)Divine Word College of Laoag

School of Nursing
Laoag City
In Partial Fulfilment of the Course Requirements in NCM 103

Community Acquired Pneumonia High Risk (HR),

Pulmonary Tuberculosis Far Advanced (FA)

Submitted By:
Agtang, Xenos Guian C.
Acob, Aileen Fe Veronica U.
Agsunod, Rizza Joy C.
Dumbrique, Euselle Jenine C.
Manuel, Anne Clarisse S.
Rafanan, Tey Angela H.
Simeon, Jamaica Austine E.
Suguitan, Ian Christopher D.
Group 8

Submitted to:
Halston Joseph Castro R.N
Paula Marie C. Mariano R.N
Penelope A. Paz R.N
Aida D. Balucay R.N, MAN

October 17, 2012

I. PERSONAL DATA
NAME: Perlita Abaton
ADDRESS: Brgy. 10-N Lacub, Batac, Ilocos Norte
HOSPITAL NUMBER: 029891
GENDER: Female
AGE: 58 y/o
DATE OF BIRTH: April 13, 1954
PLACE OF BIRTH: Sinait, Ilocos Sur
CIVIL STATUS: Married
RELIGION: Church of Christ
OCCUPATION: Housewife
CHIEF COMPLAINT/ S: Cough and difficulty of breathing
ADMITTING DIAGNOSIS: Bronchial Asthma with Acute Exacerbation, Community
Acquired Pneumonia T/C PTB.
DATE AND TIME OF ADMISSION: August 19, 2012 @ 5:30 PM
ATTENDING PHYSICIAN: Dr. Cocson/Dr. Tomas
FINAL DIAGNOSIS: Community Acquired Pneumonia High Risk (HR), Pulmonary
Tuberculosis Far Advance (FA)
DATE AND TIME OF DISCHARGE: August 28, 2012 @ 1:00 PM

II. PATHOPHYSIOLOGY
1. ANATOMY AND PHYSIOLOGY
RESPIRATORY SYSTEM

The respiratory system is composed of the upper and lower respiratory tracts. Together,
the two tracts are responsible for ventilation (movement of air in and out of the airways). The
upper respiratory tract, known as the upper airway, warms and filters inspired air so that the
lower respiratory tract (the lungs) can accomplish gas exchange.

Gas exchange involves

delivering oxygen to the tissues through the bloodstream and expelling waste gases, such as
carbon dioxide, during expiration.

The respiratory system works in concert with the

cardiovascular system; the respiratory system is responsible for ventilation and diffusion, and the
cardiovascular system is responsible for perfusion.

The organs of the respiratory system include the nose, pharynx, larynx, trachea, bronchi
and their smaller branches and the lungs, which contain the alveoli, or terminal air sacs. Because
gas exchanges with the blood happen only in the alveoli, the other respiratory system structures
are really just conducting passageways that allow air to reach the lungs.

However, these

passageways have another, very important job. They purify, humidify, and warm incoming air.

Thus, the air finally reaching the lungs has many fever irritants (such as dust or bacteria) than
when it entered the system, and it is warm and damp.

Organs of the Respiratory System

Upper Respiratory Tract

1. Nose
The nose is the only externally visible part of the respiratory system. During breathing,
air enters the nose by passing through the nostrils, or nares. The interior of the nose consists of
the nasal cavity, divided by a midline nasal septum. The olfactory receptors for the sense of
smell are located in the mucosa in the slitlike superior part of the nasal cavity, just beneath the
ethmoid bone. The rest of the mucosa lining the nasal cavity, called the respiratory mucosa, rests
on a rich network of thin walled veins that warms the air as it flows past. (Because of the
superficial location of these blood vessels, nosebleeds are common and often profuse.) In
addition, the sticky mucus produced by the mucosas glands moistens the air and traps incoming
bacteria and other foreign debris, and lysozyme enzymes in the mucus destroy bacteria
chemically.
The lateral walls of the nasal cavity are uneven owing to three mucosa-covered
projections, or lobes, called conchae, which greatly increase the surface area of the mucosa

exposed to the air. The conchae also increase the air turbulence in the nasal cavity. As the air
swirls through the twists and turns, inhaled particles are deflected onto the mucus-coated
surfaces, where they are trapped and prevented from reaching the lungs.
2. Pharynx
The pharynx is a muscular passageway about 13cm (5 inches) long that vaguely
resembles a short length of red garden hose. Commonly called the throat, the pharynx serves as
a common passageway of food and air. It is continuous with the nasal cavity anteriorly via the
posterior nasal aperture.
Air enters the superior portion, the nasopharynx, from the nasal cavity and then descends
through the oropharynx and laryngopharynx to enter the larynx below. Food enters the mouth
and then travels along with air through the oropharynx and laryngopharynx. But instead of
entering the larynx, food is directed into the esophagus posteriorly.
Clusters of lymphatic tissue called tonsils are also found in the pharynx. The pharyngeal
tonsil, often called adenoid, is located high in the nasopharynx. The palatine tonsils are in the
oropharynx at the end of the soft palate, as are the lingual tonsils, which lie at the base of the
tongue.
3. Larynx
The larynx or voice box routes air and food into the proper channels and plays a role in
speech. Located inferior to the pharynx, it is formed by eight rigid hyaline cartilages and a
spoon-shaped flap of elastic cartilage, the epiglottis. The largest of the hyaline cartilages is the
shield-shaped thyroid cartilage, which protrudes anteriorly and is commonly called the Adams
apple. The epiglottis protects the superior opening of the larynx. When we are not swallowing,
the epiglottis does not restrict the passage of air into the lower respiratory passages. When we
swallow food or fluids, the larynx is pulled upward and the epiglottis tips, forming a lid over the
opening of the larynx. If anything other than air enters the larynx, a cough reflex is triggered to
expel the substance and prevent it from continuing into the lungs.

Part of the mucous membrane of the larynx forms a pair of folds, called the vocal folds,
or true vocal cords, which vibrate with expelled air. This ability of the vocal folds to vibrate
allows us to speak. The slitlike passageway between the vocal folds is the glottis.
4. Trachea
Air entering the trachea, or windpipe, from the larynx travels down its length (10-12cm)
to the level of the fifth thoracic vertebra, which is approximately midchest.
The trachea is fairly rigid because its walls are reinforced with C-shaped rings of hyaline
cartilage. The open parts of the rings abut the esophagus and allow it to expand anteriorly when
we swallow a large piece of food. The solid portions support the trachea walls and keep it
patent, or open, in spite of the pressure changes that occur during breathing.
The trachea is lines with a ciliated mucosa. The cilia beat continuously and in a direction
opposite to that of the incoming air. They propel mucus, loaded with dust particles and other
debris, away from the lungs to the throat, where it can be swallowed or spat out.
Lower Respiratory Tract
1. Main Bronchi
The right and left main (primary) bronchi are formed by the division of the trachea. Each
main bronchus runs obliquely before it plunges into the medial depression (hilum) of the lung on
its own side.

The right main bronchus is wider, shorter, and straighter than the left.

Consequently, it is the more common site for an inhaled foreign object to become lodged. By the
time incoming air reaches the bronchi, it is warm, cleansed of most impurities, and well
humidified. The smaller subdivisions of the main bronchi within the lungs are direct routes to
the air sacs.

2. Lungs
The lungs occupy the entire thoracic cavity except for the most central area, the
mediastinum, which houses the heart, the great blood vessels, bronchi, esophagus and other
organs. The narrow superior potion of each lung, the apex, is just deep to the clavicle. The
broad lung area resting on the diaphragm is the base. Each lung is divided into lobes by fissures;
the left lung has two lobes, and the right lung has three, because the heart takes up some of the
space in the left side of the chest. The lungs can also be divided up into even smaller portions,
called bronchopulmonary segments.
The surface of each lung is covered with a visceral serosa called the pulmonary, or
visceral, pleura, and the walls of the thoracic cavity are lined by the parietal pleura. The pleural
membranes produce pleural fluid, a slippery serous secretion which allows the lungs to glide
easily over the thorax wall during breathing movements and causes the two pleural layers to
cling together. Consequently, the lungs are held tightly to the thorax wall, and the pleural space
is more of a potential space than an actual one.
Air enters the lungs through a system of pipes called the bronchi. These pipes start from
the bottom of the trachea as the left and right bronchi and branch many times throughout the
lungs, until they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The
alveoli are where the important work of gas exchange takes place between the air and the blood.
Covering each alveolus is a whole network of little blood vessel called capillaries, which are
very small branches of the pulmonary arteries. It is important that the air in the alveoli and the
blood in the capillaries are very close together, so that oxygen and carbon dioxide can move (or
diffuse) between them. During breathing, air comes down the trachea and through the bronchi
into the alveoli. This fresh air has lots of oxygen in it, and some of this oxygen will travel across
the walls of the alveoli into the bloodstream. Travelling in the opposite direction is carbon

dioxide

, which crosses from the blood in the capillaries into the air in the alveoli and then

breathed out.
Consequently, the lungs are mostly air spaces. The balance of the lung tissue, its stroma,
is mainly elastic connective tissue that allows the lungs to recoil passively as we exhale. Thus, in
spite of their relatively large size, the lungs weigh only about 2 pounds, and they are soft and
spongy.
3. Diaphragm
It is responsible for 75% of air in the lungs; the 25% contribute to the intercostal muscle.
It is a large dome skeletal muscle that separates the thoracic and abdominal cavity.
The Respiratory Membranes
The walls of the alveoli are composed largely of a single, thin layer of squamous
epithelial cells. Alveolar pores connect neighboring air sacs and provide alternative routes for air
to reach alveoli whose feeder bronchioles have been clogged by mucus or otherwise blocked.
The external surfaces of the alveoli are covered with a cobweb of pulmonary capillaries.
Together, the alveolar and capillary walls, their fused basement membranes, and occasional
elastic fibers construct the respiratory membrane, which has gas (air) flowing past on one side
and blood flowing past on the other. The gas exchanges occur by simple diffusion through the
respiratory membrane oxygen passing from the alveolar air into the capillary blood and carbon
dioxide leaving the blood to enter the gas-filled alveoli. It has been estimated that the total gas
exchange surface provided by the alveolar walls of a healthy man is 50 to 70 square meter or
approximately 40 times greater than the surface area of his skin.
The final line of defense for the respiratory system is in the alveoli. Remarkably efficient
alveolar macrophages, sometimes called dust cells wander in and out of the alveoli picking up
bacteria, carbon particles, and other debris. Also scattered amid the epithelial cells that form
most of the alveolar walls are chunky cuboidal cells, which look different from the squamous
epithelial cells. The cuboidal cells produce a lipid (fat) molecule called surfactant, which coats
the gas-exposed alveolar surfaces and is very important in lung function.

Respiratory Physiology
The major function of the respiratory system is to supply the body with oxygen and to
dispose of carbon dioxide. To do this, at least four distinct events, collectively called respiration,
must occur:
1. Pulmonary ventilation. Air must move into and out of the lungs so that the gases in
the air sacs (alveoli) of the lungs are continuously refreshed.

This process of pulmonary

ventilation is commonly called breathing.

2. External respiration. Gas exchange (oxygen loading and carbon dioxide unloading)
between the pulmonary blood and alveoli must take place. In external gas respiration, gas
exchanges are being made between the blood and the body exterior.
3. Respiratory gas transport. Oxygen and carbon dioxide must be transported to and
from the lungs and tissue cells of the body via the bloodstream.
4. Internal respiration. At systemic capillaries, gas exchange must be made between the
blood and tissue cells. In internal respiration, gas exchanges are occurring between the blood
and cells inside the body.

Phases of Breathing
1. Inspiration
When the inspiratory muscles, the diaphragm and external intercostals, contract, the size
of the thoracic cavity increases. As the dome-shaped diaphragm contracts, it moves inferiorly
and flattens out (is depressed). As a result, the superior-inferior dimension (height) of the
thoracic cavity increases. Contraction of the external intercostals lifts the rib cage and thrusts the
sternum forward, which increases the anteroposterior and lateral dimensions of the thorax. The
lungs adhere tightly to the thorax wall, so they are stretched to the new, larger size of the thorax.
As intrapulmonary volume (the volume within the lungs) increases, the gases within the lungs
spread out to fill the larger space. The resulting decrease in the gas pressure in the lungs

produces a partial vacuum. Air continues to move into the lungs until the intrapulmonary
pressure equals atmospheric pressure.
2. Expiration
Expiration (exhalation) in healthy people is largely a passive process that depends more
on the natural elasticity of the lungs than on muscle contraction. As the inspiratory muscles relax
and resume their initial resting length, the rib cage descends and the lungs recoil. Thus, both the
thoracic and intrapulmonary volumes decrease. As the intrapulmonary volume decreases, the
gases inside the lungs are forced more closely together, and the intrapulmonary pressure rises to
a point higher than atmospheric pressure. This causes the gas to flow out to equalize the pressure
inside and outside the lungs. Under normal circumstances, expiration is effortless, but if the
respiratory passageways are narrowed by spasms of the bronchioles (as in asthma) or clogged
with mucus of fluid (as in chronic bronchitis or pneumonia), expiration becomes an active
process. In such cases of forced expiration, the intercostal muscles are activated to help depress
the rib cage, and the abdominal muscles contract and help to force air from the lungs by
squeezing the abdominal organs upward against the diaphragm.
The normal pressure within the pleural space, the intrapleural pressure, is always
negative, and this is the major factor preventing collapse of the lungs. If for any reason the
intrapleural pressure becomes equal to the atmospheric pressure, the lungs immediately recoil
completely and collapse.

Respiratory Sounds
As air flows into and out of the respiratory tree, it produces two recognizable sounds that
can be picked up with a stethoscope. Bronchial sounds are produced by air rushing through the
large respiratory passageways (trachea and bronchi). Vesicular breathing sounds occur as air
fills the alveoli. The vesicular sounds are soft and resemble a muffled breeze.
Decreased respiratory tissue, mucus, or pus can produce abnormal sounds such as
crackles (a bubbling sound) and wheezing (a whistling sound).

External Respiration, Gas Transport, and Internal Respiration

External respiration is the actual change of gases between the alveoli and the blood
(pulmonary gas exchange), and internal respiration is the gas exchange process that occurs
between the systemic capillaries and the tissue cells. All gas exchanges are made according to
the laws of diffusion; that is, movement occurs toward the area of lower concentration of the
diffusing substance.
External Respiration
During external respiration, dark red blood flowing through the pulmonary circuit is
transformed into the scarlet river that is returned to the heart for distribution to the systematic
circuit. Although this color change is due to oxygen pickup by hemoglobin in the lungs, carbon
dioxide is being unloaded from the blood equally fast. Because body cells continually remove
oxygen from blood, there is always more oxygen in the alveoli than in the blood. Thus, oxygen
tends to move from the air of the alveoli through the respiratory membrane into the more
oxygen-poor blood of the pulmonary capillaries. In contrast, as tissue cells remove oxygen from
the blood in the systemic circulation, they release carbon dioxide into the blood. Because the
concentration of carbon dioxide is much higher in the pulmonary capillaries than it is in the
alveolar air, it will move from the blood into the alveoli and be flushed out of the lungs during
expiration. Blood draining from the lungs into the pulmonary veins is oxygen-rich and carbon
dioxide-poor and is ready to be pumped to the systemic circulation.

Gas Transport in the Blood

Oxygen is transported in the blood in two ways. Most attaches to hemogloblin molecules
inside the RBCs to form oxyhemoglobin HbO2. A very small amount of oxygen is carried
dissolved in the plasma.
Most carbon dioxide is transported in plasma as the bicarbonate ion (HCO3-), which
plays a very important role in the blood buffer system. A smaller amount (between 20 and 30
percent of the transported CO2) is carried inside the RBCs bound to haemoglobin. Carbon
dioxide carried inside the RBCs binds to hemoglobin at a different site than oxygen does, and so
it does not interfere in any way with oxygen transport. Before carbon dioxide can diffuse out of
the blood into the alveoli, it must first be released from its bicarbonate ion form. For this to
occur, bicarbonate ions must enter the red blood cells where they combine with hydrogen ions to
form carbonic acid. Carbonic acid quickly splits to form water and carbon dioxide, and carbon
dioxide then diffuses from the blood and enters the alveoli.
Internal Respiration
Internal respiration, the exchange of gases that takes place between the blood and the
tissue cells, is the opposite of what occurs in the lungs. Carbon dioxide diffusing out of tissue
cells enters the blood. In the blood, it combines with water to form carbonic acid, which quickly
releases the bicarbonate ions. Most conversion of carbon dioxide to bicarbonate ions actually
occur inside the RBCs, where a special enzyme (carbonic anhydrase) is available to speed up this
reaction. Then the bicarbonate ions diffuse out into plasma, where they are transported. At the
same time, oxygen is released from hemoglobin, and the oxygen diffuses quickly out of the
blood to enter the tissue cells. As a result of these exchanges, venous blood in the systematic
circulation is much poorer in oxygen and richer in carbon dioxide than blood leaving the lungs.

2. READINGS
Pneumonia

Pneumonia is an inflammation of the lung in which some or all of the alveoli, interstitial
tissue, and bronchioles become edematous and filled fluid or blood cells as a result of infection
or irritation by chemical agents. Proliferation of infecting pathogens can lead to a variety of
pathologic and clinical features, depending on host resistance and virulence of the organisms.
The immunocompromised, hospitalized, very young, and very old are at greatest risk for serious
lower respiratory tract infections.
Community Acquired Pneumonia
The term community-acquired pneumonia is used to describe infections from organisms
found in the community rather than in the hospital or nursing home. It is defined as an infection
that begins outside the hospital or is diagnosed within 48 hours after admission to the hospital in
a person who has not resided in a long term facility for 14 days or more before admission.
Community-acquired pneumonia may be further categorized according to risk of mortality and
need for hospitalization based on age, presence of coexisting disease, and severity of illness as
determined by physical examination, laboratory, and radiologic findings.
Types of Pneumonia
Bacterial pneumonia
People of all ages are susceptible to bacterial pneumonia, but debilitated or post-operative
people, alcoholics, and people with reduced immunity are most vulnerable. Pneumococcus
(Streptococcus pneumoniae) is the organism that causes about 70% of all bacterial pneumonias,
and is one type of pneumonia for which there is a vaccine. Pneumococcal pneumonia often
follows a viral infection such as a cold or flu that has weakened the lungs' defenses, allowing the
bacteria to invade them. Pneumococcal pneumonia used to be most commonly treated with the
antibiotics penicillin and erythromycin. But today, between 25% and 50% of pneumococcus
strains are resistant to them. Amoxicillin with clavulanate, azithromycin, and clarithromycin are
favored.
Viral pneumonia

Viruses cause about half of all pneumonias. Although most viruses simply cause a cold or
flu, others can cause pneumonia, especially in children. Viral pneumonias are common in infants
and young children but rare in adults. Antibiotics, which are effective against bacteria but not
viruses, are not helpful for this type of pneumonia. Most viral pneumonias are short-lived and go
away on their own, but a small percentage can be severe or even fatal. People with decreased
immune systems are susceptible to pneumonias caused by cytomegalovirus (CMV) and other
herpes viruses, as well as rubeola and adenovirus. Respiratory syncytial virus (RSV) and parainfluenza viruses are the most common viral causes of pneumonia in infants and children. Viral
pneumonias can also lead to secondary bacterial infections.
Mycoplasma pneumonia
Mycoplasma is the tiniest living organism and is the most common cause of pneumonia
in people age 5 to 35. It is responsible for up to 50% of adult pneumonias and an even higher
percentage of pneumonias in school-age children. Mycoplasma pneumonia (sometimes referred
to as "atypical" or "walking" pneumonia) most often occurs in the spring and tends to spread
through confined groups, such as students, military personnel, and families. Although it can be
severe, mycoplasma pneumonia is usually mild, even when left untreated. However, some people
experience long-lasting weakness.
Aspiration pneumonia
This less common pneumonia occurs when particles are inhaled into the lungs, causing
inflammation or infection. Also known as pyogenic pneumonia, aspiration pneumonia is most
common in alcoholics, people with poor dental health, and those with conditions that alter
consciousness or decrease normal gag and swallowing reflexes. Aspiration pneumonia can be
bacterial, mechanical, or chemical in nature.
Other types of pneumonia
Pneumocystis carinii pneumonia (PCP) occurs in about 80% of people with AIDS who do
not receive preventive treatment. Caused by an organism thought to be a fungus, PCP can usually
be treated successfully with trimethoprim (the generic name for Bactrim), although the infection

may return later. Legionnaire's disease accounts for 1% to 8% of all pneumonias and is most
common among middle-aged and older people. The organisms that cause the pneumonia
(Legionella species) live in water, and outbreaks tend to occur when the organism spreads
through the air conditioning systems of hospitals or hotels. Other types of pneumonia include
rickettsia and tuberculosis pneumonia.

Causes of Community Acquired Pneumonia

The causative agents for community acquired pneumonia that requires hospitalization are
most frequently S. pneumonie, H. influenzae, Pseudomonas aeruginosa, and other negative rods.
S. pneumoniae (pneumococcus) is the most common cause of CAP in people younger
than 60 years of age without comorbidity and in those 60 years and older with comorbidity. S.
pneumoniae, a gram-positive organism that resides naturally in the upper respiratory tract,
colonizes upper respiratory tract and can cause disseminated invasive infections, pneumonia and
other lower respiratory tract infections, and upper respiratory tract infections, such as otitis
media and rhinosinusitis. It may occur as lobar or bronchopneumonic form in patients of any
age and may follow a recent respiratory illness.
H. influenzae causes a type of community acquired pneumonia that frequently affects
elderly people and those with comorbid illnesses. The presentation is indistinguishable from that
of other forms of bacterial CAP and may be subacute, with cough or low-grade fever for weeks
before diagnosis.
Pseudomonas aeruginosa is a gram-negative rod that belongs to the family
Pseudomonadaceae. These pathogens are widespread in nature, inhabiting soil, water, plants and
animals (including humans). It is a frequent cause of nosocomial infections such as pneumonia,
urinary tract infections and bacteremia. Pseudomonal infections are complicated and can be life
threatening.
Risk Factors

Smoking - men and women who smoked more than 20 cigarettes per day were almost
three times more likely to acquire pneumonia than persons who never smoked. Also,
people who are chronically exposed to secondhand cigarette smoke are also at risk.
According to the researchers, the physical and chemical properties of cigarette smoke
cause oxidative stress in people and alterations in the responsiveness of inflammatory
cells. Smoking increases the bodys susceptibility to the most common bacterial causes
of pneumonia and is therefore a risk factor for pneumonia, regardless of age.
Pneumonia, if left untreated, can lead to pus pocket formation, lung collapse, blood

infection, and severe chest pain.

Air pollution/Environmental pollutants - the effect of long-term exposure to nitrogen
dioxide and sulfur dioxide, both found in motor vehicle emissions, and fine particulate
matter, found in industrial air pollution, on the risk of hospitalization for pneumonia in
older adults because they damage cilia function, which is a defense against bacteria in
the lungs. Exposure to air pollution increases the individuals' susceptibility to pneumonia

by interfering with lung immune defenses designed to protect the lung from pathogens.
Upper respiratory infection - most colds resolve on their own with few complications.
Sometimes, the inflammation caused by the upper respiratory infection may cause
drainage problems within the sinuses or the middle ear. Secondary infection by bacteria
(viral infection can cause impairment of the physical barrier in the respiratory airways
making it easier for bacteria to invade) resulting in bacterial sinusitis, bronchitis and

pneumonia.
Diet - pneumonia occurs more frequently in people who are malnourished.
Weakened Immune system - people with weakened or impaired immune systems are at
higher risk of developing pneumonia than those with strong immunity. Some weakened

immune systems can be caused by medical condition such as AIDS and malnutrition.
Alcohol or Drug use alcohol and drug use or abuse is closely associated with the
development of pneumonia. First, alcohol acts as a sedative and diminishes the reflexes
that trigger coughing and sneezing. Alcohol also interferes with white blood cells that

destroy bacteria and other microbes.

Age people younger than 1 year or older than 65 are more likely to develop
pneumonia. In particular, babies and newborns are at increased risk of breathing mucus
or saliva from the nose or mouth, liquids, or food from the stomach into the lungs.
However, one-third of cases of pneumonia occur in people over the age of 65. There are

also several different systems of classifying CAP based on factors such as age.
According to the guidelines developed by the American Thoracic Society, persons
younger than 60 years of age, who are without comorbidity and who can be treated on an
outpatient basis are persons wherein the infecting organisms can remain confined to the
lungs or they can cause bacteremia or sepsis.
Pneumonia is most likely to occur when normal defense mechanism are weakened or
overcome by the virulence, quality, or number of organisms. Young or otherwise healthy clients
may develop pneumonia as a consequence of upper respiration or viral infections. Group living
or working conditions may facilitate wide transmission.
Signs and symptoms
The onset of pneumonias is generally marked by any or all of the following:

Fever
Chills
Sweats
Pleuritic chest pain
Cough (Productive/Non-productive)
Sputum production
Hemoptysis
Dyspnea
Tachycardia
Signs of hemoglobin desaturation
Headache or fatigue

Chest auscultation reveals bronchial breath sounds over areas of consolidation.

Consolidated lung tissue transmits bronchial sound waves to outer lung fields. Crackling sounds
and whispered pectoriloquy may be heard over affected areas. Tactile fremitus is usually
increased over areas of pneumonia. Percussion is dulled over affected areas. Unequal chest wall
expansion may occur during inspiration if a large area of lung tissue is involved. This is due to
decreased distensibility in the affected area.
Complications
Bacteria in your bloodstream

The smallest airways in your lungs terminate in tiny air sacs called alveoli, where blood
cells exchange carbon dioxide for oxygen. In CAP, alveoli contain bacteria that may enter the
bloodstream during gas exchange. Infection then spreads through the bloodstream, potentially
causing shock and failure of multiple organs.
Septic shock
Unchecked bacterial growth in the bloodstream can shut down normal circulation. Blood
fills the veins and leaks through the walls of the capillaries, causing uncontrolled tissue swelling
and possibly organ failure, which can lead to death.
Fluid accumulation and infection around your lungs
Sometimes fluid accumulates between the thin, transparent membrane (pleura) covering
your lungs and the membrane that lines the inner surface of your chest wall - a condition known
as pleural effusion. When the pleurae around your lungs become inflamed (pleurisy) often as
a result of pneumonia fluid can accumulate and may become infected (empyema).
Lung abscess
Occasionally a cavity containing pus (abscess) forms within the area affected by
pneumonia.
Acute respiratory distress syndrome (ARDS)
When CAP involves most areas of both lungs, breathing is difficult and your body doesn't
get enough oxygen.

Incidence
Atypical pathogens are a common cause of CAP in all regions of the world with a global
incidence of 22%15. The main feature differentiating atypical from typical CAP pathogens is the
presence of extrapulmonary ndings.
The incidence of atypical pathogens from 4,337 CAP patients (outpatient and inpatient)
evaluated from around the world were the following: North America (22%), Europe (28%), Latin
America (21%), and Asia/Africa (20%).

In Asian studies in which the Philippines contributed 5.8% of the patients, the incidence
of atypical pathogens among 955 cases of CAP (outpatient and inpatient) was 25.2%. Mixed
infection was found in 17.2%. Another study showed an overall prevalence of 23.5 % in Asian
countries.
The Philippine prevalence data of atypical pathogens is 43% in hospitalized patients
(inpatient). They occurred either as sole pathogens in 11% or as part of mixed infection (32%).
Managements

The treatment of pneumonia includes administration of the appropriate antibiotic as

determined by the results of a Gram stain.

Management of CAP includes blood cultures performed quickly for identification of the
causal pathogen and prompt administration of antibiotics (within 4 hours) in patients in
whom CAP is strongly suspected.

In the outpatient setting, empirical treatment of CAP is often used, that is, treatment
based on the clinicians estimation of likely causative organisms. In previously healthy
people with no risk factors for drug-resistant S. pneumoniae, a macrolide antibiotic
(azithromycin, clarithromycin, or erythromycin) is recommended.

For outpatients with CAP who have cardiopulmonary disease or other modifying factors,
treatment should include a respiratory fluoroquinolone (moxifloxacin, gemifloxaxin or
levofloxacin) or a beta-lactam agent (cefpodoxime or cefuroxime) plus a macrolide.

Two vaccines are available to prevent pneumococcal disease: the pneumococcal

conjugate vaccine (PCV13) and the pneumococcal polysaccharide vaccine (PPV23;
Pneumovax). The pneumococcal conjugate vaccine is part of the routine infant
immunization schedule in the U.S. and is recommended for all children < 2 years of age
and children 2-4 years of age who have certain medical conditions. The pneumococcal
polysaccharide vaccine is recommended for adults at increased risk for developing
pneumococcal pneumonia.

Antibiotics often used in the treatment of this type of pneumonia include

penicillin, amoxicillin and clavulanic acid (Augmentin, Augmentin XR), and macrolide
antibiotics

including erythromycin (E-Mycin,

Eryc,

Ery-Tab,

PCE,

Pediazole,

Ilosone), azithromycin (Zithromax, Z-Max), and clarithromycin (Biaxin). Penicillin was

formerly the antibiotic of choice in treating this infection.

Pulmonary Tuberculosis
Tuberculosis (TB) is an infectious disease that primarily affects the lung parenchyma and
marked by formation of tubercles and caseous necrosis in tissues of any organ; in humans, the
lung is the major seat of infection and the usual portal through which infection reaches other
organ including the meninges, kidneys, bones, and lymph nodes.
Etiology
M. tuberculosis is a non-moving, slow-growing, acid-fast rod transmitted via the airborne
route. People who are usually infected are those having repeated close contact with an infectious
person who has not yet been diagnosed with TB. The risk of transmission is reduced after the
infectious person has received proper drug therapy for 2-3 weeks, clinical improvement occurs,
and acid-fast bacilli (AFB) in the sputum are reduced.

Risk Factors
Your age, health issues, life circumstances even where you work can affect your immune
system and put you at risk for tuberculosis infection. Here are the members of high-risk groups:
Seniors
As people age, their immune systems arent quite as able to fight off infections like
tuberculosis, increasing seniors risk for contracting TB.
Babies

Infants haven't yet developed strong enough immune systems to ward off tough bacterial
infections like tuberculosis and are at a greater risk.
HIV-positive or AIDS patients
HIV infection compromises the immune system, making even common illnesses a serious
threat. People with HIV infections are much more susceptible to developing active tuberculosis.
People with diabetes
Diabetes is another disease that weakens the immune system, leaving the body less able
to defend itself against bacterial infections like tuberculosis.
Cancer patients
Chemotherapy drugs also suppress the immune system, leaving the body more vulnerable
to tuberculosis infection.
Organ transplant recipients
The medications used to keep the body from rejecting a new organ suppress the immune
system, potentially allowing TB to develop.
People with kidney disease
This illness can weaken the body, including the immune system, making a person more
susceptible to illness.
People undergoing treatment for autoimmune diseases
Some treatments for illnesses like Crohn's disease and rheumatoid arthritis can affect the
immune system, creating an opportunity for tuberculosis infection to occur.
Malnourished individuals
The body can't defend itself as well if you are underweight or malnourished due to poor
diet or illness.
People surrounded by potential cases of TB

This could be anyone who lives with or works closely with someone known to be
infected; hospital workers, nursing home staff, and prison staff, for example, are at greater risk.
Living in a refugee shelter
Weakened by poor nutrition and ill health and living in crowded, unsanitary conditions,
refugees are at especially high risk of tuberculosis infection.
Poorly sanitized environment
Poor hygiene
Offers an environment for bacteria to colonize.

Signs and Symptoms

When symptoms of pulmonary TB occur, they may include:

Cough (maybe non-productive, or mucopurulent sputum may be expectorated)

Coughing up blood

Excessive sweating, especially at night

Fatigue

Low-grade fever

Unintentional weight loss

Other symptoms that may occur with this disease:

Breathing difficulty

Chest pain

Wheezing

Crackles

Complications
Without treatment, tuberculosis can be fatal. Untreated active disease typically affects your
lungs, but it can spread to other parts of the body through your bloodstream. Examples include:
Bones
Spinal pain and joint destruction may result from TB that infects your bones. In many
cases, the ribs are affected.
Brain
Tuberculosis in your brain can cause meningitis, a sometimes fatal swelling of the
membranes that cover your brain and spinal cord.
Liver or kidneys
Your liver and kidneys help filter waste and impurities from your bloodstream. These
functions become impaired if the liver or kidneys are affected by tuberculosis.
Heart
Tuberculosis can infect the tissues that surround your heart, causing inflammation and
fluid collections that may interfere with your heart's ability to pump effectively. This condition,
called cardiac tamponade, can be fatal.

Incidence
The Incidence of tuberculosis (per 100;000 people) in Philippines was last reported at
275 in 2010, according to a World Bank report published in 2012. Incidence of tuberculosis is
the estimated number of new pulmonary, smear positive, and extra-pulmonary tuberculosis cases.
Out of 22 countries identified by the World Health Organization, Philippines ranks ninth
in terms of having the most number of tuberculosis cases worldwide.

Although curable, an average of 75 Filipinos die everyday because of TB and is identified

as among the leading causes of mortality in the country.
Dr. Enrique Sancho, head of the Communicable Disease Center for Health DevelopmentCentral Visayas, said that three out of 1,000 Filipinos are infected with tuberculosis.

Management

Pulmonary TB is treated primarily with antituberculosis agents for 6 12 months. A

prolonged treatment duration is necessary to ensure eradication of the organisms and to
prevent relapse.

In current TB therapy, four first-line medications are used, INH, rifampin (Rifadin),
pyrazinamide, and ethambutol (Myambutol). Combination medications, such as INH and
rifampin (Rifamate) or INH, pyrazinamide (PZA), and rifampin (Rifater) and medications
administered twice a week are available to help improve patient adherence.

Capreomycin (Capastat), ethionamide (Trecator), para-aminosalicylate sodium, and

cycloserine (Seromycin) are second-line medications.

Recommended treatment guidelines for newly diagnosed case of pulmonary TB have two
parts: an initial treatment phase and a continuation phase. The initial phase consists of a
multiple-medication regimen of INH, rifampin, pyrazinamide, and ethambutol. This
initial intensive-treatment regimen is administered daily for 8 weeks, after which options
for the continuation phase of treatment include INH and rifampin or INH and rifapentine.

Vitamin B (pyridoxine) is usually administered with INH to prevent INH-associated

peripheral neuropathy.

III. FAMILY BACKGROUND

Members

Alexis Abaton

Sex

Age

58

Civil

Relationshi

Educational

Statu

p with the

Attainment

s
M

Patient
Husband

College

Sr.

Occupation

Religion Place of
residence

Carpenter

Undergra-

Church

Brgy. 10-N

of Christ

Lacub,

duate

Batac,
Ilocos

Perlita

58

Patient

College

Housewife

Church

Norte
Brgy. 10-

Abaton

Graduate

of

N Lacub,

Christ

Batac,
Ilocos

Jonnel Abaton

23

Son

College

None

Under-

Church

Norte
Brgy. 10-N

of Christ

Lacub,

graduate

Batac,
Ilocos
Norte

Mrs. Perlita Abaton, 58 years old, is living with her youngest child, Jonnel Abaton, and
her husband, Alexis Abaton Sr. Therefore they are considered as a nuclear type of family. The
said family is considered as patrilocal. They live in Barangay 10-N Lacub, Batac, Ilocos Norte.
The family of Mrs. Perlita Abaton is an egalitarian because she and her husband both
discuss and solve their problems. And when it comes to the budget of the family, Mrs. Perlita
Abaton is the one who decides in this matter. Regularly, Mr. Alexis Abaton Sr. earns money for
their family. Alexis Abaton, Sr. works as a carpenter as claimed by his wife, Mrs. Perlita Abaton.
He is a fulltime carpenter, contracted by their engineer, from Monday to Friday with a salary of
350 pesos per day. Mrs. Perlita Abaton is also a part time sewer because sometimes, she was
asked to sew uniform of the dancers during their town fiesta. She was able to earn 5 thousand
every time she sews. According to her, their monthly allowance is Php 13,000. Their monthly
income is allocated to their food, grocery, water bill, fare and for the remaining budget will serve
as their savings which includes their budget for their medical expenses.

DESCRIPTION

PERCENTAGE

AMOUNT

1. Food

27%

Php 3,600

2. Grocery

29%

Php 3,800

3. Fare

14%

Php 1,800

4. Water bill

5%

Php 600

5. Savings
TOTAL

25%

Php 3,200

100%

Php 13,000

According to Mrs. Perlita Abaton, the family does not buy mineral water for drinking.
They drink from the faucet which is NAWASA. Mrs. Perlita Abaton was once a member of their
barangay, a chief tanod, thats why shes familiar in their place. She joins some of the activities
in their barangay. One of those is the Oplan Dalus. Shes also active in her religion, Church of
Christ. Every Sunday she and her daughter, Vanessa, go to the church and regularly attend each
fellowship. They usually join every outreach that is conducted by their church.

A. Family Health History

Her grandparents on both side already passed away but she doesnt know what the causes
of their death are. Her father had already passed away due to ulcer but Mrs. Abaton can no longer
remember what are those medicines took by his father. As she stated, her mother, brothers, and
sisters has no hereditary diseases experienced.
The family members had experience common illnesses such as cough, colds, fever,
headache, and stomachache. All these illnesses were managed at home through herbal
medications and over-the-counter drugs. They managed cough by drinking the extract of oregano
leaves (2 tbsp. TID) and solmux.

For colds, they use ampalaya leaves extract (2tbsp. BID)

and neozep (500mg for adults). They use over-the-counter drugs such as paracetamol and
biogesic 4 times a day for 3 days to manage fever and headache and also they manage fever by
using guyabanu and atsuete leaves by placing it at their back and remove it until the leaves

will get dry. For stomachache, they usually drink boiled guava leaves glass to relieve their
pain.
They have also experienced childhood illnesses such as chicken pox and measles. She
claimed that they manage chicken pox by taking enough rest and sleep and when the blisters
become dry, they burn garami and add it in the warm water and use bath soap. For measles,
they manage it by taking enough rest and also use the smoke of burned dried leaves of onion
until the rash will subside.
Mrs. Abaton stated that their children have completed their immunizations at MMMH &
MC.
According to her, they seek consultation at MMMH MC when one of them cant
already manage their illness.

B. Past Health History

During the childhood years of Mrs. Abaton, she had experienced common illnesses such
as cough, colds, fever, headache, and stomach ache. These illnesses were managed in accordance
with their beliefs and practices. They use the extract of oregano leaves to treat cough and she
usually take it for 3 days. Through the ampalaya extract they use it to manage colds. The
guyabano and atsuete leaves are usually used by her to treat fever and placing it at their back and
remove it until the leaves will get dried. Boiling guava leaves is their beliefs on how to manage
their stomache.
She had also experienced childhood diseases like chicken pox and measles. She managed
chicken pox by taking enough rest and sleep and when the blisters become dry, she burns
garami and adds it in the warm water and uses bath soap. For measles, she managed it by

taking enough rest and also uses the smoke of dried burned leaves of onion until the rash will
subside.
When she was 17 years old, she underwent surgical procedure due to presence of cyst at
the left side of her neck and few days later after the removal of cyst, another cyst is palpated at
her chin (posterior). Her attending physician was Dr. Baquiran of Baquiran Clinic. Her
medications were ampicillin and penicillin. Mrs. Abaton had also myoma when she was 50 years
old. According to her, she underwent TAHBSO. Her attending physician was Dr. Pira and she
was operated at MMMH & MC. She was confined for four days. She can no longer remember
her medications.
Mrs. Abaton has allergies on foods such as chicken, eggplant, monggo, some variety of
fish (red-colored fish like lapu-lapu) and the cigarette smoke and other air pollutants. When
allergy attacks she usually experiences difficulty of breathing and rashes appeared at her body.
As verbalized by the patient aguyek nak nokwa nu agsidaak ti manok ken ikan nga red ti kulay
na. Nu met agsidaak ti tarong wennu monggo, marigatan nak nga umanges. She also
experienced difficulty of breathing when she inhales a smoke of cigarette or any other air
pollutants. She never indulged herself in vices such as drinking alcohol and smoking.

C. Present Health History

According to Mrs. Abaton, she first felt dry cough last December 2011 but she didnt
consult to any medical practitioner. She only managed her dry cough with over-the-counter drug
such as solmux. February 2012, her cough worsened so she decided to seek consultation at the
Corpuz Clinic she was attended by Dr. Modesty Corpuz and she was prescribed with medications
such as cotrimosaxole and salbutamol as she stated. On the month of April and May she again
felt dry cough. She didnt seek for consultation because as she stated ado ngamin ti daitek ken
ado ti ubra mi idjay church mi idi isu jak latta inasikason.
Few days prior to admission, Mrs. Abaton experienced dry cough, easy fatigability,
shortness of breathing, chest pain, and weakness. But she never went to the hospital until her

churchmates observed that her condition worsened so her churchmate Dr. Cocson talked to her
and accompanied her in going to the hospital. Hes also the one who admitted her in the MMMH
& MC last August 19, 2012 @ 5:30 PM with an admitting diagnosis of Bronchial Asthma with
Acute Exacerbation, Community Acquired Pneumonia T/C PTB.

V.

DEVELOPMENTAL DATA

A.

ERIK ERIKSONS PSYCHOSOCIAL DEVELOPMENTAL MILESTONES

In Erik Ericksons Psychosocial Theory of Development, Mrs. Abaton belongs to the age

group of 40-65 years old, which is the stage of adulthood with an area of resolution of
Generativity. Non-achievement of the said task leads to Stagnation.
Ericksons envisions life as a sequence of levels of achievement. Each stage signals a task
that must be achieved which can be viewed as a series of crises. A successful resolution would
indicate a support to the persons ego while a failure to resolve the crises is damaging to the ego.
Erickson believes that the greater the task achievement, the healthier the personality of the
person while failure to achieve the task influences the persons ability to achieve the next tasks.

According to Ericksons developmental theory, the primary developmental task of the stage
of adulthood is to achieve Generativity. Generativity is the willingness to care for and guide
others. Generativity can be achieved with their children and the others through guidance in social
interactions and assisting them to becoming productive and responsible
Our client falls under middle adulthood ages 40- 60. The developmental task in this stage
is Generativity VS. Stagnation
1.

Extends concern to community- ATTAINED

According to Mrs Abaton, she joins barangay activities such as Oplan Dalus and general

assemblies and she also became a Chief Tanod in their barangay. In their family, they share their
problems to one another. Her children who are away from her will just call her when they need
her piece of advice.
2.

Continuity of roles - ATTAINED

As a mother of her children, she was able to raise them with good morals and attitudes

towards others as she stated. She also raised them having fear of the Lord. She still plays her
role as a mother and a good wife to her husband. As a neighbour, she mingles with them when
she doesnt have any activities to do. She also became a Chief Tanod in their barangay. All in all,
she gets along well with her family, neighbors and the community.
3.

Able to assume various roles- ATTAINED

Mrs. Abaton is able to assume his role being a chief tanod in their community, and as a

mother to her children. She also assumes roles in their church by giving some advices to her
churchmates.
ANALYSIS:
Mrs. Abaton has attained the tasks under Erik Eriksons Psychosocial Developmental
Theory. She is able to extend concern to community, develop self-confidence and assume various
roles. Therefore Mrs. Abaton is ready to go to the next stage which is Ego Integrity Vs. Despair.

B.

ROBERT HAVIGHURST DEVELOPMENTAL TASKS THEORY

Havighurst believes that learning is essential to life and that people continue to learn

throughout life. He describes growth and development as occurring during six stages, each
associated with from six to ten tasks to be learned. Havighurst believes that once a person learns
to talk, it is mastered for life. Havighurst promoted the concept of development task which arises
at or about a certain period of life of an individual, successful achievement of which leads to his
happiness and to his success with later task, which failure leads to unhappiness in the individual,
disapproval by society and difficulty with later tasks.
According to Havighursts classification of age group, Mrs. Abaton belongs to middle
adulthood.
Expected tasks on this stage:
1.

Achieve adult civic and social responsibility- ATTAINED

Mrs. Abaton has been an active member of their community (as a chief tanod before) and

church. Even if she feels unwell, she tries her best to go and attend the mass every Sunday. In
their family, she also shares her problems and her family would give her some pieces of advices
to her or vice versa.
2.

Establish and maintain an economic standard of living-ATTAINED

Mrs Abaton was able to maintain an economic standard of living, as she stated, she is still

sewing clothes as a source of her income even if it is seasonal, it helps a lot to their family.
3.

Assist children to become responsible happy adults-ATTAINED

She is able to raise her children with the help of her husband. As she stated, she teaches

her children good manner and right conduct and on how to respect people specially the elder
ones. In times of problems, her children would call her through their cellphone to get advices to
their mother.
4.

Develop leisure activities-ATTAINED

Mrs Abatons leisure time is to clean their house, sewing clothes, chat with their neighbor

and watching her favorite TV show. She spends time reading her bible in their house.
5.

Relate to spouse on a more intense basis-ATTAINED

Mrs. Abaton was able to achieve this task by sharing their problems with her husband and

solving it without arguing.

6.

Accept and adjust to physiological changes of middle age-ATTAINED

She is able to adjust and accept to the physiological changes that she undergoes. She said

that she accepts the changes in her body as she gets old. She added, naubrak met amin nga
kayat kot biag kon.
Analysis:
Mrs. Abaton was able to achieve all the tasks expected in her age group. She said that she
is happy and contented with the life that God had given to her. Therefore, she is ready to go to
the next stage which is Later Maturity.

VI. PATTERNS OF FUNCTIONING

1. EATING PATTERN
BEFORE ILLNESS

BEFORE

DURING

HOSPITALIZATION
HOSPITALIZATION
She usually eats 4 pieces of She usually eats 4 pieces of Upon admission on August
pandesal in the morning at pandesal in the morning at 19, 2012 she was on DAT
5:00 am. For her snack, she 5:00am. She eats her lunch at diet.
usually

eats

biscuits

She

was

able

to

at around 11:30am with cup consume her meal during

around 9am. She eats her of inabraw, 1 cup of rice and breakfast, lunch and dinner.
lunch at around 11:30am 2 matchbox size of meat and For her breakfast she eats at
with 1 cup of inabraw, 2 1 banana. And for dinner at around 7:30 am and eats 2

pieces of fish(Galunggong), 8:30pm, she eats the same pieces of pandesal and 1 egg
1 cup of rice and 1 banana. food eaten during her lunch.

(Hard Boil). For her lunch at

For

the

12:00nn with 1 cup of rice,

afternoon she usually eats

cup of inabraw and half slice

biscuits at around 3pm. She

bangus. She eats her dinner

eats her dinner at around

at 7:00, she eats the ration

8:30pm, eating the same

given by the hospital staffs.

her

snack

in

food eaten during her lunch.

ANALYSIS:
There is a change in the eating pattern before hospitalization and during hospitalization
because her appetite decreased due to her illness. There was also a slight change regarding on the
time the patient takes her meal due to the hospital protocols on giving of ration per meal.

2. DRINKING PATTERN
BEFORE

BEFORE ILLNESS

DURING

HOSPITALIZATION
HOSPITALIZATION
Mrs. Abaton usually consumes Mrs. Abaton usually consumes Mrs. Abaton usually consumes
6-7 glasses of water a day 6-7 glasses of water a day 5-6 glasses of water a day
(1440mL-1680mL) and she (1440mL-1680mL) and she (1200mL-1440mL) and she
drinks 5-6 cups of coffee drinks 2-3 cups of coffee drinks 1-2 cups of coffee
(Nescafe 3 in 1), (1200mL- (480mL-720mL).
1440mL).

Her

total

fluid fluid

intake is 2640mL-3120mL.

ANALYSIS:

intake

2400mL.

is

Her

total (240mL-480mL).

1920mL- fluid

intake

1920mL.

is

Her

total

1440mL-

There is an alteration in the drinking pattern and in the amount of fluid intake of Mrs.
Abaton. Her fluid intake decreased because she experienced a bitter-taste during illness,
before and during hospitalization.

3. BLADDER ELIMINATION
BEFORE ILLNESS

BEFORE

HOSPITALIZATION
Mrs. Abaton urinates 10-11 Mrs. Abaton urinates

DURING
HOSPITALIZATION
6-8 Mrs. Abaton urinates

8-9

(240ml/void) times a day, (240ml/void) times a day, (240ml/void) times a day,

2400mL-2640mL. The color 1440mL-1920mL. The color 1,920mL-2,160mL. The color
of her urine is amber, aromatic of her urine is amber, aromatic of her urine is orange.
in odor.

in odor.

ANALYSIS:
There is an alteration in the bladder pattern of Mrs. Abaton due to the decrease in her
fluid intake. There is also a change in the color of her urine because of the Rifampicin that she
takes in.
4. BOWEL ELIMINATION
BEFORE ILLNESS

BEFORE

DURING

HOSPITALIZATION
HOSPITALIZATION
She usually defecates once a She usually defecates once a She defecates once a day in
day in the morning. The color day in the morning. The color the morning. The color of her
of her feces is brownish and of her feces is brownish and feces is dark brown and its
its consistency is semi formed, its consistency is semi formed, consistency is semi-formed,
moderate in amount.

ANALYSIS:

moderate in amount.

moderate in amount.

There is no significant change in the bowel elimination of Mrs. Abaton, however, there is
a change in the color in the bowel of Mrs. Abaton because of the Rifampicin she was taking.

5. SLEEPING PATTERN
BEFORE ILLNESS

BEFORE

DURING

HOSPITALIZATION
HOSPITALIZATION
Mrs. Abaton used to sleep at Mrs. Abaton used to sleep at Mrs. Abaton used to sleep at
10:00pm. She claimed that she 10:00pm. She claimed that she 9:00pm. She claimed that she
uses sleeping aids like pillow use sleeping aid like pillow use sleeping aids like pillow
and

blanket.

Walang

She

Hanggan,

watches and

blanket.

sews Walang

She

Hanggan,

watches and blanket. Even though she

sews is at the hospital she doesnt

clothes sometimes and reads clothes sometimes and reads even forget her rituals before
the bible before going to bed. bible before going to bed. She going to sleep and read her
She cannot sleep with lights cannot sleep with lights on. bible. She is often interrupted
on. She takes her nap in the She takes her nap in the and wakes up whenever she
afternoon for 1-2 hours. She afternoon for 1 hour. She voids, when the nurses take
usually wakes up at 5:00am usually wakes up at 5:00am her vital signs and due to the
her total sleeping pattern is 8 her total sleeping pattern is 8 noisy patients. She takes her
hours per day.

hours per day.

nap in the afternoon for only

30 minutes. She wakes up at
around

4:00am.

Her

total

sleeping pattern is 7 hours and

30 minutes per day.

ANALYSIS:
There is a change in the sleeping pattern of Mrs. Abaton because of the disruption of her
sleep due to the light, voiding, the vital signs taking by the nurses and noisy patients in their
ward.
6. BATHING PATTERN

BEFORE ILLNESS

BEFORE

DURING

HOSPITALIZATION
HOSPITALIZATION
Mrs. Abaton takes her bath at Mrs. Abaton takes her bath at Mrs. Abaton takes her bath at
around 9:00 in the morning. around 9:00 in the morning. around 8:00 am. She uses
She uses warm water, tender She uses warm water, tender tender care for her body soap
care for her body soap and care for her body soap and and sachet of rejoice for her
sachet of rejoice for her hair. sachet of rejoice for her hair. hair. The usual duration of her
The usual duration of her The usual duration of her bathing is 5 minutes.
bathing is 15 minutes.

bathing is 15 minutes.

ANALYSIS:
There is a slight adjustment in bathing duration of Mrs. Perlita due to the absence of
warm water.
VII. LEVELS OF COMPETENCY
LEVEL OF
COMPETENCIES

BEFORE ILLNESS

DURING ILLNESS

At home, Mrs. Abaton could During illness, Mrs. Abaton could

do her activities of daily living do her activities of daily living,
such as cleaning the house and however, she easily gets tired.
doing the laundry in the During
PHYSICAL
COMPETENCY

morning,

cooking,

hospitalization,

Mrs.

watch Abaton was not able to perform

television and sometimes sews her daily routines. What she does
clothes.

She attends the during her hospitalization was

fellowship in their church reading the bible, praying, lying in

every Sunday.

bed and sometimes talks with the

other patients in the ward.

ANALYSIS:

There is an alteration in the physical activity of Perlita as compared to before illness

because she was hospitalized and that she easily gets tired of doing her daily routines due to her
sickness.

LEVEL OF

BEFORE ILLNESS

COMPETENCIES

DURING ILLNESS

Mrs. Abaton is expressive when She was still expressive as

it comes to emotional aspect. evidenced by telling what she
Shes able to share her feelings really feels during the interview.
to her family and sometimes to She showed willingness and
EMOTIONAL

her church mates.

smiles everytime we visited her.

According to her, there was a

COMPETENCY

time when she almost shouted at

a patient in their ward due to his
repeated cough and complaints
but she was able to control her
temper.

ANALYSIS:
There is a slight alteration of her emotional aspect. She was able to express her feelings,
however, she almost lost her temper to one of the patients due to her health condition.

LEVEL OF
COMPETENCIES
SOCIAL
COMPETENCY

BEFORE ILLNESS

DURING ILLNESS

Mrs. Abaton gets along well During her hospitalization, Mrs.

with her family, neighbors and Abaton
to

her

church

established

good

mates. interpersonal relationship between

According to her, she also her doctors and nurses and her.
participates in the Oplan Dalus She also mingles with the other

in their community. She also patients inside the ward. During

attends outreach programs of the
their church.

interview

of

the

student

nurses, she never hesitated to

answer the questions being asked
to her.

ANALYSIS:
There was no alteration in the social competency of Mrs. Abaton because she has the
equal social interaction to other people.

LEVEL OF

BEFORE ILLNESS

COMPETENCIES
Mrs.

Abaton

is

able

DURING ILLNESS
to The mental capacity of Mrs.

understand and consider the Abaton remained the same. Shes

INTELLECTUAL
COMPETENCY

opinions of others. She could able to comprehend instructions

make decisions for herself and and is aware with our presence.
for her family.

Shes also She can answer questions asked

oriented to place, time, person coherently.

and situation.

ANALYSIS:
There was no significant change with regards to the mental competency of Mrs. Abaton.

LEVEL OF

BEFORE ILLNESS

DURING ILLNESS

COMPETENCIES
SPIRITUAL

Mrs. Abaton believes in God Despite the fact that she was ill,

COMPETENCY

and she reads the bible and her faith to God remained. She

prays before going to sleep. She always reads the bible and prays
stands firm in faith despite trials to God to provide her needs and
and difficulties in life.
attends

fellowship

in

She asks for healing.

their

church every Sunday.

ANALYSIS:
There was no alteration with regards to her spiritual competency. Her illness didnt hinder
her to keep on believing God.

VIII. PHYSICAL ASSESSMENT

A. Date of Assessment
August 24, 2012 @ 3:00 PM
B. General Appearance
During the assessment, Mrs. Abaton was wearing a light yellow t-shirt, black half pants
and a pair of green beachwalk slippers. She has a thin body built and exhibits coordinated
movements. She has an IVF of D5NSS @ 750 cc level regulated to 30 gtts/min connected to
right dorsum of the hand. She is conversant, coherent and oriented to person, place and time.
She also exhibits thought association, moderate pace and has sense of reality. She had a
significant weight loss as she stated.
C. Vital Signs, Height, Weight, BMI
Vital Signs:
BP: 120/80 mmHg
Temp: 36.8 C per axilla
PR: 85 bpm

RR: 24 bpm
Height: 52
Weight: 48 kg
BMI:wt in kg
(ht in m) 2
: 48 kg/ (1.59m)2
: 48 kg/ 2.53 m2
: 18.97 (lower normal)

Head to Toe Assessment

1. HEAD
Normocephalic
Proportional to body
HAIR AND SCALP
Hair is black in color
Equally distributed combed hair
Smooth in texture
Hair length is approximately 3 inches
Scalp is light brown in color
EYES
Eyelashes and eyebrows are thinly and equally distributed
Symmetrically aligned eyes
Bilateral blinking
With pinkish conjunctiva
With white sclera
Pupils Equally Round Reactive to Light and Accommodation (PERRLA)
Unable to read computerized words with a font size of 12 at a distance of 1 foot
but shes able to read with her reading glasses.
EARS
Color is the same with facial skin
Symmetrical
Pinna is in line with the outer canthus of the eyes
With minimal amount of cerumen observed
Able to hear ticking of watch in both ears
NOSE

 In midline of the face

Proportional to the face
Color is the same with facial skin
Nasal septum is in midline
With patent nares
MOUTH
Lips are dark brown in color
With pinkish gums, moist and firm
Teeth are yellowish in color.
Upper teeth is composed of 12 teeth, absence of 2 nd and 3rd molars on both sides

of the upper teeth

Lower teeth have 11 teeth, absence of 1st, 2nd and 3rd molars at the left side and

absence of the 2nd and 3rd molars at the right side

With pinkish and moist tongue
Tongue is able to move sideways, up and down
Uvula is in midline
Grade 0 tonsils

2. NECK
Uniform color at face
With V shaped scar at the left side of the neck approximately 3 inches in

length
Presence of 3 moles at the right part of the neck
Able to extend, hyperextend, turn right and left
Able to rotate at 180

3. CHEST AND BACK

Presence of moles at the sternum
Areolas are dark in color
With symmetrical chest expansion
With a cardiac rate of 86 bpm
With a respiration rate of 24 bpm
Rhales breath sounds auscultated at the left lung
(+) intercostal retractions
4. ABDOMEN

Skin is uniform in color with the rest of the body

Presence of stretch mark on the lower quadrant

Symmetrical movement during respiration

Bowel sounds present every 5-12/min and occurs 5-10 seconds

With a scar below her umbilicus, 4 inches in length

5. UPPER EXTREMITIES
Skin is light brown in color
With untrimmed dirty fingernails
Able to abduct, adduct, pronate, and supinate hands and raise both extremities
Nail beds are pinkish in color
Capillary refill returns within 2 seconds
With an IV site at the right dorsum of the hand
With a peripheral pulse rate of 85 bpm
6. LOWER EXTREMITIES
Skin is uniform in color
With untrimmed dirty toenails
Able to flex, extend, abduct, adduct and raise both extremities without difficulty

or discomfort
Nail beds are pinkish in color
Capillary refill returns within 3 seconds

IX. ON GOING APPRAISAL

1. August 25, 2012 @ 3:00 PM
Vital Signs
BP: 120/80 110/70 mmHg
Temp: 36.7 37 C
PR: 82 86 bpm
RR: 24 23 bpm

On the first day of appraisal, Mrs. Abaton was seen lying on bed. She was wearing white
shirt and gray colored leggings. She has an IVF of PNSS at 750 cc level regulated to 30
gtts/min.
On this day, she was weak and unconversant and had a complaint of headache. Wheezing
upon auscultation at the lower lobe of her left lung is still present. Her cough is deep and
unproductive. She was seen and examined by Dr. Tomas and new orders were made such as
continue medicine, IVF to follow D5NSS 1 L^24 hours and facilitate sputum collection, nebulize
patient with PNSS 2cc prior to collection. She urinated 8 times and defecated once on this day.
At 8 pm, Mrs. Abaton was febrile with a temperature of 37.9 C. At 10 pm of the same date, Dr.
Bigornia ordered Paracetamol 300 mg IV. Then her V/S was taken at 12 am and her body
temperature subsided to 36.6 C

2. August 26, 2012 @ 3:00 PM

Vital Signs
BP: 120/80 110/70 mmHg
Temp: 36.6 37.9 C
PR: 70 81 bpm
RR: 20 22 bpm
On the second day of appraisal, Mrs. Abaton was lying on bed. She was wearing stripes
orange and black jogging pants. She has an IVF of D5NSS at 300cc level regulated to 30
gtts/min.
At 8 AM of this day, Mrs. Abaton was febrile with a temperature of 37.9 C. Tepid
sponge bath was done then V/S was checked again at 12 PM and her body temperature subsided
to 37.0 C. On this day, she underwent STAT CBC. Wheezing upon auscultation at her left lung
is absent. However, her cough which is unproductive is still present. He was seen and examined
by Dr. Tomas in the morning with new orders made such as for repeat STAT CBC, facilitate

sputum collection for AFS and IVF D5NSS 1Lx12 hours. She urinated 8 times and defecated
once during the day.

3. August 27, 2012 @ 3 PM

Vital Signs
BP: 120/80 110/70 mmHg
Temp: 37.3 36.8 C
PR: 85 82 bpm
RR: 22 20 bpm
On the third day of appraisal, Mrs. Abaton was sitting on bed, fair in appearance and
conversant. She has an IVF of D5NSS to KVO at 900 cc level. She has still the complaint of
unproductive cough. He was seen and examined by Dr. Tomas with new order made and carried
out such as repeat Chest X-ray PA. She urinated 9 times and defecated once during the day.

X. DIAGNOSTIC PROCEDURES
COMPLETE BLOOD COUNT (CBC)
The complete blood count or CBC test is used as a broad screening test to check for such
disorders such as anaemia, infection and many other diseases. The complete blood count test is
performed by obtaining a few millilitres (one to two teaspoons) of blood sample directly from
the patient. It can be done in many settings including the doctors office, laboratories, and
hospitals. The skin is wiped clean with an alcohol pad, and then a needle is inserted through the

area of cleansed skin into the patients vein. The blood is then pulled from the needle by a
syringe or by a connection to a special vacuumed vial where it is collected. This sample is then
taken to the laboratory for analysis.
Hemoglobin- Red pigment responsible for the color of blood.
It is the main component of RBC and serves as the vehicle for transportation of
oxygen and carbon dioxide.
Hematocrit- Percentage of red blood cells in a given volume of blood.
-The measurement of the percentage of red cells in the total volume of the blood. It
is a measure of the packed cell volume of red cells expressed as a percentage of the total blood
volume. It indicates relative proportion of the plasma and RBCs. This is a measurement of the
percentage of the RBC in the total value of blood. This blood test, hence, evaluates blood loss,
anemia, blood replacement therapy and fluid balance and also screens blood cells.
RBC/erythrocytes- are biconcave discs. This is an adaptation for transporting gases; it increases
the surface area through which gases can diffuse. The red blood cells shape also places the cell
membrane closer to oxygen-carrying haemoglobin within the cell.
- The determination of the number of red cells found in each cubic millimeter
of whole blood. The main characteristics of erythrocyte are the presence of hemoglobin and iron
containing protein that binds oxygen.
Mean cell volume- The average volume of red cells MCV is one of the standard red blood cells
indices. It is the average amount of space occupied by each red blood cell

Mean Cell Hemoglobin Concentration- The average concentration of hemoglobin in a given

volume of packed red cells. The MCHC is a measure of the concentration of hemoglobin in a
given volume of packed red blood cell.
WBC/Leukocytes- protects againts disease. Leukocytes develop from hemoblasts in the red
bone marrow in response to hormones, much as red blood cells form from precursors upon
stimulation from erythropoietin. These hormones fall into two groups- interleukins and colony-

stimulating factors are named for the cell population they stimulate. Blood transports white blood
cells to sites of infection. White blood cells may then leave the bloodstream.
Segmenters - These are the most common of the WBCs and serve as the primary defense against
infection. The typical response to infection or serious injury is an increased production of
neutrophils.
Neutrophils- They are a part of WBC, which is the first one to launch at the site of tissue injury.
Neutrophils are the first type of immune cell to respond to and arrive at the site of infection,
often within an hour. Neutrophils will respond to infection inside the body, but also on the
surface, as in the case of gastric mucosal erosion.
Lymphocytes- are usually only slighty larger than red blood cells. A typical lymphocyte has a
large, round nucleus surrounded by a thin rim of cytoplasm. These cells account for 25-35% of
circulating leukocytes. Lymphocytes may live for years.
Monocytes- the largest blood cell, two to three times greater in diameter than red blood cells.
Their nuclei vary in shape and are round, kidney shaped, oval, or lobed. They usually make-up 39% of the leukoc ytes in a blood sample and live for years.
Eosinophils- contain coarse, uniformly sized cytoplasmic granules that appear deep red in acid
stain. The nucleus usually has only two lobes(termed bilobed). Eosinophils make up 1-3% of the
total number of circulating leukocytes.
Basophils- are similar to eosinophils in size and in the shape of their nuclei, but they have fewer,
more irregularly shaped cytoplasmic granules that become deep blue in basic stain. Basophils
usually account for less than 1% of the circulating leukocytes.
Platelet Count is a test to measure how many platelets you have in the blood. Platelets help
the blood clot. They are smaller than red or white blood cells.

Blood Urea Nitrogen (BUN) a serum test that measures the amount of nitrogenous urea, the
end product of protein metabolism.
Creatinine a test measures the amount of creatinine in the serum. Creatinine is an end product
of protein and muscle metabolism.
Sodium maintains plasma and interstitial osmolarity; responsible for generation and
transmission of action potential. It is responsible also for the acid-base balance.
Potassium it is for intracellular osmolarity and for maintaining electrical membrane
excitability.
Purpose: To identify the presence of infection and to determine whether the patient has enough
defense mechanism in fighting the illness and done to monitor the condition and/or effective of
treatment after a diagnosis is established.

1. August 19, 2012

Ordered by: Dr. Tomas
Test
Hematology
CBC
Hemoglobin
Hematocrit
RBC
Mean Cell Volume
MCHC concentration
WBC
Differential Count

Result

Reference Ranges

Interpretation

L 89.00 g/L
L 0.29
L 3.660 10^12/L
L 78.10 fL
31.10 g/dL
H 13.09 10^9/L
0.63

123-153
0.35-0.44
4.5-5.1
80-100
31-35
4.50-11.00
0.50-0.70

DECREASED
DECREASED
DECREASED
DECREASED
NORMAL
INCREASED
NORMAL

Segmenters
Lymphocytes
Monocytes
Eosinophils
Basophils
Platelet Count

L 0.17
H 0.11
H 0.08
0.01
H 710 10^9/L

0.20-0.40
0.02-0.08
0.01-0.04
0.00-0.01
150-450

DECREASED
INCREASED
INCREASED
NORMAL
INCREASED

Chemistry
Blood Urea Nitrogen
Creatinine
Sodium
Potassium

6.48 Mmol/L
75-41 Umol/L
137.00 Mmol/L
4.80 Mmol/L

1-.7-8.3
44.2-150.3
136-150
3.4-5.3

NORMAL
NORMAL
NORMAL
NORMAL

ANALYSIS:
If the Red Blood Cell decreased, subsequently the hematocrit is worsen because the blood
will dilute. The increase in WBC indicates infection and inflammatory process while the increase
in monocytes and eosinophils also indicates the presence of tuberculosis and allergic responses.
However, a low lymphocyte count indicates that due to prolonged illness. They are the soldier of
the body diving the infectious process. This is the bodys compensatory mechanism to combat
the arriving infection. There is an increase in the platelet count due to the presence of infection
and inflammation at the pleura of the lungs. In addition, as the granulomar in the lungs there
happens a possible bleeding. This would signal the production of more platelets to suppress and
repair the bleeding.

2. August 22, 2012

Test
Hematology
CBC
Hemoglobin
Hematocrit
RBC
Mean Cell Volume
MCHC concentration
WBC

Result

Reference Ranges

Interpretation

127.00 g/L
0.39
4.850 10^12/L
80.40 fL
31.10 g/dL
10.87 10^9/L

123-153
0.35-0.44
4.5-5.1
80-100
31-35
4.50-11.00

NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
NORMAL

Differential Count

0.65

0.50-0.70

NORMAL

Segmenters
Lymphocytes
Monocytes
Eosinophils
Basophils
Platelet Count

L 0.17
H 0.14
0.03
0.01
H 641 10^9/L

0.20-0.40
0.02-0.08
0.01-0.04
0.00-0.01
150-450

DECREASED
INCREASED
NORMAL
NORMAL
INCREASED

Chemistry
Blood Urea Nitrogen
Creatinine

2.69 Mmol/L
64.56 Umol/L

1-.7-8.3
44.2-150.3

NORMAL
NORMAL

ANALYSIS:
There is an increase in the platelet count due to the presence of infection and
inflammation at the pleura of the lungs. The increase of monocytes indicates the presence of a
bacterial infectious process. However, a low lymphocyte count indicates still the prolonged
illness occurred to Mrs. Abaton.

3. August 26, 2012

Test
Hematology
CBC
Hemoglobin
Hematocrit
RBC
Mean Cell Volume
MCHC concentration
WBC

Result

Reference Ranges

Interpretation

126.00 g/L
0.40
4.890 10^12/L
80.80 fL
31.90 g/dL
H 15.34 10^9/L

123-153
0.35-0.44
4.5-5.1
80-100
31-35
4.50-11.00

NORMAL
NORMAL
NORMAL
NORMAL
NORMAL
INCREASED

Differential Count

0.70

0.50-0.70

NORMAL

Segmenters
Lymphocytes

L 0.10

0.20-0.40

DECREASED

Monocytes

H 0.12

0.02-0.08

INCREASED

ANALYSIS:
The increase in WBC indicates infection and inflammatory process while the increase in
monocytes also indicates the presence of a bacterial infectious process.
lymphocyte count indicates that Mrs. Abaton experienced prolonged illness.

However, a low

Nursing Responsibilities

Rationale

1. Explain procedure to the patient.

-to gain cooperation

2.Forward laboratory request to laboratory

-for proper consideration of specific procedure

3. Follow up laboratory results

-to know if the requested examination was

done or not

4. Upon arrival of the result, refer it to the

physician and then attach it to the clients
chart.

- in order for the physician to determine

appropriate management to be given to the
client.

5. Refer accordingly significant results

-for proper intervention

CHEST X-RAY
The chest x-ray is the most commonly performed diagnostic x-ray examination. A chest
x-ray makes images of the heart, lungs, airways, blood vessels and the bones of the spine and
chest. An x-ray (radiograph) is a noninvasive medical test that helps physicians diagnose and
treat medical conditions. Imaging with x-rays involves exposing a part of the body to a small
dose of ionizing radiation to produce pictures inside the body,
Purpose: To help diagnose or monitor treatment for Pneumonia and PTB.
Ordered by: Dr. Tomas
Computed Radiography, Diagnostic Ultrasound (August 19, 2012)
Name of patient
Abaton, Perlita

Patient ID

Room No.

029891

5F
INTERPRETATION

Pleuroparenchymal infiltrates with areas of rarefaction

Both upper lobes more on the left

Sex

Birthdate/Age

Female

4-19-54/58Y

Confluent haziness bases

Heart is not enlarged
Pulmonary vascularities are within normal
Visualized osseous structures are unremarkable
IMPRESSION: Findings suggestive of PTB extensive
Both upper lobes
Pneumonia both lungs

ANALYSIS:
The confluent haziness bases indicates that there is inflammation on the lungs of the
client and that both of her lungs, but more on the left, were affected. Also, it indicates that there
is the presence of mucous and phlegm in the lungs.

Computed Radiography, Diagnostic Ultrasound (August 24, 2012)

Name of patient
Abaton, Perlita

Patient ID

Room No.

029891

5F

Sex

Birthdate/Age

Female

4-19-54/58Y

INTERPRETATION
Follow-up study compared with the previous film dated 8/19/2012 now shows minimal
blunting of the left costophrenic sulcus.
Same extent of abundant tuberculous infiltrates in both lungs with confluence in the
upper lobe is seen.
Heart is not enlarged. Diaphragm is normal in level. Bones are intact.
IMPRESSION: Extensive PTB, Bilateral
Minimal Pleural Effusion, Left

ANALYSIS:
There is a tuberculous that infiltrates on both lungs which means that there is irritation
and inflammation on her lungs which causes her to cough as the defense mechanism of the body.
Nursing Responsibilities
Rationale
1. Check if the laboratory request was To make sure that the request is properly
appropriately filled up and properly carried out and to notify the radiologist.
forwarded to the laboratory.
2. Ensure that the client understands about To know if there is a need of reemphasizing, to
the importance of the test as well as its gain cooperation and to reduce anxiety.
nature.
3. Remove patients jewelry, dentures, These objects may produce artifacts on the film
hairpins, contact lenses, eye glasses, and may alter the result.
and other metallic items.
4. Inform radiologist if the client has These can make a shadow on the X-ray picture
metal objects on the chest.

that hides part of the bones.

5. Stay with the patient if restless or To ensure safety of the patient and provide
confused.
psychological support.
6. Instruct patient to remain still during The picture may not be clear because
the procedure.

movements can cause haziness to the film.

XI. MEDICAL MANAGEMENT

A. DIET THERAPY
DAT (Diet as Tolerated)
Date of ordered: 8-19-12
Ordered by: Dr. Arnulfu Tomas
Indication: This is a food preparation which provides adequate nutrients, carbohydrates,
proteins, fats, vitamins and minerals in their normal proportion.
Purpose: This is indicated to our client to provide good and adequate nutrition for the client to
gain strength and to have greater resistance against infection.

NURSING RESPONSIBILITIES

RATIONALE

1. Check the doctors order for the To avoid error

check of diet.
2. Transcribe in the diet that the client To inform the dietician that the client is
is already DAT.

already on DAT.

3. Instruct the son or relative as well

as the client that he is in soft diet

To gain compliance.

and the importance of the diet.

4. Provide meals or food in an To enhance appetite.
attractive manner.
5. Promote

personal

hygiene

and

environmental sanitation.

To increase appetite.

6. Instruct client to eat foods rich in

carbohydrates like fibers, protein To increase the clients resistance.
and vitamin C.

B. INTRAVENOUS THERAPHY
One way of supplementing fluid for patient who requires extra fluid nutrition. The
purpose of this is to maintain or replace the bodies stored water and electrolytes and to
prevent fluid and electrolyte imbalance.
Purpose: To provide necessary nutrients to meet daily requirement and for
supplementation and also serves as an avenue in administering medication.
1L of D5NSS x 30 gtts/min
Date ordered:8-24-12 ( time started 10 PM)
8-26-12 ( time started 4 AM)
8-27-12 ( time started 2 PM)
Ordered by: Dr. Arnulfu Tomas
Purpose: IV is used as an avenue for IV drug administration and to supply or provide nutrients
to our patient.
NURSING RESPONSIBILITIES

RATIONALE

1. Prepare all necessary materials or To prevent further occurrence of infection.

equipment aseptically.
2. Observe

aseptic

technique

in To prevent infection and introduction of

assembling the infusion and during microorganisms to the punctured site.

insertion.
3. Regulate the IV fluid to the desired To prevent fluid overload
rate.

4. Assess the site frequently for the

presence of redness, swelling and
pain, blanching of the skin and
coolness or moisture.
5. Change

the

solution

Redness or swelling may indicate vein

irritation; moisture indicates that the tubing
is loose from the cannula or that the site is
leaking and needs to be change.

container To prevent embolism.

before it is completely emptied.

1L of PNSS (plain normal saline solution) x 30 gtts/min

Date ordered: 8-21-12 , 8-25-12
Ordered by: Dr. Arnulfu Tomas
Purpose: IV is used as an avenue for IV drug administration, to supply or provide nutrients and
also use for blood transfusion of our client.
NURSING RESPONSIBILITIES

RATIONALE

1. Explain the purpose and procedure To gain cooperation from the client.
to the client and family about the
management.
2. Prepare all necessary materials or To prevent further occurrence of infection.
equipment aseptically.
3. Regulate the IV fluid to the desired To prevent fluid overload
rate.
4. Change

the

solution

container To prevent embolism.

before it is completely emptied.

5. Check the IV solutions and needles To prevent infiltration and phlebitis
for patency.
6. Avoid client to manipulate the IV To prevent infiltration
fluid.

C. INTAKE AND OUTPUT MONITORING

Measurement and recording of all fluid intake and output provides important data
of the clients fluid and electrolyte balance. It also serves as a parameter for the
management rendered to the client.
Purpose: This management was done to assess fluid balance. Measuring fluids
is necessary since these fluids play significant roles in the improvement of the
client.
NURSING RESPONSIBILITIES

RATIONALE

1. Inform client, family members that To obtain cooperation of the client and
accurate

measurement

of

the family

clients fluid intake and output are

required are also included the
rationale of this management.
2. Specify the time and fluid intake
and record it such as:
Oral fluids like water, milk, For accurate measurement of fluid intake
juices, soap or cream.
Parenteral fluids
IV medications and cyclis
3. Specify the time and fluid output as
to
Urinary output
Vomitous (if there is)
4. Provide a calibrated or improvised
measuring device that maybe used

For accurate measurement of urine output

in measuring the input and output

of the patient.
5. Fluid

input

and

output

measurements are totaled at the end

of the shift to determine if there are
significant changes in the clients

For accurate measurement of intake and

fluid status.

output

6. Refer to the physician if significant

discrepancies occur.

To determine significant changes in the

fluid status of the client

For prompt intervention

D. BLOOD TRANSFUSION
Blood transfusion is the process of transferring blood or blood-based products from one
person into the circulatory system of another. This is usually done as a lifesaving maneuver to
replace blood cells or blood products lost through severe bleeding, during surgery when blood
loss occurs or to increase the blood count in an anemic patient.
PURPOSE: This management was done to our client to replace the blood that was lost due to
hematemesis and and to supply sufficient blood components responsible for coagulation
For BT -500 cc of packed RBC

Nursing Responsibilities

Rationale

1. Notify the blood bank that a To allow them to check for the availability of
the blood type.
transfusion will occur
2. Explain the procedure for giving To gain cooperation.
blood transfusion
3. Assist in obtaining the specimen and To have an effective and efficient procedure.
make sure that it will be submitted to
the laboratory for blood typing and
cross matching.
4. Check for vital signs especially To monitor effect of the blood transfusion.
during the blood transfusion before and
after the procedure.
5. Make sure the proper blood product
is given to the right patient by checking

To avoid ABO incompatibility reactions.

the serial number of the blood to be

infused.
6. Assess the
and skin color

patients urine output, To determine whether the patient can tolerate

infusion.

7. Make sure that the client has an IVF Used to prevent coagulation during transfusion
of PNSS
8. Administer a warm blood
9. The drug must be administered 4- 6
hours

To prevent chilling of the patient

To prevent clotting of the blood

E. NEBULIZATION
It is the process of using a nebulizer which is an inhaler device used to treat
asthma and allergies. The inhaler aerosolizes medication to help reduce inflammation and
dilate air passages. The treatments are used as a preventative measure against acute
allergic reactions or as a treatment during asthma attacks. Some nebulizers are available
over the counter, but most require a prescription from a doctor.
PURPOSE: To loosen the mucous of the lungs and help the client to expectorate the
phlegm from the lungs.
NURSING RESPONSIBILITIES

RATIONALE

1. Explain procedure to the patient.

To gain cooperation and for the patient to

know how to do it on the next nebulization.

2. Instruct patient not to cover the end So that the treatment will be more effective.
part of the T-tube.
3. Inform patient if he/she experiences So that there will be increase salivation and
dry mouth and bitter taste due to to alter the bitter taste and dry mouth.
medications; frequent rinses and
hard

candy

may

symptoms.
4. Instruct patient

to

relieve
use

the

sterile To prevent infection.

nebulizer solution and to change

and sterilize tubing, nebulizer and
connection atleast every 24 hours.
5. Instruct significant others to do To loosen mucous in the lungs and for
bronchial tapping.

easier expectoration.

XII. DRUG STUDY

DRUG STUDY #1
Date ordered: 08-26-12
Ordering physician: Dr. Bigornia
Generic name: Paracetamol
Brand name: Aeknil
Classification: analgesics and antipyretics
Dosage and frequency: 1 amp. For temp. of 39.6 degree Celsius
Route: IV
Mechanism of action: decreases fever by inhibiting the effects of pyrogens on the on the
hypothalamic heat regulating centers and by a hypothalamic action leading to sweating and
vasodilation. Relieves pain by inhibiting prostaglandin synthesis at the CNS but does not
have anti-inflammatory action because of its minimal effect on peripheral prostaglandin
synthesis.
Desired effect: this drug was given to the client to lower down his body temperature since our
patient has a fever and to relieve pain.
Side effect: Rashes, itching, hives, nausea, and indigestion.
Adverse effect: Renal dysfunction and liver and hypochromic anemia.

NURSING RESPONSIBILITIES
1. Test for sensitivity of the patient to

RATIONALE
-

the drug by skin testing.

2. Tell the patient to take only the

to hypersensitivity
-

prescribed drug.
3. Instruct the patient to maintain

To avoid adverse reactions related

To

prevent

tolerance

and

dependency on the drug

-

To prevent the occurrence of other

proper personal hygiene, have enough

infection

rest and sleep.

4. Encourage patient to eat foods rich
in fiber, protein and vitamins.
5. Assess fever and note the presence
of associated signs such as diaphoresis,

To help the clients body recover

from the disease.

To prevent rebound tenderness

To

tachycardia and malaise.

6. Nursing intervention for fever
Provide tepid sponge bath
for a maximum of 30 minutes
Provide good ventilation

provide

an

atmosphere

conducive for rest and relaxation

DRUG STUDY #2
Date ordered: 08-18-12
Ordering physician: Dr. Arnulfu Tomas
Generic name: Rifampicin + Isoniazid+ Pyrazinamide+ Ethambutol HCl
Brand name: Quadmax
Classification: antitubercular drug
Dosage and frequency: 275 mg / OD
Route: oral
Mechanism of action:
Rifampicin: suppress RNA synthesis by binding to the beta subunit of DNA- dependent RNA
plymerose. This prevents attachment of the enzymes to DNA and blockade of RNA
transcription. Both bacteriostatic and bacteriocidal are most active against rapidly replicating
organisms.

Isoniazid: may inhibit cell wall biosynthesis by interfering with lipid and DNA synthesis,
bactericidal.
Pyrazinamide: bacteriostatic against mycobacterium tubecolosis, mechanism of action unknown.
Ethambutol HCl: inhibits the synthesis of metabolites in growing mycobacterium cell, impairing
cell metabolism, arresting cell multiplication and causing cell death.
Desired effect: this drug was given to our patient for adjuct in treating tuberculosis. Treatment of
both smear-positive pulmonary and extrapulmonary TB.
Isoniazid: Given to the client to have negative sputum culture for AFB, to decrease neurotoxic
drug effect and also there is improvement in sympatomatic (decrease fever, decrease
secretions, increase appetite)
Ethambutol HCl: given to the client for the treatment of both smear positive pulmonary and extra
pulmonary TB
Side effect: Rifampicin: diarrhea, nausea and vomiting, headache, drowsiness, anorexia, sore
mouth, flushing
Isoniazid: CNS: peripheral neuropathy, seizures, toxic encephalopathy
GI: nausea and vomiting, epigastric distress, bilirubinemia,
Hematologic: aplastic anemia, thrombocytopenia, hyperglycemia, metabolic
acidosis,
Hypersensitivity: skin eruptinns, fever, vasculitis
Pyrazinamide: Dermatologic: rashes, photosensitivity
GI: hepatoxicity, nausea and vomiting, diarrhea, anorexia
Hematologic: sideroblastic anemia, thrombocytopenia, adverse effect on clotting
mechanism
Ethambutol HCl: CNS: optic neuritis, fever, malaise, headache, dizziness, mental confusion

GI: anorexia, nausea and vomiting, GI upset, abdominal pain

Hypersensitivity: allergic reaction, dermatitis, pruritus, anaphylactoid reaction
Adverse effect: - GI disturbance, transient abnormalities in liver function tests, elevations of
BUN and serum uric acid, anorexia, nausea, vomiting, abdominal pain, fever, malaise,
headache.
Rifampicin: thrombocytopenia, leukopenia, hemolistic anemia, esosinophilia and decreased
hemoglobin, pruritus, urticania, rash, pemphigoid reaction, soure mouth, soure tongue.
INH: peripheral neuropathy, elevated serum transaminases (SGOT, SGPT), bilirubenemia,
jaundice, fetal hepatitis
Ethambutol: optic neuritis, anaphylactoid reactions, dermatitis, pruritis, joint pain, dizziness,
mental confusion, disorientation and hallucination, numbness and tingling of the extrimities.

NURSING RESPONSIBILITIES
1. Give capsule once daily 1 hour

RATIONALE
-

To ensure maximum absorption

To effectively treat tuberculosis

To prevent the occurrence of other

before or 2 hours after meal.

2. Instruct the patient to adhere to
prescribe medication and do not
stop or skip the doses of the
medication.
3. Instruct patient to maintain proper

infection

personal hygiene, have enough

rest and sleep.
4. Assess for the side effects of the
medication

like

pain

eye

To be able to contact doctor

immediately

movement.

dose/drug

to
to

give

counteract

lesser
side

effects.
5. Instruct patient to expect orange
discoloration of urine due to the

To prevent patient from becoming

Rifampicin.

anxious.

6. Educate patient that when she

experiences gastric irritation, she
should take the medicine after a

To lessen/prevent further gastric

pain.

light meal.

DRUG STUDY #3
Date ordered: 08-21-12
Ordering physician: Dr. Arnulfu Tomas
Generic name: Acetylcysteine
Brand name: Flumex
Classification: mucolytic
Dosage and frequency: 3 times daily
Route: oral
Mechanism of action: mucolytic reduces the viscosity of pulmonary secretions by splitting
disulfide linkages between muco protein molecular complexes.
Desired effect: this drug was given to the client to improve airway exchange by decreasing
viscosity.
Side effect: bronchial/ tracheal irritation, nausea and vomiting, rash, stomatitis
Adverse effect: GI discomfort; nausea and vomiting in high doses; hyperpyrexia

NURSING RESPONSIBILITIES
1. Check for doctors order

RATIONALE
To ensure proper dosage and to

maintain the potency of the drug

2. Instruct the patient about the water

To become more effective

needed when dissolving.

3. Instruct the patient to mix drug
properly.
4. Instruct patient to increase oral fluid
intake.
5. Turn patient regularly from side to
side.

So that other particles of the drug

will be dissolve.
To

liquefy

and

for

easy

expectoration of mucous/phlegm
For mucous mobilization and for
easy

expectoration

of

the

mucous/phlegm.
6. Do bronchial tapping after taking
the drug.
7. Advice patient to do deep breathing
and coughing exercises.

DRUG STUDY #4
Date ordered: 08-21-12
Ordering physician: Dr. Arnulfu Tomas
Generic name: Vit B1 B6 B12
Brand name: Revitaplex
Classification: Coenzyme, Vitamin and Antianemic

To aid for easier expectoration of

mucous.

To strengthen the ability of the

lungs to expectorate mucous.

Dosage and frequency: 100 mg/ 5 mg/ 150 mcg OD

Route: oral
Mechanism of action: help maintain healthy nervous system and blood cell formation.
Desired effect: Vit B1 B6 B12 was given to our patient to increase his energy.
Side effect: Headache, black stools, abdominal pain, constipation, nausea and vomiting,
dizziness.
Adverse effect: Swelling of the face or tongue, difficulty of breathing, tightness in the chest and
discoloration of the skin.

NURSING RESPONSIBILITIES
1. Avoid

taking

any

RATIONALE

other Can cause overdose or serious side effect

multivitamin product within 2 hours

before

or

after

you

take

multivitamin with iron.

2. Explain the reasons for drug therapy

To prevent toxicity

3. Provide a printed list of foods high in To promote well-balanced diets are the best
vitamin B6 like potatoes, broccoli, source of vitamins and refer to dieticians as
bananas, lima beans, liver and needed
whole grain
4. Do not take large doses of vitamin Can cause serious threatening side effects
B1, B6 and B12

DRUG STUDY #5
Date ordered: 08-21-12
Ordering physician: Dr. Arnulfu Tomas

Generic name: Ceftriaxone Sodium

Brand name: Haxon
Classification: Antibacterial
Dosage and frequency: 2 g/ OD
Route: IV
Mechanism of action: the bacteriacidal activity of ceftriaxone results from inhibition of the cell
wall synthesis. It has a high degree of stability in the presence of beta-lactamase, both
penicillinase and cephalosporinase of gram-negative and gram-positive.
Desired effect: this drug was given to the patient for the resolution of signs and symptoms of
infection, negative culture reports.
Side effect:
Local reaction: pain, induration or tenderness at the site of injection
Hypersensitivity: rash, pruritis, fever, chills
Hematologic: eosinophillia, thrombocytosis, leukopenia
GI: diarrhea, nausea and vomiting
Hepatic: elevation of alkaline, phosphotase and bilirubin
Renal: increase BUN
CNS: headache, dizziness
Genitourinary: moniliasis/ vaginitis, candidiasis
Others: diaphoresis and flushing, chills
CV: phlebitis

Adverse effect: pain, duration at the site of injection; rash, eosinophilia, thrombocytosis and
leukopenia, diarrhea, elevated SGOT (liver enzyme) and BUN.
NURSING RESPONSIBILITIES
1. Verify doctors order
2. Before administering the drug ask
patient for any allergies.
3. Instruct client to be aware that
cross-sensitivity to penicillins and

RATIONALE
To prevent errors in administering the drug
To determine any reaction of the drug
To reduce anxiety

cephalosporins may occur.

4. Tell patient to notify prescriber
about loose stool or diarrhea.

To prevent any further complications.

DRUG STUDY #5
Date ordered: 08-19-12
Ordering physician: Dr. Arnulfu Tomas
Generic name: Hydrocortisone Sodium Succinate
Brand name: Solu-Cortef
Classification: Adrenal Corticosteroid
Dosage and frequency: 100 mg every 8 hours
Route: IV
Mechanism of action: decreases inflammation mainly by stabilizing leukocyte lysosomal
membranes, suppresses immune response, stimulates bone marrow and influences protein, fat
and carbohydrates metabolism.

Desired effect: this drug was given to the client for restoration of skin integrity, relief of allergic
manifestation and to decrease inflammation.
Side effect:
CNS: euphoria, insomnia, psychotic behavior, pseudotumor celeroli, vertigo, headache,
paresthesia, seizure
CV: heart failure, hypertension, edema, arrhythmias, thrombophlebitis, thromboembolism
EENT: cataract, glaucoma
GI: peptic ulceration, GI irritation, increase appetite, pancreatitis, nausea and vomiting
GU: increase urine calcium levels
Hematologic: easy bruising
Metabolic: hypokalemia, hyperglycemia, carbohydrate intolerance, hypercholesterolymia,
hypocalemia
Muscuskeletal: growth suppression in child, muscle weakness, osteoporosis
Skin: hirsutism, delayed wound healing, acne, skin eruption
Adverse effect: fluid and electrolyte disturbances, decreased carbohydrate tolerance, impaired
wound healing, thin fragile skin, muscle weakness, steroid myopathy, osteoporosis, aseptic
necrosis, peptic ulceration with possible perforation, cataracts, increased intra ocular and intra
cranial pressure, and growth retardation.
NURSING RESPONSIBILITIES

RATIONALE

1. Instruct patient to report signs of To inform the doctor immediately and

infection such as fever or chills, render immediate action.
cough, bruising or bleeding, bloody
or black, tarry stools.
2. Monitor water retention.

To prevent fluid overload in the body.

To decrease anxiety

3. Inform patient possible effects of

the drug.

To decrease possibility of accident during

4. Provide safety environment such as seizures.

raise side rails.
To
5. Do reverse isolation.

prevent

acquiring

other

illness/complication.

DRUG STUDY #6
Date ordered: 08-21-12
Ordering physician: Dr. Arnulfu Tomas
Generic name: Ampicillin sodium + Sulbactam sodium
Brand name: Sulbacin
Classification: Antibacterial
Dosage and frequency: 1.5 g every 8 hours
Route: IV
Mechanism of action: inhibits cell wall synthesis during bacterial multiplication.
Desired effect: this drug was given to the client for the resolution of infection and symptomatic
improvement.
Side effect:
GI: diarrhea, nausea, pseudomembrane colitis
Hematologic: agranulocytosis, leukopenia, thrombocytopenia, thrombocytopenic purpura
Skin: pain at injection site
Adverse effect: pain in injection site; phlebitis; nausea, vomiting and diarrhea; rash; itching;
anemia; thrombocytopenia; eosinophilia and leukopenia

NURSING RESPONSIBILITIES

RATIONALE

1. Check for sensitivity of the drug Check for any reaction

(ANST)
To prevent errors

2. Verify doctors order.

3. Advise

patient

to

report

any

discomfort after infusing.

To prevent the occurrence of other infection

and to know the immediate intervention
when it occurs

4. Inspect vial.
5. After reconstitution solution should

To ensure dissolution
So that any foaming will dissipate

stand.
6. Monitor for signs and symptoms of

To prevent any further complications.

hypersensitivity reaction.
7. Watch for bleeding tendency.

DRUG STUDY #7
Date ordered: 08-20-12
Ordering physician: Dr. Arnulfu Tomas
Generic name: Ipatropium Bromide
Brand name: Combipul
Classification: Bronchodilator
Dosage and frequency: 1 ml every 6 hours

To prevent haemorrhage/anemia.

Route: Nebule inhalation

Mechanism of action: inhibit vagally mediated reflexes by antagonizing acetylcholine at
muscarinic receptor or bronchial smooth muscles.
Desired effect: to improve airway exchange and breathing patterns, decrease wheezing and
dyspnea.
Side effect:
CNS: dizziness, headache,
CV: chest pain, palpitations
GI: GI distress
Muscoskeletal: back pain
Respi: upper respiratory tract, bronchitis, broncho spasm
Skin: rash
Adverse effect: Tremors, nervousness, tachycardia, dizziness, headache, hypokalemia, dry
mouth, throat irritation and urinary retention.

NURSING RESPONSIBILITIES

RATIONALE

1. Teach patient to perform oral To ensure proper administration of the drug

inhalation correctly.

and to ensure the potency of the drug being

inhaled.

2. Do bronchial clapping every after To promote expulsion of secretions

nebulization.
3. Advice patient to remove canister To ensure asepsis
and wash inhaler in warm water at
least once w week.
4. Supervision of the client while

nebulization.

To check if the client is doing the proper

way of nebulization.

DRUG STUDY #8
Date ordered: 08-19-12
Ordering physician: Dr. Arnulfu Tomas
Generic name: Azithromycin
Brand name: Zithromax
Classification: antibiotic, macvolide
Dosage and frequency: 500 mg TID
Route: oral
Mechanism of action: binds to the SOS subunit of bacterial ribosome, blocking protein
synthesis; bacteriostatic/ bactericidal depending on concentration
Desired effect: for the resolution of signs and symptoms of infection
Side effect:
CNS: dizziness, fatigue, vertigo
CV: chest pain
GI: abdominal pain, diarrhea, nausea, melena
GU: nephritis
Hepatic: cholestatic jaundice
Skin: rash

Adverse effect: Nausea, abdominal discomfort, vomiting, flatulence, diarrhea and loose stool,
Hearing impairment, interstitial nephritis, acute renal failure, abdominal liver function, dizziness,
convulsions, headache, somnolence, reduced lymphocyte count, increase eosinophil count,
reduced blood bicarbonate

NURSING RESPONSIBILITIES

RATIONALE

1. Do sensitivity test before giving the To determine any reaction

first dose.
2. Tell

patient

to

take

drug

as To promote further improvements on

prescribed even after he feels better. his/her illness.

3. Tell patient to report adverse effects

promptly.
4. Tablet may be taken with food or
milk.

To prevent any further complications and to

immediately act on the adverse effect.

To improve tolerability.

5. Drug should be taken at least 1 hour To ensure maximum absorption

prior to or 2 hours after meal.

XIII. GENERAL EVALUATION

Mrs. Perlita, 58 years old from Brgy. 10-N Lacub, Batac, Ilocos Norte was admitted at
Mariano Marcos Medical Hospital and Medical Center on August 19, 2012 @ 5:30 PM by Dr.
Cocson/Dr. Tomas with a diagnosis of Bronchial Asthma with Acute Exacerbation, Community
Acquired Pneumonia T/C PTB. She was attended by Dr. Cocson/Dr. Tomas who immediately
performed several tests to her condition. She was subjected to several laboratory tests such as
CBC and chest x-ray wherein the first diagnosis was confirmed.
The following managements were medications like Paracetamol, RIPE, Acetylcysteine,
Vit. B1,B6,B12, Ceftriaxone Sodium, Hydrocortisone Sodium Succinate, Ampicillin Sodium +
Sulbactam Sodium, Ipatropium Bromide and Azithromycin. Her IVFs during her hospitalization
were D5NSS 1L and PNSS 1L. After 9 days of medical and nursing intervention, the client has
improved in various ways. She was afebrile, with an occasional cough and verbalized a general
feeling of wellness.
August 28, 2012 in the afternoon, she was discharged from the hospital and went home
with a final diagnosis of Community Acquired Pneumonia High Risk (HR), Pulmonary
Tuberculosis Far Advance (FA). Home meds were prescribed and follow-up consultations were
advised and scheduled.