chief complaints: • difficulty of breathing •
DESCRIPTION
CAPTRANSCRIPT
CHIEF COMPLAINTS:
• Difficulty of Breathing
• Productive Cough
• Fever
• HISTORY OF PRESENT ILLNESSMonths PTC, patient had cough, productive
sticky on and off, relieved by nebulization and regular checking with private MD. prescribed with unrecalled medication which affected temp. relief.
3 days PTC, recurrence cough, productive time to time with associated fever. Given biopsy. Nebulization continued.
Few hrs PTC, after Visiting a private MD and prescribed become medications, patient complained of chest heaviness and sudden onset of unresponsiveness and cyanosis.
NURSING HISTORY
• PAST MEDICAL HISTORY
NURSING HISTORY
Had a chronic smoker's cough for "10 or 15 years" which relative describes as being mild, non-productive and occurring most often in the early morning
Smoked 3 packs of cigarettes a week for the past 50 years
A retired fireman, who has been treated for mild hypertension, bronchitis, appendicitis (as a young adult)
NURSING HISTORY• GENOGRAM
• A. Vital Signs
T: 39.2 o C RR: 22 cpm
PR: 70 bpm BP: 100/70 mmHg
• B. Integumentary
- Skin: Light to deep brown
Poor Skin turgor
(+) Blisters
(+) lesions
(+) edema in the left carpal
(+) mass
(+) rashes
(+) Pallor
PHYSICAL ASSESSMENT
- Hair: Unevenly distributed hair
Thin hair
(-) lesions
(+) dandruff
(-) lice
- Nails: Prompt to return in pink color
Angle of nails about >1650 Clubbed fingers
Intact epidermis
(+) capillary refill test
PHYSICAL ASSESSMENT
• C. Head and Neck
- Head: Size: Normocephalic
Asymmetrical facial features and movement
(-) nodules or masses
Rough skull contour
- Eyes: Blurred O.U Visiona
Eyebrows of hair in unevenly distributed
Puffy lower eyelids
Darkened areas around the eyes
Skin broken
PHYSICAL ASSESSMENT
- Eyes: (+) discharge; (+) discoloration
Eyelids is asymmetrical
7 involuntary blinks per minute
pale conjunctiva
(-) edema over lacrimal gland
3 mm in diameter; round, smooth border, iris flat
Both eyes are uncoordinated
PHYSICAL ASSESSMENT
PHYSICAL ASSESSMENT- Ears: External ear color: same as the
facial skin
decreased hearing perception
(+) discharge
(-) masses at sinuses
Auricle aligned with outer canthus of eye
PHYSICAL ASSESSMENT- Nose: Symmetric; straight
(+) discharge
(+) lesion
Uneven color
Pale mucosa
Nasal septum intact and in
midline
PHYSICAL ASSESSMENT- Mouth: Outer lips: pale color
rough texture
Unable to purse the lips
Gums: Pale & dry
Tongue: unable to move freely
(+) nodules
Soft Palate: pale, rough
Hard Palate: pale, irregular
Pharynx: (+) discharge
(+) Sputum
(+) Cough
Depressed gag reflex
PHYSICAL ASSESSMENT- Neck: Muscle equal size; head
centered
(+) nodules or masses
Trachea: in the middle: spaces are equal in both sides
Thyroid gland: ascends during swallowing; not visible
(-) bruit
(+) Endotracheal tube
(+) Face mask
• D. Thorax and LungsChest symmetricalshallow, weak, arhythmic & effort
respiration(+) Crackle sound & adventitious soundunder oxygen therapy
• E. Breast and AxillaeAxillary: (-) tenderness & masses
• F. Heart(+) Irregular heart sounds
PHYSICAL ASSESSMENT
• G. AbdomenUneven color(+) lesion; (+)pigmentation Asymmetrical contourAsymmetric movement caused by
respiration(+) PEG
• H. Genitourinary(+) Lesion(+) indwelling catheter
PHYSICAL ASSESSMENT
• I. Musculoskeletal
decreased immobility
(+) tremors
Uncoordinated movements
Joints immovable
Weak on both sides
PHYSICAL ASSESSMENT
• J. Neurological Language: (+) defectsUnable to communicate verballyOrientedMemory: unable to recall recent &
remote memoryAttention Span: limitedMotor function: unable to move
independently, flat on bedPain Sensation: unable to distinguish
“sharp” to “dull
Reduced level of consciousness
PHYSICAL ASSESSMENT
SIGNIFICANT SIGNS AND SYMPTOMS
Problems in breathing Adventitious Breath SoundCoughing that produces
greenish and yellow sputumFever Cyanosis Nail Clubbing
DIAGNOSTIC EXAMINATION•Sputum Tests:
Blood, which means an infection is present. Color and consistency: If it is yellow, green, or brown, an infection is likely.
•Blood test:WBC 17,000/mm3; neutrophils 70%, bands 15%, lymphocytes 15%.
•Chest x-ray:Reveals a patchy left lower lobe infiltrate
DEFINITION
DEFINITION
Streptococcus pneumoniae
PHYSIOLOGYUpper Respiratory Tract :
NARES
NASO PHARYNX
EPIGLOTTIS
TRACHEA
LARYNX
Lower Respiratory Tract :
TRACHEA
(BIFICATES INTO 2 BRONCHI)
BRONCHIOLES
UPPER
ALVEOLAR DUCTS
ALVEOLAR SACS
PATHOPHYSIOLOGY
Conditions that produce mucus or
bronchial obstruction
Immunosuppressed patients
Smoking
Prolonged immobility
Depressed cough reflex, aspiration
RISK FACTORS
NPO status, placement of NGT
Antibiotic Therapy
Alcohol intoxication
General anesthetics, sedative,
opioid preparation
Respiratory therapy
Advance age (non-modifiable)
RISK FACTORS
Actual: Ineffective airway clearance due to
inflammation of bronchi as manifested by accumulation of bronchial secretion
Impaired gas exchange related to inflammatory process, collection of secretion affecting oxygen exchange across alveolar membrane
Activity intolerance related to imbalance between oxygen supply and demand, general weakness
NURSING DIAGNOSIS
Probable:
Risk for aspiration related to decreased gag reflex
Risk for impaired skin integrity related to decreased oxygen supply in the blood circulation
NURSING DIAGNOSIS
Nursing Care Plan
I. ASSESSMENT
Subjective:
“Kapag gising niya panay ang ubo niya,” as verbalizad by the patient’s relative
Objective:
-Respiration-22 cpm
-O2 Saturation- 94%
-Presence of secretion
-Inspiratory crackles with adventitious breath sounds right base
-Increased sputum production
NURSING DIAGNOSIS
Ineffective airway clearance due to inflammation of bronchi as manifested by accumulation of bronchial secretion
PLANNING
After an hour of nursing intervention the patient will be able to expectorate
secretions
INTERVENTION
A. Monitor respirations and breath sounds, rate, rhythm, and effort
-To check for any improvements and abnormal changes
B. Auscultate breath sounds and assess air movement to ascertain status and note progress
-To assess the status
C. Monitor pulse oximeter- To check for any improvements
and abnormal changes
D. Place client in semi-fowlers position
-To facilitate breathing and lung expansion
E. Encourage coughing and deep breathing exercise
-To promote wellness
F. Increase fluid intake to at least 1000ml/day
- To loosen secretions for easily release
INTERVENTION
EVALUATION
The patient will be able to expectorate secretions
II. ASSESSMENTSubjective cues:No subjective cues
Objective cues:-With oxygen via face mask
through endotracheal tube-Pallor-Shortness of breathing-Irregular breathing pattern
NURSING DIAGNOSIS
Impaired gas exchange related to inflammatory process, collection of secretion affecting oxygen
exchange across alveolar membrane
-After an hour of nursing intervention the patient will be able to demonstrate improve ventilation and adequate oxygenation of tissues by ABG’s within the client’s normal limits
PLANNING
INTERVENTIONA. Monitor respiratory status
-to assess for any clinical manifestations respiratory distress
B. Place client in semi-fowler’s position-to promote lung expansion
C. Encourage deep breathing exercise-provides for adequate oxygenation
D. Maintain oxygen administration device as ordered- provides for adequate oxygenation
E. Change patient’s position every 2 hours- To facilitate secretion movement and drainage
EVALUATION
-After an hour nursing intervention the patient will be able to demonstrate improve ventilation and adequate oxygenation of tissues by ABG’s within the client’s normal limits
III. ASSESSMENT
Subjective cues: “Palagi na lang siya nakahiga”, as
verbalized by the patient’s relative Objective cues:Excessive coughingPresence of respiratory
problemsDevelopment of pallor
NURSING DIAGNOSIS
Activity intolerance related to imbalance between oxygen supply and demand,
general weakness
PLANNINGAt the end of the shift the client
will be able to demonstrate a measurable increase in tolerance to activity with absence of dyspnea and
exercise fatigue
INTERVENTIONA. Evaluate patient’s response to activity
-Reduce stress and excess stimulation, promoting rest
B. Provide a quiet environment and limit visitors-Bed rest is maintained during acute phase to decrease metabolic demands, thus conserving energy for healing
C. Explain importance of rest in treatment plan- Reduce stress and excess stimulation, promoting rest
EVALUATION
At the end of the shift the client will be able to demonstrate a measurable increase in
tolerance to activity with absence of dyspnea and exercise fatigue
VII. ASSESSMENT
Subjective cues:
-No subjective cues
Objective cues:
-impaired swallowing
-depressed cough and gag reflex
-reduced level of consciousness
NURSING DIAGNOSIS
Risk for aspiration related to depressed gag reflex
PLANNING
At the end of shift the client will be able to exhibit preventions of
aspiration
INTERVENTIONA. Assess and monitor amount and
consistency of respiratory secretions
-To assess contributing factors
B. Assess and monitor strength of cough and gag reflex
-To assess causative factors
C. Auscultate lung sounds frequently
-To determine presence of secretions
D. Encourage coughing and deep breathing exercise
-To loosen secretionsE. Provide chest physiotherapy
-To loosen secretionsF. Maintain suction equipment at bedside
-As needed to clear secretions at the respiratory tract and oral cavityG. Turning patient to semi-fowler’s position
-To prevent gastroesophageal reflux
EVALUATION
At the end of shift the client will be able to exhibit preventions of
aspiration
VIII. ASSESSMENT
Subjective cues:
- No subjective cues
Objective cues:
- Weak joints
- Decreased immobility
- cyanosis
NURSING DIAGNOSIS
Risk for impaired skin integrity related to decreased oxygen supply in the blood
circulation
PLANNING
At the end of the shift, the client will be able to prevent the risk for skin
integrity
INTERVENTION
A. Elevate the lower extremities every 15 minutes
-To promote venous return
B. Massage the upper and lower extremities
-to promote blood circulation
C. Repositioning every 2 hours
-to prevent pressure ulcers
D. Encourage Deep Breathing exercise
-To promote gas exchange
E. Provide oxygen therapy
- for adequate oxygenation
F. Assist patient in turning side to side
-To promote mobilization
EvaluationAt the end of the shift, the client will be able to prevent the risk for skin integrity
DRUG STUDYGENERIC: Ceprofloxacin
BRAND: Cipro XR
Classification: Antibiotic
Drug Action: broad-spectrum antibiotic that is active against both Gram-positive and Gram-negative bacteria. It functions by inhibiting DNA gyrase, a type II topoisomerase, and topoisomerase IV, enzymes necessary to separate bacterial DNA, thereby inhibiting cell division.
Side effects: Dizziness, Fever, Headache, Sore throat, Skin rash, Nausea and vomiting, Sleep problems, Anxious, Increased sensitivity to sunlight exposure
DRUG STUDY
Indication: Urinary tract infection, Chronic bacterial prostatitis, Lower respiratory infection, Acute sinusitis, Skin infection, Typhoid fever
Contraindication: Pregnancy, Breast feeding mother, Kidney diseases, STD, Pedia
Nursing Intervention:•Advise patient not to take with dairy products•Assess patient for any kidney disease, joint problems, hypokalemia•Avoid taking antacid, vitamin supplements, or chewable tablets 6 hours before of 2 hours after taking ceprofloxacin
DRUG STUDYGENERIC: Metronidazole
BRAND: Flagyl
Classification: Antiamoebics, Antibiotics
Drug Action: Antibiotic effective against anaerobic bacteria and certain parasites. Anaerobic bacteria are single-celled, living organisms that thrive in environments in which there is little oxygen (anaerobic environments) and can cause disease in the abdomen (bacterial peritonitis), liver (liver abscess), and pelvis (abscess of the ovaries and the Fallopian tubes)
DRUG STUDYSide effects: Nausea, Diarrhea, Vomiting, Dizziness, Headache, Rash, Itch, Fever, Dark urine
Indication: Anaerobic bacterial infection
Contraindication: Hypersensitivity, History of blood dyscrasias, Active organic disease of CNS, 1st trimester of pregnancy, lactation
Nursing Intervention:•Avoid alcohol intake•Check the blood glucose level of the patient before administration of drug•Assess for liver problems, seizure disorder and any allergies
DRUG STUDYGENERIC: Ansimar
BRAND: doxofylline
Classification: Anti-asthmatic
Drug Action: Adenosine-nonblocking anti-asthmatic drug with potent bronchodilator activity that does not display the typical extrapulmonary side effects of theophylline--a potent adenosine antagonist The contractile force of electrically stimulated left atria was affected by doxofylline starting at 0.3 mM.
DRUG STUDYSide effects: Nausea & Vomiting, Epigastric pain, Tachycardia, Insomnia, Tachypnea
Indication:Bronchial asthma, Pulmonary disease with spastic bronchial content
Contraindication: Acute MI, Hypotension, Lactation, Liver disease, Chronic obstructive lung disease, Pregnancy
Nursing Intervention•Check the blood pressure•Instruct the patient to take ansimar with or without food•Check the heart rate
DRUG STUDYGENERIC: Maicostat
BRAND: Nystatin
Classification: Antifungal and Antibiotics
Drug Action: nystatin binds to ergosterol, a major component of the fungal cell membrane. When present in sufficient concentrations, it forms pores in the membrane that lead to K+ leakage and death of the fungus.
DRUG STUDYSide effects: Diarrhea, Oral irritation, GI distress, Nausea and vomiting, Rashes
Indication: Intestinal or esophageal candidiasis, Oral lesion
Contraindication: Pregnancy
Nursing Intervention:•Instruct patient to take nystatin with an empty stomach•Instruct patient not to take food or drinks 1 hour after the administration
1. Take the entire course of any prescribed medications
2. Get plenty of rest
3. Drink lots of fluids, especially water.
4. Keep all of follow-up appointments
5. Encourage the guardians to wash patient’s hands.
6. Tell guardians to avoid exposing the patient to an environment with too much pollution (e.g. smoke).
7. Give supportive treatment
8. Protect others from infection.
DISCHARGE PLANNING