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: Married Religion: Roman Catholic Nationality: Filipino Date of Admission: December 20, 2007 Time of Admission: 8:00 am Chief complaint: productive cough for 3 months, fever, body weakness and dyspnea for 3 days PTA Admitting Diagnosis: Dr. Jesper D. Bayaua MD Final Diagnosis: Chronic bronchitis secondary to chronic smoking Nursing History I. History of Present Illness The patient is known to be a chain smoker on their barangay. He usually consumes 2 packs of cigarette (Champion) everyday for the past 6 years. On this year, he usually experiences upper respiratory tract infection such as colds and cough occurring at least 5-8 times a year. He usually treats this condition using OTC drugs such as Neozep 1 tab TID and Robitussin 1 tbsp TID and the condition subsides. Until 3 months prior to admission the patient had experienced productive cough that persist for 3 months and not relieve by his neozep and robitussin. He also experienced body weakness and dyspnea 3 days PTA. Due to his condition he was rushed by his wife to Quezon City memorial hospital. He was seen and examined by the physician and CBC, urinalysis, ABG analysis, pulse oxymetry and chest X-ray was ordered. After physical and medical examination he was diagnosed as having chronic bronchitis. Past Medical History The patient had experienced measles, chicken pox and diphtheria during his childhood days and they are properly treated. The patient had experienced diarrhea, fever and headache usual medication taken by the patient were paracetamol 1 tab q 4h, Imodium 1 tab TID and diatabs 1 tab, taken until symptoms are gone No other illnesses noted to the patient Pedigree Patient X Mother
The patient weighs 55 kg (PTA) The patient usually drinks 7-8 glasses of water During Hospitalization The patient could not able to eat well. Fecal elimination Patient weight is 54 kg The patient drinks 5-6 glasses of water (1. vitamins and minerals are necessary for the body to prevent infection especially on the respiratory tract Dyspnea could able to make the patient resist food intake for patient’s energy is directed to increase O2 intake 2. Elimination pattern a. and consistency is formed The patient does not feel any discomfort during defecation Bowel movement is one vital assessment in order to monitor tissue perfusion on GIT (Kozier. he usually consumes 1 cup of rice.000 ml only) Abdominal girth of Abdominal girth is 28 inches (PTA) 27 inches The patient usually The patient could defecates once a not able to move day with stool color her bowel for the of golden yellow past 3 days. Upon meals. Fundamentals of Nursing) The patient could not able to move his bowel for 3 days due to decrease tissue . Nutrition Before Hospitalization The patient usually eats three times a day with food preferences of meat.Lolo Lola Lolo Lola Patient X Mother Fioning Charing Mojo = No genetic illness = HPN = Asthma Daily Activity Pattern Pattern of Functioning 1.. et al. Rationale Adequate nutrition. he usually consume ¼ of his meal (lugaw) due to DOB. chicken and vegetables.
Voiding pattern The patient usually urinates 6-7 times a day with urine characteristic of amber color and clear urine.380 packs of cigarette consumed for the The patient is instructed to stop smoking gradually (reduce 2-3 sticks per day) The patient takes the recommended drug regimen for the treatment of Exercise is an essential part of healthy lifestyle to prevent illnesses CBR is necessary to the patient to decrease O2 demand on the body Turning. deep breathing and coughing exercise and turning is initiated by the nurse Personal hygiene plays a role in transmission of microorganisms 4. The patient usually takes a bath every day and he usually shampoos his hair every day as well The patient usually sleeps at around 9pm and wakes up at 5 am with total sleep span of 8 hours The patient has no regular exercise pattern his usual form of exercise is walking from their house to his office. DBE and coughing exercise are necessary to facilitate mobilization and expectoration of bronchial secretion The primary cause of chronic bronchitis is the chronic cigarette smoking Smoking is so difficult to stop once becomes routine of one’s . Exercise 6. The patient experienced sleep disturbance with usual sleep span of 5-6 hours The patient is under CBR. Substance abuse The patient is known to be chain smoker. he usually consumes 2 packs of cigarette everyday for 6 years.oxygenation to intestinal cell caused by decrease peristalsis and also caused by dyspnea b. About 4. 3. every morning and afternoon Patient urinates 700-800 ml/day (usual intake of 2000-3000ml) Voiding pattern is essential in assessing fluid balance in the body and also in assessing renal tissue perfusion. Rest and Sleep Sleep disturbation experienced by the patient was caused by DOB 5. The patient does not experienced any pain and discomfort upon urination. passive exercise. Bathing The patient is cleansed and bathed with a wet towel by his wife on the bed. approximately 1 km distance. Personal Hygiene a.
Cognitive Pattern The patient is an Information Technology graduate from University of Santo Tomas. they usually go to KFC restaurant. Interactive Pattern The patient has good relationship to his family and officemate. C. Recreational pattern The usual form of recreation of the patient was smoking for he verbalizes that he feels relaxed everytime he smokes. He usually makes his officemate smile and laugh by his funny jokes every time he comes around their office. He usually makes sure that ever Sunday his family celebrates mass as one family. but advised by her family to follow what his physician had advised. the patient hangs out with his friends after working. . Sometimes. They said that their income sometimes not enough to support their family. He usually asks cigarette to his relatives. He verbalizes that he still can make decisions easily and decides for himself despite his condition. His wife is a public school teacher on Manuel Roxas National High School with usual earning of 5-6 thousand per month.past 6 years (Champion) The patient do not use any illegal/prohibited drugs The patient has no supplemental vitamins and minerals his condition life. Physiological Health Pattern A. Economic pattern The patient work as process server on Regional Trial Court of Metro Manila branch II. He believes that he will be cured from his disease. He said that smoking is a one form of his stress reliever. They usually smell the unpleasant odor from the factory. B. Their house is near the national highway where they were many buses and vehicles traveling. Due to hospital stay. he could not able to smoke inside the hospital and he was required by his physician to stop smoking. they spent their time chatting and smoking.000 a month. Their drinking water is purified water from Aqua Vida. C. He usually earns 6-7. so we must encourage gradual cessation of smoking Sociocultural Pattern A. Their water supply is enough to supply their daily water need. Environmental pattern The patient lives in Tondo Manila besides the two rubber factory (about 5 meters distance). Coping Pattern The patient views situations to his life positively. Their toilet facility is clean and comfortable (with flush and drainage tank). B.
. immediate and remote memory as evidence by. has productive cough (expectoration of at least 6-8 times a day). 2007) Vital signs BP: 130/80 PR: 98 bpm RR: 40 cpm Temp: 38. Patient is under oxygen therapy regulated at 2LPM Level of Consciousness The patient is oriented to time. the patient is observed to be weak. Anthropomimetric data Patient’s height: 5 feet. General Appearance Seen patient lying on bed. 2007) Patient’s abdominal girth: 28 inches (PTA) and 27 inches (December 21.0oC II. III. person and place and able to recall recent. with HOB elevated at 30 o and with IVF of D5LR at 600 ml regulated at 41 gtts/min. the patient could able to recall his breakfast. his birthdate and able to repeat information given by the examiner. 3 inches Patient’s weight: 55 kg (PTA) and 54 kg (December 21. 2007 Time: 8:00 am I.Physical Examination Date: December 21. IV. pale. and has difficulty of breathing.
symmetrical to the body Normocephalic Black. equally distributed EYES PERRLA White Both palpebral conjunctiva are pale upon inspection Equally distributed Equally distributed (+) dark circles below the lower eyelid EARS Able to recoil No discharge. with minimal cerumen (+) nasal flaring Intact MOUTH (+) purse lip breathing Interpretation Normal Normal Normal Normal Normal Due to ↓ tissue oxygenation secondary to inflammation of bronchi Normal Normal Due to sleep pattern disturbance caused by dyspnea Normal Normal Body’s mechanism to increase tissue oxygenation Normal Body’s mechanism to increase tissue oxygenation Pinna Internal canal Nose Nasal septum Lips Palpation Inspection Inspection Inspection Inspection both upper and lower lips are pale and dry Due to ↓ tissue oxygenation secondary to inflammation of the bronchi (+) cyanosis around the lips Teeth Gums Neck Inspection Inspection Inspection (+) Tartar (+) dark discoloration on the gum line Symmetrical to the body No palpable mass (+) rapid and shallow breathing (RR: 40 cpm) (+) Chest indrawing Chest size and Due to prolonged oxygen deprivation on tissue caused by inflammation of bronchi Due to chronic use of cigarette Due to chronic use of cigarette Normal Chest Palpation Inspection Normal Barrel chest due to .Body Part Head Method Used Inspection Skull Hair Palpation Inspection Pupil Sclera Conjunctiva Inspection Inspection Inspection Eyelashes Eyebrows Eyelids Inspection Inspection Inspections Findings No lesions.
Due to accumulation of phlegm on the upper lung lobe Auscultation Due to accumulation of phlegm in the lower lung lobe Percussion Due to accumulation of air on the lung caused by obstructed bronchi Abdomen Inspection Normal Due to decrease tissue oxygenation caused by inflammation of bronchi Normal Palpation (-) tenderness all over the quadrant of abdomen (-) palpable mass. Abdominal size and shape is symmetrical to the body Abdominal skin is observed to be pale increased retained air on the lung causing expansion of rib cage. nodules and lesions (+) Borborygmi sound bowel sound of 1 every minute Normal Auscultation Normal Due to decrease tissue oxygenation of GIT caused by inflamed bronchi Normal Percussion (+) drum like sound on epigastric area (+) flat sound upon percossion of RUQ of abdomen (+) nail clubbing (angle between nail bed and root is 200o (+) pale skin Normal Lower and Upper Extremities Inspection Due to prolonged oxygen deprivation Due to decrease tissue .shape is longer and larger and unsymmetrical than the abdominal size Palpation (+) fremitus upon speaking on left and right lobe of the lung (+) Rales/ crackles upon auscultation of all over the left and right lobe of lungs (+) hyperresonance upon percussion of both upper and lower of the right and left lung lobe.
or bridge of the nose. brachial artery and femoral artery is the common site for withdrawal of blood specimen (10 ml) Avoid air on syringe and should be heparinized to prevent blood clot 2. CBC (December 20. 85% indicates tissues are not receiving enough oxygen Laboratory Results I.000/mm3 Interpretation Normal Leukocytosis due to underlying bacterial infection Normal Normal Normal Platelet Hct Hgb 150-350. earlobe. forehead. 2007) Parameters RBC WBC Normal Values 5-7 mil/mm3 5-10. Pulse Oximetry Non invasive method of continuously monitoring the oxygen saturation of hemoglobin Although pulse oximetry does not replace arterial blood gas measurement. 000/mm3 32-42% 8. Arterial Blood Gas Analysis Measurements of blood pH and of arterial oxygen and carbon dioxide tensions are obtains when managing patients with respiratory problems and in adjusting oxygen therapy as needed.oxygenation caused by inflammation of the bronchi (+) bluish discoloration of nail bed (cyanosis) Due to prolonged O2 deprivation on tissue caused by inflammation of bronchi Due to decrease tissue oxygenation caused by inflammation of the bronchi Normal Palpation (+) Cold and clammy skin Capillary of 3 seconds Diagnostic Tests 1.000/mm3 33 9 mmol/L . Comprises of PaO2 and PaCO2 PaO2 indicates degree of oxygenation of the blood and PaCO2 indicates the adequacy of alveolar ventilation Radial artery. it is an effective tool to monitor for subtle or sudden changes in oxygen saturation A probe/sensor is attached to fingertip.2 mmol/L 300.1-11. The sensor detects changes in oxygen saturation levels by monitoring light signals Normal SaO2 is 95%-100%. 000/mm3 Result 6 mil/mm3 13.
Pulse Oximetry Normal Value Result Interpretation Due to decrease availability of oxygen caused by decrease O2 intake secondary to inflammation of bronchi Oxygen Saturation 95-100% 83% VI.5 – 5 mEq/L 135-145 mEq/L PO2 PCO2 Normal Value 80-100 mmHg 35-45 mmHg Result 60 mmHg 55 mmHg Impression: Respiratory acidosis Hypoxemia and hypercopnea V.005 – 1.200 ml Result 1.300 ml 2.600 ml 3. 2007) Normal Result Yellow .400 ml Vital Capacity 4. Urinalysis (December 20. Blood Chemistry (December 20.030 5.015 7 Negative Negative Interpretation Normal Normal Normal Normal Normal Parameters Color Specific Gravity PH Glucose Protein III.II. 2007) Normal Result Actual Result 35 g/L 70 g/L 4 mEq/L 140 mEq/L Interpretation Normal Normal Normal Normal Serum albumin Serum protein Serum K Serum Na IV.900 ml Functional Residual Capacity 2.0 Negative Negative Actual Result Straw colored urine 1. ABG analysis 35-50 g/L 60-84 g/L 3.straw 1.800 ml Interpretation Due to increase air remaining on the lungs after maximum exhalation caused by obstruction on bronchi Due to decrease air exhaled caused by obstructed bronchi Due to increase air remains on lung after normal expiration caused by .0 – 8. Pulmonary Function Test Normal Value Residual Volume 1.
Total Lung Capacity 5. jogging.500 ml obstruction on bronchi Due to increase air in the lung after a maximum expiration caused by obstructed bronchi Discharge Plan Medication Exercise Instruct patient about DBE Instruct patient about coughing exercise Any tolerable exercise (Walking.800 ml 6. RM Clinical Instructor. etc) Health Teaching Instruct patient to avoid cigarette smoking gradually (at least2-3 sticks per day) and provide health teaching regarding effect cigarette smoking to ones health Instruct patient about the importance of adherence to medication Instruct patient about importance of follow up care OPD For weekly check up For nebulization every other day Diet Instruct patient to increase fluid intake (2-3 L/day) Diet as tolerated by the patient Mucolytic ( Ambroxol 1 tab BID) Ceftriaxone 500 mg PO q 12h Bronchodilator (Atropine Sulfate 12. College of Nursing University Of La Salette Health Assessment Summer 2011 .5 mg IV q6) Hydrocortisone 50 mg IV OD Prepared By: JESPER DOMINCIL-BAYAUA RN. aerobic.
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