Case Study - Bronchopneumonia

TRACE COLLEGETraceville Subdivision, El Danda Street, Los Baños, Laguna

COLLEGE OF NURSINGBachelor of Science in Nursing

In partial fulfillment of the course requirement in

Nursing Care Management 101 with RLE

NURSING CASE STUDYBronchopneumonia

Submitted by:

Date Submitted:

This is a property of College of Nursing – TRACE College. No part of this manuscript may be reproduced or transmitted in any form or by any means. Please obtain permission from the College of Nursing – TRACE College.

COLLEGE OF NURSINGBachelor of Science in Nursing

NURSING CASE STUDYBronchopneumonia

After having presented, the Nursing Case Study is hereby approved by the following

Clinical Instructor

Date Submitted:


CHAPTER 1

INTRODUCTION

Last August 18, 2008, a group of students with eleven members were assigned to Mrs. Aura Venus B. Ramos at Los Baños Doctor’s Hospital and Medical Center to complete their affiliation and to gain lots of new knowledge, and develop their skills and passion on the field of nursing.

Each members of the group were required to submit an individual nursing case study. We have our orientation on the first day of duty and were told that being assigned on the main ward we must expect that each of us will have at least 2 patients everyday.

What interests me to take Mr. RR’s case to be studied is that I handled him almost for the whole week of my duty. I think, I already established a good nurse-patient relationship with this patient and because of that it’ll be easier for me to ask information needed for my case study.

Another thing is that he’s always alone in his room. Nobody among the members of his family is there to take care of him and assist him while staying at the hospital. Through taking him as my case study, I can have the reason to stay longer with him and take care of him.

And lastly, it is my first time to handle a patient with bronchopneumonia. This is my chance to gain new information related to geriatric nursing. I’m aiming to be a geriatric nurse, hoping to be suitable and deserving to be a nurse with the specialty of taking care of elderly, and I’m thankful that almost all my patient, even before, we’re old aged.

Bronchopneumonia is a classification of Pneumonia according to its distribution of inflammation. Pneumonia is the leading cause of morbidity in the Philippines as of year 2004 and the 5th leading cause of mortality in the Philippines as of year 2004 among male and female, and among all ages.


CHAPTER 2

OBJECTIVES

General Objectives:

My general objective is to understand what Bronchopneumonia is.

Specific Objectives:

Specifically:1.) To know what causes to have Bronchopneumonia.2.) To know the anatomy and physiology of the body organ involved in

Bronchopneumonia.3.) To understand the pathophysiology of Bronchopneumonia.4.) To relate my patient chief complaint on his condition having

Bronchopneumonia.5.) To improve myself on formulating Nursing Care Plans.6.) To relate the medications and medical procedures done to Mr. RR on his

condition of having Bronchopneumonia.


CHAPTER 3

HEALTH HISTORY

i. PATIENT’S DATA

Patient's Name: “Mr. RR” Hospital Case No.: 0441208Address: Timugan, Los Baños, LagunaBirth Date: 09/04/1954 Placeof Birth: San Pablo City, Laguna, PhAge: 54Y0M Insurance: MedoCareSex: Male Date & Time Admitted: 09/21/08 06:58pmOrdinal Rank (if pedia patient): n/a Ward/Room No./Bed No.: Rm # *03Nationality: Filipino Inclusive Date of Confinement: ---Civil Status: Married Discaharge Date&Time: ---Religion: Catholic Attending Physician: Dr. M, MDOccupation: Pay Collector Educational Background: 3rd Yr Highschool

Payment Source for Discharges: Self/Family: Employer/Union (give name): Public Agency (give name): Others (pls. specify): Private Insurance (pls. specify name of insurance company): MedoCare

Name of Spouse (if married): Mrs. NR Age: 50Occupation: Teacher Educational Attainment: College Graduate

Admitted per: Ambulatory: Stretcher: Wheelchair:

Level of Consciousness upon Admission:

Alert:

*Oriented: Responds to Verbal: Unresponsive:

Drowsy: Disoriented: Responds to Pain: Confused:

Lethargic: Asleep: Easily Aroused:

Chief Complaint/s:Fever with chills

Impression/ Admitting Diagnosis:T/C Bronchopneumonia

Final Diagnosis:Community-acquired Pneumonia


ii. PAST HEALTH HISTORY

Mr. RR verbalized that it’s been a long time since he was confined in the hospital, and he can’ remember it. He is conscious about his health. He has no allergy to any foods or other stuffs. He never smoked. He occasionally drinks alcoholic beverages but not to the point that he’ll get drunk. He never had undergone any surgery.

iii. PRESENT HEALTH HISTORY

Two days prior to admission, he developed productive cough of whitish sputum followed by low grade fever. He took Carbocisteine (Solmux) and Paracetamol (Biogesic), but because symptoms persist, he consulted his doctor and was abruptly admitted.

iv. ADMISSION HISTORY

The patient was admitted last September 21, 2008 around 6:58 pm with the chief complaint of fever with chills. He was admitted under the service of Dr. M, MD with the admitting impression of “To Consider Bronchopneumonia”. Consent for admission was secured. The doctor ordered administration of Intravenous Fluid D5LRS 1 L x 10o and to follow with D5NM 1 L x 10o. The doctor also ordered to monitor his Vital Signs every 4o and record it. His diet was Diet as Tolerated (DAT). The doctor also ordered for the Laboratory Results of CBC, Urinalysis, Na, K, CXR-PA, RBS, BUN, and Crea with administration of the following drugs: Paracetamol 500mg/tab 1 tab every 4o PRN for To > 37.8 oC, Sinecod Forte 1 tab TID, Nebulize with Venolin 1 neb TID, Levofloxacin 500mg/tab 1 tab OD am.

v. GENOGRAM

On the genogram of Mr. RR, you’ll noticed that most members of the family have hypertension and died because of cardiac arrest. Mr. RR’s mother is the only one among the members of the family with weak lungs, and the only disease associated with my pt’s diagnosis – Bronchopneumonia.




Grandfather N

Grandmother N

?

?

?

Mother R

Grandfather R

Grandmother R

?

?

Grandfather R

?

PR, BR, SR,

RR, 54 (Wife) NR, 48

DR, 12

MR, 18

NR, 14

Legends: ? - unknown

- cardiac disease

- deceased

- weak lungs - female - male

CHAPTER 4

PHYSICAL ASSESSMENT

I General Survey

Patient’s mobility was limited, with slow onset and speaks slowly. She is conscious but looks drowsy and very weak on the first two days of my care. Dress appropriately on the condition of her room (specifically the room temperature): wearing sleeveless blouse and doesn’t have any unnecessary/unpleasant odor. On the next two days of my care, the patient shows alertness on answering. But I noticed that he’s always lonely and he verbalized boredom.

Vital Signs results are: Temperature: 36 oC Pulse Rate: 80 bmp Respiratory Rate: 20 cpm Blood Pressure: 100/70 mmHg

II Skin, Hair and Nails

The color of his hair is black. His skin is smooth, intact and warm to touch without any rashes, bruises nor cuts. His nails are intact, cut, clean and with three seconds capillary perfusion.

III Head, Neck and Lymph Nodes

Facial expressions show grimace. Neck and lymph nodes palpation is not done.

IV Nose and Sinuses

No secretions in the nose noted but the patient verbalized

V Mouth and Throat

Lips look pale in color. Patient verbalized itchiness on throat and difficulty on clearing his throat. The patient uses dentures. Teeth are clean with whitish color.

VI Eyes

Assessment not done.

VII Ears



VIII Respiratory System

Upon auscultation, I heard a breathe sound that sounds like scratching a stainless steel. It is near on the sound of the breath sound “crackles”. Percussion was not done. Use of accessory muscles while coughing was noted. The patient verbalized that he sometimes feels difficulty on breathing.

IX Cardiovascular System

He is not hypertensive with BP of 100/70 mmHg during our shift. The patient doesn’t feel any chest pain during my shift. Upon auscultation, Heart Rate was

X Breasts


XI Gastro-Intestinal System

Patient shows loss of appetite. He eats small amount of food. He defecated twice during my whole week of care.

XII Urinary System

Patient’s urinated twice. Amount of urine depends on the amount of fluid intake.

XIII Reproductive System


XIV Nervous System


XV Musculoskeletal System

Patient is but shows weakness on doing activities like walking and changing positions.

XVI Immune and Hematologic System

XVII Endocrine System



GORDON’S FUNCTIONAL HEALTH PATTERN

A. HEALTH PERCEPTION – HEALTH MANAGEMENT PATTERN

Whenever he is sick he buy OTC drugs, then if symptoms persists, that’s the time he’ll go to his doctor and have check-up.

B. NUTRITIONAL – METABOLIC PATTERN

He eats whatever he wants to eat. He loves to eat fatty foods. He verbalized that he’s not eating street foods.

C. ELIMINATION PATTERN

In the span of my whole week of care, the patient defecated twice and urinated twice everyday. The amount of urine depends on the amount of his fluid intake.

D. ACTIVITY – EXERCISE PATTERN

Before admitted in the hospital, he works as a pay collector and his work is associated with traveling that’s why he is at risk to develop bronchopneumonia because of the pollution he encountered every time he travels. He verbalized that he do not exercise.

E. SLEEP – REST PATTERN

Before admitted, he sleeps early. He verbalized that after watching news, around 7pm and awakes early around 4am.

F. COGNITIVE – PERCEPTUAL PATTERN

The patient is conscious but shows loneliness and boredom. Coherent and answers my questions directly.

G. SELF– PERCEPTION PATTERN/SELF – CONCEPT PATTERN

The patient is conscious but shows loneliness and boredom.

H. ROLE – RELATIONSHIP PATTERN

He verbalized that all the members of the family were close with each other. And he’s happy with how his relationship with his family goes.

I. SEXUALLY – REPRODUCTIVE PATTERN

Not asked.


J. COPING STRESS TOLERANCE PATTERN

Whenever he’s bored or sad, he takes rest and sleeps. He is not that fond of watching TV.

K. VALUES/BELIEF PATTERN

Their whole family religion is Catholic. They do not believe in hilot and faith healers.


CHAPTER 5

DEFINITION OF COMPLETE MEDICAL DIAGNOSIS

Bronchopneumonia is a type of pneumonia that is characterized by an inflammation of the lung generally associated with, and following a bout with bronchitis. This is really a specific type of pneumonia that is localized in the bronchioles and surrounding alveoli. This article provides a general overview of this condition, including symptoms and treatment options for those who have been diagnosed with bronchopneumonia. The most common pneumonia-causing bacterium in adults is Streptococcus pneumoniae (pneumococcus)

Symptoms of bronchopneumonia:Cough with greenish or yellow mucus; Fever; chest pain; Rapid, shallow breathing;

Shortness of breath; Headache; Loss of appetite; fatigue

Treatment of bronchopneumonia:If the cause is bacterial, the goal is to cure the infection with antibiotics. If the cause is

viral, antibiotics will NOT be effective. In some cases it is difficult to distinguish between viral and bacterial pneumonia, so antibiotics may be prescribed. Pneumococcal vaccinations are recommended for individuals in high-risk groups and provide up to 80 percent effectiveness in staving off pneumococcal pneumonia. Influenza vaccinations are also frequently of use in decreasing one’s susceptibility to pneumonia, since the flu precedes pneumonia development in many cases.

Unlike lobar pneumonia, in which an entire section or subdivision of the lung may be inflamed; bronchopneumonia tends to appear in patches in and around the small airways and passages. Outward clinical symptoms will be similar to those of lobar pneumonia, however, and can include fever, coughing, chest pain, chest congestion, chills, difficulty with breathing and blood-streaked mucus that is coughed up. Bronchopneumonia is more common in elderly people, and in association with other viral respiratory illnesses (bronchitis), and as a complication of those who have asthma. Pneumonia, including bronchopneumonia is a fairly common illness and it affects millions of people annually in the United States. The severity of the illness will depend on the type of bacteria or infection causing the illness, as well as the overall health of the person who has bronchopneumonia.

In order to diagnosis this illness, a doctor may take a chest X-ray, may test a sample of the sputum, may do a CBC to get a count of the white blood cells in the blood, may take a CAT scan, and/or may take a pleural fluid culture of the fluid surrounding the lungs.

Upon diagnosis, most people will be treated at home with antibiotics. If the patient is suffering from dehydration or has a severe case of bronchopneumonia, he or she may be treated in the hospital where the illness can be more closely monitored. With appropriate treatment, most people recover fully within a couple weeks. Very infirm or elderly people who do not get appropriate treatment can die from bronchopneumonia.



CHAPTER 6

ANATOMY AND PHYSIOLOGY

Lungs: The Bronchioles

The Lungs are the principal organs of respiration. Each lung is cone-shaped, with its base resting on the diaphragm and its apex extending superiorly to a point about 2.5 cm above the clavicle. The right lung has three lobes called the superior, middle and inferior lobes. The left lung has two lobes called the superior and inferior lobes. The lobes of the lungs are separated by deep, prominent fissures on the surface of the lung. Each lobe is divided into bronchopulmonary segments separated from one another by connective tissue septa, but these separations are not visible as surface fissures. There are nine bronchopulmonary segments in the left lung and ten in the right lung.

The main bronchi branch many times to form the tracheobronchial tree. Each main bronchus divides into lobar bronchi as they enter their respective lungs. The lobar (secondary) bronchi, two in he left lung and three in the right lung, conduct air to each lobe. The lobar bronchi in turn give rise to segmental (tertiary) bronchi, which extend to the bronchopulmonary segments of the lungs. The bronchi continue to branch many times, finally giving rise to bronchioles. The bronchioles also subdivide numerous times to give rise to terminal bronchioles, which then subdivide into respiratory bronchioles. Each respiratory bronchiole subdivides to form alveolar ducts, which are like long, branching hallways with many open doorways. The doorways open into alveoli, which are small air sacs. The alveoli


become so numerous that the alveolar duct wall is little more than a succession of alveoli. The alveolar ducts end as two or three alveolar sacs, which are chambers connected to two or more alveoli. There are about three million alveoli in the lungs.

The bronchioles are very small airways that extend from the bronchi to the alveoli. The bronchioles are made up of smooth muscle cells and are smaller than 1 millimeter in diameter. The bronchioles do not have glands or cartilage. The epithelial cells of the bronchioles are cuboidal in shape.


CHAPTER 7

PATHOPHYSIOLOGY

Pneumonia:

Bronchopneumonia


Predisposing FactorsAgeWork/JobHistory of weak lungsWithout history of pneumococcal

vaccinationWithout history of influenza

vaccine in previous yearsHistory of being exposed to viral

or influenza infectionLifestyle

Precipitating FactorsAirborne Pathogenic

Inhalation of infectious organism

Infectious organism penetrate airway mucosa

Multiplication of infectious organism in the alveolar spaces

Inflammatory response of the lungs

WBC migrate to the area of infection

Local capillary leak, edema and exudates


Fluids collect in and around alveoli

Alveolar walls thicken

RBC and fibrin also move into alveoli

Manifests ↓ gas exchange

Capillary leak spread of infection into the other areas of the lungs

Fibrin and edema of inflammation stiffen the lungs

Alveolar collapsed

Manifests ↓ vital capacity

Exudates digested by enzymes

Manifests ↓ ability of lungs to oxygenate the blood moving through it

Action provides excellent culture media to ↑ spread of organism

IF NOT TREATEDIF TREATED

Clinical Manifestation Fever and chills Plueric Chest Pain Shortness of breath Crackles and wheezes Cough Sputum production Rapid, shallow respirations


Diagnostic Exams: Chest X-ray Blood/Serologic ExamTreatment: Antimicrobial therapy Bronchodilators Deep Breathing and

Coughing Exercise Increase Fluid Intake Absolute bedrest

COMPLICATIONS: Hypoxemia Ventilatory Failure Atelectasis Pleural Effusion Pleurisy Continued infection

despite of use of antimicrobial therapy

GOOD PROGNOSIS

POOR PROGNOSIS

Abscess formation

Necrosis of pulmonary tissues

Overwhelming sepsis

Death

Resolution

CHAPTER 8

LABORATORY AND DIAGNOSTIC EXAMINATIONS

DATE ORDERED

DIAGNOSTIC EXAMINATIONS WITH

DEFINITIONSNORMAL FINDINGS

ACTUAL RESULTS

CLINICAL SIGNIFICANCE(RATIONALE)

NURSING CONSIDERATIONS

BEFORE AND AFTER THE PROCEDURES

*08/20/08 HEMATOLOGY/CBC – the most commonly performed blood test which is a basic evaluation of the cellular components of blood.

Hemoglobin 13 – 18 gms *12.8 Within normal range

1. Instruct family about the requirements or instructions

2. Inform the mother/family about the time period before the results will be available.

3. Document teachings. Include the client’s responses.

Hematocrit 40 - 54 vol % *40 %

Within normal range

RBC Count 4.5 – 5.5 M/ml *4.1 M/ml Anemia

WBC Count 5,000-10,000

cumm*8,400/μl Within normal range

Differential WBC Count

Segmented Neutrophils:

55 - 65%*85%

Lymphocytes: 25 - 35%

*15% Monocytes:

3 - 7% *0% - - -

Eosinophils: 0 - 5%

*0% - - -

Basophils:0 - 3% *0% - - -


12/12/2007 Urinalysis – the chemical analysis of urine sample

Appearance: Clear Slightly turbid

UrinalysisTo measure and detect the level of a variety of substances in the urine.

Obtaining a clean catch urine sample:

The head of the man’s penis or opening of a woman’s urethra is cleansed, usually with a small pad that contains an antiseptic substance.

A few drops of urine are allowed to flow into the toilet washing out the urethra.

Urination is resumed and a sample is collected from the stream into a sterile cup.

Always wash your hands before and after holding your patient.

Color: straw/amber Yellow

Odor : aromatic Not specified

Transparency: Slightly hazySpecific Gravity :

1.005 - 1.030 1.015Glucose :

negative NegativeCasts :

noneAlbumin-traced;

WBC : 0 - 4 2 – 4/cast

RBC : 2

1 - 3

12/12/2007 BLOOD CHEMISTRY – measure the Sodium : BLOOD CHEMISTRY1. Instruct patient and

family about the


substances in the blood 135 – 145 mmol/l

143 mmol/l To evaluate organ function and to help diagnose and monitor various disorders.

requirements or instructions.

2. Provide information about what the client may feel.

3. Encourage questions about dialogue about fear and apprehension.

4. Inform the client about the time period before the results will be available.

5. Document teachings. Include the client’s responses.

Potassium : 3.5 – 5 mmol/l

3.7 mmol/l

RBC : 4.2 – 5.9 M/ml 97 M/ml


CHAPTER 9

MEDICAL MANAGEMENT

DOCTOR’S ORDER

Sept. 21, 2008 Pls. admit to ROC under service of Dr. M. Secure consent for admission Monitor VS q 4o & record Diet: DAT (Diet as Tolerated) IVF D5LRS 1L x 10 o

D5NM 1L x 10 o

Dx: CBC, Urinalysis, Na, K CXR-PA, RBS, BUN, Crea Therapeutics: Paracetamol 500mg/tab 1tab q4o PRN for T o =37.8 Sinecod Forte 1 tab TID Nebulize with Ventolin 1 neb TID Levofloxacin 500mg/tab, 1tab OD Inform AP of this admission Relay lab results to AP once available Refer accordingly Dr. M.

Sept. 22, 20088:30am

IVF to IVF: D5NM 1L x 10 o (2 cyasets) Dr. M.

Sept. 22, 20084:30pm

Klaricin 500mg OD For Tubex Test IVF TF: D5NM 1L x 10 o (2 cyasets) Dr. M.

Sept. 22, 200810:15 pm

Lasix 1 amp IV now Shift Flox to IV 500mg q12 ANST ↓ rate of IV to KVO Measure I&O q shift Refer to Dr. Romeo

Dr. M.Sept. 23, 200810:35am

Refer temp referral to Dr. Romeo Dr. M.

Sept. 24, 2008


4:20am Start Lasix 40mg 1 tab OD – 8am Dr. M.

MEDICAL PROCEDURES

INTRAVENOUS THERAPY

Intravenous therapy or IV therapy is the giving of liquid substances directly into a vein. It can be intermittent or continuous; continuous administration is called an intravenous drip. The word intravenous simply means "within a vein", but is most commonly used to refer to IV therapy. Therapies administered intravenously are often called specialty pharmaceuticals.

Compared with other routes of administration, the intravenous route is the fastest way to deliver fluids and medications throughout the body. Some medications, as well as blood transfusions and lethal injections, can only be given intravenously.

NEBULIZATION

It is the process of using a nebulizer that changes liquid medicine into fine droplets (in aerosol or mist form) that are inhaled through a mouthpiece or mask Nebulizers is used to deliver bronchodilator (airway-opening) medicines such as albuterol or ipratropium bromide. Nebulizers are hand-held machines with an airflow meter that measures oxygen flow. These machines administer a variety of medications. Nebulizers vaporize this mixture and deliver it as a fine mist or steam. Nebulizers are usually used in the hospital or nursing home setting. Disposable nebulizers are often sent home with a patient and are cleaned and reused for a limited time.

TEPIDS SPONGE BATH

Tepid sponging is a time honored and well known method of reducing the elevated temperature. Tepid sponging is useful as an immediate but transient measure in bringing down the temperature and it should always be supplemented with drugs like paracetamol for a longer antipyretic effect. A tepid sponge bath relieves fever without cooling the body too fast. Eighty degrees Fahrenheit is still 20oF below body temperature and yet warm enough not to drive blood from the skin, thereby preventing the cooling from getting to the body's core. Limbs are bathed first and then the chest, abdomen, back, and buttocks. Tepid baths should be 80-93oF (26.7-34oC).


CHAPTER 10

NURSING CARE MANAGEMENT

NURSING CARE PLAN

AssessmentNursing

DiagnosisObjectives Interventions Rationale Evaluation

Date/TimeSept. 23, 2008

Problem #1:Cough

Subjective Data:“Inuubo parin ako paminsan-minsan, pero hindi na tulad nung mga nakaraang araw. “ as verbalized by the patient

Objective Data:- productive cough- body malaise- poor appetite- use of accessory muscles while breathing-with yellowish sticky mucous secretions-crackles breath

Ineffective airway clearance related to the presence of

secretions

At the end of our duty shift we must:

- be able to cough out phlegm effectively

- maintain patient’s airway patency

- Auscultate for breath sound

- Monitor Vital Signs

- Regulate IVF as desired

- Encourage patient to drink more water (should be warm)

- Teach patient to do deep breathing exercise

- To identify abnormal breath sounds

- To know the status or progress in/of the pt.

- Helps to maintain hydration and fluid status, as well as to thin viscous secretions to allow

- To liquefy secretions

- To mobilize secretions so that patient may be able to more easily expectorate mucous

Criteria for GOAL MET:

At the end of my 8o span of care:

-Patient will maintain patent airway

-Patient will be able to expectorate sputum and cough effectively


sound

-Instruct patient/family to notify nurse/physician of sputum color changes, increase work of breathing, or onset of chest pain

- Encourage patient to rest

- Position patient to High-Fowler’s Position

- Administer medicines as prescribed

secretions

- To monitor signal of worsening of condition that requires immediate medical intervention to prevent further complications

- To promote wellness

- To facilitate airway

- To helps relief cough


AssessmentNursing


Problem #2:Fever


Subjective Data:Pt. verbalized...“nilalamig ako”

Objective Data- Temp: 38.1 oC- skin warm to touch- body malaise- poor appetite- chills noted

Hyperthermia related to disease

process as evidenced by chills noted

That within my 8o span of care, the patient’s body temperature will lower from 38.1 oC to 37.5oC and will demonstrate absence of chills

- Perform tepid sponge bath

- Apply cold wet compress if necessary

- Remove some blankets and clothes which are not necessary

- If patient’s skin feels cold to touch, apply friction

- Advise to wear loose and comfortable clothes

Vaporization of water relieves heat from the surface of the skin

To help normalize body temperature

To provide air movement, to augment heat loss.

To stimulate circulation

To be more comfortable

Criteria forGOAL MET:

At the end of my 8o span of care:

- the patient’s temperature will lowers to 37.5oC

- The patient will manifest negative chilling

- The patient will verbalize comfort


- Encourage patient to increase fluid intake

- Monitor Temperature every 15 mins

- Repeat TSB if needed

- Administer antipyrentic drugs as prescribed

- Regulate IVF as desired

To prevent dehydration

To see effectiveness of said interventions

Vaporization of water relieves heat from the surface of the skin

Helps relief of

fever

Helps maintain hydration


AssessmentNursing


Problem #5:Boredom


Subjective Data:Pt. verbalized...“Naiinip nga ako e,”

Objective Data- loneliness noted- talkative when visited- frequent change in position noted when visited- seen ambulating inside room- body malaise

Deficient Diversional

Activity related to boredom as

evidenced by verbalized report

That within my 8o span of care, the patient will be able to divert his attention into something that will make him feel busy.

- Advise patient to do leisure activities such as reading books and watching TV.

- Advise family, if possible, to visit the patient or provide someone to be with him while staying at the hospital

- Frequently visit the patient

- To divert his attention so he’ll not feel boredom

- To prevent development of anxiety/ emotional depression

- To ensure to the patient that he can trust me as his nurse and he’s not alone, also to be able to attend immediately nursing care needed by the patient

Criteria forGOAL MET:

At the end of my 8o span of care, the patient will divert his attention and will lessen the feeling of boredom.


CHAPTER 11

DRUG STUDY

A. INTRAVENOUS THERAPY

IV fluidClassification/

TypeIndications

MechanismsOf Action

Adverse Reaction/Side Effects

Nursing Responsibilities

D5NM Or

Normosol-M in 5% Dextrose

Hypertonic Solution

Normosol-M and 5% Dextrose Injection

(Multiple Electrolytes and 5% Dextrose Injection Type 1, USP) is

indicated for parenteral

maintenance of routine daily fluid and electrolyte

requirements with minimal

carbohydrate calories from

dextrose. Magnesium in the

formula may help to prevent iatrogenic

magnesium deficiency in

patients receiving prolonged

parenteral therapy.

Normosol-M and

5% Dextrose Injection provides

water and electrolytes (with

dextrose as a readily available

source of carbohydrate) for maintenance of daily fluid and

electrolyte requirements, plus

minimal carbohydrate

calories.

Reactions which may occur because of the solution or the technique of administration include febrile response, infection at the site of injection, venous thrombosis or phlebitis extending from the site of injection, extravasation and hypervolemia.If an adverse reactiondoes occur, discontinue the infusion, evaluate the patient, institute appropriate therapeutic countermeasures and save the

Solutions containing sodium ions should be used with great care, if at all, in patients with congestive heart failure, severe renal insufficiency and in clinical states in which there exists edema with sodium retention.Solutions which contain potassium should be used with great care, if at all, in patients with hyperkalemia, severe renal failure and in conditions in which potassium retention is present.In patients with diminished renal function, administration of solutions containing sodium or potassium ions may result in sodium or potassium retention.Solutions containing acetate should be used with great care in patients with metabolic or respiratory alkalosis, and in those conditions in which there is an increased level or an impaired


remainder of the fluid for examination if deemed necessary.

utilization of acetate, such as severe hepatic insufficiency.Administration of this solution can cause fluid and/or solute overloading resulting in dilution of serum electrolyte concentrations, overhydration, congested states or pulmonary edema. The risk of dilutional states is inversely proportional to the electrolyte concentrations of administered parenteral solutions. The risk of solute overload causing congested states with peripheral and pulmonary edema is directly proportional to the electrolyte concentrations of such solutions.

IV fluidClassification/

TypeIndications

MechanismsOf Action

Adverse Reaction/

Side EffectsNursing Responsibilities


D5LRSOr

Lactated Ringer’s

Solution in 5%

Dextrose

Lactated Ringer’s and 5% Dextrose Injection, USP is

indicated as a source of water, electrolytes and calories or as an

alkalinizing agent.

Lactated Ringer’s and 5% Dextrose Injection, USP has value as a source

of water, electrolytes, and

calories. It is capable of inducing diuresis depending

on the clinical condition of the

patient.Lactated Ringer’s and 5% Dextrose

Injection, USP produces a metabolic

alkalinizing effect. Lactate ions are

metabolized ultimately to

carbon dioxide and water, which requires the

consumption of hydrogen cations.

Allergic reactions or anaphylactoid symptoms such as localized or

generalized urticaria and

pruritus; periorbital, facial, and/or laryngeal

edema, coughing,

sneezing, and/or difficulty with

breathing have been reported

during administration of Lactated Ringer’s and 5% Dextrose Injection, USP. The reporting frequency of

these signs and symptoms is

higher in women during

pregnancy.Reactions which

may occur because of the solution or the technique of

administration include febrile

Lactated Ringer’s and 5% Dextrose Injection, USP should be used with great care, if at all, in patients with congestive heart

failure, severe renal insufficiency, and in clinical states in which

there exists edema with sodium retention.

Lactated Ringer’s and 5% Dextrose Injection, USP should be used with great care, if at all, in patients with hyperkalemia,

severe renal failure, and in conditions in which potassium

retention is present.Lactated Ringer’s and 5%

Dextrose Injection, USP should be used with great care in patients with metabolic or respiratory alkalosis. The

administration of lactate ions should be done with great care in those conditions in which there is an increased level or an impaired utilization of these ions, such as

severe hepatic insufficiency.Lactated Ringer’s and 5%

Dextrose Injection, USP should not be administered

simultaneously with blood through the same administration set because of the likelihood of

coagulation.The intravenous administration of


response, infection at the site of injection,

venous thrombosis or

phlebitis extending from

the site of injection,

extravasation, and

hypervolemia.If an adverse reaction does

occur, discontinue the

infusion, evaluate the patient,

institute appropriate therapeutic

countermeasures, and save the

remainder of the fluid for

examination if deemed

necessary.

Lactated Ringer’s and 5% Dextrose Injection, USP can

cause fluid and/or solute overloading resulting in dilution of serum electrolyte concentrations, overhydration, congested states, or pulmonary edema. The risk of

dilutional states is inversely proportional to the electrolyte

concentrations of the injection. The risk of solute overload

causing congested states with peripheral and pulmonary edema

is directly proportional to the electrolyte concentrations of the

injection.In patients with diminished renal

function, administration of Lactated Ringer’s and 5%

Dextrose Injection, USP may result in sodium or potassium

retention.Lactated Ringer’s and 5%

Dextrose Injection, USP is not for use in the treatment of lactic

acidosis.

B. MEDICATIONS


GenericName

Brand Name

ClassificationMechanisms

Of ActionIndication

Paracetamol Biogesic Antipyretics Paracetamol has long been suspected of

having a similar mechanism of action to aspirin because of the similarity in structure. That is, it has been

assumed that paracetamol acts by

reducing production of prostaglandins, which

are involved in the pain and fever processes,

by inhibiting the cyclooxygenase (COX)

enzyme as aspirin does.

PRN 1 tab q 4o For T o >37.8

For Fever

Interactions Side Effects Adverse Reactions Nursing Considerations


Dose/Frequency

Do not start, stop, or change the dosage of any medicine before

checking with your doctor or pharmacist first. Before using this product, tell your doctor or

pharmacist if you use any of the following products: anti-seizure medications (e.g., phenytoin,

carbamazepine, phenobarbital), "blood thinners" (e.g., warfarin), isoniazid, phenothiazines (e.g.,

chlorpromazine).Acetaminophen is an ingredient in many

nonprescription products and in some combination prescription

medications.

easy bruising/bleeding, new signs of infection (e.g., fever, persistent

sore throat)

Tell your doctor immediately if any of the following symptoms of liver

damage have: persistent nausea/vomiting, yellowing

eyes/skin, dark urine, stomach/abdominal pain, extreme tiredness. A very serious allergic

reaction to this drug is rare.However, seek immediate medical

attention if you notice any symptoms of a serious allergic

reaction, including: rash, itching, swelling, severe dizziness, trouble breathing.If you notice other effects not listed above, contact your doctor

or pharmacist.


GenericName

Brand Name


Of ActionIndication

Butamirate citrate

Sinecod Cough & Cold Preparations

1 tab TIDAcute cough of any etiology


Rarely, skin rash, nausea, diarrhea or dizziness.

GenericName

Brand Name


Of ActionIndication

Albuterol Sulfate

VentolinNebule

Inhalation Solution

beta2-adrenergic bronchodilator

1 neb TIDVENTOLIN NEBULES Inhalation

Solution is indicated for the relief of bronchospasm. This drug relaxes


Dose/Frequency

Dose/Frequency

the smooth muscle in the lungs and dilates airways to improve

breathing.


- Tell your doctor of all prescription and nonprescription drugs you may use, especially of drugs used for asthma, depression or colds; and beta-blockers (e.g., atenolol, propranolol).

- Do not start or stop any medicine without doctor or pharmacist approval.

Cases of urticaria, angioedema, rash,

bronchospasm, hoarseness,

oropharyngeal edema, and arrhythmias (including atrial

fibrillation, supraventricular

tachycardia, extrasystoles) have been reported after the use of VENTOLIN NEBULES

Inhalation Solution.

Tremors, Dizziness, Nervousness, Headache, Sleeplessness, Gastrointestinal, Nausea, Dyspepsia , Ear, nose, and throat, Nasal congestion, Tachycardia, Hypertension, Bronchospasm, Cough, Bronchitis, Wheezing

- Tell your doctor if you have heart disease, high blood pressure, an overactive thyroid gland, epilepsy or diabetes.

- Tell your doctor if you ever had a bad reaction to bitolterol, ephedrine, epinephrine, metaproterenol, phenylephrine, phenylpropanolamine, pseudoephedrine, or terbutaline.

- Many nonprescription products contain these drugs (e.g., diet pills and medication for colds and asthma), so check the labels carefully.

- Do not take any of these medications without consulting your doctor (even if you never had a problem taking them before).

- Do not allow anyone else to take this medication.


GenericName

Brand Name


Of ActionIndication

Levofloxacin Floxel Quinolones Antibacterial 500mg/tab, 1 tab OD

Treatment of more than 18 years of age with mild, moderate and

severe infection caused by susceptible strains of

microorganisms in community-acquired pneumonia

InteractionsSide

EffectsAdverse Reactions Nursing Considerations

Antacids, metal cations and multivitamin

preparations containing zinc may interfere with

absorption

Diarrhea, abdominal discomfort, nausea, anorexi, vomiting, stomatitis, and heart burns; insomia,

headache and dizziness; rash, pruritis, and aczema; muscles and joints pain; bone marrow

depression, increase liver enzymes; pain, rednes at injection site; phlebitis

Patient should be adequately hydrated. History of convulsive disease should be watched out. Discontinue if CNS stimulation

occurs. Hypersensitivity.

GenericName

Brand Name


Of ActionIndication

Furosemide Lasix

Diuretics Lasix is a loop diuretic (water pill) that prevents your body from absorbing too much salt, allowing the

40mg 1 tab OD – 8am

Mild – moderate hypertension; renal failure


Dose/Frequency

Dose/Frequency

salt to instead be passed in your urine.


Glucocorticoids; laxatives;

aminoglucosides; NSAIDS; antidiabetics

Symptomatic hypertension; dehydration; hemoconcentration;

hypokalemia; hyponathermia; metabolic acidosis; increase

blood lipid levels, crea, uric acid; reduced glucose tolerance; hearing disorder; tinnitus;

pancreatitis; anaphylactic and anaphylactoid reaction;

cutaenous reaction; fever; anemia.

Do not use Lasix if you are unable to urinate. Before using this medication, tell your doctor if you have kidney disease, liver disease, gout, lupus, diabetes, or an allergy to sulfa drugs.To be sure Lasix is not causing harmful effects, your blood will need to be tested on a regular basis. Your kidney or liver function may also need to be tested. Do not miss any scheduled appointments.Lasix will make you urinate more often and you may get dehydrated easily. Follow your doctor's instructions about using potassium supplements or getting enough salt and potassium in your diet.Avoid becoming dehydrated. Follow your doctor's instructions about the type and amount of liquids you should drink while you are taking this medication.If you are being treated for high blood pressure, keep using Lasix even if you feel fine. High blood pressure often has no symptoms.


CHAPTER 12

PROGNOSIS/EVALUATION

Criteria Poor Fair Good JustificationDuration of Illness Duration of illness is fair because it

didn’t get worse.Onset of Illness Onset of illness is fair because it is

immediately attended.Precipitating Factors Precipitating factors were poor

because of his job. His job being a pay collector was prone on pollution that can make his lungs weak. Making him at risk of developing respiratory illnesses.

Willingness to take medicines He is willing to take his medications and doesn’t have any difficulty on swallowing tablets and capsules.

Compliance to treatment regimen

Compliance to treatment was good because he is willing to do whatever his doctor told him so.

Age Age as criteria is fair because he is not too old and not too young to develop such illness.

Environment Environment as criteria is poor because he is exposed on pollutions especially hen traveling.

Family Support Family Support as criteria is fair even no one among the family can take care of him while in the hospital. Because his wife is a teacher, she is very busy on his work but still take some time to be with him after her


work. His children were still studying and were busy.

*** - Mark of choice

Prognosis of the patient is fair. He can overcome this disease if he knows how to prevent being exposed on its predisposing factors and prevent being sick, especially acquiring cough and colds. Family Support is also a big help for his recovery.

CHAPTER 13

DISCHARGE PLAN

MEDICATION Mosegor Vita 1 cap once a day for seven days – indicated to underweight due to lack of appetite associated with Vitamin B

deficiency secondary to impaired dietary intake or absorption. Adverse reactions are sedation, rarely dizziness, dry mouth, constipation and nervousness.

Ansimar 400mg ½ tab twice a day for seven days – indicated for respiratory disease

EXERCISE Be sure to get enough rest and sleep on a daily basis. Practice deep breathing and coughing exercise to easily excrete phlegm

TREATMENT Have annual influenza vaccine after discussing appropriate timing of the vaccination as recommended Discuss the pneumococcal vaccine with your primary health care provider, and have the vaccination as recommended If you do not smoke, don’t start. Avoid stress, fatigue, sudden changes in temperature and excessive alcohol intake, all of this lowers resistance to

pneumonia.

HYGIENE Take bath daily.


Wear masks especially when traveling for the first week after being discharged. Promote frequent oral hygiene.

OUTPATIENT ORDERS/FOLLOW UPS Follow up check up will be on Oct. 4, 2008, 1-6pm

DIET Drink plenty of water (at least 8 glasses every day), especially during warm weather. Eat a healthy, balanced diet and take in a sufficient amount of non-alcoholic fluids each day.

BIBLIOGRAPHY

Beers, M. H., et al. The Merck Manual of Medical Information (2nd Home Ed.). NY, USA. Merck & Co., Inc. 2003

Cleveland Clinic Health System. (November 23, 2005). Home Nebulizer Therapy. Cleveland Clinic Health. http://www.cchs.net/health/health-info/docs/0300/0352.asp?index=4297.

Comer, S. R. Delmar’s Critical Care: Nursing Care Plans (2nd edition). Singapore. Thomson Learning Asia Pte. Ltd. 2005

CWAnswer. Bronchopneumonia. CWAnswer. http://www.cwanswers.com/8921/bronchopneumonia


Department of Health. Health Indicators: Morbidity. (2006). Department of Health. http://www.doh.gov.ph/kp/statistics/morbidity

Department of Health. Health Indicators: Mortality. (2006). Department of Health. http://www.doh.gov.ph/kp/statistics/mortality

Department of Health. Pneumonia. (2006). Department of Health. http://www.doh.gov.ph/faqs/pneumonia

Doenges, M.E., et al. Nurses’ Pocket Guide (ed. 10). Philadelphia, Pennsylvania. F.A. Davis Co. 2006

Gupta, L.C.. Illustrated Nurses’ Dictionary (2nd Ed.). India. AITBS Publishers and Distributors. 2005.

RxList:The Internet Drug Index. (2008). RxList Inc. http://www.rxlist.com/script/main/hp.asp.

Seeley, R.R., et al. Essentials of Anatomy and Physiology (5th ed., international ed.). NY, USA. The McGraw-Hill Co.,Inc. 2005

Wikipedia. (22 May 2008,). Intravenous Therapy. http://en.wikipedia.org/wiki/Intravenous_therapy


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Case Study - Bronchopneumonia