Pneumonia Case Study 1

Case Study: Respiratory Nursing
Pneumonia
Prepared by:
Matrix No.: 304293040
Cohort: DIN 68
Year 2 Sem 2
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Table of Contents
Preface.................................................................................................................................................... 3
Acknowledgement ................................................................................................................................. 4
Objective Case Study:........................................................................................................................... 5
Learning Outcome ............................................................................................................................ 5
Introduction ........................................................................................................................................... 6
Orientation To Ward ............................................................................................................................ 8
Assessment ........................................................................................................................................... 11
History Taking ................................................................................................................................ 12
Physical Assessment ........................................................................................................................ 13
Activity Daily Living ....................................................................................................................... 21
Investigation ........................................................................................................................................ 23
Summary Investigation .................................................................................................................. 23
Laboratory Study ............................................................................................................................ 24
Radiology Study .............................................................................................................................. 32
Spirometry Test............................................................................................................................... 33
Electrocardiogram (ECG) .............................................................................................................. 35
Anatomy & Physiology: ...................................................................................................................... 36
Definition ............................................................................................................................................. 50
Classification Of Pneumonia .......................................................................................................... 52
Aetiology Of Pneumonia..................................................................................................................... 55
Predisposed factor: ......................................................................................................................... 56
Pathophysiology Of Pneumonia......................................................................................................... 58
Clinical Manifestations ....................................................................................................................... 60
Complications ...................................................................................................................................... 61
Treatment ............................................................................................................................................ 62
Pharmacological Therapy .............................................................................................................. 63
Chest Physiotherapy ....................................................................................................................... 83
Nursing Care Plan............................................................................................................................... 88
Health Education ................................................................................................................................ 99
Discharge ........................................................................................................................................... 109
Follow Up ........................................................................................................................................... 111
Summary............................................................................................................................................ 112
Conclusion ......................................................................................................................................... 113
References .......................................................................................................................................... 114
Appendices ......................................................................................................................................... 118
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Preface
Pneumonia is a complex infection or inflammation that begins with initial contact with a
pathogenic microorganism and culminates in the invasion of the lower respiratory tract. This
infection can be acquired in the community or in the hospital, and it is spread through aspirated
or inhaled microorganisms. Pneumonia is a serious health issue that causes significant mortality
and morbidity around the world.
I would like to present my case presentation as a student nurse with matrix number
3042193040. I chose pneumonia as my case presentation because it is an interesting topic that
allows me to learn more about our respiratory system and how I can reapply knowledge in
taking care of patient. On March 14, 2023, a 55-year-old man was admitted and diagnosed with
pneumonia. After interviewing Mr. M, I decided to use this case as my case presentation. I was
overjoyed because he was cooperative and provided me with sufficient information. I believe
my presentation on pneumonia will pique other people's interest, and I want to ensure that they
have a thorough understanding of the disease.
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Acknowledgement
First and foremost, I'd like to thank Allah for providing me with the opportunity to complete
my first case study during my clinical semester 4 placement at KPJ Seremban Specialist
Hospital. Thank you to all of my lecturers and friends who helped me finish this case study.
Thank you also to all of the nurse instructors at this hospital for continuously guiding me in the
preparation of this case study, and don't forget to thank all of the staff nurses and my seniors
for their cooperation and assistance in completing this task. This is my first time doing this
case study. I am grateful for this opportunity because it will allow me to improve my data
collection skills, computer creativity, and time management.
Millions of thanks to the most important person, Mr. S, who is very friendly and willing to help
me by providing adequate information and cooperating well during my preparations for this
case study. Last but not least, I want to thank my family and friends for their unending support.
To be honest, each of you has given me a good way to improve myself. Thank you for being
an inspiration.
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Objective Case Study:
The general objective of this case study is to provide holistic approach of care to patient,
applying nursing theory and gain comprehensive knowledge as well as practical experience
about a particular disease or case. The case that I have chosen for my case study was
Pneumonia.
Learning Outcome
At the end of case study, I will be able to:
1) Explain the anatomy & physiology of respiratory system.
2) State definition of pneumonia
3) List the aetiology of pneumonia
4) Describe and explain pathophysiology of pneumonia
5) State clinical manifestation of pneumonia
6) List the complications of pneumonia
7) Discuss the investigation carried out to patient with pneumonia
8) Explain the medication that has been administered to the patient with pneumonia
9) Explain the treatment that receive for patient with pneumonia
10) Implement effective nursing care plan to patient using nursing process for patient
pneumonia
11) Explain health education provided to patient with pneumonia
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Introduction
Mr. M, 55 years old male, admitted in Anggerik ward, KPJ Seremban from accident &
emergency department on 14/3/2023 with complaint of cough with thick greenish sputum,
fever, flu & sore throat for 4 days.
Name Mr. M
Age / gender 55 years old man
MRN 11XXXX
Date of birth 26/2/1968
IC number 680226XXXXXXX
Race Malay
Religion Islam
Marital status Married
Occupation Officer at Malaysian Airline
Language spoken English and Malay
Address PT XXXX Jalan X, Taman Jimah Jaya 71960 Port Dickson
Date and time of admission 14/3/2023 @ 1500HRS
Attending doctor Dr. A
Room 372
Accompanied by Wife
Mode of admission Walk in
Source of admission Accident & Emergency
Complaint of cough with thick greenish sputum, fever, flu &

Reason of admission
sore throat for 4 days.
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Clinical manifestation on
Cough, flu, fever, sore throat, tachypnea,
admission
Diagnosis Pneumonia
Pre-Admission – Accident & Emergency Department(A&E)
On 14.3.2023 at 1000 HRS, Mr. M & his wife came to emergency department with complaint
of cough with thick greenish sputum, fever, flu & sore throat for 4 days. General appearance
restless and conscious. Vital sign taken and reviewed by MO R. Referred to Dr. S. Dr. S review
and ordered Covid RTK, ECG & Chest X- ray. Mr. M received 200ml/hour normal saline for
an hour & 1g T.paracetamol.
Vital sign in accident & emergency department:
Vital signs Result
Blood pressure 112/75mmHg
Heart rate 120 bpm
Respiration rate 26 breath/ min
Pain score 5/10
SPO2 95%
Temperature 38.9℃
Admission in Anggerik Ward
Patient transferred from A&E to anggerik ward room 372 on 1500HRS under care of Dr. S.
Accompanied by staff nurse A&E, patient came to ward via wheelchair. Patient condition alert
& look comfortable. History taking, vital sign & physical examination done. No stat
medication. Dr, S ordered 4-pint normal saline.
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Orientation To Ward
Orientation is essential for new patients and their families. Once the patient is admitted to the
ward, the orientation must be completed. The main goal is to familiarise the patient with the
ward and surroundings. This will make the patient feel less anxious and more at ease in the
ward.
• Introduce Self & Ward Members
I introduce myself as student nurse from College KPJ Nilai. I also teach how to differ
staff base on uniform
• Identification Band (ID Band)
I put on ID band at patient at wrist patient. I instruct patient this ID Band have to wear
until discharged. I also explained about the difference of colour ID band.
• TV/ Telephone
I show the location television and telephone in patient room. I instruct patient if
telephone rang answer the call.
• Call Bell
I show the location of the call bell near the bed side and toilet and I teach patient how
to use.
• Room Number/ Location
I tell patient the room number, the name of ward and the location.
• Meal Time
I tell patient this hospital has meal time for breakfast, lunch, tea time & dinner.
• Breakfast: 0830 HRS
• Lunch: 1200HRS
• Tea time: 1600HRS
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• Dinner: 1800HRS
• Medication/ Doctor/ Nurses Rounds
I tell patient what time the nurse will give medication. The doctor will come to make
round 2 times morning and evening. The nurse will make shift every shift.
• Smart Locker
I tell patient there is smart locker and tell patient how to use it. Patient can lock as they
want to go out
• Patient are not allowed to go home leave
I instruct the patient patients are not allowed to return unless approved by the doctor
• Visiting Hours
I explained to patient about the visiting hours. Patient relatives must follow the schedule
of visiting time.
• Grievance Mechanism
I tell patient there is grievance mechanism. This typically takes the form of an internal
procedure for complaints, followed by consideration and management response and
feedback.
• Waiting area
I tell and show patient the ward have waiting area as family can sit there.
• Surau / Kiblat
I tell patient qiblat direction and the location of surau if patient not comfortable to pray
in room
• Hand Hygiene
I instruct patient to perform hand hygiene frequently
• Fire / Emergency Exit
I tell patient where the location of emergency exit and how the fire emergency alarm
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• Smoking policy
I warned patient and his relatives that smoking is prohibited in the hospital. I told patient
about the effect of smoking in the hospital
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Assessment
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History Taking
Mr. M is a 55 years old man who complaint of cough 4 days. The sputum is thick and greenish.
He developed fever, flu and sore throat for 4 days along with the cough. On 12/3/2023 he
developed pain in his chest, more during coughing. Stabbing chest pain that get worse when
breathe deeply or cough. Mr. M had undergone appendicectomy in 2017 at KPJ SSH. He denies
have asthma. His mother has hypertension and his father died due to motor vehicle accident
(MVA). He smokes and stops at age 45 years old due to worries about his health condition. No
recent travel but work as officer at MAS airlines. He denies any sick contact. Currently he has
2 cats. He complaint of poor appetite, poor fluid intake but regular bowel habit. The urine is
dark coloured due to poor fluid intake. Mr. M allergies is unknown. No medication currently
taken.
This information obtained from patient and his wife.
Vital sign was charted as below:
Vital sign Patient’s vital sign Normal range
Temperature 38.0℃ 36.5 – 37.4℃
Pulse 110 bpm 60 – 100 bpm
Blood pressure 127/85 mmHg 90/60 – 140/90 mmHg
Respiration 25 breath/ min 12 – 20 breath/ min
Oxygen saturation
95% 95 – 100%
(spo2)
Pain score 4/10
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Weight 98kg
Height 169cm 18.5 – 24.9 kg/m2
BMI 34.3 kg/m2 (obesity)
Physical Assessment
Pleurisy pain due

to persistent cough
Iv canula
inserted
Scar of the
appendicectomy
Diagram 1shows abnormality found during physical examination
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No. Physical Examination Result
• Consciousness level: he is conscious
and oriented to time, place and person.
• Appearance: he is alert & calm
• Posture/gait: balanced
1) General appearance • Hygiene and grooming: patient well
groomed. Personal hygiene maintained.
• Behaviour: co-operative.
• Speech: clear and loud. Easily
understandable. Speaks fluent
• Skin colour: brown
• Texture: smooth and soft
• Cyanosis: absent
• Turgor: poor elastic
2) Integumentary • Oedema: nil
• Erythema: not seen
• Hair: evenly distributed, black coloured
• Nails: no clubbing, capillary refill
delayed
• Normocephalic
3) Head • No any mass, nodules or scar
• No depressed swelling or injury.
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• Scalp clear, no dandruff, lice
• Eyebrows: equally distributed hair,
symmetrical, equal movement of
eyebrows.
• Eyelid: no exopthalmus, no ectropion
and no entropion, symmetrical closing,
no swelling, redness, no drooping.
• Bulbar conjunctiva: transparent and
white in colour.
• Palpebral conjunctiva: slightly pinkish in
colour, slight discharge.
4) Eyes • Sclera: white in colour.
• Cornea: transparent, no abrasions, no
opacity.
• Lens: equal, light reflex is equal, clear,
no opacities. Pupils: symmetrical, round
constricts on light and well
accommodated.
• Ocular movement-smooth, symmetrical,
bilateral equal movement, no divergence
in any positions/no squint present.
• Conjunctival haemorrhage-not present.
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• Location - normal, the margins of the
pinna, outer canthus of the eye meets at
occipital protuberance.
• Pinna-no lesion, lump, smooth rounded
counter and B/L symmetrical.

5) Ears
• External ear canal-no redness, discharge,
mass or foreign body. Wax present.
• Lymph nodes and mastoid area-not
palpable, no swelling and tenderness.
• No discharge or drainage from the ear.
• Location-centrally located on face.
• Nostrils-uniform, no nasal flaring and
discharge.
• Nasal septum-normal, no deviation, no
extra growth.
• Nasal canal-pinkish mucosa, no extra
6) Nose growth.
• Sinuses-no tenderness and pain when
palpating maxillary and frontal sinuses.
• Turbinate and mucous membrane-
normal, no inflammation or redness.
Symmetrical at rest and with voluntary
movements.
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• Symmetrical – symmetrical in terms of
palpebral fissure, nasolabial folds. No
facial palsy.
7) Face • Skin- dry
• Sensation- Able to feel normally. Has
touch sensation.
• Temporal pulse – Present
• Lips-brown in colour but no cyanosis,
dry, no injury.
• Teeth-yellowish in colour, no dental
carries and no missing teeth.
• Mucosa-a little bit dry and whitish in
colour.
• Gums-no ulcer or inflammation. No gum
bleeding.
8) Mouth and throat
• Tongue-pink, no ulcer, can move freely.
• Palate-soft palate (pink in colour), hard
palate (pink in colour)
• Tonsils-present, no swelling.
• Pharynx-pink, smooth oropharynx.
• Uvula-free hanging, single, pear-shaped
projection.
• Gag reflex-present.
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• Range of motion-normally flexed, no
stiffness normal extension.
• Thyroid gland-no enlargement, no
swelling, no lump on the neck.

9) Neck
• Jugular vein-no distention.
• Lymph nodes-no tenderness. Tracheal
position-mid line
• Carotid pulse-bilateral equal and strong.
• Inspection
- Normal in size, shape and
symmetry. Lateral diameter is
wider than anterior posterior
diameter.
- Symmetrical range of movement
on inspiration and expiration.

10) Chest
• Palpation:
- No any lump, tenderness,
depression along the ribs.
• Percussion:
- Dull sound
• Auscultation:
Crackles present.
• No lump
11) Axillary area
• Clean and dry
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• Spine-centrally located, ’s’ shaped,
concave on cervical region, convex on
thoracic region, concave lumbar region
and convex on sacral region.
• Slightly leaned forward.
12) Back • Spinous process-vertically aligned, non-
tender, muscle mass equal, no any
lesions.
• Breath sounds-crackles present.
• Range of motion-full, reversal of lumbar
spinal curvature upon flexion.
• Have surgical scar at right site of lower
abdomen
• No visible blood vessels.

13) Abdomen
• No abdominal distention.
• Liver and spleen are not palpable.
• Gurgling bowel sound present.
• Normal
14) Perineum part • No abnormal discharges.
• No history of bleeding during defecation.
Upper extremities/arms
15) Extremities
• Skin-slightly dark
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• Nails-hard, pink in colour, no clubbing
of nail or thickening, delay capillary
refill.
• Symmetry-symmetrical in shape and
size.
• Range of motion-full in all joints,
bilaterally equal.
• Joints-no tenderness no swelling.
• Hands-no flapping tenderness, all fingers
are full of motion symmetrical on right
and left
• Pulses-brachial pulses are felt. Radial
pulses are felt.
Lower extremities/legs
• Skin-slightly gray hair distribution
present. A little bit pale no cyanosis.
• Nails-hard, no clubbing, delay capillary
refill
• Symmetrical-symmetrical in shape and
size.
• Range of motion full in all joints,
bilaterally equal.
• Joints-no tenderness, no swelling.
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• Pulses-dorsalis pedis, posterior tibials
and popliteal pulses are present.
• Posture and gait-normal.
• Standing on one feet-not able.
Activity Daily Living
No. Activity daily living Results
1) Breathing Mr. have difficulty in breathing, shallow breathing & tachypnea
2) Eating & drinking Mr. M have poor appetite and nauseous sensation
3) Sleeping Disturb sleep pattern due to persistent cough
Mr. M has maintained his good personal hygiene and able to take
4) Personal hygiene
over of his personal hygiene by himself.
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5) Elimination Mr. M doesn’t have any issue with bowel movement
Mr. M doesn’t have any difficulty in passing urine but he has dark
6) Bladder
colour urine due to poor fluid intake
7) Speech Mr. M is able to communicate normally
8) Mobility Mr. M able to ambulate that didn’t acquire assistant
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Investigation
Summary Investigation
Date & Time Date & Time

No. Examination
Received Reported
14.3.2023 14.3.2023
1) Chest X -Ray (PA Erect)
1100HRS 1700HRS
14.3.2023 14,3.2023
2) Admission Profile
1600HRS 1630HRS
14.3.2023 14,3.2023
3) Urine FEME
1600HRS 1630HRS
14.3.2023 14.3.2023
4) RTK
1217HRS 1255HRS
14.3.2023 14.3.2023
5) ECG
1600 HRS 1615 HRS
14.3.2023 14.3.2023
6) Crp, Myco Plasma Igm
1935 HRS 2017 HRS
15.3.2023 19.3.2023
7) Sputum Cns
0728 HRS 1236 HRS
16.3.2023 16.3.2023
8) Spirometry
1030 HRS 1200 HRS
18.3.2023 18.3.2023
9) Crp
0732 HRS 0803 HRS
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Laboratory Study
COVID-19/SARS CoV-2 Molecular Detection
A swab test is used to determine if patient have an active coronavirus infection. A specialised
swab is inserted into the nose and or throat to collect the sample needed to determine an active
infection.
The Antigen Rapid Test Kit (RTK-Ag) is a method for determining whether or not a patient
has contracted the virus. This method detects viral protein related to the coronavirus to
determine whether the result is reactive or non-reactive. The rapid test, as the name implies, is
a faster method of detecting the virus in the body and can provide results in as little as 15
minutes.
Sample collected 14/3/2023
Sample type nasopharyngeal and oropharyngeal swab
SARS CoV-2/COVID-19 RNA Not detected
Admission Profile
• Contain FBC, ESR, CRP, Renal Profile, Liver Function Test & URINE FEME.
• FBC is full blood count test to look for abnormality in blood such as unusually high or
low numbers of blood cells
• ESR is erythrocyte sedimentation rate that can show inflammation in body
• C – reactive protein test (CRP) measures the level of c – reactive protein in blood. CRP
is protein that liver makes. Liver releases more CRP into bloodstream if have
inflammation.
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• Renal profile a test to evaluate renal function. Give information on level of creatinine,
sodium, calcium, chloride, blood urea & potassium.
• Liver function test is blood test that measure different enzymes, proteins and other:
➢ Albumin, protein made in liver
➢ Total protein measures the total amount of protein in blood
➢ ALP (alkaline phosphatase), ALT (alanine transaminase), AST (aspartate
aminotransferase) & gamma – glutamyl transferase (GGT), These are enzymes
made by liver
➢ Bilirubin waste product made by liver
➢ Lactate dehydrogenase (LD) enzyme found in body’s cell. LD released into the
blood when cell have been damaged.
➢ Prothrombin time (PT) protein involved in blood clotting
• Urine FEME
• Full & Microscopic Examination of urine sample. Provide breakdown of content urine,
& determine if there is too much protein, cell, glucose or salt within sample.
Haematology
Full blood count(FBC)
Examination Result Unit Reference range
Haemoglobin 14.4 g/dL 13.0-18.0
Red cell count 5.6 10^12/L 4.5 – 6.5
Haematocrit (PCV) 45 % 38 – 52
MCV 84 fL 80 – 100
MCH 27 pg 27 – 32
MCHC 32 g/dL 31 – 37
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RDW 14.6 % <15.6
Platelet count 207 10^3/uL 150 – 400
MPV 9.9 fL 7.0 – 12.0
White Blood Cell 11.2 10^3/uL 4.0 – 11.0
Count
White blood cell differential count
Neutrophil 81.4 % 40.0 – 80.0
Lymphocyte 21.6 % 20.0 – 40.0
Eosinophil 7.8 % 1.0 – 6.0
Monocyte 13.7 % 2.0 – 10.0
Basophil 0.5 % <2.0
ESR 28 mm/hr <12
Biochemistry
Diabetic Mellistus Screen
Glucose 4.2 mmol/L 3.9 – 6.1
Renal Function and Bone Metabolism Screen
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Uric acid 322 umol/L 202 – 434
Creatinine 89 umol/L 59 - 104
Urea 5.1 mmol/L 2.0 – 6.8
Sodium 138 mmol/L 135 - 155
Potassium 4.0 mmol/L 3.5 – 5.5
Chloride 106 mmol/L 95 – 111
Calcium 2.26 mmol/L 2.14 – 2.55
Phosphate 0.99 mmol/L 0.78 – 1.50
Lipid Profile
Total cholesterol 3.9 mmol/L <5.2
Triglycerides 1.42 mmol/L <1.71
HDL cholesterol 1.5 mmol/L >1.42
LDL cholesterol 1.9 mmol/L <2.6
Chol/ HDL Chol 2.8 Up to 4.0
Liver Function Screen
Total protein 74 g/L 63 – 83
Albumin 42 g/L 35 – 50
Globulin 32 g/L 25 – 40
A/G ratio 1.3 1.0 – 2.0
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Total bilirubin 7.8 umol/L 2.0 – 28.0
0.5 mg/dL 0.1 – 1.6
Direct bilirubin 3.9 umol/L <6.8
0.2 mg/dL <0.4
Indirect bilirubin 3.9 umol/L <20.5
0.2 mg/dL <1.2
SGOT/AST 25 U/L 7 – 44
SGPT/ALT 36 U/L 7 – 48
Alkaline 99 U/L 40 – 128
phosphatase
Gamma – GT 45 U/L 7 – 55
SEROLOGY
VENEREAL DISEASE SCREEN
VDRL (RPR) Non-Reactive Non-Reactive
URINE FEME (URINALYSIS)
Examination Result Reference range
Appearance, urine Dark yellow Yellow/ pale yellow
Specific gravity, 1.03 1.002 – 1.028
urine
pH, urine 5.0 4.8 – 7.5
Protein, urine Negative Negative
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Glucose, urine Negative Negative
Ketone, urine Negative Negative
Bilirubin screen, Negative Negative
urine
Urobilinogen screen, Negative Negative
urine
Blood, urine Negative Negative
microscopic examination, urine
WBC, urine 2 /uL 0 – 10
RBC, urine 2 /uL 0–5
Epithelial cell, urine Occasional Occasional
Cast, urine Nil Nil
Crystal, urine Nil Nil
Bacteria, urine Nil Nil
Others, urine Nil Nil
Mycoplasma pneumonia IgM
The detection of M. pneumoniae IgM has been used to determine the presence of an acute
infection.
Examination Results
Mycoplasma pneumonia Not detected
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C – reactive protein (hs – CRP)
hs – CRP 50.48 mg/L <5.0
Sputum CNS
Test to check presence of bacteria or any other pathogen that cause infection.
Specimen: sputum
Examination: culture and sensitivity
Bacteria 1: light growth of klebsiella pneumonia
Susceptibility 1
Amoxicillin/ clavulanis acid S Augmentin
Amikacin S Amikin
Ampicillin/ sulbactam S Unasyn
Cefazolin S
Cefixime S Cephoral
Cefributen S Cedax
Ciprofloxacin S Ciprobay
Ceftriaxone S Rocephin
Cefotaxime S Claforan
Cefuroxime S Zinacef
Ertapenem S Invanz
Cidomycin, septopal,
Gentamycin S
garamycin
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Moxifloxacin S Avelox
Netilmicin S Netromycin
Ofloxacin S Tarivid, inoflox
Piperacillin/ tazobactam S Tazocin
Co – trimoxazole (Trim/
S Bactrim, septrin
Sulfa)
Omnipen, polycillin,
Ampicillin R
principen
Amoxycilin R Amoxil, amolin
Pefloxacin R Peflacin
C – reactive protein (hs – CRP)
hs – CRP 21.88 mg/L <5.0
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Radiology Study
Chest X Ray (PA Erect)
Chest x-rays produce images of the inside of the chest using a very small dose of ionising
radiation. It is used to assess the lungs, heart, and chest wall and may aid in the diagnosis of
shortness of breath, persistent cough, fever, chest pain, or injury. It may also be used to aid in
the diagnosis and monitoring of a variety of lung conditions such as pneumonia, emphysema,
and cancer.
The posteroanterior (PA) chest view examines the lungs, bony thoracic cavity, mediastinum
and great vessels.
Finding:
• No local lung lesion or consolidation
• No pleural effusion
• Both hilar are not enlarged
• Normal cardiac silhouette
• No suspicious bone lesions
Impression:
• no active lung lesions
Diagram 2 shows patient’s chest

xray
Reported by Dr. N
Consultant Radiologist
Page | 32
Spirometry Test
• Spirometry is a simple test that measures how
much air can expel in one forced breath to help
diagnose and monitor certain lung conditions.
• It determines objective measurement of lung
volume.
• This procedure is performed using a
spirometer.
• Prior to procedure
• The patient's identification should be checked, their height without shoes or boots and
weight measured (if scales are available, as this is not used in prediction equations but is
useful to know, as volume in obese patients may be restricted), and their age, gender, and
race recorded. If the patient is unable to stand, arm span can be used to estimate their
height.
• Factor that patient should avoid before procedure
Activity Length Of Time to Stop Before Spirometry

Drinking alcohol 4H
Eating large meal 2H
Vigorous exercise 30min
Smoking >1H
Medication use Document treatment & when last taken
For reversibility testing
Taking short acting bronchodilator 6H
Taking long-acting bronchodilators (including
combination inhalers) or twice-daily 24H
preparations
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Taking tiotropium or once-daily preparations 48H
Contraindication:
• Haemoptysis of unknown origin
• Pneumothorax
• Unstable cardiovascular status, recent myocardial infarction or pulmonary embolism
• Thoracic, abdominal or cerebral aneurysm
• Recent eye surgery
• Acute disorder affecting test performance such as nausea or vomiting
• Recent thoracic or abdominal surgical procedure
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Electrocardiogram (ECG)
Test used to evaluate the heart. Electrode are placed at certain spots on the chest, arms & legs.
The electrode is connected to ECG machine by lead wires.
The electrical activity of heart is measured, interpreted & printed out. No electricity sent into
the body.
Patient result:
Doctor noted this ECG
Tachycardia, heart rate is faster than 100 beats per minute. With sinus tachycardia, electrical
signals from heart’s sinoatrial (SA) node are telling heart to beat faster than normal. This is a
common condition that is usually a result of stressors like fear, exercise or not drinking enough
fluids.
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Anatomy & Physiology:
Respiratory System
Page | 36
The respiratory system is composed of the upper and lower respiratory tracts. Together, the
two tracts are responsible for ventilation (movement of air in and out of the airways). The upper
tract, known as the upper airway, warms and filters inspired air so that the lower respiratory
tract, the lungs, can accomplish gas exchange. Gas exchange involves delivering oxygen to the
tissues through the blood stream and expelling waste gases such as carbon dioxide during
expiration. The respiratory system works in together with the cardiovascular system. The
respiratory system is responsible for ventilation and diffusion, and the cardiovascular system
is responsible for perfusion.
The upper airway structures consist of the nose, sinuses and nasal passages, pharynx,
tonsils and adenoids, larynx and trachea.
The lower respiratory tract consists of the lungs, which contain the bronchial and
alveolar structures needed for gas exchange.
The cells of the body need energy for their chemical activity that maintains
homeostasis. Most of this energy is derived from chemical reaction which can only take place
in the presence of oxygen (O2). The main waste product of these reactions is carbon dioxide
(CO2).
External respiration: Exchange of gases between the blood and the lung
Internal respiration: between blood and cells.
The organ of the respiratory system:
• Nose
• Pharynx
• Larynx
• Trachea
• Two bronchi (one bronchus to each lung)
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• Bronchioles and the smaller air passages
• Two lungs and their coverings, the pleura
• Muscle of respiration the intercostal muscles and the diaphragm
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Nose & Nasal Cavity
• Nasal cavity divided by septum.
• The roof is formed by the
cribriform plate of the ethmoid
bone, and the sphenoid bone,
frontal bone & nasal bones.
• The floor is formed by the roof of
the mouth and consist of the hard
palate in front and the soft palate
behind. The hard palate is composed of the maxilla and palatine bones and soft palate
consist of involuntary muscle.
• The medial wall is formed by the septum
• The lateral wall is formed by the maxilla, the ethmoid bone and the inferior conchae
• The posterior wall is formed by the posterior wall of the pharynx
• The nose is lined with ciliated columnar epithelium (ciliated mucus membrane) which
contain mucus that secreting goblet cells.
• The anterior nares or nostril are the opening from the exterior into nasal cavity, hair is
present.
• The posterior nares are the openings from the nasal cavity into the pharynx
• The paranasal sinuses are cavities in the bones of the face and the cranium which
contain air.
• There are tiny openings between the paranasal sinuses and the nasal cavity. They are
lined with mucus membrane, continuous with nasal cavity.
• Main sinus:
➢ Maxillary sinuses in lateral walls
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➢ Frontal and sphenoidal sinuses in the roof
➢ Ethmoidal sinuses in the upper part of the lateral wall
• Function of sinuses:
➢ Increasing the resonance of speech
➢ To lighten the skull
➢ Respiratory function of nose
• The function of nose is warmed, moistened and filtered the air.
• Warming
• The immense vascularity of the mucosa permits rapid warming as the air flows past.
• This also explains the large blood loss when a nosebleed (epistaxis) occurs.
• Filtering and cleaning.
• Hairs at the anterior nares trap larger particles. Smaller particles such as dust and
bacteria settle and adhere to the mucus. Mucus protects the underlying epithelium from
irritation and prevents drying. Synchronous beating of the cilia wafts the mucus towards
the throat where it is swallowed or expectorated.
• Humidification.
• This occurs as air travel over the moist mucosa and becomes saturated with water
vapour. Irritation of the nasal mucosa results in sneezing, a reflex action that forcibly
expels an irritant.
• Olfactory function in nose
• There are nerve endings that detect smell, located in the roof of nose in the area of
cribriform plate of the ethmoid bones and the superior conchae.
• The nerve stimulated by chemical substance that given off by odorous materials. The
resultant nerve impulses are conveyed by the olfactory nerves to brain.
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Pharynx
Divided into 3 parts:
• The nasopharynx
Lies behind the nose above the
level of soft palate.
On its lateral walls are the two
opening of auditory tubes, one
leading to middle ear
On posterior wall, they are
pharyngeal tonsil (adenoid)
• The oropharynx
The oral part of the pharynx lies behind the mouth, extending from below the level of
the soft palate to the level of the upper part of the body of the 3rd cervical vertebra.
The lateral walls of the pharynx blend with the soft palate to form two folds on each
side. Between each pair of folds is a collection of lymphoid tissue called the palatine
tonsil.
When swallowing, the soft palate and uvula are pushed upwards, sealing off the nasal
cavity and preventing the entry of food and fluids
• The laryngopharynx
The laryngeal part of the pharynx extends from the oropharynx above and continues
as the oesophagus below, with the larynx lying anteriorly.
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Functions
• Passageway for air and food
The pharynx is involved in both the respiratory and the digestive systems: air passes
through the nasal and oral sections, and food through the oral and laryngeal sections.
• Hearing
The auditory tube, extending from the nasopharynx to each middle ear, allows air to
enter the middle ear. This leads to air in the middle ear being at the same pressure as
the outer ear, protecting the tympanic membrane from any changes in atmospheric
pressure.
• Protection
The lymphatic tissue of the pharyngeal and laryngeal tonsils produces antibodies in
response to swallowed or inhaled antigens.
• Speech
Acting as a resonating chamber for sound ascending from the larynx, it helps (together
with the sinuses) to give the voice its individual characteristics.
Larynx (voice box)
Position
Links the laryngopharynx and the trachea. It lies in front of the laryngopharynx and the 3rd,
4th, 5th and 6th cervical vertebrae.
The larynx is composed of several irregularly shaped cartilages attached to each other by
ligaments and membranes. The main cartilages are:
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The epiglottis
It closes off the larynx during swallowing, protecting the lungs from accidental inhalation of
foreign objects.
Function of larynx
Production of sound and speech
Trachea
The trachea or windpipe is a continuation of the
larynx and extends downwards to about the level of
the 5th thoracic vertebra where it divides at the
carina into the right and left primary bronchi, one
bronchus going to each lung.
Three layers of tissue:
• the outer layer
consist fibrous and elastic tissue and
encloses the cartilages
• the middle layer
consist of cartilages and bands of smooth
muscle that wind round the trachea in a helical arrangement
• the inner lining
consist ciliated columnar epithelium contain mucus that secret goblet cell
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Function:
• Support and patency
Tracheal cartilages hold the trachea permanently open (patent), but the soft tissue bands
in between the cartilages allow flexibility so that the head and neck can move freely
without obstructing or kinking the trachea.
• Mucociliary escalator
This is the synchronous and regular beating of the cilia of the mucous membrane lining
that wafts mucus with adherent particles upwards towards the larynx where it is either
swallowed or coughed up.
• Cough reflex
Nerve endings in the larynx, trachea and bronchi are sensitive to irritation, which
generates nerve impulses conducted by the vagus nerves to the respiratory centre in the
brain stem. The reflex motor response is deep inspiration followed by closure of the
glottis, closure of the vocal cords. The abdominal and respiratory muscles then contract
causing a sudden and rapid increase of pressure in the lungs. Then the glottis opens,
expelling air through the mouth, taking mucus and/or foreign material with it.
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Bronchi & Bronchioles
Composed same tissues as trachea
Right bronchus is wider, shorter and more vertical than left bronchus
Functions of air passages not involved in gaseous exchange it controls of air entry, the diameter
of respiratory passages may be altered by contraction or relaxation the involuntary muscle.
Alveoli
• Process of gas exchange occur
• The exchanges of gases during respiration takes place across two membranes the
alveolar and capillary membrane.
• It also defends against microbe. It contains lymphocytes and plasma cells, which
produce antibodies in the presence of antigens, and macrophages and phagocytes
Lungs
• Coned shaped
• Right lung divided into three lobes
• Left lung is smaller as heart is situated left of midline. Divided into 2 lobes.
• The divisions between the lobes are called fissures.
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Pleura & Pleural Cavity
The pleura consists of closed sac of serous membrane which contain serous fluid
The lung is invaginated into this sac so it forms two layers:
➢ One adheres to lung
➢ To wall thoracic cavity
The visceral pleura
• Adherent to lung that cover lobe and passing into fissure which separates them
The parietal pleura
• Adherent to inside of chest wall and thoracic surface of diaphragm
• It remains detached from the adjacent structures in the mediastinum and continuous
with visceral pleura round the edge of hilum
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The pleura cavity
Two layers of pleura are separated by only thin film serous fluid which allow them to glide
over prevent friction between them. the serous fluid secreted by the epithelial cell of the
membrane.
Muscles of respiration
Intercostal muscles
11 pairs of intercostal muscles that occupy the
spaces between the 12 pairs of ribs
Arranged in two layers:
• The external intercostal muscles fibres
Extend in downward and forward direction from
the lower border of rib above to the upper border
of the rib
• The internal intercostal muscle fibres
Extend in downward and backwards direction from the lower border of rib above to the upper
border of the rib, cross the external intercostal muscles fibre
Diaphragm
It separating the thoracic cavity and abdominal cavities.
It consists tendon from which muscle fibre radiate to be attached to lower ribs and sternum and
to the vertebral column by 2 crura.
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Respiration Mechanism
Mechanism of respiration have two phases, namely inspiration and expiration. Inspiration is the process
of inhaling air into the lungs.
During inspiration, the muscles of diaphragm contract and the diaphragm moves downward. This
results in the increase in the volume of the chest cavity, The air pressure inside the chest cavity
decreases. The oxygenated air present outside the body being at high-pressure flow rapidly into the
lungs. In the lungs, oxygenated air reaches the alveoli. Alveoli are thin walled and are surrounded by a
network of blood capillaries. The oxygen passes through the walls of the alveoli into the blood present
in blood capillaries. The oxygen is then supplied to all the tissues of the body. From the tissues, the
waste product, carbon dioxide is absorbed by blood and carried to the alveoli of lungs for expiration.
Expiration is the process of exhaling air from lungs. During expiration, the muscles of diaphragm relax
and diaphragm moves upward. This results in the decrease in the volume of the chest cavity. The air
pressure inside the chest cavity increases. This pushes out carbon dioxide outside the body.
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Gas exchange
Diffusion of oxygen (O2) & carbon
dioxide (CO2) depends on difference
pressure, e.g., between atmospheric air &
the blood or blood and the tissue
External respiration:
• O2 concentration in blood is lower
than alveoli. Co2 is high.
• Oxygen from alveoli diffuses to blood. Co2 from blood diffuse to alveoli.
Internal inspiration:
• Oxygen concentration in tissue lower than blood. Co2 is high.
• Oxygen in blood diffuses to the tissue. Co2 from tissue diffuse to the blood.
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Definition
1) Pneumonia is inflammation of the lung parenchyma caused by various microorganism,
including bacteria, mycobacteria, fungi & viruses.
(Brunner & Suddarth’s Textbook of Medical-surgical Nursing, 2018)
2) Pneumonia is an infection of the lungs that may be caused by bacteria, viruses, or fungi.
The infection causes the lungs' air sacs (alveoli) to become inflamed and fill up with
fluid or pus. That can make it hard for the oxygen to breathe in to get into bloodstream.
(American Lung Association)
3) Pneumonia is an infection that affects one or both lungs. It causes the air sacs, or alveoli,
of the lungs to fill up with fluid or pus. Bacteria, viruses, or fungi
may cause pneumonia.
(National Heart, Lung & Blood Institute, 2022, March 24)
4) Pneumonia is an infection of the lung tissue. When a person has pneumonia the air sacs
in their lungs become filled with microorganisms, fluid and inflammatory cells and
their lungs are not able to work properly.
(National Institute for Health & Care Excellence 2022, July 7)
5) Pneumonia is a form of acute respiratory infection that affects the lungs. The lungs are
made up of small sacs called alveoli, which fill with air when a healthy person breathes.
When an individual has pneumonia, the alveoli are filled with pus and fluid, which
makes breathing painful and limits oxygen intake.
(World Health Organization: WHO. (2022, November 11)
6) The lungs are an organ containing millions of alveoli which is responsible for the
exchange of oxygen and carbon dioxide. Pneumonia is the inflammation or infection in
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the lungs. This happens when the alveoli are filled up with inflammatory cells. As a
result, gas exchange is compromised.
(PORTAL MyHEALTH, (2017, April 28).
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Classification Of Pneumonia
Classified into 4 types:
1) Community Acquired Pneumonia (CAP)
Occur either in the community setting or within 48HRS after hospitalization mostly by
inhalation of microorganism.
Need for hospitalization depend on severity
The causative microorganism is most frequently S. Pneumonia, H. Influenza,
Legionella, Pseudomonas aeruginosa, and other gram-negative rods
2) Hospital Acquired Pneumonia (HAP)
Develop 48HRS or more after admission and does not appear to be incubating at time
of admission.
Factors may predispose patients to HAP
1) Due to impaired immune response (e.g., acute or chronic illness)
2) Variety of comorbid illness
3) Supine positioning and aspiration
4) Coma
5) Malnutrition
6) Prolonged hospitalization
7) Hypotension
8) Metabolic disorder
The common organisms responsible for HAP include the pathogens Enterobacter sp.,
Escherichia Coli, Influenzas, Klebsiella species, proteus, Serratia marcescens, P.
Aeruginosa, Staphylococcus aureus, and S.pneumoniae.
Pneumonia in the immunocompromised host occurs with the use of corticosteroids or
other immunosuppressive agents, chemotherapy, nutritional depletion, use of broad-
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spectrum antimicrobial agents, Acquired Immuno Deficiency Syndrome, genetic
immune disorders, and long-term advanced life support technology (mechanical
ventilation).
3) Healthcare Acquired Pneumonia (HAP)
HAP was defined as pneumonia in non-hospitalized patients who had significant
contact with the healthcare system and were thought to be at a higher risk of infection
with multidrug-resistant (MDR) organisms as a result of such contact.
Multidrug-resistant organisms are bacteria that have developed resistance to certain
antibiotics and can no longer be controlled or killed by these antibiotics.
Common multi drug resistant organism:
1) Candida kruseii
2) Carbapenem resistant gram-negative organisms, such as Carbapenem resistant
Enterobacteriaceae or Carbapenem resistant Pseudomonas
3) Extended spectrum β-lactamase (ESBLs) producing Gram-negative bacteria
4) Methicillin Resistant Staphylococcus aureus (MRSA)
5) Vancomycin Resistant Enterococci (VRE)
4) Ventilator acquired pneumonia
Subtype of HAP but the patient uses endotracheally intubated and has received
mechanical ventilatory support for at least 48 HRS.
Aspiration Pneumonia
Aspiration pneumonia is an infectious pulmonary process that occurs as a result of abnormal
fluid entry into the lower respiratory tract. The fluid aspirated could be oropharyngeal
secretions, particulate matter, or gastric content. Aspiration pneumonitis is an inhalational
acute lung injury caused by aspiration of sterile gastric contents.
Common pathogens are anaerobes, S. aureus, Streptococcus species & gram-negative bacilli.
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In terms of structural distribution, pneumonia is divided into two different terms:
1. Bronchopneumonia
Bronchopneumonia is defined as pneumonia that spreads in a patchy pattern, beginning
in one or more localised areas of the bronchi and extending to the adjacent surrounding
lung parenchyma. As the tissue becomes inflamed, fibrous exudates accumulate,
causing consolidation and, in many cases, incomplete resolution and fibrosis.
2. Lobar pneumonia
A complete lung lobe or even two lobes are affected, with the most noticeable changes
occurring in the alveoli, resulting in the production of watery inflammatory exudates in
the alveoli. This builds up and fills the lobules, causing them to overflow and infect
nearby lobules.
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Aetiology Of Pneumonia
• Depends on causative agent.
• Inhalation of pathogen.
Bacteria
Examples pathogen:
1) Streptococcus pneumoniae: Rust-coloured sputum
2) Pseudomonas, Haemophilus, and pneumococcal species: May produce green sputum
3) Klebsiella species pneumonia: red currant-jelly sputum
4) Anaerobic infections: Often produce foul-smelling or bad-tasting sputum
Virus
The flu (influenza virus) and the common cold (rhinovirus) are the most common causes of
viral pneumonia in adults.
Respiratory syncytial virus (RSV) is the most common cause of viral pneumonia in young
children.
Fungi
Fungal pneumonia is a lung infection caused by one or more endemic or opportunistic fungi.
Fungal infection occurs as a result of spore inhalation, conidia inhalation, or the reactivation
of a latent infection.
Endemic fungal pathogens (eg, Histoplasma capsulatum, Coccidioides immitis, Blastomyces
dermatitidis, Paracoccidioides brasiliensis, Sporothrix schenckii, Cryptococcus neoformans)
cause infection in healthy hosts and in immunocompromised persons.
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Opportunistic fungal organisms (eg, Candida species, Aspergillus species, Mucor species) tend
to cause pneumonia in patients with congenital or acquired defects in the host immune
defences.
Predisposed factor:
• Chronically ill patients, the elderly, and cancer patients.
• Thoracic surgery patient
• Long periods of immobility and shallow breathing.
• Immunosuppressed Patients who have a low neutrophil count (Neutropenic)
• Cigarette smoke interferes with both mucociliary and macrophage activity.
• Cough reflex suppression (due to medications, weak respiratory muscles, etc.)
• Foreign material aspiration into the lungs while unconscious (head injury, anaesthesia,
low level of consciousness) or abnormal swallowing mechanism.
• NPO status; insertion of a nasogastric, orogastric, or endotracheal tube.
• Supine positioning is used in patients who are unable to protect their airway.
• Antibiotic treatment (in very ill people, the oropharynx is likely to be colonised by
gram-negative bacteria)
• Intoxication with alcohol (because alcohol suppresses the body's reflexes, may be
associated with aspiration, and reduces white cell mobilisation and tracheobronchial
ciliary motion)
• Respiratory therapy using unclean equipment
• Patient with fibrocystic disease, tracheostomy.
• Exposed to noxious gases, exposed to cold, exposed to dirty and dusty environments.
• Because of possible depressed cough and glottic reflexes, as well as nutritional
deficiency, advanced age.
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• Virus transmission from health care providers.
Transmission of the pathogen by:

Aspiration
• The pathogen is transmitted from the oropharynx & GIT system to lungs
• Bacteria found in oropharyngeal secretion
• Patient with decreased gag reflex, oesophageal disorder such as Oesophageal
achalasia, endotracheal & nasogastric tubes.
Inhalation
• The pathogen is suspended in water droplet
• The pathogen enter air when infected individual cough, sneezes or talks
• The droplet nucleus with the pathogen can be inhaled deeply into lung of individual
and invades the cells lining the airways & alveoli
• The more virulent the organism is, the smaller the number required to
• infect the lungs.
Circulation
• The pathogen transmitted to lung via the circulatory system from infections in other
part of the body.
• E.g., septicaemia, endocarditis, immunosuppression & other lung disease
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Pathophysiology Of Pneumonia
Inhalation of pathogen, impaired mucociliary action
Invades the cells lining the airways and alveoli
Inflammatory response occurs, inflammatory exudate fills alveolar air spaces
The pathogen growth spreads to other sacs, bronchioles, bronchi
Lung consolidation with thick exudate in the spaces of lungs
Block gas exchange / impaired ventilation in the affected alveoli
Excess mucus production, bronchospasm
Hypoxemia, discoloured sputum, dyspnoea.
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Pneumonia affects both
ventilation and diffusion It
starts with inhalation of
pathogen that cause upper
respiratory tract infection. The
pneumonia arises from the
pathogen in the oropharynx.
Inflammatory reaction occurs
in alveoli produce exudates
that interferes within diffusion
of oxygen and carbon dioxide.
White blood cell migrates into
alveoli and fill the normally air-filled spaces due to invasion of pathogen. Lung become
consolidate due to exudate and thick secretion. So, it affects the ventilation and diffusion due
to gas exchange block. The mucus will accumulate and muscles that line the bronchi tighten
and narrow the airways. Which resulting in dyspnoea.
The venous blood entering the pulmonary circulation passes through the under ventilated area
and travels to the left side of the heart poorly oxygenated. The mixing of oxygenated &
unoxygenated or poorly oxygenated blood will result in arterial hypoxemia.
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Clinical Manifestations
Clinical manifestation depending on type & pathogen:
1) Sudden onset of chills, rapid rising fever (38.5℃ − 40.5℃)
2) Pleuritic chest pain that is aggravated by deep breathing &
coughing
3) Tachypnea
4) Shortness of breath (dyspnea)
5) The use of accessory muscle in respiration
6) Bradycardia (temperature decrease which the pulse is
slower)
7) Nasal congestion
8) Sore throat
9) Myalgia/ easily tires/ fatigue
10) Lip and nails bed demonstrates central cyanosis (late
sign of oxygenation – hypoxemia)
11) Poor appetite
12) Purulent sputum
13) Delayed capillary refill
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Complications
Respiratory Failure
This complication happens when the patient did not receive specific treat or delayed or the
patient is resistant to therapy. It also happens when patient with comorbid disease such as high
blood pressure, diabetes and chronic kidney disease also immunocompromised patient.
Pleural Effusion
Pleural effusion is accumulation of pleural fluid in the pleural space. Due to same side of lung
infection, the fluid accumulated in pleural space If this pleural effusion becomes infected, it is
labelled a complicated parapneumonic effusion, whereas the presence of frank pus in the
pleural space defines an empyema.
Empyema
Empyema is built up of pus in pleura space. As the WBC migrate to alveoli due to invasion of
pathogen. The process of phagocytosis occur which produce pus. The accumulation of pus will
spread to pleural space.
Atelectasis
Atelectasis is a partial or complete collapse of the entire lung or a specific area, or lobe, of the
lung, leading to impaired exchange of carbon dioxide and oxygen. Atelectasis occurs when the
alveoli (small air sacs) within the lung become deflated or fill with alveolar fluid.
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Treatment
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Pharmacological Therapy
Administration of medication
Principles of medication:
1) Right medication
• Check the doctor written orders
• Check the medication container with the medication form
• Before removing container from the drawer or shelf,
• Before removing from container
• Before returning the container to the storage.
• Unit dose medications must be checked before opening at the patient’s bedside.
2) Right dose
• When calculating dose or converting the system of medication, the nurse should have
another qualified nurse to check.
• Must use graded cups, syringes& scaled droppers can be used to measure the
medication accurately
• If it needs to be crushed & mixed with very small number of foods or liquid
• Not all medications can be crushed. Some are time –released or extended-release
capsules
3) Right patient
• Nurse must check the medication administration form against the patient’s
identification bracelet
• Asks him to state his name to ensure the patient's identification bracelet has the correct
information
4) Right route
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• If doctor’s order dose not designate a route of administration, the nurse consults the
doctor.
• If the specified route is not recommended route, the nurse should alert the doctor
immediately.
• Wrong route may cause sterile abscess or it may be fatal.
5) Right time
• The prescriber often gives specific instructions about when to administer.
• Check last dose of medication given to patient
6) Right documentation
• It is an important part in safe medication administration.
• It should clearly reflect staff nurse name, name of the medication, the time medication
was administered & medication’s dosage, route & the frequency
• It serves as a way of communication to other health team members to avoid duplication.
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Summary medication that doctor prescribe for Mr. M:
Date Date
No. Name Group Dose Frequency
Start Off
1) IV Tramadol Analgesic 50mg TDS 14.3 18.3
2) IV Zofran Antiemetic 8mg BD 14.3 18.3
3) IV Rocephine Antibiotic 1g OD 14.3 18.3
Antibacterial &
4) Diflam lozenges 1/1 TDS 14.3 19.3
antiinflammation
5) T. Azithromycin Antibiotic 500mg OD 15.3 19.3
Antihistamines
6) Sy. Aerius 15ml TDS 14.3 19.3
& antiallergic
7) T. Paracetamol Antipyretic 1g TDS 14.3 16.3
Bronchodilator/
8) Neb. Combivent 2.5ml TDS 14.3 19.3
antiasthmatic
24 HRS
9) Normal Saline Electrolyte 4 – pint 1– 14.3 18.3
PINT=6HRS
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Generic Name/ Trade Name Tramadol HCL/ Acugesic
Drug Group Analgesic (oipiod)
Dosage 50 mg
Route IV
Frequency TDS
Indication Severe acute & chronic pain
Contraindication Acute intoxication with alcohol, hypnotics,
analgesics, opioids or psychotropic drugs.
Side Effect Sweating, dizziness, nausea and vomiting,
dry mouth, fatigue
Nursing Responsibilities • Explain the indication and side effect of
the medication
• Assess the level of pain relief and
administer a prn dose as needed, but not
more than the total daily dose
recommended.
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• Monitor vital signs and look for signs of
orthostatic hypotension or central
nervous system depression or respiratory
depression.
• If sign and symptom of hypersensitivity
occur, discontinue the drug and notify
your doctor.
• Examine bowel and bladder function and
report on urinary frequency or retention.
• Take appropriate safety precautions and
monitor ambulation.
• After administered, advice patient to rest
in bed.
Generic Name/ Trade Name Zofran / ondansetron
Drug Group Antiemetic
Dosage 8mg
Route IV
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Frequency BD
Indication Management of nausea & vomiting induced
by cytotoxic chemotherapy & radiotherapy.
Prevention & treatment of post-op nausea &
vomiting.
Contraindication Hypersensitivity. Concomitant use w/
apomorphine.
Side Effect Headache. Sensation of warmth or flushing,
constipation, local IV injection site reactions,
diarrhoea and constipation
Nursing Responsibilities • Explain the indication and side effect of the
medication.
• Assess side effect of medication
• Assess and monitor sign and symptom of
respiratory depression
• Monitor intake and output chart
• Advice patient to take more fluid
• Advice patient to rest in bed
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Generic Name/ Trade Name Rocephin / ceftriaxone
Drug Group Antibiotic
Dosage 1g
Route IV
Frequency OD
Indication • Pathogens sensitive to Rocephin,
e.g.: sepsis; meningitis; disseminated
Lyme borreliosis
• Abdominal infections (peritonitis,
infections of the biliary and
gastrointestinal tracts)
• Infections of the bones, joints, soft
tissue, skin and of wounds
• Infections in patients with impaired
defence mechanisms
• Renal and urinary tract infections;
respiratory tract infections,
particularly pneumonia
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• Ear, nose and throat infections
• Genital infections, including
gonorrhoea.
Perioperative prophylaxis of
infections.
Contraindication patients with known hypersensitivity to
ceftriaxone, any of its excipients or to any
other cephalosporin.
Patients with previous hypersensitivity
reactions to penicillin and other beta-lactam
agents may be at greater risk of
hypersensitivity to ceftriaxone.
Lidocaine: Contraindications to lidocaine
must be excluded before intramuscular
injection of ceftriaxone when lidocaine
solution is used as a solvent
Ceftriaxone solutions containing lidocaine
should never be administered intravenously.
Side Effect • Eosinophilia
• Leucopenia
• Thrombocytopenia
• Diarrhea
• Rash
• Hepatic Enzymes Increased.
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the medication.
• Assess side effect of medication.
• Watch for seizures; notify doctor
immediately if patient develops or
increases seizure activity.
• Monitor signs of pseudomembranous
colitis, including diarrhea, abdominal
pain, fever, pus or mucus in stools, and
other severe or prolonged GI problems
(nausea, vomiting, heartburn). Notify
doctor or staff nurse immediately of these
signs.
• Monitor signs of allergic reactions and
anaphylaxis, including pulmonary
symptoms (tightness in the throat and
chest, wheezing, cough dyspnea) or skin
reactions (rash, pruritus, urticaria). Notify
doctor or staff nurse immediately if these
reactions occur.
• Monitor signs of blood dyscrasias,
including eosinophilia (fatigue,
weakness, myalgia), haemolytic anaemia
(malaise, dizziness, jaundice, abdominal
pain), leukopenia (fever, sore throat,
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mucosal lesions, signs of infection),
thrombocytopenia (bruising, nose bleeds,
bleeding gums, other unusual bleeding),
or thrombocytosis (headache, dizziness,
chest pain, fainting, visual disturbances,
numbness or tingling in the hands and
feet). Report these signs to the physician.
• Monitor injection site for pain, swelling,
and irritation. Report prolonged or
excessive injection site reactions to the
physician.
Generic Name/ Trade Name Difflam lozenges
Drug Group Anti inflammatory
Dosage 1/1
Route Oral
Frequency TDS
Indication • Tonsillitis
• Sore throat
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• Radiation mucositis
• Aphthous ulcer
• Post-orosurgical
• Periodontal procedures.
Contraindication Hypersensitivity to benzydamine
Side Effect • Sudden swelling in mouth / throat
• Difficulty in breathing
• Rash or itching
• Burning sensation or dryness of the
mouth
the medication.
• Advice patient the lozenges should be
dissolved in mouth
• Advice patient to avoid hot food or drink
for two hours after use
Generic Name/ Trade Name T. Axithromycin
Drug Group Antibiotic
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Dosage 500mg
Route Oral
Frequency OD
Indication • Lower respiratory tract infections e.g.,
bronchitis & pneumonia
• Skin & soft tissue infections
• Acute otitis media
• URTI eg, sinusitis &
pharyngitis/tonsillitis. Streptococci
eradication in oropharynx. STD:
Uncomplicated genital infections due to
Chlamydia trachomatis, chancroid due to
Haemophilus ducreyi, uncomplicated
genital infections due to non-
multiresistant Neisseria gonorrhoea
excluding concurrent infection with
Treponema pallidum.
Contraindication Hypersensitivity to azithromycin,
erythromycin, any macrolide or ketolide
antibiotics.
Side Effect • Diarrhoea
• Headache
• Vomiting
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• Abdominal pain
• Nausea
• Decreased lymphocyte count & blood
bicarbonate
• Increased eosinophil count basophils,
monocytes & neutrophils.
the medication.
• Advice patient to take with meals to
reduce GI discomfort
• Advice patient to take full dose for 4 days
• Monitor intake and output chart
• Advice patient to rest in bed due to
headache
Generic Name/ Trade Name Sy. Aerius / desloratadine
Drug Group Antihistamine
Page | 75
Dosage 15ml
Route Oral
Frequency TDS
Indication • Allergic rhinitis, such as sneezing,
nasal discharge and itching,
congestion/stuffiness, as well as
ocular itching, tearing and redness.
• Chronic idiopathic urticaria such as
the relief of itching and the size and
numbers of hives.
Contraindication Hypersensitivity to the active substance or to
any of the excipients
Side Effect • Dry mouth, nose or throat
• Fatigue
• Tachycardia or irregular heart beat
• Nausea and vomiting
• Diarrhea
• Loss of appetite
• Weight loss
• Yellowing of skin or white eyes
• Dark urine
• Pale stools
Page | 76
the medication.
• Monitor input and output chart
• Advice patient to take before take
lozenges and increase fluid intake
• Advice patient if skin dry use skin lotion
Generic Name/ Trade Name Paracetamol
Drug Group Analgesic/ antipyretic
Dosage 1g
Route Oral
Frequency TDS
Indication Fever mild to moderate pain
Contraindication Hypersensitivity to paracetamol, liver or
kidney problem
Side Effect Tachycardia
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Nausea & vomiting
Hypertension
the medication.
• Monitor kidney and liver function
• Monitor signs of bleeding if patient take
any anticoagulant drug
• Assess vital sign after 1 hr after
administered
Generic Name/ Trade Name Combivent / ipratropium bromide +
salbutamol sulphate
Drug Group Bronchodilator/ antiasthma
Dosage 2.5ml
Route Inhalant
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Frequency TDS
Indication Treat bronchospasm associated with
obstructive airway diseases in patients who
require more than a single bronchodilator.
Contraindication • Hypersensitivity to ipratropium Br,
salbutamol sulphate or atropine.
• Hypertrophic obstructive
cardiomyopathy or tachyarrhythmia.
Side Effect • Headache
• Dizziness
• throat irritation
• cough
• dry mouth
• GI motility disorders (eg, constipation,
diarrhoea, vomiting), nausea.
the medication.
• Advice patient cough out the phlegm
• Assess vital sign as patient can get
tachycardia
• Advice patient take it before meal
• Advice patient to rest in bed
• Advice to increase fluid intake
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Generic Name/ Trade Name Normal saline
Drug Group Electrolyte
Dosage 4pint
Route IV
Frequency 24hrs
1 pint: 6hrs
Indication • Hyponatremia
• Shock
• Maintenance fluid
• Dehydration
Contraindication Contraindicated in any situation where salt
retention is undesirable such as edema, heart
disease, cardiac decompensation and primary
or secondary aldosteronism
Page | 80
Side Effect • Febrile response
• Infection at the site of injection
• Venous thrombosis
• Phlebitis
• Extravasation
• Hypervolemia
Nursing Responsibilities • Monitor injection site
• Monitor input and output chart
• Check capillary refill and edema
• Monitor for continued signs of
hypovolemia, including urine output <
0.5 mL/kg/hour, poor skin turgor,
tachycardia, weak pulse, and
hypotension.
• Monitor for signs of hypervolemia such
as hypertension, bounding pulse,
pulmonary crackles, dyspnea, shortness
of breath, peripheral edema & jugular
vein distension (JVD)
Page | 81
Care of patient with IV drip
1) Verify doctor order to prevent medication error
2) Practice strict asepsis to prevent infection
3) Inform patient explain the purpose of IV drip to gain cooperation
4) Priming the IV tube to expel air to prevent air embolism
5) Change and rotate insertion site every 72HRS to prevent thrombophlebitis
6) Monitor sign and symptom of complication such as infiltration, hematoma, air
embolism, phlebitis & extravasation.
7) Change tegaderm if wet to prevent infection as wet can attract pathogen growth.
8) Advice patient to report any swelling at IV canulation site.
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Chest Physiotherapy
Therapy that used in treatment of respiratory diseases. Its goal is to clear the patient's airways
and allow them to resume physical activity and exertion.
Purpose of chest physiotherapy:
• To aid in the removal of retained or excessive airway secretions.
• To improve gas exchange and optimise lung compliance and the ventilation-perfusion
ratio.
• To reduce the amount of work required for breathing.
• Increase tolerance to exercise.
• Avoid secondary complications.
Type of chest physiotherapy
Postural drainage
Postural drainage involves positioning a person using gravity to help the normal airway
clearance mechanism. Postural drainage positioning varies depending on which parts of the
lungs have a lot of secretions. Postural drainage is the movement of secretions from one or
more lung segments to the central airways via gravity, where secretion can be removed by a
cough or mechanical aspiration.
Can be facilitated with percussion & vibration in postural drainage.
Postural drainage positions:
• Head down (Trendelenburg)
• To drain effectively lower lobes (anterior & lateral segment) of bronchi
• Prone
• Lower lobe, superior segment
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• Supine
• Upper lobes, anterior segment
• Right & left lateral
• Upper lobes, lingular segment
• Sitting upright
• Upper lobes, apical segment
Nursing responsibilities:
1) Schedule procedure before meal to prevent nausea, vomiting & aspiration
2) Administer bronchodilators as prescribed by doctor before drainage to dilate the
bronchioles, reduce bronchospasm, decrease thickness of mucus and sputum
3) Provide vomit bag to make patient comfortable
4) Encourage patient to cough out the secretion to prevent the it from retains and causing
more infection
5) Encourage patient to breath in slowly through the nose and out slowly through pursed
lips to help keep airways
6) After procedure note amount, colour, viscosity & characteristic of sputum
7) Instruct patient to gargle with water to clean mouth
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Diagram 3 shows position of postural drainage
Chest percussion
Therapy that manually cupping over the
chest wall to mobilize the secretion by
mechanically dislodging viscous secretion in
lung.
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It is done rhythmically clapping on the chest wall with cupped hand over the lung segment to
be drained
Percussion is performed forcefully and consistently. Each beat should sound hollow. Because
the majority of the movement is in the wrist and the arm is relaxed, percussion is less tiring to
perform. Percussion should not be painful or sting if the hand is properly cupped.
Special attention must be taken to not clap over the:
• Spine
• Breastbone
• Stomach
• Lower ribs or back (to prevent injury to the spleen on the left, the liver on the right and
the kidneys in the lower back)
Vibration
Technique of apply manual
compression and tremor to the chest
wall during exhalation phase of
respiration. Vibration is done with the
flattened hand.
To help increase the velocity of the air expired from small airways, freeing the mucus
After 3 – 4 vibrations, patient is encouraged to cough, using abdominal muscles.
Deep Breathing & Coughing Exercise
Is relaxation technique that can be self-taught improving both physical & mental wellness.
Purpose:
Page | 86
• Help to expand the lungs
• Helping the body rid of toxin & leaving more room in the cells for an optimal exchange
of oxygen
• Forces better distribution of the air into all section of the lung
• For relaxation, it calms the the mind & body to cope stress
• To prevent postoperative respiratory complications e.g., atelectasis, pneumonia
Coughing exercise to mobilizes secretion in the lung & help prevent postoperative pulmonary
complication
Encourage patient to splint the abdomen area by place hand or small pillow. The purpose of
splinting the abdomen area:
It supports the incision and surrounding tissue and also help reduce pain during coughing
Page | 87
Nursing Care Plan
No. Date & Time Nursing Care Plan

Deficient fluid volume related to high fever &
1) 14/3/20203 & 1700hrs
poor fluid intake
Impaired gas exchange related to collection of

2) 14/3/20203 & 1700hrs
sputum
Ineffective airway clearance related to increased

3) 14/3/20203 & 1700hrs
sputum production.
4) 14/3/20203 & 1700hrs Hyperthermia related to inflammatory process
5) 14/3/20203 & 1700hrs Acute pain related to persistent coughing
Page | 88
Nursing Care Plan 1
Date and time: 14/3/2023 & 1900hrs
Nursing diagnosis: deficient fluid volume related to high fever & poor fluid intake.
Goal:
Short term: patient maintain hydration status adequate fluid intake and normal skin turgor.
Long term: patient demonstrate adequate fluid intake as evidenced by moist mucus membrane,
good skin turgor, capillary refill time less than 2 seconds and vital signs in normal range.
Objective data: respiration rate: 24 and temperature: 38.0℃.
Subjective data: mucus membrane look dry and skin look pale
Nursing intervention:
1) Assess vital sign & check capillary refill.
R: elevated temperature and prolonged fever increase metabolic rate and fluid loss.
The respiratory rate of patient with pneumonia increases because of the increased
workload imposed by laboured breathing and fever. Increase respiratory rate leads to
increase in insensible fluid loss during exhalation and can lead to dehydration. Capillary
refill will be delayed due to dehydration. High fever can lead to dehydration due to
diaphoresis & sore throat.
I: I assess vital sign for the baseline data and for further treatment. I notice delayed
capillary refill more than 2 sec.
2) Assess skin turgor and mucus membrane.
R: decreased skin turgor and dry mucus membrane is signs of dehydration
I: I assess the moisture of mucus membrane and notice the mucus membrane quite dry.
3) Assess the patient about nausea and vomiting.
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R: high fever can make patient nauseous and loss of appetite.
I: I assess the patient by asking did patient having nauseous feeling and the patient
verbalize that he having nauseous feeling as well as loss of appetite.
4) Monitor intake and output, note the colour of urine.
R: it provides about the adequacy of fluid intake and output.
I: I monitor the intake and output chart as well as calculate the fluid balance as to
prevent from hypovolemia and hypervolemia.
5) Perform tepid sponge to patient.
R: to reduce the body heat through evaporation.
I: I perform tepid sponging to my patient using tap water and small towel. I also instruct
patient to put the wet towel on forehead as to loss the heat by conduction.
6) Encourage patient to increase fluid intake.
R: to reduce the risk of hypovolemia and mobilizing the secretion as well as promotes
secretion.
I: I advise patient to take at least 2L per day if not contraindicated
7) Encourage patient for frequent oral hygiene
R: it increases comfort and prevent from dry mucus
I: I advise patient to frequent oral hygiene as it gives positive impact on appetite.
8) Once gain appetite, begin to advance the diet in volume and composition. Such as
chicken broth.
R: it is recommended to advance the diet to gain energy as well as increase the fluid
intake.
I: I recommend patient to take chicken broth as it has protein and volume diet. This
food might also aid in the body's ability to heal and regenerate tissues.
9) Advise patient to take small and frequent meal.
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R: this enhance the intake even though appetite may be slow return as
I: I Encourage patient to take small amount of food but more frequent as to provide
adequate energy as well as prevent feeling nauseous.
10) Administer medication antipyretic tablet paracetamol 1g as prescribed by doctor.
R: it is to treat fever and relief pain.
I: I administer tablet paracetamol 1g as prescribed by doctor under supervision of staff
nurse.
11) Administer intravenous fluid 4-pint normal saline in 24HRS as prescribed by doctor.
R: it is for fluid replacement, maintain hydration as well as increase the hydration status
to liquefy the secretion.
I: I administer 4-pint normal saline as prescribed by doctor under supervision staff
nurse.
Evaluation:
Patient body temperature within normal range & patient demonstrate adequate fluid by
showing no signs of dehydration.
Evidence
1) Temperature: 36.7℃
2) Urine is pale yellow
3) Moist mucus membrane.
4) Elastic skin
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Nursing Care Plan 2
Date & time: 14/3/20203 & 1700hrs
Nursing diagnosis: impaired gas exchange related to collection of thick sputum
Goal:
Short term: The patient will have improved ventilation and oxygenation of tissues by more than
96% of oxygen saturation (SpO2) and no symptoms of respiratory distress.
Long term: The patient will be able to perform activity daily living without symptoms of
respiratory distress.
Subjective data: patient complaint of shortness of breath and having difficulty
Objective data: respiration rate: 24 and skin colour: pale.
1) Assess the respiration rate, rhythm and depth of inhalation and the use of accessory
muscles.
R: Gas exchange is directly affected by rapid, shallow breathing patterns and
hypoventilation. Signs of increased breathing effort are associated with hypoxia.
I: I monitor and assess respiration rate, rhythm and depth of inhalation and the use of
accessory muscles and notice patient having rapid and shallow breathing.
2) Assess and monitor heart rate and blood pressure.
R: Tachycardia is usually caused by fever and dehydration, but it can also be caused by
hypoxemia. The initial hypoxia raises blood pressure and heart rate. Blood pressures
may drop as hypoxia worsens, while heart rates tend to be rapid with dysrhythmias.
I: I assess and monitor heart rate and blood pressure and notice patient is tachycardia
as well as patient temperature is 38℃.
3) Assess the skin, nails bed and mucus membrane for pallor and cyanosis.
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R: Peripheral tissues become cyanotic as oxygenation and perfusion are altered.
Cyanosis of the nail beds may be caused by vasoconstriction or the body's reaction to
fever. Cyanosis of the mucous membranes and skin around the mouth, on the other
hand, is indicative of systemic hypoxemia.
I: I assess the skin nails bed and mucus membrane and the skin are pale and check for
the capillary refill time take a while to back to normal.
4) Instruct patient to elevate the head of the bed and encourage patient to change position
frequently.
R: Elevating the head of the bed would lower the diaphragm and encourage chest
expansion, mobilisation, and secretion expectoration.
I: I put my patient on semi fowlers position and encourage to change position for
maximum lung expansion and mobilization of secretion.
5) Encourage patient to complete rest in bed.
R: excessive movement will increase oxygen demand and can make the condition worst
I: I advise patient to complete rest in bed and minimizes the physical activity as this
will increase the oxygen demand.
6) Instruct patient to do deep breathing exercise as well as coughing out the secretion.
R: Taking a deep breath will aid in the removal of mucus from the lungs. Mucus
provides an ideal environment for germs to thrive. Deep breathing and coughing will
increase oxygen delivery to healing tissues and remove any mucus in the lungs.
I: I teach and demonstrate to patient to do deep breathing exercise as well as how to
cough effectively.
7) Administered medication such as nebulizer Combivent 2.5ml. as prescribed by doctor
R: Combivent nebuliser solution in unit dose vials are indicated for the management of
reversible bronchospasm and helping in loose the mucus.
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I: I administer neb Combivent 2.5ml/ 1 vial via nebulizer face mask as doctor prescribed
with supervision of staff nurse.
8) Instruct patient for smoking cessation as well as second hand smoker.
R: Tobacco smoke inhibits the activation of innate immune responses to bacterial
infection, a front-line defence mechanism thought to be important in pneumonia
susceptibility.
I: I assess how many cigarettes per one day and advice patient for smoking cessation as
it can make it worst.
9) Instruct patient to eat small but more frequent
R: Smaller meals require less effort to consume, which can assist patients in conserving
energy. A very full stomach can put pressure on the lungs and breathing muscles,
making it difficult to breathe.
I: I instruct patient to eat 5 – 6 small meal per day rather than 3 large meals.
10) Instruct patient to plan activity and rest periods to minimizes the patient energy.
R: Activities increase metabolic rates and oxygen consumption and should be planned
so the patient does not become hypoxic. Rest helps conserve the energy needed for
more effective breathing and coughing efforts.
I: I teach patient on how planning activity as well as planning the care for patient and
give some period of times for patient to rest.
Date & time: 14/3/2023 & 1900hrs
Evaluation:
The patient is maintaining in optimal gas exchange and able to perform activity daily living
without assistant.
Evidence:
1) No sign of respiratory distress
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2) Vital signs in normal range
Date & Time: 15/3/2023 & 1000HRS
Re-evaluation:
Patient no sign of hypoxia and can sleep overnight with assistant of medication
Evidence:
Capillary refill in 2 sec
Vital signs in normal range.
Nursing Care Plan 3
Date & time: 14/3/20203 & 1700hrs
Nursing diagnosis: Ineffective airway clearance related to increased sputum production.
Goal:
Short term: patient will have no difficulty in breathing and less sputum secretion
Long term: patient will maintain patent airway & patient able to expectorate the secretion.
Subjective data: patient complaint of difficulty in breathing and thick sputum secretion
Objective data: tachypnea, the use of accessory muscle to breath and abnormal breath sounds.
1) Assess the respiration rate, rhythm and depth of inhalation and the use of accessory
muscles.
R: Altered respiration rate may occur with accessory muscle used to increase the
expansion of chest to facilitate breathing. Alteration in respiration rate, rhythm and
depth are sign of respiratory difficulties.
Page | 95
I: I assess the vital sign and notice the patient is tachypneac, the depth is shallow and
the accessory muscle been used.
2) Assess patient’s hydration status by check skin turgor, capillary refill time & the colour
of urine.
R: Inadequate hydration and the thickening of secretions is one of the causes alterations
in airway clearance.
I: I check skin turgor by gently pinch the skin over the antecubital fossa and dorsum of
the hand using 2 fingers. I notice it take a while to return to normal. I also check
capillary refill time and notice it takes more than 2 second. I ask patient how about urine
and it is medium-dark yellow urine.
3) Assess cough for effectiveness and productivity.
R: Coughing is helpful to remove the secretions. Thick and tenacious secretion is one
of possible cause of ineffective cough.
I: I asses the productivity and effectiveness of cough by ask about severity, frequency,
intensity, the urge to cough and the impact on their activity daily living.
4) Obtain the sputum and observe the characteristic of sputum colour, viscosity and odour
and sent to lab for culture and sensitivity.
R: Sign of infection is discoloured sputum and odour. Thick secretion increases airway
resistance and work of breathing.
I: I instruct patient to collect sputum at the early morning, no brushing teeth or
antibacterial gargle. And instruct patient to breath in and out 2-3 times and cough deeply
and expectorate into sputum specimen container.
5) Auscultate the lung, note the area of decreased ventilation.
Page | 96
B: In areas where fluid has consolidated, airflow is reduced. In these consolidated areas,
bronchial breath sounds can also occur. On inspiration and expiration, crackles,
rhonchi, and wheezes are heard due to fluid accumulation and thick secretions.
I: I auscultate the lung sound and take note the area of abnormal sound and notice
patient have crackles sound
6) Assist and encourage patient with coughing, deep breathing and splinting.
R: coughing is helpful to remove the secretions. Deep breathing improves the
productivity of cough. Frequent non-productive cough can result in hypoxemia.
Splinting the abdomen promotes more effective coughing by increasing abdominal
pressure and upward diaphragmatic movement.
I: I teach patient on how to perform deep breathing exercise and encourage patient to
perform more frequently as it encourages to remove the secretions.
7) Encourage patient to ambulate or perform light physical activity as tolerated.
R: ambulation mobilizes the secretion and reduces atelectasis.
I: I encourage patient to ambulate around as tolerated
8) Encourage patient to increase fluid intake and maintain hydration.
R: maintaining hydration increase the ciliary action to remove secretion and reduce the
viscosity of secretion. It is easier for patient to mobilize thinner secretion with
coughing.
I: I encourage patient to take at least 2l a day if not contraindicated
9) Encourage patient to elevate the head of the bed
R: it can promote lung expansion & relieve discomfort
I: I instruct patient when to sleep or rest in bed elevate the head of bed and put to semi
fowlers.
10) Administered medication such as nebulizer Combivent 2.5ml. as prescribed by doctor
Page | 97
R: Combivent nebuliser solution in unit dose vials are indicated for the management of
reversible bronchospasm and helping in loose the mucus.
I: I administer neb Combivent 2.5ml/ 1 vial via nebulizer face mask as doctor prescribed
with supervision of staff nurse.
Evaluation: patient maintain clear and open airway.
Evidence:
1) Clear breath sound
2) Absence of dyspnea
3) Effectively clearing secretions
Date & time: 15/3/2023 @ 1000HRS
Re-evaluation: patient maintain patent airway without crackles sound heard by auscultation
Evidenced:
No crackles sound heard
Respiration rate: 20breath / min
Page | 98
Nursing Care Plan 4
Date & time: 14/3/20203 & 1900hrs.
Nursing diagnosis: hyperthermia related to inflammatory process
Goal:
Short term: temperature patient reduced
Long term: patient maintain body temperature within normal range
Objective data: temperature: 38℃. Tachycardia, tachypnoea
Subjective data: flushed skin
Nursing intervention.
1) Assess patient temperature.
R: fever suggest infection. Heart rate and blood pressures increase as hyperthermia
progress.
I: I monitor vital sign especially temperature as it suggests of infection
2) Assess signs and symptom of dehydration as well as patient having fever.
R: as patient having fever, patient may become risk for dehydration. This is due to the
fact that an increase in body temperature increases your metabolism and breathing rate,
causing you to expel more moisture.
3) Monitor intake and output chart.
R: if there are sign of symptom of dehydration fluid resuscitation may be require.
I: I assess and ask how many much the patient drink and monitor the output as for
baseline data for further treatment.
4) Advice patient to drink more water at least 2L per day if not contraindicated.
R: To decrease the body temperature through urination as well as to maintain hydration.
Page | 99
I: I encourage patient to drink more water as the patient can be creative to choose
nourishing fluid also such as Gatorade.
5) Perform tepid sponging to patient
R: to reduce the body heat through evaporation.
I: I perform tepid sponging as well as I instruct patient to put a small cool towel on
forehead, axilla area
6) Advice patient to wear thin clothes and removes extra blanket.
R: to reduce the heat through conduction process.
I: I advise patient to wear thin, light and loose cloth that can allow to sweat properly
7) Provide conducive environment such as by increase air conditioner level.
R: to let the body heat exit through convection process
I: I increase the air conditioner level as well as provide quiet environment to rest.
8) Encourage patient to rest in bed
Excessive movement will increase metabolism process and body temperature.
I: I advise patient as to minimal movement while having fever as to prevent fall as well
as prevent the temperature relapse back getting high
9) Administer medication such as Rocephin 1g as prescribed by doctor.
R: to treat bacterial infection
I: I administer antibiotic iv Rocephin 1g as prescribed by doctor under supervision staff
nurse
10) Administer iv fluid 4-pint normal saline for 24 HRS as prescribed by doctor
R: to maintain hydration status as well as help regulates body temperature
I: I administer iv fluid 4-pint normal saline as prescribed by doctor under supervision
of nurse.
Date & time: 14/3/2023 & 2200 hrs
Page | 100
Evaluation
Patient body temperature maintained in normal range
Evidence:
1) Body temperature: 36.8℃
2) Skin warm temperature reduce
3) Skin looks pink and less flush
Page | 101
Nursing Care Plan 5
Date & time: 14/3/20203 & 1900hrs
Nursing diagnosis: acute pain related to persistent coughing
Goal:
Short term: patient report satisfactory of pain control at a decrease level using numeric pain
scale.
Long term: patient able to perform activity daily living without interrupted by cough and the
pain.
Subjective data: patient verbalizes that he having pain during coughing
Objectives data: patient grimace look in pain as well as having difficulty in coughing.
1) Assess the location, characteristics, onset, duration, frequency, quality, and severity
of pain. Examine the pain's characteristics: sharp, constant, and stabbing. Examine
changes in the nature, location, or intensity of pain. Examine complaint of pain
associated with breathing or coughing. The pain can result in shallow breathing and
poor cough effort.
R: For the baseline data. Chest pain, usually present with pneumonia, may also
herald the onset of complications of pneumonia, such as pericarditis and
endocarditis.
I: I assess patient’s level of pain using numeric pain scale and found that patient’s
level pain is 5 and patient complaint of chest pain when coughing.
2) Monitor vital sign especially heart rate.
R: Changes in heart rate or blood pressure may indicate that the patient is in pain.
Page | 102
I: I check patient’s vital sign and the reading of heart rate is 110 beat/min
3) Instruct patient to elevate the head of bed.
R: for patient comfort, and easy patient to spit out the phlegm as well as promote
maximum lung expansion.
I: I advise patient to rest and relax in fowler position as well as when the patient
want to spit out sputum.
4) Teach patient during coughing use chest splinting coughing techniques.
R: it increases the effectiveness of coughing while helping to control chest
discomfort.
I: I teach patient squeezing a pillow against abdomen when cough.
5) Encourage patient to perform deep breathing exercise.
R: it helps in managing the pain, promote relaxation as well as expand the lung to
maximum and helping in spit out the sputum.
I: I teach patient to perform deep breathing exercise as it promotes relaxation.
6) Advice patient to avoid oily and high fat foods that can causes throat irritation and
provokes more coughing.
R: Fried foods tend to make the condition of cough worse. The fatty acids from
butter and omega-6 fatty acids can make the body produce more mucus.
I: I advise patient to avoid oily food as well as I advise the family to avoid giving
the oily food to patient.
7) Encourage patient to drink water at least 2L per day if not contraindicated.
R: warm water helpful in liquefy the thick secretion and facilitate patient to spit out
the sputum.
I: I advise patient to drink warm water and avoid drink cold water.
8) Advice patient to frequent oral hygiene.
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R: mouth breathing and oxygen therapy can dry mucus membrane as well as impact
comfortless
I: I advise to frequent oral hygiene as it promotes hygiene, prevent upper respiratory
tract infection and promote comfort.
9) Advice patient to use humidifier.
R: humidifier cannot prevent pneumonia, it helps ease the symptom like cough. It
reduces the likelihood that a dry, hacking cough will wake patient up. It will also
help a productive cough by thinning mucus and making it easier to cough up.
I: I advise patient to use humidifier in room as give moisture to air to thinning the
mucus.
10) Administer medication such as IV Tramadol 50 mg as prescribed by doctor.
R: For relief of pain
I: I administer 50 mg IV Tramadoll as prescribed by doctor under supervision of
nurse.
Date & time: 14/3/2023 & 2100HRS
Evaluation: patient chest pain reduced after nursing intervention and patient can sleep
peacefully.
Evidence:
1) Patient not verbalized he having pain
2) Patient can sleep and look more relax.
Page | 104
Health Education
Stop or smoking cessation.
• Tobacco smoke exposure is strongly linked to the development of CAP in both current
and ex-smokers. Adults over the age of 65 who are passive smokers are also at increased
risk of CAP. There is a significant dose-response relationship for current smokers.
Healthy diet
• Advice patient to take balance diet
• Avoid food that contain oil and spicy
• Diet that recommended:
➢ Protein rich food such as nuts, white meat & cold-water fish that have anti-
inflammatory qualities and also help in heal and regenerate tissues
➢ Green leafy vegetables that nutrient dense and aid in recovery of respiratory infection
such as kale, lettuce & spinach. It also has anti-oxidant that shield the body from
pathogen
➢ Dairy product such as cheese, yogurt & milk that high in anti-inflammatory properties
➢ Drink a lot of water at least 2L / day
Lifestyle modification
• Practice good hygiene. Wash hand regularly before and after having meal
• Cough etiquette
• Wearing mask if having symptom
• Maintain oral hygiene prevent upper respiratory infection
• Exercise on a regular basis to keep the immune system in good shape. To keep lungs
healthy, practise yoga and deep breathing exercises.
Page | 105
• Get 7-8 hours of sleep per night and plenty of rest.
• Physical activity lowers the risk of developing pneumonia. Yoga, in particular, is
effective at improving lung function due to its combination of deep breathing and
movements. Furthermore, pneumonia can cause stress and anxiety, which can
exacerbate symptoms and slow recovery, and exercise is a healthy way to deal with
stress.
• Get vaccinated pneumococcal & flu
• Avoid public space as to avoid infection spread and getting it.
Follow up
• Inform the patient about the importance of follow up
• Advice patient to attend follow up on the date written
• Advice patient if having same symptom seek doctor or come to emergency department
Medication
• Complete antibiotic to prevent resistant to antibiotic
• Provide instruction about the medication prescribed
Knowledge about disease
• Advice patient to identify allergen & try to avoid
• Explain signs & symptom of disease
• Advice patient to go to hospital if condition not relieve by medication
Page | 106
Summary Of Progress Note
14.3.2023
• Mr. M admit to Anggerik ward room 372 under care of Dr. S.
• Vital sign as follows:
➢ Temperature: 38.0℃
➢ Pulse: 110bpm
➢ Blood pressure: 139/90 mmHg
➢ Respiration 25breath /min
➢ Spo2: 95%
➢ Pain score 5/10
• Dr S ordered:
➢ 4pint normal saline, Sputum CNS, Admission profile, CRP, Myco Plasma IGM
• Medication:
➢ IV tramadol, IV Zofran, IV Controloc, T. Diflam Lozenges, IV Rocephine, Sy. Aerius,
T. Paracetamol, Neb. Combivent
15.3.2023
• IVD 2-pint normal saline, sputum send and to trace result, continue same treatment
• Medication: T. azithromycin start.
16.3.2023
• IVD 1-pint normal saline, to trace result sputum
• To send patient for spirometry test
Page | 107
17.3.2023
• Medication: IV Tramadol, Zofran as PRN
18.3.2023
• Dr S ordered to take blood for CRP
• To off IVD after current pint
• Completed IV Rocephine,
19.3.2023
• Discharge pm, result sputum CNS to trace
Page | 108
Discharge
On 19.3.2023 1200 HRS after being examined by Dr. S on that day, Dr. S has plan for discharge
the patient that evening. The condition of the patient Mr. M is in good condition. Dr. S has
given Medical Certificate (MC) from 14/3/2023 to 25.3.2023. next, appointment the patient at
Dr. S clinic on 1.4.2023 1000 HRS.
On the same day, at 1700 hours. The patient appears to be in good health, and the patient's vital
signs are stable. Before leaving, I reminded the patient to return to the doctor's clinic on the
scheduled date and time. The patient walks home with his wife. Patient M was also given an
xray film and blood results while being admitted to this hospital. Health education is also
provided.
Vital sign during discharge
No. Vital sign Patient’s vital sign
1) Temperature 36.8℃
2) Pulse 75bpm
3) Bloop pressure 125/80mmHg
4) Respiration rate 20 breath/ min
5) Spo2 98%
6) Pain score 1/10
Page | 109
Discharge medication:
No. Prescription Instruction
1. Uphadyl forte syrup (diphenhydramine) 5ml TDS 5 days
2. Tab unasyn 375 mg 1 tab BD 5 days
Page | 110
Follow Up
Mr. M follow up on 1.4.2023 at 1000HRS at clinic Dr. S. Actually, I can't write the procedure
that Dr. S performed on this patient. This is due to the fact that the time and date of the patient's
follow-up have passed since the date of sending the case study book to the college. However,
when my patients visit the doctor's clinic, I will continue to monitor their cases and conditions.
On 28/3/2023 I try to call Mr. M to remind about his follow up and also asking about his
condition. Mr. M said his condition is getting better. I reinforce patient about the medication
that doctor prescribed to complete the antibiotic. I also reinforce about the health education
given after discharge.
Page | 111
Summary
On 14.3.2023 at 1000HRS, MR. M came to accident & emergency department KPJ SSH
complained of cough with thick greenish sputum, fever, flu & sore throat for 4 days. The patient
has record with KPJ SSH for appendicectomy in 2017. The patient has no medical history &
only has surgical history as presented above. Patient also has no allergies to food & drugs.
However patient mother has hypertension and his father died due to MVA. After examined by
doctor, the patient was instructed by doctor to be admitted at Anggerik Ward to get further
treatment.
Mr. M had performed several procedures before being allowed to enter ward among them
admission profile, Urine Full Examination Microscopic Examination (FEME), covid RTK &
chest Xray. Blood test shown eosinophil monocyte count a bit high indicate there is
inflammation occur. Chest xray infiltrate that indicate patient have pneumonia. Patient’s
sputum also sent for CNS which shown low growth klebsiella pneumonia.
After treatment given on 19.3.2023 Dr. S decide to discharge on evening after complete a few
antibiotics as goes the patient condition well and Dr. prescribed some med to take away.
Page | 112
Conclusion
During our 10 months posting at KPJ Seremban Specialist, for semester 4 everyone should take
case study, document and present in comprehensive and systematic way with real situation to
patient. By this way I also got the chance to have case study in Anggerik ward with the
diagnosis of Pneumonia. I gained knowledge in depth by comparing the care with patient, I
collected information from books, website, doctors, nurse instructor & doctor and compared it
with patient in real situation.
During my duty period in Anggerik ward, I provided him holistic care, diversional therapy in
every aspect like physical, emotional & mental. I also gained the knowledge about the nursing
theory and its application in real situation. So, the case study not only gives the cognitive
domain but also provides us the opportunity to develop psychomotor domain, which is very
important in nursing field, so the patient is the main source of conveying knowledge in practice.
I also got the chance to know about my patient’s family, socio-culture economic status,
religious, background which helps me in providing care effectively. I also identified the stress,
anxiety and problem arise in my patient and techniques of handling this situation.
I’m really very lucky because I got a great opportunity to know about the most common
disease. Before this case study my knowledge about Pneumonia was limited to book but after
the case study my knowledge has broadened as I had the opportunity to relate this in real
situation. During the course of this case study my communication skill was also developed with
patient, visitors, doctors, ward sisters & other members involved in the health team. In addition,
I want to say that case study is the best method to gain knowledge, skill & attitude which is
very important for the students.
Page | 113
References
American Lung Association. (n.d.-a). Pneumonia. https://www.lung.org/lung-health-
diseases/lung-disease-lookup/pneumonia
American Lung Association. (n.d.-b). Spirometry. https://www.lung.org/lung-health-
diseases/lung-procedures-and-tests/spirometry
Baer, S. L., MD. (n.d.). Community-Acquired Pneumonia (CAP): Practice Essentials,
Overview, Etiology of Community-Acquired Pneumonia.
https://emedicine.medscape.com/article/234240-overview
Chest Physical Therapy. (n.d.). Cystic Fibrosis Foundation. https://www.cff.org/managing-
cf/chest-physical-therapy
D. (2017, April 28). Pneumonia - PORTAL MyHEALTH. PORTAL MyHEALTH.
http://www.myhealth.gov.my/en/pneumonia/
Facp, K. S. M. (n.d.). Hospital-Acquired Pneumonia (Nosocomial Pneumonia) and
Ventilator-Associated Pneumonia: Overview, Pathophysiology, Etiology.
https://emedicine.medscape.com/article/234753-overview
Facp, R. a. M. M. (n.d.). Fungal Pneumonia: Overview, Risk Factors, Epidemiology of
Fungal Pneumonia. https://emedicine.medscape.com/article/300341-overview
Fccp, Z. M. M. F. (n.d.). Viral Pneumonia: Practice Essentials, Background,
Pathophysiology. https://emedicine.medscape.com/article/300455-overview
Gamache, J., MD. (n.d.-a). Aspiration Pneumonitis and Pneumonia: Overview of Aspiration
Pneumonia, Predisposing Conditions for Aspiration Pneumonia, Pathophysiology of
Aspiration Pneumonia. https://emedicine.medscape.com/article/296198-overview
Gamache, J., MD. (n.d.-b). Bacterial Pneumonia Clinical Presentation: History, Physical
Examination, Risk Stratification. https://emedicine.medscape.com/article/300157-
clinical#b3
Page | 114
Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth’s Textbook of Medical-surgical
Nursing.
http://www.sealworks.com. (n.d.). Craven & Hirnle’s Nursing Procedures and Fundamentals
Online. https://downloads.lww.com/wolterskluwer_vitalstream_com/sample-
content/9780781788786_Craven/samples/mod09/topic10a/text.html
Moore, V. (2012). Spirometry: step by step. Breathe, 8(3), 232–240.
https://doi.org/10.1183/20734735.0021711
Multidrug-Resistant Organisms (MDRO) - HAIAR. (2019, November 1). HAIAR.
https://www.vdh.virginia.gov/haiar/ar/multidrug-resistant-organisms-mdro/
Murphy, A. J. (2016). Chest (PA view). Radiopaedia.Org. https://doi.org/10.53347/rid-44853
NICE. (2014, December 3). Pneumonia | Information for the public | Pneumonia in adults:
diagnosis and management | Guidance | NICE.
https://www.nice.org.uk/guidance/cg191/ifp/chapter/Pneumonia
Respiratory Physiotherapy. (n.d.). Physiopedia. https://www.physio-
pedia.com/Respiratory_Physiotherapy#cite_note-:3-6
Sereti, M. (2023, March 16). Pneumonia Patients - Recommended Lifestyle Changes.
CoughProTM. https://coughpro.com/blog/lifestyle-changes-for-pneumonia-
patients/#footnote_16_4564
Team, C. B. M. (n.d.-a). Aerius Full Prescribing Information, Dosage & Side Effects | MIMS
Malaysia. https://www.mims.com/malaysia/drug/info/aerius?type=full
Team, C. B. M. (n.d.-b). Azithromycin - Oral Patient Medicine Information | MIMS
Malaysia.
https://www.mims.com/malaysia/drug/info/azithromycin/patientmedicine/azithromyci
n%2B-%2Boral
Page | 115
Team, C. B. M. (n.d.-c). Ceftriaxone: Indication, Dosage, Side Effect, Precaution | MIMS
Malaysia. https://www.mims.com/malaysia/drug/info/ceftriaxone?mtype=generic
Team, C. B. M. (n.d.-d). Combivent Full Prescribing Information, Dosage & Side Effects |
MIMS Malaysia. https://www.mims.com/malaysia/drug/info/combivent?type=full
Team, C. B. M. (n.d.-e). Controloc Full Prescribing Information, Dosage & Side Effects |
MIMS Malaysia. https://www.mims.com/malaysia/drug/info/controloc?type=full
Team, C. B. M. (n.d.-f). Difflam Anti-Inflammatory Loz (with antibacterial) Dosage & Drug
Information | MIMS Malaysia.
https://www.mims.com/malaysia/drug/info/difflam%20anti-
inflammatory%20loz%20(with%20antibacterial)
Team, C. B. M. (n.d.-g). Ondansetron: Indication, Dosage, Side Effect, Precaution | MIMS
Malaysia. https://www.mims.com/malaysia/drug/info/ondansetron?mtype=generic
Team, C. B. M. (n.d.-h). Paracetamol: Indication, Dosage, Side Effect, Precaution | MIMS
Malaysia. https://www.mims.com/malaysia/drug/info/paracetamol?mtype=generic
Team, C. B. M. (n.d.-i). Tramadol: Indication, Dosage, Side Effect, Precaution | MIMS
Malaysia. https://www.mims.com/malaysia/drug/info/tramadol?mtype=generic
Tonog, P. (2022, October 16). Normal Saline. StatPearls - NCBI Bookshelf.
https://www.ncbi.nlm.nih.gov/books/NBK545210/
What Is Pneumonia? | NHLBI, NIH. (2022, March 24). NHLBI, NIH.
https://www.nhlbi.nih.gov/health/pneumonia
World Health Organization: WHO. (2022, November 11). Pneumonia in children.
https://www.who.int/news-room/fact-sheets/detail/pneumonia
World Pneumonia Day 2022: Foods That Aid Recovery From Pneumonia. (n.d.).
NDTV.com. https://www.ndtv.com/health/world-pneumonia-day-2022-foods-that-
aid-recovery-from-pneumonia-3504941
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Zhao, J. B., MD. (n.d.). Pneumonia in Immunocompromised Patients: Overview, Causes of
Pneumonia, HIV/AIDS. https://emedicine.medscape.com/article/807846-overview
Page | 117
Appendices
Page | 118
Spirometry result. Interpretation:
FVC, FEV1, and FEV1/FVC all within the normal range.
FVC: Forced vital capacity
FEV1 : Forced expiratory volume in the first second
Page | 119

Pneumonia Case Study 1

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Pneumonia Case Study 1

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Case Study: Respiratory Nursing

Matrix No.: 304293040

and morbidity around the world.

3042193040. I chose pneumonia as my case presentation because it is an interesting topic that

have a thorough understanding of the disease.

collection skills, computer creativity, and time management.

At the end of case study, I will be able to:

1) Explain the anatomy & physiology of respiratory system.

2) State definition of pneumonia

3) List the aetiology of pneumonia

4) Describe and explain pathophysiology of pneumonia

5) State clinical manifestation of pneumonia

6) List the complications of pneumonia

7) Discuss the investigation carried out to patient with pneumonia

9) Explain the treatment that receive for patient with pneumonia

11) Explain health education provided to patient with pneumonia

fever, flu & sore throat for 4 days.

Age / gender 55 years old man

Date of birth 26/2/1968

Marital status Married

Occupation Officer at Malaysian Airline

Language spoken English and Malay

Address PT XXXX Jalan X, Taman Jimah Jaya 71960 Port Dickson

Date and time of admission 14/3/2023 @ 1500HRS

Attending doctor Dr. A

Mode of admission Walk in

Source of admission Accident & Emergency

Complaint of cough with thick greenish sputum, fever, flu &

Pre-Admission – Accident & Emergency Department(A&E)

an hour & 1g T.paracetamol.

Vital sign in accident & emergency department:

Vital signs Result

Blood pressure 112/75mmHg

Heart rate 120 bpm

Respiration rate 26 breath/ min

Pain score 5/10

Admission in Anggerik Ward

medication. Dr, S ordered 4-pint normal saline.

• Introduce Self & Ward Members

staff base on uniform

• Identification Band (ID Band)

until discharged. I also explained about the difference of colour ID band.

telephone rang answer the call.

• Room Number/ Location

• Breakfast: 0830 HRS

• Tea time: 1600HRS

• Medication/ Doctor/ Nurses Rounds

• Patient are not allowed to go home leave

procedure for complaints, followed by consideration and management response and

I instruct patient to perform hand hygiene frequently

• Fire / Emergency Exit

about the effect of smoking in the hospital

This information obtained from patient and his wife.

Vital sign was charted as below:

Vital sign Patient’s vital sign Normal range

Temperature 38.0℃ 36.5 – 37.4℃

Pulse 110 bpm 60 – 100 bpm

Blood pressure 127/85 mmHg 90/60 – 140/90 mmHg

Respiration 25 breath/ min 12 – 20 breath/ min

Pain score 4/10

Height 169cm 18.5 – 24.9 kg/m2

BMI 34.3 kg/m2 (obesity)

Pleurisy pain due