I

C. INTRODUCTIONUpper respiratory tract infection (URI) is a nonspecific term used to describe acute infections involving the nose, paranasal sinuses, pharynx, larynx, trachea, and bronchi. The prototype is the illness known as the common cold, which will be discussed here, in addition to pharyngitis, sinusitis, and tracheobronchitis. Influenza is a systemic illness that involves the upper respiratory tract and should be differentiated from other URIs.

Viruses cause most URIs, with rhinovirus, parainfluenza virus, coronavirus, adenovirus, respiratory syncytial virus, coxsackievirus, and influenza virus accounting for most cases. Human metapneumovirus is a newly discovered agent causing URIs. Group A beta-hemolytic streptococci (GABHS) cause 5% to 10% of cases of pharyngitis in adults. Other less common causes of bacterial pharyngitis include group C beta-hemolytic streptococci, Corynebacterium diphtheriae, Neisseria gonorrhoeae, Arcanobacterium haemolyticum, Chlamydia pneumoniae, Mycoplasma pneumoniae, and herpes simplex virus. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common organisms that cause the bacterial superinfection of viral acute sinusitis. Less than 10% of cases of acute tracheobronchitis are caused by Bordetella pertussis, B. parapertussis, M. pneumoniae, or C. pneumoniae. Most URIs occurs more frequently during the cold winter months, because of overcrowding. Adults develop an average of two to four colds annually. Antigenic variation of hundreds of respiratory viruses results in repeated circulation in the community. A coryza syndrome is by far the most common cause of physician visits in the United States. Acute pharyngitis accounts for 1% to 2% of all visits to outpatient and emergency departments, resulting in 7 million annual visits by adults alone. Acute bacterial sinusitis develops in 0.5% to 2% of cases of viral URIs. Approximately 20 million cases of acute sinusitis occur annually in the United States. About 12 million individuals are diagnosed with acute tracheobronchitis annually, accounting for one third of patients presenting with acute cough. The estimated economic impact of noninfluenza-related URIs is $40 billion annually. Influenza epidemics occur every year between November and March in the Northern Hemisphere. Approximately two thirds of those infected with influenza virus exhibit clinical illness, 25 million seek health care, 100,000 to 200,000 require hospitalization, and 40,000 to 60,000 die each year as a result of related complications. The average cost of each influenza epidemic is $12 million, including the direct cost of medical care and indirect cost resulting from lost work days. Pandemics in the 20th century claimed the lives of more than 21 million people. A widespread H5N1 pandemic in birds is ongoing, with threats of a human pandemic. It is projected that such a pandemic would cost the United States $70 to $160 billion.

The reason why i chose this patient was that her case was the most interesting among all the patients in the ward. There were a lot of problems that I could identify that caught my interest and where we can give a lot of health teachings and interventions to our client. In short, her case fits best in the criteria for choosing a case study because her diagnosis was something a common one. I also want to go deeper with this kind of case and learn more from it.

D. Definition of diagnosisUpper respiratory tract infection (URI) is a nonspecific term used to describe acute infections involving the nose, paranasal sinuses, pharynx, larynx, trachea, and bronchi. The prototype is the illness known as the common cold, which is discussed here, in addition to pharyngitis, sinusitis, and tracheobronchitis. Influenza is a systemic illness that involves the upper respiratory tract and should be differentiated from other URIs.

Viruses cause most URIs, with rhinovirus, parainfluenza virus, coronavirus, adenovirus, respiratory syncytial virus, Coxsackie virus, human metapneumovirus, and influenza virus accounting for most cases. Group A beta-hemolytic streptococci (GABHS) cause 5% to 10% of cases of pharyngitis in adults. Other less common causes of bacterial pharyngitis include group C beta-hemolytic streptococci, Corynebacterium diphtheriae, Neisseria gonorrhoeae, Arcanobacterium haemolyticum, Chlamydophila (formerly Chlamydia) pneumoniae, Mycoplasma pneumoniae, and herpes simplex virus. Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis are the most common organisms that cause the bacterial superinfection of viral acute rhinosinusitis. Less than 10% of cases of acute tracheobronchitis are caused by Bordetella pertussis, B. parapertussis, M. pneumoniae, or C. pneumoniae.Scope and Limitation

The case study merely covers data that have been gathered through interview per assessment tool and chart referral on the day of the assessment phase in loading assigned patients and in the succeeding days of the rotation, in the care formulated and intervened to its progress as the weeks rotation ended. Thus, it is limited to the days in the rotation the student nurse interacted with the client in the hope to gather the necessary data to support the presentation which is not enough to acquire a bulk of specific details.

E. Patients ProfileI. HEALTH HISTORY

Patients Profile

Clients Name:

Mr. XAge:

15 years old

Birthday:

12/15/1999Address:

Mangga st., Juna Subd., Davao CityCivil Status:

Single

Sex:

Male

Nationality:

Filipino

Religion:

Roman Catholic

Height:

167 cm (52)

Weight:

78 kg

Admitting Physician:

Dr. Romulo T. Uy, M.DDate of Admission:

July 06, 2015Time of Admission:

1:21 PMChief Complaint:

Fever and cough

Admitting Diagnosis:

URTI (Upper Respiratory Tract Infection)A. Past Health HistoryPrior to the admission, the patient had 1 previous admission. The patient was admitted 10 years ago due to Amoebiasis.

B. Present Health HistoryThe patient was a non-alcoholic. His diet consist of foods rich in vegetables and fruits because he loves to eat those. He seldom consumed foods rich in fats, but he was a frequent consumer of softdrinks. He doesnt exercise since he had been very busy with school and some household chores. He always slept late at night and woke up early often.

C. Family HistoryThe patients father was diagnosed with Renal Failure, and he also had High blood pressure. While the patients mother was diagnosed with type 2 Diabetes. No other trace of underlying condition was reported by the patient.

Chief Complaint and History of present Illness:

A case of pt. M.E., 15-year old male, Mangga st., Juna Subd., Davao City. Three (3) days prior to admission, patient noted to have productive cough with feverish sensation and decrease appetite, at July 7, 2015 at 1:21 pm due to her chief complaints of productive cough he was admitted at Davao Doctors Hospital and he was diagnosed by Dr. Uy that she suffered with Upper Respiratory Tract Infection

F. REVIEW OF ANATOMY AND PHYSIOLOGY

Respiratory system

The Respiratory System is crucial to every human being. Without it, we would cease to live outside of the womb. Let us begin by taking a look at the structure of the respiratory system and how vital it is to life. During inhalation or exhalation air is pulled towards or away from the lungs, by several cavities, tubes, and openings.

The organs of the respiratory system make sure that oxygen enters our bodies and carbon dioxide leaves our bodies.

The respiratory tract is the path of air from the nose to the lungs. It is divided into two sections: Upper Respiratory Tract and the Lower Respiratory Tract. Included in the upper respiratory tract are the Nostrils, Nasal Cavities, Pharynx, Epiglottis, and the Larynx. The lower respiratory tract consists of the Trachea, Bronchi, Bronchioles, and the Lungs.

As air moves along the respiratory tract it is warmed, moistened and filtered.

Breathing and Lung Mechanics

Ventilation is the exchange of air between the external environment and the alveoli. Air moves by bulk flow from an area of high pressure to low pressure. All pressures in the respiratory system are relative to atmospheric pressure (760mmHg at sea level). Air will move in or out of the lungs depending on the pressure in the alveoli. The body changes the pressure in the alveoli by changing the volume of the lungs. As volume increases pressure decreases and as volume decreases pressure increases. There are two phases of ventilation; inspiration and expiration. During each phase the body changes the lung dimensions to produce a flow of air either in or out of the lungs.

The body is able to stay at the dimensions of the lungs because of the relationship of the lungs to the thoracic wall. Each lung is completely enclosed in a sac called the pleural sac. Two structures contribute to the formation of this sac. The parietal pleura are attached to the thoracic wall whereas the visceral pleura are attached to the lung itself. In-between these two membranes is a thin layer of intrapleural fluid. The intrapleural fluid completely surrounds the lungs and lubricates the two surfaces so that they can slide across each other. Changing the pressure of this fluid also allows the lungs and the thoracic wall to move together during normal breathing. Much the way two glass slides with water in-between them are difficult to pull apart, such is the relationship of the lungs to the thoracic wall.

The rhythm of ventilation is also controlled by the "Respiratory Centre" which is located largely in the medulla oblongata of the brain stem. This is part of the autonomic system and as such is not controlled voluntarily (one can increase or decrease breathing rate voluntarily, but that involves a different part of the brain). While resting, the respiratory center sends out action potentials that travel along the phrenic nerves into the diaphragm and the external intercostal muscles of the rib cage, causing inhalation. Relaxed exhalation occurs between impulses when the muscles relax. Normal adults have a breathing rate of 12-20 respirations per minute.

The Pathway of Air

When one breathes air in at sea level, the inhalation is composed of different gases. These gases and their quantities are Oxygen which makes up 21%, Nitrogen which is 78%, Carbon Dioxide with 0.04% and others with significantly smaller portions.

In the process of breathing, air enters into the nasal cavity through the nostrils and is filtered by coarse hairs (vibrissae) and mucous that are found there. The vibrissae filter macroparticles, which are particles of large size. Dust, pollen, smoke, and fine particles are trapped in the mucous that lines the nasal cavities (hollow spaces within the bones of the skull that warm, moisten, and filter the air). There are three bony projections inside the nasal cavity. The superior, middle, and inferior nasal conchae. Air passes between these conchae via the nasal meatuses.

Air then travels past the nasopharynx, oropharynx, and laryngopharynx, which are the three portions that make up the pharynx. The pharynx is a funnel-shaped tube that connects our nasal and oral cavities to the larynx. The tonsils which are part of the lymphatic system, form a ring at the connection of the oral cavity and the pharynx. Here, they protect against foreign invasion of antigens. Therefore the respiratory tract aids the immune system through this protection. Then the air travels through the larynx. The larynx closes at the epiglottis to prevent the passage of food or drink as a protection to our trachea and lungs. The larynx is also our voicebox; it contains vocal cords, in which it produces sound. Sound is produced from the vibration of the vocal cords when air passes through them.

The trachea, which is also known as our windpipe, has ciliated cells and mucous secreting cells lining it, and is held open by C-shaped cartilage rings. One of its functions is similar to the larynx and nasal cavity, by way of protection from dust and other particles. The dust will adhere to the sticky mucous and the cilia helps propel it back up the trachea, to where it is either swallowed or coughed up. The mucociliary escalator extends from the top of the trachea all the way down to the bronchioles, which we will discuss later. Through the trachea, the air is now able to pass into the bronchi.

Inspiration

Inspiration is initiated by contraction of the diaphragm and in some cases the intercostal muscles when they receive nervous impulses. During normal quiet breathing, the phrenic nerves stimulate the diaphragm to contract and move downward into the abdomen. This downward movement of the diaphragm enlarges the thorax. When necessary, the intercostal muscles also increase the thorax by contacting and drawing the ribs upward and outward.

As the diaphragm contracts inferiorly and thoracic muscles pull the chest wall outwardly, the volume of the thoracic cavity increases. The lungs are held to the thoracic wall by negative pressure in the pleural cavity, a very thin space filled with a few milliliters of lubricating pleural fluid. The negative pressure in the pleural cavity is enough to hold the lungs open in spite of the inherent elasticity of the tissue. Hence, as the thoracic cavity increases in volume the lungs are pulled from all sides to expand, causing a drop in the pressure (a partial vacuum) within the lung itself (but note that this negative pressure is still not as great as the negative pressure within the pleural cavity--otherwise the lungs would pull away from the chest wall). Assuming the airway is open, air from the external environment then follows its pressure gradient down and expands the alveoli of the lungs, where gas exchange with the blood takes place. As long as pressure within the alveoli is lower than atmospheric pressure air will continue to move inwardly, but as soon as the pressure is stabilized air movement stops.

Expiration

During quiet breathing, expiration is normally a passive process and does not require muscles to work (rather it is the result of the muscles relaxing). When the lungs are stretched and expanded, stretch receptors within the alveoli send inhibitory nerve impulses to the medulla oblongata, causing it to stop sending signals to the rib cage and diaphragm to contract. The muscles of respiration and the lungs themselves are elastic, so when the diaphragm and intercostal muscles relax there is an elastic recoil, which creates a positive pressure (pressure in the lungs becomes greater than atmospheric pressure), and air moves out of the lungs by flowing down its pressure gradient.

Although the respiratory system is primarily under involuntary control, and regulated by the medulla oblongata, we have some voluntary control over it also. This is due to the higher brain function of the cerebral cortex.

When under physical or emotional stress, more frequent and deep breathing is needed, and both inspiration and expiration will work as active processes. Additional muscles in the rib cage forcefully contract and push air quickly out of the lungs. In addition to deeper breathing, when coughing or sneezing we exhale forcibly. Our abdominal muscles will contract suddenly (when there is an urge to cough or sneeze), raising the abdominal pressure. The rapid increase in pressure pushes the relaxed diaphragm up against the pleural cavity. This causes air to be forced out of the lungs.

Another function of the respiratory system is to sing and to speak. By exerting conscious control over our breathing and regulating flow of air across the vocal cords we are able to create and modify sounds.

Lung Compliance

Lung Compliance is the magnitude of the change in lung volume produced by a change in pulmonary pressure. Compliance can be considered the opposite of stiffness. A low lung compliance would mean that the lungs would need a greater than average change in intrapleural pressure to change the volume of the lungs. High lung compliance would indicate that little pressure difference in intrapleural pressure is needed to change the volume of the lungs. More energy is required to breathe normally in a person with low lung compliance. Persons with low lung compliance due to disease therefore tend to take shallow breaths and breathe more frequently.

Determination of Lung Compliance Two major things determines lung compliance. The first is the elasticity of the lung tissue. Any thickening of lung tissues due to disease will decrease lung compliance. The second is surface tensions at air water interfaces in the alveoli. The surface of the alveoli cells is moist. The attractive force, between the water cells on the alveoli, is called surface tension. Thus, energy is required not only to expand the tissues of the lung but also to overcome the surface tension of the water that lines the alveoli.

To overcome the forces of surface tension, certain alveoli cells (Type II pneumocytes) secrete a protein and lipid complex called ""Surfactant, which acts like a detergent by disrupting the hydrogen bonding of water that lines the alveoli, hence decreasing surface tension.

Upper Respiratory Tract

The upper respiratory tract consists of the nose and the pharynx. Its primary function is to receive the air from the external environment and filter, warm, and humidify it before it reaches the delicate lungs where gas exchange will occur.

Air enters through the nostrils of the nose and is partially filtered by the nose hairs, then flows into the nasal cavity. The nasal cavity is lined with epithelial tissue, containing blood vessels, which help warm the air; and secrete mucous, which further filters the air. The endothelial lining of the nasal cavity also contains tiny hair like projections, called cilia. The cilia serve to transport dust and other foreign particles, trapped in mucous, to the back of the nasal cavity and to the pharynx. There the mucus is either coughed out, or swallowed and digested by powerful stomach acids. After passing through the nasal cavity, the air flows down the pharynx to the larynx.

Lower Respiratory Tract

The lower respiratory tract starts with the larynx, and includes the trachea, the two bronchi that branch from the trachea, and the lungs themselves. This is where gas exchange actually takes place.

1. Larynx

The larynx (plural larynges), colloquially known as the voice box, is an organ in our neck involved in protection of the trachea and sound production. The larynx houses the vocal cords, and is situated just below where the tract of the pharynx splits into the trachea and the esophagus. The larynx contains two important structures: the epiglottis and the vocal cords.

The epiglottis is a flap of cartilage located at the opening to the larynx. During swallowing, the larynx (at the epiglottis and at the glottis) closes to prevent swallowed material from entering the lungs; the larynx is also pulled upwards to assist this process. Stimulation of the larynx by ingested matter produces a strong cough reflex to protect the lungs. Note: choking occurs when the epiglottis fails to cover the trachea, and food becomes lodged in our windpipe.

The vocal cords consist of two folds of connective tissue that stretch and vibrate when air passes through them, causing vocalization. The length the vocal cords are stretched determines what pitch the sound will have. The strength of expiration from the lungs also contributes to the loudness of the sound. Our ability to have some voluntary control over the respiratory system enables us to sing and to speak. In order for the larynx to function and produce sound, we need air. That is why we can't talk when we're swallowing.

1. Trachea

2. Bronchi

3. Lungs

The Right Primary Bronchus is the first portion we come to, it then branches off into the Lobar (secondary) Bronchi, Segmental (tertiary) Bronchi, then to the Bronchioles which have little cartilage and are lined by simple cuboidal epithelium (See fig. 1). The bronchi are lined by pseudostratified columnar epithelium. Objects will likely lodge here at the junction of the Carina and the Right Primary Bronchus because of the vertical structure. Items have a tendency to fall in it, whereas the Left Primary Bronchus has more of a curve to it which would make it hard to have things lodge there.

The Left Primary Bronchus has the same setup as the right with the lobar, segmental bronchi and the bronchioles.

The lungs are attached to the heart and trachea through structures that are called the roots of the lungs. The roots of the lungs are the bronchi, pulmonary vessels, bronchial vessels, lymphatic vessels, and nerves. These structures enter and leave at the hilus of the lung which is "the depression in the medial surface of a lung that forms the opening through which the bronchus, blood vessels, and nerves pass" (medlineplus.gov).

There are a number of terminal bronchioles connected to respiratory bronchioles which then advance into the alveolar ducts that then become alveolar sacs. Each bronchiole terminates in an elongated space enclosed by many air sacs called alveoli which are surrounded by blood capillaries. Present there as well, are Alveolar Macrophages, they ingest any microbes that reach the alveoli. The Pulmonary Alveoli are microscopic, which means they can only be seen through a microscope, membranous air sacs within the lungs. They are units of respiration and the site of gas exchange between the respiratory and circulatory systems.

G. Comprehensive Health Assessment

A. Integumentary

GENERAL APPEARNCE

Patients skin colour has white skin complexion, no discoloration and skin texture is smooth. Patient has good skin turgor as I pinched his skin and goes back immediately in place. There was no presence of scaling noted. Hair is evenly distributed, thin, short, black hair and no infestations noted. In patients finger nails and toe nails, there was no problem deviations assessed.

Head and Neck

Head motion is normal; he can move or flex his head without difficulty and shrugs shoulders. Upon assessment, no problem noted.

Nose and Sinuses

For the nose and sinuses, upon assessment no problem was noted.

Mouth and Pharynx

For the mouth and pharynx assessment of the patient, no inflammation/lesions was noted, lips are moist, has complete set of teeth, no tooth decay was noted and normal findings upon assessment on gag reflex.

Eyes and Ears

The eyes and ears are same as the facial skin. There is symmetry in size position. Patient visual acuity is not normal because patient uses eye glass and patient s near sighted. The rest upon assessment is normal. Patient hearing acuity is normal/can hear in both ears and no any abnormalities/discharges/pain noted.

Cardiopulmonary

No murmurs upon auscultated, and clients heart sound is characteristics is regular and strong in rhythm, no edema noted, Blood pressure is 110/80mmHg, peripheral pulses is 78bpm.

Thorax and Lungs

Upon assessment, there is no thorax deviation but there is a presence of wheezes sounds upon auscultation. Respiratory rate is 22cpm.Gastrointestinal

Bowel sounds is present in all quadrants. Abdomen is flat, skin is intact and no other unusualities noted.

Nutritional/metabolic Patterns

Height is 176cm and weight is 76kg which indicates within the ideal body weight. Patient has good appetite and able to consume all food served.

BMI computation:

176cm/100= 1.76x2 = 3.52 (76kg/3.52= 21.59)

Body Mass Index Ranges

Underweight: BMI is less than 18.5

Normal weight: BMI is 18.5 to 24.9

Overweight: BMI is 25 to 29.9

Obese: BMI is 30 or more

Genitourinary Musculoskeletal

Upon assessment with the patients gait, posture weight bearing stance, there are no abnormalities noted. No decrease of ROM, tenderness and misalignment noted.

Neurological System

Patient is responsive, able to interact and socialize with other people, there was no change in level of consciousness, and vocalizes sounds.

Cranial Nerve Function

CN 1-Olfactory [/] intact [] impaired [] unknown

CN VI-Trigeminal

[/] intact [] impaired

CN VII-Facial [/] intact [] impaired

CN VIII-Acoustic [/] intact [] impaired

CN IX-Glossopharyngeal [/] intact [] impaired

CN X-Vagus [/] intact [] impaired

CN XI-Spinal accessory [/] intact [] impaired

CN XII-Hypoglossal [/] intact [] impaired

Sensory Function

Touch and Pain were intact.

Reflexes

Reflexes are normal, visible muscle twitch and extension of lower leg.

Etiology

Upper respiratory infection is generally caused by the direct invasion of the inner lining (mucosa or mucus membrane) of the upper airway by the culprit virus or bacteria. In order for the pathogens (viruses and bacteria) to invade the mucus membrane of the upper airways, they have to fight through several physical and immunologic barriers. The hair in the lining of the nose acts as physical barrier and can potentially trap the invading organisms. Additionally, the wet mucus inside the nasal cavity can engulf the viruses and bacteria that enter the upper airways. There are also small hair-like structures (cilia) that line the trachea which constantly move any foreign invaders up towards the pharynx to be eventually swallowed into the digestive tract and into the stomach. In addition to these intense physical barriers in the upper respiratory tract, the immune system also does its part to fight the invasion of the pathogens or microbes entering the upper airway. Adenoids and tonsils located in the upper respiratory tract are a part of the immune system that helps fight infections. Through the actions of the specialized cells, antibodies, and chemicals within these lymph nodes, invading microbes are engulfed within them and are eventually destroyed.H. PathophysiologyNarrative ReportUpper Respiratory Tract Infection is caused by bacteria called rhinovirus, coronavirus, parainfluenza virus adenovirus,enterovirus, andrespiratory syncytial virusStreptococcus pyogenesaGroup A streptococcusinStreptococcal pharyngitis that can be transfer through direct hand to hand contact and droplet and can inter internally through inhalation suppresses immune system some pathogen will be trapped by use of by hair lining called cilia but some will enter and invade. it will settle in upper respiratory tract and some will go to the posterior part of nose and in the throat and will be coated by mucus. Since its already coated with mucus pathogen can enter now in pharynx inflammatory response to immune system causing the S&S erythema, increase in mucus secretion manifested by productive cough and colds and fever.Predisposing Precipitating

Family history of Bronchial asthmaComputer gamer

15 years oldSecondhand smoker

Allergy rhinitis Sedentary lifestyle

I. Course in the wardDoctors Order

Date/ TimeDoctors OrderRationale of Order

7/ 6/201

7/7/2015

>please admit patient under the service of Doctor Yu>secure consent to care

>IVF: D5LR 1L @ 20 gtts/min

>LABS:

-CBC

-U/A

-CXR (PA)

MEDs

1. Ambrolex OD 75 mg/ PO

2. Brompheniramine ( Nasatapp) 1 tab BID

3. Omeprazole

4. Hexetidine (Bactidol) Gargle

5. Salbuterol

>V/S q 4o

>I&O q shift

>Pls inform AP

>refer accordingly

>start Laitun 200mg IV q 12 ANST

>Fluimucil 600 dissolve in a glass of water after dinner

>Krerr 1 cap OD

>PCM 500 mg tab q4 PRN fever

> IVF to follow D5LR @ 20 gtts/ min (2 bottles)

>increase IVF rate to 30 gtts/min

> To intervene & give the needed health service

> As a form for legal purposes.

> for hydration

-To monitor the blood components

-To check if there is any abnormalities

- Treatment of acute respiratory tract diseases with impaired formation of secretions- lowers or stops the body's reaction to the allergen.- used to treat gastroesophageal reflux disease (GERD)

- used fortopical treatment of sore throat and oral infections

- used to treat asthma and other lung-related problems-to monitor baseline data

-to monitor hydration status

-to inform the physician about the condition of the patient.

-for continuity of care

- used to treat certain bacterial infections of the nose, lungs, etc.- Treatment of respiratory affections characterized by. thick and viscous secretions

-

- used over-the-counter pain reliever and a fever reducer- use for hydration

- to increase hydration status

Laboratory Results

7/6/2015Urine Analysis

ResultNormal ValuesRationale

Color

Glucose

Transparency

Protein

Specific Gravity

Microscopic Exam:

Pus Cells

RBC

Amourphous Urates / Phosphates

Epithelial Squamous Cells

Bacteria Yellow

Negative

Clear

Negative

1.015

1-3/hpf

0-2/hpf

Few

Few

OccasionalPale Yellow- Amber

Negative

Clear to Slightly hazy

Negative

1.002-1.030

0-4/hpf

0-3/hpf

NegativeNormal

Normal

Normal

Normal

Normal

Normal

Normal

Indicates Infection

7-6-2015Complete Blood Count

ResultNormal valuesImplication

HCT

HGB

WBC

PLATELET40.1

12.9

8,200

310,00037-47vol %

12-16gms %

5,000-10,000/mm3

150,000-400,000/mm3 Normal

Normal

Normal

Normal

Diff. Count

Neutrophils

Granulocyte

Lymphocytes

Monocytes69

50

43

750-62 %

43.4-76.2 %

17.4-48.2 %

4.5-10.5 %Respond to any inflammation

Normal

Normal

Normal

Generic name/Brand nameClassificationDose/ route FrequencyMechanism of ActionSpecific indicationContra-indicationAdverse reactionNursing Precaution

Ambrolex

antibioticOD 75 mg PO

Concentration of antibiotics when given concomitantly.Acute and chronic disorder of the respiratory tract associated with pathologically thickened mucus and impaired mucus transport.There are no absolute contraindications but in patients with gastric ulceration relative caution should be observed.Occasional gastrointestinal side effects may occur but these are normally mild.Observe respiratory rate and obtain baseline data. Check drug interactions if taking other medications.

It is advisable to avoid use during the first trimester of pregnancy.

Generic /brand nameClassificationDose/ route FrequencyMechanism of ActionSpecific indicationContra-indicationAdverse reactionNursing Precaution

Salbuterolbronchodilator1 neb Stimulates Beta 2 receptors of bronchioles by increasing levels which relaxes smooth muscles to produce bronchodilation. Also cause CNS stimulation, cardiac stimulation, increase in diuresis, skeletal muscle tremors and increase gastric acid secretions.Relief of bronchospasm in bronchial asthma, chronic bronchitis, emphysema and other reversible obstructive pulmonary diseaseHypersensitivity to salbutamol, also to atropine and its derivatives. Threatened abortion during first or second trimester.Fine skeletal muscle tremors, leg cramps, palpitations, tachycardia, hypertension, headache, nausea, vomiting, dizziness, hyperactivity, insomnia, hypotension, heartburn, epistaxis, cough-Assess cardio- respiratory function, BP, heart rate and rhythm, and breathe sounds.

-Determine history of previous meds and ability to self-medicate.

-Monitor for evidence of allergic action and paradoxical bronchospasm

Generic /brand nameClassificationDose/ route FrequencyMechanism of ActionSpecific indicationContra-indicationAdverse reactionNursing Precaution

Omeprazole

Antisecretory

Proton pump inhibitor40mg IVTT ODGastric acid-pump inhibitor: Suppresses gastric acid secretion by specific inhibition of the hydrogen-potassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the final step of acid production.Reduction of risk of upper GI bleedingContraindicated with hypersensitivity to Omeprazole or its components.Headache, dizziness, asthenia, vertigo, insomnia, apathy, anxiety, paresthesias,

dream abnormalities, rash, inflammation, urticaria, pruritus, alopecia, dry skin, diarrhea, abdominal pain, nausea, vomiting, constipation, dry mouth-Arrange regular medical check-ups.

-Advise pt to report immediately for side effects.

Generic /brand nameClassificationDose/ route FrequencyMechanism of ActionSpecific indicationContra-indicationAdverse reactionNursing Precaution

ParacetamolAntipyreticPRN for fever q 4 hrsInhibits the synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS

>Mild pain

>Fever

Hypersensitivity to acetaminophen or phenacetin; use with alcohol.Hema: hemolytic anemia, neutropenia, leukopenia, pancytopenia.Hepa: jaundice

Metabolic: hypoGGI: HEPATIC FAILURE, HEPATOTOXICITY (overdose)GU: renal failure (high doses/chronic use). Derm: rash, urticaria.

~ Advise parents or caregivers to check concentrations of liquid preparations. Errors have resulted in serious liver damage.

~ Assess fever; note presence of associated signs (diaphoresis, tachycardia, and malaise).

~ Adults should not take acetaminophen longer than 10 days and children not longer than 5 days unless directed by health care professional.

~ Advise mother or caregiver to take medication exactly as directed and not to take more than the recommended amount.

BRAND NAMEGENERIC NAMEMECHANISM OF ACTIONADVERSE REACTIONSIDE EFFECTSDOSAGENURSING RESPONSIBILITIES

Augmentin

Reference :Daviss drug guide for nurses 11th editionCo-Amoxiclav

antibioticAn antibiotic that combines amoxicillin and clavulanic acid. It destroys bacteria by disrupting their ability to form cell walls mild diarrhea, gas, stomach pain;

nausea or vomiting;

headache;

skin rash or itching

feeling like you might pass out; nosebleed (especially in a child);

pain or fullness in your ear, hearing problems;

depression, agitation, aggression, hallucinations;

numbness or tingling around your lips or mouth;

jaundice (yellowing of your skin or eyes);

painful or difficult urination;

dark-colored urine, foul-smelling stools; or

Fever, stomach pain, loss of appetite.

Usual:

2.5 mg/5 mL (0.5 mg/mL)

Actual:

10 mg 1 tab OD>Assess bowel pattern before and during treatment as pseudo membranous colitis may occur.

>Report hematuria oroliguria as high doses canbe nephrotoxic.

>Assess respiratorystatus.

>Observe for anaphylaxis.

>Ensure that the patient has adequate fluid intake during any diarrhea attack

BRAND NAMEGENERIC NAMEMECHANISM OF ACTIONADVERSE REACTIONSIDE EFFECTSDOSAGENURSING RESPONSIBILITIES

Acetylcysteine

Reference :Daviss drug guide for nurses 11th editionExflem

Mucolytic

Acetylcysteine exerts its mucolytic action through its free sulfhydryl group, which opens the disulfide bonds and lowers mucus viscosity. This action increases with increasing pH and is most significant at pH 7 to 9. The mucolytic action of acetylcysteine is not affected by the presence of DNA.> fever> drowsiness

> tachycardia

> dyspnea

> rash

> chillsstomatitis,nausea,vomiting,

fever, rhinorrhea,

drowsiness, clamminess, chest tightness, and broncho constrictionUsual:

60 mg 1 tab in

glass ofwater

Actual:

600 1 tab+ glass of H2O OD @hs>Assess type, frequency, and characteristics of

patients cough

. >Monitor patient fortachycardia

>Monitor for S&S of aspiration of excess secretions, and for

Bronchospasm (unpredictable); withhold drug and notify physician immediately if either occurs.

>Instruct patient to notify prescribe immediately about nausea, rash or vomiting

VII. NURSING MANAGEMENT

Assessment

DiagnosisPlanningInterventions

RationaleEvaluation

Subjective:

gahi kayo akong ubo as verbalized.

Objective:

Conscious/coherent

Productive cough (yellow to green sputum

Restlessness noted

Discomfort noted Facial Grimace noted Ineffective airway clearance r/t increased production of bronchial secretions as manifested by

Body malaise

Wheezes upon auscultation

Productive cough (yellow to green sputum

Restlessness

Chest pain

Discomfort

Facial Grimace After 8 hours of continues nsg. Interventions the pt. will be able to maintain airway patency

Expectorate secretions

Learn and perform breathing and coughing exercise.

Verbalized relief form dyspnea. Monitor Vital signs

Place the pt. in fowlers or semi-fowlers position

Teach the pt. how to do proper deep breathing and coughing exercise

Avoid exposure to irritants such as cigarette smoke, aerosol and fumes

Auscultate breath sounds

Increase fluid intake

Suction as ordered

Provide oxygen inhalation as ordered

Administer medication as ordered Serves as baseline data

To facilitate maximum lung expansion

Improves ventilation and helps in mobilizing secretions w/o causing fatigue

To avoid allergic reaction

To ascertain status and note progress

Helps liquefy secretions

To clear airway

Provide adequate amount of oxygen

Will help loosen secretions for easy expulsion.Patient was able to expectorate secretions, goal met.

Assessment

DiagnosisPlanningInterventions

RationaleEvaluation

Subjective:

Gitugnaw ko as verbalized

Objective:

Conscious/coherent

Warm to touch noted

Flushed face noted

Febrile with a temperature of 37.9C Ineffective thermoregulation r/t increased body temperature as manifested by

Warm to touch

Flushed face

Febrile with a temperature of 38.2C After 8 hours of continuous TSB, the pt.s temperature will decrease from 37.9 to 37C Monitor VS

Increase fluid intake

Maintain bed rest

Provide sufficient clothing

Perform TSB

Administer antipyretics as ordered Serves as baseline data

To help cool down core temperature

To decrease metabolism that produce heat

Facilitate comfort

Facilitate heat loss by means of evaporation

Helps lower temperature within normal rangeThe patient temperature is fluctuating, goal partially met.

Assessment

DiagnosisPlanningInterventions

RationaleEvaluation

Subjective:

dili ko ganahan mo kaon

Objective:

Refusal to eat

Poor muscle tonicity

Body weakness noted

Restlessness

Altered nutrition less than body requirements R/T loss of appetite as evidenced by dysfunctional eating pattern. After 4 hours of nursing interventions, patients appetite will be improved: from 2 tablespoons to at least 5 tablespoons per meal. Monitor vital signs

Weight on regular basis

Discuss eating habits including food preferences.

Serve favourite foods that are not contraindicated.

Serves foods that are palatable and attractive.

Prevent and minimize unpleasant odours.

Emphasize the importance of well-balanced nutrition diet For baseline data

Monitor nutritional state and effectiveness of interventions

To appeal to client likes and dislikes

To stimulate the appetite

To stimulate the appetite

May have negative effect on appetite/eating

Promote wellness

Goal was met because the patient was able to understand the importance of nutritious food intake and was able to eat with fair appetite.

UPPER RESPIRATORY TRACT INFECTION

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