CASE PRESENTATION On PNEUMONIA

Prepared by:
Group 2 Alforte, Abegail A. Buenaventura, Kristine V. Datingaling, Maria Karren J. Gaudier, Kimzie E. Gonzales, Petricia Angeli M. Mendoza, Mono Yngwie R. Parsram, Frances Hetty I. Reyes, Rodney R. Tabudlong, Laurynel M.

NURSING CASE STUDY

Admission Diagnosis Pneumonia

I. HEALTH HISTORY

A.

DEMOGRAPHIC (BIOGRAPHICAL DATA) 1. Clients Initial: R.S.C. 2. Gender: Male 3. Age, Birth date, and Birthplace: 31 y/o, February 1, 1980, Manila 4. Marital (Civil) Status: Married 5. Race and Nationality: Filipino 6. Religion: Roman Catholic 7. Address/Telephone No: City of Dasmarias, Cavite 8. Educational Background: College Undergraduate 9. Occupation: Inventory Assistant 10. Usual Source of Medical Care: Hospital (DLSUMC and St. Paul Hospital) 11. Date of Admission: August 8, 2011

B.

SOURCE AND RELIABILITY OF INFORMATION Client himself who seems to be reliable. The patients chart as secondary source of information.

C.

CHIEF COMPLAINTS SOB for 2 days. DOB associated with stabbing chest pain for 2 days Intermittent high grade fever for 2 days.

D.

HISTORY OF PRESENT ILLNESS The patient was in his usual state of health until 2 days PTA; he had fever with a temperature of 40C accompanied with chills and excessive sweating while he was on work. The patient also verbalized that he had productive cough with yellowish phlegm.

According to the patient, he immediately consulted in the company clinic wherein the company nurse administered an initial dose of Biogesic 500 mg tab and was advised to go home and rest. At home, the patient continued to experience the same signs and symptoms with the addition of headache while having a fever of 39C. As verbalized by the patient, his DOB was alleviated by rest. The patient continued to take Biogesic 500 mg tab every 4 hours. 1 day PTA, the patient still manifest the same signs and symptoms with his temperature still ranging from 38-39C while his cough became non productive. His medication was consistent throughout the day. During that night the patient felt that his condition is getting worse that is why he decided to consult a physician the next day. Few hours PTA, the patient still experienced the same complaints he had the previous days but his cough became productive again. The patient sought consultation with a private physician at De La Salle University Medical Center for further monitoring and diagnostic procedure to confirm his current health condition.

E.

PAST MEDICAL HISTORY

Since his childhood days, R.S.C. often have cough and colds, which were being worsen by his nature of work. His pediatric or childhood illnesses are mumps, influenza, sore throat, chicken pox, and measles. As far as patient can remember, he was complete in his immunization. He claimed that he had no known allergies with any food nor any medications. However, he usually experiences cough and colds when being exposed to dust and hot places. Patient verbalized that he had a minor operation when he was six years old. He accidentally fell off the ground and was cut with a piece of glass on his right upper lateral part of abdomen. He was again hospitalized during his childhood because of having persistent cough and colds. Moreover, last 2008, he was admitted at St. Paul Hospital because of having pneumonia. Unfortunately, he cannot remember the medications prescribed to him. He usually takes Paracetamol for fever. His last check-up was August 8, 2011.

F. FAMILY HISTORY

Based on the patients Genogram, he was not able to recall the age and cause of death of his grandparents on both sides. According to the patient, both his parents as well as his 5 siblings are still alive but his mother has arthritis while his father is hypertensive. As verbalized by the patient, he is the only one in their family who has a low resistance against illnesses.

G.

SOCIOECONOMIC

Family Member

Occupation/ Source of Income

Monthly Income (optional)

R.S.C.- Patient

Inventory Assistant

12, 000 Php/month

The patient is now living with his wife and their newly born baby in a subdivision in Dasmarias. According to him, he is their only source of income as of the moment as his wife just gave birth to their first baby last July 24, 2011. He currently works as an inventory assistant while his wife is currently taking care of their baby. As verbalized by the patient, his monthly income is 12, 000 Php per month and according to him this is not enough due to their everyday expenses plus the new needs of their baby. H. DEVELOPMENTAL THEORY Patients Age: 31 years old Developmental Theory: Havighursts Developmental Tasks Developmental Stage: Middle Adulthood (30-60 years old) Robert J. Havighursts theory of Developmental Tasks states that achievement of tasks leads to happiness and success with the future tasks while failure leads to unhappiness, disapproval by society and difficulty with later tasks. At the age of 31 years old, patient R.S.C. belongs to the middle adulthood stage wherein he has tasks including: assisting children to become responsible and happy adults, achieving adult social and civic responsibility, developing adult leisure time activities, relating to spouse as a person and attaining satisfactory performance in occupation. The patient at the age of 31 had just started to create a family by having their first baby last July 24, 2011. As a first time father, he was really nervous and anxious of what he is supposed to do to ensure that their baby will grow in the right path. But according to him, he is going to try his best to be a good and responsible father to their baby and a loving husband to his wife. He is planning to impart all the important lessons he learned from his parents to their baby. The patient verbalized that he is satisfied with his current work because he was recently promoted as an inventory assistant. But according to him, he would like to be promoted again in the future to earn more money for his familys daily needs and for the future of their baby. During his day off, he usually finds time to play basketball with his friends as his leisure activity

and stress reliever. As verbalized by the patient, he was already well adjusted to his new roles and responsibilities as a husband and a father and that he will try his best in order for him to meet his goals. I. REVIEW OF SYSTEMS AND PHYSICAL EXAMINATION

1. ROS and PE 08/10/11 SYSTEM 1. General Masaki R.O.S tang ulo P.E ko. IVF: PNSS 1L x 16 patient was awake,

Sumasakit din ang dibdib ko -The kapag tinutusok. Medyo nahihirapan naubo.

Parang conscious, cooperative and coherent -Temp. = 36.2C din -PR = 72 bpm, regular, equal and bilateral in strength -RR = 30 cpm, irregular, unequal and shallow -BP = 110/60 mmHg -Pain scale (Headache): 4/10 -Pain 6/10 scale (Chest pain):

akong huminga.

2.Integument

Wala

naman

akong SKIN

nararanasang problema sa Inspection balat ko. Wala din akong -The patients skin was light allergy. Normal pa naman brown in color with no

discolorations ang -The patient has a lesion @ upper quadrant of

pagtubo ng buhok ko. Di pa right naman ako nakakalbo wala naman akong kuto.

at abdomen; Length = 2 inches --He has a good skin turgor of <3 secs. Palpation

-The

patients

skin

was

smooth, soft and warm to touch HAIR Inspection -The patients hair is black in color, equally distributed with no parasites or lesions

evident Palpation -The patients scalp is

symmetrical, smooth and firm NAILS Inspection - The patient has round, hard nails with pink nail beds -The patient has a good capillary refill of < 3 seconds 3. Head Sumasakit ang ulo ko. Para Inspection akong nahihilo. -The patients head is

symmetrical and round in shape; it has a smooth and controlled movement with no lesions -His facial features are

symmetrical -Pain scale (Headache): 4/10 4. Eyes Nasakit mata ko kapag Inspection matagal akong nakababad sa -The patients eyelids are computer. Pero moist and pink with

symmetrical and involuntary hindi pa naman blinking -His pupils are equally round and reactive to light nanglalabo ang paningin ko.

accommodation (PERRLA) -He has a round and equal iris with white sclera -The patients eyes have extra

smooth,

coordinated

ocular movement -Pupils constricted upon

illumination -Normal peripheral vision Palpation -No tenderness and

discharge upon palpation 5. Ears Hindi pa naman nanghihina Inspection ang pandinig ko. -The patients ears are equal in size and similar in

appearance with no lesions and disharge Equal in size and similar appearance Palpation -The patients auricle and tragus are non tender -No tenderness or pain on palpation of mastoid process -Passed Whisper test -Passed Romberg test for equilibrium 6. Nose and Sinuses Madalas akong mag kaubo Inspection at sipon lalo na kapag -The patients mucosa are pink and moist with no

malamig.

lesions -Air is felt during expiration Palpation -No nodules and pain upon

palpation -Non tender sinuses 7. Mouth and Throat Hindi naman nasakit ang Inspection mga ngipin ko. Hindi -The patients lips is dry but with no lesions rin ako madaling -His buccal mucosa is pink, dahil -Pink gums -Pink, moist tongue with no lesions 8. Neck Hindi naman siya nasakit at Inspection wala ko. naman akong -The patient manidested

mapaos at wala ding masakit smooth, moist without lesion sa lalamunan ko minsan lang ako kumain ng -Dental carries are observed matatamis.

napapansing kakaiba sa leeg smooth, controlled movement of neck -His neck has no lesions Palpation -No palpable lymph nodes 9. Breast and Axilla Hindi naman masakit at wala Inspection naman akong nakakapang -The bukol. patients breast are

symmetrical in size, with his areolas and nipples are

brown in color and inverted Palpation -No discharge -Non tender breast and axilla 10. Respiratory Masakit ang dibdib ko kapag Inspection humihinga. -The patient has dry cough and experiences stabbing

Minsan nahihirapan akong chest pain upon coughing huminga at may kasama pa -Pain scale: 6/10 itong pananakit ng dibdib. -Symmetrical expansion chest

-The patient also manifests tachypnea -RR = 31 cpm, irregular, unequal and shallow Palpation -Vibrations speaking -Symmetrical excursion Ausculation -Bronchial breath sounds thoracic are felt upon

heard over trachea -Bronchovesicular breath

sounds heard below clavicles and between scapula -Vesicular breath sounds

heard over peripheral chest -Crackles are heard over left lung area -Sounds are muffled during Bronchopony test (99) -Sounds are muffled during Egophony test (E) -Sounds are muffled during Pectoriloquy test (1,2,3) 11. Cardiac Wala namang kakaiba sa Palpation tibok ng puso ko at wala No sakit sa puso. vibrations or thrills

naman kaming namamanang palpated Auscultation -S1 and S2 heard upon auscultation -1st sound heard: Lub -No S3 or S4 heard upon auscultation

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-Radial and apical pulse are identical -PR = 72 bpm, regular, equal and bilateral in strength 12. Gastrointestinal Hindi naman sumasakit ang Inspection tiyan ko at normal naman - The patient has a lesion @ ang pag dumi ko. right upper quadrant of

abdomen with a length = 2 inches -No striae are observed -His abdomen is round, and symmetrical -Color of stool: brown Auscultation -Bowel movement: 1-2 times a day -Bowel sounds = 20 BS/min. Palpation -No organs -No tenderness or masses in all four quadrants of enlarged abdominal

abdomen upon palpation -No pain upon deep

palpation 13. Urinary Hindi naman nasakit kapag Inspection naihi ako. Kulay dilaw halos -No history of UTI palagi ang iniihi ko. -Bladder not distended -Urination:5-6 voids/day

-Urine color: yellow

14. Genitalia Wala naman problema -No PE due to patients refusal 15. Musculoskeletal Sumasakit yung kaliwang Inspection

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tuhod ko kapag nakain ako -Full ROM of upper and lower ng taba ng baka. extremities -Muscles equally strong and non tender -Able to shrug shoulders

against resistance -Smooth movement of TMJ with no clicking sounds or pain upon opening -Can turn head laterally

against resistance 16. Neurologic Madalas akong ma stress Inspection dahil sa trabaho. Wala namang -LOC: Conscious, coherent and awake may -Responds appropriately to -Aware of place, time, person -CN I: Identifies scent

diperensya sa pag iisip sa questions and instructions aming pamilya.

correctly -CN II: Normal vision -CN III, IV, VI: PERRLA -CN V: Eyelids identifies and to blink light sharp

bilaterally, touch, dull

sensations

forehead,

cheeks and chin -CN VII: Identifies taste

correctly -CN VIII: Passed whisper test -CN IX: Identifies and gag taste reflex

correctly present

-CN X: Gag reflex present -CN XI: Symmetrical, strong

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contraction muscles

of

trapezius and

sternocleidomastoid mucles -CN XII: Symmetrical tongue with smooth, outward

movement 17. Hematologic Wala naman kaming sakit sa Inspection dugo. -No presence of bleeding -No presence of bruises Hindi naman ako madalas -No history of BT magkapasa at bihira lang din dumugo ang ilong ko. 18. Endocrine Pawisin ako lalo na pag Inspection sobrang init tapos madaming -No DM or other metabolic ginagawa sa trabaho. disorders -Excessive sweating present 2. LABORATORY STUDIES AND DIAGNOSTICS Procedure and Date Hematology 08/09/2011 Normal Values / Findings Hemoglobin 140-175 G/L 123 G/L L (Low hemoglobin level may indicate nutritional deficiency (iron, vitamin B12, folate)) Hematocrit Actual Findings / Interpretation Nursing Responsibilities (pre, intra, post) PRE: Check doctors order Assess patients condition Instruct the client about the requirements and restriction Explain to the patient the purpose and

Indication

The complete blood count (CBC) is a screening test, used to diagnose and manage numerous diseases. It can reflect problems with fluid volume (such as dehydration) or

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loss of blood. It can show abnormalities in the production, life span, and destruction of blood cells. It can reflect acute or chronic infection, allergies, and problems with clotting.

0.41-0.50

0.37 N

procedure Inform the client

WBC 5-10 x10^9/L 13.3 x10^9/L H (High WBC level indicates inflammation and infection caused by causative agent of pneumonia such as S. pneumonia, H. influenza, M. pnemoniae, etc.))

of the time period before the results will be available Prepare the equipment and supplies needed Withhold medications that may after the result of the test

INTRA: Use standard precaution and apply sterile technique in

Differential count Segmenters 0.36-0.66 0.75 H (High segmenter level indicates presence of bacterial infection)

obtaining specimen Provide emotional and physical support while monitoring the client as needed Ensure labeling, storage and transportation of

Lymphocytes 0.22-0.40 0.21 L (Low lymphocyte level indicates sepsis)

the specimen

POST: Monitor v/s Monitor daily weight

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 Observe and monitor client Monocytes 0.04-0.08 Platelet Count 150-450 x10^9/L 322 x10^9/L N 0.03 L Compare the previous and current test result Modify nursing intervention as needed Report significant result to health care provider Urinalysis 07/29/2011 Urine test or urinalysis is a procedure conducted for testing the various components of urine and more importantly, their concentration. Any fluctuation from the normal levels can be an indication of some underlying diseases. Thus, the urinalysis results are compared with standard parameters to find out abnormal changes. WBC 0-5HPF Sugar Negative Negative N INTRA: Direct client to the bathroom Albumin Negative Negative N pH 4.5-8.0 6.0 N Specific gravity 1.010-1.025 1.015 N Characteristic Clear to slightly hazy Clear N Color Pale yellow to amber Yellow N PRE: Check the doctors order Determine the ability of the client to provide the specimen Give instructions to the on how to produce a specimen, why the sample is being collected and the reason for the test Provide privacy Instruct patient to collect at least 10 ml of urine

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0.2/HPF N RBC 0-3HPF 0-2/HPF N Epithelial cells Few Few

Ask the client to wash and dry the genitals and perineal area with soap and water Instruct to collect midstream urine and cap the container tightly Ensure storage instructions are adhered to the date of opening should be recorded on the bottle POST: Label the specimen and transport it to the laboratory Observe and monitor client Compare the previous and current test result Modify nursing intervention as needed Report significant result to health care provider

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3.

OTHER ASSESSMENT TOOLS

Date (s) Taken

Comprehensive Actual Content/Legend 0-no pain

Actual Result

Pain Scale 06/21/11

1-3-mild pain 4-6-moderate pain 7-10-severe pain Level 0 - Full Self care Level 1 - Requires use of requirements or

4/10 (Headache) 6/10 (Chest pain)

Feeding - Level 0 Grooming - Level 2 Bathing - Level 1 Gen. Mobility - Level 2 Toiling - Level 2 Bed mobility - Level 0 Dressing - Level 0

Functional Level Code 6/21/2011

device Level 2 - Requires assistance or supervision from another person Level 3 - Requires assistance or supervision from another person or device Level 4 - Is dependent and does not participate

J. FUNCTIONAL ASSESSMENT

1. Health Perception/health management pattern The client described himself as unhealthy because according to him he easily has cough and colds. For him one of the things that can help him to be healthy is to go to have an check up whenever he feels sick. He usually acquires cough and colds after exposing to dust and when he is over fatigue. He is often to exposed to dust because of his work. The patient doesnt worry about the disease running through their family.

2. Self Perception Pattern The patient is contented about himself. According to him, he has been weak and he lost his appetite since he was admitted in the hospital because of pneumonia. The clients work usually gives him stress and he prefers to be alone when he has any problems.

3. Activity-Exercise Pattern

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The patient verbalized that his exercise is at work. But he verbalized that during his day of every Thursday he usually finds himself doing exercise. He often spends 3 hours of his time very Thursday to exercise. NORMAL DAY Ability Feeding Bathing Toiling Bed Mobility Dressing Grooming General Mobility Cooking Home maintenance Shopping Level 0 0 0 0 0 0 0 2 2 2

As we can see in the table below, we can see that the person can handle himself very well when he is not hospitalized. But doing some other things also require him to ask for advice just like in cooking.

HOSPITALIZATION Ability Feeding Bathing Toiling Bed Mobility Dressing Grooming General Mobility Level 0 1 1 0 0 2 2

As we can seen in the table, the patient can feed himself even he is hospitalized, but when going to the hospitalized he need some supervision.

*Legend: Legend Level 0 Level 1 Level 2 Level 3 Level 4 Functional Level Code Full Self Care Requires use of requirements or device Requires assistance or supervision from another person Requires assistance or supervision from another person or device Is dependent and does not participate

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4. Sleep/Rest Pattern During the course of the interview, the patient looked awaked and conscious. The patient verbalized that he sleeps for about 5 hours a day only. he usually sleep at 1AM and woke up as early as 6AM. The patient verbalized that watching television is his usual activity to put himself to sleep. The patient verbalized that he dont used any sleeping pills to just make himself fall to sleep. And as the patient verbalized usually when he woke up he still feel sleepy because of not having enough sleep.

5. Nutrition/Elimination The patient typical meal is friend meat and sometimes vegetable. The patient didnt observe for a balanced diet. According to the patient, before he was hospitalized his appetite was good but when he was brought in the hospital he observe that his appetite decrease. The patient didnt experience difficulty in swallowing or any discomfort when he ate. He also verbalized that he dont have any food allergies. The patient denied any dental problems. According to the patient he voids 5-6 times a day having a characteristic of clear and yellowish in color. The patient verbalized that he usually defecates 1-2 times a day. But according to him since he was brought in the hospitalized he still doesnt have any urge to defecate. And the patient also experience having excessive perspiration even hes in a cold place. 6. Sexuality/Reproductive He is contented with his sexuality. He have one son that was born only for a few weeks ago. He doesnt encounter any problem in his reproductive life. 7. Interpersonal Relationships The patient have a good relationship with his family, he is a loving husband, a responsible son to his parents. He also have a good relationship with his friends and coworkers in his work. Usually when he have problem he just keep it by himself. He just asks for help if it is a big problem that he cant manage already.

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8. Coping and Stress Management As of now the primary source of the patients stress is financial. Since he was operated and was been hospitalized in a week he dont know where to get money to pay for the hospital bills. One of the methods that the patient does when he experience stress he just sleep or sometimes he talk with his wife. As verbalized by the patient his common source of his stress is about his work. And he usually kept it by himself he usually dont open up with his wife or to others, he just think deeply to find ways to solve his problem.

9. Personal Habits The patient doesnt have any personal habits. Hes is not smoking since he already know that he have a weak lungs thats why hes not smoking. But he verbalized that he drink alcohol but not that much and not that frequent.

10. Environmental Hazards The patient is living with his wife and son but he lives nearby his mothers house. According to the patient they live in a Muslim community and almost all of his neighbors are Muslims. The patient describes his work place as hazardous for him because of dust which causes him to have cough and colds. II. PROBLEM LIST

A. ACTUAL or Active Problem No. Problem Date Identified Date Resolved / Remarks 08/9/11 1 Ineffective airway clearance 08/9/11 The patient verbalized decrease in difficulty in breathing and decrease RR from 31 cpm to 25 cpm. 08/9/11 2 Acute chest pain 08/9/11 The patient stated that hes not experiencing chest pain anymore.

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B. HIGH RISK or Potential Problem No. 1 Imbalance nutrition Problem Date Identified 08/9/11

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IV. ANATOMY AND PHYSIOLOGY

THE RESPIRATORY SYSTEM

The respiratory

system consists

of

organs

involved in breathing. These include the nose, pharynx, larynx, trachea, bronchi and lungs. It does two very important things: it brings oxygen into our bodies, which we need for our cells to live and function properly; and it helps us get rid of carbon dioxide, which is a waste product of cellular function. The nose, pharynx, larynx, trachea and bronchi all work like a system of pipes through which the air is funneled down into our lungs. There, in very small air sacs called alveoli, oxygen is brought into the bloodstream and carbon dioxide is pushed from the blood out into the air. When something goes wrong with part of the respiratory system, such as an infection like pneumonia, it makes it harder for us to get the oxygen we need and to get rid of the waste product carbon dioxide. Common respiratory symptoms include breathlessness, cough, and chest pain. The Upper Airway and Trachea

When you breathe in, air enters your body through your nose or mouth. From there, it travels down your throat through the larynx (or voice box) and into the trachea (windpipe) before entering your lungs. All these structures act to funnel fresh air down

from the outside world into your body. The upper airway is important because it must always stay open for you to be able to breathe. It also helps to moisten and warm the air before it reaches your lungs.

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The Lungs

The lungs are paired, cone-shaped organs which take up most of the space in our chests, along with the heart. Their role is to take oxygen into the body, which we need for our cells to live and function properly, and to help us get rid of carbon dioxide, which is a waste product. We each have two lungs, a left lung and a right lung. These are divided up into 'lobes', or big sections of tissue separated by 'fissures' or dividers. The right lung has three lobes but the left lung has only two, because the heart takes up

some of the space in the left side of our chest. The lungs can also be divided up into even smaller portions, called 'bronchopulmonary segments'. These are pyramidal-shaped areas which are also separated from each other by

membranes. There are about 10 of them in each lung. Each segment receives its own blood supply and air supply. These are a vascular organ; they receive a very large blood supply. This is because the pulmonary arteries, which supply the lungs, come directly from the right side of your heart. They carry blood which is low in oxygen and high in carbon dioxide into your lungs so that the carbon dioxide can

be blown off, and more oxygen can be absorbed into the bloodstream. The newly oxygen-rich blood then travels back through the paired pulmonary veins into the left

side of your heart. From there, it is pumped all around your body to supply oxygen to cells and organs.

The primary function of the respiratory system is to supply the blood with oxygen in order for the blood to deliver oxygen to all parts of the body. The respiratory system does this through breathing. When we breathe, we inhale oxygen and exhale carbon dioxide. This exchange of gases is the respiratory system's means of getting oxygen to the blood.

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Respiration is achieved through the mouth, nose, trachea, lungs, and diaphragm. Oxygen enters the respiratory system through the mouth and the nose. The oxygen then passes through the larynx (where speech sounds are produced) and the trachea which is a tube that enters the chest cavity. In the chest cavity, the trachea splits into two smaller tubes called the bronchi. Each bronchus then divides again forming the bronchial tubes. The bronchial tubes lead directly into the lungs where they divide into many smaller tubes which connect to tiny sacs called alveoli. The average adult's lungs contain about 600 million of these spongy, air-filled sacs that are surrounded by capillaries. The inhaled oxygen passes into the alveoli and then diffuses through the capillaries into the arterial blood. Meanwhile, the waste-rich blood from the veins releases its carbon dioxide into the alveoli. The carbon dioxide follows the same path out of the lungs when you exhale.

The diaphragm's job is to help pump the carbon dioxide out of the lungs and pull the oxygen into the lungs. The diaphragm is a sheet of muscles that lies across the bottom of the chest cavity. As the and takes

diaphragm relaxes,

contracts breathing

place. When the diaphragm contracts, oxygen is pulled into the lungs. When the diaphragm relaxes, carbon dioxide is pumped out of the lungs.

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V. PATHOPHYSIOLOGY
Precipitating factors: Advanced age, smoking, non functional immune system, malnutrition, dehydration, homelessness. Inhalation of toxic or caustic chemicals.

Blood borne organism enter the pulmonary circulation

Aspiration of infectious organisms

cough, fever, purulent sputum, sudden onset of shaking chills, stabbing chest pain, tachypnea, cyanosis, profuse sweating, rusty blood, crackling breath sounds, rapid bounding pulse

Infectious organism trapped in the pulmonary capillary bed

Inflammatory reaction

Hypertrophy of mucous membrane lining in the lungs.

Inflammation of pleura

Increased WBC

Increase capillary permeability

Fever
Bronchospasm Partial occlusion of bronchial alveoli

Risk Factors Sequence of Events s/sx Diagnostics s/sx present in pt Disease Process

Abcdefg

*ABG *sputum analysis *CBC, WBC *pulse oximetry *PE & history *bronchoscopy *blood culture *Chest X-ray

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Pneumonia is a serious infection or inflammation of your lungs. The air sacs in the lungs fill with pus and other liquid. Oxygen has trouble reaching your blood. If there is too little oxygen in your blood, your body cells cant work properly. Because of this and spreading infection through the body pneumonia can cause death. Pneumonia affects your lungs in two ways. Lobar pneumonia affects a section (lobe) of a lung. Bronchial pneumonia (or bronchopneumonia) affects patches throughout both lungs. Bacteria are the most common cause of pneumonia. Of these,

Streptococcus pneumoniae is the most common. Other pathogens include

anaerobic bacteria, Staphylococcus aureus, Haemophilus influenzae, Chlamydia

pneumoniae, C. psittaci, C. trachomatis, Moraxella Legionella pneumoniae, bacilli. Major (Branhamella) pneumophila, and other catarrhalis, Klebsiella gram-negative pathogens in

pulmonary

infants and children are viruses: respiratory syncytial virus, parainfluenza virus, and influenza A and B viruses. The causative agent or organism gains entry into the body through the respiratory tract by way of inspiration or aspiration of oral secretions. The organisms can reach the lungs through blood circulation. The body's defense mechanism, that is, pulmonary defense mechanism in case of lungs comes into action. A cough reflex, mucocillary transport and pulmonary macrophages try to protect the body against the infection. However, in some people there defense mechanism is either suppressed or overwhelmed by the invading agent and leads to development of infection. The invading organism starts to multiply and release damaging toxins that cause inflammation and edema of the lung parenchyma. This action leads to

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accumulation of cellular debris and exudes within the lungs. Soon the airless state of the lungs is changed to a consolidated state due to the fluid and exudate filling up.

The usual mechanisms of spread are inhaling droplets small enough to reach the alveoli and aspirating secretions from the upper airways. Other means include hematogenous or lymphatic dissemination and direct spread from contiguous infections. Predisposing factors include upper respiratory viral infections, alcoholism, institutionalization, cigarette smoking, heart failure, chronic obstructive airway disease, age extremes, debility, immunocompromise (as in diabetes mellitus and chronic renal failure), compromised consciousness, dysphagia, and exposure to transmissible agents.

Typical symptoms include cough, fever, and sputum production, usually developing over days and sometimes accompanied by pleurisy. Physical examination may detect tachypnea and signs of consolidation, such as crackles with bronchial breath sounds. This syndrome is commonly caused by bacteria, such as S. pneumoniae and H. influenzae. VI. MEDICAL- SURGICAL MANAGEMENT

1. Procedures PROCEDURE INDICATION/ANALYSIS NURSING RESPONSIBILITIES USN Q8 DUAVENT Management of reversible Pre: bronchospasm with associated - Check doctors order airway - Observe 10 Rs - Explain to the client the indication of the drug -Obtain baseline vital signs and assessments. -Have patient void before taking medication to avoid urinary retention

obstructive

diseases.

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Intra: -Tell patient to breathe

normally.

Post: -Protect from light -Observe for any adverse reaction and note them. -Ensure hydration. - CPT -coughing exercise. -Documentation adequate the medication

2. Pharmaceutics/ Medicines Generic name (Brand Name) Classification Stock Dose Indication Dosage Frequency Levofloxacin (Levocin) Classification: Quinolones Stock Dose: 750 mg IV Indication: to treat infections caused by susceptible strains of microorganisms Dosage: 1 vial Frequency: OD Pre: - Check doctors order - Observe 10 Rs - Explain to the client the indication of the IV used - Check the patency of IV site. -Obtain baseline vital signs And assessments -Obtain C&S before starting drug therapy. Nursing Responsibilities / Implications

Intra: -Take this drug without

regards to meal.

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-Administer in slow IV push

Post: -Drink plenty of fluids while using this drug -Observe for any adverse

reaction and note them. -Report any involuntary

movements. -Assess renal function. -Assess bowel patterns: if severe diarrhea occurs, drug should be discontinued. -Documentation Erdosteine ( Zertin) Classification: Mucolytic Stock Dose: 300mg tab PO Indication: for acute/ chronic bronchopulmonary diseases in association with mucus production. Dosage: 300 mg tab PO Frequency: q6 Intra: -May be taken w/ meals to reduce GI discomfort. Post: -Monitor client for adverse reactions complications. -Tell patient to expectorate the secretions to avoid or possible Pre: -. Check doctors order - Observe 10 Rs -Tell the side effects to the patient

aspiration. -Documentation

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Salmetrol + fluticasone (Seretide) Classification: beta- selective adrenergic agonist Stock Dose: 25/50 mg

Indication: Long-term maintenance treatment of bronchospasm Dosage: 2 puffs. Frequency: q6

Pre: - Check doctors order - Tell the side effects to the patient - Observe 10 Rs - Check inside and outside of the inhaler including the

mouthpiece, for the presence of loose object. - Shake the inhaler well - Hold the inhaler upright between fingers and thumb with the thumb on the base, below the mouthpiece. - Breathe out as far as is comfortable and then place the mouthpiece in the mouth between the teeth and close the lips around it, but do not bite it.

Intra: - Just after starting to breathe in through the mouth, press firmly down on the top of the inhaler to release salmeterol and fluticasone propionate,

while still breathing in steadily and deeply. - While holding the breath, take the inhaler from the mouth and take the finger from the top of the inhaler. Continue holding the breath

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for as long as is comfortable. - Take the 2nd puff keep the inhaler upright

Post: -Cover the mouthpiece. -Documentation Ipratropium/Salbutamol (Duavent) Classification: Anticholinergics Stock Dose: 2.5 ml Indication: Management of reversible bronchospasm Dosage:2.5 ml Frequency: q8 Pre: - Check doctors order - Observe 10 Rs - Explain to the client the indication of the drug -Obtain baseline vital signs and assessments. -Have patient void before taking medication to avoid urinary retention

Intra: -Tell patient to breathe

normally. Post: -Protect the medication from light -Observe for any adverse

reaction and note them. -Ensure adequate hydration. - CPT -Documentation Dolcet (Tramadol) Classification: Analgesic Stock Dose: 1 tab Indication: Treatment for moderate to severe pain Dosage: 1 tab Frequency: TID x pain Pre: - Check doctors order - Countercheck IV label, type, duration of infusion

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- Observe 10 Rs - Assess pain scale

Intra: -Administer after meals, do not crush or chew Post: -Report lack of response, any symptoms of CNS toxicity. -No alcohol until at least 48 hr after therapy completed. Documentation. PNSS Classification: Isotonic solution Stock Dose: 1000cc Indication: To establish or maintain fluid and electrolyte balance. Dosage: 1000 cc Frequency: 16gtts/min. Pre: - Verify written prescription and make IV label. -Observe 10 Rs when preparing and administering IVF -Explain procedure to reassure patient/ significant others -Assess patients vein, choose appropriate site, location and condition. -Do hand hygiene before the procedure. -Check sterility and integrity of IV solution and set. -Place IV label on IVF bottle duly signed by RN/SN who prepared it. Intra:

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-Open IV set aseptically. - Fill drip chamber to at least half and prime it with fluid aseptically. -Expel air bubbles if any. Post: -Do hand hygiene after administration -Documentation.

VII. PROGRESS NOTES

Existing Cues/problems Day # Interventions Actually Done Clients Response The patient is conscious, coherent and oriented all the time. He is sociable with the staff and initiates conversations. Received patient awake, lying on bed with an ongoing IVF of PNSS 1 L x 16 running at 15 16 gtts/min at his right metacarpal vein. The patient verbalized that he is experiencing difficulty in breathing. During the assessment the patient manifested having tachypnea and nasal flaring. The nursing interventions done were: CPT to the patient and positioning the client from supine to semi fowlers position to facilitate effective Day #1 breathing. The patient also complains difficulty in breathing associated with chest pain that brought him to not be able to sleep long. When asked on the degree of the pain using pain scale, he said that the pain was on the degree of 5. The first dose of Dolcet was given to the patient at 12 pm as ordered by the doctor. The nursing intervention done in this problem was encouraging the patient to do deep breathing exercises to alleviate pain. After the nursing intervention, the patient verbalized decrease in pain in the chest area from 5/10 to 3/10 and he was able to sleep for at least 3 hours.

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Day #2

The patient is alert and coherent. Received patient awake, lying on bed with an ongoing of IVF of PNSS 1L to run for 16 hours running at 15- 16 gtts/min at his right metacarpal vein. The patient verbalized more effective airway compared yesterday. The patient didnt manifest tachypnea and nasal flaring and during the assessment the breathing pattern of the patient improved. The nursing interventions done were: advised the patient to do deep breathing exercise to help to facilitate in the expansion of the lungs and medications are given. When the patient was asked on how he was feeling that day, he says that he was able to breathe easily and he sleeps well.

VIII. SUMMARY OF CLIENTS STATUS OR CONDITION AS OF LAST DAY OF

CONTACT

Date

Problems encountered (Actual and Resolved) Actual problems that were identified last August 9, 2011:

First problem is Ineffective Breathing Pattern due to pulmonary infection as evidenced by high-grade fever, difficulty of breathing, and shortness of breath. It should be the first priority since breathing is the only means to supply our bodies and its various organs with the supply of oxygen that is vital for our survival. In August 10, 2011 addition, breathing is one way to get rid of waste products and toxins from the body. Any obstruction with breathing may aggregate other complications.

Second problem is Acute Pain due to inflammatory process and dyspnea. Patient verbalized that he was having stabbing chest pain. It should be the next priority since pain is an unpleasant feeling or experience both physically and emotionally. Clients pain scale is 5/10 that can be categorized as moderate pain. Various nursing interventions was done with the cooperation of the client together with the medications given that lessened the pain he experienced. August 10, 2011 There is a potential problem that had been identified during our contact with the client and that is the risk for imbalanced nutrition due to loss of appetite. Necessary nursing interventions were done to prevent imbalances and complications.

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Prepared by:

_______________________ Abegail A. Alforte, SN 13

______________________ Mono Yngwie R. Mendoza, SN 13

_______________________ Kristine V. Buenavnetura, SN 13

______________________ Frances Hetty I. Parsram, SN 13

_______________________ Maria Karren J. Datingaling, SN 13

______________________ Rodney R. Reyes, SN 13

_______________________ Kimzie E. Gaudier, SN 13

_______________________ Laurynel M. Tabudlong, SN13

_______________________ Petricia Angeli M. Gonzales, SN 13

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