SRN Noorhazamin HamidNursing Education Services

Mr LMale36 years oldTechnicianMalay10/10/11 @ 1635HWheeled in to ward

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

Fever & coughSorethroatRhinorrhoeaHeadacheMuscle & joint painHis wife had fever before.

Doctor = Dato’ I

Diagnosis = URTI (upper respiratory tract infection)

= Acute Bronchitis

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

Smoking – 12 sticks / dayCough with whitish sputumMild shortness of breathLoss of appetite

Other ADL normal

SUNKEN EYESDRY LIPS

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

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

An inflammation of bronchi (medium-size airways) in the lungs that is usually caused by viruses or bacteria and may last several days or weeks

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

NCP 1Alteration in body

temperature : hyperthermia related to infection

Date / Time : 10/10/11 @ 1635H

Goal : Patient’s body temperature will reduce to normal range (36.2 – 37.5˚C) after 1 hour 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. flushing face, skin warm to touch, lethargic, temperature etc.

R – As a baseline data for further action.

2. Monitor T˚ every 4 hourly.R – To detect any elevation in body

T˚.

3. Provide conducive environment such as switch on aircond or fan.

R – To promote heat loss via evaporation.

4. Encourage patient to rest in bed.R – To reduce activity which can

increase body metabolism & raise temperature.

5. Provide cold compress if T˚ < 38.5˚CR – To reduce temperature by radiation.

6. Do tepid sponge if T˚ > 38.5˚CR – To promote heat loss by evaporation.

7. Advise pt to wear thin cloth.R – To reduce heat by radiation & evaporation.

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

R – To replace fluid loss.

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

R – To help reduce the T˚.

10. Administer IVD as ordered by doctor.

R – To replace body fluid loss.

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

R – To rule out source of infection.

12. Record patient’s improvement or deterioration.

R – To indicates progress or abnormalities.

10. Inform doctor if condition deteriorating or not improving.

R – For review of changing of treatment or further intervention.

Date / Time : 10/10/11 @ 1730H

Evaluation :Patient body temperature has reduce to normal range.

Evidence :Non Verbal – Skin not warm to touch, no more flushing face, T˚ = 36.8˚C

Verbal – Patient verbalized no more chills

Re – evaluation :

Date / Time : 10/10/11 @ 2000H

Patient temperature is normal = 36.8˚C

Alteration in breathing pattern related to cough.

Alteration in comfort related to cough.

Alteration in comfort related to headache and joint / muscle pain.

Ineffective airway clearance related to hypersecretion.

Alteration in nutritional status related to loss of appetite.