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CASE PRESENTATION

Pneumothorax

INTRODUCTION: NAME: MR. R.O.M AGE: 46 YEARS OLD CIVIL STATUS: MARRIED DATE OF BIRTH: 11/19/64 PLACE OF BIRTH: NEGROS OCC. EDUCATIONAL ATTAINMENT: HIGH
SCHOOL GRADUATE RELIGION: CATHOLIC DIAGNOSIS: PNEUMOTHORAX (R) PTB

2º TO

.PRESENT HISTORY OF ILLNESS: -ONE DAY PRIOR TO ADMISSION. A FEW HOURS LATER. THE CLIENT EXPERIENCED SUDDEN DIFFICULTY OF BREATHING WITH COUGH WITH YELLOW SPUTUM. THE CLIENT STATED THAT HE HAD DIFFICULTY GOING TO SLEEP DUE TO COUGH AND DOB. THE CLIENT REPORTED DRINKING TWO BOTTLES OF LIQUOR (EMPERADOR) BEFORE GOING TO BED.

PAST HISTORY OF ILLNESS: -THE CLIENT WAS HOSPITALIZED LAST 2005 AND WAS DIAGNOSED WITH PTB. AFB AND SPUTUM EXAMS AND WAS STATED THAT HE WAS CURED. HE COMPLETED HIS 6 MONTHS ANTI-KOCH·S TREATMENT AND OTHER CONFIRMATORY TEST SUCH AS XRAY·S. .

He also states that he is aware that excessive or frequent alcohol consumption is not good for his body. He defines being healthy by having good relationship to his family and friends. and being able to drink alcohol after a day·s work.FUNCTIONAL HEALTH PATTERN Health Perception. and not worrying about any problems. He states that he·s aware that being a jeepney driver predisposes him to sickness and he just takes OTC meds to relieve sickness.Health management pattern The client states that he perceives himself to be healthy when he feels good and happy. .

only ´sometimesµ The client usually weighs 130 lbs.2 cups of rice. which is evidenced by his current weight 131. 6 ² 7 days a week and drinks cobra/ sting within a day. He reports feeling of weight gain. His food and fluid preferences are meat and alcoholic beverages. he eats meat only twice a week. . His usual diet comprises of mostly fish and vegetables with 1 ½ .Metabolic pattern The client·s typical daily food intake includes breakfast.Nutritional. lunch. brandy) a day.3 lbs. plus 2 or less bottles of alcohol (gin. afternoon snack and dinner. He drinks 5 ² 8 glasses of water. . He doesn·t regularly take vitamin C and multivitamins.

He doesn·t use any laxatives or stool softeners as he doesn·t experience any difficulty in bowel elimination. The client·s usual urine pattern is 3 ² 5 times a day without any discomfort or burning sensation.formed not watery. His stool characteristics are brown and soft stool.Elimination ² Bowel pattern The client·s usual bowel pattern is 2 ² 3 times a day. semi. . He often just leaves his sweat to dry. He sweats a lot. He characterizes his urine to be yellowish in color.

he works until 9PM or 10PM before he goes drinking with his friends and goes home at 11PM and by 12MN he goes to sleep. he eats afternoon snacks before working as a jeepney driver by 4PM. the client takes his lunch afterwards and rests or takes a nap from 1PM . eats breakfast and goes to work in the community farm. upon awakening between 4-5am. the client takes a bath.3PM. .Activity ² Exercise pattern The client·s activities of daily living are: in the mornings.

general and bed mobility. grooming. . cooking and home maintenance with full of self care. The client is able to do feeding. like shoveling and fetching pails of water. client states that his form of exercise is doing work in the farm. dressing. which is level 0 in the Functional Level. bathing. in the mornings.

He feels rested and ready for daily activities after sleep. from 12MN ² 4 or 5AM.Sleep ² Rest pattern The client experiences early awakening and interval between those. He states that he usually takes afternoon naps from 1PM ² 3PM. He has an inadequate amount of sleep ranging from 4 ² 5 hours every night. . The client states that he·s used to having only 4 ² 5 hours of sleep.

the client states having no problems. reasoning of ´getting old. He mentioned experiencing trouble recalling dates and names. He can recognize color and objects for what they are. He has never visited an ophthalmologist but reports no blurring of vision or difficulty in seeing or reading.Cognitive ² Perceptual pattern The client states that he has no problems with his vision and does not wear eyeglasses. . he is able to hear sounds clearly and does not experience any pain or ringing in the ears. and only a few words and common phrases in English. In terms of hearing.µ The client can fluently speak Tagalog and Bisaya. In taste and smell.

He states that he generally feels good about himself except when he experiences financial problems. He feels proud that he is still capable of doing strenuous activities and work in his age. .Self-perception/Self-concept pattern The client describes himself to be a cheerful and friendly person who enjoys spending time with family and friends.

They spend time together during Sundays when they go to church and to the mall. the eldest two of which are also working and helping with financing daily expenses.Role ² Relationship pattern The client describes his relationship with his family to be good. He states being close friends with neighbors in their community. . He is the primary breadwinner and decision maker of his family which comprises of his wife and 8 children. The client states being part of a large group of friends who belong to the same profession and like going out for drinks.

as evidenced by having 8 children and as stated by the client to occur during special occasions or when they ´feel like it. . The client was circumcised when he was 13 years old.Sexuality ² Reproductive pattern The client describes himself to be sexually active.µ The client uses condom and coitus interruptus.

and going with family every Sundays to church and the mall. He states that he copes with stress by sleeping ´bumabawi ng tulogµ. enjoying nights out drinking alcohol with friends and colleagues in Zapote-Paliparan Association.Coping ² Stress pattern The client usually experiences physical stress from work demands and financial stress. he feels better and relaxed afterwards. . Most of the time.

He states that he is strict with his children when it comes to disciplining and teaching them about faith. The client states that his plans for the future are retiring with his wife back to their province once all his children graduate from high school. every Sundays.Value ² Belief pattern The client·s religion is Catholic. He and his family go to church 4 times a month. . only now he could not go to church with his family every Sundays. He states that having his current disease and being hospitalized do not affect his faith.

FREQUENCY AND ROUTE ALSO ITS SIDE EFFECTS TO THE CLIENT ADVISED PATIENT TO TAKE MULTIVITAMINS E.DISCHARGE PLANNING M.ENCOURAGE CLIENT TO HAVE DAILY LIGHT EXERCISE TO PROMOTE HEALTHY LIFESTYLE ENCOURAGED TO MAINTAIN CLEANLINESS OF THE HOUSE AND SURROUNDINGS. ADVISED PATIENT TO AVOID OVEREXPOSURE TO DUST AND ALLERGENS.ADVICE CLIENT·S SO TO GIVE FOLLOWING MEDICINE AT RIGHT TIME. DOSE. .

such as fever. O.T. Instructed patient to perform daily change of dressing over incision site while observing aseptic technique. .Advised patient to perform deep breathing exercises. oximetry and chest x-ray. Observed for signs of complications of pneumothorax. Checked laboratory results for ABG. H. and redness and swelling around the incision site.Observed for signs of infection in incision site of CTT.advice client to go to check-up regularly even though he·s no longer experiencing pain/ discomfort.

. Advised patient to keep being sexually active while observing contraceptive methods.Diet Encouraged limiting of alcohol intake to prevent liver impairment Instructed patient to eat nutritious meals and avoid fatty foods which interfere with normal liver cell function. Spiritual/Sexual Activities Advised to continue praying to God and hear mass on Sundays.