Pneumonia

I. INTRODUCTION

Pneumonia is an acute infection of the lung parenchyma that

commonly impairs gas exchange. The prognosis is usually good for people
who have normal lungs and adequate host defenses before the onset of
pneumonia; however, bacterial pneumonia is the fifth leading cause of death
in debilitated patients. The disorder occurs in primary and secondary forms
(Medical Surgical-Nursing Made Incredibly Easy).

PREDISPOSING FACTORS AND RISK FACTORS

The nurse should be acquainted with the factors and circumstances

that commonly predispose the person to pneumonia. Hence, the nurse is able
to identify the patient at high risk and to engage in anticipatory and
preventive nursing.

• Any condition that produces mucus or bronchial obstruction and

interferes with normal drainage of the lung (cancer, chronic
obstructive pulmonary disease [COPD]) renders the patient
susceptible to pneumonia.
• Immunosuppressed patients are risk.
• People who smoke are at risk because cigarette smoke disrupts both
mucociliary and macrophage activity.
• Any patient who is permitted to lie passively in bed for prolonged
periods, relatively immobile and breathing shallowly, is highly
vulnerable to the risk of bronchopneumonia.
• Any person who has a depressed cough reflex (due to medications or
weakness), has aspirated foreign material into the lungs during a
period of unconsciousness (head injury, anesthesia), or has an
abnormal swallowing mechanism is very likely to develop
bronchopneumonia.
• Any hospitalized patient on a nothing-by-mouth regimen or who is
receiving antibiotics has increased pharyngeal colonization of
organisms and is at risk. In very ill persons, the oropharynx is likely to
be colonized by gram-negative bacteria.
• People who are intoxicated frequently are particularly susceptible to
pneumonia, because alcohol suppresses the body’s reflexes, white cell
mobilization, and tracheobronchial ciliary motion.
• Any person scheduled to receive a sedative is observed for respiratory
rate and depth before the drug is given; if respiratory depression is
apparent, the medication should not be administered. Respiratory
depression predisposes to the pooling of bronchial secretions and
subsequent development of pneumonia.
• Frequent suctioning of secretions in patients who are unconscious or
have poor cough and gag reflexes is an important preventive measure.
This reduces he likelihood that secretions will be aspirated or
accumulate in the lungs and induce bronchopneumonia.
 • Elderly people are especially vulnerable to pneumonia because of
depression of cough and glottic reflexes. Postoperative pneumonia
should be anticipated in the elderly and forestalled by frequent
mobilization, effective coughing, and breathing exercises.
• Anyone receiving treatment with respiratory therapy equipment can
develop pneumonia if the equipment has not been properly cleaned.

Incidence Rate of Pneumonia and Acute Lower Respiratory Tract Infection

in the Philippines by Sex
No. and Rate/100,000 Population as of 2004

MALE FEMALE BOTH SEXES

CAUSE
Rate** Rate** Number Rate*
1. Acute Lower RTI and 888.8 868.0 776,562 929.4
Pneumonia

PATHOPHYSIOLOGY

Bacterial pneumonia creates problems in both ventilation and

diffusion. An inflammatory reaction initiated by pneumococci occurs in the
alveoli and produces an exudate. This exudate, in turn, interferes with both
movement and diffusion of oxygen and carbon dioxide. White blood cells,
mostly neutrophils, also migrate into the alveoli, so that the lung segment
assumes a more solid structure as the air-containing spaces become filled.
Areas of the lung are not adequately ventilated because of secretions,
mucosal edema, and bronchospasm. These conditions cause partial occlusion
of the bronchi or alveoli, producing a drop in the alveolar oxygen tension.
Venous blood coming into the lungs passes through the left side of the heart
without being oxygenated. In essence, the blood is shunted from the right to
the left side of the heart. This mixing of oxygenated blood eventually results
in arterial hypoxemia.

CLINICAL MANIFESTATIONS

Pneumonia usually starts with a sudden onset of shaking chills, rapid

rising fever (39.5 ˚ to 40.5 ˚ C [100˚ to 105˚ F]), and stabbing chest pain that
is aggravated by respiration and coughing. The patient is severely ill with
marked tachypnea (25 to 45 bpm) accompanied by respiratory grunting,
nasal flaring, and the use of accessory muscles of respiration. He often lies
on his affected side in an attempt to splint his chest. The pulse is rapid and
bounding. It usually increases about 10 bpm for every degree of Celsius
temperature elevation. A relative bradycardia for the amount of fever should
suggest viral infection, Mycoplasma infection, or infection with Legionella
species. The cheeks are flushed, the eyes bright, and the lips and nailbed
cyanotic. The patient prefers to be propped up in bed and leans forward,
trying to achieve adequate gas exchange without trying to cough or breathe
deeply. He perspires profusely. The sputum is purulent and not a reliable
indicator of the etiologic agent. Rusty, blood-tinged sputum is produced in
pneumococcal, staphylococcal, Klebsiella, and streptococcal pneumonia.
Klebsiella pneumonia frequently also has viscous sputum. H. influenzae
sputum is green.

Other signs occur in patients who suffer from a condition such as

cancer or those who are undergoing treatment with immunosuppressants,
which lower the resistance to infection and to organisms heretofore not
considered serious pathogens. Such patients present with fever, crackles and
physical signs of lobar consolidation , including increased tactile fremitus,
percussion dullness, bronchovesicular or bronchial breath sounds, egophony
(change of patient’s “ee” to “ay” sound on auscultation), and whispered
pectoriloquy (whispered sounds heard louder and more clearly than normal
on auscultation). These changes occur because sound is transmitted better
through solid tissue (consolidation) than through normal tissue.

In older patients or those with COPD, the symptoms maydevelop

insidiously. Purulent sputum may be the only sign of pneumonia in these
patients. It is difficult to detect subtle changes in their conditions because
they have seriously compromised pulmonary function.

MANAGEMENT

The treatment of pneumonia depends largely on administration of the

appropriate antibiotic as determined by the results of the Gram stain.
Penicillin G is clearly the antibiotic of choice for infection with S.
Pneumoniae. Other effective drugs include erythromycin, clindamycin, the
cephalosporins, other penicillins, and trimethoprim-sulfamethoxazole
(Bactrim).

The patient is placed on bed rest until infection shows signs of

clearing. He is observed carefully and continually until his clinical condition
improves.

The patient who is hypoxemic is given oxygen. Arterial blood gas

analysis is performed to determine the need for oxygen and to evaluate its
effectiveness. A high concentration of oxygen is contraindicated in patients
with COPD because it may worsen alveolar ventilation by removing the
patient’s only remaining ventilatory drive and lead to respiratory
decompensation. Respiratory support measures such as endotracheal
intubation, high inspiratory oxygen concentrations, mechanical ventilation,
and positive end expiratory pressure (PEEP) may be requires for some
patients.
NURSING CARE

 Improvement of Airway Patency

Retained secretions interfere with gas exchange and may cause slow
resolution of the disease. A high level of fluid intake (2-3 l/day) is
encouraged, as adequate hydration thins and loosens pulmonary secretions
and also replaces fluid losses resulting from fever, diaphoresis, dehydration
and dyspnea.

Chest physiotherapy is extremely important in loosening and

mobilizing secretions. The patient is placed in the proper position to drain
the involved lung, and then the chest is vibrated and percussed. After the
lung has drained for 10 to 20 minutes, the patient is encouraged to breath
deeply and cough. If he is too weak to cough effectively, the mucus may
have to be removed by nasotracheal suctioning or by bronchoscopic
aspiration as determined by the physician.

If oxygen is prescribed, the nurse provides the necessary method of

oxygen administration and monitors the effectiveness of the oxygen
concentration by assessing for the clinical manifestations of hypoxia.

 Rest and Energy Conservation

The patient is encouraged to rest and remain in bed to avoid

overexertion and possible exacerbation of symptoms. He is placed in a
comfortable position for resting and breathing (e.g. semi-Fowlers) and
encouraged to change position frequently.

If sedatives or tranquilizers are prescribed, the patient’s sensorium is

evaluated first. Restlessness, confusion, and aggression may be due to
cerebral hypoxemia, in which case sedatives are contraindicated.

 Proper Fluid Intake

The patient’s respiratory rate increases because of dyspnea and fever.

With an increased rate there is an increase in insensible fluid loss during
exhalation. The patient can quickly become dehydrated. Therefore, fluids are
encouraged (at least 2 L/day). Frequently, a patient who is dyspneic is also
anorexic and will only take fluids. Fluids, then, are beneficial for volume
replacement as well as nutrition.

 Patient Education and Home Health Care

After the fever subsides, the patient may gradually increase his
activities. Fatigue, weakness, and depression may be prolonged after
pneumonia. Breathing exercises to clear the lungs and promote full lung
expansion are encouraged. The patient is instructed to the clinic or
physician’s office for follow up chest x-rays.

The nurse explains to the patient that it is wise to stop cigarette

smoking because it destroys tracheobronchial ciliary action, which is the
first line of defense of the lungs. Smoking also irritates the mucous cells of
the bronchi and inhibits the function of alveolar macrophage (scavenger)
cells. The patient is instructed to avoid fatigue, sudden changes in
temperature, and excessive alcohol intake, which lower resistance to
pneumonia. The nurse reviews with the patient the principles of adequate
nutrition and rest, because one episode of pneumonia may make him
susceptible to recurring respiratory tract infections. He is encouraged to
obtain influenza vaccine ate the prescribed times, because influenza
increases susceptibility to secondary bacterial pneumonia, especially that
caused by Staphylococcus, H. influenzae, and S. pneumoniae.
 II. OBJECTIVES

A. GENERAL OBJECTIVE

The general objective for conducting this case study is for students to
incorporate concepts and enhance knowledge in Medical and Surgical
Nursing and to apply the appropriate nursing management for clients with
pneumonia accurately and efficiently. This study also aims to develop the
skills that are applied for the care of patient’s wit this condition.

B. SPECIFIC OBJECTIVE

1. Define pneumonia accurately.

2. Discuss briefly the causative factors that may have precipitated the
onset of this condition.
3. Discuss thoroughly the signs and symptoms manifested by the
patient.
4. Discuss the different drugs; indications, mechanism of action,
therapeutic effects, adverse effects and contraindications.
5. Present accurately the condition of the patient.
6. Acquire knowledge and understanding of the pathophysiology of
pneumonia.
7. Discuss the nursing care plan appropriate in providing care to
alleviate the manifestation of the patient’s symptoms.
8. Identify and provide the health teachings needed for the continuum
of care.
9. Use the nursing care plan as the framework of the patient’s care.
 III. Nursing History

1. Personal Data

a. Name: Patient VC
b. Age: 68 yrs. Old
c. Sex: Female
d. Address: 551 Gen. Hizon St., Bangkal, Makati CPO,
Makati City 1200
e. Occupation: Household Personnel
f. Religion: Roman Catholic
g. Date and time of admission: June 14, 2009 9:00 AM
h. Admitting Physician: Dr. Florencio Chavez M.D.
i. Date and time of discharge: June 18, 2009

2. Chief Complaint:

Cough

3. History of Present Illness:

Two weeks PTA, patient experienced cough and whitish

phlegm, productive and associated pain. Patient self medicate with
Guaifenisin syrup with afforded slight relief. Few hours PTA
persistence of cough and associated easy fatigability and shortness of
breath prompted the patient to consult hence admitted.

4. Past Medical History

• As cites - 1976
• Pneumonia - 2006
• Hypertension - 2005 Therebloc 50 with BP 150/100
• S/P Cyst Removal (hand) - 1975
• Goiter - 1975

5. Family Medical History

Hypertension - both father (deceased) and mother (deceased)

6. Clinical Impression

Pneumonia, Right Lower Lobe

 IV. PATTERNS OF FUNCTIONING (GORDON’S)

Patterns of Before During / After Analysis

Functioning Hospitalization Hospitalization
1. Health The client The client still The client
Perception perceives herself perceives herself tries to cope
as a healthy as a healthy with her
person because person. condition by
according to her, thinking
she eats positively.
nutritious food
and has a good
personal hygiene.
2. Nutritional / The client likes The client’s The client
Metabolic Pattern to eat rice, diet is low salt follows her
vegetables and and low fat as doctor’s advice
some fatty foods. instructed by the and vows that
She also drinks doctor. she will
about 1L of continue for her
water per day. own good.
3. Elimination The client The client The client
Pattern urinates urinates 7-12 urinates more
frequently (4-7 times and moves frequently in
times) daily and her bowel once the hospital
moves her bowel per day. because of her
once a day. I.V. therapy
which is a
good sign.
4. Activity / The client The client is The client can
Exercise Pattern easily gets tired now able to perform her
and her body move freely tasks well
feels weak as she without easily when she’s in
does her getting tired and good
household work. weak. condition.
5. Sleep / Rest The client The client’s The client
Pattern sleeps 7 hours sleeping pattern developed
every night and is disturbed disturbed
takes 30 minutes because of sleeping
to 1 hour naps difficulty in pattern because
every afternoon. breathing. of her
condition.
6. Cognitive- The client said The client is The client did
Perceptual Pattern that she is not hesitant to not change her
cooperative. answer the attitude.
questions asked.
7. Self-perception The client has The client, The client is
/ Self Concept a high self- upon learning not affected of
Pattern esteem. about her her condition.
condition, still
has a positive
perception.
8. Role- The client even The client The client’s
relationship at her age, still thinks that she children
Pattern works for her will still continue motivate and
family and loves working to earn inspire her to
the family she money. work.
works with.
9. Sexuality- The client is a The client is a
Reproductive senior citizen. senior citizen.
Pattern
10. Coping / The client is The client is The client is
Stress Tolerance stressed with her more stressed more stressed
Pattern employer due to her because of her
everytime she condition. present
doesn’t do her condition.
tasks well.
11. Value belief The client is a The client has The client’s
Pattern Roman Catholic strong faith in faith in God is
and still believes God and believes strong that
in herbolarios. that she will get gives her a
well soon. positive
outlook.
 V. PHYSICAL ASSESSMENT

Date: June 17, 2009

Time: 8:00 p.m.
Vital sign:
Temperature: 36.5̊ Celius
Pulse rate: 69 bpm
Respiratory rate: 20 cpm
Blood Pressure: 130/80 mmHg
 Technique Used
Body Parts Findings Analysis
(IPPA)
Appearance and Inspection -clean, - normal
Mental status presentable,
cooperative
Skin Inspection and -light brown - normal
-poor skin
turgor(elders)

Palpation -no edema - sign of aging

-excessive number
of moles
Nails Inspection - convex, smooth, - normal
return to pink
when press
Skull and Face Inspection and - coordinated - normal
facial movements

Palpation - mass below the - may be a sign

right ear of cyst
Eyes Inspection and -both eyes are
coordinated
-able to read news
papers
-black in color; normal
equal in size

Palpation -no tenderness in

lacrimal duct and
glands
Ears Inspection and -color same as
facial skin
-auricle in line Normal
with the outer
canthus of the eye

Palpation -not tender

Testing -only the right ear Poor hearing

able to hear. due
Nose and sinuses Inspection and -air can pass - normal
Palpation through without
obstruction
- no pain
when palpated
-no discharge
Mouth Inspection and Lips – pinkish
Palpation Teeth and Gums –
with dentures normal
Tongue – moves
freely, no
tenderness
Neck Inspection, -Muscles equal in
Palpation, and size and strength
Percussion Lymph nodes- not normal
palpable
Thyroid glands-
not palpable
 VI. ANATOMY AND PHYSIOLOGY

Our lung is a pair of elastic, spongy organs used in breathing and

respiration. Lungs are present in all mammals, birds, and reptiles. Most
amphibians and a few species of fish also have lungs.
In humans the lungs occupy a large portion of the chest cavity from
the collarbone down to the diaphragm, a dome-shaped sheet of muscle that
walls off the chest cavity from the abdominal cavity. At birth the lungs are
pink, but as a person ages, they become gray and mottled from tiny particles
breathed in with the air. Generally, people who live in cities and industrial
areas have darker lungs than those who live in the country.
Air travels to the lungs through a series of air tubes and passages. It
enters the body through the nostrils or the mouth, passing down the throat to
the larynx, or voice box, and then to the trachea, or windpipe. In the chest
cavity the trachea divides into two branches, called the right and left bronchi
or bronchial tubes, which enter the lungs.
In the adult human, each lung is 25 to 30 cm (10 to 12 in) long and
roughly conical. The left lung is divided into two sections, or lobes: the
superior and the inferior. The right lung is somewhat larger than the left lung
and is divided into three lobes: the superior, middle, and inferior. The two
lungs are separated by a structure called the mediastinum, which contains
the heart, trachea, esophagus, and blood vessels. Both right and left lungs are
covered by an external membrane called the pleura. The outer layer of the
pleura forms the lining of the chest cavity.
The branches of the bronchi eventually narrow down to tubes of less
than 1.02 mm (less than 0.04 in) in diameter. These tubes, called
bronchioles, divide into even narrower tubes, called alveolar ducts. Each
alveolar duct ends in a grapelike cluster of thin-walled sacs, called alveoli (a
single sac is called an alveolus). From 300 million to 400 million alveoli are
contained in each lung. The air sacs of both lungs have a total surface area of
about 93 sq m (about 1000 sq ft), nearly 50 times the total surface area of the
skin.
In addition to the network of air tubes, the lungs also contain a vast
network of blood vessels. Each alveolus is surrounded by many tiny
capillaries, which receive blood from arteries and empty into veins. The
arteries join to form the pulmonary arteries, and the veins join to form the
pulmonary veins. These large blood vessels connect the lungs with the heart.
Through the right lung has three lobes, the left lung, with a cleft to
accommodate the heart, has only two lobes. The two branches of trachea
called bronchi, subdivide within the lobes into smaller and smaller air
vessels. They terminate into alveoli, tiny air sacs surrounded by capillaries.

When the alveoli inflate with inhaled air, oxygen diffuses into the
blood in the capillaries to be pumped by the heart to the tissues of the body
and carbon dioxide diffuses out of the blood into the lungs to be exhaled.

THE FLOW

Nose (nasal passages)

Pharynx

Larynx

Trachea

Bronchi

Bronchioles

Alveoli
VII. PATHOPHYSIOLOGY
 VIII. LABORATORY / DIAGNOSTIC
EXAMINATIONS
Date: June 14, 2009

Department of Pathology
CLINICAL CHEMISTRY SECTION
Specimen: Serum

Lipid Profile (Cholesterol, HDL, TRI, LDL)

Examination Result Reference Value

Serum Cholesterol 4.98 less than 5.2

mmol/L
Triglycerides 1.10 less than 2.26
mmol/LHDL
HDL- high density lipo protein 0.86 1-0-1.6 mmol/L
LDL (low density lipoprotein) 3.62 less than 3.4
mmol/L

Department of Pathology
CLINICAL CHEMISTRY SCETION
Date: June 14, 2009

FBS- Fasting blood sugar 8.0 4.1-5.9 mmol/L

Date: June 14, 2009

X-RAY SECTION

Examination: Chest (PA oar AP)

Hazed densities are seen in the right lower lobe.
Heart is enlarged obscuring the Left hemidiaphragm and Left sulcus. Aortic
knob is selerotic.
Right hemidiaphragm and sulcus are intact.
Bones are unremarkable.

Impression:
Pneumonia, Right lower lobe
Cardiomegaly
Atheromatous Aorta
 Department of Pathology
Hematology Section
Specimen: Blood
CBC- complete blood count
Date: June 14, 2009

Examination Result Reference Value

Hemoglobin 12.9 12.5- 16.0g/dL

Hematocrit 39.3 37-43%
Red Blood Cells 4.30 4.2-5.4 – 10 6/uL
mean Corpusculae hemoglobin 30.0 26-32pg
mean corpusculae volume 91.4 77-93 FL
mean corpuscular hemoglobin 32.8 31-35 g/dL

Concentration
white blood cells 6.0 4.0-10.5 10 3/uL
neutrophils 54.2 43-65%
lymphocyte 32.1 20.5-40.5%
monocyte 7.8 5.5-11.7%
eosonophil 4.9 0.9-2.9%
basophil 1.0 0.2-1.0%

Department of Pathology
Clinical Chemistry Section

Date: June 14, 2009

Test name Result

RBS-Reflo : 9.3 mmol/L as of 1:10pm
 Department of Pathology
Clinical Chemistry Section
Specimen: serum
electrolyte determination- NA, K, CL

Date: June 14, 2009

Examination Result Reference Value

Sodium 137.0 135-148 mmol/L

Potassium 3.86 3.5-5.3 mmol/L
Chloride 1o4.8 98-107 mmol/L

Department of Pathology
Clinical Chemistry Section
Specimen: serum

Date: June 14, 2009

Bun- Blood Urea Nitrogen 36 2.5- 6.1

mmol/L
Creatinine (serum) 53.0 46-92
umol/L
SGPT- Aspartate Amino Transferase 26.0 14.36 u/L
UA- blood Uric acid 0.378 0.149-0.369
mmol/L

Date: June 14, 2009

DR. CHAVEZ, FLORENCIO R.

URINALYSIS REPORT: REFERENCE VALUES

Physical Examination Results: Yellow

Color : Light Yellow Clear
Transparency: Slightly Hazy 4.6- 8.0
Reaction: 6.5 1.06- 1.022
CHEMICAL EXAMINATION

Leukocytes: Trace (15 ca. CELLS/UL) Negative

Nitrate: Negative Negative
Urobilinogen: Normal (3.2 umol/L) Negative
Protein: Negative Negative
Blood: Negative Negative
Ketone: Negative Negative
Bilirubin: Negative Negative
Glucose: Negative Negative

Date: June 14, 2009

URINE FLOWCYTOMETRY

CONVENTIONAL UNIT S.I. Unit

Result Unit Reference Result Unit Reference
Range Range
RBC 0.4 /hpf 0.2 2.1 /ul 0-11
WBC 6.1 /hpf 0.3 33.8 /ul 0-17
BACTERIA 0.5 /hpf 0-50 2.9 /ul 0-278
Epthelial
Cells 0.6 /hpf 0-3 3.2 /ul 0-17
Casts 0.0 /hpf 0-3 0.0 /ul 0-1

Department of Pathology
Clinical Chemistry Section

Date: June 16, 2009

Test Name Result

RBS_ Reflo : 5-6 mmoL/ as of 5pm
 Department of Pathology
Clinical Chemistry Section

Date: June 16, 2009

Test Name Result

RBS- Reflo : 9.3 mmol/L as of 2pm

IX. MEDICAL INTERVENTIONS

 Medical Operations Date and Classificatio Rationale
Time n
ordered
D5NM 1L + BNC x 4 06/14/09 Therapeutic For maintenance
hrs. 9:00 am
D5W 1L + BNC x 4 hrs. Therapeutic For cardio patients

Tazocin (4.5 gms) IV Q Therapeutic For the treatment of

8 hrs. patients with
Community-acquired
pneumonia
Norvasc (5 mg) 1 tab. Therapeutic Helps to lower the
Aft. breakfast BP
Plavix (75 mg) 1 tab OD Therapeutic Helps to treat
Myocardial
Infarction

Vastarel (35 mg) 1 tab. Therapeutic Treatment for of

BID visual disorders of a
circulatory origin.
Levopront (2 tsp.) TID Therapeutic
Combivent neb TID Therapeutic To relax muscles in
the airways and
increase air flow to
the lungs.
Coralan (5 mg) 1 tab. Therapeutic
OD
For CBC, UA, BUN, Diagnostic To provide general
CREA Electrolytes, measure of kidney
RBS, SGPT, SGOT, function,to check if
Chest x-ray, P.A., Uric there are imbalances
acid and to know if there
are any
abnormalities.
For 2decho and sputum 06/15/09 Diagnostic To determine if there
GSCS 11:25 am are any abnormalities
present and ensure
that microorganisms
can be accurately
detected.
IVF TF – D5NM 1L + Therapeutic For cardio patients
BNC x For maintenance
4 hrs.
IVF to ff: D5NM 1L + 1 06/16/09 Therapeutic For cardio patients
amp. BNC x 4hrs. 3:42 am For maintenance
OD ANST
Glucophage (500 mg) 1 10:45 am Therapeutic To control blood
tab. TID sugar levels.
HGT monitoring TID ac Therapeutic
IVF to consume 06/17/09 Therapeutic For cardio patients
11:20 am
D/C Tazocin IV Therapeutic For the treatment of
patients with
Community-acquired
pneumonia
Shift Levox x 500 IV to Therapeutic For the treatment of
Levox 500 mg/tab. patients with
1 tab. OD aft. breakfast Community-acquired
pneumonia
 X. DRUG STUDY

Generic and Classification Dosage, Mechanism Indications Contraindications Adverse Nursing

Brand name Frequency of action Reactions Considerations
& Route
Amlodipine Calcium 5 mg Cause a Hyperten- allergy to CNS: Dizziness, Assessment
channel- (1 tab.) reduction in sion diltiazem, lightheadedness,
Norvasc blocker OD pc peripheral impaired hepatic headache, History:
(breakfast) vascular Chronic or renal function, asthenia, fatigue, Allergy to
Antianginal p.o. resistance and Stable sick sinus lethargy amlodipine
drug reduction in Angina syndrome, heart Physical: Skin
blood block (second or GI: Nausea, lesions, color,
Antihypertens pressure. third degree) abdominal edema
ive discomfort
Implementatio
CV: Peripheral n
edema,
arrhythmias Monitor
patient
Dermatologic: carefully (BP,
Flushing, rash cardiac
rhythm, and
output)

Clopidogrel Adenosine 5 mg Inhibits Treatment allergy to CNS: Headache, Assessment

diphosphate (1 tab) platelet of patients clopidogrel dizziness,
Plavix OD aggregation at risk for weakness, History:
 p.o. by blocking ischemic syncope,
Antiplatelet ADP events-- flushing Allergy to
agent receptors on history of clopidogrel,
platelets MI GI: Nausea, GI
distress, Physical: Skin
constipation, color,
diarrhea, GI temperature,
bleed lesions

Dermatologic: Implementatio
Skin rash, n
pruritus
Provide small,
frequent meals
if GI upset
occurs
Trimetazi- Anti-Anginal 35 mg MAOIs. Prophylacti Pregnancy & Rare cases of GI
dine di-hcl Drugs 1 tab. c treatment lactation. disorders
BID of episodes
Vastarel p.o. of angina
pectoris;
adjuvant
symptomati
c treatment
of vertigo
& tinnitus.

Levopront Antitussive 2 tsp. The Dry Hypersensitivity, It is an

 TID medication unproducti the excess rate, antitussive drug,
p.o. with drug ve cough expressed it can cause
Levopront yet with violations of the dizziness,
to pharyngitis, liver. somnolence,
materialize. , influenza, nausea,
pneumonia, vomiting,
bronchial heartburn,
asthma, diarrhea,
emphysema abdominal
lungs discomfort,
faintness
Coralan Ivabradine 5 mg Reduces Symptomat Unstable angina May cause
HCL ( 1 tab.) cardiac ic treatment Severe liver prob. temporary
Ivabradin OD pacemaker of chronic Severe heart venous visual
p.o. activity, angina failures phenomena
slowing the pectoris in
heart rate patients w/
normal
sinus
rhythm
Metformin Antidiabetic 50 mg/tab. Exact Adjunct to Allergy to GI: anorexia, Assessment
agent TID mechanism is diet to metformin; nausea,
Glucophage p.o. not lower diabetes vomiting, History:
understood blood complicated by epigastric Allergy to
glucose fever, severe discomfort, metformin;
with non- infections, severe heartburn, diabetes
insulin- trauma, major diarrhea complicated
dependent surgery, ketosis, by fever
Endocrine:
 diabetes acidosis, coma Physical: Skin
mellitus (use insulin) hypoglycemia, color, lesions,
lacticacidosis
Implementatio
Hypersensitivity: n
allergic skin
reactions, Monitor urine
eczema, pruritus, and serum
erythema, glucose levels
urticaria frequently

Arrange for
transfer to
insulin therapy
during periods
of high stress
Levofloxa- Antibiotic 500 g Bactericidal Treatment allergy to CNS: Headache,
cin (1 tab.) of adults fluoroquinolones, dizziness, Assessment
Flouroquinolo OD aft. with CAP insomnia,
Levaquin ne Breakfast fatigue, History:
(Levox) p.o. Treatment somnolence, Allergy to
of acute depression, fluoroquinolon
exacerbatio blurred vision es, renal
n of dysfunction,
chronic GI: Nausea, seizures
bronchitis vomiting, dry Physical: Skin
mouth, diarrhea color, lesions
Treatment
Implementatio
of Hematologic:
n
 uncomplica Elevated BUN, Arrange for
ted skin SGOT, SGPT, culture and
and skin serum creatinine, sensitivity
structure and alkaline tests before
infections phosphatase beginning
therapy.
Treatment
of Ensure that
complicate patient is well
d UTIs and hydrated
acute during course
pyelonephri of therapy.
tis

Ipratropiu Anticholinerg 1 neb Anticholinerg Bronchodil hypersensitivity CNS: Assessment

m bromide ic TID ic, chemically a to atropine or its Nervousness,
related to tor for derivatives, acute dizziness, History:
Combivent Antimuscarini atropine maintenanc episodes of headache, Hypersensitivit
c agent e treatment bronchospasm. fatigue, y to atropine;
of insomnia, acute
Parasympatho bronchospa blurred vision bronchospasm,
ly sm narrow-angle
associated GI: Nausea, GI glaucoma,
tic with COPD distress, dry prostatic
mouth hypertrophy
Physical: Skin
Respiratory: color, lesions,
 Cough Implementatio
n

Ensure
adequate
hydration

Have patient
void before
taking
medication to
avoid urinary
retention.

ADVERSE NURSING
DRUG NAME DOSAGE ACTION INDICATIONS CONTRAINDICATIONS
EFFECTS RESPONSIBILITIES

• Acetaminoph 500 mg 1 Unknown. Thought • mild pain • Patients • Hematologic: • Question for
en tab q 40 to produce • fever hypersensitive to - hemolytic sensitivity to
PRN if analgesia by drug anemia acetaminophen.
Brand Name: temp≥37. blocking pain • Use cautiously in - neutropenia • Obtain baseline data
Paracetamol 80C impulses by patients with long - leucopenia before giving
inhibiting synthesis term alcohol use - pancytopeni medication.
Classification: of prostaglandin in a • Document presence of
Nonopiod the CNS or • Jaundice pain/fever.
Analgesic and receptors to • Hypoglycemia • Administer drug with
Antipyretics stimulation. The • Rash food or milk to
drug may relieve
 fever through decrease GI upset.
central action in the • Assess for clinical
hypothalamic heat- improvement and
regulating center. relief of pain and
fever.

• Levofloxacin 750 mg 1 Inhibits bacterial • Acute • Patients • CNS: • Obtain specimen

tab OD DNA gyrase and maxillary hypertensive to - headache culture and sensitivity
Brand Name: prevents DNA sinusitis drug, its - insomnia tests before starting
Levox replication, caused by components or - dizziness therapy and as
transcription, susceptible other - seizures needed to determine
Classification: repair, and strains of fluoroquinolones. • CV: if bacterial résistance
Antibiotic: recombination in Streptococcu • Use cautiously in - chest pain has occurred.
Quinolone/Fluor susceptible s patients with history - palpitations • Let the patient take
oquinolones bacteria. pneumoniae, of seizure disorders - vasodilation the drug with plenty
Moraxella or other CNS • GI of fluids and to
catarrhalis, diseases such as - nausea appropriately space
Haemophilus cerebral - diarrhea antacids, sucralfate,
influenzae. arteriosclerosis. - vomiting and products
• Mild to • Use cautiously and - abdominal containing iron or zinc
moderate with dosage pain after each dose of
skin and skin- adjustments in - dyspepsia Levofloxacin.
structure patients with renal - flatulence • Advise patient to
infections impairment. • back pain avoid excessive
caused by • allergic sunlight, use
Staphylococc pneumonitis sunscreen, and wear
us or S. - vasodilation protective clothing
pyrogens. • SKIN when outdoors.
• Acute - rash • Notify prescriber if
bacterial - photosensiti rash of other signs or
worsening of vity symptoms of
chronic - pruritus hypersensitivity
 bronchitis develop.
• Community- • Monitor glucose level
acquired and renal, hepatic,
pneumonia and hematopoietic
blood studies.

• Fluimucil 600 mg 1 Reduces the • acute and • drug sensitivity • increased • Use nonreactive
tab in ½ viscosity of chronic • Phenylketonuric incidence of plastic, glass or
Brand Name: glass of purulent and respiration s bronchospas stainless steel for
Zambon water nonpurulent tract infection m administration.
secretions and with • GI: • May administer via
Classification: facilitates their abundant - nausea face mask, face tent,
Acetylcysteine removal by splitting mucus - vomiting oxygen tent or by
disulfide bonds. secretion - stomatitis positive pressure
Action increases apparatus.
with increasing pH. • Administer with
Also reduces liver compressed air for
injury due to nebulization.
acetaminophen • Have suction available
over dosage by for emoval of
maintaining or increased secretions.
restoring
glutathione levels
or by acting as an
alternate substrate
for the reactive
metabolite of
acetaminophen.
 XI. LIST OF NURSING DIAGNOSIS
Nursing Diagnoses
Ineffective airway clearance related
to presence of secretion
Risk for unstable blood glucose
related to dietary intake: weight gain
Sleep pattern disturbance related to
cough
Fatigue related to stress in
occupation
Risk for activity intolerance related
to presence of respiratory problem
NURSING CARE PLAN
Interpretation
Ineffective airway clearance is a life
threatening problem. The main
concern is to promote immediate
oxygenation and eliminate the
secretions.
The risk for unstable blood glucose is
another problem. However if the
client is informed about the proper
diet, the problem may not develop as
an actual problem. There is no
intervention needed just continue the
assessment.
Lack of sleep is a life threatening.
But to threat the ineffective airway
clearance, will change this priority.
Therefore, measure to promote sleep
will be less prioritized until bedtime.
The client often feels fatigue due to
her occupation. One of the
interventions needed is to help the
client manage the problem to
maximize her energy.
The problem won’t develop into an
actual problem if the highest
prioritized problem will be
threatened. No intervention need.
 XII. NURSING CARE PLAN

NURSING IMPLEMENTATIO
ASSESSMENT INFERENCE GOAL OF CARE RATIONALE EVALUATION
DIAGNOSIS N
S – “madali ako Fatigue related to After 4 hours of Independent:
mapagod” as disease condition nursing
verbalized by the as manifested by intervention will Monitor vital sign. For baseline Goal partially
patient. decreased report an improved data. met, the client
performance, lack sense of energy demonstrated a
O – decreased of energy and and participate in Encourage client to To conserve her feeling of being
performance restlessness. activities at level take rest during energy. relieved and
- lack of energy of ability. activities and ask for rested as
- restlessness assistance. manifested by
her cooperation
Instruct client to eat To give energy. with the nurse.
nutritious food and
avoid caffeine.
 NURSING IMPLEMENTATIO
ASSESSMENT INFERENCE GOAL OF CARE RATIONALE EVALUATION
DIAGNOSIS N
S – “Hirap ako Sleep pattern Cough resulting The client will Independent:
matulog dahil sa disturbance to sleep pattern demonstrate an
ubo ko” as related to cough disturbance. optimal balance Provide comfort After the nursing
verbalized by the as manifested by of rest and measures to induce intervention goal
client. restlessness. activity after the sleep: was met as
Drowsiness, nursing evidenced by
O – restlessness irritability intervention of an a. Back tapping • To longer hours of
- drowsiness interrupted sleep loosen the sleep.
- irritability at night. secretion

After the nursing b. Fluid intake • To liquefy

intervention the secretion
client will be
relieve from the c. Pillow support • Provide
comfort

Dependent:

Medication if needed
a. levopront • To
relieve or
to suppress
cough
 GOAL OF CARE
NURSING
ASSESSMENT INFERENCE IMPLEMENTATION RATIONALE EVALUATION
DIAGNOSIS
S - "Nahihirapan Ineffective 1.Accumulation After 1 hour of Independent:
akong huminga" airway clearance of secretion in nursing
as verbalized by related to lung field intervention the • Check vital sings • To Goal partially
the patient. presence of 2.altered client will be able and auscultate establish met. The patient
secretion as exchange of gas to demonstrate breath sounds. baseline display patent
O - changes manifested by 3.decrease behaviors to data. airway with
in rate, changes in rate, oxygenation achieve airway breath sounds
depth of respi- depth of 4.leading to clearance. • Position to semi- • To clearing and
ration. respiration, ineffective fowlers. promote absence of
- dyspnea dyspnea and airway lung dyspnea.
abnormal breath abnormal breath AMB difficulty expansion
sound. sound. in breathing • Increase fluid
intake. • To liquefy
secretion.

Dependent:

• Administer
medication • Aids in
reduction
of
bronchosp
asm and
mobilizati
 on of
secretions.
• Chest
physiotherapy • To remove
secretion
from the
breathing
passages
of the
patient.