np final.doc

7/27/2019 NP final.doc

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Far Eastern University

Institute of Nursing

Summer 2009

CASE PRESENTATION

CALALANG GENERAL HOSPITAL

Presented by:

Chua, Michelle France

Costales, Ronida

Cristobal, Jo-anne

Cubos, Maria Excelsa

Del Rosario, Marvin

Dizon, Keppler Hannes

De Guzman, Erika Bianca

Domingo, AvegailDomingo, Dionebe Jane

Duru, Mary Grace

Estrella, Christian R.

Gonzaga, Jean Petit

BSN 026-Group 102

Submitted to:

Mrs. Ramona Jean Miraflores


2/13

TABLE OF CONTENTSIntroduction

Background of the study

Rationale for choosing the case

Significance of the study

Scope and limitation of the study

Clinical Summary

General data

c/c

History of present illness

Past medical history

Family history

Physical assessment

Body Part

standard actual finding

interpretation

analysis with reference

Patterns of functioning

actual

interpretation

analysis

Daily Activity Patterns

before hospitalization during hospitalization

Interpretation and analysis

Patient's Concept of Health, Illness and Hospitalization. Labs / Diagnostic exams

a. Date ordered

b. examc. Normal value

d. Actual result

e. Interpretation and analysis

Impression/ Diagnosis Course in the ward (day to day progress report)

Clinical Discussion of the disease

Anatomy and Physiology

Schematic Diagram of the disease

Drug Studya. Date


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b. Generic and brand name

c. Dosage, frequency and route (actual as ordered)

d. classificatione. Specific indication

f. action

g. side effectsh. adverse reaction

i. Nursing Considerations

Ecologic Model

Nursing Care Plan

Long term objective

Problem list/ prioritization

NCP

a. cuesb. Nursing diagnosis

c. goals and ojectivesd. introduction

e. rationalef. evaluation

Discharge Planning

medicines

exercise

treatments

health teachings

outpatient follow up

diet Spiritual advice


4/13

Far Eastern University

Institute of Nursing

Case Presentation

Calalang General Hospital

I. INTRODUCTION

Pneumonia is an inflammation of the lungs caused by an infection. It is also

called Pneumonitis or Bronchopneumonia. The air sacs in the lungs fill with pus andother liquid. Oxygen has trouble reaching your blood. If there is too little oxygen in your

blood, your body cells can't work properly. Because of this and spreading infection

through the body pneumonia can cause death. Pneumonia affects your lungs in two ways.

Lobar pneumonia affects a section (lobe) of a lung. Bronchial pneumonia (orbronchopneumonia) affects patches throughout both lungs.

For most people, pneumonia can be treated at home. It often clears up in 2 to 3

weeks. But older adults, babies, and people with other diseases can become very ill. They

may need to be in the hospital. You can get pneumonia in your daily life, such as atschool or work. This is called community-based pneumonia. You can also get it when

you are in a hospital or nursing home. This is called hospital-based pneumonia. It may bemore severe because you already are ill. Respiratory viruses are the most common causes

of pneumonia in young children, peaking between the ages of 2 and 3. By school age, the

bacterium Mycoplasma pneumoniae becomes more common.Pneumonia usually starts when you breathe the germs into your lungs. You may

be more likely to get the disease after having a cold or the flu. These illnesses make it

hard for your lungs to fight infection, so it is easier to get pneumonia. Having a long-

term, or chronic, disease like asthma, heart disease, cancer, or diabetes also makes youmore likely to get pneumonia.

Pneumonia can be a serious threat to our health. Although pneumonia is a special

concern for older adults and those with chronic illnesses, it can also strike young, healthypeople as well. It is a common illness that affects thousands of people each year in the

Philippines, thus, it remains an important cause of morbidity and mortality in the country.

There are many kinds of pneumonia that range in seriousness from mild to life-threatening. In infectious pneumonia, bacteria, viruses, fungi or other organisms attack

your lungs, leading to inflammation that makes it hard to breathe.

Pneumonia can affect one or both lungs. In the young and healthy, early treatment

with antibiotics can cure bacterial pneumonia. The drugs used to fight pneumonia aredetermined by the germ causing the pneumonia and the judgment of the doctor. Its best

to do everything we can to prevent pneumonia, but if one do get sick, recognizing and

treating the disease early offers the best chance for a full recovery.A case with a diagnosis of Pneumonia may catch ones attention, though the

disease is just like an ordinary cough and fever, it can lead to death especially when no

intervention or care is done. Since the case is a toddler, an appropriate care has to be doneto make the patients recovery faster. Treating patients with pneumonia is necessary to

prevent its spread to others and make them as another victim of this illness.
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B. Rationale for Choosing the Case

This study focuses on the client's diagnosis with pneumonia. This will help thenurse to be knowledgeable about the background of this illness. This will reveal etiology,

causes, signs and symptoms, treatments and the proper nursing intervention and

management that should be given to the patient experiencing this respiratory illness. Itcan be a guide for the nurses in rendering quality care to their clients having this

condition, and so that we could also apply them on our future exposures as a student and

eventually as a nurse.

C. Significance of the Study

The study will produce ways to further improve nursing practice in patient withpneumonia as it points out factors that contribute to poor nursing care.

The study will extend the previous knowledge in dealing the cases of pneumonia. This will also provide further adequate information for future studies.

D. Scope and Limitation of the Study

Our study will discuss about pneumonia. We will going to define the different

concepts and terms that is related to our study. We will also discuss the anatomyand physiology of the respiratory system. We will also discuss the different

factors (modifiable and non-modifiable) that can contribute to this disease. The

signs and symptoms of signs and symptoms, the medical treatment and the

prevention of this disease will be discussed also.

II. CLINICAL SUMMARY

A. General Data

NAME: C.A. M.

SEX: Female

BIRTHDATE: April 6, 1999

AGE: 10 y/o

ADDRESS: 4A Rubyville Subd. F Lazaro ST. Canumay. Valenzuela City

RELIGIOUS AFFILIATION: Roman Catholic

CHIEF COMPLAINT: fever

DIAGNOSIS: t/c ATP r/o Pneumonia

ROOM AND BED NO.: 304

ATTENDING PHYSICIAN: Dr. Calalang and Dr. Licuanan

B. Chief Complaint

The client was brought to Calalang General Hospital by her parents because the client

manifested a high temperature of 38c and accompanied by epigastric pain.


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C. Nursing History

History of present illness:

The client first experienced sudden onset of fever last Thursday May 7, 2009. The

family decided to confine C.M. at Calalang General Hospital in Valenzuela. Four days

prior to confinement the client had fever with a temperature of 37.7 degrees centigrade.Three days before confinement the client was taken to a private clinic because she

experienced low grade fever the medication that were given cefaclor,paracetamol. She

still experienced fever 2day before admission into the hospital. One day prior toconfinement still with fever and headache and client reported that she also experienced

pain in chest that radiates towards her abdomen. No other symptoms were noted such as

cough,colds, dysuria, vomiting and diarrhea. The chief complaint of the client when she

was admitted is fever and the diagnosis is t/c Acute tonsillopharyngitis and r/opneumonia. The medication given to her are Dicyclocerine 10 mg/ 5ml q8h, Ampicillin

500 mg/ 10 ml intravenous q6h, Paracetamol 500 mg/ 5ml q RTC & q4h 5ml and

Ranitidine 250mg/10 ml q8h.

Past health history:

According to her motherC.M. has a childhood illnesses such as pneumonia at theage of 6months years old, Amoebiasis at age of 1yr. old and reoccurred when she was

2yrs. old. She also had a primary complex at the age of 7 yrs. old. The mother said that

her daughter was vaccinated at the Chinese General Hospital and continued the remainingshots at Valenzuela. C.M. has a complete vaccinations and boosters. Her mother stated

that her daughter has no allergies for foods but for the medications, she said that when

C.M. was 7 yrs. old the nurse told them that the result of the skin test was positive and

that drug cannot be used for her daughter. The mother cannot recall the name and thepurpose of that drug. C.M. doesnt have any accidents. Our client had been hospitalized

four times; the first time that she was hospitalized is at the Santa Rosario hospital in

Valenzuela. She was confined there for 2 to 3 days because of pneumonia. The secondtime she had been hospitalized is at the Monte Falco in Maycauayan and she was

confined there for 2 to 3 days because of amebiasis. The third time is again in Monte

Falco Hospital, she was confined there for about 2 days because of her primary complex.The fourth time is her recent hospitalization in Calalang general hospital; the diagnosis is

acute tonsillopharyngitis and r/o pneumonia. The medications that were prescribed and

used by our client are the ff: Cefalaxin 250 mg 3x a day, Cefaclor 250 mg, Cloxacicilin

and Ibufropen. While the medications that are being taken currently by our client are theff: Dicyclocerine 10 mg/ 5ml q8h, Ampicillin 500 mg/ 10 ml intravenous q6h,

Paracetamol 500 mg/ 5ml q RTC & q4h 5ml and Ranitidine 250mg/10 ml q8h. The

client has never left the country before.

Family History of present Illness

D. Physical Assessment

HEAD TO TOE PHYSICAL ASSESSMENT


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E. Patterns of Functioning

A. Psychological Health

Analysis:

Many elderly persons feel a lack of purpose and decreased self-esteem. Thesefeelings in turn reduce their motivation to engage in health-promoting behaviors, such as

exercise or community and family involvement.

Fundamentals of Nursing

By Barbara Kozierpp. 194

Elders experience many losses and changes in their lives. They may beincremental and, over time, become stressful and possibly overwhelming. Changes in

health decreased functional ability and independence.

Fundamentals of NursingBy Kozier

pp. 1026

Communication normally contributes to a clients sense of security andfeelings that he or she is not alone.


By Barbara Kozierpp.439

B. Socio-cultural Health

Analysis:

Having a support network (family, friends, or a confidant) and job satisfaction

helps people avoid illness. Support people also help the person confirm that illness exists.People with inadequate support networks sometimes allow themselves to become

increasingly ill before confirming the illness and seeking therapy. Support people alsoprovide the stimulus for an ill person to become well again.


By Barbara Kozierpp. 178


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C. Spiritual Pattern

Analysis:

Fowler describes faith as being present in both religious and non-religious

people. Faith gives life meaning, providing the individual with strength in times ofdifficulty. For the client who is ill, faith whether in a higher authority (e.g., God, Allah,

Jehovah), in oneself, in the health care team, or in a combination of all provides

strength and hope.Fundamentals of Nursing

By Barbara Kozier

pp.997

Patients concept of health, illness and hospitalization.

Her own concept about health is that if a person can perform activities such asplay with friends, eat, dance the person is healthy. Where as if a person cant perform the

activities eat, dance, play with friends the person is ill.

She said the environment in the hospital is quite and she is feels bored most

times. But she feels better healthier than before when she was ill.

F. LABORATORY AND DIAGNOSTICS EXAMINATIONS RESULT

Date Procedure Norms Result Interpretation andAnalysis

5/10/09 CBC

Hemoglobin 120-160 g/L 135.0 Normal

Total WBC 5-10x10 g/L 9.0 Normal

Total PHI 150-350 x 10 g/L 272 Normal

Hematocrit 0.38-0.50 0.41 Normal

Segmenter 0.40-0.60 0.69 Abnormal

Analysis:Elevation of

segmenters may

indicates presence ofinfection; means that

many band

(immature)cells arepresent as the body

fights infection

Lymphocytes 0.20-0.40 0.31 Normal


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5/10/09 Urinalysis

Color straw, amber andtransparent toyellowish

1+ yellow Normal

Specific gravity 1.010-1.025 1.010 Normal

pH(Reaction) 4.5-8.0

(average:6)slightly acidic

6.5 Normal

Transparency Clear hazy Abnormal

Analysis: White bloodcells, bacteria, pus or

contaminants may cause

cloudy urine.

(Fundamentals ofNursing 7th edition by

Kozier pg. 1264)

Interpretation:

Albumin absent negative Normal

Sugar absent negative Normal

Puss cell absent 0.2/hpf abnormal

Sq. epithelium few

Bacteria occasional

IMPRESSION/ DIAGNOSIS

COURSE IN THE WARD (DAY TO DAY PROGRESS REPORT)

On the first day of our interaction with the client we asked her situation before she

was admitted; her mother said she had fever and headache. Her facial expression,

movements, and the way she answers questions are appropriate for her conditions. Shesmiled, she was jolly she said she feels better and stronger than before.

The next day which was on the 13th, the mother told us that her daughter will bedischarged. She looked happy and she felt relieved from the obstruction such as the IV

infusion, not long before then, she vomited and had an increase in temperature so thedoctor ordered another IV infusion to infuse and continuation of medication.

The third day, she said she felt better than before. Then we checked her vital

signs, and give her medications.


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III. CLINICAL DISCUSSION

A. Anatomy and Physiology

The lungs constitute the largest organ in the respiratory system. They play an

important role in respiration, or the process of providing the body with oxygen andreleasing carbon dioxide. The lungs expand and contract up to 20 times per minute takingin and disposing of those gases.

Air that is breathed in is filled with oxygen and goes to the trachea, which

branches off into one of two bronchi. Each bronchus enters a lung. There are two lungs,one on each side of the breastbone and protected by the ribs. Each lung is made up of

lobes, or sections. There are three lobes in the right lung and two lobes in the left one.

The lungs are cone shaped and made of elastic, spongy tissue. Within the lungs,

the bronchi branch out into minute pathways that go through the lung tissue. The

pathways are called bronchioles, and they end at microscopic air sacs called alveoli. Thealveoli are surrounded by capillaries and provide oxygen for the blood in these vessels.

The oxygenated blood is then pumped by the heart throughout the body. The

alveoli also take in carbon dioxide, which is then exhaled from the body. Inhaling is dueto contractions of the diaphragm and of muscles between the ribs. Exhaling results from

relaxation of those muscles.

Each lung is surrounded by a two-layered membrane, or the pleura, that under

normal circumstances has a very, very small amount of fluid between the layers. Thefluid allows the membranes to easily slide over each other during breathing.

Lungs

The right lung has three lobes, while the left lung has two lobes. The two lungs are separated by a space called mediastinum.

There are approximately three hundred million alveoli in the lungs.

The right lung is broader, but shorter due to the presence of the liver on the right

side of the abdomen.

Residual volume is the amount of air that remains in the lungs after forceful

expiration. It prevents collapse of the lungs during expiration.(1200ml)

Tidal volume is the amount of air that moves in and out of the lungs with eachnormal breaths (500ml)

Inspiratory reserve volume is the amount of extra air that can be inhaled after a

normal breath Expiratory reserve volume is the amount of extra air that can be exhaled after a

normal breath

Total lung capacity is the total of all four volumes (residual, tidal, Inspiratory andexpiratory reserve volume)

Functional residual capacity is the amount of air that remains in the lungs after

normal exhalation


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Pneumocytes. The type I pneumocytes line the alveoli whereas type II

pneumocytes produce surfactant.

Thorax and diaphragm

The thorax provides protection for the lungs, heart and great vessels

The thorax is made up of 12 pains of ribs, bounded anteriorly by the sternum andposteriorly by the thoracic vertebrae

The diaphragm is the main respiratory muscle for inspiration. It is supplied by the

phrenic nerve.

The ff are the accessory muscles: for inspiration: sternocleidomastoid,

scalene,parasternal, trapezius, and perctoralis muscles. They are used during

increased work of breathing

C. Schematic Diagram of the disease

Pathophysiology of Pneumonia

Entry of Microorganism to Nasal Passage

invasion of the respiratory system

activation of immune response (cough)

ineffective immune response results to overwhelming

invading lung parenchyma

release of endotoxins and exotoxins

continuous mucus production

massive inflammation (pneumonia) with hazy portion of the chest and dyspnea

altered gas exchange

consolidation

C. Drug Study (see landscape page)

III. ECOLOGIC MODEL (see landscape page)


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IV. NURSING PROCESS

A. Long-term Objective

B. Problem List

C. Nursing Care Plans (see landscape page)

D. Discharge Planning

METHODS

Medication

Describe the importance of regularly taking of prescribed medications including the

potential unpleasant effects of non compliance

Instruct the client to continue with follow up medical care

Advise the client not to miss the intake of medications given by her physician upon

discharge.

Environment and exercise

Maintain a quiet, pleasant, environment to promote relaxation.-Provide clean and

comfortable environment.

Have regular exercise. Encourage walking everyday.

Be active on physical activities.

Treatment

Continue home medications.

For the follow-up check-up repeat.

Encourage patient to take multivitamins for immunity

Health Teachings

Explain the underlying disorder and treatment plan.

Lifestyle change (proper food preference)

general health measures (adequate sleep, proper diet, and maintaining a clean

surrounding).

Instruct patient to limit his activity for 24 to 48 hrs after discharge.

Provide written and oral instructions about activity, diet recommendations, medications, and

follow-up visits.


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Out Patient

Patient will be advised to go back in the hospital in a specific date to have a follow-up check

up after discharge.

Consult doctor for are any problems or complications encountered.

Diet

diet as tolerated as much as possible

Spiritual

Nursing actions to help clients meet their spiritual needs include:

providing presence

supporting religious practices

assisting clients with prayer

referring client for spiritual counseling

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