Community Acquired Pneumonia

Community Acquired Pneumonia

Patient Health History:
Chief Complaint:
Abdominal Pain
Present Health History:
Three hours prior to admission, the client experienced abdominal pain radiating towards the back accompanied by 1 episode of vomiting and cough.
Past Health History:
The client is known as diabetic (type 2) for 5 years and has a maintenance of four different medications. The client has no allergies in any kind of foods and drugs. Her last hospitalization was last 2008 in St. Frances Cabrini Medical Center.
Family Health History:
Diabetes Mellitus (Mother of the patient)
Hypertension (Relatives)

Physical Assessment:
Eyes: (+) blindness
Abdomen: (+) surgical incision and tenderness (epigastric area)
Arms: (+) swelling (left arm)
Lips: dry

Diagnostics Procedures and Laboratory Results:
Hemoglucotest: Latest 212 mg/dL
CBC with platelet: WBC- 16.3 Normal Range: 5.0-10.0
TPAG
Total Protein: 61 Normal Range: 65-80 g/L
Albumin (colorimetric): 2.8 Normal Range: 39.7-49.4 g/L
Globulin: 58.20 Normal Range: 30-35 g/L
Bilirubin Test
Bilirubin, total: 14.57
Bilirubin, direct: 10.4 Normal Range: <3.4 umol/L
Bilirubin, indirect: 4.2 Normal Range: 5.0-17.6 umol/L
Lipid Profile
Cholesterol, LDL: 2.14 Normal Range: 3.90-4.90 mmol/L
Fasting Blood Sugar (Hexokinase):8.30 Normal range: 4.11-5.8 g
Fecalysis
Color: Greenish brown
Consistency: Semi-formed
Pus cells: 1-2
RBC: 0-1
Fat Globules: Few

Drug Study

Cefuroxime
Action: Second-generation cephalosporin that inhibit cell-wall synthesis, promoting osmotic instability; usually bactericidal.
Indications: For serious lower respiratory tract infection; perioperative prevention
Dosage: 750 mg IV q8
Nursing Considerations:
* Before giving drug, ask patient if he is allergic to penicillins or cephalosporins.
* Absorbtion of oral drug is enhanced by food.
* Obtain culture and sensitivity tests before giving first dose. Therapy may begin while awaiting results.
Omeprazole

Action: Inhibit activity of acid (proton) pump and binds to hydrogen-potassium adenosine triphosphatase at secretory surface of gastric parietal cells to block formation of gastric acid.

Indications: For symptomatic gastroesophageal reflux disesase (GERD) without esophageal lesions.

Dosage: 40 mg IV o.d

Nursing Considerations:
* Dosage adjustment may be necessaryin Asians and patients with hepatic impairment.
* Drug increases its own bioavailability with repeated doses. Drug is unstable in gastric acid.
* Gastrin level rises in most patients during the first 2 weeks of therapy.

Amlodipine
Action: Inhibits calcium ion influx across cardiac and smooth-muscle cells, dilates coronary arteries and anterioles, and decreases blood pressure and myocardial oxygen demand.
Indications: For hypertension
Dosage: 10 mg o.d
Nursing Considerations:
* Monitor patient carefully. Some patients, especially those with severe obstructive coronary artery disease, have developed increased frequency, duration, or severity of angina or acute MI after initiation of calcium channel blocker therapy or at time of dosage increase.
* Monitor blood pressure frequently during initiation of therapy. Because drug-induced vasodilation has a gradual onset, acute hypotension is rare.
* Notify prescriber if signs of heart failure occur, such as swelling of hands and feet or shortness of breath.

Diphenhydramine hydrochloride (Nervine)
Action: Competes with histamine for H1-receptor sites. Prevents, but does’nt reverse, histamine-mediated responses, particularly those of the bronchial tubes, GI tract, uterus, and blood vessels. Structurally related to local anesthetics, drug provides local anesthesia and supresses cough reflex.
Indications: For nonproductive cough
Dosage: 25 mg tab b.i.d

Nursing Considerations:
* Stop drug 4 days before diagnostic skin testing.
* Dizziness are more likely to occur in the elderly.

Loperamide (Motilium)
Action: Inhibits peristalsis.
Indications: For acute, nonspecific diarrhea
Dosage: 10 mg tab t.i.d
Nursing Considerations:
* If symptoms don’t improved within 48 hours, stop therapy and consider another drug.
* Drug produces antidiarrheal action similar to that of diphenoxylate but without as many as adverse CNS effects.

Clarithromycin
Action: Binds to the 50S subunit of bacterial ribosomes, blocking protein synthesis; bacteriostatic or bactericidal, depending on concentration.
Indications: For acute worsening of chronic bronchitis.
Dosage: 250 mg cap b.i.d
Nursing Considerations:
* Monitor patient for superinffection.
* Giving clarithromycin with a drug metabolized CYP3A may increased drug levels and prolonged therapeutic and adverse effects.

Insulin glargine (rDNA origin) injection (Lantus)
Action: Insulin glargine lowers glucose level by stimulating peripheral glucose uptake, especially by skeletal muscle and fat, and by inhibiting hepatic glucose production.
Indications: To manage type 2 (non-insulin-dependent) diabetes in patients who need basal (long-acting) insulin to control hyperglycemia
Dosage: 16 “u” SQ O.d

Nursing Considerations:
* Don’t give IV.
* As with any insulin therapy, lipodystrophy may occur at the injection site and delay insulin absorbtion. Reduce this risk by rotating the injection site with each injection.

Metronidazole
Action: Direct-acting trichomonacide and amebicide that works inside and outside the intestine. It’s thought to enter the cells of microorganisms that contain nitroreduuctase, forming unstable compounds that bind the DNA and inhibit synthesis, causing cell death.
Indiications: Bacterial infections caused by anaerobic microorganisms.
Dosage: 500 mg IV q8
Nursing Considerations:
* Observe patient for edema, especially if he’s giving corticosteroids.
* Monitor liver function test results carefully in elderly patients.

Scopolamine butylbromide( hyoscine butylbromide) (Buscopan)
Action: Inhibits muscarinic actions of acetylcholine on autonomic effectors innervated by postganglionic cholinergic neurons. May affect neural pathways originating in the inner ear to inhibit nausea and vomiting.
Indications: For abdominal pain; to prevent nausea and vomiting
Dosage: Capule IV q8
Nursing Considerations:
* Tolerance may develop when therapy is prolonged.
* Raise side rails as precaution because some patient become temporarily excited or disoriented and some become drowsy.

Meperidine hydrochloride (pethidine hydrochloride) (Demerol)
Action: Unknown. Binds with opiate receptors in the CNS, alteringg perception of and emotional response to pain.
Indications: For moderate to severe pain
Dosage: 25 mg IV q4
Nursing Considerations:
* Drug may used in soome patients who are allergic tto morphine.
* Reassess patient’s level of pain atleast 15 to 30 minutes after administration.
* Monitor the respirations carefully.

Ketoprofen
Action: Unknown. Produces anti-inflammatory, analgesic, and antipyretic effects, possibly by inhibiting prostaglandin synthesis.
Indications: minor aches and pain or fever
Dosage: 100 mg IV q8
Nursing Considerations:
* Don’t use sustained-released form for patients in acute pain.
* Serious GI toxicity, iincluding peptic ulcers and bleeding, can occur in patient taking NSAIDs, despite lack of symptoms.
* Drug decreases platelet adhesion and aggregation, and can prolong bleeding time 3 to 4 minutes from baseline.

Famotidine
Action: Competitively inhibits action of histamine on the H2 at receptorsites of parietal cells, decreasing gastric acid secretion.
Indications: Short-term treatment for benign gastric ulcer; for GERD
Dosage: 20 mg IV q12
Nursing Consaiderations:
* Assess patient for abdominal pain. Look for blood in emesis, stool, or gastric aspirate.
Nursing Care Plan

ASESSMENT DIAGNOSIS PLANNING INTERVENTIONS EVALUATION
Subjective:
“Masakit ang tahi ko” as verbalized by the patient.
Pain scale: 7 over 10

Objectives:
BP: 90/70
P: 68
RR: 24
(+) facial grimace
Weak in appearance
Pain related to Surgical Incision
After 30 minutes, the pain experienced by the client with a scale of 7 over 10 (10 is the highest and 0 is the lowest) will decreased to 3 to 4.
>Provide comfort measures (e.g. touch, use of hot/cold packs, nurse’s presence) and quiet environment.
>Identify ways to avoid/minimiziing pain (e.g. splinting incision during cough; using mattress; good body mechanics).
>Encourage adequate rest periods.
>Administer analgesics, as indicated, to maximum dosage, as needed, to maintain “acceptable” level of pain.
Goal met: After doing all the nursing interventions, the pain experienced by the patient was decreased from pain scale of 7 to 3.
Nursing Care Plan

ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS EVALUATION
Subjective: “Medyo nahihilo ako” as verbalized by the patient.

Objectives:
BP: 90/70
P: 68
(+) Dizziness
Weak in appearance

Activity Intolerance related to bedrest/immobility as evidenced by dizziness
After 1 to 2 days, the client will identify negative factors affecting activity intolerance and eliminate or reduce their effects when possible.
>Monitor VS, watching for changes in blood pressure, heart and respiratory rate.
>Provide positive atmosphere, while acknowledging difficulty of the situation for the client.
>Provide adequate rest and keep patient relaxed.
Goal met: After doing all the nursing interventions, the client was able to identify negative factors affecting activity tolerance (ex. operation done, pain because of the incision, body weakness and dizziness).
Diary

It’s been my first time here in Station 1 and I have so many things experienced and knowledge acquired. March 14, is our first day and I have 2 patients. Just the same activities like vital signs taking, plotting, charting, IV regulation and changing of IVF. And also history taking for our case study. March 15, our second day with the same patients. Here, I experienced on how to removed or terminate IV. I also learned on how to feed patients using nasogastric tube through observation. We also had our Pre-test and I am happy with the results because I passed it. March 16, our 3rd day and I have 3 patients. Here, I experienced and learned on how to drain urine on one of my patient who are using folly catheter. Our C.I also did a discussion regarding the different parts of the chart, different colors and gages of a cannula and of course the E-chart. March 14, our 4th day

Lyceum of The Philippines University-St.Cabrini

Case Study
Community Acquired Pneumonia (CAP)

Girlyn Diana O. Lalap. Mrs. Celeste Miranda
BSN 2-1 Clinical Instructor

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