UNIVERSITY OF SOUTHERN PHILIPPINES FOUNDATION

COLLEGE OF HEALTH SCIENCES

DEPARTMENT OF NURSING
Salinas Drive, Lahug Cebu City

na

A Care of a 72 year old Patient with

Acute Respiratory Failure Secondary to
Pneumonia

Submitted by:

Marie Ashley E. Casia

BSN - IV

Clinical Instructor:

Mr. Peter Arnold T. Tubayan, RN, MAN, PHD

 TABLE OF CONTENTS

i. Title Page i
ii. Table of Contents ii
A. Introduction 1
B. Patient's Profile 4
C. Patient History
a) History of Present Illness 5
b) Past Health History 5
c) Family Health History 5
d) Environmental History 6
D. Developmental Task 7
E. Health Assessment 9
F. Physical Examination 15
G. Laboratory and Diagnostic Studies 24
H. Summary of Significant Findings 27
I. Anatomy and Physiology 29
J. Pathophysiology 32
K. Nursing Care Plan
NCP # 1 35
NCP # 2 48
NCP # 3 60
L. Discharge Plan 73
M. Health Teaching / Teaching Plan
HTP #1 77
HTP #2 81
HTP #3 88
N. Drug Study
DS # 1 91
DS # 2 93
DS#3 96
DS#4 98
DS#5 100
O. Bibliography 102
 1

INTRODUCTION

As stated by the National Institute of Health, Respiratory failure is a serious condition

that makes it difficult to breathe on your own. Respiratory failure develops when the lungs can’t

get enough oxygen into the blood. Our lungs take in oxygen from the outside air, and we exhale

carbon dioxide, a waste product of the body's cells. The act of breathing is necessary for life. For

our tissues and organs to function correctly, oxygen must travel from our lungs into our blood.

The accumulation of carbon dioxide can harm the body's cells and organs and hinder or delay the

transport of oxygen.Acute respiratory failure strikes suddenly and with little notice. It is

frequently brought on by a condition or illness that impairs your ability to breathe, such as

pneumonia, an opioid overdose, a stroke, a lung damage, or a spinal cord injury. Respiratory

failure can also develop slowly. When it does, it is called chronic respiratory failure. Symptoms

include shortness of breath or feeling like you can’t get enough air, extreme tiredness, an

inability to exercise as you did before, and sleepiness. A doctor may diagnose you with

respiratory failure based on the oxygen and carbon dioxide levels in your blood, a physical exam

to see how fast and shallow your breathing is and how hard you are working to breathe, as well

as the results of lung function tests. If you are diagnosed with a serious lung disease such as

respiratory failure, you may need extra oxygen through tubes in your nose or support with a

breathing machine called a ventilator.

In accordance with Cedars Sinai, Acute respiratory failure in relation with aspiration

pneumonia, is when aspiration is when something enters your airway or lungs by accident. It

may be food, liquid, or some other material. This can cause serious health problems, such as

pneumonia. Aspiration can happen when you have trouble swallowing normally. The pharynx is

also part of the system that brings air into your lungs. When you breathe, air enters your mouth
 2

and moves into the pharynx. The air then goes down into your main airway (trachea) and into

your lungs. A flap of tissue called the epiglottis sits over the top of the trachea. This flap blocks

food and drink from going down into the trachea when you swallow. But in some cases, food or

drink can enter the trachea causing aspiration. Stroke is a very common cause of both dysphagia

and aspiration. About half of people who have had a stroke also have dysphagia. A major

complication of aspiration is harm to the lungs. When food, drink, or stomach contents make

their way into your lungs, they can damage the tissues there. The damage can sometimes be

severe. Aspiration also increases your risk of pneumonia. This is an infection of the lungs that

causes fluid to build up in the lungs. Pneumonia needs to be treated with antibiotics. In some

cases, it may cause death. About one-third of these people will need treatment for pneumonia at

some point.

Based on the NIH, Acute respiratory failure ranges in incidence from 10-80/100,000/y

based on where it is recorded worldwide.This is partly due to different practices and thresholds

for intubation in these cases and the use of different definitions of ARDs. According to one

report, it is estimated that 10% of all patients admitted to ICU and 23% of mechanically

ventilated patients meet ARDS criteria.

Two hundred thirty-nine episodes of acute respiratory failure were studied prospectively

in 146 patients with chronic respiratory insufficiency during 4 years. Survivors were followed

from 6 to 48 months. Patients survived 68% of episodes. Sixty percent of patients survived the

initial episodes of respiratory failure, and 55% were alive after 6 months. During the next 2 years

the mortality of these patients was high so that only 20% survived 30 months, and the same

percentage survived 48 months. (Kilburn,2018)

 3

In the Philippines, More than 300,000 cases of acute respiratory infection have been

recorded in the country in the first six months of this year, the Department of Health (DOH)

reported. Data showed that during the second quarter of 2022, a total of 340,031 people suffered

from acute respiratory infection.(Villanueva, 2022).

This case study aimed to impart knowledge to the student nurses regarding Acute

Respiratory Failure secondary to Aspiration Pneumonia and ways to restore or maintain a

patient's health status utilizing a holistic approach to promoting and rehabilitating nursing

managements. The researcher chose this case study topic because Respiratory Failure is the

leading cause of death among adult patients here in the Philippines. Also, this would help them

learn how to provide holistic and effective care to a pediatric patient with respiratory failure

secondary to aspiration pneumonia in the future as nursing care focuses mainly on maintaining

and improving respiratory function, support for the recuperative process, and preventing further

complications.
 4

PATIENT’S PROFILE

Name: J T

Age: 72 year old

Sex: Male

Status: Married

Address: Alaska, Mambaling Cebu City

Name of Hospital: Cebu City Medical Center

Date of Admission: September 20, 2023

Case N: 551725

Ward and Bed No: Adult Pulmonary Ward – 08

Chief Complaint: Dyspnea

Medical Diagnosis: Acute Respiratory Failure secondary to Aspiration Pneumonia

 5

PERTINENT NURSING HEALTH HISTORY & PHYSICAL ASSESSMENT

HISTORY OF PRESENT ILLNESS

On September 20, 2023, hours prior to admission, the patient had sudden onset of
dyspnea after taking milk via nasogastric tube feeding. At 4 AM, they were transferred to the
adult pulmonary ward as the patient was showing dyspnea.

PAST HEALTH HISTORY

The patient was hospitalized in Cebu City Medical Center last August 24, 2023 and
diagnosed with Stroke Hypertension Stage 2. He is placed in the medical ward. The patient was
in and out of the hospital as stated by the S.O.

FAMILY HISTORY

The patient’s father and mother is hypertensive. Her daughter is also hypertensive.
GENOGRAM
 6

ENVIRONMENTAL HISTORY

The patient is living in a congested neighborhood in Mambaling away from the main
street. The S.O claimed that the patient is a heavy smoker and keeps on smoking cigarettes inside
and outside their house. Most of the time they fight because her husband doesn’t listen to her.
Also, their environment is not very sanitary as they live in a slums area; there are open canals
and garbage scattered everywhere.
 7

DEVELOPMENTAL TASK

In ages 65- death , Erik Erikson believed that in this group of age, older adulthood face the

stage Integrity vs Despair wherein Erikson’s theory suggests that people pass through eight

distinctive developmental stages as they grow and change through life. Integrity vs Despair is

the last stage in Erik Erikson's theory of psychosocial development. Integrity vs. despair

involves a retrospective look back and life and either feeling satisfied that life was well-lived

(integrity) or regretting choices and missed opportunities (despair). In order to understand this

stage, it is important to first understand what Erikson meant by integrity and despair. (Cherry,

2023).

From the age of about 65 years, individuals face the last of eight psychosocial crises, namely

a crisis concerning achieving a sense of ego integrity while avoiding despair. During this crisis,

elderly reflect on their life in an attempt to unify past events into a meaningful “life puzzle” and

they come to terms with past negative events. When successful, individuals will experience a

sense of ego integrity, where they can accept past events, see their life in a coherent perspective,

and regard death as a natural and integral part of life. Despair, on the other hand, is concerned

with difficulties in accepting and finding wholeness in one’s own life path and often comes with

high levels of regret. Although most studies focused solely on ego integrity, several studies have

shown that ego integrity and despair are not mere opposites. When elderly do not feel desperate

about life choices that were made, they have not necessarily achieved a sense of ego integrity.

Demonstrating the distinction between both orientations, they were found to develop differently

across time, with ego-integrity increasing particularly between early midlife (age 43) and late life

(age 72) and with despair increasing from age 43 to age 53 and then decreasing until the age of

72 (Newton et al. 2019).

 8

Although the crisis of ego integrity and despair becomes especially salient during late

adulthood, it can also surface when older individuals are confronted with challenging contexts

and events, such as the loss of loved ones and illness (Kivnick and Wells 2018).

Patient J T is a 72 year old approaching the end of his psychosocial stage of development.

The patient builds a good relationship with his family and his community. He is a supportive

father to his children. He always prioritizes their needs and always finds time to bond with them.

He has a very united relationship with his wife and is very satisfied with his life with her.

Therefore, the patient achieved integrity through parenting and mentorship and creative pursuits

through his work as a staff admin.

 9

HEALTH ASSESSMENT

Gordon’s Functional Health Patterns

Table 1

Gordon’s Functional Health Patterns

Functional Health Pattern Before Hospitalization During hospitalization

1. Health Perception and According to S.O, The patient was active for The patient is attached to NGT - OD. He is
Health maintenance his age. The patient is also hypertensive.He attached to an ETT to protect airway from
does have medications for health aspiration. Most of the time he was asleep.
maintenance such as losartan and Currently, patient has #2 1L PNSS @ 30 gtts/min
amlodipine. and Norepinephrine drip @ 5 mL/hr.

The patient goes to any health facilities for The S.O verbalized that the patient experienced
health check-ups. He was admitted to the difficulty in breathing every time he speaks or
CCMC medical ward last August 24, 2023. during minimal movements or even at rest.
The patient smokes at least 5 sticks per day
and drinks alcohol at least twice per week. During the shift, the patient is ordered to take
carvedilol at 12.5 mg/tab via NGT because his BP
According to S.O, He wasn’t sure if he is high.
received a complete vaccination when he
was a kid. Also, he was vaccinated against
COVID-19.
 10

Table 1

Gordon’s Functional Health Patterns (continued)

2. Nutritional - Metabolic According to S.O, The patient eats all kinds The patient is on NGT .
of foods with a good appetite. He has no food
allergies. Also, he has no difficulties with On September 21, 2023, the patient was on a
eating and swallowing. Blenderized diet with restrictions on salty and
fatty foods.
Most of the time, the foods he eats depends
on the foods that his wife cooks for the
family. He usually eats pork and chicken. He
usually had his breakfast at 5 AM, lunch at 12
Nn, and dinner at 6 PM. Also, he drinks at
least 6 glass of water per day.

3. Elimination The patient stated that he has no problem with On September 21, 2023, the patient was attached
urination and defecation. He voids 3-5 times a to FBC – with UDB. Urine amount of 20 cc from
day, estimated to have 210mL per urination 2 pm – 10 pm, dark yellow in color. The patient
with yellow color. He defecates once a day wears a diaper and has not defecated during the
with brown, well-formed stool measuring shift.
about 1 ½ cup (360 mL).
 11

Table 1

Gordon’s Functional Health Patterns (continued)

4. Activity and Exercises According to S.O, The patient does not have The patient is on complete bed rest without toilet
enough exercise everyday. Furthermore, he privilege.
can independently perform ADLs and other
activities he desires but not extraneously.

He drinks alcohol (redhorse) at least once a

week and smokes at least 5 sticks per day.

5. Sleep and Rest The patient sleeps at around 7 PM and wakes The patient sleeps most of the time at the ward.
up at 5 AM. He rests when he has time. He He was also on complete bed rest without toilet
usually sleeps 8-10 hours per day. He has no privilege.
problem with sleep such as insomnia; and has
never used any sleeping aids and sedatives to
rest.
 12

Table 1

Gordon’s Functional Health Patterns (continued)

6. Cognition and perception According to S.O, Patient has blurry vision GCS = 11. The patient is lethargic,coherent,
and depends on wearing his eyeglasses.The oriented and responsive. He can’t comprehend
patient can also hear properly. He does and can’t communicate well but he could hear
understand many things and asks for and see well (short distance).
clarifications.

7. Self-perception and According to S.O, The patient described The patient has difficulty moving due to his
self-concept himself as a kind and responsible father, and condition but the patient’s S.O is very supportive
husband. Though, he also said that he wasn’t of him and hopes that he will recover soon.
that strong anymore compared to before
because of his old age.

Also, he respects everyone and shows

kindness towards others.
 13

Table 1

Gordon’s Functional Health Patterns (continued)

8. Sexuality and The patient is married. He has 2 children but The patient is in complete bed rest without toilet
Reproduction only 1 are currently living because the eldest privilege. His wife takes care of him at the
is living in Manila. Also,he has a close bedside.
relationship with his wife but the patient’s
S.O said he doesn’t have a very active sex
life anymore because of his age.

9. Roles and Relationship According to S.O, The patient is a loving The patient was cared for by his wife at the
husband to his wife, a good father to his bedside. However, all of the members in the
children. He had a close and good family support him in his recovery journey.
relationship with his family. He works as a
government employee, specifically a staff
admin. He is not the breadwinner of the
family. Her wife and children are the ones
working to provide food on their table and
pay their monthly bills.
 14

Table 1

Gordon’s Functional Health Patterns (continued)

10. Stress and tolerance The patient doesn’t get stressed easily. He coped up his stress by sleeping .
coping However, if he gets stressed, he just goes
outside to get some fresh air or talk with his
neighbors. He also drinks alcohol or smokes
if he can’t handle too much stress sometimes.
11. Values and Belief The patient is a Roman Catholic. He goes at The patient prays to the Lord for faster recovery.
the Chapel near their house alone or with his
family every Sunday. His goal is to provide
continued support to his family and make
them happy.
 15

PHYSICAL EXAMINATION
Table 2. Physical Examination
ASSESSMENT DATA NORMAL FINDINGS ABNORMAL FINDINGS MANIFESTED BY
MANIFESTED BY THE PATIENT THE PATIENT
GENERAL SURVEY
INSPECTION Received patient lying supine on bed, asleep, and
conscious; with on going IVF #2 PNSS 1L at
120cc/hr, with Norepinephrine drip at 5ml/hr, with
Endotracheal tube size 7.5 at 22 cm lip level in
place, attached to mechanical ventilator, with NGT
place at left nostril, with FBC in place attached to
urobag, Crackles noted upon auscultation.
PALPATION Patient has a baseline VS of T: 35.7 c; P: 110 Patient has a baseline VS of BP 150/90 mmhg, HR
bpm; & R: 37 cpm. of 46 bpm.
SKIN, HAIR AND NAILS
INSPECTION • Skin is evenly brownish-colored, not pale, Skin is dry and pale
moist.
• Surrounding skin around the stoma is dry
and free from any signs of infections.
• Hair is black and is evenly distributed. No
dandruffs and lice noted.
 16

• Nails are clean and kept short with pink Nails are long and dirty.
tones at 160-degree angle between the nail
base and skin. No signs of clubbing noted.

PALPATION • Skin is moist, soft and not warm to touch. Skin is dry,soft and cold to touch.
• Good skin turgor
• Scalp is smooth and oily and there were
no lesions noted. Poor skin turgor noted

• The nails are hard and immobile. Nails are

smooth and firm
• CRT 2 sec
• Patient withdraws from painful stimuli

HEAD, NECK AND CERVICAL LYMPH NODES

INSPECTION • Head is hard and smooth. Head size is
symmetric, round and in midline with no
involuntary movements.
• The neck is symmetric, with head
centered and without bulging masses.
 17

• No lesions and swelling noted on the

neck. Patient is able to freely move his
neck.
• There is no presence of lesions in both
head and neck

PALPATION • Temporal artery is palpable (2+) bilateral

• Full ROM of the neck
• Trachea is midline
• Thyroid was non palpable and no
enlargements noted
• Carotid pulse is palpated with strong
bounding pulse
• The temporomandibular joint has no
swelling.
• The preauricular, tonsillar, submandibular,
submental, superficial, posterior, deep
cervical chain, and supraclavicular nodes
of the neck are not palpable.

AUSCULTATION • Carotid arteries no blowing or swishing

sound

MOUTH, NOSE AND SINUSES

 18

INSPECTION • Complete set of teeth, with minimal dental • Incomplete set of teeth noted with dental carries.
caries noted. • Lips were pale, dry, and with minimal cracks.
• Oral mucosa is not pale and dry. No
lesions were noted.
• Gingiva is pink and dry. No lesions and
bleeding noted. No inflammation noted
• Tonsils not swollen.
• Nose is symmetrical with the nasal septum
at the midline.

• No lesions and ulcerations noted on the

mouth
• No lesions and masses noted on the nose
• Nasal tenderness not noted.
PALPATION • Sinuses are non-tender and are trans
illuminated by the penlight.
• Frontal and maxillary sinuses tenderness
can’t be assessed. No crepitus is evident.

EYES AND EARS

INSPECTION • Iris is black in color.
• Sclera is cloudy white in color.
• Cornea is moist.
 19

• Eyelashes are evenly distributed and curls

outward.
• No lesions noted on the ears and the skin
is intact.
• Ears are not aligned.
• Size of ears are symmetrical and
proportional to the head.
• Ear canal is brownish in color
• PERRLA

PALPATION • No palpable masses noted on the ears

• The auricle, tragus and mastoid processes
tenderness not noted.

THORACIC AND LUNGS

INSPECTION • Side to side symmetric chest shape • Ineffective Airway clearance noted.
• Irregular respiratory rate & pattern not • Presence of productive cough
noted • Orthopnea
• The thorax is the same color as the rest of • Ineffective coughing
the body with no presence of lesion.
 20

• Equal Chest Expansion noted

• No retractions or bulging of ICS are
noted.

PALPATION • No lumps and nodules felt upon palpation.

Tenderness not noted.

AUSCULTATION Presence of crackles on bilateral lower lobes of the

lungs

CARDIOVASCULAR
INSPECTION • Jugular Venous pulse is not visible and
distended
• No prominent venous patterns on the
peripheral extremities

PALPATION • Extremities are bilaterally symmetrical

• Extremities are equally not warm to touch
• Extremities have equal bilateral pulse
strength (2+)
 21

AUSCULTATION • Pulse rate is 110 bpm Pulse rate at 46 bpm

• No blowing and swishing sounds noted on
jugular arteries
• Irregular heart rhythm
• Audible heart sound Absence of extra
heart sound

BREAST
INSPECTION • Patient’s breast is symmetrical and round
in shape
• The areola is rounded with dark brown in
color.
• Nipples are round, same size and equal in
color.
• Flat chest

PALPATION • No lesions and masses noted

• Axillary lymph nodes were not palpable

ABDOMEN
INSPECTION • Umbilicus is located midline
• Skin not pale.
• No ascites noted.
 22

PALPATION • Abdomen soft upon palpation

• No masses noted
• No Tenderness noted.

AUSCULTATION • Active bowel sound noted on all 4

quadrants

GENITOURINARY-REPRODUCTIVE
INSPECTION • No Pubic hair noted
• No swelling of Penis noted.
• No swelling of Testes noted.
• Scrotum not swollen.

MUSCULOSKELETAL
INSPECTION • Both upper extremities are equal in size.
• Both lower extremities are equal in size
• Have the same contour with prominences
of joints.
• No involuntary movements noted
• Has equal contraction and is even.
 23

PALPATION • Temperature is not warm and even.

• No Tenderness noted.
• No crepitus noted on joints.
• Full ROM noted
• Sensations are intact.
• CRT = 2 sec

NEUROLOGIC
INSPECTION • Sensations are intact.
• GCS = 15
GCS=11

PALPATION • Reflexes present.

• Plantar grasp reflex noted.
• Temporal Artery pulse is present (2+)
 24

LABORATORY AND DIAGNOSTIC STUDIES

Clinical Chemistry
Table 3

Clinical Chemistry Result

Test Name Result Unit Reference Range Interpretation

(September
20, 2023 @
9:23 PM)
Creatinine 2.32 H mg/dL 0.7-1.3 High. This indicates poor
kidney function often
lead to hypoxemia and
hypercapnia, both of
which affect renal blood
flow and can lead to
direct renal ischemia
and subsequent
injury.(Arikan,2021)
BUN 35.7 H mmol/L 3.5-5.0 High. Higher BUN levels
indicate overhydration,
liver disease, or
malnutrition
(Healthwise, 2021).

SGPT 4.65 H mmol/L 135-148.0 High. When the liver is

SGOT 5.74 H not functioning properly,
blood vessels in the
lungs may dilate. If this is
severe enough, the lungs
can lose their ability to
 25

effectively transfer
oxygen to the body
(NORD,2023).
High. When the liver is
not functioning properly,
blood vessels in the
lungs may dilate. If this is
severe enough, the lungs
can lose their ability to
effectively transfer
oxygen to the body.
(NORD,2023).

Resting ECG

Date: September 20, 2023

Time: 21:08:02
HR 92 bpm RR 655 ms Sokolow 2.73 mV
P axis: 57O P 124 ms Cornell 4.02 mV
QRS axis: 78 O PR 152 ms Lewis 1.37 mV
T axis: 105 O QRS 40 ms Romhilt 4
QT 362ms
QTC 497 ms
 26

ABG TEST
Date: September 20, 2023
Time: 2:45 PM
Table 4

ABG Test Result

Test Name Result Unit Reference Interpretation

Range
pH 6.80 7.35-7.45. Low. This may indicate by reduce level CO2.
Hyperventilation (respiratory alkalosis). (Pattel, 2022)
PCO2 81 mmol/L 8 – 78 High. This may indicate Respiratory acidosis typically
occurs due to failure of ventilation and accumulation of
carbon dioxide. (Sharma,2023)
BE 9.9 mmol/l -3.0-3.0 Low. Respiratory acidosis typically occurs due to failure
of ventilation and accumulation of carbon dioxide.
(Sharma,2023)

X-Ray Result
Table 5

X-ray Result

Date Findings Impression/Interpretation

September 20, 2023
@ 2:32 PM • Inflammation are noted on both lower lungs • Aspiration Pneumonia both lower
lungs. Suggest reray in 7 days.
 27

SUMMARY OF SIGNIFICANT FINDINGS

Table 6. Summary of Significant Findings

GORDON’S FUNCTIONAL LABORATORY & THERAPEUTIC KEY NURSING

HEALTH PATTERNS/ DIAGNOSTIC STUDIES MANAGEMENT PROBLEMS
PHYSICAL ASSESSMENT
Patient has difficulty breathing X-ray suggests aspiration Ineffective Airway
and speaking with minimal pneumonia on both lungs • Monitor V/s especially RR Clearance
movements or even at rest. and O2 Sat
• attached with Endotracheal • Elevate HOB
tube • Auscultate lung sounds
• attached to mechanical • Suction ETT and oral
ventilator secretions
• Ineffective coughing • facilitate frequent position
• nonproductive cough changes
• retained secretions • Monitor mechanical
• Inability to expectorate ventilator setting
• Bilateral crackles heard on • Clindamycin IVTT every 6
the lower lobes hours
• Reduced activity tolerance • Piperacillin Tazobactam 45
g IV Drip q6H
 28

• crackles upon auscultation • Monitor RR and O2 sat Impaired Gas Exchange

noted • Monitor mechanical
ventilator setting
• Position Patient
Comfortably
• Monitor for signs of
respiratory distress
• Reduced oral intake --- • Monitor weight regularly Risk for Imbalanced
• dysphagia noted • Oral Care Nutrition: Less than Body
• BMI of 18.4 indicates • Provide the Prescribed Diet requirements
underweight • Monitor for signs of
malnutrition or dehydration
 29

ANATOMY & PHYSIOLOGY

RESPIRATORY SYSTEM
.

The respiratory system may be divided into the upper respiratory tract and the lower
respiratory tract. The upper respiratory tract consists of the parts outside the chest cavity: the
air passages of the nose, nasal cavities, pharynx, larynx, and upper trachea.

The lower respiratory tract consists of the parts found within the chest cavity: the lower
trachea and the lungs themselves, which include the bronchial tubes and alveoli. Also, part of the
respiratory system are the pleural membranes and the respiratory muscles that form the chest
cavity: the diaphragm and intercostal muscles.

NOSE AND NASAL CAVITIES

Air enters and leaves the respiratory system through the nose, which is made of bone and
cartilage covered with skin. Just inside the nostrils are hairs, which help block the entry of dust.
 30

The two nasal cavities are within the skull, separated by the nasal septum, which is a bony plate
made of the ethmoid bone and vomer.

The nasal mucosa (lining) is ciliated epithelium, with goblet cells that produce mucus.
Three shelf-like or scroll-like bones called conchae project from the lateral wall of each nasal
cavity Just as shelves in a cabinet provide more flat space for storage, the conchae increase the
surface area of the nasal mucosa

In the upper nasal cavities are the olfactory receptors, which detect vaporized chemicals that
have been inhaled. The olfactory nerves pass through the ethmoid bone to the brain.

PHARYNX

The pharynx is a muscular tube posterior to the nasal and oral cavities and anterior to the
cervical vertebrae. For descriptive purposes, the pharynx may be divided into three parts: the
nasopharynx, oropharynx, and laryngopharynx.

The nasopharynx is a passageway for air only, but the remainder of the pharynx serves
as both an air and food passageway, although not for both at the same time.

The oropharynx is behind the mouth; its mucosa is stratified squamous epithelium,
continuous with that of the oral cavity.

The laryngopharynx is the most inferior portion of the pharynx. It opens anteriorly into
the larynx and posteriorly into the esophagus. Contraction of the muscular wall of the
oropharynx and laryngopharynx is part of the swallowing reflex.

The larynx is often called the voice box, a name that indicates one of its functions, which
is speaking. The other function of the larynx is to be an air passageway between the pharynx and
the trachea. Air passages must be kept open at all times, and so the larynx is made of nine pieces
of cartilage connected by ligaments.

The largest cartilage of the larynx is the thyroid cartilage which you can feel on the
anterior surface of your neck.
 31

The epiglottis is the uppermost cartilage. During swallowing, the larynx is elevated, and
the epiglottis closes over the top, rather like a trap door or hinged lid, to prevent the entry of
saliva or food into the larynx.

TRACHEA AND BRONCHIAL TREE

The trachea is about 4 to 5 inches (10 to 13 cm) long and extends from the larynx to the
primary bronchi. The wall of the trachea contains 16 to 20 C-shaped pieces of cartilage, which
keep the trachea open. The gaps in these incomplete cartilage rings are posterior, to permit the
expansion of the esophagus when food is swallowed.

The mucosa of the trachea is ciliated epithelium with goblet cells. As in the larynx, the
cilia sweep upward toward the pharynx. The right and left primary bronchi are the branches of
the trachea that enter the lungs. Their structure is just like that of the trachea, with C-shaped
cartilages and ciliated epithelium. Within the lungs, each primary bronchus branches into
secondary bronchi leading to the lobes of each lung (three right, two left) The further branching
of the bronchial tubes is often called the bronchial tree.

Lungs

At birth, a newborn’s lungs are filled with fluid and they are not inflated. They take their
first few breaths within 10 seconds after delivery. The function of the lungs is to take in oxygen
which the cells of the body need to carry out its normal function. The lungs also get rid of carbon
dioxide which is a waste product of the cells.

Alveoli

The functional units of the lungs are the air sacs called alveoli. The flat alveolar type I
cells that form most of the alveolar walls are simple squamous epithelium. In the spaces between
clusters of alveoli is elastic connective tissue, which is important for exhalation.

References

Marieb, E. N., & Keller, S. M. (2018). Essentials of human anatomy &

physiology (Twelfth edition, global edition.). Pearson.

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PATHOPHYSIOLOGY
33
 34

Source:
Sarwar, A. (2023, May 30). Nursing Care Plan for Aspiration Pneumonia. Made For Medical. Retrieved September 24, 2023,
from https://www.madeformedical.com/nursing-care-plan-for-aspiration-pneumonia/
Hinkle, J.L. & Cheever, K.H. (2008). Brunner & Suddarth's Textbook of Medical-Surgical Nursing
(10th ed.). Philadelphia: Wolters Kluwer.
Aspiration from Dysphagia. (n.d.). Cedars-Sinai. Retrieved September 24, 2023, from
https://www.cedars-sinai.org/health-library/diseases-and-conditions/a/aspiration-from-dysphagia.html
 35

NURSING CARE PLAN # 1

Nursing Diagnosis: Ineffective airway clearance related to excessive secretions as evidenced by difficulty in expectorating
sputum

Table 7. Nursing Care Plan # 1

ASSESSMENT SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

BASIS
SUBJECTIVE Pneumonia is a form SHORT SAFE & QUALITY After 8 hours of
DATA: of acute respiratory TERM NURSING CARE nursing
✔ N/A infection that affects GOAL: ● Obtained and ● To provide baseline interventions,
the lungs. The air Within 8 hours monitored VS and data the patient
OBJECTIVE sacs may fill with of nursing endorsed for any showed
DATA: fluid or pus (purulent interventions, abnormalities. improvement in
- Received material), causing the patient will airway clearance
patient lying cough with phlegm show ● Measured I & O ● to measure the I&O and maintain a
supine on bed, or pus, fever, chills, improvement upon receiving and of the patient patent airway as
asleep, and and difficulty in airway closing the chart evidenced by
conscious; with breathing. (WHO, clearance and RR and SPO2
on going IVF #2 2021). maintain a ● Positioned the ● To ease breathing within normal
PNSS 1L at patent airway patient appropriately and avoid range.
120cc/hr, with REFERENCES as evidenced by elevating the aspiration.
Norepinephrine by RR and head of bed and
 36

drip at 5ml/hr, WHO (2021). SPO2 within positioning on side

with Pneumonia. normal limits. lying.
Endotracheal Retrieved from
tube size 7.5 at https:// LONG TERM ● Changed patient’s ● To avoid pooling of
22 cm lip level www. GOAL: position frequently secretions.
in place, who.int/ After 24-72
attached to news-room/ hours of ● Auscultated breath ● to ascertain
mechanical fact-sheets/detail/ nursing sounds and assess current status and
ventilator, with pneumonia#:~ interventions, air movement note effects of
NGT place at :text=Pneumonia the patient will treatment in
left nostril, with %20is% be able to clearing airways.
FBC in place 20a maintain
attached to %20form%20of, airway patency ● Observed for signs ● To provide
urobag, Crackles painful%20and% and of respiratory immediate
noted upon 20limits%20 clear secretions distress (increased interventions
auscultation. oxygen%20intake. readily. rate, restlessness/
- ineffective anxiety, or use of
coughing accessory muscles
- productive for breathing).
cough
- inability to
expectorate
 37

-crackles heard ● Observed for ● To provide

on the lower signs/symptoms of immediate
lobes exacerbation of interventions
- reduced infection (e.g.,
activity increased dyspnea
tolerance with onset of fever
or change in sputum
color, amount,
or character)

● Noted the character ● This affects the

and effectiveness of ability to clear
the cough airways of
mechanism. secretions.

MANAGEMENT OF
RESOURCES &
ENVIRONMENT
● Raised side rails ● to prevent fall
● Lessened ● to avoid distractions
environmental to sleep & rest
noises
 38

● Provided patient ● to promote rest &

with a comfortable sleep
mattress and
blanket.

● Observed protocols ● To prevent

on pollution-control transmission of
& observed proper microbes from one
disposal of wastes place to another

● Adhered to policies,
procedures and ● To avoid
protocols on cross-contamination
prevention and
control of infection

HEALTH
EDUCATION
● Determined SO ● Identifies own
readiness as well as learning needs
her barriers to
learning
 39

LEGAL
RESPONSIBILITY
● Informed S/O about ● To adhere practices
any procedures in accordance with
performed & nursing law and
obtained informed other relevant
consent legislation

● Accomplished ● for legal purposes

accurate
documentation in
all matters
concerning client
care in accordance
to the standards of
nursing practice.

● Acted in ● To practice
accordance with the professionalism
established norms
of conduct of the
 40

institution /
organization/legal
and regulatory
requirements

ETHICO-MORAL
RESPONSIBILITY
● Rendered nursing ● To respect patient’s
care consistent with rights
the client’s bill of
rights

● Provided patient’s ● To respect the rights

privacy of the pt

● Provided ● To respect the rights

confidentiality to of the pt
patient’s data and
records
 41

PERSONAL &
PROFESSIONAL
DEVELOPMENT
● Applied learned ● To render updated
information for the pt. care
improvement of care

● Demonstrated good ● To practice

manners and right professionalism
conduct at all times

QUALITY
IMPROVEMENT
● Encouraged the SO ● Questions facilitate
to raise feedback open
and questions communication
between patient and
health care
professionals and
allow verification
of understanding of
given information
 42

● Solicited feedback ● To verify the

from SO regarding quality of care
care given.
Rendered

● Shared with the ● To provide holistic

team relevant patient care.
information
regarding clients’
condition and
significant changes
in clients’
environment

RESEARCH
● Specified ● To provide solution
researchable to the problem
problems regarding
client care and
community health
 43

RECORD
MANAGEMENT
● Completed updated ● to record the care
documentation of given to patient and
client care to respect patient’s
rights

● Applied principles ● To accurately

of record record the data
management

● Monitored and ● For legal purposes

improves accuracy, & ensure holistic &
completeness and collaborative pt
reliability of care
relevant data
Made record readily
accessible to
facilitate client care
 44

● Maintained ● To provide accurate

integrity, safety, data &
access and security confidentiality
of records

● Followed protocol ● To protect patient’s

in releasing records dignity
and other
information

COMMUNICATION
● Built rapport to SO ● to build trust
& gain patient trust

● Spoke with the SO ● to facilitate in

with a understanding the
well-modulated words
voice
 45

● Provided an ● Conveying respect

atmosphere of is especially
respect, openness, important when
trust, and providing education
collaboration to patients with
different values and
beliefs about health
and illness
● Interpreted and ● Non verbal cues are
validated client’s form of
body language and communication.
facial expressions

● Provided ● To provide
reassurance through emotional support.
therapeutic touch,
warmth and
comforting words
of encouragement
 46

✔ Ensured good ● To avoid

communication misunderstanding
within the health & ensure patient
care team safety

COLLABORATION
& TEAM WORK
● Regulated & ● To avoid
monitored IVF as dehydration & for
prescribed. fluid replacements.

● Monitored ● To provide

mechanical sufficient

ventilation oxygenation.

● Reviewed laboratory ● To determine the

studies status of the
patient’s condition.

✔ Collaborated with ● To provide a

all the HCP holistic care for the
patient’s needs
 47

involved in the
patient care

REFERENCES
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2006). Nurse’s Pocket Guide. (10th ed.). Philadelphia:
F.A. Davis Company
WHO (2021). Pneumonia. Retrieved from https://www.who.int/news-
room/factsheets/detail/pneumonia#:~:text=Pneumonia%20is%20a%20form%20of,painful%20and%20limits%20oxygen%20in
take.
 48

NURSING CARE PLAN # 2

Nursing Diagnosis: Impaired Gas Exchange related to alveolar damage and inflammation as evidenced by crackles noted upon
auscultation

Table 8. Nursing Care Plan # 2

ASSESSMENT SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

BASIS
SUBJECTIVE Pneumonia is a form SHORT SAFE & QUALITY After 6 hours of
DATA: of acute respiratory TERM NURSING CARE nursing
✔ N/A infection that affects GOAL: ● Obtained and ● To provide baseline interventions,
the lungs. The air Within 8 hours monitored VS and data the patient
OBJECTIVE sacs may fill with of nursing endorsed for any demonstrated
DATA: fluid or pus (purulent interventions, abnormalities. improved
Received patient material), causing the patient will ventilation and
lying supine on cough with phlegm demonstrate ● Measured I & O ● to measure the I& adequate
bed, asleep, and or pus, fever, chills, improved upon receiving and O of the patient oxygenation
conscious; with and difficulty ventilation and closing the chart of tissues as
on going IVF #2 breathing. (WHO, adequate evidenced by
PNSS 1L at 2021). Also, some of oxygenation ● Noted the presence ● To determine the normal SPO2 of
120cc/hr, with the common causes of tissues as of conditions that cause 95%.
Norepinephrine of anemia in evidenced by can cause or be
drip at 5ml/hr, pediatrics are normal SPO2. associated
 49

with infection and in some way with

Endotracheal nutritional LONG TERM gas exchange
tube size 7.5 at deficiencies. Due to GOAL: problems
22 cm lip level this, the body doesn’t After 24-72
in place, get enough hours of ● Noted respiratory ● This provides
attached to oxygen-rich blood nursing rate, depth, use of insight into the
mechanical (Boston Children’s interventions, accessory muscles, work of breathing
ventilator, with Hospital, 2022). the patient will pursed-lip breathing, and adequacy of
NGT place at be able to and areas of alveolar ventilation.
left nostril, with REFERENCES maintain pallor/cyanosis
FBC in place WHO (2021). adequate
attached to Pneumonia. oxygenation ● Auscultated breath ● Abnormal breath
urobag, Crackles Retrieved from of tissues as sounds, note areas sounds are
noted upon https:// evidenced by of decreased/ indicative of
- Orthopnea www. normal SPO2 adventitious numerous problems
- Irritability who.int/ and CBC breath sounds
- pale and dry news-room/ values (RBC,
lips fact-sheets/detail/ Hcb, & Hct. ● Noted the character ● This affects the
- ineffective pneumonia#:~ and effectiveness of ability to clear
coughing :text=Pneumonia the cough airways of
- productive %20is% mechanism. secretions.
cough 20a
 50

- inability to %20form%20of, ● Elevated the head of ● Elevation or upright

expectorate painful%20and% the bed and position position facilitates
- reduced 20limits%20 the client respiratory
activity oxygen%20intake. appropriately. function by gravity
tolerance
MANAGEMENT OF
Boston Children’s RESOURCES &
Hospital (2022). ENVIRONMENT
Anemia. Retrieved ● Raised side rails ● to prevent fall
from https://
www. ● Lessened ● to avoid distractions
Childrens environmental to sleep & rest
hospital. noises
org/conditions ● Provided patient ● to promote rest &
/anemia with a comfortable sleep
mattress and
blanket.

● Observed protocols ● To prevent

on pollution-control transmission of
& observed proper microbes from one
disposal of wastes place to another
 51

● Adhered to policies, ● To avoid

procedures and cross-contamination
protocols on
prevention and
control of infection

HEALTH
EDUCATION
● Determined SO ● Identifies own
readiness as well as learning needs
her barriers to
learning

LEGAL
RESPONSIBILITY
● Informed S/O about ● To adhere practices
any procedures in accordance with
performed & nursing law and
obtained informed other relevant
consent legislation
●
 52

● Accomplished ● for legal purposes

accurate
documentation in
all matters
concerning client
care in accordance
to the standards of
nursing practice.

● Acted in ● To practice
accordance with the professionalism
established norms
of conduct of the
institution /
organization/legal
and regulatory
requirements

ETHICO-MORAL
RESPONSIBILITY
● Rendered nursing ● To respect patient’s
care consistent with rights
 53

the client’s bill of

rights

● Provided patient’s ● To respect the rights

privacy of the pt

● Provided ● To respect the rights

confidentiality to of the pt
patient’s data and
records

PERSONAL &
PROFESSIONAL
DEVELOPMENT
● Applied learned ● To render updated
information for the pt. care
improvement of care

● Demonstrated good ● To practice

manners and right professionalism
conduct at all times
 54

QUALITY
IMPROVEMENT
● Encouraged the SO ● Questions facilitate
to raise feedback open
and questions communication
between patient and
health care
professionals and
allow verification
of understanding of
given information

● Solicited feedback ● To verify the

from SO regarding quality of care
care given.
Rendered

● Shared with the ● To provide holistic

team relevant patient care.
information
regarding clients’
condition and
 55

significant changes
in clients’
environment

RESEARCH
● Specified ● To provide solution
researchable to the problem
problems regarding
client care and
community health

RECORD
MANAGEMENT
● Completed updated ● to record the care
documentation of given to patient and
client care to respect patient’s
rights

● Applied principles ● To accurately

of record record the data
management
 56

● Monitored and ● For legal purposes

improves accuracy, & ensure holistic &
completeness and collaborative pt
reliability of care
relevant data
Made record readily
accessible to
facilitate client care

● Maintained ● To provide accurate

integrity, safety, data &
access and security confidentiality
of records

● Followed protocol ● To protect patient’s

in releasing records dignity
and other
information
 57

COMMUNICATION
● Built rapport to SO ● to build trust
& gain patient trust

● Spoke with the SO ● to facilitate in

with a understanding the
well-modulated words
voice
● Provided an ● Conveying respect
atmosphere of is especially
respect, openness, important when
trust, and providing education
collaboration to patients with
different values and
beliefs about health
and illness

● Interpreted and ● Non verbal cues are

validated client’s form of
body language and communication.
facial expressions
 58

● Provided ● To provide
reassurance through emotional support.
therapeutic touch,
warmth and
comforting words
of encouragement

✔ Ensured good ● To avoid

communication misunderstanding
within the health & ensure patient
care team safety

COLLABORATION
& TEAM WORK
● Regulated & ● To avoid
monitored IVF as dehydration & for
prescribed. fluid replacements.

● To provide
● Monitored
sufficient
Mechanical
oxygenation.
 59

ventilation
frequently

● Reviewed laboratory ● To determine the

studies status of the
patient’s condition.

✔ Collaborated with ● To provide a

all the HCP holistic care for the
involved in the patient’s needs
patient care

REFERENCES
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2006). Nurse’s Pocket Guide. (15th ed.). Philadelphia:
F.A. Davis Company
WHO (2021). Pneumonia. Retrieved from https://www.who.int/news-
room/factsheets/detail/pneumonia#:~:text=Pneumonia%20is%20a%20form%20of,painful%20and%20limits%20oxygen%20in
take.
 60

NURSING CARE PLAN # 3

Nursing Diagnosis: Nutritional Imbalance:less than body requirements r/t decrease oral intake as evidenced by BMI of 18.4
which is underweight

Table 9. Nursing Care Plan # 3

ASSESSMENT SCIENTIFIC PLANNING INTERVENTION RATIONALE EVALUATION

BASIS
SUBJECTIVE Lung damage is a SHORT SAFE & QUALITY After 8 hours of
DATA: major complication TERM NURSING CARE nursing
✔ N/A of aspiration. When GOAL: ● Assessed nutritional ● Progressive weight interventions,
food, drink, or Within 8 hours status & needs, loss, muscle the patient was
OBJECTIVE stomach contents of nursing noting weight, withering, loss of able to
DATA: enter your lungs, they interventions, caloric intake, and skin tone, and demonstrate
- Received might cause tissue the patient, will protein values. reductions in total behaviors to
patient lying damage. The harm demonstrate protein can all have reduce risk
supine on bed, might be serious at behaviors to a negative impact factors by
asleep, and times. Aspiration also reduce risk on wound healing participating i in
conscious; with raises your chances factors by and the patient's planning for his
on going IVF #2 of getting participating i capacity to resist dietary regimen
PNSS 1L at pneumonia. This is a in planning for infection.
120cc/hr, with lung infection that his dietary
Norepinephrine causes fluid to regimen
 61

drip at 5ml/hr, accumulate in the LONG TERM ● Measured I & O ● to measure the I&O
with lungs. Antibiotics are GOAL: upon receiving and of the patient
Endotracheal required to treat After 1-2 closing the chart
tube size 7.5 at pneumonia. weeks of
22 cm lip level Dysphagia can lead nursing ● Perform NGT ● To ensure
in place, to mortality in rare interventions, feeding properly compliance with
attached to situations. Other the patient will the dietary
mechanical possible problems be able to treatment
ventilator, with include dehydration, demonstrate ● Supervised the ● To ensure
NGT place at malnutrition, and progressive patient during compliance with
left nostril, with weight loss. weight gain, mealtimes and for a the dietary
FBC in place Risk of various be free from specified period treatment program.
attached to illnesses is increased. any signs of after meals (usually For a hospitalized
urobag, Crackles malnutrition , one hour). patient with
noted upon REFERENCES & demonstrate anorexia, food is
auscultation Aspiration from behaviors and considered a
- BMI of 18.4 Dysphagia. (n.d.). lifestyle medication.
which is Cedars-Sinai. changes to
underweight Retrieved September regain ● Encouraged ● Patients likely will
-skin is cold to 24, 2023, from significant others to benefit from
touch https://www.cedars-si visit at mealtimes socialization at
nai.org/health-library and bring the mealtime, which
 62

- restlessness /diseases-and-conditi patient's favorite also may promote

noted ons/a/aspiration-from high-calorie, intake of these
-dysphagia.html high-protein foods high-calorie,
from home. high-protein foods.
● Provided ● To provide
supplemental adequate nutrition
vitamins and to the patient
minerals as
prescribed.

MANAGEMENT OF
RESOURCES &
ENVIRONMENT
● Raised side rails ● to prevent fall

● Lessened ● to avoid
environmental distractions to sleep
noises & rest

● Provided the patient ● to promote rest &

with a comfortable sleep
 63

mattress and
blanket.
● Observed protocols ● To prevent
on pollution-control transmission of
& observed proper microbes from one
disposal of wastes place to another

● Adhered to policies, ● To avoid

procedures and cross-contaminatio
protocols on n
prevention and
control of infection

HEALTH
EDUCATION
● Educated S.O about ● To gain knowledge
Parenteral Nutrition base on the
patient’s condition
● Determined SO ● To prevent
readiness as well as infection
her barriers to
learning
 64

LEGAL
RESPONSIBILITY
● Informed S/O about ● To adhere practices
any procedures in accordance with
performed & nursing law and
obtained informed other relevant
consent legislation

● Accomplished
accurate ● for legal purposes
documentation in all
matters concerning
client care in
accordance to the
standards of nursing
practice.

● Acted in accordance ● To practice

with the established professionalism
norms of conduct of
the
 65

institution /
organization/legal
and regulatory
requirements
ETHICO-MORAL
RESPONSIBILITY
● Rendered nursing ● To respect patient’s
care consistent with rights
the client’s bill of
rights

● Provided patient’s ● To respect the

privacy rights of the pt

● Provided ● To respect the

confidentiality to rights of the pt
patient’s data and
records

PERSONAL &
PROFESSIONAL
DEVELOPMENT
 66

● Applied learned ● To render updated

information for the pt. care
improvement of care

● Demonstrated good
manners and right ● To practice
conduct at all times professionalism

QUALITY
IMPROVEMENT
● Encouraged the SO ● Questions facilitate
to raise feedback open
and questions communication
between patient and
health care
professionals and
allow verification
of understanding of
given information
 67

● Solicited feedback ● To verify the

from SO regarding quality of care
care given.

● Shared with the ● To provide holistic

team relevant patient care.
information
regarding clients’
condition and
significant changes
in clients’
environment

RESEARCH
● Specified ● To provide solution
researchable to the problem
problems regarding
client care and
community health
 68

RECORD ● to record the care

MANAGEMENT given to patient and
● Completed updated to respect patient’s
documentation of rights
client care
● Applied principles ● To accurately
of record record the data
management

● Monitored and ● For legal purposes

improves accuracy, & ensure holistic &
completeness and collaborative pt
reliability of care
relevant data
Made record readily
accessible to
facilitate client care

● Maintained ● To provide accurate

integrity, safety, data &
access and security confidentiality
of records
 69

● Followed protocol ● To protect patient’s

in releasing records dignity
and other
information

COMMUNICATION
● Built rapport to SO ● to build trust
& gain patient trust

● Spoke with the SO ● to facilitate in

with a understanding the
well-modulated words
voice
● Conveying respect
● Provided an is especially
atmosphere of important when
respect, openness, providing education
trust, and to patients with
collaboration different values and
beliefs about health
and illness
 70

● Interpreted and ● Non verbal cues are

validated client’s form of
body language and communication.
facial expressions

● Provided
reassurance through ● To provide
therapeutic touch, emotional support.
warmth and
comforting words
of encouragement

● Ensured good ● To avoid

communication misunderstanding
within the health & ensure patient
care team safety
 71

COLLABORATION
& TEAM WORK
● Regulated & ● To avoid
monitored IVF as dehydration & for
prescribed. fluid replacements.
● Monitored ● To provide
mechanical sufficient
ventilator frequently oxygenation.
.
● Reviewed laboratory ● To determine the

studies status of the

patient’s condition.

● Collaborated with
● To provide a
all the HCP
holistic care for the
involved in the
patient’s needs
patient care

REFERENCES
Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2006). Nurse’s Pocket Guide. (15th ed.). Philadelphia:
F.A. Davis Company
72
 73

DISCHARGE PLAN

Table 10. Discharge Plan

● Continue giving meds as prescribed by the physician.
● Advice S.O avoid self medication
Medication ● Remind patient to follow medication treatment plan as
prescribed
● Educate the S.O of the expected therapeutic effect of the meds to
the patient
● Advice SO to follow these general guidelines:
o Give medication as directed.
o Do not change the amount or the schedule.
o Do not stop taking prescription medication without
talking to the doctor.
o Do not share prescription medication.
o Ask what results and side effects to expect. Report them
to your doctor.
o Some medications can be dangerous when mixed.
o Remind to notify healthcare providers immediately if
experiencing any adverse reactions to the medications

● Advise patient and SO to provide a clean environment to avoid

infections especially respiratory infection.
Environment ● Encourage the parents/SO to provide a well-ventilated area
● Advice SO to provide environment conducive for rest and sleep
● Instruct S.O to wash the patient's beddings, clothing, and
personal items separately from those of other household
members using hot water and detergent. Dry them in direct
sunlight if possible
● Encourage /SO to maintain a safe home free from any health
hazards such as sharp objects, chemicals and matches.
● Encourage the parents/SO to maintain cleanliness of the house
 74

and surroundings

● Advise patient to comply with follow-up schedules

● Stressed the importance of adhering to the recommended course
Treatment of treatment.
● Increase fluid intake as tolerated
● To help prevent infection:
o Keep the patient’s area clean.
o Proper hand washing before and after in contact with the
patient
o Have a well-ventilated area
o Hand washing before and after meals

● Emphasized the importance of mobility to prevent

complications.

Teach patient the following:

Health Teaching • Instruct the SO to have a proper hygiene for the patient such as
bathing daily & washing hands regularly to prevent infection
• Instruct the significant others to do hand washing before and
after in contact with the patient.
• Instruct the Significant others not to take the patient to crowded
places to prevent risk of having infection.

Call your local emergency number (911) if:

Observable ● If the patient develops difficulty breathing
signs & symptoms Call your doctor if:
● Hard time breathing
● Chest muscles are pulling in with each breath
● Breathing faster than 50 to 60 breaths per minute (when not
crying)
 75

● Skin, nails, gums, or lips are a blue or gray color

● The area around your patient's eyes is a blue or gray color
● Very tired or fatigued
● Not moving around much
● Nostrils are flaring out when breathing
● Does not feel like eating or drinking
● Irritable
● Has trouble sleeping

Diet ● Emphasized the importance of a balanced diet that includes a

variety of food groups such as fruits, vegetables, whole grains,
and lean proteins.
● Encouraged the consumption of lean sources of protein, such as
poultry and fish, as protein is essential for healing and immune
function.
● Reminded to follow a prescribed diet: low salt, low fat diet.
● Stressed the importance of staying well-hydrated by drinking
plenty of fluids throughout the day.
● Suggested eating smaller, more frequent meals to prevent
nausea.
● Discussed the potential need for vitamin and mineral
supplements, especially if there are dietary restrictions or
deficiencies.
● Instructed the patient to limit the consumption of sugary and
processed foods, as they can negatively impact immune function
and overall health.
● Emphasized proper food handling and safety practices to reduce
the risk of foodborne illnesses.
 76

● Encouraged the patient to express his feelings, concerns, and

Spirituality
fears to healthcare providers, family members, or a trusted
individual.

● Recommended self-care activities that improve resilience, such

as avoid smoking,drinking alcohol, eating a nutritious diet,
exercising regularly and getting enough rest

● Encouraged the patient to maintain his faith in God, pray for his
recovery and well-being.
 77

HEALTH TEACHING # 1

TOPIC: STRICT ADHERENCE TO MEDICATION

GENERAL OBJECTIVES: After 15 minutes of interactive lecture demonstration by a student nurse, a patient, and a nurse SO at the
CCMC adult-pulmo ward, the SO will be able to know and apply medication compliance.

Table 11. Health Teaching Plan No. 1

Learning Objectives Learning content Learning Activity Time Teaching plan Evaluation
allotted
After 15 minutes of I. Attention 5 minutes One on one After 15 minutes of
nurse-client interaction, the Catching Activity discussion, student nurse –
patient will be able to: How important is sharing patient & nurse SO
medication interactive lecture
Explain the meaning of Medication adherence? demonstration at
Medication Adherence Adherence is defined CCMC adult –
as the action of pulmo ward, the SO
taking medical was able to:
treatment on schedule Explain medication
or as instructed. It adherence ,
gives the best understand its
opportunity to purpose and Identify
manage conditions ways to follow
and maintain the best prescribed
 78

possible health for medication.

yourself.

Understand the purpose of Medicines are used II. LECTURE 5 minutes One on one
medication for the treatment of PROPER lecture-demonstrat
diseases or to • Definition of ion, and sharing
decrease the related medication
symptoms and to adherence
restore normal body • Purpose of
functions. Medication Medication
adherence is • Ways to follow
important because it prescribed
allows you and your medications
healthcare provider to
conduct an accurate
assessment of how
well a drug and III. Learning 5 minutes Q & A, & sharing
dosage work for your Assessment
treatment. If you • Enumeration of
don’t take your ways to follow
medication medication
consistently and as adherence
 79

directed, you won’t

truly know if it can
help relieve your
symptoms or not.

• Identify ways to strictly -If you’re feeling

follow prescribed overwhelmed, it’s
medications time to get organized.
Try a
multi-compartment
pill box. Or talk to
your doctor about
getting your
medications in blister
packs. Some
pharmacies will even
send your
prescriptions
packaged and labeled
with the date and time
you need to take
them. And don’t
 80

forget:Your
pharmacist is a great
resource who’s there
to help you keep your
prescriptions in order.
 81

HEALTH TEACHING # 2

TOPIC: HOW TO PREVENT INFECTION AND RECURRENCE OF ASPIRATION PNEUMONIA

GENERAL OBJECTIVES: After 20 minutes of student nurse – patient & nurse SO interactive lecture demonstration at CCMC
adult-pulmo ward, the SO will be able to know and apply and learned ways on how to prevent infections and recurrence of Aspiration
Pneumonia.

Table 12. Health Teaching Plan No. 2

Learning Objectives Learning content Learning Activity Time Teaching plan Evaluation
allotted
After 15 minutes of I. Attention 5 minutes One on one After 20 minutes of
nurse-client interaction, the Catching Activity discussion, student nurse –
patient will be able to: What is aspiration sharing patient & nurse SO
pneumonia? interactive lecture
demonstration at
-Explain the meaning of Aspiration pneumonia II. LECTURE 10 One on one CCMC adult –
Aspiration Pneumonia is an infection of the PROPER minutes lecture-demonstrat pulmo ward, the SO
lungs caused by • Definition of ion, and sharing was able to:
inhaling saliva, food, aspiration • Explain the
liquid, vomit and even pneumonia meaning of
small foreign objects. • Causes and aspiration
It can be treated with Symptoms of pneumonia,
appropriate Pneumonia
 82

medications. If left Gain

untreated, • Ways to knowledge
complications can be manage and about its
serious, even fatal. prevent causes and
aspiration symptoms,
-Gain knowledge about Aspiration pneumonia penumonia Identify and
what causes aspiration is caused by inhaling apply the
pneumonia and its foreign materials into ways to
symptoms your lungs. These III. Learning 5 minutes Q & A, & sharing prevent
materials can be: Assessment Aspiration
Bacteria from saliva - Enumerate the Pneumonia
and secretions from management and
your mouth and nose, prevention of
Stomach contents Pneumonia
such as digestive
juices or vomit, Food
or beverages and
Small foreign objects.
Aspiration pneumonia
symptoms include:
Shortness of breath
(dyspnea) or
 83

wheezing.
Coughing up blood or
pus,Chest pain, Bad
breath and
extreme tiredness.
Symptoms of
aspiration (inhaling
something like
secretions) start very
quickly, even one to
two hours after you
inhale something you
shouldn’t have. It may
take a day or two for
pneumonia to
develop.

• Identify and apply the Aspiration pneumonia

ways to prevent is treated primarily
aspiration pneumonia with antibiotics.
(Viral pneumonia
requires treatment
 84

with antiviral
medications.) The
choice of antibiotics
depends on several
things, including any
allergies to penicillin
and where the
pneumonia was
acquired.
Hospital-acquired
infections must be
treated with
antibiotics that are
effective against
many types of
bacteria.

Even though
aspiration
pneumonitis isn’t an
infection, your
provider may start
 85

antibiotic therapy,
depending on the
clinical situation and
underlying medical
conditions.Additional
treatment might
include oxygen
therapy or, in
life-threatening cases,
mechanical
ventilation.Mechanica
l ventilation means
that a machine (a
ventilator) is
breathing for you.
Preventing further
aspiration is an
important part of
treatment, since every
episode of aspiration
can lead to
inflammation or
 86

infection. Things that

you can do to reduce
your risk of aspiration
pneumonia include
the following:

Avoid drinking
alcohol to excess and
using recreational
drugs. These can
affect your ability to
swallow.
Stay upright when
you are eating.
Chew slowly and
completely.
If you have problems
swallowing (things
often “go down the
wrong pipe”), talk to
your healthcare
provider. They might
 87

need to change or
adjust your diet or
medication. They can
also order tests or
refer you to a speech
professional or
swallowing specialist.
Don’t smoke or use
nicotine products.
Take good care of
your teeth.

REFERENCES

Aspiration Pneumonia: What It Is, Causes, Diagnosis, Treatment. (2021, October 7). Cleveland Clinic. Retrieved September 24, 2023,
from https://my.clevelandclinic.org/health/diseases/21954-aspiration-pneumonia
 88

HEALTH TEACHING # 3

TOPIC: DIET AND EATING TECHNIQUES TO AVOID ASPIRATION PNEUMONIA

GENERAL OBJECTIVES: After 15 minutes of interactive lecture demonstration by a student nurse, a patient, and a nurse SO at the
CCMC adult-pulmo ward, the SO will be able to know and apply the diet and eating techniques to avoid aspiration pneumonia.

Table 13. Health Teaching Plan No. 3

Learning Objectives Learning content Learning Activity Time Teaching plan Evaluation
allotted
After 15 minutes of I. Attention 5 minutes One on one After 15 minutes of
nurse-client interaction, the Catching Activity discussion, student nurse –
patient will be able to: What is the diet sharing patient & nurse SO
and eating interactive lecture
techniques? demonstration at
-Identify the foods allowed Tender foods are CCMC adult –
to eat easier to chew and pulmo ward, the SO
swallow, helping was able to:
reduce the chance that Identify ways to eat
- they get swallowed and avoid and know
down the wrong pipe. the eating
Examples are techniques to
Bananas, Rice, prevent aspiration.
Potatoes, Fish and
 89

peeled fruit. Pureed

foods are allowed and
they should be
smooth and not have II. LECTURE 5 minutes One on one
any lumps such as PROPER lecture-demonstrat
smoothie,soup,yogurt • Identify ways ion, and sharing
and pudding. of foods to eat
-Identify foods to avoid Food to avoid are and avoid
eating whole fruit,pasta,raw • Know the
vegetables,corn,scram eating
bled,fired techniques
eggs,crackers and
chips

-Know the eating techniques Maintaining proper III. Learning

eating techniques Assessment
during each meal can • Enumeration of 5 minutes Q & A, & sharing
help reduce the risk of foods to eat and
aspiration pneumonia. avoid
The following are to • Enumerate the
Sit up straight when eating
eating and drinking, techniques
 90

take small bites of

foods,eat slowly,
reduce distractions
during
mealtime,maintain
good oral hygiene,
use assistive utensils
as needed and avoid
talking while eating.

REFERENCES

Cemental, M. (n.d.). INFOGRAPHIC: Diet to Avoid Aspiration Pneumonia. Caring Senior Service. Retrieved September 24, 2023,
from https://www.caringseniorservice.com/blog/infographic-diet-avoid-aspiration-pneumonia
 91

DRUG STUDY # 1

PIPERACILLIN + TAZOBACTAM

Table 14
Name of Drug Classifica Mechanism Indication Contraindi Adverse Nursing responsibilities
tion of action cation effect
Generic Name: General Tazobactam Used to treat Hypersensi CNS: Before
Piperacillin Classifica is an pneumonia tivity to Headache, • Assess for the cautions and
Tazobactam tion inhibitor of a and skin, piperacillin insomnia, contraindications to prevent any
beta-lacta wide variety gynecologica , fever, untoward complications.
Trade Name: mase of bacterial l, and tazobactam dizziness, • Perform a thorough physical
Zosyn inhibitor beta–lactama abdominal , pain. assessment & obtain VS
ses. It has (stomach penicillins, • Monitor hematologic and
Patient’s Dose little area) cephalospo GI: Diarrhea, coagulation parameters
45g IV drip q6h Function antibacterial infections rins, or constipation,
al activity caused by beta-lactam nausea, During
Maximum Classifica itself; bacteria. ase vomiting, • Administer appropriate dosage at
Dose: tion: however, in inhibitors dyspepsia right route and frequency
13.5 g Antibiotic combination Patient’s such as • Educate client/SO on drug therapy to
s with Indication: clavulanic Skin: Rash, promote understanding and
Minimum piperacillin, Infection acid and pruritus, compliance.
Dose: it extends the sulbactam. hypersensitiv • Monitor patient carefully during the
2.25 g spectrum of ity reactions. first 30 min after initiation of the
bacteria that infusion for signs of hypersensitivity
are
susceptible to
piperacillin.
 92

Table 14

Drug Study No. 1: Piperacillin Tazobactam (continued)

After
• Monitor patient response to therapy
• Monitor for adverse effects
• Evaluate patient/SO understanding
on drug therapy by asking patient to
name the drug, its indication, and
adverse effects to watch for.
• Monitor patient compliance to drug
therapy

Reference
Karch, A. M. (2020). Focus on nursing pharmacology. Seventh edition. Philadelphia: Wolters Kluwer
 93

DRUG STUDY # 2

Clindamycin

Table 15 .
Name of Classification Mechanism Indication Contraindication Adverse Nursing
Drug of Action Reactions Responsibilities
Generic General Exert Second-generat - hypersensitivity to GI: nausea, Before
Name: Classification bactericidal ion cephalosporins or vomiting, • Assess for the cautions
Clindamyci and cephalosporins penicillins diarrhea, and contraindications
n Cephalosporins bacteriostatic are effective anorexia, (e.g. drug allergies,
2nd gen effects by against abdominal CNS depression, cv
Trade interfering previously pain, flatulence disorders, etc.) to
Name: Functional with the mentioned prevent any untoward
Classification: cell-wall strains as well CNS: headache, complications.
Zinacef Antibiotics building as H. dizziness, • Perform a thorough
ability of influenzae, lethargy, physical assessment
bacteria E.aerogenes, paresthesia • Perform culture and
during cell and Neisseria sensitivity tests at the
division. spp. These Nephrotoxicity in site of infection to
Patient’s Therefore, drugs are less patients who ensure appropriate use
Dose: 600 they prevent effective have of the drug.
mg IVTT the bacteria against predisposing • Conduct orientation and
 94

q6H from bio gram-positive renal reflex assessment, as

synthesizing bacteria. insufficiency well as auditory testing
Maximum the to evaluate any CNS
Dose: framework of Patient’s Superinfections effects of the drug
1000mg their cell Indication: (aminoglycosides)
walls. Respiratory Phlebitis and
Minimum infection local abscess at During
Dose: (PCAP) the site of IM • Check culture and
20mg injection sensitivity reports.
and/or IV • Administer appropriate
administration. dosage at right route and
frequency
• Ensure that patient
receives full course.
• Monitor infection site
and presenting signs and
symptoms throughout
course of drug therapy.
• Educate client/SO on
drug therapy to promote
understanding and
compliance
 95

After
• Monitor patient response
to therapy (decrease in
signs and symptoms of
infection).
• Monitor for adverse
effects
• Evaluate patient/SO
understanding on drug
therapy by asking
patient to name the drug,
its indication, and
adverse effects to watch
for.
• Monitor patient
compliance to drug
therapy
Sources:
BOOK
Karch, A. M. (2020). Focus on nursing pharmacology. Seventh edition. Philadelphia: Wolters Kluwer
 96

DRUG STUDY # 3

OMEPRAZOLE

Table 16
Name of Classification Mechanis Indication Contraindicat Adverse Nursing Responsibilities
Drug m of ion Reaction
Action
Generic General Omeprazol • Treatment and Contraindicate CNS: Before:
Name Classification e inhibits maintenance of d in patients Headache, • Assess for possible
Omeprazole Antisecretory proton erosive hypersensitive dizziness, contraindications and cautions
compound pump esophagitis, to drug or its vertigo, • Perform a physical examination
Trade activity by treatment of components insomnia. • Inspect the skin
Name binding to heartburn and in patients Skin: • Assess neurological status
Prilosec Functional hydrogen associated with receiving Rash. • Inspect and palpate the abdomen
Classification potassium GERD. rilpivirine-cont GI: to determine potential underlying
Patient`s Proton-pump adenosine • Treatment of aining Diarrhea, medical conditions possible
Dose inhibitors triphosphat GERD, severe products. abdominal adverse effects.
40 mg ase, erosive pain, • Assess respiratory status
IVTT q24H located at esophagitis, nausea,
secretory duodenal ulcers, vomiting. During:
Maximum surface of and pathological Resp: • Administer drug before meals to
Dose gastric hypersecretory Upper ensure that the patient does not
270mg parietal condition. respiratory open, chew, or crush capsules;
cells, to • Treatment of infections, they should be swallowed whole.
suppress gastric ulcer. cough. • Provide safety and comfort
Minimum gastric • Maintenance measures
Dose acid therapy for • Monitor the patient for diarrhea or
40mg secretion healing constipation
duodenal ulcers • Monitor nutritional status.
 97

Table 16

Drug Study No. 3: Omeprazole (continued)

and esophagitis. • Ensure follow-up.

• In combination • Provide patient support.
therapy for • Educate the patient and SO
eradicating including the drug name and
Helicobacter prescribed dosage; the importance
pylori infection. of taking the drug whole without
• Approved for opening, chewing, or crushing it;
use in children signs and symptoms of possible
for treatment of adverse effects and measures to
GERD, peptic minimize or prevent them.
ulcer, and
Zollinger-Elliso After:
n syndrome. • Monitor patient response to the
drug
• Patient’s • Monitor for adverse effects
Indication: • Monitor the effectiveness of
patient is on comfort and safety measures and
NGT compliance with the regimen.
Evaluate the effectiveness of the
teaching plan
Reference
Karch, A. M. (2017). Focus on nursing pharmacology. Seventh edition. Philadelphia: Wolters Kluwer
 98

DRUG STUDY # 4

ATORVASTATIN

Table 17
Name of Classification Mechanis Indication Contraindicat Adverse Nursing Responsibilities
Drug m of ion Reaction
Action
Generic General atorvastati General Atorvastatin is Nasophary Before:
Name Classification n is a Indications contraindicated ngitis; Conduct thorough physical
Atorvastati HMG-CoA selective, Adjunct to diet in patients who hyperglyc assessment before beginning drug
n Reductase competitiv for the treatment have: emia; therapy.
Inhibitors e inhibitor of patients w/ Hypersensitivit pharyngol Assess closely patient’s heart rate
Trade Functional of elevated total y to any aryngeal and blood pressure
Name Classification HMG-CoA cholesterol component of pain, During:
Lipitor Lipid reductase, (total-C), LDL this epistaxis; Administer drug at bedtime to
Lowering the cholesterol medication, diarrhea, maximize effectiveness of the drug
Patient`s Agents rate-limitin (LDL-C), such as, dyspepsia, because peak of cholesterol
Dose g enzyme apolipoprotein B atorvastatin nausea, synthesis is from midnight to 5
80 mg 1 tab that (apo B), & calcium, flatulence; AM.
converts triglycerides calcium arthralgia, Provide patient support.
OD at HS
HMG-Co- (TG). carbonate, pain in Educate the patient and SO
via NGT A to Patient’s microcrystallin extremity, including the drug name and
mevalonat Indication: e cellulose, musculosk prescribed dosage; the importance
Maximum
e, a For lactose eletal of taking the drug whole without
Dose
precursor hyperlipidemia monohydrate, pain, opening, chewing, or crushing it;
270mg
of sterols, croscarmellose muscle signs and symptoms of possible
including sodium, spasms, adverse effects and measures to
Minimum
cholesterol polysorbate 80, myalgia, minimize or prevent them.
Dose
hydroxypropyl joint
40mg
swelling;
 99

abnormal After
liver Monitor patient response to therapy
function as evidenced by normal serum
test, cholesterol and LDL levels,
increased absence of first MI, and slowing of
blood CAD progression.
creatine Monitor patient compliance to drug
phospokin therapy.
ase

References
BOOKS
Karch, A. M. (2020). Focus on nursing pharmacology. Seventh edition. Philadelphia: Wolters Kluwer
Nursing 2020 Drug Handbook (Vol. 1). (2020). Wolters Kluwer Health.
 100

DRUG STUDY #5

CARVEDILOL

Table 18
Name of Drug Classifica Mechanism Indication Contraindi Adverse Nursing responsibilities
tion of action cation effect
Generic Name: General These drugs Hypertension Hypersensi NS: Before
Carvedilol Classifica inhibit the , alone or tivity to headache, • Assess for the mentioned
tion movement of with other severe dizziness, contraindications to this drug (e.g.
Trade Name: Alpha and calcium ions oral drugs chronic light-headedn headache, rash, bradycardia, etc.).
Coreg Beta across Treatment for heart ess, fatigue • Monitor cardiopulmonary status
adrenegic myocardial CHF failure,bron closely as the drug can cause severe
Patient’s Dose blockers and chial CV: effects on these two body systems
12.5 mg/tab 1 arterial Patient’s asthma or hypotension,
tab BID via Function muscle cell Indication: related bradycardia, During
NGT al membranes. Hypertension bronchospa peripheral • Educate patient on importance of
Maximum Classifica As a result, stic edema, heart healthy lifestyle choices which
Dose: tion: action conditions, block include regular exercise, weight loss,
13.5 g Antihyper potential of severe smoking cessation, and lowsodium
tensive these cells hepatic GI: nausea, diet .
Minimum are altered impairment hepatic • Monitor blood pressure and heart
Dose: and cell injury rate and rhythm.
2.25 g contractions • Provide comfort measures for the
are blocked EENT: rash, patient to tolerate side effects (e.g.
skin flushing small frequent meals for nausea,
limiting noise and controlling room
light and temperature to prevent
After
• Monitor patient response to therapy
through blood pressure monitoring.
• Monitor for presence of mentioned
adverse effects.
 101

• Monitor for effectiveness of comfort

measures.
• Monitor for compliance to drug
therapy regimen.
• Monitor laboratory tests

References
BOOKS
Karch, A. M. (2020). Focus on nursing pharmacology. Seventh edition. Philadelphia: Wolters Kluwer
Nursing 2020 Drug Handbook (Vol. 1). (2020). Wolters Kluwer Health.
 102

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Respiratory Failure - What Is Respiratory Failure? (2022, March 24). NHLBI.

Retrieved September 24, 2023, from https://www.nhlbi.nih.gov/health/respiratory-failure

Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2006). Nurse’s Pocket Guide.
(15th ed.). Philadelphia: F.A. Davis Company
Hinkle, J.L. & Cheever, K.H. (2008). Brunner & Suddarth's Textbook of
Medical-Surgical Nursing (14th ed.). Philadelphia: Wolters Kluwer.
Karch, A. M. (2021). Focus on nursing pharmacology. Seventh edition.
Philadelphia: Wolters Kluwer
Weber, J. R., & Kelley, J. H. (2017). Health assessment in nursing (6th ed.).
Lippincott Williams and Wilkins.
Eisel, S. J. (2016, November 17). Nursing Management: Respiratory Failure and Acute
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https://nursekey.com/nursing-management-respiratory-failure-and-acute-respiratory-distress-syn
drome/

Aspiration from Dysphagia. (n.d.). Cedars-Sinai. Retrieved September 24, 2023, from
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html

Aspiration Pneumonia: What It Is, Causes, Diagnosis, Treatment. (2021, October 7). Cleveland
Clinic. Retrieved September 24, 2023, from
https://my.clevelandclinic.org/health/diseases/21954-aspiration-pneumonia

Cemental, M. (n.d.). INFOGRAPHIC: Diet to Avoid Aspiration Pneumonia. Caring Senior

Service. Retrieved September 24, 2023, from
https://www.caringseniorservice.com/blog/infographic-diet-avoid-aspiration-pneumonia

Medication Adherence - Taking Your Meds as Directed. (n.d.). American Heart Association.
Retrieved September 24, 2023, from
 103

https://www.heart.org/en/health-topics/consumer-healthcare/medication-information/medication-
adherence-taking-your-meds-as-directed

Sarwar, A. (2023, May 30). Nursing Care Plan for Aspiration Pneumonia. Made For Medical.
Retrieved September 24, 2023, from
https://www.madeformedical.com/nursing-care-plan-for-aspiration-pneumonia/