CHIEF COMPLAINTS:

• Difficulty of Breathing

• Productive Cough

• Fever

• HISTORY OF PRESENT ILLNESSMonths PTC, patient had cough, productive

sticky on and off, relieved by nebulization and regular checking with private MD. prescribed with unrecalled medication which affected temp. relief.

3 days PTC, recurrence cough, productive time to time with associated fever. Given biopsy. Nebulization continued.

Few hrs PTC, after Visiting a private MD and prescribed become medications, patient complained of chest heaviness and sudden onset of unresponsiveness and cyanosis.

NURSING HISTORY

• PAST MEDICAL HISTORY

NURSING HISTORY

Had a chronic smoker's cough for "10 or 15 years" which relative describes as being mild, non-productive and occurring most often in the early morning

Smoked 3 packs of cigarettes a week for the past 50 years

A retired fireman, who has been treated for mild hypertension, bronchitis, appendicitis (as a young adult)

NURSING HISTORY• GENOGRAM

• A. Vital Signs

T: 39.2 o C RR: 22 cpm

PR: 70 bpm BP: 100/70 mmHg

• B. Integumentary

- Skin: Light to deep brown

Poor Skin turgor

(+) Blisters

(+) lesions

(+) edema in the left carpal

(+) mass

(+) rashes

(+) Pallor

PHYSICAL ASSESSMENT

- Hair: Unevenly distributed hair

Thin hair

(-) lesions

(+) dandruff

(-) lice

- Nails: Prompt to return in pink color

Angle of nails about >1650 Clubbed fingers

Intact epidermis

(+) capillary refill test

PHYSICAL ASSESSMENT

• C. Head and Neck

- Head: Size: Normocephalic

Asymmetrical facial features and movement

(-) nodules or masses

Rough skull contour

- Eyes: Blurred O.U Visiona

Eyebrows of hair in unevenly distributed

Puffy lower eyelids

Darkened areas around the eyes

Skin broken

PHYSICAL ASSESSMENT

- Eyes: (+) discharge; (+) discoloration

Eyelids is asymmetrical

7 involuntary blinks per minute

pale conjunctiva

(-) edema over lacrimal gland

3 mm in diameter; round, smooth border, iris flat

Both eyes are uncoordinated

PHYSICAL ASSESSMENT

PHYSICAL ASSESSMENT- Ears: External ear color: same as the

facial skin

decreased hearing perception

(+) discharge

(-) masses at sinuses

Auricle aligned with outer canthus of eye

PHYSICAL ASSESSMENT- Nose: Symmetric; straight

(+) discharge

(+) lesion

Uneven color

Pale mucosa

Nasal septum intact and in

midline

PHYSICAL ASSESSMENT- Mouth: Outer lips: pale color

rough texture

Unable to purse the lips

Gums: Pale & dry

Tongue: unable to move freely

(+) nodules

Soft Palate: pale, rough

Hard Palate: pale, irregular

Pharynx: (+) discharge

(+) Sputum

(+) Cough

Depressed gag reflex

PHYSICAL ASSESSMENT- Neck: Muscle equal size; head

centered

(+) nodules or masses

Trachea: in the middle: spaces are equal in both sides

Thyroid gland: ascends during swallowing; not visible

(-) bruit

(+) Endotracheal tube

(+) Face mask

• D. Thorax and LungsChest symmetricalshallow, weak, arhythmic & effort

respiration(+) Crackle sound & adventitious soundunder oxygen therapy

• E. Breast and AxillaeAxillary: (-) tenderness & masses

• F. Heart(+) Irregular heart sounds

PHYSICAL ASSESSMENT

• G. AbdomenUneven color(+) lesion; (+)pigmentation Asymmetrical contourAsymmetric movement caused by

respiration(+) PEG

• H. Genitourinary(+) Lesion(+) indwelling catheter

PHYSICAL ASSESSMENT

• I. Musculoskeletal

decreased immobility

(+) tremors

Uncoordinated movements

Joints immovable

Weak on both sides

PHYSICAL ASSESSMENT

• J. Neurological Language: (+) defectsUnable to communicate verballyOrientedMemory: unable to recall recent &

remote memoryAttention Span: limitedMotor function: unable to move

independently, flat on bedPain Sensation: unable to distinguish

“sharp” to “dull

Reduced level of consciousness

PHYSICAL ASSESSMENT

SIGNIFICANT SIGNS AND SYMPTOMS

Problems in breathing Adventitious Breath SoundCoughing that produces

greenish and yellow sputumFever Cyanosis Nail Clubbing

DIAGNOSTIC EXAMINATION•Sputum Tests:

Blood, which means an infection is present. Color and consistency: If it is yellow, green, or brown, an infection is likely.

•Blood test:WBC 17,000/mm3; neutrophils 70%, bands 15%, lymphocytes 15%.

•Chest x-ray:Reveals a patchy left lower lobe infiltrate

DEFINITION

DEFINITION

Streptococcus pneumoniae

PHYSIOLOGYUpper Respiratory Tract :

NARES

NASO PHARYNX

EPIGLOTTIS

TRACHEA

LARYNX

Lower Respiratory Tract :

TRACHEA

(BIFICATES INTO 2 BRONCHI)

BRONCHIOLES

UPPER

ALVEOLAR DUCTS

ALVEOLAR SACS

PATHOPHYSIOLOGY

Conditions that produce mucus or

bronchial obstruction

Immunosuppressed patients

Smoking

Prolonged immobility

Depressed cough reflex, aspiration

RISK FACTORS

NPO status, placement of NGT

Antibiotic Therapy

Alcohol intoxication

General anesthetics, sedative,

opioid preparation

Respiratory therapy

Advance age (non-modifiable)

RISK FACTORS

Actual: Ineffective airway clearance due to

inflammation of bronchi as manifested by accumulation of bronchial secretion

Impaired gas exchange related to inflammatory process, collection of secretion affecting oxygen exchange across alveolar membrane

Activity intolerance related to imbalance between oxygen supply and demand, general weakness

NURSING DIAGNOSIS

Probable:

Risk for aspiration related to decreased gag reflex

Risk for impaired skin integrity related to decreased oxygen supply in the blood circulation

NURSING DIAGNOSIS

Nursing Care Plan

I. ASSESSMENT

Subjective:

“Kapag gising niya panay ang ubo niya,” as verbalizad by the patient’s relative

Objective:

-Respiration-22 cpm

-O2 Saturation- 94%

-Presence of secretion

-Inspiratory crackles with adventitious breath sounds right base

-Increased sputum production

NURSING DIAGNOSIS

Ineffective airway clearance due to inflammation of bronchi as manifested by accumulation of bronchial secretion

PLANNING

After an hour of nursing intervention the patient will be able to expectorate

secretions

INTERVENTION

A. Monitor respirations and breath sounds, rate, rhythm, and effort

-To check for any improvements and abnormal changes

B. Auscultate breath sounds and assess air movement to ascertain status and note progress

-To assess the status

C. Monitor pulse oximeter- To check for any improvements

and abnormal changes

D. Place client in semi-fowlers position

-To facilitate breathing and lung expansion

E. Encourage coughing and deep breathing exercise

-To promote wellness

F. Increase fluid intake to at least 1000ml/day

- To loosen secretions for easily release

INTERVENTION

EVALUATION

The patient will be able to expectorate secretions

II. ASSESSMENTSubjective cues:No subjective cues

Objective cues:-With oxygen via face mask

through endotracheal tube-Pallor-Shortness of breathing-Irregular breathing pattern

NURSING DIAGNOSIS

Impaired gas exchange related to inflammatory process, collection of secretion affecting oxygen

exchange across alveolar membrane

-After an hour of nursing intervention the patient will be able to demonstrate improve ventilation and adequate oxygenation of tissues by ABG’s within the client’s normal limits

PLANNING

INTERVENTIONA. Monitor respiratory status

-to assess for any clinical manifestations respiratory distress

B. Place client in semi-fowler’s position-to promote lung expansion

C. Encourage deep breathing exercise-provides for adequate oxygenation

D. Maintain oxygen administration device as ordered- provides for adequate oxygenation

E. Change patient’s position every 2 hours- To facilitate secretion movement and drainage

EVALUATION

-After an hour nursing intervention the patient will be able to demonstrate improve ventilation and adequate oxygenation of tissues by ABG’s within the client’s normal limits

III. ASSESSMENT

Subjective cues: “Palagi na lang siya nakahiga”, as

verbalized by the patient’s relative Objective cues:Excessive coughingPresence of respiratory

problemsDevelopment of pallor

NURSING DIAGNOSIS

Activity intolerance related to imbalance between oxygen supply and demand,

general weakness

PLANNINGAt the end of the shift the client

will be able to demonstrate a measurable increase in tolerance to activity with absence of dyspnea and

exercise fatigue

INTERVENTIONA. Evaluate patient’s response to activity

-Reduce stress and excess stimulation, promoting rest

B. Provide a quiet environment and limit visitors-Bed rest is maintained during acute phase to decrease metabolic demands, thus conserving energy for healing

C. Explain importance of rest in treatment plan- Reduce stress and excess stimulation, promoting rest

EVALUATION

At the end of the shift the client will be able to demonstrate a measurable increase in

tolerance to activity with absence of dyspnea and exercise fatigue

VII. ASSESSMENT

Subjective cues:

-No subjective cues

Objective cues:

-impaired swallowing

-depressed cough and gag reflex

-reduced level of consciousness

NURSING DIAGNOSIS

Risk for aspiration related to depressed gag reflex

PLANNING

At the end of shift the client will be able to exhibit preventions of

aspiration

INTERVENTIONA. Assess and monitor amount and

consistency of respiratory secretions

-To assess contributing factors

B. Assess and monitor strength of cough and gag reflex

-To assess causative factors

C. Auscultate lung sounds frequently

-To determine presence of secretions

D. Encourage coughing and deep breathing exercise

-To loosen secretionsE. Provide chest physiotherapy

-To loosen secretionsF. Maintain suction equipment at bedside

-As needed to clear secretions at the respiratory tract and oral cavityG. Turning patient to semi-fowler’s position

-To prevent gastroesophageal reflux

EVALUATION

At the end of shift the client will be able to exhibit preventions of

aspiration

VIII. ASSESSMENT

Subjective cues:

- No subjective cues

Objective cues:

- Weak joints

- Decreased immobility

- cyanosis

NURSING DIAGNOSIS

Risk for impaired skin integrity related to decreased oxygen supply in the blood

circulation

PLANNING

At the end of the shift, the client will be able to prevent the risk for skin

integrity

INTERVENTION

A. Elevate the lower extremities every 15 minutes

-To promote venous return

B. Massage the upper and lower extremities

-to promote blood circulation

C. Repositioning every 2 hours

-to prevent pressure ulcers

D. Encourage Deep Breathing exercise

-To promote gas exchange

E. Provide oxygen therapy

- for adequate oxygenation

F. Assist patient in turning side to side

-To promote mobilization

EvaluationAt the end of the shift, the client will be able to prevent the risk for skin integrity

DRUG STUDYGENERIC: Ceprofloxacin

BRAND: Cipro XR

Classification: Antibiotic

Drug Action: broad-spectrum antibiotic that is active against both Gram-positive and Gram-negative bacteria. It functions by inhibiting DNA gyrase, a type II topoisomerase, and topoisomerase IV, enzymes necessary to separate bacterial DNA, thereby inhibiting cell division.

Side effects: Dizziness, Fever, Headache, Sore throat, Skin rash, Nausea and vomiting, Sleep problems, Anxious, Increased sensitivity to sunlight exposure

DRUG STUDY

Indication: Urinary tract infection, Chronic bacterial prostatitis, Lower respiratory infection, Acute sinusitis, Skin infection, Typhoid fever

Contraindication: Pregnancy, Breast feeding mother, Kidney diseases, STD, Pedia

Nursing Intervention:•Advise patient not to take with dairy products•Assess patient for any kidney disease, joint problems, hypokalemia•Avoid taking antacid, vitamin supplements, or chewable tablets 6 hours before of 2 hours after taking ceprofloxacin

DRUG STUDYGENERIC: Metronidazole

BRAND: Flagyl

Classification: Antiamoebics, Antibiotics

Drug Action: Antibiotic effective against anaerobic bacteria and certain parasites. Anaerobic bacteria are single-celled, living organisms that thrive in environments in which there is little oxygen (anaerobic environments) and can cause disease in the abdomen (bacterial peritonitis), liver (liver abscess), and pelvis (abscess of the ovaries and the Fallopian tubes)

DRUG STUDYSide effects: Nausea, Diarrhea, Vomiting, Dizziness, Headache, Rash, Itch, Fever, Dark urine

Indication: Anaerobic bacterial infection

Contraindication: Hypersensitivity, History of blood dyscrasias, Active organic disease of CNS, 1st trimester of pregnancy, lactation

Nursing Intervention:•Avoid alcohol intake•Check the blood glucose level of the patient before administration of drug•Assess for liver problems, seizure disorder and any allergies

DRUG STUDYGENERIC: Ansimar

BRAND: doxofylline

Classification: Anti-asthmatic

Drug Action: Adenosine-nonblocking anti-asthmatic drug with potent bronchodilator activity that does not display the typical extrapulmonary side effects of theophylline--a potent adenosine antagonist The contractile force of electrically stimulated left atria was affected by doxofylline starting at 0.3 mM.

DRUG STUDYSide effects: Nausea & Vomiting, Epigastric pain, Tachycardia, Insomnia, Tachypnea

Indication:Bronchial asthma, Pulmonary disease with spastic bronchial content

Contraindication: Acute MI, Hypotension, Lactation, Liver disease, Chronic obstructive lung disease, Pregnancy

Nursing Intervention•Check the blood pressure•Instruct the patient to take ansimar with or without food•Check the heart rate

DRUG STUDYGENERIC: Maicostat

BRAND: Nystatin

Classification: Antifungal and Antibiotics

Drug Action: nystatin binds to ergosterol, a major component of the fungal cell membrane. When present in sufficient concentrations, it forms pores in the membrane that lead to K+ leakage and death of the fungus.

DRUG STUDYSide effects: Diarrhea, Oral irritation, GI distress, Nausea and vomiting, Rashes

Indication: Intestinal or esophageal candidiasis, Oral lesion

Contraindication: Pregnancy

Nursing Intervention:•Instruct patient to take nystatin with an empty stomach•Instruct patient not to take food or drinks 1 hour after the administration

1. Take the entire course of any prescribed medications

2. Get plenty of rest

3. Drink lots of fluids, especially water.

4. Keep all of follow-up appointments

5. Encourage the guardians to wash patient’s hands.

6. Tell guardians to avoid exposing the patient to an environment with too much pollution (e.g. smoke).

7. Give supportive treatment

8. Protect others from infection.

DISCHARGE PLANNING