VIRTUAL CLINICAL DUTY

DAILY REQUIREMENTS

STUDENTS’ PROFILE

STUDENT NURSES’ NAME Edgie Jeric C. Fabre

YEAR / SECTION / GROUP 3-NE-Ward Group
SCHOOL ID NUMBER 20160010053
CONTACT NUMBER 09569260164
OFFICIAL EMAIL ADD edgiejericfabre@yahoo.com
HOSPITALS’ NAME Maria Reyna Xavier University Hospital
AREA OF DUTY STATION 2B
SHIFT PM Shift
DATE / DAY 03/04/21 SATURDAY WEEK 2
CLINICAL INSTRUCTOR Joseph B. Abang, AHSE, BSN, RN, MN, MAN©

1
 TABLE OF CONTENTS

Page
Introduction 1
Nursing Health History 1
Physical Assessment 2
Anatomy & Physiology 3
Pathophysiology 4

Diagnostic Tests 5
Drug Study 6
Problem Lists 7
Nursing Care Plan 8
Discharge Plan 9
Learning Outcome 10
Critical Thinking Answers 11
References (APA Style) 12
Authenticity Statement 13

2
 INTRODUCTION

Multiple sclerosis (MS) is a condition affecting the brain and spinal cord, resulting
from damage to the nerve cells in the central nervous system. MS is a chronic and
disabling disease that usually starts in young adulthood and is 2-3 times more common
in women than men. MS is a lifelong disease, commonly progressing to serious and
permanent disability, although can occasionally have only mild symptoms. The main
symptoms of MS vary between sufferers and can affect any part of the body. These
may include fatigue, blurred vision, difficulties with walking, balance and co-ordination,
loss of bladder control, numbness throughout different parts of the body, muscle
stiffness or spasms, and issues with thinking and learning. Although in many cases it is
possible to treat the symptoms, there is no curative treatment and life expectancy is
slightly reduced. Some drugs (such as beta-interferon or glatiramer acetate) may modify
the course of the disease.

Multiple sclerosis (MS) is an unpredictable disorder that can cause a variety of

symptoms, which for many, can flare-up and then subside over the course of days,
months, or even years. While MS is not contagious, its causes are not yet fully
understood and researchers continue to search for answers. MS is most frequently
diagnosed in young adults, although individuals of any age may be diagnosed with this
neurological condition. People who are not familiar with MS can easily be confused by
its name and its unique symptoms. Particularly with today’s approved treatments and
wellness strategies, most individuals with MS are able to live a full and productive life,
with much hope for the future. In MS, the immune system attacks the protective sheath
(myelin) that covers nerve fibers and causes communication problems between your
brain and the rest of your body. Eventually, the disease can cause permanent damage
or deterioration of the nerves. Signs and symptoms of MS vary widely and depend on
the amount of nerve damage and which nerves are affected. Some people with severe
MS may lose the ability to walk independently or at all, while others may experience
long periods of remission without any new symptoms. There's no cure for multiple
sclerosis. However, treatments can help speed recovery from attacks, modify the
course of the disease and manage symptoms.

3
 NURSING HEALTH HISTORY

Patient E.F is a 25-year-old man, a call center agent in one of the BPO companies in
the city, an Iglesia Filipina Independiente (IFI) by faith currently residing at Barangay 48,
Cagayan de Oro City. He is admitted in the Neurology Medical Unit of Maria Reyna
Xavier University Hospital. His admission in the unit was referred by his internist, who
suspects him of having symptoms of multiple sclerosis (MS). Patient E.F. has
experienced increasing urinary frequency and urgency over the past 2 months. Because
his female partner was treated for sexually transmitted infection, patient E.F also
underwent treatment, but the symptoms did not resolve. Patient E.F has also recently
had two brief episodes of eye “fuzziness” associated with diplopia and flashes of
brightness. He has noticed ascending numbness and weakness of the right arm with the
inability to hold objects over the past few days. Now he reports rapid progression of
weakness in his legs.

Patient E.F. is diagnosed with MS. He confides in you that he has been depressed
since his parents’ get annulled and the onset of these symptoms. He tells you that he
knows his girlfriend hasn’t been faithful, but he’s afraid of living alone. He’s afraid if he
tells her about his MS diagnosis, she’ll leave him.

Patient E.F. was discharged from the hospital and appropriate referrals were made for
support groups. He takes advantage of his time with a psychiatric nurse specialist, joins
a local MS support group, and tells his girlfriend to move out. He later marries a woman
from the support group.

4
 PHYSICAL ASSESSMENT

General Assessment
Medical/ Surgical Ward
Xavier University College of Nursing

Name: E.F. Age: 25

Birthday: - Civil Status: Single

Religion: Inglesia Filipina Occupation: Call center

Sex: Male Indepediente agent

Address: Barangay 48, Cagayan de Oro City

Informant: Patient E.F. Relation: -

Admission Date: - Time: -

Increasing urinary frequency and urgency over the

Chief Complaint: past 2 months

Attending Physician: -

Diagnosis: Multiple Sclerosis

Admission Date & Time: Day 1 Day 2 Day 3

ACTIVITY/REST
SUBJECTIVE

5
 Usual Activities or
Hobbies:

Leisure Time Activities:

Limitations Imposed by
Condition:

Number of Hours of
Sleep:
Naps:

Aids:

Difficulty in Sleeping:

Feeling on Awakening:

Others/Comments:

OBJECTIVE
Observed Response to
Activity:
Cardiovascular:

Respiratory:

Mental Status: Appropriate

Posture:

Limitation of Motion
(LOM):

Tremors:

CIRCULATION
SUBJECTIVE
History of Hypertension:

6
 Heart Trouble:

Ankle/Leg Edema:

Claudication:

Cough/Hemoptysis:

Numbness in Right arm and

Extremities: legs

Tingling in Extremities:

Change in Over the past

Frequency/Amount 2 months
of Urine:

OBJECTIVE
Blood Pressure:

Right Arm:
Left Arm:

Pulse Pressure:

Point of Maximal
Impulse (PMI):

Heart Rate/Sounds:

Rhythm:

Pulse:

Vascular Bruit:

Breath Sounds:

Jugular Vein Distention:

Extremities:
Temperature

7
 Color:

Capillary Refill Time:

Homan’s Sign:

SUBJECTIVE
Reports of Stress Confides that
Factors: he has been
depressed
since his
parents` got
annulled.
Reports that
his girlfriend
hasn`t been
faithful and
afraid of living
alone.
Ways of Handling
Stress:

Financial Concerns:

Relationship Status: Single

Lifestyle:

Recent Changes:

Feelings of Yes
Helplessness:

Feelings of Yes
Hopelessness:

Feelings of Yes
Powerlessness:

8
 Others/Comments:

OBJECTIVE
Emotional Status: Pt feels sad
and reports
being
“depressed”
Observed Physiologic Feeling of
Response: hopelessness

ELIMINATION
SUBJECTIVE
Usual Bowel Pattern:

Character of Stool:

Last Bowel Movement:

Laxative Use:

History of Bleeding:

Hemorrhoids:

Constipation:

Diarrhea:

Usual Voiding Pattern:

Incontinence: Increased over

the past 2
months
Urgency: Increased over
the past 2
months
Retention:

Frequency: Increased over

the past 2
months

9
Pain/Burning/Difficulty
in Voiding:

History of Kidney/
Bladder Disease:

Others/Comments:

OBJECTIVE
Abdomen
Tender:
Soft/Firm:

Palpable Mass:

Size/Girth:

Other comments:
Bowel Sounds:

Bladder Palpable:

Distended:

FOOD AND FLUIDS

SUBJECTIVE
Usual Diet:

No. of Meals a Day:

Last Meal Intake:

Loss of Appetite:

Nausea/Vomiting:

Dentures:

Allergies/Food
Intolerance:

Heartburn/Indigestion:

Swallowing Problems:

10
 Weight
Usual:

Changes:

Diuretics:

OBJECTIVE
Current Weight:

Height:

Body Build:

Skin Turgor:

Mucous Membranes:

Hernia/Masses:

Edema: General
Dependent:

Periorbital:

Ascites:

Thyroid Enlarged:

Halitosis:

Condition of Teeth:

Appearance of Tongue:

Others/Comments:

HYGIENE
SUBJECTIVE
Activities of Daily Living
Mobility:
Hygiene:
Toileting:
Feeding:
Dressing:

11
 Others:

Equipment/ Presence of
Devices Required:
Assistance Provided by:

Others/Comments:

OBJECTIVE
General Appearance:

Manner of Dress:

Habits:

Body Odor:

Condition of Scalp:

Presence of Vermin:

Others/Comments:

NEUROSENSORY
SUBJECTIVE
Fainting Spells/
Dizziness:

Headache:

Location:

Frequency:

Tingling/Numbness/ Right arm and

Weakness Location: legs

Seizures:

Aura:

How Controlled:

Eyes
Vision Loss:

12
Last Examination:

Glaucoma:

Cataract:

Sense of Smell:

Epistaxis:

Others/Comments:

OBJECTIVE
Mental Status: Appropriate
Alert: Yes

Stuporous:

Combative:

Drowsy:

Lethargic:

Comatose:

Cooperative:

Affect:

Delusions:

Hallucinations:

Memory Able to recall

Recent: recent and
past events
Remote:

Speech Pattern:

Congruence:

Glasses:

13
 Contacts:

Hearing Aids:

Pupil Size Reaction:

Left:

Right:

Facial Droop:

Swallowing:

Handgrip/Release
Right:

Left:

Posturing:

Deep Tendon Reflex:

Paralysis:

Others/Comments:

PAIN AND COMFORT

SUBJECTIVE
Onset:

Duration:

Location:

Frequency:

Intensity (1-10):

Quality:

Description of Pain:

Precipitating Factors:

Aggravating Factors:

14
 How Relieved:

Associated Symptoms:

Others/Comments:

OBJECTIVE
Observed Symptoms:

RESPIRATION
SUBJECTIVE
Dyspnea related to:

Cough/Sputum of:

Smoker:

Packs:

Brand:

Number of Years:

Use of Respiratory Aids:

Oxygen:

Others/Comments:

OBJECTIVE
Respiratory Rate:

Depth:

Symmetry:

Use of Accessory
Muscles:

Nasal Flaring:

Fremitus:

Breath Sounds:

15
 Cyanosis:

Clubbing of Fingers:

Sputum Characteristics:

Restlessness:

Others/Comments:

SAFETY
SUBJECTIVE
Allergies/Sensitivity:

Reaction:

History of STD
(Date/Type):

Blood Transfusion
Number:

When:

History of Accidental
Injuries:

Fractures/Dislocations:

Arthritis/Unstable Joints:

Back Problems:

Changes in Moles:

Enlarged Nodes:

Prosthesis:

Ambulatory Devices:

Expression of Ideation
of Violence (Self/
Others)

16
 Others/Comments:

OBJECTIVE
Temperature:

Diaphoresis:

Skin Integrity:

Scars:

Rashes:
Lacerations:

Ulcerations:

Bruises

Blisters:

Burns (Degree %)

Drainage (Note
Location):

General Strength:

Muscle Tone:

Gait:

Paresthesia/Paralysis:

Others/Comments:

SEXUALITY
Sexually Active:

Sexual Concerns/
Difficulties:

Recent Changes in
Frequency /Interest:

17
 SOCIAL INTERACTIONS
SUBJECTIVE
Marital Status: Single

Years in Relationship:

Living with:

Concerns/Stresses: Aware of
unfaithfulness
of girlfriend
and shows
concern about
her leaving him
upon knowing
of diagnosis
Extended Family:

Other Support Person:

Role within Family

Structure:

Reports of Problems
related to Illness
Condition:

Others/Comments:

TEACHING/LEARNING
SUBJECTIVE
Dominant Language:

Literate:

Educational Level:

Health Beliefs/Practices:

ANATOMY & PHYSIOLOGY

18
 The immune system is a complex network of cells and proteins that defends the
body against infection. The immune system keeps a record of every germ (microbe)
it has ever defeated so it can recognize and destroy the microbe quickly if it enters
the body again. Abnormalities of the immune system can lead to allergic diseases,
immunodeficiencies and autoimmune disorders.

The primary components of the immune system are: The tonsils and the thymus:
These are responsible for producing antibodies, which are some of the combatants
against foreign invaders in the body. Lymphatic system: Made up of lymph nodes
and vessels, this is a network that carries lymph fluid, nutrients and waste material
between the body’s tissues and the bloodstream. The lymph nodes filter lymph fluid
as it flows through them, trapping bacteria, viruses and other invaders. These
invaders are then destroyed by special white blood cells called lymphocytes. Bone
marrow: This is the soft tissue found primarily inside the long bones of the arms,
legs, vertebrae and the pelvic bones in the body. It’s made of red marrow, which
produces red and white blood cells along with platelets and yellow marrow. Yellow
marrow contains fat and connective tissue and helps produce some white blood
cells. Spleen: The spleen filters the blood by removing old or damaged cells or
platelets. It also helps the immune system by destroying bacteria and other invaders.
White blood cells: Made in the bone marrow, these cells protect your body from
infection. If an infection develops, white blood cells attack and destroy the organism
causing it, whether it’s bacteria, a virus or another organism.

Key cells in your immune system, lymphocytes known as B and T cells, help
destroy invaders within the lymphatic system. Their process goes as follows: After T
cells develop in the thymus, all immune system cells gather in the lymph nodes and
spleen. First, antigens are ingested and partially digested. They are then presented
to helper T cells by other cells called macrophages. This activates the T cells to
release hormones that help B cells develop. These hormones, plus the recognition
of further antigens, change the B cell into a plasma cell that produces antibodies—
these antibodies may come in several types and will fit the antigen like a lock fits a
key, thus rendering the antigen itself harmless. Helper T cells also aid in
development of cytotoxic T cells, which can directly kill antigens. In addition, memory
T cells are produced so that any re-exposure to the same antigen will produce a
quicker and more effective response.

DIAGNOSTIC TESTS
TEST NORMAL VALUE ACTUAL RESULT SIGNIFICANCE
CBC with differential B Cells (100-600 - These cells are

19
 cells/µL; 10-15% produced from the
of total pluripotent stem cells in
lymphocytes) the bone marrow and
stay in the marrow to
mature. B cells are in
charge of antibody.
Antibody binding alerts
the immune system to
target the bound
molecule for destruction
Serum 700-1600 mg/dL - Measures the level of
immunoglobulin types of antibodies in
levels the blood. The immune
system makes
antibodies to protect the
body from bacteria,
viruses, and allergens.
The body makes
different antibodies, or
immunoglobulins, to
fight different things.

20
 DRUG STUDY
Generic Name Interferon beta-1a
Brand Name Avonex, Rebif
Dosage 30 mcg
Route IM
Frequency Per week
Preparation Inject interferon beta-1a intramuscular in your upper arms or
thighs. If you are using a prefilled auto injection pen, you can
inject interferon beta-1a intramuscular in the outer surface of
your upper thighs. Use a different spot for each injection.
Classification Immunomodulators
Indication Treatment of patients with relapsing forms of multiple sclerosis
to slow the accumulation of physical disability and decrease
the frequency of clinical exacerbations.
Mechanism of Interferon beta balances the expression of pro- and anti-
Action inflammatory agents in the brain, and reduces the number of
inflammatory cells that cross the blood brain barrier. Overall,
therapy with interferon beta leads to a reduction of neuron
inflammation.

Contraindication Overactive thyroid gland. a condition with low thyroid hormone

s levels. decreased function of bone marrow. significant anemia.
decreased blood platelets. low levels of white blood cells. low
levels of a type of white blood cell called neutrophils. mental
problems.

Adverse Body as a Whole: Alopecia, myalgias, flu-like syndrome,

Reactions anaphylaxis.
CNS: Headache, fever, fatigue, lethargy, depression,

21
 somnolence, weakness, agitation, malaise, confusion or
reduced ability to concentrate, anxiety, dementia, emotional
lability, depersonalization, suicide attempts, worsening of
psychiatric disorders.
CV: Tachycardia, CHF (rare).
GI: Nausea, vomiting, diarrhea, hepatic injury. Hematologic:
Leukopenia, thrombocytopenia, anemia, pancytopenia (rare),
thrombocytopenia (rare).
Metabolic: Hypocalcemia, elevated serum creatinine, elevated
liver transaminases. Skin: Local skin necrosis at injection site,
pain at injection site.

Side Effects  tight muscles

 dizziness

 numbness, burning, tingling, or pain in hands or feet

 joint pain

 eye problems

 runny nose

 toothache

 hair loss

 bruising, pain, redness, swelling, bleeding, or

irritation at the injection spot

Nursing  Withhold drug and notify physician if depression or

Responsibilities suicidal ideation develops or if there is a worsening of
psychiatric symptoms.
 Monitor patients with cardiac disease carefully for
worsening cardiac function.
 Lab tests: Monitor periodically liver function tests, renal
function tests, routine blood chemistry, and CBC with
differential, and platelet count. Monitor thyroid function

22
 tests q6mo with preexisting thyroid dysfunction or when
clinically indicated.
 Take a missed dose as soon as possible but not within
48 h of next scheduled dose.
 Learn about common adverse effects, especially flu-like
syndrome (headache, fatigue, fever, rigors, chest pain,
back pain, myalgia).
 Withhold drug and notify physician of depression or
suicidal ideation or exacerbation of a preexisting seizure
disorder.

Generic Name Interferon beta-1b

Brand Name Betaseron
Dosage 0.0625 mg
Route SQ
Frequency q.o.d.
Preparation Inject interferon beta-1a intramuscular in your upper arms or
thighs. If you are using a prefilled auto injection pen, you can
inject interferon beta-1a intramuscular in the outer surface of
your upper thighs. Use a different spot for each injection.
Classification Immunomodulators
Indication Treatment of patients with relapsing forms of multiple sclerosis
to slow the accumulation of physical disability and decrease
the frequency of clinical exacerbations.
Mechanism of Interferon beta balances the expression of pro- and anti-
Action inflammatory agents in the brain, and reduces the number of
inflammatory cells that cross the blood brain barrier. Overall,
therapy with interferon beta leads to a reduction of neuron
inflammation.

Contraindication Overactive thyroid gland. a condition with low thyroid hormone

s levels. decreased function of bone marrow. significant anemia.
decreased blood platelets. low levels of white blood cells. low
levels of a type of white blood cell called neutrophils. mental

23
 problems.

Adverse Body as a Whole: Alopecia, myalgias, flu-like syndrome,

Reactions anaphylaxis.
CNS: Headache, fever, fatigue, lethargy, depression,
somnolence, weakness, agitation, malaise, confusion or
reduced ability to concentrate, anxiety, dementia, emotional
lability, depersonalization, suicide attempts, worsening of
psychiatric disorders.
CV: Tachycardia, CHF (rare).
GI: Nausea, vomiting, diarrhea, hepatic injury. Hematologic:
Leukopenia, thrombocytopenia, anemia, pancytopenia (rare),
thrombocytopenia (rare).
Metabolic: Hypocalcemia, elevated serum creatinine, elevated
liver transaminases. Skin: Local skin necrosis at injection site,
pain at injection site.

Side Effects  tight muscles

 dizziness

 numbness, burning, tingling, or pain in hands or feet

 joint pain

 eye problems

 runny nose

 toothache

 hair loss

 bruising, pain, redness, swelling, bleeding, or

irritation at the injection spot

Generic Name Interferon beta-1a

24
 Brand Name Avonex, Rebif
Dosage 30 mcg
Route IM
Frequency Per week
Preparation Inject interferon beta-1a intramuscular in your upper arms or
thighs. If you are using a prefilled auto injection pen, you can
inject interferon beta-1a intramuscular in the outer surface of
your upper thighs. Use a different spot for each injection.
Classification Immunomodulators
Indication Treatment of patients with relapsing forms of multiple sclerosis
to slow the accumulation of physical disability and decrease
the frequency of clinical exacerbations.
Mechanism of Interferon beta balances the expression of pro- and anti-
Action inflammatory agents in the brain, and reduces the number of
inflammatory cells that cross the blood brain barrier. Overall,
therapy with interferon beta leads to a reduction of neuron
inflammation.

Contraindication Overactive thyroid gland. a condition with low thyroid hormone

s levels. decreased function of bone marrow. significant anemia.
decreased blood platelets. low levels of white blood cells. low
levels of a type of white blood cell called neutrophils. mental
problems.

Adverse Body as a Whole: Alopecia, myalgias, flu-like syndrome,

Reactions anaphylaxis.
CNS: Headache, fever, fatigue, lethargy, depression,
somnolence, weakness, agitation, malaise, confusion or
reduced ability to concentrate, anxiety, dementia, emotional
lability, depersonalization, suicide attempts, worsening of
psychiatric disorders.
CV: Tachycardia, CHF (rare).
GI: Nausea, vomiting, diarrhea, hepatic injury. Hematologic:
Leukopenia, thrombocytopenia, anemia, pancytopenia (rare),
thrombocytopenia (rare).
Metabolic: Hypocalcemia, elevated serum creatinine, elevated
liver transaminases. Skin: Local skin necrosis at injection site,
pain at injection site.

Side Effects  tight muscles

 dizziness

25
  numbness, burning, tingling, or pain in hands or feet

 joint pain

 eye problems

 runny nose

 toothache

 hair loss

 bruising, pain, redness, swelling, bleeding, or

irritation at the injection spot

Generic Name Interferon beta-1a

Brand Name Avonex, Rebif
Dosage 30 mcg
Route IM
Frequency Per week
Preparation Inject interferon beta-1a intramuscular in your upper arms or
thighs. If you are using a prefilled auto injection pen, you can
inject interferon beta-1a intramuscular in the outer surface of
your upper thighs. Use a different spot for each injection.
Classification Immunomodulators
Indication Treatment of patients with relapsing forms of multiple sclerosis
to slow the accumulation of physical disability and decrease
the frequency of clinical exacerbations.
Mechanism of Interferon beta balances the expression of pro- and anti-
Action inflammatory agents in the brain, and reduces the number of
inflammatory cells that cross the blood brain barrier. Overall,
therapy with interferon beta leads to a reduction of neuron
inflammation.

Contraindication Overactive thyroid gland. a condition with low thyroid hormone

s levels. decreased function of bone marrow. significant anemia.
decreased blood platelets. low levels of white blood cells. low
levels of a type of white blood cell called neutrophils. mental
problems.

26
 Adverse Body as a Whole: Alopecia, myalgias, flu-like syndrome,
Reactions anaphylaxis.
CNS: Headache, fever, fatigue, lethargy, depression,
somnolence, weakness, agitation, malaise, confusion or
reduced ability to concentrate, anxiety, dementia, emotional
lability, depersonalization, suicide attempts, worsening of
psychiatric disorders.
CV: Tachycardia, CHF (rare).
GI: Nausea, vomiting, diarrhea, hepatic injury. Hematologic:
Leukopenia, thrombocytopenia, anemia, pancytopenia (rare),
thrombocytopenia (rare).
Metabolic: Hypocalcemia, elevated serum creatinine, elevated
liver transaminases. Skin: Local skin necrosis at injection site,
pain at injection site.

Side Effects  tight muscles

 dizziness

 numbness, burning, tingling, or pain in hands or feet

 joint pain

 eye problems

 runny nose

 toothache

 hair loss

 bruising, pain, redness, swelling, bleeding, or

irritation at the injection spot

PROBLEM LISTS

27
PRIORITY NURSING DIAGNOSIS
1 Ineffective airway clearance r/t excessive nasal secretions
2 Risk for infection r/t compromised host defenses
3 Imbalance nutrition r/t history of gastrointestinal infection
4 Deficient knowledge r/t lack of information
5 Anxiety r/t threat to self-concept

NURSING CARE PLANS

ASSESSMENT
Objective: Subjective:
- Complaints of stuffy nose - None
- History of chronic respiratory
infections

DIAGNOSIS Ineffective airway clearance r/t excessive nasal secretions

PLANNING
Short Term:
At the end of 8 hours of nursing interventions the client will be able to:

 Patient will classify methods to enhance secretion removal.

 Patient will recognize the significance of changes in sputum to include
color, character, amount, and odor.
 Patient will identify and avoid specific factors that inhibit effective airway
clearance.
Long Term:
At the end of 1-2 days of nursing interventions the client will be able to:

 Patient will maintain clear, open airways as evidence by normal breath

sounds, normal rate and depth of respirations, and ability to effectively
cough up secretions after treatments and deep breaths.

28
  Patient will demonstrate increased air exchange.

INTERVENTIONS
Ongoing 1. Assess airway for patency.
Assessmen Rationale: Maintaining patent airway is always the first priority,
t especially in cases like trauma, acute neurological decompensation,
or cardiac arrest.
2. Auscultate lungs for presence of normal or adventitious breath
sounds, as in the following: decreased or absent breath sounds,
wheezing, coarse crackles, bronchospasm, expiratory grunt, etc.
Rationale: Abnormal breath sounds can be heard as fluid and mucus
accumulate. This may indicate ineffective airway clearance.
3. Assess respirations. Note quality, rate, pattern, depth, flaring of
nostrils, dyspnea on exertion, evidence of splinting, use of
accessory muscles, and position for breathing.
Rationale: A change in the usual respiration may mean respiratory
compromise. An increase in respiratory rate and rhythm may be a
compensatory response to airway obstruction.
Therapeutic Independent
Actions 4. Teach the patient the proper ways of coughing and breathing.
Rationale: The most convenient way to remove most secretions is
coughing. So it is necessary to assist the patient during this activity.
Deep breathing, on the other hand, promotes oxygenation before
controlled coughing.
5. Position the patient upright if tolerated. Regularly check the
patient’s position to prevent sliding down in bed.
Rationale: Upright position limits abdominal contents from pushing
upward and inhibiting lung expansion. This position promotes better
lung expansion and improved air exchange.
6. Encourage patient to increase fluid intake to 3 liters per day within
the limits of cardiac reserve and renal function.
Rationale: Fluids help minimize mucosal drying and maximize ciliary
action to move secretions.
7. Provide oral care every 4 hours.
Rationale: Oral care freshens the mouth after respiratory secretions
have been expectorated.
8. Pace activities especially for patients with reduced energy.
Maintain planned rest periods. Promote energy-conservation
methods.
Rationale: Fatigue is a contributing factor to ineffective coughing.
Effective coughing requires enough energy and may consume an
extra effort to the patient.
Dependent
9. Give medications as prescribed, such as antibiotics, mucolytic
agents, bronchodilators, expectorants, noting effectiveness and

29
 side effects.
Rationale:
10. Maintain humidified oxygen as prescribed.
Rationale: Increasing humidity of inspired air will reduce thickness of
secretions and aid their removal.
11. Perform nasotracheal suctioning as necessary, especially if
cough is ineffective.
Rationale: Suctioning is needed when patients are unable to cough
out secretions properly due to weakness, thick mucus plugs, or
excessive or tenacious mucus production.
Interdependent
12. Coordinate with a respiratory therapist for chest
physiotherapy and nebulizer management as indicated.
Rationale: Chest physiotherapy includes the techniques of postural
drainage and chest percussion to mobilize secretions from smaller
airways that cannot be eliminated by means of coughing or
suctioning.
13. Refer to the pulmonary clinical nurse specialist, home health
nurse, or respiratory therapist as indicated.
Rationale: Consultants may be helpful in ensuring that proper
treatments are met.
Patient 14. Educate patient on coughing, deep breathing, and splinting
Education techniques.
Rationale: Patient will understand the underlying principle and proper
techniques to keep the airway clear of secretions.
15. Provide patient understanding about the proper use of
prescribed medications and inhalers.
Rationale: Understanding prescriptions promote safe and effective
medication administration.
EVALUATION:
GOAL MET:
After 1-2 days of nursing interventions patient was able to maintain clear open
airways as evidenced by normal breath sounds, normal rate and depth of
respirations and avoiding furthermore complications.

ASSESSMENT
Objective: Subjective:
- History of chronic respiratory and - None
gastrointestinal infections
- Diagnosed with primary
immunodeficiency

DIAGNOSIS Risk for infection r/t compromised host defenses

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PLANNING
Short Term:
At the end of 8 hours of nursing interventions the client will be able to:

 Achieve timely healing of wounds/lesions.

 Identify/participate in behaviors to reduce risk of infection.
Long Term:
At the end of 1-2 days of nursing interventions the client will be able to:

 Be afebrile and free of purulent drainage/secretions and other signs of

infectious conditions.

INTERVENTIONS
Ongoing 1. Assess patient knowledge and ability to maintain opportunistic
Assessmen infection prophylactic regimen.
t Rationale: Multiple medication regimen is difficult to maintain over a
long period of time. Patients may adjust medication regimen based
on side effects experienced, contributing to inadequate prophylaxis,
active disease, and resistance.
2. Provide a clean, well-ventilated environment. Screen visitors and
staff for signs of infection and maintain isolation precautions as
indicated.
Rationale: Reduces number of pathogens presented to the immune
system and reduces possibility of patient contracting a nosocomial
infection.
3. Monitor vital signs, including temperature.
Rationale: Provides information for baseline data; frequent
temperature elevations and onset of new fever indicates that the
body is responding to a new infectious process or that medications
are not effectively controlling incurable infections.
Therapeutic Independent
Actions 4. Investigate reports of headache, stiff neck, altered vision. Note
changes in mentation and behavior. Monitor for nuchal rigidity and
seizure activity.
Rationale: Neurological abnormalities are common and may be
related to HIV or secondary infections. Symptoms may vary from
subtle changes in mood and sensorium (personality changes or
depression) to hallucinations, memory loss, severe dementias,
seizures, and loss of vision..
5. Clean patient’s nails frequently. File, rather than cut, and avoid
trimming cuticles.
Rationale: Reduces risk of transmission of pathogens through
breaks in skin. Fungal infections along the nail plate are common.
6. Inspect wounds and site of invasive devices, noting signs of local

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 inflammation and infection.
Rationale: Early identification and treatment of secondary infection
may prevent sepsis.
7. Provide oral care every 4 hours.
Rationale: Oral care freshens the mouth after respiratory secretions
have been expectorated.
8. Perform measures to break the chain of infection and prevent
infection
Rationale: An effective way of preventing the spread of infection.
Dependent
9. Administer medications antibiotics as prescribed
Rationale: To help fight infections.

Patient 10. Discuss extent and rationale for isolation precautions and
Education maintenance of personal hygiene.
Rationale: Promotes cooperation with regimen and may
lessen feelings of isolation..
11. Educate patient to report any signs of infection such as fever,
pain, etc.
Rationale: Help prevent and have early detection of infection.
EVALUATION:
GOAL MET:
After 1-2 days of nursing interventions patient was able to remain free from
infection and verbalize the importance of safety measure.

ASSESSMENT
Objective: Subjective:
- History of chronic gastrointestinal - None
infections

DIAGNOSIS Imbalance nutrition r/t history of gastrointestinal infection

PLANNING
Short Term:
At the end of 8 hours of nursing interventions the client will be able to:

 Maintain weight or display weight gain toward desired goal

Long Term:
At the end of 1-2 days of nursing interventions the client will be able to:

 Demonstrate positive nitrogen balance, be free of signs of malnutrition

and display improved energy level.

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INTERVENTIONS
Ongoing 1. Assess patient’s ability to chew, taste, and swallow.
Assessmen Rationale: Lesions of the mouth, throat, and esophagus (often
t caused by candidiasis, herpes simplex, hairy leukoplakia,
Kaposi’s sarcoma other cancers) and metallic or other taste
changes caused by medications may cause dysphagia, limiting
patient’s ability to ingest food and reducing desire to eat.
2. Auscultate bowel sounds
Rationale: Hypermotility of intestinal tract is common and is
associated with vomiting and diarrhea, which may affect choice of
diet/route. Lactose intolerance and malabsorption (with CMV, MAC,
cryptosporidiosis) contribute to diarrhea and may necessitate change
in diet or supplemental formula.
3. Weigh as indicated. Evaluate weight in terms of premorbid weight.
Compare serial weights and anthropometric measurements..
Rationale: Indicator of nutritional adequacy of intake. Because of
depressed immunity, some blood tests normally used for testing
nutritional status are not useful.
Therapeutic Independent
Actions 4. Limit food(s) that induce nausea and/or vomiting or are poorly
tolerated by patient because of mouth sores or dysphagia. Avoid
serving very hot liquids and foods. Serve foods that are easy to
swallow like eggs, ice cream, cooked vegetables.
Rationale: Pain in the mouth or fear of irritating oral lesions may
cause patient to be reluctant to eat. These measures may be
helpful in increasing food intake.
5. Provide frequent mouth care, observing secretion precautions.
Avoid alcohol-containing mouthwashes.
Rationale: Reduces discomfort associated with nausea and
vomiting, oral lesions, mucosal dryness, and halitosis. Clean mouth
may enhance appetite and provide comfort.
6. Provide rest period before meals. Avoid stressful procedures
close to mealtime.
Rationale: Minimizes fatigue; increases energy available for work of
eating and reduces chances of nausea or vomiting food.
7. Remove existing noxious environmental stimuli or conditions that
aggravate gag reflex.
Rationale: Reduces stimulus of the vomiting center in the medulla.
8. Consider six small nutrient-dense meals instead of three larger
meals daily to lessen the feeling of fullness.
Rationale: Eating small, frequent meals lessens the feeling of
fullness and decreases the stimulus to vomit.
Dependent
9. Insert or maintain nasogastric (NG) tube as indicated.
Rationale: May be needed to reduce vomiting or to administer tube
feedings. Esophageal irritation from existing infection (Candida,

33
 herpes, or KS) may provide site for secondary infections and
trauma; therefore, NG tube should be used with caution.
10. Administer appetite stimulants as indicated
Rationale: Marinol (an antiemetic) and Megace (an antineoplastic)
act as appetite stimulants in the presence of AIDS. Oxandrin is
currently being studied in clinical trials to boost appetite and
improve muscle mass and strength.

Patient 11. Encourage patient to sit up for meals.

Education Rationale: Facilitates swallowing and reduces risk of aspiration.
12. Plan diet with patient and include SO, suggesting foods from
home if appropriate. Provide small, frequent meals and snacks
of nutritionally dense foods and non-acidic foods and beverages,
with choice of foods palatable to patient. Encourage high-calorie
and nutritious foods, some of which may be considered appetite
stimulants. Note time of day when appetite is best and try to
serve larger meal at that time.
Rationale: Including patient in planning gives sense of control of
environment and may enhance intake. Fulfilling cravings for
noninstitutional food may also improve intake. In this population,
foods with a higher fat content may be recommended as tolerated
to enhance taste and oral intake.
EVALUATION:
GOAL MET:
After 1-2 days of nursing interventions patient was able to be free of signs of
malnutrition and display an improved energy level.

DISCHARGE PLAN
Medications 1. Immune serum/Immunomodulator
- substance that stimulates or suppresses the immune system
and may help the body fight cancer, infection, or other
diseases. Specific immunomodulating agents, such as
monoclonal antibodies, cytokines, and vaccines, affect
specific parts of the immune system.

Exercise 1. Promote rest and deep breathing exercises

- Help maintain a patent airway and prevent airway collapse

2. Moderate physical activity

34
 - Help reduce the risk of infection

Treatment 1. Practice good hygiene and proper hand washing

2. Encourage balance between rest and exercise.
3. Encourage frequent position changes to reduce the stasis of
secretions in the lungs.
4. Educate to comply with medications to avoid infections and
further complications.

Health 1. Instruct to avoid places with crowdy people gathering.

Education 2. Comply with medical check ups and medicatiions.

Observable 1. Instruct to report immediately if experiencing shortness of

Signs / Out- breath, chest pain, rapid heart rate, numbness or weakness.
Patient 2. Instruct patient to report any adverse effects of medications.
Follow-up 3. Remind follow up medication of gamma globulin after 3
weeks.

Diet 1. Instruct patient to consume only pasteurized milk, yogurt,

cheese and other dairy products. Avoid soft mold-ripened
and blue-veined cheeses such as Brie, Camembert,
Roquefort, Stilton, Gorgonzola and Bleu or other soft,
unpasteurized cheeses. Avoid raw sprouts, such as alfalfa
sprouts. Wash fresh fruits and vegetables before peeling.

35
 Spirituality 1. Encourage patient to follow his faith and pray to help cp[e
and reduce any stress.

LEARNING OUTCOME

On completion of this case study for our first week of virtual duty for NCM 116, I was
able to:
1. Build knowledge regarding the case given to us which is an
Immunocompromised patient.
2. Know the different diagnostic test and medications regarding this case.
3. Assess the patient regarding his case.
4. Plan nursing care that would best benefit and help my patient.
5. Created a discharge plan that would help my patient maintain optimal health
outside the hospital.

CRITICAL THINKING ANSWERS

1. Compare how primary immunodeficiencies differ from secondary
immunodeficiencies.
- Primary immunodeficiencies are the result of genetic defects, and secondary
immunodeficiencies are caused by environmental factors, such as HIV/AIDS or
malnutrition. This briefing explains the two different types of immunodeficiencies
and how they are currently treated. It also discusses the future research required
in this field to develop better curative treatments for these immune disorders.
Primary immunodeficiency (PID) – inherited immune disorders resulting from
genetic mutations, usually present at birth and diagnosed in childhood.
Secondary immunodeficiency (SID) – acquired immunodeficiency as a result of
disease or environmental factors, such as HIV, malnutrition, or medical treatment
(e.g. chemotherapy).

2. What is the most common primary immunodeficiency?

- Common primary immunodeficiencies include disorders of humoral immunity
(affecting B-cell differentiation or antibody production), T-cell defects and
combined B- and T-cell defects, phagocytic disorders, and complement
deficiencies. Major indications of these disorders include multiple infections
despite aggressive treatment, infections with unusual or opportunistic organisms,
failure to thrive or poor growth, and a positive family history. Early recognition
and diagnosis can alter the course of primary immunodeficiencies significantly
and have a positive effect on patient outcome.

36
3. Explain why patient CD is at greater risk for developing infections than his
classmates.
- Many people like patient CD with primary immunodeficiency are born missing
some of the body's immune defenses or with the immune system not working
properly, which leaves them more susceptible to germs that can cause infections.
Some forms of primary immunodeficiency are so mild they can go unnoticed for
years. Other types are severe enough that they're discovered soon after an
affected baby is born. Treatments can boost the immune system in many types
of primary immunodeficiency disorders. Research is ongoing, leading to
improved treatments and enhanced quality of life for people with the condition.

4. Before patient CD leaves you assess his knowledge and give specific
precautions. What will you assess, and what precautions will you give?
- Washing your hands often with soap and water is probably the single most
important step you can take to prevent Crypto and many other illnesses. Always
wash your hands before eating and preparing food. Wash your hands well after
touching children in diapers; after touching clothing, bedding, toilets, or bed pans
soiled by someone who has diarrhea; after gardening; any time you touch pets or
other animals; and after touching anything that might have had contact with even
the smallest amounts of human or animal stool, including dirt in your garden and
other places. Practice safer sex, infected people may have Crypto on their skin in
the anal and genital areas, including the thighs and buttocks. However, since you
cannot tell if someone has Crypto, you may want to take these precautions with
any sex partner. Avoid sexual practices that might result in oral exposure to stool
(e.g., oral-anal contact). Wash and cook food, fresh vegetables and fruits may be
contaminated with Crypto. Therefore, wash well all vegetables or fruit you will eat
uncooked. Take extra care when travelling if you travel, particularly to developing
nations, you may be at a greater risk for Crypto because of poorer water
treatment and food sanitation. Warnings about food, drinks, and swimming are
especially important in such settings. Foods and beverages, in particular raw
fruits and vegetables, tap water, ice made from tap water, unpasteurized milk or
dairy products, and items purchased from street vendors might be contaminated.
Steaming-hot foods, fruits you peel yourself, bottled and canned processed
drinks, and hot coffee or hot tea are probably safe. Talk with your health care
provider about other guidelines for travel abroad.

5. If patient CD is developing a sinus infection, what signs are you likely to

encounter on examining him?
- Sinus pressure behind the eyes and the cheeks. A runny, stuffy nose that lasts
more than a week. A worsening headache. A fever. Cough. Bad breath. Thick
yellow or green mucus draining from your nose or down the back of the throat
(postnasal drip) and fatigue.

37
 WEEK 1
REFLECTIVE JOURNAL READING

TITLE OF READING Current treatment options with

immunoglobulin G for the
individualization of care in patients with
primary immunodeficiency disease

PUBLISHED DATE 2014

SUMMARY / ABSTRACT

Primary antibody deficiencies require lifelong replacement therapy with

immunoglobulin (Ig)G to reduce the incidence and severity of infections. Both
subcutaneous and intravenous routes of administering IgG can be effective and well
tolerated. Treatment regimens can be individualized to provide optimal medical and
quality‐of‐life outcomes in infants, children, adults and elderly people. Frequency,
dose, route of administration, home or infusion‐centre administration, and the use of
self‐ or health‐professional‐administered infusion can be tailored to suit individual
patient needs and circumstances. Patient education is needed to understand the
disease and the importance of continuous therapy. Both the subcutaneous and
intravenous routes have advantages and disadvantages, which should be considered
in selecting each patient's treatment regimen. The subcutaneous route is attractive to
many patients because of a reduced incidence of systemic adverse events, flexibility
in scheduling and its comparative ease of administration, at home or in a clinic. Self ‐
infusion regimens, however, require independence and self‐reliance, good
compliance on the part of the patient/parent and the confidence of the physician and
the nurse. Intravenous administration in a clinic setting may be more appropriate in
patients with reduced manual dexterity, reluctance to self‐administer or a lack of self‐
reliance, and intravenous administration at home for those with good venous access
who prefer less frequent treatments. Both therapy approaches have been
demonstrated to provide protection from infections and improve health‐related quality
of life. Data supporting current options in IgG replacement are presented, and
considerations in choosing between the two routes of therapy are discussed.

38
PERSONAL REFLECTION

It is now possible to adjust individually the IgG administration route, infusion

technique, frequency of infusion, number of infusion sites, and volumes to suit
patients of any age or circumstance (pregnancy, infants and elderly people) with IVIG
or SCIG regimens. Measures that increase the flexibility and convenience of therapy
are important, and choices may be different for pediatric and elderly patients. These
allow the tailoring of an optimal IgG regimen to enhance compliance, strengthen
patient and provider confidence, improve HRQoL, and achieve the best possible
clinical and patient outcomes. IVIg gives you antibodies that your body is not making
on its own so you can fight infections. In autoimmune diseases like lupus, the
treatment may help your body raise low red-blood-cell counts. Not enough of these
and you can become anemic and feel very tired. One reason you might need IVIG is if
your body does not make enough antibodies. This is called "humoral
immunodeficiency" like in the case of our patient. The IVIG simply provides extra
antibodies that your body cannot make on its own. The antibodies usually last for
several weeks to months and help your body fight off a large variety of infections.

WEEKLY EVALUATION 1

SELF In our first week of duty it is a preparation for us for medical ward
rotation that we will be having. We discussed our topics this week well

39
 and I am happy to be able to learn something from them. I am adapting
well into to the online classes but I am still hoping in having face to face
classes in the future. I am learning a lot from this rotation and looking
forward to the actual duty.

PEER Our clinical instructor is very good at handling and teaching us. He
always checks if we have good internet connection and how we are
holding up in our online classes. In terms of the duty itself he is very
patient when we cannot answer his questions and gives us time to
reflect and answer the questions ourselves, he discusses the lessons
thoroughly and applies his past experience which gives us and overview
on what will happen in the operating room. Overall, he has been of a
great help to us in our online duty and rotation this week.

CI For my groupmates they are helpful. We always remind each other

about deadlines and what to do. We always got each other’s backs so
that we will all pass this subject and nursing in general together. As for
terms and questions we answer each other inquiries about the lessons.
Overall, they are all great and I love working with them.

SETTIN Internet connection is still a very big problem for me because it is

unstable and slow. The same goes for my other groupmates. But
G
overall, I am able to listen to the discussion because I am using my
mobile data as of the moment.

I have nothing else to say but this was an amazing final week and I am
OVER- sure that I will be able to adjust with the current circumstances and be
able to learn a lot from this experience and duty.
ALL

40
 REFERENCES
T. Anderson, Vincent R. Bonagura, Juthaporn Cowan, Connie Hsu, S. Shahzad
Mustafa, Niraj C. Patel, John M. Routes, Panida Sriaroon, Donald C. Vinh, Jutta H.
Hofmann, Michaela Praus, Mikhail A. Rojavin, Safety and Tolerability of Subcutaneous
IgPro20 at High Infusion Parameters in Patients with Primary Immunodeficiency:
Findings from the Pump-Assisted Administration Cohorts of the HILO Study, Journal of
Clinical Immunology, 10.1007/s10875-020-00912-5, 41, 2, (458-469), (2021).

Wayne, G. (2019, March 20). Ineffective airway clearance – nursing diagnosis &
care plan. Retrieved March 24, 2021, from https://nurseslabs.com/ineffective-airway
clearance/#:~:text=An%20ineffective%20airway%20clearance%20is, Dyspnea

Maria G. Frid, B. Alexandre McKeon, Joshua M. Thurman, Bradley A. Maron, Min

Li, Hui Zhang, Sushil Kumar, Timothy Sullivan, Jennifer Laskowsky, Mehdi A.
Fini, Samantha Hu, Rubin M. Tuder, Aneta Gandjeva, Martin R. Wilkins, Christopher J.
Rhodes, Pavandeep Ghataorhe, Jane A. Leopold, Rui-Sheng Wang, V. Michael
Holers, Kurt R. Stenmark, Immunoglobulin-driven Complement Activation Regulates
Proinflammatory Remodeling in Pulmonary Hypertension, American Journal of
Respiratory and Critical Care Medicine, 10.1164/rccm.201903-0591OC, 201, 2, (224-
239), (2020).

Dandan Luo, Gautam Baheti, Michael A. Tortorici, Jutta Hofmann, Mikhail A.

Rojavin, Pharmacometric Analysis of IgPro10 in Japanese and Non-Japanese Patients

41
With Primary Immunodeficiency, Clinical
Therapeutics, 10.1016/j.clinthera.2019.11.013, (2020).

Joanna Lechanska‐Helman, Agnieszka Sobocinska, Joanna Jerzynska, Iwona

Stelmach, The influence of hospital‐based intravenous immunoglobulin and home‐
based self‐administrated subcutaneous immunoglobulin therapy in young children with
primary immunodeficiency diseases on their parents’ / caregivers’
satisfaction, Pediatrics International, 10.1111/ped.14119, 62, 3, (316-318), (2020).
John

AUTHENTICITY STATEMENT

I herewith declare that this submission is my very own work, which to the
most effective of my information and belief, it contains no material
antecedently printed or written by another person nor material to that to a
considerable extent has been accepted for award of any degree or diploma
of a university or other institute of higher learning, except wherever due
acknowledgement is formed within the text.

I conjointly declare that the intellectual content of this case analysis is that
the product of my work, despite the fact that I’ll have received help from
others on style, presentation and language expression.

EDGIE JERIC C. FABRE 03/27/21

COMPLETE NAME DATE SUBMITTED

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