BRONCHITIS

MATRIX NO : I674

GROUP : 29 (2 / 2005)

At the end of my case study, I will able to:

State the definition of bronchitis
Described the anatomy and physiology of the
respiratory system.
List the type of bronchitis
State the etiology of bronchitis
Explain the pathophysiology of bronchitis
State the clinical manifestation of bronchitis
The complication of bronchitis
Explain the investigation for patient with
bronchitis

LEARNING OBJECTIVE

State the treatment of bronchitis
Carrying out the nursing intervention for
patient with bronchitis
Provide health education to patient with
bronchitis
Appreciate the important of the good nurse
care for patient with bronchitis
ADMISSION

Mr. K was admitted in 3rd floor on 5th June 2006 at
2050 hours by wheel chair at room 307C.
On that day, he had c/o dyspnea x 2/7, cough & chest
discomfort due to excessive cough x 1/52 & fever x 3/7.
Dr. F diagnosed him as bronchitis. His condition was
conscious, orientated & calm during admission. The vital
sign taken as below:-

Temperature : 37.8 C
Pulse : 92 bpm
Respiration : 23 bpm
Blood pressure : 136/82mmHg
ADMISSION DATA

Name of patient : Mr. K
Sex / Age : Male / 38 years
Marital status : Married
Race / Religion : Malay /Islam
Occupation : YPJ staff
Language spoken : B.Melayu & English
Consultant : Dr. F
Ward : 307C
Date& time admit : 5/6/06@ 2050 hours
Date& time discharge: 8/6/06@ 0945 hours
Reasons admission : C/o dyspnea x 2/7,
cough & chest discomfort
due to excessive cough
x 1/52 & fever x 3/7
Diagnosis : Bronchitis
Medical history : Sinusitis in 2004
Surgical history : Bilateral tonsillectomy in
2005
Family medical his : Asthma (father)
Current medication : Clarinase 250mg (2 tab)
BD, Paracetamol 500mg
(2 tab) TDS
Allergic : Seafood especially crabs

ACTIVITY DAILY LIVING

BREATHING
Mr. K have difficulty in breathing X 3/7
Cough
He had unproductive cough & chest discomfort
due to excessive cough X 1/52
Smoking
He also smoking about 20s sticks per day

EATING / DRINKING
Mr. K told me that he didnt eat seafood especially
crabs because allergic

BLADDER
Mr. K dont have problem in passing urine
ELIMINATION BOWEL
Mr. K defecates once a day. He didnt have any
problem in bowel movement

SLEEPING
Mr. K complain cant sleep enough because
dyspnea X 2/7 & coughing X 5/7 He dont take any
medication for sleep.

MOBILITY
Mr. K told me that he can ambulate by himself.

PERSONAL HYGIENE
Mr. K can take care of his own personal hygiene
SELF ENVIRONMENT
Side rails up and call bell near him.
COMMUNICATION
The speech is normal and no abnormality detected such
as slurred.

VISSION
Mr. K vision is normal & no needed visual aids.

HEARING
Mr. K can listen clearly and carefully.

HOBBIES
Mr. K hobbies are reading books & surf internet


This indicate abnormal ADL of my patient
PHYSICAL EXAMINATION

Rapid chest
IV Branula


RESPIRATORY SYSTEM
UPPER RESPIRATORY TRACT

Nose Pharynx
Larynx Trachea
LOWER RESPIRATORY TRACT

Lung Bronchi
Alveoli Ribs &
Intercostals muscle
Pleura cavity
PHYSIOLOGY OF RESPIRATION

Air Nostril Nasal hair Nasal cavity &sinus


Trachea Larynx (Adams apple) Pharynx


Bronchi Lungs Bronchioles Alveoli


Air exchange


Gases exchange
Gas exchange
INSPIRATION & EXPIRATION
DEFINITION OF BRONCHITIS

Inflammation of the large airways that branch off
the trachea (bronchi) usually caused by
infection but sometimes caused by irritation from
a gas or particles.
-The Merck Manual Of Medical Information -

Inflammation of the mucous membrane in the
airways (bronchial tubes) of the lungs, resulting
from infection or irritation and causing breathing
problems and severe coughing
- American Association Site.htm -
TYPE OF BRONCHITIS

Acute bronchitis
Infection in the passages that carry air
from the throat to the lung causing a cough that
produces phlegm. The airway tubes are
inflamed & collect mucus.

Chronic bronchitis
Excessive mucus secretion in the bronchi
& a chronic or recurrent mucus producing cough
that lasts 3 or more month & recurs year after
year.
TYPES OF BRONCHITIS
Acute bronchitis Chronic bronchitis
ETIOLOGY OF BRONCHITIS

1) # Smoking

2) Infections
i) Bacteria streptococcus haemolytic
ii) Virus adenovirus, measles virus
iii) Allergic pollen, organic dust

3) Environment - cold, haze, dust, smoke & wet

4) Occupations (like coal mining, textile
manufacturing, grain handling)

5) Physical /chemical area that disturb mucous
membrane of respiratory tract such as vapour,
gases & dust

6) Heart or lung disease

7) Air pollution ( aerosol, smokes, fumes,
charcoal)

# This is indicate the etiology of Mr. K
ETIOLOGY OF BRONCHITIS
Smoking Infection Cold/Flu


Infection Virus,
Bacteria


Lung disease


Air pollution fumes, smokes, charcoal
PATHOPHYSIOLOGY
Smoking
Irritate lining of
respiratory tract
Increase goblet
cell
Increase mucus
Inflamed Bronchospasm
BRONCHITIS



CLINICAL MANIFESTATIONS

Fever 38C to 39C with rigor

Malaise infection of virus or bacteria

Dyspnea inadequate oxygen because the
airway is inflamed & narrow

Chest discomfort - excessive cough cause
the pressure at the chest

Sweating use accessory muscle to breathing

Cough damage of sensory nerve ending

Wheezing thick secretion lining the lung
because of increasing in mucus
production

Palpitation the heart work more harder to get
adequate oxygen

Soreness in the throat infection at the bronchi

This indicate Mr. K clinical manifestations
COMPLICATION OF BRONCHITIS

Chronic bronchitis
Excessive mucus secretion in the bronchi &
chronic / recurrent mucus producing cough
that last 3 or more months & recurs year after
year.

Bronchiolitis
The airway become inflamed, swell & full with
the mucus, making in difficult to breathe.


Bronchiolitis

Lobar pneumonia
Inflammation of the alveolar spaces of the
lung caused by bacteria, viruses, chemicals,
dust & allergens, lung tissue are consolidated
as alveoli fill with the exudates.

Bronchiectasis
The bronchi become obstructed by mucus,
pus & inflammatory exudates

Acute respiratory distress syndrome
Noncardiogenic pulmonary edema caused by
inflammatory damage to alveolar & capillary
walls.
COMPLICATION OF BRONCHITIS
Chronic bronchitis

Bronchiolitis

Bronchiectasis Lobar pneumonia
INVESTIGATION

Chest x-ray
To detect any abnormalities in the lung &
pleural effusion

Arterial blood gases
To detect acidosis or alkalosis in the blood

Full blood count
To detect anemia & culture & sensitivity to
antibiotic


Sputum culture & sensitivity
To detect the type of infectious bacteria & the
sensitivity to the what type of antibiotic

Sputum Acid Fast Bacilli
To detect pulmonary tuberculosis (PTB)

Ultra sound abdomen
To detect any infection in the liver, spleen,
kidneys & gall bladder.

The investigation that doctor ordered
RADIOLOGIST REPORT

Date : 5th June 2006
Time : 2150 hours

ULTRA SOUND ABDOMEN
- There is no focal liver lesion, liver edge &
echotexture are normal
- Intrahepatic ducts & CBD are not dilated.
- There are no stones in gallbladder. No
pericholeycystic collection
- The gallbladder wall is not thickened
- The spleen is normal. No focal lesions in the
pancreas
- Both kidneys have normal renal enchogenities
- No stones, no hydronephrosis
- Bladder is normal
- There is inhomogenicity in the right fossa
-No paraaortic nodes

IMP : Possibility on an inflammation in the right
iliac fossa
No obstructive uropathy

RADIOLOGIST REPORT

Date : 5th June 2006
Time : 2207 hours

CHEST X-RAY
-There are peribronchial thickening in the
perihilar regions bilaterally.
- Heart size is normal
-No pleural abnormalities

IMP : Features would be suggestive of
bronchitis

LABORATORY REPORT

Date@ time received: 5th June 2006@2154
Date@ time reported: 5th June 2006@2227

Examination Result unit Reference range
DENGUE STUDIES (GP29E@MI6)

- Hematology -
Haemoglobin 16.8 g / dL 13.00 18.00
Haematocrit (PVC) 50% 41 53
Platelet count 186 10 / uL 150 450
**ESR 34 mmol / hr 0 15
White blood cell 8.1 10 / uL 4.3 10.5
- White blood cell different count -
Neutrophil 73.3% 40 75
**Lymphocyte 16.0% 20 45
Eosinophil 0.2% 0 6
Monocyte 9.7% 1 11
Basinophil 0.8% 0 2
Blood film for Not seen Not seen
malaria parasit

Examination Result unit Reference range

- Biochemistry -
Glucose 5.0 3.9 6.1
Reference range: Random blood sugar <7.8
mmol / L ( <140 mg / dL )

Urea 5.1 mmol / L 2.0 6.8
Sodium 137 mmol / L 135 155
Potassium 4.1 mmol / L 3.5 5.5
Chloride 100 mmol / L 95 111
SGPT / ALT 10 u / L 7 48
Calcium 2.29 mmol / L 2.10 2.42

- Serology -
Dengue I Gm Non reactive Non reactive

Dengue viral serology interpretation. No
detectable IgG and IgM. Antibodies to dengue
virus. The result does not exclude dengue virus
infection: Repeat test in 3 4 days if
dengue virus infection is suspected.

Examination Result unit Reference range

- urine FEME ( urinalysis) -
Appearance, yellow slightly yellow / pale
urine turbid yellow
specific gravity 1.009 1.005 1.025
pH, urine 7.0 4.8 7.5
protein, urine negative negative
glucose, urine normal normal
ketone, urine negative negative
bilirubin screen negative negative
urobilinogen negative negative
screen
blood, urine negative negative
Examination Result unit Reference range

- Microscopic examination urine -
WBC, urine 3 / hpf 0 5
RBC, urine 3/ hpf 0 3
Epithelial cell occasional occasional

INVESTIGATION

Examples the result of chest x ray that
suggestive of bronchitis

MEDICATIONS

Medication during hospitalization
1) Tablet Paracetamol 1gm QID
2) Tablet Zithromax 500mg daily
3) IV Rocephine 1gm daily
4) Syrup Duro- tuss 15mls TDS
5) Nebulizer Duovent 1 nebule 4 hourly
6) Menthol inhalation TDS
7) Rhinocort Aqua 2 puff (nasal) BD
8) IM Pethidine 50mg STAT
10)Tablet Xanax 0.25mg STAT
Medication on discharge
1) Rhinocort Aqua 2 puff (nasal) BD
2) Tablet Unasyn 375mg BD
3) Menthol Inhalation daily

Medication on follow up
No medication prescribed by doctor
PARACETAMOL
Date on : 5th June 2006
Date off : 8th June 2006
Generic name: Acetaminophen
Group : Analgesic & antipyretic
Route : Oral (tablet)
Dosage : 1gm
Frequency : QID
Indication : Relieve of fever, pain,
headache & discomfort due to
cold / flu
Contra indication: Liver failure, allergic to
paracetamol
Adverse reaction: Rarely, rash& allergic.
ZITHROMAX
Date on : 5th June 2006
Date off : 8th June 2006
Generic name : Azithromycin dihydrate
Group : Macrolides (antibiotic)
Route : Oral (tablet)
Dosage : 500mg
Frequency : Daily
Indication : Lower respiratory tract
infections including bronchitis &
Pneumonia, upper respiratory
tract infections including
sinusitis & pharyngitis / tonsillitis,
skin & soft tissue infections.
Contra indication : Hypersensitivity to macrolides

Special precaution:
Moderate or severe renal impairment, severe renal
impairment : patient at increased risk for prolonged
cardiac repolarization: pregnancy & lactation. Avoid
coadministration with ergot derivatives

Adverse reaction :
Nausea, abdominal discomfort, vomiting, flatulence,
diarrhea, loose stool, dizziness, headache, vertigo

ROCEPHINE
Date on : 5th June 2006
Date off : 8th June 2006
Generic name : Ceftriaxone Na
Group : Cephalosporins (antibiotic)
Route : IV (intravenous)
Dosage : 1gm
Frequency : Daily
Indication : Respiratory tract, ENT, sepsis,
meningitis, infection of bones,
joints, soft tissue, skin &
wound, renal urinary tract
infection & genital infection
Contra indications : Hypersensitivity to
cephalosporins
Special precaution : Previous hypersensitivity
to penicillin. Anaphylactic
shock. Severe renal &
hepatic failure. Pregnancy
Adverse reaction : GI upset, haematology
changes, skin reaction,
coagulation disorders,
phlebitis,


SYRUP DURO TUSS
Date on : 5th June 2006
Date off : 8th June 2006
Generic name: Pholcodine
Group : Cough & cold remedies
Route : Oral (syrup)
Dosage : 15mls
Frequency : TDS
Indication : Relief of unproductive cough
associated with common cold,
sinusitis, flu & infections of the
upper respiratory tract.

Special precaution :
Decreased respiratory reverse, asthma, hepatic
impairment. Not recommended for infants.

Adverse reaction :
Occasional nausea and vomiting, drowsiness,
restlessness, excitement, ataxia & respiratory
depression (large doses)
DUOVENT
Date on : 5th June 2006
Date of : 8th June 2006
Group : Antiasthmatic & COPD
preparation
Route : Nebulizer
Dosage : 1 nebule
Frequency : 4 hourly
Indication :Prevention & treatment of
symptoms in chronic obstructive
airway disease with reversible
bronchospasm such as bronchial
asthma & especially chronic
bronchitis with/without emphysema.
Contra indication :
Hypertrophic obstructive cardiomyopathy
tachyarrythmia. Hypersensitivity to atropine
like substances.

Special precaution:
Insufficiency controlled diabetes mellitus, recent
MI, severe organic heart or vascular disorder,
hyperthyroidism. Severe asthma.

Adverse reaction :
Frequently, fine tremors, of skeletal muscles &
nervousness. Less frequency, tachycardia,
Dizziness, headache
MENTHOL INHALATION
Date on : 6th June 2006
Date off : 8th June 2006
Route : Oral (inhalation by mouth)
Frequency: TDS
Indication : To release thick secretions, to
release bronchospasm, to clear
airway
Contra indication : Post nasal surgery, mouth
ulcer, unconscious patient
Adverse reaction : Headache, agitation,
restlessness

RHINOCORT AQUA
Date on : 6th June 2006
Date off : 8th June 2006
Generic name: Budesonide
Group : Decongestant & other nasal
preparation
Route : Nasal (spray)
Dosage : 2 puff
Frequency : BD
Indication : Symptomatic relief of nasal &
nasopharyngeal congestion.
Facilitates intranasal exam
before surgery. Allergic & non
allergic perenial rhinitis.
PETHIDINE
Date on : 5th June 2006
Date off : 5th June 2006
Generic name : Pethidine HCL
Group : Analgesic & antipyretic
Route : IM (Intramuscular)
Dosage : 50mg
Frequency : STAT
Indication : Short term relief of moderate to
severe pain. As an anesthetic
adjunct & for obstetric analgesia

Contra indication : Respiratory depression or
where respiratory reverse
is depleted. Head injury,
raised intra cranial
pressure, brain tumor.
Cardiac arrhythmias.
Concurrent use of MAOIs.
Pre-eclampsia, eclampsia.
Convulsive states. Acute
alcoholism or delirium
tremens. Severe liver
disease, incipient
encephalopathy low platelet
count,
anticoagulant disorder
XANAX
Date on : 5th June 2006
Date off : 5th June 2006
Generic name : Alprazolam
Group : Minor tranquilliser
Route : Oral
Dosage : 0.25mg
Frequency : STAT
Indication : Anxiety
Contra indication : Hypersensitivity to
benzodiazepines

Special precaution :
Avoid operating vehicles or machinery; abuse
prone individuals; pregnancy; lactation; renal or
hepatic dysfunction. Patients whose primary
diagnose is schizophrenia. Avoid abrupt
discontinuation. Children <18 years.

Adverse reaction : Drowsiness, blurred vision,
coordination disorder; GI
effects; autonomic effects;
dependence, confusion.
UNASYN
Date on : 8th June 2006
Generic name : Sultamicillin
Group : Penicillin (antibiotic)
Route : Oral
Frequency : BD
Dosage : 375mg
Indication : Upper respiratory tract infections
including sinusitis & tonsillitis;
lower respiratory tract infections
including bacterial pneumonias &
bronchitis, UTI & pyelonephritis;
skin & soft tissue infections.Oral
follow therapy to Unasyn IM/IV
Example of medications





Xanax
Zithromax
NURSING CARE PLAN

1) Alteration in breathing pattern related to
dypsnea
2) Alteration in comfort ; cough related to thick
secretion
3) Chest discomfort due to excessive cough
4) Alteration in body temperature ; fever related to
infection at bronchiol
5) Disturbance in sleeping pattern related to
dypsnea
6) Knowledge deficit regarding self care
management

1
Date : 5th June 2006
Time : 2050 hours

Nursing diagnosis:
Alteration in breathing pattern related to dypsnea
Supporting data:
1) Patient using accessory muscle to breath
2) Need to nursed in propped up
3) Vital sign for respiration rate is 23 bpm
Goal:
Patient breathing pattern will be more effective
within 4 hours after nursing intervention and
during hospitalization
Nursing intervention

1)Assess patient general condition examples
respiration pattern, breathing pattern &
characteristic of phlegm.
To plan appropriate nursing care plan
I : I will observe the chest movement &
breathing sound weather wheezing,
crackles or not.

2)Position patient in semi-fowlers/fowlers position
To promote clear airways for lung expand
I : I raised up the bed to 45C to 90C until
patient comfortable to the position
3) Monitor vital sign 2 hourly till within normal
range than 4 hourly
To act as baseline data to detect any
abnormalities
I : I take blood pressure, respiration rate &
pulse rate & record it in the observation
chart. His vital signs as below:

Blood pressure : 136/82mmHg
Respiration rate : 23 bpm
Pulse rate : 92 bpm
4) Advised patient to reduced physical activity
To reduced oxygen demand
I : I advised patient to rest in bed and explain
the importance of rest

5) Teach patient deep breathing exercise
For muscle relaxation
I :I teach and shown to patient the correct
technique how to do deep breathing
exercise
6) Administer oxygen as ordered by doctor
through nasal pronge
To supply adequate oxygen to avoid
hypoxia
I : I administer the oxygen through nasal
pronge 3L/min to the patient observing by
staff nurse

7) Inform to the doctor if patient dypsnea
worsening
For further treatment and management
I : I will inform to doctor if my patient keep on
complain of dypsnea

Evaluation :
Patient breathing pattern more effective
Supporting data :
1) Patient respiration rate is 19 beat per minute
2) Patient oxygen therapy level that administer
through nasal pronge is reduced to 2L/ min.

Date : 5th June 2006
Time : 0050 hours

Initiated by,
(STN ROSMALINA)
2
Date : 5th June 2006
Time : 2050 hours

Nursing diagnosis :
Alteration in comfort ; cough related to thick
secretion
Supporting data :
1) Patient had cough on & off on assessment
2) Patient lethargic looking
Goal :
Patient cough will be reduced within 4 hour after
nursing intervention and during hospitalization

Nursing intervention

1) Assess patient general condition such as level
of cough weather mild, moderate or severe and
characteristic of phlegm
To plan appropriate nursing care plan
I : I will observe the characteristic and frequent
of cough & my patient had moderate cough
but unproductive cough.
2) Advise patient to reduce physical activity
To reduced oxygen demand that can
cause short of breath
I : I advise my patient to rest in bed and call
staff nurse if needed helped by press the
bell

3) Advise patient to drink more warm water about
1.5 to 2 liters as body requirement
To liquefy the secretion
I : I encourage my patient to drink more
warm water by serve one jug for him and
filled up once it finished
4) Teach the patient deep breathing & coughing
exercise
To promote loose secretion
I : I teach and shown to my patient how to do
deep breathing and coughing exercise
through correct technique

5) Provide vomit bowl to patient
For patient to excrete the secretion
I : I put the vomit bowl near to my patient and
explain the used of it
6) Administer steam inhalation or nebulizer as
prescribed by doctor
To promote clear airway loose secretions
I : I assist the staff nurse to administer
nebulizer and steam inhalation by teach
and show to the patient how to use it

7) Administer the cough & cold remedies
medication such as Syrup Duro- tuss 15mls
TDS
To reduce cough
I : I giving the oral medication to the patient
observing by the staff nurse

8) Inform to the doctor if patient cough not reduced
For further treatment and management
I : I will inform to the doctor if my patient keep
on complain of cough not reduced or
become more worse


Evaluation :
Patient cough is reduced
Supporting data :
1) Patient verbalized frequency of cough is
reduced
2) Patient look more comfortable
3) Patient drink half a jug of warm water that I
had served for him

Date : 5th June 2006
Time : 0050 hours

Initiated by,
(STN ROSMALINA)
3
Date : 5th June 2006
Time : 2050 hours

Nursing diagnosis :
Chest discomfort due to excessive cough
Supporting data :
1) Patient put the hand at the chest when cough
2) Patient uncomfortable when cough and needed
to propped up
Goal :
Chest discomfort will be reduced within 2 till 4
hour after nursing intervention and during
hospitalization
Nursing intervention

1) Assess patient general condition such as level
of pain weather mild, moderate or severe and
facial expression of patient when cough
To plan appropriate nursing care plan
I : I observed the facial expression of my
patient when cough and he having frowning
face when cough and listening what he had
complain
2) Position patient in semi-fowlers or fowlers
To maintain clear airways for better lung
expand
I : I raised up the bed 45 to 90 until patient
comfortable with the position

3) Monitor vital sign 2 hourly till stable than 4 hourly
To act as baseline data to detect any
abnormalities
I : I take the blood pressure, respiration rate and
pulse rate and record it in the observation
chart. The vital signs of my patient as below:
Blood pressure : 136/82mmHg
Respiration rate : 23 bpm
Pulse rate : 92 bpm
4) Advise patient to reduced physical activity
To reduced movement to reduced workload
of heart, so metabolism is decreased
I : I advised my patient to rest in bed and told
patient to press the bell near if needed
helped by put the bell near the patient

5) Teach deep breathing & coughing exercise
To reduced chest discomfort due to
excessive cough and for muscle relaxation
I: I teach and show to the patient the correct
technique of deep breathing and coughing
exercise and advise him to do at least 10
times per day.
6) Provide divertional environment such as
aircond, television, lamp and bed
To promote ventilation & comfortable in room
I :I switch on the aircond, television, lamp, tidy
the bed and provide the magazines to relax

7) Administer analgesic & antipyretics drug e.g. IM
Pethidine 50mg STAT as prescribed by doctor
To reduced pain for muscle relation
I : I giving intramuscular injection observing of
staff nurse and explain the side effect of
medication such as nausea and vomiting

8) Inform the doctor if patient complain of pain
For further treatment and management
I : I will inform to doctor if my patient keep on
complain of chest discomfort not reduced by
observed the frequency an level of pain

Evaluation :
Patient chest discomfort due to excessive cough
is reduced
Supporting data :
1) Patient cough is reduced
2) Patient can ambulate around
3) Patient verbalized chest discomfort is reduced
and he look more comfortable

Date : 5th June 2006
Time : 2250 hours

Initiated by,
(STN ROSMALINA)
4
Date : 5th June 2006
Time : 2050 hours

Nursing diagnosis :
Alteration in body temperature; fever related to
infection at bronchial
Supporting data :
1) Patient had flushing face
2) Patient removed the blanket because c/o warm
3) Patient body temperature is 37.8C
Goal : Patient body temperature will be reduced
to normal range (36C 37.2C) within 2
hours after nursing intervention and during
hospitalization
Nursing intervention

1) Assess patient general condition such as flu,
flushing face, dry lips, sweating or shivering
To plan appropriate nursing care plan
I : I observe patient condition such as having
flushing face and he removed the blanket
because complain of warmth
2) Monitor vital signs 2 hourly till stable and the 4
hourly
To act as baseline data to detect any
abnormalities
I : I take the body temperature every 2 hour, if
the temperature increase I will take
frequently about every hour and record it in
the observation chart. My patient body
temperature is 37.8C

3) Advise patient to reduced physical activity
To minimize the movement, so that it
reduced metabolism activity
I : I advised patient to rest in bed and told him to
press the bell if needed helped

4) Encourage patient to drink more plain water
about 1-2.5 liters per day as body requirement
To avoid dehydration and to minimize body
temperature
I : I advised the patient to drink more plain
water by served one jug for him and filled up
once it finished

5) Advised patient to wear thin clothes and
remove extra blankets
To promote heat loss through evaporation
I : I advised patient to wear thin clothes and
removed the extra blankets

6) Provide cold compress if body temperature is
more than 37.5C and tepid sponge if
temperature more than 38.5C.
To reduced body temperature through
conduction and evaporation
I : I apply the cold compress to my patient at
forehead because the temperature is 37.8C
and I will do tepid sponge if body
temperature increase more than 38.5C
7) Provided condusive environment such as
aircond and fan
To promote heat loss and general
ventilation
I : I switch on the aircond and fan to promote
the cool air

8) Administer antipyretics and analgesic
medication such as Tablet Paracetamol 1gm
QID
To reduced body temperature
I : I giving the oral medication observing by
staff nurse to the patient

9) Inform the doctor if patient body temperature is
not reduced
For further treatment and management
I : I will inform to doctor if body temperature is
not reduced or increase



Evaluation :
Patient body temperature is reduced to normal
range (36C to 37.2C)
Supporting data :
1)Patient face not flushing anymore
2) Patient ambulate around
3) Patient body temperature is 37.2C

Date : 5th June 2006
Time : 0050 hours

Initiated by,
(STN ROSMALINA)
5
Date : 5th June 2006
Time : 2050 hours

Nursing diagnosis :
Disturbance in sleeping pattern related to dyspnea
Supporting data :
1) Patient have fatigue appearance
2) Patient dont sleep during bedtime
3) Patient verbalized unable to sleep
Goal : Patient sleeping pattern will achieve
optimal amount of sleep 6 to 8 hours with
evidence of rested appearance within 24
hours after nursing intervention and during
hospitalization
1) Assess patient general condition such as
bedtime ritual, duration, position or any
interfere factor
To plan appropriate nursing care plan
I : I ask the patient regarding his bedtime
ritual, duration and comfortable position
for bedtime. My patient say usually he
sleep for 6 hours.

2) Put patient in desired position examples semi-
fowlers
To promote comfort and help patient easy
to sleep
I : I put patient in semi- fowlers position by
raised up the bed to 45 until patient
comfortable with that position

3) Advised patient to avoid heavy meals, caffeine
drink or smoking before bedtime
This food and drink make the body more
active
I : I advised my patient to avoid taken it and
explain the side effect of that food or drink
4) Advised patient to take hot chocolate or Milo
before sleep
To promote sleep
I : I suggest patient to take hot chocolate or
Milo before sleep

5) Advised patient to engage in any relaxing
activity before sleep such us warm bath and
changing wet clothes
To promote sleep
I : I advised patient to rest in bed before sleep
and changing wet clothes so patient feel
more comfortable
6) Provided condusive, quiet environment and
limited visitor
To avoid disturbances to patient during
bedtime
I : I switch off the head light, pull up the curtain
and advised the visitor not to disturbed the
patient during bedtime

7) Administer minor tranquilliser medication e.g.
Tablet Xanax 0.25mg STAT as doctor ordered
To promote sleep because this medication is
sedation
I : I assist the staff nurse to serve the Tablet
Xanax 0.25mg and give it to patient
8) Inform to doctor if patient keep on complain
unable to sleep
For further treatment and management
weather doctor will increase the dosage or
prescribed another medication
I : I will inform the doctor if my patient
complain unable to sleep

Evaluation :
Patient achieve optima amount of sleep 6 to 8
hours with evidenced of rested
Supporting data :
1) Patient sleep well on night
2) Patient look more energy when wake up in the
morning
3) Patient no complain of unable to sleep

Date : 6th June 2006
Time : 2050 hours

Initiated by,
(STN ROSMALINA)
6
Date : 5th June 2006
Time : 2050 hours

Nursing diagnosis :
Knowledge deficit regarding to self care
management
Supporting data :
1) Patient ask many question what happened
2) Patient ask the treatment to cure his disease
3) Patient always ask when the staff nurse do the
procedure to him
Goal : Patient will able to understood and follow
the instruction and gain more knowledge
about self care management after 24 hours
Nursing intervention

1) Assess the patients level of understanding
and knowledge regarding the self care
management
To ensure patients level of understanding
about the disease and self care
management at home
I : I ask my patient weather he know about
self
care management at home and he told me
that he didnt knew and aware about that.
2) Give the ward orientation regarding the
hospital situation such as self environment,
ID band
To give information about environment in
the ward
I : I orientate and explain to the patient about
policy in the hospital

3) Use simple and clear language when explain
to the patient and avoid medication term
while giving the explanation
To avoid misunderstanding
I : I use simple and speak clearly when
giving explanation to the patient
4) Explain the importance of maintaining good
diet e.g. high protein diet
To help in growth of new tissue & healing
I : I advised my patient to maintain good diet
and told his wife to avoid high cholesterol
in cooking.

5) Explain the important of taking the medication
at the home e.g. completing the antibiotics.
To ensure the patient will get cured faster
and understood the importance of it
I : I explain to Mr. K to complete the
medications when hes back. He
promised to me to finish up his medications.
6) Advised patient to avoid go to bad environment
such as dust, haze, fumes and exzos.
To avoid infection and clear airway from
inflamed
I : I advised and explain to my patient to
avoid go to bad environment

7) Encourage patient to drink more water at least
1.5 to 2 liters as body requirement
To loosen secretions and to flush out the
toxin in the body
I : I explained to Mr. K to take more water and
he verbalized that he will drink more water
8) Advised patient to stop smoking
To prevent recurrence and further
complications
I : I advised my patient to stop smoking as it
will make his condition worst and further
complication may occur

9) Remind the patient to come follow up at the
right date and time and explain the
importance of follow up
To assess the progress and improvement
of the patient after discharge
I : I remind the follow up date and explain
the importance of follow up.
Evaluation :
Mr. K able to understand and get adequate
knowledge of home care management after 24
hours
Supporting data :
Patient verbalized that he understood about his
treatment, health education and hospital policy.

Date : 6th June 2006
Time : 2250 hours

Initiated by,
(STN ROSMALINA)

EXAMPLES OF

Administer Nebulizer
EXAMPLES OF:

Nebulizer

Peak flow meter

Steam inhalation

Steam inhalation

Administer oxygen
HEALTH EDUCATION

The health education was given to as following:

MEDICATION
Reinforce to take the medication on the right
time and right dosage as doctor prescribed.
Explain the importance of medication that the
doctor had given

DIET
Advised to take well balance diet such as
carbohydrates, proteins, vegetables and fruits
Advised to drink more warm water if having
cough about 1.5 2 liters as body requirement
LIFESTYLE
Advised to stop smoking slowly to avoid get
again the disease.
Advised to avoid exposed himself to
occupational hazards such as fumes and
smokes because it can effect our respiratory
system.

FOLLOW UP
Reinforce about the date for his follow up.The
follow up day is 15th June 2006 on Thursday.
Informed to refer back to Dr. F if having sign
and symptoms of chest pain, dypsnea and
other complication.
EXERCISE
Teach and shown the correct technique to do
deep breathing and coughing exercise . I
teach Mr. K to take 2 times deep breath, hold
it as can and do double cough to exhale.
Advised to do DBE about 10 times per day for
easy to loose secretion.
Teach Mr. K and his family how to do
percussion at the chest or back when cannot
cough out the phlegm to promote secretion.

DISCHARGED

Mr. K has been discharged on 8th June 2006
at 0945am after 4 days hospitalization from 5/6/06
till 8/6/06.On that day, he looked better, cough is
reduced and no complain of chest discomfort
due to excessive cough.
On that day, Mr. K vital sign are below:

Temperature : 36 C
Pulse rate : 75 bet per minute
Respiration rate: 17 beat per minute
Blood pressure : 128/70mmHg
Doctor also prescribed some medication to
him as below:

1) Rhinocort aqua 2 puff (nasal) BD
2) Tablet Unasyn 375mg BD
3) Menthol inhalation BD

Before discharged, I gave some health
education to him.
FOLLOW UP

The doctor had given follow up as below:
Date : 15/6/06
Day : Thursday
Place : Dr. F clinic
Time : Office hour but in the morning

ON FOLLOW UP DAY
Mr. K come for follow up as below:
Date : 15/6/06
Day : Thursday
Place : Dr. F clinic
Time : 1145am
On that day, Mr. K condition looked stable and
more energy. He had no any complain. The
doctor was told him that his condition more
better and needed to continue medication as
prescribed before until very well. Dr. F also
advise him to stop smoking slowly because if he
still smoke the risk to get again the disease is
higher and more worse. On that day, no
medication was prescribed.

SUMMARY

My patient, Mr. K, male 38 years old was
admitted to Puteri Specialist Hospital on 5/6/06 at
2050 hours. He was admitted because c/o of
dypsnea x2/7, cough &chest discomfort due to
excessive cough x1/52 and fever x3/7

Dr. F had review the patient & told the patient
to do chest x ray, M16 & ultra sound abdomen
for investigation.
The chest x ray result shown that there are
peribronchial thickening in the perihilar regions
bilaterally & suggestive of bronchitis. The result for
blood test @ M16 shown that the range of
lymphocyte & ESR are abnormal. The ultra sound
abdomen result shown that there is
inhemogenicity in the right iliac fossa & possibility
on an inflammatory process in the right illiac fossa.
Mr. K also having medical history of sinusitis
in 2004 and had done surgery of bilateral
tonsillectomy in 2005. He also got family history
that is his father having asthma. Mr. K is allergic to
seafood especially crabs.

On admission, Mr. K is conscious &
orientated but he having cough, chest discomfort
due to excessive cough & fever.

After the treatment, medication &
nursing care given, Mr. K look more better,
cough & chest discomfort due to excessive cough
is reduced & more comfortable.
After review by Dr. F on 8th June 2006 in the
morning and see the patient progress, doctor
ordered to discharge him.

Before discharge, I was gave health
education regarding the disease, diet,
medication, lifestyle, follow up and exercise to Mr.
K. My patient going home around 0945am.
REFERENCE

BOOK :
Grant & Waugh, A& A. (2001), Ross and Wilson Anatomy
and Physiology In Health and Illness (9th ed), Churchill
Livingstone, London, p 240-263

Smeltzer, S.C. (2004), Text Book of Medical-Surgical
Nursing (10th ed) Lippincott, Philapeldia, p 466-468

Lemone P. and Burke K. (2004) Medical- Surgical Nursing
Critical Thinking in Client Care (3rd ed). New Jersy, p 1077

Weller B. F. (1998) Baillieres Nurses Dictionary (23rd ed).
United Kingdom, p 60

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