table of contents i. introduction a. overview

8/14/2019 TABLE of CONTENTS I. Introduction a. Overview

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TABLE OF CONTENTS

I. Introduction

a. Overview of the case

b. Objective of the study

c. Scope and Limitation of the study

II. Health History

a. Profile of patient

b. Family and Personal Health history

c. Chief Complaint & History of Present Illness

III. Developmental Data

IV. Medical Management

a. Medical Orders and Rationale

b. Laboratory Results

c. Drug Study

V. Pathophysiology with Anatomy and PhysiologyVI. Nursing Assessment (System Review & Nursing Assessment II)

VII. Nursing Management

a. Ideal Nursing Management (NCP)

b. Actual Nursing Management (SOAPIE)

VIII. Referrals and Follow-up

IX. Evaluation and Implications

X. Bibliography


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INTRODUCTION

a. Overview of the Study

This is the case of 24 year old male machine operator who diagnosed withCommunity Acquired pneumonia.

Pneumonia is an inflammation or infection of the lungs most commonly caused

by a bacteria or virus. Pneumonia can also be caused by inhaling vomit or other

foreign substances. In all cases, the lungs' air sacs fill with pus , mucous, and

other liquids and cannot function properly. This means oxygen cannot reach the

blood and the cells of the body.

Most pneumonia is caused by bacterial infections.The most common infectious

cause of pneumonia in the United States is the bacteria Streptococcus

pneumoniae. Bacterial pneumonia can attack anyone. The most common cause

of bacterial pneumonia in adults is a bacterium called Streptococcus pneumoniae

or Pneumococcus. Pneumococcal pneumonia occurs only in the lobar form.

An increasing number of viruses are being identified as the cause of respiratory

infection. Half of all pneumonias are believed to be of viral origin. Most viral

pneumonias are patchy and the body usually fights them off without help from

medications or other treatments.

Pneumococcus can affect more than the lungs. The bacteria can also cause

serious infections of the covering of the brain (meningitis), the bloodstream, and

other parts of the body.

Community-acquired pneumonia develops in people with limited or no contact

with medical institutions or settings. The most commonly identified pathogens are

Streptococcus pneumoniae, Haemophilus influenzae, and atypical organisms

(ie, Chlamydia pneumoniae,Mycoplasma pneumoniae, Legionella sp). Symptoms

and signs are fever, cough, pleuritic chest pain, dyspnea, tachypnea, and


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tachycardia. Diagnosis is based on clinical presentation and chest x-ray.

Treatment is with empirically chosen antibiotics. Prognosis is excellent for

relatively young or healthy patients, but much pneumonia, especially when

caused by S. pneumoniae or influenza virus, are fatal in older, sicker patients.

b. Objective of the Study

This study aims to:

Conduct and evaluate an assessment for the client

Determine the causes, predisposing and precipitating factors that

constitute the onset of the disease process.

Render series of nursing interventions for the clients care

Provide and disseminate important information as teachings to the client

and the significant others to boost the knowing and understanding of the

nature of the said health condition.

Improve skills and knowledge as health care providers in the clinical area.

c. Scope and Limitation of the Study

This study includes the collection of information specifically to the patients

health condition. The study also includes the assessment of the physiological

and psychological status, adequacy of support systems and care given by the

family as well as other health care providers.


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II. Patients Profile

Clients Name: Madredano Chandlier Paclicjan

Age: 24

Birthdate: February 2 1985

Address: Zone 5 Sili-Sili Pagatpat CDO

Civil Status: Single

Sex: Male

Nationality: Filipino

Religion: Roman Catholic

Weight: 55kg

Informant: Self

Date of admission: January 18 2010

Time of admission: 03:31 PM

Chief complaint: Fever

Admitting diagnosis: Community acquired pneumonia

Attending physician: Dr. Patriana


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DEVELOPMENTAL DATA

Erikson's stages of psychosocial development

Love: Intimacy vs. Isolation (Young Adults, 20 to 34 years)

Main Question: "Am I loved and wanted?" or "Shall I share my life with

someone or live alone?"

Ego quality: Love

Related Elements in Society: patterns of cooperation (often marriage)

Body and ego must be masters of organ modes and of the other nuclear conflicts

in order to face the fear of ego loss in situations that call for self-abandonment.

Avoiding these experiences leads to openness and self-absorption

The Intimacy vs. Isolation conflict is emphasized around the ages of 20 to 34. At

the start of this stage, identity vs. role confusion is coming to an end, and it still

lingers at the foundation of the stage (Erikson, 1950).

Based on Eriksons stages of psychosocial development my patient is in

young adults stage from 20 to 34 years old which he can established his

identities, he is ready to make long-term commitments to others. He becomes

capable of forming intimate, reciprocal relationships. and willingly make the

sacrifices and compromises that such relationships require


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Developmental Task of Robert Havighurst

Selecting a mate. * Learning to live with a partner. * Starting family. * Rearingchildren. * Managing home. * Getting started in occupation. * Taking on civic

responsibility. * Finding a congenial social group.

Based on Havighurst developmental theory my patient can manage on his own

he can get and start an occupation and have a family on his own and take a

responsibility if his children.

Developmental Task of Sigmund Freud

The person must learn how to form intimate relationships, both in friendship and

love. The development of this skill relies on the resolution of other stages. It may

be hard to establish intimacy if one has not developed trust or a sense of identity.

If this skill is not learned the alternative is alienation, isolation, a fear of

commitment, and the inability to depend on others.

Based on Freuds developmental task my patient cannot support on his own or

he needs support of his family. He learn how to form an intimate relationship with

others both friendship and love.

Developmental Task of Jean Piaget

Formal operational (11 years and up)

Can think logically about abstract propositions and test hypotheses systemtically

Based on Piagets developmental task my patient becomes concerned with the

hypothetical, the future, and ideological problems


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IV. HEALTH HISTORY

a. Family Health History

According to my patient regarding his father has a history ofhypertension. On the other hand his Grandfather on his Mother side

have diabetes mellitus. His younger sister has fever last month

(December) which is treated by over the counter drugs

b. Past Health History

My patient claimed that he experience cough, colds and fever this

last year which usually lasted for 3-4 days. Over the counter medicinessuch Paracetamol and Salbutamol.. He claimed also that he never

experience major illness that required hospitalization until this January

18, 2010 where he has been admitted at Maria Reyna Hospital with a

diagnosis of Community acquired pneumonia. He claimed that he

does not have known allergies to drugs and foods nor received a blood

transfusion this past year.

c. History of Present Illness

A case of Madredano Chandlier Paclicjan, 24 years old , Filipino, a

Resident of Zone 5 Sili-Sili Pagatpat Cagayan de Oro City,Admitted for

the first time at Maria Reyna Hospital with a chief complaint of Fever

and cough 4 days prior to admission


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V. Nursing Assessment (System Review & Nursing Assessment II)

Name: Madredano, Chandlier Paclicjan Date: 01-18-10

Temp: 37.9C PR: 79bpm BP: 120/70 Height 59 Weight:55 kgs RR:26cpm

INSTRUCTIONS: Place an [X] in the area of abnormality. Comment at the space

provided. Indicate the location of the problem in the figure using [X].

EENT:

[ ] impaired vision [ ] blind[ ] pain [ ] reddened [ ] drainage[ ] gums [ ] hard of hearing [ ] deaf[ ] burning [ ] edema [ ] lesion [ ] teethAssess eyes, ears, nose, and throatFor abnormality [x] no problemRESPIRATORY[ ] asymmetric [ ] tachypnea[ ] apnea [ ] rales [ x]cough[ ] barrel chests[ ] bradypnea [ ] shallow [ ] rhonchi[x ] sputum [ ] diminished [ x]dyspnea

[ ] orthopenea [ ] labored [ ] wheezing[ ] pain [ ] cyanoticAssess resp.rate, rhythm, depth, and patternBreath sounds, comfort [ ] no problemCARDIOVASCULAR[ ] arrhythmia [ ] tachycardia [ ] numbness[ ] diminished pulses [ ] edema [ ] fatigue[ ] irregular [ ] bradycardia [ ] murmur[ ] tingling [ ] absent pulses [ ] painAssess heart sounds, rate, rhythm, pulse,Circulation, fluid retention, comfort [ ] no

GASTRO INTESTINAL TRACT[ ] obese [ ] distention [ ] mass[ ] dysphagia [ ] rigidity [ ] painAssess abdomen, bowel habits, swallowing,Bowel sound, comfort [ } no problemGyn-bleeding, discharge [x] no problemNEURO[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures

Pale eyes and lipsProductive cough,

restlesness

dyspnea

Generalizedweakness


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[ ] lethartic [ ] comatose [ ] vertigo [ ] tremors[ ] confused [ ] vision [ ] gripAssess motor function, sensation, LOC, strength,Grip, gait, coordination, orientation, speech [x] no problemMUSCULOSKELETAL and SKIN

[ ] appliance [ ] stiffness [ ] itching [ ] petechiae[ ] hot [ ] drainage [ ] prosthesis [ ] swelling[ ] lesion [ ] poor turgor [ ] cool [ ] deformity[] wound [ ] rash [ ] skin color [ ] flushed[ ] atrophy [ ] pain [ ] eccymosis [ ] diaphoretic [ ] moistAssess mobility, motion, galt, alignment, joint function/Skin color, texture, turgor, integrity [ ] no problem


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VI. Pathophysiology with Anatomy & Physiology

Anatomy & Physiology

The Lungs

The lungs are paired, cone-shaped organs which take up most of the space in

our chests, along with the heart. Their role is to take oxygen into the body, which

we need for our cells to live and function properly, and to help us get rid of

carbon dioxide, which is a waste product. We each have two lungs, a left lung

and a right lung. These are divided up into 'lobes', or big sections of tissue

separated by 'fissures' or dividers. The right lung has three lobes but the left lung

has only two, because the heart takes up some of the space in the left side of our

chest. The lungs can also be divided up into even smaller portions, called

'bronchopulmonary segments'.

These are pyramidal-shaped areas which are also separated from each other by

membranes. There are about 10 of them in each lung. Each segment receives its

own blood supply and air supply.

Air enters your lungs through a system of pipes called the bronchi. These pipes

start from the bottom of the trachea as the left and right bronchi and branch many

times throughout the lungs, until they eventually form little thin-walled air sacs or

bubbles, known as the alveoli. The alveoli are where the important work of gas

exchange takes place between the air and your blood. Covering each alveolus isa whole network of little blood vessel called capillaries, which are very small

branches of the pulmonary arteries. It is important that the air in the alveoli and

the blood in the capillaries are very close together, so that oxygen and carbon

dioxide can move (or diffuse) between them. So, when you breathe in, air comes

down the trachea and through the bronchi into the alveoli. This fresh air has lots
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of oxygen in it, and some of this oxygen will travel across the walls of the alveoli

into your bloodstream. Travelling in the opposite direction is carbon dioxide,

which crosses from the blood in the capillaries into the air in the alveoli and is

then breathed out. In this way, you bring in to your body the oxygen that you

need to live, and get rid of the waste product carbon dioxide.


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Medical Orders and Rationale

Unfortunately, I was not able to obtain the actual Doctors orders and the time

it was ordered due to lack of information that will make a case study out of our

assigned patients. But the doctors order that will be reflected here is based only

on my recollection on what has been ordered.

Date Doctors Orders Rationale

01/20/10 Dr. Patriana

Pls. monitor vital signs every 4

hours(BP,HR,RR,temp)

Diet: DAT

Run IVF at the hand with 4th D5NSS

at 30 gtts/min.

Continue meds: pls. follow timely

regimens

Meds: Fluimucil 600 mg qid

Azithromycin

To monitor patients

health status

For fluid electrolytecorrection. And for

fluid

supplementation.

In order that the

meds will be taken

and carried on time.

To help liquefy

mucus secretion

To lessen lower and

upper respiratory


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01/21/10

(zithromax) 75cc qid

CBC

NPO

Ultrasound

tract infection.

To know the total of

all blood component

To avoid alteration of

ultrasound result

To check cor any

abnormalities

B. LABORATORY RESULT

CBC

RBC 9.8 X10^g/L

WBC 9.81 X10^g/L


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HEMOGLOBIN 14.3 g/L

HEMATOCRIT 43.0 %

MCU 89.4 fL

MCH 29.7 Pg

MCHC 33.3 g/dl

PLATESLETS 268 X10^g/L

UA

COLOR YELLOW

TRANSPARENCY CLEAR

SPECIFIC GRAVITY 1.005

PH 7.0

SUGAR NEG

PROTIEN NEG

ULTRASOUND 01/21/10

GALLBLADDER IS OF NORMAL SIZE.


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FLUID SERUM

GLUCOSE HI 113

ALT HI 115

GRAM STAINING.

GRAM ( - ) RODS = OCCASIONAL

GRAM ( - ) COCCI IN PAIRS = FEW

GRAM ( - ) COCCI IN CLUSTER = FEW

c. Drug study


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DRUG NAME

FLUIMUCILDOSE/FREQUENCY/ROUTE

600mg 1 tab qidCLASSIFICATION

mucolyticMECHANISM OF ACTION

Decreases viscosity of pulmonary secretions by breaking disulfide links of

mucoproteins.SPECIFIC INDICATION

Acute & Chronic resp tract affection with abundant mucus secretionsCONTRAINDICATION

Effervescent tab/SachetPhenylketonurics.SIDE EFFECTS

changes in taste, drowsiness, mouth sores, nausea, vomiting, runny noseNURSING PRECAUTION

Use in caution in patient 60 yrs old. Patient with high blood pressure, ischemic

heart disease.

DRUG NAME

zithromaxDOSE/FREQUENCY/ROUTE

500mg 1tab qidCLASSIFICATION

antibioticMECHANISM OF ACTION

Decreases viscosity of pulmonary secretions by breaking disulfide links of

mucoproteins.SPECIFIC INDICATION

Upper and lower resp tract infection, skin and soft tissue infection .CONTRAINDICATION

Hypersensitivity to macrolidesSIDE EFFECTS

diarrhea/loose stools, nausea and abdominal pain being the most frequently

reportedNURSING PRECAUTION

If you have any of these conditions, you may need a dose adjustment or special

tests to safely use Zithromax:

liver disease, kidney disease; myasthenia gravis; a heart rhythm disorder; or a

history of Long QT syndrome.


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S

sa wala pako na admit cige nako og ubo-ubo. As verbalized by the

patient

O

Non productive Cough

Yellow color Sputum

Restlessness

A

Ineffective Airway Clearance related to mucus secretion secondary to

cough

P

Long Term: After 1 day of intervention, patient will Demonstrate a

decrease in physiologic sign of intolerance

Short Term: After 1-2 hours of intervention, patient will report

measurable increase in activity tolerance

I

1.) Instructed to increases fluid intake.

2.)Monitored pulse rate and respiration rate

3.) Position Pt. in a 45 degree angle in comfortable position.

4.) Performed chest tapping.

E

At the end of 8 hours the client was able to improved proper ventilation

and participated actions to maximize oxygenation.


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S

gehelantan ko 4 days before ko ge admit. As verbalized by the

patient

O

Generalized weakness

Pale eyes and lips

Limited motion

Temp:38.3 C

A

Hyperthermia related to increase metabolic rate secondary to illness

P

Long Term: At the end of 30 mins patient temperature will be down to

normal range.

Short Term: After 3-4 hours of intervention, patient body temperature

will decreases within normal ranges.

I

1.) Performed Tepid sponge bath

2.) Monitored body temperature

3.) Increased fluid intake.


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E

At the end of 1 hour the client body temperatures decrease within

range of 37.6 C.

S

kapoy man ag lihok-lihok as vervalized by the pt.

O

Generalized weakness

Pale eyes and lips

Limited motion

A

Activity Intolerance related to generalized weakness secondary to

presence of circulatory/ respiratory problems.

P

Long Term: At the end of 30 mins, patient temperature will be down to

normal range.

Short Term: After 3-4 hours of intervention, patient body temperature

will decreases within normal ranges.


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I

1.) Instructed to provide adequate rest

2.) Monitored vital sign

3.) Administered medication as prescribe.

E

At the end of 1 hour the client body temperatures decrease within

range of 37.6 C.

IX. Referrals and Follow-up

Our further Inpatient care includes monitoring of changes in vital signs,

assessment of effectiveness of treatment regimen, reinforcement of dietary

advice(At par with age regular diet), and the advice regarding the importance of

adequate bed rest.

Our further Outpatient care includes instructions to Mr.Chandlier the

compliance with treatment regimen, and reporting any side effect or adverse

effects of medications to his physician. The patient was also instructed to have a

regular check-up at MRH Hospital in order to monitor the current condition. HE

can also visit nearest health centers

X. Evaluation and Implications


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This Care Study enabled me to further my learning associated with

disease condition of the patient. From it, I have gained knowledge in the

progression of the disease and the reaction of the body to maintain homeostasis

and how it eventually causes harm.

The Care Study improved my understanding and skills in the

management of the patient through the experiences Ive had in implementary my

care. It also enhanced my confidence in intervening because of the input gained

from my research.

Within the span of 2 day of rendering care to Mr. Madredano Chandlier. I

was able to identify potential problems and specific nursing interventions were

provided. With the help of health teachings and other interventions, Mr.

Madredano were able to learn how to recognize signs and symptoms and other

risk factors of his condition. Mr. Madredano was able to verbalized the

importance of his medications. He also recognized the importance of compliance

to his treatment regimen in order to manage his condition.

XI. BIBLIOGRAPHY:

o Luckman and Sorensen, Medical-Surgical Nursing. 3rd Edition W.B.

Saunders Company (1987)

o Kozier, B, et al Fundamentals of Nursing. 7th Edition Pearson Education

South Asia PTE LTD Philippines 2004

o Smeltzer, Medical-Surgical Nursing. 11th edition, Lippincott William &

Wilkins, 2007

o The Lippincott Manual of Nursing Practice. Sixth Edition. Manila . Merriam

& Webster Bookstore, Inc. 1996.

o


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o Mosby, Mosbys Nursing Drug Reference, Elesevier Mosby, 2005

o Doengoes, Nurses Pocket Guide. 9th edition, F.A. Davis, 2004

o www.wikipedia.org

o www.mims.com
http://www.wikipedia.org/http://www.mims.com/http://www.wikipedia.org/http://www.mims.com/

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