Professional Documents
Culture Documents
Alveoli are microscopic air- filled sacs in the lungs responsible for
absorbing oxygen. Pneumonia can be result from a variety of causes
including infection of bacteria, viruses, fungi or parasites and chemical
or physical injury to the lungs. Its can be also officially described as
idiopathic that is, unknown when infectious causes has been excluded.
For the patient’s trust, privacy, dignity and respect we gave him
and we decided to hide his name and called him Patient X.
Upon interview, his mother told us that Patient X had its first
immunization (BCG). He has also no other diseases from past. As the
mother told us that Patient X has an allergies on talc powders such as
Johnson and Johnson powder and some non- hypoallergenic powders.
Patient Teaching:
-Instruct patients on dosage and not
Nursing Consideration:
-Use contiously in patients hypersensitive to penicillin because of
possibility of cross-sensitivity with other beta-lactam antibiotics. Also use contiously
in breastfeeding women and in patients with history of colitis.
-For intramuscular administration, inject deeply into a large muscle
mass such as the gluteus maximus or the lateral aspect of the thigh.
-Absorption of cefuroxime axetil is enhanced by food.
-Cefuroxime axetil tablets may be crushed fpr patients who can’t
swallow tablets .Tablets may be dissolves in small amount of juice. However the
drug has a bitter taste that is difficult to mask even with food.
Patient’s Teaching:
-Tell patient or patient’s significant other to take all of the drug as
prescribed even after he feels better.
-Advised patient’s significant others whwn patient receiving drugs
intra venous through tubing to report discomfort at intra venous insertion site.
Nursing Consideration:
-Use contious in patients with hypersensitive to penicillin
because of the possibility of cross-sensitivity with other beta-lactam antibiotic. Also
use contiously in breastfeeding women and in patients with history of colitis.
-If large doses are given, therapy is prolonged or patient is
high-risk, monitor patient for super infection.
Patient Teaching:
-Instruct patient or patient’s significant others to take drug
with food or milk to lessen gastro intestinal discomfort.
-Tell the patient or patient’s significant others to take the
entire amount of drug exactly as prescribed even after the patient feels better.
7. Elimination
Normally consumed more than four diapers. The consumption of
diapers before and during hospitalization is decreased. Patient X
consumed only two diapers.
9. Activity-Exercise Pattern
According to the mother, PTA the client is “napaka likot” as verbalized
by the mother. In the hospital the client is unable to move freely due to
his health condition and his IV infusion. Because of his young age and
his condition he requires assistance and supervision from his parents in
all his daily activities.
Nostrils/Nasal Cavity
During inhalation, air enters the nostrils and passes into the nasal
cavities which the foreign are removed, the air is heated and
moisturized before it is brought further into the body. It is the part of
the body that houses the sense of smell.
Sinuses
It is a small cavities that lined the mucous membrane within the
bones of the skull.
Pharynx
It is a throat carries foods and liquids into the digestive tract and
carries air into the respiratory tract.
Larynx
It is also called voice box located between the pharynx and
trachea. It is the location of the adam’s apple, which in reality a thyroid
gland and houses the vocal cords.
There are two types of alveolar epithelial cells. Type I cells have long
cytoplasmic extensions which spread out thinly along the alveolar walls
and comprise the thin alveolar epithelium. Type II cells are more
compact and are responsible for producing surfactant, a phospholipid
which lines the alveoli and serves to differentially reduce surface tension
at different volumes, contributing to alveolar stability.
Pathophysiology of Pneumonia
Infectious organism
lodges Infiltration of
bronchus Airway damage
Tissues
Alveolar collapse Necrosis of pulmonary
tissue
Increase
pyrogen in the
body
Bad prognosis
Good prognosis:
-Tepid sponge
bath
-Paracetamol, Overwhelming
Mucolytics/bo sepsis
nchodilators/
expectorants
Increase Death
pyrogen in the
body Fever
Sign and symptoms: Difficulty of breathing, Cough, colds, Shivering, Nausea and vomiting, Itchiness of the throat
Physical Assessment
Mental Status
Patient X is still a baby and can’t be questioned.
O>Motor Function
not yet applicable
O>Assessment of the Head
Head is round in shape. Hair is still short, straight and evenly
distributed. Scalp is smooth and white in color, minimal lesions were
noted.
O>Assessment of the Eyes
His eyes are symmetrical, white in color, almond shape. Pupils constricts
when diverted to light and dilates when he gazes afar, conjunctivas are
pink. Eyelashes are equally distributed and skin around the eyes is intact.
The eyes involuntarily blink.
O>Assessment of the Mouth
She has yet complete set of teeth. Oral mucosa and gingival are pink in
color, moist and there were no lesions nor inflammation noted. Tongue is
pinkish and is free of swelling and lesions. Presence of uvula was noted
and there is absence of swelling.
O>Assessment of the Neck
Lymph nodes noted. Neck has strength that allows movement back and
forth, left and right. Patient is able to freely move her neck.
O>Assessment of the Lungs and Thoracic Region
Chest is symmetric in volume, no tenderness and masses. Rib cage is also
symmetrical and full- lung expansion. He has difficulty in breathing.
Independent Rationale
1.) Assess the general condition of -To gather baseline data of the
the patient. patient.
2.) Monitor patient’s temperature.
-To determine if there’s any
3.) Determine the recent alteration of the temperature.
environmental exposure of the -May help identify causative
patient. environmental factors.
4.) Demonstrate Tepid Sponge -May help to lower down
Bath to the patient. temperature.
5.) Instruct the patient’s significant
others to let the baby wear loose -To prevent from feeling cold and
clothing and bed linens. shivering.
6.) Encourage the patient’s
significant others to avoid the baby -To have adequate rest and sleep.
in noisy environment.
7.) Advise the patient’s significant
others to increase fluid intake or -To meet the increased metabolic
breastfeeding as possible. demands and prevent dehydration.
8.) Advise the mother to provide
cooling blanket.
-Used to reduce fever.
Collaborative Rationale
1.) Administer antipyretics -To reduce fever by it’s central
medication. action on the hypothalamus.
Interventions Rationale
1.) Assess the condition of the -To identify the health needs of the
patient patient.
2.) Monitor for the respirations -To determine the alteration of
and breath sounds of the patient. respiratory rate.
3.) Monitor the infant for feeding -May compromise airway.
intolerance, abdominal distention
and emotional stresses. -To help identify the cause of
4.) Observe for signs of respiratory airway obstruction.
distress. -To take advantage of the
5.) Demonstrate the proper relaxation on the diaphragm and
position of the patient elevate the enhancing ventilation.
head of bed. -To prevent fatigue of the patient.
6.) Encourage patient’s significant
others to let the patient have -Can help liquefy viscous
adequate rest and sleep secretions.
7.) Instruct the mother to let the
baby increase breastfeeding as
possible.
Collaborative Rationale
1.) Administer analgesic -To improve cough when pain is
medication. inhibiting effort.
-To clear airway when viscous
2.) Suction naso/tracheal/oral. secretions are blocking airway.
Interventions Rationale
1.) Assess the vital signs especially - To monitor any alteration
respiratory rate
2.) Auscultate breath sounds of the -To note areas of decreased
patient. adventitious breath sounds.
3.) Elevate head of bed . -To maintain airway.
4.) Maintain adequate intake -For mobilization of secretions.
output of the patient.
5.) Emphasized the importance of -To improve stamina and reducing
nutrition to the patient’s the work of breathing.
significant others.
6.) Encourage the patient’s -To promote optimal chest
significant others to maintain expansion and drainage of
frequent position changes of the secretions.
patient.
7.) Instruct the patient’s significant
others to identify specific supplier -To facilitate independency.
for supplemental oxygen necessary
the respiratory devices.
Collaborative Rationale
1.) Administer medications as -To treat underlying conditions.
prescribed by the doctor such as
antibiotic and bronchodilators.
Collaborative Rationale
1.) Administer medications as -To prevent difficulty of treatment.
prescribed by the doctor if severe
reactions occur including
antihistamines.
Interventions:
Independent Rationale
Collaborative Rationale
1.) Administer medication as prescribed -
by the doctor appropriately.
DISCHARGE PLANNING
• Take the entire course of any prescribed medications. After a
patient’s temperature returns to normal, medication must be
continued according to the doctor’s instructions, otherwise the
pneumonia may recur. Relapses can be far more serious than the
first attack.
• Get plenty of rest. Adequate rest is important to maintain
progress toward full recovery and to avoid relapse.
• Drink lots of fluids, especially water. Liquids will keep patient
from becoming dehydrated and help loosen mucus in the lungs.
• Keep all of follow-up appointments. Even though the patient feels
better, his lungs may still be infected. It’s important to have the
doctor monitor his progress.
• Encourage the guardians to wash patient’s hands. The hands
come in daily contact with germs that can cause pneumonia.
These germs enter one’s body when he touch his eyes or rub his
nose. Washing hands thoroughly and often can help reduce the
risk.
• Tell guardians to avoid exposing the patient to an environment
with too much pollution (e.g. smoke). Smoking damages one’s
lungs’ natural defenses against respiratory infections.
• Give supportive treatment. Proper diet and oxygen to increase
oxygen in the blood when needed.
• Protect others from infection. Try to stay away from anyone with
a compromised immune system. When that isn’t possible, a
person can help protect others by wearing a face mask and always
coughing into a tissue.
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