CASE STUDY
( PNEUMONIA )
SUBMITTED BY:
Group 1 A3D
SUBMITTED TO:Mrs. Guendelyn Feleciano
INTRODUCTION
Pneumonia for infants is pneumonia that occurs in very young infants. This lung disease can develop in infants as young as 24 hours old and often occurs partially because of abnormalities in
the airways and lungs. Pneumonia is a significant cause of death in newborns/infants; in deaths that occur in the first 30 days of life, pneumonia is a contributing factor in as much as 25 percent of cases. Infants with pneumonia complicated by blood-borne infection have a mortality risk of 10 percent, and this risk triples if the infant had a low birth weight.
There are several risk factors for infants with pneumonia that can be present before birth. These include maternal fever, tenderness or pain in the uterine area, urinary tract infection and tachycardia of the fetus. Signs that can be noted at or shortly after birth include preterm labor, cloudy or foul-smelling amniotic fluid and rupture of uterine membranes before labor begins. An additional risk factor is gestational maternal illness with an infectious organism known to be capable of crossing the placental barrier.
Infants with pneumonia can have a number of different symptoms. These include abnormally high respiratory rate, grunting when exhaling, yellow or green airway secretions, aspiration of blood, oxygen deprivation in certain tissues and discolored skin, hair and nails. Newborns might also have fluctuating temperature, skin rash, jaundice, irregular heartbeat and a distended abdomen.
Prompt diagnosis and treatment of neonatal pneumonia is crucial because of the high mortality risk associated with this disease. Pneumonia can significantly alter gas exchange in the lungs of neonates, potentially resulting in oxygen
deprivation and compromise of metabolism of all cell types in the body. Structural and immunological defense mechanisms are not fully formed in neonates, which makes it all but impossible for the newborn to fight the infection effectively. In addition, there is an increased risk that the infection might spread from the lungs to other parts of the body.
The goals of treatment for infants with pneumonia are to eradicate the infectious agent and at the same time to protect the infant by providing respiratory support. There are some risks involved in treatment; however, that must be minimized to ensure the infant’s lungs are not permanently damaged. The main risk of antimicrobial treatment is that antimicrobial medications can temporarily worsen lung inflammation, which might increase the risk of permanent lung damage. To reduce this risk, antimicrobial medications are chosen carefully to minimize the dose required to combat the infection.
Antimicrobial medications are the key to successfully treating this disease, but medication alone cannot provide the infant with adequate support. In addition to antimicrobial medication, the infant is provided with a source of oxygen to ensure that he or she is not oxygen-deprived because of reduced lung function. Neonates might also receive blood transfusions and intravenous fluids to ensure adequate nutrition and blood-oxygen capacity.
OBJECTIVES
GENERAL OBJECTIVE:
The researchers will be able to know what pneumonia is, causes of pneumonia, how it is acquired and prevented, its treatments and prevention of the occurrence of pneumonia.
SPECIFIC OBJECTIVE:
Define what is pneumonia Trace the pathophysiology of pneumonia Enumerate the different signs and symptoms of
pneumonia Formulate and apply nursing care plans utilizing the
nursing process To learn new clinical skills as well as sharpen our
current clinical skills required in the management of the patient with pneumonia
ASSESSMENT FINDINGS
I. Demographic Data
The name of the patient is Carmelita Isip. The patient
lives at 1717 Loyola St.,Tondo, Manila. Her age is 54 years
old. Her gender is female. Her birthday is on June 13, 1956.
Filipino is her nationality.The information gathered are
provided by the daughter who is coherent and reliable.She has
a history of hospital admissions due to breast cancer. Prior to
admission stated by his daughter she was experiencing cough
for 3 consecutive days. According to the daughter, these
symptoms occur last_______, _________, 2010. Due to this
condition, her mother decided to consult him in
____________where she was nebulized with Salbutamol
X3 doses and diagnosed with pneumonia. Her vital signs
were, Temperature – __ 8 C, Cardiac Rate – ___ bpm,
Respiratory rate – ___ bpm and weight is ___kg. She was
referred at Gat Andress Medical hospital and admitted on
November 2, 2010 at around 10:45 pm due to cough. The
patient’s vital signs upon admission were, Temperature –
____ 8C, Cardiac Rate – ___ bpm, Respiratory rate – __
bpm and weighs ___ kg. The patient’s daughter decided to
admit her to have proper management of her condition. Her
attending physician is Dr. Torres, M.D. and Dra. See, M.D.
Chief Complaint is cough for 3 days. Her admitting clerk is
V. Espiritu. Monitor her vital signs every 1 hour and must be
recorded.
II. Present and Past Health History
According to the patient’s chart, the patient’s present
health history is distressed non-productive.According to the
daughter of the patient, her mother has no history of injuries
and accidents. There are no known allergies based on the
daughter’s claim. Currently the client is taking Ambroxol,
Cefalexin and Salbutamol.
III. Family History
ISIP FAMILY
FATHER
MOTHER
A&W HD
32yrs. old
30 yrs. old
A&W A&W
Legend:
Living female A&W – Alive & Well
Living male HD – Heart Disease
Upper panel shows a normal lung under a microscope. The
white spaces are alveoli that contain air. Lower panel shows a
lung with pneumonia under a microscope. The alveoli are filled
with inflammation and debris.
The symptoms of infectious pneumonia are caused by the
invasion of the lungs by microorganisms and by the immune
system's response to the infection. Although over one hundred
strains of microorganism can cause pneumonia, only a few of
them are responsible for most cases. The most common causes
of pneumonia are viruses and bacteria. Less common causes of
infectious pneumonia include fungi and parasites.
Viruses
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.
In addition to damaging the lungs, many viruses affect
other organs and thus can disrupt many different body functions.
Viruses also can make the body more susceptible to bacterial
infections; for this reason, bacterial pneumonia often
complicates viral pneumonia.
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).
Bacteria
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 the 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
bacterium Streptococcus pneumonia, a common cause of
pneumonia, photographed through an electron microscope.
Bacteria often travel from an infected lung into the bloodstream,
causing serious or even fatal illness such as septic shock, with
low blood pressure and damage to multiple part of the body
including the brain, kidneys, and heart. Bacteria can also travel
to the area between the lungs and the chest wall (the pleural
cavity) causing a complication called an empyema.
The most common causes of bacterial pneumonia are
Streptococcus pneumonia, 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 call the Gram stain.
The term “atypical” is used because atypical bacteria commonly
affect healthier people, cause generally lea 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 pneumonia, 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 influenza, Klebsiella pneumonia,
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 pneumonia,
Mycoplasma pneumonia, and Legionella pneumophila.
ANATOMY
The respiratory system consists of all the organs
involved in breathing. These include the nose, pharynx,
larynx, trachea, bronchi and lungs. The respiratory system
does two very important things: it brings oxygen into our
bodies, which we need for our cells to live and function
properly; and it helps us get rid of carbon dioxide, which is a
waste product of cellular function. The nose, pharynx, larynx,
trachea and bronchi all work like a system of pipes through
which the air is funneled down into our lungs. There, in very
small air sacs called alveoli, oxygen is brought into the
bloodstream and carbon dioxide is pushed from the blood out
into the air. When something goes wrong with part of the
respiratory system, such as an infection like pneumonia, it
makes it harder for us to get the oxygen we need and to get rid
of the waste product carbon dioxide. Common respiratory
symptoms include breathlessness, cough, and chest pain.
The Upper Airway and Trachea
When you breathe in, air enters your body through your
nose or mouth. From there, it travels down your throat
through the larynx (or voice box) and into the trachea (or
windpipe) before entering your lungs. All these structures act
to funnel fresh air down from the outside world into your
body. The upper airway is important because it must always
stay open for you to be able to breathe. It also helps to
moisten and warm the air before it reaches your lungs.
The Lungs
Structure
The lungs are paired, cone-shaped organs which take up
most of the space in our chests, along with the heart. Their
role is to take oxygen into the body, which we need for our
cells to live and function properly, and to help us get rid of
carbon dioxide, which is a waste product. We each have two
lungs, a left lung and a right lung. These are divided up into
'lobes', or big sections of tissue separated by 'fissures' or
dividers. The right lung has three lobes but the left lung has
only two, because the heart takes up some of the space in the
left side of our chest. The lungs can also be divided up into
even smaller portions, called 'bronchopulmonary segments'.
These are pyramidal-shaped areas which are also
separated from each other by membranes. There are about 10
of them in each lung. Each segment receives its own blood
supply and air supply.
How they work
Air enters your lungs through a system of pipes called
the bronchi. These pipes start from the bottom of the trachea
as the left and right bronchi and branch many times
throughout the lungs, until they eventually form little thin-
walled air sacs or bubbles, known as the alveoli. The alveoli
are where the important work of gas exchange takes place
between the air and your blood. Covering each alveolus is a
whole network of little blood vessel called capillaries, which
are very small branches of the pulmonary arteries. It is
important that the air in the alveoli and the blood in the
capillaries are very close together, so that oxygen and carbon
dioxide can move (or diffuse) between them. So, when you
breathe in, air comes down the trachea and through the
bronchi into the alveoli. This fresh air has lots of oxygen in it,
and some of this oxygen will travel across the walls of the
alveoli into your bloodstream. Traveling in the opposite
direction is carbon dioxide, which crosses from the blood in
the capillaries into the air in the alveoli and is then breathed
out. In this way, you bring in to your body the oxygen that
you need to live, and get rid of the waste product carbon
dioxide.
MEDICAL MANAGEMENT
The goal of treatment is to cure the infection with
antibiotics. If the pneumonia is caused by a virus, antibiotics
will not be effective. Supportive therapy includes oxygen and
respiratory treatments to remove secretions.
NURSING MANAGMENT
The patient will need to have breath sounds monitored q
2 to determine if pneumonia is progressing.
O2 Sats should be done regularly ( at least q4during acute
phase) to make sure that patient is getting adequate
perfusion.
Make sure to give all scheduled antibiotics on schedule so
that therapeutic ranges are maintained.
Any s/s of infection must be monitored and reported to
MD.
Care given to patient includes nebulization.
Performed tepid sponge bath.
I and O taken every shift.
Positioning the patient in Semi-Fowler’s position
LABORATORY AND DIAGNOSTIC PROCEDURE
HEMATOLOGY REPORT
Examination Request: CBC
Date of the procedure: 11/04/2010
PARAMETER ACTUAL RESULT NORMAL
VALUES
Hemoglobin
Hematocrit
WBC Count
Differential Count
Segmenters
Lymphocytes
103
0.31
11.6
80
20
M=140-170g/L;
F=120-150g/L
M=0.40-0.50;
F=0.37-0.42
5-10 X 109/L
0.55-0.65
0.25-0.35
Date of the procedure: 11/06/2010
PARAMETER ACTUAL RESULT NORMAL
VALUES
Hemoglobin 108 M=140-170g/L;
F=120-150g/L
Hematocrit
WBC Count
Differential Count
Segmenters
Lymphocytes
0.32
14.8
79
21
M=0.40-0.50;
F=0.37-0.42
5-10 X 109/L
0.55-0.65
0.25-0.35
Date of the procedure: 11/04/2010
PARAMETER ACTUAL RESULT NORMAL
VALUES
Hemoglobin
Hematocrit
WBC Count
101
0.30
12.0
M=140-170g/L;
F=120-150g/L
M=0.40-0.50;
F=0.37-0.42
5-10 X 109/L
Differential Count
Segmenters
Lymphocytes
88
18
0.55-0.65
0.25-0.35
Urinalysis
Color: Yellow
Transparency: Clear
Reaction: (pH) 6.0
Protein: negative
Glucose: negative
Specific Gravity: 1.010
Pus cells: 0-1/HPF
RBC: 0-1/hpf
Epithelial Cell:
Chest X-ray
Date of the Procedure: 11/04/2010
CHEST AP/L
Streaky densities are seen in both lower lungs
Heart is not enlarged
Diaphragm and sulci are intact
Impression: Pneumonia, Bilateral
Date of the Procedure: 11/06/2010
CHEST AP/L
Follow-up film shows clearing of the previously noted bilateral
Pneumonia infiltrates
DISCHARGE PLAN
M – MEDICATION TO TAKE
- Instruct and explain the patient’s daughter that the medication is very important to continue depending on the duration that the doctor ordered for the total recovery of the patient.
E – EXERCISE
- Instruct the daughter to let the patient do normal activities but it should be limited to a short period
of time only to prevent the occurrence of shortness of breathing.
T – TREATMENT
- Advice the daughter to keep patient relax in order to recover in her present condition. Instruct the daughter to minimize the patient from exposure to an open environment such as dusty and smoky area, which airborne microorganism are present that can be a high risk factor that may cause severity of his condition.
H – HEALTH TEACHING
- Encourage and explain to patient’s family that it is important to maintain proper hygiene to prevent further infection. Instruct the patient every day and explain that bathing early in the morning is not a factor or cause of having pneumonia.
O – OUT PATIENT
- Regular consultation to the physician can be a factor for recovery and to assess and monitor the patient’s condition.
D – DIET
- Diet as tolerated.Diet plays a big role in fast recovery.
Etiology
Pneumonia is a serious infection or inflammation of
your lungs. The air sacs in the lungs fill with pus and other
liquid. Oxygen has trouble reaching your blood. If there is
too little oxygen in your blood, your body cells can’t work
properly. Because of this and spreading infection through
the body pneumonia can cause death. Pneumonia affects
your lungs in two ways. Lobar pneumonia affects a section
(lobe) of a lung. Bronchial pneumonia (or
bronchopneumonia) affects patches throughout both
lungs.
Bacteria are the most common cause of pneumonia.
Of these, Streptococcus pneumoniae is the most common.
Other pathogens include anaerobic bacteria,
Staphylococcus aureus, Haemophilus influenzae,
Chlamydia pneumoniae, C. psittaci, C. trachomatis,
Moraxella (Branhamella) catarrhalis, Legionella
pneumophila, Klebsiella pneumoniae, and other gram-
negative bacilli. Major pulmonary pathogens in infants and
children are viruses: respiratory syncytial virus,
parainfluenza virus, and influenza A and B viruses. Among
other agents are higher bacteria including Nocardia and
Actinomyces sp; mycobacteria, including Mycobacterium
tuberculosis and atypical strains; fungi, including
Histoplasma capsulatum, Coccidioides immitis,
Blastomyces dermatitidis, Cryptococcus neoformans,
Aspergillus fumigatus, and Pneumocystis carinii; and
rickettsiae, primarily Coxiella burnetii (Q fever).
The usual mechanisms of spread are inhaling
droplets small enough to reach the alveoli and aspirating
secretions from the upper airways. Other means include
hematogenous or lymphatic dissemination and direct
spread from contiguous infections. Predisposing factors
include upper respiratory viral infections, alcoholism,
institutionalization, cigarette smoking, heart failure, chronic
obstructive airway disease, age extremes, debility,
immunocompromise (as in diabetes mellitus and chronic
renal failure), compromised consciousness, dysphagia,
and exposure to transmissible agents.
Typical symptoms include cough, fever, and sputum
production, usually developing over days and sometimes
accompanied by pleurisy. Physical examination may
detect tachypnea and signs of consolidation, such as
crackles with bronchial breath sounds. This syndrome is
commonly caused by bacteria, such as S. pneumoniae
and H. influenza.
Drug Study
Medications:
Name of
Drug
Dosag
e &
Freque
Rout
e
Curative
Effects
Side Effects
ncy
AMPICILIN 110 mg
q6
TIV Antibiotic; for
bacterial
infection
caused by
Gram positive
and some
Gram
negative; for
anaerobic
bacteria
Diarrhea,
itching, difficulty
in breathing and
swallowing,
mild skin
rash,upset
stomach,vomiti
ng,wheezing
GENTAMI
CIN
17g
q24
TIV Antibiotic; for
bacterial
infection that
cause by
gram
negative
bacteria
Toxicity to the
vestibular
apparatus of
the inner
ear(OTOTOXIC
ITY) ,
Nephrotoxicity,
Gentamicin
toxicity
PARACET 50mg TIV Decrease Stimulation,
AMOL q4 for
37.8⁰
fever by
inhibiting the
effects of
pyrogens on
the
hypothalamic
heat
regulating
centers and
by a
hypothalamic
action leading
to sweating
and
vasodilatation
s.
drowsiness,
nausea,
vomiting,
abdominal pain,
hepatoxicity,
hepa
seizure(overdos
e), renal
failure(high
prolonged
doses),leucope
nia, rash,
hypersensitivity,
cyanosis,
anmenia,
jaundice etc..
GENTAMICIN- bacteriacidal
Symptoms of gentamicin toxicity include:
Balance difficulty
Bouncing, unsteady vision
Physical Assessment
Date assessed: November 9, 2010
Time Assessed: 3:00 P.M
Initial Vital Signs:
Temperature: 37.8C
Cardiac Rate: 80 beats per minute
Respiratory Rate: 34 breaths per minute
General Appearance: The pt. is asleep, lying on bed
with CTT on the right 5th ICS
Area Assessed Normal
Findings
Actual
Findings
Analysis
SKIN
color Tan(Dark
Brown)
Tan(Dark
Brown)
Normal
Texture Smooth, soft Smooth, soft Normal
Turgor Skin snaps
back
immediately
When
pinched
Skin snaps
back
immediately
when
pinched
Normal
Hair Distribution Evenly
distributed
Evenly
distributed
Normal
Temperature Warm to
touch
Too warm
when
touched
Febrile
Moisture Dry, skin
folds are
normally
moist
Dry, skin
folds are
normally
moist
Normal
NAILS
Color of Nail
bed
Pink and
clear
Pink and
clear
Normal
Texture Smooth Smooth Normal
Shape Convex
curvature
Convex
curvature
Normal
Nail base Firm Firm Normal
Capillary refill
time
2-3 seconds 2 sec. Normal
HAIR
Color Black
(varies)
Black Normal
Distribution Evenly
distributed
Evenly
distributed
Normal
Moisture Neither
excessively
dry nor oily
Neither
excessively
dry nor oily
Normal
Texture Silky,
resilient
Silky,
resilient
Normal
HEAD
Scalp symmetry Symmetrical Symmetrical Normal
Skull size Normocephal
ic
Normocephal
ic
Normal
Shape Round Round Normal
Nodules/ Absence of Absence of Normal
masses nodules and
masses
nodules and
masses
FACE
Symmetry Symmetrical Symmetrical Normal
Facial
movement
Symmetrical Symmetrical Normal
Skin color Tan Tan Normal
EYES
Eyebrows
Symmetricall
y aligned
Symmetricall
y aligned
Normal
Eyelashes Slightly
curved
upward
Slightly
curved
upward
Normal
Eyelids Smooth, tan,
do not cover
pupil as
sclera, close
symmetricall
y
Smooth, tan,
do not cover
pupil as
sclera, close
symmetricall
y
Normal
Ability to blink Blinks
voluntarily
Blinks
voluntarily
Normal
and
bilaterally
and
bilaterally
Ocular
movement
Eye moves
freely
Eye moves
freely
Normal
Position Drawn from
lateral angel
Drawn from
lateral angel
Normal
Size Medium Medium Normal
Texture Mobile, firm
and non-
tender
Mobile, firm
and non-
tender
Normal
CONJUCTIVA
Color Transparent
with light
color
Transparent
with light
color
Normal
Texture Shiny and
smooth
Shiny and
smooth
Normal
Presence of
lesions
No lesions No lesions Normal
APPARATUS
Cornea
Color Black Black Normal
Texture Shiny and
smooth
Shiny and
smooth
Normal
PUPILS
Color Black Black Normal
Size Equal Equal Normal
Shape Round and
constrict
briskly
Round and
constrict
briskly
Normal
Symmetry Equal in size Equal in size Normal
Ocular Eyes move
freely
Eyes move
freely
Normal
NOSE
Symmetry,
shape, size and
color
Symmetrical,
smooth and
tan
Symmetrical,
smooth and
tan
Normal
Mucosa color Reddish to
pinkish
Reddish to
pinkish
Normal
NASAL
SEPTUM
Nares
Oval,
symmetrical
Oval,
symmetrical
Normal
Nasal discharge No discharge No discharge Normal
Sinuses Not tender Not tender Normal
MOUTH
Secretion (neutral in
color) without
mucus
production
Mucus
production
Abnormal
due to
inflammati
on
Lips
Color
Pinkish to
slightly
brown
Pinkish to
slightly
brown
Normal
Symmetry Symmetrical Symmetrical Normal
Texture Soft, moist,
smooth
Soft, moist,
smooth
Normal
Moisture Soft and
moist
Soft and
moist
Normal
GUMS
Color Pinkish Pinkish Normal
Moisture Moist Moist Normal
BUCCAL
MUCOSA
Color Glistening
pink
Glistening
pink
Normal
Moisture Moist Moist Normal
TOUNGE
Color Pinkish Pinkish Normal
Size Medium Medium Normal
Symmetry Symmetrical Symmetrical Normal
Mobility Moves freely Moves freely Normal
UVULA
Location At the
midline
At the
midline
Normal
Symmetry Symmetrical Symmetrical Normal
TONSILS
Color Pinkish Pinkish Normal
Discharges No No Normal
discharges discharges
NECK
Position Head-
centered
Head-
centered
Normal
Movement Moves freely Moves not
freely
Due to age
Range of
motion
Full range Full range Normal
HEART
Heart rate 120-160
beats per
minute for
infants
130 beats
per minute
Normal
Heart sounds Clear,
without
crackles
Crackling Due to the
presence
of phlegm
and
increased
mucus
production
Lung field Resonant With crackles Due to
secretions
THORAX &
LUNGS
POSTERIOR
THORAX
Symmetry Symmetrical Symmetrical Normal
Respiratory rate 30-60
breaths per
minute for
the infant
54 Normal
Spinal
Alignment
Spine
vertically
align
Spine
vertically
align
Normal
Skin integrity Skin intact Skin intact Normal
ANTERIOR
THORAX
Breathing
pattern
Breathing is
automatic
and
effortless,
Breathing is
with effort,
produces
noise when
Due to
secretions
in the
regular and
even and
produces no
noise
breathing lungs
Lung/ breath
sounds
Bronchia-
vesicular
crackles Due to the
constriction
of the
bronchus
ABDOMEN
Contour Flat Flat Normal
Texture Smooth Smooth Normal
Frequency and
character
Audible; soft
gurgling
sound occur
irregularly
and rages
from 5-30
mins
Audible; soft
gurgling
sound occur
irregularly
and rages
from 5-30
mins
Normal
UPPER
EXTREMITY
Skin color Tan Tan Normal
Size (arms) Equal Equal Normal
Symmetry Symmetrical Symmetrical Normal
Hair distribution Evenly
distributed
Evenly
distributed
Normal
LOWER
EXTREMITY
Skin color Tan Tan Normal
Size (legs) Equal Equal Normal
Symmetry Symmetrical Symmetrical Normal
Hair distribution Evenly
distributed
Evenly
distributed
Normal
NEUROLOGIC
AL
Level of
consciousness
Alert and
responsive
Irritable Due to her
fever and
IV line
TONE High pitched
sound when
crying
Low pitched
sound when
crying
Due to her
inflammate
d lungs
Assessm
ent
Diagno
sis
Inference Planning Interventi
on
Evalauati
on
Subjecti
ve:
“nahihira
pan
akong
huminga
”
Objectiv
e:
Dyspnea
Acute
pain at
the
chest
and
persisit
ent
cough
Malnutriti
on
Difficulty
of
braething
Persisitent
cough
After 4
gours of
nursing
intervent
ion, the
patient
will
display
patent
airway
with
breath
sounds
Imdepend
ent
Eleva
te
head
of
bed,
chan
ge
positi
on
frequ
ently
After 4
hours of
nursing
interventi
ons, the
patient
was able
to display
patent
airway
with
breath
sounds
Fatigue
PNEUMO
NIA
clearing
and
absence
of
dyspnea
Assis
t
patie
nt
with
deep
breat
hing
exerc
ises
Help
patie
nt to
perfo
rm
activi
ty
like
effect
ive
coug
clearing
and
absence
of
dyspnea
hing
while
in
uprig
ht
positi
on
What is ranitidine?
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Ranitidine is in a group of drugs called histamine-2 blockers. Ranitidine works by reducing the amount of acid your stomach produces.
Ranitidine is used to treat and prevent ulcers in the stomach and intestines. It also treats conditions in which the stomach produces too much acid, such as Zollinger-Ellison syndrome. Ranitidine also treats gastroesophageal reflux disease (GERD) and other conditions in which acid backs up from the stomach into the esophagus, causing heartburn.
Before using ranitidine
Do not use this medication if you are allergic to ranitidine.
Heartburn is often confused with the first symptoms of a heart attack. Seek emergency medical attention if you have chest pain or heavy feeling, pain spreading to the arm or shoulder, nausea, sweating, and a general ill feeling.
Ask a doctor or pharmacist if it is safe for you to take ranitidine if you have:
kidney disease; liver disease; or
porphyria.
Ranitidine side effects
Stop using ranitidine and get emergency medical help if you have any of these signs of an allergic reaction to ranitidine: hives; difficulty breathing; swelling of your face, lips, tongue, or throat. Stop taking ranitidine and call your doctor at once if you have a serious side effect such as:
chest pain, fever, feeling short of breath, coughing up green or yellow mucus;
easy bruising or bleeding, unusual weakness;
fast or slow heart rate;
problems with your vision;
fever, sore throat, and headache with a severe blistering, peeling, and red skin rash; or
nausea, stomach pain, low fever, loss of appetite, dark urine, clay-colored stools, jaundice (yellowing of the skin or eyes).
Less serious ranitidine side effects may include:
headache (may be severe); drowsiness, dizziness;
sleep problems (insomnia);
decreased sex drive, impotence, or difficulty having an orgasm; or
swollen or tender breasts (in men);
nausea, vomiting, stomach pain; or
diarrhea or constipation.
What other drugs will affect ranitidine?
Before taking ranitidine, tell your doctor if you are taking triazolam (Halcion). You may not be able to use ranitidine, or you may need dosage adjustments or special tests during treatment.
There may be other drugs that can interact with ranitidine. Tell your doctor about all medications you use. This includes prescription, over-the-counter, vitamin, and herbal products. Do not start a new medication without telling your doctor.