotic Therapy (Augmentin) Inflammatory response following effusion
Surface phagocytosis
Alveolar consolidation (alveoli filled with fluid, RBCs, polymorphonuclear

leukocytes, and macrophages)
The Berlin Diagnostic Criteria for Acute respiratory distress syndrome from
ARDS (respiratory symptoms within community-acquired pneumonia
1 week, bilateral chest infiltrates on
CXR, respiratory failure not from
heart failure/fluid overload,
moderate/severe oxygenation Pulmonary capillary engorgement and increased
impairment)
alveolar-capillary membrane permeability
Scattered areas of hemorrhagic consolidation

and airway smooth muscle constriction Cough, bilateral
PAGE \*infiltrates
opacities/chest MERGEFORMAT
on 2
CXR, dull percussion note
upon percussion, bronchial
breath sounds and crackles
upon auscultation
Bronchodilator Therapy (Ventolin
HFA)+ ACT (CPT, flutter devices)
Lung Expansion Therapy
↓ surfactant, alveolar collapse/atelectasis (PEEP/CPAP)
Lining of intraalveolar walls with thick,

Increased
radiodensity in CXR rippled hyaline membrane
having a “ground-
glass appearance”
Respiratory infection activates lymphocytes, cytokines, and proteinases, specifically

tumor necrosis factor alpha (TNF-a), Interleukin 1, 4 and 6 and
matrix metalloproteinases (MMP3 and MMP9).
Activation of Oligoclonal IgA plasma cells prominent in the respiratory tract
Onset of myocarditis and coronary arteritis IV Immunoglobulin and Aspirin

Therapy with Budesonide (down-
regulation of inflammation)
CBC (↓ hemoglobin,
↑ neutrophil count and
other WBC components) Vessel wall weak spot development
(predisposition to aneurysmal formation)
Echocardiogram (to rule

Systemic medium vessel vasculitis out coronary artery
aneurysm)
Warm CREAM and Mucocutaneous lymph node syndrome

FEBRILE Mnemonics
AKA “KAWASAKI DISEASE”
Psychosocial concerns (unpredictable mood

swings, irritability, depression)
Fever of >39 C for >5
days, rash on
genital/diaper area,
neck lymph node
enlargement, Fluoxetine Hydrochloride Therapy (Sarafem):
conjunctivitis (red treatment of major depressive disorder
eyes), swollen
“strawberry” tongue
V/Q mismatch
Hypoxemia and stimulation of O2 receptors

Hypoxia and stimulation of alveolar ventilation
ABG Acute alveolar hyperventilation with Low flow O2 therapy

(pH >7.45,
↓PaCO2, ↓HCO3-, mild hypoxemia (2 LPM nasal prongs)
↓PaO2, ↓SaO2) (mild-moderate ARDS)
ABG
Acute ventilatory failure with Invasive ventilatory
(pH <7.35, uncorrected hypoxemia support via nasotracheal
↑PaCO2, ↑HCO3-, (severe ARDS) intubation
↓PaO2, ↓SaO2)
If treatment is responsive:
 Continue pharmacological therapy
until inflammatory markers return to If treatment is unresponsive:
normal  Consider tracheostomy if
 Consider extubation if criteria is met intubation exceeds >2 weeks
If treated, can lead to: If left untreated, can lead to:

 Resolution of disease in the  Coronary aneurysms leading to
convalescent phase stenosis
 Normal body temperature  Thrombus formation leading to MI
 Airway clearance and regulation of  Ischemia-related dysrrhythmias
inflammatory markers  Death
 Good prognosis
D. Pathophysiology Narrative
IX. DIAGNOSTICS
Early and accurate diagnosis of respiratory diseases is critically important to
improve the effectiveness of treatments and avoid long-term complications for the
patient. Getting the right diagnosis is a key aspect of health care, as it provides an
explanation of a patient's health problem and informs subsequent health care decisions
(Holmboe & Durning, 2014). Diagnostics are divided to actual and other possible tests,
which are keys to diagnose Patient Livander’s condition.
A. Actual Diagnostic Tests

Actual diagnostic tests for RVHD are tools that are helpful for the following
reasons: (1) to diagnose acute CF setback and RVHD, and (2) monitor the progression
of the disease process along the course of ongoing treatment. To confirm the diagnosis,
diagnostic tests include the chest radiography, echocardiogram, and sputum culture.
Diagnostic tests for monitoring disease progression include arterial blood gas sampling,
complete blood count, electrocardiogram, and hemodynamic monitoring. All these tests
were done to Patient Livander found in the respiratory therapy care plan (section 11).
Chest Radiography
Chest radiography is the most common radiographic procedure performed in
medical imaging departments, and one of the most often repeated exams (Hobbs, 2007;
Bontrager & Lampignano, 2005). It is usually the first test performed to evaluate any
concerns based on a careful history and physical assessment. This noninvasive test is
also the most commonly preferred diagnostic examination to produce images of the
heart, lungs, airways, blood vessels, and the bones of the spine and chest.
Chest X-rays are a form of radiation like light or radio waves. It passes through
most objects, including the body. The technologist carefully aims the x-ray beam at the
area of interest. The machine produces a small burst of radiation that passes through
the body. The radiation records an image on photographic film or a special detector.
Chest radiograph has limited utility in identifying RVHD. It might show evidence of the
underlying cause of RVHD like pulmonary embolism, congenital heart diseases or in
Patient Livander’s case, cystic fibrosis. Common chest radiograph of a patient with right
ventricular heart disease are right ventricular and proximal pulmonary artery
enlargement with distal arterial attenuation. Table 9-1 summarizes the baseline chest X-
ray films of Patient Livander found in the respiratory therapy care plan.
TABLE 9-1
Chest Radiography (AP views) Baseline Results
Impression: Taken on 11/05/2021,

Lungs are hyperlucent, heart is vertical Impression: Taken on 11/07/2021,
and narrow, diaphragm is flattened, Lungs overinflation with diffuse infiltrates
retrosternal air is increased, AP diameter and large main pulmonary segment. Lung
is increased. fields are dark; heart size, interstitial
markings, and AP diameter are
increased, retrosternal space is enlarged,
diaphragm is flattened.
Impression: Taken on 11/10/2021, Lungs are still hyperinflated, heart is vertical and
narrow, diaphragms are flattened, retrosternal air is minimally increased, AP diameter
is slightly increased.
Echocardiography
A procedure that uses high-energy sound waves (ultrasound) to look at tissues
and organs inside the chest. Echoes from the sound waves form a picture of the size,
shape, and position of the heart on a computer screen. The pictures can also show the
parts of the inside of the heart, such as the valves, and the motion of the heart while it is
beating. Echocardiography may be used to help diagnose heart problems, such as
abnormal heart valves and heart rhythms, heart murmurs, and damage to the heart
muscle from a heart attack (National Cancer Institute, 2020).
Assessment of right ventricular (RV) function is important to ascertain clinical
outcome in patients with symptoms of right ventricular failure as well as the degree of
severity. Table 9-2 shows the ECHO result of Patient Livander which confirmed the right
ventricular hypertrophy and an enlarged heart on the right side.
TABLE 9-2
Echocardiography Baseline Result
Impression: Taken on 11/07/2021,
Right ventricular hypertrophy is observed and an enlarged heart on the right side.
Sputum Culture
Sputum culture is an examination under a microscope of cells found in sputum. It
is the testing of lung secretions or phlegm to look for bacteria. The patient coughs up a
sample of mucus, which is viewed under the microscope to identify possible bacteria
(Felson, 2017). A normal test result means that few white blood cells and no bacteria
have been found in the sputum sample. In cystic fibrosis, the accumulation of secretions
and loss of airway defenses leads to the colonization of the airways with characteristic
bacteria such as Staphylococcus aureus and Pseudomonas aeruginosa. It estimated by
Mogayzel et al. (2014) that approximately 80% of patients eventually become infected
with P. aeruginosa. Patient Livander tested positive for P. aeruginosa infection on 10th of
November, 2021. Table 9-3 shows the sputum analysis result of Patient Livander found
in the respiratory therapy care plan.
TABLE 9-3
Sputum Culture Result for Pathogen Identification, 11/10/2021, 10:52 am
Sample Collection Date : 11/04/2021 Pathogen: Gram-negative
Sputum Color/Consistency: Green, mucoid Pseudomonas aeruginosa
Arterial Blood Gas Sampling

Results obtained from an ABG sampling are the foundation for the diagnosis and
management of acid-base disturbances, determine the degree of hypoxemia, and
monitor the possibility of impending failure for chronic diseases (Gentile et al., 2017).
This is considered the gold standard of gas-exchange analysis compared to all other
methods.
A way of obtaining arterial blood gas is through direct cannulation using
indwelling catheters which provides ready access for blood sampling and allows
monitoring of vascular pressures without the traumatic risks associated with repetitive
percutaneous punctures. Table 9-4 summarizes the baseline ABG results of Patient
Livander found in the respiratory therapy care plan.
TABLE 9-4
pH : ↓ 7.23 7.38 7.35-7.39
-
SaO2 : ↓ 80% 90% 88-92%
Impression: Acute ventilatory failure superimposed on chronic ventilatory failure with
uncorrected hypoxemia
pH : N 7.36 7.38 7.35-7.39
PaCO2 : N 55 mmHg 55 mmHg 45-55 mmHg
PaO2 : N 77 mmHg 78 mmHg 70-80 mmHg
-
HCO3 : N 41 mEq/L 37 mEq/L >26 mEq/L
SaO2 : N 89% 90% 88-92%
Impression: Chronic ventilatory failure with corrected hypoxemia
Baseline ABG at 2 LPM via Nasal Prongs at 28% FiO2, 11/10/2021
pH : N 7.37 7.38 7.35-7.39
-
SaO2 : N 88% 90% 88-92%
Complete Blood Count
A blood culture is a test of a blood sample to find microorganisms such as
bacteria or a fungus that can cause an infection. A bacterial infection in the blood called
bacteremia, can be serious, that is because the blood can spread the bacteria to any
part of the body. A CBC requires a small blood specimen. Blood is drawn from a vein,
usually from the inside of the elbow or the back of the hand (Michigan Medicine, 2020).
In Patient Livander’s case, WBC count and its components were elevated
suggestive of presence of inflammation and infection indicating a persisting infection
and the immune system is fighting alongside the inflammatory response. Table 9-5
summarizes the baseline CBC results of Patient Livander found in the respiratory
therapy care plan.
TABLE 9-5
Complete Blood Count Result for Infection Evaluation, 11/05/2021
CBC Result Received at 10:15 am Reference Value
HGB : N 15.8 g/dL 13.5-17.5 g/dL
HCT : N 49% 35-53%
6
RBC : N 5.08 x10 /uL 4.50-5.90 x 106/uL
WBC : ↑ 19.5 x 103/uL 4.5-11.0 x 103/uL
Lymph : ↑ 47% 24-44%
Mono : ↑ 11% 4-10%
Eos : ↑ 3.11% 0-3%
Bas : ↑ 1.78% 0-1%
3
PLT : N 203 x 10 /uL 150-450 x 103/uL
MCH : N 28 pg 26-34 pg
MCHC : N 33% 32-36%
MCV : N 81 fl 80-100 fl
Impression: WBC count and its components were elevated.
HGB : ↑ 17.8 g/dL 13.5-17.5 g/dL
HCT : ↑ 54% 35-53%
RBC : ↑ 5.99 x106/uL 4.50-5.90 x 106/uL
WBC : ↑ 14.6 x 103/uL 4.5-11.0 x 103/uL
Lymph : ↑ 49% 24-44%
Mono : ↑ 13% 4-10%
Eos : ↑ 5.2% 0-3%
Bas : ↑ 3.1% 0-1%
PLT : N 362 x 103/uL 150-450 x 103/uL
MCH : N 32 pg 26-34 pg
MCHC : N 35.1% 32-36%
MCV : N 85 fl 80-100 fl
Impression: Patient has slightly elevated HGB, HCT, RBC count and WBC
components.
HGB : N 17.3 g/dL 13.5-17.5 g/dL
HCT : N 52.4% 35-53%
6
RBC : N 5.05 x10 /uL 4.50-5.90 x 106/uL
WBC : ↑ 11.8 x 103/uL 4.5-11.0 x 103/uL
Lymph : ↑ 45% 24-44%
Mono : ↑ 13.1% 4-10%
Eos : ↑ 3.9% 0-3%
Bas : ↑ 1.45% 0-1%
3
PLT : N 367 x 10 /uL 150-450 x 103/uL
MCH : N 31 pg 26-34 pg
MCHC : N 34.8% 32-36%
MCV : N 89 fl 80-100 fl
Impression: Patient has elevated WBC components.
Electrocardiogram
Electrocardiogram is a medical test that detects cardiac (heart) abnormalities by
measuring the electrical activity generated by the heart as it contracts. The machine that
records the patient’s ECG is called an electrocardiograph (Better Health Channel,
2012). Electrocardiograph is done by placing electrodes (small, plastic patches that
stick to the skin) at certain spots on the chest, arms, and legs. The electrodes are
connected to an ECG machine by lead wires. The electrical activity of the heart is then
measured, interpreted, and printed out. The recording of an ECG on standard paper
allows the time taken for the various phases of electrical depolarization to be measured,
usually in milliseconds. Normal ECG values for waves and intervals are as follows: RR
interval: 0.6-1.2 seconds. P wave: 80 milliseconds. PR interval: 120-200 milliseconds
(Price, 2019).
Electrocardiographic (ECG) abnormalities in RVHD reflect the presence of right
ventricular hypertrophy (RVH), RV strain, or underlying pulmonary disease such as
cystic fibrosis. The common EKG results are the right-axis deviation (RAD) suggestive
of right-sided heart failure, common abnormalities include Q waves, abnormalities in the
T wave and ST segment, left ventricular hypertrophy, bundle branch block, and atrial
fibrillation. Table 9-6 summarizes the baseline ECG strips of Patient Livander found in
the respiratory therapy care plan.
TABLE 9-6
12-Lead EKG Result, 11/05/2021
EKG Result Received at 10:51 am
Impression: Increased heart rate and close R-R intervals in leads V2- V6
Impression: Lead I has negative deflection and aVF has positive deflection
Impression: Normal sinus rhythm evidenced by regular ventricular rate, uniform R-R
intervals, and complete waveforms.
Hemodynamic Monitoring
Hemodynamics refer to the forces, such as preload and afterload that affect
circulating blood throughout the body. Hemodynamic monitoring is the assessment of
the patient’s circulatory status. It includes measurements of heart rate, intra-arterial
pressure, pulmonary artery and pulmonary capillary wedge pressures, central venous
pressure, cardiac output, and blood volume.
Because of the complexity of Patient Livander’s disease, hemodynamic
monitoring is an essential component of quality patient care. Swan-Ganz catheterization
(also called right heart catheterization or pulmonary artery catheterization) is the
passing of a thin tube into the right side of the heart and the arteries leading to the
lungs. It is done to monitor the heart's function and blood flow and pressures in and
around the heart (Hartley, 2019). Table 9-7 summarizes the baseline Hemodynamic
monitoring results of Patient Livander found in the respiratory therapy care plan.
TABLE 9-7
Vascular Pressure Monitoring via 7-French Swan-Ganz Catheter, 11/07/2021
Pressure Monitored at 11:11 am Reference Value
CVP : 11 mmHg 0-6 mmHg (SVC near RA)
RAP : 13 mmHg 2-7 mmHg (RA)
RVEDP : 13 mmHg 2-7 mmHg (RV)
MPAP : 26 mmHg 5-10 mmHg (PA)
PAOP/PCWP: 5 mmHg 8-12 mmHg
CO : 3.2 L/min 4-8 L/min
Impression: Monitoring revealed elevated CVP, RAP, RVEDP, MPAP and low PAOP
and CO.
B. Other Possible Diagnostic Tests

These are additional tests that can possibly diagnose Patient Livander with
RVHD but were not performed as these tests offer little significance to the current
patient presentation like the CT pulmonary angiography and cardiac MRI.
CT Pulmonary Angiography
Pulmonary angiography is a test to see how blood flows through the lung. This
type of angiography is an imaging test that uses x-rays and a special dye to see inside
the arteries which are blood vessels that carry blood away from the heart (Sudheendra,
2020). A CT pulmonary angiogram or CTPA is a CT scan that looks for blood clots in
the lungs which is also known as pulmonary embolism. It has the ability to show the
following: blood clot (pulmonary embolism), bulging blood vessel (aneurysm), an artery
abnormally connected to a vein (arteriovenous malformation), heart and blood vessel
problems present at birth, foreign body in a blood vessel, and the arrowing of a blood
vessel wall or stenosis (Johns Hopkins University, 2021).
Findings in CTPA including left ventricular enlargement, left atrial enlargement,
and right ventricular enlargement were shown to be specific for a diagnosis of RVHD.
CTPA should be used by physicians awaiting echocardiography to help guide treatment
in cases of suspected heart failure (Halloran & Brien, 2020). In the present case, CTPA
was not done to Patient Livander because echocardiography was already enough to
confirm the diagnosis of right ventricular heart disease.
Cardiac MRI
A cardiac MRI is a painless imaging test that uses radio waves, magnets, and a
computer to create detailed pictures of the heart. Cardiac MRI can provide detailed
information on the type and severity of heart disease to help physicians decide the best
way to treat heart problems such as cor pulmonale, coronary heart disease, heart valve
problems, pericarditis, cardiac tumors, or damage from a heart attack (Washburn,
2020). Cardiac MRI may be done in a medical imaging facility or hospital.
Cardiac MRI was not done to Patient Livander because all the actual diagnostic
tests done to diagnose and monitor the patient’s RVHD were already enough, based on
the physician assessment. The test also includes an additional insertion of IV-line
catheter which imposes greater risk of complications to the patient.
X. DRUG STUDY
As more medicines become available today, drug study has become more
important in determining the potential interactions caused by patients taking multiple
prescribed, over-the-counter and homeopathic medications. Whether these chemical
agents are natural or synthetic, they can have physiological effects on those that take
them.
Drug Study #1
Brand Name : Ventolin HFA

Generic Name : Albuterol
Classification : Short-acting beta agonist
Mode of Action: Stimulates beta2 -adrenergic receptors in lungs, resulting in relaxation
of bronchial smooth muscle (Merrell & Bounds, 2021).
Dosage/Frequency/Route (Slowiczek, 2020):

 Nebulization: Given 5 ml of 20% solution q6
Indication/s: Treatment or prevention of bronchospasm with reversible obstructive

airway disease (Merrell & Bounds, 2021).
Contraindication/s: Hypersensitivity to albuterol and severe hypersensitivity to milk

protein (Merrell & Bounds, 2021).
Side Effect/s (Slowiczek, 2020):

 Headache, restlessness, nervousness, tremors, nausea, dizziness, dryness of
throat, irritation, pharyngitis
Adverse Effect/s (Slowiczek, 2020):

 Excessive sympathomimetic stimulation may produce:
 Palpitations, ectopy, tachycardia
 Chest pain slight increase in B/P followed by:
 Substantial decrease, chills, diaphoresis, blanching of skin
 Too frequent or excessive use may lead to:
 Decreased bronchodilating effectiveness/severe paradoxical bronchoconstriction.
Drug Interaction/s (Slowiczek, 2020):

 Beta-blockers antagonize effects
 May produce bronchospasm: Atomoxetine, MAOIs, tricyclic antidepressants may
potentiate cardiovascular effects.
 May increase effects of loop diuretics, and sympathomimetics.
RT Responsibilities:
1. Baseline assessment: Monitor respiratory rate, oxygen saturation, and lungs
sounds before and after administration.
2. Do not exceed recommended dosage: Administer pressurized inhalation drug
forms during second half of inspiration, because the airways are open wider and
the aerosol distribution is more extensive. Since it is pressurized and localized in
the lungs, immediate response will occur. Hence, overdose will cause immediate
complications and adverse effects or loss of effectiveness may result.
3. Use minimal doses for minimal periods: Long-term usage of a medication,
tolerance can develop. When tolerance occurs, physician may suggest increase
of dosage and will result to frequent tachycardia and palpitations.
4. Maintain sterility of nebulization kit: To deter the spread of microorganism and
ensure the effectives of the medication.
5. Assess lung sounds for wheezing and rales: May provide crucial information
on the source of respiratory symptoms. Crunching noises may indicate a
collapsed lung, especially in chest discomfort and shortness of breath.
6. Evaluate urinary output and prostate palpation as appropriate: To monitor
anticholinergic effects of the medication.
7. Document nebulization: Accurate and timely documentation and reporting of
pertinent data promotes patient’s safety and transparency of records.
Drug Study #2
Brand Name : Pulmozyme

Generic Name : Dornase alfa
Classification : Mucolytic
Mode of Action: Dornase alfa cleaves the DNA released from the neutrophils and
reduces mucous viscosity, and further prevent airway infections and damage to the lung
parenchyma. Overall, improving pulmonary function (Altaf & Parmar, 2021).
Dosage/Frequency/Route:
 Nebulization: 2.5 mg single-use ampule inhaled qd using a recommended jet
nebulizer compressor system (“Pulmozyme”, 2021).
Indication/s: Daily administration in conjunction with standard therapies for the

management of cystic fibrosis (CF) patients to improve pulmonary function. In CF
patients with an FVC ≥ 40% of predicted, daily administration of pulmozyme has also
been shown to reduce the risk of respiratory tract infections requiring parenteral
antibiotics (Yang & Montgomery, 2021).
Contraindication/s: Patients with known hypersensitivity to the drug, Chinese hamster

ovary cell products, or any component of the product (Altaf & Parmar, 2021).
Side Effect/s (“Pulmozyme”, 2021):

 Sore/dry throat and hoarseness, eye redness and irritation, rash, laryngitis, eye
inflammation, or runny or stuffy nose
Adverse Effect/s (“Pulmozyme”, 2021):

 An allergic reaction, increased difficulty breathing, chest pain, fever
Drug Interaction/s: No known drug interaction.
1. Assess for hypersensitivity: Always note for patient’s past medical health
history of drugs and medication allergies before administration.
2. Assess the quantity and consistency of sputum: Assessing the quantity and
consistency of sputum to help document whether this drug is successful in
reducing the viscosity of respiratory secretions.
3. Monitor vital signs: Monitor blood pressure, pulse rate, heart rate, respiratory
rate, and temperature to have a baseline if there are any changes and
improvements in the patient.
4. Observe for signs of bronchospasm: If bronchospasm occurs, discontinue
treatment. Notify the physician immediately to recommend other medication to
use.
5. Discard ampules after administration: Ampules of dornase alfa do not contain
a preservative. It is intended for one-time use only. Once opened, the entire
contents of the ampule must be used or discarded.
6. Note and observe for possible risk factors and contraindications: To
immediately respond and prevent further complication.
7. Assess if the patient's symptom or health problem gradually get better or
worse: To report and suggest any alteration of drug to effectively ease patient's
condition.
Drug Study #3
Brand Name : Zithromax

Generic Name : Azithromycin
Classification : Broad-spectrum antibiotic
Mode of Action: Azithromycin is the first of a subclass of antibiotics, and is
chemically different from erythromycin. Rapidly absorbed from the gastrointestinal tract.
Extensively distributed in the tissues and sputum (“Zithromax”, 2019):
Dosage/Frequency/Route (“Zithromax”, 2019):

 Intravenous: 500 mg daily as a single dose for 1 or 2 days, given at a rate of 1
mg/mL over 3 hours or 2 mg/mL over 1 hour.
Indication/s: Azithromycin (AZM) is indicated for treatment of Pseudomonas infections.

It has shown promising results in the treatment of Pseudomonas aeruginosa chronic
lung infections such as those occurring in cystic fibrosis (“Zithromax”, 2019).
Contraindication/s: Severe hepatic impairment, hypersensitivity (“Zithromax”, 2019).
Side Effect/s (“Zithromax”, 2019):

 Diarrhea or loose stools, nausea, abdominal pain, stomach upset, vomiting,
constipation, dizziness, tiredness, headache, vaginal itching, nervousness, sleep
problems, skin rashes, hearing problems
Adverse Effect/s (“Zithromax”, 2019):

 GI upset, deafness, pruritus, rash, arthralgia, decreased lymphocyte count, raised
granulocyte count, decreased blood bicarbonate, reports of serious
hypersensitivity, arrhythmia, hepatitis C
Drug Interaction/s (“Zithromax”, 2019):

 Nelfinavir
 Warfarin
 Potential drug-to-drug interaction with macrolides
1. Monitor the patient's vital signs: This is to avoid complications. This also
serves as the baseline data of the patient’s health status.
2. Assess if the patient is allergic to any component of the drug: Some
patients are allergic to the components of the drug. It is important to monitor and
assess the severity of allergy present, which must be observed if medication is to
continue or not.
3. Assess for hepatotoxicity: Observe for signs and symptoms of malaise, fever,
abdominal pain and GI disturbances for this could be an early indication for
hepatoxicity.
4. Notify an attending physician when side effects and adverse effects occur:
To immediately respond and prevent further complication
5. Administer the medication to the patient as directed: Prevents overdose,
under dose and toxicity. If on a scheduled dosing regimen, take the missed dose
as soon as remembered, spacing remaining doses at regular intervals. Do not
double doses or increase the dose or frequency of doses.
6. Monitor symptoms of high plasma potassium levels: Monitoring signs and
symptoms of hyperkalemia, including bradycardia, fatigue, weakness, numbness,
and tingling is vital to immediately identify sudden complications because severe
cases can lead to life-threatening arrhythmias and paralysis.
7. Monitor sign of pseudomembranous colitis including diarrhea, abdominal
pain mucus in stool and other server GI disturbances: RT should know that
antibiotics could disrupt the normal flora of the gastrointestinal system and further
complication of GI upset could be fatal. Report immediately to the attending
physician for management and intervention.
Drug Study #4
Brand Name : Lasix

Generic Name : Furosemide
Classification : Diuretic
Mode of Action: Enhances excretion of sodium, chloride, potassium by direct action at
ascending limb of loop of Henle (Marks, 2019).
Dosage/Frequency/Route (“Furosemide”, 2021):

 Intravenous: Administered at 80 mg via pulmonary artery catheter.
Indication/s: For the treatment of peripheral edema or edema associated with heart
failure, chronic lung disease, or nephrotic syndrome.
Contraindication/s: Hypersensitivity to furosemide and anuria (“Furosemide”, 2021).
Side Effect/s (“Furosemide”, 2021):

 Increased urinary frequency, nausea, dyspepsia, abdominal cramps, diarrhea,
electrolyte disturbances, dizziness, headache, blurred vision, paresthesia,
photosensitivity, rash, fatigue, bladder spasm, restlessness, diaphoresis
Adverse Effect/s (“Furosemide”, 2021):

 Vigorous diuresis may lead to profound water/electrolyte loss resulting in:
 Hypokalemia, hyponatremia and dehydration
 Sudden volume depletion may result in:
 Increased risk of thrombosis, circulatory collapse and sudden death
 Acute hypotensive episodes may occur, several days after beginning therapy
 Ototoxicity may occur, especially in patients with severe renal impairment
Drug Interaction/s (“Furosemide”, 2021):

 Amphotericin B, nephrotoxic ototoxic medications may increase risk of
nephrotoxicity, ototoxicity: May increase risk of lithium toxicity.
 Other medications causing hypokalemia may increase risk of hypokalemia.
1. Check the patient’s chart before the administration of the drug: To avoid
giving the wrong medication to the patient.
2. Obtain baseline assessment: Check vital signs especially BP, pulse for
hypotension before administration and assess baseline renal function, serum
electrolytes, especially serum sodium and potassium. This will help the RT to rule
out possible complications and assess the effectiveness of the medication.
3. Note the extent of diuresis: To monitor the possible symptoms for electrolyte
imbalance. Hypokalemia may result in changes in muscle strength, tremor,
muscle cramps, altered mental status, cardiac arrhythmias; hyponatremia may
result in confusion, thirst, cold/clammy skin. Recommend potassium
supplementation if hypokalemia occurs.
4. Measure and record weight to monitor fluid changes: One method to detect
whether heart failure is becoming worse or there is a need to modify the
medicine is to reduce excess fluid in the body.
5. Monitor for the patient’s bowel movement: Any changes in the bowel
movement may indicate diarrhea, abdominal pain, fever, or bloody stool.
6. Note and observe for risk factors: This can help to avoid developing a more
serious health problem.
7. Assess skin turgor, mucous membranes for hydration status, observe for
edema: To assess the degree of dehydration or fluid loss in the body.
Drug Study #5
Brand Name : Cardepine

Generic Name : Nicardipine
Classification : Calcium channel blocker
Mode of Action: Inhibits calcium ion movement across cell membranes, depressing
contraction of cardiac, vascular smooth muscle. Increases cardiac output, myocardial
oxygen delivery, decreases systemic vascular resistance, BP (Nursing Central, 2021).
Dosage/Frequency/Route (“Nursing Central”, 2021):

 Intravenous: Administered by slow continuous infusion at a conc. of 0.1 mg/ml
Indication/s (“Nursing Central”, 2021):

 For the treatment of chronic stable (effort-associated) angina, hypertension.
 Short-term treatment of hypertension when oral therapy not feasible or desirable.
Contraindication/s (“Nursing Central”, 2021):

 Ventricular tachycardia, ventricular fibrillation, arrhythmia
Side Effect/s (“Nursing Central”, 2021):

 Frequent (10%–7%):
 Headache, peripheral edema, lightheadedness, facial flushing, dizziness
 Occasional (6%–3%):
 Asthenia, palpitations, angina, tachycardia
 Rare (less than 2%):
 Nausea, abdominal cramps, dyspepsia, dry mouth, rash
Adverse Effect/s (“Nursing Central”, 2021):

 Overdose produces confusion, slurred speech, drowsiness, hypotension,
bradycardia
Drug Interaction/s (“Nursing Central”, 2021):

 May increase concentration of cyclosporine
1. Assess medications: To avoid complications. This serves as the baseline data
of the patient’s health status.
2. Titrate slowly during administration: RT should be careful during
administration of the drug to avoid systemic hypotension and possible negative
inotropic effects.
3. Note the normal vital signs: Checking vitals sign before and after
administration of drugs is important to know the baseline data of the patient.
4. Monitor blood pressure periodically during therapy: Always monitor the
blood pressure because the time course of blood pressure decrease is
dependent on the initial rate of infusion and the frequency of dosage adjustment.
With constant infusion, blood pressure begins to fall within minutes. It reaches
about 50% of its ultimate decrease in about 45 minutes.
5. Monitor the heart and pulse rate: RT should also monitor the heart rate. If
there is concern of impending hypotension or tachycardia, the infusion should be
discontinued.
6. Check the intravenous infusion site: To reduce the possibility of venous
thrombosis, phlebitis, local irritation, swelling, extravasation, and the occurrence
of vascular impairment, administer drug through large peripheral veins such as
hand or wrist. To minimize the risk of peripheral venous irritation, change the site
of the drug infusion every 12 hours.
7. Monitor the signs of serious adverse effects: To immediately respond and
prevent further complication.
Drug Study #6
Brand Name : Kabiven

Generic Name : Total parenteral nutrition (TPN)
Classification : Intravenous nutritional products
Mode of Action: Parenteral nutrition, also known as total parenteral nutrition (TPN) or
hyperalimentation (HAL), provides required nutrients to patient by IV route of
administration. The goal of PN is to maintain or restore nutritional status caused by
disease, injury, or inability to consume nutrients by other means (“Kabiven”, 2021).
Dosage/Frequency/Route:
 Intravenous: Infusion via a central vein 20 ml/kg/day
Indication/s: TPN is indicated as a credit of calories, protein, electrolytes and essential

fatty acids for adult patients requiring parenteral nutrition when oral or enteral nutrition is
not possible, insufficient, or contraindicated (“Kabiven”, 2021).
Contraindication/s: Known hypersensitivity to egg, soybean proteins, peanut proteins,

corn or corn products, or to any of the active substances or excipients. Severe
hyperlipidemia or severe disorders of lipid metabolism with serum triglycerides >1000
mg/dL. Inborn errors of amino acid metabolism (“Kabiven”, 2021).
Side Effect/s (“Kabiven”, 2021):

 Mouth sores, poor night vision, skin changes
Adverse Effect/s (“Kabiven”, 2021):

 Dehydration and electrolyte imbalances
 Thrombosis (blood clots)
 Hyperglycemia (high blood sugars)
 Hypoglycemia (low blood sugars)
 Infection
 Liver Failure
 Micronutrient deficiencies (vitamin and minerals)
Drug Interaction/s (“Kabiven”, 2021):
 Treatment with parenteral nutrition solution can interfere with indium oxyquinoline
in-111 test results.
1. Prior to drug administration, skin test is to be done: To determine signs and
symptoms of hypersensitivity.
2. Monitor vital signs from time to time: Observing for signs of infection such as
elevated temperature since bacteria may grow in high-glucose and high-protein
solutions. Note changes in blood pressure, pulse rate, heart rate, respiratory rate,
and temperature before and after administration.
3. Ensure strict aseptic technique in IV tubing: Maintaining sterility like dressing
changes because infusion site is at high risk for development of infection.
4. Observe IV site carefully: To prevent patient dislodgement of catheter and
occurrence of hematoma.
5. Change IV syringe every 24 hours: When changing syringe, ensure line is
clamped to prevent administering a bolus. Ensure line is unclamped after lines
changed to prevent infections and dislodgement.
6. Maintain patent IV at all times: To ensure that the TPN is being administered
directly into the patient’s vascular system.
7. Monitor for signs of fluid overload: RT should be aware that TPN is a
hypertonic solution and can create intravascular shifting of extracellular fluid. So,
signs and symptoms of fluid overload should be monitored.
8. Monitor renal status: Intake and output ratio, daily weight, and laboratory
studies such as serum creatinine and BUN are used to assess renal function.
This will help RT determine if the TPN is effective.
9. Maintain accurate infusion rate with infusion pump: Monitor the infusion rate
and never discontinue TPN abruptly. Abrupt discontinuation may cause
hypoglycemia, and a sudden change in flow rate can cause fluctuations in blood
glucose levels.
Drug Study #7
Brand Name : Diprivan

Generic Name : Propofol
Classification : Short-acting, lipophilic IV general anesthetic
Mode of Action: Propofol works by increasing GABA-mediated inhibitory tone in the
CNS. Propofol decreases the rate of dissociation of the GABA from the receptor,
thereby increasing the duration of the GABA-activated opening of the chloride channel
with resulting hyperpolarization of cell membranes (“Diprivan”, 2019).
Dosage/Frequency/Route (“Diprivan”, 2019):

 Intravenous: Induction/maintenance of 0.3-4 mg/kg/hr via infusion over 5 min
Indication/s: Induction and maintenance of monitored anesthesia care sedation;

combined sedation & regional anesthesia; and ICU sedation of intubated, mechanically
ventilated adult patients (“Diprivan”, 2019).
Contraindication/s: Hypersensitivity to propofol or any of the excipients of diprivan

(“Diprivan”, 2019).
Side Effect/s (“Diprivan”, 2019):

 Low blood pressure, injection site burning/stinging/pain
 Respiratory acidosis during weaning, hypertriglyceridemia, high blood pressure
 Rash, itching, irregular heartbeat, slow heart rate
 Cardiac output decreased, fast heart rate
Adverse Effect/s (“Diprivan”, 2019):

 Electrocardiogram effects, hypertriglyceridemia, perioperative myoclonus
 Hypotension, injection-site reaction, involuntary movement
 Postoperative unconsciousness with or without an increase in muscle tone
 Anaphylaxis, hypersensitivity reactions
Drug Interaction/s (“Diprivan”, 2019):
 Additive sedation/anesthetic and cardiorespiratory depressant effect with other
CNS depressants
 Profound hypotension with rifampicin
 Valproate may increase serum levels of propofol
1. Assess respiration: To quantify suspected changes in ventilation and
respiratory function. Apnea or excessive respiratory depression requires
emergency care. Notify physician immediately if patient exhibits any interruption
in respiratory rate (apnea) or signs of respiratory depression, including
decreased respiratory rate, confusion, bluish color of the skin and mucous
membranes (cyanosis), and difficult, labored breathing (dyspnea).
2. Administer the medication to the patient as directed: Do not double doses or
increase the dose or frequency of doses. Prevents overdose, under dose and
toxicity
3. Assess heart rate, ECG, and heart sounds, especially during long-term (>24
hr): Bradycardia and other arrhythmias may indicate propofol infusion syndrome,
a potentially fatal event accompanied by metabolic acidosis, rhabdomyolysis, and
renal failure.
4. Be alert for residual muscle rigidity and involuntary muscle movements: To
identify any sustained or problematic changes in muscle tone or excitability.
5. Monitor whether the patient is adequately sedated: The chest wall should be
relaxed and compliant with ventilation. RT should identify if the patient is agitated
or appears to be resisting mechanical ventilation.
6. Identify drug interactions: RT should be aware to check the patient’s chart
because when taken with other sedative drugs could result to seizure.
7. Monitor the signs of serious adverse effects: To immediately respond and
prevent further complication.
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 : 11/05/2021
Age : 4 years old Time : 8:07 am
Sex : Male Diagnosis : Acute CF exacerbation
Unit : Adult ICU 2, Room 7 Physician : Prince Estorlataasinoso, RTRP, MD
Subjective: Patient is intubated.

Objective:
TABLE 11-2
Temperature : ↑ 38.2°C (ax.) 36.5-37.5°C (ax.)
SaO2 : ↓ 80% 88-92%
Impression: VS reveal increased temperature, PR, RR, BP, HR; and low SaO2
Implication: Patient is febrile, tachypneic, tachycardic, and hypertensive
GCS Score : 8
Impression: Severe brain injury (8), patient is easily aroused with minimal stimuli
Patient’s Height: 5’5” (65 inches/165.1 cm)
Patient’s IBW: 136 lbs. (62 kg); Patient’s BSA: 1.53 m2
pH : ↓ 7.23 7.38 7.35-7.39
-
SaO2 : ↓ 80% 90% 88-92%
Impression: Acute ventilatory failure superimposed on chronic ventilatory failure with
uncorrected hypoxemia
Implication: Patient is in acute ventilatory failure and still hypoxemic despite invasive
support at 100% FiO2.
Head
Eyes
Ears
Nose
Mouth
Neck
Upon inspection, the neck muscles were equal in size with no evidence of neck
vein distention.
Thorax and Lungs

has been expanded.
Upon auscultation, bilateral wheezing and fine crackles were heard, as well as
diminished breath and heart sounds.
Abdomen
with no discernible vascular pattern. The abdomen appeared soft and bloated.
Upper Extremities
deformity. Acrocyanosis was noted.
Lower Extremities
same skin color. There was no presence of a bone deformity. Acrocyanosis was noted.
TABLE 11-3
HGB : N 15.8 g/dL 13.5-17.5 g/dL
HCT : N 49% 35-53%
RBC : N 5.08 x106/uL 4.50-5.90 x 106/uL
WBC : ↑ 19.5 x 103/uL 4.5-11.0 x 103/uL
Lymph : ↑ 47% 24-44%
Mono : ↑ 11% 4-10%
Eos : ↑ 3.11% 0-3%
Bas : ↑ 1.78% 0-1%
PLT : N 203 x 103/uL 150-450 x 103/uL
MCH : N 28 pg 26-34 pg
MCHC : N 33% 32-36%
MCV : N 81 fl 80-100 fl
Impression: WBC count and its components were elevated.
Implication: Inflammation and infection were present.
Chest Radiography Result, 11/05/2021
CXR Result Received at 10:29 am Reference Image (AP view)
Impression: Lungs are hyperlucent, heart is vertical and narrow, diaphragm is

flattened, retrosternal air is increased, AP diameter is increased.
Implication: Air trapping is present.
Impression: Increased heart rate and close R-R intervals in leads V2- V6
Implication: EKG result showed sinus tachycardia with regular ventricular rate.
Analysis: Ineffective airway clearance related to excessive bronchial secretions
secondary to acute CF exacerbation as evidenced by bilateral wheezing and crackles
upon auscultation, lung hyperinflation, and bacterial infection
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 38.2°C to range of 36.5-37.5°C
 Decline in heart and pulse rates from 137-138 bpm to range of 60-100 bpm
 Decline in spontaneous respiratory rate from 35/min to range of 12-20/min
 Decrease in blood pressure from 145/95 to range of 120/80
 Improvement in oxygen saturation from 80% to range of 88-92%
b) Gradual improvement in ABG values to chronic stable state and improved
oxygenation as evidenced by:
 pH of 7.23 increasing to acidotic normal range of 7.35-7.39;
 Increase in PaO2 from 57 mmHg to range of 70-80 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 essential to frequently monitor the acid-base status and
A-line Access oxygenation status of the patient. ABG contains vital
information whether to maintain/escalate FiO2 requirements.
Chest radiography should be ordered to assess lung field
Chest Radiography
consistency and monitor any heart structure abnormalities.
Electrocardiogram EKG should be ordered to assess the patient’s cardiac status
Monitoring and regularity of heart rhythm.
Fluids are given into a vein to provide most of the nutrients
IV Total Parenteral
the body needs. TPN is used since the patient cannot or
Nutrition
should not receive feedings or fluids by mouth.
IV Antibiotic Azithromycin, a broad-spectrum antibiotic given 500 mg daily
Therapy IV for 2 days, is administered both as treatment for patient’s
lung infection and as prophylaxis for CF exacerbation.
Albuterol nebulization and dornase alfa are given 5 ml of 20%
Aerosolized
solution q6 to increase the caliber of the airway and soften up
Medication Therapy
the mucus to expectorate.
This is to improve the acid-base status of the patient. The
following MV adjustments were made during the 8-hour shift:
1. New frequency.
Desired PaCO2 = 55 mmHg
Current f x Current PaCO 2

New f =
Adjusted MV Set-Up Desired PaCO 2
12
as per Doctor’s x 78 mmHg
New f = min
Order
55 mmHg
𝑵𝒆𝒘 𝒇 = 𝟏7/𝒎𝒊𝒏
2. New minute ventilation.

VE = f x V T
VE = 17/min (410 ml)
VE = 7 L/min
Independent Interventions and Rationale

Vital Signs Vital signs monitoring is important to evaluate improvement in
Monitoring patient’s RR, SpO2, BP, and other VS parameters.
Auscultation of To check for the presence of secretions, bronchospasm, or
Breath Sounds any lung abnormalities.
GCS/LOC Obtaining GCS and assessing LOC are important to monitor
Assessment the neurological status of the patient.
Ensuring the patency of A-line ensures safety against
A-line Patency
infection and inadvertent bleeding on the indwelling site.
Frequent Drainage Water accumulated in the water trap attached from the
and Disinfection of corrugated tube should be drained frequently to reduce the
Water Trap likelihood and transmission of infection.
Chest CPT is done after nebulization to mobilize the loosen
Physiotherapy secretions into the central airways.
To maintain a patent airway and improve oxygenation by the
Endotracheal
facilitation of mucous secretion removal and pooling of saliva
Suctioning
in the mouth and back of throat.
Patient Oral Care Chlorhexidine oral care done by RTs should be performed
following the infection-reduction protocol to reduce risk of an
infection recurrence. Oral hygiene also prevents stagnation of
saliva that promotes proliferation of bacteria.
Assessing the endotracheal tube patency and integrity are
ET Tube Care
essential to effectively deliver supplemental O2 to the patient.
Evaluation:
Goal partially met as evidenced by:
TABLE 11-5
Summary of Vital Sign Values Throughout the 8-hr Shift, 11/05/2021
Parameters 8:11 am 11:53 am 2:45 pm Reference Value
Temperature 38.2°C (ax.) 37.8°C (ax.) 37.5°C (ax.) 36.5-37.5°C (ax.)
Pulse Rate 137 bpm 129 bpm 116 bpm 60-100 bpm
Respiratory Rate 35/min 29/min 26/min 12-20/min
Blood Pressure 145/95 144/91 141/90 120/80 mmHg
Heart Rate 138 bpm 130 bpm 116 bpm 60-100 bpm
SaO2 80% 86% 88% 88-92%
 Drop in body temperature from 38.2°C to 37.5°C
 Improvement in oxygen saturation from 80% to 88%
Summary of ABG Values Throughout the 8-hr Shift, 11/05/2021
pH 7.23 7.27 7.29 7.35-7.39
PaCO2 78 mmHg 68 mmHg 64 mmHg 45-55 mmHg
PaO2 57 mmHg 65 mmHg 75 mmHg 70-80 mmHg
-
HCO3 41 mEq/L 38 mEq/L 38 mEq/L >26 mEq/L
SaO2 80% 86% 88% 88-92%
 Improvement in PaO2 from 57 mmHg to 75 mmHg
 Increase in sputum production as evidenced by more frequent suctioning and
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 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 with a suction catheter of 14 Fr:
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 patient oral care:
R: Oral hygiene helps prevent colonization of bacteria in the oral cavity.
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. Continue MV Set Up [Mode: V/AC, VT: 410 ml, flow: 40 L/min, f: 17/min, V E: 7
L/min, I:E of 1:4] until patient is stable and ready for extubation:
R: Mechanical ventilation should be continued until acid-base status is stabilized
to chronic state.
13. Wean FiO2 as per doctor’s order:
R: Weaning the FiO2 is indicated only if normoxemia is achieved and to avoid
oxygen toxicity and complications.
B. Respiratory Therapy Care Plan #2
TABLE 11-6
Name : Patient Livander Date : 11/07/2021
Age : 34 Time : 7:54 am
Sex : Male Diagnosis : RVHD secondary to RF
Unit : Adult ICU 2, Room 7 Physician : Prince Estorlataasinoso, RTRP, MD
Subjective: Patient is intubated.

Objective:
TABLE 11-7
Temperature : N 37.2°C (ax.) 36.5-37.5°C (ax.)
Respiratory Rate : N 19/min 12-20/min
SaO2 : N 89% 88-92%
Impression: VS reveal increased PR, BP, and HR
Implication: Patient is afebrile, tachycardic, and hypertensive
GCS Score : 8
Impression: Severe brain injury (8), patient is easily aroused with minimal stimuli
pH : N 7.36 7.38 7.35-7.39
-
SaO2 : N 89% 90% 88-92%
Implication: Patient’s acid-base status is restored to chronic stable state.
Head
Eyes
Ears
Nose
Mouth
Neck
Upon inspection, the neck muscles were equal in size with new finding of neck
vein distention on the right side.
Thorax and Lungs

has been expanded.
Upon auscultation, bilateral wheezing and fine crackles were still heard, as well
as diminished breath and heart sounds. Heart murmur with a loudness of 4 (6 as
loudest) was also noted.
Abdomen
with no discernible vascular pattern. The abdomen appeared soft and slightly bloated.
Upper Extremities
deformity. A new finding of digital clubbing on both hands was observed.
Bones and joints were non-tender. A new finding of peripheral edema was noted.
Capillary refill time was >2 seconds.
Lower Extremities
same skin color. There was no presence of a bone deformity. A new finding of digital
clubbing on both feet was observed.
Bones and joints were non-tender. A new finding of pedal edema was noted. Capillary
refill time was >2 seconds.
TABLE 11-8
HGB : ↑ 17.8 g/dL 13.5-17.5 g/dL
HCT : ↑ 54% 35-53%
6
RBC : ↑ 5.99 x10 /uL 4.50-5.90 x 106/uL
WBC : ↑ 14.6 x 103/uL 4.5-11.0 x 103/uL
Lymph : ↑ 49% 24-44%
Mono : ↑ 13% 4-10%
Eos : ↑ 5.2% 0-3%
Bas : ↑ 3.1% 0-1%
3
PLT : N 362 x 10 /uL 150-450 x 103/uL
MCH : N 32 pg 26-34 pg
MCHC : N 35.1% 32-36%
MCV : N 85 fl 80-100 fl
Impression: Patient has slightly elevated HGB, HCT, RBC count and WBC
components.
Implication: Slightly elevated RBC, HGB, and HCT indicate ongoing recovery from
secondary polycythemia. Elevated WBC components suggest presence
of infection.
Impression: Lungs overinflation with diffuse infiltrates and large main pulmonary
Segment. Lung fields are dark; heart size, interstitial markings, and AP
diameter are increased, retrosternal space is enlarged, diaphragm is
flattened.
Implication: Further testing should be performed to confirm diagnosis.

Impression: Lead I has negative deflection and aVF has positive deflection
Implication: Right axis deviation suggestive of right-sided heart failure
Echocardiogram Result, 11/07/2021
ECHO Result Received at 10:31 am
Impression: Right ventricular hypertrophy is observed and an enlarged heart on the

right side.
Implication: Right ventricular hypertrophy is confirmed.
The physician decided to perform the pulmonary artery catheterization to monitor
the patient’s hemodynamics. Since the patient needs to be monitored since he had a
recent history of myocardial infarction and chest pain prior to admission, PAC must be
inserted as the anticipated benefit outweighs the potential risks.
TABLE 11-9
Vascular Pressure Monitoring via 7-French Swan-Ganz Catheter, 11/07/2021
Pressure Monitored at 11:11 am Reference Value
CVP : 11 mmHg 0-6 mmHg (SVC near RA)
RAP : 13 mmHg 2-7 mmHg (RA)
RVEDP : 13 mmHg 2-7 mmHg (RV)
MPAP : 26 mmHg 5-10 mmHg (PA)
PAOP/PCWP: 5 mmHg 8-12 mmHg
CO : 3.2 L/min 4-8 L/min
Impression: Monitoring revealed elevated CVP, RAP, RVEDP, MPAP and low PAOP
and CO.
Implication: Hemodynamics is unstable and the problem originates in the pulmonary
artery.
Analysis: Ineffective tissue perfusion related to impaired pulmonary blood flow
secondary to right ventricular heart disease as evidenced by heart murmur upon
auscultation, right-axis deviation, and elevated MPAP of >25 mmHg
Planning: At the end of our 8-hour shift, the patient’s ineffective tissue perfusion will
be improved as evidenced by the following:
a) Gradual improvement in vital signs as evidenced by:
 Decline in heart and pulse rates from 131 bpm to range of 60-100 bpm
 Decrease in blood pressure from 147/96 to range of 120/80
b) Improvement in hemodynamics as evidenced by:
 Gradual decline in mean PAP from 26 mmHg to range of 5-10 mmHg
 Gradual decline in CVP from 11 mmHg to range of 0-6 mmHg
 Gradual increase in PAOP from 5 mmHg to range of 8-12 mmHg
 Gradual increase in CO from 3.2 L/min to range of 4-8 L/min
c) Tolerance of the weaning process prior to SBT as evidenced by:
 Changes in vital sign parameters of less than 20%
Intervention:
TABLE 11-10

Obtaining ABG via an indwelling vascular line is essential to
ABG Extraction via
frequently monitor the acid-base status and oxygenation
A-line Access
status of the patient.
Chest radiography should be ordered to assess lung field
Chest Radiography
consistency and monitor any heart structure abnormalities.
Electrocardiogram EKG should be ordered to assess the patient’s cardiac status
Monitoring and regularity of heart rhythm.
Hemodynamic
This invasively monitors the hemodynamics of the patient.
Monitoring
Fluids are given into a vein to provide most of the nutrients
IV Total Parenteral
the body needs. TPN is used since the patient cannot or
Nutrition
should not receive feedings or fluids by mouth.
Azithromycin, a broad-spectrum antibiotic given 500 mg daily
IV Antibiotic
IV for 2 days, is administered both as treatment for patient’s
Therapy
lung infection and as prophylaxis for CF exacerbation.
Albuterol nebulization and dornase alfa are given 5 ml of 20%
Aerosolized
solution q6 to increase the caliber of the airway and soften up
Medication Therapy
the mucus to expectorate.
Furosemide, a diuretic, enhances diuresis for the treatment of
IV Diuretic Therapy
peripheral edema and is administered at 80 mg IV via PAC.
Nicardipine injection, a calcium channel blocker, helps lower
IV Antihypertensive
blood pressure and is administered intravenously by slow
Therapy
continuous infusion at a conc. of 0.1 mg/ml.
Weaning Initiation
This is to assess the tolerance of the patient by gradually
(Doctor’s Order)
decreasing the FiO2 delivery according to preset schedule.
see evaluation
Vital Signs Vital signs monitoring is important to evaluate improvement in
Monitoring patient’s RR, SpO2, BP, and other VS parameters.
Auscultation of To check for the presence of secretions, bronchospasm, or
Breath Sounds any lung abnormalities.
GCS/LOC Obtaining GCS and assessing LOC are important to monitor
Assessment the neurological status of the patient.
Ensuring the patency of A-line ensures safety against
A-line Patency
infection and inadvertent bleeding on the indwelling site.
Frequent Drainage Water accumulated in the water trap attached from the
and Disinfection of corrugated tube should be drained frequently to reduce the
Water Trap likelihood and transmission of infection.
CPT is done after nebulization to mobilize the loosen
CPT w/ Vibratory secretions into the central airways. Vibratory PEP (Acapella)
PEP Therapy is used combining both benefits of PEP therapy and airway
vibrations to mobilize pulmonary secretions.
To maintain a patent airway and improve oxygenation by the
Endotracheal
facilitation of mucous secretion removal and pooling of saliva
Suctioning
in the mouth and back of throat.
Chlorhexidine oral care done by RTs should be performed
following the infection-reduction protocol to reduce risk of an
Patient Oral Care
infection recurrence. Oral hygiene also prevents stagnation of
saliva that promotes proliferation of bacteria.
Assessing the endotracheal tube patency and integrity are
ET Tube Care
essential to effectively deliver supplemental O2 to the patient.
Evaluation:
Goal partially met as evidenced by:
TABLE 11-11
SaO2 89% 91% 90% 88-92%
 Decrease in blood pressure from 147/96 to 130/84 mmHg
Summary of Hemodynamic Values Throughout the 8-hr Shift, 11/07/2021
Parameters 11:11 am 2:36 pm Reference Value
CVP 11 mmHg 8 mmHg 0-6 mmHg (SVC near RA)
RAP 13 mmHg 9 mmHg 2-7 mmHg (RA)
RVEDP 13 mmHg 9 mmHg 2-7 mmHg (RV)
MPAP 26 mmHg 15 mmHg 5-10 mmHg (PA)
PAOP/PCWP 5 mmHg 8 mmHg 8-12 mmHg
CO 3.2 L/min 4.0 L/min 4-8 L/min
 Increase in PAOP from 5 mmHg to 8 mmHg
 Increase in CO from 3.2 L/min to 4.0 L/min
Weaning Sheet, 11/07/2021
Name: Patient Livander Age/Sex: 34/M
ICU/Room No:
Attending Physician: Hospital No:
Adult ICU 2, No. 7
Prince Estorlataasinoso, RTRP, MD (082) 226-2732
Doctor’s Order: ↓ FiO2 by 10% qhourly until 40%, maintain SaO2 of ≥ 88%
Date/Time Ordered: 11/07/21, 8:30 am
Vital Signs
Time Parameter FiO2 Remarks RT-OD
SaO2 BP HR RR Temp
- - - *89% *146/94 *132 19 *37.2 - -
9:30 am ↓ FiO2 90% 89% 130/87 127 19 36.9 Tolerated JASSI
1:30 pm ↓ FiO2 50% 90% 131/92 119 17 37.1 Tolerated JASSI
2:30 pm ↓ FiO2 40% 90% 130/84 116 17 36.9 Tolerated JASSI
*Obtained reference vital signs prior to weaning process.
 Tolerance of the weaning process (changes in vital sign parameters of <20%).
Goals were not fully met as heart and pulse rates were still elevated at 116 bpm;
mean PAP still increased at 15 mmHg; and CVP still elevated at 8 mmHg.
Recommendation:
1. Endorse post-weaning ABG to next shift after completion of the weaning
process:
R: To assess any significant changes in arterial blood gas values after weaning.
2. Continue hemodynamic monitoring:
R: To assess effectiveness of medications and assess status of hemodynamic
pressures.
3. Terminate IV antihypertensive therapy once hemodynamics is restored:
R: To avoid occurrence of side effects associated with the drug.
treatment and intervention.
7. Continue administration of IV TPN:
R: Patient is reliant on TPN to sustain bodily nutrient requirements especially
when the patient cannot receive feeding PO.
8. Perform suctioning as needed with a suction catheter of 14 Fr:
R: To clear out secretion and help maintain patent airway.
9. Continue frequent disinfection of ventilator equipment:
R: To prevent nosocomial infection and transmission of infection to the patient.
10. Continue patient oral care:
R: Oral hygiene helps prevent colonization of bacteria in the oral cavity.
11. Monitor A-line patency:

R: This avoids the likelihood of inadvertent bleeding, infection, and pre-analytic
errors in ABG samples.
12. Continue and maintain ET tube integrity:
R: Monitoring ETT integrity ensures effective delivery of O2 to the patient.
13. Request for CBC:
R: To monitor patient’s blood count and assess effectiveness of IV antibiotics.
14. Request for a new chest radiograph:
R: To monitor progression of lung overinflation, pulmonary artery enlargement,
and right ventricular hypertrophy.
C. Respiratory Therapy Care Plan #3
TABLE 11-12
Name : Patient Livander Date : 11/10/2021
Age : 34 Time : 7:21 am
Sex : Male Diagnosis : RVHD secondary to RF
Unit : General Ward 1, Bed 3 Physician : Prince Estorlataasinoso, RTRP, MD
Subjective: “Sige gihapon akuang ubo ug plema” (Cough still frequent and productive).
Objective:
TABLE 11-13
Temperature : N 37.3°C (ax.) 36.5-37.5°C (ax.)
Pulse Rate : N 96 bpm 60-100 bpm
Blood Pressure : N 131/87 mmHg 120/80 mmHg
Heart Rate : N 98 bpm 60-100 bpm
SaO2 : N 88% 88-92%
Impression: VS revealed an increased RR
Implication: Patient is afebrile, tachypneic, and normotensive.
Eye Opening : 4 (spontaneous)
GCS Score : 15
Verbal Response : 5 (oriented)
Motor Response : 6 (obeys command) LOC : Alert
Impression: Alert (15), patient is responsive, awake, and conscious.
Baseline ABG at 2 LPM via Nasal Prongs at 28% FiO2, 11/10/2021
pH : N 7.37 7.38 7.35-7.39
-
SaO2 : N 88% 90% 88-92%
Implication: Patient’s acid-base status is restored to chronic stable state.
Head
Eyes
Ears
Nose
Upon inspection, nasal prongs at 2 LPM was attached to the patient’s nares.
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.
Mouth
Upon inspection, the lips of the patient were symmetric, and had a smooth
texture. The patient coughed with evidence of green sputum. There were no
discoloration of the teeth enamels and no retraction of gums.
Neck
Upon inspection, the neck muscles were equal in size with no signs of neck
vein distention.
Thorax and Lungs

has been expanded.
Upon percussion, a minimal hyperresonant note was noted.
Upon auscultation, wheezing and low-pitched fine crackles were still heard.
Abdomen
with no discernible vascular pattern. The abdomen appeared soft and slightly bloated.
Upper Extremities
Upon inspection, a 24-gauge IV cannula for antibiotics was inserted at the
metacarpal vein of the right arm. The upper extremities were symmetrical in size and
length and had no presence of a bone deformity.
Lower Extremities
same skin color. There was no presence of a bone deformity.
TABLE 11-14
HGB : N 17.3 g/dL 13.5-17.5 g/dL
HCT : N 52.4% 35-53%
RBC : N 5.05 x106/uL 4.50-5.90 x 106/uL
WBC : ↑ 11.8 x 103/uL 4.5-11.0 x 103/uL
Lymph : ↑ 45% 24-44%
Mono : ↑ 13.1% 4-10%
Eos : ↑ 3.9% 0-3%
Bas : ↑ 1.45% 0-1%
PLT : N 367 x 103/uL 150-450 x 103/uL
MCH : N 31 pg 26-34 pg
MCHC : N 34.8% 32-36%
MCV : N 89 fl 80-100 fl
Impression: Patient has elevated WBC components.
Implication: Fighting off the infection is ongoing.
Impression: Lungs are still hyperinflated, heart is vertical and narrow, diaphragms
are flattened, retrosternal air is minimally increased, AP diameter is
slightly increased.
Implication: Cardiopulmonary complications have been resolved.
Impression: Normal sinus rhythm evidenced by regular ventricular rate, uniform R-R
intervals, and complete waveforms.
Implication: Electrocardiographic waveforms and rate are normal.
Sputum Culture Result for Pathogen Identification, 11/10/2021, 10:52 am
Sample Collection Date : 11/04/2021 Pathogen: Gram-negative
Sputum Color/Consistency: Green, mucoid Pseudomonas aeruginosa
Analysis: Ineffective airway clearance related to mucopurulent secretions secondary

to stable cystic fibrosis as evidenced by occasional sputum production, wheezing and
low-pitched fine crackles upon chest auscultation, and P. aeruginosa infection
Planning: At the end of our 8-hour shift, the patient’s ineffective airway clearance will
be improved as evidenced by the:
a) Improvement in vital signs as evidenced by:
 Decline in spontaneous respiratory rate from 22/min to range of 12-20/min
b) Increase in sputum production as evidenced by more frequent suctioning and
Intervention:
TABLE 11-15

ABG Extraction via Obtaining ABG is essential to monitor the acid-base
Percutaneous Puncture status and oxygenation status of the patient.
Chest radiography should be ordered to assess lung
Chest Radiography field consistency and monitor any heart structure
abnormalities.
Electrocardiogram EKG should be ordered to assess the patient’s cardiac
Monitoring status and regularity of heart rhythm.
Azithromycin, a broad-spectrum antibiotic given 500 mg
IV Antibiotic Therapy daily IV for 2 days, is administered as prophylaxis for
CF.
Albuterol nebulization and dornase alfa are given 5 ml of
Aerosolized Medication
20% solution q6 to increase the caliber of the airway and
Therapy
soften up the mucus to expectorate.
To assist patient’s oxygenation while providing low flow
Low Flow O2 Therapy
oxygen.
Vital signs monitoring is important to evaluate the
Vital Signs Monitoring
tolerance of the patient regarding the weaning process.
Auscultation of Breath To check for the presence of secretions, bronchospasm,
Sounds or any lung abnormalities.
Obtaining GCS and assessing LOC are important to
GCS/LOC Assessment
monitor the neurological status of the patient.
To facilitate movement of secretions in the larger
CPT (Postural Drainage,
airways making the phlegm to be easily expelled out by
Percussion, Vibration)
the patient while coughing.
To ensure comfort especially when the patient might
Patient Comfort
experience sudden changes on vital signs or intolerance
Monitoring
of the oxygen device.
Evaluation:
Goal is met as evidenced by:
TABLE 11-16
SaO2 88% 88% 89% 88-92%
 Decrease in spontaneous RR from 22 to 18/min
 Increase in sputum production as evidenced by more frequent coughing and
Recommendation:
1. Observe amount and consistency of secretions:
R: To assess the effectiveness of medication. Increased amounts of colorless (or
blood-streaked) or watery secretions are normal initially and should decrease as
recovery progresses. Presence of thick, tenacious, bloody, or purulent sputum
suggests development of secondary problems like dehydration or infection that
require correction or treatment.
2. Continue IV antibiotics:
R: To help combat P. aeruginosa infection.
intervention.
6. Instruct watcher to observe unusual physical findings then notify the
physician/ nurse on duty:
R: To change/ make action as soon as possible.
7. Provide health teachings to the patients and watcher:
R: To know the contraindications while on treatment.
8. Opt to formulate a pulmonary rehabilitation discharge plan:
R: To guide Patient Livander upon the course of his treatment and prolong
survival rate by keeping up with his patient-specific medications, exercises,
treatment, health teaching, diet, and spiritual growth.
XII. PULMONARY REHABILITATION

The pulmonary rehabilitation section contains information upon the discharge of
the patient. It consists of medications, exercises, treatment, health teachings/education,
outpatient, diet, and spirituality to be prescribed, given, or taught to the patient for faster
recovery. Doing rehabilitation keeps the disease in check and monitor its progress while
also slowing the course of the disease. This also helps the patient to be more positive
on his life and to have good lifestyle in return.
Medication
It is imperative to explain the medications that should be administered to Patient
Livander; and the correct dose and mode of administration are the responsibility of
Patient Livander and his family. He should follow the doctor's instructions and take the
medications prescribed to him and must be taken in the correct order and at the proper
time. Patient Livander should continue with his maintenance drugs such as mucolytic
(dornase alfa) single-use 2.5 mg ampule inhaled qd to maintain airway clearance
allowing air to flow better and preventing bacteria from building up as well as Ventolin
HFA, a short-acting beta agonist taken 2 inhalations repeated q4-6h. He is also
provided with calcium channel blockers (amlodipine) 1 tablet (10mg) per day at night for
prophylaxis to avoid and manage pulmonary hypertension. Patient Livander is also
advised to continue the intake of azithromycin for post prophylaxis treatment for 14 days
to avoid bacterial infection in the lungs.
Exercise
Exercises play a role in clearing mucus from the lungs, improving physical bulk
and strength, and improving the overall health of Patient Livander. Activities may be
classified into three categories that include aerobic, strength, and flexibility. Before
doing any form of exercise, Patient Livander must first do warm-ups. Warm-ups usually
last for about 5 to 10 minutes and start with gentle walking and stretching; this helps
increase the heart rate and reduce the risk of injury. For aerobic exercise, it is
considered the most suitable for Patient Livander as it keeps the heart active and
healthy. Aerobic exercises help in strengthening the respiratory muscles and in
loosening secretions. Some exercises include walking, jogging, rowing, swimming,
dancing, cycling, and stair climbing. In doing so, a 6-minute walk test by walking slowly
while gradually increasing the pace of movement until the activity feels moderate can be
done. Doing a 3-minute step test on stairs or a chair may also be performed. For
strength training, Patient Livander may improve his leg strength by increasing muscle
tone and bone density and increasing his upper body strength to improve chest mobility
and posture, which may benefit his breathing. Such exercise can be done through free
weights, plyometrics, or with elastic resistance. Lastly, flexibility exercises will also help
keep the spine, ribcage, and shoulders flexible, allowing good posture and breathing.
For this to work efficiently, stretches are suggested to be done for at least 30 seconds.
Note that during exercise, Patient Livander can get tired and dehydrated, making the
secretions thicker, making the airway clearance more difficult. Cooling down for around
3 to 7 minutes should be adequate and must be performed by gradually decreasing the
exercises' intensity level, performing stretching, and allowing Patient Livander to
rehydrate.
Treatment
The goal of the treatment is to improve the comfort of Patient Livander. Managing
strategy for cystic fibrosis includes clearing the airway of secretions, pulmonary
rehabilitation, which consists of physical exercise, nutritional counseling, and education
about the disease. Many types of chest physiotherapy can help remove the secretions,
such as the active cycle of breathing which is a huffing and coughing strategy,
autogenic drainage where controlled breathing techniques are used, and airway
clearance devices by using PEP device and high-frequency chest wall oscillation
(HFCWO). If Patient Livander’s SaO2 is reduced to below 89%, a standby oxygen tank
should be available for oxygen therapy to avoid hypoxemia due to the weakened heart
of the patient.
Health Teachings
The health education of Patient Livander and his family members is essential.
They need to keep the disease in check if there are any problems and monitor Patient
Livander to adhere and comply with the medications prescribed by the doctor. Advise
the patient to do the following: first is to give instructions on how to cough correctly.
Using airway clearance procedures can help the patient breathe more easily by moving
mucus out of the airways. Second, is to eat healthy food and must reduce how much
water he drinks as drinking too much can make the heart work more. Third, get some
physical activity but do not engage in any strenuous activities that can exhaust his body
and keep doing the hobbies or activities that he enjoys and as his body and energy
allow. Lastly is to maintain good hygiene and maintain good sanitary care to avoid
infection.
Outpatient
Outpatient care for patients with right ventricular heart disease is critical for
maintaining adherence to the prescribed treatment regimen and avoiding complications.
Patients Livander is encouraged to undergo frequent check-ups depending on the
severity of his sickness and the onset of signs and symptoms. Patient Livander is
advised to visit the clinic every 2-3 months for monitoring to ensure that growth and
development and lung function are maintained as close to normal as possible. Patient
Livander should have routine immunizations, including the seasonal influenza vaccine,
to stay healthy. Medication adherence, treatment response, side effects, and disease
progression should all be evaluated. In order to maintain the good quality of life, Patient
Livander has to comply and adhere to his maintenance drugs.
Diet
Patient Livander's decisions in his daily life can make a significant difference in
preventing various illnesses, including the meals he will partake in. A nutritious diet can
assist Patient Livander in maintaining and improving his overall health. It is essential to
consume the proper nutrients regularly to maintain a healthy diet that includes
carbohydrates, proteins, fruits, vegetables, fats, iron, calcium, and food high in salt
content. For carbohydrates, it is suggested that Patient Livander will eat at least 250
grams of such food group per day. This includes meals that are high in carbohydrates,
such as cereals, rice, and potato. Complex carbohydrates like whole-grain bread and
pasta may also be added. Sugary meals may also be included to provide additional
calories needed for exercises such as jam, honey, cakes, and biscuits. For fats, Patient
Livander may eat avocados, nuts, fish like salmon and tuna, and dairy products like
butter and cheese. It is preferable for Patient Livander to use olive or coconut oil to
avoid any heart disease complications.
Moreover, fresh fruits and vegetables should also be added to the diet. Protein-
rich meals could help the tissues heal and bolster the immune system, such as meat,
eggs, and poultry. Additionally, food rich in calcium may help in improving bone health
as Patient Livander is at risk of having a low bone density. Other than that, food rich in
iron can also help as its lack can exacerbate his condition by having impaired oxygen
transport in the body, leading to symptoms like extreme fatigue and an increased
likelihood of infections. Patient Livander must also note that he is advised to eat salty
snacks since having CF entails losing a lot of salt in his sweat.
Spirituality
Inform Patient Livander that all members of the healthcare team are doing their
best to help him recover and become stable. Family support is vital to allow Patient
Livander express his worries and anxieties in the interest of providing emotional support
throughout his hospital stay and beyond. Remind Patient Livander to strengthen his
faith in God and ask for guidance and strength through prayer and rely on the most
divine healer, Jesus Christ. Advise Patient Livander not to worry and trust the Lord who
gives comfort and does His best through the help of the clinicians who also do their best
to provide care and treat Patient Livander.
XIII. PROGNOSIS
One of the causes of right ventricular heart disease (RVHD) is respiratory failure
which occurs when there is an inability to maintain normal oxygen delivery to the
tissues. Patient Livander, a 34-year-old male, who was diagnosed with cystic fibrosis at
a young age, started using prophylactic medications to treat his pulmonary symptoms.
However, his chronic condition had an acute setback when he was exposed to
secondhand smoke for a long time due to his occupational environment. Upon
admission in SPH on November 4, his chief complaints were exertional dyspnea,
fatigue, and complains of persistent and productive cough. Patient was closely
monitored for impending failure and was intubated on the same day.
Patient Livander’s condition progressed to right ventricular heart disease
secondary to acute ventilatory failure (respiratory failure) on November 7. His family
was able to afford the confirmatory tests that the physician ordered including
echocardiography, chest radiography, and sputum culture. Patient Livander’s family did
not have any problem financially, so they could pay all his hospital expenses including
other monitoring procedures, equipment for mechanical ventilation, medications, and
hospital facility. His family and co-workers provided him with emotional support in any
way they can. The care plans were done in a 2–3-day interval, and the trend of the
patient’s health status was improving due to the interventions done by the physician,
RTs, and other members of the healthcare team.
After days of monitoring and based on the formulated care plans, the overall
prognosis of Patient Livander is good as evidenced by the restoration of his acid-base
status to stable chronic state (chronic ventilatory failure), consistency in improved
oxygenation status, recovery from cardiac complications, and adherence to overall
intervention. The patient is also a candidate for SBT and extubation making the patient
likely of faster recovery. If the pulmonary rehabilitation is pursued and if the patient fully
recovers, Patient Livander must consistently take his maintenance medications to
prevent another acute setback from happening. It is also suggested to reconsider his
job relocation, as his previous line-of-work location was not helpful and did not do him
any good.
XIV. REFERENCES
Centers for Disease Control and Prevention [CDC]. (2020). Kawasaki disease. https://w
ww.cdc.gov/kawasaki/index.html
Caguit, P.I., Tee, C.A., & Dans, L.F. (2020). AB1010 cardiac involvement in kawasaki
disease patients in Philippine General Hospital: a retrospective study.
http://dx.doi.org/10.1136/annrheumdis-2015-eular.5367

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Case Study On Kawasaki Disease Secondary to Acute Respiratory Distress Syndrome

from Community Acquired Pneumonia

In Partial Fulfillment of the Requirements

GENERAL RESPIRATORY CARE

Also known as mucocutaneous lymph node syndrome, Kawasaki disease (KD) is

Globally, the epidemiology of kawasaki disease varies significantly among those

Hedrich et al. (2018) simply defined kawasaki disease (KD) as an acute-onset

Langford and Fauci (2018) defined kawasaki disease as an acute, febrile,

Rife and Gedalia (2020) defined KD as a disease of unknown etiology. However,

Religion : Roman Catholic

Time Admitted : 4:00 AM

A. Past Health History

B. Present Health History

ABG on Room Air, 03/14/2022

PATERNAL SIDE MATERNAL SIDE

= Male = Deceased = Hypertensive

= Female = Diabetic = Has Kawasaki disease

Kawasaki disease (KD) is characterized as an acute systemic vascular disease

Thorax and Lungs

Cranial Nerve Reflexes and Rationale

Erik Erikson’s Eight Stages of Development

Initiative vs. Guilt

Robert Havighurst’s Developmental Task Theory

Bronchi and Bronchioles

Histology of the Airway Wall

Pleura of the Lungs

Homeostatic Control of Respiration

Pathway of Pulmonary Circulation

A Multitude of Small Air Sacs

Capillaries in the Body

Lymph Trunks and Ducts

Lymphatic Organs and Tissue

High Fever. It is a temporary increase in an individual’s temperature. It is the

Rash on genital area/diaper area. Rash is an area of irritated or swollen skin

Neck lymph node enlargement. Swollen or enlarged lymph nodes usually

Conjunctivitis. It is an inflammation on the conjunctiva or the transparent

Swollen “strawberry” tongue. Strawberry tongue is a term refers to a tongue

Sore throat. It is an irritation, pain, or scratchiness of the throat and often

Shortness of breath. Difficulty in breathing is defined as an intense air hunger,

Crackles. It is defined as an adventitious lung sound that can be heard upon

Predisposing and Precipitating Factors Causing Kawasaki Disease Secondary to

Diagnostic Test Manifestation Management

GENETICS FOLLOWING RESPIRATORY INFECTION

Community social contact (droplets spread through coughing/sneezing)

Typical community acquired pneumonia CAP confirmed through bacterial

Oral Antibiotic Therapy (Augmentin) Inflammatory response following effusion

Alveolar consolidation (alveoli filled with fluid, RBCs, polymorphonuclear

Scattered areas of hemorrhagic consolidation

Lining of intraalveolar walls with thick,

Respiratory infection activates lymphocytes, cytokines, and proteinases, specifically

Activation of Oligoclonal IgA plasma cells prominent in the respiratory tract

Onset of myocarditis and coronary arteritis IV Immunoglobulin and Aspirin

Echocardiogram (to rule

Warm CREAM and Mucocutaneous lymph node syndrome

Psychosocial concerns (unpredictable mood

Hypoxemia and stimulation of O2 receptors

ABG Acute alveolar hyperventilation with Low flow O2 therapy

If treated, can lead to: If left untreated, can lead to:

A. Actual Diagnostic Tests