COLEGIO SAN AGUSTIN BACOLOD

COLLEGE OF HEALTH AND ALLIED PROFESSIONS

NURSING PROGRAM
B.S. Aquino Drive, Bacolod City
Contact Number: (034) 434 – 24 71 Local 162
Email Address: csab.chap@gmail.com

PROBLEM BASED-LEARNING WRITTEN REQUIREMENT

1ST SEMESTER AY 2020 – 2021

LEVEL:
GROUP #:
AREA OF ROTATION: DATE:
SUMMARY/OVERVIEW OF THE CASE:

Name: Mr. Cohen

Address:
Age: 75
Ethnicity: Jewish American
Spiritual/religious affiliation: Judaism
Civil status: Married
Occupation:
Admission: November 7, 2020
Time: 7:00 am
Admitting diagnosis:
Chief Complaint: DOB
Attending physician: Dr. XX

I. Patient’s Assessment
Patient History DATE/TIME
Pre-existing Condition
 The patient has a long-standing history of
COPD secondary to chronic tobacco use.
 Tobacco smoker for 25 years
 Diagnosed with emphysema 5 years ago
 Hypertension
Coexisting Condition:
 Lower back pain
Family History:
 Family history revealed that both parents had
been smokers and the patient’s father have
asthma since in his childhood; the patient’s
mother died of lung cancer at the age of 64.
 Cultural/Spiritual perception:
 According to the patient, there are no practices
that affect his hospitalization when it comes to pain
management. He follows therapeutic regimen and
has strong faith in YHWH accounts for his fast
progress.
 As discussed about Cultural/spiritual
perceptions of pain and pain management pain
relief by analgesic, including morphine, to prevent
suffering is allowed and recommended, even if it
hastens death, since actions are judged by their
intention.
 In Judaism, they belief that death is evil, dovetails
with many Jews' desire to “do everything” to try for
a cure. Even if the goal is not a cure, one common
approach is to do whatever is possible to extend
life, since one moment of life in this world is more
valuable than the entire world to come.
Subjective Data/s:  “I cannot walk without assistance”
 “I cannot breathe properly without oxygen support”
 “My lower back is aching, and it is so
uncomfortable while walking to the bathroom.”
 “The pain is like a dull ache with the pain scale of 6
out of 10”
 “The Percocet tablets has helped relieved my back
pain with the pain scale of 2 out of 10”

 Needs assistance of one person while ambulating

Objective Data/s: due to unsteady gait and dyspnea on exertion
 Weakness and fatigue
 Inability to perform ADL’s
 oxygen saturation at rest of 90% to 94% on 2 litres
of oxygen by nasal cannula

I.Head
Physical  Face
Assessment - With wrinkles, symmetrical. With expression of
pain and anxiety
 Lips
– pale, crack and dry lips
 Throat
- No inflammation, Presences of cough with
greenish yellow phlegm and experiencing
 difficulty in swallowing
- Excessive mucus production in his lower lung
due to impaired defense mechanisms caused
by prolonged years of smoking.
II.Thorax
 Breathing
- Respiratory distress noted
- His lung sounds are clear but diminished
bilaterally
- Expiratory wheezes are heard bilaterally
III.Limbs
 Hands
- pale nail beds with capillary refill of 4 seconds
- and slight clubbing of his fingers noted

Diagnostic Studies Pulmonary examination:

and Procedures  Bilateral breath sounds were audible with a few
expiratory wheezes at the Lung bases; there were
no rales.

Chest x-rays:
 Revealed very prominent bronchial markings
consistent with chronic bronchitis and possibly
bronchiectasis; no acute infiltrates were identified.

Pulmonary function tests:

 Grade II COPD, moderate severity and pulmonary
function of FEV1/FEV <70%,
FEV1 50-80% predicted
09/11/20
After Vital signs:
breakfast  BP: 150/78
9:00 am  Pulse 90
 RR:26

Oxygen saturation test:

9:45 am  92% at rest
10:00 am  86% after walking 60 ft
10:10 am  91% after few deep breaths and rest
10:25 am  87% when he return to his room
10:40 am  91% after few minutes of rest
11:50 am  93% at rest
II. Pathophysiologic Basis: Illustrates: Definition, Concept of the disease/procedure, Etiology,
Pathophysiological Information

III. Analysis/Nursing Diagnosis: Formulation of Nursing Diagnosis based on the Information

gathered
IV. Nursing Therapeutic Plan Development and Implementation of Care

NURSING THERAPEUTIC PLAN IMPLEMENTATION OF CARE

A. Plan for Health Promotion A. Independent Nursing Care

A.1 Physiologic A.1. Physiologic Care

A.2. Psychosocial A.2. Psychosocial Care

A.3 Spiritual A.3 Spiritual Care

B. Plan for Health Restoration and B. Interdependent Care

Maintenance B.1. Pharmacologic
B.1 Pharmacologic

B.2 Nutrition and Diet B.2. Nutrition and Diet

B.3. Surgical Intervention B.3 Surgical Intervention

V. Evaluation of the presented plan of Care

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