A Case Study on

Community Acquired Pneumonia

In partial fulfillment for the requirements in RLE 50

Submitted to: Sir Hamed Leo H. Fabre, RN, MN Clinical Instructor Submitted by: Estrella, Ronna Gale J. Eulatriz, Razel P. Graciosa, Gladys Melody L. Gualdaquever, Claire A. Gumapac, Quennie Love B. Handag, Fevin Love Dorothy Laurilla, Czyrin Lofranco, Irish Dyan I. Lumacad, Jackie Lou Monsanto, Vic Michael Z. Naringahon, Czarina Gay R. RLE 50 GROUP 2 Date July 12, 2011 TABLE OF CONTENTS

Chapter

I. Introduction=\ II. III. 1

IV. Objectives (General & Specific) ...............................................................3

V. Scope and Limitation ............................................................................... 4

VI. Patients Data ............................................................................................5

VII. Physical Assessment................................................................................7

VIII. Diagnostic Exams and Results ...............................................................14

IX. Anatomy and Physiology .........................................................................17

X. Pathophysiology .......................................................................................21

XI. Drug Study .................................................................................................27

XII. Nursing Care Plan .....................................................................................31

XIII. Discharge Plan (M. E. T. H. O. D.) ............................................................38

XIV. Related Learning Experience ...................................................................41

I.

INTRODUCTION
Back ground of the study This is a case of a 63 year old woman who was diagnosed with Community

Acquired Pneumonia Community-acquired pneumonia (CAP) is a disease in which individuals who have not recently been hospitalized develop an infection of the lungs (pneumonia). CAP is a common illness and can affect people of all ages and often causes problems like difficulty in breathing, fever, chest pains, and a cough. CAP occurs because the areas of the lung which absorb oxygen (alveoli) from the atmosphere become filled with fluid and cannot work effectively. Community acquired pneumonia occurs throughout the world and is a leading cause of illness and death. Causes of CAP include bacteria, viruses, fungi, and parasites. CAP can be diagnosed by symptoms and physical examination alone, though x-rays, examination of the sputum, and other tests are often used. Individuals with The kind of disease sometimes require treatment in a hospital and are primarily treated with antibiotic medication. Community-acquired pneumonia develops in people with limited or no contact with medical institutions or settings. The most commonly identified pathogens are Streptococcus pneumoniae, Haemophilus influenzae, and atypical organisms (ie, Chlamydia pneumoniae, Mycoplasma pneumoniae, Legionella sp). Symptoms and signs are fever, cough, pleuritic chest pain, dyspnea, tachypnea, and tachycardia. Diagnosis is based on clinical presentation and chest x-ray. Treatment is with empirically chosen antibiotics. Prognosis is excellent for relatively young or healthy patients, but much pneumonia, especially when caused by S. pneumoniae or influenza virus, are fatal in older, sicker patients. Etiology Many organisms cause community-acquired pneumonia, including bacteria, viruses, and fungi. Pathogens vary by patient age and other factors 1: Pneumonia: CommunityAcquired Pneumonia in Children 2: Pneumonia: Community-Acquired Pneumonia in Adults but the relative importance of each as a cause of community-acquired pneumonia is uncertain, because most patients do not undergo thorough testing, and because even with testing, specific agents are identified in < 50% of cases.

S. pneumoniae, H. influenzae, C. pneumoniae, and M. pneumoniae are the most common bacterial causes. Pneumonia caused by chlamydia and mycoplasma are often clinically indistinguishable from pneumonias with other causes. Common viral agents include respiratory syncytial virus (RSV), adenovirus, influenza viruses, metapneumovirus, and parainfluenza viruses. Bacterial superinfection can make distinguishing viral from bacterial infection difficult. C. pneumoniae accounts for 2 to 5% of community-acquired pneumonia and is the 2nd most common cause of lung infections in healthy people aged 5 to 35 yr. C. pneumoniae is commonly responsible for outbreaks of respiratory infection within families, in college dormitories, and in military training camps. It causes a relatively benign form of pneumonia that infrequently requires hospitalization. Chlamydia psittaci pneumonia (psittacosis) is rare and occurs in patients who own or are often exposed to birds. A host of other organisms cause lung infection in immunocompetent patients, although the term community-acquired pneumonia is usually reserved for the more common bacterial and viral etiologies. Q fever, tularemia, anthrax, and plague are uncommon bacterial syndromes in which pneumonia may be a prominent feature; the latter three should raise the suspicion of bioterrorism. Adenovirus, Epstein-Barr virus, and coxsackievirus are common viruses that rarely cause pneumonia. Varicella virus and hantavirus cause lung infection as part of adult chickenpox and hantavirus pulmonary syndrome; a coronavirus causes severe acute respiratory syndrome (SARSsee Respiratory Viruses: Corona Viruses and Severe Acute Respiratory Syndrome (SARS)). Common fungal pathogens include Histoplasma capsulatum (histoplasmosis) and Coccidioides immitis (coccidioidomycosis). Less common fungi include Blastomyces dermatitidis (blastomycosis) and Paracoccidioides braziliensis (paracoccidioidomycosis). Pneumocystis jiroveci commonly causes pneumonia in patients who have HIV infection or are immunosuppressed. Parasites causing lung infection in developed countries include Toxocara canis or T. catis (visceral larva migrans), Dirofilaria immitis (dirofilariasis), and Paragonimus westermani (paragonimiasis). (For a discussion of pulmonary TB or of specific microorganisms, see Mycobacteria.)

Symptoms include malaise, cough, dyspnea, and chest pain. Cough typically is productive in older children and adults and dry in infants, young children, and the elderly. Dyspnea usually is mild and exertional and is rarely present at rest. Chest pain is pleuritic and is adjacent to the infected area. Pneumonia may manifest as upper abdominal pain when lower lobe infection irritates the diaphragm. Symptoms become variable at the extremes of age; infection in infants may manifest as nonspecific irritability and restlessness; in the elderly, as confusion and obtundation. Signs include fever, tachypnea, tachycardia, crackles, bronchial breath sounds, egophony, and dullness to percussion. Signs of pleural effusion may also be present (see Mediastinal and Pleural Disorders: Symptoms and Signs). Nasal flaring, use of accessory muscles, and cyanosis are common in infants. Fever is frequently absent in the elderly. Symptoms and signs were previously thought to differ by type of pathogen, but presentations overlap considerably. In addition, no single symptom or sign is sensitive or specific enough to predict the organism. Symptoms are even similar for noninfective lung diseases such as pulmonary embolism, pulmonary malignancy, and other inflammatory lung diseases.

Diagnosis
y y y

Chest x-ray Consideration of pulmonary embolism Sometimes identification of pathogen

Diagnosis is suspected on the basis of clinical presentation and is confirmed by chest xray (see Table 3: Pneumonia: Probability of Pneumonia Given Chest X-ray Infiltrate ).

The most serious condition misdiagnosed as pneumonia is pulmonary embolism, which may be more likely in patients with minimal sputum production, no accompanying URI or systemic symptoms, and risk factors for thromboembolism (see Table 1: Pulmonary Embolism (PE): Risk Factors for Deep Venous Thrombosis and Pulmonary Embolism ). Chest x-ray almost always demonstrates some degree of infiltrate; rarely, an infiltrate is absent in the first 24 to 48 h of illness. In general, no specific findings distinguish one type of infection from another, although multilobar infiltrates suggest S. pneumoniae or Legionella pneumophila infection and interstitial pneumonia suggests viral or mycoplasmal etiology.

Hospitalized patients should undergo WBC count and electrolytes, BUN, and creatinine testing to classify risk and hydration status. Two sets of blood cultures are often obtained to detect pneumococcal bacteremia and sepsis, because about 12% of all patients hospitalized with pneumonia have bacteremia; S. pneumoniae accounts for
2

3 of these cases. Whether the results of blood cultures alter therapy commonly enough

to warrant the expense is under study. Pulse oximetry or ABG should also be done. Pathogens: Attempts to identify a pathogen are not routinely indicated; exceptions may be made for critically ill patients, patients in whom a drug-resistant or unusual organism is suspected (eg, TB, P. jiroveci), and patients who are deteriorating or not responding to treatment within 72 h. The use of Gram stain and culture of sputum for diagnosis is of uncertain benefit, because specimens often are contaminated and because overall diagnostic yield is low. Samples can be obtained noninvasively by simple expectoration or after hypertonic saline nebulization for those unable to produce sputum. Alternatively, patients can undergo bronchoscopy or endotracheal suctioning, either of which can be easily done through an endotracheal tube in mechanically ventilated patients. Testing should include mycobacterial and fungal stains and cultures in patients whose condition is deteriorating and in those unresponsive to broad-spectrum antibiotics. Additional tests are indicated in some circumstances. Patients at risk of Legionella pneumonia (eg, patients who smoke, have chronic pulmonary disease, are > 40, receive chemotherapy, or take immunosuppressants for organ transplantation) should undergo testing for urinary Legionella antigen, which remains present long after treatment is initiated, but the test detects only L. pneumophila serogroup 1 (70% of cases). A 4-fold rise in antibody titers to 1:128 (or a single titer of 1:256 in a convalescent patient) is also considered diagnostic. These tests are specific (95 to 100%) but are not very sensitive (40 to 60%); thus, a positive test indicates infection, but a negative test does not exclude it. Infants and young children with possible RSV infection should undergo rapid antigen testing of specimens obtained with nasal or throat swabs. No other tests for viral pneumonias are done; viral culture and serologic tests are rarely clinically warranted. Recent Studies: New Treatment May Protect Against Pneumonia

Intranasal administration of the protein flagellin may activate innate immunity and protect against acute pneumonia say researchers from France. They report their findings in the October 2010 issue of the journal Infection and Immunity. Streptococcus pneumoniae is a major cause of respiratory infections in infants and the elderly worldwide. Many humans carry the bacterium in their throat, but remain asymptomatic due to activated innate immunity, however, inadequate immune responses in susceptible individuals can result in invasive pneumococcal pneumonia. Researchers determined the capacity of flagellin to protect against pneumonia by intranasally inoculating two groups of mice with S. pneumoniae and simultaneously treating only one with flagellin. Mice treated with flagellin had a survival rate between 75 and 100% while untreated mice died within 3 to 4 days. Also, infected mice receiving flagellin treatment demonstrated significant bacterial reduction in the lungs after 24 hours and complete clearance after 2 days. Additionally, researchers evaluated the therapeutic value of flagellin treatment by infecting two groups of mice with S. pneumoniae and then intranasally administering flagellin to only one after 24 hours. Protection levels among treated mice were 60 to 100 %, while all untreated mice died. "Our results showed that local stimulation with a single and well-characterized molecule, specifically flagellin, is sufficient for augmenting lung innate immune defenses and controlling pneumococcal pneumonia, highlighting the benefits of using microbe-associated molecular patterns as the basis for developing antimicrobial therapies," say the researchers. http://www.sciencedaily.com/releases/2010/10/101016080122.htm

Reason for choosing Pneumonia as our case

This case study aims to identify patients health needs and problems in order to identify goals to promote the general health of the patient by providing proper intervention through the application of nursing process.

We chose this case study in order to identify and determine the general health problems and needs of the patient with an admitting diagnosis of Community Acquired Pneumonia. This study also intends to help patient as well as its significant others to

promote health and medical understanding of such condition through the application of the nursing theories and nursing skills. Our inadequate knowledge on Community Acquired Pneumonia motivated us to study the case suffered by most of our patients in medical ward. I wanted to have enough knowledge regarding this condition so that we could apply and handle such this kind of condition correctly. Nursing theory Nightingale's environmental theory She stated in her nursing notes that nursing "is an act of utilizing the environment of the patient to assist him in his recovery" (Nightingale 1860/1969),[3], that it involves the nurse's initiative to configure environmental settings appropriate for the gradual restoration of the patient's health, and that external factors associated with the patient's surroundings affect life or biologic and physiologic processes, and his development. Environmental factors affecting health Adequate ventilation has also been regarded as a factor contributing to changes of the patient's process of illness recovery Defined in her environmental theory are the following factors present in the patient's environment:
y y y y y y

Pure or fresh air Pure water Sufficient food supplies Efficient drainage Cleanliness Light (especially direct sunlight)

Any deficiency in one or more of these factors could lead to impaired functioning of life processes or diminished health status. Provision of care by environment The factors posed great significance during Nightingale's time, when health institutions had poor sanitation, and health workers had little education and training and were frequently incompetent and unreliable in attending to the needs of the patients. Also emphasized in her environmental theory is the provision of a quiet or noise-free

and warm environment, attending to patient's dietary needs by assessment, documentation of time of food intake, and evaluating its effects on the patient. Nightingale's theory was shown to be applicable during the Crimean War when she, along with other nurses she had trained, took care of injured soldiers by attending to their immediate needs, when communicable diseases and rapid spread of infections were rampant in this early period in the development of disease-capable medicines. The practice of environment configuration according to patient's health or disease condition is still applied today, in such cases as patients infected with Clostridium tetani (suffering from tetanus), who need minimal noise to calm them and a quiet environment to prevent seizure-causing stimulus. http://en.wikipedia.org/wiki/Nightingale%27s_environmental_theory OBJECTIVES OF THE STUDY y Establish rapport and gain the trust and cooperation of the patient and

immediate family members. y y y Gather factual health assessment of the patient. To gain new facts and ideas about the disease.. To disseminate information to the patient as well as his relative about the illness and how to care for the patient. y To be able to formulate related nursing diagnosis from the patients health data and to the current problems the patient experiences and to come out with different nursing interventions effective for the patient to improve and progress on the most possible time. y Set realistic objectives of care.

II.

CLIENT PROFILE
1. Demographic Data:

This is a case of Patient X, a 63 year old, widow with 11 childrens, a roman catholic from Gusal, Cagayan De Oro City, she was admitted last June 29, 2011 at exactly in the 2:00 in the morning in Capitol University Medical City with a medical diagnosis of Community Acquired Pneumonia. Vital signs:

Blood pressure(90/60mmhg120/80mmhg)

July 03,2011 12am-140/80mmHg 8am- 140/80mmHg 12nn- 140/100 mmHg 4pm- 130/90mmHg 8pm- 140/80 mmhg 12am- 38 degree celsius 8am- 37.8 degree celsius 12nn-37.8 degree celsius 4pm- 37.9 degree celsius 8pm-37.8 degree celsius 12am-112bpm 8am-110bpm 12nn-115bpm 4pm-98bpm 8pm-100bpm 12am-35cpm 8am-36cpm 12nn-28cpm 4pm-24cpm 8pm-28cpm

July 04, 2011 12am-140/80mmHg 8am- 120/80mmHg 12nn- 130/80 mmHg 4pm- 120/80mmHg 8pm- 130/80 mmhg 12am-37 degree celsius 8am-37.8 degree celsius 12nn-37.6degree celsius 4pm-36.8degree celsius 8pm-36.8 degree celsius 12am-110bpm 8am-105bpm 12nn-98bpm 4pm-98bpm 8pm-90bpm 12am-26cpm 8am-24cpm 12nn-26cpm 4pm-22cpm 8pm-22cpm

Temperature(35.5-37.5)

Pulse Rate(60-100bpm)

Respiratory Rate(1224cpm)

Oxygen saturation( 95100%)

12am-88% 8am-88% 12nn-90% 4pm-95% 8pm-95% 5

12am-94% 8am-96% 12nn-97% 4pm-96% 8pm-99% 2

Pain(0-10)

2. Health patterns assessment:

Health perception and health management Chief Complaint: Difficulty of Breathing History of present illness: A week prior to admission, the patient already complained fatigue; three days before she brought to the hospital the patient had positive signs and symptoms of cough, yellowish phlegm, persistent fever and back pain. Knowing that these signs and symptoms were just forms of little discomforts, she medicated herself with paracetamol. However, she noticed no changes and experienced difficulty of breathing so she sought medical consultation until on the day of June 29, 2011 hence she brought and was confined at Station 2 Capitol University Medical City. Nutritional and metabolic pattern Special diet: The diet of the patient is low sodium and low fat. Nutritional state: The patients general appearance is nourished.

Physical Assessment: Mouth: Date: Lips Mucosa Tongue Teeth gums July 03,2011 Pale Pinkish Midline Missing teeth Pinkish July 04, 2011 Pale Pinkish Midline Missing teeth Pinkish

Pharynx: Date: Uvula Tonsils July 03,2011 Midline Not inflamed July 04, 2011 Midline Not inflamed

Neck: Date: Trachea Thyroids July 03,2011 Midline Non-palpable July 04, 2011 Midline Non-palpable

Skin: Date: General color Texture Turgor Temperature July 03,2011 Pallor Smooth Supple Warm July 04, 2011 Pallor Smooth Supple Warm

Intravenous fluid: Plain LR 1 liter at KVO rate . Elimination pattern: Once a day, brown, formed no foul odor. Last bowel movement in the morning of July 03, 2011 in the morning.

Usual Urinary pattern: Patient urinates for about 5-6 times per day.

Activity-Exercise pattern: Patient X walks every morning for about 30 minutes to 1 hour nearby the seashore.

Cardiovascular status: Date: Heart sounds Peripheral pulses Capillary Refill July 03,2011 Regular Symmetrical 3sec. July 04, 2011 Regular Symmetrical 2sec.

Respiratory Status: Date: Breathing Pattern Lung expansion Vocal/tactile Breath sounds July 03,2011 Irregular Symmetrical Symmetrical Positive crackles at left lower lobe Cough Productive with a white color secretion July 04, 2011 Regular Symmetrical Symmetrical Positive coracles at left lower lobe Cough non-productive

Activities of daily living and Mobility status (during confinement): Feeding: total independence Bathing: total independence Dressing: total Independent Meal preparation: total independence Cleaning: total independence Bed mobility: total independence Chair/toilet transfer: total independence Ambulation: assist with person(assist with person due to presence of IV insertion) Cognitive-perceptual Pattern: Date: Level of consciousness Orientation Oriented to time, person, and place. Emotional state restless Oriented to time, person, and place. calm July 03,2011 Oriented, July 04, 2011 Oriented

Head: Date: Head Facial movements fontanels Hair Scalp July 03,2011 Normocephalic Symmetrica Closed Fine Clean July 04, 2011 Normocephalic Symmetrical Closed Fine Clean

Eyes: Date: Lids July 03,2011 Symmetrical July 04, 2011 Symmetrical

Conjunctiva Sclera Pupils Peripheral vision

pale Anicteric Equal in size 2 mm intact

pale Anicteric Equal in size 2mm intact

Ears: Date: External pinnae Tympanic membrane Gross hearing Normal normal July 03,2011 Normoset Intact July 04, 2011 Normoset Intact

Nose: Date: Mucosa Patency Gross smell July 03,2011 Pinkish Both patent Normal July 04, 2011 Pinkish Both patent Normal

Cognition: The Primary language of patient x is Bisaya The Educational attainment had reached up to college level.

Pain: Patient X usually complaints moderate pain located at anterior chest upon coughing. A pain scale of 5 out of 10

Sleep-Rest Pattern:

Date: Sleep pattern

July 03,2011 5 hours

July 04, 2011 5 hours

LEGEND: RED COLOR - ABNORMAL BLACK COLOR NORMAL

Nursing System Review Chart

Patient: ____X__________ Dx: Community Acquired pneumonia

EENT Impaired Vision Pain Gums Burning Reddened Blind Drainage Deaf Teeth

Hard on hearing Edema Lesion

Assessed eyes, ears, nose, throat for abnormality No problem

wheezing RESPIRATORY Asymmetric Apnea Tachypnea Cough Barrel Chest crackles

Rales

Bradypnea Sputum Orthopnea Pain

Shallow

Ronchi Dyspnea Wheezing Crackles

Diminished Labored

Cyanotic

Assessed respi rate, rhythm, depth, pattern, breath sounds, comfort No problem

CARDIO VASCULAR Arrhythmia Tachycardia Edema Numbness Fatigue

Diminished pulses Irregular Tingling

Bradycardia Absent pulse

Murmur Pain

Assessed heart sounds, rate, rhythm, pulse, blood, pressure, clrs, fluid retention, comfort No problem GASTRO INTESTINAL TRACT Obese Distention Rigidly Mass Pain

Dysphagia

Assessed abdomen, bowel habits, swallowing, bowel sounds, comfort No Problem

GENITO-URINARY and GYNE Pain Urine color Vaginal bleeding Nocturia

Hematuria

Discharge

Assessed urine freq., control, color, odor, comfort/ Gyn-bleeding, discharge No problem

NEURO Paralysis Lethargic Confused Stuporous Comatose Vision Unsteady Vertigo Seizures Tremors

Grip

Assessed motor function, scusation, LOC, strength, grip, gait, coordination, orientation, speech No problem Wheezing

MUSCULOSKELETAL and SKIN Appliauce Hot Stiffness Itching Petechiae Swelling Deformity Flushed

Crackles

Drainage

Prosthesis Cool

Lesion Wound Atrophy

Poor turgor Rash Pain

Skin color Ecchymosis

Disphoretic

Moist

Assessed mobility, motion, gait, alignment, joint function Skin color, texture, turgor, integrity No problem

III.

ANATOMY AND PHYSIOLOGY

The Lungs The lungs lie within the thoracic cavity on either side of the heart. They are coneshaped, with the apex above the first rib and the base resting on the diaphragm. Each

lung is divided into superior and inferior lobes by an oblique fissure. The right lung is further divided by a horizontal fissure, which creates a middle lobe. The right lung, therefore, has three lobes; the left lobe has only two. In addition to these 5 lobes, which are visible externally, each lung can be subdivided into about 10 smaller units (bronchopulmonary segments). Each segment represents the portion of the lung that is supplied by a specific tertiary bronchus. These segments are important surgically, because a diseased segment can be resected without the need to remove the entire lobe or lung. The two lungs are separated by a space (the mediastinum) where the heart, aorta, vena cava, pulmonary vessels, esophagus, part of the trachea and bronchi, and the thymus gland are located. The lungs contain gas, blood, thin alveolar walls, and support structures. The alveolar walls contain elastic and collagen fibers; these form a three-dimensional, basket-like structure that allows the lung to inflate in all directions. These fibers are capable of stretching when a pulling force is exerted on them from outside of the body or when they are inflated from within. The elastic recoil helps in return the lungs to their resting volume. The lung itself is covered with a membrane called the visceral (or pulmonary) pleura. The visceral pleura are adjacent to the lining of the thoracic cavity which is called the parietal pleura. Between the two membranes is a thin, serous fluid which acts as a lubricant reducing friction as the two membranes slide across one another when the lungs expand and contract with respiration. The surface tension of the pleural fluid also couples the visceral and parietal pleura to one another, thus preventing the lungs from collapsing. Since the potential exists for a space between the two membranes, this area is called the pleural cavity or pleural space The respiratory system is situated in the thorax, and is responsible for gaseous exchange between the circulatory system and the outside world. The respiratory system is divided into two systems namely the upper respiratory system, which composed of the nasal cavity, pharynx and larnyx: and the lower respiratory system, which are the trachea, bronchus, bronchioles and the alveoli.

UPPER RESPIRATORY TRACT Respiration is defined in two ways. In common usage, respiration refers to the act of breathing, or inhaling and exhaling. Biologically speaking, respiration strictly

means the uptake of oxygen by an organism, its use in the tissue, and the release of carbon dioxide. By either definition, respiration has two main functions: to supply the cells of the body with the oxygen needed for metabolism and to remove carbon dioxide formed a waste product from metabolism. This lesson describes the components of the upper respiratory tract. The upper respiratory tract conducts air from outside the body to the lower respiratory tract and helps to protect the body from irritating substances. The upper respiratory tract consists of the following structures: The nasal cavity, the mouth, the pharynx, the epiglottis, the larynx, and the upper trachea. The esophagus leads to the digestive tract. One of the feature of both the upper and lower respiratory tracts is the mucociliary apparatus that protects the airways from irritating substances, and is composed of the ciliated cells and mucus-producing glands in the nasal epithelium. The glands produce a layer of mucus that traps unwanted particles as they are inhaled. These are swept towards the posterior pharynx, from where they are either swallowed, spat out, sneezed, or blown out. Air passes through each of the structures of the upper respiratory tract on its way to the lower respiratory tract. When a person at rest inhales, air enters via the nose and mouth. The nasal cavity filters, warms, and humidifies air. The pharynx or throat is a tube like structure that connects the back of the nasal cavity and mouth to the larynx, a passageway for air, and the esophagus, a passageway for food. The pharynx serves as a common hallway for the respiratory and digestive tracts, allowing both air and food to pass through before entering the appropriate passageways The pharynx contains a specialized flap-like structure called the epiglottis that lowers over the larynx to prevent the inhalation of food and liquid into the lower respiratory tract.

The larynx or voice box, is a unique structure that contains the vocal cords, which are essential for human speech. Small and triangular in shape, the larynx extends from the epiglottis to the trachea. The larynx helps control movement of the epiglottis. In addition, the larynx has specialized muscular folds that close it off and also prevent

food, foreign objects, and secretions such as saliva from entering the lower respiratory tract. Mechanism of Breathing To take a breath in, the external intercostal muscles contract, moving the ribcage up and out. The diaphragm moves down at the same time, creating negative pressure within the thorax. The lungs are held to the thoracic wall by the plueral membranes and so expand outward as well. This creates negative pressure within the lungs, and so air rushes in through the upper and lower airways. Expirations are mainly due to the natural elasticity of the lungs, which tend to collapse if they are not held against the thoracic wall. This mechanism behind lung collapse if there is air in the pleural space (pneumothorax).

How does the respiratory system work? The respiratory system works with the body to help our body function correctly. One of the things it does is it gives our cells/blood oxygen to take to the rest of our body.

IV.

PATHOPHYSIOLOGY PRECIPITATING FACTORS: Environment air pollution Occupation: housewife Second hand smoker

PREDISPOSING FACTOR: Age: 63 years old Gender: Female Past medical history: + PTB

Streptococcus Pneumoniae

Microorganism enters the nose

Passes through the larynx, pharynx, trachea

Microorganism enters and affect left lung

Microorganism lodge in the bronchioles and alveoli

Infection occurs

Increase Secretion
Fever 37.8 degree celsius

Broncho will inflame

Prednisone

Pooled of secretions in the alveoli Bronchioles will constrict

Pareacetamol Combevent

Less O2sat (88%) (+) cough (+) crackles Narrative Pathophysiology

Tachypnea (RR= 34cpm Dyspnea

Pneumonia is an infection that occur in the lungs, in the case of patient X, the predisposing factors are Age- 63, gender- Female, and she had past medical history of PTB last 2 years ago and with the current health status of asthma. In the other hand the

precipitating factors are environment. She uses wood for cooking that creates smoke. Also patient X is on hydrocortisone therapy (steroid therapy) which is an immunosuppressive drug. Patient X occupation is house wife were patient X complains that she feels tired most of the time doing household chores and also being a plain house wife.

The process of the diseases is begins when the streptococcus pneumoniae enters the nose (nasal cavity) then passes through the larynx, pharynx and trachea, going to the bronchus then it enters to the left side of the lung and the microorganism will proliferate and cause infection, when the infection progresses it can increase the secretion and it can inflame the bronchus which is the defense mechanism of our lungs.

When there is an increase of secretions there will be pooled of secretion in the alveoli. Patient X then manifest decrease in Oxygen saturation , cough and crackle. When there will be inflammation of the bronchus the bronchioles constrict resulting to dyspnea were the respiratory status is 34 cycles per minute.

LEGEND:
MANIFISTATION

Medication

Pathology

V.

DIAGNOSTIC PROCEDURES and LABORATORY RESULTS

CLINICAL CHEMISTRY June 29, 2011 Test Result Reference value unit Interpretation

Uric acid

4.40

2.6-2.7

Mg/dl

NORMAL

June 29, 2011 Test Result Reference value unit Interpretation This means that extra glucose sticking to your red blood cells. A high HbA1c level means the blood glucose HBA1c 6.5 % 3.5%-5.5% level has been consistently high over recent weeks, and the diabetes treatment plan may need to be changed

June 29, 2011 Test Creatinine BUN SGPT Sodium Potassium Result 1.11 16.00 26.30 129.20 3.57 Reference value 0.6-1.3 7-18 10-40 135-148 3.5-5.3 unit mg/dl mg/dl IU/L mmol/L Mmol/L Interpretation NORMAL NORMAL NORMAL NORMAL NORMAL

July 1, 2011 Test FBS Result 161.00 Reference value unit 75-115 mg/dl Interpretation This means that the patient has increased in her blood sugar above

normal range .it indicates that the patient is hyperglycaemic and diabetic.

Cholesterol Triglycerides

146.00 249.00

140-239 35-160

mg/dl mg/dl A high triglyceride level may lead to atherosclerosis, which increases your risk of heart attack and stroke. A high triglyceride level may also cause inflammation of your pancreas.

HDL-D LDL- C

40.10 56.10

35-85 66-178

mg/dl mg/dl The lower the LDL, the lesser the risk for any heart diseases.

Chol/ HDL

49.80

0-40

mg/dl

High levels of HDL often indicate a decreased risk of disease

July 2, 2011 Test Potassium Result 3.13 Reference value 3.5-5.3 unit mmol/L Interpretation NORMAL

MICROBIOLOGY July 7, 2011 AFB STAIN REPORT

Result: NEGATIVE Grade: 0 Specimen: SPUTUM

July 7, 2011

GRAM STAIN REPORT Specimen: SPUTUM Result: Gram (+) cocci in pairs: rare Gram (-) bacilli: rare Polymorphonuclear cells: moderate Epithelial cells: FEW

July 7, 2011

CULTURE REPORT

FINDINGS: no growth after 38 hours of incubation

CLINICAL MICROSCOPY AND PARASITOLOGY June 30, 2011

Test Color Transparency Reaction Sp.gravity

Result Yellow Slightly hazy 6.0 1.030

Reference value yellow clear 4.5-8 It means that the

patient is dehydrated and because of that her sp. Gravity in urine is concentrated Sugar Protein Pus cells RBC EPITHELIAL CELLS Squamous epithelial Bacteria Amorphous urates FEW FEW MODERATE URINALYSIS +1 Trace 1-3 cells/HPF 0-1 cell/ HPF negative negative negative

X RAY REPORT Follow-up exam relative to 6/29/11 shows:

There is significant decrease in the size of the previously noted mass-like density in the left middle lung and superior segment of the left lower lung. No significant interval change in the previously noted fibro-reticular densities in both upper lobes, more confluent on the right with traction of the tracheal air column and upliftment of the ipsilateral hilum. Cystic luscencies are also seen on the right upper lung. Heart is within normal limits in size. Aortic knob is calcified. Tenting is noted in the right hemidiaphragm. Both costophrenic sulci are now blunted. Osseous structures and soft tissues are remarkable.

IMPPRESSION: 1. Pneumonia left, regressing 2. Bilateral minimal pleural effusion vs. pleural thickening 3. Pulmonary tuberculosis, bilateral with atelectatic component and bronchiectatic changes on the right showing no change. 4. Atherosclerotic aorta.

X RAY REPORT

Follow up exam relative to 6/23/11 shows:

A round, mass-like density is seen in the left middle lung field. No significant interval change in the previously noted fibro-reticular densities in both upper lobes, more confluent on the right with traction of the tracheal air column and upliftment of the ipsilateral hilum. Cystic luscencies are also seen on the right upper lung. Heart is within normal limits in size. Aortic knob is calcified. Tenting is noted in the right hemidiaphragm. The right sulcus is blunted. The left hemidiaphragm and sulcus are intact. The rest of the visualized chest structures are unremarkable.

IMPRESSION: 1. Pneumonia, left; cannot rule out other inflammatory and neoplastic process suggest follow up 2. Pulmonary tuberculosis, bilateral with atelectatic component and biochiectatic changes on the right showing no change. 3. Atherosclerotic aorta. 4. Pleudiaphragatic adhesion and pleural thickening, right showing no change.

VI.

NURSING CARE PLAN NURSING DIAGNOSIS (Problem and Etiology) Impaired gas exchange related to altered delivery of inspired oxygen an air trapping GOALS AND OBJECTIVES Short term: NURSING INTERVENTIONS AND RATIONALE Independent: 1. Monitored vital signs EVALUATION

ASSESSMENT DATA (Subjective & Objective Cues) Subjective cue: Galisud kog ginhawa as verbalized by the patient Objective cues: Oxygen saturation( 90%) Tachypnea (28cpm) Restlessness Irritability Pallor

Rationale: It is use as a baseline After 1 hour of 2. Elevated head of bed and nursing intervention position client appropriately the patient will be able Rationale: to maintain airway to demonstrate proper 3. Encourage to use breathing breathing technique. technique

Short term: Goal met After 1 hour of nursing intervention, the patient was able to demonstrate proper breathing

Long term:

Long term: Goal met Rationale: Helps limit oxygen consumed After 48 hours of After 48 hours of 5. kept environment allergen nursing intervention nursing intervention the and pollutant free the patient will be able Rationale: to reduce irritant effect goal was met. The to display adequate patient was able to oxygenation. display adequate Dependent: 6. Administered oxygen therapy oxygenation 2lpm as prescribe by the physician 4. Encouraged adequate rest Collaborative: 7. Referred to medical technician for ABGs test
Rationale: to know acid base imbalance

Rationale: to promote lung expansion

ASSESSMENT DATA (Subjective & Objective Cues) Subjective cue: Galisud ko ug ginhawa as verbalized by the patient Objective cues:  Crackles /Rales noted left lower lobe of the lung upon auscultation  Tachypnea (28cpm)  Restlessness  Irritability

NURSING DIAGNOSIS (Problem and Etiology) Ineffective airway clearance related to increase mucus production

GOALS AND OBJECTIVES Short term:

NURSING INTERVEN TIONS AND RATIONALE Independent: 1. monitor vital sign

EVALUATION

rationale: Use as a baseline After 15 minutes of 2. Elevate head of the bed nursing intervention, Rationale: To have enough breathing the patient will be able 3. Keep environment allergen free to Reduce sign of Rationale: Prevent allergies dyspnea 4. Encourage deep breathing technique

Short term: Goal met After 15 minutes of nursing intervention the patient was able to reduce sign of dyspnea Long term: Goal met After 48 hours of nursing intervention the patient was able to improve airway patency

Long term:

Rationale: To promote lung expansion

5. Provide adequate rest

Rationale: Prevent stress

After 48 hours of nursing intervention Dependent: the patient will be able 6. Administer Salbutamol as to improve airway indicated patency. 7. Administered oxygen therapy 2lpm as prescribe by the physician Collaborative: 8. Refer to medical technician for sputum exam.
Rationale: To know underlying cause.

ASSESSMENT DATA (Subjective & Objective Cues) Subjective data:

NURSING DIAGNOSIS (Problem and Etiology)

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE Independent: 1. Monitored respiratory rate, rhythm, and depth
Rationale: Respiratory rate and rhythm changes are early signs of impending respiratory difficulties

EVALUATION

Ineffective breathing pattern related to Usahay mag lisod ko ug constricted bronchioles ginhawa as verbalized.

Short-term After 30min.of nursing interventions, the patient will be able

Short-term: Goal met After 30min.of nursing interventions, the patient was able to establish effective respiratory pattern

Objective data:


to establish effective respiratory pattern

2. Monitored the position that the patient assumes for breathing

Rationale: At three point position or orthopnea is associated with breathing difficulty

Crackles and wheezes heard upon auscultation

Ineffective cough

Long-term After 24 hours of nursing intervention,

3. Auscultated chest, noting presence or character of breath sounds presence of secretions 4. Changed the patients position every 2 hours
Rationale: This facilitates secretion movement and drainage

Long-term: Goal partially met After 24 hours of nursing intervention, the patient was not able to Maintain normal respiratory pattern

 

Dyspnea Tachypnea (28cpm)

5. Instruct deep breathing exercise the patient will be able Rationale: To promote lung expansion 6. Instruct to increase fluid intake to Maintain normal for at least 2-3 liters per day Rationale: To help easily cough up secretions respiratory pattern Dependent: 7. Administer medication as ordered by the physician.
R: to treat underlying condition

ASSESSMENT DATA (Subjective & Objective Cues)

NURSING DIAGNOSIS (Problem and Etiology) Acute pain related to persistent cough

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Subjective cues: Sakit kaayo akong dughan pag mag-ubo ko as verbalized by the patient. Objective cues:     Facial grimace Guarding behavior Irritable Pain scale of 5 out of 10

Short Term: After 30 minutes of nursing intervention the patient will be able to reduce pain from a pain scale of 5 to 1

Independent: 1. Monitored vital signs

Rationale: Used as a baseline

2. Monitored for referred pain as appropriate.

Rationale: To help determine possibility of underlying condition.

3. Provided with comfort measures (e.g., back rub)

Rationale: To provide nonpharmacologic pain management.

Short Term: Goal partially met After 30 minutes of nursing intervention the patient was able to reduce pain from a pain scale of 5 to 2.

Long term: After 48 hours of nursing intervention the patient will be able to report that the pain is relieved

4. Promote bed rest, allowing patient to assume position of comfort.

Rationale: Bed rest in low Fowlers position reduces intra-abdominal pressure

5. Encouraged adequate rest periods.

Rationale: To prevent fatigue.

Long term: Goal met After 48 hours of nursing intervention the patient was able to report that the pain is relieved

Dependent: 6. Administered analgesics as indicated 7. Administered combivent as ordered Collaborative: 8. Referred to physical therapist for pain management

ASSESSMENT DATA (Subjective & Objective Cues) Subjective cue : init akong paminaw as verbalized by the patient objective cues:     hyperthermia(37.8) flushed skin warm to touch restlessness

NURSING DIAGNOSIS (Problem and Etiology) Hyperthermia related to release of pyrogens secondary to infection.

GOALS AND OBJECTIVES

NURSING INTERVENTIONS AND RATIONALE

EVALUATION

Short term: after 1 hour of nursing intervention the patient will be able to display core temperature of 36.8 degree Celsius

Independent: 1. Monitored vital signs

Rationale: Use as a baseline

2. Promoted surface cooling by means of tepid sponge bath.

Rationale: to reduce heat

3. Identified causative factor by means of interviewing

Rationale: to know the underlying Cause

Short term: Goal partially met after 1 hour of nursing intervention, the patient was able to display core temperature 36.8 degree Celsius as evidenced by 37.2 Long term: Goal met After 48 hours of nursing intervention, the patient was be able to maintain core temperature within normal range of 35.537.5 degree Celsius

Long term: after 48 hours nursing intervention the patient will be able to maintain core temperature within normal range of 35.537.5 degree Celsius

4. Noted presence and absence of increase body temperature

Rationale: to prevent increase of temperate

5. Promoted adequate rest period

Rationale: To prevent fatigue

Dependent : 6. Administered Paracetamol 500mg as indicated.

Rationale: paracetamol is antipyretic

7. Administered Solu-Cortef 100mg IVTT as ordered by the physician Collaborative: 8. Referred to medical technician for CBC test

VII.

DRUG STUDY

DRUG ORDER (Generic name, brand

name, classification, dosage, route, frequency)

MECHANISM OF ACTION

INDICATIONS

CONTRAINDICATIONS

ADVERSE EFFECTS OF NURSING THE DRUG RESPONSIBILITIES / PRECAUTIONS

Generic Name: Omeprazole Brand Name: omepron Classification: Proton pump inhibitor Dosage: 20mg Route: PO Frequency: OD - 6am

Suppresses gastric Prohylactic Hypersensitivity to secretion by medication for gastric omeprazole inhibiting hydrogen 1 potassium ATPase enzyme system in the gastric parietal cell; characterized as a gastric acid pump inhibition since it blocks the final step of acid production

CNS: headache, dizziness.asthenia CV: Chest pain, angina, tachycardia, bradycardia, palpitaions, peripheral edema EENT: tinnitus, taste perversion GI: diarrhea, abdominal pain vomiting, nausea, constipation, flatulence, acid regurgitation, abdominal swelling, anorexia, irritable colon, esophageal candidiasis, dry mouth

 assess GI system bowel sounds, abdomen for pain and swelling, anorexia  Monitor hepatic enzymes AST, ALT, increase alkaline phosphatase during treatment

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS

NURSING RESPONSIBILITIES / PRECAUTIONS ADVERSE EFFECTS OF THE DRUG

Generic Name: Potassium Chloride Brand Name: Kalium Durule Classification: Electrolytic an d water balance agent, replacement solution Dosage: 1 tab Route: PO Frequency: TID 8am, 1pm, 6pm

Principal intracellular cation; essential for maintenance of intracellular isotonicity, transmission of nerve impulses. Plays a prominent role in both formation and correction of imbalances in acidbase metabolism.

To prevent and treat potassium deficit secondary to diuretic or corticosteroid therapy.

Severe renal impairement reactions or severe hemolytic

CV: Hypotension, bradycardia, cardiac depression GI: diarrhea, abdominal pain vomiting, nausea, constipation, BODY AS A WHOLE: Pain, mental confusion, ir paresthesias of tremities, muscle weakness. UROGENITAL: Oliguria, anuria RESPIRATORY: Respiratory distress

 Monitor I&O ratio and patterns patients receiving the parenteral drug.  Monitor patients receiving parenteral potassium closely with cardiac monitor. Irregular heart beat is usually the earliest clinical indication of hyperkalemia

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS

NURSING RESPONSIBILITIES / PRECAUTIONS ADVERSE EFFECTS OF THE DRUG

Generic Name: Sabutamol Brand Name: Combivent Classification: Bronchodilator Dosage: 1neb Route: Inhalation Frequency: q8 8am, 4pm, 12mn

Synthetic sympathomimetic amine and moderately selective beta2-adrenergic agonist with comparatively long action. Inhibits histamine release by mast cells.

To relieve Hypersensitivity to drug bronchospasm associated with acute or chronic asthma.

CNS: tremor, nervousness, dizziness, insomnia, headache, yperactivity, weakness, CNS stimulation and malaise. CV: tachycardia, palpitations, hypertension. EENT: dry and irritated nose and throat with inhaled form, nasal congestion, epistaxis. GI: heartburn, nausea, vomiting, anorexia, METABOLIC: hypokalemia

 Tell the patient to gargle after nebulization.  Monitor therapeutic effectiveness which is indicatedby significant subjective improvement in pulmonar function within 60-90 minutes after drug administration .

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS

NURSING RESPONSIBILITIES / PRECAUTIONS ADVERSE EFFECTS OF THE DRUG

Generic Name: Prednisone Brand Name: Oracort Classification: Corticosteroid Dosage: 20mg

Immediate-acting syynthetic analog of hydrocortisone. Effect depends on biotransformation to prednisole, a conversion that may be impaired in patient with liver dysfunction.

For inflammatory conditions and as an immunosuppressant.

Systemic fungal infections and known hypersensitivity.

CNS: dizziness, headcahe, malaise, drowsiness

GI: abdominal pain or discomfort with or without nausea, vomiting, anorexia, diarrhea

BODY AS A WHOLE: Route: PO Frequency: BID 8am, 6pm Fever, sweating, symptoms of hostmediated immunologic response to antigen release from worms

 Give with meals to reduce gastric irritation  Be aware hat temporary local discomfort may allow injection of prednisolone  Report gastric distress or any signs of peptic ulcer  Adhere to established dosage regimen.

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS

NURSING RESPONSIBILITIES / PRECAUTIONS ADVERSE EFFECTS OF THE DRUG

Generic Name: Acetylcysteine Brand Name: Mucosol Classification: Mucolytic, acetaminophen antidote Dosage: 600mg Route: PO Frequency: 8am

Decreases viscosity of secretions, promoting secretions removal through coughing, postural drainage, and mechanical means. In acetaminophen overdose, maintains and restores hepatic glutathione, needed to inactivate toxic metabolites

Mucolytic agent in adjunctive treatment of acute or chronic bronchopulmonary disease

 Hypersensitivity to drug (except with antidotal use)  Status asthmaticus (except with antidotal use

CNS: dizziness, drowsiness GI: nausea, vomiting, stomatitis, hepatotoxicity RESP: bronchospasm, rhinorrhea, burning sensation in upper respratory passages, epistaxis.

 Monitor respirations, cough, and character of secretions.  Instruct pt to report worsening cough and other respiratory symptoms.  Advise pt to mix oral form w/ juice or cola to mask bad taste and odor

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS

NURSING RESPONSIBILITIES / PRECAUTIONS ADVERSE EFFECTS OF THE DRUG

Generic Name: Hydrocortisone Sodium succinate Brand Name: Solu-Cortef Classification: Corticosteroid, short acting Dosage: 100mg Route: IV Frequency: q12 8am and 8pm

Stabilizes leukocyte lysosomal memebranes; inhibits phagocytosis and release of allergis substances and short acting synthetic steroid with both glucocorticoid and mineralocorticoid properties that affect nearly all systems of the body.

Suppress Hypersensitivity to undesirable glucocorticoid inflammatory or immune responses, to promote temporary remission in nonadrenal disease and to block ACTH production in diagnostic tests.

CNS: Headache, asthesia, sleep disturbance

GI: Flatulence, diarrhea, abdominal pain. Cramps, constipation, nausea, dyspepsia, heartburn, liver failure

RESPIRATORY: Sinusitis, pharyngitis

 Space multiple dose evenly throughout the day.  Use minimal dose for minimal duration to minimize adverse effects.  Use alternate day maintenance therapy with short acting corticosteroid s whenever possible

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS

NURSING RESPONSIBILITIES / PRECAUTIONS ADVERSE EFFECTS OF THE DRUG

Generic Name: Levofloxacin Brand Name: Levaquin Classification: antibiotic Dosage: 500mg Route: PO Frequency: OD 8am

Inhibits the enzyme DNA gyrase in susceptible gramnegative ad grampositive aerobic and anaerobic bacteria, interfering with bacterial DNA synthesis.

Prevention of nosocomial pneumonia

Hypersensitivity to drug, its components, or other quinoles

BODY AS A WHOLE: Abdominal symptoms, diarrhea, muscle aches, back pain, chlls, edema, cough, malaise, rash, sweating, yawning CNS: abdominal dreams, anxiety, decreased libido, depression, euphoria, headache, insomnia, nervousness, somnolence GI: abdominal pain, constipation, diarrhea

 Check vital signs, especially blood pressure. Too rapid infusion can cause hypotension  Watch for hypersensitivi ty reaction.  Discontinue drug immediately if rash or other signs r symptoms occur.

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS

NURSING RESPONSIBILITIES / PRECAUTIONS ADVERSE EFFECTS OF THE DRUG

Generic Name: Fluticasone Brand Name: Seretide Classification: Bronchodilator, respiratory smooth muscle relaxant Dosage: 1puff Route: Inhalation Frequency: BID 8am and 6pm

Long acting beta2adreno receptor agonist and an analog of albuterol. Stimulation of beta2adrenoreceptors relaxes bronchospasm and increases ciliary motility, thus facilitating expectoration.

Regular treatment of asthma where long acting 2-agonist and inhaled corticosteroid is appropriate. Moderate to severe COPD.

Hypersensitivity to salmeterol; primary treatment of status asthmaticus

CNS: dizziness, headache, tremor CV: palpitations, sinus tachycardia RESP: respiratory arrest SKIN: rash BODY AS A WHOLE: Tolerance(tachyphylaxis)

 Withhold drug and notify physician immediately if bronchospas ms occur following its use.  Monitor cardiovascula r status; report tachycardia  Monitor liver enzymes periodically with long-term therapy.

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS

NURSING RESPONSIBILITIES / PRECAUTIONS ADVERSE EFFECTS OF THE DRUG

Generic Name: Vildagliptn Brand Name: Galvusmet Classification: Antidiabetic agent Dosage: 50g Route: PO Frequency: BID 8am and 6pm

Galvus Met combines 2 antihyperglycaemic agents with complimentary mechanisms of action to improve glycaemic control in patients with type 2 diabetes: Vildagliptin, a member of the islet enhancer class, and metformin HCl, a member of the biguanide class.

Treatment of type 2 diabetes mellitus patients who are unable to achieve sufficient glycaemic control at their maximally tolerated dose of oral metformin alone or who are already treated with the combination of vildagliptin and metformin as separate tablets.

Hypersensitivity to vildagliptin, metformin HCl or to any of the excipients of Galvus Met; diabetic ketoacidosis or pre-coma; renal failure

NERVOUS SYSTEM: Tremor, dizziness, headache, fatigue. GI: Nausea VASCULAR DISORDERS: Peripheral edema. GASTROINTESTINAL DISORDERS: Constipation. INFECTIONS AND INFESTATIONS: Upper respiratory tract infection, nasopharyngitis.

 Administer medicine at  the time specified or as close to that time as

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS

NURSING RESPONSIBILITIES / PRECAUTIONS ADVERSE EFFECTS OF THE DRUG

Generic Name: Celecoxib Brand Name: Celebrex Classification: Analgesics, antipyretic Dosage: 200mg Route: PO

NSAID that exhinits antiinflammatory, analgesic, and antipyretic activities.

Treatment for acute pain.

Severe hepatic impairement, hypersensitivity to celecoxib.

BODY AS A WHOLE: Back pain, peripheral edema GI: abdominal pain, diarrhea, dyspepsia, flatulence, nausea. CNS: dizziness, headache, insomnia. RESP: Pharyngitis, rhinitis, sinusitis SKIN: rash

Frequency: PRN

 Monitor for fluid retention and edema especially in those with a history of htpertension or CHF.  Store in tightly closed container and protect from light.  Promptly report any of the following: unexpalined weight gain, edema, skin rash.

DRUG ORDER (Generic name, brand name, classification, dosage, route, frequency) Generic: Paracetamol Brand name: Biogesic Classification: Anti-pyretic Dosage: 500mg Route: Oral Frequency: Every 4 hours(as needed) MECHANISM OF ACTION INDICATIONS CONTRAINDICATIONS

NURSING RESPONSIBILITIES / PRECAUTIONS ADVERSE EFFECTS OF THE DRUG

reducing the activity of the cyclooxygenase enzyme; this enzyme participates in the production of prostaglandins which in turn are involved in the pain and fever processes.

for fever

Allergic in acethaminophen

GI: transient flatulence, abdominal distension, intestinal cramps, belching, nausea, diarrhea,

 Administer medicine at  the time specified or as close to that time as

OTHER: acid-base imbalance

VIII. HEALTH TEACHING/ DISCHARGE PLAN

MEDICINE  Stress the need for medication compliance and explain the purpose, dosage, schedule, and route of administration of prescribed drugs, as well as side effects to report to physician  Instruct patient to avoid taking over-the-counter medications without first consulting physician

 Advice patient and significant others to facilitate in taking medications on time and in proper administration, as prescribed.  Point out the importance of completing the duration of take home medications even if the patient shows wellness.  Instruct patient to take the maintained medications as prescribed.

EXERCISE  Explain the need to limit exercise and activity to tolerance to avoid fatigue, and to plan two to three rest periods during the day

TREATMENT

Teach client and significant others about importance in eating nutritious foods. Practice healthy way for managing stress such as muscle relaxation and deep breathing exercises.  Emphasized to the patient to have adequate rest

 Instruct patient as well as the significant others to continue his medicines for the entire length of prescribed period.  Advise patient or significant others to always read the label of the medication and be aware of the date of expiration of the drug.  Always follow doctors order or instruction.

HEALTH  Explain the need to avoid recurrence of the disease by avoiding persons with infections, crowded places and secondhand smoke  Demonstrate and explain the importance of postural drainage and deep breathing exercises four times a day for 6 8 weeks  Instruct on methods of clearing secretions such as coughing, positioning  Teach about relaxation techniques like meditation, biofeedback, involvement in pastimes that provide respite from stressful demands  Monitor blood pressure regularly DIET  Discuss about DASH (dietary approaches to stop hypertension) diet- grains, vegetables, fruits, low-fat dairy products, meats, poultry and fish.

 Advise patient to eat nutritious foods such as fruits and vegetables such as pineapple, carrots, legumes, grains.  Advise the patient to avoid drinking alcoholic beverages.  Advise the patient to avoid eating foods rich in fats and salt.  Encourage patient to have adequate fluid intake.

Spiritual
 Encourage patient to pray always to be thankful to God for his goodness.

IX.

RELATED LEARNING EXPERIENCE

Things were learned and discovered while making this requirement a succesful

one. And basically, I learned a lot from this duty especially to our clinical instructor. And through that experience, different views and perspectives were raised to have it more comprehensive.

Indeed, experience has always been the best teacher. This case study and hospital exposure are some proofs that the life of a nursing student is never easy. But my eagerness and passion to have a successful nursing career enable me to move on and face the many challenges in the study of nursing. Through that experience I was able to realize that being a Health Care Provider is not easy. We need to understand each situation that the individuals are having. Every single step that we made must be true, understandable and with passion. And from the steps that we had made, we are ought to become responsible in a way that we serve people especially the patients were taking for in a simplest way.

As a result, I have learned the nature of the disease. These things that I have learned will be useful when I become professional nurses someday. I am very grateful to my clinical instructor Mr. Rick Wilson Bunao, for giving me the chance to study this case. Through his guidance, I am able to implement my interventions successfully. Lastly, but never has been the least, I thank God for the many blessings, especially the gift of good and healthy lives.

X.

REFERRENCE

 http:// www.nursingblogspot.com  (http://nursingcrib.com/).

 http://www.sciencedaily.com/releases/2010/10/101016080122.htm  http://en.wikipedia.org/wiki/Nightingale%27s_environmental_theory  www.google.com

 http://nursingcrib.com/nursing-care-plan/nursing-care-plan-community-acquiredpneumonia/  http://merck-ut.merck.com/mmpe/sec05/ch052/ch052b.html  http://en.wikipedia.org/wiki/Community-acquired_pneumonia  Medical Surgical by: Black  NANDA Guide

 Lippincotts drug handbook