U.R.T.I.

(Upper Respiratory Tract Infection)

Submitted to:
Ms. Lourdes Saracho
Submitted by:
Constantino, Jenna Kristelle R.
Section 2 Group 5

INTRODUCTION
Upper respiratory tract infection (URI) is a nonspecific term used to describe acute infections
involving the nose, paranasal sinuses, pharynx, larynx, trachea, and bronchi. The prototype is the
illness known as the common cold, which will be discussed here in addition to pharyngitis, sinusitis,
and tracheobronchitis. Influenza is a systemic illness that involves the upper respiratory tract and
should be differentiated from other causes of URI. Acute laryngotracheobronchitis (croup), epiglottitis,
and otitis media are infections that occur primarily in the pediatric population and will not be discussed
in this chapter.

Pathophysiology

Mycobacterium tuberculosis

Invades mucosal lining

Intense inflammatory
response

Mucosal inflammation

Phlegm

Increased secretion

Cough

Immune response

Mycobacterium Tuberculosis invades mucosal lining leading to intense inflammatory response.

Mucosal inflammation leads to increased secretion causes irritation leading to cough that also leads to
immune response.

I. Personal Data
Name of Client: Birosel, Lourdes
Address: 18 alley St. Proj 8. QC
Nationality: Filipino

Birth place: Ilocos

Birth date: January 21, 1920

Age: 86 y/o

Religion: Roman Catholic

Civil Status: Widow

Educational Attainment: College Graduate

Gender: Female

Occupation: Retired
Admission Data
Chief Complaint: cough, productive
Date of Admission: May 5, 2006
Room no.: 806
Provisional Diagnosis: Upper respiratory tract infection
Attending Physician: Dr. Quiogue
II.

Nursing History

History of Present Illness:

One week prior to admission, patient experiences cough, non-distressing, non-productive.
Signs and symptoms such as fever, dyspnea or dysuria. They sought consult at UP health service,
patient was given N acetylcysteine (flumucil). Tablet 2 cifrolaxin 500mg/tab. 1 tab BID x 7 days.
Patient had amnesia and general body weakness.
Few hours prior to admission, still with cough. Patient experienced vomiting of previous
ingested food and phlegm, they sought consult at a private physician and she was advised
admission, they sought consult at an institution hence to admission
Past Medical History:
The patient has history of cholecystectomy year 1957. Has a heart problem starting 2001, also
suffered from heat stroke at year 2005.
Family Medical History
Her parents have no history of Diabetes Mellitus, hypertension, cardiovascular disease and
cancer.

CAPITOL MEDICAL CENTER COLLEGES, INC.

College of Nursing
#4 Sto. Domingo Avenue, Quezon City

Drug Study
Drug
Imdur
isosorbide
mononitrate

Cordarone
Amiodarone
hydrochloride

Dose Classification
60g
1 tab
OD

Antianginal
agent

1 tab
OD

Antiarrhythmi
c

Mechanism of
Indication
Action
Relaxes
Treatment and
vascular smooth
prevention of angina
muscle with a
pectoris (dinitrate)
resultant
decrease in
Prevention of angina
venous return
pectoris (mononitrate)
and decrease in
arterial BP,
which reduces
left ventricular
workload and
decreases
myocardial
oxygen
consumption.
Acts directly on Only for treatment of
cardiac cell
the following
membrane;
documented lifeprolongs
threatening recurrent
repolarization
ventricular arrhythmias
and refractory
that do not respond to
period;
other antiarrhythmics or
increases
when alternative agents
ventricular
are not tolerated:
fibrillation
recurrent ventricular

Contraindication

Side-effect

Nursing Responsibilities

Allergy to nitrates,
severe anemia,
head trauma,
cerebral
hemorrhage,
hypertrophic
cardiomyopathy,
pregnancy,
lactation.

Headache
Tachycardia
Palpitations
Hypotension
Nausea
Vomiting
Perspiration
Muscle
twitching

Give oral preparations on an empty

stomach, 1 hr before or 2 hr after
meals; take with meals if severe,
uncontrolled headache occurs.
Maintain life support equipment on
standby if overdose occurs or
cardiac condition worsens.
Gradually reduce dose if anginal
treatment is being terminated; rapid
discontinuation can lead to
problems of withdrawal.

Contraindicated
with
hypersensitivity to
amiodarone, sinus
node dysfunction,
heart block, severe
bradycardia,
hypokalemia,
lactation.

Malaise
Fatigue
Dizziness
Cardiac arrest
Hypotension
Liver toxicity

Monitor cardiac rhythm

continuously.
Monitor for an extended period
when dosage adjustments are made.
Monitor for safe and effective
serum levels (0.52.5 mcg/mL).
Give drug with meals to decrease

threshold; acts
on peripheral
smooth muscle
to decrease
peripheral
resistance

Norvasc

10g
1 tab
OD

amlodipine
besylate

Calcium
channelblocker
Antiangina
l drug
Antihypert
ensive

Zithromax
azithromycin

500
mg
1 tab

Macrolide
antibiotic

Inhibits the
movement of
calcium ions
across the
membranes of
cardiac and
arterial muscle
cells;

fibrillation, recurrent
hemodynamically
unstable ventricular
tachycardia. Serious and
even fatal toxicity has
been reported with this
drug; use alternative
agents first; very closely
monitor patient
receiving this drug
Angina pectoris due to
coronary artery spasm
Chronic stable angina,
alone or in combination
with other agents
Essential hypertension,
alone or in combination
with other
antihypertensive

Bacteriostatic or Treatment of lower

bactericidal in
respiratory tract
susceptible
infections: streptococcal
bacteria
pharyngitis/tonsillitis
due to Streptococcus
pyogenes in those who
cannot take penicillin

GI problems.
Arrange for ophthalmologic exams;
reevaluate at any sign of optic
neuropathy.

Contraindicated
with allergy to
amlodipine,
impaired hepatic
or renal function,
sick sinus
syndrome, heart
block (second or
third degree),
lactation

Nausea
Dizziness
Lightheadedness
Headache
Fatigue
lethargy

Monitor cardiac rhythm regularly

during stabilization of dosage and
periodically during long-term
therapy.

Contraindicated
with
hypersensitivity to
azithromycin,
erythromycin, or
any Macrolide
antibiotic.
Use cautiously
with gonorrhea or
syphilis, pseudo
membranous
colitis, hepatic or
renal impairment,
lactation.

Dizziness
Headache
Flatulence
Vomiting
Diarrhea
abdominal pain
nausea

Administer on an empty stomach--1

hr before or 23 hr after meals.
Food affects the absorption of this
drug

Administer drug without regard to

meals

Counsel patients being treated for

STDs about appropriate precautions
and additional therapy

CAPITOL MEDICAL CENTER COLLEGES, INC.

College of Nursing
#4 Sto. Domingo Avenue, Quezon City

Nursing Care Plan

Assessment
Subjective:
Moody siya madalas,
madalas di ka na niya
kilala as verbalized
by the daughter
Objective:
Difficulty in
comprehension
Behavior often
inconsistent
Measurement:
BP: 120/80 mmHg
PR: 70 bpm
RR: 22 cpm
Temp. 36.7 C

Nursing Diagnosis
with Background
knowledge
Weakness related to
trauma as manifested
by disorientation and
confusion
Background
Knowledge
Dementia of the
Alzheimers type is a
degenerative process
occurring primarily in
the cells located at the
base of the forebrain
that send information
to the cerebral cortex
and hippocampus

Planning
1. Provide safe
environment; prevent
trauma
2. Promote socially
acceptable responses;
limit inappropriate
behavior.
3. Maintain reality
orientation/prevent
sensory
deprivation/overload
4. Encourage
participation in selfcare within individual
abilities
Goal
After the shift the client
will be able to feel the
comfort and free from
trauma
Expected Outcome:
Recognize potential risks
in the environment

Intervention

Independent
1. Assess degree of impairment in
ability/competence, presence of impulsive
behavior.
2. Eliminate/minimize identified hazards in the
environment
3. Monitor behavior routinely, note timing of
behavioral changes, increasing confusion,
hyperactivity. Initiate least restrictive
interventions before behavior escalates.
4. Distract/redirect clients attention when behavior
is agitated or dangerous
5. Obtain identification jewelry showing name,
phone number, and diagnosis.
6. Be attentive to nonverbal physiological symptoms.
Monitor for medication side effects, signs of overmedication (e.g., extrapyamidal signs, orthostatic
hypotension, visual disturbances, GI upsets).
7. Provide quiet room/activity.
Collaborative
1. Administer medications as appropriate

Evaluation
Goal Met: The clients
daughter felt the comfort
for her mother and free
from trauma.

CAPITOL MEDICAL CENTER COLLEGES, INC.

College of Nursing
#4 Sto. Domingo Avenue, Quezon City

Nursing Care Plan

Assessment
Subjective:
Di Siya makahinga
ng maayos dahil sa
ubo niya as
verbalized by the
daughter
Objective:
Generalized
Weakness
Irritability
Flaky skin
Cough
Measurement:
BP: 120/80 mmHg
PR: 70 bpm
RR: 22 cpm
Temp. 36.7 C

Nursing Diagnosis
with Background
knowledge
Ineffective be related
to
Airway Clearance
poor cough effort as
evidenced by wheezes
Background
Knowledge
Upper Respiratory
Tract Infection is an
extra pulmonary and
affect organs and
tissues other than the
lungs

Planning
1. Achieve/maintain
adequate
ventilation/oxygenation.
2. Prevent spread of
infection.
3. Support
behaviors/tasks to
maintain health.
4. Promote effective
coping strategies.
5. Provide information
about disease
process/prognosis and
treatment needs.
Goal
After the shift the client
will be able to clean her
secretions without
assistance
Expected Outcome:
Expectorate secretions
without assistance

Intervention

Independent
1. Assess respiratory functions
2. Note ability to expectorate mucus
cough/effectively
3. Place patient in Semi or High Fowlers
position
4. Clear secretion from mouth and trachea
Collaborative
1. Administer medications as indicated:
Azithromycin (Zithromax)

Evaluation
Goal Partially Met: The
client was able to
expectorate secretion
without assistance

Research Paper help

https://www.homeworkping.com/