I.

PATIENT PROFILE

Name: Siding, Marlene

Age: 25
Gender: Female
Civil Status: Single
Address: Barucucung, Suyo, Ilocos Sur
Birthdate: March 13, 1983
Religion: Roman Catholic
Highest Educational Attainment: High school Graduate
Occupation: n/a
Time and Date of Admission: August 7, 2008 at 5 A.M.
Chief Complaint: productive cough, 1 day PTA
Diagnosis: Acute Respiratory Infection
Attending Physician: Dra. Makiling

II. HEALTH HISTORY

A. Present Health History

The patient claimed that one day prior to admission, she had persistent dry hacking cough accompanied by fast and difficulty in breathing. Her
SOs performed bronchial tapping and let her breathe into a brown paper bag, but to no avail. Seeing that her condition was not alleviated, she was
then brought to Tagudin General Hospital and Capillariasis Center for immediate medical help.

B. Past Health History

The patient reported that she had no serious illnesses until after she has undergone cesarean section last June. She claimed that a few hours before
the incident, she noticed a bloody discharge on her underwear and later experienced abdominal pain. She was brought to the hospital thereafter,
and upon assessment the healthcare providers told her that the fetal heart tone was absent and that the fetus died in utero due to excessive
amounts of amniotic fluid present and because the fetus was too large. After the surgery, the patient claimed to have experienced momentary
post-partum depression but declined to elaborate on it. Moving on, the patient claimed that while recovering several diagnostic tests were
performed on her including 2D echo and Ultrasound because of suspected heart murmurs. She was then diagnosed of Rheumatic Heart Disease
and was given a number of medicines including Aspirin, Digoxin, Carvedilol, Isosorbide, Captopril, and Spinmolactone. In addition to this, she
also claimed to have developed pneumonia while recovering from surgery. She claimed to have manifested the same dry hacking to productive
cough accompanied by fast and difficulty in breathing. She was given antibiotics upon diagnosis and reportedly recovered from it a few weeks
later. In both of these cases, the patient suspects that these were caused by her exposure to other patients in the ward who have infectious
diseases.
 C. Family Health History
The patient reported that aside from her mother having hypertension and one of her siblings who also has Rheumatic Heart Disease, their family
have no other serious illnesses.

D. Socio-economic Health History

The patient is about to married next year to her fiancé and the father of her supposed child. She is currently unemployed due to her health
conditions but claimed to have worked as a saleslady in Villasis, Pangasinan. Her needs are supported by her fiancé, a laborer at Buguias, and her
family. She is greatly involved in household chores and in caring for her younger siblings. She spends most of her leisure time in making
handicrafts such as cross stitches. She also claimed to have spent a lot of time out with friends and co-workers while she was still employed,
however due to her condition she prefers staying at home with her family nowadays.

III. PHYSICAL ASSESSMENT- 13 Areas

A. Psychosocial Status (Pls. refer to Socio-economic History and Patient Profile)

B. Mental and Emotional Status

1. Mental Status
Using the Glasgow Coma Scale, the mental state of the patient is as follows:

Action Response Score

Eyes open To speech 3
Best Verbal response Oriented 5
Best Motor response Obeys commands 6
Total 14

A total score of 14 (GCS 14=E3 V5 M6) implies that the patient is conscious, coherent, and is responsive to stimuli.

2. Emotional Status
Patient expresses appropriate feelings that correspond to the situation. She readily conveys feelings of helplessness and powerlessness. She exhibits
irritability and has mood swings at times.

C. Environmental Status

1. Safety Factors
Patient has difficulty moving on bed without assistance. She must be supported when changing positions. Since there are no side rails, constant
monitoring and proper positioning are the means in promoting safety.
2. Infection Control
Patient is admitted to a medical ward and is exposed to other patients, therefore increasing the risk for contact with pathogens.

D. Sensory Status

1. Visual
Patient does not wear any correctional or prosthetic devices such as eyeglasses and contact lenses. She can distinguish objects at a specific distance.
There is no notable problem with her eyes.

2. Auditory
Patient’s sense of hearing is functioning normally as evidenced by her prompt response to questions and instructions.

3. Olfactory
Patient can normally distinguish olfactory stimuli as evidenced by verbal reports of fragrant or foul odors in the area.

4. Gustatory
Patient reported that she has sour and bitter tastes in the mouth most of the time especially when feeling nauseous or after vomiting. However, she
admitted that she can still taste all other flavors in the food prepared for her.

5. Language Perception and Formation

Patient is able to understand spoken instructions and is able to express self well through words and gestures. However, her voice inflection and tone
are soft and convey a weak state.

E. Motor Status

1. Musculoskeletal system
Patient appears generally weak and needs assistance in accomplishing activities of daily living. She also reported that her left hand has become numb
and is incapable of being clenched and controlled.

2. Mobility
Minimal activities were observed in patient as she was notably weak. She has a hard time repositioning and sitting herself on bed and attempts to
increase her activity were deterred by reports of dizziness and general weakness.

F. Nutritional Status
1. Dietary Habits
Patient has poor appetite and makes poor food choices whenever she feels hungry. She eats only crackers and water or rice and soup or rice and soft
drink.
2. Adequacy of Diet
Patient has considerably poor appetite for any food and fluids during the first 2 days of admission resulting to decreased or inadequate intake for her
metabolic needs.

G. Elimination Status
Patient has a notable decrease in urination and bowel elimination since admission due to decreased food and fluid intake. It was also noted that
patient’s urine was dark brown in color and was only about 30 cc/voiding.

H. Fluids and Electrolytes

Reports of nausea, vomiting, and poor appetite may result to fluid and electrolyte losses and imbalances, although signs of dehydration are not yet
apparent. IV fluids were administered to compensate for the condition.

I. Respiratory Status
Patient exhibited dry hacking cough with apparent use of accessory muscles for breathing, nasal flaring, and fast (RR= 24 breaths/min) and difficulty
of breathing. Condition required oxygen administration at times.

J. Circulatory Status
Patient’s blood pressure is within normal range, however pulse rate was noted to be weak at times. She also exhibited paleness and has no bleeding
tendencies or any evident blood flow obstructions.

K. Temperature Status
Patient’s temperature is within normal range prior to and during the duration of her hospital stay.

L. Integumentary Status
Patient has pale dry skin but with good skin turgor. A scar was apparent on the hypogastric area after CS, however there were no other suspicious
nevi, rash, petechiae, or ecchymoses were evident. Nail clubbing or cyanosis were not observed as well.

M. Comfort and Rest Status

Patient was generally restless as evidenced by constant attempts to take naps during the day. Such may be due to factors such as being situated in an
open medical ward, lighting, round-the-clock monitoring, and untoward feelings as part of the disease process.

IV. LABORATORY STUDY

> Laboratory results of urinalysis and CBC are not yet available.
V. PATHOPHYSIOLOGY OF DISEASE
Exposure to other patients with infectious diseases

Inhalation of infectious organism/ irritating agent

Organisms penetrate the airway mucosa

Infectious organisms multiply in the alveolar spaces

Migration of WBC to the area of infection

Migration of RBC and fibrin to the infected area

Local capillary leak

Edema
Exudate

Collection of these fluids in and around the alveoli

Alveolar wall thickens

Reduced Gas Exchange

Lung stiffens which reduces compliance and decreasing vital capacity

Alveolar collapse

Hypoxia

Cough
Shortness of Breath

Acute Respiratory Infection

VI. DRUG STUDY

Name of Action/s Indication/s Contraindications/ Side Effects Interactions Nursing Responsibilities

Drug Cautions
Generic General > Pharyngitis > Contraindicated [CNS] > dizziness, Drug- Drug: Assessment > Assess
Name: Action: As an > Tonsillitis in patients headache, malaise, [Diuretics] > may patient’s infection before
cefuroxime antibiotic- > Infections of hypersensitive to paresthesia increase risk of therapy and regularly
bactericidal, urinary and drug or other [GI] > abdominal adverse renal thereafter.
Brand kills lower cephalosporins. cramps, anal pruritus, reactions > Before giving first dose,
Name/s: susceptible respiratory > Use cautiously in anorexia, diarrhea, [Probenecid] > May obtain specimen for culture
Furoxy bacteria tracts, patients with dyspepsia, glossitis, increase drug and sensitivity tests. Begin
including > Skin & skin history of nausea, absorption and therapy pending results.
many gram- structure sensitivity to pseudomambranous increase level of > Before giving first dose,
positive and infections penicillin and in colitis, tenesmus, cefuroxime ask about patient’s
enteric gram- > Bone and joint patients with renal vomiting Drug-Food: [Any previous reactions to
negative infections impairment. [GU] > genital pruritus, food] > May increase cephalosprins or penicillin.
bacilli > Septicemia > Use cautiously in candidiasis drug absorption and > Be alert for adverse
> Meningitis pregnant and [Hematologic] > bioavailability of reactions and drug
Specific > Gonorrhea breastfeeding eosinophilia, hemolytic suspension interactions.
Action: As a > Perioperative women. anemia, > If adverse GI reactions
second- prohylaxis thrombocytopenia, occur, monitor patient’s
generation >Otitis media transient neutropenia hydration.
cephalosporin, > Acute [Respiratory] > dyspnea > Assess patient’s and
inhibits cell bacterial [Skin] > maculopapular family’s knowledge of
wall synthesis maxillary and erythematous rashes, drug therapy.
thereby sinusitis caused urticaria Planning/Implementation:
promoting by S. [Others] > > Food enhances
osmotic pneumoniae or hypersensitivity absorption of cefuroxime.
instability. H. influenzae reactions (serum > Cefuroxime axetil is
> Secondary sickness, anaphylaxis), available only in tablet
bacterial pain, induration, sterile form, which may be
infection of absecesses, warmth, crushed foor patients who
acute bronchitis tissue sloughing at cannot swallow tablets.
> Early Lyme injection site, phlebitis, Tablets may be dissolved
disease as thrombophelbitis with in small amounts of apple,
manifested by I.V. injection orange, or grape juice or
erythema chocolate milk. However,
migrans drug has a bitter that’s
difficult to mask even with
 food.
> Inject deep into large
muscle mass, such as
gluteus maximus or lateral
aspect of thigh. Before I.M.
injection, aspirate to avoid
injection into blood vessel.
> Cefuroxime is not
considered the drug of
choice for meningitis or
gonorrhea infections.
Patient Teaching: >
Instruct patient to take drug
exactly as prescribed, even
after he feels better.
> Advise patient to take
oral drug with food to
enhance absorption.
Explain that tablets may be
crushed, but drug has bitter
taste that’s difficult to
mask even with food.
> Tell patient to report any
adverse reactions.

VII. NURSING CARE PLANS

Nursing Assessment Explanation of the Objectives of Care Nursing Rationale Evaluation
Problem Interventions
S: > “Maululaw ak.” Exposure to other STO:> Within 8 Dx:> Monitor v/s and > Provides baseline data > Goal was fully met.
> “ Di ko pa kayang patients with hours of nursing record. for comparison; elevation Pt. reported a
tumayo.” infectious diseases intervention the Pt. in rates may indicate decrease in dizziness
will report dizziness worsening condition. to a tolerable level,
O:> v/s taken as Inhalation of to have decreased to a > Assess > Provides baseline data verbalized interest in
follows: infectious organism/ tolerable level, will functional level. for comparison and as increased physical
T= 36C irritating agent verbalize interest in reference for appropriate activity, and
RR= 24 breaths/min increased physical diagnosis and management. exhibited toleration
PR= 78 bpm Organisms penetrate activity, and will Tx:> Establish NPI. > Facilitates participation when sitting and
BP= 90/70 mmHg the airway mucosa exhibit toleration of both the Pt. and SOs in standing for at least
> appears weak when sitting and the management of the half an hour with
> grimaces upon Infectious organisms standing for at least condition. minimal assistance.
movement multiply in the half an hour with > Assist to > Promotes comfort;
> needs assistance alveolar spaces minimal assistance. position of comfort. Maximizes respiratory and
during movement, cardiac functions.
elimination, and in Migration of WBC to > Assist in > Promotes physical
changing clothes the area of infection movement and activity and circulation
Migration of RBC LTO:> Within 3 days repositioning. while facilitating > Goal was fully met.
A:> Activity and fibrin to the of nursing participation of Pt.; allows Pt. reported absence
Intolerance r/t infected area intervention, the Pt. further assessment of Pt. of dizziness, was able
generalized weakness will report absence of > Assist in self- > Promotes hygiene while to perform self-care
Local capillary leak dizziness, will be able care activities. facilitating participation of activities
Edema to perform self-care Pt.; allows further independently, and
Exudate activities assessment of Pt. was able to walk at a
independently, and > Assist in > Supports adequate normal pace for at
Collection of these will be able to walk feeding. nutrition while facilitating least 30 minutes
fluids in and around at a normal pace for participation of Pt.; allows without assistance.
the alveoli at least 30 minutes further assessment of Pt.
without assistance. > Assist in > Promotes waste excretion
Alveolar wall elimination. while facilitating
thickens participation of Pt; allows
further assessment of Pt.
Reduced Gas > Promote > Promotes energy
Exchange adequate rest periods. conservation and decreased
metabolic demands.
Lung stiffens which > Ensure safety. > Decreases possible
reduces compliance occurrence of falls and
and decreasing vital other injuries.
capacity > Regulate IVF to > Facilitates fluid-
prescribed rate. electrolyte replacement and
Alveolar collapse balance; support
circulating blood volume to
Hypoxemia hasten healing process.
> Administer due > Treats underlying cause
Generalized meds. of weakness and dizziness.
weakness Edx:> Encourage to > Allows continuous
verbalize any monitoring of Pt.’s
Activity Intolerance untoward feelings. condition; Facilitates
participation of the Pt. and
SOs in the management of
the condition.
> Encourage to > Ensures continuity of
gradually increase care; Facilitates circulation
activity. and
Nursing Assessment Explanation of the Objectives Nursing Rationale Evaluation
Problem Interventions
S: > “ Pakaunti-kaunti Exposure to other STO:> Within 8 hours Dx:> Monitor v/s and > Provides baseline > Goal was fully met.
lang ang kain at inom patients with of nursing record. data for comparison; The Pt. verbalized
ko.” infectious diseases intervention, the Pt. elevation in rates may interest in food and
will verbalize interest indicate worsening increased frequency of
O:> observed lack of Inhalation of in food and will condition. food and fluid intake
interest in food infectious organism/ increase frequency of > Assess nutritional > Provides baseline from twice in 8 hours
irritating agent food and fluid intake status including eating data for comparison to 4x.
A:> Risk for from twice in 8 hours habits and food and as reference for
imbalanced nutrition: Organisms penetrate to 4x. preferences. appropriate diagnosis
less than body the airway mucosa and management.
requirements r/t Tx:> Establish NPI. > Facilitates
decreased intake in Infectious organisms participation of both
relation to metabolic multiply in the the Pt. and SOs in the
need. alveolar spaces LTO:> Within 3 days management of the > Goal was fully met.
of nursing condition. The Pt. increased
Migration of WBC to intervention, the Pt. > Provide for > Supports adequate frequency of food and
the area of infection will further increase gradual increase in nutrition and fluid intake from 4x to
Migration of RBC and frequency of food and food and fluid intake. hydration. 6x in 8 hours, and
fibrin to the infected fluid intake from 4x to > Regulate IVF to > Facilitates fluid- included fluids, fruits,
area 6x in 8 hours, and will prescribed rate. electrolyte vegetables, and good
include fluids, fruits, replacement and carbohydrates/oils in
Local capillary leak vegetables, and good balance; support meals as evidence of
Edema carbohydrates/oils in circulating blood making proper food
Exudate meals as evidence of volume to hasten choices.
making proper food healing process.
Collection of these choices. > Administer due > Treats underlying
fluids in and around meds. disease.
the alveoli Edx:> Encourage to > Supports adequate
continue gradual nutrition and
Alveolar wall thickens increase in food and hydration; ensures
fluid intake. continuity of care.
Reduced Gas > Emphasize > Promotes adequate
Exchange importance of well- and proper nutrition;
balanced nutritive Facilitates cooperation
Lung stiffens which intake. of Pt. in management;
reduces compliance Promotes a change in
and decreasing vital lifestyle.
 capacity > Educate on > Promotes a change
proper food choices in lifestyle; Facilitates
Alveolar collapse and eating patterns. cooperation of Pt. in
management; Ensure
Hypoxemia continuity of care

Generalized weakness
> inability to reach
food sources

Acute Respiratory
Infection

Administration of
antibiotics

Causes gastric
irritation

Nausea

Vomiting
> sour and bitter tastes
in mouth = lack of
interest in food
> increased fluid
losses

Risk for imbalanced

nutrition: less than
body requirements