I.

INTRODUCTION

Upper respiratory tract infection (URI) is a nonspecific term used to describe

acute infections involving the nose, paranasal sinuses, pharynx, larynx, trachea, and
bronchi. The prototype is the illness known as the common cold, which will be
discussed here, in addition to pharyngitis, sinusitis, and tracheobronchitis. Influenza is a
systemic illness that involves the upper respiratory tract and should be differentiated
from other URIs.

Viruses cause most URIs, with rhinovirus, parainfluenza virus, coronavirus,

adenovirus, respiratory syncytial virus, coxsackievirus, and influenza virus accounting
for most cases. Human metapneumovirus is a newly discovered agent causing URIs.
Group A beta-hemolytic streptococci (GABHS) cause 5% to 10% of cases of pharyngitis
in adults. Other less common causes of bacterial pharyngitis include group C beta-
hemolytic streptococci, Corynebacterium diphtheriae, Neisseria gonorrhoeae,
Arcanobacterium haemolyticum, Chlamydia pneumoniae, Mycoplasma pneumoniae,
and herpes simplex virus. Streptococcus pneumoniae, Haemophilus influenzae, and
Moraxella catarrhalis are the most common organisms that cause the bacterial
superinfection of viral acute sinusitis. Less than 10% of cases of acute tracheobronchitis
are caused by Bordetella pertussis, B. parapertussis, M. pneumoniae, or C.
pneumoniae.

Most URIs occurs more frequently during the cold winter months, because of
overcrowding. Adults develop an average of two to four colds annually. Antigenic
variation of hundreds of respiratory viruses results in repeated circulation in the
community. A coryza syndrome is by far the most common cause of physician visits in
the United States. Acute pharyngitis accounts for 1% to 2% of all visits to outpatient and
emergency departments, resulting in 7 million annual visits by adults alone. Acute
bacterial sinusitis develops in 0.5% to 2% of cases of viral URIs. Approximately 20
million cases of acute sinusitis occur annually in the United States. About 12 million
individuals are diagnosed with acute tracheobronchitis annually, accounting for one third
of patients presenting with acute cough. The estimated economic impact of non–
influenza-related URIs is $40 billion annually.

Influenza epidemics occur every year between November and March in the
Northern Hemisphere. Approximately two thirds of those infected with influenza virus
exhibit clinical illness, 25 million seek health care, 100,000 to 200,000 require
hospitalization, and 40,000 to 60,000 die each year as a result of related complications.
The average cost of each influenza epidemic is $12 million, including the direct cost of
medical care and indirect cost resulting from lost work days. Pandemics in the 20th
century claimed the lives of more than 21 million people. A widespread H5N1 pandemic
in birds is ongoing, with threats of a human pandemic. It is projected that such a
pandemic would cost the United States $70 to $160 billion.

The reason why i chose this patient was that her case was the most interesting
among all the patients in the ward. There were a lot of problems that I could identify that
caught my interest and where we can give a lot of health teachings and interventions to
our client. In short, her case fits best in the criteria for choosing a case study because
her diagnosis was something a common one. I also want to go deeper with this kind of
case and learn more from it.

Objectives of the Study

I will be able to conduct a thorough and comprehensive study of the assigned

patient according to the data that was gathered through a series of interviews. The
condition of the aforementioned will augment and free of possible complications from
the disorder.

The completion of this case study enables the proponent to do the following:

1. To organize my patient’s data for the establishment of good background

information
2. To show the family history as well as the history of past and present illness for
the knowledge of what could be the predisposing factors that might contribute to
the patient’s illness
3. To review Patient’s Chart and carry out Medical Orders; thus, relate these
interventions to the alleviation of the Patient’s health condition
4. To present the different results of the patient’s diagnostic exams together with the
comparison of normal values for the understanding of what changes during the
disease
5. To discuss the Anatomy, Physiology and Pathophysiology of the Patient’s health
condition
6. To present the data from the nursing assessment performed on the patient using
the cephalocaudal approach for the good overview of her over-all health
7. To identify Patient’s Clinical Manifestations as basis for a specific, measurable,
attainable, realistic and time-bounded Actual and Ideal Nursing Care Plans.
8. To impart appropriate health teachings specifically for the patient to promote
wellness and appropriate discharge plan
9. To have an over-all conclusion and recommendation about the care study

II. HEALTH HISTORY

Patient’s Profile
Client’s Name: Patient M. P
Age: 27 years old
Address: Zone 4, Agusan, Cagayan de Oro City
Civil Status: Married
Spouse: Mr. M. D
Sex: Female
Job: House wife
Nationality: Filipino
Religion: Roman Catholic
Birthday: November 20, 1985
Height: 152.59 cm (5’2’’)
Weight: 59 kgs
Educational Attainment: College Level

Admitting Physician: Dr. Caballero

Date of Admission: January 27, 2012
Time of Admission: 8: 35 in the morning
Chief Complaint: Fever and cough
Admitting Diagnosis: Upper Respiratory Tract Infection

Chief Complaint and History of present Illness:

A case of 63-year old female, married, Poblacion Sur, Sta. Barbara Pangasinan.
Two (2) days prior to admission, patient noted to have productive cough with feverish
sensation and difficulty of breathing, at October 7, 2019 due to her chief complaints of
productive cough she was admitted at Luzon Medical Center and she was diagnosed
that she suffered with Upper Respiratory Tract Infection

Family History
The family of the patient is known to have a history of asthma.

III. MEDICAL MANAGEMENT

Doctor’s Order
Date/ Time Doctor’s Order Rationale of Order

10-7-19 >please admit patient > To intervene & give the needed
health service

> As a form for legal purposes.

>secure consent to care

> for hydration

>IVF: D5LR 1L @ 20 gtts/min

>LABS:
-To monitor the blood components
-CBC
-To check if there is any
-U/A
abnormalities
-CXR (PA)

MEDs
- Treatment of acute respiratory tract
1. Ambrolex OD 75 mg/ PO diseases with impaired formation of
secretions

2. Brompheniramine - lowers or stops the body's reaction

( Nasatapp) 1 tab BID to the allergen.

- used to treat gastroesophageal

3. Omeprazole
reflux disease (GERD)

- used for topical treatment of sore

4. Hexetidine (Bactidol) Gargle throat and oral infections

- used to treat asthma and other lung-

5. Salbuterol related problems

-to monitor baseline data

>V/S q 4o

-to monitor hydration status

>I&O q shift
-to inform the physician about the
>Pls inform AP condition of the patient.

>refer accordingly -for continuity of care

- used to treat certain bacterial

infections of the nose, lungs, etc.
10-10-2019 >start Laitun 200mg IV q 12 ANST
>Fluimucil 600 dissolve in a glass
of water after dinner
- Treatment of respiratory affections
characterized by. thick and viscous
secretions
-

- used over-the-counter pain reliever

and a fever reducer
>Krerr 1 cap OD

>PCM 500 mg tab q4 PRN fever

- use for hydration

> IVF to follow D5LR @ 20 gtts/ min - to increase hydration status

(2 bottles)

>increase IVF rate to 30 gtts/min

Laboratory Results

1/27/2013

Urine Analysis

Result Normal Values Rationale

Color Yellow Pale Yellow- Amber Normal

Glucose Negative Negative Normal

Transparency Clear Clear to Slightly hazy Normal

Protein Negative Negative Normal

Specific Gravity 1.015 1.002-1.030 Normal

Microscopic Exam:

Pus Cells 1-3/hpf 0-4/hpf Normal

 RBC 0-2/hpf 0-3/hpf Normal

Amourphous Urates /
Phosphates
Few
Epithelial Squamous
Cells
Few
Bacteria
Occasional Negative Indicates Infection

11-21-2012
Complete Blood Count

Result Normal values Implication

HCT 40.1 37-47vol % Normal

HGB 12.9 12-16gms % Normal
WBC 8,200 5,000-10,000/mm3 Normal
PLATELET 310,000 150,000-400,000/mm3 Normal

Diff. Count
Neutrophils 69 50-62 % Respond to any
inflammation
Normal
Granulocyte 50 43.4-76.2 %
Normal
Lymphocytes 43 17.4-48.2 %
Normal
Monocytes 7 4.5-10.5 %
 DRUG STUDY

Generic /brand Indication Action Adverse Interaction Contraindication Patient’s Teachings Nursing Implication
name Reactions

antibiotic OD 75 concentration of Acute and There are Occasional gastrointestinal Observe respiratory rate
Ambrolex mg PO antibiotics when chronic no absolute side effects may occur but and obtain baseline data.
given disorder of the contraindications these are normally mild. Check drug interactions if taking
concomitantly. respiratory other medications.
but in patients
tract
associated with gastric It is advisable to avoid use
with ulceration relative during the first trimester of
pathologically caution should be pregnancy.
thickened observed.
mucus and
impaired
mucus
transport.
 DRUG STUDY

Generic /brand Indication Action Adverse Interaction Contraindication Patient’s Teachings Nursing Implication
name Reactions
Salbuterol 1 neb Stimulates Beta Relief of Hypersensitivity Fine skeletal muscle -Assess cardio- respiratory
2 receptors of bronchospasm to salbutamol, tremors, leg cramps, function, BP, heart rate and
bronchioles by in bronchial also to atropine palpitations, tachycardia, rhythm, and breath sounds.
increasing asthma, and its hypertension, headache,
levels which chronic derivatives. nausea, vomiting, -Determine history of
relaxes smooth bronchitis, Threatened dizziness, hyperactivity, previous meds and ability to
muscles to emphysema abortion during insomnia, hypotension,
self medicate.
produce and other first or second heartburn, epistaxis,
bronchodilation. reversible trimester. cough -Monitor for evidenceof
Also cause CNS obstructive allergic action and
stimulation, pulmonary paradoxical bronchospasm
cardiac disease
stimulation,
increase in
diuresis,
skeletal muscle
tremors and
increase gastric
acid secretions.

DRUG STUDY
Generic /brand Indication Action Adverse Interaction Contraindication Patient’s Teachings Nursing Implication
name Reactions

Omeprazole Antisecretory 40mg Gastric acid- Reduction of Contraindicated Headache, dizziness, -Arrange regular medical
Proton pump IVTT OD pump inhibitor: risk of upper with asthenia, vertigo, check-ups.
inhibitor Suppresses GI bleeding hypersensitivity to insomnia, apthy, anxiety, -Advise pt to report
gastric acid Omeprazole or its paresthesias, immediately for side effects.
secretion by components. dream abnormalities, rash,
specific inflammation, urticaria,
inhibition of the pruritus, alopecia, dry
hydrogen- skin, diarrhea, abdominal
potassium pain, nausea, vomiting,
ATPase enzyme constipation, dry mouth
system at the
secretory
surface of the
gastric parietal
cells; blocks the
final step of acid
production.

DRUG STUDY

Generic /brand Indication Action Adverse Interaction Contraindication Patient’s Teachings Nursing Implication
name Reactions
Paracetamol Antipyretic PRN for Inhibits the >Mild pain Hypersensitivity Hema: hemolytic anemia, ~ Advise parents or
fever q 4 synthesis of >Fever to acetaminophen neutropenia, leukopenia, caregivers to check
hrs prostaglandins or phenacetin; pancytopenia. concentrations of liquid
that may serve use with alcohol. Hepa: jaundice preparations. Errors have
as mediators of Metabolic: hypoG resulted in serious liver
pain and fever, GI: HEPATIC FAILURE, damage.
primarily in the HEPATOTOXICITY ~ Assess fever; note
CNS (overdose)GU: renal presence of associated signs
failure (high doses/chronic (diaphoresis, tachycardia,
use). and malaise).
Derm: rash, urticaria. ~ Adults should not take
acetaminophen longer than
10 days and children not
longer than 5 days unless
directed by health care
professional.
~ Advise mother or caregiver
to take medication exactly as
directed and not to take more
than the recommended
amount.
V.PATHOPHYSIOLOGY WITH ANATOMY AND PHYSIOLOGY

Respiratory system

The Respiratory System is crucial to every human being. Without it, we would cease to
live outside of the womb. Let us begin by taking a look at the structure of the respiratory
system and how vital it is to life. During inhalation or exhalation air is pulled towards or
away from the lungs, by several cavities, tubes, and openings.

The organs of the respiratory system make sure that oxygen enters our bodies and
carbon dioxide leaves our bodies.

The respiratory tract is the path of air from the nose to the lungs. It is divided into two
sections: Upper Respiratory Tract and the Lower Respiratory Tract. Included in the
upper respiratory tract are the Nostrils, Nasal Cavities, Pharynx, Epiglottis, and the
Larynx. The lower respiratory tract consists of the Trachea, Bronchi, Bronchioles, and
the Lungs.

As air moves along the respiratory tract it is warmed, moistened and filtered.

Breathing and Lung Mechanics

Ventilation is the exchange of air between the external environment and the alveoli. Air
moves by bulk flow from an area of high pressure to low pressure. All pressures in the
respiratory system are relative to atmospheric pressure (760mmHg at sea level). Air will
move in or out of the lungs depending on the pressure in the alveoli. The body changes
the pressure in the alveoli by changing the volume of the lungs. As volume increases
pressure decreases and as volume decreases pressure increases. There are two
phases of ventilation; inspiration and expiration. During each phase the body changes
the lung dimensions to produce a flow of air either in or out of the lungs.

The body is able to stay at the dimensions of the lungs because of the relationship of
the lungs to the thoracic wall. Each lung is completely enclosed in a sac called the
pleural sac. Two structures contribute to the formation of this sac. The parietal pleura is
attached to the thoracic wall where as the visceral pleura is attached to the lung itself.
In-between these two membranes is a thin layer of intrapleural fluid. The intrapleural
fluid completely surrounds the lungs and lubricates the two surfaces so that they can
slide across each other. Changing the pressure of this fluid also allows the lungs and
the thoracic wall to move together during normal breathing. Much the way two glass
slides with water in-between them are difficult to pull apart, such is the relationship of
the lungs to the thoracic wall.

The rhythm of ventilation is also controlled by the "Respiratory Center" which is located
largely in the medulla oblongata of the brain stem. This is part of the autonomic system
and as such is not controlled voluntarily (one can increase or decrease breathing rate
voluntarily, but that involves a different part of the brain). While resting, the respiratory
center sends out action potentials that travel along the phrenic nerves into the
diaphragm and the external intercostal muscles of the rib cage, causing inhalation.
Relaxed exhalation occurs between impulses when the muscles relax. Normal adults
have a breathing rate of 12-20 respirations per minute.
The Pathway of Air

When one breathes air in at sea level, the inhalation is composed of different gases.
These gases and their quantities are Oxygen which makes up 21%, Nitrogen which is
78%, Carbon Dioxide with 0.04% and others with significantly smaller portions.

In the process of breathing, air enters into the nasal cavity through the nostrils and is
filtered by coarse hairs (vibrissae) and mucous that are found there. The vibrissae filter
macroparticles, which are particles of large size. Dust, pollen, smoke, and fine particles
are trapped in the mucous that lines the nasal cavities (hollow spaces within the bones
of the skull that warm, moisten, and filter the air). There are three bony projections
inside the nasal cavity. The superior, middle, and inferior nasal conchae. Air passes
between these conchae via the nasal meatuses.

Air then travels past the nasopharynx, oropharynx, and laryngopharynx, which are the
three portions that make up the pharynx. The pharynx is a funnel-shaped tube that
connects our nasal and oral cavities to the larynx. The tonsils which are part of the
lymphatic system, form a ring at the connection of the oral cavity and the pharynx. Here,
they protect against foreign invasion of antigens. Therefore the respiratory tract aids the
immune system through this protection. Then the air travels through the larynx. The
larynx closes at the epiglottis to prevent the passage of food or drink as a protection to
our trachea and lungs. The larynx is also our voicebox; it contains vocal cords, in which
it produces sound. Sound is produced from the vibration of the vocal cords when air
passes through them.

The trachea, which is also known as our windpipe, has ciliated cells and mucous
secreting cells lining it, and is held open by C-shaped cartilage rings. One of its
functions is similar to the larynx and nasal cavity, by way of protection from dust and
other particles. The dust will adhere to the sticky mucous and the cilia helps propel it
back up the trachea, to where it is either swallowed or coughed up. The mucociliary
escalator extends from the top of the trachea all the way down to the bronchioles, which
we will discuss later. Through the trachea, the air is now able to pass into the bronchi.

Inspiration

Inspiration is initiated by contraction of the diaphragm and in some cases the

intercostals muscles when they receive nervous impulses. During normal quiet
breathing, the phrenic nerves stimulate the diaphragm to contract and move downward
into the abdomen. This downward movement of the diaphragm enlarges the thorax.
When necessary, the intercostal muscles also increase the thorax by contacting and
drawing the ribs upward and outward.

As the diaphragm contracts inferiorly and thoracic muscles pull the chest wall outwardly,
the volume of the thoracic cavity increases. The lungs are held to the thoracic wall by
negative pressure in the pleural cavity, a very thin space filled with a few milliliters of
lubricating pleural fluid. The negative pressure in the pleural cavity is enough to hold the
lungs open in spite of the inherent elasticity of the tissue. Hence, as the thoracic cavity
increases in volume the lungs are pulled from all sides to expand, causing a drop in the
pressure (a partial vacuum) within the lung itself (but note that this negative pressure is
still not as great as the negative pressure within the pleural cavity--otherwise the lungs
would pull away from the chest wall). Assuming the airway is open, air from the external
environment then follows its pressure gradient down and expands the alveoli of the
lungs, where gas exchange with the blood takes place. As long as pressure within the
alveoli is lower than atmospheric pressure air will continue to move inwardly, but as
soon as the pressure is stabilized air movement stops.
Expiration

During quiet breathing, expiration is normally a passive process and does not require
muscles to work (rather it is the result of the muscles relaxing). When the lungs are
stretched and expanded, stretch receptors within the alveoli send inhibitory nerve
impulses to the medulla oblongata, causing it to stop sending signals to the rib cage and
diaphragm to contract. The muscles of respiration and the lungs themselves are elastic,
so when the diaphragm and intercostal muscles relax there is an elastic recoil, which
creates a positive pressure (pressure in the lungs becomes greater than atmospheric
pressure), and air moves out of the lungs by flowing down its pressure gradient.

Although the respiratory system is primarily under involuntary control, and regulated by
the medulla oblongata, we have some voluntary control over it also. This is due to the
higher brain function of the cerebral cortex.

When under physical or emotional stress, more frequent and deep breathing is needed,
and both inspiration and expiration will work as active processes. Additional muscles in
the rib cage forcefully contract and push air quickly out of the lungs. In addition to
deeper breathing, when coughing or sneezing we exhale forcibly. Our abdominal
muscles will contract suddenly (when there is an urge to cough or sneeze), raising the
abdominal pressure. The rapid increase in pressure pushes the relaxed diaphragm up
against the pleural cavity. This causes air to be forced out of the lungs.

Another function of the respiratory system is to sing and to speak. By exerting

conscious control over our breathing and regulating flow of air across the vocal cords
we are able to create and modify sounds.

Lung Compliance

Lung Compliance is the magnitude of the change in lung volume produced by a change
in pulmonary pressure. Compliance can be considered the opposite of stiffness. A low
lung compliance would mean that the lungs would need a greater than average change
in intrapleural pressure to change the volume of the lungs. A high lung compliance
would indicate that little pressure difference in intrapleural pressure is needed to change
the volume of the lungs. More energy is required to breathe normally in a person with
low lung compliance. Persons with low lung compliance due to disease therefore tend to
take shallow breaths and breathe more frequently.

Determination of Lung Compliance Two major things determine lung compliance. The
first is the elasticity of the lung tissue. Any thickening of lung tissues due to disease will
decrease lung compliance. The second is surface tensions at air water interfaces in the
alveoli. The surface of the alveoli cells is moist. The attractive force, between the water
cells on the alveoli, is called surface tension. Thus, energy is required not only to
expand the tissues of the lung but also to overcome the surface tension of the water
that lines the alveoli.

To overcome the forces of surface tension, certain alveoli cells (Type II pneumocytes)
secrete a protein and lipid complex called ""Surfactant””, which acts like a detergent by
disrupting the hydrogen bonding of water that lines the alveoli, hence decreasing
surface tension.

Upper Respiratory Tract

The upper respiratory tract consists of the nose and the pharynx. Its primary function is
to receive the air from the external environment and filter, warm, and humidify it before it
reaches the delicate lungs where gas exchange will occur.

Air enters through the nostrils of the nose and is partially filtered by the nose hairs, then
flows into the nasal cavity. The nasal cavity is lined with epithelial tissue, containing
blood vessels, which help warm the air; and secrete mucous, which further filters the air.
The endothelial lining of the nasal cavity also contains tiny hairlike projections, called
cilia. The cilia serve to transport dust and other foreign particles, trapped in mucous, to
the back of the nasal cavity and to the pharynx. There the mucus is either coughed out,
or swallowed and digested by powerful stomach acids. After passing through the nasal
cavity, the air flows down the pharynx to the larynx.

Lower Respiratory Tract

The lower respiratory tract starts with the larynx, and includes the trachea, the two
bronchi that branch from the trachea, and the lungs themselves. This is where gas
exchange actually takes place.

1. Larynx

The larynx (plural larynges), colloquially known as the voice box, is an organ in our neck
involved in protection of the trachea and sound production. The larynx houses the vocal
cords, and is situated just below where the tract of the pharynx splits into the trachea
and the esophagus. The larynx contains two important structures: the epiglottis and the
vocal cords.

The epiglottis is a flap of cartilage located at the opening to the larynx. During
swallowing, the larynx (at the epiglottis and at the glottis) closes to prevent swallowed
material from entering the lungs; the larynx is also pulled upwards to assist this process.
Stimulation of the larynx by ingested matter produces a strong cough reflex to protect
the lungs. Note: choking occurs when the epiglottis fails to cover the trachea, and food
becomes lodged in our windpipe.

The vocal cords consist of two folds of connective tissue that stretch and vibrate when
air passes through them, causing vocalization. The length the vocal cords are stretched
determines what pitch the sound will have. The strength of expiration from the lungs
also contributes to the loudness of the sound. Our ability to have some voluntary control
over the respiratory system enables us to sing and to speak. In order for the larynx to
function and produce sound, we need air. That is why we can't talk when we're
swallowing.

1. Trachea
2. Bronchi
3. Lungs

The Right Primary Bronchus is the first portion we come to, it then branches off
into the Lobar (secondary) Bronchi, Segmental (tertiary) Bronchi, then to the
Bronchioles which have little cartilage and are lined by simple cuboidal
epithelium (See fig. 1). The bronchi are lined by pseudostratified columnar
epithelium. Objects will likely lodge here at the junction of the Carina and the
Right Primary Bronchus because of the vertical structure. Items have a tendency
to fall in it, where as the Left Primary Bronchus has more of a curve to it which
would make it hard to have things lodge there.
The Left Primary Bronchus has the same setup as the right with the lobar,
segmental bronchi and the bronchioles.

The lungs are attached to the heart and trachea through structures that are
called the roots of the lungs. The roots of the lungs are the bronchi, pulmonary
vessels, bronchial vessels, lymphatic vessels, and nerves. These structures
enter and leave at the hilus of the lung which is "the depression in the medial
surface of a lung that forms the opening through which the bronchus, blood
vessels, and nerves pass" (medlineplus.gov).

There are a number of terminal bronchioles connected to respiratory bronchioles

which then advance into the alveolar ducts that then become alveolar sacs. Each
bronchiole terminates in an elongated space enclosed by many air sacs called
alveoli which are surrounded by blood capillaries. Present there as well, are
Alveolar Macrophages, they ingest any microbes that reach the alveoli. The
Pulmonary Alveoli are microscopic, which means they can only be seen through
a microscope, membranous air sacs within the lungs. They are units of
respiration and the site of gas exchange between the respiratory and circulatory
systems.

ProductiveTRACT
UPPER RESPIRATORY coughINFECTION colds
 VI.NURSING REVIEW CHART (Assessment)
INSTRUCTION: Place an (X) in the area of abnormalities. Write comment on the space provided. Indicate the
location of the problem in the figure using (X).

EENT
[] impaired vision [] blind [] Pain
[] reddened [] drainage [] lesion seen
[] gums [] hard of hearing [] deaf
[] burning [] edema
Assess eyes, ears, and nose throat for abnormality Productive cough
[x] no problem

RESPIRATORY Decrease appetite

[] asymmetric [] tachypnea [] apnea
[] rales [x] cough [] barrel chest
[] bradypnea [] shallow [] rhonchi
[x] sputum [] diminished [] dyspnea
[] orthopnea [] labored [] wheezing Fever 37.9
[] pain [] cyanotic
Assess respiration, rate, rhythm, depth, pattern,
breathe sounds, comfort Skin warm to
[] no problem touch
CARDIO VASCULAR
[] arrhythmias [] tachypnea [] numbness
[] diminished pulses [] edema [] fatigue
[] irregular [] bradycardia [] murmur
[] tingling [] absent pulses [] pain
Assess heart sounds, rate rhythm, pulse, blood pressure, circulation,
fluid retention, comfort
[] no problem

GASTROINTESTINAL TRACT
[] obese [] distention [] mass
[] dysphagia [] rigidity [] pain
Assess abdomen, bowel habits, swallowing, bowel sounds, comfort
[x] no problem

GENITO- URINARY TRACT and GYNE

[] pain [] urine color [] vaginal bleeding
[] hematuria [] discharges [] nocturia
Assess urine freq., control, color, odor, comfort,
gyne- bleeding, discharge Fever 37.9
[x] no problem
Skin warm to
NEURO
[] paralysis [] stuporous [] unsteady touch
[] seizures [] lethargic [] comatose
[] vertigo [] tremors [] confuse
[] vision [] grip
Assess motor function, sensation, LOC, strength, grip, gait,
Coordination, orientation, speech.
[x] no problem

MUSCULOSKELETAL and SKIN

[] appliance [] flushed [] cool [] drainage
[] Petechiae [] ecchymosis [] rash [] lesion
[] prosthesis [] stiffness [] atrophy [] deformity
[] poor turgor [x] hot [] diaphoretic [] skin color [] moist
[] wound [] swelling [] itching [] pain
Assess mobility, motion, galt, alignment, joint function, skin color, texture, turgor, integrity
[] no problem
VII. NURSING MANAGEMENT

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective:  Ineffective airway
 “gahi kayo akong
ubo” as verbalized.
Objective:
 Conscious/coherent
 Productive cough
(yellow to green
sputum
 Restlessness noted
 Discomfort noted
 Facial Grimace noted
Short term Goal  Monitor Vital signs  Serves as baseline Patient was able to
clearance r/t data expectorate
increased production  After 8 hours of  To facilitate
of bronchial continues nsg.  Place the pt. in maximum lung secrections, goal met.
secretions as Interventions the pt. fowler’s or semi- expansion
evidence by will be able to fowler’s position  Improves ventilation
Wheezes upon maintain airway  Teach the pt. how to and helps in
auscultation patency do proper deep mobilizing secretions
Productive cough  Expectorate breathing and w/o causing fatigue
(yellow to green secretions coughing exercise  To avoid allergic
sputum)  Avoid exposure to reaction
Restlessness Long term Goal irritants such as
Chest pain cigarette smoke,
Discomfort  Learn and perform aerosol and fumes
Facial Grimace breathing and  Auscultate breath
coughing exercise. sounds  To ascertain status
 Verbalized relief form  Increase fluid intake and note progress
dyspnea.  Helps liquefy
secretions
 Suction as ordered  To clear airway
 Provide oxygen  Provide adequate
inhalation as ordered amount of oxygen
 Administer  Will help loosen
medication as secretions for easy
ordered expulsion.
VIII. REFERRALS AND FOLLOW-UP

HEALTH TEACHINGS

The patient is instructed strict compliance of home medications:

MEDICATION

Instructed the patient to perform active ROM exercises and

EXERCISES encouraged to perform ADL independently as per limitation.

Instructed to follow the treatment given by the physician, which

includes the proper administration of the medications, the time the
TREATMENT medication be given and the diet that the patient must have. That
treatment is necessary for the complete recovery.

The patient is encouraged to visit attending physician as

OUT-PATIENT prescribed for follow- up check- up upon discharge. It is critically
important to follow up with the doctor
Instructed tofoods rich in fibers such as vegetables and also to
DIET increase the fluid intake to 6 – 10 glasses a day.