casestudy cap
TRANSCRIPT
ANGELES UNIVERSITY FOUNDATION
Angeles City
COLLEGE OF NURSING
S.Y. 2008-2009
A Case Study
COMMUNITY-ACQUIRED PNEUMONIA
In Partial Fulfilment of the Requirements in Related Learning
Experience
Submitted by:
David, Nikki Louise Kina Z.
Gutierrez, Mary Joy R.
Manalo, Ma. Adrianne V.
BSN III-15
Group 57
Submitted to:
Ms. Johana L. Dimla, R.N.
September 19, 2008
TABLE OF CONTENTS
DEDICATION
ACKNOWLEDGEMENT
I. INTRODUCTION…………………………………………………………………
…….1
II. NURSING ASSESSMENT
A. Demographic Data, Socio Economic, Cultural
And Environmental Factors……………………………
B. Personal
History……………………………………………………….
C. Pertinent Family Health
History……………………………………..
D. History of Past
illness…………………………………………………
E. History of Present
Illness…………………………………………….
F. Physical Examination
(IPPA, Cephalocaudal Approach)
G. Diagnostic and Laboratory
Procedures……………………………
III. ANATOMY AND
PHYSIOLOGY……………………………………………………
IV. THE PATIENTS ILLNESS
A. Synthesis of the disease
1. Definition of the disease…………………………………………
2. Predisposing and Precipitating Factors………………………
3. Signs and Symptoms…………………………………………
4. Health promotion and preventive aspects of the
disease…
V. THE PATIENT AND HIS/HER CARE
Medical Management
A. IVF’s……………………………………………………………………
.
B. Drugs………………………………………………………………
C. Diet…………………………………………………………………….
D. Activity and Exercise………………………………………………
Nursing Management:
A. Nursing Care Plans………………………………………………
B. Actual SOAPIER’s………………………………………………
VI. CLIENT’S DAILY PROGRESS IN THE HOSPITAL
A. Client’s Daily Progress Chart……………………………………
B. Discharge Planning……………………………………………….
1.General Conditions of the Patient Upon Discharge
2.M.E.T.H.O.D.
VII. CONCLUSION AND
RECOMMENDATIONS…………………………………
VIII. BIBLIOGRAPHY
DEDICATION
We would like to dedicate this fruit of our toiling to our Heavenly
Father, our Almighty God, for without Him our case would be unfeasible.
To our parents, friends, brothers and sisters in the nursing profession
and to every person who has an affinity to this profession, we dedicate this to
all of you. Moreover, we offer this to those who strive hard to raise the notch
for the development and improvement of the noblest profession on earth –
the nursing profession.
ACKNOWLEDGEMENT
The aim of this study was attained through the help and guidance of
the following people who have extended their time, support and
encouragements to make this study possible.
The researchers would like to express their appreciation and give
thanks to the Almighty Father, the source of their talent, now more than ever,
and for bestowing upon us patience, strength, wisdom and determination
that helped us to materialize this study.
To their loving families, for providing all the love and care, for always
being there to give guidance and care in times of difficulties and for the
support they have given form the start of this study.
To Ms. Johana L. Dimla, their clinical instructor, for all the patience,
advice and undying support and kindness. Her mere guidance enables us to
produce the best result.
To their patient and the significant others, for their cooperation and
willingness to participate in this study and for providing them essential
information about this study and making their doors open.
Finally, to many unnamed friends, for their support and serving as their
inspiration that helped them believe in their capabilities, we would like to
extend our deepest gratitude.
I. INTRODUCTION
Pneumonia is an infection of the lower respiratory tract caused by
bacteria, viruses, fungi, protozoa, or parasites. It is the eighth leading cause
of death in the United States. The incidence and mortality of pneumonia are
highest in the elderly. Risk factors for pneumonia include advanced age,
immunocompromise, underlying lung disease, alcoholism, altered
consciousness, smoking, endotracheal intubation, malnutrition, and
immobilization. The causative microorganisms influence the symptoms and
signs with which the patient presents, how the pneumonia should be treated
and the prognosis.
Pneumonias can be classified into several ways. Pathologists originally
classified them according to the anatomic changes that were found in the
lungs during autopsies. As more became known about the microorganisms
causing pneumonia, a microbiologic classification arose, and with the advent
of x-rays, radiological classification. Another important system of
classification is the combined clinical classification, which combines factors
such as age, risk factors for certain microorganism, the presence of
underlying lung disease and underlying systemic disease, and whether the
person has recently been hospitalized.
The combined clinical classification, now the most commonly used
classification scheme, attempt to identify the person’s risk factors when he or
she first comes to medical attention. The advantage of this classification
scheme over previous systems is that it can help guide the selection of
appropriate initial treatments even before the microbiologic cause of
pneumonia is known. There are two broad categories of pneumonia in this
scheme: community-acquired pneumonia and hospital-acquired pneumonia.
A recently introduced type of healthcare-associated pneumonia lies between
this two categories.
Community-acquired pneumonia develops in people with limited or no
contact with medical institutions or settings. CAP tends to be caused by
different microorganisms than those infections acquired in the hospitals. The
characteristics of the individual are important in determining which etiologic
microorganism is likely. For example, immunocompromised persons tend to
be susceptible to opportunistic infections that are uncommon in normal
adults. In general, nosocomial infections and those affecting
immunocompromised individuals have higher mortality rate community-
acquired pneumonias.
The most common community-acquired pneumonia is caused by
Streptococcus pneumoniae, which has a relatively low mortality rate,
although it is higher in the elderly. Mycoplasma pneumoniae is a common
cause of pneumonia in young people especially those living in group housing
such as dormitories and army barracks. Influenza is the most common viral
community-acquired pneumonia in adults. Legionella species, which also
cause CAP, can contaminate cooling systems and water supplies leading to
outbreaks of disease. Signs and symptoms of CAP are fever, cough, dyspnea,
tachypnea and tachycardia. Diagnosis is based on clinical presentation and
chest x-ray. Treatment is with empirically chosen antibiotics. Prognosis is
excellent for relatively young and healthy patients, but many pneumonias,
especially when caused by Streptococcus pneumoniae and influenza virus,
are fatal in older, sicker patients.
According to the World Health Report by the World Health
Organization, lower respiratory infections, which include community-acquired
pneumonia, ranks ninth among the leading causes of mortality on individuals
aging 15 to 59 worldwide and ranks fourth on individuals aging 60 and over,
and that it is the leading killer of children worldwide.
CAP is one of the most common entities seen in Filipino adults. It is the
most common infectious disease prompting hospitalization and the first and
fifth leading cause of morbidity and mortality in the Philippines, respectively.
Incidence rates mentioned above is primarily the reason of the group
for choosing this case. The prevalence of community-acquired pneumonia in
the local and foreign communities needs attention and through this study,
CAP would be known better and would be helpful for the group to effectively
play their role as advocates of their patients care and well-being. This will
serve as an important tool for them to render proper nursing care, facilitate
health promotion and perform appropriate interventions to individuals with
such condition.
This study aims to provide the group a clear view of the pertinent facts
surrounding community-acquired pneumonia, which will lead them to become
effective and efficient in the nursing field.
II. NURSING ASSESSMENT
A. Personal History
a. Demographic Data
Mr. Cap is a 69-year old naturally born Filipino. He was born on
February 17, 1939 and is presently residing at Magalang. He was
admitted last August 17, 2008 at a district hospital somewhere in
Angeles City with a chief complain of difficulty of breathing. His
admitting diagnosis was Bronchopneumonia and Acute Gastroenteritis.
He had a final diagnosis of community-acquired Pneumonia. He was
discharged last August 25, 2008.
b. Socio-economic and Cultural Factor
Brought by their economic status in life, Mr. Cap had only
finished elementary at a public school in Magalang. After graduating in
elementary, he started working as a farmer in their own land. He got
married at an early age of 17 and became the sole provider of his
family by working as a farmer. For many years up to now, he is still the
president of the Association of Farmers in Magalang. His last job was in
the department of agriculture. He retired last 2004 at the age of 66. At
present, his source of income is their land which he tills together with
his grandson. He is earning approximately Php 100,000 a year from
their harvests, which is equivalent to Php 8, 333 per month. Having
this monthly income for the eight members of his family, they are then
considered poor.
Mr. Cap is a religious member of the Iglesia ni Cristo and never
fails to visit their church. He does not believe in hebolarios but uses
medicinal plants available in their yard like guava and oregano
whenever he has a cough.
Mr. Cap is a frequent smoker. He started smoking when he was
16 year old and started taking alcoholic beverages at the age of 27. He
starts smoking early in the morning and consumes approximately half
pack of cigarettes a day.
c. Environmental Factors
Mr. Cap has 13 children, six of which are males and seven are
females. All of them already have their own family. Twelve of them are
living away from their parents and only one, who is the youngest, lives
with her parents in their ancestral home. Mr. Cap’s family is classified
under an extended type of family with his wife, daughter, son-in-law
and three grandchildren living in the same house. They have a
bungalow type of house made of concrete materials. It has three
bedrooms, a dining room, a living room and a bathroom.
The road in their place is not cemented. Only few part is
cemented before you reach their barangay is cemented. The place
they live is not congested. Their community is quite crowded. The
location of their house is an agricultural land that is why most of the
people there are farmers. No factories or any establishments that can
contribute to air pollution are located in their vicinity. Lung diseases
are not prevalent in their community.
B. SCHEMIC DIAGRAM ON FAMILY HEALTH-ILLNESS HISTORY
Mr. Cap ranks fifth in their family. Among his seven siblings, only
four are alive. His eldest brother died of pneumonia at an early age of
age 27. His third eldest sibling died at the age of 31 whose death was
believed to have been caused by nervous breakdown. Both Mr. Cap’s
parents already passed away. His father died because of a liver
disease at the age of 35. His mother, when she was still living,
frequently experienced episodes of allergic reactions from the food she
eats. The last time she had allergies, she experienced pruritus and
difficulty of breathing which lead to her death, as narrated by Mr. Cap.
His grandparents on the maternal side both died because of old
age and they did not have any history of diabetes mellitus,
hypertension, respiratory diseases and cancer. On his paternal side, his
grandfather’s cause of death was unknown while her grandmother died
because of childbirth.
B. History of Past Illness
Mr. Cap rarely consults a physician in the past. He only visits
clinics or hospitals whenever his condition gets worse. He had been
admitted before only once in a district hospital in Angeles City around
1960s with a chief complain of epistaxis. He stayed at the hospital for
a day and a night. Also in 1960’s, he had a check-up at another district
hospital in Angeles City and was ordered to undergo chest x-ray and it
was found out that he had an accumulation of fluid in the lungs or
pleural effusion. According to Mr. Cap, aspiration of the fluid was done
after being diagnosed of such condition. Specific medications taken
cannot be recalled by Mr. Cap but prescribed medications were taken
for three months until the condition was resolved. Succeeding check-
ups at district hospital in Magalang were prompted by unrelieved fever
and cough. On mild fever and coughs, he usually does self-medication
by taking Medicol and Paracetamol. In some cases he uses herbal
plants like guava and oregano to relieve his cough which are cheaper
and always available. He has no history of diabetes mellitus, cancer or
hypertension and had not undergone any surgical procedures in the
past.
C. History of Present illness
In 1960’s, Mr. Cap had an epistaxis which prompted him to go to
the hospital. Also in 1960’s he had been diagnosed of having pleural
effusion and he had taken medications prescribed for his condition for
three months. The health problems he experienced in the past were
fever, cough and flu which he managed by taking over-the-counter
drugs and herbal plants.
Last August 10, 2008, seven days prior to his admission at a
district hospital in Magalang, Mr. Cap experienced productive cough
and fever. The next day, he still experienced cough and had difficulty
at breathing. A day prior to his admission, he experienced loose watery
stool and few hours before he was admitted, he still had difficulty of
breathing which prompted his family to bring him to the hospital. He
was then referred to a district hospital in Angeles City to better
manage his condition.
He was then admitted last August 17, 2008 with a chief
complain of difficulty of breathing and had an admitting diagnosis of
Bronchopneumonia and Acute Gastroenteritis.
D. Physical Examination
August 22. 2008
General appearance: Patient appears weak and is conscious to time,
place and person. He is afebrile with vital signs taken and recorded as
follows:
VS: BP= 130/70 mmHg; PR=104 bpm; RR= 20 bpm;
T=36.9 C/Axilla
Skin: Uniform in color, good skin turgor, pale, no edema, with skin
rashes
Skull: Round, symmetrical, normocephalic, absence of nodules and
masses
Face: Symmetrical, absence of nodules and masses
Eyes: Round and symmetrical, equally distributed eyelashes and
eyebrows, no discoloration on eyelids, eyelids close symmetrically,
blinks involuntarily, pale conjunctiva
Ears: Symmetrical with no discharges, auricles aligned with the outer
canthus of the eye
Nose: Symmetrical and straight, both nares are patent, no tenderness
Mouth: Dry and pale lips
Neck: With palpable modules on the left side of the neck,
jugular veins are not distended, neck muscles are equal in size
Chest/Lungs: Has symmetrical chest expansion, presence of rales
on both lung fields upon auscultation
Abdomen: Slightly globular in shape, with 18 bowel sounds per
minute, presence of resonance upon percussion
Extremities: Equal in size and length, absence of edema, both lower
and upper extremities move with coordination, with pale nailbeds
August 23, 2008
General Appearance: Patient is awake, coherent and conscious to
time, place and person. He is afebrite with vital signs taken and
recorcded as follws:
VS: BP=110/70 mmhg; Pr=95 bpm; rr=21 bpm; T=36.9 C/axilla
Skin: Uniform in color, good skin turgor, pale, no edema, with skin
rashes
Skull: Round, symmetrical, normocephalic, absence of nodules and
masses
Face: Symmetrical, absence of nodules and masses
Eyes: Round and symmetrical, equally distributed eyelashes and
eyebrows, no discoloration on eyelids, eyelids close symmetrically,
blinks involuntarily, pale conjunctiva
Ears: Symmetrical with no discharges, auricles aligned with the outer
canthus of the eye
Nose: Symmetrical and straight, both nares are patent, no tenderness
Mouth: Dry and pale lips
Neck: With palpable modules on the left side of the neck,
jugular veins are not distended, neck muscles are equal in size
Chest/Lungs: Has symmetrical chest expansion, presence of rales
on both lung fields upon auscultation
Abdomen: Slightly globular in shape, with 15 bowel sounds per
minute, presence of resonance upon percussion
Extremities: Equal in size and length, absence of edema, both lower
and upper extremities move with coordinatio
E. LABOORATORY AND DIAGNOSTIC PROCEDURE
Diagnostic and Laboratory Procedure :
Date OrderedDate Resulted
Indicationor
PurposesResults Normal
Values
Analysis and
Interpretation
RadiologyChest (PA)
Date Ordered :August 17, 2008
Date Resulted:August 17, 2008
Chest Radiography or x-ray yields information about the pulmonary, cardiac and skeletal systems.
Evaluate known or suspected pulmonary disorders and cardiovascular disorders.
Monitor resolution, progression or maintenance of the disease.
Nodule- haze densities are evident in the right lung with traction of the trachea rightwards and right hemi diaphragm upwards. The right apical pleuralis thickened. Hazy densities are like wise seen in the left lungs base. Heart is not enlarged body thorax is unremarkable.
Normal lung fields, cardiac size, mediastinal structures, thoracic size, ribs and diaphragm
The result shows that patient are congruent to the diagnosis of pneumonia
Nursing Responsibilities
Prior to the Procedure
Inform the patient that the procedure assess cardiopulmonary status
Obtain history of the patient symptoms and complains, including list of
known allergens
Obtain history of results of previously performed laboratory test,
surgical procedures and other diagnostic procedures
Obtain list of the medication the patient is taking
Review the procedure with the patient.
Explain to the patient that no pain will be experience during the test,
but there may be moments of discomforts
There are no food, fluid or medication restrictions unless by medical
direction
During the Procedure:
Ensure the patient has removed jewellery, dentures, all external
metallic objects, wires and the like prior to the procedure
Patient are given a gown, rob and foot coverings to wear and
instructed to void prior to the procedure
Observed standard precautions
Instruct the patient to cooperate fully and to follow directions. Instruct
the patient to remain still throughout the procedure because
movements produces unreliable result
Place the patient in the standing position in front of the x-ray film or
detector
Have the patient place hands on hips, extend neck and position
shoulders forward
Ask the patient to inhale deeply and hold his breath while the x-ray
images are taken and then exhale after the image are taken
After the Procedure:
A written report of the examination will be completed by a healthcare
provider specializing in this branch of medicine. The report will be sent
to the requesting health care practitioner who will discuss the result to
the patient.
Recognize anxiety related to test result and be supportive of impaired
activity related to respiratory capacity and perceived loss of physical
activity
Reinforce information given by the patient health care practitioner
regarding proper testing, treatment or referral to another health care
provider
Diagnostic and Laboratory Procedure :
Date OrderedDate Resulted
Indicationor
PurposesResults Normal
Values
Analysisand
Interpretation
Coplete Blood Count
Hematocrit
Hemoglobin
Date Ordered :August 17, 2008
Date Resulted:August 18, 2008
2am
Measures the concentration of WBC within the blood volume. It is used to aid diagnosis abnormal states of dehydration, polycythemia and anemia
This test evaluates blood loss, erythropoietin ability, anemia and response to therapy. It is an important component of RBC that carries oxygen and CO2 to and from the tissues.
.42
145
.40-54
140-180
The result shows that the hematocrit is within the normal suggesting that has less chance of developing hemmorhage.
The result shows that the haemoglobin is within normal range. IT suggests that there is enough number of circulating hemoglobin thus no deprivation of oxygen supply to the different body organs.
White blood Cell Count(WBC)
Red Blood Cell(RBC)
Platelet Count
Serve as a buffer to maintain acid and base balance in the extracellular fluid.
Test used to detect infection or inflammation to evaluate effectiveness of antibiotic prescribed.
Has a principal means of delivery of oxygen to the body tissues via the blood
Platelet has essential function in coagulation, homeostasis and blood thrombus formation
Confirm low platelet
5.9
4.99
233
5-10x10 9/L
4.5-6.3
150-400
The result is within the normal range
The result is within the normal range
The result is within the normal range
Lymphocytes
Segmenters
RBC
count which can be associated with bleeding
Lymphocytes play a major role in body’s natural defense system
Monitor the response on reaction to the drugs of the patient
A type of neutrophil, its primary function is in phagocytosis.
Measures blood glucose regardless of when you last eat.
0.38
0.62
118
0.10-0.48
0.66 -0.70
118-140
The result indicates with in the normal range.
This indicates that the body is has low capacity to fight against invading microorganisms.
The result is within the normal range
Nursing Responsibilities
Prior to the Procedure
Check the doctor’s order
Verify patient’s name
Inform the patient that the test is used to evaluate anemia and
hydration status and to monitor therapy.
Obtain a history of the patient’s complaints, including a list of known
allergens (especially allergies or sensitivities to latex), and inform the
appropriate health care practitioner accordingly.
Obtain a history of the patient’s cardiovascular, gastrointestinal,
hematopoietic, hepatobiliary, immune, musculoskeletal, and
respiratory systems, as well as results of previously performed
laboratory tests, surgical procedures.
Note any recent procedures that can interfere with test results.
Obtain a list of the medications the patient is taking, including herbs,
nutritional supplements so that their effects can be taken into
consideration when reviewing results.
Review the procedure with the patient. Inform the patient that
specimen collection takes approximately 5 to 10 minutes. Address
concerns about pain related to the procedure. Explain to the patient
that there may be some discomfort during venipuncture.
Sensitivity to social and cultural issues, as well as concern for modesty
is important in providing psychological support before, during and after
the procedure.
There are no food, fluid, or medication restrictions, unless by medical
direction.
During the Procedure
Instruct the patient to cooperate fully and follow directions. Direct the
patient to breathe normally and to avoid unnecessary movement.
Observe standard precautions. Positively identify the patient, and label
the tubes corresponding patient demographics, date and time of
collection. Perform a venipuncture; collect the specimen in a 5 ml
lavender top tube. The specimen should be mixed gently by inverting
the tube 10 times. The specimen should be analyzed within 4 to 6
hours; two blood smears should be made immediately after the
venipuncture and submitted with the blood sample. Smears made from
specimens older than 6 hours will contain an unacceptable number of
misleading artificial abnormalities of red blood cells as well as white
blood cells.
Remove the needle, and apply a pressure dressing over the puncture
site.
Promptly transport the specimen to the laboratory for processing and
analysis.
After the Procedure
Observe venipuncture site for bleeding or hematoma formation. Apply
paper tape or other adhesive to hold pressure bandage in place or
replace with a plastic bandage.
A written report of the examination will be sent to the requesting
health care practitioner, who will discuss the result with the patient.
Reinforce information given by the patient’s health care provider
regarding proper testing, treatment or referral to other health care
practitioner. Answer any questions or address any concerns voiced by
the patient or family.
Depending on the results of this procedure, additional testing may be
performed to evaluate or monitor progression of the disease process
and determine the need for a change in therapy. Evaluate teat results
in relation to the patient’s symptoms and other tests performed.
Diagnostic and Laboratory Procedure :
Date OrderedDate Resulted
Indicationor
PurposesResults Normal
Values
Analysisand
Interpretation
Blood Chemistry
Creatinine
Cholesterol
Date Ordered :August 17, 2008
Date Resulted:August 18, 2008
5 am
Ordered to patient to diagnose impaired renal function.
To test the total amount of fatty substance in the blood
Helps in building up cells and produce hormones
Traditional
1.7150.3
130.03.4
SI
0.4-1.735-124
150-2503.4-6.48
The result is higher than the normal range which indicates decreased function of the kidney.
The result is within the normal range
Nursing Responsibilities
Prior to the Procedure
Check the doctor’s order
Verify the patient
Explain the procedure to the patient.
Inform the patient of the sample required and that some discomfort
may be felt from the needle punctures and the pressure of the
tourniquet.
Tell patient to avoid diet high in meat. (No special preparation is
required before having a random blood sugar test.)
Check and/or validate doctor’s order.
During the Procedure
Put on gloves.
After cleaning the venipuncture site with an alcohol swab, clean it
again with a povidone-iodine swab, starting at the site and working
outward in a circular motion. Wait at least 1 minute for the skin to dry,
and then remove the residual iodine with an alcohol swab.
Apply the tourniquet.
Perform a venipuncture and draw 7 ml.
After the Procedure
Send the sample immediately in the laboratory.
The nurse focuses on nursing care of the patient and follows up
activities and observations.
You may develop a small bruise at the puncture site. You can reduce
the risk of bruising by keeping pressure on the site for several minutes
after the needle is withdrawn.
The nurse also reports the results to appropriate health team members.
Diagnostic and Laboratory Procedure :
Date OrderedDate Resulted
Indicationor
PurposesResults Normal
Values
Analysis and
Interpretation
Urinalysis Date Ordered :August 17, 2008
Date Resulted:August 18, 2008
Is used for basic screening purposes. It is a group of test that evaluate the kidney’s ability to selectively excrete and reabsorb substances while maintaining water balance
Monitor fluid imbalance
Monitor response to the drug therapy and evaluate undesired react was to drug that may impair renal function
Ordered to determine whether the urine contains substances indicate
Color : Yellow
Transparency: Clear
Ph : 6.0
Sp Gravity : 1.015
Sugar : Negative
Albumin : Trace
Microscopic findings:
Pus cells : 0.1 HPF
Light Yellow to deep amber
Clear
4-6.8
1.05-1.030
Negative
Normal/Trace
0-3
Urine color is within normal range
Urine transparency is within the normal range
Urine PH is within the normal range
Sp Gravity is within the normal range
Sugar is within the normal range
Urine albumin is within the normal range
Pus cells is within the normal range
Sputum AFB
Date Ordered :August 17, 2008
Date Resulted:August 23, 2008August 24, 2008August 25, 2008
of normally absent from urine and detected by urinalysis are proteins, glucose acetone, blood, pus and casts
This test is used to identify pathogenic organisms to determine whether malignant cells are present
RBC 0.1 HPF
Epithelial Cells : Rare
NegativeNegativeNegative
Less than 2
Few
Negative
Urine RBC is within the normal range
Epithelial cells is within the normal range
This indicates that there is absence of pathogenic microorganisms that can cause diseases such as PTB.
Nursing Responsibilities for Urinalysis
Prior to the Procedure
Inform the patient that the test is used to assist in the diagnosis of
renal diseases and as an indication of inflammatory diseases.
Obtain a history of the patient’s genitourinary, surgical procedures and
other diagnostic procedures.
Obtain a list of medication the patient is taking.
Review the procedure with the patient.
There are no food, fluid or medication restrictions, unless by medical
direction.
During the Procedure
Instruct the patient to thoroughly wash his hands, cleanse the meatus,
void a small amount in the toilet and void directly into the specimen
container.
Promptly transport the specimen to the laboratory for processing and
analysis.
After the Procedure
Instruct the patient to report symptoms such as pain related to tissue
inflammation, pain or irritation during void or alterations in urinary
elimination.
Answer any questions or address any concerns voiced by the patient or
family.
Evaluate test results in relation to the patient’s symptoms and other
test performed.
Nursing Responsibilities for Sputum AFB
Prior to the Procedure
Inform the patient that the test is used to obtain analysis to identify
pathogenic organisms and to determine whether malignant cells are
present
Obtain a list of medication the patient is taking.
Review the procedure with the patient.
There are no food, fluid or medication restrictions, unless by medical
direction.
Take the test early in the morning
During the Procedure
Instruct the patient to clear the nose and throat and rinse the mouth to
decrease contamination of the sputum.
Instruct the patient to inhale and exhale two times then inhale again
and cough rather than spit, using the diaphragm and expectorates into
a sterile container
Promptly transport the specimen to the laboratory for processing and
analysis.
After the Procedure
Instruct the patient to report symptoms such as pain related to tissue
inflammation, pain or irritation during void or alterations in urinary
elimination.
Answer any questions or address any concerns voiced by the patient or
family.
Evaluate test results in relation to the patient’s symptoms and other test
performed.
Diagnostic and Laboratory Procedure :
Date OrderedDate Resulted
Indicationor
PurposesResults Normal
Values
Analysisand
Interpretation
Fecalysis Date Ordered :August 17, 2008
Date Resulted:August 18, 2008
7:20 am
Fecalysis aids in this evaluation of digestive efficiency and the integrity of the stomach and intestines.
Used as a screening or diagnostic tool because its can identify substance present in, the feces such as ova and parasites so that appropriate treatment can be ordered.
Color : Brown
Consistency : Soft
Intertinal Parasites:
Negative
Brown
Bulky
Negative
The result shows that the stool have a normal color
The result shows that the consistency is normal
The results indicates that there are no ova or parasites present
Nursing Responsibilities
Prior to the Procedure
Check the doctor’s order Check the patients name and his identification band Explain to the patient ad significant others why stool specimen is being
collected
During the Procedure
Provide privacy Decrease discomforts and anxiety allow adequate time Instruct the patient’s significant others to put the specimen on the
container Collect stool specimen
After the Procedure
Ensure that the specimen labelled and laboratory acquisition form are
filed out correctly
Send the specimen to the laboratory at once
Document what you have done
III. ANATOMY AND PHYSIOLOGY
Respiratory System
The respiratory system functions to deliver the oxygen to the blood --
the transport medium of the cardiovascular system -- and to remove oxygen
from the blood. The actual exchange of oxygen and carbon dioxide occurs in
the lungs.
The respiratory centers in the brain stem (pons and medulla) control
respiration's rhythm, rate, and depth. Primary controlling factors include 1)
the concentration of carbon dioxide in the blood (high CO2 concentrations
initiate deeper, more rapid breathing) and 2) air pressure within lung tissue.
Expansion of the lungs stimulates nerve receptors (vagus nerve X) to signal
the brain to "turn off" inspiration. When the lungs collapse, the receptors give
the "turn on" signal, termed the Hering-Breuer inspiratory reflex. Other
regulators are: 3) an increase in blood pressure, which slows down
respiration; 4) a drop in blood acidity, which stimulates respiration; and 5) a
sudden drop in blood pressure, which increases the rate and depth of
respiration. Voluntary controls -- "holding one's breath" -- can also affect
respiration, but not indefinitely. Carbon dioxide build-up soon forces an
automatic start-up.
The respiratory system consists of two tracts: The upper respiratory
tract includes the nose (nasal cavity, sinuses), mouth, larynx, and trachea
(windpipe). The lower respiratory tract includes the lungs, bronchi, and
alveoli.
The two lungs, one on the right and one on the left, are the body's
major respiratory organs. Each lung is divided into upper and lower lobes,
although the upper lobe of the right lung contains a third subdivision known
as the right middle lobe. The right lung is larger and heavier than the left
lung, which is somewhat smaller in size because of the predominately left-
side position of the heart.
A clear, thin, shiny coating -- the pleura -- envelopes the lungs. The
inner, visceral layer of the pleura attaches to the lungs; the outer, parietal
layer attaches to the chest wall (thorax). Pleural fluid holds both layers in
place, in a manner similar to two microscope slides that are wet and stuck
together. The lungs are separated from each other by the mediastinum, an
area that contains the heart and its large vessels, the trachea (windpipe),
esophagus, thymus, and lymph nodes. The diaphragm, the muscle that
contracts and relaxes in breathing, separates the thoracic cavity from the
abdominal cavity.
The chart of the respiratory system shows the intricate structures
needed for breathing. Breathing is the process by which oxygen in the air is
brought into the lungs and into close contact with the blood, which absorbs it
and carries it to all parts of the body. At the same time the blood gives up
waste matter (carbon dioxide), which is carried out of the lungs when air is
breathed out.
1. The SINUSES (frontal, maxillary, and sphenoidal) are hollow spaces in the
bones of the head. Small openings connect them to the nose. The functions
they serve include helping to regulate the temperature and humidity of air
breathed in, as well as to lighten the bone structure of the head and to give
resonance to the voice.
2. The NOSE (nasal cavity) is the preferred entrance for outside air into the
respiratory system. The hairs that line the wall are part of the air-cleaning
system.
3. Air also enter through the MOUTH (oral cavity), especially in people who
have a mouth-breathing habit or whose nasal passages may be temporarily
obstructed, as by a cold or during heavy exercise.
4. The ADENOIDS are lymph tissue at the top of the throat. When they
enlarge and interfere with breathing, they may be removed. The lymph
system, consisting of nodes (knots of cells) and connecting vessels, carries
fluid throughout the body. This system helps to resist body infection by
filtering out foreign matter, including germs, and producing cells
(lymphocytes) to fight them.
5. The TONSILS are lymph nodes in the wall of the throat (pharynx) that often
become infected. They are part of the germ-fighting system of the body.
6. The THROAT (pharynx) collects incoming air from the nose and mouth and
passes it downward to the windpipe (trachea).
7. The EPIGLOTTIS is a flap of tissue that guards the entrance to the windpipe
(trachea), closing when anything is swallowed that should go into the
esophagus and stomach.
8. The VOICE BOX (larynx) contains the vocal chords. It is the place where
moving air being breathed in and out creates voice sounds.
9. The ESOPHAGUS is the passage leading from the mouth and throat to the
stomach.
10. The WINDPIPE (trachea) is the passage leading from the throat (pharynx)
to the lungs.
11. The LYMPH NODES of the lungs are found against the walls of the
bronchial tubes and windpipe.
12. The RIBS are bones supporting and protecting the chest cavity. They
move to a limited degree, helping the lungs to expand and contract.
13. The windpipe divides into the two main BRONCHIAL TUBES, one for each
lung, which subdivide into each lobe of the lungs. These, in turn, subdivide
further.
14. The right lung is divided into three LOBES, or sections. Each lobe is like a
balloon filled with sponge-like tissue. Air moves in and out through one
opening -- a branch of the bronchial tube.
15. The left lung is divided into two LOBES.
16. The PLEURA are the two membranes, actually one continuous one folded
on itself, that surround each lobe of the lungs and separate the lungs from
the chest wall.
17. The bronchial tubes are lines with CILIA (like very small hairs) that have a
wave-like motion. This motion carried MUCUS (sticky phlegm or liquid)
upward and out into the throat, where it is either coughed up or swallowed.
The mucus catches and holds much of the dust, germs, and other unwanted
matte that has invaded the lungs. You get rid of this matter when you cough,
sneeze, clear your throat or swallow.
18. The DIAPHRAGM is the strong wall of muscle that separates the chest
cavity from the abdominal cavity. By moving downward, it creates suction in
the chest to draw in air and expand the lungs.
19. The smallest subdivisions of the bronchial tubes are called BRONCHIOLES,
at the end of which are the air sacs or alveoli (plural of alveolus).
20. The ALVEOLI are the very small air sacs that are the destination of air
breathed in. The CAPILLARIES are blood vessels that are imbedded in the
walls of the alveoli. Blood passes through the capillaries, brought to them by
the PULMONARY ARTERY and taken away by the PULMONARY VEIN. While in
the capillaries the blood gives off carbon dioxide through the capillary wall
into the alveoli and takes up oxygen from the air in the alveoli.
Air Distribution
On inspiration, air enters the body through the nose and the mouth.
Nasal hairs and mucosa (mucus) filter out dust particles and bacteria and
warm and moisten the air. Less warming, filtering, and humidification occur
when air is inspired through the mouth.
Air travels down the throat, or pharynx, where two openings exist, one
into the esophagus for passage of food, and the other into the larynx (voice
box) and trachea (windpipe) for continued airflow. When food is swallowed,
the opening of the larynx (the epiglottis) automatically closes, preventing
food from being inhaled. When air is inspired, the walls of the esophagus are
collapsed, preventing air from entering the stomach. The larynx, which also
contain the vocal cords, is lined with mucus that further warms and
humidifies the air.
Air continues continues down the trachea, which branches into the
right and left bronchi. The main-stem bronchi divide into smaller bronchi,
then into even smaller tubes called bronchioles. The bronchial structures
contain hair-like, epithelial projections, called cilia, that beat rythmically to
sweep debris out of the lungs toward the pharynx for expulsion. Once in the
bronchioles, the air is at body temperature, contains 100% humidity, and is
(hopefully) completely filtered.
Bronchioles end in air sacs called alveoli -- small, thin-walled
"balloons," arranged in clusters. When you breathe in, enlarging the chest
cavity, the "balloons" expand as air rushes in to fill the vacuum. When you
breathe out, the "balloons" relax and air moves out of the lungs. It is at the
alveoli that gas exchange occurs. Tiny blood vessels, capillaries, surround
each of the alveoli. On inspiration, the concentration of dissolved oxygen is
greater in the alveoli than in the capillaries. Oxygen, therefore, diffuses
across the alveolar walls into the blood plasma. In the reverse process,
carbon dioxide concentration is greater in the blood than the alveoli, so it
passes from the blood into the alveoli and is ultimately breathed out.
As oxygen diffuses into the plasma, hemoglobin in the red blood cell
picks up the oxygen, permitting more to flow into the plasma. The oxygen-
carrying capacity of hemoglobin allows the blood to carry over 70 times more
oxygen than if the oxygen were simply dissolved in the plasma alone.
Therefore, the total oxygen uptake depends on: 1) the difference in oxygen
concentration between the blood and alveoli, 2) the healthy functioning of
the alveoli, and 3) the rate of respiration.
Pulmonary Circulation
The pulmonary circulatory circuit describes the process whereby
oxygen and carbon dioxide are delivered to and from the lungs. Oxygen-poor
blood travels to the right atrium via the inferior and superior vena cavae,
then to the right ventricle. The right ventricle subsequently pumps the blood
into the pulmonary artery, which branches to the right and left lungs. The
pulmonary arteries subdivide until reaching the arteriole, then capillary
levels. After gas exchange, the capillaries recombine to form venules and
veins. Ultimately two right and two left pulmonary veins carry oxygen-rich
blood to the heart for distribution, via the aorta/systemic circuit, to the rest of
the body.
Lung Volumes/ Capacities
The air that the lungs can hold can be divided into smaller
designations called "volumes."
The amount of air a person breathes in and out at rest is called the
Tidal Volume (Vt about 500ml). During such breathing, a person could
actually take in more air or blow more out. The additional amount a person
could inhale, such as during maximum physical activity, is called the
Inspiratory Reserve Volume (IRV 3,000 ml). The additional amount a person
could exhale is called the Expiratory Reserve Volume (ERV 1,000 ml). The
Residual Volume (RV) is the amount of air that stays in the lung even after
maximum expiration.
Breathing is an active process - requiring the contraction of skeletal
muscles. The primary muscles of respiration include the external intercostal
muscles (located between the ribs) and the diaphragm (a sheet of muscle
located between the thoracic & abdominal cavities).
The external intercostals plus the diaphragm contract to bring about
inspiration:
Contraction of external intercostal muscles > elevation of ribs &
sternum > increased front- to-back dimension of thoracic cavity >
lowers air pressure in lungs > air moves into lungs
Contraction of diaphragm > diaphragm moves downward > increases
vertical dimension of thoracic cavity > lowers air pressure in lungs > air
moves into lungs:
To exhale:
relaxation of external intercostal muscles & diaphragm > return of
diaphragm, ribs, & sternum to resting position > restores thoracic cavity
to preinspiratory volume > increases pressure in lungs > air is exhaled
Intra-alveolar pressure during inspiration & expiration
As the external intercostals & diaphragm contract, the lungs expand.
The expansion of the lungs causes the pressure in the lungs (and alveoli) to
become slightly negative relative to atmospheric pressure. As a result, air
moves from an area of higher pressure (the air) to an area of lower pressure
(our lungs & alveoli). During expiration, the respiration muscles relax & lung
volume descreases. This causes pressure in the lungs (and alveoli) to become
slight positive relative to atmospheric pressure. As a result, air leaves the
lungs.
The walls of alveoli are coated with a thin film of water & this creates a
potential problem. Water molecules, including those on the alveolar walls, are
more attracted to each other than to air, and this attraction creates a force
called surface tension. This surface tension increases as water molecules
come closer together, which is what happens when we exhale & our alveoli
become smaller (like air leaving a balloon). Potentially, surface tension could
cause alveoli to collapse and, in addition, would make it more difficult to 're-
expand' the alveoli (when you inhaled). Both of these would represent serious
problems: if alveoli collapsed they'd contain no air & no oxygen to diffuse into
the blood &, if 're-expansion' was more difficult, inhalation would be very,
very difficult if not impossible. Fortunately, our alveoli do not collapse &
inhalation is relatively easy because the lungs produce a substance called
surfactant that reduces surface tension.
Role of Pulmonary Surfactant
Surfactant decreases surface tension which increases pulmonary
compliance (reducing the effort needed to expand the lungs) and reduces
tendency for alveoli to collapse.
Partial Pressure
Partial pressure is the individual pressure exerted independently by a
particular gas within a mixture of gasses. The air we breath is a mixture of
gasses: primarily nitrogen, oxygen, & carbon dioxide. So, the air you blow
into a balloon creates pressure that causes the balloon to expand (& this
pressure is generated as all the molecules of nitrogen, oxygen, & carbon
dioxide move about & collide with the walls of the balloon). However, the
total pressure generated by the air is due in part to nitrogen, in part to
oxygen, & in part to carbon dioxide. That part of the total pressure generated
by oxygen is the 'partial pressure' of oxygen, while that generated by carbon
dioxide is the 'partial pressure' of carbon dioxide. A gas's partial pressure,
therefore, is a measure of how much of that gas is present (e.g., in the blood
or alveoli).
The partial pressure exerted by each gas in a mixture equals the total
pressure times the fractional composition of the gas in the mixture. So, given
that total atmospheric pressure (at sea level) is about 760 mm Hg and,
further, that air is about 21% oxygen, then the partial pressure of oxygen in
the air is 0.21 times 760 mm Hg or 160 mm Hg.
IV THE PATIENT’S ILLNESS (Book-based and Patient’s Centered)
Synthesis of the Disease
1. Definition of the Disease
Community- Acquired Pneumonia (CAP) is a condition caused by
Streptococcus pneumoniae (also known as the pneumococcus) which
has a relatively low overall mortality rate, although it is higher in the
elderly. Influenza is the most common viral community-acquired
pneumonia in adults. Community-Acquired Pneumonia occurs either in
the community setting or within the first 48 hours after hospitalization or
institutionalization. The need of hospitalization for CAP depends on the
severity of pneumonia. (Adrews, Nadjm, Gant, et.al. 2003)
The causative agent for CAP that requires hospitalization are most
frequently S. Pneumoniae, H. Influenzae, Legionella, Pseudomonas
aeruginosa and other gram-negative rods. CAP is a common illness and
can affect people of al ages. It often causes problems like breathing,
fever. Chest pain and cough. CAP occurs because the areas of the lung
which absorbed oxygen from the atmosphere become filled with fluid
and cannot work efficiently.
CAP occurs throughout the world and is the leading cause of illness
and death. CAP ranks as the fourth most common death in the United
Kingdom and sixth as the leading infectious cause of death when
combined with influenza in the United States. Overall, CAP mortality rate
range from less than 1% to 9% for those managed as out-patient, but
increase to 50% for those requiring ICU management ( Retrieved at
www. Medscape.com/viewarticle/475218 accessed on August 29, 2008
10:20 pm) The Global burden of the disease study publish by the World
Health Organization ranks pneumonia as the third leading cause of
mortality. Ass of 2002there were 3.8 million or 6.8% deaths out of the
6.1 billion total estimated population (Brunner, 2008)
In the Philippines, pneumonia ranks as the 4th leading cause of
morbidity and 3rd leading cause of mortality based on the latest health
statistics report of the Department of Health. The morbidity and
mortality tred for pneumonia has fallen from 96.7 deaths per 100,000
populations to 49 deaths per 100,000 populations. (Philippine Health
Statistics, 2006)
2. Predisposing and Precipitating Factors
Predisposing / Non- modifiable factors
a. Age
Most common in people younger than 60 years of age without
comorbidity and in those 60 years and older among at risk
factors for the development of CAP
b. Race
African- American has higher rates of Community Acquired
pneumonia than among whites.
c. Gender
CAP is most common among men than in women due to their
lifestyle such as smoking and drinking.
d. Seasonality
It is most prevalent during winter and spring, where Upper
Respiratory Tract infections are frequent.
e. Medical History and Treatments
Those people who have illness such as diabetes, HIV infection,
Bronchielectasis, Neutropenia, COPD and other factors involving
microorganisms.
Precipitating / Modifiable Factors
a. Lifestyle
CAP can occur with people who are smoking, 2nd hand smokers
and alcohol abuse
b. Occupation
People who are expose in microorganisms especially in the
community. Laboratories, Veterinarians clinics and other
institution involving microorganisms.
c. Hygiene
Those that have a poor hygiene, improper hand washing,
perineal care, and preparing foods.
d. Poor Immune System
CAP could be common in children as well as n adults if they have
poor immune system or didn’t acquire vaccination. malnutrition
can also contribute to poor immune.
3. Signs and Symptoms
a. Pleuritic Chest pain that is aggravated by deep breathing and
coughing
Indicates of having pleural inflammation arising from parietal
pleura, which is richly supplied by sensory nerve endings
b. Rapid Rising Fever (38.5 to 40.5 °c)
Cause by release of endogenous pyrogens that reset the
hypothalamus thermostat
c. Sudden onset of chills
Due to invasion of microorganisms causing inflammatory
process
d. Tachypnea, rapid pulse and bounding
It usually increase about 10 bpm for every degee acts as
compensatory echanism for hyperthermia
e. Crackles
Due to lung congestion or consolidation
f. Wheezes
Due to accumulation of secretions the airway becomes narrowed
g. Dyspnea, cyanosis
Due to the interference in oxygen and carbon dioxide exchange
that caused hypoxemia
h. Bacteremia
The invasion of microorganisms in the body
i. Cough
Brings up a greenish and yellowish mucous due to the bacterial
invasion
4. Health Promotion and Prevention aspects of disease
Several ways to prevent infectious Community- Acquired
Pneumonia like smoking, it is important since it will not only helps to
limit lung damage but also because cigarette smoking interferes with
many of the bodies natural defenses against pneumonia.
Vaccination is also important in preventing pneumonia in
children and adults. Vaccination against Haemophilus Influenzae and
Streptococcus pneumoniae in the first year of life have greatly reduced
their role in pneumonia in children. These would also decreased
incidence of these against infections in adults because adults may
acquire infections from children. Flu vaccine prevents pneumonia and
other problems cause by the influenza virus. Furthermore, health care
workers, nursing home residents and pregnant women should receive
the vaccine. A repeat vaccination may also be required after five to ten
years, the vaccines that confers immunity against pneumococus. It is
also given to people who most at risk like those the age of 65 with
chronic heart, lung and liver disease.
Aside from vaccines, deep-breathing exercise may also help in
preventing pneumonia especially if you are in the hospital—for
example, while recovering from surgery. Drinking plenty of fluids does
not suppress, because retained secretions interfere with gas exchange
and may slow recovery. Hydration of 2-3 L/day because adequate
hydration thins and loosens pulmonary secretions. Humidification may
be used to loosen secretions and improve ventilation.
Lastly the best solution to prevent infections is proper hand
washing and sanitation. Always wash your hands frequently can
prevent the spread of viral respiratory illness, taking vitamins
especially vitamin C will also be helpful in reducing the risk for having
CAP. Avoiding stress, avoid over exertion and possible exacerbation of
symptoms.
The solution to the problem is preventing the infections rather
than curing them. As the saying goes “PREVENTION IS BETTER THAN
CURE”, these preventive measures includes avoid uncooked or
unwashed fruits and vegetables in areas when sanitation is poor, good
personal hygiene, wee protective clothing and use insect repellent are
some of the ways to prevent pneumonia.
B. Pathophysiology of Community-Acquired Pneumonia (Book-Based)
Inhalation of microorganisms
Invasion of foreign bodies in the URT
Activation of the upper airway defense mechanism, cough reflex, mucociliary clearance and nasopharyngeal defense
Pathogens begin to colonize
Pathogens enter the lower The body tries to remove Release of respiratory tract pathogen that entered the nasal
discharges upper respiratory tractDamage occurs to mucous membrane
Activation of the inflammatory process, release of chemical mediators
Histamine Bradykinin Prostaglandin Leukotriene Increase inVascular
Stimulates goblet cells Stimulate muscle spasm Chemotaxis Permeability to increase mucus that contributes to production bronchoconstriction Migration of WBC to Leaking of fluids and fluid
the site of injury shifting resulting to Accumulation of mucus Narrowing of airway accumulation of fluid insecretions in the airway Release of pyrogens the alveolar sacs contributing to the narrowing of airway Stimulates the thermoregulatory This accumulation of fluids
center of the body to reset impairs gas exchange body temperature resulting to ventilation-
Crackles Wheezes Dyspnea/ perfusion mismatch
Nasal flaring Fever Tachypnea Pallor
Chest PainPathophysiology of Community-Acquired Pneumonia (Client-Based)
Inhalation of microorganisms
Invasion of foreign bodies in the URT
Activation of the upper airway defense mechanism, cough reflex,mucociliary clearance and nasopharyngeal defense
Pathogens begin to colonize
Pathogens enter the lower
Damage occurs to mucous membrane
Activation of the inflammatory process,release of chemical mediators
Histamine Bradykinin Prostaglandin Leukotriene Increase inVascular
Stimulates goblet cells Stimulate muscle spasm Chemotaxis Permeability to increase mucus that contributes to production bronchoconstriction Migration of WBC to Leaking of fluids and fluid
the site of injury shifting resulting to Accumulation of mucus Narrowing of airway accumulation of fluid insecretions in the airway Release of pyrogens the alveolar sacs contributing to the
narrowing of airway Stimulates the thermoregulatory This accumulation of fluids
center of the body to reset impairs gas exchange
body temperature resulting to ventilation- Crackles Productive Dyspnea Nasal flaring perfusion mismatch (Aug.17-25’08) cough (Aug.17,18,24’08) (Aug.21’08) Fever
(Aug.17-25’08) (Aug.17-18’08) Tachypnea Pallor Chest
Pain (Aug.17,18, (Aug.22-23’08)
(Aug.18&24’08)19,21,22,23’08)
Malaise
(Aug.17-23’08)
V. THE PATIENT AND HIS CAREA.MEDICAL MANAGEMENT
a. Intravenous FluidsMedical
Management/Treatment
Date orderedDate performedDate changed
General Description
Indications or purpose
Client’s response to treatment
IVF: Plain Normal Saline Solution 1L x 31-
32 gtts/min
5% Dextrose and Lactated Ringer’s
DO: 8-17-8DP: 8-17-8
8-18-88-18-88-19-88-20-8
DC: 8-21-8
DO: 8-21-8DP: 8-21-8
PNSS is under isotonic solution where they have
the same concentration of
solutes (osmolarity as blood plasma).
This prevents sudden shift of
fluids & electrolytes in the body. This solution contains 154 mEq/L of Na
and Cl. It expands plasma and
interstitial volume and does not enter
the cells.
Used as a vehicle for
administration of drugs.
Source of water,
electrolytes and calories or
as an alkalinizing
agent.
The patient complied with the doctors
order.
The patient complied
Solution 1L x 31-32 gtts/min
D5NM 1L x 31-32 gtts/min
8-21-88-22-8
DC: 8-22-8
DO: 8-22-8DP: 8-22-8
8-23-88-23-88-23-88-24-88-24-88-25-8
Date Terminated:8-25-8
5% Dextrose and Lactated Ringer’s
Solution is a hypertonic infusion
raise serum osmolality by
causing a pull of fluids from the
intracellular and interstitial
compartments into the blood vessels. They act to greatly
expand the intravascular
compartment. Its shows how red
blood cells shrink when place in a
hypertonic solution.
Hypertonic solution that has osmolarity higher than serum osmolarity, when a patient receives a
hypertonic IV solution, serum
osmolarity initially increasing fluid to
To prevent electrolyte
imbalance and serve as a route for
administration for IV
medication;absorbs fluid
in the interstitial cell;replacement
of fluid, sodium,
chloride and calories
with the doctors order and the patient was able to maintain
normal hydration status.
The patient complied with the doctors
order.
be pulled from the interstitial and
intracellular compartment into the blood vessels.
Nursing ResponsibilitiesPrior to the procedure:
Ask the patients name, verify the physicians order. Explain the procedure to the patient. Explain the importance and purpose of the procedure. Assess the status of the vein to determine venipuncture site. Prepare the IV bottle and necessary materials for insertion.
During the procedure: Maintain aseptic technique. Select venipuncture site. Put on gloves and clean the insertion site. Insert catheter and initiate infusion. Hang the solution on the IV pole. Check for the patency. Regulate as ordered.
After the procedure: Label the bottle; write the name of the patient, the date, time, no. of bottle,
and the rate. Check for the patency and if it’s infusing well. Monitor patient’s response and flow of IV. Record all procedures don
Medical Management/Treat
ment
Date orderedDate performedDate changed
General Description
Indications or purpose
Client’s response to treatment
Oxygen Therapy at 3-4 lpm via nasal canula
DO: 8-17-8DP: 8-17-8
8-18-88-19-88-24-8
Oxygen occurs in atmosphere air in approximately 20-
21% concentration. It is
a colorless, tasteless gas
which is essential for maintaining life. It must be
continually supplied to body cells, since it is stored in any
parts of the body. All body cells
require oxygen in order to function and supply the
body with oxygen is fundamental to
life.
For patients experiencing dyspnea or difficulty of breathing
The patient is relieved from dyspnea and decreased patients
respiration rate.
Oxygen Therapy
Nursing ResponsibilitiesPrior to the procedure:
Ask the patient’s name, verify the physicians order. Inform the patient and patient’s SO about the procedure. Explain the importance and use of such treatment. Tell the patient that there is no pain upon administration of it.
During the procedure: Set the flow rate as prescribed. Check if there is air coming out from the tube. Place the nasal cannula in the patient. Make sure that the air delivered is humidified.
After the procedure: Assess the patient and inspect the equipment regularly. Fill up the chart and document the procedure.
Medical Management/Treatm
ent
Date orderedDate
performedDate changed
General Description
Indications or purpose
Client’s response to treatment
Nebulization: Combivent
Neb q 6
DO: 8-17-8DP: 8-17-8
8-18-88-19-88-20-88-21-88-22-88-23-88-24-88-25-8
A method of administering
medication through the use of aerosol
mist.
Bronchodilation and effective
mucous expectoration
The patient complied with the doctor’s
order and was relieved from
dyspnea.
Nursing ResponsibilitiesPrior to the procedure:
Ask the patients name, verify the physicians order. Assess the respiratory status. Explain the importance of the treatment. Be alert for adverse reactions. Make sure the equipment is clean.
During the procedure: Assist the patient in nebulization. Advice patient to:
Sit upright so that the air gets deep into his lungs. Breathe normally through the mouthpiece.
After the procedure: Document, date and time of therapy. Make sure the nebulizer is dry and clean. Monitor the patient’s status especially respiratory rate.
b. DRUGS
Name of drugs, generic
name, Brand name
Date ordered
Date performed
Date changed
Route of administration,
dosage and frequency of
administration
General action and mechanism
of action
Indications or purpose
Client’s response to the meds with
actual S/E
Generic name:
CefuroximeBrand name:
Zinacef
DO: 8-17-8DP: 8-17 8
8-23-8DC: 8-24-8
IV, 750mg TID q3 (-) ANST
General action:
AntiinfectiveMechanism of
action:Binds to
bacterial cell wall
membrane causing cell
death.
Lower respiratory
tract infections due to
s.pneumoniae
Patient complied woth the doctors
order and there are no undesirable effect experienced by the
patient.
Nursing ResponsibilitiesPrior to the procedure:
Ask the patients name, verify the physicians order. Obtain previous history of medical allergies. Explain the need for the medication. Assess for anemia, renal dysfunction. Observe the 10 rights of giving medications.
During the procedure: Check for the patency. Observe for aseptic technique. Clean the IV port with alcohol. Administer drug slowly.
After the procedure: Check for the regulation of the IVF. Document the time of the given medication. Monitor for adverse reactions.
Name of drugs, generic name,
Brand name
Date ordered
Date performed
Date changed
Route of administration,
dosage and frequency of
administration
General action and
mechanism of action
Indications or purpose
Client’s response to the meds with
actual S/E
Generic name:
Ipratropium bromide
Brand name:Combivent,
Duoneb
DO: 8-17-8DP: 8-17 8
8-18-88-19-88-20-88-21-88-22-88-23-88-24-88-25-8
Neb. (inhalation) q6
General action:Cholinergic
blocking drug and
sympathomimetic
Mechanism of action:
Ipratropium is an
anticholinergic drug that acts to inhibit the effect of acetylcholine following vagal
nerve stimulation. This
results in bronchodilation
which is primarily a local,
site specific
Treatment of COPD in those
who are on regular aerosol.
Bronchodilator therapy and
who require a second
bronchodilator.
Patient complied with the doctors order and
was relieved of dyspnea.
effect. Albuterol is a beta 2 adrenergic
agonist that also causes
bronchodilation.
Nursing ResponsibilitiesPrior to the procedure:
Ask the patients name, verify the physicians order. Assess the respiratory status. Explain the importance of the treatment. Be alert for adverse reactions. Make sure the equipment is clean.
During the procedure: Assist the patient in nebulization. Advice patient to:
Sit upright so that the air gets deep into his lungs. Breathe normally through the mouthpiece.
After the procedure: Document, date and time of therapy. Make sure the nebulizer is dry and clean. Monitor the patient’s status especially respiratory rate.
Name of drugs, generic
name, Brand name
Date ordered
Date performed
Date changed
Route of administration,
dosage and frequency of
administration
General action and mechanism
of action
Indications or purpose
Client’s response to the meds with
actual S/E
Generic name: Acetaminophe
n Brand name:Paracetamol
DO: 8-17-8DP: 8-17 8
PO, 500mg tab q4 RTC
General action:
Analgesic and Anti-pyretics
Mechanism of action:
Inhibits the synthesis of
prostaglandin that may serve as
mediators of pain and
fever, primarily in
the CNS. Have no significant
anti-inflammatory properties or GI toxicity.
It relieves pain and reduces
fever.
Patient complied with the doctor’s order and the patient’s
temperature decreases.
Nursing ResponsibilitiesPrior to the procedure:
Ask the patients name, verify the physicians order. Before giving the medication, obtain previous history of medical allergies. Assess for fever. Explain the purpose of the drug. Observe the 10 rights of giving medications.
During the procedure: Assist patient while taking the drug; offer water.
After the procedure: Monitor for decrease in temperature.
Document.
Name of drugs, generic
name, Brand name
Date ordered
Date performed
Date changed
Route of administration,
dosage and frequency of
administration
General action and mechanism
of action
Indications or purpose
Client’s response to the meds with
actual S/E
Generic name:
Loperamide HydrochlorideBrand name:
Imodium
DO: 8-17-8 – 8-25-8
DP: 8-22 8
PO, 1 tab for loose stool
General action:
Anti-diarrheal
Mechanism of action:Slows
intestinal motility by
acting on the nerve endings
and/or intraneural
ganglia embedded in the intestinal
wall. The prolonged
retention of the feces in the intestine
results in reducing the
Symptomatic relief of acute non-specific
diarrhea associated with inflammatory
bowel disease.
Patient complied with the doctor’s order
and was relieved from diarrhea.
volume of the stools,
increasing viscosity and decreasing fluid and
electrolyte loss.
Nursing ResponsibilitiesPrior to the procedure:
Ask the patients name, verify the physicians order. Before giving the medication, obtain previous history of medical allergies. Explain the purpose of the drug. Observe the 10 rights of giving medications.
During the procedure: Witness the intake of medication.
After the procedure: Monitor he patients reaction to the drug.
Document date, and time the medication was given.
Name of drugs, generic
name, Brand name
Date ordered
Date performed
Date changed
Route of administration,
dosage and frequency of
administration
General action and mechanism
of action
Indications or purpose
Client’s response to the meds with
actual S/E
Generic name:
Butamirate citrate
Brand name:Sinecod forte
DO: 8-17-8DP: 8-17-8
8-18-88-19-8Date
discontinued:8-20-8
PO, 1 tab TID General action:Cough
Suppresants
Mechanism of action:
Butamirate citrate belongs
to the anti cough
medicines of central action. Sinecod exerts expectorant,
moderate bronchodilation
, and inflammatory action. It also increases the spirometery indexes and
blood
For acute cough of any
etiology/Cough
associated with thickened mucus and impaired mucus
transport.
Patient complied with the doctor’s order and was relieved
from cough.
oxygenation.
Nursing ResponsibilitiesPrior to the procedure:
Ask the patients name, verify the physicians order. Before giving the medication, obtain previous history of medical allergies. Explain the purpose of the drug. Observe the 10 rights of giving medications.
During the procedure: Witness the intake of medication.
After the procedure: Monitor for adverse reactions like nausea, diarrhea and dizziness.
Document date, and time the medication was given.
Name of drugs, generic
name, Brand name
Date ordered
Date performed
Date changed
Route of administration,
dosage and frequency of
administration
General action and mechanism
of action
Indications or purpose
Client’s response to the meds with
actual S/E
Generic name:
CarbocisteineBrand name:
Abluent
DO: 8-20-8DP: 8-20-8
8-21-88-22-88-23-88-24-88-25-8
PO, 500mg/cap TID General action:
Mucolytics
Mechanism of action:
Its major action is on
the metabolism of
mucus producing
cells. It reduces or prevents bronchial
inflammation and
bronchospasm.
Acute and chronic
disorders of respiratory
tract associated with excessive
mucous.
Patient complied with the doctor’s order and his secretions partially loosen.
Nursing ResponsibilitiesPrior to the procedure:
Ask the patients name, verify the physicians order. Before giving the medication, obtain previous history of medical allergies. Explain the purpose of the drug. Observe the 10 rights of giving medications.
During the procedure: Witness the intake of medication.
After the procedure: Monitor he patient’s reaction to the drug.
Document date, and time the medication was given.
Name of drugs, generic
name, Brand name
Date ordered
Date performed
Date changed
Route of administration,
dosage and frequency of
administration
General action and mechanism
of action
Indications or purpose
Client’s response to the meds with
actual S/E
Generic name:
FurosemideBrand name:
Lasix
DO: 8-21-8DP: 8-21-8
8-22-88-23-88-24-8
IV, 20mg now, then q12 with bp precaution
General action:Loop diuretic
Mechanism of action:
Inhibits the readsorption of
sadium and chloride from the loop Henle
and distal renal
tubule.Increases renal
excretion of water, sodium,
chloride, magnesium,
hydrogen and calcium.
Effectiveness persists in
For acute pulmonary
edema.
Patient complied with the doctor’s order.
Upon taking the drug, undesirable effects
were not experienced.
impaired renal function.
Nursing ResponsibilitiesPrior to the procedure:
Ask the patients name, verify the physicians order. Obtain previous history of medical allergies. Explain the need for the medication. Observe the 10 rights of giving medications.
During the procedure: Check for the patency. Observe for aseptic technique. Clean the IV port with alcohol. Administer drug slowly.
After the procedure: Check for the regulation of the IVF. Document the time of the given medication. Monitor for adverse reactions.
Name of drugs, generic
name, Brand name
Date ordered
Date performed
Date changed
Route of administration,
dosage and frequency of
administration
General action and mechanism
of action
Indications or purpose
Client’s response to the meds with
actual S/E
Generic name:
AzithromycinBrand name:
Zithromax
DO: 8-21-8DP: 8-21-8
8-22-88-23-8
PO, 500mg tab, 1 tab OD x 3 days
General action:
Antibiotic, macrolide
Mechanism of action:
A macrolide derived from erythromycin.
Acts by binding to the p site of the
50 s ribosomal subunit and may inhibit
RNA dependent
protein synthesis by stimulating
the
For pneumonia, and lower respiratory
tract infections.
Patient complied with the doctor’s order.
Upon taking the drug, undesirable effects
were not experienced such as
hypersensitivity reactions and GI
disturbances.
dissociation of peptidyl t-RNA
from ribosomes.
Nursing ResponsibilitiesPrior to the procedure:
Ask the patients name, verify the physicians order. Before giving the medication, obtain previous history of medical allergies. Explain the purpose of the drug. Observe the 10 rights of giving medications.
During the procedure: Witness the intake of medication.
After the procedure: Monitor he patient’s reaction to the drug.
Document date, and time the medication was given.
Name of drugs, generic
name, Brand name
Date ordered
Date performed
Date changed
Route of administration,
dosage and frequency of
administration
General action and mechanism
of action
Indications or purpose
Client’s response to the meds with
actual S/E
Generic name:
Ceftriaxone Na
Brand name:Chevron
DO: 8-24-8DP: 8-24-8
IV, 1 gm q12 General action:
Antibiotic, cephalosporins
Mechanism of action:
They kill the bacteria to
form cell walls. The bacteria
therefore break up and
die.
For lower respiratory
tract infections and
pneumonia.
Patient complied with the doctor’s order
and the occurrence of severe infection is
reduced. And also he experienced slight discomfort when infusing of the
medication is done.
Nursing ResponsibilitiesPrior to the procedure:
Ask the patients name, verify the physicians order. Obtain previous history of medical allergies. Explain the need for the medication. Observe the 10 rights of giving medications.
During the procedure: Check for the patency. Observe for aseptic technique. Clean the IV port with alcohol. Administer drug slowly.
After the procedure: Check for the regulation of the IVF. Document the time of the given medication. Monitor for adverse reactions.
Name of drugs, generic name,
Brand name
Date ordered
Date performed
Date changed
Route of administration,
dosage and frequency of
administration
General action and
mechanism of action
Indications or purpose
Client’s response to the meds with
actual S/E
Generic name:
AlbuterolBrand name:
Ventolin
DO: 8-24-8DP: 8-24-8
8-25-8
PO, 1 capsule TID General action:Sympathomimeti
c
Mechanism of action:
Stimulates beta-2 receptors of the bronchi, leading to
bronchodilation.
Prophylaxis and treatment
of bronchospasm
due to reversible
obstructive airway disease.
Patient complied with the doctor’s order and demonstrated
improvement in breathing pattern.
Nursing ResponsibilitiesPrior to the procedure:
Ask the patients name, verify the physicians order. Explain the purpose of the drug. Obtain history, assess EKG and CNS status. Assess symptom characteristics, onset, duration, frequency, and any
precipitating factors. Observe the 10 rights of giving medications.
During the procedure: Witness the intake of medication.
After the procedure: Monitor he patient’s reaction to the drug.
Document date, and time the medication was given.
c.DIET
TypeOf
Diet
Date ordered
Date performed
Date changed
General Description
Indications or purpose
Specific foods taken
Client’s response and/or reaction to
the diet
Soft Diet DO: 8-17-8DP: 8-17-8
8-18-88-19-88-20-88-21-88-22-88-23-88-24-88-25-8
The texture of food is soft. It can be
nutritionally adequate, but prophylactic
supplementation of diets with vitamins
and minerals is recommended if for
long term use.
To rest the GI tract of the
patient.
Water, grapes, gruel
Patient complied with the doctor’s order.
Nursing responsibilities:
Prior to the procedure:
Check the doctor’s order about the diet.
Identify the patient & instruct SO about the diet.
During:
Give foods in small frequent meals to check for tolerance.
Assist patient when eating & provide comfort measures.
Observe for aspiration precaution.
Avoid interruption while eating.
After:
Encourage the patient to follow the diet regimen.
Assess patient’s condition on how to respond to the diet.
TypeOf
Activity
Date ordered
Date performed
Date changed
General Description
Indications or purpose
Specific foods taken
Client’s response and/or reaction to
the diet
Complete Bed Rest
Deep Breathing Exercise
BOOK-bASEd
Patient is prohibited to
strenuous activities/ exercises.
Respiratory functioning can be facilitated by deep breathing exercises
to remove secretions from the
airways. A commonly employed
breathing exercise is abdominal
(diaphragmatic) and pursed-lip
To avoid discomfort,
restore energy, and to
decrease oxygen
consumption thus
decreasing the work load of the heart.
To enhance lung
expansion and mobilize
secretions, thereby
preventing atelectasis
and pneumonia.
Water, gruel
Water, gruel
He was able to take a rest and whenever he
wants to eat or change position he
asked for assistance.
breathing. Abdominal
breathing permits deep full breaths with little effort.
Pursed-lip breathing helps the
client develop control over
breathing. The pursed-lip create a resistance to the air flowing out of
the lungs, thereby prolonging
exhalation and preventing airway
collapse by maintaining
positive airway pressure. The client purses the lips as if
about to whistle and breaths out
slowly and gently, tightening the
abdominal muscle to exhale more
effectively.
Nursing ResponsibilitiesPrior to the procedure:
Assess for vital signs.
Check the doctors order and verify the client.
Assess hearing ability to ensure the elder client hears the information.
Explain to the client what is the importance of the activity.
During the procedure: Assist the patient in the activity.
Demonstrate deep breathing exercises.
Instruct the patient to hold his breath, then exhale slowly through the mouth.
After the procedure: Document all the teachings given and the assessment.
NURSING MANAGEMENT
Problem No. 1 Ineffective Airway Clearance
Assessme
nt
Nursing
Diagnosis
Scientific
Explanation
Planning Nursing
Intervention
Rationale Evaluation
S= patient
may
verbalize
“magkasaki
t ku
papalwal
ing plema
pag
manguku
ku.”
O=Patient
Manifeste
d the
following :
Ineffective
Airway
Clearance
related to
retained
secretions in
the bronchi
( increased
thick
mucous
secretions)
and lung
inflammatio
n leading to
accumulatio
n of mucous
in the
Community-
Acquired
Pneumonia is the
inflammation of
the lung
parenchyma
when the
offending
organism
reaches the
alveoli via
droplets or saliva
in whi8ch goblet
cells produces an
outpouring fluid
into the alveoli.
The organisms
Short Term
:
After 5
hours of
Nursing
Intervention
s, the
patient will
expectorate
mucous as
evidenced
by
productive
cough,
effective
coughing
> Assess
respiratory
status: breath
sounds,
respiratory rate,
oxygen
saturation, note
abnormalities
such as dyspnea,
presence of
cyanosis, use of
accessory
muscles, flaring
of nostrils
> Assess anxiety
and reassure
> Abnormal
breathing patterns
may signal
worsening of
condition: flaring of
nostrils indicate a
significant decline in
respiratory status:
assessment
establishes baseline
and monitor
response to
interventions
> Being unstable to
breath causes
Short
Term :
The patient
shall be
able to
expectorate
mucous as
evidenced
by
productive
cough
effective
coughing
and
breathing
exercise
>appears
weak
>pale
palpebral
conjunctiva
>ć rales on
both lung
lobes upon
chest
auscultatio
n
>ć difficulty
of
breathing
> shortness
of breath
> ć non-
alveoli multiply in the
serous fluid and
the infection is
spread. The
organisms
damage the host
by their
overwhelming
growth and
interference with
lung function
leading to
massive
accumulation of
mucus.
Disruption of the
mechanical
defenses of
cough and ciliary
motility leads to
the colonization
of the lungs and
and
breathing
exercise
Long
Term :
After 2 days
of Nursing
Intervention
s, the
patient will
maintain
airway
patency as
evidenced
by clear
breath
sounds,
absence of
dyspnea,
patient ć
presence
> Place patient
in high fowler’s
position and
support ć
overbed table as
needed.
> Encourage
expectoration of
secretions and
assess the
viscosity amount
and color of
secretions
anxiety and fear:
the patient needs a
calming presence:
anxiety increases
the demand for
oxygen
> Maximize chest
excursion and
subsequent
movement of air
> Thickened
secretions of Cap re
more likely to
occlude the airway:
making this
observation would
allow for
implementation if
Long Term
:
The patient will maintain airway patency as evidenced by clear breath sounds, absence of dyspnea, etc.
productive
cough
Patient
may
manifest
the
following :
>decreased oxygen saturation
> Cyanosis>Tachypnea
>Abnormal blood gases(decreased O2, Increased CO2)
> Restlessness
> ć
accumulation of
secretions in the
alveoli and
bronchi leading
to ineffective
airway clearance
as evidence by
non-productive
cough etc.
alveolar
exudates tend to
consolidate,
increasingly
difficult to
expectorate.
etc.
> Assist the
patient ć
coughing and
deep breathing
> Increase fluid
intake
> Provide for
periods of rest
and activity,
assisting ć
devices as
needed
> Elevate head
of bed/ change of
measures to thin
and loosen the
secretions
> Mobilizes
secretions and
prevent atelectasis
> Assists with
liquefying secretions
and enhancing
ability to clear
airways
> Decrease demand
for oxygen
Orthopnea
> Flaring of nostrils
position every 2
hours
> Assist
respiratory
therapist ć the
administration of
nebulizer
> Establish
intravenous
access as
ordered
> Assess arterial
blood gases
(ABG)
> To maintain an
open airway and to
take advantage of
gravity decreasing
pressure on the
diaphragm and
enhancing drainage
of secretions.
>This causes
bronchiodilation to
ease breathing
> Ensures a route
for rapid- acting
medications
>ABG provide data
for treatment
regarding the lungs’
> Provide
humidified
oxygen as
ordered to
maintain O2
saturation >90%
ability to oxygenate
tissues
> Loosen
secretions, making
them easier to
expectorate ć
coughing: improves
oxygenation
Problem No. 2 Impaired Gas Exchange
Assessment Nursing Scientific Planning Nursing Rationale Evaluatio
Diagnosis Explanation Intervention n
S= patient
may
verbalize
“magkasakit
ku
mangisnawa
ampo agad
ku papagal
gang
maglakad
kumu.”
O=Patient
Manifested
the
following :
>difficulty of
breathing
Impaired
Gas
Exchange
related to
inflamed
lung tissue
and
consolidati
on of
mucous /
ffluid in
specific
lung lobes
preventing
transfer of
gases
across the
alveolar
capillary
cellular
Community-
Acquired
Pneumonia is
defined as a
lower respiratory
tract infection of
the lungs
parenchyma with
onset in the
community or
during thre first
2days of
hospitalization.
Pneumonia
occurs when the
offending
organism
stimulate
inflammatory
response the
Short Term
:
After 8hours
of Nursing
Intervention
s, the
patient will
be relieved
from
dyspnea by
participating
in breathing
exercises,
effective
coughing
and use of
oxygen as
evidenced
by absent of
> Perform a
complete
respiratory
assessment ;
respiratory rate,
rhythm, chest
expansion, ease
of breathing, use
of accessory
muscles, pursed
lip breathing,
breath sounds,
mucous
expectoration,
perioral cyanosis,
tachypnea,
dyspnea, pulse
oximetry and
monitor
laboratory and
> Because airway
inflammation and
mucous
accumulation,
pneumonia can
cause fluid in the
lungs and increase
the work of
breathing, resulting
in impaired gas
exchange. These
assessment provide
data use for planning
Interventions and
assessing progress.
Sputum cultures
identify the causative
organisms, arterial
blood gases
demonstrate
Short
Term :
The
patient
shall be
relieved
from
dyspnea
by
participati
ng in
breathing
exercise,
effective
coughing
and use of
oxygen as
evidenced
by
absence of
>nasal
flaring
>shortness
of breath/
exertional
discomfort
>with
presence of
crackles on
both lung
lobes upon
auscultation
> with non
productive
cough
> easy
fatlgability
membrane defense
mechanism of
the lung lo9se
effectiveness
and allow
organisms to
penetrate the
sterile, lower
respiratory tract,
where
inflammation
develops.
Inflammation
occurs due to
colonization of
offending
organization
wherein there is
the release of
chemical
mediators,
attraction of
nasal
flaring,
shortness of
breath, easy
fatigability,
etc.
Long
Term :
After 1 to 3
days of
Nursing
Intervention
s, the
patient will
have an
improved
ventilation
and
adequate
diagnostic
procedures such
as sputum
cultures,
complete blood
count, arterial
blood gases, etc.
> Obtain
subjective data
from the patient
or significant
other, including
history of chronic
respiratory
disease and
history of
smoking
> Assist patient
to semi fowler’s
position
decreased oxygen
concentration, chest
x-ray will confirm the
presence of fluid in
the lungs or areas of
consolidation
> knowledge of the
patient respiratory
status contributes to
information that can
assist in
determination other
factors that may
have contributed to
pneumonia or
influence its
treatment
> Sitting upright
nasal
flaring,
shortness
of breath,
easy
fatigability
. Etc.
Long
Term :
The patient shall have an improved ventilation and adequate oxygenation of lung tissue as evidenced
> Patient hooked to O2 therapy 2-3 LPM
Patient may
manifest
the
following :
>abnormal blood gases / arterial ptt ( hypoxia, increase CO2 )
>Diaphoresis
>Tachycardia
> abnormal rate rhythm, depth of breathing
> abnormal
neutrophils,
accumulation of
fibrinous
exudates, red
blood cells and
macrophages.
These would in
turn trigger
erythema
swelling, edema
and stimulation
of nerve fibers,
leading to pain.
Goblet cells will
increase mucus
production in
attempt to dilute
amd wash away
offending
organisms out of
the respiratory
tract. Inflamed
oxygenation
of lung
tissue as
evidenced
by normal
arterial
blood gases,
patient will
have a clear
breath
sounds,
absence of
purulent
discharge
>Take
temperature
every 4 hours
> Provide
comfort
measures
change linen or
clothing
> Encourage
adequate fluid
intake to 2000
cc/day
> Assess mucous
allows the diaphragm
to descend, resulting
in easier breathing
> Infectious
processes can cause
an increase body
temperature
>Following
temperature spikes,
linen and clothing
may become
saturated with
perspiration
> Helps thin and
liquefy secretions
>Helps to detect
by normal arterial blood gases, clear Breathing sounds, absence of purulent discharges, etc.
skin color (pale, dusty)
> abnormal capillary refill
>Restlessness
>Confusion
>O2 saturation of less than 90%
>fever
O2
fluid-filler
alveolar sacs
cannot exchange
O2 and CO2
effectively
leading to
hypoxia of the
lung tissue and a
significant
ventilation-
perfusion
mismatch
amount, color
consistency.
>Encourage
coughing and
deep breathing
with mucous
expectoration
> Provide chest
physiotherapy
postural
drainage, chest
improving status of
pneumonia, amount
should be decreasing
and viscosity should
be thinning following
interventions; green,
brown or purulent
mucus indicate
continued presence
of pneumonia
>Coughing and deep
breathing cause
alveoli to open and
loosen mucous to
help clear the
airways
>Loosen mucous
plugs thus increasing
are available for gas
percussion and
vibration
> Elevate head
of bed
> Encourage
frequent position
changes
> Encourage
adequate rest
and limit
activities to with
in patient
tolerance.
Promote calm
and restful
environment
> Administer
oxygen as
exchange
> To maintain
airway patency
>Promotes optimal
chest expansion and
drainage of secretion
> Helps limit oxygen
needs/ consumption
>Pneumonia
increased mucous
ordered
>Administer
antibiotic as
ordered and
monitor for side
effects.
Ado
production and fluid
retention in lungs
which decreases
adequate gas
exchange;
supplemental oxygen
provides additional
oxygen for tissue
oxygenation
>Helps to stop the
proliferation of
microorganisms
Problem No. 3 Ineffective Breathing PatternAssessment Nursing
Diagnosis
Scientific
Explanation
Planning Nursing
Intervention
Rationale Evaluation
S= patient
may
verbalize
“Magkasakit
ku
mangisnawa.
”
O=Patient
Manifested
the
following :
>difficulty of
breathing
>shortness
of breath on
exertion,
paleness
Ineffective
breathing
pattern
related to
thick
tenacious
secretions
in the
bronchi
due to
inflammati
on of lung
tissue
Community-
Acquired is a
disease process
involving
inflammation of
lung tissue. It
typically results
when
microorganisams
enter the
normally sterile
lungs from the
nasopharynx and
produces
inflammation of
the lung
parenchyma.
Because of the
inflammation of
the alveoli are
filed with fluid
Short Term
:
After 4
hours of
Nursing
Intervention
s, the
patient shall
have a
normal
respiratory
rate,
rhythm,
depth and
reports a
shortness of
breath as
evidence by
decrease RR
from 38
> Assess
respiratory
system by noting
respiratory rate,
depth chest
expansion,
breath sounds,
arterial blood
gases, etc.
> Assist Patient
in assuming a
high- fowler’s
position or
position of choice
such as leaning
forward or over
bed table
> Increase oral
> Any of this
abnormalities would
indicate the studies
of the respiratory
system and
progression of
disease; also
establishes a
baseline comparison
>maximizes
thoracic cavity
space, decreases
pressure from
diaphragm and
abdominal organs
and facilitates use of
accessory muscles
>help to improve
hydration status and
Short
Term :
The patient
shall have a
normal
respiratory
rate,
rhythm,
depth of
breathing
and relief
from
shortness
of breath as
evidence
by
decrease
RR from 38
cpm to 16-
20 cpm
>RR of 38
cpm with
shallow,
rapid
breathing
>use of
supraclavicul
ar muscles
for
respiration as
well as
shoulder
muscles
> ć non-
productive
cough
> with
presence of
and mucus and
oxygen and
carbon dioxide
exchange cannot
take place at a
alveolar capillary
cellular
membrane level
due to blood flow
decreases
(deceased
perfusion of
blood in the
lungs)and
leukocytes and
fibrin consolidate
in the affected
part of the lung
due to a
decreased blood
flow there is a
decreased supply
cpm to 16-
20 cpm
Long
Term :
After 2 days
of Nursing
Intervention
s, the
patient shall
be free from
any signs
and
symptoms
of hypoxia
as
evidenced
by normal
ABG, etc.
fluids to 2000-
3000 ml/day as
tolerated
> Provide chest
physiotherapy,
bronchial
tapping,
vibration, etc.
>Assist with
activities of daily
living as required
> Teach patient
how to decrease
shorthness of
breath by
decrease secretions.
> mobilizes thick
secretions, and
facilitates clearing
of lung fields.
>patient with
pneumonia may lack
sufficient oxygen
reserves to perform
activites; even
eating may cause
severe dyspnea
> Knowing how to
control shortness of
breath will help
cope and have
optimal functioning
Long Term
:
The patient shall be free from any signs and symptoms of hypoxia as evidenced by normal ABG, etc.
rales on both
lung lobe
upon chest
auscultation
easily
fatigability
Patient may
manifest
the
following :
>severe dyspnea
> sitting up leaning forward, hands on knees
>Abnormal blood gases
of oxygen to
other tissues
leading to
ineffective
breathing
pattern
restructuring
activities
>Teach
pulmonary
hygiene;
prevention of
spread of
infection
>Provide
humidified low
flow of oxygen as
ordered
>Administer
bronchodilators
and expectorants
> Preventing spread
of infection and
subsequent
hospitalization
>Provide some
supplemental
oxygen to improve
oxygenation and to
make secretions
less viscous
>Enhances
expectoration of
secretions of
previously
ineffective cough
> abnormal inspiratory or/and expiratory ration
> pursed lip breathing
> altered chest excursion
>hypoxia (Confusion, restlessness, decreased vital capacity)
> Administer
antibiotics as
ordered
>Helps to prevent
or eradicate
infections to reduce
secretions and to
end to inflammation
Problem No. 4 Hyperthermia
Assessment Nursing Scientific Planning Nursing Rationale Evaluation
Diagnosis Explanation Intervention
S= patient
may
verbalize
“Mapali ku
panandman .
”
O=Patient
Manifested
the
following :
>flushed skin
>skin is
warm to
touch
> increased
Hyperther
mia
CAP is the
inflammation of
the lung
parenchyma due
to offending
organisms,
inflammatory
lung response
will be
stimulated
leading to the
release of
chemical
mediators that
would increase
blood flow to the
lung tissues
leading to
erythema,
swelling, pain,
Short Term
:
After 4
hours of
Nursing
Intervention
s, the
patient’s
body
temperature
will
decrease
from 38oC to
37oC.
Long
> Monitor body
core temperature
>Note presence
or absence of
sweating as body
attempts to
increase heat
loss by
evaporation,
conduction,
diffusion
> promote
surface cooling
by means of
loose clothing;
cool
>To have a baseline
data
>Evaporation is
decreased by
environmental
factors of high
humidity and high
ambient
temperature as well
as the body factors
producing loss of
ability to sweat
>Promote heat loss
by radiation,
conduction and
evaporation
Short
Term :
The
patient’s
body
temperatur
e shall have
decreased
from 38oC
to 37oC.
Long Term
:
RR
>
Diaphoresis
Patient may
manifest
the
following :
>Convulsions
> Hypotension
>Fluid and electrolyte imbalance
and increased
body
temperature that
would reset the
hypothalamus
which is the
major center for
regulation of
body
temperature
Term :
After 24
hours of
Nursing
Intervention
s, the
patient will
maintain a
normal body
temperature
during
hospitalizati
ons and be
free from
any
complicatio
ns of
pneumonia.
environment/fan;
cool/tepid
sponge bath
local icepack
especially in the
axilla and groin
> Review signs
and symptoms of
hyperthermia
>Encourage the
patient to take
vitamin C in the
diet such as
citrus fruits, etc.
>Discuss
importance of
adequate fluid
intake
>indicates need for
prompt
interventions
> to increase
resistance
> To prevent
dehydration
>To reduce
The patient shall have maintained a normal body temperature during hospitalizations and be free from any complications of pneumonia.
>Maintain bed
rest
>Provide high-
calorie diet
>Provide
supplemental
oxygen
>administer anti-
pyretics as
ordered
metabolic demands/
oxygen
consumption
> to meet increased
metabolic demands
>To offset increased
oxygen demand and
consumption
>To control
shivering and
seizure
Problem No. 5 Activity Intolerance
Assessmen
t
Nursing
Diagnosis
Scientific
Explanation
Planning Nursing
Intervention
Rationale Evaluation
S= patient
may
verbalize
“magkasakit
ku
mangisnawa
ampo
mimingal ku
gan
maglakad
kumu.”
O=Patient
Manifested
the
following :
> appears
weak
> poor skin
Activity
Intolerance
related to
increased
oxygen
demand
with
activity and
hypoxia
(lack of
oxygen
supply with
oxygen
demand)
The onset of
pneumonia is
generally marked
by fever,
dyspnea, and
shortness of
breath and easy
fatigability that
may lead to
inability to
perform
activities of daily
living.
Due to the
accumulation of
thick tenacious
mucous in the
alveoli altering
gas exchange
( oxygen and
Short Term
:
After 4
hours of
Nursing
Intervention
s, the
patient is
able to
perform
activities of
daily living
without
shortness of
breath such
as doing
personal
hygiene,
etc.
> Obtain
subjective data
from patient
regarding normal
activities prior to
onset of
pneumonia;
monitor for
labored
breathing,
fatigue and
exhaustion.
> Reduce level
of activity as
required in
response to
shortness of
breath.
>Helps to determine
the effects of
pneumonia on the
patient’s ability to
be active.
>If increased
physical activity
causes shortness of
breath, activity
should be reduced
until oxygenation is
adequate.
> Conserves energy
and reduces oxygen
demand patients
with pneumonia lack
enough oxygen
Short
Term :
The patient
shall be
able to
perform
activities of
daily living
without
shortness
of breath
such as
doing
personal
hygiene,
etc.
turgor
>pale nail
beds
> easy
fatigability
> non-
productive
cough
>shortness
of breath
during
activities
> RR of 38
cpm, with
shallow,
carbon dioxide)
between the
alveoli And
Long
Term :
After 24
hours of
Nursing
Intervention
s, the
patient
states that
he is
comfortable
with activity
performanc
e and
shortness of
breath is
improved
following
> Assist with
activities as
needed.
>Pace activities
and encourage
periods of rest
and activity
during the day.
> Monitor VS and
oxygen
saturation before
and after
activity.
> Gradually
increase activity
reserves to perform
activities
independently.
>It conserves
energy.
> Use the result to
indicate when the
activity may be
increased or
decreased.
> Activities should
be increased
gradually, as
tolerated, to avoid
over taxing the
patient.
Long Term
:
The patient shall states that he is comfortable with activity performance and shortness of breath is improved following cessation of activity, and the patient’s RR returns to baseline within 5 minutes.
rapid
breathing
Patient
may
manifest
the
following :
>Inability to perform physical activities
> level I functional level classification ( walk, regular phase, on level indefinitely; one flight or more but more
cessation of
activity, and
the patient’s
RR returns
to baseline
within 5
minutes.
as tolerated and
share guidelines
for progression
with patient.
> Discuss with
the patients
activities that
would be
appropriate once
at home that
would be within
the patient’s
activity
tolerance.
> Inform the
patient to stop
any activity that
> Physical activity
increases endurance
and stamina;
following
pneumonia, return
to normal activity
may take time.
> This indicate
intolerance to
activity and the
level of activity
should be
evaluated.
> Iron has a role in
oxygen transport
and increases
energy level.
shortness of breath than normal)
>labored breathing
>physical exhaustion
>oxygen saturation less than 90%
phy
produces
shortness of
breath.
> Encourage
intake of foods
high in iron and
good source of
energy such as
lean meat,
legumes which
are rich in
protein.
> Assist patient
to learn and
demonstrate
appropriate
safety measures.
> Have the
patient use
>To prevent
injuries.
>Improves
oxygenation and
provides oxygen
reserves to be used
with increased
demand.
oxygen
immediately
prior to activity
in the acute
setting, as
ordered.
2. Actual SOAPIERs
August 22, 2008
S= Ø
O= Received patient supine on bed, conscious & coherent; with an IVF
no. 10 of D5NM 1l at 550 cc level, regulated at 31-32 qtts/min, infusing
well on the left dorsal metacarpal vein
Vs taken and recorded are as follows: BP= 130/70 mmHg;
PR=104 bpm; RR=20bpm; T=36.9C/axilla
Patient appears weak
With pale conjunctiva and nailbeds
With dry lips and buccal mucosa
With symmetrical chest expansion
With non-productive cough
With rales upon auscultation on both lungs
Capillary refill of <3sec
A= Ineffective airway clearance r/t retained secretions secondary to
COPD AEB rales upon auscultation and non-produce cough
D= After 1 hr of NI, the patient will demonstrate behaviors to
improve/maintain clear airway
I= • Establish Rapport
Monitored and recorded VS
Identifies presence of dyspnea, cyanosis, and hemoptysis
Auscultated wealth sounds
Observe for signs of respiratory distress
Measured capillary refill
Encouraged patient to perform breathing/coughing exercises
and pursed-lip breathing
Encouraged patient to change positions every two hours
Instructed patient to increase fluid intake with SAP
Encouraged and provided adequate rest periods
Instructed to limit activities to level of respiratory tolerance
Encouraged patient to permanently quit smoking
Encouraged patient to eat nutritious foods
E= Goal met AEB patient’s demonstration of coughing exercise and
pursed-lip breathing and position changes.
August 23, 2008
S= “Agad kung susunga.” as verbalized by the patient
O= Received patient supine on bed, conscious and coherent; with an
IVF no. 12 of D5NM 1L at 150 cc level regulated at 31-32 qtts/min
infusing well on the left dorsal metacarpal vein
VS taken and recorded are as follows: Bp=110/70 mmhg; PR-95
bpm; RR=21 bpm; T=36.9 C/axilla
Patient appears weak
With pail conjunctiva and nailbeds
With productive coughs, yellowish in color
With rales on both lungs upon auscultation
Capillary refill of <3sec
Patient reports fatigue and weakness
A= Activity intolerance r/t imbalanced between oxygen supply and
demand AEB pallor, fatigue and Weakness
P= After 1hr of NI, the patient will participate willingly in necessary
activities within the level of own ability
I= • Established Rapport
Monitored and recorded VS
Noted presence of factors contributing to fatigue
Evaluated current limitations/degree of deficit in light of usual
status.
Noted client reports of weakness, fatigue, pain, difficulty
accomplishing tasks or insomia
Assessed emotional/psychological factors affecting the current
situation
Adjusted activities to prevent overexertion
Taught method to conserve energy.
Encouraged rest periods during /between activities to reduce
fatigue
Assisted with activities
Promoted comfort measures
Instructed patient on appropriate safety measures to prevent
injuries
Provided information about the effect of lifestyle and overall
health factors on activity tolerance
E= Goal Met AEP patient’s participation in activities within the level of
his own ability.
IV. CLIENT’S DAILY PROGRESS IN THE HOSPITAL
Admission
17 18 19 20 21 22 23 24
Discharged
25
NURSING PROBLEMS
Ineffective Airway
Clearance
Impaired Gas Exchange
Ineffective breathing
Pattern
Hyperthermia
Activity Intolerance
VITAL SIGNS
Temperature
Pulse Rate
Respiratory Rate
Blood Pressure
LABORATORY /
DIAGNOSIS
Φ
Φ
Φ
38.7
90
38
120/80
Φ
Φ
Φ
37.6
80
24
120/70
Φ
36.2
79
24
120/70
Φ
36.4
76
20
110/80
Φ
Φ
36.3
90
26
120/70
Φ
Φ
36.9
90
24
10/70
Φ
36.8
95
21
110/80
Φ
36.6
80
20
110/70
Φ
36.4
82
20
130/10
0
Φ
Chest X-ray
Sputum AFB
Blood Chemistry
Complete BLood
Count(CBC)
Urinalysis
Fecalysis
MEDICAL MANAGEMENT
PNSS 1L x 8 hours
D5LRS 1L x 8 hours
D5NM 1L x 8 hours
Nebulization
O2 Therapy
DRUGS
Cefuroxime 750 mg TID
Combivent neb q 6 hours
Paracetamol 500mg Tab
q 4 RTC
Loperamide 1 Tab for
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
loose stool
Carbocesteine 500mg 1
cap TID
Furosemide 20 mg IV
now then q 12 ć BP
precaution
Azithromycin 500 mg
Tab 1 tab OD x 3 days
Ceftriaxone 1gm IV q 12
ANST (-)
Sinecod 1 Tab TID
Ventoline Expectorant
Capsule 1 cap TID
DIET
Soft
Φ
Φ
Φ
Φ
Φ
Φ Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
Φ
2 DISCHARGE PLANNINGa. General Condition of Client Upon Discharge
Patient was not assessed upon discharge but was noted to have recovered.
b.S= O= Received patient on bed on supine position, conscious and coherent
VS taken and recorded as follows: T: 36.4C PR: 82bpm RR: 20bpm BP: 130/100mmHg.
Patient appears good and afebrile.
A= For home maintenance and management.P= After 2 hrs of nursing interventions patient will be able to verbalize understanding given prior to discharge. I= M> Ciprofloxacin 500mg/cap BID x 7 days. > Salbutamol tab 2mg BID > Ansimar neb/1 tab ½ BID. E> Deep Breathing Exercises
> Coughing Exercises> Limit activities and have rest periods.
T> IV fluids and medications. H> Encourage d to keep environment allergen free.
> Encouraged warm versus cold liquids as appropriate.> Provided information about the necessity of raising and expectorating secretions versus swallowing them.> Encouraged to have rest periods and limit activities to level of respiratory tolerance.> Encouraged to have a monthly check-up.> Encouraged to stop smoking.> Demonstrated pursed lip or diaphragmatic breathing techniques.> discussed rationale for and encourage continuation of successful interventions.
O> Advised patient to have a Follow-up check-up after one week.
D> Increased oral fluid intake. > High calorie, high protein diet of soft foods.
E= Goal Met AEB patient verbalized understanding of the health teachings give
CONCLUSION
Community- Acquired Pneumonia is one of the most common
infectious diseases addressed by clinician’s cause of morbidity and mortality
worldwide
In the case of Mr. CAP, the disease was caused primarily by personal
and environmental factors such as cigarette smoking, lack of vaccinations
during childhood years, job exposure to pathogens, and other factors. This
lead to the development of the disease and lack of action on the part of the
caretakers. Mr. CAP manifested difficulty of breathing, productive cough,
crackles on both lung fields, wheezing and angina pectoris
Through these manifestations different laboratory and diagnostic
procedures that would confirm and support the admitting diagnosis were
performed. Different results have been taken out such as to consider illness
such as PTB, AGE and Atelectasis which have been ruled out and the hospital
final diagnosis was Community- Acquired Pneumonia.
The result played an essential part on the part of the patient. Since the
family has no information about the signs and symptoms of the disease they
will now be aware on those things in order to prevent this illness.
Years have passed and still these diseases are present especially with
developing countries. The solution is simple but needs great discipline to
make it concrete. A clean surrounding will definitely boost our chances of
invading such disease condition.
The group strongly recommends that further studies are to be done to
clear out other vague information and misconceptions regarding this disease.
RECOMMENDATIONS
Information dissemination is the most important factor in this study.
In the ongoing battle against the pneumonia and its different types, the
turning point is the ability of the people to recognize the signs and
symptoms of the disease as well as the ability of the existing health sector
to respond immediately about the incidence. With these, the group
formulated the following recommendations in order to maternalize this
vision of emancipation from Community-Acquired Pneumonia.
Since pneumonia is one of the leading cause of mortality and
morbidity in the Philippines, the Department of Health as the major arm of
the Government when it comes to health together with the other sectors
of the society, allied medical professionals both in the government or
private sectors, must work and in hand arresting the incidence and
prevalence of pneumonia in the country. The programs of these sectors
should not only focus on the treatment but more importantly on the
preventive aspect. Department of health must also conduct studies on the
incidence, prevalence of the disease so as to mitigate its occurrence.
Community Health Workers must make an effort to update their
data about the incidence, prevalence of the disease by doing studies,
research and surveys. This should be done periodically. They should do
medical mission and target the vulnerable sectors of the society. Members
of the Health care team must gear themselves by continual education
about the disease so as to properly diagnose and manage of pneumonia in
the community level.
Since family members are the one who are always in contact with
the other members of the family, they are the better position of
monitoring the health of everyone. They should promote then health of
each member so as o prevent any progression of the disease like
Community- Acquired Disease. Acting in a swift manner regarding signs
and symptoms of the disease, is very important. This may empower
everyone and fulfil the goal of the Department of Health which is “Health
in the hands of the people by 2020.”
VIII. BIBLIOGRAPHY
BOOK SOURCES:
Smeltzer, et. al. Medical-Surgical Nursing: 11th Edition. Lippincott Williams
and Wilkins. 2008
DeglinHopfer, Valierant, Nazorel. Davis’ Drug Guide for Nurses: 10th Edition.
F.A. Davis Company, Philadelphia. 2007
Doenges, et. al. Nurses Pocket Guide: Diagnosis, Prioritized Interactions and
Rationales: 10th Edition. F.A. Davis Company, Philadelphia
McCance, et. al. Pathophysiology: The Biologic Basis for Disease Adul and
Children: 4th Edition. 2002
Schilling, et. al. Nursing Process Approach To Excellent Care: 4the Edition.
Lippincott Williams and Wilkins. 2006
ONLINE SOURCES:
http://www.medscape.com/viewarticle/475218
http://www.emedicine.com/MEDtopic3162.htm
http://www.utmedicalcenter.org/encyclopedia/1/000145.htm
http://www.mims.com/
http://www.doh.gov.ph/data_stat/html/mortality.htm
http://www.wrongdiagnosis.com/p/pneumonia/prevalenve.htmtypes
http://www.lungusa.org/site/c.dvLUK900E/b.22576/K.7FFF/
Human_Respiratory_System.htm