case study
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I. Introduction
Pneumonia is an illness of the lungs and respiratory system in which the
alveoli (microscopic air-filled sacs of the lung responsible for absorbing
oxygen from the atmosphere) become inflamed and flooded with fluid.
Pneumonia can result from a variety of causes, including infection with
bacteria, viruses, fungi, or parasites. Pneumonia may also occur from
chemical or physical injury to the lungs.
One can get pneumonia in daily life, such as at school or work. This is
called community-based pneumonia. One can also get it in a hospital or
nursing home. This is called hospital-based pneumonia. It may be more
severe because one is already are ill. You may cough, run a fever, and have
hard time breathing. For most people, pneumonia can be treated at home. It
often clears up in 2 to 3 weeks. But older adults, babies, and people with
other diseases can become very ill. It is one of the leading causes of death
among the elderly and people who are chronically and terminally ill.
People with infectious pneumonia often have a cough that produces
greenish or yellow sputum and a high fever that may be accompanied by
shaking chills. Shortness of breath is also common, as is pleuritic chest pain,
a sharp or stabbing pain, either felt or worse during deep breaths or coughs.
People with pneumonia may cough up blood, experience headaches, or
develop sweaty and clammy skin. Other symptoms may include loss of
appetite, fatigue, blueness of the skin, nausea, vomiting, mood swings, and
joint pains or muscle aches. Less common forms of pneumonia can cause
other symptoms. For instance, pneumonia caused by Legionella may cause
abdominal pain and diarrhea, while pneumonia caused by tuberculosis or
Pneumocystis may cause only weight loss and night sweats. In elderly people
the manifestations of pneumonia may not be typical. Instead, they may
develop new or worsening confusion or may experience unsteadiness leading
to falls. Infants with pneumonia may have many of the symptoms above, but
in many cases, they are simply sleepy or have decreased appetite.
According to the Unicef/WHO report, India, with 44 million pneumonia
cases, China with 18 million cases and Nigeria and Pakistan with seven
million cases top the chart.
The disease causes acute infections in any part of the respiratory system
— from the middle ear to the nose to the lungs. Acute respiratory infection is
also a serious problem in India, accounting for 14.3 per cent deaths during
infancy and 15.9 per cent deaths among children aged between 1-5 years in
India, claim studies undertaken by experts.
It is estimated that more than 150 million cases of pneumonia occur
every year among children under five in developing countries, accounting for
more than 95 per cent of all new cases worldwide. Between 11 million and 20
million children with pneumonia will require hospitalization, and more than
two million will die from the disease, the report warns.
According to Dr. Josefina Cadorna-Carlos, associate professor at the
University of the East Ramon Magsaysay Memorial Medical Center, that the
characteristics of Streptococcus pneumoniae and atypical bacterial
pneumonia in children may be difficult to distinguish. The question now is,
“how is one going to suspect atypical pneumonia?” "When there is delay in
resolution of symptoms, [presence of] diffuse bilateral infiltrates, and if it's
refractory to standard treatment," Carlos pointed out.
In the 2004 Philippine Consensus Guidelines in the Evaluation and
Management of Pediatric Community Acquired Pneumonia, amoxycillin
remains the drug of choice against pneumonia. Macrolides, quinolones,
and tetracyclines are the drugs useful against atypical pathogens.
Clarithromycin answers the need for a better macrolide. It has 50-percent
bioavailability with significantly fewer GI adverse effects, and has increased
activity against H. influenzae due to the active metabolite 14-
hydroxyclarithromycin. Compared with time-dependent erythromycin,
clarithromycin is concentration dependent, which provides for better
compliance at twice-daily dosing. In vitro, potency is marked by lower
minimum-inhibitory-concentration (MIC) values at 50 and 90 percent against
M. pneumoniae and C. pneumoniae. Against common respiratory tract
infections, clinical success is achieved with 93- to 97-percent alleviation of
symptoms (Germany, Italy, 1994).
The primary role of nurses is to provide care to all their patients. They
play an important role for patient’s survival. As aspiring nurses, it is best that
we are now practicing the core of nursing, which is caring.
The case of Clark Kent, an eleven-month old baby boy, is common
among infants these days. It is an acute pneumonia with spells of cough and
fever. It is also one of the leading causes of morbidity. The researchers will
expand their knowledge regarding the pathophysiology of the disease,
develop their critical thinking about the essential interventions when dealing
with pneumonia, and most importantly, be able to appreciate the fact that
they are already handling real patients in which individuality of each persons
is highly regarded.
The researchers are fortunate to have the chance to apply their skills
and knowledge while delivering or rendering essential health care to the
patient. Given the opportunity to handle a client with the same condition in
the future, the researchers can take care of the client with competence and
can provide the best possible care in attaining the optimum health for their
client.
OBJECTIVES
A. Student-Nurse Centered
After the completion of the case study, the researchers will be able
to:
General Objective:
Gain knowledge and deeper understanding of the disease
process itself, be able to provide the best nursing care for the client,
and impart health teachings regarding the client’s condition in
maintaining an optimum level of functioning.
Specific Objectives:
1. Interpret the current trends and statistics regarding the
disease condition;
2. Relate the present state of the client with his personal and
pertinent family history;
3. Analyze and interpret the different diagnostic and laboratory
procedures, its purpose and its essential relationship to
client’s disease condition;
4. Identify treatment modalities and its importance like drugs,
diet and exercise;
5. Identify surgical management and its purpose that is
applicable with the disease condition;
6. Formulate nursing care plans based on the prioritized health
needs of the client;
7. Gain knowledge on the acquisition and progression of the
disease;
8. Impart knowledge on fellow students in providing care for
clients with the same illness.
B. Patient-Centered
After the completion of the study, the patient will be able to:
General Objective:
Acquire knowledge on the risk factors that have contributed to
the development of the disease, gain understanding of the disease
process and demonstrate compliance on the treatment management
rendered by the health care team.
Specific Objectives:
1. Gain knowledge about the disease;
2. Identify different interventions in his condition;
3. Gain knowledge on the importance of compliance to treatment
regimen;
4. Demonstrate compliance on the treatment management;
5. Identify different measures to prevent further aggravation of
condition;
6. Participate in his plan of care; and
7. Demonstrate independence on self-care and home
management upon discharge and during follow-up home visits.
II. Nursing Assessment
A. Personal History
A.1.Demographic Data
Clark Kent is an eleven month old baby boy and he is the
youngest in his family. He was born as a Filipino citizen on July 7,2006
at their home somewhere in Magalang, Pampanga. He was admitted at
a hospital in Magalang, Pampanga last June 23, 2007 with a chief
complaint of cough, cyanosis, and fever. His admitting diagnosis is
Pneumonia with Anemia.
A.2. Socio-economic, Environmental, and Cultural Factors
Baby Clark Kent in an extended type of family specifically
composed of his father, mother, one sibling; also includes his
grandfather, grandmother, aunties, uncles, and cousins on the
maternal side. With regards to their operating cost only a total amount
of P 2,000-P3,000 is spent to suffice for their daily needs for a month.
His father, who is said to be a construction worker, earns about P7,000
per month. The members of the family pools together the money that
they can get to supply for the monthly needs. The family is affiliated to
“Iglesia Ni Cristo.” With regards to culture, they believe that whenever
a child is sick, he should not take a bath during Fridays and Tuesdays,
plus, he shouldn’t cut his nails. They also embrace the healing powers
of “manghihilot.
With regards to their resettlement area, the place is said to be
clean although it is not yet developed. Also, the houses aren’t evenly
spaced. They have poor mode of transportation, and they are remote
from the market and church.
Baby Clark Kent’s activities of daily living includes the following:
• 6am – Baby Raven wakes up
• 7am – 8am – Breakfast
• 8am – 10am – Plays with his older sister
• 10am – 11am – Takes a bath
• 11:30am – Lunch
• 12pm - 2pm – Siesta for Baby Raven
• 2pm – 4:30pm – Plays again
• 4:30pm – 5pm – Snack Time
• 5:30pm – Another bath session
• 6pm – 6:30pm – Dinner
• 7pm - Sleep
B. Maternal and Child Health History
Obstetric History
According to Martha, a 20 year old mother, she had an obstetric
history of 2 gravidarum (number of pregnancy), 2 parity (number of
pregnancy in which the fetus reach the age of viability whether or not the
baby was born alive or not), 1 term (number of infants born at 37 weeks or
after), 1 preterm ( number of infants born before 37 weeks), 0 for abortion,
(number of spontaneous or induced abortion), and 2 for living children.
Prenatal History
According to Martha, she had her prenatal check up a month. In every
pregnancy that she had, she takes ferrous sulfate capsule for her daily
supplement that is taken once a day.
Antepartal History
She had chicken pox during her first pregnancy. While on her second pregnancy,
she had fever on the first trimester, and she had cough and cold on the second trimester
for a month. She described that she had really difficulty in laboring the second baby.
Erik Eriksson
(Theory of Trust
and Mistrust)
-1 year old
An infant depends
almost exclusively
on parents,
specially the
mother, for food,
sustenance and
comfort. Parents
are the primary
representatives of
society to the
child. If the
parents would be
discharging their
infant-related
duties with
warmth, regularity
and affection, the
infant will develop
the feeling of trust
towards the world,
a trust that
someone will
always be around
to care for one’s
needs.
Alternatively, a
sense of mistrust
develops if the
Normal
The infant would
be able to
develop the sense
of trust with his
parents/ world
because they are
able to support
the infants’ needs
in his life.
Abnormal
The infant was
not able to
develop his trust
with his parents/
world because
they are not able
to support the
infants’ needs in
his life.
Client’s
response
In relation to
Baby Clark
Kent’s case, the
researchers
discovered that
he could
manifest a
feeling of trust
towards the
world. This is
evident in a way
that his parents
are providing
him his basic
needs such as
love and safety
as well as
physiologic
needs (food,
proper home,
etc.)
parents fail to
provide for the
infant’s needs in
their roles as
caregivers.
Erik Eriksson
(Theory of shame
and doubt)
-2 to 3 years old
The infant gains
control over
eliminative
functions and
motor abilities. At
this point, children
show a strong
push for exploring
their world and
assessing their
will. Parents who
are encouraging
and patient allow
the child to
develop a sense of
autonomy, but
parents who are
highly restrictive
and impatient
promote a sense
of shame and
doubt.
Normal
The infant has
developed a
sense of
autonomy and
gains control over
eliminative
functions and
motor abilities.
Abnormal
The infant hasn’t
developed a
sense of
autonomy and
gains control over
eliminative
functions and
motor abilities
because of some
restrictions being
given to him.
Client’s
response
In the case of
Baby Clark Kent,
it is possible that
he will develop
shame and
doubt because
of the way his
parents restrict
him in being
playful. This was
seen during the
nurse-patient
interaction while
carrying out the
interview.
Jean Piaget
(Sensorimotor
Stage)
-birth to 2 years
old
The infant
constructs an
understanding of
the world by
coordinating
sensory
experiences such
as seeing and
hearing with
physical and
motoric actions,
hence, the term
sensorimotor. At
the beginning of
the stage, the
newborn has little
more than
reflexive patterns
with which to
work; at the end of
the stage, the two
year old has
complex
sensorimotor
patterns and is
beginning to
Normal
The infant is able
to constructs an
understanding of
the world by
coordinating
sensory
experiences such
as seeing and
hearing with
physical and
motoric actions.
Abnormal
The infant is not
able to constructs
an understanding
of the world by
coordinating
sensory
experiences such
as seeing and
hearing with
physical and
motoric actions.
Client’s
response
In Baby Clark
Kent’s case, he
can be depicted
as a very
responsive
infant. Unlike
other tots, he
can be
considered as an
extrovert; this is
because of the
way he deals
with new faces.
operate with
primitive symbols.
Sigmund Freud
(Psychosexual
theory)
-birth to 1 year old
This theory
thought that our
adult personality
was determined
by the way
conflicts between
these early
sources of
pleasure (the
mouth, the anus
and the genitals),
and the demands
of the reality were
resolved when
these conflicts are
not resolved, the
individual may
become fixated at
a particular stage
of development.
During birth to the
first year of life,
the activities that
bring the greatest
amount of
Normal
During the
infants’
development, he
should be able to
develop the said
activities in his
life. He should be
able to complete
the said stage
with the help of
the people
surrounding him.
Abnormal
The infant has not
completed the
said stages of
development in
his life maybe
because of lack of
support from his
family.
Client’s
response
With regards to
Baby Clark
Kent’s case, he
was able to
demonstrate the
first stage which
is the oral face
(sucking, biting
and chewing).
pleasure center on
the mouth; in the
oral stage of
development,
chewing, sucking
and biting are the
chief pleasure
sources. This
action reduce the
infants tension
while the anal
stage which is
from 1 to 3 years
of life of the
infant, it is in this
stage that the
infant is being
toilet train by his
parents.
According to Baby Clark Kent’s mother, she had a history of parasitism when she was young and she has
only one brother who has asthma, her father had a history of appendectomy and her mother has
hypertension and cardiomegaly. Her younger sister was hospitalized due to cough and colds and was born
premature while on Baby Clark Kent’s paternal side, his grandfather has renal failure and his grandmother
suffers from diabetes mellitus and asthma that led to his father having asthma. One of Baby Clark Kent’s
cousin on the paternal side suffers with asthma too.
Jonathan28 years old
-Asthma
GrandfatherPreston Burke50 years old-Renal Failure
GrandmotherCristina Yang49 years old
-Diabetes Mellitus-Asthma
Father’s Side
Lionel27 years old
-history of smoking and alcoholism
Clark Kent11 months
-Fever-Cough &
ColdPneumoniaPre-mature (3 weeks)
Lois3 years
old-Asthma
Lana8 years old
Lex6 years
old-Asthma
Alex21 years
old-Asthma
GrandfatherDerek Shepherd
42 years old-history of appendectomy
GrandmotherMeredith Grey40 years old
-Hypertension-Cardiomagaly
Mother’s Side
Clark Kent
11 months-Fever
-Cough & Cold
PneumoniaPre-mature (3 weeks)
George10 years old
-Asthma
Martha20 years old-history of parasitism
Elizabeth16 years old
Caley3 months
-hospitalized due to cough &
colds-premature (3 weeks)
Lois3 years old
-Asthma
E. History of Past Illness
It was reported that after Baby Clark Kent was born, he had
experienced difficulty of breathing which was manifested by cyanosis. Other
than that, he also experienced hyperthermia, cough, colds, asthma, and
lastly, jaundice.
F. History of Present Illness
Prior to admission to the hospital in Magalang last June 23,2007, Baby
Clark Kent had experienced fever and cough.
G. Physical Examination
☼ Upon Admission (lifted from the chart): June 23, 2007
Vital Signs:
T - 40°C
☼ First Nurse-Patient Interaction: June 26, 2007
Vital Signs:
T – 38.1°C,
P - 150,
R - 23
Physical Assessment:
SKIN: no odor; pale; unblemished; goes back when pinched; with
temperature within normal limit.
HAIR: thick; black in color; short; evenly distributed; no dandruff or lice
upon inspection
HEAD: symmetrical & normocephalic; no mass noted upon palpation
FACE: symmetric features; facial movement
EYEBROWS: hair evenly distributed; skin intact; symmetrically aligned;
equal movement
EYELASHES: equally distributed; curled slightly upward
EYELIDS: skin intact; no discharge; no discoloration; lids close
symmetrically; involuntary blinks approximately 15 to 20 per minute
EYES: sclera appears white no discharges noted; pale palpebral conjunctiva;
no edema or tenderness over the lacrimal glands; transparent, smooth
and shiny, details of iris are visible; the client blinks when cornea is
touched; pupils black in color, equal in size; smooth border; iris flat and
round
NOSE: symmetrical in shape and size; nasal flaring and secretions noted upon
inspection; uniform
MOUTH: symmetric; uniform pink; moist, smooth; no lesions
TONGUE: central position; pink; moist; slightly rough; thin whitish coating;
no lesions
EARS: symmetrical; no lesions noted upon inspection; same color as facial
skin, auricle is aligned with the outer canthus of the eye; mobile; firm; non
tented; pinna recoils after it is folded
NAILS: short with minimal dirt; capillary refill time less than 3 seconds;
convex curve; intact epidermis
NECK: symmetrical; with no lesions noted upon inspection, muscles equal
in size; head centered; coordinated, smooth movement with no discomfort
CHEST: symmetrical expansion,
LUNGS: adventitious breath sounds (rales)
HEART: no pulsations heard upon auscultation; symmetric pulse volumes;
full pulsations; thrusting quality; quality remains same when client
breaths, turns head and changes from sitting to supine position; elastic
arterial wall
ABDOMEN: symmetric contour, no evidence of enlargement of liver and
spleen, symmetric movements caused by respiration, audible bowel
sounds; unblemished skin; uniform color
EXTREMITIES: (-) edema
☼ Second Nurse-Patient Interaction: June 27, 2007
Vital Signs:
T – 37.4°C,
P -150 bpm ,
R -23cpm
Physical Assessment:
SKIN: no odor; pale; unblemished; goes back when pinched; with
temperature within normal limit.
HAIR: thick; black in color; short; evenly distributed; no dandruff or lice
upon inspection
HEAD: symmetrical & normocephalic; no mass noted upon palpation
FACE: symmetric features; facial movement
EYEBROWS: hair evenly distributed; skin intact; symmetrically aligned;
equal movement
EYELASHES: equally distributed; curled slightly upward
EYELIDS: skin intact; no discharge; no discoloration; lids close
symmetrically; involuntary blinks approximately 15 to 20 per minute
EYES: sclera appears white no discharges noted; pale palpebral conjunctiva;
no edema or tenderness over the lacrimal glands; transparent, smooth
and shiny, details of iris are visible; the client blinks when cornea is
touched; pupils black in color, equal in size; smooth border; iris flat and
round
NOSE: symmetrical in shape and size; nasal flaring and secretions noted upon
inspection; uniform
MOUTH: symmetric; uniform pink; moist, smooth; no lesions
TONGUE: central position; pink; moist; slightly rough; thin whitish coating;
no lesions
EARS: symmetrical; no lesions noted upon inspection; same color as facial
skin, auricle is aligned with the outer canthus of the eye; mobile; firm; non
tented; pinna recoils after it is folded
NAILS: short with minimal dirt; capillary refill time less than 3 seconds;
convex curve; intact epidermis
NECK: symmetrical; with no lesions noted upon inspection, muscles equal
in size; head centered; coordinated, smooth movement with no discomfort
CHEST: symmetrical expansion,
LUNGS: adventitious breath sounds (rales)
HEART: no pulsations heard upon auscultation; symmetric pulse volumes;
full pulsations; thrusting quality; quality remains same when client
breaths, turns head and changes from sitting to supine position; elastic
arterial wall
ABDOMEN: symmetric contour, no evidence of enlargement of liver and
spleen, symmetric movements caused by respiration, audible bowel
sounds; unblemished skin; uniform color
EXTREMITIES: (-) edema noted
Reflexes Description Appea-
ance
Disappear-
ance
Baby Clark
Kent
Babinski Toes fan upward when
sole of the foot is
stroke.
Birth 9 months Absence
of
Babinski
Reflex
Galant Arching of trunk toward
stimulated side when
infant is stroke along
the spine.
Birth Neonatal
Period
Absence
of Galant
Reflex
Moro (startle) Sudden outward
extension of arms with
midline returns when
startled by loud noise
or rapid change in
position.
Birth 4months Absence
of Moro
Reflex
EXTREMITIES: (-) edema noted
Righting Attempting to maintain
head in an upright
position.
Birth 24
months
Presence
of
Righting
Reflex
Rooting Turning head toward
stimulated side of
cheek.
Birth 6 months Absence
of Rooting
Reflex
Sucking Initiation of sucking
when an object is place
on the mouth.
Birth Indefinite Presence
of Sucking
Reflex
Swimming Mimicking swimming
movement when held
horizontally in wate.
Birth 4 months Absence
of
Swimming
Reflex
Walking Making stepping
movements when held
upright with feet
touching the surface.
First
weeks;
reappe
ars at
4-5
months
12
months
Presence
of
Walking
Reflex
H. Diagnostic and Laboratory Findings
Diagnostic/ Laboratory Procedures
Date Ordered & Date
Result(s) In
Indication(s) or Purpose(s)
Results (1st, 2nd) Normal Values Analysis & Interpretation of Results
1. CBC or
Hematology
To determine
whether specific
blood levels are
higher or lower
than normal and
can be useful in
the diagnosis of
such diseases as
anemia, leukemia
and infection.
Analysis of
RBCs, WBCs,
PT, PTT,
Erythrocyte
Sedimentation
Rate, Platelets,
Hemoglobin
is the iron-
containing
oxygen-
transport
metalloprotein
in the red
blood cells of
the blood in
vertebrates
and other
animals.
120 – 160 Low Hb concentration may indicate
DO:
06/23/07
DRI:
06/23/07
H/H 88
9 – 6
Hematocrit
is the
measures of
the proportion
of blood
volume that is
occupied by
red blood
cells.
g/L
mg% (12 –
16 mg%)
anemia, recent hemorrhage or fluid
retention, which can cause
hemodilution.
Low Hct suggests anemia,
DO:
06/26/07
DRI:
06/26/07
0.29
31 – 0
WBC or
leukocytes
are cells of
the immune
system which
defend the
body against
both
infectious
disease and
foreign
materials.
11.8
0.40 – 0.50
vol% (37 –
47 vol%)
5.0 – 10 x
106/
hemodilution or massive blood loss.
A low WBC count (leukopenia)
indicates bone marrow depression,
which may result from viral
DO:
06/23/07
DRI:
06/23/07
3.6
Differential
Count
Neutrophils
are the most
abundant type
of white blood
cells and form
an integral
part of the
immune
system.
w/cu.mm
(5000 –
10000/
cu.mm)
infections or from toxic reactions,
such as those following treatment
with antineoplastics, ingestion of
mercury or other heavy metals or
exposure to benzene or arsenicals.
Normal. Neutrophils are
DO:
06/26/07
DRI:
06/26/07
.62
68
Lymphocyte
is a type of
white blood
cell in the
vertebrate
immune
system. By
their
appearance
under the
.45 – .65
% (60 – 70)
phagocytes, capable of ingesting
microorganisms or particles. They
can internalise and kill many
microbes, each phagocytic event
resulting in the formation of a
phagosome into which reactive
oxygen species and hydrolytic
enzymes are secreted.
light
microscope,
there are two
broad
categories of
lymphocytes,
namely the
large granular
lymphocytes
and the small
lymphocytes.
Functionally
distinct
subsets of
lymphocytes
correlate with
their
appearance.
.33
.25 – .40
% (30 – 40)
Normal. Most, but not all large
granular lymphocytes are more
commonly known as the natural
killer cells (NK cells). The small
lymphocytes are the T cells and B
DO:
06/23/07
DRI:
06/23/07
91
Monocyte is
a leukocyte,
part of the
human body's
immune
system that
cells. Lymphocytes play an
important and integral role in the
body's defenses.
An increase in lymphocytes may
indicate infection: tuberculosis,
hepatitis, infectious mononucleosis,
mumps, rubella, cytomegalovirus
Thyrotoxicosis, hypoadrenalism,
ulcerative colitis, immune diseases,
lymphocytic leukemia
DO:
06/26/07
DRI:
06/26/07
protects
against blood-
borne
pathogens
and moves
quickly to
sites of
infection in
the tissues.
.05
none
Eosinophils
are white
blood cells of
.02 – .06 Normal. A monocyte count is part of
a complete blood count and is
expressed either as a ratio of
monocytes to the total number of
white blood cells counted, or by
absolute numbers.
the immune
system that
are
responsible
for combating
infection by
parasites in
vertebrates.
They also
control
mechanisms
associated
with allergy
and asthma.
They are
granulocytes
that develop
in the bone
marrow
before
DO:
06/23/07
DRI:
06/23/07
migrating into
blood.
none
01
Platelets or
thrombocyte
% (0 – 3) Normal. Eosinophils produce and
store many secondary granule
proteins prior to their exit from the
bone marrow. After maturation,
eosinophils circulate in blood and
migrate to inflammatory sites in
tissues, or to sites of helminth
infection in response to chemokines
like CCL11 (eotaxin) and CCL5
(RANTES), and certain leukotrienes
like leukotriene B4 (LTB4).
DO:
06/26/07
s are the cell
fragments
circulating in
the blood that
are involved
in the cellular
mechanisms
of primary
hemostasis
leading to the
formation of
blood clots.
153
184
150 – 450 x
106/mL
150 – 450 x
106/mL
Normal. Normal platelet counts are not
a guarantee of adequate function. In
some states the platelets, while being
adequate in number, are dysfunctional.
For instance, aspirin irreversibly
disrupts platelet function by inhibiting
cyclooxygenase-1 (COX1), and hence
normal hemostasis; normal platelet
function may not return until the
aspirin has ceased and all the affected
platelets have been replaced by new
ones, which can take over a week.
Similarly, uremia (a consequence of
renal failure) leads to platelet
dysfunction that may be ameliorated
DRI:
06/26/07
by the administration of desmopressin.
NURSING RESPONSIBILITIES1. Prior
☺ Note current drug therapy before procedure.
☺ Check the physician’s order.
☺ Identify the client.
☺ Prepare the needed materials.
☺ Explain the procedure, its purpose and how it is done.
☺ Inform the patient/SO that there are no food or fluid restrictions.
☺ Inform the patient that the test may require blood specimen and might bring a little pain to the punctured site.
☺ Wash hands.
2. During
☺ Collect approximately 5 to 10 ml of venous blood in a purple top tube.
☺ Avoid hemolysis.
☺ Maintain aseptic technique.
3. After
☺ Apply pressure to the punctured site to prevent bleeding.
☺ Discuss with SO signs of inflammation of punctured site and advice to report immediately.
☺ Check the site for bleeding after procedure.
☺ Wash hands.
Diagnostic/
Laboratory
Procedures
Date
Ordered
& Date
Result(s)
In
Indication(s) or
Purpose(s)Results Normal Values Analysis & Interpretation of Results
2.
Urinalysis
DO:
06/23/0
7
DRI:
06/23/0
7
Determination
of urine
composition
and possible
abnormal
components
(e.g. protein
or glucose) or
infection
To screen for
metabolic and
kidney
disorders and
for urinary
Color: Yellow
Transparency:
Clear
pH: 7.5
Specific
Gravity: 1.010
Albumin:
Negative
Sugar: Negative
Microscopic
Exam
Pus Cell:
Color: Yellow
Transparency:
Clear to faintly
hazy
pH: 4.5 – 8.0
Specific
Gravity:
1.003 – 1.030
Albumin:
Negative
Sugar: Negative
A normal urinalysis also does
not guarantee that there is no
illness. Some people will not
release elevated amounts of a
substance early in a disease
process and some will release
them sporadically during the
day (which means they may be
missed by a single urine
sample).
tract
infections
0-3/hpf
RBC: 2-5/hpf
Epithelial Cells:
Rare
Pus Cell:
0-1/hpf
RBC: < 4
cells/hpf
Epithelial Cells:
< 11 cells/hpf
Mild infection
An elevated RBC count may
indicate absolute or relative
polycythemia.
NURSING RESPONSIBILITIES
1. Prior
☺ Tell the patient to avoid stress and strenuous exercise before the test.
☺ Check for drugs that influence urinalysis.
☺ Explain the procedure to the mother.
2. During
☺ Collect a random urine specimen of at least 15 ml, preferably a first-voided morning specimen.
☺ If the patient is being evaluated for renal colic, strain the specimen to catch stones or stone fragments.
☺ Refrigerate the specimen if analysis will be delayed longer than 1 hour.
☺ Maintain aseptic technique.
3. After
☺ Send specimen to the laboratory immediately.
☺ Perform proper hand-washing.
☺ Document.
Diagnostic/
Laboratory
Procedures
Date
Ordered &
Date
Result(s) In
Indication(s) or
Purpose(s)Results Normal Values
Analysis &
Interpretation of
Results
3. X-ray or
Rontgen
Rays
DO:
06/25/07
DRI:
06/25/07
To determine
pulmonary edema or
congestion
To identify the
abnormalities of the
lungs and the
structures on the
thorax. And also to
identify the size of the
heart and the
abnormalities in the
ribs and diaphragm.
Hazy infiltrates are
noted on both lower
lungfields
Heart is normal in size
Diaphragm and sulci
are intact
Other chest structures are
Normal lung
fields.
Pneumonia,
bilateral
Visible in the
anterior left
mediastinal
cavity; appears
solid because of
blood contents
remarkable
NURSING RESPONSIBILITIES
1. Prior
☺ Check the doctor’s order.
☺ Identify the client.
☺ Describe the procedure to the patient.
☺ Determine the patient’s ability to inhale and hold breath.
☺ Explain to the mother that this test assesses respiratory status.
☺ Tell the mother that no fasting is required.
☺ Inform the mother that the test takes 5 to 10 minutes.
☺ Describe the test to the mother including who will perform it and when will it take place.
☺ Assist transporting the client in going to the x-ray room.
2. During
☺ Provide a gown without snaps, and ask the patient to remove all jewelry in the radiographic field. Tell
him he’ll be asked to take a deep breath and hold it momentarily while the film is being taken, to
provide a clear view of pulmonary structures.
☺ If the patient is intubated, check that no tubes have been dislodged during positioning.
☺ To avoid exposure to radiation, leave the room or the immediate area while the films are being taken. If
you must stay in the area, wear a lead-lined apron.
☺ Assist and keep patient still as possible during the procedure.
3. After
☺ Inform the mother the possible need for additional x-ray.
☺ Document.
III. Anatomy and Physiology
The Respiratory System
The respiratory System of the Human body is primarily for the sole
purpose of facilitating respiration. This includes the exchange of gases
between the environment and the lungs through the process of ventilation.
Also, it provides a mechanism for the body’s exchange of oxygen and carbon
dioxide in the lungs and in the blood. As the oxygen being inspired travel to
the bloodstream to allow for cellular exchange, carbon dioxide, which is a
waste material of a cell, is replaced by oxygen to attain maximum
functioning.
Other than respiration, the human body’s respiratory system is also
responsible for regulation of blood pH, voice production, olfaction, and innate
immunity.
The respiratory system is divided into two, namely: the upper and the
lower respiratory tract. Under the upper respiratory tract refers to the nose,
nasal cavity, and pharynx. While the lower respiratory tract refers to the
larynx, bronchi, the trachea, and the lungs; Pneumonia, a very serious
disease causes inflammation in the lungs. The air sacs in the lungs fill with
pus and other liquid. Oxygen has trouble reaching your blood. If there is too
little oxygen in your blood, your body cells can't work properly. Because of
this and spreading infection through the body pneumonia can cause death.
Bronchi and Bronchial Tree
In the mediastinum, at the level of the fifth thoracic vertebra, the trachea
divides into the right and left primary bronchi. The bronchi branch into
smaller and smaller passageways until they terminate in tiny air sacs called
alveoli.
The cartilage and mucous membrane of the primary bronchi are similar to
that in the trachea. As the branching continues through the bronchial tree,
the amount of hyaline cartilage in the walls decreases until it is absent in the
smallest bronchioles. As the cartilage decreases, the amount of smooth
muscle increases. The mucous membrane also undergoes a transition from
ciliated pseudostratified columnar epithelium to simple cuboidal epithelium to
simple squamous epithelium.
The alveolar ducts and alveoli consist primarily of simple squamous
epithelium, which permits rapid diffusion of oxygen and carbon dioxide.
Exchange of gases between the air in the lungs and the blood in the
capillaries occurs across the walls of the alveolar ducts and alveoli.
Lungs
The two lungs, which contain all the components of the bronchial tree
beyond the primary bronchi, occupy most of the space in the thoracic cavity.
The lungs are soft and spongy because they are mostly air spaces
surrounded by the alveolar cells and elastic connective tissue. They are
separated from each other by the mediastinum, which contains the heart.
The only point of attachment for each lung is at the hilum, or root, on the
medial side. This is where the bronchi, blood vessels, lymphatics, and nerves
enter the lungs.
The right lung is shorter, broader, and has a greater volume than the left
lung. It is divided into three lobes and each lobe is supplied by one of the
secondary bronchi. The left lung is longer and narrower than the right lung. It
has an indentation, called the cardiac notch, on its medial surface for the
apex of the heart. The left lung has two lobes.
Each lung is enclosed by a double-layered serous membrane, called the
pleura. The visceral pleura is firmly attached to the surface of the lung. At the
hilum, the visceral pleura is continuous with the parietal pleura that lines the
wall of the thorax. The small space between the visceral and parietal pleurae
is the pleural cavity. It contains a thin film of serous fluid that is produced by
the pleura. The fluid acts as a lubricant to reduce friction as the two layers
slide against each other, and it helps to hold the two layers together as the
lungs inflate and deflate.
A Diagram showing the
Trachoebronchial Tree and the Diaphragm
Oxygen Transport System
The flow of air in and out of the lungs is controlled by the nervous
system, which ensures that humans breathe in a regular pattern and at a
regular rate. Breathing is carried out day and night by an unconscious
process. It begins with a cluster of nerve cells in the brain stem called the
respiratory center. These cells send simultaneous signals to the diaphragm
and rib muscles, the muscles involved in inhalation. The diaphragm is a large,
dome-shaped muscle that lies just under the lungs. When the diaphragm is
stimulated by a nervous impulse, it flattens. The downward movement of the
diaphragm expands the volume of the cavity that contains the lungs, the
thoracic cavity. When the rib muscles are stimulated, they also contract,
pulling the rib cage up and out like the handle of a pail. This movement also
expands the thoracic cavity. The increased volume of the thoracic cavity
causes air to rush into the lungs. The nervous stimulation is brief, and when it
ceases, the diaphragm and rib muscles relax and exhalation occurs. Under
normal conditions, the respiratory center emits signals 12 to 20 times a
minute, causing a person to take 12 to 20 breaths a minute. Newborns
breathe at a faster rate, about 30 to 50 breaths a minute.
The diaphragm works by creating a negative pressure area. When
pulling downward it makes the thoracic cavity have a substantially lower
internal pressure than what exists out side the cavity. Air rushes into the
respisrtory system.
When the diaphragm relaxes it pushes upward causing the pressure in
the thoracic cavity to become greater than exists outside the cavity. Air is
forced out of the respiartory system.
The rhythm set by the respiratory center can be altered by conscious
control. The breathing pattern changes when a person sings or whistles, for
example. A person also can alter the breathing pattern by holding the breath.
The cerebral cortex, the part of the brain involved in thinking, can send
signals to the diaphragm and rib muscles that temporarily override the
signals from the respiratory center. The ability to hold one’s breath has
survival value. If a person encounters noxious fumes, for example, it is
possible to avoid inhaling the fumes.
A person cannot hold the breath indefinitely, however. If exhalation
does not occur, carbon dioxide accumulates in the blood, which, in turn,
causes the blood to become more acidic. Increased acidity interferes with the
action of enzymes, the specialized proteins that participate in virtually all
biochemical reaction in the body. To prevent the blood from becoming too
acidic, the blood is monitored by special receptors called chemoreceptors,
located in the brainstem and in the blood vessels of the neck. If acid builds up
in the blood, the chemoreceptors send nervous signals to the respiratory
center, which overrides the signals from the cerebral cortex and causes a
person to exhale and then resume breathing. These exhalations expel the
carbon dioxide and bring the blood acid level back to normal.
A person can exert some degree of control over the amount of air
inhaled, with some limitations. To prevent the lungs from bursting from
overinflation, specialized cells in the lungs called stretch receptors measure
the volume of air in the lungs. When the volume reaches an unsafe threshold,
the stretch receptors send signals to the respiratory center, which shuts
down the muscles of inhalation and halts the intake of air.
In pulmonary circulation, deoxygenated blood returning from the
organs and tissues of the body travels from the right atrium of the heart to
the right ventricle. From there it is pushed through the pulmonary artery to
the lung. In the lung, the pulmonary artery divides, forming the pulmonary
capillary region of the lung. At this site, microscopic vessels pass adjacent to
the alveoli, or air sacs of the lung, and gases are exchanged across a thin
membrane: oxygen crosses the membrane into the blood while carbon
dioxide leaves the blood through this same membrane. Newly oxygenated
blood then flows into the pulmonary veins, where it is collected by the left
atrium of the heart, a chamber that serves as collecting pool for the left
ventricle. The contraction of the left ventricle sends blood into the aorta,
completing the circulatory loop. On average, a single blood cell takes roughly
30 seconds to complete a full circuit through both the pulmonary and
systemic circulation.
A Diagram showing both the process of Pulmonary Circulationand Systemic Circulation
Gas exchange or respiration takes place at a respiratory surface - a
boundary between the external environment and the interior of the body. For
unicellular organisms the respiratory surface is simply the cell membrane,
but for large organisms it usually is carried out in respiratory systems.
In humans and other mammals, respiratory gas exchange or
ventilation is carried out by mechanisms of the lungs. The actual exchange of
gases occurs in the alveoli.
Convection occurs over the majority of the transport pathway.
Diffusion occurs only over very short distances. The primary force applied in
the respiratory tract is supplied by atmospheric pressure. Total atmospheric
pressure at sea level is 760 mm Hg, with oxygen (O2) providing a partial
pressure (pO2) of 160 mm Hg, 21% by volume, at the entrance of the nares,
and an estimated pO2 of 100 mm Hg in the alveoli sac, pressure drop due to
conduction loss as oxygen travels along the transport passageway.
Atmospheric pressure decreases as altitude increases making effective
breathing more difficult at higher altitudes.
A Diagram showing gas exchange that
occurs only at pulmonary and systemic capillary beds near the alveoli.
CO2 is a result of cellular respiration. The concentration of this gas in
the breath can be measured using a capnograph. As a secondary
measurement, respiration rate can be derived from a CO2 breath waveform.
Trace gases present in breath at levels lower than a part per million
are ammonia, acetone, isoprene. These can be measured using selected ion
flow tube mass spectrometry.
Blood carries oxygen, carbon dioxide and hydrogen ions between
tissues and the lungs.
The majority (70%) of CO2 transported in the blood is dissolved in
plasma (primarily as dissolved bicarbonate; 60%). A smaller fraction (30%) is
transported in red blood cells combined with the globin portion of hemoglobin
as carbaminohemoglobin.
Hemoglobin in the red blood cells increases the carrying capacity of
oxygen hundreds of times greater than plain water.
CO2 that diffuses into the blood enters red blood cells where an
enzyme converts the CO2 into bicarbonate ions (HCO3-). Converting the
CO2 into Bicarbonate ions increases the carrying capacity of CO2 molecules.
In addition, formation of bicarbonate ions offers the body an effective
method of regulating blood pH. CO2 will react with water to produce carbonic
acid. If carbonic acid were to increase (which can occur as a result of
increased cellular activity) blood pH would lower which could effect enzyme
activity. The fact that red blood cells convert CO2 into Bicarbonate ions,
which are basic, enables the body to maintain a constant pH in the blood.
IV THE PATIENT AND HIS ILLNESS
SCHEMATIC DIAGRAM OF PNEUMONIA(Book-Based)
Modifiable Factors Non-modifiable Factors
-Poor Diet -Age: 11 months
-Unhygienic Practices based on culture -Sex: Male
-Place of residence is far from market-Underdeveloped place of residence
Body’s defense is lowered/ low immune system
Failure of the respiratory tree to be free of infection
Exposure to an environment which serves as niche for M.O. (microorganisms
Acquisition of M.O.s (bacterial, viral, fungal)
Inhalation of M.O.s and become lodged Aspiration of foreign body, food, vomit or In naso pharyngeal secretions other irritating substances such as products (cleaners) into the lungs
PATHOGENS BEGIN TO COLONIZE
Infection Starts
Bacteria reaches Tracheo- Virus attacks Irritation to the airway mucosa bronchial Tree Bronchiolar epithelial cells and lung parenchyma
Mucosal Edema Desquamation
(peeling off of mucous
membrane in lungs
Impairment of the Invasion in mucous glands
Mucociliary escalator goblet cells (produces mucus)
Absence of major barrier Reaches alveoli (fills with blood/fluid)
against infection
Further infection Interstitial inflammation with
Infiltrates in the alveolar walls (no exudates)
Local pulmonary defenses Infects alveoli No. of WBC in the
Resists infection peripheral blood is higher than normal
Cough Reflex Triggers alveolar inflammation Elevated temperature
Chills
Stress in the lungs; disrupts function Produces an area of low ventilation w/ normal perfusion
Injury reduces normal blood flow to lungs Introduction of fluids on tissues by their injection into
blood vessels (veins)
Platelets aggregate and release histamine, capillaries become engorged with blood
Serotonin, & bradykinins
Stasis (cessation of flow of blood/ body fluids)
Alveolocapillary membrane breaks down Increase capillary permeability
Alveoli fills with blood and exudate Proteins and fluids Leak out
Atelectasis( gas exchange is not accomplished Cont. Hypoxemia
by the shrunken alveoli) Reaches Pleural surface
in some areas Decrease pulmonary
compliance
Diminished O2 in body (cyanosis) Irritation and inflammation of the pleura Crackles and
ronchi
Inflammatory exudates accumulates Hypoxemia in the Pleural surfaces
Hypoxia in muscles and brain Consolidation Friction in the pleura upon respiration
Vascular changes in Body malaise Partial loss of lung function Chest pain Cephalic area
Headache Decrease Brain impulses Oxygenation of blood is impaired Cont. Increase in interstitial In taste buds’ function osmotic
pressure
Loss of appetite Shortness of breath Pulmonary Edema
Heart pumps more blood Decreased Blood flow (compensatory mechanism) and fluids in the alveoli damage
Surfactant
Tachycardia Impairs cells’ ability to produce more
Alveoli collapses
Sufficient O2 can’t cross the Increase in respiratory distress Impaired gas
exchangealveolocapillary membrane
Fibrosis
CO2 is lost w/ every exhalation Hypoxemia Metabolic acidosis develops Atelectasis
Hemorrhage
Tissue necrosis
Acute Respiratory Failure Formation of exudates
Further pulmonary Edema
SCHEMATIC DIAGRAM OF PNEUMONIA(Client-Centered)
Modifiable Factors Non-modifiable Factors
-Poor Diet -Age: 11 months
-Unhygienic Practices based on culture -Sex: Male-Place of residence is far from market-Underdeveloped place of residence
Body’s defense is lowered/ low immune system
Failure of the respiratory tree to be free of infection
Exposure to an environment which serves as niche for M.O. (microorganisms
Acquisition of M.O.s (bacterial, viral, fungal)
Inhalation of M.O.s and become lodged In naso pharyngeal secretions
PATHOGENS BEGIN TO COLONIZE
Infection Starts
Bacteria reaches Tracheo- Virus attacks Irritation to the airway mucosa bronchial Tree Bronchiolar epithelial cells and lung parenchyma
Desquamation (peeling off of mucous membrane in lungs
Invasion in mucous glands goblet cells (produces mucus)
Reaches alveoli (fills with blood/fluid)
Interstitial inflammation with Infiltrates in the alveolar walls (no exudates)
Local pulmonary defenses Infects alveoli Resists infection
Cough Reflex Triggers alveolar inflammation
Stress in the lungs; disrupts function Produces an area of low ventilation w/ normal perfusion
Injury reduces normal blood flow to lungs Introduction of fluids on tissues by their injection into
blood vessels (veins)
Platelets aggregate and release histamine, capillaries become engorged with bloodSerotonin, & bradykinins
Stasis (cessation of flow of blood/ body fluids)
Alveolocapillary membrane breaks down
Alveoli fills with blood and exudate
Atelectasis( gas exchange is not accomplished
by the shrunken alveoli) Reaches Pleural surface in some areas
Diminished O2 in body Irritation and inflammation of the pleura
Inflammatory exudates accumulates Hypoxemia in the Pleural surfaces
Hypoxia in muscles and brain Headache Decrease Brain impulses
Vascular changes in Body malaise In taste buds’ function Cephalic area
Loss of appetite
Synthesis of the Disease (Book-Centered)
Pneumonia is the inflammation of the lung parenchyma and also of the
interstitium of the lungs. It is acquired either in the community, where a host
is exposed to and together with lowered immune system could cause an
infection, or in the hospital where immunocompromised patients such as
pediatrics, and geriatrics where there is failure of the body to be free of
infection.
A lot of different factors may have a contribution in the development of
the disease. Among the factors are, poor diet, unhygienic practices based on
culture, and an underdeveloped place of residence. Also, in addition to that,
the presence of non-modifiable factors such as age of the client ad the sex
(e.i. to which sex is the disease condition more prominent).
Baby Clark Kent is an eleven month old baby boy, living in an
underdeveloped place of residence which is far from the market. They
observe unhygienic practices under the influence of culture. With all these
combined, the defense mechanism of the client is lowered or impaired, there
is failure of e respiratory tract to be free of infection. Upon exposure to an
environment that serves as a niche for microorganisms, pathogens begin to
start colonizing the body when the body undergoes two processes. First,
inhalation of microorganisms in which they become lodged in the
nasopharyngeal secretions. Second, Aspiration of foreign body, food, vomit or
other irritating substances such as cleaning products into the lungs.
There are three modes in which infection may start. First, a bacterium
reaches the tracheobrochial tree. By then, local pulmonary defenses resists
infection as manifested in coughing. The alveoli become infected and it
triggers alveolar inflammation. With this, the number of WBC in the
peripheral blood is higher than normal. And so there is elevated temperature
plus chills may also be seen as a form of involuntary compensatory
mechanism.
When the alveoli inflames, there is a presence of stress in the lungs
that disrupts respiration. Therefore normal blood flow to the lungs is reduced.
So what happens is that, platelets aggregate and release histamine,
serotonin and bradykinins as an inflammatory response. Alveolar capillary
membrane breaks down which will eventually lead to the filling of blood and
exudates in the alveoli and increase capillary permeability. In the mean time,
when alveolar inflammation occurs, there is a production of an area of low
ventilation with normal perfusion which means that there is an introduction of
fluids on tissues by their injection into blood vessels (veins). Capillaries now
becomes engorged with blood so its flow will stop, thus stasis will occur.
Atelectasis impairs gas exchange because the alveoli had already been
shrunken when the alveoli was filled with blood and exudates. So what
happens is that there is diminished oxygen in the body, which is evident in
the occurrence of cyanosis; because of this there would be hypoxemia in the
entire body which leads to hypoxia in the muscles and brain. Due to this
occurrence, there would be vascular changes in the cephalic area which leads
to headache and loss of appetite (decrease brain impulses in taste buds),
body malaise will also be experienced.
Also, when alveoli fill with blood and exudates pleural surfaces are
being irritated and inflamed. Production of inflammatory exudates
accumulates in the pleural surfaces; this causes consolidation of exudates
which leads to partial loss of lung function in which oxygenation of blood is
impaired. Therefore, there will be shortness of breath. Heart pumps more
blood as a compensatory mechanism which leads to tachycardia.
Furthermore, inflammatory exudates cause friction in the pleura upon
respiration instigates chest pain.
In relation to the increase in capillary permeability, proteins and fluids
leak out; this increases interstitial osmotic pressure causing pulmonary
edema. Pulmonary edema is an abnormal buildup of fluid within the tissues of
the lung. Fluid can build up in the lungs for many reasons. This fluid makes it
difficult for the lungs to give oxygen to the blood. There will be low oxygen in
the blood and the fluid itself; this damages the surfactant. When this
happens, cells’ ability to produce more surfactant is impaired which leads to
alveoli collapses. Gas exchange is impaired and respiratory distress
increases. Sufficient Oxygen can’t cross the alveolocapillary membrane; CO2
is lost with every exhalation. Hypoxemia occurs and metabolic acidosis
develops soon after. When this happens, the client is at risk for having
Fibrosis, Atelectasis, Hemorrhage, Tissue Necrosis, formation of exudates,
and further Pulmonary Edema.
In relation to the onset of infection, viruses attacks bronchiolar
epithelia cells causing mucosal edema which impairs the mucociliary
escalator. This leads to further infection because of the absence of a major
barrier.
Another factor when pathogens begin to colonize is the irritation to the
airway mucosa and lung parenchyma. This directs to desquamation, which is
the peeling off of mucous membrane in the lungs. This leads to invasion of
mucous glands and goblet cells, which produces the mucous. Then, it fills the
alveoli with blood and fluid when reached, and there will be interstitial
inflammation with infiltrates in the alveolar walls; there are no present
exudates.
Synthesis of the Disease (Client-Centered)
Baby Clark Kent is an 11-month old baby boy living in an
underdeveloped residence which is far from market. His diet is poor and their
family performs unhygienic practices based on their culture.
All of the above mentioned factors contributed to the lowered body
defense of baby Clark. He failed to have a respiratory tree that is free from
infection.
Upon exposure to an environment which serves as a niche for
microorganisms (M.O.), baby Clark had acquired these MO’s because of
lowered immunity. He acquired it through inhalation in which the MO’s
became lodged in the nasopharyngeal secretions. Pathogens began to
colonize and infection has started.
Bacteria which is the tracheobronchial tree causing coughing reflex as
a defense mechanism. Baby Clark was infected with quite a number of a MO’s
therefore he became susceptible and the alveoli in his lungs became infected
causing an inflammation. Because of the inflammation the alveoli was filled
with blood and exudates. Gas exchange is compromised leading to
diminished oxygen in the body. There is low oxygen in the blood which leads
to hypoxia in the muscles and brain causing headache and body malaise. Plus
a decrease in appetite was attributed to that cause; since there is a decrease
in the nerve impulses that stimulate the tastebuds’ function.
Because of viral attacks to the bronchiolar epithelial cells, there was an
impairment of the mucocilliary escalator which adds up to further infection.
In addition to the blood and exudates that had filled the alveoli, pleural
surfaces had been irritated and inflamed causing an accumulation in the
inflammatory exudates leading to consolidation resulting in poor oxygenation
in blood. This will pilot the body to have shortness of breath, and as a
compensatory mechanism, the heart pumps more blood and the outcome will
be tachycardia.
Lastly, due to the irritation in the airway mucosa and lung
parenchyma, interstitial inflammation with infiltrates in the alveolar walls
occurs when the alveoli is filled with blood or fluid. This action is due to the
invasion of M.O.s in the mucous glands which stimulates the goblet cells to
produce more mucus.
Modifiable and Non-modifiable Factors
1. Poor Diet is a modifiable factor in which this is crucial in the
strengthening of the immune system of the client. Without the
sufficient intake of vitamins and minerals that are present in the diet,
the defense mechanism of the body is weakened; making it
susceptible to infection and invasion of possible microorganisms that
are present in the environment. This can be attributed to the possibility
that these microorganisms are dwelling in the environment itself.
Specifically, fruits and vegetables such as oranges, apples and green
leafy vegetables would be helpful in strengthening the immune
system. Plus, the compliance of the mother in giving due amount of
breast milk to the client, who is Baby Clark Kent.
2. Unhygienic Practices based on culture is a modifiable factor
because it may or may not be done. It was found out that during
Fridays and Tuesdays Baby Clark Kent is prohibited from taking a bath
whenever he is sick. It is important to take a bath everyday and if this
will be continually practiced, possible microorganisms could thrive on
moist environments in the body making the client susceptible for
diseases.
3. Place of residence is underdeveloped is another modifiable factor
since crowdedness of the people living in a particular geographical
area would facilitate direct contact mode of transmission of possible
microorganisms or through droplet infection, as well. This will make the
client susceptible for acquiring a disease from someone proximal to
him; therefore, a disease may or may not develop depending on the
distance of the client from an infected person and the virulence of the
disease.
4. Place of residence is far from market is a modifiable factor; this
factor is very important because the food that are said to be essential
for the strengthening of the immune system of the child is present in
the market. If it will be distal to the client’s place of residence, then it
will be hard for the family to supply for the needs of the client in terms
of food. This difficulty lessens the food that Baby Clark Kent could have
eaten should they live in a close proximity to the market.
5. Age is a non-modifiable factor in which the client’s immunity against
possible diseases is not that developed in comparison to adults.
6. Sex is a non-modifiable factor in which the occurrence of the said
disease in prevalent in males more it is in females.
Signs and Symptoms
1. Cough an important way to keep your throat and airways clear.
However, excessive coughing may mean you have an underlying
disease or disorder. Some coughs are dry, while others are considered
productive; a reflex which is said to be a natural defense mechanism
because of its action of expulsing bacteria out of the tracheobronchial
tree.
Manifestation in baby Clark:
Baby Clark seldom coughs as a form of resistance to infection because the
bacteria has already reached the tracheobronchial tree.
2. Cyanosis refers to a blue or purple hue to the skin. It is most easily
observed on the lips, tongue and fingernails. Cyanosis indicates there
may be decreased oxygen in the bloodstream. It may suggest a
problem with the lungs, but most often is a result of mixing blue and
red blood due to defects of the heart or great vessels. Cyanosis is a
finding based on observation, not a laboratory test. Cyanosis is usually
caused by either serious lung or heart disease, or circulation problems.
3. Loss of Appetite is a result of decrease in the brain impulses that
stimulates the function of the taste buds. It is because of the vascular
changes in the cephalic area. Since the alveoli where filled with fluids
and exudates, gas exchange was not accomplished well; so what
happened was, there was diminished Oxygen in the body, as it was
manifested by the presence of cyanosis. Hypoxemia had erupted
resulting to low oxygen in the brain and muscles which eventually lead
to the vascular changes.
Manifestation in baby Clark:
As a result of loss of appetite, baby Clark had a weight reduction as
verbalized by the mother. It is because of the decrease brain impulses in
taste bud’s function because of low oxygen in the body tissues particularly
in the brain.
4. Headache is the outcome when there is low oxygen in the brain.
There are vascular changes in the cephalic area.
Manifestation in baby Clark:
Baby Clark had experienced headache because of the vascular changes in
the cephalic area when there is low oxygen in the head. This can be
attributed to the diminished oxygen in the body due to the fluid that filled
the alveoli.
5. Body Malaise had resulted out of low oxygen content in the muscles.
Since the cells in the body require sufficient amount in oxygen, it
cannot work properly if its level is decrease resulting to malaise.
V. THE PATIENT AND HIS CARE
A. Planning
a. Nursing Care Plan
ASSESSME
NT
NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATIO
N
OBJECTIVES INTERVENTI
ONS
RATIONALE EXPECTED
OUTCOME
S> the S.O
verbalized
“manguku
ya ampong
lalagnat”
O> the
patient
manifested
>Flushed
skin
>skin warm
to touch
>with body
Hyperther
mia
When the
causative
agent enters
the body and
invades the
respiratory
system, the
inflammatory
process is
triggered
releasing
platelets,
WBC, RBC,
which
Short term:
After 6 hours
of nursing
interventions
the patient
will maintain
core
temperature
within the
normal
range.
Long Term:
1.Measure
temperature
2. Assess skin
temperature
and color.
3. Monitor
WBC count.
1. Indicates if
fever exists
and its extent.
2. Warm, dry,
flushed skin
may indicate
a fever.
3. Leucocytes
indicate an
inflammatory
and infectious
process
Short term:
The patient
shall have
maintained
core
temperature
within the
normal
range.
Long term:
The patient
shall have
been free of
temperature
of 38.1ºC
> with skin
rashes
present in
the
abdomen,
back and
face
> rales on
both lung
field
-The
patient
may
manifest
>dehydratio
n
>Irritability
produces
exudates of
fibrin, which
enhances the
spread of
microorganis
m, causing
infection. In
response to
infection, the
individual
WBC release
pyrogens.
These
pyrogens
affect the
body
temperature-
regulating
mechanism in
After 1 day
of nursing
intervention
the patient
will be free
from
hyperthermi
a.
4. Encourage
fluid intake
orally or
intravenously
as ordered.
5. Measure
intake and
output.
6. Give tepid
sponge bath.
presence.
4. Replaces
fluid lost by
insensible loss
and
perspiration.
5. Determine
fluid balance
and need to
increase fluid
intake.
6. To facilitate
heat loss
through
evaporation.
7. To facilitate
hyperthermi
a.
the
hypothalamus
of the brain.
As a
consequence,
heat
production
and
conservation
increase, a
body
temperature
increases.
Fever
promotes
activities of
the immune
system, such
as
phagocytosis,
7. Apply an
ice bag
covered with
towel to the
axilla and
groin.
8. Administer
antipyretics
as ordered.
heat loss
through
conduction.
8. To interrupt
the growth of
microorganis
m.
inhibits the
growth of
some
microorganis
m.
ASSESSM
ENT
NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATI
ON
OBJECTIVES INTERVENTI
ONS
RATIONALE EXPECTED
OUTCOME
S>
O>the
patient
manifested
>fever of
38.4ºC
>presence
of
adventitiou
s sounds in
both lung
field.
>productiv
e cough
>skin pale
in color
Risk for infection
(spread) related
to inadequate
secondary
defenses(decreas
e hemoglobin,
hematocrit and
immunosuppressi
on)
Immuno-
suppression
due to
decrease in
hemoglobin,
leukopenia,
and suppress
inflammator
y response
gives a
greater
opportunity
for
pathogenic
bacteria to
invade and
Short term:
After 6 hours
of nursing
interventions
the patient’s
S.O will
verbalize her
understandin
g of
individual
causative/risk
factors and
demonstrate
lifestyle
changes to
prevent
1. Monitor v/s
closely,
especially
during
initiation of
therapy.
2. Instruct the
S.O
concerning
about the
disposition of
secretions
and report
changes in
color, amount
1. To know
potential
fatal
complication
that may
occur.
2. To
promote
safety
disposal of
secretions
and to
assess for
the
resolution of
Short
term:
The patient’s
S.O shall
have
verbalized
her
understandin
g of
individual
causative/risk
factors and
demonstrate
lifestyle
changes to
prevent
further
>restlessn
ess
-The
patient
may
manifest
>body
malaise
>activity
intolerance
>decrease
oxygen
level
inoculate in
a specific
body part of
a susceptible
human body.
Thus,
leading to a
further
damage or
infection.
further
infection.
Long term:
After 1-2 days
of nursing
interventions
the patient will
be free from
possible
spread of
infection.
and odor of
secretions.
3. Encourage
good hand
washing
techniques.
4. Encourage
adequate
rest.
5. Stress the
importance of
increasing the
childs
pneumonia
or
development
of secondary
infection.
3. To reduce
spread or
acquisition
of infection.
4. To enhance
fast recovery
and regain
strength.
5. A good
nutritional
intake can
strengthen
body
infection.
Long term:
The patient
shall have
been free
from
possible
spread of
infection.
nutritional
intake.
6. Encourage
the mother to
keep an eye
to the baby
and observe
anything that
the baby is
putting in his
mouth.
7. Administer
antimicrobials
as ordered.
immune
defense.
6. To
prevent
entry of
microbes.
7. To combat
microbial
pneumonias.
ASSESSME
NT
NURSING
DIAGNOSIS
SCIENTIFIC
EXPLANATION
OBJECTIVE
S
INTERVENTI
ONS
RATIONALE EXPECTED
OUTCOME
S> the S.O
verbalized
“masalese
neng
mangan,
kayamu
sasanat
yapa
ampong
sisispun.”
O>the
patient
manifested
>pale
palpibral
conjunctiva
Ineffective
Airway
Clearance
related to
retained
secretions
When the
causative agent
triggers the
inflammatory
process of the
lungs, exudates
of fibrin
containing fluid,
polymononuclea
r leucocytes and
erythrocytes is
produce.
Furthermore, the
mucous produce
joins it by the
goblet cells in
response to the
Short
term:
After 4-6
hours of
nursing
intervention
s the
patient will
maintain
airway
patency.
Long
term:
After 1-2
days of
nursing
1. Auscultate
lungs for
crackles,
consolidation
and pleural
friction rub.
2. Assess
characteristic
s of
secretions:
quantity,
1. To
determine
the
adequacy of
gas
exchange
and extent
of airways
obstructed
with
secretions.
2. Because
presence of
infection is
suspected
when
Short term:
The patient
shall have
maintained
airway
patency.
Long term:
The patient
shall have
expectorated
secretions
readily.
>rales on
both lung
fluid
>restless
-The
patient
may
manifest
>dyspnea
>cyanosis
>chest pain
>headache
invading
microorganism,
this combination
produce and
increase in the
tracheo-
bronchial tree.
intervention
s the
patient will
expectorate
secretions
readily.
consistency,
color, and
odor.
3. Keep the
environment
allergen free
according to
the individual
needs.
4. Encourage
the mother to
increase the
fluid intake of
the child.
secretions
are thick,
yellow or
rust in color
and foul
smelling.
3. To
prevent
allergic
reactions
that may
cause
bronchial
irritation.
4. As to
liquefy
secretions so
that they are
5. Position the
patient in
HOB.
6. Encourage
eating high
caloric foods,
food rich in
iron like liver
and dark
green leafy
vegetables,
and foods rich
in vitamin C.
easy to
expectorate.
5. To
Facilitate
optimal
breathing.
6. To
supplement
the iron
needs of the
child as well
as to
facilitate
absorption
and
strengthenin
g his
immune
7. Perform
and instruct
chest-
physiotherapy
after
nebulization.
8. Administer
meds per
doctor’s
order.
system.
7. For easy
secretion
expulsion.
8. To
facilitate fast
recovery.
ASSESSME
NT
NURSING
DIAGNOSIS
SCINETIFIC
EXPLANATION
OBJECTIVES INTERVENTIO
NS
RATIONALE EXPECTED
OUTCOME
S>the S.O
verbalized
“meyayat
ya”
O>the
patient
manifested
>Pale
conjunctiva
and mucous
membranes
>Sunken
eyes
>Lethargy
-The
patient may
manifest
>Anorexia
>Malnutritio
Imbalance
nutrition:
less than
body
requiremen
ts related
to loss of
appetite.
Many taste
sensations are
strongly
influenced by
olfactory
sensations.
This influence
can be
demonstrated
by comparing
the taste of
some food
before and
after pinching
your nose it is
easy to detect
that the sense
of taste is
reduce will the
nose is pinch.
Thus having
Short term:
After 5-6
hours of
nursing
interventions
the patient
will
demonstrate
increase
appetite.
Long term:
After 2-3 days
of nursing
interventions
the patient
will maintain
normal body
weight.
1. Monitor and
record vital
sign.
2. Assess for
patient’s BMI.
3. Instruct the
S.O to give food
to the infant in
an appetizing
manner.
4. Encourage
small frequent
feeding.
1. To establish
baseline data.
2. To know the
nutritional
status of the
client.
3. To boost
patient’s
appetite.
4. To enhance
intake even
though
appetite may
be slow to
return.
Short term:
The patient
shall have
demonstrated
an increased
in appetite.
Long term:
The patient
shall have
maintained
normal body
weight.
n
>Gastric
irritation
secretions in
the nasal cavity
will impede
your taste buds
from giving you
the appetite
you need.
Physical illness,
unfamiliar or
unpalatable
food,
environmental
and
psychologic
factors and
physical
discomfort or
pain may
depress the
appetites of
may clients.
5. Monitor
electrolyte
values and
report any
abnormalities.
6. Promote
adequate rest.
7. Encourage
the mother to
give the child
multivitamins.
5. Poor
nutritional
status may
cause
electrolyte
imbalances.
6. To reduce
fatigue and
improve the
child’s ability
and desire to
eat.
7. To
supplement
the nutritional
needs of the
child.
ASSESSM
ENT
NURSING
DIAGNOSI
S
SCIENTIFIC
EXPLANATI
ON
OBJECTIVE
S
INTERVENTIO
NS
RATIONALE EXPECTED
OUTCOME
S>
O> the
patient
manifested
>restlessn
ess
>irritability
>nasal
flaring
-The
patient
may
manifest
>diaphores
Impaired
gas
exchange
related to
alveolar
capillary
membran
e changes
secondary
to
inflammat
ion.
Bronchospas
m, which
occurs in
many
pulmonary
diseases,
reduces the
caliber of
the small
bronchi and
may cause
dyspnea,
static
secretions
and
infections.
Short term:
After 6 hours
of nursing
intervention
s the patient
will
demonstrate
ease in
breathing.
Long term:
After 2-3
days of
nursing
intervention
s the
1. Monitor vital
signs and
assess
patient’s
conditions.
2.Auscultate
lungs for
crackles
, consolidation
and pleural
friction rub.
1. To
establish
baseline
data.
2. Determine
adequacy of
gas
exchange
and detect
areas of
consolidation
and pleural
friction rub.
Short term:
The patient shall
have
demonstrated
ease in
breathing.
Long term:
The patient’s
S.O will
verbalized
understanding
of the causative
factors that
is
>tachycard
ia
>dyspnea
Bronchospas
m can
sometimes
be detected
by
stethoscope
when
wheezing or
diminished
breath
sounds are
heard.
Increase
mucous
production
along with
decrease
mucous
ciliary’s
action,
patient’s S.O
will verbalize
understandi
ng of the
causative
factors that
could
aggravate
the
condition
and
appropriate
factors that
could help
the patient
relive from
gas
exchange
impairment.
3. Assess LOC,
distress and
irritability.
4. Observe skin
color and
capillary refill.
5. Encourage
rest.
3. This signs
may indicate
hypoxia.
4. Determine
circulatory
adequacy,
which is
necessary for
gas
exchange to
tissues.
5. Rest
prevents
tissue o
xygen
demand and
enhances
tissue
could aggravate
the condition
and appropriate
factors that
could help the
patient relive
from gas
exchange
impairment.
contributes
to further
reduction in
the caliber
of the
bronchi and
results in
decrease air
flow and
decrease
gas
exchange.
6. Encourage
elevated HOB.
7. Perform
chest
physiotherapy
after
nebulisation.
8. Administer
oxygen as
ordered.
oxygen
perfusion.
6. To
facilitate lung
expansion to
enhance
breathing.
7. To
dislodge the
secretions,
for easy
expectoration
8. Improves
gas-
exchange
decrease
work of
breathing.
B. Implementation
B.1. Medical Management
B.1.a. IVF’s and Nebulization
Medical
Management/
Treatment
Date Ordered
Date Performed
Date Changed/DC
General
Description
Indication(s) or
Purpose(s)
Client’s Response
to the Treatment
Intravenous
Fluids
D5IMB 500cc ×
28-29 µgtts/min
D5LRS 500cc ×
28-29 µgtts/min
DO: 06-23-07
DP: 06-23-07
DC: 06-26-07
DO: 06-26-07
DP: 06-26-07
It is a hypertonic
solution, which
makes the cells
shrink, composes of
water and
carbohydrates, as
source of energy
and both cations
and anions.
It is a hypertonic
solution, which
draws fluid out of
It is use to supply
the necessary
nutrients.
And this solution is
given usually when
serum osmolality
has decreased to
dangerously low
levels.
It provides caloric
Client fluid loss due
to insensible fluid
loss was replaced
and nourished.
Client fluid loss due
to insensible fluid
DC: 06-28-07 the intracellular
and interstitial
compartments into
the vascular
compartment,
expanding vascular
volume.
nutrients, thus
resembles the
electrolyte
composition of the
normal blood
serum and plasma.
loss was replaced.
Nursing Responsibilities:
Prior to the procedure:
Check doctor’s order. Check for ordered IVF.
Check for the patency of the IV tubing, cloudiness and expiration date.
Explain the procedure.
During the procedure:
Clean the site of administration. Choose a vein in the distal arm.
Support client hand and maintain aseptic technique.
After the procedure:
Monitor rate as ordered, flow and patency.
Document the time and date.
Medical
Management/
Treatment
Date Ordered
Date Performed
Date Changed/DC
General
Description
Indication(s) or
Purpose(s)
Client’s Response
to the Treatment
Nebulization DO: 06-23-07
DP: 06-24-07
DC: 06-28-07
Adding medication
or moisture to
inspired air by
mixing particles of
various sizes with
air.
It aids bronchial
hygiene by
restoring and
maintaining
mucous blanket
continuity,
hydrating dried,
retained secretions,
promoting
expectoration of
secretions. To
relive
bronchospasm, to
The client still
manifested rales
even though
nebulization is
given. And was able
to cough out
secretions. On the
other hand his
respiratory rate
decreases from
37cpm as of 06-24-
07 to 27cpm as of
provide relief to a
hyperresponsive
airway and to
liquefy and clear
tenacious
secretions.
06-28-07.
Nursing Responsibilities:
Prior to the procedure:
Check doctor’s order.
Check for the amount of medication that is to be incorporate in the procedure.
Explain the procedure to the patient’s S.O.
Arranged all the material needed. Wash hand.
During the procedure:
Hold the mouthpiece of the nebulizer upright to avoid spilling of medicines.
Continue nebulization until the medication is already nebulized.
Do chest physio-therapy after nebulisation.
After the procedure:
Assess the client’s vital signs after nebulisation, especially the respiratory rate.
Document the time of the procedure was done.
B.1.b Drugs
Name of Drugs
Generic Name
Brand Name
Date Ordered
Date Taken/Given
Date Changed/DC
Route of
Administration,
Dosage and
Frequency of
Administration
Indication(s) and
Purposes(s)
Client Response
to the Medication
with Actual Side
Effects
CEPHALOSPORIN
Ceftazidime
DO: 06-23-07
DP: 06-23-07
DC: 06-28-07
IV 300mg every 8
hours
An anti-infective
drug which
eliminates bacteria
that cause many
kinds of infections,
including lung, skin,
bone, joint,
stomach, blood,
gynecological, and
urinary tract
infections.
The patient had
skin rashes on his
face, abdomen and
back for the first 3
days of medication.
The patient
manifested a
decrease infection
as evidence by
absence of fever as
of 06-27-07 until
discharged.
Nursing Responsibilities:
Prior to the procedure:
Check doctor’s order.
Check patient’s sensitivity to penicillin and to other cephalosporins.
Explain to the action of the drug.
During the procedure:
Recompute the drug formula and inspect for the patency of the needle.
Check for any resisitence.
Clean the IV port with an alcohol before injecting the medication.
Push the IV medication slowly as possible.
After the procedure:
Observe for any discomfort in the IV insertion site.
Tell the S.O to immediately report any signs of adverse effect.
Document.
Name of Drugs
Generic Name
Brand Name
Date Ordered
Date Taken/Given
Date Changed/DC
Route of
Administration,
Dosage and
Frequency of
Administration
Indication(s) and
Purposes(s)
Client Response
to the Medication
with Actual Side
Effects
ALBUTEROL
Salbutamol
DO: 06-23-07
DP: 06-23-07
DC: 06-28-07
Inhalation
(nebulizer) 1 every
4 hours.
Salbutamol is used
in cases of
bronchospasm in
patients with
reversible airway
obstruction: mild
and moderate
attacks of dyspnea
in patients suffering
from bronchial
asthma; mild and
moderate
bronchoobstruction
in patients with
After the each
medication the
patient feels relief
and able to
expectorate
secretions easily.
chronic bronchitis
and lung
emphysema.
Nursing Responsibilities:
Prior to the procedure:
Check doctor’s order.
Assess for the lung sounds, pulse and blood pressure before administration.
Warn the S.O for possible paradoxical bronchospasm.
During the procedure:
Put the medication into the inhaler and shake it well.
Clear nasal passenges and throat.
Place the mouthpiece well into mouth as dose from the inhaler is released, and instruct the patient to inhale
deeply. Perform chest-physio therapy.
After the procedure:
Instruct the S.O on how to perform nebulisation.
Emphasize to the S.O to take missed dose as soon as remembered, spacing remaining doses at regular
interval.
Do not double the dose or increase the dose or frequency of dosage.
Document.
Name of Drugs
Generic Name
Brand Name
Date Ordered
Date Taken/Given
Date Changed/DC
Route of
Administration,
Dosage and
Frequency of
Administration
Indication(s) and
Purposes(s)
Client Response
to the Medication
with Actual Side
Effects
ACETAMINOPHEN
Paracetamol
Tempra
DO: 06-23-07
DP: 06-23-07
DC: 06-23-07
DO: 06-23-07
DP: 06-24-07
DC: 06-28-07
V 90cc every 4
hours if
temperature
is > 38.8 degree
Celsius
Oral (drops) 1ml or
1 tsp. every 4 hours
It is a common
analgesic and
antipyretic drug
that is used for the
relief of fever,
headaches, and
other minor aches
and pains.
The patient’s body
temperature
decreases from 40
degree Celcius to
37.5 degree
Celcius.
The client’s body
temperature was
maintained within
the normal range.
Nursing Responsibilities:
Prior to the procedure:
Check doctor’s order.
Explain the action of the drug.
Assess fever note presence of associated signs like diaphoresis, tachycardia and malaise.
Tell the S.O that this drug can be taken with food or an empty stomach.
During the procedure:
IV: Clean the IV port before slowly injecting the medication.
ORAL (drops): Drop medication at the side of the cheeks to prevent aspiration.
After the procedure:
Advice the S.O to check concentrations of liquid preparations. Errors have resulted in serious liver damage.
Have the S.O determine the correct formulation and dose for their child.
Document.
B.1.c Diet
Type of Diet Date OrderedDate
PerformedDate
Changed/DC
General Description
Indication(s) and
Purpose(s)
Specific Food Taken
Client’s Response
and/or Reaction to
the DietDAT
REGULAR DIETDIET AS
TOLERATED
DO: 06-23-07DP: 06-23-07DC: 06-28-07
Ordered when the client’s
appetite, ability to eat, and
tolerance for certain food may change.
To increase the caloric intake of
food to maintain or
achieve optimal health status.
This diet is indicated to
ambulatory or bed patients
whose conditions to
not necessitate a modified diet.
Food rich in iron such as liver
and dark green leafy
vegetables.
The client appetite was increased.
Nursing Responsibilities:
Prior to the procedure:
Check doctor’s order.
Advice the S.O to give the food to the patient in an appetizing manner.
Instruct the S.O to give nutritious and balance foods to the patient.
During the procedure:
Stress the importance of compliance to the diet.
If the patient loss his appetite, instruct the S.O to give food to the patient in a small frequent feeding.
After the procedure:
Assess the patient’s health status.
Compare previous health status from the present.
Document.
B.1.d Activity Exercise
Type of Exercise Date Ordered
Date Performed
Date Changed/DC
General
Description
Indication(s) and
Purpose(s)
Client’s Response
and/or Reaction
to the
Activity/Exercise
CBR with
elevated HOB
DO: 06-23-07
DP: 06-23-07
DC: 06-28-07
The patient is
required to stay in
bed to reduce
metabolic activity
and to facilitate
proper lung
expansion for easy
breathing.
Bed rest- rest
prevents tissue
oxygen demand
and enhances
tissue oxygen
perfusion. While
elevated head of
bed facilitates lung
expansion to
enhance breathing.
The client reached
his optimum level
of recovery.
Nursing Responsibilities:
Prior to the procedure:
Check doctor’s order.
Explain the importance of complying in the said exercise.
Monitor patient’s vital signs.
During the procedure:
Provide a relaxing resting environment to the patient.
Observe the patient for any difficulty in performing the said exercise.
After the procedure:
Assess patient condition after the exercise.
Document.
B.2 Nursing Management
Actual Nursing Care
(SOAPIE)
June 26, 2007 Tuesday
S> “Manguku ya ampong lalagnat” as verbalized by the S.O
O> received patient lying on bed in a supine position with mother,
restless, conscious, with an IVF out of D5IMB, skin warm to
touch, with skin rashes on face, abodomen and back, febrile, with
productive cough, (-)DOB, pale, with rales on both lung field, with
vital signs as follows T:38.1ºC CR:150bpm RR:29cpm
A> Hyperthermia
P> After 6 hours of nursing interventions, patients temperature will
decrease from 38.1 ºC to 37.5 ºC.
I> >Established rapport.
>Monitored and recorded vital signs.
>Assessed patient’s condition.
>Provided comfort measures such as changing patient’s clothes.
>Maintained back dry and encouraged loosen patient’s clothing.
>Performed TSB.
>Emphasized to the mother the importance of increasing the
fluid intake of the child.
>Encouraged the mother to give the child nutritious foods rich in
iron such as liver and dark green leafy vegetables.
>Instucted and performed chest physiotherapy after
nebulization.
>Reinfused IVF @ 9:00am and regulated.
>Administered medications per doctors order.
E> Goal met. As evidence by decreased patients body temperature
to 37.5 ºC.
June 27, 2007 Wednesday
S> “Masalese ne, okay neng mangan, kayamu nengkayi sasanat
yapa ampong sisispun” as verbalized by the S.O
O> received patient lying on bed in a supine position with mother,
aware, conscious, with IVF of D5IMB 500cc ×28-29 µgtts/min @
200cc level, infusing well at his right foot, with pale palpebral
conjunctiva, with rales onboth lung field, with vital signs as
follows T: 37.4 ºC CR:150bpm RR:23cpm
A> Ineffective airway clearance related to retained secretions.
P> After 4-6 hours of nursing interventions the patient will maintain
airway patency.
I> >Established rapport.
>Monitored and recorded vital signs.
>Assessed patient condition.
>Maintained back dry.
>Auscultated lungs for crackles, consolidation and pleural
friction rub.
>Assessed characteristics of secretions, quantity color
consistency and odor.
>Stressed the importance of increasing fluid intake.
>Positioned patient in elevated HOB for optimal breathing
pattern.
>Encouraged the S.O to give the patient high caloric foods.
>Instructed the S.O to give foods rich in Iron like liver and dark
green leafy vegetables and Vitamin C.
>Performed and instructed chest-physio therapy and postural
drainage after nebulization.
>Encourage bed rest.
>Administered meds per doctor’s order.
E> Goal met. As evidence by patient’s maintenance patent airway.
VI. CLIENTS DAILY PROGRESS IN THE HOSPITAL
1. Clients Daily Progress chart (from admission to discharge)
DAYS June 23,
2007 24-Jun-07 25-Jun-07 26-Jun-07 27-Jun-07June 28.
2007
Nursing ProblemsIneffective Airway
Clearnce * * * * * Imbalace Nutrition:
less than body requirements * * *
Risk for Infection
(spread) * * * * Impaired Gas
Exchange * * * *
Hyperthermia * * *
Vital SignsT: 40ºC 37.8 ºC 38.4 ºC 38.1 ºC 37.4 ºC 37.3 ºC
CR: 101bpm 150bpm 150bpm 129RR: 37cpm 29cpm 23cpm 27cpm
Diagnostic ExamsCBC Hematocrit:
0.29Hemoglobin:
Hemoglobin: 9-6
Hematocrit:
88WBC: 11.8
Neutrophils: .62
Lymphocytes: .33
Monocytes: .05
Platelet:153
31-0WBC: 3.6
Differential count
Polys: 68Lymphocyte
: 91Eosinophil:
01Platelet: 184
X-tray
Hazy infiltrates are noted on both lower
lungfields; Heart is
normal in size;
Diaphragm and
sulci are intact; Other chest
structures are
remarkable
Urinalysis Color: Yellow
Transparency: ClearpH: 7.5Specific Gravity: 1.010
Albumin: NegativeSugar:
NegativeMicroscopic
ExamPus Cell: 0-
3/hpfRBC: 2-5/hpf
Epithelial Cells: Rare
Medical ManagementIVF D5 IMB * * * *D5 LRS * * *NebulizationNebulization * * * * * *Drugs
Acetaminophen Paracetamol IV *Tempra PO * * * * *
Albuterol
Salbutamol * * * * * *Cephalosporin
Ceftazidime * * * * * *Diet Diet as tolerated * * * * * *Exercise/ActivityCBR with elevated HOB * * * * * *
VII. DISCHARGE PLANNING
A. General condition about the client upon discharge.
The client achieved his optimum health status after his
hospitalization. He has already adequate ventilation and oxygenation.
There were no complications noted. Still, on the process of recovery.
B. METHOD
M> Vitamin C 1 tsp once a day
Nebulization: Salbutamol once a day
E> >Deep breathing exercise.
>have adequate rest
T> >Instruct to follow treatment regimen.
>Instruct the S.O to perform chest physiotheraphy after nebulisation.
>Emphasize that too much nebulization my cause paradoxymal
spasm.
H> >Increase fluid intake
>Avoid strenuous activities
>Eat high caloric foods, rich in iron and vitamin C
>Maintain back dry
>Warn the S.O to report any signs and symptoms of the disease
condition that she had observed immediately to the physician or nurse.
Like elevated temperature, diaphoresis, difficulty of breathing,
persistent cough and cold or flu.
>Encourage proper handwashing.
>Have an adequate rest.
O> >Instructed to come back after a week for check up.
D> >DAT
VIII. CONCLUSION AND RECOMMENDATION
The proponents of this study conclude about the effect of low socio-
economic status and nutritional deficiency to the vulnerability of an
individual against microorganisms. They are as follows:
• The environment plays a vital role in the health of a person.
• The viruses and bacteria that cause pneumonia are contagious and are
usually found in fluid from the mouth or nose of an infected person.
• Illness can spread when an infected person coughs or sneezes on a
person, by sharing drinking glasses and eating utensils, and when a person
touches the used tissues or handkerchiefs of an infected person.
• Risk for infection will always be blamed to the decrease in the primary
defenses as well as with the virulence of a microorganism.
The proponents of this study recommends the following:
If your child's doctor has prescribed antibiotics for bacterial
pneumonia, give the medicine on schedule for as long as the doctor
directs. This will help your child recover faster and will decrease the
chance that infection will spread to other household members.
Don't force a child who's not feeling well to eat, but encourage your
child to drink fluids, especially if fever is present. Ask your child's
doctor before you use a medicine to treat your child's cough because
cough suppressants stop the lungs from clearing mucus, which may
not be helpful in some types of pneumonia.
If your child has chest pain, try a heating pad or warm compress on the
chest area. Take your child's temperature at least once each morning
and each evening, and call the doctor if it goes above 102 degrees
Fahrenheit (38.9 degrees Celsius) in an older infant or child, or above
100.4 degrees Fahrenheit (38 degrees Celsius) in an infant under 6
months of age.
Check your child's lips and fingernails to make sure that they are rosy
and pink, not bluish or gray, which is a sign that your child's lungs are
not getting enough oxygen.
VIII. CONCLUION AND RECOMMENDATION
A. Nurse-centered
The researchers were able to gain knowledge and deeper understanding
of the disease process itself and impart health teachings regarding the
client’s condition in maintaining an optimum level of functioning. Plus, the
researches were able to accomplish the following:
1. Interpret the current trends and statistics regarding the disease
condition;
2. Relate the present state of the client with his personal and pertinent
family history;
3. Analyze and interpret the different diagnostic and laboratory
procedures, its purpose and its essential relationship to client’s disease
condition;
4. Identify treatment modalities and its importance like drugs, diet and
exercise;
5. Identify surgical management and its purpose that is applicable with
the disease condition;
6. Formulate nursing care plans based on the prioritized health needs of
the client;
7. Gain knowledge on the acquisition and progression of the disease;
8. Impart knowledge on fellow students in providing care for clients with
the same illness.
B. Patient-Centered
The proponents were able to acquire knowledge on the risk factors that
have contributed to the development of the disease; also, gain understanding
of the disease process and demonstrate compliance on the treatment
management rendered by the health care team.
In relation to the patient’s condition, the proponents were also able to
accomplish these tasks:
1. Gain knowledge about the disease of Baby Clark Kent;
2. Identify different interventions in his condition;
3. Gain knowledge on the importance of compliance to treatment
regimen;
4. Demonstrate compliance on the treatment management;
5. Identify different measures to prevent further aggravation of condition;
6. Participate in his plan of care; and
7. Demonstrate independence on self-care and home management upon
discharge and during follow-up home visits.
The proponents of this study conclude about the effect of low
socio-economic status and nutritional deficiency to the vulnerability of
an individual against microorganisms. They are as follows:
The environment plays a vital role in the health of a person.
The viruses and bacteria that cause pneumonia are contagious and are
usually found in fluid from the mouth or nose of an infected person.
Illness can spread when an infected person coughs or sneezes on a
person, by sharing drinking glasses and eating utensils, and when a
person touches the used tissues or handkerchiefs of an infected
person.
Risk for infection will always be blamed to the decrease in the primary
defenses as well as with the virulence of a microorganism.
The proponents of this study recommends the following:
If your child's doctor has prescribed antibiotics for bacterial
pneumonia, give the medicine on schedule for as long as the doctor
directs. This will help your child recover faster and will decrease the
chance that infection will spread to other household members.
Don't force a child who's not feeling well to eat, but encourage
your child to drink fluids, especially if fever is present. Ask your child's
doctor before you use a medicine to treat your child's cough because
cough suppressants stop the lungs from clearing mucus, which may
not be helpful in some types of pneumonia.
If your child has chest pain, try a heating pad or warm compress
on the chest area. Take your child's temperature at least once each
morning and each evening, and call the doctor if it goes above 102
degrees Fahrenheit (38.9 degrees Celsius) in an older infant or child, or
above 100.4 degrees Fahrenheit (38 degrees Celsius) in an infant
under 6 months of age.
Check your child's lips and fingernails to make sure that they are
rosy and pink, not bluish or gray, which is a sign that your child's lungs
are not getting enough oxygen.
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