Medical Mission Group Hospital

And Health Services Cooperative

of Davao

Case Presentation

Bacterial Meningitis
October 21, 2016
Presented by:
Burlando Angelo C. Pascual Jr.

Introduction
Meningitis is defined as an acute inflammation of the protective
membranes covering the brain and the spinal cord, collectively known
as the meninges. It can be life-threatening and, thus, is considered a
medical emergency. Meningitis can be caused by bacteria or a virus.
Viral meningitis is the most common but least severe type. Almost all
patients recover without any permanent damage, although full
recovery can take many weeks.
Bacterial meningitis, which is the most severe and common form of
meningitis, causes around 120,000 deaths globally every year. Most
cases of bacterial meningitis are caused by meningococcus,
pneumococcus, and Haemophilus Influenzae Type B (Hib).

Bacterial meningitis can be life-threatening. In pre-antibiotic days

it had a greater than 90% mortality rate, and those that did recover
nearly always had permanent disabilities like deafness and blindness.
Undiagnosed or untreated it has a similar mortality rate today; hence
the vital importance of early diagnosis and treatment..
We chose patient X as our client because of the duration and
thoroughness of care provided by our staff in both the PR/ICU and
Pediatric Departments in the hospital.

Objective of the Study

The objective of the study is to bestow quality-nursing care to
assigned patient, utilizing the knowledge based on the nursing
process and critical thinking skills. This care study aims to guide the
student nurses in providing client-centered nursing care while
applying critical thinking in all phases of nursing care from
assessment to evaluation.
Also, awareness and knowledge of the patients disease condition
and its corresponding pathophysiology is vital in providing suitable
intervention to the client.
Thus, with accurate application of physical assessment, actual and
potential health problems are being detected and resolved through
the nursing care plan.

After completing the care for the patient with Pneumonia the student
nurses will be able to:
Utilize the nursing process in the management of patients health
condition and in giving quality nursing care.
Obtain a complete health data that can be used in the follow-up
care.
Impart health teachings about necessary information pertaining to
the disease condition.
Understand the course and essence of the chosen care study.
Add up additional knowledge and understanding in the Nursing

Scope and Limitation of the Study

The primary concern of the study is health maintenance and

detection of actual and potential health problem that could further
exacerbate the clients disease.
Nevertheless, the clients history of present illness including family
history is being scrutinized to detect any possible health problem or
knowledge deficit regarding family care.
This study will include the effort of the student nurses and the
assigned patient in the male ward at Sabal Hospital. The study was
directed towards the aforementioned objectives. The study includes
the overview of the case, health history of the patient, developmental
data, medical management, pathophysiology with anatomy and
physiology, nursing assessment, nursing management, referrals and
follow-up and evaluation and implication. Attributes like the health
history and honesty of the response to the questions asked were the

PATIENT PROFILE

Name:
Patient X
Age:
73 years old
Address:
Lugait, Misamis Oriental
Gender:
Male
Civil Status:
Married
Date of Birth:
September 3, 1983
Place of Birth:
Cagayan de Oro City
Religion:
Roman Catholic
Nationality:
Filipino
Occupation:
Farmer
Educational Attainment:
Grade 6
Height:
52
Name of Hospital:
Sabal Hospital
Weight:
65 kgs.

Date of Admission:
January 13, 2011
Time Admitted:
9:10 pm
Chief Complaint:
Cough and Shortness of Breath
Admitting Physician:
Dr. Arthur Tan
Admitting Diagnosis:
Bronchial Asthma in Acute Exacerbation
Income:
2,500/month
Temperature:
36.2 C
Pulse:
64 bpm
Respiration Rate:
28 cpm
Blood Pressure:
110/70 mmHg

HEALTH HISTORY
The informant mentioned that both families had no history of asthma.
He also mentioned that his mother side had hypertension.
Patient X is known to be asthmatic since he was 10 years old. At age
of 59, patient was admitted for the first time in Bega, Lugait Misamis
Oriental for 15 days due to over fatigue.
He is maintaining medications such as cetirizine 10 mg, salbutamol
500mg, doxofylline 400 g, methyl prednisolone 4 g. A known smoker, he
is able to consumed two packs of cigarette a day. He also consumed
alcohol almost thrice a week.

For the past 6 months, our patient was able to experience these
conditions:
Headache

HISTORY OF PRESENT ILLNESS

A case of 73 years old, Male, Roman Catholic, a farmer from Lugait,

Misamis Oriental, admitted for the second time due to shortness of
breath.
Three days prior to admission, patient felt and complained about cough
associated with shortness of breath. Patient was referred to Dr. Arthur
Tan.
One day prior to admission, patient had washed dishes and was wet
under the rain.
The night prior to admission, patient complained of weakness, coughing
and shortnes of breath from too much worked. Then was immediately
rushed to Sabal hospital Incorporated, where Blood Pressure was taken
and was recorded 110/70mmHg, respiratory rate 28 cpm, pulse rate 64
bpm.

DEVELOPMENTAL DATA
A.Erik Eriksons Psychosocial Development Theory

Erik Erickson envisioned life as a sequence of levels of achievement.

Each stage signals a task that must be achieved. He believed that the
greater that task achievement, the healthier the personality of the
person. Failure to achieve a task influences the persons ability to
achieve the next task. Stages of Eriksons Psychosocial Theory are as
follows:
Infancy
Birth 18 months
Trust vs. Mistrust
Early Childhood 18 months 3 years
Autonomy vs. Shame &
Doubt
Late Childhood 3 5 years
Initiative vs. Guilt
School Age 6 12 years
Industry vs. Inferiority
Adolescence 12 20 years
Identity vs. Role Confusion
Young Adulthood18 25 years
Intimacy vs. Isolation

Basing on this theory, our patient belongs to maturity. The

development task at this time is ego integrity versus despair. People
who attain ego integrity view life with a sense of wholeness and
derive satisfaction from past accomplishments. They view death as an
acceptable completion of life. According to Erikson (1963), people who
develop integrity accept ones one and only life cycle. By contrast,
people who despair often believe they have made poor choices during
life and wish they could live life over.

B.Sigmund Freuds Psychosexual Development Theory

The psychosexual stages of Sigmund Freud are five different
developmental periods during which the individual seeks pleasure
from different areas of the body associated with sexual feelings.
Our patient falls under Genital Stage of Freuds theory. It is the
fifth and last stage of psychosexual development, the , from puberty
onwards. It actually continues until development stops. This stage
represents the major portion of life, and the basic task for the
individual is the detachment from the parents. It is also the time when
the individual tries to come in terms with unresolved residues of the
early childhood. These stages are as follows:
Oral
Birth to 1 year
Anal
2 3 years
Phallic
4 5 years
Latency
6 12 years

C.Robert Havighursts Developmental Task Theory

A developmental task is a task which arises at or about a certain
period in the life of an individual. Havighurst has identified six major
age periods: infancy and early childhood (0-5 years), middle childhood
(6-12 years), adolescence (13-18 years), early adulthood (19-29
years), middle adulthood (30-60 years), and later maturity (61+).
Basing on Havighursts Theory, our patient belongs in the later
maturity stage.

D. Jean Piagets Cognitive Theory of Development

Cognitive development refers to how a person perceives, thinks,
and gains understanding of his or her world through the interaction
and influence of genetic and learning factors. This is divided into five
major phases:
Sensorimotor Phase
Pre-conceptual Phase
Intuitive Thought Phase
Concrete Operations Phase
Formal Operational Phase

Birth to 2 years
2 3 years
4 6 years
7 11 years
12 adulthood

Basing on this theory, our patient belongs to the Formal

operational stage. Changes in the cognitive structures occur as a
person ages. It is believed that progressive loss of neurons occurs,
decreased of blood flow in the brain, the meninges appear to thicken,
and brain metabolism slows. In older adults, changes in cognitive
abilities are more often a difference in speed than in ability.
Overall the older adult maintains intelligence, problem solving,
judgment, creativity, and other well practiced cognitive skills.
Intellectual loss generally reflects a disease process such as
atherosclerosis, which causes the blood vessels to narrow and
diminishes perfusion of nutrients to the brain. Most older adults do not
experience cognitive impairments.

Older people need additional time for learning, largely because of

the problem of retrieving information. Motivation is also important. It
is suggested that the older person should remain mentally active to
maintain cognitive ability at the highest possible level.
Lifelong mental activity, particularly verbal activity, helps the
older person retain a high level of cognitive function and may help
maintain long-term memory. Cognitive impairment that interferes with
normal life is not considered part of normal aging.

MEDICAL MANAGEMENT
A. Medical Orders with Rationale

DIAGNOSTICS AND LABORATORY

ANATOMY AND PHYSIOLOGY

The respiratory system is an integrated network of and tubes
that coordinates the exchange of and between an organism and its
environment. Harmony is seen in the fact that the respiratory system
in involves the consumption of oxygen and contribution of carbon
dioxide to the environment, while in the respiratory system involves
the consumption of carbon dioxide and contribution of oxygen to the
environment.
In humans, enters the nose or mouth and travels down different
tubes to the , where gas exchange takes place. The diaphragm pulls
air in and pushes it out. However, there are many different respiratory
systems found across various organisms, including , many of which
can breathe through their skin.

In , including humans, the respiratory

system begins with the nose and mouth; air
enters the oral and nasal cavities, which
combine to form the pharynx, which becomes
the trachea. Air then travels down the various
tubes to the lungs. Respiratory muscles
mediate the movement of air into and out of
the body. The alveolar system of the lungs
functions in the passive exchange of molecules
of and , by diffusion, between the gaseous
environment and the blood.
Thus, the respiratory system facilitates
oxygenation of the blood with a concomitant
removal of carbon dioxide and other gaseous
wastes from the circulation. The system also

Anatomy
In humans and other mammals, the respiratory system can be
conveniently divided into an upper respiratory tract (or "conducting
zone") and a lower respiratory tract ("respiratory zone").
Air entering the nose moves through the body in
the following order:
Nostrils
Nasal cavity
Pharynx (naso-, oro-, laryngo-)
Larynx (voice box)
Trachea (wind pipe)
Thoracic cavity (chest)
Bronchi (right and left)
(site of gas exchange)

Upper respiratory tract/conducting zone

The upper respiratory tract begins with the nares (nostrils) of the
nose, which open into the nasopharynx (nasal cavity). The primary
functions of the nasal passages are to: 1) filter, 2) warm, 3) moisten,
and 4) provide resonance in speech. Dust and other air impurities can
be very harmful to the body, as can extremely cold or dry air. The
nasopharnyx opens into the oropharynx (behind the oral cavity).
During inhalation, air entering the oropharynx passes into the
laryngopharynx and empties into the larynx (voicebox), which
contains the vocal cords. Air then continues past the glottis down into
the trachea (wind pipe).

Lower respiratory tract/respiratory zone

The trachea leads down to the chest, where it divides into the
right and left "main stem" bronchi. The subdivisions of the bronchus
are: Primary, secondary, and tertiary divisions (first, second, and third
levels). In total, the bronchi divide 16 times into even smaller
bronchioles.
The bronchioles lead to the respiratory zone of the lungs, which
consists of respiratory bronchioles, alveolar ducts, and the , the multilobulated sacs in which most of the gas exchange occurs.

Physiology:
Ventilation
Ventilation of the lungs in humans is carried out by the muscles of
respiration, which include intercostal muscles.
Control
Ventilation is controlled by the . The breathing regulatory center is in
the medulla oblongata and the pons, parts of the brain stem
containing a series of interconnected that coordinate respiratory
movements. The sections are the pneumotaxic center, the apneustic
center, and the dorsal and ventral respiratory groups (CRISP 2007).
This section of the brain is especially sensitive during infancy, and the
neurons can be destroyed if the infant is dropped or shaken violently.
The result can be early death due to "shaken baby syndrome" (SIPH

Inhalation
Inhalation is driven primarily by the diaphragm with help from the
intercostal muscles. When the diaphragm contracts, the ribcage
expands and the contents of the abdomen are moved downward. The
expansion of the ribs results in a greater chest volume, which in turn
causes a decrease in intrathoracic pressure, according to Boyles Law.
When the pressure inside the lungs is lower than the atmospheric
pressure outside the body, air moves into the respiratory tract in an
attempt to equalize the pressures.
At rest, normal respiration is about 10 to 18 breaths per minute, with
each inhalation lasting about 2 seconds. Rates of breathing can
increase during exercise, fever, or illness. During vigorous inhalation
(at rates exceeding 35 breaths per minute), or when approaching
respiratory failure, other accessory muscles are recruited for support.
During forced inhalation, as when taking a deep breath, the external

Exhalation
Exhalation is generally a passive process,
however, active, or "forced," exhalation can be
achieved with the help of the abdominal and the
internal intercostal muscles.
The lungs have a natural elasticity; following the
stretch of an inhalation, the lungs recoil and air
flows back out until the pressures in the chest
and the atmosphere reach equilibrium. The flow
of air during exhalation can be compared to that
of an inflated but released balloon recoiling to
force air out. At the end of both inhalation and
exhalation, the pressure in the lungs equals that
of the atmosphere.
During forced exhalation, as when blowing out a
candle, the abdominal muscles and internal

Gas exchange
The major function of the respiratory system is gas exchange. As gas
exchange occurs in humans, the acid-base balance of the body is
maintained as a component of homeostasis. In the absence of proper
ventilation, two conditions could occur: 1)respiratory acidosis, a life
threatening condition caused by a deficiency of ventilation, or
2)respiratory alkalosis, caused by an excess of ventilation, or
hyperventilation.
The actual gas exchange occurs at the alveoli, the basic functional
component of the lungs. The alveolar walls are extremely thin
(approx. 0.2 micrometers), and are permeable to gases. Pulmonary
capillaries line the alveoli; the walls of these capillaries are also thin
enough to permit gas exchange.

NURSING ASSESSMENT II
SUBJECTIVE

OBJECTIVE

COMMUNICATION:
[ ] hearing loss
[ ] visual changes
[x ] denied

Comments:

[x ] glasses

[ ] languages

makakita man

[ ] contact lenses

[ ] hearing aide

ko, gamit lang

Pupil size: 3 mm

[ ] speech

ko

difficulties

eyeglass

panalagsa

ug

makadungon ug

Reaction: Pupils equally round and

react to light accommodation

tarong
OXYGENATION:
[ x] dyspnea
[x] smoking history
___________
[x ] cough
[x ] sputum
[ ] denied

Resp. [x ] regular
Comments: Gi
ubo lagi ko, naa
pa
plemas

dyud

[ ] irregular

Describe: Patient has normal

respiration.
R:

27cpm full and symmetrical to

the left lung

L: 27cpm full and symmetrical to the
right lung

CIRCULATION:
[x ] chest pain

Heart Rhythm

[x ] regular

[ ] leg pain

Comments Ga sakit

Ankle Edema (-) None

[ ] numbness of

akong

Pulse

extremities

dughan

kong

ubhon,

[ ] denied

Car.

Rad.

DP

[ ] irregular
Fem*

R_____ +____ +_ _____+_____+__

L

+____ +_ _____+_____+___

Comments: Right and left pulses are

Equal; strong and palpable.
______________________________

NUTRITION:
Diet: Full diet
[ ]N[]V

Comments: pakan-on

Character

man ko maski unsa sa

[ ] recent change in

akong doctor.

weight
[ ] swallowing
Difficulty
[ x] denied

[ ]dentures

[x]none
Full

Partial

with patient

Upper

[]

[]

[]

Lower

[]

[]

[]

ELIMINATION:

Comments:

Usual bowel pattern

Once everyday in am

the

Bowel Sound

patient has a normal

Audible normoactive

[ ] urinary frequency

bowel and urination

bowel sounds

5x to 7x a day

pattern.

Abdominal Distention

[x] constipation

[ ] urgency

Present [X ] yes [ ] no

remedy

[ ] dysuria

Urine* (color,

[ ] hematuria

consistency, odor)

[ ] incontinence

Urine color is yellow

[ ] polyuria

and aromatic odor.

none
Date of last BM
[ ] diarrhea
Character

[ ] foley in place

None

[x ] denied

MGT. OF HEALTH &

Briefly describe the

ILLNESS:

patients

ability

[ ] alcohol [ ] denied

follow

treatments

(amount & frequency)

(diet, meds, etc.) for

sa una ga inom ko, pero g

chronic

undangan na nako tungod sa

problems

akong sakit

present).

[ ] SBE:N/A Last Pap

Patient is able to

Smear: N/A

comply

to

health
(if

and

treatment

follow

regimen

as claimed and as
reflected

in

health history.

his

MGT. OF HEALTH & ILLNESS:

Briefly describe the patients ability

[ ] alcohol [ ] denied

to follow treatments (diet, meds,

(amount & frequency)

etc.) for chronic health problems (if

sa una ga inom ko, pero g undangan

present).

na nako tungod sa akong sakit

Patient is able to comply and follow

[ ] SBE:N/A Last Pap Smear: N/A

treatment regimen as claimed and

as reflected in his health history.

OBJECTIVE
SUBJECTIVE
SKIN INTEGRITY:
[ ] dry
[ ] other

Comments: sakto raman

[ ] dry

[ ] cold

[x ] denied

akong panit.

[ ] flushed

[ ]warm

[ ] moist

[ ] pale

[ ] cyanotic

*rashes, ulcers, decubitus (describe size, location,

drainage: (-) rashes; (-) ulcers ; (-) decubitus

ACTIVITY/ SAFETY:

Comments: maka lakaw man

[x] LOC and orientation Patient is conscious, coherent

[ ] convulsion

ko nga ako ra,.

and is oriented to time, date and place.

[ ] dizziness

Gait: [ ]

[ ] limited motion of

walker

joints

[x] steady [ ] unsteady____________

[ ] Limitation in

[ ] sensory and motor losses in face or extremities

Ability to

None was observed

[ ] ambulate

[x] ROM limitations: limited to active ROM.

[ ] bathe self
[ x] other
[ ] denied

[ ] cane

[ ] other

COMFORT/SLE
EP/AWAKE:
[ ] pain:
(location:pelvic)
[ ] Frequency:
[

Comments:
mata-mata
ubhon ko..

maka
q

kng

[] facial grimaces
[ ] guarding
[ ] other signs of pain :
[ ] side rail release form signed (60 +

intermittent

years)

None

Remedies:

Bed
rest
[ ] nocturia
[ x] sleep
difficulties
[ ] denied

COPING:
Occupation: retired armed forces

Observed non-verbal behavior: None

Members of household: 7 members in the

Phone number that can be reached

family

anytime: not given

Most supportive person: daughter

. IDEAL NURSING MANAGEMENT

NURSING DIAGNOSIS: Airway Clearance, ineffective

May be related to
Tracheal bronchial inflammation, edema formation, increased sputum
production
Pleuritic pain
Decreased energy, fatigue
Possibly evidenced by
Changes in rate, depth of respirations
Abnormal breath sounds, use of accessory muscles
Dyspnea, cyanosis
Cough, effective or ineffective; with/without sputum production
DESIRED OUTCOMES/EVALUATION CRITERIAPATIENT WILL:
Respiratory Status: Airway Patency (NOC)
Identify/demonstrate behaviors to achieve airway clearance.
Display patent airway with breath sounds clearing; absence of
dyspnea, cyanosis.

ACTIONS/INTERVENTIONS
Airway Management (NIC)
Independent
Assess rate/depth of respirations and
chest movement.
Auscultate lung fields, noting areas of
decreased/absent airflow and
adventitious breath sounds, e.g.,
crackles, wheezes.
Elevate head of bed, change position
frequently.

RATIONALE
Tachypnea, shallow respirations, and
asymmetric chest movement are
frequently present because of
discomfort of moving chest wall and/or
fluid in lung.
Decreased airflow occurs in areas
consolidated with fluid. Bronchial
breath sounds (normal over bronchus)
can also occur in consolidated areas.
Crackles, rhonchi, and wheezes are
heard on inspiration and/or expiration
in response to fluid accumulation,
thick secretions, and airway
spasm/obstruction.
Lowers diaphragm, promoting chest
expansion, aeration of lung segments,
mobilization and expectoration of
secretions.

NURSING DIAGNOSIS: Gas Exchange, impaired

May be related to
Alveolar-capillary membrane changes (inflammatory effects)
Altered oxygen-carrying capacity of blood/release at cellular level (fever, shifting
oxyhemoglobin curve)
Altered delivery of oxygen (hypoventilation)
Possibly evidenced by
Dyspnea, cyanosis
Tachycardia
Restlessness/changes in mentation
Hypoxia
DESIRED OUTCOMES/EVALUATION CRITERIAPATIENT WILL:
Respiratory Status: Gas Exchange (NOC)
Demonstrate improved ventilation and oxygenation of tissues by ABGs within
patients acceptable range and absence of symptoms of respiratory distress.
Participate in actions to maximize oxygenation.

ACTIONS/INTERVENTIONS
Respiratory Monitoring (NIC)
Independent
Assess respiratory rate, depth, and
ease.
Observe color of skin, mucous
membranes, and nailbeds, noting
presence of peripheral cyanosis
(nailbeds) or central cyanosis
(circumoral).
Assess mental status.
Monitor heart rate/rhythm.
Monitor body temperature, as
indicated. Assist with comfort measures
to reduce fever and chills, e.g.,
addition/removal of bedcovers,
comfortable room temperature, tepid or
cool water sponge bath.
Maintain bedrest. Encourage use of
relaxation techniques and diversional
activities.

RATIONALE
Manifestations of respiratory distress
are dependent on/and indicative of the
degree of lung involvement and
underlying general health status.
Cyanosis of nailbeds may represent
vasoconstriction or the bodys response
to fever/chills; however, cyanosis of
earlobes, mucous membranes, and skin
around the mouth (warm
membranes) is indicative of systemic
hypoxemia.
Restlessness, irritation, confusion, and
somnolence may reflect hypoxemia/
decreased cerebral oxygenation.
Tachycardia is usually present as a
result of fever/dehydration but may
represent a response to hypoxemia.
High fever (common in bacterial
pneumonia and influenza) greatly
increases metabolic demands and
oxygen consumption and alters cellular
oxygenation.
Prevents overexhaustion and reduces
oxygen consumption/demands to
facilitate resolution of infection.

ACTIONS/INTERVENTIONS
Respiratory Monitoring (NIC)
Independent
Elevate head and encourage frequent
position changes, deep breathing, and
effective coughing.
Assess level of anxiety. Encourage
verbalization of concerns/feelings. Answer
questions honestly. Visit frequently, arrange
for SO/visitors to stay with patient as
indicated.
Observe for deterioration in condition,
noting hypotension, copious amounts of
pink/bloody sputum, pallor, cyanosis,
change in level of consciousness, severe
dyspnea, restlessness.
Collaborative
Monitor ABGs, pulse oximetry.
Oxygen Therapy (NIC)
Administer oxygen therapy by appropriate
means, e.g., nasal prongs, mask, Venturi
mask.
Prepare for/transfer to critical care setting if
indicated.

RATIONALE
These measures promote maximal
inspiration, enhance expectoration of
secretions to improve ventilation. (Refer to
ND: Airway Clearance, ineffective.)
Anxiety is a manifestation of psychological
concerns and physiological responses to
hypoxia. Providing reassurance and
enhancing sense of security can reduce the
psychological component, thereby
decreasing oxygen demand and adverse
physiological responses.
Shock and pulmonary edema are the most
common causes of death in pneumonia and
require immediate medical intervention.
Follows progress of disease process and
facilitates alterations in pulmonary therapy.
The purpose of oxygen therapy is to
maintain Pao2 above 60 mm Hg. Oxygen is
administered by the method that provides
appropriate delivery within the patients
tolerance.
Intubation and mechanical ventilation may
be required in the event of severe

NURSING DIAGNOSIS: Infection, risk for [spread]

Risk factors may include
Inadequate primary defenses (decreased ciliary action, stasis of respiratory secretions)
Inadequate secondary defenses (presence of existing infection, immunosuppression), chronic
disease, malnutrition
]
Possibly evidenced by
[Not applicable; presence of signs and symptoms establishes an actual diagnosis.]
DESIRED OUTCOMES/EVALUATION CRITERIAPATIENT WILL:
Infection Status (NOC)
Achieve timely resolution of current infection without complications.
Knowledge: Infection Control (NOC)
Identify interventions to prevent/reduce risk/spread of/secondary infection.

ACTIONS/INTERVENTIONS
Infection Control (NIC)
Independent
Monitor vital signs closely, especially during initiation
of therapy.
Instruct patient concerning the disposition of secretions
(e.g., raising and expectorating versus swallowing) and
reporting changes in color, amount, odor of secretions.
Demonstrate/encourage good handwashing technique.
Change position frequently and provide good
pulmonary toilet.
Limit visitors as indicated.
Institute isolation precautions as individually
appropriate.
Encourage adequate rest balanced with moderate
activity. Promote adequate nutritional intake.
Monitor effectiveness of antimicrobial therapy.
Investigate sudden changes/deterioration in condition,
such as increasing chest pain, extra heart sounds,
altered sensorium, recurring fever, changes in sputum
characteristics.
Collaborative
Administer antimicrobials as indicated by results of
sputum/blood cultures: e.g., penicillins: erythromycin
(E-Mycin), tetracycline (Achromycin), doxycycline
hyclate (Vibramycin), amikacin (Amikin);
cephalosporins: ceftriaxone (Rocephin); amantadine
(Symmetrel); sparfloxacin (Zagam); macrolide
derivatives, e.g, azithromycin (Zithromax).

RATIONALE
During this period of time, potentially fatal
complications (hypotension/shock) may develop.
Although patient may find expectoration offensive and
attempt to limit or avoid it, it is essential that sputum
be disposed of in a safe manner. Changes in
characteristics of sputum reflect resolution of
pneumonia or development of secondary infection.
Effective means of reducing spread or acquisition of
infection.
Promotes expectoration, clearing of infection.
Reduces likelihood of exposure to other infectious
pathogens.
Dependent on type of infection, response to antibiotics,
patients general health, and development of
complications, isolation techniques may be desired to
prevent spread/protect patient from other infectious
processes.
Facilitates healing process and enhances natural
resistance.
Signs of improvement in condition should occur within
2448 hr.
Delayed recovery or increase in severity of symptoms
suggests resistance to antibiotics or secondary
infection. Complications affecting any/all organ
systems include lung abscess/empyema, bacteremia,
pericarditis/endocarditis, meningitis/encephalitis, and
superinfections.
These drugs are used to combat most of the microbial
pneumonias. Combinations of antiviral and antifungal
agents may be used when the pneumonia is a result of
mixed organisms. Note: Vancomycin and thirdgeneration cephalosporins are the treatment of choice

ACTIONS/INTERVENTIONS
Infection Control (NIC)
Collaborative
Prepare for/assist with diagnostic
studies as indicated.

RATIONALE
Fiberoptic bronchoscopy (FOB) may
be done in patients who do not
respond rapidly (within 13 days) to
antimicrobial therapy to clarify
diagnosis and therapy needs.

NURSING DIAGNOSIS: Activity intolerance

Risk factors may include
Imbalance between oxygen supply (delivery) and demand
Possibly evidenced by
Weakness and fatigue
Reports of decreased exercise/activity tolerance
Greater need for sleep/rest
Palpitations, tachycardia, increased BP/respiratory response with minor exertion
DESIRED OUTCOMES/EVALUATION CRITERIA PATIENT WILL:
Report an increase in activity tolerance (including ADLs).
Demonstrate a decrease in physiologic signs of intolerance, e.g., pulse, respirations,
and BP remain within patients normal range.

ACTUAL NURSING MANAGEMENT

S

Grabe akong ubo-ubo karon.

Fast breathing RR: 28 cpm

Coughing ineffectively
Abnormal breath sounds presence of crackles
Changes in depth respiration
Little/ no sputum when expectorating
Use of accessory muscles

Ineffective airway clearance related to tracheal bronchial secretion.

Long Term:
At the end of 12 hours rendering nursing care, patient will be able to
understand and capable to do, practice and apply the different nursing
interventions that will help him to breath properly and expectorate the
secretions with the aid of coughing effectively.

INDEPENDENT:
1. Head of the bed elevated, patient turned to sides at intervals. Keeping the head of the
bed elevated lowers the diaphragm, promoting chest expansion, aeration of the lung
segments, mobilization and expectorations to keep airway clear.
2. Deep-breathing exercise assisted. Deep-breathing facilitates maximum expansion of
lungs/smaller airways.
3. Effective coughing performed while in upright position. Coughing is a natural selfcleaning mechanism, assisting the cilia to maintain patent airways and an upright
position favors deeper, more forceful cough effort.
4. Fluid intake especially warm encouraged. Fluid especially warm liquids aid in
mobilization and expectoration of secretion.
5. Do chest tapping. It will help to loosen secretions.
DEPENDENT:
6. Supplemental fluids and humidified oxygen provided. Fluids are required to replace fluid
losses (including insensible) and aid in mobilization of secretions.
7. Administered combivent nebulization q 4 hrs. A bronchodilator relaxes the smooth
muscle.

At the end of 12 hours of rendering nursing care, patient was able to do,
practice and apply the different nursing interventions that will help him to
breathe properly and expectorate the secretions with the aid of coughing
effectively.

Ga lisod jud ko og ginhawa labi na pag maghigda ko tungod sa akong ubo.

Fast breathing RR: 28 cpm

Coughing ineffectively
Abnormal breath sounds presence of crackles
Changes in depth respiration
Little/ no sputum when expectorating
Use of accessory muscles

Impaired Gas Exchange related to altered delivery of oxygen secondary to

pneumonia.

P
At the end of 5 minutes, the patient will be able to breathe properly.

INDEPENDENT:
1. Observed color of skin, mucous membranes, and nailbeds, noting presence of
peripheral cyanosis (nailbeds) or central cyanosis (circumoral). Cyanosis of nailbeds
may represent vasoconstriction or the bodys response to fever/chills; however,
cyanosis of earlobes, mucous membranes, and skin around the mouth (warm
membranes) is indicative of systemic hypoxemia.
2. Maintained bedrest. Encourage use of relaxation techniques and diversional activities.
Prevents overexhaustion and reduces oxygen consumption/demands to facilitate
resolution of infection.
3. Elevate head and encourage frequent position changes, deep breathing, and effective
coughing. These measures promote maximal inspiration and enhance expectoration of
secretions to improve ventilation.
4. Provided humidified oxygen. To facilitate breathing.

At the end of 5 minutes, the patient was able to breathe properly.

VIII. HEALTH TEACHINGS

A. MEDICATION

The patient and his significant other are instructed to

follow the medication ordered by the doctor to be taken at
home. This medication is prescribed to help her to
promote wellness. Patient teachings are also imparted,
regarding on precaution and side effects of the
medications.

B. EXERCISES

Encouraged the patient to perform passive range of

motion exercises and to perform chest physiotherapy in
order to help loosen secretions and promote lung
expansion.

C. TREATMENT

Encouraged the patient to provide adequate rest periods

and observe and promote proper personal hygiene
Encouraged to practice relaxation technique such as
deep breathing, to help control airway clearance.

D. OUTPATIENT

Encouraged the patient to return to the hospital a week

after discharge for a follow-up check-up from Monday to
Friday, from 8:00am to 5:00pm for a follow-up check-up.

E. DIET
The patient is also instructed to take in nutritious food rich
in vitamins and minerals like fruits and vegetables; have a
balanced diet; increased fluid intake, like drinking milk rich
in calcium and water. She is also instructed to increased
fluid intake.

REFERRALS AND FOLLOW-UP

Our further Inpatient care includes monitoring of changes in vital signs, assessment of
effectiveness of treatment regimen, reinforcement of dietary advice, facilitate deep
breathing exercise while in sitting position, cough effectively, practice energy-saving
techniques and do simple activity with rest. Provide ongoing education and
reinforcement while monitoring the patients progress.
Our further Outpatient care includes instructions of our patients dietary modification,
compliance with treatment regimen, and patients participation through reporting of
adverse effects of medications to his physician. The patient as well as its significant
others was also instructed to have a regular check-up at the nearest hospital in their
place in order to monitor his current condition.

EVALUATION AND IMPLICATION

Within the span of 4 days of rendering care to our patient we were able to identify potential
problems and a specific nursing intervention was provided. With the help of our health teachings and
other interventions, our patient as well as to his significant others were able to learn how to
recognize signs and symptoms and other risk factors of his condition.
Significant others were able to verbalize the importance of avoiding too much exposure to
environmental allergens, restricting too much salt in his diet and were encouraged to increase fluid
consumption of their family member. They had also recognized the importance of compliance to
treatment regimen in order to manage his condition. Significant others were able to learn and
verbalized some concerns regarding to the condition of the patient. They were now knowledgeable
and are able to comprehend better.

PROGNOSIS

PROGNOSIS
PROGNOSTIC

GOOD

POOR

INDICATORS
a. Knowledge of disease

conditions
b. Extent of disease
c. Availability of

X
X

medications
d. Attitude and willingness

to take the medications

and follow treatment
regimen
e. Family support

f. Financial support

g. Family history


Knowledge of disease conditions
The patient doesnt have enough knowledge regarding his condition and its possible complication
Extent of disease
Complications would greatly arise if medication and care would have pitfalls. And also, the
willingness of the patient to participate in the treatment regimen would greatly help to improve his
well being.
Availability of medications
The availability of medications was good because they can provide and respond to the prescription
of the physician.
Attitude and willingness to take the medications and follow treatment regimen
The patient takes all his medications and follows all treatment regimens given to him.

Family support
Family support was good because significant others were there to care and assist him in the hospital.
Financial support
Financial support was good because the family can afford since some of his siblings were financially
able and her nephews were employees.
Family history
The present condition of the patient is not influence by heteredo-familial disease.

DOCUMENTATION

PROGNOSIS

XIII. BIBLIOGRAPHY
Nursing2003 DRUG HANDBOOK. 23rd Edition
Brunner & Suddarths Textbook of MEDICAL-SURGICAL NURSING by Suzanne C. Smeltzer and Brenda
G. Bare. 11th Edition
FUNDAMENTALS OF NURSING concepts, process, and practice by Barbara Kozier, Glenora Erb, Audrey
Berman, and Shirlee Snyder. 8th Edition
Website:
(www.UNICEF.org-infobycountry-Philippines)

END
God Bless Everyone..

Liceo de Cagayan University

College Of Nursing
NCM501-205
Related Learning Experience

Case Presentation

Bronchial Asthma in Acute

Exacerbation
January 26, 2011
Group B6
Clinical Instructor
Mr. Andy Roy Salabas RN, MN