CHAPTER 1 - ASSESSMENT

A. NURSING HEALTH HISTORY

ADULT HISTORY
1.1 PERSONAL DATA

Name: Mr. ASI

Age: 54 years old
Birthdate: November 1, 1968
Sex: Male
Address: Sable street Concepcion Dos, Marikina City
Citizenship: Filipino
Marital Status: Married to Mrs. JQI
Occupation: Unemployed
Religion: Roman Catholic
Family Members:
Wife: Mrs. JQI - 56 years old
Daughter: Ms. AQI - 23 years old
Mother: Mrs. A.I - 83 years old
Attending Physician: Dr. Vesalto
1.2. CHIEF COMPLAINT:
A 54 year old man was admitted to Amang Rodriguez Memorial Medical Center last April 14, 2023, due to his incidental findings of
community-acquired pneumonia and his rehabilitation that was advised by his Doctor. Due to his corresponding strokes, he had a
history of 4 strokes during the years of 2011, 2013, 2017, and 2021. He has presence of edema on the leg and coughing.

1.3. HISTORY OF PRESENT ILLNESS:

Patient ASI was admitted to Amang Rodriguez Memorial Medical Center last April 14, 2023. He was received with NGT, level 2 of
bed sore, and vital signs were taken that is noted by the PT with a known case of Community Acquired Pneumonia and
Cerebrovasculat Accident. The patient’s physician recommended the removal of nasogastric tube and for the replacement of
gastrotomy tube insertion. As an observation the patient would feel any pain because of the medication administration nevertheless the
patient doesn’t have any major pain. Furthermore, the wife stated that the patient acquired the pneumonia because of his lack of
activity, and prolonged bed rest. Based on observation and his wife stated that he has difficulty in swallowing and has slurred speech,
he also has difficulty in walking, and a grade 2 bed sore. According to his wife the patient has prescribed medications due to his latest
confinement; Vitamin C, Paracetamol, Vitamin K, Ferrous Sulfate Diphenhydramine, and Omeprazole.

1.4. PAST MEDICAL HISTORY

As stated by his wife, the mother side of the patient had a history of strokes and hypertension. Furthermore, patient ASI had a history
of 4 corresponding strokes in the years of 2011, 2013, 2017 and 2021. In the year 2021, the patient underwent an NGT insertion and in
the year 2016, the patient acquired a case of pulmonary tubercolosis. In addition, there are no major surgeries done in his past medical
history. As for injuries, the wife stated that the patient experienced an injury due to his fall on the ground and had cuts on his forehead.
As per allergies, the patient has allergies in seafoods, which caused him a swollen eyes, and swelling of face. The patient underwent
some diagnostic test which are: Chest X-ray, 2-D Echochardiogram, Electrocardiogram, CT scan, Blood tests, and Urinalysis. The
attending physician prescribed patient ASI with this medications prior to his first episode of stroke: Amlodipine, Atorvastatin,
Coticoline, Doxepin, Carvedilol, and Flemisten.

1.5. GORDON’S FUNCTIONAL HEALTH PATTERNS

 AREA BEFORE DURING ANALYSIS Reference
AND
INTERPRETA
TION

Health Prior to getting admitted Mr. ASI and his According to Oche, M.,
Perception and patient Mr. ASI wasn’t wife are eagerly Oche, M. and & Adamu,
Health unable to speak due to his waiting for his Adamu, H. H. (2013,
Management condition so his NGT to be (2013) Patients October).
representative is his wife. removed who are waiting Determinants of
His wife stated that her because they are unnecessarily patient waiting
husband, patient ASI already waiting can be a cause of time in the
underwent 4 corresponding for about 2 stress for both General
strokes that happened last weeks now for Doctor and Outpatient
2011, 2013, 2017, and his husband’s patient which Department of a
2021. The patient’s clearance in can be a barrier tertiary health
physician advised that his order to proceed to perceive a institution in
NGT must be removed and the removal of long waiting North Western
be replaced by gastrotomy. his NGT. time. According Nigeria. Annals
to Oche, M. and of medical and
. Adamu, H. health sciences
(2013) 61% of research.
the respondents Retrieved April
waited for about 30, 2023, from
90-180 minutes https://www.ncbi
in the hospital, .nlm.nih.gov/pm
whereas the c/articles/PMC3
patients spent 868129/
less than 5
minutes with the
doctor in a
consulting room
is at 36.1%. The
 common reason
why patients
waited that long
is because of the
large number of
patients with
few healthcare
workers.

SAFETY AND Based on observation, Based on Make sure that Department of

SECURITY patient ASI does feel safe observation, the patient is Health &
from his environment, but patient ASI does getting the right Human Services.
still he is in the hospital and feel safe from treatment, (2015, October
there is a virus that is still his environment, prevent them 12). Security and
ongoing. but still he is in from having an safety at
the hospital and infections, and hospital. Better
there is a virus to give the right Health Channel.
that is still medications. Retrieved April
ongoing. Also hospitals 30, 2023, from
should use a https://www.bett
range of security erhealth.vic.gov.
measures, which au/health/service
includes the use sandsupport/sec
of CCTVs, urity-and-safety-
emergency at-hospital
alarms for staff
members and for
the patients,
lastly hospitals
should have a
security staff
that have a quick
response once
 there is an
emergency
(Department of
Health &
Human Services,
2015).

OXYGENATIO Patient ASI have difficulty According to his Our body needs Why is oxygen
N in breathing. He coughed records that enough oxygen important to the
with sputum that was noted patient was in order to keep body?: Socratic.
in his records and he was removed of it saturated Socratic.org.
prescribed to have an oxygen mask within the blood. (2016, January
oxygen mask. and doesn’t have In order to 19). Retrieved
difficulty in function April 30, 2023,
breathing based properly we from
on the need to make https://socratic.o
intervention. sure that our rg/questions/why
tissues is getting -is-oxygen-impo
enough oxygen. rtant-to-the-body

According to the patient’s According to the It helps their

NUTRITION wife, patient ASI is taking a patient’s wife, anabolism and
AND liquid diet, and his foods patient ASI is can control
METABOLISM are osterized foods as per taking a liquid catabolism to
the doctors diet, and his maintain its
recommendation. foods are proper immune
osterized foods system.
as per the
doctors
recommendation
.
 Patient ASI urinates According to As a student Tips on helping
ELIMINATION through his drainage bag patient’s wife, nurse, it is a person in
and has light yellow color patient ASI important to our elimination.
or urine. Patient ASI defecates daily role in observing (n.d.). Retrieved
doesn't have any problems and through his and recording May 1, 2023,
in defecating. He defecates diaper without the quantity and from
daily without any any discomfort quality of the http://www.healt
discomfort, and he voids in or pain. His patient’s body hnetcafe.com/co
his diaper. urine output are waste, and we ntent/day-to-day
normal and it is must be aware of _care/general/eli
light yellow a normal mination.html
color. physiology of
elimination
process.

According to the patient’s Patient ASI is in When people are Patient

SLEEP AND wife, patient ASI has the hospital and ill they education |
REST enough sleep of 8 hours or sometimes his experience Information
more, and during the sleeping patterns difficulty in Series -
afternoon he also do were disturbed sleeping. In American
nappings. because of the addition, Thoracic
noise and some hospitals are Society. (n.d.).
nurses are very busy in Retrieved April
roundings for stimulating the 30, 2023, from
vital signs. place. They said https://www.thor
that the more acic.org/patients/
older and sicker patient-resources
you are, it is /resources/hospit
more likely to alization-and-sle
have a poor ep.pdf
sleeping pattern,
it can affect on
how well you
 will recover and
sometimes it can
lead to a health
issue.

B. PHYSICAL ASSESSMENT

GENERAL APPEARANCE: Patient ASI has a small body build, he is in a upright position; relaxed, he has no body odor and
always clean, and patient ASI is appropriately dressed.

MENTAL STATUS: Patient ASI is conscious, he knows what time, and place he is in, and he knows who is the person right infront
of him. Whenever patient ASI’s wife asked him questions he cooperatively nod if it is a yes and make sounds if he doesn’t like it.

SKIN: Patient ASI has a light skin color, with a normal range of temperature after his febrile episode.. Grade 2 bed sores and ulcers
have observed, and the patient has edema on his left leg.

NAILS: Patient ASI has a 160 convex nail shape. His nail has a pale color with capillary refill is within 3 seconds.

HEAD and FACE: Patient ASI face is asymmetrical and has difficulties in moving, the skull is proportionate to his body size, hair
condition is still thick, and the scalp was not assessed.

EYES: Not Assessed

EARS: Not Assessed

NOSE: Not Assessed

MOUTH: Not Assessed

PHARYNX: Not Assessed

NECK: Not Assessed

BREAST AND AXILLA: Not Assessed

CHEST and LUNGS: The chest is symmetric. There are no tenderness or any bulges. The patient has a history of using an oxygen
mask prior to checking, crackles that were heard upon auscultation.

ABDOMEN: Upon assessment, the palpation of the abdomen is tender, it has a normal racial tone, the abdomen is flat, has
symmetrical movement, has bot rashes and ulcers on the sides. The bladder and liver was not assessed.

UPPER and LOWER EXTREMITIES: Patient ASI’s left arm is normal but his right arm was swelling due to his stroke according
to his wife. There are no apparent bone deformities in his lower extremities.

C. DIAGNOSTIC PROCEDURE:

1. Name of the diagnostic Procedure: Urinalysis

Definition/Description: is used to detect and treat a wide range of conditions, including urinary tract infections, kidney disease, and
diabetes. Identifying the appearance, concentration, and content are all examined. A urinary tract infection, for example, can cause
urine to appear hazy rather than clear. Protein levels in the urine can indicate renal dysfunction.

Nursing Considerations:

● Instruct the patient to void directly into a clean, dry container.

● Cover all specimens tightly, label properly and send immediately to the laboratory.
● If a urine sample is obtained from an indwelling catheter, it may be necessary to clamp the catheter for about 15-30 minutes
before obtaining the sample.
● Observe standard precautions when handling urine specimens.
● If the specimen cannot be delivered to the laboratory or tested within an hour, it should be refrigerated.

Name of the procedure Date ordered Normal values (based Values obtained (results Clinical interpretation
on standards of the of the test )
hospital)

Urinalysis April 14, 2023

53.0 – 114.9 umol/L
 2.1 – 7.1 mmol/L

136 – 145 mmol/L

3.5 – 5.1 mmol/L

97 – 111 mmol/L

*No reference range for

RBS*

URINALYSIS - 4/14/2023

I. PHYSICAL EXAMINATION:
Color: Yellow
Transparency: Slightly turbid
Specific Gravity: 1.015 Alkaline
 II. CHEMICAL EXAMINATION:
Reaction:Alkaline
Glucose: Negative
Protein: Negative
Ketones: Negative
Urobilinogen: Normal
Nitrate: Negative
Erythrocytes: Negative
Ascorbic Acid: Negative
Leukocyte: Negative

I. MICROSCOPIC EXAMINATION:
Cells: Reference Value
WBC(microscopic) 5/hpf 0-3
21.93/ul 0-17

Pus Cells: 0-1/hpf

RBC: 0-1/hpf
Epithelial Cells: few
Bacteria: rare
Hyaline cast: 0-1/hpf

2. Name of the diagnostic Procedure: Chest Xray

Definition/Description: An x-ray of the structures inside the chest. An x-ray is a type of high-energy radiation that can go through the
body and onto film, making pictures of areas inside the chest, which can be used to diagnose disease.

Nursing Considerations:
 ● Remove all metallic objects. Items such as jewelry, pins, buttons etc can hinder the visualization of the chest.
● No preparation is required. Fasting or medication restriction is not needed unless directed by the health care provider.
● Ensure the patient is not pregnant or suspected to be pregnant. X-rays are usually not recommended for pregnant women unless
the benefit outweighs the risk of damage to the mother and fetus.
● Assess the patient’s ability to hold his or her breath. Holding one’s breath after inhaling enables the lungs and heart to be seen
more clearly in the x-ray.
● Provide appropriate clothing. Patients are instructed to remove clothing from the waist up and put on an X-ray gown to wear
during the procedure.
● Instruct patient to cooperate during the procedure. The patient is asked to remain still because any movement will affect the
clarity of the image.

Name of the Date ordered Normal values Values obtained Clinical interpretation
procedure (based on standards (results of the test )
of the hospital)

Chest Xray April 22, 90 kV and 1.4 mAs shows clearing noted
2023 pneumonic densities in
right lower lobe, for
follow up expiratory
radiograph, normal
pulmonary ranking, heart
remains magnified,
diaphragm and sulci
intact, visualized osseous
are unremarkable.
3. Name of the diagnostic Procedure: Complete Blood Count

Definition/Description: A typical blood test that is often included in a normal visit is a complete blood count. Complete blood counts
can be used to identify a number of conditions, such as infections, anemia, immune system diseases, and blood cancers.

Nursing Considerations:

● Explain test procedure. Explain that slight discomfort may be felt when the skin is punctured.
● Encourage to avoid stress if possible because altered physiologic status influences and changes normal hematologic values.
● Explain that fasting is not necessary. However, fatty meals may alter some test results as a result of lipidemia.
● Apply manual pressure and dressings over puncture site on removal of dinner.
● Monitor the puncture site for oozing or hematoma formation.
● Instruct to resume normal activities and diet.

Name of the Date ordered Normal values Values obtained Clinical

procedure (based on standards (results of the interpretation
of the hospital) test )

CBC April 14, WBC 5-10 5.44

2023 RBC 4.6 -6.2 4.33
HGB 14.0-18.0 13.0 RBC, HGB,
Hematocrit Hematocrit,
40.0-54.0 39.0 Segmenters,
Mcv 80.0-100 87.7 Lymphocytes,
Mch 27.0-32.0 30.0 Monicyte, and
Mchc 32.0-36.0 34.3 Eosinophil are in
Platelet 150-450 248 below range of
Segmenters normal values.
150-450 79.6
 Lymphocytes
20-40 18.3
Monocyte 2.0-8.0 1.4
Eosinophil 1.0-6.0 0.7

4. Name of the diagnostic Procedure: HGT Hemo Glucose Test

Definition/Description: A technique for determining the blood's glucose level is blood glucose monitoring. Using a reagent strip
(such as Glucostix), tests are carried out quickly and simply by taking a tiny drop of capillary blood from the client's fingertip, toe,
earlobe, or heel. This test may be carried out anywhere, including at home, the office, hospitals, clinics, and even while traveling,
provided the patient has all the necessary equipment.

Nursing Considerations:

● Watch out for signs of morning hyperglycemia.

● Report BP of more than 160 mm Hg (systolic). Administer hypertensive as prescribed.
● Instruct the patient on the proper storage of insulin.
● Educate the patient on maintaining consistency in food and the approximate time intervals between meals.
● Educate the patient about the health benefits and importance of exercise in the management of diabetes.

Name of the Date ordered Normal values Values obtained Clinical

procedure (based on standards (results of the interpretation
of the hospital) test )

Hgt April 14, 0-50 years - < 140 119 mg/dl

2023 mg/dL or < 7.8 98 mg/dl
mmol/L (SI units)
 50-60 years - < 150 99 mg/dl
April 15, mg/dL. 60 years 97 mg/dl
2023 and older - < 160 109 mg/dl
mg/dL.

All of the values

April 16, 80 mg/dl obtained are in
2023 85 mg/dl normal range.
86 mg/dl
119 mg/dl

April 19,
2023
124 mg/dl
113 mg/cl
April 20,
2023

109 mg/dl
105 mg/dl
117 mg dl

5. Name of the diagnostic Procedure: Hepatobiliary Tract Ultrasound

Definition/Description: Acute cholecystitis, a bile duct blockage, problems after gallbladder surgery, or the monitoring of a liver
transplant are all diagnosed with this method. To assess gallbladder dysfunction, hepatobiliary scan may also be performed.

Nursing Considerations:
 ● Intervene to relive pain; give prescribed analgesics
● Promote adequate rest
● Administer IV fluids, monitor intake and output
● Monitor nasogastric tube and suctioning
● Administer antibiotics if prescribed.

Name of the Date ordered Normal values Values obtained Clinical interpretation
procedure (based on (results of the test )
standards of the
hospital)

Hepatobiliary April 18, HBT ( Liver, Liver is not enlarged, Incidental finding of Renal
ultrasound 2023 Gallbladder, there is a round parenchymal disease
Biliary Tree) anechoic cystic focus
with septations and Impression:
calcifications in
segments of the right Complex hepatic cyst
lobe. Focus is seen in segment V
segment 2 of the left
lobe 0.6cm x 0.6cm x Simple hepatic cyst
0.6cm. The intra segment 2
hepatic duct is not
dilated, common bile Contracted Gallbladder
duct 0.1cm , portal Ascites
vein and tributaries
are unremarkable. Unremarkable sonogram
Gallbladder is of bile ducts and pancreas
contracted measuring
0.7cm in the widest
centimeter. Pancreas
shows a homogeneous
 parenchymal echo
pattern, and the
pancreatic duct is not
dilated . Anechoic
fluid is seen in the
right/left quadrant of
the abdomen.

6. Name of the diagnostic Procedure: Hematology

Definition/Description: The study of blood and blood diseases is known as hematology. Healthcare professionals with advanced
training in blood and blood component illnesses include hematologists and hematopathologists. They consist of bone marrow and
blood cells.

Nursing Considerations:

Name of the Date Normal values Values obtained Clinical interpretation

procedure ordered (based on (results of the test )
standards of the
hospital)

Hematology April 25,

2023 Protime 10.5-13.5 Pt 12.1 seconds
sec Percent Act 80.8%
INR 1.03
Control 12.9 The values obtained is
seconds normal.
 Aptt 25-44 sec
Pt 32.0
Control 27.7

7. Name of the diagnostic Procedure: Liver Function Panel

Definition/Description: Blood tests called liver function tests, commonly referred to as liver panels, examine several enzymes,
proteins, and other chemicals produced by the liver. These tests examine your liver's overall condition. Frequently, multiple substances
are tested simultaneously on a single blood sample.

Nursing Considerations:

● Supporting body systems

● Managing signs and symptoms of decreased liver function
● Avoiding worsening cerebral edema
● Monitor level of consciousness, blood pressure, volume status, blood and coagulation tests

Name of the Date ordered Normal values Values obtained Clinical interpretation
procedure (based on standards (results of the test )
of the hospital)

Liver Function April 25,

Panel 2023 SGOT/AST
5-34 u/L 162.50 High
 SGPT/ALT
0-55 u/L 292.47 High

Alkaline
Phosphatase
40-150 u/L 235.32 High

Total Bilirubin
3.4-20.5 umol/L 30.56 High

Direct Bilirubin
0.0-8.6 umol/L 15.07 High

Indirect Bilirubin
5.13 -15.39 umol/L 15.49 High

HBsag Non Reactive

Anti HCv Non Reactive

Blood Type Blood Type O Rh+

8. Name of the diagnostic Procedure: Sars cov 2 Rt-Pcr

Definition/Description: The COVID-19 virus, which is a respiratory illness. The coronaviruses are a broad family of viruses that
includes the SARS-CoV-2. Both humans and certain animals may get these viruses. In 2019, SARS-CoV-2 was first identified as a
human pathogen. The virus is believed to be transmitted from person to person by droplets expelled when coughing, sneezing, or
talking by an infected person. A less prevalent method of transmission is through contacting one's mouth, nose, or eyes after touching
a surface that has the virus on it.
Nursing Considerations:

● Monitor vital signs

● Monitor O2 saturation
● Manage fever
● Maintain respiratory isolation
● Enforce strict hand hygiene
● Provide information

Name of the Date Normal values Values obtained Clinical interpretation

procedure ordered (based on (results of the test )
standards of the
hospital)

Hematology April 14, Not Detected- Negative

2023 - Dr. Romeo
Villarojas Belleza

D. ANATOMY AND PHYSIOLOGY

Organs/ body parts involved - short description ex. Ribs, heart,vertebrae etc.

RIBS - The ribs are the bony framework of the thoracic cavity

HEART - Blood is pumped through your body by the heart, an organ roughly the size of your fist.

VERTEBRAE -The cervical spine is a kind of vertebra in the spine. Discs are present between each vertebra. The spinal cord is
encircled by the vertebrae and thus shielded.

LUNGS - a set of organs in the chest that remove carbon dioxide from the organism and provide oxygen to it.

E. PATHOPHYSIOLOGY/ DISEASE PROCESS

Figure from: Pathophysiology of Pneumonia https://www.rnceus.com/pneumo/patho_pneumonia.html
REFERENCE:

Pathophysiology of pneumonia. (n.d.). Www.rnceus.com. https://www.rnceus.com/pneumo/patho_pneumonia.html

Community Acquired Pneumonia - A major factor in hospital admissions, death, and high medical expenses is community-acquired
pneumonia. Determining the appropriate level of care is crucial for improving outcomes in addition to early diagnosis and appropriate
and timely treatment because disease presentation can range from a mild illness that can be managed as an outpatient to a severe
illness that requires treatment in the intensive care unit.Pneumonia acquired outside of a hospital is referred to as community-acquired
pneumonia. Streptococcus pneumoniae, Haemophilus influenzae, atypical bacteria (such as Chlamydia pneumoniae, Mycoplasma
pneumoniae, and Legionella species), and viruses are the most often found pathogens.

Risk Factors:

- Age
- Smoking
- Exposure to the environment
- Malnourishment, prior CAP
- Chronic bronchitis/chronic obstructive pulmonary disease
- Asthma
- Functional impairment

Manifestation:

- Productive Cough,
- Hypoxemia
- Dyspnea
- Crackles
- Pleuritic chest pain

CHAPTER 2: NURSING CARE PLAN

A. LIST OF PRIORITIZE NURSING DIAGNOSIS

RA PROBLEM CUES JUSTIFICATION

NK

1 Franz Subjective: as verbalized by the patient’s

Ineffective Airway wife: “lagi siyang naubo ng may plema Ineffective Airway Clearance
 Clearance related to madalas yung plema niya yung makapal na related to neuromuscular
neuromuscular impairment cloudy siya. Nahihirapan din siyang ilabas
impairment secondary to
secondary to yung plema niya ayaw naman niyang cerebrovascular disease is a
cerebrovascular disease as isuction yung plema kasi masakit daw. priority nursing diagnosis
evidenced by difficulty in Sabi ng Doctor dahil daw sa walang tayo that should be treated
breathing, crackles heard tayo sa kama kaya siya nagkakaganon kasi immediately as it can have a
upon nastroke siya kaya ayon di niya kayang significant impact on the
auscultation,ineffective tumayo at maglakad ng kusa, kailangan patient’s critical condition. It
cough and excessive may taga buhat o alalay.” would lead to more serious
sputum secretion. complications such as low
oxygenation to organ
Objective: The Patient was observed to systems, imminent death etc.
have Difficulty in Breathing, Difficulty
of expectorating phlegm, excessive
sputum, Crackles was heard upon
auscultation. Patient had a febrile
episode dated April 21, 2023 and April
27, 2023.

2 Marvs Subjective: as verbalized by the patient’s

wife; “nastroke na siya ng apat na beses, Impaired Physical Mobility
Impaired physical nung 2011, 2013, 2017 and 2021”, related to cerebrovascular
mobility “Madalas na siyang naka upo at walang accident is also a top priority
galawan kasi naka NGT siya at nastroke nursing diagnosis as it
din ng apat na beses kaya bumigay na rin involves the overall
yung katawan niya”. capability of the person
which affects his Activity of
Objective: Based on observation, the daily living. And may affect
patient is also 54 years old, he has his/her social life,
decrease in muscle function, reduction of occupation, family etc.
muscle strength and has limited mobile
joints. He is also bedridden.
3 Franz Subjective: as verbalized by the patient’s
wife: “ yung likod niya papunta sa pwetan
Impaired Tissue Skin niya puro sugat sugat dahil din siguro sa
Integrity related to lagi siyang nakahiga. Nung pagkaadmit
hemiparesis and decreased niya dito ayon din ang napansin ng Doctor
immobility as evidenced niya sa kanya na meron daw siyang
by grade 2 sacral pressure Pressure Ulcers.”
ulcers
Objective:
As assessed April 14,2023 Grade 2
Bedsores was noted by the admitting
Doctor , April 15, 2023 it was reported
that the patient has sacral ulcers.
Impaired tissue Skin integrity
related to hemiparesis and
decreased immobility is also
a priority nursing diagnosis
as these impairment in the
skin may be inflicted by the
situation of the client such as
Hygiene, environment and
would lead to complications
such as Infection.

B. NURSING CARE PLANS

CUES NURSING SCIENTIFIC PLANNING IMPLEMENT SCIENTIFIC EVALUATION

DIAGNOSIS EXPLANATIO ATION RATIONALE
N

Subjective Ineffective The profuse Short term: Independent Short term

Subjective: as Airway secretions and After 1 hour of Assessment After 1 hour of
verbalized by Clearance inefficient or nurse-patient 1. Assess 1. Changes nurse-patient
the patient’s related to unproductive interaction and the rate, in interaction and
wife: “lagi neuromuscular coughing that go nursing rhythm, breathing nursing
siyang naubo ng impairment along with this intervention, the and patterns intervention, the
may plema secondary to diagnosis. In patient will: depth of and the patient will:
madalas yung cerebrovascular pneumonia, respiratio use of 1. Maintain
plema niya yung disease as inflammation 1. Maintain n, chest auxiliary ed proper
makapal na evidenced by and increased proper moveme muscles fluid
cloudy siya. difficulty in secretions make fluid nt, and may volume.
Nahihirapan din breathing, it challenging to volume. use of improve 2. Maintain
siyang ilabas crackles heard keep an airway 2. Maintain accessor chest ed
yung plema niya upon open. of y excursio adequate
ayaw naman auscultation,inef adequate muscles. n and nutrition.
niyang isuction fective cough nutrition. 2. Assess promote 3. Understo
yung plema kasi and excessive 3. Understa cough efficient od the
masakit daw. sputum nd the effective breathing treatment
Sabi ng Doctor secretion. treatment ness and . protocol
dahil daw sa protocol producti 2. The best and
walang tayo and vity techniqu preventiv
tayo sa kama preventiv 3. Observe e to get e
kaya siya e the secretion measures
nagkakaganon measures sputum s out of .
kasi nastroke . color, the body 4. Rest to
siya kaya ayon 4. Rest to viscosity, is to conserve
di niya kayang conserve and odor. cough. d energy.
tumayo at energy. Report Patients Long term
maglakad ng changes. who After of
kusa, kailangan Long Term: 4. Assess have nurse-patient
may taga buhat After of the pneumon interaction and
o alalay.” nurse-patient patient’s ia may nursing
interaction and hydratio develop intervention, the
Objective: nursing n status. thick, patient will:
intervention, the tenacious 1. Patient
Objective: The patient will: Dependent secretion will
Patient was Assessment: s. maintain
observed to have 1. Patient 1. Administ 3. Sputum ed a
Difficulty in will er changes patent
Breathing, display/ prescribe might be airway
Difficulty of maintain d a sign of with
expectorating a patent medicati an breath
phlegm, airway ons as infection. sounds
excessive with ordered Sputum clearing;
sputum, breath by the that is absence
Crackles was sounds physicia discolore of
heard upon clearing; n. d, dyspnea,
auscultation. absence 2. Maintain persisten cyanosis,
Patient had a of and t, or as
febrile episode dyspnea, monitor offensive evidence
dated April 21, cyanosis, IV may d by
2023 and April as patient-c increase keeping
27, 2023. evidence ontrolled airway a patent
d by as resistanc airway
Chest Ap: April keeping ordered e and and
22, 2023 shows a patent by the call for effectivel
clearing noted airway physicia further y
pneumonic and n. treatment clearing
densities in right effectivel . secretion
lower lobe, for y 4. Inadequa s.
follow up clearing Health te
expiratory secretion Teaching hydratio
radiograph, s. 1. Teach n and
normal and thickness
pulmonary assist the of
ranking, heart patient secretion
remains with s impede
magnified, proper airway
diaphragm and deep-bre passage.
sulci intact, athing
visualized exercises
osseous are .
unremarkable. Demonst
rate
 proper
splinting
of the
chest and
effective
coughing
while in
an
upright
position.
Encoura
ge the
patient to
do so
often.

Collaborative
Nursing
intervention
1. O2
Therapy

CHAPTER 3: IMPLEMENTATION

1. DRUG STUDY
DRUG CLASSIFICA DOSE, MECHAN CONTRADIC SIDE EFFECTS Nursing
TION/ ROUTE ISMS OF TIONS Responsibilities
INDICATION AND ACTION
FREQUE
NCY

Generic Classification: Dose: Through hypersensitivit In particular after

Name: Mucolytics 300mg depolymeri y to any IV treatment, keep
Acetylcyste zing ingredient in Bronchospasm an eye out for
ine Indication Route: mucoprotei the mixture, Drowsiness, Fever, further allergic
oral n including Coughing up response and
Brand complexes acetylcysteine. blood, Increased anaphylactic
name: Frequency and nucleic volume of symptoms.
Flemisten : acids, bronchial Pulmonary
Every 6 acetylcyste secretions, symptoms and skin
hrs ine exerts Irritation of responses are
an intense tracheal or indications.
mucolytic- bronchial tract,
fluidizing Nausea, Runny or Monitor signs of
action on stuffy nose, bronchospasm and
mucus and Swelling and sores respiratory
mucopurul inside the mouth, irritation,
ent Vomiting including
secretions. wheezing, cough,
This gives dyspnea, increased
the secretions, and
vitreous tightness in the
and chest and throat.
purulent Report excessive
parts of or prolonged
sputum respiratory
and other problems to the
secretions physician.
 viscosity.

Generic Classification: Dose: Its exact Acetaminophe Check that the

Name: Analgesic/Antip 300 mg mechanism n patient is not
Skin rash,
Acteminop yretic of action is contraindicatio taking any other
hypersensitivity
hen Route: Iv yet ns include medication
reactions,
Indication: unknown, acetaminophen containing
Brand but hypersensitivit paracetamol.
name: because it y, severe Nephrotoxicity
Paracetam blocks the hepatic (elevations in Alcohol increases
ol cyclooxyge impairment, or BUN, creatinine), the risk of liver
nase severe acute damage that can
(COX) hepatitis. Hematological: occur if an
pathways, anemia, overdose of
it has leukopenia, paracetamol is
previously neutropenia, taken. The hazards
been pancytopenia of paracetamol
grouped overdose are
with greater in
NSAIDs. Metabolic and persistent heavy
Acetamino electrolyte drinkers and in
phen is people with
hypothesiz alcoholic liver
ed to have disease.
analgesic
and
antipyretic
properties
because it
inhibits the
COX
pathway,
which in
 turn
decreases
prostaglan
din
synthesis
in the
central
nervous
system.
The central
nervous
system's
(CNS)
descending
serotonergi
c pathways
may be
stimulated,
which
would
explain the
analgesic
effects.

Generic Classification: Dose: The Clinical febrile response, Before infusion,

Name: Crystalloid 1000ml primary assessments of infection at the site assess the patient’s
Fluid electrolytes the usage of of injection, vital signs, edema
Route: IV of normal saline venous thrombosis status, lung
Brand extracellul contraindicatio or phlebitis sounds, and heart
name: Indication: Frequency ar fluid are ns vary from extending from the sounds. Continue
0.9% PNSS : sodium patient to site of injection, monitoring during
4hrs ions, which patient. It is extravasation, and and after the
play a strongly hypervolemia. infusion.
crucial role advised against
in the using normal Look for signs that
dispersion saline if doing indicate continued
of fluids so causes hypovolemia such
and other pulmonary as, decreased urine
electrolytes edema, output, poor skin
. Chloride overhydration, turgor, tachycardia,
is another congested weak pulse, and
significant conditions, or hypotension.
ion that dilution of
acts as a serum
buffer in electrolyte
the tissues values.
and lungs.
Here,
chloride
aids in
facilitating
the binding
of carbon
dioxide
and
oxygen to
hemoglobi
n. The
kidneys,
which
regulate
homeostasi
s by
absorbing
substances
or
 excreting
them
through
tubules, are
principally
in charge
of
controlling
these ions.

Generic Classification: Dose: 10 Amlodipin Patients with a peripheral edema, When dosage is
Name: Calcium mg e inhibits history of heart failure, stabilizing and on
Amlodipin Channel the first amlodipine or pulmonary edema, occasion while
e Blocker Route: calcium its dosage form flushing, dizziness, receiving
Oral route influx by hypersensitivit headache, long-term therapy,
Brand Indication: blocking y should not drowsiness, skin regularly check the
name: Frequency the take rash, nausea, heart rate.
Norvasc : once a voltage-de amlodipine. abdominal pain,
day pendent Amlodipine is and constipation. If the patient is
L-type also generally also on nitrates,
calcium not advised for closely watch their
channels. use in those blood pressure.
Vasodilatio who have heart
n results failure, severe
from aortic stenosis,
enhanced unstable
smooth angina, severe
muscle hypotension,
relaxation, and hepatic
decreased impairment.
vascular
smooth
muscle
 contractilit
y, and
decreased
intracellula
r calcium.

Classification: Due to its Severe weight gain, When adjusting

Generic Beta Adrenergic Dose: 12.5 alpha1-blo hypotension, depression, the dose and
Name: Blocking Agent mg cking second- or impotence, and periodically
Carvedilol properties, third-degree memory loss. throughout
Indication: Route: carvedilol AV block, sick therapy, check the
Brand Oral route lowers sinus blood pressure and
name: blood syndrome, pulse frequently.
Coreg Frequency pressure severe When assisting the
: once a primarily bradycardia in patient to stand up
day by the absence of from the supine
reducing a working position, check for
arterial pacemaker, orthostatic
vascular severely hypotension.
resistance, decompensated Reduce dosage if
which heart failure heart rate falls to
lowers requiring less than 55 beats
afterload. inotropic per minute.
It is support, and a
extremely history of a Watch the intake to
helpful in serious output ratios and
treating hypersensitivit daily weight.
hypertensi y reaction are Check the patient
on in absolute often for signs of
people contraindicatio fluid excess. When
with renal ns to using starting HF
impairment carvedilol. therapy, patients
, when may notice an
 doctors aggravation of
should their symptoms.
steer clear
of diuretics
and
ACEIs.

Classification: Dose: 20 Statin Patients who arthralgia, Obtain a thorough

HMG-CoA mg drugs are dyspepsia, medical history
Generic reductase reduce hypersensitive diarrhea, nausea, that includes the
Name: inhibitors Route: cholesterol to any of the nasopharyngitis, patient's current
Atorvastati Oral route production ingredients in insomnia, urinary list of medications,
n in the liver atorvastatin are tract infection, and their dosages,
Indication: Frequency by contraindicated pain in the frequency, and
Brand : once a blocking . extremities. duration of use, as
name: day the Despite the well as any other
Lipitor conversion benefits of medications or
of lipid-lowering dietary
HMG-CoA therapy in supplements they
to chronic liver may be taking.
mevalonate diseases like
. non-alcoholic Consider checking
Atorvastati fatty liver for any other
n disease and cardiovascular risk
competitiv hepatitis, factors, such as
ely inhibits including diabetes, high
3-hydroxy- patients with blood pressure,
3-methylgl active liver smoking, and
utaryl-coen disease, family history.
zyme A atorvastatin is
(HMG-Co contraindicated
A) also during
reductase. pregnancy or
 The in female
amount of patients who
LDL may become
receptors pregnant.
on the
surface of
hepatic
cells is
likewise
increased
by
atorvastati
n.

2. TREATMENT

NGT - A nasogastric tube (NG tube) is a type of catheter used in medicine that is placed into the stomach through the nose. For brief
periods, it is used to draw out substances or deliver substances to your stomach, such as food or medications.

Indication:

● Difficulty swallowing (dysphagia)

● Head and neck cancers.
● Altered mental status/unconsciousness.
● Malnutrition.
● Inflammatory bowel disease (IBD).
● Endotracheal intubation.
Nursing Responsibilities

Before: Ensure the NGT has no kinks.

During: Approximate the length of the tube to be inserted by measuring from the tip of nose to the earlobe, and then from the earlobe
to the xiphoid process.

After: Secure the nasogastric tubes (NGT) to the nose with a trouser tape.

IVT - The administration of fluids directly into a vein is known as intravenous (IV) therapy. It helps with treatment by allowing the
body to receive nutrients, blood, water, and medications more quickly through the circulatory system.

Indication:

● severe dehydration by administering fluids

● health conditions by administering medication
● pain by administering pain relief
● blood loss by blood transfusion
● malnutrition or inability to take food by administering nutrients

Nursing Responsibilities

Before: Assessing an IV site

During: Priming and hanging a primary IV bag

Preparing and hanging a secondary IV bag

Calculating IV rates

After: Monitoring the effectiveness of IV therapy

 Discontinuing a peripheral IV

BLOOD TRANSFUSION - If a person loses blood as a result of an injury, during surgery, or due to certain medical conditions that
affect blood or its components, a blood transfusion can provide blood or blood components. Typically, donors provide the blood. The
safety and minimal danger of transfusions are guaranteed by blood banks and medical professionals

Indication:

● Anemia.
● Certain cancers.
● Hemophilia.
● Sickle cell disease.
● Injury
● During Surgery

Nursing Responsibilities

Before: Take baseline vital signs just prior to the infusion of blood or a blood product

During: Monitor the client for at least 15 minutes after the transfusion begins at a slow rate

After: Monitor for any signs and symptoms that may indicate a transfusion reaction. If there are no problems within the first 15
minutes, the transfusion flow rate must be regulated accordingly so it will be completed within 2 to 4 hours.

3. DIET

Patient ASI previously experienced bouts of CVA that rendered him immobile and necessitated the insertion of an NGT; at this time,
the patient was hospitalised for community-acquired pneumonia and was suggested by his doctor to have a gastrostomy as a substitute.
The patient was given sterile food supplied by the institution while being kept in seclusion, as per the doctor's instruction, along with a
certain amount of food. The patient's spouse said verbally that she would mix up things like bread, dairy, fruits, etc. and feed her
husband via the NGT.
Dates Prescribed Quantity

4/14/2023 1800 kcal / 6x = 300 kcal

4/15/2023 Referral to nutrition for nutritional buildup

4/23/2023 2100 kcal / 6x = 350 kcal

4/24/2023 2100 kcal / 6x = 350 kcal

4/26/2023 2100 kcal / 6x = 350 kcal

4/27/2023 2400 kcal / 6x

4. ACTIVITY/EXERCISE

a. Definition: A bedridden patient must be kept as healthy both psychologically and physically as feasible. Long periods of
idleness in bed pose serious risks. Muscles, for instance, may contort or change in appearance. Bedsores typically develop in
patients who are confined to their beds. They might be the main source of the patient's discomfort and infections. Patients who
are confined to beds are urged to exercise often to avoid all of these problems.

b. Specific indication

● Bedridden patients
● Patients in recovery
● Old Aged

c. Date Ordered - not indicated Patient consulted the Amang Rodriguez Memorial Medical Center’s Rehabilitation
Department last February 2022

d. Date performed/ given - not indicated

 e. Client's reaction - The wife of the patient said that her husband does a number of low-impact activities while lying in bed.
The patient receives aid from the therapy in tasks including standing with assistance as well as stretching and flexing.

f. Nursing responsibilities

5. SURGICAL MANAGEMENT

As an alternative to his NGT, the patient was recommended to have a gastrostomy. The patient was scheduled for a procedure on
March 29, 2023, but it was postponed to the same day as March 31, 2023, per the doctor's recommendation from May 20, 2022. To
schedule an appointment, the patient was requested to return. A gastrostomy is when a feeding tube is inserted through the skin and
stomach wall. Instantaneously, it enters the stomach. The installation of G-tubes, or gastrostomy feeding tubes, is a technique that
involves endoscopy. This method entails putting a flexible tube inside the body that has a small camera attached to the end of it. The
endoscope is inserted via the mouth before being passed through the stomach and down the esophagus.

B. NURSING MANAGEMENT
D. CLIENT’S DAILY PROGRESS CHART
ADMISSION DIAGNOSTIC DIET ACTIVIT MEDICATION TREATMENTS SURGERY
PROCEDURE Y S

Admission - Lab tests for the NGT Not Paracetamol IVF- PLR No Surgery is
April 14, 2023 ff: indicated 300mg Iv q4 prn 1000ml ordered
Blood test - 1800 kcal /
Na,K, creatinine, 6 feedings
albumin,Fbs,
Lipid profile
 Ecg

April 26, No Diagnostic NGT Not -amlodipine -2 Prbc blood No Surgery is

2023 test was ordered. indicated 10mg transfusion ordered
2100 kcal / Omeprazole 40 -Iv line 2nd 18g
6x mg iv

April 27, 2023 For Cp clearance NPO Not -Paracetamol No further No Surgery is
and gastro indicated 500 1 tab q6 treatment was ordered
clearance 2400 kcal / -Vit c 1 amp q6 ordered
6x -ferrous sulfate
1tab

CHAPTER 4 - EVALUATION

A. NARRATIVE EVALUATION OF ACTUAL NURSING PROBLEMS (cues, )

Male patient ASI, 54, was admitted to Amang Rodriguez Memorial Medical Center on April 14, 2023, as a result of an unplanned
discovery of community-acquired pneumonia. The patient had a persistent cough, thick sputum, and breathing problems. His vital
signs were as follows when he was admitted to the hospital: temperature 36.3, BP 100/70 mmHg, RR 21, and oxygen saturation 98%.
Patient was on Ngt for feeding and was due for a gastrostomy. The facility provided the patient with osterized meals.

The following are the Nursing Diagnosis for the patient’s case:

1. Ineffective Airway Clearance related to neuromuscular impairment secondary to cerebrovascular disease as evidenced by
difficulty in breathing, crackles heard upon auscultation,ineffective cough and excessive sputum secretion.

2. Impaired physical mobility related to cerebrovascular accident as evidenced by decreased muscle function and decreased
muscle strength.

3. Impaired Tissue Skin Integrity related to hemiparesis and decreased immobility as evidenced by grade 2 sacral pressure ulcers.