Mindanao State University

COLLEGE OF HEALTH SCIENCES

Marawi City

Name of Student ______________________________________ Clinical Instructor ___________________________________

Area of Assignment MEDICINE WARD Date Submitted _____________________________________

NURSING ASSESSMENT I

PATIENT’S PROFILE

Name Mr. XXX Address Maigo, Lanao del Sur Age 11 y.o_

Sex M Religion Islam Civil Status _Single Occupation Grade 5 student__

HEALTH HABITS

Frequency Amount Period/Duration

1. Tobacco X X X
2. Alcohol X X X
3. OTC-drugs/ non-prescription drugs Paracetamol (every 4 hours) 250 mg 1 day
Mefenamic Acid (3 x a day) 250 mg 2 days___

A. CHIEF COMPLAINTS
Fever 1 day PTA

B. HISTORY OF PRESENT ILLNESS (HPI) {location, onset, character, intensity, duration, aggravation, and alleviation, associated symptoms, previous treatment and results, social and
vocational responsibilities, affected diagnoses}.

1 day PTA – the pt had a fever that would not subside even when the patient was given Paracetamol and Mefenamic Acid. The SOs observed the pt’s condition but no
improvement happened. The fever went up to 40°C, pt chilled. They recalled, 2 days PTA, the pt was complaining of intermittent abdominal pain and slight chest pain aggravated by
coughing and breathing. It would last 3-5 mins and eventually subside when at rest and do deep breathing. The said complaint was ignored by the SO maybe because of pt’s too much play
outside the house. The pt has never been admitted and never been sick like this before. When TSB and medications given at home did not treat the fever and the pt was complaining of
difficulty breathing, SOs rushed the pt to the hospital. Patient was diagnosed with “pneumonia, sepsis probably 2° chronic illness”.
C. HISTORY OF PAST ILLNESS (previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illnesses, allergies, medications, habits, birth
and developmental history, nutrition- for pedia)

The pt was never been hospitalized or admitted before, no previous injury, no medical (invasive) procedures undergone. The pt had chicken pox when still young; completed
immunization; no major illness; no allergies; no medications, supplements or vitamins maintained. The pt a poor nutritional status; poor hygiene and poor grooming; he loved playing
outside then taking rest or sleep after school or during weekends. No known congenital or developmental problem, and was born via NSVD.

FAMILY HISTORY WITH GENOGRAM

Legend:

↗ Male Acquired Diseases: Heredo- familial Diseases:

Female Father (38 y.o) Mother( 34 y.o) Hypercholesterolemia x Diabetes x

With Asthma Kidney Disease x Heart Diseases x
Patient Tuberculosis x Hypertension x
Alcoholism x Cancer x
Drug Addiction x Asthma ̷
Hepatitis A x Epilepsy x
Pt(11 y.o)
B x Mental Illness x
C x Rheuma/Arthritis x

Others (pls. specify) x Others (pls. specify) x

D. PATIENT’S PERCEPTION OF:

1. Present Illness

“Diyako gaid pakagnawa igira,” as verbalized by the pt.

2. Hospital Environment

“ Okay lang ang hospital,” as verbalized by the pt.

E. SUMMARY OF INTERACTION
 The assessment was good and spontaneous. The pt is cooperative in answering SNs question to him. As a result SN gathered information needed by the SN.

REVIEW OF SYSTEMS

Name Patient X Date July 22,2009

Vital Signs: Height 4’ 11”
Temperature 39.6 ° C Weight not taken
Pulse 114 bpm Observation 7:30 am, received pt lying on bed, conscious, drowsy with # 4 D₅NM 1 L___
Respiration 52 cpm regulated @ 30 gtts/min, hooked @ L arm, infusing well, no bleeding, no

Blood Pressure backflow of blood, no swelling noted.

The pt has thin, small body built. He is tense, slouched, and has bent posture upon sitting. The pt is weak but could still sit down,
1.GENERAL but most of the time he is lying down. Sometimes, the pt is bending over because of abdominal pain. Pt has poor hygiene and
grooming. He is generally pale but his forehead and armpit are warm to touch.

H- Rounded (Normocephalic and symmetrical with frontal, parietal, and occipital prominences), also has smooth skull contour,
presence of dandruff and nits on many areas of the hair. Scalp has few 1 cm lesions but no swelling.
E- Level with the ears, has pale conjunctiva, dried mucus on both eyes present; noticeably sunken, tired/weak eyes. PERRLA.
Eyebrows are symmetrically aligned, also with equal movement. Eyelashes are equally distributed. Eyelid’s skin are intact, no
2. HEENT masses and tenderness. Lacrimal sac has no edema and tearing.
E- Symmetrical, in line with the inner canthus on the eyes. Earcanals have dries, yellowish cerumen. No lesions and masses
present.
N- Symmetrical, no septal deviation; with dried mucus on both nares; no bleeding noted; nasal flaring noted; no masses and
tenderness.
T- Tonsils are not inflamed, no bleeding but has pale oral mucosa.
 The pt’s upper and lower extremities are pale. With a body temperature of 39.6°. Hair all over the body is evenly distributed. Hairs on head are dry and thick.
3. INTEGUMENTARY Pt has skin color uniformity. Toenails and fingernails are not trimmed and noticeably dirty; nail folds are smooth and rounded. Pt has cold and clammy skin,
relatively dry and has poor turgor.

Pt’s cheat wall is intact; tachypnea noted ( RR – 52 cpm); reported slight chest pain aggravated by breathing and coughing; productive cough noted with rusty
4. RESPIRATORY sputum; no chest deformities noted; no lesions and tenderness. Posterior chest: asymmetrical and/ or has decreased chest expansion. Rhonchi is heard upon
auscultation of both sides of the lungs.

Nail beds are lightly pale; Capillary refill, less than 3s; HR – 114 bpm; Carotid and other peripheral arteries are palpable; strong, bounding, irregular pulse. No
5. CARDIOVASCULAR murmurs of the heart are heard.

Pt is on DAT; no food allergies; no observed nausea and vomiting; no mastication and swallowing difficulty. Lips, buccal mucosa, palate re pale. Dental
6. DIGESTIVE cavities present; foul odor breath noted. Tongue is at the midline, uvula is also at the midline.
The pt is assessed to have distended rounded and glistening abdomen, also with limited abdominal movement due to pain; audible bowels sound; no lesions
but with tenderness noted in all quadrants of the abdomen.

The pt usually voids 2-3x per shift (yellow in color ), defecates soft, formed stool, once per day; no reported problem on voiding and also in defecating, no
7. EXCRETORY report hemorrhoids; no abnormalities present in urine and stool.

The pt has equal muscle size on both sides of the body; normally firm; no tremors observed; no deformities present on both extremities, joints move smoothly;
8. MUSCULOSKELETAL posterior spine is at the midline without deviation on either side. Muscle strength -3/5, functional level-IV (dyspnea, fatigue and rest). Weakness is related to
fatigue.

Level of Consciousness (LOC) = Level II – drowsy but still oriented to person and place but not to time. The pt has no alteration on sight, hearing and touch but
9. NERVOUS has slight problem on tasting and smelling foods and drinks. Could move eyes to 6 direction (Extra ocular muscle test), Good reflex (corneal sensitivity test),
GCS= E-4, V-5, M-5 (14). The pt responds to questions; has appropriate actions, feelings, and perception towards situation. Speech is clear and moderate in
pace.

10. ENDOCRINE When in deep pain, the pt is diaphoretic; there is no sign of thyroid enlargement; ht- 4’11”, wt of the pt was not taken.
 DRUG STUDY

BRAND NAME GENERIC Prescribed and Mechanism

NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration

Generic Name: Prescribed: Bind to bacterial cell wall > Respiratory tract >Hypersensitivity CNS : Seizure > Assess for infection.
Cefuroxime 1 gram IVTT q 12 ° membrane, causing cell infection; skin and skin >Use cautiously in
hours ANST death. structure infection; bone patient with renal GI : Diarrhea, jaundice, >Instruct patient to the
Brand Name: and joint infection; impairment, geriatric, nausea, vomiting meds around the clock at
Ceften urinary tract infection; debilitated, or evenly spaced times and
Derm : Rashes, urticarial to finish the meds
and gynecologic emaciated, has history of
>Therapeutic effect. completely even feeling
Classification: Recommended: infection. GI tract disease colitis. Hemat : Bleeding, blood
Bactericidal action. better.
Anti-infective IM, IV (Children and dyscrasias, hemolytic
2nd Generation infant >3 months) >16.7- anemia. >Advise pt to report
Cephalosporin 33.3 mg/kg q 8 ° or 15-50
signs of super infection
mg/kg q 12° Misc : Allergic reactions
(furry growth in the
including anaphylaxis
tongue, allergy)
and serum sickness,
superinfection. >Notify care provider if
fever and diarrhea
develop especially if
stools contain blood, pus
or mucus.
 DRUG STUDY

BRAND NAME GENERIC Prescribed and Mechanism

NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration

AMINOGLYCOSIDES Prescribed: Inhibits protein synthesis >Treatment of serious >Hypersensitivity. Most EENT: Ototoxicity >Assess for infection.
100mg IVTT q 8 ° in the bacteria at level of gram-negative bacteria parenteral products
Generic Name: ANST 30S ribosome. infection and infection contain bisulfates and GU : Nephrotoxicity >Evaluate 8 cranial nerve
Amikacin caused by staphylpcocci should be avoided in the functions by audiometry
F&E : Hypomagnesemia before the throughout
when penicillins or other patient with known
Brand Name: Therapeutic effect: less toxic drugs are intolerance. therapy.
MS : Muscle paralysis
Amikin Recommended: Bactericidal action contraindicated.
>Monitor intake and
Adult, children and Misc : Hypersensitivity
output and daily weight
Classification: older infant reaction
to assess hydration
Anti-infective
status and renal
function.

>Assess patient for signs

of superinfection.

>Advice patient for the

importance of drinking
plenty of liquids.
 DRUG STUDY

BRAND NAME GENERIC Prescribed and Mechanism

NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration

Generic Name: Prescribed: Binds to beta-adrenergic >Used as a >Hypersensitivity to CNS: Nervousness, >Assess for lung sound,
Albuterol receptors in airway bronchodilator to control adrenergic amines. restlessness, tremors, pulse and BP before
1 neb q 6° smooth muscle, leading and prevent reversible insomnia administration and
Brand Name: to alteration of adenyl airway obstruction >Hypersensitivity to during peak of
Salbutamol cyclase of cyclic – 3’, 5’ caused by ashma and fluorocarbon (some CI : Chest pain, medication.
adenosine COPD. inhalers) palpitations, angina
Recommended:
Classification: monophosphate (cAMP) >May cause transient
>Quick relief agent for GI : Hyperglycemia decrease in serum K
Therapeutic: Children 2-12 yr. 0.15
Bronchodilators mg/kg/dose (minimum bronchospasm. concentrations with
F&E : Hypokalemia
Pharmacologic dose 2.5 mg) q 20 nebulization or higher
Adrenergic minutes for 3 doses then Neuro : tumor than recommended
0.15-0.3 mg/kg q 1-4° doses.
PRN.
>Inform patient that
albuterol may cause
unusual bad taste.

>Advise patient to rinse

mouth with water after
each inhalation dose to
minimize dry mouth.
 DRUG STUDY

BRAND NAME GENERIC Prescribed and Mechanism

NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration

Generic Name: Prescribed: Inhibits the action of >Short term treatment of >Hypersensitivity. Cross CNS: confusion, >Assess for epigastric or
Ranitidine 30 mg IVTT q 3° histamine at the H2 active duodenal ulcers sensitivity may occur. dizziness, headache. abdominal pain.
receptor site located and benign gastric ulcers.
Brand Name: Recommended: primary in parietal cell, Prophylaxis of duodenal >Some products contain CI: Arrhythmias >Monitor CBC with
Zantac IV, Children month - thus decreasing gastric ulcers. alcohol and should be differential count
avoided in patient with GI: Black tongue, periodically during
12 yrs. acid secretion.
>Treatment and known intolerance. constipation, dark stool therapy.
Classification:
Histamine H2 receptor prevention of heart burn, GU: Decrease sperm >Advice patient to take
antagonist acid indigestion, and count medication as directed
sour stomach. even if feeling is better.
Hemat: Agranulocytes,
anemia, neutropenia >Advise patient to report
onset of black, tarry
Local: pain at IM site
stools, fever, sore throat,
diarrhea, rash, confusion
promptly.
 DRUG STUDY

BRAND NAME GENERIC Prescribed and Mechanism

NAME CLASSIFICATION Recommended dosage, Of
frequency, route of Action Indication Contraindication Adverse Reaction Nursing Responsibilities
administration

Generic Name: Prescribed: Inhibits the reabsorption Edema due to: >Hypersensitivity. Cross CNS: dizziness, >Assess fluid status
Furosemide 20mg q 30 mins POST of sodium and chloride sensitivity with thiazides encephalopathy, during therapy.
from the Loop of Henle >CHF, hepatic or renal and sulfonamides may headache, insomnia,
Brand Name: Recommended: and distal renal tubule. disease. occur. nervousness. >Monitor BP and pulse
Lasix PO, Children > 1 rate before and during
>Hypertension >Pre-existing electrolyte EENT: hearing loss, administration.
month:
Classification: 2mg/kg as a single imbalance, hepatic coma tinnitus.
or anemia. >Monitor electrolytes,
Loop diuretics dose: may be increased
CV: hypotension renal and hepatic
by 1-2mg/kg q 6-12
>Some liquid products function, serum glucose
hours. GI: constipation, dry
may contain alcohol, and uric acid levels.
avoid in patients with mouth.
IM, IV Children: >Caution patient to
alcohol tolerance.
1-2 mg/kg/dose q 6- GU: excessive urination change position slowly to
12 hours; continuous minimize orthostatic
infusion-0.05 Endo: hyperglycemia
hypotension.
mg/kg/hour, titrate to
F&E: dehydration,
clinical effect. >Caution patient to use
hypochloremia,
sun screen and
hypokalemia
protective clothing to
Metab: hyperglycemia prevent photosensitivity
reactions.
MS: muscle cramps

Misc: increased BUN

 NURSING ASSESSMENT II

Name: Mr. X Age 11 y.o____ Sex Male____

Chief Complaint FEVE R _________________________________
Impression/Diagnosis: Anemia probably 2o to chronic illness, pneumonia, sepsis
Date/Time of Admission 7-20-2009/ 10 am Inclusive Dates of Care _July 22-24,2009 _
Diet: ______DAT Allergies No known allergies _______ __
Type of Operation (if any) _______None

NORMAL PATTERN BEFORE HOSPITALIZATION INITIAL CLINICAL APPRAISAL

DAY 1 DAY 2

1.ACTIVITIES- REST Pt is sable to perform ADLs and goes The pt was conscious, weak and The pt could somehow sleep but Still the pt did not want to get up in
to school and oftentimes play. He drowsy. he could not get up from easily awaken with noise. He bed, He felt so dizzy and weak. H tried
a. Activities bed, he felt so weak. He felt a lot participated in activities like ROM to sit on the bed and perform some
usually sleeps at night at around 8
of discomforts and could not exercises. He just stayed in bed, he exercises like deep breathing, coughing
b. Rest pm and wakes up early for school. He
sleep properly. The pt was very felt weak to get up from bed. and ROM exercises within his capacity.
does not usually take a nap during irritable. He could not take enough sleep or rest.
c. Sleeping pattern
the day because of so much play.

2.NUTRITIONAL- METABOLIC The pt usually eats a lot of rice, meat, During the initial assessment, the This time, the pt was on the DAT. He The pt was still on DAT, but he ate little
but a little of fruits and vegetables. pt was on NPO. ate little amount of rice and fish and amount of rice and vegetables. He took
a. Typical intake(food, He loves eating street foods like sipped a little amount of soup. He a sip of water and went back to sleep.
fluid) adidas, barbecues, junk foods, etc. Medications given were: could not taste the food well but he He was given fruits but he just ignore it.
He usually drinks less than 5 glasses tried to eat because he was very The pt had no difficulty in swallowing,
b. Diet
of water a day. He also loves salty 
Cefuroxime 1g IVTT q 12o angry. He was encouraged calorie- he just lost hi appetite
c. Diet restrictions and fatty foods. 
Ranitidine 30 mg IVTT q riched foods. His weight was not
 No diet restriction 8o taken. Medications given were:
d. Weight  Weight not determined 
Salbutamol 1 neb  Salbutamol 1 neb
 The patient is not taking any Medication give were:
e.Medications/supplement vitamins or supplements, but  Salbutamol 1 neb
food when he got fever, he is  Cefuroxime 1 g IVTT q 12o
usually given paracetamol.
3. ELIMINATION
The pt usually voids 4-x a day. Urine The pt urinated 3x for the entire The pt voided 3-4x the entire day, The pt voided 2x for the entire 8 hour
a. Urine (frequency, color, is usually from clear to yellowish in 8 hour shift, with yellow color yellow in color and aromatic in shift, yellowish in color and aromatic in
 transparency) color. The px also usually defecates urine. The pt had not defecated odor. The pt also defecated once a odor. The pt defecated 2x same, for the
1-2x a day. It is oftentimes formed the entire day. day, with a semi- solid brown in entire day, with semi-solid and
and yellowish-brown in color. color stool. He did the elimination brownish stool.
b. Bowel (frequency, color, on bed, given with a container, no
consistency) pain was reported.

4. EGO INTEGRITY

a. Perception of self The pt has a lot of time playing The patient tries to smile when The pt wanted to go home already. The pt could listen now to advices and
outside than studying. He is often talked to but he was very irritable He was crying and asking her would initiate in doing activities within
b. Coping Mechanism scolded in not completing his chores oftentimes. He said he was sick mother to always get near. He his capacity. He was already calmed,
at home. He usually wants to do because he plays a lot, especially hated the medications; needles and though there were times he felt
c. Support System
whatever he wishes. When he has in dirty places. He knows whom everything dine to him by the uneasy. He listened when told he
d. Mood/Affect problem, he approaches to his to approach when in need. nurses. He hated his long stay in the needed to stay in the hospital to get
mother. He is often times scolded hospital; he could not rest well. He well.
and disciplined through brooms by was very irritable. In order to help
his father but he always ignores it. himself from stress, he would just
sleep or talk to his cousins at his
age.

5. NEURO-SENSORY
The pt is mentally healthy as The patient to person and place. The patient is oriented to place and No significant change observed on the
a. Mental state His actions and facial expressions person. Though language barrier is a pt. He was oriented but obviously weak
evidenced by going to school
regularly, plays a lot with playmates were appropriate to his feelings problem upon interview and in responding to some situations/
and to the situation as observed. assessment, the pt was responding activities. The pt. still had problems on
at his age. His mood and facial
b. Condition of five senses: No reported problems related to well and acting appropriately. No tasting and smelling foods and drinks.
expression is observed to be
(sight, hearing, smell, taste, sight, hearing and touch but h reported problems related to sight,
appropriate o his feelings and action. could slightly taste and smell hearing and touch but he could
touch)
He acts to situations appropriately. foods and drinks. slightly taste and smell foods and
He can clearly see, hear, smell, taste drinks.
and touch.
6. OXYGENATION

a. Vital signs
T- 37.6° C T- 37.5° C
Temperature T- 39.6 Co
P- 112 bpm P- 114 bpm
Respiratory rate P- 114 bpm
R- 48 cpm R- 52 cpm
Heart rate RR- 52 cpm
Blood pressure
Rhonchi was heared upom Rhonchi was heared upom auscultating
b. Lung sounds The SOs can hear the pt wheezing Rhonchi was heared upom
auscultating pt’s back in area where pt’s back in area where the lungs is
c. History of Respiratory and sighing oftentimes, especially auscultating pt’s back in area
the lungs is located. located.
Problems when the pt is tired. where the lungs is located.

7. PAIN-COMFORT
2 days PTA, the pt felt a light chest The pt had a fever and could not The ot was complaining of The pain the pt was complaining was
a. Pain (location, onset,
pain aggrevated by breathing and get up on bed; he felt so dizzy abdominal pain. The pain was the same pain he felt the other day. It
character, intensity,
coughing, but then alleviated ehn got and weak. He was complaining of intermittent that disturbed the rest. localized in the abdomen. He tried to
duration,
rest but oould occur again. headache and a warm feeling all T=he tried to sit on bed to alleviate sit in bed and performed deep
associated symptoms,
over his body. He was flexing his the pain. He could not explain the breathing exercises. SO did back
aggravation)
1 day PTA – the pt had a fever that body in order not to chill. pain and it really made him restless. rubbing to lessen pain.
would not subside even though He just tried to change his position
medications like paracetamol and to ease the pain.
b. Comfort
mefenamic acids were given.
measures/Alleviation

He was given paracetamol PO. Medication given was: Medications given was Salbutamol 1
c. Medications
Salbutamol 1 neb neb
8. HYGIENE AND ACTIVITIES The pt usually needs to be checked in The pt was poorly groomed. He The pt and SO did try to perform elf- The pt initiated to change his clothes
OF DAILY LIVING doing grooming and bathing or else stayed on bed with unchanged care activities like combing hair and with assistance. The SO changed his
he will not do it every day. Because clothes, uncombed hair, and changing clothes. The pt was linens. Still, he was provided TSB to
of so much play outside, it makes him messy linens. The pt’s hair is long provided TSB to somehow get rid of clean his body. Because of the
tired in doing the washing and with presence of nits in many the dirt all over his body. Pt’s intermittent pain felt by the pt, it was
cleaning. areas. He had died mucus on hygiene was somehow improved very difficult for the pt to maintain self-
The SOs can’t always attend to the both ears and dirty nails on both when encouraged to do so. care activities.
pt’s daily hygiene and changing of fingers and toes.
clothes.

9. SEXUALITY

a. female (menarche,
menstrual
cycle, civil status, number
of
children, reproductive
status)

b. male (circumcision, civil

The pt was 11 years old, male. He The pt was 11 years old, male. He The pt was 11 years old, male. He The pt was 11 years old, male. He was
status, number of children)
was not yet circumcised. The pt is was not yet circumcised. The pt is was not yet circumcised. The pt is not yet circumcised. The pt is afraid to
afraid to undergo the procedure. afraid to undergo the procedure. afraid to undergo the procedure. undergo the procedure.
 LABORATORY AND DIAGNOSTIC PROCEDURES

DATE NAME OF THE RESULT NORMAL VALUE NURSING IMPLICATION NURSING CONSIDERATION/RESPONSIBILITY
PROCEDURE
7/20/2009 RBC 2.8X10 12 L 5-6.4 x 10 12L Decreased in Anemia Encourage pt to eat foods rich in iron like
monggo, live, ampalaya, etc.

Hematocrit 25.4 L/L 40-54 L/L Decreased in Anemias Encourage pt to eat foods rich in iron like
monggo, live, ampalaya, etc.

Decreased in various Anemia

Hemoglobin 8.4 mg/DL 14-18 mg/DL Encourage pt to eat foods rich in iron like
monggo, live, ampalaya, etc.

WBC 29.3 x 10⁹/L 4-11 x 10⁹/L Increased in acute infectious Encourage pt to eat foods rich in Vit. C to
diseases predominantly in the boost pt’s immune system encourages
neutrophilic fraction with bacterial observation of infectious control procedure
diseases. like proper handwashing.
Neutrophils 86.0% 50-70%
 Lymphocytes 8.4% 20-40% Decreased in Anemia Encourage pt to eat foods rich in iron like
mango, liver, ampalaya, etc.

Within normal limits

Monocytes 4.3% 2-5%
Decreased in Anemia Encourage pt to eat foods rich in iron like
Eosinophils 1.0% 2-9% monggo, liver, ampalaya, etc.

SUMMARY OF INTRAVENOUS FLUID

DATE/TIME STARTED INTRAVENOUS FLUID AND VOLUME DROP RATE NUMBER OF HOURS DATE/TIME CONSUMED

7-20-2009 / 10:30 pm PLR 1L 30 gtts/min 8 hours and 20 minutes 7-20-2009/ 6:50 pm

7-20-2009/ 06:50 pm #1 D₅NM 1L 30 gtts/min 8 hours and 20 minutes 7-21-2009/ 3:10 am

7-21-2009/ 03:10 pm #2 D₅NM 1L 30 gtts/min 8 hours and 20 minutes 7-21-2009/ 12:30 pm

7-21-2009/ 12:30 pm #3 D₅NM 1L 30 gtts/min 8 hours and 20 minutes 7-21-2009/ 8:50 pm

7-21-2009/ 08:50 pm #4 D₅NM 1L 30 gtts/min 8 hours and 20 minutes 7-22-2009/ 5:10 pm

7-22-2009/ 05:10 pm #5 D₅NM 1L 30 gtts/min 8 hours and 20 minutes 7-22-2009/ 12:30 pm

7-22-2009/ 12:30 pm #6 D₅NM 1L 30 gtts/min 8 hours and 20 minutes 7-23-2009/ 8:50 pm

7-22-2009/ 08:50 pm #7 D₅NM 1L 30 gtts/min 8 hours and 20 minutes 7-23-2009/ 5:10 pm

7-23-2009/ 05:10 pm #8 D₅NM 1L 30 gtts/min 8 hours and 20 minutes 7-23-2009/ 12:30 pm

7-23-2009/ 12:30 pm #9 D₅NM 1L 30 gtts/min 8 hours and 20 minutes 7-24-2009/ 8:50 pm

7-23-2009/ 08:50 pm #10 D₅NM 1L 30 gtts/min 8 hours and 20 minutes 7-22-2009/ 5:10 pm

CALCULATION:
Hrs to run = vol in cc x gtts factor = 15,000
gtts/min x 60 ml 1,800
= 1000 x 15 gtts/min = 8.33 or 8 hrs and 20
30 gtts/min x 60 min minutes

SUMMARY OF MEDICATION

DATE MEDICATIONS- dosage, frequency, route Remarks

July 20-22, 2009 Cefuroxime 1 g IVTT q 2° ANST (-) Given by the nurse at bed side, tolerated
(Anti-Infective) and recorded

July 20-21, 2009 Amikacin 100 g IVTT q 8° ANST (-) Given by the nurse at bed side, tolerated
(Anti-Infective) and recorded

July 20-24, 2009 Salbutamol 1 neb q 6° Given by the nurse at bed side, tolerated
(Bronchodilator) and recorded

July 20-22, 2009 Ranitidine 30 mg IVTT q 8° Given by the nurse at bed side, tolerated
(H2 – receptors antagonists) and recorded

Given by the nurse at bed side, tolerated

July 20-23, 2009 Paracetamol 500 mg 1 tab q 4° PO and recorded
 (Antipyretic)

July 2, 2009 Furosemide 20 mg 30 mins PO Given by the nurse at bed side, tolerated
(Loop-Diuretics) and recorded
ANATOMY AND PHYSIOLOGY

Respiratory System
LUNGS
The lungs are paired elastic structures enclosed in the thoracic cage, which is an airtight chamber with distensible walls. Ventilation requires movement of the walls of the thoracic cage and
of its floor, the diaphragm. The effect of these movements is alternately to increase and decrease the capacity of the chest. When the capacity of the chest is increased, air enters through the
trachea (inspiration) because of the lowered pressure within and inflates the lungs. When the chest wall and diaphragm return to their previous positions (expiration), the lungs recoil and force
the air out through the bronchi and trachea. The inspiratory phase of respiration normally requires energy; the expiratory phase is normally passive. Inspiration occurs during the first third of
the respiratory cycle, expiration during the latter two thirds.
PLEURA
The lungs and wall of the thorax are lined with a serous membrane called the pleura. The visceral pleura covers the lungs; the parietal pleura lines the thorax. The visceral and parietal
pleura and the small amount of pleural fluid between these two membranes serve to lubricate the thorax and lungs and permit smooth motion of the lungs within the thoracic cavity
with each breath.
MEDIASTINUM
The mediastinum is in the middle of the thorax, between the pleural sacs that contain the two lungs. It extends from the sternum to the vertebral column and contains all the thoracic
tissue outside the lungs.
LOBES
Each lung is divided into lobes. The left lung consists of an upper and lower lobe, whereas the right lung has an upper, middle, and lower lobe (Fig. 21-4). Each lobe is further
subdivided into two to five segments separated by fissures, which are extensions of the pleura.
BRONCHI AND BRONCHIOLES
There are several divisions of the bronchi within each lobe of the lung. First are the lobar bronchi (three in the right lung and two in the left lung). Lobar bronchi divide into segmental
bronchi (10 on the right and 8 on the left), which are the structures identified when choosing the most effective postural drainage position for a given patient. Segmental bronchi then
divide into sub segmental bronchi. These bronchi are surrounded by connective tissue that contains arteries, lymphatic’s, and nerves. The sub segmental bronchi then branch into
bronchioles, which have no cartilage in their walls. Their patency depends entirely on the elastic recoil of the surrounding smooth muscle and on the alveolar pressure. The bronchioles
contain sub mucosal glands, which produce mucus that covers the inside lining of the airways. The bronchi and bronchioles are lined also with cells that have surfaces covered with cilia.
These cilia create a constant whipping motion that propels mucus and foreign substances away from the lung toward the larynx. The bronchioles then branch into terminal bronchioles,
which do not have mucous glands or cilia. Terminal bronchioles then become respiratory bronchioles, which are considered to be the transitional passageways between the conducting
airways and the gas exchange airways. Up to this point, the conducting airways contain about 150 mL of air in the tracheobronchial tree that does not participate in gas exchange. This is
known as physiologic dead space. The respiratory bronchioles then lead into alveolar ducts and alveolar sacs and then alveoli. Oxygen and carbon dioxide exchange takes place in the
alveoli.
ALVEOLI
The lung is made up of about 300 million alveoli, which are arranged in clusters of 15 to 20. These alveoli are so numerous that if their surfaces were united to form one sheet, it
would cover 70 square meters—the size of a tennis court. There are three types of alveolar cells. Type I alveolar cells are epithelial cells that form the alveolar walls. Type II alveolar cells
are metabolically active. These cells secrete surfactant, a phospholipid that lines the inner surface and prevents alveolar collapse. Type III alveolar cell macrophages are large phagocytic
cells that ingest foreign matter (eg, mucus, bacteria) and act as an important defense mechanism.
FUNCTION OF THE RESPIRATORY SYSTEM
The cells of the body derive the energy they need from the oxidation of carbohydrates, fats, and proteins. As with any type of combustion, this process requires oxygen. Certain vital tissues,
such as those of the brain and the heart, cannot survive for long without a continuing supply of oxygen. However, as a result of oxidation in the body tissues, carbon dioxide is produced and
must be removed from the cells to prevent the buildup of acid waste products. The respiratory system performs this function by facilitating life-sustaining processes such as oxygen transport,
respiration and ventilation, and gas exchange.

Oxygen Transport
Oxygen is supplied to, and carbon dioxide is removed from, cells by way of the circulating blood. Cells are in close contact with capillaries, whose thin walls permit easy passage or
exchange of oxygen and carbon dioxide. Oxygen diffuses from the capillary through the capillary wall to the interstitial fluid. At this point, it diffuses through the membrane of tissue
cells, where it is used by mitochondria for cellular respiration. The movement of carbon dioxide occurs by diffusion in the opposite direction—from cell to blood.
Respiration
After these tissue capillary exchanges, blood enters the systemic veins (where it is called venous blood) and travels to the pulmonary circulation. The oxygen concentration in blood
within the capillaries of the lungs is lower than in the lungs’ air sacs (alveoli). Because of this concentration gradient, oxygen diffuses from the alveoli to the blood. Carbon dioxide, which
has a higher concentration in the blood than in the alveoli, diffuses from the blood into the alveoli. Movement of air in and out of the airways (ventilation) continually replenishes the
oxygen and removes the carbon dioxide from the airways in the lung. This whole process of gas exchange between the atmospheric air and the blood and between the blood and cells of
the body is called respiration.
Ventilation
During inspiration, air flows from the environment into the trachea, bronchi, bronchioles, and alveoli. During expiration, alveolar gas travels the same route in reverse. Physical factors
that govern air flow in and out of the lungs are collectively referred to as the mechanics of ventilation and include air pressure variances, resistance to air flow, and lung compliance.

AIR PRESSURE VARIANCES

Air flows from a region of higher pressure to a region of lower pressure. During inspiration, movement of the diaphragm and other muscles of respiration enlarge the thoracic cavity and
thereby lower the pressure inside the thorax to a level below that of atmospheric pressure. As a result, air is drawn through the trachea and bronchi into the alveoli. During normal expiration,
the diaphragm relaxes and the lungs recoil, resulting in a decrease in the size of the thoracic cavity. The alveolar pressure then exceeds atmospheric pressure, and air flows from the lungs into
the atmosphere.

AIRWAY RESISTANCE
Resistance is determined chiefly by the radius or size of the airway through which the air is flowing. Any process that changes the bronchial diameter or width affects airway resistance and
alters the rate of air flow for a given pressure gradient during respiration With increased resistance, greater-than-normal respiratory effort is required by the patient to achieve normal levels of
ventilation.

COMPLIANCE
The pressure gradient between the thoracic cavity and the atmosphere causes air to flow in and out of the lungs. When pressure changes are applied in the normal lung, there is a
proportional change in the lung volume. A measure of the elasticity, expandability, and dispensability of the lungs and thoracic structures is called compliance. Factors that determine lung
compliance are the surface tension of the alveoli (normally low with the presence of surfactant) and the connective tissue (ie, collagen and elastin) of the lungs. Compliance is determined by
examining the volume–pressure relationship in the lungs and the thorax. In normal compliance (1.0 L/cm H2O), the lungs and thorax easily stretch and distend when pressure is applied. High or
increased compliance occurs when the lungs have lost their elasticity and the thorax is over distended (ie, in emphysema). When the lungs and thorax are “stiff,” there is low or decreased
compliance. Conditions associated with this include pneumothorax, hemothorax, pleural effusion, pulmonary edema, atelectasis, pulmonary fibrosis, and acute respiratory distress syndrome
(ARDS), all of which are discussed in later chapters in this unit. Measurement of compliance is one method used to assess the progression and improvement in ARDS. Lungs with decreased
compliance require greater-than-normal energy expenditure to achieve normal levels of ventilation. Compliance is usually measured under static conditions.
BLOOD SUPPLY
The lungs are very vascular organs, meaning they receive a very large blood supply. This is because the pulmonary arteries, which supply the lungs, come directly from the right side of
you heart. The carry blood which is low in oxygen and high in carbon dioxide into your lungs so that the carbon dioxide can be blown off and more oxygen can be absorbed into the blood
stream. The newly oxygen-rich blood then travels back through the paired pulmonary veins into the left side of the heart. From there, it is pumped all around your body to supply your cells and
organs.

CIRCULATORY SYSTEM

The cardiovascular system transports food, hormones, metabolic wastes, and gases (oxgen, carbon dioxide) to and
from cells. Components of the circulatory of the circulatory system include:

Blood: consisting of liquid plasma and cells.

Blood vessels (vascular system): the “channels” (Arteries, veins, capillaries) which blood to from all tissues.
(Arteries carry blood away from the heart. Veins return blood to the heart. Capillaries are thin-walled blood
vessels in which gas nutrient waste exchange occur).

There are two circulatory “circuits”: Pulmonary circulation involving the “right heart” delivers blood to and from the
heart. The pulmonary artery carries oxygen-poor blood from the “right heart” to the lungs, where the oxygen and
carbon-dioxide removal occur. Pulmonary veins carry oxygen-rich blood from the lungs back to the “left heart”.
Systemic circulation, driven by the “left heart” carries blood to the rest of the body. Food product enters the system
from the digestive organs into the portal vein. Waste products are removed by the liver and kidneys. All systems
ultimately return to the “right heart” via the inferior and superior vena cavae.

A specialized component of the circulatory system is the lymphatic system, consisting of a moving fluid
(lymph/interstitial fluid); vessels (lymphatics); lymphatic nodes, and organs (bone marrow, liver, spleen, thymus).
Through the flow of blood in and out of arteries, and into the veins, and through the lymph nodes and into the
lymph, the body is able to eliminate the products of cellular breakdown and bacterial invasion.

Blood Components
 Adults have up to ten pins of blood.

Forty-five percent (45%) consists of cells – platelets, red blood cells, and white blood cells (neutrophils, basophils, eosinophils, lymphocytes, monocytes). Of the white blood cells,
neutrophils and lymphocytes ate the most important.

Fifty-five percent (55%) consists of plasma, the liquid component of blood.

Major Blood Components

Component Type Source Function

Platelets, cell fragmets Bone Marrow Blood Clothing
Life-span: 10 days
Lymphocytes (leukocytes) Bone marrow, spleen, lymph nodes Immunity
T-cells attack cells containing viruses.
B-cells produce antibodies
Red blood cells (erythrocytes), Filled with hemoglobin, Bone marrow Oxygen transport
a compound of iron and protein Life span: 120 days
Neutrophils (leukocytes) Bone marrow Phagocytosis

Plasma, consisting of 90% water and 10% dissolved materials – nutrients 1. Maintenance of pH level near 7.4
(proteins, salts, glucose), wastes (urea, creatinine), hormones, enzymes. 2. Transport of large molecules (e.g. cholesterol)
3. Immunity (globulin)
4. Blood clotting (fibrinogen)

Vascular System – the Blood Vessels

Arteries, veins and capillaries comprise the vascular system. Arteries and veins run parallel throughout the body with a web-like network of capillaries connecting them. Arteries use
vessel size, controlled by the sympathetic nervous system, to move blood by pressure, veins use way valves controlled by muscle contractions.

Arteries are strong, elastic vessels adapted for carrying blood away from the heart at relatively high pumping pressure. Arteries divide into progressively thinner tubes and eventually
become fine branches called artrerioles. Blood in arteries in oxygen-rich, with the exception of the pulmonary artery, which carries blood to the lungs to be oxygenated.

The aorta is the largest artery in the body, the main artery for systemic circulation. The major branches of (aortic arch, ascending aorta, descending aorta) supply blood to the head,
abdomen, and extremities. Of special importance are the right and left coronary arteries, that supply blood to the heart itself.
 PATHOPHYSIOLOGY

Upper airway characteristics normally prevent potentially infectious particles from reaching the normally sterile lower respiratory tract. Thus, patients with pneumonia caused by
infectious agents often have an acute or chronic underlying disease that impairs host defenses. Pneumonia arises from normally present flora in a patient whose resistance has been altered, or
it results from aspiration of flora present in the oropharynx. It may also result from blood borne organisms that enter the pulmonary circulation and are trapped in the pulmonary capillary bed,
becoming a potential source of pneumonia.
Pneumonia often affects both ventilation and diffusion. An inflammatory reaction can occur in the alveoli, producing an exudate that interferes with the diffusion of oxygen and carbon
dioxide. White blood cells, mostly neutrophils, also migrate into the alveoli and fill the normally air-containing spaces. Areas of the lung are not adequately ventilated because of secretions and
mucosal edema that cause partial occlusion of the bronchi or alveoli, with a resultant decrease in alveolar oxygen tension. Bronchospasm may also occur in patients with reactive airway disease.
Because of hypoventilation, a ventilation–perfusion mismatch occurs in the affected area of the lung. Venous blood entering the pulmonary circulation passes through the under ventilated area
and exits to the left side of the heart poorly oxygenated. The mixing of oxygenated and unoxygenated or poorly oxygenated blood eventually results in arterial hypoxemia.
If a substantial portion of one or more lobes is involved, the disease is referred to as “lobar pneumonia.” The term “bronchopneumonia” is used to describe pneumonia that is
distributed in a patchy fashion, having originated in one or more localized areas within the bronchi and extending to the adjacent surrounding lung parenchyma. Bronchopneumonia is more
common than lobar pneumonia.
 Diagram of Pathophysiology
Predisposing Factors: Precipitating factor:
> Environment >Acute/Chronic underlying disease
>Nutrition
Altered immune system

Aspiration of flora present in the oropharynx Blood borne organisms enter pulmonary circulation

Microorganisms pass thru tracheobronchial tree to the parenchyma of the lungs

Microorganisms proliferate & spread to adjacent alveoli

Increase WBC (neutrophils) migrates & fills into the alveoli

Inflammation reaction occur in the alveoli, producing exudates Transport of pathogenic microorganisms
(s/sx: fever, productive cough with rusty sputum) into the systemic circulation

Sepsis(s/sx: fever, chills, inc WBC)

Decrease diffusion of the oxygen and carbon dioxide

Hypoventilation in the affected area of lung

Mixing of oxygenated & non-oxygenated blood

Arterial hypoxemia

Lacking of Hemoglobin/ # of RBCs are too low

Impaired oxygen transport

Tissue hypoxia

Inadequate RBC volume Compensatory mechanism for loss of RBC fxn Decrease RBC fxn
>hypostatic hypotension, oliguria, fatigue >tachycardia tachypnea, cool clammy skin >dyspnea, chest pain, acidosis, headache, vertigo,
pallor, constipation, altered LOC, dec.bowel
sounds.
 MEDICAL MANAGEMENT

The treatment of pneumonia includes administration of the appropriate antibiotic as determined by the results of the Gram stain. However, an etiologic agent is not identified in 50% of
CAP cases and empiric therapy must be initiated. Therapy for CAP is continuing to evolve. Guidelines exist to guide antibiotic choice; however, the resistance patterns, prevalence of etiologic
agents, patient risk factors, and costs and availability of newer antibiotic agents must all be taken into consideration. Several organizations have published guidelines for the medical
management of CAP (Bartlett et al., 2000; American Thoracic Society, 2001). Recommendations are classified by existing risk factors, setting (inpatient vs. outpatient treatment), or specific
pathogens. Examples of risk factors that may increase the risk of infection with certain types of pathogens appear in Chart 23-3.
Recommendations for treatment of outpatients with CAP who have no cardiopulmonary disease or other modifying factors include a macrolide (erythromycin, azithromycin
[Zithromax], or clarithromycin [Biaxin]), doxycycline (Vibramycin), or a fluoroquinolone (eg, gatifloxacin [Tequin], levofloxacin [Levaquin]) with enhanced activity against S. pneumoniae (Bartlett
et al., 2000; American Thoracic Society, 2001). Erythromycin should be avoided in areas where H. influenzae and S. aureus are more prevalent (Kenreigh & Wagner, 2000; Lynch, 2000). For those
outpatients who have cardiopulmonary disease or other modifying factors, treatment should include a beta-lactam (oral cefpodoxime [Vantin], cefuroxime [Zinacef, Ceftin], high-dose
amoxicillin or amoxicillin/clavulanate [Augmentin, Clavulin]) plus a macrolide or doxycycline. Also, a beta-lactam plus an antipneumococcal fluoroquinolone can be used (American Thoracic
Society, 2001). These are guidelines; treatment for individual patients may be modified. For patients with CAP who are hospitalized and do not have cardiopulmonary disease or modifying
factors, management consists of intravenous azithromycin (Zithromax) or monotherapy with an antipneumococcal fluoroquinolone.
For inpatients with cardiopulmonary disease or modifying factors, the treatment involves an intravenous beta-lactam plus an intravenous or oral macrolide or doxycycline. An
intravenous antipneumococcal fluoroquinolone may also be used alone (American Thoracic Society, 2001). For acutely ill patients admitted to the intensive care unit, management includes an
intravenous beta-lactam plus either an intravenous macrolide or fluoroquinolone. For patients at high risk for P. aeruginosa, more select antipseudomonal antibiotics are administered
intravenously.
If specific pathogens have been identified for the CAP, more specific agents may be utilized. Mycoplasma pneumonia is treatedwith doxycycline or a macrolide. PCP responds best to
pentamidine and trimethoprim–sulfamethoxazole (TMP-SMZ). Amantadine and rimantadine are effective with influenza A and have been shown to reduce the duration of fever and other
systemic complications when administered within 24 to 48 hours of the onset of an uncomplicated influenza infection. These medications also reduce the duration and quantity of virus
shedding in the respiratory secretions. They are most effective when used in combination with influenza vaccine. Ganciclovir is used to treat cytomegalovirus in the non-AIDS patient;
cytomegalovirus immunoglobulin may also be used.
HAP has a different etiology from CAP. In suspected HAP or nosocomial pneumonia, empirical treatment is usually initiated with a broad-spectrum intravenous antibiotic and may be
monotherapy or combination therapy. In patients who are mildly to moderately ill with a low risk of Pseudomonas, the following antibiotics may be used: second-generation cephalosporins (eg,
cefuroxime [Ceftin, Zinacef] or cefamandole [Mandol]), nonpseudomonal third-generation cephalosporins (ceftriaxone [Rocephin], cefotaxime [Claforan], ampicillin-sulbactam [Unasyn]), or
fluoroquinolones (eg, ciprofloxacin [Cipro], levofloxacin [Levaquin]). For combination therapy, any of the above may be used with an aminoglycoside.
For patients at high risk for Pseudomonas infection, an antipseudomonal penicillin plus an aminoglycoside (amikacin [Amikin], gentamicin) or beta-lactamase inhibitor (ampicillin/
sulbactam [Unasyn], ticarcillin/clavulanate [Timentin]) may be used. Other types of combination therapy may also be used depending upon the individual characteristics of the patient. Of
concern is the rampant rise in respiratory pathogens that are resistant to available antibiotics. Examples include vancomycinresistant enterococcus (VRE) and drug-resistant S. pneumonia
(McGeer & Low, 2000). There is a tendency for clinicians to aggressively use antibiotics inappropriately or to use broad-spectrum agents when narrow-spectrum agents are more appropriate.
Mechanisms to monitor and minimize the inappropriate use of antibiotics are in place. Education of clinicians to use evidence evidence based guidelines in the treatment of respiratory infection
is important. Monitoring and surveillance of susceptibility patterns for pathogens are also important. Therapy with parenteral agents usually is changed to oral antimicrobial agents when there
is evidence of a clinical response and the patient is able to tolerate oral medications. The recommended duration of treatment for pneumococcal pneumonia is 72 hours after the patient
becomes afebrile. Most other forms of pneumonia caused by bacterial pathogens are treated for 1 to 2 weeks after the patient becomes afebrile. Atypical pneumonia is usually treated for 10 to
21 days (Bartlett, Dowell, Mandell et al., 2000).
Treatment of viral pneumonia is primarily supportive. Antibiotics are ineffective in viral upper respiratory infections and pneumonia and may be associated with adverse effects.
Treatment of viral infections with antibiotics is a major reason for the overuse of these medications in the United States. Antibiotics are indicated with a viral respiratory infection only when a
secondary bacterial pneumonia, bronchitis, or sinusitis is present. Hydration is a necessary part of therapy because fever and tachypnea may result in insensible fluid losses. Antipyretics may be
used to treat headache and fever; antitussive medications may be used for the associated cough. Warm, moist inhalations are helpful in relieving bronchial irritation. Antihistamines may
provide benefit with reduced sneezing and rhinorrhea. Nasal decongestants may also be used to treat symptoms and improve sleep; however, excessive use may cause rebound nasal
congestion. Treatment of viral pneumonia (with the exception of antimicrobial therapy) is the same as that for bacterial pneumonia. The patient is placed on bed rest until the infection shows
signs of clearing. If hospitalized, the patient is observed carefully until the clinical condition improves.
If hypoxemia develops, oxygen is administered. Pulse oximetry or arterial blood gas analysis is performed to determine the need for oxygen and to evaluate the effectiveness of the
therapy. A high concentration of oxygen is contraindicated in patients with COPD because it may worsen alveolar ventilation by decreasing the patient’s ventilatory drive, leading to further
respiratory decompensation. Respiratory support measures include high oxygen concentrations (fraction of inspired oxygen [FiO2]), endotracheal intubation, and mechanical ventilation.
Different modes of mechanical ventilation may be required.
 NURSING MANAGEMENT

IDEAL:

The nurse should monitor the following:

• Changes in temperature and pulse • Changes in physical assessment findings (primarily assessed
• Amount, odor, and color of secretions by inspecting and auscultating the chest)
• Frequency and severity of cough • Changes in the chest x-ray findings
• Degree of tachypnea or shortness of breath
In addition, it is important to assess the elderly patient for unusual behavior, altered mental status, dehydration, excessive fatigue, and concomitant heart failure.
IMPROVING AIRWAY PATENCY
Removing secretions is important because retained secretions interfere with gas exchange and may slow recovery. The nurse encourages hydration (2 to 3 L/day) because adequate
hydration thins and loosens pulmonary secretions. Humidification may be used to loosen secretions and improve ventilation. A high humidity facemask (using either compressed air or
oxygen) delivers warm, humidified air to the tracheobronchial tree, helps to liquefy secretions, and relieves tracheobronchial irritation. Coughing can be initiated either voluntarily or by
reflex. Lung expansion maneuvers, such as deep breathing with an incentive spirometer, may induce a cough. A directed cough may be necessary to improve airway patency. The nurse
encourages the patient to perform an effective, directed cough, which includes correct positioning, a deep inspiratory maneuver, glottic closure, contraction of the expiratory muscles
against the closed glottis, sudden glottis opening, and an explosive expiration. In some cases, the nurse may assist the patient by placing both hands on the patient’s lower rib cage
(anteriorly or posteriorly) to focus the patient on a slow deep breath, and then manually assisting the patient by applying external pressure during the expiratory phase. Chest
physiotherapy (percussion and postural drainage) is important in loosening and mobilizing secretions (see Chap. 25). Indications for chest physiotherapy include sputum retention not
responsive to spontaneous or directed cough, a history of pulmonary problems previously treated with chest physiotherapy, continued evidence of retained secretions (decreased or
abnormal breath sounds, change in vital signs), abnormal chest x-ray findings consistent with atelectasis or infiltrates, or deterioration in oxygenation. The patient is placed in the proper
position to drain the involved lung segments, and then the chest is percussed and vibrated either manually or with a mechanical percussor. After each position change, the nurse
encourages the patient to breathe deeply and cough. If the patient is too weak to cough effectively, the nurse may need to remove the mucus by nasotracheal suctioning (see Chap. 25). It
may take time for secretions to mobilize and move into the central airways for expectoration. Thus, it is important for the nurse to monitor the patient for cough and sputum production
after the completion of chest physiotherapy. The nurse administers and titrates oxygen therapy as prescribed. The effectiveness of oxygen therapy is monitored by improvement in clinical
signs and symptoms, and adequate oxygenation values measured by pulse oximetry or arterial blood gas analysis.
PROMOTING REST AND CONSERVING ENERGY
The nurse encourages the debilitated patient to rest and avoid overexertion and possible exacerbation of symptoms. The patient should assume a comfortable position to promote rest
and breathing (eg, semi-Fowler’s) and should change positions frequently to enhance secretion clearance and ventilation/perfusion in the lungs. It is important to instruct outpatients not
to over exert themselves and to engage in only moderate activity during the initial phases of treatment.
PROMOTING FLUID INTAKE
The respiratory rate of a patient with pneumonia increases because of the increased workload imposed by labored breathing and fever. An increased respiratory rate leads to an increase
in insensible fluid loss during exhalation and can lead to dehydration. Therefore, it is important to encourage increased fluid intake (at least 2 L/day), unless contraindicated.
MAINTAINING NUTRITION
Patients with shortness of breath and fatigue often have a decreased appetite and will take only fluids. Fluids with electrolytes (commercially available drinks, such as Gatorade) may help
provide fluid, calories, and electrolytes. Other nutritionally enriched drinks or shakes may be helpful. In addition, fluids and nutrients may be administered intravenously if necessary.
PROMOTING THE PATIENT’S KNOWLEDGE
The patient and family are instructed about the cause of pneumonia, management of symptoms of pneumonia, and the need for follow-up (discussed later). The patient also needs
information about factors (both patient risk factors and external factors) that may have contributed to developing pneumonia and strategies to promote recovery and to prevent
recurrence. If hospitalized for treatment, the patient is instructed about the purpose and importance of management strategies that have been implemented and about the importance of
adhering to them during and after the hospital stay. Explanations need to be given simply and in language that the patient can understand. If possible, written instructions and information
should be provided. Because of the severity of symptoms, the patient may require that instructions and explanations be repeated several times.
SURGICAL MANAGEMENT
 DISCHARGE PLAN

NAME _X_____________________________________________ DATE OF DISCHARGE: ____________________

CONDITION UPON DISCHARGE ___________ Nature: Home per request ( ) Discharge against medical advice ( )

>Encourage pt not to take any OTC drugs without consulting the doctor.
>Encourage pt to continue taking medications prescribed by the physician, following the right time, right dose and right route as indicated by the physician.
1. MEDICATIONS >Encourage patient to continue the medications prescribed even signs and symptoms subside not until to the date ordered by the physician.
>Instruct patient and SOs to report to physician to appropriate personnel if adverse reactions occur.
>Encourage patient to take the medications religiously.
>Encourage pt to do deep breathing and coughing exercises to promote lung expansion.
>Encourage pt to do mild exercises as tolerated, or to do ROM exercises to promote blood circulation and prevent muscle atrophy.
2. EXERCISE >Encourage pt to increase activities gradually.
>Remind pt to have adequate rest and sleep to prevent fatigue.
>Encourage pt to maintain adequate intake of fluids to promote hydration and prevent constipation.
>Encourage pt to eat high-caloric foods to have sufficient amount of energy.
3. DIET >Encourage pt to increase intake of foods rich in Vit. C such as fruits and vegetables to boast immune system.
>Encourage pt to increase intake of foods rich in potassium.
>Instruct pt to observe low salt diet to prevent or minimize edema in eating.
>Instruct patient not to eat or drink anything when there’s dyspnea or difficulty or breathing until subsides to prevent aspiration.
>Encourage pt to maintain personal hygiene daily to prevent infection.
> Encourage pt keep her surroundings clean and free from dust to prevent asthma attacks.
> Encourage pt’s family members to stop smoking.
>Provide health teaching on pt and pt’s SO about the effects of smoking in our health.
> Encourage pt to wear loose-fitting clothes to promote comfort and proper blood circulation.
4. HEALTH TEACHING >Remind pt to seek medical advice if unusual in pts body are observed to prevent further complication of the condition.
> Encourage pt to expectorate secretions.
>Teach pt to dispose secretion property and avoid splitting everywhere to prevent spread of the disease.
> Encourage pt to cover the mouth when coughing.
> Encourage pt to avoid going to crowded places.
> Encourage pt to have divert ional activities to divert attention when rashes are itching and to prevent skin breakdown.
> Encourage pt to keep her finger nails short.
> Encourage pt to return in the scheduled next visit as ordered by the physician.
5. SCHEDULE FOR THE > Encourage pt to visit nearest health care facility if health problems occur.
NEXT VISIT > Encourage pt to seek medication advice if signs and symptoms reappear.
> Encourage pt to seek medical advices to appropriate personnel if unusual ties occur.
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

S: “Da bagar akun”, as >Activity intolerance r/t body >After my 8 hrs of care pt will >Check and monitor v/s. >To serve as baseline data. >After my 8 hrs of care, pt
verbalized by the pt. weakness related to anemia. be able to decrease >Check and regulate IVF as >To prevent fluid overload. was able to gradually
psychological signs of activity prescribed. manifest improvement of
O: 7:30 am, received pt lying >Maintain HOB elevated. >To promote lung expansion.
intolerance as manifested by activity tolerance.
on bed semi fowlers position >Assist client in changing bed >To promote comfort and
signs of comfort. positions on bed. maximize breathing.
with ongoing IVF #4 D₅NM 1L
>Encourage pt to perform >To promote activity
with 500 cc level left, hooked
ADLS that can be tolerated. tolerance, independence and Final V/S:
at left arm regulated@ lung expansion. >Temperature 38° C
30gtts/min infusing well. >Encourage pt to have high >To provide energy. >Weight not taken
calorie diet. >Pulse 105 bpm
>weakness noted >Assist client during >To prevent injury, promote
> productive cough noted >Respiration 40 cpm
ambulation. activity tolerance,
with rusty sputum independence, and lung
>restlessness noted expansion.
>pallor noted >Encourage rest periods >To prevent fatigue and
>rhonchi heard upon between activities and sleep promote O₂ exchange.
auscultation to pt.
>general body weakness >Encourage pt to perform >To promote optimum lung
noted coughing exercises and to expansion and expectoration
>no appetite noted cough effectively. of secretions.
>dizziness noted >Teach and encourage >To promote lung expansion
>muscular strenght of 3/5 breathing exercise. and clearing.
>RBC= 2.8X10 12 L >Instruct pt to have strict >To achieve desired
compliance of medications. therapeutic effect of meds
Initial V/S: and facilitate faster recovery.
>Temperature 39.6 ° C >Instruct pt and SO correct >To avoid spread of disease.
>Weight not taken disposal of secretions.
>Pulse 114 bpm
>Respiration 52 cpm
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

S: “Pkaregenan ako >Ineffective breathing pattern >Within my 8 hrs of care, pt >Check and monitor v/s. >To serve as baseline data. >After my 8 hrs of care, pt
guminawa”, as verbalized by r/t pulmonary secretions. will gradually manifest >Check and regulate IVF as >To prevent fluid overload. was able to gradually
the pt. effective breathing pattern as prescribed. manifest effective breathing
>Provide bedside and >To promote comfort and
O: Received pt at 7:15 am evidenced by decrease pattern as evidenced by
morning care to pt. relaxation.
lying on bed ,concsious, abnormal sounds upon >Maintain HOB elevated. >To promote lung expansion. decrease abnormal sounds
coherent, oriented to time , auscultation. >Encourage rest periods >To avoid stress. upon auscultation.
place and person with between activities and sleep
oingoing IVF #4 D₅NM 1L to pt. Final V/S:
with 600 cc level left, hooked >Encourage pt to perform >To promote optimum lung >Temperature 38° C
at left arm regulated @ 30 coughing exercises. And to expansion and expectoration >Weight not taken
cough effectively. of secretions. >Pulse 114 bpm
gtts/min, infusing well.
>Teach and encourage >To promote lung expansion >Respiration 40cpm
>paleness noted breathing exercise. and clearing.
>restlessness noted >Perform chest >To expectorate secretions.
>rhonchi heard upon physiotherapy to the pt.
auscultation >Instruct pt to have strict >To achieve desired
>nasal flaring noted compliance of medications. therapeutic effect of meds
>use of accessory muscle and facilitate faster recovery.
>Instruct pt and SO correct >To avoid spread of disposal.
upon breathing
disposal of secretions.
>cheat pain 4/10
Initial V/S:
>Temperature 39.6 ° C
>Weight not taken
>Pulse 114 bpm
>Respiration 52 cpm
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

S: “May ubo parin ako,” as >Ineffective airway clearance >Within my 8 hrs of care, pt >Check and monitor v/s. >To serve as baseline data. >After my 8 hrs of care, pt
verbalized by the patient. r/t retained secretions. will gradually manifest signs >Check and regulate IVF as >To prevent fluid overload. was able to gradually
of patent airway. prescribed. manifest signs of patent
O: 8:00 am, received pt sitting >Provide bedside and >To promote comfort and
airway.
on bed, conscious, coherenr, morning care to pt. relaxation.
oriented to time, place and >Maintain HOB elevated. >To promote lung expansion.
>Instruct pt to consume >To loose secretions and
person with IVF # 4 D₅NM 1L
liquid appropriate to weight prevent dehydration. Final V/S:
with 450 cc level left, hooked (2-3 L/day).
at left arm regulated @ 30 >Temperature 36.6 ° C
>Assist client in charging bed >To promote comfort and >Weight not taken
gtts/min, infusing well. positions on bed. maximize breathing. >Pulse 105 bpm
>Perform chest >To expectoration secretions.
>Respiration 40 cpm
>weakness needed physiotherapy to pt.
>rhonchi heard upon >Encourage pt to perform >To promote optimum lung
coughing exercises ant to expansion and expectoration
auscultation
cough effectively. of secretions.
>tachypnea noted >Teach and encourage >To promote lung expansion
>use of accessory muscles breathing exercises. and clearing.
noted upon breathing
>chest pain 4/10 >Instruct pt to have strict >To achieve desired
compliance of medications. therapeutic effect of meds
and facilitate faster recovery.
V/S:
>Encourage rest periods >To prevent fatigue and
>Temperature 36.6 ° C between activities and sleep promote O₂ exchange.
>Weight not taken to pt.
>Pulse 110 bpm
>Respiration 50 cpm >Instruct pt and SO correct >To avid spread of disease.
disposal of secretions.
 NURSING CARE PLAN

CUES NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

S: “Mainit ang pakiramdam >Increase body temperature Within my 8 hrs of care, pt >Check and monitor v/s. >To serve as baseline data. After my 8 hrs of care, pt was
ko,” as verbalized by the related to infection. will be able to manifest >Check and regulate IVF as >To prevent fluid overload. able to verbalize feeling of
patient. gradual decrease in body prescribed. comfort and manifest
>Provide bedside and >To promote comfort and
temperature. decrease level of body
O: Received pt at 8:00 am morning care to pt. relaxation.
>Provide tepid sponge bath. >To decrease level of body temperature.
sitting on bed, conscious,
>Maintain HOB elevated. temperature.
coherent, oriented to time,
>Instruct pt to consume >To promote lung expansion.
place and person with IVF # 4 liquid appropriate to weight >To loose secretions and
D₅NM 1L with 450 cc level Final V/S:
(2-3 L/day). prevent dehydration.
left, hooked at left arm >Assist client in charging bed >Temperature 37.5 ° C
regulated @ 30 gtts/min, positions on bed. >To promote comfort and >Weight not taken
infusing well. >Perform chest maximize breathing. >Pulse 110 bpm
physiotherapy to pt. >To expectoration secretions.
>Respiration 45 cpm
>Encourage pt to perform
>weakness needed
coughing exercises ant to >To promote optimum lung
>rhonchi heard upon cough effectively. expansion and expectoration
auscultation >Teach and encourage of secretions.
>tachypnea noted breathing exercises. >To promote lung expansion
>use of accessory muscles and clearing.
noted upon breathing >Instruct pt to have strict
compliance of medications. >To achieve desired
>chest pain 4/10
therapeutic effect of meds
>With WBC=29.3 x 10⁹/L
>Encourage rest periods and facilitate faster recovery.
between activities and sleep >To prevent fatigue and
to pt. promote O₂ exchange.
V/S:
>Instruct pt and SO correct
>Temperature 39.6 ° C >To avid spread of disease.
disposal of secretions.
>Weight not taken
>Pulse 114 bpm
>Respiration 52 cpm