Republic of the Philippines

ISABELA STATE UNIVERSITY

Echague Campus
San Fabian, Echague, Isabela

A Case Study of Pneumonia with underlying Covid 19

Presented to:
Sir, Jojo Justo
May 15, 2020

Presented by:
Angelica Carl Mae P. Cauilan
I. GENERAL OBJECTIVES

. To be able to come up with an understanding of the disease process and formulate

a comprehensive nursing care plan using the specific objectives nursing process.

SPECIFIC OBJECTIVES
1. To review the anatomy and physiology of the disease.
2. To understand the pathophysiology of it.
3. To know the medical treatment such as the medications and laboratory works
involved.
4. To know the importance of laboratory and diagnostic procedures.
5. To know the nursing management for the disease.
6. To practice nursing assessment during data gathering.
7. To prioritize identified health problems of the patient.
8. To formulate nursing process as a framework in making the nursing care plan.
9. To be able to acquire adequate knowledge on health education needed by the
patient and relatives for the continuous care at home.
 Table of content

Page:

I. Patient Profile………………………………………..

II. Patient History

III. Overview of the study…………………………………

IV. Anatomy and physiology……………………………..

V. Gordon’s 11 Functional Health Pattern…………….

VI. Pathophysiology……………………………………….

VII. Nursing Care Plan ……………………………………

VIII. Drug Study…………………………………………….

IX. Discharge Plannig ……………………………………

 I. Patient
Profile

I. Patient Profile
Patient name: Patient LAA
Age: 12yrs old
Birthdate: 1/1/2008
Birthplace: Echague Isabela
Civil Status: Single
Gender: Female
Nationality: Filipino
Religion: Catholic
Address: Cabuago Echague, Isabela
Fathers name: Mr. X
Mothers name: Mrs. Y
Date of administration: 4/30/2020
Time of administration: 5:00pm
Chief complaint: Cough
Admitting diagnosis: Pneumonia
Attending physician: Dr. Q. Cristobal
Room: Private 6
II.Patient

History
 II. Patient History

History of Present Illness

2 weeks prior to confinement She has low grade fever and productive
cough but he ignored it. Her Mother give her a medicine Solmux
I day prior to admission the patient had a right sided chest pain and
difficulty of breathing, her mother decided to bring her to the hospital

Past Health History:

 No hospitalization / medical history
 No operations / surgical history
 No accidents or injuries
 No allergies

Social History:

The patient does not have any bices and bad habit, SHe lives with her
Mother and father and She’s only child daughter.
III.Overview
of the study
Introduction
Coronavirus disease (COVID-19) - is an infectious disease caused by a newly
discovered coronavirus.
- Most people infected with the COVID-19 virus
will experience mild to moderate respiratory
illness and recover without requiring special
treatment.  Older people, and those with
underlying medical problems.

Pneumonia -  is an infection in one or both lungs. Bacteria,

viruses, and fungi cause it.

The main types of pneumonia are:

 Bacterial pneumonia - This type is caused by various bacteria. The most

common is Streptococcus pneumoniae. It usually occurs when the body is
weakened in some way, such as by illness, poor nutrition, old age, or impaired
immunity, and the bacteria are able to work their way into the lungs. Bacterial
pneumonia can affect all ages, but you are at greater risk if you abuse alcohol,
smoke cigarettes, are debilitated, have recently had surgery, have a respiratory
disease or viral infection, or have a weakened immune system.
 Viral pneumonia - This type is caused by various viruses, including the flu
(influenza), and is responsible for about one-third of all pneumonia cases. You
may be more likely to get bacterial pneumonia if you have viral pneumonia.
 Mycoplasma pneumonia - This type has somewhat different symptoms and
physical signs and is referred to as atypical pneumonia. It is caused by the
bacterium Mycoplasma pneumoniae. It generally causes a mild, widespread
pneumonia that affects all age groups.
 Other pneumonias - There are other less common pneumonias that may be
caused by other infections including fungi.

Sign and symptoms of Pneumonia

 Bluish color to lips and fingernails
  Confused mental state or delirium, especially in older people

 Cough that produces green, yellow, or bloody mucus

 Fever

 Heavy sweating

 Loss of appetite

 Low energy and extreme tiredness

 Rapid breathing

 Rapid pulse

 Shaking chills

 Sharp or stabbing chest pain that’s worse with deep breathing or coughing

 Shortness of breath that gets worse with activity

Early symptoms of viral pneumonia are the same as those of bacterial pneumonia,
which may be followed by:

 Headache

 Increasing shortness of breath

 Muscle pain

 Weakness

 Worsening of the cough

Mycoplasma pneumonia has somewhat different symptoms, which include a severe

cough that may produce mucus.

Sign and symptoms of Covid 19

Common symptoms:
 fever.
 tiredness.
 dry cough.
 Some people may experience:
  Muscle pains.
 sore throat.
 diarrhea.

CAUSES of Pneumonia

Many germs can cause pneumonia. The most common are bacteria and viruses in the
air we breathe. Your body usually prevents these germs from infecting your lungs. But
sometimes these germs can overpower your immune system, even if your health is
generally good.

Pneumonia is classified according to the types of germs that cause it and where you got
the infection.

Community-acquired pneumonia

Community-acquired pneumonia is the most common type of pneumonia. It occurs

outside of hospitals or other health care facilities. It may be caused by:

 Bacteria. The most common cause of bacterial pneumonia in the U.S. is

Streptococcus pneumoniae. This type of pneumonia can occur on its own or after
you've had a cold or the flu. It may affect one part (lobe) of the lung, a condition
called lobar pneumonia.

 Bacteria-like organisms. Mycoplasma pneumoniae also can cause pneumonia.

It typically produces milder symptoms than do other types of pneumonia. Walking
pneumonia is an informal name given to this type of pneumonia, which typically
isn't severe enough to require bed rest.

 Fungi. This type of pneumonia is most common in people with chronic health

problems or weakened immune systems, and in people who have inhaled large
doses of the organisms. The fungi that cause it can be found in soil or bird
droppings and vary depending upon geographic location.
  Viruses. Some of the viruses that cause colds and the flu can cause pneumonia.
Viruses are the most common cause of pneumonia in children younger than 5
years. Viral pneumonia is usually mild. But in some cases it can become very
serious.
Hospital-acquired pneumonia

Some people catch pneumonia during a hospital stay for another illness. Hospital-
acquired pneumonia can be serious because the bacteria causing it may be more
resistant to antibiotics and because the people who get it are already sick. People who
are on breathing machines (ventilators), often used in intensive care units, are at higher
risk of this type of pneumonia.

Health care-acquired pneumonia

Health care-acquired pneumonia is a bacterial infection that occurs in people who live in
long-term care facilities or who receive care in outpatient clinics, including kidney
dialysis centers. Like hospital-acquired pneumonia, health care-acquired pneumonia
can be caused by bacteria that are more resistant to antibiotics.

Aspiration pneumonia

Aspiration pneumonia occurs when you inhale food, drink, vomit or saliva into your
lungs. Aspiration is more likely if something disturbs your normal gag reflex, such as a
brain injury or swallowing problem, or excessive use of alcohol or drugs.

Risk factors

Pneumonia can affect anyone. But the two age groups at highest risk are:

 Children who are 2 years old or younger

 People who are age 65 or older

CAUSES of Covid 19
Infection with the new coronavirus (severe acute respiratory syndrome coronavirus 2, or
SARS-CoV-2) causes coronavirus disease 2019 (COVID-19).

The virus appears to spread easily among people, and more continues to be discovered
over time about how it spreads. Data has shown that it spreads from person to person
among those in close contact (within about 6 feet, or 2 meters). The virus spreads by
respiratory droplets released when someone with the virus coughs, sneezes or talks.
These droplets can be inhaled or land in the mouth or nose of a person nearby.

It can also spread if a person touches a surface with the virus on it and then touches his
or her mouth, nose or eyes.

Risk factors

Risk factors for COVID-19 appear to include:

 Recent travel from or residence in an area with ongoing community spread of COVID-
19 as determined by CDC or WHO

 Close contact with someone who has COVID-19, , such as being within 6 feet, or 2
meters, or being coughed on — which can occur when a family member or health care
worker takes care of an infected person

Complications

Although most people with COVID-19 have mild to moderate symptoms, the disease

can cause severe medical complications and lead to death in some people. Older adults
or people with existing chronic medical conditions are at greater risk of becoming
seriously ill with COVID-19.

Complications can include:

 Pneumonia in both lungs

 Organ failure in several organs

 Respiratory failure
 Heart problems, such as heart rhythm problems and a disease of the heart muscle that
makes it hard for your heart to pump blood to the body (cardiomyopathy)

 Acute kidney injury

 Additional viral and bacterial infection

IV. ANATOMY AND

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

The Upper Airway and Trachea

When you breathe in, air enters your body through your nose or mouth. From
there, it travels down your throat through the larynx (or voicebox) and into the
trachea (or windpipe) before entering your lungs. All these structures act to
funnel fresh air down from the outside world into your body. The upper
airway is important because it must always stay open for you to be able to
breathe. It also helps to moisten and warm the air before it reaches your
lungs.
The Lungs
Structure
The lungs are paired, cone-shaped organs which take up most of the space in
our chests, along with the heart. Their role is to take oxygen into the body,
which we need for our cells to live and function properly, and to help us get rid
of carbon dioxide, which is a waste product. We each have two lungs, a left
lung and a right lung. These are divided up into ‘lobes’, or big sections of
tissue separated by ‘fissures’ or dividers. The right lung has three lobes but
the left lung has only two, because the heart takes up some of the space in
the left side of our chest. The lungs can also be divided up into even smaller
portions, called ‘bronchopulmonary segments’.
These are pyramidal-shaped areas which are also separated from each other
by membranes. There are about 10 of them in each lung. Each segment
receives its own blood supply and air supply.
How they work
Air enters your lungs through a system of pipes called the bronchi. These
pipes start from the bottom of the trachea as the left and right bronchi and
branch many times throughout the lungs, until they eventually form little thin-
walled air sacs or bubbles, known as the alveoli. The alveoli are where the
important work of gas exchange takes place between the air and your blood.
Covering each alveolus is a whole network of little blood
vessel called capillaries, which are very small branches of the pulmonary
arteries. It is important that the air in the alveoli and the blood in the capillaries
are very close together, so that oxygen and carbon dioxide can move (or
diffuse) between them. So, when you breathe in, air comes down the trachea
and through the bronchi into the alveoli. This fresh air has lots of oxygen in it,
and some of this oxygen will travel across the walls of the alveoli into your
bloodstream. Travelling in the opposite direction is carbon dioxide, which
crosses from the blood in the capillaries into the air in the alveoli and is then
breathed out. In this way, you bring in to your body the oxygen that you need
to live, and get rid of the waste product carbon dioxide.

How Do We Breathe?
Breathing starts when you inhale air into your nose or mouth. It travels down the back of your
throat and into your windpipe, which is divided into
air passages called bronchial tubes.
For your lungs to perform their best, these airways
need to be open.  They should be free
from inflammation or swelling and extra mucus.
As the bronchial tubes pass through your lungs, they
divide into smaller air passages called bronchioles.
The bronchioles end in tiny balloon-like air sacs
called alveoli. Your body has about 600 million
alveoli.
The alveoli are surrounded by a mesh of tiny blood vessels called capillaries. Here, oxygen from
inhaled air passes into your blood.
After absorbing oxygen, blood goes to your heart. Your heart then pumps it through your body to
the cells of your tissues and organs.
As the cells use the oxygen, they make carbon dioxide that goes into your blood. Your blood
then carries the carbon dioxide back to your lungs, where it’s removed from your body when you
exhale.

Parts of the Respiratory System

 nasal cavity is the inside of your nose. It is lined with a mucous membrane that helps
keep your nose moist by making mucus so you won't get nosebleeds from a dry nose.
There are also little hairs that help filter the air you breathe in, blocking dirt and dust from
getting into your lungs.
 sinuses are a connected system of hollow cavities in the skull. The
largest sinus cavities are about an inch across. Others are much smaller. 
 mouth is an oval-shaped cavity inside the skull. The two main functions of
the mouth are eating and speaking.
 throat (pharynx) is a muscular tube that runs from the back of your nose down into your
neck. 
  larynx (/ˈlærɪŋks/), commonly called the voice box, is an organ in the top of the neck
involved in breathing, producing sound and protecting the trachea against food aspiration.
 trachea, colloquially called the windpipe, is a cartilaginous tube that connects the larynx
to the bronchi of the lungs, allowing the passage of air, and so is present in almost all
air-breathing animals with lungs.
 diaphragm is a thin skeletal muscle that sits at the base of the chest and separates the
abdomen from the chest.
  lungs are a pair of spongy, air-filled organs located on either side of the chest (thorax).

 Bronchi and Bronchus When a person breathes, air taken in through the nose or mouth then
goes into the trachea (windpipe). From there, it passes through the bronchial tubes, into the
lungs, and finally back out again. The bronchial tubes, which branch into
smaller tubes called bronchioles, are sometimes referred to as bronchi or airways.
 Bronchioles are air passages inside the lungs that branch off like tree limbs from the
bronchi—the two main air passages into which air flows from the trachea (windpipe)
after being inhaled through the nose or mouth.
 Alveoli are tiny air sacs in your lungs that take up the oxygen you breathe in and keep
your body going.
 Capillaries are very tiny blood vessels — so small that a single red blood cell can barely
fit through them.
Blood Supply
The lungs are very vascular organs, meaning they receive a very large blood
supply. This is because the pulmonary arteries, which supply the lungs, come
directly from the right side of your heart. They carry blood which is low in
oxygen and high in carbon dioxide into your lungs so that the carbon dioxide
can be blown off, and more oxygen can be absorbed into the bloodstream.
The newly oxygen-rich blood then travels back through the paired pulmonary
veins into the left side of your heart. From there, it is pumped all around your
body to supply oxygen to cells and organs.
V.Gordon’s 11
Functional
Health Pattern

Areas of Before During Analysis Interpretation

Functional Hospitalization Hospitalization
Pattern
Health Patient LAA is a Patient LAA is The onset of all Patient LAA
Perception – 12 yrs old girl now being pneumonias is marked by cannot function
Health with a Mother hospitalized and any or all of the following well with respect
Management who is an active consider she’s manifestations; fever, chills, to her illness
business not healthy sweats, fatigue, cough, pneumonia
woman who anymore; She sputum production and evidenced by
sells sweet was diagnosed dyspnea. (Medical-Surgical difficulty of
goods “ube.” As with Community Nursing Vol. 2 8th Edition breathing and
part of their Acquired by Joyce Black p.1599) fever. Patient
daily routine Pneumonia High also undergone
Patient LAA and Risk and had oxygenation
her Mother undergone during
vends their confinement. confinement,
product door-to- She manifests and now
door in the fever prior to her declared as a
community. She confinement and Covid 19
rarely visits the difficulty of suspect
barangay health breathing. She And needed a
center for is expecting to swab test for
check-ups recover from her verification of
because she present Covid-19 illness
thinks she is condition with
young and the help and
keeping herself support of her
healthy will family and the
prevent getting health providers
illness. attending to her
Whenever she needs.
has a free day
patient walks
around their
community for
an exercise.

Nutritional - Patient LAA is Patient LAA is “An individual health status Nutritional and
Metabolic living a healthy on her low sugar greatly affects eating habits metabolic status
lifestyle her diet consisting and nutritional status” of patient LAA
appetite is well. mainly of fruits, (Fundamentals of Nursing has been
She’s fond of and vegetables. by Kozier p.1178) changed slightly
eating different That’s being to her
types of dishes served in the confinement and
consisting of hospital. to her medical
vegetables, condition.
fishes and
 meats. She
drinks plenty of
water and
patient takes
her supplement
(Centrum.)

Elimination Bowel Bowel Elimination is important Bowel

Patient LAA Patient LAA because urinary and bowel There was a
defecates 1-2 defecates daily. movement affects your change in
times a week Stool is entire physiology. It makes frequency of
without brownish in the body pH in balance and bowel
experiencing color, normal in it eliminates body toxins elimination
discomfort. amount but with with it.
Stool is color discomfort.
brown and well- Urinalysis is an array of test
formed. performed on urine and
Bladder one of the most common
Bladder Patient LAA methods of medical
Patient LAA urinates 5-7 diagnosis.
usually voids 5- times daily (Fundamentals of Nursing
7 times a day. without having by Taylor, Lillis)
Urine is light- discomfort.
yellow in color Urine is light-
and without any yellow in color
discomfort. without any
discomfort.

Activity- In the morning Patient LAA’s “Individuals who have During patient
Exercise patient LAA activities in the inactive lifestyles all who EO’s
walks around hospital are are faced with inactivity confinement,
their community limited only because of illness or injury there is a
as an exercise. within her room. are at risk for many limitation and
At her business, Patient LAA is problems that can affect his activities of
she usually sells activity- major body systems” daily living and a
door-to-door intolerance due (Fundamentals of Nursing disruption in his
goods. After her to her condition. by Kozier page 1068.) leisure and
work patient She often lies in recreation
LAA mingles bed and only pattern.
with her shifts to a chair
Siblings. Patient with the help of
LAA likes her relatives
playing outside whenever she
and watching wants to sit.
television shows She talks with
with her her relatives
siblings. whenever she
feels boredom
and frequently
watching T.V
Cognitive- Patient LAA is a Patient LAA’s “When a patient is admitted There was a
Perceptual Grade 6 pupil. present to a health agency he or change in
She can read condition affects she is confronted with cognitive and
and speaks well her cognitive- stimuli that are different in perceptual
and listens perceptual quality and quantity than pattern in terms
attentively. pattern. Her that to which he or she is of stimuli is
sensory accustomed.” limited only to
perception is (Fundamentals of Nursing, the environment
limited to her 5th ed. By Taylor, Lillis, which is within
hospital room, p.906) the hospital area
and within the and patient’s
hospital area. room.

Sleep- Rest Patient LAA Patient LAA’s “Illness that causes pain or Patient LAA’s
usually sleeps sleeping pattern distress can result in sleep sleep and rest
around 11 pm. is disturbed due problems. People who are pattern was
She drinks her to every 1 hour ill require more sleep than changed when
milk before she of vital signs to normal and normal rhythm she was
goes to bed; this be taken. Cold and wakefulness is often admitted to the
helps her to fall breeze of the disturbed. hospital. Due to
asleep. She air-conditioning (Fundamentals of Nursing her illness and
wakes up early of the patient’s by Kozier.7th ed.) other
in the morning room also adds contributing
around 5 am as as a factor to factors.
her daily routine her difficulty in
and body clock. sleeping.

Self- Patient LAA is a Patient’s LAA “Events or situations may Due to her
Perception – friendly and considers her- change the level of self- present
Self-Concept happy person. self sick. She concept overtime illness condition, there
And she use to now thinks that and trauma can also effect is a change to
play with her she can’t the self-concept” the level of
friends in their function well as (Fundamentals of Nursing patient self
neighborhood . before. by Kozier page 959 and perception and
to her clients in 962.) self concept due
their small to her illness on
business. She is her age of life.
a well- She now thinks
determined that her
person and a activities will be
very limited when
hardworking girl, she is sick.
she wants to be
happy and Her
family and
relatives is
always there for
her to give
 assistance and
support. She
wants to have
good health and
live her life to “When and illness occurs,
Role- the fullest. roles changes for both
Relationship patient and family.”
Patient’s LAA (Fundamentals of Nursing
family is with her by Taylor page 63).
during her
confinement,
they are
supportive in Patient LAA
giving the achieves her
necessary emotional and
Patient LAA needs and moral support
speaks Tagalog wishing the from her families
and clearly patient to be and friends,
understands well and to which will help
English. She recover soon. her to cope with
can express The patient’s her present
her-self very visited by her condition.
well. Patient is a friends and
widower and relatives during
lives with her her stay in the
siblings. She is hospital.
also very active
and socializes
with her friends
and neighbors.

Sexuality- Patient LAA Patient LAA “Sexual response involves There are no
Reproductive doesn’t engage doesn’t engage people’s emotional changes in
in any form of in any form of psychological physical and patient sexuality
sexuality sexuality spiritual makeup, which and
plays a significant role in reproductive
sexual pattern.
satisfaction.”(Fundamental
s of Nursing by Kozier
page 980.

Coping – When she is During her “According to Folkman and The patient has
Stress- anxious patient hospitalization Lazarus, coping is the outlet to let her
Tolerance LAA wants to be patient’s LAA cognitive and behavioral feelings of
alone and haves copes by with effort to manage specific stress out by
some rest. family and external and internal interacting with
When she has friends with their demands that are the family and
problems she support. appraised as taxing friends during
used to exceeding the resources of visitation hours
communicate the person.” and the ability of
and share her (Fundamentals of Nursing the patient to
problems to his by Kozier page 1020.) adapt on her
family and condition to
 friends. She lessen stress.
makes herself “A person’s values
Value-Belief busy like influences belief about
watching human needs, health, and
television or Patient LAA still illness, the practice of
playing games believe that God health behaviors and
on her will always help human responses to
cellphone. them. According illness.” (Fundamentals of Patient LAA
to her family Nursing, 5th Ed. By Taylor, believes that
they still attend Lillis, LeMone, p. 91) everything has a
Patient LAA is a mass even purpose or a
Roman without her, reason, the
Catholic, and praying for patient take her
she goes to patient’s faster present situation
mass every recovery. as a challenge,
Sunday with her and with the
family. The supports of her
patients have a families, she
great value of accepted her
sense when it condition and
comes to she will seek
religion. medical
assistance for
check-ups for
prevention of
her illness in the
future.
VI.
PATHOPYSIOLOGY
PATHOPYSIOLOGY
VII.Nursing
Care Plan

Nursing Care Plan

Assessment Diagnosis Plannin Intervention Rationale Evaluation

 g
Ineffective Short term: Independent: Goal met, the
Subjective: patient maintain
airway
“Nahihirapan clearance After 8hours patient airway,
ako sa pag hinga” of *Monitor and keep *precipitators secretions will
As verbalized by
related to environmental of respiratory be mobilized,
Nursing
the patient increased intervention, pollution to a reaction that airway patency
production secretions minimum can trigger or will be
of will be exacerbate maintained free
Objective: respiratory mobilized, onset of acute of secretions and
*Rapid breathing/ airway episode clear lung sound.
secretions
Tachypnea patency will
*Cough with be maintain *Assess respiratory *assesses the
yellow sputum free of patterns, including condition of
production secretions rate, depth, and the client
* Have and clear lung effort, and assess
adventitious sound the vital sign
sound
(Crackles) *assist the patient *Elevation of
PR. 89Bpm Long term: to elevate head of the bed
RR. 36Cpm After 1week the bed for about facilities
of nursing 30 degrees and ask respiratory
interventions, the client to function by
the patient assume dorsal use of gravity.
will maintain recumbent It also
a patent position. decreases
airway and pressure on the
get result test abdomen when
for Covid 19. assuming the
position.
*Assist patient to *To mobalized
Change position secretions
every 30 mins.

*Educate patient *To promote

deep breathing chest
exercise expansion

Educative:
*To give right
*Educate patient
knowledge to
about medication,
the patient
indication, dosage,
side effect of the
medicine

Treatment:
*Giving by
 Bronchodilators/ *medication
antibiotic that make
medication based breathing
on doctors order easier by
relaxing the
muscles in the
lungs and
widening the
*Give a airways
supplement oxygen *To make
as ordered (via breathing
nasal cannula) easier

Dependent

Collaborative:

*Obtain blood
*Collaborative
specimen for atrial
with other
blood gas study
health care
and covid test as
provider to
indicated
know if they
have
abnormalities

Assessment Diagnosis Planning Intervention Rationale Evaluation

 Activity •After 4 * Evaluate *Establishes •After 4hours
Objective: Intolerance hours of patient’s patient’s Of nursing intervention,
“hindi ako maka Related to nursing Response capabilities the patient adopted new
tulog dahil sa ubo Exhaustion intervention To activity or needs and information on how to
ko” as verbalized Associated the patient facilitates prevent herself for
by the patient With will choice of infection
Interruption demonstrate interventions
Subjective: In usual a
*Fatigue Sleep pattern measurable
*Dyspnea Because of increase
*Irritability discomfort, in tolerance
Excessive activity *Provide a quiet *Reduces
coughing with absence environment stress and
And dyspnea of dyspnea And limit visitors excess
and During acute stimulation,
excessive phase promoting
fatigue rest
*Elevate *These
Head and measures
encourage promote
frequent position maximal
changes, deep inspiration,
breathing enhance
And effective Expectoratio
coughing n of secretion
to improve
ventilation.

*Encourage *To provide

adequate rest relaxation
balance with
moderate activity.
Promote adequate
nutritional intake.

Assessment Diagnosis Planing Intervention Rationale Evaluation

*Flushed skin After 4 hours After *Establish rapport *To gain trust After 4hours of
*Skin warm to of nursing 4hours of and have a nursing
touch intervention nursing nurse intervention the
*38.5C the patient intervention Patient patient
temperature temperature the patient relation- temperature
*Irritability will drop from temperature Ship shall drop from
*Dry skin 38.5C to will drop *Monitor vital sign *To establish 38.5C to 37.2C
37.5C from 38.5C every 4hours baseline data
to 37.5C of the patient

*Provide TSB as a *To lower

measure patient
temperature
*To release
*Instruct SO to heat and to
provide with loose provide
clothing comfort
*Warm, dry,
*Assess skin flushed skin
temperature may indicated
and color a fever
Assessment Diagnosis Planning Intervention Rationale Evaluation
“apat na Diarrhea r/t *After 2-3hours *Auscultate the *For presence After 2-3 hours
beses napo infectious of nursing abdomen location and of nursing
syang dumumi” process intervention characteristics intervention
as verbalized by the patients of bowel sounds the patient’s
the mother mother will gain mother shall
Objective: knowledge gain knowledge
*Loosed bowel about diarrhea, about diarrhea
movement verbalize *Discuss to the *For the and verbalized
*Abdominal understanding mother the education of the understanding
cramping of causative different patient’s mother of causative
factor causative factors factors of
and rationale for diarrhea and
treatment rationale
regimen for treatment
regimen.
*Restrict solid *To allow for
food intake bowel rest and
reduce intestinal
workload

*Provide for *To allow foods

changers in that precipitate
dietary intake diarrhea
*Limit caffeine, *To prevent
high fiber foods gastric irritation.
and fatty foods
 V
III.DRUG
STUDY
 DRUG STUDY
Medications Indications Adverse Contraindication Nursing
effect responsibilities

Azithromycin Treatment for lower Mild to Contraindicated Culture site of

respiratory infection moderate with infection before
DOSAGE: nausea, hypersensitivity therapy
500mg CLASSIFICATION vomiting, to azithromycin,
abdominal erythromycin, or Administer on an
ROUT: belongs to the class pain, any macrolide empty stomach 1hr.
Oral of drugs known as dyspnea, antibiotic before or 2-3 hours
macrolide antibiotics vertigo, after meal. Foods
Diarrhea affect of this
absorption of this
drug

Do not take with

antacid
Biaxin Treatment for lower hearing loss, Contraindicated Inquire about
respiratory infection mental/mood with previous
DOSSAGE: Caused by S. changes, hypersensitivity hypersensitivity to
 500 mg pyogenes, S. muscle to other macrolides.
pneumonia weakness, clarithromycin,
ROUT: eye erythromycin, or Withhold drug and
Oral CLASSIFICATION: problems any macrolide notify physician, if
Macrolide antibiotic antibiotic hypersensitivity
occurs 

Monitor for and

report loose stools
or diarrhea, since
pseudomembranous
colitis must be
ruled out.

Ciprofloxacin Susceptible infection, Nausea, Ciprofloxacin is Notify physician

including lower Vomiting. contraindicated or nursing staff
DOSSAGE: respiratory tract, Diarrhea, in persons with immediately if
500mg acute exacerbations Abdominal a history of these reactions
of chronic bronchitis pain, hypersensitivity occur.
ROUT: Rash, to ciprofloxacin,
Oral CLASSIFICATION Headache. any member of Watch for signs of
Antibacterial Restlessness. the quinolone pseudomembranous
  class of colitis, including
antimicrobial diarrhea, abdominal
agents or any of pain, fever, pus or
the product mucus in stools, or
components other severe or
prolonged GI
problems
IX.Discharge
planning
 Discharge planning
M-edication
• the patient is advised to follow and take the prescribe medication regimen needed for
Effective treatment and fast recovery
E-xercise
• Instruct the patient to exercise regularly like stretching
T-reatment
• Encouraged patient to have adequate rest
• Encouraged patient to drink 2-3 litters of water everyday
H-ygiene
•Educated patient about proper hygiene and its importance
• Encourage patient to practice good hygiene
O-ut patient
• Instructed the patient to have follow up check-up after 7 days
• Advise to notify physician if there is any problem or complications arises
D-iet
• Instructe the patient to eat atleast 2 fruits and 2 vegetable
•Instruct the patient to drink plenty of water
• Advised the patient to avoid eating junk foods and refrain from drinking sodas
• Advised patient to avoid foods that are rich in fat
S-pirituity
•Encouraged patient to go to Church every Sunday
• Instructed to patient o pray for fast recovery
• Instruct the patient to have faith in God
• Advised to patient to always thanks God