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Liceo de Cagayan University

College of Nursing
Related Learning Experience

In Partial Fulfillment of the Requirements of


NCM 501204

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

a. OVERVIEW OF THE STUDY:

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)

Eight of the 10 leading causes of morbidity in the Philippines are caused by


infections. They are: acute lower respiratory tract infection and pneumonia; acute
watery diarrhoea; bronchitis/ bronchiolitis; influenza; tuberculosis; malaria; acute
febrile illness; and dengue fever. Among these communicable diseases, pneumonia
and tuberculosis continue to be among the 10 leading causes of mortality, causing a
significant number of deaths across the country.
(http://www.wpro.who.int/countries/2009/phl/health_situation.htm)
This care study presents a condition of patient in Polymedic General
Hospital Cagayan de Oro City, General ward having a diagnosis of Acute
Bronchitis. This case study aims to achieve a better understanding of the
patient’s condition and was made for the benefit of the students conducting the
study.

b. OBJECTIVE OF THE STUDY:

At the end of 24 hours of duty I will be able to be enlightened regarding

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

be researched and discussed thoroughly.

c. SCOPE AND LIMITATION OF THE STUDY:

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;

develop physiology, nursing assessment, nursing management, referrals and

follow-up and evaluation and implication.


1. HEALTH HISTORY

a. PATIENT PROFILE

NAME : Francisco Mario Mendaro


AGE : 35 years old
SEX : Male
BIRTH DATE : May 29, 1975
CIVIL STATUS : Married
ADDRESS : Rabadon Apartment Hi-way Lapasan CDO
RELIGION : Roman Catholic
WEIGHT : 120lbs
HEIGHT : 5’3
NATIONALITY : Filipino
DATE ADMITTED : december05, 2010
TIME : 8; 10am
ALLERGY : No known food and drug allergies
CHIEF COMPLAINT : fever, cough and upper left quadrant pain
DIAGNOSIS : Acute Bronchitis t/c UTI r/o cholelithiasis
PHYSICIAN : Dr. E. Bacal

VITAL SIGNS ASSESSMENT


Temperature: 38°C
Pulse Rate: 84 cpm
Respiratory Rate: 20bpm
Blood pressure: 130/80
b. FAMILY AND PERSONAL HEALTH HISTORY

Mr. Francisco 35 years old married; male is a resident of Rabandon


Apartment Hi-way Lapasan CDO. He is the only child in the family. His mother
has a complete prenatal check-up during her pregnancy. He was delivered via
Normal Spontaneous Vaginal Delivery .He received complete immunization when
he was still an infant. December of this month date December 05, 2010 at
8;00am he was admitted at Polymedic General Hospital due to fever, cough and
upper left quadrant pain and was diagnosed with acute bronchitis to consider UTI
to r/o cholelithiasis.
On his grand mother’s side there no known history of illness. While on his
grand father’s side asthma, high blood pressure, diabetes mellitus and smoking
history was noted.
The most common health problems they encounter were headache, cough,
colds, stomach ache, and fever. They take over the counter drug like
Medicol (500mg), Biogesic (500mg) for fever and Solmux (500mg) for
cough
c. HISTORY OF PRESENT ILLNESS
November 2010 Mr. Francisco has experience a cough, fever, body ache
and pain at his upper left quadrant of his abdomen. Due to that problem
he just ignored by taking over the counter drugs such as paracetamol,
alaxan and kremil s. A month after December 05, 2010 at 8; am due to
intense discomfort of his abdomen with fever and cough he decided to
confine in the hospital after the doctor’s examined him by Doctor Bacal. A
BP of 140/100 Temp. 38°C
He was given a prescription buscupan, ranitidine, paracetamol with fasting
And his blood sugar level of 108.42.
III. DEVELOPMENTAL DATA

SIGMUND FREUD’S PSYCHOSEXUAL THEORY


 Genital Stage (puberty and beyond)

During the final stage of psychosexual development, the individual develops a


strong sexual interest in the opposite sex. Where in earlier stages the focus was
solely on individual needs and, interest in the welfare of others grows during this
stage. If the other stages have been completed successful, the individual should
now be well-balanced, warm, and caring. The goal of this stage is to establish a
balance between the various life areas. Inability to resolve conflicts can in sexual
problems, such as frigidity, impotence, unsatisfactory sexual relationships

ERIK ERICKSON’S THEORY OF PSYCHOSOCIAL DEVELOPMENT

Middle Adulthood: Generativity vs. Stagnation

(35 to 65 years)

• Psychosocial Crisis: Generativity vs. Stagnation


• Related Elements in Society: parenting, educating, or other productive
social involvement

Generativity is the concern of establishing and guiding the next generation.


Socially-valued work and disciplines are expressions of generativity. Simply
having or wanting children does not in and of itself achieve generativity.

Central tasks of Middle Adulthood:

• Express love through more than sexual contacts.


• Maintain healthy life patterns.
• Develop a sense of unity with mate.
• Help growing and grown children to be responsible adults.
• Relinquish central role in lives of grown children.
• Accept children's mates and friends.
• Create a comfortable home.
• Be proud of accomplishments of self and mate/spouse.
• Reverse roles with aging parents.
• Achieve mature civic and social responsibility.
• Adjust to physical changes of middle age.
• Use leisure time creatively.
• Love for others

ROBERT HAVIGHURST’S DEVELOPMENTAL TASK:

Middle Age (30-60years old)

• Assisting teenage children to become responsible and happy adults.


• Achieving adult social and civic responsibility.
• Reaching and maintaining satisfactory performance in one’s occupational
career.
• Developing adult leisure time activities.
• Relating oneself to one’s spouse as a person.
• To accept and adjust to the physiological changes of middle age.
• Adjusting to aging parent
MEDICAL MANAGEMENT

a. DOCTOR’S ORDER AND RATIONALE

Day 1 December 05, 2010 Time: 8; 10am

Doctor’s Order Rationale


 Please admit under service of Dr. E  For proper management
Bacal
 Secure consent  To allow the health care provider to give
quality care and for proper
documentation and legal purposes.

 TPR every 4 hours  To monitor vital signs of the patient


and detect abnormalities
 Diet for Age  To give proper diet to the patient

• Start D5 LR 1L@ 20 gtts per To provide nutrients, electrolytes and fluids


min. @8;20 am in the body and for medication
administration
> Labs: *RBCs, hemoglobin and hematocrit are
• CBC important to the oxygen-carrying capacity
of the blood.
• Urinalysis * Urinalysis is the physical, chemical, and
microscopic examination of urine. It
involves a number of tests to detect and
measure various compounds that pass
through the urine.

Fasting Blood Sugar To tests cholesterol, fats, and sugar level

Chest X- ray To evaluate organs and structure within the


chest for symptoms and disease.
>Medications:
1.Paracetamol 500 mg q 4 hours PRN • Non-opiod Analgesic and anti pyretic
@8;25am for Fever
2. Ranitidine 50mg IVTT @ 8;25 am • Histamine-2 blockers to reduce the
amount of acid in the stomach
3.Buscupan 1 amp IVTT @ 8;20am • Smooth muscle anti spasmodic
4.Amlodipine (Nonasc) 1 tablet OD po • Treatment for anti hypertensive
q 6 hours drugs
5.Erdosteine (zertin) 300 mg 1 cap BID • Treatment for acute and chronic
broncho pulmonary diseases.

Laboratory Results
Date ordered: 02/19/10
DIAGNOSTIC EXAM RESULT NORMAL VALUES SIGNIFICANCE OF
THE RESULT
Complete Blood
Count

-WBC Increased 10.71 5.0-10.0/L Increased (Infection)


- RBC 4.36 3.69-5.90/L Normal Result
- hemoglobin 12.0 11.70-14.5g/dl Normal result
- hematocrit 38.9 34.1-44.3vols% Normal result
- MCV 78.0 70-97 Normal result
-MCH 25.2 26.10-33 Normal Result
- MCHC 32.4 32.0-35.0 Normal result
- platelet 275 150-390 Normal result
- Lymphocyte 20.3 20-40% Normal result
- Neutrophils 55 54.0-62.0 Normal result
- Monocytes 10 4.0-10.0 Normal result
- Eosinophils 1.0 1.0-6.0 Normal Result
- Basophils 0.0 0.0-1.00

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.

Generic Name of Hyoscine Butylbromide


ordered drug
Brand Name Buscopan
Date Ordered 12-05-2010
Classification Anti-cholinergic/Anti-spasmodic
Dose/Frequency/Rout 1amp IVTT
e
Mechanism of Action Smooth muscle Anti-spasmodic
Specific Indication Indicated for the relief of genitor urinary tract or
gastrointestinal tract and for the symptomatic relief of
bowel or irritable bowel syndrome.
Contraindication Mega colon narrow angle glaucoma
Side Effects/Toxic Tachycardia, palpitation hot dry or flushed skin.
Effects
Nursing Precaution Ask for doctors advice if patients pregnant.
Generic Name of Amlodipine
ordered drug
Brand Name Norvasc
Date Ordered 12-05-2010
Classification Anti-hypertensive drugs
Dose/Frequency/Rout 5mg 1 tablet OD po q 6 hours
e
Mechanism of Action Relaxes or widens blood vessels and to improves
blood flow.
Specific Indication Indication for the treatment of hypertension
Contraindication Contraindicated with patient with known sensitivity to
amlodipine
Side Effects/Toxic G.I Anorexia, constipation, dyspepsia
Effects
Nursing Precaution .Should exercise when administering norvasc
particularly with patients severe aortic stenosis.

Generic Name of Erdostein


ordered drug
Brand Name Zertin
Date Ordered 12-05-2010
Classification Bronchodilator
Dose/Frequency/Rout 300mg1 cap BID
e
Mechanism of Action Treatment for acute and chronic pulmonary diseases.
Specific Indication Healing and prevention of acute pulmonary disease
Contraindication Active peptic ulcer
Side Effects/Toxic Nausea, vomiting, loss stool
Effects
Nursing Precaution .pregnancy lactation.

I. PATHOPHYSIOLOGY WITH

ANATOMY AND PHYSIOLOGY

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.

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