C.

INTRODUCTION
Upper respiratory tract infection (URI) is a nonspecific term used to describe
acute infections involving the nose, paranasal sinuses, pharynx, larynx, trachea, and
bronchi. The prototype is the illness known as the common cold, which will be
discussed here, in addition to pharyngitis, sinusitis, and tracheobronchitis. Influenza is a
systemic illness that involves the upper respiratory tract and should be differentiated
from other URIs.
Viruses cause most URIs, with rhinovirus, parainfluenza virus, coronavirus,
adenovirus, respiratory syncytial virus, coxsackievirus, and influenza virus accounting
for most cases. Human metapneumovirus is a newly discovered agent causing URIs.
Group A beta-hemolytic streptococci (GABHS) cause 5% to 10% of cases of pharyngitis
in adults. Other less common causes of bacterial pharyngitis include group C betahemolytic

streptococci,

Corynebacterium

diphtheriae,

Neisseria

gonorrhoeae,

Arcanobacterium haemolyticum, Chlamydia pneumoniae, Mycoplasma pneumoniae,

and herpes simplex virus. Streptococcus pneumoniae, Haemophilus influenzae, and
Moraxella catarrhalis are the most common organisms that cause the bacterial
superinfection of viral acute sinusitis. Less than 10% of cases of acute tracheobronchitis
are caused by Bordetella pertussis, B. parapertussis, M. pneumoniae, or C.
pneumoniae.
Most URIs occurs more frequently during the cold winter months, because of
overcrowding. Adults develop an average of two to four colds annually. Antigenic
variation of hundreds of respiratory viruses results in repeated circulation in the
community. A coryza syndrome is by far the most common cause of physician visits in
the United States. Acute pharyngitis accounts for 1% to 2% of all visits to outpatient and
emergency departments, resulting in 7 million annual visits by adults alone. Acute
bacterial sinusitis develops in 0.5% to 2% of cases of viral URIs. Approximately 20
million cases of acute sinusitis occur annually in the United States. About 12 million
individuals are diagnosed with acute tracheobronchitis annually, accounting for one

third of patients presenting with acute cough. The estimated economic impact of non
influenza-related URIs is $40 billion annually.
Influenza epidemics occur every year between November and March in the
Northern Hemisphere. Approximately two thirds of those infected with influenza virus
exhibit clinical illness, 25 million seek health care, 100,000 to 200,000 require
hospitalization, and 40,000 to 60,000 die each year as a result of related complications.
The average cost of each influenza epidemic is $12 million, including the direct cost of
medical care and indirect cost resulting from lost work days. Pandemics in the 20th
century claimed the lives of more than 21 million people. A widespread H5N1 pandemic
in birds is ongoing, with threats of a human pandemic. It is projected that such a
pandemic would cost the United States $70 to $160 billion.

The reason why i chose this patient was that her case was the most interesting
among all the patients in the ward. There were a lot of problems that I could identify that
caught my interest and where we can give a lot of health teachings and interventions to
our client. In short, her case fits best in the criteria for choosing a case study because
her diagnosis was something a common one. I also want to go deeper with this kind of
case and learn more from it.

D. Definition of diagnosis

Upper respiratory tract infection (URI) is a nonspecific term used to describe acute
infections involving the nose, paranasal sinuses, pharynx, larynx, trachea, and bronchi.
The prototype is the illness known as the common cold, which is discussed here, in
addition to pharyngitis, sinusitis, and tracheobronchitis. Influenza is a systemic illness
that involves the upper respiratory tract and should be differentiated from other URIs.
Viruses cause most URIs, with rhinovirus, parainfluenza virus, coronavirus,
adenovirus, respiratory syncytial virus, Coxsackie virus, human metapneumovirus, and
influenza virus accounting for most cases. Group A beta-hemolytic streptococci
(GABHS) cause 5% to 10% of cases of pharyngitis in adults. Other less common
causes of bacterial pharyngitis include group C beta-hemolytic streptococci,
Corynebacterium diphtheriae, Neisseria gonorrhoeae, Arcanobacterium haemolyticum,
Chlamydophila (formerly Chlamydia) pneumoniae, Mycoplasma pneumoniae, and
herpes simplex virus. Streptococcus pneumoniae, Haemophilus influenzae, and
Moraxella catarrhalis are the most common organisms that cause the bacterial
superinfection of viral acute rhinosinusitis. Less than 10% of cases of acute
tracheobronchitis are caused by Bordetella pertussis, B. parapertussis, M. pneumoniae,
or C. pneumoniae.
Scope and Limitation
The case study merely covers data that have been gathered through interview per
assessment tool and chart referral on the day of the assessment phase in loading
assigned patients and in the succeeding days of the rotation, in the care formulated and
intervened to its progress as the weeks rotation ended. Thus, it is limited to the days in
the rotation the student nurse interacted with the client in the hope to gather the
necessary data to support the presentation which is not enough to acquire a bulk of
specific details.
E. Patients Profile

I.

HEALTH HISTORY

Patients Profile
Clients Name:

Mr. X

Age:

15 years old

Birthday:

12/15/1999

Address:

Mangga st., Juna Subd., Davao City

Civil Status:

Single

Sex:

Male

Nationality:

Filipino

Religion:

Roman Catholic

Height:

167 cm (52)

Weight:

78 kg

Admitting Physician:

Dr. Romulo T. Uy, M.D

Date of Admission:

July 06, 2015

Time of Admission:

1:21 PM

Chief Complaint:

Fever and cough

Admitting Diagnosis:

URTI (Upper Respiratory Tract Infection)

A. Past Health History

Prior to the admission, the patient had 1 previous admission. The patient was
admitted 10 years ago due to Amoebiasis.
B. Present Health History
The patient was a non-alcoholic. His diet consist of foods rich in
vegetables and fruits because he loves to eat those. He seldom consumed foods
rich in fats, but he was a frequent consumer of softdrinks. He doesnt exercise
since he had been very busy with school and some household chores. He
always slept late at night and woke up early often.
C. Family History
5

The patients father was diagnosed with Renal Failure, and he also had
High blood pressure. While the patients mother was diagnosed with type 2
Diabetes. No other trace of underlying condition was reported by the patient.

Chief Complaint and History of present Illness:

A case of pt. M.E., 15-year old male, Mangga st., Juna Subd., Davao City. Three
(3) days prior to admission, patient noted to have productive cough

with feverish

sensation and decrease appetite, at July 7, 2015 at 1:21 pm due to her chief complaints
of productive cough he was admitted at Davao Doctors Hospital and he was diagnosed
by Dr. Uy that she suffered with Upper Respiratory Tract Infection

F. REVIEW OF ANATOMY AND PHYSIOLOGY

Respiratory system

The Respiratory System is crucial to every human being. Without it, we would cease to
live outside of the womb. Let us begin by taking a look at the structure of the respiratory
system and how vital it is to life. During inhalation or exhalation air is pulled towards or
away from the lungs, by several cavities, tubes, and openings.
The organs of the respiratory system make sure that oxygen enters our bodies and
carbon dioxide leaves our bodies.
The respiratory tract is the path of air from the nose to the lungs. It is divided into two
sections: Upper Respiratory Tract and the Lower Respiratory Tract. Included in the
upper respiratory tract are the Nostrils, Nasal Cavities, Pharynx, Epiglottis, and the
Larynx. The lower respiratory tract consists of the Trachea, Bronchi, Bronchioles, and
the Lungs.
As air moves along the respiratory tract it is warmed, moistened and filtered.
Breathing and Lung Mechanics
Ventilation is the exchange of air between the external environment and the alveoli. Air
moves by bulk flow from an area of high pressure to low pressure. All pressures in the
7

respiratory system are relative to atmospheric pressure (760mmHg at sea level). Air will
move in or out of the lungs depending on the pressure in the alveoli. The body changes
the pressure in the alveoli by changing the volume of the lungs. As volume increases
pressure decreases and as volume decreases pressure increases. There are two
phases of ventilation; inspiration and expiration. During each phase the body changes
the lung dimensions to produce a flow of air either in or out of the lungs.
The body is able to stay at the dimensions of the lungs because of the relationship of
the lungs to the thoracic wall. Each lung is completely enclosed in a sac called the
pleural sac. Two structures contribute to the formation of this sac. The parietal pleura
are attached to the thoracic wall whereas the visceral pleura are attached to the lung
itself. In-between these two membranes is a thin layer of intrapleural fluid. The
intrapleural fluid completely surrounds the lungs and lubricates the two surfaces so that
they can slide across each other. Changing the pressure of this fluid also allows the
lungs and the thoracic wall to move together during normal breathing. Much the way
two glass slides with water in-between them are difficult to pull apart, such is the
relationship of the lungs to the thoracic wall.
The rhythm of ventilation is also controlled by the "Respiratory Centre" which is located
largely in the medulla oblongata of the brain stem. This is part of the autonomic system
and as such is not controlled voluntarily (one can increase or decrease breathing rate
voluntarily, but that involves a different part of the brain). While resting, the respiratory
center sends out action potentials that travel along the phrenic nerves into the
diaphragm and the external intercostal muscles of the rib cage, causing inhalation.
Relaxed exhalation occurs between impulses when the muscles relax. Normal adults
have a breathing rate of 12-20 respirations per minute.
The Pathway of Air
When one breathes air in at sea level, the inhalation is composed of different gases.
These gases and their quantities are Oxygen which makes up 21%, Nitrogen which is
78%, Carbon Dioxide with 0.04% and others with significantly smaller portions.
8

In the process of breathing, air enters into the nasal cavity through the nostrils and is
filtered by coarse hairs (vibrissae) and mucous that are found there. The vibrissae filter
macroparticles, which are particles of large size. Dust, pollen, smoke, and fine particles
are trapped in the mucous that lines the nasal cavities (hollow spaces within the bones
of the skull that warm, moisten, and filter the air). There are three bony projections
inside the nasal cavity. The superior, middle, and inferior nasal conchae. Air passes
between these conchae via the nasal meatuses.
Air then travels past the nasopharynx, oropharynx, and laryngopharynx, which are the
three portions that make up the pharynx. The pharynx is a funnel-shaped tube that
connects our nasal and oral cavities to the larynx. The tonsils which are part of the
lymphatic system, form a ring at the connection of the oral cavity and the pharynx.
Here, they protect against foreign invasion of antigens. Therefore the respiratory tract
aids the immune system through this protection. Then the air travels through the larynx.
The larynx closes at the epiglottis to prevent the passage of food or drink as a
protection to our trachea and lungs. The larynx is also our voicebox; it contains vocal
cords, in which it produces sound. Sound is produced from the vibration of the vocal
cords when air passes through them.
The trachea, which is also known as our windpipe, has ciliated cells and mucous
secreting cells lining it, and is held open by C-shaped cartilage rings. One of its
functions is similar to the larynx and nasal cavity, by way of protection from dust and
other particles. The dust will adhere to the sticky mucous and the cilia helps propel it
back up the trachea, to where it is either swallowed or coughed up. The mucociliary
escalator extends from the top of the trachea all the way down to the bronchioles, which
we will discuss later. Through the trachea, the air is now able to pass into the bronchi.
Inspiration
Inspiration is initiated by contraction of the diaphragm and in some cases the intercostal
muscles when they receive nervous impulses. During normal quiet breathing, the
phrenic nerves stimulate the diaphragm to contract and move downward into the
9

abdomen. This downward movement of the diaphragm enlarges the thorax. When
necessary, the intercostal muscles also increase the thorax by contacting and drawing
the ribs upward and outward.
As the diaphragm contracts inferiorly and thoracic muscles pull the chest wall
outwardly, the volume of the thoracic cavity increases. The lungs are held to the
thoracic wall by negative pressure in the pleural cavity, a very thin space filled with a
few milliliters of lubricating pleural fluid. The negative pressure in the pleural cavity is
enough to hold the lungs open in spite of the inherent elasticity of the tissue. Hence, as
the thoracic cavity increases in volume the lungs are pulled from all sides to expand,
causing a drop in the pressure (a partial vacuum) within the lung itself (but note that this
negative pressure is still not as great as the negative pressure within the pleural cavity-otherwise the lungs would pull away from the chest wall). Assuming the airway is open,
air from the external environment then follows its pressure gradient down and expands
the alveoli of the lungs, where gas exchange with the blood takes place. As long as
pressure within the alveoli is lower than atmospheric pressure air will continue to move
inwardly, but as soon as the pressure is stabilized air movement stops.
Expiration
During quiet breathing, expiration is normally a passive process and does not require
muscles to work (rather it is the result of the muscles relaxing). When the lungs are
stretched and expanded, stretch receptors within the alveoli send inhibitory nerve
impulses to the medulla oblongata, causing it to stop sending signals to the rib cage
and diaphragm to contract. The muscles of respiration and the lungs themselves are
elastic, so when the diaphragm and intercostal muscles relax there is an elastic recoil,
which creates a positive pressure (pressure in the lungs becomes greater than
atmospheric pressure), and air moves out of the lungs by flowing down its pressure
gradient.

10

Although the respiratory system is primarily under involuntary control, and regulated by
the medulla oblongata, we have some voluntary control over it also. This is due to the
higher brain function of the cerebral cortex.
When under physical or emotional stress, more frequent and deep breathing is needed,
and both inspiration and expiration will work as active processes. Additional muscles in
the rib cage forcefully contract and push air quickly out of the lungs. In addition to
deeper breathing, when coughing or sneezing we exhale forcibly. Our abdominal
muscles will contract suddenly (when there is an urge to cough or sneeze), raising the
abdominal pressure. The rapid increase in pressure pushes the relaxed diaphragm up
against the pleural cavity. This causes air to be forced out of the lungs.
Another function of the respiratory system is to sing and to speak. By exerting
conscious control over our breathing and regulating flow of air across the vocal cords
we are able to create and modify sounds.
Lung Compliance
Lung Compliance is the magnitude of the change in lung volume produced by a change
in pulmonary pressure. Compliance can be considered the opposite of stiffness. A low
lung compliance would mean that the lungs would need a greater than average change
in intrapleural pressure to change the volume of the lungs. High lung compliance would
indicate that little pressure difference in intrapleural pressure is needed to change the
volume of the lungs. More energy is required to breathe normally in a person with low
lung compliance. Persons with low lung compliance due to disease therefore tend to
take shallow breaths and breathe more frequently.
Determination of Lung Compliance Two major things determines lung compliance. The
first is the elasticity of the lung tissue. Any thickening of lung tissues due to disease will
decrease lung compliance. The second is surface tensions at air water interfaces in the
alveoli. The surface of the alveoli cells is moist. The attractive force, between the water
cells on the alveoli, is called surface tension. Thus, energy is required not only to
11

expand the tissues of the lung but also to overcome the surface tension of the water
that lines the alveoli.
To overcome the forces of surface tension, certain alveoli cells (Type II pneumocytes)
secrete a protein and lipid complex called ""Surfactant, which acts like a detergent by
disrupting the hydrogen bonding of water that lines the alveoli, hence decreasing
surface tension.
Upper Respiratory Tract
The upper respiratory tract consists of the nose and the pharynx. Its primary function is
to receive the air from the external environment and filter, warm, and humidify it before
it reaches the delicate lungs where gas exchange will occur.
Air enters through the nostrils of the nose and is partially filtered by the nose hairs, then
flows into the nasal cavity. The nasal cavity is lined with epithelial tissue, containing
blood vessels, which help warm the air; and secrete mucous, which further filters the
air. The endothelial lining of the nasal cavity also contains tiny hair like projections,
called cilia. The cilia serve to transport dust and other foreign particles, trapped in
mucous, to the back of the nasal cavity and to the pharynx. There the mucus is either
coughed out, or swallowed and digested by powerful stomach acids. After passing
through the nasal cavity, the air flows down the pharynx to the larynx.
Lower Respiratory Tract
The lower respiratory tract starts with the larynx, and includes the trachea, the two
bronchi that branch from the trachea, and the lungs themselves. This is where gas
exchange actually takes place.
1. Larynx
The larynx (plural larynges), colloquially known as the voice box, is an organ in our
neck involved in protection of the trachea and sound production. The larynx houses the
vocal cords, and is situated just below where the tract of the pharynx splits into the
12

trachea and the esophagus. The larynx contains two important structures: the epiglottis
and the vocal cords.
The epiglottis is a flap of cartilage located at the opening to the larynx. During
swallowing, the larynx (at the epiglottis and at the glottis) closes to prevent swallowed
material from entering the lungs; the larynx is also pulled upwards to assist this
process. Stimulation of the larynx by ingested matter produces a strong cough reflex to
protect the lungs. Note: choking occurs when the epiglottis fails to cover the trachea,
and food becomes lodged in our windpipe.
The vocal cords consist of two folds of connective tissue that stretch and vibrate when
air passes through them, causing vocalization. The length the vocal cords are stretched
determines what pitch the sound will have. The strength of expiration from the lungs
also contributes to the loudness of the sound. Our ability to have some voluntary control
over the respiratory system enables us to sing and to speak. In order for the larynx to
function and produce sound, we need air. That is why we can't talk when we're
swallowing.
1. Trachea
2. Bronchi
3. Lungs
The Right Primary Bronchus is the first portion we come to, it then branches off
into the Lobar (secondary) Bronchi, Segmental (tertiary) Bronchi, then to the
Bronchioles which have little cartilage and are lined by simple cuboidal
epithelium (See fig. 1). The bronchi are lined by pseudostratified columnar
epithelium. Objects will likely lodge here at the junction of the Carina and the
Right Primary Bronchus because of the vertical structure. Items have a tendency
to fall in it, whereas the Left Primary Bronchus has more of a curve to it which
would make it hard to have things lodge there.

13

The Left Primary Bronchus has the same setup as the right with the lobar,
segmental bronchi and the bronchioles.
The lungs are attached to the heart and trachea through structures that are
called the roots of the lungs. The roots of the lungs are the bronchi, pulmonary
vessels, bronchial vessels, lymphatic vessels, and nerves. These structures
enter and leave at the hilus of the lung which is "the depression in the medial
surface of a lung that forms the opening through which the bronchus, blood
vessels, and nerves pass" (medlineplus.gov).

There are a number of terminal bronchioles connected to respiratory bronchioles

which then advance into the alveolar ducts that then become alveolar sacs. Each
bronchiole terminates in an elongated space enclosed by many air sacs called
alveoli which are surrounded by blood capillaries. Present there as well, are
Alveolar Macrophages, they ingest any microbes that reach the alveoli. The
Pulmonary Alveoli are microscopic, which means they can only be seen through
a microscope, membranous air sacs within the lungs. They are units of
respiration and the site of gas exchange between the respiratory and circulatory
systems.
G. Comprehensive Health Assessment

A. Integumentary
GENERAL APPEARNCE
Patients skin colour has white skin complexion, no discoloration and skin texture
is smooth. Patient has good skin turgor as I pinched his skin and goes back
immediately in place. There was no presence of scaling noted. Hair is evenly
distributed, thin, short, black hair and no infestations noted. In patients finger
nails and toe nails, there was no problem deviations assessed.

14

Head and Neck

Head motion is normal; he can move or flex his head without difficulty and
shrugs shoulders. Upon assessment, no problem noted.
Nose and Sinuses
For the nose and sinuses, upon assessment no problem was noted.
Mouth and Pharynx
For the mouth and pharynx assessment of the patient, no inflammation/lesions
was noted, lips are moist, has complete set of teeth, no tooth decay was noted
and normal findings upon assessment on gag reflex.
Eyes and Ears
The eyes and ears are same as the facial skin. There is symmetry in size
position. Patient visual acuity is not normal because patient uses eye glass and
patient s near sighted. The rest upon assessment is normal. Patient hearing
acuity is normal/can hear in both ears and no any abnormalities/discharges/pain
noted.
Cardiopulmonary
No murmurs upon auscultated, and clients heart sound is characteristics is
regular and strong in rhythm, no edema noted, Blood pressure is 110/80mmHg,
peripheral pulses is 78bpm.
Thorax and Lungs
Upon assessment, there is no thorax deviation but there is a presence of
wheezes sounds upon auscultation. Respiratory rate is 22cpm.
Gastrointestinal
Bowel sounds is present in all quadrants. Abdomen is flat, skin is intact and no
other unusualities noted.
15

Nutritional/metabolic Patterns
Height is 176cm and weight is 76kg which indicates within the ideal body weight.
Patient has good appetite and able to consume all food served.
BMI computation:
176cm/100= 1.76x2 = 3.52 (76kg/3.52= 21.59)
Body Mass Index Ranges

Underweight: BMI is less than 18.5

Normal weight: BMI is 18.5 to 24.9

Overweight: BMI is 25 to 29.9

Obese: BMI is 30 or more

Genitourinary
Musculoskeletal
Upon assessment with the patients gait, posture weight bearing stance, there
are no abnormalities noted. No decrease of ROM, tenderness and misalignment noted.
Neurological System
Patient is responsive, able to interact and socialize with other people, there was
no change in level of consciousness, and vocalizes sounds.
Cranial Nerve Function
CN 1-Olfactory
CN VI-Trigeminal
CN VII-Facial

[/] intact [] impaired [] unknown

[/] intact [] impaired
[/] intact [] impaired
16

CN VIII-Acoustic
CN IX-Glossopharyngeal
CN X-Vagus
CN XI-Spinal accessory
CN XII-Hypoglossal

[/] intact [] impaired

[/] intact [] impaired
[/] intact [] impaired
[/] intact [] impaired
[/] intact [] impaired

Sensory Function
Touch and Pain were intact.
Reflexes
Reflexes are normal, visible muscle twitch and extension of lower leg.

Etiology

Upper respiratory infection is generally caused by the direct invasion of the inner
lining (mucosa or mucus membrane) of the upper airway by the culprit virus or bacteria.
In order for the pathogens (viruses and bacteria) to invade the mucus membrane of the
upper airways, they have to fight through several physical and immunologic barriers.
The hair in the lining of the nose acts as physical barrier and can potentially trap the
invading organisms. Additionally, the wet mucus inside the nasal cavity can engulf the
viruses and bacteria that enter the upper airways. There are also small hair-like
structures (cilia) that line the trachea which constantly move any foreign invaders up
towards the pharynx to be eventually swallowed into the digestive tract and into the
stomach. In addition to these intense physical barriers in the upper respiratory tract, the
immune system also does its part to fight the invasion of the pathogens or microbes
entering the upper airway. Adenoids and tonsils located in the upper respiratory tract
are a part of the immune system that helps fight infections. Through the actions of the
17

specialized cells, antibodies, and chemicals within these lymph nodes, invading
microbes are engulfed within them and are eventually destroyed.

18

H. Pathophysiology

19

Narrative Report

Upper Respiratory Tract Infection is caused by bacteria called rhinovirus,

coronavirus, parainfluenza virus adenovirus, enterovirus, and respiratory syncytial
virus Streptococcus pyogenes a Group A streptococcus in Streptococcal pharyngitis
that can be transfer through direct hand to hand contact and droplet and can inter
internally through inhalation suppresses immune system some pathogen will be trapped
by use of by hair lining called cilia but some will enter and invade. it will settle in upper
respiratory tract and some will go to the posterior part of nose and in the throat and will
be coated by mucus. Since its already coated with mucus pathogen can enter now in
pharynx inflammatory response to immune system causing the S&S erythema, increase
in mucus secretion manifested by productive cough and colds and fever.

Predisposing

Precipitating

Family history of Bronchial

asthma

Computer gamer

15 years old

Secondhand smoker

Allergy rhinitis

Sedentary lifestyle

20

I. Course in the ward

Doctors Order
Date/ Time
7/ 6/201

Doctors Order

Rationale of Order

>please admit patient under the

> To intervene & give the needed

service of Doctor Yu

health service

>secure consent to care

> As a form for legal purposes.

>IVF: D5LR 1L @ 20 gtts/min

> for hydration

>LABS:
-CBC

-To monitor the blood components

-U/A

-To check if there is any

abnormalities

-CXR (PA)

MEDs
1. Ambrolex OD 75 mg/ PO

- Treatment of acute respiratory

tract diseases with impaired
formation of secretions

2. Brompheniramine
( Nasatapp) 1 tab BID

- lowers or stops the body's

reaction to the allergen.

3. Omeprazole

- used to treat gastroesophageal

4. Hexetidine (Bactidol) Gargle
21

reflux disease (GERD)

5. Salbuterol

- used for topical treatment of sore

throat and oral infections

>V/S q 4o

- used to treat asthma and other

lung-related problems
-to monitor baseline data

>I&O q shift
>Pls inform AP

-to monitor hydration status

-to inform the physician about the

>refer accordingly

condition of the patient.

-for continuity of care

>start Laitun 200mg IV q 12 ANST

7/7/2015

- used to treat certain bacterial

>Fluimucil 600 dissolve in a glass

infections of the nose, lungs, etc.

of water after dinner

- Treatment of respiratory
affections characterized by. thick
>Krerr 1 cap OD

and viscous secretions

>PCM 500 mg tab q4 PRN fever

- used over-the-counter pain

> IVF to follow D5LR @ 20 gtts/ min

(2 bottles)
22

reliever and a fever reducer

>increase IVF rate to 30 gtts/min

- use for hydration

- to increase hydration status

Laboratory Results
7/6/2015

Urine Analysis

Color

Result

Normal Values

Rationale

Yellow

Pale Yellow- Amber

Normal

23

Negative
Glucose

Negative

Clear to Slightly hazy

Normal

Transparency

Clear

Negative

Normal

Protein

Negative

1.002-1.030

Normal

Specific Gravity

1.015

Normal

0-4/hpf

Microscopic Exam:
Pus Cells

1-3/hpf

RBC

0-2/hpf

0-3/hpf

Normal
Normal

Amourphous Urates /
Phosphates
Epithelial

Few

Squamous

Cells
Negative

Few

Bacteria

Occasional

Indicates Infection

7-6-2015
Complete Blood Count
Result

Normal values

Implication

HCT

40.1

37-47vol %

Normal

HGB

12.9

12-16gms %

Normal

WBC

8,200

5,000-10,000/mm3
24

Normal

PLATELET

310,000

150,000-400,000/mm3

69

50-62 %

Normal

Diff. Count
Neutrophils

Respond to any
inflammation

Granulocyte

50

43.4-76.2 %

Lymphocytes

43

17.4-48.2 %

Monocytes

4.5-10.5 %

25

Normal
Normal
Normal

Generic
name/Brand
Generic
name
/brand name
Ambrolex

Classificati

Dose/

Mechanism

Specific

Contra-

on

route

of Action

indication

indication

Mechanism

Specific

Contra-

indication
Acute and

indication
There

Classificatio Freque
Dose/
n
antibiotic

route
ncy
of Action
OD 75 Concentratio
Freque
mg PO n of
ncy
antibiotics

Adverse reaction

Nursing Precaution

Adverse reaction

Nursing Precaution

Occasional

Observe

chronic

are

no gastrointestinal side respiratory

disorder of

absolute

effects may occur but obtain

when given

the

contraindicatio

these are normally Check drug interactions

concomitantl

respiratory

ns

y.

tract

patients

associated

gastric

with

ulceration

pathological

relative

ly thickened

caution should

mucus and

be observed.

but

in mild.
with

if

rate

and

baseline

data.

taking

other

medications.
It is advisable to avoid
use

impaired
mucus
transport.

26

during

the

first

trimester of pregnancy.

Salbuterol

bronchodila
tor

1 neb

Stimulates

Relief of

Hypersensitivit

Fine skeletal muscle

-Assess cardio-

Beta 2

bronchospa

y to

tremors, leg cramps,

respiratory function, BP,

receptors of

sm in

salbutamol,

palpitations,

heart rate and rhythm,

bronchioles

bronchial

also to

tachycardia,

and breathe sounds.

by increasing

asthma,

atropine and

hypertension,

levels which

chronic

its derivatives.

headache, nausea,

relaxes

bronchitis,

Threatened

vomiting, dizziness,

smooth

emphysem

abortion

hyperactivity,

muscles to

a and other

during first or

insomnia,

-Monitor for evidence of

produce

reversible

second

hypotension,

allergic action and

bronchodilati

obstructive

trimester.

heartburn, epistaxis,

paradoxical

on. Also

pulmonary

cough

bronchospasm

cause CNS

disease

stimulation,
cardiac
stimulation,
increase in
diuresis,
skeletal
muscle
tremors and
increase
27

-Determine history of
previous meds and
ability to self-medicate.

gastric acid
secretions.

28

Generic

Classificatio

Dose/

Mechanism

Specific

Contra-

Adverse reaction

/brand name

route

of Action

indication

indication

Nursing Precaution

Freque
ncy
Omeprazole

Antisecretor

40mg

Gastric acid-

Reduction

Contraindicate

Headache, dizziness,

-Arrange regular

IVTT

pump

of risk of

d with

asthenia, vertigo,

medical check-ups.

inhibitor:

upper GI

hypersensitivit

insomnia, apathy,

-Advise pt to report

pump

Suppresses

bleeding

y to

anxiety, paresthesias,

immediately for side

inhibitor

gastric acid

Omeprazole or dream abnormalities,

secretion by

its

rash, inflammation,

specific

components.

urticaria, pruritus,

Proton

OD

inhibition of

alopecia, dry skin,

the

diarrhea, abdominal

hydrogen-

pain, nausea,

potassium

vomiting,

ATPase

constipation, dry

enzyme

mouth

system at the
secretory
surface of
the gastric
parietal cells;
29

effects.

blocks the
final step of
acid
production.

Generic

Classificatio

Dose/

Mechanism

Specific

Contra-

Adverse reaction

/brand name

route

of Action

indication

indication

Freque
ncy

30

Nursing Precaution

Paracetamol Antipyretic

PRN

Inhibits the

>Mild pain

Hypersensitivit

Hema: hemolytic

~ Advise parents or

for

synthesis of

>Fever

y to

anemia,

caregivers to check

acetaminophe

neutropenia,

concentrations of liquid

s that may

n or

leukopenia,

preparations. Errors

serve as

phenacetin;

pancytopenia.

have resulted in serious

mediators of

use with

Hepa: jaundice

liver damage.

pain and

alcohol.

Metabolic: hypoG

~ Assess fever; note

fever,

GI: HEPATIC

presence of associated

primarily in

FAILURE,

signs (diaphoresis,

the CNS

HEPATOTOXICITY

tachycardia, and

(overdose)GU: renal

malaise).

failure (high

~ Adults should not take

doses/chronic use).

acetaminophen longer

Derm: rash, urticaria.

than 10 days and

fever q prostaglandin
4 hrs

children not longer than

5 days unless directed
by health care
professional.
~ Advise mother or
caregiver to take
medication exactly as
directed and not to take
31

more than the

recommended amount.

BRAND NAME
Acetylcysteine

GENERIC NAME
Exflem
Mucolytic

Reference :

MECHANISM OF

ADVERSE

SIDE EFFECTS

ACTION
Acetylcysteine

REACTION
> fever

exerts its mucolytic

> drowsiness

action through its

> tachycardia

fever, rhinorrhea,

32

stomatitis, nausea, vomiting

DOSAGE

NURSING

Usual:

RESPONSIBILITIES
>Assess type,
frequency, and

60 mg 1 tab in

characteristics of

Daviss drug guide

free sulfhydryl

> dyspnea

drowsiness, clamminess,

glass of

patients cough

for nurses 11th

group, which opens

> rash

chest tightness, and

water

edition

the disulfide bonds

> chills

broncho constriction

>Monitor patient

and lowers mucus

fortachycardia

viscosity. This
action increases

>Monitor for S&S of

with increasing pH

aspiration of excess

and is most

secretions, and for

significant at pH 7

Bronchospasm

to 9. The mucolytic

Actual:

(unpredictable);

action of

600 1 tab+ glass

withhold drug and

acetylcysteine is not

of H2O OD @hs

notify physician

affected by the

immediately if either

presence of DNA.

occurs.
>Instruct patient to
notify prescribe
immediately about
nausea, rash or
vomiting

33

VII. NURSING MANAGEMENT

Assessment

Diagnosis

Planning

Interventions

34

UPPER RESPIRATORY TRACT

Rationale

Evaluation

Subjective:

gahi kayo akong

ubo as
verbalized.

Objective:

Conscious/cohere

After 8 hours of

clearance r/t

continues nsg.

increased

Interventions the

production of

pt. will be able to

bronchial

maintain airway

secretions as

patency

manifested by

nt

Body malaise

Productive cough

Wheezes upon

(yellow to green

secretions

Productive cough

and coughing

Restlessness

(yellow to green

exercise.

noted

sputum

Discomfort noted

Restlessness

Facial Grimace

Chest pain

noted

Discomfort

Facial Grimace

Monitor Vital

signs

fowlers position

To facilitate

secretions, goal met.

Improves

mobilizing
secretions w/o

coughing exercise

causing fatigue

Avoid exposure to

To avoid allergic
reaction

cigarette smoke,

form dyspnea.

expectorate

helps in

breathing and

Verbalized relief

baseline data

ventilation and

Teach the pt. how

irritants such as

Patient was able to

expansion

to do proper deep

Serves as

maximum lung

Place the pt. in

fowlers or semi-

Learn and
perform breathing

Expectorate

auscultation

sputum

Ineffective airway

aerosol and
fumes

Auscultate breath
sounds

status and note

Increase fluid
intake

To ascertain
progress

Helps liquefy
secretions

35

Suction as

To clear airway

ordered

Provide adequate

Provide oxygen
inhalation as

amount of oxygen

Will help loosen

ordered

secretions for

Administer

easy expulsion.

medication as
ordered

36

Assessment

Subjective:

Diagnosis

Conscious/cohere
nt

Warm to touch
noted

Flushed face
noted

Febrile with a

After 8 hours of
continuous TSB,

r/t increased body

the pt.s

temperature as

temperature will

manifested by

decrease from

Warm to touch

37.9 to 37C

Flushed face

Febrile with a

verbalized

thermoregulation

Gitugnaw ko as

Objective:

Ineffective

Planning

Interventions

Monitor VS

Increase fluid
intake

Maintain bed rest

The patient

baseline data

temperature is

To help cool down

fluctuating, goal

core temperature

partially met.

To decrease
produce heat

Facilitate comfort

Facilitate heat

temperature of
38.2C

Provide sufficient

loss by means of

clothing

evaporation

Perform TSB

Helps lower
temperature

Administer

within normal

antipyretics as

range

37

Evaluation

Serves as

metabolism that

temperature of
37.9C

Rationale

ordered

38

Assessment

Subjective:

dili ko ganahan
mo kaon

Objective:

Refusal to eat

Poor muscle
tonicity

Body weakness

Diagnosis

Altered nutrition

Planning

Interventions

Evaluation

After 4 hours of

Monitor vital signs

For baseline data

Goal was met

less than body

nursing

Weight on regular

Monitor nutritional

because the patient

requirements R/T

interventions,

state and

was able to

loss of appetite as

patients appetite

effectiveness of

understand the

evidenced by

will be improved:

interventions

importance of

dysfunctional

from 2

To appeal to client

nutritious food intake

eating pattern.

tablespoons to at

likes and dislikes

and was able to eat

basis

Discuss eating

least 5

habits including

tablespoons per

food preferences.

meal.

Serve favourite

with fair appetite.

To stimulate the
appetite

foods that are not

noted

Rationale

contraindicated.

Restlessness

Serves foods that

are palatable and

To stimulate the
appetite

attractive.

Prevent and
minimize
39

May have

unpleasant

negative effect on

odours.

appetite/eating

Emphasize the
importance of
well-balanced
nutrition diet

40

Promote wellness

41