CHAPTER I INTRODUCTION

Pneumonia is an inflammatory condition of the lungs, especially of the alveoli (microscopic air sacs in the lungs) or when the lungs are filled with fluid (called consolidation and exudation). There are many causes, of which infection is the most common. Infecting agents can be bacteria, viruses, fungi, or parasites. Chemical burns or physical injury to the lungs can also produce pneumonia. Typical symptoms include cough, chest pain, fever, and difficulty in breathing. Diagnostic tools include x-rays and examination of the sputum. Treatment depends on the cause of pneumonia; bacterial pneumonia is treated with antibiotics.Pneumonia can be due to microorganisms, irritants or unknown causes. When pneumonias are grouped this way, infectious causes are the most common. The symptoms of infectious pneumonia are caused by the invasion of the lungs by microorganisms and by the immune system's response to the infection. Although more than one hundred strains of microorganism can cause pneumonia, only a few are responsible for most cases. The most common causes of pneumonia are viruses and bacteria. Less common causes of infectious pneumonia are fungi and parasites. Pneumonia can be classified in several ways, most commonly by where it was acquired (hospital verses community), but may also by the area of lung affected or by the causative organism. There is also a combined clinical classification, which combines factors such as age, risk factors for certain microorganisms, the presence of underlying lung disease or systemic disease, and whether the person has recently been hospitalized.

Rationale
I prefer to select this case study to be aware with the information that are associated with Pneumonia. Based on my exposure in Medical Ward, I can say that there are often patients who are admitted with that particular complication. According to theWorld Health Organization, estimated one in three newborn infant deaths are due to pneumonia, the annual incidence rate of pneumonia is approximately 6 cases per 1000 people in individuals aged 18 39 years. For those over 75 years of age, the incidence rate rises to 75 cases per 1000 people. Roughly 20 40% of individuals who contract pneumonia require hospital admission, with between 5 10% of these admitted to a critical care unit. The community-acquired pneumonia affects 5.6 million people per year, and ranks 6th among leading causes of death. I also choose this case to further enhance my understanding, management skills and behavioral manner on caring for the patient who has Pneumonia.

General Objectives The purpose of the presentation is to know the related information and knowledge about the patient s case/ condition and disease. This presentation will serve as guidelines for us, student nurses in assessing and providing proper nursing care to our patient with the same problem or disease.

Case Study in Medical Ward

Specific Objectives
Behavior /Affective  To provide rapport and interact with client utilizing therapeutic communication.  To develop understanding and appreciation with the client`s condition.

Cognitive  To define its meaning and have a further learning and comprehension about Pneumonia  To identify the risk factors that have been linked to this health problem, the signs and symptoms, and its clinical manifestations  To learn the treatment and other related management regarding the case. Psychomotor  To develop and enhanced the skills in handling and caring for an patient who is suffering from Pneumonia  To use my theoretical skills in performing the actual nursing process for effectiveness and achievement of nursing care.  To provide the necessary care for the patient efficiently.  To practice the application of nursing care plan.

Case Study in Medical Ward

CHAPTER II CLINICAL SUMMARY A. General Data CATEGORY Name Unit Assignment Age Birthdate Birthplace Gender Religion Address Civil Status Occupation Date of Admission Time of Admission Admitting Diagnosis B. Chief Complaint
The patient was admitted at New Oriental Mindoro Provincial Hospital with chief complaint of difficulty in breathing, and fever.

DEMOGRAPHIC DATA Mr.Jj .A Medical Ward 16 yrs. Old July 09, 1994 Calapan City Male Roman Catholic Brgy. San Antonio, Calapan City Single Farming June 21, 2011 02:18 p.m
Pneumonia

C. History of Present Illness

A 16 year old teenager was admitted in New Oriental Mindoro Provincial Hospital on June 21, 2011 at 02:18 p.m. ambulatory, accompanied by his relative with chief complaint of difficulty in breathing and fever prior to admission. According to the patient sister, the patient was admitted at the hospital because they are worried about his fever that is almost two days prior to admission.

D. Past Medical History

Childhood Years According to the patient, he had measles when he was young. Aside to some common disease like fever and sometimes flu that he encounters he has been hospitalized because of Enteric Fever.

Case Study in Medical Ward

Teenage Years According to the patienthe doesn t encounter any chronic illness except for the usually disease like fever, cough, cold and sometimes influenza. The patient also stated that he doesn t have any vices that may contribute to any disease. A day prior to hospitalization The patient stated that he has difficulty in breathing; he also stated that his fever for almost two days.

E. Family History
The Grandmother of the patient has asthma. One of his Uncle and also his mother has asthma. And the rest of the family member is still alive and well, except to the patient who is suffering from pneumonia. Male PNU - Pneumonia

Female

AST - Asthma

Patient

AW Alive and Well

ASTAW 65 68

49 AWAWAW

46 AST

44 AST AW

41

38

42

18

AW

PNU

Case Study in Medical Ward

F. Physical Assessment
General Appearance (June 24, 2011) Patient is seen sitting on his bed, with ongoing IV fluid on his left metacarpal vein regulated at 25gtts/min a infusing well. Patient has poor grooming and was oriented to time, date and place.

VITAL SIGNS
June 21, 2011 (02:18 pm) Vital Sign According to the Patient s Chart June 24, 2011 (04:00 pm) According to the Student Nurses DAY 1

TEMPERATURE PULSE RATE RESPIRATORY RATE BLOOD PRESSURE

38.8C 89 bpm 25 cpm 120/90 mmHg

37.1C 97 bpm 31 cpm 110/ 90 mmHg

Case Study in Medical Ward

G. PHYSICAL ASSESSMENT
VITAL SIGNS: June 24, 2011 BP: 110/90 mmHg PR: 97bpm RR: 31cpm TEMP: 37.1 C

AREA ASSESSED Skin

TECHNIQUE USED Inspection

NORMAL FINDINGS Intact not open, broken or blemished. Skin color varies in color depending on race, sun exposure, nutrition, and pigmentation of the skin. Normal skin is usually warmth to touch, moist, smooth and demonstrate good elasticity depending upon age, nutritional intake and other factors. Normally head and face is symmetrical, intact. Can accommodate facial expression with no lesion. Head should be free from scalp flaking, no mass, hair is smooth not easily get plucked

SIGNIFICANT FINDINGS Brown in color. Some open wound noticed

ANALYSIS AND ENTERPRETATION Indicates poor hygiene

Palpation

When pinched, skin springs back to previous state

Normal

Head

Inspection

Intact, no lesion

Normal

Palpation

Head skin has absence of inflammation, lumps, and symmetrical.

Normal

Case Study in Medical Ward

and free from louse.

Eyes and vision

Inspection

Moist and pinkish sclera, No inflammations or periorbitaledema, Eyes have no blurring of vision involuntary drooping of eyelids (ptosis). Pupils are equal; round, reacted to light and accommodation (PERRLA). No growths, redness or inflammation, swelling. Can normally hear low pitch sounds.

Pinkish conjunctiva, no noted inflammation, ptosis noted

Significant sign sleepiness

Ears and hearing

Inspection

Both ears have no inflammation, tenderness, and normally adopt to accommodation of hearing.

Normal

Palpation

No tenderness on the outer ear.

Nose and sinuses

Inspection

Outer ear is intact and no tenderness or masses noted Normal nose have Absence of Indicates presence of no foreign bodies smelling secretion or obstruction, sensation, and secretion, and obstruction in the also no indication air ways noted of bleeding, symmetrical in shape. Can smell and identify, Outer anatomical part of the mouth should be equal, have no swelling, Presence of odor noted Indicate poor hygiene

Mouth and Oropharynx Lips and buccal mucosa

Inspection and palpation

Case Study in Medical Ward

Teeth and Gums

Inspection

smooth, moist and color of lips may varies (however check for abnormalities). Tongue should be medium red and appear smooth at the margins and rough at the center. Then the back of tongue and throat has no lesions. Teeth are complete, has no cavities. Pinkish gums and well aligned. Mucosa of the mouth are not inflamed and swell.

Teeth are incomplete and with presence of cavities on lower molar teeth.

Indication of poor mouth hygiene.

Palate tonsils and uvula

Inspection

A normal palate is symmetrical pinkish color, have no abnormalities like viral patches, redness, and swelling as well as the uvula and tonsil,

Bony palate are equal, have no redness, swelling and good color appearance of tonsil and uvula.

Normal

Neck

Inspection and palpation.

No palpable mass and nodules with maximum head movement and good muscle strength. Thyroid is not enlarged and no detected swelling of the lymph nodes. Veins are intact

Palpable lymph nodes present

Indicates present of infection

Case Study in Medical Ward

normal carotid pulse

Chest

Inspection and palpation

Thorax and lungs

Inspection, auscultation percussion and palpation

Breasts are symmetrical in size and shape. Areola areas are symmetrical in size and shape. No masses, tenderness and any discharge. Normal curvature of the spine, symmetry of the rib cage, no crackles, whizzing, murmurs sounds and other abnormal sounds. Resonance sound as indication of normal lung sound.

No masses and tenderness noted

Normal

Crackles noted in both lower lobe

Indicate presence of secretion,

Respiratory rate31 cpm

Indicate Tachypnea

Heart

Auscultation

Normal apical heart rate from 60-100 bpm. <60 indicate bradycardia, tachycardia>100-tachypnea. No murmurs and abnormal sound. Abdomen has good skin integrity, contour and symmetry. No palpable mass.

Pulse rate is 97 bpm (normal pulse for teenager is 50-90 bpm)

Indicate tachycardia

Abdomen

Inspection, auscultation and palpation

Flat and soft no palpable mass

Normal

Case Study in Medical Ward

Upper and lower extremities

Inspection and Palpations

No lesion, swelling. Inflammations. Have good reflex reactions. Limbs are complete and symmetrical. Good peripheral pulses.

Some lesion noted in both lower extremities

May indicate poor hygiene

Nails

Inspection

Good peripheral pulses.

Presence of dirt noted

This may indicate poor hygiene.

Nail bed

Inspection

Normal nail bed have a good capillary refill for 2-3 seconds. Colors may vary in pinkish for white people, and poorly determined in black color skin.

Capillary refill is 2 seconds.

Normal

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H. Review of System

LEVEL

FINDINGS
Pakiramdamkoparanglalagnatinuliako, peroayus pa namanako,ganun pa din naman as verbalized by the patient. Nungna-confined akohangangngayonwala pa rin nag babagomedyohirap pa din akonghuminga as verbalized by the patient. Pakiramdamkomedyomabilisatangtumibokangpusoko, perohindinamanakonahihirapan as verbalized by the patient

Integumentary System

Respiratory System

Cardiovascular System

Gastrointestinal/Digestive /Metabolic

Ganun pa din namanyunpagdumi at pagihiko, normal pa namankasomedyowalalangakongganangkumain as verbalized by the patient. Normal namanangpagihiko, kasonakakapagodlang mag pabalikbaliksaC.R . as verbalized by the patient.

Genitoreproductive System

Musculoskeletal System

Hindi akokumportablengkumilosditosaloobngkwartodahilmadalasangdamin gbantaynungibangpasyente at isa pa medyonanghihinaangpakiramdamko as verbalized by the patient.

Neurologic System

Okay namanhindinamannasakityunulokokasomedyomadalasakongantukin, madalas din akongtulog as verbalized by the patient.

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I. Gordon s Patterns of Functioning

During Hospitalization Functional Health Patterns Prior to Hospitalization Day 1 June 24, 2011 The client defined health as the absence of disease and as a healthy person it can do anything without hesitation. The client also mentioned that he doesn t seek to the hospital unless he is in critical condition. The client considered himselfill because of his present condition; he also mentionedthat he trusted the health care provider in the hospital that help him

Analysis and Interpretation

Health Perception health management pattern

Prior to hospitalization, the client do not manage his health seriously and does not seek doctor`s assistance but when hospitalized, the client really seek on doctors and relied his health unto them. When the client was at home, he eats what he wants but has limitations during hospitalization. When the client was at home, he defecates and voids regularly, because of the regular work of the body and so promoting peristalsis The client has a lot of work when he is outside the hospital but all of those were stopped when he was hospitalized. 12

Nutritional/Metabolic Pattern

The client eats a lot, as long as he wanted and hisfavorite dishes was vegetables and dry fish

The client said that he wasn t able to eat well because of his condition.

Elimination Pattern

The client said that he voids normally (78 times a day) and eliminate everyday

The patient said that he voids and eliminate normally but sometimes, a day pass he doesn t meet his number of voids and sometimes he don t eliminate well.

Activity and Exercise Pattern

The patient exercise was his job as a farmer, walking going to school and sometimes naguuling

The client said that he wasn t able to do exercise because of his present condition

Case Study in Medical Ward

Sleep and Rest Pattern

The client stated that he doesn t have any problem regarding sleep and rest he usually sleep at 09:00 - 06:00 a.m(he has a regular sleep)

The patient said that he can t sleep well because of noisy and he is also uncomfortable with the environment.

The client has a regular sleep pattern at home but disturbed when hospitalized

Cognitive Pattern/Perceptual Pattern

The client stated that he was able to cooperate and understand things well

The patient was first feel a little anxious but after several hours the patient responds clearly to the health care provider team and other people in the room

The client has no problem at home but a little bit anxious when brought at the hospital but then easily adapted The client shows strong faith and confidence

Self Perceptual/Self Concern Pattern

The client believes that he is strong to face problems and worst situations. The client stated that he uses to interact with people around him. He also said that as the youngest in the family he must do all he can to promote good communication in the family

The patient was confident that he will recover immediately

Role/Relationship Pattern

The client stated that he used to interact with people around him

The patient is doing all he could to become a good son in the family.

Sexuality/Reproductive Pattern

The patient stated that even though he does not have girlfriend he still enjoys his relationship with his family

His Family is been very supportive and understanding to the patient

The patient is very confident because of the support of his family

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13

Coping/Stress Tolerance Pattern

Whenever the patient was stress and tired he always goes to his room and sleep.

The client feels uncomfortable because of his condition, he always remember his room

The patient could always cope with her problems by sleeping.

Values/Belief Pattern

The patient stated that he doesn t fond on consulting faith healer. He also verbalized that he has a strong faith to God.

The client said that his belief does not change.

The client has a strong belief thatthe doctors can cure his illness, and the Lord is always guiding him

J. Activities of Daily Living

PRIOR TO HOSPITALIZATION

DURING HOSPITALIZATION

ANALYSIS

Madalasakoangkumikitaparasapamilyas yempreakokasiang padre de pamilyakahitpagod o kaya ginagabisapamamasadaayuslangbastaku mitangmaayospara may pantawidgutom at pambaonsa as verbalized by the patient.

Nakakapanibagoditosa hospital kahitdatinaoospitalnaakonaninibago pa rinakodahilwalakanamanginagawadito nakahilatakalang at matutulog as verbalized by the patient.

Hospitaliz ation affects the daily activities of the patient. He cannot perform his daily responsibi lities as the father of his family and also his
14

Case Study in Medical Ward

activities on her job as a driver. He was not able to sleep well during hospitaliza tion.

Patient s Concept of Health, Illness, and Hospitalization

Pumupuntaako dun sapinsankokapagpakiramdamkongmataasnaang BP ko, agadagadakong mag papakuhang BP, pagmedyomataasang BP ko nag papa-check up kaagadakopagkakaibanaangnararamdamanko, nagpapasamaakosaakingasawa. Malimitakonggumamitngmgahalamanggamotkasipakiramdamko mas epektiboitokesasatableta at pineapple juice namanmalimitangnainumkokapaghindinadadalasamgahalamanggamotpero kung malalana ay dun sagamotnalangnainiresetanung doctor angbibilhinko, payagnamanakongbumilikahithirap kami. Hindi akokumukunsultasamgaalbularyo, dahilbakalalonglumala pa angpakiramdamkobakalalongmalakiangmagastoskokapagmayroongnangyarisa akin , as verbalized by the patient.

The patient is concern with his health. He usually consult doctors and health care providers because he know that they can provide the quality care he needed instead of going to quack doctors. The patient uses herbal medicines rather than tablets unless the doctor prescribed it. He usually rely on government supplies because it is cheaper and sometimes free.

Laboratory and Diagnostic Exams

Complete Blood Count

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Diagnostic Exam Hemoglobin Hematocrit Leukocyte Ct. Neutrophils Lymphocytes Blood type = O+

Normal Value 120 160 g/l 0.36 0.48 4.0-11.0x10L 0.40-0.60 0.20-0.40

Significant Findings 120 0.35 11.05 0.91 0.09

Analysis Normal Possible Renal (kidney) failure Possible to infection

HBsAG non-reactive

Ward Medical

CHAPTER III CLINICAL DISCUSSION OF THE DISEASE

A. Anatomy and Physiology

RESPIRATORY SYSTEM The Nose or Nasal Cavity As air passes through the nasal cavities it is warmed and humidified, so that air that reaches the lungs is warmed and moist. The Nasal airways are lined with cilia and kept moist by mucous secretions. The combination of cilia and mucous helps to filter out solid particles from the air an Warm and moisten the air, which prevents damage to the delicate tissues that form the Respiratory System. The moisture in the nose helps to heat and humidify the air, increasing the amount of water vapour the air entering the lungs contains. This helps to keep the air entering the nose from drying out the lungs and other parts of our respiratory system. When air enters the respiratory system through the mouth, much less filtering is done. It is generally better to take in air through the nose. The Pharynx The pharynx is also called the throat. As we saw in the digestive system, the epiglottis closes off the trachea when we swallow. Below the epiglottis is the larynx or voice box. This contains 2 vocal cords, which vibrate when air passes by them. With our tongue and lips we convert these vibrations into Speech. The area at the top of the trachea, which contains the larynx, is called the glottis. Case Study in Medical Ward 16

The Trachea The trachea or windpipe is made of muscle and elastic fibres with rings of cartilage. The cartilage prevents the tubes of the trachea from collapsing. The trachea is divided or branched into bronchi and then into smaller bronchioles. The bronchioles branch off into alveoli. The Lungs The lungs constitute the largest organ in the respiratory system. They play an important role in respiration, or the process of providing the body with oxygen and releasing carbon dioxide. The lungs expand and contract up to 20 times per minute taking in and disposing of those gases.

Air that is breathed in is filled with oxygen and goes to the trachea, which branches off into one of two bronchi. Each bronchus enters a lung. There are two lungs, one on each side of the breastbone and protected by the ribs. Each lung is made up of lobes, or sections. There are three lobes in the right lung and two lobes in the left one. The lungs are cone shaped and made of elastic, spongy tissue. Within the lungs, the bronchi branch out into minute pathways that go through the lung tissue. The pathways are called bronchioles, and they end at microscopic air sacs called alveoli. The alveoli are surrounded by capillaries and provide oxygen for the blood in these vessels. The oxygenated blood is then pumped by the heart throughout the body. The alveoli also take in carbon dioxide, which is then exhaled from the body. Inhaling is due to contractions of the diaphragm and of muscles between the ribs. Exhaling results from relaxation of those muscles. Each lung is surrounded by a two-layered membrane, or the pleura, that under normal circumstances has a very, very small amount of fluid between the layers. The fluid allows the membranes to easily slide over each other during breathing.

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B. Pathophysiology
Contributing Factor bacteria Streptococcus Pneumonia Predisposing Factor *age-16y/o *work-Farming

Entry of microorganism to nasal passages Invasion of the respiratory system Cough

Activation of immune response (mucus production)

Ineffective Immune Response resulting from overwhelming infection

Invading lung parenchyma Release of endotoxins and exotoxins

Hazy portion of the chest pain

Continuous mucus production

dyspnea

Massive inflammation (pneumonia)

Altered gas exchange

C. Drug Study
Case Study in Medical Ward

Consolidations 18

Drug

Frequency

Action

Classification

Indication

Contraindication

Side Effects/Adverse Effects

Nursing Responsibilit ies

GENERIC

NAME: Guaifen esin

BRAND NAME:

500 mg PO q6h

*Reduces viscosity of tenacious secretions by increasing respiratory tract fluid

Expectorant

Symptomatic management of coughs associated with upper respiratory tract infection

Hypersensitivity, Alcohol content meds Use Cautiously in: diabetics patients receiving disulfiram Pregnancy or Lactation

CNS: dizziness, headache GI: nausea, vomiting, diarrhea, stomach pain

-became alert with adverse reactions -assessed patient and family knowledge of drug therapy

*mobilizati on and subsequent expectorati on of mucus

-instruct patient to cough effectively -advise patient to limit talking, stop smoking, and take sugarless gum or hard candy

CHAPTER IV.
Case Study in Medical Ward 19

NURSING PROCESS A. Problem List

Actual Problem Date of Onset Nursing Problem Date Identified Date Resolved

June 21, 2011

1. Ineffective airway clearance r/t increased sputum production in response to respiratory infection 2. Impaired gas exchange r/t collection of mucus in airways 3. Self care deficit r/t environmental barriers 4. Disturbed sleep pattern r/t environmental changes during hospitalization

June 22, 2011

June 22, 2011

June 22, 2011

June 22, 2011

June 22, 2011

June 22, 2011

June 22, 2011

June 22, 2011

5. Activity Intolerance related to generalized weakness 6. Anxiety r/t change in health status

June 22, 2011

June 22, 2011

June 22, 2011

June 22, 2011

B. Nursing Care Plan

Case Study in Medical Ward 20

Data

Nursing Diagnosis

Background Knowledge

Short-Term Goal

Intervention

Rationale

Evaluation

S: -Ayawkonadito gusto kongumuwihindik onaalam kung anungnangyayari as verbalized by the patient. O: >V/S T: 36.2 C PR: 90 bpm RR: 22 cpm BP: 230/160 mmHg >The patient looks restless

Anxiety Related to change in health Status

>difficulty
speaking

in

>uncomfortable
with his situation

Vague uneasy feeling of discomfort or dread accompanied by an autonomic response; a feeling of apprehension caused by anticipation of danger. It is an altering signal that warns of impending danger and enables the individual to take measures to deal w/ threat.

After 2 hours of nurse patient interaction the patient will manifest less irritable with his situation and will able to verbalized is problem

1.Established rapport with the patient

1. To build good nursepatient relationship. 2. Provides as baseline data

2.Monitored vital signs of the patient.

3. Provided calm, restful surroundings, minimize environmental activity or noise.

3. Help reduce sympathetic stimulation, promotes relaxation to the patient.

After the 2 hours of nurse patient interaction the patient display less irritable and with increase concentrating in combating with anxiety problems

4.Maintained activity restrictions.

4.Reduces physical stress and tension that affect blood pressure and course of hypertension. 5.To establish good rapport

5.Provided an emotional support to the patient

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Data

Nursing Diagnosis

Background Knowledge

Short-Term Goal

Intervention

Rationale

Evaluation

S: > pambihirahindia komakatulogbuwi sit as verbalized by the patient.

O: >Slight difficulty in breathing >Adventitious breath sound present upon auscultation >Tachypnea >RR:26 cpm >Secretions noted

Disturbed sleep pattern related to environ mental changes during hospitalization

Sleep is required to provide energy for physical and mental activities. Disturbed sleep pattern is a timelimited disruption of sleep amount and quality.

1.Vital signs After 4 hours monitored and of nursing recorded. intervention, airway 2. Assisted in patency will semi-fowler s be position. maintained, secretions will be readily 3.Encouraged expectorated deep breathing and there will exercise. be signs of reduction in 4.Administered congestion. prescribed medications.

1.This is for baseline comparison. 2.Proper positioning helps in draining secretions. 3.This will promote proper lung expansion. 4.Prescribed meds such as bronchodilators helps in aiding effective airway clearance. 5.Nebulization helps in liquefying secretions for better and faster expectorating the secretions. May help loosen up secretion

After 4 hours of nursing intervention, the goal is met through maintenance of airway patency and reduction in congestion.

5.Provided supplemental humidification via use of nebulizer.

6.Rendered CPT and instructed about steam inhalation

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Data

Nursing Diagnosis

Background Knowledge

Short-Term Goal

Intervention

Rationale

Evaluation

S: > Nanghihina pa ako at masakit pa angakingulo as verbalized by the patient.

Activity Intolerance related to generalized weakness

O: >The patient looks restless >Presence of Edema >V/S: PR: 97 bpm RR: 26 cpm BP: 150/100 mmHg

Insufficient physiological or psychological energy to endure or complete required or desirable daily activities

After 3-4 hours of nursing interventions , the patient will use identified techniques to improve activity intolerance

1.Established rapport 2.Monitored and recorded vital signs 3.Assessed patient s general condition 4. Adjusted client s daily activities and reduce intensity of level. 5.Encourage patient to have adequate bed rest and sleep 6. Provide the patient with a calm and quiet environment 7.Assist the client in ambulation 8.Note presence of factors that could contribute to fatigue

1.To gain patient s trust and cooperation 2.To obtain baseline data 3.To note for any abnormalities and deformities present within the body 4.To prevent strain and overexertion 5.to relax the body

Goal partially met, after 4 hours of nursing intervention, the patient was able to use identified techniques to improve activity intolerance

6. to provide relaxation

9.Ascertain client s ability to stand and move about and degree of assistance needed or use of equipment 10.Encourage the client to maintain a positive attitude 11.Assist the client in a semi-fowlers position 12.Elevate the head of the bed 13.Assist the client in learning and demonstrating appropriate safety measures

7.to prevent risk for falls that could lead to injury 8.fatigue affects both the client s actual and perceived ability to participate in activities 9.to determine current status and needs associated with participation in needed or desired activities 10.to enhance sense of well being 11.to promote easy breathing 12.to maintain an open airway 13.to prevent injuries

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Data

Nursing Diagnosis

Background Knowledge

Short-Term Goal

Intervention

Rationale

Evaluation

S: > medyonahi hirapanakong huminga as verbalized by the patient.

O: >The patient has cough >rhonchi >V/S: PR: 97 bpm RR: 24cpm BP: 120/90 mmHg

Ineffective airway clearance related to increased sputum production in response to respiratory infection

Pneumonia has the symptom of sputum production as a response to bacterial infection. It alters the normal breathing of the patient.

Patient s airway will be free of secretions after 2 hours as evidenced by eupnea and clear breath sounds after coughing or suctioning.

1.

Assessed vital signs and auscultated breath sounds Observed sputum color, odor, amount and report significant changes. Assisted patient with coughing, deep breathing, splinting as necessary. Encouraged patient to cough

1.

2.

2.

For baseline and to note the effectiveness of care rendered To assess the progress of patient To improve airway clearance Frequent nonproductive coughing can result in hypoxemia To facilitate effective breathing and coughing Fluids aid in the mobilization of secretion To aid in loosening secretions To remove sputum and mucus plugs

3.

3.

4.

4.

5.

Positioned the patient in semi fowler Maintained adequate hydration Administered medications as ordered Instituted suctioning of airway as needed

5.

After 2 hours of nursing interventio ns, the patient s airway is free of secretions as evidenced by eupnea and clear breath sounds

6.

6.

7.

7.

8.

8.

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24

Data

Nursing Diagnosis

Background Knowledge

Short-Term Goal

Intervention

Rationale

Evaluation

S: > angsamangp akiramdamko as verbalized by the patient.

O: >cyanosis >decrease activity intolerance >restlessness >V/S: PR: 97 bpm RR: 26 cpm BP: 130/90mmHg

Impaired gas exchange related to collection of mucus in airways

Pneumonia causes decrease in oxygen supply because of mucus secretions that also leads to difficulty in breathing

After 1 hour, the patient will maintain optimal gas exchange as evidenced by eupnea, normal ABGs, and alert responsive mentation

1.

2.

3.

Assessed respiration, noting the quality, rate, pattern, depth, dyspnea on exertion and use of accessory muscles Assessed for cyanosis and changes in orientation and noted increasing restlessness Monitored for changes in vital signs

1.

To have baseline data with the respiratory status of client.

2.

These can be signs of hypoxia and/or hypercarbia

Goal partially met, after 4 hours of nursing intervention, the patient was able to use identified techniques to improve activity intolerance

3.

4.

Paced activities to patient s tolerance

4.

5. 5. Maintained oxygen device administratio n as ordered (2L/min)

With initial hypoxia,BP, PR,RR will all rise as it severes, BP will drop Activities will increase oxygen consumptio n and should be planned To supply necessary oxygen within the body

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Data

Nursing Diagnosis

Background Knowledge

Short-Term Goal

Intervention

Rationale

Evaluation

Subjective: Gusto kongmaligokaso tinatamadko at walarinnamanak ongmaliguandit o. as verbalized by the patient Objective: >presence of dirt >presence of odor >Inability to bathe and groom self independently

Self-care deficit related to environmen tal barriers

Impaired ability to perform or complete activities of daily living, such as feeding, dressing, bathing or toileting due to lack of motivation.

After two hours of nurseclient interaction, the patient will be able to express achievement of necessary care accompanied by enhanced motivation to attain selfneeds

1. Established rapport with the patient 2. Monitored vital signs & conducted physical examination 3. Assessed client s needs 4. Provided clean environment and utensils for patient s hygiene (dress, toilet, beddings) 5. Provided privacy in assisting client during dressing, grooming, toileting and maintaining proper hygiene 6. Given health teaching regarding the essence of proper hygiene and grooming 7. Taught family and caregivers to foster independence and to intervene if the patient becomes fatigued, is unable to perform task, or becomes excessively frustrated. 8. Encouraged patient to perform minimal oral-facial and personal hygiene as soon after rising as possible.

1.To promote good communication 2.To obtain baseline data 3.To identify patient needs and right management 4.To enhance motivation for selfcare 5.To ensure safety and attainment of needs

After two hours of nurse-client interaction, the patient verbalized achievement of necessary care accompanied by enhanced motivation to attain self-needs

6.To provide necessary information and learning 7.To furnish continuing care and motivation for self-care

8.This enables the patient to maintain autonomy for as long as possible

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C. Discharge Planning
Medication: y y y Instructed the client to take the following home medication as ordered by the physician. Make sure that the prescription is well understood by the patient. Drink the medicines on the prescribed time. Instruct client to take multivitamins for her health and for her baby.

Exercise: y y Instructed the client to avoid strenuous activities. Instructed the patient to exercise social interaction with the family

Treatment: y Instructed the client to return to hospital whenever hypertension persists Health Teaching: y y y y y y Instructed the client to take a bath every day. Advice to eat plenty of vegetables and fruits and maintain 8 glasses of water every day. Take good care of pregnancy by a follow up check up on near centers or hospitals. After delivery of the baby, always observe proper breastfeeding because it helps in the total growth of the child. Practice family planning method such as using condoms, withdrawal method, calendar method and others to prevent unwanted pregnancies. Update patient on the latest trends on hospital setting such as the programs conducted for the health concerns of patients.

Out patient follow up: y Diet: y y y y y y Iron rich foods such as fish and vegetables. Vitamin C rich foods such as fruits and green vegetables. Low fat diet such as bulanglang and avoid prito. Low salt diet. Calcium rich food such as milk and dilis. Vitamin B rich foods such as meat and vegetables. Advice to have a check up whenever she feels something uncomfortable.

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y y

Advice the client to do not lose faith Have a positive outlook in life and be faithful

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