INTRODUCTION

A. Pneumonia is an inflammation of the lung that is most often caused by infection with bacteria, viruses, or other organisms. Occasionally, inhaled chemicals that irritate the lungs can cause pneumonia. Healthy people can usually fight off pneumonia infections. However, people who are sick, including those who are recovering from the flu (influenza) or an upper respiratory illness, have weakened immune systems that make it easier for bacteria to grow in their lungs.

Aspiration is defined as the inhalation of either oropharyngeal or gastric contents into the lower airways. Inhalation of these contents can lead to aspiration pneumonia. Aspiration pneumonia results from chronic, usually unwitnessed, inhalation of small amounts of oropharyngeal contents leading to an infectious process.

Substances other than bacteria may be aspirated into the lung, such as gastric contents, exogenous chemical contents, or irritating gases. This type of aspiration or ingestion may impair the lung defenses, cause inflammatory changes, and lead to bacterial growth and a resulting pneumonia.

This inflammation causes an outpouring of fluid in the infected part of the lungs, affecting either one or both lungs. The blood flow to the infected portion of the lung (or lungs) decreases, meaning oxygen levels in the bloodstream can decline.

The body attempts to preserve blood flow to vital organs and decrease blood flow to other parts of the body such as the GI tract. The effects of pneumonia are widespread even though the infection is localized to the lung. The complications of pneumonia in the elderly can be life-threatening, from low blood pressure and kidney failure to bacteremia, an infection that spreads to the bloodstream.

Elderly people are more susceptible to pneumonia for several reasons. Often they already suffer from co-morbid conditions such as heart disease, which means they don’t tolerate infection as well as younger people. Age also causes a decrease in an older person’s immune system response, so his defenses are weaker. Some virulent organisms can cause infection in younger people, but the infections can be worse in older people.

Common pathogens are Streptococcus pneumoniae. Other causes include Haemophilus influenzae, and Streptococcus aureus.

B. (Incidence and Prevalence rate)

Incidence Rate for Pneumonia: approx 1 in 56 or 1.76% or 4.8 million people in USA

Extrapolation of Incidence Rate for Pneumonia to Countries and Regions: The following table attempts to extrapolate the above incidence rate for Pneumonia to the populations of various countries and regions. As discussed above, these incidence extrapolations for Pneumonia are only estimates and may have limited relevance to the actual incidence of Pneumonia in any region:

Country/Region Extrapolated Incidence Population Estimated Used

Pneumonia in North America (Extrapolated Statistics)

USA 5,182,154 293,655,4051

Canada 573,668 32,507,8742

Pneumonia in Europe (Extrapolated Statistics)

Austria 144,260 8,174,7622

Belgium 182,616 10,348,2762

Britain (United Kingdom) 1,063,600 60,270,708 for UK2

Czech Republic 21,991 1,0246,1782

Denmark 95,530 5,413,3922

Finland 92,020 5,214,5122

France 1,066,309 60,424,2132

Greece 187,897 10,647,5292

Germany 1,454,551 82,424,6092

Iceland 5,187 293,9662

Hungary 177,041 10,032,3752

Liechtenstein 590 33,4362

Ireland 70,051 3,969,5582

Italy 1,024,543 58,057,4772

Luxembourg 8,165 462,6902

Monaco 569 32,2702

Netherlands (Holland) 287,968 16,318,1992

Poland 681,641 38,626,3492

Portugal 185,720 10,524,1452

Spain 710,837 40,280,7802

Sweden 158,583 8,986,4002

Switzerland 131,485 7,450,8672

United Kingdom 1,063,600 60,270,7082

Wales 51,494 2,918,0002

Pneumonia in the Balkans (Extrapolated Statistics)

Albania 62,555 3,544,8082

Bosnia and Herzegovina 7,193 407,6082

Croatia 79,356 4,496,8692

Macedonia 36,001 2,040,0852

Serbia and Montenegro 191,045 10,825,9002

Pneumonia in Asia (Extrapolated Statistics)

Bangladesh 2,494,243 141,340,4762

Bhutan 38,568 2,185,5692

China 22,920,840 1,298,847,6242

East Timor 17,986 1,019,2522

Hong Kong s.a.r. 120,972 6,855,1252

India 18,795,363 1,065,070,6072

Indonesia 4,207,993 238,452,9522

Japan 2,247,052 127,333,0022

Laos 107,084 6,068,1172

Macau s.a.r. 7,857 445,2862

Malaysia 415,102 23,522,4822

Mongolia 48,552 2,751,3142

Philippines 1,521,912 86,241,6972

Papua New Guinea 95,652 5,420,2802

Vietnam 1,458,755 82,662,8002

Singapore 76,833 4,353,8932

Pakistan 2,809,347 159,196,3362

North Korea 400,545 22,697,5532

South Korea 851,184 48,233,7602

Sri Lanka 351,267 19,905,1652

Taiwan 401,467 22,749,8382

Thailand 1,144,685 64,865,5232

Pneumonia in Eastern Europe (Extrapolated Statistics)

Azerbaijan 138,853 7,868,3852

Belarus 181,950 10,310,5202

Bulgaria 132,670 7,517,9732

Estonia 23,676 1,341,6642

Georgia 82,833 4,693,8922

Kazakhstan 267,241 15,143,7042

Latvia 40,699 2,306,3062

Lithuania 63,668 3,607,8992

Romania 394,509 22,355,5512

Russia 2,540,718 143,974,0592

Slovakia 95,710 5,423,5672

Slovenia 35,496 2,011,473 2

Tajikistan 123,733 7,011,556 2

Ukraine 842,330 47,732,0792

Uzbekistan 466,066 26,410,4162

Pneumonia in Australasia and Southern Pacific (Extrapolated Statistics)

Australia 351,408 19,913,1442

New Zealand 70,479 3,993,8172

Pneumonia in the Middle East (Extrapolated Statistics)

Afghanistan 503,182 28,513,6772

Egypt 1,343,248 76,117,4212

Gaza strip 23,382 1,324,9912

Iran 1,191,233 67,503,2052

Iraq 447,788 25,374,6912

Israel 109,394 6,199,0082

Jordan 99,021 5,611,2022

Kuwait 39,839 2,257,5492

Lebanon 66,656 3,777,2182

Libya 99,380 5,631,5852

Saudi Arabia 455,222 25,795,9382

Syria 317,944 18,016,8742

Turkey 1,215,775 68,893,9182

United Arab Emirates 44,539 2,523,9152

West Bank 40,785 2,311,2042

Yemen 353,380 20,024,8672

Pneumonia in South America (Extrapolated Statistics)

Belize 4,816 272,9452

Brazil 3,248,843 184,101,1092

Chile 279,246 15,823,9572

Colombia 746,660 42,310,7752

Guatemala 252,010 14,280,5962

Mexico 1,852,228 104,959,5942

Nicaragua 94,583 5,359,7592

Paraguay 109,259 6,191,3682

Peru 486,075 27,544,3052

Puerto Rico 68,787 3,897,9602

Venezuela 441,483 25,017,3872

Pneumonia in Africa (Extrapolated Statistics)

Angola 193,739 10,978,5522

Botswana 28,927 1,639,2312

Central African Republic 66,043 3,742,4822

Chad 168,327 9,538,5442

Congo Brazzaville 52,906 2,998,0402

Congo kinshasa 1,029,124 58,317,0302

Ethiopia 1,258,880 71,336,5712

Ghana 366,300 20,757,0322

Kenya 582,037 32,982,1092

Liberia 59,834 3,390,6352

Niger 200,480 11,360,5382

Nigeria 313,241 12,5750,3562

Rwanda 145,388 8,238,6732

Senegal 191,508 10,852,1472

Sierra leone 103,833 5,883,8892

Somalia 146,551 8,304,6012

Sudan 690,849 39,148,1622

South Africa 784,384 44,448,4702

Swaziland 20,633 1,169,2412

Tanzania 636,543 36,070,7992

Uganda 465,710 26,390,2582

Zambia 194,571 11,025,6902

Zimbabwe 64,797 1,2671,8602

There are 25 million cases of pneumonia world wide are reported each year and about 63,500 people died from the disease.

II. OBJECTIVES

General:I should be able to able to make use of the knowledge, skills, and attitude I have built up in myself as a preparation for this clinical exposure. In the process, I should be able to improve these three domains and motivate our patient to the road of recovery.

Specific:Cognitive

1. Learn important information about Pneumonia; its causes, signs and symptoms, occurrence, diagnostic tests, and treatment.

2. Know what happens to the body once this disease occurs.3. Formulate an effective nursing care plan to relieve the problems

experienced by the patient and achieved plan goals.4. Apply the different kinds of interventions performed.

Psychomotor

1. Assess the patient’s condition in a cephalocaudal manner noting her general physique and patterns of functioning.

2. Perform appropriate interventions to each of the NANDA-approved diagnoses we have formulated.

Attitude

1. Interview the patient / folks in a therapeutic manner using different means of therapeutic communication.

2. Successfully establish trust and rapport with the patient

I.ANATOMY AND PHYSIOLOGY

The respiratory system is situated in the thorax, and is responsible for gaseous exchange between the circulatory system and the outside world. Air is taken in via the upper airways (the nasal cavity, pharynx and larynx) through the lower airways (trachea, primary bronchi and bronchial tree) and into the small bronchioles and alveoli within the lung tissue.

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.

Each alveolus has a thin membrane that allows oxygen and carbon dioxide to pass in and out of the capillaries, the smallest of the blood vessels. When you take a deep breath, the membrane unfolds and expands. Fresh oxygen moves into the capillaries, and carbon dioxide passes from the capillaries into the bloodstream, where it is carried out of the body through the lungs.

When air is inhaled through the nose or mouth, it travels down the trachea to the bronchus, where it first enters the lung. From the bronchus, air goes through the bronchi, into the even smaller bronchioles and lastly into the alveoli.

Pneumonia may be defined according to its location in the lung:

1.Lobar pneumonia occurs in one part, or lobe, of the lung.2.Bronchopneumonia tends to be scattered throughout the lung.

VITAL INFORMATION

Name: E.AAge: 87 years oldSex: FemaleAddress: Cogon, Panitan CapizCivil Status: MarriedReligion: Roman CatholicOccupation: ----Date & Time admitted: August 18, 2009 / 3:29 pmWard: IHM – Room 224Chief Complaint: CoughImpression/Admitting Diagnosis: Aspiration PneumoniaFinal Diagnosis: Aspiration PneumoniaAttending Physician: Dr. M. Obligacion and Dr. J.

Arancillo

V. CLINICAL ASSESSMENT

A. Nursing History1 month prior to admission, the patient is (+) to CVA but it is

undiagnosed. Mrs. E.A. is (-) to HPN and (-) DM.1 week prior to admission, E.A. was noted to have cough associated

with fever, undocumented. So she sought consult with AP given Co.amoxiclav with relief of symptoms.

Day of admission, folks decided to have patient admitted for general check – up.

B. Past Health Problem/StatusMrs. E.A has no notable Illness. She sometimes

experiences cough, fever and cold. She is a Non alcoholic and Non Smoker.

C. Family History IllnessMrs. E.A. family is (+) in Hypertension.OBGyne HX = G10P10

Lung cancer

Died of Asthma E.A

87

6567 60

58

56

18

4154 5240

F.A.94

DISEASED

FEMALE

MALE

LEGEND:

VI. BRIEF SOCIAL, CULTURAL, AND RELIGIOUS BACKGROUND

Educational BackgroundMrs. E.A. is a high school graduate.

Occupational BackgroundMrs. E.A. is a housewife.

Religious PracticesMrs. E.A. is a Roman Catholic.

Economic Status

Mrs. E.A. is supported by her children in her daily living.

VII. CLINICAL INSPECTION

A. Vital Signs

V/S taken upon admission:T – 36.1 °C P – 89 bmp RR – 18 bmp CR – 92 bmp BP–

130/90mmHg

V/S taken during my care:T – 36.5 °C P – 83 bmp RR – 21 bmp CR – 86 bmp BP –

120/80 mmHg

B. Height: 152 cm Weight: 44 kg

BMI: 19.0Mrs. M.L is in a Normal Weight.

C. Physical Assessment

General Appearance: Patient is as sleep most of the time, cannot move freely and is not responsive.

Skin: MoistHair: There is no presence of dandruff and no presence of lice.Nails: She had a short nails.Head: normocephalic and symmetric; no lesions, lumps, tenderness. Face: Face symmetric.Lymphatic: no involuntary movements, symmetric facial movements.Eyes: Dirty sclera, Pale conjunctiva, Presence of cataract at the left eye.Ears: Auricles brown in color, symmetrical in size and position; no lesions, tenderness,

scaling, and discharge in palpation. Unable to hear sounds distinctly.Nose: symmetric in size and position. No lesions, tenderness, scaling, and discharge

on palpation. No nasal congestion observed.Mouth: lips symmetrical, soft, and dry. Neck and upper extremities: symmetrical, no masses or swelling.Chest, breast and axilla: symmetrical; no masses noted.Respiratory System: symmetrical chest expansion, (+) crackles both LF, (+) rhonchi

both LF. VIII. Cardiovascular System: cardiac rate is normal and weak. IX. Gastrointestinal system: bowel movement is regular.X.Genitor-urinary system: she can micturate well, no pain noted.XII. Musculoskeletal system: Unable to flex and extend both upper and lower

extremities. No tenderness or swelling on joints or bones. Good hand grip.

D. GENERAL APPRAISAL

Speech: She cannot speak clearly but able to make sounds.Language: BisayaHearing: She can’t easily responds when called and claims to hear well.Mental status: She is illogical. Cannot respond easily to verbal command but is not experiencing any mental deficits.Emotional Status: she is emotionally stable. She is currently not grieving for anyone.

VIII. LABORATORY AND DIAGNOSTIC DATAA. Chemistry

Fluid: serumAugust 24, 2009

16:52:35

Result Normal Values Significance of the Abnormal Result

Creatinine 28.2 62.0 – 106.0 umol/L renal disease that affects the glomerular

filtration rate.

Potassium 3.10 3.50 – 5.10 mmol/L Within Normal Range

Sodium 136.3 62.0 – 106.0 umol/L Starvation & diabetic acidosis,

Dehydration

ALT 26

B. Hematology

Blood ExamAugust 24, 2009

Result Normal ValuesSignificance of the Abnormal Result

WBC 3.8 4.5 – 11.0 10^ g/L Within Normal Range

RBC 4.62 M: 4-6 – 6.2 10^ 12/LF: 4.2 – 5.4 10^ 12/L

Within Normal Range

Hemoglobin 135 M: 130 – 180 g/LF: 115 – 165 g/L

Within Normal Range

Hematocrit L 0.41 M: 0.40 – 0.54 vol - frF: 0.37 – 0.47 vol – fr

Within Normal Range

Mean Cell volume(MVC)

90.0 78 – 79 fl Folate deficiency,B12 deficiency,

Hereditary spherocytosis

Mean cell Hemoglobin (MCH)

29.1 27 – 32 pg Within Normal Range

Mean Cell haemoglobin concentration(MCHC)

32.5 30 – 35 g/dl Within Normal Range

RDW 13.2 11 – 16 % Within Normal Range

Neutrophil 50.0 50-70 % Within Normal Range

Stabs 1.0 2-3

Eosinophil 11.0 0 - 3% Infection, Inflammation,

Leukemia, Allergic reaction

Basophil 0.0 0 – 1 % Anaplastic anemia, Bone marrow depression,

Pernicious anemia, Some infectious or parasitic disease

Lymphocytes 29.0 20 – 45 % Within Normal Level

Monocytes 9.0 0 – 8 % Chronic Infection

C. ABG analysis

August 24, 2009 Result Normal Values Significance of the Abnormal Result

pH 7.45 7.35 – 7.45 Within Normal Value

PCO2 41.3 35 – 45 mmHg Within Normal Value

PO2 46.0 80 – 100 mmHg Anemia & Obstructive

Pulmonary disease

HCO2 28.3 22 – 26 mmol/L

TCO2 66.4 Mmol/L

X-RAY result

Bibasal pneumonia with consolidation with minimal regression in the Right.Right upper lobe Pneumonia, no significant interval changeAtheromatons & Tortuous aortaBronhiectasis, both lung basesDextroscooliosis, thoracic spine

IX. PATHOPHYSIOLOGY

Liquid or object enters the respiratory system through inhalation of microorganism

(Infectious Process)

Infection occurs

Immune reaction follows

Under the infection and immune response inflammation process proceeded.

Vasoconstriction

Release of chemical mediators

Vasodilatation and increase capillary permeability

Increase blood pressure then formation of heat and redness to the site

Swelling and pain emerges then led to loss of tissue functions

Increase in local Capillary leaks

Increased permeability of cell members allowing leukocytes and fibrin to consolidate in involved areas

fibrin and leukocytes stiffen there will be a decrease in lung compliance & decrease lung vital capacity which decreases gas

exchange that leads to hypoxemia

Hypoxia

Triggers the compensatory mechanism

ASPIRATION PNEUMONIA

Name of Drug with Dosage

Generic Name

Action Mechanism of Action

Indication

Side Effects

Contraindication

s

Nursing Responsib

ilities

1.Zantac 150 mg 1 tab (BID)

Ranitidine Histamine Antagonist

Completely inhibits the action of histamine at the H2

receptors of the parietal cells of the stomach inhibiting basal gastric acid and secretion that is stimulated by food, insulin, histamine, cholinergic agonist, gastrin and penta gastrin.

- Short term treatment of active duodenal ulcer- Maintenance therapy for duodenal ulcer at reduce dosage- Short term treatment for benign gastric ulcer

HeadacheDizzinessConfusionHallucinationSkin rash

Contraindicated with allergy to ranitidine, lactation

-Administer oral drug with meals and at bed time.- Decrease doses in renal and liver failure.- Provide concurrent antacid therapy to relieve pain.- Administer IM dose undiluted, deep into large muscle group.- Arrange for regular follow-up including blood tests, to evaluate effects.

2. Metronidazole 500 MG 1 tab (TID)

Apo-Metronidazole

Flagyl

Noritate Protostat Vandazol Viaflex

Anti-Bacterial

Antibiotic

Anti-Protozoal

Amebicide

Inhibits infection with suscep-tible anaerobes, causing cell death, antiprotozoal – trichomonacidal, amebicidal.

Acute infection with susceptible anaerobic bacteria

Acute intestinal amebiasis

Bacterial vaginosis

Dry mouth with strange metallic taste

Nausea

Vomiting

Diarrhea

Contraindicated with not hypersensitivity to metronidazole, pregnancy. (Do not use for trichomoniasis in 1st trimester )

- Take full course of drug therapy; take with food if GI upset occurs.-Advice the client to avoid drinking alcohol to avoid severe reaction.

Name of Drug with Dosage

Generic Name

Action Mechanism of Action

Indication

Side Effects

Contraindication

s

Nursing Responsib

ilities

3.) Fluimucil600 mg 1 tab in ½ glass of water (OD)

Acetylcysteine

Mucolytic

Expectorant

Antiviral agent

Antidote

Used to reduce the viscocity of mucous secretions. It has also been shown to have antiviral effects in patients with HIV due to inhibition of viral stimulation by reactive oxygen intermediates.

Acute and chronic respiratory tract infection with abundant mucous secretions

Increased productive cough

Nausea

GI upset

Dyspnea

Effervescent tab / sachet Phenylketenuris

- Dilute the 20 & acetylcysteine solution with either normal saline or sterile water for injection, use the 10% solution undiluted.- Administer the following drugs separately, because they are incompatible with acetylcysteine solutions.- Use water to remove residual drug solution on the patient’s face after administration by face.- Inform the patient that nebulization may reduce an initial disagreeable odor, but the odor will soon disappear.

4) Celebrex200mg 1 cap (PRN)

Celecoxib

NSAIDS

Analgesic

Specific COX-2 enzyme inhibitor

Analgesic & anti-inflammatory activities related to cause the signs and symptoms associated with inflammation; does not affect the COX-1 enzyme, which protects the lining of the GI tract and has blood clotting and renal functions.

Acute and long-term treatment of signs and symptoms of rheumatoid arthritis and osteoarthritis

Acute pain

Menstrual pain

Lower impairment

Primary dysmenorrhea

Diarrhea

Dyspepsia

Headache

Upper respiratory tract infection

Abdominal pain

Flatulence

Nausea

Back pain

Dizziness

Edema

Rash

Contraindicated with allergies to sulphonamides, celecoxib, NSAIDS, or aspirin; significant renal impairment; pregnancy (3rd trimester), lactation

-Assess therapeutic responses:

1. Pain relief

2.Decreased stiffness

3.Swelling

4.Reduced grip strength

5. Improved grip strength-If GI upset occurs, take with food.-Avoid aspirin, alcohol (increase risk of GI bleeding)

5. Macrobee with Iron1 tab (OD)

Macrobee with Iron

Antianemics

Vitamins and Minerals

Prevention of FE-deficiency anemia especially in periods of rapid Adolescent growth, pregnancy & lactation, excessive menstrual flow, old age

Treatment of FE-deficiency anemia associated with traumatic or endogenous haemorrhages, surgery on the GIT

Malnutrition

Take the Macrobee with Iron before meals / empty stomach (Best taken between meals, maybe taken with meals to reduce GI discomfort)

XI. NURSING MANAGEMENT

Concept Map of Nursing Problems

Impaired Gas ExchangeS/Sx: -Tachycardia-Restlessness-Dyspnea-HypoxiaTherapy: O2 therapy, 2 liters.

Activity IntoleranceS/Sx: -Lethargy-Verbal reports of weakness-Fatigue-ExhaustionMeds & Therapy: ZantacRehab / Exercise therapy.

Ineffective Airway ClearanceS/Sx: -Inability to cough effectively-Anxiety-Dyspnea-Dry coughMeds: MetronidazoleFluimucilCelebrex

Risk for less than body requirements

S/Sx: - Starvation- Diabetic acidosis- Dehydration Meds & Diet: OTF (1,500 kilocalories / day ÷ 6 feedings). Macrobee with Iron

CC: CoughDx: Aspiration

Pneumonia

Ineffective Airway Clearance

ASSESSMENT

Subjective:“Gina ubo siya”As verbalized by the folks.

Objective:Inability to cough effectivelyAnxietyDyspneaDry cough

DIAGNOSIS

Ineffective Airway Clearance r/t:-Increased sputum production in response to respiratory infection.-Decreased energy, fatigue

PLANNING•After 8 hours of nursing intervention the patient will be able to cough effectively and clear secretions.

•After 8 hours of duty the patient will display patent airway with breath sounds clearing, absence of dyspnea.

Independent:a.) Monitor Vital signs

every hours.

b.) Position patient in a moderated high position or semi fowler’s position.

c.) Turn patient every two hours and PRN.

RATIONALE

a.) To asses baseline data of the patient.

b.) To promote maximal lung function.

c.) For repositioning, it promotes drainage of pulmonary secretions and it enhances ventilation to decrease potential of atelectasis.

INTERVENTION NURSING THEORY

Dorothy Johnson(Human Behavioral System)This theory focuses on the balance to maintain stability in the system. It also focuses on the behavior of the patient threatened with illness.

Ida Jean Orlando(Nursing Process – ADPIE)Nurses can help the patient what they cannot do to their self.Exploring the meaning of the need and validating the effectiveness of the action.

d.) Provide oral care.

e.) Instruct patient or the folks regarding medications, side effects, and symptoms of adverse reaction to report to the nurse or physician.

d.) Secretions from CAP are often foul tasting and smelling. Providing oral care may decrease nausea and vomiting associated with the taste of secretions.

e.) Promotes prompt identification of potential adverse reaction to facilitate timely intervention.

Virginia Henderson(14 components of Nursing Care)

- Nurses will do what the things that patients cannot do.-From dependence to independence.

Hildegarde Peplau(Basic care components)Orientation, Identification, Exploitation & Resolution.

Dependent:

a.)Administer medication such as antibiotics and expectorants for productive cough.

b.) Instruct the patient or the folks to notify nurse if the patient is experiencing shortness of breath or air hunger.

a.) A variety of medications are available to treat specific problems.

b.) It may indicate bronchial tubes are blocked with mucus, leading to hypoxia and hypoxemia.

Lydia Hall(Component of Nursing Care)

- Care, Core and Cure.- Through medicines the patient can be cured and infection can be cured.

GOAL METAfter the end of the shift, the patient is able to cough effectively and clear secretions.After the end of the shift, the patient display patent airway with breath sounds clearing, absence of dyspnea.

EVALUATION

ASSESSMENT

Subjective:“Nabudlayan siya mag ginhawa”As verbalized by the folks.

Objective:•Tachycardia•Restlessness•Dyspnea•Hypoxia

Impaired Gas Exchange

DIAGNOSIS

Impaired Gas Exchange

r/t:•Altered oxygen-carrying capacity of blood / release at cellular level•Altered delivery of oxygen (hypoventilation)

PLANNING

After 8 hours of duty, the patient will improved ventilation and oxygenation of tissues by ABGs within patient’s acceptable range and absence of symptoms of respiratory distress.

INTERVENTION Independent:a.) Observe color of

skin, mucous membranes, and nail beds, noting presence of peripheral cyanosis or central cyanosis.

b.) Assess mental status.

c.)Monitor heart rate / rhythm.

RATIONALE

a.) Cyanosis of nail beds may represent vasoconstriction or the body’s response to fever / chills; however, cyanosis of earlobes, mucous membranes, and skin around the mouth is indicative of systemic hypoxemia.

b.) Restlessness, irritation, confusion, and somnolence may reflect hypoxemia / decreased cerebral oxygenation.

c.) Tachycardia is usually present as a result of fever / dehydration but may represent a response to hypoxemia.

NURSING THEORY

Hildegarde Peplau(Basiccare components)Orientation, Identification, Exploitation& Resolution.

Dorothy Johnson(Human Behavioral System)- This theory focuses on the balance to maintain stability in the system. It also focuses on the behavior of the patient threatened with illness.

d.) Monitor body temperature. Assist with comfort measures to reduce fever and chills.

e.) Maintain bedrest. Encouirage use of relaxation techniques and diversional activities.

f.) Elevate head and encourage frequent position changes, deep breathing, and ineffective coughing.

d.) High fever greatly increases metabolic demands and oxygen consumption and alters cellular oxygenation.

e.) Prevents overexhaustion and reduces oxygen consumption / demands to facilitate resolution of infection.

f.) These measures promotes maximal inspiration, enhance expectorantion of secretions to improve ventilation.

Ida Jean Orlando(Nursing Process – ADPIE)

- Nurses can help the patient what they cannot do to their self.- Exploring the meaning of the need and validating the effectiveness of the action.

Dependent:

a.) Monitor ABGs a.) Follows progress of disease process and facilities alterations in pulmonary therapy

Dorothy Johnson(Human Behavioral System)

- This theory focuses on the balance to maintain stability in the system. It also focuses on the behavior of the patient threatened with illness.

GOAL PARTIALLY METAfter 8 hours of duty, the patient was able to improved ventilation and oxygenation of tissues by ABGs within patient’s acceptable range and

absence of symptoms of respiratory distress. pH - 7.45 (7.35 – 7.45)PCO2 - 41.3 (35 – 45 mmHg)PO2 - 46.0 (80 – 100 mmHg)HCO2 - 28.3(22 – 26 mmol/L)TCO2 - 66.4

EVALUATION

Risk for less than body requirements

ASSESSMENT Subjective:“Wala siya mayad nagakaon, wala gana” as verbalize by the folks.

Objective:Sodium – 136.3- Starvation- Diabetic acidosis- Dehydration Height: 152 cmWeight: 44 kgBMI: 19.0

DIAGNOSIS Risk for less than body requirements

R/t:- Increased metabolic needs - Abdominal distension / gas associated with swallowing air during dyspneic episodes

PLANNING After nursing intervention the patient will demonstrate a measurable increase in appetite and can tolerate her OTF of 1,500 kilocalories per day / 6 (250 cc of OTF per feeding)

INTERVENTION

Independent:a.) Provide covered container for sputum and remove at frequent intervals. Assist with / encourage oral hygiene after emesis, after aerosol and postural drainage treatments, and before meals.

b.) Auscultate bowel sounds. Observe / palpate fro abdominal distention.

a.) Eliminates noxious sights, tastes, smells from the patient environment and can reduce nausea.

b.) Bowel sounds may be diminished / absent if the infectious process is sever / prolonged. Abdominal distention may occur as a result of air swallowing or reflect the influence of bacterial toxins on the gastrointestinal tract.

RATIONALE NURSING THEORY

Virginia Henderson(14 components of Nursing Care)-Nurses will do what the things that patients cannot do.

Ida Jean Orlando(Nursing Process – ADPIE)- Nurses can help the patient what they cannot do to their self.- Exploring the meaning of the need and validating the effectiveness of the action.

c.) Evaluate general nutritional state, obtain baseline weight.

c.) Presence of chronic conditions or financial limitations can contribute to malnutrition, lowered resistance to infection, and / or delayed response to therapy.

Ida Jean Orlando(Nursing Process – ADPIE)

- Nurses can help the patient what they cannot do to their self.- Exploring the meaning of the need and validating the effectiveness of the action.

EVALUATION

GOAL MET

After nursing intervention the patient were able to demonstrate measurable increase in appetite and can tolerate her feeding.

Activity Intolerance

Subjective:“Nagapangluya siya kag indi siya mayad kahulag” as verbalize by the folks.

Objective:•Lethargy•Verbal reports of weakness•Fatigue•Exhaustion

Activity Intolerance

R/t:General weakness and imbalance between oxygen supply and demand.

ASSESSMENT DIAGNOSIS

PLANNING

After nursing intervention the patient will demonstrate a measurable increase in tolerance to activity with absence of lethargy and excessive fatigue, and vital signs within client’s acceptable range.

INTERVENTION

Independent:a.) Evaluate client’s response to activity. Note reports of dyspnea, increased weakness / fatigue, an changes in vital signs during and after activities.

b.)Provide a quite environmental and limit visitors during acute phase as indicated. Encourage use of stress management and diversional activities as appropriate.

RATIONALE

a.) Establishes patient’s capabilities / needs and facilitates choice of interventions.

b.) Reduces stress and excess stimulation, promoting rest.

Dorothy Johnson(Human Behavioral System)- This theory focuses on the balance to maintain stability in the system. It also focuses on the behavior of the patient threatened with illness. Also in the medicines that the patient is receiving. Florence Nightingale(Environment theory)- Organizing and manipulating environment (physical, social, and psychosocial) in order to put the person in the best condition alleviate unnecessary pain and suffering.

NURSING THEORY

c.) Explain importance of rest in treatment plan and necessity for balancing activities with rest.

d.) Assist patient to assume comfortable position for rest / sleep.

e.) Assist with self – care activities as necessary. Provide for progressive increase in activities during recovery phase.

c.) Bed rest is maintained during acute phase to decrease metabolic demands, thus conserving energy for healing. Activity restrictions thereafter are determined by individual client response to activity and resolution of respiratory insufficiency. d.) Patient may be comfortable with the head of bed elevated, sleeping in a chair, or leaning forward on overboard table with pillow support.

e.) Minimizes exhaustion and helps balance oxygen supply and demand.

Dorothy Johnson(Human Behavioral System)-This theory focuses on the balance to maintain stability in the system. It also focuses on the behavior of the patient threatened with illness.

Ida Jean Orlando(Nursing Process – ADPIE)- Nurses can help the patient what they cannot do to their self.- Exploring the meaning of the need and validating the effectiveness of the action.

GOAL PARTIALLY METAfter nursing intervention the patient were able to demonstrate measurable increase in tolerance to activity, but not totally. Vital signs within client’s acceptable range

EVALUATION

XII. DISCHARGE PLANNING

M (MEDICATION) Take the entire course of any prescribed medications. After a patient’s

temperature returns to normal, medication must be continued according to the doctor’s instructions, otherwise the pneumonia may recur. Relapses can be far more serious than the first attack.

E (EXERCISE & ACTIVITY)Get plenty of rest. Adequate rest is important to maintain progress

toward full recovery and to avoid relapse. Instruct the folks to monitor the client’s position, she must be in moderate

high back rest and change position every two hours.

T (TREATMENT)Give supportive treatment. Proper diet and oxygen to increase oxygen

in the blood when needed.Treatment is one of the main factors in restoration of health and curing of the

failure in the body system. Treatments are given to the patient for a specific time until treatment is not more needed by the patient.

H (HOME TEACHING IN REACTION TO DISEASE, ETIOLOGY & HYGIENE MEASURES)

Encourage the folks to wash patient’s hands. The hands come in daily contact with germs that can cause pneumonia. These germs enter one’s body when he touch his eyes or rub his nose. Washing hands thoroughly and often can help reduce the risk.

Tell folks to avoid exposing the patient to an environment with too much pollution (e.g. smoke). Smoking damages one’s lungs’ natural defenses against respiratory infections.

Protect others from infection. Try to stay away from anyone with a compromised immune system. When that isn’t possible, a person can help protect others by wearing a face mask and always coughing into a tissue.

O (OUT PATIENT FOLLOW – UP)Keep all of follow-up appointments. Even though the patient feels better, his

lungs may still be infected. It’s important to have the doctor monitor his progress.

D (DIET)Drink lots of fluids, especially water. Liquids will keep patient from becoming

dehydrated and help loosen mucus in the lungs.Controlled diets are designed to avoid excessive sodium retention.

S (SPIRITUALITY)Advise the patient to join the church activities. Keeping faith in God and

believing in him can uplift some distress.

XIV. MY JOURNEYBeing a third year student taking up Nursing is challenging, nerve breaking, head

cracking, interesting, and exhausting. But being a Nurse is somewhat opposite, because every single intervention you do is remarkable and very accommodating to your patient. I am a future Nurse and I admit that I’ve been devoted in rendering care to my patient until such time that she recovers from her illness.

Mrs E.A is an 87 years old woman. She’s from Cogon, Panitan Capiz and has been admitted in the Immaculate Heart of Mary (IHM) last August 18, 2009 at around 3:20 pm, with the Chief Complaint of Cough & with the Diagnosis of Aspiration Pneumonia. She has a Nasogastric Tube Feeding (NGT) and Oxygen Saturation of 2 liters.

I always check her IVF (PNSS 1L x 80 cc/hour) every hour to be sure that it is not delayed or advanced. I follow up her IVF when it was consumed. Her vital signs are monitored every hour and her Intake & Output is monitored Q shift. I assist her in her OTF (1,500 kilocalories / day ÷ 6 feedings). I always see to it that her medications are given at the right time to prevent complications. I assist her in her morning care and oral care every morning. I also changed her linens and assist her in combing her hair.

It feels so great to know that you did something right and good to your patient. When you will ask me, “What is good in being a nurse?” I would answer this way, being a Nurse is AWESOME because I know that I am one of God’s instruments to save people and help the poor in my own dearest way. I believe that being a Nurse is not merely a job or a chosen career. It is a Responsibility, Commitment, Destiny and it’s your Calling from up above. To tell you frankly, those are part of the things that motivates me for doing the best that I can do as a STUDENT NURSE.

XIV.BIBLIOGRAPHY / REFERENCES

•Nursing Care Plan (Guideline for individualizing Client Care across the life span).•Nurse’s Pocket Guide•Nurse’s Manual of Laboratory Tests and Diagnostic Procedures•Fundamentals of Nursing •2009 Lippincott’s Drug Guide•MIMS•www. Yahoo.com•www. Google.com•www. Wekipedia.com