Laguna College Nursing Department Case Presentation Community Acquired Pneumonia

BSN III Group 1 Members: Dalwampu, Sharmine Maghirang, Keilah Silva, Stephanie Sumadsad, Lean

Introduction
DEFINITION Community-acquired pneumonia (CAP) is one of the most common infectious diseases addressed by clinicians. CAP is an important cause of mortality and morbidity worldwide. A number of pathogens can give rise to CAP. Typical bacterial pathogens that cause the condition include Streptococcus pneumoniae (penicillin-sensitive and -resistant strains), Haemophilus influenzae (ampicillin-sensitive and -resistant strains), and Moraxella catarrhalis (all strains penicillin-resistant). These 3 pathogens account for approximately 85% of CAP cases. CAP is usually acquired via inhalation or aspiration of pulmonary pathogenic organisms into a lung segment or lobe. It is a disease in which individuals who have not recently been hospitalized develop an infection of the lungs (pneumonia). CAP is a common illness and can affect people of all ages. It occurs because the areas of the lung which absorbs oxygen (alveoli) from the atmosphere become filled with fluid and cannot work effectively. POSSIBLE CAUSES FOR ADULT 1. Bacteria The most common cause of pneumonia in adults is a bacterium called Streptococcus pneumoniae. This form of pneumonia is sometimes called pneumococcal pneumonia.

Haemophilus influenzae Staphylococcus aureus Streptococcus pneumonia Mycoplasma pneumoniae (outbreaks tend to occur every four to seven years, more commonly in children and young people)

2. Viruses Viruses cause 20% of CAP cases. The most common viruses are influenza, parainfluenza, respiratory syncytial virus, metapneumovirus, and adenovirus. Less common viruses causing significant illness include chicken pox, SARS, avian flu, and hantavirus. Viruses can also cause pneumonia, most commonly the respiratory syncytial virus (RSV), and sometimes the flu (influenza) type A or B virus.Viruses are a common cause of pneumonia in young children.

3. Fungi In the UK, pneumonia caused by fungal infection of the lungs is rare in people who are normally healthy. It more often affects people whose immune systems are weakened. Fungal pneumonia can rarely affect people who travel to places where these infections are more commonly found, such as some parts of the US, Mexico, South America and Africa. The medical names for fungal pneumonia include histoplasmosis, coccidioidomycosis and blastomycosis. RISK FACTORS * Obstruction When part of the airway (bronchi) leading to the alveoli is obstructed, the lung is not able to clear fluid when it accumulates. This can lead to infection of the fluid resulting in CAP. One cause of obstruction, especially in young children, is inhalation of a foreign object such as a marble or toy. The object is lodged in the small airways and pneumonia can form in the trapped areas of lung. Another cause of obstruction is lung cancer, which can grow into the airways, blocking the flow of air. * Lung disease People with underlying lung disease are more likely to develop CAP. Diseases such as emphysema or habits such as smoking result in more frequent and more severe bouts of CAP. In children, recurrent episodes of CAP may be the first clue to diseases such as cystic fibrosis or pulmonary sequestration.

* Immune problems People who have immune system problems are more likely to get CAP. People who have AIDS are much more likely to develop CAP. Other immune problems range from severe immune deficiencies of childhood such as Wiskott-Aldrich syndrome to less severe deficiencies such as common variable immunodeficiency

SIGN AND SYMPTOMS * Problem breathing * Coughing that produces greenish or yellow mucus * A high fever that may be accompanied with sweating, chills and uncontrollable shaking * Sharp or stabbing chest pain * Rapid, shallow breathing that is often painful

* Coughing up of blood (hemoptysis) * Headaches (including migraine headaches) * Loss of appetite *Excessive fatigue * Blueness of the skin (cyanosis) * Nausea * Vomiting * Diarrhea * Joint pain (arthralgia) * Muscle aches (myalgia)

COMPLICATIONS * Sepsis Sepsis can occur when microorganisms enter the blood stream and the immune system responds. Sepsis most often occurs with bacterial pneumonia; Streptococcus pneumoniae is the most common cause. Individuals with sepsis require hospitalization in an intensive care unit. They often require medications and intravenous fluids to keep their blood pressure from going too low. Sepsis can cause liver, kidney, and heart damage among other things. * Respiratory failure Because CAP affects the lungs, often individuals with CAP have difficulty breathing. If enough of the lung is involved, it may not be possible for a person to breathe enough to live without support. Non-invasive machines such as a bilevel positive airway pressure machine may be used. Otherwise, placement of a breathing tube into the mouth may be necessary and a ventilator may be used to help the person breathe. * Pleural effusion and Empysema Occasionally, microorganisms from the lung will cause fluid to form in the space surrounding the lung, called the pleural cavity. If the microorganisms themselves are present, the fluid collection is often called an empyema. If pleural fluid is present in a person with CAP, the fluid should be collected with a needle (thoracentesis) and examined. Depending on the result of the examination, complete drainage of the fluid may be necessary, often with a chest tube. If the fluid is not drained, bacteria can continue to cause illness because antibiotics do not penetrate well into the pleural cavity. * Abscess Rarely, microorganisms in the lung will form a pocket of fluid and bacteria called an abscess. Abscesses can be seen on an x-ray as a cavity within the lung. Abscesses typically occur in aspiration pneumonia and most often contain a mixture of anaerobic bacteria. Usually antibiotics are able to fully treat abscesses, but sometimes they must be drained by a surgeon or radiologist.

TYPES OF PNEUMONIA 1. Community- Acquired Pneumonia- lower respiratory tract infection of the lung parenchyma with onset in the community or first two days of hospitalization. 2. Hospital- Acquired Pneumonia- occurring 48 hours of longer after hospitalization. 3. Opportunistic Pneumonia- patient at risk : Protein Energy Malnutrition, immune deficiency, received transplants, treated with immune suppressive drugs, and treated with chemotherapy, radiotherapy and corticosteroids.

Patients Profile
Name: Mr. X Age:75 Years old Birth Date: 10\07\1937 Gender: Male OCCUPATION: JEEPNEY DRIVER Case#: 093353 Admission Date: 01\31\13 DISCHARGE: 02/15/2013 Admission diagnosis: CAP, COPD Principal diagnosis: pulmonary mass left upper lobe with pleural effusion

Assessment
History: on and off cough and back pain for 3 months (+) COPD (-) DM (-) HPN (+) smoking (-)alcohol PHYSICAL EXAMINATION VITAL SIGNS (upon admission) BP: 160/80 PR: 82 BPM

RR: 30 CPM T: 36 C O2 SAT: 97% CONCIOUS, COHERENT, SLIGHT RESPIRATORY DISTRESS (-) PALENESS (+) ADVENTITIOUS SOUND IN LEFT LUNG FIELDS (-) EDEMA (+) COUGH (+) UPPER BACK PAIN (+) CHEST PAIN

Pathophysiology
Predisposing Factors History of COPD Smoking and previous occupation Immunocompromised (old age: 75y/o) .

Bacterial Infiltration of the Lungs

Hypertrophy of mucous membrane Increased fluid production

Multiplication of mcg and Spread of Infection

- dyspnea - cough w/ sputum - crackles

Increased capillary permeability

Inflammation of the Pleura

Abrupt, sharp chest pain

fluid accumulation In the pleural space

persistent infection

Shallow, rapid breathing

residual consolidation

Delayed resolution

Laboratory Studies
1/31 Hemoglobin Hematocrit RBC Platelet WBC Neutrophils Lymphocytes Monocytes Results 13.1 g/dl 43 % 5.3 x 109/L 305 x 109/L 10.9 x 109/L 84 % 11 % 5% Range 13 18 40 50 4.5 6.2 x 109/L 150 400 x 109/L 4 10 x 109/L 55 65 % 25 35 % 0.03 0.06 % Interpretation Normal Normal Normal Normal Slightly elevated * Increased ** Decreased *** Increased ****

*WBC count is slightly elevated due to the presence of microorganisms in the patients body. **The increase in the number of neutrophils is due to its immediate response to the infiltration of the microorganisms into the lungs. ***Decrease in the concentration of lymphocytes is only secondary due to the increased number of neutrophils in the blood ****Monocytes are also increased as they are present for the phagocytosis of the microorganisms.

Diagnostic Studies
I. Chest X-ray CXR was performed to confirm the admission diagnosis of pneumonia. Results reveal massive pleural effusion in the left lung. A lobulated density noted in the left parahilar region with surrounding infiltrates. Haziness is seen in the left lower lung field, obscuring the left costophrenic sulcus and hemidiaphragm. Right lung otherwise clear. II. CT Scan CT scan was done to rule out lung cancer as there was a primary consideration of a neoplastic process from the soft tissue pulmonary mass in the anterior segment of the upper lobe of the left lung. The scan confirms the presence of a heterogeneously enhancing soft tissue that compresses the left side of the mediastinum and left mainstem bronchus.

Drug Study
1. Drug Name: Hydrocortisone(cortizan) Classification: Steroid Indications:To reduce inflammation during an allergic reaction, severe

anaphylaxis, asthma, or COPD. Dosage:Adult: 40-250 mg IV/IM. Contraindication: Patients with hypersensitivity to glucocorticoid, systemic fungal infection Side Effects: Long-term steroid therapy can cause gastrointestinal bleeding, prolonged wound healing Nursing Responsibility: Assess the patients weight blood pressure, glucose and electrolyte level Assess carefully for signs of infection(low WBC count). 2. Drug Name: Salbutamol + ipratropium(Combivent) Classification: Bronchodilator Indications:Used for Chronic obstructive pulmonary disease (COPD) Dosage:neb every 30 min Contraindication:patients with a history of hypersensitivity to soya lecithin or related food products such as soybean and peanut, patients hypersensitive to any other components of the drug product or to atropine or its derivatives. Side Effects: Dry mouth, cough,Constipation, Head ache and Dizziness, Blurred vision Nursing Responsibility:

Check inhaler technique. Ensure that patients are able to correctly use the delivery device for their medication. Advise patients not to exceed the prescribed dose. Advice the patient to rinse mouth after each use of the inhaler Frequent drinks and the use of sugar-free gum can help with dry mouth. Take a missed dose as soon as remembered unless it is almost time for the next dose. Do not take a double dose. Avoid getting in eyes. 3. Drug Name: Fluticasone (Seretide) Classification:Anti-asthmatic Indications:Regular treatment of reversible obstructive airway disease, including asthma, Maintenance treatment for COPD including chronic bronchitis and emphysema. Dosage:200 mg/inhalation 2 puffs bid Contraindication: patients with hypersensitivity to drug or any of its components. Caution to patients who are unusually responsive to sympathomimetic and patients with coronary artery insufficiency, Tremor, subjective palpitations and headache, cardiac arrhythmias, arthralgia, hypersensitivity reactions, oropharyngeal irritation, hoarseness, oralcandidiasis, paradoxical bronchospasm. Side Effects: Headache, tremor, palpitations, candidiasis, Throat irritation, Hoarse voice, Muscle cramps, tachycardia, arrhythmias, bronchospasm, Pain in the muscles and joints, Anxiety, Sleep disorders, Behavioral changes, including hyperactivity and irritability . Nursing Responsibility: Assess patients respiratory condition before starting therapy.

Be alert for adverse reactions and drug reactions Dont give drug for acute bronchospasm. Tell patient to take the drug at about 12-hour intervals even if he is feeling better. 4. Drug Name:Doxofylline(Ansimar) Classification: Anti- asthmatic & COPD Preparations Indications:Bronchial asthma & pulmonary disease w/spastic bronchial component Dosage:400 mg bid Contraindication:Acute MI, hypotension Side Effects:Nausea, vomiting, epigastric pain, cephalalgia, irritability, insomnia, tachycardia, extra systole, tachypnea, hyperglycemia, albuminuria. Nursing Responsibility: Assess lung sounds, pulse and blood pressure before administration and during peak of medication. Monitor pulmonary function tests before initiating therapy and periodically during therapy to determine effectiveness of medication. Observe for paradoxical bronchospasm (wheezing). If conditions occur, withhold medication and notify physician of other health care professional immediately. 5. Drug Name:Albuterol Sulfate (DUAVENT) Classification: Anticholinergic / Beta2-agonist Indications:use in patients with COPD on a regular inhaled bronchodilator who continue to have evidence of bronchospasm and who require a second bronchodilator Dosage:inhalation PRN

Contraindication:Hypertrophic obstructivecardiomyopathy or tachyarrhythmia. Hypersensitivity to atropineand its derivatives. Side Effects:Headache, pain, chest pain, nausea, Bronchitis,dyspnea Nursing Responsibility: Position patient onhigh back rest position. Do back tappingafter you nebulizethe patient .do not give a foodimmediately it cancause vomiting 6. Drug Name:procaterol hydrochloride(meptin) Classification: Bronchodilator Indications:Relief of dyspnea and other symptoms caused by respiratory obstructive disturbance in the following diseases: bronchial asthma, chronic bronchitis, and pulmonary emphysema Dosage:5 0 - 1 0 0 m g P O B I D Contraindication: H y p e r s e n s i t i v i t y t o p r o c a t e r o l . Side Effects:n e r v o u s n e s s , t r e m o r a n d h e a d a c h e Nursing Responsibility: 7. Drug Name:IsosorbideMononitrate (Imdur) Classification:nitrates Indications:used for treating and preventing angina Dosage:60 mg od

Contraindication:patients who have shown hypersensitivity or idiosyncratic reactions to other nitrates or nitrites. Side Effects: Headaches, Flushing, Weakness, dizziness, palpitations, Severe drop in blood pressure Nursing Responsibility: Assess for pain duration ,time started activity being performed,character and intensity Monitor bp, pulse at baseline and during treatment 8. Drug Name: CARVEDILOL(Coreg) Classification:Alpha-adrenergic blocking agent, Beta-adrenergic blocking agent. Indications:treat high blood pressure and angina pectoris Dosage:6 mg OD Contraindication:Bronchial asthma or related bronchospastic conditions. Deaths from status asthmaticus have been reported following single doses of COREG (carvedilol), Side Effects:Dizziness, lightheadedness, drowsiness, diarrhea, or tiredness Nursing Responsibility: assess for patient history of hypertension Montorbp before and during treatment 9. Drug Name:cefuroxime( zinacef) Classification:cephalosporin antibiotic Indications:useful in treating acute bacterial bronchitis in patients with chronic obstructive pulmonary disease(COPD). bacteria causing infections of pneumonia

Dosage:750 mg iv every 8 hours Contraindication:Hypersensitivity to Cefuroxime or to any other cephalosporin antibiotics, Previous immediate and/or severe hypersensitivity reaction to penicillin or any beta-lactam drug. Side Effects: diarrhea, nausea, vomiting, abdominal pain, headache, rash, hives, vaginitis, and mouth ulcers. Nursing Responsibility: Should the check the patients name, the correct route, dosage, and frequency of the medicine that should be given. 10. Drug Name:hydrocortisone sodium succinate(Solu- cortef) Classification:anti-inflammatory glucocorticoid Indications:to treat severe allergic reactions, breathing problems, reduces symptoms such as swelling and allergic-type reactions. Dosage:100 mg iv stat Administration: Contraindication: systemic fungal infections and patients with known hypersensitivity to the product and its constituents. Side Effects: : Stomach upset, headache, dizziness, menstrual period changes, trouble sleeping, increased appetite, weight gain, or pain/redness/swelling at the injection Nursing Responsibility: Instruct clients to use glucocorticoid inhalers on a regular, fixed schedule for long-term therapy of asthma. Glucocorticoids are not to be used to treat an acute attack. Administer using an MDI device, DPI, or nebulizer. 11. Drug Name:Esomeprazole (Gastrozole) Classification:Proton-Pump Inhibitors Indications:Acid related dyspepsia in patients with epigastric pain and/or discomfort with or without heartburn. Dosage:40 mg OD Contraindication: Hypersensitivity to Omeprazole.

Side Effects:abdominal pain, tiredness, headache, dizziness,constipation, diarrhea, flatulence, nausea, vomitingand skin rashes. Nursing Responsibility: Assess bowel sound every 8 hours, abdomen for pain and swelling, petite loss Assess other medication patients may be taking for effectiveness and interaction. Monitor therapeutic effect and adverse reaction. 12. Senna (Senokot Forte) Classification: Laxatives Indications: Relief of functional constipation through peristaltic stimulation, helps relief & control of constipation in the elderly Dosage: 1 tab at bedtime Administration: May be taken with or without food. Preferably taken at bedtime. Contraindication: acute surgical abdomen, appendicitis, intestinal hemorrhage or obstruction, diarrhea Side Effects: rapid heart rate, weakness, dizziness, fainting, sweating, skin rash, abdominal Pain Nursing Responsibility: Reduce dose in patients who experience abdominal cramping. Be aware that drug may alter urine and feces color (yellowish brown/reddish brown). Continued use may lead to dependence. 13. Furosemide (Lasix) Classification: loop diuretic Indications: used to eliminate water and salt from the body, inhibits reabsorption of Na and Cl in Loop of Henle Dosage: 20gIV every 8 hours

Contraindication: anuria, hepaticcoma, severe hypokalemia, hyponatremia hypovolemia, hypotension Side Effects: low blood pressure, dehydration, nausea, diarrhea, abdominal pain, and dizziness. Nursing Responsibility: Monitor BP (orthostatic hypotension). Monitor I and O. Monitor for signs of hypokalemia (malaise, fatigue, arrhythmias, shallow breathing). 14. Tramadol + Paracetamol (Algesia) Classification: Analgesics (Opioid) Indications: Management of moderate to severe pain. Dosage: 1-2 tab TID Administration: May be taken with or without food. Contraindication: hypersensitivity to opioids, acute intoxication with alcohol, hypnotics Side Effects: Dizziness, nausea, fatigue, hot flushes, headache, tremor, abdominal pain, constipation Nursing Responsibility: Assess for pain. Monitor RR before and after. Monitor BP before and after. 15. Omeprazole (Prilosec) Classification: Antacids, Antireflux Agents & Antiulcerants Indications: Acid-related dyspepsia, prophylaxis of acid aspiration during general anesthesia to be completed 1 hr before the surgery. Dosage: 40mg OD Administration: Give before food, preferably breakfast; capsules must be swallowed whole (do not open, chew, or crush).

Contraindication: hypersensitivity to omeprazole or its components. Side Effects: nausea, fatigue, constipation, vomiting, flatulence, acid regurgitation, myalgia, dry mouth, dizziness, headache, abdominal pain Nursing Responsibility: Monitor urinalysis for hematuria and proteinuria. Report any changes in urinary elimination such as pain or discomfort associated with urination, or blood in urine.

16. Dibencozide (Heraclene) Classification: group of vitamin B12 (cyanocobalamin) Indications: for faulty nutrition in older people, for treating tuberculosis and additional persistent diseases, recuperating from severe surgery or infection and defective nutrition in elderly patients. Dosage: 1 capsule daily Administration: before or after food but advised to use it with meal or after meal Contraindication: Thromboembolism, erythremia, erythrocytosis, increased sensitivity to cyanocobalamin. Side Effects: nausea, vomiting, diarrhea, acidity, headache, stomach upset Nursing Responsibility: Stop using the drug immediately and seek for immediate medical help in case of any symptoms of allergic reactions such as rashes, hives and inflammation. 17. Ketorolac tromethamine (Toradol) Classification: nonsteroidal anti-inflammatory drug (NSAID) Indications: inflammation and pain, for the short-term (up to 5 days in adults), management of moderately severe acute pain that requires analgesia at the opioid level Dosage: 1 ampule IV every 8 hours Contraindication: dehydration, renal impairment, hemorrhage Side Effects: hemorrhage, GI bleeding, rash, ringing in the ears, headaches, dizziness, drowsiness, abdominal pain, nausea, constipation, heartburn, and fluid retention.

Nursing Responsibility: Monitor urine output. Monitor for signs of GI distress/bleeding.GI ulceration with perforation can occur anytime during treatment. Drug decreases platelet aggregation and thus may prolong bleeding time. 18. Bisacodyl (Dulcolax) Classification: stimulant laxative Indications: constipation Dosage: 1 to 2 tab (5 to 15 mg) * if (-) BM Administration: Do not crush, chew, or break the tablet or take it within 1 hour of antacids, milk, or milk products. Contraindication: intestinal obstruction, severe dehydration, appendicitis Side Effects: Stomach/abdominal pain or cramping, nausea, diarrhea, or weakness Nursing Responsibility: Elevate periodically patients need for continuance of drug. Adequate fluid intake includes at least 68 glasses/d. 19. Tranexamic Acid (Cyklokapron) Classification: antifibrinolytic Indications: for bleeding, treatment of hemorrhage Dosage: 500g every 8 hours Contraindication: presence of blood clots has a history of blood clots, or are at risk for blood clots, thromboembolic disease Side Effects: hypotension, nausea, vomiting, and diarrhea. Abdominal pain, dizziness, headache Nursing Responsibility: Unusual change in bleeding pattern should be immediately reported to the physician Inform the client that he/she should inform the physician immediately if severe side effects occur.

20. Diclofenac Sodium (Voltaren) Classification: nonsteroidal anti-inflammatory drugs (NSAIDs) with analgesic and antipyretic activity Indications: to relieve pain Dosage: 1 ampule IV every 8 hours Contraindication: gastric or duodenal ulcer Side Effects: constipation, gas or bloating, headache, dizziness, ringing in the ears Nursing Responsibility: Monitor BP for hypertension. Observe and report signs of bleeding (hematuria, black tarry stools) 21. Ampicillin(Omnipen) Classification: antibiotic Indications: treat many different types of infections caused by bacteria, such as pneumonia Dosage: 1 to 2 g IV q12 hours Contraindication: previous hypersensitivity reaction to any of the penicillins Side Effects: fever, sore throat, and headache with a severe blistering, peeling, and red skin rash; diarrhea that is watery or bloody; fever, chills, body aches, flu symptoms; easy bruising or bleeding, unusual weakness Nursing Responsibility: Determine previous hypersensitivity reactions to penicillin. Baseline C&S tests prior to initiation of therapy. Inspect skin daily for ampicillin rash.

Management
1. CTT insertion Left -is a surgical opening in the chest wall and inserting. A thoracostomy tube (chest catheter) is inserted into the chest wall above the area of the second or third rib. A local anesthetic ( xylocaine 1% or 2%) is administered and an incision is then made into the pleural space of the chest wall. The tube is inserted, positioned, and clamped, and silk sutures are use to secure the chest tube in place

Chest tube thoracostomy is done to drain fluid, blood, or air from the space around the lungs. Some diseases, such as pneumonia can cause an excess amount of fluid or blood to build up in the space around the lungs (called pleural effusion). Also, some severe injuries of the chest wall can cause bleeding around the lungs. Sometimes, the lung can be accidentally punctured allowing air to gather outside the lung, causing its collapse (called a pneumothorax). Chest tube thoracostomy (commonly referred to as "putting in a chest tube") involves placing a hollow plastic tube between the ribs and into the chest to drain fluid or air from around the lungs. The tube is often hooked up to a suction machine to help with drainage. The tube remains in the chest until all or most of the air or fluid has drained out, usually a few days. Occasionally special medicines are given through a chest tube.

Common reasons for its use and benefits: Collapsed lung (pneumothorax) - Air has built up in the pleural space from a leak in the lung. This leak may be the result of lung disease. It can also occur as a risk (complication) of certain procedures. Chest tubes are frequently needed to remove air from around the lung. Failure to remove such air can be life- threatening. Removing the air allows the lung to re-expand and seal the leak. Infection - If the fluid building up around the lung is infected, it may be necessary to insert a chest tube to remove the fluid. Comfort - A large build up of fluid or air in the chest can make it difficult to breathe. Removing some of the fluid or air may decrease discomfort. Risks: Pain during placement - Discomfort can result as the chest tube is inserted.. The discomfort can be severe at first but usually decreases once the tube is in place. Bleeding - During insertion of the tube, a blood vessel in the skin or chest wall may be accidentally cut. Bleeding is usually minor and stops on its own. Bleeding can occur as a bruise of the chest wall. Rarely bleeding can occur into or around the lung and may require surgery. Infection - Bacteria can enter around the tube and cause an infection around the lung. The longer the chest tube stays in the chest, the greater the risk for infection. The risk of infection is decreased by special care in bandaging the skin at the point where the tube goes into the chest.

Simple One - bottle system It provides water-seal gravity drainage. The gravity system allows the flow of air or water into the bottle when the pressure in the pleural space is sufficient to displace the water in the glass rod. The long glass rod is submerged about 2 cm below the water surface; an intrapleuralp r e s s u r e g r e a t e r t h a n 2 c m i n t h e p l e u r a l s p a c e w i l l b e r e q u i r e d t o displace it. The reader may demonstrate this concept by taking a drinking straw and blowing in through the straw while it is submerge in a glass of water. More effort is required to blow air through the straw when it is at the bottom of the glass than when it is just slightly under the surface, because a l o n g e r c o l u m n o f w a t e r m u s t b e d i s p l a c e f r o m t h e s t r a w . S i n c e t h e gravity water-seal drainage bottle is covered with a stopper, the short glass rod simply serves to allow the escape of air from the bottle. If this short glass rod becomes occluded, air pressure could build up within the bottle. This increase pressure pushes

the water in the bottle up the long glass tube toward the chest, risking back flow of fluid into the chest. Nursing responsibility: (CTT) a. The glass rods should be below the level of water 2-5cm. b. The bottle should be 18 inches below the patients chest to prevent air and fluid backflow. c. Tape the bottle on the floor to prevent accidental breakage of the bottle. d. Observe for fluctuation of the water. e. Avoid milking of the tube. f. Measure output correctly. Put date and time in the bottle. g. Never empty the bottles. h. Notify physician if drainage is greater than 100ml/hr and bright red. i. Always check for loops/ kinks of the bottle. 2. 3. 4. 5. O2 Therapy Monitor Intake and Output Diet as Tolerated Strict Aspiration Precaution

Nursing Care Plan

Assessment S> Hinahapo ako as verbalized by the patient. O> - RR 30cpm - Use of accessory muscles - Labored breathing -orthopnea Diagnosis Ineffective breathing pattern related to chest pain secondary to pulmonary infection Planning At the end of the shift, patient will: 1. Establish a normal / effective respiratory pattern. 2. Demonstrate appropriate coping behavior. Implementation 1. Auscultate chest, noting presence/character of breath sounds, presence of secretions. 2. Note depth and rate of respirations, type of breathing pattern. 3. Administer oxygen. 4. Assist with chest tube insertion as indicated. 5. Elevate head of the bed as appropriate to promote physiological/psycholo gical ease of maximal inspiration. 6. Encourage slower respirations, use of purse lip breathing. 7. Maintain calm attitude while dealing with patient to limit level of anxiety. 8. Encourage position of comfort. Evaluation The patient has: Decreased RR (22cpm) Less labored breathing Improved condition

9. Avoid eating gasforming foods; may cause abdominal distention. 10. Encourage adequate rest periods to limit fatigue.

Assessment S> Nahihirapan ako huminga as verbalized by the patient. O> - Wheezing - Yellowish sputum - Cough - 30cpm

Diagnosis Ineffective airway clearance related to COPD as evidenced by abnormal breath sounds

Planning At the end of the shift, patient will: 1. Maintain airway patency. 2. Expectorate/ clear secretions. 3. Demonstrate absence of congestion with breath sounds clear. 4. Improve respiratory function.

Implementation 1. Assess rate and depth of respiration. 2. Auscultate breath sounds. 3. Elevate head of the bed, change position every two hours and prn. 4. Encourage deep breathing and coughing exercises. 5. Administer analgesics to improve cough when pain is inhibiting effort. 6. Give expectorants/bronchodilat ors as ordered. 7. Monitor v/s 8. Observe signs for respiratory distress; increase RR, restless, use of accessory muscle. 9. Monitor/document serial chest x-rays. 10. Examine and report changes in color and amount of sputum.

Evaluation The patient: Responded to the medications Demonstrated compliance to the use respiratory device (nebulizer) Has an RR of 22cpm. Improved overall respiratory function

Assessment S> Masakit ang dibdib ko pag naubo as verbalized by the patient. O> - pain scale of 8 out of 10 - facial

Diagnosis Acute Pain related to pleurisy secondary to pneumonia

Planning After the end of the shift, the patient will: 1. receive the prescribed pharmacological regimen for pain 2. learn techniques to reduce pain 3. report relief of pain

Implementation 1. Provide comfort measures (repositioning) and quiet environment. 2. Administer analgesics as indicated. 3. Monitor vital signs. 4. Teach client how to provide support/splinting during coughing.

Evaluation The patient: Took the medication as prescribed. Performs splinting during coughing. Reported less pain with a pain

grimace upon coughing - guarding behavior

scale of 6 out of 10.

Assessment S> Naging pihikan si tatay as verbalized by the clients daughter. O> - loss of appetite - slight weight loss Assessment S> Masakit ang opera ko as verbalized by the patient. O> - pain scale of 9 out of 10 - facial grimace - guarding behavior

Diagnosis Imbalanced nutrition: less than body requirements related to loss appetite secondary to pain

Planning During hospitalization, the patient will: 1. Not develop malnutrition 2. Gradually return to normal eating habits. 3. Consume the appropriate RDA for his age.

Implementation 1. Discuss eating habits, including food preferences of the client. 2. Encourage small frequent meals. 3. Give appetite stimulants as indicated. 4. Promote pleasant, relaxing environment when possible to enhance intake. 5. Emphasize importance of well-balanced, nutritious intake.

Evaluation The patient: Regained his appetite Consumes appropriate RDA for his age.

Diagnosis Acute Pain at CTT insertion site related to post-op wound

Planning After the end of the shift, Patient will: 1. follow prescribed pharmacological regimen 2. Divert attention to lessen perception of pain 3. Report relief of pain to a more tolerable level

Implementation 1. Monitor vital signs 2. Provide comfort measures. 3. Administer analgesics as ordered. 4. Provide proper CTT care. 5. Provide ways to divert clients attention from post-op pain

Evaluation The patient: Took the medication as prescribed. Reported less pain with a pain scale of 6 out of 10.

Discharge Planning
Home medications: 1. Seretide 25-250mg 2puffs BID 2. Imdur 60 mg OD

3. Carvedilol 6.25mg OD 4. Cefuroxime 500mg BID 5. Duavent PRN 6. Lactulose 30cc PRN 7. Algesia 1tab BID Health Teaching: 1. Deep breathing and coughing exercises. 2. Compliance to medications. 3. Avoid strenuous activities. 4. Referral to pulmonologist for bronchoscopy.