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I. PERSONAL DATA
Name of the client:Felipe Domingo Acob Sr.
Address:37Ganagan, Bacarra Ilocos Norte
Hospital Number:101750
Sex:Male
Age:71
Date of Birth: October 23, 1938
Place of birth: Bacarra, Ilocos Norte
Civil Status: Married
Religion: Roman Catholic
Educational attainment: Elementary Graduate
Occupation: Farmer
Chief Complaint: Cough and difficulty of breathing
Admitting Diagnosis: Chronic Obstructive Pulmonary Disease in Acute exacerbation
Bronchitis, Pulmonary Tuberculosis Class IV
Date of admission:August19, 2010
Time of Admission: 11:55 pm
Admitting Physician:Decinna Quilala, M.D./ Emely T. Pumaras, M.D.
Attending Physician: Dr. Lijauco/ Dr. Rasos
Final Diagnosis: COPD exacerbation controlled Bronchitis resolved PTB class IV
Date of Discharge: August 24, 2010
Time of discharge: 4:30 PM
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III. FAMILY BACKGROUND
Name Sex Ag
e
Civil
Status
Relationshi
p to the
Patient
Educational
Attainment
Occupatio
n
Religio
n
Address
Felipe
Acob
Sr.
Male 71
y/o
Marrie
d
Patient Elementary
Graduate
None Catholi
c
37
Ganaga
n Doro,
Bacarra
Catalin
a Acob
Femal
e
65
y/o
Marrie
d
Wife High School
Graduate
None Catholi
c
37
Ganaga
n Doro,
Bacarra
Jose
Acob
Male 50
y/o
Marrie
d
Son College
Graduate
Office
Worker
Catholi
c
Milan,
Italy
Dolore
s Agas
Femal
e
48
y/o
Marrie
d
Daughter College
Graduate
Office
Worker
Catholi
c
Milan,
Italy
Felipe
Acob
Jr.
Male 47
y/o
Marrie
d
Son College
Graduate
Farmer Catholi
c
37
Ganaga
n Doro,
Bacarra
Norma
Galut
Femal
e
46
y/o
Marrie
d
Daughter College
Graduate
Office
Worker
Catholi
c
Milan,
Italy
Helen
Adina
Femal
e
44
y/o
Marrie
d
Daughter College
Graduate
Office
Worker
Catholi
c
Milan,
Italy
Julie
Acob
Male 24
y/o
Marrie
d
Son College
Undergraduat
e
Farmer Catholi
c
37
Ganaga
n Doro,
Bacarra
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Acob family is a nuclear type of family. They are living within the vicinity of the father,
thus, considered to be patrilocal type of family. The family is oriented with both the mother and
the fathers kin, thus, they are bilineal type of family. With regards to decision making, the
family is an egalitarian type of family where in both the father and mother makes the decision.
Mr. and Mrs. Acob participate in barangay activities such as Oplan Dalus. For other
activities such as fiestas and other assemblies they are not that active. The family have
misunderstanding sometimes like when Tata Felipe insists to work even though they tell him
not to work because of the fact that this may aggravate this condition (collecting fire woods)
but it is easily resolved When we argue about such things, my wife gives me a cold shoulder
but after an hour, she talks to me again like nothing happened, as added by Tata Felipe. Mr.
and Mrs. Acob are the only ones who are living in their family house since their children
already have their own families. The family has a good relationship and they communicate
properly. They communicate through phone calls and letters with their children abroad.
Reading magazines, listening radio, watching television, gardening and chatting to their
neighbours are their leisure time.
Mr. and Mrs. Acob dont have monthly allowance on their own since they do not have
job at present. Mrs Acob claimed that they depend on their children for their financial needs
since they are already old to work. Their children working abroad send them money every
month. They receive a total of 10,000 a month. Each of their children contributes Php. 2,500.
According to Mrs. Acob, she is the one who decides for the allocation of their monthly
allowance. The amount is allocated mainly for their needs and is broken down as follows; Php
3000 is allotted for food and groceries with toiletries, Php 500 each are allotted for
transportation and electricity, Php 1000 is for miscellaneous expenses such as sudden illness or
hospitalization, load and magazines, Php 180 is spend for drinking water and Php 1820 is their
savings. Php 1000 is also allocated for medicines like Dulcolax, Ventolin and their multivitamins.
According to Mrs. Acob, their monthly allowance is enough to meet their daily necessities for
living.
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FOOD (w/ groceries and toiletries)-3000
MEDICINES---------------------------- 3000
SAVINGS-------------------------------1820
MISCELLANEOUS---------------------1000
TRANSPORTATION-------------------500
ELECTRICITY--------------------------- 500
WATER(mineral water)-------------180
IV. HEALTHHISTORY
A. Family Health History
Nana Catalina, the wife of our patient revealed that the family had experienced having
coughs, colds, and fever during extreme temperatures, muscle aches, toothache, headache and
30%
30%
18%
10%
5%5%
2%
monthly budget
food
Medicines
savings
miscellaneous
electricity
transporatation
water
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stomach aches. Such minor discomforts are usually managed with over- the- counter drugs such
as Solmux 500 mg PC until the symptoms will subside for cough, Neozep 500 mg PC for colds,
Biogesic 500 mg PRN for fever, Mefenamic Acid 500 mg PRN for headache, Alaxan 500 mg PRN
for body pains, and Kremil-S 500 mg or Lomotil 2 mg both PRN for stomach ache; as claimed by
Nana Catalina. The family had experienced some infectious and communicable diseases such as
chicken pox, measles, mumps and sore eyes. They usually manage chickenpox thru bed rest
and by exposing the sick child to the smoke of burnt onions when lesions are healing. For
measles, they would let the member wear any black clothes for they believe that this will lessen
the itchiness and for mumps they would apply akot-akot mixed with vinegar on the affected
area. For other managements of diseases, he mentioned bed rest, adequate intake of nutritious
foods such as vegetables and enough sleep as their health habit practices.
They also utilize herbal medicines like oregano decoction, kutsay extract and guava
extract. They would use the oregano decoction for cough, kutsay extract for wounds and the
guava leaves for washing and cleansing wounds. As added by Tata Felipe, they do not usually
consult to the Bacarra health centre; instead, they go straight to tertiary hospital like MMMH &
MC whenever the condition of one family members health is severe or it worsens.
Mata Acob, grandmother of our client on paternal side had asthma but Nana Catalina
(wife of our client) do not know if she was diagnosed, who diagnosed her and what were the
managements done to her. As claimed by Nana Catalina, Mata Acob was a heavy smoker, and
she can consume 10 tobacco sticks a day. Nana Catalina added that she was the one who
taught our client to smoke when he was just grade 5. Apolinario Acob, husband of Mata Acob
died because of complications of old age. Apolinario Acob and Mata Acob were blessed with 12
children; unfortunately Nana Catalina can only remember 3 of them namely; Kolas Acob, Pilo
Acob, and Juan Acob. All of them already died because of complications of old age.
Santan, grandmother of our client on maternal side, died already because of
complications of old age. Santiago, husband of Santan died because of complications of old age.
They were blessed with 3 children, namely; Ferming, Dorothea and Crispin Domingo. They
already died because of complications of old age.
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Juan Acob and Dorothea Acob, parents of our client were blessed with 6 children.
Milagros Ancheta, 62 years old, Marta, 64 years old, residing now at Mindanao, Lory Bagaoisan
66 years old, residing at Hawaii, Susima Bagaoisan 70 years old, Maria Garcia died at the age of
69 years because of bone cancer but they cannot remember any informations regarding the
disease and Felipe Acob our patient who was diagnosed with COPD last August 19, 2010.
As for their immunizations, Nana Catalina is not sure if they received any and Tata
Felipe did not have any scar that would reveal that he have received his BCG vaccine. According
to Nana Catalina their children completed all their immunizations.
He stressed out that they do not believe in ghosts, bad spirits, witchcraft, and quack
doctor. But he stated that he often consults to manghihilot whenever there are sprains and
muscle aches and he claimed to be effective.
B. Past Health History
Tata Felipe already experienced having common illnesses such as cough, fever,
headache and toothache as claimed. These were managed through taking in over the counter
drugs such as Solmux for cough, Paracetamol for fever and headache and Mefenamic acid for
toothache.
Infectious diseases he encountered during his childhood were the following: measles,
chickenpox and mumps. No medical consultation done, instead they treated it by taking in
Paracetamol to relieve fever and they let the smoke of garlic and onions with a charcoal in a pot
to their body to relieve itchiness for chickenpox. When he had his mumps, his mother topically
applied akot-akot on the affected site. Tata Felipe did not undergo any minor or major
operations except for circumcision when he was in grade four.
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According to Tata Felipe, he had no allergies to food or to drugs. He prefers eating
vegetables and meat especially internal organs like liver. As claimed, He began smoking at a
very young age which actually at grade 5. His Lola taught him to try tobacco whenever he goes
home after school. He begun to consume 2-3 sticks a day at age of 13 and gradually increase to
8-10 sticks during high school years. As became older, he could already consume as much as 1
pack of cigarettes until his mid 40s. On the other hand, he also started drinking liquor such as
GSM Bilog and beer when he was 14 y/o consuming 2-3 bottles of each every week. He,
together with his friends drinks occasionally.
C. PRESENT HEALTHHISTORY
In the year 1972, when he was 42, he experienced and complaint difficulty of breathing
which prompted him to have a check up at their Health Center. He had undergone x-ray and
diagnosed with asthma. Tata Felipe can no longer remember the doctor who attended him but
he was given take home medications which he took in preventing his asthma attacks but he
doesnt remember the medications given to him.
Two months past, he was rushed to Ranada General Hospital when he suffered again
from difficulty of breathing. He was diagnosed to be an asthma case again and was given
Ventolin inhaler and other unrecalled medicines. As far on what his wife remembered, he was
confined for 3 days. When he suffers from the above symptoms or from asthma attacks, he no
longer sought consultation to any medical facility, instead, the family buys Ventolin inhaler to
relieve difficulty of breathing and Solmux for cough with their current prescription.
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In year 1990 of December, Nana Catalina decided to let her husband consult to Doctor
Reyes Clinic. She was alarmed seeing her husband expectorates phlegm, rusty in colour and
vicious when coughing and sweats mostly at night even in cold season. Nana Catalina knew
about Dr. Reyes since she read several articles written by the said doctor on Bannawag which
talks about asthma and other lung disorders. And so Tata Felipe together with his wife agreed
to go at Dr. Reyes Clinic in Ilocos Sur. Tata Felipe had a sputum examination, he was instructed
to collect 1 sputum specimen in the morning and 2 specimens were collected in the clinic. Dr.
Reyes also examined Mr. Acobs X-ray according to him. His sputum examination and X-ray
reveals that he was positive of pulmonary tuberculosis. As for treatment, he was prescribed to
take Rifampin, Pyrazinamide and Isoniazid pyridoxine for 6 months. When asked about the
dosages, they could no longer remember it. Dr. Reyes made a referral letter saying about Tata
Felipes condition to Bacarra Health Center so that those medicines would be given for free.
Tata Felipe revealed that he did not take the medication religiously for 6 months because
sometimes he would forget to take or, if we run out of medicines, sometimes we dont have
time to go and get from the health center and, we didnt continue it since Im feeling better
then as claimed. 1991 Tata Felipe went back to the Health Center for check-up after 6 months
and his examinations revealed that he is still positive of PTB, he was again given another 6
months treatment with an additional medication which is Ethambutol. According to Tata Felipe
he religiously took the medication until 6 months and when they went for another check-up for
evaluation, his PTB was already resolved. Tata Felipe was so happy and thankful
He continued to work as a farmer. But had asthma attacks especially during cold
seasons as well as when triggered by irritants such as dust, smoke and fumes as claimed. His
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asthma was not really that serious as he verbalized since medications can just relieved it
(Ventolin Inhaler, Solmux).
Because of his condition, his family advises him to quit smoking and drinking liquor.
It was also told by his doctor before that smoking can expose him to more severe disorders.
Tata Felipe didnt deny that once in while he still taste a bit after which but he emotionally
expressed that he made an effort to stop it for the sake of his children and to have a longer life
together with his family. Though it is difficult in his part; he successfully quitted such vices in a
gradual manner.
Upon waking up in the morning of August 17, 2010 he experienced sudden dryness and
itchiness of throat and finally ending up to productive cough. As his cough progresses,
shortness of breath had been developed it is hard for him to breath and he complaints of the
sound of rales he was experiencing as verbalized by Nana Catalina. He thought that this was
just brought by weather changes and exhaustion from doing house hold choirs such as cleaning
the backyard. At first, he does not sought consultation with the thought that he again had been
attacked by asthma. He had taken medicines previously prescribed by a private physician such
as Ventolin inhaler and Solmux. He gained temporary relief from those drugs. Nana Catalina
also added that his husband was sneezing caused maybe by frequently taking a bath just after a
perspiring work and weather changes so she bought Neozep Forte (500mg) as management of
cold which he took every 4 hours. However, as days pass by, his cough became recurrent and
persistent. On the evening of august 19, 2010, he suffered from difficulty of breathing and
severe coughing. He was immediately rushed to the Mariano Marcos Memorial Hospital and
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Medical Center at exactly 11:55 PM with an admitting diagnosis of COPD in acute exacerbation
bronchitis, PTB Class IV. He was admitted by Dr. Quilala and Dr. Pumaras.
V. DEVELOPMENTAL DATA
Ericksons Theory of Psychosocial Development
Ericksons Theory of Psychosocial Development
It is necessary to study the development of a person to be able to understand the responses
that are seen in the client in certain circumstances or situations. One theory that had been
devised to do such study is the Psychosocial or Emotional Development by Erik H. Erickson. He
believes that maturation of bodily functions is linked with expectations of society and culture inwhich the person lives. According to him, in each stages of a persons emotional development,
there are particular changes, which he called crisis that exists for a healthy development to
occur. When needs are met, a healthy or positive personality is developed and the individual
moves to the future stages with particular strength; but if not, an unhealthy outcome occurs
which will influence future relationships.
Erickson identified Ego Integrity versus Despair as the developmental stage to be
achieved during the Late Adulthood (60 years old and above) in which our client belongs. He
said that ego integrity suggest an acceptance of ones lifestyle and a belief the choices made
where the best that could be made at a particular time. Into our client, he accepts this stage by
showing a positive attitude instead of grumping feature when talking of his old age.
Despair, the opposite of ego integrity, implies that the older person feels dissatisfied
and disappointed with his or her life and if given another chance the person would live life
differently. It is being manifested by our client by longing for his drinking sessions and smoking
cigarettes.
In this span of age, the client is expected to feel good about his choices in life, and self
acceptance of the inevitable death and the acceptance that his ability to contribute to the
community is minimized. On the other hand, our client is not expected to wish life could turn
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out differently as with him now, to be angry of the aging bodies, and withdrawn from the
society.
Tata Felipe, 71 y/o is in his late adulthood stage with the central task of achieving Ego
Integrity vs. Despair. Tata Felipe feels good about his past life choices. He was able to form a
family and commit himself to his own responsibilities. And now that his children are all happily
married, still Tata Felipe never failed to be the good father to them. Towards his wife, Tata
Felipe has maintained same warmth or sweetness and a good relationship. They also quarrel at
times but the conflict does not last long because they would immediately settle it.
Tata Felipe belongs to certain organization in their barangay such as the Senior Citizen
Club, when he was still younger he would attend to Barangay Fiestas and Oplan Dalus. He alsostated that they won as the cleanest house in their barangay last 2008.
He is also regarded as a good neighbor and a good person because he knows how to
help others and he knows how to get along with them.
The negative indicators such as a persons feeling of dissatisfaction and disappointment
with his life and if given another chance the person would live life differently is not seen to our
client.
He said that he accepts the changes of his physical stature and that death is inevitable.
Analysis: Based from his accomplishments over the years, Tata Felipe could be said to be
manifesting the indicators of a positive resolution such as satisfaction with his life and the
decisions and acceptance of the inevitable death.
Havighursts Theory of Developmental Task
Havighursts theory of Developmental Tasks states that learning is essential to life and
that to understand growth and development; one must understand and accept the premise
that the human being continues to learn throughout life. Effective learning and achievement of
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tasks during one period leads to happiness and success with later task while failure leads to
unhappiness, disapproval by the society and difficulty with later tasks.
Tata Felipe belongs to Havighursts age group of Later Maturity wherein he is expected
to develop tasks like Accepting and adjusting to decrease physical strength and health Tata
Felipe already accepted and adjusted himself to his decreased physical strength and health. He
admitted that his activities now are no longer like his activities when he was still younger and
stronger. He also told us that these changes in strength and health are just normal to aging
people. Adjusting to retirement and lower income Tata Felipe long decided to stop doing
farming for he can no longer be productive with his work and his health can be worsen if he still
do strenuous activities. He has already retired and just stayed mostly in their home, and
enjoying the company of his wife. Even if he already retired from farming, he doesnt worry in
terms of financial terms for his children sends their income. Though his income is no longer like
of that when he was still farming, he already adjusted to a lower income and accepts it since he
and his wife also spends lesser now. Aging and inevitable death of age and spouse When we
asked Tata Felipe if he already accepted aging and death, he gladly told us that it is just a
normal part of living and that also includes death. As much as he wanted to return to his youth,
he also looks forward about the life that is to come after death. Establish Affiliation with Age
Group Despite of his age, he still maintained a relationship with the people, especially hisfriends who are at the same time belongs to his age group, they still have conversations yet it is
not as often as it was of the past since they no longer see each others often. Meet Social and
Civic Obligations, Even if Tata Felipe is now old, he makes sure that his social and civic
obligations are still met, such as exercising his right to vote. And during the 2010 National
Elections he voted and was delighted and accepted the new system of voting. He told us that
these are the things that he can never grow old with. Live in Satisfactory Physical Environment,
Being with his wife in their home, they maintain their physical environment with its cleanlinessand their community is also composed of a good environment. He was also satisfied with the
peacefulness of their community and his environment.
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Analysis:
Based from his accomplishments over the years, Tata Felipe could be said to have
achieved the expected tasks like practicing his rights to vote, satisfaction with his physical
environment and peacefulness of the community and acceptance of the inevitable death.
VI. Patterns of Functioning
Patterns of
Functioning
Before Illness During Illness
Before Hospitalization During Hospitalization
Eating The patient was
diagnosed of COPD on
August 19, 2010. Prior
to this, he claimed
that he eats three
times a day and have
snacks in between.
He usually eats his
breakfast between
6:00-6:30 AM, lunch
at 11:00-11:30 AM,
and dinner at 6:30-
Before hospital admission, he
usually eats the same foods
as that mentioned in before
illness as long as they are well
cooked and prepared such as
nilagang baka (1/2-1 bowl),
pancit (1 serving) and
sinabawang gulay with meat
(1 serving). He only can only
consume half of the food he
was eating before illness.
He eats his meal, 6:00-6:30
AM for breakfast, 11:00-
During his stay on hospital
he can consume all the
hospital rations served for
each meal which consist of
one serving for meat and
vegetable and one cup of
rice. He was on DAT diet. His
snacks usually consist of
fruits such as apples and
oranges.
He eats his meal around 6
AM for breakfast, 11:30-
12:30 PM at lunch and as
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7:00 in the evening.
He prefers to eat meat
especially nilagang
baka (1/2-1 bowl), he
also like pancit (1
serving) and
sinabawang gulay
with meat (1 serving).
He doesnt like to eat
foods that have bland
taste and no additives
and also raw foods
like kinilaw. He usually
consume 1- 1 1/2 cup
of rice each meal.
His snack usually
consists of native
delicacies like suman-
latik, banana cue, and
ginataan. According to
him he doesnt have
11:30 AM at lunch and 6:30-
7:00 for dinner.
His snack usually consists of
native delicacies like suman-
latik, banana cue, and
ginataan. According to him he
doesnt have any allergies to
food.
early as 5:30-6:00 PM for his
dinner.
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any allergies to food.
Analysis: There was a change on the eating pattern of the patient before illness and before
hospitalization due to difficulty of breathing. However when he was confined at the hospital,
his appetite increases as manifested by consuming all the rations served.
Patterns of
Functioning
Before Illness During Illness
Before Hospitalization During Hospitalization
Drinking He claimed that he
drinks upto 9 glasses
(250mL/glass) of
water per day. He also
like to drink alcoholic
beverages like gin
(bilog) which he
consume upto 2
bottles per week and
sometimes beer which
he can consumes 3
bottles in a week. He
doesnt like to drink
He already discontinued
drinking alcoholic beverages.
He can consume 2250 mL of
water in a day. He also drinks
1 glass of tea (320 ml)
whenever he feels
constipated. His total fluid
intake for 24 hours was
approximately 2,250- 2,570
ml.
During hospitalization, he only
drinks water with an amount of
600-1000 mL in a day.
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beverage that is
sweet. He also drinks
1 glass (320 ml) of tea
when he feels
constipated. He
doesnt have any
allergies to beverages.
All in all he can
consume
approximately 2,570-
2,850 ml/day.
Analysis: There was a change in the drinking pattern of the patient before illness and before
hospitalization since the patient discontinued drinking beer and gin, this is associated with the
presence of his ailment. There is also change during hospitalization due to decrease intake of
water because he is confined to bed.
Patterns of
Functioning
Before Illness During Illness
Before Hospitalization During Hospitalization
Bladder He voids 3-5 times a
day. Usually, he
Since Tata Felipe stop drinking
alcoholic beverages, his
He voids 2-3 times a day with
an approximate amount of
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Elimination urinates once in the
morning after he
wakes up, in the
afternoon and before
bedtime. He claimed
that his urine color
was yellowish to clear,
no foul odor,
bubbling, and the
duration during
voiding is not the
same.
bladder elimination is the
same as when they do not
have drinking session (3-5
times). His urine output is
approximately 1800-2000 ml/
day.
1200-1500 mL. Urine is
characterized as yellowish to
clear, no offensive odor.
Analysis: There was an alteration in bladder elimination as to frequency and amount before
illness to during illness attributed to the discontinuation of drinking alcoholic beverages.
However, during illness (before hospitalization) comparing during hospitalization, there was a
decrease in bladder elimination secondary to increase insensible losses due to the respiratory
tract.
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Patterns of
Functioning
Before Illness During Illness
Before Hospitalization During Hospitalization
Bowel
Elimination
Our client defecates
once a day. As to the
characteristics of his
feces, he describes it
as brownish in color,
aromatic, and its
consistency is soft. He
feels constipated
sometimes and
defecates early in the
morning around 3
AM.
He claimed that he defecates
the same before illness. As to
the characteristics of his
feces, he describes it as
brownish in color, aromatic,
and its consistency is soft. He
feels constipated sometimes
and defecates early in the
morning around 3 AM.
He claimed that he only
defecated on the day of
discharge. He doesnt use
Dulocolax anymore because
of the unavailability if the
drug. As to the characteristics
of his feces, he claimed that
its the same before illness
which is brownish in color,
and its consistency is hard.
Analysis: There was a change in the bowel elimination during illness (before hospitalization) to
during hospitalization due to the decrease activity and because he didnt use any Dulcolax.
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Patterns of
Functioning
Before Illness During Illness
Before Hospitalization During Hospitalization
Sleeping Our patient sleeps at
8:00-9:00 PM and
wakes up at 4:30-5:00
AM. He claimed that
his sleep was not
continuous and the
duration is 8 hours.
His bed time rituals
include watching TV
for 1-2 hours and
reading magazines
until he feels sleepy.
He also takes a nap
for 1-2 hours. All in all
he sleeps 9-10 hours
in a day. He utilizes 1
pillow on his head and
1 on his side. He also
applies gas and oil
He sleeps and wakes up the
same time at 8:00-9:00 PM
and wakes up at 4:30-5:00 AM
before hospitalization but he is
more frequently awakened
not like before illness. He
frequently awakes because of
profuse sweating. He still
applies gas and oil before
wearing sock at bedtime, he
uses 1 pillow on his head and
1 on his side and uses
mosquito net.
He sleeps at 10-11 PM and
wakes up around 5-7 AM. He
claimed that he is disturbed
during his sleep because of
the nurses routine. He uses 1
pillow on his head. He didnt
apply gas and oil before
bedtime. He also takes a nap
for 1-2 hours.
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before wearing socks
at bedtime and uses
mosquito net.
Analysis: There is a change in the sleeping pattern before hospitalization to during
hospitalization due to the new environment and nurses routine (vital sings taking and giving
medication).
Patterns of
Functioning
Before Illness During Illness
Before Hospitalization During Hospitalization
Bathing He takes a bath twice
a day, once in the
morning and before
he sleeps. He prefers
to use warm water.
He uses a pail of
water, Safeguard soap
and Sunsilk shampoo
and uses stone that
serve as body scrub
during bathing. He
He claimed that he do his
usual bathing the same
before illness such as using
herbal leaves, prefer warm
water, and utilize stone as
body scrub. He uses a pail of
water, Safeguard soap and
Sunsilk shampoo.
Sponge bath was rendered by
her wife once in the morning
and before his bedtime.
Sometimes his daughters do
her wifes activities.
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also uses herbal
decoction such as
lagundi and
sambong leaves
that he apply after
scrubbing for soothing
effect.
Analysis: There was a change in the in the bathing pattern of our patient during illness, before
hospitalization and during hospitalization due to the environment (dirty CR and its availability)
and presence of IV fluid prior to his confinement.
VII. LEVELS OF COMPETENCIES
PHYSICAL
Before Illness During Illness
Before Hospitalization During Hospitalization
Our clients daily routine
includes different kinds of
activities such as eating,
sleeping, bathing, feeding
their pets at home and
working at the farm. Even
The daily routine of our client
still includes eating, sleeping,
and bathing. But he cannot
do these without assistance
of his wife. By this time, he
can no longer also do feeding
Tata Felipe can no longer do
hes usual activities such as
eating, and bathing without
assistance of his wife. Because
Tata was easily being
exhausted when he does these
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though hes on the stage of
late adulthood, he can still
perform these things without
any assistance or any assistive
devices. He also performs
household chores like
washing the dishes and
cleaning their house. He does
these activities without being
exhausted.
their pets at home and
working at the farm because
of easy fatigability and the
presence of difficulty of
breathing.
things. He doesnt take a
whole bath during his 4 days of
confinement but nana Catalina
rendered him only Partial
Bath. He spend most of his
time on lying on bed, reading
magazines and chatting with
his wife and to those who
visits him.
Analysis: There was a change in the physical competency of our client because of the
discomforts such as difficulty of breathing and easy fatigability he is suffering.
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EMOTIONAL
Analysis: There was a change in the emotional competency of Tata Felipe because he became
irritable due to the presence of his illness.
SOCIAL
Before Illness During Illness
Before Hospitalization During Hospitalization
Before Illness During Illness
Before Hospitalization During Hospitalization
As claimed, Tata Felipe is a
cheerful one. However, nana
Catalina added that he is not
a type of person who is
expressive. As verbalized by
Nana Catalina, I just can
sense what my husband feels
even if he wont tell me.
When they quarrel, Nana
Catalina will just scold him
and Tata Felipe will stop
arguing.
According to Nana Catalina,
Tata Felipe is still cheerful.
Tata Felipe told us that he
can do anything he wanted
when he was at home which
is of his comfort. According to
him, when he doesnt feel
well, he tried to suppress it,
but nana Catalina can sense
his discomforts.
As we observed, Tata Felipe is
a cheerful person. But there
are times that he gets irritable.
He sometimes shouts to the
nurses. According to him,
when the nurses administer
medications in the night while
he is sleeping, he doesnt want
to be disturbed.
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Tata Felipe is a friendly type
of person. He has a good
relationship with his relatives
and other people in their
community. Whenever he has
nothing to do in their house,
he goes out and chats with
their neighbours. He is kind to
them and he knows how to
help them whenever they
have problems. He alsostated that he doesnt have
any enemies in their
community.
He maintains a good
relationship with other
people. He can still go out
from their house and chat
with their neighbours but
unlike before, he rarely does
it.
Even if tata Felipe have only
few people to interact with, he
still maintained his social
competency by having a
respecting relationship with
his room mate. He often has a
good conversation with the
people around him and his
fellow patient.
Analysis: There were changes in the social competency of our client since he still interact with
other people in a good manner.
MENTAL
Before Illness During Illness
Before Hospitalization During Hospitalization
Tata is a person who easily
understands of what is beingexplained to him. He is well
oriented about events, time,
place, person, and what is
happening around him. In
During the course of illness
he could still comprehend ofwhat is being explained and
being told to him. He can still
decide on things on his own.
Tata Felipe can still
comprehend what is beingexplained to him. He is still
well oriented about the time,
place, person and the things
happening about him. And
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terms of decision making on
such things like for the
welfare of their family, he can
decide on it.
during our interview, he
answers our questions
appropriately such as where
he lives and what date is their
anniversary.
Analysis: Tata Felipes mental capacity to comprehend and retain information and make
decisions did not change before and during illness. When we asked him questions, he
answers it appropriately and correctly.
SPIRITUAL
Before Illness During Illness
Before Hospitalization During Hospitalization
He rarely goes to church
because their house is too far
from their church. He has a
strong faith to God and
according to him,
eventhough i dont attend
the mass i never forget to
pray. He claimed that he
prays upon waking up in the
morning, before he eats his
meals and before he goes to
sleep.
Tata Felipes faith is still
strong. When we have asked
him if he still prays, he
claimed that he does. He
prays upon waking up in the
morning, before he eats his
meals and before he goes to
sleep. He affirmed that he
still believes in God despite
his illness.
Our clients faith was still the
strong as what he claimed it to
be. He told us that he always
pray to God when he wakes up
in the morning, before eating
his meals and before he will go
to sleep.
Analysis: There was no alteration in the spiritual competency of our client since his faith to God
remains before he got ill and during the course of his illness.
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VIII. PHYSICAL ASSESSMENT
General Appearance:
During the day of physical assessment, our client is wearing a yellow sando and a
white printed pajama. He is neat in appearance, with a brown complexion. His hair is well
combed. He has an IV fluid of D5NM inserted as venoclysis regulated at 27-28 gtts/min was
intact on his left basilic vein. He has a noticeable barrel chest. His body built is considered as an
ectomorph. He was cooperative during the assessment.
Height: 174 cm BMI: 20 kg/m2
Weight: 60 kg
Date of Assessment: August 20, 2010 Time of assessment: 3:00 PM
Vital Signs:
BP: 120/70mmHg, in sitting position, taken at right arm
PR: 81 bpm, regular in rhythm
Temperature: 36.5C per axilla
RR: 25 breaths per minute, regular in rhythm
Head:
- Normocephalic, round and proportional to the body- Hair is evenly distributed, with presence of white hair, thick, smooth and resilient- No discolorations, lesions or itchiness, no dandruff on the scalp- Facial features are found to be symmetric- No involuntary movements noted
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Eyes
- Almond shaped- Eyebrows are evenly distributed, thick and with few white hairs- Eyelashes are short, thin and evenly distributed- Eyelids are wrinkled- With noticeable eye bags- Pale conjunctiva, smooth, no lesions found- Cornea are opaque, moist and with reports of blurry vision on his left eye
Grade of eyeglass: 2.5
- Iris found to be round and black in color- PERRLA (Pupils Equally Round and Reactive to Light and Accommodation)- Has good ocular movement-able to move eyeballs from left to right, up and down
Ears
- Same color with the other parts of the body- In line with the outer canthus of the eye- Bean shaped, attached earlobe- With minimal cerumen- With a good hearing acuity- able to reiterate the words we uttered to him in a soft voice
Nose
- Same color with the face- No nasal discharges noted- High bridged nose- Pinkish nasal mucosa- With patent nares- No swelling observed around the nose
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Mouth and Throat
- Lips has symmetrical contour, pinkish in color but somewhat brownish at the edge- Lips are smooth and moist in appearance- Pinkish tongue- Able to move tongue left to right, up-down, in-out- Buccal mucosa is pinkish, smooth in appearance, with no lesions noted- Gums are pinkish, no lesions, no bleeding found and veins are slightly visible- No tooth is present at the upper part (he uses dentures)- Lower part has 5 teeth- yellowish and blackish in color and with carries- Hard palate appears bony and whitish while soft palate appears pinkish- Uvula positioned in the midline of the soft palate, pink in color- With visible veins on the buccal mucosa
Neck
- Same color with the other parts of the body- Skin is wrinkled and sagging- Trachea palpated in the midline- Has normal range of motion-able to flex and hyperextend- No engorgement of the neck vein
Chest
- Symmetrical- Has lighter color than the other parts of the body- Areola are round and black in color- Nipples are symmetrical in color- With a Barrel chest;
AP diameter: 17cm
Transverse diameter: 15cm
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- With normal lung expansion- With hyperresonant sound upon percussion- With a cardiac rate of 82 bpm- regular in rhythm- With abnormal breath sounds(wheezes) - lower lobe of the lungs- With a RR of 25 breaths per minute- regular in rhythm
Abdomen
- Lighter in color than the other parts of the body- Slightly protruberant- With normoactive bowel sound
RUQ- 7 LUQ- 8
RLQ- 8 LLQ- 8
- With tympanitic abdominal sound upon percussion
Upper Extremities
- Symmetrical in size and color- With hanging shoulders- Same color with the other parts of the body- No tenderness, lesions, deformities noted- With heart shape tattoo on the left forearm; about 2 inches in size- With sagging skin on the arm- With poor skin turgor- IV line inserted at left basilic vein- With a pulse rate of 81 bpm- regular in rhythm in both peripheral pulses- With good capillary refill of 2 seconds- With a good range of motion-able to adduct and abduct arms without restriction- With pinkish nailbeds- With short clean nails- With good muscle strength
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- Blood pressure taken at the right brachial artery: 120/70 mmHg
Lower Extremities
- Symmetrical in size and color- Same color with the other parts of the body- No tenderness, lesions, deformities noted- With good capillary refill of 2 seconds- With poor skin turgor- With a good range of motion-able to adduct and abduct legs without restriction- With pinkish nail beds- With short clean nails
IX. On- Going Appraisal
IX. On- Going Appraisal
August 21, 2010
1st
day appraisal
Tata Felipe was seen lying on bed in supine position with an IVF of D 5NM 1L @ 500 cc
level regulated to 27-28 gtts/min inserted at right basilic vein, infusing well. He complains of
back pain and wheezes every time he breathes. Tata Felipe has a productive cough with
yellowish sputum. He also reported having difficulty of getting sleep. The client was seen by
Dr. Lijauco with new orders made such as to continue meds (Salbutamol + Fluticasone 50
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mg/250 mg diskus inhalation BID, MV+Buclizine 1 cap OD and decrease Salbutamol +
Ipratroprium Neb to every 6 hours). Nebulization was done at 6 pm.
Tata Felipe is on DAT with strict aspiration precaution and was able to consume all of his
hospital rations served for breakfast, lunch and dinner. His vital signs were taken and
recorded as follows:
Body temperature (C) 36.2 36.6
Blood Pressure (mmHg) 110-120/70-80
Pulse Rate (beats/min) 80-88
Respiratory Rate (breaths/min) 22-28
Tata Felipe had partial bath this assisted by his wife.
His I and O for 24 hours monitoring were: for the 3-11 shift, his Clysis was 400 cc, oral
intake of 300 cc and output of 380 ml. For 11-7, his Clysis was 400 cc, oral intake of 200 cc
and output of 380 ml and for the 7-3 shift, his Clysis was 100 cc, oral intake of 300cc and
output of 400 ml.
Over all, his total Clysis was 900cc, oral intake of 800 cc and urine output of 1160 ml. he
urinated three times and did not defecate
August 22, 2010
2nd
day appraisal
Tata Felipe was seen sitting on the bedside with an IVF of D5NM 1L at 400cc
level regulated to 27-28 gtts/min. He is active in appearance. There were no back pains
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noted but he has still wheezes every time he breathes. He has still productive cough and
yellowish sputum and still with complains of difficulty in getting sleep. The client was seen
by Dr. Lijauco with new orders made such as to continue the meds (Budesonide every 12
hrs, N-acetylcysteine 200mg sachet in glass water BID , Salmeterol + Fluticasone 50
mg/250 mcg diskus inhalation BID, MV+Buchizine 1 cap OD, Salbutamol + Ipratropium Neb
every 6 hours, and Hydrocortisone 100 mg IV every 8 hours).
Tata Felipe is still on DAT with aspiration precaution and was able to consume all of his
hospital rations for breakfast, lunch and dinner.
His vital signs were taken and recorded as follows:
Body temperature (C) 36.2-36.8
Blood Pressure (mmHg) 120/70-80
Pulse Rate (beats/min) 80-88
Respiratory Rate (breaths/min) 24-28
Tata Felipe had a partial bath assisted by his wife. He was awake most of the time and
took two one-hour sleeps in the morning and afternoon.
His I and O for 24 hours monitoring were: for the 3-11 shift, his Clysis was 400 cc,
oral intake of 300 cc and output of 380 ml. For 11-7, his Clysis was 400 cc, oral intake of 200
cc and output of 380 ml and for the 7-3 shift, his Clysis was 100 cc, oral intake of 300cc and
output of 400 ml.
Over all, his total Clysis was 900cc, oral intake of 800 cc and urine output of 1160 ml. he
urinated three times and did not defecate
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August 23, 2010
3rd
day appraisal
Tata Felipe was seen lying on bed with an IVF of D5NMiL at 900 cc level regulated to
KVO. He is active in appearance and still complains of wheezes each time he breathes. Tata
Felipe has productive cough and with complaints of unable to sleep. The client was seen by
Dr. Rasos at 4:45 pm with new orders such as to facilitate spirometry but he refused, and
IVF to consume and shift to heplock.
Tata Felipe is still on DAT and was able to consume all of his hospital rations served for
breakfast and for lunch.
His vital signs were taken and recorded as follows:
Body temperature (C) 36.1-36.5
Blood Pressure (mmHg) 130- 110/70
Pulse Rate (beats/min) 60-88
Respiratory Rate (breaths/min) 22-25
He took a partial bath again with the help of his wife. He was awake most of the time
reading magazines and chatting to his wife and his roommate.
His I and O for 24 hours monitoring were: for the 3-11 shift, his clysis was 250 cc, oral
intake of 300 cc and output of 420 ml. For 11-7, his clysis was 200 cc, oral intake of 200 cc
and output of 380 ml and for the 7-3 shift, his clysis was 450 cc, oral intake of 250cc and
output of 400 ml.
Over all, his total Clysis was 900cc, oral intake of 750 cc and urine output of 1200 ml. he
urinated three times and did not defecate
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August 24, 2010
4th
day appraisal
Tata Felipe was seen sitting on bedside chair with heplock at right cephalic vein. He is
conversant and still with complains of wheezes but it is minimized compared to the
previous days. The client was seen by Dr. Lijauco at 1:30 pm with new orders made such as
MGH and prescribed with take home meds (Salmeterol + Fluticasone 50 mg per 250 mg
diskus inhalation BID, Salbutamol + Ipratroprium Nebule PRN if DOB, Levofloxacin 750 mg 1
tab OD for seven days) and for follow check up at OPD on September 2, 2010. Tata Felipe is
still on DAT and was able to consume all of his hospital rations for breakfast and for lunch.
His vital signs were taken and recorded as follows:
Body temperature (C) 36.3-36.7
Blood Pressure (mmHg) 130-110/90-70
Pulse Rate (beats/min) 80-72
Respiratory Rate (breaths/min) 24-28
He was able to take a full bath today but still with the assistance of his wife. He also
defecated once.
His I and O for 24 hours monitoring were: for the 7-3 shift he urinated and defecated
once, his oral intake was 450 cc. And total amount of urine was 380 cc. And at 4:30 pm he
already went home in good condition and disposition.
X. Medical Management
A. Diagnostic Procedures
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1. Complete Blood Count
DEFINITION
The CBC is used as a broad screening test to check for such disorders as anemia,
infection, and many other diseases. It is actually a panel of tests that examines different
parts of the blood and includes the following: Hemoglobin, Hematocrit, RBC indices, WBC,
and the differential count.
Purpose
Complete Blood Count (CBC) was done to our patient to determine significant changes
on the blood components brought about by the disease.
Date Requested: August 20, 2010
Date Performed: August 20, 2010
Requesting Physician: Mia Grace Lijauco, M.D.
RESULTS
EXAMINATIONS RESULT REFERENCE VALUE SIGNIFICANCE
Hemoglobin 140 140-175 g/L NORMAL
Hematocrit 0.41 0.41-0.50 NORMAL
RBC 4.560 4.5-5.9 x 10^12L NORMAL
MCV 89.00 80-100 fL NORMAL
MCH 30.70 27-32 pg NORMAL
MCHC 34.50 31-35 g/dL NORMAL
WBC 7.38 4.50-11.0 x 10^9/L NORMAL
Platelet 224 150-450 x 10^9/L NORMAL
DIFFERENTIAL COUNT
Segmenter 0.61 0.50-0.70 NORMAL
Lymphocyte 0.29 0.20-0.40 NORMAL
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Monocytes 0.08 0.02-0.08 NORMAL
Eosinophils 0.01 0.01-0.04 NORMAL
Basophils 0.01 0.00-0.01 NORMAL
Analysis
The result of the CBC was within normal range because our patient has good immune
system
Nursing Responsibilities Rationale
1. Verify doctors order To validate the existence of the procedure2. Reemphasize to the client about the
type of procedure and its purpose.
In order to establish rapport and gain
cooperation.
3. Explain to the client that a tinglingsensation maybe felt while collecting
the specimen.
In order for the client to know what to be felt
during the collection of specimen.
4. Refer to the doctor the results andattach to the patients chart
In order for the physician to evaluate the
results and perform the necessary
interventions.
2. Blood Chemistry
Purpose
Blood chemistry was done to our patient to determine significant changes on the
electrolyte components brought about by the disease.
Date Requested: August 20, 2010
Date Performed: August 20, 2010
Requesting Physician: Mia Grace Lijauco, M.D.
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RESULTS
EXAMINATION RESULT REFERENCE VALUE SIGNIFICANCE
Blood Urea Nitrogen 7.54 1.7-8.3 mmol/L NORMAL
Creatinine 66.25 44.2-150.3 mmol/L NORMAL
Sodium 142.00 136-150 mmol/L NORMAL
Potassium 4.20 3.4-5.3 mmol/L NORMAL
Chloride 102.00 96-106 mmol/L NORMAL
Analysis:
The result of the blood chemistry was within normal range and has no affectation on the
kidneys.
Nursing Responsibilities Rationale
1. Verify doctors order To validate the existence of the procedure2. Reemphasize to the client about the
type of procedure and its purpose.
In order to establish rapport and gain
cooperation.
3. Explain to the client that a tinglingsensation maybe felt while collecting
the specimen.
In order for the client to know what to be felt
during the collection of specimen.
4. Refer to the doctor the results andattach to the patients chart
In order for the physician to evaluate the
results and perform the necessary
interventions.
3. Arterial Blood Gases
DEFINITION
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This test is used to evaluate oxygenation and acid/base status. This test assesses both
the ventilation and diffusion capacity of the lungs to assist in diagnosis and to give an objective
assessment of improvement or deterioration.
Purpose
This was done to our patient to identify an impending acid-base imbalances
Date Requested: August 22, 2010
Date Performed: August 23, 2010
Requesting Physician: Emely T. Pumaras, M.D.
Result
EXAMINATIONS RESULT REFERENCE VALUE SIGNIFICANCE
pH Arterial Blood 7.414 7.35-7.45 mmHg NORMAL
pCO2 35.2 3.5.0 -45.0 mmHg NORMAL
pO2 64.4 80.0 -105.0 mmol/L DECREASE
HCO3 22.0 22.0-26.0 mmol/L NORMAL
Base Excess -2.6 -2.00 3.00 % NORMAL
O2 Saturation 92.4 95% NORMAL
Analysis:
The abnormal low level of pO2 and O2 saturation results to hypoxemia is due to
impaired ventilation perfusion mismatch, narrowed airways secondary to the disease process
and decrease ventilation.
Nursing Responsibilities Rationale
1. Verify doctors order To validate the existence of the procedure2. Reemphasize to the client about the To gain cooperation and compliance
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type of procedure and its purpose.
3. Inform the patient that arterial bloodsample collection is usually more
painful than regular venipuncture.
To be able to know by the patient what to be
felt during the collection of specimen.
4. Instruct the patient to sit with thearm hyper extended and wrist resting
on a small pillow
For proper collection of specimen from the
venipuncture site
5. Instruct the client to relax while bloodis being collected.
To void false positive results
5. Refer to the physician the result ofthe examination then attach to the
patients chart
In order for the physician to evaluate the
results and perform the necessary
interventions.
6. Administer oxygen as prescribed This is to address O2 saturation anddecreased pO2
7. Position patient in semi-fowlersposition
To loosen airways and facilitate
3. Acid-Fast Bacilli
DEFINITION
This test of various body fluids identifies tubercle bacilli in order to diagnose andmonitor the treatment of tuberculosis. Findings of acid-fast bacilli on microscopic examination
indicate possible tuberculosis and allow for timely initiation of anti-tuberculosis therapy.
Smears and cultures, primarily of sputum but also of other body specimens such a s urine, skin
biopsies, cerebrospinal fluids, gastric washing and blood are stained to detect acid-fast bacilli.
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Purpose
This procedure was done to our patient to confirm hi tuberculosis by determining the
causative agent involved and to determine the appropriate treatment.
Date Requested: August 19, 2010
Date Performed: August 20, 2010
Requesting Physician: Dr. Lijauco
Result
Gram Stain
Gram (+) cocci singly and short chain
Gram (-) bacilli many
WBC > 25/lpo
Fungal elements moderate
AFB Stain
(-) for fungal elements
Culture: x Aerobic x Anaerobic
Result:
Moderate growth of AmpC beta-lactamase producing Pseudomonas aeroginosa and
moderate growth ofCandida albicans
Susceptibility Test Result:
AmpC beta-lactamase producing pseudomonas aeroginosa (disk diffusion)
Susceptible to:
Amikacin
Cefepime
Ciprofloxacin
Gentamicin
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Imipenem
Levofloxacin
Meropenem
Tobramycin
Analysis
The presence of microorganisms (candida albicans and pseudomonas aeroginosa)
signifies that our client is suffering from tuberculosis
Nursing Responsibilities Rationale
1. Verify doctors order To validate the existence of the procedure2. Reemphasize the purpose of such
diagnostic procedure.
To gain cooperation and compliance
3. Reemphasize to the patient thecorrect procedure of specimen
collection
In order for the client to become aware on
the correct procedure of gathering
specimen for accurate results
4. Encourage the client to increasefluid intake the night before
To loosen secretions and to expectorate
sputum and specimen easier
5. Refer to the doctor the result ofthe examination then attach to the
patients chart
So that the physician will see the result
and if abnormalities is present proper
management will be given
4. ELECTROCARDIOGRAPHY (ECG)
DEFINITION
The ECG is a diagnostic tool used in assessing the cardiovascular system. ECG is used to
measure the rate and regularity of heartbeats as well as the size and position of the chambers,
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the presence of any damage to the heart, and the effects of drugs or devices used to regulate
the heart (such as a pacemaker). It is a graphic recording of the electrical activity of the heart.
The ECG is obtained by placing disposable electrodes in standard positions on the skin of the
chest wall and extremities.
Purpose
This procedure was done to our patient to determine if there is an affectation in the
heart brought about by the disease.
Date Ordered: August 19, 2010
Date Performed: August 20, 2010
Requesting Physician: Mia Grace Lijauco M.D.
Result: Regular sinus rhythm, left axis deviation
Analysis: the left axis deviation may be possibly caused by the cardiac muscle enlargement due
to the increase workload of the heart to compensate for the ventilation perfusion.
Nursing Responsibilities Rationale
1. Verify doctors order To validate the existence of the procedure2. Reemphasize to the patient and
significant other about the
procedure, including where it will
take place and its expected
duration
To alleviate anxiety and to gain
cooperation of the patient
3. Instruct patient to remove allmetals attached
To prevent any alteration in the result of
the ECG
4. Refer to the physician the ECG So that the physician will be able to
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result once available and then
attach it to the clients chart
determine the appropriate management
to be applied to the patient based on the
result
5. Report any abnormalities in the v/sand urine output to the physician
To make an immediate intervention to
prevent complication
B. Treatment
1. Intravenous Therapy
DEFINITION:
Intravenous Therapy is the giving of fluid substances into a vein. Intravenous Fluids aims
to maintain homeostatic functioning or maintain and replace body stores of water, electrolytes,
vitamins, minerals, proteins and calories in patients who cannot maintain an adequate intake
by the mouth; provide an avenue for the administration of IV medications and monitor central
venous pressure; restore acid-base balance and restore volume of blood components.
Purpose:
This was given to our client for rehydration and serves as an avenue for medications,
supplementary of nutrients and electrolytes.
IV Fluid Date Performed Requesting Physician
D5NM August 19, August 20, August
21, August 22
Dr. Lijauco
D5W August 20 Dr. Lijauco
Nursing Responsibilities Rationale
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1. Verify doctors order to validate the presence of the procedure2. Reemphasize to the patient the
purpose of the therapy.
To gain the patients compliance and
cooperation.
3. Check the fluids and equipments tobe used for infusions for any
discoloration, cloudiness, presence of
particles, cracks of bottle, punctured
bottle, IV tubing and catheters
discoloration.
To identify possible indications of expiration or
contamination.
4. Clean the infusion site using cottonballs with alcohol.
To prevent infection.
5. Regulate IV Fluid to the desired flowrate.
In order to meet necessary fluid and
electrolyte needed by the body within the
specified length of infusion as well as to
prevent circulatory overload.
6. Check for the presence of signs ofinfiltrations such as coolness of the
area, absence of blood backflow,
leaking of solution, sluggish flow rate
and swelling at the IV site.
To assess for the patency of IV line and to
ensure proper infusion
7. Read the clysis at eye level. To ensure a more accurate measurement.8. Document the type of IV solution
infused, its volume, its desired flow
rate, the date and time it was infused
and consumed.
This would serve as a record or for legal
purposes.
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2. Nebulization
It provides a visible mist of water articles for the patient to inhale. This is used to liquefy
secretions, to warm and humidify air, relieve edema of airways and an avenue for medication purposes.
Purpose:
This was done to our patient to administer medications which will relieve mucosal edema thus
dilating airway thus facilitating ventilation.
Nursing Responsibilities Rationale
1. Verify doctors order To validate the existence of the procedure2. Reemphasize the procedures to the
patient and significant others
To gain cooperation
3. Prepare and assemble the equipment.Check the electrical device before use
To ensure an effective nebulization
To prevent short circuit
4. Place the client in a semi-fowlersposition
For lung expansion for effective breathing
5. Place the prescribed dose ofmedication. Fill the nebulizer with
prepared medication
To ensure proper amount of medication is
given to the patient
6. Let the patent seal mouth on themouthpiece
To inhale the nebulizer vapor through the
mouth
7. Encourage the patient to breathe thenebulized vapor thru the mouthpiece
For maximum effect of the drug
8. Remain with the patient until all thesolution has been administered
To make sure that the patient consume all the
drug
9. May render bronchial clapping thenencourage patient to do deep
breathing and coughing exercise
To loosen the secretions thus easy to beexpectorate
10.Provide good oral hygiene after theprocedure
To remove the remaining mist of the drug
present in the mouth
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11.Wash and dry the nebulize equipment,tubing or mouthpiece and put in a
sealed plastic and into a proper place
To be ready for another use
12.Document the procedureappropriately
To record the improvement or any abnormal
finding
13. Increase oral fluid intake To synergize the effect of the therapy
C. Drug Study
GENERIC NAME:BUDESONIDE
BRAND NAME: Pulmicort Turbuhaler
CLASSIFICATION: Corticosteroid
DESIRED DOSAGE, ROUTE & FREQUENCY: two inhalations every 12 hours
DESIRED EFFECT: This drug is given to our patient to reduce inflammation in the bronchi.
MECHANISM OF ACTION:
Budesonide is an anti-inflammatory corticosteroid exhibits potent glucocorticoid
activity and weak minerolocorticoid activity. The exact mechanism of the cortiosteroids
isnt known, but they have a wide range of inhibitory activity against such cell types such
as mast cells and macrophages and mediators (such as leukotrienes) involved in allergic
and non-allergic inflammation.
Date Ordered: August 20, 2010
Requesting Physician: Dr. Lijauco
Nursing Responsibilities Rationale
1. Reemphasize to client the purpose,and effects of the drug
To gain cooperation and compliance
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2. Use cautiously, if at all, in patientswith active or quiescent TB of the
respiratory tract, ocular herpes
simplex, or untreated systemic fungal,
bacteria, viral, or parasitic infections
To avoid further complications.
3. Refer to physician if bronchospasmsoccur after using budesonide
To prevent further complications such as
bronchospasms
4. Watch for candida infections of thepharynx
For immediate treatment of the said
complication
5. Tell patient that budesonide inhalerisnt a bronchodilator and isntintended to treat episodes of asthma
For precautionary measures
6. Pulmicort Turbuhaler must be kept up-right(mouthpiece on top) during
loading
To provide correct dosage
7. instruct patient to place mouthpiecebetween lips and to inhale forcefully
and deeply
To obtain the desired effect of the drug faster
8. Tell the patient that he may not tastethe drug or sense it entering his lungs,
but it doesnt mean it isnt effective.
To make the patient aware on the possible
outcome of the drug given
9. Replace mouthpiece cover after useand always keep it clean and dry
To prevent the contamination from micro
organisms, thereby preventing the occurrence
of infection
10. Instruct the patient to carry or wearmedical identification indicating need
for supplementary corticosteroid
during periods of stress or an asthma
attack.
For identification purposes
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Generic name:N- Acetylcysteine
Classification: Mucolytic
Mode of action: This drug is a mucolytic that reduces the viscosity of pulmonary secretions by
splitting disulfide linkages between mucoprotein molecular complexes
Dosage, Route, Frequency: 200 mg / sachet in glass H20 BID
Desired Effect: This drug was given to our patient to improve airway flow and to provide a more
comfortable breathing.
Date Ordered: August 19, 2010
Requesting Physician: Dr. Lijauco/Dr. Rasos
Nursing Responsibilities Rationale
1. Reemphasize to client the purpose,and effects of the drug
To gain cooperation and compliance
2. Instruct patient or watcher thefrequency and dosage of the drug
To prevent toxicity
3. Administer cautiously to elderly ordebilitated patients with severe
respiratory insufficiency.
To avoid further problems since drug also
stimulates cardiac muscle.
4. Mix with juice Because drug smells strongly like sulfur soas to improve its palatability.
5. Monitor cough type andfrequency.
For more effective treatment.
6. Instruct client to report signs ofside effects of the medication
To prevent further complications
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GENERIC NAME: HYRDROCORTISONE
BRAND NAME: Sodium Succinate
CLASSIFICATION: Corticosteroids
DOSAGE, ROUTE AND FREQUENCY: 100 mg, IV every 8 hours
MECHANISM OF ACTION: Decreases inflammation by entering target cells and binding to
cytoplasmic receptors initiating many complex reactions thus resulting to blockage on the
release of histamine, bradykinine and serotonin.
DESIRED EFFECT: This drug is given to our patient to potentiate other drugs(Budesonide) to
reduce pulmonary inflammation.
Date Ordered: August 20, 2010
Requesting Physician: Dr. Lijauco/Dr. Rasos
Nursing Responsibilities Rationale
1. Reemphasize to client the purpose, andeffects of the drug
To gain cooperation and compliance
2. Do skin testing To determine any allergic reaction3. Check the patency of the IV line To make sure that it is in the vein4. Monitor I & O accurately Since one of the following signs is fluid
retention
5. Monitor BP Because this drug causesvasoconstriction effect thereby
increasing BP. Prompt monitoring of
side effects.
6. Weigh the patient daily with the sameclothing and weighing scale
To determine if he gained weight and
fluid retention
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7. Encourage patient to increase intake ofVitamin C and potassium rich foods
such as banana, cantaloupe, potato,
etc.
To increase body resistance and to
prevent the occurrence of hypokalemia
8. Increase fluid intake To loosen the secretions
Generic Name:Fluticasone-Salmeterol
Brand Name: Advair Diskus
Classification: Bronchodilators
Dosage, route, frequency: Fluticasone-Salmeterol 250mcg/50mcg Diskus Inhalation BID
Mechanism of Action:
It prevents the release of substances such as leukotrienes in the body that cause inflammation
and relaxing muscles in the airways to improve breathing.
Desired Effect:
This drug was given to our patient to dilate the bronchioles thereby facilitating normal
breathing pattern and air exchange
Date Prescribed: August 21, 2010
Requesting Physician: Dr. Quilala/Dr. Lijauco
Nursing Responsibilities Rationale
1. Reemphasize to client the purpose ofthe drug
to gain cooperation
2. Tell the client to gargle and rinse mouthafter using this medication
to help prevent dryness, relieve throat irritation,
and to prevent mouth infections
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3. Inform the patient to report any unusualweakness, sudden weight loss, dizziness.
This is a side effect of the drug that needs
immediate treatment
4. Instruct the patient to carry a medical IDbracelet at anytime as noted
This would help identify that the patient need
for oral corticosteroids during times ofstress
5. Instruct the watcher or patient tostore the medication in a dry place
Drug content may be altered
6. Instruct the patient not to overdose This drug causes ototoxicity7. Increase oral fluid intake To loosen the cesretions
Generic Name: BUCLIZINE
Brand Name:
Classification: Antiemetic/Antihistamine
Dosage, Route, Frequency: 1 cap 50 mg oral OD
Mechanism of Action:
Vomiting (emesis) is essentially a protective mechanism for removing irritant or otherwiseharmful substances from the upper GI tract. Emesis or vomiting is controlled by the vomiting centre in
the medulla region of the brain, an important part of which is the chemotrigger zone (CTZ). The vomiting
centre possesses neurons which are rich in muscarinic cholinergic and histamine containing synapses.
These types of neurons are especially involved in transmission from the vestibular apparatus to the
vomiting centre. Motion sickness principally involves overstimulation of these pathways due to various
sensory stimuli. Hence the action of buclizine which acts to block the histamine receptors in the
vomiting centres and thus reduces activity along these pathways. Furthermore since buclizine possesses
anti-cholinergic properties as well, the muscarinic receptors are similarly blocked.
Desired effect:
This drug was given to our client to address nausea, vomiting and drowsiness.
Date ordered: August 21, 2010
Requesting Physician: Dr. Lijauco
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Nursing Intervention Rationale
1. Reemphasize to client the purpose andeffects of the drug
To gain cooperation and compliance
2. Advice the client to store the drug in dryplaces.
Heat or moisture may alter the content of the drug
3.
Advise patient to report any unusualweakness, sudden weight loss, dizziness. This maybe a side effect of the drug that requiresimmediate treatment
4. Should be taken with food. (Take within hr before meals.)
To avoid GI upset
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NURSING CARE PLAN
I. Nursing Diagnosis
Impaired Gas Exchange related to narrowed airway secondary to overproduction of
thick tenacious mucus secretion, hypertrophy and hyperplasia of mucus glands as manifested
by body weakness, presence of adventitious sounds (wheezes), productive cough, respiratory
rate of 28 bpm and a verbalization of marigatan nak nga mangirwar ti plemas ko anak ko.
Nursing Inference
The increase production and accumulation of thick tenacious mucus secretions, due to
the hypertrophy and hyperplasia of goblet cell,s causes obstruction in the airway. Obstruction
of the airway causes decrease in ventilation in the affected alveoli hence impairing gas
exchange.
Nursing Goal
After 30-60 minutes of rendering nursing interventions, the patient will have effective
gas exchange as manifested by absence of body weakness, absence of adventitious sounds and
absence of cough.
Nursing Intervention
1. Position the client in high Fowlers position.
To promote lung expansion.
2. Administer bronchodilator (salbutamol + ipratropium) as the ordered.
To relax the smooth muscle of tracheobronchial tree thereby increasing thelumen.
3. Administer oxygen inhalation 1-2 lpm.
To deliver oxygen adequate for tissue perfusion.
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4. Encourage the patient to drink plenty of water at least 3L/ day if it is not
contraindicated.
To loosen the secretions by decreasing its viscosity thus easier to expectorate.
5. Move patient side to side every two hours.
To promote postural drainage.
6.. Encourage deep, slow or pursed lip breathing.
To prevent airway collapse, dyspnea and work of breathing
7. Administer mucolytics (N-acetylcysteine)as ordered.
To liquefy or dissolve viscous mucus secretions thereby promoting easier
expectoration.
Nursing Evaluation
After 1 hourof rendering nursing intervention, the patient has an effective gas exchange
as manifested by absence of body weakness, absence of adventitious sounds, and absence of
cough.
II. Nursing Diagnosis
Ineffective airway clearance related to accumulation of secretions which are thick and
tenacious as manifested by an RR of 28 bpm rales and wheezes, productive cough and
verbalization of the client marigatan nak nga mangirwar toy plemas ko.
Nursing Inference
Due to hyperplasia of mucus glands, there will be increased production of
tracheobronchial secretions which interferes the flow of gases in the airway, thus ineffective
airway clearance occurs.
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Nursing Goal
After 30 minutes-1 hour of nursing intervention the client will be able to maintain
patent airway as would be manifested by absence of adventitious sound, and verbalization of
the client haanak unay marigatan nga umangesen ken nalakak mairwar ti plemas kon.
Nursing Intervention
1. Position the client in high Fowlers position.
To promote lung expansion and promote postural drainage.
2. Encourage the patient to drink plenty of water at least 3L/ day as tolerated.
To loosen the secretions by decreasing its viscosity thus easier to expectorate
3. Encourage deep, slow or pursed lip breathing.
To prevent airway collapse, dyspnea and work of breathing
4. Administer mucolytics as ordered.
Breaks chemical bonds in the mucus, which are responsible for the increase
viscosity if such bonds are broken, mucus becomes easier to be expectorate.
5. Do postural drainage before meals and after nebulization
to help drain secretions
6. Administer oxygen inhalation 1-2 lpm
deliver oxygen adequate to meet the body cells needs.
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Nursing evaluation
After 1 hourof nursing intervention the client is able to maintain patent airway as manifested
by absence of adventitious sound, and verbalization of the client haanak unay marigatan nga
umangesen.
III.Nursing Diagnosis
Sleep pattern disturbances related to difficulty of breathing, and hospital settings and
routines as manifested by presence of eye bags, irritability, restlessness and a total sleep of 5
hours and verbalization of the client marigatanak nga mangala ti turog ko isu haanak unay
makatur-turog ken.
Nursing Inference
Due to change in the environment, difficulty of breathing and hospital settings and
routines, the client feels discomfort that may alter the usual or normal length of getting asleep
thus there is an alteration in the sleeping pattern of the client.
Nursing Goal
After of rendering nursing intervention, the clients sleep hour will be normalized as
manifested by absence of eyebags, sleep hour of 7-8 hours and verbalization of the client
hanak met marigatan mangala ti turog kon isu mayat met ti panagturog kon.
Nursing Intervention
1. Provide comfort measures such as backrub.
To promote physical and mental relaxation.
2. Encourage patient not to have a nap during daytime.
To have a larger duration of being awake thus early getting sleep at night.
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3. Encourage patient to drink warm milk before going to bed.
It contains trypthopan which induces sleep.
4. Provide quiet environment conducive to sleep such as closing the door.
These measures promotes rest and sleep by decreasing stimulus
5. Encourage patient to turn off the light, but if not, provide cover to the eyes with the likes of
towellete/handkerchief.
By covering the eyes, light cant pass through thus increasing production of melatonin,
sleep inducing hormone.
6. Inform client of necessary care interruptions ahead of time.
Preparing the client for awakenings and planning to minimize awakenings, decrease
unnecessary stress and anxiety that may prevent subsequent sleep.
7. Implement measures as indicated to prevent frequent voiding at night, such as decreasing
fluid intake before bedtime.
These measures prevent the need to wake up for frequent voiding.
8. Administer bronchodilator and humidifiers as ordered
To prevent mucus membrane from drying and becoming irritated and to loosen
secretions for easier expectoration.
9. Encourage purse lip breathing .
It creates resistance to the air flowing out of the lungs, thereby prolonging exhalation
10. Encourage patient to assume semi fowlers while sleeping.
This posture permits full lung expansion.
11. Plan satisfying activities for the client during daytime.
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Satisfying daytime activities stimulate wakefulness and discourage daytime napping
which can disrupt circadian rhythms and night time sleep
12. Encourage the client to express concerns when unable to sleep.
To decrease anxiety thus promoting relaxation.
Nursing evaluation
After 2 days of rendering nursing intervention, the clients sleep hour have normalized
and decreased frequent awakenings as manifested by absence of eye bags, sleep hour of 7-8
hours and verbalization of the client hanak met marigatan mangala ti turog kon isu mayat met
ti panagturog kon.
IV. Nursing Diagnosis
Activity Intolerance related to body weakness secondary to decrease oxygen supply to
the different muscles of the body as manifested by easy fatigability and inability to bath
without assistance.
Nursing Inference
Oxygen is needed for the production of energy of the body. Once oxygen supply is
deprived, there will be poor production of body energy causing weakness. Since there is
weakness activity intolerance results.
Nursing Goal
After 1 to 2 days of rendering nursing interventions, the patient will be able to tolerate
activities as would be manifested by ability of the patient to do his usual mild routines in a long
period of time such as taking a bath without experiencing weakness and without assistance.
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Nursing Interventions
1. Encourage the patient to drink plenty of water, do bronchial clapping to the patient and
administer bronchodilator and mucolytic as order.
To improve airflow
2. Encourage the patient to have adequate rest.
To lessen the oxygen demand of body tissues and conserve energy
3. Instruct the watcher to assist the patient in doing his ADL
To reduce energy expenditure
4. Encourage passive exercise such as dangling and deep breathing exercises.
To maintain muscle strength
5. Avoid doing for the patient what the patient can do for him and avoid giving exercises to
which he cant do.
To increase self esteem of the patient
Nursing Evaluation
After 2 days of rendering nursing interventions, the patient is able to tolerate
activities as manifested by ability of the patient to perform his usual mild activities in longer
period such as taking a bath a bath without experiencing weakness and without assistance.
GENERAL EVALUATION
Tata Felipe, 71 years old,residing at Brgy. 37 Ganagan Doro, Bacarra, was admitted to
emergency room last August 19, 2010 at 11:55 in the evening with a chief complaint of cough
and difficulty of breathing. After thorough history taking and physical examination done by Dr.
Quilala and Dr. Pumaras, he was admitted to Mariano Marcos Memorial Hospital and Medical
Center (MMMH & MC). Tata Felipe had an admitting diagnosis of Chronic Obstructive
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Pulmonary Disease in Acute Exacerbation Bronchitis, PTB Class IV. After a continuous
management and examination, the final diagnosis was COPD exacerbation controlled Bronchitis
resolved PTB class IV.
Laboratory works were done such as Hematology, ECG, ABG and Acid Fast Bacili. Results
revealed some abnormalities such as decreased oxygen, has moderate of AmpC Beta-lactamase
producing Pseudomonas Aerogenosa and moderate growth of Candida albicans. Spirometry
was also ordered but the client refused because he said that he wants to perform the
procedure when he will have his check up.IV therapy such as D5NM and D5W were given and
medications such as Budesonide, N-acetylcystein, Hydrocortisone, and Fluticasone-Salmeterol
for nebulization to liquefy secretions.
After four days of nursing interaction, assessment, planning, and interventions, the
clients condition had improved in many ways.
The difficulty of breathing experienced by the client has been managed by proper
positioning, increasing its fluid intake as well as rest, comfort and conducive environment were
provided. Nutrition was also emphasized to increase strength and endurance for the body
weakness complained by the patient. Fortunately, the patient regained his strength. Body
weakness was no longer felt during the last days of confinement.
On August 24, 2010 the client was discharged in good condition and disposition. He was
given salmetrol + fluticasone 50 mg/250mg diskus inhalation twice a day,
salbutamol+ipatropium nebulization as needed if there is difficulty of breathing, and
levofloxacin 750 mg 1 tablet once a day for 7 days as his home medication and was ordered to
come back on September 2, 2010 for follow up check up.
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Mariano Marcos State University
COLLEGE OF HEALTH SCIENCES
Department of Nursing
Batac, Ilocos Norte
Chronic Obstructive Pulmonary
Disease in Acute exacerbation
Bronchitis, Pulmonary Tuberculosis
C