CHIEF

COMPLAINTS:

• Difficulty of Breathing

• Productive Cough

• Fever
 NURSING HISTORY
• HISTORY OF PRESENT ILLNESS
Months PTC, patient had cough, productive
sticky on and off, relieved by nebulization and
regular checking with private MD. prescribed with
unrecalled medication which affected temp. relief.
3 days PTC, recurrence cough, productive time
to time with associated fever. Given biopsy.
Nebulization continued.
Few hrs PTC, after Visiting a private MD and
prescribed become medications, patient
complained of chest heaviness and sudden onset
of unresponsiveness and cyanosis.
NURSING HISTORY
• PAST MEDICAL HISTORY

Had a chronic smoker's cough for "10 or

15 years" which relative describes as being
mild, non-productive and occurring most
often in the early morning
Smoked 3 packs of cigarettes a week for
the past 50 years
A retired fireman, who has been treated
for mild hypertension, bronchitis,
appendicitis (as a young adult)
NURSING HISTORY
• GENOGRAM
PHYSICAL ASSESSMENT
• A. Vital Signs
T: 39.2 o C RR: 22 cpm
PR: 70 bpm BP: 100/70 mmHg

• B. Integumentary
- Skin: Light to deep brown
Poor Skin turgor
(+) Blisters
(+) lesions
(+) edema in the left carpal
(+) mass
(+) rashes
(+) Pallor
PHYSICAL ASSESSMENT
- Hair: Unevenly distributed hair
Thin hair
(-) lesions
(+) dandruff
(-) lice

- Nails: Prompt to return in pink color

Angle of nails about >1650
Clubbed fingers
Intact epidermis
(+) capillary refill test
PHYSICAL ASSESSMENT
• C. Head and Neck
- Head: Size: Normocephalic
Asymmetrical facial features and
movement
(-) nodules or masses
Rough skull contour

- Eyes: Blurred O.U Visiona

Eyebrows of hair in unevenly
distributed
Puffy lower eyelids
Darkened areas around the eyes
Skin broken
PHYSICAL ASSESSMENT
- Eyes: (+) discharge; (+) discoloration
Eyelids is asymmetrical
7 involuntary blinks per minute
pale conjunctiva
(-) edema over lacrimal gland
3 mm in diameter; round, smooth
border, iris flat
Both eyes are uncoordinated
PHYSICAL ASSESSMENT
- Ears: External ear color: same as the
facial skin
decreased hearing perception
(+) discharge
(-) masses at sinuses
Auricle aligned with outer
canthus of eye
PHYSICAL ASSESSMENT
- Nose: Symmetric; straight

(+) discharge

(+) lesion

Uneven color

Pale mucosa

Nasal septum intact and in midline

PHYSICAL ASSESSMENT
- Mouth: Outer lips: pale color
rough texture
Unable to purse the lips
Gums: Pale & dry
Tongue: unable to move freely
(+) nodules
Soft Palate: pale, rough
Hard Palate: pale, irregular
Pharynx: (+) discharge
(+) Sputum
(+) Cough
Depressed gag reflex
PHYSICAL ASSESSMENT
- Neck: Muscle equal size; head centered
(+) nodules or masses
Trachea: in the middle: spaces are equal in both
sides
Thyroid gland: ascends during swallowing; not
visible
(-) bruit
(+) Endotracheal tube
(+) Face mask
PHYSICAL ASSESSMENT
• D. Thorax and Lungs
Chest symmetrical
shallow, weak, arhythmic & effort
respiration
(+) Crackle sound & adventitious sound
under oxygen therapy
• E. Breast and Axillae
Axillary: (-) tenderness & masses
• F. Heart
(+) Irregular heart sounds
PHYSICAL ASSESSMENT
• G. Abdomen
Uneven color
(+) lesion; (+)pigmentation
Asymmetrical contour
Asymmetric movement caused by
respiration
(+) PEG
• H. Genitourinary
(+) Lesion
(+) indwelling catheter
PHYSICAL ASSESSMENT
• I. Musculoskeletal
decreased immobility
(+) tremors
Uncoordinated movements
Joints immovable
Weak on both sides
PHYSICAL ASSESSMENT
• J. Neurological
Language: (+) defects
Unable to communicate verbally
Oriented
Memory: unable to recall recent &
remote memory
Attention Span: limited
Motor function: unable to move
independently, flat on bed
Pain Sensation: unable to distinguish
“sharp” to “dull
Reduced level of consciousness
SIGNIFICANT SIGNS AND
SYMPTOMS
 Problems in breathing
 Adventitious Breath Sound
Coughing that produces
greenish and yellow sputum
Fever
 Cyanosis
 Nail Clubbing
 DIAGNOSTIC
EXAMINATION
•Sputum Tests:
Blood, which means an infection is
present.
Color and consistency: If it is yellow,
green, or brown, an infection is likely.

•Blood test:
WBC 17,000/mm3; neutrophils 70%,
bands 15%, lymphocytes 15%.

•Chest x-ray:
Reveals a patchy left lower lobe
infiltrate
DEFINITION
 DEFINITION

Streptococcus pneumoniae
PHYSIOLOGY
Upper Respiratory Tract :

NARES

NASO PHARYNX

EPIGLOTTIS
Lower Respiratory Tract :
TRACHEA
TRACHEA
LARYNX
(BIFICATES INTO 2 BRONCHI)

BRONCHIOLES

UPPER

ALVEOLAR DUCTS

ALVEOLAR SACS
PATHOPHYSIOLOG
Y
 RISK FACTORS
Conditions that produce mucus
or bronchial obstruction
Immunosuppressed patients
Smoking
Prolonged immobility
Depressed cough reflex, aspiration
RISK FACTORS
NPO status, placement of NGT

Antibiotic Therapy

Alcohol intoxication

General anesthetics, sedative, opioid

preparation

Respiratory therapy

Advance age (non-modifiable)

NURSING DIAGNOSIS
Actual:
 Ineffective airway clearance due to
inflammation of bronchi as manifested by
accumulation of bronchial secretion
Impaired gas exchange related to
inflammatory process, collection of secretion
affecting oxygen exchange across alveolar
membrane
Activity intolerance related to imbalance
between oxygen supply and demand,
general weakness
 NURSING DIAGNOSIS
Probable:

Risk for aspiration related to decreased gag

reflex
Risk for impaired skin integrity related to
decreased oxygen supply in the blood circulation
Nursing Care Plan
I. ASSESSMENT
Subjective:
“Kapag gising niya panay ang ubo niya,” as
verbalizad by the patient’s relative

Objective:
-Respiration-22 cpm
-O2 Saturation- 94%
-Presence of secretion
-Inspiratory crackles with adventitious breath
sounds right base
-Increased sputum production
NURSING DIAGNOSIS
Ineffective airway clearance due to
inflammation of bronchi as manifested
by accumulation of bronchial secretion

PLANNING
After an hour of nursing intervention the
patient will be able to expectorate
secretions
INTERVENTION
A. Monitor respirations and breath sounds, rate,
rhythm, and effort
-To check for any improvements and
abnormal changes

B. Auscultate breath sounds and assess air

movement to ascertain status and note
progress
-To assess the status

C. Monitor pulse oximeter

- To check for any improvements and
abnormal changes
INTERVENTION
D. Place client in semi-fowlers position
-To facilitate breathing and lung expansion

E. Encourage coughing and deep breathing

exercise
-To promote wellness

F. Increase fluid intake to at least 1000ml/day

- To loosen secretions for easily release
EVALUATION
The patient will be able to expectorate secretions
II. ASSESSMENT
Subjective cues:
No subjective cues

Objective cues:
-With oxygen via face mask
through endotracheal tube
-Pallor
-Shortness of breathing
-Irregular breathing pattern
NURSING DIAGNOSIS
Impaired gas exchange related to inflammatory process, collection of
secretion affecting oxygen exchange across alveolar membrane
PLANNING
-After an hour of nursing intervention
the patient will be able to demonstrate
improve ventilation and adequate
oxygenation of tissues by ABG’s within
the client’s normal limits
INTERVENTION
A. Monitor respiratory status
-to assess for any clinical manifestations
respiratory distress
B. Place client in semi-fowler’s position
-to promote lung expansion
C. Encourage deep breathing exercise
-provides for adequate oxygenation
D. Maintain oxygen administration device as
ordered
- provides for adequate oxygenation
E. Change patient’s position every 2 hours
- To facilitate secretion movement and
drainage
EVALUATION

-After an hour nursing intervention the

patient will be able to demonstrate
improve ventilation and adequate
oxygenation of tissues by ABG’s
within the client’s normal limits
III. ASSESSMENT
Subjective cues:
“Palagi na lang siya nakahiga”, as verbalized
by the patient’s relative

Objective cues:
Excessive coughing
Presence of respiratory problems
Development of pallor
 NURSING DIAGNOSIS
Activity intolerance related to imbalance
between oxygen supply and demand,
general weakness
PLANNING
At the end of the shift the client
will be able to demonstrate a
measurable increase in
tolerance to activity with
absence of dyspnea and
exercise fatigue
INTERVENTION
A. Evaluate patient’s response to activity
-Reduce stress and excess stimulation,
promoting rest

B. Provide a quiet environment and limit

visitors
-Bed rest is maintained during acute phase
to decrease metabolic demands, thus
conserving energy for healing

C. Explain importance of rest in treatment plan

- Reduce stress and excess stimulation,
promoting rest
EVALUATION

At the end of the shift the client will be able

to demonstrate a measurable increase in
tolerance to activity with absence of
dyspnea and exercise fatigue
VII. ASSESSMENT
Subjective cues:
-No subjective cues

Objective cues:
-impaired swallowing
-depressed cough and gag reflex
-reduced level of consciousness
NURSING DIAGNOSIS
Risk for aspiration related to
depressed gag reflex
PLANNING

At the end of shift the client will

be able to exhibit preventions of
aspiration
INTERVENTION
A. Assess and monitor amount and
consistency of respiratory secretions
-To assess contributing factors
B. Assess and monitor strength of cough
and gag reflex
-To assess causative factors
C. Auscultate lung sounds frequently
-To determine presence of secretions
D. Encourage coughing and deep
breathing exercise
-To loosen secretions
E. Provide chest physiotherapy
-To loosen secretions
F. Maintain suction equipment at bedside
-As needed to clear secretions at the
respiratory tract and oral cavity
G. Turning patient to semi-fowler’s
position
-To prevent gastroesophageal reflux
EVALUATION

At the end of shift the client will

be able to exhibit preventions of
aspiration
VIII. ASSESSMENT
Subjective cues:
- No subjective cues

Objective cues:
- Weak joints
- Decreased immobility
- cyanosis
NURSING DIAGNOSIS
Risk for impaired skin integrity related to
decreased oxygen supply in the blood
circulation
PLANNING
At the end of the shift, the client will
be able to prevent the risk for skin
integrity
INTERVENTION
A. Elevate the lower extremities every
15 minutes
-To promote venous return
B. Massage the upper and lower
extremities
-to promote blood circulation
C. Repositioning every 2 hours
-to prevent pressure ulcers
D. Encourage Deep Breathing exercise
-To promote gas exchange
E. Provide oxygen therapy
- for adequate oxygenation
F. Assist patient in turning side to side
-To promote mobilization
Evaluation
At the end of the shift, the client
will be able to prevent the risk
for skin integrity
 DRUG STUDY
GENERIC: Ceprofloxacin
BRAND: Cipro XR
Classification: Antibiotic
Drug Action: broad-spectrum antibiotic that is
active against both Gram-positive and Gram-
negative bacteria. It functions by inhibiting DNA
gyrase, a type II topoisomerase, and
topoisomerase IV, enzymes necessary to separate
bacterial DNA, thereby inhibiting cell division.
Side effects: Dizziness, Fever, Headache, Sore
throat, Skin rash, Nausea and vomiting, Sleep
problems, Anxious, Increased sensitivity to sunlight
exposure
 DRUG STUDY
Indication: Urinary tract infection, Chronic
bacterial prostatitis, Lower respiratory infection,
Acute sinusitis, Skin infection, Typhoid fever
Contraindication: Pregnancy, Breast feeding
mother, Kidney diseases, STD, Pedia
Nursing Intervention:
•Advise patient not to take with dairy products
•Assess patient for any kidney disease, joint
problems, hypokalemia
•Avoid taking antacid, vitamin supplements, or
chewable tablets 6 hours before of 2 hours after
taking ceprofloxacin
 DRUG STUDY
GENERIC: Metronidazole
BRAND: Flagyl
Classification: Antiamoebics, Antibiotics
Drug Action: Antibiotic effective against
anaerobic bacteria and certain parasites.
Anaerobic bacteria are single-celled, living
organisms that thrive in environments in
which there is little oxygen (anaerobic
environments) and can cause disease in the
abdomen (bacterial peritonitis), liver (liver
abscess), and pelvis (abscess of the ovaries
and the Fallopian tubes)
 DRUG STUDY
Side effects: Nausea, Diarrhea, Vomiting,
Dizziness, Headache, Rash, Itch, Fever, Dark
urine
Indication: Anaerobic bacterial infection
Contraindication: Hypersensitivity, History of
blood dyscrasias, Active organic disease of CNS,
1st trimester of pregnancy, lactation
Nursing Intervention:
•Avoid alcohol intake
•Check the blood glucose level of the patient
before administration of drug
•Assess for liver problems, seizure disorder and
any allergies
 DRUG STUDY
GENERIC: Ansimar
BRAND: doxofylline
Classification: Anti-asthmatic
Drug Action: Adenosine-nonblocking anti-
asthmatic drug with potent bronchodilator
activity that does not display the typical
extrapulmonary side effects of theophylline--a
potent adenosine antagonist The contractile
force of electrically stimulated left atria was
affected by doxofylline starting at 0.3 mM.
 DRUG STUDY
Side effects: Nausea & Vomiting, Epigastric
pain, Tachycardia, Insomnia, Tachypnea
Indication:Bronchial asthma, Pulmonary
disease with spastic bronchial content
Contraindication: Acute MI, Hypotension,
Lactation, Liver disease, Chronic obstructive
lung disease, Pregnancy
Nursing Intervention
•Check the blood pressure
•Instruct the patient to take ansimar with or
without food
•Check the heart rate
 DRUG STUDY
GENERIC: Maicostat
BRAND: Nystatin
Classification: Antifungal and Antibiotics
Drug Action: nystatin binds to ergosterol, a
major component of the fungal
cell membrane. When present in sufficient
concentrations, it forms pores in the
membrane that lead to K+ leakage and death
of the fungus.
DRUG STUDY
Side effects: Diarrhea, Oral irritation, GI
distress, Nausea and vomiting, Rashes
Indication: Intestinal or esophageal
candidiasis, Oral lesion
Contraindication: Pregnancy
Nursing Intervention:
•Instruct patient to take nystatin with an
empty stomach
•Instruct patient not to take food or drinks 1
hour after the administration
DISCHARGE PLANNING
1. Take the entire course of any prescribed
medications
2. Get plenty of rest
3. Drink lots of fluids, especially water.
4. Keep all of follow-up appointments
5. Encourage the guardians to wash
patient’s hands.
6. Tell guardians to avoid exposing the
patient to an environment with too much
pollution (e.g. smoke).
7. Give supportive treatment
8. Protect others from infection.