LICEO DE CAGAYAN UNIVERSITY

COLLEGE OF NURSING

IN PARTIAL FULFILLMENT OF THE REQUIREMENTS

IN

NCM50120O

Submitted to:

Mrs. Livia B. Dato RN

Clinical Instructor

Submitted by:

Acebu, Kirk

Bacan, Marjorie

Baculanta, Rojelyn

Balagot, Julie Mae

Baran, Jayzel

Baterna, Carousel

Blanco, Maureen

Bustallino, Aiko

Caintoy, Jim

TABLE OF CONTENTS

I. Introduction and patient profile

II. Developmental Data

III. Health history

IV. History of present illness and assessment

V. Diagnostic exam

VI. Anatomy and Physiology and pathophysiology

VII. Medical Management (Doctors orders)

VIII. Ideal Nursing Managements

IX. Actual Nursing Management

X. Discharge Plan and Prognosis

XI. Evaluation and Implication

XII. Bibliography

I . Introduction

a.Overview of the case

Acute bronchitis is inflammation of the upper airways, commonly following a URI (upper

respiratory tract infection). The cause is usually a viral infection, though it is sometimes

a bacterial infection; the pathogen is rarely identified. The most common symptom is

cough, with or without fever, and possibly sputum production. In patients with COPD,

hemoptysis, burning chest pain, and hypoxemia may also occur. Diagnosis is based on

clinical findings. Treatment is supportive; antibiotics are necessary only for selected

patients with chronic lung disease. Prognosis is excellent in patients without lung

disease, but in patients with COPD, acute respiratory failure may result.

Acute bronchitis is frequently a component of a URI caused by rhinovirus,

parainfluenza, influenza A or B, respiratory syncytial virus, coronavirus, or human

metapneumovirus. Less common causes may be Mycoplasma pneumoniae, Bordetella

pertussis, and Chlamydia pneumoniae. Patients at risk include those who smoke and

those with COPD or other diseases that impair bronchial clearance mechanisms, such

as cystic fibrosis or conditions leading to bronchiectasis

Symptoms are a nonproductive or minimally productive cough accompanied or

preceded by URI symptoms. Subjective dyspnea results from chest pain or tightness

with breathing, not from hypoxia, except in patients with underlying lung disease. Signs

are often absent but may include scattered bronchi and wheezing. Sputum may be

clear, purulent, or, occasionally, bloody. Sputum characteristics do not correspond with

a particular etiology. Mild fever may be present, but high or prolonged fever is unusual

and suggests influenza or pneumonia.

Diagnosis is based on clinical presentation. Chest x-ray is necessary only if findings

suggest pneumonia (eg, abnormal vital signs, crackles, signs of consolidation,

hypoxemia). Elderly patients are the occasional exception. They may require chest x-

ray for productive cough and fever in the absence of auscultatory findings (particularly if

there is a history of COPD or another lung disorder).

Objective of the Study

b.General Objectives:

At the end of this care study, the students shall enhance their knowledge base, improve

their immediate skills, and manifest positive attitude and behavior towards the care of

the patient diagnosed with acute bronchitis.

Specific Objectives:

Define important terms used in the presentation correctly.

Show the pathophysiology of acute bronchitis correctly.

Present care study appropriately.

c. Scope and Limitations

The care study is about a patient who had been diagnosed with Acute Bronchitis at

Polymedic General Hospital. The scope of this study covers from the patient’s profile,

family and personal health history, developmental data, and as well as with his medical

and nursing management.

The study has limited information due to time bounded span and incomplete and

lacking of information of the patient from her personal chart. The patient was being

assessed and cared of for only 1 day, on September 18, 2009.

Patient Profile

Name: Diaz, Lorijean L.

Age: 47 years old

Birthday: July 20, 1962

Birthplace: Macasandig, Cagayan de Oro City

Sex: Female

Status: Married

Nationality: Filipino

Religion: Roman Catholic

Educational Attainment: College Graduate

Occupation: Government Employee

Income: 7,000/ month

II. Developmental Data

Researchers have advanced several theories about the various stages and aspects

of growth and development. In order to enhance our understanding to our patient,

different theories were used to relate it to her.

Our first theory is the theory of Pscyhosocial by Erick Erickson where our patient

belongs to the middle adult stage where generativity v stagnation is the task.

Positive outcomes from this crisis stage depend on contributing positively and

unconditionally. We might also see this as an end of self-interest. Having children is not

a prerequisite for Generativity, just as being a parent is no guarantee that Generativity

will be achieved. Caring for children is the common Generativity scenario, but success

at this stage actually depends on giving and caring - putting something back into life, to

the best of one's capabilities.Stagnation is an extension of intimacy which turns inward

in the form of self-interest andself-absorption. It's the disposition that represents feelings

of selfishness, self-indulgence, greed, lack of interest in young people and future

generations, and the wider world. Generativity v Stagnation Care & Production (giving

unconditionally in support of children and/or for others, community, society and the

wider world where possible and applicable, altruism, contributing for the greater good,

making a positive difference, building a good legacy, helping others through their own

crisis stages mid-adult / children, community / 'giving back

Our patient belongs to the middle-aged adult, from 35-65, have been called the

years of Generativity v stagnation. We can say that the patient had positively

accomplished the previous stages. But, since she has been hospitalized, We have

observed that she is worried about her condition. The good thing about our patient is

she has a very positive outlook in life. She follows all the treatments and takes the

medications as prescribed. She has a good relationship with her childrens giving care

and unconditional support not just for her own children but for others.

The second theory is Developmental Task by Robert Havighurst

Middle Age (30-60)

(Ages 30-60)

Assisting teenage children to become responsible and happy adults. * Achieving adult

social and civic responsibility. * Reaching and maintaining satisfactory performance in

one’s occupational career. * Developing adult leisure time activities. * Relating oneself

to one’s spouse as a person. * To accept and adjust to the physiological changes of

middle age. * Adjusting to aging parents.

Our patient belongs to the middle age with his corresponding task to be achieved

and has achieved. In his current stage, she already achieved the selecting of mate

where he married with her good husband. She had fulfilled her role as a good mother.

She has been a good wife to her husband. In assisting teenage children to become

responsible and happy adults, we believed that she has fully achieved this since she

has a good relationship with her children. In accepting and adjusting to the physiologic

changes of middle age, we have observed that she has fully accepted his condition and

has adjusted to the changes being experienced in the middle age stage.

The third theory is the Cognitive developmental stage of Piaget’s

Piaget concluded that there were four different stages in the cognitive

development of children. The first was the Sensory Motor Stage, which occurs in

children from birth to approximately two years. The Pre-operational Stage is next, and

this occurs in children aged around two to seven years old. Children aged around seven

to eleven or twelve go through the Concrete Operational stage, and adolescents go

through the Formal Operations Stage, from the age of around eleven to sixteen or more.

Formal operational stage (Adolescence and adulthood). In this stage, intelligence

is demonstrated through the logical use of symbols related to abstract concepts. Early in

the period there is a return to egocentric thought. Only 35% of high school graduates in

industrialized countries obtain formal operations; many people do not think formally

during adulthood. Can think logically about abstract propositions and test hypotheses

systematically becomes concerned with the hypothetical, the future, and ideological

problems. 

Our patient belongs to Formal Operations Stage (11yrs-more) .In the formal

operational stage of adolescence; the structures of development become the abstract,

logically organized system of adult intelligence. When faced with a complex problem,

the adolescent speculates about all possible solutions before trying them out in the real

world. The formal operational stage begins around age 11 and is fully achieved by age

15, bringing with it the capacity for abstraction. This permits adolescents to reason

beyond a world of concrete reality to a world of possibilities and to operate logically on

symbols and information that do not necessarily refer to objects and events in the real

world.

Since our patient has been hospitalized, she was knowledgeable enough to

handle her situation. She was able to find solutions to her problems encountered.

Facing each of her problems was been a positive outlook in her life. She was an open-

minded person to thinks deeply about what are the things happened and soon to be

happen.

The 4th theory is psychosexual development of Sigmund Freud

Sigmund Freud believed that each stage of a child's development beginning at birth is

directly related to specific needs and demands, each based on a particular body part

and all rooted in a sexual base. While simplification of his theories is necessary in order

to give an overview, he held beliefs that are quite complex. In order to understand the

basics of his developmental stages, it is important to note a few things: Freud's age

ranges varied a bit over the course of his work, largely because he acknowledged that

development can vary a bit from individual to individual. Additionally, experience of the

stages may overlap at times. Finally, Freud believed that the way that parents handle

their children during each of the stages has a profound and lasting impact on the overall

development of the child's psyche.

Our patient belongs to The Genital Stage: From Puberty On

In this final stage of psychosexual development, Freud theorized that the onset of

puberty represented the reawakening of sexual urges. At this more mature age,

however, adolescents focus not only on their genitals, but also on developing sexual

relationships with Normal" heterosexuality. According to Freud, heterosexual

intercourse should be the goal of psychosexual development (a position that has since

been questioned by feminists and queer theorists. In this way, the individual enters

adulthood and ensures the survival of the species. For Freud, a desire for oral or anal

pleasure constitutes a fixation on or a regression to an earlier stage in one's

psychosexual development. Members of the opposite sex and on seeking sexual

satisfaction.

Characteristics were energy is directed toward attaining a mature sexual

relationship. Inability to resolve conflicts can result in sexual problems, such as frigidity,

impotence, and the inability to have a satisfactory sexual relationship.

Since our patient belongs to the psychosexual development under from puberty

stage, she has the mature age by developing sexual relationship with her husband. She

was been separated with her parents after marriage and build up with her own family

with the help of her husband. She has been an independent person and in terms of

decision making, she is fully creative on it.

III. Health History

According to Mrs. Lorijean Diaz, neither of her parents has the history of having

respiratory distress. She mentioned that her father was a hypertensive. And her mother

had no major illness or problematic health condition. She is the youngest of all 5

siblings. A college graduate and married at the age of 28 years old, blessed with 4

siblings. She worked in the government for almost 3 years at Cagayan de Oro city.

She stated during physical assessment that she believed she acquired her

condition because of her activities everyday she go to worked. Every time she felt sweat

she goes directly to the air condition room to keep herself cool. She didn’t even

manage to drink water because she claimed that water was just a tasteless. And she

added every time she goes to her work, she always inhaled the air pollution from the

jeepneys and other garbage’s. After worked, she followed shopping in the market.

IV. History of present illness

A case of pt. Mrs. Lorijean Diaz, 47, female, married from Cagayan de Oro city

and admitted on September 16,2009 due to persistent coughing and on and off fever. 8

days PTA, had amount of productive cough of yellowish phlegm, consulted with

Attending Physician, 4 days PTA and was given solmux and unrecalled antibiotics.

Cough persisted without relief from the prescribed med.

Nursing Assessment (System Review)

Nursing System Review Chart I

Name:Diaz, Lorijean L. Date: September 16,2009

Vital Signs:

Pulse: 85b/m BP: 100/90 mmhg Temp: 37 c Respi: 22 cyc/m Height: 5’0”

Weight: 55 kls

EENT

( ) impaired vision ( ) blind ( ) pain ( ) hard of hearing

( ) reddened ( ) drainage ( ) gums ( ) deaf

( ) burning ( ) edema ( ) lesion ( ) teeth

(x) No problem

RESP:

( ) asymmetric ( ) tachypnea

( ) apnea ( ) rales (x) cough

( ) barrel chest ( ) bradypnea

(x) shallow ( ) bronchi (x) sputum

( ) diminished (x) dyspnea

( ) orthopnea ( ) labored

(x) wheezing (x) chest pain ( ) cyanotic

( ) no problem

CARDIO VASCULAR

( )arrhythmia ( ) tachycardia ( ) numbness

( ) diminished pulses ( ) edema ( ) fatigue

Deep shallow

breathing

Wheezing sound

ausculted

Chest pain Upon coughing

( ) irregular ( ) bradycardia ( ) murmur

( ) tingling ( ) absent pulses ( ) pain

(x) No problem

GASTRO INTESTINAL TRACT

( )obese ( )distention ( ) mass

( ) dysphasia ( ) rigidity ( ) pain

(x) No problem

GENITO-URINARY and GYNE

( ) pain ( ) urine color ( )vaginal bleeding

( ) hermaturia ( )discharge ( ) noctoria

(x) No problem

NEURO

( ) paralysis ( ) stuporous ( ) unsteady ( ) seizures

( ) lethargic ( ) comatose ( ) vertigo ( ) tremors

( ) confused ( ) vision ( ) grip

(X) No problem

MUSCULOSKELETAL and SKIN

( ) appliance ( ) stiffness ( ) itching ( ) petechiae

( ) hot ( ) drainage ( ) prosthesis ( )swelling

( ) lesion ( ) poor turgor ( ) cool ( ) deformity

( ) wound ( ) rash ( ) skin color ( ) flushed

( ) atrophy ( ) pain ( ) ecchymosis

( ) diaphoretic ( ) moist(x) No problem

Productive cough, yellowish in color of pleghm

Dry skin, pale

Dark brown skin color

Weak in appearance

NURSING ASSESSMENT II

SUBJECTIVE OBJECTIVE

COMMUNICATION :

( ) hearing Loss Comments: ok

( ) visual Changes ra man aku pan

(x) denied dungog ” as

verbalized by the

patient.

( ) glasses ( ) languages

( ) contract lens ( ) hearing aide

( )s speech difficulties

Pupil Size: 3mm

Reaction: PERRLA

OXYGENATION :

( ) dyspnea Comments: “cge ko

( ) smoking history ubo naa pd plemas ”

as verbalized by the

Patient.

(/) cough

(/ ) sputum

( ) denied

Resp. ( ) regular (/) irregular

Describe: Deep shallow breathing

R: Assymmetric to the right lung

L: Assymmetric to the left lung

CIRCULATION :

(/) Chest pain Comments: “ sakit

akng dughan pag mag ubo ’’ as verbalized by the patient

( ) Leg pain

( ) Numbness

Of extremities

( ) Denied

Heart Rhythm ( /) regular ( ) irregular

Ankle Edema: theres no noted ankle edema

Pulse Car. Rad. DP Fem

R 85 + + +

L 85 + + +

Comments: pulses are papable

NUTRITION :

Diet DAT

( ) N ( ) V Comments:”

Character “ok rman kaon rman ko

Bsan unsa ila ihatag ”

( ) Recent change as verbalized by the

In weight, appetite patient

( ) Swallowing

difficulty

(/) denied

Dentures None

( ) ( /)

FULL PARTIAL with patient

Upper: ( ) (/) ( )

Lower: ( ) (/) ( )

ELIMINATION :

Usual bowel pattern urinary frequency

Once a day 3-4 times a day

( /) constipation ( ) urgency

remedy ( ) dysuria

none ( ) hematuria

Date of last BM ( ) incontinence

September 16,2009 ( ) polyuria

( ) Diarrhea ( ) foly in place

Character ( ) denied

Comments: patient’s Bowel Sounds OK

Vowel sound was Abdominal

Hypoactive. Her last Distention

bowel was September 16,2009 Present ( /) yes ( )no

Urine* (color,consistency, odor) patient’s urine color was light yellow

.

MGT. OF HEALTH ILLNESS

( ) Alcohol ( /) denied

(amount , frequency)

“ Dili man ku gabisyo ” as verbalized by the patient.

SBE: Last Pap Smear n/a

LMP: n/a

Briefly describe the patient’s abiltity to follow treatments for chronic health problems.

Patient was able to comply with her medications and treatment regimen as prescribed by the physician

SUBJECTIVE OBJECTIVE

SKIN INTEGRITY:

sComments:”wala man

( /) Dry pud katol-katol”

( ) Itching as verbalized by the patient

( ) other

( ) Denied

(/) Dry ( ) cold (/) pale

( ) Flushed ( ) warm

( ) Moist ( ) cyanotic

The patient was affebrile with 37.0 degree celcius

ACTIVITY/SAFETY:

( ) Convulsion Comments: “ maka-

( ) dizziness lihoklihok man ko.

( ) limited motion wala man problema’

of joints as verbalized by the

Limitation in patient.

Ability to

( ) Ambulate

( ) Bathe self

(/) denied

( ) LOC and Orientation: patient is oriented to time and place

Gait: (/) walker () cane ( ) other

( ) sensory and motor lossess in face or extremities no noted motor lossess in her face and extremities

ROM limitations: patient has no limitation in range of motion

COMFORT/SLEEP/AWAKE:

( ) Pain Comments: “ maka-

(location) mata ko ug hutoyon ko”

frequency as verbalized by the patient

remedies)

( ) Nocturia

(/) sleep difficulties

Denied

( ) Facial Grimaces

( ) Guarding

( ) Other signs of pain : there is no other signs of pain noted

( ) siderail release form signed ( 60 + years) N/A

COPING:

Occupation: Self employed

Members of Household: 8

Most supportive Person: her childrens

Observed non-verbal behavior: no noted

The person and his phone number that can be reached any time: Not given an opportunity.

Special patient information (use lead pencil)

55 kls . Daily weight ____ PT/OT ____

Every 4 hours Bp q shift ____ Irradiation ___

________ Neuro vs ____ Urine test ____

________ CVP/SG. Reading ___ ____ 24 hours Urine collection _

DATE

ORDERE

D

DIAGNOSTIC/

LABORATORY

EXAM

DATE

DONE

DATE

ORDER

ED

I.V

FLUIDS/BLO

OD

DATE

DISC.

Sept.16,

09

Complete blood count Sept.16,09 Sept.16,

09

PLR;TL@KV

O

On

going

Sept.16,

09

Urinalysis Sept.16,09

Sept.16,

09

Blood chemistry Sept.16,09

Sept.16 ,

09Chest X-ray

Sept.16,09

V. Diagnostic Exams

Hematology Report

Test Results Normal Values Remarks

WBC 15.35 10^3/uL 5.0-10.0 Abnormal findings

RBC 4.17 10^6/uL 3.69-5.90 Normal Findings

Hemoglobin 11.8 g/dL 11.70-14.00 Normal findings

Hematocrit 35.9 % 34-.10-44.00 Normal findings

MCV 86.1 fL 70.00-97.00L Normal Findings

MCH 28.3 pg 26.10-33.30 Normal Findings

MCHC 32.9 g/dL 32.0-35.00 Normal Findings

Differential counts

Lymphocytes 8.3 % 20.0-40.0 Abnormal findings

Neutrophils 86.8 % 55.0-62.0 Abnormal findings

Platelet 639 10^3/uL 150.0-390.0 Abnormal findings

Monocytes 3.7 % 4.0-10.0 Abnormal Findings

Urinalysis

Test Results Normal values remarks

Color Light Yellow straw yellow to

amber

Normal findings

Clarity Slightly cloudy Transparent Concentrated urine,

also due to

medication

pH 7.5 4.5-8 Normal findings

Specific Gravity 1.010 1.010-1.025 Normal findings

Proteins Negative Negative glomerulonephritis,

pyelonephritis,

nephrotic

syndrome, pre-

eclampsia,

malignancies,

heavy exercise,

stress, CHF,

malignant

hypertension

Glucose Negative Negative Normal findings

Sediments/microscopic

Examination

Epithelial cell 2-4

RBC Plenty

Mucus threads None seen negative infection

Blood Chemistry

Test Results Normal values Remarks

Creatinine 0.50 mgs/dL 0.70-1.30 Abnormal findings

Potassium 3.27 meq/L 3.50-5.50 Abnormal findings

Na+ 142.40 meq/L 153.00-155.00 Normal findings

September 16, 2009-10-09

EXAMINATION: CHEST PA

There is no evidence of active parenchynal infiltrates.

Heart is not enlarged.

Aorta is unremarkable.

Sinuses are Intact.

IMPRESSION:

No radiographic abnormalities in the chest.

VI. Anatomy and physiology with pathophysiology

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 tissues, 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 as 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 the lower respiratory tract

and helps 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 mucoclliary

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 the

posterior pharynx, from whereby they are either swallowed, spat out, sneezed, or blow

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.

In descending order, these generations of branches include:

trachea

right bronchus and left bronchus

secondary bronchi

tertiary bronchi

bronchioles

terminal bronchioles

respiratory bronchioles

alveoli

THE LUNGS

The thoracic cage, or ribs, and the diaphragm bound the thoracic cavity. There are two

lungs that occupy a significant portion of this cavity. The diaphragm is a broad, dome-

shaped muscle that separates the thoracic and abdominal cavities and generates most

of the work of breathing. The inter-costal muscles, located between the ribs, also aid in

respiration. The internal intercostals muscles lie close to the lungs and are covered by

the external intercostal muscles. The lungs are cone-shaped organs that are soft,

spongy and normally pink. The lungs cannot expand or contract on their own, but their

softness allows them to change shape in response to breathing. The lungs rely on

expansion and contraction of the thoracic cavity to actually generate inhalation and

exhalation. This process requires contraction of the diaphragm.

Pathophysiology

Definition: Acute bronchitis is an infection of the bronchial (say: “brawn-kee-ull”) tree. The bronchial tree is made up of the tubes that carry air into your lungs. When these tubes get infected, they swell and mucus (thick fluid) forms inside them. This makes it hard for you to breathe.

Microorganisms

Entry into the nasal passages

Travel around the pharynx and to larynx

Deposit into the bronchioles

Multiplication of microorganisms

Neutrophils and macrophages engulf by microorganism

Partial occlusion of the bronchi or alveoli

Interferes with the diffusion of oxygen and carbon dioxide

Areas of the lungs are not adequately ventilated

Medical management Continuation of replication

Treated Death

s/sx:

-cough with yellowish pleghm

-body aches

s/sx:

-fever

-wheezing sound

-pain when coughing

s/sx:

-shortness of breath

Predisposing factor:

- exposure to the polluted air

- Age (older adults are at greater risk because normal aging or illness weaken their immune system)

- Malnutrition (a poor diet or one too low calories puts someone at greater risk)

Precipitating factor:

Inhalation of the polluted air in the

surroundings.

VII. Medical Management (Doctors order)

DATE DOCTOR’S ORDER RATIONALESeptember 16, 2009

8:05 am

- pls. admit under the service of Dr. Go

- leave consent to care

- TPR q 4

- DAT-

- Start with PLR iL @ KVO

- Diagnostics: CBC, Chest X-ray, Urinalysis

- Meds:

- Ultramox (amoxicillin) 1.5 mg q PO ANST (-)

- for further evaluation of the patient

- for patient and doctor’s protection in case of any problems may occur

-TPR taking are done to provide accurate monitoring of vital signs considering that fluctuations in vital signs especially temperature may indicate presence of infection.

-this provides adequate nutrition

-for medication purposes

-Done to determine/ confirm provisional diagnosis and check for other abnormalities. They also provide baseline data for future comparison.

-Medications are prescribed to relieve symptoms, control, and prevent further complications.

September 17,2009

9:00am

September 18,2009-10-10:15am

- Duavent I neb q 8hrs (salbutamol)

- Refer accordingly

- Continue meds

- IVTF PLR il @ same rate

- MGH tomorrow AM

- Shift ultramox to 1 gram/tab BID to start tonight

- IVF to consume

- Ff up tue 9/22/09

- Referral is order so to provide medical management for any condition abnormalities

-to medical management

-for medication purposes

-patient’s condition is improved

-for medication purposes

- For medication purposes

- For further monitoring of the patient’s condition

Nursing Management

Ideal Nursing Management

1. Nursing Management:

Impaired Gas exchange related to altered delivery of oxygen (hypoventilation)

Objectives:

At the end of 15 minutes my client will be able to participate in actions to

maximize oxygenation and demonstrate improved ventilation and oxygenation of

tissues within client’s acceptable range and absence of symptoms of respiratory

distress.

Interventions/Rationale:

Independent:

Pt will need to have breath sounds monitored q 4° to determine if pneumonia is

progressing. For baseline data’s for determining the progress of the disease.

O2 sats should be done regularly ( at least q4°during acute phase) to make sure

that patient is getting adequate perfusion.

Make sure to give all scheduled antibiotics on schedule so that therapeutic

ranges are maintained. To avoid any delayed of therapeutic effects.

Any s/s of infection must be monitored and reported to MD.

Elevate head and encourage the watcher to change porition of the baby;

Enhance expectoration of secretions to improved ventilation

Dependent:

Administer Oxygen therapy by appropriate means; e.g. nasal prongs, mask,

venture mask.; The purpose of O2 therapy is to maintain PaO2 greater thatn

90% o2 saturation.

2. Nursing Management:

Ineffective airway clearance related to increase sputum production and decrease

energy.

Objectives:

At the end of 15 minutes, client will be able to demonstrate behaviors to achieve

airway clearance and display patent airway with breath sounds clearing, absence

of dyspnea, cyanosis.

Interventions/Rationale:

Independent:

Monitor the patients vital signs of respiratory failure ( cyanosis, severe

tachypnea); Tachypnea, shallow respirations, and asymmetric chest movement

are frequently present because of discomfort of moving chest wall and or fluid

lung.

Elevate head of the bed, change position frequently; keeping the head elevated

lowers diaphragm, promoting chest expansion and expectoration to keep the

airway clear.

Suctioning as indicated; stimulates cough or mechanically clears airway in client

who is unable to do so especially infants.

Offer warm, rather than cold fluids; Fluids especially warm liquids aid in

mobilization and expectoration of secretions.

Dependent:

Assist with/monitor effects of nebulizer treatments and other respiratory

physiotherapy. Facilitates liquefaction and removal of secretions.

Provide supplemental fluids e.g IVF, humidified oxygen and room humidification.

Fluids are required to replace losses and aid in mobilization of secretions, room

humidification thought to improved the risk of transmitting infection.

3. Nursing Management:

Acute pain related to persistent coughing.

Objectives;

At the end of 15 minutes, my patient will be able to demonstrate relaxed manner

(e.g. Stop crying) and engage in some activity (e.g. laughing, can grasp things)

appropriately.

Interventions/Rationale:

Independent:

Monitor Vital signs;. Changes in heart rate mey indicate that client is

experiencing pain, especially when other reasons for changes in vital signs have

been ruled out.

Provide comfort measures, e.g., sense of touch, change in position, quiet music;.

No analgesic measures administered with gentle touch can lessen discomfort.

Offer frequent oral hygiene;, mouth breathing and oxygen therapy can initiate

and dry out mucous membranes, potentiating general discomfort.

Offer warm, rather than cold fluids;, it will aid in mobilization and expectoration

thus minimizes coughing and lessen pain.

Dependent:

Administer analgesics and antitussives as indicated by the physician;, To reduce

excess mucus, therapy enhancing general discomforts and rest.

X. Discharge Plan and Prognosis

The Group advised the patient to have a frequent monthly check-up to let her know

about the improvement of her health. She can have it their nearest Barangay Health

Center. But in emergency cases, she should immediately seek for medical assistance at

the nearest hospital.

We encouraged patient of any little alteration of the normal condition and functioning

should be given an immediate treatment and should not be ignored. A simple disease

can easily be treated and thus, avoiding any fatal consequences. We instructed to have

the following take home medication: ultramox (amoxicillin and sulbactam) 1grm/tab BID

PO and duavent ( salbutamol and 2 practropicen) 1tab q 8 and frequent intake of fluids,

adequate rest and encourage to have a adequate nutrition.

The prognosis is good since the onset and duration of illness and precipitating

factors were identified. Immediate management response was provided to the patient to

address her condition. The patient also positively complied with medications and

adhered to treatment plan. Family support has also been evident while in the hospital.

XI. Evaluation and Implication

Mrs. Diaz was diagnosed with Acute Bronchitis. In span of two 1 day, we have

provided the care and maintenance he needed like morning care, vital signs monitoring,

giving medications, and nebulizing.

The patient immediately responded to the treatment due to the proper care given

among medical team coupled with the support of significant others. It resulted to better

improvement of the patient’s condition.

This implies that a patient like Mrs. Diaz needs a holistic approach for a faster health

improvement. Increased rate of recovery will be manifested if the patient and her family

fully cooperate towards the treatment given by the medical team.

XII. Bibliography

Kozier, et. al (1998). Fundamentals of Nursing.

Pearson education Asia pte Ltd. 5th edition: Philippine

Doenges, et. al. (1997) Nursing Care Plan.

F>A/ Davis Company. Philadelphia. 14th edition

Deglin, et. al. (1997). Davi’s drug guide for nurses.

F>S. Davis company. Philadelphia. 5th edition

www.yahoo.com

Generic

Name of

Ordered

Drug

Brand

Name

Date

Orde-

red

Classifica-

tion

Dose/

Frequency/

Route

Mechanism of

action

Specific

Indication

Contra-

indication

Side

Effects/

Toxic

Effects

Nursing

Precaution

Ultramo

x

Amoxicillin Septem

ber

16,2009

Amoxicillin,p

enicillin

1.5 mg/tab

PO

penicillin which

kills bacteria by

interfering with

the synthesis of

the bacterial

cell wall. It

binds to

penicillin-

binding proteins

(PBPs) on the

bacterial cell

wall and blocks

peptidoglycan

synthesis.

Treatment

of

tracheobron

chitis,

pneumonia,

bronchopne

umonia.

hypersens

itivity

Nausea,

vomiting,

enterocolitis

, dyspepsia,

epigastralgi

a, glossitis,

stomatitis,

and

diarrhea.

- asses fluid

status during

therapy.

Monitor daily

weight, intake

and output,

amount and

location of

edema, lung

sounds.

- monitor blood

pressure.

Generic

Name of

Ordered

Drug

Brand

Name

Date

Orde-

red

Classifica-tion Dose/

Frequenc

y/

Route

Mechanism of

action

Specific

Indication

Contra-

indication

Side

Effects/

Toxic

Effects

Nursing

Precaution

Duavent Salbutam

ol

Septem

ber

16,2009

Bronchodilator

Antiasthmatic

& COPD

Preparations

I neb q 8

hr

Acts relatively

at beta2

adrenergic

receptors to

cause broncho -

dilation and

vasodilation

relief and

prevention

of broncho -

spasm in

patient with

reversible

obstructive

airway

disease

-prevention

of exercise

induced

broncho -

spasm

hypersensit

ivity

-history of

stoke

-CAD

Anxiety,

tremors,

headache,

vertigo,

weakness,

nausea,

vomiting

-check urine pH

-protect solution

from light

IX. Actual Nursing Management

CUES OBJECTIVE NURSING DIAGNOSIS

NURSING INTERVENTION

RATIONALE EVALUATION

Subjective:

“cge man ku ubo naa pud plemas”as verbalized by the patient

Objective:

coughing weak

shortness of breath

At the end of 30 min, the patient will be able to improve airway

Ineffective airway clearance related to thickened mucus production as evidenced by changes in rate and depth of respiration

1.Assess for changes in respiratory rate and depth

2. Encourage to increased fluid intake unless contraindicated

3. Do chest tapping

4. Demonstrate the coughing and breathing exercise

5. Administer medications as prescribed such as duavent

-Respiratory rate and rhythm changes are early sign respiratory compromise

-This prevents dehydration from increased insensible loss and keeps the secretions thin

-to mobilize secretions and facilitate airway

-helps mobilize the secretions

-a bronchodilator that opens the air passages, making it easier to breathe

At the end of 30 min, the patient was able to improved airway

CUES OBJECTIVE NURSING DIAGNOSIS

NURSING INTERVENTION

RATIONALE EVALUATION

Subjective:

“galisod ku ginhawa” as verbalized by the patient

Objective:

body weakness

shortness of breath

At the end of 30 mins, the patient will be able to improve ventilation and provide adequate oxygenation

Ineffective breathing Pattern related to copious secretions as evidenced by changes in depth/rate of respiration

1.Elevate head of the bed/change position frequently

2. Encourage deep breathing and coughing exercise

3. Provide routine comfort measures (backrub,chest tapping)

4. Maintain Bed rest

5. Administer medication as prescribed such as duavent

-promoting chest expansion,mobilization of secretions.

- to mobilize secretions

- alleviate the discomfort

- prevents over exhaustion and reduces oxygen consumption

- a bronchodilator that helps to lessen the secretions

At the end of 30 mins, the patient was able to improved ventilation and provided an adequate oxygenation.

CUES OBJECTIVE NURSING DIAGNOSIS

NURSING INTERVENTION

RATIONALE EVALUATION

Subjective:

“galisod ko ginhawa tungod sa aku ubo”

As verbalized by the patient

Objective:

Shortness of breath

Body weakness

At the end of 30 mins, the patient will be able to improve ventilation and provide adequate oxygenation

Impaired Gas Exchange related to altered oxygen supply as evidenced by inability to move secretions

1. Assess respiratory rate, depth.

2. Elevate Head of bed. Assisst client to assume position to ease work of breathing.

3. Encourage significant others to have frequent position changes of a patient.

4. Assess/ routinely montitor skin/mucous membrane color

5. Administer medication as ordered like vitromox.

-Useful in evaluating the degree of respiratory distress and / or chronicity the disease process

- Oxygen delivery may be improved by upright position/breathing exercises to decrease airway collapse, dyspnea, and work of breathing.

- this measures promote maximal inspiration, enhance expectoration of secretions to improve ventilation

- Duskiness and central cyanosis indicate advanced hypoxemia

- helps to liquefy the secretions

At the end of 30 mins, the patient was able to improved ventilation and provided adequate oxygenation