Date post: | 22-Feb-2017 |
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SRN Noorhazamin HamidNursing Education Services
Define upper respiratory tract infection.
Identify the pathophysiology of URTI.
State the sign & symptom of URTI.
Identify the risk factors of URTI.
Identify the complication of URTI.
Identify the nursing intervention & appreciate the nursing care for URTI patient.
Mr LMale26 years oldTechnicianMalay
Doctor = Dato’ I
Diagnosis = URTI (upper respiratory tract infection)
= Influenza B
Medical history - NilFamily history - NilSurgical history - NilAllergic - Nil
Smoking – 12 sticks / day
All normal
Temp = 38.5˚CPulse = 72 bpmResp = 22 bpmB/P = 130/80 mmHgWeight = 99 kg
Mr L was admitted to 4XX-1 with complaint of :
FeverCough 2/57RhinorrhoeaMuscle & joint pain
Dext saline slow dripMed profile, ASOT, dengue serology
CXR , CT SinusNasal swab for flu A & BSputum AFB & C&S
Inflammation of the upper respiratory tract cause by viral or bacterial infection.
Infectious disease cause by RNA viruses (Orthomyxoviridae) and mutates 2-3 times slower than type A.
High feverCoughRhinorrheaMuscle & joint painRigorSore throatHeadacheFatigue
SmokingOld age & childrenLow immune systemPoor hygiene habitClose contact with sick people
Pregnant
PneumoniaSinusitisEar infectionMeningitis
White blood cell count- 10.7 (4.3 – 10.5 10³/UL)
Monocyte- 11.7% (1-11%)
Sodium- 134 mmol/L (135 – 155)
Bacteria- Occasional (Nil)
CXR - Normal
CT SINUS -Pansinusitis
AFB - Not seen
C&S - No growth seen
Influenza A antigen-Not detected
Influenza B antigen- Detected
Group : Anti inflammatory, analgesic, antirheumatic
I : Reduce pain & fever
Group : Corticosteroid hormones
I : Anti inflammatory, anti-allergic & antitoxic
Group : PenicillinI : Antibiotic
Group : Anti viralI : Halt the spread of virus in body, reduce symptom & complication
Group : Cough & cold remedies
I : Relief of congestion & dry irritating cough e.g. those associated with common cold, upper resp tract infection & allergic rhinitis
1. Alteration in body T˚: hyperthermia related to infection
2. Alteration in breathing pattern related to cough.
3. Fluid & electrolyte imbalance related to decrease fluid intake & diaphoresis.
4. Alteration in nutritional status related to loss of appetite.
Goal : Patient’s body temperature will reduce to normal range after 4 hours nursing intervention given & during hospitalization.
Supporting data :Non verbal : T˚ = 38.5˚C, shivering, skin is warm to touch & having flushing face.
Verbal : C/O chills & rigor.
1. Assess pt gen condition e.g. appearance & complaint.
R – As a baseline data for further action.
2. Monitor pt’s T˚ every 4 hourly.R – To detect any elevation in body T˚.
3. Do tepid sponge if T˚ >38.5˚CR – To promote heat loss via diaphoresis.
4. Provide condusive environment e.g. switch on aircond and good ventilation.
R – To promote heat loss from body.
5. Encourage pt to drink > 2L of water per day.
R – To replace fluid loss.
6. Advise pt to wear thin cloth.R – To prevent heat accummulation.
7. Administer IVD as ordered by doctor.
R – To replace body fluid loss.
8. Monitor IX as ordered e.g. med profile, dengue serology, sputum AFB etc.
R – To rule out source of infection.
9. Administer medication e.g Voren Supp 50mg STAT/PRN as ordered by doctor.
R – To help reduce the T˚.
10. Inform doctor if condition deteriorating or not improving.
R – For review of changing of treatment.
Goal : Patient’s breathing pattern will be maintain at normal respiration rate after 4 hours nursing intervention given and during hospitalization.
Supporting dataNon-verbal : Resp rate = 22 bpm, irregular pattern & coughing.
Verbal : C/O difficulty to breathe .
1. Assess pt gen condition e.g. resp rate, breathing pattern & complaint.
R – As a baseline data for further management.
2. Monitor resp rate & pattern every 4 hourly.
R – To detect any abnormalities.
3. Positon patient in semi Fowlers or Fowlers.
R – To promote lung expansion.
4. Teach patient DBE and effective cough technique.
R – To promote effective breathing.
5. Advise patient to rest in bed and minimize activities.
R – To prevent more oxygen consumption.
6. Carry out IX as ordered e.g. CXR, CT sinus & sputum.
R – To rule out cause of infection.
7. Administer medication as ordered e.g. Sedelix 10ml TDS.
R – To help reduce cough.
8. Inform doctor if condition deteriorate or got any abnormalities.
R – For review of treatment & changes.