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St.

Anthony College of Roxas city


College of Nursing
San Roque St. Roxas City

NURSING PROCESS GUIDE

I. Vital Information

Name: M. C.
Age: 72 yrs. Old
Sex: Female
Address: Nasagud, Lanot Roxas City
Civil Status: Married
Religion: Roman Catholic
Date and Time Admitted: Jan 14, 2009 @ 2:10 p.m.
Ward: Immaculate Heart of Mary ward Room # 217
Chief Complaints: DOB
Impression/Diagnosis: Pneumonia, Bibasal Asthma, DM
Attending Physician: Dr. A. & Dr. B.

II. Clinical Assessment

A. Nursing History

1. History of Present Illness:

4 days PTA, pt. was noted to have low-grade fever,


undocumented, associated with cough with yellowish
sputum & DOB, (+) generalized body malaise, no consult
done, no meds taken. 1 day PTA, pt. was noted to have
decrease appetite, persistence of other symptoms, given
nebulization with combivent + medrol, (+) episode of
vomiting, (+) 2x loose stools, persistence of symptoms thus
consult admission.

2. Past Health Problems/Status:

No past health problems taken.

3. Family History of Illness:

No Family History of Illness taken.

4. Patterns of Functioning:
a. Breathing Patterns: RR- 36 BPM, (+) bibasal
crackles, (+) wheezing, (+) rhonchi
b. Circulation: BP- 170/100 mmHg, PR- 120 BPM,
CR- 123 BPM
c. Sleeping Patterns: sleeps in lateral position, with 2
pillows.
d. Drinking Patterns: Daily Intake of 120 cc per 8
hrs. Usually drinks juice and water.
e. Eating Patterns: Eats vegetables, fruits, rice, meat
and fish.
f. Elimination Pattern:
i. Bowel Movement: Every other day
ii. Urination: Twice per 8 hrs.
g. Personal Hygiene: Takes a bath every day.
h. Recreation and Exercise: Sits on bed every 2 hrs,
Passive ROM every 8 hrs.

5. Brief Social, Cultural and Religious Background:

a. Educational Background: Elementary


Undergraduate
b. Occupation: Housewife
c. Religious Practices: Usually hears mass every
Sunday.
d. Economic Status: Middle Class

B. Clinical Inspection:

1. Vital Signs:

T- 38.4 C BP- 170/100 mmHg


PR- 120 BPM RR- 36 BPM

2. Height: N/A
Weight: N/A

3. Physical Assessment (CEPHALOCAUDAL)


a. General Appearance- appears to be weak,
bedridden with 2 pillows.
b. Skin, hair and nails- dry and wrinkled skin, sticky
hair, poor-trimmed nails.
c. Head, Face, and Lymphatics- Clean face, no mass
found.
d. Eyes, Ears, Nose, Mouth, and Throat- PERRLA,
hearing acuity is good, no discharges noted.
e. Neck and Upper Extremities- No lymphatics
noted, no mass noted.
f. Chest, Breast, and Axilla- Tenderness not noted,
no mass found, lymphatics not noted.
g. Respiratory System- (+) bibasal crackles, (+)
wheezing, (+) rhonchi
h. Cardiovascular system- Tachycardic, AP: 123
BPM
i. Gastrointestinal System- Flat, Soft, Non-Tender
j. Genito-Urinary System- No mass noted.
k. Musculoskeletal System- Left side of the body is
paralyzed.

4. General Appraisal:
a. Speech- Coherent
b. Language- Hiligaynon
c. Hearing- Hears and listen well
d. Mental Status- Conscious, response to questions in
manner, mostly quiet.
e. Emotional Status-Worry about their financial
problems.

C. Laboratory Data:

1. Chemistry

Name of Significance of
Result Normal Values
Examination Abnormal Result
Having a low level
of blood creatinine
indicates nothing
Creatinine LO 48.3 umol/L 62.0-106.0 more than an
efficient and
effective pair of
kidneys.
Low sodium levels
Sodium LO 127.3 mmol/L 137.0- 145.0 may indicate
Hyponatremia.
Potassium 4.18 mmol/L 3.50-5.10

2. X-Ray Result

Impression:

Atheromatous Aorta
Levoscoliosis, thoracic spine
Pulmonary Emphysema
Bibasal Pneumonia
PTB w/ Residual Calcified Granulomas, both upper
lobes

3. Sputum: Gram Stain

Seen on gram stained smear were occasional gram (+)


cocci in pair, cluster, and in chain, occasional gram (-)
bacilli arranged singly, squamous epithelial cells are few,
pus cells are 14-24/oif, and yeast cells are occasional.

4. Fecalysis

Color: Greenish-brown
Consistency: Soft
Bacteria: Many

5. Urinalysis

Color: Yellow
Transparency: Slightly Hazy
Reaction: pH 5.0
Sp. Gravity: 1.030
Protein: ++
Glucose: Negative
Amorph. U/P: Few
RBC/hpf: 0-3
WBC/hpf: 2-5
Epith. Cells: Squamous- Moderate
Bacteria: Moderate

D. Drug Study

Name of
Generic Side Contra- Nsg.
Drug w/ Action Indication
Name Effect Indications Responsibilities
Dosage
Tergece Cephalos- Anti- Lungs, Mild Hyper- Watch out for
f 100 phorins Bacterial skin, soft rashes, sensitive to hyper-sensitivity
mg. 1 tissue, fever, drugs, with reactions,
Cap Penicillin bones, abdominal renal or Monitor renal
BID joints, pain, hepatic function study,
urinary diarrhea, impairment, Monitor Intake
and dyspepsia, history of and Output
respiratory glossitis, GI disease,
tracts, nausea, or allery to
blood, tenesmus, penicillins
abdomen, and
and heart vomiting
infections

Ventolin Salbu- Broncho- Bronchitis, Dizzines, Hyper- Be alert for


1 tab tamol dilator Broncho- headache, sensitive to adverse
TID Sulfate spasm insomnia, drugs, CV reactions
hyper- disorders,
tension, Hyper-
nausea, thyroidism
vomiting

E. Textbook Discussion

Definition:

Pneumonia is an inflammatory illness of the lung. Frequently, it is


described as lung parenchyma/alveolar inflammation and abnormal
alveolar filling with fluid (consolidation and exudation).

The alveoli are microscopic air-filled sacs in the lungs responsible


for absorbing oxygen. Pneumonia can result from a variety of causes,
including infection with bacteria, viruses, fungi, or parasites, and chemical
or physical injury to the lungs. Its cause may also be officially described
as idiopathic—that is, unknown—when infectious causes have been
excluded.

Signs and Symptoms:

S/S in the Textbook----S/S manifested by Pt.

1. Cough w/ greenish or yellow sputums. 


2. High Fever w/ Chills 
3. Difficulty of Breathing 
4. Headaches 
5. Loss of Appetite 
6. Fatigue 
7. Nausea 
8. Vomiting 
9. Joint Pain
Pathophysiology:

Bacteria typically enter the lung when airborne droplets are inhaled, but
can also reach the lung through the bloodstream when there is an infection in another part
of the body. Many bacteria live in parts of the upper respiratory tract, such as the nose,
mouth and sinuses, and can easily be inhaled into the alveoli. Once inside, bacteria may
invade the spaces between cells and between alveoli through connecting pores. This
invasion triggers the immune system to send neutrophils, a type of defensive white blood
cell, to the lungs. The neutrophils engulf and kill the offending organisms, and also
release cytokines, causing a general activation of the immune system. This leads to the
fever, chills, and fatigue common in bacterial and fungal pneumonia. The neutrophils,
bacteria, and fluid from surrounding blood vessels fill the alveoli and interrupt normal
oxygen transportation.

Bacteria often travel from an infected lung into the bloodstream, causing
serious or even fatal illness such as septic shock, with low blood pressure and damage to
multiple parts of the body including the brain, kidneys, and heart. Bacteria can also travel
to the area between the lungs and the chest wall (the pleural cavity) causing a
complication called an empyema.

The most common causes of bacterial pneumonia are Streptococcus


pneumoniae, Gram-positive bacteria and "atypical" bacteria. The terms "Gram-positive"
and "Gram-negative" refer to the bacteria's color (purple or red, respectively) when
stained using a process called the Gram stain. The term "atypical" is used because
atypical bacteria commonly affect healthier people, cause generally less severe
pneumonia, and respond to different antibiotics than other bacteria.

The types of Gram-positive bacteria that cause pneumonia can be found in


the nose or mouth of many healthy people. Streptococcus pneumoniae, often called
"pneumococcus", is the most common bacterial cause of pneumonia in all age groups
except newborn infants. Another important Gram-positive cause of pneumonia is
Staphylococcus aureus, with Streptococcus agalactiae being an important cause of
pneumonia in newborn babies. Gram-negative bacteria cause pneumonia less frequently
than gram-positive bacteria. Some of the gram-negative bacteria that cause pneumonia
include Haemophilus influenzae, Klebsiella pneumoniae, Escherichia coli, Pseudomonas
aeruginosa and Moraxella catarrhalis. These bacteria often live in the stomach or
intestines and may enter the lungs if vomit is inhaled. "Atypical" bacteria which cause
pneumonia include Chlamydophila pneumoniae, Mycoplasma pneumoniae, and
Legionella pneumophila.

Management:
Most cases of pneumonia can be treated without hospitalization. Typically,
oral antibiotics, rest, fluids, and home care are sufficient for complete resolution.
However, people with pneumonia who are having trouble breathing, people with other
medical problems, and the elderly may need more advanced treatment. If the symptoms
get worse, the pneumonia does not improve with home treatment, or complications occur,
the person will often have to be hospitalized.

Prevention:

There are several ways to prevent infectious pneumonia. Appropriately


treating underlying illnesses (such as AIDS) can decrease a person's risk of pneumonia.
Smoking cessation is important not only because it helps to limit lung damage, but also
because cigarette smoke interferes with many of the body's natural defenses against
pneumonia.

Vaccination is important for preventing pneumonia in both children and


adults. Vaccinations against Haemophilus influenzae and Streptococcus pneumoniae in
the first year of life have greatly reduced their role in pneumonia in children. Vaccinating
children against Streptococcus pneumoniae has also led to a decreased incidence of these
infections in adults because many adults acquire infections from children. A vaccine
against Streptococcus pneumoniae is also available for adults. In the U.S., it is currently
recommended for all healthy individuals older than 65 and any adults with emphysema,
congestive heart failure, diabetes mellitus, cirrhosis of the liver, alcoholism, cerebrospinal
fluid leaks, or those who do not have a spleen. A repeat vaccination may also be required
after five or ten years.
F. Nursing Care Plan

Assessment Diagnosis Planning Nsg. Intervention Rationale Evaluation


Subjective: Ineefective Airway After Nsg. 1. Monitor 1. Indicative of Goal Met. After 3
Clearance related to Interventions, the pt respirations and respiratory distress weeks of nsg
“ Nabudlayan siya excessive, thickened will be able to breath sounds, and/or accumulation interventions, the
mag ginhawa” as mucus secretions as expectorate/clear noting rate and of secretions. patient was able to
verbalized by folks evidenced by secretions readily sounds. excrete secretions
presence of rhochi, and maintain airway 2. To open or readily and
Objective: tachypnea, and patency. 2. Position the pt to maintain open maintained airway
ineffective cough moderate high back airway in at rest or patency.
(+) Rhonchi rest. compromised
(+) Bibasal Crackles individual.
(+) Wheezing 3. Elevate head of
(+) Greenish bed/change position 3. To take advantage
Sputum every 2 hrs. and prn. of gravity
RR: 36 BPM decreasing pressure
BP: 170/100 mmHg 4. Encourage deep- on the diaphragm
AP: 123 BPM breathing and and enhancing
coughing exercise. drainage
of/ventilation to
5. Give expectorants different lung
and bronchodilators segments.
as ordered.
4. To maximize
effort.

5. Bronchodilators
relaxes bronchial
and uterine smooth
muscle by acting on
Beta2-adrenergic
receptors.
Subjective: Activity Intolerance After Nsg. 1. Provide positive 1. Helps to Goal Met. After
(Level IV) related Interventions, the atmosphere, while minimize frustration Nsg. Interventions,
“Nabudlayan ako to dyspnea and pt. will be able to acknowledging and re-channel the pt was able to
mag ginhawa kag abnormal vital signs report measurable difficulty of the energy. report measurable
maluya akon increase in activity situation for the increase in activity
kalawasan” as tolerance. client. 2. To enhance tolerance. Pt. was
verbalized by the pt. ability to participate able to sit on bed,
2. Promote comfort in activities. and walk slowly
Objective: measures and with assistance.
provide for relief
BP: 170/100 mmHg and pain.
CR: 123 BPM
RR: 36 BPM
Temp: 38.4 C
(+) body malaise
(+) facial grimace

Subjective: Acute Pain related After Nsg. 1. Provide comfort 1. To promote non-
to persistent cough Interventions, the pt measures (e.g. pharmacological
“Masakit na akon as evidenced by will be able to touch, pain management
dughan sang inubo” reports of report pain is repositioning)
as verbalized by the discomfort. relieved/controlled. 2. To distract
pt. 2. Encourage attention and reduce
diversional tension.
Objective: activities (watching
T.V., listening to 3. Analgesics blocks
(+) loss of appetite pain impulses,
(+) facial grimace
BP: 170/100 mmHg radio) probably inhibiting
Temp: 38.4 C prostaglandin or
RR: 36 BPM 3. Administer pain receptor
CR: 123 BPM analgesics as sensitizers.
Verbal report of ordered.
pain: 9 in pain scale

Submitted By: Ketch Armiza BSN 3-C Grp. 1

Submitted To: Mrs. Pearl Joy Degoma R.N.