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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 Indication Analysis


Laboratory Date Ordered or Results Normal and
Procedure : Date Resulted Purposes Values Interpretation

Radiology Date Chest Radiography Nodule- haze Normal lung The result shows that
Chest (PA) Ordered : or x-ray yields densities are fields, cardiac patient are
August 17, information about evident in the size, congruent to the
2008 the pulmonary, right lung with mediastinal diagnosis of
cardiac and skeletal traction of the structures, pneumonia
systems. trachea thoracic size,
Date rightwards and ribs and
Resulted: Evaluate known or right hemi diaphragm
August 17, suspected diaphragm
2008 pulmonary disorders upwards. The
and cardiovascular right apical
disorders. pleuralis
thickened. Hazy
Monitor resolution, densities are like
progression or wise seen in the
maintenance of the left lungs base.
disease. Heart is not
enlarged body
thorax is
unremarkable.
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 Indication Analysis
Laboratory Date Ordered or Results Normal and
Procedure : Date Resulted Purposes Values Interpretation

Coplete Blood
Count

Hematocrit Date Measures the .42 .40-54 The result shows that
Ordered : concentration of the hematocrit is
August 17, WBC within the within the normal
2008 blood volume. It is suggesting that has
used to aid less chance of
diagnosis abnormal developing
Date states of hemmorhage.
Resulted: dehydration,
August 18, polycythemia and
2008 anemia
2am

Hemoglobin 145 140-180 The result shows that


This test evaluates the haemoglobin is
blood loss, within normal range.
erythropoietin IT suggests that
ability, anemia and there is enough
response to therapy. number of circulating
It is an important hemoglobin thus no
component of RBC deprivation of oxygen
that carries oxygen supply to the
and CO2 to and different body
from the tissues. organs.
Serve as a buffer to
maintain acid and
base balance in the
extracellular fluid.

White blood Cell 5.9 5-10x10 9/L


Count Test used to detect The result is within
(WBC) infection or the normal range
inflammation to
evaluate
effectiveness of
antibiotic
prescribed.

Red Blood Cell 4.99 4.5-6.3


(RBC) The result is within
Has a principal the normal range
means of delivery of
oxygen to the body
tissues via the blood

Platelet Count 233 150-400


The result is within
Platelet has the normal range
essential function in
coagulation,
homeostasis and
blood thrombus
formation

Confirm low platelet


count which can be
associated with
bleeding
Lymphocytes 0.38 0.10-0.48
The result indicates
Lymphocytes play a with in the normal
major role in body’s range.
natural defense
system

Monitor the
response on
reaction to the
Segmenters drugs of the patient 0.62 0.66 -0.70
This indicates that
the body is has low
A type of neutrophil, capacity to fight
its primary function against invading
RBC is in phagocytosis. 118 118-140 microorganisms.

Measures blood
glucose regardless
of when you last The result is within
eat. 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 Indication Analysis
Laboratory Date Ordered or Results Normal and
Procedure : Date Resulted Purposes Values Interpretation

Blood Chemistry Traditional SI

Creatinine Date Ordered to patient 1.7 0.4-1.7 The result is higher


Ordered : to diagnose 150.3 35-124 than the normal
August 17, impaired renal range which indicates
2008 function. decreased function of
the kidney.

Date
Resulted:
August 18,
2008 The result is within
5 am the normal range
Cholesterol 130.0 150-250
To test the total 3.4 3.4-6.48
amount of fatty
substance in the
blood

Helps in building up
cells and produce
hormones
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 Indication Analysis
Laboratory Date Ordered or Results Normal and
Procedure : Date Resulted Purposes Values Interpretation

Urinalysis Date Is used for basic


Ordered : screening purposes. Color : Yellow Light Yellow Urine color is within
August 17, It is a group of test to deep normal range
2008 that evaluate the amber
kidney’s ability to
selectively excrete Transparency: Urine transparency is
Date and reabsorb Clear Clear within the normal
Resulted: substances while range
August 18, maintaining water
2008 balance Ph : 6.0 Urine PH is within the
4-6.8 normal range

Monitor fluid
imbalance Sp Gravity : Sp Gravity is within
1.015 1.05-1.030 the normal range

Monitor response to Sugar is within the


the drug therapy Sugar : Negative Negative normal range
and evaluate
undesired react was Urine albumin is
to drug that may Albumin : Trace Normal/Trace within the normal
impair renal function range
Microscopic
findings:
Ordered to
determine whether Pus cells : 0.1 0-3 Pus cells is within the
the urine contains HPF normal range
substances indicate
of normally absent Less than 2 Urine RBC is within
from urine and RBC 0.1 HPF the normal range
detected by
urinalysis are Few Epithelial cells is
proteins, glucose Epithelial Cells : within the normal
acetone, blood, pus Rare range
and casts

Sputum AFB
This indicates that
This test is used to there is absence of
identify pathogenic pathogenic
organisms to microorganisms that
Date determine whether can cause diseases
Ordered : malignant cells are such as PTB.
August 17, present Negative
2008 Negative
Negative
Negative
Date
Resulted:
August 23,
2008
August 24,
2008
August 25,
2008
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 Indication Analysis
Laboratory Date Ordered or Results Normal and
Procedure : Date Resulted Purposes Values Interpretation

Fecalysis Date Fecalysis aids in this Color : Brown Brown The result shows that
Ordered : evaluation of the stool have a
August 17, digestive efficiency normal color
2008 and the integrity of
the stomach and
intestines. Consistency : Bulky The result shows that
Soft the consistency is
Date normal
Resulted: Used as a screening
August 18, or diagnostic tool Intertinal
2008 because its can Parasites: Negative The results indicates
7:20 am identify substance that there are no ova
present in, the feces Negative or parasites present
such as ova and
parasites so that
appropriate
treatment can be
ordered.
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 tract
Damage occurs to mucous membrane

Activation of the inflammatory process, release of chemical mediators

Histamine Bradykinin Prostaglandin Leukotriene Increase in


Vascular
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 in
secretions 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 Pain
Pathophysiology 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 in


Vascular
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 in
secretions 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 CARE
A.MEDICAL MANAGEMENT
a. Intravenous Fluids
Medical Date ordered
General Indications Client’s response
Management/Treatm Date performed
Description or purpose to treatment
ent Date changed

IVF: Plain Normal DO: 8-17-8 PNSS is under Used as a


Saline Solution 1L x 31- DP: 8-17-8 isotonic solution vehicle for The patient complied
32 gtts/min 8-18-8 where they have administration with the doctors
8-18-8 the same of drugs. order.
8-19-8 concentration of
8-20-8 solutes (osmolarity
DC: 8-21-8 as blood plasma).
This prevents
sudden shift of
fluids & electrolytes
in the body. This Source of
solution contains water,
154 mEq/L of Na electrolytes
and Cl. It expands and calories or
plasma and as an
interstitial volume alkalinizing
5% Dextrose and DO: 8-21-8 and does not enter agent.
Lactated Ringer’s DP: 8-21-8 the cells. The patient complied
Solution 1L x 31-32 8-21-8 5% Dextrose and with the doctors
gtts/min 8-22-8 Lactated Ringer’s order and the patient
DC: 8-22-8 Solution is a was able to maintain
hypertonic infusion normal hydration
raise serum status.
osmolality by
causing a pull of
fluids from the To prevent
intracellular and electrolyte
interstitial imbalance and
compartments into serve as a
the blood vessels. route for
They act to greatly administration
expand the for IV
intravascular medication;
compartment. Its absorbs fluid
D5NM 1L x 31-32 shows how red in the
gtts/min DO: 8-22-8 blood cells shrink interstitial cell;
DP: 8-22-8 when place in a replacement
8-23-8 hypertonic solution. of fluid, The patient complied
8-23-8 sodium, with the doctors
8-23-8 Hypertonic solution chloride and order.
8-24-8 that has osmolarity calories
8-24-8 higher than serum
8-25-8 osmolarity, when a
patient receives a
Date Terminated: hypertonic IV
8-25-8 solution, serum
osmolarity initially
increasing fluid to
be pulled from the
interstitial and
intracellular
compartment into
the blood vessels.
Nursing Responsibilities
Prior 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


Oxygen Therapy

Medical Date ordered Client’s


General Indications or
Management/Treatm Date performed response to
Description purpose
ent Date changed treatment

Oxygen occurs in For patients The patient is


Oxygen Therapy at 3-4 DO: 8-17-8 atmosphere air in experiencing relieved from
lpm via nasal canula DP: 8-17-8 approximately 20- dyspnea or dyspnea and
8-18-8 21% difficulty of decreased patients
8-19-8 concentration. It is breathing respiration rate.
8-24-8 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.
Nursing Responsibilities
Prior 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.


Date ordered
Medical
Date General Indications Client’s response
Management/Treatm
performed Description or purpose to treatment
ent
Date changed

Nebulization: DO: 8-17-8 A method of Bronchodilatio The patient complied


Combivent DP: 8-17-8 administering n and effective with the doctor’s
Neb q 6 8-18-8 medication through mucous order and was
8-19-8 the use of aerosol expectoration relieved from
8-20-8 mist. dyspnea.
8-21-8
8-22-8
8-23-8
8-24-8
8-25-8
Nursing Responsibilities
Prior 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
Date
Name of Route of
ordered General
drugs, administration, Client’s response to
Date action and Indications or
generic dosage and the meds with
performed mechanism purpose
name, Brand frequency of actual S/E
Date of action
name administration
changed

Generic name: DO: 8-17-8 IV, 750mg TID q3 (-) General action: Lower Patient complied woth
Cefuroxime DP: 8-17 8 ANST Antiinfective respiratory tract the doctors order and
Brand name: 8-23-8 Mechanism of infections due there are no
Zinacef DC: 8-24-8 action: to undesirable effect
Binds to s.pneumoniae experienced by the
bacterial cell patient.
wall
membrane
causing cell
death.
Nursing Responsibilities
Prior 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.


Date
Name of Route of
ordered General action
drugs, administration, Client’s response
Date and Indications or
generic dosage and to the meds with
performed mechanism of purpose
name, Brand frequency of actual S/E
Date action
name administration
changed

Generic DO: 8-17-8 Neb. (inhalation) q6 General action: Treatment of Patient complied with
name: DP: 8-17 8 Cholinergic COPD in those the doctors order and
Ipratropium 8-18-8 blocking drug who are on was relieved of
bromide 8-19-8 and regular aerosol. dyspnea.
Brand name: 8-20-8 sympathomimeti Bronchodilator
Combivent, 8-21-8 c therapy and
Duoneb 8-22-8 who require a
8-23-8 Mechanism of second
8-24-8 action: bronchodilator.
8-25-8 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
effect. Albuterol
is a beta 2
adrenergic
agonist that also
causes
bronchodilation.
Nursing Responsibilities
Prior 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.


Date
Name of Route of
ordered General
drugs, administration, Client’s response
Date action and Indications
generic dosage and to the meds with
performed mechanism or purpose
name, frequency of actual S/E
Date of action
Brand name administration
changed

Generic DO: 8-17-8 PO, 500mg tab General It relieves Patient complied
name: DP: 8-17 8 q4 RTC action: pain and with the doctor’s
Acetaminoph Analgesic reduces order and the
en and Anti- fever. patient’s
Brand name: pyretics temperature
Paracetamol decreases.
Mechanism
of action:
Inhibits the
synthesis of
prostaglandi
n that may
serve as
mediators of
pain and
fever,
primarily in
the CNS.
Have no
significant
anti-
inflammator
y properties
or GI
toxicity.
Nursing Responsibilities
Prior 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 Date
Route of
drugs, ordered General
administration, Client’s response
generic Date action and Indications
dosage and to the meds with
name, performed mechanism or purpose
frequency of actual S/E
Brand Date of action
administration
name changed

Generic DO: 8-17-8 – PO, 1 tab for General Symptomatic Patient complied
name: 8-25-8 loose stool action: relief of acute with the doctor’s
Loperamide DP: 8-22 8 Anti- non-specific order and was
Hydrochlorid diarrheal diarrhea relieved from
e associated diarrhea.
Brand Mechanism with
name: of action: inflammatory
Imodium Slows bowel
intestinal disease.
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
volume of
the stools,
increasing
viscosity and
decreasing
fluid and
electrolyte
loss.

Nursing Responsibilities
Prior 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.


Date
Name of Route of
ordered General
drugs, administration, Client’s response to
Date action and Indications or
generic dosage and the meds with
performed mechanism of purpose
name, Brand frequency of actual S/E
Date action
name administration
changed

Generic name: DO: 8-17-8 PO, 1 tab TID General action: For acute cough Patient complied with
Butamirate DP: 8-17-8 Cough of any etiology/ the doctor’s order and
citrate 8-18-8 Suppresants Cough was relieved from
Brand name: 8-19-8 associated with cough.
Sinecod forte Date Mechanism of thickened
discontinued: action: mucus and
8-20-8 Butamirate impaired mucus
citrate belongs transport.
to the anti
cough
medicines of
central action.
Sinecod exerts
expectorant,
moderate
bronchodilation
, and
inflammatory
action. It also
increases the
spirometery
indexes and
blood
oxygenation.
Nursing Responsibilities
Prior 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 Date
Route of
drugs, ordered General
administration, Client’s response
generic Date action and Indications
dosage and to the meds with
name, performed mechanism or purpose
frequency of actual S/E
Brand Date of action
administration
name changed

Generic DO: 8-20-8 PO, 500mg/cap General Acute and Patient complied
name: DP: 8-20-8 TID action: chronic with the doctor’s
Carbocistein 8-21-8 Mucolytics disorders of order and his
e 8-22-8 respiratory secretions partially
Brand 8-23-8 Mechanism tract loosen.
name: 8-24-8 of action: associated
Abluent 8-25-8 Its major with
action is on excessive
the mucous.
metabolism
of mucus
producing
cells. It
reduces or
prevents
bronchial
inflammation
and
bronchospas
m.
Nursing Responsibilities
Prior 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 Date
Route of
drugs, ordered General
administration, Client’s response
generic Date action and Indications
dosage and to the meds with
name, performed mechanism or purpose
frequency of actual S/E
Brand Date of action
administration
name changed

Generic DO: 8-21-8 IV, 20mg now, General For acute Patient complied
name: DP: 8-21-8 then q12 with bp action: pulmonary with the doctor’s
Furosemide 8-22-8 precaution Loop diuretic edema. order.
Brand 8-23-8
name: 8-24-8 Mechanism Upon taking the
Lasix of action: drug, undesirable
Inhibits the effects were not
readsorption experienced.
of sadium
and chloride
from the loop
Henle and
distal renal
tubule.Increa
ses renal
excretion of
water,
sodium,
chloride,
magnesium,
hydrogen
and calcium.
Effectiveness
persists in
impaired
renal
function.

Nursing Responsibilities
Prior 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 Date
Route of
drugs, ordered General
administration, Client’s response
generic Date action and Indications
dosage and to the meds with
name, performed mechanism or purpose
frequency of actual S/E
Brand Date of action
administration
name changed

Generic DO: 8-21-8 PO, 500mg tab, 1 General For Patient complied
name: DP: 8-21-8 tab OD x 3 days action: pneumonia, with the doctor’s
Azithromyci 8-22-8 Antibiotic, and lower order.
n 8-23-8 macrolide respiratory
Brand tract Upon taking the
name: Mechanism infections. drug, undesirable
Zithromax of action: effects were not
A macrolide experienced such
derived from as hypersensitivity
erythromycin reactions and GI
. Acts by disturbances.
binding to
the p site of
the 50 s
ribosomal
subunit and
may inhibit
RNA
dependent
protein
synthesis by
stimulating
the
dissociation
of peptidyl t-
RNA from
ribosomes.
Nursing Responsibilities
Prior 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.
Date
Name of Route of
ordered General
drugs, administration, Client’s response to
Date action and Indications or
generic dosage and the meds with
performed mechanism purpose
name, Brand frequency of actual S/E
Date of action
name administration
changed

Generic name: DO: 8-24-8 IV, 1 gm q12 General action: For lower Patient complied with
Ceftriaxone DP: 8-24-8 Antibiotic, respiratory tract the doctor’s order and
Na cephalosporins infections and the occurrence of
Brand name: pneumonia. severe infection is
Chevron Mechanism of reduced. And also he
action: experienced slight
They kill the discomfort when
bacteria to infusing of the
form cell walls. medication is done.
The bacteria
therefore
break up and
die.
Nursing Responsibilities
Prior 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 Date
Route of
drugs, ordered General
administration Client’s response
generic Date action and Indications
, dosage and to the meds with
name, performed mechanism or purpose
frequency of actual S/E
Brand Date of action
administration
name changed

Generic DO: 8-24-8 PO, 1 capsule General action: Prophylaxis Patient complied
name: DP: 8-24-8 TID Sympathomim and with the doctor’s
Albuterol 8-25-8 etic treatment of order and
Brand bronchospas demonstrated
name: Mechanism of m due to improvement in
Ventolin action: reversible breathing pattern.
Stimulates obstructive
beta-2 airway
receptors of disease.
the bronchi,
leading to
bronchodilatio
n.
Nursing Responsibilities
Prior 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

Date
ordered
Type Client’s response
Date General Indications or Specific foods
Of and/or reaction to
performed Description purpose taken
Diet the diet
Date
changed

Soft Diet DO: 8-17-8 The texture of food To rest the GI Water, grapes, Patient complied with
DP: 8-17-8 is soft. It can be tract of the gruel the doctor’s order.
8-18-8 nutritionally patient.
8-19-8 adequate, but
8-20-8 prophylactic
8-21-8 supplementation of
8-22-8 diets with vitamins
8-23-8 and minerals is
8-24-8 recommended if for
8-25-8 long term use.
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.
Date
ordered
Type Client’s response
Date General Indications Specific
Of and/or reaction
performed Description or purpose foods taken
Activity to the diet
Date
changed

Complete Patient is To avoid Water, gruel He was able to take


Bed Rest prohibited to discomfort, a rest and
strenuous restore whenever he wants
B activities/ energy, and to eat or change
O exercises. to decrease position he asked
O oxygen for assistance.
K consumption
-b thus
A decreasing
S the work
E load of the
d heart. Water, gruel
Deep Respiratory
Breathing functioning can
Exercise be facilitated by To enhance
deep breathing lung
exercises to expansion
remove and mobilize
secretions from secretions,
the airways. A thereby
commonly preventing
employed atelectasis
breathing and
exercise is pneumonia.
abdominal
(diaphragmatic)
and pursed-lip
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
Nursing Responsibilities
Prior 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 Nursing Scientific Planning Nursing Rationale Evaluation
nt Diagnosis Explanation Intervention

S= patient Ineffective Community- Short Term > Assess > Abnormal Short
may Airway Acquired : respiratory breathing patterns Term :
verbalize Clearance Pneumonia is the status: breath may signal
“magkasaki related to inflammation of After 5 sounds, worsening of The patient
t ku retained the lung hours of respiratory rate, condition: flaring of shall be
papalwal secretions in parenchyma Nursing oxygen nostrils indicate a able to
ing plema the bronchi when the Intervention saturation, note significant decline in expectorate
pag ( increased offending s, the abnormalities respiratory status: mucous as
manguku thick organism patient will such as dyspnea, assessment evidenced
ku.” mucous reaches the expectorate presence of establishes baseline by
secretions) alveoli via mucous as cyanosis, use of and monitor productive
and lung droplets or saliva evidenced accessory response to cough
O=Patient inflammatio in whi8ch goblet by muscles, flaring interventions effective
Manifeste n leading to cells produces an productive of nostrils coughing
d the accumulatio outpouring fluid cough, and
following : n of mucous into the alveoli. effective > Assess anxiety > Being unstable to breathing
in the The organisms coughing and reassure breath causes exercise
>appears alveoli multiply in the and patient ć anxiety and fear:
weak serous fluid and breathing presence the patient needs a
the infection is exercise calming presence:
>pale spread. The anxiety increases
palpebral organisms the demand for
conjunctiva damage the host Long oxygen
by their Term : > Place patient Long Term
>ć rales on overwhelming in high fowler’s > Maximize chest :
both lung growth and After 2 days position and excursion and
lobes upon interference with of Nursing support ć subsequent The patient
will
chest lung function Intervention overbed table as movement of air
maintain
auscultatio leading to s, the needed. airway
patency as
n massive patient will
evidenced
accumulation of maintain > Encourage by clear
breath
>ć difficulty mucus. airway expectoration of > Thickened
sounds,
of Disruption of the patency as secretions and secretions of Cap re absence of
dyspnea,
breathing mechanical evidenced assess the more likely to
etc.
defenses of by clear viscosity amount occlude the airway:
> shortness cough and ciliary breath and color of making this
of breath motility leads to sounds, secretions observation would
the colonization absence of allow for
> ć non- of the lungs and dyspnea, implementation if
productive accumulation of etc. measures to thin
cough secretions in the and loosen the
alveoli and > Assist the secretions
Patient bronchi leading patient ć
may to ineffective coughing and > Mobilizes
manifest airway clearance deep breathing secretions and
the as evidence by prevent atelectasis
following : non-productive > Increase fluid
cough etc. intake
>decreased alveolar > Assists with
oxygen
exudates tend to liquefying secretions
saturation
consolidate, and enhancing
> Cyanosis
increasingly ability to clear
>Tachypne
a difficult to > Provide for airways
expectorate. periods of rest
>Abnormal
blood gases and activity, > Decrease demand
(decreased
assisting ć for oxygen
O2,
Increased devices as
CO2)
needed
>
Restlessnes
> Elevate head
s
of bed/ change of

Orthopnea position every 2 > To maintain an
hours open airway and to
> Flaring of
nostrils take advantage of
gravity decreasing
pressure on the
diaphragm and
enhancing drainage
> Assist of secretions.
respiratory
therapist ć the >This causes
administration of bronchiodilation to
nebulizer ease breathing

> Establish
intravenous > Ensures a route
access as for rapid- acting
ordered medications

> Assess arterial


blood gases >ABG provide data
(ABG) for treatment
regarding the lungs’
ability to oxygenate
tissues
> Provide
humidified > Loosen
oxygen as secretions, making
ordered to them easier to
maintain O2 expectorate ć
saturation >90% coughing: improves
oxygenation

Problem No. 2 Impaired Gas Exchange


Assessment Nursing Scientific Planning Nursing Rationale Evaluatio
Diagnosis Explanation Intervention n
S= patient Impaired Community- Short Term > Perform a > Because airway Short
may Gas Acquired : complete inflammation and Term :
verbalize Exchange Pneumonia is respiratory mucous The
“magkasakit related to defined as a After 8hours assessment ; accumulation, patient
ku inflamed lower respiratory of Nursing respiratory rate, pneumonia can shall be
mangisnawa lung tissue tract infection of Intervention rhythm, chest cause fluid in the relieved
ampo agad and the lungs s, the expansion, ease lungs and increase from
ku papagal consolidati parenchyma with patient will of breathing, use the work of dyspnea
gang on of onset in the be relieved of accessory breathing, resulting by
maglakad mucous / community or from muscles, pursed in impaired gas participati
kumu.” ffluid in during thre first dyspnea by lip breathing, exchange. These ng in
specific 2days of participating breath sounds, assessment provide breathing
lung lobes hospitalization. in breathing mucous data use for planning exercise,
O=Patient preventing Pneumonia exercises, expectoration, Interventions and effective
Manifested transfer of occurs when the effective perioral cyanosis, assessing progress. coughing
the gases offending coughing tachypnea, Sputum cultures and use of
following : across the organism and use of dyspnea, pulse identify the causative oxygen as
alveolar stimulate oxygen as oximetry and organisms, arterial evidenced
>difficulty of capillary inflammatory evidenced monitor blood gases by
breathing cellular response the by absent of laboratory and demonstrate absence of
membrane defense nasal diagnostic decreased oxygen nasal
>nasal mechanism of flaring, procedures such concentration, chest flaring,
flaring the lung lo9se shortness of as sputum x-ray will confirm the shortness
effectiveness breath, easy cultures, presence of fluid in of breath,
>shortness and allow fatigability, complete blood the lungs or areas of easy
of breath/ organisms to etc. count, arterial consolidation fatigability.
exertional penetrate the blood gases, etc. Etc.
discomfort sterile, lower
respiratory tract, Long > Obtain
>with where Term : subjective data > knowledge of the
presence of inflammation from the patient patient respiratory
crackles on develops. After 1 to 3 or significant status contributes to Long
both lung Inflammation days of other, including information that can Term :
lobes upon occurs due to Nursing history of chronic assist in
auscultation colonization of Intervention respiratory determination other The
patient
offending s, the disease and factors that may
shall have
> with non organization patient will history of have contributed to an
improved
productive wherein there is have an smoking pneumonia or
ventilation
cough the release of improved influence its and
adequate
chemical ventilation > Assist patient treatment
oxygenatio
> easy mediators, and to semi fowler’s n of lung
tissue as
fatlgability attraction of adequate position > Sitting upright
evidenced
neutrophils, oxygenation allows the diaphragm by normal
arterial
> Patient accumulation of of lung to descend, resulting blood
hooked to O2 gases,
fibrinous tissue as >Take in easier breathing
therapy 2-3 clear
LPM exudates, red evidenced temperature Breathing
sounds,
blood cells and by normal every 4 hours > Infectious
absence of
Patient may
macrophages. arterial processes can cause purulent
manifest discharges
These would in blood gases, an increase body
, etc.
the
turn trigger patient will > Provide temperature
following :
erythema have a clear comfort
swelling, edema breath measures >Following
>abnormal
and stimulation sounds, change linen or temperature spikes,
blood gases /
arterial ptt of nerve fibers, absence of clothing linen and clothing
( hypoxia,
leading to pain. purulent may become
increase CO2
) Goblet cells will discharge saturated with
increase mucus perspiration
>Diaphoresis
production in
>Tachycardi
attempt to dilute > Encourage > Helps thin and
a
amd wash away adequate fluid liquefy secretions
> abnormal
offending intake to 2000
rate rhythm,
depth of organisms out of cc/day
breathing
the respiratory
tract. Inflamed > Assess mucous >Helps to detect
> abnormal
fluid-filler amount, color improving status of
skin color
(pale, dusty) alveolar sacs consistency. pneumonia, amount
cannot exchange should be decreasing
> abnormal
capillary refill O2 and CO2 and viscosity should
effectively be thinning following
>Restlessnes
s leading to interventions; green,
hypoxia of the brown or purulent
>Confusion
lung tissue and a mucus indicate
>O2
significant continued presence
saturation of
less than ventilation- of pneumonia
90%
perfusion
>fever mismatch >Encourage >Coughing and deep
coughing and breathing cause

deep breathing alveoli to open and
O2
with mucous loosen mucous to
expectoration help clear the
airways

> Provide chest


physiotherapy >Loosen mucous

postural plugs thus increasing
drainage, chest are available for gas
percussion and exchange
vibration

> Elevate head


of bed > To maintain
airway patency
> Encourage
frequent position >Promotes optimal
changes chest expansion and
drainage of secretion
> Encourage
adequate rest > Helps limit oxygen
and limit needs/ consumption
activities to with
in patient
tolerance.
Promote calm
and restful
environment

> Administer >Pneumonia


oxygen as increased mucous
ordered production and fluid
retention in lungs
which decreases
adequate gas
exchange;
supplemental oxygen
provides additional
oxygen for tissue
oxygenation

>Administer >Helps to stop the


antibiotic as proliferation of
ordered and microorganisms
monitor for side
effects.

Ado
Problem No. 3 Ineffective Breathing Pattern
Assessment Nursing Scientific Planning Nursing Rationale Evaluation
Diagnosis Explanation Intervention
S= patient Ineffective Community- Short Term > Assess > Any of this Short
may breathing Acquired is a : respiratory abnormalities would Term :
verbalize pattern disease process system by noting indicate the studies
“Magkasakit related to involving After 4 respiratory rate, of the respiratory The patient
ku thick inflammation of hours of depth chest system and shall have a
mangisnawa. tenacious lung tissue. It Nursing expansion, progression of normal
” secretions typically results Intervention breath sounds, disease; also respiratory
in the when s, the arterial blood establishes a rate,
bronchi microorganisams patient shall gases, etc. baseline comparison rhythm,
O=Patient due to enter the have a depth of
Manifested inflammati normally sterile normal >maximizes breathing
the on of lung lungs from the respiratory > Assist Patient thoracic cavity and relief
following : tissue nasopharynx and rate, in assuming a space, decreases from
produces rhythm, high- fowler’s pressure from shortness
>difficulty of inflammation of depth and position or diaphragm and of breath as
breathing the lung reports a position of choice abdominal organs evidence by
parenchyma. shortness of such as leaning and facilitates use of decrease
>shortness Because of the breath as forward or over accessory muscles RR from 38
of breath on inflammation of evidence by bed table cpm to 16-
exertion, the alveoli are decrease RR >help to improve 20 cpm
paleness filed with fluid from 38 > Increase oral hydration status and
and mucus and cpm to 16- fluids to 2000- decrease secretions.
>RR of 38 oxygen and 20 cpm 3000 ml/day as
cpm with carbon dioxide tolerated
shallow, exchange cannot > mobilizes thick
rapid take place at a Long > Provide chest secretions, and
breathing alveolar capillary Term : physiotherapy, facilitates clearing
cellular bronchial of lung fields. Long Term
>use of membrane level After 2 days tapping, :
supraclavicul due to blood flow of Nursing vibration, etc. The patient
shall be
ar muscles decreases Intervention >patient with
free from
for (deceased s, the >Assist with pneumonia may lack any signs
and
respiration as perfusion of patient shall activities of daily sufficient oxygen
symptoms
well as blood in the be free from living as required reserves to perform of hypoxia
as
shoulder lungs)and any signs activites; even
evidenced
muscles leukocytes and and eating may cause by normal
ABG, etc.
fibrin consolidate symptoms severe dyspnea
> ć non- in the affected of hypoxia
productive part of the lung as > Knowing how to
cough due to a evidenced > Teach patient control shortness of
decreased blood by normal how to decrease breath will help
> with flow there is a ABG, etc. shorthness of cope and have
presence of decreased supply breath by optimal functioning
rales on both of oxygen to restructuring
lung lobe other tissues activities
upon chest leading to > Preventing spread
auscultation ineffective >Teach of infection and
easily breathing pulmonary subsequent
fatigability pattern hygiene; hospitalization
prevention of
Patient may spread of
manifest infection
the >Provide some
following : >Provide supplemental
humidified low oxygen to improve
>severe flow of oxygen as oxygenation and to
dyspnea
ordered make secretions
less viscous
> sitting up
leaning
forward, >Enhances
hands on
>Administer expectoration of
knees
bronchodilators secretions of
and expectorants previously
>Abnormal
blood gases ineffective cough
> abnormal
inspiratory
>Helps to prevent
or/and
expiratory > Administer or eradicate
ration
antibiotics as infections to reduce
> pursed lip ordered secretions and to
breathing
end to inflammation
> altered
chest
excursion

>hypoxia
(Confusion,
restlessness,
decreased
vital
capacity)
Problem No. 4 Hyperthermia
Assessment Nursing Scientific Planning Nursing Rationale Evaluation
Diagnosis Explanation Intervention

S= patient Hyperther CAP is the Short Term > Monitor body >To have a baseline Short
may mia inflammation of : core temperature data Term :
verbalize the lung The
“Mapali ku parenchyma due After 4 >Note presence >Evaporation is patient’s
panandman . to offending hours of or absence of decreased by body
” organisms, Nursing sweating as body environmental temperatur
inflammatory Intervention attempts to factors of high e shall have
lung response s, the increase heat humidity and high decreased
O=Patient will be patient’s loss by ambient from 38oC
Manifested stimulated body evaporation, temperature as well to 37oC.
the leading to the temperature conduction, as the body factors
following : release of will diffusion producing loss of
chemical decrease ability to sweat
>flushed skin mediators that from 38oC to
would increase 37oC. >Promote heat loss
>skin is blood flow to the > promote by radiation,
warm to lung tissues surface cooling conduction and
touch leading to by means of evaporation
erythema, loose clothing; Long Term
> increased swelling, pain, Long cool :
RR and increased Term : environment/fan;
The patient
body cool/tepid
shall have
> temperature that After 24 sponge bath maintained
a normal
Diaphoresis would reset the hours of local icepack
body
hypothalamus Nursing especially in the temperatur
e during
Patient may which is the Intervention axilla and groin >indicates need for
hospitalizati
manifest major center for s, the prompt ons and be
free from
the regulation of patient will > Review signs interventions
any
following : body maintain a and symptoms of complicatio
ns of
temperature normal body hyperthermia
pneumonia.
>Convulsions temperature > to increase
during >Encourage the resistance
>
Hypotension hospitalizati patient to take
ons and be vitamin C in the
>Fluid and
electrolyte free from diet such as
imbalance
any citrus fruits, etc.
complicatio > To prevent
ns of >Discuss dehydration
pneumonia. importance of
adequate fluid
intake
>To reduce
>Maintain bed metabolic demands/
rest oxygen
consumption

>Provide high- > to meet increased


calorie diet metabolic demands

>Provide >To offset increased


supplemental oxygen demand and
oxygen consumption

>administer anti- >To control


pyretics as shivering and
ordered seizure

Problem No. 5 Activity Intolerance


Assessmen Nursing Scientific Planning Nursing Rationale Evaluation
t Diagnosis Explanation Intervention

S= patient Activity The onset of Short Term > Obtain >Helps to determine Short
may Intolerance pneumonia is : subjective data the effects of Term :
verbalize related to generally marked from patient pneumonia on the
“magkasakit increased by fever, After 4 regarding normal patient’s ability to The patient
ku oxygen dyspnea, and hours of activities prior to be active. shall be
mangisnawa demand shortness of Nursing onset of able to
ampo with breath and easy Intervention pneumonia; perform
mimingal ku activity and fatigability that s, the monitor for >If increased activities of
gan hypoxia may lead to patient is labored physical activity daily living
maglakad (lack of inability to able to breathing, causes shortness of without
kumu.” oxygen perform perform fatigue and breath, activity shortness
supply with activities of daily activities of exhaustion. should be reduced of breath
O=Patient oxygen living. daily living until oxygenation is such as
Manifested demand) without > Reduce level adequate. doing
the Due to the shortness of of activity as personal
following : accumulation of breath such required in hygiene,
thick tenacious as doing response to > Conserves energy etc.
> appears mucous in the personal shortness of and reduces oxygen
weak alveoli altering hygiene, breath. demand patients
gas exchange etc. with pneumonia lack
> poor skin ( oxygen and enough oxygen
turgor carbon dioxide) > Assist with reserves to perform
between the activities as activities Long Term
>pale nail alveoli And needed. independently. :
beds Long
The patient
Term : >It conserves
shall states
>Pace activities energy. that he is
comfortable
> easy After 24 and encourage
with
fatigability hours of periods of rest activity
performanc
Nursing and activity > Use the result to
e and
Intervention during the day. indicate when the shortness
of breath is
> non- s, the activity may be
improved
productive patient increased or following
cessation of
cough states that decreased.
activity,
he is > Monitor VS and and the
patient’s
>shortness comfortable oxygen > Activities should
RR returns
of breath with activity saturation before be increased to baseline
within 5
during performanc and after gradually, as
minutes.
activities e and activity. tolerated, to avoid
shortness of over taxing the
> RR of 38 breath is patient.
cpm, with improved > Gradually
shallow, following increase activity
rapid cessation of as tolerated and > Physical activity
breathing activity, and share guidelines increases endurance
the patient’s for progression and stamina;
RR returns with patient. following
Patient to baseline pneumonia, return
may within 5 to normal activity
manifest minutes. > Discuss with may take time.
the the patients
following : activities that
would be > This indicate
>Inability to appropriate once intolerance to
perform
at home that activity and the
physical
activities would be within level of activity
the patient’s should be
> level I activity evaluated.
functional
tolerance.
level
classificatio
n ( walk,
regular
phase, on > Iron has a role in
level
> Inform the oxygen transport
indefinitely;
one flight or patient to stop and increases
more but
any activity that energy level.
more
shortness of produces
breath than
shortness of >To prevent
normal)
breath. injuries.
>labored
breathing
> Encourage >Improves
>physical
intake of foods oxygenation and
exhaustion
high in iron and provides oxygen
>oxygen
good source of reserves to be used
saturation
less than energy such as with increased
90%
lean meat, demand.
 legumes which
phy
are rich in
protein.

> Assist patient


to learn and
demonstrate
appropriate
safety measures.
> Have the
patient use
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 Discharged

17 25
18 19 20 21 22 23 24

NURSING PROBLEMS
Ineffective Airway Φ
Clearance Φ
Impaired Gas Exchange Φ
Ineffective breathing Φ Φ
Pattern Φ Φ Φ Φ Φ Φ Φ
Hyperthermia
Activity Intolerance
38.7 37.6 36.2 36.4 36.3 36.9 36.8 36.6 36.4
VITAL SIGNS 90 80 79 76 90 90 95 80 82
Temperature 38 24 24 20 26 24 21 20 20
Pulse Rate 120/80 120/70 120/70 110/80 120/70 10/70 110/80 110/70 130/10
Respiratory Rate 0
Blood Pressure
Φ
LABORATORY / Φ Φ
DIAGNOSIS Φ
Chest X-ray Φ
Sputum AFB Φ
Φ
Blood Chemistry Φ
Complete BLood
Count(CBC)
Urinalysis Φ Φ Φ Φ
Fecalysis Φ Φ
Φ Φ Φ
MEDICAL MANAGEMENT Φ Φ Φ Φ Φ Φ Φ Φ
PNSS 1L x 8 hours Φ Φ Φ Φ Φ
D5LRS 1L x 8 hours
D5NM 1L x 8 hours
Nebulization Φ Φ Φ Φ Φ Φ Φ
O2 Therapy Φ Φ Φ Φ Φ Φ Φ Φ
Φ Φ Φ
DRUGS
Cefuroxime 750 mg TID Φ
Combivent neb q 6 hours
Paracetamol 500mg Tab Φ Φ Φ Φ Φ
q 4 RTC Φ
Loperamide 1 Tab for Φ Φ Φ Φ
loose stool
Carbocesteine 500mg 1 Φ Φ Φ
cap TID
Furosemide 20 mg IV Φ
now then q 12 ć BP
precaution Φ Φ Φ
Azithromycin 500 mg Φ
Tab 1 tab OD x 3 days Φ
Ceftriaxone 1gm IV q 12
ANST (-)
Sinecod 1 Tab TID Φ Φ Φ Φ Φ Φ Φ Φ
Ventoline Expectorant Φ
Capsule 1 cap TID

DIET
Soft
2 DISCHARGE PLANNING
a. 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