SRN Noorhazamin HamidNursing Education Services

Define upper respiratory tract infection.

Identify the pathophysiology of URTI.

State the sign & symptom of URTI.

Identify the risk factors of URTI.

Identify the complication of URTI.

Identify the nursing intervention & appreciate the nursing care for URTI patient.

Mr LMale26 years oldTechnicianMalay

Doctor = Dato’ I

Diagnosis = URTI (upper respiratory tract infection)

= Influenza B

Medical history - NilFamily history - NilSurgical history - NilAllergic - Nil

Smoking – 12 sticks / day

All normal

Temp = 38.5˚CPulse = 72 bpmResp = 22 bpmB/P = 130/80 mmHgWeight = 99 kg

Mr L was admitted to 4XX-1 with complaint of :

FeverCough 2/57RhinorrhoeaMuscle & joint pain

Dext saline slow dripMed profile, ASOT, dengue serology

CXR , CT SinusNasal swab for flu A & BSputum AFB & C&S

Inflammation of the upper respiratory tract cause by viral or bacterial infection.

Infectious disease cause by RNA viruses (Orthomyxoviridae) and mutates 2-3 times slower than type A.

High feverCoughRhinorrheaMuscle & joint painRigorSore throatHeadacheFatigue

SmokingOld age & childrenLow immune systemPoor hygiene habitClose contact with sick people

Pregnant

PneumoniaSinusitisEar infectionMeningitis

White blood cell count- 10.7 (4.3 – 10.5 10³/UL)

Monocyte- 11.7% (1-11%)

Sodium- 134 mmol/L (135 – 155)

Bacteria- Occasional (Nil)

CXR - Normal

CT SINUS -Pansinusitis

AFB - Not seen

C&S - No growth seen

Influenza A antigen-Not detected

Influenza B antigen- Detected

Group : Anti inflammatory, analgesic, antirheumatic

I : Reduce pain & fever

Group : Corticosteroid hormones

I : Anti inflammatory, anti-allergic & antitoxic

Group : PenicillinI : Antibiotic

Group : Anti viralI : Halt the spread of virus in body, reduce symptom & complication

Group : Cough & cold remedies

I : Relief of congestion & dry irritating cough e.g. those associated with common cold, upper resp tract infection & allergic rhinitis

1. Alteration in body T˚: hyperthermia related to infection

2. Alteration in breathing pattern related to cough.

3. Fluid & electrolyte imbalance related to decrease fluid intake & diaphoresis.

4. Alteration in nutritional status related to loss of appetite.

Goal : Patient’s body temperature will reduce to normal range after 4 hours nursing intervention given & during hospitalization.

Supporting data :Non verbal : T˚ = 38.5˚C, shivering, skin is warm to touch & having flushing face.

Verbal : C/O chills & rigor.

1. Assess pt gen condition e.g. appearance & complaint.

R – As a baseline data for further action.

2. Monitor pt’s T˚ every 4 hourly.R – To detect any elevation in body T˚.

3. Do tepid sponge if T˚ >38.5˚CR – To promote heat loss via diaphoresis.

4. Provide condusive environment e.g. switch on aircond and good ventilation.

R – To promote heat loss from body.

5. Encourage pt to drink > 2L of water per day.

R – To replace fluid loss.

6. Advise pt to wear thin cloth.R – To prevent heat accummulation.

7. Administer IVD as ordered by doctor.

R – To replace body fluid loss.

8. Monitor IX as ordered e.g. med profile, dengue serology, sputum AFB etc.

R – To rule out source of infection.

9. Administer medication e.g Voren Supp 50mg STAT/PRN as ordered by doctor.

R – To help reduce the T˚.

10. Inform doctor if condition deteriorating or not improving.

R – For review of changing of treatment.

Goal : Patient’s breathing pattern will be maintain at normal respiration rate after 4 hours nursing intervention given and during hospitalization.

Supporting dataNon-verbal : Resp rate = 22 bpm, irregular pattern & coughing.

Verbal : C/O difficulty to breathe .

1. Assess pt gen condition e.g. resp rate, breathing pattern & complaint.

R – As a baseline data for further management.

2. Monitor resp rate & pattern every 4 hourly.

R – To detect any abnormalities.

3. Positon patient in semi Fowlers or Fowlers.

R – To promote lung expansion.

4. Teach patient DBE and effective cough technique.

R – To promote effective breathing.

5. Advise patient to rest in bed and minimize activities.

R – To prevent more oxygen consumption.

6. Carry out IX as ordered e.g. CXR, CT sinus & sputum.

R – To rule out cause of infection.

7. Administer medication as ordered e.g. Sedelix 10ml TDS.

R – To help reduce cough.

8. Inform doctor if condition deteriorate or got any abnormalities.

R – For review of treatment & changes.