NCM 112 CL CASE PRESENTATION

9/24/2021 10:00-2:00

CASE PROFILE

Mr. Jong is a 52-year-old white man who comes to the emergency department complaining of
shortness of breath. He has not seen a health care provider for many years.

SUBJECTIVE DATA
● Has a 38 pack-year history of cigarette smoking
● States that he has always been slender but has had 25-lb weight loss despite a normal
appetite in the past few months.
● Admits to a “smoker’s cough” for the past 2 to 3 years; recently coughing up blood, Is
married and the father of three adult children

OBJECTIVE DATA
Physical Examination
● Thin, pale man looking older than stated age
● Height 6 ft; weight 135 lb (61.2 kg)
● Intermittently confused and anxious with rapid shallow respirations
● Vital signs: temperature 102.6° F (39.2° C), heart rate 120, respiratory rate 36
● Chest wall has limited excursion on right side; auscultation of left side reveals coarse
crackles but clear with cough; right side has diminished breath sounds

DIAGNOSTIC STUDIES

Arterial blood gases: pH 7.21, PaO2 58 mm Hg, PaCO2 82 mm Hg, HCO3−

33 mEq/L, O2 saturation 84%
●
● Chest x-ray: consolidation of the right lung, especially in the base with possible mass in
the area of right bronchus; pleural effusion on the right side
● Bronchoscopy with biopsy of mass: small cell lung carcinoma

FIRST SCENE (school)

NARRATOR EJ: Before the start of their shift, the student nurses were gathered at the premises
of Brokenshire College along with their CIs -Mr. Jikiri and Mr. Lada. The CI started checking
their paraphernalia and after that, Mr. Jikiri called Miss Intao, a student nurse, to lead their
prayer.
JIKIRI: Okay, that’s it. Let’s start our day with a prayer. [pause] Miss Intao, please lead the
prayer.

INTAO: O divine healer, guide me to be the nurse I ought to be with great care and compassion
with gentle touch and affection and nurse those whom you entrust in me. If in the journey of my
profession I stumble, fall and wither., lift me, assist me, carry me and be my source of strength,
courage and divinity. Let every word, deed and thought be filled with patience, love and serenity.
Lead me to the way, O Lord, to the path now to selfishness but to generosity and that through me
may this calling be a vocation and an offering to you the great miracle worker. Amen.

SECOND SCENE (ER)

MIKA: Good morning po, I am Mikaela Nadine Montalbo, the nurse on duty here in the
emergency room po. Naunsa ta sir? And mangutana nalang pud ko sir ha kung unsa imong
pangalan ug naa ba kay kauban sir?

MARTIN: Bale ako diay si Paul Jong, kauban nako diri akong asawa na si Crea Jong (ubo ubo)
Nurse kanang (ubo ubo) tabangi ko, maglisod kog ginhawa, nurse. [insert lalom kaayog pag
ginhawa]

CREA: [worried] Ma’am tabangi mi ma’am, naga ubo na pud siyag dugo ma’am.

Martin: [Mag ubo ubo, kanang ubo jud sa masakiton master ha. Murag matangtang imong
lungs, ana na ubo] Ma’am, mao bitaw niadto nami diri kay naglisod na jud kog ginhawa [ubo
ubo, ginhawa na mura jud kag naglisod], ug nakabantay ko na sa akong pag ubo kay naa na diay
toy kasama na dugo. [Ubo ubo]

MIKA: Mangutana ko ma’am ha, bale pila na ni ka days ingani si sir, ma’am? sir, mag check
kog vital signs sir ha, ah adjust nako imong bed sir ha lingkod ta sir then isandal ra imong likod
sir okay very good sir.

CREA: [Worried jud kaayo] Nurse, bale 38 years na na siya naga panagarilyo, namayat pud na
siya ma’am mga 25lb ang nabawas saiyang timbang ma’am. Dugay naman na siya naga ubo jud,
dili man gusto nga mag adtog hospital o magpa check up man lang.

MIKA: okay ma’am, Relax ra ta sir ha, hinga lang ta. Tawagon sa nako ang resident physician,
sir

CREA: (yawyaw sa asawa) Mao na sige panigarilyo tan awa karon! Basin gi TB naka sa imong
kalaki! Unsaon nalang atong tulo ka anak ani?
MARTIN: UBO UBOOOO!

MIKA: Okay ma’am, sir, this is Doctor Salvana, our resident doctor po.

SALVANA: Hello Mr. and Mrs. Jong, I am Doctor John Salvana. Smoker ka sir for 38 years no?

MARTIN: Opo, doc. [ubo ubo]

SALVANA: Okay, paminawon nako ang tingog sa imong dughan sir ha. Ginhawag lalom sir
[ginhawa kuno martin], okay exhale sir. Ubo daw sir? [ubo ubo] Okay, sir Jong, upo
auscultation, the left side reveals coarse crackles but clear with cough ug ang right side kay naay
diminished breath sounds. Patan aw daw ko balik sa chart, Nurse Mika. Base diri sir ug sa akong
pag observe ug assess sa imoha kay need nato mag pa chest x-ray sir, aron mahibal-an nato kung
unsa jud ang problema, request pud ug bronchoscopy aron ma-sure lang nato kung naa pa bay
lain problema sa imong lungs. And Nurse Mika, pa request pud ko ABG. Palihog sad ko
administer ug oxygen therapy kay sir Jong, 2L per minute lang nurse. So for now ma’am and sir
pa admit jud ta ha aron ma bantayan natog maayo si sir.

MIKA: Noted and thank you po doc.

THIRD SCENE (WARD)

NARRATOR: Upon the arrival of the student nurses and their clinical instructors at the BIHMI,
they were introduced and endorsed to the newly admitted patient from the emergency room.

MIKA: (ENDORSEMENT TO NURSE ON DUTY IN THE WARD) Hello nurse aya bale mag
endorse kog patient gikan E.R, so Patient Mr. Jong, 52 years old, reason for admission was due
to pt’s complaint of shortness of breathing. He was admitted on September 23 2021, under the
care of Dr. John Salvana. Pt has no known allergies and latest vital signs are as follows:
temperature is 39.2° C, heart rate 120 bpm, respiratory rate 36 rpm, blood pressure is 150/100
Doc Salvana asked for a chest x-ray and ABG. Also, he ordered a bronchoscopy for the patient.
Pero off na ni Doc Salvana karon so Doc Sombong will take it from here, siya na ang magbasa sa
mga results mamaya. So yun lang nurse aya.

AYA: Thank you, Nurse Mika. So as you’ve heard and noted, ang atoang case for today kay si
Mr. Jong. We will continue the oxygen therapy that was administered in the ER and we will
follow up the results of the lab tests na giorder ni Doc Salvana.

LIAN: Good Morning Nurse Aya, these are my students who will be under your patient to
assess. Nurse Aya, pwede na ba kami pa endorse sa patient?
AYA: Ay okay po ma’am. Sure, so endorsing pt. Mr. Jong 52 years old, male, born on Sep. 27,
1969, chief complaint of persistent coughing and shortness of breathing, room number 105,
under Dr.sombong. Pt diagnose of pneumonia with cell lung cancer with given medication of
Azithromycin 500 mg P.O., bronchodilators patient diet (DAT) diet as tolerated. With IVF #1
D5W 1L @900cc infusing well at R metacarpal vein. Patient follow up result of Chest X-ray and
ABG. Input and output are monitored q shift. Vital sign taken Q2 and the Latest
vital sign taken: BP: 120/70 PR: 120 Respiratory rate:36 Temp: 39C. and O2 saturation of 84%.
so, ang pasyente bantayan jud nato in monitoring.

NARRATOR: A few minutes after that, the results of the lab tests came back [pwede ba yun
agad-agad? Hahaha di jud ko sure ani akong ginapangbutang diri]. The physician looked at it and
ordered some medications for the pt like bronchodilators; and azithromycin for the patient’s
pneumonia.

IMBOY: Okay, so kung ibase nato sa mga lab results, it coincides with the diagnosis of the
patient. Pero for further studies, we’ll still proceed with the bronchoscopy. For now, let’s give
the patient Bronchodilators 2.5 mg via inhalation 3 times a day, azithromycin 500 mg. Per orem
daily for 3 days[pls pakibutang sa route and dosage Martin hehe thanks!]

Bronchodilators 2.5 mg via inhalation 3 times a day

Azithromycin 500 mg, P.O. daily for 3 days

Acetaminophen 325 mg P.O. 6 hours daily

AYA: Copy, doc. Salamat po.

NARRATOR: At 7:30AM, Nurse Aya, along with the two CIs and the student nurses, did
rounds. They assessed the patient once again, monitored and checked the oxygen flow. Then at
8AM, the student nurses came back to take Mr. Jong’s vital signs and I&O.

INTAO: Good morning, Mr. Jong! I’m Marietes Intao, student nurse at Brokenshire College.

MIRAS: Hello sir! I’m Christel Miras, a student nurse from Brokenshire College po. Ug naa mi
diri para magkuha sa imong vital signs sama sa imong temperature, blood pressure, heart rate ug
respiratory rate, sir.
INTAO: Icheck pud namo ang imong Input and output sir.

MIRAS: Kumusta man ka, sir? Naglisod gihapon kag ginhawa?

MARTIN: Arang arang naman intawon [ubo ubo] pero gina ubo lang gihapon ko [ubo ubo]

INTAO: Unya sir, kinsa man imong bantay karon sir?

MARTIN: Akong asawa, namalit lang siya ug pamahaw namo [ubo ubo]

MIRAS: Naa pa kay laing gibati, sir? Basin kailangan nimog tabang, ingna lang mi sir.

MARTIN: Okay ra ko [ubo] arang arang na jud akong pamati.

NARRATOR: After monitoring the vital signs, checking the I&O and doing the bedside care,
the student nurses reported their findings and assessments to the nurse on duty and their clinical
instructors. Then at 9AM, student nurses are already preparing for their drug study for the 12
noon meds.

JIKIRI: Student nurses check your due meds, then present it to me before you administer?

Students: yes, sir.

Students mag present MARTIN DIRI GURO IBUTANG ANG DRUG STUDY??? TAMA
BA ATE AYA? KUNG KINSA MAN ASSIGNED DIRI, BASAHA LANG DRUG STUDY
ISEND NI MARTIN LATER yeah

At 10AM, the student nurses went to Mr. Jong's room once again.

MIRAS: Hello sir! Check lang nako ang IV Flow sir ha, thank you!
NARRATOR: It is now 11am and it is time for the student’s lunch break, before eating the
student nurses will endorse first the patient to their classmate

MIRAS: (ENDORSE YOUR PATIENT)

NARRATOR: Later that day, at 12 noon, the student nurses along with their clinical instructors
came back to Mr. Jong's room to administer oral medications.

INTAO: Good noon, sir Jong! Once again, I’m Marietes Intao and this is my partner, Ms.
Christel Miras naa mi diri para magskin test and to give you your 12 noon medications ug ang
una sir kay ang azithromycin It's widely used to treat chest infections such as pneumonia,
infections of the nose and throat such as sinus infection (sinusitis), skin infections, Lyme disease,
and some sexually transmitted infections.

MIRAS: Adjust sa nako ang IV flow sir ha

MARTIN: sige nurse

INTAO: Naa kay questions regarding sa imong tambal, sir?

MARTIN: Wala na, salamat kaayo

NARRATOR: At 12 NOON

INTAO: Good afternoon sir, I am Maritess Intao your student nurse for this afternoon, sir mag
kuha kog vital signs sir ha

MARTIN: okay nurse

INTAO: Bale imong bp sir kay (120/70) , imong temp kay 102.6 (39.2), imong respiratory rate
sir kay (_36__) ug imong pulse rate sir kay (100 ) normal ra imong BP sir, pero imong RR,
Tempt, ug Pulse Rate sir taas jud siya.

MIRAS: sir bale mag hatag kog tambal saimo sir ha ( MARTIN PAKI INSERT KO SA
TAMBAL DRI, KUG PARA ASA)

MARTIN: sige nurse inuman na nako na

MIRAS: sir balik lang mi unya sir ha, if naa moy kailangan ingon lang sa nurse station sir

INTAO: salamat sir

NARRATOR: At 1:00PM the student nurse continued their care to the patient and at 2:00 pm at
the patient’s room..

MIRAS: Hello sir good afternoon naka ihi or libang ta sir?

MARTIN: ( PAU PAKI CHECK IF NAKA IHI OR LIBANG BAKA SA CASE)

INTAO: sir mag hatag nasad ko tambal sir ha

MARTIN: okay nurse

MIRAS: sige sir salamat kaayo

NARRATOR:
MIRAS: (endorse your patient)

IMBOY: Hello Mr and Mrs jong, I am here to inform you that based on your bronchoscopy you
have a small cell lung carcinoma. And based on your chest x-ray it has consolidation of the right
lung, especially in the base with possible mass in the area of the right bronchus and pleural
effusion on the right side.

MARTIN: HILAK

LAST SCENE
DISCUSSION QUESTIONS

KHALIL: Okay student nurses, gather everyone. For your discussion question this is the first
question 1.How would you classify Mr. Jong`s pneumonia? Why is this important?

ONG: We classify this as bacterial pneumonia, it is the most commonly caused by Streptococcus
pneumoniae. But also we need to know the culture result to know what bacteria could have aused
this. The reason why we think it is a bacteria is because this type usually occurs when the body is
weakened in some way such as lung carcinoma and the patient will be at greater risk if they
smoke as well.

KHALIL: 2. What is your analysis of Mr. Jong’s arterial blood gas results?

ORTEGA: Respiratory alkalosis, because the pH is higher than 7.45 making it basic, the PaCO2
is lower than 35 making it also basic, and the HCO3 is 22 which is at the low end of the normal
which is 22-26.
KHALIL: 3. Priority decision: Based on the assessment data presented, what is the priority
nursing diagnosis? Are there any collaborative problems?

ERL:Nursing Diagnosis= impaired gas exchange, ineffective breathing patterns, and ineffective
airway clearance.
Problem=Patients O2 saturation is too low at 84%, but if we put him on too much O2 then his
body will not be able to expire the extra CO2.

LIAN: 4. Priority decision: What are the priority nursing interventions for Mr Jong’s?

RAIZZAH: Put a nasal cannula to the patient at 2L to increase his 02 saturation, but we don't
want to increase his O2 sat. too much because he seems to have a COPD because of his
increased RR and rapid shallow breathing. Next is if we increase his oxygen too much that he
will have a buildup of CO2 because he is unable to expire all of it currently so increasing his 02
would mean his body would have to work even harder to still blow off all of the CO2.

LIAN: 5. Evidence Based- practice: Mr Jong’s children tell you that they are worried they will
get lung cancer, since their father has it and they grew up around his secondhand smoke. They
want to know what kind of screening is available for them. How will you respond?

SALAIDE: We will get the resources needed and information available to them. We would also
comfort them, but be sure not to say “you are fine.”

LIAN: 6. What is the goal if radiation therapy is used for Mr. Jong?

SIACOR: To make sure he is on precautions because he will be immunocompromised so we

don't need him getting sick from this time. Patient and family teaching are very important about
good hygiene and to make sure he does not get sick from visitors or staff.

LIAN: Okay for the last question number 7. What issues should be addressed in your teaching of
Mr. Jong and his wife as you prepare him for discharge and care at home?

ERL: read doctors discharge and care notes to see what the doctor is planning on doing for
treatment. Patient teaching on not lying flat to help breathe easier, good hygiene to decrease risk
of illness for the patient since his immune is down, and different care strategies like home health,
comfort care, and other ideas to help the family and the patient feel more secure and not feel so
overwhelmed. Also, counseling could be a good idea because it was a lot of information to grasp
at one time for the family and for the patient.