Al-Quds University

Faculty of Health Profession

Nursing department

Critical Care Nursing Clinical

Case Study About: Chest Infection

STUDENT NAME: Khaled m Hantash

CLINICAL SITE : : Ramallah medical complex

PERIOD OF CLINICAL PRACTICE: __5/10 –

____________________12/1

Instructor Name: Ahmed Qadadha

..…… GOOD LUCK

The reason for choosing this case: I chose this case because I see too much case like
that and I want to learn how to deal with cases like this.

*** Biographic Data:

Name of Patient "Initials" H.M

HospitalPalestine medical complex /// Ward: CCU : 1

Gender :female Age :67

Admission Date:7/11/2022

Type of Admission: Emergency

Allergies 1. Food:non 2. Medication :non

Others :non 4. Unknown :non .3

Diet Patient on: Diabetic diet , low sodium and low sugar

Religion :Muslim /// Marital Status :Married

Informant: From the team member and patient file and from the patient and her
daughter.

*** Medical Diagnosis:

Chest infection.

***Nursing Health History

**Chief complaint: Reason for seeking health care: She came to the hospital
because she had fever and dyspnea and chest pain.

**History of present illness:

The patient suffer from influenza last two weeks and she had fever and shortness
of breath and HTN .
**Other Current health problems:

The patient suffers from hypertension and constipation .

**Past medical Health History:

The patient has constipation and HTN.

** Past surgical history: no surgery .

Family History:

Her mother was suffering from hypertension and diabetes, her father free from
medical history her husband HTN.

**Psychosocial History :

She is married and has 5 children 2 boys and 3 girls all of them in good health and
with out medical problems, and all of them help her and in good relationship, and
the patient is a social person has a lot of friends

**Environmental History:

The patient lives in a ramallah, the surrounding environment is clean, free of dust
and pollutants, and she lives in a comfortable big house containing 5 big rooms and
everything in the house is in good condition.
*** Review of system: Physical assessment:

**General Appearance: Pt grooming difficult, height:172cm,

wehight:82kg ,age67years, she has swelling and pain medial of abdomen& chest
pain , has shortness of breath , she speech slowly and up normal posture body
build of PT good health, PT conscious, oriented and can walk .

**Skin, Hair & Nails:

The skin is the same in all parts of the body, there is no infection or inflammation,
it is clean, its texture is smooth to dryness, and it has no lesions, lumps or edema,
and the sweat glands secrete sweat in a normal amount, , no bed sores, no
cyanosis, no pigmentation Or erythema, no fungi or bacteria, no skin disease, no
color changes throughout the body, white hair and normal and clean nails.

**Head and neck:

S : The patient said she did not have any problems with the neck and there was no
pain in the head
O : The head was in harmony with her body, moving right and left and down and
up naturally, there were no bruises on her head, there were no wounds on her
head, the skin of the head was moist and clean, and there was no enlarged lymph
nodes.

** Head:

S: The patient said she was not experiencing head pain

O: The head was symmetrical, there was no swelling, wounds or bumps, and the
skin of the head was moist and clean

**Hair:

S: The patient said that she cares about her hair and there are no problems with
hair

O: The Pt have a not distributed of hair, and the texture of the hair is coarse to
dryness, and the color is white, no bad care habits of hair, no sweating (no lipids
hair), no resilient, reddish.

**Eyes:

S: The patient said that she was not experiencing any eye pain

O: They brown in color, do not use glasses, do not use lenses, there is no
inflammation, do not use any eye medicines, and the eyes are similar in size and
shape, neither short nor farsightedness, good visual acuity.

**Ears:

S: The patient said that she does not suffer from any voice problems, that she was
not using artificial hearing aids, and that she was interested in cleaning her ears.

O: Natural secretion of wax, good auditory response, consistency in size and

shape, no infection or inflammation, no pain, no ear medication, no pus or blood,
no headphones, normal alignment.

**Nose and sinus:

S: The patient said that she takes care of her nose and that there is no nosebleed.
O: No bleeding, no infection or inflammation, mucus is normal green color, no
blood in it, the two channels are open, the nose is symmetrical in size and shape,
without using the NG tube, the septum is straight, the structure of the nose is
natural elastic (foldable).

**Mouth and pharynx:

S: The patient said she cares about cleaning her mouth and there are no problems
or pain in his throat or mouth

O: She could distinguish between different tastes, the teeth of pt were clean, there
were no injuries to the gums, her gums were pink, there was no food between her
teeth or a foul smell, her mouth and lips were pink, and her lips were wet and soft,
and she had no lesions, bleeding, cleft lip or cleft palate

**Neck and nodes:

S: The patient said she did not have any problems with her neck.

O: The movement of the neck muscles is normal from top, bottom, left and right,
there are no lumps, edema, pain or bleeding, there is no inflammation, no
distension in the jugular veins

**Respiratory system:

S: The patient said she had chest pain and feel discomfort and dyspnea, and she
does not smoke.

O: Breathing is normal 14 b / m, there is crackle sound, there is wheezing, there is

cough, the chest movement is good and the shape is normal, the size of the chest is
elliptical is normal, there is problem in the upper system, the lungs are full of fluid,
the alveoli is not full with air, there's fluid.

**Cardiovascular system:

S: The patient said that she had no surgeries

O: Normal heart sound S1 and S2, no puffs, pulse was 63 b / m (carotid pulse and
apical pulse), good circulation in body and limbs (checked by capillary refilling),
pulse was regular.

**Breast and axillary:

S: The patient said that she cares about axillary cleanliness and that there is no
allergies or blisters under the armpit and is concerned with cleaning her chest.

O: The two breasts it's symmetry in size and shape and color and no edema or
masses or any abnormal discharge and no pain.
**Abdomen:

S: The patient said that she suffer from abdominal pain and constipation

O: She has a clean umbilicus, there are no scars, the abdomen is flaccid and
laxative, the patient does not suffer from nausea and vomiting, , the abdomen is
raised and fell during breathing, bowel sounds are found, no lumps, no organ
enlargement.
***General & Reproductive System :

**Female:

S: The patient said he had no problems with the reproductive system or any type of
infection.

O: The reproductive system is free of deformities and there are no infections, clean
and free from dirt.

**Obstetrical History:

S: the PT said that she has 5 children all of them normal delivery, and that she does
not had any problems in pregnancy.

O:she has 5 children all of them normal delivery no past medical history of
problems in pregnancy.

**Rectum& Anus:

There were no injuries in the genital area, no swelling, no bleeding in the genital
tract, and the anal sphincter was opening and closing during excretion, and no
secretions.

**Eliminations:

** Bowel:

S: She said that there is no problem in the bowel.

O: Doesn’t have any problems with urine or faeces, it is normal

((Stool)): brown, the smell is normal, the amount is abnormal because has
constipation

**Urinary:

S: the pt said that is no burn or pain in the urination.

O: the pt with foley catheter normal urine output normal color, , there was no octyl
blood and there was no burn in the patient during urination.

**Diet and Nutrient:

S: The patient said she eat low sugar diet and she does not smoke and low sodium

O:the pt on low sugar and soft diet.

**Musculoskeletal:

S:She said that she in good condition and does not had any problems.

O:Patient was in complete bed rest, no deformities, no masses, no muscle cramp, no

use of moving aids.

**Neurological:

S:she said that she had not any problem in the past.

O: Pt has no problems in the brain, memory or nervous system, responds to any

action or stimulation, is conscious and has no problems with speech, hearing,
movement or sensation, answering 3 questions of pt prompt guide (person, place,
time) GCS is 14.
_____________________________________

Intravenous therapy given to the patient:

The pt. with out any IVF fluid because she has to discharge

Special diagnostic test done for the patient:

** X-RAYS-CT SCAN-MRI…etc: CHEST X-RAYS done showed that pt has chest

infection

** ECG&ECHO:

ECG done and normal rhythm ECG.

 Others: (CBC, KFT, LFT……. ETC :

Lab test done and the result was:

Test Result Normal range Interpretation of
results

WBC 13.9 5-11k/ul Abnormal due to

 infection

RBC 5.7 4.3-5.7 million cells Within normal

/ mcl range

HGB 13.8 12-16 g/dl. Within normal

range

HCT 42.6 (38.8-50.0)% Within normal

range

PLATLET COUNT 280 150-450 k/ul Within normal

range

SODIUM 132 135-145 meq/l Within normal

range

POTTASIUM 3.7 3.5-5 meq/l Within normal

range

AST 61.9 0-30 u/l Abnormal

ALT 149 0-40 u/l Abnormal

CREATININ 1.12 0.5-0.9 mg/dl Abnormal

BUN 37 7-21 mg/dl Abnormal

CRB 22 0-5mg/l Abnormal high

result due to
inflammation

LDH 202 207-414 Abnormal

CALCIUM. SERUM 8.4 8.8-10.2 Abnormal

Pathophysiology of the disease (In your own words) Mention references

A chest infection is an infection that affects your lungs, either in the larger airways
(bronchitis) or in the smaller air sacs, There is a build-up of pus and fluid (mucus),
 and the airways become swollen, making it difficult for you to breathe. Chest
.infections can affect people of all ages

.References in the end of the data

Medication Sheet

Generic \ Dose \ Classification Side effect of Nursing priorities

trade name frequency medication
)assessment, V\S, lab tests(
route\

Aspirin 100mg Antiplatelet/ GI ulcerations/ .MONITOR V/S and assess the pt

NSAIDs /Headache
1*1
Upset
PO
stomach

Abdominal
pain/
heartburn

Clexan 40mg Anticoagulant Bleeding PT test

gums/
1/1 Low
nosebleeds/
molecular
S/C coughing up
heparin
blood/
prolonged
bleeding for
cuts

75mg Antiplatelet Fever • Monitor patient •

PLAVIX 1*1 • Monitor signs of bleeding •

Headache
P.O
•
Weakness

Feeling •
tired
 MG 2.5 Bisoprolol • Monitor BP frequently during periods of dose
Dizziness adjustment or drug withdrawal
CONCOR 1*1 Beta blocker
•
P.O
Headache

Fatigue •

Cold •
hand and feet

:Main pt problem according to the NANDA

1. impaired gas exchange related to alveolar membranes inflammation as evidence

by restlessness .

2. ineffective breathing R/T collection of secretion in airway evidence by inspection

productive cough.

3. Hyperthermia R/T inflammatory disease as evidenced by thermometer , hot

flushed skin and chills .

4. anxiety R/T stay in the CCU as evidenced by the PT discomfort and scared.

5. acute pain R/T the chest infection as evidenced by the PT complaing and shooting.

6. dyspnea R/T narrowing of the airway path and collection of secretion as evidenced
by the PT chest movement and sound.

Nursing Care Plan

Pt Problem : impaired gas exchange

Nursing Dx: impaired gas exchange related to alveolar membranes inflammation as
evidence by restlessness .

. Short goal: client will maintain clear lung fields and remain free of signs of
respiratory distress.

Long goal: client will demonstrate improved ventilation and adequate oxygenation as
evidenced by blood gas levels within normal

Nursing Interventions Rationale Evaluation

1-Monitor v/s closely, To know potentially fatal gas exchange began

especially during initiation complication that may improve without side

of therapy. occur. effects so the goal is met.

Assess and routinely Peripheral and central

monitor skin and mucous cyanosis indicate

membrane color advanced hypoxemia.

Administer oxygen Oxygen therapy help

therapy 2-3 L using nasal in maintaining oxygen

cannula saturation above 90%.

Maintain patient in semi To facilitate ventilation

fowler position. and to prevent any

accumulation of

secretions.

Monitor level of Restlessness and anxiety

consciousness and mental are common

status.. manifestations of

hypoxia.

teaching the patient To make the PT more

relaxation exercises such as comfortable and prevent

deep breathing restlessness.

Pt Problem : ineffective airway clearance

Nursing Dx: ineffective breathing R/T collection of secretion in airway evidence by

inspection productive cough.

short goal: to relief the dyspnea and comfort the pt as soon as possible

long goal: The patient will maintain a clean and effective airway, and there will be no
complications and the patient will be stable.

Nursing Interventions Rationale Evaluation

Assess cough effectiveness Coughing is the most

and productivity, Observe effective way to remove

the sputum color, viscosity, secretions. Chest

.and odor. Report changes infection may cause thick

and tenacious secretions

to patients, Changes in

sputum characteristics
 may indicate infection.

Teach the patient the The most convenient way

proper ways of coughing to remove most

and breathing. (e.g., take a secretions is coughing. So

deep breath, hold for 2 it is necessary to assist

seconds, and cough two or the patient during this

three times in succession) activity. Deep breathing,

on the other hand,

promotes oxygenation

before controlled

coughing.

Perform nasotracheal Suctioning is needed

suctioning as necessary, when patients are unable

especially if cough is to cough out secretions

ineffective. properly due to

weakness, thick mucus

plugs, or excessive or

tenacious mucus

production

Maintain humidified Increasing humidity of

oxygen as prescribed. inspired air will reduce

thickness of secretions
 and aid their removal.

Give medications as .To comfort the PT

prescribed, such as

.bronchodilators

Do physiotherapy To keep the airway open

Pt Problem : Hyperthermia

Nursing Dx: Hyperthermia R/T inflammatory disease as evidenced by thermometer ,

hot flushed skin and chills .

short goal: the patient body temperature will be decreased to normal range within
. 15miutes

long goal:. The patient's body temperature drops to the normal range and the
patient's condition is kept stable.

Nursing Interventions Rationale Evaluation

Monitor v/s temperature , To check on the patient's The goal was meet and

heart rate ,and blood temperature constantly the temperature was in

pressure frequently. and if the patient needs normal range after the

pharmacological interventions and the PT

was comfortable.
therapy or not.

administer antipyretic as To reduces the fever.

prescribed.

Modify the patient’s To reduce the fever.

environment such as room

temperature and bed

linens as indicated and

Eliminate excess clothing

and covers.

Provide cold compresses Until the body loses

excess heat.

Loosen or remove excess Exposing skin to room air

clothing and covers. decreases heat and

increases evaporative

cooling.

Encourage adequate fluid provide cool liquids to

intake. help lower the body

temperature.

Teaching and Instructions given to patient during hospitalization related

to his disease about diet, exercises, life style, managing stress,
medications, comfort and rest…etc

(If needed)
- Provide information in written and verbal form.
- Identify signs and symptoms requiring notification of health care provider:
increasing dyspnea, chest pain, prolonged fatigue, weight loss, fever, chills,
persistence of productive cough, changes in mentation.
- Emphasize necessity for continuing antibiotic therapy for prescribed period.
- Discuss debilitating aspects of disease, length of convalescence, and
recovery expectations. Identify self-care and homemaker needs
- Instruct patient to avoid using antibiotics indiscriminately during minor viral
infections.

Summary : A 67-year-old patient came, a female, who was suffering from fever
and heave chest and dyspnea and chest pain ,enter Kafr-Aqab clinic and transform to
hospital antipyretic given as order from the doctor then lab test and chest x ray done
to detect that the PT was suffering from severe chest infection then all nursing
intervention and the PT feel better and more comfortable

: References

1)Morton G. Patricia and Fontaine K. Dorrie. Essentials of Critical Care Nursing: a

Holistic Approach. Philadelphia: Lippincott Williams & Wilkins, 2013.Medical surgical
book.

2)Smeltzer C. Suzanne, Bare G. Brenda, Hinkle L. Janice and Cheever H. Kerry.

Brunner & Suddarth's Textbook of Medical-Surgical Nursing. 12th ed. Philadelphia:
Lippincott Williams Wilkins, 2009.

https://www.nhsinform.scot/illnesses-and-conditions/infections-and-poisoning/
..%chest-infection#:~:text=A%20chest%20infection%20is%20an,infected%20person
.

Good Luck