CAP-MR

Community Acquired Pneumonia Moderate Risk

Prepared by: Sheena Marie Germinal

General objectives: Within 6 days of related learning experience, I will be able to apply my knowledge, skills and attitude regarding the concept cellular aberrations. Specific objectives: Within 8 hours of exposure I will be able to:

Knowledge
1.) Identify the different illness in the area of exposure in order to give appropriate nursing interventions. 2.) Provide information about the medications of the client. 3.) State the exact rationale for every nursing intervention. 4.) Formulate a comprehensive nursing care plan. 5.) Provide appropriate health teaching for my client.

Skills
1.) Organize data properly to ensure a systematic data collection. 2.) Gather relevant data needed in formulating the plan of care. 3.) Construct a data analysis using initial data base. 4.) Develop teaching plan to achieve wellness promotion. 5.) List down important information and answers given by client which is necessary in planning an effective nursing care.

Attitude
1.) Display a good role model to my fellow classmates to the folks and my client. 2.) Follow consciously all rules and regulation of the hospital. 3.) Show respect to the staff, clinical instructor and my fellow classmates. 4.) Seek clinical instructors guide before rendering any procedure. 5.) Display Augustinian values at all times especially honesty in doing any procedures and telling the truth.

Prepared By: Frestine Joanne Ibon

I.

Vital Information

Name: J.L Address: Poblacion Ilawod Lambunao, Iloilo Birth Date: April 2, 1982 Gender: Female Marital Status: Married Religion: Roman Catholic Date and Time of Admission: October 1, 2013 @ 5 a.m. Physician: Dr. S. Chief complaint: Cough and Difficulty of Breathing Admitting Diagnosis: CAP, MR

II.

History of Present Illness

Two months prior to admission the client experienced exertional dyspnea but she did not made any intervention to this. Then two weeks prior to admission she is experiencing non productive cough and increased severity of exertional dyspnea. The following day client went on a hilot nearby and was advised to take some herbal plants. Thereafter, when she noticed that her cough is not minimizing she decided to go to WVSUMC and admitted in San Vicente Ferrer Ward and undergone different tests like CBC, platelet, protime, 12L ECG, Blodd typing, Urinalysis, creatinine, S. K+ and Na+, and CT Scan.

III.

Past Medical History

J.L. has no history of hospitalization. Received a complete immunizations. She have not committed any childhood accidents. She also had no food, drug, and environmental allergies. She had suffered from childhood illnesses such as fever and runny nose that would last at least three days as far as she could remember. She takes over the counter drugs such as 1 tab of biogesic to relieve the pain and discomfort and herbal medicines such as lapunaya that her mother would use to hampol. She takes 1tab of Enervon every day before hours of sleep as his vitamin supplement.

Disease Asthma Hypertension

Paternal x

Maternal x

DM
Cancer

V.

Socioeconomic Status

J.L is a highschool physics Teacher, married with a college Rizal teacher with 3 children aging 6 months, 2 and 3 years. The number of their family members who are living in their house is 6 which includes her mother who took care of their children when they are at work. The family earns Php 10,000.00and above monthly. They live in a bungalow style house, semi-concrete, with galvanized roof. There are two rooms, a kitchen and a comfort room separated from their house. They store foods in their refrigerator. They get water from the their own deep well and buys mineral water as their source of drinking. They sometimes celebrate fiesta in accordance to their budget. They always go to church every Sunday and sometimes participate in their barangay activities. He claims to have a mutual relationship with his neighbors because some of them were his childhood friends and he also claimed that he has a good and happy life with his family.

VI.

Activities of Daily Living

A. Nutrition Client eats three times a day with no difficulty. At Breakfast, she usually drinks a cup of coffee while she dips 3-5 pieces of hot pandesal. During lunch, she prefers to eat vegetables and fish, sometimes meat and chicken if available with 3-4 cups of rice per meal. By the time supper arrives, she eats canned goods and steamed vegetables like okra together with a cup of rice. He drinks 10-12 glasses of water a day.
B. Elimination She urinates 3-7 times a day, her urine is pale straw and the amount of her urine depends on how much he usually takes. She defecates thrice a week, usually 7am in the morning. Her stools are brown and well-formed as he claimed. She has no difficulty or pain felt upon urination and defecation.

C. Rest and Sleep Client sleeps after dinner at around 9pm and wakes up at 4am with a single pillow he usually puts under his head and in a side lying position while sleeping. When she cant sleep he watches television or listening to radio or drinking 3-4 glasses of fermented coconut chucks. D. Activity and Exercise She refers doing household chores and school works as her exercise. When she hears a pop music over the radio, he would tend to sway his hips and stretch his arms and dance to the beat of the tune, that is if shes inside of their house.

Drug Study

Generic Name: Hydrocortisone Brand Name: Hydrocortone

CLASSIFICATION

ACTION

CONTRA -INDICATIONS Allergy to anycomponent of the drug- Fungal infectionsAmebiasis- Hepatitis B- Vaccinia or varicella- AntibioticresistantinfectionsImmunosuppression

PRECAUTIONS

SIDE EFFECTS

NURSING RESPONSIBILITY - Give daily before 9am to mimicnormal peak diurnal corticosteroi dlevels.- Space multiple doses evenlythroughout the day.- Use minimal doses for minimalduration to minimize adverse effects.- Do not give IM injections if patienthas thrombocytopenic purpura.- Taper doses when discontinuinghighdose or long-term therapy

Corticosteroid

enters target cells and bindsto cytoplasmic receptor;initiates many complexreactions that are responsiblefor its antiinflammatory,immuno suppressive(glucocorti coid), and saltretaining (mineralocorticoid)acti ons. Some actions maybe undesirable, dependingon drug use.

kidney disease- Liver disease- CirrhosisHypothyroidismUlcerative colitis withimpending perforationDiverticulitis- Recent GI surgery- Active or latent pepticulcer Inflammatory boweldiseaseHypertension- Heart failureThromboembolicten denciesOsteoporosisConvulsive disordersMetastatic carcinoma- Diabetes mellitus- TBLactation

Vertigo, headache,paresthesi as, insomnia,seizures, psychosis

Generic Name: Ribavirin Brand Name: Virazole

CLASSIFICATION

ACTION

CONTRA -INDICATIONS contraindicated in individuals who have shown hypersensitivity to the drug or its components, and in women who are or may become pregnant during exposure to the drug

PRECAUTIONS

SIDE EFFECTS

NURSING RESPONSIBILITY Observe 10 Rs. Take this medication by mouth, usually twice daily with food for 24 to 48 weeks or as directed by your doctor. Swallow this medication whole. Do not crush, break or chew the tablet. The dosage and length of treatment is based on your age, weight, medical condition, and response to therapy.

Treatment of hospitalized infants and young children with severe lower respiratory tra ct infections due to respiratory syncytial virus.

act as an analogue of these cellular metabolites

USE OF AEROSOLIZED VIRAZOLE IN PATIENTS REQUIRING MECHANICAL VENTILATOR ASSISTANCE SHOULD BE UNDERTAKEN ONLY BY PHYSICIANS AND SUPPORT STAFF FAMILIAR WITH THE SPECIFIC VENTILATOR BEING USED AND THIS MODE OF ADMINISTRATION OF THE DRUG. STRICT ATTENTION MUST BE PAID TO PROCEDURES THAT HAVE BEEN SHOWN TO MINIMIZE THE ACCUMULATION OF DRUG PRECIPITATE, WHICH CAN RESULT IN MECHANICAL VENTILATOR DYSFUNCTION AND ASSOCIATED INCREASED PULMONARY PRESSURES

fever, chills, body aches, flu symptoms; severe pain in upper stomach spreading to your back, nausea and vomiting, fast heart rate; stabbing chest pain, wheezing, hallucinations, thoughts of suicide chest pain or heavy feeling, pain spreading to the arm or shoulder, nausea, dark colored urine, easy bruising or bleeding, confusion, or unusual weakness.

AVAILABLE FORMS & Dosage: Tablets, 400 mg PO qAM, 600mg PO qPM

Generic Name: Oseltamivir Brand Name: Tamiflu

CLASSIFICATION

ACTION

CONTRA -INDICATIONS treatment of uncomplicated acute illness due to influenza virus (a or b) in adults and children who have been symptomatic for 2 days or less. Prevention of naturally occurring influenza A and B in adults and children in close contact with the flu.

PRECAUTIONS

SIDE EFFECTS

NURSING RESPONSIBILITY Instruct your client not take Tamiflu if you are allergic to the main ingredient, oseltamivir phosphate, or to any other ingredients of Tamiflu. Report severe diarrhea, severe nausea, worsening of respiratory symptoms

Antiviral, neuraminidase inhibitor

Severely inhibits influenza virus neuraminidase, by blocking the actions of this enzyme there is decreased viral release from infected cells, increased formation of viral aggregates, and decreased spread of virus.

Allergy to any component of drug. Use cautiously with pregnancy, lactation, asthma, COPD

nausea, vomiting, diarrhea; dizziness, headache; nosebleed; eye redness or discomfort; sleep problems (insomnia); or cough or other respiratory symptoms

AVAILABLE FORMS & Dosage: Oral suspension 12.5 mL. Capsule of 75 mg

Generic Name: Lopinavir / Ritonavir Brand Name: Oseltamivir

CLASSIFICATION

ACTION

CONTRA -INDICATIONS patients with previously demonstrated clinically significant hypersensitivity (e.g., toxic epidermal necrolysis, StevensJohnson syndrome, erythema multiforme) to any of its ingredients, including ritonavir

PRECAUTIONS

SIDE EFFECTS

NURSING RESPONSIBILITY

Protease Inhibitors

Exhibits antiviral activity, inhibits HIV protease activity, leading to the decrease of HIV particles, inhibits metabolism of lopinavir, allowing for increased plasma levels of lopinavir

KALETRA is an HIV-1 protease inhibitor indicated in combination with other antiretroviral agents for the treatment of HIV-1 infection in adults and pediatric patients

Pancreatitis, Hepatotoxicity, Diarrhea, nausea and vomiting, abdominal pain, flatulence, insomnia

Instruct client to eat before taking the oral solution of medication In tablets, May be taken with or without food, swallowed whole and not chewed, broken, or crushed

Laboratory Results
Prepared By: Ma. Theresa Abanilla

Date: October 1, 2013 Time: 5:00 PM

Blood Typing: O, Rh + Protime: Normal Urinalysis Composition Results Physical Properties Color Pale Straw Transparency Hazy Normal Values Straw/Amber Clear Significance Normal Pyuria, Pacleriuria Phosphate in Urine Normal Normal

Reaction (ph) STGR

6.0 1.010

4.5-7.8 1.001-1.035

Pyuria- containing pus

Chemical Test Sugar Albumin Microscopic Findings: Pus cells RBC Negative Negative Negative Negative Normal Normal

0-2/hpf 4-5/hpf

3-6/hpf 0-3/hpf

May indicate infection a disease condition is often present. One of the

most common causes of RBC's in the urine, is infection or inflammation of the urinary tract itself (i.e., cystitis).

Amorphous Urates Squamous Epithelial cells

Occasional

None

can be caused by gout Normal

few

15-20/hpf

Hematology Composition Hemoglobin Hematocrit RBC WBC Platelet Count Results 134 g/L 0.40 L/L 4.67 10^g/L 11.21 10^g/L 427 10^ g/L Normal Values 120-160 g/L 0.37-0.47 g/L 4.2-5.4 10^g/L 4.5-11 10^ g/L 150-450 10^g/L Afebrile Composition Results Normal Values Significance Significance Normal Normal Normal Normal Normal

O2 Saturation INR

95% 1.02

95-99% 2.0-3.0

Normal blood clots more quickly than desired

Chest: CT Scan Limit oral fluid intake to Liter per day Maintain to high back rest IVF to KVO

Pertinent Findings: + Vocal Fremitus; Left Middle Lung Field (Airway obstruction, Pneumothorax) - - Crackles & wheezes - + Pulmonary mass: Left Middle to upper - (May indicate Lung cancer) - Pulmonary nodules, Right - (maybe benign/malignant) - Intercurrent PHA Pneumonia at Bilateral - Serum Creatinine: - Chest Ct scan with Contrast pending

MEDICAL & SURGICAL

INTERVENTIONS

MEDICAL interventions
Pharmacological
Ventilation with low tidal volumes (6 mL/kg of ideal body weight) in patients requiring mechanical ventilation secondary to bilateral pneumonia or acute respiratory distress syndrome (ARDS)

High doses of steroids to reduce swelling in the lungs.

Administer Antiviral, Antibiotic or Steroidal medications with proper prescription from physician.

Endotracheal Tube

Monitor Vital Signs.

An IV route is established to provide an accessible means for emergency

drug therapy.

Suctioning and bronchial hygiene Pulmonary toilet may include active suction of secretions, chest physiotherapy, positioning to promote dependent drainage, and incentive spirometry to enhance elimination of purulent sputum and to avoid atelectasis.

MEDICAL interventions
Non-Pharmacological
Position the patient to semi- or high-fowlers position to minimize risk

of aspiration.

Be sure that all members of your household are washing their hands

frequently with soap and hot water or using an alcohol-based hand rub.

Wear disposable gloves if you will have direct contact with body fluids of a person with SARS. However, wearing gloves is not a substitute for good hand hygiene. After contact with body fluids of a person with SARS, remove the gloves, throw them out, and wash your hands. Do not wash or reuse the gloves.

Encourage the person with SARS to cover his or her mouth and nose with a
tissue when coughing or sneezing. If possible, the infected person should wear a surgical mask during close contact with other people in the home. If the person with SARS cannot wear a surgical mask, other members of the household should wear one when they are in the room with that person.

Do not use silverware, towels, bedding, clothing, or other items that have been used by the person with SARS until these items have been washed with soap and hot water.

Clean surfaces in the infected person's room and bathroom fixtures used by

this person daily with a household disinfectant used according to the

manufacturer's instructions. When cleaning, wear disposable gloves and dispose of them after use. Household utility gloves may also be used.

Limit the number of people in the household to those who are essential for
patient support. Other household members should either be relocated or minimize their contact with the infected person in the home. This is particularly important for people at risk of serious complications of SARS (e.g., persons with underlying heart or lung disease, diabetes mellitus, older age).

Unexposed people who do not have an essential need to be in the home should not visit.

For 10 days after your last exposure to the person with SARS, keep a vigilant watch for signs of fever (i.e., measure your temperature twice daily), respiratory

symptoms, and other early SARS symptoms. If you do not have any of these
symptoms, you do not need to limit your activities outside the home. You may go to work, school, out-of-home childcare, church, or activities in other public areas.

Follow any other instructions provided by local health authorities.

If you start feeling sick, especially if you develop a fever, respiratory symptoms, or other early symptoms of SARS, contact your healthcare provider immediately, and tell the healthcare provider that you have had close contact with a SARS patient.

surgical intervention

Endotracheal insertion
Endotracheal intubation is a medical procedure in which a tube is placed into the windpipe (trachea), through the mouth or the nose. In most emergency situations it is placed through the mouth.

Endotracheal intubation is done to:

Open the airway to give oxygen, medication, or anesthesia

Remove blockages from the airway

Allow the doctor to get a better view of the upper airway Protect the lungs in certain patients

Patient position
The patient should be aligned without lateral deviation of the head or neck. The head should be extended on the neck with a pillow under the occiput. If cervical spine trauma is suspected, have an assistant provide in-line immobilization. The neck should be flexed to approximately 15 degrees on the chest. Try to keep the external auditory meatus and sternal notch in same horizontal plane (except infants or when cervical spine injury is present or suspected).

Nursing Diagnosis

As evidenced by:
Subjective: -I cant breath well because of my chest pain, as verbalized by the patient. Objective: -Difficulty of breathing - Shortness of breath - Altered breath depth - Timing ratio; prolonged expiration phases - Altered chest excursion - Nasal flaring - Grunting v/s TEMP: 35.7 C BP: 120/80 mmHg RR: 23 cpm PR: 110 bpm

GOAL
After 4 hours of nursing intervention, the patient will able to do coping mechanisms to improve his breathing pattern

INTERVENTION
Auscultate chest; to evaluate pressure and character of breath sounds

EVALUATION
After 4 hours of nursing intervention, the patient did the coping mechanisms to improve his breathing pattern

- Administer oxygen at lowest concentration indicated and prescribed repiratory medication for management of underlying pulmonary condition

As evidenced by:

GOAL

INTERVENTION
-Evaluate HOB or have client sit up in chair, as appropriate to promote physiologic ease of maximal inspiration - Encourage slower/deeper respirations, use purse lip technique, to assist client in taking control of the situation - Monitor pulse oximetry, as indicated to verify maintenance in oxygen saturation - Maintain calm attitude while dealing with the client to limit level of anxiety

EVALUATION

As evidenced by:
Subjective: - Questioning members of the Heath Care Team. - lack of questions about SARS - verbalizing inaccurate information Objective: - unaware of proper prevention methods - denial need to learn

GOAL
After 2 hours, the pxatient will be able to verbalize the disease process, transmission, treatment, and complications of SARS.

INTERVENTION
1.) Provide information about disease transmission. 2.) Provide information about disease process/complications. 3.) Provide information on treatments. 4.) Provide information on general protection from SARS.

EVALUATION
After 2 hours of nursing intervention, the patient will be able to verbalize the disease process, transmission, treatment, and complications of SARS.

As evidenced by:
Subjective: - general feeling of discomfort - body aches - headache - exposure to persons with SARS Objective: - Temperature >38oC for 2-7 days - Chills - Diarrhea - Non-productive cough 2-7 days - hypoxia - positive diagnostic test

GOAL
After 8 hours of nursing intervention, the patient will be able to maintain normal body temperature of 36-35oC And reduce the respiratory symptoms.

INTERVENTION
INDEPENDENT: 1.) Monitor lung sounds and cough 2.) Monitor Temperature 3.) Monitor oxygen saturation 4.) Maintain respiratory circulation: keep tissues on the bedside dispose secretions properly have the patient cover mouth when

EVALUATION
Patient exhibits absence of fever and absence of respiratory symptoms. Risk of spread of infections is reduced. The goal was partially met.

As evidenced by:

GOAL

INTERVENTION
have the patient cover mouth when sneezing or coughing use masks have anyone entering the patients room wear a mask keep door closed all the time and place respiratory isolation sign visible assist visitors to follow appropriate isolation techniques

EVALUATION

5.) teach the patient to wash hands after coughing

As evidenced by:

GOAL

INTERVENTION
6.) use appropriate therapy to decrease temperature 7.) encourage the patient to cough unless the cough is nonproductive

EVALUATION

8.) for patients with reduced energy, pace activities

9.) provide a highprotein , high calorie, increase fluid diet in small frequent servings.

As evidenced by:

GOAL

INTERVENTION
DEPENDENT: 1.) Administer antiviral medications as ordered. COLLABORATIVE: 1.) Consult a respiratory therapist for chest physiotherapy and nebulizer treatments 2.) Collect and monitor diagnostic results

EVALUATION

Novel Corona virus Well-Adapted to Humans, Susceptible to Feb. 19, 2013 The new coronavirus that has emerged Immunotherapy in the Middle East is well-adapted to infecting humans
but could potentially be treated with immunotherapy, according to a study to be published on February 19 in mBio, the online open-access journal of the American Society for Microbiology. The study indicates that the virus HCoV-EMC can penetrate the lining of the passageways in the lung and evade the innate immune system as easily as a cold virus can, signs that HCoV-EMC is well-equipped for infecting human cells. The study also reveals that the virus is susceptible to treatment with interferons, components of the immune system that have been used successfully to treat other viral diseases, opening a possible mode of treatment in the event of a large-scale outbreak.
American Society for Microbiology (2013, February 19). Novel coronavirus well-adapted to humans, susceptible to immunotherapy.ScienceDaily. Retrieved August 7, 2013, from http://www.sciencedaily.com/releases/2013/02/130219091010.htm