CALUMPIT FINAL

8/7/2019 CALUMPIT FINAL

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CASE PRESENTATION: Bronchial AsthmaFATIMA UNIVERSITY MEDICAL CENTER

McArthur Highway, Marulas, Valenzuela City

In Partial Fulfillment in the Requirements in NCM 103A RLE

Submitted to:

Ms. Edna Co, RN, MAN

Submitted by:

Estares, Jaina

Fatima, Francisco

Jacinto, Alexandra Necone

Macabio, Evangeline

Manahan, Grace

Maravilla, Danica

Misajon, MaryvieMorales, Donna

Morales, Joanna

Paguio, Catherine

Quico, Sherry

Rocha, RIcha

BSN 3Y1- 4B S.Y. 2nd

Sem 2010-2011


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TABLE OF CONTENTS

I. INTRODUCTION

II. ACKNOWLEDGEMENT

III. OBJECTIVES

IV. SCOPE AND LIMITATION

V. ASSESSMENT

1. PERSONAL DATA

2. FAMILY BACKGROUND

3. HEALTH HISTORY

A. FAMILY HEALTH HISTORY

B. PAST HEALTH HISTORY

C GENOGRAM

VI. PHYSICAL ASSESSMENT

VII. DEVELOPMENTAL DATA

A. ERIK ERIKSON

VIII. PATTERNS OF FUNCTIONING

VIII. LEVELS OF COMPETENCIES

IX. GORDONS ASSESSMENT

X. ANATOMY AND PHYSIOLOGY

XI. PATHOPHYSIOLOGY

XII. MEDICAL MANAGEMENT

XIII.NURSING CARE PLAN

XIV. DISCHARGE PLAN

XV. BIBLIOGRAPHY


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Case Presentation of Patient Diagnosed with Bronchial Asthma

I.Introduction:

The student nurse of Our Lady of Fatima University picked a case about Bronchial Asthma. As a health care provider, the student nu

responsibility for planning with the patient and the family the continuation of care with eventual outcome of an optimal state of wellness.

Creating a plan of care begins with the collection of data or assessment. It consists of subjective and objective data information.

Asthma is a condition in which the airways narrow usually reversibly in response to stimuli. It is a chronic inflammatory disorder of the airwa

many cells and cellular elements play a role, in a particular, mast cells, eosinophil, T lymphocytes, macrophages, neutrophils, and epithelial cells. In

individuals this inflammation causes recurrent episodes of wheezing, breathlessness, coughing. There are forms of asthma first is cardiac asthma,

asthma, it is the reduced of pumping efficiency of the left side of the heart leads to a buildup of fluid in the lungs. This fluids causes airways to narr

cause wheezing. Cardiac asthma is often indistinguishable from bronchial asthma. The main symptoms are shortness of breath, increase in rapid

breathing, increase in blood pressure and heart rate and a feeling of apprehension. Second forms of asthma is Bronchial Asthma, for most peop

asthma is the pattern periodic attacks of wheezing alternating with periods of quite normal breathing. Strong risk of getting Bronchial asthma incl

person genetically susceptible to asthma and being exposed early in life to indoor allergens, such as dust mites and cockroaches, and having fam

asthma. Symptoms of bronchial asthma include a feeling of tightness of the chest, difficulty of breathing or shortness of breath, wheezing and coughin

at night.


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ACKNOWLEDGEMENT

First of all, we, the researchers would like to thanks to our beloved Lord Jesus Christ who guided as through the days of our duty which enables

our case study.

Second, to the family who allow us to interview about the health status of their child.

Third, to the Staff Nurses and to the Chief Nurse who let us feel their heart-warming welcome as we started duty. To the Owner of the Hospital w

opportunity to learn other knowledge about in caring the patients. To the Hospital itself, who gave us another different experience that will help to our c

To our Clinical Instructor, Ms. Edna CO, who guided us and pursued us to finish our Case Study.

Fourth, to our Family who gave us a physical and moral support.

And last but not the least, we would like to thanks ourselves because of the knowledge we shared as each of us was able to contribute and fini

Study within the time frame set by our clinical instructor..

Thats all. God Bless.


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OBJECTIVES

y To provide the patient a good and quality of care.

y To teach the patient in learning how to effective health and nutrition information in helping their young children to be more healthy.

y To learn and understand the disease.

y To present the case properly.

SCOPE AND LIMITATION

y The patient was admitted at the Emergency Room last Feb. 22, 2011 at around 6pm. The patient was diagnosed with Bronchial Asthma. The

transferred at the Suite Room A MS Ward at the same time.

y Student Nurse JainaEstareshandled the patient from August 22-23, 2011. Jaina take care the baby. She took vital signs and monitored the con

baby.

y Our group assigned to have a Case Presentation and focused on our patient who have been diagnosed with BAI

y The information and other gathered data by our group all came from the primary sources, the parents.

y Physical Assessment was carefully done and conducted on Feb. 23, 2011.


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ASSESSMENT

I. GENERAL INFORMATION:

NAME: PATIENT X

AGE: 1 months

Birthday: October 25, 2009

Place of Birth: Marulas, Valenzuela City

Sex: Male Civil Status: Single Religion: Catholic

Nationality: Filipino Weight: 12 kg Length: 62 cm

HEALTHHISTORY

FAMILY HEALTH HISTORY

Baby X is the youngest child of Mr. and Mrs. X. He is 1 1/2yrs. old or 18 mos. old and weighs 12 kg and length of 62 cm. He was diagnosed

makes him to have difficulty of breathing.

According to his mother, baby X father and grandfather have asthma. Also his grandfather has hypertension while his grandmother on his mothe

a history of Diabetes Mellitus. Mr. and Mrs. X have enough earnings to sustain their financial need and other expenses.


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PAST ILLNESSES:

(+) cough and colds for 9days and have low grade fever.

GENOGRAM

FATHERS SIDE MHERS SIDE

-Boy - Patient -Girl

Boy (Father)

ASTHMA

Boy (11mos.) BAI

Lolo 1 HPN

ASTHMA

Lola 2

Lola 2 Lolo 2 DM

Girl

(Aunt)

Girl

(Mother)

Boy

(Uncle)

Girl

(Aunt)

Boy (13)

Girl (7y.o)


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PHYSICAL ASSESSMENT:

I. GENERAL INFORMATION:

NAME: PATIENT X

AGE: 18 months

SEX: male

II. VITAL SIGNS:

TEMP: 37. 9rC CR: 106 RR: 33

III. GENERAL APPEARANCE:

GENERAL SURVEY

BODY PART EXAMINED NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATI

Body built, height and weight in relationto the clients age, lifestyle and health

Proportionate height and weight, has ahealthy lifestyle.

Upon inspection and observation thepatient is fat enough for her height.

NORMAL. The pts wto her height.


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SKULL

BODY PART EXAMINED NORMAL FINDINGS ACTUAL FINDINGS INTERPRETAT

Inspect the skull for size, shape, and

symmetry

Rounded, smooth skull contour The skull is normocephalic and it is

smooth in contour

NORMAL. The skull

Palpate the skull for nodules, masses,

or depressions

Smooth, uniform consistency The skull has no nodules, masses, or

depressions

NORMAL. It has no

depressions

Note symmetry of facial movements. Symmetry in facial movement As the patient moves her face it has

symmetrical movement

NORMAL. The ptsfa

symmetrical.

Overall hygiene and grooming Clean and Neat As we do the inspection, we noticed that

the patients hygiene is normal because

she take a bath everyday

NORMAL. The pts h

Attitude Non-cooperative The patient is non-cooperative every

time we ask her some questions.

ABNORMAL The pa

cooperative.


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SCALP

BODY PART EXAMINED NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATIO

Color and appearance Lighter that the skin color The pts scalp is lighter that the skin

color

NORMAL. The pts sc

skin color

Areas of tenderness No signs of tenderness There is no tenderness on the pts scalp NORMAL. The pts sctenderness

HAIR


Hair distribution and thickness Evenly distributed. Thick hair The hair of the patient is evenly

distributed and thick enough.

NORMAL. The patient

distributed and thick.

Texture and oiliness over the scalp. Silky, smooth Upon inspection the pts hair is silky and

smooth

NORMAL. The pts hai

making it normal.


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CONJUNCTIVA


Palpebral conjunctiva for color, texture,

and presence of lesion

Pink in color, smooth and no presence

of lesion

Pts conjunctiva is color pink, smooth in

texture and no presence of lesions

NORMAL. The pts con

be pink in color, smooth

lesion.

EARS

BODY PART EXAMINED NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

Cerumen Dry cerumen, has presence of hairfollicles, no pus or blood

The pts ear has dry cerumen, and nopresence of pus or blood.

NORMAL. Has dry ceruno blood or pus


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MOUTH, LIPS, GUMS

BODYPART EXAMINED NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

Symmetry of contour, color and texture Uniform pink color, soft, moist, smooth

texture, symmetry of contour, ability to

purse lips

The patient has pink, moist, smooth lips.

The patient has also the ability to purse

her lips.

NORMAL. The patie

Color and condition, pink, moist, firm, no

retraction and bleeding of gums

Pink, moist, no bleeding The pts teeth have no signs of bleeding. NORMAL. Has no b

CHEST:


Adventitious breath sounds, chest

expansion

Symmetrical expansion, no presence of

chest in drawing during breathing

The patient has wheezing breath

sounds.

ABNORMAL. Has a sig


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ABDOMEN


Abdomen integrity and condition Unblemished skin, uniform in color The pts skin is light brown in color

because abdomen is not exposing to

sun.

NORMAL. Pts skin

LOWER EXTREMITIES:


Condition of legs Uniformity in color and size. The pts lower extremities are aligned

and have uniform color.

NORMAL. The pts

uniform.


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DEVELOPMENTAL DATA

Erik Erikson believe that people continue to develop throughout life so he described 8 stages of development.

Eriksons theory proposes that life is a sequence of developmental stages of levels of achievement each stage signals a task that must be ac

The resolution of the task can be complete, partial or unsuccessful. Erikson believed that the more success an individual has at each developmenta

healthier the person is. Failure to complete any developmental stage influences the persons ability to progress to the next level. These developmentabe viewed as a series of crises. Successful resolution of these crises supports healthy ego development. Failures to resolve the crises damage the ego

I. PHYSICAL DEVELOPMENT

Baby X weighs 12 kg with a length of 62 cm. The rate of increase in height and weight is largely influenced by babys size at birth and by nutrition. Hi

normal function by moving eyes and follows large objects and blinks in response to bright lights. He has an intact hearing because he reacts with a stanoise called Moro reflex. He also understands many words like no, ma. His smell and taste are functional because he was able to recognize the s

mothers milk and he respond to the smell by turning his head toward to his mother. His sense of touch is well developed because of his response

reflexes are involuntary responses of nervous system to external and internal stimuli like rooting and sucking reflex. His motor development is also norm

he can reach and grasp object and transfer from hand to hand.

II. PSYCHOSOCIAL DEVELOPMENT

Baby X is still depends to his parents because he is 1 mos. Old that needs attention and care to fulfill his nutrition.


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III. COGNITIVE DEVELOPMENT

Baby X has a concept of both space and time like his experiment to reach a goal such as a toy in a chair.

IV. MORAL DEVELOPMENT

Baby X is an infant. He doesnt know how to feed and care himself thats why he needs his parents support and care.

VI. SPIRITUAL DEVELOPMENT As an infant, he has not fully developed his sense of spirituality


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PATTERNS OF FUNCTIONING

Eating Pattern

Before Illness During Illness During Hospitalization Analysis

Patient can consume:

Breakfast:

Breast Milk

Lunch:

300mL formula milk through bottle feeding.

Dinner:

Breast Milk

300mL formula milk through bottle feeding.

Patient can consume:

Breakfast:

2 cup of cereals

50mL of formula milk

through bottle feeding.

Lunch:

300mL formula milk through

bottle feeding.

Dinner:

Breast Milk


bottle feeding.

Breakfast:


bottle feeding.

Lunch:


bottle feeding.

Dinner:

200mL formula milk throughbottle feeding.

The patients food intake before

illness doesnt change bu

hospitalization, the diet for the pa

MF-SAP diet.


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Drinking Pattern


Total Intake:

600-800mL of milk per day and

100-150mL of water per day.

Intake:

700-950mL/day

Total Intake:

2-3 half of bottle of milk

and 1-2 half bottle of water

per day.

1-1 bottle of milk per day.

The intake of fluid before and during illness is still

while during hospitalization the fluid intake decrease

Bowel Movement Pattern


Frequency: 3 times a day.

Frequency: 2-3 times a day.

Frequency: 1-2 times a day.

The patients bowel movement is still

in before and during illness whil

hospital, the bowel movement decreas


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Bath Pattern


Takes a bath once a day in the morning.

Tepid Sponge Bath

Tepid Sponge Bath

The patients bathing

changed to TSB due

illness.

Sleeping Pattern


Usually sleeps 8 hours and 3-4 hours nap.

Usually sleeps 8 hours and

3-4 hours nap.

Sleep 5 hours and 1-2

hours nap.

The patients sleeping

during hospitalization de

because of the Nurs

interrupt the sleep in

meds and taking the vita


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LEVEL OF COMPETENCIES

Physical

Emotional

Social

Moral

BeforeIllness DuringHospitalization Analysis

-Baby weighs 7.8 kg or 17.16 lbs. witha length of 30 cm. The weight is

largely influenced by babys size at

birth and by his nutrition. His head

circumference is 37 cm. and chest

circumference is 35 cm. within the

normal range.

-He needs his parents to fulfill hisneeds because he cant manage his

own life as an infant.

-He expresses himself through cryingto know if hes hungry or any

irritations about his body and this is

the way to interact with his parents.

-As an infant, he doesnt know whatsgoing on in his world, thats why heneeds his parents to support and

guide him.

-His physical appearance is stillthe same.

-Cannot be determined

-The same in Before Illness, heexpresses himself through

crying.

-Cannot determine because of

his age.

-Within all normal

-He feels irritataking his vital why he will cry.

-Crying is the oused to intera

parents and othe

-Cannot determinof his age.


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Spiritual

-As an infant, he doesnt know abouthis spiritual level.

-Cannot determine because ofhis age.

-Cannot determinof his age.


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NursingHistory(Gordons Assessment)

Name: Baby X

Address: Marulas, Valenzuela City

Age: 18 mos.

Occupation: None

Religion: Roman Catholic

Race: Filipino

Medical Diagnosis: Bronchial Asthma

Informant: Mr. and Mrs. X

I. Patient perception and expectation related to illness/ hospitalization

1. Why did you come to the hospital?

Nahihirapanhumingaanakko

2. What do you think caused your baby to get sick?

Dahilsasobrangubo at sinisipon na din

3. Has being sick made any difference in your babys usual way of life?

Tinginko, hindi naman

4. What do you expect is going to happen to your baby in the hospital?


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Ineexpectko na magigingmaginhawa ang kalagayanng baby ko

5. What is like for being in the hospital?

Dahilayokonglumala pa ang sakitng baby ko.

6. How long do you expect to be in hospital?

Mga 3-4 dayssiguro

7. Who is the most important person for your baby?

Akonamanpalagikasama at nag aalagang baby ko, madalasniyaakohinahanap

8. What effect has your coming to the hospital had on your family?

Nag-alalasyempre

9. Are any of your family visit your baby in the hospital?

Oo.Tuladngkanyang mga lola at lolotsaka mga tito at tita

10. How do you expect to get along after you leave the hospital?

Sigurobabalik na ulitunglakasng baby ko


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ANATOMY AND PHYSIOLOGY OF THE LUNGS


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Anatomy and Physiology

About the Lungs and Respiratory System

Breathing is so vital to life that it happens automatically. Each day, you breathe about 20,000 times, and by the time you're 70 years old, you'll have taken

million breaths.

All of this breathing couldn't happen without the respiratory system, which includes the nose, throat, voice box, windpipe, and lungs.

At the top of the respiratory system, the nostrils (also called nares) act as the air intake, bringing air into the nose, where it's warmed and humidified. Tiny ha

protect the nasal passageways and other parts of the respiratory tract, filtering out dust and other particles that enter the nose through the breathed air.

Air can also be taken in through the mouth. These two openings of the airway (the nasal cavity and the mouth) meet at the pharynx, or throat, at the back of

mouth. The pharynx is part of the digestive system as well as the respiratory system because it carries both food and air. At the bottom of the pharynx,

divides in two, one for food (the esophagus, which leads to the stomach) and the other for air. The epiglottis, a small flap of tissue, covers the air-only passa

swallow, keeping food and liquid from going into the lungs.

The larynx, or voice box, is the uppermost part of the air-only pipe. This short tube contains a pair of vocal cords, which vibrate to make sounds.

The trachea, or windpipe, extends downward from the base of the larynx. It lies partly in the neck and partly in the chest cavity. The walls of the trachea are s

by stiff rings of cartilage to keep it open. The trachea is also lined with cilia, which sweep fluids and foreign particles out of the airway so that they stay out of

Trachea and Bronchi


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extent 'overbuilt' and have a tremendous reserve volume as compared to the oxygen exchange requirements when at rest. Such excess capacity is one of

that individuals can smoke for years without having a noticeable decrease in lung function while still or moving slowly; in situations like these only a small p

lungs are actually perfused with blood for gas exchange. As oxygen requirements increase due to exercise, a greater volume of the lungs is perfused, allow

to match its CO2/O2 exchange requirements. Additionally, due to the excess capacity, it is possible for humans to live with only one lung, with the other com

its loss.

The environment of the lung is very moist, which makes it hospitable for bacteria. Many respiratory illnesses are the result of bacterial or viralinfection

Inflammation of the lungs is known as pneumonia; inflammation of the pleura surrounding the lungs is known as pleurisy.

Vital capacity is the maximum volume of air that a person can exhale after maximum inhalation; it can be measured with a spirometer. In combinatio

physiological measurements, the vital capacity can help make a diagnosis of underlying lung disease.

The lung parenchyma is strictly used to refer solely to alveolar tissue with respiratory bronchioles, alveolar ducts and terminal bronchioles.[4]

However, it o

any form of lung tissue, also including bronchioles, bronchi, blood vessels and lung interstitium.

What the Lungs and Respiratory System Do

The air we breathe is made up of several gases. Oxygen is the most important for keeping us alive because body cells need it for energy and growth. Withou

body's cells would die.

Carbon dioxide is the waste gas produced when carbon is combined with oxygen as part of the energy-making processes of the body. The lungs and respir

allow oxygen in the air to be taken into the body, while also enabling the body to get rid of carbon dioxide in the air breathed out.


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PATHOPHYSIOLOGY of BRONCHIAL ASTHMA

Etiologic Factor Intense Exposure to irritatingstimuli (dust, pollutants)

Environmental factors (Changesin temperature) Exercise, stressful event

Family history of asthma

Predisposing Factor

Age (11mo)

Gender (male)

Family history ofasthma

IgE production

Airway hyper-responsiveness

(ASTHMA ATTACK)

Bronchospasm

Shortness of breathWheezing

Chest tightness

Re-exposure to antigen

Further release of leukocytes

Mass cell degranulation

Inflammation of bronchial

walls

Release of chemical

Altered air exchange

Inc. airway resistanceMuscle & fatigue

exhaustion

No. of mucus by goblet cells

in mucosa and hypertrophy of

submandibular glands

Productive cough


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Step 4 - Maintenance treatment with oral corticosteroids. This is given if adequate control is not achieved in step 3. Preparation with short prednisolone is preferred, esp. in alternate day regimen to minimise suppression of adrenal pituitary hypothalamic axis.

Step 5 - High dose of inhaled bronchodilators with nebuliser with special solution of salbutamol (5 mg) terbutaline (10 mg) 3-4 times/day. The usewithout proper evaluation is not advisable. Before considering giving nebuliser bronchodilator, increased bronchodilator, increasedbronchodilaunacceptable side effect should be demonstrated.

Step 6 - High dose of inhaled bronchodilators with nebuliser, steroids BDP or BUD should be increased to a maximum daily dose of 2 mg. A large vodevice is recommended to reduce oropharyngeal candidiasis and systemic absorption. Internationally this is advocated at step 3 but because of therapy it is not practical in India.

Step 5 and 6 should be considered depending upon patients economic background.

Step 7 - Treatment with short course of oral steroids : 1. Symptoms and PEFR gets progressively worse each day, 2. Sleep is disturbed by asthmasymptoms persist until midday, 4. Emergency nebuliser or injectable bronchodilators are needed. Give prednisolone 2 to 40 mg daily until two drecovery, when the drug may be stopped or the dose tapered.

Step down - The patients requirement for treatment should be reviewed from time to time. If asthma is well controlled, (asymptomatic, optimum PEFR

reduction in the medication must be planned. In chronic asthma a 6 month period of stability should be shown before stopping anti inflammatory drugs.

OTHER TREATMENT

Anti histaminics including ketotifen have proved disappointing in clinical practice. There is anecdotal evidence that some patients have benefitted froacupuncture, ayurvedic and homoeopathic treatment but so far there are no controlled clinical trials to justify the same. Hyponsensitization / desensitiznot accepted because of uncertainty about the result, cost and availability of better treatment.

5. Give sufficient doses to maintain best lung function

This is possible with regular monitoring of PEFR at home. If normal PEFR cant be achieved, the best PEFR readings can be maintained.

6. Investigate trigger factor


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This requires taking a careful history and performing skin test (pollens, fungi, animal dander, mite, dust, etc.) and in some cases provocationaoccupational ingested agents. Where it is practical, these trigger factors should be removed.

7. Treat aggravating conditions

Asthma is worsened by smoking, rhinitis, gastric reflux, and excessive snoring. Smoking should cease. The other conditions should be investigated and

8. Write a crisis plan

A patient has to be briefed about the symptoms of exacerbation and medicines to be taken in emergency. They should be taught diaphragmatic

minimise sense of breathlessness.

9. See the patient regularly

Regular visits are needed to monitor progress, reassure the patient, check inhaler technique, and adjust doses of bronchodilators. This will prevent eand hospitalization.

10. Minimise therapy


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NURSING CARE PLAN

ASSESSMENT

DIAGNOSIS

BACKGROUND

KNOWLEDGE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE:

Nahihirapanhuminga

ang baby ko as

verbalized by themother

OBJECTIVE:

Abnormal breath

sounds

V/S taken & recorded

as follows:

Temp: 37. 9C

CR: 106bpm

RR: 33cpm

Ineffective airway

clearance r/t

bronchospasm

Bronchial Asthma

bronchospasm

increased mucus

production

wheezing sounds

blocking of the

bronchioles

Ineffective airway

clearance

Within 30mins of

nursing

intervention the

patient will be able

to demonstratebehaviors to

improve airway

clearance

INDEPENDENT:

Monitored V/S

Monitor breath sounds

Suction naso/oral prn

Monitor patient forfeeding intolerance,

abdominal distention

and emotional stressor

Assist with the use of

respiratory devices or

treatments

Keep environmentallergen free

DEPENDENT:

Administer

medications as

prescribed

To obtain baseline

data

Indicative of

respiratory distressand/or

accumulation of

secretions

To clear airway

when excessive or

viscous secretion

are blocking airway

That maycompromise

airways

To clear the airway

To maintain

adequate, patent

airway

To mobilize

secretions

After 30mins of

nursing intervention

the patient was able

to demonstrate

behaviors to improveairway clearance


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NURSING CARE PLAN

ASSESSMENT

DIAGNOSIS

BACKGROUND

KNOWLEDGE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE:

Hindimasyadonagkikilos

anganakko as

verbalized by the

mother

OBJECTIVE:

The patient

manifested lowlevel of activity.

V/S taken and

recorded as follows:

Temp: 37. 9C

CR: 106bpm

RR: 33cpm

Risk for Activity

Intolerance r/t

presence ofcirculatory

responsive

problems

Upper respiratory tract

infection

bronchospasm

collection of mucus

secretion

Productive cough

Blocking of the bronchioles

DOB

Risk for Activity

Intolerance

After 8 hrs of


the patient will beable to participate

in program to

enhance clarity to

perform

INDEPENDENT:

Monitored V/S

Implement physical

therapy

Note presence of

medical diagnosis

or therapeutic

regimens.

Identify and discussto mother the

symptoms o the

illness.

Refer to appropriate

resources for

assistance or

equipments as

needed.

To obtain baseline

dataTo develop

alternative ways to

remain active.

To determine the

abilityto perform at

a desired level of

activity

To promotewellness.

To sustain activity

level

After 8 hrs of

nursing

intervention thepatient was able to

participate in

program to enhance

clarity to perform


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NURSING CARE PLAN

ASSESSMENT

DIAGNOSIS

BACKGROUND

KNOWLEDGE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE:

Nahihirapandumede

ang baby ko as

verbalized by themother

OBJECTIVE:

weakness

V/S taken and


Temp: 37. 9C

CR: 106bpm

RR: 33cpm

:

ImbalancedNutrition: les thanbody requirementsr/t inability to

ingest/digest food

Pneumonia

Bacteria in the lungs

Weakened immune system

nausea may

experience

inability to ingest/digest

food

Imbalanced nutrition

Within 3 hrs of


the patient will be

able to swallow

food

INDEPENDENT:

Determine patients

ability to chew,

swallow food

Note age, body build,

strength, rest level

Evaluate total daily

food intake

Promote pleasant &

relaxing environment

Monitor nutritional

All factors that can

affect ingestion

and/or digestion of

foodHelps determine

nutritional needs

Changes that could be

made in patients

intake

To enhance food

intake

To enhance food

satisfaction

After 3 hrs of

nursing

intervention the

patient was able to

swallow food


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NURSING CARE PLAN

ASSESSMENT

DIAGNOSIS

BACKGROUND

KNOWLEDGE

PLANNING

INTERVENTION

RATIONALE

EVALUATION

SUBJECTIVE:

May ubo ang baby

ko as verbalized by

the mother

OBJECTIVE:

Productive cough

to non-productive

cough

V/S taken and


Temp: 37. 9C

CR: 106bpm

RR: 33cpm

Ineffective airway

clearance r/t

cough

Upper respiratory tract

infection

Cough

Non productive cough

Productive cough

Accumulated secretion

Blocking of the bronchioles

Ineffective airway

clearance

Within 30 mins of


the patient will be

able to maintain

airway patency

INDEPENDENT:

Monitored V/S

Monitor patient on

small feedingPosition the patient

at Moderate high

back rest

Increase fluid intake

Assist with the use

of respiratory

devices or treatments

DEPENDENT:

Administer

medications as

prescribed

To obtain baseline

data

To maintain adequate

airwayTo maintain open

airway in at-rest

To liquefy viscous

secretion & improve

secretion clearance

To acquire/maintain

adequate airways

To improve lung

function

After 30 mins of

nursing

intervention the

patient was able

to maintainairway patency


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DISCHARGE PLAN

After patient has been hospitalized. He needs an attention and monitoring

AREA CONTENT

MEDICATION Give medication on scheduled time and when the symptooccurs.

EXERCISE

HYGIENE Maintain his cleanliness, must render TSB if the patient fee

irritable to improved his comfort.

TREATMENT Maintain his proper ventilation, must maintain clean surroundinsudden attacks ofhis condition about his illness

HEALTH TEACHING

OUT PATEINT The patient should have a monthly check-up for further mon

evaluatehis condition about his illness.

DIET Provide milk formula especially breast feed to improve gnutrition.

BIBLIOGRAPHY

Nurses Pocket Guide 11th Edition

Lippincotts Nursing Drug Guide 2010 Edition

Kozier and Erbs Fundamentals of nursing, 8th edition vol 1

http://kidshealth.org/parent/general/body_basics/lungs.html#

CALUMPIT FINAL

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