Pneumonia Case Presentation

1
Case Presentation Le Donneur 15 Pneumonia

I. INTRODUCTION
A. Overview of the Case
Pneumonia is an inflammation of the lung parenchyma caused by various
microorganisms, including bacteria, mycobacteria, fungi, and viruses. Pneumonitis is a more
general term that describes an inflammatory process in the lung tissue that may predispose or
place the patient at risk for microbial invasion. Pneumonia and influenza are the most common
causes of death from infectious diseases in the United States. Together they account for nearly
60,000 deaths annually and rank as the eighth leading cause of death in the United States
(Minino, Heron, Murphy, et al.,2007)
Pneumonias are classified as community-acquired pneumonia (CAP), hospital-acquired
(nosocomial) pneumonia (HAP), pneumonia in the immunocompromised host, and aspiration
pneumonia. There is overlap in how specific pneumonias are classified, because they may occur
in differing settings.

CAP occurs either in the community setting or within the first 48 hours after
hospitalization or institutionalization. The need for hospitalization for CAP depends on the
severity of the pneumonia. The causative agents for CAP that requires hospitalization are most
frequently S. pneumoniae, H. influenzae, Legionella, Pseudomonas aeruginosa, and other
gramnegative rods. The specific etiologic agent is identified in about 50% of cases. It is
estimated that more than 915,000 episodes of CAP occur in adults 65 years of age and older
each year in the United States (Mandell, Wunderink, Anzueto, et al., 2007).
S. pneumoniae (pneumococcus) is the most common cause of CAP in people younger
than 60 years of age without comorbidity .S. pneumoniae, a gram positive organism that resides
naturally in the upper respiratory tract, colonizes the upper respiratory tract and can cause
disseminated invasive infections, pneumonia and other lower respiratory tract infections, and
upper respiratory tract infections, such as otitis media and rhinosinusitis. It may occur as a lobar
or bronchopneumonic form in patients of any age and may follow a recent respiratory illness.
H. influenzae causes a type of CAP that frequently affects elderly people and those with
comorbid illnesses (eg, chronic obstructive pulmonary disease [COPD], alcoholism, diabetes
mellitus).
The presentation is indistinguishable from that of other forms of bacterial CAP and may
be subacute, with cough or low-grade fever for weeks before diagnosis. Mycoplasma
pneumonia is caused by M. pneumoniae. Mycoplasma pneumonia is spread by infected
respiratory droplets through person-to-person contact. Patients can be tested for mycoplasma
antibodies. The inflammatory infiltrate is primarily interstitial rather than alveolar. It spreads
throughout the entire respiratory tract, including the bronchioles, and has the characteristics of
a bronchopneumonia. Earache and bullous myringitis are common. Impaired ventilation and
diffusion may occur. Viruses are the most common cause of pneumonia in infants and children
but are relatively uncommon causes of CAP in adults. In immunocompromised adults,
cytomegalovirus is the most common viral pathogen, followed by herpes simplex virus,
adenovirus, and respiratory syncytial virus. The acute stage of a viral respiratory infection
occurs within the ciliated cells of the airways, followed by infiltration of the tracheobronchial
tree. With pneumonia, the inflammatory process extends into the alveolar area, resulting in
edema and exudation. The clinical signs and symptoms of a viral pneumonia are often difficult
to distinguish from those of a bacterial pneumonia.

Overuse and misuse of antimicrobial agents are major risk factors for the emergence of
these resistant pathogens. Development of a cough or increased cough and sputum production
are common presentations, along with low-grade fever and general malaise. In debilitated or
dehydrated patients, sputum production may be minimal or absent. Pleural effusion, high fever,
and tachycardia are common.
Pneumonia is the single largest cause of death in children worldwide. Every year, it kills
an estimated 1.2 million children under the age of five years, accounting for 18% of all deaths of
children under five years old worldwide. Pneumonia affects children and families everywhere,
but is most prevalent in South Asia and sub-Saharan Africa
(http://www.who.int/mediacentre/factsheets/fs331/en/)
Pneumonia is among the leading causes of mortality in about five years, ranging from
2004-2008. It ranks no. 4 in the list with about 42,642 cases nationwide contributing to 46.2
rate in 2009 (http://www.doh.gov.ph/node/198.htm)
Pneumonia in bukidnon ranks 3
rd
in the acute upper respiratory infections which is
pertaining to the leading causes of morbidity. It averages from 47,867 cases with rating of
1,273.60. Also it ranks 2
nd
in the leading causes of mortality, 1,903 cases with a rating of 50.63.
Pneumonia ranks 1
st
in infant mortality with cases of 145 and a rating of 1.84
(http://www.popcom.gov.ph/regions/10/Regional%20Profile.htm)
Maria Anagonkakai, the subject of the study, a 6 year old female, was admitted last July
26, 2013 and was diagnosed with Pneumonia. The subject was chosen because she ranked
first in the scoring made. The subject also resides closer compared to other patients the class
has handled which help save time, effort and money. The parents also allowed the class to
conduct the said case study with their daughter as the subject of the said study.

B. Objective of the study

General objectives:

At the end of 8 hours case presentation, the students will be able
to discuss properly the condition of the client with the use of skills,
knowledge and attitudes including the application o nursing process.

Specific objectives:
At the end of 8 hours case presentation, the students will be able
to
Skills:
Accurately present of thorough general health assessment
of the client which includes physical assessment and family
history taking
Effectively discuss and collaborate actual signs and
symptoms of the disease process by the client with
confidence
Knowledge:
Learn basic and appropriate nursing interventions,
treatment plan of prognosis of the disease condition of the
patient
Understand the normal anatomy and physiology of the
affected organ that are affected by the underlying disease
condition
Attitude:
Demonstrate and understand about ones strength and
weakness and take measures to enhance ones skills and
abilities
Able to accept criticism and comments from the clinical
instructor
Scope of limitation

C. Scope and limitation
The scope of the study was to find out more about the
patients condition through assessment, interviews with her
family, reviewing the patients profile, the doctors orders, the
laboratory exams made and interpreting its results and
researching and reading more about the patients condition from
books, journals and internet sources among others.
The scope of the study would also include all the vital information
about the patient and her family, her present health condition;
the ideal medical and nursing and the actual nursing
interventions/care that was done and given to the patient all
throughout his confinement at the, BPH-Maramag Pedia Ward.
The limitation of the study was the short amount of time
that was allotted for the group in giving care to the patient. The
patient was given care for 12 hours with actual nursing care done
during our hospital rotation. All actual nursing interventions were
all carried out with the supervision of a clinical instructor and
were limited only to those procedures which were permitted. This
study was completed altogether by both research and actual
hands-on exposure and interaction with the patient.

I. Health History

A. Patients Profile

Name: Maria AnagonKakai
Gender: Female
Age: 6 years old
Birthdate: August 9, 2013
Birthplace: Maramag, Bukidnon
Marital Status: Single
Race: Asian
Nationality: Filipino
Religion: Pentecostal
Address: P-1A,San Miguel, Maramag,Buk.
Educational Attainment: Elementary Undergraduate
Occupation: Student
Usual Source of Medical Care: Hospital
Source of Information: Mario AnagonKokoi
Admitting Diagnosis: Pediatric Community Acquired
Pneumonia (CAP)
UTI (Urinary Tract Infection)
Admitting Physician: Dr. Elaine Aurora A. Castanares

i. CHIEF COMPLAINTS

The patient was apparently well until two weeks ago, the patient
suffered with cough which had caused her to have a difficulty of
breathing (could not breath when lying) and accompanied with
fever and vomiting thus resulting to the admission of the patient
at BPH-Maramag.

ii. PAST HEALTH HISTORY
No history of hospitalization but has history of cough and fever.

B. HISTORY OF PRESENT ILLNESS
Often experiences cough but not addressed properly with no
appropriate intervention.

a. Gordons Functional Health Pattern
DESCRIPTION PRE-ADMISSION
ASSESSMENT
INITIAL
ASSESSMENT

Health Perception
and Health
Management

Perceived level of
health and well-
being, and practices
for maintaining
health. Habits that
may be detrimental
to health are also
evaluated, including
smoking and use of
alcohol or other
drugs.

Parents seek
immediate medical
advice once childs
illness is serious.
Parents let patient
use herbal
medications (lagundi,
hilbas).

Seeks medical
advice on July 26,
2013 because of
fever
accompanied with
vomiting and
cough which had
caused her to
have a difficulty of
breathing (could
not breath when
lying) thus
resulting to the
admission of the
patient.

Nutrition and
Metabolism

Pattern of food and
fluid intake relative to
metabolic needs. The
adequacy of local
nutrient supplies is
evaluated.

The client doesnt
have any changes on
weight. Patients SO
described her
appetite as good,
presently fair and
dont have any food
intolerances. Doesnt
want to eat
vegetables as
verbalized by the
patients father.
Usual diet is
comprised with
processed
goods/meat and eats

NPO temporarily
except
medication. Input
and output
monitoring every
shift.

three times a day.
Claimed no known
allergies in any foods
or drugs.

Elimination Pattern

Excretory patterns
(GI, GU, and skin).
Incontinence,
constipation,
diarrhea, and urinary
retention may be
identified.

Client defecates once
in every other day.
Usually in the
morning. Urinates 2-
3 times a day (50
cc/void).

Patient is in Input
and output
monitoring and
the urine is
yellowish in color.
Average input of
480 cc / 12 hours.
Average output of
100 cc/ 12 hours.

Activity and
Exercise
Activities of daily
living (ADLs) requiring
energy expenditure
including self-care
activities. Assess
major body systems
involved with activity
and exercise
including the
respiratory,
cardiovascular, and
musculoskeletal
systems.
Able to perform
activities of daily
living as a child. Plays
with other children in
the community.
Active.
Weak, tires easily.
Unable to perform
normal activities
of a child.
Manifest problem
in sleeping noted
due to presence
of cough and
difficulties in
breathing.
Lethargic and is
irritable.

Cognition and
Perception

Ability to
comprehend and use
information. Assess
sensory functions.
Sensory experiences
such as pain and
altered sensory input
may be identified and
evaluated.

Patient is oriented to
person, place, and
has good memory.
Able to comprehend
information.

No changes on
cognitive and
perceptual
pattern. Just
physically weak.

Sleep and Rest

Sleep, rest, and
relaxation practices.
Dysfunctional sleep
patterns and fatigue

The patient sleeps 6-
8 hours a day. Naps
1-2 times a day. Able
to have adequate

Energy level is
weak and tires
easily. The patient
could not really
may be identified. rest at night. sleep well
because of her
cough.

Self-Perception and
Self-Concept

Attitudes toward self,
including identity,
body image, and
sense of self-worth.
Level of self-esteem
and response to
threats of self-
concept.

According to mother,
patient has a good
personality, able to
deal with other
children
appropriately.
Dependent to her
parents.

According to
mother, patient
has a good
personality, but is
able to deal with
other children
appropriately with
her current
condition.
Dependent to her
parents.

Roles and relations

Roles in the world
and relationships
with others.
Satisfaction with
roles, role strain, or
dysfunctional
relationships maybe
further evaluated.

The patient is the
second child of the
couple. Able to
perform her role as a
child. Able also to
maintain a good
relationship with
peers and other
siblings.

The patient live
with her parents.
Bond of the family
grew stronger.
The attention of
the parents
turned and
focuses to the
patient due to her
confinement.

Sexuality and
Reproduction

Satisfaction and
dissatisfaction with
sexual patterns and
reproductive
functions. Concerns
with sexuality may be
identified.

Patient is a female
and is not yet
sexually matured.
The child is feminine

Patient is a female
and is not yet
sexually matured.
The child is
feminine.

Coping and Stress
Tolerance

Perceptions of stress
and coping strategies.
Support systems are
evaluated, and
symptoms of stress
are noted.
Effectiveness of
coping strategies in

The patient is stress-
free. Has a strong
support system from
family and friends.

The patient is
under stress due
to her current
condition. Copes
through sleeping
terms of stress
tolerance may be
evaluated.

Values and Beliefs

Values beliefs, and
goals that may guide
choices or decisions

The family is
affiliated with the
Pentecostal church of
Christ. They have a
strong faith to the
almighty father.

The family is
affiliated with the
Pentecostal
church of Christ.
They have a
strong faith to the
almighty father.
Theyre praying
for the fast
recovery of the
patient.
b. Review by systems and Physical Examination
General Health Survey
Area/ System Review of
system
Physical Assessment Nursing Problem
Identified Subjective Inspection Palpation Percussion Auscultation
Integumentar
y
No lesions
No rashes
Color of
the skin is
pinkish
Smooth
skin, moist
skin
Pinkish
nail beds
and soles
Ga uga lagi ang
panit sa akong
anak maam,
dayun luspad ang
iya kuku ug mga
lapa-lapa, as
verbalized by the
father.
No lesions
No rashes
Color of the
skin is pinkish
A bit rough
and Dry skin
noted
Pale nail beds,
pale soles

Poor skin
turgor
Cool skin

-----------------
---
------------------- Deficient Fluid
Volume
Impaired skin
integrity
Tissue perfusion,
ineffective (cardio
pulmonary) related
to decreased cellular
exchange

Head and
Neck
No
history of
headache
Nag sakit lagi na
iya ulo maam ato
pang pagka admit
niya pero dili na
kayo karun, as
verbalized by the
father.
HEAD
Skull is
symmetric
Asymmetric
facial
features
Hair evenly
distributed
on scalp
Hair color is
black

NECK
Thyroid is
HEAD
Absence of
masses and
lesions
noted
NECK
Absence of
palpable
masses
noted
Lymph
nodes are
not
palpable
-----------------
---
--------------------
--
Acute pain
not visible

Thyroid not
palpable

Hair and Nails No history
of alopecia
No history
of nail
fungus
No verbal cues HAIR
Fair
distributio
n
Some lice/
nits noted
NAILS
Not
trimmed

NAILS
Capillary Refill
beyond 5
seconds

-----------------
----
--------------------
---
Deficient Fluid
Volume
Tissue perfusion,
ineffective
(cardio
pulmonary)
related to
decreased
cellular
exchange

Eyes No history
of surgical
operation
No
impaired
vision
No
eyeglasses
No contact
lenses
good eye sight
as verbalize by
the father
Pupils are
equally round
White sclera
Globular
eyeballs
Black and
round iris
Pale
conjunctiva
No lesions
Periorbital
edema not
noted
-----------------
----
--------------------
--
Tissue perfusion,
ineffective
(cardio
pulmonary)
related to
decreased
cellular
exchange

Ears No
history
impaired
hearing
No
No problem as
verbalized by the
father
Skin intact
without lesions
Cerumen
present
Both auricles
Soft and pliable -----------------
---
--------------------
--
--------------------------------
--------
history of
ear
infections
No
hearing
aid
are level with
the both outer
canthus of the
eyes
Nose and
Sinus
Septum
located at
midline
No
obstructi
on in
nose
No
pain/tend
erness in
the
sinuses
Ge oxygen na
lagi na siya
maam kay
galisud ug
ginhawa dayun
luya na sad siya
maam, as
verbalized by the
father.

O2 inhalation
via nasal
cannula at 2-3
L/min
Septum
located at
midline
No
obstruction in
nose

Masses not
noted
No
pain/tenderness
in the sinuses
-----------------
---
--------------------
--
Impaired gas
exchange
Fatigue
Mouth and
Throat
No
lesions
No mass
Moist
mucous
membran
es
No verbal
cues
Dry
mucous
membrane
s

-----------------------
-
-----------------
---
--------------------
--
Impaired Oral
Mucous membrane
Respiratory No cough
Normal
breath
sounds
Luya na lagi kayo
na siya maam
kay walay undang
iya ubo dili sad
kaayo gusto
makipag istorya
O2 inhalation
via nasal
cannula
Tachypnea
noted
RR=>40bpm
----------------------- --------------
---------
Rales noted
Positive of
cough
Presence of
secretions,
sputum in
Altered
Respiratory
Pattern
Ineffective Airway
Clearance
Fatigue
mam , as
verbalized by the
father.
the airway

Verbal
communication,
impaired related
to physical
barriers

Cardiovascula
r central
Heart
Rate
within
normal
limits
No
murmurs,
extra
heart
sounds
No verbal cues --------------------
------
-------------------------- -----------------
---
Tachycardi
a noted
HR=>140bp
m
No
murmurs
, extra
heart
sounds
Poor tissue
perfussion
Cardiovascula
r Peripheral
Pulse
palpable
Pulse rate
within
normal
range
No verbal cues --------------------
---
Pulse is
palpable
-----------------
----
Pulse rate
above
normal
limits

Poor tissue
perfussion
Breast No
lesions
No mass
No verbal cues No lesions
noted

No mass noted -----------------
----
--------------------
---
--------------------------------
--------
Genitourinary
System
No pain
while
voiding
Good
eliminatio
No verbal cues No lesion in
the genitalia
Decreased
urinary
output
----------------------- -----------------
-----
--------------------
-
Urinary retention
n pattern
No
lesions in
the
genitalia
Musculoskele
tal
No signs
of
weakness
No
fractures
or use of
walkers/
crutches
Ge luyahan lang
siya mam, pero
wala siyay
problema sa
bahin sa bukog-
bukog, as
verbalized by the
father.
No fractures
or use of
walkers/cru
tches
-------------------- -----------------
----
--------------------
-
fatigue

c. Genogram

III. Developmental Data
1. Nursing Theories
Florence Nightingale: Environmental Philosophy
The patient lives in a rural place and quiet environment. It is
located near in the syre highway wherein pollution sees as a health
threat to the condition of the patient. Their house is made with light
materials and half concrete, still for construction. They only have one
room and one kitchen for the family which means transmissions of
microorganism is easy. They have a poor sanitation at home and do not
have a proper bins for their garbage. The family is prone in acquiring
diseases such as dengue because of the open drainage soiled with
garbage. The family is also prone in acquiring communicable diseases due
to the close construction of houses. And on her diet, she doesnt likes to
eat vegetables, often eat meat, and drinks 6 to 8 glasses of water per day.
Faye Glenn Abdellah. 21 Nursing Problems

The patient was being determined to have some of this
problems regarding her health condition such as difficulty in breathing
and maintaining physical hygiene, doesnt communicate well with others
except for her mother. Inexpressive on her feelings due to her age. All
medicine and nursing intervention helped the patient overcome this
recognized problem. As a health care partner and nurse should identify
the alert and covert problems of the patient before giving the
intervention to each identified problems.
Virginia Henderson- 14 Basic Human Needs
Care includes the following:
Breathe normally
The patient has oxygen inhalation of 1 to 2-3 l/min since
the day of admission
Eating drinking adequately
The patient was ordered NPO upon admission. Low
appetite.
Eliminate body waste
Chest physiotherapy to remove secretions
Maintaining proper physical hygiene
Difficulty in expectorating sputum
Poor nutrition
Does not eat nutritious food such as vegetables
Proper ventilation and lighting
No air coming into the room at the hospital and aircon is
not functional. Manual fanning is given to the patient.

The patient was identified to have some of these problems
regarding her health condition. All medicine and nursing intervention
helped the patient. As a health care provider, the nurse should identify
the overt and covert problems of the patient before giving the
intervention to each identified problems.

2. Developmental Theories
Developmental theories provide a framework for the psychosocial
profile. Identifying patients development stage will help determine the
relationship between the patients health status and her growth and
development.

Developmental
Theories/Theorist
Description

A. Sigmund
Freuds
Psychosexu
al Theory
Age range: Birth to 1 year- Oral.
The patient do not manifest any oral fixation. The patient can drink,
eat well and do not manifest biting mannerism. Started talking easy
words like mama & papa when she was 6 months old. Breastfeed
until she was at 1 year old old and has a complete tooth and satisfied her
needs at this level.

Age range: 1 to 3 years- Anal:
The patient does not manifest any sign of anal-retentive behaviour
or any signs which indicates fixation at this stage. She was also toilet
trained during this time but still had nocturnal urination. The patient is
independent or has a control on both urination and defecation. The
patient doesnt have any catheter attached upon admission as ordered
by the Doctor.

Age range: 3 to 6 years- Phallic.
The patients dont have any fixation of this stage. The
patient is manifesting a normal bond and interaction towards opposite
sex. Play with her friends mostly with same gender according to her
mother

B. Erik
Eriksons
Psychosocia
l theory.
Stage 1: Trust vs. Mistrust. (birth-1 year)
Chronologically, this is the period of infancy through the first year of
life. The child, well-handled, nurtured, and loved, develops trust and
secutity and a basic optimism. Badly handled, she becomes insecure and
mistrustful.
The patients mother reported that the patient demonstrated
physical growth within normal range, was responsive to them through
body movements and vocalizations. The patient was breast fed and was
drinking breast milk very well. The mother reported that the patient
started walking when she was 8 months old.

Stage 2: Autonomy vs. Shame and doubt. (1-3 years)
The mother of the patient reported that the client was able to walk
alone at about one year old. At this age, the patient already had
favourites and was very curious about things around her. The patient
holds pencil and started drawing or stroking. She was also toilet trained
during this time but still had nocturnal urination.
Between the ages of one and three, children begin to assert their
independence, by walking away from their mother, picking which toy to
play with, and making choices about what they like to wear, to eat, etc. If
children in this stage are encouraged and supported in their
independence, they become more confident and secure in their own
ability to survive in the world. If children are criticized, overly controlled,
or not given opportunity to assert themselves, they begin to feel
inadequate in their ability to survive, and may then become overly
dependent upon others, lack self-esteem, and feel a sense of shame or
doubt in their own abilities.

Stage 3: Initiative vs. Guilt. (4-6 years).
During the pre-school years, children begin to assert their power
and control over the world through directing play, and other social
interactions. Children who are successful at this stage feel capable and
able to lead others. Those who fall to acquire these skills are left with a
sense of guilt, self doubt, and lack of initiatives.
The patient has a control of everything. She begin direct playing,
and socialized with other child.

Stage 4: Industry vs. Inferiority.
This stage cover the early school years from approximately age 5 to
11. Through social interactions, children begin to develop a sense of
pride in their accomplishments and abilities. Children who are
encouraged and commended by parents and teachers develop a feeling
of competence and belief in their skills. Those who received little or no
encouragement from parents, teachers, or peers will doubt their abilities
to be successful.
The patient is socially active. She has a feeling of competence and
belief on her skills, she already know how to write and started schooling.
She can manifest no doubt on any of her abilities.

C. Jean
Piagets
Cognitive
theory
Sensorimotor.
This stage lasts from birth to about two years of age. In this stage,
the mother reported that the patient constructs an understanding of the
world by coordinating sensory experiences such as (seeing and hearing)
with physical, motoric action.

Preoperational stage.
This stage lasts from approximately two to seven years of age. The
patient at this stage begins to represent the world with words, images,
and drawings. She started saying mama when she was 6 months old,
holding pencil for drawing when she was 3 years old, and can write when
she was 5 years old.

IV. Medical Management
A. Medical Management and Rationale
Summary of Doctors Orders
Date Time Doctors Order Rationale
July 26,
13

2:05pm

Please admit

Secure consent to care

Problem: fever, cough

Condition: fair

Allergies: none

For proper monitoring,
management, and
evaluation
For the legality of all the
procedures to be done to
the patient; an evidence
that the patient has
willingly agreed
To identify signs and
symptoms
Determine the severity of
condition
To check for allergies that
may have caused the

Activity: bed rest, with toilet
privilege

Diet: NPO temporarily except
meds

Routine nursing care:
1. I &O every shift

2. V/S every 4HR

Start IVF with D50.3% NaCl 3
bottles 500mL @65-70 cc/hr

Labs:
1. CBC with platelet count

2. U/A, please attach

3. OPD result CXR

Meds:
1. Cefuroxime 750 mg/mL,
give 700mg IVTT every
6hours ANST
2. Hydrocortisone 270mg
IVTT every6HR x 4 doses,
1
st
dose then 15mg every
8HR

problems
To promote rest and
healing

To promote relaxation of
GI; client was vomiting PTA

Gauges fluid status that
may help in determining
the condition of the patient

To monitor for any
unusualities or
improvement in the
patients condition.

To balance out patients
electrolytes; for hydration

To determine the general
status of the patient

An examination of the urine
to detect and measure
various compounds that
pass through the urine

To have internal
visualization of the chest,
especially the lungs and the
heart.

Bactericidal

Enters target cells and binds
to cytoplasmic receptors;
initiates many complex
reactions that are
responsible for its anti-
inflammatory,
immunosuppressive

July 26,
13

July 27,

7:30 pm

6:00 pm

3. Salbutamol 1 nebule +2cc
NSS, nebulize every
15minutes x 3 doses, then
every 4HR thereafter

4. Ranitidine 50mg/ampule,
give 25mg IVTT every 12HR

5. Ambroxol 75g/mL, give
1.75 mL 3 times a day

6. Cetirizine 5 mg/5mL, give
5mL once a day @ bedtime

7. Paracetamol 250 mg/5mL,
give 7.5mL every 4HR pm if
temp is 38C

Chest tapping every after
nebulisation

Refer accordingly

May give hydrocortisone 15g
IV every 8HR, 1
st
dose 270mg

produces bronchodilation
by stimulating production
of cyclic adenosine
monophosphate (cAMP)

Inhibits gastric secretion by
inhibiting the action of
histamine at histamine-2
receptors in gastric parietal
cells.

Decreases the viscosity of
tenacious secretions by
increasing fluid in the
respiratory tract.

Compete with histamine to
bind to H-1 receptors
throughout the body; block
histamines effects on body
in hypersensitivity or
allergic reactions.

Inhibits prostaglandin
synthesis in the CNS and
stimulate peripheral
vasodilation to reduce
fever.

Mobilizes secretions

For continuity of care;
collaborative treatment
between client and health
providers.
reactions that are
inflammatory,
immunosuppressive.
13

July 28,
13

July 29,
13

Continue meds

May have diet as tolerated

IVFTF D5IMB 2 bottles 500mL
@SR

Repeat U/A and CBC with
platelet count

Continue nebulisation

IVFTF D5IMB 500mL @SR

Decrease IV fluid rate to KVO
rate

Repeat CBC with platelet
count

Refer to Dr. Danlag regarding
leukocytosis
Hold nebulization

Decrease salbutamol
nebulisation to every 12HR

Continue meds

Compliance with meds will
avert any complications;
promote improvement of
condition of the patient.

Client can now tolerate any
food she desires that is
nutritious, if this will not
lead to any complications
and if the client needs
further monitoring for lab
test.
This solution gives patient
calories and keeps them
hydrated with water.

To determine any
improvement in the results.

Promotes bronchodilation


To reduce excessive intake
of fluid volume

To see if WBC has returned
to normal

To confirm leukemia

Patients have tachycardia

Bronchodilators can cause
tachycardia


July 30,
13

Acetylcystein (Falvix) 100 g
/sachet, 1 sachet mixed in
cup of water 3xa day

UTZ whole abdomen

Kindly place Chest X-ray films
at Nurses Station, must
officialy read

Discontnue salbutamol
nebulisation

Nebulize with salbutamol +
ipratropium 1 neb every 4HR

Start clarithromycin
125mg/5mL, 4mL BID, PO

Start cefuroxime

Refer

IVFTF D5IMB 2 bottles 500 mL
Decrease mucus viscosity
by breaking or altering the
chemical bonds of
glycoprotein complexes in
mucus.

To determine enlargement
of organs (could be caused
by the accumulation of
WBCs since leukemia is
suspected)

To have internal
heart.
Theres a change of
medication

The ipratropium ingredient is
an anticholinergic drug which
relaxes smooth muscle in the
lung. The salbutamol
ingredient i sa beta-2agonist
whichstimulatesbeta-2 sites
in the lungs to relax the bronchi

Inhibits microbial protein
synthesis, causing cell lysis.

Inhibits cell-wall synthesis,
promoting
osmotic instability; usually
bactericidal.

providers.


July 31,
13

Aug. 1, 13

4:41pm

(-)
tachycardia

Still crackles
and
@SR

Continue meds.

Follow-up UTZ result

Continue IV meds

Continue nebulization

Secure procurement of meds

IVFTF D5IMB 500 mL at SR

Increase nebulization to every
2 hours

Repeat CBC, platelet count,
and CXR (compare with
previous film)

Still for CXR

Continue Meds

IVFTF D5IMB 500c @SR



To determine enlargement
of organs (could be caused
by the accumulation of
WBCs since leukemia is
suspected)


Promotes vasodilation.

For compliance of meds


To loosen secretions

To determine any changes
in the condition of the
client.

For internal visualization of
the chest.



Aug. 1, 13

Aug. 1, 13

Aug. 2, 13

Aug. 2, 13

wheezes

(+)
tachypnea

11:50 am
(+)
tachypnea
(+) crackles
and
wheezes

O
2
inhalation via nasal cannula
@1-2L/min, PRN for dyspnea

Kindly follow up CXR result

Nebulize with Budenoside 1neb
q12HR

Monitor V/S q2HR

Continue O
2
inhalation

Continue all meds

Advised

Transfer patient to ICU

Monitor V/S q1HR

NPO temporarily except meds

Labs: Sputum AFB

IVF: D5IMB 500cc @ 70cc/hr

Meds:
1. Hydrocortisone 100mg IVTT,
q6HR

To relief client from
shortness of breath.

To determine unusualities
and to give immediate
intervention
Prevent release of or
counteract biochemical
mediators that cause the
tissue inflammation
responsible for edema and
airway narrowing.

To closely examine changes
of vital signs
To sufficiently supply
oxygen to the client

For the continuity of care

To closely monitor the
condition of the client and
to give immediate
interventions when
unusualities occur.

To closely examine the
clients status

To avoid aspiration
pneumonia.

To determine tuberculosis

Make up for the increased
urine output.

Aug. 2, 13

Aug. 3, 13

8:10 pm

Decrease
urine
output
(+)
tachypnea

2. Piperacillin tazobactam 1.25 g
IV q8HR

3. Clarithromycin 125g /5mL, 7.5
mL BID, PO

4. Budenoside 1 neb q12HR

5. Famotidine 10mg IV q12HR

Discontinue other meds

Refer accordingly

May have DAT with SAP

Discontinue Famotidine

Apply cold compress on
hypogastric area alternately with
warm compress
reactions that are
inflammatory,
immunosuppressive.

Inhibit synthesis of bacterial
wall and cause rapid cell
lysis.


tissue inflammation
airway narrowing.

Inhibits gastric secretion by
inhibiting the action of
histamine at histamine-2
receptors in gastric parietal
cells.

There is a change in
medication.
providers.

Eating is limited and strictly
monitored to prevent
choking

Patient is already able to
ingest food

For client relief and comfort

Aug. 4, 13

Decrease present IVF rate to
50cc/hr

Give furosemide 20mg 1tab now
with BP precaution

Decrease hydrocortisone IV q8HR

Decrease O
2
inhalation to 1LPM
via nasal cannula

Continue all meds

For repeat CBC

For peripheral blood smear as
ordered

Cough patient now then daily
(every7am)

Nebulize with salbutamol +
ipatropium q4HR

O
2
inhalation to discontinue

Patients RR increases
(more than 40)

Inhibit sodium and chloride
reabsorption, thereby
increasing urine output.

reactions that are
inflammatory,
immunosuppressive

To sufficiently supply
oxygen to the client


To determine changes in
the general status of the
client

The cell types are examined
under a microscope for
unusual shapes or sizes.

To religiously secrete
phlegm


Aug. 5, 13

Aug. 6, 13

(+)
tachypnea
(+) crackles
and
wheezes
(+) mild
edema,
bipedal
angiedema

Hydrocortisone q12HR

To consume available
hydrocortisone IV

Shift prednisone 10mg/5mL, 5mL
TID, PO

Refer accordingly

IVFTF with D5IMB 2 bottles 500 cc
@50cc/hr

Follow up Chest X-ray result

Give furosemide 20mg 1 tab now,
with BP precaution

IVFTF D5IMB @SR

Resume O
2
inhalation @1, 5LPM
via nasal cannula

For observation

reactions that are
inflammatory,
immunosuppressive

tissue inflammation
airway narrowing.

For further assessment,
management, and
evaluation.


To have internal
heart.



For good oxygenation;

(+) CXR=
Pneumonia
Continue meds

IVFTF D5IMB @SR

Continue O
2
inhalation

Continue meds

1. Piperacillin + Tazobactam
1.25g IV, q8HR

2. Clarithromycin 125 mg/5mL,
7.5 mL BID PO

3. Prednisone 10mg/5mL, 5mL
TID PO

4. Montelukast 5mg 1 tab, OD
@HS

5. Salbutamol + Ipratropium 1
neb q4HR

patients RR increase.



For oxygenation.


Inhibit synthesis of bacterial
wall and cause rapid cell
lysis.


tissue inflammation
airway narrowing.

Selectively compete for
leukotriene receptor sites,
thereby blocking
inflammatory action that
causes the signs and
symptoms of asthma.


Aug. 6, 13

Aug. 7, 13


Furosemide 20mg 1 tab now, with
BP precaution

Refer

Decrease IVF rate to 30cc/hr

Place on moderate high back rest

O
2
inhalation to 1LPM via nasal
cannula

Nebulize with 1 neb salbutamol +
Budenoside 1 neb 30 minutes x 2
doses only

Continue meds

Continue nebulization

Nebulize with 1 neb salbutamol
every 20 minutes x 3 doses then
resume salbutamol + ipratropium
for nebulisation q4HR

Start seretide 25 mg/50mg x 2
puffs BID

tissue inflammation
airway narrowing.


management, and
evaluation.

To avoid fluid overload

Promotes lung expansion

For good oxygenation

To dilate bronchi and
loosen secretions

Compliance with meds may
avert complications

For continuity of care

To loosen secretions

Selectively activates beta
2adrenergicreceptors,
which results in

Aug. 8, 13

Discontinue montelukast

IVFTF D5IMB 500cc @SR

To consume available piperacillin
+ tazobactam

Continue other meds

Discontinue O
2
inhalation

Refer accordingly

May transfer to ward

V/S every 4 hours

Diet for age

Continue meds

1. Salbutamol + Ipratropin 1
neb q4HR

bronchodilation and blocks
the release of allergic
mediators from the mast
cells in the respiratory tract

Change of medication

For continuity of care

Compliance with meds may
avert complications
For oxygenation

management, and
evaluation.

Stable vital signs; does not
need more immediate
interventions.
To monitor for any
unusualities or
improvement in the
patients condition.

Appropriate nutrition for
the patient



Aug. 8 ,13

Aug. 9, 13

4:30pm
(+) wheezes
and crackles

3. Clarithromycin 125 mg/5mL,
7.5 mL BID PO

4. Prednisone 10mg/5mL, 5mL
TID PO

5. Seretide 25mg/50mg x 2
puffs BID

IVFTF D5IMB 500cc @SR

O
2
inhalation 2-3 LPM via nasal
cannula PRN for dyspnea/SOB

Please refer accordingly

Thank you

Decrease Salbutamol + Ipratropin
neb timing to q6HR


tissue inflammation
airway narrowing.


tissue inflammation
airway narrowing.

Selectivelyactivates beta
2adrenergicreceptors,
whichresults
inbronchodilation andblcks
the release of allergic
mediatorsfrom the mast
cellsin the respiratorytract

calories and keeps them.

For good oxygenation

management, and
evaluation.

Aug. 9, 13

Aug. 9, 13

12:40pm
Still with
productive
cough but
decreased
frequency
Decreased
crackles and
wheezes

Continue other meds

Follow up result for peripheral
blood smear

Continue present meds

IVFTF D5IMB 2 bottles 500cc @SR

Repeat urinalysis

Follow up result of Chest X-ray
(#3)

Follow up peripheral blood smear

MGH once with official results

Home meds

OPD check-up on August 12, 2013

There is an improvement of
the patients cough.




calories and keeps them.

An examination of the urine
to detect and measure
various compounds that
pass through the urine.

To have internal
heart.


Stable or there is an
improved condition.


Fairly advised

Home per request

Follow-up and for
monitoring the condition;
continuity of care.

For compliance

Client request to go home;
right of the client to make
decision

B. Drug study
NAME OF
DRUG
CLASSIFICATIO
N
SPECIFIC
INDICATION
CONTRAINDIC
ATION
ADVRESED/
TOXIC
EFFECTS
NURSING
RESPONSIBILITIE
S
GENERIC
NAME:

Cefuroxime

Second-
generation
Cephalosporins
Treatment
for
infections of
the lower
respiratory
tract
Used
cautiously with
patients
allergic to
penicillins;
those with
history of GI
disease
(particularly
Colitis)

Nausea
Vomiting
Diarrhea
Anaphyla
xis
Pseudom
embrano
us colitis
12 rights of drug
administration

Obtain patients
allergy history
before
administering
drug

Observe for
signs and
symptoms of
BRAND
NAME:

Ceftin

DATE
ORDERED

July 26,
2013

MECHANISM
OF ACTION:

Inhibits cell-
wallsynthesis,
promoting
osmotic instabi
lity;usually
bactericidal.
allergic
reactions after
giving drug,
discontinue the
drug and notify
the physician
immediately if
reaction occur

DOSE:

750mg/mL,
give 700mg

FREQUENC
Y:

Every 6
hours
ROUTE:

IVTT

NAME OF
DRUG
CLASSIFICATIO
N
SPECIFIC
INDICATIO
N
CONTRAINDICAT
ION
ADVRESED/
TOXIC
EFFECTS
NURSING
RESPONSIBILITIE
S
GENERIC
NAME:

Hydrocortis
one

Corticosteroids
(Glucocorticost
eroids)
Treat
respiratory
tract
diseases
Contraindicated
in patients with
CNS:
Headache,
dizziness,
fatigue,
neuropsychi
atric effect
12 rights of drug
administration

BRAND
NAME:

Solu-cortef

GI: nausea,
diarrhea,
abdominal
pain, dental
pain, liver
impairment

RESPIRATO
RY:
Influenza,
cold, nasal
congestion

ORTHER:
Generalized
pain, fever,
rash,
fatigue

DATE
ORDERED:
July 26,
2013

MECHANISM
OF ACTION:

Enters target
cells and binds
to cytoplasmic
receptors;
initiates many
complex
reactions that
are responsible
for its anti-
inflammatory,
immunosuppre
ssive
(glucocorticoid
)

DOSE:

15 mg

FREQUENC
Y:

Every 8
hours

ROUTE:

IVTT

NAME OF
DRUG
CLASSIFICATIO
N
SPECIFIC
INDICATION
CONTRAINDIC
ATION
ADVRESED/
TOXIC
EFFECTS
NURSING
RESPONSIBILITIE
S
GENERIC
NAME:

Albuterol

Bronchodilator
Treat acute
bronchospa
sm

Patients
with
uncontrol
led
arrhythmi
as,
hyperten
sion,
CAD, or
history of
stroke
Used
cautiousl
y in
patients
with
diabetes,
hyperthyr
oidism,
or history
of
seizures

Anxiety
Nervousne
ss
Tremor
Tachycardi
a
Palpitation
Hypertensi
on
Arrhythmia
s
Dry mouth
Bronchosp
asm
Hypokalem
ia in
dialysis
patients

Monitor the
patients v/s as
well as breath
sounds

Dont
administer drug
during acute
asthma attack

Instruct patient
to maintain fluid
intake

Instruct the
patient to avoid
respiratory
irritants such as
smoke, dusts,
and strong
scents

BRAND
NAME:
Salbutamol
DATE
ORDERED

July 26,
2013

MECHANISM
OF ACTION:

produces
bronchodilatio
n by
stimulating
production of
cyclic
adenosine
monophosphat
e (cAMP)
DOSE:

1 neb + 2cc
NSS

FREQUENC
Y:

Every 12
hours

ROUTE:

Inhalation

NAME OF
DRUG
CLASSIFICATIO
N
SPECIFIC
INDICATION
CONTRAINDIC
ATION
ADVRESED/
TOXIC
EFFECTS
NURSING
RESPONSIBILITIE
S
GENERIC
NAME:

Ranitidine

Histamine-2
Receptor
Antagonists
Decrease
gastric acid
production
and prevent
stress ulcers
in severely
ill patients

Breast-
feeding
patients
Known
hypersenstiv
ity
Used
cautiously in
pregnant
patients,
with
impaired
renal or
hepatic
function,
and elderly
patients

Headache
Dizziness
Confusion
Mild
diarrhea

Teach the
patient that
smoking
worsens ulcer
disorders and
counteracts the
effects of H-2
antagonists

Dont give
antacid within 1
hour of
administering
drug; it may
decrease
absorption of
drug

Assess for
epigastric or
abdominal pain

Teach to avoid
gastric irritants
such as
smoking,
alcohol
BRAND
NAME:

Zantac
DATE
ORDERED

July 26,
2013

MECHANISM
OF ACTION:

Inhibits gastric
secretion by
inhibiting the
action of
histamine at
histamine-2
receptors in
gastric parietal
cells.
DOSE:

50mg/amp,
give 25mg

FREQUENC
Y:

Every 12
hours

ROUTE:

IVTT

NAME OF
DRUG
CLASSIFICATIO
N
SPECIFIC
INDICATIO
N
CONTRAINDICAT
ION
ADVRESED/
TOXIC
EFFECTS
NURSING
RESPONSIBILITIE
S
GENERIC
NAME:

Ambroxol
Expectorant Treat
cough
associated
with
bronchial
athma

Contraindicated
in patients with
hypersensitivity

Used cautiously
in patients with
ineffective
cough reflex or
respiratory
insufficiency.

Vomiting (if
taken in
large
doses),
diarrhoea,
nausea,
drowsiness,
and
abdominal
pain.
12 rights of drug
administration

Maintain airway
patency,
provide suction
if necessary

Assess breath
sounds,
evaluate the
characteristics
of cough and
frequency

Instruct to
maintain fluid
intake.

BRAND
NAME:

Aeroflux

DATE
ORDERED:
July 26,
2013

MECHANISM
OF ACTION:
Decrease the
viscosity of
tenacious
secretions by
increasing fluid
in the
respiratory
tract.
DOSE:

1.75 mL

FREQUENC
Y:

TID

ROUTE:

NAME OF
DRUG
CLASSIFICATIO
N
SPECIFIC
INDICATION
CONTRAINDIC
ATION
ADVRESED/
TOXIC
EFFECTS
NURSING
RESPONSIBILITIE
S
GENERIC
NAME:

Cetirizine

antihistamine
Symptomati
c relief of
symptoms

Patients
with
previous
history of
allergiv
reactions
Shouldnt
in
patients
with
allergy to
hydroxyzi
ne
Narrow-
angle
glaucoma
, BPH, or
asthma

GI upset
CNS
depression
and CNS
effects
(disturbed
coordinatio
n)
Dryness of
mouth,
throat, and
nose
Increased
respiratory
secretions
Increased
heart rate
Fever, rash
palpitation
s

Observe signs
and symptoms
of
hypersensitivity
reactions

Administer drug
with food or
milk to decrease
GI irritation

Withhold drug if
the patient is
scheduled to
receive an
allergy skin test

Use Z-track
method if giving
drug
parenterally

BRAND
NAME:

Zyrtec
DATE
ORDERED

July 26,
2013

MECHANISM
OF ACTION:

Compete with
histamine to
bind to H-1
receptors
throughout the
body; block
hitamines
effects on body
in
hypersensitivit
y or allergic
reactions
DOSE:

5mg/5mL,
give 25mg

FREQUENC
Y:

Once a day

ROUTE:

IVTT

NAME OF
DRUG
CLASSIFICATIO
N
SPECIFIC
INDICATION
CONTRAINDIC
ATION
ADVRESED/
TOXIC
EFFECTS
NURSING
RESPONSIBILITIE
S
GENERIC
NAME:

Paracetam
ol

Nonopioid
Analgesics;
Antipyreitc
Reduce
fever
Used
cautiously in
patients with
asthma or
nasal polyps

GI pain and
upset
Nausea
and
vomiting
Diarrhea

For a more
rapid effect,
administer
the drug
before
meals, to
reduce GI
irritation,
administer
with meals
Monitor
CBC,
platelet, and
hepatic and
renal
function
tests
Dont
administer
more than
the
recommend
ed dosage
because of
increased
risk of
toxicity
BRAND
NAME:

Biogesic
DATE
ORDERED

July 26,
2013

MECHANISM
OF ACTION:

Inhibits
prostaglandin
synthesis in the
CNS and
stimulate
peripheral
vasodilation to
reduce fever
DOSE:

250mg/5m
L, give 5mL
FREQUENC
Y:

Q4hr PM if
temp is
38C

ROUTE:

Oral

NAME OF
DRUG
CLASSIFICATIO
N
SPECIFIC
INDICATION
CONTRAINDIC
ATION
ADVRESED/
TOXIC
EFFECTS
NURSING
RESPONSIBILITIE
S
GENERIC
NAME:

Acetylcyste
ine

Mucolytics
Treat
abnomrla ,
viscid, or
thick and
hard mucus
Patients with
known
hypersensitivi
ty

Used
cautiously in
elderly,
debilitated,
pregnant, or
breast-
feeding
patients and
those with
asthma

Nausea
and
vomiting
Bronchosp
asms,
especially
in
asthmatic
patients

Maintain
airway
patency;
suction if
necessary
Assess
patients
breath
sounds,
evaluate
cough for
characteristi
c
Encourage
patient to
increase
fluid intake
Warn the
patient
about
acetylcystei
nes rotten
egg smell
BRAND
NAME:

Flavix
DATE
ORDERED

July 29,
2013

MECHANISM
OF ACTION:

decrease
mucus
viscosity by
breaking or
altering the
chemical
bonds of
glycoprotein
complexes in
mucus
DOSE:

100g/sache
t, 1 sachet
mixed in
cup of
water
FREQUENC
Y:

3x a day

ROUTE:

Oral

NAME OF
DRUG
CLASSIFICATIO
N
SPECIFIC
INDICATION
CONTRAINDIC
ATION
ADVRESED/
TOXIC
EFFECTS
NURSING
RESPONSIBILITIE
S
GENERIC
NAME:

Salbutamol
+
Ipratropiu
m

Anti asthmatic;
adrenergic-
agonist
bronchodilator
Prevention
and
maintenanc
e therapy
for
bronchospa
sms
Patients with
uncontrolled
arrhythmias,
hypertension,
coronary
heart disease,
or history of
stroke

Palpitation
s
Tachycardi
a
Arrhythmia
s
Hypertensi
on
Increases
severity of
any asthma
episodes
that occur

Monitor the
patients v/s as
well as breath
sounds

Dont
administer drug
during acute
asthma attack

Instruct patient
to maintain fluid
intake

Instruct the
patient to avoid
respiratory
irritants such as
smoke, dusts,
and strong
BRAND
NAME:

Combivent
DATE
ORDERED

July 29,
2013

MECHANISM
OF ACTION:

The ipratropium
ingredient is an
anticholinergic
drug which relaxes
smooth muscle
in the lung. The
DOSE:

1 neb
FREQUENC
Y:

Q4hr

salbutamol
ingredient i sa
beta-2agonist
whichstimulates
beta-2 sites in
the lungs to relax
the bronchi
scents
ROUTE:

inhalation

NAME OF
DRUG
CLASSIFICATIO
N
SPECIFIC
INDICATIO
N
CONTRAINDICAT
ION
ADVRESED/
TOXIC
EFFECTS
NURSING
RESPONSIBILITIE
S
GENERIC
NAME:

Budenoside
Corticosteroids Control
bronchial
asthma

Prophylacti
c
treatment
for
exercise-
induced
asthma
Contraindicated
in patients with
bronchospasms

Used with
extreme caution
in patients with
clinical
tuberculosis or
viral respiratory
infections, etc.

Mouth
irritation,
oral
candiasis,
and upper
respiratory
infections
12 rights of drug
administration

Instruct the
patient to rinse
mouth after
using inhaled
steroids

Instruct on
proper use and
care of inhaler
and spacer

Give oral doses
with food to
minimize GI
upset
BRAND
NAME:

Pulmicort
DATE
ORDERED

August 1,
2013

MECHANISM
OF ACTION:
Prevent
release of or
counteract
biochemical
DOSE:

1 neb

mediators that
cause the
tissue
inflammation
responsible for
edema and
airway
narrowing.
FREQUENC
Y:

Every 12
hours

ROUTE:

P.O

NAME OF
DRUG
CLASSIFICATIO
N
SPECIFIC
INDICATION
CONTRAINDIC
ATION
ADVRESED/
TOXIC
EFFECTS
NURSING
RESPONSIBILITIE
S
GENERIC
NAME:

Peppiracilli
n/Tazobact
am

Extended-
spectrum
Penicillins
Treat
infections
caused by
gram-
negative
bacteria
(Nosocomia
l or CAP)
Patients with
hypersensitivi
ty with
penicillins
and/or
cephalosporin
s

GI pain and
upset
Nausea
and
vomiting
Diarrhea
Rash

Obtain
patients
allergy
history
before
administerin
g the drug
Know that
an allergic
reaction to
penicillin
may occur
even in
patients
BRAND
NAME:

Zosyn
DATE
ORDERED

MECHANISM
OF ACTION:

August 2,
2013

Inhibit
synthesis of
bacterial wall
and cause
rapid cell lysis
with no
history of
allergic
reactions
Observe
signs and
symptoms
for allergic
reactions
Instruct the
patient to
avoid taking
oral
penicillin
with acidic
juices, may
reduce drug
absorption
DOSE:

1.25g
FREQUENC
Y:

Q8hr

ROUTE:

IV

NAME OF
DRUG
CLASSIFICATIO
N
SPECIFIC
INDICATION
CONTRAINDIC
ATION
ADVRESED/
TOXIC
EFFECTS
NURSING
RESPONSIBILITIE
S
GENERIC
NAME:

Clarithrom
ycin

Antibiotic
(Miscellaneous
Anti-
Infectives)
Treat
infections
caused by
gram-
positive and
gram-
Hypersen-
sitivity
toclarithro-
mycin,
other macroli
de

GI:
diarrhea,
nausea,vo
miting,
abdominal

Before:-
Note
sensitivity
toerythromy
cin or
BRAND
NAME:

Biaxin
negative
organisms,
pneumococ
ci
antibiotics,or
erythro-
mycin.Clients
takingpimozid
e.

pain
CNS:
headache,
dizziness,h
allucinatio
n,insomnia
,
Allergic:
urticaria,mi
ld skin
eruption,a
naphylactic
anymacrolid
e antibiotics.
List drugs
currentlypre
scribed to
preventany
interactions.
Document
onset,severi
ty
andcharacte
ristics
of S&S.Durin
g:
May
administer
withor
without
food.
Explain
effects
of the drug
and its
sideeffects.
Administer
asprescribed
.After:
Report
adverse
effects or
lack
of improvem
ent after 48-
72 hr.
DATE
ORDERED

July 29,
2013

MECHANISM
OF ACTION:

Inhibits
microbial
protein
synthesis,
causing cell
lysis and cell
death
DOSE:

125mg/5m
L, give 4mL
FREQUENC
Y:

BID

ROUTE:

Oral

NAME OF
DRUG
CLASSIFICATIO
N
SPECIFIC
INDICATIO
CONTRAINDICAT
ION
ADVRESED/
TOXIC
NURSING
RESPONSIBILITIE
N EFFECTS S
GENERIC
NAME:

Monteluka
st
Antasthmatic

Leukotriene
receptor
antagonist
Treatment
for Asthma
Contraindicated
in patients with
previous allergy
to any
leukotriene
modifier

Shouldnt be
used for
treatment of
status
asthmaticus r
acute asthma
attacks

CNS:
Headache,
dizziness,
fatigue,
neuropsychi
atric effect

GI: nausea,
diarrhea,
abdominal
pain, dental
pain, liver
impairment

RESPIRATO
RY:
Influenza,
cold, nasal
congestion

ORTHER:
Generalized
pain, fever,
rash,
fatigue

12 rights of drug
administration

Know that
montelukast is
best absorbed
when given at
night.

Instruct about
the use of
rescue
medication for
acute attacks or
when a short-
acting inhaled
medications is
needed.

BRAND
NAME:

Singulair

DATE
ORDERED:
July 26,
2013

MECHANISM
OF ACTION:
Selectively
compete for
leukotriene
receptor sites,
thereby
blocking
inflammatory
action that
causes the
signs and
symptoms of
asthma.
DOSE:
5 mg

FREQUENC
Y:
O.D
ROUTE:
P.O

NAME OF
DRUG
CLASSIFICATIO
N
SPECIFIC
INDICATION
CONTRAINDIC
ATION
ADVRESED/
TOXIC
EFFECTS
NURSING
RESPONSIBILITIE
S
GENERIC
NAME:

Famotidine
Histamine-2
Receptor
Antagonists
Decrease
gastric acid
production
and prevent
stress ulcers
in severely ill
patients

Breast-
feeding
patients
Known
hypersenstiv
ity
Used
cautiously in
pregnant
patients,
with
impaired
renal or
hepatic
function,
and elderly
patients

Headach
e
Dizziness
Confusio
n
Mild
diarrhea

Teach the
patient that
smoking
worsens ulcer
disorders and
counteracts the
effects of H-2
antagonists

Dont give
antacid within 1
hour of
administering
drug; it may
decrease
absorption of
drug

Assess for
epigastric or
abdominal pain

Teach to avoid
gastric irritants
such as
smoking,
alcohol
BRAND
NAME:

Pepcid
DATE
ORDERED

August 2,
2013

MECHANISM
OF ACTION:
Inhibits gastric
secretion by
inhibiting the
action of
histamine at
histamine-2
receptors in
gastric parietal
cells.
DOSE:

10 mg

FREQUENC
Y:

Every 12
hours

ROUTE:

IV

NAME OF
DRUG
CLASSIFICATIO
N
SPECIFIC
INDICATION
CONTRAINDIC
ATION
ADVRESED/
TOXIC
EFFECTS
NURSING
RESPONSIBILITIE
S
GENERIC
NAME:

Furosemid
e

Potassium-
sparing
Diuretic
Increase
urine
output
Contraindicat
ed with
allergy to
furosemide,
sulfonamides.
Use
dcautiously
with diabetes
mellitus./
with
metabolic
disorders.

Nausea
and
vomiting
Constipatio
n
Orthostatic
hypotensio
n

Arrange to
monitor sodium
and potassium
serum electrolyt
es.

Give early in the
day so that
increased
urination will not
disturb sleep.

Blood glucose
levels may
become
temporarily
elevated in patients
with diabetes
after starting
this drug.

Give medications
as ordered that
will help loosen
stools in case
of constipation.

BRAND
NAME:

Lasix
DATE
ORDERED

Aug. 2,
2013

MECHANISM
OF ACTION:

Inhibit sodium
and chloride
reabsorption,
thereby
increasing
urine output.

DOSE:

20 mg
FREQUENC
Y:

Now

ROUTE:

Oral

NAME OF
DRUG
CLASSIFICATIO
N
SPECIFIC
INDICATIO
N
CONTRAINDICAT
ION
ADVRESED/
TOXIC
EFFECTS
NURSING
RESPONSIBILITIE
S
GENERIC
NAME:

Prednisone
Cortecosteroid
s
Control
bronchial
asthma

Contraindicated
in patients with
bronchospasms

Used with
extreme caution
in patients with
clinical
tuberculosis or
viral respiratory
infections, etc

Mouth
irritation,
oral
candiasis,
and upper
respiratory
infections
12 rights of drug
administration

Instruct the
patient to rinse
mouth after
using inhaled
steroids

Instruct on
proper use and
care of inhaler
and spacer

Give oral doses
with food to
minimize GI
upset
BRAND
NAME:

Deltasone
DATE
ORDERED:
Aug. 6,
2013

MECHANISM
OF ACTION:
Prevent
release of or
counteract
biochemical
mediators that
cause the
tissue
inflammation
responsible for
edema and
airway
narrowing.
DOSE:
5 mg

FREQUENC
Y:
O.D
ROUTE:
P.O

NAME OF
DRUG
CLASSIFICATIO
N
SPECIFIC
INDICATION
CONTRAINDIC
ATION
ADVRESED/
TOXIC
EFFECTS
NURSING
RESPONSIBILITIE
S
GENERIC
NAME:

Salmetrol+
Fluticasone

Anti asthmatic;
adrenergic-
agonist
bronchodilator
Prevention
and
maintenanc
e therapy
for
bronchospa
sms
Patients with
uncontrolled
arrhythmias,
hypertension,
coronary
heart disease,
or history of
stroke

Palpitation
s
Tachycardi
a
Arrhythmia
s
Hypertensi
on
Increases
severity of
any asthma
episodes
that occur

Monitor the
patients v/s as
well as breath
sounds

Dont
administer drug
during acute
asthma attack

Instruct patient
to maintain fluid
intake

Instruct the
patient to avoid
respiratory
irritants such as
smoke, dusts,
and strong
scents
BRAND
NAME:

Seretide
DATE
ORDERED

Aug. 7,
2013

MECHANISM
OF ACTION:

Selectivelyactiv
ates beta
2adrenergicrec
eptors,
whichresults
inbronchodilati
on andblcks
the release
of allergic
mediatorsfrom
the mast
cellsin the
respiratorytrac
t
DOSE:

250mg/50
mg x 2
puffs
FREQUENC
Y:

BID

ROUTE:

Oral

C. Diagnostic and Laboratories
July 26, 2013
DIAGNOSTIC
TEST/NORMAL
VALUES

RESULT INTERPRETATION SIGNIFICANCE
Hematology:
Hemoglobin (11-
16gms)
13.1 Normal Normal
Hematocrit (37-
47vol%)
39.1 Normal Normal
WBC (5,000-
10,000/cu.mm)
24,900/cu.mm Above normal limits Infection
Platelet (150,000-
450,000/cu.mm)
418,000/cu.mm Normal Normal
Segmenters (55-65%) 44% Below normal limits Infections
Lymphocytes (25-
35%)
53% Above normal limits Infections
Monocytes (2-4%) 03% Normal Normal

U/A
Specific gravity
(1.015-1.020)
1.020 Normal Normal
Pus cell (0-1) 1.5 Above normal Infections
RBC (3-5 hpf) 0-1 Below normal Anemia

July
DIAGNOSTIC
TEST/NORMAL
VALUES

CBC
Hemoglobin (11-
16gms)
14.6 Normal Normal
Hematocrit (37-
47vol%)
44.4 Normal Normal
WBC (5,000-
10,000/cu.mm)
46,500/cu.mm Above normal limits Infections
Platelet (150,000-
450,000/cu.mm)
Lymphocytes (25-
35%)
Eosinophils (2-4%) 06% Above normal limits Allergies

U/A
Specific gravity
(1.015-1.030)
1.015 Normal Normal
Pus cell (0-1) 2.0 Above normal limits Infections
RBC (3-5) 1-3 Below normal limits Anemia

July
DIAGNOSTIC
TEST/NORMAL
VALUES

Hematology:
Hemoglobin (11-
16gms)
13.6 Normal Normal
Hematocrit (37-
47vol%)
40.9 Normal Normal
WBC (5,000- 43,600/cu.mm Above normal limits Infections
10,000/cu.mm)
Platelet (150,000-
450,000/cu.mm)
Segmenters (55-65%) 51% below normal limits Infections
Lymphocytes (25-
35%)

August 1, 2013
DIAGNOSTIC
TEST/NORMAL
VALUES

Hematology:
Hemoglobin (11- 15.8 Normal Normal
16gms)
Hematocrit (37-
47vol%)
49.1 Normal Normal
WBC (5,000-
10,000/cu.mm)
35,400/cu.mm Above normal limits Infection
Platelet (150,000-
450,000/cu.mm)
Lymphocytes (25-
35%)
Monocytes (2-4%) 07% Above normal limits Infections

August 4, 2013 (ICU)
DIAGNOSTIC RESULT INTERPRETATION SIGNIFICANCE
TEST/NORMAL
VALUES

Hematology
Hemoglobin (11-
16gms)
13.1 Normal Normal
Hematocrit (37-
47vol%)
40.7 Normal Normal
WBC (5,000-
10,000/cu.mm)
40,200/cu.mm Above normal limits Infections
Platelet (150,000-
450,000/cu.mm)
Lymphocytes (25-
35%)
Eosinophils (1-4% 01% Normal Normal

August 8, 2013
PERIPHERAL SMEAR
Smear shows normochromic and normocytic red cells.
The white blood cells count estimate is increase normal range with predominance of
lymphocytes.
No immature forms seen.
Platelets are adequate in number.

SPUTUM EXAMINATION
AFB = 0

ULTRASOUND RESULT
Whole abdomen
The liver is normal in size and tissue attenuation. The intrahetaptic ducts are not dilated.
No focal lesions noted. The gallbladder is normal in size and configuration. No wall
thickening, abnormal intraluminal echos and calculi demonstrated.
The pancreas is normal in sizeand parenchymal echo. No focal lesions noted here.
No enlarged lymph nodes or mass appreciated in the vicinity of the abdominal aorta.
The spleen is normal in size. No focal lesions noted. Splenic hilum is unremarkable.
There is no significant disparity in size, shape, and location of the kidneys.
DIMENSION RIGHT KIDNEY LEFT KIDNEY
In Length 8.5cm 8.6cm
Cortical Thickness 1.0cm 1.0cm
Both kidneys exhibit hypoechoic parenchyma relative to the liver and spleen. The
central echo-complexes are normal. The pelvocalyceal system and ureters are not
dilated. No focal lesions and calculi appreciated.
The urinary bladder is adequately filled showing regular contour and smooth walls. No
abnormal echo or calculi noted intraluminally.
No mass lesions noted in bilateral adnexae
Chest x-ray result (July 26, 2013)
Hazy densities are seen in both inner lung zones. The heart is not enlarged. Both
hemidiaphragm and cp sulci are intact. Rest of included structures are unremarkable.
Chest x-ray result (July 31, 2013)
Hazy densities are seen in both inner lung zones. The heart is not enlarged. Both
hemidiaphragm and cp sulci are intact. Rest of included structures are unremarkable.

V. Anatomy and Physiology
The respiratory system

General Function
A primary requirement for all body cell activities and growth is oxygen, which is needed
to obtain energy from food. The fundamental purpose of the respiratory system is to supply
oxygen to the individual tissue cells and to remove their gaseous waste product, carbon
dioxide. Breathing, or ventilation, refers to the inhalation and exhalation of air. Air is
a mixture of oxygen, nitrogen, carbondioxide and other gases; the pressure of these gases
varies, depending on the elevation above sea level. The first, called external expiration, takes
place only in the lungs, where oxygen from the outside air enters the blood and carbondioxide
leaves the blood to be breathed into the outside air (Figure 10-1).
In the second, called internal respiration, gas exchanges take place between the blood
and the body cells, with oxygen leaving the blood and entering the cells at the same time that
carbon dioxide leaves the cells and enters the blood. The respiratory system is an intricate
arrangement of spaces and passageways that conduct air into the lungs. These spaces include
the nasal cavities; the pharynx, which is common to the digestive and respiratory systems; the
voice box, or larynx; the windpipe, or trachea; and the lungs themselves, with their conducting
tubes and air sacs. The entire system might be thought of as a pathway for air between the
atmosphere and the blood.

Structure and Function of Respiratory Pathways
The Nasal Cavities
Air makes its initial entrance into the body through the openings in the nose called the
nostrils. Immediately inside the nostrils, located between the roof of the mouth and the
cranium, are the two spaces known as the nasal cavities. These two spaces are separated from
each other by a partition, the nasal septum. The septum and the walls of the nasal cavities are
constructed of bone covered with mucous membrane. From the lateral (side) walls of each
nasal cavity are three projections called the conchae. The conchae greatly increase the surface
over winch air must travel on its way through the nasal cavities. The lining of the nasal cavities
is a mucous membrane, which contains many blood vessels that bring heat and moisture to it.
The cells of this membrane secrete a large amount of fluid. It is better to breath through the
nose than through the mouth because of changes produced in the air as it comes in contact
with the lining of the nose:
1. Foreign bodies, such as dust particles and pathogens, are filtered out by the hairs of the
nostrils or caught in the surface mucus.
2. Air is warned by the blood in the vascular membrane.
3. Air is moistened by the liquid secretion
The sinuses are small cavities lined with mucous membrane in the bones of the skull. The
sinuses communicate with the nasal cavities, and they are highly susceptible to infection.

Figure 10-1. Diagram of external respiration showing the diffusion of gas molecules through
the cell membranes and throughout the capillary blood and air in the alveolus. (From
Memmler and Wood: The Human Body in Health and Disease, ed 6, Philadelphia, 1987, J. B.
Lippincott co.)

The Pharynx
The muscular pharynx (throat) carries air into the respiratory tract and foods and liquids
into the digestive system. Theupper portion located immediately behind the nasal cavity is
called the nasopharynx , the middle section located behind the mouth is called the oropharynx,
and the lowest portion is called the laryngeal pharynx. This last section opens into the larynx
toward the front and into the oesophagus toward the back.

The Larynx
The larynx (voice box) is located between the pharynx and the trachea. It has a
framework of cartilage that protrudes in the front of the neck and sometimes is referred to as
the Adams apple. The larynx is considerably larger in the male than in the female; hence, the
Adams apple is much more prominent in the male. At the upper end of the larynx are the vocal
cords, which serve in the production of speech. They are set into vibration by the flow of air
from the lungs. A difference in the size of the larynx is what accounts for the difference
between the male and female voices; because a mans larynx is larger than a womans, his voice
is lower in pitch.
The nasal cavities, the sinuses, and the pharynx all serve as resonating chambers for
speech, just as the cabinet does for a stereo speaker. The space between these two vocal cords
is called the glottis, and the little leaf-shaped cartilage that covers the larynx during swallowing
is called the epiglottis. The epiglottis helps keep food out of the remainder of the respiratory
tract. As the larynx moves upward and forward during swallowing, the epiglottis moves
downward, covering the opening into the larynx. You can feel the larynx move upward toward
the epiglottis during this process by placing the flat ends of your fingers on your larynx as you
swallow. The larynx is lined with ciliated mucous membrane. The cilia trap dust and other
particles, moving them upward to the pharynx to be expelled by coughing, sneezing, or blowing
the nose.

The Trachea (Windpipe)
The trachea is a tube that extends from the lower edge of the larynx to the upper part of
the chest above the heart. It has a framework of cartilages to keep it open. These cartilages,
shaped somewhat like a tiny horseshoe or the letter C, are found along the entire length of the
trachea. All the open sections of these cartilages are at the back so that the esophagus can
bulge into this section during swallowing. The purpose of the trachea is to conduct air between
the larynx
and the lungs.

The Bronchi and Bronchioles
The trachea divides into two bronchi which enter the lungs. The right bronchus is
considerably larger in diameter than the left and extends downward in a more vertical
direction. Therefore, if a foreign body is inhaled, it is likely to enter the right lung. Each
bronchus enters the lung at a notch or depression called the hilus or hilum. The blood vessels
and nerves also connect with the lung in this region.

The Lungs
The lungs are the organs in which external respiration takes place through the extremely
thin and delicate lung tissues.The two lungs, set side by side in the thoracic cavity, are
constructed in the following manner: Each bronchus enters the lung at the hilus and
immediately subdivides. Because the subdivision of the bronchi resembles the branches of a
tree, they have been given the common name bronchial tree. The bronchi subdivide again and
again, forming progressively smaller divisions, the smallest of which are called bronchioles. The
bronchi contain small bits of cartilage, which give firmness to the walls and serve to hold the
passageways open so that air can pass in and out easily.
However, as the bronchi become smaller, the cartilage decreases in amount. In the
bronchioles there is no cartilage at all; what remains is mostly smoothly muscle, which is under
the control of the autonomic nervous system. At the end of each of the smallest subdivisions of
the bronchial tree, called terminal bronchioles, is a cluster of air sacs, resembling a bunch of
grapes. These sacs are known as alveoli. Each alveolus is a single-cell layer of squamous (flat)
epithelium. This very thin wall provides easy passage for the gases entering and leaving the
blood as it circulates through millions of tiny capillaries of the alveoli. Certain cells in the
alveolar wall produce surfactant, a substance that prevents the alveoli from collapsing by
reducing the surface tension (pull) of the fluids that line them. There are millions of alveoli in
the human lung. Because of the many air spaces, the lung is light in weight; normally a piece of
lung tissue dropped into a glass of water will float. As mentioned the pulmonary circuit brings
blood to and from the lungs. In the lungs blood passes through the capillaries around the
alveoli, where the gas exchange takes place.

The Lung Cavities
The lungs occupy a considerable portion of the thorax cavity, which is separated from
the abdominal cavity by the muscular partition known as the diaphragm. Each lung is enveloped
in a double sac of serous membrane called the pleura. The portion of the pleura that is
attached to the chest wall is called parietal pleura, while the portion that is reflected onto the
surface of the lung is called visceral pleura. The pleural cavity around the lungs is an air-tight
space with a
partial vacuum, which causes the pressure in this space to be less than atmospheric pressure.
Because the pressure inside the lungs is higher than that in the surrounding pleural cavity, the
lungs tend to remain inflated. The entire thoracic cavity is flexible, capable of expanding and
contracting along with the lungs. The region between the lungs, the mediastinum, contains the
heart, great blood vessels, esophagus, trachea, and lymph nodes.

Physiology of Respiration
Pulmonary Ventilation
Ventilation is the movement of air into and out of the lungs, as in breathing. There are two
phases of ventilation (Figure10-3):
1. Inhalation is the drawing of air into the lungs.
2. Exhalation is the expulsion of air from the lungs.
In inhalation, the active phase of breathing, the respiratory muscles contract to enlarge
the thoracic cavity. The diaphragm is a strong dome-shaped muscle attached around the base
of the rib cage. The contraction and relaxation of the diaphragm cause a piston-like downward
motion that result in an increase in the vertical dimension of the chest. The rib cage is also
moved upward and outward by contraction of the external intercostals muscles and, during
exertion, by contraction of other muscles of the neck and chest. During quiet breathing, the
movement of the diaphragm accounts for most of the increase in thoracic volume.

Figure 10-3. (A) Inhalation. (B) Exhalation (Source: Carola, R., Harley,J.P.,
Noback R.C., (1992), Human anatomy and physiology, Mc Graw hill inc, New
York, 2nd ed,)
As the thoracic cavity increases in size, gas pressure within the cavity decreases. When
the pressure drops to slightly below atmospheric pressure, air is drawn into the lungs. In
exhalation, the passive phase of breathing, the muscles of respiration relax, allowing the ribs
and diaphragm to return to their original positions. The tissues of the lung are elastic and recoil
during exhalation. During forced exhalation, the internal intercostals muscles and the muscles
of the abdominal wall contracts, pulling the bottom of the rib cage in and down. The abdominal
viscera are also pushed upward against the diaphragm.

Air Movement
Air enters the respiratory passages and flows through the ever-dividing tubes of the
bronchial tree. As the air traverses this passage, it moves more and more slowly through the
great number of bronchial tubes until there is virtually no forward flow as it reaches the alveoli.
Here the air moves by diffusion, which soon equalizes any differences in the amounts of gases
present. Each breath causes relatively little change in the gas composition of the alveoli, but
normal continuous breathing ensures the presence of adequate oxygen and the removal of
carbon dioxide.

Table 10-1 gives the definition of and average values for some of the breathing volumes that
are important in any evaluation of respiratory function.

Table 17-1 Breathing Volumes
Volume Definition Average volume
Tidal volume The amount of air moved into
or out
of the lungs in quiet, relaxed
breathing
500 cc
Vital capacity The volume of air that can be
expelled from the lungs by
maximum
exhalation following
maximum
inhalation
4800 cc
Residual capacity The volume of air that
remains in the
lungs after maximum
exhalation
1200 cc
Total capacity The total volume of air that
can be
contained in the lungs after
maximum
inhalation
6000 cc
Functional residual capacity The amount of air remaining
in the
lungs after normal exhalation
2400 cc

Regulation of respiration
Regulation of respiration is a complex process that must keep pace with moment-to-
moment changes in cellular oxygen requirements and carbon dioxide production. Regulation
depends primarily on the respiratory control centers located in the medulla and pons of the
brain stem. Nerve impulses from the medulla are modified by the centers in the pons.
Respiration is regulated so that the levels of oxygen, corbon dioxide, and acid are kept within
certain limits. The control centers regulate the rate, depth, and rhythm of respiration. From the
respiratory center in the medulla, motor nerve fibers extend into the spinal cord. From the
cervical (neck) part of the cord, these nerve fibers continue through the phrenic nerve to the
diaphragm. The diaphragm and the other muscles of respiration are voluntary in the sense that
they can be regulated by messages from the higher brain centers, notably the cortex. It is
possible for a person to deliberately breath more rapidly or more slowly or to hold his breath
and not breath at all for a time. Usually we breath without thinking about it, while the
respiratory centers in the medulla and pon do the controlling. Of vital importance in the control
of respiration are the chemoreceptors.
These receptors are found in structures called the carotid and aortic bodies, as well as
out side the medulla of the brain stem. The carotid bodies are located near the bifurcation of
the common carotid arteries, while the aortic bodies are located in the aortic arch. These
bodies contain many small blood vessels and sensory neurons, which are sensitive to decreases
in oxygen supply as well as to increases in carbon dioxide and acidity (H+). Impulses are sent to
the brain from the receptors in the carotid and aortic bodies. The receptor cells outside the
medulla are affected by the concentration of hydrogen ion in cerebrospinal fluid (CSF) as
determined by the concentrations of carbon dioxide in the blood.
VI. Nursing Care Plan
Assessment
Data/Cues
Nursing
Diagnosis
Objectives of Care Nursing Care Plan Rationale Evaluation
SUBJECTIVE CUES:
Dili kayo siya
kaginhawa,
galisud siya ug
ginhawa, s
verbalized by the
father.
Complaints of
weakness as
reported by the
father
Ineffective
Airway
Clearance
related to
accumulation
of secretions
in the
respiratory
tract
Short Term
Objective:
At the end of 3 hours
of nursing
intervention the
patient will be able
to:
Expectorate
sputum
Breath deeply &
cough to remove
secretions
When helping patient cough &
deep-breathe, use whatever
position best ensures
cooperation & minimizes
energy expenditure, such as
high fowlers position or sitting
on side of bed.
Teach patient an easily
performed cough technique

Encourage sputum
expectoration. Provide
containers for the sputum.

Such positions
promotes chest
expansion &
ventilation of
basilar lung fields.

To clear airway
without fatigue

To remove
pathogens &
prevent the
spread of
At the end
of 3 hours
of nursing
interventi
on the
patient
was able
to
expectorat
e about 5-
10 cc of
sputum &
was able
to cough it
out.
Patients Name: Shekeanah U. Sacay Date: August 1, 2012.
2.
Assessment
Data/Cues
Nursing
Diagnosis
SUBJECTIVE CUES:
Galisud siya ug
ginhawa, as
verbalized by SO.
Ineffective
Breathing
Pattern related
to decreased
energy or
fatigue
Short term Objective:
At the end of five
hours of nursing
intervention the
to:
Achieve
maximum lung
expansion with
Assist patient to a comfortable
position, such as supporting
upper extremities with pillow
to lean on, & elevating head
of bed.
Teach patient about:
Pursed-lip breathing
Abdominal breathing
These measures
promote comfort,
chest expansion &
ventilation of
basilar lung fields.
These measures
allow patient to
participate in
At the end of 5
hours of
nursing
intervention
the patient was
not able to
achieve
maximum lung
expansion with
OBJECTIVE CUES:
RR= 40 cpm
Use of alar
muscles

Cause Analysis:
Associated
medical
diagnosis:
Pneumonia
Long Term Objective:
At the end of 12
hours of nursing
intervention the
to:
Maintain a patent
airway
Have an adequate
ventilation
Achieve oxygen
level at a normal
range as
evidenced by a
normal RR

Give expectorants,
bronchodilators & other drugs,
as ordered & monitor
effectiveness.
Encourage fluids, increase
intake
Provide bronchodilators
treatment before chest
physiotherapy
Turn patient every two hours
always position for maimal
aeration of lung fields &
mobilization of secretions

infection.
These measures
enhance
clearance of
secretions from
airways.
To liquefy
secretions
To optimize
results

This prevents
pooling and stasis
of respiratory
secretions

At the end of 12
hours of
nursing
intervention
the patient was
not able to
maintain a
patent airway &
has needed to
have O
2

supplementatio
n. Instructions
already given.
adequate
ventilation
Performing
relaxation technique
Taking prescribed
meds
Scheduling activities
to avoid fatigue &
provide rest periods
Auscultate breath sounds at
least every 4 hours

Assess & record respiratory
rate & depth at least every 4
hours

maintaining health
status and
improve
ventilation

To detect
decreased or
adventitious
sounds; report
changes
To detect early
signs of
respiratory
compromise
inadequate
ventilation
aided with 0
2
inhalation.
OBJECTIVE CUES:
Accessory
muscle use
Shortness of
breath
Nasal flaring
Altered
respiratory
rate=40 cpm
Cause Analysis:
Associated
medical
diagnosis:
Pneumonia
Long term Objective:
At the end of 12
hours of nursing
intervention the
to:
Report feeling
comfortable
when breathing
At the end of 12
hours of
nursing
intervention
the patient was
not able to
report feeling
of being
comfortable
when breathing
with O
2
inhalation via
nasal cannula.

3.
Assessment
Data/Cues
Nursing
Diagnosis
SUBJECTIVE CUES:
Complaints of
difficulty in
breathing by the
patient & SO
Impaired Gas
Exchange
related to
Altered oxygen
supply
Short Term
Objective:
of nursing
intervention the
Assess & record pulmonary
status every 4 hours or if
patients condition is unstable
Place patient in position that
For pulmonary
status may result
in hypoxemia
To enhance gas
At the end of 5
hours of
nursing
intervention
the patient was
to:
Have normal
breath sounds
Expectorate
sputum
best facilitates chest expansion
Change patients position at
least every 2 hours

Perform bronchial hygiene as
ordered including coughing,
percussion, postural drainage
and even suctioning.
Record intake and output

Report signs of dehydration or
overload

Teach patient relaxation
techniques
exchange
To mobilize
secretions &
allow aeration of
all lung fields.
These measures
promote
drainage & keep
airways clear.
To monitor
patients fluid
status
Dehydration
may hinder
tissue perfusion
& secretion
mobilization;
fluid overload
may cause
pulmonary
edema.
To reduce tissue
oxygen demand.
not able have
normal breath
sounds as
evidenced by
rales upon
auscultation
but has
expectorated
some of the
sputum.
OBJECTIVE CUES:
Nasal flaring
Use of accessory
muscles
Altered HR=140
bpm &
RR=40cpm
Cause Analysis:
Associated
medical
diagnosis:
Pneumonia
Long term Objective:
At the end of 12
hours of nursing
intervention the
to have her HR and
RR within normal
range
At the end of 12
hours of
nursing
intervention
the patient was
not able to
achieve HR &
RR within
normal limits,
with the latest
HR of 140 and
RR of 40.

(*O
2
inhalation
given
monitored
every two
hours)

4.
Assessment
Data/Cues
Nursing
Diagnosis
SUBJECTIVE CUES:
Ga uga lagi ang
panit sa akong
anak maam,
dayun luspad
ang iya kuku ug
mga lapa-lapa,
as verbalized by
the father.
Deficient
Fluid Volume
related to
active loss
Short Term
Objective:
of nursing
intervention the
to:
Have Stable vital
signs
Have normal Skin
color evaluations
Have her Fluid
volume remain
adequate
Have normal skin
turgor
Monitor and record
vital signs every 2
hours or as often as
necessary until stable,
then monitor and
record vital signs every
4 hours
Cover patient lightly.
Avoid overheating.

Measure intake and
output every 1 to 4
hours. Report and
record significant
changes. Include urine,
stools, vomitus and
other output.
Assess skin turgor and
oral mucous
membranes every 8
hours
Give meticulous mouth
Tachycardia, dyspnea,
or hypotension may
indicate fluid volume
deficit or electrolyte
imbalance.

To prevent
vasodilation, blood
pooling in extremities,
and reduced
circulating blood
volume.
Low urine output and
high specific gravity
indicate hypovolemia.

To check for
dehydration.

To avoid dehydrating
At the end
of 3 hours of
nursing
intervention
the patient
was not able
to have
Stable vital
signs but
the patient
was able to
have normal
skin color
evaluations,
have her
fluid volume
remain
adequate
and
patients
skin turgor
became
normal.

OBJECTIVE CUES:
A bit rough and
Dry skin noted
Pale nail beds,
pale soles
Poor skin turgor
Pale conjuctiva

Cause Analysis:
Associated
medical
diagnosis:
Pneumonia
At the end of 12
hours of nursing
intervention the
to:
Have normal fluid
and blood volume
care every 4 hours
Dont allow patient to
sit or stand up quickly
as long as circulation is
compromised

Administer and
monitor medications
Explain reasons for
fluid loss, and teach
significant others of
patient how to monitor
fluid volume-for
example, by measuring
intake and output.
mucous membranes
To avoid orthostatic
hypotension and
possible syncope

To prevent further
fluid loss
This encourages
patients SO
involvement in
personal care.
At the end of 12
hours of
nursing
intervention
the patient was
able to have
normal fluid
and blood
volume as
evidenced by
normal skin
color
evaluations, but
conjunctiva
remains pale.

5.
Assessment
Data/Cues
Nursing
Diagnosis
SUBJECTIVE
CUES:
dayun
luspad ang
iya kuku ug
mga lapa-
lapa, as
verbalized by
the father.
Ineffective
Tissue
Perfusion
(Cardiopulm
onary)
related to
decreased
cellular
exchange
Short Term Objective:
of nursing
intervention the
patient will be able to:
have a warm skin
have a normal skin
color evaluation
have achieve fluid
balance, with
intake and output
Monitor patients heart rate
and rhythm until stable, then
every two hours record and
report any changes above or
below established limits.
Monitor skin color and
temperature every 2 hours.
Monitor respiratory rate and
depth every hour until stable,
then every 2 to 4 hours.
Record and report changes
outside established limits.

Measure and record urine
output every hour until
output exceeds 30ml/hr then
every 2 to 4 hours. *If patient
has no history of renal
disease, urine output is a
good indicator of tissue
perfusion.
Relieve anxiety and pain.

Change patients position
regularly, following turning
schedule, inspect his skin
every shift, record and report
any potential areas of
Decreased heart rate
can indicate
hypovolemia, which
leads to decreased
tissue perfusion. Cool
skin indicates decreased
tissue perfusion.

Increased respiratory
rate is a compensatory
mechanism of tissue
hypoxia that can result
from decreased tissue
perfusion.
Decreased or absent
urine output usually
indicates poor renal
perfusion.

Anxiety and pain can
cause a sympathetic
reaction that results in
vasoconstriction and
decreased tissue
perfusion.
These measures avoid
decreased tissue
perfusion and the risk of
skin breakdown.
At the end of 3
hours of
nursing
intervention
the patient was
able to have a
warm skin, a
normal skin
color evaluation
and
was able to
achieve fluid
balance, with
intake and
output
OBJECTIVE
CUES:
Capillary
Refill
beyond 5
seconds
Pale
conjunctiva
Cool skin

Cause Analysis:
Associated
medical
diagnosis:
Pneumonia
of nursing
intervention the
Exhibit improved
circulation as
evidenced by a
capillary refill less
than 5 seconds,
and a normal skin
color evaluation
At the end of
12 hours of
nursing
intervention
the patient was
able to exhibit
improved
circulation as
evidenced by a
capillary refill
less than 5
seconds, and a
normal skin
color
evaluation.
6.
breakdown.
Assessment
Data/Cues
Nursing
Diagnosis

SUBJECTIVE
CUES:
Luya na lagi
kayo na siya
maam kay
walay undang
iya ubo dili
sad kaayo
gusto makipag
istorya mam
, as
verbalized by
the father.
Fatigue Short Term Objective:
of nursing
intervention the
Feel comfortable
and report absence
of tiredness
Prevent unnecessary fatigue;
for example, avoid scheduling
many energy draining
procedures at the same time.

Conserve energy through
rest, planning and setting
priorities
Reduce demands placed on
patient; for example, ask one
family member to call at
specified times and relay
messages to friends and other
family members
Encourage patient to eat
foods rich in iron and
minerals, unless
contraindicated.
Postpone eating when patient
is fatigued
Avoid highly emotional
situations
Encourage SO to feed the
patient with nutritious foods
which are rich in vitamins and
minerals like fruits and
vegetables.
Using energy
conserving
techniques avoids
overexertion and
potential for
exhaustion.
To prevent or
alleviate fatigue
To reduce physical
and emotional stress.

This helps avoid
anemia and
demineralization.
To avoid aggravating
the condition.
To avoid aggravating
the condition.
To boost the
patients immune
system and helps in
her recovery from
her condition.

At the end of 3
hours of nursing
intervention the
patient was able
to report absence
of tiredness as
evidenced by jolly
interaction with
the health
practitioners but
still the patient
was not feeling
comfortable as
manifested by
irritability of
patient.
OBJECTIVE CUES:
Lack of
energy
Lethargic

Cause
Analysis:
Associated
medical
diagnosis:
Pneumonia
of nursing
intervention the
Regain strength as
evidenced by
active participation
in her health
regimen
At the end of 12
hours of nursing
intervention the
patient was able
to regain strength
as evidenced by
active
participation in
her health
regimen.
79


VII. Discharge and Prognosis
Summary
GOOD FAIR POOR

a. Physiologic response of the body to disease process /
b. Relief of symptoms associated with disease condition /
c. Performance of the activities of the patient during /
confinement (e.g. eating toileting, dressing, etc.)
d. Compliance of the patient to the medication and/or /
therapy
e. Adequacy of rest periods and sleep /
f. Consumption of the patient with nutrition and therapeutic /
regimen
g. Patients significant others behaviour regarding the /
health teaching given by the physician
Calculations
Formula: amount # of (good, fair,poor) X 100 = (percentile)
7
Amount of Percentile
Good = 2 28.57
Fair = 3 42.86
Poor = 2 28.57
Interpretation:
The result shows that the patient has a fair prognosis has fair responses of her body to
disease process, fair to cope performance of the activities during confinement, fair to have
adequate rest periods and sleep, poor relief of symptoms associated with disease condition,
poor consumption of with nutrition and therapeutic regimen, also ,... has good compliance of
the patient to medication and/or therapy and good patients significant others behaviour
regarding the health teaching given by the physician.
80


III. APPENDIX
a. Vital signs Monitoring

0
20
40
60
80
100
120
140
160
July 26,
2:00 AM
6:00 AM 10:00 AM 2:00 PM 6:00 PM 10:00 PM July 27,
2:00 AM
6:00 AM 10:00 AM 2:00 PM 6:00 PM 10:00 PM
Heart rate
Respiratory rate
Temperature
81


0
20
40
60
80
100
120
140
160
July 28,
2:00 AM
6:00 AM 10:00 AM 2:00 PM 6:00 PM 10:00 PM July 29,
2:00 AM
6:00 AM 10:00 AM 2:00 PM 6:00 PM 10:00 PM
Heart rate
Respiratory rate
Temperature
82


0
20
40
60
80
100
120
140
160
July 30,
2:00 AM
6:00 AM 10:00 AM 2:00 PM 6:00 PM 10:00 PM July 31,
2:00 AM
6:00 AM 10:00 AM 2:00 PM 6:00 PM 10:00 PM
Heart rate
Respiratory rate
Temperature
83


0
20
40
60
80
100
120
140
160
180
August 1, 10:00
AM
2:00 PM 4:00 PM 6:00 PM 10:00 PM 2:00 AM 6:00 AM 6:00 AM
Heart rate
Respiratory rate
Temperature
84


85


0
20
40
60
80
100
120
140
160
Heart rate
Respiratory rate
Temperature
86


0
20
40
60
80
100
120
140
160
Heart rate
Respiratory rate
Temperature
87


0
20
40
60
80
100
120
140
160
180
Heart rate
Respiratory rate
Temperature
88


0
20
40
60
80
100
120
140
160
Heart rate
Respiratory rate
temerature
89


0
20
40
60
80
100
120
140
160
180
Heart rate
Respiratory rate
temperature
90


0
20
40
60
80
100
120
140
160
Heart rate
Respiratory rate
temperature
91


0
20
40
60
80
100
120
140
August 8,
1:00 AM
2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 10:00 AM 2:00 PM 6:00 PM August 9,
2:00 AM
6:00 AM 10:00 AM 2:00 PM
Heart rate
Respiratory rate
Temperature
92


Legend: Black- Normal Blue - Below
normal Red- Above Normal
93


BLOOD PRESSURE MONITORING
94


DATE & TIME RESULT
JULY 26, 2013
2:00 AM 100/60
AUGUST 2, 2013 (8AM-8PM)
3:00PM 90/70
4:00PM 90/70
5:00PM 90/60
6:00PM 90/70
7:00PM 90/60
AUGUST 2, 2013 (8PM-8AM)
8:00PM 90/60
9:00PM 90/60
10:00PM 90/60
11:00PM 90/60
12:00MN 90/70
1:00AM 90/70
2:00AM 90/60
3:00AM 90/70
4:00AM 100/70
4:00AM 90/60
5:00AM 100/60
6:00AM 90/70
7:00AM 90/60
8:00AM 100/70
9:00AM 100/70
10:00AM 110/80
11:00AM 100/70
12:00NN 90/65
1:00PM 90/60
2:00PM 100/70
95


DATE & TIME RESULT
5:00AM 90/60
6:00AM 90/60
7:00AM 90/60
8:00AM 90/60
9:00AM 90/70
10:00AM 90/70
11:00AM 90/70
12:00NN 90/70
1:00PM 100/80
2:00PM 100/80
3:00PM 90/70
4:00PM 90/70
4:00PM 90/80
5:00PM 90/70
6:00PM 100/80
7:00PM 100/80
8:00PM 90/60
9:00PM 90/60
10:00PM 90/60
11:00PM 100/60
12:00MN 90/60
1:00AM 90/60
2:00AM 80/60
3:00AM 90/60
4:00AM 90/60
5:00AM 90/60
6:00AM 90/60
DATE & TIME RESULT
3:00AM 100/70
4:00AM 90/70
5:00AM 90/60
6:00AM 90/60
7:00AM 100/70
8:00AM 90/60
9:00AM 90/70
10:00AM 90/60
11:00AM 90/60
12:00NN 100/70
1:00PM 100/70
2:00PM 100/80
3:00PM 100/70
4:00PM 100/80
4:00PM 100/80
5:00PM 100/80
6:00PM 100/70
7:00PM 90/60
8:00PM 90/60
9:00PM 110/60
10:00PM 100/70
11:00PM 90/60
12:00MN 100/60
1:00AM 100/60
2:00AM 90/60
3:00AM 90/60
4:00AM 90/60
96


DATE & TIME RESULT
AUGUST 5, 2013 (8PM-
8AM)

7:00AM 80/60
AUGUST 6, 2013 (8AM-
8PM)

8:00AM 90/60
9:00AM 90/60
10:00AM 90/70
11:00AM 90/60
12:00NN 90/60
1:00PM 80/60
2:00PM 90/60
3:00PM 90/60
4:00PM 90/60
5:00PM 90/60
6:00PM 100/60
7:00PM 100/80
AUGUST 6, 2013 (8PM-
8AM)

8:00PM 100/80
9:00PM 100/70
10:00PM 90/60
11:00PM 90/60
12:00MN 90/60
1:00AM 90/60
2:00AM 90/60
3:00AM 90/60
4:00AM 90/70
5:00AM 90/70
6:00AM 90/70
7:00AM 90/70
AUGUST 7, 2013 (8AM-
8PM)

8:00AM 90/70
9:00AM 100/60
10:00AM 90/60
11:00AM 90/60
12:00NN 90/60
DATE & TIME RESULT
1:00PM 90/60
2:00PM 90/60
3:00PM 90/60
4:00PM 90/60
5:00PM 90/60
6:00PM 90/60
7:00PM 90/70
8:00PM 90/70
9:00PM 90/70
10:00PM 90/70
11:00PM 90/70
12:00MN 90/70
1:00AM 90/70
2:00AM 90/70
3:00AM 90/70
4:00AM 90/70
5:00AM 90/70
6:00AM 90/60
7:00AM 90/60
10:00 AM 90/60
2:00PM 100/70
6:00PM 90/70
10:00PM 90/60
2:00AM 90/60
6:00AM 90/60
AUGUST 9,2013 (8AM-8PM)
10:00AM 90/60
2:00PM 90/60
6:00PM 90/60
DATE & TIME RESULT
10:00PM 90/60
2:00PM 90/50
97


b. Intake and Output
July 29. 2013
Shift IVF IVTT P.O. Oth
ers
Total Urin
e
Stool Oth
ers
Total
3 am- 8
pm
130
scc
0 350
cc
0 480 cc 100
cc
0 0 100
cc

August 2, 2013
ers
Total Urin
e
Stool Oth
ers
Total
3 am- 8
pm
50
cc
7 cc 180
cc
0 192 cc 350
cc
0 0 350
cc
8 pm -
8am
720
cc
13.1
cc
80 cc 0 213 cc 0 0 0 0

August 3, 2013
ers
Total Urin
e
Stool Oth
ers
Total
8 am- 8
pm
560
cc
7 cc 280
cc
0 847 cc 430
cc
once 0 430
cc
8 pm -
8am
560
cc
13.1 cc 240
cc
0 813 cc 155
cc
once 0 155

August 5, 2013

August 6, 2013
ers
Total Urin
e
Stool Oth
ers
Total
8 am- 8
pm
360
cc
11 cc 150
cc
0 521 cc onc
e
0 0 once
8 pm -
8am
360
cc
5.5 cc 300
cc
0 665.5
cc
400
cc
once 0 400
cc

Shift IVF IVTT P.O. Othe
rs
Total Urin
e
Stool Oth
ers
Total
8 am- 8
pm
600
cc
5.5 cc 280
cc
0 600.5
5 cc
580
cc
0 0 580
cc
12 pm -
4am
250
cc
11.1
cc
240
cc
0 461 cc onc
e
0 0 1 cc
98


Urine and stool output

July 26,2013 July 27,2013 July 28,2013 July 29, 2013 July 30 ,2013 July 31,2013
Urine
8 pm- 8 am
2 2 2 3 3 4
8 am- 8 pm 1 1 0 2 2 1
Stool
8 pm- 8 am
0 0 1 1 2 2
8 am- 8 pm 0 0 0 1 1 0

August 1, 2013 August 2, 2013 August 3, 2013 August 4, 2013 August 5, 2013 August 6, 2013
Urine
8 pm- 8 am
3 0 0 0 2 3
8 am- 8 pm 0 0 0 0 0 0
Stool
8 pm- 8 am
0 0 0 1 0 0
8 am- 8 pm 0 0 1 1 0 0

August 7, 2013 August 8, 2013 August 9, 2013
Urine 4 4 2
99


8 pm- 8 am
8 am- 8 pm 5 1 1
Stool
8 pm- 8 am
1 4 0
8 am- 8 pm 2 1 0
100


c. Discharge Plan

Medication
Salbutamol + Ipratropine nebule, 1 nebule every 6 hours (10 am-4 pm- 10 pm- 4 am)
Budesomide nebule, 1 nebule every 12 hours (8 am- 8 pm)
Clarithromycin nebule, 7 ml 2x a day, 5 more days (8 am-8 pm)
Montelukast, 1 tab. Once a day at hour of sleep (8 pm)
Senetide 25/80g inhaler, 2 puffs a day (8 am- 6 pm)
Exercise ROM
Deep breathing
Treatment Stress reduction (yoga, reading and other relaxing activities)
Chest physiotherapy
Health Teaching Provide information on balancing food intake, brochodilator agents and energy expenditure.
How and when to take medication
Teach on the things that can trigger asthma
Out Patient Consult with a dietitian about specific dietary needs based on patients current condition.
Instruct to return on August 12, 2013 fo follow up check-up.
Diet Diet as tolerated
fruits, higher fiber (wheat) & low fat content (low fat milk products, low fat dairy/commercial
products).
Avoid foods which are eggs, dairy products, soy, nuts, etc. That can trigger asthma.
Increase fluid intake into 3-4 liters per day

101


REFERENCE
Bombrys, A.E. et.al. (2008). Retrieved last February 28, 2013. Retrieved from
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2621052/.

Doenges, Moorehouse, M.F. & Murr, A.C. (2010). NursesPocket Guide : Diagnosis, Prioritized Interventions and Rationales.
Philadelphia, Pennsylvania:F.A Davis Company

Luxner, K. L. (2005). Delmar's Maternal Infant Nursing care Plans. Singapore: DELMAR LEARNING.

Norwitz, E.R. Preeclampsia. Retrieved last March 1, 2013. Retrieved from www.mayoclinic.com
Delmars nurses Drug Hand Book. (2010)
Spratto, G.R. & Woods, A.L. (2010). Delmars Nurses Drug Handbook. United States of America: Delmar Cengage Learning
Ralph, S.S. & Taylor, C.M. (2005). Nursing Diagnosis Reference Manual

102


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