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CAP-MRCommunityAcquired
Pneumonia Moderate Risk
Prepared by:
Sheena Marie Germinal
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General objectives:
Within 6 days of related learning experience,I will be able to apply my knowledge, skillsand attitude regarding the concept cellular
aberrations.
Specific objectives:Within 8 hours of exposure I will be able to:
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Knowledge
1.) Identify the different illness in the area ofexposure in order to give appropriate nursinginterventions.
2.) Provide information about the medications ofthe client.3.) State the exact rationale for every nursingintervention.
4.) Formulate a comprehensive nursing care plan.5.) Provide appropriate health teaching for myclient.
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Skills
1.) Organize data properly to ensure a systematicdata collection.2.) Gather relevant data needed in formulating theplan of care.
3.) Construct a data analysis using initial data base.4.) Develop teaching plan to achieve wellnesspromotion.5.) List down important information and answersgiven by client which is necessary in planning aneffective nursing care.
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Attitude
1.) Display a good role model to my fellow classmatesto the folks and my client.2.) Follow consciously all rules and regulation of thehospital.
3.) Show respect to the staff, clinical instructor andmy fellow classmates.4.) Seek clinical instructors guide before renderingany procedure.5.) Display Augustinian values at all times especiallyhonesty in doing any procedures and telling thetruth.
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Prepared By:Frestine Joanne Ibon
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I. Vital Information
Name: J.LAddress: Poblacion Ilawod Lambunao, IloiloBirth Date: April 2, 1982
Gender: FemaleMarital Status: MarriedReligion: Roman CatholicDate and Time of Admission: October 1, 2013 @ 5 a.m.Physician: Dr. S.
Chief complaint: Cough and Difficulty of BreathingAdmitting Diagnosis: CAP, MR
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II. History of Present Illness
Two months prior to admission the client
experienced exertional dyspnea but she did not made
any intervention to this. Then two weeks prior to
admission she is experiencing non productive cough andincreased severity of exertional dyspnea. The following
day client went on a hilot nearby and was advised to
take some herbal plants. Thereafter, when she noticed
that her cough is not minimizing she decided to go to
WVSUMC and admitted in San Vicente Ferrer Ward andundergone different tests like CBC, platelet, protime, 12-
L ECG, Blodd typing, Urinalysis, creatinine, S. K+ and Na+,
and CT Scan.
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III. Past Medical History
J.L. has no history of hospitalization. Received a
complete immunizations. She have not committed any
childhood accidents. She also had no food, drug, and
environmental allergies. She had suffered fromchildhood illnesses such as fever and runny nose that
would last at least three days as far as she could
remember. She takes over the counter drugs such as 1
tab of biogesic to relieve the pain and discomfort and
herbal medicines such as lapunaya that her motherwould use to hampol. She takes 1tab of Enervon every
day before hours of sleep as his vitamin supplement.
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Disease Paternal Maternal
Asthma x
Hypertension x DM
Cancer x x
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V. Socioeconomic Status
J.L is a highschool physics Teacher, married with a college Rizal teacher
with 3 children aging 6 months, 2 and 3 years. The number of their family
members who are living in their house is 6 which includes her mother who took
care of their children when they are at work.
The family earns Php 10,000.00and above monthly. They live in a bungalow stylehouse, semi-concrete, with galvanized roof. There are two rooms, a kitchen and a
comfort room separated from their house. They store foods in their refrigerator.
They get water from the their own deep well and buys mineral water as their
source of drinking. They sometimes celebrate fiesta in accordance to their
budget. They always go to church every Sunday and sometimes participate in
their barangay activities. He claims to have a mutual relationship with his
neighbors because some of them were his childhood friends and he also claimed
that he has a good and happy life with his family.
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VI. Activities of Daily Living
A. Nutrition
Client eats three times a day with no difficulty. At Breakfast, she usually
drinks a cup of coffee while she dips 3-5 pieces of hot pandesal. During lunch, she
prefers to eat vegetables and fish, sometimes meat and chicken if available with 3-4
cups of rice per meal. By the time supper arrives, she eats canned goods and steamedvegetables like okra together with a cup of rice. He drinks 10-12 glasses of water a
day.
B. Elimination
She urinates 3-7 times a day, her urine is pale straw and the amount of her
urine depends on how much he usually takes. She defecates thrice a week, usually7am in the morning. Her stools are brown and well-formed as he claimed. She has no
difficulty or pain felt upon urination and defecation.
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C. Rest and SleepClient sleeps after dinner at around 9pm and wakes up at 4am with a
single pillow he usually puts under his head and in a side lying position while
sleeping. When she cant sleep he watches television or listening to radio or drinking
3-4 glasses of fermented coconut chucks.
D. Activity and ExerciseShe refers doing household chores and school works as her exercise. When
she hears a pop music over the radio, he would tend to sway his hips and stretch his
arms and dance to the beat of the tune, that is if shes inside of their house.
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Drug
Study
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CLASSIFICATION ACTION CONTRA
-INDICATIONS
PRECAUTIONS SIDE EFFECTS NURSING
RESPONSIBILITY
Corticosteroid enters target cells andbindsto cytoplasmic
receptor;initiates
many
complexreactions that
are responsiblefor
its anti-
inflammatory,immuno
suppressive(glucocorti
coid), and salt-
retaining
(mineralocorticoid)acti
ons. Some actions
maybe undesirable,
dependingon drug
use.
Allergy to
anycomponent of
the drug- Fungal
infections-
Amebiasis- Hepatitis
B- Vaccinia or
varicella- Antibiotic-
resistantinfections-
Immunosuppression
kidney disease- Liver
disease- Cirrhosis-
Hypothyroidism-
Ulcerative colitis
withimpending
perforation-
Diverticulitis- Recent
GI surgery- Active or
latent pepticulcer -
Inflammatory
boweldisease-
Hypertension- Heart
failure-
Thromboembolicten
dencies-
Osteoporosis-
Convulsivedisorders-
Metastatic
carcinoma- Diabetes
mellitus- TB-
Lactation
Vertigo,
headache,paresthesi
as,
insomnia,seizures,
psychosis
- Give daily before
9am to mimicnormal
peak
diurnal corticosteroi
dlevels.- Space
multiple doses
evenlythroughout
the day.- Use
minimal doses for
minimalduration to
minimize adverse
effects.- Do not give
IM injections if
patienthas
thrombocytopenic
purpura.- Taper
doses whendiscontinuinghigh-
dose or long-term
therapy
Generic Name: Hydrocortisone
Brand Name: Hydrocortone
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CLASSIFICATION ACTION CONTRA
-INDICATIONS
PRECAUTIONS SIDE EFFECTS NURSING
RESPONSIBILITY
Treatment ofhospitalized infantsand young children
with severelower respiratory tra
ct infections dueto respiratory
syncytial virus.
act as an analogue ofthese cellularmetabolites
contraindicated inindividuals who
have shownhypersensitivity to
the drug or itscomponents, and inwomen who are or
may becomepregnant duringexposure to the
drug
USE OF AEROSOLIZEDVIRAZOLE IN PATIENTS
REQUIRINGMECHANICALVENTILATOR
ASSISTANCE SHOULDBE UNDERTAKEN ONLY
BY PHYSICIANS ANDSUPPORT STAFF
FAMILIAR WITH THESPECIFIC VENTILATORBEING USED AND THIS
MODE OFADMINISTRATION OF
THE DRUG. STRICTATTENTION MUST BE
PAID TO PROCEDURESTHAT HAVE BEEN
SHOWN TO MINIMIZETHE ACCUMULATION
OF DRUG PRECIPITATE,WHICH CAN RESULT IN
MECHANICALVENTILATOR
DYSFUNCTION ANDASSOCIATEDINCREASED
PULMONARYPRESSURES
fever, chills, bodyaches, flu
symptoms;severe pain in upperstomach spreading
to your back,nausea and
vomiting, fast heartrate;
stabbing chest pain,wheezing,
hallucinations,thoughts of suicidechest pain or heavy
feeling, painspreading to the
arm or shoulder,nausea,dark colored urine,
easy bruising orbleeding, confusion,
or unusualweakness.
Observe 10 Rs.Take this
medication bymouth, usuallytwice daily with
food for 24 to 48weeks or as
directed by yourdoctor. Swallowthis medicationwhole. Do notcrush, break or
chew the tablet.The dosage and
length of treatmentis based on your
age, weight,medical condition,and response to
therapy.
Generic Name: Ribavirin
Brand Name: Virazole
AVAILABLE FORMS & Dosage: Tablets, 400 mg PO qAM, 600mg PO qPM
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CLASSIFICATION ACTION CONTRA
-INDICATIONS
PRECAUTIONS SIDE EFFECTS NURSING
RESPONSIBILITY
Antiviral,neuraminidase
inhibitor
Severely inhibitsinfluenza virus
neuraminidase, byblocking the actionsof this enzyme there
is decreased viralrelease from infected
cells, increasedformation of viralaggregates, and
decreased spread ofvirus.
treatment ofuncomplicated
acute illness due toinfluenza virus (a or
b) in adults andchildren who havebeen symptomaticfor 2 days or less.
Prevention ofnaturally occurringinfluenza A and B inadults and children
in close contactwith the flu.
Allergy to anycomponent of drug.Use cautiously with
pregnancy,lactation, asthma,
COPD
nausea, vomiting,diarrhea;
dizziness, headache;nosebleed;
eye redness ordiscomfort;
sleep problems(insomnia); orcough or other
respiratorysymptoms
Instruct your clientnot take Tamiflu ifyou are allergic to
the main ingredient,oseltamivir
phosphate, or toany other
ingredients ofTamiflu.
Report severediarrhea, severe
nausea, worseningof respiratory
symptoms
Generic Name: Oseltamivir
Brand Name: Tamiflu
AVAILABLE FORMS & Dosage: Oral suspension 12.5 mL. Capsule of 75 mg
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CLASSIFICATION ACTION CONTRA
-INDICATIONS
PRECAUTIONS SIDE EFFECTS NURSING
RESPONSIBILITY
Protease Inhibitors Exhibits antiviralactivity, inhibits HIV
protease activity,
leading to the
decrease of HIV
particles, inhibits
metabolism of
lopinavir, allowing for
increased plasma
levels of lopinavir
patients withpreviously
demonstratedclinically significant
hypersensitivity(e.g., toxicepidermal
necrolysis, Stevens-Johnson syndrome,
erythemamultiforme) to anyof its ingredients,including ritonavir
KALETRA is an HIV-1protease inhibitor
indicated incombination with
other antiretroviralagents for the
treatment of HIV-1infection in adults
and pediatricpatients
Pancreatitis,Hepatotoxicity,
Diarrhea, nauseaand vomiting,
abdominal pain,flatulence, insomnia
Instruct client toeat before takingthe oral solution
of medicationIn tablets, May
be taken with orwithout food,
swallowed wholeand not chewed,
broken, orcrushed
Generic Name: Lopinavir / Ritonavir
Brand Name: Oseltamivir
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Laboratory
ResultsPrepared By:Ma. Theresa Abanilla
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Pyuria- containing pus
Blood Typing: O, Rh +
Composition Results Normal Values Significance
Physical Properties
Protime: Normal
Urinalysis
Color
Transparency
Reaction (ph)STGR
Pale Straw
Hazy
6.01.010
Straw/Amber
Clear
4.5-7.81.001-1.035
Normal
Pyuria, Pacleriuria
Phosphate in
Urine
Normal
Normal
Date: October 1, 2013
Time: 5:00 PM
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Chemical Test
Sugar
Albumin
Negative
Negative
Negative
Negative
Normal
Normal
Microscopic Findings:
Pus cells
RBC
Amorphous Urates
Squamous Epithelial
cells
0-2/hpf
4-5/hpf
Occasional
few
3-6/hpf
0-3/hpf
None
15-20/hpf
May indicate
infection
a disease
condition is often
present. One of themost common causesof RBC's in the urine, is
infection or
inflammation of the
urinary tract itself (i.e.,
cystitis).
can be caused by
gout
Normal
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Hematology
Composition Results Normal Values Significance
Hemoglobin
HematocritRBC
WBC
Platelet Count
134 g/L
0.40 L/L4.67 10^g/L
11.21 10^g/L
427 10^ g/L
120-160 g/L
0.37-0.47 g/L4.2-5.4 10^g/L
4.5-11 10^ g/L
150-450 10^g/L
Normal
Normal
Normal
Normal
Normal
Afebrile
Composition Results Normal Values Significance
O2 Saturation
INR
95%
1.02
95-99%
2.0-3.0
Normal
blood clots more
quickly than
desired
Chest: CT Scan
Limit oral fluid intake to Liter per day
Maintain to high back rest
IVF to KVO
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MEDICAL & SURGICAL
INTERVENTIONS
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MEDICAL interventions
Ventilation with low tidal volumes (6 mL/kg of ideal body weight) in patients
requiring mechanical ventilation secondary to bilateral pneumonia or acute
respiratory distress syndrome (ARDS)
High doses of steroids to reduce swelling in the lungs.
Administer Antiviral, Antibiotic or Steroidal medications with proper
prescription from physician.
Endotracheal Tube
Pharmacological
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Monitor Vital Signs.
An IV route is established to provide an accessible means for emergency
drug therapy.
Suctioning and bronchial hygiene Pulmonary toilet may include active
suction of secretions, chest physiotherapy, positioning to promote dependent
drainage, and incentive spirometry to enhance elimination of purulent sputum
and to avoid atelectasis.
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MEDICAL interventions
Position the patient to semi- or high-fowlers position to minimize risk
of aspiration.
Be sure that all members of your household are washing their hands
frequently with soap and hot water or using an alcohol-based hand rub.
Wear disposable gloves if you will have direct contact with body fluids
of a person with SARS. However, wearing gloves is not a substitute for
good hand hygiene. After contact with body fluids of a person with SARS,
remove the gloves, throw them out, and wash your hands. Do not wash
or reuse the gloves.
Non-Pharmacological
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Encourage the person with SARS to cover his or her mouth and nose with a
tissue when coughing or sneezing. If possible, the infected person should wear a
surgical mask during close contact with other people in the home. If the personwith SARS cannot wear a surgical mask, other members of the household should
wear one when they are in the room with that person.
Do not use silverware, towels, bedding, clothing, or other items that havebeen used by the person with SARS until these items have been washed with
soap and hot water.
Clean surfaces in the infected person's room and bathroom fixtures used by
this person daily with a household disinfectant used according to the
manufacturer's instructions. When cleaning, wear disposable gloves and dispose
of them after use. Household utility gloves may also be used.
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Limit the number of people in the household to those who are essential for
patient support. Other household members should either be relocated or
minimize their contact with the infected person in the home. This is particularlyimportant for people at risk of serious complications of SARS (e.g., persons with
underlying heart or lung disease, diabetes mellitus, older age).
Unexposed people who do not have an essential need to be in the homeshould not visit.
For 10 days after your last exposure to the person with SARS, keep a vigilant
watch for signs of fever (i.e., measure your temperature twice daily), respiratory
symptoms, and other early SARS symptoms. If you do not have any of these
symptoms, you do not need to limit your activities outside the home. You may go
to work, school, out-of-home childcare, church, or activities in other public areas.
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Follow any other instructions provided by local health authorities.
If you start feeling sick, especially if you develop a fever, respiratory
symptoms, or other early symptoms of SARS, contact your healthcare provider
immediately, and tell the healthcare provider that you have had close contact
with a SARS patient.
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surgical intervention
Endotracheal insertion
Endotracheal intubation is a medical procedure in
which a tube is placed into the windpipe (trachea),through the mouth or the nose. In most emergencysituations it is placed through the mouth.
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Endotracheal intubation is done
to:
Open the airway to give oxygen, medication,or anesthesia
Remove blockages from the airway
Allow the doctor to get a better view of theupper airway
Protect the lungs in certain patients
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Patient position
The patient should be aligned without lateral deviation ofthe head or neck.
The head should be extended on the neck with a pillow
under the occiput. If cervical spine trauma is suspected,have an assistant provide in-line immobilization.
The neck should be flexed to approximately 15 degrees onthe chest.
Try to keep the external auditory meatus and sternalnotch in same horizontal plane (except infants or whencervical spine injury is present or suspected).
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Nursing
Diagnosis
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As evidenced by: GOAL INTERVENTION EVALUATION
Subjective:
-I cant breath wellbecause of my chestpain, as verbalized by
the patient.Objective:
-Difficulty of breathing- Shortness of breath
- Altered breath depth
- Timing ratio; prolonged
expiration phases
- Altered chest excursion
- Nasal flaring
- Grunting
v/s
TEMP: 35.7 C
BP: 120/80 mmHg
RR: 23 cpmPR: 110 bpm
After 4 hours of nursing
intervention, the patient
will able to do coping
mechanisms to improve
his breathing pattern
After 4 hours of nursing
intervention, the patient
did the coping
mechanisms to improve
his breathing pattern
Auscultate chest; to
evaluate pressure and
character of breath
sounds
- Administer oxygen at
lowest concentration
indicated and prescribed
repiratory medicationfor
management of
underlying pulmonary
condition
As evidenced by: GOAL INTERVENTION EVALUATION
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y
-Evaluate HOB or have
client sit up in chair, as
appropriate to promote
physiologic ease of
maximal inspiration
- Encourage
slower/deeper
respirations, use purse
lip technique, to assist
client in taking control of
the situation
- Monitor pulse oximetry,
as indicated to verify
maintenance in oxygen
saturation
- Maintain calm attitude
while dealing with the
client to limit level of
anxiety
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As evidenced by: GOAL INTERVENTION EVALUATION
Subjective:
- Questioning members
of the Heath Care Team.
- lack of questionsabout SARS- verbalizing inaccurate
information
Objective:
- unaware of proper
prevention methods- denial need to learn
After 2 hours, thepxatient will be able toverbalize the diseaseprocess, transmission,
treatment, andcomplications of SARS.
1.) Provide informationabout diseasetransmission.
2.) Provide informationabout diseaseprocess/complications.
3.) Provide informationon treatments.
4.) Provide informationon general protectionfrom SARS.
After 2 hours of nursingintervention, the patientwill be able to verbalizethe disease process,
transmission,treatment, andcomplications of SARS.
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As evidenced by: GOAL INTERVENTION EVALUATION
Subjective:
- general feeling of
discomfort
- body aches- headache- exposure to persons
with SARS
Objective:
- Temperature >38oC
for 2-7 days- Chills- Diarrhea- Non-productive
cough 2-7 days- hypoxia- positive diagnostic
test
After 8 hours of nursingintervention, the patientwill be able to maintainnormal body
temperature of 36-35oCAnd reduce therespiratory symptoms.
INDEPENDENT:1.) Monitor lung soundsand cough
2.) MonitorTemperature
3.) Monitor oxygensaturation
4.) Maintain respiratorycirculation:
keep tissues on thebedside dispose secretionsproperly
have the patientcover mouth when
Patient exhibits absenceof fever and absence ofrespiratory symptoms.Risk of spread of
infections is reduced.The goal was partiallymet.
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As evidenced by: GOAL INTERVENTION EVALUATION
have the patientcover mouth whensneezing or coughing use masks
have anyone enteringthe patients room wear
a mask keep door closed allthe time and placerespiratory isolation
sign visible assist visitors tofollow appropriateisolation techniques
5.) teach the patient towash hands after
coughing
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As evidenced by: GOAL INTERVENTION EVALUATION
6.) use appropriatetherapy to decreasetemperature
7.) encourage thepatient to cough unlessthe cough isnonproductive
8.) for patients withreduced energy, paceactivities
9.) provide a high-protein , high calorie,increase fluid diet insmall frequent servings.
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As evidenced by: GOAL INTERVENTION EVALUATION
DEPENDENT:
1.) Administer antiviralmedications as ordered.
COLLABORATIVE:1.) Consult a respiratorytherapist for chestphysiotherapy andnebulizer treatments
2.) Collect and monitordiagnostic results
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ovel Corona virus Well-Adapted
to Humans, Susceptible to
ImmunotherapyFeb. 19, 2013 The new coronavirus that has emerged
in the Middle East is well-adapted to infecting humans
but could potentially be treated with immunotherapy,
according to a study to be published on February 19
in mBio, the online open-access journal of the
American Society for Microbiology. The study indicates
that the virus HCoV-EMC can penetrate the lining of thepassageways in the lung and evade the innate immune
system as easily as a cold virus can, signs that HCoV-EMC
is well-equipped for infecting human cells. The study
also reveals that the virus is susceptible to treatment
with interferons, components of the immune system
that have been used successfully to treat other viraldiseases, opening a possible mode of treatment in the
event of a large-scale outbreak.
American Society for Microbiology (2013, February 19).
Novel coronavirus well-adapted to humans, susceptible
to immunotherapy.ScienceDaily. Retrieved August 7,
2013, from http://www.sciencedaily.com-
/releases/2013/02/130219091010.htm
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