I. INTRODUCTION
Acute bronchitis is an inflammation of the large bronchi (medium-
sized airways) in the lungs that is usually caused by viruses or bacteria and
may last several days or weeks. Characteristic symptoms include cough,
sputum (phlegm) production, and shortness of breath and wheezing related
to the obstruction of the inflamed airways. Diagnosis is by clinical
examination and sometimes microbiological examination of the phlegm.
Treatment for acute bronchitis is typically symptomatic. As viruses cause
most cases of acute bronchitis, antibiotics should not be used unless
microscopic examination of Gram stained sputum reveals large numbers of
bacteria.
Acute bronchitis can be caused by contagious pathogens. In about half
of instances of acute bronchitis a bacterial or viral pathogen is identified.
Typical viruses include respiratory syncytial virus, rhinovirus, influenza, and
others.
Bronchitis may be indicated by an expectorating cough, shortness of
breath (dyspnea) and wheezing. Occasionally chest pains, fever, and fatigue
or malaise may also occur. Additionally, Bronchitis caused by Adenoviridae
may cause systemic and gastrointestinal symptoms as well. However the
coughs due to bronchitis can continue for up to three weeks or more even
after all other symptoms have subsided.
Acute bronchitis usually lasts a few days. It may accompany or
closely follow a cold or the flu, or may occur on its own. Bronchitis usually
begins with a dry cough, including waking the sufferer at night. After a few
days it progresses to a wetter or productive cough, which may be
accompanied by fever, fatigue, and headache. The fever, fatigue, and
malaise may last only a few days; but the wet cough may last up to several
weeks. Should the cough last longer than a month, some doctors may issue
a referral to an otorhinolaryngologist (ear, nose and throat doctor) to see if
1
a condition other than bronchitis is causing the irritation. It is possible that
having irritated bronchial tubes for as long as a few months may inspire
asthmatic conditions in some patients.
In addition, if one starts coughing mucus tinged with blood, one should see
a doctor. In rare cases, doctors may conduct tests to see if the cause is a
serious condition such as tuberculosis or lung cancer. Acute bronchitis may
lead to pneumonia.
Inncidence rate of Acute Bronchitis is 4.6 per 100; 14.2 million cases
annually, approximately 1 in 21 individual or 4.60% or 12.5 million people
in USA Incidence extrapolations for USA for Acute Bronchitis: 12,511,999
per year, 1,042,666 per month, 240,615 per week, 34,279 per day, 1,428
per hour, 23 per minute, 0 per second. Note: this extrapolation calculation
uses the incidence statistic: 4.6 per 100 (NHIS96: acute bronchitis); 14.2
million cases annually
Deaths from Acute Bronchitis 388 deaths reported in USA 1999 for
acute bronchitis and bronchiolitis (NVSR Sep 2001) Death rate
extrapolations for USA for Acute Bronchitis: 387 per year, 32 per month, 7
per week, 1 per day, 0 per hour, 0 per minute, 0 per second. Note: this
extrapolation calculation uses the deaths statistic: 388 deaths reported in
USA 1999 for acute bronchitis and bronchiolitis (NVSR Sep 2001)
A. Current trends about the disaese condition
“Advance Toward Early Diagnosis Of Chronic Obstructive Pulmonary
Disease”
Researchers in Finland are reporting identification of the first
potential "biomarker" that could be used in development of a sputum test
for early detection of chronic obstructive pulmonary disease (COPD). That
2
condition, which causes severe difficulty in breathing — most often in
cigarette smokers — affects 12 million people in the United States.
Vuokko L. Kinnula and colleagues point out that no disease marker for
COPD currently exists, despite extensive efforts by scientists to find one.
Past research pointed to a prime candidate — surfactant protein A (SP-A),
which has a major role in fighting infections and inflammation in the lung.
The scientists compared levels of a variety of proteins obtained from the
lung tissues of healthy individuals, patients with COPD, and those with
pulmonary fibrosis. They found that the lungs of COPD patients contained
elevated levels of SP-A. The scientists also found elevated levels of SP-A in
the sputum samples of COPD patients. "This suggests that SP-A might
represent a helpful biomarker in the early detection of COPD and other
related disorders," the article notes.
American Chemical Society (2008, December 17). Advance Toward Early
Diagnosis Of Chronic Obstructive Pulmonary Disease. ScienceDaily.
Retrieved June 27, 2009, from http://www.sciencedaily.com
/releases/2008/12/081208085002.htm
B. Reasons for choosing such case for presentation
I choose this case as we all know that acute bronchitis is a recurrent and
reversible disease once develop, but it can easily prevented by avoiding
their contributing factor, such as allergens, dust, pollens, prolonged
exposure to tobacco smokes and air pollutants. It can be prevented by
means of cessation of cigarette smoking and by prevention of air pollutants,
therefore this disease is disabling if not properly prevented or avoided.
C. Objectives
NURSE CENTERED
Short term
3
After 4-5 hours of nursing interventions, the student nurse shall be
able to:
Establish rapport with the patient
Identify the needs of the patient
Assess the general condition of the patient
Implement interventions that could help in maintaining the health of
the patient in a good condition
Explain to the patient the rationale for each interventions
Long term
After 2 days of nursing interventions, the student nurse shall be able
to:
Gain the trust and cooperation of the patient
Know the general condition of the patient
Identify the precipitating and predisposing factors that causes the
patient’s condition
Give health teachings about the condition of the patient
Help the patient recover from her condition
CLIENT CENTERED
Short term
After 4-5 hours of nursing interventions, patient shall be able to:
Establish rapport with the student nurse
Listen and cooperate with the student nurse
Verbalize feelings
Ask questions regarding her condition
Participate on the activities or health teachings given by the student
nurse
Able to understand the reason for such interventions
4
Long term
After 2 days of nursing interventions, the patient shall be able to:
Trust and have a good rapport with the student nurse
Verbalize her present condition/feelings
State the interventions given by the student nurse for the betterment
of her condition
Follows the activities or health teachings given by the student nurse
Able to have an improve condition/ gain her state of wellness
II. NURSING ASSESSMENT
1. Personal Data
Patient is a six-year old female, Filipino citizen and a Roman Catholic.
She was born on the 3rd of April, 2003 via Normal Spontaneous Delivery in
a private hospital in Manila. She is the only child in her family. Currently,
the Patient Family are residing in Porac, Pampanga.
Last June 23, 2009, at 11:30 in the morning, Patient’s mother rushed
Patient to a private hospital in Angeles City with chief complaints of cough
and fever. Upon admission, Patient was diagnosed of Acute Bronchitis.
2. Pertinent Family History
Patient belongs to an extended type of family which is composed of
four members. She lives with her parents and her grandparents.
Patient’s father is a highschool undergraduate who is currently
working as a factory worker, whereas Patient’s mother is a college graduate
who is currently working in CDC.
5
Patient’s Grandfather died due to Pulmonary Tubercolosis who lived
with the patient.
The Patient family owns their own house and they have been living in
their home since 2002. Their house is located along the highway. The
current residence has a living room, dining room, kitchen, two bedrooms
and two toilets. Patient’s mother also verbalized that the house is always
clean; however, trucks drive along the highway so dust always circulate
around their home. The family uses a gas stove as their means of cooking
and their water is obtained from NAWASA. Patient’s grandmother also goes
to the market to buy their food and cooks their own dishes.
The family’s source of income comes from both parents. Patient’s
Daddy earns approximately P15, 000 per month while Patient’s mother
earns approximately P20, 000. The family’s monthly expenses would
include: P 10,000 per month for their food, P 600 for their telephone bill
and P2,000 per month for their electricity. And the rest are mostly saved for
their other expenses.
In terms of family's culture, beliefs and perceptions, the family
consults their private physicians, such as when it is time for her child to be
immunized as well as for early prevention of a disease condition.
6
Paternal Side Maternal Side
GRANDFATHER ( +
)GRANDMOTHER Arthritis
GRANDFATHER DM Hypertension Asthma
GRANDMOTHER Asthmatic
AUNT 1 ( + ) leukemia
AUNT 2
Uncle 1
Uncle 2
Uncle 3
Uncle 4
AUNT 3
AUNT 4
AUNT 5
(+)asthm
a,
AUNT 6
FATHER
MOTHER
Uncle 1
AUNT 1 Uncle 2
Uncle 2
PATIENTACUTE
BRONCHITIS
7
3. Personal History
As verbalized by Patient’s mother, she had her pre-natal visits in her
pregnancy. She believes in “paglilihi” so she tends to eat nutritious food
when she was pregnant.
As stated by Patient’s mother, Patient was fully breastfed because she
believes that the milk coming from the mother is best for babies as well as
for economical reasons. Patient was breastfed until she was 1 ½ years old.
She also mentioned that Patient is fond of eating chicken, French fries, and
vegetables. Patient only eats small amounts of food and patient’s mother
always have difficutly feeding Patient. Patient is not taking any vitamins.
Patient’s mother stated that Patient had completed his Immunization
in their local health center. These vaccines included: BCG (Bacillus
Calmette Guerin), DPT (Diphtheria, Tetanus, Pertussis), OPV (Oral Polio
Vaccine), Hepatitis B and Measles.
Growth and Development
Erik Erikson
Patient, being 6 years of age, is in the Initiative vs. Guilt stage of
Erikson’s psychosocial conflict wherein she learns to take initiative of the
actions she wants to perform and learns to master the world around her. At
this stage the child wants to begin and complete his or her own actions for a
purpose. Guilt is a new emotion and is confusing to the child; he or she may
feel guilty over things which are not logically guilt producing, and he or she
will feel guilt when his or her initiative does not produce the desired results.
This stage is shown by her eagerness to study and to go to school as said by
her mother.
Jean Piaget
8
Patient is in the Preoperational or Egocentric stage of Piaget’s Theory
of cognitive development wherein the child does not show any particular
interest or concern with rules. It is also when children start employing
mental activities to solve problems and obtain goals but they are unaware of
how they came to their conclusions. Upon playing, mother stated that
patient shows that she is more focused on having fun rather than the rules
of the game. She also is not aware of what others think and focuses only
about having fun.
Sigmund Freud
Based on the patient’s age, she falls under the Phallic stage of Freud’s
Psychosexual stages wherein genitals are supposed to be the primary
source of pleasure for the child. Upon observation, there were no
manifestations of this stage noted from patient’s behaviour.
4. History of Past Illnesses
Patient was hospitalized before in the same health institution with a
diagnosis of Primary Complex. When she was four years old, she was
hospitalized in a private hospital in Manila due to Patient’s eye problem.
Patient also experienced fever, cough and colds and her mother treats her
with Paracetamol. Patient is also asthmatic since birth but was managed.
5. History of Present Illness
A five days prior to admission (June 18, 2009), Patient had cough and
colds and fever and Patient’s mother managed this by giving Paracetamol.
Four days prior to admission (June 20, 2009) same signs and symptoms
were noted and consulted their private physician and Patient was diagnosed
with Upper Respiratory Tract infection and was given Mucosolvan and
Allerkid. Condition persisted and admitted last June 23, 2009 with an
admitting diagnosis of Acute Bronchitis.
9
6. Physical Assessment
Initial Assessmant upon Admission (June 23 , 2009) – lifted from the
client’s chart
Vital Signs
T: 36.1o C
P: 75 bpm
R: 38 bpm
Chief complaint/s: Cough and colds
General Appearance
(+) difficulty of breathing with used of accessory muscles
with nasal flaring and positive rales and wheezes on both
lungs fields
With cough and colds
Acyanotic
(-) Retractions
(-) edema
(-) rashes
Pink Palpebral conjunctiva
1st NPI ( June 24 , 2009)
General Appearance
During the assessment, patient was wearing shirt and a pajama. she
has productive cough with clear nasal secretions. she also has
difficulty of breathing with Rales on both lung fields and nasal
flaring.
Vital Signs
Temperature: 36.9 ˚C
10
Pulse Rate: 95 bpm
Respiratory rate: 26 bpm
BP: 90/60 mmHg
Cephalocaudal Assessment
Head
Round, symmetrical & normocephalic
No lesions, nodules or masses
Hair is thin and well distributed; no infestations noted
Symmetric facial features noted
Eyes
Eyebrows are symmetrical, evenly distributed
Eyelids no discharge / discoloration
Eyes are equally round
Transparent cornea
Pink palpebral conjunctiva
Ears
Symmetrical, no lesions, no pain
Recoils into original position after pinching
Auricles have same color as facial skin and aligned with outer canthus
of eye
Nose
Not tender, uniform color
Nasal septum in the midline and intact
No nodules or masses palpated
(+) Nasal Secretions
(+) Nasal Flaring
Mouth / Throat
11
Pinkish, moist, smooth
Tongue in central position
Neck
No pain upon palpation, masses
Muscles equal in size
Head located at the center
Skin
Capillary refill test 1-2 seconds
Uniform in color
Good skin turgor
Scanty hair equally distributed
Hair
Evenly distributed
No pediculosis / dandruff
Thorax / Lungs
(+) Rales on both lung fields
(-) retraction
Skin is intact
Chest is symmetric
No masses noted
Abdomen
Uniform color noted
Flat and symmetric movements caused by respiration
Extremities
Uniform in color
12
No palpable nodules or masses
Hair equally distributed
NEUROLOGICAL ASSESSMENT
CRANIAL
NERVE
PROCEDURE NORMAL
FINDINGS
ACTUAL
FINDINGS
CN I :
Olfactory
Type: Sensory
Function: Smell
Ask the client to
identify aromas
with eyes
closed.
Client must be
able to identify
the scent of an
agent with eyes
closed when
asked to smell
it.
Patient was able
to identify the
scent of alcohol
with eyes
closed.
CN II: Optic
Type: Sensory
Function: Vision
Ask the client to
read a number
written on a
piece of paper
at a given
distance.
Client must be
able to read a
number
correctly
written on a
piece of paper
at a given
distance.
Patient was able
to read the
number
correctly and
clearly at a
given distance
CN III:
Oculomotor
Type: Motor
Function: Pupil
constriction and
raising eyelids
Make use of
penlight in
order to test
papillary
reaction and
instruct the
Pupils should
constrict (+
PERRLA )
consensually
once light
passes through.
Patient pupils
constricted
consensually.
She was able to
open and close
her eyelids.
13
client to open
and close
eyelids.
Eyelids should
open and close.
CN IV:
Trochlear
Type: Motor
Function:
Oblique
movement of the
eye
Instruct client
to move eyes
downward and
upward without
moving head.
Client must be
able to follow
the pen’s
movement
downward and
upward without
moving head.
Patient was able
to follow the
pen’s movement
downward and
upward without
moving his
head.
CN VI:
Abducens
Type: Motor
Function:
Lateral eye
movement
Tell the client to
devoid his head
steadily and
follow the pen’s
direction
Client should be
able to follow
the lateral
movement of
the pen
Patient was able
to follow the
lateral
movement of the
pen.
CN VII: Facial
Type: Motor
Function:
Movement of
muscles of the
face
Ask client to
smile, frown,
and raise the
eyebrows.
Client should be
able to smile,
frown, and raise
the eyebrows
without
difficulty.
Patient was able
to smile, frown
and raise
eyebrows
without
difficulty.
CN IX:
Glossopharyng
eal
Type: Motor
Function:
Pharyngeal
movement and
Instruct client
to swallow.
Client should be
able to swallow
without
difficulty.
Patient was able
to swallow
without
difficulty.
14
swallowing
CN XI:
Accessory
Type: Motor
Function:
Movement of
shoulder
muscles
Ask the client to
shrug shoulders
against
resistance.
Client should be
able to shrug
shoulders
against
resistance.
Patient was
able to shrug
shoulders
against
resistance.
CN XII:
Hypoglossal
Type: Motor
Function:
Movement of
tongue, strength
of the tongue
Instruct the
client to
protrude tongue
and move it
laterally,
downward and
upward.
Client should be
able to protrude
tongue and
move it
laterally,
downward and
upward.
Patient was able
to protrude her
tongue and
move it laterally,
downward and
upward.
15
7. Diagnostic and Laboratory Procedures
DIAGNOSTIC
AND
LABORATORY
PROCEDURES
DATE
ORDERE
D
DATE
RESULT(
S) IN
INDICATIO
NS AND
PURPOSE(S)
RESULT
S
NORMA
L
VALUES
ANALYSIS AND
INTERPRETATIO
N
1. Hematology
a.
HEMOGLOBI
N
Date
ordered:
June 23
2009
Date
resulted:
June 23
2009
The
hemoglobin
concentration
is a measure
of the total
amount of
hemoglobin in
the peripheral
blood, which
reflects the
number of
RBC in the
blood. This
test evaluates
blood loss,
anemia,
erythropoietic
123 g/L 120-150
g/L
The result is
within normal
range which
means that there
is adequate
perfusion in the
body’s tissues.
16
ability,
dehydration
and
polycythemia.
b.HEMATOCR
ITThe
hematocrit is
a measure of
the total
blood volume
that is made
up by RBC.
This test also
evaluates
blood loss,
anemia,
erythropoietic
ability,
dehydration
and
polycythemia.
0.370.35-0.40
The result is
normal with the
aid of
administration of
IVF of PLRS which
is known to be an
isotonic solution it
also indicates that
the patient is not
suffering from
dehydration.
C.
LEUKOCYTESThis test is
performed to
determine the
amount of
WBC’s in the
blood. The
body fights
infection by
4.52 X
109
7.50 -
13.50 X
109
It is decrease
which signifies
that theirs is
bacterial infection
17
using WBC’s
or leukocyte.
They
encapsulate
organism and
destroy them.
d.
LYMPHOCYTE
S
Lymphocytes
are the one’s
responsible
for activities
of the
immune
system, which
produces
antibodies.
0.43 0.15 -
0.65
The result is with
in normal limits
that there is no
presence of viral
infection or
inflammation.
e. PLATELET
COUNT
are the cell
fragments
circulating in
the blood that
are involved
in the cellular
mechanisms
of primary
hemostasis
leading to the
formation of
blood clots.
241 X
109
150-400
X 109
Normal. Normal
platelet counts are
not a guarantee of
adequate function.
In some states the
platelets, while
being adequate in
number, are
dysfunctional.
18
NURSING RESPONSIBILITIES
PRIOR TO THE PROCEDURE
- Explain the procedure to the client
- Tell the patient that no fasting is required
DURING THE PROCEDURE
- Collect approximately 5 to 7 ml of venous blood in a lavender-top
tube; however, only 0.5 ml is required when using capillary tubes.
- Avoid hemolysis
- List on the laboratory slip any drugs that may affect test results
AFTER THE PROCEDURE
- Apply pressure to the venipuncture site.
- Explain that some bruising, discomfort and swelling may appear at
the site and warm compress can alleviate this.
- Monitor signs of infection
Diagnostic and
laboratory
procedures
Dates Indication Results
CHEST X-RAY Date ordered:
June 23 2009
Date resulted:
June 23 2009
To identify the
abnormalities of
the lungs and
structures on the
thorax and also to
identify the size
Radiographic
report
There are hazy
infiltrate at the left
lower lung region.
19
of the heart and
abnormalities in
the ribs and
diaphragm.
The rest of the
lung are clear
heart and great
vessel with in
normal size and
configuration and
other chest
structure are not
remarkable
IMPRESSION:
Pneumonia, left
lower lobe
CHEST X-RAY
Before the procedure
1. check doctors order
2. Identify the client
3. Explain the procedure to SO and its importance
4. Inform the Patient to remove all metal objects like clothing with
metal, fastener, necklace, pins for better visualization of the chest
5. tell the patient that the test will only take a few minutes and is
painless
6. assist transporting the client in going to the X-Ray room
During the procedure
1. Protect client’s other body parts from exposure to radiation
2. Wear lead apron to protect one’s self from exposure to radiation
20
3. assist and keep patient still as possible during the procedure
After the procedure
1. Document the time and procedure performed
Urinalysis - (or "UA") is an array of tests performed on urine and one of
the most common methods of medical diagnosis. A part of a urinalysis can
be performed by using urine dipsticks, in which the test results can be read
as color changes.
DIAGNOSTIC AND
LABORATORY
PROCEDURES
DATE ORDERE
D
DATE RESULT(
S) IN
INDICATIONS AND
PURPOSE(S)RESULTS NORMA
L VALUES
ANALYSIS AND INTERPRETATIO
N
Urine chemistry
Date ordered:June 23
2009
Date resulted:June 23
2009
To screen the patient’s urine for renal or urinary tract disease.To help detect metabolic or systemic disease unrelated to renal disorders.To detect substances (drugs).
COLOR: light yellow
TRANSPARENCY: clear
pH: acidic
SP. GRAVITY: 1.005
MICROSCOPIC
yellow
clear
acidic
1.005-1.035
Slightly abnormal in color. Suggests signs of concentration of urine
Turbidity in urine transparency may indicate no presence of RBC , albumin and bacteria.
An acid pH (below 7.0)—typical of a high-protein diet—produces turbidity and the formation of oxalate, cystine, leucine, tyrosine, amorphous urate, and uric acid crystals
Result within normal range.
21
EXAMPUS CELL: 0-1/hpf
RBC: none found
ALBUMIN: ( - )
SUGAR: ( - )
BACTERIA: ( - )
( - )
( - )
( - )
( - )
( - )
Urine is not concentrated or packed with other element such as proteins.
May indicate infection
Within normal limits, indicate no presence of blood in the urine.
No impairment in the permeability of the glomelular capillaries.
Normal finding
Normal finding
NURSING RESPONSIBILITIES:
Before:
Check for the doctor’s order
Inform the patient/SO before doing the procedure. Explain to the
patient’s SO the importance of the test.
Inform the patient/SO that there is no need to restrict food or fluids
before the test.
Explain to the patient’s So that the laboratory procedure is non-
invasive; no pain will be felt.
During:
Assist patient in going to bathroom or CR.
Describe the procedure for collecting a clean-catch or midstream
specimen.
22
Advise the patient’s SO to wash patient’s genitalia prior to collection
of specimen.
After:
Chart time of collection of urine specimen.
Attach result to the chart as soon as they are available.
Record and document findings.
DIAGNOSTIC
AND
LABORATORY
PROCEDURES
INDICATI
ONAND
PURPOSE
(S)
RESULTS NORMA
L
VALUES
ANALYSIS AND
INTERPRETATIO
N
COLD
AGGLUTININS
DETERMINATIO
N
This test in
done to
test the
presences
of unusual
bacteria.
Presence
of
agglutionat
ion at 1.32
Titer
above
1.64 are
consider
significan
t
The result is in
normal limit
meaning which
indicates that
there is no
presence of
unusual bacteria.
NURSING RESPONSIBILITIES
PRIOR TO THE PROCEDURE
- Explain the procedure to the client
- Tell the patient that no fasting is required
DURING THE PROCEDURE
- Collect approximately 5 to 7 ml of venous blood in a lavender-top
tube; however, only 0.5 ml is required when using capillary tubes.
- Avoid hemolysis
- List on the laboratory slip any drugs that may affect test results
23
AFTER THE PROCEDURE
- Apply pressure to the venipuncture site.
- Explain that some bruising, discomfort and swelling may appear at
the site and warm compress can alleviate this.
- Monitor signs of infection
24
III. ANATOMY AND PHYSIOLOGY
Respiratory System
The respiratory system functions to deliver the oxygen to the blood --
the transport medium of the cardiovascular system -- and to remove oxygen
from the blood. The actual exchange of oxygen and carbon dioxide occurs in
the lungs.
The respiratory centers in the brain stem (pons and medulla) control
respiration's rhythm, rate, and depth. Primary controlling factors include 1)
the concentration of carbon dioxide in the blood (high CO2 concentrations
initiate deeper, more rapid breathing) and 2) air pressure within lung
tissue. Expansion of the lungs stimulates nerve receptors (vagus nerve X) to
signal the brain to "turn off" inspiration. When the lungs collapse, the
receptors give the "turn on" signal, termed the Hering-Breuer inspiratory
reflex. Other regulators are: 3) an increase in blood pressure, which slows
down respiration; 4) a drop in blood acidity, which stimulates respiration;
and 5) a sudden drop in blood pressure, which increases the rate and depth
of respiration. Voluntary controls -- "holding one's breath" -- can also affect
respiration, but not indefinitely. Carbon dioxide build-up soon forces an
automatic start-up.
25
The respiratory system consists of two tracts: The upper respiratory
tract includes the nose (nasal cavity, sinuses), mouth, larynx, and trachea
(windpipe). The lower respiratory tract includes the lungs, bronchi, and
alveoli.
The two lungs, one on the right and one on the left, are the body's
major respiratory organs. Each lung is divided into upper and lower lobes,
although the upper lobe of the right lung contains a third subdivision
known as the right middle lobe. The right lung is larger and heavier than
the left lung, which is somewhat smaller in size because of the
predominately left-side position of the heart.
A clear, thin, shiny coating -- the pleura -- envelopes the lungs. The
inner, visceral layer of the pleura attaches to the lungs; the outer, parietal
layer attaches to the chest wall (thorax). Pleural fluid holds both layers in
place, in a manner similar to two microscope slides that are wet and stuck
together. The lungs are separated from each other by the mediastinum, an
area that contains the heart and its large vessels, the trachea (windpipe),
esophagus, thymus, and lymph nodes. The diaphragm, the muscle that
contracts and relaxes in breathing, separates the thoracic cavity from the
abdominal cavity.
26
The chart of the respiratory system shows the intricate structures
needed for breathing. Breathing is the process by which oxygen in the air is
brought into the lungs and into close contact with the blood, which absorbs
it and carries it to all parts of the body. At the same time the blood gives up
waste matter (carbon dioxide), which is carried out of the lungs when air is
breathed out.
1. The SINUSES (frontal, maxillary, and sphenoidal) are hollow spaces in
the bones of the head. Small openings connect them to the nose. The
functions they serve include helping to regulate the temperature and
humidity of air breathed in, as well as to lighten the bone structure of the
27
head and to give resonance to the voice.
2. The NOSE (nasal cavity) is the preferred entrance for outside air into the
respiratory system. The hairs that line the wall are part of the air-cleaning
system.
3. Air also enter through the MOUTH (oral cavity), especially in people who
have a mouth-breathing habit or whose nasal passages may be temporarily
obstructed, as by a cold or during heavy exercise.
4. The ADENOIDS are lymph tissue at the top of the throat. When they
enlarge and interfere with breathing, they may be removed. The lymph
system, consisting of nodes (knots of cells) and connecting vessels, carries
fluid throughout the body. This system helps to resist body infection by
filtering out foreign matter, including germs, and producing cells
(lymphocytes) to fight them.
5. The TONSILS are lymph nodes in the wall of the throat (pharynx) that
often become infected. They are part of the germ-fighting system of the
body.
6. The THROAT (pharynx) collects incoming air from the nose and mouth
and passes it downward to the windpipe (trachea).
7. The EPIGLOTTIS is a flap of tissue that guards the entrance to the
windpipe (trachea), closing when anything is swallowed that should go into
the esophagus and stomach.
8. The VOICE BOX (larynx) contains the vocal chords. It is the place where
moving air being breathed in and out creates voice sounds.
28
9. The ESOPHAGUS is the passage leading from the mouth and throat to
the stomach.
10. The WINDPIPE (trachea) is the passage leading from the throat
(pharynx) to the lungs.
11. The LYMPH NODES of the lungs are found against the walls of the
bronchial tubes and windpipe.
12. The RIBS are bones supporting and protecting the chest cavity. They
move to a limited degree, helping the lungs to expand and contract.
13. The windpipe divides into the two main BRONCHIAL TUBES, one for
each lung, which subdivide into each lobe of the lungs. These, in turn,
subdivide further.
14. The right lung is divided into three LOBES, or sections. Each lobe is like
a balloon filled with sponge-like tissue. Air moves in and out through one
opening -- a branch of the bronchial tube.
15. The left lung is divided into two LOBES.
16. The PLEURA are the two membranes, actually one continuous one
folded on itself, that surround each lobe of the lungs and separate the lungs
from the chest wall.
17. The bronchial tubes are lines with CILIA (like very small hairs) that have
a wave-like motion. This motion carried MUCUS (sticky phlegm or liquid)
upward and out into the throat, where it is either coughed up or swallowed.
The mucus catches and holds much of the dust, germs, and other unwanted
matte that has invaded the lungs. You get rid of this matter when you
29
cough, sneeze, clear your throat or swallow.
18. The DIAPHRAGM is the strong wall of muscle that separates the chest
cavity from the abdominal cavity. By moving downward, it creates suction in
the chest to draw in air and expand the lungs.
19. The smallest subdivisions of the bronchial tubes are called
BRONCHIOLES, at the end of which are the air sacs or alveoli (plural of
alveolus).
20. The ALVEOLI are the very small air sacs that are the destination of air
breathed in. The CAPILLARIES are blood vessels that are imbedded in the
walls of the alveoli. Blood passes through the capillaries, brought to them
by the PULMONARY ARTERY and taken away by the PULMONARY VEIN.
While in the capillaries the blood gives off carbon dioxide through the
capillary wall into the alveoli and takes up oxygen from the air in the
alveoli.
Air Distribution
On inspiration, air enters the body through the nose and the mouth.
Nasal hairs and mucosa (mucus) filter out dust particles and bacteria and
warm and moisten the air. Less warming, filtering, and humidification occur
when air is inspired through the mouth.
Air travels down the throat, or pharynx, where two openings exist, one
into the esophagus for passage of food, and the other into the larynx (voice
box) and trachea (windpipe) for continued airflow. When food is swallowed,
the opening of the larynx (the epiglottis) automatically closes, preventing
food from being inhaled. When air is inspired, the walls of the esophagus
30
are collapsed, preventing air from entering the stomach. The larynx, which
also contain the vocal cords, is lined with mucus that further warms and
humidifies the air.
Air continues continues down the trachea, which branches into the
right and left bronchi. The main-stem bronchi divide into smaller bronchi,
then into even smaller tubes called bronchioles. The bronchial structures
contain hair-like, epithelial projections, called cilia, that beat rythmically to
sweep debris out of the lungs toward the pharynx for expulsion. Once in the
bronchioles, the air is at body temperature, contains 100% humidity, and is
(hopefully) completely filtered.
Bronchioles end in air sacs called alveoli -- small, thin-walled
"balloons," arranged in clusters. When you breathe in, enlarging the chest
cavity, the "balloons" expand as air rushes in to fill the vacuum. When you
breathe out, the "balloons" relax and air moves out of the lungs. It is at the
alveoli that gas exchange occurs. Tiny blood vessels, capillaries, surround
each of the alveoli. On inspiration, the concentration of dissolved oxygen is
greater in the alveoli than in the capillaries. Oxygen, therefore, diffuses
across the alveolar walls into the blood plasma. In the reverse process,
carbon dioxide concentration is greater in the blood than the alveoli, so it
passes from the blood into the alveoli and is ultimately breathed out.
As oxygen diffuses into the plasma, hemoglobin in the red blood cell
picks up the oxygen, permitting more to flow into the plasma. The oxygen-
carrying capacity of hemoglobin allows the blood to carry over 70 times
31
more oxygen than if the oxygen were simply dissolved in the plasma alone.
Therefore, the total oxygen uptake depends on: 1) the difference in oxygen
concentration between the blood and alveoli, 2) the healthy functioning of
the alveoli, and 3) the rate of respiration.
Pulmonary Circulation
The pulmonary circulatory circuit describes the process whereby
oxygen and carbon dioxide are delivered to and from the lungs. Oxygen-
poor blood travels to the right atrium via the inferior and superior vena
cavae, then to the right ventricle. The right ventricle subsequently pumps
the blood into the pulmonary artery, which branches to the right and left
lungs. The pulmonary arteries subdivide until reaching the arteriole, then
capillary levels. After gas exchange, the capillaries recombine to form
venules and veins. Ultimately two right and two left pulmonary veins carry
oxygen-rich blood to the heart for distribution, via the aorta/systemic
circuit, to the rest of the body.
32
Lung Volumes/ Capacities
The air that the lungs can hold can be divided into smaller
designations called "volumes."
The amount of air a person breathes in and out at rest is called the
Tidal Volume (Vt about 500ml). During such breathing, a person could
actually take in more air or blow more out. The additional amount a person
could inhale, such as during maximum physical activity, is called the
Inspiratory Reserve Volume (IRV 3,000 ml). The additional amount a person
could exhale is called the Expiratory Reserve Volume (ERV 1,000 ml). The
Residual Volume (RV) is the amount of air that stays in the lung even after
maximum expiration.
Breathing is an active process - requiring the contraction of skeletal
muscles. The primary muscles of respiration include the external intercostal
muscles (located between the ribs) and the diaphragm (a sheet of muscle
located between the thoracic & abdominal cavities).
The external intercostals plus the diaphragm contract to bring about
inspiration:
Contraction of external intercostal muscles > elevation of ribs &
sternum > increased front- to-back dimension of thoracic cavity >
lowers air pressure in lungs > air moves into lungs
Contraction of diaphragm > diaphragm moves downward > increases
vertical dimension of thoracic cavity > lowers air pressure in lungs >
air moves into lungs:
33
To exhale:
relaxation of external intercostal muscles & diaphragm > return of
diaphragm, ribs, & sternum to resting position > restores thoracic
cavity to preinspiratory volume > increases pressure in lungs > air is
exhaled
Intra-alveolar pressure during inspiration & expiration
As the external intercostals & diaphragm contract, the lungs expand.
34
The expansion of the lungs causes the pressure in the lungs (and alveoli) to
become slightly negative relative to atmospheric pressure. As a result, air
moves from an area of higher pressure (the air) to an area of lower pressure
(our lungs & alveoli). During expiration, the respiration muscles relax &
lung volume descreases. This causes pressure in the lungs (and alveoli) to
become slight positive relative to atmospheric pressure. As a result, air
leaves the lungs.
The walls of alveoli are coated with a thin film of water & this creates
a potential problem. Water molecules, including those on the alveolar walls,
are more attracted to each other than to air, and this attraction creates a
force called surface tension. This surface tension increases as water
molecules come closer together, which is what happens when we exhale &
our alveoli become smaller (like air leaving a balloon). Potentially, surface
tension could cause alveoli to collapse and, in addition, would make it more
difficult to 're-expand' the alveoli (when you inhaled). Both of these would
represent serious problems: if alveoli collapsed they'd contain no air & no
oxygen to diffuse into the blood &, if 're-expansion' was more difficult,
inhalation would be very, very difficult if not impossible. Fortunately, our
alveoli do not collapse & inhalation is relatively easy because the lungs
produce a substance called surfactant that reduces surface tension.
Role of Pulmonary Surfactant
Surfactant decreases surface tension which increases pulmonary
compliance (reducing the effort needed to expand the lungs) and reduces
tendency for alveoli to collapse.
35
Partial Pressure
Partial pressure is the individual pressure exerted independently by a
particular gas within a mixture of gasses. The air we breath is a mixture of
gasses: primarily nitrogen, oxygen, & carbon dioxide. So, the air you blow
into a balloon creates pressure that causes the balloon to expand (& this
pressure is generated as all the molecules of nitrogen, oxygen, & carbon
dioxide move about & collide with the walls of the balloon). However, the
total pressure generated by the air is due in part to nitrogen, in part to
oxygen, & in part to carbon dioxide. That part of the total pressure
generated by oxygen is the 'partial pressure' of oxygen, while that
generated by carbon dioxide is the 'partial pressure' of carbon dioxide. A
gas's partial pressure, therefore, is a measure of how much of that gas is
present (e.g., in the blood or alveoli).
The partial pressure exerted by each gas in a mixture equals the total
pressure times the fractional composition of the gas in the mixture. So,
given that total atmospheric pressure (at sea level) is about 760 mm Hg
and, further, that air is about 21% oxygen, then the partial pressure of
oxygen in the air is 0.21 times 760 mm Hg or 160 mm Hg.
36
Pathophysiology of Acute Bronchitis ( Book-Based)
a. Schematic Diagram
Modifable Factors-Smoke or fume inhalation-Malnutrition or poor immune system-Asthma-Viral infection-Environment
Non-modifiable factors
-Age (advance age/very young)
Entry of Virulent Microorganisms
Infectious Microorganisms lodges in the Bronchioles
Proliferation of Microorganisms
Inflammatory Response
Production of Mucus from Epithelial Cells
Releases Toxins
Bronchial epithelial injury
37
Exudates Formation
Release of Chemical Mediators
Parenchymal and Alveolar Consolidation
RESPIRATORY SECRETIONS
Cytokines
Release of Pyrogens
HYPERTHERMIA BODY WEAKNESS
Bradykinins Histamine
Stimulation of Goblet Cells
Accumulation of Secretions
WHEEZES AND COUGH
Narrowing of Blood Vessels
Air passes through narrowed lumen
SOB/DYSPNEA
Compensatory Mechanism
ELEVATED WBC
Bronchial Edema
Stimulates increase in Body
Temperature
CHEST PAIN
RALES
COUGHING UP BLOOD
Bronchial Obstruction
38
Pathophysiology of Acute Bronchitis (CLIENT-CENTERED)
a. Schematic Diagram
USE OF ACCESSORY MUSCLES
INCREASED RR and PR
Modifable Factors-Smoke or fume inhalation-Malnutrition or poor immune system-Asthma-Viral infection-Environment
Non-modifiable factors
-Age (advance age/very young)
Entry of Virulent Microorganisms
Infectious Microorganisms lodges in the Bronchioles
Proliferation of Microorganisms
Production of Mucus from Epithelial Cells
Releases Toxins
Bronchial epithelial injury
39
Inflammatory Response
Exudates Formation
Release of Chemical Mediators
Parenchymal and Alveolar Consolidation
RESPIRATORY SECRETIONS
Cytokines
Release of Pyrogens
HYPERTHERMIAJune 24 2009
BODY WEAKNESS June 23 2009
Bradykinins Histamine
Stimulation of Goblet Cells
Accumulation of Secretions
WHEEZES AND COUGH June 23 2009
Narrowing of Blood Vessels
Air passes through narrowed lumen
SOB/DYSPNEA
Compensatory Mechanism
Decreased WBC
Bronchial Edema
Stimulates increase in Body
Temperature
CHEST PAIN
RALESJune 23
2009
NON PRODUCTIVECOUGHJune 23 2009
Bronchial Obstruction
40
USE OF ACCESSORY MUSCLES
INCREASED RR and PRJune 24 2009
41
SYNTHESIS OF THE DISEASE (BOOK BASED)
Bronchitis is an inflammation of the lining of your bronchial tubes, which
carry air to and from your lungs. Bronchitis may be either acute or chronic.
Acute bronchitis is a lower respiratory tract infection that causes reversible
bronchial inflammation. In up to 95 percent of cases, the cause is viral.
Acute bronchitis is caused in most cases by a viral infection and may begin
after developing a cold or sore throat. Bronchitis usually begins with a dry
cough. After a few days it progresses to a productive cough, which may be
accompanied by fever, fatigue, and headache. The cough may last up to
several weeks. If not treated acute bronchitis can progress to pneumonia.
True acute purulent bronchitis is characterized by infection of the bronchial
tree with resultant bronchial edema and mucus formation. Because of these
changes, patients develop a productive cough and signs of bronchial
obstruction, such as wheezing or dyspnea on exertion. Unlike the chronic
inflammatory changes of asthma, the inflammation in acute bronchitis is
transient and usually resolves soon after the infection clears. In some
patients, however, the inflammation can last several months. In rare cases,
a postbronchitis cough can persist for up to six months.
Bronchitis can have causes other than infection. Bronchial wall
inflammation can occur in asthma or can be secondary to mucosal injury in
an acute event, such as smoke or chemical fume inhalation. This
inflammation can also result from chronic toxic exposure, such as cigarette
smoking. It is important to realize that when underlying inflammation is
present, such as in asthmatics or smokers, infective agents are likely to
cause more severe cough and wheezing.
Viruses are the most common cause of bronchial inflammation in otherwise
healthy adults with acute bronchitis. Only a small portion of acute
bronchitis infections are caused by nonviral agents, with the most common
42
organism being Mycoplasma pneumoniae. Study findings suggest that
Chlamydia pneumoniae may be another nonviral cause of acute bronchitis.
MODIFIABLE/ NON-MODIFIABLE FACTORS
Non-modifiable Factors (book based)
Age (Advanced Age/Very Young). For elderly, this is brought about
by the degenerative changes which put them at high risk in acquiring
and developing the disease condition. For young individuals especially
those newborns, they still have immature immune systems which makes
them more susceptible in acquiring the disease condition.
Modifiable Factors
Smoke or chemical fume inhalation. Smoking damages the
mucosal lining of the bronchus.
Asthma. Also causes bronchial wall inflammation.
Malnutrition and poor immune system. Improper nutrition and
poor nutrition can contribute to the development and acquiring of the
disease condition.
Viral Infection. Mostly the cause of the disease viral infection.
Environment. Presence of dust and pollutant may contribute in
occurrence of the said condition.
SIGNS AND SYMPTOMS
43
Difficulty of breathing or dyspnea. This results from the
continuous narrowing and obstruction of the airways. Manifestations
of dyspnea would include:
o Nasal flaring
o Pursed-lip breathing
o Use of accesory muscles
Chest tightness or pain. This results from the inflammation of the
airway, and due to labored breathing
Chest Pain. Usually, it is cause by shortness of breath, wheezes and
presence of cough.
Non-Productive/Productive Cough. Coughing is an important way
to keep the throat and airways clean. It is usually cause by the
presence of increase mucus secretion stimulated by the presence of
Microorganisms causing irritation in the lungs.
Presence of Adventitious Sounds on the Lungs (rales, wheezes,
ronchi). Presence of abnormal breath sounds is due to accumulation
of secretions in the alveolar sac which traps air producing theses
distinct sounds. Adventitious breath sounds may also occur when
narrowing of the bronchus occurs.
Dyspnea. This is because of the narrowing blood vessel caused by the
release of chemical mediators leading to difficulty of inspiration and
expiration.
Shortness of Breath. It is caused by obstruction of the air passages
that may lead to labored or difficulty in breathing.
Body Weakness. This is due to the physical exertion brought about
by compensatory mechanisms through breathing.
Fever with Chills. Increase in body temperature is caused by the
inflammatory response of the body due to the presence of virulent
microorganisms.
44
Coughing up Blood. It is the splitting up of blood or bloody mucus
from the lungs and throat usually cause by the extensive lesion in the
respiratory tract.
Elevated White Blood Cells. Increased in number of leukocytes is
brought about by the presence of bacterial infection in the body.
Increase Pulse Rate and Respiratory Rate. This is caused by
imbalance of oxygen supply and demand.
Use of Accessory Muscle when Breathing. This is a compensatory
mechanism in order to allow proper inhalation and exhalation.
SYNTHESIS OF THE DISEASE (CLIENT CENTERED)
MODIFIABLE/ NON-MODIFIABLE FACTORS
Non-modifiable Factors
Age (Very Young). The patient is 6 years old.
Modifiable Factors
Asthma. Also causes bronchial wall inflammation. She has
asthma since birth.
45
Malnutrition and poor immune system. Improper nutrition and
poor nutrition can contribute to the development and acquiring
of the disease condition. She has decreased appetite.
Viral Infection. Mostly the cause of the disease viral infection.
She was diagnose with URTI 4 days prior to admission.
Environment. Presence of dust and pollutant may contribute in
occurrence of the said condition. Patients house is located
along the highway.
SIGNS AND SYMPTOMS
Difficulty of breathing or dyspnea. (June 23,24 2009) This
results from the continuous narrowing and obstruction of the
airways. Manifestations of dyspnea would include:
o Nasal flaring
o Increased respiratory rate
Non-Productive/Productive Cough. (June 23-24 2009) Coughing
is an important way to keep the throat and airways clean. It is
usually cause by the presence of increase mucus secretion
stimulated by the presence of Microorganisms causing
irritation in the lungs.
Presence of Adventitious Sounds on the Lungs (rales) (June 23-
24 2009). Presence of abnormal breath sounds is due to
accumulation of secretions in the alveolar sac which traps air
producing theses distinct sounds. Adventitious breath sounds
may also occur when narrowing of the bronchus occurs.
Dyspnea. (June 23-24 2009) This is because of the narrowing
blood vessel caused by the release of chemical mediators
leading to difficulty of inspiration and expiration.
Respiratory Rate. This is caused by imbalance of oxygen supply
and demand.
46
Body Weakness. (June 23-24 2009) This is due to the physical
exertion brought about by compensatory mechanisms through
breathing.
Fever with Chills. (June 23-24 2009) Increase in body
temperature is caused by the inflammatory response of the
body due to the presence of virulent microorganisms.
Elevated White Blood Cells. (June 24 2009) Increased in
number of leukocytes is brought about by the presence of
bacterial infection in the body.
V. THE PATIENT AND HIS CARE
47
A. Medical Management
A.1 IVF’s and Nebulization
Medical
Manageme
nt/
Treatment
Date Ordered
Date Performed
Date
Changed/DC
General
Description
Indication(
s) or
Purpose(s)
Client’s
Response to
the
Treatment
Intravenous Fluids
D5 IMB 500cc, @ 45 ugtts/min
Date
ordered:
June 23 2009
Date started:
June 23 2009
It is a
hypertonic
solution, which
makes the cells
shrink,
composes of
water and
carbohydrates,
as source of
energy and both
cations and
anions
It is use to
supply the
necessary
nutrients.
And this
solution is
given
usually
when serum
osmolality
has
decreased to
dangerously
low levels.
Client fluid
loss due to
insensible
fluid loss
was replaced
and
nourished.
Nursing Responsibilities:
Prior to the procedure:
Check doctor’s order. Check for ordered IVF.
Check for the patency of the IV tubing, cloudiness and expiration
date.
48
Explain the procedure, importance and its benefits to the patient’s
SO.
Secure all materials for IV insertion
During the procedure:
Clean the site of administration. Choose a vein in the distal arm.
Support client hand and maintain aseptic technique.
Regulate the flow rate as ordered.
Always check if it the infusion site and in place.
Monitor I and O.
Monitor patient for fluid overload.
be sure that IV line is free from any kinds of bubbles.
Make sure that all incorporated IVF’s and its desired doses are
followed according to the doctor’s order.
Provide a splint to prevent injury of the vein.
Inspect for level of IV always.
After the procedure:
Monitor rate as ordered, flow and patency.
Document the time and date.
49
Medical
Manageme
nt/
Treatment
Date
Ordered
Date
Performed
Date
Changed/DC
General
Description
Indication(s) or
Purpose(s)
Client’s
Response to
the
Treatment
Nebulizati
on
Date ordered:
June 23 2009
Date started:
June 23 2009
Inhalation
therapy that
produces
droplets that
are suspended
in a gas such
as oxygen.
The dug
which was
formed to
mist would be
inhaled better
It aids bronchial
hygiene by
restoring and
maintaining
mucous blanket
continuity,
hydrating dried,
retained
secretions,
promoting
expectoration of
secretions. To
relive
bronchospasm,
to provide relief
to a
hyperresponsive
airway and to
liquefy and clear
tenacious
secretions.
The patient
demonstrated
an improved
in the
breathing
pattern. And
was able to
cough out
secretions
more often.
50
Nursing Responsibilities
Prior to the procedure:
Check doctor’s order.
Check for the amount of medication that is to be incorporate in the
procedure.
Explain the procedure to the patient’s S.O.
Arranged all the material needed. Wash hand.
During the procedure:
Hold the mouthpiece of the nebulizer upright to avoid spilling of
medicines.
Continue nebulization until the medication is already nebulized.
Do chest physio-therapy after nebulisation.
After the procedure:
Assess the client’s vital signs after nebulization, especially the
respiratory rate.
Document the time of the procedure was done.
B. Drugs
Name of
Drugs
Generic
Name
Brand Name
Date
Ordered
Date
Taken/Give
n
Date
Changed/D
C
Route of
Administr
ation,
Dosage
and
Frequenc
y of
Administr
ation
General
action; Drug
classification;
Mechanism of
action
Client
Response to
the
Medication
with Actual
Side Effects
Convibent
Date
ordered:
June 23 2009
Neb
combivent
plus 1
Anti asthmatic
Management of
The patient
maintained a
patent airway
51
Date started:
June 23 2009
nebule
fluticasone
q 6 hour
weight
22kg IVF
D5 IMB
50cc
reversible
bronchospasm
associated w/
obstructive
airway diseases
in patients who
require more
than a single
bronchodilator.
Name of
Drugs
Generic
Name
Brand Name
Date
Ordered
Date
Taken/Give
n
Date
Changed/D
C
Route of
Administrat
ion, Dosage
and
Frequency
of
Administrat
ion
General
action; Drug
classification;
Mechanism of
action
Client
Response
to the
Medicatio
n with
Actual
Side
Effects
FLUTICASON
E
Date
ordered:
June 23
2009
Date
Route of
Administratio
n:
Nebulizer
Dosage:
1 nebule
Inhalation
Prophylaxis of
asthma
The client
didn’t
experience
broncospa
sm
52
started:
June 23
2009
Nursing Responsibilities:
>Before administering, check for doctor’s order.
>Give drug with right dosage, route, and time for administration.
Prior to the procedure:
Read the Doctor’s order before giving the medication to the patient,
and always remember the 10 R’s
Inform the patient about the action and the purpose of the drug.
Before giving the medication ask the patient first if she already take
the medications or not.
Note if all the medications are available, if one of the medication are
not available make a prescription and ask the patient’s SO to buy it
for the patient.
Check if the nebulizer is functioning
Prepare the drug by diluting it with distilled water
During the procedure:
Make sure that the patient will take the medications on time.
If the medication is an IV route, make sure that you administer it on
time.
Always be at the bedside of the patient in order to help the patient in
taking her medications.
Follow the directions on your prescription label
Monitor the patient while inhaling the atomized drug if it is in proper
place
Instruct patient to take medication as directed for the full course of
therapy.
After the procedure:
53
Instruct patient to take medication at evenly spaced times and to
finish the medication completely.
Observe for side effects or allergies.
Inform the patient on the specific time the medication is to taken
again.
Inform patient that increased fluid intake and exercise may minimize
constipation
Document.
Name of
Drugs
Generic
Name
Brand
Name
Date
Ordered
Date
Taken/Give
n
Date
Changed/D
C
Route of
Administrat
ion, Dosage
and
Frequency
of
Administrat
ion
General
action; Drug
classification;
Mechanism of
action
Client
Response
to the
Medicatio
n with
Actual
Side
Effects
Paracetamo
l
aceteminop
hen
Date
ordered:
June 23
2009
Date
started:
June 23
2009
Route of
Administratio
n:
Per Orem
Dosage:
1ml q 4 hrs
Anti –pyretic
Inhibits
prostaglandins
in CNS but
lacks anti-
inflammatory
effects in
periphery;
reduces fever
through direct
action on
hypothalamic
The client
experience
relief from
fever
54
heat-regulating
center.
Nursing responsibilities
Prior to drug administration
Check the written medication order for completeness. It should
include the drug name, dosage, frequency, and duration of therapy.
Check if there are any special circumstances surrounding
administration of the dose to the patient
Be certain that you know the expected action, safe dosage range,
special instructions for administration and adverse effects associated
with drug orders
Wash you hands
Prepare the necessary equipment like the medication tray and
medication card.
Prepare the dosage as ordered
Check the label on the medication three times before administering
any drug
Ever prepare a dosage of medication, which is discolored,
contaminated, or outdated
During drug administration
Verify the patients name first.
Administer once daily
May be given with or without meals
After drug administration
Assess for adverse effect of the drug
Assess for temperature
Documentation the procedure
55
Name of
Drugs
Generic
Name
Brand
Name
Date
Ordered
Date
Taken/Give
n
Date
Changed/D
C
Route of
Administrat
ion, Dosage
and
Frequency
of
Administrat
ion
General
action; Drug
classification;
Mechanism of
action
Client
Response
to the
Medicatio
n with
Actual
Side
Effects
PEDZINC Date
ordered:
June 23
2009
Date
started:
June 23
2009
Route of
Administratio
n:
Per Orem
Dosage:
5 ml syrup
once a day
Vit C and zinc
supplement to
keep child
strong, healthy
and mentally
alert. Increase
immunity
against
common
infections &
everyday
The client
immune
system
was
boosted.
56
stress. Reduces
the risk,
severity &
duration of
common colds,
malaria,
pneumonia &
diarrhea.
Nursing responsibilities
Prior to drug administration
Check the written medication order for completeness. It should
include the drug name, dosage, frequency, and duration of therapy.
Check if there are any special circumstances surrounding
administration of the dose to the patient
Be certain that you know the expected action, safe dosage range,
special instructions for administration and adverse effects associated
with drug orders
Wash you hands
Prepare the necessary equipment like the medication tray and
medication card.
Prepare the dosage as ordered
Check the label on the medication three times before administering
any drug
Ever prepare a dosage of medication, which is discolored,
contaminated, or outdated
During drug administration
Verify the patients name first.
Administer once daily
57
May be given with or without meals
After drug administration
Assess for adverse effect of the drug
Name of
Drugs
Generic
Name
Brand Name
Date
Ordered
Date
Taken/Give
n
Date
Changed/D
C
Route of
Administrat
ion, Dosage
and
Frequency
of
Administrat
ion
General
action; Drug
classification;
Mechanism of
action
Client
Response
to the
Medicatio
n with
Actual
Side
Effects
COAMOXCILA
V
( Amoclav )
Date
ordered:
June 23
2009
Date
started:
June 23
2009
Route of
Administratio
n:
Per Orem
Dosage:
300mg +
20cc IV
diluent q
8hrs.
Lower resp
tract
infections,
otitis media,
sinusitis, skin
& soft tissue
infections, UTI,
pre & post-
surgical
procedures,
bone & joint, O
& G infections,
dental
infections.
The client
reduces
infection
58
Nursing responsibilities
Prior to drug administration
Check the written medication order for completeness. It should
include the drug name, dosage, frequency, and duration of therapy.
Check if there are any special circumstances surrounding
administration of the dose to the patient
Be certain that you know the expected action, safe dosage range,
special instructions for administration and adverse effects associated
with drug orders
Wash you hands
Prepare the necessary equipment like the medication tray and
medication card.
Prepare the dosage as ordered
Check the label on the medication three times before administering
any drug
Ever prepare a dosage of medication, which is discolored,
contaminated, or outdated
During drug administration
Verify the patients name first.
Administer every 8 hours
May be given with or without meals
After drug administration
Assess for adverse effect of the drug
59
C. Diet
Type of
Diet
Date
Ordered
Date
Performed
Date
Changed/D
C
General
Descriptio
n
Indication
(s) and
Purpose(s
)
SPECIFIC
FOODS
TAKEN
Client’s
Response
and/or
Reaction
to the Diet
DAT Date
ordered:
June 23
2009
Date
started:
June 23
2009
Nearly the
normal diet
on the basic
four food
groups. The
diet must
be
withdrawn
with signs
of
aspiration.
A balanced
diet is
necessary
for the
recovery of
the patient
that is why
the
physician
ordered a
normal
diet.
However,
the SO
must
discontinu
e the
The patient
prefers to
eat food
such as
bread,
soda, and
coffee.
The patient
demonstrat
ed
improved
appetite.
60
patient’s
feeding if
severe
DOB
occurs to
prevent
aspiration
which may
aggravate
the
patient’s
condition.
Nursing Responsibilities:
Check doctor’s order regarding the type of diet.
Explain to patient’s SO regarding NPO
Give health teachings regarding proper preparation of food for the
patient
Always emphasized aseptic technique
Be sure patient is taking or eating foods she can tolerate.
Be sure patient is taking or eating foods she can tolerate.
Assess for patent’s condition, how she respond to the diet.
Provide foods which are indicated for DAT
D. Activity/Exercise
Type of Date
Ordered
General
Descripti
Indication
(s) and
Client’s
response or
61
Exercise Date
Performed
Date
Changed/D
C
on Purpose(s
)
reaction to
the
activity/exerc
ise
HIGH
BACK
REST
Date
ordered:
June 23
2009
Date stated:
June 23
2009
Head of
bed is
elevated
to 45-90
degrees
To
maximize
lung
expansion
since
patient is
having
DOB
Relieved from
DOB
Nursing Responsibilities
Check doctor’s order
Elevate head of bed to 45-90 degrees
Place pillows on the side edge of the bed
Raise side rails if the patient prefer
62
Nursing Care Plan
Problem #1 - Ineffective airway clearance r/t retained secretions in the bronchi
Assessment Nursing Diagnosis
Scientific Explanation
Objectives Interventions Rationale Expected Outcome
S>Ø
O> patient
may
manifest:
Adventitiou
s breath
sounds
(crackles/w
heezes)
Tachypnea
Dyspnea
Productive/
non-
productive
cough
Cyanosis
Difficulty
of
Ineffective
airway
clearance
r/t retained
secretions
in the
bronchi
Inflammation
and swelling of
the linings of the
airways leads to
narrowing and
obstruction of
the airways. The
inflammation
also stimulates
production of
mucous
(sputum), which
can cause
further
obstruction of
airways.
ST> after 1
hour of
nursing
intervention
the patient
will
maintain
patent
airway
LT>after 3
days of
nursing
intervention
the patient
will
demonstrat
1. Assess energy
level and
endurance and
effect on chest
expansion
2. Assess
respiratory
status for rate,
depth and ease,
presence of
tachypnea,
dyspnea in
relation to
disease process
or decrease
1. Decrease with
age, more than
one chronic
disorder further
compromises
maintenance of
ventilation
2. Changes vary
from minimal to
extreme caused
by obstruction
(bronchial
swelling),
increased mucus
secretions
(oversecretions
of goblet cells,
ST> after 1
hour of
nursing
intervention
the patient
shall have
maintained
patent airway
LT>after 3
days of
nursing
intervention
the patient
shall have
demonstrated
absence/redu
63
vocalizing
Wide-eyed
orthopnea
e
absence/red
uction of
congestion
with breath
sounds
clear,
respiration
noiseless,
improve
oxygen
exchange
energy level
3. Auscultate for
adventitious
sounds
(crackles,
wheezes)
tracheobronchia
infection),
bronchospasm
and narrowing of
air passages
(stmulation of
irritant receptors
in smooth muscle
layer of
conducting
airways)
3. Wheezing
results from
squeezing of air
past narrowed
airways during
expiration
caused by
bronchospasms,
edema and
obstructive
secretions;
ction of
congestion
with breath
sounds clear,
respiration
noiseless,
improve
oxygen
exchange
64
4. Assess for
cough and
sputum
production for
amount, color,
viscosity, ability
to cough and
expectorate
secretions in
relation to
energy levels
5. Administer
crackles result
from lung
consolidation of
leukocytes and
fibrin in an area
caused by
infectious
process or fluid
accumulation in
the lungs
4. Changes in color
to green in
morning and
yellow during
day indicate
infection;
tenacious, thick
secretions
require more
enrgy and effort
to remove and
65
bronchodilators,
anti-
inflammatories,
expectorants,
mucolytics, anti-
infectives
6. Provide
environmental
air
humidification\
7. Offer 2-3 L (10-
12 glasses)/day
unless
contraindicated;
offer hourly
including a
warm beverage
upon arising
8. Position in
may cause
obstruction and
stasis leading to
infection and
respiratory
changes
5. Treats
bronchospasm,
prevents or
treats infection,
liquefies
secretions and
enhances outflow
and removal of
respiratory tract
fluids
6. Adds moisture
to the air to thin
mucus for easier
removal
7. Assist to
66
semi-fowler’s
and change
position q 2h
9. Perform
postural
drainage using
gravity,
percussion,
vibration, avoid
postions that
may be
contraindicated
in the elderly
10. Maintain
activity pattern,
mobilize thin
secretions for
easier removal
8. Prevents
accumulation of
secretions;
promotes
comfort and ease
breathing and
decreases airflow
resistance and
enhances gas
distribution,
facilitates chest
expansion
9. Raises
secretions, clears
sputum and
67
encourage
ambulation
within
limitations
11. Encourage
deep breathing
and coughing
exercises by
taking a deep
breath, exhale
as much as
possible, inhale
again and cough
twice from the
chest
12. Suction if
appropriate
increases force
of expiration
10. Mobilize
secretions for
easier removal
11. Assist in
dislodging
secretions for
easier
expectoration by
initiating the
cough reflex
which protects
the lungs from
accumulation of
secretions by
action on
receptors in
68
13. Instruct
patient to avoid
milk, caffeine
drinks and
alcohol
14. Instruct
patient to avoid
excessively hot
or cold fluids;
cold air and
wind exposure
by wearing
mask
15. Encourage
cessation of
smoking;
tracheobronchial
wall
12. Removes
secretions in
those too weak
to cough or with
mentation or
LOC deficits
13. Milk
thickens mucus,
caffeine reduces
effect of
medication
( bronchodilators
), alcohol
increases cell
dehydration and
bronchial
constriction
14. Predisposes
to coughing
69
suggest
program to
support the
reduction or
cessation of
smoking
16. Program of
daily exercises;
supervised if
needed
17. Instruct
patient to avoid
crowds and
those with
upper
respiratory tract
infections
spells; dyspnea,
bronchospasm
15. Smoking
causes increased
mucus,
vasoconstriction,
increased BP,
inflammation of
the lung lining,
decreased
number of
macrophages in
airways and
mucociliary
blanket
16. Promotes
secretion
removal
70
18. Instruct
patient on
proper use of
and disposal of
tissues used for
expectoration
17. Prevents
possible
transmission of
infection
18. Prevents
transmission of
microorganism
as sputum
contains
infecting
organism and
inflammatory
debris
Problem #2 - Ineffective breathing pattern r/t tracheobronchial obstruction
Assessment Nursing Diagnosis
Scientific Explanation
Objectives Interventions Rationale Expected Outcome
S>Ø
O> patient Ineffective Irritants inflame ST> after 1 1. Assess 1. Changes vary ST> after 1
71
may
manifest:
Prolonged
dyspnea
Exhausted
appearanc
e
Lethargy
Listlessnes
s
Drowsy
breathing
pattern r/t
tracheobro
nchial
obstruction
the
tracheobronchial
tree, leading to
increase mucus
production and a
narrowed or
blocked airway.
As the
inflammation
continues, goblet
and epithelial
cell hypertrophy.
Because the
natural defense
mechanism is
blocked, the
airway
accumulate
debris in the
respiratory tract.
hour of
nursing
intervention
the patient
will
verbalize
awareness
of causative
factors and
iniate
needed
lifestyle
changes
LT>After 3
days of
nursing
intervention
the patient
will be free
of cyanosis
and other
respiratory
status for rate,
depth and ease,
presence of
dyspnea and use
of accessory
muscles,
lengthened
expiratory
phase
2. Asses energy
level, fatigue
and effect on
breathing
with acuteness of
condition and are
caused by airway
resistance,
bronchospasm,
decreased lung
expansion,
dyspnea results
from stimulation
of lung receptors
or reduced
ventilatory
capacity or
breathing
reserve
2. Limited energy
reserve in elderly
quickly
dissipated as
work of
breathing
increases
hour of
nursing
intervention
the patient
shall have
verbalized
awareness of
causative
factors and
iniate needed
lifestyle
changes
LT>After 3
days of
nursing
intervention
the patient
shall be free
of cyanosis
and other
signs and
72
signs and
symptoms
of hypoxia
with ABGs
within
client
acceptable
range
3. Assess pain or
chest
discomfort, sore
chest muscles,
effort on chest
excursion
4. Auscultate for
diminished or
absent breath
sounds,
wheezes or
crackles
5. Have client to
breath into
paper bag
6. Administer
bronchodilator
3. Results from
excessive
coughing , use of
muscles for work
of breathing
causing reduced
chest expansion
and shallow
breathing
pattern
4. Changes caused
by infectious
process as
consolidation
develops;
damage to
bronchioles
restrict air
movement
5. To correct
hyperventilation
symptoms of
hypoxia with
ABGs within
client
acceptable
range
73
as ordered
7. Position in
semi- or high
fowler’s
8. Perform deep
breathing
exercises and
pursed lip
breathing,
isometric
exercises for
intercostals
muscle and
diaphragm
6. Treats
bronchospasm,
prevents or
treats infection
7. Promotes
comfort and ease
of breathing and
gas distribution,
facilitates chest
expansion by
causing
abdominal
organs to sag
way from
diaphragm
8. Strengthens
chest and
abdominal
muscles to
enhance
breathing ;
pursed lip
74
strengthening;
upper body
exercises by
raising arms
and using 2-3 lb
hand weight if
available
9. Provide proper
body alignment
in positioning
for sleep, use
pillows, to
elevate head
and support
chest.
10. Pace
activities, allow
for rest between
periods of
exercises
11. Instruct
patient to avoid
breathing
prolongs
expiratory phase
and prevents
alveoli from
collapsing to
decrease CO2
retention
9. Ensures optimal
ventilation
10. Prevents
changes in
respirations
brought about by
exertion
75
extending any
activity beyond
baseline of
tolerance
12. Encourage
patient of
relaxation
techniques,
guided imagery,
music when
breathing
pattern changes
or anxiety
increases
11. Causes
exacerbation of
dyspnea
12. Decrease
respiratory rate
Problem #3-Impaired gas exchange r/t ventilation perfusion imbalance
Assessment Nursing Diagnosis
Scientific Explanation
Objectives Interventions Rationale Expected Outcome
76
S>Ø
O> patient
may
manifest:
Irritability
Hypoxemia
Hypercapni
a
Confusion
Somnolenc
e
Hypoxia
impaired
gas
exchange
r/t
ventilation
perfusion
imbalance
Bronchospastic
disease changes
gas flow and
blood
distribution
possibly causing,
in some cases,
ventilation-
perfusion
mismatching.
With
bronchospasm,
autoregulation
mechanisms
change blood
flow patterns in
an attempt to
maintain a match
between
ventilated
regions and
ST> After 1
hour of
nursing
intervention
the patient
will
verbalize
understandi
ng of the
causative
factors and
appropriate
intervention
s
LT> after 3
days of
nursing
intervention
the patient
will
maintain
1.Assess
respiratory
status for rate,
depth and ease,
dyspnea and
respiratory
effort on
exertion, length
of inspiratory
and expiratory
phase
2.Assess for
cyanosis and
monitor arterial
blood gas for
1. Gas exchange
carried out by
pulmonary
circulation is
affected by body
position and
posture as is
ventilation; it is
dependent on the
matching of
ventilation and
perfusion of equal
amounts of air
and blood
entering the
lungs at the
alveoli level
2. O2 and CO2
diffusion and
exchange are
affected by the
ST> After 1
hour of
nursing
intervention
the patient
shall have
verbalized
understandi
ng of the
causative
factors and
appropriate
intervention
s
LT> after 3
days of
nursing
intervention
the patient
shall have
77
perfuse regions.
Nevertheless,
chronic
bronchitis and
acute asthma
often result in a
low
ventilation/perfu
sion condition
(V/Q) with
associated
oxygen
desaturation and
hypoxemia.
adequate
oxygen and
carbon
dioxide
levels with
return of
respiratory
baselines
decreased
oxygen and
increase carbon
dioxide levels,
possible
lowered pH; O2
saturation by
oximetry
3.Assess for
changes in
consciousness,
mentation,
restlessness,
irritability,
rapid fatigue
surface area
available,
thickness of the
alveolocapillary
membrane of
both of which
characteristic of
aging or disease
lung tissue;
cyanosis results
from the
reduction in
oxygenated
hemoglobin in the
blood and leads
to hypoxia
(reduced tissue
oxygenation)
3. Results of
decreased oxygen
to brain tissue
with progressive
maintained
adequate
oxygen and
carbon
dioxide
levels with
return of
respiratory
baselines
78
4.Position patient
in semi/high-
fowler’s using
chair or pillow
on over bed
table to lean
forward
5.Breathing
exercise
6.Administer
oxygen at 2-3
L/min via
cannula, non
breather mask
hypoxia
4. Promotes
breathing and
gas distribution
facilitates chest
expansion and
pulmonary blood
flow; sitting
position stabilizes
chest structures
5. Restores
function of
diaphragm which
decreases work
of breathing and
improves gas
exchange
6. Maintain
adequate oxygen
79
7.Instruct patient
to avoid
activities that
cause change
in respirations
especially
shortness of
breath
8.Instruct patient
to report any
changes in
fatigue level or
any mental
clouding,
increasing
dyspneic
episodes
9.Encourage
adequate rest
and limit
activities to
within client
level without
depressing
respiratory drive
which increases
CO2 retention
7. Increase in
oxygen
consumption
changes
breathing pattern
8. Indicates
impending
hypoxia
9. Help limit O2
needs/consumptio
80
tolerance
10. Instruct
patient to keep
his
environment
allergen/polluta
nt free
11. Encourage
cessation of
smoking;
suggest
program to
support the
reduction or
cessation of
smoking
n
10. To reduce
irritant effect on
airways
11. To improve
lung function
Problem #4 – High risk for infection r/t inadequate primary defenses (decrease ciliary action)
Assessment Nursing Diagnosis
Scientific Explanation
Objectives Interventions Rationale Expected Outcome
S>Ø
O> patient ST> After 1 1. Assess for 1. Early detection ST> After 1
81
may
manifest :
Productive
cough
Fever
Restlessne
ss
Tiredness
Increase
WBC count
Pinkish
skin
Drowsiness
Green or
yellow
sputum
High risk
for
infection r/t
inadequate
primary
defenses
(decrease
ciliary
action)
Smoke and other
pollutants
irritate the
airways,
resulting in
hypersecretion of
mucus and
inflammation.
This constant
irritation causes
the mucus
secreting glands
and goblet cells
to increase in
number. Ciliary
function is
reduced and
more mucus is
produced. The
bronchial walls
become
thickened, the
hour of
nursing
intervention
the patient
will have
vital signs
within
normal
ranges
LT> After 3
days of
nursing
intervention
the patient
will identify
intervention
s to prevent
infection
and
demonstrat
e
increased
dyspnea,
change in color
and viscosity of
sputum (yellow
or green),
cough
2. Administer
antibiotic
therapy
3. Obtain periodic
sputum
cultures
4. Avoid smoking,
chilling,
inhalation of
environmental
pollutants
5. Avoid large
of respiratory
infection allows
for immediate
treatment
before
respiratory
system is
compromise
2. Prevents or
treats
respiratory
infection if
symptoms
appear
3. Reveal
infectious agent,
evaluates effect
of treatment
4. Irritates mucosa
and initiates
dyspneic attack
hour of
nursing
intervention
the patient
shall have
vital signs
within
normal
ranges
LT> After 3
days of
nursing
intervention
the patient
shall have
identified
interventions
to prevent
infection and
demonstrated
techniques to
82
bronchial lumen
narrows and
mucus may plug
the airway.
Alveoli adjacent
to the
bronchioles may
become damaged
and fibrosed,
resulting in
altered function
of the alveolar
macrophages.
This is significant
because the
macrophages
play an
important role in
destroying
particles,
including
bacteria.
techniques
to promote
safe
environmen
t
groups,
exposure
6. Proper hand
washing,
disposal of
tissues, cover
mouth and nose
when coughing,
cleansing and
disinfection off
respiratory
equipment
7. Proper
administration
and expected
effect of
antibiotic
therapy and to
take complete
prescription
8. Instruct patient
5. Prevent s
contact with
potential
infectious
agents
6. Prevents
transmission of
infectious
agents from
contaminated
articles
7. Prevents
recurrence of
infection
promote safe
environment
83
to report fever
or change in
sputum
9. Encourage
early
ambulation,
deep breathing
and coughing
position change
8. May indicate
infection
9. For mobilization
of respiratory
secretions
84
Problem#5 - Sleep pattern disturbance r/t internal factors of illness and psychological stress of
dyspnea
Assessment Nursing Diagnosis
Scientific Explanation
Objectives Interventions Rationale Expected Outcome
S>Ø
O> patient
may
manifest:
Irritability
Frequent
yawning
Tiredness
Drowsiness
Listlessnes
s
Sleep
pattern
disturbance
r/t internal
factors of
illness and
psychologic
al stress of
dyspnea
Sleeplessness
and daytime
sleepiness are
common
problems.
Studies indicate
that between 80
- 93% of people
with asthma
have sleeping
ST>after 1
hour of
nursing
intervention
the patient
will
verbalize
understandi
ng of sleep
disturbance
1. Assess sleep
pattern and
changes, naps
and frequency,
amount of
activity or
sedentary
status,
awakenings
and when they
1. Provides data
for resolving
sleep
deprivation in
relation to
aging changes
ST>after 1
hour of
nursing
intervention
the patient
shall have
verbalized
understandin
g of sleep
disturbance
85
Lethargy
Disorientat
e
Dark
circles
under eyes
problems about
three times a
week. Asthma
has been
associated with
snoring and
obstructive sleep
apnea, a
condition in
which blockage
of the upper
airway causes
the sleeper to
temporarily stop
breathing, then
resume with a
gasp, often many
times during
each hour of
sleep.
LT>after 3
days of
nursing
intervention
the patient
will report
improveme
nt of
sleep/rest
pattern
occur and
frequency,
feelings of
fatigue,
apathy,
lethargy,
impotence
2. Assess
presence of
dyspnea
3. Assess
presence of
depression,
confusion and
anxiety
4. Assess use of
alcohol,caffein
e,medication
regimen
2. Causes of
frequent
awakenings
and
interruptions in
sleep
3. Common causes
of insomnia and
sleep
disturbance
pattern
4. Alters sleep
which may
cause
irritability,
lethargy, drug
action,
absorption and
excretion may
LT>after 3
days of
nursing
intervention
the patient
shall have
reported
improvement
of sleep/rest
pattern
86
5. Assess
environment
for lighting,
noises, odors,
temperature,
ventilation
6. Provide
ritualistic
procedures of
be delayed in
elderly and
adverse effects
and toxicity at
higher
riskExternal
stimuli
interferes with
going to sleep
and increases
wakenings as
sleep in the
elderly is of
less intensity
5. Prevents break
in established
pattern
And promotes
comfort and
relaxation
before sleep
87
warm drink,
extra covers,
clean linens,
warm bath
before bedtime
7. Provide quiet,
calm, peaceful
environment
8. Allow naps
during day
according to
need
recognizing
that they may
interfere with
sleep and
6. Promotes falling
asleep
7. Some elderly
prefer to sleep
throughout 24
hours with
short naps
providing
adequate rest
8. Promotes
relaxation
before sleep
and reduces
anxiety and
88
cause
insomnia
9. Provide back
rub, relaxation
techniques,
imagery,
music,
massage at
bedtime
10. Instruct
patient to
refrain from
use of alcohol
and CNS
depressants
11. Inform
patient of
aging changes
and their
relation to
sleep changes
tension
9. Depresses sleep
10. Assist in
acceptance of
changes and
need for sleep
revision of
sleep pattern
11. Prevents
falling asleep
because of
overstimulation
89
Problem #6 - Fatigue r/t respiratory effort
Assessment Nursing Diagnosis
Scientific Explanation
Objectives Interventions Rationale Expected Outcome
S>Ø
O> patient
may
manifest:
Irritability
Exhausted
appearanc
e
Lethargy
Listlessnes
s
Drowsy
Fatigue r/t
respiratory
effort
Hyperventilation
is triggered by
lung receptors to
increase lung
volume because
of trapped air
and obstructions.
Intrapleural and
alveolar gas
pressure rise,
causing a
ST> After 1
hour of
nursing
intervention
the patient
will
participate
in
therapeutic
regimen
1. Assess for
extreme
weakness and
fatigue; ability
to rest, sleep
and amount;
movement in
bed
1. Provides
information to
determine
effects of
dyspnea and
work of
breathing over
period of time,
which becomes
exhaustive and
depletes energy
ST> After 1
hour of
nursing
intervention
the patient
shall have
participated
in
therapeutic
regimen
90
Disinterest
in
surroundin
gs
decreased
perfusion of
alveoli.
Increased
alveolar gas
pressure,
decreased
ventilation, and
decreased
perfusion result
in uneven
ventilation-
perfusion ratios
and mismatching
within different
lung segments.
LT> after 3
days of
nursing
intervention
the patient
will report
improved
sense of
energy
2. Accept client’s
report of
fatigue
3. Establish
realistic goals
with client
4. Plan care to
allow adequate
rest periods.
Schedule
activities for
periods when
client has the
most energy
5. Provide
environment
reserve and
ability to rest,
eat, drink
2. To assist client
to cope with
fatigue and to
manage within
individual limits
of ability
3. Enhances
commitment to
promoting
optimal
outcomes
4. To maximize
participation
5. Temperature
and level of
LT> after 3
days of
nursing
intervention
the patient
shall have
reported
improved
sense of
energy
91
conducive to
relief of fatigue
6. Provide
supplemental
oxygen as
indicate
7. Encourage use
of measures to
prevent fatigue
(diversional
activities such
as wathcing
TV, small
frequent
feedings)
humidity are
known to affect
exhaustion
6. Presence of
anemia/hypoxe
mia reduces
oxygen available
for cellular
uptake and
contributes to
fatigue
7. Provide support
and conserves
energy
Problem #7 - Activity intolerance r/t imbalance between oxygen demand and supply
Assessment Nursing Diagnosis
Scientific Explanation
Objectives Interventions Rationale Expected Outcome
92
S>Ø
O> Patient
may
manifest:
Dyspnea
Tachypnea
Body
weakness
Use of
accessory
muscles to
breathe
Fatigue
Pale nail
beds
Pale
palpebral
conjunctiva
Cyanosis
Activity
intolerance
r/t
imbalance
between
oxygen
demand
and supply
Oxygen is
needed by the
body especially
in the process of
metabolism to
produce energy.
Due to excessive
mucus
production and
decrease
function of the
cilia to remove
secretions,
impaired
breathing results
to imbalance
between oxygen
demand and
supply from the
lungs to the body
and retention of
carbon dioxide
ST>After 1
hour of
nursing
intervention
the patient
will
participate
willingly in
necessary
activities to
increase
activity
tolerance
LT> After 3
days of
nursing
intervention
the patient
will
maintain
optimal
1. Assess for
baseline
tolerance for
activity, ability
to adapt,
amount of rest
and sleep
2. Assess pulse
and respirations
before, during
and after
activity
3. Provide periods
of rest after
activity around
rest or sleep
periods; allow
self pacing of
activities
1. Promotes and
protects
respiratory
functions
2. Pulse increase
of 10 or
more/min. or
increase and any
difficulty in
respirations
indicate that
activity limit has
been reached
3. Prevents
dyspneic episode
and provides
uninterrupted
rest and sleep
necessary for
physical and
ST>After 1
hour of
nursing
intervention
the patient
shall have
participated
willingly in
necessary
activities to
increase
activity
tolerance
LT> After 3
days of
nursing
intervention
the patient
shall have
maintained
93
occurs. activity
level within
energy and
breathing
limitations.
4. Provide quiet,
stress free
environment
5. Provide oxygen
during activities
if appropriate
6. Assist with
activities as
needed
7. Provide slowly
progressive
activity/exercise
program and
promote
independent
mental health to
prevent fatigue
4. Stress and
stimuli produce
anxiety and
increase
respirations
5. Pulmonary
function tests
indicate
hypoxemia
during exercise
and determine
need for
additional
oxygen
6. Conserves
energy and
oxygen
consumption;
prevents dyspnea
7. Increases
optimal
activity level
within energy
and
breathing
limitations.
94
ADL
participation
8. Instruct the
patient to avoid
extending
activities
beyond fatigue
level or
tolerance that
may provoke
dyspne
9. Instruct the
patient to utilize
energy saving
devices such as
arm rest, sitting
on stool in
shower, placing
articles
commonly used
within reach
delivery of
oxygen to
tissues;
increases
tolerance to
activities and
decreases feeling
of helplessness
8. Conserves
energy and
prevents
exacerbation of
dyspnea
9. Prevents fatigue
95
10. Instruct the
patient to
schedule
activities during
peak or optimal
effect time of
systemic
medication; use
inhalers before
activity
10. Allows for
activities without
dyspneic
episodes
96
ACTUAL NURSING CARE (SOAPIE)
June 24 2009
S>Ø
O>Received patient sitting on bed, awake and coherent to person place and
time, with an ongoing IVF#3 D5IMB 500cc regulated at 45 ugtts/min at a
level of 350cc, infusing well at the left hand, good skin turgor, rales on both
lung fields upon auscultation, with nonproductive cough, with nasal flaring,
CRT of 1-2 seconds with pinkish palpebral conjuctiva, with leukocytes of
4.52 dated June 24 2009 with vital signs as follows : T=36.9°C, HR= 95
bpm, RR= 26 cycles/min, BP=90/60 mmHg
A>
1. Ineffective airway clearance r/t retained secretions in the bronchi
2. Impared gas exchange r/t obstructions on the airway AEB rales upon
auscultation.
3. Ineffective protection r/t altered blood profile AEB decreased
leukocytes secondary to acute bronchitis.
P>
1. After 3° of NI the patient will maintain airway patency AEB absence of
respiratory distress.
2. After 3° of NI the patient will able to maintain adequacy of gas
exchange AEB absence of respiratory distress.
3. After 2° of NI the patient will be free from infection.
I>Established rapport
>Monitored and recorded vital signs
>Assessed patient’s condition and watch out for signs and symptoms of
respiratory distress
>provided comfort and safety measures
>kept patient’s back dry
>Encouraged to increase fiber intake and vitamin C
>Elevated the head of bed
97
>performed chest tapping/back rub to mobilize secretions
>provided nebulization as ordered
>Encourage turning position changes
>due meds given
>Further needs attended
>endorsed
E>
1. Goal met AEB patient able to maintain airway patency AEB
absence of respiratory distress.
2. Goal met AEB patient able to maintain adequacy of gas exchange
AEB absence of respiratory distress.
3. Goal met AEB patient was free from infection.
VI. CLIENT’S DAILY PROGRESS IN THE HOSPITAL
1) Client’s Daily Progress Chart
Days Admission
06/23/09 06/24/09
Nursing Problems
1.) Ineffective airway clearance r/t retained
secretions in the bronchi
2.) Ineffective breathing pattern r/t
tracheobronchial obstruction
3.) Impaired gas exchange r/t ventilation
perfusion imbalance
4.) High risk for infection r/t inadequate
primary defenses (decrease ciliary action)
5.) Sleep pattern disturbance r/t internal
factors of illness and psychological stress of
98
dyspnea
6.) Fatigue r/t respiratory effort
7.) Activity intolerance r/t imbalance
between oxygen demand and supply
Vital Signs
1.) Temp. 36.1C 36.8C
2.) PR 75bpm 95bpm
3.) RR 38cpm 26cpm
4.) BP 90/60 90/60
Diagnostic/Lab Procedures
1) Hematology
2.) CXR PA
3.) Urinalysis
4.) cold agglutinin determination
1)IVF D5 IMB 500 cc
2.) Neb
Drugs:
Paracetamol
Co amoxiclav
Pedzinc
Comvibent + fluticasone
Diet:
DAT
Activity/Exercise
Bederest
99
100
2. DISCHARGE PLANNING
A. General condition about the client upon discharge.
The client achieved his optimum health status after his hospitalization. He
has already adequate ventilation and oxygenation. No other associated
signs and symptoms of respiratory distress he appears generally in good
condition. There were no complications noted. Still, on the process of
recovery.
S> Ø
O> Received patient sitting on bed, awake and coherent, with an ongoing
IVF #6 D5 IMB 500cc x 45ugtts/min at level of 300cc infusing well at the
left dorsal veinof the hand, c good skin turgor, c cough, c (-) DOB, c V/S as
follows : T=36.8, PR= 90 bpm, RR= 25, BP=90/60 mmHg
A> Readiness for enhanced well being
P> After 2 hours of nursing intervention the patient will remain free of
preventable complications/progression of illness and sequelae and will
verbalize understanding of health teachings
M>
Paracetamol syrup 5ml every 4 hours for fever
Co amoxiclav 300mg every 8 hours for 5 days
Pedzinc syrup 5ml once a day
Combivent 1 neb every 6 hours
E> May resume activities as tolerated
101
T> Home maintenance and management
H> reinforce increase fluid intake
Avoid strenuous activities
Eat high caloric foods, rich in iron and vitamin C
Encourage proper hand washing.
Have an adequate rest
Instructed patient to be in high fowler’s position whenever
experiencing DOB
O> OPD after 1 week
D> DAT; preferably hypoallergenic diet
E> Goal met as evidenced by patient remained free of preventable
complications/progression of illness and verbalized understanding of health
teachings
VII. CONCLUSION AND RECOMMENDATION:
Acute bronchitis is a lower respiratory tract infection that causes
reversible bronchial inflammation. In up to 95 percent of cases, the cause is
viral. Acute bronchitis is caused in most cases by a viral infection and may
begin after developing a cold or sore throat. Bronchitis usually begins with
a dry cough. After a few days it progresses to a productive cough, which
may be accompanied by fever, fatigue, and headache. The cough may last
up to several weeks. If not treated acute bronchitis can progress to
pneumonia.
102
Bronchitis can have causes other than infection. Bronchial wall
inflammation can occur in asthma or can be secondary to mucosal injury in
an acute event, such as smoke or chemical fume inhalation. This
inflammation can also result from chronic toxic exposure, such as cigarette
smoking. It is important to realize that when underlying inflammation is
present, such as in asthmatics or smokers, infective agents are likely to
cause more severe cough and wheezing.
The role of nurses as well as student nurses as health care providers
is indeed important in order to attain the optimum level of wellness of all
clients. Suitable care must be carried out and health teachings must be
given to the client and/or relatives so that the needed care of the client is
not only bounded in the hospital rather could also be extended at home.
Thus, awareness of the disease condition will help the health care providers,
especially nurses. Enough information about diseases will help us to know
the proper interventions we can provide to our patients. It is important for
the health care provider to know the proper interventions and
responsibilities so that the patient will able to meet his/ her health needs.
Upon concluding this study, the group is fortunate enough to
understand the disease condition of the patient. It helped them to read
more topics about the patient’s condition and find ways to help the patient.
It also helped the group to understand different medications that the patient
has, and how it would affect the patient’s normal functioning. Through the
case, the student nurses were able to appreciate the value of preventing the
risks that may possibly arise from this condition and were able to gain
everlasting knowledge that will be sure of great help in rendering effective
and therapeutic care for future patients with the same case.
After having completed the said study, the group recommends the
study:
103
to the patients who have such disease conditions that they may
become aware of the disease they have and provide appropriate self
care.
to the health care providers especially nurses since they are the ones
who has direct interaction with the patient. Enough knowledge of the
health care providers will enable them to provide the correct
intervention for the patient.
VIII. Bibliography
BOOKS
Seeley R.; Essentials of Anatomy and Physiology(6th edition); McGraw-
Hill;New York USA
Doenger, et al. Nurse’s Pocket Guide (10th Edition); Schilling J. 2003
Black, Joyce et al. Medical-Surgical Nursing. St. Louis Missouri. 2005
Pilliteri, A., Maternal and Child Health Nursing: Care of the
Childbearing ang Childbearing Family (5th edition); Lippincott
Williams and Wilkins.2007
WEB
http://health.yahoo.com/respiratory-overview/acute-bronchitis-topic- overview/healthwise--hw32162.html
http://en.wikipedia.org/wiki/Acute_bronchitis
http://www.webmd.com/a-to-z-guides/acute-bronchitis-topic-overview
http://www.peacehealth.org/kbase/topic/major/hw32160/descrip.htm
http://en.wikipedia.org/wiki/Bronchitis
http://www.nlm.nih.gov/medlineplus/asthma.html#cat1
http://www.healthline.com/adamcontent/asthma/3
104
http://www.answers.com/topic/bronchopneumonia
http://www.sciencedaily.com /releases/2008/12/081208085002.htm
105
ANGELES UNIVERSITY FOUNDATIONCOLLEGE OF NURSING
ANGELES CITY
Acute Bronchitis
SUBMITTED BY:Bondoc, John Celestine
Group 54 BSN IV-14
SUBMITTED TO:Elmer D. Bondoc R.N. M.N.
DATE:
June 29, 2009