CAP Case Study

127
CASE PRESENTATION COMMUNITY ACQUIRED PNEUMONIA III February 19, 2010 GROUP 93 SUBMITTED TO: MR. OLIVER A.SANIDAD R.N.

Transcript of CAP Case Study

Page 1: CAP Case Study

CASE PRESENTATIO

NCOMMUNITY ACQUIRED

PNEUMONIA IIIFebruary 19, 2010

GROUP 93SUBMITTED TO: MR. OLIVER

A.SANIDAD R.N.

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• The Presentors

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Introduction• The pathogens that cause community-acquired

pneumonia (CAP) are predictable; copathogens are involved rarely, if ever. Extrapulmonary clinical features are helpful in distinguishing between typical and atypical causes of CAP. Various clinical findings can also point to specific diagnoses, such as Klebsiella pneumonia or Legionella infection. Severe CAP suggests the presence of underlying problems in the patient, such as cardiopulmonary dysfunction or impaired splenic functioning. Empiric therapy should cover typical and atypical pathogens. Oral antibiotics should be used for as much of the treatment course as is practicable.

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ObjectivesThis case study significantly identifies the factors that gave rise for our client to have the diagnosed problem. The ff. are the identified objectives for the case study

• To develop a comprehensive assessment of the client.• To establish a pathophysiology for the disease of the

client.• To develop a nursing care plan appropriate for the

client’s diagnosed problem.• To be able to teach the mother of the client for proper

health maintenance.• To lessen the risk of infection and development of

complications of the client.• To be able to provide an environment conducive for

health.• To enhance the care that will be given for other client’s

with the same diagnosis.

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BIOGRAPHIC DATAName: CLAddress: Age: Marital Status: Room and Bed number: Chief Complaint: Diagnosis: Community Acquired Pneumonia Gender: maleReligion: Birthday:

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NURSING HEALTH HISTORY

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PAST HEALTH HISTORY

AYR has Bronchial asthma in acute exacerbation. It was 2004 when he was first diagnosed with the supposed illness. His mother stated that he had complete immunizations. He does not have any allergies. When she was five years old, CL fell-off her bicycle.

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PAST HEALTH HISTORY

He had two hospital admissions prior to his recent condition. In 2005, he was first admitted to SCDMMC due to Pneumonia then he was hospitalized again last 2008 due to typhoid fever. He is currently taking Paracetamol for his fever. He does not take any vitamin supplements.

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HISTORY OF PRESENT ILLNESS

One day prior to her condition, CL experienced low-grade fever, productive cough with watery nasal discharge. Due to this instance, her mother brought her to SCDMMC and was then admitted with the diagnosis of Community-Acquired Pneumonia.

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FAMILY HISTORY

The client has familial history of hypertension and asthma. CL’s mother said that her mother-in-law has hypertension and her father-in-law has asthma.

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LL

(73 y/o)LL

(73 y/o)

JL

(73 y/o)JL

(73 y/o)

EL

(50 y/o)EL

(50 y/o)

CL

(50y/o)CL

(50y/o)

JFL

(23 y/o)JFL

(23 y/o)

CL

(8 y/o)CL

(8 y/o)

NL

(19 y/o)NL

(19 y/o)

LEGEND:

HYPERTENSION

ASTHMA

GENOGRAM

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Developmental History

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Emotional

Cognitive

LanguageSpiritual

Body concept

Moral

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• The child said that her problems would only include academic activities. She does not want to be sick and absent because she said she would miss school. She is active in school activities. She belongs to a class of excellent students. Her mother said that her teacher does not find any particular problem with her at all. Her greatest fear is the darkness. CL said that she would only cry when her brother teased her or when her parents scold her.

Emotional Health

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Social Health • She has a good relationship with her

family. She stated that she is bonded with her family members. She also has good relationship with her teachers, schoolmates and playmates. She allots time for self-enjoyment. Her hobby includes artworks. She loves to draw. She also verbalized that she is active in school. In fact, she joins athletic activities. Her favorite is obstacle race. When her father is available, they would often play badminton. Computer games serve as her bonding activity with her brothers. Walking around the school and eating are her friends’ past time. She has variety of toys to share with her playmates and cousins. She is always provided with time to play and mingle with them.

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Cognitive Patterns• The child said that she does well in school.

She excels in their academic subjects most especially in Mathematics. She had won in Quiz Bee last school’s fest with bronze medal. She belongs to a class of excellent students. She is proud of her achievements in school. She said that her parents are glad about it. She is always present in class. She would only be absent in times of sickness. She loves to do her homework and likes to recite during class discussions.

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Language• She has good language skills. She

speaks Filipino fluently and is able to understand English language. She attentively answered to the questions presented. She would set examples when asked to describe a situation. She had an explorative mind. She too listened carefully and was very eager to answer.

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Self-Concept• She has no physical defects. • She is an active girl, very attentive and

smart. The child verbalized, “Gusto ko maging doktor at saka teacher paglaki ko.”

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Religious Beliefs and Practices• The child belongs to Christian-

Pentecostal religion. Her mothersaid that CL also does the things that people usually do as Christians. Every Sunday they would go to their church and attend their mass. CL still believes in God Almighty. Her mother stated that they just don’t believe in spiritual images and does not worship saints.

SPIRITUAL HEALTH

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Moral Development

The child at her age has a good understanding about the concept of good and bad. She knows the simple bad deeds that she has to avoid. She said that she is being scolded by her parents when she had done bad things such as being naughty sometimes. She understands that her wrong deeds have corresponding punishments.

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ACTIVITIES OF DAILY LIVING

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Before hospitalization

Breakfast: cereal,milk

Lunch:Rice with fish and water

Dinner:Rice with fish and water

During hospitalization

Client has IV fluid attached. Breakfast: pansit, longganisa

and waterLunch:

Rice and vegetable(sitaw)

Interpretation and analysis

Hospitalization can contribute to

decreased food intake in children and adolescents

with cancer, making it a

challenge to meet their nutritional

needs

Nutrition

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Before hospitalization

During hospitalization

Dinner: Not

ApplicablePatient’s mother

states that client has decreased appetite.

Interpretation and analysis

(A Multidisciplinary Review of Nutrition Considerations in

the Pediatric Oncology

Population: A Perspective From

Children's Oncology Group

Nutr Clin Pract, August 1, 2005;

20(4): 377 – 393)

Nutrition

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Before hospitalization

During hospitalization Interpretation and analysis

Interpretation:The patient intake of food is different

when she was hospitalized. Her intake of food is

much better when she was not

hospitalized. The patient’s food intake is affected by hospitalization

Nutrition

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Before hospitalization

Usually urinates at least 4 times a

day; defecates

every morning

During hospitalization

Usually urinates at least 5 times a

day; defecates

a soft stool

Interpretation and analysis

Normal urine is a straw yellow color

and is clear and free of sediment or

mucous.The usual amount voided is 200-300

mL five to six times a day; or 1,000 to 1,

500 mLevery 24 hours;

Elimination

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Before hospitalization

During hospitalization

Interpretation and analysis

(http://missouricareereducation.org/CDs/CIHA/

CIHA_ch22.pdf)

Interpretation:

The patient have a normal

elimination.

Elimination

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Before hospitalization

Biking

During hospitalization

walk in the

ward

Interpretation and analysis

School age children need daily exercise.

Although they go to school all day,

they do not automatically receive much

exercise because school is basically

a sit-down activity.

(A. Pillitteri. Maternal and Child Health

Nursing Volum 2. P.923)

Exercise

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Before hospitalization During hospitalization Interpretation and analysis

Interpretation:

The patient doesn’t have

normal pattern of exercise.

Exercise

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Before hospitalization

Takes a bath daily

And brushes

her teeth 2x a day

During hospitalization

She is being

sponged-bath by

her mother.

Interpretation and analysis

By age 8, children are generally

capable of bathing themselves but

may not do it well because they are to

busy to take the time or because they do not find

bathing as important as their

parents do. (Maternal and Child

Health Nursing volume II by Adele

Pillitteri p. 923)

Hygiene

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Before hospitalization

During hospitalization

Interpretation and analysis

Interpretation:Due to the client’s condition he was

not able to do bathing.

Hygiene

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Before hospitalization

Sleeps at10 pm and wake up at 5:30am

and takes a nap when she reaches home after school

(during school days); she actually wakes up at 8am

and sleeps at 8:30 pm during weekends

During hospitalization

Usually sleeps 5 hours a day

Interpretation and analysis

It is because of the strange environment

and the anxieties associated with

illness and hospitalization. Environmental control, such as

reduction of noiseand

interruptions, and conservative

relaxation measures, such as a back rub

should be tried before resorting to a

hypnotic agent

Sleep and Rest

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Before hospitalization

During hospitalization

Interpretation and analysis

(http://www.nursingplan

et.com/pn/nursing_manage

ment_sleep_disorders.html#IV

HOSPITALACQUIRED

SLEEP DISTURBANCES)

Interpretation:The client was

not able to sleep well due to his

condition.

Sleep and Rest

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• Physical Assessment

NORMS(Based on Fundamentals of Nursing 8th Edition, by Kozier, et al., published by Pearson Education Inc., ©2008, pp. 572 – 641)

ACTUAL FINDINGSINTERPRETATION &

ANALYSIS

General Appearance

Posture/gait Relaxed, erect posture;Coordinated movement

Posture is slightly slouching

Physical difficulty can affect the posture and gait of a person. This may be accompanied by observable physical responses. (Medical-Surgical Nursing 8th Edition, by Black & Hawks, published by Saunders Inc., ©2009, p. 613)

Personal Hygiene/Grooming

Clean, neat The client appears neat, wearing clean clothes

Normal

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• Physical Assessment

Nutritional status

Optimal Height 127 cms  Range (108 - 142 cms)  Optimal Weight 26 kg Range (18 - 40 kg)(http://www.medindia.net/patients/calculators/ht_wt_chartResult.asp)

Height: 114.3 cmWeight: 24 kgBMI: 18.37

Normal

Verbal Behavior

Understandable, moderate pace, exhibits though association

The client is able to understand the instructions and questions asked

Normal

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• Physical AssessmentMeasurements: Axillary= 36.5°C - 37.5°C (Fundamentals of Nursing, Taylor, p526)

37.2°C Normal

80-120 beats/min (Medical-Surgical Nursing, 5th ed., p1814)

106 bpm Normal

20-25 cycles/min 28 cpm An increase in respiratory rate is a common manifestation experienced by clients with

pulmonary disorders. Also in the case, the client is experiencing difficulty

breathing because of the increased mucus production in her nasal area. (Medical-Surgical Nursing 8th Edition,

by Black & Hawks, published by Saunders Inc., ©2009, p.

1526)

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• Physical AssessmentBODY PARTS NORMS AND

STANDARDSACTUAL FINDING

ANALYSIS

INTEGUMENTARY

A. Skin

a. inspect for color and uniformity

Generally uniform except in areas exposed to the sun; areas lighter pigmentation (palm, lips, nail beds) in dark skinned people

The client’s skin looks pale. Darker areas are seen on skin folds like on the arm folds.

Normal

b .inspect for presence of edema

No edema No edema Normal

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• Physical Assessment

c. inspect for lesions according to location, distribution, color configuration, size, shape, type or structure

Freckles, birthmarks, flat and raised nevi: no abrasions or other lesions

The client has birthmark on the left upper arm, about 2 cm in size, circular in shape.

Normal

d. palpate skin moisture

Moisture in skin folds The client’s skin has moisture in skin folds.

Normal

e. palpate skin temperature

Uniform; with normal range

The client’s skin temperature is uniform

Normal

f. palpate for skin turgor

When pinched ,skin springs back to previous state

When pinched skin returns back to its previous state

Normal

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• Physical AssessmentB. NAILS

a. inspect fingernail plate shape to determine its curvature and angle

Convex curvature; angle of nail pate about 160°

Convex curvature; angle is 160°

Normal

b .inspect fingernail and toenail color

Highly vascular and pink in light-skinned clients; dark-skinned clients may have brown or black pigmentation in longitudinal streaks

The fingernail and toenail of the client is pink in color.

Normal

c. palpate fingernail and toenail texture

Smooth texture Smooth in texture Normal

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• Physical Assessment d. inspect tissue surrounding nail

Intact epidermis Intact epidermis Normal

e. perform blanch test capillary refill

Prompt return in pink or usual in less than 3 seconds.

delayed return of pink in 4 seconds.

Delayed return of pink or usual color. This may indicate

circulatory impairment in the

body. (Fundamentals of

Nursing 8th Edition, by Kozier, et al.,

published by Pearson Education Inc., ©2008, p. 584)

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• Physical AssessmentHEAD

A. SKULLSize, shape,SymmetryNodules, massesAnd depressions

rounded/normocephalic; smooth, uniform consistency; absence of nodules or masse

Rounded; smooth skull contour; symmetrical; Absence of nodules or masses; uniform consistency

Normal

B. SCALP -evenly distributed hair; whitish color; no dandruff; no tenderness, nodules, masses and edema

White scalp; no lice, nits and dandruff; no lumps, gently curved; no nodules, masses and edema.

Normal

C. HAIR -evenly distributed; thick hair; silky, resilient hair; no infection or infestation

The client’s hair is thick and evenly distributed.

Normal

D. FACE -Symmetric facial movements

Facial movements is symmetric

Normal

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• Physical Assessment

EYES

A. EYEBROWSDistribution, Alignment, skin Quality and movement

Hair evenly distributed, skin intact; eyebrows symmetrically aligned; equal movement

The eyebrows of the client are evenly distributed, symmetrically aligned, and equal in movement.

Normal

B. EYELASHESEvenness ofDistribution andDirection of curl

Equally distributed; curled slightly outward

The client’s eyelashes are equally distributed and curled upward

Normal

C. EYELIDSSurface characteristics position in relation to the cornea ability to blink; frequency of blinking

Skin intact, no discharge; no discoloration; lids close symmetrically

The client’s eyelids close symmetrically.

Normal

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• Physical AssessmentD. CONJUNCTIVABulbar conjunctiva:Color, texture, Presence of lesionsPalpebral conjunctiva:Color, texture, Lesions

Transparent; capillaries sometimes evident; Shiny, smooth, and pink or red

Transparent, evident capillaries, shiny, smooth and pink in color

Normal

E. SCLERAColor and clarity

Sclera appears White(yellowish in dark-skinned clients)

Clear and white in color with visible veins.

Normal

F. CORNEAClarity and texture

Transparent, smooth, shiny, details of iris are visible

Transparent, smooth texture and shiny

Normal

G. IRISShape and color

Color brown, flat and round Color brown and round in shape

Normal

H. PUPILSColor, shape,and size

Black in color equal in size, normally 3-7 mm in diameter, round, smooth borders

Pupils are equal; round and reacts to light accommodation, color black, 6 mm

Normal

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• Physical AssessmentI. VISUAL ACUITY Near visionDistance vision

Able to identify pictures;

Able to identify pictures

Normal

J. LIGHT REACTION AND ACCOMODATIONLight reaction andaccommodation

Pupil constrict when looking at near object; Illuminated pupil constrict andNon illuminated pupil dilates

The pupil constricts when light is pointed and dilates when light is removedThe pupil constrict when an object is placed near to it and the pupil dilate when the object is far from it.

Normal

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• Physical Assessment

K. LACRIMAL GLAND, LACRIMAL SAC, AND NASOLACRIMAL DUCT

No edema or tenderness over lacrimal gland, no edema or tearing

No edema or tenderness

Normal

L. EXTRAOCULAR MUSCLEAlignment;coordination

Both eyes coordinated, move with unison, with parallel alignment

With parallel alignment and coordinated visual field

Normal

M. VISUAL FIELDSPeripheral visualfields

When looking straight ahead, client can see objects in periphery.

Client can see objects in periphery

Normal

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• Physical AssessmentEARS

A. AuriclesColor, size, PositionTexture, elasticity,and tenderness

Symetrical; color same as the facial skin; pinna recoils after it is folded; mobile, firm and not tender.

Color same as facial skin; mobile, firm, recoils when it is folded

Normal

B. External Ear CanalsCerumen, skinLesions, pusAnd blood

Distal third contains hair follicles and glands, and tha external ear canals has cerumen.

The client’s external ear canal has no lesions, pus, and blood and has presence of cerumen.

Normal

C. Hearing In normal voice onesWatch tick test

Must be audibleThe client is able to hear the ticking in both ears

The client verbalized that she can hear clearly what the student nurse says.Able to hear ticking in both ears

NormalNormal

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• Physical Assessment

NOSE

Shapes, size, and color

The client’s nose is symmetric and straight. The color of the nose ranges from medium to light brown. Uniform to the color of the face.

Symmetric and straight. Light brown color of the nose, uniform to the face.

Normal

Nasal cavities:>Redness, swelling,Growths, and discharge

Mucosa is pink and no watery discharge and lesions

Discharges are seen.

Discharges from the nasal cavity are often

influenced by the increased secretion of mucus, and/or brought

about by allergic reaction.

(Fundamentals of Nursing 8th Edition, by

Kozier, et al., published by Pearson Education Inc., ©2008, p. 613)

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• Physical Assessment

Nasal septum Nasal septum is in the midline

Intact and in the midline

Normal

Nasal cavity patency

Air moves freely as the client breathes through the nares

The air moves freely on the left side, and obstructed on the right side.

Air movement is restricted in one nares

since the client has increased mucus

production. (Fundamentals of

Nursing 8th Edition, by Kozier, et al., published by Pearson Education Inc., ©2008, p. 613)

Tenderness, masses and displacement of bone and cartilage

No tenderness; no lesions No tenderness; no lesions

Normal

FACIAL SINUSESFrontalSupraorbital ridgesSphenoidmaxillary

No tenderness No tenderness Normal

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• Physical Assessment

MOUTH

A. LipsSymmetry of contour, color, texture

Uniform pink color; moist soft, glistening and elastic texture Lips should be pink, moist and smooth.

The client’s lip is pale in color, dry and chappy. It is symmetrical in contour. She has ability to purse lips and it has no lesions.

Deviation from normal because of dry, pale lips.This may indicate fluid intake deficiency. (Fundamentals of Nursing 8th Edition, by Kozier, et al., published by Pearson Education Inc., ©2008, p. 613)

B. Buccal MucosaColor, moisture, texture and lesions

Uniform pink color; Moist soft, glistening, elastic and no lesions

It is smooth, soft and elastic. It does not have lesions.

Normal

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• Physical Assessment

C. TeethColor,number,conditiona

20 teeth; smooth, white, shiny tooth enamel.The teeth should be regular and free of cavities or have dental restorations.

yellowish, shiny tooth enamel

with 6 broken upper teeth and 6 broken lower teeth

Dental caries is one of the problems that frequently affect the teeth. It is associated with plaque and tartar deposits. It is common to children since they like to eat sweets and hard to teach dental hygiene. (Fundamentals of Nursing 8th Edition, by Kozier, et al., published by Pearson Education Inc., ©2008, p. 601)

D. GumsColor, condition

Gums should be pink and smoothPink gums; firm texture; moist

Pale gums, dry when mouth breathing, the brain thinks carbon dioxide is being lost too quickly and sensing this, will stimulate the goblet cells to produce mucous, slow the breathing and cause constriction of

blood vessels.(http://www.breathing.com/

articles/nose-breathing.htm)

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• Physical AssessmentE. Tongue/ Floor of the MouthSurface of the tongueFor position ,color, texture and tongue movementNodules, lumps or enlarged lymph

The tongue relaxed on the floor of the mouthSmooth tongue base; prominent veins. Smooth moves freely; no tenderness.

Pink color of the tongue. Slightly rough. Semi moist, move freely, central position, smooth with no palpable nodules. Functions normally. No tenderness.

Dry/furry tongue may indicate or be

associated with fluid deficiency.

(Fundamentals of Nursing 8th Edition, by

Kozier, et al., published by Pearson Education Inc., ©2008, p. 603)

F. Palates & Uvula>Palate color, shape, texture and body prominence>Position of uvula and mobility

Light pink hard palate, more irregular texture The uvula is normally centered and freely movable.

Light pink, smooth (soft palate)Lighter pink, more irregular texture (hard palate)The uvula is at the center and freely movable.

Normal

G. Oropharynx & TonsilsColor, textureTonsils colorDischarge

Pink and smooth posterior wall Tonsils are small, pink and symmetric in size.

Tonsils are pink and symmetric in size, Grade 1 tonsils

Normal

H. Gag Reflex Present Present Normal

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• Physical AssessmentNECK AND LYMPH NODESA. LYMPH NODESLocate/palpate/ identify lymph nodes and note for tenderness

 Not palpable  Lightly enlarged submandibular lymph node   

Enlarged, palpable, possibly tender lymph

nodes are often associated with infection

and tumors(Fundamentals of Nursing 8th Edition, by Kozier, et

al., published by Pearson Education Inc., ©2008, p.

607)

B. TRACHEAInspect and palpate for placement

Central placement in midline of neck are equal on both sides 

Central placement in midline of neck are equal on both sides

Normal

C. THYROID GLANDInspect symmetry and visible masses

Not visible in inspection Not visible Normal

Palpate for smoothness and areas of enlargement, masses or nodules.

Lobes not palpable  The client has no palpable masses or nodules.

Normal

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• Physical Assessment

POSTERIOR THORAX

Inspect the spinal alignment

Spine vertically aligned Spine vertically aligned

Normal

Palpate for temperature, tenderness and masses

Skin intact; uniform temperature

Uniform temperature, skin intact, chest wall intake, (-) tenderness and masses

Normal

Auscultate the posterior thorax

Vesicular and bronchovesicular breath sounds

High-pitched breath sounds, Occasional crackles and wheezing

Adventitious breath sounds heard as a result of secretions,

narrowed air passages (Fundamentals of

Nursing 8th Edition, by Kozier, et al.,

published by Pearson Education Inc., ©2008,

p. 613)

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• Physical AssessmentANTERIOR THORAXThe breathing pattern is effortless respiration and quite rhythmic.

Difficulty of breathing Typical symptoms associated with pneumonia include

cough, chest pain, fever, and difficulty in breathing.

Diagnostic tools include x-rays and examination of the

sputum.(http://en.wikipedia.org/wiki/

Pneumonia)

Skin intact; uniform temperatureNo respiratory complaintsNo tenderness and no masses

Uniform temperature, skin intact, chest wall intake, (-) tenderness and masses

Normal

Bronchovesicular-moderate –intensity and moderate- pitched blowing Vesicular-soft intensity, low pitched, gentle sishing

High-pitched breath sounds, Occasional crackles and wheezing

Adventitious breath sounds heard as a result of

secretions, narrowed air passages (Fundamentals of

Nursing 8th Edition, by Kozier, et al., published by Pearson

Education Inc., ©2008, p. 613)

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• Physical AssessmentBREAST AND AXILLAEA. BreastSize, symmetry ,and shape

Rounded shape; slightly unequal in size; generally symmetricSkin uniform in color; skin smooth and intact

Flat, uniform in color, smooth and intact skin.

Normal

B. AreolaShape, color, masses or lesions

Round or oval and bilaterally the same; color varies widely from light pink to dark brown; irregular placement of sebaceous glands on the surface of the areolaNo tenderness, masses, nodules, or nipple discharge

Light pink, no tenderness, masses, nodules, or nipple discharge.

Normal

C. NipplesSize, shape, color, position, discharge , and lesions

Round, everted, and equal in size; similar in color; soft and smooth; both points in same directionNo tenderness, masses, nodules, or nipple discharge

Round, everted, equal in size, similar in color, both points in same direction

Normal

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• Physical AssessmentABDOMEN

InspectionAbdomen skin

Unblemished skin; uniform color; silver-white striae (stretch marks) or surgical scars

The client has unblemished skin; no striae or stretch marks

Normal

Abdominal contour and symmetry

Flat, rounded (convex), or scaphoid (concave)

Convex in shape Normal

Vascular patterns No visible vascular pattern No visible vascular pattern

Normal

Bowel sounds, vascular sounds, and peritoneal friction rubs

Audible bowel sounds, absence of arterial bruits, absence of friction rub

Audible bowel sounds, (-) arterial bruits and friction rub

Normal

Percussion each of the four quadrants

Tympany over the stomach and gas-filled bowels; dullness, especially over the liver and spleen, or a full bladder

Tympany and gas filled bowels; dull abdomen

Normal

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• Physical AssessmentMUSCULOSKELETALMuscles:>Size>Tendons for contractures>Fasciculation and tremors>Palpate muscle tonicity>Muscle Strength

Equal size on both sides of the body; no contractures; no fasciculation or tremors; normally firm; smooth coordinated movements; equal strength on each body side

Equal size on both sides of the body; no contractures or shortenings; no fasciculation or tremors; normally firm; equal leg strength,

Normal

Bones No deformities; no tenderness or swelling

No deformities; no edema or tenderness

Normal

Joints:>Joints for swelling>Palpation for tenderness

No swelling; no tenderness, swelling, crepitation, or nodules; joints move smoothly

No swelling; no tenderness and nodules

Normal

Range of motion Varies to some degree in accordance with person’s genetic makeup and degree of physical activity

The client’s right arm can not move well due to the IV site.

Limited range of motion in one or more joints.

(Fundamentals of Nursing 8th Edition, by

Kozier, et al., published by Pearson Education Inc., ©2008, p. 641)

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Entire Laboratory and Diagnostic ResultsGENERIC NAME DOSAGE/

FREQUENCY

CLASSIFICATION

INDICATION CONTRAINDICATION SIDE EFFECTS NURSING RESPONSIBILITIES

1. ACETYLCYSTEINE (Fluimucil)

300 MG(NEB) OD

Mucolytic Agent

Treatment of respiratory infection characterized by thick and viscous hyper secretions: Acute Bronchitis, Chronic Bronchitis and its exacerbation, Pulmonary emphysema and bronchiectasis 

MAO inhibitor therapy within 14 days initiating therapy; severe HPN; severe CAD; hypersensitivity to Pseudoedephrine, acrivastine or any component; renal impairment

Bronchospasm, angioedema, pruritus, nausea and vomiting, syncope, sweating, fever, arthralgia, blurred vision, disturbances of liver function

1. Monitor effectiveness of therapy and advent of allergic/adverse effect.2. Instruct client in appropriate use and adverse effect to report.

2. IPRATROPIUM SALBUTAMOL (Duavent)

(Neb) TID Antiasthmatic and COPD preparation

prevent wheezing, difficulty breathing, chest tightness, and coughing in people with chronic obstructive pulmonary disease (COPD

Hypersensitivity to so lecithin and other related products like soybean and peanuts, and to any component of Duavent, atropine and its derivatives, Hypertophic obstructive cardiomyopathy or tachyarrhythmia

Headache, dizziness, cough, sinusitis, dry cough, dyspnea, bronchitis, dry mouth, rash, pain, hypersensitivity reaction

Teach the client about the medication; Assess for allergy before administration and at the peak of administration; Check or evaluate the client after giving the medication.

3. Paracetamol 325 mg Tab q4

Non-opiod analgesic

Acute pain treatment There are no absolute contraindications but in patient with gastric ulceration relative caution should be observed.

Occasional GI side effect may occur but these are almost invariably mild.

Monitor SBS of hepatomegaly esp. in individuals with poor nutrition; Don’t take other medications containing acetaminophen without medical advice; Patient and family education

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MEDICATION, IV INFUSION, BLOOD

TRANSFUSION, TREATMENT GIVEN

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DOSAGE/ FREQUENCY

300 MG(NEB)

OD

CLASSIFICATION

Mucolytic Agent

INDICATION

ACETYLCYSTEINE (Fluimucil)

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CONTRAINDICATION

MAO inhibitor therapy within 14

days initiating therapy; severe HPN;

severe CAD; hypersensitivity to Pseudoedephrine, acrivastine or any component; renal

impairment

SIDE EFFECTS

Bronchospasm, angioedema,

pruritus, nausea and vomiting, syncope,

sweating, fever, arthralgia, blurred

vision, disturbances of liver function

NURSING RESPONSIBILITY

1. Monitor effectiveness of

therapy and advent of allergic/adverse

effect.2. Instruct client in appropriate use and

adverse effect to report.

ACETYLCYSTEINE (Fluimucil)

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DOSAGE/ FREQUENCY

(Neb) TID

CLASSIFICATION

Antiasthmatic and COPD preparation

INDICATION

prevent wheezing, difficulty breathing, chest tightness, and coughing in people

with chronic obstructive

pulmonary disease (COPD)

IPRATROPIUM SALBUTAMOL (Duavent)

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CONTRAINDICATION

Hypersensitivity to so lecithin and other

related products like soybean and

peanuts, and to any component of

Duavent, atropine and its derivatives,

Hypertophic obstructive

cardiomyopathy or tachyarrhythmia

SIDE EFFECTS

Headache, dizziness, cough, sinusitis, dry

cough, dyspnea, bronchitis, dry

mouth, rash, pain, hypersensitivity

reaction

NURSING RESPONSIBILITY

Teach the client about the

medication; Assess for allergy before

administration and at the peak of

administration; Check or evaluate

the client after giving the medication.

IPRATROPIUM SALBUTAMOL (Duavent)

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DOSAGE/ FREQUENCY

325 mg Tab q4

CLASSIFICATION INDICATION

Acute pain treatment

Paracetamol

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CONTRAINDICATION

There are no absolute

contraindications but in patient with

gastric ulceration relative caution

should be observed.

SIDE EFFECTS

Occasional GI side effect may occur but

these are almost invariably mild.

NURSING RESPONSIBILITY

Paracetamol

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Treatment/ Infusion

Nebulization

CLASSIFICATION

Bronchodilator

INDICATION

AcuTo administer beta-adrenergics

(albuterol, isoproterenol, isoetharine, levalbuteral,

metaproterenol), anticholinergics (ipratropium), corticosteroids

(budesonide), and cromolyn for the management of

obstructive pulmonary diseases (chronic bronchitis,

emphysema, asthma, etc.).te pain treatment

Nebulization

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Contraindication

Contraindicated in those patients who have shown hypersensitivity

to cromolyn sodium.

NURSING RESPONSIBILITY

Monitor SBS of hepatomegaly esp. in individuals with poor nutrition; Don’t take other

medications containing acetaminophen without medical

advice; Patient and family education

Paracetamol

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ANATOMY AND PHYSIOLOGY

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• Upper Respiratory Tract• Nose Inspiration and expiration usually

occurs through the nose. The nose has main two functions: The cilia and hairs which line the nasal cavities trap dust and other foreign particles and the rich supply of blood surrounding the cavities warms the air before it enters the lungs. Pharynx Allows for separation of food and air. The epiglottis closes the trachea when we eat and opens when we breathe.

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• Lower Respiratory Tract Larynx This structure sits on top of the trachea. Air rushing across two ligaments causes sounds that we shape into speech. Also called the voice box. Trachea Also called the windpipe

• Bronchi The trachea branches into two forks each called a bronchi Bronchioles The smaller and smaller passageways that come off the bronchi

• Alveoli These are the small air sacs where actual gas exchange takes place. The respiratory system's function is to allow gas exchange through all parts of the body. The space between the alveoli and the capillaries, the anatomy or structure of the exchange system, and the precise physiological uses of the exchanged gases vary depending on organism. Molecules of oxygen and carbon dioxide are passively exchanged, by diffusion, between the gaseous external environment and the blood. This exchange process occurs in the alveolar region of the lungs.

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• Respiratory System is made up of different organs that work together in the process of respiration.

• All parts of the Respiratory system helps in the process of respiration

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• Main Parts of the Respiratory System• Nose• Trachea• Bronchial Tubes• Lungs• • Other Parts:• Pharynx• Larynx• Alveoli

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• The Nose• The nose has two openings called nostrils. The air enters the

nasal passages through the nostrils. The air that you breathe may not be fit to enter the lungs. It must be cleaned, warmed, and moistened before it reaches the lungs. The hairs in your nostrils filter the larger particles of dust and dirt as air enters the nostrils. The nasal passages are lined with tiny hairs called cilia and a moist tissue lining called mucous membrane.

• • The cilia filter the smaller particles of dust and dirt. • The moist mucous membrane also catches particles of dirt. It

also warms and moistens the incoming air. • The tiny blood vessel inside the nose also warm and moisten

the passing air.

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• The Pharynx • The clean, warm, and moist air travels from the

nasal passages to the pharynx. The pharynx is found at the back of the throat.

• The pharynx separates into two tubes:• Esophagus – leading to the stomach.• Trachea – leading to the lungs. • At the bottom of the pharynx is a flap of cartilage

called the epiglottis. • The epiglottis opens and closes the trachea. It

prevents the food from going to the trachea by closing it during swallowing. Most of the time, the epiglottis is open to allow the flow of air in the breathing process.

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• The Larynx • From the pharynx, the clean air moves

down to the larynx. The Larynx is found at the lower end of the pharynx. It is the enlarged upper portion of the trachea. It is also called the voice box. The larynx contains the vocal cords that vibrate when air passes through them. The vibration of the vocal cords, together with the movements of the mouth and tongue, produces the sound of your voice.

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• The Trachea or Windpipe• The trachea, or windpipe, is a tube about 13 centimeters

long. It is the tube leading to the lungs. It is a tough, flexible passageway that air can move through all the time. The trachea lies just in front of the esophagus at the lower part of the larynx.

• Like the nasal passages, the inner wall of the trachea is lined with cilia. The cilia catch the dust particles that reach the windpipe. The dust particles are then pushed out and up toward the throat and mouth for expulsion. This explains why one coughs or sneezes when dirt gets into the upper respiratory tract. The lower end of the trachea branches into two large tubes called the bronchi.

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• The Lungs • The Lungs are the main organs for breathing. The left

bronchus leads to the left lung while the right bronchus leads to the right lung.

• Inside the lungs, each bronchus divides into smaller tubes called bronchial rami. The bronchial rami branches off further into smaller tubes called bronchial tubes or bronchioles. At the ends of these bronchioles are the tiny air sacs called alveoli.

• The bronchioles and alveoli look like the branches of a tree. The biggest branches are the bronchi. Bronchi are covered by cilia and a thin film of mucus. Dust and pollen are trapped by the mucus before they reach the alveoli.

• Each of the lungs contains about 300 million alveoli. Each alveolus is surrounded by tiny blood vessels called capillaries. The exchange of oxygen and carbon dioxide during the breathing process takes place in the capillaries of each alveolus.

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• The Respiratory Process• Breathing is the process by which air is taken into the lungs and carbon

dioxide is pushed out of the lungs.• Breathing involves two parts. Breathing in is called inhaling, and

breathing out is called exhaling or expiration. When you inhale, you fill your lungs with air. When you exhale, you push air with more carbon dioxide out of the lungs.

• The lungs, being important and delicate organs, are protected by a set of bones called the rib cage. The rib cage forms the chest cavity where the lungs are found. At the lower portion of the chest cavity is a sheet of muscles called diaphragm. The diaphragm separates the chest from the abdomen. Both the rib cage and the diaphragm are important in the breathing process.

• When you inhale, the ribs move upward and outward while the diaphragm moves downward. The volume of the chest cavity becomes larger. The pressure inside it is lower that the air pressure outside the body. Air is drawn into the lungs by the atmospheric pressure outside the body.

• When you exhale, the opposite happens. The ribs move downward and inward while the diaphragm moves upward. These actions make the chest cavity smaller. The pressure in the chest cavity becomes greater than the air outside the body. This cause the air to rush out of the lungs and out of the body.

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PATHOPHYSIOLOGY

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Streptococcus Pneumoniae

Inspiration of S. Pneumoniae

Reach the lungs through circulation

Invading organisms multiplies and release damage toxins Normal Pulmonary defense

inflammation

edema of lung parenchyma

accumulation of cellular debris and exudates

lung tissue fills with exudates and fluids, changes from airless to consolidated

(Cough reflex, transport and pulmonary macrophages)

fever

chills

cough

Normal dyspnea defense

wheezes

pleuritic pain

Precipitating factors:Inhalation of Streptococcal Pneumoniae

Predisposing Factor:Exposure to a carrier

High risk community

History of respiratory illness(Asthma)

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NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Evaluation

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Assessment(Subjective)

The patient states “Nahihirapan po akong huminga dahil sa mga nakabara sa

lalamunan.”

Cl also verbalized “Andami ko pong nilalabas na plema.”

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Assessment(Objective)

wheezes auscultated at right and left lower lung lobes increased WBC count Posture is slightly slouching

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Assessment(Objective)

Frequent expectorations Thick Mucous, Yellow Sputum Disharged Dyspnea

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Assessment(Objective)

delayed capillary return of pink in 4 seconds High-pitched breath sounds, Occasional crackles and wheezing

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Diagnosis

• Ineffective Airway Clearance related to increased production of secretions as manifested by

productive cough

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Analysis

•Clearance of secretions is a common problem in patients who experience acute respiratory tract infections. Although the offending agent is a major factor, the degree of severity of ineffective airway clearance depends on many other factors: pulmonary host defenses, presence of underlying pulmonary disease, age, lifestyle habits, environments, airway clearance self-management skills, and time of specific treatment. In the client’s case the major factor that contributed is having a bronchial asthma.

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Goals and Objectives

•Within 1 hour of nursing intervention the patient will exhibit normal and effective

airway clearance

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Intervention(Supplemental)•Assess client’s description of pain. Acknowledge the pain experience and convey acceptance of client’s response.

Rationale•Pain is a subjective experience and cannot be felt by others.

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Intervention(Supplemental)

•Establish rapport with the client

Rationale•To promote client’s cooperation

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Intervention(Supplemental)

•Auscultate wheezing and crackles

Rationale•Some degree of bronchospasm is present with obstructions in airway and may/may not be manifested in adventitious breath sounds, e.g., scattered, moist crackles (bronchitis); faint sounds, with expiratory wheezes (emphysema); or absent breath sounds (severe asthma).

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Intervention(Supplemental)•Assess respiratory rate.

Rationale•Respirations may be shallow and rapid, with prolonged expiration in comparison to inspiration.

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Intervention(Supplemental)•Maintained an open airway.

Rationale•Provides for adequate ventilation and gas exchange

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Intervention(Supplemental)

•Assist patient to elevate head of bed

Rationale•Elevation of the bed faciliates respiratory function by use of gravity

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Intervention(Supplemental)•Keep environmental pollution to a minimum

Rationale•Precipitator type of allergy reactions can trigger onset of acute episodes

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Intervention(Supplemental)•Encourage with cough exercise and pursed lip breathing.

Rationale•Provides patient with some means to cope with/control dyspnea and reduce air-trapping.

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Intervention(Supplemental)•Increase fluid intake to 2000 mL/day. Provide warm/tepid liquids.Use warm liquids.

Rationale•Hydration helps decrease the viscosity of secretions, facilitating expectoration. Using warm liquids may decrease bronchospasm. Fluids during meals can increase gastric distension and pressure on the diaphragm

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Intervention(Supplemental)•Determined changes in breath sounds through auscultation.

Rationale

•Indication for effectiveness of intervention

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Intervention(Facilitative)

•Administer medications as ordered: mucolytics-acetylcysteine, expectorant-ipratropium bromide

Rationale•Bronchodilators aidin reduction of bronchospasm.Mucolytics and expectorants mobilize secretions.

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Intervention(Facilitative)

•Administered humidification & nebulizer therapy as prescribed.

Rationale•Secretions must be moistened and thinned if they are to be raised from the chest with the least amount of effort.

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Intervention(Developmental)•Use play toencourage child to cough and deep breathe; involve parents in said activities

Rationale•Play enhances participation. Coughing and deep breathing promotes maximum ventilation.

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Intervention(Developmental)•Provide parents and patient with health teachings on proper handwashing techniques and covering of mouth and nose when coughing or blowing nose

Rationale•Involving parent promotes active participation. The patient and parents should be taught the basics of infection control to prevent transmissionof microorganisms.

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Evaluation

•After 1 hour of Nursing intervention, the client will

exhibit increased effectiveness of airway

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Assessment(Subjective)

The patient verbalized “Medyo masakit po ang dibdib ko tuwing umuubo.” The client’s mother said that “Madalas

syang umubo at maglabas ng plema.”

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Assessment(Objective)

Frequent expectorations Yellow Sputum Disharged Dyspnea

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Assessment(Objective)

productive coughwith thick purulent

sputum

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Assessment(Objective)

increased WBC count Pain Scale of 7/10

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Diagnosis

•Acute pain related to Coughing as verbalized by the patient

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Analysis

• Acute pain is described as an unpleasant sensory or emotional experience associated with actual or potential tissue damage or injury as lasting from seconds to 6 months. In cases of fracture, pain is continuous & increasing in severity but will subside significantly on the 5th to 7th day. Pain may be attributed to the increase of pressure caused by the increase production of exudates thus causing pain radiating over the site.

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Goals and Objectives

•After 8 hours of duty and nursing care interventions the patient will be able to have a decreased sensation of pain

every time she coughs

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Intervention(Supplemental)

•Establish Rapport with the client

Rationale•Enable client’s cooperation

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Intervention(Supplemental)

•Assess vital signs

Rationale•changes in vital signs may indicate acute pain or discomfort

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Intervention(Supplemental)•Repositioned patient as indicated

Rationale•may relieve pain and enhances circulation; prevents development of pressure sores

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Intervention(Supplemental)•Provided additional comfort measures like backrub, heat/cold application

Rationale•improves circulation, reduces muscle tension and anxiety associated with pain. enhances well-being

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Intervention(Supplemental)•Encourage use of relaxation techniques such as deep breathing exercises, diaphragmatic and pursed lip breathing

Rationale•relieves muscle and emotional tension

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Intervention(Supplemental)

•Encouraged increase intake of fluids

Rationale•helps mobilize secretions, promotes hydration

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Intervention(Supplemental)•Keep environmental pollution to a minimum

Rationale•Precipitator type of allergy reactions can trigger onset of acute episodes

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Intervention(Supplemental)

•Positioned patient to semi-Fowler

Rationale•promotes lung expansion, helps mobilize secretions and minimizes pressure on chest-bronchodilator; relaxes bronchial, uterine, an vascular smooth muscles by stimulating beta 2 receptors

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Intervention(Facilitative)

•Administered medications as indicated(ParacetamolJr.)

Rationale•bronchodilator; relaxes bronchial, uterine, an vascular smooth muscles by stimulating beta 2 receptors

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Evaluation

•Patient still has pain during coughing but is now improved in

quality.

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DISCHARGE PLAN

MEDICATIONS

EXERCISE

TREATMENTS

HEALTH T. OPD DIET SEX

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EDICATIONS• Advise client to take medicine as prescribed by

the Physician. The following are the medications prescribed: Acetylcysteine to liquefy secretions, Ipratroprium salbutamol for bronchodilation and Paracetamol Jr. to lower body temperature. Medicines used to treat pneumonia may include antibiotics to make the infection be cured

M

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XERCISE• Take adequate rest. If tolerated, do light

exercises such as walking. And also do deep breathing and coughing.

E

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REATMENT• Medications should be taken exactly as

prescribed by a physician. If it is not helping, call the doctor. Do not quit taking it unless told to do so by a doctor. Nebulization as ordered by the doctor. Increase fluid intake to 2,500 to 3000ml per day to help liquefy secretions incentive

T

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EALTH TEACHING• Comply with the treatment regimen: place the

client in a comfortable position. And ask the mother to take care and give time to the child to take good care for herself. Encourage deep breathing and cough exercises.

H

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UTPATIENT DEPARTMENT

• Comply to the scheduled follow up check up

O

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IET• Eat healthy and nutritious food. Eat fruits rich in

vitamin C or take vitamin c to increase the resistance of the client against infection. Increase fluid intake if not contraindicated to the patient.

D

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Congrats93!