Professional Documents
Culture Documents
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I. Introduction
A. Overview of the Case 2
B. Objective of the Study 4
C. Scope and Limitation of the Study 4
II. Health History
A. Profile of Patient 5
B. Family and Personal Health History 6
C. History of Present Illness 6
D. Chief Complain 6
III. Developmental Data 7
IV. Medical Management
A. Medical Orders and Laboratory Results 10
B. Drug Study 15
V. Pathophysiology with Anatomy and Physiology 17
VI. Nursing Assessment
(System Review and Nursing Assessment II) 22
1
I. INTRODUCTION
Pneumonia is an
parenchyma/alveolar (microscopic
physical injury to the lungs. Its cause may also be officially described as idiopathic, that
Often, pneumonia is the final illness in people who have other serious, chronic
diseases. It is the sixth most common cause of death overall, and the most common
2
The setting in which pneumonia develops is one of the most important features to
setting often helps determine what infecting organism is responsible for the pneumonia.
For example, community-acquired pneumonia is more likely to stem from infection with
infecting organism, there is usually a difference in the severity of pneumonia and the
way it is treated (for example, whether with oral drugs at home or with intravenous
Consolidation ®; to consider Pulmonary Mass (L). This case aims to achieve a better
understanding of the patient’s condition and was made for the benefit of the student
3
B. Objective of the Study
Obtain a complete health data that can be used in the follow-up care
disease condition
The extent of study includes the overall data gathered during the interview and
observation as claimed by the patient and her significant others. It also deals with the
several factors observed during the assessment within the span of time given. The
information gathered was the exact answers and complaints of the patient and not a
mere opinion by the student. Interventions were rendered gradually depending on the
objective assessment of the student. The following information only involves the exact
4
The limitation of the study includes the place of interaction itself which was in x.
The study was completed altogether by both research and actual hands-on exposure
and interaction with the patient during the two (2) days clinical duty.
Name: x
Age: x
Sex: Male
Birth date: x
Religion: x
Civil Status: x
Nationality: Filipino
Address: x
Name of Wife: x
Temperature: 38.3oC
5
Height: 5 inches 6 cm
Weight: 80 kilograms
The xfamily resides in x. Mr. and Mrs. x have one (1) child. The couple’s income
is approximately P300 per day. The family has no heredo familial disorders that place
their health at risk. Aside from that, the most common health problems they encounter
were headache, cough, colds, stomach ache, and fever. Although they did not consult a
doctor for these conditions but they took Over the Counter Drug (OTC) such as
I month prior to admission, patient had cough with whitish phlegm, has no fever
5 days prior to admission, patient had low to moderate cough, had fever and
4 days prior to admission, patient had cough with whitish to brownish phlegm;
with on and off fever; had shortness of breath after few meters walk.
D. Chief Complaint
A case of x, MJ, x, male, married, from x, was admitted for the first time atx Last
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VI. DEVELOPMENTAL TASK
Psychosocial theory
This theory combines both internal psychological factors and external social
factors. Each stage builds upon the others and focuses on a challenge (or crisis) that
must be resolved during that stage in order to move effectively into the next stage of
development. The resolution of each crisis depends upon the interaction of the
Therefore, unresolved conflicts from earlier stages may continue to affect later
development.
In case of the patient, it belongs to the Intimacy vs. Isolation stage. This stage
covers the period of early adulthood when people are exploring personal relationships.
Erikson believed it was vital that people develop close, committed relationships with
other people. Those who are successful at this step will develop relationships that are
committed and secure. Remember that each step builds on skills learned in previous
steps. Erikson believed that a strong sense of personal identity was important to
developing intimate relationships. Studies have demonstrated that those with a poor
sense of self tend to have less committed relationships and are more likely to suffer
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In connection to Mr. x he was committed to his work, love, and activities that is
suited for his age. As what was observed, he was not detached to personal environment
develop the ability to think about abstract concepts. Skills such as logical thought,
deductive reasoning, and systematic planning also emerge during this stage. Piaget
believed that deductive logic becomes important during the formal operational stage.
Deductive logic requires the ability to use a general principle to determine a specific
outcome. This type of thinking involves hypothetical situations and is often required in
science and mathematics. While children tend to think very concretely and specifically in
earlier stages, the ability to think about abstract concepts emerges during the formal
problems. During the formal operational stage, the ability to systematically solve a
problem in a logical and methodical way emerges. Children at the formal operational
stage of cognitive development are often able to quickly plan an organized approach to
solving a problem.
With regards to Mr. x’s case, it was observed that he has reached complete
maturity and he can think and reason in abstract terms. He already developed logical
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Developmental task
and emotionally engaged. Has information and engages in long term planning including
educational plans. Have stable vocational goals and plans. He makes decisions
But as what is observed to the patient, he has not yet achieved his goals in life
basing with his occupation. The patient can make his decisions independently but
Psychosexual Theory
strong sexual interest in the opposite sex. Where in earlier stages the focus was solely
on individual needs and, interest in the welfare of others grows during this stage. If the
other stages have been completed successfully, the individual should now be well
balanced, warm, and caring. The goal of this stage is to establish a balance between
the various life areas. As what was observed, the patient has a strong sexual interest
with the opposite sex. He was also able to have a balance between the different areas
of life.
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IV. MEDICAL MANAGEMENT
obstruction
• Intake and output every shift • To check and note for imbalances in the
measurement
10
11
• Laboratory test required:
1. CBC with platelet • To check for occurrence of infection in
the body
2. Urinalysis • A standard procedure; used to check
abnormalities in the renal system
3. Serum creatinine, BUN,Na, • To evaluate gas exchange and
K alterations in body electrolytes
4. Sputum exam • To identify the infecting organism,
gram (+) or gram (-) bacteria
5. Chest X-ray – PA • To check the extent and pattern of
lung involvement
6. ECG 12 leads • Helps to detect abnormalities in the
cardiovascular system
7. CT Scan with chest contrast
• Imaging studies allows visualization of
the extent of the affected organ
• Medications:
1. Azithromycin 500mg 1 tab • To treat the underlying cause of the
OD disease pharmacologically
2. Salbutamol 1neb + 2cc
• Provides a relief for airway obstruction
NSS
3. Paracetamol 500mg 1 tab • Medication used for relieving fever and
q4 pain
12
January 27, 2008
rate
management
oxyhemoglobin
measurements
• Intake and output hourly refer if • Check for imbalances in intake and
13
January 28, 2008
area
the body
• Still for CT scan of the chest with • Imaging studies allows visualization of
LABORATORY RESULTS
14
TEST RESULT REFERENCE NURSING IMPLICATION
(BUN)
function
Count infection
Count
parasitic infection
B. DRUG STUDY
15
Generic Name of Salbutamol Sulfate
ordered drug
Brand Name Ventolin
Date Ordered January 26, 2008
Classification Bronchodilator
Dose/Frequency/Rout 1 neb/ q6h/ steam inhalation
e
Mechanism of Action Relaxes bronchial smooth muscle by acting on beta2-
adrenergic receptors; improves ventilation
Specific Indication Bronchospam in patient’s with reversible obstructive airway
disease
Contraindication To patient’s hypersensitive to the drug and its components
Side Effects/Toxic Tremor; palpitations; tachycardia; nausea and vomiting;
Effects irritation
Nursing Precaution Perform chest tapping every after nebulization
16
Brand Name Zosyn
Date Ordered January 27, 2008
Classification Antibiotic
Dose/Frequency/Rout 2.25 mg/ q 8h/ IVTT
e
Mechanism of Action Piperacillin inhibits cell wall synthesis during microorganism
multiplication; Tazobactam increases puiperacillin
effectiveness by inactivating beta-lactamases, which destroys
penicillin
Specific Indication For moderately severe Community-Acquired Pneumonia
Contraindication To patient’s hypersensitive to the drug and its components
Side Effects/Toxic Insomnia; hypertension; rhinitis; dyspnea; pruritus; phlebitis to
Effects IV site
Nursing Precaution Advise patient to limit intake of sodium because piperacillin
contains 1.98 mEq of Na per gram
17
In humans, the trachea divides into the two main bronchi that enter the roots of
continue to divide
give rise to
bronchioles. The
bronchial tree
continues branching
of terminal bronchioles,
sacks. Alveolar sacs are made up of clusters of alveoli, like individual grapes within a
bunch. The individual alveoli are tightly wrapped in blood vessels, and it is here that gas
exchange actually occurs. Deoxygenated blood from the heart is pumped through the
pulmonary artery to the lungs, where oxygen diffuses into blood and is exchanged for
carbon dioxide in the hemoglobin of the erythrocytes. The oxygen-rich blood returns to
the heart via the pulmonary veins to be pumped back into systemic circulation.
Human lungs are located in two cavities on either side of the heart. Though
similar in appearance, the two are not identical. Both are separated into lobes, with
three lobes on the right and two on the left. The lobes are further divided into lobules,
hexagonal divisions of the lungs that are the smallest subdivision visible to the naked
eye. The connective tissue that divides lobules is often blackened in smokers and city
18
dwellers. The medial border of the right lung is nearly vertical, while the left lung
accommodate the shape of the heart. Lungs are to a certain extent 'overbuilt' and have
at rest. This is the reason that individuals can smoke for years without having a
noticeable decrease in lung function while still or moving slowly; in situations like these
only a small portion of the lungs are actually perfused with blood for gas exchange. As
19
The lungs flank the heart and great vessels in the chest cavity.
20
Definition: Pneumonia is the inflammation of the lung parenchyma (the respiratory
bronchioles and alveoli).
Predisposing Factors:
Upper respiratory tract infection
History of smoking
Chronic disease states
Diabetes Mellitus
Cardiovascular disorders
Chronic lung disease
Renal disease
Cancer
Air pollution
Inhalation of noxious substances
Aspiration of food, liquid, or foreign or gastric materials
Residence in institutional setting
Precipitating Factors: Clinical Manifestation:
Advanced Age -- Onset of shaking shills
Tracheal intubations -- Fever
Prolonged immobility -- Cough production of rust-
Immunosuppressive therapy colored or purulent sputum
Nonfunctional immune system -- Chest pain
Malnutrition -- Limited breath sounds
Dehydration -- Fine crackles o rales heard
Target Organs: -- Dyspnea
Brain -- Cyanosis
Heart
Peritoneal cavity
Complications:
Meningitis
21
Endocarditis
Peritonitis
22
Via by
Aspiration of Streptococcus pneumonia via Inhalation of microbes after
oropharyngeal secretions into lungs cough, sneeze, or talking
Cough 23
Initiation of inflammation response
Fever
Dyspnea Chills
Colonization of alveoli or penetration of
lower respiratory tract
Crackling sounds
Consolidation of Lung Tissue Whispered pectoriloquy
24
VI. NURSING ASSESSMENT:
NAMEx
DATE: x
Vital signs: Pulse 130bpm BP: 90/70mmHg Temp 38.3°C Resp: 48 cpm
INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space provided. Indicate the location of
the problem in the figure using [X].
EENT
[ ] impaired vision [ ] blind
[ ] pain [ ] reddened [ ] drainage
[ ] gums [x] hard of hearing [ ] deaf
[ ] burning [ ] edema [ ] lesion of teeth
assess eyes, ears, nose, throat for abnormality
[x] no problem
RESPIRATION
[ ] asymmetric [x] tachypnea
[ ] apnea [ ] rales [ x ] cough [ ] barrel chest
[ ] bradypnea [ ] shallow [ ] ronchi
[x] sputum [ ] diminished [x] dyspnea
[ ] orthopnea [ ] labored [ ] wheezing
[ ] pain [x] cyanotic Blurred vision
asses resp. rate, rhythm, depth, pattern
breath sounds, comfort [ ] no problem Speech pattern:
CARDIO VASCULAR A few words
[ ] arrhythmia [x] tachycardia [ ] numbness between noticeable
[ ] diminished pulses [ ] edema [ ] fatigue breaths
[ ] irregular [ ] bradycardia [ ] murmur =Cough with
[ ] tingling [ ] absent pulses [ ] pain sputum
Assess heart sounds, rate, rhythm, pulse, blood =tachypneic
pressure, clearance, fluid retention, comfort RR=48cpm
[ ] no problem Increased
GASTROINTESTINAL TRACT HR=130bpm
[ ] obese [ ] distention [ ] mass
[x] dysphagia [ ] rigidity [ ] pain
assess abdomen, bowel habits, swallowing
bowel sounds, comfort [ ] no problem Hot and dry skin
GENITO-URINARY AND GYNE
[ ] pain [ ] urine color [ ] vaginal bleeding
[ ] hematuria [ ] discharge [ ] nocturia
assess urine frequency, control, color, odor,
comfort, discharge With IV: D5W
[x] no problem @KVO rate
NEURO
[ ] paralysis [x] stuporous [ ] unsteady [ ] seizures With Foley bag
[ ] lethargic [ ] comatose [ ] vertigo [ ] tremors catheter attached to
[ ] confused [ ] vision [ ] grip urobag
assess motor function, sensation, LOC, strength
grip, gait, coordination, speech [ ] no problem Pale nail beds
MUSCULOSKELETAL AND SKIN
[ X ] dry [ ] stiffness [ ] itching [ ] diaphoresis
[x] hot [ ] drainage [ ] prosthesis [ ] swelling
[ ] lesion [ ] poor turgor [X] cool [ ] flushed
[ ] atrophy [ ] pain [ ] ecchymosis [ ] moist
assess mobility, motion galt, alignment, joint function
skin color, texture, turgor, integrity [ ] no problem
NURSING ASSESSMENT II
SUBJECTIVE OBJECTIVE
Communication:
[ ] glasses [ ] languages
[ ] hearing loss Comments: “usahay” [ ] contact lens [ ] hearing aid
[X] visual changes blurred akong pana-aw R L
[ ] denied pero okay ra akong Pupil Size 3mm- normal [ ] speech diff.
pandungog” Reaction PERRLA
Oxygenation:
[x] dyspnea Comments: “ Galisod ko Resp. [ ] regular [x] irregular
[x] smoking history ug ginhawa tapos gi-ubo Describe: Respiratory rate is above the normal
20 sticks per day pud ko.” range; RR=48cpm
[X] cough R Symmetrical lung expansion with left
[x] sputum L Symmetrical lung expansion with right
[ ] Denied
Circulation:
[ ] chest pain Comments: “ Wala may sakit Heart Rhythm [ ] regular [x] irregular
[ ] leg pain sa akong kamoy ug tiil, okay Ankle Edema Not seen
[ ] numbness of ra man.”
extremities Pulse Car. Rad. DP Fem*
[x] denied R + + + +
L + + + +
Comments: Pulses are palpable
Nutrition:
Diet: Diet as Tolerated [ ] dentures [x] none
[]N []V Comments: “ Lahi ra
Character karon, ginagmay ra akong Full Partial with Patient
[x] recent change in kaon ug usahay dili jud ko Upper [ ] [ ] [ ]
weight, appetite gakaon.”
[ ] swallowing Lower [ ] [ ] [ ]
difficulty
[ ] denied
Elimination:
Usual bowel pattern [ ] urinary frequency Comments: Bowel Sounds
1x a day With FBC Nakalibang ko Normoactive bowel sounds
[ ] urgency ganina pero Abdominal Distention
[ ] constipation [ ] dysuria gamay ra, wala Present [ ] yes [X] no
remedy [ ] hematuria pud ko poblema Urine* (color,
none [ ] incontinence sa akong pag-ihi consistency, odor)
Date of Last BM [ ] polyuria Yellowish
January 26, 2008 [x] foly in place *if they are in place
[ ] diarrhea character [ ] denied
The pt. has no diarrhea
26
SKIN INTEGRITY: [x] dry [ ] cold [x] pale
[ ] dry Comments: “ Dili man gakatol- [ ] flushed [x] warm
[ ] itching katol akong panit.” [ ] moist [ ] cyanotic
[ ] other * Rashes, ulcers, decubitus (describe size,
[x] denied location, drainage) No rashes, ulcers.
ACTIVITY/ SAFETY:
[ ] convulsion Comments: “Gakalipong ko [x] LOC and orientation: The pt. is oriented in
[X] dizziness kung mutindog ko. Dili time, place and person.
[ ]limited motion kayo ko makalihok.” Gait: [ ] walker [ ] cane [ ] other
of joints
Limitation in [ ] steady [x] unsteady ______
Ability to [ ] sensory and motor losses in face
[ ] ambulate Or extremities: The pt. displays no sensory
[ ] bathe self and motor losses in the face and extremities.
[ ] other [ ] ROM limitations: The patient can freely
[x] denied move his joints.
COMFORT/SLEEP/AWAKE:
[ ] pain Comments: “ Galisod ko [x] facial grimace
(location, frequency, ug pagkatulog kay gi- [ ] guarding
remedies) ubo ko.” [ ] other signs of pain: No other signs of pai
[ ] nocturia observed
[x] sleep difficulties [ ] side rail release form signed (60+ years)
[ ] denied Not applicable.
COPING:
Occupation: Driver Observed non-verbal behavior: Closing of
Members of Household: 3 members eyes when experiencing dyspnea
Most Supportive Person: Wife- Lewan Galon The person and his phone number that can be
reached anytime no phone
27
VII. NURSING MANAGEMENT
Interventions Rationale
Independent:
2h
secretions
Dependent:
medications as ordered
(bronchodilators)
28
Interventions Rationale
Independent:
work of breathing
Dependent:
29
Interventions Rationale
Independent:
diaphoresis, or cyanosis
activity tolerance
demands
30
O Pursed-lip breathing
Dyspnea
coughing
P Long term: At the end of 3 days, client will verbalize clear airway
Shot term: At the end of 30 minutes, will have improved airway clearance, as
Dependent:
1. Given bronchodilators (Salbutamol sulfate) as ordered, to relax bronchial
smooth muscles thus facilitating airflow.
E After 30 minutes, the client’s cough was productive and breath sounds are
clearer.
Increased RR=48cpm
Dyspnea
31
A Activity intolerance RT inadequate oxygenation and dyspnea
P Long term: At the end of 1 week, patient will tolerate any activity
Short term: At the end of 30 minutes, client will have improved activity
conservation techniques.
I Independent:
requirement.
Dependent:
is still present.
O Absent-minded
Anxious
Dyspnea
A Anxiety RT acute breathing difficulties and fear of suffocation
32
P Long term: At the end of 1 week, client will have a psychological comfort and
Short term: At the end of 3 hours, the client will express an increase in
reception to pain
anxiety
Dependent:
MEDICATION Home medications were not yet given to the patient because he
was still in the hospital after the 2-day clinical duty. But he was
following:
33
Piperacillin + Tazobactam 2.25 mg q8h
expansion
dyspnea
TREATMENT Proper hygiene measures was also imparted
ciliay action
pneumonia
After conducting this care study, I was able to appreciate more the essence of
utilizing the nursing process in the care and management of my patient. It was indeed a
34
tough job on conducting this study yet, it gave me a big impact regarding how useful it is
demands patience and it is calling that cannot be merely taken for granted.
Moreover, this care study taught us to stand on our own by not depending on
others just to make this. This provides us, the students, a big learning regarding on how
well we take care of or patients in the real clinical setting. Most of all, this study teaches
the students to provide clients care more efficiently and competently to achieve an
X. BIBLIOGRAPHY
A. BOOKS
B. WEBLIOGRAPHY
http://psychology.about.com/od/developmentstudyguide/p/devtheories.htm
35
http://psychology.about.com/od/theoriesofpersonality/ss/psychosexualdev_5.htm
http://psychology.about.com/od/piagetstheory/p/formaloperation.htm
www.wikipedia.org/wiki/Pneumonia
www.nlm.nih.gov/medlineplus/pneumonia.html
www.google.com
www.yahoo.com
www.wikipedia.org/wiki/Community-acquiredpneumonia
www.emedicine.com/MED/topic3162.htm
www.merck.com/mmhe/sec04/ch042/ch042b.html
Rating Scale
36
a. Medical Orders with Rationale (10)
b. Drug Study (10)
V. Pathophysiology with anatomy and physiology 10
VI. Nursing Assessment 10
a. Nursing System Review Chart 30
b. Nursing Assessment II (10)
VII. Nursing Management (20)
a. Ideal Nursing Management
b. Actual Nursing Management
VIII. Referrals and Follow-up 5
IX. Evaluation and Implication 5
X. Documentation 5
a. Documentation of Evidence of Care for 1 Week
Rotation
b. Organization/Grammar/Bibliography
Total Score
Equivalent Grade
37