TABLE OF CONTENTS

Page

I. Introduction

A. Overview of the Case 2

B. Objective of the Study 4

C. Scope and Limitation of the Study 4

II. Health History

A. Profile of Patient 5

B. Family and Personal Health History 6

C. History of Present Illness 6

D. Chief Complain 6

III. Developmental Data 7

IV. Medical Management

A. Medical Orders and Laboratory Results 10

B. Drug Study 15

V. Pathophysiology with Anatomy and Physiology 17

VI. Nursing Assessment

(System Review and Nursing Assessment II) 22

VII. Nursing Management

A. Ideal Nursing Management (NCP) 28

B. Actual Nursing Management (SOAPIE) 28

VIII. Referrals and Follow-up 31

IX. Evaluation and Implications 32

X. Documentation

A. Documentation of evidence of care for 1 week rotation

B. Organization/ Grammar/ Bibliography 33

XI. Rating Scale 34

1

I. INTRODUCTION

A. Overview of the Case

Pneumonia is an

inflammatory illness of the lung.[1]

Frequently, it is described as lung

parenchyma/alveolar (microscopic

air-filled sacs of the lung

responsible for absorbing oxygen

from the atmosphere) inflammation

and (abnormal) alveolar filling with

fluid. Pneumonia can result from a

variety of causes, including

infection with bacteria, viruses,

fungi, or parasites, and chemical or

physical injury to the lungs. Its cause may also be officially described as idiopathic, that

is unknown, when infectious causes have been excluded.

Often, pneumonia is the final illness in people who have other serious, chronic

diseases. It is the sixth most common cause of death overall, and the most common

fatal infection acquired in hospitals. In developing countries, pneumonia is either the

leading cause of death or second only to dehydration from severe diarrhea.

2

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

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

acquired pneumonia), in the hospital (hospital-acquired pneumonia), or in some other

institutional setting, such as a nursing home (institution-acquired pneumonia). The

setting often helps determine what infecting organism is responsible for the pneumonia.

For example, community-acquired pneumonia is more likely to stem from infection with

the gram-positive bacterium Streptococcus pneumoniae. Hospital-acquired pneumonia

is more likely to be caused by Staphylococcus aureus or a gram-negative bacterium,

such as Klebsiella pneumoniae or Pseudomonas aeruginosa. Depending on the

infecting organism, there is usually a difference in the severity of pneumonia and the

way it is treated (for example, whether with oral drugs at home or with intravenous

drugs in the hospital).

This care study presents a condition of patient in Northern Mindanao Medical

Center having a diagnosis of Community-Acquired Pneumonia, Mitral Regurgitation with

Consolidation ®; to consider Pulmonary Mass (L). This case aims to achieve a better

understanding of the patient’s condition and was made for the benefit of the student

conducting the study.

3

B. Objective of the Study

Individual care study provides goals or objectives which is necessary to serve as

an instrument in comprehensively assessing the patient’s health status and present

condition. It also focuses on the following aims:

Utilizing the nursing process in the management of patient’s health

condition and in giving quality nursing care

Obtain a complete health data that can be used in the follow-up care

Impart health teachings about necessary information pertaining to the

disease condition

Understand the course and essence of the chosen care study

Add up additional knowledge and understanding in the Nursing profession

C. Scope and Limitation of the Study

The extent of study includes the overall data gathered during the interview and

observation as claimed by the patient and her significant others. It also deals with the

several factors observed during the assessment within the span of time given. The

information gathered was the exact answers and complaints of the patient and not a

mere opinion by the student. Interventions were rendered gradually depending on the

objective assessment of the student. The following information only involves the exact

words and answers supported by the client.

4

The limitation of the study includes the place of interaction itself which was in x.

The study was completed altogether by both research and actual hands-on exposure

and interaction with the patient during the two (2) days clinical duty.

II. HEALTH HISTORY

A. Profile of the Patient

Name: x

Age: x

Sex: Male

Birth date: x

Religion: x

Civil Status: x

Nationality: Filipino

Address: x

Income and Job: 300 per day; Driver

Name of Wife: x

Date of Admission: January 26, 2008

Time of Admission: 10:00 PM

Vital Signs Assessment

Temperature: 38.3oC

Pulse Rate: 130 bpm

Respiratory Rate: 48 cpm

Blood Pressure: 90/70 mmHg

5

Height: 5 inches 6 cm

Weight: 80 kilograms

Allergy: No known allergy to food and drugs

B. Family History and Personal Health History

The xfamily resides in x. Mr. and Mrs. x have one (1) child. The couple’s income

is approximately P300 per day. The family has no heredo familial disorders that place

their health at risk. Aside from that, the most common health problems they encounter

were headache, cough, colds, stomach ache, and fever. Although they did not consult a

doctor for these conditions but they took Over the Counter Drug (OTC) such as

Mefenamic Acid, Paracetamol, and other pain relievers.

C. History of Present Illness

I month prior to admission, patient had cough with whitish phlegm, has no fever

and with absent shortness of breath.

5 days prior to admission, patient had low to moderate cough, had fever and

chills; self-medicated with Paracetamol.

4 days prior to admission, patient had cough with whitish to brownish phlegm;

with on and off fever; had shortness of breath after few meters walk.

D. Chief Complaint

A case of x, MJ, x, male, married, from x, was admitted for the first time atx Last

January 26, x due to cough and shortness of breath.

6

VI. DEVELOPMENTAL TASK

Theories of development provide a framework for thinking about human growth,

development, and learning.

Psychosocial theory

This theory combines both internal psychological factors and external social

factors. Each stage builds upon the others and focuses on a challenge (or crisis) that

must be resolved during that stage in order to move effectively into the next stage of

development. The resolution of each crisis depends upon the interaction of the

individual’s characteristics and the support provided by the social environment.

Therefore, unresolved conflicts from earlier stages may continue to affect later

development.

In case of the patient, it belongs to the Intimacy vs. Isolation stage. This stage

covers the period of early adulthood when people are exploring personal relationships.

Erikson believed it was vital that people develop close, committed relationships with

other people. Those who are successful at this step will develop relationships that are

committed and secure. Remember that each step builds on skills learned in previous

steps. Erikson believed that a strong sense of personal identity was important to

developing intimate relationships. Studies have demonstrated that those with a poor

sense of self tend to have less committed relationships and are more likely to suffer

emotional isolation, loneliness, and depression.

7

In connection to Mr. x he was committed to his work, love, and activities that is

suited for his age. As what was observed, he was not detached to personal environment

and is not withdrawn to the commitment he has.

Cognitive Development theory

On formal operational stage of cognitive development by Jean Piaget, people

develop the ability to think about abstract concepts. Skills such as logical thought,

deductive reasoning, and systematic planning also emerge during this stage. Piaget

believed that deductive logic becomes important during the formal operational stage.

Deductive logic requires the ability to use a general principle to determine a specific

outcome. This type of thinking involves hypothetical situations and is often required in

science and mathematics. While children tend to think very concretely and specifically in

earlier stages, the ability to think about abstract concepts emerges during the formal

operational stage. Instead of relying solely on previous experiences, children begin to

consider possible outcomes and consequences of actions. This type of thinking is

important in long-term planning. In earlier stages, children used trial-and-error to solve

problems. During the formal operational stage, the ability to systematically solve a

problem in a logical and methodical way emerges. Children at the formal operational

stage of cognitive development are often able to quickly plan an organized approach to

solving a problem.

With regards to Mr. x’s case, it was observed that he has reached complete

maturity and he can think and reason in abstract terms. He already developed logical

thiking and reasoning.

8

Developmental task

In Havighurst developmental task, person knows to choose his need to be made

and emotionally engaged. Has information and engages in long term planning including

educational plans. Have stable vocational goals and plans. He makes decisions

independently. Decisions fit aptitude, ability, and resources.

But as what is observed to the patient, he has not yet achieved his goals in life

basing with his occupation. The patient can make his decisions independently but

haven’t accomplished his educational plans.

Psychosexual Theory

During the final stage of psychosexual development, the individual develops a

strong sexual interest in the opposite sex. Where in earlier stages the focus was solely

on individual needs and, interest in the welfare of others grows during this stage. If the

other stages have been completed successfully, the individual should now be well

balanced, warm, and caring. The goal of this stage is to establish a balance between

the various life areas. As what was observed, the patient has a strong sexual interest

with the opposite sex. He was also able to have a balance between the different areas

of life.

9

IV. MEDICAL MANAGEMENT

A. MEDICAL ORDERS with RATIONALE

Medical Orders Rationale

10

January 26, 2008

DAT with aspiration precaution

Intake and output every shift

TPR every 4h

O2 inhalation @3L/min by nasal

cannula

Watch out and refer if persistent

SOB, cyanosis, change in

sensorium and other unusualities

Patient is allowed intake of food that he

can tolerate but with precaution to

avoid aspiration that may cause airway

obstruction

To check and note for imbalances in

the intake and output

To monitor any alterations and

deviations in patients’ vital

measurement

To provide adequate O2 supply,

minimizing the occurrence of hypoxia

To check for signs of inadequate

oxygenation and impaired gas

exchange

11

Laboratory test required:

1. CBC with platelet

2. Urinalysis

3. Serum creatinine, BUN,Na,

K

4. Sputum exam

5. Chest X-ray – PA

6. ECG 12 leads

7. CT Scan with chest contrast

Start IVF with PNSS 1L

Medications:

1. Azithromycin 500mg 1 tab

OD

2. Salbutamol 1neb + 2cc

NSS

3. Paracetamol 500mg 1 tab

q4

To check for occurrence of infection in

the body

A standard procedure; used to check

abnormalities in the renal system

To evaluate gas exchange and

alterations in body electrolytes

To identify the infecting organism,

gram (+) or gram (-) bacteria

To check the extent and pattern of

lung involvement

Helps to detect abnormalities in the

cardiovascular system

Imaging studies allows visualization of

the extent of the affected organ

To restore sodium chloride deficit and

ECF volume

To treat the underlying cause of the

disease pharmacologically

Provides a relief for airway obstruction

Medication used for relieving fever

and pain

12

January 27, 2008

Change IVF to D5W 500cc @ KVO

rate

Insert FBC-UB

Start ampicillin and tazobactam

2.25mg IVTT q8 (ANST)

Start Dopamin premix 200mg

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

q15mins BP below 90/60mmHg

Transfer to ICU

O2 sat q4

Vital signs q2 and record

Intake and output hourly refer if

less than 30cc/hr

Promotes rehydration and elimination

To measure correct urine output

To kill susceptible bacteria

A vasoconsctrictor agent that relieves

hypotension

For further evaluation and thorough

management

To check for adequate saturation of

oxyhemoglobin

To check for alterations in vital

measurements

Check for imbalances in intake and

output

13

January 28, 2008

Still for Chest CT Scan

Still for ABG

For visualization of extent of affected

area

To check for gas exchange and levels

of electrolytes in the body

January 29, 2008

Repeat CBC, Urinalysis

For serum Na, K, SGPT, SGOT

To facilitate sputum exam

Still for CT scan of the chest with

contrast

Monitor O2 saturation q2, refer if

less than 95%

To check for presence of infection and

imbalances in the renal system

To check for levels of electrolytes in

the body

To identify the infecting organism

Imaging studies allows visualization of

the affected area

To check for adequacy of saturation

of oxyhemoglobin

14

LABORATORY RESULTS

TEST RESULT REFERENCE NURSING IMPLICATION

Blood Urea Nitrogen

(BUN)

154.0 4.6-23.4 May indicate infection

Creatinine 4.17 0.6-1.2 May indicate impaired renal

function

White Blood Cell

Count

33.5 5-10 mm3 May indicate presence of

infection

Red Blood Cell

Count

3.91 4.2-5.4 May indicate Anemia

Hemoglobin Count 11.7 12-16 May indicate Anemia

Hematocrit Count 32.9 37-47 May indicate Anemia

Neutrophils 95.3 43.4-76.2 May indicate bacterial or

parasitic infection

15

B. DRUG STUDY

Generic Name of

ordered drug

Salbutamol Sulfate

Brand Name Ventolin

Date Ordered January 26, 2008

Classification Bronchodilator

Dose/Frequency/

Route

1 neb/ q6h/ steam inhalation

Mechanism of Action Relaxes bronchial smooth muscle by acting on beta2-

adrenergic receptors; improves ventilation

Specific Indication Bronchospam in patient’s with reversible obstructive airway

disease

Contraindication To patient’s hypersensitive to the drug and its components

Side Effects/Toxic

Effects

Tremor; palpitations; tachycardia; nausea and vomiting;

irritation

Nursing Precaution Perform chest tapping every after nebulization

Generic Name of

ordered drug

Paracetamol

Brand Name Biogesic

Date Ordered January 26, 2008

Classification Non-opioid analgesic;antipyretic

Dose/Frequency/

Route

500 mg/ PRN/ PO

Mechanism of Action Produces analgesic effect by blocking pain impulses, by

inhibiting prostaglandins or pain receptors sensitizers; may

relieve fever by acting in hypothalamic heat regulating center

Specific Indication For mild pain and fever

Contraindication To patient’s going long-term therapy for chronic

noncongestive angle-closure glaucoma; hyponatremia;

16

hypokalemia; hepatic impairment; adrenal gland failure’

hypechloremic acidosis

Side Effects/Toxic

Effects

Confusion; anorexia; aplastic anemia; rash; renal calculi

Nursing Precaution Report signs of F/E imbalance

Generic Name of

ordered drug

Piperacillin sodium and Tazobactam Sodium

Brand Name Zosyn

Date Ordered January 27, 2008

Classification Antibiotic

Dose/Frequency/

Route

2.25 mg/ q 8h/ IVTT

Mechanism of Action Piperacillin inhibits cell wall synthesis during microorganism

multiplication; Tazobactam increases puiperacillin

effectiveness by inactivating beta-lactamases, which

destroys penicillin

Specific Indication For moderately severe Community-Acquired Pneumonia

Contraindication To patient’s hypersensitive to the drug and its components

Side Effects/Toxic

Effects

Insomnia; hypertension; rhinitis; dyspnea; pruritus; phlebitis

to IV site

Nursing Precaution Advise patient to limit intake of sodium because piperacillin

contains 1.98 mEq of Na per gram

17

V. PATHOPHYSIOLOGY with ANATOMY AND PHYSIOLOGY

Anatomy and Physiology

In humans, the

trachea divides into the

two main bronchi that

enter the roots of the

lungs. The bronchi

continue to divide

within the lung, and

after multiple divisions,

give rise to

bronchioles. The

bronchial tree

continues branching

until it reaches the level of terminal bronchioles, which lead to alveolar sacks. Alveolar

sacs are made up of clusters of alveoli, like individual grapes within a bunch. The

individual alveoli are tightly wrapped in blood vessels, and it is here that gas exchange

actually occurs. Deoxygenated blood from the heart is pumped through the pulmonary

artery to the lungs, where oxygen diffuses into blood and is exchanged for carbon

dioxide in the hemoglobin of the erythrocytes. The oxygen-rich blood returns to the

heart via the pulmonary veins to be pumped back into systemic circulation.

18

Human lungs are located in two cavities on either side of the heart. Though

similar in appearance, the two are not identical. Both are separated into lobes, with

three lobes on the right and two on the left. The lobes are further divided into lobules,

hexagonal divisions of the lungs that are the smallest subdivision visible to the naked

eye. The connective tissue that divides lobules is often blackened in smokers and city

dwellers. The medial border of the right lung is nearly vertical, while the left lung

contains a cardiac notch. The cardiac notch is a concave impression molded to

accommodate the shape of the heart. Lungs are to a certain extent 'overbuilt' and have

a tremendous reserve volume as compared to the oxygen exchange requirements when

at rest. This is the reason that individuals can smoke for years without having a

noticeable decrease in lung function while still or moving slowly; in situations like these

only a small portion of the lungs are actually perfused with blood for gas exchange. As

oxygen requirements increase due to exercise, a greater volume of the lungs is

perfused, allowing the body to match its CO2/O2 exchange requirements.

19

20

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

Definition: Pneumonia is the inflammation of the lung parenchyma (the respiratory

bronchioles and alveoli).

Predisposing Factors:

Upper respiratory tract infection

History of smoking

Chronic disease states

Diabetes Mellitus

Cardiovascular disorders

Chronic lung disease

Renal disease

Cancer

Air pollution

Inhalation of noxious substances

Aspiration of food, liquid, or foreign or gastric materials

Residence in institutional setting

Precipitating Factors: Clinical Manifestation:

Advanced Age -- Onset of shaking shills

Tracheal intubations -- Fever

Prolonged immobility -- Cough production of rust-

Immunosuppressive therapy colored or purulent sputum

Nonfunctional immune system -- Chest pain

Malnutrition -- Limited breath sounds

Dehydration -- Fine crackles o rales heard

Target Organs: -- Dyspnea

Brain -- Cyanosis

Heart

Peritoneal cavity

Complications:

Meningitis

Endocarditis

Peritonitis

21

Via via

Colonization of alveoli or penetration of lower respiratory tract

Initiation of inflammation responseCoughFeverChills

Alveolar edema Exudates formation

DyspneaImpaired Gas ExhangeCyanosis

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

bacteria

Hypoventilation

Consolidation of Lung TissueCrackling soundsWhispered pectoriloquy

Pleuritis Bacteremia- spread to other tissues

Aspiration of Streptococcus pneumonia by oropharyngeal secretions into lungs

Inhalation of microbes after cough, sneeze, or talking

Meningitis, endocarditis, peritonitis DEATH

22

VI. NURSING ASSESSMENT:

NAMEx DATE: xVital signs: Pulse 130bpm BP: 90/70mmHg Temp 38.3°C Resp: 48 cpm INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space provided. Indicate the location of the problem in the figure using [X].

EENT[ ] impaired vision [ ] blind[ ] pain [ ] reddened [ ] drainage[ ] gums [x] hard of hearing [ ] deaf[ ] burning [ ] edema [ ] lesion of teeth assess eyes, ears, nose, throat for abnormality [x] no problemRESPIRATION[ ] asymmetric [x] tachypnea [ ] apnea [ ] rales [ x ] cough [ ] barrel chest[ ] bradypnea [ ] shallow [ ] ronchi[x] sputum [ ] diminished [x] dyspnea[ ] orthopnea [ ] labored [ ] wheezing[ ] pain [x] cyanoticasses resp. rate, rhythm, depth, patternbreath sounds, comfort [ ] no problemCARDIO VASCULAR[ ] arrhythmia [x] tachycardia [ ] numbness[ ] diminished pulses [ ] edema [ ] fatigue[ ] irregular [ ] bradycardia [ ] murmur[ ] tingling [ ] absent pulses [ ] painAssess heart sounds, rate, rhythm, pulse, bloodpressure, clearance, fluid retention, comfort[ ] no problemGASTROINTESTINAL TRACT[ ] obese [ ] distention [ ] mass[x] dysphagia [ ] rigidity [ ] painassess abdomen, bowel habits, swallowingbowel sounds, comfort [ ] no problemGENITO-URINARY AND GYNE[ ] pain [ ] urine color [ ] vaginal bleeding[ ] hematuria [ ] discharge [ ] nocturiaassess urine frequency, control, color, odor, comfort, discharge[x] no problemNEURO[ ] paralysis [x] stuporous [ ] unsteady [ ] seizures[ ] lethargic [ ] comatose [ ] vertigo [ ] tremors[ ] confused [ ] vision [ ] gripassess motor function, sensation, LOC, strengthgrip, gait, coordination, speech [ ] no problemMUSCULOSKELETAL AND SKIN[ X ] dry [ ] stiffness [ ] itching [ ] diaphoresis[x] hot [ ] drainage [ ] prosthesis [ ] swelling[ ] lesion [ ] poor turgor [X] cool [ ] flushed[ ] atrophy [ ] pain [ ] ecchymosis [ ] moist

Blurred vision

Speech pattern: A few words between noticeable breaths =Cough with sputum =tachypneic RR=48cpm Increased HR=130bpm

Hot and dry skin

With IV: D5W @KVO rate

With Foley bag catheter attached to urobag

Pale nail beds

assess mobility, motion galt, alignment, joint functionskin color, texture, turgor, integrity [ ] no problem

NURSING ASSESSMENT II

SUBJECTIVE OBJECTIVECommunication:

[ ] hearing loss Comments: “usahay” [X] visual changes blurred akong pana-aw [ ] denied pero okay ra akong

pandungog”

[ ] glasses [ ] languages[ ] contact lens [ ] hearing aid R LPupil Size 3mm- normal [ ] speech diff.Reaction PERRLA

Oxygenation:[x] dyspnea Comments: “ Galisod ko [x] smoking history ug ginhawa tapos gi-ubo 20 sticks per day pud ko.”[X] cough [x] sputum [ ] Denied

Resp. [ ] regular [x] irregularDescribe: Respiratory rate is above the normal

range; RR=48cpmR Symmetrical lung expansion with leftL Symmetrical lung expansion with right

Circulation:[ ] chest pain Comments: “ Wala may sakit [ ] leg pain sa akong kamoy ug tiil, okay[ ] numbness of ra man.” extremities [x] denied

Heart Rhythm [ ] regular [x] irregularAnkle Edema Not seen

Pulse Car. Rad. DP Fem*R + + + + L + + + + Comments: Pulses are palpable

Nutrition:Diet: Diet as Tolerated[ ] N [ ] V Comments: “ Lahi ra Character karon, ginagmay ra akong[x] recent change in kaon ug usahay dili jud ko weight, appetite gakaon.”[ ] swallowing difficulty[ ] denied

[ ] dentures [x] none

Full Partial with PatientUpper [ ] [ ] [ ]

Lower [ ] [ ] [ ]

Elimination:Usual bowel pattern [ ] urinary frequency 1x a day With FBC [ ] urgency [ ] constipation [ ] dysuriaremedy [ ] hematuria none [ ] incontinenceDate of Last BM [ ] polyuria January 26, 2008 [x] foly in place

Comments: Bowel SoundsNakalibang ko Normoactive bowel soundsganina pero Abdominal Distentiongamay ra, wala Present [ ] yes [X] nopud ko poblema Urine* (color,sa akong pag-ihi consistency, odor) Yellowish *if they are in place

24

[ ] diarrhea character [ ] deniedThe pt. has no diarrhea

MGT. OF HEALTH ILLNESS:[x] alcohol [ ] denied(amount, frequency)2 glassDrinks alcohol on occasional basis [ ] SBE Last Pap Smear N/ALMP: N/A

Briefly describe the pt.’s ability to follow treatments (diet, meds, etc.) for chronic health problems (if present).Not applicable

SKIN INTEGRITY:[ ] dry Comments: “ Dili man gakatol-[ ] itching katol akong panit.”[ ] other [x] denied

[x] dry [ ] cold [x] pale[ ] flushed [x] warm [ ] moist [ ] cyanotic* Rashes, ulcers, decubitus (describe size, location, drainage) No rashes, ulcers.

ACTIVITY/ SAFETY:[ ] convulsion Comments: “Gakalipong ko[X] dizziness kung mutindog ko. Dili [ ]limited motion kayo ko makalihok.” of joints Limitation in Ability to [ ] ambulate[ ] bathe self[ ] other[x] denied

[x] LOC and orientation: The pt. is oriented in time, place and person.Gait: [ ] walker [ ] cane [ ] other

[ ] steady [x] unsteady ______[ ] sensory and motor losses in faceOr extremities: The pt. displays no sensory and motor losses in the face and extremities.[ ] ROM limitations: The patient can freely move his joints.

COMFORT/SLEEP/AWAKE:[ ] pain Comments: “ Galisod ko (location, frequency, ug pagkatulog kay gi-remedies) ubo ko.”[ ] nocturia [x] sleep difficulties [ ] denied

[x] facial grimace[ ] guarding[ ] other signs of pain: No other signs of pai observed[ ] side rail release form signed (60+ years) Not applicable.

COPING:Occupation: DriverMembers of Household: 3 membersMost Supportive Person: Wife- Lewan Galon

Observed non-verbal behavior: Closing of eyes when experiencing dyspneaThe person and his phone number that can be reached anytime no phone

Date ordered

Diagnostic/ Laboratory

ExamsDate done

Date Ordered IV Fluids/Blood Date Disc.

Jan. 27, 2008

Blood Chemistry Jan. 27, 2008

Jan. 27, 2008 PNSS @ 40

gtts/min

-Requested for follow-up

25

Jan.27, 2008

Complete Blood Count

Jan. 27, 2008

Jan. 27, 2008 D5W @KVO rate - on going IVF

VII. NURSING MANAGEMENT

1. Ineffective Airway Clearance RT excessive secretions and ineffective coughing

Interventions Rationale

Independent:

1. Assess respiratory status,

including vital signs, breath

sounds and skin color at least q

2h

2. Monitor ABG results

3. Place in high-Fowler’s position

4. Provide a fluid intake at least

2500-3000 mL

Early identification of respiratory

compromise allows intervention before

tissue hypoxia is significant.

Blood gas changes may reveal

impaired gas exchange

To pomotes complete lung expansion

and ambulation facilitates movement

of secretions

Liberal fluid intake helps to liquefy

secretions, facilitating lung clearance

Dependent:

1. Administer prescribed

medications as ordered

To help maintain open airway

26

(bronchodilators)

2. Ineffective breathing pattern RT pleural inflammation

Interventions Rationale

Independent:

1. Provide periods of rest

2. Provide reassurance during

periods of respiratory distress

3. Teach slow abdominal breathing

4. Teach use of relaxation techniques

To reduce metabolic demands and

the work of breathing

It reduces high level of anxiety which

further increases tachypnea

This breathing pattern helps promote

complete lung expansion

This technique helps reduce anxiety

and slow the breathing pattern.

27

Dependent:

1. Administer oxygen as ordered Oxygen therapy increases alveolar

oxygen concentration, reducing

hypoxia and anxiety

3. Activity intolerance RT inadequate oxygenation and dyspnea

Interventions Rationale

Independent:

1. Assess activity tolerance, noting

any increase in pulse,

respirations, dyspnea,

diaphoresis, or cyanosis

2. Schedule activities, planning for

rest periods

3. Perform active or passive ROM

4. Assist the family to minimize

stress and anxiety levels

The assessment findings may

indicate limited or impaired activity

tolerance

= Rest periods minimizes fatigue and

improves activity tolerance

Exercise help maintain muscle tone

and joint mobility

Stress and anxiety increases

metabolic demands and can increase

activity tolerance

28

5. Provide assistive device, such as

an overhead trapeze

These assistive device facilitate

movement and reduce energy

demands

B. ACTUAL NURSING MANAGEMENT

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

O Pursed-lip breathing

Dyspnea

Cough with sputum

A Ineffective airway clearance RT excessive secretions and ineffective

coughing

P Long term: At the end of 3 days, client will verbalize clear airway

Shot term: At the end of 30 minutes, will have improved airway clearance, as

evidenced by effective coughing techniques and patent airways

I Independent:

1. Taught the client to maintain adequate hydration by drinking at least 8-10

glasses of fluid per day (if not contraindicated), to thin secretions.

2. Taught and supervised effective coughing techniques, to conserve energy

and reduce airway collapse.

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3. Performed chest physical therapy, it uses force of gravity and motion to

facilitate secretion removal.

4. Assessed the client’s breath sounds before and after coughing episodes,

to help in evaluation of coughing effectiveness.

Dependent:

1. Given bronchodilators (Salbutamol sulfate) as ordered, to relax bronchial

smooth muscles thus facilitating airflow.

E After 30 minutes, the client’s cough was productive and breath sounds are

clearer.

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

O SOB after few meters walk

Increased RR=48cpm

Dyspnea

A Activity intolerance RT inadequate oxygenation and dyspnea

P Long term: At the end of 1 week, patient will tolerate any activity

Short term: At the end of 30 minutes, client will have improved activity

tolerance, AEB maintaining a realistic activity level and demonstrating energy

conservation techniques.

I Independent:

1. Advised to avoid conditions that increase oxygen demand, this increases

peripheral resistance thus increasing cardiac workload and oxygen

requirement.

2. Taught to always use pursed-lip breathing and diaphragmatic breathing, to

30

ensure maximal use of available respiratory function.

3. Assessed the client for signs of negative response to activity, significant

changes in respiratory, cardiac, or circulatory status signals activity tolerance

Dependent:

1. Maintained supplemental oxygen therapy as ordered, to alleviate exercise-

induced hypoxemia thus improving activity tolerance.

E After 30 minutes, client had a tolerable level of performing an activity but SOB

is still present.

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

O Absent-minded

Anxious

Dyspnea

A Anxiety RT acute breathing difficulties and fear of suffocation

P Long term: At the end of 1 week, client will have a psychological comfort and

will cope up to condition

Short term: At the end of 3 hours, the client will express an increase in

psychological comfort and demonstrate use of effective coping mechanism

I Independent:

1. Remained with the client during acute episodes of breathing difficulty,

reassures the client that competent help is available if needed.

2. Provided with a quiet, calm environment, to promote relaxation

3. Limited the number of people during acute episodes, to lessen client’s

reception to pain

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4. Encouraged the use of breathing retraining and relaxation techniques, a

feeling of self-control and success in facilitating breathing helps reduce

anxiety

Dependent:

1. Given sedatives with caution as ordered, to facilitate sleeping

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

breathing techniques and appears rested.

VII. REFERRALS AND FOLLOW-UP

MEDICATION Home medications were not yet given to the patient because he

was still in the hospital after the 2-day clinical duty. But he was

instructed for compliance of medication regimen which includes

the following:

Salbutamol 1 neb + 2cc NSS q6h

Piperacillin + Tazobactam 2.25 mg q8h

Paracetamol 500 mg PRN

EXERCISE Encouraged to increase activity tolerance per day

Assume a high-fowler’s position to promote adequate lung

expansion

Instructed to do deep-breathing exercises several times (5-10)

per hour to help keep lungs fully expanded thereby reducing

dyspnea

TREATMENT Proper hygiene measures was also imparted

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Encouraged to quit smoking as this inhibits tracheobronchial

ciliay action

Instructed to avoid stress and fatigue as this lowers resistance

to pneumonia

Encouraged with adequate nutrition and rest

OUT PATIENT After discharged, client was instructed to return to clinic for

follow-up checkup and X-ray and physical exam

DIET Health teachings on DIET gave emphasis on:

Diet as tolerated with aspiration precaution

Increase intake of foods with calorie for adequate oxygen supply

Increase fluid intake to 2500-3000 mL

IX. EVALUATION AND IMPLICATIONS

After conducting this care study, I was able to appreciate more the essence of

utilizing the nursing process in the care and management of my patient. It was indeed a

tough job on conducting this study yet, it gave me a big impact regarding how useful it is

in my chosen profession. Nursing really demands a tender loving care attitude. It

demands patience and it is calling that cannot be merely taken for granted.

Moreover, this care study taught us to stand on our own by not depending on

others just to make this. This provides us, the students, a big learning regarding on how

well we take care of or patients in the real clinical setting. Most of all, this study teaches

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the students to provide clients care more efficiently and competently to achieve an

effective and quality nursing care.

X. BIBLIOGRAPHY

A. BOOKS

Black, Joyce M. Medical –Surgical Nursing, 7 th edition .

Smeltzer, Suzanne. Medical-Surgical Nursing, 11 th edition

Lippincott Williams and Wilkins A guide to Medical-Surgical Nursing

Lemone, Priscilla Medical-Surgical Nursing

B. WEBLIOGRAPHY

http://psychology.about.com/od/developmentstudyguide/p/devtheories.htm

http://psychology.about.com/od/theoriesofpersonality/ss/psychosexualdev_5.htm

http://psychology.about.com/od/piagetstheory/p/formaloperation.htm

www.wikipedia.org /wiki/ Pneumonia

www.nlm.nih.gov/medlineplus/ pneumonia .html

www.google.com

www.yahoo.com

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www.wikipedia.org /wiki/ Community - acquiredpneumonia

www. emedicine.com /MED/topic3162.htm

www. merck.com /mmhe/sec04/ch042/ch042b.html

Rating ScaleRating Scale

A. WRITTEN WEIGHT RATING

I. Introduction

a. Overview of the Case

b. Objective of the Study

c. Scope and Limitation of the Study

II. Health History

a. Profile of the Patient

b. Family and Personal Health History

c. Chief Complaint

III. Developmental Data

IV. Medical Management

a. Medical Orders with Rationale

b. Drug Study

V. Pathophysiology with anatomy and physiology

VI. Nursing Assessment

a. Nursing System Review Chart

b. Nursing Assessment II

5

5

5

20

(10)

(10)

10

10

30

(10)

35

VII. Nursing Management

a. Ideal Nursing Management

b. Actual Nursing Management

VIII. Referrals and Follow-up

IX. Evaluation and Implication

X. Documentation

a. Documentation of Evidence of Care for 1 Week

Rotation

b. Organization/Grammar/Bibliography

(20)

5

5

5

Total Score

Equivalent Grade

36