INTRODUCTION

Bronchopneumonia (Lobular pneumonia) is one of two types of bacterial pneumonia as

classified by gross anatomic distribution of consolidation (solidification). In bacterial
pneumonia, invasion of the lung parenchyma by bacteria produces an inflammatory
immune response. This response leads to a filling of the alveolar sacs with exudates. The
loss of air space and its replacement with fluid is called consolidation. In
bronchopneumonia, or lobular pneumonia, there are multiple foci of isolated, acute
consolidation, affecting one or more pulmonary lobes.

It should be noted that although these two patterns of pneumonia, lobar and lobular, are
the classic anatomic categories of bacterial pneumonia, in clinical practice the types are
difficult to apply, as the patterns usually overlap. Bronchopneumonia (lobular) often
leads to lobar pneumonia as the infection progresses. The same organism may cause one
type of pneumonia in one patient, and another in a different patient. From the clinical
standpoint, far more important than distinguishing the anatomical subtype of pneumonia,
is identifying its causative agent and accurately assessing the extent of the disease.

Causes

Bacterial pneumonias tend to be the most serious and, in adults, the most common cause
of pneumonia. The most common pneumonia-causing bacterium in adults is
Streptococcus pneumoniae (pneumococcus).

Symptoms

• Cough with greenish or yellow mucus

• Fever
• chest pain
• Rapid, shallow breathing
• Shortness of breath
• Headache
• Loss of appetite
• fatigue
Treatment

If the cause is bacterial, the goal is to cure the infection with antibiotics. If the cause is
viral, antibiotics will NOT be effective. In some cases it is difficult to distinguish
between viral and bacterial pneumonia, so antibiotics may be prescribed. Pneumococcal
vaccinations are recommended for individuals in high-risk groups and provide up to 80
percent effectiveness in staving off pneumococcal pneumonia. Influenza vaccinations are
also frequently of use in decreasing one’s susceptibility to pneumonia, since the flu
precedes pneumonia development in many cases.
 Gordon’s 11 Functional Pattern

1. Health Perception – Health Management Pattern

BEFORE HOSPITALIZATION
According to the patient, for him, health is being free form illness, able to
play and go to school and eating nutritious foods.
The S.O states that whenever patient suffers from simple illnesses they
make him take over-the-counter medicines such as paracetamol and solmux-
syrup.
DURING HOSPITALIZATON
According to the patient, he views himself as weak and wasn’t able to do
his daily activities. He manages his condition by complying with the entire
doctor’s order and taking adequate rest.
According to the S.O., patient has a strong sensitive smell towards
aromatic things and easily gets a headache upon smelling those.

2. Nutritional – Metabolic Pattern

BEFORE HOSPITALIZATION:
He eats 3 times a day. He preferred to eat more on meat and a little
amount of vegetable .He drinks at least 4-5 glasses of water throughout the day.
He also eats crackers, biscuits and bread for his snacks with fresh fruit juices. He
had no difficulty in swallowing noted.
DURING HOSPITALIZATION:
“Hindi siya masyadong kumakain. . Mga 2-3 kutsara lang siguro and
nakakain niya every meal.” as verbalized by the S.O. He also eats fruits with
slices of orange and apple but aboul 2-3 slices only. He drinks for about 3 glasses
of 100ml of water every shift.

3. Elimination Pattern

BEFORE HOSPITALIZATION:
According to the S.O., the patient has no difficulty in urinating. He voids
4-5 times a day. The S.O. describes his urines as light yellow.
DURING HOSPITALIZATION:
According to the S.O., the patient urinates smoothly without difficulty but
needs assistance on going to the bathroom. He urinates about 2-3 times a day with
 the same color of urine. During his stay in the hospital, he wasn’t able to defecate
since day 1.

4. Activity – Exercise Pattern

BEFORE HOSPITALIZATION:
According to the S.O., the patient loves to play with his playmates after
school. They usually play “agawan base” and “tagutaguan”. The S.O. also states
that the patient helps in the household chores like washing the dishes and cleaning
their table after dinner. Patient also plays with his younger brother.
DURING HOSPITALIZATION:
The patient is dependent to his parents. He said that he can’t do his usual
activities because of his illness.

5. Sleep – Rest Pattern

BEFORE HOSPITALIZATION:
During weekdays, he sleeps about 6-7 hours at night, around 9pm to 5am
and doesn’t take his naps. During weekends, he sleeps about 9-10 hours. He
usually takes a nap to rest at about 1-2 hours after lunch.
DURING HOSPITALIZATION:
According to the S.O., the patient has difficulty in getting his sleep.
“Madalas na putol-pitol ang tulog niya, nagigising siya dahil sa kanyang ubo at sa
sakit ng ulo nya,” as verbalized by the S.O. He sleeps about 2-5 hours at night and
about 2-3 hours during daytime.

6. Cognitive Perceptual

The patient has no cognitive problem. He is oriented to time, place, and

persons. He can see and hear clear. He is able to understand and follow the
instructions given by the nurses, doctors and SO.

7. Role – Relationship Pattern

The patient is the youngest among his siblings. He lives with his mother,
father, sister, brothers and his grandparents. He doesn’t have difficulty in dealing
with his family, relatives and friends.
8. Self- perception/Self-concept Pattern

He perceives his self as a caring person. “Malambing po ako kina mama.

Mabait po ako sa mga kalaro ko at classmate ko. Hindi po ko nakikipag away
palagi paminsan-minsan lang pag tama po ako,” as verbalized by the patient.

9. Sexual – Reproduction Pattern

According to the S.O., patient K.M. was circumcised when he was five
years of age. She is aware of her sexual social status.

10. Coping – Stress Management Pattern

The patient relies on her parents for support. Whenever he feels down and
sad he runs to her mother and grandmother for comfort.

11. Value – Belief

He is a Roman Catholic. He goes to mass together with his family every

Sunday. He prays before and after eating and sleeping.
 PHYSICAL ASSESSMENT
Initial Vital Sign: PR= 118 RR= 28 T= 36.8 WT: 17kgs

AREA METHOD NORMAL ACTUAL ANALYSIS

ASSESSED USED FINDINGS FINDINGS

SKIN

- Color Inspection Light to Deep Brown Normal

brown
- Texture Inspection/ Smooth Smooth Normal
Palpation

- Hair Inspection Evenly Evenly Normal

distribution distributed distributed
- Temperature Palpation Normally warm Body Normal
Temperature:
37oC
- Moisture Palpation Moist to dry Moist to dry Normal

HAIR

- Color Inspection Black Black Normal

- Disribution Inspection Evenly Evenly Normal
distributed distributed
HEAD

- Shape Inspection Regular Regular Normal

EYES

Eyebrows
- Hair Inspection Evenly Evenly Normal
distribution distributed distributed

Eyelashes
- Hair Inspection Evenly Evenly Normal
distribution distributed distributed
- Direction of Inspection Curved outward Curved outward Normal
curl

Eyelids
- Texture Inspection/ Smooth Smooth Normal
Palpation
- Color Inspection Same as the Same as the Normal
skin skin
PUPILS

- Color Inspection Black Black Normal

- Shape Inspection Round and Round and Normal
regular in shape regular in shape
- Size Inspection 2-3 mm 2-3 mm Normal
 AREA METHOD NORMAL ACTUAL ANALYSIS
ASSESSED USED FINDINGS FINDINGS

OCULAR Inspection Both eyes move Both eyes move Normal

MOVEMENT parallel with parallel with
each other in each other in
directions of directions of
gaze gaze
EARS

- Symmetry Inspection Auricles are at Auricles are at Normal

and position level of each level of each
other other
EXTERNAL
AUDITORY
CANAL

- Hearing Inspection Hears equally Hears equally Normal

in both ears in both ears

NOSE

- Symmetry Inspection Symmetrical Symmetrical Normal

- Color Inspection Same color as Same color as Normal
the face and the face and
skin skin

LIPS AND
MOUTH

- Symmetry Inspection Symmetrical Symmetrical Normal

- Color (lips) Inspection Pink Pale Due to
decreased
hemoglobin
- Moisture Inspection Moist Dry Due to
decreased fluid
NECK intake

- Symmetry Palpation Symmetrical Symmetrical Normal

- Alignment of Inspection Symmetrical Symmetrical Normal
the trachea

THORAX

- Chest Inspection Symmetrical Symmetrical Normal

contour
- Clavicle Inspection Prominent Prominent Normal
- Chest wall Inspection/ Absence of Crackles breath Due to presence
Auscultation crackles upon sound upon of secretions on
auscultation auscultation the bronchioles
ABDOMEN

- General Inspection Flat Flat Normal

contour
- Color Inspection Same as the Same as the Normal
skin skin
 ASSESSED METHOD NORMAL ACTUAL ANALYSIS
USED FINDINGS FINDINGS

UPPER
EXTREMITIES

- Skin color Inspection Light to deep Brown Normal

brown
- Size (arms) Inspection Equal Size Equal Size Normal
- Symmetry Inspection Symmetrical Symmetrical Normal

LOWER
EXTREMITIES

- Skin color Inspection Light to deep Brown Normal

brown
- Size (legs) Inspection Equal Size Equal Size Normal
- Symmetry Inspection Symmetrical Symmetrical Normal
 LABORATORY RESULT

Chest X-Ray PAL Views

September 17,’07

Parihilar and paracardiac infiltrates, bilateral.

Hilar nodularities
Heart is normal in size
Diaphragm and sinuses are normal
Intact bony thorax

Impression: Parahilar and Paracardiac pneumonitis, bilateral.

Hilar adenophaties maybe secondary to ongoing infection
versus Primary TB

BLOOD CHEMISTRY REPORT

Date : September 17, 2007

Examination Requested : RBS, Na, K, Ca

Normal Findings Actual Findings Analysis

Random Blood 70-110 mg/dL 110 mg/dL Normal

Sugar

Sodium 135-155 mmol/L 140.4 Normal

Potassium 3.6 – 5.5 mmol/L 3.65 Normal

Calcium 2.02 – 2.6 mmol/L 2.1 Normal

HEMATOLOGY RESULT
Date : September 17, 2007

Examination result Normal findings Actual findings Analysis

WBC 5-10 x 10 ^ 9/L 8.7 Normal

HGB: Hemoglobin
13-18 g/dL 11.5 Due to hemodilution

HTC: Hematocrit Due to hemodilution

39.0 – 54.0 % 35
Differential count:

Segmenters 0.60 – 0.70 0.76 Due to infection

Lymphocytes 0.20 – 0.30 0.24 Normal

 PATHOPHYSIOLOGY

Etiologic Agent:
Predisposing Factors: -Streptococcus pneumoniae Precipitating Factors:
-Race -Staphylococcus Aureus -Environment
-Gender -Mycoplasma -weather
-Age -Chlamydias
-Viruses

Aspiration of virulent microorganisms

Impairs extensive defense mechanism in the upper respiratory system

Bacteria reach trachea

System has recognized it as irritant and Bacteria affects the globlet cell
antigen

Increase in secretions
Reaches the lungs Cough reflex

Inflammation of respiratory passage

Inflammatory response
Cough
`
A
 A

WBC and neutrophils migrate into the alveoli

Impaired permeability of alveolar Pyrogen is released

walls

Fever
Fluid accumulates in alveoli

Pulmonary edema

Reduce surface area for gas exchange

Spasmodic contraction of walls of bronchi

CO2 increases and O2 decreases

Bronchospasm

Stimulate respiratory center Failure of left side of heart

Pooling of secretions

Hyperventilation Cells receive inefficient O2 Adventitious Unproductive cough

breath sounds
Fatigue Partial cyanosis
 PATIENT’S PROFILE

Name : K.M.
Age :5
Sex : Male
Date of birth : March 06, 2000
Civil status : Single
Address : Tuao, Cagayan
Religion : Roman Catholic
Date of Admission : September 17, 2007
Chief complaint : Cough
Attending Physician : Dr. E. Babaran
Final Diagnosis : Bronchopneumonia

PATIENT’S MEDICAL HISTORY

Family Health History
The patient’s father had a hypertension. His father also had a strong sensitive
smell toward aromatic things which the patient also manifest. They easily get a headache
or vomit upon smelling such.

Past Health History

Patient K.M had his share of childhood immunization such as DPT, OPV, and
Measles. The patient experiences cough and cold in the past.

History of Present Illness

Two weeks prior to consultation the patient had (+) on and off cough, with
yellowish phlegm.
Four days prior to admission, the patient had (+) on and off fever, (+) vomiting
and (+) headache.
The patient consults at Tuao District hospital and was given ampicilin 400g IV q
6 and Neto .3g IV q 6.
Few hours prior to admission, the patient had (+) seizure.
 ANATOMY AND PHYSIOLOGY

The lower respiratory tract

Larynx
Is located in the anterior throat, and it connects superiorly to the pharynx and
inferiorly to the trachea. It is the site of voice production. Air moving past the vocal folds
causes them to vibrate producing sound. It is also called “voice box”.

Trachea
It is also called windpipe. It is a membranous tube that consists of connective
tissue ad smooth muscle, reinforced with 16-20 C-shaped pieces of cartilage. It is lined
with pseudostratified columnar epithelium, which contains numerous cilia and goblet
cells. The cilia propel mucus produced by the goblet cells, as well as foreign particles
embedded in the mucus, out of the trachea, through the larynx, and into the pharynx,
from which they are swallowed.
It is the main passageway of air
Lungs
The lungs are paired elastic structures enclosed in the thoracic cage which is an
airtight chamber with distensible walls. It is the principal organs of respiration. Each lung
is cone-shaped, with its base resting on the diaphragm and its apex extending superiorly
to a point about 2.5 cm above the clavicle.

Pleura
It is a serous membrane that lined the lungs and wall of the thorax. The visceral
pleura cover the lungs; the parietal pleura line the thorax. The visceral and parietal pleura
and the small amount of pleural fluid between these two membranes serve to lubricate the
thorax and lungs and permit smooth motion of the lungs within the thoracic cavity with
each breath.

Lobes
Each lung is divided into lobes. The left lung consists of an upper and lower lobe,
whereas the right lung has an upper, middle and lower lobe. Each lobe is further
subdivided into two to five segments separated by fissures which are extensions of the
pleural.

Bronchi and Bronchioles

 There are several divisions of bronchi within each lobe of the lungs. First are the
lobar bronchi (three in the right and 2 in the left lung). Lobar bronchi divide into
segmental bronchi, which are the structures identified when choosing the most effective
postural drainage position for given patient. Segmental bronchi then divide into
subsegmental bronchi. These bronchi are surrounded by connective tissue that contains
arteries, lymphatics, and nerves.
Bronchioles have no cartilage on their walls. Their patency depends entirely on
the elastic recoil of the surrounding smooth muscle and on the alveolar pressure. It
contain submucosal glands, which produce mucus that covers the inside lining of the
airway.
Terminal bronchioles do not have mucous glands or cilia. It becomes the
respiratory bronchioles which are considered to be the passageways between the
conducting airways and the gas exchange airways.

Alveoli
The lung is made up of 300 million alveoli, which are arranged in a cluster of 15
to 20.
There are three types of alveolar cells. Type I alveolar cells are epithelial cells
that from the alveolar walls. Type II alveolar cells are metabolically active. These cells
secrete surfactant, a phospholipids that lines the inner surface and prevents alveolar
collapse. Type III alveolar cell macrophages are large phagocytic cells that ingest foreign
matter and act as important defense mechanism.
 DRUG STUDY

Name of medicine : Paracetamol

Classification : Antipyretic; Analgesic
Action : Thought to produce analgesia by blocking pain impulses by
inhibiting synthesis of prostaglandin in the CNS or of other
substances that sensitize pain receptors to stimulation. The
drug may relieve fever through central action in the
hypothalamic heat-regulating center.
Adverse Reaction : Hematologic : Hemolytic anemia, neutropenia,
leukopenia, pancytopenia.
Hepatic : Jaundice
Metabolic : Hypoglycemia
Skin : Rash, Urticaria
Contraindications : Contraindicated in patients hypertensive to drug. Use
cautiously in patients with long-term alcohol use because
therapeutic doses cause hepatoxicity in these patients.
Dosage : 250mg/5ml q 4
Nursing consideration :
 Use liquid form for children and patients who have
difficulty swallowing.
 In children, don’t exceed 5 doses in 24 hours.
Patient teaching :
 Tell parents to consult prescriber before giving drug to
children younger than age 2.
 Advise patient that drug is only for short-term use and
to consult prescriber if giving to children for longer
than5 days or adults for longer than 10 days.
 Warn patient that high doses or unsupervised long-term
use can cause liver damage.
 Tell breast-feeding woman that acetaminophen appears
in breast milk in low levels. Drug may be used safely if
therapy is short-term and doesn’t exceed recommended
doses.
Name of medicine : Diazepam (Valium)
Classification : Minor Tranquillizer
Indication : The management of anxiety disorders or for the short-term
relief of the symptoms of anxiety. Anxiety or tension
associated with the stress of everyday life usually does not
require treatment with an anxiolytic. It is a useful adjunct
for the relief of skeletal muscle spasm due to reflex spasm
to local pathology (such as inflammation of the muscles or
joints, or secondary to trauma); spasticity caused by upper
motor neuron disorders (such as cerebral palsy and
paraplegia); athetosis; stiff-man syndrome; and tetanus. It is
also a useful adjunct in status epilepticus and severe
recurrent convulsive seizures.

Adverse Reaction : Commonly reported were drowsiness, fatigue and ataxia;

venous thrombosis and phlebitis at the site of injection.
Other adverse reactions less frequently reported include:
CNS: confusion, depression, dysarthria, headache,
hypoactivity, slurred speech, syncope, tremor, vertigo.
GI: constipation, nausea.
GU: incontinence, changes in libido, urinary retention.
Cardiovascular: bradycardia, cardiovascular collapse,
hypotension.
EENT: blurred vision, diplopia, and nystagmus. Skin:
urticaria, skin rash.
Other: hiccups, changes in salivation, neutropenia,
jaundice. Paradoxical reactions such as acute hyperexcited
states, anxiety, hallucinations, increased muscle spasticity,
insomnia, rage, sleep disturbances and stimulation have
been reported; should these occur, use of the drug should
be discontinued.

Contraindications : Contraindicated to patients with a known hypersensitivity to

this drug; acute narrow angle glaucoma; and open angle
glaucoma unless patients are receiving appropriate therapy.

Dosage : 3.5 mg IV prn

Nursing consideration: In pediatric use, in order to obtain maximal clinical effect
with the minimum amount of drug and thus to reduce the risk
of hazardous side effects, such as apnea or prolonged periods
of somnolence, it is recommended that the drug be given
slowly over a 3-minute period in a dosage not to exceed 0.25
mg/kg. After an interval of 15 to 30 minutes the initial
dosage can be safely repeated. If, however, relief of
symptoms is not obtained after a third administration,
adjunctive therapy appropriate to the condition being treated
is recommended.
Name of medicine : Klaricid
Classification : Macrolides
Indication : Treat infections such as:

 Throat and sinus infections

 Chest infections such as bronchitis and pneumonia
 Skin and skin structure infections
 Ear infections particularly inflammation of the middle
ear (acute otitis media)

Adverse Reaction : Nausea, dyspepsia, abdominal pain & diarrhea, headache &
skin rash.

Contraindications : Known hypersensitivity to macrolides. Concomitant use of

clarithromycin w/ cisapride, pimozide or terfenadine.
Patients receiving terfenadine therapy w/ preexisting
cardiac abnormalities or electrolyte disturbances.

Dosage : 7.5 ml q 12o

Nursing consideration:
 Do not give if the patient is allergic to clarithromycin or
other macrolide antibiotics such as erythromycin or
azithromycin.
 Ask patient if he/she has any liver or kidney problems
before giving the medicine.
 Ask patient if he/she has intolerance to sugars before
giving the medicine.
 LEARNING FEEDBACK DIARY

Name: Charisse Marichu P. Baculi Date: September 05, 2007

Clinical Instructor: Mrs. Leonor De Laza Area: SPH F2 and F1

Objectives: At the end of the rotation, I will be able to:

1. Establish rapport to my patient
2. Be efficient in giving total patient care
3. Augment my skills and confidence

Not like during our past rotation, this time I felt more confident and a little
knowledgeable on the things to be done in the hospital. The hospital protocols were
clearly registered on my mind.
It was my first time to be on the area, floor 1, and it made me a little tense
because the atmosphere was totally different. The staff nurses were not approachable
unlike in the second floor which made me back down a little because I might get a
negative response and that I would be belittled by it.
I composed myself and focused my attention to my patient. I got the chance to
play with my patient which made me happy and enjoy caring him. I didn’t just administer
medications but as well made my patient comfortable and happy.
The whole rotation was enjoyable and full of knowledge sharing. Our C.I. is
approachable, fun to be with and humorous. She made us feel comfortable being around
her.
The week was long and tiring but it gave me a feeling of fulfillment.
 LEARNING FEEDBACK DIARY

Name: Charisse Marichu P. Baculi Date: October 01, 2007

Clinical Instructor: Mr. Randolph Balungaya Area: SPH F1

Objectives: At the end of the rotation, I will be able to:

4. Establish rapport to my patient
5. Be efficient in giving total patient care
6. Augment my skills and confidence

Not like during our past rotation, this time I felt more confident and a little
knowledgeable on the things to be done in the hospital. The hospital protocols were
clearly registered on my mind.
It was my first time to be on the area, floor 1, and it made me a little tense
because the atmosphere was totally different. The staff nurses were not approachable
unlike in the second floor which made me back down a little because I might get a
negative response and that I would be belittled by it.
I composed myself and focused my attention to my patient. Most of my patient
was children and they annoy me. It pains me when I see them complaint about
something. I gave them the appropriate care they need. It pays those sleepless night when
you see your patient smile, laugh and roam like nothing happened or they haven’t felt
anything.
The whole rotation was enjoyable and full of knowledge sharing. Our C.I. is
approachable, fun to be with and humorous. He made us feel comfortable being around
him. He is more like a friend rather than an instructor.
The week was long and tiring but it gave me a feeling of fulfillment.
A Case
Study
On
Dengue
Fever

Submitted to:
Mrs. Leonor de Laza, RN
 Submitted by:
Jane Galiza
Charisse Marichu Baculi
(RLE- 08)

A Case
Study
On
Bronchopneum
onia
 Submitted to:
Mr. Randolph Balungaya, RN

Submitted by:
Charisse Marichu Baculi
(RLE- 08)
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective data: Ineffective airway At the end of 1 hour, the  Elevate head of the  To take advantage of Goal partially met. At the
clearance related to patient will be able to bed/ change position gravity decreasing end of 1 hour, the patient
“ hindi ko mailabas ang excessive, thickened maintain airway potency every 2 hours. pressure on the was able to maintain
plema ko po paginuubo mucus secretions as and expectorate/clear diaphragm. airway potency and
ako,” as verbalized by evidenced by ineffective secretions readily. expectorate/clear
the patient. cough.  Encouraged deep-  To mobilize secretions readily.
breathing and coughing secretions.
exercises.
Objective data:
 Increase fluid intake  To help liquefy
 crackles secretions.
 difficulty
vocalizing  Provide supplemental  To ascertain status and
 ineffective humidification note progress.
coughing (nebulizer).

 Monitored vital signs.  To assess changes and

note complications.

 Performed chest  To loosen secretions.

physiotherapy.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective data: Alteration in body At the end of 2 hours, the  Monitor vital signs,  Continued fever may Goal partially met. At the
temperature: patient will be able to closely monitoring be caused by drug abuse, end of 2 hours, the
“mainit ang pakiramdam hyperthermia related to experience improvement temperature fluctuations. drug-resistant bacteria, patient was able to
ko at giniginaw ako,” as increase pyrogens in the in infection as evidence super infection, or demonstrate
verbalized by the patient. body. by normothermia and inadequate lung improvement in infection
negative sputum culture drainage. as evidence by:
report.
 Monitor WBC  High white blood cell  Temperature : 37.3 0C
Objective data: counts indicate the
presence of an infection
 Chills or inflammation.
 Elevated temperature
of 38.2 0C.  Encourage to increase Fluid loss contributes
fluid intake. to fever.

 Promote surface To reduce body

cooling by means of temperature/restore
undressing; cool/tepid normal body/organ
sponge bath or function.
immersion; local ice
packs especially in groin
or axillae.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective data: Disturbed sleep pattern At the end of 2 hours, the  Provide nursing aid:  To promote rest and Goal partially met. At the
related to statis of patient will be able to back rub bedtime care, relaxation. end of 2 hours, the
“hindi ako nakaka-tulog secretions. achieve optimal amounts pain relief, comfortable patient was able to
ng husto dahil sa pag- of sleep as evidence by position, and relaxation achieved optimal
ubo ko,” as verbalized by rested appearance, technique. amounts of sleep as
the patient. verbalization of feeling evidence by rested
rested, and improvement  Attempt to allow for  To promote appearance and
in sleep pattern. sleep cycles of at least completion of one verbalization of feeling
Objective data: 90mins. complete cycle and rested.
completion of an entire
 Dark circles under cycle is necessary to
eyes benefit from sleep.
 Restlessness
 Expressionless face Discourage pattern of  Napping can disrupt
 Frequent yawning daytime naps unless normal sleep pattern.
necessary or part of usual
pattern.

 Limit fluids before  To reduce need for

bedtime. voiding during night.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective data: Impaired bowel At the end of the shift,  Auscultate abdomen  To reflect bowel Goal partially met. At the
elimination pattern r/t the patient will be able to for presence, location activity. end of the shift, patient
“Hindi pa siya tumatae inadequate fluid intake pass soft, formed stool at and characteristic of was able to pass soft,
mula nung pumasok a normal pattern of bowel sounds. formed stool at a normal
kame dito sa hospital,” as defecation. pattern of defecation.
verbalized by the S.O.  Encourage and  To promote moist/soft
provide adequate fluid stool
Objective data: intake, including water
and high-fiber fruit
 Dull headache juices.
 Restlessness
 Abdominal distention
 Encourage balance  To improve
fiber and bulk diet. consistency of stool and
facilitate passage through
the colon.

 Encourage  To stimulate
activity/exercise within contractions of the
limits of patient’s ability intestine.