nursing care plan for community acquired pneumonia 2009
DESCRIPTION
In continuation of the Case Study on Community Acquired Pneumonia, these are the Nursing Care Plans renderedTRANSCRIPT
Nursing Care Plan
Client: Bartolabac, Fidela Hospital No.: 0-800-22500-773
Age: 66 years old Room No.: C414
Impression: cough, dyspnea Physician: Dr. R. Go
Diagnosis: Community acquired pneumonia – high risk in acute respiratory failure Nurse’s
Signature: R.C.R. UCSN
Clinical Portrait Pertinent Data
Assessment
Upon assessment patient X, 66 years old, a
Roman Catholic from 0671 Sitio Anagan, Apas, Cebu
City, was seen lying on bed conscious and a febrile
with the S.O. at the bedside. Patient had an IVF of
D5NSS infused at right arm/hand running at 30
gtts/min + dopamine at 10gtts/min. A NGT was
inserted and was aided with a mechanical ventilator.
History of Present Illness
A case of Mrs. Fidela B. Bartolabac, 66 years
old, born on April 24, 1942 at Berida, Leyte,
Roman Catholic and is widowed for 3 years,
residing at 0671 Sitio Amagan, Apas, Cebu City
6000 was admitted on November 29, 2008 at 1:44
pm at Chong Hua Hospital.
Mrs. Bartolabac has Bronchial Asthma taking
91
Pulse oximeter was connected at the right hand and
FBC-UB was noted.
Significant Findings
Patient was tachypniec with vital sighs of BP=
90/60 mm/Hg. HR of 117 bpm and RR of 31 cpm.
Roles positive at binasal assessment and occasional
wheeze BLF. Patient was tachycardic with regular
murmurs. Positive cyanosis on finger nail beds of
both hands. With history of PTB.
Nursing Review of Systems Gordon's 11 Functional
Health Patterns
1. Health perception/ Health management
Patient had history of Pneumonia and
Pulmonary Tuberculosis. Doctors prescribed her with
medicines but the patient was not able to maintain it
Seretide and Ventolin inhaler for treatment but is
poorly compliant. She was taking vitamins. Family
history of diabetes.
Mrs. Bartolabac used to for about 30 packs
per year and drinks alcohol occasionally. She was
positive of pulmonary tuberculosis and was poorly
taking anti TB medications for 2 years. Months
prior to admission weight loss was positive and
occasional chest pains noted
Chief Complaints
Cough, dyspnea
Vital Signs Taken Upon Admission
T= 36.2◦C R= 31 cpm
P= 117 bpm BP= 90/60 mmHg
92
due to financial problem. She never complained
about her condition though she experienced short of
breathe and cough. Her family decided to admit her
to Chong Hua hospital when she cannot tolerate it
anymore and when cyanosis was observed by the
family member.
She used Wachichao plant for her
maintenance.
2. Nutrition/ Metabolic
Patient is choosy about her food. She usually
eats rice and liver barbeque. She loves to eat fruits
as long as they have. She seldom eats meat. She
eats vegetables once in a while. In the morning, she
eats bread and ate breakfast and lunch (brunch) at
around 11:00AM
Few weeks before admission, she just want to
Laboratory results
X-Ray
12/14/08
Conclusion
1. Chronic inflammation process in both lung fields
2. Modified silhouette
3. Atherosclerosis of the thoracic aorta
4. Calcified trachoebronchial tree
5. Generalized osteopenia/osteoporosis
CBC
12/13/08
93
eat porridge for her meal. Now, she has Nasogastric
tube attached.
3. Elimination
Patient had normal elimination pattern but
then, few days after her admission, she experienced
constipation but had good urine output. Now, she
defecates daily and maintain good urine output.
4. Activity/ Exercise
Patient usually does sedentary activities at
home, like eating, watching television, talking with
some friends, and sometimes does sweeping.
On first contact with the patient, seen patient
lying on bed, weak, and with limited movements.
Eight days after admission, patient had great
Result reference unit
WBC 6.28 4.8-10.8
10^3/ul
RBC 5.45 4.2-5.4 10^0/ul
HGB 16.5 12-16 g/dl
HCT 50.6 37-47 %
MCV 92.8 81.99 fl
MCH 30.3 27-31 pg
MCHC 32.6 33-37 g/dl
Plt 193 130-140 10^3/ul
Result reference unit
Neutrophil % 72 40-74 %
Lymphocyte % 1707 19-48 %
Monocyte 9.9 3.4-9 %
Eosinophil .2 0-7 %
Basophil .2 0-1.5 %
Neutrophil # 4.53 1.9-8 10^3/ul
Lymphocyte # 1.11 1.9-8 10^3\ul
94
improvement, she can now smile, do sign language,
move her extremities and with glow on her face.
Though she still needs assistance, she can turn to
sides now with ease.
5. Cognitive/ Perceptual
Patient needs to be oriented with the time and
date though she is aware that she is currently
admitted in the hospital. She is responsive (through
gestures), coherent, and can relate to conversations.
She even smile with jokes and wave her hands when
someone she used to see visited her. She speaks in a
very low voice at present because the Endotracheal
tube was just removed.
6. Sleep/Rest Patterns
Patient usually sleeps between 8:00PM –
9:00PM and wakes up around 5:00AM. She had
afternoon nap everyday.
Monocyte .62 .16-1 10^3/ul
Eusinophil .01 0-.8 10^3/ul
Basophil .01 0-.2 10^3/ul
RDW 14 11-16 %
PDW 9.8 9-14 %
MPV 9.5 7.2-11.1 fl
Ionized calcium .75 1.09-1.33 mmol/L
Na 121.9 135-148 mmol/L
K 4.25 3.5-5.0 mmol/L
Temperature 36.6 C
Thb 15.0 g/dl
FIO2 21 %
pH 7.287 7.35-7.45
pCo2 68 35-45 mmHg
PO2 54.5 >80 mmHg
HCO3 31.8 mmHg
95
Now that she is admitted, she could hardly
sleep because of her condition. Her vital signs need
to be monitored hourly. She is also disturbed by her
cough.
7. Self Perception/ Self Concept
Though the patient looses weight, she doesn’t
look under weight at all. She is just weak because
she is sick. She looks accommodating and friendly
despite of her condition.
8. Role/ Relationship
Patient lives in her own house with her
daughter and two grandchildren. They have close
family ties. She is open to them with her feelings. She
is fond of talking. She spends most of her time at
home with her family.
+CO2 33.9 mmHg
SO2 84.4 95-98 %
U/A
12/13/08
Physical Characteristics
Color dark yellow
Transparency sly cloudy
pH 6.0 5-6
Sp-gray1.030 1.003-1.005 random
Chemical Characteristics
Result reference unit
Protein 100 - mg/dl
Glucose - - mg/dl
Ketone - - mg/dl
Urobilinogen normal up to 2
mg/dl
Leukocyte - - WBC/ul
96
9. Sexuality/ Reproductive Health
The patient has five children, two boys
(deceased) and three girls. Her husband died long
time ago.
10. Coping/ stress tolerance
The patient is open to her family about her
problems. But then, with regards to her sickness, she
never complained about it. She kept it to herself as
long as she can tolerate it.
11. Values and beliefs
Patient is a Roman Catholic but didn’t go to
church. She didn’t join any religious community.
Bld - - mg/dl
Bilirubin - - mg/dl
Nitrite - -
mg/dl
Vit C 40 * mg/dl
Microscopic
RBC 2 2-18 /ul
WBC 8 6.14 /ul
Bacteria Mucus none * /ul
Hyaline cast 10 * /ul
Glucose Fasting 149 60-110 mg/dl
Cholesterol 165 150.0-240.0
mg/dl
Triglycerides 109 45.0-150.0
mg/dl
VLDL 21.8 .0-40.0 mg/dl
97
Nursing Problems
1.) Ineffective airway clearance
2.) Impaired physical mobility
3.)Risk for aspiration
4.)Risk for impaired skin integrity
5.) Impaired verbal communication
Nursing Diagnosis
1. Ineffective Airway Clearance related to increased
sputum production as evidenced by cough.
2. Impaired Physical Mobility related to restrictive
devices
3. Impaired Verbal communication r/t attachment to
mechanical ventilator.
4. Risk for infection related to depressed immune
system
5. Risk for aspiration r/t tube feedings and
LDL 115.6 .0 150.0 mg/dl
HDL 27.6 30.0-9.0 mg/dl
Temperature 36 C
FIO2 14.2 g/dl
pCO2 21.0 %
pH 7.335 7.35-7.45
PO2 60.4 35-45 mmHg
HCO3 238.1 780 mmol/L
+CO2 33.7 mmol/L
BE 3.8 mmol/L
SO2 99.8 95-98 %
Acid fast stain
Specimen – sputum
Report: no acid fast bacilli seen
98
secretions.
Nursing Care Plan
Cues Nursing
Diagnosis
Scientific
Basis
Goal and
Outcome
Criteria
Nursing Actions Rationale Evaluation
S: “Giubo ug
kutasan ako
mama ug
maglisod
Actual
Ineffectiv
e Airway
A cough is
a protective
reflex that
cleanses
After 8
hours of
nursing
interventio
To perform nursing
care to help patient
improved Airway
Goal
Partially
met
99
siya ug
ginhawa” As
verbalized
by the
clients
daughter.
O:
1.Received
patient lying
on bed,
conscious,
coherent
afebrile,
tachypneic
and with
mechanical
ventilator
support.
Clearance
related to
increased
sputum
productio
n as
evidence
d by
cough.
the lower
airways by
an
explosive
expiration.
Inhaled
particles,
accumulate
d mucus,
inflammatio
n or
presence of
a foreign
body
initiates the
reflex by
stimulating
the irritant
receptors in
the airway.
n, client’s
airway is
free of
secretions
as
evidenced
by eupnea
and clear
lung
sounds
after
coughing
or
suctioning.
Specifically
:
1. Client
will
Independent;
1. Assess respiratory
movements and
use of accessory
muscles.
2. Assess cough for
effectiveness and
productivity.
Use of
accessory
muscles to
breathe
indicates an
abnormal
increase in
work of
breathing.
(Gulanickl et.
al.: 2007,480).
Patients may
have
ineffective
cough due to
fatigue or thick
tenacious
After 8
hours of
nursing
interventio
n, client’s
airway was
free of
secretions
as
evidenced
by eupnea
and clear
lung
sounds
after
coughing or
suctioning.
Specifically
100
2. Change in
respiratory
status.
3. Patient
demonstrat
e persistent
coughing
and
dyspnea
4. Abnormal
lung sounds
5. With
pulse
oximeter
attached
The cough
consists of
inspiration,
closure of
glottis, and
vocal cord,
contraction
of glottis,
causing
sudden,
forceful
expiration
that
removes
the
offending
matter. The
effectivene
ss of the
cough
maintain a
stable
breathing.
2. Client’s
mucus will
be thin
and scant.
3. Client’s
breath
sounds are
clear.
3. Observe sputum
color, amount,
and odor and
report significant
changes.
Dependent:
1. Monitor pulse
oximeter and
ABGs.
secretions.
(Gulanickl et.
al.: 2007,480).
A sign of
infection is
discolored
sputum. An
odor may be
present.
(Gulanickl et.
al.: 2007,480).
Hypoxemia
may result
from impaired
gas exchange
:
1. Client
maintaine
d a stable
breathing.
2. Client’s
mucus
wasthin
and scant.
101
- T=
36.2oC
- P= 81
bpm
- R= MV
- BP=
90/55
mmHg
.
depends on
the depth
of the
inspiration
and the
degree to
which the
airway
narrow,
increasing
the velocity
of the
expiratory
gas flow.
Cough
occurs
frequently
in healthy
individuals.
2. Monitor chest x-
ray reports.
Collaborative:
from build up
of secretions.
ABGs provide
data about
carbon dioxide
levels in the
blood.
(Gulanickl et.
al.: 2007,480).
These
determine
progression of
disease
process.
(Gulanickl et.
al.: 2007,480).
102
A persistent
cough
indicates
presence of
disorder or
a disease.
An acute
non
productive
cough often
indicates
bronchitis
or viral
pneumonia.
A persistent
cough is
commonly
caused by a
tumor,
1. Consult the
respiratory
therapist for
chest
physiotherapy
and nebulizer
treatments, as
appropriate and
ordered.
Chest
physiotherapy
includes the
techniques of
postural
drainage and
chest
percussion to
loosen and
mobilize
secretions in
smaller
airways that
cannot be
removed by
coughing or
suctioning. A
nebulizer may
103
congestion,
or
hypertensiv
e airways.
A cough
that
produces
purulent
sputum
usually
indicates
infection,
whereas a
cough that
produces
non
purulent
sputum is
non specific
and merely
2. Assist with
bronchoscopy and
thoracentesis, as
appropriate.
be used to
humidify the
airway to thin
secretions to
facilitate their
removal.
(Gulanickl et.
al.: 2007,481).
Bronchoscopy
is done to
obtain lavage
samples for
culture and
sensitivity and
to remove
mucous plugs;
thoracentesis
is done to
drain
104
indicates
irritation.
(McCance,
2000:1150
3. Anticipate
possible need for
intubation if
patient’s
condition
deteriorates.
4. Administer
medications such as
antibiotics and
associated
pleural
effusions.
(Gulanickl et.
al.: 2007,481).
Intubation may
be needed to
facilitate deep
suctioning
efforts and to
provide source
for
augmenting
oxygenation.
(Gulanickl et.
al.: 2007,481).
A variety of
medications
105
expectorants for
productive coughs.
Administe r inhaled
bronchodilators and
inhaled steroids, as
prescribed, to open
airway and decrease
inflammation.
are available
to treat
specific
problems.
(Gulanickl et.
al.: 2007,481).
Nursing Care Plan
Cues Nursing
Diagnosi
Scientific Basis Goal and
Outcome
Nursing
Actions
Rationale Evaluatio
n
106
s Criteria
S- Patient
pointing
her throat.
-no
verbalizatio
ns
O- • NGT
inserted
•Mechanic
al
ventilator
noted
•Suction
machine at
bedside.
•patient
pointing on
Potential
Risk for
aspiratio
n r/t
tube
feedings
and
secretion
s.
Crackles indicate
static pulmonary
secretions that
need to be
mobilized. This
also includes
accumulation of
saliva on the
airways .When
this obstructs the
airway the
pulmonary tissues
beyond the
collapses and
massive
atelectasis
results.
(Smeltzer,Bare,,Hi
After 8
hours of
nursing
interventi
on the
patient
will be
able to
maintain
a patent
airway
Specificall
y the
patient
and s.o.
will be
able to:
To perform
nursing care
to prevent
aspiration
Independent
:
1. Monitor
level of
consciousne
ss.
2. Auscultate
bowel
A decreased level
of consciousness is
a prime factor for
aspiration
(
Gulanick/Mayers:20
08
pp18)
• Decreased
gastrointestinal
goal met:
After 8
hours of
nursing
interventi
on the
patient
was able
to
maintain
a patent
airway.
Specificall
y the
patient
and s.o.
107
her neck. nkle
cheever;2008,534
)
Pulmonary
complications
from NGT
intubation occur
because coughing
and cleaning of
the pharynx is
impaired ,
because gas build
up can irritate the
phrenic nerve and
because
tubes may
dislodged,
retracting the
distal and above
the
1. Feel
relief with
concerns
of
secretions
2. Will be
able to do
basic
suctioning
procedure
s.
3. Have a
secured
NGT
placemen
t.
sounds to
evaluate
bowel
motility and
assess for
abdominal
distention
and
firmness.
3. Position
patient in an
elevated
upper body
or side lying.
mobility increases
the risk of
aspiration because
foods and fluids
accumulate in the
stomach(Gulanick/
Mayers:2008;pp19
• This decreases
the risk of
aspiration by
promoting the
drainage and
secretions away
from the airway.
(Gulanick/Mayers:2
008
pp.19)
•Reduces oro-
was able
to:
1. Feel
relief of
concerns
about
secretions
.
2. Able to
do basic
suctioning
procedure
s.
3. Have a
secured
NGT
placemen
t
4.Have no
108
esophagogastric
sphincter places
the patient of risk
for aspiration
(Smeltzer,Bare,Hi
nkle,
Cheever;
2008,1180-1181)
4. Have
no
abnormal
breath
sounds
upon
assessme
nt.
5. Have
normal
breathing
pattern.
4. In Patients
with artificial
airways.
• Perform
oral
suctioning as
needed.
5. In
patients with
NGT
• Check
placement of
tube before
feeding by
color or
pharyngeal
secretions and
reduces aspiration
rising.
((Gulanick/Mayers:
2008
pp.19)
•A placed tube
may erroneously
deliver tube
feeding into the
airway.
((Gulanick/Mayers:
2008
pp.19)
abnormal
breathe
sounds
upon
assessme
nt
5. Have a
normal
breathing
pattern.
109
aspirate or
listening for
bubbling
sounds upon
air induction.
Collaborative
:
6.Collaborat
e with
respiratory
therapist, as
needed to
determine
cuff
pressure(tub
es)
7.
•On ineffective or
over inflated cuff
can increase the
risk for aspiration.
((Gulanick/Mayers:
2008
pp.19)
• Appropriate
mixture of food as
well as balanced
110
Collaborate
with the
dietitians
about having
blenderized
diet for the
patient.
Dependent:
8. Suction
hourly as
ordered by
the
physician.
9.
Administer
drugs in
meal provides
nutrients needed.
((Gulanick/Mayers:
2008
pp.63)
•To eliminate
secretions
(Doenges 63)
• Drugs in tablet
forms must be
crushed during
administration
(Doenges 63)
111
appropriate
preparation
as ordered
by the
physician.
112
Nursing Care Plan
Cues Nursing
Diagnosi
s
Scientific
Basis
Goal and
Outcome
Criteria
Nursing
Actions
Rationale Evaluation
S: Patient
wrote on
a piece of
paper
“gusto na
ko
mulakaw”
O:
1.Receive
d patient
lying on
bed,
Actual
Impaired
Physical
Mobility
related
to
restrictiv
e
devices
In place
mechanic
al devices
are
common
to non
ambulator
y patients
but in
cases
where
patients
are able
After 8 hours of
nursing
intervention
the patient will
be relieved
from
discomfort
Specifically
1. Patient will
be free of
complications
To perform
nursing care
to help
patient
exercise in
bed
1. Assess
patient’s
ability to
perform ADL’s
effectively
and safely on
>Restricted
movement
affects the
ability to
perform most
ADL’s .
Goal met
After 8 hours of
nursing
intervention the
patient was
relieved from
discomfort
Specifically
1. Patient was
free of
113
conscious,
coherent
afebrile,
tachypnei
c and
with
mechanic
al
ventilator
support.
2. Pulse
oximeter
at right
hand
3. IVF
infused at
right hand
to walk,
the
devices
would
likely limit
their
activities
provided
that
machines
are easily
altered by
movemen
t
examples
would be
casts,
neck
support
and
of immobility,
as evidenced
by intact skin,
absence of
thrombophlebit
is, & normal
bowel pattern.
2. Patient will
perform
exercises in
bed
3. Patient will
move allowed
body parts for
exercise.
a daily basis.
2 Assess
ability to
perform ROM
to all joints.
3 Encourage
& facilitate
early
ambulation &
other ADL’s
when possible
.
4 Provide
positive
reinforcement
>This provides
baseline
measurement
for the future
evaluation and
guides therapy.
>The sooner
the patients
becomes
mobile, less
chance that
debilitation will
occur.
>Patients may
be reluctant to
move or initiate
new activity
complications
of immobility,
as evidenced
by intact skin,
absence of
thrombophlebiti
s, & normal
bowel pattern.
2. Patient was
able to perform
exercises in
bed
3. Patient
moved allowed
body parts for
exercise.
114
4. Weak
muscles
ventilator.
(Microsoft
® Encarta
® 2007)
during
activity.
5 Evaluate
patient’s
performance
in doing
ADL’s.
due to fear of
falling. A
positive
approach allows
the learner to
feel good about
learning
accomplishmen
ts.
> Evaluating
performance
helps in
improving once
abilities &
maximizing
activities.
Even patients
who are
temporarily
115
6 Assess
patient or
caregiver’s
knowledge of
immobility &
its
complication.
immobile are at
risk for effects
of immobility
such as skin
breakdown,
muscle
weakness,
thrombophlebiti
s, constipation,
pneumonia, &
depression.
> Regular
examination of
skin (especially
over bony
prominences)
will allow for
prevention or
early
116
7 Assess skin
integrity
8 Assess
elimination
pattern.
9 Turn &
position the
patient every
2 hours or as
recognition &
treatment of
pressure sores.
> Turning the
patients
optimizes
circulation to all
tissues &
relieves
pressure.
> Immobility
promotes
constipation
> It helps in
evaluating
patient’s
outcome from
117
needed.
10 Evaluate
the patient
free of
complications
of immobility.
11 Assess
patient’s
difficulty in
walking.
12 Encourage
walking
exercise
interspersed
with rest
nursing
interventions.
> It helps in
determining
factors that
contributed to
patient’s
difficulty in
moving
> To reduce
fatigue.
> To enhance
safety for client
& SO/
118
periods
13 Involve
client/ SO in
care, assisting
them to learn
ways of
managing
deficits.
14 Instruct
client/ SO in
safety
measures as
individually.
(eg.
maintaining
safe travel
pathway,
proper
caregivers.
> To reduce
risk of falls
> It helps in
determining
patient’s
outcome to be
effective or not.
119
lightning.
120