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PATHOPHYSIOLOGY
The usual mechanisms of spread are inhaling droplets small enough to reach the
alveoli and aspirating secretions from the upper airways. Other means include
hematogenous or lymphatic dissemination and direct spread from contiguous
infections. Predisposing factors include upper respiratory viral infections,
alcoholism, institutionalization, cigarette smoking, heart failure, chronic
obstructive airway disease, age extremes, debility, immunocompromise (as in
diabetes mellitus and chronic renal failure), compromised consciousness,
dysphagia, and exposure to transmissible agents.
NURSING PROFILE
a. Patients Profile
Name: R.C.S.B.
Age: 1 yr,1 mo.
Weight:10 kgs
Religion: Roman Catholic
Mother: C.B.
Address: Valenzuela City
b. Chief Complaint: Fever
Date of Admission: 1st admission
Hospital Number: 060000086199
c. History of Present Illness
2 days PTA (+) cough
(+) nasal congestion, watery to greenish
(+) nasal discharge
Tx: Disudrin OD
Loviscol OD
Few hrs PTA (+) fever, Tmax= 39.3 C
(+) difficulty of breathing
(+) vomiting, 1 episode
Tx: Paracetamol
Sought consultation at ER: Rx=BPN, Salbutamol neb.
IE: T = 38.3C, CR= 122s, RR= 30s
(+) TPC
SCE, (-) retractions, clear BS, (-) cyanosis, (-) edema
d. Past Illness
(-) asthma
(-) allergies
e. Family History
PMHx: (+) asthma (mother)
DRUG STUDY
View NCP
NURSING ACTIONS
INDEPENDENT
positioning of the patient with head on mid line, with slight flexion
rationale: to provide patent, unobstructed airway , maximum lung excursion
auscultating patients chest
rationale: to monitor for the presence of abnormal breath sounds
provide chest and back clapping with vibration
rationale: chest physiotheraphy facilitates the loosening of secretions
considering that the patient is an infant, and has developed a strong stranger
anxiety
as manifested by white coat syndrome , it is a nursing action to play with
the patient.
rationale: to establish rapport, and gain the patients trust
DEPENDENT
Admit patient to ROC under the service of Dr. Vitan secure consent for admission
and management, TPR every shift then record. May have diet for age with strict
aspiration precaution, IVF D5 0.3NaCl 500cc to run at 62-63mgtts/min.May give
paracetamol 125mg 1supp/rectum if oral paracetamol is not tolerated.
11/20/06
For urinalysis, IVF to follow D5 0.3 NaCl 500 at SR (62-63mgtt/m Use zinacef brand
of cefuroxine 750mg- given vial 375mg every 8hours, nebulize (Ventolin 1
nebule) every 6 hours, paracetamol drugs prn every 4hours (Temp 37.8).
11/21/06
Continue cefuroxine and nebulizer every 6 hours. May not reinsert IVF, revise
Cefuroxine IV to Cefuroxine 500mg via deep Intramuscular
BID,continue management.
11/22/06
DISCHARGE PLANNING
Take the entire course of any prescribed medications. After a patients
temperature returns to normal, medication must be continued according to
the doctors instructions, otherwise the pneumonia may recur. Relapses can
be far more serious than the first attack.
Get plenty of rest. Adequate rest is important to maintain progress toward
full recovery and to avoid relapse.
Drink lots of fluids, especially water. Liquids will keep patient from
becoming dehydrated and help loosen mucus in the lungs.
Keep all of follow-up appointments. Even though the patient feels better,
his lungs may still be infected. Its important to have the doctor monitor his
progress.
Encourage the guardians to wash patients hands. The hands come in
daily contact with germs that can cause pneumonia. These germs enter ones
body when he touch his eyes or rub his nose. Washing hands thoroughly and
often can help reduce the risk.
Tell guardians to avoid exposing the patient to an environment with too
much pollution (e.g. smoke). Smoking damages ones lungs natural
defenses against respiratory infections.
Give supportive treatment. Proper diet and oxygen to increase oxygen in
the blood when needed.
Protect others from infection. Try to stay away from anyone with a
compromised immune system. When that isnt possible, a person can help
protect others by wearing a face mask and always coughing into a tissue.