NURSING HEALTH HISTORY

I. BIOGRAPHIC DATA

NAME E.T.S
AGE 89
SEX Male
MARITAL STATUS Widowed
RELIGION Roman Catholic
OCCUPATION Retired
EDUCATIONAL ATTAINMENT N/A
ADDRESS #38 Sampaguita Street
IMPRESSION/FINAL DIAGNOSIS Pneumothorax left probably secondary to
emphymatus bleb rupture CAP-MR COPD in
moderate exacerbation, S/P PTB traumatic
(2012) PTR relapse; HE HYNA FC from JAH
IHHD, Chronic Acute failure in CUR BPE
DATE AND TIME ADMITTED January 10, 2024 – 9:25 PM
ATTENDING PHYSICIAN Dr. Ryan S. Mambulao

II. CHIEF COMPLAINT OR REASON FOR VISIT

“Difficulty of breathing”, as verbalized by the caregiver.

III. HISTORY OF PRESENT ILLNESS

Patient was previously admitted at our institution, managed CAP-MR, with
thorax, Acute Failure and pneumonia. Patient had his NGT changed seen with date as
request reveal pneumothorax 60% they brought tele consult with a pulmonologist,
advised to look consult with a surgeon for possible CTT. However, did not comply. Thus
PTA, had RR 30 and desaturation, called AMD, advised ER admission had chest pain
and palpitation as claimed.

IV. PAST HISTORY

N/A

V. FAMILY HISTORY OF ILLNESS (GENOGRAM)

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VI. COGNITIVE-PERCEPTUAL PATTERN

VII. PHYSICAL/HEALTH ASSESSMENT

INSPECTION PALPATION PERCUSSION AUSCULTATION

General Patient appears With bilateral Wheezing and
appearance awake, lying on edema crackles noted.
bed
Neurologic GCS: 10
Oriented and
conscious
Skin Brown Cold and
complexion; dry clammy skin;
and senile skin right hand pitting
turgor edema
Hair Black and white
in color; dry; not
evenly
distributed;
minimal hair
Scalp Absence of
dandruff; no
lesions; moles
Head and neck Head is firm;
tracheostomy
tube attached
Tongue Pinkish, slightly
deviated to left
side
Eyes Pupils are faded
gray 2-3 mm,
round, and
reactive to light
Ears No skin lesions
and discharge
Nose Centrally
located; same

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 color with facial
skin;
Nasogastric
Tube attached
Mouth Lips are dry and
pale in color,
absence of
teeth, and pink
gums
Heart Heart rate of 92
bpm
Chest Moves No tenderness; Hyperresonant
symmetrically lesions; masses;
during nodule
respiration
Lungs Respiratory rate Grunting,
of 20 cpm wheezing,
Thoracostomy at crackles are
left lung heard
attached to 3-
way bottle
system
Abdomen Sunken
Genitalia No lesions;
With Foley Bag
Catheter
inserted
Nail Pale in color, Dry texture;
dry, with capillary refill of
clubbing noted <5 seconds
Back and With bedsore at
extremities the back of the
spine and lesion
seen

VIII. LABORATORY FINDINGS

Chemistry Department

IX. ANATOMY AND PHYSIOLOGY

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 Hematology Department

Differential Count

X. ANATOMY AND PHYSIOLOGY

The respiratory system is the system of the body responsible for breathing, which is the
process of taking in oxygen and expelling carbon dioxide. It is composed of the upper and lower
respiratory tract, bronchial/systemic circulation, and gas exchange at the level of the lungs and
tissue cells which work together to function for one main function: to deliver oxygen into the
human body while removing waste gases.
In addition to gas exchange, the respiratory system performs other roles that make it essential
to our breathing which include:

 Warming the air to match your body temperature and moisturizing it to the
humidity level your body needs.

 Protecting your airways from harmful substances and irritants. This is done by
coughing, sneezing, filtering, or swallowing them.

 Supporting your sense of sense of smell.

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UPPER RESPIRATORY TRACT

The upper respiratory tract includes the nose, paranasal sinuses, pharynx, larynx, and
epiglottis. These structures not only provide passage for air to be breathed in and out, but they
also filter, humidify, warm the outside air, and equalize the ear pressure.
Nose

- It allows air to enter the body, then filters debris and warms and moistens the air

Paranasal Sinuses

- One of many small hollow spaces in the bones around the nose. Paranasal sinuses are
named after the bones that contain them: frontal (the lower forehead), maxillary
(cheekbones), ethmoid (beside the upper nose), and sphenoid (behind the nose). They
secrete mucus to protect against infection and humidify the air you breathe before it
reaches the lungs. The thin mucus traps dirt, dust, and pollutants and drains out into the
throat where stomach acid ultimately destroys it when it's swallowed. Sinuses help to
lighten the weight of the skull.
Pharynx

- The pharynx, commonly called the throat. It is the passageway connecting the nasal
cavity, larynx, oral cavity, and esophagus. Routes air coming in your nose and mouth
down to your larynx (voice box), which, in turn, moves air to your trachea and lungs. It
also delivers food and liquid to your esophagus, which sends them on to your stomach.
In general, it supports your respiratory and digestive systems.
Larynx

- Located in the third to sixth cervical vertebra. It is a cartilage, connective tissue

framework that connects the pharynx to the trachea. Its function is to route food and air
into appropriate passageways. It is also responsible for voice production.
Epiglottis

- It is a cartilage flap atop the larynx that seals the airway off when swallowing to prevent
foods from entering the larynx.

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LOWER RESPIRATORY TRACT

The major passages and structures of the lower respiratory tract include the windpipe
(trachea) and within the lungs, the bronchi, bronchioles, and alveoli. The primary purpose of
these structures is to move oxygen to and carbon dioxide from the alveoli where gas exchange
takes place. The primary purpose of these structures is to move oxygen to and carbon dioxide
from the alveoli where gas exchange takes place.

Trachea

- Also called as “windpipe”, is a narrow tube that connects the larynx to the bronchi of the
lungs. The windpipe is prone to a lot of infections as air is inhaled through this pipe, and
hence it is filled with mucus to trap the microbes. During inhalations, the air is drawn into
the trachea, where it is warmed and moisturized before entering the lungs. As the air is
being warmed up, the trachea helps in thermoregulation.
Lungs

- These are the primary organs of the respiratory system.

- Their main functions are to transfer oxygen from the air to the blood and to release
carbon dioxide from the blood to the air.

- It takes up most of the space inside the chest and is surrounded by the chest wall which
is made up of the ribs and the muscles between the ribs.

- It is separated by the mediastinum, which contains the heart and other organs. Below
the lungs is the diaphragm, a thin muscle that separates the chest cavity from the
abdomen.

- The lungs also play a role in the body’s defenses against harmful substances in the air,
such as smoke, pollution, bacteria or viruses.

- These substances can pass through the nose and become trapped in the lungs. The
lungs would then produce a thick, slippery fluid (mucus), which can trap and partly
destroy these substances from the air. The cilia move rapidly to push the mucus up
through the bronchi, where it is removed by coughing or swallowing.

- Lung Lobes

o The left lung has 2 lobes. The heart sits in a groove (cardiac notch) in the lower
lobe.
o The right lung has 3 lobes and is slightly larger than the left lung.

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Bronchi

- It is the main passageway into the lungs. Bronchi carry air to and from your lungs. It also
helps moisturize the air you breathe and screen out foreign particles. The airways are
lined with cells that create mucus.
Bronchioles

- The function of the respiratory bronchioles is to bring air to the alveolar clusters for gas
exchange. Respiratory bronchioles are made of cells. They have an inner lining made of
epithelial cells and mucus secreting cells. This layer is surrounded by smooth muscle
cells that control the dilation of the bronchioles. The bronchioles are attached to the rest
of the lung with connective tissue such as collagen proteins.
Alveoli

- Alveoli are microscopic balloon-shaped structures located at the end of the respiratory
tree. They expand during inhalation, taking in oxygen, and shrink during exhalation,
expelling carbon dioxide. These tiny air sacs are the site where gas exchange between
inspired air and the blood takes place.

PLEURA MEMBRANE
The pleura is a thin membrane that covers the lungs and lines the chest wall. It protects
and cushions the lungs and produces a fluid that acts like a lubricant so the lungs can move
smoothly in the chest cavity. The pleura is made up of 2 layers:
o inner (visceral) pleura – the layer next to the lung.

o outer (parietal) pleura – the layer that lines the chest wall

o The area between the 2 layers is called the pleural space.

PULMONARY SURFACTANT
The lungs produce a mixture of fats and proteins called lung or pulmonary surfactant.
The surfactant coats the surfaces of the alveoli, making it easier for them to expand and deflate
with each breath.

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XI. PATHOPHYSIOLOGY

Risk Factors:

o Smoking (tobacco)
o PTB
o Diabetes  Digital clubbing
o COPD bronchiectasis  Mucus production
o Septic pneumonia

Gradual damage of lung tissue

Alveolar rupture

Formation of
emphysematous blebs

Air pressure changes

Rupture of emphysematous  Chest pain

blebs  SOB

Air escape into chest cavity

Secondary spontaneous
pneumothorax

Disruption of parietal or Irritation of highly Acute onset

visceral pleura or the sensitive parietal severe, stabbing
tracheobronchial tree pleura pleuritic chest pain

Injured tissue forms a one

way valve into pleural space

Air enters and fills pleural

space but cannot leave
(tension pneumothorax)

Pressure in ipsilateral Ipsilateral Mediastinal Tracheal

hemithorax rib splaying shifting deviation

Ipsilateral lung collapse

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 Sound resonance through No air entry into Compresses Impaired gas
air compared to lung tissue affected lungs superior and/or exchange in the
inferior vena cava affected alveoli

Chest wall
Tympany/ hyper- resonant
expansion Blood return to V/Q mismatch and
right atrium blood shunt

Breath sounds
Blood backs up into Hypoxia
venous system
Peripheral edema

 Blood oxygenation
Tachycardia CO  Tachypnea

XII. MODEL DIAGRAM

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 XIII. NURSING CARE PLANS
ASSESSMENT NURSING RATIONALE PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION
Subjective Cue: Ineffective airway Inability to clear Short-term Goal: - Suction -To clear airway Short term Goal:
clearance related to secretions or After 8 hours of secretion when excessive or After 8 hours of nursing
“Nahingadi ini hiya kay nag- increased mucus obstructions from nursing regularly viscous secretions care the patient had
iinubo ngan nakurian na secretion as the respiratory intervention the are blocking slight improvement in
gud lat hiya paghinga” as evidenced by tract to maintain a patient will be able airway. maintaining air way
verbalized by caregiver. bronchiectasis clear away to maintain airway patency
patency. - Elevate head -To promote lung
Objective Cue: of bed and expansion and Goal Partially met
- RR 28cpm Long term Goal: change of reduces risk of
- Difficulty of breathing After 2-4 days of position every obstruction
-audible wheezing and (Nurse’s Pocket nursing 2hrs Long-term Goal:
crackles upon auscultation Guide, 12th intervention the After 2-4 days of
-productive cough with Edition,P-80) patient will be able - Auscultate -Crackles and nursing care the
yellow sputum to: breath sound wheezing are secretions are not fully
-latest ABG (respiratory - Eliminate heard due to eliminated.
Acidosis retained presence of
secretion breathing Goal not met

- Ensure proper -Adequate

hydration hydration thins
mucus, making it
easier to
expectorate

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 ASSESSMENT NURSING RATIONALE PLANNING NURSING RATIONALE EVALUATION
DIAGNOSIS INTERVENTION

Objective: Impaired ability to Pressure sores are Long term goal: 1. Assist with 1. to maximize Long term goal:
reposition self in areas of damage After 4 days of treatment of potential for After 4 days of nursing
-Immobility bed related to to the skin and the nursing underlying condition. mobility and intervention the patient
-Insufficient muscle decreased mobility underlying tissue intervention the optimal function. has been able to:
strength as evidenced by caused by patient will be able 1. received stage-
pressure ulcer constant pressure to: 2. Ascertain that 2. to promote appropriate
stage II. or friction. 1.receive stage- dependent client is mobility and wound care and
Pressure ulcers appropriate wound placed in best bed for enhance has controlled
are also called care and has situation (e.g., correct environmental risk factors for
bedsores, or controlled risk size, support surface, safety. the prevention of
pressure sores. factors for the and mobility additional ulcers.
They can form prevention of functions). 2. experienced the
when your skin additional ulcers. healing of
and soft tissue 2. experience the 3. Instruct 3. Promotes pressure injuries
press against a healing of pressure client/caregiver in bed independence and and experience
harder surface, injuries and capabilities (e.g., purposeful pressure
such as a chair or experience mobility functions and movement. reduction.
bed, for a pressure reduction. set positions),
prolonged time. encouraging client to
Short term goal: participate as much Short term goal:
This pressure After 8 hours of as possible, even if After 8 hours of nursing
reduces blood nursing only to move head or intervention the patient
supply to that area. intervention the run bed controls. has been able to:
Lack of blood patient will be able 1. Maintain or increase
supply can cause to: 4. Change client's 4. to improve strength and function of
the skin tissue in 1.Maintain position position frequently, circulation, reduce affected body part.
this area to of function and moving individual tightening of
become damaged skin integrity. parts of the body muscles and joints, GOAL PARTIALLY
or die. When this 2.Maintain or (e.g., legs, arms, normalize body MET
happens, a increase strength head) using tone, and more
pressure ulcer may and function of 5. To assist closely simulate
form. This type of affected body part. movements; body positions an
skin damage can 3. Turn dependent reposition in good individual would
develop quickly to client frequently, body alignment, using normally use.
anyone with utilizing bed and appropriate supports.
reduced mobility, mattress11
such as older positioning 6. to provide support
people or those settings. for the client's body
confined to a bed. 4. Instruct client and to prevent injury
XIV. DISCHARGE PLANNING

Prescribe antibiotics and bronchodilators as per the treating

physician's recommendations for pneumonia and bronchiectasis
management. Provide a clear medication schedule with detailed
MEDICATION instructions, considering the patient's age and any potential side
effects. Include a comprehensive medication review during follow-
up appointments.

Collaborate with a physiotherapist to design a gentle exercise plan

that focuses on breathing exercises, mobility, and endurance.
Tailor the plan to accommodate the patient's age and physical
EXERCISE condition, promoting respiratory health without causing undue
strain. Emphasize the importance of consistent, low-impact
exercises.
Educate the patient and their caregivers on the nature of
pneumonia, OCPD, and bronchiectasis. Provide information on
symptom recognition, early intervention, and self-management
TEACHINGS strategies. Address concerns related to exacerbation triggers and
ensure clear communication on when to seek immediate medical
attention.

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