ibrahim rawhi ayasreh -case presentation

8/6/2019 Ibrahim Rawhi Ayasreh -Case Presentation

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Case Presentation

Acute Care Nursing / Practical

Pulmonary Edema

Prepared byPrepared byIbrahim AyasrehIbrahim Ayasreh

Supervised bySupervised byDr. Musa AlDr. Musa Al--HassanHassan

20092009


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Pulmonary Edema


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Pathogenesis of pulmonary Edema


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Ventilation Perfusion Match


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Signs & symptoms

Acute Dyspnea , Orthopnea

Paroxysmal nocturnal dyspnea

Crackles ,Rales, Ronchi

Wheezing

Cough, Pink frothy sputum

Tachycardia, tachypnea

Prolonged expiration phase

Accessory muscle use

Lung crepitations


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Investigations for pulmonary Edema

Chest X-rays ::

Cardiomegally, Pulmonary edema, infections , pleural effusion, etc)Cardiomegally, Pulmonary edema, infections , pleural effusion, etc)

ECG ::

Brady or tachy arrhythmias, Atrial fibrillation, ischemia, previous orBrady or tachy arrhythmias, Atrial fibrillation, ischemia, previous orsilent myocardial infarction, L.V. hypertrophysilent myocardial infarction, L.V. hypertrophy

ABGs ::

hypoxia, respiratory acidosis.hypoxia, respiratory acidosis.

Echocardiogram ::

Ejection fraction, LV size.Ejection fraction, LV size.

CBCCBC::

Hb, RBCs, WBCs, PT, PTTHb, RBCs, WBCs, PT, PTT


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Treatment

Oxygen therapy.Oxygen therapy. Diuretics: remove excess fluids from theDiuretics: remove excess fluids from the

body.body.

Digoxin: increase myocardial contractility.Digoxin: increase myocardial contractility.

Dopamine : if hypotension occur.Dopamine : if hypotension occur.

Aspirin: for all patients of CADs.Aspirin: for all patients of CADs. CPAP: if severe congestion occur.CPAP: if severe congestion occur.


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Patient Profile

Patient's namePatient's name: Salem Mahmoud: Salem Mahmoud

AgeAge: 66 yr: 66 yr

occupationoccupation : Retired: Retired

HospitalHospital: KAUH.: KAUH.WardWard: CCU.: CCU.

Admission dateAdmission date: 9 / 5 / 2009.: 9 / 5 / 2009.

Medical diagnosisMedical diagnosis: Pulmonary edema.: Pulmonary edema.

DietDiet: low sugar, low salt diet.: low sugar, low salt diet.

Physical limitationPhysical limitation: bed rest.: bed rest.

AllergiesAllergies: no history of allergy to food or drugs.: no history of allergy to food or drugs.


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Chief Compliant & Present History

Pt said: Yesterday at 8 O'clock, I came to hospital because I hadPt said: Yesterday at 8 O'clock, I came to hospital because I had

severe shortness of breathing and fatigue severe shortness of breathing and fatigue

last night, during watching TV patient experienced severe dyspnea andlast night, during watching TV patient experienced severe dyspnea and

shortness of breathing and cough associated with frothy pink sputum, inshortness of breathing and cough associated with frothy pink sputum, inaddition to severe fatigue that patient couldnt move alone even for small steps.addition to severe fatigue that patient couldnt move alone even for small steps.

He was admitted to emergency room of KAUH , the physician ordered OxygenHe was admitted to emergency room of KAUH , the physician ordered Oxygenadministration through O2 mask, and ECG was done but there is no significantadministration through O2 mask, and ECG was done but there is no significantchanges except Q wave on leads V2changes except Q wave on leads V2--V4 indicating that patient had old anteriorV4 indicating that patient had old anterior

MI, and cardiac enzymes were within normal, Blood pressure was slightlyMI, and cardiac enzymes were within normal, Blood pressure was slightlyelevated 140 /95 mmHg, heart rate was 112 beats/minute, other vital signs wereelevated 140 /95 mmHg, heart rate was 112 beats/minute, other vital signs werenormal. Xnormal. X--rays was ordered and the result indicates that there is pulmonaryrays was ordered and the result indicates that there is pulmonaryedema in both lungs , physician ordered Lasix (Furosemide) to remove excessedema in both lungs , physician ordered Lasix (Furosemide) to remove excessfluids from the body. The physician decided to admit the patient to CCU forfluids from the body. The physician decided to admit the patient to CCU forfurther monitoring and treatment.further monitoring and treatment.


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Past History & Family History

Past History:Past History:

1) Hypertension : since 26 years.1) Hypertension : since 26 years.

2) Diabetes Mellitus : since 20 years2) Diabetes Mellitus : since 20 years

3) Old anterior myocardial Infarction : before 12 years (1997).3) Old anterior myocardial Infarction : before 12 years (1997).

Family History:Family History:

-- His father is died with age of 75 years, as a result of heart attack.His father is died with age of 75 years, as a result of heart attack.

-- His mother is died, as a result of heart attack.His mother is died, as a result of heart attack.

-- His older brother is died with heart attack and was complaining of DM.His older brother is died with heart attack and was complaining of DM.

Strong Family historyStrong Family history


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Functional Assessment

@Activity/ Exercise:@Activity/ Exercise:

-- He said that he doesn't do any type of regular exercise.He said that he doesn't do any type of regular exercise.-- He said that he had severe fatigue , so simple daily activitiesHe said that he had severe fatigue , so simple daily activities

such as feeding, dressing, toileting need assistance.such as feeding, dressing, toileting need assistance.

@ Sleep:@ Sleep:

-- He said that he usually wake up during night because ofHe said that he usually wake up during night because ofshortness of breathing.shortness of breathing.

-- He cant sleep except in sitting position , because he feelHe cant sleep except in sitting position , because he feel

heaviness on chest during supine position.heaviness on chest during supine position.


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Functional Assessment

@ Nutrition:@ Nutrition:-- The patient likes to eat sweet, and he like to drink gaseous drinks.The patient likes to eat sweet, and he like to drink gaseous drinks.

-- He usually drinks tea, but with low sugar, he drinks about 12He usually drinks tea, but with low sugar, he drinks about 12

glasses of tea daily. He also doesn't like drinking coffee.glasses of tea daily. He also doesn't like drinking coffee.-- He avoid eating highHe avoid eating high--fat food .fat food .

@@ Smoking and substance use:Smoking and substance use:

-- The patient said that he smokes about 1 packet (20 cigarettes) /day.The patient said that he smokes about 1 packet (20 cigarettes) /day.-- He said that he smokes since about 45 years.He said that he smokes since about 45 years.

-- The patient doesn't take any drugs except prescribed medication forThe patient doesn't take any drugs except prescribed medication for

Hypertension ( Norvasc, Capoten) and diabetes (Glucophage,Hypertension ( Norvasc, Capoten) and diabetes (Glucophage,

Glibenclamide) , in addition to aspirin.Glibenclamide) , in addition to aspirin.


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Physical Examination

@ General survey:@ General survey:

-- Patient appeared anxious and pale in general.Patient appeared anxious and pale in general.-- Patient is alert and oriented.Patient is alert and oriented.-- No recent weight changes .No recent weight changes .-- Weight : 55 Kg. Height: 158 cm.Weight : 55 Kg. Height: 158 cm.-- BMI now is about 22.03BMI now is about 22.03 -------------------------- Normal.Normal.-- Facial expressions are symmetric and appropriate with hisFacial expressions are symmetric and appropriate with hisanxious mood and affect (furrow eyebrows and absence ofanxious mood and affect (furrow eyebrows and absence ofsmile).smile).

-- Patient at most times is in sitting position, because it is betterPatient at most times is in sitting position, because it is betterfor breathing.for breathing.


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Physical Examination

@ Respiratory System:@ Respiratory System:

- Respiratory rate is 28 breathes/ minute ( tachypnea).- Lateral diameter (72 cm) is approximately 2: 1 Anterioposterior diameter (38 cm).

- There is periodical coughs with pink frothy sputum.- Symmetrical but shallow chest expansion during breathing.- Patient use muscles other than normal such as abdominal muscles and

strneomastoid muscle

- Tactile Fremitus: Increased in Fremitus- Percussion over lungs:

There is evident dullness over the inferior parts of the lungs and scattered over thesuperior parts , indicating abnormal accumulation of fluids in lung tissues.

- Abnormal sounds of crackles are obvious and clear during auscultation over lungs,they are intermittent . They are heard at both inspiration and expiration.

- There is decreased breath sounds during auscultation related to bronchialconstriction.


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Cardiovascular system

Estimation ofjugular venous pressure:Estimation ofjugular venous pressure:

was about 2 cm above sternal angle on the vertical ruler.was about 2 cm above sternal angle on the vertical ruler.

Interpretation: JVP = (2 + 5) = 7 mmHgInterpretation: JVP = (2 + 5) = 7 mmHg ---------------- within normal.within normal.

Apical impulse is palpable at fifth intercostals space with midclavicular line.Apical impulse is palpable at fifth intercostals space with midclavicular line.

* Rate: 110 beats/ minute (tachycardia). * Rhythm: regular.* Rate: 110 beats/ minute (tachycardia). * Rhythm: regular.* Strength: weak. * Duration: very short.* Strength: weak. * Duration: very short.

Percussion of heart:Percussion of heart:

Dullness between 2nd and 6th intercostals space at left ( Cardiomegally).Dullness between 2nd and 6th intercostals space at left ( Cardiomegally).

Inspection and palpation of arms:Inspection and palpation of arms:

* Hands and arms are pale in color, with slightly cyanosed nailbeds.* Hands and arms are pale in color, with slightly cyanosed nailbeds.

* Capillary refill: previously discussed (within 4 seconds the nailbeds return* Capillary refill: previously discussed (within 4 seconds the nailbeds return

pink).pink).* Radial Pulse: 110 beats/minute, regular, weak (+1 on scale), symmetric bilaterally.* Radial Pulse: 110 beats/minute, regular, weak (+1 on scale), symmetric bilaterally.

* Blood pressure: 130 / 75 mmHg.* Blood pressure: 130 / 75 mmHg.

* Allen's test: the color returned within 7 seconds after releasing pressure over radial.* Allen's test: the color returned within 7 seconds after releasing pressure over radial.

Inspection and palpation of legs:Inspection and palpation of legs:

* Legs are pale in color, Femoral pulse: 109 beats/minute (regular, weak, symmetric).* Legs are pale in color, Femoral pulse: 109 beats/minute (regular, weak, symmetric).

* Popliteal pulses: very weak, symmetric bilaterally.* Popliteal pulses: very weak, symmetric bilaterally.

* Posterior tibialis and dorsalis pedis are not palpable.* Posterior tibialis and dorsalis pedis are not palpable.


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Subjective Data

Patient said: I can't move outside my bed, I feel fatigued rapidly

after even two steps".

Patient said: " I have a difficulty in breathing, I can't breath well

except if I in setting position

Patient said:" During sleep at night , I wakes up many times because I feel

may breathing stop, but I feel better when I go outside and

breathe fresh air".

Patient said:" Sometimes I cant do anything by my self such as bathing

or dressing , I need assistance to do these activities".

Patient said:" I feel anxious , because of inability to breathe sometimes, and

the side effects of medications such as polyuria.


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Laboratory Findings

CBC

resultresult Normal rangeNormal range

RBCsRBCs 5.1x 106 / mm35.1x 106 / mm3 WNLWNL

WBCsWBCs 6.3 x 103 mm36.3 x 103 mm3 WNLWNL

PlateletsPlatelets 200 x 103 / mm3200 x 103 / mm3 WNLWNL

HgbHgb 16.4 g/dL16.4 g/dL WNLWNL

HctHct 49 %49 % WNLWNL

PTTPTT 27 seconds27 seconds WNLWNL

PTPT 17 seconds17 seconds Increased (warfarin)Increased (warfarin)


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Laboratory Findings

ABGs

TestTest ResultsResults NoteNote

PHPH 7.327.32 DecreasedDecreased -- AcidosisAcidosis

PCO2PCO2 49 mmHg49 mmHg increasedincreased

PO2PO2 85 mmHg85 mmHg WNLWNL

O2 saturationO2 saturation 91 %91 % Slightly decreasedSlightly decreased

HCO3HCO3 25 mEq/L25 mEq/L WNLWNL


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Laboratory Findings

Blood ChemistryNa+Na+ 139 mEq/L139 mEq/L WNLWNL

K+K+ 3.9 mEq/L3.9 mEq/L WNLWNL

Ca+Ca+ 2.3 mmol/L2.3 mmol/L WNLWNL

CreatinineCreatinine 63 mol/L63 mol/L WNLWNL

BUNBUN 13 mg/dL13 mg/dL WNLWNL

CholesterolCholesterol 255 mg/dL255 mg/dL At upper border lineAt upper border line

HDLHDL 40 mg/dL40 mg/dL Must be > 40Must be > 40

For this patientFor this patient

LDLLDL 170 mg/dL170 mg/dL Slightly elevatedSlightly elevated

GlucoseGlucose 135 mg/dL135 mg/dL elevatedelevated


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Laboratory Findings

Cardiac Enzymes

TestTest Result Result

CPKCPK NegativeNegative

TroponineTroponine NegativeNegative


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Diagnostic Procedures

ECG:ECG:-- There sinus tachyarrhythmia ( P : 110 b/m).There sinus tachyarrhythmia ( P : 110 b/m).

-- There is abnormal Q wave at leads V2There is abnormal Q wave at leads V2 V4 this indicates oldV4 this indicates oldanterior MI.anterior MI.

Echocardiogram:Echocardiogram:-- Ejection Fraction: 40 %Ejection Fraction: 40 %

-- Anterior wall hypokinesia.Anterior wall hypokinesia.

-- other results are normal .other results are normal .


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Diagnostic Procedures

Chest XChest X--rays:rays:

-- There is obvious white patches at lower parts of lungs indicatingThere is obvious white patches at lower parts of lungs indicatingpulmonary edema.pulmonary edema.

-- There is white patchy area along the bronchi.There is white patchy area along the bronchi.

-- There is obvious Cardiomegally.There is obvious Cardiomegally.


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X-rays patient with PE


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Medications

Name classification Dose

& Route

Frequency

Digoxin CardiacCardiacglycosidesglycosides

40 mg40 mg

P.OP.O

1X11X1

Furosemid Loop diureticsLoop diuretics 5 mg5 mg

P.OP.O

1/2 X 11/2 X 1

Atenolol BetBet--blockersblockers

AntiAnti--hypertensivehypertensive

100 mg100 mg

P.OP.O

1/2 X 11/2 X 1

Lipitor HMGHMG--CoACoAreductasereductaseinhibitorsinhibitors

20 mg20 mg

P.OP.O

1 X 11 X 1

Zantac H2H2--blockersblockers

Antacid.Antacid.

150 mg150 mg

P.OP.O

1 X11 X1


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Nursing Diagnosis

Ineffective Airway clearanceIneffective Airway clearance related torelated to Increased bronchial secretions andIncreased bronchial secretions andbronchial constrictionbronchial constriction As manifested byAs manifested by cough and sputum productioncough and sputum production(pink, frothy), dyspnea, and X(pink, frothy), dyspnea, and X--rays show white patchy area along therays show white patchy area along thebronchi.bronchi.

Impaired Gas ExchangeImpaired Gas ExchangeRelated toRelated to accumulation of fluids in the alveoli andaccumulation of fluids in the alveoli andimpaired ventilation perfusion ratioimpaired ventilation perfusion ratioAs manifested byAs manifested by ABGs results (PCO2:ABGs results (PCO2:49 mmHg, PH: 7.32, PO2: 85mHg, SPO2: 91%), and tachypnea, Dyspnea,49 mmHg, PH: 7.32, PO2: 85mHg, SPO2: 91%), and tachypnea, Dyspnea,and fatigue, cyanosis of fingers.and fatigue, cyanosis of fingers.

Decreased cardiac outputDecreased cardiac outputRelated toRelated to inability to meet metabolic demandinability to meet metabolic demandAMB, dyspnea, & delay capillary refill (4 seconds), positive Allen's test.AMB, dyspnea, & delay capillary refill (4 seconds), positive Allen's test.


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Nursing Diagnosis

Activity intoleranceActivity intoleranceRelated toRelated to Decrease cardiac output and alteration ofDecrease cardiac output and alteration of

oxygen transportationoxygen transportationAs manifested byAs manifested by inability to walk two steps withoutinability to walk two steps without

being fatigued, severe dyspnea with exertion, and patient verbalizations .being fatigued, severe dyspnea with exertion, and patient verbalizations .

Anxiety related to breathlessness and medications side effectsAnxiety related to breathlessness and medications side effectsAsAs

manifested bymanifested bypatient verbalization and facial expressions.patient verbalization and facial expressions.


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PlanningPlanning

Goals:Goals:

-- To improve airway clearance and potency.To improve airway clearance and potency.

-- To maintain optimal gas exchange.To maintain optimal gas exchange.

-- To improve cardiac output.To improve cardiac output.

-- To improve patients activity tolerance.To improve patients activity tolerance.

-- To relieve anxiety.To relieve anxiety.


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PlanningPlanning

Expected outcomes ( Ineffective airway Clearance):* Patient will be able to show decrease cough

and sputum production.

* Patient will be able to report less dyspnea

and effective deep breathing.

* Patient will be able to show increased breath sounds during

auscultation.

Expected outcomes ( Impaired Gas Exchange):* Patient will be able to show ABGs within acceptable limits.

* Patient will be able to show absence of cyanosis at fingers.


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PlanningPlanning

Expected outcomes ( Decreased Cardiac Output):* Patient will be able to show return of pink color of nailbeds

within 2 seconds during capillary refill test.

* Patient will be able to show negative Allen's test.

Expected outcomes ( Activity Intolerance):* Patient will be able to show a measurable increase in

tolerance to activity with absence of dyspnea and excessive

fatigue.

* Patient's skin will remain warm and dry during activity.


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PlanningPlanning

Expected outcomes ( Anxiety):

* Patient will be able to verbalize decrease in feeling of anxiety .

* Patient will be able to show more comfortable about side effects

of medication.


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ImplementationImplementation

Ineffective airway clearanceIneffective airway clearance

Assist the patient in performing coughing and deep breathingAssist the patient in performing coughing and deep breathingexercises to enhance patients breathing and cheat expansion andexercises to enhance patients breathing and cheat expansion andto remove excess secretions from tracheobrochial tree to improveto remove excess secretions from tracheobrochial tree to improve

airways potency.airways potency.

Put patient is semiPut patient is semi Fowler position to enhance chest expansionFowler position to enhance chest expansionand improve gas exchange.and improve gas exchange.

Perform chest physiotherapy if needed to this patient which includesPerform chest physiotherapy if needed to this patient which includes

1010 --15 minutes two or three time per day of postural drainage and15 minutes two or three time per day of postural drainage andchest percussion to mobilize secretions in smaller airways that cantchest percussion to mobilize secretions in smaller airways that cantbe removed by coughing or suctioning.be removed by coughing or suctioning.

CPAPCPAP


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CPAPCPAP


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Impaired Gas ExchangeImpaired Gas Exchange

Maintain oxygen administration device as ordered, attempting toMaintain oxygen administration device as ordered, attempting tomaintain oxygen saturation at 90% or greater. This provides formaintain oxygen saturation at 90% or greater. This provides foradequate oxygenation.adequate oxygenation.

Position patient in highPosition patient in high--Fowlers position to facilitateFowlers position to facilitateventilation/perfusion matching.ventilation/perfusion matching.

Assess arterial blood gases regularly to assess the level of oxygenAssess arterial blood gases regularly to assess the level of oxygenand carbon dioxide , and to assess the effectiveness of therapeuticand carbon dioxide , and to assess the effectiveness of therapeutic

interventions.interventions.

Give diuretics as doctor order to remove excess water from theGive diuretics as doctor order to remove excess water from thealveoli.alveoli.

Assess skin color for development of cyanosis, as result of hypoxiaAssess skin color for development of cyanosis, as result of hypoxia


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Decreased Cardiac OutputDecreased Cardiac Output

Give Digoxin and other inotropic medication as doctor order.Give Digoxin and other inotropic medication as doctor order.

Maintain optimal fluid balance.Maintain optimal fluid balance.

Maintain physical and emotional rest :Maintain physical and emotional rest :

1) Restrict activity.1) Restrict activity. This reduces oxygen demands.This reduces oxygen demands.

2) Provide quiet, relaxed environment.2) Provide quiet, relaxed environment. Emotional stress increasesEmotional stress increasescardiac demands.cardiac demands.

3) Organize nursing and medical care.3) Organize nursing and medical care. This allows rest periods.This allows rest periods.


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ActivityActivity intoleranceintolerance Assess the levels of oxygen in the blood (by evaluating ABGs), because decreased bloodAssess the levels of oxygen in the blood (by evaluating ABGs), because decreased blood

supplysupplyis one of the most causes of fatigue and activity intolerance.is one of the most causes of fatigue and activity intolerance.

Encourage the patient to do energy conservative techniques such as:Encourage the patient to do energy conservative techniques such as:a) Sitting to do tasksa) Sitting to do tasks Standing requires more work.Standing requires more work.b) Pushing rather than pulling exercises is encouraged.b) Pushing rather than pulling exercises is encouraged.c) Sliding rather than lifting exercise.c) Sliding rather than lifting exercise.d) Resting for at least 1 hour after meals before starting a new activity.d) Resting for at least 1 hour after meals before starting a new activity.

Assist with Activities of daily living (ADLs) as indicated; however, avoid doing for patient whatAssist with Activities of daily living (ADLs) as indicated; however, avoid doing for patient whathe or she can do for self. Assisting the patient with ADLs allows for conservation of energy.he or she can do for self. Assisting the patient with ADLs allows for conservation of energy.Caregivers need to balance providing assistance with facilitating progressive endurance that willCaregivers need to balance providing assistance with facilitating progressive endurance that willultimately enhance the patient's activity tolerance and selfultimately enhance the patient's activity tolerance and self--esteem.esteem.

Progress activity gradually, as with the following:Progress activity gradually, as with the following:

a) Active rangea) Active range--ofof--motion (ROM) exercises in bed, progressing to sittingmotion (ROM) exercises in bed, progressing to sittingand standingand standing

b) Dangling 10 to 15 minutes three times daily.b) Dangling 10 to 15 minutes three times daily.c) Deep breathing exercises three times daily.c) Deep breathing exercises three times daily.d) Sitting up in chair 30 minutes three times dailyd) Sitting up in chair 30 minutes three times dailye) Walking in room 1 to 2 minutes three times dailye) Walking in room 1 to 2 minutes three times dailyf) Walking in hall 25 feet or walking around the house, then slowlyf) Walking in hall 25 feet or walking around the house, then slowly

progressing, saving energy for return tripprogressing, saving energy for return trip


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AnxietyAnxiety Psychological support.Psychological support.

Provide quiet goodProvide quiet good--ventilated environment forventilated environment forpatient to decrease stress.patient to decrease stress.

Develop a trusting & caring relationship with theDevelop a trusting & caring relationship with the

patient is critical in reducing anxiety.patient is critical in reducing anxiety.

Spiritual role.Spiritual role.


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EvaluationEvaluation

1) Goal was met: (for ineffective airway clearance)1) Goal was met: (for ineffective airway clearance)

-- Patient show decrease in amount of sputum and less frequent coughs.Patient show decrease in amount of sputum and less frequent coughs.

-- Patient reports less dyspnea and no wheezing when auscultation.Patient reports less dyspnea and no wheezing when auscultation.

-- Normal breath sounds are heard better than before application ofNormal breath sounds are heard better than before application of

nursing interventions.nursing interventions.

2) Goal was met: (for impaired gas exchange)2) Goal was met: (for impaired gas exchange)

-- Last testing of ABGs results were within normal limits (PO2: 90Last testing of ABGs results were within normal limits (PO2: 90

mmHg, PCO2: 41 mmHg, PH: 7.41, O2 saturation: 94 %).mmHg, PCO2: 41 mmHg, PH: 7.41, O2 saturation: 94 %).

-- Cyanosis disappeared in the tips of fingers.Cyanosis disappeared in the tips of fingers.-- Patient became more energetic rather than previous status beforePatient became more energetic rather than previous status before

intervening, and this indicate good oxygenation.intervening, and this indicate good oxygenation.


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3) Goal was not met: (for decreased cardiac output)3) Goal was not met: (for decreased cardiac output)

-- capillary refill: the pink color return within4 seconds.capillary refill: the pink color return within4 seconds.

-- Allens test still positive ( 7 seconds).Allens test still positive ( 7 seconds).

4) Goal was partially met: (for activity intolerance)4) Goal was partially met: (for activity intolerance)

-- The patient now is able only to move inside his bed, such as taking aThe patient now is able only to move inside his bed, such as taking a

glass of water, responds to telethon at bedside.glass of water, responds to telethon at bedside.

-- The patient still have fatigue or dyspnea for some activities such asThe patient still have fatigue or dyspnea for some activities such as

dressing, walking inside his room, and he need assistance to do thesedressing, walking inside his room, and he need assistance to do these

activities.activities.


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5) Goal was met: (for Anxiety)5) Goal was met: (for Anxiety)

-- patient show more comfort to the environment andpatient show more comfort to the environment and

therapeutic regimen.therapeutic regimen.-- facial expression show smile with straight eyebrowsfacial expression show smile with straight eyebrows

(comfort)(comfort)

ibrahim rawhi ayasreh -case presentation

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