Gabales, Audrie Allyson H.

BSN 3F CASE SCENARIO 1 Pneumonia

Physical Assessment
Physical examination performed in an upright position.
Findings:
Decreased breath sounds and with rales/crackles on the left lower lung segments upon
auscultation. Occasional productive cough with yellowish sputum; rapid and shallow
breathing. Appears to look restless and pale. Swollen inflamed throat was noted.
Abdomen, HEENT, skin and extremities are essentially normal. Seen and examined by
ROD.

Past and Present History

Past medical history reveals he is hypertensive. He has been a smoker since he was in
highschool at an early age of18 years old. Consumes 2 sticks of cigarettes per day. Has
pollen allergies and frequently suffers from rhinitis. He works in an office as a
consultant and often works overtime. Due to his nature of work, he is occasionally sent
by the manager as a representative of the company to travel places for any work related
activities.
1 week prior to admission the patient had cough associated with back pain and has poor
appetite. Took over the counter drugs to relieve pain/discomfort. Sought consult and
was requested a chest x-ray. Advised admission due to left lung field infiltration.
Admission care rendered by ER Nurse.

Symptoms Manifested
• High grade fever
• Chills
• Difficulty of breathing
• Decreased breath sounds with rales/crackles on the left lung
• Occasional productive cough (yellowish)
• Rapid and shallow breathing
• Restless and pale
• Swollen and inflamed throat
• Back pain
Significance Findings/ Diagnostic Findings
His laboratory results shows: Chest x-ray PA view- left lower lobe infiltration,
Sputum culture and sensitivity positive for Streptococcus Pneumoniae.
HEMATOLOGY RESULT
Lab Exam Result Normal Values Significance
WBC Count 23.84 3.6-11.0
RBC Count 4.98 4.2-5.9
Hemoglobin 150 135-175
Hematocrit 0.45 0.40-0.54
Platelet 200,000 150,000-450,000
Neutrophils 0.83 2.0-7.5
Lymphocytes 0.09 1.5-4.5
Monocytes 0.01 0.2-0.8
Eosinophil 0.01 0-0.4
Basophils 0.1 0-0.01

URINALYSIS
Exam Result Normal Values Significance
Color Straw Yellow (light/pale
to dark/deep
chamber)
Transparency Hazy Clear or cloudy
pH 5.0 4.5-6
Sp Gravity 1.015 1.005-1.025
Albumin Negative Negative
Sugar Negative Negative

Impression: CAP-MR, left lower lung considered

Pathophysiology

Community Acquired Pneumonia

Bacteria: Streptococcus Pneumoniae

Predisposing Factors Precipitating Factors
Hypertensive Male
Chain Smoker 58 years old
Pollen Allergies

Suffers from rhinitis

Weak immune system

Chain smoker

Cough, back pain, poor appetite.

Growth and development of
Streptococcus Pneumoniae.

Organism enters the respiratory tract

through inspiration/aspiration

Acute inflammation occurs that

causes excess water and plasma
proteins go to the dependent areas of
the lower lobes.

Stage of congestion:

Engorgement of alveolar spaces with

fluid and hemorrhagic exudates.

Stage of gray hepatization:

The decrease in number of RBC in the

exudates is replaced by neutrophils.

PNEUMONIA
Laboratory Result
Hematology Result:
• WBC Count: 23.84
• RBC Count: 4.98
• Hemoglobin: 150
• Hematocrit: 0.45
• Platelet: 200,000
• Neutrophils: 0.83
• Lymphocytes: 0.09
• Monocytes: 0.01
• Eosinophils: 0.01
• Basophils: 0.1

Urinalysis:
• Color: Straw
• Transparency: hazy
• pH: 5.0
• Sp Gravity: 1.015
• Albumin: Negative
• Sugar: Negative

Medical and Surgical Management

Mr. Roque was treated with IV fluids, antibiotics and oxygen therapy.
• Paracetamol
• Azithromycin
• Piperacillin + Tazobactam
• Losartan K
• Sodium Ascorbate + Zinc
• Acetylcysteine
• PAI with Salbutamol sulfate
Monitor vital signs; increase fluid intake; activity as tolerated.
Nursing Care Plan
Defining Nursing Outcome Nursing Rational Evaluation
Characteristics Diagnosis Identification Interventio e
n
Subjective: Short Term: Independen Short term:
Ineffecti After 8hrs of t: After 8hrs of
“Ga kurog gid ve nursing nursing
ako sang airway interventions, Monitor Provides interventions,
katugnaw sang clearanc the patient rate, a basis patient was
akon e related will be able to rhythm, for able to
pamatyag” as to think expectorate depth, and evaluati expectorate
verbalized by sputum or clear effort of ng or clear
the patient. secondar secretions respirations
adequac secretions
y to readily. y of readily.
“Nabudlayan pneumon ventilati
ako ia as Long Term: on. Long Term:
magginhawa” evidence After 1 week Presenc After 1 week
d by of nursing Note chest e of of nursing
Objective: adventiti interventions, movements nasal interventions,
• T: 38.5 ous the patient , watch for flaring the patient
degrees breath will be able to symmetry, and use was able to
• RR: sounds maintain use of of maintain
28cpm and airway accessory accessor airway
• O2 sat: yellow patency by muscles, y patency by
90% sputum. showing: and muscles showing:
• Looks • Normal supraclavic of • Normal
restless breath ular and respirati breath
and pale sounds intercostal ons may sounds
• Inspirato when muscle occur in when
ry auscult retractions. response auscult
rales/cr ated to ated.
ackles • Respira ineffecti • Respira
with tory ve tory
diminish rate of ventilati rate of
ed 16-20 on. 16-20
breath breaths Elevate To take breaths
sounds /min head of the advanta /min
when • Looks bed/chang ge of • Looks
ausculta rested e position gravity rested
ted and every 2 hrs decreasi and
• Yellow regaine and prn ng regaine
sputum d color pressure d color
is on the
present diaphrag Goals met.
with m.
occasion Dependent:
al Administer To help
coughing ordered loosen
. medication and
s such as clear
mucolytic the
agents, mucus
bronchodila from the
tors and airways;
expectoran decreas
ts. e
resistan
ce in the
respirat
ory
airway
and
Administer increase
nebulizatio airflow
ns as to the
needed lungs.
To open
constrict
ed
airways
and
liquefy
secretio
ns.
 ILOILO DOCTORS’ COLLEGE
COLLEGE OF NURSING
West Avenue, Molo, Iloilo City

DRUG STUDY

Drug Name Classification and Indications and Side Effects and Adverse Special Precautions Nursing Responsibilities
Mechanism of Action Contraindications Effects
• CNS: headache • Liver toxicity • Do not exceed 4gm/24hr.
Generic Name: Classifications Indications: • CV: chest pain, (hepatocyte necrosis) in adults and 75mg/kg/day
Paracetamol Analgesic Temporary reduction of dyspnea, myocardial may occur with doses not in children.
Antipyretic fever, temporary relief of damage far beyond labeled • Do not take for >5days for
minor aches and pains • GI: hepatic toxicity dosing. pain in children, 10 days
caused by common cold and failure, jaundice • If 3 or more alcoholic for pain in adults, or more
and influenza, headache, • GU: acute renal drinks per day are than 3 days for fever in
Trade/ Brand Name: sore throat, toothache, failure, renal tubular consumed, consult a adults.
Not stated in the case backache, menstrual necrosis physician prior to use. • Extended-Release tablets
scenario cramps, etc. • Hematologic: are not to be chewed.
methemoglobinemia- • Monitor CBC, liver and
cyanosis renal functions.
• Hypersensitivity: rash • Assess for fecal occult
Dosage: Actions: Contraindications and fever blood and nephritis.
500mg/tab Reduces fever by acting • Contraindicated with • Avoid using OTC drugs
directly on the allergy to with Acetaminophen.
hypothalamic heat- acetaminophen. • Take with food or milk to
regulating center to cause • Use cautiously with minimize GI upset.
Route: vasodilation and sweating, impaired hepatic • Report N&V. cyanosis,
Oral which helps dissipate heat. function, chronic shortness of breath and
alcoholism, pregnancy, abdominal pain as these
lactation are signs of toxicity.
• Report paleness,
Frequency and Timing
weakness, and heartbeat
Q4H for 24hrs, PRN
skips
• Report abdominal pain,
jaundice, dark urine,
itchiness or clay-colored
stools.
• Phenmacetin may cause
 urine to become dark
brown or wine-colored.
• Report pain that persists
for more than 3-5 days
• Avoid alcohol.
• This drug is not for
regular use with any form
of liver disease.

Drug Name Classification and Indications and Side Effects and Adverse Special Precautions Nursing Responsibilities
Mechanism of Action Contraindications Effects
• diarrhea or loose • Call your doctor right • Culture site of
Generic Name: Classifications Indications: stools, away if you or your child infection before
Azithromycin Macrolide Antibiotics • Pertussis • nausea, have a rash, itching,
therapy.
• Penicillin allergic • abdominal pain, hives, hoarseness, trouble
• Administer on an
rheumatic fever • stomach upset, breathing, trouble
prophylaxis • vomiting, swallowing, or any empty stomach 1 hr
Trade/ Brand Name: • Campylobacter • constipation, swelling of your hands, before or 2–3 hr
Not stated in the case • Uncomplicated genital • dizziness, face, or mouth after you after meals. Food
scenario take this medicine.
infections • tiredness, affects the
• Drug resistant enteric • Check with your doctor
• headache, absorption of this
fever right away if you or your
Actions: • vaginal itching or drug.
• Chlamydial child have blistering,
Dosage: Blocks transpeptidation by Trachomatis Infection
discharge,
peeling, or loosening of • Prepare by adding 60
• nervousness,
500mg binding to 50s ribosomal • Cat Scratch Disease the skin, red skin lesions, mL water to bottle,
subunit of susceptible • sleep problems
• Mycobacterium avium (insomnia),
severe acne or skin rash, shake well.
organisms and disrupting sores or ulcers on the
Route: RNA-dependent protein
complex • skin rash or itching, • Counsel patients
skin, or fever or chills
• Chancroid • ringing in the ears, being treated for
Oral synthesis at the chain while you are using this
elongation step. • Babesiosis • hearing problems, STDs about
medicine.
• Yersinia • or decreased sense of appropriate
pseudotuberculosis
Frequency and Timing
infections
taste or smell. precautions and
OD for 7 days
• Mycoplasma additional therapy.
pneumonia

Contraindications
Patients with known
hypersensitivity to
 azithromycin, or any other
macrolide and in hepatic
disease. Use caution in
renal failure

Drug Name Classification and Indications and Side Effects and Adverse Special Precautions Nursing Responsibilities
Mechanism of Action Contraindications Effects
• Diarrhea • Check with your doctor • Monitor signs of
Generic Name: Classifications Indications: • Bladder Pain right away if you notice pseudomembranous
Piperacillin/Tazobactam Extended spectrum Indicated for adults for the • Bloating and swelling any usual bleeding or colitis, including diarrhea,
penicillins treatment of uncomplicated of the face, arms, bruising, black, tarry abdominal pain, fever, pus
and complicated skin and hands, lower legs, or stool, or pinpoint red or mucus in stools and
Trade/ Brand Name: skin structure infection, feet spots on your skin. other severe or prolonged
Not stated in the case including cellulitis, • Blurred vision • Bloody urine, a decrease GI problems (nausea,
scenario cutaneous abscesses and • Burning upper in frequency or amount vomiting, heartburn).
ischemic/diabetic foot abdominal or stomach of urine, an increase in
infections caused by beta- pain blood pressure, increased
lactamase producing • Changes in urination thirst, loss of appetite,
Dosage: isolates of Staphylococcus lower back or side
• Chest pain
1 vial via soluset Actions: aureus. breathing, unusual
• Confusion
The beta-lactamase tiredness or weakness,
inhibitors are recognized as vomiting or weight gain.
Route: substrates for the beta- Contraindications:
IV lactamases produced by • Diarrhea from an
bacteria. This allows the infection with
actual beta-lactams to Clostridium
Frequency and Timing attack the bacterial cell difficile bacteria
Q4H ANST wall by binding to • Low amount of
penicillin binding proteins. potassium in the
blood
 • Increased risk of
bleeding due to
clotting disorder
• Seizures
• A significant drop
in a certain type of
white blood cell
(neutrophil)

Drug Name Classification and Indications and Side Effects and Adverse Special Precautions Nursing Responsibilities
Mechanism of Action Contraindications Effects
• Light headedness • Fetal Toxicity • Monitor BP
Generic Name: Classifications Indications: • Pain or burning • Hypotension in volume- • Monitor patients who are
Losartan K Angiotensin II receptor Hypertension sensation when you or salt depleted patients also taking diuretics for
antagonists Nephepatically in type 2 urinate • Renal Function symptomatic hypotension.
diabetic patients • Nausea Deterioration • Assess patients renal
• Weakness • Hyperkalemia function
Trade/ Brand Name: • Tingly feeling
Not stated in the case Contraindications • Chest Pain
scenario Patients hypersensitive to
• Irregular heartbeats
drugs, breast-feeding is not
• Loss of movements
recommended, causes fetal
• Little or no urination
and neonatal morbidity and
Dosage: Actions: death • Rapid weight gain
50mg/tab Inhibits vasoconstrictive • Swelling in your
and aldosterone secreting hands, feet or ankles
action of angiotensin II by
Route: blocking angiotensin II
Oral receptor on the surface of
vascular smooth muscle
and other tissue cells.
Frequency and Timing
OD
 Drug Name Classification and Indications and Side Effects and Adverse Special Precautions Nursing Responsibilities
Mechanism of Action Contraindications Effects
• N&V • Present ascorbic acid • Give medication with
Generic Name: Classifications Indications: • Heartburn allergy or any ingredients right timing
Sodium Ascorbate/Zinc Vitamins Dietary Supplement • Diarrhea • Usage of tobacco • Inform patient about he
Frank and subclinical • Acute Hemolytic products possible side effects
scurvy Anemia • If pregnant and • Instruct patient to be
Extensive burns, delayed • Head ache breastfeeding cautious of the
Trade/ Brand Name: fracture or wound healing, contraindications of the
Not stated in the case severe febrile or chronic drugs.
scenario disease states

Contraindications:
Actions: Use of sodium ascorbate in
Dosage: Increases protection patients on sodium
500mg/10mg tab mechanism of the immune restriction
system, thus supporting Use of calcium ascorbate
wound healing. on patient receiving
Route: digitalis.
Oral

Frequency and Timing

OD after breakfast
 Drug Name Classification and Indications and Side Effects and Adverse Special Precautions Nursing Responsibilities
Mechanism of Action Contraindications Effects
• Fever • Not for injection • Observe 10 rights of drug
Generic Name: Classifications Indications: • Drowsiness administration
Acetylcysteine N-acetylcesteine, Mucolytic therapy • Abnormal thinking • Use plastic, glass,
Mucomyst Management of • Gait disturbances stainless steel, or another
acetaminophen overdose • Tachycardia nonreactive metal when
• Hypotension giving by nebulization.
Trade/ Brand Name: • Hypertension • Drug is physically or
Not stated in the case Contraindications chemically incompatible
• Flushing
scenario Patients with with tetracyclines
• Chest tightness
hypersensitivity to the drug erythromycin
Use cautiously in elderly or lactobionate, amotericin
debilitated patients with B, and ampicillin sodium.
Dosage: Actions: severe respiratory
600mg 1 effervescent tablet Mucolytic that reduces the insufficiency.
viscosity of pulmonary Use IV carefully in patients
secretions by splitting with asthma or history of
Route: disulfide linkages between bronchospasm.
Oral mucoprotein molecular
complexes. Also, restores
liver stores of glutathione
Frequency and Timing to treat acetaminophen
OD HS toxicity.
 Drug Name Classification and Indications and Side Effects and Adverse Special Precautions Nursing Responsibilities
Mechanism of Action Contraindications Effects
• Nervousness • Cardiac Disease • Assess lung sounds, PR
Generic Name: Classifications Indications: • Restlessness including coronary and BP before drug
Albuterol Bronchodilators To control and prevent • Tremor insufficiency, a history of administration and during
reversible airway • Headache stroke, coronary artery peak of medication.
obstruction caused by • Insomnia disease and cardiac • Administer PO medication
asthma or COPD • Chest Pain arrhythmias with meals to minimize
Trade/ Brand Name: Quick relief for
• Palpitations • Hypertension gastric irritation
PAI with Salbutamol sulfate bronchospasm
• Angina • Hyperthyroidism
• Arrhythmias • Diabetes
• Hypertension • Glaucoma
Contraindications • Geriatric Patients
Dosage: Actions: Hypersensitivity to
1mg/ml 1 nebule Relieves nasal congestion adrenergic amines
and reversible Hypersensitivity to
bronchospasm by relaxing fluorocarbons
Route: the smooth muscles of the
Nebulizer bronchioles.

Frequency and Timing

TID
Discharged Plan
Seek care immediately if:
• You cough up blood
• Your heart beats more than 100 beats in 1 minute
• You are very tired, confused and cannot think clearly
• Your lips or fingernails turn gray or blue
Medicines:
• Take your medicine as directed
• Make sure to not skip as it may cause overdosage
Follow up with your doctor as directed.
Manage your symptoms:
• Rest as needed
• Drink liquids as directed
• Do not smoke
• Limit alcohol
• Use a cool mist humidifier
• Keep your head elevated