Clinical Grand Case Study

St.
Paul University Philippines

Tuguegarao City, Cagayan 3500
SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES
COLLEGE OF NURSING
nd
2 SEMESTER, A.Y. 2022-2023
BACHELOR OF SCIENCE NURSING – LEVEL III
A CASE STUDY
OF COMMUNITY
ACQUIRED PNEUMONIA
Members:
Alan, Trisha
Asuncion, Kim Joshua
Butay, Kristal Jane
Catabay, Gwyneth Felmari
Dalo, Ma. Dhanizelle
Dayrit, Christian
Maddara Jasmine Mari
BY GROUP 5 - BSN 3B
Ms. Jonna Morales, RN, MSN
Clinical Instructor - Medical Ward

St. Paul University Philippines
COLLEGE OF NURSING
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2 SEMESTER, A.Y. 2022-2023
Table of Contents
I. Introduction
II. Health History
a. Biographic Data
b. Patient Admission Record
c. Chief Complaint
d. History of Present Illness
e. Past Medical History
f. History of Family Illness
III. Gordon’s Typology of 11 Functional Health Pattern
a. Health Perception and Health Concept Pattern
b. Nutritional and Metabolic Pattern
c. Elimination Pattern
d. Activity-Exercise Pattern
e. Sleep-Rest Pattern
f. Cognitive Perceptual Pattern
g. Self-Perception and Self Concept Pattern
h. Role-Relationship Pattern
i. Sexuality Reproductive Pattern
j. Coping Stress Tolerance Pattern
k. Value-Belief Pattern
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IV. Review of Systems

a. Physical Assessment Upon Admission
b. Head-to-Toe Physical Assessment
V. Laboratory Examinations and Results
VI. Drug Study
a. Azithromycin
b. Candesartan
c. Clopidogrel
d. Trimetazidine
e. Ismin
f. Keto analogue
g. Sodium chloride
h. Aspirin
i. Atorvastatin
j. Rosuvastatin
k. Arixtra
l. Ceftriaxone
m. Furosemide
VII. Pathophysiology
VIII. Nursing Care Plan
a. Ineffective Breathing Pattern
b. Ineffective Airway Clearance
c. Acute Pain
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I. INTRODUCTION
Community-acquired pneumonia (CAP) is one of the most common

infectious diseases and an important cause of mortality and morbidity
worldwide. Typical bacterial pathogens that cause CAP include
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella
catarrhalis. However, with the advent of novel diagnostic technologies, viral
respiratory pathogens are increasingly being identified as frequent
etiologies of CAP. The most common viral pathogens recovered from
hospitalized patients admitted with CAP include human rhinovirus and
influenza.
According to World Health Organization, Pneumonia killed more than 808 000 children
under the age of 5 in 2017, accounting for 15% of all deaths of children under 5
years. People at-risk for pneumonia also include adults over the age of 65 and
people with preexisting health problems.
The lungs are made up of small sacs called alveoli, which fill with air when a healthy
person breathes. When an individual has pneumonia, the alveoli are filled with pus
and fluid, which makes breathing painful and limits oxygen intake. These infections
are generally spread by direct contact with infected people.
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The estimated worldwide incidence of community-acquired pneumonia varies between 1.5 to

14 cases per 1000 person-years, and this is affected by geography, season, and population
characteristics. In the United States, the annual incidence is 24.8 cases per 10,000 adults with
higher rates as age increases. Pneumonia is the eighth leading cause of death and first among
infectious causes of death. The mortality rate is as high as 23% for patients admitted to the
intensive care unit. All patients with comorbid illness are considered at risk for pneumonia,
but specific risk factors exist for specific pathogens including (1) drug-resistant pneumococci
- age greater than 65, exposure to children in daycare centers, intake of beta-lactam in
previous 90 days, alcohol use disorder, chronic medical conditions, immune-suppression; and
(2) pseudomonas - bronchiectasis, malnutrition, corticosteroid therapy, antibiotic intake for
greater than seven days in the preceding month. Other etiological clues from epidemiology
include the following: coccidioidomycosis in the Southwestern United States, blastomycosis
or histoplasmosis in the states of the Ohio River valley, bird exposures for Chlamydia
psittaci, contact with flea-infested or infected rodent or rabbits during outside activities such
as lawn mowing in the Northeast U.S. (Martha's Vineyard, Cape Cod, etc.) for tularemia
pneumonia.
II. HEALTH HISTORY
A. Biographic Data
Patient CD is a Filipino citizen, 69 years old, and was born on October 9, 1953. He is
married and he currently lives at Zone 6, Auitan, San Pablo, Isabela. He is a Roman
Catholic.
He was admitted at Divine Mercy Wellness Center with a chief complaint of difficulty
breathing. He has an admitting diagnosis of Community Acquired Pneumonia -
Moderate; Congestive Heart Failure by Mr. Efren M. David JR. RN, MS in the
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medical ward on May 11. 2023 at 8:27 AM, Case #18683, with hospital number of
230120779. The attending physician of the patient was Dr. G. Pattaguan.
According to the past history illness data, the patient has a cough, cold, fever, loose
bowel movement and also had a pertinent past medical history of hypertension.
B. Reason for seeking care/present health concern

According to Patient C.D, the reason why he sought medical help is that he was
experiencing difficulty breathing, fever with a temperature of 38 Celcius, and a persistent
cough.
C. History of present health concern

Patient C.D is experiencing cough, colds, and fever 3 days prior to his
admission. He is also experiencing difficulty breathing and shortness of breathing
prior to consultation. Hence admitted.
D. Past Medical History

Patient C.D was diagnosed with Chronic Heart Failure in 2017 and he
undergoes Coronary Artery Bypass Graft Surgery (CABG) in 2021.
E. History of Family Illness
According to the patient, his family from both sides has a history of
hypertension. His families were taking maintenance for hypertension because
hypertension runs in their blood.
III. GORDON’S TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERN
PRIOR TO DURING
ADMISSION HOSPITALISATION
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1. Health Perception and Patient C.D stated that Patient C.D was
Health Management he isn’t in good health admitted to Divine
Pattern since he has much Mercy Wellness Center
maintenance due to his on May 11, 2023, at
bypass surgery 5 years 8:27 AM. When the
ago. Although patient patient was asked
C.D stated that he does regarding his current
not adhere to a certain health perception, he
diet, he does ensure stated “Felt like a lot
that he eats the changed sa katawan ko
recommended amount dahil sa mga sakit ko.
of food. He added that Nagkaroon ako ng
rice meals are his go-to surgery wherein na-
food. The patient bypass ako.” Patient
receives everyday C.D further added that
maintenance and due to his current health
doesn’t take any condition, he doesn’t
vitamins due to his feel as healthy as the
reasons that he has a way before he wasn’t
lot of maintenance yet diagnosed with any
already. He had his diseases and
COVID-19 vaccination undergone surgeries.
shot in 2022 and
already received his Patient C.D was also
booster last January. asked regarding how
he’s coping up with his
Patient C.D mentioned health status while he is
that he goes gardening on hospitalization,
every morning, Patient C.D answered
generally about 6 AM. that he is trying to get
Then before eating his better by listening to his
first meal of the day, he doctors and the nurses,
rests for 30 minutes taking his medications
and watches some TV as advised to him, and
shows. He goes to bed eating nutritious food.
before 9:00 PM and
typically sleeps for six Moreover, when asked
to seven uninterrupted about the patient’s
hours. Health Management
Pattern, he answered
“Nagagawa ko pa rin
naman yung mga dati
kong ginagawa pero
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hindi na as in totally.
Ginagawa ko na lang
sila in moderation kasi I
feel weak.”
2. Nutrition and Metabolism Patient C.D stated that When Patient C.D was
Pattern he doesn’t follow any further asked about his
regular diets but he’s Nutrition and
trying to manage his Metabolism Pattern now
intakes because that he is admitted to
according to him the hospital, he said “Of
“Malaki ang katawan ko course may changes din
kaya I needed to lose lalo na nandito ako sa
weight.” hospital. I can eat well
naman pero not the way
When the patient was I enjoy my foods kapag
also asked about their nasa bahay and I feel
day to day meal, he like wala akong ganang
stated that they usually kumain kahit kahit okay
drink coffee and eat naman mga pinapakain
banana and oatmeal for sa akin.”
breakfast. For lunch,
the patient said that He also mentioned that
most of their meals he keeps having fruits to
consist of chicken, regain his energy and to
vegestables, and fish. help his body gain his
He also added that they health.
don’t eat pork meat.
And for their dinner, When asked about if
they usually have the there’s any food that
same meals. he’s not allowed to eat,
he stated that there are
Overall, when the many and he’s trying to
patient asked about his avoid them.
Nutrition and
Metabolism Pattern Lastly, according to the
prior to his admission, patient’s significant
he has a healthy and other, they are trying to
good appetite and can maintain and balance
enjoy his foods. He his food intake and
also added that he encourage the patient to
doesn’t see any drink an adequate
problems with his volume of water.
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metabolism.
3. Elimination Pattern Patient C.D said that he Patient C.D stated that
doesn’t have any “Ngayon naman na na-
problems with his hospital ako, they are
elimination pattern monitoring yung pag-ihi
even before he was ko kaya kailangan alam
hospitalized. ko kung ilang beses na
ako umihi. Ngayon, 13
When asked about his times na ako umihi.”
urinating cycle, he
answered “Noon, Patient was also asked
maraming beses sa about the color of his
hapon hanggang gabi. urine and said it was
Umiihi ako mga pitong light yellow.
beses.”
Furthermore, when
Patient also shared that patient was asked more
he doesn’t use about his elimination
laxatives and he pattern, he stated that
doesn’t have any “Alam ko naman if
problems when it there’s something
comes to urinating and wrong with my urine or
defecating. kapag mejo mataas
yung creatinine ko ay
mabula yung ihi ko.”
4. Activity and Exercise Patient C.D shared that “Hindi ako magalaw-
Pattern he doesn’t have any galaw dito sa hospital.
exercise pattern. Limited movements kasi
According to him, “Sa nga naka-higa lang ako,
totoo lang, wala akong minsan lang nakakatayo
exercise. Puro pag- kapag umiihi ganon
hahalaman ang kaya I feel like hindi nai-
ginagawa ko sa bahay stretch yung katawan
as my activity.” ko”, the patient stated
when asked about his
He also shared that he current Activity and
doesn’t get tired easily Exercise Pattern now
when he’s gardening that he is admitted on
and said that it’s a good the hospital.
sign for a person like
him who undergoes Moreover, when Patient
heart surgery. C.D was asked to
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describe his overall

He also said that right activity in the hospital,
after coffee, he’s out he said “Parang
there in their lawn nanghihina ako at
watering their plants. walang energy.”
In an overall aspect, Thus, Patient C.D is

Patient C.D stated that sedentary all throughout
he felt okay with his his hospitalization.
habits and activities
and can consider them
as a way for him to
exercise.
5. Cognitive-Perceptual Patient C.D stated that According to the patient,

Pattern when it comes to his now that he is admitted
cognitive and again on the hospital he
perceptual, he has easily gets distracted
already a hard time and sometimes lack of
remembering details focus but he further
and he thought that this added “Baka dahil na rin
is because of his long ito sa mga dami ng
hospitalization in UST tinetake kong gamit at
Hospital wherein he side effects nito yung
stayed there for 1 pagka-distract ko at
month and 10 days. pagiging makalimutin.”
“Actually, second life ko When Patient C.D was

na to. I was revived further asked about
noon sa UST” added by more of Cognitive-
the patient. Perceptual Pattern, he
said that the things he
Overall, it is just the mentioned are the only
way he remembers things he is concerned
some details that about.
Patient C.D has a
problem with and not to
some major cognitive
problem like anxiety,
vision problems, and
confusion as stated by
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the patient.
6. Sleep and Rest Pattern Patient C.D stated that Patient C.D mentioned
they usually sleep at 8 that he had a hard time
PM because they have having a good sleep
nothing to do. while being admitted.
“Dadalawa lang kami “Minsan paputol-putol
sa bahay, walang yung tulog ko, o kaya
magawa kaya alas otso naman hindi maayos,”
pa lang tulog na kami.” stated by Patient C.D.
He further verbalized “Nahihirapan ako sa

that before he got pagtulog dito tapos sa
hospitalized “Sa totoo tanghali naman hindi
lang, alas tres pa lang ako makatulog kasi
gising na ako dala na hindi ako sanay,” he
rin siguro ng edad added.
namin kaya maaga
nagigising.”
Patient C.D also shared

that his sleep gets
distracted when he
needs to urinate in
between at night and
because of that he has
a hard time regaining
back his sleep.
Furthermore, the
patient said that he is
not taking any pills or
medications for sleep.
7. Self-Perception and Self- Patient C.D stated that Patient C.D stated that
Concept Pattern he has no trouble, “Ngayong na-hospital
problems, or concerns ako, wala naman pa rin
with his Self-Perception nagbago. Ganon pa rin,
and Self-Concept wala naman akong
Pattern. nararamdaman na
problema kasi I am old
When asked about his to worry about my
overall self-perception physical image.”
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before his
hospitalization, he
answered “Matanda na
ako kaya hindi ko na rin
yan naiisip and
pakiramdam ko naman
wala akong problema
diyan.”
8. Roles and Relationships Patient C.D shared that Patient C.D further
Pattern he is the head of the added that his role as
household and he is the household was
the one who manages taken for the meantime
the bills, expenses, and when he got admitted.
money in the house. “Lahat ng problema sa
bahay, si Misis muna
He also mentioned that ang in-charge lalo
he has a good ngayon, I usually feel
relationship with his weak dahil sa mga sakit
wife stating “Kami lang ko.”
dalawa ng asawa ko sa
bahay.” He also said that even
when he got
With his relationship hospitalized, nothing
with his children, changed with his
Patient C.D said “Okay relationship with his
yung relationship ko sa wife. “Mas nagging
mga anak ko kahit hindi concern siya sa akin,”
namin sila kasama at he stated.
since nasa malayo at
ibang bansa sila, When it comes to his
minemake-sure namin relationship with his
na nakaka-usap pa rin children, Patient C.D
naman sila.” that they call from time
to time, asking about his
health status, and telling
him to get well soon.
9. Sexuality and Patient C.D said that Patient C.D reiterated

Reproductive Pattern when he was younger, that he doesn’t have
he did not have any any problems even now
problems with his that he got hospitalized
sexuality and when it comes to his
reproductive pattern. Sexuality and
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Reproductive Pattern.
And even now that he
is getting older, he still
didn’t see any
problems.
“Thankful ako kasi

tumanda ako na
walang problema sa
mga ganitong bagay,”
he mentioned.
10. Coping and Stress “Dahil tumatanda na “As of now, yung pagka-
Tolerance Pattern ako, at kami lang ding hospital ko ang source
dalawa ng asawa ko sa ng stress namin ng
bahay, wala naman asawa ko. Hindi man
kami masyadong niya sabihin syempre
problema na alam kong napapagod
nakakaharap. We try to din wife ko,” Patient C.D
avoid stress kasi said when asked about
matanda na nga kami his Stress Tolerance.
and thankfully wala
namang mga major He also mentioned that
problems na he hopes to get better
dumarating sa ami. Yun soon for them to be
nga lang, hindi home already because
maiwasan yung stress being in the hospital is
dahil sa mga sakit ko stressful for him.
kasi ang hirap
magkasakit,” Patient Moreover, Patient C.D
C.D stated. said that he keeps on
praying to lessen the
He also shared that stress he feels.
praying is their way of
coping with stress and
relying on God for
everything they
encounter.
11. Values and Belief Pattern Patient C.D said that he Patient C.D shared that
and his wife are very he and his wife’s values
faithful and religious got even more profound
people and they value especially that they are
God so much. in the hospital.
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“Napapagaan ng loob
He stated that God is ko yung idea na meron
their source of strength si God sa life namin ng
especially now that wife ko and
they are getting older. pinagdadasal ko lang na
“Ipinagkakatiwala na gumaling na ako.”
lang namin sa lahat sa
Diyos kasi matanda na He added that values
nga kami and yon na and faith are very
rin ang parang isang important even most
purpose namin dito,” he especially that he is
added. having diseases.
When asked about his Lastly, Patient C.D said

belief pattern, Patient that he still doesn’t
C.D stated that they believe in any belief or
don’t believe in any superstition even when
such. he got hospitalized.
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IV. REVIEW OF SYSTEMS
Skin, Hair and Nails: Skin color is dark brown; scars and rashes are present. Hair is black in color with few white hairs; hair
thinning is present. Nail beds are white in color; capillary refill is within 3 seconds.
Head and Neck: Reports experiencing headache sometimes; no pain in swallowing and sore throat.
Eyes: Wears glasses, no eye infections and eye pain, but eyes have a little redness, and teary eyes.
Ears: No loss of hearing but hearing became weak because of adulting age; no dizziness and no exposure to loud noises.
Mouth, throat, nose and sinuses: No bleeding of gums or other dental problems, no sore throats and hoarseness.
Thorax and lungs: has difficulty in breathing; experiences pain and shortness of breath during activity.
Breast and regional lymphatics: No lumps on the breast area or any unusual nipple discharge. No tenderness on lymph nodes.
Heart and neck vessels: Reports last blood pressure of 130/80mmHg; Experiences chest pain or pressure, edema and
palpitations.
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Peripheral Vascular: Reports leg cramping during cold weather. No swelling on legs and feet. No sores on legs, pedal extremity is
pale in color, leg rashes and scars are present.
Abdomen: No pain and tenderness; No loss of appetite and abdominal fullness.
Anus and rectum: No pain in defecation; blood in stool; constipation and diarrhea; Reports daily bowel movement of well-formed
brown stool.
Musculoskeletal: No redness, swelling and stiffness of joints; Reports inability to perform heavy ADLs.
Neurologic: Reports experiencing headache sometimes. No depression, anger and suicidal thoughts; no difficulty in speaking,
strange thoughts and actions, and difficulty in learning. Has memory loss due to adulthood.
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A. Physical Assessment Upon Admission
Date: May 11, 2023

Vital Signs:
Body Temperature: 36.4 °C
Blood Pressure: 140/90 mmHg
Pulse Rate: 86 bpm
Respiratory Rate: 21 cpm
Oxygen Saturation: 97%
Physical Assessment Upon Duty

Date: May 12, 2023
Vital Signs
Time: 10:00 AM
Interviewer: Jasmine Mari Maddara and Dhanizelle Dalo
Body Temperature: 38 °C
Blood Pressure: 120/90 mmHg
Pulse Rate: 77 bpm
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Respiratory Rate: 18 cpm

Oxygen Saturation: 99%
B. Head-to-Toe Physical Assessment
General Survey:
AREA ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL INTERPRETATION

FINDING
Skin Color Inspection Normal skin color varies The skin color of the Normal
from white to pink, brown, patient is dark
light brown, and black. brown.
Temperature Palpation Skin is normally warm Skin is warm. Normal

temperature.
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Moisture Palpation Skin surfaces vary from Skin is moist to dry. Normal
moist to dry depending on the
area.
Texture Palpation The skin is smooth even. The skin is smooth Normal
Integrity Inspection Skin is intact and there are Skin is intact. Normal
no reddened areas.
Lesions Inspection Lesion does not fluoresce. Does not have any Normal
lesions
Mobility and Palpation The skin is mobile with Skin returns Normal
turgor elasticity and returns to immediately to its
shape quickly. normal position
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Edema Palpation Skin rebounds and does not Has presence of Abnormal
remain indented when mild edema.
pressure is released. -possible sign of CHF
AREA ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDING INTERPRETATION
Color and Normal

Hair condition Inspection Natural hair color, as Hair is black with few
opposed to chemically white hairs.
colored hair, varies among
Hair is smooth and hair
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clients from pale blond to thinning is present.

black to gray or white. The
color is determined by the
amount of melanin present.
Cleanliness, Normal
dryness or Inspection Scalp is clean and dry. No presence of dandruff,
oiliness, Sparse dandruff may be or lice.
parasites, lesion visible, and the hair is
Smooth
smooth and firm, somewhat
elastic. Has no presence of
lesions.
Amount and Normal

Distribution Inspection Varying amounts of Has a hardly thin hair
terminal hair cover the but even distribution of
scalp, axillary, body and hair
pubic areas according to
normal gender distribution.
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Normal
Nails Grooming and Inspection Nails are clean. Has trimmed nails but
cleanliness not clean.
Normal
Color and Inspection Pink tones should be seen. Pinkish
markings Some longitudinal ridging
is normal
Shape Inspection There is normally a 160- Nail shape is natural. Normal

degree angle between the
nail base and the skin.
Texture and Palpation Nails are basically soft and Smooth Normal
consistency smooth.
Capillary refill Palpation Pink tones return Nail color returns within Normal
time immediately to blanched 3 seconds
nail beds when pressure is
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released.
AREA ASSESSED
TECHNIQUE NORMAL FINDINGS ACTUAL FINDING INTERPRETATION
Head Involuntary Inspection Head should be held still Has no involuntary Normal
movement and upright movements
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Consistency Palpation Head is normally hard Head is hard and has Normal
and smooth without no bumps and lesions
lesions
Head Inspection Should range between 43.2 44.5 cm Normal

circumference and 47.86cm
AREA ASSESSED TECHNIQUE NORMAL FINDING ACTUAL FINDING INTERPRETATION
Eyebrows Hair Inspection Symmetrically aligned to Eyebrow is Normal

distribution, each other and equal symmetrically
alignment, skin movement
aligned and equal in
quality
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Hair is evenly distributed and movement

intact on skin
Eyebrows has even
distribution and
intact on skin with no
scaling flaking
elicited
No presence of
lesions
Eyelashes Evenness and Inspection Eyelashes are distributed Eyelashes is Normal

direction of curl along the margin and curve distributed evenly
downward.
Thin lashes
Eyelids Surface Inspection The upper and lower eyelids The upper eyelids Normal
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characteristics, are close easily and meet overlap the superior

position in completely when closed. part of the iris, and
relation to the
approximately
cornea, ability
to blink, lower complete with the
eyelids lower eyelids are
closed. He has no
inverted nor everted
eyelids.
Eyeballs Alignment Inspection The eyeballs are Eyeballs are Normal

symmetrically aligned in the symmetrical.
socket without protruding or
sinking.
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AREA ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION
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Ears
Auricles Size and Inspection Color: Light Brown Has the same color as Normal
shape, skin
the rest of the face.
condition Alignment and
and the Dark brown.
position symmetry: equal in size
bilateral. Aligned and
symmetrical
Skin is intact and has

Skin integrity: Intact and
no presence of
firm with no presence of
swelling.
swelling and thickness.
No lumps or bumps
palpated.
Palpation findings: pinna
elastic and no masses,
lesions or tenderness.
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Auditory Meatus Note for the Inspection A small amount of Has hair inside the Normal
color yellowish, odorless
ears and has a little
cerumen (ear wax) is
present and no swelling presence of yellow
and redness
earwax.
Earwax has no odor
MOUTH, THROAT, AND NOSE
Lips Outer lips Inspection Color is pinkish with no Has dark lips Normal
Color presence of blisters,
generalized or localized
swelling, fissures, crust,
or scales.
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Inner lips Inspection There was no bleeding, No presence of Normal

excessive dryness, swelling or lumps.
Appearan mucosal cysts, denture
ce irritations, abrasions, Moist
ulceration, or nodules in
the buccal mucosa.
Teeth Integrity Inspection The teeth are complete Teeth are not Abnormal
and still growing complete.
-maybe because of the
patient’s history of smoking
Color Inspection No black or brown Teeth is white. Abnormal

discoloration.
Has presence of -should ensure regular
cavity. mouth hygiene
Tongue Appearan Inspection The tongue has not The tongue is not pale Normal
ce deviated from the center,
and it looks healthy with
no dry fur, white patches,
or excessive trembling.
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Nose Color Inspection The color is the same as Dark brown Normal
the rest of the face.
No presence of
redness
Nasal Palpation The nasal structure is Smooth. Normal

structure smooth and symmetrical.
No swelling or bumps.
Small and short nose.
LUNGS AND THORAX
Posterior Thorax Inspection Thorax should be Symmetrical Normal

symmetrical.
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Spine Inspection Spine should be vertically No presence of scoliosis Normal

aligned.
shoulder is aligned.
Posterior Thorax Palpation No tenderness, pain or Presence of tenderness or Abnormal

unusual sensations. pain upon palpation.
-palpation is a technique to
confirm a specific diagnosis
wherein this part the patient
showed sign of chest pain
Posterior Thorax Percussion Underlying tissue should be Presence of tenderness Abnormal

filled with air and resonance upon percussion
sound should be elicited in -palpation is a technique to
normal lung tissue. confirm a specific diagnosis
wherein this part the patient
showed possible sign of fluid
build up in the lungs
Posterior Chest Auscultation Normal breath sounds should Crackles are heard as Abnormal
be heard namely: bronchial, evidenced by sputum
(Breath sounds) vesicular, bronchovesicular. production. -sign of sputum/mucus
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No crackled sound should be production caused by

heard. community acquired
pneumonia
ANTERIOR THORAX
Breathing Patterns Inspection It should be quiet, rhythmic, Presence of difficulty in Abnormal

and effortless respirations breathing upon inspection
-sign of impaired gas
exchange due to history of
patient’s CHF
Coastal angle and the Inspection Costal angle should be less Normal Normal
angle at which the ribs than 90°, and the ribs should
enter the spine be inserted into the spine at No presence of abnormal
approximately a 45° angle deviation
Anterior chest Percussion Percussion notes should Dullness on percussion Abnormal

resonate down to the sixth rib
at the level of the diaphragm -sign of community acquired
but are flat over areas of pneumonia
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heavy muscle and bone, dull

on areas over the heart and
the liver, and tympanic over
the underlying stomach.
Trachea Auscultation It should have bronchial and Adventitious sound is heard Abnormal
tubular breath sounds
-sign of ineffective airway
clearance due to mucus
production
Anterior chest Auscultation It should have Adventitious sound is heard Abnormal

bronchovesicular and
vesicular breath sounds -sign of ineffective airway
clearance due to mucus
production
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Heart Irregular Palpation and The radial and apical Radial and apical pulses Normal
rhythm and auscultation pulse rates should be are strong.
pulse rate identical
deficit Upon auscultation no
swishing sound was
heard.
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Abdomen Coloration of Inspection Abdominal skin may be The color of the abdomen Normal
the skin paler than the general skin is paler than the
skin tone because this skin general skin.
is so seldom exposed to
the natural elements
Lesions and Inspection Abdomen is free of lesions No lesions or rashes were Normal
rashes or rashes, Flat or raised seen
brown moles, however,
are normal and may be
apparent
Abdomen Light palpation Abdomen is non-tender Non-tender Normal

and soft, there is no
guarding
All quadrants Deep palpation Normal (mild) tenderness Non-tender Normal

is possible over the
xiphoid, aorta, cecum,
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sigmoid colon, and ovaries

with deep palpation
Assessment of Auscultation Bowel sounds consist of Absence of bowel sounds Normal

bowel sounds clicks and gurgles
NEUROLOGICAL SYSTEM
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Level of consciousness Inspection The client engages when Client reacts in the Normal
being interacted with interaction
Grooming, dress and Inspection The client wears The client’s outfit is Normal
hygiene appropriately and looks appropriate
hygienic
Well groomed
Has a good hygiene
Eye Opening (with Inspection The client opens eyes Spontaneous eye Normal
Facial expression) spontaneously, can opening
maintain eye contact and
shows appropriate facial Client maintains eye
expression contact.
Client is attentive
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Motor response (with Inspection The client posture is Spontaneous with no Normal
posture) normal and there is no involuntary body
involuntary body movements.
movement
Verbal response Inspection The client smiles and coos Client smiles and coos Normal
appropriately properly
V. LABORATORY EXAMINATIONS AND RESULTS
HEMATOLOGY
Specimen: Whole Blood Test: CBC PC
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PARAMETER RESULT UNIT REFERENCE INTERVAL INTERPRETATION
RBC Count 4.88 X 1012/L 4.5-6.0 Normal
Hemoglobin 139 g/L 140-180 Hemoglobin is high that

indicates impaired gas
exchange and carbon
dioxide.
Hematocrit 0.408 Vo Frac. 0.40-0.54 Hematocrit is high that

indicates there is an increase
blood flow that also indicates
more susceptible to infection.
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MCV 83.6 fL 80-94
MCH 28.5 pg 27-31
MCHC 341 g/L 310-360
RDW 12.4 % 11.5-14.5
Platelet Count 213 X 109/L 150-450
MPV 10.5 fL 7.8-11.0
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WBC Count 8.05 X 100/L 4.5-11.0
Differential
Count:
65 % 35-65
Neutrophils
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25 % 20-40
Lymphocytes
10 % 2-6 Monocyte is high that indicates more

Monocytes susceptible or multiplication of bacteria.
0 % 0-5
Eosinophils
Basophils 0 % 0-1
Bands 0 %
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Immature 0 %
Cells
CLINICAL
Specimen: Serum Test: CREA, ALT, NA, K
Serum Sodium 123.3 mmol/L 136-145 (ISE) Serum Sodium is low that indicates
(NA+) consumption of too much fluids/
indicates heart failure.
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Serum 3.73 mmol/L 3.5-5.1 (ISE)

Potassium (K+)
Creatinine 90 umol/L 80-115
ALT (GPT) 38 U/L 0-42
Specimen: Serum Test: LP, BUA, FBS
Uric Acid 269 umol/L 200-420
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Glucose, Fasting 8.50 mmol/L 0-5.50 Glucose, fasting is high this indicates
prediabetes or increased blood pressure.
Total 5.11 mmol/L 0-5.17

Cholesterol
HDL- 0.99 mmol/L More than 1.55 Low HDL indicates a problem with the
Cholesterol heart.
LDL- 3.85 mmol/L 0-2.59 High LDL indicates hypertension/

Cholesterol problem with the heart.
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VLDL- 0.26 mmol/L 0-0.78

Cholesterol
Triglycerides 0.57 mmol/L 0-1.70
Specimen: Serum Test: CK-MB, TROP I
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CK-MB 8.01 ng/ml 0-7.0 High CK-MB indicates heart problem.
Troponin I, Less than ng/ml 0-0.03

Quantitative 0.01
Pro-BNP 474.65 Pg/ml 0-300 High Pro-BNP indicates heart failure.
VI. DRUG STUDY
DRUG STUDY #1
Generic Name of Drug: Azithromycin Brand Name of Drug: Zithromax
Pharmacologic Class: Macrolide Therapeutic Class: Antibiotic
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Dosage, Route, Frequency: 500 mg/1 tab OD Desired Effect: It works by stopping the growth of bacteria.
ACTION INDICATION CONTRAINDICATI ADVERSE NURSING PATIENT TEACHINGS

ON REACTION CONSIDERATION
Binds to a ribosomal To treat mild History of CNS: ● Know that ● Tell patient to report
subunit of susceptible community- cholestatic jaundice Aggressiveness, azithromycin signs and
bacteria, blocking peptide acquired or hepatic agitation, anxiety, should not symptoms of
translocation and pneumonia, otitis dysfunction asthenia, dizziness, be used in allergic reaction
inhibiting RNA- media, pharyngitis, associated with fatigue, headache, patients who (such as rash,
dependent protein tonsillitis, and prior use of hyperactivity, have itching, hives, chest
synthesis. Drug uncomplicated skin azithromycin; malaise, undergone tightness, and
concentrates in and soft-tissue hypersensitivity to nervousness, donor stem trouble breathing)
phagocytes, infections caused azithromycin, paresthesia, cell immediately.
macrophages, and by susceptible erythromycin, seizures, transplant for
fibroblasts, which release bacteria ketolide antibiotics, somnolence, cancer of the ● Warn patient that
it slowly and may help other macrolide syncope, vertigo blood or abdominal pain and
move it to infection sites. antibiotics or their CV: Arrhythmias, lymph nodes loose, watery stools
components chest pain, edema, because of may occur. If
elevated serum CK an increased diarrhea persists or
level, hypotension, risk for becomes severe,
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palpitations, cancer urge him to contact

prolonged QT relapse and the prescriber and
interval, torsades possibly replace fluids.
de pointes, death.
ventricular ● Teach patient to
tachycardia ● Use watch for and
EENT: Hearing azithromycin immediately report
loss, oral cautiously in signs of
candidiasis, patients with superinfection, such
perversion or loss hepatic as white patches in
of taste or smell, dysfunction the mouth.
tinnitus, tongue not
discoloration associated
ENDO: with prior
Hyperglycemia use of
GI: Abdominal pain, azithromycin
anorexia, (drug is
cholestatic metabolized
jaundice, in the liver)
constipation, or renal
diarrhea, dysfunction
dyspepsia, elevated (effects are
liver enzymes, unknown in
flatulence, hepatic this group).
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necrosis or failure,
hepatitis, nausea, ● Give
pancreatitis, pyloric azithromycin
stenosis, capsules 1
pseudomembranou hour before
s colitis, vomiting or 2 to 3
GU: Acute renal hours after
failure, elevated food. Give
BUN and serum tablets or
creatinine levels, suspension
nephritis, vaginal without
candidiasis regard to
HEME: food.
Leukopenia,
neutropenia,
thrombocytopenia
MS: Arthralgia
SKIN: Acute
generalized
exanthematous
pustulosis,
erythema
multiforme,
photosensitivity,
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pruritus, rash,
Stevens–Johnson
syndrome, toxic
epidermal
necrolysis, urticaria
Other: Allergic
reaction,
anaphylaxis,
angioedema, drug
reaction with
eosinophilia and
systemic symptoms
(DRESS), elevated
serum phosphorus
level, hyperkalemia,
infusion-site
reaction (such as
pain and redness),
new or worsening
myasthenia
syndrome,
superinfection
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DRUG STUDY #2
Generic Name of Drug: Candesartan Brand Name of Drug: Atacand
Pharmacologic Class: Angiotensin Receptor Blockers (ARBs) Therapeutic Class: Antihypertensive
Dosage, Route, Frequency: 8mg 1tab OD Desired Effect: Lowers blood pressure and increases the supply of
blood and oxygen to the heart.

Selectively blocks To manage, or as Concurrent CNS: Dizziness, ● Determine if ● Advise patient that
binding of angiotensin adjunct in aliskiren therapy in headache the patient full effects of
(AT) II to AT1 receptor managing, presence of CV: Hypotension has fluid or candesartan may
sites in many hypertension diabetes, EENT: Pharyngitis, salt not occur for 4 to 5
tissues, including adrenal hypersensitivity to rhinitis depletion weeks.
glands and vascular candesartan or its GI: Elevated liver prior to
smooth muscle. This components. enzymes, hepatitis, starting ● Explain the
inhibits vasoconstrictive impaired liver candesartan. importance of
and aldosterone- function If patient has lifestyle choices in
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secreting effects of AT II, GU: Elevated BUN known or controlling

which reduces blood and serum suspected hypertension.
pressure. creatinine levels hypovolemia
HEME: and/or salt
Agranulocytosis, depletion
leukopenia, such as may
neutropenia occur with
MS: Back pain, prolonged
rhabdomyolysis diuretic
RESP: Cough, therapy,
upper respiratory dietary salt
tract infection restriction,
SKIN: Pruritus, dialysis,
rash, urticaria diarrhea or
OTHER: vomiting,
Angioedema, expect to
hyperkalemia, provide
hyponatremia treatment,
such as I.V.
normal
saline
solution, as
prescribed,
to correct it
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before
starting
candesartan.
Continue to
monitor
blood
pressure
throughout
candesartan
therapy,
especially
after a
dosage
increase.
● Watch for
elevated
BUN and
serum
creatinine
levels,
especially if
patient has
heart failure
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or
impaired
renal
function;
drug may
cause acute
renal failure.
Report
significant or
persistent
increases
immediately.
● Monitor
patient for
hypotension.
If a patient
develops
hypotension,
expect to
stop the drug
temporarily.
Immediately
place the
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COLLEGE OF NURSING
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patient in
supine
position and
prepare to
give I.V.
normal
saline
solution, as
prescribed.
Expect to
resume
therapy after
blood
pressure
stabilizes.
● Monitor
patient for
fluid deficit. If
patient
receives a
diuretic,
provide
hydration, as
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ordered, to
help
prevent
hypovolemia
. Watch for
evidence,
such as
hypotension
with
dizziness
and fainting.
If patient
has heart
failure and
develops
hypotension,
dosage of
diuretic,
candesartan,
or both may
be reduced
when blood
pressure
stabilizes
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and therapy
resumes.
● Check CBC
for
decreases in
hemoglobin
and
hematocrit. If
they’re
significant or
persistent,
notify
prescriber
immediately
DRUG STUDY #3
Generic Name of Drug: Clopidogrel Brand Name of Drug: Plavix
Pharmacologic Class: P2Y12 platelet inhibitor Therapeutic Class: P2Y12 platelet inhibitor
Dosage, Route, Frequency: 75mg 1tab OD Desired Effect: It prevents platelets (a type of blood cell) from sticking
together and forming a dangerous blood clot.
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Binds to adenosine To reduce Active pathological CNS: Confusion, ● Determine if ● Caution patient that
diphosphate (ADP) thrombotic events, bleeding, including depression, the patient bleeding may
receptors on the surface such as MI and intracranial dizziness, fatal has a history continue longer than
of activated stroke, in patients hemorrhage and intracranial of usual. Instruct him
platelets. This action with peptic bleeding, fatigue, hypersensitiv to report unusual
blocks ADP, which atherosclerosis ulcer; fever, ity that may bleeding or bruising.
deactivates nearby documented by hypersensitivity to hallucinations, have
glycoprotein IIb/IIIa recent MI, clopidogrel or its headache included a ● Advise patient to
receptors and prevents peripheral artery components CV: Chest pain, hematologic notify prescriber
fibrinogen from attaching disease, or edema, reaction to promptly if he
to receptors. Without stroke hypercholesterolem any other experiences
fibrinogen, platelets can’t ia, hypertension, thienopyridin extreme skin
aggregate and form hypotension, e drug, such paleness, fever,
thrombi. vasculitis as prasugrel neurologic changes,
EENT: Altered or or purple skin patches,
loss of taste; ticlopidine, weakness, or
conjunctival, ocular, because yellowing of his skin
or retinal bleeding; allergic or eyes.
epistaxis; rhinitis; cross-
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stomatitis; taste reactivity has ● Instruct patient not

disorders been to discontinue
ENDO: Insulin reported. clopidogrel abruptly
autoimmune or without first
syndrome, severe ● Use consulting
hypoglycemia clopidogrel prescriber.
GI: Abdominal pain; cautiously in
acute liver failure; patients with
colitis; diarrhea; severe
duodenal, gastric, hepatic or
or renal
peptic ulcer; disease, risk
elevated liver of bleeding
enzymes; gastritis; from surgery
gastrointestinal and or trauma, or
retroperitoneal conditions
hemorrhage; that
indigestion; predispose
nausea; to bleeding
noninfectious (such as
hepatitis, peptic ulcer
pancreatitis disease or
GU: Elevated thrombotic
serum creatinine thrombocyto
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level, penic
glomerulopathy, purpura).
UTI
HEME: Acquired ● Expect to
hemophilia A, give aspirin
agranulocytosis, with
aplastic anemia, clopidogrel
neutropenia, in patient
pancytopenia, with acute
prolonged bleeding coronary
time, syndrome.
thrombocytopenic
purpura, thrombotic
thrombocytopenic
purpura, unusual
bleeding or
bruising
MS: Arthralgia,
back pain,
musculoskeletal
bleeding, myalgia
RESP: Bronchitis,
bronchospasm,
cough, dyspnea,
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eczema,
eosinophilic
pneumonia,
interstitial
pneumonitis,
respiratory tract
bleeding, upper
respiratory tract
infection
SKIN: Acute
generalized
exanthematous
pustulosis, bullous
dermatitis,
erythema
multiforme,
exfoliative
dermatitis, lichen
planus, pruritus,
skin
bleeding, Stevens–
Johnson syndrome,
toxic epidermal
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Other:
Anaphylaxis,
angioedema, drug
reaction with
eosinophilia and
systemic symptoms
(DRESS), flu-like
symptoms, serum
sickness
DRUG STUDY #4
Generic Name of Drug: Trimetazidine Brand Name of Drug: Angimax
Pharmacologic Class: Fatty acid oxidation inhibitors Therapeutic Class: Anti-anginal drugs
Dosage, Route, Frequency: 75mg 1tab OD Desired Effect: It helps to maintain the energy metabolism of heart
muscle cells, protecting them from the effects of reduced oxygen
supply.
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Trimetazidine inhibits It is used to prevent Parkinson's ● Significant: ● Assessment ● This drug may
beta-oxidation of fatty and treat the disease, New-onset of the cause drowsiness
acids by blocking long- symptoms of parkinsonian or worsening patient’s or dizziness, if
chain 3-ketoacyl-CoA, angina (chest pain). symptoms, restless of medical affected, do not
which enhances glucose Angina is caused leg syndrome, parkinsonian history: drive or operate
oxidation. by lack of blood tremors, and other symptoms Before machinery.
supply and oxygen related movement (e.g administerin ● Advise patients to
to your heart. disorders. Severe akinesia, g have blood pressure
Trimetazidine helps renal impairment. hypertonia, trimetazidine checked routinely.
to maintain the Lactation. tremor) , the nurse
energy metabolism ● Cardiac should
of heart muscle disorder: review the
cells, protecting Rarely, patient’s
them from the palpitations, medical
effects of reduced extrasystoles history
oxygen supply. , including any
tachycardia. known
● Gastrointesti allergies,
nal previous
disorders: adverse
Nausea, reactions to
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vomiting, medications,
abdominal and any pre-
pain, existing
diarrhea, medical
dyspnea. conditions
● General that may
disorders contraindicat
and e the use of
administratio trimetazidine
n site .
conditions:
Asthenia.
● Nervous
system
disorder:
Headache,
dizziness.
● Skin and
subcutaneou
s tissue
disorders:
Rash,
urticaria,
pruritus.
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● Vascular
disorders:
Rarely,
arterial
hypotension,
orthostatic
hypotension,
flushing.
DRUG STUDY #5
Generic Name of Drug: Isosorbide Mononitrate Brand Name of Drug: ISMN
Pharmacologic Class: Nitrate Therapeutic Class: Antianginal
Dosage, Route, Frequency: 30 mg 1 tab OD Desired Effect: It prevents chest pain associated with angina.

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Isosorbide may interact To prevent angina Concurrent use of CNS: Agitation, ● Use ● Caution patient that
with nitrate receptors in phosphodiesterase confusion, isosorbide abrupt drug
vascular smooth-muscle inhibitors (sildenafil, dizziness, cautiously in discontinuation may
cell membranes. By tadalafil, vardenafil) headache, patients with cause angina and
interacting with receptors or riociguat; insomnia, hypovolemia increase the risk of
sulfhydryl groups, drug is hypersensitivity to restlessness, or mild MI.
reduced to nitric oxide. isosorbide, other syncope, vertigo, hypotension.
Nitric oxide activates the nitrates, or their weakness Monitor ● Instruct patient to
enzyme guanylate components CV: Arrhythmias, patients for notify prescriber
cyclase, increasing orthostatic increased about blurred vision,
intracellular formation of hypotension, hypotension fainting, increased
cyclic guanosine palpitations, and reduced angina attacks,
monophosphate (cGMP). peripheral edema, cardiac rash, and
An increased cGMP level tachycardia output. severe or persistent
may relax vascular EENT: Blurred headaches.
vision, diplopia (all ● Give drugs 1
smooth muscle by forcing forms); sublingual hour before ● Teach patient to
calcium out of muscle burning (S.L. form) or 2 hours reduce the effects of
cells, causing GI: Abdominal pain, after meals. orthostatic
vasodilation. This diarrhea, Give with hypotension by
improves cardiac output indigestion, meals if the changing position
by reducing mainly nausea, vomiting patient slowly. Advise
preload but GU: Dysuria, experiences him to lie down if he
also afterload. impotence, urinary adverse GI becomes dizzy.
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frequency reactions or
HEME: Hemolytic severe
anemia headaches.
MS: Arthralgia,
muscle twitching ● Know that
RESP: Bronchitis, patient may
pneumonia, upper experience
respiratory tract daily
infection headaches
SKIN: Diaphoresis, from
flushing, rash isosorbide’s
vasodilating
effects. Give
acetaminoph
en, as
prescribed,
to relieve
pain.
DRUG STUDY #6
Generic Name of Drug: Ketoanalogue + Essential Amino Acid Brand Name of Drug: Renoguard
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Pharmacologic Class: G04BX- Other Urologicals Therapeutic Class: Ketoanalogues of amino acids (KAs)
Dosage, Route, Frequency: 600mg 1tab BID Desired Effect: It helps improve renal function.

Believed to be involved in Prevention and Known to be ● Hypercalcem ● Ketoanalogu ● Purpose of Keto

the prevention and therapy of damage hypersensitive or ia may es of Analogue: Explain
therapy of damages due due to faulty or who have develop. essential to the patient that
to faulty or deficient deficient protein previously had a ● Generalized amino acids keto analogues are
metabolism in chronic metabolism in hypersensitivity to flushing, should be prescribed to
renal insufficiency. chronic renal one or more amino fever, and used with manage the build-
Ketoanalogues of insufficiency in acids or nausea have caution in up of waste
essential amino acids connection with idiosyncratic been the following products in the body
allow the intake of limited protein in reaction to reported in patients: due to impaired
essential amino acids food of 40 g per Ketoanalogues of the literature With severe kidney function.
while minimizing the day and less in essential amindo during the heart ● Dosage and timing:
amino nitrogen intake. patients with acids. administratio disease; Instruct the patient
glomerular filtration n of amino Known to be on the specific
rate (GFR) below acids. hypersensitiv dosage and timing
25 mL/min. ● At the e or who of the keto
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beginning of have analogue.

therapy, previously ● Dietary
fever, had a Modifications:
nausea, hypersensitiv Discuss any
vomiting, ity to one. necessary dietary
abdominal modifications that
pain, should be followed
diarrhea, in conjunction with
and fatigue taking the keto
may occur, analogue.
those ● Side effects and
reactions are Adverse reactions:
usually mild Educate the patient
and about the potential
disappear side or adverse
within a few reactions
weeks even associated with the
if treatment keto analogue.
is continued. ● Medication
management:
Remind the patient
to take the keto
analogue as
prescribed and to
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avoid skipping or
altering doses
without medical
guidance.
DRUG STUDY #7
Generic Name of Drug: Sodium Chloride Brand Name of Drug:
Pharmacologic Class: Electrolytes Supplement Therapeutic Class: Dietary Supplement
Dosage, Route, Frequency: 1tab TID Desired Effect: It helps prevent heat cramps caused by too much
sweating

Sodium chloride is the Sodium chloride is Conditions whereby ● Hypernatrae ● Assessment: ● Provide clear
major extracellular used as an admin of sodium mia; thirst, Assess the instruction to the
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cation. It is important in electrolyte chloride would be reduced patient’s patient regarding

electrolyte and fluid replenisher to help detrimental. Not to salivation medical the purpose,
balance, osmotic prevent heat be used to induce and history, dosage, and
pressure control and cramps caused by emesis. Sustained lachrymation including any administration of
water distribution as it too much sweating. release tablets: GI , fever, conditions or sodium chloride.
restores sodium ions. It is disorders tachycardia, medications Explain the
used as a source of associated with hypertension that may importance of taking
electrolytes and water for strictures or , headache, affect the medication as
hydration, treatment of diverticula. dizziness, sodium prescribed and any
metabolic acidosis, restlessness, balance in potential side
priming solution in irritability the body. effects or adverse
haemodialysis and and Monitor the reactions to watch
treatment of weakness. patient’s vital for.
hyperosmolar diabetes. It signs, fluid ● Educate the patient
is also used as diluents balance, about the risks of
for infusion of compatible electrolyte excessive sodium
drug additives. levels, and intake and the need
renal to monitor their
function overall sodium
before and intake from diet and
during other resources.
sodium
chloride
administratio
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COLLEGE OF NURSING
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n.
● Dosage and
Administratio
n: Ensure
that the
correct
concentratio
n and
dosage of
sodium
chloride are
prescribed
and
administered
.
● Electrolyte
Monitoring:
Regularly
monitor the
patient’s
serum
electrolyte
levels,
especially
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sodium and
chloride, to
assess their
balance and
adjust the
treatment if
necessary.
● Fluid
Balance:
Monitor the
patient’s fluid
balance
closely,
particularly if
they are
receiving
intravenous
sodium
chloride.
DRUG STUDY #8
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Generic Name of Drug: Aspirin Brand Name of Drug: Aspilet EC
Pharmacologic Class: Salicylate Therapeutic Class: NSAIDS (anti-inflammatory, antiplatelet, antipyretic,

nonopioid analgesic)
Dosage, Route, Frequency: 80 mg 1 tab OD Desired Effect: Prevention of thromboembolic disorders and
cardiovascular events like ischemic stroke.
ACTION INDICATION CONTRAINDICATION ADVERSE NURSING PATIENT TEACHINGS

REACTION CONSIDERATION
Aspirin is a nonsteroidal Prevention of Known CNS: Confusion, ● Don’t crush ● Instruct patient to
anti-inflammatory agent. recurrent MI; hypersensitivity to CNS depression timed- stop taking aspirin
The antithrombotic Unstable angina aspirin. EENT: Hearing release or and notify prescriber
activity of aspirin is due pectoris; Chronic Patients with asthma, loss, tinnitus controlled- if any symptoms of
to its inhibitory effect on stable angina rhinitis, and nasal GI: Diarrhea, GI release stomach or
platelets which is pectoris. polyps. Aspirin may bleeding, aspirin intestinal bleeding
mediated via irreversible cause severe urticaria, heartburn, tablets occur such as
acetylation of platelet angioedema, or hepatotoxicity, unless passage of bloody
cyclooxygenase with bronchospasm. nausea, directed. or tarry stools or if
subsequent blockade of Avoid use in children stomach pain, patient is coughing
platelet thromboxane or teenagers for viral vomiting ● Ask about up blood or vomit
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COLLEGE OF NURSING
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synthesis. infections, with or HEME: tinnitus. This that looks like coffee
without fever, because Decreased blood reaction grounds.
of the risk of Reye's iron level, usually
syndrome with leukopenia, occurs when ● Instruct patient to
concomitant use of prolonged blood aspirin take aspirin with
aspirin in certain viral bleeding time, level food or after meals
illnesses. shortened life reaches or because it may
span of RBCs, exceeds cause GI upset if
thrombocytopeni maximum taken on an empty
a dosage for stomach.
RESP: therapeutic
Bronchospasm effect. ● Advise patient to
SKIN: avoid alcohol while
Ecchymosis, taking aspirin to
rash, urticaria decrease risk of
Other: ulcers.
Angioedema,
Reye’s
syndrome,
salicylism (CNS
depression,
confusion,
diaphoresis,
diarrhea,
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COLLEGE OF NURSING
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difficulty hearing,
dizziness,
headache,
hyperventilation,
lassitude,
tinnitis, and
vomiting) with
regular use of
large doses
DRUG STUDY #9
Generic Name of Drug: Rosuvastatin Brand Name of Drug: Lustatin
Pharmacologic Class: HMG-CoA reductase inhibitor Therapeutic Class: Antilipemic
Dosage, Route, Frequency: 10 mg 1 tab OD Desired Effect: Lowering cholesterol and protecting against a heart
attack and stroke.
ACTION INDICATION CONTRAINDICATION ADVERSE NURSING PATIENT TEACHINGS
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REACTION CONSIDERATION
Cholesterol and Rosuvastatin is Hypersensitivity to any CNS: Asthenia, ● Use ● Encourage patient
triglycerides circulate in used to reduce LDL component of these cognitive rosuvastatin or family to notify
the blood as part of cholesterol, products; active liver impairment, cautiously in prescriber if patient
lipoprotein apolipoprotein B, disease or confusion, patients who begins to notice
and triglycerides, unexplained persistent depression, consume new onset or
complexes. Rosuvastatin and to increase elevated liver function dizziness, large worsening of
inhibits the enzyme 3- HDL-cholesterol in tests; pregnancy, headache, quantities of confusion,
hydroxy-3-methylglutaryl- the management of lactation. hypertonia, alcohol or forgetfulness, or
coenzyme A (HMG-CoA) hyperlipidemias, insomnia, who have a memory loss.
reductase. This inhibition including primary memory loss, history of
reduces lipid levels by hypercholesterolae nightmares, liver disease, ● Instruct patient
mia (type IIa), paresthesia, because prescribed capsule
increasing the number of mixed dyslipidemia peripheral drug is form, not to chew or
hepatic low-density (type IIb), and neuropathy contraindicat crush capsules. If
lipoprotein (LDL) hypertriglyceridemi CV: Chest pain, ed in patient cannot
receptors on the a (type IV), as well hypertension, patients with swallow the
cell surface to increase as in patients with peripheral active liver capsule, it can be
uptake and catabolism of homozygous edema disease or opened and the
LDL. It also inhibits familial EENT: unexplained granules carefully
hepatic hypercholesterolae Pharyngitis, persistent emptied onto one
synthesis of very-low- mia. rhinitis, sinusitis elevations of teaspoon of
density lipoprotein ENDO: Elevated transaminas applesauce. Patient
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COLLEGE OF NURSING
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(VLDL), which decreases glycosylated e levels. should swallow the

the total hemoglobin mixture
number of VLDL and LDL levels, ● Expect immediately, without
particles. gynecomastia, rosuvastatin chewing.
hyperglycemia, to be
thyroid function discontinued ● Instruct patient to
abnormalities if the patient notify prescriber
GI: Abdominal develops immediately about
pain, markedly muscle pain,
constipation, elevated tenderness, or
diarrhea, creatinine weakness,
elevated liver kinase especially if
enzymes, levels, or if accompanied by
gastroenteritis, myopathy is fever or malaise. He
hepatic failure, diagnosed or should also tell the
hepatitis, suspected. prescriber if these
jaundice, Drug may be symptoms occur
nausea, temporarily even after drug is
pancreatitis withheld if discontinued.
GU: Acute renal patient
failure, develops
proteinuria, UTI any
HEME: condition
Thrombocytopen that may be
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ia related to
MS: Arthralgia, myopathy or
arthritis, back that
pain, immune- predisposes
mediated her to renal
necrotizing failure, such
myopathy, as
myalgia, hypotension;
myopathy, major
rhabdomyolysis surgery;
RESP: sepsis;
Bronchitis, severe
increased electrolyte,
cough, interstitial endocrine, or
lung disease metabolic
SKIN: Rash, disorders;
urticaria trauma, or
Other: uncontrolled
Angioedema, seizures.
flu-like
symptoms, ● Obtain
generalized baseline liver
pain, infection enzymes
and expect
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COLLEGE OF NURSING
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to monitor
them
thereafter,
as indicated.
Notify
prescriber if
proteinuria
or hematuria
appears in
patient’s
routine
urinalysis,
because
rosuvastatin
dosage may
need to be
reduced.
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DRUG STUDY #10
Generic Name of Drug: Atorvastatin Brand Name of Drug: Lipitor
Pharmacologic Class: HMG-CoA reductase inhibitor Therapeutic Class: Antihyperlipidemic
Dosage, Route, Frequency: 40 mg 1 tab OD Desired Effect: It works by slowing the production of cholesterol in the
body to decrease the amount of cholesterol that may build up on the
walls of the arteries and block blood flow to the heart, brain, and other
parts of the body.

Reduces plasma To control lipid Active hepatic CNS: Abnormal ● Use ● Advise patient to
cholesterol and levels as adjunct to disease, dreams, amnesia, atorvastatin notify prescriber
lipoprotein levels by diet in primary breastfeeding, asthenia, cognitive cautiously in immediately if he
inhibiting HMG-CoA (heterozygous hypersensitivity to impairment, patients who develops
reductase and familial atorvastatin or its depression, consume unexplained muscle
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COLLEGE OF NURSING
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2 SEMESTER, A.Y. 2022-2023
cholesterol synthesis in and nonfamilial) components, dizziness, substantial pain, tenderness, or

the liver and by hypercholesterolem pregnancy, emotional lability, quantities of weakness,
increasing the number of ia and mixed unexplained facial paralysis, alcohol or especially if
LDL receptors on liver dyslipidemia persistent rise in fatigue, fever, have a accompanied by
cells to enhance LDL serum headache, history of fatigue or fever.
uptake and breakdown. transaminase level hyperkinesia, lack liver disease
of coordination, because ● Tell patient to take
malaise, atorvastatin drug at the same
paresthesia, use time each day to
peripheral increases maintain its effects.
neuropathy, risk of liver
somnolence, dysfunction. ● Instruct the patient
syncope, weakness to take a missed
CV: Arrhythmias, ● Expect liver dose as soon as
elevated serum CK function possible. If it’s
level, orthostatic tests to be almost time for his
hypotension, performed next dose, he
palpitations, before should skip the
phlebitis, atorvastatin missed dose. Tell
vasodilation therapy him not to double
EENT: Amblyopia, starts and the dose.
altered refraction, then
dry eyes, dry thereafter as
mouth, epistaxis, clinically
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COLLEGE OF NURSING
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eye necessary. If
hemorrhage, clinical
gingival symptoms
hemorrhage, such as
glaucoma, glossitis, hyperbilirubi
hearing loss, lip nemia and
swelling, jaundice
loss of taste, occur, notify
pharyngitis, prescriber
sinusitis, stomatitis, and expect
taste perversion, atorvastatin
tinnitus therapy to be
ENDO: discontinued
Hyperglycemia, until the
hypoglycemia cause of
GI: Abdominal or liver
biliary pain, dysfunction
anorexia, colitis, has been
constipation, identified. If
diarrhea, duodenal no cause
or stomach ulcers, can be
dysphagia, found,
elevated liver expect the
enzymes, drug to be
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COLLEGE OF NURSING
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eructation, discontinued
esophagitis, permanently.
flatulence,
gastroenteritis, ● Monitor
hepatic failure, diabetic
hepatitis, increased patient’s
appetite, blood
indigestion, glucose
jaundice, melena, levels
pancreatitis, rectal because
hemorrhage, atorvastatin
vomiting therapy can
GU: Abnormal affect blood
ejaculation; cystitis; glucose
decreased libido; control.
dysuria;
epididymitis;
hematuria;
impotence;
nephritis; nocturia;
renal calculi;
urinary frequency,
incontinence, or
urgency; urine
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retention; vaginal
hemorrhage
HEME: Anemia,
thrombocytopenia
MS: Arthralgia,
back or muscle
pain, bursitis, gout,
immune-mediated
necrotizing
myopathy, leg
cramps, myalgia,
myasthenia gravis,
myopathy,
myositis, neck
rigidity,
rhabdomyolysis,
tendon contracture
or rupture,
tenosynovitis,
torticollis
RESP: Dyspnea,
pneumonia
SKIN: Acne,
alopecia, contact
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dermatitis,
diaphoresis, dry
skin, ecchymosis,
eczema, erythema
multiforme,
petechiae,
photosensitivity,
pruritus, rash,
seborrhea,
Stevens-Johnson,
toxic epidermal
necrolysis,
ulceration, urticaria
Other:
Anaphylaxis,
angioedema, flu-
like symptoms,
infection,
lymphadenopathy,
weight gain
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DRUG STUDY #11
Generic Name of Drug: Fondaparinux sodium Brand Name of Drug: Arixtra
Pharmacologic Class: Activated factor X inhibitor Therapeutic Class: Anticoagulant
Dosage, Route, Frequency: 2.5mg SQ OD Desired Effect: To treat serious blood clots in the legs and/or lungs.

Exhibits antithrombotic Arixtra is indicated Known

activity, which is the for the treatment of hypersensitivity to CNS: Confusion, ● Inspect
results of antithrombin III acute pulmonary fondaparinux dizziness, fever, fondaparinux ● Inform the patient
(ATIII) - mediated embolism when sodium or any of headache, for that fondaparinux
selective inhibation of administered in the excipients of insomnia discoloration can’t be taken
Factor Xa. conjunction with Arixtra. CV: Edema, or particles orally.
warfarin sodium elevated serum before
when initial therapy aminotransferase administratio
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COLLEGE OF NURSING
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is administered in
the hospital. level, hypotension n. Be aware
that needle
GI: Constipation, guard on ● Instruct the patient
diarrhea, elevated prefilled to seek immediate
liver enzymes, syringe help if he
indigestion, contains dry experiences signs
nausea, vomiting natural latex of
rubber and thromboembolism,
GU: Urine shouldn’t be such as neurologic
retention, UTI handled by changes and severe
HEME: Anemia, those shortness of breath.
bleeding, elevated sensitive to
APTT, hematoma, latex.
hemorrhage,
● Caution patient to
thrombocytopenia, minimize bruising,
thrombocytopenia ● Alternate by not rubbing the
with thrombosis injection injection site after
SKIN: Bullous sites using giving the drug.
eruption, increased left and right
wound drainage, anterolateral
purpura, rash or left and
right
Other: posterolatera
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Anaphylaxis; l abdominal
angioedema; wall. Don’t
generalized pain; expel air
hypokalemia; bubbles from
injection- site a prefilled
bleeding, pruritus, syringe
and rash before
injection to
prevent
expelling
drugs from
syringe.
Don’t give
drug by I.M.
injection.
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DRUG STUDY #12
Generic Name of Drug: Ceftriaxone Brand Name of Drug: Ceftrex
Pharmacologic Class: Third-generation cephalosporin Therapeutic Class: Antibiotic
Dosage, Route, Frequency: 1g IV OD Desired Effect: It works by killing bacteria or preventing their growth.

Ceftriaxone is a 3rd Ceftriaxone is used Hyperbilirubinemic CNS: Chills, fever, ● Assess for ● Tell the patient to
generation broad- for the treatment of or premature headache, signs of report evidence of
spectrum cephalosporin the infections neonates (up to a hypertonia, superinfectio blood dyscrasia or
antibiotic. It binds to 1 or (respiratory, skin, postmenstrual age reversible n, such as superinfection to the
more penicillin-binding soft tissue, UTI, of 41 hyperactivity, cough or prescriber
proteins (PBPs) inhibiting ENT) caused by weeks); seizures sputum immediately.
the final transpeptidation susceptible hypersensitivity to CV: Edema changes,
step of peptidoglycan organisms.11 ceftriaxone, other diarrhea, ● Advise patient to
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COLLEGE OF NURSING
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synthesis in the bacterial Organisms that are beta-lactam EENT: Glossitis, drainage, report any
cell walls, leading to generally antibacterials or hearing loss, fever, hypersensitivity
bacterial cell lysis and susceptible to cephalosporins, stomatitis malaise, reactions, such as a
death. ceftriaxone include penicillins, or their GI: Abdominal pain, rash, itching skin, or
S. pneumoniae, S. components; cramps, perineal hives, to
pyogenes (group A intravenous cholestasis, itching, rash, prescriber
beta-hemolytic administration of Clostridium redness, and immediately and to
streptococci), ceftriaxone difficile–associated swelling. stop taking the drug.
coagulase-negative solutions containing diarrhea,
staphylococci, lidocaine; neonates diarrhea, elevated ● Assess for ● Report any signs of
Some Enterobacter who are 28 days liver enzymes, arthralgia, bleeding.
spp, H. influenzae, old or less gallbladder bleeding,
N. gonorrhoeae, P. if they’re expected dysfunction, hepatic ecchymosis,
mirabilis, E. coli, to need calcium- failure, and
Klebsiella spp, M. containing hepatitis, pharyngitis;
catarrhalis, B. solutions, including hepatomegaly, they may
burgdorferi, and parenteral nausea, oral indicate a
some oral nutrition. candidiasis, blood
anaerobes.1 pancreatitis, dyscrasia.
pseudolithiasis,
pseudomembranou
s colitis, vomiting ● Determine
GU: Acute renal history of
failure, elevated hypersensitiv
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BUN level,
nephrotoxicity, ity reactions
oliguria, vaginal to
candidiasis, ureteric cephalospori
obstruction, ns and
urolithiasis penicillins
HEME: and history
Agranulocytosis, of other
aplastic anemia, allergies,
eosinophilia, particularly
hemolytic anemia, to drugs,
hemorrhage, before
hypoprothrombine therapy is
mia, leukopenia, initiated.
neutropenia,
thrombocytopenia
MS: Arthralgia
RESP: Allergic
pneumonitis,
dyspnea
SKIN: Allergic
dermatitis,
ecchymosis,
erythema,
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erythema
multiforme,
exanthema,
pruritus, rash,
Stevens–Johnson
syndrome, toxic
epidermal
Other: Anaphylaxis;
drug fever;
injection-site pain,
redness, and
swelling;
serum sickness;
superinfection
DRUG STUDY #13
Generic Name of Drug: Furosemide Brand Name of Drug: Furoside
Pharmacologic Class: Loop diuretic Therapeutic Class: Antihypertensive, diuretic
Dosage, Route, Frequency: 40mg IV Q6 Desired Effect: It reduces extra fluid in the body (edema) caused by
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conditions such as heart failure, liver disease, and kidney disease.

Inhibits sodium and water To reduce edema Anuria, CNS: Dizziness, ● Monitor ● Instruct patient to
reabsorption in the loop caused by cirrhosis, hypersensitivity to drowsiness, fever, blood take furosemide at
of Henle and increases heart failure, and furosemide or its headache, lethargy, pressure and the same time each
urine renal disease, components paresthesia, hepatic and day to maintain
formation. As the body’s including nephrotic restlessness, renal therapeutic effects.
plasma volume syndrome vertigo, weakness function as Urge her to take it
decreases, aldosterone CV: Arrhythmias, well as BUN, as prescribed, even
production elevated blood if she feels well.
increases, which cholesterol and glucose, and
promotes sodium triglyceride levels, serum ● Advise patient to
reabsorption and the loss orthostatic creatinine, change position
of potassium and electrolyte, slowly to minimize
hydrogen ions. hypotension, shock, and uric acid effects of orthostatic
Furosemide also tachycardia, levels, as hypotension and to
increases the excretion thromboembolism, appropriate take
of calcium, magnesium, thrombophlebitis furosemide with
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COLLEGE OF NURSING
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bicarbonate, ammonium, vertigo ● Monitor food or milk to

and phosphate. By EENT: Blurred patient for reduce GI distress.
reducing intracellular and vision, deafness, hypokalemia
extracellular fluid volume, dry mouth, oral which may ● Caution patient
the drug reduces blood irritation, ototoxicity, occur with about drinking
pressure and decreases stomatitis, tinnitus, brisk alcoholic
cardiac output. Over hearing loss (rapid diuresis, beverages, standing
time, cardiac output I.V. injection), inadequate for prolonged
returns to normal. yellow vision oral periods, and
ENDO: electrolyte exercising in
Hyperglycemia intake, or hot weather
GI: Abdominal when because these
cramps, anorexia, cirrhosis is actions increase the
constipation, present. It hypotensive effect
diarrhea, elevated may also of furosemide.
liver enzymes, occur during
gastric irritation, concomitant
hepatocellular use of ACTH
insufficiency, or
indigestion, corticosteroi
jaundice, nausea, d therapy,
pancreatitis, intake of
vomiting large
GU: Azotemia, amounts of
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bladder spasms, licorice, or

glycosuria, oliguria prolonged
HEME: use of
Agranulocytosis laxatives.
(rare), anemia,
aplastic anemia ● Notify
(rare), eosinophilia, prescriber if
hemolytic anemia, patient
leukopenia, experiences
thrombocytopenia hearing loss,
MS: Muscle pain or vertigo, or
spasms ringing,
SKIN: Acute buzzing, or
generalized sense of
exanthematous fullness in
pustulosis, bullous her ears.
pemphigoid, Drug may
erythema need to be
multiforme, discontinued
exfoliative .
dermatitis,
photosensitivity,
pruritus,
purpura, rash,
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Stevens–Johnson
syndrome, toxic
epidermal
necrolysis,
urticaria
Other: Allergic
reaction,
anaphylaxis,
dehydration, drug
reaction with
eosinophilia and
systemic symptoms
(DRESS),
hyperuricemia,
hypocalcemia,
hypochloremia,
hypokalemia,
hypomagnesemia,
hyponatremia,
hypovolemia,
thirst
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VIII. NURSING CARE PLAN
Nursing Care Plan #1
CUES/ NURSING BACKGROUND GOALS AND NURSING EVALUATION

ASSESSMENT DIAGNOSIS KNOWLEDGE OBJECTIVES INTERVENTIONS
AND RATIONALE
Subjective: Ineffective Inspiration and/or NOC: Respiratory NIC: Ventilation GOAL MET
-Difficulty of Breathing Pattern expiration that does Status: Ventilation
breathing r/t Community not provide
Acquired adequate After 2 hours of
Objective: Pneumonia as ventilation. Objectives: After 2 nursing
- 2-3 Lpm via evidenced by report (NANDA 15th hours of nursing intervention, the
nasal of DOB. Edition) intervention, the patient was able to
cannula patient will be able maintain an
- Dyspnea to maintain an effective breathing
Vital Signs: effective breathing pattern, as
pattern, as evidenced by
BP: 130/80 mmHg evidenced by relaxed and normal
RR: 24 relaxed and normal breathing.
PR: 85 breathing, 12-20
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COLLEGE OF NURSING
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O2sat: 95% respiration per

minute, an O2
saturation level 95-
100% and absence
of Chest
discomfort. The nurse will:
1. Participate A1. Monitor and The patient was

during the record respiratory able to show patent
assessment rate, depth and airway breath
auscultate breath sounds clearing
sounds at least and be free of any
every 2 hours. Note respiratory distress
manifestation of
ineffective
breathing.
The average rate of
respiration for
adults is 12 to 20
breaths per minute.
It is important to
take action when
there is an
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COLLEGE OF NURSING
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alteration in
breathing patterns
to detect early
signs of
compromise on the
respiratory system.
Auscultation is
used to detect
decreased or
adventitious breath
sounds.
A2. Monitor ABG

levels.
This monitors
oxygenation and
ventilation.
2. Maintain a 2. Elevate the head The patient was

position of of the bed into able to feel
comfort semi-fowler’s increased airway
position (30 patency and
degree) and prevented possible
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encourage the respiratory

patient to sit up. problems
Promotes
maximal
inspirations;
enhances
lung
expansion
and
ventilation.
3. Improve 3. Administer The patient was

breathing oxygen therapy as able to maintain
ordered by the oxygen saturation
physician. Oxygen within normal levels
therapy aids
breathing and it
helps increase
oxygen levels in
the blood. This
facilitates increase
of SpO2 and
stabilizes vital
signs such as
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respiratory rate and

pulse rate within
normal range.
3.1 Assess oxygen

saturation, pulse
rate and respiratory
rate. Continuous
assessment of
SpO2, PR and RR
enables healthcare
providers to know if
interventions
providers to know if
interventions
provided were
effective in
establishing
effective breathing The patient was
patterns. able to do and
understand the non
4. Perform 4. Encourage - pharmacological
breathing sustained breaths. management
techniques Techniques include
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by utilizing (1) using

non- demonstration:
pharmacolog highlighting slow
ical therapy. inhalation, holding
end inspiration for a
few seconds, and
passive exhalation.
These techniques
promote deep
inspiration, which
increases
oxygenation.
Prolonged
expiration prevents
air trapping.
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CUES/ NURSING BACKGROUN GOALS AND NURSING INTERVENTIONS EVALUATION
ASSESSMENT DIAGNOSI D OBJECTIVES AND RATIONALE
S KNOWLEDGE
Subjective: Ineffective According to NOC: Respiratory NIC: Airway Management
airway the Nurse’s Status: Airway GOAL MET:
- Patient clearance Pocket Guide Patency
verbalize related to 15th Edition,
d“ increased Ineffective GOAL:
inuubo production Airway
ako at of mucus Clearance is After 2-3 hours of After 2-3 hours of nursing
nahihirap and the inability of nursing interventions, the client:
an ako bronchospa an individual to interventions, the The nurse will:
ilabas sm. clear client will be able
yung secretions or to:
plema obstructions Provide a comfortable
kaya from the environment for the client and
nahihirap respiratory establish a rapport
an ako tract to relationship.
huminga” maintain a
Objective: clear airway
ko.
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- 2-3 LPM 1. Have an 1. Attained clear lung

via Nasal improved airway sounds as evidenced by
Cannula patency as 1.1. Assess airway patency absence of adventitious
- Productiv evidenced by of the client by auscultating sounds from auscultation.
e Cough normal breath breath sounds for presence
- Crackles sounds, normal of normal or adventitious
rate and depth of breath sounds such as
respiration,(normal wheezing or coarse
Sp02) and ability to crackles. Maintaining patent
effectively cough airway is always the first
up secretions. priority. Presence of coarse
crackles during late
inspiration indicates fluid in
the airway; wheezing
indicates an airway
obstruction.
1.2. Position the client to

optimize respiration such
as the head of bed elevated
to 30 to 45 degrees. An
upright position allows
maximal lung expansion;
lying flat causes abdominal
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COLLEGE OF NURSING
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2 SEMESTER, A.Y. 2022-2023
organs to shift toward the

chest, which crowds the
lungs and makes it more
difficult to breathe.
1.3. Administer oxygen via
nasal cannula as ordered.
Oxygen administration has
been shown to correct
hypoxemia (Wong & Elliot,
2009).
2. Show 2.1. Monitor the client’s 2. Demonstrated
improved vital mental status. Increasing adequate ventilation and
signs lethargy, confusion, oxygenation as evidenced by
restlessness, and irritability ABGs and oximetry.
can be a sign of cerebral
hypoxia.
2.2. Monitor the client if

there is change with his
vital signs. Increased work
of breathing can lead to
tachycardia and
hypertension. Retained
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COLLEGE OF NURSING
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secretions may be a sign of

an existing infection or
inflammatory process
manifested by a fever or
increased temperature.
3. Gain
enough knowledge
about the proper 3.1. Teach the patient the 3. Verbalized
ways of coughing, proper ways of coughing understanding of non-
breathing, and and breathing; Taking a pharmacological intervention.
positioning. deep breath, holding it for
two seconds, and coughing
two or three times in
succession. The most
convenient way to remove
most secretions is coughing.
So, it is necessary to assist
the client during this activity.
Deep breathing promotes
oxygenation before controlled
coughing.
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3.2. Educate the client with

proper positioning to
breath properly such as;
• Optimal positioning
(sitting position)
• Use of pillow or hand
splints when coughing
• Use of abdominal
muscles for more forceful
cough
• Use of quad and huff
techniques
• Use of incentive
spirometry
The proper sitting position

and splinting of the abdomen
promote effective coughing
by increasing abdominal
pressure and upward
diaphragmatic movement.
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Controlled coughing methods

help mobilize secretions from
smaller airways to larger
airways because the
coughing is done at varying
times. Ambulation promotes
lung expansion, mobilizes
secretions
3.3. Evaluate client’s
cough/ gag reflex, amount
and type of secretions, and
swallowing ability. To
determine the ability to
protect their own airway
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CUES/ NURSING BACKGROUND GOALS/ NURSING EVALUATION

ASSESSMENT DIAGNOSIS KNOWLEDGE OBJECTIVES INTERVENTION
Subjective: Activity Intolerance Insufficient NOC: Activity NIC: Energy

related to inability physiological or Tolerance Management GOAL MET
- N/A to prefuse oxygen psychological
energy to endure or GOAL: GOAL:
Objective: complete required
- 2-3 Lpm via or desired daily After 8 hours of After 8 hours of nursing
nasal activities. (NANDA, nursing intervention, the patient
cannula 2015) intervention, the was able to report and
- Bed rest patient will be able demonstrate a
to report and measurable increase in
Vital signs: demonstrate a tolerance to activity with
measurable absence of dyspnea and
BP: 130/80 mmHg increase in The nurse will: excessive fatigue, with
RR: 24 tolerance to activity vital signs within the
PR: 85 with absence of patient's acceptable
O2sat: 95 dyspnea and range.
excessive fatigue,
with
vital signs within
the patient's
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COLLEGE OF NURSING
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2 SEMESTER, A.Y. 2022-2023
acceptable range.
OBJECTIVES:
After 6 hours of
nursing
intervention, the
patient will be able
to:
1. Participate 1.1. Evaluate 1. Actively

all patient’s response Participated all
throughout to activity. Note throughout the
assessment reports of assessment and
and dyspnea, management
management increased
of her weakness and
condition fatigue; changes
in oxygen
saturation(O2sat,
pulse oximetry)
and vital signs
during and after
activities.
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COLLEGE OF NURSING
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2 SEMESTER, A.Y. 2022-2023
Establishes client’s
capabilities and
needs and
facilitates choice of
interventions.
2. Provide non 2.1 Provide a quiet 2. Demonstrated the

pharmacolog environment and use of non
ical limit visitors pharmacological
managemen during acute strategies
phase, as
indicated.
Encourage use of
stress
management and
diversional
activities as
appropriate.
Reduces stress
and excess
stimulation,
promoting rest
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2 SEMESTER, A.Y. 2022-2023
2.2. Explain
importance of rest
in treatment plan
and necessity for
balancing
activities with
rest. Bed and chair
rest is maintained
during acute phase
to decrease
metabolic
demands, thus
conserving energy
for healing. Activity
restrictions
thereafter are
determined by
individual patient
response to activity
and resolution of
respiratory
insufficiency.
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2.3. Assist patient

to assume a
comfortable
position for rest
and sleep. Patient
may be
comfortable with
the head of bed
elevated, sleeping
in a chair, or
leaning forward on
over-bed table with
pillow support.
2.4. Assist with

self-care activities
as necessary.
Provide for
progressive
increase in
activities during
recovery phase.
Reduce intensity
level or postpone
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COLLEGE OF NURSING
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2 SEMESTER, A.Y. 2022-2023
activities that
cause undesired
physiological
changes.
Minimizes
exhaustion and
helps balance
oxygen supply and
demand.
2.5. Refer to
physical/occupati
onal therapy, as
indicated. May be
needed/desired to
develop individually
appropriate
exercise/progressiv
e activity plans.
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119

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Clinical Grand Case Study

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St.

Paul University Philippines

Ms. Jonna Morales, RN, MSN

Clinical Instructor - Medical Ward

IV. Review of Systems

Community-acquired pneumonia (CAP) is one of the most common

The estimated worldwide incidence of community-acquired pneumonia varies between 1.5 to

II. HEALTH HISTORY

B. Reason for seeking care/present health concern

C. History of present health concern

D. Past Medical History

E. History of Family Illness

III. GORDON’S TYPOLOGY OF 11 FUNCTIONAL HEALTH PATTERN

describe his overall

In an overall aspect, Thus, Patient C.D is

5. Cognitive-Perceptual Patient C.D stated that According to the patient,

“Actually, second life ko When Patient C.D was

He further verbalized “Nahihirapan ako sa

Patient C.D also shared

9. Sexuality and Patient C.D said that Patient C.D reiterated

“Thankful ako kasi

When asked about his Lastly, Patient C.D said

IV. REVIEW OF SYSTEMS

Abdomen: No pain and tenderness; No loss of appetite and abdominal fullness.

A. Physical Assessment Upon Admission

Date: May 11, 2023

Physical Assessment Upon Duty

Respiratory Rate: 18 cpm

B. Head-to-Toe Physical Assessment

AREA ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL INTERPRETATION

Temperature Palpation Skin is normally warm Skin is warm. Normal

AREA ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDING INTERPRETATION

Color and Normal

clients from pale blond to thinning is present.

Amount and Normal

Shape Inspection There is normally a 160- Nail shape is natural. Normal

Head Inspection Should range between 43.2 44.5 cm Normal

AREA ASSESSED TECHNIQUE NORMAL FINDING ACTUAL FINDING INTERPRETATION

Eyebrows Hair Inspection Symmetrically aligned to Eyebrow is Normal

Hair is evenly distributed and movement

Eyelashes Evenness and Inspection Eyelashes are distributed Eyelashes is Normal

characteristics, are close easily and meet overlap the superior

Eyeballs Alignment Inspection The eyeballs are Eyeballs are Normal

AREA ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

Skin is intact and has

Earwax has no odor

MOUTH, THROAT, AND NOSE

AREA ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

Inner lips Inspection There was no bleeding, No presence of Normal

Color Inspection No black or brown Teeth is white. Abnormal

Nasal Palpation The nasal structure is Smooth. Normal

Small and short nose.

LUNGS AND THORAX

AREA ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION

Posterior Thorax Inspection Thorax should be Symmetrical Normal

Spine Inspection Spine should be vertically No presence of scoliosis Normal

Posterior Thorax Palpation No tenderness, pain or Presence of tenderness or Abnormal

Posterior Thorax Percussion Underlying tissue should be Presence of tenderness Abnormal

No crackled sound should be production caused by

Breathing Patterns Inspection It should be quiet, rhythmic, Presence of difficulty in Abnormal

Anterior chest Percussion Percussion notes should Dullness on percussion Abnormal

heavy muscle and bone, dull

Anterior chest Auscultation It should have Adventitious sound is heard Abnormal

AREA ASSESSED TECHNIQUE NORMAL FINDINGS ACTUAL FINDINGS INTERPRETATION