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TABLE OF CONTENTS

Page
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

VII. Nursing Management
A. Ideal Nursing Management (NCP) 28
B. Actual Nursing Management (SOAPIE) 28
VIII. Referrals and Follow-up 31
IX. Evaluation and Implications 32
X. Documentation
A. Documentation of evidence of care for 1 week rotation
B. Organization/ Grammar/ Bibliography 33
XI. Rating Scale 34

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I. INTRODUCTION

A. Overview of the Case

Pneumonia is an

inflammatory illness of the lung.[1]

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.

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The setting in which pneumonia develops is one of the most important features to

doctors. Pneumonia may develop in people living in the community (community-

acquired 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.

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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

 Understand the course and essence of the chosen care study

 Add up additional knowledge and understanding in the Nursing profession

C. 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.

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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: x

Age: x

Sex: Male

Birth date: x

Religion: x

Civil Status: x

Nationality: Filipino

Address: x

Income and Job: 300 per day; Driver

Name of Wife: x

Date of Admission: January 26, 2008

Time of Admission: 10:00 PM

Vital Signs Assessment

Temperature: 38.3oC

Pulse Rate: 130 bpm

Respiratory Rate: 48 cpm

Blood Pressure: 90/70 mmHg

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Height: 5 inches 6 cm

Weight: 80 kilograms

Allergy: 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.

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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.

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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

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.

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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.

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IV. MEDICAL MANAGEMENT

A. MEDICAL ORDERS with RATIONALE

Medical Orders 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 • To provide adequate O2 supply,

cannula minimizing the occurrence of hypoxia

• Watch out and refer if persistent • To check for signs of inadequate

SOB, cyanosis, change in oxygenation and impaired gas

sensorium and other unusualities exchange

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• 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

• Start IVF with PNSS 1L
• To restore sodium chloride deficit and
ECF volume

• 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

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January 27, 2008

• Change IVF to D5W 500cc @ KVO • Promotes rehydration and elimination

rate

• Insert FBC-UB • To measure correct urine output

• Start ampicillin and tazobactam • To kill susceptible bacteria

2.25mg IVTT q8 (ANST)

• Start Dopamin premix 200mg • A vasoconsctrictor agent that relieves

@20cc/hr with increment of 5cc/hr hypotension

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

measurements

• Intake and output hourly refer if • Check for imbalances in intake and

less than 30cc/hr output

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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 • To identify the infecting organism

• Still for CT scan of the chest with • Imaging studies allows visualization of

contrast the affected area

• Monitor O2 saturation q2, refer if • To check for adequacy of saturation of

less than 95% oxyhemoglobin

LABORATORY RESULTS

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TEST RESULT REFERENCE NURSING IMPLICATION

Blood Urea Nitrogen 154.0 4.6-23.4 May indicate infection

(BUN)

Creatinine 4.17 0.6-1.2 May indicate impaired renal

function

White Blood Cell 33.5 5-10 mm3 May indicate presence of

Count infection

Red Blood Cell 3.91 4.2-5.4 May indicate Anemia

Count

Hemoglobin Count 11.7 12-16 May indicate Anemia

Hematocrit Count 32.9 37-47 May indicate Anemia

Neutrophils 95.3 43.4-76.2 May indicate bacterial or

parasitic infection

B. DRUG STUDY

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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

Generic Name of Paracetamol
ordered drug
Brand Name Biogesic
Date Ordered January 26, 2008
Classification Non-opioid analgesic;antipyretic
Dose/Frequency/Rout 500 mg/ PRN/ PO
e
Mechanism of Action Produces analgesic effect by blocking pain impulses, by
inhibiting prostaglandins or pain receptors sensitizers; may
relieve fever by acting in hypothalamic heat regulating center
Specific Indication For mild pain and fever
Contraindication To patient’s going long-term therapy for chronic
noncongestive angle-closure glaucoma; hyponatremia;
hypokalemia; hepatic impairment; adrenal gland failure’
hypechloremic acidosis
Side Effects/Toxic Confusion; anorexia; aplastic anemia; rash; renal calculi
Effects
Nursing Precaution Report signs of F/E imbalance

Generic Name of Piperacillin sodium and Tazobactam Sodium
ordered drug

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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

V. PATHOPHYSIOLOGY with ANATOMY AND PHYSIOLOGY

Anatomy and Physiology

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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

bronchioles. The

bronchial tree

continues branching

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

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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.

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The lungs flank the heart and great vessels in the chest cavity.

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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

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 Endocarditis
 Peritonitis

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Via by
Aspiration of Streptococcus pneumonia via Inhalation of microbes after
oropharyngeal secretions into lungs cough, sneeze, or talking

Meningitis, endocarditis, peritonitis DEATH

Colonization of alveoli or penetration of
lower respiratory tract

Cough 23
Initiation of inflammation response
Fever
Dyspnea Chills
Colonization of alveoli or penetration of
lower respiratory tract

Initiation of inflammation response Cough
Fever
Dyspnea Chills
Impaired Gas
Exhange Alveolar edema Exudates formation
Cyanosis

Alveoli and respiratory bronchioles fill with
seous exudates, blood cells, fibrin, and Hypoventilation
bacteria

Crackling sounds
Consolidation of Lung Tissue Whispered pectoriloquy

Pleuritis Bacteremia- spread to other tissues

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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

MGT. OF HEALTH ILLNESS: Briefly describe the pt.’s ability to follow
[x] alcohol [ ] denied treatments (diet, meds, etc.) for chronic health
(amount, frequency)2 glass problems (if present).
Drinks alcohol on occasional basis Not applicable
[ ] SBE Last Pap Smear N/A
LMP: N/A

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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

Diagnostic/ Date Ordered IV Fluids/Blood Date Disc.
Date
Laboratory Date done
ordered
Exams
Jan. 27, Blood Chemistry Jan. 27, Jan. 27, 2008 PNSS @ 40 -Requested for
2008 2008 follow-up
gtts/min
Jan.27, Complete Blood Jan. 27, Jan. 27, 2008 D5W @KVO rate - on going IVF
2008 Count 2008

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VII. NURSING MANAGEMENT

1. Ineffective Airway Clearance RT excessive secretions and ineffective coughing

Interventions Rationale

Independent:

1. Assess respiratory status,  Early identification of respiratory

including vital signs, breath compromise allows intervention before

sounds and skin color at least q tissue hypoxia is significant.

2h

2. Monitor ABG results  Blood gas changes may reveal

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 To help maintain open airway

medications as ordered

(bronchodilators)

2. Ineffective breathing pattern RT pleural inflammation

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Interventions Rationale

Independent:

1. Provide periods of rest  To reduce metabolic demands and the

work of breathing

2. Provide reassurance during  It reduces high level of anxiety which

periods of respiratory distress further increases tachypnea

3. Teach slow abdominal breathing  This breathing pattern helps promote

complete lung expansion

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

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Interventions Rationale
Independent:

1. Assess activity tolerance, noting  The assessment findings may

any increase in pulse, indicate limited or impaired activity

respirations, dyspnea, tolerance

diaphoresis, or cyanosis

2. Schedule activities, planning for = Rest periods minimizes fatigue and

rest periods improves activity tolerance

3. Perform active or passive ROM  Exercise help maintain muscle tone

and joint mobility

4. Assist the family to minimize  Stress and anxiety increases

stress and anxiety levels metabolic demands and can increase

activity tolerance

5. Provide assistive device, such as  These assistive device facilitate
an overhead trapeze movement and reduce energy

demands

B. ACTUAL NURSING MANAGEMENT

S ”Galisod ko ug ginhawa tapos gi-ubo pud ko”

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O  Pursed-lip breathing

 Dyspnea

 Cough with sputum
A Ineffective airway clearance RT excessive secretions and ineffective

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

evidenced by effective coughing techniques and patent airways
I 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.
E After 30 minutes, the client’s cough was productive and breath sounds are

clearer.

S ”Dili kaayo ko galihok-lihok kay gahanguson ko ug galisod ko ug ginhawa.”

O  SOB after few meters walk

 Increased RR=48cpm

 Dyspnea

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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

tolerance, AEB maintaining a realistic activity level and demonstrating energy

conservation techniques.
I 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 exercise-

induced hypoxemia thus improving activity tolerance.
E After 30 minutes, client had a tolerable level of performing an activity but SOB

is still present.

S “ Usahay dili nako massabtan ang akong gi-bate.”

O  Absent-minded

 Anxious

 Dyspnea
A Anxiety RT acute breathing difficulties and fear of suffocation

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P 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
I 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
E After 3 hours, the client’s anxiety is decreased. The client demonstrated

breathing techniques and appears rested.

VII. REFERRALS AND FOLLOW-UP

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

instructed for compliance of medication regimen which includes the

following:

 Salbutamol 1 neb + 2cc NSS q6h

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 Piperacillin + Tazobactam 2.25 mg q8h

 Paracetamol 500 mg PRN
EXERCISE  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
TREATMENT  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

 Encouraged with adequate nutrition and rest
OUT PATIENT  After discharged, client was instructed to return to clinic for

follow-up checkup and X-ray and physical exam
DIET 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

34
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

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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

A. WRITTEN WEIGHT RATING
I. Introduction 5
a. Overview of the Case
b. Objective of the Study
c. Scope and Limitation of the Study
II. Health History 5
a. Profile of the Patient
b. Family and Personal Health History
c. Chief Complaint
III. Developmental Data 5
IV. Medical Management 20

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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