I. INTRODUCTION

Acute bronchitis is an inflammation of the large bronchi (medium-

sized airways) in the lungs that is usually caused by viruses or bacteria and

may last several days or weeks. Characteristic symptoms include cough,

sputum (phlegm) production, and shortness of breath and wheezing related

to the obstruction of the inflamed airways. Diagnosis is by clinical

examination and sometimes microbiological examination of the phlegm.

Treatment for acute bronchitis is typically symptomatic. As viruses cause

most cases of acute bronchitis, antibiotics should not be used unless

microscopic examination of Gram stained sputum reveals large numbers of

bacteria.

Acute bronchitis can be caused by contagious pathogens. In about half

of instances of acute bronchitis a bacterial or viral pathogen is identified.

Typical viruses include respiratory syncytial virus, rhinovirus, influenza, and

others.

Bronchitis may be indicated by an expectorating cough, shortness of

breath (dyspnea) and wheezing. Occasionally chest pains, fever, and fatigue

or malaise may also occur. Additionally, Bronchitis caused by Adenoviridae

may cause systemic and gastrointestinal symptoms as well. However the

coughs due to bronchitis can continue for up to three weeks or more even

after all other symptoms have subsided.

Acute bronchitis usually lasts a few days. It may accompany or

closely follow a cold or the flu, or may occur on its own. Bronchitis usually

begins with a dry cough, including waking the sufferer at night. After a few

days it progresses to a wetter or productive cough, which may be

accompanied by fever, fatigue, and headache. The fever, fatigue, and

malaise may last only a few days; but the wet cough may last up to several

weeks. Should the cough last longer than a month, some doctors may issue

a referral to an otorhinolaryngologist (ear, nose and throat doctor) to see if

1

a condition other than bronchitis is causing the irritation. It is possible that

having irritated bronchial tubes for as long as a few months may inspire

asthmatic conditions in some patients.

In addition, if one starts coughing mucus tinged with blood, one should see

a doctor. In rare cases, doctors may conduct tests to see if the cause is a

serious condition such as tuberculosis or lung cancer. Acute bronchitis may

lead to pneumonia.

Inncidence rate of Acute Bronchitis is 4.6 per 100; 14.2 million cases

annually, approximately 1 in 21 individual or 4.60% or 12.5 million people

in USA Incidence extrapolations for USA for Acute Bronchitis: 12,511,999

per year, 1,042,666 per month, 240,615 per week, 34,279 per day, 1,428

per hour, 23 per minute, 0 per second. Note: this extrapolation calculation

uses the incidence statistic: 4.6 per 100 (NHIS96: acute bronchitis); 14.2

million cases annually

Deaths from Acute Bronchitis 388 deaths reported in USA 1999 for

acute bronchitis and bronchiolitis (NVSR Sep 2001) Death rate

extrapolations for USA for Acute Bronchitis: 387 per year, 32 per month, 7

per week, 1 per day, 0 per hour, 0 per minute, 0 per second. Note: this

extrapolation calculation uses the deaths statistic: 388 deaths reported in

USA 1999 for acute bronchitis and bronchiolitis (NVSR Sep 2001)

A. Current trends about the disaese condition

“Advance Toward Early Diagnosis Of Chronic Obstructive Pulmonary

Disease”

Researchers in Finland are reporting identification of the first

potential "biomarker" that could be used in development of a sputum test

for early detection of chronic obstructive pulmonary disease (COPD). That

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condition, which causes severe difficulty in breathing — most often in

cigarette smokers — affects 12 million people in the United States.

Vuokko L. Kinnula and colleagues point out that no disease marker for

COPD currently exists, despite extensive efforts by scientists to find one.

Past research pointed to a prime candidate — surfactant protein A (SP-A),

which has a major role in fighting infections and inflammation in the lung.

The scientists compared levels of a variety of proteins obtained from the

lung tissues of healthy individuals, patients with COPD, and those with

pulmonary fibrosis. They found that the lungs of COPD patients contained

elevated levels of SP-A. The scientists also found elevated levels of SP-A in

the sputum samples of COPD patients. "This suggests that SP-A might

represent a helpful biomarker in the early detection of COPD and other

related disorders," the article notes.

American Chemical Society (2008, December 17). Advance Toward Early

Diagnosis Of Chronic Obstructive Pulmonary Disease. ScienceDaily.

Retrieved June 27, 2009, from http://www.sciencedaily.com

/releases/2008/12/081208085002.htm

B. Reasons for choosing such case for presentation

I choose this case as we all know that acute bronchitis is a recurrent and

reversible disease once develop, but it can easily prevented by avoiding

their contributing factor, such as allergens, dust, pollens, prolonged

exposure to tobacco smokes and air pollutants. It can be prevented by

means of cessation of cigarette smoking and by prevention of air pollutants,

therefore this disease is disabling if not properly prevented or avoided.

C. Objectives

NURSE CENTERED

Short term

3

After 4-5 hours of nursing interventions, the student nurse shall be

able to:

Establish rapport with the patient

Identify the needs of the patient

Assess the general condition of the patient

Implement interventions that could help in maintaining the health of

the patient in a good condition

Explain to the patient the rationale for each interventions

Long term

After 2 days of nursing interventions, the student nurse shall be able

to:

Gain the trust and cooperation of the patient

Know the general condition of the patient

Identify the precipitating and predisposing factors that causes the

patient’s condition

Give health teachings about the condition of the patient

Help the patient recover from her condition

CLIENT CENTERED

Short term

After 4-5 hours of nursing interventions, patient shall be able to:

Establish rapport with the student nurse

Listen and cooperate with the student nurse

Verbalize feelings

Ask questions regarding her condition

Participate on the activities or health teachings given by the student

nurse

Able to understand the reason for such interventions

4

Long term

After 2 days of nursing interventions, the patient shall be able to:

Trust and have a good rapport with the student nurse

Verbalize her present condition/feelings

State the interventions given by the student nurse for the betterment

of her condition

Follows the activities or health teachings given by the student nurse

Able to have an improve condition/ gain her state of wellness

II. NURSING ASSESSMENT

1. Personal Data

Patient is a six-year old female, Filipino citizen and a Roman Catholic.

She was born on the 3rd of April, 2003 via Normal Spontaneous Delivery in

a private hospital in Manila. She is the only child in her family. Currently,

the Patient Family are residing in Porac, Pampanga.

Last June 23, 2009, at 11:30 in the morning, Patient’s mother rushed

Patient to a private hospital in Angeles City with chief complaints of cough

and fever. Upon admission, Patient was diagnosed of Acute Bronchitis.

2. Pertinent Family History

Patient belongs to an extended type of family which is composed of

four members. She lives with her parents and her grandparents.

Patient’s father is a highschool undergraduate who is currently

working as a factory worker, whereas Patient’s mother is a college graduate

who is currently working in CDC.

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Patient’s Grandfather died due to Pulmonary Tubercolosis who lived

with the patient.

The Patient family owns their own house and they have been living in

their home since 2002. Their house is located along the highway. The

current residence has a living room, dining room, kitchen, two bedrooms

and two toilets. Patient’s mother also verbalized that the house is always

clean; however, trucks drive along the highway so dust always circulate

around their home. The family uses a gas stove as their means of cooking

and their water is obtained from NAWASA. Patient’s grandmother also goes

to the market to buy their food and cooks their own dishes.

The family’s source of income comes from both parents. Patient’s

Daddy earns approximately P15, 000 per month while Patient’s mother

earns approximately P20, 000. The family’s monthly expenses would

include: P 10,000 per month for their food, P 600 for their telephone bill

and P2,000 per month for their electricity. And the rest are mostly saved for

their other expenses.

In terms of family's culture, beliefs and perceptions, the family

consults their private physicians, such as when it is time for her child to be

immunized as well as for early prevention of a disease condition.

6

Paternal Side Maternal Side

GRANDFATHER ( +

)GRANDMOTHER Arthritis

GRANDFATHER DM Hypertension Asthma

GRANDMOTHER Asthmatic

AUNT 1 ( + ) leukemia

AUNT 2

Uncle 1

Uncle 2

Uncle 3

Uncle 4

AUNT 3

AUNT 4

AUNT 5

(+)asthm

a,

AUNT 6

FATHER

MOTHER

Uncle 1

AUNT 1 Uncle 2

Uncle 2

PATIENTACUTE

BRONCHITIS

7

3. Personal History

As verbalized by Patient’s mother, she had her pre-natal visits in her

pregnancy. She believes in “paglilihi” so she tends to eat nutritious food

when she was pregnant.

As stated by Patient’s mother, Patient was fully breastfed because she

believes that the milk coming from the mother is best for babies as well as

for economical reasons. Patient was breastfed until she was 1 ½ years old.

She also mentioned that Patient is fond of eating chicken, French fries, and

vegetables. Patient only eats small amounts of food and patient’s mother

always have difficutly feeding Patient. Patient is not taking any vitamins.

Patient’s mother stated that Patient had completed his Immunization

in their local health center. These vaccines included: BCG (Bacillus

Calmette Guerin), DPT (Diphtheria, Tetanus, Pertussis), OPV (Oral Polio

Vaccine), Hepatitis B and Measles.

Growth and Development

Erik Erikson

Patient, being 6 years of age, is in the Initiative vs. Guilt stage of

Erikson’s psychosocial conflict wherein she learns to take initiative of the

actions she wants to perform and learns to master the world around her. At

this stage the child wants to begin and complete his or her own actions for a

purpose. Guilt is a new emotion and is confusing to the child; he or she may

feel guilty over things which are not logically guilt producing, and he or she

will feel guilt when his or her initiative does not produce the desired results.

This stage is shown by her eagerness to study and to go to school as said by

her mother.

Jean Piaget

8

Patient is in the Preoperational or Egocentric stage of Piaget’s Theory

of cognitive development wherein the child does not show any particular

interest or concern with rules. It is also when children start employing

mental activities to solve problems and obtain goals but they are unaware of

how they came to their conclusions. Upon playing, mother stated that

patient shows that she is more focused on having fun rather than the rules

of the game. She also is not aware of what others think and focuses only

about having fun.

Sigmund Freud

Based on the patient’s age, she falls under the Phallic stage of Freud’s

Psychosexual stages wherein genitals are supposed to be the primary

source of pleasure for the child. Upon observation, there were no

manifestations of this stage noted from patient’s behaviour.

4. History of Past Illnesses

Patient was hospitalized before in the same health institution with a

diagnosis of Primary Complex. When she was four years old, she was

hospitalized in a private hospital in Manila due to Patient’s eye problem.

Patient also experienced fever, cough and colds and her mother treats her

with Paracetamol. Patient is also asthmatic since birth but was managed.

5. History of Present Illness

A five days prior to admission (June 18, 2009), Patient had cough and

colds and fever and Patient’s mother managed this by giving Paracetamol.

Four days prior to admission (June 20, 2009) same signs and symptoms

were noted and consulted their private physician and Patient was diagnosed

with Upper Respiratory Tract infection and was given Mucosolvan and

Allerkid. Condition persisted and admitted last June 23, 2009 with an

admitting diagnosis of Acute Bronchitis.

9

6. Physical Assessment

Initial Assessmant upon Admission (June 23 , 2009) – lifted from the

client’s chart

Vital Signs

T: 36.1o C

P: 75 bpm

R: 38 bpm

Chief complaint/s: Cough and colds

General Appearance

(+) difficulty of breathing with used of accessory muscles

with nasal flaring and positive rales and wheezes on both

lungs fields

With cough and colds

Acyanotic

(-) Retractions

(-) edema

(-) rashes

Pink Palpebral conjunctiva

1st NPI ( June 24 , 2009)

General Appearance

 During the assessment, patient was wearing shirt and a pajama. she

has productive cough with clear nasal secretions. she also has

difficulty of breathing with Rales on both lung fields and nasal

flaring.

 

Vital Signs

Temperature: 36.9 ˚C

10

Pulse Rate: 95 bpm

Respiratory rate: 26 bpm

BP: 90/60 mmHg

Cephalocaudal Assessment

Head

Round, symmetrical & normocephalic

No lesions, nodules or masses

Hair is thin and well distributed; no infestations noted

Symmetric facial features noted

Eyes

Eyebrows are symmetrical, evenly distributed

Eyelids no discharge / discoloration

Eyes are equally round

Transparent cornea

Pink palpebral conjunctiva

Ears

Symmetrical, no lesions, no pain

Recoils into original position after pinching

Auricles have same color as facial skin and aligned with outer canthus

of eye

Nose

Not tender, uniform color

Nasal septum in the midline and intact

No nodules or masses palpated

(+) Nasal Secretions

(+) Nasal Flaring

Mouth / Throat

11

Pinkish, moist, smooth

Tongue in central position

Neck

No pain upon palpation, masses

Muscles equal in size

Head located at the center

Skin

Capillary refill test 1-2 seconds

Uniform in color

Good skin turgor

Scanty hair equally distributed

Hair

Evenly distributed

No pediculosis / dandruff

Thorax / Lungs

(+) Rales on both lung fields

(-) retraction

Skin is intact

Chest is symmetric

No masses noted

Abdomen

Uniform color noted

Flat and symmetric movements caused by respiration

Extremities

Uniform in color

12

No palpable nodules or masses

Hair equally distributed

NEUROLOGICAL ASSESSMENT

CRANIAL

NERVE

PROCEDURE NORMAL

FINDINGS

ACTUAL

FINDINGS

CN I :

Olfactory

Type: Sensory

Function: Smell

Ask the client to

identify aromas

with eyes

closed.

Client must be

able to identify

the scent of an

agent with eyes

closed when

asked to smell

it.

Patient was able

to identify the

scent of alcohol

with eyes

closed.

CN II: Optic

Type: Sensory

Function: Vision

Ask the client to

read a number

written on a

piece of paper

at a given

distance.

Client must be

able to read a

number

correctly

written on a

piece of paper

at a given

distance.

Patient was able

to read the

number

correctly and

clearly at a

given distance

CN III:

Oculomotor

Type: Motor

Function: Pupil

constriction and

raising eyelids

Make use of

penlight in

order to test

papillary

reaction and

instruct the

Pupils should

constrict (+

PERRLA )

consensually

once light

passes through.

Patient pupils

constricted

consensually.

She was able to

open and close

her eyelids.

13

client to open

and close

eyelids.

Eyelids should

open and close.

CN IV:

Trochlear

Type: Motor

Function:

Oblique

movement of the

eye

Instruct client

to move eyes

downward and

upward without

moving head.

Client must be

able to follow

the pen’s

movement

downward and

upward without

moving head.

Patient was able

to follow the

pen’s movement

downward and

upward without

moving his

head.

CN VI:

Abducens

Type: Motor

Function:

Lateral eye

movement

Tell the client to

devoid his head

steadily and

follow the pen’s

direction

Client should be

able to follow

the lateral

movement of

the pen

Patient was able

to follow the

lateral

movement of the

pen.

CN VII: Facial

Type: Motor

Function:

Movement of

muscles of the

face

Ask client to

smile, frown,

and raise the

eyebrows.

Client should be

able to smile,

frown, and raise

the eyebrows

without

difficulty.

Patient was able

to smile, frown

and raise

eyebrows

without

difficulty.

CN IX:

Glossopharyng

eal

Type: Motor

Function:

Pharyngeal

movement and

Instruct client

to swallow.

Client should be

able to swallow

without

difficulty.

Patient was able

to swallow

without

difficulty.

14

swallowing

CN XI:

Accessory

Type: Motor

Function:

Movement of

shoulder

muscles

Ask the client to

shrug shoulders

against

resistance.

Client should be

able to shrug

shoulders

against

resistance.

Patient was

able to shrug

shoulders

against

resistance.

CN XII:

Hypoglossal

Type: Motor

Function:

Movement of

tongue, strength

of the tongue

Instruct the

client to

protrude tongue

and move it

laterally,

downward and

upward.

Client should be

able to protrude

tongue and

move it

laterally,

downward and

upward.

Patient was able

to protrude her

tongue and

move it laterally,

downward and

upward.

15

 7. Diagnostic and Laboratory Procedures

DIAGNOSTIC

AND

LABORATORY

PROCEDURES

DATE

ORDERE

D

DATE

RESULT(

S) IN

INDICATIO

NS AND

PURPOSE(S)

RESULT

S

NORMA

L

VALUES

ANALYSIS AND

INTERPRETATIO

N

1. Hematology

a.

HEMOGLOBI

N

Date

ordered:

June 23

2009

Date

resulted:

June 23

2009

The

hemoglobin

concentration

is a measure

of the total

amount of

hemoglobin in

the peripheral

blood, which

reflects the

number of

RBC in the

blood. This

test evaluates

blood loss,

anemia,

erythropoietic

123 g/L 120-150

g/L

The result is

within normal

range which

means that there

is adequate

perfusion in the

body’s tissues.

16

ability,

dehydration

and

polycythemia.

b.HEMATOCR

ITThe

hematocrit is

a measure of

the total

blood volume

that is made

up by RBC.

This test also

evaluates

blood loss,

anemia,

erythropoietic

ability,

dehydration

and

polycythemia.

0.370.35-0.40

The result is

normal with the

aid of

administration of

IVF of PLRS which

is known to be an

isotonic solution it

also indicates that

the patient is not

suffering from

dehydration.

C.

LEUKOCYTESThis test is

performed to

determine the

amount of

WBC’s in the

blood. The

body fights

infection by

4.52 X

109

7.50 -

13.50 X

109

It is decrease

which signifies

that theirs is

bacterial infection

17

using WBC’s

or leukocyte.

They

encapsulate

organism and

destroy them.

d.

LYMPHOCYTE

S

Lymphocytes

are the one’s

responsible

for activities

of the

immune

system, which

produces

antibodies.

0.43 0.15 -

0.65

The result is with

in normal limits

that there is no

presence of viral

infection or

inflammation.

e. PLATELET

COUNT

are the cell

fragments

circulating in

the blood that

are involved

in the cellular

mechanisms

of primary

hemostasis

leading to the

formation of

blood clots.

241 X

109

150-400

X 109

Normal. Normal

platelet counts are

not a guarantee of

adequate function.

In some states the

platelets, while

being adequate in

number, are

dysfunctional.

18

NURSING RESPONSIBILITIES

PRIOR TO THE PROCEDURE

- Explain the procedure to the client

- Tell the patient that no fasting is required

DURING THE PROCEDURE

- Collect approximately 5 to 7 ml of venous blood in a lavender-top

tube; however, only 0.5 ml is required when using capillary tubes.

- Avoid hemolysis

- List on the laboratory slip any drugs that may affect test results

AFTER THE PROCEDURE

- Apply pressure to the venipuncture site.

- Explain that some bruising, discomfort and swelling may appear at

the site and warm compress can alleviate this.

- Monitor signs of infection

Diagnostic and

laboratory

procedures

Dates Indication Results

CHEST X-RAY Date ordered:

June 23 2009

Date resulted:

June 23 2009

To identify the

abnormalities of

the lungs and

structures on the

thorax and also to

identify the size

Radiographic

report

There are hazy

infiltrate at the left

lower lung region.

19

of the heart and

abnormalities in

the ribs and

diaphragm.

The rest of the

lung are clear

heart and great

vessel with in

normal size and

configuration and

other chest

structure are not

remarkable

IMPRESSION:

Pneumonia, left

lower lobe

CHEST X-RAY

Before the procedure

1. check doctors order

2. Identify the client

3. Explain the procedure to SO and its importance

4. Inform the Patient to remove all metal objects like clothing with

metal, fastener, necklace, pins for better visualization of the chest

5. tell the patient that the test will only take a few minutes and is

painless

6. assist transporting the client in going to the X-Ray room

During the procedure

1. Protect client’s other body parts from exposure to radiation

2. Wear lead apron to protect one’s self from exposure to radiation

20

3. assist and keep patient still as possible during the procedure

After the procedure

1. Document the time and procedure performed

Urinalysis - (or "UA") is an array of tests performed on urine and one of

the most common methods of medical diagnosis. A part of a urinalysis can

be performed by using urine dipsticks, in which the test results can be read

as color changes.

DIAGNOSTIC AND

LABORATORY

PROCEDURES

DATE ORDERE

D

DATE RESULT(

S) IN

INDICATIONS AND

PURPOSE(S)RESULTS NORMA

L VALUES

ANALYSIS AND INTERPRETATIO

N

Urine chemistry

Date ordered:June 23

2009

Date resulted:June 23

2009

To screen the patient’s urine for renal or urinary tract disease.To help detect metabolic or systemic disease unrelated to renal disorders.To detect substances (drugs).

COLOR: light yellow

TRANSPARENCY: clear

pH: acidic

SP. GRAVITY: 1.005

MICROSCOPIC

yellow

clear

acidic

1.005-1.035

Slightly abnormal in color. Suggests signs of concentration of urine

Turbidity in urine transparency may indicate no presence of RBC , albumin and bacteria.

An acid pH (below 7.0)—typical of a high-protein diet—produces turbidity and the formation of oxalate, cystine, leucine, tyrosine, amorphous urate, and uric acid crystals

Result within normal range.

21

EXAMPUS CELL: 0-1/hpf

RBC: none found

ALBUMIN: ( - )

SUGAR: ( - )

BACTERIA: ( - )

( - )

( - )

( - )

( - )

( - )

Urine is not concentrated or packed with other element such as proteins.

May indicate infection

Within normal limits, indicate no presence of blood in the urine.

No impairment in the permeability of the glomelular capillaries.

Normal finding

Normal finding

NURSING RESPONSIBILITIES:

Before:

Check for the doctor’s order

Inform the patient/SO before doing the procedure. Explain to the

patient’s SO the importance of the test.

Inform the patient/SO that there is no need to restrict food or fluids

before the test.

Explain to the patient’s So that the laboratory procedure is non-

invasive; no pain will be felt.

During:

Assist patient in going to bathroom or CR.

Describe the procedure for collecting a clean-catch or midstream

specimen.

22

Advise the patient’s SO to wash patient’s genitalia prior to collection

of specimen.

After:

Chart time of collection of urine specimen.

Attach result to the chart as soon as they are available.

Record and document findings.

DIAGNOSTIC

AND

LABORATORY

PROCEDURES

INDICATI

ONAND

PURPOSE

(S)

RESULTS NORMA

L

VALUES

ANALYSIS AND

INTERPRETATIO

N

COLD

AGGLUTININS

DETERMINATIO

N

This test in

done to

test the

presences

of unusual

bacteria.

Presence

of

agglutionat

ion at 1.32

Titer

above

1.64 are

consider

significan

t

The result is in

normal limit

meaning which

indicates that

there is no

presence of

unusual bacteria.

NURSING RESPONSIBILITIES

PRIOR TO THE PROCEDURE

- Explain the procedure to the client

- Tell the patient that no fasting is required

DURING THE PROCEDURE

- Collect approximately 5 to 7 ml of venous blood in a lavender-top

tube; however, only 0.5 ml is required when using capillary tubes.

- Avoid hemolysis

- List on the laboratory slip any drugs that may affect test results

23

AFTER THE PROCEDURE

- Apply pressure to the venipuncture site.

- Explain that some bruising, discomfort and swelling may appear at

the site and warm compress can alleviate this.

- Monitor signs of infection

24

III. ANATOMY AND PHYSIOLOGY

Respiratory System

The respiratory system functions to deliver the oxygen to the blood --

the transport medium of the cardiovascular system -- and to remove oxygen

from the blood. The actual exchange of oxygen and carbon dioxide occurs in

the lungs.

The respiratory centers in the brain stem (pons and medulla) control

respiration's rhythm, rate, and depth. Primary controlling factors include 1)

the concentration of carbon dioxide in the blood (high CO2 concentrations

initiate deeper, more rapid breathing) and 2) air pressure within lung

tissue. Expansion of the lungs stimulates nerve receptors (vagus nerve X) to

signal the brain to "turn off" inspiration. When the lungs collapse, the

receptors give the "turn on" signal, termed the Hering-Breuer inspiratory

reflex. Other regulators are: 3) an increase in blood pressure, which slows

down respiration; 4) a drop in blood acidity, which stimulates respiration;

and 5) a sudden drop in blood pressure, which increases the rate and depth

of respiration. Voluntary controls -- "holding one's breath" -- can also affect

respiration, but not indefinitely. Carbon dioxide build-up soon forces an

automatic start-up.

25

The respiratory system consists of two tracts: The upper respiratory

tract includes the nose (nasal cavity, sinuses), mouth, larynx, and trachea

(windpipe). The lower respiratory tract includes the lungs, bronchi, and

alveoli.

The two lungs, one on the right and one on the left, are the body's

major respiratory organs. Each lung is divided into upper and lower lobes,

although the upper lobe of the right lung contains a third subdivision

known as the right middle lobe. The right lung is larger and heavier than

the left lung, which is somewhat smaller in size because of the

predominately left-side position of the heart.

A clear, thin, shiny coating -- the pleura -- envelopes the lungs. The

inner, visceral layer of the pleura attaches to the lungs; the outer, parietal

layer attaches to the chest wall (thorax). Pleural fluid holds both layers in

place, in a manner similar to two microscope slides that are wet and stuck

together. The lungs are separated from each other by the mediastinum, an

area that contains the heart and its large vessels, the trachea (windpipe),

esophagus, thymus, and lymph nodes. The diaphragm, the muscle that

contracts and relaxes in breathing, separates the thoracic cavity from the

abdominal cavity.

26

The chart of the respiratory system shows the intricate structures

needed for breathing. Breathing is the process by which oxygen in the air is

brought into the lungs and into close contact with the blood, which absorbs

it and carries it to all parts of the body. At the same time the blood gives up

waste matter (carbon dioxide), which is carried out of the lungs when air is

breathed out.

1. The SINUSES (frontal, maxillary, and sphenoidal) are hollow spaces in

the bones of the head. Small openings connect them to the nose. The

functions they serve include helping to regulate the temperature and

humidity of air breathed in, as well as to lighten the bone structure of the

27

head and to give resonance to the voice.

2. The NOSE (nasal cavity) is the preferred entrance for outside air into the

respiratory system. The hairs that line the wall are part of the air-cleaning

system.

3. Air also enter through the MOUTH (oral cavity), especially in people who

have a mouth-breathing habit or whose nasal passages may be temporarily

obstructed, as by a cold or during heavy exercise.

4. The ADENOIDS are lymph tissue at the top of the throat. When they

enlarge and interfere with breathing, they may be removed. The lymph

system, consisting of nodes (knots of cells) and connecting vessels, carries

fluid throughout the body. This system helps to resist body infection by

filtering out foreign matter, including germs, and producing cells

(lymphocytes) to fight them.

5. The TONSILS are lymph nodes in the wall of the throat (pharynx) that

often become infected. They are part of the germ-fighting system of the

body.

6. The THROAT (pharynx) collects incoming air from the nose and mouth

and passes it downward to the windpipe (trachea).

7. The EPIGLOTTIS is a flap of tissue that guards the entrance to the

windpipe (trachea), closing when anything is swallowed that should go into

the esophagus and stomach.

8. The VOICE BOX (larynx) contains the vocal chords. It is the place where

moving air being breathed in and out creates voice sounds.

28

9. The ESOPHAGUS is the passage leading from the mouth and throat to

the stomach.

10. The WINDPIPE (trachea) is the passage leading from the throat

(pharynx) to the lungs.

11. The LYMPH NODES of the lungs are found against the walls of the

bronchial tubes and windpipe.

12. The RIBS are bones supporting and protecting the chest cavity. They

move to a limited degree, helping the lungs to expand and contract.

13. The windpipe divides into the two main BRONCHIAL TUBES, one for

each lung, which subdivide into each lobe of the lungs. These, in turn,

subdivide further.

14. The right lung is divided into three LOBES, or sections. Each lobe is like

a balloon filled with sponge-like tissue. Air moves in and out through one

opening -- a branch of the bronchial tube.

15. The left lung is divided into two LOBES.

16. The PLEURA are the two membranes, actually one continuous one

folded on itself, that surround each lobe of the lungs and separate the lungs

from the chest wall.

17. The bronchial tubes are lines with CILIA (like very small hairs) that have

a wave-like motion. This motion carried MUCUS (sticky phlegm or liquid)

upward and out into the throat, where it is either coughed up or swallowed.

The mucus catches and holds much of the dust, germs, and other unwanted

matte that has invaded the lungs. You get rid of this matter when you

29

cough, sneeze, clear your throat or swallow.

18. The DIAPHRAGM is the strong wall of muscle that separates the chest

cavity from the abdominal cavity. By moving downward, it creates suction in

the chest to draw in air and expand the lungs.

19. The smallest subdivisions of the bronchial tubes are called

BRONCHIOLES, at the end of which are the air sacs or alveoli (plural of

alveolus).

20. The ALVEOLI are the very small air sacs that are the destination of air

breathed in. The CAPILLARIES are blood vessels that are imbedded in the

walls of the alveoli. Blood passes through the capillaries, brought to them

by the PULMONARY ARTERY and taken away by the PULMONARY VEIN.

While in the capillaries the blood gives off carbon dioxide through the

capillary wall into the alveoli and takes up oxygen from the air in the

alveoli.

Air Distribution

On inspiration, air enters the body through the nose and the mouth.

Nasal hairs and mucosa (mucus) filter out dust particles and bacteria and

warm and moisten the air. Less warming, filtering, and humidification occur

when air is inspired through the mouth.

Air travels down the throat, or pharynx, where two openings exist, one

into the esophagus for passage of food, and the other into the larynx (voice

box) and trachea (windpipe) for continued airflow. When food is swallowed,

the opening of the larynx (the epiglottis) automatically closes, preventing

food from being inhaled. When air is inspired, the walls of the esophagus

30

are collapsed, preventing air from entering the stomach. The larynx, which

also contain the vocal cords, is lined with mucus that further warms and

humidifies the air.

Air continues continues down the trachea, which branches into the

right and left bronchi. The main-stem bronchi divide into smaller bronchi,

then into even smaller tubes called bronchioles. The bronchial structures

contain hair-like, epithelial projections, called cilia, that beat rythmically to

sweep debris out of the lungs toward the pharynx for expulsion. Once in the

bronchioles, the air is at body temperature, contains 100% humidity, and is

(hopefully) completely filtered.

Bronchioles end in air sacs called alveoli -- small, thin-walled

"balloons," arranged in clusters. When you breathe in, enlarging the chest

cavity, the "balloons" expand as air rushes in to fill the vacuum. When you

breathe out, the "balloons" relax and air moves out of the lungs. It is at the

alveoli that gas exchange occurs. Tiny blood vessels, capillaries, surround

each of the alveoli. On inspiration, the concentration of dissolved oxygen is

greater in the alveoli than in the capillaries. Oxygen, therefore, diffuses

across the alveolar walls into the blood plasma. In the reverse process,

carbon dioxide concentration is greater in the blood than the alveoli, so it

passes from the blood into the alveoli and is ultimately breathed out.

As oxygen diffuses into the plasma, hemoglobin in the red blood cell

picks up the oxygen, permitting more to flow into the plasma. The oxygen-

carrying capacity of hemoglobin allows the blood to carry over 70 times

31

more oxygen than if the oxygen were simply dissolved in the plasma alone.

Therefore, the total oxygen uptake depends on: 1) the difference in oxygen

concentration between the blood and alveoli, 2) the healthy functioning of

the alveoli, and 3) the rate of respiration.

Pulmonary Circulation

The pulmonary circulatory circuit describes the process whereby

oxygen and carbon dioxide are delivered to and from the lungs. Oxygen-

poor blood travels to the right atrium via the inferior and superior vena

cavae, then to the right ventricle. The right ventricle subsequently pumps

the blood into the pulmonary artery, which branches to the right and left

lungs. The pulmonary arteries subdivide until reaching the arteriole, then

capillary levels. After gas exchange, the capillaries recombine to form

venules and veins. Ultimately two right and two left pulmonary veins carry

oxygen-rich blood to the heart for distribution, via the aorta/systemic

circuit, to the rest of the body.

32

Lung Volumes/ Capacities

The air that the lungs can hold can be divided into smaller

designations called "volumes."

The amount of air a person breathes in and out at rest is called the

Tidal Volume (Vt about 500ml). During such breathing, a person could

actually take in more air or blow more out. The additional amount a person

could inhale, such as during maximum physical activity, is called the

Inspiratory Reserve Volume (IRV 3,000 ml). The additional amount a person

could exhale is called the Expiratory Reserve Volume (ERV 1,000 ml). The

Residual Volume (RV) is the amount of air that stays in the lung even after

maximum expiration.

Breathing is an active process - requiring the contraction of skeletal

muscles. The primary muscles of respiration include the external intercostal

muscles (located between the ribs) and the diaphragm (a sheet of muscle

located between the thoracic & abdominal cavities).

The external intercostals plus the diaphragm contract to bring about

inspiration:

Contraction of external intercostal muscles > elevation of ribs &

sternum > increased front- to-back dimension of thoracic cavity >

lowers air pressure in lungs > air moves into lungs

Contraction of diaphragm > diaphragm moves downward > increases

vertical dimension of thoracic cavity > lowers air pressure in lungs >

air moves into lungs:

33

To exhale:

relaxation of external intercostal muscles & diaphragm > return of

diaphragm, ribs, & sternum to resting position > restores thoracic

cavity to preinspiratory volume > increases pressure in lungs > air is

exhaled

Intra-alveolar pressure during inspiration & expiration

As the external intercostals & diaphragm contract, the lungs expand.

34

The expansion of the lungs causes the pressure in the lungs (and alveoli) to

become slightly negative relative to atmospheric pressure. As a result, air

moves from an area of higher pressure (the air) to an area of lower pressure

(our lungs & alveoli). During expiration, the respiration muscles relax &

lung volume descreases. This causes pressure in the lungs (and alveoli) to

become slight positive relative to atmospheric pressure. As a result, air

leaves the lungs.

The walls of alveoli are coated with a thin film of water & this creates

a potential problem. Water molecules, including those on the alveolar walls,

are more attracted to each other than to air, and this attraction creates a

force called surface tension. This surface tension increases as water

molecules come closer together, which is what happens when we exhale &

our alveoli become smaller (like air leaving a balloon). Potentially, surface

tension could cause alveoli to collapse and, in addition, would make it more

difficult to 're-expand' the alveoli (when you inhaled). Both of these would

represent serious problems: if alveoli collapsed they'd contain no air & no

oxygen to diffuse into the blood &, if 're-expansion' was more difficult,

inhalation would be very, very difficult if not impossible. Fortunately, our

alveoli do not collapse & inhalation is relatively easy because the lungs

produce a substance called surfactant that reduces surface tension.

Role of Pulmonary Surfactant

Surfactant decreases surface tension which increases pulmonary

compliance (reducing the effort needed to expand the lungs) and reduces

tendency for alveoli to collapse.

35

Partial Pressure

Partial pressure is the individual pressure exerted independently by a

particular gas within a mixture of gasses. The air we breath is a mixture of

gasses: primarily nitrogen, oxygen, & carbon dioxide. So, the air you blow

into a balloon creates pressure that causes the balloon to expand (& this

pressure is generated as all the molecules of nitrogen, oxygen, & carbon

dioxide move about & collide with the walls of the balloon). However, the

total pressure generated by the air is due in part to nitrogen, in part to

oxygen, & in part to carbon dioxide. That part of the total pressure

generated by oxygen is the 'partial pressure' of oxygen, while that

generated by carbon dioxide is the 'partial pressure' of carbon dioxide. A

gas's partial pressure, therefore, is a measure of how much of that gas is

present (e.g., in the blood or alveoli).

The partial pressure exerted by each gas in a mixture equals the total

pressure times the fractional composition of the gas in the mixture. So,

given that total atmospheric pressure (at sea level) is about 760 mm Hg

and, further, that air is about 21% oxygen, then the partial pressure of

oxygen in the air is 0.21 times 760 mm Hg or 160 mm Hg.

36

Pathophysiology of Acute Bronchitis ( Book-Based)

a. Schematic Diagram

Modifable Factors-Smoke or fume inhalation-Malnutrition or poor immune system-Asthma-Viral infection-Environment

Non-modifiable factors

-Age (advance age/very young)

Entry of Virulent Microorganisms

Infectious Microorganisms lodges in the Bronchioles

Proliferation of Microorganisms

Inflammatory Response

Production of Mucus from Epithelial Cells

Releases Toxins

Bronchial epithelial injury

37

Exudates Formation

Release of Chemical Mediators

Parenchymal and Alveolar Consolidation

RESPIRATORY SECRETIONS

Cytokines

Release of Pyrogens

HYPERTHERMIA BODY WEAKNESS

Bradykinins Histamine

Stimulation of Goblet Cells

Accumulation of Secretions

WHEEZES AND COUGH

Narrowing of Blood Vessels

Air passes through narrowed lumen

SOB/DYSPNEA

Compensatory Mechanism

ELEVATED WBC

Bronchial Edema

Stimulates increase in Body

Temperature

CHEST PAIN

RALES

COUGHING UP BLOOD

Bronchial Obstruction

38

Pathophysiology of Acute Bronchitis (CLIENT-CENTERED)

a. Schematic Diagram

USE OF ACCESSORY MUSCLES

INCREASED RR and PR

Modifable Factors-Smoke or fume inhalation-Malnutrition or poor immune system-Asthma-Viral infection-Environment

Non-modifiable factors

-Age (advance age/very young)

Entry of Virulent Microorganisms

Infectious Microorganisms lodges in the Bronchioles

Proliferation of Microorganisms

Production of Mucus from Epithelial Cells

Releases Toxins

Bronchial epithelial injury

39

Inflammatory Response

Exudates Formation

Release of Chemical Mediators

Parenchymal and Alveolar Consolidation

RESPIRATORY SECRETIONS

Cytokines

Release of Pyrogens

HYPERTHERMIAJune 24 2009

BODY WEAKNESS June 23 2009

Bradykinins Histamine

Stimulation of Goblet Cells

Accumulation of Secretions

WHEEZES AND COUGH June 23 2009

Narrowing of Blood Vessels

Air passes through narrowed lumen

SOB/DYSPNEA

Compensatory Mechanism

Decreased WBC

Bronchial Edema

Stimulates increase in Body

Temperature

CHEST PAIN

RALESJune 23

2009

NON PRODUCTIVECOUGHJune 23 2009

Bronchial Obstruction

40

USE OF ACCESSORY MUSCLES

INCREASED RR and PRJune 24 2009

41

SYNTHESIS OF THE DISEASE (BOOK BASED)

Bronchitis is an inflammation of the lining of your bronchial tubes, which

carry air to and from your lungs. Bronchitis may be either acute or chronic.

Acute bronchitis is a lower respiratory tract infection that causes reversible

bronchial inflammation. In up to 95 percent of cases, the cause is viral.

Acute bronchitis is caused in most cases by a viral infection and may begin

after developing a cold or sore throat. Bronchitis usually begins with a dry

cough. After a few days it progresses to a productive cough, which may be

accompanied by fever, fatigue, and headache. The cough may last up to

several weeks. If not treated acute bronchitis can progress to pneumonia.

True acute purulent bronchitis is characterized by infection of the bronchial

tree with resultant bronchial edema and mucus formation. Because of these

changes, patients develop a productive cough and signs of bronchial

obstruction, such as wheezing or dyspnea on exertion. Unlike the chronic

inflammatory changes of asthma, the inflammation in acute bronchitis is

transient and usually resolves soon after the infection clears. In some

patients, however, the inflammation can last several months. In rare cases,

a postbronchitis cough can persist for up to six months.

Bronchitis can have causes other than infection. Bronchial wall

inflammation can occur in asthma or can be secondary to mucosal injury in

an acute event, such as smoke or chemical fume inhalation. This

inflammation can also result from chronic toxic exposure, such as cigarette

smoking. It is important to realize that when underlying inflammation is

present, such as in asthmatics or smokers, infective agents are likely to

cause more severe cough and wheezing.

Viruses are the most common cause of bronchial inflammation in otherwise

healthy adults with acute bronchitis. Only a small portion of acute

bronchitis infections are caused by nonviral agents, with the most common

42

organism being Mycoplasma pneumoniae. Study findings suggest that

Chlamydia pneumoniae may be another nonviral cause of acute bronchitis.

MODIFIABLE/ NON-MODIFIABLE FACTORS

Non-modifiable Factors (book based)

Age (Advanced Age/Very Young). For elderly, this is brought about

by the degenerative changes which put them at high risk in acquiring

and developing the disease condition. For young individuals especially

those newborns, they still have immature immune systems which makes

them more susceptible in acquiring the disease condition.

Modifiable Factors

Smoke or chemical fume inhalation. Smoking damages the

mucosal lining of the bronchus.

Asthma. Also causes bronchial wall inflammation.

Malnutrition and poor immune system. Improper nutrition and

poor nutrition can contribute to the development and acquiring of the

disease condition.

Viral Infection. Mostly the cause of the disease viral infection.

Environment. Presence of dust and pollutant may contribute in

occurrence of the said condition.

SIGNS AND SYMPTOMS

43

Difficulty of breathing or dyspnea. This results from the

continuous narrowing and obstruction of the airways. Manifestations

of dyspnea would include:

o Nasal flaring

o Pursed-lip breathing

o Use of accesory muscles

Chest tightness or pain. This results from the inflammation of the

airway, and due to labored breathing

Chest Pain. Usually, it is cause by shortness of breath, wheezes and

presence of cough.

Non-Productive/Productive Cough. Coughing is an important way

to keep the throat and airways clean. It is usually cause by the

presence of increase mucus secretion stimulated by the presence of

Microorganisms causing irritation in the lungs.

Presence of Adventitious Sounds on the Lungs (rales, wheezes,

ronchi). Presence of abnormal breath sounds is due to accumulation

of secretions in the alveolar sac which traps air producing theses

distinct sounds. Adventitious breath sounds may also occur when

narrowing of the bronchus occurs.

Dyspnea. This is because of the narrowing blood vessel caused by the

release of chemical mediators leading to difficulty of inspiration and

expiration.

Shortness of Breath. It is caused by obstruction of the air passages

that may lead to labored or difficulty in breathing.

Body Weakness. This is due to the physical exertion brought about

by compensatory mechanisms through breathing.

Fever with Chills. Increase in body temperature is caused by the

inflammatory response of the body due to the presence of virulent

microorganisms.

44

Coughing up Blood. It is the splitting up of blood or bloody mucus

from the lungs and throat usually cause by the extensive lesion in the

respiratory tract.

Elevated White Blood Cells. Increased in number of leukocytes is

brought about by the presence of bacterial infection in the body.

Increase Pulse Rate and Respiratory Rate. This is caused by

imbalance of oxygen supply and demand.

Use of Accessory Muscle when Breathing. This is a compensatory

mechanism in order to allow proper inhalation and exhalation.

SYNTHESIS OF THE DISEASE (CLIENT CENTERED)

MODIFIABLE/ NON-MODIFIABLE FACTORS

Non-modifiable Factors

Age (Very Young). The patient is 6 years old.

Modifiable Factors

Asthma. Also causes bronchial wall inflammation. She has

asthma since birth.

45

Malnutrition and poor immune system. Improper nutrition and

poor nutrition can contribute to the development and acquiring

of the disease condition. She has decreased appetite.

Viral Infection. Mostly the cause of the disease viral infection.

She was diagnose with URTI 4 days prior to admission.

Environment. Presence of dust and pollutant may contribute in

occurrence of the said condition. Patients house is located

along the highway.

SIGNS AND SYMPTOMS

Difficulty of breathing or dyspnea. (June 23,24 2009) This

results from the continuous narrowing and obstruction of the

airways. Manifestations of dyspnea would include:

o Nasal flaring

o Increased respiratory rate

Non-Productive/Productive Cough. (June 23-24 2009) Coughing

is an important way to keep the throat and airways clean. It is

usually cause by the presence of increase mucus secretion

stimulated by the presence of Microorganisms causing

irritation in the lungs.

Presence of Adventitious Sounds on the Lungs (rales) (June 23-

24 2009). Presence of abnormal breath sounds is due to

accumulation of secretions in the alveolar sac which traps air

producing theses distinct sounds. Adventitious breath sounds

may also occur when narrowing of the bronchus occurs.

Dyspnea. (June 23-24 2009) This is because of the narrowing

blood vessel caused by the release of chemical mediators

leading to difficulty of inspiration and expiration.

Respiratory Rate. This is caused by imbalance of oxygen supply

and demand.

46

Body Weakness. (June 23-24 2009) This is due to the physical

exertion brought about by compensatory mechanisms through

breathing.

Fever with Chills. (June 23-24 2009) Increase in body

temperature is caused by the inflammatory response of the

body due to the presence of virulent microorganisms.

Elevated White Blood Cells. (June 24 2009) Increased in

number of leukocytes is brought about by the presence of

bacterial infection in the body.

V. THE PATIENT AND HIS CARE

47

A. Medical Management

A.1 IVF’s and Nebulization

Medical

Manageme

nt/

Treatment

Date Ordered

Date Performed

Date

Changed/DC

General

Description

Indication(

s) or

Purpose(s)

Client’s

Response to

the

Treatment

Intravenous Fluids

D5 IMB 500cc, @ 45 ugtts/min

  

Date

ordered:

June 23 2009

Date started:

June 23 2009

It is a

hypertonic

solution, which

makes the cells

shrink,

composes of

water and

carbohydrates,

as source of

energy and both

cations and

anions

It is use to

supply the

necessary

nutrients.

And this

solution is

given

usually

when serum

osmolality

has

decreased to

dangerously

low levels.

Client fluid

loss due to

insensible

fluid loss

was replaced

and

nourished.

Nursing Responsibilities:

Prior to the procedure:

Check doctor’s order. Check for ordered IVF.

Check for the patency of the IV tubing, cloudiness and expiration

date.

48

Explain the procedure, importance and its benefits to the patient’s

SO.

Secure all materials for IV insertion

During the procedure:

Clean the site of administration. Choose a vein in the distal arm.

Support client hand and maintain aseptic technique.

Regulate the flow rate as ordered.

Always check if it the infusion site and in place.

Monitor I and O.

Monitor patient for fluid overload.

be sure that IV line is free from any kinds of bubbles.

Make sure that all incorporated IVF’s and its desired doses are

followed according to the doctor’s order.

Provide a splint to prevent injury of the vein.

Inspect for level of IV always.

After the procedure:

Monitor rate as ordered, flow and patency.

Document the time and date.

49

Medical

Manageme

nt/

Treatment

Date

Ordered

Date

Performed

Date

Changed/DC

General

Description

Indication(s) or

Purpose(s)

Client’s

Response to

the

Treatment

Nebulizati

on

Date ordered:

June 23 2009

Date started:

June 23 2009

Inhalation

therapy that

produces

droplets that

are suspended

in a gas such

as oxygen.

The dug

which was

formed to

mist would be

inhaled better

It aids bronchial

hygiene by

restoring and

maintaining

mucous blanket

continuity,

hydrating dried,

retained

secretions,

promoting

expectoration of

secretions. To

relive

bronchospasm,

to provide relief

to a

hyperresponsive

airway and to

liquefy and clear

tenacious

secretions.

The patient

demonstrated

an improved

in the

breathing

pattern. And

was able to

cough out

secretions

more often.

50

Nursing Responsibilities

Prior to the procedure:

Check doctor’s order.

Check for the amount of medication that is to be incorporate in the

procedure.

Explain the procedure to the patient’s S.O.

Arranged all the material needed. Wash hand.

During the procedure:

Hold the mouthpiece of the nebulizer upright to avoid spilling of

medicines.

Continue nebulization until the medication is already nebulized.

Do chest physio-therapy after nebulisation.

After the procedure:

Assess the client’s vital signs after nebulization, especially the

respiratory rate.

Document the time of the procedure was done.

B. Drugs

Name of

Drugs

Generic

Name

Brand Name

Date

Ordered

Date

Taken/Give

n

Date

Changed/D

C

Route of

Administr

ation,

Dosage

and

Frequenc

y of

Administr

ation

General

action; Drug

classification;

Mechanism of

action

Client

Response to

the

Medication

with Actual

Side Effects

Convibent  

Date

ordered:

June 23 2009

Neb

combivent

plus 1

Anti asthmatic

Management of

The patient

maintained a

patent airway

51

Date started:

June 23 2009

nebule

fluticasone

q 6 hour

weight

22kg IVF

D5 IMB

50cc

reversible

bronchospasm

associated w/

obstructive

airway diseases

in patients who

require more

than a single

bronchodilator.

Name of

Drugs

Generic

Name

Brand Name

Date

Ordered

Date

Taken/Give

n

Date

Changed/D

C

Route of

Administrat

ion, Dosage

and

Frequency

of

Administrat

ion

General

action; Drug

classification;

Mechanism of

action

Client

Response

to the

Medicatio

n with

Actual

Side

Effects

FLUTICASON

E

Date

ordered:

June 23

2009

Date

Route of

Administratio

n:

Nebulizer

Dosage:

1 nebule

Inhalation

Prophylaxis of

asthma

The client

didn’t

experience

broncospa

sm

52

started:

June 23

2009

Nursing Responsibilities:

>Before administering, check for doctor’s order.

>Give drug with right dosage, route, and time for administration.

Prior to the procedure:

Read the Doctor’s order before giving the medication to the patient,

and always remember the 10 R’s

Inform the patient about the action and the purpose of the drug.

Before giving the medication ask the patient first if she already take

the medications or not.

Note if all the medications are available, if one of the medication are

not available make a prescription and ask the patient’s SO to buy it

for the patient.

Check if the nebulizer is functioning

Prepare the drug by diluting it with distilled water

During the procedure:

Make sure that the patient will take the medications on time.

If the medication is an IV route, make sure that you administer it on

time.

Always be at the bedside of the patient in order to help the patient in

taking her medications.

Follow the directions on your prescription label

Monitor the patient while inhaling the atomized drug if it is in proper

place

Instruct patient to take medication as directed for the full course of

therapy.

After the procedure:

53

Instruct patient to take medication at evenly spaced times and to

finish the medication completely.

Observe for side effects or allergies.

Inform the patient on the specific time the medication is to taken

again.

Inform patient that increased fluid intake and exercise may minimize

constipation

Document.

Name of

Drugs

Generic

Name

Brand

Name

Date

Ordered

Date

Taken/Give

n

Date

Changed/D

C

Route of

Administrat

ion, Dosage

and

Frequency

of

Administrat

ion

General

action; Drug

classification;

Mechanism of

action

Client

Response

to the

Medicatio

n with

Actual

Side

Effects

Paracetamo

l

aceteminop

hen

Date

ordered:

June 23

2009

Date

started:

June 23

2009

Route of

Administratio

n:

Per Orem

Dosage:

1ml q 4 hrs

Anti –pyretic

Inhibits

prostaglandins

in CNS but

lacks anti-

inflammatory

effects in

periphery;

reduces fever

through direct

action on

hypothalamic

The client

experience

relief from

fever

54

heat-regulating

center.

Nursing responsibilities

Prior to drug administration

Check the written medication order for completeness. It should

include the drug name, dosage, frequency, and duration of therapy.

Check if there are any special circumstances surrounding

administration of the dose to the patient

Be certain that you know the expected action, safe dosage range,

special instructions for administration and adverse effects associated

with drug orders

Wash you hands

Prepare the necessary equipment like the medication tray and

medication card.

Prepare the dosage as ordered

Check the label on the medication three times before administering

any drug

Ever prepare a dosage of medication, which is discolored,

contaminated, or outdated

During drug administration

Verify the patients name first.

Administer once daily

May be given with or without meals

After drug administration

Assess for adverse effect of the drug

Assess for temperature

Documentation the procedure

55

Name of

Drugs

Generic

Name

Brand

Name

Date

Ordered

Date

Taken/Give

n

Date

Changed/D

C

Route of

Administrat

ion, Dosage

and

Frequency

of

Administrat

ion

General

action; Drug

classification;

Mechanism of

action

Client

Response

to the

Medicatio

n with

Actual

Side

Effects

PEDZINC Date

ordered:

June 23

2009

Date

started:

June 23

2009

Route of

Administratio

n:

Per Orem

Dosage:

5 ml syrup

once a day

Vit C and zinc

supplement to

keep child

strong, healthy

and mentally

alert. Increase

immunity

against

common

infections &

everyday

The client

immune

system

was

boosted.

56

stress. Reduces

the risk,

severity &

duration of

common colds,

malaria,

pneumonia &

diarrhea.

Nursing responsibilities

Prior to drug administration

Check the written medication order for completeness. It should

include the drug name, dosage, frequency, and duration of therapy.

Check if there are any special circumstances surrounding

administration of the dose to the patient

Be certain that you know the expected action, safe dosage range,

special instructions for administration and adverse effects associated

with drug orders

Wash you hands

Prepare the necessary equipment like the medication tray and

medication card.

Prepare the dosage as ordered

Check the label on the medication three times before administering

any drug

Ever prepare a dosage of medication, which is discolored,

contaminated, or outdated

During drug administration

Verify the patients name first.

Administer once daily

57

May be given with or without meals

After drug administration

Assess for adverse effect of the drug

Name of

Drugs

Generic

Name

Brand Name

Date

Ordered

Date

Taken/Give

n

Date

Changed/D

C

Route of

Administrat

ion, Dosage

and

Frequency

of

Administrat

ion

General

action; Drug

classification;

Mechanism of

action

Client

Response

to the

Medicatio

n with

Actual

Side

Effects

COAMOXCILA

V

( Amoclav )

Date

ordered:

June 23

2009

Date

started:

June 23

2009

Route of

Administratio

n:

Per Orem

Dosage:

300mg +

20cc IV

diluent q

8hrs.

Lower resp

tract

infections,

otitis media,

sinusitis, skin

& soft tissue

infections, UTI,

pre & post-

surgical

procedures,

bone & joint, O

& G infections,

dental

infections.

The client

reduces

infection

58

Nursing responsibilities

Prior to drug administration

Check the written medication order for completeness. It should

include the drug name, dosage, frequency, and duration of therapy.

Check if there are any special circumstances surrounding

administration of the dose to the patient

Be certain that you know the expected action, safe dosage range,

special instructions for administration and adverse effects associated

with drug orders

Wash you hands

Prepare the necessary equipment like the medication tray and

medication card.

Prepare the dosage as ordered

Check the label on the medication three times before administering

any drug

Ever prepare a dosage of medication, which is discolored,

contaminated, or outdated

During drug administration

Verify the patients name first.

Administer every 8 hours

May be given with or without meals

After drug administration

Assess for adverse effect of the drug

59

C. Diet

Type of

Diet

Date

Ordered

Date

Performed

Date

Changed/D

C

General

Descriptio

n

Indication

(s) and

Purpose(s

)

SPECIFIC

FOODS

TAKEN

Client’s

Response

and/or

Reaction

to the Diet

DAT Date

ordered:

June 23

2009

Date

started:

June 23

2009

Nearly the

normal diet

on the basic

four food

groups. The

diet must

be

withdrawn

with signs

of

aspiration.

A balanced

diet is

necessary

for the

recovery of

the patient

that is why

the

physician

ordered a

normal

diet.

However,

the SO

must

discontinu

e the

The patient

prefers to

eat food

such as

bread,

soda, and

coffee.

The patient

demonstrat

ed

improved

appetite.

60

patient’s

feeding if

severe

DOB

occurs to

prevent

aspiration

which may

aggravate

the

patient’s

condition.

Nursing Responsibilities:

Check doctor’s order regarding the type of diet.

Explain to patient’s SO regarding NPO

Give health teachings regarding proper preparation of food for the

patient

Always emphasized aseptic technique 

Be sure patient is taking or eating foods she can tolerate.

Be sure patient is taking or eating foods she can tolerate.

Assess for patent’s condition, how she respond to the diet.

Provide foods which are indicated for DAT

D. Activity/Exercise

Type of Date

Ordered

General

Descripti

Indication

(s) and

Client’s

response or

61

Exercise Date

Performed

Date

Changed/D

C

on Purpose(s

)

reaction to

the

activity/exerc

ise

HIGH

BACK

REST

Date

ordered:

June 23

2009

Date stated:

June 23

2009

Head of

bed is

elevated

to 45-90

degrees

To

maximize

lung

expansion

since

patient is

having

DOB

Relieved from

DOB

Nursing Responsibilities

Check doctor’s order

Elevate head of bed to 45-90 degrees

Place pillows on the side edge of the bed

Raise side rails if the patient prefer

62

Nursing Care Plan

Problem #1 - Ineffective airway clearance r/t retained secretions in the bronchi

Assessment Nursing Diagnosis

Scientific Explanation

Objectives Interventions Rationale Expected Outcome

S>Ø

O> patient

may

manifest:

Adventitiou

s breath

sounds

(crackles/w

heezes)

Tachypnea

Dyspnea

Productive/

non-

productive

cough

Cyanosis

Difficulty

of

Ineffective

airway

clearance

r/t retained

secretions

in the

bronchi

Inflammation

and swelling of

the linings of the

airways leads to

narrowing and

obstruction of

the airways. The

inflammation

also stimulates

production of

mucous

(sputum), which

can cause

further

obstruction of

airways.

ST> after 1

hour of

nursing

intervention

the patient

will

maintain

patent

airway

LT>after 3

days of

nursing

intervention

the patient

will

demonstrat

1. Assess energy

level and

endurance and

effect on chest

expansion

2. Assess

respiratory

status for rate,

depth and ease,

presence of

tachypnea,

dyspnea in

relation to

disease process

or decrease

1. Decrease with

age, more than

one chronic

disorder further

compromises

maintenance of

ventilation

2. Changes vary

from minimal to

extreme caused

by obstruction

(bronchial

swelling),

increased mucus

secretions

(oversecretions

of goblet cells,

ST> after 1

hour of

nursing

intervention

the patient

shall have

maintained

patent airway

LT>after 3

days of

nursing

intervention

the patient

shall have

demonstrated

absence/redu

63

vocalizing

Wide-eyed

orthopnea

e

absence/red

uction of

congestion

with breath

sounds

clear,

respiration

noiseless,

improve

oxygen

exchange

energy level

3. Auscultate for

adventitious

sounds

(crackles,

wheezes)

tracheobronchia

infection),

bronchospasm

and narrowing of

air passages

(stmulation of

irritant receptors

in smooth muscle

layer of

conducting

airways)

3. Wheezing

results from

squeezing of air

past narrowed

airways during

expiration

caused by

bronchospasms,

edema and

obstructive

secretions;

ction of

congestion

with breath

sounds clear,

respiration

noiseless,

improve

oxygen

exchange

64

4. Assess for

cough and

sputum

production for

amount, color,

viscosity, ability

to cough and

expectorate

secretions in

relation to

energy levels

5. Administer

crackles result

from lung

consolidation of

leukocytes and

fibrin in an area

caused by

infectious

process or fluid

accumulation in

the lungs

4. Changes in color

to green in

morning and

yellow during

day indicate

infection;

tenacious, thick

secretions

require more

enrgy and effort

to remove and

65

bronchodilators,

anti-

inflammatories,

expectorants,

mucolytics, anti-

infectives

6. Provide

environmental

air

humidification\

7. Offer 2-3 L (10-

12 glasses)/day

unless

contraindicated;

offer hourly

including a

warm beverage

upon arising

8. Position in

may cause

obstruction and

stasis leading to

infection and

respiratory

changes

5. Treats

bronchospasm,

prevents or

treats infection,

liquefies

secretions and

enhances outflow

and removal of

respiratory tract

fluids

6. Adds moisture

to the air to thin

mucus for easier

removal

7. Assist to

66

semi-fowler’s

and change

position q 2h

9. Perform

postural

drainage using

gravity,

percussion,

vibration, avoid

postions that

may be

contraindicated

in the elderly

10. Maintain

activity pattern,

mobilize thin

secretions for

easier removal

8. Prevents

accumulation of

secretions;

promotes

comfort and ease

breathing and

decreases airflow

resistance and

enhances gas

distribution,

facilitates chest

expansion

9. Raises

secretions, clears

sputum and

67

encourage

ambulation

within

limitations

11. Encourage

deep breathing

and coughing

exercises by

taking a deep

breath, exhale

as much as

possible, inhale

again and cough

twice from the

chest

12. Suction if

appropriate

increases force

of expiration

10. Mobilize

secretions for

easier removal

11. Assist in

dislodging

secretions for

easier

expectoration by

initiating the

cough reflex

which protects

the lungs from

accumulation of

secretions by

action on

receptors in

68

13. Instruct

patient to avoid

milk, caffeine

drinks and

alcohol

14. Instruct

patient to avoid

excessively hot

or cold fluids;

cold air and

wind exposure

by wearing

mask

15. Encourage

cessation of

smoking;

tracheobronchial

wall

12. Removes

secretions in

those too weak

to cough or with

mentation or

LOC deficits

13. Milk

thickens mucus,

caffeine reduces

effect of

medication

( bronchodilators

), alcohol

increases cell

dehydration and

bronchial

constriction

14. Predisposes

to coughing

69

suggest

program to

support the

reduction or

cessation of

smoking

16. Program of

daily exercises;

supervised if

needed

17. Instruct

patient to avoid

crowds and

those with

upper

respiratory tract

infections

spells; dyspnea,

bronchospasm

15. Smoking

causes increased

mucus,

vasoconstriction,

increased BP,

inflammation of

the lung lining,

decreased

number of

macrophages in

airways and

mucociliary

blanket

16. Promotes

secretion

removal

70

18. Instruct

patient on

proper use of

and disposal of

tissues used for

expectoration

17. Prevents

possible

transmission of

infection

18. Prevents

transmission of

microorganism

as sputum

contains

infecting

organism and

inflammatory

debris

Problem #2 - Ineffective breathing pattern r/t tracheobronchial obstruction

Assessment Nursing Diagnosis

Scientific Explanation

Objectives Interventions Rationale Expected Outcome

S>Ø

O> patient Ineffective Irritants inflame ST> after 1 1. Assess 1. Changes vary ST> after 1

71

may

manifest:

Prolonged

dyspnea

Exhausted

appearanc

e

Lethargy

Listlessnes

s

Drowsy

breathing

pattern r/t

tracheobro

nchial

obstruction

the

tracheobronchial

tree, leading to

increase mucus

production and a

narrowed or

blocked airway.

As the

inflammation

continues, goblet

and epithelial

cell hypertrophy.

Because the

natural defense

mechanism is

blocked, the

airway

accumulate

debris in the

respiratory tract.

hour of

nursing

intervention

the patient

will

verbalize

awareness

of causative

factors and

iniate

needed

lifestyle

changes

LT>After 3

days of

nursing

intervention

the patient

will be free

of cyanosis

and other

respiratory

status for rate,

depth and ease,

presence of

dyspnea and use

of accessory

muscles,

lengthened

expiratory

phase

2. Asses energy

level, fatigue

and effect on

breathing

with acuteness of

condition and are

caused by airway

resistance,

bronchospasm,

decreased lung

expansion,

dyspnea results

from stimulation

of lung receptors

or reduced

ventilatory

capacity or

breathing

reserve

2. Limited energy

reserve in elderly

quickly

dissipated as

work of

breathing

increases

hour of

nursing

intervention

the patient

shall have

verbalized

awareness of

causative

factors and

iniate needed

lifestyle

changes

LT>After 3

days of

nursing

intervention

the patient

shall be free

of cyanosis

and other

signs and

72

signs and

symptoms

of hypoxia

with ABGs

within

client

acceptable

range

3. Assess pain or

chest

discomfort, sore

chest muscles,

effort on chest

excursion

4. Auscultate for

diminished or

absent breath

sounds,

wheezes or

crackles

5. Have client to

breath into

paper bag

6. Administer

bronchodilator

3. Results from

excessive

coughing , use of

muscles for work

of breathing

causing reduced

chest expansion

and shallow

breathing

pattern

4. Changes caused

by infectious

process as

consolidation

develops;

damage to

bronchioles

restrict air

movement

5. To correct

hyperventilation

symptoms of

hypoxia with

ABGs within

client

acceptable

range

73

as ordered

7. Position in

semi- or high

fowler’s

8. Perform deep

breathing

exercises and

pursed lip

breathing,

isometric

exercises for

intercostals

muscle and

diaphragm

6. Treats

bronchospasm,

prevents or

treats infection

7. Promotes

comfort and ease

of breathing and

gas distribution,

facilitates chest

expansion by

causing

abdominal

organs to sag

way from

diaphragm

8. Strengthens

chest and

abdominal

muscles to

enhance

breathing ;

pursed lip

74

strengthening;

upper body

exercises by

raising arms

and using 2-3 lb

hand weight if

available

9. Provide proper

body alignment

in positioning

for sleep, use

pillows, to

elevate head

and support

chest.

10. Pace

activities, allow

for rest between

periods of

exercises

11. Instruct

patient to avoid

breathing

prolongs

expiratory phase

and prevents

alveoli from

collapsing to

decrease CO2

retention

9. Ensures optimal

ventilation

10. Prevents

changes in

respirations

brought about by

exertion

75

extending any

activity beyond

baseline of

tolerance

12. Encourage

patient of

relaxation

techniques,

guided imagery,

music when

breathing

pattern changes

or anxiety

increases

11. Causes

exacerbation of

dyspnea

12. Decrease

respiratory rate

Problem #3-Impaired gas exchange r/t ventilation perfusion imbalance

Assessment Nursing Diagnosis

Scientific Explanation

Objectives Interventions Rationale Expected Outcome

76

S>Ø

O> patient

may

manifest:

Irritability

Hypoxemia

Hypercapni

a

Confusion

Somnolenc

e

Hypoxia

impaired

gas

exchange

r/t

ventilation

perfusion

imbalance

Bronchospastic

disease changes

gas flow and

blood

distribution

possibly causing,

in some cases,

ventilation-

perfusion

mismatching.

With

bronchospasm,

autoregulation

mechanisms

change blood

flow patterns in

an attempt to

maintain a match

between

ventilated

regions and

ST> After 1

hour of

nursing

intervention

the patient

will

verbalize

understandi

ng of the

causative

factors and

appropriate

intervention

s

LT> after 3

days of

nursing

intervention

the patient

will

maintain

1.Assess

respiratory

status for rate,

depth and ease,

dyspnea and

respiratory

effort on

exertion, length

of inspiratory

and expiratory

phase

2.Assess for

cyanosis and

monitor arterial

blood gas for

1. Gas exchange

carried out by

pulmonary

circulation is

affected by body

position and

posture as is

ventilation; it is

dependent on the

matching of

ventilation and

perfusion of equal

amounts of air

and blood

entering the

lungs at the

alveoli level

2. O2 and CO2

diffusion and

exchange are

affected by the

ST> After 1

hour of

nursing

intervention

the patient

shall have

verbalized

understandi

ng of the

causative

factors and

appropriate

intervention

s

LT> after 3

days of

nursing

intervention

the patient

shall have

77

perfuse regions.

Nevertheless,

chronic

bronchitis and

acute asthma

often result in a

low

ventilation/perfu

sion condition

(V/Q) with

associated

oxygen

desaturation and

hypoxemia.

adequate

oxygen and

carbon

dioxide

levels with

return of

respiratory

baselines

decreased

oxygen and

increase carbon

dioxide levels,

possible

lowered pH; O2

saturation by

oximetry

3.Assess for

changes in

consciousness,

mentation,

restlessness,

irritability,

rapid fatigue

surface area

available,

thickness of the

alveolocapillary

membrane of

both of which

characteristic of

aging or disease

lung tissue;

cyanosis results

from the

reduction in

oxygenated

hemoglobin in the

blood and leads

to hypoxia

(reduced tissue

oxygenation)

3. Results of

decreased oxygen

to brain tissue

with progressive

maintained

adequate

oxygen and

carbon

dioxide

levels with

return of

respiratory

baselines

78

4.Position patient

in semi/high-

fowler’s using

chair or pillow

on over bed

table to lean

forward

5.Breathing

exercise

6.Administer

oxygen at 2-3

L/min via

cannula, non

breather mask

hypoxia

4. Promotes

breathing and

gas distribution

facilitates chest

expansion and

pulmonary blood

flow; sitting

position stabilizes

chest structures

5. Restores

function of

diaphragm which

decreases work

of breathing and

improves gas

exchange

6. Maintain

adequate oxygen

79

7.Instruct patient

to avoid

activities that

cause change

in respirations

especially

shortness of

breath

8.Instruct patient

to report any

changes in

fatigue level or

any mental

clouding,

increasing

dyspneic

episodes

9.Encourage

adequate rest

and limit

activities to

within client

level without

depressing

respiratory drive

which increases

CO2 retention

7. Increase in

oxygen

consumption

changes

breathing pattern

8. Indicates

impending

hypoxia

9. Help limit O2

needs/consumptio

80

tolerance

10. Instruct

patient to keep

his

environment

allergen/polluta

nt free

11. Encourage

cessation of

smoking;

suggest

program to

support the

reduction or

cessation of

smoking

n

10. To reduce

irritant effect on

airways

11. To improve

lung function

Problem #4 – High risk for infection r/t inadequate primary defenses (decrease ciliary action)

Assessment Nursing Diagnosis

Scientific Explanation

Objectives Interventions Rationale Expected Outcome

S>Ø

O> patient ST> After 1 1. Assess for 1. Early detection ST> After 1

81

may

manifest :

Productive

cough

Fever

Restlessne

ss

Tiredness

Increase

WBC count

Pinkish

skin

Drowsiness

Green or

yellow

sputum

High risk

for

infection r/t

inadequate

primary

defenses

(decrease

ciliary

action)

Smoke and other

pollutants

irritate the

airways,

resulting in

hypersecretion of

mucus and

inflammation.

This constant

irritation causes

the mucus

secreting glands

and goblet cells

to increase in

number. Ciliary

function is

reduced and

more mucus is

produced. The

bronchial walls

become

thickened, the

hour of

nursing

intervention

the patient

will have

vital signs

within

normal

ranges

LT> After 3

days of

nursing

intervention

the patient

will identify

intervention

s to prevent

infection

and

demonstrat

e

increased

dyspnea,

change in color

and viscosity of

sputum (yellow

or green),

cough

2. Administer

antibiotic

therapy

3. Obtain periodic

sputum

cultures

4. Avoid smoking,

chilling,

inhalation of

environmental

pollutants

5. Avoid large

of respiratory

infection allows

for immediate

treatment

before

respiratory

system is

compromise

2. Prevents or

treats

respiratory

infection if

symptoms

appear

3. Reveal

infectious agent,

evaluates effect

of treatment

4. Irritates mucosa

and initiates

dyspneic attack

hour of

nursing

intervention

the patient

shall have

vital signs

within

normal

ranges

LT> After 3

days of

nursing

intervention

the patient

shall have

identified

interventions

to prevent

infection and

demonstrated

techniques to

82

bronchial lumen

narrows and

mucus may plug

the airway.

Alveoli adjacent

to the

bronchioles may

become damaged

and fibrosed,

resulting in

altered function

of the alveolar

macrophages.

This is significant

because the

macrophages

play an

important role in

destroying

particles,

including

bacteria.

techniques

to promote

safe

environmen

t

groups,

exposure

6. Proper hand

washing,

disposal of

tissues, cover

mouth and nose

when coughing,

cleansing and

disinfection off

respiratory

equipment

7. Proper

administration

and expected

effect of

antibiotic

therapy and to

take complete

prescription

8. Instruct patient

5. Prevent s

contact with

potential

infectious

agents

6. Prevents

transmission of

infectious

agents from

contaminated

articles

7. Prevents

recurrence of

infection

promote safe

environment

83

to report fever

or change in

sputum

9. Encourage

early

ambulation,

deep breathing

and coughing

position change

8. May indicate

infection

9. For mobilization

of respiratory

secretions

84

Problem#5 - Sleep pattern disturbance r/t internal factors of illness and psychological stress of

dyspnea

Assessment Nursing Diagnosis

Scientific Explanation

Objectives Interventions Rationale Expected Outcome

S>Ø

O> patient

may

manifest:

Irritability

Frequent

yawning

Tiredness

Drowsiness

Listlessnes

s

Sleep

pattern

disturbance

r/t internal

factors of

illness and

psychologic

al stress of

dyspnea

Sleeplessness

and daytime

sleepiness are

common

problems.

Studies indicate

that between 80

- 93% of people

with asthma

have sleeping

ST>after 1

hour of

nursing

intervention

the patient

will

verbalize

understandi

ng of sleep

disturbance

1. Assess sleep

pattern and

changes, naps

and frequency,

amount of

activity or

sedentary

status,

awakenings

and when they

1. Provides data

for resolving

sleep

deprivation in

relation to

aging changes

ST>after 1

hour of

nursing

intervention

the patient

shall have

verbalized

understandin

g of sleep

disturbance

85

Lethargy

Disorientat

e

Dark

circles

under eyes

problems about

three times a

week. Asthma

has been

associated with

snoring and

obstructive sleep

apnea, a

condition in

which blockage

of the upper

airway causes

the sleeper to

temporarily stop

breathing, then

resume with a

gasp, often many

times during

each hour of

sleep.

LT>after 3

days of

nursing

intervention

the patient

will report

improveme

nt of

sleep/rest

pattern

occur and

frequency,

feelings of

fatigue,

apathy,

lethargy,

impotence

2. Assess

presence of

dyspnea

3. Assess

presence of

depression,

confusion and

anxiety

4. Assess use of

alcohol,caffein

e,medication

regimen

2. Causes of

frequent

awakenings

and

interruptions in

sleep

3. Common causes

of insomnia and

sleep

disturbance

pattern

4. Alters sleep

which may

cause

irritability,

lethargy, drug

action,

absorption and

excretion may

LT>after 3

days of

nursing

intervention

the patient

shall have

reported

improvement

of sleep/rest

pattern

86

5. Assess

environment

for lighting,

noises, odors,

temperature,

ventilation

6. Provide

ritualistic

procedures of

be delayed in

elderly and

adverse effects

and toxicity at

higher

riskExternal

stimuli

interferes with

going to sleep

and increases

wakenings as

sleep in the

elderly is of

less intensity

5. Prevents break

in established

pattern

And promotes

comfort and

relaxation

before sleep

87

warm drink,

extra covers,

clean linens,

warm bath

before bedtime

7. Provide quiet,

calm, peaceful

environment

8. Allow naps

during day

according to

need

recognizing

that they may

interfere with

sleep and

6. Promotes falling

asleep

7. Some elderly

prefer to sleep

throughout 24

hours with

short naps

providing

adequate rest

8. Promotes

relaxation

before sleep

and reduces

anxiety and

88

cause

insomnia

9. Provide back

rub, relaxation

techniques,

imagery,

music,

massage at

bedtime

10. Instruct

patient to

refrain from

use of alcohol

and CNS

depressants

11. Inform

patient of

aging changes

and their

relation to

sleep changes

tension

9. Depresses sleep

10. Assist in

acceptance of

changes and

need for sleep

revision of

sleep pattern

11. Prevents

falling asleep

because of

overstimulation

89

Problem #6 - Fatigue r/t respiratory effort

Assessment Nursing Diagnosis

Scientific Explanation

Objectives Interventions Rationale Expected Outcome

S>Ø

O> patient

may

manifest:

Irritability

Exhausted

appearanc

e

Lethargy

Listlessnes

s

Drowsy

Fatigue r/t

respiratory

effort

Hyperventilation

is triggered by

lung receptors to

increase lung

volume because

of trapped air

and obstructions.

Intrapleural and

alveolar gas

pressure rise,

causing a

ST> After 1

hour of

nursing

intervention

the patient

will

participate

in

therapeutic

regimen

1. Assess for

extreme

weakness and

fatigue; ability

to rest, sleep

and amount;

movement in

bed

1. Provides

information to

determine

effects of

dyspnea and

work of

breathing over

period of time,

which becomes

exhaustive and

depletes energy

ST> After 1

hour of

nursing

intervention

the patient

shall have

participated

in

therapeutic

regimen

90

Disinterest

in

surroundin

gs

decreased

perfusion of

alveoli.

Increased

alveolar gas

pressure,

decreased

ventilation, and

decreased

perfusion result

in uneven

ventilation-

perfusion ratios

and mismatching

within different

lung segments.

LT> after 3

days of

nursing

intervention

the patient

will report

improved

sense of

energy

2. Accept client’s

report of

fatigue

3. Establish

realistic goals

with client

4. Plan care to

allow adequate

rest periods.

Schedule

activities for

periods when

client has the

most energy

5. Provide

environment

reserve and

ability to rest,

eat, drink

2. To assist client

to cope with

fatigue and to

manage within

individual limits

of ability

3. Enhances

commitment to

promoting

optimal

outcomes

4. To maximize

participation

5. Temperature

and level of

LT> after 3

days of

nursing

intervention

the patient

shall have

reported

improved

sense of

energy

91

conducive to

relief of fatigue

6. Provide

supplemental

oxygen as

indicate

7. Encourage use

of measures to

prevent fatigue

(diversional

activities such

as wathcing

TV, small

frequent

feedings)

humidity are

known to affect

exhaustion

6. Presence of

anemia/hypoxe

mia reduces

oxygen available

for cellular

uptake and

contributes to

fatigue

7. Provide support

and conserves

energy

Problem #7 - Activity intolerance r/t imbalance between oxygen demand and supply

Assessment Nursing Diagnosis

Scientific Explanation

Objectives Interventions Rationale Expected Outcome

92

S>Ø

O> Patient

may

manifest:

Dyspnea

Tachypnea

Body

weakness

Use of

accessory

muscles to

breathe

Fatigue

Pale nail

beds

Pale

palpebral

conjunctiva

Cyanosis

Activity

intolerance

r/t

imbalance

between

oxygen

demand

and supply

Oxygen is

needed by the

body especially

in the process of

metabolism to

produce energy.

Due to excessive

mucus

production and

decrease

function of the

cilia to remove

secretions,

impaired

breathing results

to imbalance

between oxygen

demand and

supply from the

lungs to the body

and retention of

carbon dioxide

ST>After 1

hour of

nursing

intervention

the patient

will

participate

willingly in

necessary

activities to

increase

activity

tolerance

LT> After 3

days of

nursing

intervention

the patient

will

maintain

optimal

1. Assess for

baseline

tolerance for

activity, ability

to adapt,

amount of rest

and sleep

2. Assess pulse

and respirations

before, during

and after

activity

3. Provide periods

of rest after

activity around

rest or sleep

periods; allow

self pacing of

activities

1. Promotes and

protects

respiratory

functions

2. Pulse increase

of 10 or

more/min. or

increase and any

difficulty in

respirations

indicate that

activity limit has

been reached

3. Prevents

dyspneic episode

and provides

uninterrupted

rest and sleep

necessary for

physical and

ST>After 1

hour of

nursing

intervention

the patient

shall have

participated

willingly in

necessary

activities to

increase

activity

tolerance

LT> After 3

days of

nursing

intervention

the patient

shall have

maintained

93

occurs. activity

level within

energy and

breathing

limitations.

4. Provide quiet,

stress free

environment

5. Provide oxygen

during activities

if appropriate

6. Assist with

activities as

needed

7. Provide slowly

progressive

activity/exercise

program and

promote

independent

mental health to

prevent fatigue

4. Stress and

stimuli produce

anxiety and

increase

respirations

5. Pulmonary

function tests

indicate

hypoxemia

during exercise

and determine

need for

additional

oxygen

6. Conserves

energy and

oxygen

consumption;

prevents dyspnea

7. Increases

optimal

activity level

within energy

and

breathing

limitations.

94

ADL

participation

8. Instruct the

patient to avoid

extending

activities

beyond fatigue

level or

tolerance that

may provoke

dyspne

9. Instruct the

patient to utilize

energy saving

devices such as

arm rest, sitting

on stool in

shower, placing

articles

commonly used

within reach

delivery of

oxygen to

tissues;

increases

tolerance to

activities and

decreases feeling

of helplessness

8. Conserves

energy and

prevents

exacerbation of

dyspnea

9. Prevents fatigue

95

10. Instruct the

patient to

schedule

activities during

peak or optimal

effect time of

systemic

medication; use

inhalers before

activity

10. Allows for

activities without

dyspneic

episodes

96

ACTUAL NURSING CARE (SOAPIE)

June 24 2009

S>Ø

O>Received patient sitting on bed, awake and coherent to person place and

time, with an ongoing IVF#3 D5IMB 500cc regulated at 45 ugtts/min at a

level of 350cc, infusing well at the left hand, good skin turgor, rales on both

lung fields upon auscultation, with nonproductive cough, with nasal flaring,

CRT of 1-2 seconds with pinkish palpebral conjuctiva, with leukocytes of

4.52 dated June 24 2009 with vital signs as follows : T=36.9°C, HR= 95

bpm, RR= 26 cycles/min, BP=90/60 mmHg

A>

1. Ineffective airway clearance r/t retained secretions in the bronchi

2. Impared gas exchange r/t obstructions on the airway AEB rales upon

auscultation.

3. Ineffective protection r/t altered blood profile AEB decreased

leukocytes secondary to acute bronchitis.

P>

1. After 3° of NI the patient will maintain airway patency AEB absence of

respiratory distress.

2. After 3° of NI the patient will able to maintain adequacy of gas

exchange AEB absence of respiratory distress.

3. After 2° of NI the patient will be free from infection.

I>Established rapport

>Monitored and recorded vital signs

>Assessed patient’s condition and watch out for signs and symptoms of

respiratory distress

>provided comfort and safety measures

>kept patient’s back dry

>Encouraged to increase fiber intake and vitamin C

>Elevated the head of bed

97

>performed chest tapping/back rub to mobilize secretions

>provided nebulization as ordered

>Encourage turning position changes

>due meds given

>Further needs attended

>endorsed

E>

1. Goal met AEB patient able to maintain airway patency AEB

absence of respiratory distress.

2. Goal met AEB patient able to maintain adequacy of gas exchange

AEB absence of respiratory distress.

3. Goal met AEB patient was free from infection.

VI. CLIENT’S DAILY PROGRESS IN THE HOSPITAL

1) Client’s Daily Progress Chart

Days Admission

06/23/09 06/24/09

Nursing Problems

1.) Ineffective airway clearance r/t retained

secretions in the bronchi

2.) Ineffective breathing pattern r/t

tracheobronchial obstruction

3.) Impaired gas exchange r/t ventilation

perfusion imbalance

4.) High risk for infection r/t inadequate

primary defenses (decrease ciliary action)

5.) Sleep pattern disturbance r/t internal

factors of illness and psychological stress of

98

dyspnea

6.) Fatigue r/t respiratory effort

7.) Activity intolerance r/t imbalance

between oxygen demand and supply

Vital Signs

1.) Temp. 36.1C 36.8C

2.) PR 75bpm 95bpm

3.) RR 38cpm 26cpm

4.) BP 90/60 90/60

Diagnostic/Lab Procedures

1) Hematology

2.) CXR PA

3.) Urinalysis

4.) cold agglutinin determination

1)IVF D5 IMB 500 cc

2.) Neb

Drugs:

Paracetamol

Co amoxiclav

Pedzinc

Comvibent + fluticasone

Diet:

DAT

Activity/Exercise

Bederest

99

100

2. DISCHARGE PLANNING

A. General condition about the client upon discharge.

The client achieved his optimum health status after his hospitalization. He

has already adequate ventilation and oxygenation. No other associated

signs and symptoms of respiratory distress he appears generally in good

condition. There were no complications noted. Still, on the process of

recovery.

S> Ø

O> Received patient sitting on bed, awake and coherent, with an ongoing

IVF #6 D5 IMB 500cc x 45ugtts/min at level of 300cc infusing well at the

left dorsal veinof the hand, c good skin turgor, c cough, c (-) DOB, c V/S as

follows : T=36.8, PR= 90 bpm, RR= 25, BP=90/60 mmHg

A> Readiness for enhanced well being

P> After 2 hours of nursing intervention the patient will remain free of

preventable complications/progression of illness and sequelae and will

verbalize understanding of health teachings

M>

Paracetamol syrup 5ml every 4 hours for fever

Co amoxiclav 300mg every 8 hours for 5 days

Pedzinc syrup 5ml once a day

Combivent 1 neb every 6 hours

E> May resume activities as tolerated

101

T> Home maintenance and management

H> reinforce increase fluid intake

Avoid strenuous activities

Eat high caloric foods, rich in iron and vitamin C

Encourage proper hand washing.

Have an adequate rest

Instructed patient to be in high fowler’s position whenever

experiencing DOB

O> OPD after 1 week

D> DAT; preferably hypoallergenic diet

E> Goal met as evidenced by patient remained free of preventable

complications/progression of illness and verbalized understanding of health

teachings

VII. CONCLUSION AND RECOMMENDATION:

Acute bronchitis is a lower respiratory tract infection that causes

reversible bronchial inflammation. In up to 95 percent of cases, the cause is

viral. Acute bronchitis is caused in most cases by a viral infection and may

begin after developing a cold or sore throat. Bronchitis usually begins with

a dry cough. After a few days it progresses to a productive cough, which

may be accompanied by fever, fatigue, and headache. The cough may last

up to several weeks. If not treated acute bronchitis can progress to

pneumonia.

102

Bronchitis can have causes other than infection. Bronchial wall

inflammation can occur in asthma or can be secondary to mucosal injury in

an acute event, such as smoke or chemical fume inhalation. This

inflammation can also result from chronic toxic exposure, such as cigarette

smoking. It is important to realize that when underlying inflammation is

present, such as in asthmatics or smokers, infective agents are likely to

cause more severe cough and wheezing.

The role of nurses as well as student nurses as health care providers

is indeed important in order to attain the optimum level of wellness of all

clients. Suitable care must be carried out and health teachings must be

given to the client and/or relatives so that the needed care of the client is

not only bounded in the hospital rather could also be extended at home.

Thus, awareness of the disease condition will help the health care providers,

especially nurses. Enough information about diseases will help us to know

the proper interventions we can provide to our patients. It is important for

the health care provider to know the proper interventions and

responsibilities so that the patient will able to meet his/ her health needs.

Upon concluding this study, the group is fortunate enough to

understand the disease condition of the patient. It helped them to read

more topics about the patient’s condition and find ways to help the patient.

It also helped the group to understand different medications that the patient

has, and how it would affect the patient’s normal functioning. Through the

case, the student nurses were able to appreciate the value of preventing the

risks that may possibly arise from this condition and were able to gain

everlasting knowledge that will be sure of great help in rendering effective

and therapeutic care for future patients with the same case.

After having completed the said study, the group recommends the

study:

103

to the patients who have such disease conditions that they may

become aware of the disease they have and provide appropriate self

care.

to the health care providers especially nurses since they are the ones

who has direct interaction with the patient. Enough knowledge of the

health care providers will enable them to provide the correct

intervention for the patient.

VIII. Bibliography

BOOKS

Seeley R.; Essentials of Anatomy and Physiology(6th edition); McGraw-

Hill;New York USA

Doenger, et al. Nurse’s Pocket Guide (10th Edition); Schilling J. 2003

Black, Joyce et al. Medical-Surgical Nursing. St. Louis Missouri. 2005

Pilliteri, A., Maternal and Child Health Nursing: Care of the

Childbearing ang Childbearing Family (5th edition); Lippincott

Williams and Wilkins.2007

WEB

http://health.yahoo.com/respiratory-overview/acute-bronchitis-topic- overview/healthwise--hw32162.html

http://en.wikipedia.org/wiki/Acute_bronchitis

http://www.webmd.com/a-to-z-guides/acute-bronchitis-topic-overview

http://www.peacehealth.org/kbase/topic/major/hw32160/descrip.htm

http://en.wikipedia.org/wiki/Bronchitis

http://www.nlm.nih.gov/medlineplus/asthma.html#cat1

http://www.healthline.com/adamcontent/asthma/3

104

http://www.answers.com/topic/bronchopneumonia

http://www.sciencedaily.com /releases/2008/12/081208085002.htm

105

ANGELES UNIVERSITY FOUNDATIONCOLLEGE OF NURSING

ANGELES CITY

Acute Bronchitis

SUBMITTED BY:Bondoc, John Celestine

Group 54 BSN IV-14

SUBMITTED TO:Elmer D. Bondoc R.N. M.N.

DATE:

June 29, 2009