Patient’s Profile

Name: Santiago Papiona

Address: Brgy. San Juan, Baras Rizal

Age: 50 years old

Birthday & Birthplace: May 10, 1960 @ Pangil Laguna

Date of Admission: December 8, 2010

Time of Admission: 12:03pm

Diagnosis: Viral Hepatitis

Attending Physician: Dra. Ocampo

Religion: Catholic

Status: Married

The patient, Santiago Papiona is a 50 year old male, married, lived in Brgy. San
Juan, Baras Rizal. He was born on the 10 th of May 1960 at Pangil Laguna. The patient was
suffering from flu, chest pain and difficulty of breathing that’s why he was admitted at the
Medical ward of Rizal Provincial Hospital last December 8, 2010 at 12:03pm with a diagnosis
of Viral Hepatitis by Dra. Ocampo.

Medical History

A week prior to admission, the patient felt weak because of his flu. And he was admitted to
the hospital last December 8 because of his flu, difficulty in breathing, chest pain and
dizziness. The patient has no history of diabetes mellitus in their family but have a history of
hypertension in the family.

Assessment

The patient usually eats vegetables, fish, meat, and some salty and fatty foods. He is a
regular smoker, he usually smokes a pack of cigarettes a day and the patient is also an
alcoholic. The patient’s job is a ‘mason’.

Course of patient in the ward & ER

LAB

Hgb 108 Lymphocytes 0.10 (0.20 – 0.10)

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Hct 0.32vol% HbSAg: Non Reactive

WBC 13.0 Segments 0.90 (0.40 – 0.60)

RADIOLOGICAL REPORT

Type of examination: Chest PA

Requesting Physician: Dra. Ocampo

Suspicious densities in both upper lung fields. Minimal haziness in both lower lungs. Heart is
not enlarged. Diaphragm and sulci are intact.

Impression: suggest apicolordotic view. Pneumonitis, bilateral

ELECTROCARDIOGRAM

Interpretation: Sinus rhythm

Interventricular conduction

Old anterior wall injury

ULTRASOUND REPORT

Impression: - mild hepatomegaly

- Normal gallbladder & biliary tree
- Normal pancreas & spleen
- Diffuse renal parenatymal disease, bilateral
- Small renal calculi, right
- Renal cortical cyst, right
- Partially filled urinary bladder
- Minimal pleural effusion, right

Physiology (db schematic daw?)

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Respiratory System

 Primary function is to obtain oxygen for use by body's cells & eliminate carbon
dioxide that cells produce
 Includes respiratory airways leading into (& out of) lungs plus the lungs themselves
 Pathway of air: nasal cavities (or oral cavity) > pharynx > trachea > primary bronchi
(right & left) > secondary bronchi > tertiary bronchi > bronchioles > alveoli (site of
gas exchange)

Pathophysiology

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4
 Nursing Care Plan - Min. 5 interventions

ASSESSMENT: DIAGNOSIS: PLANNING: INTERVENTIONS: RATIONALE: EVALUATION:

Subjective: Ineffective
“Nahihirapan akong breathing pattern
huminga” as related to fatigue
verbalized by the
patient. Impaired gas
exchange related to
Objective:
- weak
- yellowish sclera
-

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 ASSESSMENT: DIAGNOSIS: PLANNING: INTERVENTIONS: RATIONALE: EVALUATION:

Subjective: STG: Independent:

“Hindi rin nga ako Activity Intolerance After 3 hours of >Establish rapport >to establish trust After 3 hours of nsg
nursing on the client and cooperation on interventions, the
masyado related to weakness interventions, the the client goal was met, the
makakilos.. at patient will use patient used
makapagsalita.. identified techniques >Provide health >to provide identified techniques
nahihirapan ako” as to enhance activity teaching on the adequate knowledge to enhance activity
tolerance. client regarding the on the client tolerance.
verbalized by the
organization and
patient. time management
technique to prevent
Objectives: while on activity
LTG: After 5 days of
- tired facial
After 5 days of >Develop and adjust >to monitor client’s
expression simple activity like nursing
nursing respond to activities
taking a bath interventions, the
- uncomfortable
interventions, the
- BP-100/50mmHg >Assist client with patient was able to
patient will progress >to prevent over
activity exertion progress to a much
to highest level of
>Promote comfort higher level of
mobility possible. >to protect client
measures on the mobility than before.
from injury
activity The goal was
partially met.

Drug Study

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 CONTRAINDICATIO NURSING
MEDICATION CLASSIFICATION INDICATION ADVERSE EFFECTS
N RESPONSIBILITY

Generic Name: Anti-anginal Angina pectoris Severe hypotension Hypotension, vertigo Keep life support
isosorbide and chest pain equipment readily
mononitrate (ISMN) available if overdose
occurs or cardiac
Brand name: condition worsens.
Imdur

Generic Name: Diuretics Hypertension Patients with fluid and Hyperkalemia, Monitor electrolyte
spironolactone electrolyte imbalances, headache, diarrhea levels, fluid intake
impaired renal and output and blood
Brand Name: function, or hepatic pressure.
Aldactone disease.
spironolactone 25mg
OD

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 Discharge Plan

Min. 5 intervention