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CHAPTER I INTRODUCTION

Respiratory disorders are among the most common causes of illness and hospitalization in children. Overall, respiratory dysfunction in children tends to be more serious than in adults because the lumens in a childs respiratory tract are smaller and therefore likely to become obstructed. (Pillitteri, 2008) While the most common respiratory diseases in children are colds and flu, there are other lung diseases that children are also vulnerable to, which include Bronchitis. Bronchitis refers to a nonspecific bronchial inflammation and is associated with a number of childhood conditions. There are two types of Bronchitis: Acute Bronchitis and Chronic Bronchitis. (Kliegman et al, 2007)

Acute Bronchitis is a syndrome, usually viral in origin, with cough as a prominent feature. It refers to an inflammation of the bronchi or air passage of the lungs. It is a breathing disorder affecting the expiratory function in most cases, some infections also occur in the nose and throat. The presentation of acute bronchitis is usually mild and self-limited, requiring only supportive treatment. Cough may be productive or nonproductive. Associated symptoms include low-grade fever, chest discomfort, sore throat, and fatigue. In children, the smaller airways are easily obstructed by inflammation, so that severe obstruction may occur. The smallness of airways in proportion to body size is due to a smaller lumen in relation to the vessel wall. (Copstead et al. 2008) There are different ways on how to diagnose a patient with Acute Bronchitis. Diagnosis of Acute Bronchitis is usually based on the clinical presentation, with recent onset of cough being the distinctive hallmark. Neither the appearance of purulent sputum

nor a WBC count is a reliable diagnostic indicator. A chest radiograph is required to distinguish acute bronchitis (normal radiograph) from pneumonia (pulmonary infiltrates on radiograph). (Copstead et al. 2008) Treatment for patients with Acute Bronchitis is mainly symptomatic and includes rest, humidification, and increased fluid intake. Exposure to cigarette smoke should be avoided. Cough suppressants are not recommended unless cough interferes with the childs ability to rest. Antihistamines should be avoided because of their drying effect on secretions. Antibiotics should be given only if a bacterial infection is confirmed by culture or if the clinical picture supports the diagnosis. (Leifer et al, 2007)

The gastrointestinal system involves a long body tract with numerous organs. Because it is so long and diverse; a multitude of possible disorders can occur along it, including both congenital disorders and acquired illness. (Pilliteri, 2008) Most common GI disorders seen in children are Constipation, Irritable Bowel Syndrome, Reflux, Fecla incontinence, and Gastroenteritis. (www.aboutkidsgi.org)

Acute Gastroenteritis, an inflammation of the mucous membranes of the stomach and intestines, is defines as diarrheal disease of rapid onset with or without accompanying manifestations such as nausea, vomiting, fever, and abdominal pain. Most cases of gastroenteritis are self-limited; however, more severe or prolonged illnesses can result in dehydration with significant morbidity and mortality. (Kliegman) Acute Gastroenteritis accounts for as many as 5 million deaths each year worldwide. It primarily affects the small bowel and can be either viral or bacterial origin. Both forms have similar manifestations and are considered self-limiting in the course unless complications occur. All organisms that are implicated in gastroenteritis cause diarrhea.

The universal manifestation of Acute Gastroenteritis is diarrhea, which occurs in varying intensity, depending on the organisms involved and the health status of the individual client. The diarrhea may be mild (two or three stools per day) or intense (more than 10 watery stools per day). Nausea, vomiting, and anorexia may occur from abdominal distention caused by increased fluid content and undigested food. Abdominal pain, cramping, and borborygmi may occur from gas released from undigested food, irritation of bowel mucosa, and distention of the intestines. The client may have a fever, depending on the causative organisms. Diagnosis for Acute Gastroenteritis is based on the history, physical exam, and laboratory studies focused on evaluation the childs hydration status and identifying the causative agent. The history should include the following data: Recent exposure to infectious agents, Travel history, and Exposure to contaminated food and water supplies. The childs hydration status is evaluated, including a history of fluid intake, such as types, amounts, and how tolerated. The stooling pattern, frequency, and volume, as well as urination frequency, amount, and color, is also investigated. Current weight compared to pre-illness weight is useful in determining fluid loss. Generally, if no systemic manifestations are present and if dehydration is absent diagnostic laboratory tests are not indicated. Stool cultures should be performed for children with a fever lasting more than 24 hours, blood or mucus in the stool, a family or household member with similar symptoms, or a positive stool white blood cell stain. (Potts et al, 2007) Treatment for acute gastroenteritis focuses on fluid replacement and correction of electrolyte disturbances, and is dependent on the degree of dehydration. Initial management should begin at home since early interventions can reduce complications such as dehydration and poor nutrition. The most important aspect underlying home treatment is the need to administer increased volumes of appropriate fluids as well as to maintain caloric intake. Children with no dehydration and mild diarrhea may be treated

with 10ml/kg of ORS to replace fluis lost with each stool. However, since most children who are not dehydrated dislike ORS, they can be offered age-appropriate foods and additional fluids. (Potts et al, 2007)

According to the Environment health country profile conducted by the World Health Organization, the ten leading causes of morbidity in the Philippines are diarrhea, Bronchitis/Bronchiolitis, pneumonia, influenza, hypertension, tuberculosis, diseases of the heart, malaria, measles, and chickenpox. (WHO, 2005) Respiratory diseases and COPD are in the top ten causes of morbidity in the Philippines. Research show that the incidence of Bronchitis among Metro Manila children is 11 times the national average and that chronic cough, chronic phlegm, wheezing and shortness breath are highest among drivers and commuters. (WHO, 2005)

PURPOSE AND OBJECTIVES This case study aims to analyze the contributing factors leading to the development of the problem through the use of the nursing process on the care of a pediatric client diagnosed with Acute Bronchitis and with secondary diagnosis of Acute Gastroenteritis. Specifically, this study seeks to accomplish the following objectives: 1. Identify the contributing factors leading to the development of the problem 2. Analyze the relationship of the factors leading to the development of the problem 3. Discuss nursing interventions that were utilized to solve the problems 4. Explain the patients response towards the nursing interventions being utilized

SIGNIFICANCE OF THE STUDY The case study is conducted for the benefits of the following: To the future patients, this case will provide them knowledge and information regarding this condition which they might acquire in the future. To the student nurses, this case will suffice them with knowledge that will help them deliver proper nursing interventions for clients. It will also help them improve their clinical skills in rendering appropriate care to the client with this kind of condition. This case will also serve as a guide for them for future references. To the clinical instructors, this case will equip them with additional knowledge regarding the clients condition thus, keeping them updated with the actions done in the clinical area. This case will also help them evaluate their students clinical performances. To the future researchers, this case will serve as a future references to their cases or studies. It will also serve as a guide for them in making efficient case studies for future utilization.

SCOPE AND LIMITATION The scope of the study was focused on utilization of the nursing process in the care of a 4 year old client diagnosed with Acute Bronchitis with asthmatic component and Acute Gastroenteritis. A retrospective type A of study was conducted for Mr. J.A.P. diagnosed with Acute Bronchitis and Acute Gastroenteritis. The study was conducted on August 2 from 0600H to 1400H only. The study was conducted at the 8th floor rear of the hospital affiliated with the college of nursing. The researcher was able to assess the clients history through interview with the patients significant others. Aspects that were looked into were the clients demographic profile, history of present illness, medications, and interventions done by the nurses and the physicians. Other aspects that were not thoroughly assessed during the interview were verified in the patients chart. Meeting the needs of the patient, the researcher was able to perform routine vital signs monitoring, monitoring intake and output, and assisting in the administration of medications. Health teachings were also provided to the patient and the significant others. All interventions were also properly documented in the patients chart.

Data collection was done during the duty hours between 0600H and 1400H on August 3, 2010. There are limitations of the study that was noted by the researcher. The researcher wasnt able to interview the patient directly because of his age, which is 4 years old. The researcher wasnt also able to assess the environmental history of the patient.

BACKGROUND OF THE STUDY The study was conducted at a private institution located in Makati City, which offers a wide array of services for treatment and specialization. The hospital has a vision to be a world class hospital of everyones choice. Likewise, the nursing service division has its own vision also which is to be a world class nursing services division of everyones choice. The study was conducted in the 8th floor rear of the said constitution. It is a High Risk Nursing Unit, admitting pediatrics from day old up to 18 years old. The unit has a total bed capacity of 20 with 9 large private rooms and 11 small private rooms. To meet the needs of the patients, the nursing unit maintains a nurse-patient interaction of 1 nurse to 5 patients based on patients acuity. It is manned by a unit manager, charge nurses, staff nurses, ward clerks, nursing aides, and orderlies. The nursing staff correlates with the physician, surgical care services, rehabilitation services, and the registered dietician to formulate the maximum care to benefit the patient. The nurses utilize the nursing process (ongoing multi-system physical and psychological assessment, planning, intervention, education, and evaluation) when rendering care to patients they serve. They observe the procedures accepted by the hospital in the medication, delivery, administration and management, patient/family

education, nutritional support, oxygen therapy and pulse oximetry, IV line management, complexes laboratory investigations and emergency resuscitation procedures. Moreover, the staff practices universal precautions for infection control in doing all the day to day procedures. Patient A.P. was handled by the researcher who, on that time, was occupying room 828. The researcher chose this topic because of the presence of two different diagnoses present in the patient. The researcher also chose this topic for the reason that it may enhance the knowledge of the researcher regarding appropriate care to pediatric clients with these similar problems.

CHAPTER II REVIEW OF RELATED LITERATURE This chapter discuss about the analysis of preceding study, articles and journals that have relationship with the present study. This chapter also deals with the relationship between the dependent variables and independent variables identified in the study.

ACUTE BRONCHITIS

DEFINITION The following articles are all about the different definitions of Acute Bronchitis. These articles will help the researchers understand more about the present condition of the patient. These articles would also help the researcher in distinguishing the presence of differences in the perceptions about the Acute Bronchitis.

Lewis, A., et al. (2008). Medical Surgical Nursing: Assessment and management of clinical problems 2008. Mosby Elsevier Acute bronchitis is an inflammation of the bronchi in the lower respiratory tract, usually due to infection. It is one of the most common conditions seen in primary care. It usually occurs a sequela to an upper respiratory tract infection. A type of acute bronchitis seen in chronic obstructive pulmonary disease is acute exacerbation of chronic bronchitis. AECB represents an acute infection superimposed on chronic bronchitis. AECB is potentially serious condition that may lead to respiratory failure.

Pillitteri, Adele (2007). Maternal and Child Health Nursing: care of the child bearing and childrearing family 5th edition 2007. Lippincott William and Wilkins Bronchitis, or the inflammation of the major bronchi and trachea, is one of the more illnesses affecting preschool and school-age children. It is characterized by fever and cough, usually in conjunction with nasal congestion. Causative agents include the influenza viruses, adenovirus, and Mycoplasma pneumonia, among others.

ETIOLOGY AND INCIDENCE The following articles are all about the underlying etiology of Acute Bronchitis. These articles will help the researcher recognize the expected causes of the condition present in the client.

Leifer G., et al. (2007). Introductory to maternity and pediatric nursing 5th edition 2007. Saunders Elsevier Acute bronchitis is usually viral in origin. Rhinoviruses are the most common causative organisms. Other viruses thought to cause bronchitis include respiratory syncytial virus, influenza virus, parainfluenza virus, and adenovirus. Most bacterial infections occur secondary to a primary viral infection or some other airway problem. They may also occur as a result of foreign body aspiration. Air pollution has also been implicated in the disease. The disorder is more common in young children and boys. It can occur anytime but is more common during the winter months than in other seasons.

Greene, Alan. Acute Bronchitis. University of Maryland Medical Center. May 16, 2007 <http://www.umm.edu/careguides/000105.htm>

Bronchitis results from an infection such as colds or flu. The infection inflames the bronchial tubes, which cause symptoms of bronchitis. Although acute bronchitis is relatively common, some people are more prone to it than others. People at a higher risk include smokers, individuals with respiratory illnesses such as asthma, and individuals exposed to high levels of airborne pollutants. Although acute bronchitis itself is not dangerous, the infection that causes the bronchitis may progress further into pneumonia. Bronchitis may also aggravate the symptoms of asthma or other breathing disorders. Of a young child show signs of bronchitis, consult a doctor, who may watch for any serious developments.

Diagnosis and Management of Acute Bronchitis. American Academy of family physicians. <http://www.aafp.org/afp/2002/0515/p2039.html> Acute bronchitis is usually caused by a viral infection. In patients younger than one year, respiratory syncytial virus, parainfluenza virus, and coronavirus are the most common isolates. In patients one to 10 years of age, parainfluenza virus, enterovirus, respiratory syncytial virus, and rhinovirus predominate. In patients older than 10 years, influenza virus, respiratory syncytial virus, and adenovirus are most frequent. Parainfluenza virus, enterovirus, and rhinovirus infections most commonly occur in the fall. Influenza virus, respiratory syncytial virus, and coronavirus infections are most frequent in the winter and spring.

MANIFESTATIONS AND DIAGNOSTICS The following articles include different signs and symptoms present in Acute Bronchitis. These articles also include the different diagnostic procedures that should be done to patients with Acute Bronchitis. These articles would help the researcher in

distinguishing the expected manifestations as well as be knowledgeable of the different diagnostics that are to be done to a patient with Acute Bronchitis.

Lewis, A., et al. (2008). Medical Surgical Nursing: Assessment and management of clinical problems 2008. Mosby Elsevier In acute bronchitis, persistent cough following an acute upper airway infection (e.g. rhinitis, pharyngitis) is the most common symptom. Cough is often accompanied by production of clear, mucoid sputum, although some patients produce purulent sputum. Associated symptoms include fever, headache, malaise, and shortness of breath on exertion. Physical examination may reveal mildly elevated temperature, pulse, and respiratory rate with either normal breath sounds or rhonchi and expiratory wheezing.

Leifer G., et al. (2007). Introductory to maternity and pediatric nursing 5th edition 2007. Saunders Elsevier Bronchitis is characterized by the gradual onset of rhinitis and a cough that is initially non-productive but may change to a loosed cough with increased mucus production. Auscultation may reveal coarse and fine, moist crackles and high pitched rhonchi (resembling the wheezing of asthma). Associated symptoms include malaise, low-grade fever, and increased mucus, which may be purulent. Chest radiographs are usually normal. The diagnosis is based on clinical picture.

Diagnosis and Management of Acute Bronchitis. American Academy of family physicians. <http://www.aafp.org/afp/2002/0515/p2039.html> Cough is the most commonly observed symptom of acute bronchitis. The cough begins within two days of infection in 85 percent of patients. Most patients have a cough for less than two weeks; however, 26 percent are still coughing after two weeks, and a

few cough for six to eight weeks. When a patient's cough fits this general pattern, acute bronchitis should be strongly suspected. Other signs and symptoms may include sputum production, dyspnea, wheezing, chest pain, fever, hoarseness, malaise, rhonchi, and rales. Each of these may be present in varying degrees or may be absent altogether. Sputum may be clear, white, yellow, green, or even tinged with blood. Peroxidase released by the leukocytes in sputum causes the color changes; hence, color alone should not be considered indicative of bacterial infection.

Leifer G., et al. (2007). Introduction to maternity and pediatric nursing 5th edition 2007. Saunders Elsevier The gradual onset of an unproductive hacking cough is preceded by an upper respiratory tract infection, or cold. The cough may become productive with purulent sputum. Children under 7 years of age cannot voluntarily cough and usually swallow their sputum.

Lewis, A., et al. (2008). Medical Surgical Nursing: Assessment and management of clinical problems 2008. Mosby Elsevier Chest x-rays can differentiate acute bronchitis from pneumonia because there is no evidence of consolidation or infiltrates on x-ray with bronchitis.

Diagnosis and Management of Acute Bronchitis. American Academy of family physicians. <http://www.aafp.org/afp/2002/0515/p2039.html> Recommendations on the use of Gram staining and culture of sputum to direct therapy for acute bronchitis vary, because these tests often show no growth or only normal respiratory flora.6,7 In one recent study,8 nasopharyngeal washings, viral serologies, and sputum cultures were obtained in an attempt to find pathologic

organisms to help guide treatment. In more than two thirds of these patients, a pathogen was not identified. Similar results have been obtained in other studies. Hence, the usefulness of these tests in the outpatient treatment of acute bronchitis is questionable.

Copstead et al. (2005). Pathophysiology third edition. Saunders Elsevier incorporated The presentation of acute bronchitis is usually mild and self-limited, requiring only supportive treatment. Cough may be productive or nonproductive. Associated symptoms include low-grade fever, chest discomfort, sore throat, and fatigue. In children, the smaller airways are easily obstructed by inflammation, so that severe obstruction may occur. The smallness of airways in proportion to body size is due to a smaller lumen in relation to the vessel wall.

THERAPEUTIC MANAGEMENT The following articles include different therapeutic management for a patient with Acute Bronchitis. These articles further help the researcher in rendering care to a patient with Acute Bronchitis.

Leifer G., et al. (2007). Introduction to maternity and pediatric nursing 5th edition 2007. Saunders Elsevier Treatment is mainly symptomatic and includes rest, humidification, and increased fluid intake. Exposure to cigarette smoke should be avoided. Cough suppressants are not recommended unless cough interferes with the childs ability to rest. Antihistamines should be avoided because of their drying effect on secretions. Antibiotics should be given only if a bacterial infection is confirmed by culture or if the clinical picture supports the diagnosis.

Lewis, A., et al. (2008). Medical Surgical Nursing: Assessment and management of clinical problems 2008. Mosby Elsevier Acute bronchitis is usually self-limiting, and the treatment is generally supportive, including fluids, rest, and anti-inflammatory agents. Cough suppressants or

bronchodilators may be prescribed for symptomatic treatment of nocturnal cough or wheezing. Antibiotics generally are not prescribed unless the person has a prolonged infection associated with constitutional symptoms. If this is an acute bronchitis due to influenza virus, treatment with antiviral drugs either zanamivir (Relenza) or oseltamivir (Tamiflu) can be started, but the antiviral drug must be initiated within 48 hours of the onset of symptoms.

Price, et al. (2006). Pediatric Nursing, an introductory text 2006. Elsevier As with all respiratory disorders, fluids are important. Bronchitis is generally selflimiting and resolves in 2 to 3 weeks. Antibiotics, cough suppressants, antihistamines, and expectorants are not indicated.

Pillitteri, Adele (2007). Maternal and Child Health Nursing: care of the child bearing and childrearing family 5th edition 2007. Lippincott William and Wilkins Therapy is aimed at relieving at respiratory symptoms, reducing fever, and maintaining adequate hydration. An antibiotic is prescribed for bacterial infections if mucus is viscid, an expectorant may be needed to help he child raise it. It is important that children with bronchitis cough to raise accumulating sputum. Cough syrups to suppress coughing, therefore, are rarely indicated.

ACUTE GASTROENTERITIS

DEFINITION The following articles include different definitions of Acute Gastroenteritis. These articles would assist the researcher in understanding more about the present condition of the patient.

Kliegma et al. (2007). Nelson textbook of Pediatrics 18th Edition 2007. Saunders Elsevier The term gastroenteritis denotes infections of the gastrointestinal tract caused by bacterial, viral, or parasitic pathogens. Many of these infections are food-borne illnesses. The most common manifestations are diarrhea and vomiting, which may also be associated with systemic features such as abdominal pain and fever. The term gastroenteritis captures the bulk of infectious causes of diarrhea.

Ignatavicious et al. (2006). Medical-Surgical Nursing: critical thinking for collaborative care 5th edition 2006. Elsevier Acute Gastroenteritis is an increase in the frequency and water content of stools or vomiting as a result of inflammation of the mucous membranes of the stomach and intestinal tract. It primarily affects the small bowel and can be either viral or bacterial origin. Both forms have similar manifestations and are considered self-limiting in the course unless complications occur. All organisms that are implicated in gastroenteritis cause diarrhea.

ETIOLOGY AND RISK FACTORS The following articles are all about etiology and risk factors of Acute Gastroenteritis.

Kliegma et al. (2007). Nelson textbook of Pediatrics 18th Edition 2007. Saunders Elsevier Acute Gastroenteritis is due to infection acquired through the feco-oral route or by ingestion of contaminated food or water. AGE is associated with poverty, poor environmental hygiene, and development indices. Enteropathogens that are infectious in small inoculums (Shigella, E. coli, noroviruses, rotavirus, Giardia lamblia,

Cryptosporidium parvum, and Entamoeba histolytica) can be transmitted by person-toperson, whereas others such as cholera are generally a consequence of contamination of food or water supply.

Lewis, A., et al. (2008). Medical Surgical Nursing: Assessment and management of clinical problems 2008. Mosby Elsevier Pathogens that cause GI disease are transmitted by the fecal-oral route, from person to person, and through ingestion of focally contaminated food and water. GI infections are often referred to as Food poisoning because food is frequently the vehicle for transmission of actively growing microbes or their toxins.

MANIFESTATIONS The following articles show different manifestations expected to be seen in patients with Acute Gastroenteritis. These articles will help the researcher in detecting some manifestations that are present to his/her patient.

Black, J., et al. (2009). Medical-Surgical Nursing: clinical management for positive outcome 2009. Elsevier

The universal manifestation of AGE is diarrhea, which occurs in varying intensity, depending on the organisms involved and the health status of the individual client. The diarrhea may be mild (two or three stools per day) or intense (more than 10 watery stools per day). Nausea, vomiting, and anorexia may occur from abdominal distention caused by increased fluid content and undigested food. Abdominal pain, cramping, and borborygmi may occur from gas released from undigested food, irritation of bowel mucosa, and distention of the intestines. The client may have a fever, depending on the causative organisms.

Disease

and

Symptoms

caused

by

Adenoviridae.

Adenoviridae.

<http://www.stanford.edu/group/virus/adeno/2004takahashi/webpage/Disease%20 and%20Symptoms%20caused%20by%20Adenoviruses.htm> Acute gastroenteritis symptoms, including abdominal pain and diarrhea have been reported and are caused by serotypes 40 and 41. In children, respiratory symptoms are also commonly found with gastrointestinal infections. These infections, while not often identified as being specifically caused by adenoviruses, are quite common - studies have shown that 50% of children have antibodies to adenoviruses by the age of 4.

Viral Gastroenteritis. Center for Disease Control and Prevention. January 14, 2010. <http://www.cdc.gov/ncidod/dvrd/revb/gastro/faq.htm> The main symptoms of viral gastroenteritis are watery diarrhea and vomiting. The affected person may also have headache, fever, and abdominal cramps ("stomach ache"). In general, the symptoms begin 1 to 2 days following infection with a virus that causes gastroenteritis and may last for 1 to 10 days, depending on which virus causes the illness.

DIAGNOSIS The following articles include methods on how to diagnose Acute Gastroenteritis.

How is gastroenteritis diagnosed? Health-cares. July 18, 2005. http://digestivedisorders.health-cares.net/gastroenteritis-diagnosis.php The symptoms of gastroenteritis are usually enough to identify the illness. Unless there is an outbreak affecting several people or complications are encountered in a particular case, identifying the specific cause of the illness is not a priority. However, if identification of the infectious agent is required, a stool sample will be collected and analyzed for the presence of viruses, disease-causing (pathogenic) bacteria, or parasites. It is important to consider infectious gastroenteritis as a diagnosis of exclusion. A few loose stools and vomiting may be the result of systemic infection such as pneumonia, septicaemia, urinary tract infection and even meningitis. Surgical conditions like appendicitis, intussusception and, rarely, even Hirschsprung's disease may mislead the clinician.

Viral Gastroenteritis. Center for Disease Control and Prevention. January 14, 2010. <http://www.cdc.gov/ncidod/dvrd/revb/gastro/faq.htm> Generally, viral gastroenteritis is diagnosed by a physician on the basis of the symptoms and medical examination of the patient. Rotavirus infection can be diagnosed by laboratory testing of a stool specimen. Tests to detect other viruses that cause gastroenteritis are not in routine use.

PATHOPHYSIOLOGY

The following articles are all about the Pathophysiology of Acute Gastroenteritis. These articles would help the researcher in understanding the progression of the said condition.

Ignatavicious et al. (2006). Medical-Surgical Nursing: critical thinking for collaborative care 5th edition 2006. Elsevier Infection with viral and bacterial organisms can produce gastrointestinal illnesses, in which watery diarrhea is the primary feature. These disorders can be caused by noninflammatory, inflammatory, or penetrating mechanisms. The infecting organisms can release enterotoxin (a noninflammatory toxic substance specific to the intestinal mucosa), which results in diarrhea. The organism can also attach itself to mucosal epithelium without penetrating it. Cells of the intestinal villi are then destroyed and malabsorption results. Infections that are mediated by bacterial toxins cause the absorptive capacity of the distal small bowel and proximal colon to be overcome, resulting in diarrhea. Finally, the organism can penetrate the intestine, causing cellular destruction, necrosis, and a potential for ulceration. Diarrhea occurs often with white blood cells or red blood cells present in the stool.

Nowak, T., et al. (2005). Pathophysiology: concepts and applications for Health Care Professionals third edition 2008. Mcgraw-Hill Specific pathogens colonize the surface of the gastric epithelium below its mucus layer. While unable to penetrate deeply, the organism is adapted to resist gastric acid and thrives at the epithelial surface. It induces an infiltration of PMNs and over time, metaplasia in the epithelium that may predispose to gastric carcinoma.

Black, J., et al. (2009). Medical-Surgical Nursing: clinical management for positive outcome 2009. Elsevier Normally, human flora protects the bowel from colonization of pathogens; however, the intestinal flora can be (1) disrupted by harmful bacteria and viruses that cause tissue damage and inflammation or (2) depressed by antibiotic therapy, administered either orally or parenterally. Pathogens cause tissue damage and inflammation by releasing endotoxins that stimulate the mucosal lining of the intestine, resulting in greater secretion of water and electrolytes into the intestinal lumen. The active secretion of chloride and bicarbonate ions in the small bowel leads to inhibition of sodium reabsorption. To balance the excess sodium, large amounts of protein-rich fluids are secreted into the bowel, overwhelming the large bowels ability to reabsorb the fluid and leading to diarrhea. Pathogens also cause damage and inflammation by invading and destroying the mucosal lining of the bowel, resulting in bleeding and ulceration. When the integrity of the GI tract is impaired, its ability to carry out digestive and absorptive functions can be affected.

TREATMENT AND NURSING CARE The following articles include different nursing care and treatment for Acute Gastroenteritis. These articles would help the researcher in dealing with the patient with this kind of condition.

Leifer et al. (2007). Introduction to maternity and pediatric nursing 5th edition 2007. Saunders Elsevier Treatment is focused on identifying and eradicating the cause. Nursing responsibilities include teaching parents and caregivers proper and age-appropriate diet and feeding techniques. The priority goal of care includes preventing fluid and electrolyte

imbalance. Oral rehydrating solutions such as Pedialyte, Lytren, Ricelyte, and Resol are used for infants in small frequent feedings. The nursing care of gastroenteritis includes maintaining intake and output records and providing skin care and frequent changes to prevent excoriation from the frequent stools. Parents should be taught good hand washing techniques, proper food handling, and principles of cleanliness and infection prevention.

Ignatavicious et al. (2006). Medical-Surgical Nursing: critical thinking for collaborative care 5th edition 2006. Elsevier For clients with the most types of gastroenteritis, supportive treatment is instituted. Therapy is focused on fluid replacement, and the amount and route of fluid administration are determined by fluid status. For mild cases of gastroenteritis, the client is treated on an ambulatory care basis or in the nursing home if he or she is a resident there. If the fluid volume is severely depleted, the client is admitted to the hospital for administration of IV fluids. Drugs that suppress intestinal motility, such as anticholinergics and antiemetics, are not routinely given for bacterial or viral gastroenteritis. Use of these drugs can prevent the infecting organism from being eliminated from the body. Treatment with antibiotics may be warranted of the gastroenteritis is due to bacterial infection with fever and severe diarrhea.

DEVELOPMENTAL AGE The following are articles about the developmental age of the patient.

PRESCHOOLER

Pillitteri, Adele (2007). Maternal and Child Health Nursing: care of the child bearing and childrearing family 5th edition 2007. Lippincott William and Wilkins The preschool period traditionally includes ages 3, 4, and 5 years. Although physical growth slows considerably during this period, personality and cognitive growth are substantial. This is also an important period of growth for parents. They may be unsure about how much independence and responsibility for self-care they should give their preschooler. Most children of this age want to do things for themselves choose their own clothing and dress by themselves, feed themselves completely, wash their own hair, and so forth. As a result, parents of preschooler may find their child dressed in one red and one green sock, going to preschool with unwashed ears, or trying to eat soup with a fork. They need reassurance that this behavior is typical and helps a child develop more initiative and control of life. They may also need some guidance in separating those tasks a preschooler can accomplish independently from those that still require some adult supervision so they can set sensible limits. Setting limits protect children from harming themselves or others while participating in all the interesting experiences available to them.

PHYSIOLOGICAL DEVELOPMENT Potts, et al. (2007) Pediatric Nursing; caring for children and their families. 2 nd Edition. Thomson Delmar Learning, Thomson corporation During the preschool years, the rate of physical growth and change shows as compared to the rate experienced during the infant and toddler years. Generally, children will gain an average of 2.3 kg or 5 pounds per year in weight and 7.5 cm or 3 inches per year in height. The preschool period is a time of refinement of eye-hand coordination and muscle coordination. Walking, running, and jumping are well established by the

preschool years, and by 3 the child is able to ride a tricycle, balance on one foot for a few seconds, jump off the bottom step, and use alternate feet when going up the stairs.

COGNITIVE DEVELOPMENT Pillitteri, Adele (2007). Maternal and Child Health Nursing: care of the child bearing and childrearing family 5th edition 2007. Lippincott William and Wilkins At age 3 years, cognitive development according to Piaget is still preoperational. Although children during this period do enter a second phase called intuitional thought, they lack the insight to view themselves as others see them or put themselves in anothers place. Because preschoolers cannot make this kind of mental substitution, they feel they are always right. This causes them to argue with the forcefulness that comes from believing they are 100% correct. This is an important point to remember when explaining procedures to preschoolers.

MORAL DEVELOPMENT Pillitteri, Adele (2007). Maternal and Child Health Nursing: care of the child bearing and childrearing family 5th edition 2007. Lippincott William and Wilkins Children of preschool age determine right from wrong based on their parents rules. They have little understanding of the rationale for these rules or even whether the rules are consistent. Because preschoolers depend on their parents to supple rule for them, when faced with a new situation they have difficulty seeing that the rules they know may also apply to a new situation such as a hospital.

PSYCHOSOCIAL DEVELOPMENT Pillitteri, Adele (2007). Maternal and Child Health Nursing: care of the child bearing and childrearing family 5th edition 2007. Lippincott William and Wilkins

Erikson defines the developmental task of a preschool period as learning initiative versus guilt. Learning initiative is learning how to do things. Children can initiate motor activities of various sorts on their own and no longer merely respond to or imitate the actions of other children or of their parents. The same is true for language and fantasy activates.

ACTIVITY OF A PRESCHOOLER Potts, et al. (2007) Pediatric Nursing; caring for children and their families. 2nd Edition. Thomson Delmar Learning, Thomson corporation The preschool child is refining both gross and fine motor coordination and skill. This allows the child to participate in more physical games and sports where more activity is used. An emphasis on physical fitness has emerged in the last few years, and regular physical activity can benefit a child in many ways for example improved ability to perform motor skills; enhanced self-confidence and body image; development of lifetime habits; and prevention f disease processes associated with inactivity. Physical activity can also help get rid of tension and excess energy.

STATISTICS Philippines: Environmental Health Country Profile. http://www.wpro.who.int The ten leading causes of morbidity are diarrhea, bronchitis/bronchiolitis, pneumonia, influenza, hypertension, tuberculosis, diseases of the heart, malaria, measles and chickenpox. The prevalence of communicable diseases is still very high while that of non-communicable diseases is increasing and will continue to do so. This double burden of disease places a great toll on the health and economy of the people and of the nation as a whole. Respiratory diseases and COPD are in the top ten causes of mortality in the Philippines.

Research shows that the incidence of bronchitis among Metro Manila children is 11 times the national average and that chronic cough, chronic phlegm, wheezing and shortness of breath are highest among drivers and commuters. SYNTHESIS All authors of the books being used and all the internet sources stated similar definitions of Acute Bronchitis and Acute Gastroenteritis, which refer to the inflammation of the major bronchi in the lower respiratory tract, and infections of the gastrointestinal tract caused by bacterial, viral, or parasitic pathogens, respectively. There were no distinctive differences noted about the signs and symptoms, etiology, pathophysiology, and therapeutic management of the said problems.

CHAPTER III CLIENT PRESENTATION

This is a case of a male pediatric client with initials of J.A.P., 4 years of age, under the services of Dr. C. and Dr. R., and is currently living at Taguig City. The patient is a Filipino and Catholic. The patient was admitted last July 31, 2010, accompanied by his mother and with a chief complaint of severe cough, nahihirapang huminga, as verbalized by his mother. Initial assessment was done to the patient. The assessment revealed that the patient was awake, alert, and ambulatory. Initial vital signs were taken with results of: Temperature 36.2C, Heart rate 125bpm, Respiratory rate 24cpm. The patient was not in respiratory distress with Oxygen Saturation of 98%-99%. History of present illness revealed that the patient was apparently well until 2 weeks prior to admission, when the patient was noted to have dry cough, no colds, and no fever. Five days prior to admission, the patient had experienced fever with a temperature of 40C. The patient still had dry cough and no colds. For this reason, the patient sought consult. His prescribed medications were given Clarithormycin, Asmalinbroncho, Ibuprofen, and Combivent nebulization. Four days prior to admission, the patient still suffered from dry cough and fever. The patient also experienced episodes of vomiting. Softening of stools was also noted. They sought consult and Clarithormycin was then shifted to Co-Amoxiclav. Three days prior to admission, there has still persistence of symptoms with five episodes of vomiting while coughing and more than three episodes of watery stools. The patient sought again consult and was given Metroclorpramide, Paracetamol, Ibuprofen, Acetylcysteine and Oral Rehydration Solution. Complete Blood Count was done and the result was within normal range. One day prior to admission, the patient had brassy cough and decreased appetite.

Persistence of signs and symptoms was still present hence the patient was advised for admission. At 1215H, the patient was admitted and handed to the 8th floor of MMC. Upon admission, physicians orders include vital signs monitoring every 4 hours, monitoring intake and output, follow up results of Complete Blood Count and Chest X-ray, and Chest Physiotherapy to be done by the pulmonary personnel. Intravenous fluid of D5 0.3 NaCl 500 ml to run at 140-141 gtts/min and D5MMB 500 ml to run at 93-94 gtts/min were started upon admission. Further assessment of the patient revealed that he was noted to have decreased appetite and has experienced weight loss. He also experienced headache, chest pain, and difficulty of breathing. Cough and episodes of vomiting were also noted. On July 31, 2010, Complete Blood Count result revealed that the patients White Blood Cells were low 5.59 x 103 (NV: 6.0 17.5 x 10 3). Other blood components were within normal range: RBC 4.7 x 106 (NV: 3.7 5.4 x 106), Hematocrit 34.90% (NV: 33%-39%), Hemoglobin 12.20 g/dL (NV: 10.5-13.5 g/dL), Platelet count 303,000 (NV: 150,000 450,000). Chest X-ray was also done and result showed that the lungs are clear. Hila and pulmonary vessels are within normal limits. Heart is normal in size and configuration. Mediastinum and diaphragm are normal. Visualized bones are unremarkable. Soft tissues do not appear unusual. On August 1, 2010, the patient underwent skin test for cefuroxime. The result was negative, no induration, and no erythema. The patient was afebrile and has claimed to breathe easier than the day of admission. Patients vital signs were: Temperature 37C, Heart rate 82bpm, and Respiratory rate 22cpm.

The patient was endorsed by the Clinical instructor to the researcher last August 2, 2010 however, interactions and proper interventions for the patient was yet to be made on the following day. The patient was first seen and handled by the researcher last August 3, 2010 from 0600H 1400H. The researcher received the following endorsements: Patients working diagnosis is - to consider Pneumonia versus Croup, and Acute Gastroenteritis, patient was on regular diet, and hooked on an Intravenous Fluid of D5MMB 500 ml at 93 gtts/min, located at the left peripheral line. The duties of the researcher were to monitor vital signs every 4 hours, assist in administration of medications, and bedside care. Medications being endorsed were: Combivent UDV 2.5ml (Ipratropium bromide + Albuterol sulfate) 1 Unit-dose vial, three times a day; Budecort Respule 250mcg/ml (Budesonide) 1 respule for inhalation, three times a day; Zegen vial 750mg (Cefuroxime) 1 vial every 8 hours through intravenous fluid. Chest physiotherapy was also ordered every after nebulization, care of pulmonary personnel. At 0615H, routine rounds were done by the bedside nurse together with the clinical instructor and the researcher. The patient was asleep and he was with his father. Preparation of the medications was also observed by the researcher. At 0800H, vital signs monitoring was done by the researcher. Results were: Temperature - 36C, Heart Rate 98bpm, Respiratory rate 20cpm. The researcher was able to perform initial assessment to the patient. The researcher was able to auscultate the patients lungs for presence of adventitious breath sounds. It was noted that the patient had presence of occasional rhonchi on the left upper lung field. Presence of productive cough was also noted. The patient had warm, moist skin and was positive of dry lips. The patient was not in respiratory distress. Rapid and shallow respiration was also observed by the researcher. The researcher was able to interview the patients significant others regarding his current health status. When asked about the patients

health condition, the grandmother verbalized, Medyo nahihirapan siyang huminga pero lumuluwag naman kapag nag ne-nebulize siya. Therefore, Ineffective Breathing Pattern related to airflow limitation as evidenced by occurrence of dyspnea and presence of occasional rhonchi was identified. Proper nursing interventions were done to the patients in order to improve his breathing pattern. These include assessment of the respiratory status as well as the presence of adventitious breath sounds, assisting in proper positioning of the patient, elevating the head of the bed which helps in loosening mucus secretions in the airway, encouraging the patient to perform breathing exercises and to have adequate rest periods between activities, and encouraging the patient to increase his fluid intake. Ineffective Airway Clearance related to inability to clear mucus as evidenced by occurrence of dyspnea and presence of productive cough was also identified by the researcher. Interventions done were assisting patient in performing coughing and breathing maneuvers, monitoring vital signs and respiratory status, assisting in administration of medications, and encouraging patient to increase fluid intake. Further assessment of the patient revealed that he had moist buccal mucosa and negative of enlarged lymph nodes. Abdominal assessment revealed that the patient had flat abdomen and normoactive bowel sounds. No cyanosis and edema were noted by the researcher. Patients activity was noted to be fair; however assistance was needed whenever the patient does his daily activities. It was also noted that he was experiencing weakness during coughing hence; Risk for Activity Intolerance related to presence of respiratory problem secondary to dyspnea and persistent coughing was recognized. History of the patient was also obtained which revealed that he had asthma, diagnosed last 2006. He also had history of hospitalization with Pneumonia as the

cause. Family history revealed that his aunt also had asthma. Both Grandparents is positive of hypertension and Diabetes Mellitus. At 0830H, Combivent UDV 2.5ml (Ipratropium bromide + Albuterol sulfate) and Budecort Respule 250mcg/ml (Budesonide) were administered by means of nebulization therapy. Chest Physiotherapy was also done after administering nebulization treatment to the patient. Proper health teachings were also done by the researcher. At 1200H, vital signs monitoring was done and results showed normal results: Temperature 36.6C, Heart rate 88bpm, and Respiratory rate 28cpm. The client was not in respiratory distress, was negative of cyanosis, and had an episode of posttussive vomiting. The patient experienced no diarrhea and vomiting however, the patient was still susceptible of dehydration due to the previous episodes of vomiting and soft stools. Therefore, Risk for Deficient Fluid Volume related to excessive loss through normal route secondary to episodes of vomiting was noted by the researcher. When asked about the nutritional status of the patient, the grandmother stated, Hindi pa rin siya gaano kumakain, pero mas dumami kinakain niya ngayon kaysa nung dati. The researcher noted that the patient could only consume three-fourth of his food. Therefore, Risk for Imbalanced Nutrition: Less than body requirements related to decreased appetite secondary to disease process was identified. Proper interventions were done for these problems which include: assessing for patients vital signs and noting for any signs of dehydration, encouraging patient to increase fluid intake, instructing patient to eat small but frequent meals, noting for changes of the patients weight, providing medications and supplements such as Heraclene (1mg Capsule two times a day), and Cherifer (5ml daily; AM), and providing a safe and quiet environment. The patients weight was 22.5 kilograms (Ideal Body weight: 14.3 23.3 kilograms). At 1300H, the researcher accompanied the patient and his significant others to his attending physician. Assessment was done by the physician and made an order that

the patient may go home, provided that the intravenous fluid must be consumed first. The physician also modified the patients clinical diagnosis; from t/c Pneumonia versus Croup to Acute Bronchitis with secondary diagnosis of Acute Gastroenteritis. Intake and output was also taken and recorded: Intake 125 ml, Urine Output three times, and no bowel movement. At 1330H, endorsement was done and health teaching was conducted before the end of the shift.

CHAPTER IV ANALYSIS AND INTERPRETATION

I. Ineffective Airway Clearance related to inability to clear mucus as evidenced by occurrence of dyspnea and presence of productive cough

Ineffective Airway Clearance refers to the inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway. (Doenges, 2008) Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway. However, the cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions/ trauma, respiratory muscle fatigue, or neuromuscular weakness. Other mechanisms that exist in the lower

bronchioles and alveoli to maintain the airway include the mucociliary system, macrophages, and the lymphatics. Factors such as anesthesia and dehydration can affect function of the mucociliary system. Likewise, conditions that cause increased production of secretions (e.g., pneumonia, bronchitis, and chemical irritants) can overtax these mechanisms. Ineffective airway clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., from cerebrovascular accident [CVA] or spinal cord injury) problem. (Gulanick, et al., 2010) In relation to the client, he was noted to have difficulty expelling the mucus as manifested by episodes of dyspnea. The patient has been diagnosed of Acute Bronchitis and was positive of productive cough and occasional rhonchi on left upper lung field. The goal of the problem is to have patent airway. Proper interventions for this problem include: assisting patient in performing coughing and breathing maneuvers, monitoring vital signs and respiratory status, assisting in administration of medications, and encouraging patient to increase fluid intake. The goal of this problem was partially met for the patient had experienced development from the disease although there is still presence of productive cough. The patient also claimed to breathe easily than before. (Gulanick, et al., 2010)

II. Ineffective Breathing Pattern related to airflow limitation as evidenced by occurrence of dyspnea and presence of occasional rhonchi Ineffective Breathing Pattern is defined as inspiration and/or expiration that does not provide adequate ventilation. (Doenges, 2008) Respiratory pattern monitoring addresses the patients ventilatory pattern, rate, and depth. Most acute pulmonary deterioration is preceded by a change in breathing pattern. Respiratory failure can be seen with a change in respiratory rate, change in

normal abdominal and thoracic patterns for inspiration and expiration, change in depth of ventilation, and respiratory alternans. (Gulanick, et al., 2010) The patient had accumulation of secretions and breathing pattern was altered because of the presence of occasional rhonchi on the left upper lung field. The patient also claimed to have experienced difficulty of breathing. Assessment revealed that patient was positive of dry lips however; no signs of hypoxia were noted. The goal of this problem is to improve breathing pattern. Proper interventions done by the researcher include: assessment of the respiratory status as well as the presence of adventitious breath sounds, assisting in proper positioning of the patient, elevating the head of the bed which helps in loosening mucus secretions in the airway, encouraging the patient to perform breathing exercises and to have adequate rest periods between activities, and encouraging the patient to increase his fluid intake. The goal was partially met because there was still presence of occasional rhonchi however; ease of breathing was noted and observed by the researcher. Presence of productive cough was still observed but the patient did not experience any respiratory distress.

III. Risk for Deficient Fluid Volume related to excessive loss through normal route secondary to episodes of vomiting

Risk for Deficient Fluid Volume refers to risk for experiencing vascular, cellular, or intracellular dehydration. (Doenges, 2008) Fluid volume deficit, or hypovolemia, occurs from a loss of body fluid or the shift of fluids into the third space, or from a reduced fluid intake. Common sources for fluid loss are the gastrointestinal tract, polyuria, and increased perspiration. Fluid volume deficit may be an acute or chronic condition managed in the hospital, outpatient center,

or home setting. The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Treatment consists of restoring fluid volume and correcting any electrolyte imbalances. Early recognition and treatment are paramount to prevent potentially life-threatening hypovolemic shock. The patient was diagnosed to have an Acute Gastroenteritis. The patient had experienced episodes of vomiting and soft stools. He also experienced post-tussive vomiting. Assessment revealed that the patient had no cyanosis, no edema, and did not manifest any signs of dehydration such as sunken eyeballs, dry skin, and poor skin turgor. The goal of the problem is to maintain normal fluid volume. Proper interventions were done by the researchers such as assessing for patients vital signs and noting for any signs of dehydration, encouraging patient to increase fluid intake, noting for changes of the patients weight, monitoring intake and output, and providing medications as ordered. The goal was fully met for the patient had not experienced or manifested any signs of dehydration. Intake and output of the patient were: Intake 125ml, Urine Output three times, no bowel movement. During the researchers shift, the patient did not experience episodes of vomiting and diarrhea.

IV. Risk for Imbalanced Nutrition: Less than body requirements related to decreased appetite secondary to disease process

Risk for Imbalanced Body Nutrition: Less than body requirements refers to risk of having insufficient intake of nutrients to meet metabolic needs. Adequate nutrition is necessary to meet the bodys demands. Nutritional status can be affected by disease or injury states (e.g., gastrointestinal malabsorption, cancer,

burns); physical factors (e.g., muscle weakness, poor dentition, activity intolerance, pain, substance abuse); social factors (e.g., lack of financial resources to obtain nutritious foods); or psychological factors (e.g., depression, boredom). During times of illness (e.g., trauma, surgery, sepsis, burns), adequate nutrition plays an important role in healing and recovery. Cultural and religious factors strongly affect the food habits of patients. (Gulanick, et al, 2010) In relation to the patient, it was noted that he had experienced weight loss and had decreased appetite. He could only consume three-fourth of the food beings served to him. He also experienced episodes of vomiting which became a factor for this problem. The patients weight was 22.5 kilograms (Ideal Body weight: 14.3 23.3 kilograms). He had a regular diet. The goal of this problem is to promote good nutrition. Interventions were done by the researchers to promote good nutrition. These include: instructing patient to eat small but frequent meals, noting for changes of the patients weight, providing medications and supplements such as Heraclene (1mg Capsule two times a day) and Cherifer (5ml daily; AM), and providing a safe and quiet environment. The goal of the problem was fully met for the patient had increased his food intake. As verbalized by his grandmother, he had fair appetite and could consume threefourth of his food, not like before by which he could only consume one-half of his food.

V. Risk for Activity Intolerance related to presence of respiratory problem secondary to dyspnea and persistent coughing

Risk for Activity Intolerance is defines as at risk of experiencing insufficient physiological or psychological energy to endure or complete required or desired daily activities.

Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. Activity intolerance may also be related to factors such as obesity, malnourishment, side effects of medications (e.g., -

blockers), or emotional states such as depression or lack of confidence to exert one's self. Nursing goals are to reduce the effects of inactivity, promote optimal physical activity, and assist the patient to maintain a satisfactory lifestyle. (Gulanick, et al, 2010) The patient was diagnosed with Acute Bronchitis and Acute Gastroenteritis. It was noted that he had a fair activity but needed assistance whenever doing desired daily activities. It was also noted that he had experienced weakness during coughing which was a major factor for this problem. The goal of this problem is to promote optimal physical activity. Interventions for this problem were done by the researcher which consist of Encourage adequate rest periods, especially before meals, other ADLs, exercise sessions, and ambulation, Assist with ADLs as indicated; however, avoid doing for patient what he or she can do for self, Teach ROM and strengthening exercises, and encouraging patient or relatives to address concerns about this problem. The goal of the problem was fully met for the patient did manifest optimal physical activity. He was able to perform light activities such as walking. Weakness during coughing was also minimized due to nebulization and Chest Physiotherapy.

CHAPTER V SUMMARY OF FINDINGS

I. Factors that led to the development of the problem Predisposing Factors Age History Genetics Precipitating Factors Upper Respiratory Infection

II. Interrelationship of the factors that led to the development of the problem Taking into account the age of the patient, he is at risk for acquiring Acute Bronchitis with secondary diagnosis of Acute Gastroenteritis because his immune system is still immature therefore, his body could not adequately fight the pathogens that were entering his body. Taking into considerations the history of the patient, he had an asthma and he also acquired Pneumonia last 2009. The patient also had an upper respiratory infection before consulting a physician concerning the severity of the symptoms that the patient had experienced. The genetics is also a major factor for the development of this problem because of the risk that it may contribute to the patient. According to the family history, the patients aunt also had asthma. Because of these factors, the goal and center of the care for this patient is the elimination of the signs and symptoms of the two clinical diagnoses. III. Nursing Interventions rendered to the patient 1. Ineffective airway clearance related to inability to clear mucus as evidenced by occurrence of dyspnea and presence of productive cough Promotive/Preventive -Assess and monitor Vital Signs, noting changes in respiratory status. -Auscultate lungs for presence of normal or adventitious breath sounds.

-Monitor patients intake and output -Assist in proper positioning of the patient. Curative -Administer Medications, as ordered, noting its effectiveness and side effects -Consult respiratory therapist for chest physiotherapy treatment, as indicated. Rehabilitative -Teach patient in performing coughing and breathing exercises. -Instruct patient to increase fluid intake. 2. Ineffective breathing pattern related to accumulation of secretions as evidenced by occurrence of dyspnea and presence of occasional rhonchi Promotive/Preventive -Assess respiratory rate and depth by listening to lung sounds -Monitor patients breathing pattern and presence of dyspnea -Note for retractions, nasal flaring, skin color and capillary refill. -Position the patient properly for normal or easy breathing. Curative -Administer Medications, as ordered, noting its effectiveness and side effects Rehabilitative -Teach patient or relatives appropriate breathing and coughing techniques. -Teach patient to have adequate rest periods between activities 3. Risk for Deficient Fluid Volume related to excessive loss through normal route secondary to episodes of vomiting Promotive/Preventive -Monitor and document Vital Signs -Assess for any signs of dehydration

-Monitor for patients fluid intake and output -Note for the patients weight, documenting its changes. -Encourage patient to increase fluid intake. Rehabilitative -Inform patient or relatives the importance of maintaining prescribed fluid intake and special diet considerations involved 4. Risk for Imbalanced Nutrition: Less than body requirements related to decreased appetite secondary to disease process Promotive/Preventive -Assess weight, activity/rest, and body build. -Note patients eating habits, including food preferences. Curative -Administer vitamins, as ordered. Rehabilitative -Provide relaxing and soothing environment for the patient 5. Risk for Activity Intolerance related to presence of respiratory problem secondary to dyspnea and persistent coughing Promotive/Preventive -Assess for patients daily activities and level of mobility. -Encourage adequate rest periods, especially before meals, other ADLs, exercise sessions, and ambulation. Rehabilitative - Teach ROM and strengthening exercises -Encourage patient and relatives to address concerns about this problem -Teach patient to gradually increase activity

IV. Effectiveness of Nursing Interventions rendered to the patient The goals of the following problems were partially met: Ineffective airway clearance related to inability to clear mucus as evidenced by occurrence of dyspnea and presence of productive cough After rendering interventions for 8 hours, the patient still manifest signs and symptoms but claimed to breathe easily than before. Normal vital signs were normal throughout the researchers shift. Respiratory rate was normal and patient did not manifest any signs of distress. Ineffective breathing pattern related to accumulation of secretions as evidenced by occurrence of dyspnea and presence of occasional rhonchi After rendering interventions for 8 hours, the patient did not manifest any signs of hypoxia. Respiratory status was normal. Patient had experienced dyspnea but was relieved with nebulization therapy. The goals of the following problems were fully met: Risk for Deficient Fluid Volume related to excessive loss through normal route secondary to episodes of vomiting After rendering interventions for 8 hours, the patient had not experienced vomiting and diarrhea. The patient did not also manifest any signs of dehydration. Health teaching about increasing fluid intake was provided by the researcher. Risk for Imbalanced Nutrition: Less than body requirements related to decreased appetite secondary to disease process

After rendering interventions for 8 hours, the patient had increased his food intake, from being able to consume one half of his food to three-fourth of food being served to him. Patients vital signs were also noted to be within normal. Risk for Activity Intolerance related to presence of respiratory problem secondary to dyspnea and persistent coughing After rendering interventions for 8 hours, the patient claimed to perform light activities such as walking. Weakness during coughing was also minimized with the help of nebulization and Chest Physiotherapy. Health teachings about promoting optimal physical activity were also noted by the patient and his relatives.

CHAPTER VI CONCLUSION AND RECOMMENDATION

CONCLUSION Based on the Summary of Findings, the researcher concluded that the factors that led to the development of the problem are both predisposing and precipitating in nature. The actual and potential problems present were modified through the use of appropriate nursing interventions and proper nursing care to the patient. Therefore, the problems that were fully met consist of: Risk for deficient fluid volume related to excessive loss through normal route secondary to episodes of vomiting, Risk for imbalanced nutrition related to decreased appetite secondary to disease process, and Risk for activity intolerance related to presence of respiratory problem secondary to dyspnea and persistent coughing. There are also some problems that were partially met,

these include: Ineffective airway clearance related to inability to clear mucus as evidenced by occurrence of dyspnea and occurrence of dyspnea and presence of productive cough, and Ineffective breathing pattern related to accumulation of secretions as evidenced by occurrence of dyspnea and presence of occasional rhonchi.

RECOMMENDATIONS There were problems and weaknesses that were encountered by the researcher during the course of data completion for the said case study. The researcher only handled the patient for just a day and time coverage in handling and dealing with the patient was also limited due to the condition of the patient. As a result, the researcher was able to identify recommendations that would assist the future researchers in doing their future case studies. The researcher recommends that future researchers should spend more time in assessing and visiting their patient in order to obtain a more accurate data for future utilization. Researcher also recommends that the future researchers should have sufficient time in gathering information about their future patient so that they would come up with more appropriate nursing problems.