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Angeles City
COLLEGE OF NURSING
S.Y. 2008-2009
A Case Study
COMMUNITY-ACQUIRED PNEUMONIA
Submitted by:
David, Nikki Louise Kina Z.
Gutierrez, Mary Joy R.
Manalo, Ma. Adrianne V.
BSN III-15
Group 57
Submitted to:
Ms. Johana L. Dimla, R.N.
I. INTRODUCTION…………………………………………………………………
…….1
Medical Management
A. IVF’s……………………………………………………………………
.
B. Drugs………………………………………………………………
C. Diet…………………………………………………………………….
D. Activity and Exercise………………………………………………
Nursing Management:
A. Nursing Care Plans………………………………………………
B. Actual SOAPIER’s………………………………………………
VIII. BIBLIOGRAPHY
DEDICATION
The aim of this study was attained through the help and guidance of
the following people who have extended their time, support and
encouragements to make this study possible.
To their loving families, for providing all the love and care, for always
being there to give guidance and care in times of difficulties and for the
support they have given form the start of this study.
To Ms. Johana L. Dimla, their clinical instructor, for all the patience,
advice and undying support and kindness. Her mere guidance enables us to
produce the best result.
To their patient and the significant others, for their cooperation and
willingness to participate in this study and for providing them essential
information about this study and making their doors open.
Finally, to many unnamed friends, for their support and serving as their
inspiration that helped them believe in their capabilities, we would like to
extend our deepest gratitude.
I. INTRODUCTION
CAP is one of the most common entities seen in Filipino adults. It is the
most common infectious disease prompting hospitalization and the first and
fifth leading cause of morbidity and mortality in the Philippines, respectively.
Incidence rates mentioned above is primarily the reason of the group
for choosing this case. The prevalence of community-acquired pneumonia in
the local and foreign communities needs attention and through this study,
CAP would be known better and would be helpful for the group to effectively
play their role as advocates of their patients care and well-being. This will
serve as an important tool for them to render proper nursing care, facilitate
health promotion and perform appropriate interventions to individuals with
such condition.
This study aims to provide the group a clear view of the pertinent facts
surrounding community-acquired pneumonia, which will lead them to become
effective and efficient in the nursing field.
Mr. Cap has 13 children, six of which are males and seven are
females. All of them already have their own family. Twelve of them are
living away from their parents and only one, who is the youngest, lives
with her parents in their ancestral home. Mr. Cap’s family is classified
under an extended type of family with his wife, daughter, son-in-law
and three grandchildren living in the same house. They have a
bungalow type of house made of concrete materials. It has three
bedrooms, a dining room, a living room and a bathroom.
The road in their place is not cemented. Only few part is
cemented before you reach their barangay is cemented. The place
they live is not congested. Their community is quite crowded. The
location of their house is an agricultural land that is why most of the
people there are farmers. No factories or any establishments that can
contribute to air pollution are located in their vicinity. Lung diseases
are not prevalent in their community.
B. SCHEMIC DIAGRAM ON FAMILY HEALTH-ILLNESS HISTORY
Mr. Cap ranks fifth in their family. Among his seven siblings, only
four are alive. His eldest brother died of pneumonia at an early age of
age 27. His third eldest sibling died at the age of 31 whose death was
believed to have been caused by nervous breakdown. Both Mr. Cap’s
parents already passed away. His father died because of a liver
disease at the age of 35. His mother, when she was still living,
frequently experienced episodes of allergic reactions from the food she
eats. The last time she had allergies, she experienced pruritus and
difficulty of breathing which lead to her death, as narrated by Mr. Cap.
D. Physical Examination
August 22. 2008
General appearance: Patient appears weak and is conscious to time,
place and person. He is afebrile with vital signs taken and recorded as
follows:
VS: BP= 130/70 mmHg; PR=104 bpm; RR= 20 bpm;
T=36.9 C/Axilla
Skin: Uniform in color, good skin turgor, pale, no edema, with skin
rashes
Skull: Round, symmetrical, normocephalic, absence of nodules and
masses
Face: Symmetrical, absence of nodules and masses
Eyes: Round and symmetrical, equally distributed eyelashes and
eyebrows, no discoloration on eyelids, eyelids close symmetrically,
blinks involuntarily, pale conjunctiva
Ears: Symmetrical with no discharges, auricles aligned with the outer
canthus of the eye
Nose: Symmetrical and straight, both nares are patent, no tenderness
Mouth: Dry and pale lips
Neck: With palpable modules on the left side of the neck,
jugular veins are not distended, neck muscles are equal in size
Chest/Lungs: Has symmetrical chest expansion, presence of rales
on both lung fields upon auscultation
Abdomen: Slightly globular in shape, with 18 bowel sounds per
minute, presence of resonance upon percussion
Extremities: Equal in size and length, absence of edema, both lower
and upper extremities move with coordination, with pale nailbeds
Radiology Date Chest Radiography Nodule- haze Normal lung The result shows that
Chest (PA) Ordered : or x-ray yields densities are fields, cardiac patient are
August 17, information about evident in the size, congruent to the
2008 the pulmonary, right lung with mediastinal diagnosis of
cardiac and skeletal traction of the structures, pneumonia
systems. trachea thoracic size,
Date rightwards and ribs and
Resulted: Evaluate known or right hemi diaphragm
August 17, suspected diaphragm
2008 pulmonary disorders upwards. The
and cardiovascular right apical
disorders. pleuralis
thickened. Hazy
Monitor resolution, densities are like
progression or wise seen in the
maintenance of the left lungs base.
disease. Heart is not
enlarged body
thorax is
unremarkable.
Nursing Responsibilities
Prior to the Procedure
Coplete Blood
Count
Hematocrit Date Measures the .42 .40-54 The result shows that
Ordered : concentration of the hematocrit is
August 17, WBC within the within the normal
2008 blood volume. It is suggesting that has
used to aid less chance of
diagnosis abnormal developing
Date states of hemmorhage.
Resulted: dehydration,
August 18, polycythemia and
2008 anemia
2am
Monitor the
response on
reaction to the
Segmenters drugs of the patient 0.62 0.66 -0.70
This indicates that
the body is has low
A type of neutrophil, capacity to fight
its primary function against invading
RBC is in phagocytosis. 118 118-140 microorganisms.
Measures blood
glucose regardless
of when you last The result is within
eat. the normal range
Nursing Responsibilities
Date
Resulted:
August 18,
2008 The result is within
5 am the normal range
Cholesterol 130.0 150-250
To test the total 3.4 3.4-6.48
amount of fatty
substance in the
blood
Helps in building up
cells and produce
hormones
Nursing Responsibilities
Put on gloves.
After cleaning the venipuncture site with an alcohol swab, clean it
again with a povidone-iodine swab, starting at the site and working
outward in a circular motion. Wait at least 1 minute for the skin to dry,
and then remove the residual iodine with an alcohol swab.
Apply the tourniquet.
Perform a venipuncture and draw 7 ml.
Monitor fluid
imbalance Sp Gravity : Sp Gravity is within
1.015 1.05-1.030 the normal range
Sputum AFB
This indicates that
This test is used to there is absence of
identify pathogenic pathogenic
organisms to microorganisms that
Date determine whether can cause diseases
Ordered : malignant cells are such as PTB.
August 17, present Negative
2008 Negative
Negative
Negative
Date
Resulted:
August 23,
2008
August 24,
2008
August 25,
2008
Nursing Responsibilities for Urinalysis
Inform the patient that the test is used to assist in the diagnosis of
renal diseases and as an indication of inflammatory diseases.
Obtain a history of the patient’s genitourinary, surgical procedures and
other diagnostic procedures.
Obtain a list of medication the patient is taking.
Review the procedure with the patient.
There are no food, fluid or medication restrictions, unless by medical
direction.
Instruct the patient to thoroughly wash his hands, cleanse the meatus,
void a small amount in the toilet and void directly into the specimen
container.
Promptly transport the specimen to the laboratory for processing and
analysis.
Inform the patient that the test is used to obtain analysis to identify
pathogenic organisms and to determine whether malignant cells are
present
Obtain a list of medication the patient is taking.
Review the procedure with the patient.
There are no food, fluid or medication restrictions, unless by medical
direction.
Take the test early in the morning
Instruct the patient to clear the nose and throat and rinse the mouth to
decrease contamination of the sputum.
Instruct the patient to inhale and exhale two times then inhale again
and cough rather than spit, using the diaphragm and expectorates into
a sterile container
Promptly transport the specimen to the laboratory for processing and
analysis.
Fecalysis Date Fecalysis aids in this Color : Brown Brown The result shows that
Ordered : evaluation of the stool have a
August 17, digestive efficiency normal color
2008 and the integrity of
the stomach and
intestines. Consistency : Bulky The result shows that
Soft the consistency is
Date normal
Resulted: Used as a screening
August 18, or diagnostic tool Intertinal
2008 because its can Parasites: Negative The results indicates
7:20 am identify substance that there are no ova
present in, the feces Negative or parasites present
such as ova and
parasites so that
appropriate
treatment can be
ordered.
Nursing Responsibilities
Prior to the Procedure
• Provide privacy
• Decrease discomforts and anxiety allow adequate time
• Instruct the patient’s significant others to put the specimen on the
container
• Collect stool specimen
Ensure that the specimen labelled and laboratory acquisition form are
filed out correctly
Send the specimen to the laboratory at once
Document what you have done
III. ANATOMY AND PHYSIOLOGY
Respiratory System
The respiratory centers in the brain stem (pons and medulla) control
respiration's rhythm, rate, and depth. Primary controlling factors include 1)
the concentration of carbon dioxide in the blood (high CO2 concentrations
initiate deeper, more rapid breathing) and 2) air pressure within lung tissue.
Expansion of the lungs stimulates nerve receptors (vagus nerve X) to signal
the brain to "turn off" inspiration. When the lungs collapse, the receptors give
the "turn on" signal, termed the Hering-Breuer inspiratory reflex. Other
regulators are: 3) an increase in blood pressure, which slows down
respiration; 4) a drop in blood acidity, which stimulates respiration; and 5) a
sudden drop in blood pressure, which increases the rate and depth of
respiration. Voluntary controls -- "holding one's breath" -- can also affect
respiration, but not indefinitely. Carbon dioxide build-up soon forces an
automatic start-up.
The two lungs, one on the right and one on the left, are the body's
major respiratory organs. Each lung is divided into upper and lower lobes,
although the upper lobe of the right lung contains a third subdivision known
as the right middle lobe. The right lung is larger and heavier than the left
lung, which is somewhat smaller in size because of the predominately left-
side position of the heart.
A clear, thin, shiny coating -- the pleura -- envelopes the lungs. The
inner, visceral layer of the pleura attaches to the lungs; the outer, parietal
layer attaches to the chest wall (thorax). Pleural fluid holds both layers in
place, in a manner similar to two microscope slides that are wet and stuck
together. The lungs are separated from each other by the mediastinum, an
area that contains the heart and its large vessels, the trachea (windpipe),
esophagus, thymus, and lymph nodes. The diaphragm, the muscle that
contracts and relaxes in breathing, separates the thoracic cavity from the
abdominal cavity.
The chart of the respiratory system shows the intricate structures
needed for breathing. Breathing is the process by which oxygen in the air is
brought into the lungs and into close contact with the blood, which absorbs it
and carries it to all parts of the body. At the same time the blood gives up
waste matter (carbon dioxide), which is carried out of the lungs when air is
breathed out.
1. The SINUSES (frontal, maxillary, and sphenoidal) are hollow spaces in the
bones of the head. Small openings connect them to the nose. The functions
they serve include helping to regulate the temperature and humidity of air
breathed in, as well as to lighten the bone structure of the head and to give
resonance to the voice.
2. The NOSE (nasal cavity) is the preferred entrance for outside air into the
respiratory system. The hairs that line the wall are part of the air-cleaning
system.
3. Air also enter through the MOUTH (oral cavity), especially in people who
have a mouth-breathing habit or whose nasal passages may be temporarily
obstructed, as by a cold or during heavy exercise.
4. The ADENOIDS are lymph tissue at the top of the throat. When they
enlarge and interfere with breathing, they may be removed. The lymph
system, consisting of nodes (knots of cells) and connecting vessels, carries
fluid throughout the body. This system helps to resist body infection by
filtering out foreign matter, including germs, and producing cells
(lymphocytes) to fight them.
5. The TONSILS are lymph nodes in the wall of the throat (pharynx) that often
become infected. They are part of the germ-fighting system of the body.
6. The THROAT (pharynx) collects incoming air from the nose and mouth and
passes it downward to the windpipe (trachea).
7. The EPIGLOTTIS is a flap of tissue that guards the entrance to the windpipe
(trachea), closing when anything is swallowed that should go into the
esophagus and stomach.
8. The VOICE BOX (larynx) contains the vocal chords. It is the place where
moving air being breathed in and out creates voice sounds.
9. The ESOPHAGUS is the passage leading from the mouth and throat to the
stomach.
10. The WINDPIPE (trachea) is the passage leading from the throat (pharynx)
to the lungs.
11. The LYMPH NODES of the lungs are found against the walls of the
bronchial tubes and windpipe.
12. The RIBS are bones supporting and protecting the chest cavity. They
move to a limited degree, helping the lungs to expand and contract.
13. The windpipe divides into the two main BRONCHIAL TUBES, one for each
lung, which subdivide into each lobe of the lungs. These, in turn, subdivide
further.
14. The right lung is divided into three LOBES, or sections. Each lobe is like a
balloon filled with sponge-like tissue. Air moves in and out through one
opening -- a branch of the bronchial tube.
16. The PLEURA are the two membranes, actually one continuous one folded
on itself, that surround each lobe of the lungs and separate the lungs from
the chest wall.
17. The bronchial tubes are lines with CILIA (like very small hairs) that have a
wave-like motion. This motion carried MUCUS (sticky phlegm or liquid)
upward and out into the throat, where it is either coughed up or swallowed.
The mucus catches and holds much of the dust, germs, and other unwanted
matte that has invaded the lungs. You get rid of this matter when you cough,
sneeze, clear your throat or swallow.
18. The DIAPHRAGM is the strong wall of muscle that separates the chest
cavity from the abdominal cavity. By moving downward, it creates suction in
the chest to draw in air and expand the lungs.
19. The smallest subdivisions of the bronchial tubes are called BRONCHIOLES,
at the end of which are the air sacs or alveoli (plural of alveolus).
20. The ALVEOLI are the very small air sacs that are the destination of air
breathed in. The CAPILLARIES are blood vessels that are imbedded in the
walls of the alveoli. Blood passes through the capillaries, brought to them by
the PULMONARY ARTERY and taken away by the PULMONARY VEIN. While in
the capillaries the blood gives off carbon dioxide through the capillary wall
into the alveoli and takes up oxygen from the air in the alveoli.
Air Distribution
On inspiration, air enters the body through the nose and the mouth.
Nasal hairs and mucosa (mucus) filter out dust particles and bacteria and
warm and moisten the air. Less warming, filtering, and humidification occur
when air is inspired through the mouth.
Air travels down the throat, or pharynx, where two openings exist, one
into the esophagus for passage of food, and the other into the larynx (voice
box) and trachea (windpipe) for continued airflow. When food is swallowed,
the opening of the larynx (the epiglottis) automatically closes, preventing
food from being inhaled. When air is inspired, the walls of the esophagus are
collapsed, preventing air from entering the stomach. The larynx, which also
contain the vocal cords, is lined with mucus that further warms and
humidifies the air.
Air continues continues down the trachea, which branches into the
right and left bronchi. The main-stem bronchi divide into smaller bronchi,
then into even smaller tubes called bronchioles. The bronchial structures
contain hair-like, epithelial projections, called cilia, that beat rythmically to
sweep debris out of the lungs toward the pharynx for expulsion. Once in the
bronchioles, the air is at body temperature, contains 100% humidity, and is
(hopefully) completely filtered.
As oxygen diffuses into the plasma, hemoglobin in the red blood cell
picks up the oxygen, permitting more to flow into the plasma. The oxygen-
carrying capacity of hemoglobin allows the blood to carry over 70 times more
oxygen than if the oxygen were simply dissolved in the plasma alone.
Therefore, the total oxygen uptake depends on: 1) the difference in oxygen
concentration between the blood and alveoli, 2) the healthy functioning of
the alveoli, and 3) the rate of respiration.
Pulmonary Circulation
The air that the lungs can hold can be divided into smaller
designations called "volumes."
The amount of air a person breathes in and out at rest is called the
Tidal Volume (Vt about 500ml). During such breathing, a person could
actually take in more air or blow more out. The additional amount a person
could inhale, such as during maximum physical activity, is called the
Inspiratory Reserve Volume (IRV 3,000 ml). The additional amount a person
could exhale is called the Expiratory Reserve Volume (ERV 1,000 ml). The
Residual Volume (RV) is the amount of air that stays in the lung even after
maximum expiration.
The walls of alveoli are coated with a thin film of water & this creates a
potential problem. Water molecules, including those on the alveolar walls, are
more attracted to each other than to air, and this attraction creates a force
called surface tension. This surface tension increases as water molecules
come closer together, which is what happens when we exhale & our alveoli
become smaller (like air leaving a balloon). Potentially, surface tension could
cause alveoli to collapse and, in addition, would make it more difficult to 're-
expand' the alveoli (when you inhaled). Both of these would represent serious
problems: if alveoli collapsed they'd contain no air & no oxygen to diffuse into
the blood &, if 're-expansion' was more difficult, inhalation would be very,
very difficult if not impossible. Fortunately, our alveoli do not collapse &
inhalation is relatively easy because the lungs produce a substance called
surfactant that reduces surface tension.
Partial Pressure
The partial pressure exerted by each gas in a mixture equals the total
pressure times the fractional composition of the gas in the mixture. So, given
that total atmospheric pressure (at sea level) is about 760 mm Hg and,
further, that air is about 21% oxygen, then the partial pressure of oxygen in
the air is 0.21 times 760 mm Hg or 160 mm Hg.
The causative agent for CAP that requires hospitalization are most
frequently S. Pneumoniae, H. Influenzae, Legionella, Pseudomonas
aeruginosa and other gram-negative rods. CAP is a common illness and
can affect people of al ages. It often causes problems like breathing,
fever. Chest pain and cough. CAP occurs because the areas of the lung
which absorbed oxygen from the atmosphere become filled with fluid
and cannot work efficiently.
CAP occurs throughout the world and is the leading cause of illness
and death. CAP ranks as the fourth most common death in the United
Kingdom and sixth as the leading infectious cause of death when
combined with influenza in the United States. Overall, CAP mortality rate
range from less than 1% to 9% for those managed as out-patient, but
increase to 50% for those requiring ICU management ( Retrieved at
www. Medscape.com/viewarticle/475218 accessed on August 29, 2008
10:20 pm) The Global burden of the disease study publish by the World
Health Organization ranks pneumonia as the third leading cause of
mortality. Ass of 2002there were 3.8 million or 6.8% deaths out of the
6.1 billion total estimated population (Brunner, 2008)
b. Race
African- American has higher rates of Community Acquired
pneumonia than among whites.
c. Gender
CAP is most common among men than in women due to their
lifestyle such as smoking and drinking.
d. Seasonality
It is most prevalent during winter and spring, where Upper
Respiratory Tract infections are frequent.
a. Lifestyle
CAP can occur with people who are smoking, 2nd hand smokers
and alcohol abuse
b. Occupation
People who are expose in microorganisms especially in the
community. Laboratories, Veterinarians clinics and other
institution involving microorganisms.
c. Hygiene
Those that have a poor hygiene, improper hand washing,
perineal care, and preparing foods.
e. Crackles
Due to lung congestion or consolidation
f. Wheezes
Due to accumulation of secretions the airway becomes narrowed
g. Dyspnea, cyanosis
Due to the interference in oxygen and carbon dioxide exchange
that caused hypoxemia
h. Bacteremia
The invasion of microorganisms in the body
i. Cough
Brings up a greenish and yellowish mucous due to the bacterial
invasion
Inhalation of microorganisms
Activation of the upper airway defense mechanism, cough reflex, mucociliary clearance and nasopharyngeal
defense
Inhalation of microorganisms
Malaise
(Aug.17-23’08)
V. THE PATIENT AND HIS CARE
A.MEDICAL MANAGEMENT
a. Intravenous Fluids
Medical Date ordered
General Indications Client’s response
Management/Treatm Date performed
Description or purpose to treatment
ent Date changed
Regulate as ordered.
→ Sit upright so that the air gets deep into his lungs.
Generic name: DO: 8-17-8 IV, 750mg TID q3 (-) General action: Lower Patient complied woth
Cefuroxime DP: 8-17 8 ANST Antiinfective respiratory tract the doctors order and
Brand name: 8-23-8 Mechanism of infections due there are no
Zinacef DC: 8-24-8 action: to undesirable effect
Binds to s.pneumoniae experienced by the
bacterial cell patient.
wall
membrane
causing cell
death.
Nursing Responsibilities
Prior to the procedure:
Ask the patients name, verify the physicians order.
Generic DO: 8-17-8 Neb. (inhalation) q6 General action: Treatment of Patient complied with
name: DP: 8-17 8 Cholinergic COPD in those the doctors order and
Ipratropium 8-18-8 blocking drug who are on was relieved of
bromide 8-19-8 and regular aerosol. dyspnea.
Brand name: 8-20-8 sympathomimeti Bronchodilator
Combivent, 8-21-8 c therapy and
Duoneb 8-22-8 who require a
8-23-8 Mechanism of second
8-24-8 action: bronchodilator.
8-25-8 Ipratropium is an
anticholinergic
drug that acts to
inhibit the effect
of acetylcholine
following vagal
nerve
stimulation. This
results in
bronchodilation
which is
primarily a local,
site specific
effect. Albuterol
is a beta 2
adrenergic
agonist that also
causes
bronchodilation.
Nursing Responsibilities
Prior to the procedure:
Ask the patients name, verify the physicians order.
→ Sit upright so that the air gets deep into his lungs.
Generic DO: 8-17-8 PO, 500mg tab General It relieves Patient complied
name: DP: 8-17 8 q4 RTC action: pain and with the doctor’s
Acetaminoph Analgesic reduces order and the
en and Anti- fever. patient’s
Brand name: pyretics temperature
Paracetamol decreases.
Mechanism
of action:
Inhibits the
synthesis of
prostaglandi
n that may
serve as
mediators of
pain and
fever,
primarily in
the CNS.
Have no
significant
anti-
inflammator
y properties
or GI
toxicity.
Nursing Responsibilities
Prior to the procedure:
Ask the patients name, verify the physicians order.
Generic DO: 8-17-8 – PO, 1 tab for General Symptomatic Patient complied
name: 8-25-8 loose stool action: relief of acute with the doctor’s
Loperamide DP: 8-22 8 Anti- non-specific order and was
Hydrochlorid diarrheal diarrhea relieved from
e associated diarrhea.
Brand Mechanism with
name: of action: inflammatory
Imodium Slows bowel
intestinal disease.
motility by
acting on the
nerve
endings
and/or
intraneural
ganglia
embedded in
the intestinal
wall. The
prolonged
retention of
the feces in
the intestine
results in
reducing the
volume of
the stools,
increasing
viscosity and
decreasing
fluid and
electrolyte
loss.
Nursing Responsibilities
Prior to the procedure:
Ask the patients name, verify the physicians order.
Generic name: DO: 8-17-8 PO, 1 tab TID General action: For acute cough Patient complied with
Butamirate DP: 8-17-8 Cough of any etiology/ the doctor’s order and
citrate 8-18-8 Suppresants Cough was relieved from
Brand name: 8-19-8 associated with cough.
Sinecod forte Date Mechanism of thickened
discontinued: action: mucus and
8-20-8 Butamirate impaired mucus
citrate belongs transport.
to the anti
cough
medicines of
central action.
Sinecod exerts
expectorant,
moderate
bronchodilation
, and
inflammatory
action. It also
increases the
spirometery
indexes and
blood
oxygenation.
Nursing Responsibilities
Prior to the procedure:
Ask the patients name, verify the physicians order.
Generic DO: 8-20-8 PO, 500mg/cap General Acute and Patient complied
name: DP: 8-20-8 TID action: chronic with the doctor’s
Carbocistein 8-21-8 Mucolytics disorders of order and his
e 8-22-8 respiratory secretions partially
Brand 8-23-8 Mechanism tract loosen.
name: 8-24-8 of action: associated
Abluent 8-25-8 Its major with
action is on excessive
the mucous.
metabolism
of mucus
producing
cells. It
reduces or
prevents
bronchial
inflammation
and
bronchospas
m.
Nursing Responsibilities
Prior to the procedure:
Ask the patients name, verify the physicians order.
Generic DO: 8-21-8 IV, 20mg now, General For acute Patient complied
name: DP: 8-21-8 then q12 with bp action: pulmonary with the doctor’s
Furosemide 8-22-8 precaution Loop diuretic edema. order.
Brand 8-23-8
name: 8-24-8 Mechanism Upon taking the
Lasix of action: drug, undesirable
Inhibits the effects were not
readsorption experienced.
of sadium
and chloride
from the loop
Henle and
distal renal
tubule.Increa
ses renal
excretion of
water,
sodium,
chloride,
magnesium,
hydrogen
and calcium.
Effectiveness
persists in
impaired
renal
function.
Nursing Responsibilities
Prior to the procedure:
Ask the patients name, verify the physicians order.
Generic DO: 8-21-8 PO, 500mg tab, 1 General For Patient complied
name: DP: 8-21-8 tab OD x 3 days action: pneumonia, with the doctor’s
Azithromyci 8-22-8 Antibiotic, and lower order.
n 8-23-8 macrolide respiratory
Brand tract Upon taking the
name: Mechanism infections. drug, undesirable
Zithromax of action: effects were not
A macrolide experienced such
derived from as hypersensitivity
erythromycin reactions and GI
. Acts by disturbances.
binding to
the p site of
the 50 s
ribosomal
subunit and
may inhibit
RNA
dependent
protein
synthesis by
stimulating
the
dissociation
of peptidyl t-
RNA from
ribosomes.
Nursing Responsibilities
Prior to the procedure:
Ask the patients name, verify the physicians order.
Generic name: DO: 8-24-8 IV, 1 gm q12 General action: For lower Patient complied with
Ceftriaxone DP: 8-24-8 Antibiotic, respiratory tract the doctor’s order and
Na cephalosporins infections and the occurrence of
Brand name: pneumonia. severe infection is
Chevron Mechanism of reduced. And also he
action: experienced slight
They kill the discomfort when
bacteria to infusing of the
form cell walls. medication is done.
The bacteria
therefore
break up and
die.
Nursing Responsibilities
Prior to the procedure:
Ask the patients name, verify the physicians order.
Generic DO: 8-24-8 PO, 1 capsule General action: Prophylaxis Patient complied
name: DP: 8-24-8 TID Sympathomim and with the doctor’s
Albuterol 8-25-8 etic treatment of order and
Brand bronchospas demonstrated
name: Mechanism of m due to improvement in
Ventolin action: reversible breathing pattern.
Stimulates obstructive
beta-2 airway
receptors of disease.
the bronchi,
leading to
bronchodilatio
n.
Nursing Responsibilities
Prior to the procedure:
Ask the patients name, verify the physicians order.
Date
ordered
Type Client’s response
Date General Indications or Specific foods
Of and/or reaction to
performed Description purpose taken
Diet the diet
Date
changed
Soft Diet DO: 8-17-8 The texture of food To rest the GI Water, grapes, Patient complied with
DP: 8-17-8 is soft. It can be tract of the gruel the doctor’s order.
8-18-8 nutritionally patient.
8-19-8 adequate, but
8-20-8 prophylactic
8-21-8 supplementation of
8-22-8 diets with vitamins
8-23-8 and minerals is
8-24-8 recommended if for
8-25-8 long term use.
Nursing responsibilities:
Prior to the procedure:
Check the doctor’s order about the diet.
Identify the patient & instruct SO about the diet.
During:
Give foods in small frequent meals to check for tolerance.
Assist patient when eating & provide comfort measures.
Observe for aspiration precaution.
Avoid interruption while eating.
After:
Encourage the patient to follow the diet regimen.
Assess patient’s condition on how to respond to the diet.
Date
ordered
Type Client’s response
Date General Indications Specific
Of and/or reaction
performed Description or purpose foods taken
Activity to the diet
Date
changed
S= patient Ineffective Community- Short Term > Assess > Abnormal Short
may Airway Acquired : respiratory breathing patterns Term :
verbalize Clearance Pneumonia is the status: breath may signal
“magkasaki related to inflammation of After 5 sounds, worsening of The patient
t ku retained the lung hours of respiratory rate, condition: flaring of shall be
papalwal secretions in parenchyma Nursing oxygen nostrils indicate a able to
ing plema the bronchi when the Intervention saturation, note significant decline in expectorate
pag ( increased offending s, the abnormalities respiratory status: mucous as
manguku thick organism patient will such as dyspnea, assessment evidenced
ku.” mucous reaches the expectorate presence of establishes baseline by
secretions) alveoli via mucous as cyanosis, use of and monitor productive
and lung droplets or saliva evidenced accessory response to cough
O=Patient inflammatio in whi8ch goblet by muscles, flaring interventions effective
Manifeste n leading to cells produces an productive of nostrils coughing
d the accumulatio outpouring fluid cough, and
following : n of mucous into the alveoli. effective > Assess anxiety > Being unstable to breathing
in the The organisms coughing and reassure breath causes exercise
>appears alveoli multiply in the and patient ć anxiety and fear:
weak serous fluid and breathing presence the patient needs a
the infection is exercise calming presence:
>pale spread. The anxiety increases
palpebral organisms the demand for
conjunctiva damage the host Long oxygen
by their Term : > Place patient Long Term
>ć rales on overwhelming in high fowler’s > Maximize chest :
both lung growth and After 2 days position and excursion and
lobes upon interference with of Nursing support ć subsequent The patient
will
chest lung function Intervention overbed table as movement of air
maintain
auscultatio leading to s, the needed. airway
patency as
n massive patient will
evidenced
accumulation of maintain > Encourage by clear
breath
>ć difficulty mucus. airway expectoration of > Thickened
sounds,
of Disruption of the patency as secretions and secretions of Cap re absence of
dyspnea,
breathing mechanical evidenced assess the more likely to
etc.
defenses of by clear viscosity amount occlude the airway:
> shortness cough and ciliary breath and color of making this
of breath motility leads to sounds, secretions observation would
the colonization absence of allow for
> ć non- of the lungs and dyspnea, implementation if
productive accumulation of etc. measures to thin
cough secretions in the and loosen the
alveoli and > Assist the secretions
Patient bronchi leading patient ć
may to ineffective coughing and > Mobilizes
manifest airway clearance deep breathing secretions and
the as evidence by prevent atelectasis
following : non-productive > Increase fluid
cough etc. intake
>decreased alveolar > Assists with
oxygen
exudates tend to liquefying secretions
saturation
consolidate, and enhancing
> Cyanosis
increasingly ability to clear
>Tachypne
a difficult to > Provide for airways
expectorate. periods of rest
>Abnormal
blood gases and activity, > Decrease demand
(decreased
assisting ć for oxygen
O2,
Increased devices as
CO2)
needed
>
Restlessnes
> Elevate head
s
of bed/ change of
>ć
Orthopnea position every 2 > To maintain an
hours open airway and to
> Flaring of
nostrils take advantage of
gravity decreasing
pressure on the
diaphragm and
enhancing drainage
> Assist of secretions.
respiratory
therapist ć the >This causes
administration of bronchiodilation to
nebulizer ease breathing
> Establish
intravenous > Ensures a route
access as for rapid- acting
ordered medications
>hypoxia
(Confusion,
restlessness,
decreased
vital
capacity)
Problem No. 4 Hyperthermia
Assessment Nursing Scientific Planning Nursing Rationale Evaluation
Diagnosis Explanation Intervention
S= patient Hyperther CAP is the Short Term > Monitor body >To have a baseline Short
may mia inflammation of : core temperature data Term :
verbalize the lung The
“Mapali ku parenchyma due After 4 >Note presence >Evaporation is patient’s
panandman . to offending hours of or absence of decreased by body
” organisms, Nursing sweating as body environmental temperatur
inflammatory Intervention attempts to factors of high e shall have
lung response s, the increase heat humidity and high decreased
O=Patient will be patient’s loss by ambient from 38oC
Manifested stimulated body evaporation, temperature as well to 37oC.
the leading to the temperature conduction, as the body factors
following : release of will diffusion producing loss of
chemical decrease ability to sweat
>flushed skin mediators that from 38oC to
would increase 37oC. >Promote heat loss
>skin is blood flow to the > promote by radiation,
warm to lung tissues surface cooling conduction and
touch leading to by means of evaporation
erythema, loose clothing; Long Term
> increased swelling, pain, Long cool :
RR and increased Term : environment/fan;
The patient
body cool/tepid
shall have
> temperature that After 24 sponge bath maintained
a normal
Diaphoresis would reset the hours of local icepack
body
hypothalamus Nursing especially in the temperatur
e during
Patient may which is the Intervention axilla and groin >indicates need for
hospitalizati
manifest major center for s, the prompt ons and be
free from
the regulation of patient will > Review signs interventions
any
following : body maintain a and symptoms of complicatio
ns of
temperature normal body hyperthermia
pneumonia.
>Convulsions temperature > to increase
during >Encourage the resistance
>
Hypotension hospitalizati patient to take
ons and be vitamin C in the
>Fluid and
electrolyte free from diet such as
imbalance
any citrus fruits, etc.
complicatio > To prevent
ns of >Discuss dehydration
pneumonia. importance of
adequate fluid
intake
>To reduce
>Maintain bed metabolic demands/
rest oxygen
consumption
S= patient Activity The onset of Short Term > Obtain >Helps to determine Short
may Intolerance pneumonia is : subjective data the effects of Term :
verbalize related to generally marked from patient pneumonia on the
“magkasakit increased by fever, After 4 regarding normal patient’s ability to The patient
ku oxygen dyspnea, and hours of activities prior to be active. shall be
mangisnawa demand shortness of Nursing onset of able to
ampo with breath and easy Intervention pneumonia; perform
mimingal ku activity and fatigability that s, the monitor for >If increased activities of
gan hypoxia may lead to patient is labored physical activity daily living
maglakad (lack of inability to able to breathing, causes shortness of without
kumu.” oxygen perform perform fatigue and breath, activity shortness
supply with activities of daily activities of exhaustion. should be reduced of breath
O=Patient oxygen living. daily living until oxygenation is such as
Manifested demand) without > Reduce level adequate. doing
the Due to the shortness of of activity as personal
following : accumulation of breath such required in hygiene,
thick tenacious as doing response to > Conserves energy etc.
> appears mucous in the personal shortness of and reduces oxygen
weak alveoli altering hygiene, breath. demand patients
gas exchange etc. with pneumonia lack
> poor skin ( oxygen and enough oxygen
turgor carbon dioxide) > Assist with reserves to perform
between the activities as activities Long Term
>pale nail alveoli And needed. independently. :
beds Long
The patient
Term : >It conserves
shall states
>Pace activities energy. that he is
comfortable
> easy After 24 and encourage
with
fatigability hours of periods of rest activity
performanc
Nursing and activity > Use the result to
e and
Intervention during the day. indicate when the shortness
of breath is
> non- s, the activity may be
improved
productive patient increased or following
cessation of
cough states that decreased.
activity,
he is > Monitor VS and and the
patient’s
>shortness comfortable oxygen > Activities should
RR returns
of breath with activity saturation before be increased to baseline
within 5
during performanc and after gradually, as
minutes.
activities e and activity. tolerated, to avoid
shortness of over taxing the
> RR of 38 breath is patient.
cpm, with improved > Gradually
shallow, following increase activity
rapid cessation of as tolerated and > Physical activity
breathing activity, and share guidelines increases endurance
the patient’s for progression and stamina;
RR returns with patient. following
Patient to baseline pneumonia, return
may within 5 to normal activity
manifest minutes. > Discuss with may take time.
the the patients
following : activities that
would be > This indicate
>Inability to appropriate once intolerance to
perform
at home that activity and the
physical
activities would be within level of activity
the patient’s should be
> level I activity evaluated.
functional
tolerance.
level
classificatio
n ( walk,
regular
phase, on > Iron has a role in
level
> Inform the oxygen transport
indefinitely;
one flight or patient to stop and increases
more but
any activity that energy level.
more
shortness of produces
breath than
shortness of >To prevent
normal)
breath. injuries.
>labored
breathing
> Encourage >Improves
>physical
intake of foods oxygenation and
exhaustion
high in iron and provides oxygen
>oxygen
good source of reserves to be used
saturation
less than energy such as with increased
90%
lean meat, demand.
legumes which
phy
are rich in
protein.
Admission Discharged
17 25
18 19 20 21 22 23 24
NURSING PROBLEMS
Ineffective Airway Φ
Clearance Φ
Impaired Gas Exchange Φ
Ineffective breathing Φ Φ
Pattern Φ Φ Φ Φ Φ Φ Φ
Hyperthermia
Activity Intolerance
38.7 37.6 36.2 36.4 36.3 36.9 36.8 36.6 36.4
VITAL SIGNS 90 80 79 76 90 90 95 80 82
Temperature 38 24 24 20 26 24 21 20 20
Pulse Rate 120/80 120/70 120/70 110/80 120/70 10/70 110/80 110/70 130/10
Respiratory Rate 0
Blood Pressure
Φ
LABORATORY / Φ Φ
DIAGNOSIS Φ
Chest X-ray Φ
Sputum AFB Φ
Φ
Blood Chemistry Φ
Complete BLood
Count(CBC)
Urinalysis Φ Φ Φ Φ
Fecalysis Φ Φ
Φ Φ Φ
MEDICAL MANAGEMENT Φ Φ Φ Φ Φ Φ Φ Φ
PNSS 1L x 8 hours Φ Φ Φ Φ Φ
D5LRS 1L x 8 hours
D5NM 1L x 8 hours
Nebulization Φ Φ Φ Φ Φ Φ Φ
O2 Therapy Φ Φ Φ Φ Φ Φ Φ Φ
Φ Φ Φ
DRUGS
Cefuroxime 750 mg TID Φ
Combivent neb q 6 hours
Paracetamol 500mg Tab Φ Φ Φ Φ Φ
q 4 RTC Φ
Loperamide 1 Tab for Φ Φ Φ Φ
loose stool
Carbocesteine 500mg 1 Φ Φ Φ
cap TID
Furosemide 20 mg IV Φ
now then q 12 ć BP
precaution Φ Φ Φ
Azithromycin 500 mg Φ
Tab 1 tab OD x 3 days Φ
Ceftriaxone 1gm IV q 12
ANST (-)
Sinecod 1 Tab TID Φ Φ Φ Φ Φ Φ Φ Φ
Ventoline Expectorant Φ
Capsule 1 cap TID
DIET
Soft
2 DISCHARGE PLANNING
a. General Condition of Client Upon Discharge
In the case of Mr. CAP, the disease was caused primarily by personal
and environmental factors such as cigarette smoking, lack of vaccinations
during childhood years, job exposure to pathogens, and other factors. This
lead to the development of the disease and lack of action on the part of the
caretakers. Mr. CAP manifested difficulty of breathing, productive cough,
crackles on both lung fields, wheezing and angina pectoris
The result played an essential part on the part of the patient. Since the
family has no information about the signs and symptoms of the disease they
will now be aware on those things in order to prevent this illness.
Years have passed and still these diseases are present especially with
developing countries. The solution is simple but needs great discipline to
make it concrete. A clean surrounding will definitely boost our chances of
invading such disease condition.
RECOMMENDATIONS
Information dissemination is the most important factor in this study.
In the ongoing battle against the pneumonia and its different types, the
turning point is the ability of the people to recognize the signs and
symptoms of the disease as well as the ability of the existing health sector
to respond immediately about the incidence. With these, the group
formulated the following recommendations in order to maternalize this
vision of emancipation from Community-Acquired Pneumonia.
Since family members are the one who are always in contact with
the other members of the family, they are the better position of
monitoring the health of everyone. They should promote then health of
each member so as o prevent any progression of the disease like
Community- Acquired Disease. Acting in a swift manner regarding signs
and symptoms of the disease, is very important. This may empower
everyone and fulfil the goal of the Department of Health which is “Health
in the hands of the people by 2020.”
VIII. BIBLIOGRAPHY
BOOK SOURCES:
DeglinHopfer, Valierant, Nazorel. Davis’ Drug Guide for Nurses: 10th Edition.
F.A. Davis Company, Philadelphia. 2007
Doenges, et. al. Nurses Pocket Guide: Diagnosis, Prioritized Interactions and
Rationales: 10th Edition. F.A. Davis Company, Philadelphia
McCance, et. al. Pathophysiology: The Biologic Basis for Disease Adul and
Children: 4th Edition. 2002
Schilling, et. al. Nursing Process Approach To Excellent Care: 4the Edition.
Lippincott Williams and Wilkins. 2006
ONLINE SOURCES:
http://www.medscape.com/viewarticle/475218
http://www.emedicine.com/MEDtopic3162.htm
http://www.utmedicalcenter.org/encyclopedia/1/000145.htm
http://www.mims.com/
http://www.doh.gov.ph/data_stat/html/mortality.htm
http://www.wrongdiagnosis.com/p/pneumonia/prevalenve.htmtypes
http://www.lungusa.org/site/c.dvLUK900E/b.22576/K.7FFF/Human_Respiratory
_System.htm