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I. INTRODUCTION A.

Overview
What is Bronchial Asthma
Bronchial asthma is a disease caused by increased responsiveness of the tracheobronchial tree to various stimuli. The result is paroxysmal constriction of the bronchial airways. Bronchial asthma is the more correct name for the common form of asthma. The term 'bronchial' is used to differentiate it from 'cardiac' asthma, which is a separate condition that is caused by heart failure. Although the two types of asthma have similar symptoms, including wheezing (a whistling sound in the chest) and shortness of breath, they have quite different causes.

Bronchial asthma is a disease of the lungs in which an obstructive ventilation disturbance of the respiratory passages evokes a feeling of shortness of breath. The cause is a sharply elevated resistance to airflow in the airways. Despite its most strenuous efforts, the respiratory musculature is unable to provide sufficient gas exchange. The result is a characteristic asthma attacks, with spasms of the bronchial musculature, edematous swelling of the bronchial wall and increased mucus secretion. In the initial stage, the patient can be totally symptom-free for long periods of time in the intervals between the attacks. As the disease progresses, increased mucus is secreted between attacks as well, which in part builds up in the airways and can then lead to secondary bacterial infections. Bronchial asthma causes cough, shortness of breath, and wheezing. Bronchial asthma is an allergic condition, in which the airways (bronchi) are hyper-reactive and constrict abnormally when exposed to allergens, cold or exercise.

What is Pneumonia? Pneumonia is a respiratory condition in which there is infection of the lung. Communityacquired pneumonia refers to pneumonia in people who have not recently been in the hospital or another health care facility (nursing home, rehabilitation facility). Pneumonia is a common illness that affects millions of people each year in the United States. Germs called bacteria, viruses, and fungi may cause pneumonia. Bacteria and viruses living in your nose, sinuses, or mouth may spread to your lungs. You may breathe some of these germs directly into your lungs. You breathe in (inhale) food, liquids, vomit, or secretions from the mouth into your lungs through aspiration. Pneumonia caused by bacteria tends to be the most serious. In adults, bacteria are the most common cause of pneumonia. The most common pneumonia-causing germ in adults is Streptococcus pneumoniae (pneumococcus). Atypical pneumonia, often called walking

pneumonia, is caused by bacteria such as Legionella pneumophila, Mycoplasma pneumoniae, and Chlamydophila pneumoniae. Pneumocystis jiroveci pneumonia is sometimes seen in people whose immune system is impaired (due to AIDS or certain medications that suppress the immune system). Staphylococcus aureus, Moraxella catarrhalis, Streptococcus pyogenes, Neisseria meningitidis, Klebsiella pneumoniae, or Haemophilus influenzae are other bacteria that can cause pneumonia. Tuberculosis can cause pneumonia in some people, especially those with a weak immune system. Viruses are also a common cause of pneumonia, especially in infants and young children. The risk factors in getting pneumonia are those people who are smoking, those immunocompromised hosts and those people who have chronic lung disease or COPD, those who have chronic bronchitis, bronchiectasis and cystic fibrosis. The most common symptoms of Pneumonia are cough, shortness of breath, fever, chills, Headache, excessive sweating and cold clammy skin. Confusion also may occur, lost of appetite and stabbing or sharp chest pain that gets worse when you breathe deeply or cough. For the treatment, your doctor must first decide whether you need to be in the hospital. If you are treated in the hospital, you will receive fluids and antibiotics in your veins, oxygen therapy, and possibly breathing treatments. It is very important that your antibiotics are started very soon after you are admitted. However, many people can be treated at home. If bacteria are causing the pneumonia, the doctor will try to cure the infection with antibiotics. It may be hard for your health care provider to know whether you have a viral or bacterial pneumonia, so you may receive antibiotics. Patients with mild pneumonia who are otherwise healthy are sometimes treated with oral macrolide antibiotics (azithromycin, clarithromycin, or erythromycin). With treatment, most patients will improve within 2 weeks. Elderly or debilitated patients may need longer treatment. To prevent having pneumonia, you should wash your hands frequently, especially after blowing your nose, going to the bathroom, diapering, and before eating or preparing foods. Don't smoke. Tobacco damages your lung's ability to ward off infection. Vaccines may help prevent pneumonia in children, the elderly, and people with diabetes, asthma, emphysema, HIV, cancer, or other chronic conditions.

B.Objective of the study


This study generally aims to: Gather necessary information regarding with the patients condition. Understand and comprehend the occurrence of the condition. Implement appropriate nursing interventions to the client. Determine the predisposing and precipitating factors that contribute to the occurrence of the condition. Provide opportunity to the student to exercise the attitude of determination in order to come up with the successful study. Perform physical assessment, database and history- taking Identify priority nursing problems Implement Nursing Care Plan based on the priority nursing problems identified. Evaluate by using preventive and therapeutic interventions effectively. To learn more the disease condition and improve our skills related to our profession by allowing ourselves to assess and build a good relationship towards to other people, and to gain more confidence in ourselves in times that we have to perform our task. We render quality care to our client.

C. Scope and limitation


This study covers only the information regarding the occurrence of Bronchial Asthma in exacerbation, Pneumonia condition such as patients profile, nursing assessment, diagnostic test, nursing management, health teachings as well as the evaluation and implications. The scope of plan encompasses the days of clinical rotation in the date of January 13, 2011 wherein I assessed the client with cumulative interaction and good rapport to the client. Nursing management covers the above mentioned date. The areas of nursing care give concern are limited to the discussion of Bronchial Asthma in exacerbation, Pneumonia and the quality of nursing care given to the client. The information is limited to the data gathered from the client, significant others and medical records. Data gathering was conducted at Polymedic General Hospital, Velez at Station 4.

II. HEALTH HISTORY A. Patients Profile

Clients Name: Age: Birth date: Address: Civil Status: Sex: Nationality: Religion:

Telecio, Lilia C. 60 years old Feb. 1, 1950 B 11, L 3 Gold City Village, Ph 2, Balulang, Cagayan De Oro City married female Filipino Roman Catholic

Educational Attainment: College Graduate Height: Weight: 5 3 55 kg

Occupation: Employer (DENR CENRO) Income: Informant: 10,000 per month none

Date of Admission: January 12, 2011 Time of Admission: 5: 40 pm Admitting Diagnosis: Bronchial Asthma in exacerbation, Pneumonia Attending Physician: Dr. Judee Go

Physical Examination: BP=120/80 mmHg Skin: no abnormalities Head: normal condition of hair / scalp Eyes: Normal light reflex Ears: normal hearing Nose: symmetrical Throat: no abnormalities Neck: symmetrical Chest/lungs: wheeze Heart: regular heart rate and rhythm Breast: symmetry Abdomen: normal hyper/hypo bowel sounds Genitalia: no significant findings Rectal: No significant findings Extremities: no visible swelling B. Personal and Family Health History Food allergies : Chicken and shrimps Heredofamilial disaease (-) Hypertension Both mother and father side (-) Diabetes PR: 76 bpm RR: 20 cpm Temp: 36 C

A. History of Present Illness 2 weeks prior to admission, patient Telecio noted on and off cough, with shortness of breath associated with fever, consulted AP, advised admission. D. Chief Complaint: cough and shortness of breath

III. Developmental data


Middle age is the period of age beyond young adulthood but before the onset of old age. Various attempts have been made to define this age, which is around the third quarter of the average life span of human beings.

Ericksons Theory of psychosocial Development


Generativity vs. Stagnation (Middle Adulthood, 65 years) Related Elements in Society: parenting, educating, or other productive social involvement Generativity is the concern of establishing and guiding the next generation. Sociallyvalued work and disciplines are expressions of generativity. Simply having or wanting children does not in and of itself achieve generativity. During middle age the primary developmental task is one of contributing to society and helping to guide future generations. When a person makes a contribution during this period, perhaps by raising a family or working toward the betterment of society, a sense of generativity- a sense of productivity and accomplishment- results. In contrast, a person who is self-centered and unable or unwilling to help society move forward develops a feeling of stagnation- a dissatisfaction with the relative lack of productivity. Maintain healthy life patterns. Develop a sense of unity with mate. Help growing and grown children to be responsible adults. Relinquish central role in lives of grown children. Individuals experience during middle adulthood. A chief concern is to assist the younger generation in developing and leading useful lives- this is what Erikson means by generativity. The feeling of having done nothing to help the next generation is stagnation.

Havighursts Developmental Theory


The developmental tasks concept has a long and rich tradition. Its acceptance has been partly due to recognition of sensitive periods in our lives and partly due to the practical nature of Havighurst's tasks. Knowing that a youngster of a certain age is encountering one of the tasks of that period (learning an appropriate sex role) helps adults to understand a child's behavior and establish an environment that helps the child to master the tasks. In the middle years, from about thirty to about fifty-five, men and women reach the peak of their influence upon society, and at the same time the society makes its maximum demands upon them for social and civic responsibility. It is the period of life to which they have looked forward during their adolescence and early adulthood. And the time passes so quickly during these full and active middle years that most people arrive at the end of middle age and the beginning of later maturity with surprise and a sense of having finished the journey while they were still preparing to commence it.

The biological changes of ageing, which commence unseen and unfelt during the twenties, make themselves known during the middle years. The developmental tasks of the middle years arise from changes within the organism, from environmental pressure, and above all from demands or obligations laid upon the individual by his own values and aspirations. Since most middle-aged people are members of families, with teen-age children, it is useful to look at the tasks of husband, wife, and children as these people live and grow in relation to one another. Each family member has several functions or roles. Achieving adult civic and social responsibility. Establishing and maintaining an economic standard of living. Assisting teen-age children to become responsible and happy adults. Developing adult leisure-time activities.

Jean Piagets Cognitive Theory


The intellectual process of knowing characterizes cognition, which includes perception, judgment, use of language and memory. Cognitive development represents progression of mental abilities from illogical thinking to logical thinking, from simple to complex problem solving and from understanding concrete ideas to understanding abstract ideas. Piaget described cognitive development as involving the increasing ability to think and reason in logical manner. Piaget believed that intellectual development is an adaptive process that occurs as a regulatory function of both physiological and intellectual growth. According to Piaget, a person uses 3 abilities during cognitive development: assimilation, accommodation and adaptation. Assimilation is the process of learning from new experiences; people acquire knowledge and skills as well as insight, into the world around them.

Sigmund Freuds Psychosexual theory


Freudian Theory considers the main events of this period to be the establishment of new sexual aims and the finding of new love objects. It also involves the capacity for true intimacy.

IV. Medical management


A) MEDICAL ORDERS WITH RATIONALE

DOCTORS ORDER Doctors order


01-12-11 CPGH ER Pls. admit to ROC, under my service Vital signs q 4 hours and record I and O q shift IVF: PNSS 1L at 15 gtts/min Labs: CBC, K+, Crea, SGPT, 12 L ECG, FBS, Lipid Profile, Uric acid tomorrow Chest X ray PA, U/A Meds: - Duavent nebulization now, then another after 15 minutes, then q 6 hours - Symbicort turbohaler 2 inhalations BID - Cefuroxime 750 g IVTT now then q 8 hours ANST ( ) Inform me of admission. Refer accordingly.

Rationale

01-12-11 5:40 pm Pls. admit to ROC, under my service Vital signs q 4 hours and record I and O q shift IVF: PNSS 1L at 15 gtts/min Labs: CBC, K+, Crea, SGPT, 12 L ECG, FBS, Lipid Profile, Uric acid tomorrow Chest X ray PA, U/A Meds: - Duavent nebulization now, then another after 15 minutes, then q 6 hours - Symbicort turbohaler 2 inhalations

BID - Cefuroxime 750 g IVTT now then q 8 hours ANST ( ) Inform me of admission. Refer accordingly.

01-13-11 Continue medications Decreased neb to q 8 hours. IVF to follow: PNSS 1L @ 15 gtts/min 01-13-11 5:30 pm For sputum AFB 3x 6 pm May have DAT

V. Pathophysiology PNEUMONIA
--is the injflammaation of the lung parenchyma caused by various microorganisms, including bacteria, mycobacteria, chlamydiae, mycoplasma, fungi, parasites and viruses.
RISK FACTORS: Environmental pollutants Inhalation of toxic gases, chemicals, and smokes.

MICROORGANISMS: Bacteria, mycobacteria, mycoplasma, chlamydiae, fungi, parasites, viruses.

Arises from normal flora in oropharynx whose resistance has been altered. Pneumonia result from blood borne organisms in the community setting that enter the pulmonary circulation and trapped in pulmonary capillary bed. It affects both ventilation and diffusion Inflammatory reaction occur in the alveoli Producing an exudates that interferes with the diffusion of O2 and CO2 WBC ( neutrophils) migrate into alveoli and fill the normally air-containing spaces Presence of secretions and mucosal edema Areas of the lungs are not adequately ventilated (Hypoventilation) Partial occlusion of the bronchi or alveoli Decreased in alveolar oxygen tension Ventilation perfusion mismatch occurs in the affected area of the lung.

Venous blood entering the pulmonary circulation passes through the under ventilated area and travels to the left side of the heart poorly oxygenated.

Mixing of oxygenated and unoxygenated or poorly oxygenated blood.

Arterial hypoxemia
LOBAR PNEUMONIA If substantial portion of 1 or more lobes are involved.
BRONCHOPNEUMONIA Pneumonia that is not distributed in a patchy fashion, originated in 1 or more localized area in bronchi.

SIGNS AND SYMPTOMS: Shortness of breath, dyspnea Productive cough whitish in color. Chest pain Nausea and vomiting

Anatomy and Physiology of the Respiratory System


The respiratory system is an intricate arrangement of spaces and passageways that conduct air from outside the body into the lungs and finally into the blood as well as expelling waste gasses. This system is responsible for the mechanical process called breathing, with the average adult breathing about 12 to 20 times per minute. When engaged in strenuous activities, the rate and depth of breathing increases in order to handle the increased concentrations of carbon dioxide in the blood. Breathing is typically an involuntary process, but can be consciously stimulated or inhibited as in holding your breath.

Mechanics of Breathing To take a breath in, the external intercostal muscles contract, moving the ribcage up and out. The diaphragm moves down at the same time, creating negative pressure within the thorax. The lungs are held to the thoracic wall by the pleural membranes, and so expand outwards as well. This creates negative pressure within the lungs, and so air rushes in through the upper and lower airways. Expiration is mainly due to the natural elasticity of the lungs, which tend to collapse if they are not held against the thoracic wall. This is the mechanism behind lung collapse if there is air in the pleural space (pneumothorax). Each branch of the bronchial tree eventually sub-divides to form very narrow terminal bronchioles, which terminate in the alveoli. There are many millions of alveloi in each lung, and these are the areas responsible for gaseous exchange, presenting a massive surface area for exchange to occur over. Each alveolus is very closely associated with a network of capillaries containing deoxygenated blood from the pulmonary artery. The capillary and alveolar walls are very thin, allowing rapid exchange of gases by passive diffusion along concentration gradients. CO2 moves into the alveolus as the concentration is much lower in the alveolus than in the blood, and O2 moves out of the alveolus as the continuous flow of blood through the capillaries prevents saturation of the blood with O2 and allows maximal transfer across the membrane.

Nostrils/Nasal Cavities During inhalation, air enters the nostrils and passes into the nasal cavities where foreign bodies are removed, the air is heated and moisturized before it is brought further into the body. It is this part of the body that houses our sense of smell. Sinuses The sinuses are small cavities that are lined with mucous membrane within the bones of the skull. Pharynx The pharynx or throat carries foods and liquids into the digestive tract and also carries air into the respiratory tract. Larynx The larynx or voice box is located between the pharynx and trachea. It is the location of the Adam's apple, which in reality is the thyroid gland and houses the vocal cords.

Trachea The trachea or windpipe is a tube that extends from the lower edge of the larynx to the upper part of the chest and conducts air between the larynx and the lungs. Lungs The lungs are the organ in which the exchange of gasses takes place. The lungs are made up of extremely thin and delicate tissues. At the lungs, the bronchi subdivides, becoming progressively smaller as they branch through the lung tissue, until they reach the tiny air sacks of the lungs called the alveoli. It is at the alveoli that gasses enter and leave the blood stream. Bronchi The trachea divides into two parts called the bronchi, which enter the lungs. Bronchioles The bronchi subdivide creating a network of smaller branches, with the smallest one being the bronchioles. There are more than one million bronchioles in each lung. Avleoli The alveoli are tiny air sacks that are enveloped in a network of capillaries. It is here that the air we breathe is diffused into the blood, and waste gasses are returned for elimination. Respiratory Organs

Lungs: The lungs primary function is gas exchange. Oxygen is delivered to the tissue and carbon dioxide is removed from the tissues. Breathing is an automatic, rhythmic mechanical process, which delivers O2 to the tissues and removes CO2 from the tissues.

Alveoli: The exchange of gases between the external environment and cells of the body takes place in the individual alveolus. Oxygen and carbon dioxide exchange passively between the pulmonary capillaries and the alveoli; these gases move along their partial pressure gradients, i.e- from high to low.

Function of the Respiratory System

Protection: Cilia, both in the upper airways and trachea, beat and move mucous continually towards the mouth. Macrophage Alveolar macrophages phagocytose inhaled particulate matter and pathogens.

Thermoregulation: Heat loss from the respiratory system helps the body regulate internal body temperature.

Respiratory Mechanics

Differential pressure during inspiration: At the end of expiration, just before the beginning of inspiration, the pressure inside the lung is the same as the atmospheric pressure outside the body. 15/29 when the diaphragm actively contracts, the internal lung volume increases and the pressure inside the lung decreases. The change in internal pressure causes air to rush into the lungs and down its pressure gradient.

Differential pressure during expiration: At the end of inspiration, the diaphragm relaxes passively. The lung volume decreases and this causes the internal pressure inside the lungs to increase to a level higher than atmospheric pressure outside the body.

Lung elasticity and surface tension effects: the ability of the lungs elastic tissue to recoil during expiration. Elastins are elastic fibers present in the walls of the alveoli, which allow the lungs to return to their resting volume after expiration.

Pulmonary surfactant: Pulmonary surfactant is a phospholipid, similar to those found in a lipid bilayer surrounding human cells. It is made by pneumocytes in the lungs.

VI. NURSING SYSTEM REVIEW CHART


Name: Lomonggo, Aurito Date: Nov 24, 2010 Vital signs: Pulse: 78 bpm BP: 120/80 mmHg Temp: 35.8 C Height:52 Weight: 53 kg INSTRUCTIONS: Place an (x) in the area of abnormality. Write comment on the space. Indicated the location of the problem in the figure using (x). EENT: [ ] impaired vision [ ] blind [x] Pain reddened [ ] drainage [ ] gums [ ] hard of hearing [ ] deaf [ ] throat for abnormality [ ] no problem RESPIRATION

Painful eyes dyspnea Cough (productive) Chest pain

[ ] asymmetric [ ] tachypnea [ ] barrel chest [ ] apnea [ ] rales [x] cough [ ] bradypnea [ ] shallow [ ] rhonchi [ ] sputum [ ] diminished [x] dyspnea [ ] orthopnea [ ] labored [ ] wheezing [ ] pain [ ] cyanotic [ ] assess resp. rate, rhythm, depth, and pattern [ ] Breathe sound, comfort or no problem GASTROINTESTINAL TRACT CARDIOVASULAR [x] pain [ ] obese [ ] distention [ ] mass [ ] dysphagia [ ] rigidly [x] pain [ ] assess abdomen, bowel habits, swallowing [ ] Bowel sounds, comfort o no problem GENITO-URINARY AND GYNE [ ] pain [ ] urine color [ ] vaginal bleeding [ ] hematuria [ ] discharge [ ]nocturia [ ] assess urine freq., color, odor, comfort [ ] 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, galt, coordination, speech, [x] no problem MUSCULOSKELETAL [ ] appliance [ ] stiffness [ ] itching [ ] petechiae [ ] hot [ ] drainage [ ] prosthesis [ ] swelling [ ] lesion [x] poor turgor [ ] cool [ ] deformity [ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic o moist [ ] assess mobility, motion, gait, alignment, joint function [ ] skin color, texture, turgor, integrity o no problem NURSING ASSESSMENT 2 SUBJECTIVE COMMUNICATION: [ ] Hearing loss comments: medyo gasakit [x]Visual changes akong mata.as verbalized [ ] Denied by the patient. OBJECTIVE

Abdominal pain

Pale Slight poor skin turgor

Warm skin

[ ] glasses [ ] language [ ] contract lenses [ ] speech difficulties [ ] hearing aide R L Pupil size: 3 mm 3 mm Reaction: (PERRLA) Pupil equally round, reactive to light and accommodation. Resp. [x] regular [ ] irregular Describe: The patient has a regular breathing

OXYGENATION [x] dyspnea comments: Galisud kog [x] smokling history ginhawa usahay ug ga-

1 pack per day panigarilyo ko sa una. [x] cough as verbalized by the pa[x] Sputum tient. [ ] denied CIRCULATION: [x] chest pain comments: Gasakit ako [ ] leg pain dughan tungod kay naa [ ] numbness of koy sakit sa kasing2x. as Extremities verbalized by the pt. [ ] denied NUTRITION: Diet : DAT []N []V comments: wala man Characteristic ko gasuka ug ganado [ ] recent appetite in man ko mukaon permi Weight, appetite as verbalized by the pt. [ ] Swallowing Difficulty [ ] denied ELIMINATION: Usual bowel pattern [ ] urine frequency 2x a day 3x a day [ ] constipation [ ] urgency Remedies [ ] dysuria Fluid intake [ ] hematuria Date of last BM [ ] incontinence [ ] polyuria [ ] diarrhea [ ] foly in place Character [ ] denied

pattern. R: right lung symmetric is to the left L: left lung symmetric is to the right Heart rhythm [x] regular [ ] iiregular Ankle edema : none Carotid radial dorsal pedis femoral R: + 78 + + L: + 78 + + Comments: palpable pulses [ ] dentures Full Upper [ ] Lower [ ] partial [] [] [x] none with patient [] []

Comments: Bowel sounds: Normal bowel Normal sounds heard every Bowel sounds(5-20seconds 5-20 seconds. Abdominal Distention Present [ ] yes [ ] no Urine ( color, consistency Odor) yellow, moderate,aromatic * if foley bag catheter is

SUBJECTIVE

OBJECTIVE

MGT. OF HEALTH & ILLNESS: Briefly describe the patients ability to follow [ ] Alcohol [ ] denied treatments ( diet, meds, etc.) for chronic health ( amount, frequency) problems.( if present) Dili man ko gainum, niundang nako. As The patient shows excellent enthusiasm in verbalized by the patient. listening to instructions especially with regard to his health.

SKIN INTEGRITY: [ ] dry [ ] itching [ ] other [ ] denied comments: Wala man koy katol2x sa lawas. As verbalized by the pt. [ ] dry [ ] cold [x] pale [ ] flushed [x] warm [ ] moist [ ] cyanotic rashes, ulcers, decubitus( describe size, location, drainage) The patient skin is warm to touch and he has no rashes. He was pale in appearance [x] LOC and orientation: The patient is conscious and oriented to time and place. [ ] gait [ ] walker [ ] care [ ] other [ ] steady [x] unsteady Sensory and motor losses in face or extremities: none [ ] ROM limitations: He has the ability to ambulate and can bath himself.

ACTIVITY/ SAFETY: [ ] convulsion comments:Wala man ko [ ] dizziness gakalipong ug makatin[ ] limited motion dog2x man ko. As verOf joints balized by the patient. Limitation in ability to [ ] ambulate [ ] bathe self [ ] other [ ] denied COMFORT/ SLEEP/ AWAKE: [x] pain comments:Ushay gama( location) ta-mata ko kay sakit man frequency akong dughan ug akong Remedies tiyan.as verbalized by the [ ] nocturia patient. [x] sleep difficulties [ ] denied COPING: Occupation: cafgu Members of household: 6 Most supportive person: Himself

[ ] facial grimaces [ ] guarding [ ] other signs of pain no signs of pain [ ] side rail release form signed (60 + years) The patient has no side rails

Observed non- verbal behavior: He can gain knowledge in any advices and health teachings given. Person ( phone number): NONE

SPECIAL PATIENT INFORMATION (USE LEAD PENCIL)


66 kg Daily Weight 120/80BP q shift None Neuro VS _none__PT/OT none Irradiation ___/___ Urine Test

none CVP/SG. Reading___

___/__ 24 hour urine collections

Date Ordered

Diagnostic/ Lab Exams

Date done

Date ordered

IV Fluids/Blood

Date disconti nue

10-30-10 10-30-10 10-30-10 11-02-10 11-03-10 11-10-10 11-10-10

UTZ REPORT KUB CBC Sputum Culture CBC CBC Ultrasound report ECG

NONE

A. Laboratory results CBC 01-12-11 CBC WBC RBC Hgb Hct MCV MCH MCHC Platelet count Differential Count Neutrophils Lymphocytes Monocytes Eosinophils Basophils RDW-CV 01-12-11 RESULT 9.55 X 10^ 9/L 4.32 X 10^ 12/L 13.4 g/dl 41.2 % 95.4 fL 31.0 pg 32.5 g/dl 214 x 10^ 9/L NORMAL RANGE 5.0-10.0 3.69-5.90 11.70-14.00 34.10-44.00 70.00-97.00 26.10-33.30 32.0-35.0 150.0-390.0 IMPLICATION

50.8 % 37.0 % 6.4 % 5.8 % 0.0 % 13.1 % URINALYSIS

55.0-62.0 20.0-40.0 4.0-10.0 1.0-6.0 0.0-1.00 11.5-14.5

--to determine any abnormalities and microorganisms present in the urine.

MACROSCOPIC Color Appearance Glucose Protein Reaction Specific Gravity MICROSCOPIC WBC RBC Epithelial cells Mucous Threads Urates Bacteria

IMPLICATIONS Yellow Cloudy 1+ Negative 6.5 pH 1.015

50-60 0-2 2-4 Few Few Few

Epithelial cells in urine indicate infections, inflammation.

Nov 13, 2010

URINALYSIS

--to determine any abnormalities and microorganisms present in the urine.

Color Transparency Sugar and albumin Specific Gravity PH WBC Amorphous Urates Mucus Threads

Nov 13, 2010 Yellow Clear Negative 1.015 6.5 WBC= 2-3/hpf few moderate

IMPLICATIONS NORMAL NORMAL NORMAL NORMAL NORMAL WBC = WBCs in the urine may mean a UTI is present.
Nitrates in urine show a UTI is present.

This is a common finding in urine since the entire urine system is filled with mucus.

LATEST Color Bar brown

IMPLICATIONS Brown urine can be a side effect of a medication or may be caused by consumption of beets, or certain food colorings. It is also characteristic of a urinary tract disorder in which bleeding occurs such enlarged prostate, TB. Cloudy is a sign of a urinary tract infection, which may also have an offensive smell. It may also be caused by the presence of bacteria, mucus, WBC and RBC. NORMAL NORMAL NORMAL WBC = WBCs in the urine may mean a UTI is present. RBC= Inflammation, disease, or injury to the kidneys, ureters, bladder, or urethra can cause blood in urine. Nitrates in urine show a UTI is moderately present. This is a common finding in urine since the entire urine system is filled with mucus.
Epithelial cells in urine indicate infections, inflammation.

Transparency

Slight Turbid/CLOUDY Negative 1.020 6.0 WBC=2-3/hpf RBC=25.35/hpf moderate moderate few

Sugar and albumin Specific Gravity PH WBC RBC

Amorphous Urates Mucus Threads Epithelial Cells

Brown urine can be a side effect of a medication or may be caused by consumption of beets, or certain food colorings. It is also characteristic of a urinary tract disorder in which bleeding occurs such enlarged prostate, tuberculosis,

VII. Nursing Management IDEAL NURSING CARE PLAN


Name of Patient: Telecio, Lilia

Cues

Nursing diagnosis
Impaired Gas exchange related to inflammator y process

Objectives

Interventions

Rationale

Evaluation
At the end of 30 minutes, the patient will be able to demonstrate improved ventilation and adequate oxygenation of tissues.

Subjective: Galisud kog ginhawa usahay. As verbalized by the patient.

At the end of 30 minutes, the patient will be able to demonstrate improved ventilation and adequate

1. Elevate the head of the bed or position the patient appropriately. 2. Encourage frequent position changes and deep-breathing, coughing exercises. 3. Maintain adequate intake and output and to increase oral fluid intake but avoid fluid overload. 4. Encourage adequate rest and limit activities within clients tolerance. 5. Keep environment allergen and pollutant free.

1. To maintain airway.

2. To promote optimal chest expansion and drainage of secretions. 3. For mobilization of secretions. 4. Helps limit oxygen needs or consumption.

Objectives: Nasal flaring Productiv e cough RR= 20 cpm

oxygenation of tissues and participate in treatment regimen like breathing exercises.

5. To reduce irritant effects on airways.

ACTUAL NURSING MANAGEMENT


S
Galisud kog ginhawa usahay. As verbalized by the patient. Nasal flaring Productive cough RR= 20 cpm

Impaired Gas exchange related to inflammatory process

At the end of 30 minutes, the patient will be able to demonstrate improved ventilation and adequate oxygenation of tissues and participate in treatment regimen like breathing exercises. 1. Elevate the head of the bed or position the patient appropriately. To maintain airway. 2. Encourage frequent position changes and deep-breathing, coughing exercises. To promote optimal chest expansion and drainage of secretions. 3. Maintain adequate intake and output and to increase oral fluid intake but avoid fluid overload. For mobilization of secretions. 4. Encourage adequate rest and limit activities within clients tolerance. To promote releasing of secretions during coughing. 5. Keep environment allergen and pollutant free. To clear secretions and to treat underlying conditions. At the end of 30 minutes, the patient will be able to demonstrate improved ventilation and adequate oxygenation of tissues and participate in treatment regimen like breathing exercises.

IDEAL NURSING CARE PLAN


Name of Patient: Telecio, Lilia

Cues

Nursing diagnosis Ineffective airway clearance related to increase sputum production.

Objectives

Interventions

Rationale

Evaluation At the end of 30 minutes, the patient will be able to establish a normal, effective respiratory pattern and

Subjective: Galisud kog ginhawa usahay. As verbalized by the patient.

At the end of 30 1. Elevate the head of the bed or change position minutes, the every 2 hours and if patient will be necessary. able to establish a normal, effective respiratory pattern and can demonstrate appropriate coping mechanisms. 3. Maintain calm attitude while dealing with the client and significant others. 4. Encourage adequate rest periods between activities. 5. Turn the patient to the sides every 2 hours. 2. Encourage slower or deeper respirations, use of pursed-lip technique.

Objectives: Productive cough(whiti sh) Nasal flaring RR= 20 cpm

1. To decrease the pressure on the diaphragm and enhancing drainage to different lung segments. 2. To assist client in taking control of the situation and to promote optimal lung expansion. 3. To limit the level of anxiety.

4. To limit fatigue.

can demonstrate appropriate

5. To help release secretions and to prevent bed sores.

coping mechanisms.

ACTUAL NURSING MANAGEMENT


S Galisud kog ginhawa usahay. As verbalized by the patient. Productive cough(whitish) Nasal flaring RR= 20 cpm Ineffective airway clearance related to increase sputum production. A Short term: At the end of 30 minutes, the patient will be able to establish a normal, effective respiratory pattern and can demonstrate appropriate coping mechanisms. 1. Elevate the head of the bed or change position every 2 hours and if necessary. To decrease the pressure on the diaphragm and enhancing drainage to different lung segments 2. Encourage slower or deeper respirations, use of pursed-lip technique. To assist client in taking control of the situation and to promote optimal lung expansion. 3. Maintain calm attitude while dealing with the client and significant others. To limit the level of anxiety. 4. Encourage adequate rest periods between activities. To limit fatigue. 5. Turn the patient to the sides every 2 hours. To help release secretions and to prevent bed sores.

At the end of 30 minutes, the patient will be able to establish a normal, effective respiratory pattern and can demonstrate appropriate coping mechanisms.

IDEAL NURSING CARE PLAN


Name of Patient: Telecio, Lilia

Cues

Nursing diagnosis

Objectives

Interventions

Rationale

Evaluation

Subjective: Ginaubo ko ug nay plema ako ubo.as verbalized by the patient.

Risk for infection related to presence of existing infection.

At the end of 1 hour, the patient will be able to verbalize understanding of the individuals causative or risk

1. Stress power hand washing techniques by all caregivers givers between therapies and client. 2. Maintain sterile technique for any invasive procedures like pulmonary functioning. 3. Encourage early ambulation, deep breathing, coughing, and position change. 4. Maintain adequate hydration, sand/sit to void. 5. Administer or monitor medication regimen.

1. A first-line defense against nosocomial infections and cross contamination. 2. To prevent any contamination.

At the end of 1 hour, the patient will be able to verbalize understanding of the individuals

Objectives: Productive cough(whiti sh)

factors and identify interventions to prevent or reduce risk of infection.

causative or risk 3. For mobilization of respiratory secretions. factors and identify interventions to 4. To avoid bladder distention. 5. To determine effects, therapy, presence of side effects. prevent or reduce risk of infection.

ACTUAL NURSING MANAGEMENT


Ginaubo ko ug nay plema ako ubo.as verbalized by the patient.

Productive cough(whitish)

O
Risk for infection related to presence of existing infection.

A
At the end of 1 hour, the patient will be able to verbalize understanding of the individuals causative or risk factors and identify interventions to prevent or reduce risk of infection. 1. Stress power hand washing techniques by all caregivers givers between therapies and client. A first-line defense against nosocomial infections and cross contamination. 2. Maintain sterile technique for any invasive procedures like pulmonary functioning. To prevent any contamination. 3. Encourage early ambulation, deep breathing, coughing, and position change. For mobilization of respiratory secretions. 4. Maintain adequate hydration, sand/sit to void. To avoid bladder distention. 5. Administer or monitor medication regimen. To determine effects, therapy, presence of side effects.

At the end of 1 hour, the patient will be able to verbalize understanding of the individuals causative or risk factors and identify interventions to prevent or reduce risk of infection.

VIII. Referrals and Follow-up


Mrs. Telecio was admitted at Polymedic General Hospital, Velez at Station 4. She came in with a history; 2 weeks prior to admission, patient noted on and off cough with shortness of breath, without fever, consulted AP, and advised admission. She experienced cough and shortness of breath. During my first assessment with her, she experienced shortness of breath, productive cough whitish in color, chest pain with a pain scale of 3 over 10, muscle cramps, numbness of the lower extremities, blurred vision, she has a poor skin turgor, and her skin is warm to touch. As I observed her during that time, she has a poor skin turgor as I have pinched her skin in the arms. My patient was diagnosed with Bronchial asthma inn exacerbation, Pneumonia. She was under the treatment of Dr. Judee Go. For my referrals, the patient should have a proper compliance of medications, Continue medications as ordered. I also instructed and educate them patient and the significant others about the action, classification and possible side effects of the medications. I also encouraged the patient to have early ambulation as much as possible. I also instructed the patient to have calm activities and to avoid any strenuous activity and prevent stress by teaching them some relaxation techniques. The patient should also increase her oral fluid intake to excrete metabolic wastes. The Significant others should report any signs of unusualities to health care providers to provide adequate interventions and for the continuity of care. I also educate the significant others regarding the optimal care for the patient who has Pneumonia. I also gave health teaching to the patient about proper hygiene, infection control and proper mouth wash. I also encouraged the patient to have bed rest and to have a proper nutrition diet which is avoidance of foods that are irritating like alcoholic beverages, spices and chocolates, juices which are high in acids. It is good also for her to eat fruits rich in vitamins and high calorie foods for energy. I also instructed the patient to have a follow-up check up, one week after.

HEALTH TEACHINGS
Proper compliance to medications. Continue medications as ordered. Instruct and educate the patient and significant others about the action, classification and possible side effects of the medications.

MEDICATION

EXERCISE

Encouraged the patient to have early ambulation as much as possible. Instruct to have calm activities and prevent stress by teaching them some relaxation techniques. Proper compliance of medications at the right time and at the right dose. Increased oral fluid intake and proper nutrition diet. Report any signs of unusualities to health care provider to provide adequate interventions and for the continuity of care.

TREATMENT

OUTPATIENT

Educate the significant others regarding the optimal care for patient who was post-op. Proper hygiene and infection control and proper wound dressing. Encouraged to have bed rest. Increased oral fluid intake and proper nutrition diet. Proper compliance to medications. Follow-up check after 1 week.

DIET

Increased oral fluid intake. High calorie foods for energy. Eat foods rich in vitamins. Avoid irritating foods like alcohols, carbonated drinks, spices and chocolates.

IX. Evaluation and Implications Evaluation


After conducting the study, I was able to apply nursing process and critically analyze my patients condition. Through practicing nursing process, interventions were rendered effectively. At the end of the case study, I am thankful that I was able to come up with nursing care plans that somehow alleviate my patients condition. I considered my nursing interventions as effective one because I have rendered my care to the patient properly and heartily. I have done my actual nursing interventions with my clinical instructor. She supervised me whenever I performed nursing procedures to my patient. Although, I have performed some of the nursing procedures, but I really enjoyed our duty at the surgical ward and building rapport to my patient and her watcher. Our clinical instructor and some of the hospital staffs helped us whenever we encountered difficulties. Our CI was very approachable and always instructed us on what to do and always supervised us. At the end of one day of giving care to my patient, I have learned also to improve the use of knowledge, skills and good attitude and I was able to give health teachings and build rapport to my patient and significant others and I have provided my nursing care heartily. I was able also to provide therapeutic communication to my patient.

Implication
Early detection of an ailment is vital to the patient. Often times lack of in depth knowledge regarding a condition of a disease May hinder a patient in seeking immediate advice from medical specialist. Fear and financial problems may sometimes interfere which may often lead to the severity of the disease The patient should take an adequate rest and proper administration of medications at the right time and at the right dose. The significant others should be educated with the unusualities and possible complications that may occur.

X. BIBLIOGRAPHY
Books:
1. Suzanne C Smeltzer et al.,Textbook of Medical-Surgical Nursing. 11th edition. Volume 1. Lippincott Williams and Wilkins, 2008. pp. 643-650(Pulmonary Tuberculosis) , pp. 17511752( Benign Prostatic hyperplasia), pp.1209-1217 ( Peptic Ulcer Disease -vol 1) 2. Fundamentals of Nursing. Lippincott Williams and Wilkins, 2007. pp. 419-430. 3. Adele Pilliteri. Maternal and Child Health Nursing: Care of the Child Bearing and Childrearing Family. 5th ed. Vol 2. Lippincott Williams and Wilkins, 2007. Pp. 813-822. 4. Mr. Denise O. Orong, PTRP et al., Anatomy and Physiology Compilation of Lecture Notes and Workbook. Pp.72-84. 5. Seeley, Rod et al. Anatomy and Physiology, 6th edition. Mc-Graw Hill Companies, Inc., 2003. Pp. 813-829. 6. Harkreader, Helen et al. Fundamentals of Nursing. Caring and Clinical Judgment, 3 rd edition. Saunders, Elsivier Inc., 2007. Pp 324-381.

Internet:
http://darkwing.uoregon.edu/~moursund/Math/developmental_theory.htm http://www.essortment.com/all/piagetjeancogn_rkje.htm http://www.soulhealer.com/anatomy-res.htm http://www.scribd.com/doc/11888556/Tuberculosis