CS on acute bronch 2

8/7/2019 CS on acute bronch 2

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Introduction

Bronchitis is an acute inflammation of the air passages within the lungs. It occurs

when the trachea (windpipe) and the large and small bronchi (airways) within the lungs

become inflamed because of infection or other causes.

The thin mucous lining of these airways can become irritated and swollen. The cells that

make up thislining may leak fluids in response to the inflammation. Coughing is a reflex

thatworks to clear secretions from the lungs. Often the discomfort of a severe cough

leads you to seek medical treatment. Both adults and children can get bronchitis.

Bronchitis can either be of brief duration (acute) or have a long course (chronic). Acute

bronchitis is usually caused by a viral infection but can also be caused by a bacterial

infection and can heal without complications. Chronicbronchitis is a sign of serious lung

disease that may be slowed but cannot be cured. This form is found almost exclusively

in adult smokers. Bronchitis in children is often misdiagnosed as asthma.

Acute bronchitis is most prevalent in winter. It is most often caused by a viral infection

and may be accompanied by a secondary bacterial infection. Acute bronchitis resolves


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within two weeks, although the cough may persist longer. Acute bronchitis, like any

upper airway inflammatory process, can increase a child's likelihood of developing

pneumonia.

Acute bronchitis is one of the more common illnesses affecting preschool and

school-age children. It is more commonly diagnosed among children under age five

than any other age group. It occurs more often in young males. It can occur anytime but

is more frequent during the winter months. In otherwise healthy children complications

are few.

Acute bronchitis usually begins with the symptoms of a cold, such as a runny

nose, sneezing, and drycough. However, the cough soon becomes deep and painful.

Coughing brings up a greenish yellow phlegm or sputum. These symptoms may be

accompanied by a fever of up to 102F (38.8C). Wheezing after coughing is common.

In uncomplicated acute bronchitis, the fever and most other symptoms, except the

cough, disappear after three to five days. Coughing may continue for several weeks.

Acute bronchitis is often complicated by a bacterial infection, in which case the fever

and a general feeling of illness persist. To be cured, the bacterial infection should be

treated with antibiotics..

Physical findings of acute bronchitis vary with the age of the child, and the stage of the

disease, but may include the following:

y runny nose

y dry, hacking unproductive cough that may change to a loose cough with

increased mucus

y sore throat

y back and other muscle pains

y chills and low grade fever

y headache and general malaise (feeling unwell)


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Objective of the Study

This study aims to understand more about the pathophysiologic event

of the disorder experienced by the patient. In this way we can enhance our

learning through actual assessment of the client in the clinical area. And

incorporate the theories in the book to the actual setting. The main goals of

this study are the following:

Provide appropriate nursing intervention and attend to the patients

specific needs.

Discuss to the patient, family members or significant others the

simple and understandable way of the disease process, and the

causative and risk factors of it.

Provide training and instructions to patient and family members

regarding the therapeutic management in alleviating this disease

condition such as breathing and coughing exercises, positioning,

chest tapping, pursed-lip breathing, and healthy lifestyle.

Apply the nursing process in the actual setting.

Broaden our knowledge and skills as a health care provider.

Achieve the best outcome and progress of the patients health

condition.


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Scope and limitation of the study

The study was conducted throughout our medical ward exposure at PGH

Velez and was only limited to the patient admitted at the medical ward

department. The study was done for 3 days which is approximately more or

less 20 hours all in all to be specific. The study only encompasses the health

condition of the patient that was been assessed and determined in the actual

setting on that given span of time.


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Patients Profile

Name: Mrs. Ana (not his real name)

Age: 53 yrs. Old

Date of birth: June 5, 1957

Address: Macasandig

Sex: Female

Religion: Roman Catholic

Civil status: Married

Nationality: Filipino

Height: 5 ft

Weight: 138 Ibs

Educational attainment: College graduate

Occupation: Government employee


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Health History

Family and Personal Health History

Pt. was a diagnosed case of pneumonia last 2000.

Is hypertensive with no maintenance of medications

had cough

paternal side none

maternal side hypertension

History of Present Illness

Pt complains about fever, on and off productive cough with yellowish

secretion. Few weeks prior to admission, pt has been having cough which

subsided, but 3 days PTA recurrence of cough associated with undocumented

fever. She took Azithromycin which was prescribed by Dr. Ucab, a relative

physician. Persistence of condition thus prompted admission.

Chief Complaint

Fever and cough

Previous illness

Pneumonia (2000)

Gallstone removal (2010)


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Developmental data

Mrs. Ana belongs to the middle adult stage. In which we can correlate the possible

manifestations of behaviors to the following developmental theories.

1) Robert Havighursts Developmental Task Theory in middle adult

According to Havighursts, the person in this stage assists teenage

children to become responsible and happy adults, achieving adult social and

civic responsibility, reaching and maintaining satisfactory performance in ones

occupational career, develops adult leisure time activities. And accept and

adjust to the physiological changes of middle age. And these characteristics

really manifested to my patient since she really works hard just to sustain his

family regardless w/ his condition. And they had a close bonding with her

daughters and wife as they keep on teasing each other at the hospital. And I

conclude that mrs. Ana was able to accept and adjust to the physiologic needs

of middle age.

2) Ericksons theory in middle adult

The middle adult is in a period of generativity versus stagnation. The tasks are

accepting middle age changes, and reevaluate ones goals and

accomplishments. Adults who do not achieve these tasks tend to focus on

themselves, becoming overly concerned w/ their own physical and emotional

health needs. I can see that mrs. Ana has achieve this stage because she

always think of the hospital expense that her family will be paying, thats why

she wanted to go home. He doesnt think of his self alone.


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Doctors order and Rationale

DATE/TIME Doctors Order Rationale

January 11,

2011

4:00 pm

S: Cough and fever

O: Harsh breath sounds (occasional wheeze)

A: to consider Acute Bronchitis, Hypertension

P: Pls. admit under Dr. Gamolo

- Secure consent to care & management

- Low fat, low salt diet

- IVF: PNSS 1L @ 10gtts/m

- LABS:

y CBC

y UA

y Na+, K

+

y 12 L ECG

y CXR PA

y FBS, lipid profile

- Medications:

y Paracetamol

y Fluimucil 600mg 1cap in glass of

- For initiation of care.

- To prevent further increase in

blood pressure

- An isotonic solution that

expands the extracellular fluid

volume. To provide water,

electrolytes & nutrients to

meet daily requirements in the

pt.s hospital stay.

- To examine hematologic

condition for any instability.

- To examine urine for any

abnormalities

- To monitor serum Na+ & K+

levels for any disturbances.

- To provide information about

the electrical activity of the

myocardium.

- To examine patients lung

status & support the

underlying diagnosis.

- To check blood glucose levels

- To relieve fever

- A mucolytic given to thin


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5:35 pm

7:00 pm

water

y Nebulizer w/ Combivent 1neb now,

then q 6hrs

- Monitor vital signs q 4hrs & record

- I and O q shift

- Pls. inform attending physician

- Refer accordingly

- Start Kenaxef 1gram IV q 12hrs ANST

- Duavent 1 neb q 6hrs

- Start Zenith 500mg 1tab OD, P.O

- Replace Combinant neb to Duavent 1neb q

6hrs

- Pls. follow up maintenance meds of patient

and continue

mucus & help remove mucus

secretions.

- To relieve bronchospasms

- To watch for any deviations

from normal

- To determine the proportion of

intake and output

- To report pts condition

- For continuous care

- Antimicrobial used to treat

bronchitis

- An anti-infective

- To go on w/ the pts

maintenance of meds

January 12,

2011

- Lipitor 80mg 1tab OD, P.O

- Rely CXR result

- Discontinue Azithromycin

- An antilipemics used to

decrease LDL cholesterol

- to provide basis for care

- to withdraw meds

January 13,

2011

- Nasatidera 1cap TID

- Amlodipin 5mg 1tab OD, P.O

- P

- An antianginals given to pt to

decrease myocardial

contractility and oxygen

demands and dilates coronary

arteries and arterioles.

January 14,

2011

- IVF TF: PNSS 1L @ 10 gtts/m - An isotonic solution that

expands the extracellular fluid


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- MGH

- Home meds

volume. To provide water,

electrolytes & nutrients to

meet daily requirements in the

pt.s hospital stay.

- Advised to go home

- To hasten recovery.


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Drug study

1)Paracetamol

Generic name: Paracetamol

Brand Names: Biogesic

Classification: Analgesic/Antipyretic

Mechanism of Action

Paracetamol possesses prominent antipyretic and analgesic effects. Its anti-inflammatory activity is weak and has no clinical significance. The mechanism of actionis related to depression of the prostaglandin synthesis by inhibition of the specific cellcyclooxygenase, and depression of the thermoregulatory center in the medullaoblongata. Inhibits prostaglandins in CNS, but lacks anti-inflammatory effects inperiphery; reduces fever through direct action on hypothalamic heat-regulating center.

Indications

The preparation is indicated in diseases manifesting with pain and fever:headache, toothache, mild and moderate postoperative and injury pain, hightemperature, infectious diseases and chills (acute catarrhal inflammations of the upperrespiratory tract, flu, small-pox, parotitis, etc.).

Contraindications

Paracetamol should not be used in hypersensitivity to the preparation and in

severe liver diseases.

Adverse reactions

In rare cases hypersensitivity reactions, predominantly skin allergy (itching andrash), may appear. Long-term treatment with high doses may cause a toxic hepatitiswith following initial symptoms: nausea, vomiting, sweating, and discomfort.Occasionally a gastrointestinal discomfort may be seen.

Nursing Responsibilities

The preparation should be used with care in patients with liver and renal diseases. The

treatment with Paracetamol may change the laboratory tests of uric acid and bloodglucose analysis. In severe renal failure the interval between two consecutive takingsshould not be shorter than 8 hours.


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2) Acetylcysteine

Generic name: Acetylcysteine

Brand Names: Fluimucil

Classification: Mucolytic

Mechanism of Action

Muculytic that reduces the viscosity of pulmonary secretions

Indications

For abnormal viscid and thickened mucous secretions

Contraindications

Use cautiously in elderly or debilitated patients with severe respiratoryinsufficiency

adverse reactions

fever, drowsiness, tachycardia, dyspnea and rash


Bronchial tapping and monitor for bronchospasm


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3) Duavent

Generic name: Ipratropium + salbutamol

Brand Names: Duavent

Classification: Bronchodilator

Mechanism of Action

A Bronchodilator used for Treatment of obstructive airway diseases.

Indications

Management of reversible bronchospasm associated obstructive airway disease.Patient with chronic obstructive pulmonary disease on a regular enhaled bronchospasmand who required a 2nd bronchodilator.

Contraindications

Hypertrophic obstructive cardiomyopathy or tachyarrhythmia. Hypersensitiviity toatropine and its derivatives

adverse reactions

Headache, pain, influenza, chest pain, nausea.Bronchitis, dyspnea, coughing,pneumonia, bronchospasm pharyngitis, sinusitis, rhinitis, edema, fatigue,hypertension,dizziness, nervousness, paresthesia, tremor, dyspepsia, vomiting,arrhythmia, palpitation, tachycardia, arthralgia, angina, increased sputum, tasteperversion and UTI/dysuria, allergic-type reactions.


Drugs should be given only if the potential benefit justifies thepotential risk to the foetus.

Position patient on high back rest position. Do back tapping after you nebulize the patient. do not give a food immediately it can cause vomiting


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4) Azithromycin

Generic name: Azithromycin

Brand Names: Zithromax

Classification: Anti-infective

Mechanism of Action

A macrolide anti-biotic that is a derivative of erythromycin. It Binds to the 50ssubunit of bacterial ribosomes blocking protein synthesis.

Indications

Acute bacterial exacerbation of COPD caused by Haemophilus influenzae,Moroxella catarrhalis, or Streptococcus pneumoniae; uncomplicated skin and skin-structure infection caused by Staphylococcus aureus, Streptococcus pyogenes, or S.agalactiae; second line therapy of pharyngitis or tonsillitis caused by S. pyogenes.

Contraindications

Contraindicated in patients hypersensitive to erythromycin or other macrolides.

Adverse reactions

nausea and vomiting, headache, dizziness, fatigue, diarrhea, dyspepsia,abdominal pain, anorexia


Monitor patient for super infection. Instruct patient to take medication as prescribed even if he feels better. Instruct patient that if hypersensitivity occurs during the medication

immediately notify the physician.


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5) Atorvastatin

Generic name: Atorvastatin

Brand Names: Lipitor

Classification: Antilipidemic (cholesterol reducer)

Mechanism of Action

Atorvastatin inhibits the rate-determining enzyme located in hepatic tissue thatproduces mevalonate, a small molecule used in the synthesis of cholesterol and othermevalonate derivatives. This lowers the amount of cholesterol produced which in turnlowers the total amount of LDL cholesterol. Atorvastatin is a competitive inhibitor ofHMG-CoA reductase.

Indications

For management as an adjunct to diet to reduce elevated total-C, LDL-C, apo B,and TG levels in patients with primary hypercholesterolemia and mixed dyslipidemia.

Contraindications

Use cautiously in pregnant patients, those with liver disease, alcoholics and patientswith uncontrolled seizures

Adverse reactions

Rash, itchy skin, hair loss. Abdominal cramps, constipation, diarrhea, flatus,heartburn,


Instruct patient to avoid eating foods that are high in fat or cholesterol.Atorvastatin will not be as effective in lowering your cholesterol if you do not follow acholesterol-lowering diet plan, and to avoid drinking alcohol while taking atorvastatin.Alcohol can raise triglyceride levels, and may also damage your liver while you aretaking atorvastatin.


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Anatomy and physiologic review of the respiratory system

The respiratory system is composed of the upper and lower respiratory

tracts. Together, the two tracts are responsible for ventilation (the movement of

air in and out of the airways). The upper tract known as the upper airway warms

and filters inspired air so that the lower respiratory tract (the lungs) can

accomplish gas exchange. The gas exchange involves delivering oxygen to the

tissues through the blood stream and expelling waste gases, such as carbon

dioxide, during expiration.

Anatomy of the Upper respiratory Tract: Upper Airway

Nose

Sinuses and Nasal passages

Pharynx, tonsils and adenoids

Larynx

Trachea

Anatomy of the lower respiratory Tract: Lungs

Pleura

Mediastinum

Lobes

Bronchi and bronchioles

Alveoli


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The respiratory system consists of all the organs involved in breathing. These include the nose,

pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two very important things: it

brings oxygen into our bodies, which we need for our cells to live and function properly; and it helps us

get rid of carbon dioxide, which is a waste product of cellular function. The nose, pharynx, larynx,

trachea and bronchi all work like a system of pipes through which the air is funneled down into our

lungs. There, in very small air sacs called alveoli, oxygen is brought into the bloodstream and carbon

dioxide is pushed from the blood out into the air. When something goes wrong with part of the

respiratory system, such as an infection like pneumonia, it makes it harder for us to get the oxygen we

need and to get rid of the waste product carbon dioxide. Common respiratory symptoms include

breathlessness, cough, and chest pain.


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Functions of the respiratory system

Certain vital tissues such as those of the brain and the heart cannot

survive for long without a continuing supply of oxygen. However, as a result of

oxidation in the body tissues, carbon dioxide is produced and must be

removed from the cells tp prevent build up of acid waste products. The

respiratory system performs this function by facilitating life-sustaining process

such as oxygen transport, respiration and ventilation, and gas exchange.


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Pathophysiology

Inflammation

Bradykinin, histamine, prostaglandin

Increased capillary permeability

Fluid cellular exudation

Edema of mucous membrane

Hyper secretion of mucus

Persistent of cough

Bronchitis

ACUTE BRONCHITIS

It is inflammation of the main air

passages to the lungs. Bronchitis may be

short-lived (acute) or chronic, meaning

that it lasts a long time and often recurs.

Predisposing Factors:

y Age 53 yrs old

y Recurrent

respiratory tractinfections

Precipitating

Factors:

y Cough

y

Bacterialinfection

y Air

pollutants

Signs & symptoms noted:

Fever

Fatigue

Productive cough


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EENT:

[X] Impaired vision [ ] blind[ ] pain redden [ ] drainage

[ ] gums [] hard of hearing [ ] deaf

[ ] burning [ ] edema [ ] lesion teeth[ ] assess eyes ears nose[ ] throat for abnormality [] no problemRESP:

[ ] asymmetric [ ] tachypnea [ ] barrel chest[ ] apnea [ ] rales [X] cough

[ ] bradypnea [] shallow [ ] rhonchi

[X] Sputum [ ] diminished [X] dyspnea[] orthopnea [ ] labored [ ] wheezing

[] pain [ ] cyanotic

Assess resp. rate, rhythm, pulse bloodBreath sounds, comfort [X] no problemCARDIOVASCULAR:

[ ] arrhythmia [ ] tachycardia [ ] numbness[ ] diminished pulses [] edema [X] fatigue[ ] irregular [ ] bradycardia [ ] murmur

[ ] tingling [ ] absent pulses [ ] pain

Assess heart sounds, rate rhythm, pulse, bloodPressure, circ., fluid retention, comfort

[ ] No problemGASTROINTESTINALTRACT:

[ ] obese [ ] distention [ ] mass[ ] dyspagea [ ] rigidity [ ]pain

Assess abdomen, bowel habits, swallowing

Bowel sounds, comfort [X] no problemGENITO URINARYAND GYNE

[ ] pain [ ] urine [ ] color [ ] vaginal bleeding

[ ] hematuria [ ] discharge [ ] nocturiaAssess urine frequency, control, color, odor, comfort

gyne bleeding [ ] discharge [X] no problemNEURO:

[ ] paralysis [ ] stuporus [] unsteady [ ] seizure

[ ] lethargic [ ] comatose [] vertigo [ ] treamors

[ ] confused [ ] vision [X] gripAssess motor, function, sensation, LOC, strengthGrip, gait, coordination, speech [] no problemMUSCULOSKELETAL and SKIN:

[ ] appliance [ ] stiffness [ ] itching [ ] petechie[X] hot [ ] drainage [ ] prosthesis [ ] swelling

[ ] lesion [ ] poor turgor [ ] cool [ ] wound [ ] flushed

[ ] atrophy [ ] pain [ ] ecchymosis [ ] diaphoretic [] moistassess mobility, motion gait, alignment, joint function

Skin color, texture, turgor, integrity [] no problem

NURSING SYSTEM REVIEW CHART

Name:Mrs. Ana Date: January13, 2011

PR: 76 bpm BP: 140/90 mmHg Temp: 37.9C Height: 5 ft Weight: 138 Ibs

An [X] is placed in the area of abnormality. Comment at the space provided. Indicate the location of the problem in

the figure using [X].

Used of eyeglasses,

blurry vision

Productive cough w/

thick yellowish

secretions

BP -140/90 mmHg

,

- Loss of

appetite

- Weak in

appearance

- Fatigability

- has fever

T- 37oc


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SUBJECTIVE OBJECTIVE

COMMUNICATION

[ ] hearing loss

[X] visual changes

[ ]denied

[X] glasses [ ]languages

[ ] contact lens [ ] hearing aide

R L

Pupil size:2 mm

Reaction: Sluggishly reactive

OXYGENATION:

[ ]dyspnea

[ ]smoking history

[X] cough

[X]sputum

[]denied

Resp. [X]regular []irregular

Describe: Respiratory cycle is normal RR=16cpm.

Not dyspneic and chest excursion is symmetrical.

R: Right lung is symmetrical with the left lung.

L: left lung is symmetrical with the right lung.

CIRCULATION

[ ]chest pain

[ ] leg pain

[] numbness of extremities

[X] denied

Heartrhythm [X] regular [ ] irregular

Ankle Edema: none

Carotid Radial Dorsal pedis femoral

R: + 67 + +

L: + 65 + +

Comments: Pulses are palpable but kind of a weak.

NUTRITION:

Diet: low salt, low fat diet

[ ] N [ ] V

Character

[ ] recent change in weight

and appetite

[X]dentures []none

Full partial with patient

Upper [] [X] []

Lower [] [X] []

Comments: halap-

halap na ako

panan.aw as

verbalized by

patient.

Comments:gahi

pa gihapon ako

ubo, ug naay

plemas, as

verbalized by the

patient.

Comments: ok

raman wala man koy

nabatian as

verbalized by the

patient.

Comments:ok

raman, gana man

gihapon ko mu

kaon, as verbalized

by the patient.


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[ ] swallowing difficulty

[X]denied

ELIMINATION

Usual bowel pattern urinary frequency

formed, softl stool_ ___6x/day___

[]constipation [ ]urgency

remedy: [ ]dysuria

Date of last BM [ ] hematuria

__1/11/11_ [ ] incontinence

[ ] diarrhea [ ] polyuria

Character: [] foly in place

[X] denied

Comments: Bowel sounds: normoactive

yellowish Urine Abdominal distention

Odor , malodorous Present [ ] yes [X] No

. Urine (color,consistency,

odor)

MGT. OFHEALTH & ILLNESS:

[ ] alcohol [X]denied

(amount frequency)

NA

[X] SBE last Pap smear:

LMP:2 yrs ago

Briefly, describe the patients ability to follow

treatments (diet, meds, etc.) for chronic health

problems (if present).

The patient follows religiously to the treatment and

submissive to treatment care.Pt. is not an alcoholic drinker


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SKIN INTEGRITY:

[ ] dry Comment: ok raman la

[ ] other man koy nabatian nga

[X] denied deperensiya as verbalized

by the patient.

[ ] dry [ ] cold [] pale[ ] flushed [X] warm[] moist [ ] cyanotic*rashes, ulcers, decubitus (describe size, location,

drainage)

ACTIVITY/SAFETY:

[ ] convulsion

[] dizziness

[] Limited motion

OfJointsLimitation inAbility to[ ] ambulate[ ] bathe self

[ ] other[X] denied

[ ] LOC and orientation: patient is weak in

appearance but still oriented

Gait: [ ] walker [ ] cane [X] other[ ] steady [] unsteady

[ ] sensory and motor losses in face orExtremities: No sensory and motor losses on face

or extremities noted.

[ ] ROM limitations: there were no ROM

limitations noted.

COMFORT/SLEEP/

AWAKE:

[ ] pain (location)

(Frequency)

(Remedies)

[ ] nocturia[X]sleep difficulties

[ ] denied

[ ] facial grimaces[ ] guarding[ ] other signs of pain :

[ ] siderail release form signed (60+ years)

No siderails released

COPING:Occupation: Government employeeMembers ofhousehold: 4Most supportiveperson: husband

Observed non-verbal behavior: patient is irritablePhone number that can be reached anytime: It is

kept confidential.

Comments:la may

problema, maka lihok-lihok

raman ko, as verbalized by

the patient.

Comments:mag mata-

mata lge k okay ping-ot

ako ilong, as verbalized

by the patient.


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Nursing CarePlan

CUES NURSINGDIAGNOSIS

SPECIFICOBJECTIVES

NURSINGINTERVENTIONS

RATIONA

Subjective:

Ping-ot kayo ako

ilong, as

verbalized by the

patient.

Objective:

- Productivecough w/thickyellowishsecretion

- Has colds

Ineffective Airwayclearance r/tincreased mucus

production asmanifested byProductive cough(yellow sputum)and congested

nose

At the end of 8

hours, the client

will be able to

expectorate

secretions readily

and demonstrate

behaviours to

improve andmaintain clear

airway.

Independent:

Keep environmentallergen free, fromdust and smoke.

Instruct DBE andcoughing

exercises.

Instruct pt. Onincrease fluidintake.

o .

Place pt onmoderate highbackrest.

Provide chesttapping

To maintaienvironmeairway.

To mobiliz

To liquefy

For total luexpansion

To dislodgsecretions


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CUES NURSING

DIAGNOSIS

SPECIFIC

OBJECTIVES

NURSING

INTERVENTIONS

RATIONA

Subjective:

luya pa ako

paminaw, as

verbalized by the

patient.

Objective:

- Weak in

appearance

- Complainsof fatigue

Activityintolerance r/t togeneralized bodyweakness as

At the end of 8hours, the clientwill be able tolearn how toconserve energyand verbalize relieffrom fatigue

Independent:

Evaluate the pt.scurrent activitytolerance

Adjust activity andreduce intensity oftask that maycause undesiredphysiological

changes Increase exerciseand activity levelsgradually

Teach methods toconserve energysuch as sitting thanstanding whiledressing

Assist the pt. whiledoing ADLs andGive the pt. info.That providesevidence ofprogress

Provide coopbaseline

To prevent ov

Enhance acti

Helps minimienergy

Prevent the pand to sustaimotivation


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CUES NURSING

DIAGNOSIS

SPECIFIC

OBJECTIVES

NURSING

INTERVENTIONS

RATIONA

Subjective:

gi tugnaw ko, as

verbalized by the

patient.

Objective:

- Warm totouch

- Febrile T-38

0C

Ineffectivethermoregulationr/t increased bodytemperature

After 30 minutes ofcontinuous TSB,the pt.stemperature willdecrease from 380C to 37.5C and

below

Independent:

Monitor VS

Increase fluid intake

Maintain bed rest

Provide sufficientclothing

Perform TSB

Administerantipyretics asordered

Serves as ba

To help cool temperature

To decrease that produce

Facilitate com

Facilitate heameans of evaHelps lower twithin norma


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Actual Nursing Management (SOAPIE)

S Ping-ot kayo ako ilong as verbalized by the patient.

o- Received awake lying on bed w/ ongoing IVF of PNSS 1L @ 120 cc level regulated

@ 10 gtts/m, infusing well- Has colds

A Ineffective airway clearance related to congested nose

P To improve airway patency

I

1) Pt was instructed to increase fluid intake

2) Instructed to expectorate mucus secretions rather than swallowing it.3) Taught on pursed lip breathing and deep breathing exercise.

4) Placed on moderate high back rest

5) Due meds given

E The pt was able to verbalize improvement of airway patency.


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S gahi pa gihapon ako ubo, ug naay plemas, as verbalized by the patient.

O- Received awake lying on bed w/ ongoing IVF of PNSS 1L @ 120 cc level regulated

@ 10 gtts/m, infusing well

- Weak in appearance

- Productive cough noted w/ yellowish secretions.

A Ineffective airway clearance related to thick mucus secretions

P The pt will be able to expectorate excessive mucus secretions properly

I

1) Instructed on coughing exercise

2) Chest tapping done

3) Instructed on postural drainage

4) Nebulization done

5) Placed on moderate high back rest

E The pt was able to expectorate copious secretions.


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S kapoy pa ako lawas, luya pa, as verbalized by the patient.

O

- Un comb hair

- Un groomed- Weak in appearance

A Self-care deficit related to body weakness and fatigability

P The client will be able to do self-care activities progressively and will look fresh, cool andclean.

I

1) Watcher was instructed to provide Oral mouth care every after meal.

2) Provide CBB to pt to make patient fresh and tidy.

3) Comb patients hair for good grooming

4) Provide a towel under patients neck to prevent clothing from mouth secretions.

5) Patient was kept cool and dry.

E After giving the interventions, the client became fresh and clean and well groomed.


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Referrals and Follow-up

The patient and watcher was instructed and informed to have a Follow-up

health check at OPD after 1 week of discharge, or to seek an immediate

consultation to any health clinics if signs of respiratory distress occurs. This is

to check for changes and progress in the clients health status, and be

intervened as early as possible to prevent further complications.


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Page | 31

Evaluation

Mrs. Ana is currently still on the road to progress, and getting his strength

back to hasten recovery. She still have productive cough. Medical

interventions were already implemented and he is receiving various home

medication drugs to alleviate sign and symptoms experienced and achieve

maximum progress and recovery. Goals and objectives are expected to be

met during the upcoming days of hospital stay.


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Bibliography

y Brunner & Suddarths textbook ofMedical-Surgical Nursing by Suzanne

C. Smeltzer & Brenda G. Bare, 10th ed. vol. 1, pp.569-586)

y 26th edition , Nursing2006 Drug handbook by Lippincott Williams &

Wilkins

y http://www.livestrong.com/ls_images/disease/0-999/23-

17099.jpg?v=1220483504

y http://www.answers.com/topic/bronchitis

CS on acute bronch 2

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