A CASE STUDY PRESENTATION ON

ACUTE COMMUNITY- ACQUIRED PNEUMONIA (ACAP)

Presented to the Faculty of the School of Nursing

Adventist Medical Center College
Brgy. San Miguel, Iligan City

In Partial Fulfillment
of the Requirements for the Degree
BACHELOR OF SCIENCE IN NURSING

LAGUNA, GODFAITH B.
NESLE, MARIANNE JOYCE J.
PANES, DANIELLE GRACIA D.
PAQUIBUT, HAZEL JANE Y.
ROMERO, RICHELLE GRACE M.
SINAHON, HONEY JEAN F.

March 22,2021
 OBJECTIVES

General Objective:

At the end of the one and half hour case presentation, the presenters will be able to

establish complete comprehension and insight about the disease progression and management of

a patient with Acute Community-Acquired Pneumonia (ACAP).

Specific Objectives:

At the end of the one and half hour case presentation, the presenters will be able to:

1. Define pneumonia and illustrate how it develops;

2. Present a comprehensive general assessment of the patient that includes physical

assessment and family history taking;

3. Create and discuss the etiology and pathophysiology of the case being presented;

4. Illustrate the disease progression through concept mapping.

5. Construct nursing care plans for the problems identified.

6. Formulate a discharge plan appropriate for the patient and;

7. Discuss the charting and summary notes made throughout the 2-day duty period.

At the end of the one and half hour case presentation, the students will be able to:

1. Define what pneumonia is, how it is transmitted, and how the disease progresses;

2. Identify the risk factors associated with Acute Community-Acquired Pneumonia

(ACAP).

3. Ask questions related to the current presentation to gain a much deeper understanding

about the case.

At the end of the one and half hour case presentation, the clinical instructions will be able to:

1. Review and confirm the information provided by the presenters;

2. Ask the presenters questions about the case to test their knowledge and grasp on the

disease;

3. Suggest better ways to improve the presentation and emphasize areas of improvement

and;

4. Make corrections about the case to help presenters avoid making the same mistakes in the

future.
 DEFINITION OF TERMS
● Accessory muscles. The use of accessory muscles is defined as inspiratory contraction of
the sternocleidomastoid and scalene muscles (McGee,2018).

● Acute Community-Acquired Pneumonia. Defined as pneumonia that is acquired

outside the hospital. The most commonly identified pathogens are Streptococcus
pneumoniae, Haemophilus influenzae, atypical and viruses (Merck & Co., Inc.,
Kenilworth, NJ, USA, 1899).

● Capillary refill. (CRT) is a measure of the time it takes for a distal capillary bed, such
as those found in the fingers, to regain colour after pressure has been applied to cause
blanching (Cecconi M et al, 2014 ).

● Diabetes mellitus. It is an endocrine disorder in which the pancreas cannot produce

adequate insulin to regulate blood glucose levels. (Bradley ,Duprey, & Castorino ,2016)

● Diaphoresis. Is used to describe excessive or abnormal sweating of the body

(Healthline ,2005-2021).

● Hypertension. Elevated or raised blood pressure which the blood vessels have
persistently raised pressure (WHO, 2021).

● Lobe consolidation. Consolidation refers to the alveolar airspaces being filled with fluid
(exudate/transudate/blood), cells (inflammatory), tissue, or other material
(Radiopaedia.org).

● Paraseptal emphysema. Characterized by swelling and tissue damage to the alveoli

(Cleveland Clinic,2021).

● Pleural effusion. Referred to as “water on the lungs,” is the build-up of excess fluid
between the layers of the pleura outside the lungs (Cleveland Clinic,2021).
 INTRODUCTION

Pneumonia is a type of lung infection that causes inflammation of the air sacs or alveoli

inside the lungs. When pneumonia strikes, it fills the lungs with fluid or pus, which causes

coughing, fever, chills, and difficulty of breathing, and shortness of breath (Cedars-Sinai, 2021).

Community-acquired pneumonia (CAP) refers to a type of pneumonia that patients acquire

outside the hospital (Sethi, 2020).

Community-acquired pneumonia and influenza is among the top leading causes of

hospitalizations and morbidity worldwide. In the United States alone, both diseases accounted

for 50,636 deaths in 2012 and more than 1 million hospital discharges (Centers for Disease

Control and Management (CDC), 2015). Globally, there are over 1,400 cases of pneumonia per

100,000 children, or 1 case per 71 children every year, with the greatest incidence occurring in

South Asia (2,500 cases per 100,000 children) and West and Central Africa (1,620 cases per

100,000 children) (UNICEF, 2020). In 2017, the Philippines' number of pneumonia cases

amounted to approximately 495.2 thousand in the Philippines (Statista, 2020).

Pneumonia can be classified into three (3) main types: Community-Acquired Pneumonia

(CAP), Nosocomial Pneumonia, and Pneumonia in immunocompromised hosts. Community-

acquired pneumonia (CAP) as defined is a type of pneumonia acquired outside the healthcare

facility. Nosocomial pneumonia is a type acquired from the hospital and could come in three

forms: Ventilator-associated pneumonia which happen in patients with endotracheal intubation

and has received mechanical ventilation for the past 48 hours; Healthcare-Associated pneumonia

which is pneumonia acquired from the hospital after 48 hours after receiving outpatient care and;

hospital-acquired pneumonia which patients develop 48 hours after being admitted in the

hospital. Lastly, pneumonia in the immunocompromised host includes pneumocystis pneumonia

(PCP), fungal pneumonias, and Mycobacterium tuberculosis which can be manifested by people

whose immune system have been compromised because of an underlying disease (i.e., HIV-

AIDS, cancer, autoimmune diseases, etc.) or weakened because of old age (Cheever and Hickle,

2018).
 The World Health Organization identifies three classifications of pneumonia in children:

(1) Severe pneumonia or very severe disease which can have signs and symptoms like chest

indrawing or stridor in calm child ; (2) Pneumonia which can show signs like fast breathing; (3)

no pneumonia or cough or cold in which the child show no signs and symptoms.

Table 1. Pneumonia Classification (IMCI) according to the World Health Organization

(2020).

The most common cause of CAP is bacterial infection. Pathogens such as S. pneumoniae,

H. influenzae, and M. cattarhalis ((Hinkle & Cheever, 2018). A person can get infected through

inhalation or aspiration of these pathogenic organisms (Baer, 2019). In most cases, the bacteria

can spread from person to person. When a person infected with these types of pathogen coughs,

sneezes, or breathes out forcefully, the pathogens can be released into the air and inhaled by the

uninfected person. Once inside the lungs, the bacteria replicates and reproduces and if the

person’s immune system can’t kill off all of the bacteria, it can cause an infection (Cedars-Sinai,

2021). If not treated immediately, CAP would lead to severe complications.

The treatment for pneumonia includes administration of the appropriate antibiotic as

determined by the results of a culture and sensitivity test. Both intravenous and oral antibiotics

are administered to patients. Admitted patients are usually given IV antibiotics and are switched

to oral antibiotics once they are clinically stable (Hinkle & Cheever, 2018).
 Short-term mortality is related to severity of illness. Mortality is less than 1% in patients

who are candidates for outpatient treatment. Mortality in hospitalized patients is 8%. Death may

be caused by pneumonia itself, progression to sepsis syndrome, or exacerbation of coexisting

conditions. In patients hospitalized for pneumonia, risk of death is increased during the year after

hospital discharge (Cedars-Sinai, 2020).

Mortality varies to some extent by pathogen. Mortality rates are highest with gram-

negative bacteria and CA-MRSA. However, because these pathogens are relatively infrequent

causes of community-acquired pneumonia, S. pneumoniae remains the most common cause of

death in patients with community-acquired pneumonia. Atypical pathogens such as Mycoplasma

have a good prognosis. Mortality is higher in patients who do not respond to initial empiric

antibiotics and in those whose treatment regimen does not conform with guidelines (Sethi, 2020).

In this case presentation, the presenters aim to achieve several goals: to study and gain

insights about the disease process of acute community-acquired pneumonia (ACAP); discuss the

causes, risk factors, complications, and clinical manifestations of the said disease; trace the

progression of the disease, identify ways to manage the illness and formulate a plan of care for

clients with ACAP. In this way, student nurses will know how to handle and care for ACAP

patients in the future.

 GENOGRAM
CODENAME: MR. C.D

A P 70 yrs.A
old

Legend:

- Female

- Male

- Deceased
A - Alive

- Diabetic mellitus

-Accident

-Asthma

- Hypertension

- Cardiac arrest

- Breast cancer

P - Patient
 VITAL INFORMATION

● Code name: Mr. C.D

● Age: 70 years old
● Gender: Male
● Civil status: Married
● Date of birth: October 08, 1949
● Place of birth: Antipolo, Rizal
● Race: Asian
● Cultural or Ethnic Background/Group: Tagalog
● Primary Language (Spoken and Read): Tagalog
● Secondary Language (Spoken and Read): English
● Religion: Roman Catholic
● Occupation (Client): Accountant
● Occupation (Partner/Spouse): Health worker
● Usual Health Care Provider/s: Hospital
● Date of Admission: March 13, 2021
● Date of Discharge: March 17, 2021
● Source/s of History: 20% - chart, 20% - SO, 60% - client
● Reason/s For Seeking Health Care: Patient presents with shortness of breath
● Primary Attending Physician: Dr. Dane Abella, MD
● Consultants/Specialists: Dr. Hazel Amba-an, MD
● Initial Impression/Diagnosis: Acute Community-Acquired Pneumonia (ACAP)

● Final Diagnosis: Acute Community-Acquired Pneumonia (ACAP)

HISTORY OF PRESENT HEALTH CONCERN

Mr. C.D presents with confusion as to time and place. He complains of fatigue and

shortness of breath and verbalizes that he cannot even finished a short sentence without

experiencing shortness of breath. And also his nail beds and lips turned a bluish tinge. The

patient also complains of using his accessory muscles and is diaphoretic. He coughs weakly and

does not raised any sputum. Also, the patient complains of dry skin, and blurring of vision and

cannot hear the sound clearly. He was disoriented and uneased so he decided to bring him to the

hospital for admission.

PAST HEALTH HISTORY

Mr. C.D has no problems at birth. He never experienced an accident, and claims to have

childhood illness like chickenpox, cough, fever, LBM and flu, but manage to be treated in the

house. He is uncertain whether he has been given complete immunization as he could no longer

recall. He has paraseptal emphysema and was diagnosed 3 years ago. The patient has a history of

hypertension, and diabetes controlled with oral diabetic agents. He has maintenance medications

such as Losartan Potassium (Cozaar) 50 mg 1 tab daily and Metformin HCl (Glyburide) and

claims to take his medications regularly. He has not undergone any surgery in the past.
 PHYSICAL EXAMINATION AND REVIEW OF SYSTEMS

AREAS ASSESSED SUBJECTIVE OBJECTIVE PROBLEMS

FINDINGS FINDINGS IDENTIFIED

General Health ● According to ● Body is ● Disturbed

Survey the S/O the proportionate thought
patient ● Male process
Physical presents ● Apparent age
development and ● Impaired verbal
confusion as was related to communication
body fluids
to time and reported age ● Altered body
Gender and sexual place and that temperature:
this is a new ● Dry and warm hyperthermia
Developmental change to the to touch,
patient. wrinkled,
Apparent age as to
compared to
brown in color
reported age ● Patient with aging
complains he spots.
Skin color and cannot finish a ● Well dress
condition short sentence and good
due to hygiene
Dress and hygiene
increased RR ● The client is
Posture and gait lying on bed.
● Shows
Level of irritability
consciousness

Facial expression ● O2 @ 6L/min

● Bluish tinge
Speech nail beds and
lips
Vital signs ● T: 101.5
°F=38.6oC
● PR: 101bpm
● RR: 28 bpm
● BP: 90/50
mmHg

INTEGUMENTARY ● Dry and warm ● Altered body

SYSTEM to touch; temperature:
wrinkled hyperthermia
● Skin color is
brown with
aging spots
● No scars or
lesions
observed
● Has good skin
turgor - less
than 2 secs
● The color of
the nail bed is
bluish tinge.

HEENT ● Complains ● Head & face

● Head and face blurring of is ● Altered sensory
● Eyes vision symmetrical; perception: visual
● Ears ● Complains (-) masses; (-) and auditory
● Nose cannot hear tenderness ● Risk for Fall
● Oral Cavity sound clearly ● (-) redness,
swelling and
any discharges
● The ears are
symmetrical, ● Impaired airway
● (+) nasal clearance.
flaring; (-)
discharges,
masses.
● The color of
the lips is blue
tinge; oral
cavity is moist

NECK ● Symmetrical No problem identified

neck
● No tenderness
● (-) distended
veins

RESPIRATORY ● Patient ● Tachypneic- – ● Ineffective airway

SYSTEM complains of RR: 28bpm clearance r/t
shortness of ● Chest x-ray excessive mucus
breath and result shows secretions
cannot finish a pneumonia secondary to
short sentence ● Coughs pneumonia
due to
weakly but ● Impaired gas
increased RR
does not raise exchange r/t
any sputum excessive mucus
● Oxygen production
inhalation @
6L/min
● (+) nasal
flaring
● Lung
auscultation
reveals
severely
diminished
breath sounds
in the right
lower lobe
and absence
of breath
sounds at the
base. The
breath sounds
in the rest of
the lungs are
 slightly
decreased.
● Oxygen
Saturation=
82%
● Uses
accessory
muscles when
breathing

CARDIOVASCULAR ● (-) edema ● Decreased Cardiac

SYSTEM ● (-) distended Output
jugular vein
● PR: 101 bpm
● BP: 90/50
mmHg
● O2 Sat = 82%
● Hgb = 10 g/dL.
● No presence of
adventitious and
extra heart
sounds.

BREAST AND ● No masses No problem identified

AXILLA ● No redness
● No tenderness
or pain during
palpation

GENITOURINARY/ ● No lesions No problem identified

REPRODUCTIVE ● No distensions
SYSTEM ● No pain in
urinating
● No tenderness
upon
percussion
over kidneys

MUSCULOSKELETAL ● Complains ● Cannot rotate ● Activity

SYSTEM fatigue and neck, shoulders Intolerance
body weakness and arms ● Fatigue
● (+) joint and accordingly ● Impaired physical
muscle pains ● Patient is having mobility
difficulties in ● Risk for Injury
flexing or
extending his
arms and legs

● (+) muscle
stiffness

NEUROLOGIC ● S/O stated that ● (-) Dizziness ● Disturbed sensory

SYSTEM the client and Headache perception
presents ● No feeling of
 confusion as to numbness
time and place ● Client was
and it is a new conscious but
change to the not coherent
patient.

LYMPHATIC/HEM ● No bruises ● Infection

ATOLOGIC ● No rashes
SYSTEM ● No lumps in the
neck &
underarms
● (-) Enlargement
of nodes
● Increased WBC
= 12,500/mcL;
● Increased
platelets
=350,000/mcL;
● Decreased HCT
= 30%;
● Decreased Hgb
= 10 g/dL.
● pH 7.30 =
acidic
● PaO2= 55;
decreased
● PaCO2 = 50;
increased
● HCO3= 25
within the
normal range

ENDOCRINE ● The client ● Feet and hands ● Risk for fluid

SYSTEM complains are proportional volume deficit
fatigue ● (-) Buffalo
hump
● (-)
exophthalmia
● (-) Excessive
hunger, thirst
and urination
● (+) Diaphoresis

Gordon’s Before Admission During Admission

Functional Health
Patterns
Assessment
Health ● Patient C.D smoked ● Patient C.D is feeling weak and restless.
Perception/Health
Management cigarettes one pack He is now hospitalized and considering
Pattern
per day for 55 years he’s not healthy anymore; He was

and quit 3 years ago. diagnosed with Community Acquired

He was also a social Pneumonia High Risk and had

drinker before. Never undergone treatments. He manifests

experience an fever prior to her confinement and

accident. Claim to difficulty of breathing. He is expecting

have childhood to recover from his present condition

illnesses like with the help and support of his family

chickenpox, cough, and the health providers attending to his

fever, LBM and flu, needs

but managed in the

house.

Nutritional/Metab The patient can remember the Patient is on a Low Salt Low Fat w/ Aspiration
olic Pattern
food that he eats and Precaution diet. The patient’s appetite now

verbalizes that he loves to eat decreases even though he wants to eat, he feels

meat more than vegetables nauseated whenever he eats more and he has

before. He loves to eat in poor appetite because of his chest pain and

restaurants & fast foods but difficulty of breathing. He drinks 4-5 glasses.

not now.   Before As of his finances it's still adequate to provide

hospitalization days, he had a their food.

good appetite. He drinks 6-8

glasses of water a day. He

 eats on time even if he's not

hungry.  He eat meals on

table with the family and also

verbalizes that finances are

adequate in providing for

food.

Elimination The patient voids 9-13 times a day with a

Pattern He usually voids 6-8 times a
moderate amount. Urine is light yellow in
day, denies experiencing any
color. Denies any pain, incontinence, dysuria
incontinence, dysuria,
and burning sensation. For the bowel
burning sensation, dribbling,
movement, the patient defecates every other
nocturia, oliguria, polyuria.
day. Stool is formed, yellowish in color and
His urine is yellowish in
moderate in amount. The client didn’t
color.  The stool is formed,
experience diarrhea and has never utilized
brown in color  and is not too
suppositories supplements or medications
soft or too hard. He doesn’t
during the hospitalization.
have any problems in

defecating nor feel any pain. He had dry and warm skin to touch and doesn’t

Doesn’t experience have any rashes, swelling, acne, or any change

constipation, diarrhea or in temperature. Patient is also diaphoretic. 

ileostomy. He has never

utilized suppositories,

supplements or other

medication for either

constipation or diarrhea. 
Exercise and Patient reported that he does Patient C.D’s activities in the hospital are
Activity Pattern
not engage in any form of limited only within his room. Patient C.D is

exercise other than walking. activity intolerance due to his condition.

Denies having a regular Verbalized complaints of fatigue and shortness

exercise plan. And according of breath and cannot finish a short sentence

to him, his work serves as his before the respiratory rate increases above the

everyday exercise. The baseline. In present, he needs assistance in

patient smoked cigarettes one doing self-care like bathing because of easy

pack per day for 55 years and fatigability.

quit 3 years ago. He was also

a social drinker before.

Cognitive and
Perceptual Pattern The patient presents with confusion as to time
Patient C.D is an Accountant.
and place. SO stated that this is a new change
He can read, speak well and
for the patient.
listens attentively. The patient

has no difficulty in hearing There is blurring of vision and cannot hear

and denies blurring vision. He sound clearly. Despite having a blurry vision he

doesn’t have any problem is not wearing any prescription glasses. Patient

with concentration and experienced chest pain.

change in memory. Lastly,

Character:
he denies any discomfort.
The client felt chest pain.

Onset:

The client felt continuous pain every breathing.

Location:
 The client felt a chest pain in his right lower
lobe.

Duration:

According to the client, the pain lasts for about

5 minutes then recurs periodically.

Severity:

The client describes the pain 7 out of 10.

Pattern:

The client said that the pain recurs every now

and then.

Associated factors:

Pain worsen when he coughs, sneezes, or

moves around.

Sleep and Rest Patient C.D’s sleeping pattern is disturbed due

Pattern Patient verbalized that he
to sudden onset of difficulty breathing. Cold
usually sleeps 11pm or 12 am
breeze of the air-conditioning of the patient’s
but he feels rested. Never
room also adds as a factor to her difficulty in
experienced nightmares or
sleeping
dreams. He seldom sleeps

during noontime.  Denies any

aid to sleep. Denies insomnia

and sleep apnea. 

Self-Perception Patient C.D is a friendly and The patient states that he feels anxious
and Self-Concept
Pattern happy person. He used to sometimes when he feels that his condition is

socialize with his friends in getting worse.  The client also pointed out that

their neighborhood and to his he recently experienced a situation that felt like

workmates in the office. He is there is no hope at all, but he prayed and spent

a well-determined person and time with his family to cope up with his

he wants to be happy and free condition. Lastly, he doesn’t want to change

from anxieties. His family anything about himself because he’s content

and relatives are always there with what he has.

for him to give assistance and

support. He wants to have

good health and live his life

to the fullest.

Role-Relationship Verbalized unity and harmony among family

Pattern
The patient states that his
family is the most important
people in his life. His role in
the family is as a parent to his
children and grand –children.
He lives with his children
members. They usually cooperate with each
other when it comes to family decisions. The
patient finds it pleasurable sometimes when
spending alone with self. He expressed that his
family are always there to help him and
willingly support his needs.
Sexuality and The patient denies performing Patient C.D is not sexually active anymore. He
Reproduction
Pattern testicular self-examination doesn’t complain any problem regarding his

and denies prostate problems. breast and prostate.

Coping-Stress Prayers give him strength to During his hospitalization patient C.D copes
Management
Pattern hold on.  At his early age he with family and friends with their support.

usually takes alcohol and

cigarettes to relieve her

tension. Sometimes, when he

is lonely and bored, he

usually mingles with his

peers and barkada’s through

drinking alcohol.
Values and Belief The patient hopes that in the future he will
Pattern The patient states that the
restore back his health so that he can still have a
most important thing for him
quality time with his family.
is his family. His family is the

one who supports him

emotionally. 

He is a Roman Catholic.  He

practices the value and

traditions of Christianity. He

attends every Sunday mass

and verbalizes that his faith

and belief is an important part

of his life. His faith

influenced him to have faith

that God will help him in his

condition and prayers help

him connect with God. The

patient verbalizes that his

condition does not affect his

relationship with God.

 Anatomy and Physiology
● Nasal passage- The nasal cavity functions to allow air to enter the respiratory system
upon respiration. 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.
● Pharynx - is part of both the digestive system and the respiratory system. As a
component of the upper respiratory tract, the pharynx is part of the conducting zone for
air into the lungs.
●  Larynx- commonly called the voice box or glottis, is the passageway for air between the
pharynx above and the trachea below.
● Epiglottis -acts like a trap door to keep food and other particles from entering the larynx.
● Trachea- called the windpipe, is the main airway to the lungs.
● Mainstem Bronchi- The mainstem bronchi divide into secondary or lobar bronchi that
enter each of the five lobes of the lung. The bronci are lined with cilia , which propel
mucus up and away from the lower airway to the trachea , where it can be expectorated or
swallowed.
● Bronchioles – Branch from the secondary bronchi and subdivide into the small terminal
and respiratory bronchioles. The bronchioles contain no cartilage and depend on the
recoil of the lung for patency.
● Alveoli -are grouped together like a lot of interlinked caves, rather than existing as
separate individual sacs. The alveoli have a structure specialised for efficient gaseous
exchange.
● Lungs- Located in the pleural cavity in the thorax. The lungs' main function is to help
oxygen from the air we breathe enter the red cells in the blood.
 CONCEPT MAP

MODIFIABLE RISK FACTORS

NON-MODIFIABLE RISK FACTORS  SMOKING
 ALCOHOL ABUSE
 Age (elderly 65 and up
 POOR DENTAL HYGIENE
and children below 2
 CO-MORBID
years old or born
CONDITIONS (i.e., COPD,
prematurely)
asthma, and DM)
 Gender (most common
 Lifestyle
in male)
 Occupation
 Home/community
environment

Entrance of bacteria in airway (S.

pneumoniae, H. influenzae, M. pneumonia)

Independent:

>Instruct patient concerning the disposition of Material propelled into alveolar system
secretions.

>Limit visitors as indicated.

Adherence to alveolar macophages
>Investigate sudden change in condition, such as
increasing chest pain, extra heart sounds, altered
sensorium, recurring fever, changes in sputum
characteristics. Exposure of cell wall components (bacterial
invasion to lungs)
> Encourage adequate rest balanced with moderate
activity. Promote adequate nutritional intake.

Acute inflammatory response

Loss of effectiveness of defense mechanism

 >Azithromycin
(Zithromax) 500 mg

>Levofloxacin Penetrate the sterile lower respiratory tract

(Levocin) 750mg IV (lungs)

>Cefuroxime (Kefox)
750 mg IV Affects alveoli

Paracetamol
Colonization Multiplication of bacteria
for fever

Release of damaging Irritation of airways Coughing

Infection r/t exotoxins  Removal of
compromised host Fever secretions
defenses Increased goblet cells  Adequate hydration
Infection of 2 to 3 L per day
Acute pain r/t  Humidification
inflammation of lung Airway constriction
parenchyma

WBC -12,500 Tissue Necrosis

Platelet-350,000
Inflammation of the lunch Increased mucus production
parenchyma
Impaired gas exchange
 Solu-Cortef 100 mg IV
Occlusion of airway r/t collection of mucus
>Budesonide  Montelukast sodium (Co-
O2 inhalation in the airway
(Nabulization) altrea) 10mg

>Ventolin 1 neb Vasodilation and Impairing O2 and CO2 gas exchange HGB – 10 g/dL
Alveolar overinflates and bursts
q4h increase blood flow to
Fluid leakage to area
pleural place HCT – 30% Independent:
Alveolar leakage
> Assist the patient in a
Air leaks to chest cavity
comfortable position, semi-
folwer’s or high fowler’s
Decreased lung expansion
position.
Ineffective airway clearance > Demonstrate and help the
r/t pleuritic pain Pleural Effusion Ineffective breathing pattern patients perform
r/t decreased lung volume diaphragmatic and pursed
capacity lip breathing.
Lung collapse Dependent:

>Administer supplemental
 Chest X-Ray

 Right lower lobe

consolidation
 Presence of apical Activity intolerance r/t
bullae imbalance between oxygen
 Flattened diaphragm Low blood O2 levels in the body
supply and demand

 Chest pain Multiple organs deprived of O2

Independent:
 Shortness
of breath >Assess the physical activity level and mobility of
 Chills Death the patient.

> Assess the patient’s baseline cardiopulmonary

status
If left untreated (e.g., heart rate, orthostatic BP) before
initiating activity

> Teach the patient and/or SO to recognize signs

 Encourage avoidance of of physical overactivity or overexertion
overexertion
>Encourage conscious-controlled breathing
 Position client into semi-fowler to
techniques (e.g., pursed-lip breathing and
promote rest and breathing
diaphragmatic breathing) during increased activity
 Maintenance of proper fluid volume
and times of emotional or physical stress
 Encourage adequate nutrition
 Administer analgesics as prescribed

Independent: Independent: Independent:

>Provide comfort measues: back rubs,
position changes, relaxation techniques
and imagery.
>Encourage frequent oral hygiene.
> Instruct and assist patient on chest
splinting techniques during coughing
episodes.
>Elevated head of the bed for about 30
degrees and ask the client to assume dorsal
recumbent position.
>Encouraged deep breathing exercises
> Kept environmental pollution to a
minimum
>Asses rate, rhythm, and depth of
respiration, chest movement, and use
accessory muscles.
> Assess cough effectiveness and
productivity.
>Observe sputum color, viscosity, and
odor. Report any changes or unusualities.

> Monitored respiratory patterns, including

Collaborative:
> Administer analgesics as prescribed.
Encourage patient to take analgesics
before discomfort becomes severe.
rate, depth, and effort q2. Collaborative:
>Administer medications as indicated
(mucolytics, expectorants, bronchodilators,
Dependent: analgesics).
>Gave O2 inhalation @ 6L/min via face
Legend:

Risk Factors Diagnostic test Nursing Diagnosis Medications

Pathophysiology Nursing Signs and Interventions

Management Symptoms
 DRUG STUDY

DRUG CLASSIFICATIO DOSAGE/ROUTE/ INDICATIONS/ MECHANISM SIDE EFFECTS NURSING

N OF ACTION CONSIDERATIONS
FREQUENCY CONTRAINDICATIONS
Losartan angiotensin 11 Oral ,50 mg 1 tab Indication : Losartan is used to ● diarrhea Obtan B/P, apical
Potassium receptor daily treat high blood pulse immediately
Blocks ● stomach pain
(Cozaar) antagonist. pressure (hypertension) and to help before each dose, in
vasoconstrictor ,
protect the kidneys from damage due ● muscle addition to regular
Antihypertensive. aldosterone–
to diabetes. It is also used to lower the cramps monitoring. Question
secreting effects
risk of strokes in patients with high for possibility of
of angiotension ● leg or back
blood pressure and an enlarged heart. pregnancy. Assess
11,inhibiting pain
Lowering high blood pressure helps medication history.
binding of
prevent strokes, heart attacks, ● dizziness Assess for evidence of
angiotension 11
and kidney problems upper respiratory
to AT1 receptor. ● headache
infection ,cough .
Therapeutic
● sleep
Effect :Causes
It is contraindicated in problems
vasodilation,
pregnancy.As losartan acts on the (insomnia)
decreases
renin-angiotensin system, it causes
peripheral ● tiredness, and
oligohydramnios, thus resulting in
resistance ,
fetal lung hypoplasia and skeletal ● cold or flu
decreases B/P.
deformities. Potential neonatal symptom
adverse effects are skull hypoplasia,
hypotension, anuria, renal failure, and
death.
Metrofor Antidiabetic Oral ,I tab TID Adjunct to diet to lower blood Metformin is a ● physical  History: Allergy to
min HCI glucose with type 2 diabetes mellitus biguanide weakness  metformin; diabetes
(glyburid in patients > 10 yr; extended-release antihyperglycaem (asthenia) complicated by fever,
e) in patients > 17 yr. As part of ic agent which ● diarrhea. severe infections,
combination therapy with aimproves glucose severe trauma, major
● gas (flatul
sulfonylurea or insulin when either tolerance by surgery, ketosis,
ence)
drug alone cannot control glucose lowering both acidosis, coma; type 1
levels in patients with type 2 diabetesbasal and ● symptoms diabetes, serious
mellitus postprandial of weakne hepatic or renal
plasma glucose. It ss, muscle impairment, uremia,
decreases hepatic pain thyroid or endocrine
glucose (myalgia) impairment,
Contraindication includes
hypersensitivity, chronic heart production by ● upper glycosuria,
failure, metabolic acidosis with or inhibiting respirator hyperglycemia
without coma, diabetic gluconeogenesis y tract associated with
ketoacidosis (DKA), severe and infection. primary renal disease,
renal disease, glycogenolysis, ● low blood CHF, pregnancy,
abnormal creatinine clearance delays intestinal sugar lactation.
resulting from shock, septicemia, glucose (hypoglyc
Physical: Skin color,
or myocardial absorption, and emia)
lesions; T, orientation,
infarction and lactation. improves insulin ● abdominal reflexes, peripheral
sensitivity by pain (GI sensation; R,
enhancing complaint adventitious sounds;
peripheral s) liver evaluation, bowel
glucose uptake
sounds; urinalysis,
and utilisation.
BUN, serum
creatinine, LFTs,
blood glucose, CBC
Levofloxacin Fluoroqui Oral, 500 mg 1 Acute bacterial sinusitis, Acute Inhibits DNA ● nausea, Question for
(Levocin) nolone, cap OD exacerbations of chronic obstructive enzyme gyrase in hypersensitivity to
● vomiting,
antibiotic pulmonary disease including susceptible levofloxacin, other
bronchitis, Community-acquired microorganism, ● diarrhea fluoroquinolones.
pneumonia, Complicated urinary tract interfering with Monitor serum
infections, etc. bacterial cell ● headache glucose, renal
replication, ● constipati function, LFT .
repair. on, Monitor daily pattern
In patients hypersensitive to Therapeutic of bowel activity, stool
levofloxacin or other quinolones,in Effect: ● difficulty consistency. Report
patients with epilepsy, in patients Bactericidal. sleeping (i hypersensitivity
with history of tendon disorders nsomnia) reaction : Skin rash,
related to fluoroquinolone ● dizziness urticarial, pruritus,
administration,in children or growing photosensitivity
adolescents, during pregnancy,n ● abdominal promptly.
breast-feeding women. pain

Cefuroxime Second 750 mg IV q 8h Susceptible mild to Binds to bacterial ● Discomfo Obtain CBC,renal
(Kefox) generation moderate infections including cell membranes, rt with Imfunction tests.
cephalosp pharyngitis/tonsillitis, acute maxillary inhibits cell wall administraQuestion for history of
orin, sinusitis, chronic bronchitis, acute synthesis. tion, allergies particularly
antibiotic otitis media, uncomplicated skin and Therapeutic effect cephalosporins
● thrush,
skin structure, UTIs, gonorrhea, early :Bactericidal ,penicillins. Assess
Lyme disease. ● mild oral cavity for white
diarrhea patches on mucuos
membranes, tongue
● mild (thrush). Monitor daily
Cefuroxime is contraindicated in
abdominal pattern of bowel
patients with cephalosporin
cramping
 hypersensitivity or cephamycin ● vaginal activity. Mild GI
hypersensitivity. Cefuroxime should candidiasi effects may be
be used cautiously in patients with s tolerable . Minotr I&O
hypersensitivity to penicillin.
● nausea.

Montelukast Leukotrien Oral, 10 mg 1 Tab Montelukast sodium is indicated for Binds to cysteinyl ● Headache Chewable tablet
Sodium (Co- e receptor HS the relief of symptoms of
leukotriene, contains phenylalanine
inhibitor, ● Abdomina
Altria) seasonal allergic rhinitis in patients 2
receptors , (component of
antiasthmat l pain,
years of age and older and perennial inhibiting effects aspartame) ; parents of
ic.
allergic rhinitis in patients 6 months of leukotrienes on ● Cough phenylketonuric pts
of age and older. bronchial smooth should be informed.
muscles. ● Dyspepsia Assess lung sounds for
Therapeutic ● dizziness, wheezing . Monitor for
Montelukast is contraindicated in effect: Decreases change in mood,
patients with a history of bronchoconstricti ● fatigue behavior. Assess for
hypersensitivity to the drug or its on, vascular ● dental allergy symptoms.
components. For patients with pain. Increase fluid Intake.
permeability,
phenylketonuria (PKU), caution
mucosal edema
should be exercised with
and mucus
phenylalanine-containing
production.
formulations.
Ca Carbonate Electrolyte Oral, 1 tab QID Calcium carbonate is a dietary Calcium ● Pain , Assess B/P,EKG and
replenisher supplement used when the amount of carbonate is used cardiac rhythm, renal
. Antacid, ● Rush
calcium taken in the diet is not as a function , serum
antihypocal enough. Calcium is needed by the supplementary magnesium, phosphate
● Redness
cemic.
body for healthy bones, muscles, source of Ca to ,potassium.
nervous system, and heart. Calcium help prevent or ● burning at
carbonate also is used as an antacid to decrease the rate injection
of bone loss in site
relieve heartburn,acid indigestion,
 and upset stomach. osteoporosis. It ● flushing
also acts as an
● nausea
antacid by
Hypercalcaemia resulting from neutralising ● vomiting
myeloma, bone metastases or other gastric acidity
resulting in ● diaphoresi
malignant bone disease, sarcoidosis,
increased gastric s,
primary hyperparathyroidism, vitamin
D overdosage. Osteoporosis due to and duodenal ● hypotensi
long term immobilization. pH. . on ,
● mild
constipati
on
PCM Central Oral, 500 mg 1 tab Used to relieve pain and to reduce Paracetamol ● Stomach Monitor for S&S of:
nervous q4h prn for fever. It is used to treat many exhibits analgesic pain hepatotoxicity, even
system T>37.70C conditions such as headache, body action by with moderate
● Nausea
agent; ache, toothache and common cold. It peripheral acetaminophen doses,
nonnarcoti works by inhibiting the release of blockage of pain ● Vomiting especially in
c certain chemical that cause pain and impulse individuals with poor
analgesia, fever. generation. It nutrition or who have
produces ingested alcohol over
antipyretic
antipyresis by prolonged periods;
.
Hypersensitivity to acetaminophen or inhibiting the poisoning, usually
phenacetin; use with alcohol. hypothalamic from accidental
heat-regulating ingestion or suicide
centre. Its weak attempts; potential
anti-inflammatory abuse from
activity is related psychological
to inhibition of dependence. Assess
prostaglandin allergic reactions: rash,
synthesis in the urticaria; if these
 CNS. occur, drug may have
to be discontinued.

Solu-cortef Corticoste 100 mg IV qh Allergic states, Dermatologic A corticosteroid ● Allergic History: Infections;
riods diseases, used for its anti- or kidney disease; liver
inflammatory and hypersens disease,
Endocrine disorders, Gastrointestinal
immunosuppressi itivity hypothyroidism;
diseases, Respiratory diseases, Renal
ve effects. Its reactions, ulcerative colitis with
diseases
anti-inflammatory impending perforation;
● anaphylac
action is due to diverticulitis; recent GI
toid
the suppression of surgery; active or
 Contraindicated in systemic fungal migration reaction,
of latent peptic ulcer;
infections and patients with known polymorphonucle inflammatory bowel
● anaphylax
hypersensitivity to the product and its ar leukocytes and disease; hypertension.
is,
constituents, reversal of Physical: Systemic
increased ●  angioede administration:
capillary ma. Weight, T; reflexes,
permeability. It ● Abdomina affect, bilateral grip
may also be used l distentio strength,
as replacement n ophthalmologic
therapy in examination,discolorat
adrenocortical ● bowel/bla ion, pain or
insufficiency. dder dysfu prominence of
nction superficial vessels , 2-
(after hr postprandial blood
intrathecal glucose, urinalysis,
administra thyroid function tests,
tion), serum cholesterol
● elevation
 in serum
liver
enzyme
levels .
●  hepatome
galy,
● increased
appetite,
● nausea
Azithromycin Macrolide Oral ,500 mg daily Antibiotic medication used for the Azithromycin ● diarrhea History: Hypersensitiv
(Zithromax) antibiotics pc lunch treatment of a number of bacterial prevents bacteria  ity to azithromycin,
● nausea
infections. This includes middle ear from growing by erythromycin, or any
infections, strep interfering with ● abdominal macrolide antibiotic;
throat, pneumonia, traveler's diarrhea, their protein (belly) gonorrhea or syphilis,
and certain other intestinal synthesis. It binds pain pseudomembranous
infections. It can also be used for a to the 50S subunit ● vomiting colitis, hepatic or renal
number of sexually transmitted of the impairment, lactation.
infections,including chlamydia and g bacterial ribosom ● headache
Physical: Site of
onorrhea infections. e, thus
infection; skin color,
inhibiting translat
lesions; orientation, GI
ion of mRNA.
output, bowel sounds,
Diarrhea from an infection with liver evaluation;
Clostridium difficile bacteria, low culture and sensitivity
amount of magnesium in the blood, tests of infection,
low amount of potassium in the urinalysis, LFTs, renal
blood, myasthenia gravis, a skeletal function tests
muscle disorder, hearing loss.
 NURSING CARE PLAN
ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Subjective: Ineffective After the Independent: At the end of
airway nursing the nursing
Verbalized fatigue ● Assess the rate, ● Tachypnea
clearance r/t interventions, interventions
rhythm, and shallow
excessive the client should the client has
depth of respirations
mucus be able to: able to:
Objective: respiration, and
secretions
Short term: chest asymmetric ● demonstrate
● Shortness of movement, and chest behaviors to
breath ● identify/demo
use of accessory movement achieve
nstrate
● Can’t finish a muscles. are patent
behaviors to
short sentence frequently airway
achieve
present clearance.
● Nail beds and airway
because of
lips bluish tinge clearance. ● maintain
discomfort
in color patent
Long term: of moving
airway with
● Diaphoretic chest wall
● maintain the absence
and/or fluid
● Uses accessory patent airway of any
in lung due
muscles with breath adventitious
to a
sounds lung sounds
● Coughs weakly compensator
clearing, y response to ● achieve
with no sputum absence of airway normal
● Skin is warm dyspnea, obstruction. breathing
and dry cyanosis, as
pattern and
evidenced by
● Capillary refill improved
keeping a ● Coughing is
less than 2 secs condition.
patent airway the most
● Lips were dry and effective
and pale effectively way to
clearing remove
BP- 90/50mmHg secretions. secretions.
PR- 101bpm Pneumonia
● Assess cough may cause
RR-28bpm
effectiveness thick and
T- 101.5oF and tenacious
productivity. secretions to
O2 Sat- 82% patients.
pH- 7.30
PaO2 – 55
PaCO2-50
HCO3 - 25
 ● Decreased
airflow
occurs in
areas with
consolidated
fluid.

● Auscultate lung
fields, noting
areas of
decreased or ● Sputum that
absent airflow is
and adventitious discolored,
breath sounds: tenacious, or
crackles, has an odor
wheezes. may increase
airway
resistance
and may
warrant
● Observe the further
sputum color, intervention.
viscosity, and
odor. Report
changes.

● Airway
clearance is
hindered
with
inadequate
hydration
and
thickening
of
secretions.

● Doing so
would lower
● Assess the
the
patient’s
diaphragm
hydration
and promote
status.
chest
expansion,
 aeration of
lung
segments,
mobilization
and
expectoratio
n of
secretions.

● Elevate head of
bed, change ● Deep
position breathing
frequently. exercises fac
ilitates
maximum
expansion of
the lungs
and smaller
airways, and
improves the
productivity
of cough.
● Coughing is
a reflex and
a natural
self-cleaning
mechanism
that assists
the cilia to
maintain
patent
airways. It is
the most
● Teach and assist helpful way
patient with to remove
proper deep- most
breathing secretions.
exercises. ● Splinting red
Demonstrate uces chest
proper splinting discomfort
of chest and and an
effective upright
coughing while position
in upright favors
position. deeper and
Encourage him more
to do so often. forceful
cough effort
making it
 more
effective.

● Helps
mobilize
secretions
and reduces
atelectasis.

● To improve
airway
condition.

● Increasing
the humidity
will decrease
the viscosity
of
secretions.
Clean the
humidifier
before use
to avoid
bacterial
growth.

● Encourage
ambulation.
● Therapeutic
regimen, and
may
facilitate
necessary
alterations in
therapy.
Oxygen
 saturation
should be
maintain at
Collaborative: 90% or
greater.
● Administer Imbalances
medications as in PaCO2
indicated and PaO2
(mucolytics, may indicate
expectorants, respiratory
bronchodilators, fatigue.
analgesics)

● Use humidified
oxygen or ● To prevent
humidifier at atelectasis or
bedside. collapse of
the lungs.

● Monitor serial
chest x-rays,
ABGs, pulse
oximetry
readings.
 ● Assist with
bronchoscopy
and/or
thoracentesis, if
indicated.

Assessment Diagnosis Planning Intervention Rationale Evaluation

Ineffectiv After 30 Independent: After 30
e minutes of 1. Elevated minutes of
Subjective: 1. Elevation of
breathing nursing head of the nursing
the bed
“The patient pattern r/t intervention bed for about intervention
facilitates
complains of fatigue decrease , the client 30 degrees , the client
respiratory
and shortness of lung will and ask the manifested
function by use
breath.” expansion experience client to lessened
of gravity. It
as lessened assume dorsal difficulty of
Objective: also decreases
manifeste difficulty of recumbent breathing as
pressure on the
● T:101.5°F d by dry, breathing as position. manifested
abdomen when
pale, and manifested by
● BP:90/50 assuming the
bluish by decreased
 mm Hg tinged decreased position in RR from
lips, in RR from (Wayne, 28 bpm to
● RR:28 bpm
cyanotic 29 bpm to 2019). 20bpm with
● HR: 101 nail beds, 20bpm with the absence
bpm diaphoreti the absence of using
c and is of using 2. Promote accessory
● Blue tinged using accessory muscles,
2. Encouraged chest
nail beds accessory muscles, and
deep breathing expansion
and lips muscles, and presence of
exercises (Wayne,
● Dry and pale severely presence of 2019). calm
lips. diminishe calm breathing.
d breath breathing.
● The patient sounds in
cannot finish the right
a sentence. lower lobe 3.Precipitators
and of allergic type
● The patient
absence of 3. Kept of respiratory
is
breath environmental reactions that
diaphoretic
pollution to a can trigger or
and is using sounds at
the base. minimum exacerbate
accessory
onset of acute
muscles.
episode(Wayn
● Severely e, 2019).
diminished
breath
sounds in
the right
4. Assesses the
lower lobe
condition of
and absence
the
of breath
client(Wayne,
sounds at the
2019).
base. 4. Monitored
● ABG as respiratory
follows: patterns,
including rate,
● pH, 7.30; depth, and
PaO2, 55; effort q2.
PaCO2, 50;
and HCO3,
25
● Chest x-ray
results
reveal right
lower lobe
consolidatio 5. Helps in
n, presence giving
of apical adequate
Dependent: oxygen to th e
bullae,
flattened 5. Gave O2 client(Wayne,
diaphragm, inhalation @ 2019).
and a small 6L/min via
pleural face mask as
effusion in ordered.
the right
lower lobe.
6. Assess the
condition of
the
Collaborative client(Wayne,
: 6. Obtained 2019).
blood
specimen for
Arterial Blood
Gas study
 Assessment Diagnosis Planning Intervention Rationale Evaluation

Subjective: Acute pain Long-term goal: Independent: Long-term goal:

related to After 3 days of After 3 days of
“patient verbalize ● Provide comfort ● Non-analgesic measures
inflammation of interventions, goals interventions, goals
pain on the right measures: back rubs, administered with a
lung parenchyma are fully met as are fully met as
lower lobe with a position changes, gentle touch can lessen
evidenced by: evidenced by:
pain scale of 7/10” relaxation techniques discomfort and augment
● Diminished and imagery, massage. therapeutic effects of ● Diminished
pain Encourage use of analgesics. Patient pain
Objective: relaxation and/or involvement in pain
● Relaxed and ● Relaxed and
breathing exercises. control measures
● T:101.5°F increased increased
promotes independence
activity activity
● BP:90/50 mm and enhances sense of
appropriately appropriately
Hg well-being.

● RR:28 bpm
Short-term goal: Short-term goal:
● HR: 101 bpm
After 12 hours of After 12 hours of
● Blue tinged nail interventions, goals interventions, goals
beds and lips are fully met as ● Mouth breathing and are fully met as
● Encourage frequent
● Dry and pale evidenced by: oral hygiene. oxygen therapy can evidenced by:
lips. irritate and dry out
● Diminished ● Diminished
mucous membranes,
● The patient weakness weakness
potentiating general
cannot finish a ● Diminished discomfort ● Diminished
sentence. restlessness restlessness
● The patient is ● Absence of ● Absence of
diaphoretic and ● Aids in control of chest
 is using irritability discomfort while irritability
accessory enhancing the
muscles. effectiveness of cough
● Instruct and assist effort.
● Severely
patient in chest
diminished
splinting techniques
breath sounds in
during coughing
the right lower
episodes.
lobe and absence
of breath sounds
at the base.
● ABG as follows:
● pH, 7.30; PaO2, ● Medications allow for
55; PaCO2, 50; pain relief and the ability
and HCO3, 25 to deep breathe and
Dependent:
cough. Analgesics help
● Chest x-ray ● Administer analgesics prevent peak periods of
results reveal as prescribed. pain.
right lower lobe Encourage patient to
consolidation, take analgesics before
presence of discomfort becomes
apical bullae, severe.
flattened
diaphragm, and a ● These medications
small pleural may be used to
effusion in the suppress non-
right lower lobe. productive cough or
● Administer antitussives reduce excess
as indicated. Do not mucus, thereby
suppress a productive enhancing
cough; moderate general comfort.
amounts of analgesics
are used to relieve
pleuritic pain.
 ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTIONS
Subjective: Impaired gas Long term goal: Independent: >Understanding the >Pt. is able to
exchange r/t disease process allows verbalize the disease
Fatigue The patient will be >Explain the disease
collection of the patient to realize process and
able to maintain a process and
mucus in the how he/she acquired enumerate ways how
normal respiratory management of
airway the disease, resulting to to prevent reinfection
Objective: rate (12 to 20 symptoms to the
better understanding of in the future.
breaths per min) patient.
● O2 Sat = 82% how they can prevent
without any
reinfection in the future
● Diaphoresis difficulty.
(Vera, 2020).
● Dyspneic > Pt. is able to breathe
● Tachypneic Short-term goals: normally and
respirations are within
● RR= 28 breaths/min Within 8 hours of
normal range (12-20
nursing
● ABG breaths per min).
intervention: >To promote lung
o pH=7.30 expansion and decrease
>Assist the patient in a respiratory effort
o PaO2= 55 ● Demonstrate comfortable position, (Hinkle and Cheever,
o PaCO2=50 improved semi-folwer’s or high 2018). >SaO2 has increased
ventilation and fowler’s position to 95% and ABG
o HCO3= 25 adequate values has returned to
oxygenation of >Early recognition of normal values.
● HCT=30%
tissues by ABG deterioration in
● Hgb= 10 g/dL of: respiratory function
>Monitor respiratory will avert further
● Peripheral cyanosis pH= 7.35-7.45 status, including rate, complications (Vera,
pattern of respirations, 2020).
paCO2= 35-
● Using accessory muscles 45mmHg and breath sounds.
paO2= 80-
95mmHg
● Stabilize >Helps patient prolong
respirations and expiration time and
decrease RR to decreases air tapping
12-20 breaths (Hinkle and Cheever,
per minute. 2020).
>Demonstrate and
help the patients
perform diaphragmatic
and pursed lip
breathing.
>To prevent
overexhaustion and
reduces oxygen
consumption (Doenges
et.al., 2016).
>Advise the patient to
allow the patient to
rest and limit
activities.

>Maximizes available
oxygen, especially
while ventilation is
 reduced (Doenges,
etl.al, 2016).
Dependent:
>Administer
supplemental oxygen >To monitor and
as indicated. prevent potential
complications
(Doenges, et.al., 2016).

>Administer IV fluids
and medications and
respitory suppoer as
ordered.

ASSESSMENT NURSING PLANNING NURSING RATIONALE

DIAGNOSIS INTERVENTIONS
Subjective: Infection related to Within 1hr of Independent:
compromised host nursing
“maglisog kog ● During this
defenses intervention/ health
ginhawa , dli ko ka period of time,
teaching, client will ● Monitor vital
dali2 ug human ug potentially fatal
be able to: signs closely,
storya kay mag abot ● Participate in especially during complications
akong ginhawa, prevention initiation of (hypotension,
dayun kapoy akong measures and therapy. shock) may
paminaw” treatment develop.
program.
As verbalized by
the client
● sputum be
● Achieve timely disposed of in a
resolution of ● Instruct patient safe manner.
The client claims to
current concerning the Changes in
smoked cigarettes
infection disposition of characteristics
one pack per day
without the secretions: of sputum
for 55 years and
complications. raising and reflect
quit 3 years ago and
expectorating
a social drinker. resolution of
versus
Also, has history of pneumonia or
● Identify swallowing; and
hypertension and development of
interventions to reporting
diabetes. secondary
prevent/reduce changes in color,
risk/spread amount, odor of infection.
of/secondary secretions.
Objective:
infection.
Bp- 90/50mHg
HR- 101bp ● Effective means
of reducing
RR- 28 breaths/min spread or
● Demonstrate and acquisition of
T- 101.5°F
encourage good infection.
Pulse oximeter – hand washing
85% on room air technique.
CBC: ● Promotes
expectoration,
WBC- 12,5000
clearing of
Platelets – 350, 000 ● Change position infection.
frequently and
HCT – 30%
provide good
Hgb – 10g/dl pulmonary
hygiene.
● Reduces
likelihood of
AGB on room air: exposure to
pH – 7.30 other infectious
pathogens.
PaO2- 55
PaCO2- 50
● Limit visitors as ● Isolation
HCO3 – 25 indicated. techniques may
be desired to
prevent spread
-Chest x-ray results from other
reveal right lower infectious
lobe consolidation, processes.
presence of apical
bullae, flattened
diaphragm, and a ● Institute
small pleural isolation
effusion in the right precautions as
lower lobe. individually
appropriate.
Keep patient
-Lung auscultation away from other
reveals severely patients who are
diminished breath at high risk for
● Facilitates
sounds in the right developing
healing process
lower lobe and pneumonia.
and enhances
absence of breath
natural
sounds at the base.
resistance.
The breath sounds ● Encourage
in the rest of the adequate rest
lungs are slightly balanced with
decreased. moderate
activity. Promote
adequate
-The patient is nutritional
diaphoretic and is intake. ● Signs of
using accessory improvement in
muscles, coughs condition
weakly but does not ● Monitor should occur
raise any sputum. effectiveness of within 24–48
antimicrobial hr. Note any
therapy. changes.
-Skin is dry
-Warm to touch
Dependent:
-Lips is dry and
pale ● Delayed
recovery or
● Investigate
-Capillary refill is increase in
sudden change
less than 2 seconds severity of
in condition,
symptoms
- blurring vision such as
suggests
increasing chest
-cannot hear sound resistance to
pain, extra heart
 clearly sounds, altered antibiotics or
sensorium, secondary
recurring fever, infection.
changes in
sputum
characteristics.

● Administer ● To prevent
prescribed relapse of
antimicrobial pneumonia, the
agents as patient needs to
ordered. complete the
course of
antibiotics as
prescribed.

ASSESSMENT NURSING PLANNING NURSING RATIONALE EVALUATION

DIAGNOSIS INTERVENTION
Subjective: Activity After the At the end of
intolerance r/t nursing the nursing
Complains ● Assess the ● Provides
to imbalance interventions, interventions
Shortness of breath physical activity baseline
between the client should the client has
level and information
oxygen be able to: able to:
mobility of the for
supply and
Objective: patient. formulating ● To perform
demand ● Maintain
nursing regular
● Can’t finish a goals during activities
short sentence regular goal setting healthily
cardiovascular without
● Nail beds and and experiencing
lips bluish tinge respiratory any signs or
in color functions symptoms of
during ● In with activity
● Shortness of ● Assess the
activities. position intolerance.
breath patient’s
changes.
baseline
● Diaphoretic
cardiopulmonar
● Uses accessory y status (e.g., ● Demonstrate
muscles heart rate, behaviors to
orthostatic BP) This helps the achieve
● Coughs weakly patent
before initiating patient to cope.
with no sputum airway
activity. Acknowledgme
● Capillary refill nt that living clearance.
less than 2 secs with activity
intolerance is
● Lips were dry ● Verbalized
both physically
and pale understandin
and emotionally
difficult. g about
physical
BP- 90/50mmHg overactivity
PR- 101bpm ● Knowled or
ge overexertion
RR-28bpm promotes .
T- 101.5oF awarenes
s to
O2 Sat- 82% prevent
pH- 7.30 the comp
lication
PaO2 – 55 ● Encourage of
verbalization of overexert
PaCO2-50
feelings ion.
HCO3 - 25 regarding
limitations.

● The
more
oxygen
that is
able to
go to
● Teach the your
patient and/or brain,
SO to recognize the more
signs of relaxed
physical you'll
overactivity or be. Cons
overexertion. cious
breathin
g can
reduce
● Encourage your
conscious- stress
controlled and
breathing move
techniques (e.g., your
pursed-lip body
breathing and towards
 diaphragmatic more
breathing) ease.
during
increased
activity and
times of
emotional or
physical stress.

Helps promote a
sense of
autonomy while
● Encourage being realistic
physical activity about
consistent with capabilities.
the patient’s
energy levels.
To prevent
exertion and
keep vital signs
● Provide a calm at normal range.
and non
stimulating
environment.
 DISCHARGE PLAN

Name of Client : Cardo Dalisay Age: ___70__ Gender: Male

Religion: Roman Catholic____ Diagnosis: Surgery if any:

Hospital: Adventist Medical Center Iligan Room/Ward Bed No. 264

Attending Physician/s: Dr. Dane Abella

A. OBJECTIVES
At the end of an hour of health education the client will be able to:
1. Maintain a patent airway
2. Maximize breathing capacity
3. Relieve of his mucus secretions
4. Educate on providing adequate care at home
5. Know when to seek physician’s care

B. METHODS

1. Exercise/Activity and Home Environment

a. Coughing and deep breathing exercises:

● Pursed lip breathing:
-Relax your neck and shoulders.
-Keeping your mouth closed, inhale slowly through your nose for 2 counts.
-Pucker or purse your lips as though you were going to whistle.
-Exhale slowly by blowing air through your pursed lips for a count of 4.
● Diaphragmatic breathing:
-Lie on your back with your knees slightly bent and your head on a pillow.
-You may place a pillow under your knees for support.
-Place one hand on your upper chest and one hand below your rib cage, allowing you to
feel the movement of your diaphragm.
-Slowly inhale through your nose, feeling your stomach pressing into your hand.
-Keep your other hand as still as possible.
-Exhale using pursed lips as you tighten your stomach muscles, keeping your upper hand
completely still.
● Controlled cough technique
-Sit comfortably with your feet resting firmly on the floor, and lean forward slightly.
-Take three to four deep diaphragmatic breaths before coughing.
- Take a deep breath, hold your breath for three seconds, tighten your abdominal muscles and
cough twice. The first cough will loosen your sputum. The second cough will move the sputum
high in your throat.
- Spit it into a piece of tissue and check the color. If it is a yellow, green or red in colour, talk to
your doctor. Throw the tissue away.
-Take a break and repeat once or twice if you do not cough up any sputum.

b. Light activities:
-15-30 minutes of walking

c. Restrictions:

-Strenuous Activities

- Smoking/vaping

d. Environment:

-Encouraged to maintain a safe home and free from any health hazards such as sharp objects,
chemicals and matches.

- Encouraged to provide adequate lighting on stairs and bathrooms to avoid injury.

- Encouraged to maintain cleanliness of the house and surroundings.

- Encouraged to provide a well-ventilated area.

- Encouraged to listen to soft music for relaxation.

2. Treatments/Therapies :

a. Comply with medications

b. Increase Fluid Intake
c. Utilize Deep Breathing Exercise for at least twice a day
3. Health Teaching/Education :
a. Instructed to observe proper hygiene such as bathing the daily to keep from
infection.
b. Instructed to keep the patient always clean and dry.
c. Instructed to do proper hand washing.
d. Instructed not to go near crowded places to prevent risk of having infection
e. Instructed to give medications at the right route, dose and time.
f. Encouraged to have a good sleeping time and adequate nutrition.
g. Drink adequate fluid 2-3L per day.
h. Instruct SO to help the patient with chest physiotherapy.
i. Instruct patient how to get capillary refill time.
j. Observed signs & symptoms that need reporting:
● Increase dyspnea
● Elevated Body Temperature
● Presence of adventitious sounds.
● Respiratory distress
● Pale and cold clammy skin
● General weakness
● Hypotension
k. . Interventions / Home remedies that may be done immediately prior to seeking
consultation:
● Increase Fluid Intake
● Position to High Fowlers
● Adequate bed rest
Meal Plan: LSLF DIABETIC DIET
Meal DAY 1 DAY 2 DAY 3
BREAKFAST -1 glass of Low fat -Salabat tea -1 glass of Low fat
milk milk
-1/4 medium papaya
-1/2 cup oatmeal -1 cup plain yogurt
-1 cup rice
-1 serving of fruit -1 large apple
-vegetable stew
(orange)
-1 cup oatmeal
-1 serving of lean
meat (1oz dalagang
bukid)
MORNING SNACK -1/2 slice apple -½ cup nuts -1 glass of water
-1 glass of water -1 glass of water -1/2 corncob
(steamed)
LUNCH -1 glass of water 1 glass of water 1 glass of water
-1 cup brown rice -1 cup rice -1 cup rice
-fish tinola -Fried tofu -steamed
fish(bangus)
-1pc banana -1pc orange
-1pc banana
AFTERNOON -1 glass of water -1 glass of water -1 glass of water
SNACK
-1 packet of crackers -1 slice of -1 packet of crackers
watermelon
DINNER -1 glass of water -Ginger tea
-Pinakbet -Chicken nilaga -fish tinola.
-1 cup rice -1 cup rice -1 cup rice
-1 glass of water -1 pc banana -1/2 slice apple

4. OPD Visit
Clinic Appointment Schedule: _
Follow-up Diagnostic or Laboratory Exam:
Referrals: monthly visit in the health centers for check up_

5. Diet
a. Prescribed Diet: LSLF Diabetic diet
b. Diet Restrictions: salty foods and fatty foods
7.Spiritual Care and Psychological
Spiritual and Psychological Needs
a. Spiritual Counseling
b. Provide moral and emotional support
c. Join Church Organizations/Activities
d. Prayer
e. Meditation, Reflection, and Spiritual Devotion
I. DISCHARGE DETAILS

a. Date and Time of Discharge: March 17, 2021 9:30 am

b. Accompanied by:
c. Mode of Transportation:
d. General Condition upon Discharge:

This discharge plan was explained to me by my student nurse and I have understood it.

_____________________________
CLIENT/SIGNIFICANT OTHER
(Signature over Printed Name)

Instructed By: Approved By:

____________________________ ________________________________
STUDENT NURSE CLINICAL INSTRUCTOR
(Signature over Printed Name) (Signature over Printed Name)
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