Case Study URTI

BATAAN PENINSULA STATE UNIVERSITY
MAIN CAMPUS
College of Nursing and Midwifery www.bpsu.edu.ph
City of Balanga, 2100 Bataan bpsu.cnm.2018@gmail.com
OFFICE OF THE DEAN

SANCHEZ, DANAH GRACE A. BSN-3A GROUP-3
DIAGNOSIS: UPPER RESPIRATORY TRACT INFECTION
I. Introduction:
URTI is an illness caused by an acute infection, which involves the upper respiratory tract,
including the nose, sinuses, pharynx, or larynx. This commonly includes nasal obstruction,
sore throat, tonsillitis, pharyngitis, laryngitis, sinusitis, otitis media, and the common cold.
Most infections are viral in nature, and in other instances, the cause is bacterial.
Predisposing Factors:
An URTI is generally caused by the direct invasion of the inner lining (mucosa or mucus
membrane) of the upper airway by the culprit virus or bacteria. In order for the pathogens
(viruses and bacteria) to invade the mucus membrane of the upper airways, they have to fight
through several physical and immunologic barriers.
The hair in the lining of the nose acts as physical barrier and can potentially trap the invading
organisms. Additionally, the wet mucus inside the nasal cavity can engulf the viruses and
bacteria that enter the upper airways. There are also small hair-like structures (cilia) that line
the trachea which constantly move any foreign invaders up towards the pharynx to be
eventually swallowed into the digestive tract and into the stomach.
In addition to these intense physical barriers in the upper respiratory tract, the immune
system also does its part to fight the invasion of the pathogens or microbes entering the upper
airway. Adenoids and tonsils located in the upper respiratory tract are a part of the immune
system that help fight infections. Through the actions of the specialized cells, antibodies, and
chemicals within these lymph nodes, invading microbes are engulfed within them and are
eventually destroyed.
Despite these defense processes, invading viruses and bacteria adapt various mechanisms to
resist destruction. They can sometimes produce toxins to impair the body's defense system or
change their shape or outer structural proteins to disguise from being recognized by the
immune systems (change of antigenicity). Some bacteria may produce adhesion factors that
allow them to stick to the mucus membrane and hinder their destruction.
Our Vision Our Mission

A leading university in the Philippines To develop competitive graduates and empowered community members by
recognized for its proactive contribution to providing relevant, innovative and transformative knowledge, research,
Sustainable Development through equitable and extension and production programs and services through progressive
inclusive programs and services by 2030. enhancement of its human resources capabilities and institutional
mechanism.
MAIN CAMPUS
bpsu.cnm.2018@gmail.com
City of Balanga, 2100 Bataan
OFFICE OF THE DEAN
II. Physical Assessment:
Day: 1 (Tuesday)
BODY PART TECHNIQUE FINDINGS NORMAL FINDINGS INTERPRETATION
Hair Inspection Evenly distributed Evenly distributed
Eyes Inspection Watery No tearing Due to colds
Eyes Inspection Redness Appears white Due to colds
Eyes Inspection Swelling of eyelids No edema or tenderness Due to cough/colds
Conjunctiva Inspection Pinkish Pinkish
Nose Inspection Clogged No secretion Due to colds
Mouth Inspection Pinkish and dry Pinkish and not dry Due to sore throat
Throat Inspection Reddish and swollen Light pink&Normal size Due to sore throat
Tongue Palpation Pinkish and moist Pinkish and moist
Submandibular Palpation Palpable lymph nodes No masses Due to sore throat
Breath sounds Auscultation With rales Normal breath sound Due to cough
Rhythmic and effortless
Anterior Thorax Inspection Rapid breathing Due to colds
respiration
Our Mission
Our Vision
To develop competitive graduates and empowered community members by
A leading university in the Philippines providing relevant, innovative and transformative knowledge, research,
recognized for its proactive contribution to extension and production programs and services through progressive
Sustainable Development through equitable and enhancement of its human resources capabilities and institutional
inclusive programs and services by 2030. mechanism.
MAIN CAMPUS
bpsu.cnm.2018@gmail.com
City of Balanga, 2100 Bataan
OFFICE OF THE DEAN

Day: 2 (Wednesday)
BODY PART TECHNIQUE FINDINGS NORMAL FINDINGS INTERPRETATION
Hair Inspection Evenly distributed Evenly distributed
Eyes Inspection Watery No tearing Due to colds
Eyes Inspection Redness Appears white Due to colds
Eyes Inspection Swelling of eyelids No edema or tenderness Due to cough/colds
Conjunctiva Inspection Pinkish Pinkish
Nose Inspection Clogged No secretion Due to colds
Mouth Inspection Pinkish and dry Pinkish and not dry Due to sore throat
Throat Inspection Reddish and swollen Light pink&Normal size Due to sore throat
Tongue Palpation Pinkish and moist Pinkish and moist
Submandibular Palpation Palpable lymph nodes No masses Due to sore throat
Breath sounds Auscultation With rales Normal breath sound Due to cough
Rhythmic and effortless
Anterior Thorax Inspection Rapid breathing Due to colds
respiration
(Hg count 11.6gm%)
Respiratory system
responds by increasing
Skin color Inspection Pale Pinkish the depth and rate of
breathing, which anemic
person experiences as
shortness of breath
Our Mission
Our Vision
A leading university in the Philippines providing relevant, innovative and transformative knowledge, research,
recognized for its proactive contribution to extension and production programs and services through progressive
Sustainable Development through equitable and enhancement of its human resources capabilities and institutional
inclusive programs and services by 2030. mechanism.
MAIN CAMPUS
OFFICE OF THE DEAN

III. Pathophysiology:
Modifiable Non- Modifiable

 Overcrowding  Age
 Outdoor air pollution  Weather/ Climate
 Indoor pollution
 Close contact with someone with a URTI
 Second-hand smoking
 Health care facilities, hospitals, nursing
homes
Bacteria and Viruses
Direct hand-to- Droplet

hand contact
Enter to the nose by inhaling
Immune defenses
Hair lining
filters and trap
some
pathogens
Potential invaders
Traps in upper respiratory

tract which coats by mucus
Junction of the posterior

nose to pharynx
Impinge on the back of the

throat
Transport pathogens up to
the pharynx
Inflammatory response to
immune
Swelling Erythema Increase mucous Fever

secretions
Cough Cold

mechanism.
MAIN CAMPUS
OFFICE OF THE DEAN
Adenoids and tonsils contain

immune cell that respond to
pathogens
Humoral immunity and cellular

immunity acts to reduce infections
throughout the entire respiratory tract
Suboptimal humoral and

phagocytic immune
Pathogens resist destruction

by a variety of mechanism
Production of toxins
proteases
Initial nasopharyngeal
infection maybe spread to
adjacent
Sinusitis Rhinitis Laryngitis Pharyngitis

mechanism.
MAIN CAMPUS
OFFICE OF THE DEAN

IV. Signs and Symptoms:
 Nasal congestion  Low-grade fever (more common in

 Runny nose (rhinorrhea) children)
 Nasal discharge (may change from  Foul breath
clear to white to green)  Reduced ability to smell (hyposmia)
 Nasal breathing  Headache
 Sneezing  Shortness of breath
 Sore or scratchy throat  Sinus pain
 Painful swallowing (odynophagia)  Itchy and watery eye (conjunctivitis)
 Cough (from laryngeal swelling and  Nausea
post nasal drip)  Vomiting
 Malaise  Diarrhea
 Body aches
V. Laboratory:
Normal
Procedure Result Interpretation
Value
The tissues out in the body are
starved for oxygen, because there
is not enough hemoglobin to get it
14-17 gm% to them. Patients with URTI
Hemoglobin 11.6 gm%
(Male) responds by increasing the depth
and rate of breathing, which the
anemic person experiences as
shortness of breath.
 An insufficient supply of healthy
red blood cells (anemia)
 A large number of white blood
cells due to long-term illness,
40-50 vol% infection or a white blood cell
Hematocrit 35 vol%
(Male) disorder such as leukemia or
lymphoma
 Vitamin or mineral deficiencies
 Recent or long-term blood loss
5,000-
WBC 5,200/mm3
10,000/mm3
Segmenters 55-65% 56%
Indicate your body is dealing with

Lymphocytes 25-35% 38% an infection or other inflammatory
condition.
May indicate the presence of
Monocytes 2-4% 6% chronic infection, inflammation,
an autoimmune, or blood disorder.
150,000-
Platelet 280,000/mm3
400,000/mm3

mechanism.
MAIN CAMPUS
OFFICE OF THE DEAN
VI. Drug Study:
Name of Mechanism of
Classification Indication Adverse Effect Nursing Consideration
Drug Action
Generic Antibiotic Bind to bacterial cell It is effective for the GI: Determine history of hypersensitivity reactions to
Name: wall membrane, treatment of Diarrhea, cephalosporins, penicillins, and history of allergies,
Cefuroxime Second causing cell death penicillinase- producing nausea, antibiotic- particularly to drugs, before therapy is initiated.
generation Neisseria associated colitis.
Cephalosporins Lab tests: Perform culture and sensitivity tests
Brand Gonorrhea (PPNG).
Name: Effectively treats bone Skin: before initiation of therapy and periodically during
Therapeutic therapy if indicated. Therapy may be instituted
Profurex and joint infections, Rash ,
Effects:
bronchitis, meningitis, pruritus, urticaria. pending test results. Monitor periodically BUN and
Dosage: gonorrhea, otitis media, creatinine clearance.
Bactericidal action
300 mg pharyngitis/tonsillitis,
sinusitis, lower Urogenital: Inspect IM and IV injection sites frequently for
Route: respiratory tract Increased serum signs of phlebitis.
IV infections, skin and soft creatinine and
tissue infections, BUN, decreased Advise patient to report signs of superinfection and
urinary tract infections, Creatinine allergy
Frequency: clearance.
and is used for surgical
q8o
prophylaxis, reducing Instruct patient to notify health professional if fever
or eliminating infection. and diarrhea develop
Hemat:
Hemolytic anemia
MISC:
Anaphylaxis
Our Mission
providing relevant, innovative and transformative knowledge, research,
extension and production programs and services through progressive
enhancement of its human resources capabilities and institutional
mechanism.
mechanism.
MAIN CAMPUS
OFFICE OF THE DEAN
Drug Action
Generic Analgesic Paracetamol may To relieve mild to Hematologic: Assess patient’s fever or pain: type of pain,
Name: ( Non-opioid) cause analgesia by moderate pain due to Hemolytic location, intensity, duration, temperature, and
Paracetamol inhibiting CNS things such as anemia, diaphoresis.
Antipyretic headache, muscle and leukopenia,
prostaglandin
joint pain, backache and neutropenia,
Brand synthesis. The period pains. It is also pancytopenia,
name: mechanism of used to bring down a thrombocytopenia. Assess allergic reactions: rash, urticaria; if these
Acephen morphine is believed high temperature. For occur, drug may have to be discontinued.
to involve decreased this reason, paracetamol Hepatic:
Dose: permeability of the can be given to children liver damage,
300 mg cell membrane to after vaccinations to jaundice
prevent post- Teach patient to recognize signs of chronic
sodium, which
immunization pyrexia Metabolic: overdose: bleeding, bruising, malaise, fever, sore
Route: results in diminished (high temperature). hypoglycemia throat.
Rectal transmission of pain Paracetamol is often
suppository impulses therefore included in cough, cold Skin: rash,
analgesia. and flu remedies urticuria
Frequency: Tell patient to notify prescriber for pain/ fever
q4° lasting for more than 3 days.
Our Mission
mechanism.
mechanism.
MAIN CAMPUS
OFFICE OF THE DEAN
Drug Action
Generic Therapeutic: It relieves nasal 1.To control and 1.Nervousness Assess lung sounds, PR and BP before drug
Name: congestion and prevent reversible administration and during peak of medication.
Bronchodilator airway obstruction 2.Restlessness
Albuterol reversible
caused by asthma or Observe fore paradoxical spasm and withhold
bronchospasm by 3.Tremor
chronic obstructive medication and notify physician if condition occurs.
Brand relaxing the smooth pulmonary disorder 4.Headache
name: muscles of the (COPD) If administering medication through inhalation,
Salbutamol bronchioles. 5.Insomnia allow at least 1 minute between inhalation of aerosol
2.Quick relief for
bronchospasm 6.Chest pain medication.
Dose:
2.5mg 3.For the prevention of 7.Palpitations Advise the patient to rinse mouth with water after
exercise-induced each inhalation to minimize dry mouth.
bronchospasm 8.Angina
Route:
Inhalation Inform the patient that Albuterol may cause an
4.Long-term control 9.Arrhythmias
unusual or bad taste.
agent for patients with 10.Hypertension
Frequency: chronic or persistent
q6° bronchospasm 11.Nausea and
vomiting
12.Hyperglycemia
13.Hypokalemia
Our Mission
mechanism.
mechanism.
MAIN CAMPUS
OFFICE OF THE DEAN
VII. Sample Charting:
FEVER
Subjective Objective Assessment Planning Intervention Evaluation
“Nilalagnat sya”  Conscious Altered body After 1 hour of  Established rapport Goal was met
verbalized by  Weak in appearance temperature related nursing intervention,  Morning care done
patient’s mother  Irritable the temperature of the  Bedside care done
to bacterial infection
 With dry cough patient will decrease  IVF checked/regulated
 Clogged nose as evidenced by from 38.1OC to 37.0  Monitored accordingly
O
 T= 38.1OC T=38.1OC C  Assessed underlying condition and
 Flushed face body temperature
 Restlessness  Performed TSB
 Crying  Removed unnecessary clothing that
 Warm to touch could only aggravate heat
 Redness of throat  Promoted a well –ventilated area to
patient
 VS taken/recorded
 Keep rested/comfortable
 Diet instructed
 Due meds given
 Laboratory test done
Our Mission
mechanism.
mechanism.
MAIN CAMPUS
OFFICE OF THE DEAN
COUGH
“Inuubo sya”  Conscious Ineffective airway After 6 hours of  Established rapport Goal was met
verbalized by  Weak in appearance clearance related to nursing interventions,  Morning care done
patient’s mother  Irritable increased production the client will have  Bedside care done
 With dry cough of bronchial improved airway  IVF checked/regulated
 Clogged nose secretions as clearance as  VS taken/recorded
 Restlessness manifested by evidenced by clear  Monitored accordingly
ineffective cough breath sounds.
 Crying  Monitored lung sounds every 4 to 8
 Redness of throat hours
 Gagging sensation  Observed for signs of respiratory
 With crackles distress(increased rate, restlessness/
 Watery eyes anxiety, use of accessory muscles for
breathing)
 Assessed the condition of the oral
mucous membranes and oral care every
2 hours.
 Keep rested/comfortable
 Diet instructed
 Due meds given
 Nebulized done by RT
Our Mission
mechanism.
mechanism.
MAIN CAMPUS
OFFICE OF THE DEAN
COMMON COLDS
“Barado ang  Conscious Ineffective breathing After 2-4 hours of  Established rapport Goal was met
ilong nya sa  Weak in appearance pattern related to nursing intervention  Morning care done
sipon”  Irritable presence of semi- the client will  Bedside care done
verbalized by  With dry cough thick nasal demonstrate enhance  IVF checked/regulated
patient’s mother  Clogged nose discharges as breathing pattern from  VS taken/recorded
 Restlessness evidenced by RR= 37cpm to 25cpm  Monitored accordingly
congested nose
 Crying  Placed the client in semi- fowlers using
 Redness of throat pillows.
 Gagging sensation  Assessed RR and pattern
 With crackles  Keep rested/comfortable
 Watery eyes  Diet instructed
 RR= 37cpm  Due meds given
 Seen on rounds with Dra. Santos with
new order and carried out
 Nebulized done by RT
Our Mission
mechanism.
mechanism.
MAIN CAMPUS
OFFICE OF THE DEAN
SORE THROAT
“Namamaga  Conscious Impaired oral After 1 hour of  Established rapport Goal was met
ang lalamunan  Weak in appearance mucous membrane nursing intervention,  Morning care done
nya” verbalized  Irritable related to infectious patient’s mother will  Bedside care done
by patient’s  With dry cough process as evidenced verbalize  IVF checked/regulated
mother  Clogged nose by inflamed tonsils understanding of the  VS taken/recorded
 Restlessness etiology and  Monitored accordingly
management of
 Crying  Keep rested/comfortable
tonsillitis of her child.
 Redness of throat  Advised mother to continue with the
After applying the
 Swollen throat antibiotics as prescribed by the doctor
health teachings given
 Gagging sensation even if symptoms subside
to the mother,
 With crackles  Advised mother to avoid giving sweets
patient’s condition
 Watery eyes will improve and
and cold beverage to the patient
 Palpable lymph  Due meds given
recurrence of the
nodes in sub  Seen on rounds with Dra. Santos with
infection will be
mandibular new order and carried out
avoided.
Our Mission
mechanism.
mechanism.
MAIN CAMPUS
OFFICE OF THE DEAN
RESTLESSNESS
“Hindi siya  Conscious Disturbed sleeping After 6 hours, the  Established rapport Goal was met
makatulog ng  Weak in appearance pattern related to patient will achieve  Morning care done
maayos”  Irritable generated optimal amount of  Bedside care done
verbalized by  With dry cough awakening, and sleep as evidenced by  IVF checked/regulated
patient’s mother  Clogged nose excessive rested appearance,  VS taken/recorded
 Restlessness stimulation (noise verbalization of  Monitored accordingly
and lighting) as feeling rested, and
 Crying  Assessed sleep pattern disturbances
evidenced by improvement in sleep
 Redness of throat that are associated with specific
restlessness pattern.
 Swollen throat underlying illnesses.
 Gagging sensation  Put patient in comfortable position that
 With crackles provide adequate support
 Watery eyes  Did as much care as possible without
 Agitated waking the client, and did as much care
 5 hours of sleep at as possible while the patient is still
night awake.
 Seen on rounds with Dra. Santos with
new order and carried out
Our Mission
mechanism.
mechanism.

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BATAAN PENINSULA STATE UNIVERSITY

OFFICE OF THE DEAN

Our Vision Our Mission

OFFICE OF THE DEAN

II. Physical Assessment:

OFFICE OF THE DEAN

OFFICE OF THE DEAN

Modifiable Non- Modifiable

Bacteria and Viruses

Direct hand-to- Droplet

Enter to the nose by inhaling

Traps in upper respiratory

Junction of the posterior

Impinge on the back of the

Swelling Erythema Increase mucous Fever

Our Vision Our Mission

OFFICE OF THE DEAN

Adenoids and tonsils contain

Humoral immunity and cellular

Suboptimal humoral and

Pathogens resist destruction

Sinusitis Rhinitis Laryngitis Pharyngitis

Our Vision Our Mission

OFFICE OF THE DEAN

 Nasal congestion  Low-grade fever (more common in

Segmenters 55-65% 56%

Indicate your body is dealing with

Our Vision Our Mission

OFFICE OF THE DEAN

VI. Drug Study:

OFFICE OF THE DEAN

OFFICE OF THE DEAN

OFFICE OF THE DEAN

VII. Sample Charting:

Subjective Objective Assessment Planning Intervention Evaluation

OFFICE OF THE DEAN

Subjective Objective Assessment Planning Intervention Evaluation

OFFICE OF THE DEAN

Subjective Objective Assessment Planning Intervention Evaluation

OFFICE OF THE DEAN

Subjective Objective Assessment Planning Intervention Evaluation

OFFICE OF THE DEAN

Subjective Objective Assessment Planning Intervention Evaluation

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