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    Case Study On CAP

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    jcarysuitos
    This nursing care plan summarizes the care for a 50-year-old female patient with community acquired pneumonia. The patient presents with chest pain, dyspnea, and a cough. Vital signs show an elevated temperature and respiratory rate. The plan involves elevating the head, deep breathing exercises, coughing and splinting techniques, administering medications as prescribed, and ensuring adequate fluid intake to mobilize secretions. The goal is for the patient to display a clear airway and absence of dyspnea or apnea within 4 hours.

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    Case Study On CAP

    Uploaded by

    jcarysuitos
    2K views4 pages
    This nursing care plan summarizes the care for a 50-year-old female patient with community acquired pneumonia. The patient presents with chest pain, dyspnea, and a cough. Vital signs show an elevated temperature and respiratory rate. The plan involves elevating the head, deep breathing exercises, coughing and splinting techniques, administering medications as prescribed, and ensuring adequate fluid intake to mobilize secretions. The goal is for the patient to display a clear airway and absence of dyspnea or apnea within 4 hours.

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    Case Study on CAP

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    This nursing care plan summarizes the care for a 50-year-old female patient with community acquired pneumonia. The patient presents with chest pain, dyspnea, and a cough. Vital signs show an elevated temperature and respiratory rate. The plan involves elevating the head, deep breathing exercises, coughing and splinting techniques, administering medications as prescribed, and ensuring adequate fluid intake to mobilize secretions. The goal is for the patient to display a clear airway and absence of dyspnea or apnea within 4 hours.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    2K views4 pages

    Case Study On CAP

    Uploaded by

    jcarysuitos
    This nursing care plan summarizes the care for a 50-year-old female patient with community acquired pneumonia. The patient presents with chest pain, dyspnea, and a cough. Vital signs show an elevated temperature and respiratory rate. The plan involves elevating the head, deep breathing exercises, coughing and splinting techniques, administering medications as prescribed, and ensuring adequate fluid intake to mobilize secretions. The goal is for the patient to display a clear airway and absence of dyspnea or apnea within 4 hours.

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    of 4

    ARELLANO UNIVERSITY

    College of Nursing
    S. Y. 2009 – 2010

    NURSING CARE PLAN on


    Community Acquired Pneumonia (CAP)

    FEMALE WARD – JOSE REYES MEMORIAL MEDICAL CENTER


    STA. CRUZ, MANILA, PHILIPPINES

    SUBMITTED BY:

    JUN CARY V. SUITOS, AUSN


    GROUP – 64
    III – MUSCARINICS

    SUBMITTED TO:

    _________________________________________
    CLINICAL INSTRUCTOR

    07 SEPTEMBER 2009
    I. PERSONAL DATA

    NAME : Patient ABC


    AGE : 50 y/o
    DATE OF BIRTH : May 8, 1959
    GENDER : Female
    ADDRESS : Recto, Manila
    PRIMARY DIALECT SPOKEN: Tagalog
    ETHNIC GROUP : None
    RELIGION : Roman Catholic
    OCCUPATION : Public Servant (Brgy. Secretary)
    HIGHEST EDUC’L ATTAINMENT: High School
    MARITAL STATUS : Separated

    II. MEDICAL HISTORY

    When she was a child, she have had experienced measles and chicken pox but was not medically diagnosed.
    According to the patient, she doesn’t know if she was vaccinated of certain immunization at childhood due to her
    parents died as early as she was 5 y/o. Also, according to her, she was admitted at the Jose Reyes Memorial Medical
    Center due to complaint of cough, dyspnea, and chest pain.

    III. PHYSICAL ASSESSMENT – VITAL SIGNS

    SEPT. 1, 2009 (8:00 AM) SEPT. 1, 2009 (12:00 NN)


    Pulse Rate : 80 bpm Pulse Rate : 100 bpm
    Blood Pressure : 110/70 mmHg Blood Pressure : 110/80 mmHg
    Respiratory Rate : 21 cpm Respiratory Rate : 34 cpm
    Temperature : 36.5º C Temperature : 37.6 º C
    IV. MEDICATION

    Medications Frequency Time Remark


    1. Levoflaxacin 500mg/ tab OD 8:00am; 2pm Not administered
    2. Combinent Neb. q4h 8:00am; 12nn; 4pm; 8pm Done at 12:05 nn
    3. FeSO4 + FA Tab TID 8:00am; 4pm Not administered
    4. NaCl Tab TID 8:00am; 4pm Not administered

    V. NURSING CARE PLAN

    ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

    Subjective: Independent:

    “Masakit ang Acute pain r/t After four (4) hours • Elevate head Lowers diaphragm, After four (4) hours
    dibdib ko”, as localized of nursing of the bed, promoting chest of nursing
    verbalized by the inflammation and intervention, the change expansion and interventions, the
    patient. persistent cough. patient will display position expectoration of patient was able to
    patent airway with frequently. secretions. display patent of
    Objective: breath sounds airway with breath
    clearing and • Assist patient Deep breathing sounds clearing
    • Use of absence of apnea with deep facilitates maximum and absence of
    accessory breathing expansion of the dyspnea.
    muscle exercises. lungs and smaller
    • Dyspnea airways.
    • Fatigue
    • V/S taken • Demonstrate Coughing is a
    as follows: of patient to natural self-
    perform cleaning
    (as of 9/1/09 – actively like mechanism.
    8:00 am) splinting chest Splinting reduces
    BP : 110/70 mmHg and effective chest discomfort,
    PR : 80 BPM coughing and an upright
    T : 36.5º C while in position favors
    RR : 21 CPM upright deeper, more
    position. forceful cough
    (as of 9/1/09 – efforts.
    12:00nn)
    BP : 110/80 mmHg • Force fluids to Fluids especially
    PR : 100 BPM at least warm liquids aid in
    T : 37.6º C 3000ml / day mobilization and
    RR : 34 CPM and offer expectoration of
    warm, rather secretions.
    than cold
    fluids.

    Collaborative:

    • Administer Aids in reduction of


    medications bronchospasm and
    as prescribed mobilization of
    by the secretions.
    physician/s.

    • Provide Fluids are required


    supplemental to replace losses
    fluids. and aid in
    mobilization of
    secretions.

    Prepared by:

    JUN CARY V. SUITOS, AUSN


    Arellano University – 0900252
    College of Nursing – Batch 2011
    BSN III - Muscarinics

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