I. MEDICAL MANAGEMENT a.

Drug Study

b. Treatment 1. D5IMB Intravenous Fluid

Definition: D5imb is an IV solution that consists of 5% dextrose and water level. It is usually given to patients in hospitals that could potentially become ill through high sodium levels or low blood sugar levels.

Indication/Purpose: It is used when the patient needs an increase in calories, hydration and electrolytes in the body.

Nursing Responsibilities: a) Do not administer unless solution is clear and container is undamaged. b) Caution must be exercised in the administration of parenteral fluids, especially those containing sodium ions to patient receiving corticosteroids or corticotrophin. c) Solution containing acetate should be used with caution as excess administration may result in metabolic alkalosis. d) Solution containing dextrose should be used with caution in patients with known subclinical or overt diabetes mellitus. e) Discard unused portion. f) In very low birth weight infants, excessive or rapid administration of dextrose injection may result in increased serum osmolality and possible intracerebral hemorrhage.

2. Oxygen via Nasal Cannula

Definition: A nasal cannula is a narrow, flexible plastic tubing used to deliver oxygen through the nostrils of patients using nasal breathing. It connects to an oxygen outlet, a tank source or compressor, on one end and has a loop at the other end with dual pronged extended openings at the top of the loop. The prongs are slightly curved to fit readily into the front portion of a patient's nostrils. The tubing of the loop is fitted over the patient's ears and is brought together under the chin by a sliding connector that holds the cannula in place.

Indication/Purpose: It is used to deliver oxygen in as concentrated a form as required for patients who are hypoxic. There are many conditions that cause hypoxemia and require the administration of supplemental oxygen, including respiratory disease, cardiac disease, shock, trauma, severe electrolyte

imbalance (hypokalemia), low hemoglobin or severe blood loss, and seizures. Prompt treatment of these conditions with non-invasive oxygen administration can prevent the need for more invasive procedures such as intubation and mechanical ventilation. It is also used to deliver low concentrations of oxygen. It can deliver from 24% to 40% oxygen at a flow rate of 0.26-1.58 gal (1-6 L) per minute.

Nursing Responsibilities: Before administration a) Place the patient in a comfortable position, preferably semi-Fowler's or full Fowler's position (to assist breathing). b) Take baseline vital signs and note the patient's level of consciousness. A pulse-oximetry reading or draw blood gases should be done as ordered for baseline lab values. c) Oxygen delivery to the patient should be explained, including what equipment is to be used (such as a mask or nasal cannula) and the importance of keeping the apparatus in place. d) Instruct patient that the oxygen is flammable and a "No Smoking" sign should be posted. e) Instruct the patient/significant others to notify for increasing distress, air hunger, nausea, anxiety, dry nasal passages, or "sore throat" (due to drying). f) Properly assemble equipment, including the oxygen-flow meter, humidity bottle if ordered, nasal cannula, or appropriate face mask. g) The mask or cannula should be connected securely to the oxygen flow meter. Extension tubing should be used between the mask tubing and the oxygen flow meter if necessary so that the patient may move about without pulling the mask off or pulling the tubing out of the oxygen source. h) Place a pulse oximeter machine at hand if ordered, to monitor the patient's response to oxygen therapy. After administration i) Stay with the patient for a while to reassure the patient and observe his or her reactions to the therapy. j) Monitor patients vital signs along with the level of consciousness, comfort with the oxygen apparatus, and oximetry levels, as ordered by the physician or as directed by policy of the medical setting. k) Check oxygen connections and settings.

l)

Observe the patient, either for improvements in color, respiratory rate and rhythm, and comfort levels, or for increased or decreased respiratory effort, diaphoresis, alteration in mental status, anxiety and restlessness. Facemasks will interfere with communication and eating. Oxygen will dry out the mucous membranes of the nose and mouth.

m) When the mask or cannula is off, the skin on the face and above the ears should be checked for signs of skin irritation. If the skin is irritated above the ears, cotton padding can be placed between the ears and the elastic band or the cannula tubing to protect the skin. If the skin of the face is irritated, the face can be massaged gently and a water-based moisturizer applied. The mask can be loosened slightly to decrease irritation.

3. Nebulizer (Salbutamol) Definition: Nebulization is the process of medication administration via inhalation. It utilizes a nebulizer that transports medications to the lungs by means of mist inhalation.

Indication: Nebulization therapy is used to deliver medications along the respiratory tract and is indicated to various respiratory problems and diseases such as chest tightness, excessive and thick mucus secretions, respiratory congestions, Pneumonia, atelectasis and asthma.

Nursing Responsibilities: a) Position the patient appropriately, allowing optimal ventilation. b) Assess and record breath sounds, respiratory status, pulse rate and other significant respiratory functions. c) Teach patient the proper way of inhalation: Slow inhalation through the mouth via the mouthpiece Short pause after the inspiration Slow and complete exhalation Some resting breaths before another deep inhalation d) Prepare equipments at hand e) Check doctors orders for the medication, prepare thereafter f) Place the medication in the nebulizer while adding the amount of saline solution ordered. g) Attach the nebulizer to the compressed gas source h) Attach the connecting tubes and mouthpiece to the nebulizer i) Turn the machine on (notice the mist produced by the nebulizer)

j) Offer the nebulizer to the patient, offer assistance until he is able to perform proper inhalation (if unable to hold the nebulizer [pediatric/geriatric/special cases], replace the mouthpiece with mask k) Continue until medication is consumed l) Reassess patient status from breath sounds, respiratory status, pulse rate and other significant respiratory functions needed. Compare and record significant changes and improvement. Refer if necessary m) Attend to possible side effects and inhalation reactions.

c. Diet Breastfeeding Breastmilk has important ingredients that are not found in any infant formula, to build the babys immune system. Breastmilk changes from feed to feed to suit each babys unique needs, making it the perfect food to promote healthy growth and development.

d. Activity and Exercise Complete Bed Rest The patient is advised for a bed rest to prevent further shortness of breath. II. NURSING MANAGEMENT a. Maintain a patent airway and adequate oxygenation. b. Obtain sputum specimens as needed. c. Use suction if the patient cant produce a specimen. d. Provide a high calorie, high protein diet of soft foods. e. To prevent aspiration during nasogastric tube feedings, check the position of tube, and administer feedings slowly. f. To control the spread of infection, dispose secretions properly. g. Provide a quiet, calm environment, with frequent rest periods. h. Monitor the patients ABG levels, especially if hes hypoxic. i. Assess the patients respiratory status. Auscultate breath sounds at least every 4 hours. j. Monitor fluid and intake output. k. Evaluate the effectiveness of administered medications. l. Explain all procedures to the patient and family.

MEDICATION
Instruct and explain the patient's mother that the medication is very important to continue depending on the duration that the doctor ordered for the total recovery of the patient, otherwise it may recur. Relapses can be far more serious than the first attack. Teach patient and her family or significant others the proper dosage and the right time to take the medication. Emphasize to the patient the importance of obediently taking the prescribed medications and the disadvantages or complications that may arise if these are not taken properly. Inform and discuss the possible side effects and reactions that these drugs might produce and seek medical attention immediately is these arise.

EXERCISE
Instruct mother to let her child play but it should be limited to a short period of time only to prevent the occurrence of shortness of breathing.

TREATMENT
Advice the mother to keep the baby relax in order to recover in her present condition. Instruct the mother to minimize the patient from exposure to an open environment such as dusty and smoky area, which airborne microorganism are present that can be a high risk factor that may cause severity of his condition. Avoid exposing the patient to an environment too much of pollution (e.g. smoke). Smoke damages one's lungs natural defences against respiratory infection. Avoid the things that can cause their symptoms. Of course, some things that can cause symptoms can't be completely avoided (like catching a cold!), but people can control their exposure to some triggers, such as pet dander, for example.

HEALTH TEACHING
Encourage and explain to the patient's mother that it is important to maintain proper hygiene to prevent further infection. Instruct the patient's mother to bath her baby everyday and explain that bathing early in the morning is not a factor or cause of having pneumonia. Instruct to increase fluid intake of the patient's condition. Encourage the guardians to wash patient's hands. The hands come in daily contact with germs that can cause pneumonia. These germs enter one's body

when she touch her eyes or rub her nose. Washing hands thoroughly and often can help reduce and often can help reduce the risk. Protect others from infection. Try to stay away from anyone with a compromised immune system. When that isn't possible, a person can help protect others by wearing a face mask and always coughing into a tissue. Teach the family about the management required for the disorder. Keep your environment clear of potential allergens. Pay attention to the weather and take precautions when you know weather or air pollution conditions may affect you. You may need to stay indoors or limit your exercise to indoor activities. Be smart about exercise. Encourage significant others to do chest tapping to facilitate mobilization of secretion. Encourage changing patient's position regularly to facilitate drainage and mobilization of secretion. Encourage providing well-ventilated area. Instruct to give medications at the right route, dose, and time. Remind significant others to always assess to patient needs. Instruct significant others to keep child always clean and dry. Advise to go to the physician if signs and symptoms of pneumonia and bronchial asthma are observed. Teach the folks the importance of monitoring the progress and compliance with the treatment regimen. Patient needs health promotions activities and health screening. Emphasize to the significant others the importance of having regular check-up to know her present condition

OUT-PATIENT
Regular consultation to the physician can be a factor for recovery and to assess and monitor the patient's condition. Even though the patient feels better her lungs may still be infected. It is important to have the doctor monitor her progress.

DIET
Breastfeeding plays a big role in fast recovery. Instruct mother to eat nutritious foods that could benefit to the baby s condition as she breastfeeds.

ASSESSMENT Subjectives: Nahihirapan siyang huminga at minsan inuubo, as verbalized by the mother.

NURSING DIAGNOSIS Ineffective Airway Clearance related to excessive mucus secretion as evidenced by thick clear sputum, harsh breath sound with crackles and use of accessory muscles

SCIENTIFIC EXPLANATION Bacterial microorganism enters the airway

PLANNING

INTERVENTIONS (IMPLEMENTATION)) INDEPENDENT: a) Assess rate/depth of respirations and chest movement.

SCIENTIFIC RATIONALE

EVALUATION LONG TERM OUTCOME ACHIEVED. After discharged, the patient has able to demonstrate absence of congestion with clear breath sounds, and improved oxygen exchange as evidenced by not compromised respiratory rate, moves sputum out of airway and no adventitious breath sounds. SHORT TERM OUTCOME ACHIEVED. After 1 hour of nursing interventions: the patient: achieved successful T-piece weaning sustained respiratory rate of

Objectives: fatigue anxious facial grimace restless nasal flaring thick clear sputum dyspnea harsh breath sound with crackles use of accessory muscles RR: 43

LONG TERM OUTCOME: Upon discharge, the patient will be able to transmission to the demonstrate absence of alveoli congestion with clear breath sounds, and less function improved oxygen (impaired gas exchange as evidenced exchange) by not compromised respiratory rate, moves mucus production sputum out of airway and (inflammation of no adventitious breath bronchoiles and sounds. alveoli) SHORT TERM Phagocyte OUTCOME: production After 1 hour of nursing interventions: accumulation of exudates the patient will be able to: in alveoli achieve successful progressive T-piece increase mucus weaning secretion sustain respiratory rate Ineffective airway within normal range: clearance RR: 25 40 cpm nasal flaring thick clear sputum display decreasing dyspnea amount of secretions

Tachypnea, shallow respirations, and asymmetric chest movement are frequently present because of discomfort of moving chest wall and/or fluid in lung. Decreased airflow occurs in areas consolidated with fluid. Bronchial breath sounds (normal over bronchus) can also occur in consolidated areas. Crackles, rhonchi, and wheezes are heard on inspiration and/or expiration in response to fluid accumulation, thick secretions, and airway spasm/obstruction. Lowers diaphragm, promoting chest

b) Auscultate lung fields, noting areas of decreased/absent airflow and adventitious breath sounds like crackles or wheezes.

c) Teach and assist mother to elevate

harsh breath sound with crackles use of accessory muscles Reference: Pathophysiology by Thomas J. Nowak

allay restlessness

the mother will be able to:

head of bed and change patients position appropriate for age and condition every 2 hours.

expansion, aeration of lung segments, mobilization and expectoration of secretions. Deep breathing facilitates maximum expansion of the lungs/smaller airways. Coughing is a natural selfcleaning mechanism, assisting the cilia to maintain patent airways.

38cpm displayed decrease amount of secretions allayed restlessness the mother: verbalized the cause of breathing pattern disturbances in relation to the patients condition such as thick clear sputum.

verbalize the cause of d) Instruct and assist breathing pattern mother to initiate disturbances in relation patient with frequent to the condition deep-breathing exercises. Understand and state ways to improved breathing pattern.

e) Teach and assist mother how to perform activity such as splinting chest and effective coughing while in upright position. f) Promote systemic fluid hydration, as appropriate.

Splinting reduces understood and chest discomfort, stated ways to and an upright improved breathing position favors pattern such as deeper, more performing deepforceful cough effort. breathing pattern and splinting or back tapping. Fluids (especially warm liquids) aid in mobilization and expectoration of secretions To report changes in color and the amount in the event

g) Provide mother the information about the necessity of raising

and expectorating secretions versus swallowing them

that medical interventions may be needed to prevent/ treat infection.

h) Monitor for increased restlessness, anxiety, and air hunger.

These clinical manifestations would be early indicators of hypoxia.

COLLABORATIVE: a) Assist with/monitor effects of nebulizer treatments and other respiratory physiotherapy. Perform treatments between meals and limit fluids when appropriate.

Facilitates liquefaction and removal of secretions. Postural drainage may not be effective in interstitial pneumonias or those causing alveolar exudate/destruction. Coordination of treatments/schedule s and oral intake reduces likelihood of vomiting with coughing, expectorations. Aids in reduction of bronchospasm and

b) Administer medications as

indicated: mucolytics, expectorants, bronchodilators, analgesics. c) Provide supplemental fluids, e.g., IV, humidified oxygen, and room humidification

mobilization of secretions and improves coughing effort. Fluids are required to replace losses (including insensible) and aid in mobilization of secretions. Note: Some studies indicate that room humidification has been found to provide minimal benefit and is thought to increase the risk of transmitting infections. Reference: Fundamentals of Nursing by Kozier and Erb

ASSESSMENT Subjective: Nahihirapan siyang huminga at minsan inuubo, as verbalized by the mother.

NURSING DIAGNOSIS Ineffective Breathing Pattern related to obstruction of airway as evidenced by thick clear sputum, irregular respiratory rhythm and crackle breath sound

SCIENTIFIC EXPLANATION Parasympathetic stimulation in response to the presence of bacterial infection mucus production (inflammation of bronchioles and alveoli) less function (impaired gas exchange) inability to maintain clear airway insufficient air needed by the body Ineffective Breathing Pattern irregular respiratory rhythm nasal flaring thick clear sputum dyspnea harsh breath

PLANNING LONG TERM OUTCOME: Upon discharge, the patient will be able to establish a normal, effective respiratory pattern as evidenced by absence of signs of hypoxia and cyanosis. SHORT TERM OUTCOME: After 30 minutes hours of nursing interventions: the patient will be able to experience no signs of respiratory compromise and complications

INTERVENTIONS (IMPLEMENTATION)) INDEPENDENT: a) Assess respiratory rate/depth.

SCIENTIFIC RATIONALE

EVALUATION LONG-TERM OUTCME ACHIEVED. After discharged, the patient established a normal, effective respiratory pattern as evidenced by absence of signs of hypoxia and cyanosis. SHORT-TERM OUTCOME ACHIEVED. After 30 minutes of nursing interventions:

Shallow breathing, splinting with respirations, holding breath may result in hypoventilation/atele ctasis. Areas of decreased/absent breath sounds suggest atelectasis, whereas adventitious sounds (wheezes, rhonchi) reflect congestion.

b) Auscultate breath sounds.

Objectives: fatigue anxious facial grimace restless irregular respiratory rhythm nasal flaring thick clear sputum dyspnea harsh breath sound with crackles use of accessory muscles

c) Assist patient to turn, cough, and deep breathe periodically.

the mother will be able to verbalize awareness of causative factors of d) Teach and assist breathing pattern mother how to splint disturbances in relation and instruct in to the condition and effective breathing initiate needed lifestyle techniques such as changes deep breathing.

Promotes ventilation the patient of all lung segments experienced no and mobilization signs of respiratory and expectoration of compromise and secretions. complications such as cyanosis and Facilitates lung lethargy. expansion. Splinting provides incisional the mother support/decreases verbalized muscle tension to awareness of promote causative factors of cooperation with breathing pattern therapeutic regimen. disturbances in relation to the

sound with crackles use of accessory muscles Reference: Pathophysiology by Thomas J. Nowak

e) Teach and assist mother to elevate head of bed and change patients position appropriate for age and condition every 2 hours. f) Promote systemic fluid hydration, as appropriate.

Lowers diaphragm, promoting chest expansion, aeration of lung segments, mobilization and expectoration of secretions. Fluids (especially warm liquids) aid in mobilization and expectoration of secretions These clinical manifestations would be early indicators of hypoxia.

condition and initiated needed lifestyle by avoiding infections such as disinfecting hands before touching the infant

g) Monitor for increased restlessness, anxiety, and air hunger.

COLLABORATIVE: a) Administer medications as indicated: mucolytics, expectorants, bronchodilators, analgesics. b) Provide supplemental fluids as prescribed. E.g., IV, humidified oxygen, androom humidification

Aids in reduction of bronchospasm and mobilization of secretions and improves coughing effort. Fluids are required to replace losses (including insensible) and aid in mobilization of secretions.

Note: Some studies indicate that room humidification has been found to provide minimal benefit and is thought to increase Reference: Fundamentals of Nursing by Kozier and Erbs

ASSESSMENT Subjective: Paputol-putol ang tulog niya kasi mayat maya hindi siya makahinga dahil sa sipon niya, as verbalized by the mother.

NURSING DIAGNOSIS Sleep Pattern Disturbances related to difficulty of breathing as evidenced by restlessness after sleep and weak cry.

SCIENTIFIC EXPLANATION Health care interventions and difficulty of breathing as stimuli sumpathetic nervous system increase norepinephrine hypothalamus and cerebral cortex decrease serotonin and GABA sends nerve impulse activates reticular activating system (RAS) decrease REM and NREM disturbed sleeping pattern irritable

PLANNING LONG TERM OUTCOME: Upon discharge, the patient will be able to maintain normal continuous sleeping pattern with no any disturbance and achieve optimal amount of sleep as evidenced by rested appearance and improve sleep pattern.

INTERVENTIONS (IMPLEMENTATION)) INDEPENDENT: a) Assess sleep pattern disturbances that are associated with specific underlying illnesses. b) Observe and obtain feedback from mother or significant others regarding usual bedtime, routines, number of hours of sleep, and environmental needs.

SCIENTIFIC RATIONALE

EVALUATION LONG-TERM OUTCME ACHIEVED. After discharged, the patient maintained normal continuous sleeping pattern with no any disturbance and achieved optimal amount of sleep as evidenced by rested appearance and improve sleep pattern. SHORT-TERM OUTCOME ACHIEVED. After 30 minutes of nursing interventions the patient: woke up less frequently and followed 6 8 hours of sleep at night displayed feeling of rested after sleep

High percentage of sleep disturbances are affected by illnesses.

To determine usual sleep pattern and provide appropriate interventions.

Objectives: irritable body malaise restlessness after sleep taking a nap when there is a chance yawning weak cry shortness of breath thick clear sputum

SHORT TERM OUTCOME: After 30 minutes hours of nursing interventions, c) Provide care as the patient will be able to: possible without waking the client and wakes up less while the patient is frequently and follow still awake. sleeping 6 8 hours at night d) Explain to the display feeling of mother/significant rested after sleep others the necessity of disturbances for monitoring vital signs and care.

To avoid disturbances during sleep and to maximize sleeping process. This is to let the mother and significant others to understand the importance of care being done to the patient and also to minimize complaints.

 restlessness after sleep yawning body malaise Reference: Fundamentals of Nursing by Kozier and Erbs

COLLABORATIVE: a) Administer medications as indicated: pain reliever

To relieve discomfort and take maximum advantage of sedative effect Reference: Fundamentals of Nursing by Kozier and Erb