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Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES
Tamag, Vigan City
COLLEGE OF NURSING
A Case Study on
Atrial Septal defect
Hospital acquired pneumonia
Acute urinary retention
In Partial Fulfillment of the Requirement of the subject: Nursing
Elective 2
Metro Vigan Cooperative Hospital
Intensive Care Unit
Presented To:

2. Presented By:
Republic of the Philippines
UNIVERSITY OF NORTHERN PHILIPPINES
Tamag, Vigan City
COLLEGE OF NURSING
Grading Sheet
Categories Percentage Actual Grade
Introduction and
Objectives
5
Personal Date 2.5
Nursing History of Past
and Present Illness
2.5
PEARSONAssessment 15
Diagnostics (Idela and
Actual)
5
Anatomy and
Physiology
5
Algorithm and
Explanation of
Pathophysiology
15
Medical and Surgical
Management
5
Nursing Care Plan 20
Promotive and
Preventive
Management
5
Drug Study 5

3. Discharge Planning 5
Updates 5
Bibliography 2.5
Organization and
Punctuality
2.5
Total 100
C. I. Remarks
Clinical Instructor
INTRODUCTION
This is a case of Sergio Abbago, 75 years old, male, widower, Filipino, Roman Catholic,
born on April 5, 1936 in San Quintin, Abra currently residing in the same locality. He was
admitted in Metro Vigan Cooperative Hospital on February 8, 2012 due to difficulty of breathing
and bipedal edema. After thorough investigation, atrial septal defect, hospital acquired
pneumonia and acute urinary retention was found out.
One of the more commonly recognized congenital cardiac anomalies presenting in
adulthood, Atrial Septal defect (ASD) is characterized by a defect in the interatrial septum
allowing pulmonary venous return from the left atrium to pass directly to the right atrium.
Depending on the size of the defect, size of the shunt, and associated anomalies, this can result
in a spectrum of disease from no significant cardiac sequelae to right-sided volume overload,
pulmonary arterial hypertension, and even atrial arrhythmias.
Hospital-acquired pneumonia on the other hand is an infection of the lungs that occurs
24 hours after hospital stay. It tends to be more serious than other lung infections, because
patients in the hospital are often sicker and unable to fight off germs and the types of germs
present in a hospital are often more dangerous than those encountered in the community. It
occurs more often in patients who are using a respirator machine (also called a ventilator) to
help them breathe.
Lastly, Acute Urinary Retention is usually symptomatic of another condition that requires
treatment. At about the age of 60, men are more often affected as a result of benign prostatic
hyperplasia (BPH), by obstruction in the bladder or in the tube that carries urine from the
bladder outside the body (urethra), by a disruption of sensory information in the nervous system
(e.g., spinal cord or nerve damage), or by distention (swelling) of the bladder (e.g., by delaying
urination for a long period of time).
OBJECTIVES OF THE STUDY
General Objective:

4. With the acquired information given by the patient and his family, we aim to present the
case of patient X comprehensively and formulate a case analysis that would provide essential
knowledge and skills in delivering quality health care to patients diagnosed with atrial septal
defect, hospital acquired pneumonia and acute urinary retention.
Specific Objectives for the Student- Nurses:
1. To present accurate patient’s profile
2. To obtain a comprehensive past, present and family history of patient’s illness.
3. To assess the health status of the patient using the cephalocaudal method and organize
cues for Nursing Care Plan.
4. To know the different diagnostic examinations (ideal and actual) related to the patient’s
case and understand the purpose and limitation of each examination.
5. To study the results/outcome of the diagnostic procedures that the patient has
undergone and explain how these are related to the case of the patient.
6. To discuss the anatomy and physiology of the organ involved in the case.
7. To illustrate through a schematic diagram the pathophysiology of the patient’s case and
explain the mechanism that is involved.
8. To present the medical and surgical management done to the patient.
9. To formulate a practical and realistic plan of care for the patient through:
a. systematic organization of the subjective and the objective cues related to the
case.
b. identifying and prioritizing nursing diagnoses using the PES format (Problem-
Etiology-Signs/Symptoms) and according to NANDA.
c. analysis of the pathophysiology of the identified diagnosis based on the
presentation of the patient
d. formulating appropriate nursing objectives following the SMART criteria.
e. planning for independent, dependent and collaborative interventions and
explaining the rationale for every intervention done.
f. evaluating the degree of achievement for all the objectives set at the beginning of
the intervention.
10. To make a list of the different drugs taken and is presently taking by the patient with their
corresponding dosages, mechanisms of action, side/adverse effects and nursing
responsibilities.
11. To formulate a Discharge Plan covering the following areas: METHOD (Medications,
Exercises, Treatments, Health Teachings, Out-Patient Department and Diet).
12. To present updates related to client’s case and condition.
Specific Objectives for the Patient/ Family:
This case study also aims to attain the following specific objectives on the part of the
patient and his family:
 To develop an understanding about the condition of the patient.
 To determine the underlying risk factors that predisposed and precipitated the
patient to develop the disease
 To be fully- informed about the significance of patient’s laboratory results in
conjunction with his current condition.
 To understand, in the simplest way possible the anatomy and physiology of the
organ involved in the patient’s disease.
 To gain information about the drugs administered.
 To develop a coordinated plan of care in partnership with the healthcare team.
 To recognize the importance of medical- surgical interventions being rendered to
him and to gain knowledge on promotive and preventive measures that can be
applied.

5. PATIENT’S PROFILE
Personal Information:
Name: Sergio C. Abbago
Address: San Quintin, Abra
Birthday: April 5, 1936
Age: 75 years old
Sex: Male
Civil Status: Widower
Nationality: Filipino
Religion: Roman Catholic
Medical Information:
Hospital: Metro Vigan Cooperative Hospital
Chief complaint: Difficulty of breathing and bipedal edema
Date of Admission: February 8, 2012
Time of admission: 2:10 pm
Admitting Physician: Dr. Charles Hubert Rabara
Attending physician: Dr. Deanne Quilala
Dr. Charles Hubert Rabara

6. Dr. Robert Lim
Dr. Datu
Admitting Diagnosis: Bronchial Asthma in Acute Exacerbation
Chronic Heart Failure
Room: ICU (bed 5)
Final Diagnosis: Atrial Septal Defect, Hospital-Acquired Pneumonia
and Acute Urinary Retention
NURSING HISTORY OF PAST AND PRESENT ILLNESS
PAST HISTORY
Per interview regarding the past health history of the client, pertinent data were obtained.
According to his eldest son, the patient is a farmer who spends most of his time in the farm. He
stayed under the sun from 8am to 5pm most of the days. Furthermore, he is not allergic to any
intrinsic (certain foods and medications) or extrinsic factors (dust, environment) but admitted to
have history of hypertension (mother side). He added that even his mother died due to
cardiovascular problem (name was forgotten). With regards to childhood illnesses, the patient
typically experienced fever, cough and colds and diarrhea. Primary interventions usually
rendered include water therapy and rest.
About 4-5 years ago, he noticed that his father frequently complained of DOB and easy
fatigability accompanied by non-productive cough which usually lasts for weeks. The duration of
DOB usually lasted about 3-5 minutes occurring right after physical exertion. Being financially
handicapped, the client never had any medical consultations instead, they relied on alternative
remedies such as herbal plant usage (lagundi) to manage cough in conjunction likewise with
their cultural preferences of treating illnesses.
Considering his personal/ health habits and practices, the client usually ate green- leafy
vegetables like string beans, saluyot and horseradish (2-3 servings per meal in a day). He was
not fond of eating foods rich in fats particularly meat.Moreover, he drank alcohol occasionally (2-

7. 3 bottles of any kind) but was not engaged in smoking. His water intake was estimated to be 2-
3 glasses a day (about 150-200ml/ glass). Infrequently, he defecated once a day, brownish in
color, formed and small in size while he voided twice a day, depending on the amount of fluid he
take. His sleep pattern that usually lasts 8 hours (from 9 pm- 5 am) was enough for him.
Exercise was done in the form of normal household chores (farming).
PRESENT HISTORY
According to patient’s relative, 1 week prior to admission, patient experienced shortness
of breath with easy fatigability and bipedal edema. Nine days prior to admission, he had chest x-
ray showing gross cardiomegaly with pulmonary congestion. Patient was admitted at Abra
Christian Hospital 2 days prior to admission due to persistence of the condition. The attending
physician referred the patient to an internal medicine specialist so was later transferred to Metro
Vigan Cooperative Hospital for further evaluation and management.
Upon admission, Dr. Rabara, his attending physician assessed him thoroughly. He was
put on a low salt and low fat diet. Diagnostic work up done were, Complete Blood Count,
Sodium (Na), Potassium (K), Fasting Blood Sugar, Blood Urea Nitrogen, Creatinine, BUA, Lipid
Profile, 12 lead ECG, Chest X-ray and Troponin T quantitative. The present IVF, D5W 1/2L was
regulated to KVO and was hooked to oxygen inhalation 2-4LPM via nasal cannula. Medications
started were Furosemide 20 mg IV every 8 hours, Salbutamol + Ipratropium Bromide
nebulisation every 4 hours, Hydrocortisone 100mg IV every 4 hours. Patient was also referred
to a Cardiologist for co-management and was scheduled for 2D echo.

8. PEARSON ASSESSMENT
February 13, 2012 February 14, 2012
P
Psychosocial
 75 years old, male, widower,
Filipino, Roman Catholic and was
born on April 5, 1936 currently
residing at San QuintinAbra.
 Admitted last February 8, 2012 at
2:10pm due to Difficulty of
breathing and bipedal edema
 According to Erick Erikson’s
Psychosocial Development,
Patient is under “Generativity vs.
Stagnation. He strived to create or
nurture things that will outlast
them; often by having children or
contributing to positive changes
that benefits other people.
 75 years old, male,
widower, Filipino, Roman
Catholic and was born on
April 5, 1936 currently
residing at San
QuintinAbra.
 Admitted last February 8,
2012 at 2:10pm due to
Difficulty of breathing and
bipedal edema
 He strived to create or
nurture things that will
outlast them; often by
having children or
contributing to positive
changes that benefits
other people.
E
Elimination
 Patient is with IFC connected to
urine bag draining into yellow
colored urine 970 cc in amount
during the shift
 No bowel movement noted during
the shift.
 With thick copious endotracheal
tube aspirate
 No diaphoresis noted
 No vomiting noted
 Patient is with IFC
connected to urine bag
draining into yellow
colored urine 775 cc in
amount during the shift
 No bowel movement
noted during the shift.
 With thick copious
endotracheal tube
aspirate
 No diaphoresis noted
 No vomiting noted

9. 
A/R
Activity and
rest
 Patient’s activity is limited since he
is weak and can’t tolerate normal
activities of his age.
 Usually sleeps during the shift
lasting for 1- 2 hours each.
 Slept on the bed with side rails up
in a semi fowler’s position with a
medium sized pillow under his
head.
 Patient’s activity is
limited since he is weak
and can’t tolerate normal
activities of his age.
 Usually sleeps during
the shift lasting for 1- 2
hours each.
 Slept on the bed with
side rails up in a semi
fowler’s position with a
medium sized pillow
under his head.
S
Safe
Environment
 Patient’s primary caregiver is his
youngest daughter.
 He has a good skin turgor,
wrinkled dry skin and fair in
complexion.
 With slightly long and uncut nails at
both upper and lower extremities.
 Skin is not warm to touch. Afebrile
at 37.1*C
 Patient is placed on bed in
appropriate and comfortable
position (semi fowlers); side rails
up; bed linens are wrinkle-free and
clean. Room is well lit and
ventilated.
 IVF is regulated accordingly and is
infusing well
 Constant provision of safety was
observed during the shift.
 No known allergies to drugs
 Patient’s primary
caregiver is his youngest
daughter.
 IVF is regulated
accordingly and is
infusing well
 He has a good skin
turgor, wrinkled dry skin
and fair in complexion.
 With slightly long and
uncut nails at both upper
and lower extremities.
 Skin is not warm to
touch. Afebrile at 36.2*C
 Patient is placed on bed
in appropriate and
comfortable position
(semi fowlers); side rails
up; bed linens are
wrinkle-free and clean.
Room is well lit and
ventilated.
 IVF is regulated
accordingly and is
infusing well
 Constant provision of
safety was observed
during the shift.
 No known allergies to
drugs
O
Oxygenation
 Room is well ventilated
 With endotracheal tube connected
to mechanical ventilator with the
following set up:
FiO2- 40%
TV 450
BUR 12
 Room is well ventilated
 With mild productive
cough noted
 With endotracheal tube
connected to mechanical
ventilator with the
following set up:

10. PFR 60
AC mode
 With audible crackles noted on
both lungs upon expiration
 With mild productive cough noted
 With thick copious ETA
 pale palpebral conjunctiva and nail
beds
 RR:25CPM
 CR:110 bpm
 BP: 140/80mmHg
 No cyanosis noted
FiO2- 40%
TV 450
BUR 8
PFR 60
SIMV mode
 With thick copious ETA
 RR:20 cpm
 CR:98 bpm
 BP: 140/90mmHg
 pale palpebral
conjunctiva and nail
beds
 No cyanosis noted
N
Nutrition
 Not cachectic in appearance
 Low salt low fat diet
 With NGT for feeding and
medications; OF 1400kcal/day
every 4 hours; able to tolerate 125
cc of OF PLUS 50 CC water every
4 hours.
 With an IVF of D5W IL at 250 CC
level for 24 hours
 Intake during the shift: 413.2 cc
 No known allergy to foods
 Not cachectic in
appearance
 Low salt low fat diet
 With NGT for feeding
and medications; OF
1400kcal/day every 4
hours; able to tolerate
125 cc of OF PLUS 50
CC water every 4 hours.
 With an IVF of D5W IL at
250 CC level for 24
hours
 Intake during the shift:
1140cc
 No known allergy to
foods

11. DIAGNOSTIC EXAMS
I. ACTUAL
COMPLETE BLOOD COUNT
February 8,
2012
February 14,
2012
February 16,
2012
February 18,
2012
Hemoglobin 135-180
g/L
121 L 132 N 145 N 144 N
Hematocrit 40-54% 39 L 42 N 47 N 47 N
RBC 4.6- 6.2 4.31 N 4.62 N 5.10 N 5.15 N
WBC
4.5-11x
10 9/L
11.3 H 23.3 H 15.4 H 20.0 H
Implications:
 Increased RBC count indicates hemoconcentration(dehydration), and polycythemia vera
while decreased RBC count indicates hemorrhage, anemias,
hemodilution(overhydration)
 Increased hematocrit indicates hemoconcentration(dehydration), and polycythemia vera
while decreased hematocrit indicates anemias, acute blood loss and hemodilution
 Increased in hemoglobin indicates hemoconcentration(dehydration), and polycythemia
vera while decreased in haemoglobin results in anemias and hemodilution
Nursing Responsibility
Explain the purpose of the test and its procedure to the Significant Others
Assist the med. Tech while obtaining specimen.
Apply pressure to vein for 5 minutes after specimen is obtained
Provide rest after procedure
Refer the result to the physician
SERUM ELECTROLYTES
Februa
ry 8,
2012
Februa
ry 10,
2012
Februa
ry 13,
2012
Februa
ry 14,
2012
Februa
ry 15,
2012
Februa
ry 16,
2012
Februa
ry 18,
2012
Februa
ry 19,
2012
N
a
135-
148
mmol/
L
137.2 N 137.4 N 134.0 L
----------
132 L 129 L 126.3 L 124.2 L

12. K
3.5-
5.3
mmol/
L
3.6 N 3.34 L 2.18 L 2.96 L 2.51 L 3.09 L 2.88 L 4.05 N
Cl
98-
107
mmol/
L
---------- ----------- ----------- -----------
133 H 155 H 70.5 L 75.5 L
Implications
 Na- muscle weakness
 K-hypotension,cardiac dysrhythmias, muscle weakness
Nursing Responsibility
Explain the purpose of the test and its procedure to the Significant Others
Assist the med. Tech while obtaining specimen.
Apply pressure to vein for 5 minutes after specimen is obtained
Provide rest after procedure
Refer the result to the physician
BLOOD CHEMISTRY
Normal
values
February
8, 2012
February
14, 2012
February
15, 2012
February
16, 2012
February
18, 2012
BUN
5-
25mg/dl
9.1 -------------- ------------ ------------ ------------
CREATININE 80-115
umol/L
133 H 135 H 133 H 155 H 141 H
Implication
 BUN -hypotension, increased respirations, overhydration
 Creatinine - CRF
Nursing Responsibility
Explain the purpose of the test and its procedure to the Significant Others
Assist the med. Tech while obtaining specimen.
Apply pressure to vein for 5 minutes after specimen is obtained
Provide rest after procedure
Refer the result to the physician
TPAG
Normal Values February 8, 2012
Total Protein 64-83 g/L 71 N
Albumin > 60 years : 24-38 34 N
Globulin 23-35 g/L 38 H
A/G 0.9: 1 1.1- 1.8 : 1 H

13. Implication:
 Globulin-DHN
Nursing Responsibility
Explain the purpose of the test and its procedure to the Significant Others
Assist the med. Tech while obtaining specimen.
Apply pressure to vein for 5 minutes after specimen is obtained
Provide rest after procedure
Refer the result to the physician
LIPID PROFILE
Normal Values February 9, 2012
FBS 3.89- 5.83 mmol/L 7.4 H
Uric acid 210 – 420 umol/L 851 H
Total Cholesterol <5.20 mmol/L 3.6 N
Triglycerides 0.70- 1.70 mmol/L 0.81 H
HDL Cholesterol >1.56 mmol/L 1.3 N
LDL Cholesterol < 2.6 mmol/L 1.95 N
Implication
 FBS: infection
 Triglycerides: hyperlipoproteinuria, HTN
Nursing Responsibility
Explain procedure to patient.
NPO 8 hours before exam.
Notify the laboratory department to start the procedure.
Apply pressure to the puncture site.
ARTERIAL BLOOD GAS
Normal Values February 14, 2012 February 16, 2012
pH 7.35- 7.45 7.605 H 7.548 N
pCO2 35- 48 mmHg 71.5 H 75.1 H
pO2 83- 108 mmHg 77 L 330 H
HCO3 21-28 mmol/L 71.2 H 65.9 H
SO2 95-99 97 N 100 N
Nursing Responsibility
Explain the purpose of the test and its procedure to the Significant Others
Assist the med. Tech while obtaining specimen.
Apply pressure to vein for 5 minutes after specimen is obtained
Provide rest after procedure
URINALYSIS

14. 02-10-12 02-12-12
Transparency Clear Slightly turbid
Color Yellow Yellow
Specific gravity 1.101 1.010
pH 5 5
Albumin (-) (-)
Blood(hgb) (-) +2
Nitrates (-) (-)
Sugar (-) (-)
Nursing Responsibility
Explain procedure to patient.
Collect a freshly voided urine, approximately 50ml, in a clean, dry, container and send it
to the laboratory within 30mins.
Impression:
 Increased USG indicates fluid retention
 Presence of hgb in the urine indicates hemoglobinuria
Chest X-Ray
(01-30-12)
Impression:
 Gross cardiomegaly with pulmonary congestion
 Developing pneumonia is not excluded
 Suspicious pulmonary nodule, Right suggests follow-up
 Atheromatous aorta
(02-08-12)
Impression:
 Pneumonia with minimal pleural effusion, Right
 Minimal PTB, Right upper lobe not initially excluded
 Solitary pulmonary nodule, Right(Koch’s granuloma vs. New growth)
 Mild cardiomegaly
 Atheromatous aorta
(02-13-12)
Impression:
 Mild regression of the pneumonia infiltrate
 Resolution of the minimal pleural effusion, Right
 The solitary nodule is in the Right upper lobe is again seen (probably Koch’s granuloma)
 Other previous chest findings are the same
Nursing Responsibility
Explain procedure to patient.
Foods and fluids are not restricted
Assist in positioning patient
Remove clothing and jewelry
Tell patient to take a deep breath and hold it as the x-ray is taken.

15. Kidney-Ureter-Bladder Ultrasound
Impression:
 Distended urinary bladder with significant urinary retention
 Mild bilateral pelvocaliectasia(probably due to pressure effect from the distended urinary
bladder
 Unremarkable prostate gland
Nursing Responsibility
Explain procedure to patient.
NPO 6 hours prior to abdominal studies.
Assist patient in voiding and positioning.
Confirm if patient has other tests that may interfere with the study like upper GI series
Echocardiogram Report
Impression:
 Normal left ventricular dimension with adequate wall and contractility
 Normal left atrium dimension
 Dilated left atrium and right ventricle dimensions without evidences of thrombus
 Structurally mitral valve, aortic valve, tricuspid valve, and pulmonic valve
 Mitral annular calcification and aortic annular calcification structurally at main pulmonary
artery dimension
Nursing Responsibility
Explain procedure to patient.
Foods and fluids are not restricted
Assist in positioning patient
Remove clothing and jewelry
Tell patient to take a deep breath and hold it as the procedure is taken.
Electrocardiogram Report
 CR BBB
 Multiple PVC’s
 RVH
 RAD
Nursing Responsibility
Explain procedure to patient.
Foods and fluids are not restricted
Assist in positioning patient
Remove clothing and jewelry
Tell patient to take a deep breath and hold it as the procedure is taken.
II. IDEAL DIAGNOSTIC TEST
ATRIAL SEPTAL DEFECT

16. Diagnosis in children
Most individuals with a significant ASD are diagnosed in utero or in early childhood with the use
of ultrasonography or auscultation of the heart sounds during physical examination.
Diagnosis in adults
Some individuals with an ASD will have undergone surgical correction of their ASD during
childhood. The development of signs and symptoms due to an ASD are related to the size of the
intracardiac shunt. Individuals with a larger shunt tend to present with symptoms at a younger
age.
Adults with an uncorrected ASD will present with symptoms of dyspnea on exertion (shortness
of breath with minimal exercise), congestive heart failure, or cerebrovascular accident (stroke).
They may be noted on routine testing to have an abnormal chest x-ray or an abnormal ECG and
may have atrial fibrillation.
Physical exam auscultation of the heart
The physical findings in an adult with an ASD include those related directly to the intracardiac
shunt, and those that are secondary to the right heart failure that may be present in these
individuals.
Upon auscultation of the heart sounds, there may be an ejection systolic murmur that is
attributed to the pulmonic valve. This is due to the increased flow of blood through the pulmonic
valve rather than any structural abnormality of the valve leaflets.
In unaffected individuals, there are respiratory variations in the splitting of the second heart
sound (S2). During respiratory inspiration, the negative intrathoracic pressure causes increased
blood return into the right side of the heart. The increased blood volume in the right ventricle
causes the pulmonic valve to stay open longer during ventricular systole. This causes a normal
delay in the P2 component of S2. During expiration, the positive intrathoracic pressure causes
decreased blood return to the right side of the heart. The reduced volume in the right ventricle
allows the pulmonic valve to close earlier at the end of ventricular systole, causing P2 to occur
earlier.
In individuals with an ASD, there is a fixed splitting of S2. The reason that there is a fixed
splitting of the second heart sound is that the extra blood return during inspiration gets
equalized between the left and right atrium due to the communication that exists between the
atria in individuals with ASD.
The right ventricle can be thought of as continuously overloaded because of the left to right
shunt, producing a widely split S2. Because the atria are linked via the atrial septal defect,
inspiration produces no net pressure change between them, and has no effect on the splitting of
S2. Thus, S2 is split to the same degree during inspiration as expiration, and is said to be
“fixed.”
Echocardiography
In transthoracic echocardiography, an atrial septal defect may be seen on color flow imaging as
a jet of blood from the left atrium to the right atrium.
If agitated saline is injected into a peripheral vein during echocardiography, small air bubbles
can be seen on echocardiographic imaging. It may be possible to see bubbles travel across an
ASD either at rest or during a cough. (Bubbles will only flow from right atrium to left atrium if the
RA pressure is greater than LA).
Because better visualization of the atria is achieved with transesophageal echocardiography,
this test may be performed in individuals with a suspected ASD which is not visualized on
transthoracic imaging.

17. Newer techniques to visualize these defects involve intracardiac imaging with special catheters
that are typically placed in the venous system and advanced to the level of the heart. This type
of imaging is becoming more common and involves only mild sedation for the patient typically.
If the individual has adequate echocardiographic windows, it is possible to use the
echocardiogram to measure the cardiac output of the left ventricle and the right ventricle
independently. In this way, it is possible to estimate the shunt fraction using echocardiograpy.
Transcranial Doppler (TCD) Bubble study
A less invasive method for detecting a PFO or other ASDs than transesophagal ultrasound is
Transcranial Doppler with bubble contrast.This method reveals the cerebral impact of the ASD
or PFO.
Electrocardiogram
The ECG findings in atrial septal defect vary with the type of defect the individual has.
Individuals with atrial septal defects may have a prolonged PR interval (a first degree heart
block). The prolongation of the PR interval is probably due to the enlargement of the atria that is
common in ASDs and the increased distance due to the defect itself. Both of these can cause
an increased distance of internodal conduction from the SA node to the AV node.
In addition to the PR prolongation, individuals with a primum ASD have a left axis deviation of
the QRS complex while those with a secundum ASD have a right axis deviation of the QRS
complex. Individuals with a sinus venosus ASD exhibit a left axis deviation of the P wave (not
the QRS complex).
A common finding in the ECG is the presence of incomplete RBBB (Right Bundle Branch
Block). In fact this finding is so characteristic that if it is absent, the diagnosis of ASD should be
revised.
URINARY RETENTION
Urine flow tests may aid in establishing the type of micturition (urination) abnormality. Common
findings, determined by ultrasound of the bladder, include a slow rate of flow, intermittent flow,
and a large amount of urine retained in the bladder after urination. A normal test result should
be 20-25 mL/sec peak flow rate. A post-void residual urine greater than 50 ml is a significant
amount of urine and increases the potential for recurring urinary tract infections. In adults older
than 60 years, 50-100 ml of residual urine may remain after each voiding because of the
decreased contractility of the detrusor muscle. In chronic retention, ultrasound of the bladder
may show massive increase in bladder capacity (normal capacity being 400-600 ml).
Determination of the serum prostate-specific antigen (PSA) may aid in diagnosing or ruling out
prostate cancer, though this is also raised in BPH and prostatitis. A TRUS biopsy of the prostate
(trans-rectal ultra-sound guided) can distinguish between these prostate conditions. Serum urea
and creatinine determinations may be necessary to rule out backflow kidney damage.
Cystoscopy may be needed to explore the urinary passage and rule out blockages.
In acute cases of urinary retention where associated symptoms in the lumbar spine are present
such as pain, numbness (saddle anesthesia), parasthesias, decreased anal sphincter tone, or
altered deep tendon reflexes, an MRI of the lumbar spine should be considered to further
assess caudaequina syndrome.
HOSPITAL-ACQUIRED PNEUMONIA
In hospitalised patients who develop respiratory symptoms and fever one should consider the
diagnosis. The likelihood increases when upon investigation symptoms are found of respiratory
insufficiency, purulent secretions, newly developed infiltrate on the chest X-Ray, and increasing
leucocyte count. If pneumonia is suspected material from sputum or tracheal aspirates are sent
to the microbiology department for cultures. In case of pleural effusionthoracentesis is

18. performed for examination of pleural fluid. In suspected ventilator-associated pneumonia it has
been suggested that bronchoscopy(BAL) is necessary because of the known risks surrounding
clinical diagnoses.
Bronchoscopy is a technique of visualizing the inside of the airways for diagnostic and
therapeutic purposes. An instrument (bronchoscope) is inserted into the airways, usually
through the nose or mouth, or occasionally through a tracheostomy. This allows the practitioner
to examine the patient's airways for abnormalities such as foreign bodies, bleeding, tumors, or
inflammation. Specimens may be taken from inside the lungs. The construction of
bronchoscopes ranges from rigid metal tubes with attached lighting devices to flexible optical
fiber instruments with realtime video equipment.
Chest X-ray (CXR), is a projection radiograph of the chest used to diagnose conditions
affecting the chest, its contents, and nearby structures. Chest radiographs are among the most
common films taken, being diagnostic of many conditions.
Leukocytosis is a raised white blood cell count (the leukocyte count) above the normal range in
the blood.It is frequently a sign of an inflammatory response,most commonly the result of
infection, and is observed in certain parasitic infections. It may also occur after strenuous
exercise, convulsions such as epilepsy, emotional stress, pregnancy and labour, anesthesia,
and epinephrine administration.
Thoracentesis, also known as thoracocentesis or pleural tap, is an invasive procedure to
remove fluid or air from the pleural space for diagnostic or therapeutic purposes. A cannula, or
hollow needle, is carefully introduced into the thorax, generally after administration of local
anesthesia.

19. ANATOMY AND PHYSIOLOGY OF ORGANS INVOLVED
HEART
Coronary Arteries
Because the heart is composed primarily of
cardiac muscle tissue that continuously contracts and
relaxes, it must have a constant supply of oxygen and
nutrients. The coronary arteries are the network of
blood vessels that carry oxygen- and nutrient-rich
blood to the cardiac muscle tissue.
The blood leaving the left ventricle exits
through the aorta, the body’s main artery. Two
coronary arteries, referred to as the "left" and "right"
coronary arteries, emerge from the beginning of the
aorta, near the top of the heart.
The initial segment of the left coronary artery
is called the left main coronary. This blood vessel is
approximately the width of a soda straw and is less
than an inch long. It branches into two slightly smaller arteries: the left anterior descending coronary
artery and the left circumflex coronary artery. The left anterior descending coronary artery is embedded in
the surface of the front side of the heart. The left circumflex coronary artery circles around the left side of
the heart and is embedded in the surface of the back of the heart.
Just like branches on a tree, the coronary arteries branch into progressively smaller vessels. The
larger vessels travel along the surface of the heart; however, the smaller branches penetrate the heart
muscle. The smallest branches, called capillaries, are so narrow that the red blood cells must travel in
single file. In the capillaries, the red blood cells provide oxygen and nutrients to the cardiac muscle tissue
and bond with carbon dioxide and other metabolic waste products, taking them away from the heart for
disposal through the lungs, kidneys and liver.
When cholesterol plaque accumulates to the point of blocking the flow of blood through a
coronary artery, the cardiac muscle tissue fed by the coronary artery beyond the point of the blockage is
deprived of oxygen and nutrients. This area of cardiac muscle tissue ceases to function properly. The
condition when a coronary artery becomes blocked causing damage to the cardiac muscle tissue it
serves is called a myocardial infarction or heart attack.

20. Superior Vena Cava
The superior vena cava is one of the two main veins bringing de-oxygenated blood from the body to the
heart. Veins from the head and upper body feed into the superior vena cava, which empties into the right
atrium of the heart.
Inferior Vena Cava
The inferior vena cava is one of the two main veins bringing de-oxygenated blood from the body to the
heart. Veins from the legs and lower torso feed into the inferior vena cava, which empties into the right
atrium of the heart.
Aorta
The aorta is the largest single blood vessel in the body. It is approximately the diameter of your thumb.
This vessel carries oxygen-rich blood from the left ventricle to the various parts of the body.
Pulmonary Artery
The pulmonary artery is the vessel transporting de-oxygenated blood from the right ventricle to the lungs.
A common misconception is that all arteries carry oxygen-rich blood. It is more appropriate to classify
arteries as vessels carrying blood away from the heart.
Pulmonary Vein
The pulmonary vein is the vessel transporting oxygen-rich blood from the lungs to the left atrium. A
common misconception is that all veins carry de-oxygenated blood. It is more appropriate to classify veins
as vessels carrying blood to the heart.
Right Atrium
The right atrium receives de-oxygenated blood from the body through the superior vena cava (head and
upper body) and inferior vena cava (legs and lower torso). The sinoatrial node sends an impulse that
causes the cardiac muscle tissue of the atrium to contract in a coordinated, wave-like manner. The
tricuspid valve, which separates the right atrium from the right ventricle, opens to allow the de-oxygenated
blood collected in the right atrium to flow into the right ventricle.
Right Ventricle
The right ventricle receives de-oxygenated blood as the right atrium contracts. The pulmonary valve
leading into the pulmonary artery is closed, allowing the ventricle to fill with blood. Once the ventricles are
full, they contract. As the right ventricle contracts, the tricuspid valve closes and the pulmonary valve
opens. The closure of the tricuspid valve prevents blood from backing into the right atrium and the
opening of the pulmonary valve allows the blood to flow into the pulmonary artery toward the lungs.
Left Atrium
The left atrium receives oxygenated blood from the lungs through the pulmonary vein. As the contraction
triggered by the sinoatrial node progresses through the atria, the blood passes through the mitral valve
into the left ventricle.
Left Ventricle
The left ventricle receives oxygenated blood as the left atrium contracts. The blood passes through the
mitral valve into the left ventricle. The aortic valve leading into the aorta is closed, allowing the ventricle to
fill with blood. Once the ventricles are full, they contract. As the left ventricle contracts, the mitral valve
closes and the aortic valve opens. The closure of the mitral valve prevents blood from backing into the left
atrium and the opening of the aortic valve allows the blood to flow into the aorta and flow throughout the
body.

21. Papillary Muscles
The papillary muscles attach to the lower portion of the interior wall of the ventricles. They connect to the
chordae tendineae, which attach to the tricuspid valve in the right ventricle and the mitral valve in the left
ventricle. The contraction of the papillary muscles closes these valves. When the papillary muscles relax,
the valves open.
Chordae Tendineae
The chordae tendineae are tendons linking the papillary muscles to the tricuspid valve in the right
ventricle and the mitral valve in the left ventricle. As the papillary muscles contract and relax, the chordae
tendineae transmit the resulting increase and decrease in tension to the respective valves, causing them
to open and close. The chordae tendineae are string-like in appearance and are sometimes referred to as
"heart strings."
Tricuspid Valve
The tricuspid valve separates the right atrium from the right ventricle. It opens to allow the de-oxygenated
blood collected in the right atrium to flow into the right ventricle. It closes as the right ventricle contracts,
preventing blood from returning to the right atrium; thereby, forcing it to exit through the pulmonary valve
into the pulmonary artery.
Mitral Value
The mitral valve separates the left atrium from the left ventricle. It opens to allow the oxygenated blood
collected in the left atrium to flow into the left ventricle. It closes as the left ventricle contracts, preventing
blood from returning to the left atrium; thereby, forcing it to exit through the aortic valve into the aorta.
Pulmonary Valve
The pulmonary valve separates the right ventricle from the pulmonary artery. As the ventricles contract, it
opens to allow the de-oxygenated blood collected in the right ventricle to flow to the lungs. It closes as the
ventricles relax, preventing blood from returning to the heart.
Aortic Valve
The aortic valve separates the left ventricle from the aorta. As the ventricles contract, it opens to allow the
oxygenated blood collected in the left ventricle to flow throughout the body. It closes as the ventricles
relax,preventing blood from returning to the heart.
LUNGS
The lower respiratory tract begins with
the trachea, which is just below the larynx.
The trachea, or windpipe, is a hollow, flexible,
but sturdy air tube that contains C-shaped
cartilage in its walls. The inner portion of the
trachea is called the lumen. The first
branching point of the respiratory tree occurs
at the lower end of the trachea, which divides
into two larger airways of the lower respiratory
tract called the right bronchus and left

22. bronchus. The wall of each bronchus contains substantial amounts of cartilage that help keep the airway
open. Each bronchus enters a lung at a site called the hilum. The bronchi branch sequentially into
secondary bronchi and tertiary bronchi. The tertiary bronchi branch into the bronchioles. The bronchioles
branch several times until they arrive at the terminal bronchioles, each of which subsequently branches
into two or more respiratory bronchioles. The respiratory bronchiole leads into alveolar ducts and alveoli.
The alveoli are bubble-like, elastic, thin-walled structures that are responsible for the lungs most vital
function: the exchange of oxygen and carbon dioxide. Each structure of the lower respiratory tract, beginning
with the trachea, divides into smaller branches. This branching pattern occurs multiple times , creating
multiple branches. In this way, the lower respiratory tract resembles an upside -down tree that begins with
one trachea trunk and ends with more than 250 million alveoli leaves. Because of this resemblance, the
lower respiratory tract is often referred to as the respiratory tree.In descending order, these generations of
branchesinclude:trachea,right bronchus andleft bronchus,secondary bronchi,tertiary bronchi,bronchioles,
terminal bronchioles,respiratorybronchioles,alveoli
MALE BLADDER AND
URETHRA
The urinary bladder stores
urine prior to its elimination from
the body (functions of the urinary
system). At micturation/urination,
the bladder expels urine into the
urethra, leading to the exterior of
the body. The bladder is a
musculomembranous sac
located on the floor of the pelvic
cavity, anterior to the uterus and
upper vagina (in females).
Outer surfaces of the
Bladder: The upper and side
surfaces of the bladder are
covered by peritoneum (also
called "serosa"). This serous
membrane of the abdominal
cavity consists of mesthelium and elastic fibrous connective tissue. "Visceral peritoneum" covers the
bladder and other abdominal organs, while "parietal peritoneum" lines the abdomen walls.
Ureters: The ureters deliver urine to the bladder from the kidneys (one ureter from each kidney - see
components of human urinary system). The ureters pass through the posterior surface of the bladder at
the Ureter Orifices (shown above). Urine drains through the ureters directly into the bladder as there are
no sphincter muscles or valves at the ureter orifices.
The bladder itself consists of 4 layers:- (1) Serous - this outer layer being a partial layer derived from
the peritoneum, (2) Muscular - the detrusor muscle of the urinary bladder wall, which consists of 3
layers incl. both longitudinal and circularly arranged muscle fibres, (3) Sub-mucous - a thin layer of
areolar tissue loosely connecting the muscular layer with the mucous layer, and (4) Mucous - the
innermost layer of the wall of the urinary bladder loosely attached to the (strong and substantial) muscular
layer. The mucosa falls into many folds known as rugae when the bladder is empty or near empty.
The features observable on the inside of the bladder are the ureter orifices, the trigone, and the
internal orifice of the urethra. Thetrigone is a smooth triangular region between the openings of the
two ureters and the urethra and never presents any rugae even when the bladder is empty - because this
area is more tightly bound to its outer layer of bladder tissue. The internal urethral sphincter is a
sphincter (circular) muscle located at the neck of the bladder and formed from a thickening of the detrusor
muscle. It closes the urethra when the bladder has emptied.

23. Pathophysiology
Algorithm
Foramen ovale after birth failed to seal entirely
Defect in the inter-atrial septum
Blood draws back from left atrium to the right atrium (left-
right-shunt)
Increase volume andpressure
in the right chambers of the
heart
Ventricular hypertrophy
Atrial Septal
Defect
Mixing of venous and
arterial blood
Decrease oxygen
concentration in
blood; low hgb
(121g/dl); low HCT
(39%)
Decrease oxygenated
blood in the circulation
Pulmonary hypertension
Pulmonary
congestion
and mild
Cardiomegal
y (CXR)
Dilated left
atrium and
right
ventricle
(Echocardiog
ram)
DOB
Mucosal inflammationandHypersecretion
Secretions are retained
Risk Factor (Familial History of
Cardiovascular Disease and HPN)
Prolonged
stay in the
hospital
Mechanical Ventilation
Pale palpebral
conjunctiva and nail
beds; RR:25CPM;
CR:110 bpm

24. Legend:
Explanation:
The patient has Familial History of Cardiovascular Disease and HPN. Because of this,
he was predisposed to develop abnormality during fetal development. His foramen ovale, an
opening between the two atria which allows blood to bypass the nonfunctional fetal lungs when
the fetus obtains its oxygen from the placenta may have been failed to seal entirely soon after
birth. These cases often occur to 25% of all adults. Since no consultation was made, this
condition arose or worsens allowing the inter-atrial septum of the patient to become defective
which caused backflow of blood from left atrium to the right atrium or vice versa.This results in
the mixing of arterial and venous blood, which may or may not be clinically significant. This
mixture of blood may or may not result in what is known as a "shunt". The amount of shunting
present, if any, dictates hemodynamic significance- a condition called Atrial Septal Defect. In
fact, the usual cause of congenital heart disorders is failure of the heart structure to progress
beyond an early stage of embryonic development.
Since pressure is higher in the left side of the heart, blood tends to return to the right
side which has lesser pressure though the created communication between the two atria. The
right side of the heart contains venous blood with lowoxygen content, and the left side of the
heart contains arterialblood with highoxygen content. A normal heart has an inter-atrial septum
that prevents oxygen-rich blood and oxygen-deficient blood from mixing together.
This then causes an increase volume and pressure in the right chambers of the heart as
well as mixing of venous and arterial blood. The latter caused the client to have pulmonary
hypertension. The right ventricle will have to push out more blood than the left ventricle due to
the left-to-right shunt. This constant overload of the right side of the heart caused an overload of
the entire pulmonary vasculature. Eventually pulmonary hypertension developed. The
Hospital- AcquiredPnemonia
Increased
WBC:
11.3x109
/L
Clouds:riskfactor
Circle:manifestations
Rectangle:physiologicprocess

25. pulmonary hypertension in turn caused the right ventricle to face increased afterload in addition
to the increased preload that the shunted blood from the left atrium to the right atrium caused.
The right ventricle was forced to generate higher pressures to try to overcome the pulmonary
hypertension. This led to right ventricular hypertrophy. These processes gave rise to the results
of the patient’s echocardiogram (dilated left atrium and right ventricle) and Chest X-Ra
(Pulmonary congestion with mild Cardiomegaly) which led the patient to suffer from difficulty of
breathing. As left-to-right shunting occurred, venous blood (oxygen-deficient) was mixed with
arterial blood (oxygen-rich) decreasing oxygenated blood to be transported in the circulation.
This gave rise to low hgb (121g/dl), low HCT (39%), pale palpebral conjunctiva and nail beds.
RR of25CPM and CR of 110 bpm were compensatory mechanisms to increase the delivery of
oxygen to the tissues of his body.
The latter findings in conjunction with DOB subjected the client for artificial airway
insertion (Mechanical Ventilator). Frequently, translaryngeal intubation is performed to clear
secretions retained in the central airways.However, the presence of such an apparatus can also
cause mucosal inflammation and significant mucus hypersecretionpredisposing to infection and
encouraging hypoxia. Since secretions were retained, aggravated by his prolonged stay in the
institution, the patient then developed Hospital- Acquired Pnemonia as evidenced by an
increased in his WBC (11.3x109
/L).

26. MEDICAL AND SURGICAL MANAGEMENT
Ideal Management for Atrial Septal Defect
Many patients have no symptoms, and require no medications. However, some patients may
need to take medications to help the heart work better, since the right side is under strain from
the extra blood passing through the ASD. Medications that may be prescribed include the
following:
 digoxin - a medication that helps strengthen the heart muscle, enabling it to
pump more efficiently.
 diuretics - the body's water balance can be affected when the heart is not
working as well as it could. These medications help the kidneys remove excess
fluid from the body.
 Drugs may also be used to reduce the risk of complications after surgery.
Medications may include those to:
 Keep the heartbeat regular. Examples include beta blockers (Lopressor,
Inderal) and digoxin (Lanoxin).
 Reduce the risk of blood clots. Anticoagulants, often called blood
thinners, can help reduce the chances of developing a blood clot and
having a stroke. Anticoagulants include warfarin (Coumadin) and anti-
platelet agents, such as aspirin.
Infection control
Patients with certain heart defects are at risk for developing an infection of the inner surfaces of
the heart known as bacterial endocarditis. It is important that you inform all medical personnel
that the patient has an ASD so they may determine if the antibiotics are necessary before a
procedure.
Cardiac catheterization. A thin tube (catheter) is inserted into a blood vessel in the groin and
guided to the heart. Through the catheter, a mesh patch or plug is put into place to close the
hole. The heart tissue grows around the mesh, permanently sealing the hole.
Open-heart surgery. This type of surgery is done under general anesthesia and requires the
use of a heart-lung machine. Through an incision in the chest, surgeons use patches or stitches
to close the hole.

27. Ideal Medical Management for Acute Urinary Retention
Complete bladder decompression: usually with a Foley® urinary catheter. This can be
undertaken in a community or hospital setting. The patient should then be referred to the
urologists for longer term management.
Silver alloy indwelling catheters for catheterizing hospitalized adults short-term (<14 days)
reduces the risk of catheter acquired urinary tract infection, but the cost-effectiveness of their
use remains unproven.
Ideal Medical Management for Hospital Acquired Pneumonia
Treatment aims to cure the infection with antibiotics. An antibiotic is chosen based on the
specific germ found by sputum culture. However, the bacteria cannot always be identified with
tests. Antibiotic therapy is given to fight the most common bacteria that infect hospitalized
patients, taking into account the most common bacteria in each hospital -- Staphylococcus
aureus and gram-negative bacteria.
Actual Management of the Patient
Upon admission, the patient was put on low salt and low fat diet. Diagnostic work up
includeCBC,Na-K determination, Fasting Blood Sugar (FBS), Blood Urea Nitrogen (BUN),
Creatinine, Blood Uric Acid (BUA), Lipid profile, 12 lead ECG, Chest x-ray, and Troponin T
Quantitative and 2D Echo. D5W 500 cc was regulated to KVO and was hooked to oxygen
inhalation 2-4 lpm via nasal cannula. Medications started were Furosemide 20 mg IV Q8*,
Salbutamol + Ipratropium Bromide nebulization q4*, and Hydrocortisone 100 mg IV Q4*. He
was referred to a cardiologist for co-management. In the ward, additional laboratories requested
were TPAG determination, sputum AFB and sputum gram stain, and also culture and sensitivity.
Cefixime 750 mg IV Q8* was started.
The next day, laboratory results were noted. BUA was 851 umol/L. The patient was
started on Colchicine 1 tablet TID as needed, Allopurinol 100 mg 1 tablet OD and Oxygen
inhalation was decreased to 1 lpm. On the same day, the patient wassubjected for urinalysis,
repeat Na and K, for PSA determination and Kidney Ureter Bladder-Prostate ultrasound.
Azithromycin 500 mg OD was added in medication.Potassium was below normal which is 3.34
mmol/L, hence started on KCl 1 tablet once a day. Terazosin 1 g once a day was also started.
February 10, 2012, patient experienced urinary retention; alternate hot and cold
compress on hypogastric area was done. Dosage of Furosemide was increased to 40mg IV
q12*, Ramelteon 8mg 1 tablet at bedtime was started.The patient was not relieved of bladder
distention so IFC was inserted.
On the fourth day, IFC was removed. Water intake was limited to 800ml/ day. He was
referred to a nephrologist due to urinary retention the next day. Repeat urinalysis and prostate
ultrasound was ordered. IFC was reinserted due to bladder distention. Creatinine determination
was ordered. He was started on Bethanecol 23mg 1 tablet 2 times a day.Nebulization was
decreased to q6*. Hydrocortisone was also decreased to every 8* for 3 doses then to consume.
KCl drip was started, 40 mEqsKCl + 80 cc PNSS to run for 6* for 2 cycles.
On the sixth hospital day, Cefuroxime was discontinued and was started on Piperacillin-
Tazobactam 2.25 mg IV q8*. The patient was referred to a pulmonologist.Furosemide was
shifted to oral form, 40 mg tablet once a day. He was started on Buclizine 1 tablet once a day

28. and Carvidolol 25 mg ½ tablet once a day.Potassium determination was repeated. IFC was
removed but patient was for straight catheterization if still with no urine output.
Later, the patient was noted to have chills, disorientation and incoherence and difficulty
of breathing. Oxygen saturation was at 70%. He was referred to an anaesthesiologist for
endotracheal intubation and was hooked to mechanical ventilator. He was then transferred to
ICU for close monitoring. Patient had fever hence given Paracetamol 300mg IV q4* for fever.
In the ICU, the patient removed his endotracheal tube. No respiratory distress was
noted. Oxygen saturation at >90%. He was hooked back to Oxygen inhalation 2-4 Lpm per
nasal cannula.Patient’s BP was at 80/50 mmHg. Hgt determination was at 116mg/dl. Dopamine
drip was started. He was still hypotensive hence Dobutamine drip was also hooked.
On the seventh hospital day, the patient was put on soft diet with strict aspiration
precaution. Budesonide nebulisation every 12* was started. Furosemide, Carvedolol and
Terazosin were held. Na and K were repeated. Potassium was still low @ 2.51 mmol/L so
another KCl drip was ordered for 3 cycles.
The next day, the patient was noted to be restless and unable to sleep. He was given
Hydroxyzine 25mg 1 tablet. The patient had one episode of seizure then had cardiopulmonary
arrest. The patient was reintubated and was hooked to mechanical ventilator. Phenytoin was
started 200 mg as loading dose then 100mg IV every 8 hours as maintenance dose. No BP was
appreciated, hence Levophed drip was started. Diazepam 5mg IV was ordered for frank seizure.
Citicholine 500mg IV once a day was started. The patient was subjected for plain cranial CT
scan once stable.Chest x-ray, CBC, Na, K, Creatinine and Arterial Blood Gas were repeated.
Potassium (K) was still low at 3.09 mmol/L so another cycle of KCl drip was given. NGT was
inserted and osteorized feeding was started.
Later, the patient had diffuse wheezes; he was given Hydrocortisone 100mg IV every 8
hours for 3 doses. He was also noted to have myoclonic jerks. Leviteracetam 500 mg 2 times a
day and Divalproex 500mg 2 times a day were started.
On the 9th
hospital day, weaning off from mechanical ventilator was started. Inotropics
were titrated to maintain systolic BP of 100 mmHg.
On 10th
day, the patient was noted to have a labored breathing. Oxygen inhalation was
provided. Nebulization with Salbutamol+ Ipratropium was done for 3 doses, CBC, Creatinine,
Na, K, and Cl were repeated. Sodium and Potassium are low so KCl drip was continued.

29. PROMOTIVE AND PREVENTIVE MANAGEMENT
Atrial Septal Defect
 Exercise. Having an atrial septal defect usually doesn't restrict from activities or exercise as
long as it is not to strenuous. Cardiologist can help you learn what is safe.
 Diet. A heart-healthy diet based on fruits, vegetables and whole grains — and low in
saturated fat, cholesterol and sodium — can help the patient keep his heart healthy. Eating one
or two servings of fish a week also is beneficial.
 Preventing infection. Some heart defects, and the repair of defects, create changes to the
surface of the heart in which bacteria can become stuck and grow into an infection (infective
endocarditis).
 Promote relaxation techniques like DBE and positioning every 2 hours as tolerated.
Hospital Acquired Pneumonia
 Promote relaxation techniques like DBE and positioning every 2 hours as tolerated.
 Educate the staffs to perform handwashing
 Perform Chest physiotherapy unless contraindicated
 Render Nebulization as ordered.
Acute Urinary Retention
1. Identify patients at risk; consider age and fluid status
2. Avoid making the patient anxious as this may contribute to his inability to void
3. Assist the patient to ambulate as soon as possible unless contraindicated
4. Turn the water on so that the patient can hear it as it obliterates the sound of urination.
5. Lightly stroke the inner aspect of the thigh or apply ice to the inner thigh to stimulate trigger
points thus initiating the micturition reflex.

30. DISCHARGE PLAN
M
 Home medications are not yet given since patient is still in
but medications currently taking by the patient is shown in
the drug study.
E
 Encourage rest in between periods of activities.
 Passive exercises
 Gentle Massage.
T
 Instruct client and relatives in the prescribed medication
regimen.
 Encourage routine and reminders to facilitate adherence.
Teach the patient and relatives on the right time to take his
medications as well as other measures that will be advised
by his physician
 The family members must provide the patient with adequate
emotional support, care, and may pray for the patient
H
 Instruct the relatives of importance of aseptic technique in
food preparation
 Instruct the relatives to serve variety of fruits and vegetables.
These foods may help in the healing process and may keep
his body healthy.
 Instruct client to comply with the prescribed medications of
as well as treatments and modifications.
 Stress the significance of maintaining a good personal
hygiene to promote sense of well- being.
 Providing a calm environment should also be instructed to
the client’s significant others for him to take enough rest
periods.
O
 Instruct client’s mother to attend follow –up check up of her
son gave by the Physician
 Likewise, instruct his family to seek immediate medical care
if the patient experienced difficulty of breathing.
D
 Encourage to eat fruits, vegetables and whole grains and
low in saturated fat, cholesterol and sodium

31. S
 Encourage family members to pray constantly and surrender
all their worries to God especially their present condition to
lessen anxiety and to promote presence of mind.
UPDATES
High prevalence of multidrug-resistant nonfermenters in hospital-acquired pneumonia in
Asia
Am J RespirCrit Care Med. 2011 Dec 15;184(12):1409-17. Epub 2011 Sep 15.
Hospital-acquired pneumonia (HAP) and ventilator-associated pneumonia (VAP) remain
important causes of morbidity and mortality. Increasing antimicrobial resistance has aroused the
concern of the failure of antibiotic treatment.
To determine the distribution of the bacterial isolates of HAP and VAP, their antimicrobial
resistance patterns, and impact of discordant antibiotic therapy on clinical outcome in Asian
countries
A prospective surveillance study was conducted in 73 hospitals in 10 Asian countries
from 2008-2009. A total of 2,554 cases with HAP or VAP in adults were enrolled and 2,445
bacterial isolates were collected from 1,897 cases. Clinical characteristics and antimicrobial
resistance profiles were analyzed.
Major bacterial isolates from HAP and VAP cases in Asian countries were Acinetobacter
spp., Pseudomonas aeruginosa, Staphylococcus aureus, and Klebsiellapneumoniae. Imipenem
resistance rates of Acinetobacter and P. aeruginosa were 67.3% and 27.2%, respectively.
Multidrug-resistant rates were 82% and 42.8%, and extensively drug-resistant rates were 51.1%
and 4.9%. Multidrug-resistant rate of K. pneumoniae was 44.7%. Oxacillin resistance rate of S.
aureus was 82.1%. All-cause mortality rate was 38.9%. Discordant initial empirical antimicrobial
therapy increased the likelihood of pneumonia-related mortality (odds ratio, 1.542; 95%
confidence interval, 1.127-2.110).
Acinetobacter spp., P. aeruginosa, S. aureus, and K. pneumoniae are the most frequent
isolates from adults with HAP or VAP in Asian countries. These isolates are highly resistant to
major antimicrobial agents, which could limit the therapeutic options in the clinical practice.
Discordant initial empirical antimicrobial therapy significantly increases the likelihood of
pneumonia-related mortality.
SOURCE:
http://www.ncbi.nlm.nih.gov/pubmed/21920919
Elevated blood glucose level as a risk factor of hospital-acquired pneumonia among
patients treated in the intensiv care unit (ICU)]
Kubisz A, Kulig J, Szczepanik AM, Solecki R.

32. Hospital acquired-pneumonia is the most frequently occurring hospital-acquired infection
in intensive care units (ICU). The study group consisted of 233 patients treated over 12 months
in the ICU of the 1st Department of General Surgery and Gastroenterological Surgery Clinics,
University Hospital in Krakow. Patients were divided in two groups: experimental--consisting of
92 patients with hospital-acquired pneumonia, and control--consisting of 141 patients without
the disease. The following risk factors of hospital-acquired pneumonia risk were analysed for
both groups: length of stay in the ICU, duration of mechanical ventilation, kind of treatment
applied, presence of a gastrointestinal tube, blood glucose levels. Significantly more patients
with hospital-acquired pneumonia than controls had blood glucose level above 6 mmol/l (OR =
2.23). Monitoring and maintainment of glucose level within the normal ranges is an important
element of successful treatment. In fact, glucose level is the only risk factor that can be easily
modified compared with other analyzed factors.
SOURCE:
http://www.ncbi.nlm.nih.gov/pubmed/21812227
Characterization of intensive care unit acquired hyponatremia and hypernatremia
following cardiac surgery
Department of Critical Care Medicine, University of Calgary, Foothills Medical Centre, Canada.
tom.stelfox@albertahealthservices.ca
Although intensive care unit (ICU) acquired sodium disturbances are common in critically
ill patients, few studies have examined sodium disturbances in patients following cardiac
surgery. The objective of this study was to describe the epidemiology of ICU-acquired
hyponatremia and hypernatremia in patients following cardiac surgery.
We identified 6,727 adults (> or =18 yr) who were admitted consecutively to a regional
cardiovascular intensive care unit (CVICU) from January 1, 2000 to December 31, 2006 and
were documented as having normal serum sodium levels (133 to 145 mmol.L(-1)) during the
first day of ICU admission. ICU-acquired hyponatremia and hypernatremia were defined as a
change in serum sodium concentration to <133 mmol.L(-1) or >145 mmol.L(-1), respectively,
following ICU day one.
A first episode of ICU-acquired hyponatremia and hypernatremia developed in 785 (12%) and
242 (4%) patients, respectively, (95% confidence interval [CI] 11-12% and 95% CI 3-4%,
respectively), with a respective incidence density of 4.2 and 1.3 patients per 100 days of ICU
admission (95% CI 4.0-4.5 and 95% CI 1.2-1.5). The incidence of ICU-acquired sodium
disturbances varied according to the patients' demographic and clinical variables for both
hyponatremia (age, diabetes, Acute Physiology and Chronic Health Evaluation [APACHE II]
score, mechanical ventilation, length of ICU stay, serum glucose level, and serum potassium
level) and hypernatremia (APACHE II score, mechanical ventilation, length of hospital stay prior
to ICU admission, length of ICU stay, serum glucose level, and serum potassium level).
Compared with patients with normal serum sodium levels, hospital mortality was increased in
patients with ICU-acquired hyponatremia (1.6% vs 10%, respectively; P < 0.001) and ICU-
acquired hypernatremia (1.6% vs 14%, respectively; P < 0.001).
ICU-acquired hyponatremia and hypernatremia are common complications in critically ill
patients following cardiac surgery. They are associated with patient demographic and clinical
characteristics and an increased risk of hospital mortality.
SOURCE:
http://www.ncbi.nlm.nih.gov/pubmed/20405264

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