CAPITOL UNIVERSITY College of Nursing
A Case Study Presented In Partial Fulfillment of the Requirement for the Subject Related Learning Experience 9
By: Lumbay, Jane Frances Madroño, Froilan Marie Maglangit, Anthony Melecio, Lloyd Bryan Merina, Jo Ann Monteroyo, Joseph Monteroyo, Marelou Montes, Jerico Clodualdo Nacua, Lovely Naduma, Mark Jameson Navaro, Christine Nazareno, Maricel
Submitted to: Ms. Syvel Jane Mata-Caharian, RN Clinical Instructor
July 15, 2010
COMMUNITY ACQUIRED PNEUMONIA Pneumonia is an infection of the lung parenchyma, usually caused by infection. Bacteria, viruses, fungi or parasites can cause pneumonia. Community-acquired pneumonia refers to pneumonia acquired outside of hospitals or extended-care facilities. It can range in seriousness from mild to life-threatening. Pneumonia often is a complication of another condition, such as the flu. Antibiotics can treat most common forms of bacterial pneumonias, but antibiotic-resistant strains are a growing problem. The best approach is to try to prevent infection Pneumonia is a particular concern if you’re older than 65 or have a chronic illness or impaired immune system. It can also occur in young, healthy people. Community acquired pneumonia continuous to be a common and serious illness both in developed and developing countries in spite of the advent of new and sophisticated diagnostic techniques, potent antimicrobials and effective vaccines. It remains an important cause of morbidity and mortality for both non-hospitalized adults. In the Philippines, it is the fourth leading cause of morbidity and the second leading cause of death. AMONG other diseases, pneumonia reportedly ranked first in the Top 10 causes of death in 80 barangays of Cagayan de Oro, based on the 2009 records of the City Health Office. One important aspect in the management of community acquired pneumonia is the decision to hospitalize a patient. It perhaps the single most important decision during the entire course of the illness. However, in patient care does not only entail extra cost, but also, it theoretically increases the risk of iatrogenic complications associated with hospitalization. The group chose this case because of its complexity, in order to identify and determine the general health problems and needs of the patient. Since the group was able to render 3 days of care over the span of two weeks from June 2, 2010 two days prior to client’s admission at Capitol University Medical City until July 10, 2010; the group was able to monitor and participate actively in the management of the disease process. As nurses our main goal is health promotion and maintenance by preventative measures through health education. As student nurses we can contribute to the field of nursing by empowering our fellow students with knowledge on how to manage a case like pneumonia. By sharing our knowledge we hope to help improve the quality of nursing care rendered by Capitolians that will bring pride to our university. The following are the specific objectives of this study: • To raise the level of awareness of the patient and the family regarding the health problems that are present.
To motivate the patient and family to continue the health care provided by the health workers in Capitol University Medical Center and most especially by the students and Clinical Instructor of Capitol University. quiet environment is very essential for recovery. The patient had a family history of hypertension from his both parents. well-ventilated.
efficient drainage. Nightingale’s theory focuses on changing and manipulating put also Identified 5 the environment in order to
the patient in the best possible conditions for nature to act. The factors that Florence Nightingale emphasized should come together in order for the care to be effective.
Patient X is a 79-year-old female. She had history of hypertension and diabetes.
. We have chosen this theory as our guide in caring for our patient with CAP because as what we have noticed environmental factors have a big impact with the cause and the possible prevention of the said disease condition. Bukidnon. NURSING THEORY This case presentation is based on Florence Nightingale’s
Environmental Theory. cleanliness/sanitation and light/direct sunlight. married and presently residing at Valencia. non-smoker and non-alcoholic beverage drinker. Applying this theory to care of our patient will be much helpful in a way that patient will be free of the risk and avoid things that could worsen his situation. non-asthmatic.• •
To provide information about pneumonia specifically the disease process and the identification of its danger manifestation. That is where the family members and significant others come into participate in providing this type of care for the patient to help her improve her condition and be free of the symptoms of CAP. pure water. And she considered a clean. to help the lower year level in the nursing department to be more knowledgeable in making and conducting a case presentation in the higher years.
This case presentation would also try to develop the critical analysis of each case presenter in order to come up with a very good output and a team effort. deficiencies in these 5 factors produce illness or lack of health. She was baptized under Roman Catholic faith. She has environmental factors namely fresh air. Patient X was diabetic.
And lastly. no known food and drug allergies.
Elimination Pattern Catheter in placed with yellowish urine attached to Urobag drain at 200cc. had a fever. H. the following data was obtained from the Patient X: Blood pressure= 130/80 mmHg. Nutritional and Metabolic Pattern Patient X was on Osteorized Feeding. Chief Complaints The patient had cough and cold. Daily fluid consumption was inadequate. She frequently consults their barangay health center workers. about a 230 cc was consumed during 8 hours of duty. D. I. Health. Statement of Patient General Appearance Patient X had a senile skin turgor with fair and some white thin spots which were evenly distributed.7oC. short and in convex curvature shape. Previous Hospitalization/Surgeries
E. Patient X is positive for diabetes mellitus. She doesn’t have a regular schedule for exercise. and positive for hypertension. Pulse rate = 100 beats per minute. Patient X usually spent her time watching television.Illness History Three hours prior to admission patient developed increased sleeping time and snoring-vomiting. C. Vital Signs Upon assessment. Patient X was lethargic. G. Axillary temperature= 39. Nail beds were pallor. J. 2010). eye movement responsive to speech stimuli.
. F. Things done to manage health Patient was kept watched and monitored. Activity and Exercise Pattern Prior to hospitalization. B. Cognitive-Perceptual Pattern Upon assessment during the first week (July 2-3. Respiratory rate= 34 cycles per minute. She had her maintenance drugs as prescribed by her physician. had a yellow sputum.A.
Sleep-Rest Pattern Prior to admission the patient often slept at 10pm and usually woke up at 5am in the morning.K. Usually the patient sleeps for 7 to 8 hours. SKIN color temperature turgor Texture lesions integrity Assessment Findings Validation
Pale Warm (39.
Baseline Data Area of Assessment I.7°C) Senile skin turgor no lesions noted Rough skin integrity
EARS External Pinnae External Canal Groos Hearing Tympanic Membrane VII. NECK Trachea Thyroid
Normoset No discharges Normal Intact Pinkish Midline Patent No discharges Pallor Caries Pallor Pinkish Midline Midline Non-palpable
. HEAD shape size configuration headaches head injury V. HAIR color texture distribution quantity IV.II. EYES Lids Periorboital region Conjunctiva Sclera Pupils >Reaction to light >Reaction to Accommodation Visual Acuity Peripheral Vision
pallor dry convex
White with some black hair dry hair fine distributed thick
rounded normocephalic good configuration (+) headaches no head injury Symmetrical Sunken Pale Anicteric Equal in size 2mm Brisk Uniform Constriction/convergence Nearsighted Decreased
VI. MOUTH AND THROAT lips teeth mucosa gums tongue IX. NAILS color texture shape III. NOSE AND SINUSES Mucosa Septum Patency Discharge VIII.
BREAST & AXILLARY symmetry contour skin lesions consistency lymph nodes engorgement XIII. respiratory status Breathing pattern Shape of chest Lung expansion Vocal/Tactile Fremitus Percussion Breath sounds Cough Sputum
Irregular (34 RR) Flat Symmetrical Symmetrical Resonant Crackles at right chest Productive cough but cannot expectorate Yellowish colored
Inspection Palpation Percussion Auscultation
XI.X. ABDOMEN General Configuration Bowel Sound Percussion Palpation XVI.
Inspection Palpation Auscultation
equal good contour no lesions good consistency no lymph nodes no enlargement Superficial viens Symmetrical Hypo Active Tympanitic Muscle Guarding
Inspection Auscultation Palpation Percussion
midline UA coordinated No scar seen Passive Passive Passive Passive Edema noted no tenderness
. MUSCULOSKELETAL Inspection spine posture gait: scars ROM flexion extension abduction Rotation Upper Extremities Palpation Tenderness
Flat 100 bpm Irregular Strong 2 sec.CARDIOVASCULAR STATUS Preorbital Area Apical Rate Heart Sound Peripheral Pulse Capillary Refill XII.
Cerebral Function muscle coordination. rhythm & regular gait UA UA No nystagmus noted can balance well Slurred speech
. rhythm. Cranial Nerves olfactory optic oculomot or trochlear trigemina l facial acoustic glossopharyngeal vagus accessory hypoglos sal
cant distinguish odor cant identify color spontaneous can move eyes side by can sense pain can smile can hear cant distinguish taste cant shrug shoulder can curved tongue
2. flaccidity or rigidity. Head and Neck Inspection facial muscle symmetry: swelling: scars: discoloration: ROM flexion Extension 4. & regularity of gait posture balance nystagmus & slow dysrrhytmic speech
Weak muscle tone Inability to move Immobilize no tremors & rigidity Passive ROM in both upper & lower extremities Passive Passive Passive symmetrical facial muscles no swelling noted no scar seen no discoloration Passive Passive good muscle coordination.NEURO SYSTEM 1. tremors extremities flexion abduction adduction 2. Sensory system light touch vibration pain
able to sense touch can feel vibration can feel pain
Motor System muscle tone ability to move extremities against gravity spasticity.
Speech & Language Listen to speech to detect dysphasia. Mental status LOC. Grade w/ GCS Orientation 8.5. Deep tendon reflex (Grade 0-4) 6. Brain stem integrity oculocephalic reflex (doll’s eye phenomenon) oculovestibular reflex 7. GCS 11 UA Can’t speak
NURSING SYSTEM REVIEW CHART
. dysarthria or dysphonia
Grade as 1
RR= 34 cpm Crackles at right chest Yellow sputum Productive cough
nerasighted decreased visual acuity
Weak muscle tone Inability to move
Pale Unable to speak Slurred speech
Hypoactive Muscle Guarding
ANATOMY AND PHYSIOLOGY
Can’t distinguish Can’t identify clor
Pallor Warm: 39.
and presents for examination an apex. and two surfaces. (Pulmones) The lungs are the essential organs of respiration.5 to 4 cm. and is more abundant in males than in females. concave. porous. and rests upon the convex surface of the diaphragm. and as age advances. threeborders. As a rule. the left 567 gm. it is also highly elastic. The coloring matter consists of granules of a carbonaceous substance deposited in the areolar tissue near the surface of the organ. mottled in patches. spongy texture. owing to the presence of air in the alveoli. above the level of the sternal end of the first rib. The base (basis pulmonis) is broad. and the spleen. shining. a base.The Lungs
Front view of heart and lungs. placed one on either side within the thorax. in adult life the color is a dark slaty gray. 970). At birth the lungs are pinkish white in color. their proportion to the body being. The substance of the lung is of a light. but much variation is met with according to the amount of blood or serous fluid they may contain. the posterior border of the lung is darker than the anterior. The surface is smooth. in the former. it floats in water. and crepitates when handled.. A sulcus produced by the subclavian artery as it curves in front of the pleura runs upward and lateralward immediately below the apex. The apex (apex pulmonis) is rounded. this mottling assumes a black color. in the latter as 1 to 43. and marked out into numerous polyhedral areas. and extends into the root of the neck. and separated from each other by the heart and other contents of the mediastinum (Fig. The right lung usually weighs about 625 gm. The lungs are heavier in the male than in the female. indicating the lobules of the organ: each of these areas is crossed by numerous lighter lines.. Each lung is conical in shape. they are two in number. and the left lung from the left lobe of the liver. as 1 to 37. hence the retracted state of these organs when they are removed from the closed cavity of the thorax. the stomach. reaching from 2. Since the diaphragm extends
. It increases in quantity as age advances. which separates the right lung from the right lobe of the liver.
The mediastinal surface (facies mediastinalis. The base of the lung descends during inspiration and ascends during expiration. and a part of the right lung has been cut away to display the airducts and bloodvessels. and nearer the apex. inner surface) is in contact with the mediastinal pleura. while running upward. 973). a slight impression in front of the latter and close to the margin of the lung lodges the left innominate vein. (Testut. the concavity on the base of the right lung is deeper than that on the left. sharp margin which projects for some distance into the phrenicocostal sinus of the pleura. and then arching lateralward some little distance below the apex. and corresponds to the form of the cavity of the chest. the cardiac impression. behind this. It presents a deep concavity. immediately above the hilus. On the right lung (Fig. where the structures which form the root of the lung enter and leave the viscus. is a wide groove for the superior vena cava and right innominate vein. is an arched furrow which accommodates the azygos vein. on account of the heart projecting farther to the left than to the right side of the median plane. Behind
. slight grooves corresponding with the overlying ribs. and running upward from this toward the apex is a groove accommodating the left subclavian artery. of considerable extent. These structures are invested by pleura. this groove becomes less distinct below. which. On the left lung (Fig. below the hilus and behind the pericardial impression. The lungs have been pulled away from the median line.higher on the right than on the left side. is a well-marked curved furrow produced by the aortic arch.) Surfaces.
Pulmonary vessels. It is in contact with the costal pleura. owing to the inclination of the lower part of the esophagus to the left of the middle line. in specimens which have been hardened in situ. is a furrow for the innominate artery. seen in a dorsal view of the heart and lungs.—The costal surface (facies costalis. between the lower ribs and the costal attachment of the diaphragm. Above and behind this concavity is a triangular depression named thehilum. 972). Laterally and behind. convex. In front and to the right of the lower part of the esophageal groove is a deep concavity for the extrapericardiac portion of the thoracic part of the inferior vena cava. the base is bounded by a thin. being deeper behind than in front. this is larger and deeper on the left than on the right lung. and presents. which accommodates the pericardium. forms the pulmonary ligament. immediately above the hilus. external or thoracic surface) is smooth. Behind the hilus and the attachment of the pulmonary ligament is a vertical groove for the esophagus.
medially where it divides the base from the mediastinal surface it is blunt and rounded.
Mediastinal surface of right lung. and projects. and in front of this. and is received into the deep concavity on either side of the vertebral column. into the phrenicocostal sinus.—The inferior border (margo inferior) is thin and sharp where it separates the base from the costal surface and extends into the phrenicocostal sinus. and projects into the costomediastinal sinus.
. The anterior border of the right lung is almost vertical. below. The posterior border (margo posterior) is broad and rounded. Opposite this notch the anterior margin of the left lung is situated some little distance lateral to the line of reflection of the corresponding part of the pleura.the hilus and pulmonary ligament is a vertical furrow produced by the descending aorta. near the base of the lung. an angular notch. thecardiac notch. Borders. that of the left presents. the lower part of the esophagus causes a shallow impression. The anterior border (margo anterior) is thin and sharp. It is much longer than the anterior border. and overlaps the front of the pericardium. in which the pericardium is exposed. below.
by two interlobular fissures. One of these separates the inferior from the middle and superior lobes. a large portion of the costal surface. this fissure begins on the mediastinal surface of the lung at the upper and posterior part of the hilus. and reaches the lower border a little behind its anterior extremity. is broader. the larger of the two. by which the lung is connected to the heart and the trachea. The middle lobe. and the greater part of the posterior border. and inferior. The Root of the Lung (radix pulmonis). owing to the inclination of the heart to the left side. however. The right lung is divided into three lobes. and corresponds closely with the fissure in the left lung. The root is formed by the bronchus. cuts the anterior border on a level with the sternal end of the fourth costal cartilage. more vertical.5 cm. and includes the lower part of the anterior border and the anterior part of the base of the lung. It then extends downward and forward over the costal surface.5 cm.—A little above the middle of the mediastinal surface of each lung. and. the pulmonary veins. an upper and a lower. is its root. and it cuts the lower border about 7. which extends from the costal to the mediastinal surface of the lung both above and below the hilus. behind its anterior extremity. on the mediastinal surface it may be traced backward to the hilus. below the apex. and comprises almost the whole of the base. and runs backward and upward to the posterior border. the pulmonary
. As seen on the surface. and nearer its posterior than its anterior border. its total capacity is greater and it weighs more than the left lung. in consequence of the diaphragm rising higher on the right side to accommodate the liver. although shorter by 2. running horizontally forward. by an interlobular fissure. The inferior lobe. and a considerable part of the costal surface and the greater part of the mediastinal surface of the lung. the bronchial arteries and veins. The superior lobe lies above and in front of this fissure. middle.Mediastinal surface of left lung. is wedgeshaped. the anterior border. The right lung. Fissures and Lobes of the Lungs. which it crosses at a point about 6 cm. the pulmonary artery. than the left. and its further course can be followed upward and backward across the mediastinal surface as far as the lower part of the hilus.—The left lung is divided into two lobes. the smallest lobe of the right lung. superior. The other fissure separates the superior from the middle lobe. It begins in the previous fissure near the posterior border of the lung. is situated below and behind the fissure. and includes the apex. Its direction is.
lined by columnar ciliated epithelium resting on a basement membrane. it invests the entire surface of the lung. the smallest subdivisions constituting the lobular bronchioles. and is distributed to the superior lobe. The right bronchus gives off. and the vagus and posterior pulmonary plexus behind each. The parenchyma is composed of secondary lobules which. Each secondary lobule is composed of several primary lobules. bronchial lymph glands. the bronchial muscle. The lower of the two pulmonary veins. The primary lobule consists of an alveolar duct. and hence all its branches are hyparterial. and the main tube then passes downward and backward into the inferior lobe. Structure. together with the bronchial vessels. the pericardiacophrenic artery and vein. most developed at the points of division. giving off in its course a series of large ventral and small dorsal branches. lymphatics and nerves. in diameter. a branch for the superior lobe.2 mm. bronchus. The secondary lobules vary in size. from the bifurcation of the trachea. and invests the entire organ as far as the root. pulmonary artery. The first of these is distributed to the middle lobe. transparent. are quite distinct from one another. is situated below the bronchus. The intrapulmonary bronchi divide and subdivide throughout the entire organ.plexuses of nerves. behind. The root of the right lung lies behind the superior vena cava and part of the right atrium. those on the surface are large. The corium of the mucous membrane contains numerous elastic fibers running longitudinally. thus: On the right side their position is—eparterial bronchus. The branch to the middle lobe is regarded as the first of the ventral series. and (3) most internally. The subserous areolar tissue contains a large proportion of elastic fibers. The branch to the superior lobe of the left lung is regarded as the first of the ventral series. 972. The serous coat is the pulmonary pleura (page 1090). and are usually eight in number—four of each kind. lie in front of each. lymphatic vessels. the pulmonary artery in the middle. 973). The left bronchus passes below the level of the pulmonary artery before it divides. of pyramidal form. where it divides into ventral and dorsal branches similar to those in the right lung. All the other divisions of the main stem come off below the pulmonary artery. but on the left side their position is—pulmonary artery. about 2. all of which are enclosed by a reflection of the pleura. the upper of the two pulmonary veins in front.—The lungs are composed of an external serous coat. Divisions of the Bronchi. the base turned toward the surface. and consequently are termed hyparterial bronchi. it may therefore be looked upon asequivalent to that portion of the right bronchus which lies on the distal side of its eparterial branch. although closely connected together by an interlobular areolar tissue. pulmonary veins. and a certain amount of lymphoid tissue. on the two sides. and below the azygos vein. and the bronchus. it is thin. their arrangement differs. a layer of circularly disposed smooth muscle fibers. Thelobular bronchioles differ from the larger tubes in containing no cartilage and in the fact that the ciliated epithelial cells are cubical in shape. a subserous areolar tissue and the pulmonary substance or parenchyma. viz. below each is the pulmonary ligament. (2) internal to the fibrous coat. The main stem then enters the inferior lobe. and extends inward between the lobules. at the apex or lowest part of the hilus (Figs. The larger divisions consist of: (1) an outer coat of fibrous tissue in which are found at intervals irregular plates of hyaline cartilage. from the bifurcation of the trachea. The lobular bronchioles are about 0. and areolar tissue. the mucous membrane. and of various forms. the phrenic nerve.5 cm.
.—Just as the lungs differ from each other in the number of their lobes. it also contains the ducts of mucous glands.. and the anterior pulmonary plexus. This branch arises above the level of the pulmonary artery. the air spaces connected with it and their bloodvessels. the acini of which lie in the fibrous coat. and is therefore named the eparterial bronchus. The chief structures composing the root of each lung are arranged in a similar manner from before backward on both sides. pulmonary veins. The first branch of the left bronchus arises about 5 cm. so the bronchi differ in their mode of subdivision. the anatomical units of the lung. those in the interior smaller. That of the left lung passes beneath the aortic arch and in front of the descending aorta. From above downward. hyparterial bronchus. The ventral and dorsal branches arise alternately. and may be teased asunder without much difficulty in the fetus.
septum between secondary lobules. atria. polygonal. v. 6. smooth muscle. respiratory bronchiole. X 20 diameters. a. the cells of which are united at their edges by cement substance. (Miller. and each of these again divides into several alveolar ducts.) The alveoli are lined by a delicate layer of simple squamous epithelium. 3. 5. bronchiole. 1.Part of a secondary lobule from the depth of a human lung. and forming a common wall to adjacent alveoli. branch pulmonary artery. 4. with a greater number of alveoli connected with them. the atria. 2. with scattered alveoli.
. branch pulmonary vein.) Each bronchiole divides into two or more respiratory bronchioles. s. (Miller. Each alveolar duct is connected with a variable number of irregularly spherical spaces. which also possess alveoli. With each atrium a variable number (2–5) of alveolar sacs are connected which bear on all parts of their circumference alveoli or air sacs. alveolus or air cell: m. nucleated cells. Between the squames are here and there smaller. Camera drawing of one 50 μ section. alveolar duct. alveolar sac. Outside the epithelial lining is a little delicate connective tissue containing numerous elastic fibers and a close net-work of blood capillaries. showing parts of several primary lobules.
l. d. The pulmonary capillaries form plexuses which lie immediately beneath the lining epithelium. alveolar duct.. and the epithelium takes on the characters described above. the vein below. respiratory bronchiole. In the septa between the alveoli the capillary net-work forms a single layer.) X 70. b. atria. p. a. b.. a. 976). The capillaries form a very minute net-
. a. Vessels and Nerves. A bronchial tube. in the walls and septa of the alveoli and of the infundibula. lymph node. lymphatic clefts. Flint. alveolus or air cell.r.)
FIG.. long. 13 cm. alveolar sac. (Miller. lymphatic. it divides into branches which accompany the bronchial tubes and end in a dense capillary network in the walls of the alveoli. 976– Section
of lung of pig embryo. An Alveolus. In the lung the branches of the pulmonary artery are usually above and in front of a bronchial tube. al. a.. M. at. l.
The fetal lung resembles a gland in that the alveoli have a small lumen and are lined by cubical epithelium (Fig. s.. c. showing the glandular character of the developing alveoli (J. Pleura. l.: pulmonary artery: p.—The pulmonary artery conveys the venous blood to the lungs. Interstitial connective tissue. v... n. pulmonary vein.Schematic longitudinal section of a primary lobule of the lung (anatomical unit). After the first respiration the alveoli become distended. q.
but the veins freely anastomose. the radicles coalescing into larger branches which run through the substance of the lung.—The lungs are supplied from the anterior and posterior pulmonary plexuses. and on the left side in the highest intercostal or in the accessory hemiazygos vein. Those supplying the bronchial tubes form a capillary plexus in the muscular coat. the meshes of which are smaller than the vessels themselves. The bronchial arteries supply blood for the nutrition of the lung. which ultimately come into relation with the arteries and bronchial tubes. this plexus communicates with small venous trunks that empty into the pulmonary veins. bronchial veins. It does not. Nerves. The arteries of neighboring lobules are independent of each other. The filaments from these plexuses accompany the bronchial tubes. accompanying the bronchial tubes. where they form a capillary network. Finally they open into the left atrium of the heart. are distributed to the bronchial glands and upon the walls of the larger bronchial tubes and pulmonary vessels. and accompany them to the hilus of the organ. The bronchial vein is formed at the root of the lung. Small ganglia are found upon these nerves. It ends on the right side in the azygos vein. from which branches are given off to form a second plexus in the mucous coat. they are derived from the thoracic aorta or from the upper aortic intercostal arteries. and. supplying efferent fibers to the bronchial muscle and afferent fibers to the bronchial mucous membrane and probably to the alveoli of the lung. After freely communicating with other branches they form large vessels.
DIAGNOSTIC TEST AND LABORATORY RESULTS
. receiving superficial and deep veins corresponding to branches of the bronchial artery. receive all the blood supplied by the artery. however. some ramify upon the surface of the lung. partly in the superficial. as some of it passes into the pulmonary veins. The pulmonary veins commence in the pulmonary capillaries. and end partly in the deep. formed chiefly by branches from the sympathetic and vagus. conveying oxygenated blood to be distributed to all parts of the body by the aorta. Lastly. beneath the pleura.work. their walls are also exceedingly thin. Others are distributed in the interlobular areolar tissue. independently of the pulmonary arteries and bronchi.
5 Hematocrit 34.000390.000Segmenters Lymphocytes Monocytes Eusinophil Platelet RBC MCV MCH MCHC Interpretation: 10.2 27.4 80-96 27-31 32-36 Unit Result Interpretation
g/dL % x10^d/L
14.000 84.030 trace (-) 15-20 cells/HPF 0-3 cells/HPF Few Rare
HEMATOLOGY Test Reference Value Complete Blood Count Hemoglobin 11.0 2.0 9.0 14.000 4.3 WBC 5. 2010)
Color Transparency Reaction Specific Gravity Sugar Protein Pus cells RBC Squamous Epithelial Cells Bacteria Interpretation: Yellow Hazy 6.0 42.2-5.9 32.Urinalysis
(July .75 87.7 – 14.0 1.0 2 194.000 45-70 18-45 4-8 2-3 174.1-44.000 4.9
% % % x10^g/L x10^12/L fL Pg g/dL
Hemoglucotest Date Result mEq/dL mEq/dL mEq/dL mEq/dl mEq/dL
Medications Compliance to the medication regimen: • Azithromycin antibiotic 500mg 1tab PO OD • Iosartan antihypertensive 100mg 1tab PO OD • Dexofyline bronchodilator 400mg PO OD • Hydrocortisone corticosteroid 100mg IVTT q6 • Sultamicillin antibiotic 750mg 1tav PO BID • Acetylcysteine mocolytic 100mg 1tab PO OD • Hydrixyzine anxiolytic antihistamine • Salbutamol bronchodilator q6
. Monitoring blood glucose to ensure that the blood glucose level is within normal range. There is no significant interval change in the granuloma formation in the right upper lung field. Same degree of cardiomegaly. (Minimal pleural effusion vs. Reticular densities are seen in the right paracardiac area. No other remarkable interval findings. 2010)
Follow up exam relative to 6/7/2010 shows: Film taken with poor inspiratory effort. There is interval decrease in the reticular densities seen in the right paracardiac area.
Chest X-Ray (July 5. Both costrophrenic sulci are now Blunted. 2010)
Follow up exam relative to 6/30 shows: Film taken with suboptimal respiratory effort. (Pneumonitis vs confluent bronchovascular markings).
(July 30. pleural thickening). Both costrophrenic sulci and hemidiaphragms are intact. No other remarkable interval findings.Nursing Interpretation: Patient Y has diabetes mellitus II.
Health teachings • • • • Give both the patient and the caregiver verbal and written instructions about home medications. especially water. Encourage physical mobility.• Economy •
Senna concentration laxative 2tabs PO HS Encourage active participation of the patient significant others in the program including self-monitoring of vital signs and diet for increase compliance. Liquids will keep patient from becoming dehydrated and help loosen mucus in the lungs. Emphasis on the intended diet with low salt. To ensure complete recovery and prevent further complications
Inform that the one prescribed by the physician for underlying condition should be followed and should not be omitted. To decrease tension level • Compliance to medications To aid in the successful recovery
Give supportive treatment. Proper diet and oxygen to increase oxygen in the blood when needed. low sugar and low protein should be maintained. Encourage patients feeling with regards to allowances and limitations with respect to home chores. recreation and activities. Maintain peaceful environment to promote comfort and fastest recovery
Out-patient • Follow up visits to physician were encourage to significant others for further evaluation with regards to the condition of the patient.
Treatment • Encourage relaxation techniques and exercise.
. Drink lots of fluids. low fat. To promote more understanding about the need for monitoring the condition of the patient and proper food should be taken.
As a group. It was not that busy because our clinical instructor thought us to managed our time well and always be ready with the people that we are going to encounter.
. Prayer is the best weapon to all difficulties no matter what it is.
Related Learning Experience
With our 3 weeks exposure at Capitol University Medical City Station 4. we have learned that working as a team has indeed made our duty a lot easier and well-managed. we say that it is one of our very unforgettable experienced because we have learned a lot with regards to caring for our patient and dealing with people.• Spiritual •
Maintain hydration. We also have learned that having a peaceful and united group could indeed produce a better quality of work.
Advice patient to ask god’s guidance and supervision all through his life and entrust everything to him. God is always there all the time.
Being in this rotation is really a one of a kind experience. enjoyable and very exciting. Shared a lot of experiences and most of all the knowledge and the lessons she learned as a nurse.
.One interesting woman on this rotation was our Clinical Instructor for he was the one who work hard to make our rotation possible.