CRITERIA FOR NURSING CARE PRESENTATIONCRITERIA POINTS ACTUAL POINTS OBTAINED

ContentPsychosocial ProfilePersonal Data………………………………………… 5Family data (include family tree)……………………. 3

Significant Results of Nursing Assessment2.1 P.A. findings and its bases…………………………… 52.2 Laboratory Results/ Diagnostic Exam Results………. 32.3 Summary of Nursing Diagnosis……………………... 8

Plan of Care and its Implementation3.1 Objectives of Care…………………………………… 53.2 Independent Nursing Actions Implemented………… 103.3 Dependent Nursing Actions Implemented………….. 73.4 Health Teachings……………………………………. 53.5 Referrals within and outside the hospital…………… 3

Evaluation of Care4.1 Evaluation of Objectives……………………………. 44.2 Totality of Care (including G/D and …………………. 5 components of wholeness)4.3 Involvement of patient/family (integration of………… 2 anatomy and physiology, drugs, diet and principle, theories and laws in related sciences should be evident)

Organization………………………………………………. 5

MasteryLess dependence upon notes…………………………… … 5Ability to answer questions………………………………... 20

Bibliography (at least 6 recent journals)…………………… ___5___ 100 Rating: _________________________________

Date of Presentation:

Rated by:

Student’s Signature:

ACKNOWLEDGEMENT

We would like to thank the staff of Silliman University Medical Center for giving us the opportunity to be exposed to this rotation, for being so patient, friendly and by making us see the responsibilities that we have to make as a future health professional.

To Ms. Freslyn S. Lim for guiding us all the way through the pediatrics rotation. For imparting numerous knowledge that could help us become a more competent nurse someday. We thank you for understanding us for all our mistakes, and for imparting countless knowledge

that will help us pull through this rotation.

To our parents for their undying love, support from the financial aspects to encouraging us to go on in making the case book.

We thank our patient, and her family for trusting us, for cooperating, and for being a friend.

To the authors of the books that we have used as references that have provided us with valuable and vital information that we need.

And to the Almighty God to whom we gather strength, inspiration, and Who never left our side and gave us countless blessings.

TABLE OF CONTENTS

TITLE PAGE……………………………………………………. APPLICATION LETTER FOR CASE STUDY………………..MISSION AND VISION OF SILLIMAN UNIVERSITY…….. CASE ANALYSIS CRITERIA…………………………………

ACKNOWLEDGEMENT……………………………………… TOPIC DESCRIPTION………………………………………... OBJECTIVES OF THE CASE ANALYSIS…………………... INTRODUCTION……………………………………………..DEMOGRAPHIC DATA ………………………………………GENOGRAM…………………………………………………..GROWTH AND DEVELOPMENT……………………………PA FINDINGS………………………………………………….ANATOMY AND PHYSIOLOGY OF AFFECTED SYSTEMS

Respiratory SystemOVERVIEW OF THE DISEASE CONDITION

Asthma Pneumonia

PATHOPHYSIOLOGY………………………………………..DIAGNOSTIC PROCEDURES

Complete Blood Count (CBC) Urinalysis Chest X- ray

MEDICAL MANAGEMENT Nebulization Intravenous Transfusion Oxygen Therapy Suctioning

LABORATORY RESULTS……………………………………MEDICATIONS USED………………………………………..NURSING MANAGEMENT

Functional Health Pattern………………………………… Nursing Care Plan (with summary of diagnoses)……....... Procedures Done…………………………………………. Incidental Health Teachings………………………………

EVALUATION OF CASE STUDY……………………....……..RELATED READINGS…………………………………………

REFERENCES………………………...........................................

COLLEGE OF NURSINGSILLIMAN UNIVERSITY

DUMAGUETE CITY

TOPIC DESCRIPTION

This case book is in partial fulfillment of the requirements to the Pediatrics rotation. Our case is about ASTHMA with PNEUMONIA. This includes an overview of the disease itself, and the pathophysiology of the said condition. Other aspects such as the anatomy and physiology of the affected part or organs, the laboratory results, diagnostic results, and medications of our patient will be applied in the pathophysiology. In addition, this case book also includes the medical and nursing management which composed the functional health patterns, nursing care plans, and incidental health teachings.

OBJECTIVES of the CASE ANALYSIS

GENERAL OBJECTIVE

At the end of this case analysis, the learners shall be able to acquire comprehensive knowledge and develop skills on the care of a patient with asthma and pneumonia.

SPECIFIC OBJECTIVESAt the end of the case analysis, the learners will be able to:

gain knowledge about the pathophysiology of asthma and pneumonia identify factors from the functional health pattern, physical assessment and genogram that lead to the development of the condition incorporate medications, laboratory results and diagnostic results to the pathophysiology of the condition develop their own nursing diagnosis about the condition find significance of the annotated readings to the case

INTRODUCTION

Asthma is an airway obstruction or a narrowing that is characterized by bronchial irritability after exposure to various stimuli. It is an inherited disorder. If the parent has asthma, the chance a child will also develop asthma is increased.

Asthma tends to occur in children with atopy or those who tend to be hypersensitive to allergens. Most asthmatic children have sensitization to inhalant antigens such as pollens, molds, or house dust. Food allergens like cow’s milk protein can cause asthma but are generally problematic only in infants. Severe bronchoconstriction can occur because of exposure to cold air or irritating odors such as turpentine or smog as well as inhalation of known allergen. Air pollutants such as cigarette smoke may lower the threshold of hypersentivity reactions and worsen the condition. Although there may seasonal factor responsible for a particular child’s symptoms, most children have multiple sensitivities and are affected all year long. Apparently, environmental factors such as viral infection, allergens, and pollutants interact with inherited factors to produce disease. Other inciting factors can include excitatory state such stress, laughing and crying, exercise, changes in temperature, and strong odors. It is also a component of triad disease: asthma, nasal polyps, and allergy to aspirin. Aspirin can be trigger, so caution adolescents with asthma that if they begin to take aspirin as an adult, it may initiate an attack.

Pneumonia is one of the leading causes of death among children and even adults. A disease that is caused by many kinds of microorganisms which is fatal when not treated right away. Different kinds of medicines are now available to treat this disease. But, due to poverty, many people who get this illness could not directly seek for medical attention or even buy or comply with their regimens. Culture and sensitivity test, which is a very complex exam to identify specific microorganisms also is now available to determine the type of agent that causes the disease which further provides a very important information that would help in providing appropriate intervention. Through that, medical teams could look for the right medication to be given to clients with the said disease. Unfortunately, with our actual setting, this kind of test is not strictly done to identify such causes, and in turn physicians will prescribe broad spectrum medications. Even if it’s expensive, these medications can really heal such disease as long as patients are also disciplined to follow what they are told to do. Above all, nursing care is very important in order to give our patients hope and inspiration to fight with it.

DEMOGRAPHIC DATA

Name of Patient: XYZ Age: 4 y/o 11 months 20 days Sex: Female Birthday: July 16, 2006

Address: Campaclan, Sibulan Neg.Or. Religion: Roman Catholic Tel #: 419-7914111 Nationality: Filipino

Room no: 469- D Hospital #: 07-86-33 Weight: 20kg Height: 110cm

Date & Time of Admission: July 6, 2011 @ 8:50pm Doctor(s) in charge: Dr. Glenda N. Nuico, MD

Chief Complaint(s): Dyspnea

History of Present Illness: 2 days, PTA onset of cough; no check up was done. About 9hrs PTA pt. complained of mild dyspnea but pt. still went to school. 3 hrs

PTA upon dismissal from ABC learning School pt. was diaphoretic, dyspheic, self-medicated with Salbutamol nebulization one nebule & gave some relief.

Persistence of symptoms prompted admission.

General Impression of the client: Received lying on bed, with D5NM 1L @ 16gtts/min on the right metacarpal vein, infusing well and IV site not swollen.

Patient is awake, coherent, and oriented; with hair improperly kept. Minimal sweating noted. Restlessness noted. Speech was clear and understandable. Friendly and

approachable. No odor noted. Her mother was the one beside her. No pain as verbalized. No facial grimacing noted.

PAST HEALTH HISTORY

Heredo-familial diseases: lolo, aunt, brother are asthmatic, lolo HPN, lola diabetic

Food allergy: Mango

Hospitalizations: April 2010 @SMC for Acute Tonsilopharngitis

Immunization: BCG -1 dose, DPT – 3 doses, OPV – 3 doses, HEP B – 3 doses, AMV- 1 dose, HlB – 1 dose

GENOGRAM

Lolo ABC- 66 y/o-Hypertensive-smoker, drinks occasionally, loves to eat lechon baboy when he goes to fiesta- his father died because of heart attack

Lola ABC- 60 y/o- No disease- loves to eat fruits, vegetables and cleans the house when she was still young

Lola EFG-58 y/o-Diabetic- loves to eat rice, tira-tira and sugarcane when she was still young, humba,- drinks softdrinks

Lolo EFG-62 y/o-Asthmatic-mother, elder sister and elder brother are all asthmatic-eats vegetables, drinks alcohol occasionally

GROWTH AND DEVELOPMENTDEVELOPMENTAL MILESTONES

PRESCHOOLERS(3 TO 5 YEARS OLD)

Initiative vs. Guilt

Preschoolers are children between 3 to 5 years old. Children refine the mastery of their bodies and eagerly await the beginning of formal education. Many

people consider these the most intriguing years of parenting because children are less active, can more accurately share their thoughts, and can effectively interact

and communicate. Physical development occurs at a slower pace than cognitive and psychosocial development (Potter & Perry, p. 193). They have enormous

Aunt ANST-27 y/o-teacher-Asthmatic- does walking at Oval (6-7 pm, 2x a week)- eats veggies and loves marang and durian, mangoes

Aunt RBS-32 y/o-accountant-love to eat at Jollibee or chowking (halo-halo)-loves to go to fiestas

Mother-28 y/o-housewife-loves to eat at jollibee(chicken joy, fries, sundaes), chocolates, orange juice, C2 apple

Patient: XYZ-4 year and 11 mos-Asthmatic-nursery 2 at ABC learning center-loves to eat fries, candies, jellyace, C2 strawberry-loves to dance and play tag (running)-fave movie: cinderella, tom and jerry

Brother-3 y/o-Asthamtic-loves fries and candies, C2 apple-fave movie: megamind

Father-30 y/o-OFW- Civil engineer-occasional smoker and drinker-drinks softdrinks (490 ml)-fave food: crispy pata, sinugbang isda, sinigang, dinugu-an, sisig

Uncle RBS-35 y/o-businessman-smoker, alcoholic-loves to go to fiestas

advancement in their abilities to think, speak & remember. The greatest fear of preschoolers is bodily harm of body mutilations. They may fear thunderstorm

sounds, loud music, dark places, some animals like big dogs, or if in the hospital the medical personnel like nurses. This age group would also be in quest for more

information and would usually ask the questions “why?” and “how come?” They would also attribute life to inanimate objects (ANIMISM) and have a notion that

everything in this world is based upon a code of law and order.

A. PHYSICAL GROWTH

In a preschooler the heart rate is at 60 to 100 beats per minute. Respiratory rate is at 23 to 25 counts per minute. Blood pressure rises at 92/ 56 mmHg. The

child gains 5 pound per year and grow 2 ½ to 3 inches per year, doubling their length by age 4. Their legs become elongated and they slim down.

Large and fine muscle coordination improves (Potter & Perry, p. 193). They now run well, hop and climb the stairs with ease unlike toddlers who are still

having difficulty. In this developmental milestone they now can draw and copy crosses and squares and scribble. They are now better in fine motor tasks such as

tying shoelaces, drawing with crayons on paper rather than on walls & pouring cereals into the bowl not onto the floor & show preference in using right or left hand.

PHYSIOLOGIC GROWTH & CHANGE:

Slender, athlete appearanceAs abdominal muscles develop the belly tightensTrunk, arms, & legs grow longerHead is still relatively large but other parts of the body continue to catch up as body proportion steadily becomes more adult like. Weight is around 31 lbs.Boys slightly taller, heavier and have more muscles per lb. body weight.Girls have more fatty tissueBoys and girls grow 2 to 3 inches per year & gain 4-5 lbs annually.Muscular & skeletal growth progresses making them strong. Cartilage turn to bone & bones become harder giving the child a firmer shape & protecting the internal organs.These changes coordinated by the maturing brain & nervous system promote the development of a wide range of motor skills. The increased capacity of the respiratory & circulatory systems, and the development of the immune system keep children healthier. By 3 years old the primary & deciduous teeth are in place. The permanent teeth which begin to appear at about age 6 are developing.

MOTOR SKILLS

3 years old could walk a straight line & jumps on short distance can’t turn or stop quickly can jump13 to 24 inches can ascend a stairway unaided, alternating feet

4 years old hops a few steps on one foot can have more control in starting, turning or stopping when running can jump 24 to 33 inches

5 years old could jump nearly 3 feet & hops from 6 ft. can roller skate can start, turn, and stop effectively in games can make running jump of 28 to 36 inches can descend a long stairway unaided descend the stairs with alternating foot

The maturity of the cerebral cortex allows children to do what they want & what they can do whenever they want. Children under six are ready to take part in organized sports.

FINE MOTOR SKILLS The Preoperational Child (Piaget’s Theory) -2 to7 y/o

Children become more sophisticated in their use of symbolic thought, but can’t think logically until the stage of concrete operational.

Advances identified by Piaget & others:

1. Symbolic function They no longer need sensory cues to think about something. They now have the ability to use symbols or mental representations like words, numbers or images to which a person has attached meanings. They also have symbolic play in which children would make an object represent something (doll for baby).

2. Understanding identitiesThis is the concept that people and things are basically the same even if they change in form, size or appearance. This understanding underlies the emerging self-concept.

3. Understanding cause & effect They persistently ask the “why” questions. They also begin to use words like “because” or “so”.

4. Ability to classifyThey begin to categorize objects, people & events based on similarities a differences.

5. Understanding number conceptsa. 1 –to- 1 principle > saying only one number for each item being counted (one, two, three)b. Stable – order principle > numbers are set in order not scrambledc. Abstraction principle > Preschoolers can count all sorts of things.

Limitations of Preoperational Thought Centration

They focus on one aspect of the situation only and neglect others. They can’t think logically. They also can’t yet consider height & width at the same time.

Confuse with realityHe/she is confused with what he/she sees. e.g. fairy on a movie

- She may see it as real.

Focus on states rather than on transformationThey can’t see the similarity of an object. eg. Water on 1 glass is different if its poured to another glass

Transductive reasoningThey view one situation as the basis for another situation.e.g. thinks that their behavior made the other sibling ill

EgocentrismFocuses only to herself/himself as the center of the world.

AnimismThe tendency to attribute life to objects that are not living.eg. The sky cried because its sad

EmpathyAbility to understand what a person’s feeling.

Language Preschoolers’ vocabularies continue to increase rapidly. By age 6, they have more than 10,000 words that they can use to define familiar objects, identify

colors, and express their desires and frustrations. Language is more social, and questions expand to “Why?” and “How come?” in a quest for information (Potter & Perry, p. 194).

Foot rapping allows them to absorb the meaning of a new word after hearing it only once or twice in a conversation.

Grammar & Syntax3 y/o – uses plural, past tense, and know the difference I, you, & we4-5 y/o – sentence average consist of 4-5 wordsSocial Speech – speech intended to be understood by a listenerPrivate speech – taking aloud to oneself with no intent to communicate with others

MEMORY1. Recognition

The ability to identify something encountered before.

2. RecallAbility to reproduce knowledge about memoryEasily recall items that have an understandable relationship to one another (e.g. plate and spoon, shoe to a foot, scissors to a paper).

HEALTH CONCERNS

1. Nutrition

Nutrition is one of the major problems during this time. This is because preschoolers eat less. The average daily intake is 1800 calories (Potter & Perry, p. 195). Preschoolers need about 2 glasses of milk, 1 serving of meat or fish, cheese or eggs. They also need Vitamin A from carrots, spinach, egg yolk or whole milk; Vitamin C from citrus fruits, tomatoes & leafy green vegetables; and Calcium from dairy products, broccoli & salmon.

Finicky eating habits are characteristics of the 4 year old; however, the 5 year old is more interested in trying new foods (Potter & Perry, p. 195).

2. SleepPreschoolers’ average hours of sleep are 12 hours. This includes night sleep and afternoon naps. One of the problems of a preschooler is having a difficulty

in sleeping that might be due to fears like being afraid in the dark or overabundance of activity and stimulation.

B. PSYCHOSEXUAL DEVELOPMENT

By: SIGMUND FREUD- Phallic Stage or Oedipal

The genital organs become the focus of pleasure. The boy becomes interested to the penis and the girl would become aware of the penis (penis envy). Oedipal and Electra complex develop during this time.

C. PSYCHOSOCIAL DEVELOPMENT

By: ERIK ERIKSON- Initiative vs. Guilt

Children like to pretend and try out new roles. Fantasy and imagination allow children to further explore their environment. Conflicts often arise between the child’s desire to explore and the limits place to his or her behavior. These conflicts may lead to feelings of frustrations and guilt. Guilt may also develop if the caregiver’s response is too punitive. (Potter & Perry, p. 160)

D. COGNITIVE OR DEVELOPMENT

By: JEAN PIAGET- Preoperational (Use of symbols, Egocentric) 2- 7 y/o

Preschoolers would learn to use symbols and images. They see things in only one point of view and uses play as non-language use of symbols.

Kinds of play:1. Parallel Play- children play side by side without a common goal2. Imagination and make believe Play- these are plays based on the child’s experience3. Associative Play- they play together but there are no rules or organization

E. DEVELOPMENT OF MORAL REASONING

By: LAWRENCE KOHLBERG- Preconventional level

Moral reasoning is based on what the child will gain or get. The usage of “why” questions are often related to what he/ she thinks would happen. There are 2 stages in this level that contributes to the child’s development.

1. Stage 1- Punishment and Obedience OrientationThis is the absolute obedience to the rules and regulations. The child does this to avoid punishment.

2. Stage 2- Instrumental Relativist OrientationThe child now begins to recognize that there is more than 1 right view. The decision to do something morally right is based on satisfying one’s own needs, and occasionally the needs of others. Punishment is perceived not as a proof of the child being wrong but as something one wants to avoid. (Potter & Perry, p. 166)

GROWTH AND DEVELOPMENTAL TASK OF OUR PATIENT

AGE: 4 years old

BIOLOGICAL/PHYSICAL GROWTH

Normal Findings:

PROPORTIONAL CHANGES

• 3-6 grow more slowly than before but still develops progress in muscle development & coordination.

• Enormous advancement in their abilities to think, speak & remember.

Actual Findings:

Client’s weight is 20 kg and is 110cm tall

PHYSICAL DEVELOPMENT

• Slim down & shoot up• Improves in gross motor abilities such as running, hopping, skipping, jumping &

throwing balls.• Better in fine motor tasks such as tying shoelaces, drawing with crayons on paper

rather than on walls & pouring cereals into the bowl not onto the floor & show preference in using right or left hand.

• They need less sleep than before & sleep may become a problem.

PHYSIOLOGIC GROWTH & CHANGE

• Slender, athlete appearance• As abdominal muscles develop the toddler’s tight belly tightens• Trunk, arms, & legs grow longer• Head is still relatively large but other parts of the body continue to catch up as body

proportion steadily becomes more adult like. • Muscular & skeletal growth progresses making them strong. Cartilage turn to bone &

bones become harder giving the child a firmer shape & protecting the internal organs.• These changes coordinated by the maturing brain & nervous system promote the

development of a wide range of motor skills. The increased capacity of the respiratory & circulatory systems along with the development of the immune system keeps children healthier.

NUTRITION

• Preschoolers eat less. They need fewer calories per lb. of body weight. They seem to know how much food to take at a given time. What children eat is a different matter. Children whose diets are heavy in sugared cereals, cake, candy & other low-nutrient foods will not have enough appetite for the foods they need.

• Nutritional demands - 2 glasses of milk, one serving of meat or fish, cheese or eggs. Vitamin A from carrots, spinach, egg yolk or whole milk.

Client manifests a lordotic posture, an exaggerated lumbar curvature, to compensate for a high center of gravity.

Client has no problems with vision, hearing and smelling upon physical assessment. Her senses are well-coordinated and she’s able to manipulate her body functions.

Client’s respirations average about 20-30 cpm and remain abdominal. Heart rate averages about 80-90 bpm, strong and regular. Has full control of her urinary and anal sphincter which indicates that her brain has developed. Has the capacity to eat 3 times a day but has decreased appetite due to her illness.

Client has all 20 deciduous teeth but all the upper and lower incisors and canines are filled with dental caries. Mother reported that client already knows how to brush her teeth but still eats a lot of candies and jelly ace.

Yaya verbalized that the usual diet of the client

• Vitamin C from citrus fruits, tomatoes & leafy green vegetables• Calcium from dairy products, broccoli & salmon

contains of hotdogs or longganisa.

Client’s favorite vegetable is carrots but doesn’t like to eat fruits. Drinks more milk than water.

DEVELOPMENTAL MILESTONES

Psychosocial development:

Initiative vs. guilt: 3-6 years

The motor and intellectual abilities continue to increase, continue to explore the environment and to experience many new things assuming more responsibility for initiating and carrying out plans.

Guilt: if the care giver cannot accept the developing initiative and instill a feeling of guilt over misbehavior.

The favorable outcome is sense of competence

We observed that our client already has developed the ability to make decisions such as refusing to eat the food offered by her mother, not drinking the glass of water given by her yaya and deciding to lie down on bed when she feels tired. She is able to tell what she likes and what she wants such as preferring to eat French Fries.

Our client is able to tolerate separation from her mother just like when her mother went out of the hospital to buy lunch, she didn’t constantly look for her but diverted her attention to playing with her younger brother. She was able to participate during changing of bed linens and during bed bath. She is able to follow what she is asked to do.

Client constantly says “no” when asked if she feels pain during palpation of appropriate parts of physical assessment. But confirming her answers was done.

COGNITIVE DEVELOPMENT

• Piaget’s Theory (2-7y/o) - children become more sophisticated in their use of symbolic thought; but can’t think logically until the stage of concrete operational.

• Symbolic play – children make an object stand for something else-e.g. a doll may represent a child

• Understanding cause & effect – young children’s persistent “why” questions show that they are beginning to show cause & effect.

As we reach to the client’s bedside, we can hear client talking loudly to her mother and yayas, she was happy to see us. She also told us that she wants to play with us by coloring her new coloring book.

When we had our initial appraisal of the client, we observed that her appetite increases when her mother mentions about buying something from Jollibee. The thought of it makes her excited and causes her to eat.

The next day, she only consumed half of her share but ate the entire Large Fries bought by her mother.

PSYCHOSEXUAL DEVELOPMENT

Phallic stage: 3-6 years

The genital becomes an interesting and sensitive area of the body. The child recognizes differences between sexes and become curious.

Electra complex: unconscious and sexual desire of female children to their fathers

I observed that client can now control her bowel and bladder functions especially when she tells her mother to assist her to go to the CR. She also tells her mother or Yaya to hold the IV bottle for her and accompany her to the comfort room when she is about to defecate.

Client knows she is a girl and is aware that she has a vagina. She loves to talk about Cinderella and plays with her Barbie dolls.

MORAL DEVELOPMENT

Children aging 2 to 4 years old, fall under punishment and obedience orientation. An action is good or bad depending on whether it results in reward or punishment. If they are punished for it, the action is bad. If they are not punished, the action is good, regardless of the meaning of the act.

We observed that client’s actions are affected by her mother in terms of having restrictions and rules. When client tried to remove her nebulizer mask even though there was still some medicine left she was scolded by her mother. She then didn’t try to remove it after she

was scolded by her mother.

PLAY AND TOYS

• Motor skills• 4 y/o – hops a few steps on one foot• Under six – are ready to take part in organized sports• Fine motor skills such as buttoning shirts & drawing pictures involved eye & hand &

small muscle coordination.• 4 y/o – dress himself with help, can draw a near complete person• Can draw by herself, without much help, copy a square or triangle & draw a more

elaborate person. Maturation of brain & muscle• Pictorial stage – reflect cognitive development of representational ability

We observed that client has no toy on her bed. But their hospital accommodation allowed her to watch cartoons on a DVD player. The client enjoyed watching cartoons such as Cinderella. Mother reported that client is very fond of playing with her Barbie dolls at home alongside with her cousins who were almost the same age with her.

PHYSICAL ASSESSMENT FINDINGS

Review of the Systems

INTEGUMENTARY

Health History: Client has no skin allergies and has no history of serious skin disorders. Everyday she takes a bath. She does not use different cosmetic products such as lotions and cologne. Has no history of head injury.

Assessment:Skin color has the same tone in all parts of the body. Skin is smooth and relatively dry with minimal perspiration. Warm, smooth, soft, even and flexible texture. Lifts easily and immediately returns to its resting position. No edema.

Nails are pinkish with translucent tips. Has a capillary refill of 2 seconds. Moderately thick, well-rounded and convex in shape with a 160-degree angle. No inflammations. Nails are cut short.

Hair is short, black on color, and dry. Slightly thick in quantity and evenly distributed. Presence of nits/lice on hair strands. No dandruff, and scaliness of scalp. Head is in upright position, normocephalic, round and symmetrical. Scalp is lighter than the facial skin, inelastic, no dandruff, lumps, deformities and tenderness. Face is round in shape, symmetrical, has no edema, involuntary movements, and tenderness.

HEENT

1. Eyebrow and Eyes

Health History: Patient claimed that she has no history of any injuries or skin problems encountered on her face. Client does not wear eyeglasses. No previous injuries or damage in the eyes, no history of any illness in her eyes, and no previous eye examination as claimed.

Assessment:Client’s eyebrows are relatively thick and are equally distributed without scaling, lumps, and deformities. Eyelids partially cover the iris when the eyes are open and there are no masses. Conjunctiva is transparent, moist, has blood vessels that are pinkish in color, no swelling and lesions. Sclera is white and cornea has no cloudiness, transparent, shinny, and smooth. Iris is flat, round, and black in color. No difficulty in reading things in far distance.

Direct Light Reflex: pupils constricts when light is directed.Consensual Light reflex: the other pupil also constricts as light is directed to the other pupil.Convergence: eyes simultaneously turn inward when locks at an object closer to the eyes.Accommodation: pupils are dilated when looking at farther objects and constricts when looks at an object nearer to the eyes.Extraocular movements: the client can follow the six directions of gaze in parallel movement of the eyes.

2. Nose/ Sinuses

Health History: The client usually experiences cough and colds. Her mother usually gives her OTC medicines to relieve cough and colds like dimetapp or disudrin.

Assessment:

Nose has the same color of the facial skin, symmetrical to other facial features, no deformity, tenderness, and nodules. Nasal septum is centrally located. Nasal mucosa is pinkish in color but is reddish in the right side with crust formation. Turbinates are pinkish in color, no swelling, exudates, and polyp. Sinuses are not tender.

3. Ears

Health History: Client has no problem in hearing; has not experienced earaches, and no previous infection as said.

Assessment:Auricles are in level with each other, in line with the lateral canthus of the eye. Same color with the facial skin, has no deformities, tender areas, and nodules. Ear canal is pinkish in color with tiny hairs, has yellowish cerumen, no discharges, and swelling.

4. Mouth and Neck

Health History: tooth decay of the upper and lower incisors and canines. Yaya verbalize, “hilig man siya mu kaon candy, bisan unsa nga klase, mu kuha sa sila sa ref. Mukaon pod na siya og jellyace.”

Mouth is symmetrical with other facial features, and smiles in symmetry, no deformities and discharges. Lips have no lumps or cracks. Mucosa is pinkish in color, moist, no cracking, ulcers, unusual odor, bleeding edema or lesions. Gums are pink, smooth, moist with tight margin with teeth, no tenderness, lesions, or masses. Teeth are complete, smooth, with dental caries to all the upper and lower incisors and canines. Hard palate is whitish, dome- shaped. Soft palate is light pink and smooth. Tongue is pinkish, moist, rough on top surface, smooth in lateral margins, centrally located, has raised papillae, and moves freely, no deviations, hypoglossal nerve intact, symmetrical and regular in size. Pharynx is pinkish, smooth, symmetrical, no discharges. Tonsils are pink, no discharges, smooth, and regular in size. Uvula rises when client says “ah”.

Neck: Neck is symmetrical with other facial features, no scars, growth, nor enlargement of parotid glands. Lymph nodes are not easily palpable. Trachea is at the midline. Thyroid gland is non- palpable.

ROM

Health History: Client claimed that she had no serious injuries before and had no fractures.

Assessment:Client can perform R.O.M. without hesitation and difficulty.

CHEST

Health History: The patient claimed she is asthmatic. She has difficulty in breathing during asthma attacks. They have their own nebulizer in their house.

Assessment: a. Posterior ChestPosterior chest is symmetrical upon inspection.No masses or tenderness felt upon palpation

Respiratory Excursion: Symmetrical movement of the thumbs as the patient inhales and exhalesTactile Fremitus: Vibrations were felt symmetrically

Resonance sound is heard upon percussionSlight wheezing heard upon auscultation

b. Anterior ChestRespiratory rate: 24 cpm regular and effortlessIt’s symmetric and she breaths without use accessory musclesNo signs of tenderness and masses noted upon palpation.Wheezing and adventitious sound noted on the right lower part of the chest.Resonance sound is heard upon percussions2 is heard best at 2nd left MCLHR= 80bpm, strong and regular

BREAST AND AXILLAE

Health History: No history of breast complications.

Assessment:Size & Symmetry: Patient’s breast are symmetricalNipples are at the level of the 4th ICS. Color: Has the same color with her skinDimpling or Retractions: Absence of dimpling or retractions.Contour: flat- chested, breast has not yet fully developedRashes or Lesions: No rashes or lesions presentThere are no masses or tenderness palpated

NippleColor: Patient’s nipple is darker than her skin.Lesions or Cracks: absence of lesions or cracksDirection in which they point: Patient’s nipple is everted.Discharges: There were no discharges noted.

AxillaPatient’s axilla has the same color with her skin. There are no rashes or growth.Upon palpation, there are no nodules, lumps or masses.Absence of unnecessary odorNo axilla hairs present

ABDOMEN

Health History: Client claimed that she had no previous abdominal surgeries. Experienced stomachache when not eaten. She has no history of urinary tract infection. Urinates four times a day with urine that is yellow and aromatic. Moves bowel once or twice a day with stool that is semi-solid and brown in color and has no problems in bowel elimination.

Assessment:Scars: No scars notedStriae: No presence of striae

Contour: Patient’s abdomen is flat in shape.Rashes or Lesions: Absence of rashes or lesions.Symmetry: Abdomen is symmetrical.Upon auscultation, bowel sounds were evident at 7 bowel sounds/min in the RLQ.Upon light palpitation, no tenderness felt

Anatomy and Physiology of the Respiratory System

THE RESPIRATORY SYSTEM

The respiratory system generally includes tubes, such as the bronchi, used to carry air to the lungs, where gas exchange takes place. A diaphragm pulls air in and pushes it out. Respiratory systems of various types are found in a wide variety of organisms. Even trees have respiratory systems.

In humans and other mammals, the respiratory system consists of the airways, the lungs, and the respiratory muscles that mediate the movement of air into and out of the body. Within the alveolar, system of the lungs, molecules of oxygen and carbon dioxide are passively exchanged, by diffusion, between the gaseous environment and the blood. Thus, the respiratory system facilitates oxygenation of the blood with a concomitant

removal of carbon dioxide and other gaseous metabolic wastes from the circulation. The system also helps to maintain the acid-base balance of the body through the efficient removal of carbon dioxide from the blood. In humans and other animals, the respiratory system can be conveniently subdivided into an upper respiratory tract (or conducting zone) and lower respiratory tract (respiratory zone), trachea and lungs.

Air moves through the body in the following order: Nostrils à Nasal cavity à Pharynx à Larynx à Trachea à Thoracic cavity à Bronchi à Alveoli

PARTS OF THE RESPIRATORY SYSTEM: 1. Nostril

Bone and cartilage support the nose internally. Its two nostrils are opening through which the air can enter and leave the nasal cavity. Many internal hairs guard the nostrils, preventing entry of large particles carried in the air. (Butler, Lewis & Shier, p. 429)In humans the nasal cycle is the normal ultradian cycle of each nostril's blood vessels becoming engorged in swelling, and then follows shrinking. During the

course of a day they will switch over approximately every four hours or so. Meaning that only one nostril is used at any one time.

2. Nasal Cavity

The nasal cavity (or nasal fossa) is a large air-filled hollow space above and behind the nose in the middle of the face. The nasal cavity conditions the air to be received by the areas of the respiratory tract. The air passing through the nasal cavity is warmed or cooled to within 1 degree of body temperature, the air is then humidified. And finally dust and other particulate matter are removed by the fine hairs present in the nostril. The cilia of the respiratory epithelium move the particulate matter towards the pharynx where it is swallowed or the sticky mucus secreted by the mucous membrane entrap the dust and other small particles entering with air.

Blood and nerve supply:There is a rich blood supply to the nasal cavity. Blood supply comes from branches of both the internal and

external carotid artery, including branches of the facial artery and maxillary artery. The named arteries of the nose are: Sphenopalatine artery, a branch of the maxillary artery, Anterior ethmoidal artery, a branch of the opthalmic artery, and branches of facial artery supplying the vestibule of the nasal cavity.

Innervation:Responsible for the sense of smell is via the olfactory nerve, which sends microscopic fibers from the olfactory

bulb through the cribiform plate to reach the top of the nasal cavity.

General sensory innervation is by branches of the trigeminal nerve (V1 & V2):Nasociliary nerve (V1)Nasopalatine nerve (V2)Posterior nasal branches of Maxillary nerve (V2)

The entire nasal cavity is innervated by autonomic fibers. Sympathetic innervation to the blood vessels of the mucosa causes them to constrict, while parasympathetic innervation of the mucosa controls secretion by mucous glands.

3. Paranasal Sinuses

These are air- filled spaces located within the maxillary, frontal, ethmoid, and sphenoid bones of the skull and opening to the nasal cavity. Mucous membrane lines the sinuses and are continuous with the lining of the nasal cavity. The paranasal sinuses reduce the weight of the skull and are resonant chambers that affect the quality of voice. (Butler, Lewis & Shier, p. 430)

4. Pharynx

The part of the neck and throat situated immediately posterior to the mouth and nasal cavity, and cranial, or superior, to the esophagus, larynx, and trachea. It is part of the digestive system and respiratory system of many organisms. Because both food and air pass through the pharynx, a flap of connective tissue called the epiglottis closes over the trachea when food is swallowed to prevent choking or aspiration. In humans the pharynx is important in vocalization.

The human pharynx is conventionally divided into three sections:Nasopharynx-It lies behind the nasal cavity. Postero-superiorly this extends from the level of the junction of the hard and soft palates to the base of skull, laterally to include the fossa of Rosenmuller. The inferior wall consists of the superior surface of the soft palate.Oropharynx

-It is located behind the oral cavity. The anterior wall consists of the base of the tongue and the vallecula. The lateral wall is made up of the tonsil, tonsillar fossa, and tonsillar (faucial) pillars. The superior wall consists of the inferior surface of the soft palate and the uvula roughly at the level of C1.Hypopharynx-It is also known as the laryngopharynx roughly corresponds to the levels between C3 to C6, it includes the pharyngo-oesophageal junction (postcricoid area), the piriform sinus, and the posterior pharyngeal wall. Like the oropharynx above it the hypopharynx serves as a passageway for food and air and is lined with a stratified squamous epithelium. It lies directly anterior to the upright epiglottis and extends to the larynx, where the respiratory and digestive pathways diverge. At that point the laryngopharynx is continuous with the esophagus posteriorly. The esophagus conducts food and fluids to the stomach; air enters the larynx anterior ly. During swallowing, food has the "right of way", and air passage temporarily stops.

5. Larynx

The larynx is an enlargement in the airway at the top of the treachea and below the pharynx. It conducts air in and out of the trachea and prevents forieng objects from entering the trachea (Butler, Lewis & Shier, p. 431). It is also known as the voicebox. The larynx houses the vocal cords, and is situated just below where the tract of the pharynx splits into the trachea and the esophagus. Sound is generated in the larynx, and that is where pitch and volume are manipulated. The strength of expiration from the lungs also contributes to loudness, and is necessary for the vocal cords to produce speech. Fine manipulation of the larynx is used in a great way to generate a source sound with a particular fundamental frequency, or pitch. This source sound is altered as it travels through the vocal tract, configured differently based on the position of the tongue, lips, mouth, and pharynx. The process of altering a source sound as it passes through the filter of the vocal tract creates the many different vowel and consonant sounds of the world's languages.

During swallowing, the larynx (at the epiglottis and at the glottis) closes to prevent swallowed material from entering the lungs; the larynx is also pulled upwards to assist this process. Stimulation of the larynx by ingested matter produces a strong cough reflex to protect the lungs.

The vocal folds can be held close together (by adducting the arytenoid cartilages), so that they vibrate (see phonation). The muscles attached to the arytenoid cartilages control the degree of opening. Vocal fold length and tension can be controlled by rocking the thyroid cartilage forward and backward on the cricoid cartilage, and by manipulating the tension of the muscles within the vocal folds. This causes the pitch produced during phonation to rise or fall.

Injury to the external laryngeal nerve causes weakened phonation because the vocal cords cannot be tightened. Injury to one of the recurrent laryngeal nerves produces hoarseness, if both are damaged the voice is completely lost and breathing becomes difficult.

6. Vertebrate trachea

The trachea or windpipe is a flexible, cylindrical tube that has an inner diameter of about 2.5cm and a length of about 10-12cm. It extends from the larynx to the primary (main) bronchi in mammals, and from the pharynx to the syrinx in birds, allowing the passage of air to the lungs. It is lined with pseudostratified ciliated columnar epithelium cells with mucosae goblet cells which produce mucus. This lines the cells of the trachea to trap inhaled foreign particles which the cilia then waft upwards towards the larynx and then the pharynx where it can then be swallowed into the stomach.

In humans there are about 15 – 20 incomplete C-shaped cartilaginous rings which reinforces the anterior and lateral sides of the trachea to protect and maintain the airway open. There is a piece of smooth muscle connecting the ends off the incomplete cartilaginous rings called the Trachealis muscle. This contracts reducing the size of the lumen of the trachea to increase the air flow rate during coughing. The esophagus lies posteriorly to the trachea. The cartilaginous rings are incomplete because this allows the trachea to collapse slightly to allow food to pass down the esophagus. The epiglottis is the flap that closes the trachea during swallowing to prevent swallowed matter from entering the trachea.

Clinical significanceEndotracheal intubation is the medical procedure of inserting an artificial tube into the trachea to provide a secure route for ventilating the lungs.

Tracheotomy is a surgical procedure of making an opening in the front of the neck that extends to the lumen of the trachea, a short tube called a tracheostomy tube is inserted through this opening, entering below the level of the larynx and vocal cords.

7. Thoracic cavity

The thoracic cavity (or chest cavity) is the chamber of the human body (and other animal bodies) that is protected by the thoracic wall (thoracic cage and associated skin, muscle, and fascia).

Structures within the thoracic cavity include:structures of the cardiovascular system, including the heart and great vessels, which include the thoracic aorta, the pulmonary artery and its branches, the superior and inferior vena cava, the pulmonary veinsstructures of the respiratory system, including the trachea, bronchi and lungsstructures of the digestive system, including the esophagus,

endocrine glands, including the thymus gland,structures of the nervous system including the paired vagus nerves, and the paired sympathetic chains,lymphatics including the thoracic duct.It contains three potential spaces lined with mesothelium: the paired pleural cavities and the pericardial cavity. The mediastinum comprises those organs which lie in the centre of the chest between the lungs.

Clinical significanceIf the pleural cavity is breached from the outside, as by a bullet wound or knife wound, a pneumothorax, or air in the cavity, may result. If the volume of air

is significant, one or both lungs may collapse, which requires immediate medical attention.8. Bronchus

The bronchial tree is a caliber of airway in the respiratory tract that conducts air into the lungs. No gas exchange takes place in this part of the lungs. The trachea (windpipe) divides into two main bronchi, the left and the right, at the level of the sternal angle. The dividing point is called the carina. The right main bronchus is wider, shorter, and more vertical than the left main bronchus. The main bronchi subdivide into two and three secondary bronchi that each serves the left and right lungs, respectively. The lobar bronchi divide into tertiary bronchi. Each of the segmental bronchi supplies a bronchopulmonary segment. A bronchopulmonary segment is a division of a lung that is separated from the rest of the lung by a connective tissue septum. This property allows a bronchopulmonary segment to be surgically removed without affecting other segments. The segmental bronchi divide into many primary bronchioles which divide into terminal bronchioles, each of which then gives rise to several respiratory bronchioles, which go on to divide into 2 to 11 alveolar ducts. There are 5 or 6 alveolar sacs associated with each alveolar duct. The alveolus is the basic anatomical unit of gas exchange in the lung.

There is hyaline cartilage present in the bronchi, present as irregular rings in the larger bronchi (and not as regular as in the trachea), and as small plates and islands in the smaller bronchi. Smooth muscle is present continuously around the bronchi. In the mediastinum, at the level of the fifth thoracic vertebra, the trachea divides into the right and left primary bronchi. The bronchi branch into smaller and smaller passageways until they terminate in tiny air sacs called alveoli. The cartilage and mucous membrane of the primary bronchi are similar to that in the trachea. As the branching continues through the bronchial tree, the amount of hyaline cartilage in the walls decreases until it is absent in the smallest bronchioles. As the cartilage decreases, the amount of smooth muscle increases. The mucous membrane also undergoes a transition from ciliated pseudostratified columnar epithelium to simple cuboidal epithelium to simple squamous epithelium.

The alveolar ducts and alveoli consist primarily of simple squamous epithelium, which permits rapid diffusion of oxygen and carbon dioxide. Exchange of gases between the air in the lungs and the blood in the capillaries occurs across the walls of the alveolar ducts and alveoli.

Role in disease:Bronchitis is viral or bacterial infection of the bronchi. Asthma is hyper-reactivity of the bronchi with an inflammatory component, often in response to

allergens. Chronic bronchitis (COPD) is smoking- or coal dust-induced chronic inflammation of the bronchi that leads to obstruction of the airways. While the left mainstem bronchus departs from the trachea at an angle, the right mainstem bronchus is almost a vertical continuation of the trachea. This anatomy predisposes the right lung to several problems:

If the endotracheal tube used for intubation is inserted too far, it usually lodges in the right mainstem bronchus. This allows ventilation of the right lung, but leaves the left lung useless.Aspiration pneumonia preferentially affects the right middle lobe of the lung, since food and liquids take the path of least resistance.Patients with inadequate cough reflexes may develop chronic right middle lobe lung infections such as the Lady Windermere Syndrome.

8. Lungs

Lungs are soft, spongy, cone-shaped organs in the thoracic cavity. A layer of serous membranes, the visceral firmly attaches to each lung surface and folds back to become parietal pleura (Butler, Lewis & Shier, p. 435). The potential spaces between them contain a thin film of serous fluid that lubricates adjacent pleural surfaces reducing friction.

9. Pulmonary alveolus

An alveolus (plural: alveoli, from Latin alveus, "little cavity"), is an anatomical structure that has the form of a hollow cavity. In the lung, the pulmonary alveoli are spherical outcroppings of the respiratory bronchioles and are the primary sites of gas exchange with the blood. Alveoli are peculiar to mammalian lungs; different structures are involved in gas exchange in other vertebrates. The alveoli are found in the respiratory zone of the lungs. The lungs contain about 300 million alveoli, representing a total surface area of 70-90 square metres, each wrapped in a fine mesh of capillaries. The alveoli have radii of about 0.1 mm and wall thicknesses of about 0.2 µm. The alveoli consist of an epithelial layer and extracellular matrix surrounded by capillaries. In some alveolar walls there are pores between alveoli.

There are three major alveolar cell types in the alveolar wall (pneumocytes):Type I cells that form the structure of an alveolar wallType II cells that secrete surfactant to lower the surface tension of water and allow the membrane to separate thereby increasing the capability to exchange gases.Type III cells that destroy foreign material, such as bacteria.

The alveoli have an innate tendency to collapse (atelectasis) because of their spherical shape, small size, and surface tension due to water vapor. Phospholipids, which are called surfactants and pores, help to equalize pressures and prevent collapse.

Pulmonary gas exchangePulmonary gas exchange is driven by passive diffusion and thus does not require energy for exchange. Substances move down a concentration gradient.

Oxygen moves from the alveoli (high oxygen concentration) to the blood (lower oxygen concentration, due to the continuous consumption of oxygen in the body). Conversely, carbon dioxide is produced by metabolism and has a higher concentration in the blood than in the air. Oxygen in the lungs first diffuses through the alveolar wall and dissolves in the fluid phase of blood. The amount of oxygen dissolved in the fluid phase is governed by Henry's Law. Oxygen dissolved in the blood may diffuse into red blood cells and bind to hemoglobin. Binding of oxygen to hemoglobin allows a greater amount of oxygen to be transported in the blood. Although carbon dioxide and oxygen are the most important molecules exchanged, other gases are also transported between the alveoli and blood. The amount of a gas that is exchanged depends on the water solubility of the gas the affinity of the gas for hemoglobin. Water vapor is also excreted through the lungs, due to humidification of inspired air by the lung tissues.

Red blood cells transit the alveolar capillaries in about 3/4 of a second. Most gases (including carbon dioxide and nitrous oxide) reach equilibrium with the blood before the red blood cells leave the alveolar capillaries. Gases that reach equilibrium before the blood leaves the alveolar capillaries are perfusion limited, since the amount of the gas exchanged depends solely on the volumetric flow rate of blood past the alveoli. However, carbon monoxide is stored in such high concentrations in the blood, due to its strong binding to hemoglobin, that equilibrium is not reached before the blood leaves the alveolar capillary. Thus, the concentration of carbon monoxide in the arterial system can be used to assess the resistance of the alveolar walls to gas diffusion. Transport of carbon monoxide is thus termed diffusion limited. Oxygen is normally perfusion limited, but in disease conditions it can be diffusion limited.

Defense against pathogens:The lungs are constantly exposed to airborne pathogens and dust particles. The body employs many defenses to protect the lungs, including tonsils in the

nasopharynx which traps germs, small hairs (cilia) lining the trachea and bronchi supporting a constant stream of mucus out of the lungs, and reflex coughing and sneezing to dislodge mucus contaminated with dust particles or micro-organisms.

Matching air supply and blood supply in alveoli:For efficient gas exchange, the ratio of alveolar ventilation and capillary perfusion should be

matched for each lung subunit. Ventilation of a subunit can be lowered by obstruction with fluid, particulates, mucus or tumors. Perfusion is most commonly lowered by pulmonary embolism. A VQ scan is performed to detect imbalances in ventilation ('V') and perfusion ('Q'). Homeostatic responses in the lungs minimize the mismatch of ventilation and blood flow. For example, alveolar epithelia secrete vasodilating substances in response to normal levels of oxygen. Pneumonia is an infection of the alveoli,

which can be caused by both viruses and bacteria. Toxins and fluids are released from the virus causing the effective surface area of the lungs to be greatly reduced. If this happens to such a degree that the patient cannot draw enough oxygen from his environment, then the victim may need supplemental oxygen.

Ventilation

Measurement Equation Description

Minute ventilation = tidal volume x respiratory rate the total volume of gas entering the lungs per minute.

Alveolar ventilation = (tidal volume - dead space) x respiratory rate [1] the volume of gas per unit time that reaches the alveoli, the respiratory portions of the lungs where gas exchange occurs.

Dead space ventilation = dead space x respiratory rate is the volume of gas per unit time that does not reach these respiratory portions, but instead remains in the airways (trachea, bronchi, etc.).

Ventilation of the lungs is carried out by the muscles of respiration. Ventilation occurs under the control of the autonomic nervous system from the part of the brain stem, the medulla oblongata and the pons. This area of the brain forms the respiration regulatory center, a series of interconnected neurons within the lower and middle brain stem which coordinate respiratory movements. The sections are the pneumotaxic center, the apneustic center, and the dorsal and ventral respiratory groups. This section is especially sensitive during infancy, and the neurons can be destroyed if the infant is dropped or shaken violently. The result can be death due to "shaken baby syndrome."

2 PROCESSES:

1. Inhalation

It is also known as inspiration is the movement of air from the external environment, through the airways, into the alveoli during breathing. It is initiated by the diaphragm and supported by the external intercostal muscles. Normal resting respirations are 10 to 18 breaths per minute. Its time period is 2 seconds. During

vigorous inhalation (at rates exceeding 35 breaths per minute), or in approaching respiratory failure, accessory muscles of respiration are recruited for support. These consist of sternocleidomastoid, platysma, and the strap muscles of the neck.

Inhalation is driven primarily by the diaphragm. When the diaphragm contracts, the ribcage expands and the contents of the abdomen are moved downward. This results in a larger thoracic volume, which in turn causes a decrease in intrathoracic pressure. As the pressure in the chest falls, air moves into the conducting zone. Here, the air is filtered, warmed, and humidified as it flows to the lungs. During forced inhalation, as when taking a deep breath, the external intercostal muscles and accessory muscles further expand the thoracic cavity.

Other muscles that can be involved in inhalation include:External intercostal musclesScalene musclesSternocleidomastoid muscleTrapezius muscle

2. Exhalation

It is also called as expiration is the movement of air out of the bronchial tubes, through the airways, to the external environment during breathing. Exhaled air is rich in carbon dioxide, a waste product of cellular respiration during the production of ATP. Exhalation has a complementary relationship to inhalation, the cycling between these two efforts define respiration. Exhalation is generally a passive process, however active or forced exhalation is achieved by the abdominal and the internal intercostal muscles. The lungs have a natural elasticity; as they recoil from the stretch of inhalation, air flows back out until the pressures in the chest and the atmosphere reach equilibrium.

Circulation

The right side of the heart pumps blood from the right ventricle through the pulmonary semilunar valve into the pulmonary trunk. The trunk branches into right and left pulmonary arteries to the pulmonary blood vessels. The vessels generally accompany the airways and also undergo numerous branchings. Once the gas exchange process is complete in the pulmonary capillaries, blood is returned to the left side of the heart through four pulmonary veins, two from each side. The pulmonary circulation has a very low resistance, due to the short distance within the lungs,

Lung Circulation

compared to the systemic circulation, and for this reason, all the pressures within the pulmonary blood vessels are normally low as compared to the pressure of the systemic circulation loop.

Virtually all the body's blood travels through the lungs every minute. The lungs add and remove many chemical messengers from the blood as it flows through pulmonary capillary bed. The fine capillaries also trap blood clots that have formed in systemic veins.

Gas ExchangeThe major function of the respiratory system is gas exchange. As gas exchange occurs, the acid-base

balance of the body is maintained as part of homeostasis. If proper ventilation is not maintained two opposing conditions could occur: 1) respiratory acidosis, a life threatening condition, and 2) respiratory alkalosis.

Upon inhalation, gas exchange occurs at the alveoli, the tiny sacs which are the basic functional component of the lungs. The alveolar walls are extremely thin (approx. 0.2 micrometers), and are permeable to gases. The alveoli are lined with pulmonary capillaries, the walls of which are also thin enough to permit gas exchange. All gases diffuse from the alveolar air to the blood in the pulmonary capillaries, as carbon dioxide diffuses in the opposite direction, from capillary blood to alveolar air. At this point, the pulmonary blood is oxygen-rich, and the lungs are holding carbon dioxide. Exhalation follows, thereby ridding the body of the carbon dioxide and completing the cycle of respiration. In an average resting adult, the lungs take up about 250ml of oxygen every minute while excreting about 200ml of carbon dioxide. During an average breath, an adult will exchange from 500 ml to 700 ml of air. The average breath capacity is called tidal volume.

Development of the respiratory systemThe respiratory system lies dormant in the human fetus during pregnancy. At birth, the respiratory system is drained of fluid and cleaned to assure proper

functioning of the system. If an infant is born before forty weeks gestational age, the newborn may experience respiratory failure due to the under-developed lungs. This is due to the incomplete development of the alveoli type II cells in the lungs. The infant lungs do not function due to the collapse of the alveoli caused by surface tension of water remaining in the lungs. Surfactant is lacking from the lungs, leading to the condition. This condition may be avoided if the mother is given a series of steroid shots in the final week prior to delivery. The steriods accelerate the development of the type II cells.

Conditions of the respiratory system Disorders of the respiratory system can be classified into four general areas:Obstructive conditions (e.g., emphysema, bronchitis, asthma attacks)Restrictive conditions (e.g., fibrosis, sarcoidosis, alveolar damage, pleural effusion)Vascular diseases (e.g., pulmonary edema, pulmonary embolism, pulmonary hypertension)

Pulmonary gas exchange

Infectious, environmental and other "diseases" (e.g., pneumonia, tuberculosis, asbestosis, particulate pollutants) coughing is of major importance, as it is the body's main method to remove dust, mucus, saliva, and other debris from the lungs. Inability to cough can lead to infection. Deep breathing exercises may help keep finer structures of the lungs clear from particulate matter, etc.

OVERVIEW OF THE DISEASE CONDITION

ASTHMAAsthma is a chronic inflammatory disease of the airways that causes hyperresponsiveness, mucosal edema, and mucus production. This inflammation

ultimately leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheezing, and dypnea. Asthma is a common chronic disease of childhood and can occur at any age. Allergy is the strongest predisposing factor for asthma. Chronic exposure to airway irritants or allergens also increases the risk for asthma. (Smeltzer, et al. p. 710)

Common allergens:1. grass, tree, weed pollens2. mold3. dust4. roaches5. animal dander/ feces

Common triggers:1. air pollutants2. cold or heat wheather changes3. strong odors4. smoke5. stress6. emotional upset7. medications

8. viral respiratory infections

Signs/ Symptoms:The patient complains of chest tightness, dyspnea, and difficulty moving air in and out of the lungs. Once initial symptoms are controlled, airways may remain hypersensitive and prone to asthma symptoms for many weeks. On examination, you will note an increased respiratory rate as the patient attempts to compensate for narrowed airways. Inspiratory and expiratory wheezing is heard because of turbulent airflow through swollen airways with thick secretions and may sometimes be audible even without a stethoscope. Air is trapped in the lungs, and expiration is prolonged.

A cough is common and may produce thick, clear sputum. An asthma exacerbation may begin abruptly but most frequently is preceded by increasing symptoms over the previous few days. There is cough, with or without mucus production. At times the mucus is so tightly wedged in the narrowed airway that the patient cannot cough it up.

There is also what we called exercise-induced asthma which includes maximal symptoms during exercise, absence of nocturnal symptoms, and sometimes only a description of a “choking” sensation during exercise. The use of accessory muscles to breathe is a sign that the attack is severe and warrants immediate attention. Be aware that an absence of audible wheezing may not signal improvement but rather may be an ominous sign that the patient is not moving enough air to make a sound. If wheezing is not heard, use of accessory muscles and peak expiratory flow rate values must be carefully evaluated. Once treatment begins to be effective and the patient is moving more air, wheezing may become audible. Asthma is classified according to frequency of symptoms.

Status Asthmaticus

Status asthmaticus is a severe and persistent asthma that does not respond to conventional therapy. The attack can occur with little or no warning and can progress rapidly to asphyliation. Infection, anxiety, nebulizer abuse, dehydration, and nonspecific irritants may contribute to these episodes. (Smeltzer, et al. p. 717).

Classifications of Asthma:

1. Mild Intermittent Asthma- symptoms twice a week or less, night symptoms twice a month or less.

2. Mild persistent Asthma- symptoms more than twice a week, but no more than once a day; symptoms at night more than twice a month. Asthma attacks affect activity.

3. Moderate persistent Asthma- symptoms every day; nighttime symptoms more than once a week. May affect activity.4. Severe persistent- symptoms throughout the day on most days; nighttime symptoms often. Physical activity likely limited.

Therapeutic Interventions:Patients must learn to manage their asthma at home. The better they can monitor and manage their symptoms, the fewer acute episodes and hospitalizations

will be required.

Prevention and Avoidance of triggers

The patient is instructed to identify and avoid asthma triggers. If triggers cannot be avoided, the patient can use bronchodilator or mast cell inhibitor inhalers as prescribed before exposure. Inhalers can be especially useful before exercise. Recent studies have shown that a high-salt diet may worsen exercise-induced airway inflammation.Reduce pet dander. If your child is allergic to dander, it's best to avoid pets with fur or feathers. Regularly bathing or grooming your pets also may reduce the amount of dander in your surroundings. Avoid exposing the children to pollens or molds.Too much Physical activity outdoors and exposure to weather changes or cold air can also trigger asthma attack so better be avoided.Make your home more asthma friendly. Minimize dust that may aggravate nighttime symptoms by replacing certain items in your bedroom. For example, encase pillows, mattresses and box springs in dust-proof covers. Consider removing carpeting and installing hard flooring, particularly in your child's bedroom. Use washable curtains and blinds.Clean regularly. Clean your home at least once a week to remove dust and allergens.Reduce your child's exposure to cold air. If your child's asthma is worsened by cold, dry air, wearing a face mask outside can help.Smoking and exposure to secondary smoke are strongly discouraged.Keep indoor air clean. Have a heating and air conditioning professional check your air conditioning system every year. Change the filters in your furnace and air conditioner according to the manufacturer's instructions. Also consider installing a small-particle filter in your ventilation system.Encourage your child to be active. As long as your child's asthma is well controlled, regular physical activity such as exercise can condition the lungs to work more efficiently.Make sure that your child eats a variety of foods including plenty of fresh fruits and vegetables. Avoid giving foods that can cause allergies like in most cases they are allergic to sea foods (shrimps, crabs, lobster, and shells), junk foods, sodas or carbonated drinks and some chocolates.Aspirin and nonsteroidal anti-inflammatory drugs can cause asthma symptoms in some individuals and so should be avoided.

Treatments and Medications

Treating asthma involves both preventing symptoms and treating an asthma attack in progress. Preventive, long-term control medications reduce the inflammation in your child's airways that leads to symptoms. Quick-relief medications quickly open swollen airways that are limiting breathing. Most children with persistent asthma use a combination of long-term control medications and quick-relief medications, taken with a hand-held inhaler.

In some cases, medications to treat allergies also are needed. The right medication for your child depends on a number of things, including his or her age, symptoms, asthma triggers and what seems to work best to keep his or her asthma under control.

1. Long-term control medications In most cases, these medications need to be taken every day. Types of long-term control medications include:

Inhaled corticosteroidsThese medications include fluticasone (Flovent Diskus, Flovent HFA), budesonide (Pulmicort Flexhaler), mometasone (Asmanex), ciclesonide (Alvesco), flunisolide (Aerobid), beclomethasone (Qvar) and others. Inhaled corticosteroids are the most commonly prescribed type of long-term asthma medication. Your child may need to use these medications for several days to weeks before they reach their maximum benefit. Long-term use of these medications has been associated with slightly slower growth in children, but the effect is minor. In most cases, the benefits of good asthma control outweigh the risks of any possible side effects.

Leukotriene modifiersThese oral medications include montelukast (Singulair), zafirlukast (Accolate) and zileuton (Zyflo, Zyflo CR). They help prevent asthma symptoms for up to 24 hours. In rare cases, these medications have been linked to psychological reactions, such as agitation, aggression, hallucinations, depression and suicidal thinking. Seek medical advice right away if your child has any unusual reaction.

Combination inhalersThese medications contain an inhaled corticosteroid plus a long-acting beta agonist (LABA). They include fluticasone and salmeterol (Advair Diskus,Advair HFA), budesonide and formoterol (Symbicort), and mometasone and formoterol (Dulera). In some situations, long-acting beta agonists have been linked to severe asthma attacks. For this reason, LABA medications should always be given to a child with an inhaler that also contains a corticosteroid. These combination inhalers should be used only for asthma that's not well controlled by other medications.

a. Metered dose inhaler with a face maskThis is a device for infants or small children. It uses a standard metered dose inhaler with a spacer. The face mask attaches to the spacer and is sized

to fit tightly over the nose and mouth to make sure the right dose of medication reaches the lungs.

b. Nebulizer

A nebulizer is a device that turns asthma medication into a fine mist that's breathed in through a mouthpiece or mask worn over the nose and mouth. A nebulizer is generally reserved for people who can't use an inhaler, such as infants, young children, people who are very ill or people who need larger doses of medication.

2. Quick-relief medications Also called rescue medications, quick-relief medications are used as needed for rapid, short-term symptom relief during an asthma attack — or before exercise if your child's doctor recommends it. Types of quick-relief medications include:

Short-acting beta agonists. These inhaled bronchodilator (brong-koh-DIE-lay-tur) medications can rapidly ease symptoms during an asthma attack. They include albuterol (ProAir HFA, Ventolin HFA, others), levalbuterol (Xopenex HFA) and pirbuterol (Maxair Autohaler). These medications act within minutes, and effects last several hours.

Ipratropium (Atrovent). Your doctor might prescribe this inhaled medication for immediate relief of your child's symptoms. Like other bronchodilators, it relaxes the airways, making it easier to breathe. Ipratropium is mostly used for emphysema and chronic bronchitis, but it's sometimes used to treat asthma attacks.

Oral and intravenous corticosteroids. These medications relieve airway inflammation caused by severe asthma. Examples include prednisone and methylprednisolone. They can cause serious side effects when used long term, so they're only used to treat severe asthma symptoms on a short-term basis.

3. Treatment for allergy-induced asthma If your child's asthma is triggered or worsened by allergies, your child may benefit from allergy treatment as well. Allergy treatments include:

Omalizumab (Xolair). This medication is specifically for people who have allergies and severe asthma. It reduces the immune system's reaction to allergy-causing substances, such as pollen, dust mites and pet dander. Xolair is delivered by injection every two to four weeks.

Allergy medications. These include oral and nasal spray antihistamines and decongestants as well as corticosteroid, cromolyn and ipratropium nasal sprays. Allergy shots (immunotherapy). Immunotherapy injections are generally given once a week for a few months, then once a month for a period of three to

five years. Over time, they gradually reduce your child's immune system reaction to specific allergens.

4. Inhaled medication devicesInhaled short- and long-term control medications are used by inhaling a measured dose of medication.

Older children and teens may use a small, hand-held device called a pressurized metered dose inhaler or an inhaler that releases a fine powder. Infants and toddlers need to use a face mask attached to a metered dose inhaler or a nebulizer to get the correct amount of medication.

Babies need to a use a device called a nebulizer, a machine that turns liquid medication into fine droplets. Your baby wears a face mask and breathes normally while the nebulizer delivers the correct dose of medication.

PneumoniaPneumonia is an inflammation of the lung parenchyma caused by various microorganisms, including bacteria,

chlamydiae, mycoplsma, mycobacteria, fungi, parasites and viruses. Pnuemonitis is a more general term that describes an inflammatory process in the lung tissue that may predispose or place the patient at risk for microbial invasion. (Smeltzer, et al. p. 628)

Pneumonia is a common illness, occurs in all age groups, and is a leading cause of death among the elderly and people who are chronically ill. Vaccines to prevent certain types of pneumonia are available. The prognosis for an individual depends on the type of pneumonia, the appropriate treatment, any complications, and the person's underlying health.

Symptoms

greenish or yellow sputumhigh fever that may be accompanied by shaking chillsshortness of breathpleuritic chest painsharp or stabbing pain, either felt or worse during deep breaths or coughsmay cough up bloodexperience headachesdevelop sweaty and clammy skinloss of appetitefatigueblueness of the skin nauseavomitingjoint pains or muscle aches

CAUSES OF PNUEMONIA:1. VirusesViral pneumonia

Viruses must invade cells in order to reproduce. Typically, a virus reaches the lungs when airborne droplets are inhaled through the mouth and nose. Once in the lungs, the virus invades the cells lining the airways and alveoli. This invasion often leads to cell death, either when the virus directly kills the cells, or through a type of cell self-destruction called apoptosis. When the immune system responds to the viral infection, even more lung damage occurs. White blood cells, mainly lymphocytes, activate a variety of chemical cytokines which allow fluid to leak into the alveoli. This combination of cell destruction and fluid-filled alveoli interrupts the normal transportation of oxygen into the bloodstream.

Viral pneumonia is commonly caused by viruses such as influenza virus, respiratory syncytial virus (RSV), adenovirus, and metapneumovirus. Herpes simplex virus is a rare cause of pneumonia except in newborns. People with immune system problems are also at risk for pneumonia caused by cytomegalovirus (CMV).

2. BacteriaBacterial pneumonia

Bacteria typically enter the lung when airborne droplets are inhaled, but they can also reach the lung through the bloodstream when there is an infection in another part of the body. Many bacteria live in parts of the upper respiratory tract, such as the nose, mouth and sinuses, and can easily be inhaled into the alveoli. Once inside the alveoli, bacteria may invade the spaces between cells and between alveoli through connecting pores. This invasion triggers the immune system to send neutrophils, which are a type of defensive white blood cell, to the lungs. The neutrophils engulf and kill the offending organisms, and they also release cytokines, causing a general activation of the immune system. This leads to the fever, chills, and fatigue common in bacterial and fungal pneumonia. The neutrophils, bacteria, and fluid from surrounding blood vessels fill the alveoli and interrupt normal oxygen transportation.

The most common causes of bacterial pneumonia are Streptococcus pneumoniae, Gram-negative bacteria and "atypical" bacteria. The terms "Gram-positive" and "Gram-negative" refer to the bacteria's color (purple or red, respectively) when stained using a process called the Gram stain. The term "atypical" is used because atypical bacteria commonly affect healthier people, cause generally less severe pneumonia, and respond to different antibiotics than other bacteria. The types of Gram-positive bacteria that cause pneumonia can be found in the nose or mouth of many healthy people. Streptococcus pneumoniae, often called "pneumococcus", is the most common bacterial cause of pneumonia in all age groups except newborn infants. Another important Gram-positive cause of pneumonia is Staphylococcus aureus. Gram-negative bacteria cause pneumonia less frequently than gram-positive bacteria. Some of the gram-negative bacteria that cause

pneumonia include Haemophilus influenzae, Klebsiella pneumoniae, Escherichia coli, Pseudomonas aeruginosa and Moraxella catarrhalis. These bacteria often live in the stomach or intestines and may enter the lungs if vomit is inhaled. "Atypical" bacteria which cause pneumonia include Chlamydophila pneumoniae, Mycoplasma pneumoniae, and Legionella pneumophila.

3. FungiFungal pneumonia

Fungal pneumonia is uncommon, but it may occur in individuals with immune system problems due to AIDS, immunosuppresive drugs, or other medical problems. The pathophysiology of pneumonia caused by fungi is similar to that of bacterial pneumonia. Fungal pneumonia is most often caused by Histoplasma capsulatum, Cryptococcus neoformans, Pneumocystis jiroveci, and Coccidioides immitis. Histoplasmosis is most common in the Mississippi River basin, and coccidioidomycosis is most common in the southwestern United States.

4. ParasitesParasitic pneumonia

A variety of parasites can affect the lungs. These parasites typically enter the body through the skin or by being swallowed. Once inside the body, they travel to the lungs, usually through the blood. There, as in other types of pneumonia, a combination of cellular destruction and immune response causes disruption of oxygen transportation. One type of white blood cell, the eosinophil, responds vigorously to parasite infection. Eosinophils in the lungs can lead to eosinophilic pneumonia, thus complicating the underlying parasitic pneumonia. The most common parasites causing pneumonia are Toxoplasma gondii, Strongyloides stercoralis, and Ascariasis.

Types of pneumonia:

A. Community-acquired pneumoniaCommunity-acquired pneumonia (CAP) is infectious pneumonia in a person who has not recently been hospitalized. CAP is the most common type of

pneumonia. The most common causes of CAP differ depending on a person's age, but they include Streptococcus pneumoniae, viruses, the atypical bacteria, and Haemophilus influenzae. Overall, Streptococcus pneumoniae is the most common cause of community-acquired pneumonia worldwide. Gram-negative bacteria cause CAP in certain at-risk populations. CAP is the fourth most common cause of death in the United Kingdom and the sixth in the United States. An outdated term, walking pneumonia, has been used to describe a type of community-acquired pneumonia of less severity (hence the fact that the patient can continue to "walk" rather than require hospitalization). Walking pneumonia is usually caused by a virus or by atypical bacteria.

B. Hospital-acquired pneumoniaHospital-acquired pneumonia, also known as nosocomial pneumonia, is defined as the onset of pneumonia symptoms more than 48 hours after admission in

patients with no evidence of pneumonia during admission. (Smeltzer, et at. P. 629). The causes, microbiology, treatment and prognosis are different from those of community-acquired pneumonia. Up to 5% of patients admitted to a hospital for other causes subsequently develop pneumonia. Hospitalized patients may have many risk factors for pneumonia, including mechanical ventilation, prolonged malnutrition, underlying heart and lung diseases, decreased amounts of stomach acid, and immune disturbances. Additionally, the microorganisms a person is exposed to in a hospital are often different from those at home. Hospital-acquired microorganisms may include resistant bacteria such as MRSA, Pseudomonas, Enterobacter, and Serratia. Because individuals with hospital-acquired pneumonia usually have underlying illnesses and are exposed to more dangerous bacteria, it tends to be more deadly than community-acquired pneumonia. Ventilator-associated pneumonia (VAP) is a subset of hospital-acquired pneumonia. VAP is pneumonia which occurs after at least 48 hours of intubation and mechanical ventilation.

Treatment:Most cases of pneumonia can be treated without hospitalization. Typically, oral antibiotics, rest, fluids, and home care are sufficient for complete resolution.

However, people with pneumonia who are having trouble breathing, people with other medical problems, and the elderly may need more advanced treatment. If the symptoms get worse, the pneumonia does not improve with home treatment, or complications occur, the person will often have to be hospitalized.

Antibiotics are used to treat bacterial pneumonia. In contrast, antibiotics are not useful for viral pneumonia, although they sometimes are used to treat or prevent bacterial infections that can occur in lungs damaged by a viral pneumonia. The antibiotic choice depends on the nature of the pneumonia, the most common microorganisms causing pneumonia in the local geographic area, and the immune status and underlying health of the individual. Treatment for pneumonia should ideally be based on the causative microorganism and its known antibiotic sensitivity. However, a specific cause for pneumonia is identified in only 50% of people, even after extensive evaluation. Because treatment should generally not be delayed in any person with a serious pneumonia, empiric treatment is usually started well before laboratory reports are available. In the United Kingdom, amoxicillin is the antibiotic selected for most patients with community-acquired pneumonia, sometimes with added clarithromycin; patients allergic to penicillins are given erythromycin instead of amoxicillin. In North America, where the "atypical" forms of community-acquired pneumonia are becoming more common, azithromycin, clarithromycin, and the fluoroquinolones have displaced amoxicillin as first-line treatment. The duration of treatment has traditionally been seven to ten days, but there is increasing evidence that shorter courses (as short as three days) are sufficient.

Antibiotics for hospital-acquired pneumonia include vancomycin, third- and fourth-generation cephalosporins, carbapenems, fluoroquinolones, and aminoglycosides. These antibiotics are usually given intravenously. Multiple antibiotics may be administered in combination in an attempt to treat all of the possible causative microorganisms. Antibiotic choices vary from hospital to hospital because of regional differences in the most likely microorganisms, and because of differences in the microorganisms' abilities to resist various antibiotic treatments.

People who have difficulty breathing due to pneumonia may require extra oxygen. Extremely sick individuals may require intensive care treatment, often including intubation and artificial ventilation.

Viral pneumonia caused by influenza A may be treated with rimantadine or amantadine, while viral pneumonia caused by influenza A or B may be treated with oseltamivir or zanamivir. These treatments are beneficial only if they are started within 48 hours of the onset of symptoms. Many strains of H5N1 influenza A, also known as avian influenza or "bird flu," have shown resistance to rimantadine and amantadine. There are no known effective treatments for viral pneumonias caused by the SARS coronavirus, adenovirus, hantavirus, or parainfluenza virus.

Complications:

1. Respiratory and circulatory failureBecause pneumonia affects the lungs, often people with pneumonia have difficulty breathing, and it may

not be possible for them to breathe well enough to stay alive without support. Non-invasive breathing assistance may be helpful, such as with a bilevel positive airway pressure machine. In other cases, placement of an endotracheal tube (breathing tube) may be necessary, and a ventilator may be used to help the person breathe.

Pneumonia can also cause respiratory failure by triggering acute respiratory distress syndrome (ARDS), which results from a combination of infection and inflammatory response. The lungs quickly fill with fluid and become very stiff. This stiffness, combined with severe difficulties extracting oxygen due to the alveolar fluid, create a need for mechanical ventilation.

2. Sepsis or septic shockSepsis and septic shock are potential complications of pneumonia. Sepsis occurs when microorganisms enter the bloodstream and the immune system

responds by secreting cytokines. Sepsis most often occurs with bacterial pneumonia; Streptococcus pneumoniae is the most common cause. Individuals with sepsis or septic shock need hospitalization in an intensive care unit. They often require intravenous fluids and medications to help keep their blood pressure from dropping too low. Sepsis can cause liver, kidney, and heart damage, among other problems, and it often causes death.

3. Emphysema and abscessOccasionally, microorganisms infecting the lung will cause fluid (a pleural effusion) to build up in the space that surrounds the lung (the pleural cavity). If

the microorganisms themselves are present in the pleural cavity, the fluid collection is called an empyema. When pleural fluid is present in a person with pneumonia, the fluid can often be collected with a needle (thoracentesis) and examined. Depending on the results of this examination, complete drainage of the fluid

may be necessary, often requiring a chest tube. In severe cases of empyema, surgery may be needed. If the fluid is not drained, the infection may persist, because antibiotics do not penetrate well into the pleural cavity.

Rarely, bacteria in the lung will form a pocket of infected fluid called an abscess. Lung abscesses can usually be seen with a chest x-ray or chest CT scan. Abscesses typically occur in aspiration pneumonia and often contain several types of bacteria. Antibiotics are usually adequate to treat a lung abscess, but sometimes the abscess must be drained by a surgeon or radiologist.Prevention:1. Smoking cessation is important not only because it helps to limit lung damage, but also because cigarette smoke interferes with many of the body's natural defenses against pneumonia.

2. Vaccination is important for preventing pneumonia in both children and adults. Vaccinations against Haemophilus influenzae and Streptococcus pneumoniae in the first year of life have greatly reduced their role in pneumonia in children. A repeat vaccination may also be required after five or ten years. Influenza vaccines should be given yearly to the same individuals who receive vaccination against Streptococcus pneumoniae. In addition, health care workers, nursing home residents, and pregnant women should receive the vaccine. When an influenza outbreak is occurring, medications such as amantadine, rimantadine, zanamivir, and oseltamivir can help prevent influenza.

DIAGNOSTIC PROCEDURES1. COMPLETE BLOOD COUNT

Complete blood count is an invasive procedure using a needle and a syringe. The needle pierced through the skin to collect blood. The collected specimen is then sent to the lab for diagnosis concerning on the blood cells for any abnormalities.

Specimens of venous blood are taken which includes hemoglobin and hematocrit measurements, erythrocyte (RBC) count, leukocyte (WBC) count, red blood cell (RBC) indices, and a differential white cell count. The CBC is a basic screening test and one of the most frequently ordered blood test (Kozier, et al., p. 758).

A CBC determines the number and types of red and white cells per cubic millimeter of blood. RBCs, WBCs, Hgb, Hct may reveal infection, low blood volume, and potential for oxygenation problems (Potter& Perry, p. 1606). Measuring the packed cell volume, or hematocrit, is the easiest way to ascertain the concentration of red blood cells in the blood clients with anemia have a significant reduction in red blood cell mass and a decrease in oxygen—carrying capacity. (Black& Hawks, p. 1382)

Significance of CBC:1. Determine the # of leukocyte, erythrocyte, and platelets2. WBC differential count to indicate the relative % of different leukocyte3. Determines PT, PTT, and bleeding time4. Peripheral blood smear for RBC morphology

Indications: Complete blood count is used to distinguish abnormalities in blood cell production and reduction. An increase or decrease of the blood components indicates a disease.

Contraindications: Those with IVF infusion at the arm, the phlebotomist must extract blood at the other arm without IVF.

Patient teaching: Inform the patient that the procedure is beneficial to know if there are any deviations in any of the blood components and if the patient is responding well to the medical management given.

2. URINALYSIS

Urinalysis (or "UA") is an array of tests performed on urine and one of the most common methods of medical diagnosis. A part of a urinalysis can be performed by using urine dipsticks, in which the test results can be read as color changes.

Purpose:To determine urine composition and possible abnormal components. (Kozeir, et al. p. 900)

Other tests include:a description of color and appearanceIcotest - The test used to detect the destruction of old Red Blood Cells (RBC) in the urine.Nitrites and hCGHemoglobin Test (Hemolysis in the blood vessels, a rupture in the capillaries of the glomerulus, or hemorrhage in the urinary system may cause hemoglobin to appear in the urine.

Reference ranges and comments for urine tests

MeasurementLower limit

Upper limit

Unit Comments

Urine specific gravity 1.003 1.030 no unit

This test detects the ion concentration of urine. Small amounts of protein or ketoacidosis tend to elevate the urine's specific gravity (SG). This value is measured using a urinometer and indicates whether you are hydrated or dehydrated. If the SG of your urine is under 1.010 you are hydrated. If your urine SG is above 1.020, you are dehydrated.

Osmolality 400 n/a mOsm/kg

Urobilinogen 0.2 1.0 mg/dL

Red blood cells 0 2- 3 per

(RBCs) /erythrocytes

High Power Field(HPF)

RBC casts n/a 0 / neg

White blood cells (WBCs) /leukocytes

0 2/ neg WBC in urine are a marker of infection if present for greater than 5 wbc per high power field

pH 5 7 (unitless)

Protein 0trace amounts/ 20

mg/dL

Proteins may be measured with the Albustix Test. Since proteins are very large molecules (macromolecules), they are not normally present in measurable amounts in the glomerular filtrate or in the urine. The detection of protein in urine may indicate that the permeability of the glomerulus is abnormally increased. This may be caused by renal infections or it may be caused by other diseases that have secondarily affected the kidneys such as diabetes mellitus, jaundice, or hyperthyroidism.

Glucose n/a 0 / negGlucose can be measured with Benedict's Test. Although glucose is easily filtered in the glomerulus, it is not present in the urine because all of the glucose that is filtered is normally reabsorbed from the renal tubules back into the blood.

Ketone bodies n/a 0 / neg

When there is carbohydrate deprivation, such as starvation or high protein diets, the body relies increasingly on the metabolism of fats for energy. This pattern is also seen in people with the disease diabetes mellitus, when a lack of the hormone insulin prevents the body cells from utilizing the large amounts of glucose available in the blood. This happens because insulin is necessary for the transport of glucose from the blood into the body cells. The metabolism of fat proceeds in a series of steps. First, triglycerides are hydrolyzed to fatty acids and glycerol. Second the fatty acids are hydrolyzed into smaller intermediate compounds (acetoacetic acid, betahydroxybutyric acid, and acetone). Thirdly, the intermediate products are utilized in aerobic cellular respiration. When the production of the intermediate products of fatty acid metabolism (collectively known as ketone bodies) exceeds the ability of the body to metabolize these compounds they accumulate in the blood and some end up in the urine (ketonuria).

Bilirubin n/a 0 / neg The fixed phagocytic cells of the spleen and bone marrow destroy old red blood cells and convert the heme groups of hemoglobin to the pigment bilirubin. The bilirubin is secreted into the blood and carried to the liver where it is bonded to (conjugated with) glucuronic acid, a derivative of

glucose. Some of the conjugated bilirubin is secreted into the blood and the rest is excreted in the bile as bile pigment that passes into the small intestine. The blood normally contains a small amount of free and conjugated bilirubin. An abnormally high level of blood bilirubin may result from: an increased rate of red blood cell destruction, liver damage, as in hepatitis and cirrhosis, and obstruction of the common bile duct as with gallstones. An increase in blood bilirubin results in jaundice, a condition characterized by a brownish yellow pigmentation of the skin and of the sclera of the eye.

Blood n/a 0 / neg

May be present as intact RBC which indicates bleeding or discoloration. Note that a very small amount of blood is enough to give the entire urine sample or the foley bag a red/pink hue, and it is difficult to judge the amount of bleeding from a gross examination. The urine color may also be red due to excretion of pigment such as myoglobin and hemoglobin, in which case the urine dipstick shows presence of blood but there are no RBC seen on microscopic examination. Always check INR/PT/PTT and send a fresh urine sample for urinalysis when blood is detected. A case can also be made for urine cytology, especially for elderly patients.

Nitrite n/a 0 / neg

The presence of nitrites in urine indicates the presence of coliform bacteria. This may be a sign of infection, however, the other parameters such as leukocyte esterase, urine white blood cell count, and symptoms such as dysuria, urgency, fevers and chills must be correlated to diagnose an infection.

Sodium (Na) - per day 150 300 mmol / 24hoursThe sodium levels are frequently ordered during the workup of acute renal failure. The fractional excretion of sodium, abbreviated as FeNa is an important marker in distinguishing pre-renal from post-renal failure.

Potassium (K) - per day

40 90 mmol / 24hours

Urine potassium may be ordered in the workup of hypokalemia. In case of GI loss of potassium, the urine potassium will be low. In case of renal loss of potassium, the urine potassium levels will be high. Decreased levels of urine potassium are also seen in hypoaldosteronism and adrenal insufficiency.

Calcium (Ca) - per day 2.5 8.0 mmol / 24hours

Phosphate (P) - per day n/a 38 mmol / 24hours

Creatinine - per day 4.8 19 mmol / 24hours

Freecatecholamines, 90  420 μg/d

dopamine - per day

3. CHEST- X RAY

A chest x- ray may reveal an extensive pathologic process in the lungs and the absence of symptoms. The routine chest x-ray is consisst of two views, the posterioranterior projection and the lateral projection. Chest x- rays are usually taken after 1full inspiration (a deep breath) because the lungs are best visualized when they are aerated. Also, the diaphragm is at its lowest level and largest expanse of air is visible. If x- rays are taken on expiration, x- ray films may accentuate an otherwise unnoticed pnuemothorax or obstruction of a major surgery. (Smeltzer, et al. p. 580)

Significance of Chest x- ray1. detection of tumors, obstruction, excess amount of fluid, and foreign materials2. reveal possible pathologic condition of the patient3. reveal any collapse or inflammation of the lungs

Indications: Patients with COPD, obstruction, difficulty in breathing and other underlying disease conditions that affects the respiratory status of an individual.

Patient teaching:1. Instruct patient to inhale deeply if the radiologist says so.2. Inform patient that chest x- rays can be taken again after 6 months to reduce risk of radioactive exposure that may cause cancer.

MEDICAL MANAGEMENT 1. NEBULIZATION

Nebulization is a technique of administering medication by spraying it into the respiratory tract or using a nebulizer which is a device used to administer medication in the form of a mist inhaled into the lungs. Oxygen may or may not be used to assist carrying the medication into the lungs.

Nebulizers use oxygen, compressed air or ultrasonic power to break up medical solutions/suspensions into small aerosol droplets that can be directly inhaled from the mouthpiece of the device. The definition of an aerosol is a "mixture of gas and liquid particles," and the best example of a natural occurring aerosol is "mist" (being formed when small vaporized water particles mixed with hot ambient air are cooled down and condense into a fine cloud of visible airborne water droplets). When using a nebulizer for inhalation therapy with medicine to be administered directly to the lungs, it is important to note that inhaled aerosol droplets can only penetrate into the narrow branches of the lower airways if they have a small diameter of 1-5 micrometers. Otherwise they are only absorbed by the mouth cavity, where the effect is low.

Parts of a nebulizer:1. power switch2. front storage compartments3. carry handle4. non slip pads

5. vents6. power cord storage compartment7. flip top lid8. air tube9. medicine cup10. mouthpiece

Indications: patients with asthma, pneumonia, and other diseases that needs to have the medication turned into mists

Patient or family teaching:1. Instruct the family members to let the patient finish the medication before turning off the nebulizer.2. Instruct family members to always clean the face mask, medicine cup, and the nebulizer as a whole if not in use and always clean mask and medicine cup after every use.3. Advise parents, relatives or bantays to do proper administration of the medicine.4. Teach the family members or bantays that will give the medication to wash their hands first to prevent cross- contamination.5. Educate family members to remove the face mask and the medicine cup, wash it with soap and water, and boil it.6. Tell them to store it in a clean and dry place.

2. INTRAVENOUS THERAPY

IV therapy is the giving of liquid substances directly into a vein. It can be intermittent or continuous; continuous administration is called an intravenous drip. The word intravenous simply means "within a vein", but is most commonly used to refer to IV therapy. Compared with other routes of administration, the intravenous route is the fastest way to deliver fluids and medications throughout the body. The goal of IV fluid administration is to correct or prevent fluid and electrolyte disturbances. It allows for direct access to the vascular system, permitting the infusion of continuous fluids over a period of time (Potter& Perry, p. 1160).

The IV set consists of:1. short catheter or needle (gauge 18, 20, 22, 24, 26 and butterfly gauge # 19- 26)2. connecting hub3. roller clamp4. drip chamber5. spike6. IV tubing7. armboard8. hypoallergenic plaster

The catheter is inserted through the skin into a peripheral vein, any vein that is not in the chest or abdomen. Arm and hand veins are typically used. Leg and foot veins are occasionally used. On infants the scalp veins are sometimes used.ARM VEINS HAND VIENS

1. Cephalic vein 1. Cephalic vein2. Basilic vein 2. Basilic vein3. Median cubital vein 3. Metacarpal vein

The part of the catheter that remains outside the skin is called the connecting hub; it can be connected to a syringe, an intravenous infusion line, or capped with a bung between treatments. The IV tubing is attached in the connecting hub. Once the procedure is done, the IV flow can be adjusted. Microset is usually used in pediatrics. Common IV flow

Flow Rates: microdrops (microgtts), then the drip factor of the tubing is 60 gtt/ml.

Indications: Intravenous therapy is used to prevent dehydration and to replace the fluids lost in the body.

Common IVF risk or complications:

1. InfectionAny break in the skin carries a risk of infection. Although IV insertion is a sterile procedure, skin-dwelling organisms such as Coagulase-negative

Staphylococcus or Candida albicans may enter through the insertion site around the catheter, or bacteria may be accidentally introduced inside the catheter from contaminated equipment. Moisture introduced to unprotected IV sites through washing or bathing substantially increases the infection risks.

Infection of IV sites is usually local, causing easily visible swelling, redness, and fever. If bacteria do not remain in one area but spread through the bloodstream, the infection is called septicemia and can be rapid and life-threatening. An infected central IV poses a higher risk of septicemia, as it can deliver bacteria directly into the central circulation.

2. PhlebitisPhlebitis is irritation of a vein that is not caused by infection, but from the mere presence of a foreign body (the IV catheter) or the fluids or medication being

given. Symptoms are swelling, pain, and redness around the vein. The IV device must be removed and if necessary re-inserted into another extremity.

3. Fluid overloadThis occurs when fluids are given at a higher rate or in a larger volume than the system can absorb or excrete. Possible consequences include  hypertension, heart

failure, and pulmonary edema.

4. EmbolismA blood clot, other solid mass, or an air bubble that can be delivered into the circulation through an IV and end up blocking a vessel is called embolism.

Patient teaching: Inform the patient that the procedure is beneficial in preventing dehydration and replenishing lost fluids. Advise the patient not to remove or pull the catheter.

Family teaching: Tell the parents or relatives not to regulate the IV by themselves. Tell them to watch out for kinks and report if the IVF is not dripping or has stopped and pain and swelling on the insertion site has occurred.

3. OXYGEN THERAPY

Oxygen therapy is a therapy using oxygen which is a highly combustible gas and the one that human beings need in order to survive or simply supplying oxygen by artificial means. This therapy promotes lung expansion, mobilization of secretions, and maintenance of patent airways (Potter & Perry, p. 1121)

GOAL OF OXYGEN THERAPY:- to prevent and relieve hypoxia- to supply oxygen in COPD patients and other conditions that interfere with breathing and oxygen level in the blood

Oxygen should only be used as indicated and ordered by the physician. It has serious side effects like atelectasis and oxygen toxicity (Potter & Perry, p. 1122). Nurses can only give oxygen therapy of 1- 3 L/minute without the physician’s order in emergency cases.

Parts of the O2 tank:1. valve2. gauge3. flow meter4. regulator5. humidifier6. tank

Methods of Delivery:1. Nasal Cannula2. Nasal Catheter3. Face Mask

Nursing responsibilities:1. Place the “no smoking” sign to ensure safety to the patient since oxygen is a highly combustible gas.2. Make sure that all the electrical equipments are functioning well.

3. Instruct the family members not to smoke inside the patient’s room.4. Check the oxygen level of the tank to ensure that the patient would get the right amount of oxygen needed.5. Always check the physician’s order whether there’s an increase or decrease of the therapy given.4. SUCTIONING

Suctioning is a procedure that is done to help keep a patient's airway open and free of mucous. Mucous is also called "secretions". When a patient has a breathing tube in place, he or she will require intermittent suctioning. The frequency will depend on the quantity and thickness of the secretions.

During suctioning, a small catheter or tube is inserted into the breathing tube. The suction (or vacuum) is applied to the catheter as the tube is removed. The catheter is connected to the breathing tube and contained within a sterile plastic bag. This allows us to quickly suction a patient, without interrupting the breathing machine. Often, the patient will cough during the procedure. This actually helps to bring more of the secretions forward.

Suctioning is uncomfortable but it only lasts a few seconds. The patient may feel like his or her breath is being taken away. The ventilator will often alarm during suctioning. The procedure may make the patient cough and turn red in the face. After it is done, the patient will usually find it easier to breathe through the tube. It may take the patient a few minutes to settle after suctioning. We may need to give the patient a medication to relax their breathing.

A child needs suctioning if there’s:a “gurgle” sound of secretions hard time breathing blue or gray color around eyes, mouth, fingernails, or toenails you feel “rattling” on the child’s chest or back child seems anxious or restless, or cries and cannot be comforted breathing rate or heart rate increases nostrils flare (open wider when breathing in) retracting (chest or neck skin pulls in with each breath)

MEDICAL DAIGNOSIS

Dx: Asthma, Uncontrolled in Acute Moderate Exacerbation secondary to Pneumonia

Date of Admission: July 6, 2011 Date of Discharge: July 12, 2011

Physician: G. N. Nuico Date: July 19, 2011 (Return for check- up)

Clinic: 118

Home medications:

1. Cefuroxime (Zinnat) 125 mg/ 5ml suspension, 8ml every 12 hours for 8 days more2. Meptin syrup, 5ml every 12 hours for 4 days

Laboratory ResultsLaboratory Examinations:

COMPLETE BLOOD COUNTDATE: (07/06/11)

VALUES NORMAL VALUES CORRELATION IMPLICATIONSHemoglobin 12 g/dl 12-14 g/dl (females) Hemoglobin determination is

used to evaluate the hemoglobin content and the oxygen-carrying capacity of erythrocytes by measuring the number of grams of hemoglobin per deciliter (100 ml) of blood and used to determine whether there is anemia or polycythemia.

Total amount or erythryocytes is within normal range.

Hematocrit 34.7% 37- 44% (females) Hematocrit determination is often used in place of the RBC count. This is the measure of the volume of RBCs in whole blood expressed as a percentage. This is used to determine anemia, polycythemia, and abnormal hydration states.

Total amount of Hct is lower than the normal range.

WBC Count 2300/ cumm 5-11 T/cumm The white blood cell count measures the number of WBCs in a cubic milliliter of blood. It is

WBC count is lower than the normal range.

used to detect infection or inflammation and to monitor a client’s response to chemotherapy or radiation therapy. The WBC differential determines the proportion of each type of WBCs in a sample of 100 WBCs.

Segmenters 81% 55 – 70% Neutrophils/ segmenters increase with inflammatory disease or response, tissue necrosis, and granulocytic leukemia; and decrease bone marrow depression, chemotherapy, and viral diseases.

Segmenters are higher than the normal range.

Lymphocytes 11% 20 – 35% Lymphocytes increase during infectious mononucleosis, chronic bacterial infections, tuberculosis, pertussis, and lymphocytic leukemia; they decrease through drug therapy and prednisone.

Lymphocyte level is lower than the normal range.

Monocytes 6% 1– 6% Monocytes increase with viral infections, parasitic disease, collagen and hemolytic disorders; decrease with corticosteroids, RA, HIV infection.

Monocyte value is within normal range.

Basophil 0% 0 –0.5% Basophil increase if there is allergic reaction and if there is an alteration or change in the prothombin time.

Basophil value is within normal range.

Eosinophils 2% 1-4% Eosinophils increase during allergic reactions, parasitic infections, skin diseases, neoplasms, and pernicious anemia; they decrease as a response to stress and to those with Cushing’s syndrome.

Eosinophils value is within normal range.

Platelet Count 327 T/cumm 150- 400 T/cumm The platelet count measures the amount of platelets per cubic milliliter (mm3) of blood. Since platelets have a key role in blood clotting, platelet determination is used to indicate thrombocytopenia or thrombocytosis.

Platelet count is within normal range.

Mean Corp. Vol. 84.7fL 80-96fL An increase may be due to liver disease, pernicious anemia, and a decrease may be due to iron deficiency anemia.

Mean corpuscular volume is within the normal range

Mean Corp. Hgb 28. 3 27- 31pg An increase may be caused by macrocytic anemia and a decrease may be due to microcytic anemia, hypochromic anemia.

Mean corpuscular hemoglobin is within the normal range.

Mean Corp. Hgb Conc. 33.4 33- 36 An increase may be caused by intravascular hymolysis and a decrease may be caused by IDA

Mean corpuscular hemoglobin concentration is within the normal range.

COMPLETE BLOOD COUNTDATE: (07/07/11)

VALUES NORMAL VALUES CORRELATION IMPLICATIONS

Hemoglobin 12.8 g/dl 12-14 g/dl (females) Hemoglobin determination is used to evaluate the hemoglobin content and the oxygen-carrying capacity of erythrocytes by measuring the number of grams of hemoglobin per deciliter (100 ml) of blood and used to determine whether there is anemia or polycythemia.

Total amount or erythryocytes is within normal range.

Hematocrit 34.7% 37- 44% (females) Hematocrit determination is often used in place of the RBC count. This is the measure of the volume of RBCs in whole blood expressed as a percentage. This is used to determine anemia, polycythemia, and abnormal hydration states.

Total amount of Hct is lower than the normal range.

WBC Count 2100/ cumm 5-11 T/cumm The white blood cell count measures the number of WBCs in a cubic milliliter of blood. It is used to detect infection or inflammation and to monitor a

WBC count is lower than the normal range.

client’s response to chemotherapy or radiation therapy. The WBC differential determines the proportion of each type of WBCs in a sample of 100 WBCs.

Segmenters 87% 55 – 70% Neutrophils/ segmenters increase with inflammatory disease or response, tissue necrosis, and granulocytic leukemia; and decrease bone marrow depression, chemotherapy, and viral diseases.

Segmenters are higher than the normal range.

Lymphocytes 10% 20 – 35% Lymphocytes increase during infectious mononucleosis, chronic bacterial infections, tuberculosis, pertussis, and lymphocytic leukemia; they decrease through drug therapy and prednisone.

Lymphocyte level is lower than the normal range.

Monocytes 3% 1– 6% Monocytes increase with viral infections, parasitic disease, collagen and hemolytic disorders; decrease with corticosteroids, RA, HIV infection.

Monocyte value is within normal range.

Basophil 0% 0 –0.5% Basophil increase if there is allergic reaction and if there is an alteration or change in the prothombin time.

Basophil value is within normal range.

Eosinophils 0% 1-4% Eosinophils increase during allergic reactions, parasitic infections, skin diseases, neoplasms, and pernicious anemia; they decrease as a response to stress and to those with Cushing’s syndrome.

Eosinophil value is lower than the normal range.

Platelet Count 308 T/cumm 150- 400 T/cumm The platelet count measures the amount of platelets per cubic milliliter (mm3) of blood. Since platelets have a key role in blood clotting, platelet determination is used to indicate thrombocytopenia or thrombocytosis.

Platelet count is within normal range.

Mean Corp. Vol. 89 fL 80-96 fL An increase may be due to liver disease, pernicious anemia, and a decrease may be due to iron deficiency anemia.

Mean corpuscular volume is within the normal range

Mean Corp. Hgb 29 27- 31 pg An increase may be caused by macrocytic anemia and a decrease may be due to microcytic anemia, hypochromic anemia.

Mean corpuscular hemoglobin is within the normal range.

Mean Corp. Hgb Conc. 35.2% 33- 36% An increase may be caused by intravascular hymolysis and a decrease may be caused by IDA

Mean corpuscular hemoglobin concentration is within the normal range.

Chemical Examination:

URINALYSISDATE: (07/06/11)

Physical and Chemical Examination

FINDINGS NORMAL VALUES SIGNIFICANCE IMPLICATIONS

Color Yellow Straw to amber, may depend on diet

Concentrated urine is darker in color. Dilute urine may appear almost very clear or very pale yellow. Some foods or drugs may color urine. RBC in urine may be evident as pink, bright red or rusty brown urine

The color of the urine is normal.

Appearance Hazy Clear Normal urine appears transparent at voiding. Cloudy urine may result from refrigeration or from standing several minutes at room temperature. Thick cloudy urine is characterized by bacterial growth.

Urine should be clear, but occasionally comes out hazy. This is normal if it happens every once in awhile. However, if hazy urine becomes a constant problem, it could mean that mucus, phosphates, bacteria, pus, or fats are spilling into your urine. These objects should not be present.

Specific Gravity 1.015 1.001 – 1.025 Urine specific gravity is a laboratory test that measures the concentration of particles in the urine. It also reflects the patient’s hydration status

The result shows that the specific gravity of the urine is within the normal value.

as well as renal function.

pH 6.0 4.5 – 8 A urine pH test measures the acidity or alkalinity of the fluid, like blood or urine. This test is helpful for identifying body acid-base imbalances.

pH level is within normal range.

Glucose (+) Negative The glucose urine test measures the amount of sugar (glucose) in a urine sample. The presence of glucose in the urine - glucosuria.

This test is used to screen possible diabetes. Glucose is normally not detected in urine.

Protein Trace Negative A protein urine test measures the amount of proteins, such as albumin, found in a urine sample.

Normally, protein is not found in the urine because the kidneys cannot filter protein, which is a large molecule, only smaller impurities.

Bilirubin Negative Negative Bilirubin is measured to diagnose and/or monitor liver diseases, such as cirrhosis, hepatitis, or gallstones. Patients with hemolytic anemia may have episodes where excessive RBC destruction takes place, raising bilirubin levels.

Bilirubin result is normal.

Ketone Trace Negative Ketones are a by-product/or waste product when the body burns stored fat for energy. High levels may indicate that the body needs more energy from sources other than fat.

Normally, there shouldn’t be any ketone in the urine.

Blood Trace Negative Blood in the urine signifies renal origin. Presence may indicate a renal problem.

Normally, blood should not appear in urine.

Urobilirubin Normal mol/L 131 mol/L Urobilinogen is a colorless product of bilirubin reduction. Urobilinogen is converted to the yellow pigmented urobilin apparent in urine.

Urobilirubin is within normal range.

Nitirite Negative Negative Presence of nitrites in urine may indicate an infection or presence of bacteria

Nitrite result is normal.

Leukocytes Negative Negative This test indicates whether white blood cells are present in urine. Presence of leucocytes indicates infection.

Leukocyte result is normal.

DATE: (07/16/11)

Microscopic Examination FINDINGS NORMAL VALUES SIGNIFICANCE IMPLICATIONS

RBC 0-3/ hpf 0 – 5/ hpf The RBC urine test measures the number of red blood cells in a urine sample. The appearance of red blood cells in the urine depends on the concentration of specimen and the length of time the red cells have been exposed.

The result is accepted as normal.

Pus Cells 0-2/ hpf 0- 5/ hpf Indicates presence of infection The result is normal.

Epithelial Cells Rare 0 - 5/ hpf Epithelial cells in urine are generally having little specific diagnostic utility.

Few epithelial cells in urine are normal.

Bacteria Few None The presence of bacteria indicates infection. The results show rare of bacteria, thus infection is present.

Mucus threads Abundant

CHEST X- RAYDATE: 07/07/11

Name of patient: XYZ

Address: Campaclan, Sibulan, Negros Oriental

Patient ID: 57943-2006

Birthday: July 16, 2006

Accession no. : GH106137-030

Procedure: X chest PAL

Referring Physician: G.N. Nuico

Results:

Clear lungs sounds

Heart shallow is within normal

Trachea is in the middle, pulmonary vessels are distributed

Diaphragm is sharp and distinct

Thoracic cage shows no abnormality

FLUID AND ELECTROLYTES BALANCE SHEET

Bed No.: 469- D Name: XYZ Date: 07/09/11

ORALFLUID

7am 3pm 3pm 11pm 11pm 7am

C2 230H2O 30 H20 30 NO INTAKEIVF 610 IVF 700 IVF 700

TOTAL:1600 870 730 700

FLUID LOSS

7 am 3pm 3pm 11pm 11pm 7am

URINE 2x 500 x 300 x 200VISIBLE PERSPIRATION 136.66 136.66 136.66

STOOL i 150 g i Greenish soft, 60 g 0SUCTION Soft, yellow-

brownMISC.

TOTAL:1283.32

786.66 496.66 336.66

Summary in 24 hours: 2300

Total fluid loss: 1619.98

FLUID AND ELECTROLYTES BALANCE SHEET

Bed No.: 469- D Name: XYZ Date: 07/10/11

ORALFLUID

7am 3pm 3pm 11pm 11pm 7am

H2O 3x (10cc) H20 30 NO INTAKEMILK 240IVF 690 IVF 660 IVF 480

TOTAL:

1650960 690 480

FLUID LOSS

7 am 3pm 3pm 11pm 11pm 7am

URINE X 250 2x 500 2x 500VISIBLE PERSPIRATION 136.66 136.66 136.66

STOOL i 160gSUCTION

MISC.TOTAL:

1023.32386.66 636.66 796.66

Summary in 24 hours: 2130

Total fluid loss: 1819.98

FLUID AND ELECTROLYTES BALANCE SHEET

Bed No.: 469- D Name: XYZ Date: 07/11/11

ORALFLUID

7am 3pm 3pm 11pm 11pm 7am

H2O 15 H20 300MILK 150 MILK 175IVF 380 IVF 410 IVF 520

TOTAL:1255 545 710 695

FLUID LOSS

7 am 3pm 3pm 11pm 11pm 7am

URINE x 250 2x 54 x 240VISIBLE PERSPIRATION 136.66 136.66 136.66

STOOL i 30 g i 8 g 0SUCTION

MISC.TOTAL:

1133.32416.66 716.66 376.66

Summary in 24 hours: 1950

Total fluid loss: 1509.98

VITAL SIGNS SHEET

NAME OF PATINET: XYZ

Date and Time G.RRq2hrs

Misc. Remarks

07-06-11 10pm 40cpm 02 Sat= 90% without O2

12 midnight 50cpm 02 Sat= 97% with O2 @ 1LPM

2am 45cpm 02 Sat= 100% with O2 @ 5LPM

4am 40cpm 02 Sat= 100% with O2 @ 5LPM

6am 31cpm 02 Sat= 100%

07-07-118am 40cpm 02 Sat= 97%

10am 40cpm O2 Sat= 96%

12nn 32cpm

4pm 24cpm O2 Sat= 96% without O2O2 sat= 98%

8pm 25cpm

07-08-11

12midnight 30cpm O2 Sat= 97%

4am 25cpm

8am 25cpm

12nn 28cpm O2 Sat= 97%

07-09-1112 midnight 28cpm

4am 30cpm O2 sat= 98%

8am 26cpm

07-10-1112nn

20cpm

4am 24cpm

07- 11-1112 midnight 23cpm

4am 22cpm

8am 24cpm

12nn 23cpm

PHYSICIAN’S ORDER

7/12/118:30 am

-MGH-DC IV-Home meds:Cefuroxime (Zinnat) 125 mg, 15 ml suspension, 8ml every 12 hours x 8 days more

- ff up: 1 week-Addendum: Meptin syrup 5 ml every 12 hours x 4 days

7/11/118:10 am

-Discontinue Azithromycin after last dose today-IVTFT # 10 D5NM 1l @ 16 gtts/min-Combivent neb to every 8 hours-Discontinue Lanoprozole

7/ 10/1110 am

Decrease IVF to 16 gtts/ minStart Cefuroxime (Zinacef) 500mg IVTT every 6 hours ANST

7/09/118:50 am

IVFTF 7&8 – D5NM1L @ 24gtts/min

NURSES REMARKS

DATE TIME DIET & THERAPY U O NURSES REMARKS07/06/11

07/07/11

2050 H

2051H

2150H

2300 H2330 H2400 H

0100 H

0200 H

0600 H0800 H0820 H

1000 H

1130 H1200 H1500 H1505 H1600 H

Ventolin+ Budicort # 1 D5 0.3% NaCl @ 500 ccVentolin 1 nebuleO2 inhalationMuconase nasal spray

Solucortef 100mg

#2 D5NM 1LFull hypoallergenic diet

Combivent 1 nebSolucortef 100mgPrevacid 15mgFull hypoallergenic diet

#3 D5NM 1LZithromax 5mL

X

X

O

T- 37, P- 169, R- 28; WT= 20 kgO2 inhalation @ 2L/min via nasal cannulaGiven via face maskInserted @ R metacarpal vein @ 24 gtts/min

1L/ min via nasal cannulaT- 36.7, P- 150, R- 40O2 Sat= 90%

Endorsed-------------T- 37.3, P- 115, R- 50

Complained difficulty in breathing. O2 sat= 97%Wheezing noted. O2 increase to 5L/min by Dr. BulosSeen and examined by Dr. SingkoO2 sat= 100% d/t nebulization given. #2 D5NM 1L hooked. T- 36, p- 120, R- 40Served at bedside.T = 37˚C, HR= 145bpm, RR=40cpmO2 Inhalation @ 2LPM via nasal cannulaCombivent 1 neb per nebulizer starter doseSolucortef 100mg slow IVTT starter dosePrevacid 15mg/tab 1 tab PO starter doseServed at bedside.T = 37.1˚C, PR= 108bpm, RR=32cpmEndorsed--------------# 3 D5NM @ 24 gtts/minT = 36˚C, PR= 86bpm, RR=28cpm

07/08/11

07/09/11

07/10/11

1800 H2330 H2400 H0400 H

0500 H0630 H0700 H0800 H1130 H1200 H1500 H1610 H1645 H1800 H2100 H2300 H2315 H2345 H2400 H0400 H0645 H

0700 H0800 H1130 H

1600 H1640 H2000 H2400 H2410 H

Full hypoallergenic diet

#4 D5NM 1LFull hypoallergenic diet

Full hypoallergenic diet

#5 D5NM 1LFull hypoallergenic diet

# 6 D5NM 1LFull hypoallergenic diet

Full hypoallergenic diet

# 7 D5NM 1L

X

2X

X

X

2x

i

i

i

i

i

Zithromax 5mlServed at bedside.Endorsed--------------T = 37.3˚C, HR= 105bpm, RR=30cpmT = 36˚C, HR= 92bpm, RR=25cpmO2 Sat 97%#4 D5NM 1L hookedServed at bedside.Endorsed---------------T = 37.6˚C, HR= 92bpm, RR=26cpmServed at bedside.T = 37.2˚CEndorsed---------------T = 37.9˚C#5 D5NM HookedServed at bedside.T = 36.9˚C, HR= 92bpm, RR=27cpm

Semi-fowlers positionEndorsed-----------------T- 36.8, P- 75, R- 3, O2 sat= 98%T- 36.7, P- 74, R- 26# 6 D5NM 1L hooked.Served at bedside.Endorsed--------------T- 37.1, P- 104, R- 24Served at bedside.T- 37, P- 88, R- 31T- 37, P- 94, R- 29# 7 D5NM 1L hookedT- 37. 4, P- 100, R- 30T = 36.8˚C, PR= 110bpm, RR=28cpmT = 36.1˚C, PR= 100bpm, RR=24cpm

07/ 11/11

70/12/11

0700 H

0730 H1100 H1500 H1600 H1610 H

2300 H

2330 H2400 H0400 H0700 H0730 H

0800 H

1100 H1230 H1500 H1730H1800 H2000 H2330 H2400 H0400 H0645 H0800 H0945 H

#8 D5NM 1LFull hypoallergenic diet

Cefuroxime 50mg

#9 D5NM 1L

Full hypoallergenic diet

Combivent 1 nebMuconase 1 spray to each nostril

# 10 D5NM 1L

Full hypoallergenic diet

#11 D5NM 1L

X

2x

2x

X

2x

X

i greenish, soft

i

i

O

#8D5MN 1L HookedServed at bedside.Endorsed----------------T = 36.6˚C, PR= 70bpm, RR=24cpmCefuroxime (Zinacef) 50mgEndorsed--------------T = 37.2˚C#9 D5NM 1L HookedT = 36.8˚C, PR= 110bpm, RR=28cpm

Endorsed-------------T- 36. 6, P- 92, R- 23T- 36. 5, P- 90, R- 22Served at bedside.Endorsed--------------T-36.8, P- 80, R- 24Given via face maskGiven 1 pray to each nostril

T- 36. 8, P- 80, R- 29# 10 D5NM 1L hookedEndorsed---------------Served at bedside.T- 36. 6, P- 88, R- 24T- 36. 2, P- 84, R- 24Endorsed -------------T = 36.3˚C, PR= 93bpm, RR=20cpmT = 36˚C, PR= 96bpm, RR=20cpm#11 D5NM 1L hookedT = 36.8˚C, PR= 80bpm, RR=25cpmMGH

d/c IV & IV catch intact

Pharmacology Cards

1. Generic Name: SALBUTAMOL 

Brand Name: Ventolin, Combivent

Class: Bronchodilator

Indication: Asthma, COPD, SOB

Action: Produces bronchodilation through stimulation of beta2-andrenergic receptors in bronchial smooth muscle, thereby causing relaxation of bronchial muscle fibers.

Route and Dosage:

Adverse Reaction: nervousness and tremor fine tremor of skeletal muscles particularly in the hands headaches palpitations transient muscle cramps insomnia nausea weakness dizziness peripheral vasodilation & compensatory small increase in heart rate may occur cardiac arrhythmias hypersensitivity reactions including angio edema, bronchospasm, rash hypotension anaphylaxis & collapse

Dosage: 12 months - < 6yrs = 2.5 milligrams

Concentration 2.5 milligrams in 2.5 mL = vol. 2.5mL Concentration 5 milligrams in 2.5 mL = vol. 1.25mL

Contraindications: Patients with a hypersensitivity to any of the ingredients & in the patients with tachyaarhythmias

Nursing responsibilities: Use cautiously in patients with cardiovascular disorders. Warn the patient about the risk of paradoxical bronchospasm and if it occurs, stop drug immediately. Teach patient to use the inhaler correctly: Shake it, clear the throat, expel as much air as possible from the lungs, inhale deeply while releasing the drug from

the inhaler, hold breath for several seconds. Wait for 2 minutes between puffs of inhaler. Wash the canister with warm water and soap at least once a week.

2. Generic Name: LAZOPRAZOLE

Brand Name: Prevacid

Class: Proton Pump Inhibitors

Indication: Indicated as the first line therapy for erosive esophagitis, symptomatic GERD that is poorly responsive other medical treatment such as therapy with H2- Antagonists, short-term treatment of active duodenal ulcers and active begin gastric ulcers, gastric hypersecretory conditions and NSAID ulcers.

Action: PPI’s bind irreversibly to the proton pump. The binding of this enzyme prevents the movement of the hydrogen ions out of the parietal cell into the stomach & thereby blocks all gastric acid secretions.

Adverse Reaction: long term use of PPI’s might promote gastric tumors GIT infections because of the reduction of the normal acid- mediated Antimicrobial protection Headache Dizziness Cough

Epitaxis

Route and Dosage: ≤ 30kg: 15mg/day PO OD, > 30kg: 30mg/day PO OD

Contraindications: known drug allergy

Nursing responsibilities: Administer before meals. Instruct patient to swallow capsules whole, not to open, chew, or crush. Arrange to have regular medical follow-up care while you are taking this drug. Instruct patient to report severe headache, worsening of symptoms, fever, chills.

3. Generic Name: AZITHROMYCIN

Brand name: Zithromax

Classifications: antiinfective; macrolide antibiotic

Indication: Treatment to both upper and lower respiratory tract & skin structure infections

Actions: Inhibits protein synthesis in susceptible bacteria. Transfer RNA must bind to the messenger RNA ribosome. The macrolides obstruct this synthesis by binding to the portion of the ribosome called the 50% submit inside the cells of bacteria to grow & so they eventually die.

Adverse reaction: Cardiovascular: Palpitations, chest pain CNS: headache, dizziness, vertigo, somnolence GIT: nausea, hepatotoxicity, heartburn, vomiting, diarrhea, stomatitis, anoxeria Integument: rash, pruritus, thrombophlebitis Other: hearing loss, tinnitus

Route and Dosage: 50-100mg x 1 dose, then 75-200 mg daily X 4 days

Contraindications: Known drug allergy or similar drugs such as erythromycin Do not take antacids that contain aluminum or magnesium with-in 2 hrs before or after zithromax is taken

Nursing responsibilities: Monitor for and report loose stools or diarrhea. Direct sunlight (UV) exposure should be minimized during therapy with drug. Instruct patient to report onset of loose stools or diarrhea.

4. Generic Name: BUDESONIDE

Brand name: Budecort

Classifications: Indication: used for management of bronchial asthma

Actions: exerts a local anti-inflammatory effect by depression of migration of polymorphonuclear leukocytes & fibroblasts

Adverse reaction: Nasal irritation Bleeding Indigestion

Route and Dosage: child: 12 months – 12 yrs; initial dose 1-2mg

Contraindications: hHpersensitivity to drug primary treatment of acute asthma attacks

Nursing responsibilities: Assess respiratory status

Obtain patient history of condition before therapy & reasons regularly

5. Generic Name: CEFUROXIME

Brand Name: Zinacef, Zinnat

Classification: Cephalosporin antibiotics, third generation cephalosporin

Indications: bacterial infections

Action: Inhibits bacterial cell wall synthesis, rendering cell wall osmotically unstable, leading to cell death.

Route and Dosage: 500 mg 1 tab BID

Contraindications: Those who are hypersensitive to penicillin and to any ingredients of the product or drug

Adverse Effects: Hive- like rash with redness Fever Joint aches or pain Sore throat Fatigue Skin peeling, blisters GI discomforts: nausea, vomiting, constipation, abdominal pain, gas

Nursing Responsibilities: Assess for previous sensitivity to penicillin, renal function, and signs and symptoms of infection. Instruct patient to take the medication at the given length of time only. Teach patient of the possible adverse effect and to report it if it occurs. Instruct client to take it with food if GI discomfort occurs.

6. Generic Name: Hydricortisol

Brand Name: Solu- Cortef

Classification: Hormones and related drugs

Indications: Treatment of primary and secondary adrenal cortex insufficiency, rheumatic disorders, collagen diseases, dermatologic disease, allergic states, repiratory disease, hematologic disorders

Action: Gluco- corticoid with anti- inflammatory effect because of its ability to inhibit prostaglandin synthesis, inhibit migration of macrophages, leukocytes and fibroblast at sites of inflammation, phagocytosis and lysosomal enzyme release. It can also cause the reversal of increased capillary permeability.

Route and Dosage: 100 mg

Contraindications: Systemic fungal infections, acute glomerulonephritis, amebiasis, nonasthmatic bronchial disease, AIDS, children below 2 y/o, TB

Adverse effects:

Depression, mood changes Flushing, sweating Circulatory collapse, thrombophlebitis, embolism, tachycardia Fungal infections Increased ICP, blurred vision Diarrhea, nausea, weakness

Nursing Responsibilities:

Assess condition before giving the medication, mental status, mood and behavior changes. Monitor MIO, weight, BP, glucose and electrolyte levels, and possible adverse effects. Instruct family members to report any adverse effects.

7. Generic Name: 0.6 % NaCl

Brand Name: Muconase

Classification:

Indications:

Action:

Route and Dosage:

Contraindications:

Adverse effects:

Nursing Responsibilities:

FUNCTIONAL

HEALTH PATTERNS

Initial AppraisalDate of Assessment: Ongoing Appraisal Ongoing Appraisal

I. Health Perception-Health Management Pattern

Patient verbalized, “Dugay na ning akong high blood. Kaliwat man mi ug mga high blood mao ng katong akong igsuon nga si Bernabe katong inyong na check up high blood pud.”

Patient verbalized, “Naa man koy maintain ani katong gi reseta ni Dr. Tabaloc pero karun wala na kay wala may budget.”

Patient verbalized, “Daan na pud ni akong asthma. Nasakpan ni katong ni undang nako ug pamaligyag kalaha kay gapa check up man ko kay sige kong kutasan.”

Patient verbalized, “Dili man ko managiraliyo. Wala ko sukad nakapanigarilyo. Muinom nuan ko ug tuba. “

Patient verbalized, “Tungod dagway ni sa among negosyo sauna nga magpautang mi ug kalaha. Magbiyahe mi gikan sa Ilocos hantod sa Mindanao. Magsakay ra mi ana ug barko pero maglakaw nami ug magbalay2x mi.”

Commonly experiences headache, cough, and colds.

No known allergies. Doesn’t smoke. Drinks tuba before but minimized

drinking now that he has asthma.

9:30 am- Patient was cooperative and responsive to the questions being asked. Shortness of breath noted and wheezing was heard upon auscultation.

Patient verbalized, “Bag-o ra man ko gi atake ug asthma didto sa taytayan. Natumba na gud ko. Maygani naay nakasakop nako ug gidala ko sa balay. Gi nebulize dayon ko.”

Patient verbalized, “Maayo unta to ug mga dala2x ko ug katong tambal (puff), unya kay wala pud koy ikapalit ug tambal para ato. Balo ug hain napud gani to nawala naman.”

Vital signs:PR= 76 bpm strong and regularRR= 23 cpm quick, shallow breaths with the use of accessory musclesBP= 160/90 mmHg

Wheezing best heard in the expiratory phase.

Patient had difficulty talking.

1:30- Patient had an asthma attack. Cyanosis noted. Respiratory rate is raised. Accessory muscles of respiration

are employed and the chest appeared hyper-inflated.

Patient was dyspneic. Patient can no longer talk and sit

Seen patient in the waiting shed together with his cousins.

Patient verbalized, “Maayo naman akong paminaw. Salamat kaayo ninyo.”

Patient verbalized, “Nikalit ra man to gahapon human nako ug paniudto, ga lain naman akong ginhawa.”

Instructions on the given medications provided to the patient and his son.

Patient verbalized, “Salamat kaayo ninyo aning mga tambal. Salamat.”

Patient’s son verbalized, “Salamat kaayo ninyo ani te. Ako ra ning andamon.”

Return demonstration on how to use a nebulizer mask was performed by his son.Vital signs:PR= 74 strong and regularRR= 20 cpm without the use of accessory muscleBP= 140/80 mmHg

Minimal wheezing heard on the right chest, left chest is clear of wheezing.

NURSING CARE PLANSCUES/ EVIDENCES NURSING

DIAGNOSISOBJECTIVES INTERVENTION RATIONALE EVALUATION

Subjective: Verbalized, “Usahay

medjo maglisod ko

ug ginhawa.”

There is cough PTA

as claimed

Objective:

Risk for ineffective airway clearance related to retained secretions as evidenced by unproductive cough

During our 16- hours of nursing care, the client will be free from retained secretions as evidenced by:

a. Absence of cough

and colds

anymore.

Independent: Increase fluid

intake.

(Johnson’s

theory of

Behavioral

System Model)

Hydration helps

decrease the

viscosity of

secretions,

facilitating

expectoration.

At the end of our 16-hour nursing care, the client was able to be free from retained secretions as evidenced by: GOAT PARTIALLY MET:

Minimal

Upon assessment, no

presence of

wheezing was noted

at the posterior

chest.

Vital Signs: 7-11-11

T= 36.8◦ C

RR= 24cpm,

regular, deep,

without the

use of

accessory

muscle

PR= 79bpm,

regular,

strong&

bounding

.

b. Ease in breathing.

c. Expectorate

retained secretions

d. Not have noted

adventitious

sounds such as

Wheezing

e. Vital signs within

normal range:

T=36.5-37.5°C PR=60-100bpm RR=15-20cpm

f. Demonstrate behaviors to maintain or improve clear airway.

Provide warm

liquids.

Keep

environmental

pollution to a

minimum (e.g.

dust, smoke),

according to

individual

situation.

(Nightingale’s

theory of

Modern

Nursing).

Dependent: Give

expectorants or

bronchodilators

as ordered.

> Salbutamol (Combivent)

Using warm

liquids may decrease

bronchospasm.

Precipitators of

allergic type of

respiratory reactions

that can trigger or

exacerbate onset of

acute episode.

Bronchodilators

as Salbutamol

relaxes smooth

muscles by

stimulating beta₂-

receptors, thereby

cough and

colds

anymore.

GOAL MET: Vital signs

within normal range:

T= 36.8◦ CRR= 25pm, regular, deep, without the use of accessory muscle

1nebule> Lansoprozole (Pevacid) 1g 1 tablet

> 0.6% NaCl (Muconase) 1 spray nostril 4x a day

causing

bronchodilation and

vasodilation.

PPI’s bind

irreversibly to the

proton pump. The

binding of this

enzyme prevents the

movement of the

hydrogen ions out of

the parietal cell into

the stomach &

thereby blocks all

gastric acid

secretions

Nasal

decongestant,

allows

bronchodilation

for easier

expectoration of

accumulated

> Busdesonide (Budecort) 1reg q12hrs

mucus secretion

exerts a local

anti-

inflammatory

effect by

depression of

migration of

polymorphonucle

ar leukocytes &

fibroblasts

CUES AND EVIDENCES

NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective:

Mother verbalized, “Dili siya tig kaon og kan-on, gatas ra iyang gina inom.”

Mother verbalized, “One and a half oz iyang gatas na na inom”

Altered nutrition less than body requirements related to inadequate intake and loss of appetite

Within our 16- hour nursing care, the patient will exhibit adequate nutritional intake, as evidenced by:

a. Shows no weight loss

b. Consumes whole

INDEPENDENT

Monitor intake and output

Begin with small feedings and advance when tolerated

Body weight may decrease as a result of fluid loss

Enhance intake and improve metabolic demands and increases desire of eating

At the end of our 16- hour nursing care, the client had maintained adequate intake as evidenced by:

GOAL PARTIALLY MET

No significant weight loss

Objectives:

Did not eat her share at breakfast

Weight=20kg Good skin turgor Skin is warm and

moist

share of meal

c. Increase food intake, consume at least half of share

d. Skin turgor is good

e. Skin is moist and soft

f. Bowel sounds within normal range (5-35 bs/min)

Maintain the patency of D5 0.3% Nacl 500mL at 46cc/hr

Provide diet prescribed for patient specific conditions

Involve family and significant others in meal planning

Provide small, frequent meal including dry foods and foods appealing to the child.

Assess/ documents dietary intake

Monitor bowel sounds

To provide the patient with needed fluid and electrolyte

To improve the nutritional status and increase weight

To encourage them to help patient comply with diet regiment after discharge

These may enhance child’s intake of food

Aids in identifying deficiency and dietary needs.

To asses digestion and metabolism

well-hydrated skin and good skin turgor was noted

moist, and pinkish oral mucosa and palpebral conjunctive were observed

Verbalization by the father of increase in appetite

Bowel sounds within normal range

-12 bowel sounds/ min

Instruct bantay to maintain good oral hygiene before & after eating.

COLLABORATIVE

Consult dietician or food experts for proper food type and amount.

To increase satiety because poor oral hygiene decreases patients appetite

Proper food type and amount can increase nutritional status

CUES AND EVIDENCES

NURSING DIAGNOSIS OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Subjective:

Mother verbalized, “Gatas raman iya gina inom”

Objectives:

Noted intake of 15ml – 30ml of H20 on the chart

Drank approximately 50mL C2 strawberry

Risk for fluid volume deficit R/T decreased fluid intake

Within our 16- hour nursing care, our patient will be able to maintain adequate fluid volume level evidenced by:

Having a stable vital signs (T= 36.5- 37.50C; HR- 100-120 bpm regular and strong, RR- 20-30 cpm, regular and not shallow nor deep)

INDEPENDENT

Reassess the condition of the patient

Monitor the patient’s vital signs at least every four hours or as needed; report abnormalities.

Palpate peripheral pulses;

To identify new problems and modify intervention

Tachycardia is present along with a varying degree of hypotension, depending on degree of fluid deficit. Fever increases metabolism and exacerbates fluid loss.

At the end of our 16- hour nursing care, the child exhibit signs and symptoms of adequate fluid balance as evidenced by:

GOAL PARTIALLY MET

Vital signs within normal values: T= 36.8◦ C

RR=25pm,

VITAL SIGNS:8AM

Vital Signs: 7-11-11 T= 36.8◦ C RR= 24cpm, regular,

deep, without the use of accessory muscle

PR= 79bpm, regular, strong& bounding Weight=20 kg

Absence of signs of dehydration like pale mucous membranes, poor skin turgor, pale and dry skin

Normal capillary refill

No further weight loss

Maintaining an equal amount of intake and output.

Absence of edema

note capillary refill, skin color/temperature. Assess skin turgor, mucous membranes, and mentation every shift.

Note potential sources of fluid loss, presence of conditions such as vomiting, diarrhea, etc.

Monitor urinary output. Measure/estimate fluid losses from all sources, e.g., gastrointestinal losses, diaphoresis.

Monitor the IV fluid infusion carefully

Conditions that contribute to extracellular fluid deficit can result in inadequate organ perfusion to all areas and may cause circulatory collapse/shock. Poor capillary refill, poor skin turgor, and dry mucous membranes are all signs of dehydration.

Causative/contributing factors for fluid imbalances.

Fluid replacement needs are based on correction of current deficits and ongoing losses. Note: A diaphoretic episode requiring a full linen change may represent a fluid loss of as much as 1 L. A decreased urinary output may indicate insufficient renal perfusion/hypovolemia, or polyuria can be present, requiring more aggressive fluid replacement.

regular, deep, without the use of accessory muscle

PR=80bpm, regular, strong& bounding

Moist and pinkish oral mucosa

Good capillary refill= 2 seconds

Good skin turgor

No significant weight loss

No edema noted

Evaluate patient’s ability to swallow

Dependent

Administer IV fluid infusion as indicated.

To facilitate ongoing evaluation of fluid status and early detection of infiltration and phlebitis.

Impaired gag/swallow reflexes, anorexia/nausea, oral discomfort, and changes in level of consciousness/cognition are among the factors that affect patient’s ability to replace fluids orally

Intravenous IV fluid can help restore fluid volume.

(July 10, 2011)IVTFT # 9 D5NM 1l @ 16 gtts/min

(July 11, 2011)IVTFT # 10 D5NM 1l @ 16 gtts/min

LIST OF NURSING DIAGNOSES

Priority Problems:

Ineffective airway clearance related to retained secretions as evidenced by unproductive cough

Ineffective health maintenance related to insufficient resources

Risk for activity intolerance related to imbalanced oxygen supply and demand secondary to asthma

Other Problems:

Anxiety related to fear of death secondary to asthma attack

Risk for contamination related to environmental or atmospheric pollutants secondary to asthma

Impaired gas exchange related to altered oxygen supply as evidenced by reduced tolerance for activity secondary to asthma

Ineffective airway clearance related to decreased energy or fatigue as evidenced by a statement of difficulty in breathing secondary to asthma

Ineffective role performance physical illness

PRODEDURES DONE

PROCEDURES RATIONALE

Monitor Vital signs q4h: (Temperature per axilla, Radial Pulse rate, Respiratory Rate, Blood Pressure)

To obtain baseline information needed for comparison and evaluation of patient’s condition and needed to identify interventions.

Review patient’s chart for health history, doctor’s order, medications and etc.

To be guided accordingly and be updated of new physician’s orders.

Administer medications as ordered by physician. To be able to comply with physician’s orders. This will also help improve the condition of the patient and can speed up the recovery of the patient.

Do bedside care (bed bath, bed making, TSB, etc. ) & health teachings on adequate fluid intake, balanced diet and hygiene to patient and parents

To make client comfortable and make client fresh. To provide patient with necessary information needed for the maintenance of health and improvement of condition. Fluid intake - to prevent dehydration and further complications; balanced diet - to maintain good health and to have strong immune system to fight for any diseases; hygiene - to prevent infection and acquiring diseases.

Regulate IVF and check site for phlebitis, infiltration, allergic reactions and infection.

To make sure that patient is receiving adequate IVF to prevent electrolyte imbalance and to ensure that site is free from complications.

Monitor intake and output of patient To prevent fluid volume deficit or excess.

Perform physical assessment: at least related 3 systems

To examine for abnormalities and obtain data that may be significant to the patient’s proper treatment.

INCIDENTAL HEALTH TEAHINGS

HEALTH TEACHING PURPOSE

Nutrition We told her that eating vegetables and fruits would help her boost her immune system and prevents her from getting infections or illnesses quickly.

Brushing of teeth Our patient has dental caries affecting all of her upper and lower incisors and canines. We told her that brushing her teeth would further prevent the other teeth that are not yet affect from becoming decayed. We also told her that she needs to brush 3x a day and that brushing her teeth would help get rid of the harmful bacteria that are present in the mouth.

IVF Our patient is very hyperactive and does not care about the IVF inserted at her left hand. She also asked us why it’s needed. We told her not to suddenly stand and to be careful. We also told her that IVF would prevent dehydration or losing too much fluids in the body.

Nebulization Our patient asked why she was nebulized still when she is already feeling ok. We told her that she would need follow up doses to fully kill the bacteria and in order to make her breath without difficulty.

Asthma Our patient asked us about asthma. We told her that it is either inherited or inborn. it can be caused by allergies or can be triggered.

RELATED READINGSTITLE: What You Need to Know About Indoor Air Pollution

Indoor air pollution, like the name suggests, is air pollution that is inside a building like a home, an office building, or even a department store. Indoor air pollution is a major health risk because the toxins and pollutants in the indoor air pollution is confined within a small space. Because of this it has less of a chance to disperse in larger volumes of open air which would reduce the harmful impacts on humans and other indoor organisms. The EPA confirms the hazards of indoor air pollution, citing that it is in the top five health concerns in the United States. (Kaufman and Franz, 193, 265). In fact, indoor air pollution is the primary catalyst for 80% of new cases of asthma since the 1980s. (1993). Some examples of air pollution include: formaldehyde, radon222, tobacco smoke, asbestos, nitrogen oxide, carbon monoxide, sulfur dioxide, spores, and bacteria.

The seriousness of the indoor air pollution situation has steadily increased over the last decade because of the increased amount of time Americans spend inside. Because of the advancements in home entertainment products like DVDs, computers, internet, home audio systems, and video games Americans now spend 90% of their time inside. This means that they are exposed to the concentrated air pollutants contained within their homes. The second factor that has increased the seriousness of indoor air pollution is that at the present time there are no laws or regulations to help reduce indoor air pollutants in homes. (Kaufman and Franz, 1993, 266).

While there are indoor air pollutants in every building to some degree, urban and suburban areas are more effected because of their reliance on chemical cleaners, and because they have more exposure to auto exhaust and industrial exhaust that filters into their homes. Rural areas are less affected by these contributing factors and have a smaller concentration of indoor air pollutants than urban area homes.

Taking a few simple steps could lessen the seriousness of this problem. First people need to be more conscious of their selections of cleaning and deodorizing products. They should search for products that are biodegradable and bio-friendly products. This often means that they don't have harmful fumes or chemicals that are harmful to living organisms. People could also use traditional cleaning and deodorizing products like baking soda, vinegar, and good old fashion hot water.

Steam cleaning is another alternative that is an affective cleaner and deodorizer that does not release harmful air pollutants. Also to help reduce the effects of indoor air pollution people could open their windows to allow for proper ventilation, and they could also spend more time outside in the fresh air. This would help to minimize the amount of time spent in a confined area where indoor air pollutants are concentrated and can have a harmful affect on the person.

Developing countries are less impacted by indoor air pollution. This is because they have limited funds to spend on cleaning products. They instead rely on traditional cleaners like soap and water. Also people in developing countries spend a greater amount of time outside working in fields, walking or riding bikes to meet their transportation needs, etc. The structure of their buildings, especially their homes are also less "tight". and ventilation is not a problem, as windows and secure doors are not always present.

Summary: Indoor air pollution is air pollution which is inside a building like a home, an office building, or even a department store. It is a major health risk because the toxins and pollutants in the indoor air pollution are confined within a small space, and because of this it has less of a chance to disperse in larger volumes of open air which would reduce the harmful impacts on humans and other indoor organisms.

The seriousness of the indoor air pollution situation has steadily increased over the last decade because 90% people now spend much more time inside their houses because of the home entertainment products like DVDs, computers, internet, home audio systems, and video games. This means that they are exposed to the concentrated air pollutants contained within their homes. The second factor that has increased the seriousness of indoor air pollution is that at the present time there are no laws or regulations to help reduce indoor air pollutants in homes.

To lessen this problem, first people need to be more conscious of their selections of cleaning and deodorizing products. They should search for products that are biodegradable and bio-friendly products. People could also use traditional cleaning and deodorizing products like baking soda, vinegar, and good old fashion hot water. Steam cleaning is an affective cleaner and deodorizer that do not release harmful air pollutants which also help in reducing the effects of indoor air pollution people could open their windows to allow for proper ventilation, and they could also spend more time outside in the fresh air. This would help to minimize the amount of time spent in a confined area where indoor air pollutants are concentrated and can have a harmful affect on the person.

People in developing countries spend a greater amount of time outside working in fields, walking or riding bikes to meet their transportation needs, etc. The structure of their buildings, especially their homes are also less "tight" and ventilation is not a problem, because windows and secure doors are not always present. They are less impacted by indoor air pollution because they have limited funds to spend on cleaning products and instead rely on traditional cleaners like soap and water.

Reaction:

It is ironic to think that there is an indoor pollution because we normally assume that pollution happens outside, just when you think that the cleanest place in the world is your house while reading the article you begin to think otherwise. As I slowly began to read this article I began to reminisce what my mother would always tell everyone in our house that we all need to be mindful of our surroundings and that we should not wait for other people to clean up our rooms. She would always get angry if she will see tiny specs of dust inside the room or in your rooms and then everyone would start to clean once again.

I think now can understand why she stressed this, it because both my grandmother and my older brother are asthmatic. And as I read this article I learned that even though we are inside our precious homes or just going shopping or eating at a restaurant one can get asthma because of the fact that there are accumulated dusts trapped inside that place which can’t go out because they are locked inside.

I can remember how my brother would have a cough which would lead to fever and then a few minutes after that he would have an asthma attack and he would always be admitted to the hospital. I guess he had asthma attacks because he doesn’t always clean his room and the shirts that used are just being piled up in one corner of his room.

The seriousness of the indoor air pollution has increased because people spend inside their time inside their houses because of the home entertainment products like watching DVDs, playing computers games, surfing the internet, and so on and so forth. This means that they are exposed to the concentrated air pollutants contained within their homes. The second factor that has increased the seriousness of indoor air pollution is that at the present time there are no laws or regulations to help reduce doors air pollutants in homes.

The life of as asthmatic p has used are being person for me is so fragile. Just a few seconds of exposure to the irritants such as dusts within our homes or offices or shopping malls can create a massive effect on the asthmatic person.

But then no matter how neat or clean our surroundings are we can always get asthma when we go out. But the good thing about being at home is that there are other people underneath that roof which will be able to help you whenever you will have an asthma attack.

TITLE:: Living on a farm helps prevent asthma, allergies

Dirty, dusty farm life appears to be better for your health than sanitized city life, according to a recent study published in the New England Journal of Medicine. Researchers from Munich University Children's Hospital in Germany found that asthma rates among farm children was less than half the rate of other children, and experts believe the multitude of diverse microbes found in farm environments is responsible.

Researchers collected dust samples from the homes of both children who live on farms and children who live in urban and suburban areas. Upon examination, the farm samples contained a much wider variety of bacteria and fungi than the urban and suburban samples, which were directly correlated to lower overall rates of asthma and allergies.

"The risk of asthma decreased with an increase in the diversity of microbial exposure," said Dr. Markus Ege, author of the study. "Within the microbial spectrum under investigation, several germs with a potential for asthma prevention were identified. A combination of environmental microorganisms might stimulate the innate immune system and counterbalance an asthma-prone immune status."

Previous studies have found similar results, notably a 2010 study out of the University of California, San Diego (UCSD) which found that the germs in dirt help to build immunity and ward off asthma and allergies. The same study also correlated excessive cleanliness with immune impairment because in a sanitary environment, the body is unable to properly build immunity (http://www.naturalnews.com/027855_c...).

Conclusively, both studies on the subject reinforce the fact that environmental germs and microbes can be beneficial to health and immune function. Without them, the body seems unable to build a natural resistance to disease.

Summary: According to a recent study published in the New England Journal of Medicine the dirty, dusty farm life appears to be better for your health than sanitized city life. Researchers from Munich University Children's Hospital in Germany found that the asthma rating among farm children was less than half than that of other children, and experts believe the multitude of diverse microbes found in farm environments is responsible.

Researchers collected dust samples from the homes of both children who live on farms and children who live in urban and suburban areas. Upon examination, the farm samples contained a much wider variety of bacteria and fungi than the urban and suburban samples, which were directly correlated to lower overall rates of asthma and allergies.

Dr. Markus Ege, author of the study said that the risk of asthma decreased with an increase in the diversity of microbial exposure, within the microbial spectrum under investigation, several germs with a potential for asthma prevention were identified. A combination of environmental microorganisms might stimulate the innate immune system and counterbalance an asthma-prone immune status.

The germs that were found in the dirt help to build immunity and ward off asthma and allergies according to 2010 study out of the University of California, San Diego (UCSD). The same study also correlated excessive cleanliness with immune impairment because in a sanitary environment, the body is unable to properly build immunity. Both studies on the subject reinforce the fact that environmental germs and microbes can be beneficial to health and immune function. Without them, the body seems unable to build a natural resistance to disease.

Reaction: I guess I have to agree to this article, indeed there is lesser air pollution in the rural areas compared to the modern society so it not shocking that there are less cases of asthma found. Also that the fact the dirty dusty farmland contained a much wider variety of bacteria and fungi than the urban and suburban samples, which were directly correlated to lower overall rates of asthma and allergies is a plus points to those who are living in the farms.

When Dr. Markus Ege said “A combination of environmental microorganisms might stimulate the innate immune system and counterbalance an asthma-prone immune status. “ I thought to myself that it okay to be expose to the stressors in life as long as you also take the necessary precautions on how to minimize the effect of the stressors, because one of the triggers of asthma is “stress” so one should take in vitamins that can boost immune system

But then again I don’t think I would like living in the farm. I think it would be very boring although it would be healthy on my part. The thing is people now or should I say modern people don’t so much what happens to their body as long they are earning huge amounts of money. They put money first thinking it is the answer to all of their needs. They never understood that money can’t buy your life. You can’t buy another 50 years with all the savings that you have deposited in the banks. You only have one life and chance to live.

Nursing Management

PROCEDURES RATIONALE

Monitor Vital signs q4h:

Temperature per axilla, Radial Pulse rate, Respiratory Rate, Blood Pressure

To obtain baseline information needed for comparison and evaluation of patient’s condition and needed to identify interventions.

Review patient’s chart for health history, doctor’s order, medications and etc. To be guided accordingly and be updated of new physician’s orders.

Administer medications as ordered by physician. To be able to comply with physician’s orders. This will also help improve the condition of the patient and can speed up the recovery of the patient.

Do bedside care (bed bath, bed making, TSB, etc. ) & health teachings on adequate fluid intake, balanced diet and hygiene to patient and parents

To make client comfortable and make client fresh. To provide patient with necessary information needed for the maintenance of health and improvement of condition. Fluid intake - to prevent dehydration and further complications; balanced diet - to maintain good health and to have strong immune system to fight for any diseases; hygiene - to prevent infection and acquiring diseases.

Regulate IVF and check site for phlebitis, infiltration, allergic reactions and infection.

To make sure that patient is receiving adequate IVF to prevent electrolyte imbalance and to ensure that site is free from complications.

Monitor intake and output of patient To prevent fluid volume deficit or excess.

Perform physical assessment: at least related 3 systems To examine for abnormalities and obtain data that may be significant to the patient’s proper treatment.

SYNTHESIS

Making this case study, this involves a Preschooler who has Asthma which complicated to pneumonia, the good thing about our case is that both student nurses who cared for the said patient has more or less experience of the disease seeing as it is present in our families. We cannot imagine the stress we had on making this requirement because we want to submit a presentable case book filled with the needed information, plus the fact that this is our first time in making a presentation under the Pediatrics Rotation and we still don’t have enough expertise. Nevertheless, we were still able to survive as a pair and came up with the analysis and study that we have made from our patient. After days of toil and hard work, along with patience and sacrifice, we were able to sufficiently analyze the case of our patient and also correlate and studied the data that we have gathered. We also included in our study about the growth and development of our client based on standards and theories. And as manifested, our client was able to achieve the developmental task that is fitting for our patient.

To evaluate, we believe that we were able to achieve our goals for the study. We were able to gather relevant and pertinent information about the client’s condition satisfactorily and were able to identify priority problems of the client relevant to the case study/analysis. We were also able to plan care for the Pre-schooler with critical thinking satisfactorily

and applied the theories learned from the previous discussions/subjects taken in the nursing curriculum and related readings to the actual setting and practice in nursing.

REFERENCESBauman, R. (2007). Microbiology with disease by taxonomy. Singapore: Pearson Education South Asia Pte Ltd.

Black, J.M., Hawks, J.H. (2009). Medical-surgical nursing, 8th ed. Singapore: Elsevier Pte Ltd.

Butler, J. Lewis, R. & Shier, D. (2006). Hole’s essentials of human anatomy & physiology, 9th ed. New York: McGraw- Hill.

Divinagracia, C.C. et al. (2009). PPD’s nursing drug guide. Pasay City, 2nd ed. Pasig City: Medicomm Pacific, INC.

Doenges, M. E., Moorhouse, M.F, & Murrr, A.C. (2008). Nurse’s pocket guide: diagnoses, prioritized interventions, and rationales (11th ed.). Taiwan: F. A. Davis Company.

Gould, B.E. (2007). Pathophysiology for the health professional, 3rd ed. Singapore: Elsevier Pte Ltd.

Kee, J. L., Hayes, E.R., & McCuistion, L.E. (2006). Pharmacology: a nursing process approach, 5th ed. Singapore: Elsevier Pte Ltd.

Lily, L.L, Harrington, S., Synder, J.S. (2007). Pharmacology and the nursing process, 5th ed. Singapore: Elsevier Pte Ltd.

Marieb, E. (2002). Essentials of Human Anatomy and Physiology. 6th ed. Singapore: Pearson Education Asia Pte Ltd.

Kozier, B., et al. (2004). Fundamentals of nursing: concepts, process, and practices, 7th ed. Singapore: Pearson Education South Asia Pte Ltd.

Potter, P. A. & Perry, A. G. (2005). Fundamentals of nursing. Singapore: Elsevier Pte Ltd.

Silverman, H. M. (2010). The pill book. United States of America: Bamtam Books.

Smeltzer, S.C., et al. (2008). Brunner & Suddarth’s textbook of medical-surgical nursing, 11th ed. US: Lippincott Williams & Wilkins.

INTERNET SOURCES:

http://web.squ.edu.om/med-Lib/MED_CD/E_CDs/Nursing%20Drug%20Guide/mg/lansoprazole.htm

http://nursingcrib.com/drug-guides/azithromycin/

http://www.associatedcontent.com/article/13513/what_you_need_to_know_about_indoor.html?cat=58

http://www.naturalnews.com/031615_asthma_farms.html