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I. Introduction
As we go on with our hospital duty, we are able to encountered patients with
different cases that we are able to care for, as we conduct our assessment, interview
with the patient, we have to choose one of this patient for our case study. Being
exposed to the hospital ward at Polymedic General Hospital, as a nursing student it is
our duty to give care to the ill patients. We have encountered many interesting cases
that would surely enhance our knowledge and skills, and Acute Bronchitis is one of
those diseases.
Bronchitis is an acute inflammation of the air passages within the lungs. It occurs
when the trachea and the large and small bronchi within the lungs become inflamed
because of infection cause by a virus or bacteria.
A. Overview of the case
Acute bronchitis describes the inflammation of the bronchi usually
caused by a viral infection, although bacteria and chemicals also may cause
acute bronchitis.
Bronchiolitis is a term that describes inflammation of the smaller bronchi
referred to as bronchioles. In infants, this is usually caused by respiratory
syncytial viruses (RSV), and affects the small bronchi and bronchioles more than
the large. In adults, other viruses as well as some bacteria can cause
bronchiolitis and often manifest as a persistent cough at times productive of small
plugs of mucus.
Most often due to a viral infection that causes the inner lining of the
bronchial tubes to become inflamed and undergo the changes that occur with
any inflammation in the body. Common viruses include the rhinovirus, respiratory
syncytial virus (RSV), and the influenza virus.
Bronchitis may be indicated by an expectorating cough, shortness of
breath and wheezing. Occasionally chest pains, fever, and fatigue or malaise
may also occur. Symptoms of acute bronchitis usually begin 3 to 4 days after an
upper respiratory infection, such as a cold or influenza (flu), cough, mild fever,
hoarseness, general feeling of tiredness.
This care study presents a condition of medically ill patient having a diagnosis of
acute bronchitis .This case aims to achieve a better understanding of the patient’s
condition and was made for the benefit of the student conducting the study.
B. Objective of the study
Individual care study provides goals or objectives which is necessary to
serve as an instrument in comprehensively assessing the patient’s health status
and present condition. It also focuses on the following aims:
To conduct a thorough assessment of the patient in order to
formulate appropriate nursing care plan based on accurate and
complete data
To formulate nursing diagnosis, develop outcomes and plan
nursing care with specific goals for a patient with acute bronchitis.
To implement nursing care and evaluate outcomes for
effectiveness and achievement of care
Utilizing the nursing process in the management of patient’s health
condition and in giving quality nursing care.
Integrate knowledge about acute bronchitis to achieve quality of
care to the patient and understand the course and essence of the
chosen care study.
Impart health teachings about necessary information pertaining to
the disease condition.
Gain the knowledge and understanding in the Nursing profession.
C. Scope and Limitation of the study
The extent of this study includes the overall data gathered during the
interview and observation as manifested by the patient and his complaints. It also
deals with the several factors observed during the assessment within the span of
time given. The information gathered was based on the manifestations and
complaints of the patient observed and the exact answers of the patient’s support
person since the patient is only 4 year old .Interventions were rendered gradually
depending on the objective assessment of the student. The following information
only involves the exact words and answers supported by the parents.
The limitation of the study includes the place of interaction itself which was
in Polymedic General Hospital, station 6. The study was completed altogether by
both research and actual hands-on exposure and interaction with the patient
during the two (2) days clinical duty.
II. Health History
A. Profile of patient
Name: Alcantara Pierre Hendrick E.
Age: 4 years old.
Sex: Male
Birth Date: November 16, 2006
Birth place: Cagayan de Oro City
Religion: Roman Catholic
Civil Status: Single
Nationality: Filipino
Occupation: Not applicable
Address: B5 L3 Soldier Hills Subdivision Bulua Cagayan de Oro City.
Name of Father: Glen Alcantara
Occupation: Bank Employee
Name of Mother: Julie Anne Excelise
Occupation: Housewife
Date of Admission: January 3, 2010
Time of Admission: 8:05 pm
Admitting Physician: Dr. Notario
Vital Signs Assessment
Temperature: 36.5 C
Pulse rate: 102
Respiratory rate: 20
Height: 97 cm
Weight: 24 kgs.
Allergies: No known food and Drug allergies
B. Family and Personal Health History
Pierre Hendrick, it was his first time to be hospitalized because of acute.
He has not received any blood transfusion, and has no food and drug allergy.
Alcantara family resides at soldier hills subdivision Bulua Cagayan de Oro
City, and had their first baby named Pierre Hendrick. The family claims that they
have no common diseases within their family, or the so called the heridofamilial
disease. So we I ask about the common diseases that the family had acquired.
As claimed the most common diseases in their family was fever, cough, colds.
C. History of Present Illness
Four days prior to admission, Patient have productive cough, with whitish
phlegm, with mild grade fever, loss of appetite and there is shortness of
breathing. Patient is admitted at Polymedic General Hospital on January 3, 2010,
and has been diagnose with acute bronchitis
D. Chief Complaint
Alcantara Pierre Hendrick, 4 years old was admitted in Polymedic General
Hospital on January 3, 2010, 8:05 in the evening due to productive cough
and fever.
III. Developmental Data
FREUD’S PSYCHOANALYTIC THEORY
Freud termed the infant period as the oral phase because infants are so
interested in oral stimulation for pleasure during this time. According to this theory,
infants suck for enjoyment or relief of tension as well as for nourishment.
Stage Age Characteristics Nursing Implications
Infant Birth 1-1 ½ year Mouth is the center
of pleasure. Feeling
of dependence
arises and can
persist through life.
An individual who is
fixated at this stage
may have difficulty
in trusting others
and may
demonstrate nail
biting, drug abuse,
smoking,
overeating,
alcoholism,
argumentativeness
and
overdependence.
Security is the
primary need.
Major conflict:
Weaning
Provide oral
stimulation by giving
pacifiers, do not
discourage thumb
sucking.
Breastfeeding may
provide more
stimulation than
formula feeding
because it requires
the infant to expand
more energy
ERIKSON’S PSYCHOSOCIAL THEORY
According to Erikson, the developmental task for infants is learning trust
versus mistrust (other terms might be learning confidence or learning to love). Infants
whose needs are not met when these arises, whose discomforts are quickly removed,
who are cuddled, fondle, played with and talk to, come to view the world as a safe place
and people as helpful and dependable. However, when their care in inconsistent,
inadequate or rejecting, it fosters basic mistrust – infants become fearful and suspicious
of the world and of people.
Stage AgeCentral
Task
Indicators
of Positive
Resolution
Indicators of
Negative
Resolution
Developmenta
l Task
Nursing
Implication
Infancy Birth to
18
months
Trust
vs.
Mistrust
Learning
to trust
others
Mistrust,
withdrawal,
estrangement
Developmenta
l task is to
form sense of
trust. Child
learns to love
and be loved.
Provide a
primary
care
provider.
Provide
experiences
that add to
security
such as soft
sound and
touch.
Erikson envisions that life as a sequence of levels achievement. Each stage
signals a task that must achieved. The resolution of the task can be complete, partial or
unsuccessful. Erikson believes that the greater the task achievement, the healthier the
personality of the person; failure to achieve a task influences the person’s ability to
achieve the next task.
PIAGET’S COGNITIVE THEORY
Piaget refers to the infant stage as the sensorimotor stage. Sensorimotor
intelligence is practical intelligence because words and symbols for thinking and
problem solving are not yet available to the child at this stage. At the beginning of
infancy, babies relate to the world through the senses, using only reflex behavior. As
infants progress through this stage (which includes the schemes of primary and
secondary reactions and coordination of secondary reaction), they learn the basic
theory of concept that people are entities separate form their environment. piaget uses
the term “ primary” to refer to activities related to the child’s own body and “ circulatory
reaction” to demonstrate the repetition of behavior occurs ( the infant accidentally bring
his thumb to the mouth, enjoys the sensation of sucking and so repeats it.
Phase and Stage Age Significant Behavior Nursing Implication
Sensorimotor
Phase
STAGE 1: Use of
Reflex
STAGE 2:
Primary Circular
Reaction
Birth to 2 years
Birth to 1 month
1 to 4 months
Most action is
reflexive
Perception of
events is centered
on the body.
Objects are
extension of self
Stimuli are
assimilated into
beginning mental
images. Behavior
entirely reflexive.
Hand to mouth and
ear to eye
coordination
develops. Infant
spends much time
looking at objects
and separates self.
STAGE 3:
Secondary Circular
Reaction
4 to 8 months Acknowledges the
extended
environment.
Actively makes
changes in
environment.
Beginning intention
of behavior is
present (the infant
brings thumb to
mouth for a purpose
of sucking). Infants
learn to initiate,
recognize and
repeat pleasurable
experiences.
Memory traces are
present. Infant
STAGE 4:
Coordination of
Secondary
Schemata
8 – 12 months Can distinguish a
goal from a means
of attaining it.
anticipates familiar
events (a parent
coming near will
pick him up). Good
toy for this period:
mirror. Good game
and peek-a-boo.
Infant can plan
activities to attain
specific goals.
Perceives that
activities of own
body is separate
from activities of
objects. Can
search objects and
relieve it which
disappears from his
view. Recognizes
shapes and sizes of
familiar objects.
Infant experiences
separation anxiety
when primary care
giver leaves.
Able to discover
new properties of
object and events.
Capable of space
STAGE 5:
Tertiary Circular
Reaction
STAGE 6:
Invention of New
Means
12 to 18 months
18 to 24 months
Tries to discover
new goals and ways
to attain goals.
Rituals are
important
Interprets the
environment by the
mental images
perception as well
as permanence.
Good game for this
period: throw and
retrieve.
Uses memory and
imitation to act. Can
solve basic
problems, foresee
maneuvers that will
succeed or fail.
Good toys for this
period: those with
several uses such
as blocks, colored
plastic rings.
In each phase, the person uses three primary abilities: assimilation,
accommodation and adaption. Assimilation is the process which human encounters and
react to new situation by using mechanisms they already posses. Accommodation is a
process of change whereby cognitive process mature sufficiently to allow the person to
solve problems that were unsolved before. Adaptation or coping behavior is the ability to
handle the demand made by the environment.
HAVIGHURT’S DEVELOPMENTAL THEORY
Havighurst promoted the concept of developmental task in 1950’s. a
developmental task is a task which arises at or about a certain period in life of an
individual, successful achievement will lead to happiness and to succeed with later task,
while failure leads to unhappiness in the individuals, disapproval by society and difficulty
with later task.
Havighurst’s Age Periods and Developmental Task
Infancy and Early Childhood
1. Learning to walk.
2. Learning to take solid foods
3. Learning to talk.
4. Learning to control the elimination of the body waste.
5. Achieving psychologic activity.
6. Forming simple concepts of social and physical reality.
7. Learning sex differences and sexual modesty.
8. Learning to relate emotionally to parents, sibling and other people.
9. Learning to distinguish right from wrong and developing a conscience.
Havighurst’ developmental task provide a framework that the nurse can use to evaluate
a person’s general accomplishment. However, some nurses find that the broad
categories limit its usefulness as a tool in assessing specific accomplishment,
particularly those infancy and childhood.
IV. Medical Management
A. Medical Orders and Rationale
Medical Orders Rationale
January 3, 2010
8:05
Please admit pt, under the care of Dr.Notario
Secure consent to care
TPR q 4 hrs
Monitor Intake and Output q shift
RATIONALE
To closely monitor the patient
For legal purposes
To monitor patient status
Monitor fluid and electrolyte imbalance
Soft Diet: Diet as tolerated strict aspiration precaution
Laboratory Exams:- Complete Blood Count
- Radiologic Report
D5 0.3 Nacl @ 60cc/hr.
Medications:Ampicillin IVTT q 6 ANST(-)
Salbutamol (ventolin); neb q 6 hr
PRN Medications:
>Paracetamol 5 ml q 4, for fever
Tepid sponge bath
Refer accordingly
January 4, 2009
>Continue meds
IVF follow up with D5 0.3 Nacl @
The best diet of choice
For diagnostic purposes: To check for occurrence of infection in the body
Maintenance fluid therapy represents the volume of fluids and amount of electrolytes and glucose needed to replace anticipated physiological losses from breath, sweat and urine and to prevent hypoglycemia
For infections purposes
To improve ventilation and treat bronchospasm in pt.having airway obstruction.
Medication used for relieving fever and pain
. To reduces body temperature to
normal range
For further care to the patient
Diagnostic Examination
Complete Blood Count
Result Normal Values Nursing Implication
Hemoglobin 12.0 13.70 – 16.70 Risk for anemia, iron
deficiency
Hematocrit 35.1 40.5 - 49.7 vols % Anemia, folic acid
deficiency
MCH 25.4 26.10 – 33.30 Hypo chromic anemia
Neutrophils 38.9 54.0 – 62.0 Aplastic anemia, iron and
folic def.
Lymphocytes 45.8 17.4% - 48.2% Viral infection
Eosinophils 7.1 0 – 6% Parasitic infections
Radiologic Report
- pneumonia, Left lung
B. Drug Study
Name of Drug
Generic(brand)
Date
ordere
d
Classification Dose/
Frequency
route
Mechanis
m of
Action
Specific
Indication
Contraindications Side effects Nursing
precautions
Sabutamol
(ventolin)
Januar
y 3,
2010
Bronchodilator Neb q 6 hr. Relaxes
bronchial
smooth
muscle by
acting on
beta2-
adrenergic
receptors;
improves
ventilation
Bronchospa
m in
patients
with
reversible
obstructive
airway
disease
To patient’s
hypersensitive to
the drug and its
components
To patient’s
hypersensitiv
e to the drug
and its
components
Perform
chest
tapping
every after
nebulization
/ Postural
Drainage
Name of Drug
Generic(brand)
Date
ordere
d
Classification Dose/
Frequency
route
Mechanis
m of
Action
Specific
Indication
Contraindications Side effects Nursing
precautions
Paracetamol
( tempra)
Januar
y 3,
2010
Non-opioid
analgesic;antipy
retic
5 ml/P.0.q 4
hours PRN
Produces
analgesic
effect by
blocking
pain
impulses,
by inhibiting
prostaglandi
ns or pain
receptors
sensitizers;
may relieve
fever by
acting in
hypothalami
c heat
regulating
center
For mild pain
and fever
To patient’s going
long-term therapy
for chronic
noncongestive
angle-closure
glaucoma;
hyponatremia;
hypokalemia;
hepatic impairment;
adrenal gland
failure’
hypechloremic
acidosis
Confusion;
anorexia;
aplastic
anemia; rash;
renal calculi
Report signs
of F/E
imbalance
Name of Drug
Generic(brand)
Date
ordere
d
Classification Dose/
Frequency
route
Mechanis
m of
Action
Specific
Indication
Contraindications Side effects Nursing
precautions
Ampicillin
(ampilin
Januar
y 3,
2010
Penicillins 500mg IVTT q
6, ANST(-)
Inhibits cell
wall
synthesis
during
Bacterial
multiplicati
on
Respiratory
tract
infections
Contraindicated
to pt’s
hypersensitive to
drug or other
penicillins
Anxiety,
dizziness,
nausea,
vomiting, vein
irritation
Obtain
specimen
for culture
and
sensitivity
test before
giving first
dose.
V. Pathophysiology with anatomy and physiology
The respiratory system consists of all the organs involved in breathing. These
include the nose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system
does two very important things: it brings oxygen into our bodies, which we need for our
cells to live and function properly; and it helps us get rid of carbon dioxide, which is a
waste product of cellular function. The nose, pharynx, larynx, trachea and bronchi all
work like a system of pipes through which the air is funneled down into our lungs.
There, in very small air sacs called alveoli, oxygen is brought into the bloodstream and
carbon dioxide is pushed from the blood out into the air. When something goes wrong
with part of the respiratory system, such as an infection like pneumonia, it makes it
harder for us to get the oxygen we need and to get rid of the waste product carbon
dioxide. Common respiratory
symptoms include breathlessness, cough, and chest pain.
The Upper Airway and Trachea When you breathe in, air enters your body
through your nose or mouth. From there, it travels down your throat through the larynx
(or voice box) and into the trachea (or windpipe) before entering your lungs. All these
structures act to funnel fresh air down from the outside world into your body. The upper
airway is important because it must always stay open for you to be able to breathe. It
also helps to moisten and warm the air before it reaches your lungs.
The Lungs
Structure
The lungs are paired, cone-shaped organs which take up most of the space in
our chests, along with the heart. Their role is to take oxygen into the body, which we
need for our cells to live and function properly, and to help us get rid of carbon dioxide,
which is a waste product. We each have two lungs, a left lung and a right lung. These
are divided up into 'lobes', or big sections of tissue separated by 'fissures' or dividers.
The right lung has three lobes but the left lung has only two, because the heart takes up
some of the space in the left side of our chest. The lungs can also be divided up into
even smaller portions, called 'bronchopulmonary segments'.
These are pyramidal-shaped areas which are also separated from each other by
membranes. There are about 10 of them in each lung. Each segment receives its own
blood supply and air supply.
Pathophysiology
Inflammation
Increase mucous
production
VI. Nursing Assessment (System Review & Nursing Assessment II)
Environmental Pollutants,
Respiratory tract infection
Increase number of submucous glands in the large
bronchi.
Increase capillary permeability
Fluid/cellular exudation
Edema of the Mucous membrane
Hypersecretion of mucous
Persistent Cough
BRONCHITIS
Name: Alcantara Pierre Hendrick Date: January 6, 2010
Vital Signs: Pulse: 102 bpm RR: 30cpm Temp: 36.5˚ C Height: 97 cm Weight: 24 kgs
EENT:
[ ] impaired vision [ ] blind
[ ] pain [ ] reddened [ ] drainage
[ ] gums [ ] hard of hearing [ ] deaf
[ ] burning [ ] edema [ ] lesion [ ] teeth
Assess eyes, ears, nose, and throat
For abnormality [x] no problem
RESPIRATORY
[ ] asymmetric [ ] tachypnea
[ ] apnea [ ] rales [ x]cough[ ] barrel chests
[ ] bradypnea [ ] shallow [ ] rhonchi
[x ] sputum [ ] diminished [ x]dyspnea
[ ] orthopenea [ ] labored [ ]wheezing
[X] pain [ ] cyanotic
Assess resp.rate, rhythm, depth, pattern
Breath sounds, comfort [ ] no problem
CARDIOVASCULAR
[ ] arrhythmia [ ] tachycardia [ ] numbness
[ ] diminished pulses [ ] edema [ ] fatigue
[ ] irregular [ ] bradycardia [ ] murmur
[ ] tingling [ ] absent pulses [ ] pain
Assess heart sounds, rate, rhythm, pulse,
circulation, fluid retention, comfort [ ] no
Productive cough, pain
restlesness
dyspnea
GASTRO INTESTINAL TRACT
[ ] obese [ ] distention [ ] mass
[ ] dysphagia [ ] rigidity [ ] pain
Assess abdomen, bowel habits, swallowing,
Bowel sound, comfort [ } no problem
Gyn-bleeding, discharge [x] no problem
NEURO
[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures
[ ] lethartic [ ] comatose [ ] vertigo [ ] tremors
[ ] confused [ ] vision [ ] grip
Assess motor function, sensation, LOC, strength,
Grip, gait, coordination, orientation, speech [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 [ ] eccymosis [ ] diaphoretic [ ] moist
Assess mobility, motion, galt, alignment, joint function/
Skin color, texture, turgor, integrity [ ] no problem
Nursing Assessment II
SUBJECTIVE OBJECTIVE
Communication:
[ ] hearing loss [ ] visual changes
[ ]denied
Comments: “wala may problema sa panan aw sa akong anak “as verbalized by the mother.
[ ] glasses [ ] language
[ ] contact lens [ ] hearing aide
R L
Pupil size : 2mm
Reaction: Pupil equally round reactive to light and accommodation.
Oxygenation:
[ x ] dyspnea [ ] smoking history [ x ] cough [ x ] sputum [ ] denied
Comments: pg mag ubo siya nay plema “as verbalized by the mother.
Respiratory [ ] regular [ x ] irregular
Describe: Patient has irregular breathing pattern
R: Normal symmetrical breathing
L: Abnormal symmetrical breathing
Circulation:
[ ] chest pain [ ] leg pain
[ ] numbness of extremities
[ ] denied
Comments: mag sakit iya dughan pg mag ubo siya“ verbalized by the mother.
Heart Rhythm [x] regular [ ]irregular
Ankle Edema: none
Pulse Car. Rad. DP. Fem.*
R :+ 102 + _+
L :+ 102 + + +
Comments: Pulse palpable at respective sites
Nutrition:
Diet: soft diet
Character: [x ] recent change in weight,
appetite
[ ] swallowing difficulty [ ] denied
Comments: “dili siya ganahan ug kaon ”as
[ ] dentures [x] none
Full Partial With Patient
Upper [ ] [ ] [ ]
Lower [ ] [ ] [ ]
verbalized by the mother.
Elimination:
Usual bowel pattern Urinary frequency
Once a day 5 times a day
constipation remedy [ ] urgency
[ ] dysuria
Date of last BM [ ] hematuria
.January 5, 2010 [ ] incontinence
Diarrhea character: [ ] polyuria
[ ] foley in place
[x] denied
Bowel sounds: Normo Active
Abdominal Distention
Present [ ] yes [ ] no
Urine* (color, consistency, odor)
*if they are in place
Comments: patient is able to defecate and urinate.
Management of Health and Illness:
[ ] alcohol [ x] denied
(amount, frequency)
[ ] SBE Last Pap Smear: N/A
LMP: N/A
Briefly describe the patient’s ability to follow treatments (diet, meds, etc.) for chronic health problems (if present)..
SUBJECTIVE OBJECTIVE
Skin Integrity:
[ ] dry [ ] itching [ x ] denied
Comments: No verbal cues
[ ] dry [ ] cold [ ] pale [ x ] flushed
[ x ] warm [ ] cyanotic
*rashes,ulcers, decubitus (describe size, location, drainage) patient has no
rashes in upper and lower extremities.
Activity/ Safety:
[ ] convulsion [ ] dizziness
[ ] limited motion of joints
Limitation inability to:
[ ] ambulate [ ] bathe self
[ ] other [x] denied
LOC and orientation:
Patient is conscious.
Gait: [ ] walker [ ] cane [ ] other
[x ] steady [ ] unsteady
[ ]sensory and motor losses in face or extremities: none
[ ]ROM limitations: Patient range of motion is limited.
Comfort/ Sleep/ Awake
[ ] pain (location, frequency, remedies)
[] nocturia [ ] sleep difficulties [x] denied
Comments: “Makatulog man siya permente usahay makamata pg mag sige ug ubo” as verbalized by mother.
[ ] facial grimaces
[ ] guarding
[ ] other signs of pain: none
[ ] siderail release form signed ( 60 + years ) N/A
Coping:
Occupation (mother): Housewife
Members of household: Mr. & Mrs. Glen Alcantara
Most supportive person: Mr. Glen Alcantara
Observed non- verbal behavior:
none
The person and his phone number that can be reached any time: Not given
VII. Nursing Management
A. Ideal Nursing Intervention(NCP)
Ineffective Airway Clearance RT to secretions in the bronchi
Interventions Rationale
Independent:
1. Monitor ABG results
2. Assess respiratory status,
including vital signs, breath
sounds and skin color at least q
2h
3. Place in high-Fowler’s position
4. increase fluid intake appropriate
for age; offer warm rather than
clods, fluids.
5. Suction as indicated
- Blood gas changes may reveal
impaired gas exchange
-
- Early identification of respiratory
compromise allows intervention
before tissue hypoxia is significant.
-
- Lowers diaphragm, promoting chest
expansion, aeration of the lungs
segments, mobilization and
expectoration of the secretions
- fluid intake helps to liquefy
secretions
- Mechanically clear airway in patient
who is unable to do so because of
ineffective cough.
Dependent:
1. Administer prescribed
medications as ordered
(bronchodilators)
- To help maintain open airway,
relax bronchial smooth muscle
2. Salbutamol
Acute pain related to localized inflammation and persistent cough
Interventions Rationale
Independent:
1. Elevate head of the bed, change position frequently
2. Assist patient with deep breathing exercises
3. help patient learn to perform activity like effective coughing while upright position.
4. Increase fluids as tolerateeed and offer warm, rather than cold fluids (if not contraindicated)
- Lowers diaphragm, promoting chest expansion and expectoration of secretions
- Deep breathing facilitates maximum expansion of the lungs
- Coughing is a natural self cleaning mechanism. an upright position favors deeper, more forceful cough effort.
- Fluids especially warm liquid said in mobilization and expectoration of secretions
Activity intolerance RT inadequate oxygenation and dyspnea
Interventions Rationale
Independent:
1. Assess activity tolerance, noting
any increase in pulse,
respirations, dyspnea.
2. Schedule activities, planning for
rest periods
3. Perform active or passive ROM
4. Assist the family to minimize
stress and anxiety levels
5. Teach how to do deep breathing
exercises.
- The assessment findings may
indicate limited or impaired
activity tolerance
- Rest periods minimizes fatigue
and improves activity tolerance
- Exercise help maintain muscle
tone and joint mobility
- Stress and anxiety increases
metabolic demands and can
increase activity tolerance
- Promotes complete expansion of
the lungs.
B. Actual Nursing Management (SOAPIE)
S “mag sakit iya dughan pg mg sige na siya ubo” as verbalized by the mother.
O Dyspnea
Productive cough with whitish phlegm
A Ineffective airway clearance RT excessive secretions and ineffective coughing
P Long term: At the end of 2 days of care, client will verbalize clear airway
Short term: At the end of 30 minutes nursing intervention, the patient will improved airway
clearance, as evidenced by effective coughing techniques.
I Independent:
1. Elevate Head of the bed, change position frequently, promoting chest expansion,
expectoration of the secretions
2. Taught the watcher to maintain adequate hydration by increasing fluid intake, to thin
secretions.
3. Teach the patient to do deep breathing and coughing exercise, to mobilize the secretions
Dependent:
1. Given bronchodilators (Salbutamol) as ordered, to relax bronchial smooth
muscles thus facilitating airflow.
E After 30 minutes, the client’s is able to expectorate secretions.
S ” Gasakit iyang tutunlan pg mg ubo.” as varbalized by the mother.
O Sleep disturbance
crying
restlessness
A Acute pain to localized inflammation and persistent cough
P Long term: At the end of 2 days nursing care, the patient will be able to relieve pain.
Short term: At the end of 8 hours of nursing intervention, patientwill airway clearance.
I Independent:
1. Instructed the patient to elevate the bed, change position frequently, Lowersdiaphragm, promotingchest expansion and expectoration of secretions
2. Assisted the patient in deep breathing exercise, Deep breathing facilitates maximum expansion of the lungs.
3. Provided quite environment to the patient, in order to relax, during the symptoms occurs
Dependent:
1. Provided nutritional support: IV fluids
E After 8 hoursof nursinginterventions, the goal was partially met, the patient has improve his airway clearance and absence of dyspnea.
VIII. Referrals and Follow – up
HEALTH TEACHINGS
MEDICATIONS Explain to the parents of the patient each medication
prescribed.
Explain proper administration of medication according to its
route together with the knowledge about potential side effects
EXERCISE Encourage patient to avoid excessive stress and have
adequate rest and sleep.
Encourage to do deep breathing exercises.
TREATMENT The patient instructed to follow in taking the prescribed home
medication on time as ordered.
Instruct the parents to observe proper food presentations.
OUT-PATIENT
(Check-Up)
Emphasize importance of keeping schedule appointments with
health care providers 1 week after discharge especially when
there are noticeable changes in the condition and refer to Dr.
Notario.
DIET Encourage to eat nutritious food such as vegetable and fruits
Advice the parents of the patient to monitor fluid intake or
adequate hydration, to help her body re-hydrate to prevent
fluid imbalance.
Advice to have proper nutrition to enhance immune.
IX. Evaluation and Implications
Being expose to the hospital ward and implement nursing care to those ill
patients. There are many cases I have had encountered during the duty one of which is
the acute bronchitis. Sense we are all future health care providers; somehow I was able
to identify nursing diagnosis and implement possible effective nursing care.
This study will serve as a reference material in rendering competent care to my
client especially those with similar situation. Through this, I will be able to develop my
knowledge as well as my skills and attitudes in applying the prescribed procedure to
improve the health status of the patient.
This study will act as a baseline as well as a guide for a good, accurate and
comprehensive research paper dealing with issues commonly experienced by patient in
the hospital setting. This may aid the researchers to widen the scope of the study in
relation to more or less similar cases.
X. Bibliography
Smeltzer, Suzanne. Medical-Surgical Nursing, 11 th edition
Barbara Kozier; “Fundamentals of Nursing” 7th edition.
Lippincott Williams and Wilkins A guide to Medical-Surgical Nursing
Webliography
http://www.mayoclinic.com/health/bronchitis/DS00031/DSECTION=1,
RP, Fowler AA (2006). "Clinical practice. Acute bronchitis". N. Engl. J. Med
www.wikipedia.org/bronchitis
www.google.com
LICEO DE CAGAYAN UNIVERSITYRodolfo N. Pelaez Blvd. Kauswagan, Cagayan de Oro City
COLLEGE OF NURSING
NCM501202
A Care Study
Alcantara Pierre Hendrick E.
Submitted to:
Mr. Dante Diadola RN
As Partial Requirment for NCM501202
Submitted by:
Ardon, Lester C.
TABLE OF CONTENTS
I. Introduction
a. Overview of the case
b. Objective of the study
c. Scope and Limitation of the study
II. Health History
a. Profile of patient
b. Family and Personal Health history
c. Chief Complaint & History of Present Illness
III. Developmental Data
IV. Medical Management
a. Medical Orders and Rationale
b. Laboratory Results
c. Drug Study
V. Pathophysiology with Anatomy and Physiology
VI. Nursing Assessment (System Review & Nursing Assessment II)
VII. Nursing Management
a. Ideal Nursing Management (NCP)
b. Actual Nursing Management (SOAPIE)
VIII. Referrals and Follow-up
IX. Evaluation and Implications
X. Bibliography
Rating Scale
A. WRITTEN WEIGHT RATINGI. Introduction 5 a. Overview of the case b. Objective of the study c. Scope and Limitations of the studyII. Health History 5 a. Profile of patient b. Family and personal history c. Chief complaintIII. Developmental Data 5IV. Medical Management 20
(10)(10)
a. Medical Orders and Rationale b. Drug studyV. Pathophysiology with anatomy & physiology 10VI. Nursing Assessment ( system review & Nsg. Assessment
10
VII. Nursing Management 30(10)(20)
a. Ideal Nursing Management .(NCP) b. Actual Nursing Management. (SOAPIE)
VIII. Referrals and Follow-up 5IX. Evaluation and Implications 5X.Documentation 5 a. Documentation of evidence of care for 1 week rotation b. Organization/ Grammar/ Bibliography
Total Score 100 Equivalent grade