Pneumonia

I. INTRODUCTION

Pneumonia is an acute infection of the lung parenchyma that commonly impairs gas exchange. The prognosis is usually good for people who have normal lungs and adequate host defenses before the onset of pneumonia; however, bacterial pneumonia is the fifth leading cause of death in debilitated patients. The disorder occurs in primary and secondary forms (Medical Surgical-Nursing Made Incredibly Easy).

PREDISPOSING FACTORS AND RISK FACTORS

The nurse should be acquainted with the factors and circumstances that commonly predispose the person to pneumonia. Hence, the nurse is able to identify the patient at high risk and to engage in anticipatory and preventive nursing.

Any condition that produces mucus or bronchial obstruction and interferes with normal drainage of the lung (cancer, chronic obstructive pulmonary disease [COPD]) renders the patient susceptible to pneumonia.

Immunosuppressed patients are risk. People who smoke are at risk because cigarette smoke disrupts both

mucociliary and macrophage activity. Any patient who is permitted to lie passively in bed for prolonged

periods, relatively immobile and breathing shallowly, is highly vulnerable to the risk of bronchopneumonia.

Any person who has a depressed cough reflex (due to medications or weakness), has aspirated foreign material into the lungs during a period of unconsciousness (head injury, anesthesia), or has an abnormal swallowing mechanism is very likely to develop bronchopneumonia.

Any hospitalized patient on a nothing-by-mouth regimen or who is receiving antibiotics has increased pharyngeal colonization of organisms and is at risk. In very ill persons, the oropharynx is likely to be colonized by gram-negative bacteria.

People who are intoxicated frequently are particularly susceptible to pneumonia, because alcohol suppresses the body’s reflexes, white cell mobilization, and tracheobronchial ciliary motion.

Any person scheduled to receive a sedative is observed for respiratory rate and depth before the drug is given; if respiratory depression is apparent, the medication should not be administered. Respiratory depression predisposes to the pooling of bronchial secretions and subsequent development of pneumonia.

Frequent suctioning of secretions in patients who are unconscious or have poor cough and gag reflexes is an important preventive measure. This reduces he likelihood that secretions will be aspirated or accumulate in the lungs and induce bronchopneumonia.

Elderly people are especially vulnerable to pneumonia because of depression of cough and glottic reflexes. Postoperative pneumonia

should be anticipated in the elderly and forestalled by frequent mobilization, effective coughing, and breathing exercises.

Anyone receiving treatment with respiratory therapy equipment can develop pneumonia if the equipment has not been properly cleaned.

Incidence Rate of Pneumonia and Acute Lower Respiratory Tract Infection in the Philippines by Sex

No. and Rate/100,000 Population as of 2004

CAUSE MALE FEMALE BOTH SEXESRate** Rate** Number Rate*

1. Acute Lower RTI and Pneumonia

888.8 868.0 776,562 929.4

PATHOPHYSIOLOGY

Bacterial pneumonia creates problems in both ventilation and diffusion. An inflammatory reaction initiated by pneumococci occurs in the alveoli and produces an exudate. This exudate, in turn, interferes with both movement and diffusion of oxygen and carbon dioxide. White blood cells, mostly neutrophils, also migrate into the alveoli, so that the lung segment assumes a more solid structure as the air-containing spaces become filled. Areas of the lung are not adequately ventilated because of secretions, mucosal edema, and bronchospasm. These conditions cause partial occlusion of the bronchi or alveoli, producing a drop in the alveolar oxygen tension. Venous blood coming into the lungs passes through the left side of the heart without being oxygenated. In essence, the blood is shunted from the right to the left side of the heart. This mixing of oxygenated blood eventually results in arterial hypoxemia.

CLINICAL MANIFESTATIONS

Pneumonia usually starts with a sudden onset of shaking chills, rapid rising fever (39.5 ˚ to 40.5 ˚ C [100˚ to 105˚ F]), and stabbing chest pain that is aggravated by respiration and coughing. The patient is severely ill with marked tachypnea (25 to 45 bpm) accompanied by respiratory grunting, nasal flaring, and the use of accessory muscles of respiration. He often lies on his affected side in an attempt to splint his chest. The pulse is rapid and bounding. It usually increases about 10 bpm for every degree of Celsius temperature elevation. A relative bradycardia for the amount of fever should suggest viral infection, Mycoplasma infection, or infection with Legionella

species. The cheeks are flushed, the eyes bright, and the lips and nailbed cyanotic. The patient prefers to be propped up in bed and leans forward, trying to achieve adequate gas exchange without trying to cough or breathe deeply. He perspires profusely. The sputum is purulent and not a reliable indicator of the etiologic agent. Rusty, blood-tinged sputum is produced in pneumococcal, staphylococcal, Klebsiella, and streptococcal pneumonia. Klebsiella pneumonia frequently also has viscous sputum. H. influenzae sputum is green.

Other signs occur in patients who suffer from a condition such as cancer or those who are undergoing treatment with immunosuppressants, which lower the resistance to infection and to organisms heretofore not considered serious pathogens. Such patients present with fever, crackles and physical signs of lobar consolidation , including increased tactile fremitus, percussion dullness, bronchovesicular or bronchial breath sounds, egophony (change of patient’s “ee” to “ay” sound on auscultation), and whispered pectoriloquy (whispered sounds heard louder and more clearly than normal on auscultation). These changes occur because sound is transmitted better through solid tissue (consolidation) than through normal tissue.

In older patients or those with COPD, the symptoms maydevelop insidiously. Purulent sputum may be the only sign of pneumonia in these patients. It is difficult to detect subtle changes in their conditions because they have seriously compromised pulmonary function.

MANAGEMENT

The treatment of pneumonia depends largely on administration of the appropriate antibiotic as determined by the results of the Gram stain. Penicillin G is clearly the antibiotic of choice for infection with S. Pneumoniae. Other effective drugs include erythromycin, clindamycin, the cephalosporins, other penicillins, and trimethoprim-sulfamethoxazole (Bactrim).

The patient is placed on bed rest until infection shows signs of clearing. He is observed carefully and continually until his clinical condition improves.

The patient who is hypoxemic is given oxygen. Arterial blood gas analysis is performed to determine the need for oxygen and to evaluate its effectiveness. A high concentration of oxygen is contraindicated in patients with COPD because it may worsen alveolar ventilation by removing the patient’s only remaining ventilatory drive and lead to respiratory decompensation. Respiratory support measures such as endotracheal intubation, high inspiratory oxygen concentrations, mechanical ventilation, and positive end expiratory pressure (PEEP) may be requires for some patients.

NURSING CARE

Improvement of Airway Patency

Retained secretions interfere with gas exchange and may cause slow resolution of the disease. A high level of fluid intake (2-3 l/day) is encouraged, as adequate hydration thins and loosens pulmonary secretions and also replaces fluid losses resulting from fever, diaphoresis, dehydration and dyspnea.

Chest physiotherapy is extremely important in loosening and mobilizing secretions. The patient is placed in the proper position to drain the involved lung, and then the chest is vibrated and percussed. After the lung has drained for 10 to 20 minutes, the patient is encouraged to breath deeply and cough. If he is too weak to cough effectively, the mucus may have to be removed by nasotracheal suctioning or by bronchoscopic aspiration as determined by the physician.

If oxygen is prescribed, the nurse provides the necessary method of oxygen administration and monitors the effectiveness of the oxygen concentration by assessing for the clinical manifestations of hypoxia.

Rest and Energy Conservation

The patient is encouraged to rest and remain in bed to avoid overexertion and possible exacerbation of symptoms. He is placed in a comfortable position for resting and breathing (e.g. semi-Fowlers) and encouraged to change position frequently.

If sedatives or tranquilizers are prescribed, the patient’s sensorium is evaluated first. Restlessness, confusion, and aggression may be due to cerebral hypoxemia, in which case sedatives are contraindicated.

Proper Fluid Intake

The patient’s respiratory rate increases because of dyspnea and fever. With an increased rate there is an increase in insensible fluid loss during exhalation. The patient can quickly become dehydrated. Therefore, fluids are encouraged (at least 2 L/day). Frequently, a patient who is dyspneic is also anorexic and will only take fluids. Fluids, then, are beneficial for volume replacement as well as nutrition.

Patient Education and Home Health Care

After the fever subsides, the patient may gradually increase his activities. Fatigue, weakness, and depression may be prolonged after pneumonia. Breathing exercises to clear the lungs and promote full lung expansion are encouraged. The patient is instructed to the clinic or physician’s office for follow up chest x-rays.

The nurse explains to the patient that it is wise to stop cigarette smoking because it destroys tracheobronchial ciliary action, which is the first line of defense of the lungs. Smoking also irritates the mucous cells of the bronchi and inhibits the function of alveolar macrophage (scavenger) cells. The patient is instructed to avoid fatigue, sudden changes in temperature, and excessive alcohol intake, which lower resistance to pneumonia. The nurse reviews with the patient the principles of adequate nutrition and rest, because one episode of pneumonia may make him susceptible to recurring respiratory tract infections. He is encouraged to obtain influenza vaccine ate the prescribed times, because influenza increases susceptibility to secondary bacterial pneumonia, especially that caused by Staphylococcus, H. influenzae, and S. pneumoniae.

II. OBJECTIVES

A. GENERAL OBJECTIVE

The general objective for conducting this case study is for students to incorporate concepts and enhance knowledge in Medical and Surgical Nursing and to apply the appropriate nursing management for clients with pneumonia accurately and efficiently. This study also aims to develop the skills that are applied for the care of patient’s wit this condition.

B. SPECIFIC OBJECTIVE

1. Define pneumonia accurately.2. Discuss briefly the causative factors that may have precipitated the

onset of this condition.3. Discuss thoroughly the signs and symptoms manifested by the

patient.4. Discuss the different drugs; indications, mechanism of action,

therapeutic effects, adverse effects and contraindications.5. Present accurately the condition of the patient.6. Acquire knowledge and understanding of the pathophysiology of

pneumonia.7. Discuss the nursing care plan appropriate in providing care to

alleviate the manifestation of the patient’s symptoms.8. Identify and provide the health teachings needed for the continuum

of care.9. Use the nursing care plan as the framework of the patient’s care.

III. Nursing History

1. Personal Data

a. Name: Patient VCb. Age: 68 yrs. Oldc. Sex: Femaled. Address: 551 Gen. Hizon St., Bangkal, Makati CPO,

Makati City 1200e. Occupation: Household Personnelf. Religion: Roman Catholicg. Date and time of admission: June 14, 2009 9:00 AMh. Admitting Physician: Dr. Florencio Chavez M.D.i. Date and time of discharge: June 18, 2009

2. Chief Complaint:

Cough

3. History of Present Illness:

Two weeks PTA, patient experienced cough and whitish phlegm, productive and associated pain. Patient self medicate with Guaifenisin syrup with afforded slight relief. Few hours PTA persistence of cough and associated easy fatigability and shortness of breath prompted the patient to consult hence admitted.

4. Past Medical History

• As cites - 1976 • Pneumonia - 2006 • Hypertension - 2005 Therebloc 50 with BP 150/100 • S/P Cyst Removal (hand) - 1975 • Goiter - 1975

5. Family Medical History

Hypertension - both father (deceased) and mother (deceased)

6. Clinical Impression

Pneumonia, Right Lower Lobe

IV. PATTERNS OF FUNCTIONING (GORDON’S)

Patterns of Functioning

Before Hospitalization

During / After Hospitalization

Analysis

1. Health Perception

The client perceives herself as a healthy person because according to her, she eats nutritious food and has a good personal hygiene.

The client still perceives herself as a healthy person.

The client tries to cope with her condition by thinking positively.

2. Nutritional / Metabolic Pattern

The client likes to eat rice, vegetables and some fatty foods. She also drinks about 1L of water per day.

The client’s diet is low salt and low fat as instructed by the doctor.

The client follows her doctor’s advice and vows that she will continue for her own good.

3. Elimination Pattern

The client urinates frequently (4-7 times) daily and moves her bowel once a day.

The client urinates 7-12 times and moves her bowel once per day.

The client urinates more frequently in the hospital because of her I.V. therapy which is a good sign.

4. Activity / Exercise Pattern

The client easily gets tired and her body feels weak as she does her household work.

The client is now able to move freely without easily getting tired and weak.

The client can perform her tasks well when she’s in good condition.

5. Sleep / Rest Pattern

The client sleeps 7 hours every night and takes 30 minutes to 1 hour naps every afternoon.

The client’s sleeping pattern is disturbed because of difficulty in breathing.

The client developed disturbed sleeping pattern because of her condition.

6. Cognitive-Perceptual Pattern

The client said that she is cooperative.

The client is not hesitant to answer the questions asked.

The client did not change her attitude.

7. Self-perception / Self Concept Pattern

The client has a high self-esteem.

The client, upon learning about her condition, still

The client is not affected of her condition.

has a positive perception.

8. Role-relationship Pattern

The client even at her age, still works for her family and loves the family she works with.

The client thinks that she will still continue working to earn money.

The client’s children motivate and inspire her to work.

9. Sexuality-Reproductive Pattern

The client is a senior citizen.

The client is a senior citizen.

10. Coping / Stress Tolerance Pattern

The client is stressed with her employer everytime she doesn’t do her tasks well.

The client is more stressed due to her condition.

The client is more stressed because of her present condition.

11. Value belief Pattern

The client is a Roman Catholic and still believes in herbolarios.

The client has strong faith in God and believes that she will get well soon.

The client’s faith in God is strong that gives her a positive outlook.

V. PHYSICAL ASSESSMENT

Date: June 17, 2009Time: 8:00 p.m.Vital sign:

Temperature: 36.5M CeliusPulse rate: 69 bpmRespiratory rate: 20 cpmBlood Pressure: 130/80 mmHg

Body PartsTechnique Used

(IPPA)Findings Analysis

Appearance and Mental status

Inspection -clean, presentable, cooperative

- normal

Skin Inspection and

Palpation

-light brown-poor skin turgor(elders)

-no edema-excessive number of moles

- normal

- sign of aging

Nails Inspection - convex, smooth, return to pink when press

- normal

Skull and Face Inspection and

Palpation

- coordinated facial movements

- mass below the right ear

- normal

- may be a sign of cyst

Eyes

Inspection and

Palpation

-both eyes are coordinated-able to read news papers-black in color; equal in size

-no tenderness in lacrimal duct and glands

normal

Ears Inspection and

Palpation

Testing

-color same as facial skin-auricle in line with the outer canthus of the eye

-not tender

-only the right ear able to hear.

Normal

Poor hearing due

Nose and sinuses Inspection and Palpation

-air can pass through without obstruction- no pain when palpated-no discharge

- normal

Mouth Inspection and Palpation

Lips – pinkishTeeth and Gums – with denturesTongue – moves freely, no tenderness

normal

Neck Inspection, Palpation, and Percussion

-Muscles equal in size and strengthLymph nodes- not palpableThyroid glands- not palpable

normal

Thorax and Lungs

Inspection

Palpation,

Percussion

Auscultate

-Skin intact, uniform in temperature-no tenderness

-resonance filled with air-vesicular and bronchovesicular breath sound

normal

Heart and Central VesselsBreast and axillae

REFUSED REFUSED

Abdomen Inspection, Auscultate,

Percuss and Palpate

-with stretch mark-bowel sound can be heard-tympany over the stomach and gas-filled bowels, dullness over the organs such as spleen and liver, or full bladder

normal

Musculoskeletal System

Not done Not done

VI. ANATOMY AND PHYSIOLOGY

Our lung is a pair of elastic, spongy organs used in breathing and respiration. Lungs are present in all mammals, birds, and reptiles. Most amphibians and a few species of fish also have lungs.

In humans the lungs occupy a large portion of the chest cavity from the collarbone down to the diaphragm, a dome-shaped sheet of muscle that walls off the chest cavity from the abdominal cavity. At birth the lungs are pink, but as a person ages, they become gray and mottled from tiny particles breathed in with the air. Generally, people who live in cities and industrial areas have darker lungs than those who live in the country.

Air travels to the lungs through a series of air tubes and passages. It enters the body through the nostrils or the mouth, passing down the throat to the larynx, or voice box, and then to the trachea, or windpipe. In the chest cavity the trachea divides into two branches, called the right and left bronchi or bronchial tubes, which enter the lungs.

In the adult human, each lung is 25 to 30 cm (10 to 12 in) long and roughly conical. The left lung is divided into two sections, or lobes: the superior and the inferior. The right lung is somewhat larger than the left lung and is divided into three lobes: the superior, middle, and inferior. The two lungs are separated by a structure called the mediastinum, which contains the heart, trachea, esophagus, and blood vessels. Both right and left lungs are covered by an external membrane called the pleura. The outer layer of the pleura forms the lining of the chest cavity.

The branches of the bronchi eventually narrow down to tubes of less than 1.02 mm (less than 0.04 in) in diameter. These tubes, called

bronchioles, divide into even narrower tubes, called alveolar ducts. Each alveolar duct ends in a grapelike cluster of thin-walled sacs, called alveoli (a single sac is called an alveolus). From 300 million to 400 million alveoli are contained in each lung. The air sacs of both lungs have a total surface area of about 93 sq m (about 1000 sq ft), nearly 50 times the total surface area of the skin.

In addition to the network of air tubes, the lungs also contain a vast network of blood vessels. Each alveolus is surrounded by many tiny capillaries, which receive blood from arteries and empty into veins. The arteries join to form the pulmonary arteries, and the veins join to form the pulmonary veins. These large blood vessels connect the lungs with the heart.

Through the right lung has three lobes, the left lung, with a cleft to accommodate the heart, has only two lobes. The two branches of trachea called bronchi, subdivide within the lobes into smaller and smaller air vessels. They terminate into alveoli, tiny air sacs surrounded by capillaries.

When the alveoli inflate with inhaled air, oxygen diffuses into the blood in the capillaries to be pumped by the heart to the tissues of the body and carbon dioxide diffuses out of the blood into the lungs to be exhaled.

THE FLOW

Nose (nasal passages)

Pharynx

Larynx

Trachea

Bronchi

Bronchioles

Alveoli

VII. PATHOPHYSIOLOGY

VIII.LABORATORY / DIAGNOSTIC EXAMINATIONS

Date: June 14, 2009

Department of PathologyCLINICAL CHEMISTRY SECTION

Specimen: Serum

Lipid Profile (Cholesterol, HDL, TRI, LDL)

Examination Result Reference Value

Serum Cholesterol 4.98 less than 5.2 mmol/LTriglycerides 1.10 less than 2.26 mmol/LHDLHDL- high density lipo protein 0.86 1-0-1.6 mmol/LLDL (low density lipoprotein) 3.62 less than 3.4 mmol/L

Department of PathologyCLINICAL CHEMISTRY SCETION

Date: June 14, 2009 FBS- Fasting blood sugar 8.0 4.1-5.9 mmol/L

Date: June 14, 2009

X-RAY SECTION

Examination: Chest (PA oar AP)Hazed densities are seen in the right lower lobe.Heart is enlarged obscuring the Left hemidiaphragm and Left sulcus. Aortic knob is selerotic.Right hemidiaphragm and sulcus are intact.Bones are unremarkable.

Impression:Pneumonia, Right lower lobeCardiomegalyAtheromatous Aorta

Department of Pathology

Hematology SectionSpecimen: Blood

CBC- complete blood countDate: June 14, 2009

Examination Result Reference Value

Hemoglobin 12.9 12.5- 16.0g/dLHematocrit 39.3 37-43%Red Blood Cells 4.30 4.2-5.4 – 10 6/uLmean Corpusculae hemoglobin 30.0 26-32pgmean corpusculae volume 91.4 77-93 FLmean corpuscular hemoglobin 32.8 31-35 g/dL

white blood cells 6.0 4.0-10.5 10 3/uLneutrophils 54.2 43-65%lymphocyte 32.1 20.5-40.5%monocyte 7.8 5.5-11.7%eosonophil 4.9 0.9-2.9%basophil 1.0 0.2-1.0%

Department of PathologyClinical Chemistry Section

Date: June 14, 2009

Test name ResultRBS-Reflo : 9.3 mmol/L as of 1:10pm

Concentration

Department of PathologyClinical Chemistry Section

Specimen: serumelectrolyte determination- NA, K, CL

Date: June 14, 2009

Examination Result Reference Value

Sodium 137.0 135-148 mmol/LPotassium 3.86 3.5-5.3 mmol/LChloride 1o4.8 98-107 mmol/L

Department of PathologyClinical Chemistry Section

Specimen: serum

Date: June 14, 2009

Bun- Blood Urea Nitrogen 36 2.5- 6.1 mmol/LCreatinine (serum) 53.0 46-92 umol/LSGPT- Aspartate Amino Transferase 26.0 14.36 u/LUA- blood Uric acid 0.378 0.149-0.369 mmol/L

Date: June 14, 2009DR. CHAVEZ, FLORENCIO R.

URINALYSIS REPORT: REFERENCE VALUES

Physical Examination Results: YellowColor : Light Yellow Clear

Transparency: Slightly Hazy 4.6- 8.0 Reaction: 6.5 1.06- 1.022

CHEMICAL EXAMINATION

Leukocytes: Trace (15 ca. CELLS/UL) Negative Nitrate: Negative Negative

Urobilinogen: Normal (3.2 umol/L) Negative Protein: Negative Negative Blood: Negative Negative Ketone: Negative Negative Bilirubin: Negative Negative Glucose: Negative Negative

Date: June 14, 2009

URINE FLOWCYTOMETRY

CONVENTIONAL UNIT S.I. UnitResult Unit Reference

RangeResult Unit Reference

RangeRBC 0.4 /hpf 0.2 2.1 /ul 0-11WBC 6.1 /hpf 0.3 33.8 /ul 0-17BACTERIA 0.5 /hpf 0-50 2.9 /ul 0-278EpthelialCells 0.6 /hpf 0-3 3.2 /ul 0-17Casts 0.0 /hpf 0-3 0.0 /ul 0-1

Department of PathologyClinical Chemistry Section

Date: June 16, 2009

Test Name ResultRBS_ Reflo : 5-6 mmoL/ as of 5pm

Department of PathologyClinical Chemistry Section

Date: June 16, 2009

Test Name ResultRBS- Reflo : 9.3 mmol/L as of 2pm

IX. MEDICAL INTERVENTIONS

Medical Operations Date and Time

ordered

Classification

Rationale

D5NM 1L + BNC x 4 hrs.

06/14/099:00 am

Therapeutic For maintenance

D5W 1L + BNC x 4 hrs. Therapeutic For cardio patients

Tazocin (4.5 gms) IV Q 8 hrs.

Therapeutic For the treatment of patients with Community-acquired pneumonia

Norvasc (5 mg) 1 tab. Aft. breakfast

Therapeutic Helps to lower the BP

Plavix (75 mg) 1 tab OD Therapeutic Helps to treat Myocardial Infarction

Vastarel (35 mg) 1 tab. BID

Therapeutic Treatment for of visual disorders of a circulatory origin.

Levopront (2 tsp.) TID TherapeuticCombivent neb TID Therapeutic To relax muscles in

the airways and increase air flow to the lungs.

Coralan (5 mg) 1 tab. OD

Therapeutic

For CBC, UA, BUN, CREA Electrolytes, RBS, SGPT, SGOT, Chest x-ray, P.A., Uric acid

Diagnostic To provide general measure of kidney function,to check if there are imbalances and to know if there are any abnormalities.

For 2decho and sputum GSCS

06/15/0911:25 am

Diagnostic To determine if there are any abnormalities present and ensure that microorganisms can be accurately detected.

IVF TF – D5NM 1L + BNC x 4 hrs.

Therapeutic For cardio patientsFor maintenance

IVF to ff: D5NM 1L + 1 amp. BNC x 4hrs.

06/16/093:42 am

Therapeutic For cardio patientsFor maintenance

OD ANSTGlucophage (500 mg) 1 tab. TID

10:45 am Therapeutic To control blood sugar levels.

HGT monitoring TID ac TherapeuticIVF to consume 06/17/09

11:20 amTherapeutic For cardio patients

D/C Tazocin IV Therapeutic For the treatment of patients with Community-acquired pneumonia

Shift Levox x 500 IV to Levox 500 mg/tab.1 tab. OD aft. breakfast

Therapeutic For the treatment of patients with Community-acquired pneumonia

X. DRUG STUDY

Generic and Brand name

Classification Dosage, Frequency & Route

Mechanism of action

Indications Contraindications AdverseReactions

NursingConsiderations

AmlodipineNorvasc

Calcium channel-blocker

Antianginal drug

Antihypertensive

5 mg(1 tab.)OD pc (breakfast)p.o.

Cause a reduction in peripheral vascular resistance and reduction in blood pressure.

Hyperten-sion

Chronic Stable Angina

allergy to diltiazem, impaired hepatic or renal function, sick sinus syndrome, heart block (second or third degree)

CNS: Dizziness, lightheadedness, headache, asthenia, fatigue, lethargy

GI: Nausea, abdominal discomfort

CV: Peripheral edema, arrhythmias

Dermatologic: Flushing, rash

AssessmentHistory: Allergy to amlodipinePhysical: Skin lesions, color, edema

Implementation

Monitor patient carefully (BP, cardiac rhythm, and output)

ClopidogrelPlavix

Adenosine diphosphate

Antiplatelet

5 mg (1 tab)ODp.o.

Inhibits platelet aggregation by blocking

Treatment of patients at risk for ischemic

allergy to clopidogrel

CNS: Headache, dizziness, weakness, syncope,

Assessment

History: Allergy to

agent ADP receptors on platelets

events--history of MI

flushing

GI: Nausea, GI distress, constipation, diarrhea, GI bleed

Dermatologic: Skin rash, pruritus

clopidogrel,

Physical: Skin color, temperature, lesions

Implementation

Provide small, frequent meals if GI upset occurs

Trimetazi-dine di-hcl

Vastarel

Anti-Anginal Drugs

35 mg1 tab.BIDp.o.

MAOIs. Prophylactic treatment of episodes of angina pectoris; adjuvant symptomatic treatment of vertigo & tinnitus.

Pregnancy & lactation.

Rare cases of GI disorders

Levopront Antitussive 2 tsp.TID

The medication

Dry unproducti

Hypersensitivity, the excess rate,

It is an antitussive drug,

p.o. with drug Levopront yet to materialize.

ve cough with pharyngitis, , influenza, pneumonia, bronchial asthma, emphysema lungs

expressed violations of the liver.

it can cause dizziness, somnolence, nausea, vomiting, heartburn, diarrhea, abdominal discomfort, faintness

Coralan

Ivabradin

Ivabradine HCL

5 mg ( 1 tab.)ODp.o.

Reduces cardiac pacemaker activity, slowing the heart rate

Symptomatic treatment of chronic angina pectoris in patients w/ normal sinus rhythm

Unstable anginaSevere liver prob. Severe heart failures

May cause temporary venous visual phenomena

MetforminGlucophage

Antidiabetic agent

50 mg/tab.TIDp.o.

Exact mechanism is not understood

Adjunct to diet to lower blood glucose with non-insulin-dependent diabetes

Allergy to metformin; diabetes complicated by fever, severe infections, severe trauma, major surgery, ketosis, acidosis, coma

GI: anorexia, nausea, vomiting, epigastric discomfort, heartburn, diarrhea

Endocrine: hypoglycemia,

Assessment

History: Allergy to metformin; diabetes complicated by fever

Physical: Skin

mellitus (use insulin)lacticacidosis

Hypersensitivity: allergic skin reactions, eczema, pruritus, erythema, urticaria

color, lesions,

Implementation

Monitor urine and serum glucose levels frequently

Arrange for transfer to insulin therapy during periods of high stress

Levofloxa-cin

Levaquin(Levox)

Antibiotic

Flouroquinolone

500 g (1 tab.)OD aft. Breakfastp.o.

Bactericidal Treatment of adults with CAP

Treatment of acute exacerbation of chronic bronchitis

Treatment of uncomplica

allergy to fluoroquinolones,

CNS: Headache, dizziness, insomnia, fatigue, somnolence, depression, blurred vision

GI: Nausea, vomiting, dry mouth, diarrhea

Hematologic: Elevated BUN,

Assessment

History: Allergy to fluoroquinolones, renal dysfunction, seizuresPhysical: Skin color, lesions

Implementation

ted skin and skin structure infections

Treatment of complicated UTIs and acute pyelonephritis

SGOT, SGPT, serum creatinine, and alkaline phosphatase

Arrange for culture and sensitivity tests before beginning therapy.

Ensure that patient is well hydrated during course of therapy.

Ipratropium bromideCombivent

Anticholinergic

Antimuscarinic agent

Parasympatholy

tic

1 nebTID

Anticholinergic, chemically related to atropine

Bronchodilator for maintenance treatment of bronchospasm associated with COPD

hypersensitivity to atropine or its derivatives, acute episodes of bronchospasm.

CNS: Nervousness, dizziness, headache, fatigue, insomnia, blurred vision

GI: Nausea, GI distress, dry mouth

Respiratory: Cough

AssessmentHistory: Hypersensitivity to atropine; acute bronchospasm, narrow-angle glaucoma, prostatic hypertrophyPhysical: Skin color, lesions,

Implementatio

n

Ensure adequate hydration

Have patient void before taking medication to avoid urinary retention.

DRUG NAME DOSAGE ACTION INDICATIONS CONTRAINDICATIONSADVERSE EFFECTS

NURSING RESPONSIBILITIES

Acetaminophen

Brand Name: Paracetamol

Classification: Nonopiod Analgesic and Antipyretics

500 mg 1 tab q 40

PRN if temp≥37.80C

Unknown. Thought to produce analgesia by blocking pain impulses by inhibiting synthesis of prostaglandin in the CNS or receptors to stimulation. The drug may relieve fever through

mild pain fever

Patients hypersensitive to drug

Use cautiously in patients with long term alcohol use

Hematologic:- hemolytic

anemia- neutropenia- leucopenia- pancytopeni

a Jaundice Hypoglycemia Rash

Question for sensitivity to acetaminophen.

Obtain baseline data before giving medication.

Document presence of pain/fever.

Administer drug with food or milk to decrease GI upset.

Assess for clinical

central action in the hypothalamic heat-regulating center.

improvement and relief of pain and fever.

Levofloxacin

Brand Name: Levox

Classification: Antibiotic: Quinolone/Fluoroquinolones

750 mg 1 tab OD

Inhibits bacterial DNA gyrase and prevents DNA replication, transcription, repair, and recombination in susceptible bacteria.

Acute maxillary sinusitis caused by susceptible strains of Streptococcus pneumoniae, Moraxella catarrhalis, Haemophilus influenzae.

Mild to moderate skin and skin-structure infections caused by Staphylococcus or S. pyrogens.

Acute bacterial worsening of chronic bronchitis

Community-acquired

Patients hypertensive to drug, its components or other fluoroquinolones.

Use cautiously in patients with history of seizure disorders or other CNS diseases such as cerebral arteriosclerosis.

Use cautiously and with dosage adjustments in patients with renal impairment.

CNS:- headache- insomnia- dizziness- seizures

CV:- chest pain- palpitations- vasodilation

GI- nausea- diarrhea- vomiting- abdominal

pain- dyspepsia- flatulence

back pain allergic

pneumonitis- vasodilation

SKIN- rash- photosensiti

vity- pruritus

Obtain specimen culture and sensitivity tests before starting therapy and as needed to determine if bacterial résistance has occurred.

Let the patient take the drug with plenty of fluids and to appropriately space antacids, sucralfate, and products containing iron or zinc after each dose of Levofloxacin.

Advise patient to avoid excessive sunlight, use sunscreen, and wear protective clothing when outdoors.

Notify prescriber if rash of other signs or symptoms of hypersensitivity develop.

Monitor glucose level and renal, hepatic,

pneumonia and hematopoietic blood studies.

Fluimucil

Brand Name: Zambon

Classification: Acetylcysteine

600 mg 1 tab in ½ glass of water

Reduces the viscosity of purulent and nonpurulent secretions and facilitates their removal by splitting disulfide bonds. Action increases with increasing pH. Also reduces liver injury due to acetaminophen over dosage by maintaining or restoring glutathione levels or by acting as an alternate substrate for the reactive metabolite of acetaminophen.

acute and chronic respiration tract infection with abundant mucus secretion

drug sensitivity Phenylketonurics

increased incidence of bronchospasm

GI:- nausea- vomiting- stomatitis

Use nonreactive plastic, glass or stainless steel for administration.

May administer via face mask, face tent, oxygen tent or by positive pressure apparatus.

Administer with compressed air for nebulization.

Have suction available for emoval of increased secretions.

XI. LIST OF NURSING DIAGNOSIS

Nursing Diagnoses InterpretationIneffective airway clearance related

to presence  of secretionIneffective airway clearance is a life

threatening problem. The main concern is to promote immediate

oxygenation and eliminate the secretions.

Risk for unstable blood glucose related to dietary intake: weight gain

The risk for unstable blood glucose is another problem. However if the client is informed about the proper

diet, the problem may not develop as an actual problem. There is no

intervention needed just continue the assessment.

Sleep pattern disturbance related to cough

Lack of sleep is a life threatening. But to threat the ineffective airway clearance, will change this priority.

Therefore, measure to promote sleep will be less prioritized until bedtime.

Fatigue related to stress in occupation

The client often feels fatigue due to her occupation. One of the

interventions needed is to help the client manage the problem to

maximize her energy.

Risk for activity intolerance related to presence of respiratory problem

The problem won’t develop into an actual problem if the highest prioritized problem will be

threatened. No intervention need. 

NURSING CARE PLAN

XII. NURSING CARE PLAN

ASSESSMENTNURSING

DIAGNOSISINFERENCE GOAL OF CARE

IMPLEMENTATION

RATIONALE EVALUATION

S – “madali ako mapagod” as verbalized by the patient.

O – decreased performance- lack of energy- restlessness

Fatigue related to disease condition as manifested by decreased performance, lack of energy and restlessness.

After 4 hours of nursing intervention will report an improved sense of energy and participate in activities at level of ability.

Independent:

Monitor vital sign.

Encourage client to take rest during activities and ask for assistance.

Instruct client to eat nutritious food and avoid caffeine.

For baseline data.

To conserve her energy.

To give energy.

Goal partially met, the client demonstrated a feeling of being relieved and rested as manifested by her cooperation with the nurse.

ASSESSMENTNURSING

DIAGNOSISINFERENCE GOAL OF CARE

IMPLEMENTATION

RATIONALE EVALUATION

S – “Hirap ako matulog dahil sa ubo ko” as verbalized by the client.

O – restlessness- drowsiness- irritability

Sleep pattern disturbance related to cough as manifested by restlessness. Drowsiness, irritability

Cough resulting to sleep pattern disturbance.

The client will demonstrate an optimal balance of rest and activity after the nursing intervention of an interrupted sleep at night.

After the nursing intervention the client will be relieve from the

Independent:

Provide comfort measures to induce sleep:

a. Back tapping

b. Fluid intake

c. Pillow support

Dependent:

Medication if neededa. levopront

To loosen the secretion

To liquefy secretion

Provide comfort

To relieve or to suppress cough

After the nursing intervention goal was met as evidenced by longer hours of sleep.

ASSESSMENTNURSING

DIAGNOSISINFERENCE

GOAL OF CAREIMPLEMENTATION RATIONALE EVALUATION

S - "Nahihirapan

Ineffective 1.Accumulation After 1 hour of Independent:

akong huminga" as verbalized by the patient. O - changes in rate,depth of respi-ration. - dyspneaabnormal breathsound.

airway clearance related to presence of secretion as manifested by changes in rate, depth of respiration, dyspnea and abnormal breath sound.

of secretion in lung field 2.altered exchange of gas3.decrease oxygenation4.leading to ineffective airwayAMB difficulty in breathing

nursing intervention the client will be able to demonstrate behaviors to achieve airway clearance.

Check vital sings and auscultate breath sounds.

Position to semi-fowlers.

Increase fluid intake.

Dependent:

Administer medication

To establish baseline data.

To promote lung expansion

To liquefy secretion.

Aids in reduction of bronchospasm and mobilization of secretions.

Goal partially met. The patient display patent airway with breath sounds clearing and absence of dyspnea.

Chest physiotherapy

To remove secretion from the breathing passages of the patient.