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Lester Case Study

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I. Introduction As we go on with our hospital duty, we are able to encountered patients with different cases that we are able to care for, as we conduct our assessment, interview with the patient, we have to choose one of this patient for our case study. Being exposed to the hospital ward at Polymedic General Hospital, as a nursing student it is our duty to give care to the ill patients. We have encountered many interesting cases that would surely enhance our knowledge and skills, and Acute Bronchitis is one of those diseases. Bronchitis is an acute inflammation of the air passages within the lungs. It occurs when the trachea and the large and small bronchi within the lungs become inflamed because of infection cause by a virus or bacteria. A. Overview of the case Acute bronchitis describes the inflammation of the bronchi usually caused by a viral infection, although bacteria and chemicals also may cause acute bronchitis. Bronchiolitis is a term that describes inflammation of the smaller bronchi referred to as bronchioles. In infants, this is usually caused by respiratory syncytial viruses (RSV), and affects the small bronchi and bronchioles more than the large. In adults, other viruses as well as some bacteria can cause bronchiolitis and often manifest as a
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Page 1: Lester Case Study

I. Introduction

As we go on with our hospital duty, we are able to encountered patients with

different cases that we are able to care for, as we conduct our assessment, interview

with the patient, we have to choose one of this patient for our case study. Being

exposed to the hospital ward at Polymedic General Hospital, as a nursing student it is

our duty to give care to the ill patients. We have encountered many interesting cases

that would surely enhance our knowledge and skills, and Acute Bronchitis is one of

those diseases.

Bronchitis is an acute inflammation of the air passages within the lungs. It occurs

when the trachea and the large and small bronchi within the lungs become inflamed

because of infection cause by a virus or bacteria.

A. Overview of the case

Acute bronchitis describes the inflammation of the bronchi usually

caused by a viral infection, although bacteria and chemicals also may cause

acute bronchitis.

Bronchiolitis is a term that describes inflammation of the smaller bronchi

referred to as bronchioles. In infants, this is usually caused by respiratory

syncytial viruses (RSV), and affects the small bronchi and bronchioles more than

the large. In adults, other viruses as well as some bacteria can cause

bronchiolitis and often manifest as a persistent cough at times productive of small

plugs of mucus.

Most often due to a viral infection that causes the inner lining of the

bronchial tubes to become inflamed and undergo the changes that occur with

any inflammation in the body. Common viruses include the rhinovirus, respiratory

syncytial virus (RSV), and the influenza virus.

Bronchitis may be indicated by an expectorating cough, shortness of

breath and wheezing. Occasionally chest pains, fever, and fatigue or malaise

may also occur. Symptoms of acute bronchitis usually begin 3 to 4 days after an

Page 2: Lester Case Study

upper respiratory infection, such as a cold or influenza (flu), cough, mild fever,

hoarseness, general feeling of tiredness.

This care study presents a condition of medically ill patient having a diagnosis of

acute bronchitis .This case aims to achieve a better understanding of the patient’s

condition and was made for the benefit of the student conducting the study.

B. Objective of the study

Individual care study provides goals or objectives which is necessary to

serve as an instrument in comprehensively assessing the patient’s health status

and present condition. It also focuses on the following aims:

To conduct a thorough assessment of the patient in order to

formulate appropriate nursing care plan based on accurate and

complete data

To formulate nursing diagnosis, develop outcomes and plan

nursing care with specific goals for a patient with acute bronchitis.

To implement nursing care and evaluate outcomes for

effectiveness and achievement of care

Utilizing the nursing process in the management of patient’s health

condition and in giving quality nursing care.

Integrate knowledge about acute bronchitis to achieve quality of

care to the patient and understand the course and essence of the

chosen care study.

Impart health teachings about necessary information pertaining to

the disease condition.

Gain the knowledge and understanding in the Nursing profession.

Page 3: Lester Case Study

C. Scope and Limitation of the study

The extent of this study includes the overall data gathered during the

interview and observation as manifested by the patient and his complaints. It also

deals with the several factors observed during the assessment within the span of

time given. The information gathered was based on the manifestations and

complaints of the patient observed and the exact answers of the patient’s support

person since the patient is only 4 year old .Interventions were rendered gradually

depending on the objective assessment of the student. The following information

only involves the exact words and answers supported by the parents.

The limitation of the study includes the place of interaction itself which was

in Polymedic General Hospital, station 6. The study was completed altogether by

both research and actual hands-on exposure and interaction with the patient

during the two (2) days clinical duty.

II. Health History

A. Profile of patient

Name: Alcantara Pierre Hendrick E.

Age: 4 years old.

Sex: Male

Birth Date: November 16, 2006

Birth place: Cagayan de Oro City

Religion: Roman Catholic

Civil Status: Single

Page 4: Lester Case Study

Nationality: Filipino

Occupation: Not applicable

Address: B5 L3 Soldier Hills Subdivision Bulua Cagayan de Oro City.

Name of Father: Glen Alcantara

Occupation: Bank Employee

Name of Mother: Julie Anne Excelise

Occupation: Housewife

Date of Admission: January 3, 2010

Time of Admission: 8:05 pm

Admitting Physician: Dr. Notario

Vital Signs Assessment

Temperature: 36.5 C

Pulse rate: 102

Respiratory rate: 20

Height: 97 cm

Weight: 24 kgs.

Allergies: No known food and Drug allergies

Page 5: Lester Case Study

B. Family and Personal Health History

Pierre Hendrick, it was his first time to be hospitalized because of acute.

He has not received any blood transfusion, and has no food and drug allergy.

Alcantara family resides at soldier hills subdivision Bulua Cagayan de Oro

City, and had their first baby named Pierre Hendrick. The family claims that they

have no common diseases within their family, or the so called the heridofamilial

disease. So we I ask about the common diseases that the family had acquired.

As claimed the most common diseases in their family was fever, cough, colds.

C. History of Present Illness

Four days prior to admission, Patient have productive cough, with whitish

phlegm, with mild grade fever, loss of appetite and there is shortness of

breathing. Patient is admitted at Polymedic General Hospital on January 3, 2010,

and has been diagnose with acute bronchitis

D. Chief Complaint

Alcantara Pierre Hendrick, 4 years old was admitted in Polymedic General

Hospital on January 3, 2010, 8:05 in the evening due to productive cough

and fever.

Page 6: Lester Case Study

III. Developmental Data

FREUD’S PSYCHOANALYTIC THEORY

Freud termed the infant period as the oral phase because infants are so

interested in oral stimulation for pleasure during this time. According to this theory,

infants suck for enjoyment or relief of tension as well as for nourishment.

Stage Age Characteristics Nursing Implications

Infant Birth 1-1 ½ year Mouth is the center

of pleasure. Feeling

of dependence

arises and can

persist through life.

An individual who is

fixated at this stage

may have difficulty

in trusting others

and may

demonstrate nail

biting, drug abuse,

smoking,

overeating,

alcoholism,

argumentativeness

and

overdependence.

Security is the

primary need.

Major conflict:

Weaning

Provide oral

stimulation by giving

pacifiers, do not

discourage thumb

sucking.

Breastfeeding may

provide more

stimulation than

formula feeding

because it requires

the infant to expand

more energy

Page 7: Lester Case Study

ERIKSON’S PSYCHOSOCIAL THEORY

According to Erikson, the developmental task for infants is learning trust

versus mistrust (other terms might be learning confidence or learning to love). Infants

whose needs are not met when these arises, whose discomforts are quickly removed,

who are cuddled, fondle, played with and talk to, come to view the world as a safe place

and people as helpful and dependable. However, when their care in inconsistent,

inadequate or rejecting, it fosters basic mistrust – infants become fearful and suspicious

of the world and of people.

Stage AgeCentral

Task

Indicators

of Positive

Resolution

Indicators of

Negative

Resolution

Developmenta

l Task

Nursing

Implication

Infancy Birth to

18

months

Trust

vs.

Mistrust

Learning

to trust

others

Mistrust,

withdrawal,

estrangement

Developmenta

l task is to

form sense of

trust. Child

learns to love

and be loved.

Provide a

primary

care

provider.

Provide

experiences

that add to

security

such as soft

sound and

touch.

Erikson envisions that life as a sequence of levels achievement. Each stage

signals a task that must achieved. The resolution of the task can be complete, partial or

unsuccessful. Erikson believes that the greater the task achievement, the healthier the

Page 8: Lester Case Study

personality of the person; failure to achieve a task influences the person’s ability to

achieve the next task.

PIAGET’S COGNITIVE THEORY

Piaget refers to the infant stage as the sensorimotor stage. Sensorimotor

intelligence is practical intelligence because words and symbols for thinking and

problem solving are not yet available to the child at this stage. At the beginning of

infancy, babies relate to the world through the senses, using only reflex behavior. As

infants progress through this stage (which includes the schemes of primary and

secondary reactions and coordination of secondary reaction), they learn the basic

theory of concept that people are entities separate form their environment. piaget uses

the term “ primary” to refer to activities related to the child’s own body and “ circulatory

reaction” to demonstrate the repetition of behavior occurs ( the infant accidentally bring

his thumb to the mouth, enjoys the sensation of sucking and so repeats it.

Phase and Stage Age Significant Behavior Nursing Implication

Page 9: Lester Case Study

Sensorimotor

Phase

STAGE 1: Use of

Reflex

STAGE 2:

Primary Circular

Reaction

Birth to 2 years

Birth to 1 month

1 to 4 months

Most action is

reflexive

Perception of

events is centered

on the body.

Objects are

extension of self

Stimuli are

assimilated into

beginning mental

images. Behavior

entirely reflexive.

Hand to mouth and

ear to eye

coordination

develops. Infant

spends much time

looking at objects

and separates self.

STAGE 3:

Secondary Circular

Reaction

4 to 8 months Acknowledges the

extended

environment.

Actively makes

changes in

environment.

Beginning intention

of behavior is

present (the infant

brings thumb to

mouth for a purpose

of sucking). Infants

learn to initiate,

recognize and

repeat pleasurable

experiences.

Memory traces are

present. Infant

Page 10: Lester Case Study

STAGE 4:

Coordination of

Secondary

Schemata

8 – 12 months Can distinguish a

goal from a means

of attaining it.

anticipates familiar

events (a parent

coming near will

pick him up). Good

toy for this period:

mirror. Good game

and peek-a-boo.

Infant can plan

activities to attain

specific goals.

Perceives that

activities of own

body is separate

from activities of

objects. Can

search objects and

relieve it which

disappears from his

view. Recognizes

shapes and sizes of

familiar objects.

Infant experiences

separation anxiety

when primary care

giver leaves.

Able to discover

new properties of

object and events.

Capable of space

Page 11: Lester Case Study

STAGE 5:

Tertiary Circular

Reaction

STAGE 6:

Invention of New

Means

12 to 18 months

18 to 24 months

Tries to discover

new goals and ways

to attain goals.

Rituals are

important

Interprets the

environment by the

mental images

perception as well

as permanence.

Good game for this

period: throw and

retrieve.

Uses memory and

imitation to act. Can

solve basic

problems, foresee

maneuvers that will

succeed or fail.

Good toys for this

period: those with

several uses such

as blocks, colored

plastic rings.

Page 12: Lester Case Study

In each phase, the person uses three primary abilities: assimilation,

accommodation and adaption. Assimilation is the process which human encounters and

react to new situation by using mechanisms they already posses. Accommodation is a

process of change whereby cognitive process mature sufficiently to allow the person to

solve problems that were unsolved before. Adaptation or coping behavior is the ability to

handle the demand made by the environment.

HAVIGHURT’S DEVELOPMENTAL THEORY

Havighurst promoted the concept of developmental task in 1950’s. a

developmental task is a task which arises at or about a certain period in life of an

individual, successful achievement will lead to happiness and to succeed with later task,

while failure leads to unhappiness in the individuals, disapproval by society and difficulty

with later task.

Havighurst’s Age Periods and Developmental Task

Infancy and Early Childhood

1. Learning to walk.

2. Learning to take solid foods

3. Learning to talk.

Page 13: Lester Case Study

4. Learning to control the elimination of the body waste.

5. Achieving psychologic activity.

6. Forming simple concepts of social and physical reality.

7. Learning sex differences and sexual modesty.

8. Learning to relate emotionally to parents, sibling and other people.

9. Learning to distinguish right from wrong and developing a conscience.

Havighurst’ developmental task provide a framework that the nurse can use to evaluate

a person’s general accomplishment. However, some nurses find that the broad

categories limit its usefulness as a tool in assessing specific accomplishment,

particularly those infancy and childhood.

IV. Medical Management

A. Medical Orders and Rationale

Medical Orders Rationale

January 3, 2010

8:05

Please admit pt, under the care of Dr.Notario

Secure consent to care

TPR q 4 hrs

Monitor Intake and Output q shift

RATIONALE

To closely monitor the patient

For legal purposes

To monitor patient status

Monitor fluid and electrolyte imbalance

Page 14: Lester Case Study

Soft Diet: Diet as tolerated strict aspiration precaution

Laboratory Exams:- Complete Blood Count

- Radiologic Report

D5 0.3 Nacl @ 60cc/hr.

Medications:Ampicillin IVTT q 6 ANST(-)

Salbutamol (ventolin); neb q 6 hr

PRN Medications:

>Paracetamol 5 ml q 4, for fever

Tepid sponge bath

Refer accordingly

January 4, 2009

>Continue meds

IVF follow up with D5 0.3 Nacl @

The best diet of choice

For diagnostic purposes: To check for occurrence of infection in the body

Maintenance fluid therapy represents the volume of fluids and amount of electrolytes and glucose needed to replace anticipated physiological losses from breath, sweat and urine and to prevent hypoglycemia

For infections purposes

To improve ventilation and treat bronchospasm in pt.having airway obstruction.

Medication used for relieving fever and pain

. To reduces body temperature to

normal range

For further care to the patient

Page 15: Lester Case Study

Diagnostic Examination

Complete Blood Count

Result Normal Values Nursing Implication

Hemoglobin 12.0 13.70 – 16.70 Risk for anemia, iron

deficiency

Hematocrit 35.1 40.5 - 49.7 vols % Anemia, folic acid

deficiency

MCH 25.4 26.10 – 33.30 Hypo chromic anemia

Neutrophils 38.9 54.0 – 62.0 Aplastic anemia, iron and

folic def.

Lymphocytes 45.8 17.4% - 48.2% Viral infection

Eosinophils 7.1 0 – 6% Parasitic infections

Radiologic Report

- pneumonia, Left lung

Page 16: Lester Case Study
Page 17: Lester Case Study

B. Drug Study

Name of Drug

Generic(brand)

Date

ordere

d

Classification Dose/

Frequency

route

Mechanis

m of

Action

Specific

Indication

Contraindications Side effects Nursing

precautions

Sabutamol

(ventolin)

Januar

y 3,

2010

Bronchodilator Neb q 6 hr. Relaxes

bronchial

smooth

muscle by

acting on

beta2-

adrenergic

receptors;

improves

ventilation

Bronchospa

m in

patients

with

reversible

obstructive

airway

disease

To patient’s

hypersensitive to

the drug and its

components

To patient’s

hypersensitiv

e to the drug

and its

components

Perform

chest

tapping

every after

nebulization

/ Postural

Drainage

Page 18: Lester Case Study

Name of Drug

Generic(brand)

Date

ordere

d

Classification Dose/

Frequency

route

Mechanis

m of

Action

Specific

Indication

Contraindications Side effects Nursing

precautions

Paracetamol

( tempra)

Januar

y 3,

2010

Non-opioid

analgesic;antipy

retic

5 ml/P.0.q 4

hours PRN

Produces

analgesic

effect by

blocking

pain

impulses,

by inhibiting

prostaglandi

ns or pain

receptors

sensitizers;

may relieve

fever by

acting in

hypothalami

c heat

regulating

center

For mild pain

and fever

To patient’s going

long-term therapy

for chronic

noncongestive

angle-closure

glaucoma;

hyponatremia;

hypokalemia;

hepatic impairment;

adrenal gland

failure’

hypechloremic

acidosis

Confusion;

anorexia;

aplastic

anemia; rash;

renal calculi

Report signs

of F/E

imbalance

Page 19: Lester Case Study

Name of Drug

Generic(brand)

Date

ordere

d

Classification Dose/

Frequency

route

Mechanis

m of

Action

Specific

Indication

Contraindications Side effects Nursing

precautions

Ampicillin

(ampilin

Januar

y 3,

2010

Penicillins 500mg IVTT q

6, ANST(-)

Inhibits cell

wall

synthesis

during

Bacterial

multiplicati

on

Respiratory

tract

infections

Contraindicated

to pt’s

hypersensitive to

drug or other

penicillins

Anxiety,

dizziness,

nausea,

vomiting, vein

irritation

Obtain

specimen

for culture

and

sensitivity

test before

giving first

dose.

Page 20: Lester Case Study

V. Pathophysiology with anatomy and physiology

The respiratory system consists of all the organs involved in breathing. These

include the nose, pharynx, larynx, trachea, bronchi and lungs. The respiratory system

does two very important things: it brings oxygen into our bodies, which we need for our

cells to live and function properly; and it helps us get rid of carbon dioxide, which is a

waste product of cellular function. The nose, pharynx, larynx, trachea and bronchi all

work like a system of pipes through which the air is funneled down into our lungs.

There, in very small air sacs called alveoli, oxygen is brought into the bloodstream and

carbon dioxide is pushed from the blood out into the air. When something goes wrong

with part of the respiratory system, such as an infection like pneumonia, it makes it

harder for us to get the oxygen we need and to get rid of the waste product carbon

dioxide. Common respiratory

symptoms include breathlessness, cough, and chest pain.

Page 21: Lester Case Study

The Upper Airway and Trachea When you breathe in, air enters your body

through your nose or mouth. From there, it travels down your throat through the larynx

(or voice box) and into the trachea (or windpipe) before entering your lungs. All these

structures act to funnel fresh air down from the outside world into your body. The upper

airway is important because it must always stay open for you to be able to breathe. It

also helps to moisten and warm the air before it reaches your lungs.

The Lungs

Structure

The lungs are paired, cone-shaped organs which take up most of the space in

our chests, along with the heart. Their role is to take oxygen into the body, which we

need for our cells to live and function properly, and to help us get rid of carbon dioxide,

which is a waste product. We each have two lungs, a left lung and a right lung. These

are divided up into 'lobes', or big sections of tissue separated by 'fissures' or dividers.

The right lung has three lobes but the left lung has only two, because the heart takes up

some of the space in the left side of our chest. The lungs can also be divided up into

even smaller portions, called 'bronchopulmonary segments'.

These are pyramidal-shaped areas which are also separated from each other by

membranes. There are about 10 of them in each lung. Each segment receives its own

blood supply and air supply.

Page 22: Lester Case Study

Pathophysiology

Inflammation

Increase mucous

production

VI. Nursing Assessment (System Review & Nursing Assessment II)

Environmental Pollutants,

Respiratory tract infection

Increase number of submucous glands in the large

bronchi.

Increase capillary permeability

Fluid/cellular exudation

Edema of the Mucous membrane

Hypersecretion of mucous

Persistent Cough

BRONCHITIS

Page 23: Lester Case Study

Name: Alcantara Pierre Hendrick Date: January 6, 2010

Vital Signs: Pulse: 102 bpm RR: 30cpm Temp: 36.5˚ C Height: 97 cm Weight: 24 kgs

EENT:

[ ] impaired vision [ ] blind

[ ] pain [ ] reddened [ ] drainage

[ ] gums [ ] hard of hearing [ ] deaf

[ ] burning [ ] edema [ ] lesion [ ] teeth

Assess eyes, ears, nose, and throat

For abnormality [x] no problem

RESPIRATORY

[ ] asymmetric [ ] tachypnea

[ ] apnea [ ] rales [ x]cough[ ] barrel chests

[ ] bradypnea [ ] shallow [ ] rhonchi

[x ] sputum [ ] diminished [ x]dyspnea

[ ] orthopenea [ ] labored [ ]wheezing

[X] pain [ ] cyanotic

Assess resp.rate, rhythm, depth, pattern

Breath sounds, comfort [ ] no problem

CARDIOVASCULAR

[ ] arrhythmia [ ] tachycardia [ ] numbness

[ ] diminished pulses [ ] edema [ ] fatigue

[ ] irregular [ ] bradycardia [ ] murmur

[ ] tingling [ ] absent pulses [ ] pain

Assess heart sounds, rate, rhythm, pulse,

circulation, fluid retention, comfort [ ] no

Productive cough, pain

restlesness

dyspnea

Page 24: Lester Case Study

GASTRO INTESTINAL TRACT

[ ] obese [ ] distention [ ] mass

[ ] dysphagia [ ] rigidity [ ] pain

Assess abdomen, bowel habits, swallowing,

Bowel sound, comfort [ } no problem

Gyn-bleeding, discharge [x] no problem

NEURO

[ ] paralysis [ ] stuporous [ ] unsteady [ ] seizures

[ ] lethartic [ ] comatose [ ] vertigo [ ] tremors

[ ] confused [ ] vision [ ] grip

Assess motor function, sensation, LOC, strength,

Grip, gait, coordination, orientation, speech [x] no problem

MUSCULOSKELETAL and SKIN

[ ] appliance [ ] stiffness [ ] itching [ ] petechiae

[ ] hot [ ] drainage [ ] prosthesis [ ] swelling

[ ] lesion [ ] poor turgor [ ] cool [ ] deformity

[] wound [ ] rash [ ] skin color [ ] flushed

[ ] atrophy [ ] pain [ ] eccymosis [ ] diaphoretic [ ] moist

Assess mobility, motion, galt, alignment, joint function/

Skin color, texture, turgor, integrity [ ] no problem

Nursing Assessment II

Page 25: Lester Case Study

SUBJECTIVE OBJECTIVE

Communication:

[ ] hearing loss [ ] visual changes

[ ]denied

Comments: “wala may problema sa panan aw sa akong anak “as verbalized by the mother.

[ ] glasses [ ] language

[ ] contact lens [ ] hearing aide

R L

Pupil size : 2mm

Reaction: Pupil equally round reactive to light and accommodation.

Oxygenation:

[ x ] dyspnea [ ] smoking history [ x ] cough [ x ] sputum [ ] denied

Comments: pg mag ubo siya nay plema “as verbalized by the mother.

Respiratory [ ] regular [ x ] irregular

Describe: Patient has irregular breathing pattern

R: Normal symmetrical breathing

L: Abnormal symmetrical breathing

Circulation:

[ ] chest pain [ ] leg pain

[ ] numbness of extremities

[ ] denied

Comments: mag sakit iya dughan pg mag ubo siya“ verbalized by the mother.

Heart Rhythm [x] regular [ ]irregular

Ankle Edema: none

Pulse Car. Rad. DP. Fem.*

R :+ 102 + _+

L :+ 102 + + +

Comments: Pulse palpable at respective sites

Nutrition:

Diet: soft diet

Character: [x ] recent change in weight,

appetite

[ ] swallowing difficulty [ ] denied

Comments: “dili siya ganahan ug kaon ”as

[ ] dentures [x] none

Full Partial With Patient

Upper [ ] [ ] [ ]

Lower [ ] [ ] [ ]

Page 26: Lester Case Study

verbalized by the mother.

Elimination:

Usual bowel pattern Urinary frequency

Once a day 5 times a day

constipation remedy [ ] urgency

[ ] dysuria

Date of last BM [ ] hematuria

.January 5, 2010 [ ] incontinence

Diarrhea character: [ ] polyuria

[ ] foley in place

[x] denied

Bowel sounds: Normo Active

Abdominal Distention

Present [ ] yes [ ] no

Urine* (color, consistency, odor)

*if they are in place

Comments: patient is able to defecate and urinate.

Management of Health and Illness:

[ ] alcohol [ x] denied

(amount, frequency)

[ ] SBE Last Pap Smear: N/A

LMP: N/A

Briefly describe the patient’s ability to follow treatments (diet, meds, etc.) for chronic health problems (if present)..

SUBJECTIVE OBJECTIVE

Skin Integrity:

[ ] dry [ ] itching [ x ] denied

Comments: No verbal cues

[ ] dry [ ] cold [ ] pale [ x ] flushed

[ x ] warm [ ] cyanotic

*rashes,ulcers, decubitus (describe size, location, drainage) patient has no

Page 27: Lester Case Study

rashes in upper and lower extremities.

Activity/ Safety:

[ ] convulsion [ ] dizziness

[ ] limited motion of joints

Limitation inability to:

[ ] ambulate [ ] bathe self

[ ] other [x] denied

LOC and orientation:

Patient is conscious.

Gait: [ ] walker [ ] cane [ ] other

[x ] steady [ ] unsteady

[ ]sensory and motor losses in face or extremities: none

[ ]ROM limitations: Patient range of motion is limited.

Comfort/ Sleep/ Awake

[ ] pain (location, frequency, remedies)

[] nocturia [ ] sleep difficulties [x] denied

Comments: “Makatulog man siya permente usahay makamata pg mag sige ug ubo” as verbalized by mother.

[ ] facial grimaces

[ ] guarding

[ ] other signs of pain: none

[ ] siderail release form signed ( 60 + years ) N/A

Coping:

Occupation (mother): Housewife

Members of household: Mr. & Mrs. Glen Alcantara

Most supportive person: Mr. Glen Alcantara

Observed non- verbal behavior:

none

The person and his phone number that can be reached any time: Not given

VII. Nursing Management

A. Ideal Nursing Intervention(NCP)

Page 28: Lester Case Study

Ineffective Airway Clearance RT to secretions in the bronchi

Interventions Rationale

Independent:

1. Monitor ABG results

2. Assess respiratory status,

including vital signs, breath

sounds and skin color at least q

2h

3. Place in high-Fowler’s position

4. increase fluid intake appropriate

for age; offer warm rather than

clods, fluids.

5. Suction as indicated

- Blood gas changes may reveal

impaired gas exchange

-

- Early identification of respiratory

compromise allows intervention

before tissue hypoxia is significant.

-

- Lowers diaphragm, promoting chest

expansion, aeration of the lungs

segments, mobilization and

expectoration of the secretions

- fluid intake helps to liquefy

secretions

- Mechanically clear airway in patient

who is unable to do so because of

ineffective cough.

Dependent:

1. Administer prescribed

medications as ordered

(bronchodilators)

- To help maintain open airway,

relax bronchial smooth muscle

Page 29: Lester Case Study

2. Salbutamol

Acute pain related to localized inflammation and persistent cough

Interventions Rationale

Independent:

1. Elevate head of the bed, change position frequently

2. Assist patient with deep breathing exercises

3. help patient learn to perform activity like effective coughing while upright position.

4. Increase fluids as tolerateeed and offer warm, rather than cold fluids (if not contraindicated)

- Lowers diaphragm, promoting chest expansion and expectoration of secretions

- Deep breathing facilitates maximum expansion of the lungs

- Coughing is a natural self cleaning mechanism. an upright position favors deeper, more forceful cough effort.

- Fluids especially warm liquid said in mobilization and expectoration of secretions

Activity intolerance RT inadequate oxygenation and dyspnea

Page 30: Lester Case Study

Interventions Rationale

Independent:

1. Assess activity tolerance, noting

any increase in pulse,

respirations, dyspnea.

2. Schedule activities, planning for

rest periods

3. Perform active or passive ROM

4. Assist the family to minimize

stress and anxiety levels

5. Teach how to do deep breathing

exercises.

- The assessment findings may

indicate limited or impaired

activity tolerance

- Rest periods minimizes fatigue

and improves activity tolerance

- Exercise help maintain muscle

tone and joint mobility

- Stress and anxiety increases

metabolic demands and can

increase activity tolerance

- Promotes complete expansion of

the lungs.

B. Actual Nursing Management (SOAPIE)

S “mag sakit iya dughan pg mg sige na siya ubo” as verbalized by the mother.

O Dyspnea

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Productive cough with whitish phlegm

A Ineffective airway clearance RT excessive secretions and ineffective coughing

P Long term: At the end of 2 days of care, client will verbalize clear airway

Short term: At the end of 30 minutes nursing intervention, the patient will improved airway

clearance, as evidenced by effective coughing techniques.

I Independent:

1. Elevate Head of the bed, change position frequently, promoting chest expansion,

expectoration of the secretions

2. Taught the watcher to maintain adequate hydration by increasing fluid intake, to thin

secretions.

3. Teach the patient to do deep breathing and coughing exercise, to mobilize the secretions

Dependent:

1. Given bronchodilators (Salbutamol) as ordered, to relax bronchial smooth

muscles thus facilitating airflow.

E After 30 minutes, the client’s is able to expectorate secretions.

S ” Gasakit iyang tutunlan pg mg ubo.” as varbalized by the mother.

O Sleep disturbance

crying

restlessness

Page 32: Lester Case Study

A Acute pain to localized inflammation and persistent cough

P Long term: At the end of 2 days nursing care, the patient will be able to relieve pain.

Short term: At the end of 8 hours of nursing intervention, patientwill airway clearance.

I Independent:

1. Instructed the patient to elevate the bed, change position frequently, Lowersdiaphragm, promotingchest expansion and expectoration of secretions

2. Assisted the patient in deep breathing exercise, Deep breathing facilitates maximum expansion of the lungs.

3. Provided quite environment to the patient, in order to relax, during the symptoms occurs

Dependent:

1. Provided nutritional support: IV fluids

E After 8 hoursof nursinginterventions, the goal was partially met, the patient has improve his airway clearance and absence of dyspnea.

VIII. Referrals and Follow – up

HEALTH TEACHINGS

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MEDICATIONS Explain to the parents of the patient each medication

prescribed.

Explain proper administration of medication according to its

route together with the knowledge about potential side effects

EXERCISE Encourage patient to avoid excessive stress and have

adequate rest and sleep.

Encourage to do deep breathing exercises.

TREATMENT The patient instructed to follow in taking the prescribed home

medication on time as ordered.

Instruct the parents to observe proper food presentations.

OUT-PATIENT

(Check-Up)

Emphasize importance of keeping schedule appointments with

health care providers 1 week after discharge especially when

there are noticeable changes in the condition and refer to Dr.

Notario.

DIET Encourage to eat nutritious food such as vegetable and fruits

Advice the parents of the patient to monitor fluid intake or

adequate hydration, to help her body re-hydrate to prevent

fluid imbalance.

Advice to have proper nutrition to enhance immune.

IX. Evaluation and Implications

Page 34: Lester Case Study

Being expose to the hospital ward and implement nursing care to those ill

patients. There are many cases I have had encountered during the duty one of which is

the acute bronchitis. Sense we are all future health care providers; somehow I was able

to identify nursing diagnosis and implement possible effective nursing care.

This study will serve as a reference material in rendering competent care to my

client especially those with similar situation. Through this, I will be able to develop my

knowledge as well as my skills and attitudes in applying the prescribed procedure to

improve the health status of the patient.

This study will act as a baseline as well as a guide for a good, accurate and

comprehensive research paper dealing with issues commonly experienced by patient in

the hospital setting. This may aid the researchers to widen the scope of the study in

relation to more or less similar cases.

X. Bibliography

Smeltzer, Suzanne. Medical-Surgical Nursing, 11 th edition

Barbara Kozier; “Fundamentals of Nursing” 7th edition.

Lippincott Williams and Wilkins A guide to Medical-Surgical Nursing

Webliography

http://www.mayoclinic.com/health/bronchitis/DS00031/DSECTION=1,

RP, Fowler AA (2006). "Clinical practice. Acute bronchitis". N. Engl. J. Med

www.wikipedia.org/bronchitis

Page 35: Lester Case Study

www.google.com

LICEO DE CAGAYAN UNIVERSITYRodolfo N. Pelaez Blvd. Kauswagan, Cagayan de Oro City

COLLEGE OF NURSING

NCM501202

A Care Study

Alcantara Pierre Hendrick E.

Page 36: Lester Case Study

Submitted to:

Mr. Dante Diadola RN

As Partial Requirment for NCM501202

Submitted by:

Ardon, Lester C.

TABLE OF CONTENTS

I. Introduction

a. Overview of the case

b. Objective of the study

c. Scope and Limitation of the study

II. Health History

a. Profile of patient

b. Family and Personal Health history

c. Chief Complaint & History of Present Illness

Page 37: Lester Case Study

III. Developmental Data

IV. Medical Management

a. Medical Orders and Rationale

b. Laboratory Results

c. Drug Study

V. Pathophysiology with Anatomy and Physiology

VI. Nursing Assessment (System Review & Nursing Assessment II)

VII. Nursing Management

a. Ideal Nursing Management (NCP)

b. Actual Nursing Management (SOAPIE)

VIII. Referrals and Follow-up

IX. Evaluation and Implications

X. Bibliography

Rating Scale

A. WRITTEN WEIGHT RATINGI. Introduction 5 a. Overview of the case b. Objective of the study c. Scope and Limitations of the studyII. Health History 5 a. Profile of patient b. Family and personal history c. Chief complaintIII. Developmental Data 5IV. Medical Management 20

(10)(10)

a. Medical Orders and Rationale b. Drug studyV. Pathophysiology with anatomy & physiology 10VI. Nursing Assessment ( system review & Nsg. Assessment

10

VII. Nursing Management 30(10)(20)

a. Ideal Nursing Management .(NCP) b. Actual Nursing Management. (SOAPIE)

Page 38: Lester Case Study

VIII. Referrals and Follow-up 5IX. Evaluation and Implications 5X.Documentation 5 a. Documentation of evidence of care for 1 week rotation b. Organization/ Grammar/ Bibliography

Total Score 100 Equivalent grade


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