Case Study On Cap

ARELLANO UNIVERSITY College of Nursing S. Y. 2009 – 2010

NURSING CARE PLAN on Community Acquired Pneumonia (CAP) FEMALE WARD – JOSE REYES MEMORIAL MEDICAL CENTER STA. CRUZ, MANILA, PHILIPPINES SUBMITTED BY: JUN CARY V. SUITOS, AUSN GROUP – 64 III – MUSCARINICS

SUBMITTED TO: _________________________________________ CLINICAL INSTRUCTOR

07 SEPTEMBER 2009

I.

PERSONAL DATA

NAME : Patient ABC AGE : 50 y/o DATE OF BIRTH : May 8, 1959 GENDER : Female ADDRESS : Recto, Manila PRIMARY DIALECT SPOKEN: Tagalog ETHNIC GROUP : None RELIGION : Roman Catholic OCCUPATION : Public Servant (Brgy. Secretary) HIGHEST EDUC’L ATTAINMENT: High School MARITAL STATUS : Separated

II.

MEDICAL HISTORY When she was a child, she have had experienced measles and chicken pox but was not medically diagnosed. According to the patient, she doesn’t know if she was vaccinated of certain immunization at childhood due to her parents died as early as she was 5 y/o. Also, according to her, she was admitted at the Jose Reyes Memorial Medical Center due to complaint of cough, dyspnea, and chest pain.

III.

PHYSICAL ASSESSMENT – VITAL SIGNS

SEPT. 1, 2009 (8:00 AM) Pulse Rate : 80 bpm Blood Pressure : 110/70 mmHg Respiratory Rate : 21 cpm Temperature : 36.5º C

SEPT. 1, 2009 (12:00 NN) Pulse Rate : 100 bpm Blood Pressure : 110/80 mmHg Respiratory Rate : 34 cpm Temperature : 37.6 º C

IV.

MEDICATION

Medications 1. Levoflaxacin 500mg/ tab 2. Combinent Neb. 3. FeSO4 + FA Tab 4. NaCl Tab V.

Frequency OD q4h TID TID

DIAGNOSIS

PLANNING

Subjective: “Masakit ang dibdib ko”, as verbalized by the patient. Objective:

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8:00am; 2pm 8:00am; 12nn; 4pm; 8pm 8:00am; 4pm 8:00am; 4pm

Remark Not administered Done at 12:05 nn Not administered Not administered

NURSING CARE PLAN

ASSESSMENT

•

Time

Use of accessory muscle Dyspnea Fatigue V/S taken as follows:

(as of 9/1/09 – 8:00 am) BP : 110/70 mmHg PR : 80 BPM T : 36.5º C RR : 21 CPM

INTERVENTIONS

RATIONALE

EVALUATION

Independent: Acute pain r/t localized inflammation and persistent cough.

After four (4) hours of nursing intervention, the patient will display patent airway with breath sounds clearing and absence of apnea

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Elevate head of the bed, change position frequently.

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Assist patient with deep breathing exercises.

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Demonstrate of patient to perform actively like splinting chest and effective coughing while in upright

Lowers diaphragm, promoting chest expansion and expectoration of secretions.

After four (4) hours of nursing interventions, the patient was able to display patent of airway with breath Deep breathing sounds clearing facilitates maximum and absence of expansion of the dyspnea. lungs and smaller airways. Coughing is a natural selfcleaning mechanism. Splinting reduces chest discomfort, and an upright position favors deeper, more

(as of 9/1/09 – 12:00nn) BP : 110/80 mmHg PR : 100 BPM T : 37.6º C RR : 34 CPM

•

position.

forceful cough efforts.

Force fluids to at least 3000ml / day and offer warm, rather than cold fluids.

Fluids especially warm liquids aid in mobilization and expectoration of secretions.

Collaborative:

Prepared by:

JUN CARY V. SUITOS, AUSN Arellano University – 0900252 College of Nursing – Batch 2011 BSN III - Muscarinics

•

Administer medications as prescribed by the physician/s.

Aids in reduction of bronchospasm and mobilization of secretions.

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Provide supplemental fluids.

Fluids are required to replace losses and aid in mobilization of secretions.