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CAPITOL UNIVERSITYCollege of Nursing

A Case Study

Presented

In Partial Fulfillment of the

Requirement for the Subject

Related Learning Experience 9

By:

Lumbay, Jane FrancesMadroo, Froilan MarieMaglangit, Anthony

Melecio, Lloyd BryanMerina, Jo Ann

Monteroyo, JosephMonteroyo, Marelou

Montes, Jerico ClodualdoNacua, Lovely

Naduma, Mark JamesonNavaro, ChristineNazareno, Maricel

Submitted to:Ms. Syvel Jane Mata -Caharian , RN

Clinical Instructor

July 15, 2010

Introduction
http://www.facebook.com/profile.php?id=1820820179http://www.facebook.com/profile.php?id=1820820179


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COMMUNITY ACQUIRED PNEUMONIA

Pneumonia is an infection of the lung parenchyma, usually caused by infection.

Bacteria, viruses, fungi or parasites can cause pneumonia. Community-acquired

pneumonia refers to pneumonia acquired outside of hospitals or extended-carefacilities. It can range in seriousness from mild to life-threatening. Pneumonia often is a

complication of another condition, such as the flu. Antibiotics can treat most common

forms of bacterial pneumonias, but antibiotic-resistant strains are a growing problem.

The best approach is to try to prevent infection Pneumonia is a particular concern if

youre older than 65 or have a chronic illness or impaired immune system. It can also

occur in young, healthy people.

Community acquired pneumonia continuous to be a common and serious illness

both in developed and developing countries in spite of the advent of new and

sophisticated diagnostic techniques, potent antimicrobials and effective vaccines. It

remains an important cause of morbidity and mortality for both non-hospitalized adults.

In the Philippines, it is the fourth leading cause of morbidity and the second leading

cause of death. AMONG other diseases, pneumonia reportedly ranked first in the Top

10 causes of death in 80 barangays of Cagayan de Oro, based on the 2009 records of

the City Health Office.

One important aspect in the management of community acquired pneumonia is

the decision to hospitalize a patient. It perhaps the single most important decision

during the entire course of the illness. However, in patient care does not only entail

extra cost, but also, it theoretically increases the risk of iatrogenic complications

associated with hospitalization.

The group chose this case because of its complexity, in order to identify

and determine the general health problems and needs of the patient. Since the group

was able to render 3 days of care over the span of two weeks from June 2, 2010 twodays prior to clients admission at Capitol University Medical City until July 10, 2010; the

group was able to monitor and participate actively in the management of the disease

process.

As nurses our main goal is health promotion and maintenance by preventative

measures through health education. As student nurses we can contribute to the field of

nursing by empowering our fellow students with knowledge on how to manage a case

like pneumonia. By sharing our knowledge we hope to help improve the quality of

nursing care rendered by Capitolians that will bring pride to our university.

The following are the specific objectives of this study:

To raise the level of awareness of the patient and the family regarding the health

problems that are present.


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To provide information about pneumonia specifically the disease process and the

identification of its danger manifestation.

To motivate the patient and family to continue the health care provided by the

health workers in Capitol University Medical Center and most especially by the

students and Clinical Instructor of Capitol University.

And lastly, to help the lower year level in the nursing department to be more

knowledgeable in making and conducting a case presentation in the higher

years.

This case presentation would also try to develop the critical analysis of each case

presenter in order to come up with a very good output and a team effort.

NURSING THEORY

This case presentation is based on Florence Nightingales

Environmental Theory. We have chosen this theory as our guide in caring for our patient

with CAP because as what we have noticed environmental factors have a big impact

with the cause and the possible prevention of the said disease condition. Nightingales

theory focuses on changing and manipulating the environment in order to

put the patient in the best possible conditions for nature to act. She has

also Identified 5 environmental factors namely fresh air, pure water,

efficient drainage, cleanliness/sanitation and light/direct sunlight. And she considered a

clean, well-ventilated, quiet environment is very essential for recovery. Applying this

theory to care of our patient will be much helpful in a way that patient will be free of the

risk and avoid things that could worsen his situation.

The factors that Florence Nightingale emphasized should come together in order

for the care to be effective, deficiencies in these 5 factors produce illness or lack of

health. That is where the family members and significant others come into participate in

providing this type of care for the patient to help her improve her condition and be free

of the symptoms of CAP.

CLIENTS PROFILE

Patient X is a 79-year-old female, married and presently residing at Valencia,

Bukidnon. She was baptized under Roman Catholic faith.

Patient X was diabetic. She had history of hypertension and diabetes, no known

food and drug allergies, non-asthmatic, non-smoker and non-alcoholic beverage

drinker. The patient had a family history of hypertension from his both parents.


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A. Vital Signs

Upon assessment, the following data was obtained from the Patient X: Blood

pressure= 130/80 mmHg; Axillary temperature= 39.7oC; Pulse rate = 100 beats per

minute; Respiratory rate= 34 cycles per minute.

B. Chief Complaints

The patient had cough and cold.

C. Health- Illness History

Three hours prior to admission patient developed increased sleeping time

and snoring-vomiting. Patient X is positive for diabetes mellitus, had a fever, had a

yellow sputum, and positive for hypertension.

D. Previous Hospitalization/Surgeries

E. Things done to manage health

Patient was kept watched and monitored. She frequently consults their

barangay health center workers. She had her maintenance drugs as prescribed by herphysician.

F. Statement of Patient General Appearance

Patient X had a senile skin turgor with fair and some white thin spots which were

evenly distributed. Nail beds were pallor, short and in convex curvature shape.

G. Nutritional and Metabolic Pattern

Patient X was on Osteorized Feeding. Daily fluid consumption was inadequate;about a 230 cc was consumed during 8 hours of duty.

H. Elimination Pattern

Catheter in placed with yellowish urine attached to Urobag drain at 200cc.

I. Activity and Exercise Pattern

Prior to hospitalization, Patient X usually spent her time watching television. She

doesnt have a regular schedule for exercise.

J. Cognitive-Perceptual Pattern

Upon assessment during the first week (July 2-3, 2010), Patient X was lethargic,

eye movement responsive to speech stimuli.


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K. Sleep-Rest Pattern

Prior to admission the patient often slept at 10pm and usually woke up at 5am in

the morning. Usually the patient sleeps for 7 to 8 hours.

Physical Assessment

Baseline DataArea of Assessment

Assessment Findings Validation

I. SKIN

colortemperatureturgor

Texturelesionsintegrity

PaleWarm (39.7C)Senile skin turgorno lesions notedRough skin integrity

InspectionPalpation


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II. NAILScolortextureshape

pallordryconvex

InspectionPalpation

III. HAIRcolortexturedistributionquantity

White with some black hairdry hairfine distributedthick

Inspection

IV. HEADshapesizeconfigurationheadacheshead injury

roundednormocephalicgood configuration(+) headachesno head injury

InspectionPalpation

V. EYESLidsPeriorboital regionConjunctiva

ScleraPupils

>Reaction to light>Reaction toAccommodation

Visual AcuityPeripheral Vision

SymmetricalSunkenPale

AnictericEqual in size 2mmBriskUniformConstriction/convergenceNearsightedDecreased

InspectionPalpation

VI. EARSExternal PinnaeExternal CanalGroos HearingTympanic Membrane

NormosetNo dischargesNormalIntact

InspectionPalpation

VII. NOSE AND SINUSESMucosaSeptumPatencyDischarge

PinkishMidlinePatentNo discharges

InspectionPalpation

VIII. MOUTH AND THROATlipsteethmucosagums

tongue

PallorCariesPallor

PinkishMidline

Inspection

IX. NECKTracheaThyroid

MidlineNon-palpable

InspectionPalpation


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X. respiratory statusBreathing patternShape of chestLung expansion

Vocal/Tactile FremitusPercussion

Breath sounds

Cough

Sputum

Irregular (34 RR)FlatSymmetricalSymmetricalResonant

Crackles at right chestProductive cough butcannot expectorateYellowish colored

InspectionPalpationPercussionAuscultation

XI.CARDIOVASCULARSTATUS

Preorbital AreaApical RateHeart SoundPeripheral PulseCapillary Refill

Flat100 bpmIrregularStrong2 sec.

InspectionPalpationAuscultation

XII.BREAST & AXILLARYsymmetrycontourskin lesionsconsistencylymph nodesengorgement

equalgood contourno lesionsgood consistencyno lymph nodesno enlargement

InspectionPalpation

XIII. ABDOMENGeneralConfigurationBowel SoundPercussionPalpation

XVI. MUSCULOSKELETALInspection

spineposturegait:scars

ROM

flexionextensionabductionRotationUpper Extremities

Palpation

Tenderness

Superficial viensSymmetricalHypo ActiveTympaniticMuscle Guarding

midlineUAcoordinatedNo scar seen

PassivePassivePassivePassiveEdema noted

no tenderness

InspectionAuscultationPalpationPercussion

InspectionPalpation


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NEUROSYSTEM1. CranialNerves

olfactoryopticoculomot

ortrochleartrigemina

l

facialacousticglossopharyngeal

vagus

accessoryhypoglossal

cant distinguish odor

cant identify colorspontaneouscan move eyes side by

can sense pain

can smile

can hear

cant distinguish taste

cant shrug shouldercan curved tongue

Inspection

2. Sensory systemlight

touchvibrationpain

able to sense touchcan feel vibrationcan feel pain

Palpatation

Motor Systemmuscle toneability to moveextremities againstgravityspasticity, flaccidity orrigidity, tremorsextremities

flexionabductionadduction

2. Head and NeckInspection

facial muscle symmetry:swelling:scars:discoloration:

ROM

flexionExtension

4. Cerebral Functionmuscle coordination,

rhythm, & regularity ofgaitposturebalancenystagmus & slowdysrrhytmic speech

Weak muscle toneInability to moveImmobilize

no tremors & rigidityPassive ROM in both upper &lower extremities

PassivePassivePassive

symmetrical facial musclesno swelling notedno scar seenno discoloration

PassivePassive

good muscle coordination,rhythm & regular gaitUAUANo nystagmus notedcan balance wellSlurred speech

InspectionPalpation

Inspection

InspectionPalpation


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5. Deep tendon reflex(Grade 0-4)

6. Brain stem integrityoculocephalic reflex(dolls eye phenomenon)oculovestibular reflex

7. Mental statusLOC, Grade w/ GCSOrientation

8. Speech & LanguageListen to speech to

detect dysphasia,dysarthria or dysphonia

Grade as 1

responsivepresent

Lethargic, GCS 11UA

Cant speak

Percussion

Inspection

Interview

NURSING SYSTEM REVIEW CHART


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ANATOMY AND PHYSIOLOGY

SkinPallorWarm: 39.7Dry

Neurologic SystemCant distinguishCant identify clor

Respiratory SystemRR= 34 cpm

Crackles at right chestYellow sputumProductive cough

Musculoskeletal SystemWeak muscle toneInability to move

Gastrointestinal SystemHypoactiveMuscle Guarding

Eyesnerasighteddecreased visual acuity

MouthPaleUnable to speakSlurred speech


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The Lungs

Front view of heart and lungs.

(Pulmones)

The lungs are the essential organs of respiration; they are two in number, placed one oneither side within the thorax, and separated from each other by the heart and other contents ofthe mediastinum (Fig. 970). The substance of the lung is of a light, porous, spongy texture; itfloats in water, and crepitates when handled, owing to the presence of air in the alveoli; it isalso highly elastic; hence the retracted state of these organs when they are removed from theclosed cavity of the thorax. The surface is smooth, shining, and marked out into numerouspolyhedral areas, indicating the lobules of the organ: each of these areas is crossed bynumerous lighter lines.At birth the lungs are pinkish white in color; in adult life the color is a dark slaty gray,

mottled in patches; and as age advances, this mottling assumes a black color. The coloringmatter consists of granules of a carbonaceous substance deposited in the areolar tissue nearthe surface of the organ. It increases in quantity as age advances, and is more abundant inmales than in females. As a rule, the posterior border of the lung is darker than the anterior.The right lung usually weighs about 625 gm., the left 567 gm., but much variation is met

with according to the amount of blood or serous fluid they may contain. The lungs areheavier in the male than in the female, their proportion to the body being, in the former, as 1to 37, in the latter as 1 to 43.Each lung is conical in shape, and presents for examination

an apex, a base, threeborders, and two surfaces.The apex (apex pulmonis) is rounded, and extends into the root of the neck, reaching from

2.5 to 4 cm. above the level of the sternal end of the first rib. A sulcus produced by thesubclavian artery as it curves in front of the pleura runs upward and lateralward immediatelybelow the apex.

The base (basis pulmonis) is broad, concave, and rests upon the convex surface of thediaphragm, which separates the right lung from the right lobe of the liver, and the left lungfrom the left lobe of the liver, the stomach, and the spleen. Since the diaphragm extends


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higher on the right than on the left side, the concavity on the base of the right lung is deeperthan that on the left. Laterally and behind, the base is bounded by a thin, sharp margin whichprojects for some distance into the phrenicocostal sinus of the pleura, between the lower ribsand the costal attachment of the diaphragm. The base of the lung descends during inspirationand ascends during expiration.

Pulmonary vessels, seen in a dorsal view of the heart and lungs. The lungs have been pulledaway from the median line, and a part of the right lung has been cut away to display the air-

ducts and bloodvessels. (Testut.)

Surfaces.The costal surface (facies costalis; external or thoracic surface) is smooth,convex, of considerable extent, and corresponds to the form of the cavity of the chest, beingdeeper behind than in front. It is in contact with the costal pleura, and presents, in specimenswhich have been hardened in situ, slight grooves corresponding with the overlying ribs.The mediastinal surface (facies mediastinalis; inner surface) is in contact with the

mediastinal pleura. It presents a deep concavity, the cardiac impression, whichaccommodates the pericardium; this is larger and deeper on the left than on the right lung, onaccount of the heart projecting farther to the left than to the right side of the median plane.Above and behind this concavity is a triangular depression named thehilum, where thestructures which form the root of the lung enter and leave the viscus. These structures areinvested by pleura, which, below the hilus and behind the pericardial impression, forms thepulmonary ligament. On the rightlung (Fig. 972), immediately above the hilus, is an archedfurrow which accommodates the azygos vein; while running upward, and then archinglateralward some little distance below the apex, is a wide groove for the superior vena cavaand right innominate vein; behind this, and nearer the apex, is a furrow for the innominate

artery. Behind the hilus and the attachment of the pulmonary ligament is a vertical groove forthe esophagus; this groove becomes less distinct below, owing to the inclination of the lowerpart of the esophagus to the left of the middle line. In front and to the right of the lower partof the esophageal groove is a deep concavity for the extrapericardiac portion of the thoracicpart of the inferior vena cava. On the leftlung (Fig. 973), immediately above the hilus, is awell-marked curved furrow produced by the aortic arch, and running upward from thistoward the apex is a groove accommodating the left subclavian artery; a slight impression infront of the latter and close to the margin of the lung lodges the left innominate vein. Behind


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the hilus and pulmonary ligament is a vertical furrow produced by the descending aorta, andin front of this, near the base of the lung, the lower part of the esophagus causes a shallowimpression.

Mediastinal surface of right lung.

Borders.The inferior border (margo inferior) is thin and sharp where it separates the basefrom the costal surface and extends into the phrenicocostal sinus; medially where it dividesthe base from the mediastinal surface it is blunt and rounded.The posterior border (margo posterior) is broad and rounded, and is received into the deep

concavity on either side of the vertebral column. It is much longer than the anterior border,and projects, below, into the phrenicocostal sinus.The anterior border (margo anterior) is thin and sharp, and overlaps the front of the

pericardium. The anterior border of the rightlung is almost vertical, and projects into thecostomediastinal sinus; that of the leftpresents, below, an angular notch, thecardiac notch, inwhich the pericardium is exposed. Opposite this notch the anterior margin of the left lung issituated some little distance lateral to the line of reflection of the corresponding part of thepleura.


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Mediastinal surface of left lung.

Fissures and Lobes of the Lungs.The left lung is divided into two lobes, an upper and a

lower, by an interlobular fissure, which extends from the costal to the mediastinal surface ofthe lung both above and below the hilus. As seen on the surface, this fissure begins on themediastinal surface of the lung at the upper and posterior part of the hilus, and runs backwardand upward to the posterior border, which it crosses at a point about 6 cm. below the apex. Itthen extends downward and forward over the costal surface, and reaches the lower border alittle behind its anterior extremity, and its further course can be followed upward andbackward across the mediastinal surface as far as the lower part of the hilus. The superiorlobe lies above and in front of this fissure, and includes the apex, the anterior border, and aconsiderable part of the costal surface and the greater part of the mediastinal surface of thelung. The inferior lobe, the larger of the two, is situated below and behind the fissure, andcomprises almost the whole of the base, a large portion of the costal surface, and the greater

part of the posterior border.The right lung is divided into three lobes, superior, middle, and inferior, by two interlobular

fissures. One of these separates the inferior from the middle and superior lobes, andcorresponds closely with the fissure in the left lung. Its direction is, however, more vertical,and it cuts the lower border about 7.5 cm. behind its anterior extremity. The other fissureseparates the superior from the middle lobe. It begins in the previous fissure near theposterior border of the lung, and, running horizontally forward, cuts the anterior border on alevel with the sternal end of the fourth costal cartilage; on the mediastinal surface it may betraced backward to the hilus. The middle lobe, the smallest lobe of the right lung, is wedge-shaped, and includes the lower part of the anterior border and the anterior part of the base ofthe lung.The right lung, although shorter by 2.5 cm. than the left, in consequence of the diaphragm

rising higher on the right side to accommodate the liver, is broader, owing to the inclinationof the heart to the left side; its total capacity is greater and it weighs more than the left lung.The Root of the Lung (radix pulmonis).A little above the middle of the mediastinalsurface of each lung, and nearer its posterior than its anterior border, is its root, by which thelung is connected to the heart and the trachea. The root is formed by the bronchus, thepulmonary artery, the pulmonary veins, the bronchial arteries and veins, the pulmonary


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plexuses of nerves, lymphatic vessels, bronchial lymph glands, and areolar tissue, all ofwhich are enclosed by a reflection of the pleura. The root of the right lung lies behind thesuperior vena cava and part of the right atrium, and below the azygos vein. That of the leftlung passes beneath the aortic arch and in front of the descending aorta; the phrenic nerve, thepericardiacophrenic artery and vein, and the anterior pulmonary plexus, lie in front of each,and the vagus and posterior pulmonary plexus behind each; below each is the pulmonaryligament.The chief structures composing the root of each lung are arranged in a similar manner from

before backward on both sides, viz., the upper of the two pulmonary veins in front; thepulmonary artery in the middle; and the bronchus, together with the bronchial vessels,behind. From above downward, on the two sides, their arrangement differs, thus:

On the right side their position iseparterial bronchus, pulmonary artery, hyparterialbronchus, pulmonary veins, but on the left side their position ispulmonary artery, bronchus,pulmonary veins. The lower of the two pulmonary veins, is situated below the bronchus, atthe apex or lowest part of the hilus (Figs. 972, 973).Divisions of the Bronchi.Just as the lungs differ from each other in the number of their

lobes, so the bronchi differ in their mode of subdivision.The right bronchus gives off, about 2.5 cm. from the bifurcation of the trachea, a branch

for the superior lobe. This branch arises above the level of the pulmonary artery, and istherefore named the eparterial bronchus. All the other divisions of the main stem come offbelow the pulmonary artery, and consequently are termed hyparterial bronchi. The first ofthese is distributed to the middle lobe, and the main tube then passes downward andbackward into the inferior lobe, giving off in its course a series of large ventral and smalldorsal branches. The ventral and dorsal branches arise alternately, and are usually eight innumberfour of each kind. The branch to the middle lobe is regarded as the first of theventral series.The left bronchus passes below the level of the pulmonary artery before it divides, and

hence all its branches are hyparterial; it may therefore be looked upon asequivalent to thatportion of the right bronchus which lies on the distal side of its eparterial branch. The firstbranch of the left bronchus arises about 5 cm. from the bifurcation of the trachea, and isdistributed to the superior lobe. The main stem then enters the inferior lobe, where it dividesinto ventral and dorsal branches similar to those in the right lung. The branch to the superiorlobe of the left lung is regarded as the first of the ventral series.Structure.The lungs are composed of an external serous coat, a subserous areolar tissueand the pulmonary substance or parenchyma.The serous coat is the pulmonary pleura (page 1090); it is thin, transparent, and invests the

entire organ as far as the root.The subserous areolar tissue contains a large proportion of elastic fibers; it invests the

entire surface of the lung, and extends inward between the lobules.The parenchyma is composed of secondary lobules which, although closely connected

together by an interlobular areolar tissue, are quite distinct from one another, and may beteased asunder without much difficulty in the fetus. The secondary lobules vary in size; thoseon the surface are large, of pyramidal form, the base turned toward the surface; those in theinterior smaller, and of various forms. Each secondary lobule is composed of several primarylobules, the anatomical units of the lung. The primary lobule consists of an alveolar duct, theair spaces connected with it and their bloodvessels, lymphatics and nerves.The intrapulmonary bronchi divide and subdivide throughout the entire organ, the

smallest subdivisions constituting the lobular bronchioles. The larger divisions consist of: (1)an outer coat of fibrous tissue in which are found at intervals irregular plates of hyalinecartilage, most developed at the points of division; (2) internal to the fibrous coat, a layer ofcircularly disposed smooth muscle fibers, the bronchial muscle; and (3) most internally, themucous membrane, lined by columnar ciliated epithelium resting on a basement membrane.The corium of the mucous membrane contains numerous elastic fibers running longitudinally,and a certain amount of lymphoid tissue; it also contains the ducts of mucous glands, theacini of which lie in the fibrous coat. Thelobular bronchioles differ from the larger tubes incontaining no cartilage and in the fact that the ciliated epithelial cells are cubical in shape.The lobular bronchioles are about 0.2 mm. in diameter.


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Part of a secondary lobule from the depth of a human lung, showing parts of several primarylobules. 1, bronchiole; 2, respiratory bronchiole; 3, alveolar duct; 4, atria; 5, alveolar sac; 6,

alveolus or air cell: m, smooth muscle; a, branch pulmonary artery; v, branch pulmonaryvein;s, septum between secondary lobules. Camera drawing of one 50 section. X 20

diameters. (Miller.)Each bronchiole divides into two or more respiratory bronchioles, with scattered alveoli,

and each of these again divides into several alveolar ducts, with a greater number of alveoliconnected with them. Each alveolar duct is connected with a variable number of irregularlyspherical spaces, which also possess alveoli, the atria. With each atrium a variable number(25) ofalveolar sacs are connected which bear on all parts of their circumference alveoli orair sacs. (Miller.)The alveoli are lined by a delicate layer of simple squamous epithelium, the cells of which

are united at their edges by cement substance. Between the squames are here and theresmaller, polygonal, nucleated cells. Outside the epithelial lining is a little delicate connectivetissue containing numerous elastic fibers and a close net-work of blood capillaries, andforming a common wall to adjacent alveoli.


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Schematic longitudinal section of a primary lobule of the lung (anatomical unit);r.b., respiratory bronchiole; al. d., alveolar duct; at., atria; a. s., alveolar sac; a, alveolus or aircell;p. a.: pulmonary artery:p. v., pulmonary vein; l., lymphatic; l. n., lymph node. (Miller.)

FIG. 976Section of lung of pig embryo, 13 cm. long, showing the glandular character of thedeveloping alveoli (J. M. Flint.) X 70. a. Interstitial connective tissue. b. A bronchial

tube. c. An Alveolus. l. lymphatic clefts. q. Pleura.The fetal lung resembles a gland in that the alveoli have a small lumen and are lined by

cubical epithelium (Fig. 976). After the first respiration the alveoli become distended, and theepithelium takes on the characters described above.

Vessels and Nerves.The pulmonary artery conveys the venous blood to the lungs; itdivides into branches which accompany the bronchial tubes and end in a dense capillary net-work in the walls of the alveoli. In the lung the branches of the pulmonary artery are usuallyabove and in front of a bronchial tube, the vein below.The pulmonary capillaries form plexuses which lie immediately beneath the lining

epithelium, in the walls and septa of the alveoli and of the infundibula. In the septa betweenthe alveoli the capillary net-work forms a single layer. The capillaries form a very minute net-


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work, the meshes of which are smaller than the vessels themselves; their walls are alsoexceedingly thin. The arteries of neighboring lobules are independent of each other, but theveins freely anastomose.The pulmonary veins commence in the pulmonary capillaries, the radicles coalescing into

larger branches which run through the substance of the lung, independently of the pulmonaryarteries and bronchi. After freely communicating with other branches they form large vessels,which ultimately come into relation with the arteries and bronchial tubes, and accompanythem to the hilus of the organ. Finally they open into the left atrium of the heart, conveyingoxygenated blood to be distributed to all parts of the body by the aorta.The bronchial arteries supply blood for the nutrition of the lung; they are derived from the

thoracic aorta or from the upper aortic intercostal arteries, and, accompanying the bronchialtubes, are distributed to the bronchial glands and upon the walls of the larger bronchial tubesand pulmonary vessels. Those supplying the bronchial tubes form a capillary plexus in themuscular coat, from which branches are given off to form a second plexus in the mucouscoat; this plexus communicates with small venous trunks that empty into the pulmonaryveins. Others are distributed in the interlobular areolar tissue, and end partly in the deep,partly in the superficial, bronchial veins. Lastly, some ramify upon the surface of the lung,

beneath the pleura, where they form a capillary network.The bronchial vein is formed at the root of the lung, receiving superficial and deep veins

corresponding to branches of the bronchial artery. It does not, however, receive all the bloodsupplied by the artery, as some of it passes into the pulmonary veins. It ends on the right sidein the azygos vein, and on the left side in the highest intercostal or in the accessoryhemiazygos vein.

Nerves.The lungs are supplied from the anterior and posterior pulmonary plexuses, formedchiefly by branches from the sympathetic and vagus. The filaments from these plexusesaccompany the bronchial tubes, supplying efferent fibers to the bronchial muscle and afferentfibers to the bronchial mucous membrane and probably to the alveoli of the lung. Smallganglia are found upon these nerves.

DIAGNOSTIC TEST AND

LABORATORY RESULTS


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Urinalysis

(July , 2010)

Color Yellow

Transparency Hazy

Reaction 6.0

Specific Gravity 1.030

Sugar trace

Protein (-)

Pus cells 15-20 cells/HPF

RBC 0-3 cells/HPF

Squamous Epithelial Cells Few

Bacteria Rare

Interpretation:

HEMATOLOGY

Test Reference

Value

Unit Result Interpretation

Complete Blood CountHemoglobin 11.7 14.5 g/dL 14.0Hematocrit 34.1-44.3 % 42.0WBC 5,000-

10,000

x10^d/L 9,000

Segmenters 45-70 84.0Lymphocytes 18-45 % 14.0Monocytes 4-8 % 2.0Eusinophil 2-3 % 2 2Platelet 174,000-

390,000

x10^g/L 194,000

RBC 4.2-5.4 x10^12/L 4.75MCV 80-96 fL 87.2MCH 27-31 Pg 27.9MCHC 32-36 g/dL 32.9

Interpretation:

Hemoglucotest

Date ResultmEq/dLmEq/dL

mEq/dLmEq/dl

mEq/dL


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Nursing Interpretation:

Patient Y has diabetes mellitus II. Monitoring blood glucose to ensure that the blood glucose level is

within normal range.

Chest X-Ray

(July 5, 2010)

Follow up exam relative to 6/30 shows:

Film taken with suboptimal respiratory effort.

There is interval decrease in the reticular densities seen in the right paracardiac area.

Both costrophrenic sulci are now Blunted. (Minimal pleural effusion vs. pleural

thickening).

No other remarkable interval findings.

(July 30, 2010)

Follow up exam relative to 6/7/2010 shows:

Film taken with poor inspiratory effort.

Reticular densities are seen in the right paracardiac area. (Pneumonitis vs confluent

bronchovascular markings).

There is no significant interval change in the granuloma formation in the right upper lung

field.

Same degree of cardiomegaly.

Both costrophrenic sulci and hemidiaphragms are intact.

No other remarkable interval findings.

DISCHARGE PLANNING

MedicationsCompliance to the medication regimen:

Azithromycin antibiotic 500mg 1tab PO OD Iosartan antihypertensive 100mg 1tab PO OD Dexofyline bronchodilator 400mg PO OD Hydrocortisone corticosteroid 100mg IVTT q6 Sultamicillin antibiotic 750mg 1tav PO BID Acetylcysteine mocolytic 100mg 1tab PO OD Hydrixyzine anxiolytic antihistamine Salbutamol bronchodilator q6


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Senna concentration laxative 2tabs PO HS

Economy Encourage active participation of the patient significant others in the

program including self-monitoring of vital signs and diet for increasecompliance.

To promote more understanding about the need for monitoring thecondition of the patient and proper food should be taken.

Treatment

Encourage relaxation techniques and exercise.

To decrease tension level

Compliance to medications

To aid in the successful recovery

Give supportive treatment. Proper diet and oxygen to increaseoxygen in the blood when needed.

Drink lots of fluids, especially water. Liquids will keep patient frombecoming dehydrated and help loosen mucus in the lungs.

Health teachings

Give both the patient and the caregiver verbal and written instructions

about home medications.

Encourage patients feeling with regards to allowances and limitations with

respect to home chores, recreation and activities.

Encourage physical mobility.

Maintain peaceful environment to promote comfort and fastest recovery

Out-patient

Follow up visits to physician were encourage to significant others forfurther evaluation with regards to the condition of the patient.

To ensure complete recovery and prevent further complications

Diet Inform that the one prescribed by the physician for underlying condition

should be followed and should not be omitted.

Emphasis on the intended diet with low salt, low fat, low sugar and low

protein should be maintained.


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Maintain hydration.

Spiritual

Advice patient to ask gods guidance and supervision all through his lifeand entrust everything to him. Prayer is the best weapon to all difficulties

no matter what it is. God is always there all the time.

Related Learning Experience

With our 3 weeks exposure at Capitol University Medical City Station 4, we say

that it is one of our very unforgettable experienced because we have learned a lot with

regards to caring for our patient and dealing with people. It was not that busy because

our clinical instructor thought us to managed our time well and always be ready with the

people that we are going to encounter.

As a group, we have learned that working as a team has indeed made our duty a lot

easier and well-managed. We also have learned that having a peaceful and united

group could indeed produce a better quality of work.


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One interesting woman on this rotation was our Clinical Instructor for he was the one

who work hard to make our rotation possible, enjoyable and very exciting. Shared a lot

of experiences and most of all the knowledge and the lessons she learned as a nurse.

Being in this rotation is really a one of a kind experience.