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Scope and Limitation of the Study II. Health History A. Profile of Patient B. Family and Personal Health History C. History of Present Illness D. Chief Complain III. Developmental Data IV. Medical Management A. Medical Orders and Laboratory Results B. Drug Study V. Pathophysiology with Anatomy and Physiology VI. Nursing Assessment (System Review and Nursing Assessment II) VII. Nursing Management A. Ideal Nursing Management (NCP) B. Actual Nursing Management (SOAPIE) VIII. Referrals and Follow-up IX. Evaluation and Implications X. Documentation A. Documentation of evidence of care for 1 week rotation B. Organization/ Grammar/ Bibliography XI. Rating Scale 33 34 28 28 31 32 22 10 15 17 5 6 6 6 7 2 4 4
I. INTRODUCTION A. Overview of the Case Pneumonia is an
inflammatory illness of the lung. Frequently, it is described as lung parenchyma/alveolar (microscopic air-filled sacs of the lung
responsible for absorbing oxygen from the atmosphere) inflammation and (abnormal) alveolar filling with fluid. Pneumonia can result from a variety of causes, including
infection with bacteria, viruses, fungi, or parasites, and chemical or physical injury to the lungs. Its cause may also be officially described as idiopathic, that is unknown, when infectious causes have been excluded. 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 fatal infection acquired in hospitals. In developing countries, pneumonia is either the leading cause of death or second only to dehydration from severe diarrhea.
The setting in which pneumonia develops is one of the most important features to doctors. Pneumonia may develop in people living in the community (communityacquired pneumonia), in the hospital (hospital-acquired pneumonia), or in some other institutional setting, such as a nursing home (institution-acquired pneumonia). The 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 the gram-positive bacterium Streptococcus pneumoniae. Hospital-acquired pneumonia is more likely to be caused by Staphylococcus aureus or a gram-negative bacterium, such as Klebsiella pneumoniae or Pseudomonas aeruginosa. Depending on the 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 drugs in the hospital). This care study presents a condition of patient in Northern Mindanao Medical Center having a diagnosis of Community-Acquired Pneumonia, Mitral Regurgitation with 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 conducting the study.
B. Objective of the Study Individual care study provides goals or objectives which is necessary to serve as an instrument in comprehensively assessing the patient’s health status and present condition. It also focuses on the following aims: Utilizing the nursing process in the management of patient’s health condition and in giving quality nursing care Obtain a complete health data that can be used in the follow-up care Impart health teachings about necessary information pertaining to the disease condition C. Understand the course and essence of the chosen care study Add up additional knowledge and understanding in the Nursing profession
Scope and Limitation of the Study 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 words and answers supported by the client.
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. II. HEALTH HISTORY A. Profile of the Patient Name: Age: Sex: Birth date: Religion: Civil Status: Nationality: Address: Income and Job: Name of Wife: x x Male x x x Filipino x 300 per day; Driver x
Date of Admission: January 26, 2008 Time of Admission: 10:00 PM
Vital Signs Assessment Temperature: Pulse Rate: 38.3oC 130 bpm
Respiratory Rate: 48 cpm Blood Pressure: 90/70 mmHg
Height: Weight: Allergy:
5 inches 6 cm 80 kilograms No known allergy to food and drugs
B. Family History and Personal Health History 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 Mefenamic Acid, Paracetamol, and other pain relievers.
C. History of Present Illness I month prior to admission, patient had cough with whitish phlegm, has no fever and with absent shortness of breath. 5 days prior to admission, patient had low to moderate cough, had fever and chills; self-medicated with Paracetamol. 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 January 26, x due to cough and shortness of breath.
VI. DEVELOPMENTAL TASK Theories of development provide a framework for thinking about human growth, development, and learning. 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 individual’s characteristics and the support provided by the social environment. 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 emotional isolation, loneliness, and depression.
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 and is not withdrawn to the commitment he has. Cognitive Development theory On formal operational stage of cognitive development by Jean Piaget, people 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 operational stage. Instead of relying solely on previous experiences, children begin to consider possible outcomes and consequences of actions. This type of thinking is important in long-term planning. In earlier stages, children used trial-and-error to solve 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 thiking and reasoning.
Developmental task In Havighurst developmental task, person knows to choose his need to be made and emotionally engaged. Has information and engages in long term planning including educational plans. Have stable vocational goals and plans. He makes decisions
independently. Decisions fit aptitude, ability, and resources. 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 haven’t accomplished his educational plans.
Psychosexual Theory During the final stage of psychosexual development, the individual develops a 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.
IV. MEDICAL MANAGEMENT
A. MEDICAL ORDERS with RATIONALE
January 26, 2008 • DAT with aspiration precaution •
Patient is allowed intake of food that he can tolerate but with precaution to avoid aspiration that may cause airway obstruction
Intake and output every shift
To check and note for imbalances in the intake and output
TPR every 4h
To monitor any alterations and deviations in patients’ vital measurement
O2 inhalation @3L/min by nasal • cannula
To provide adequate O2 supply, minimizing the occurrence of hypoxia To check for signs of inadequate oxygenation and impaired gas exchange
Watch out and refer if persistent • SOB, cyanosis, change in
sensorium and other unusualities
Laboratory test required: 1. CBC with platelet 2. Urinalysis • • To check for occurrence of infection in the body A standard procedure; used to check abnormalities in the renal system 3. Serum creatinine, BUN,Na, • K 4. Sputum exam 5. Chest X-ray – PA 6. ECG 12 leads 7. CT Scan with chest contrast • • • • To evaluate gas exchange and alterations in body electrolytes To identify the infecting organism, gram (+) or gram (-) bacteria To check the extent and pattern of lung involvement Helps to detect abnormalities in the cardiovascular system Imaging studies allows visualization of the extent of the affected organ
Start IVF with PNSS 1L
To restore sodium chloride deficit and ECF volume
Medications: 1. Azithromycin 500mg 1 tab • OD 2. Salbutamol NSS 3. Paracetamol 500mg 1 tab • q4 Medication used for relieving fever and pain 1neb + 2cc • To treat the underlying cause of the disease pharmacologically Provides a relief for airway obstruction
January 27, 2008 • Change IVF to D5W 500cc @ KVO rate • • Insert FBC-UB Start ampicillin and tazobactam 2.25mg IVTT q8 (ANST) • Start Dopamin premix 200mg @20cc/hr with increment of 5cc/hr q15mins BP below 90/60mmHg • Transfer to ICU • For further evaluation and thorough management • O2 sat q4 • To check for adequate saturation of oxyhemoglobin • Vital signs q2 and record • To check for alterations in vital • A vasoconsctrictor agent that relieves hypotension • • To measure correct urine output To kill susceptible bacteria • Promotes rehydration and elimination
measurements • Intake and output hourly refer if less than 30cc/hr • Check for imbalances in intake and output
January 28, 2008 • Still for Chest CT Scan • For visualization of extent of affected area • Still for ABG • To check for gas exchange and levels of electrolytes in the body January 29, 2008 • Repeat CBC, Urinalysis • To check for presence of infection and imbalances in the renal system • For serum Na, K, SGPT, SGOT • To check for levels of electrolytes in the body • • To facilitate sputum exam Still for CT scan of the chest with contrast • Monitor O2 saturation q2, refer if less than 95% • • • To identify the infecting organism Imaging studies allows visualization of the affected area To check for adequacy of saturation of oxyhemoglobin
TEST Blood Urea Nitrogen (BUN)
NURSING IMPLICATION May indicate infection
May indicate impaired renal function
May indicate presence of infection
May indicate Anemia
Hemoglobin Count Hematocrit Count Neutrophils
11.7 32.9 95.3
12-16 37-47 43.4-76.2
May indicate Anemia May indicate Anemia May indicate bacterial or parasitic infection
B. DRUG STUDY
Generic Name of ordered drug Brand Name Date Ordered Classification Dose/Frequency/Rout e Mechanism of Action Specific Indication
Salbutamol Sulfate Ventolin January 26, 2008 Bronchodilator 1 neb/ q6h/ steam inhalation Relaxes bronchial smooth muscle by acting on beta2adrenergic receptors; improves ventilation 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 Nursing Precaution Generic Name of ordered drug Brand Name Date Ordered Classification Dose/Frequency/Rout e Mechanism of Action irritation Perform chest tapping every after nebulization Paracetamol Biogesic January 26, 2008 Non-opioid analgesic;antipyretic 500 mg/ PRN/ PO Produces analgesic effect by blocking pain impulses, by inhibiting prostaglandins or pain receptors sensitizers; may Specific Indication Contraindication relieve fever by acting in hypothalamic heat regulating center For mild pain and fever To patient’s going long-term therapy for chronic noncongestive angle-closure glaucoma; hyponatremia; hypokalemia; hepatic impairment; adrenal gland failure’ Side hypechloremic acidosis Effects/Toxic Confusion; anorexia; aplastic anemia; rash; renal calculi Report signs of F/E imbalance Piperacillin sodium and Tazobactam Sodium
Effects Nursing Precaution Generic Name of ordered drug
Brand Name Date Ordered Classification Dose/Frequency/Rout e Mechanism of Action
Zosyn January 27, 2008 Antibiotic 2.25 mg/ q 8h/ IVTT 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 Nursing Precaution IV site Advise patient to limit intake of sodium because piperacillin contains 1.98 mEq of Na per gram
V. PATHOPHYSIOLOGY with ANATOMY AND PHYSIOLOGY Anatomy and Physiology
In humans, the trachea divides into the two main bronchi that enter the roots of the lungs. The bronchi continue to divide
within the lung, and after multiple divisions, give rise to The tree branching
bronchioles. bronchial continues
until it reaches the level of terminal bronchioles, which lead to alveolar 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
dwellers. The medial border of the right lung is nearly vertical, while the left lung contains a cardiac notch. The cardiac notch is a concave impression molded to accommodate the shape of the heart. Lungs are to a certain extent 'overbuilt' and have a tremendous reserve volume as compared to the oxygen exchange requirements when 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 oxygen requirements increase due to exercise, a greater volume of the lungs is perfused, allowing the body to match its CO2/O2 exchange requirements.
The lungs flank the heart and great vessels in the chest cavity.
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: Advanced Age Tracheal intubations Prolonged immobility Immunosuppressive therapy Nonfunctional immune system Malnutrition Dehydration Target Organs: Brain Heart Peritoneal cavity Complications: Meningitis Clinical Manifestation: -- Onset of shaking shills -- Fever -- Cough production of rustcolored or purulent sputum -- Chest pain -- Limited breath sounds -- Fine crackles o rales heard -- Dyspnea -- Cyanosis
Via Aspiration of Streptococcus pneumonia by oropharyngeal secretions into lungs
Inhalation of microbes after cough, sneeze, or talking
Meningitis, endocarditis, peritonitis Colonization of alveoli or penetration of lower respiratory tract
Initiation of inflammation response Dyspnea
Cough Fever Chills
Colonization of alveoli or penetration of lower respiratory tract
Initiation of inflammation response Dyspnea Impaired Gas Exhange Cyanosis
Cough Fever Chills
Alveoli and respiratory bronchioles fill with seous exudates, blood cells, fibrin, and bacteria
Consolidation of Lung Tissue
Crackling sounds Whispered pectoriloquy
Bacteremia- spread to other tissues
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 asses resp. rate, rhythm, depth, pattern breath sounds, comfort [ ] no problem CARDIO VASCULAR [ ] arrhythmia [x] tachycardia [ ] numbness [ ] diminished pulses [ ] edema [ ] fatigue [ ] irregular [ ] bradycardia [ ] murmur [ ] tingling [ ] absent pulses [ ] pain Assess heart sounds, rate, rhythm, pulse, blood pressure, clearance, fluid retention, comfort [ ] no problem GASTROINTESTINAL TRACT [ ] obese [ ] distention [ ] mass [x] dysphagia [ ] rigidity [ ] pain assess abdomen, bowel habits, swallowing bowel sounds, comfort [ ] no problem GENITO-URINARY AND GYNE [ ] pain [ ] urine color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ] nocturia assess urine frequency, control, color, odor, comfort, discharge [x] no problem NEURO [ ] paralysis [x] stuporous [ ] unsteady [ ] seizures [ ] lethargic [ ] comatose [ ] vertigo [ ] tremors [ ] confused [ ] vision [ ] grip assess motor function, sensation, LOC, strength grip, gait, coordination, speech [ ] no problem 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
Blurred vision Speech pattern: A few words between noticeable breaths =Cough with sputum =tachypneic RR=48cpm Increased HR=130bpm
Hot and dry skin
With IV: D5W @KVO rate With Foley bag catheter attached to urobag Pale nail beds
NURSING ASSESSMENT II
SUBJECTIVE Communication: [ ] hearing loss Comments: “usahay” [X] visual changes blurred akong pana-aw [ ] denied pero okay ra akong pandungog” Oxygenation: [x] dyspnea Comments: “ Galisod ko [x] smoking history ug ginhawa tapos gi-ubo 20 sticks per day pud ko.” [X] cough [x] sputum [ ] Denied Circulation: [ ] chest pain Comments: “ Wala may sakit [ ] leg pain sa akong kamoy ug tiil, okay [ ] numbness of ra man.” extremities [x] denied Nutrition: Diet: Diet as Tolerated N V Comments: “ Lahi ra Character karon, ginagmay ra akong [x] recent change in kaon ug usahay dili jud ko weight, appetite gakaon.” [ ] swallowing difficulty [ ] denied Elimination: Usual bowel pattern [ ] urinary frequency 1x a day With FBC [ ] urgency [ ] constipation [ ] dysuria remedy [ ] hematuria none [ ] incontinence Date of Last BM [ ] polyuria January 26, 2008 [x] foly in place [ ] diarrhea character [ ] denied The pt. has no diarrhea MGT. OF HEALTH ILLNESS: [x] alcohol [ ] denied (amount, frequency)2 glass Drinks alcohol on occasional basis [ ] SBE Last Pap Smear N/A LMP: N/A [ ] glasses [ ] languages [ ] contact lens [ ] hearing aid R L Pupil Size 3mm- normal [ ] speech diff. Reaction PERRLA OBJECTIVE
Resp. [ ] regular [x] irregular Describe: Respiratory rate is above the normal range; RR=48cpm R Symmetrical lung expansion with left L Symmetrical lung expansion with right Heart Rhythm [ ] regular [x] irregular Ankle Edema Not seen Pulse Car. Rad. DP Fem* R + + + + L + + + + Comments: Pulses are palpable [ ] dentures Upper Lower Full [ ] [ ] [x] none Partial [ ] [ ] with Patient [ ] [ ]
Comments: Nakalibang ko ganina pero gamay ra, wala pud ko poblema sa akong pag-ihi
Bowel Sounds Normoactive bowel sounds Abdominal Distention Present [ ] yes [X] no Urine* (color, consistency, odor) Yellowish *if they are in place
Briefly describe the pt.’s ability to follow treatments (diet, meds, etc.) for chronic health problems (if present). Not applicable
SKIN INTEGRITY: [ ] dry Comments: “ Dili man gakatol[ ] itching katol akong panit.” [ ] other [x] denied
[x] dry [ ] cold [x] pale [ ] flushed [x] warm [ ] moist [ ] cyanotic * Rashes, ulcers, decubitus (describe size, location, drainage) No rashes, ulcers.
ACTIVITY/ SAFETY: [ ] convulsion Comments: “Gakalipong ko [X] dizziness kung mutindog ko. Dili [ ]limited motion kayo ko makalihok.” of joints Limitation in Ability to [ ] ambulate [ ] bathe self [ ] other [x] denied COMFORT/SLEEP/AWAKE: [ ] pain Comments: “ Galisod ko (location, frequency, ug pagkatulog kay giremedies) ubo ko.” [ ] nocturia [x] sleep difficulties [ ] denied COPING: Occupation: Driver Members of Household: 3 members Most Supportive Person: Wife- Lewan Galon
[x] LOC and orientation: The pt. is oriented in time, place and person. Gait: [ ] walker [ ] cane [ ] other [ ] steady [x] unsteady ______ [ ] sensory and motor losses in face Or extremities: The pt. displays no sensory and motor losses in the face and extremities. [ ] ROM limitations: The patient can freely move his joints.
[x] facial grimace [ ] guarding [ ] other signs of pain: No other signs of pai observed [ ] side rail release form signed (60+ years) Not applicable. Observed non-verbal behavior: Closing of eyes when experiencing dyspnea The person and his phone number that can be reached anytime no phone
Date ordered Jan. 27, 2008 Jan.27, 2008
Diagnostic/ Laboratory Exams Blood Chemistry
Date Ordered Date done Jan. 27, 2008 Jan. 27, 2008 Jan. 27, 2008
IV Fluids/Blood PNSS @ 40 gtts/min
Date Disc. -Requested for follow-up - on going IVF
Complete Blood Count
Jan. 27, 2008
D5W @KVO rate
VII. NURSING MANAGEMENT 1. Ineffective Airway Clearance RT excessive secretions and ineffective coughing Interventions Independent: 1. Assess including respiratory vital signs, status, Early breath identification of respiratory Rationale
compromise allows intervention before tissue hypoxia is significant.
sounds and skin color at least q 2h 2. Monitor ABG results
impaired gas exchange 3. Place in high-Fowler’s position To pomotes complete lung expansion and ambulation facilitates movement of secretions 4. Provide a fluid intake at least Liberal fluid intake helps to liquefy 2500-3000 mL secretions, facilitating lung clearance
Dependent: 1. Administer prescribed medications as ordered (bronchodilators) To help maintain open airway
2. Ineffective breathing pattern RT pleural inflammation
Interventions Independent: 1. Provide periods of rest
To reduce metabolic demands and the work of breathing
during It reduces high level of anxiety which further increases tachypnea This breathing pattern helps promote complete lung expansion
periods of respiratory distress 3. Teach slow abdominal breathing
4. Teach use of relaxation techniques This technique helps reduce anxiety and slow the breathing pattern.
Dependent: 1. Administer oxygen as ordered Oxygen therapy increases alveolar oxygen concentration, reducing
hypoxia and anxiety
3. Activity intolerance RT inadequate oxygenation and dyspnea
Interventions Independent: 1. Assess activity tolerance, noting any increase in pulse, dyspnea, The
indicate limited or impaired activity tolerance
respirations, diaphoresis, or cyanosis
2. Schedule activities, planning for = rest periods 3. Perform active or passive ROM
Rest periods minimizes fatigue and
improves activity tolerance Exercise help maintain muscle tone and joint mobility
4. Assist the family to minimize Stress stress and anxiety levels
metabolic demands and can increase activity tolerance
5. Provide assistive device, such as These an overhead trapeze
B. ACTUAL NURSING MANAGEMENT
”Galisod ko ug ginhawa tapos gi-ubo pud ko” 30
Pursed-lip breathing Dyspnea Cough with sputum Ineffective airway clearance RT excessive secretions and ineffective coughing 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
evidenced by effective coughing techniques and patent airways Independent: 1. Taught the client to maintain adequate hydration by drinking at least 8-10 glasses of fluid per day (if not contraindicated), to thin secretions. 2. Taught and supervised effective coughing techniques, to conserve energy and reduce airway collapse. 3. Performed chest physical therapy, it uses force of gravity and motion to facilitate secretion removal. 4. Assessed the client’s breath sounds before and after coughing episodes, to help in evaluation of coughing effectiveness. Dependent: 1. Given bronchodilators (Salbutamol sulfate) as ordered, to relax bronchial smooth muscles thus facilitating airflow. After 30 minutes, the client’s cough was productive and breath sounds are clearer.
”Dili kaayo ko galihok-lihok kay gahanguson ko ug galisod ko ug ginhawa.” SOB after few meters walk Increased RR=48cpm Dyspnea
Activity intolerance RT inadequate oxygenation and dyspnea 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 tolerance, AEB maintaining a realistic activity level and demonstrating energy
conservation techniques. Independent: 1. Advised to avoid conditions that increase oxygen demand, this increases peripheral resistance thus increasing cardiac workload and oxygen
requirement. 2. Taught to always use pursed-lip breathing and diaphragmatic breathing, to ensure maximal use of available respiratory function. 3. Assessed the client for signs of negative response to activity, significant changes in respiratory, cardiac, or circulatory status signals activity tolerance Dependent: 1. Maintained supplemental oxygen therapy as ordered, to alleviate exerciseinduced hypoxemia thus improving activity tolerance. E After 30 minutes, client had a tolerable level of performing an activity but SOB is still present.
“ Usahay dili nako massabtan ang akong gi-bate.” Absent-minded Anxious Dyspnea Anxiety RT acute breathing difficulties and fear of suffocation
Long term: At the end of 1 week, client will have a psychological comfort and will cope up to condition Short term: At the end of 3 hours, the client will express an increase in
psychological comfort and demonstrate use of effective coping mechanism Independent: 1. Remained with the client during acute episodes of breathing difficulty, reassures the client that competent help is available if needed. 2. Provided with a quiet, calm environment, to promote relaxation 3. Limited the number of people during acute episodes, to lessen client’s reception to pain 4. Encouraged the use of breathing retraining and relaxation techniques, a feeling of self-control and success in facilitating breathing helps reduce anxiety Dependent:
1. Given sedatives with caution as ordered, to facilitate sleeping After 3 hours, the client’s anxiety is decreased. The client demonstrated breathing techniques and appears rested.
VII. REFERRALS AND FOLLOW-UP
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 instructed for compliance of medication regimen which includes the following: Salbutamol 1 neb + 2cc NSS q6h
Piperacillin + Tazobactam 2.25 mg q8h Paracetamol 500 mg PRN Encouraged to increase activity tolerance per day Assume a high-fowler’s position to promote adequate lung expansion Instructed to do deep-breathing exercises several times (5-10) per hour to help keep lungs fully expanded thereby reducing
dyspnea Proper hygiene measures was also imparted Encouraged to quit smoking as this inhibits tracheobronchial ciliay action Instructed to avoid stress and fatigue as this lowers resistance to pneumonia
OUT PATIENT DIET
Encouraged with adequate nutrition and rest After discharged, client was instructed to return to clinic for follow-up checkup and X-ray and physical exam Health teachings on DIET gave emphasis on: Diet as tolerated with aspiration precaution Increase intake of foods with calorie for adequate oxygen supply Increase fluid intake to 2500-3000 mL
IX. EVALUATION AND IMPLICATIONS 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
tough job on conducting this study yet, it gave me a big impact regarding how useful it is in my chosen profession. Nursing really demands a tender loving care attitude. It 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 effective and quality nursing care.
X. BIBLIOGRAPHY A. BOOKS Black, Joyce M. Medical –Surgical Nursing, 7th edition. Smeltzer, Suzanne. Medical-Surgical Nursing, 11th edition Lippincott Williams and Wilkins A guide to Medical-Surgical Nursing Lemone, Priscilla Medical-Surgical Nursing
B. WEBLIOGRAPHY http://psychology.about.com/od/developmentstudyguide/p/devtheories.htm
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
A. WRITTEN I. Introduction a. Overview of the Case b. Objective of the Study c. Scope and Limitation of the Study II. Health History a. Profile of the Patient b. Family and Personal Health History c. Chief Complaint III. Developmental Data IV. Medical Management 5 20 36 5 WEIGHT 5 RATING
a. Medical Orders with Rationale b. Drug Study V. Pathophysiology with anatomy and physiology VI. Nursing Assessment a. Nursing System Review Chart b. Nursing Assessment II VII. Nursing Management a. Ideal Nursing Management b. Actual Nursing Management VIII. Referrals and Follow-up IX. Evaluation and Implication X. Documentation a. Documentation of Evidence of Care for 1 Week Rotation b. Organization/Grammar/Bibliography
(10) (10) 10 10 30 (10) (20)
5 5 5
Total Score Equivalent Grade
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