BULACAN STATE UNIVERSITY CITY OF MALOLOS S.Y.

2011-2012 NCM102

A CASE STUDY ON PNEUMONIA

SUBMITTED BY: DELA CRUZ, Mary Grace C. BSN 3-D

SUBMITTED TO: Rogie Abalos, RN CLINICAL INSTRUCTOR

I.

INTRODUCTION PNEUMONIA It is an inflammation of the lung parenchyma caused by an infectious agents ( mycobacteria, chlamydiae, mycoplasma, fungi, parasites, and viruses ) and non-infectious agents ( toxic, gases, chemicals, foreign matter, etc. ). Pneumonia can be classified as non-communicable, communicable and contagious. CLASSIFICATION ACCORDING TO ETIOLOGY: 1. Community-Acquired Pneumonia - Pneumonia upon admission until the 1st 48 hours of hospitalization 2. Hospital-Acquired Pneumonia - Pneumonia after 48 hours of hospitalization; Nosocomial infection 3. Pneumonia in the Immunocompromised Host - e.g. Chemotherapy patient, comatose, uses steroid 4. Aspiration Pneumonia - e.g. accidental use of handkerchief of Patient with Pneumonia

CLASSIFICATION ACCORDING TO DEGREE OF SITE OF AFFECTION: 1. Lobar Pneumonia - Infection of a substantial portion of one or more lobes of the lungs - Common among adults - Unilateral affection 2. BRONCHOPNEUMONIA - Infection distributed in a patchy consolidation in the lung parenchyma - Common among extreme ages ( too young / too old ) - Usually bilateral

STAGES OF PNEUMONIA: 1. 2. 3. 4. Congestion - 1 day with marked vasodilation leading to congestion of the lungs. Red Hepatization - 2 days with marked exudation and presence of RBCs. Grey Hepatization - 4 days with engulfment of bacterias by WBCs (e.g. macrophages). Resolution - 8 days with few WBCs on the site of infection; near-to-normal lung structures.

MANIFESTATIONS: Fever with chills SOB with chest pain Signs of Respiratory Distress Cyanosis Fatigability Increased WBC level Cough with rusty sputum

DIAGNOSTIC PROCEDURE: 1. Chest X-Ray 2. Sputum Exam 3. Complete Blood Count

II.

BIOGRAPHY NAME: ADDRESS: BIRTHDAY: AGE: SEX: STATUS: RELIGION: OCCUPATION: NATIONALITY: EDUCATIONAL ATTAINMENT: DATE OF ADMISSION: TIME: CHIEF COMPLAINT: INITIAL DIAGNOSIS: FINAL DIAGNOSIS: Mr. H. F. Cut-Cut, Guiguinto, Bulacan June 22, 1961 51 years old Male Married Catholic No permanent job, anything available on their place Filipino High School Level June 14, 2012 3:15 pm Cough and Fever Suspected to have Pneumonia, request for CBC and Chest X-Ray Pneumonia (Community-Acquired)

HISTORY OF PRESENT ILLNESS Mr. H.F. smokes packs of cigarettes every day. He also drinks alcoholic beverages once a week and they suspected that this activity causes his illness now. My client experienced productive cough and on-off fever with chest pain that intensifies when coughing for two weeks prior to being seen by a physician. His wife decided to send him to hospital because Mr. H.F. loss his appetite and dont eat for several days. HISTORY OF PAST ILLNESS According to him, he had never experienced any illness since his childhood days. As he remembers, he completed his vaccine.

III.

FAMILY HEALTH ILLNESS HISTORY (GENOGRAM)

LEGEND: - FEMALE - MALE

Mrs. A. F.

Mr. F. F.

- DEATH
- DEATH

? Unknown age
A/W Alive & Well

P - Pneumonia

Mrs. Y. F. 57 y/o A/W

Mr. J. F. 55 y/o A/W

Mr. H. F. 51 y/o P

Mrs. J. F. 56 y/o A/W

IV.

GORDONS FUNCTIONAL HEALTH PATTERN

FUNCTIONAL HEALTH PATTERN PRIOR DURING HOSPITALIZATION Health Perception Health He had unhealthy lifestyle. He drinks alcoholic beverages and Became lazy doing hygienic measures. But still follows doctors Management Pattern smoke packs of cigarette in a day. According to him, it is part of order. his leisure time after a tired day on work. He practiced hygienic measures such as taking a bath regularly, brushing the teeth, hand washing before and after meals and regular change of clothes. Nutritional Metabolic Pattern Eats 3x a day with snacks in between meals. Food usually taken: Can eat anything he wants but as doctors order with strict fish and vegetables 4-5 servings a week. Second choice: meat 2-3 aspiration precaution. servings a week. Do not have difficulty in chewing and swallowing food. Do not take any vitamins or herbal supplements. Wound heals quickly. 3-DAY DIETARY RECALL Date Noted Time of the Day Foods Taken June 23, 2012 Breakfast 1 cup of rice (Saturday) (morning) 1 pc. Egg 1 pc. dried fish (tuyo) 1 glass of water (250ml) Lunch (noon) 1 cup of rice Small bowl of ginisang munggo 2 glasses of water (250ml/glass) cup of rice Small bowl of Chopsuey 2 glasses of water (250ml/glass) Date Noted June 26, 2012 (Tuesday) 3-DAY DIETARY RECALL Time of the Day Breakfast (morning) Foods Taken small bowl lugaw 1 bottle water(250ml) of of

Lunch (noon time)

2 packs of crackers 1 bottle of water (250ml/bottle) cup of rice small bowl of tinolang manok 1 glasses of water (250ml/glass) Small bowl of lugaw 1 cup of cereal drink

Dinner (evening)

Dinner (evening)

June 27, 2012 (Wednesday)

Breakfast (morning)

June 24, 2012 Breakfast (Sunday) (morning) Lunch (noon)

2 pcs. pandesal 1 cup of cereal drink (Bearbrand/250ml) 2 packs of crackers 1 glasses of water (250ml/glass) cup of rice small bowl of pakbet 2 glasses of water (250ml) 1 cup of cereal drink (bearbrand,250ml) 1 pack of cracker cup of rice small bowl of pakbet 1 cup of water (250ml) 1 bottle of water (500ml)

(bearbrand/250ml) Lunch (noon) Dinner (evening) 2 packs of crackers 1 bottle of water (250ml/bottle) cup of rice 1 small bowl of pakbet 1 glass of water (250ml) 1 cup of cereal drink

Dinner (evening)

June 28, 2012 (Thursday)

Breakfast (morning)

June 25, 2012 Breakfast (Monday) (morning) Lunch (noon)

Dinner (evening)

Elimination Pattern

Bowel Movement

Color

Frequency

Quantity

Characteristic

Odor

Discomfort

Bowel Movement

Color

Frequency

Quantity

Characteristic

Odor aromatic

Discomfort

Urine Feces

yellow brown

4-5 x a day Once a day

-----

Slightly turbid firm

aromatic Foul odor

No discomfort No discomfort

Urine Feces

Dark yellow brown

2-3 x a day Once a day but sometime s twice a day

1500ml ---

Slightly Turbid loose

Foul odor

No discomfort Had discomfort

No voiding discomforts. Usually perspires when doing field works He usually had discomfort on his bowel movement. such as farming, Activity Exercise Pattern Doing his work and walking early morning is his form of exercise. Spends leisure time by watching television and doing household chores. According to my patient he was fully independent; he can do all of the activities. Activities Feeding Bathing Grooming Ambulation Toileting Bed Mobility Dressing Score 0 0 0 0 0 0 0 Criteria
Level 0 Full Self-care Level 1 Requires the use of equipment or device Level 2 Requires assistance or supervision from another person Level 3 Requires assistance or supervision from another person or device Level 4 Dependent and doen not participate.

Needs assistance when standing on bed and walking. Wants only to rest the whole day. As I assess my patients ADL, I notice that he was partially dependent with assistance from the nurse or significant others. Activities Feeding Bathing Grooming Ambulation Toileting Bed Mobility Dressing Score 0 3 2 2 1 0 2 Criteria
Level 0 Full Self-care Level 1 Requires the use of equipment or device Level 2 Requires assistance or supervision from another person Level 3 Requires assistance or supervision from another person or device Level 4 Dependent and do not participate.

Sexuality Reproductive Pattern Sleep Rest Pattern

According to him, he and his wife had no difficulties dealing in this Do not have an interest doing sexual intercourse matter, this makes him feel contented. Sleeps 6-8hrs. a day. He sleep at 10pm-5am/6am He slept 3-4 hrs. a day. Sometimes takes a nap in the afternoon Watching television is his form of relaxation when he had problem but not contented on that. Feel fatigued after a sleep period. falling asleep. Takes a nap in the afternoon. Others no changes. Have problem in falling asleep.

Cognitive Perceptual Pattern

No problems in his hearing abilities. Has 20/20 vision, does not Others no changes but he had difficulty communicating with wear any eyeglasses. Without memory problem. Other senses are others because of his hoarseness voice. in good condition. Has the ability to understand, communicate, remember and make decisions on his own. Feels good all the time. Mood is affected which becomes irritable. Mood is affected which becomes irritable. Sometimes he had headache and became dizzy. Worry on his condition.

Self-Perception and Self-Concept Pattern Role Relationship Pattern Coping Stress Tolerance Pattern Value Belief Pattern

Live with his wife. Doesnt have problems dealing with her. He now needs more support from his wife, they do not have Handle and solve problems through communication. children that would take care of him Tensed sometimes and just takes rest to release it. His wife Tense a lot of times because he is worried about her condition. supports him all the time to provide emotional support. Family is the most important thing in his life, thats why he Feels alone because they do not have a child to take care of him sometimes feels alone because they do not have a child. Hes but still had faith in God that everything will be okay. catholic and deeply believes that God will always be there to keep him and his wife safe, no matter what happens.

V.

PHYSICAL ASSESSMENT

DATE OF PHYSICAL EXAMINATION: BLOOD PRESSURE: TEMPERATURE: PULSE RATE: RESPIRATORY RATE:

June 29, 2012 80 / 60 mmHg . C 78bpm 28cpm

AREAS TO BE ASSESSED GENERAL SURVEY Body built, height and weight in relation to the clients age Posture and Gait Overall hygiene and grooming Body and breath odor Signs of distress Obvious sign of health or illness Clients attitude Mood and affect Quantity and quality of speech Relevance and organization of thoughts INTEGUMENTARY A. Skin Color Presence of edema Temperature Skin Turgor Skin Intactness

TECHNIQUE Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection Inspection

NORMAL FINDINGS Proportionate, varies with lifestyle Relaxed, erect Posture Clean, neat No body odor or minor odor relative to work or exercise; no breath odor No distress noted Healthy appearance Cooperative, able to follow instructions Appropriate to situation Understandable, moderate pace; clear tone and inflection Logical sequence, makes sense; has sense of reality

ACTUAL FINDINGS Ectomorph, height and weight not proportion to her age. Has an unsteady gait or slow movement My client is neat and clean No body and breath odor Dyspnea noted Looks weak Cooperative and can follow instructions Cooperative and pleasant, appropriate to situation Had difficulty vocalizing, cannot understand well what he is saying When he speaks it has sense of reality

INTERPRETATION/ANALYSIS Deviation from Normal Deviation from Normal Normal Normal Deviation from Normal Deviation from Normal Normal Normal Deviation from Normal Normal

Inspection Inspection Palpation Palpation Inspection

Generally uniform in color except in the areas that are exposed to the sun No edema Uniform; within normal range Skin springs back to previous state No lesion, skin is intact

Skin color is uniform except in the areas that are exposed to the sun (-) edema Febrile state ( . C) His skin springs back to previous state No lesion but skin is dry and scaly most especially in his

Normal Normal Deviation from Normal Normal Deviation from Normal

pedal and calcaneal B. Hair Evenness of growth over the scalp Hair texture and oiliness Amount of body hair C. Nails Fingernail plate shape, toenail texture Tissues surrounding nails Perform blanch test of capillary refill D. Skull and face Skull size, shape and symmetry Presence of nodules, masses and depression Facial features E. Eyes Eye brows for hair distribution Eyelashes for evenness of distribution and direction of curl Eyelids for surface characteristics, ability to blink and frequency of blinking Inspection Inspection Inspection Inspection Inspection Inspection and palpation Inspection Palpation Inspection Inspection Inspection Inspection Evenly distributed; thick or thin Silky, resilient hair Variable Convex curvature, angle of the nail plate about 160; smooth texture Intact epidermis Prompt return of pink or usual color Rounded and smooth skull contour Smooth, uniform consistency; absence of nodules and masses Symmetric or slightly asymmetric facial features Hair evenly distributed, eyebrows symmetrically aligned. Equally distributed; curled slightly outward Skin intact; no discharge or discoloration; lids closed symmetrically approximate. Has the ability to blink about 15-20 involuntary blinks per minute Transparent, shiny and smooth; details of the iris are visible Has thick hair, evenly distributed, color black Has silky hair Variable His nail bed is considered as an Onychorrhexis and it has rough texture Has intact epidermis Usual color of nails returns to pink after 2-3 seconds. Rounded and has smooth skull contour No nodules and masses Facial features were slightly asymmetric Hair evenly distributed, eyebrows were evenly distributed. No lesion Eyelashes equally distributed; curled outward Skin intact; no discharge or discoloration; lids closed symmetrically. Has the ability to blink bilaterally. Transparent, shiny and smooth; details of the iris are visible Normal Normal Normal Deviation from Normal Normal Normal Normal Normal Normal Normal Normal Normal

Cornea for clarity and texture

Inspection

Normal

Corneal sensitivity Pupils for color, shape and symmetry of size Pupils reaction to accommodation

Inspection Inspection Inspection

Blinks when the cornea is touched Black in color, equal in size and smooth border Pupils constrict when looking at near object; pupils dilate when looking at far; pupils converge when near object is moved towards the nose Color same as facial skin, symmetrical; auricle aligned with the outer cantus of the eye Mobile, firm and not tender; pinna recoils after being fold. Dry cerumen, grayish-tan color, sticky or wet cerumen in various shades of brown Symmetric and straight; no discharge or flaring; uniform in color Mucosa is pink; clear watery discharge; no lesions. Air moves freely as the client breathes through the nares Not tender Not tender Uniform pink color, soft, moist, smooth texture,

Client blinks when the cornea is touched His pupils are black, equal in size and has smooth borders His pupils constrict when looking at near object; pupils dilate when looking at far; pupils converge when near object is moved towards the nose. Color same as facial skin, auricle aligned with the outer cantus of the eye. Mobile, firm and not tender; pinna recoils after being fold. Has wet cerumen

Normal Normal Normal

F. Ears Auricles color, symmetry of size and position Texture, elasticity and areas of tenderness External ear canal for cerumen, skin lesions, pus and blood G. Nose Shape, size or color and flaring or discharge Nasal cavities Patency of both nasal cavities Tenderness, masses and displacement of bones and cartilage Sinuses for tenderness H. MOUTH Lips for symmetry of contour, color and texture

Inspection

Normal

Palpation Inspection

Normal Normal

Inspection Inspection Inspection Palpation Palpation Inspection

Symmetric and straight; no discharge or flaring; uniform in color Have no discharge and no lesions. When the client breathes through his nostrils, air moves freely Not tender, masses or displacement of bones and cartilage Maxillary and frontal sinuses are not tender Lips are color pink (uniform), but dry and cracked also he

Normal Normal Normal Normal Normal Normal

Teeth for color, number, condition and presence of dentures Tongue for color, position, texture and movement Position of the uvula and mobility while examining palates Tonsils for color, discharge and size I.NECK Neck muscles Head movement

Inspection Inspection Inspection Inspection Inspection Inspection

symmetry of contour, ability to purse lips 32 adult teeth, smooth white and shiny tooth enamel Central position, pink color, moist slightly rough, moves freely, no tenderness Positioned in midline of soft palate Pink and smooth, no discharge Muscles equal in size; head centered Coordinated, smooth movements with no discomfort Not palpable Central placement in midline of neck; spaces are equal on both sides Not visible on inspection, ascends during swallowing but is not visible Skin is intact; uniform in temperature, chest wall intact; no tenderness; no masses Spine vertically aligned Full and symmetric chest expansion

has the ability to purse his lips Teeth are insufficient, some have black patches on the surface of the tooth Tongue in the center, pink in color, moist and slightly rough without lesions, moves freely. Uvula is in the middle. Has pink and smooth tonsils; no discharge. Muscles on the neck are equal in size; head centered. Head movement is coordinated, has smooth movements with no discomfort. No enlargement of lymph nodes Trachea is in central position in the midline of the neck; spaces are equal in both sides. Thyroid gland is not visible on inspection; it ascends during swallowing but is not visible. Skin is intact; uniform in temperature, chest wall intact; no tenderness; no masses His spine is vertically aligned When he takes a deep breath, my thumb move apart an Deviation from Normal Normal

Normal

Normal

Normal Normal

Entire neck for enlarged lymph nodes Trachea for lateral deviation 3Thyroid Gland I.THORAX Posterior thorax

Palpation Inspection Inspection and Palpation

Normal Normal

Normal

Palpation

Normal

Spinal alignment for deformities Posterior chest for respiratory excursion

Inspection Palpation

Normal Normal

Breathing pattern Anterior chest for respiratory excursion K .BREAST AND AXILLAE Size, symmetry and contour or shape Skin of the breast Axillary, subclavicular and supraclavicular lymph nodes J. ABDOMEN Skin integrity Contour and symmetry Liver K. MUSCULOSKELETAL Muscles for size Muscles and tendons for contractures and tremors Muscle tonicity Skeleton Joint

Inspection Palpation Inspection Inspection Palpation Inspection Inspection Palpation Inspection Inspection Palpation Inspection Inspection

Quiet, rhythmic and effortless respirations Full symmetric excursion Rounded shape slightly unequal in size Uniform in color No tenderness, masses or nodules Uniform in color Flat, rounded or scaphoid May not be palpable; border feels smooth Equal size on both side of the body No contractures and tremors Normally firm No deformities, tenderness or swelling No swelling and nodule, not tender

equal distance at the same time. He experienced difficulty of breathing Full symmetric excursion Rounded shape slightly unequal in size Skin is uniform in color Absence of nodules; not tender. Uniform in color He has flat abdomen Liver is not palpable Muscles are equal in size on both side of the body. No contractures and tremors Firm No deformities, tenderness or swelling No swelling and nodule, not tender

Deviation from Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal Normal

VI.

DIAGNOSTIC PROCEDURE / LABORATORY

Date ordered/ Date Result(s) Indication(s)/ Purposes Actual Values Normal Values (Units used in Hospital) Analysis and interpretation of results Nursing Responsibilities ( prior, during, after )

Diagnostic/ Laboratory Procedures

Urinalysis

June 14, 2012

For general health screening to detect renal and metabolic disease; diagnosis of disease or disorders of the kidney or urinary tract; monitoring patients with diabetes.

Color: Dark yellow Characteristics: Slightly Turbid pH: 5.0 Sp. Gravity: 1,030 Albumin: negative Sugar: Negative WBC: 0-3/hpf +mucus thread Epithelial Cells: Moderate

Color: Straw amber Characteristics: Transparent pH: 4.8 8.0 yellow

All values are normal to which indicate that there is no disorder in kidney or in urinary tract.

Prior to: Explain significant to the others

the test, its purpose and how it done. Inform significant require specimen. Provide container specimen. During: Collect the urine in a clean specimen cup. Label the specimen properly. After: The specimen a for clean the the others urine

Sp. Gravity: 1.015 1.025 Albumin: negative Sugar: Negative WBC: less than 5/hpf Epithelial Cells: Moderate

that the test will

should be delivered to the lab within 1 hour. Obtain result and secure it to the chart Refer result to the physician.
The hemoglobin test

The hemoglobin is below Hemoglobin: 140-175 g/L Hematocrit: 0.41-0.50 WBC: 5.6/L RBC: 3.68/L DIFFERENTIAL WBC: 4.5-10.0/L RBC: 3.8-5.8/L DIFFERENTIAL COUNT: Segmenters: 43-76 Lymphocytes: 17-48 Monocytes: 4-10 Platelet: 150,000390,000cumm. normal level indicating that Prior to: the blood do not have sufficient amount to carry oxygen body. throughout the Explain client. Explain the purpose and indication of the test. Tell to the significant others or client that the test will During: Use technique obtaining aseptic when the not require feeding restriction. the procedures to the

HEMATOLOGY

June 27, 2012

measures the amount of Hemoglobin: hemoglobin in blood and 101 g/L is a good indication of the blood's ability to carry oxygen throughout the body. Hematocrit and concentration evaluates anemia and fluid balance of

Hematocrit: 0.31

measures COUNT: RBC Segmenters: 76

within the blood volume.

Lymphocytes: 18 Monocytes: 6 Platelet: 446,000cumm.

sample. Label the container properly. Bring the collected sample laboratory. After: Obtain results and secure it to the patients chart. Refer the results to the physician. to the

Diagnostic/ Laboratory Procedures

Date ordered/ Date Result(s)

Indication(s)/ Purposes

Actual Values

Normal Values (Units used in Hospital)

Analysis and interpretation of results

Nursing Responsibilities ( prior, during, after )

Upper Abdomen Ultrasound

June 20,2012

To diagnose abnormalities in various internal organs, such as the kidneys, liver, gallbladder, pancreas, spleen and abdominal aorta.

Upper Abdomen are normal

---

Normal liver, Gallbladder, Biliary Ducts, Pancreas and spleen Ultrasonically

Instruct patient to remove any metal jewelries.

Instruct patient to remain still during

the procedure. Radiological examination June 13, 2012 For the conformation of diagnosis and early detection of pleural effusion and emphysema. Follow up is necessary if pneumonia fails to resolve. Pneumonia, Lower Concomitant effusion not ruled out. Cardiomegaly Left Lobe, --In homogenous opacification of the left lower lobe. Heart is enlarged. Pulmonary vascularity is not accentuated. The left hekidoaphragm and sulcus are obscured. Prohibited pregnant women. to

VII.

DRUGS DATE
ORDERED TAKEN/GIVE N CHANGED DISCONTINUED

GENERIC/BRAND NAME/DRUG CLASSIFICATION

ROUTE OF ADMINISTRATION, DOSAGE, FREQUENCY

MECHANISMS OF ACTION

CLIENTS RESPONSE

PRIOR

NURSING RESPONSIBILITIES DURING

AFTER

Generic Name: CEFTAZIDIME Brand Name: ZEPTRIGEN Classification: -ANTIBIOTIC -CEPHALOSPORIN (third generation)

06/15/12 (7AM)

06/15/12

---

---

ROUTE: IV DOSAGE: 300mg FREQUENCY: -every 8 hr -ANST(-)

Inhibits synthesis of bacterial cell wall, causing cell death.

Do not have 1. Assess allergies on for liver and cephalosporin renal dysfunction. 2. Obtain CBC, renal function studies; reduce dose with dysfunction. 3. Culture infection, and

1. Do not mix with amino glycoside solutions, administer these drugs separately. 2. Monitor Prothrombin time in patients w/ renal

1. Store at temperatures not exceeding 30C. 2. Have Vit. K available in case hypoprothrombinemia occurs. 3. Discontinue if hypersensitivi

arrange sensitivity tests before and during therapy if expected response is not seen.

or hepatic impairment, in a poor nutritional state or are on prolonged therapy. 3. Preparation of injectable solution, sites and methods of injection are treated with utmost care. Administer IV injection as slowly as possible.

ty occurs.

GENERIC/BRAND NAME/DRUG CLASSIFICATION

DATE
ORDERED TAKEN/GIVEN CHANGED DISCONTINUED

ROUTE OF ADMINISTRATION, DOSAGE, FREQUENCY

MECHANISMS OF ACTION

CLIENTS RESPONSE

NURSING RESPONSIBILITIES PRIOR DURING AFTER

Generic Name: TRIMETAZIDINE Brand Name: VASTAREL Classification: ANTI-ANGINA

06/15/12

06/15/12

---

---

35mg tab TID

Selective inhibition of an enzyme of fatty acid Boxidation: the long-chain 3ketoacyl CoA thiolase (3KAT). This inhibition results in: Reduction in fatty acid oxidation; Stimulation of glucose oxidation. The coupling of glycolysis with glucose oxidation is improved and ATP production is further increased, while cell acidosis and Ca2+ overload are limited. The increase in total glucose utilization has

The client experienced headache.

1. Check for doctors order. 2. Monitor blood pressure and pulse rate before and after giving the meds.

1. Notify prescribing signs of heart failure such as swelling of hands and feet or SOB.

1. Advise patient of the side effects of the drug.

been evidenced by studies using 18FDG positron emission tomography (PET).

GENERIC/BRAND NAME/DRUG CLASSIFICATION

DATE
ORDERED TAKEN/GIVE N CHANGED DISCONTINUE D

ROUTE OF ADMINISTRATION, DOSAGE, FREQUENCY

MECHANISMS OF ACTION

CLIENTS RESPONSE

NURSING RESPONSIBILITIES PRIOR DURING AFTER

Generic Name: OMEPRAZOLE Classification:

ANTACIDS, ANTIREFLUX AGENTS & ANTIULCERANT ANTISECRETORY DRUG

06/15/12 06/15/12

---

---

20 mg tab BID

Gastric-acid pump inhibitor: suppresses gastric acid secretion by specific inhibition of the hydrogenpotassium ATPase enzyme system at the secretory surface of the gastric parietal.

Client experienced diarrhea

1. Know if patient has history: hypersensitivity to omeprazole.

1. Administer before meals.

2. Administer Antacids with, 2.Report if needed. severe headache, worsening of symptoms, fever, chills.

1. Have regular medica l follow-up visits

GENERIC/BRAND NAME/DRUG CLASSIFICATION

DATE
ORDERED TAKEN/GIVE N CHANGED DISCONTINUED

ROUTE OF ADMINISTRATION, DOSAGE, FREQUENCY

MECHANISMS OF ACTION

CLIENTS RESPONSE

PRIOR

NURSING RESPONSIBILITIES DURING

AFTER

Generic Name: GENTAMYCIN Classification: ANTIINFECTIVE AMINOGLYCOSIDE ANTIBIOTIC

06/20/12

06/20/12

---

---

80 mg IV q8hr.

Broad-spectrum aminoglycoside antibiotic derived from Micromonospor a purpurea. Action is usually bacteriocidal.

Do not have allergies to amino glycoside

1. Culture infected area before the therapy.

1. Perform C&S and renal function prior to first dose and periodically during therapy; therapy may begin pending test results.

1. Repeat C&S if improvement does not occur in 35 days; reevaluate the therapy

VIII.

NURSING CARE PLAN DIAGNOSIS PLANNING IMPLEMENTATION Increase fluid intake to at least 2000ml/day within cardiac tolerance. RATIONALE Hydration can help liquefy viscous secretions and improve secretion clearance. To take advantage of gravity decreasing pressure on the diaphragm and enhancing drainage and ventilation to different lung segments. Abdominal breathing exercise permits deep full breaths with little effort while pursed-lip breathing helps the patient develop control over EVALUATION After 1hr. of Nursing Intervention, the client was able to: Verbalized understanding of cause and therapeutic management regimen.

ASSESSMENT S: Minsan nahihirapan ako huminga, as verbalized by the client

O:

Ineffective Airway After 1hr. of Nursing. Clearance related to Intervention, the client will inability to maintain clear be able to: airway as manifested by rapid, shallow breathing, Verbalize difficulty vocalizing and understanding of dyspnea. cause and therapeutic management regimen. After 1 to 2 days of Nursing Intervention, the client will be able to: Maintain patency. airway

Rapid, shallow breathing Difficulty vocalizing Dyspnea R.R: 28cpm

Elevate head of bed / change position every 2 hrs. and prn.

After 1 to 2 days of Nursing Intervention, the client was able to: Maintained patency. airway

Demonstrate behaviors to improve or maintain clear airway.

Encourage the patient to do deep breathing such as abdominal and pursed-lip breathing.

Demonstrated behaviors to improve or maintain clear airway.

breathing. ASSESSMENT S: Madalas mataas ang lagnat ko, minsan naman wala, as verbalized by the patient DIAGNOSIS Altered Body Temperature related to bacterial invasion in the lungs as manifested by body temperature higher than normal, warm to touch and dyspnea. PLANNING After 2 hours of Nursing Intervention, the patient will be able to: Decrease temperature from . C to normal range 6. - . C . Cool skin. Temp.: Febrile (38.4 C) Warm to touch Dyspnea R.R: 28cpm off patients IMPLEMENTATION Encourage patient to rest. RATIONALE Allows the patient to recuperate physical strength. To maintain hydration status and helps lessen febrility. Sponge bath with warm water evaporates off his skin, thus, cooling off the patient. Promotes return of body temperature to normal rate. EVALUATION After 2 hours of Nursing Intervention, the patient was able to: Decreased temperature from . C to normal range . C. Patients skin cooled off a bit. has

Encourage patient to increase fluid intake.

O:

Normalize breathing pattern.

Encourage patient or relative to do tepid sponge bath.

Normalized breathing pattern.

Administer antipyretic medications prescribed.

as

ASSESSMENT S:

DIAGNOSIS Risk for infection related to inadequate secondary defenses(decrease hemoglobin, hematocrit and immunosuppression)

PLANNING After 6 hours of Nursing Interventions the patient will be able to: Verbalize understanding of individual causative/risk factors.

IMPLEMENTATION

RATIONALE

EVALUATION After 6 hours of Nursing Interventions the patient was able to: Verbalized understanding of individual causative/risk factors.

Encourage good hand washing techniques.

To reduce spread or acquisition of infection. To enhance fast recovery and regain strength. To enhance fast recovery.

O: Fever of 38.4C Body malaise Decrease hemoglobin level: 101 g/L

Encourage adequate rest.

After 1-2 days of Nursing Intervention the patient will be able to: Free from possible spread of infection. Demonstrate lifestyle changes to prevent further infection. To reduce spread or acquisition of infection. To enhance fast recovery and regain strength.

Administer antimicrobials as ordered

After 1-2 days of Nursing Intervention the patient was able to: Free from possible spread of infection. Demonstrated lifestyle changes to prevent further infection. Reduced spread or acquisition of infection. To enhance fast recovery and regain strength.

ASSESSMENT S:

DIAGNOSIS

PLANNING

IMPLEMENTATION Provide adequate rest periods.

RATIONALE Reduces fatigue and promote a more effective breathing pattern. It promotes lung expansion.

EVALUATION After 2-3 days the client was able to: Established a normal or effective respiratory pattern. Verbalized awareness of causative factors. Demonstrate appropriate coping behaviors.

O: Dyspnea Rapid shallow breathing R.R 28cpm

Ineffective Breathing After 2-3 days the client will Pattern related to be able to: inspiration/expiration that does not provide Establish a normal or adequate ventilation as effective respiratory manifested by rapid pattern. shallow breathing and dyspnea. Verbalize awareness of causative factors. Demonstrate appropriate coping behaviors.

Teach slow abdominal breathing. Administer oxygen as ordered.

Oxygen therapy increases alveolar oxygen concentration.

IX.

DISCHARGE PLANNING (METHODS) M- Medications: Advice the patient to continue his medication as prescribed by the doctor. E-Exercise / Activity Type of Activity allowed / to be continued: Deep Breathing Exercises and Light Activities T-Treatment Comply with medications Increase Fluid Intake Utilize Deep Breathing Exercise for at least twice a day

H-Health Teaching clinic appointment schedules use of alternative medicines follow-up laboratory examinations relapse prevention measures understanding and knowing what to do with side effects of medications Others: Health Teaching on Deep Breathing Exercise

O-Observe for the signs and symptoms: Increase dyspnea, Elevated Body Temperature and presence of adventitious sounds. D-Diet Prescribed Diet: Diet as Tolerated Restrictions: No restrictions S-Spiritual and Physiological Needs spiritual counseling confession supportive counseling grief work family therapy join organizations/church activities anger management reconciliation of conflicted relationships