Upload
toyi14
View
213
Download
0
Embed Size (px)
Citation preview
8/14/2019 TABLE of CONTENTS I. Introduction a. Overview
1/23
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 PhysiologyVI. 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
8/14/2019 TABLE of CONTENTS I. Introduction a. Overview
2/23
INTRODUCTION
a. Overview of the Study
This is the case of 24 year old male machine operator who diagnosed withCommunity Acquired pneumonia.
Pneumonia is an inflammation or infection of the lungs most commonly caused
by a bacteria or virus. Pneumonia can also be caused by inhaling vomit or other
foreign substances. In all cases, the lungs' air sacs fill with pus , mucous, and
other liquids and cannot function properly. This means oxygen cannot reach the
blood and the cells of the body.
Most pneumonia is caused by bacterial infections.The most common infectious
cause of pneumonia in the United States is the bacteria Streptococcus
pneumoniae. Bacterial pneumonia can attack anyone. The most common cause
of bacterial pneumonia in adults is a bacterium called Streptococcus pneumoniae
or Pneumococcus. Pneumococcal pneumonia occurs only in the lobar form.
An increasing number of viruses are being identified as the cause of respiratory
infection. Half of all pneumonias are believed to be of viral origin. Most viral
pneumonias are patchy and the body usually fights them off without help from
medications or other treatments.
Pneumococcus can affect more than the lungs. The bacteria can also cause
serious infections of the covering of the brain (meningitis), the bloodstream, and
other parts of the body.
Community-acquired pneumonia develops in people with limited or no contact
with medical institutions or settings. The most commonly identified pathogens are
Streptococcus pneumoniae, Haemophilus influenzae, and atypical organisms
(ie, Chlamydia pneumoniae,Mycoplasma pneumoniae, Legionella sp). Symptoms
and signs are fever, cough, pleuritic chest pain, dyspnea, tachypnea, and
8/14/2019 TABLE of CONTENTS I. Introduction a. Overview
3/23
tachycardia. Diagnosis is based on clinical presentation and chest x-ray.
Treatment is with empirically chosen antibiotics. Prognosis is excellent for
relatively young or healthy patients, but much pneumonia, especially when
caused by S. pneumoniae or influenza virus, are fatal in older, sicker patients.
b. Objective of the Study
This study aims to:
Conduct and evaluate an assessment for the client
Determine the causes, predisposing and precipitating factors that
constitute the onset of the disease process.
Render series of nursing interventions for the clients care
Provide and disseminate important information as teachings to the client
and the significant others to boost the knowing and understanding of the
nature of the said health condition.
Improve skills and knowledge as health care providers in the clinical area.
c. Scope and Limitation of the Study
This study includes the collection of information specifically to the patients
health condition. The study also includes the assessment of the physiological
and psychological status, adequacy of support systems and care given by the
family as well as other health care providers.
8/14/2019 TABLE of CONTENTS I. Introduction a. Overview
4/23
II. Patients Profile
Clients Name: Madredano Chandlier Paclicjan
Age: 24
Birthdate: February 2 1985
Address: Zone 5 Sili-Sili Pagatpat CDO
Civil Status: Single
Sex: Male
Nationality: Filipino
Religion: Roman Catholic
Weight: 55kg
Informant: Self
Date of admission: January 18 2010
Time of admission: 03:31 PM
Chief complaint: Fever
Admitting diagnosis: Community acquired pneumonia
Attending physician: Dr. Patriana
8/14/2019 TABLE of CONTENTS I. Introduction a. Overview
5/23
DEVELOPMENTAL DATA
Erikson's stages of psychosocial development
Love: Intimacy vs. Isolation (Young Adults, 20 to 34 years)
Main Question: "Am I loved and wanted?" or "Shall I share my life with
someone or live alone?"
Ego quality: Love
Related Elements in Society: patterns of cooperation (often marriage)
Body and ego must be masters of organ modes and of the other nuclear conflicts
in order to face the fear of ego loss in situations that call for self-abandonment.
Avoiding these experiences leads to openness and self-absorption
The Intimacy vs. Isolation conflict is emphasized around the ages of 20 to 34. At
the start of this stage, identity vs. role confusion is coming to an end, and it still
lingers at the foundation of the stage (Erikson, 1950).
Based on Eriksons stages of psychosocial development my patient is in
young adults stage from 20 to 34 years old which he can established his
identities, he is ready to make long-term commitments to others. He becomes
capable of forming intimate, reciprocal relationships. and willingly make the
sacrifices and compromises that such relationships require
8/14/2019 TABLE of CONTENTS I. Introduction a. Overview
6/23
Developmental Task of Robert Havighurst
Selecting a mate. * Learning to live with a partner. * Starting family. * Rearingchildren. * Managing home. * Getting started in occupation. * Taking on civic
responsibility. * Finding a congenial social group.
Based on Havighurst developmental theory my patient can manage on his own
he can get and start an occupation and have a family on his own and take a
responsibility if his children.
Developmental Task of Sigmund Freud
The person must learn how to form intimate relationships, both in friendship and
love. The development of this skill relies on the resolution of other stages. It may
be hard to establish intimacy if one has not developed trust or a sense of identity.
If this skill is not learned the alternative is alienation, isolation, a fear of
commitment, and the inability to depend on others.
Based on Freuds developmental task my patient cannot support on his own or
he needs support of his family. He learn how to form an intimate relationship with
others both friendship and love.
Developmental Task of Jean Piaget
Formal operational (11 years and up)
Can think logically about abstract propositions and test hypotheses systemtically
Based on Piagets developmental task my patient becomes concerned with the
hypothetical, the future, and ideological problems
8/14/2019 TABLE of CONTENTS I. Introduction a. Overview
7/23
IV. HEALTH HISTORY
a. Family Health History
According to my patient regarding his father has a history ofhypertension. On the other hand his Grandfather on his Mother side
have diabetes mellitus. His younger sister has fever last month
(December) which is treated by over the counter drugs
b. Past Health History
My patient claimed that he experience cough, colds and fever this
last year which usually lasted for 3-4 days. Over the counter medicinessuch Paracetamol and Salbutamol.. He claimed also that he never
experience major illness that required hospitalization until this January
18, 2010 where he has been admitted at Maria Reyna Hospital with a
diagnosis of Community acquired pneumonia. He claimed that he
does not have known allergies to drugs and foods nor received a blood
transfusion this past year.
c. History of Present Illness
A case of Madredano Chandlier Paclicjan, 24 years old , Filipino, a
Resident of Zone 5 Sili-Sili Pagatpat Cagayan de Oro City,Admitted for
the first time at Maria Reyna Hospital with a chief complaint of Fever
and cough 4 days prior to admission
8/14/2019 TABLE of CONTENTS I. Introduction a. Overview
8/23
V. Nursing Assessment (System Review & Nursing Assessment II)
Name: Madredano, Chandlier Paclicjan Date: 01-18-10
Temp: 37.9C PR: 79bpm BP: 120/70 Height 59 Weight:55 kgs RR:26cpm
INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space
provided. Indicate the location of the problem in the figure using [X].
EENT:
[ ] impaired vision [ ] blind[ ] pain [ ] reddened [ ] drainage[ ] gums [ ] hard of hearing [ ] deaf[ ] burning [ ] edema [ ] lesion [ ] teethAssess eyes, ears, nose, and throatFor abnormality [x] no problemRESPIRATORY[ ] asymmetric [ ] tachypnea[ ] apnea [ ] rales [ x]cough[ ] barrel chests[ ] bradypnea [ ] shallow [ ] rhonchi[x ] sputum [ ] diminished [ x]dyspnea
[ ] orthopenea [ ] labored [ ] wheezing[ ] pain [ ] cyanoticAssess resp.rate, rhythm, depth, and patternBreath sounds, comfort [ ] no problemCARDIOVASCULAR[ ] arrhythmia [ ] tachycardia [ ] numbness[ ] diminished pulses [ ] edema [ ] fatigue[ ] irregular [ ] bradycardia [ ] murmur[ ] tingling [ ] absent pulses [ ] painAssess heart sounds, rate, rhythm, pulse,Circulation, fluid retention, comfort [ ] no
GASTRO INTESTINAL TRACT[ ] obese [ ] distention [ ] mass[ ] dysphagia [ ] rigidity [ ] painAssess abdomen, bowel habits, swallowing,Bowel sound, comfort [ } no problemGyn-bleeding, discharge [x] no problemNEURO[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures
Pale eyes and lipsProductive cough,
restlesness
dyspnea
Generalizedweakness
8/14/2019 TABLE of CONTENTS I. Introduction a. Overview
9/23
[ ] lethartic [ ] comatose [ ] vertigo [ ] tremors[ ] confused [ ] vision [ ] gripAssess motor function, sensation, LOC, strength,Grip, gait, coordination, orientation, speech [x] no problemMUSCULOSKELETAL and SKIN
[ ] appliance [ ] stiffness [ ] itching [ ] petechiae[ ] hot [ ] drainage [ ] prosthesis [ ] swelling[ ] lesion [ ] poor turgor [ ] cool [ ] deformity[] wound [ ] rash [ ] skin color [ ] flushed[ ] atrophy [ ] pain [ ] eccymosis [ ] diaphoretic [ ] moistAssess mobility, motion, galt, alignment, joint function/Skin color, texture, turgor, integrity [ ] no problem
8/14/2019 TABLE of CONTENTS I. Introduction a. Overview
10/23
VI. Pathophysiology with Anatomy & Physiology
Anatomy & Physiology
The Lungs
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.
Air enters your lungs through a system of pipes called the bronchi. These pipes
start from the bottom of the trachea as the left and right bronchi and branch many
times throughout the lungs, until they eventually form little thin-walled air sacs or
bubbles, known as the alveoli. The alveoli are where the important work of gas
exchange takes place between the air and your blood. Covering each alveolus isa whole network of little blood vessel called capillaries, which are very small
branches of the pulmonary arteries. It is important that the air in the alveoli and
the blood in the capillaries are very close together, so that oxygen and carbon
dioxide can move (or diffuse) between them. So, when you breathe in, air comes
down the trachea and through the bronchi into the alveoli. This fresh air has lots
http://www.virtualmedicalcentre.com/glossary.asp?centre=&termid=645http://www.virtualmedicalcentre.com/glossary.asp?centre=&termid=669http://www.virtualmedicalcentre.com/glossary.asp?centre=&termid=474http://www.virtualmedicalcentre.com/glossary.asp?centre=&termid=668http://www.virtualmedicalcentre.com/glossary.asp?centre=&termid=645http://www.virtualmedicalcentre.com/glossary.asp?centre=&termid=669http://www.virtualmedicalcentre.com/glossary.asp?centre=&termid=474http://www.virtualmedicalcentre.com/glossary.asp?centre=&termid=6688/14/2019 TABLE of CONTENTS I. Introduction a. Overview
11/23
of oxygen in it, and some of this oxygen will travel across the walls of the alveoli
into your bloodstream. Travelling in the opposite direction is carbon dioxide,
which crosses from the blood in the capillaries into the air in the alveoli and is
then breathed out. In this way, you bring in to your body the oxygen that you
need to live, and get rid of the waste product carbon dioxide.
8/14/2019 TABLE of CONTENTS I. Introduction a. Overview
12/23
Medical Orders and Rationale
Unfortunately, I was not able to obtain the actual Doctors orders and the time
it was ordered due to lack of information that will make a case study out of our
assigned patients. But the doctors order that will be reflected here is based only
on my recollection on what has been ordered.
Date Doctors Orders Rationale
01/20/10 Dr. Patriana
Pls. monitor vital signs every 4
hours(BP,HR,RR,temp)
Diet: DAT
Run IVF at the hand with 4th D5NSS
at 30 gtts/min.
Continue meds: pls. follow timely
regimens
Meds: Fluimucil 600 mg qid
Azithromycin
To monitor patients
health status
For fluid electrolytecorrection. And for
fluid
supplementation.
In order that the
meds will be taken
and carried on time.
To help liquefy
mucus secretion
To lessen lower and
upper respiratory
8/14/2019 TABLE of CONTENTS I. Introduction a. Overview
13/23
01/21/10
(zithromax) 75cc qid
CBC
NPO
Ultrasound
tract infection.
To know the total of
all blood component
To avoid alteration of
ultrasound result
To check cor any
abnormalities
B. LABORATORY RESULT
CBC
RBC 9.8 X10^g/L
WBC 9.81 X10^g/L
8/14/2019 TABLE of CONTENTS I. Introduction a. Overview
14/23
HEMOGLOBIN 14.3 g/L
HEMATOCRIT 43.0 %
MCU 89.4 fL
MCH 29.7 Pg
MCHC 33.3 g/dl
PLATESLETS 268 X10^g/L
UA
COLOR YELLOW
TRANSPARENCY CLEAR
SPECIFIC GRAVITY 1.005
PH 7.0
SUGAR NEG
PROTIEN NEG
ULTRASOUND 01/21/10
GALLBLADDER IS OF NORMAL SIZE.
8/14/2019 TABLE of CONTENTS I. Introduction a. Overview
15/23
FLUID SERUM
GLUCOSE HI 113
ALT HI 115
GRAM STAINING.
GRAM ( - ) RODS = OCCASIONAL
GRAM ( - ) COCCI IN PAIRS = FEW
GRAM ( - ) COCCI IN CLUSTER = FEW
c. Drug study
8/14/2019 TABLE of CONTENTS I. Introduction a. Overview
16/23
DRUG NAME
FLUIMUCILDOSE/FREQUENCY/ROUTE
600mg 1 tab qidCLASSIFICATION
mucolyticMECHANISM OF ACTION
Decreases viscosity of pulmonary secretions by breaking disulfide links of
mucoproteins.SPECIFIC INDICATION
Acute & Chronic resp tract affection with abundant mucus secretionsCONTRAINDICATION
Effervescent tab/SachetPhenylketonurics.SIDE EFFECTS
changes in taste, drowsiness, mouth sores, nausea, vomiting, runny noseNURSING PRECAUTION
Use in caution in patient 60 yrs old. Patient with high blood pressure, ischemic
heart disease.
DRUG NAME
zithromaxDOSE/FREQUENCY/ROUTE
500mg 1tab qidCLASSIFICATION
antibioticMECHANISM OF ACTION
Decreases viscosity of pulmonary secretions by breaking disulfide links of
mucoproteins.SPECIFIC INDICATION
Upper and lower resp tract infection, skin and soft tissue infection .CONTRAINDICATION
Hypersensitivity to macrolidesSIDE EFFECTS
diarrhea/loose stools, nausea and abdominal pain being the most frequently
reportedNURSING PRECAUTION
If you have any of these conditions, you may need a dose adjustment or special
tests to safely use Zithromax:
liver disease, kidney disease; myasthenia gravis; a heart rhythm disorder; or a
history of Long QT syndrome.
8/14/2019 TABLE of CONTENTS I. Introduction a. Overview
17/23
8/14/2019 TABLE of CONTENTS I. Introduction a. Overview
18/23
S
sa wala pako na admit cige nako og ubo-ubo. As verbalized by the
patient
O
Non productive Cough
Yellow color Sputum
Restlessness
A
Ineffective Airway Clearance related to mucus secretion secondary to
cough
P
Long Term: After 1 day of intervention, patient will Demonstrate a
decrease in physiologic sign of intolerance
Short Term: After 1-2 hours of intervention, patient will report
measurable increase in activity tolerance
I
1.) Instructed to increases fluid intake.
2.)Monitored pulse rate and respiration rate
3.) Position Pt. in a 45 degree angle in comfortable position.
4.) Performed chest tapping.
E
At the end of 8 hours the client was able to improved proper ventilation
and participated actions to maximize oxygenation.
8/14/2019 TABLE of CONTENTS I. Introduction a. Overview
19/23
S
gehelantan ko 4 days before ko ge admit. As verbalized by the
patient
O
Generalized weakness
Pale eyes and lips
Limited motion
Temp:38.3 C
A
Hyperthermia related to increase metabolic rate secondary to illness
P
Long Term: At the end of 30 mins patient temperature will be down to
normal range.
Short Term: After 3-4 hours of intervention, patient body temperature
will decreases within normal ranges.
I
1.) Performed Tepid sponge bath
2.) Monitored body temperature
3.) Increased fluid intake.
8/14/2019 TABLE of CONTENTS I. Introduction a. Overview
20/23
E
At the end of 1 hour the client body temperatures decrease within
range of 37.6 C.
S
kapoy man ag lihok-lihok as vervalized by the pt.
O
Generalized weakness
Pale eyes and lips
Limited motion
A
Activity Intolerance related to generalized weakness secondary to
presence of circulatory/ respiratory problems.
P
Long Term: At the end of 30 mins, patient temperature will be down to
normal range.
Short Term: After 3-4 hours of intervention, patient body temperature
will decreases within normal ranges.
8/14/2019 TABLE of CONTENTS I. Introduction a. Overview
21/23
I
1.) Instructed to provide adequate rest
2.) Monitored vital sign
3.) Administered medication as prescribe.
E
At the end of 1 hour the client body temperatures decrease within
range of 37.6 C.
IX. Referrals and Follow-up
Our further Inpatient care includes monitoring of changes in vital signs,
assessment of effectiveness of treatment regimen, reinforcement of dietary
advice(At par with age regular diet), and the advice regarding the importance of
adequate bed rest.
Our further Outpatient care includes instructions to Mr.Chandlier the
compliance with treatment regimen, and reporting any side effect or adverse
effects of medications to his physician. The patient was also instructed to have a
regular check-up at MRH Hospital in order to monitor the current condition. HE
can also visit nearest health centers
X. Evaluation and Implications
8/14/2019 TABLE of CONTENTS I. Introduction a. Overview
22/23
This Care Study enabled me to further my learning associated with
disease condition of the patient. From it, I have gained knowledge in the
progression of the disease and the reaction of the body to maintain homeostasis
and how it eventually causes harm.
The Care Study improved my understanding and skills in the
management of the patient through the experiences Ive had in implementary my
care. It also enhanced my confidence in intervening because of the input gained
from my research.
Within the span of 2 day of rendering care to Mr. Madredano Chandlier. I
was able to identify potential problems and specific nursing interventions were
provided. With the help of health teachings and other interventions, Mr.
Madredano were able to learn how to recognize signs and symptoms and other
risk factors of his condition. Mr. Madredano was able to verbalized the
importance of his medications. He also recognized the importance of compliance
to his treatment regimen in order to manage his condition.
XI. BIBLIOGRAPHY:
o Luckman and Sorensen, Medical-Surgical Nursing. 3rd Edition W.B.
Saunders Company (1987)
o Kozier, B, et al Fundamentals of Nursing. 7th Edition Pearson Education
South Asia PTE LTD Philippines 2004
o Smeltzer, Medical-Surgical Nursing. 11th edition, Lippincott William &
Wilkins, 2007
o The Lippincott Manual of Nursing Practice. Sixth Edition. Manila . Merriam
& Webster Bookstore, Inc. 1996.
o
8/14/2019 TABLE of CONTENTS I. Introduction a. Overview
23/23
o Mosby, Mosbys Nursing Drug Reference, Elesevier Mosby, 2005
o Doengoes, Nurses Pocket Guide. 9th edition, F.A. Davis, 2004
o www.wikipedia.org
o www.mims.com
http://www.wikipedia.org/http://www.mims.com/http://www.wikipedia.org/http://www.mims.com/