College of Nursing
Related Learning Experience
Submitted by:
Ms. Romylin P. Valerio
Submitted to:
Clinical Instructor
December 2010
TABLE OF CONTENTS
Page
I. Introduction
a. Overview of the case 3
b. Objective of the study 4
c. Scope and Limitation of the study 4
II. Health History
a. Profile of patient 5
b. Family and personal health history 6
c. History of Present Illness 6
d. Developmental data 7
III. Medical Management
A. Medical Orders and Laboratory Results 9
B. Drug Study 12
IV. Pathophysiology with Anatomy and Physiology 14
V. Nursing Assessment
(System Review and Nursing Assessment II) 16
VI. Nursing Management
A. Ideal Nursing Management (NCP) 19
B. Actual Nursing Management (SOAPIE) 23
VII. Referrals and Follow-up 27
VIII. Evaluation and Implications 28
IX. Documentation
A. Documentation of evidence of care for 1 week rotation
B. Organization/ Grammar/ Bibliography 29
1. INTRODUCTION
Bronchitis occurs when the air passages in your lungs become inflamed.
Bronchitis can be acute or chronic. Acute bronchitis is usually due to a viral infection --
such as a cold -- that starts in your nose or sinuses and spreads to the airways. Acute
bronchitis usually lasts a few days, although you may have
a cough for weeks afterward. Chronic bronchitis, on the
other hand, occurs most often in people who smoke and,
together with emphysema, is known as chronic obstructive
pulmonary disease (COPD). Chronic bronchitis is
characterized by a productive (wet) cough that is persistent.
The mucus that’s produced by the inflamed airways eventually causes scar tissue to
form in the lungs, making breathing difficult
(http://www.umm.edu/altmed/articles/bronchitis-000019.htm)
Acute bronchitis is one of the most common diagnoses made by primary care
physicians. In the United States alone, the evaluation and treatment of this illness is
estimated to cost $200 million to $300 million per year. 388 deaths reported in USA
1999 for acute bronchitis and bronchiolitis (NVSR Sep 2001), And 298,000
hospitalization per year for acute bronchitis (NHLBI 1999),
(http://www.aafp.org/afp/980315ap/hueston.htmlandhttp://www.wrongdiagnosis.com/a/
acute_bronchitis/stats.htm)
the illness of the client related to the Respiratory System of the human body. Its
goal is to be able to apply the knowledge and skills learned in the classroom to
the clinical area, specifically to a certain patient, wherein the specific illness will
The study encompasses the three days care to the client. It includes the
care given and the data taken from the client’s significant others. The data taken
were gathered from the client’s chart, physician, and the significant others.
The limitation of the study includes the place of interaction itself which was
in Polymedic General Hospital Cagayan de Oro City, General ward. The study
was completed all together by both research and actual hands-on exposure and
interaction with the patient during the three (3) days of clinical duty.
The study includes the overview of the case, health history of the patient;
a. PATIENT PROFILE
(35 to 65 years)
Laboratory Results
Date ordered: 02/19/10
DIAGNOSTIC EXAM RESULT NORMAL VALUES SIGNIFICANCE OF
THE RESULT
Complete Blood
Count
Urinalysis
Normal result
- color yellow Straw Yellow, amber Presence of bacteria
- transparency slight hazy Clear Normal result
- sugar negative Negative Increased infection
- specific gravity increased 1.030 1.010-1.022 Normal result
-PH reaction 6.0 5-7 Normal result
-protein trace Negative Normal result
-pus cells few few Normal Result
- Red blood cells 0-1 0-1 Normal Result
-epithelial 1-3 1-3 Normal Result
-bacteria occasional occasional
b . DRUG STUDY
Generic Name of Paracetamol
ordered drug
Brand Name acetaminophen
Date Ordered 12-05-10
Classification Non-opiod analgesics and antipyretics
Dose/Frequency/Rout 500 q4 hours PRN
e
Mechanism of Action Non-opioid analgesic. Effective at reducing pain at
fever.
Specific Indication Mild to moderate pain. Pyrexia.
Contraindication Patients with hypersensitive to drug
Side Effects/Toxic Skin rashes and blood discrder.
Effects
Nursing Precaution Rechecked temperature after 30 minutes
Generic Name of Ranitidine
ordered drug
Brand Name Zantac
Date Ordered 12-05-10
Classification Histamine-2 blockers reducing stomach acid
production
Dose/Frequency/Rout 50 mg IVTT
e
Mechanism of Action Inhibits histamine action at parietal H2 receptor,
decreases basal and food stimulated acid secretion.
Specific Indication Duodenal ulcer, stomach ulcer
Contraindication It is not administered in super sensitivity to the
preparation. Sever liver and renal injury.
Side Effects/Toxic Malaise, dizziness, Insomnia, agitation.
Effects
Nursing Precaution Assess patient for epigastric or abdominal pain. Frank
or occult blood in the stool. Emesis or gastric aspirate.
I. PATHOPHYSIOLOGY WITH
A. Anatomy
The Respiratory System moves air in and out of the body -- using oxygen and
eliminating carbon dioxide, a gas produced when cells use oxygen. The respiratory
system includes the nose, mouth, trachea, bronchi, diaphragm and lungs.
Mouth:
Air enters the body through either the open mouth or the nose. It travels down the
trachea to the lungs, where the oxygen in it passes into the bloodstream.
Nasal passage:
Air enters the body through either the open mouth or
the nose. Tiny hairs in the nose trap unwanted
particles while a sticky liquid called mucus catches
many of the germs before they all can go too far into
the respiratory system. The mucus also warms and
moistens the air.
Trachea (Windpipe):
About half of its 13 cm length is inside the chest and
the other half is in the neck. The lower end of the
trachea divides into two bronchi (tubes) that carry air
into the lungs.
Bronchi:
The lower end of the trachea divides into two bronchi
(tubes) that carry air into the lungs. One bronchus goes to the left lung, the other to
the right lung.
Bronchiolies:
Each bronchus divides into smaller and smaller tubes called
bronchiolies.
Alveoli:
Bronchiolies eventually lead to tiny, stretchy sacs called
alveoli. These sacs blow up like tiny balloons when you
breathe in. Oxygen from the air passes through the walls of
the alveoli into capillaries while carbon dioxide is passed out.
Lung:
Balloon-like structures in the chest that bring oxygen into the
body and expel carbon dioxide from the body.
Diaphragm:
The diaphragm is a strong muscle just below the lungs. When
your breathe in and out, the diaphragm moves downwards and
upwards against the lungs.
Epiglotis:
A flap in the throat that blocks the windpipe when food or liquid is being
swallowed.