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8/8/2019 Grand CP Powerpnt

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Nursing Care Management 101

By: BSN 3 Students


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Physical Assessment & Review Of SystemDefinition Of Terms

Textbook Discussiona. Complete Diagnosisb. Anatomy and Physiologyc. Etiology and Symptomatologyd. Pathophysiology

Diagnostic ResultsComplete Doctors Order List Of DrugsDrug Study

Priorities ProblemsNursing Care PlanPrognosisBibliography


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This is a case of a 14 years old male who wasadmitted at Allah Valley Medical Specialist Center Incorporated last August 24, 2009 at 11:06 am and wasdiagnosed as having Community Acquired Pneumoniaunder the service and care of Dra. Luz F. Improgo.

Community Acquired Pneumonia refers to Pneumoniaacquired outside of hospitals or extended care facilities. Itoccurs. Either in the community setting or within first 48hours after hospitalization. It is an illness of lung which iscaused by different organism like bacteria, viruses, andfungi and characterized by acute inflammation of the wallsof the bronchioles. It is common in women and causes tothe 6% deaths. Streptococcus pneumonia and mycoplasmapneumonia both are common bacterium which causescommunity acquired pneumonia in adults and children.


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Bacterial pneumonias tend to be the most serious and, inadults the most common cause of pneumonia. The most commonpneumonia causing bacterium in adults is streptococcus

pneunoniae.

If the cause is bacteria, the goal is to cure the infectionwith antibiotics. If the cause is virus, antibiotics will not beeffective. In some case it is difficult to distinguish between viraland bacterial pneumonia, so antibiotics may be prescribed.Pneumococcal vaccinations are recommended for individuals inhigh risk groups and provide up to 80% effectiveness in stayingoff pneumococcal pneumonia.

In general pneumonia will be acquired when our immune

systems are unable to combat the virulence of the invadingorganisms. Organisms from environment, invasive devices,equipments and supplies, staff or from other people can invadethe body. All types of pneumonia can be caused by bacteria,viruses, mycoplasma, fungi, rikettsiae, protozoa and helminthes.


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Non infections causes of pneumonia include inhalation oftoxic gases, chemicals, smoke and aspiration of water, food, fluid

and vomitus.

Pneumonia is the most common of death from infectiousdisease in the United States. It is the Seventh leading cause ofdeath.

Here in the Philippines, 42.8% cases of pneumonia occureach year, and it is the fourth leading causes of death. Thehighest incidence among adults more specifically in older adults,hospitalized clients and those being mechanically ventilated.Community acquired pneumonia is more common than

mosocomial pneumonia.

This case study aims to provide knowledge to nurses andfuture nurses about Community acquired pneumonia. Improvestheir skills in saving for patients with the same illness anddevelop positive attitude towards caring for patient having CAP.


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G eneral Objectives:

After 3 5 hours of Case presentation,the presenters and attendees will be able toobtain additional knowledge regardingcommunity acquired pneumonia, developskills on the proper management orinterventions of the said illness and embracetheir attitude positively in dealing withpatients having the same condition.


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Specific Objectives:

This case aims to presents the following specificobjectives:

Present the introduction completelyPresent the general and specific objectives properly

Present the clients profile completelyTrace the Genogram of the patient correctlyDiscuss the physical assessment in line with thecurrent condition of the clientPresent the review of system of the clientcomprehensivelyIdentify the related developmental stages achieved bythe client correctlyDiscuss thoroughly the medical diagnosis of the clientDefine terms related to community acquiredpneumonia correctly


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Discuss the anatomy and physiology of the affectedsystem thoroughly

Discuss the medical, surgical and nursingmanagement of community acquired pneumoniaappropriately / brieflyEnumerate the etiology and symptomatology brieflyTrace the pathophysiology systematically.Discuss the result of diagnostic laboratory proceduresdone.Present completely the physician / doctors order Present all the drugs taken by the client and itspharmacokinetics clearlyEnumerate the 5 nursing diagnoses according topriority precisely / correctlyPresent the nursing care plan comprehensively /accurately.Discuss the prognosis of the client properlyPresent the bibliography completely


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Patients Name: Meow Age: 14 years oldBirthday: September 17, 1994Birth Place: DCH I

Address: Blk. 5 Lot 11 Agan Phase II Sta. CruzKoronadal City, South CotabatoSex: MaleTribe: IlonggoCitizenship: FilipinoRace: AsianReligion: Iglesia ni KristoChief Complaint: Cough, Fever for 5 days

Date Admitted: August 24, 2009Time Admitted: 11:06 Am

Admitting Diagnosis: Community Acquired Pneumonia Attending Physician: Dra. Luz F. ImprogoReason for admission: for management


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Name of Institution: Allah Valley MedicalSpecialist Center Incorporated

Source of Medical Financing: Phil. HealthFathers Name: Mr. Meow

Age: 48 years oldBirthdate: July 31, 1961Occupation: Government EmployeeMothers Name: Mrs. Meow

Age: 45 years oldBirthdate: November 27, 1963Occupation: House WifeSiblings: Mee(28), Oink(25), Twit(12),

Aw(6)[Asthma]Source of Information

>Patient>Patients Chart>Patients Brother >Patients Mother


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The Meow family can be considered as a

nuclear family. They live together in a concretetwo storey house that is hoisted in a privateowned lot in Agan Homes. The familys source of income is through Mr. Meows job a governmentemployed worker, while Mrs. Meow is merely ahousewife, as well as the eldest child, who works

as an engineer in abroad. These resources sufficethe familys basic needs and emergency caseslike hospitalization.

The familys bloodline is embedded withgenetic disorders and diseases as well. Asthma isthe recessive genetic endowment whereas aHeart disease such as cardiac arrest is adominant gene. Asthma causes the death of thepatients Grandfather on maternal side andCardiac arrest claims the life of the patientsgrandparents (both).


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The family utilizes different herbal medicineapproved by DOH such as Lagundi for cough,Oregano as anti oxidant, and Sambong to decreaseuric acid. According the Patients brother, the familyhas also experienced common household illnessessuch as headache, body pain, cough, cold, fever, andflu.

The family also purchases over the counter drugs to relieve themselves such as paracetamol for headeche, mefenamic acid for body pain, and Bioflufor colds. In addition to that, the family had alsoreceives series of immunization and vaccination asfollows: 1 dose of BCG, 3 doses of DPT, 3 doses of

OPV, measless vaccine and Hepa B vaccine. As to religious affiliation, the family attendschurch gatherings and participates in any activitiesconducted. The family also has their recreationalactivities tilling their vegetables bin at their backyard,going to market and attends to their program.


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History of past illness comprises the data of patients childhood illness and medical history; aswell as ways on how these conundrums wereresolve.

Zero in to the knowledge of patient Meow, hehad already passed through the childhood illnesssuch as measles, mumps and chicken pox; but byvirtue of Active natural immunity and prior vaccinations, he did not manifest the illness ever again.

Last August, in the same year, he wasadmitted at the same hospital for treatment of Asthma attack. He was given a nebulizer withVentolin, a bronchodilator; at that very moment hewas relieve.


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F ive days prior to admission, patientMeow experiences cough, fever, anddifficulty in breathing with severe headache.An hour prior to admission, Patient Meowexperiences vomiting and feels dizzy; due tothis he was admitted at once under thesupervision of Dra. Luz F. Improgo and wasdiagnosed of having a Community AcquiredPneumonia.


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To self:Patient meow expect that after few days

of hospitalization he can already recover inorder for him to go back in school to

continue his studies.

To family:They expect that the patient will

recover after hospitalization in order forthem not to worry and also for them to goback to work and do their daily routine.


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Date: August 24, 2009Time: 8:00 Pm 3 11 Shifts

G eneral:

Received patient lying on bed, conscious andcoherent with IV F of D5LR at the level of 900ccinfusing well, regulated at 20 gtts/min hooked at

the right metacarpal vein. Patient is weak, awarewith the surrounding and responsive, well orientedwith the people around him, can speak clearly at thestage of early adolescent, male, Asian in race withbrown complexion of skin.


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Vital Signs:

Temperature: 38.4 OC HyperthermiaPulse Rate: 77 beats / minRespiratory rate: 21 cycles / minBlood pressure: 130 / 90 mmHg

Head

Inspection: skull is proportionally positioned,round in shape, dandruff no noted, hairs arefixed and equally distributed, dry and black incolor.Palpation: smooth and absence of mass noted


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Facial

Inspection: slightly brown in color, eyes andnose are properly positioned, Wrinkled skinnot notedPalpation: skin are smooth and slightly oily

Eyes and vision

Inspection: eyes are in bilateral position;

pupils normally are equal in size, round,reacts to light and with accommodation.Palpation: Masses not noted, tearing of lacrimal gland not noted


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Ears and hearing

Inspection: Eardrum is normally shiny,transparent and opaque or pearly gray,slightly concave and free of lesions, can hearwhispered words, discharges not noted.Palpation: tenderness not noted

Nose

Inspection: positioned in the center of theface , discharges noted but minimal.Palpation: no tenderness noted


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Lips, mouth, pharynx

Inspection: lips are dry, slightly pale inappearance, tongue is in pinkish in color aswell as the gums, teeth are completewithout dentures present, tonsils are notinflamed.Palpation: lymph nodes not noted

Neck

Inspection: can move freely, can performrange of motion easily.Palpation: submandibular lymph nodesnoted, jugular veins noted


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Thorax and lungs

Inspection:deepness & difficulty of breathingnoted. skin same color with the rest of the bodyPalpation: Chest wall intact, no tendernessAuscultation: wheezing & Crackling sound notedin the upper & lower lobes of the lungsPercussion: Dullness

Abdomen

Inspection: same color with the rest of the body,

no lesions or abrasions notedAuscultation: bowel sounds not notedPercussion: normally bulgingPalpation: smooth and tenderness not noted


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G enitalsInspection: Patients refuse to assess his

organs

Extremities

Inspection: symmetrical in shape, lacerationsnot noted, can performed range of motioneasilyPalpation: tenderness not noted


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Skin

Inspection: brown complexion, lumps andbruises not noted, vascularity generallyuniform, temperature is 38.4 OC febrile,warm to touch with good skin turgor.

Nails

Inspection: Smooth, well trimmed, capillaryrefill back not less than 3 seconds.


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Date: August 24, 2009Time: 8:00 Pm 3 11 Shift

G eneral: Patient verbalized that he issuffering from fever and severe headachewith flu and cough.

Skin, hair, nails: Patient stated that hedoesnt have any dandruff and he cleanedand trimmed his nails every 5 days


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Head: Patient claims that he is experiencingheadache and said that he havent encounteryet head injuries.

Eyes: Patient claims that he doesnt have any

problems in his eyes

Ears: Patient claims that he can hear wordsclearly

Nose: Patient claims that he had dischargesin his nose


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Mouth and throat: Patient claims mild pain inhis throat and when swallowing foods andstate that prior to admission he experiencevomiting.

Neck: Patient claims that he haventencounter neck injuries

Lymph nodes: Patient claims that he haventexperience enlargement of lymph nodes

Respiratory: Patient claims that he has anasthma and experiencing cough and flu forthe past 5 days already

Cardiovascular: Patient claims of pain in the


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G astrointestinal: Patient claims that heexperienced gastrointestinal pain before

Endocrine: Patient devise of cold intolerance

Reproductive: Patient claims that he iswashing his genitals after doing bathroomnecessities

G enitourinary: Patient claims absence of painwhen voiding

Musculoskeletal: Patient claims musclescramping


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Hematologic: Patient claims absence oflumps and bruises

Neurologic: Patient claims of headache

Psychiatric: Patient claims of discomfort


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A respiratory system functions to allow

gas exchange . The gases that are exchanged,the anatomy or structure of the exchangesystem and the precise physiological uses of the exchanged gases vary depending on theorganism. In humans and other mammals , for example, the anatomical features of therespiratory system include airways, lungs , andthe respiratory muscles . Molecules of oxygenand carbon dioxide are passively exchanged,by diffusion , between the gaseous externalenvironment and the blood . This exchangeprocess occurs in the alveolar region of thelungs.


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THE NOSE

Air enters through two openings, the external nares or nostrils.Just inside each nostril is an expanded vestibule

containing coarse hairs.A midsagittal nasal septum divides the nasal cavity.The maxillary, nasal, frontal, ethmoid and sphenoid

bones form the lateral and superior walls of the nasalcavity.The hard and soft palate forms the floor of the cavity.

(the posterior part of the soft palate is the uvula)The external portion of the nose is composed of

cartilage that forms the bridge and the tip of the nose.

The superior, middle and inferior nasal cochae arebony shelves that project from the lateral walls of thenasal cavity.

The spaces between the conchae are the meatuses.Posteriorly the internal nares open into the

nasopharynx.


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THE PHARYNX

Is a chamber shared by the digestive andrespiratory systems.

It extends between the internal nares and theentrances to the larynx and esophagus.

A stratified squamous epithelium lines thepharynx.

The throat of pharynx is divided in threeregions:

1.Upper naso-pharynx2.Middle oropharynx3.Lower laryngopharynx


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THE NASOPHARYNX

Lies superior to the soft palateServes a passageway for airflow from nasal cavityIt contains the pharyngeal tonsils ( adenoids) inposterior wall, and the opening of the eustaquiantubes (auditory tube)

THE OROPHARYNX

Extends front soft palate down to the epiglottis(base of the tongue)

It contains the palatine and lingual tonsils.

THE LARYNGOPHARYNX

The narrow zone between the hyoid bone and theentrance to the esophagus.


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THE LARYNX

Joins the laryngopharynx with the trachea. It consist of cartilage It is called the voice box. The three main cartilage are: thyroid cartilage (Adamss apple),

epiglottis, and the cricoid cartilage.Other cartilage is: arytenoids cartilage, corniculate cartilageand the cuneiform cartilage.

The epiglottis is a piece of elastic cartilages that falls over theopening ( GLOTTIS ) during swallowing to prevent ingestedfood from entering the respiratory tract.

The corniculate cartilage are involve the opening and closingof the epiglottis, and in the production of sounds

Two pairs of folds span the glottal opening. The ventricular folds (false vocal cords) are inelastic but the tension in thevocal cords can be adjusted by voluntary muscle movements.

During expiration air flowing through the larynx vibrates thevocal cords (true vocal cords) and produces sound waves.

Coughing and laryngeal spasms are protective reflex thatprotect the glottis and trachea from objects and irritants.


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THE TRACHEA

Extends from the level of the sixth cerebral vertebra, at thebase of the larynx, to the level of the fifth thoracic vertebra.is a tubular structure with 4.25 inch length and 1 inch indiameter.At its caudal limit the trachea divides to form primary bronchi.Lies anterior to the esophagus.Along the length of the trachea are 15-20 c-shapes in piecesof hyaline cartilage (tracheal cartilages)

The tracheal muscle holds the two sides of the c-shaped cTrachea is lined with pseudo stratified ciliated columnar epithelium.The trachea branches within the mediastum, forming the leftand right bronchi.

Each bronchus enters a lung at groove, The Hilus.

Each bronchus branches into increasingly smaller passageway to conduct air into the lungs.The primary bronchi branch into as many secondary bronchi

(Intrapulmonary bronchi)As there are lobes in each lungThe smallest passageway is the bronchioles.


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THE PLEURAL CAVITIES

The thoracic cavity is bounded by the ribcage and themuscular diaphragm.

The mediastinum divides the region into TWO PLEURALCAVITIES.

The pleural cavity is lined with a serous membrane, THEPLEURA.

Parietal pleura line the thoracic wall, diaphragm, andmediastinum.

Visceral pleura cover the surfaces of the lungs. The alveolar walls are made of simple squamous

pulmonary epithelium. Scattered among epithelium are surfactant cells that

secretes oil coating to prevent the alveoli from sticking together after exhalation. Also the alveolar walls are macrophages that

phagocytes debris or potential pathogens.Pulmonary capillaries cover the exterior of the alveoli.


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Atelectasis- partial or total collapse of thelung;a condition in which lungs of a fetusremain unexpanded at birth.Inflammation- a tissue or organ reaction toinjury or irritation characterized by pain,heat, swelling, redness, and possible loss offunctionPleura- a serous membrane lining the wallsof the thorax and enclosing to the pleura.Effusion- the escape of fluid into a cavity, asthe pleura space.


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Community Acquired Pneumonia- an illnessacquired prior the hospitalization. Aninflammation of the bronchi and lungs causedby various types of pneumonia, pathogenicbacteria as well as viruses, rickettsias, andfungi.

Lungs one of two cone-shaped structureswhich function as respiratory organsresponsible for providing oxygen for the bodyand discharging waste products.

Tracheobronchial- related to both thebronchial and the trachea.


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Medical diagnosis:Community Acquired Pneumonia refers to

pneumonia acquired outside of hospital or in

the community. It is an inflammation of thewalls of the smaller bronchial tubes, withvarying amounts of pulmonary consolidationdue to spread of the inflammation into

peribronchiolar alveoli and the alveolarducts.


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Assessment Diagnosis findings:The diagnosis of pneumonia is made by

history(particular of a recent respiratorytract infection), physical examination, chestx-ray studies, blood culture (bloodstreaminvasion called bacteremia, occurs

frequently), and sputum examination. Thesputum sample is obtained by having thepatient.(1) Rinse the mouth with water tominimize contamination by normal oral flora,

(2) Breath deeply several times, (3) Coughdeeply, and (4) Expectorate the raisedsputum into a sterile container.


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More invasive procedure may used to collectspecimens. Sputum may be obtained byasotracheal or orotracheal suctioning with asputum trap or by fiberoptic bronchoscopy.Bronchoscopy is often used in patients withacute severe infection, patients with chronic

or refractory infection, or immune-compromised when a diagnosis cannot bemade from an expectorated or inducedspecimen.


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Complications:Shock and respiratory failure

Severe complication of pneumonia includehypotension and shock and respiratoryfailure (especially with gram negative bacterialdisease especially in elderly in elderly

patients).

The complications are encountered chiefly inpatients who have received no specifictreatment or inadequate or delayed treatment.These complication are also encounteredwhen the infecting organism is resistant totherapy and when a comorbid diseasecomplicates the pneumonia.


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Risk Factors:Community Acquired Pneumonia is very common illness that affectsmillions of people each year here in the Philippines.

Bacterial pneumonia tend to be the most serious and the most common causeof pneumonia in adults. The most common pneumonia causing bacteriumin adults is streptococcus pneumonia.

Respiratory viruses are the most common causes of pneumonia in youngchildren, peaking between the age or 2 and 3. by school age, the bacteriummycoplasma pneumonia becomes more common.

In some people, particularly the elderly and those who are debilitated,bacterial pneumonia may follow influenza or even a common cold.

People who have trouble swallowing are at risk of aspiration pneumonia.

In this condition, food, liquid, or saliva accidentally goes into the airways. It ismore common in people who have a stroke, parkinsons disease, or

previous throat surgery.It is often harder to treat pneumonia in people whoare in a hospital, or a nursing facility.


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The treatment of pneumonia includesadministration of the appropriate antibiotic asdetermined by the result of the cram stain.However, an etiologic agent is not identified in

50% of cap cases and empiric therapy must beinitiated. Therapy for cap is continuing toevolve. G uidelines exist to guide antibioticchoice, however, the resistance patterns,

prevalence antibiotic agents must all be takeninto consideration. Several organizations havepublished guidelines for the medicalmanagement of CAP.


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Recommendations are classified by existingrisk factors, setting (inpatient vs. outpatient

treatment), or specific pathogens. Examplesof risk factors that may increase the risk ofinfection with certain types of pathogensappear.

Recommendations for treatments ofoutpatients with CAP who have nocardiopulmonary disease or other modifying

factors include a macrolide (erythromycin,azithromycin, or clarithromycin, doxycycline,or a fluroquinolone with enhanced activityagainst streptococcus pneumoniae).


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F or treatment with CAP who are hospitalizesand do not have cardiopulmonary disease or

modifying factors, management consists ofintravenous beta-lactam plus either an oralmacrolide or doxycycline. An intravenousantipneumococcal fluoroquinolone may alsobe used alone. F or acutely ill patientsadmitted to the intensive care unit,management includes an intravenous beta-lactam plus either an intravenous macrolideor doxycycline or fluoroquinolone


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In specific pathogens have been identifiedfor the CAP, more specific agents may be

utilized. Mycoplasma pneumonia is treatedwith doxycline or macrolide. PCP respondsbest to pentamiane and rimatitidine areeffective with influenza and have been

shown to reduce the duration of fever andother systematic complications whenadministered within 24 to 48 hours of theonset of an uncomplicated influenzainfection.


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These medications are also reducing theduration and quantity of virus shedding in

the respiratory secretions.They are not effective when used incombination with influenza vaccine.G anciklovir is used to treat cytomegalo virus

in the non-aids patient; cytomegalovirusimmunoglobulin may also be used.


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Therapy with parenteral agents usually is

changed to oral antimicrobial agents whenthere is evidence of clinical response and thepatient is able to tolerate oral medications.

The recommended duration of treatment

for pneumococcal pneumonia is 72 hoursafter the patients become afebrile. Mostother forms of pneumonia caused bybacterial pathogens are treated for 1 to 2weeks after the patient become aferbile. Atypical pneumonia is usually treated for 10 to21 days.


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Treatment of viral pneumonia is primarilysupportive. Antibiotics are ineffective in viralupper respiratory infections and pneumoniamay be associated with adverse effects.Treatment of viral infections with antibioticsare the major reason for the over use of thesemedications in the United States. Antibioticsare indicated with viral respiratory infectiononly when a secondary bacterial pneumonia,bronchitis or sinusitis is present. Hydration isnecessary part of therapy because fever andtachypnea may result an insensible fluid

losses. Antipyretics may be used to treatheadache and fever; antitussive medicationsmay be used for the associated cough.


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Warm, moist inhalations are helpful inrelieving bronchial irritation. Antihistamines

may provide benefit with reducing andrhinorrhea. Nasal decongestants may also beused to symptoms and improve sleep;however, excessive use may rebound nasalcongestion. Treatment of viral pneumoniathe exception of antimicrobial therapy is thesame as that for bacterial pneumonia. Thepatient is placed on bed rest until theinfection shows signs of clearing. Ifhospitalized, the patient is observedcarefully until the clinical conditionimproves.


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If hypoxemia develops oxygen is

administered. Pulse oximetry or arterialblood gas analysis is performed to determinethe level for oxygen and to evaluate theeffectiveness of the therapy. A concentrationof oxygen is contraindicated in patients withCAP D because it may worsen alveolarventilation by decree. Aging the patientsventilator drive, leading to furtherrespiratory compensation.


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Cough Enhancement: promotion of deepinhalation by the client with subsequentgeneration of high intrathoracic pressures

and compression of the underlying lungparenchyma for the forceful expulsion of air.

Assist client to a sitting position with neck

slightly flexed, shoulders relaxed, and kneesflexed.Encourage client to take several deepbreaths.


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Encourage client to take deep breath, hold itfor 2 seconds, and cough two or three times insuccession.Instruct client to inhale deeply, bend forwardedslightly and perform three or four huffs (againstan open glottis).Initiate lateral chest wall rib spring techniques

during the expiration phase of the coughmaneuver, as appropriate.Instruct client to follow coughing with severalmaximal inhalation breaths.

Encourage use of incentivespirometer/spirometer, as appropriate.Promote systematic fluid hydration, asappropriate.


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Oxygen Therapy: Administration of Oxygen and

Monitoring of its Effectiveness.

Clear oral, nasal and tracheal secretions, asappropriate.

Restrict smoking.Maintain airway patency.Set up oxygenated equipment and administerthough a heated, humidified system.Administer supplemental oxygen as ordered.Monitor the oxygen liter flow.Monitor position of oxygen delivery device.


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Monitor position of oxygen delivery device.Instruct the client about importance of

leaving oxygen delivery device on.Periodically check oxygen delivery device toensure that the prescribed concentration isbeing delivered.

Monitor the effectiveness of oxygen therapy(eg. Pulse, okimettry, AB G s) as appropriate.Ensure replacement of oxygen mask/cannulawhenever the device is removed.

Monitor clients ability to tolerate removedof oxygen while eating.Change oxygen delivery device from mask tonasal prongs during meals, as tolerated.


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Observe for signs of oxygen-inducedhypoventilation.

Monitor for sign of oxygen toxicity andabsorption atelectasis.Monitor clients anxiety related to A EE D foroxygen therapy.

Monitor for skin breakdown from friction ofoxygen device.Provide for oxygen when client istransported.


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Palpate for equal lung expansion.Monitor for diaphragmatic muscle fatigue

(baradoxical motion). Auscultate breath sounds, noting areas of decreased/ absent ventilation and presence of adventitious sounds.Determine the need for suctioning byausculating for crackles and bronchi over major airways.

Auscultute lung sounds after treatment to noteresult.

Note changes in SaO2, SV02, end tidal CO2,and ABG values, as approved.Monitor clients to cough effectively.


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Note onset, characteristics, and duration of

cough.Monitor chest x-rays result/reports.Place the client on side, as indicated toprevent aspiration; log roll if cervicalaspiration is suspected.Institute respiratory treatments (eg.Nebulizer), as needed.


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Urin alys isAn analysis of the volume and physical,

chemical and microscopic properties ofurine.

August 24, 2009


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