ANGELES UNIVERSITY FOUNDATION Angeles City COLLEGE OF NURSING S.Y.

2008-2009

A Case Study COMMUNITY-ACQUIRED PNEUMONIA

In Partial Fulfilment of the Requirements in Related Learning Experience

Submitted by: David, Nikki Louise Kina Z. Gutierrez, Mary Joy R. Manalo, Ma. Adrianne V. BSN III-15 Group 57 Submitted to: Ms. Johana L. Dimla, R.N. September 19, 2008 TABLE OF CONTENTS

DEDICATION ACKNOWLEDGEMENT

I.

INTRODUCTION………………………………………………………………… …….1

II.

NURSING ASSESSMENT A. Demographic Data, Socio Economic, Cultural And Environmental Factors……………………………

B. Personal
History……………………………………………………….

C. Pertinent Family Health
History……………………………………..

D. History of Past
illness…………………………………………………

E. History of Present
Illness……………………………………………. F. Physical Examination (IPPA, Cephalocaudal Approach) G. Diagnostic and Laboratory Procedures……………………………

III.

ANATOMY AND PHYSIOLOGY……………………………………………………

IV.

THE PATIENTS ILLNESS A. Synthesis of the disease

1. 2. 3.

Definition of the disease………………………………………… Predisposing and Precipitating Factors……………………… Signs and Symptoms…………………………………………

4. Health promotion and preventive aspects of the disease… V. THE PATIENT AND HIS/HER CARE Medical Management A. IVF’s…………………………………………………………………… .

B. Drugs……………………………………………………………… C. Diet……………………………………………………………………. D. Activity and Exercise………………………………………………
Nursing Management:

A. Nursing Care Plans……………………………………………… B. Actual SOAPIER’s………………………………………………
VI. CLIENT’S DAILY PROGRESS IN THE HOSPITAL

A. Client’s Daily Progress Chart…………………………………… B. Discharge Planning……………………………………………….
1. 2. General Conditions of the Patient Upon Discharge M.E.T.H.O.D.

VII.

CONCLUSION AND RECOMMENDATIONS…………………………………

VIII.

BIBLIOGRAPHY

we dedicate this to all of you. Moreover. brothers and sisters in the nursing profession and to every person who has an affinity to this profession. our Almighty God.DEDICATION We would like to dedicate this fruit of our toiling to our Heavenly Father. To our parents. we offer this to those who strive hard to raise the notch for the development and improvement of the noblest profession on earth – the nursing profession. friends. . for without Him our case would be unfeasible.

advice and undying support and kindness. their clinical instructor. now more than ever. The researchers would like to express their appreciation and give thanks to the Almighty Father. wisdom and determination that helped us to materialize this study.ACKNOWLEDGEMENT The aim of this study was attained through the help and guidance of the following people who have extended their time. . To their patient and the significant others. for providing all the love and care. for always being there to give guidance and care in times of difficulties and for the support they have given form the start of this study. for their cooperation and willingness to participate in this study and for providing them essential information about this study and making their doors open. Johana L. support and encouragements to make this study possible. To Ms. for their support and serving as their inspiration that helped them believe in their capabilities. we would like to extend our deepest gratitude. the source of their talent. Finally. Her mere guidance enables us to produce the best result. for all the patience. Dimla. to many unnamed friends. strength. and for bestowing upon us patience. To their loving families.

and whether the person has recently been hospitalized. risk factors for certain microorganism. Another important system of classification is the combined clinical classification. The combined clinical classification. The advantage of this classification scheme over previous systems is that it can help guide the selection of appropriate initial treatments even before the microbiologic cause of pneumonia is known. attempt to identify the person’s risk factors when he or she first comes to medical attention. immobilization. endotracheal malnutrition. The causative microorganisms influence the symptoms and signs with which the patient presents. fungi. and with the advent of x-rays. As more became known about the microorganisms causing pneumonia. It is the eighth leading cause of death in the United States. radiological classification. immunocompromise. viruses. alcoholism. or parasites. . There are two broad categories of pneumonia in this scheme: community-acquired pneumonia and hospital-acquired pneumonia. intubation. now the most commonly used classification scheme. consciousness. how the pneumonia should be treated and the prognosis. which combines factors such as age.I. a microbiologic classification arose. protozoa. Pathologists originally classified them according to the anatomic changes that were found in the lungs during autopsies. Pneumonias can be classified into several ways. A recently introduced type of healthcare-associated pneumonia lies between this two categories. altered and smoking. the presence of underlying lung disease and underlying systemic disease. underlying lung disease. The incidence and mortality of pneumonia are highest in the elderly. INTRODUCTION Pneumonia is an infection of the lower respiratory tract caused by bacteria. Risk factors for pneumonia include advanced age.

The most common community-acquired pneumonia is caused by Streptococcus pneumoniae. Mycoplasma pneumoniae is a common cause of pneumonia in young people especially those living in group housing such as dormitories and army barracks. which also cause CAP. Legionella species. . The characteristics of the individual are important in determining which etiologic microorganism is likely. ranks ninth among the leading causes of mortality on individuals aging 15 to 59 worldwide and ranks fourth on individuals aging 60 and over. tachypnea and tachycardia. CAP is one of the most common entities seen in Filipino adults. For example. immunocompromised persons tend to be susceptible to opportunistic infections that are uncommon in normal adults. although it is higher in the elderly. Signs and symptoms of CAP are fever. but many pneumonias. Prognosis is excellent for relatively young and healthy patients. dyspnea. According to the World Health Report by the World Health Organization. nosocomial infections and those affecting immunocompromised individuals have higher mortality rate communityacquired pneumonias. Treatment is with empirically chosen antibiotics. especially when caused by Streptococcus pneumoniae and influenza virus. It is the most common infectious disease prompting hospitalization and the first and fifth leading cause of morbidity and mortality in the Philippines. which has a relatively low mortality rate. sicker patients. In general. which include community-acquired pneumonia. respectively. cough. are fatal in older. Diagnosis is based on clinical presentation and chest x-ray.Community-acquired pneumonia develops in people with limited or no contact with medical institutions or settings. Influenza is the most common viral community-acquired pneumonia in adults. lower respiratory infections. CAP tends to be caused by different microorganisms than those infections acquired in the hospitals. and that it is the leading killer of children worldwide. can contaminate cooling systems and water supplies leading to outbreaks of disease.

NURSING ASSESSMENT . facilitate health promotion and perform appropriate interventions to individuals with such condition. II. CAP would be known better and would be helpful for the group to effectively play their role as advocates of their patients care and well-being. The prevalence of community-acquired pneumonia in the local and foreign communities needs attention and through this study. This will serve as an important tool for them to render proper nursing care. which will lead them to become effective and efficient in the nursing field.Incidence rates mentioned above is primarily the reason of the group for choosing this case. This study aims to provide the group a clear view of the pertinent facts surrounding community-acquired pneumonia.

333 per month. He was born on February 17. 2008. He got married at an early age of 17 and became the sole provider of his family by working as a farmer. Cap is a religious member of the Iglesia ni Cristo and never fails to visit their church. they are then considered poor. b. his source of income is their land which he tills together with his grandson. His admitting diagnosis was Bronchopneumonia and Acute Gastroenteritis.A. . He does not believe in hebolarios but uses medicinal plants available in their yard like guava and oregano whenever he has a cough. Cap is a 69-year old naturally born Filipino. he started working as a farmer in their own land. Mr. He had a final diagnosis of community-acquired Pneumonia. At present. For many years up to now. He started smoking when he was 16 year old and started taking alcoholic beverages at the age of 27. he is still the president of the Association of Farmers in Magalang. Personal History a. He was admitted last August 17. He is earning approximately Php 100. Mr. Demographic Data Mr. Cap is a frequent smoker. Having this monthly income for the eight members of his family.000 a year from their harvests. After graduating in elementary. He starts smoking early in the morning and consumes approximately half pack of cigarettes a day. 1939 and is presently residing at Magalang. Mr. His last job was in the department of agriculture. 2008 at a district hospital somewhere in Angeles City with a chief complain of difficulty of breathing. He retired last 2004 at the age of 66. He was discharged last August 25. which is equivalent to Php 8. Socio-economic and Cultural Factor Brought by their economic status in life. Cap had only finished elementary at a public school in Magalang.

All of them already have their own family. Lung diseases are not prevalent in their community. Cap has 13 children. Their community is quite crowded. daughter. six of which are males and seven are females. Environmental Factors Mr. Cap’s family is classified under an extended type of family with his wife. son-in-law and three grandchildren living in the same house. The place they live is not congested.c. a dining room. The road in their place is not cemented. lives with her parents in their ancestral home. They have a bungalow type of house made of concrete materials. . Twelve of them are living away from their parents and only one. It has three bedrooms. who is the youngest. No factories or any establishments that can contribute to air pollution are located in their vicinity. Mr. The location of their house is an agricultural land that is why most of the people there are farmers. a living room and a bathroom. Only few part is cemented before you reach their barangay is cemented.

SCHEMIC DIAGRAM ON FAMILY HEALTH-ILLNESS HISTORY .B.

when she was still living. On mild fever and coughs. only four are alive. His eldest brother died of pneumonia at an early age of age 27. he had a check-up at another district hospital in Angeles City and was ordered to undergo chest x-ray and it was found out that he had an accumulation of fluid in the lungs or pleural effusion. as narrated by Mr. According to Mr.Mr. respiratory diseases and cancer. Succeeding checkups at district hospital in Magalang were prompted by unrelieved fever and cough. His third eldest sibling died at the age of 31 whose death was believed to have been caused by nervous breakdown. Specific medications taken cannot be recalled by Mr. He stayed at the hospital for a day and a night. aspiration of the fluid was done after being diagnosed of such condition. Cap. He had been admitted before only once in a district hospital in Angeles City around 1960s with a chief complain of epistaxis. B. she experienced pruritus and difficulty of breathing which lead to her death. Cap. Also in 1960’s. His grandparents on the maternal side both died because of old age and they did not have any history of diabetes mellitus. he usually does self-medication by taking Medicol and Paracetamol. His mother. Cap but prescribed medications were taken for three months until the condition was resolved. Cap rarely consults a physician in the past. Both Mr. History of Past Illness Mr. He only visits clinics or hospitals whenever his condition gets worse. his grandfather’s cause of death was unknown while her grandmother died because of childbirth. His father died because of a liver disease at the age of 35. Among his seven siblings. The last time she had allergies. On his paternal side. In some cases he uses herbal . Cap ranks fifth in their family. frequently experienced episodes of allergic reactions from the food she eats. hypertension. Cap’s parents already passed away.

Last August 10. Cap had an epistaxis which prompted him to go to the hospital. seven days prior to his admission at a district hospital in Magalang. He was then admitted last August 17. 2008. He has no history of diabetes mellitus. cancer or hypertension and had not undergone any surgical procedures in the past. The health problems he experienced in the past were fever. cough and flu which he managed by taking over-the-counter drugs and herbal plants. History of Present illness In 1960’s. Also in 1960’s he had been diagnosed of having pleural effusion and he had taken medications prescribed for his condition for three months. Mr. C. he still experienced cough and had difficulty at breathing. D. Mr. 2008 with a chief complain of difficulty of breathing and had an admitting diagnosis of Bronchopneumonia and Acute Gastroenteritis. A day prior to his admission. The next day. He was then referred to a district hospital in Angeles City to better manage his condition. he still had difficulty of breathing which prompted his family to bring him to the hospital. Cap experienced productive cough and fever. Physical Examination . he experienced loose watery stool and few hours before he was admitted.plants like guava and oregano to relieve his cough which are cheaper and always available.

RR= 20 bpm. pale. He is afebrile with vital signs taken and recorded as follows: VS: BP= 130/70 mmHg. pale conjunctiva Ears: Symmetrical with no discharges. equally distributed eyelashes and eyebrows. auricles aligned with the outer canthus of the eye Nose: Symmetrical and straight. blinks involuntarily. neck muscles are equal in size Chest/Lungs: Has symmetrical chest expansion.August 22. both nares are patent. 2008 . jugular veins are not distended. with pale nailbeds August 23. good skin turgor. place and person. 2008 General appearance: Patient appears weak and is conscious to time. with 18 bowel sounds per minute. T=36. presence of resonance upon percussion Extremities: Equal in size and length. absence of edema. symmetrical. absence of nodules and masses Eyes: Round and symmetrical. no edema.9 C/Axilla Skin: Uniform in color. both lower and upper extremities move with coordination. no discoloration on eyelids. eyelids close symmetrically. PR=104 bpm. absence of nodules and masses Face: Symmetrical. with skin rashes Skull: Round. normocephalic. presence of rales on both lung fields upon auscultation Abdomen: Slightly globular in shape. no tenderness Mouth: Dry and pale lips Neck: With palpable modules on the left side of the neck.

Pr=95 bpm. He is afebrite with vital signs taken and recorcded as follws: VS: BP=110/70 mmhg. eyelids close symmetrically. good skin turgor. both lower and upper extremities move with coordinatio T=36. symmetrical. neck muscles are equal in size Chest/Lungs: Has symmetrical chest expansion. no discoloration on eyelids. absence of nodules and masses Face: Symmetrical. coherent and conscious to time. absence of edema. no tenderness Mouth: Dry and pale lips Neck: With palpable modules on the left side of the neck.9 C/axilla Skin: Uniform in color. pale conjunctiva Ears: Symmetrical with no discharges. auricles aligned with the outer canthus of the eye Nose: Symmetrical and straight. with 15 bowel sounds per minute. both nares are patent. place and person. normocephalic. with skin . rr=21 bpm. equally distributed eyelashes and eyebrows.General Appearance: Patient is awake. blinks involuntarily. presence of resonance upon percussion Extremities: Equal in size and length. rashes Skull: Round. no edema. pale. absence of nodules and masses Eyes: Round and symmetrical. jugular veins are not distended. presence of rales on both lung fields upon auscultation Abdomen: Slightly globular in shape.

Hazy densities are like wise seen in the left lungs base. Heart is not enlarged body thorax is unremarkable. Evaluate known or suspected pulmonary disorders and cardiovascular disorders. LABOORATORY AND DIAGNOSTIC PROCEDURE Diagnostic and Laboratory Procedure : Date Ordered Date Resulted Indication or Purposes Results Normal Values Analysis and Interpretation Radiology Chest (PA) Date Ordered : August 17. ribs and diaphragm The result shows that patient are congruent to the diagnosis of pneumonia . cardiac and skeletal systems. 2008 Date Resulted: August 17. progression or maintenance of the disease. Monitor resolution. Nodule.E. cardiac size. Normal lung fields. The right apical pleuralis thickened. thoracic size. 2008 Chest Radiography or x-ray yields information about the pulmonary.haze densities are evident in the right lung with traction of the trachea rightwards and right hemi diaphragm upwards. mediastinal structures.

all external metallic objects. extend neck and position shoulders forward Ask the patient to inhale deeply and hold his breath while the x-ray images are taken and then exhale after the image are taken After the Procedure: . including list of known allergens Obtain history of results of previously performed laboratory test. rob and foot coverings to wear and instructed to void prior to the procedure Observed standard precautions Instruct the patient to cooperate fully and to follow directions. but there may be moments of discomforts There are no food. wires and the like prior to the procedure Patient are given a gown.Nursing Responsibilities Prior to the Procedure • • • • • • • Inform the patient that the procedure assess cardiopulmonary status Obtain history of the patient symptoms and complains. Explain to the patient that no pain will be experience during the test. surgical procedures and other diagnostic procedures Obtain list of the medication the patient is taking Review the procedure with the patient. fluid or medication restrictions unless by medical direction During the Procedure: • • • • Ensure the patient has removed jewellery. dentures. Instruct the patient to remain • • • still throughout the procedure because movements produces unreliable result Place the patient in the standing position in front of the x-ray film or detector Have the patient place hands on hips.

treatment or referral to another health care provider . The report will be sent to the requesting health care practitioner who will discuss the result to the patient.• A written report of the examination will be completed by a healthcare provider specializing in this branch of medicine. • Recognize anxiety related to test result and be supportive of impaired activity related to respiratory capacity and perceived loss of physical activity • Reinforce information given by the patient health care practitioner regarding proper testing.

2008 Date Resulted: August 18. 145 140-180 The result shows that the haemoglobin is within normal range. Hemoglobin This test evaluates blood loss. polycythemia and anemia . It is used to aid diagnosis abnormal states of dehydration.Diagnostic and Laboratory Procedure : Coplete Blood Count Hematocrit Date Ordered Date Resulted Indication or Purposes Results Normal Values Analysis and Interpretation Date Ordered : August 17. It is an important component of RBC that carries oxygen and CO2 to and from the tissues.40-54 The result shows that the hematocrit is within the normal suggesting that has less chance of developing hemmorhage. 2008 2am Measures the concentration of WBC within the blood volume. anemia and response to therapy. . erythropoietin ability.42 . IT suggests that there is enough number of circulating hemoglobin thus no deprivation of oxygen supply to the different body organs.

homeostasis and blood thrombus formation 233 150-400 The result is within the normal range 4.3 The result is within the normal range 5-10x10 9/L The result is within the normal range Red Blood Cell (RBC) Confirm low platelet .9 Test used to detect infection or inflammation to evaluate effectiveness of antibiotic prescribed.99 Has a principal means of delivery of oxygen to the body tissues via the blood Platelet Count Platelet has essential function in coagulation. White blood Cell Count (WBC) 5.Serve as a buffer to maintain acid and base balance in the extracellular fluid. 4.5-6.

0. its primary function is in phagocytosis.38 0. Measures blood glucose regardless of when you last eat.70 This indicates that the body is has low capacity to fight against invading microorganisms.62 0. Segmenters 0.count which can be associated with bleeding Lymphocytes Lymphocytes play a major role in body’s natural defense system Monitor the response on reaction to the drugs of the patient A type of neutrophil. RBC 118 118-140 The result is within the normal range .66 -0.48 The result indicates with in the normal range.10-0.

 Sensitivity to social and cultural issues. hematopoietic.    During the Procedure .  Obtain a history of the patient’s cardiovascular.  Review the procedure with the patient. hepatobiliary. during and after the procedure. and inform the appropriate health care practitioner accordingly. or medication restrictions. including herbs. Explain to the patient that there may be some discomfort during venipuncture. including a list of known allergens (especially allergies or sensitivities to latex). and respiratory systems. unless by medical direction. immune. nutritional supplements so that their effects can be taken into consideration when reviewing results. as well as concern for modesty is important in providing psychological support before. as well as results of previously performed laboratory tests.Nursing Responsibilities Prior to the Procedure Check the doctor’s order Verify patient’s name Inform the patient that the test is used to evaluate anemia and hydration status and to monitor therapy.   Note any recent procedures that can interfere with test results. surgical procedures. Obtain a list of the medications the patient is taking. musculoskeletal. gastrointestinal.  Obtain a history of the patient’s complaints.  There are no food. Address concerns about pain related to the procedure. fluid. Inform the patient that specimen collection takes approximately 5 to 10 minutes.

Perform a venipuncture. Positively identify the patient. Smears made from specimens older than 6 hours will contain an unacceptable number of misleading artificial abnormalities of red blood cells as well as white blood cells. Apply paper tape or other adhesive to hold pressure bandage in place or replace with a plastic bandage.  Depending on the results of this procedure.    After the Procedure Observe venipuncture site for bleeding or hematoma formation. who will discuss the result with the patient. Observe standard precautions.  A written report of the examination will be sent to the requesting health care practitioner. Evaluate teat results in relation to the patient’s symptoms and other tests performed. and label the tubes corresponding patient demographics. The specimen should be mixed gently by inverting the tube 10 times. The specimen should be analyzed within 4 to 6 hours. Answer any questions or address any concerns voiced by the patient or family. Instruct the patient to cooperate fully and follow directions. two blood smears should be made immediately after the venipuncture and submitted with the blood sample. Promptly transport the specimen to the laboratory for processing and analysis. Remove the needle. and apply a pressure dressing over the puncture site. date and time of collection.  .  Reinforce information given by the patient’s health care provider regarding proper testing. additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. collect the specimen in a 5 ml lavender top tube. Direct the patient to breathe normally and to avoid unnecessary movement. treatment or referral to other health care practitioner.

4-6. Date Resulted: August 18. 2008 5 am Cholesterol To test the total amount of fatty substance in the blood Helps in building up cells and produce hormones 130.4-1. impaired renal 2008 function. 1.Diagnostic and Laboratory Procedure : Blood Chemistry Creatinine Date Ordered Date Resulted Indication or Purposes Results Normal Values SI 0.7 35-124 Analysis and Interpretation Traditional Date Ordered to patient Ordered : to diagnose August 17.7 150.3 The result is higher than the normal range which indicates decreased function of the kidney.48 The result is within the normal range .4 150-250 3.0 3.

starting at the site and working outward in a circular motion. and then remove the residual iodine with an alcohol swab. clean it again with a povidone-iodine swab. You can reduce the risk of bruising by keeping pressure on the site for several minutes after the needle is withdrawn. During the Procedure Put on gloves. After cleaning the venipuncture site with an alcohol swab. Perform a venipuncture and draw 7 ml.   Apply the tourniquet. (No special preparation is required before having a random blood sugar test.Nursing Responsibilities Prior to the Procedure     Check the doctor’s order Verify the patient Explain the procedure to the patient.   After the Procedure Send the sample immediately in the laboratory.) Check and/or validate doctor’s order. Inform the patient of the sample required and that some discomfort may be felt from the needle punctures and the pressure of the tourniquet. Wait at least 1 minute for the skin to dry. . The nurse focuses on nursing care of the patient and follows up activities and observations.    The nurse also reports the results to appropriate health team members.   Tell patient to avoid diet high in meat.  You may develop a small bruise at the puncture site.

It is a group of test that evaluate the kidney’s ability to selectively excrete and reabsorb substances while maintaining water balance Monitor fluid imbalance Monitor response to the drug therapy and evaluate undesired react was to drug that may impair renal function Ordered to determine whether the urine contains substances indicate Results Normal Values Analysis and Interpretation Color : Yellow Light Yellow to deep amber Clear Urine color is within normal range Urine transparency is within the normal range Urine PH is within the normal range Sp Gravity is within the normal range Sugar is within the normal range Urine within range albumin is the normal Transparency: Clear Ph : 6. 2008 Date Resulted: August 18.0 4-6.030 Negative Normal/Trace Pus cells is within the normal range . 2008 Indication or Purposes Is used for basic screening purposes.Diagnostic and Laboratory Procedure : Urinalysis Date Ordered Date Resulted Date Ordered : August 17.05-1.8 Sp Gravity : 1.1 HPF 0-3 1.015 Sugar : Negative Albumin : Trace Microscopic findings: Pus cells : 0.

2008 August 25.of normally absent from urine and detected by urinalysis are proteins. blood. Negative Negative Negative Negative . 2008 August 24. 2008 This indicates that there is absence of pathogenic microorganisms that can cause diseases such as PTB.1 HPF Few Epithelial Cells : Rare Urine RBC is within the normal range Epithelial cells is within the normal range Date Ordered : August 17. pus and casts Sputum AFB This test is used to identify pathogenic organisms to determine whether malignant cells are present Less than 2 RBC 0. glucose acetone. 2008 Date Resulted: August 23.

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   Obtain a list of medication the patient is taking. unless by medical direction.  Evaluate test results in relation to the patient’s symptoms and other test performed. During the Procedure Instruct the patient to thoroughly wash his hands.  Answer any questions or address any concerns voiced by the patient or family. pain or irritation during void or alterations in urinary elimination. There are no food.Nursing Responsibilities for Urinalysis Prior to the Procedure Inform the patient that the test is used to assist in the diagnosis of renal diseases and as an indication of inflammatory diseases.  Obtain a history of the patient’s genitourinary. Review the procedure with the patient. fluid or medication restrictions. void a small amount in the toilet and void directly into the specimen container. After the Procedure Instruct the patient to report symptoms such as pain related to tissue inflammation. surgical procedures and other diagnostic procedures. cleanse the meatus.  Promptly transport the specimen to the laboratory for processing and analysis.    .

Nursing Responsibilities for Sputum AFB Prior to the Procedure  Inform the patient that the test is used to obtain analysis to identify pathogenic organisms and to determine whether malignant cells are present Obtain a list of medication the patient is taking. pain or irritation during void or alterations in urinary elimination. There are no food. fluid or medication restrictions. Take the test early in the morning     During the Procedure   Instruct the patient to clear the nose and throat and rinse the mouth to decrease contamination of the sputum. Review the procedure with the patient. Evaluate test results in relation to the patient’s symptoms and other test   performed.  Answer any questions or address any concerns voiced by the patient or family.  After the Procedure Instruct the patient to report symptoms such as pain related to tissue inflammation. Instruct the patient to inhale and exhale two times then inhale again and cough rather than spit. using the diaphragm and expectorates into a sterile container Promptly transport the specimen to the laboratory for processing and analysis. unless by medical direction. .

the feces such as ova and parasites so that appropriate treatment can be ordered. 2008 Indication or Purposes Fecalysis aids in this evaluation of digestive efficiency and the integrity of the stomach and intestines. Used as a screening or diagnostic tool because its can identify substance present in.Diagnostic and Laboratory Procedure : Fecalysis Date Ordered Date Resulted Date Ordered : August 17. Results Normal Values Brown Analysis and Interpretation The result shows that the stool have a normal color The result shows that the consistency is normal The results indicates that there are no ova or parasites present Color : Brown Consistency : Soft Intertinal Parasites: Negative Bulky Date Resulted: August 18. 2008 7:20 am Negative .

Nursing Responsibilities Prior to the Procedure • • Check the doctor’s order Check the patients name and his identification band Explain to the patient ad significant others why stool specimen is being collected • During the Procedure • • • Provide privacy Decrease discomforts and anxiety allow adequate time Instruct the patient’s significant others to put the specimen on the container Collect stool specimen • After the Procedure  Ensure that the specimen labelled and laboratory acquisition form are filed out correctly Send the specimen to the laboratory at once Document what you have done   .

The actual exchange of oxygen and carbon dioxide occurs in the lungs. Voluntary controls -.can also affect respiration. rate. more rapid breathing) and 2) air pressure within lung tissue. The respiratory centers in the brain stem (pons and medulla) control respiration's rhythm. termed the Hering-Breuer inspiratory reflex. ANATOMY AND PHYSIOLOGY Respiratory System The respiratory system functions to deliver the oxygen to the blood -the transport medium of the cardiovascular system -. the receptors give the "turn on" signal. Primary controlling factors include 1) the concentration of carbon dioxide in the blood (high CO2 concentrations initiate deeper. Expansion of the lungs stimulates nerve receptors (vagus nerve X) to signal the brain to "turn off" inspiration. and depth. The respiratory system consists of two tracts: The upper respiratory .and to remove oxygen from the blood. Other regulators are: 3) an increase in blood pressure. and 5) a sudden drop in blood pressure. When the lungs collapse. which slows down respiration. which increases the rate and depth of respiration. Carbon dioxide build-up soon forces an automatic start-up. which stimulates respiration. 4) a drop in blood acidity.III."holding one's breath" -. but not indefinitely.

The two lungs. parietal layer attaches to the chest wall (thorax). larynx. thin. and alveoli.the pleura -. mouth. thymus. which is somewhat smaller in size because of the predominately leftside position of the heart. visceral layer of the pleura attaches to the lungs. The right lung is larger and heavier than the left lung. The lower respiratory tract includes the lungs. and trachea (windpipe). A clear. Pleural fluid holds both layers in place. sinuses). The inner.envelopes the lungs. esophagus. . the outer. Each lung is divided into upper and lower lobes. the muscle that contracts and relaxes in breathing. in a manner similar to two microscope slides that are wet and stuck together. are the body's major respiratory organs. The lungs are separated from each other by the mediastinum.tract includes the nose (nasal cavity. and lymph nodes. although the upper lobe of the right lung contains a third subdivision known as the right middle lobe. an area that contains the heart and its large vessels. one on the right and one on the left. separates the thoracic cavity from the abdominal cavity. The diaphragm. shiny coating -. the trachea (windpipe). bronchi.

At the same time the blood gives up waste matter (carbon dioxide). as well as to lighten the bone structure of the head and to give resonance to the voice. The functions they serve include helping to regulate the temperature and humidity of air breathed in. Breathing is the process by which oxygen in the air is brought into the lungs and into close contact with the blood. Small openings connect them to the nose.The chart of the respiratory system shows the intricate structures needed for breathing. and sphenoidal) are hollow spaces in the bones of the head. The NOSE (nasal cavity) is the preferred entrance for outside air into the . which is carried out of the lungs when air is breathed out. 1. which absorbs it and carries it to all parts of the body. The SINUSES (frontal. maxillary. 2.

they may be removed. The VOICE BOX (larynx) contains the vocal chords. The hairs that line the wall are part of the air-cleaning system. The EPIGLOTTIS is a flap of tissue that guards the entrance to the windpipe (trachea). It is the place where moving air being breathed in and out creates voice sounds. They are part of the germ-fighting system of the body. The TONSILS are lymph nodes in the wall of the throat (pharynx) that often become infected. especially in people who have a mouth-breathing habit or whose nasal passages may be temporarily obstructed. This system helps to resist body infection by filtering out foreign matter. The LYMPH NODES of the lungs are found against the walls of the . The lymph system. The ADENOIDS are lymph tissue at the top of the throat. The THROAT (pharynx) collects incoming air from the nose and mouth and passes it downward to the windpipe (trachea). consisting of nodes (knots of cells) and connecting vessels. 3.respiratory system. 9. The ESOPHAGUS is the passage leading from the mouth and throat to the stomach. including germs. as by a cold or during heavy exercise. carries fluid throughout the body. The WINDPIPE (trachea) is the passage leading from the throat (pharynx) to the lungs. 4. 10. When they enlarge and interfere with breathing. 8. and producing cells (lymphocytes) to fight them. closing when anything is swallowed that should go into the esophagus and stomach. Air also enter through the MOUTH (oral cavity). 6. 5. 11. 7.

it creates suction in the chest to draw in air and expand the lungs. They move to a limited degree. 12. 18. The PLEURA are the two membranes. clear your throat or swallow. helping the lungs to expand and contract. or sections. in turn.bronchial tubes and windpipe. subdivide further. 19. germs. The RIBS are bones supporting and protecting the chest cavity. The right lung is divided into three LOBES. You get rid of this matter when you cough. 13. sneeze. This motion carried MUCUS (sticky phlegm or liquid) upward and out into the throat. The mucus catches and holds much of the dust. 17. where it is either coughed up or swallowed. Air moves in and out through one opening -. and other unwanted matte that has invaded the lungs. By moving downward. These. 14. The smallest subdivisions of the bronchial tubes are called BRONCHIOLES. The windpipe divides into the two main BRONCHIAL TUBES. 16. actually one continuous one folded on itself. The left lung is divided into two LOBES. The bronchial tubes are lines with CILIA (like very small hairs) that have a wave-like motion. one for each lung. 20. 15. which subdivide into each lobe of the lungs.a branch of the bronchial tube. Each lobe is like a balloon filled with sponge-like tissue. at the end of which are the air sacs or alveoli (plural of alveolus). The ALVEOLI are the very small air sacs that are the destination of air . that surround each lobe of the lungs and separate the lungs from the chest wall. The DIAPHRAGM is the strong wall of muscle that separates the chest cavity from the abdominal cavity.

The bronchial structures contain hair-like. that beat rythmically to sweep debris out of the lungs toward the pharynx for expulsion. enlarging the chest cavity. Air travels down the throat. Bronchioles end in air sacs called alveoli -. While in the capillaries the blood gives off carbon dioxide through the capillary wall into the alveoli and takes up oxygen from the air in the alveoli. or pharynx. the opening of the larynx (the epiglottis) automatically closes. Air Distribution On inspiration. The larynx. Once in the bronchioles. the air is at body temperature. the walls of the esophagus are collapsed. filtering. air enters the body through the nose and the mouth. When air is inspired. preventing air from entering the stomach. thin-walled "balloons. When you breathe in. Less warming. contains 100% humidity. where two openings exist. When food is swallowed. preventing food from being inhaled. called cilia. is lined with mucus that further warms and humidifies the air. the "balloons" expand as air rushes in to fill the vacuum. and the other into the larynx (voice box) and trachea (windpipe) for continued airflow. Blood passes through the capillaries. one into the esophagus for passage of food. The main-stem bronchi divide into smaller bronchi. then into even smaller tubes called bronchioles.breathed in. The CAPILLARIES are blood vessels that are imbedded in the walls of the alveoli." arranged in clusters. which branches into the right and left bronchi. Air continues continues down the trachea. epithelial projections. and is (hopefully) completely filtered. Nasal hairs and mucosa (mucus) filter out dust particles and bacteria and warm and moisten the air. brought to them by the PULMONARY ARTERY and taken away by the PULMONARY VEIN. and humidification occur when air is inspired through the mouth. It is at the . the "balloons" relax and air moves out of the lungs. When you breathe out.small. which also contain the vocal cords.

2) the healthy functioning of the alveoli. which branches to the right and left lungs. After gas exchange. the concentration of dissolved oxygen is greater in the alveoli than in the capillaries. Oxygen. then capillary levels. then to the right ventricle. to the rest of the body. . On inspiration. hemoglobin in the red blood cell picks up the oxygen. As oxygen diffuses into the plasma. carbon dioxide concentration is greater in the blood than the alveoli. In the reverse process. and 3) the rate of respiration. the total oxygen uptake depends on: 1) the difference in oxygen concentration between the blood and alveoli.alveoli that gas exchange occurs. so it passes from the blood into the alveoli and is ultimately breathed out. Therefore. permitting more to flow into the plasma. surround each of the alveoli. the capillaries recombine to form venules and veins. diffuses across the alveolar walls into the blood plasma. The oxygencarrying capacity of hemoglobin allows the blood to carry over 70 times more oxygen than if the oxygen were simply dissolved in the plasma alone. The right ventricle subsequently pumps the blood into the pulmonary artery. Tiny blood vessels. via the aorta/systemic circuit. Pulmonary Circulation The pulmonary circulatory circuit describes the process whereby oxygen and carbon dioxide are delivered to and from the lungs. therefore. Ultimately two right and two left pulmonary veins carry oxygen-rich blood to the heart for distribution. capillaries. The pulmonary arteries subdivide until reaching the arteriole. Oxygen-poor blood travels to the right atrium via the inferior and superior vena cavae.

Breathing is an active process . The primary muscles of respiration include the external intercostal muscles (located between the ribs) and the diaphragm (a sheet of muscle located between the thoracic & abdominal cavities). is called the Inspiratory Reserve Volume (IRV 3.000 ml). The additional amount a person could exhale is called the Expiratory Reserve Volume (ERV 1. . a person could actually take in more air or blow more out. The additional amount a person could inhale.requiring the contraction of skeletal muscles. such as during maximum physical activity." The amount of air a person breathes in and out at rest is called the Tidal Volume (Vt about 500ml).000 ml). The Residual Volume (RV) is the amount of air that stays in the lung even after maximum expiration. During such breathing.Lung Volumes/ Capacities The air that the lungs can hold can be divided into smaller designations called "volumes.

to-back dimension of thoracic cavity > lowers air pressure in lungs > air moves into lungs • Contraction of diaphragm > diaphragm moves downward > increases vertical dimension of thoracic cavity > lowers air pressure in lungs > air moves into lungs: .The external intercostals plus the diaphragm contract to bring about inspiration: • Contraction of external intercostal muscles > elevation of ribs & sternum > increased front.

the respiration muscles relax & lung volume descreases. would make it more difficult to 'reexpand' the alveoli (when you inhaled). the lungs expand. air leaves the lungs. which is what happens when we exhale & our alveoli become smaller (like air leaving a balloon). and this attraction creates a force called surface tension. including those on the alveolar walls. ribs. surface tension could cause alveoli to collapse and. The expansion of the lungs causes the pressure in the lungs (and alveoli) to become slightly negative relative to atmospheric pressure. As a result. This surface tension increases as water molecules come closer together. This causes pressure in the lungs (and alveoli) to become slight positive relative to atmospheric pressure. air moves from an area of higher pressure (the air) to an area of lower pressure (our lungs & alveoli). are more attracted to each other than to air.To exhale: • relaxation of external intercostal muscles & diaphragm > return of diaphragm. The walls of alveoli are coated with a thin film of water & this creates a potential problem. Potentially. Both of these would represent serious problems: if alveoli collapsed they'd contain no air & no oxygen to diffuse into . in addition. & sternum to resting position > restores thoracic cavity to preinspiratory volume > increases pressure in lungs > air is exhaled Intra-alveolar pressure during inspiration & expiration As the external intercostals & diaphragm contract. As a result. Water molecules. During expiration.

oxygen. Role of Pulmonary Surfactant Surfactant decreases surface tension which increases pulmonary compliance (reducing the effort needed to expand the lungs) and reduces tendency for alveoli to collapse. the air you blow into a balloon creates pressure that causes the balloon to expand (& this pressure is generated as all the molecules of nitrogen. very difficult if not impossible. However. inhalation would be very. in part to oxygen. The air we breath is a mixture of gasses: primarily nitrogen. oxygen. So. if 're-expansion' was more difficult. & in part to carbon dioxide. & carbon dioxide move about & collide with the walls of the balloon). the total pressure generated by the air is due in part to nitrogen.the blood &. Fortunately. That part of the total pressure generated . our alveoli do not collapse & inhalation is relatively easy because the lungs produce a substance called surfactant that reduces surface tension. Partial Pressure Partial pressure is the individual pressure exerted independently by a particular gas within a mixture of gasses. & carbon dioxide.

while that generated by carbon dioxide is the 'partial pressure' of carbon dioxide. that air is about 21% oxygen. A gas's partial pressure. although it is higher in the elderly. Influenza is the most common viral community-acquired pneumonia in adults.21 times 760 mm Hg or 160 mm Hg. IV THE PATIENT’S ILLNESS (Book-based and Patient’s Centered) Synthesis of the Disease 1. So. Community-Acquired Pneumonia occurs either in . is a measure of how much of that gas is present (e. The partial pressure exerted by each gas in a mixture equals the total pressure times the fractional composition of the gas in the mixture. Definition of the Disease Community. then the partial pressure of oxygen in the air is 0.by oxygen is the 'partial pressure' of oxygen. therefore. given that total atmospheric pressure (at sea level) is about 760 mm Hg and.Acquired Pneumonia (CAP) is a condition caused by Streptococcus pneumoniae (also known as the pneumococcus) which has a relatively low overall mortality rate.. further. in the blood or alveoli).g.

pneumonia ranks as the 4th leading cause of morbidity and 3rd leading cause of mortality based on the latest health statistics report of the Department of Health.1 billion total estimated population (Brunner. CAP mortality rate range from less than 1% to 9% for those managed as out-patient. Pseudomonas aeruginosa and other gram-negative rods. Chest pain and cough. Overall. but increase to 50% for those requiring ICU management ( Retrieved at www.7 deaths per 100.al. The morbidity and mortality tred for pneumonia has fallen from 96.000 populations to 49 deaths per 100. (Philippine Health Statistics. Medscape. Ass of 2002there were 3. Legionella. Gant. (Adrews.the community setting or within the first 48 hours after hospitalization or institutionalization. fever.8% deaths out of the 6. The need of hospitalization for CAP depends on the severity of pneumonia. Predisposing and Precipitating Factors Predisposing / Non. 2008) In the Philippines.000 populations. Nadjm. It often causes problems like breathing.8 million or 6. Influenzae.modifiable factors .com/viewarticle/475218 accessed on August 29. 2003) The causative agent for CAP that requires hospitalization are most frequently S. 2008 10:20 pm) The Global burden of the disease study publish by the World Health Organization ranks pneumonia as the third leading cause of mortality. CAP ranks as the fourth most common death in the United Kingdom and sixth as the leading infectious cause of death when combined with influenza in the United States. et. CAP is a common illness and can affect people of al ages. 2006) 2. CAP occurs throughout the world and is the leading cause of illness and death. H. CAP occurs because the areas of the lung which absorbed oxygen from the atmosphere become filled with fluid and cannot work efficiently. Pneumoniae.

Hygiene . e. COPD and other factors involving microorganisms. Bronchielectasis. where Upper Respiratory Tract infections are frequent. Lifestyle CAP can occur with people who are smoking. c. Laboratories. Medical History and Treatments Those people who have illness such as diabetes. Race African. HIV infection. 2nd hand smokers and alcohol abuse b. d. Gender CAP is most common among men than in women due to their lifestyle such as smoking and drinking. Age Most common in people younger than 60 years of age without comorbidity and in those 60 years and older among at risk factors for the development of CAP b. c. Precipitating / Modifiable Factors a. Occupation People who are expose in microorganisms especially in the community.a. Neutropenia.American has higher rates of Community Acquired pneumonia than among whites. Veterinarians clinics and other institution involving microorganisms. Seasonality It is most prevalent during winter and spring.

Pleuritic Chest pain that is aggravated by deep breathing and coughing Indicates of having pleural inflammation arising from parietal pleura. cyanosis of microorganisms causing inflammatory . Wheezes Due to accumulation of secretions the airway becomes narrowed g. and preparing foods. Sudden onset of chills Due to invasion process d. Signs and Symptoms a. rapid pulse and bounding It usually increase about 10 bpm for every degee acts as compensatory echanism for hyperthermia e. improper hand washing. Tachypnea. malnutrition can also contribute to poor immune. Dyspnea.5 °c) Cause by release of endogenous pyrogens that reset the hypothalamus thermostat c. Poor Immune System CAP could be common in children as well as n adults if they have poor immune system or didn’t acquire vaccination. 3. Crackles Due to lung congestion or consolidation f. perineal care. d.Those that have a poor hygiene.5 to 40. Rapid Rising Fever (38. which is richly supplied by sensory nerve endings b.

Bacteremia The invasion of microorganisms in the body i. while recovering from surgery. Drinking plenty of fluids does not suppress. nursing home residents and pregnant women should receive the vaccine. it is important since it will not only helps to limit lung damage but also because cigarette smoking interferes with many of the bodies natural defenses against pneumonia. Vaccination against Haemophilus Influenzae and Streptococcus pneumoniae in the first year of life have greatly reduced their role in pneumonia in children. Furthermore. Health Promotion and Prevention aspects of disease Several ways to prevent infectious CommunityAcquired Pneumonia like smoking. lung and liver disease. Vaccination is also important in preventing pneumonia in children and adults. Aside from vaccines. These would also decreased incidence of these against infections in adults because adults may acquire infections from children. deep-breathing exercise may also help in preventing pneumonia especially if you are in the hospital—for example.Due to the interference in oxygen and carbon dioxide exchange that caused hypoxemia h. Flu vaccine prevents pneumonia and other problems cause by the influenza virus. It is also given to people who most at risk like those the age of 65 with chronic heart. because retained secretions interfere with gas exchange . the vaccines that confers immunity against pneumococus. A repeat vaccination may also be required after five to ten years. health care workers. Cough Brings up a greenish and yellowish mucous due to the bacterial invasion 4.

The solution to the problem is preventing the infections rather than curing them. As the saying goes “PREVENTION IS BETTER THAN CURE”. these preventive measures includes avoid uncooked or unwashed fruits and vegetables in areas when sanitation is poor. Avoiding stress. good personal hygiene. . Lastly the best solution to prevent infections is proper hand washing and sanitation.and may slow recovery. taking vitamins especially vitamin C will also be helpful in reducing the risk for having CAP. Always wash your hands frequently can prevent the spread of viral respiratory illness. avoid over exertion and possible exacerbation of symptoms. Hydration of 2-3 L/day because adequate hydration thins and loosens pulmonary secretions. wee protective clothing and use insect repellent are some of the ways to prevent pneumonia. Humidification may be used to loosen secretions and improve ventilation.

mucociliary clearance and nasopharyngeal defense Pathogens begin to colonize Pathogens enter the lower The body tries to remove Release of respiratory tract pathogen that entered the nasal upper respiratory tract Damage occurs to mucous membrane Activation of the inflammatory process. Pathophysiology of Community-Acquired Pneumonia (Book-Based) Inhalation of microorganisms Invasion of foreign bodies in the URT Activation of the upper airway defense mechanism. release of chemical mediators Histamine Stimulates goblet cells to increase mucus production and fluid Accumulation of mucus secretions in the airway contributing to the narrowing of airway of fluids Crackles Wheezes Bradykinin Stimulate muscle spasm that contributes to bronchoconstriction Narrowing of airway Release of pyrogens Stimulates the thermoregulatory center of the body to reset body temperature Dyspnea/ Prostaglandin Chemotaxis Migration of WBC to the site of injury Leukotriene Increase in Vascular Permeability discharges Leaking of fluids shifting resulting to accumulation of fluid in the alveolar sacs This accumulation impairs gas exchange resulting to ventilationperfusion mismatch .B. cough reflex.

mucociliary clearance and nasopharyngeal defense Pathogens begin to colonize Pathogens enter the lower Damage occurs to mucous membrane Activation of the inflammatory process. cough reflex. release of chemical mediators Histamine Stimulates goblet cells to increase mucus production and fluid Accumulation of mucus secretions in the airway contributing to the Bradykinin Stimulate muscle spasm that contributes to bronchoconstriction Narrowing of airway Release of pyrogens Prostaglandin Chemotaxis Migration of WBC to the site of injury Leukotriene Increase in Vascular Permeability Leaking of fluids shifting resulting to accumulation of fluid in the alveolar sacs .Nasal flaring Fever Tachypnea Pallor Chest Pain Pathophysiology of Community-Acquired Pneumonia (Client-Based) Inhalation of microorganisms Invasion of foreign bodies in the URT Activation of the upper airway defense mechanism.

17.18&24’08) 19.24’08) Nasal flaring (Aug.17-18’08) Pallor Chest (Aug.18.narrowing of airway of fluids Stimulates the thermoregulatory center of the body to reset This accumulation impairs gas exchange body temperature Crackles (Aug.17-23’08) .17.21’08) resulting to ventilationperfusion mismatch Tachypnea (Aug.18.22-23’08) Pain (Aug.17-25’08) Productive cough (Aug. Fever (Aug.21.23’08) Malaise (Aug.22.17-25’08) Dyspnea (Aug.

electrolytes and calories or as an alkalinizing agent. Indications or purpose Used as a vehicle for administration of drugs.MEDICAL MANAGEMENT a.V. 5% Dextrose and Lactated Ringer’s DO: 8-21-8 DP: 8-21-8 Source of water. It expands plasma and interstitial volume and does not enter the cells. This prevents sudden shift of fluids & electrolytes in the body. This solution contains 154 mEq/L of Na and Cl. Intravenous Fluids Medical Date ordered Management/Treatm Date performed ent Date changed IVF: Plain Normal Saline Solution 1L x 3132 gtts/min DO: 8-17-8 DP: 8-17-8 8-18-8 8-18-8 8-19-8 8-20-8 DC: 8-21-8 General Description PNSS is under isotonic solution where they have the same concentration of solutes (osmolarity as blood plasma). Client’s response to treatment The patient complied with the doctors order. The patient complied . THE PATIENT AND HIS CARE A.

They act to greatly expand the intravascular compartment. when a patient receives a hypertonic IV solution. To prevent electrolyte imbalance and serve as a route for administration for IV medication. chloride and calories The patient complied with the doctors order. Its shows how red blood cells shrink when place in a hypertonic solution. replacement of fluid.Solution 1L x 31-32 gtts/min 8-21-8 8-22-8 DC: 8-22-8 D5NM 1L x 31-32 gtts/min DO: 8-22-8 DP: 8-22-8 8-23-8 8-23-8 8-23-8 8-24-8 8-24-8 8-25-8 Date Terminated: 8-25-8 5% Dextrose and Lactated Ringer’s Solution is a hypertonic infusion raise serum osmolality by causing a pull of fluids from the intracellular and interstitial compartments into the blood vessels. serum osmolarity initially increasing fluid to with the doctors order and the patient was able to maintain normal hydration status. . Hypertonic solution that has osmolarity higher than serum osmolarity. sodium. absorbs fluid in the interstitial cell.

be pulled from the interstitial and intracellular compartment into the blood vessels. .

 Record all procedures don . of bottle.  Explain the importance and purpose of the procedure.  Prepare the IV bottle and necessary materials for insertion.  Monitor patient’s response and flow of IV. After the procedure:  Label the bottle. During the procedure:  Maintain aseptic technique.  Assess the status of the vein to determine venipuncture site. the date. verify the physicians order.  Hang the solution on the IV pole.  Insert catheter and initiate infusion.Nursing Responsibilities Prior to the procedure:  Ask the patients name.  Explain the procedure to the patient.  Put on gloves and clean the insertion site. and the rate.  Regulate as ordered. no.  Check for the patency.  Select venipuncture site. write the name of the patient.  Check for the patency and if it’s infusing well. time.

It is a colorless. All body cells require oxygen in order to function and supply the body with oxygen is fundamental to life. since it is stored in any parts of the body. . Indications or purpose For patients experiencing dyspnea or difficulty of breathing Client’s response to treatment The patient is relieved from dyspnea and decreased patients respiration rate.Oxygen Therapy Medical Management/Treatm ent Oxygen Therapy at 3-4 lpm via nasal canula Date ordered Date performed Date changed DO: 8-17-8 DP: 8-17-8 8-18-8 8-19-8 8-24-8 General Description Oxygen occurs in atmosphere air in approximately 2021% concentration. tasteless gas which is essential for maintaining life. It must be continually supplied to body cells.

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 Explain the importance and use of such treatment. verify the physicians order.Nursing Responsibilities Prior to the procedure:  Ask the patient’s name.  Fill up the chart and document the procedure. During the procedure:  Set the flow rate as prescribed. After the procedure:  Assess the patient and inspect the equipment regularly. .  Inform the patient and patient’s SO about the procedure.  Tell the patient that there is no pain upon administration of it.  Check if there is air coming out from the tube.  Place the nasal cannula in the patient.  Make sure that the air delivered is humidified.

Medical Management/Treatm ent Nebulization: Combivent Neb q 6 Date ordered Date performed Date changed DO: 8-17-8 DP: 8-17-8 8-18-8 8-19-8 8-20-8 8-21-8 8-22-8 8-23-8 8-24-8 8-25-8 General Description A method of administering medication through the use of aerosol mist. Indications or purpose Bronchodilatio n and effective mucous expectoration Client’s response to treatment The patient complied with the doctor’s order and was relieved from dyspnea. .

Nursing Responsibilities Prior to the procedure:  Ask the patients name. → Breathe normally through the mouthpiece.  Advice patient to: → Sit upright so that the air gets deep into his lungs.  Monitor the patient’s status especially respiratory rate.  Make sure the nebulizer is dry and clean.  Make sure the equipment is clean. .  Be alert for adverse reactions. After the procedure:  Document.  Explain the importance of the treatment. During the procedure:  Assist the patient in nebulization. date and time of therapy. verify the physicians order.  Assess the respiratory status.

Brand name Generic name: Cefuroxime Brand name: Zinacef Date ordered Date performed Date changed DO: 8-17-8 DP: 8-17 8 8-23-8 DC: 8-24-8 Route of administration.b. generic name. dosage and frequency of administration General action and mechanism of action Indications or purpose Client’s response to the meds with actual S/E IV. . 750mg TID q3 (-) General action: Lower ANST Antiinfective respiratory tract Mechanism of infections due action: to Binds to s. DRUGS Name of drugs.pneumoniae bacterial cell wall membrane causing cell death. Patient complied woth the doctors order and there are no undesirable effect experienced by the patient.

 Monitor for adverse reactions.  Assess for anemia.Nursing Responsibilities Prior to the procedure:  Ask the patients name. . verify the physicians order. During the procedure:  Check for the patency. After the procedure:  Check for the regulation of the IVF.  Explain the need for the medication.  Document the time of the given medication.  Observe the 10 rights of giving medications.  Administer drug slowly.  Clean the IV port with alcohol.  Obtain previous history of medical allergies. renal dysfunction.  Observe for aseptic technique.

This results in bronchodilation which is primarily a local. . generic name. Indications or purpose Client’s response to the meds with actual S/E Treatment of COPD in those who are on regular aerosol. Duoneb Date ordered Date performed Date changed DO: 8-17-8 DP: 8-17 8 8-18-8 8-19-8 8-20-8 8-21-8 8-22-8 8-23-8 8-24-8 8-25-8 Route of administration. Brand name Generic name: Ipratropium bromide Brand name: Combivent. (inhalation) q6 General action and mechanism of action General action: Cholinergic blocking drug and sympathomimeti c Mechanism of action: Ipratropium is an anticholinergic drug that acts to inhibit the effect of acetylcholine following vagal nerve stimulation. dosage and frequency of administration Neb. Patient complied with the doctors order and was relieved of dyspnea. site specific effect.Name of drugs. Albuterol is a beta 2 adrenergic agonist that also causes bronchodilation. Bronchodilator therapy and who require a second bronchodilator.

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 Explain the importance of the treatment. During the procedure:  Assist the patient in nebulization.  Monitor the patient’s status especially respiratory rate. → Breathe normally through the mouthpiece.  Advice patient to: → Sit upright so that the air gets deep into his lungs.  Make sure the nebulizer is dry and clean.  Assess the respiratory status. verify the physicians order.  Be alert for adverse reactions. date and time of therapy.Nursing Responsibilities Prior to the procedure:  Ask the patients name. .  Make sure the equipment is clean. After the procedure:  Document.

obtain previous history of medical allergies.  Observe the 10 rights of giving medications. generic name. offer water. Indications or purpose Client’s response to the meds with actual S/E It relieves pain and reduces fever. During the procedure:  Assist patient while taking the drug. primarily in the CNS. dosage and frequency of administration PO. Brand name Generic name: Acetaminoph en Brand name: Paracetamol Date ordered Date performed Date changed DO: 8-17-8 DP: 8-17 8 Route of administration.Name of drugs. .  Assess for fever.  Before giving the medication. Nursing Responsibilities Prior to the procedure:  Ask the patients name. Have no significant antiinflammator y properties or GI toxicity. After the procedure:  Monitor for decrease in temperature.  Explain the purpose of the drug. Patient complied with the doctor’s order and the patient’s temperature decreases. verify the physicians order. 500mg tab q4 RTC General action and mechanism of action General action: Analgesic and Antipyretics Mechanism of action: Inhibits the synthesis of prostaglandi n that may serve as mediators of pain and fever.

 Document. .

Brand name Date ordered Date performed Date changed Route of administration. obtain previous history of medical allergies. Patient complied with the doctor’s order and was relieved from diarrhea. Indications or purpose Client’s response to the meds with actual S/E Generic DO: 8-17-8 – name: 8-25-8 Loperamide DP: 8-22 8 Hydrochlorid e Brand name: Imodium Symptomatic relief of acute non-specific diarrhea associated with inflammatory bowel disease.Name of drugs. The prolonged retention of the feces in the intestine results in reducing the volume of the stools.  Explain the purpose of the drug. verify the physicians order. Nursing Responsibilities Prior to the procedure:  Ask the patients name. generic name.  Before giving the medication. . dosage and frequency of administration PO. increasing viscosity and decreasing fluid and electrolyte loss. 1 tab for loose stool General action and mechanism of action General action: Antidiarrheal Mechanism of action: Slows intestinal motility by acting on the nerve endings and/or intraneural ganglia embedded in the intestinal wall.

and time the medication was given.  Document date. Observe the 10 rights of giving medications. During the procedure:  Witness the intake of medication. After the procedure:  Monitor he patients reaction to the drug. .

generic name. Indications or purpose Client’s response to the meds with actual S/E For acute cough of any etiology/ Cough associated with thickened mucus and impaired mucus transport. and inflammatory action. Brand name Generic name: Butamirate citrate Brand name: Sinecod forte Date ordered Date performed Date changed DO: 8-17-8 DP: 8-17-8 8-18-8 8-19-8 Date discontinued: 8-20-8 Route of administration.Name of drugs. Patient complied with the doctor’s order and was relieved from cough. Sinecod exerts expectorant. moderate bronchodilation . It also increases the spirometery indexes and blood oxygenation. dosage and frequency of administration PO. 1 tab TID General action and mechanism of action General action: Cough Suppresants Mechanism of action: Butamirate citrate belongs to the anti cough medicines of central action. .

.  Document date. and time the medication was given.  Explain the purpose of the drug. After the procedure:  Monitor for adverse reactions like nausea. obtain previous history of medical allergies. verify the physicians order. During the procedure:  Witness the intake of medication. diarrhea and dizziness.Nursing Responsibilities Prior to the procedure:  Ask the patients name.  Observe the 10 rights of giving medications.  Before giving the medication.

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dosage and frequency of administration PO. During the procedure:  Witness the intake of medication.  Explain the purpose of the drug. verify the physicians order. Patient complied with the doctor’s order and his secretions partially loosen.  Before giving the medication.Name of drugs. Indications or purpose Client’s response to the meds with actual S/E Acute and chronic disorders of respiratory tract associated with excessive mucous. After the procedure:  Monitor he patient’s reaction to the drug. and time the medication was given. generic name. . It reduces or prevents bronchial inflammation and bronchospas m. obtain previous history of medical allergies. Nursing Responsibilities Prior to the procedure:  Ask the patients name.  Document date. 500mg/cap TID General action and mechanism of action General action: Mucolytics Mechanism of action: Its major action is on the metabolism of mucus producing cells.  Observe the 10 rights of giving medications. Brand name Generic name: Carbocistein e Brand name: Abluent Date ordered Date performed Date changed DO: 8-20-8 DP: 8-20-8 8-21-8 8-22-8 8-23-8 8-24-8 8-25-8 Route of administration.

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 Observe for aseptic technique.Name of drugs. . 20mg now. then q12 with bp precaution General action and mechanism of action General action: Loop diuretic Mechanism of action: Inhibits the readsorption of sadium and chloride from the loop Henle and distal renal tubule. During the procedure:  Check for the patency. Indications or purpose Client’s response to the meds with actual S/E For acute pulmonary edema. generic name. Patient complied with the doctor’s order.  Obtain previous history of medical allergies. sodium. magnesium.  Observe the 10 rights of giving medications. verify the physicians order. Effectiveness persists in impaired renal function. Upon taking the drug. chloride.Increa ses renal excretion of water. dosage and frequency of administration IV. hydrogen and calcium. Brand name Generic name: Furosemide Brand name: Lasix Date ordered Date performed Date changed DO: 8-21-8 DP: 8-21-8 8-22-8 8-23-8 8-24-8 Route of administration.  Explain the need for the medication. undesirable effects were not experienced. Nursing Responsibilities Prior to the procedure:  Ask the patients name.

 Clean the IV port with alcohol.  Administer drug slowly.

After the procedure:
 Check for the regulation of the IVF.  Document the time of the given medication.  Monitor for adverse reactions.

Name of drugs, generic name, Brand name Generic name: Azithromyci n Brand name: Zithromax

Date ordered Date performed Date changed DO: 8-21-8 DP: 8-21-8 8-22-8 8-23-8

Route of administration, dosage and frequency of administration PO, 500mg tab, 1 tab OD x 3 days

General action and mechanism of action General action: Antibiotic, macrolide Mechanism of action: A macrolide derived from erythromycin . Acts by binding to the p site of the 50 s ribosomal subunit and may inhibit RNA dependent protein synthesis by stimulating the dissociation of peptidyl tRNA from ribosomes.

Indications or purpose

Client’s response to the meds with actual S/E

For pneumonia, and lower respiratory tract infections.

Patient complied with the doctor’s order. Upon taking the drug, undesirable effects were not experienced such as hypersensitivity reactions and GI disturbances.

Nursing Responsibilities Prior to the procedure:
 Ask the patients name, verify the physicians order.  Before giving the medication, obtain previous history of medical allergies.  Explain the purpose of the drug.  Observe the 10 rights of giving medications.

During the procedure:  Witness the intake of medication. After the procedure:  Monitor he patient’s reaction to the drug.

and time the medication was given. Document date. .

Name of drugs. 1 gm q12 General action and mechanism of action Indications or purpose Client’s response to the meds with actual S/E General action: For lower Antibiotic. Mechanism of action: They kill the bacteria to form cell walls. The bacteria therefore break up and die. Patient complied with the doctor’s order and the occurrence of severe infection is reduced. And also he experienced slight discomfort when infusing of the medication is done. respiratory tract cephalosporins infections and pneumonia. dosage and frequency of administration IV. generic name. . Brand name Generic name: Ceftriaxone Na Brand name: Chevron Date ordered Date performed Date changed DO: 8-24-8 DP: 8-24-8 Route of administration.

Nursing Responsibilities Prior to the procedure:  Ask the patients name. After the procedure:  Check for the regulation of the IVF.  Document the time of the given medication.  Observe the 10 rights of giving medications.  Obtain previous history of medical allergies. .  Administer drug slowly.  Explain the need for the medication.  Clean the IV port with alcohol.  Observe for aseptic technique. During the procedure:  Check for the patency.  Monitor for adverse reactions. verify the physicians order.

.

1 capsule TID General action and mechanism of action General action: Sympathomim etic Mechanism of action: Stimulates beta-2 receptors of the bronchi. Nursing Responsibilities Prior to the procedure:  Ask the patients name. verify the physicians order.  Assess symptom characteristics. generic name.  Obtain history. frequency. and time the medication was given. Brand name Generic name: Albuterol Brand name: Ventolin Date ordered Date performed Date changed DO: 8-24-8 DP: 8-24-8 8-25-8 Route of administration .  Document date. dosage and frequency of administration PO. leading to bronchodilatio n. Patient complied with the doctor’s order and demonstrated improvement in breathing pattern.  Explain the purpose of the drug. . duration. onset. Indications or purpose Client’s response to the meds with actual S/E Prophylaxis and treatment of bronchospas m due to reversible obstructive airway disease. After the procedure:  Monitor he patient’s reaction to the drug.  Observe the 10 rights of giving medications. assess EKG and CNS status. During the procedure:  Witness the intake of medication. and any precipitating factors.Name of drugs.

.

c. Water. gruel Patient complied with the doctor’s order. but prophylactic supplementation of diets with vitamins and minerals is recommended if for long term use. To rest the GI tract of the patient. It can be nutritionally adequate. grapes. .DIET Date ordered Date performed Date changed DO: 8-17-8 DP: 8-17-8 8-18-8 8-19-8 8-20-8 8-21-8 8-22-8 8-23-8 8-24-8 8-25-8 Type Of Diet General Description Indications or purpose Specific foods taken Client’s response and/or reaction to the diet Soft Diet The texture of food is soft.

 Assess patient’s condition on how to respond to the diet.  Observe for aspiration precaution. .Nursing responsibilities: Prior to the procedure:  Check the doctor’s order about the diet.  Assist patient when eating & provide comfort measures. During:  Give foods in small frequent meals to check for tolerance.  Avoid interruption while eating.  Identify the patient & instruct SO about the diet. After:  Encourage the patient to follow the diet regimen.

.

To enhance lung expansion and mobilize secretions. restore energy.Type Of Activity Date ordered Date performed Date changed General Description Indications or purpose Specific foods taken Client’s response and/or reaction to the diet Complete Bed Rest B O O K -b A S E d Deep Breathing Exercise Patient is prohibited to strenuous activities/ exercises. gruel Respiratory functioning can be facilitated by deep breathing exercises to remove secretions from the airways. To avoid discomfort. thereby preventing atelectasis and pneumonia. Water. Water. and to decrease oxygen consumption thus decreasing the work load of the heart. Pursed-lip breathing helps the client develop control over breathing. A commonly employed breathing exercise is abdominal (diaphragmatic) and pursed-lip breathing. Abdominal breathing permits deep full breaths with little effort. The pursed-lip create a resistance to the air flowing out of the lungs. thereby prolonging exhalation and preventing airway collapse by maintaining positive airway . gruel He was able to take a rest and whenever he wants to eat or change position he asked for assistance.

After the procedure:  Document all the teachings given and the assessment. then exhale slowly through the mouth.  Check the doctors order and verify the client.  Demonstrate deep breathing exercises. .  Instruct the patient to hold his breath.  Assess hearing ability to ensure the elder client hears the information.  Explain to the client what is the importance of the activity.Nursing Responsibilities Prior to the procedure:  Assess for vital signs. During the procedure:  Assist the patient in the activity.

patient via mucous Planning Nursing Intervention Short Term > Assess : respiratory status: breath 5 sounds. flaring of nostrils > Assess anxiety and reassure > Being unstable to breath causes as cyanosis. of respiratory rate. 1 Ineffective Airway Clearance Assessme nt Nursing Diagnosis Scientific Explanation CommunityAcquired Pneumonia is the inflammation the when offending organism reaches alveoli of After lung hours Nursing the Intervention s. effective organisms coughing . presence of accessory muscles.” Airway Clearance related to ku retained plema the bronchi ( increased thick mucous secretions) and lung O=Patient Manifeste d the following : inflammatio n leading to accumulatio n of mucous in the secretions in parenchyma the expectorate droplets or saliva evidenced in whi8ch goblet by cells produces an productive outpouring The fluid cough. use of > Abnormal breathing patterns may signal worsening of condition: flaring of nostrils indicate a significant decline in respiratory status: assessment establishes baseline and monitor response to interventions The patient shall be able to expectorate mucous as evidenced by productive cough effective coughing and breathing exercise Short Term : Rationale Evaluation S= patient Ineffective may verbalize “magkasaki t papalwal ing pag manguku ku. note the abnormalities will such as dyspnea. oxygen saturation.NURSING MANAGEMENT Problem No. into the alveoli.

>appears weak >pale palpebral conjunctiva >ć rales on both lung lobes upon chest auscultatio n >ć difficulty of breathing > shortness of breath > ć non- alveoli multiply the in the and is exercise patient ć presence anxiety and fear: the patient needs a calming presence: anxiety increases the demand for oxygen serous fluid and breathing infection spread. absence of dyspnea. etc. mechanical defenses their Term : The > Place patient in high fowler’s > Maximize chest excursion and subsequent movement of air Long Term : The patient will maintain airway patency as evidenced by clear breath sounds. patient of maintain airway evidenced of by and After 2 days position and Nursing support ć overbed table as the needed. . will > Encourage expectoration of as secretions and assess the and color of secretions of function Intervention > Thickened secretions of Cap re more likely to occlude the airway: making this observation would allow for implementation if Disruption of the patency clear viscosity amount cough and ciliary breath motility leads to sounds. the colonization absence of the lungs and dyspnea. overwhelming interference with of to s. organisms damage the host Long by growth lung leading massive accumulation mucus.

> Assists with liquefying secretions and enhancing ability to clear > Provide for periods of rest and activity.productive cough Patient may manifest the following : >decreased oxygen saturation > Cyanosis >Tachypne a >Abnormal blood gases (decreased O2. assisting ć devices as needed > Elevate head of bed/ change of > Decrease demand for oxygen airways . and > Assist the patient ć coughing and deep breathing > Increase fluid intake measures to thin and loosen the secretions > Mobilizes secretions and prevent atelectasis secretions in the leading ineffective airway clearance as evidence by non-productive cough alveolar exudates tend to consolidate. to etc. increasingly difficult expectorate. Increased CO2) > Restlessnes s >ć accumulation alveoli bronchi to of etc.

Orthopnea > Flaring of nostrils position every 2 hours > To maintain an open airway and to take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage > Assist respiratory therapist ć the administration of nebulizer > Establish intravenous access as ordered > Assess arterial blood gases (ABG) of secretions.acting medications >ABG provide data for treatment regarding the lungs’ . >This causes bronchiodilation to ease breathing > Ensures a route for rapid.

2 Impaired Gas Exchange Assessment Nursing Diagnosis Scientific Explanation Planning Nursing Intervention Rationale Evaluatio n .ability to oxygenate tissues > Provide humidified oxygen as ordered to maintain O2 saturation >90% > Loosen secretions. making them easier to expectorate ć coughing: improves oxygenation Problem No.

expectoration. tachypnea.” a After 8hours assessment . use muscles. the be tract infection of Intervention parenchyma with patient community 2days hospitalization. perioral cyanosis. pulse the by absent of laboratory and . ease will of breathing. lower respiratory of the onset in lungs s. in breathing mucous O=Patient Manifested the following : >difficulty of breathing preventing transfer of gases across the alveolar capillary cellular membrane occurs when the effective and use of dyspnea.S= may patient Impaired Gas Exchange related to inflamed lung tissue agad and papagal consolidati on of mucous / ffluid in specific lung lobes CommunityAcquired Pneumonia defined as is Short Term > Perform a : complete respiratory Nursing respiratory rate. resulting in impaired gas exchange. pursed breath sounds. coughing oxygen evidenced nasal during thre first dyspnea by lip breathing. effective coughing and use of oxygen as evidenced by absence of nasal verbalize “magkasakit ku mangisnawa ampo ku gang maglakad kumu. chest the expansion. arterial blood gases demonstrate decreased oxygen Short Term : The patient shall be relieved from dyspnea by participati ng in breathing exercise. Pneumonia offending organism stimulate inflammatory response defense or from of participating exercises. pneumonia can cause fluid in the lungs and increase the work of breathing. rhythm. These assessment provide data use for planning Interventions and assessing progress. Sputum cultures identify the causative organisms. as oximetry and monitor diagnostic relieved of accessory > Because airway inflammation and mucous accumulation.

where inflammation develops. complete blood count. easy cultures. lo9se shortness of as sputum breath. etc. Long > knowledge of the patient respiratory status contributes to information that can assist in determination other factors that may have contributed to pneumonia or influence its treatment > Sitting upright allows the diaphragm The patient shall have an improved ventilation and adequate oxygenatio n of lung tissue as evidenced by normal arterial Long Term : wherein there is have of improved chemical mediators. shortness of breath. > Obtain subjective data from the patient After 1 to 3 or significant days to Nursing of Intervention s. Inflammation occurs due colonization offending organization the release lung effectiveness of flaring. respiratory tract. arterial blood gases. procedures such concentration. attraction neutrophils. including history of chronic respiratory the disease and will history of an smoking > Assist patient to semi fowler’s position to etc. chest x-ray will confirm the presence of fluid in the lungs or areas of consolidation flaring. easy fatigability. Etc. ventilation and of adequate oxygenation . the lower Term : allow fatigability.>nasal flaring >shortness of breath/ exertional discomfort >with presence of crackles on both lung lobes upon auscultation > with non productive cough > easy fatlgability mechanism the and organisms penetrate sterile. patient of other.

macrophages. and of of tissue lung as >Take temperature to descend. linen and clothing may become saturated with perspiration > Encourage adequate fluid intake to 2000 cc/day > Assess mucous amount. of nerve fibers. absence of purulent discharges . stimulation sounds. etc. depth of breathing > abnormal skin color accumulation fibrinous exudates. purulent Goblet cells will discharge increase production mucus in attempt to dilute amd wash away offending organisms out of the tract.> Patient hooked to O2 therapy 2-3 LPM Patient may manifest the following : >abnormal blood gases / arterial ptt ( hypoxia. increase CO2 ) >Diaphoresis >Tachycardi a > abnormal rate rhythm. trigger patient edema breath will > Provide measures change linen or of clothing have a clear comfort blood gases. color >Helps to detect improving status of > Helps thin and liquefy secretions red evidenced arterial blood cells and by normal every 4 hours These would in blood gases. absence leading to pain. turn erythema swelling. respiratory Inflamed fluid-filler . resulting in easier breathing > Infectious processes can cause an increase body temperature >Following temperature spikes. clear Breathing sounds.

(pale. amount should be decreasing and viscosity should be thinning following interventions. green. chest percussion and >Loosen mucous plugs thus increasing are available for gas exchange . dusty) > abnormal capillary refill >Restlessnes s >Confusion >O2 saturation of less than 90% >fever  O2 alveolar O2 and sacs CO2 to of the consistency. pneumonia. brown or purulent mucus indicate continued presence of pneumonia cannot exchange effectively leading hypoxia lung tissue and a significant ventilationperfusion mismatch >Encourage coughing and deep breathing with mucous expectoration >Coughing and deep breathing cause alveoli to open and loosen mucous to help clear the airways > Provide chest  physiotherapy postural drainage.

Promote calm and restful environment > Administer oxygen as ordered >Pneumonia increased mucous production and fluid > Helps limit oxygen needs/ consumption >Promotes optimal chest expansion and drainage of secretion > To maintain airway patency .vibration > Elevate head of bed > Encourage frequent position changes > Encourage adequate rest and limit activities to with in patient tolerance.

retention in lungs which decreases adequate gas exchange. 3 Ineffective Breathing Pattern Assessment Nursing Scientific Diagnosis Explanation Planning Nursing Intervention Rationale Evaluation >Helps to stop the proliferation of microorganisms . supplemental oxygen provides additional oxygen for tissue oxygenation >Administer antibiotic as ordered and monitor for side effects.  Ado Problem No.

” results Intervention patient shall gases. the arterial blood a > Any of this abnormalities would indicate the studies of the respiratory system and progression of disease. of depth lung reports of the breath > Assist Patient in assuming a high. typically is process Short Term > Assess a : After of hours It Nursing s. depth of breathing and relief from shortness of breath as evidence by decrease RR from 38 cpm to 1620 cpm verbalize “Magkasakit ku mangisnawa.S= may patient Ineffective breathing pattern related to thick tenacious secretions in the bronchi CommunityAcquired disease involving inflammation lung when microorganisams enter normally lungs from tissue. etc. the have respiratory system by noting 4 respiratory rate. O=Patient Manifested the following : >difficulty of breathing >shortness of breath on exertion. paleness due to inflammati on of lung tissue sterile normal the respiratory rhythm.fowler’s and position or a position of choice as forward or over thoracic cavity space. produces inflammation the parenchyma. breath sounds. rhythm. decreases pressure from diaphragm and abdominal organs and facilitates use of accessory muscles >help to improve hydration status and nasopharynx and rate. of depth chest expansion. Because the filed inflammation alveoli with shortness of such as leaning of evidence by bed table are decrease RR fluid from 38 > Increase oral . also establishes a baseline comparison >maximizes Short Term : The patient shall have a normal respiratory rate.

> Provide chest physiotherapy. and facilitates clearing of lung fields. etc. etc. Intervention of patient shall activities of daily the be free from living as required any and and hypoxia signs fibrin consolidate symptoms affected of to part of the lung as a evidenced decreased blood by decreased supply flow there is a ABG.fluids to 2000>RR of 38 cpm with shallow. exchange cannot take place at a Long alveolar capillary Term : cellular due to blood flow of decreases (deceased perfusion blood in lungs)and leukocytes in due the s.and mucus and cpm to 16. severe dyspnea > Knowing how to > Teach patient shorthness of breath by control shortness of breath will help cope and have optimal functioning normal how to decrease membrane level After 2 days tapping. the >Assist with > mobilizes thick secretions. rapid breathing >use of supraclavicul ar muscles for respiration as well as shoulder muscles > ć nonproductive cough > with presence of oxygen carbon and 20 cpm dioxide 3000 ml/day as tolerated decrease secretions. etc. Long Term : The patient shall be >patient with free from pneumonia may lack any signs and sufficient oxygen symptoms reserves to perform of hypoxia as activites. even evidenced eating may cause by normal ABG. bronchial Nursing vibration. .

hands on knees >Abnormal blood gases of oxygen to to restructuring activities > Preventing spread >Teach pulmonary hygiene.rales on both lung lobe upon chest auscultation easily fatigability Patient may manifest the following : >severe dyspnea > sitting up leaning forward. prevention of spread of infection >Provide some >Provide humidified low flow of oxygen as ordered supplemental oxygen to improve oxygenation and to make secretions less viscous >Enhances >Administer bronchodilators and expectorants expectoration of secretions of previously ineffective cough of infection and subsequent hospitalization other leading ineffective breathing pattern tissues .

> abnormal inspiratory or/and expiratory ration > pursed lip breathing > altered chest excursion >hypoxia (Confusion, restlessness, decreased vital capacity)

>Helps to prevent > Administer antibiotics as ordered or eradicate infections to reduce secretions and to end to inflammation

Problem No. 4 Hyperthermia Assessment Nursing Diagnosis S= may verbalize “Mapali ” ku panandman . patient Hyperther mia Scientific Explanation CAP the to is Planning Nursing Intervention >To have a baseline data >Evaporation is decreased by environmental factors of high humidity and high ambient temperature as well as the body factors producing loss of ability to sweat >Promote heat loss > promote surface cooling by means of by radiation, conduction and evaporation Short Term : The 4 >Note presence of or absence of sweating as body attempts to loss by evaporation, conduction, diffusion the increase heat patient’s body temperatur e shall have decreased from 38oC to 37oC. Rationale Evaluation

the Short Term > Monitor body of : lung core temperature

inflammation

parenchyma due After offending hours Nursing organisms, inflammatory lung

Intervention be patient’s body the temperature of will decrease that from 38oC to

response s,

O=Patient Manifested the following : >flushed skin >skin is warm to touch

will stimulated leading release chemical mediators would lung leading to

increase 37oC. tissues to

blood flow to the

erythema, > increased RR > Diaphoresis Patient may manifest the following : >Convulsions > Hypotension >Fluid and electrolyte imbalance swelling, and body temperature that After would reset the hours hypothalamus which is Nursing the Intervention the of patient maintain pain, Long increased Term :

loose clothing; cool environment/fan; cool/tepid 24 sponge bath of local icepack especially in the axilla and groin >indicates need for prompt interventions

Long Term : The patient shall have maintained a normal body temperatur e during hospitalizati ons and be free from any complicatio ns of pneumonia.

major center for s, regulation body temperature

will > Review signs a and symptoms of

normal body hyperthermia temperature during hospitalizati free any complicatio ns of >Discuss importance of adequate fluid pneumonia. >Encourage the patient to take > to increase resistance

ons and be vitamin C in the from diet such as citrus fruits, etc. > To prevent dehydration

intake >To reduce >Maintain bed rest metabolic demands/ oxygen consumption >Provide highcalorie diet >Provide supplemental oxygen >administer antipyretics as ordered > to meet increased metabolic demands >To offset increased oxygen demand and consumption >To control shivering and seizure Problem No. 5 Activity Intolerance .

activity should be reduced until oxygenation is adequate. . fatigue and >Helps to determine the effects of pneumonia on the patient’s ability to be active.Assessmen t S= may verbalize “magkasakit ku mangisnawa ampo gan maglakad kumu. > Conserves energy and reduces oxygen demand patients the personal tenacious as etc. to patient to able perform daily living breath and easy Intervention mimingal ku activity and >If increased physical activity causes shortness of breath. Short Term : The patient shall able perform be to pneumonia by dyspnea. altering hygiene. activities of daily living without shortness of such doing personal hygiene. the monitor for is labored to breathing. Due thick mucous alveoli to generally marked fever.” O=Patient Manifested the following : > appears weak Nursing Diagnosis Scientific Explanation The onset Planning Nursing Intervention Rationale Evaluation patient Activity Intolerance related to increased oxygen demand with hypoxia (lack of oxygen supply with oxygen demand) of Short Term > Obtain is : subjective data from patient 4 regarding normal of activities prior to onset of pneumonia. without accumulation in > Reduce level the shortness of of activity as of breath such required in doing response to shortness of breath. After and hours of Nursing that s. shortness fatigability may lead inability perform living. breath as activities of daily activities of exhaustion.

to avoid over taxing the patient.gas > poor skin turgor >pale nail beds ( carbon exchange etc. . between alveoli And > easy fatigability After hours Nursing Intervention > nonproductive cough >shortness of breath during activities > RR of 38 s. > Use the result to indicate when the activity may be increased or decreased. >It conserves energy. the that is > Monitor VS and oxygen and after > Activities should be increased gradually. as tolerated. patient states he comfortable performanc e breath shortness of is with activity saturation before and activity. Long Term : >Pace activities the dioxide) with pneumonia lack enough oxygen reserves to perform activities independently. Long Term : The patient shall states that he is comfortable with activity performanc e and shortness of breath is improved following cessation of activity. 24 and encourage of periods of rest and activity during the day. and the patient’s RR returns to baseline within 5 minutes. oxygen and > Assist with activities as needed.

with shallow. > Iron has a role in > Inform the oxygen transport . regular phase. baseline 5 Patient may manifest the following : >Inability to perform physical activities > level I functional level classificatio n ( walk. return to normal activity > Discuss with the patients activities that would be > This indicate intolerance to activity and the level of activity should be evaluated. following pneumonia. on level indefinitely. and share guidelines the patient’s for progression RR returns with patient. to within minutes. rapid breathing improved following > Gradually increase activity > Physical activity increases endurance and stamina.cpm. cessation of as tolerated and activity. may take time. appropriate once at home that would be within the patient’s activity tolerance.

>Improves oxygenation and provides oxygen reserves to be used with increased demand. > Assist patient to learn and demonstrate appropriate safety measures. legumes which are rich in protein. > Encourage and increases energy level.one flight or more but more shortness of breath than normal) >labored breathing patient to stop any activity that produces shortness of breath. >To prevent injuries. >physical exhaustion >oxygen saturation less than 90%  phy intake of foods high in iron and good source of energy such as lean meat. .

as ordered.> Have the patient use oxygen immediately prior to activity in the acute setting. .

2. Actual SOAPIERs August 22, 2008 S= Ø O= Received patient supine on bed, conscious & coherent; with an IVF no. 10 of D5NM 1l at 550 cc level, regulated at 31-32 qtts/min, infusing well on the left dorsal metacarpal vein


• • • • • • •

Vs taken and recorded are as follows: BP= 130/70 mmHg; PR=104 bpm; RR=20bpm; T=36.9C/axilla Patient appears weak With pale conjunctiva and nailbeds With dry lips and buccal mucosa With symmetrical chest expansion With non-productive cough With rales upon auscultation on both lungs Capillary refill of <3sec

A= Ineffective airway clearance r/t retained secretions secondary to COPD AEB rales upon auscultation and non-produce cough D= After 1 hr of NI, the patient will demonstrate behaviors to improve/maintain clear airway I= • Establish Rapport • • • • • Monitored and recorded VS Identifies presence of dyspnea, cyanosis, and hemoptysis Auscultated wealth sounds Observe for signs of respiratory distress Measured capillary refill Encouraged patient to perform breathing/coughing exercises and pursed-lip breathing • • • • Encouraged patient to change positions every two hours Instructed patient to increase fluid intake with SAP Encouraged and provided adequate rest periods Instructed to limit activities to level of respiratory tolerance Encouraged patient to permanently quit smoking

Encouraged patient to eat nutritious foods

E= Goal met AEB patient’s demonstration of coughing exercise and pursed-lip breathing and position changes. August 23, 2008 S= “Agad kung susunga.” as verbalized by the patient O= Received patient supine on bed, conscious and coherent; with an IVF no. 12 of D5NM 1L at 150 cc level regulated at 31-32 qtts/min infusing well on the left dorsal metacarpal vein • • • • • VS taken and recorded are as follows: Bp=110/70 mmhg; PR-95 bpm; RR=21 bpm; T=36.9 C/axilla Patient appears weak With pail conjunctiva and nailbeds With productive coughs, yellowish in color With rales on both lungs upon auscultation Capillary refill of <3sec Patient reports fatigue and weakness


A= Activity intolerance r/t imbalanced between oxygen supply and demand AEB pallor, fatigue and Weakness P= After 1hr of NI, the patient will participate willingly in necessary activities within the level of own ability I= • Established Rapport • • • • Monitored and recorded VS Noted presence of factors contributing to fatigue Evaluated current limitations/degree of deficit in light of usual status. Noted client reports of weakness, fatigue, pain, difficulty accomplishing tasks or insomia


• •

Assessed emotional/psychological factors affecting the current situation Adjusted activities to prevent overexertion Taught method to conserve energy.

• • • • •

Encouraged rest periods during /between activities to reduce fatigue Assisted with activities Promoted comfort measures Instructed patient on appropriate safety measures to prevent injuries Provided information about the effect of lifestyle and overall health factors on activity tolerance

E= Goal Met AEP patient’s participation in activities within the level of his own ability.

6 80 24 120/70 36.6 80 20 110/70 36.9 90 24 10/70 36.8 95 21 110/80 36.3 90 26 120/70 36. CLIENT’S DAILY PROGRESS IN THE HOSPITAL Admission Discharged 17 18 19 20 21 22 23 24 25 NURSING PROBLEMS Ineffective Clearance Impaired Gas Exchange Ineffective Pattern Hyperthermia Activity Intolerance 38.4 76 20 110/80 36.2 79 24 120/70 36.IV.4 82 20 130/10 0 breathing Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Airway Φ Φ .7 VITAL SIGNS Temperature Pulse Rate Respiratory Rate Blood Pressure Φ LABORATORY DIAGNOSIS / Φ Φ Φ 90 38 120/80 37.

Chest X-ray Sputum AFB Blood Chemistry Complete Count(CBC) Urinalysis Fecalysis MEDICAL MANAGEMENT PNSS 1L x 8 hours D5LRS 1L x 8 hours D5NM 1L x 8 hours Nebulization O2 Therapy DRUGS Cefuroxime 750 mg TID Combivent neb q 6 hours Paracetamol 500mg Tab q 4 RTC Loperamide 1 Tab for Φ Φ Φ Φ Φ Φ BLood Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ Φ .

loose stool Carbocesteine 500mg 1 cap TID Furosemide now then q precaution Azithromycin 500 mg Tab 1 tab OD x 3 days Ceftriaxone 1gm IV q 12 ANST (-) Sinecod 1 Tab TID Ventoline Expectorant Capsule 1 cap TID DIET Soft Φ Φ Φ Φ Φ Φ Φ Φ Φ 20 12 mg ć IV BP Φ Φ Φ Φ Φ Φ Φ Φ Φ .

E> Deep Breathing Exercises > Coughing Exercises > Limit activities and have rest periods. > Salbutamol tab 2mg BID > Ansimar neb/1 tab ½ BID. > Demonstrated pursed lip or diaphragmatic breathing techniques. O> Advised patient to have a Follow-up check-up after one week. E= Goal Met AEB patient verbalized understanding of the health teachings give . > Encouraged to stop smoking. General Condition of Client Upon Discharge Patient was not assessed upon discharge but was noted to have recovered.2 DISCHARGE PLANNING a. > High calorie. H> Encourage d to keep environment allergen free.4C PR: 82bpm RR: 20bpm BP: 130/100mmHg.  Patient appears good and afebrile. P= After 2 hrs of nursing interventions patient will be able to verbalize understanding given prior to discharge. > Encouraged to have rest periods and limit activities to level of respiratory tolerance. S= ∅ O= Received patient on bed on supine position. T> IV fluids and medications. b. > Provided information about the necessity of raising and expectorating secretions versus swallowing them. high protein diet of soft foods. conscious and coherent  VS taken and recorded as follows: T: 36. > Encouraged warm versus cold liquids as appropriate. I= M> Ciprofloxacin 500mg/cap BID x 7 days. A= For home maintenance and management. > Encouraged to have a monthly check-up. D> Increased oral fluid intake. > discussed rationale for and encourage continuation of successful interventions.

wheezing and angina pectoris Through these manifestations different laboratory and diagnostic procedures that would confirm and support the admitting diagnosis were performed. CAP. and other factors.Acquired Pneumonia is one of the most common infectious diseases addressed by clinician’s cause of morbidity and mortality worldwide In the case of Mr. the disease was caused primarily by personal and environmental factors such as cigarette smoking.Acquired Pneumonia. Different results have been taken out such as to consider illness such as PTB. Since the family has no information about the signs and symptoms of the disease they will now be aware on those things in order to prevent this illness. productive cough. This lead to the development of the disease and lack of action on the part of the caretakers. RECOMMENDATIONS . The result played an essential part on the part of the patient. Years have passed and still these diseases are present especially with developing countries. The group strongly recommends that further studies are to be done to clear out other vague information and misconceptions regarding this disease. lack of vaccinations during childhood years. A clean surrounding will definitely boost our chances of invading such disease condition. crackles on both lung fields. Mr. CAP manifested difficulty of breathing. job exposure to pathogens. The solution is simple but needs great discipline to make it concrete. AGE and Atelectasis which have been ruled out and the hospital final diagnosis was Community.CONCLUSION Community.

allied medical professionals both in the government or private sectors. prevalence of the disease by doing studies. the group formulated the following recommendations in order to maternalize this vision of emancipation from Community-Acquired Pneumonia. They should promote then health of each member so as o prevent any progression of the disease like Community. the Department of Health as the major arm of the Government when it comes to health together with the other sectors of the society. The programs of these sectors should not only focus on the treatment but more importantly on the preventive aspect. This should be done periodically. research and surveys. Community Health Workers must make an effort to update their data about the incidence. they are the better position of monitoring the health of everyone. Since pneumonia is one of the leading cause of mortality and morbidity in the Philippines. In the ongoing battle against the pneumonia and its different types. must work and in hand arresting the incidence and prevalence of pneumonia in the country. They should do medical mission and target the vulnerable sectors of the society. Acting in a swift manner regarding signs and symptoms of the disease. is very important. With these.Information dissemination is the most important factor in this study. Department of health must also conduct studies on the incidence.Acquired Disease. Since family members are the one who are always in contact with the other members of the family. Members of the Health care team must gear themselves by continual education about the disease so as to properly diagnose and manage of pneumonia in the community level. the turning point is the ability of the people to recognize the signs and symptoms of the disease as well as the ability of the existing health sector to respond immediately about the incidence. prevalence of the disease so as to mitigate its occurrence. This may empower .

everyone and fulfil the goal of the Department of Health which is “Health in the hands of the people by 2020.” .

Nurses Pocket Guide: Diagnosis.com/ http://www.gov.org/site/c. al.lungusa. Philadelphia McCance. Valierant.emedicine. Philadelphia. Nazorel.htm http://www.mims.com/MEDtopic3162. Medical-Surgical Nursing: 11th Edition.VIII.com/viewarticle/475218 http://www. 2007 Doenges. Davis’ Drug Guide for Nurses: 10th Edition. 2006 ONLINE SOURCES: http://www.htmtypes http://www.com/p/pneumonia/prevalenve. al. al. Lippincott Williams and Wilkins.doh. F. Nursing Process Approach To Excellent Care: 4the Edition. Davis Company.htm .ph/data_stat/html/mortality. et. Prioritized Interactions and Rationales: 10th Edition. Lippincott Williams and Wilkins.wrongdiagnosis. et. Davis Company.org/encyclopedia/1/000145.7FFF/Human_Respiratory _System. et.htm http://www. 2002 Schilling.utmedicalcenter. al. et.A. Pathophysiology: The Biologic Basis for Disease Adul and Children: 4th Edition.22576/K.A. BIBLIOGRAPHY BOOK SOURCES: Smeltzer. 2008 DeglinHopfer.dvLUK900E/b. F.htm http://www.medscape.

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