TABLE OF CONTENTS

Title Page

Table of Contents……………………………………………………………………………........................

Introduction……………………………………………………………………………………………………………

Objectives………………………………………………………………………………………………………………

Readings………………………………………………………………………………………………………………..

I. Patient’s Profile……………………………………………………………………………………………

a. Personal Data………………………………………………………………….………………………..

II. Family Background……………………………………………………………….………………………

a. Family Background Table…………………………………………………….……………………

III. Source of Income…………………………………………………………………………………………

a. Family Income……………………………………………………………….………………………….

IV. Family Expenses………………………………………………………………….……………………….

V. Health History…………………………………………………………………….………………………..

a. Family Health History……………………………………………………………………………….

b. Past Health History…………………………………………………………………………………..

c. Present Health History………………………………………………………...……………………

VI. Developmental Task……………………………………………………………….……………………

VII. Anatomy and Physiology………………………………………………………….…………………..

VIII. Pathophysiology…………………………………………………………………………………………..

IX. Patterns of Functioning………………………………………………………………………………..

X. Level of Competencies…………………………………………………………….……………………

XI. Physical Assessment……………………………………………………………….……………………

XII. On Going Appraisal……………………………………………………………….………………………

XIII. Laboratory Procedures…………………………………………………………….…………………..

XIV. Medical Management……………………………………………………………..………………….

XV. Drug Study……………………………………………………………………….....………………………

XVI. Nursing Care Plan………………………………………………………………….……………………

XVII. General Evaluation………………………………………………………………………………………

INTRODUCTION

Normally, a person is unaware of breathing processes, a physiologic function that isessential to
life itself. However, it is quickly recognized that even a slight disturbance of the respiratory system
causes both psychological and physiological responses. Fear and anxiety are common reactions to
difficult breathing and the body attempts to gain control of its breathing. Several automatic, protective
physiological responses are also in place to increase air conduction and to protect the airways from
inhaled irritants and excess mucus when needed. Systemic mechanisms ensure gas exchange and
circulation throughout the body (Daniels, 2010).Disorders affecting the lower respiratory system [below
the larynx], pleural cavity, and chest wall can affect the ability to effectively move air into and out of the
lungs [ventilation] and the exchange of oxygen and carbon dioxide across the alveolar-capillary
membrane [respiration](LeMone, 2008).Pneumonia is an inflammatory process caused by numerous
infectious agents [e.g., bacteria, viruses, and fungi] and injurious events [e.g., aspiration and smoke]
(Story, 2012). It is a form of acute respiratory infection that affects the lungs. 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 more painful and limits
oxygen intake (WHO, 2013). One of the common type of pneumonia is Community Acquired pneumonia.
Community-acquired pneumonia (CAP) is a disease in which individuals who have not recently been
hospitalized develop an infection of the lungs (pneumonia).

According to the Philippine Health Statistics, in the year 2009, Pneumonia is the fourth leading
cause of death in the Philippines wherein out of 100,000 population, 42,642 people die of it (DOH,
2013).

A. GENERAL OBJECTIVES

This case study seek to demonstrate student’s knowledge regarding the general health and
disease of a patient diagnosed with CAP, its disease process, treatment plan, medical and nursing
intervention.
B. SPECIFIC OBJECTIVES

At the end of the study, the student nurses will be able to:

1. Accurately present a thorough general assessment of the client which includes physical assessment
and Health history taking

2. Explain the pathophysiology and etiology of CAP

3. Described the diagnostic used, its result and how it performed.

4. Understand the role of drug therapy in managing the patient related disease.

5. Recognize the contributing factors associated in the development of the diagnosed disease.

6. Acquired knowledge to apprehend the disease process by gathering important information from the
patient by the use of interview, observation, and by asking questions that correlates to the disease.

7. Appropriately apply nursing interventions necessary to enhance the patient’s condition in reference
with the learned theories and concepts of the disease.

8. Formulate a nursing care plan effective enough to help patient recover from the disease.

READINGS

Pneumonia is an infection that inflames the air sacs in one or both lungs. The air sacs may fill
with fluid or pus (purulent material), causing cough with phlegm or pus, fever, chills, and difficulty
breathing. A variety of organisms, including bacteria, viruses and fungi, can cause pneumonia.

Pneumonia can range in seriousness from mild to life-threatening. It is most serious for infants
and young children, people older than age 65, and people with health problems or weakened immune
systems.

The most common cause of pneumonia in adults >30 is Bacterial Infection.

Streptococcus pneumoniae is the most common pathogen in all age groups, settings, and
geographic regions. However, pathogens of every sort, from viruses to parasites, can cause pneumonia.

The airways and lungs are constantly exposed to pathogens in the external environment; the
upper airways and oropharynx in particular are colonized with so-called normal flora. Microaspiration of
these pathogens from the upper respiratory tract is a regular occurrence, but these pathogens are
readily dealt with by lung host defense mechanisms. Pneumonia develops in three ways. First,
pneumonia develop when defense mechanisms are compromised. Second,macroaspiration leads to a
large inoculum of bacteria that overwhelms normal host defenses and lastly a particularly virulent
pathogen is introduced.

Occasionally, infection develops when pathogens reach the lungs via the bloodstream or by
contiguous spread from the chest wall or mediastinum.

Upper airway defenses include salivary IgA, proteases, and lysozymes; growth inhibitors
produced by normal flora; and fibronectin, which coats the mucosa and inhibits adherence.

Nonspecific lower airway defenses include cough, mucociliary clearance, and airway angulation
preventing infection in airspaces. Specific lower airway defenses include various pathogen-specific
immune mechanisms, including IgA and IgG opsonization, antimicrobial peptides, anti-inflammatory
effects of surfactant, phagocytosis by alveolar macrophages, and T-cell–mediated immune responses.
These mechanisms protect most people against infection.

Numerous conditions alter the normal flora (eg, systemic illness, undernutrition, hospital or
nursing home exposure, antibiotic exposure) or impair these defenses (eg, altered mental status,
cigarette smoking, nasogastric or endotracheal intubation). Pathogens that then reach airspaces can
multiply and cause pneumonia.

Specific pathogens causing pneumonia cannot be found in < 50% of patients, even with
extensive diagnostic investigation, primarily because of the limitations of currently available diagnostic
tests. But because pathogens and outcomes tend to be similar in patients in similar settings and with
similar risk factors, pneumonias can be categorized as: Community-acquired, Hospital-acquired
(including ventilator-acquired and postoperative pneumonia), Health care–associated (including nursing
home-acquired pneumonia), Occurring in immunocompromised patients, including patients with HIV
infection (see Pneumocystis jirovecii Pneumonia), aspiration pneumonia, which occurs when large
volumes of upper airway or gastric secretions enter into the lungs

COMMUNITY-ACQUIRED PNEUMONIA
 Community-acquired pneumonia (CAP) is one of the most common infectious diseases and is 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 tract infections are being identified as
common etiologies of CAP. The most common viral pathogens recovered from hospitalized patients
admitted with CAP include human rhinovirus and influenza.

The term “typical” CAP refers to a bacterial pneumonia caused by pathogens such as S pneumoniae, H
influenzae, and M catarrhalis. Patients with typical CAP classically present with fever, a productive cough
with purulent sputum, dyspnea, and pleuritic chest pain.

Community-acquired pneumonia (CAP) is defined as pneumonia acquired outside hospital or

healthcare facilities. Clinical diagnosis is based on a group of signs and symptoms related to lower
respiratory tract infection with presence of fever >38ºC (>100ºF), cough, expectoration, chest pain,
dyspnoea, and signs of invasion of the alveolar space. However, older patients in particular are often
afebrile and may present with confusion and worsening of underlying diseases.

I. PATIENTS PROFILE

a. Personal Data

Name: Patient Ly

Address: Brgy. 33 A Lapaz Proper Laoag City

Hospital Number: 0000043

Health Record Number: 0186099

Age: 68

Gender: Female

Date of Birth: August 23, 1950

Place of Birth: Laoag City

Civil Status: Married

Religion: Roman Catholic

Educational Attainment:

Level Name of School Year Graduated

Elementary Graduate Lapaz Elementary School 1964

 Occupation: Fish Vendor

Chief Complain: Cough and Difficulty of Breathing

Admitting Diagnosis: Bronchial Asthma in Acute Exacerbation

Date of Admission: November 27, 2018

Time of Admission: 6:30 AM

Admitting Physician: Dr. Emely T. Pumaras

Final Diagnosis: Community Acquired Pneumonia

Date of Discharges: November 30, 2018

Time of Discharge: 1:00 PM

II. FAMILY BACKGROUND

MEMBERS SE AG CIVIL RELATIONSHI EDUCATION OCCUPATIO RELIGIO PLACE

OF X E STATU P WITH AL N N
OF
S PATIENT ATTAINMEN
THE T RESIDENC
FAMILY E

Melanio M 71 M Husband Elem Grad. None Roman La Paz,

Catholic Laoag City

Lydia F 68 M Patient Elem. Grad. Fish Vendor Roman La Paz,

Catholic Laoag City

Patricio M 46 M 1st born child College Grad. Fish Vendor Roman La Paz,
Catholic Laoag City

Melano M 44 M 2nd born child College Grad. None Roman La Paz,

Catholic Laoag City

Josefa F 42 M 3rd born child College Self- Roman La Paz,

Navarro Undergrad. employed Catholic Laoag City

Pacifico M 40 M 4th born child High School Constructio Roman La Paz,

 Grad. n Worker Catholic Laoag City

Marissa F 38 M 5th born child College Avon dealer Roman La Paz,

Pascual Undergrad. Catholic Laoag City

Panfilo M 32 S 6th born child High School Fish Vendor Roman La Paz,
Grad. Catholic Laoag City

The Asuncion family is a Nuclear Type of family which is composed of a father, mother and
children living together. Patient Ly and her husband is living together with their youngest son, Panfilo.
The rest of the family members live together with their own families respectively. Since they all live in
one barangay, the communication pattern is good. Conflicts and misunderstandings may arise
sometimes but with the help of Patient Ly and her husband, they managed the conflicts and
misunderstandings easily by talking and discussing the issues between them.

The family is matriarchal because regarding on decision making, she makes the decisions in the
family but still consults and discusses the issues with his husband.

The family is residing in Brgy. 33A La Paz, Laoag City, Ilocos Norte. They live at a Rural Area. They
are affiliated to Roman Catholic.

a. Family Income

The family’s primary source of income is selling fresh fishes such as tilapia, bangus, balaki,
mataan and suos. They have their own “kurong-kurong” which they used to go around to the near
barangays to sell fish every day. Their family income from selling fresh fish is ₱15,000 and Panfillo’s
girlfriend also giving ₱1,500 per month. In one month they have ₱16,500 money which they used for
family expenses.

Breakdown of Family Monthly Income

Qty/ Payment/kg Income/k Total Net Income/ Total

day g Capital/ Income/ Month Monthly
day day Net Income

Fish 20 kg ₱50 ₱25 ₱1000 ₱500 ₱15,000

₱16,500

Foreign Aid
IV. Family Expenses

Here is the monthly itemized expenses of the patient family:

MONTHLY FAMILY EXPENSES

Item Qty. Price/ unit Weekly Monthly Total/ Month

Market

Fish 0 0 FREE FREE

Pork 1kg ₱250 ₱250 ₱1,000

Chicken 1kg ₱230 ₱230 ₱920

Vegetables:

Tomato 1 pack ₱10 ₱10 ₱40

₱3,810

Kamote tops 1 bundle ₱15 ₱15 ₱60

Kangkong 1 bundle ₱15 ₱15 ₱60

Eggplant 1 pack ₱10 ₱10 ₱40

Saluyot 1 bundle ₱15 ₱15 ₱60

 Malunggay 1 bundle ₱25 ₱25 ₱100

Leaves

Others:

Rice 7 kg ₱45 ₱315 ₱1260

Eggs 12 pcs ₱6 ₱60 ₱240

Onion 3 pcs ₱5 ₱15 ₱15

Garlic 1 pcs ₱5 ₱5 ₱15

Grocery

Coffee sachet 3in 1 12 pcs ₱10 ₱120 ₱480

Bread 1 loaf ₱35 ₱35 ₱140

Detergent bar (Surf) 1sachet ₱9 ₱9 ₱36 ₱1,044

Detergent powder 2 sachet ₱10 ₱20 ₱80

(Surf)

Tooth paste sachet 1 pc ₱10 ₱12 ₱48

(colgate)

Bath soap 1 pc ₱25 ₱45 ₱100

Cooking oil 1 btl ₱25 ₱25 ₱100

Fish Sauce 1 btl ₱15 ₱15 ₱60

Health ₱210 ₱840 ₱840

Saving ₱50 ₱200 ₱200

Utilities

Electric Bill ₱500

Water Bill ₱300 ₱3,600

Mineral Water ₱400

Gasoline for Kurong-kurong ₱1,500

Kurong-kurong Maintenace ₱150

 Gasul ₱750

Here is the Illustration that shows where the family of patient Ly’s monthly income spend.
 MONTHLY EXPENSES

840

3,810

3,600

Market

Grocery

Savings

Utilities
1,044
200
Health
V. HEALTH HISTORY

a. FAMILY HEALTH HISTORY

Patient Ly claimed that there are familial diseases that are existing in their family such as ulcer,
asthma and arthritis.

According to her, she never saw her grandparents on both father and mother sides. On the
father side, she can only remember her father Napoleon. She can no longer remember the year when
her father died, but she claimed that his father’s death was due to a complication of ulcer. On the
mother side, her mother Polimena had an asthma but does not remember when she was diagnosed as
well as the medications she took. As she recalls it, the cause of her mother’s death was because of
“nagsarwa ti dara” and does not remember any details further regarding her mother’s death. Polimena’s
2nd brother died because of vehicular accident and Patient Ly does not remember what year when the
accident happened. Polimena’s 3rd brother died due to a disease but Patient Ly does not remember
what particular disease that caused his uncle’s death.

Patient Ly has 6 siblings. According to her, her eldest sister (Anastacia) is still living and she is 72
years old. She was diagnosed of arthritis but Patient Ly does not remember when her sister was
diagnosed as well as her medications that she is taking. Patient Ly’s 2nd sister (Miling) died when she
was 50 years old and according to her as she verbalized “tinamay da isuna” was the cause of her sister’s
death. Her 4 siblings are still alive and according to her, they are not diagnosed with any disease.

Ulcer and arthritis are passed down to her children. The eldest is Melanio, he was diagnosed
with ulcer and arthritis. He was diagnosed with ulcer a year ago at their brgy health center. He was given
Omepzarole and Kremil S but Patient Ly does not remember the dosage and frequency of these
medications. About his arthritis, Patient Ly only knows that Melanio takes flanax twice a day, he also
applies an efficacent oil to give a soothing effect on the affected area and to relieve the pain. He also has
“luslos” or hernia. According to Patient Ly, “nasakit kano nu agbagkat ti nadadagsen”. He went for a
consultation at a government hospital at Laoag City on September. He was advised to have a surgery but
they did not push through due to financial problem. Patient Ly’s youngest son has a goiter and was
diagnosed at a government hospital at Laoag City 2 years ago. He was given Propylthiouracil tablet and
takes it twice a day. Patient Ly does not remember the dosage of the said medication and she also
verbalized that “naminsan pay lang nga napan nagpacheck up tay anakko”. Regarding to her husband,
she claimed that he has not been diagnosed of any chronic disease but she mentioned and verbalized
“nakapsot lang isuna”.

The family experienced childhood illnesses such as measles, mumps and chicken pox. Measles
and Chicken pox were managed by avoiding seafoods, oily and salty foods, they also wear black overall
clothing because they believed that using an overall clothing “tapnu haan nga maanginan” and the
rashes will come out. For mumps, they applied “akot-akot” on the affected area to relieve the pain.

The family experienced common illnesses such as cough and colds, fever, headache, muscle
ache and toothache. For cough and colds, it is managed by taking Biogesic 500mg or Neozep 500mg and
taken twice a day after meals. They also used squeezed boiled oregano leaves and drink it once day. For
fever and headache, it is managed by taking Biogesic 500mg or Medicol 500mg and taken twice a day
after meals. For toothache, it is managed by taking Mefenamic Acid 500mg and taken once a day after
meal. For muscle ache, it is managed by applying efficacent oil on the affected area and taking flanax
once day after meal.

According to Patient Ly, she does not know if her grandparents and parents received an
immunization. All her siblings received an immunization but she does not know if it was complete. And
to her children, she claimed that all of them received a complete immunization.

The family uses herbal medicine such as oregano. They boiled it, squeezed it then drink it once a
day. They used it for cough and colds.

They also seek consultation to faith healers such as albularyo when they experienced
“anannong”. They also go to a “mangngilot” when they have a “bullo” or fractures.

The family uses OTC drugs such as Biogesic, Neozep, Flanax, Medicol and Mefenamic Acid. They
usually buy those drugs at the Botika ng Barangay. Most of the family members only go to the hospital
when they really feel ill.

Most of them do not have time to do exercises. They eat healthy foods such as fish, vegetables,
and they seldom eat pork. They seldom drink carbonated drinks. None of them is smoking cigarette.
Patient Ly’s two brothers and her two sons drink alcoholic beverages such as “red horse” or “gin”
moderately.

b. PAST HEALTH HISTORY

 Patient Ly is the 3rd born child among 7 children. She was born on August 23, 1950. According to
her, she did not receive any vaccination because she was afraid to be injected and during physical
assessment, there was no BCG scar noted on her deltoid.

During her childhood, she experienced common childhood illnesses such as chicken pox and it was
managed by avoiding oily and salty foods and her mother boiled guava leaves and used the water for
taking a bath to relieve itchiness; measles and it was managed by using black longsleeves and pajamas
to cover up the whole body; mumps and it was managed by applying an “akot-akot” at the inflammed
area to relieve the pain. According to her, she can no longer remember what age she was when she
experienced those illnesses.

Patient Ly had already experienced usual illnesses such as cough and colds, fever, toothache and
headache. For cough and colds, it is managed by taking Biogesic 500mg or Neozep 500mg and taken
twice a day after meals. She also used squeezed boiled oregano leaves and drink it once day. For fever
and headache, it is managed by taking Biogesic 500mg or Medicol 500mg and taken twice a day after
meals. For toothache, it is managed by taking Mefenamic Acid 500mg and taken once a day after meal.
According to her, she continues to work even if she is sick as long as she can still do it and to have a rest
only if she really feels ill.

Patient Ly does not smoke neither drink alcoholic beverages. She is fond of eating salty and oily
foods. She drinks carbonated drinks like coca-cola moderately. She also claimed that she has no allergies
on foods or medicines. She is a fish vendor, together with her two sons, they go around riding a “kurong-
kurong” every day to sell. According to her, if she has a free time she does the laundry the whole day
and she verbalizes “kanayun nak nga mabanbannog ta aglablaba nak nga agmalmalem nukwa”.

Patient Ly undergone breast lump removal surgery at the Ranada Hospital but she can no longer
remember the exact year of her surgery.

On 1986, Patient Ly claimed that she experienced difficulty of breathing, cough and colds and
went to MMMH & MC for consultation. She can no longer remember the physician who checked up on
her and she was given Ventolin rotacaps and was taken by inhalation using Ventolin Rotahaler for thrice
a day.

On 1996, she also undergone cataract surgery at MMMH & MC. She was given an eye drops but
she can no longer recall the name of the eye drops. She can no longer remember any details about it.

5 years ago (2013), she was hospitalized at a government hospital in Laoag City due to Bronchial
Asthma. She can no longer remember the physician and the medications she took that time.

c. PRESENT HEALTH HISTORY

Three days PTA (Nov.24, 2018), she had a productive cough with a yellowish phlegm. She
managed it by nebulization of salbutamol 2mg and took it twice a day. She also had a colds and
managed it by taking Neozep 500mg and took it twice a day.
 One day PTA, according to Patient LY, she washed their clothes the whole day.

On Nov. 27, 2018 @ around 1am in the morning she was rushed to a government hospital in Laoag City
due to a complaint of difficulty of breathing, cough and colds, chest pain and back pain. At 3:30am, the
given medications were hydrocortisone 10mg, omeprazole 40mg, clarithromycin 500mg, levacetirizine 1
tab, acetylceistin 200mg in ½ glass of water; nebulization with salbutamol + ipratropium; and oxygen via
nasal cannula @ 1-2lpm. At around 6:25 in the morning she was admitted with an admitting diagnosis of
Bronchial Asthma in Acute Exacerbation and the admitting physician was Dr. Emely T. Pumaras. The
ordered diagnostic tests were Chest X-ray and EKG. The ordered laboratory tests were FBS and
Creatinine, Blood Electrolytes and CBC.

VI. DEVELOPMENTAL DATA

a. Robert J. Havighurst’s Developmental Theory

Development can be assessed on the basis of how many tasks a person has completed, such
tasks are called developmental tasks. The developmental task was develop by Havighurst. The concept
of developmental task is characterized by a long series of tasks that a person have to learn through their
lives. According to Havighurst, successful achievement of a certain task is expected to lead to happiness
and to success with later tasks, while failure may result in unhappiness, disapproval by the society, and
difficulty with later tasks. Developmental theory have six stages this stages includes: Childhood, Middle
Childhood, Adolescence, Early Adulthood, Middle Age, and Later Maturity.

The patient growth and development in Havighurst theory is already in last stage called Later
Maturity. In this stage, the patient fully achieved the first task which is adjusting to decreasing physical
strength and health. She limits herself in carrying heavy materials as she verbalized “Nu adda
nadadagsen nga mabagkat aglalo ni inkami aglako ket pabagkat ko nukua kadidiay anak kun kasi diak
met makaya ti agbagkat ti nadadagsen nen ta nakapsut metti bagi kun. Idi kabanbanuwagak ket napigsa
nak nga agubra ken agbagkat iti nadadgsen ngem ita ket haan ko kayan isu nga kadwak nga kanayun tay
anak ko nga lalaki nu inkami aglako.” The second and third tasks are not achieved by the patient because
even she is now in her 60’s she never thinks to retired yet. She worked every day selling fish to meet the
family daily expenses. The patient husband is still alive but not able to work due to weakness. The forth
task is fully achieved by the patient. This task is fully achieved because she is an active member of the
woman’s club and senior citizen in their barangay. The fifth task is also fully achieved by the patient
because even the patient is busy working she never missed meetings and always involved herself to
barangay activities. The last task in later maturity stage is the satisfaction to physical living arrangement
and this was fully achieved by the patient. The patient doesn’t have any complain regarding the present
physical status, type of work she have and present living status. She is comfortably living a mixed
concrete and wood type of house. She have her own room with big bed. She mentioned that she sleep
together with her husband. The patient house is just 5 meters space to neighbor’s house but she have a
good relationship to her neighbors

DEVELOPMENTAL FULLY PARTIALLY NOT JUSTIFICATION

TASK ACHIEVED ACHIEVED ACHIEVED

1. Adjusting to  The patient fully achieved this task

decreasing physical because she is aware of her physical
strength and health capacity. She limits herself in
carrying heavy materials as she
verbalized “Nu adda nadadagsen
nga mabagkat aglalo ni inkami
aglako ket pabagkat ko nukua
kadidiay anak kun kasi diak met
makaya ti agbagkat ti nadadagsen
nen ta nakapsut metti bagi kun. Idi
kabanbanuwagak ket napigsa nak
nga agubra ken agbagkat iti
nadadgsen ngem ita ket haan ko
kayan isu nga kadwak nga kanayun
tay anak ko nga lalaki nu inkami
aglako.”

2. Adjusting to  The patient is not in her 60’s. She is

retirement and aware that she is already weak but
reduced income rather than enjoying her life and
relaxing, she work very everyday
selling fish to earn money to meet
their daily family expenses.

3. Adjusting to death of  This task is not achieved by the

a spouse patient because the patient
husband is still alive but not able to
work due to weakness so she is the
one working.

4. Establishing an  The patient fully achieved this task

explicit affiliation with because she is a member of senior
one’s age group citizen which she actively attend
meetings once a month.

5. Meeting social and  The patient fully achieved this task

civil obligations because even she is busy at work
she never missed attending
meetings and always involved
herself in barangay activities such as
Oplan dalus.

6. Establishing  The patient is fully satisfied to their

satisfactory physical physical living arrangement. She
living arrangement didn’t have any complain regarding
the present physical status, type of
work she have and present living
status. She is comfortably living a
mixed concrete and wood type of
house. She have her own room with
big bed. She mentioned that she
sleep together with her husband.
The patient house is just 5 meters
space to neighbor’s house but she
have a good relationship to her
neighbors. This was evidenced by
her popularity in her barangay that
when we visited her almost all of
the people know her.

ANALYSIS:

Based on the table above the patient fully achieved 4 tasks. This tasks are adjusting to
decreasing physical strength and health, establishing an explicit affiliation with her age group, meeting
her social and civil obligations and established satisfactory physical living arrangement. The two task
which are adjusting to retirement and reduced income and adjusting to death of a spouse are not
achieved by the patient.

b. ERICK ERICKSON’S THEORY OF PSYCHOSOCIAL DEVELOPMENT

Erick Erickson’s Theory is focused on the psychosocial and social aspects of human life. Erickson
maintained that personality develops in a predetermined order through eight stages of psychosocial
development, from infancy to adulthood. According to this theory, successful completion of each stage
results in a healthy personality and the acquisition of basic virtues.

The patient development under Erickson’s theory is later adulthood in which the crisis by this
life stage is integrity versus despair. Ego integrity is the result of positive resolution of the final crisis. The
ego integrity is viewed as the key to harmonious personality development. An individual who attained a
sense of integrity feel satisfaction and contentment in life. Despair in the other hand is the result of
negative resolution of the final crisis. This negative resolution is manifested by fear of death, struggle to
find purpose to their lives and wondering for self-worth.

When we assess the patient development under this stage here are the task that the patient had
achieved.

DEVELOPMENTAL FULLY PARTIALLY NOT JUSTIFICATION

TASK ACHIEVED ACHIEVE ACHIEVED

Under Ego Integrity

1. Life Contentment  The patient is already achieved

contentment in life. When we asked
what makes her satisfied in life she
stated that “Kuntento nak ti
panagbiag kun tangamin napagbasak
met dagitay anak kun, napintas met ti
kabibiag dan ken ada met sarili da nga
pamilyan. sisaganak pay ketdi nga
talawan idan ditoy lubong”

2. Working well with  The patient daughter stated that their

others mother is very friendly to other. She
was in hospital for three days and her
buyers and friends are looking for her.

ANALYSIS:

The patient is already achieved ego integrity because she is fully satisfied with her life. She have
no complains and very happy for the loved showered by buyers and friends.

VII. ANATOMY AND PHYSIOLOGY

The respiratory system consists of all the organs involved in breathing. These include the nose,
pharynx, larynx, trachea, bronchi and lungs. The respiratory system does two very important things: it
brings oxygen into the bodies, which is needed for the cells to live and function properly; and it helps to
get rid of carbon dioxide, which is a waste product of cellular function. The nose, pharynx, larynx,
trachea and bronchi all work like a system of pipes through which the air is funneled down into the
lungs. There, in very small air sacs called alveoli, oxygen is brought into the bloodstream and carbon
dioxide is pushed from the blood out into the air. When something goes wrong with part of the
respiratory system, such as an infection like pneumonia, it makes it harder to get the oxygen need and
to get rid of the waste product carbon dioxide. Common respiratory symptoms include breathlessness,
cough, and chest pain.

When breathe in, air enters the body through the nose or mouth. From there, it travels down
the throat through the larynx (or voice box) and into the trachea (or windpipe) before entering the
lungs. All these structures act to funnel fresh air down from the outside world into the body.

The upper airways is important because it must always stay open to be able to breathe. It also
helps to moisten and warm the air before it reaches the lungs.

The Lungs

The lungs are paired, cone-shaped organs which take up most of the space in the chests, along
with the heart. Their role is to take oxygen into the body, which is need for the cells to live and function
properly, and to help in getting rid of carbon dioxide, which is a waste product. Each individual have two
lungs, a left lung and a right lung. These are divided up into 'lobes', or big sections of tissue separated by
'fissures' or dividers. The right lung has three lobes but the left lung has only two, because the heart
takes up some of the space in the left side of our chest. The lungs can also be divided up into even
smaller portions, called 'bronchopulmonary segments.
 These are pyramidal-shaped areas which are also separated from each other by membranes.
There are about 10 of them in each lung. Each segment receives its own blood supply and air supply.

How they work

Air enters into the lungs through a system of pipes called the bronchi. These pipes start from the
bottom of the trachea as the left and right bronchi and branch many times throughout the lungs, until
they eventually form little thin-walled air sacs or bubbles, known as the alveoli. The alveoli are where
the important work of gas exchange takes place between the air and the blood. Covering each alveolus
is a whole network of little blood vessel called capillaries, which are very small branches of the
pulmonary arteries. It is important that the air in the alveoli and the blood in the capillaries are very
close together, so that oxygen and carbon dioxide can move (or diffuse) between them. So, when
breathe in, air comes down the trachea and through the bronchi into the alveoli. This fresh air has lots of
oxygen in it, and some of this oxygen will travel across the walls of the alveoli into the bloodstream.
Traveling in the opposite direction is carbon dioxide, which crosses from the blood in the capillaries into
the air in the alveoli and is then breathed out. In this way, the oxygen that need to live is brings into the
body, and get rid of the waste product carbon dioxide.

Blood Supply

The lungs are very vascular organs, meaning they receive a very large blood supply. This is
because the pulmonary arteries, which supply the lungs, come directly from the right side of the heart.
They carry blood which is low in oxygen and high in carbon dioxide into the lungs so that the carbon
dioxide can be blown off, and more oxygen can be absorbed into the bloodstream. The newly oxygen-
rich blood then travels back through the paired pulmonary veins into the left side of the heart. From
there, it is pumped all around your body to supply oxygen to cells and organs.
 IX. PATTERNS OF FUNCTIONING

A. EATING PATTERN

BEFORE ILLNESS DURING ILLNESS DURING HOSPITALIZARION

(At Home)

Patient Ly usually eats 3 Patient ly stated that she has the Patient Ly was on DAT as ordered
times a day. She claimed that same foods to it. She’s taking her by the physician. However, she did
she takes her breakfast at breakfast consisting of 2-3 slices not even consumed to eat 1 cup of
around 4:30-5:00 in the of bread and sometimes she eats rice that was serve to her every
morning consisting of 2-3 1 cup of rice fish and sometimes meal. Approximately half cup of
slices of bread (before going meat when she feels hungry. Her rice was only eaten.
to work) and at 8am she eats lunch usually consisting of 1 cup
1 cup of rice 1 egg and fish of rice 1 bowl of vegetables
when she feels hungry. Her (inabraw/pakbet) and sometimes
lunch usually at around meat. Her dinner is consisting of
11am consisting of 1 cup of 1 cup of rice vegetables
rice 1 bowl of vegetables (repolyo/pakbet) and sometimes
(inabraw) and sometimes vegetables with fish (bangus)
meat. She took her dinner at
around 7:30-8:00PM (after
work) consisting of 1 cup of
rice vegetables (repolyo) and
sometimes fish (bangus)

Analysis:

The patient’s pattern of eating has not changed before the illness and during illness at home.
However, during hospitalization there’s a change in eating pattern of the patient from eating 1 cup of
rice of meal it was decrease into half cup of rice.
 B. DRINKING PATTERN
of coffee in the morning)

Analysis:

Before illness the patient can consume 1750-2000ml of water per day plus 250 ml of coffee in
the morning. During illness at home, there’s an increase oral fluid intake because the patient can
consume 2250-2500ml of water per day plus 250ml of coffee in the morning. During hospitalization
there was also an increased in oral fluid intake that the patient can consume 2500-2750ml per day plus
250ml of coffee in the morning.
 There’s a change in drinking pattern of the patient because water is needed to increase to
loosen mucous.

C. BATHING PATTERN

BEFO\RE ILLNESS DURING ILLNESS DURING HOSPITALIZATION

Patient Ly usually takes a According to Patient Ly she According to Patient Ly she could only
bath twice a day for a matter could only do half bath twice do sponge bath twice a day at morning
of 5-10mins, she take a bath a day at morning when she when she wakes up and at night before
every morning at 4am wakes up and at night before going to sleep for a matter of 4-5 mins,
(before going to work) she going to bed for a matter of she can do it by herself. She verbalized
uses soap and shampoo and 2-3mins that “haan ko basbasaen toy ulok
before going to bed at 8- manipod ada nak ditoy hospital”
9pm after work. She uses
pail and dripper in bathing.

Analysis:

Before illness, the patient can take a bath twice a day before and after going to work, but during
illness she can just do half bath twice a day. During hospitalization the patient can no longer take a bath
normally, she just do sponge bath in the morning and before going to bed for a matter of 4-5mins.

There’s a change in bathing pattern of the patient from taking a bath twice a day to just taking sponge
bath mainly brought about by weakness.

D. SLEEPING PATTERN

BEFORE ILLNESS DURING ILLNESS DURING HOSPITALIZATION

Patient Ly claims that she At night patient ly verbalized According to her, she sleeps at 8pm to
sleeps at around 10-10:30pm that “nu aguy’uyek nak ket 6am and claimed that there is still
after watching the television, marigatan nak umanges” and disturbance while she’s on her first day
she said that the only she managed it through on the hospital
disturbance on her sleep is using nebulizer and
when she urinate at night. sometimes she takes
She wakes up at 4am to go
to work and 6 am if they will afternoon nap
not go to work. She claimed
that sometimes she take an
afternoon nap

Analysis:

There’s a change in sleeping pattern of the patient before and during her hospitalization. The
disturbances in sleeping pattern was due to difficulty of breathing, frequent coughing, frequent rounds
and visiting of the nurse in the patient room

E. BOWEL ELIMINATION

BEFORE ILLNESS DURING ILLNESS DURING HOSPITALIZATION

(AT home)

Patient ly stated that she During illness, she still Patient ly claimed that she defecates
defecates twice a day in the defecates twice a day which once a day with yellowish-brownish
morning and in the occurs mostly in the morning and watery stool in minimal amount.
afternoon, appearance is and afternoon, appearance is
yellowish with soft and hard yellowish with soft and hard
consistency in moderate consistency in moderate
amount amount.

Analysis:

There’s a change in bowel elimination of the patient from defecating twice a day to once a day
and from having soft and hard consistency of stool to watery because the patient is taking antibiotics
and one of the effects of antibiotic is softening of stools that’s why patients who are taking antibiotics
was required to take in potassium rich foods such as banana and apple.

F. BLADDER ELIMINATION

BEFORE ILLNESS/REGULAR DURING ILLNESS DURING HOSPITALIZATION

PATTERN
(At Home)

Patient Ly claims that she voids During illness, patient Ly During hospitalization, patient Ly
6-7 times per day amounting to stated that she voids 8-9 claimed that she voids 8-9 times per
approximately 200ml per times per day amounting to day amounting 250-300ml per
voiding. Color was yellowish approximately 250ml per voiding. Color was yellowish to dark
and sometimes colorless if she day. Color was yellowish to colored urine and smells like
drinks water. It was odorless colorless. It was odorless medications.

Analysis:

There’s a change in bladder elimination of the patient, before illness the color of her urine was
yellowish and sometimes colorless and it was odorless, it was the same during illness, but during
hospitalization the color has changed from yellowish to dark colored urine and it smells like medications.
Urine has also increased because of clysis and an increased oral fluid intake.

X. LEVELS OF COMPETENCIES

A. PHYSICAL

BEFORE ILLNESS DURING ILLNESS

Patient Ly attends work every day She prepare In the hospital, she was not able to take a bath
their foods during breakfast and dinner and able to alone so she just sponged herself to be clean. She
do household choirs as well as other daily routines also needed assistance whenever she go the
without any assistance such as taking a bath and comfort room to empty her bladder.
she can’t go to the bathroom by herself.

ANALYSIS:

Before illness, the patient perform her daily activities freely without any assistance. However
when she was in the hospital her movements was limited. She can’t go to the bathroom without
someone carrying her IV fluid and it was due to easy fatigability and difficulty of breathing.

B.EMOTIONAL

BEFORE ILLNESS DURING ILLNESS

She can easily control her emotions. She is a She is worried upon movement because of her
friendly and joyful person. condition, she get easily nervous to the point that
she can’t manage her emotions. She was easily
irritated too.

ANALYSIS:

It is shown above that there are certain changes in the emotional competency because the
patient easily got irritated and nervous whenever she moves.
 C. SOCIAL

BEFORE ILLNESS DURING ILLNESS

She has recreational activities, she’s a member of She still manage to communicate but can’t handle
woman’s club, senior citizen and participating in long conversation for she was tired to talk
oplan dalus. She communicate well with the
people that surrounds her. In fact, she is very
friendly and well known because she is friendly
and happy person.

ANALYSIS:

There is no change in her social competency. Therefore, the patient is socially related and active.

D. SPIRITUAL

BEORE ILLNESS DURING ILLNESS

She goes to church and actively attends all the She was not able to attend church service and
activities in church missed all the activities on their church however
she had rosary in side table. She also mentioned
that she was praying silently in bed before she
sleep

ANALYSIS:

As written above, there is no change in her spiritual competency because she has a strong
spirituality she carried rosary and pray silently at night before she sleep.
 E. INTELLECTUAL

BEFORE ILLNESS DURING ILLNESS

Able to make decisions by herself. She is oriented She still make decision by herself and intellectually
to time, place and person oriented to time place and person

ANALYSIS:

She is able to make decision on her own, therefore there is no change in intellectual
competency.

XI. PHYSICAL ASSESSMENT

I. APPEARANCE

DATE PERFORMED: November 27, 2018

TIME: 8:00 am

PLACE OF ASSESSMENT: Governor Roque B. Ablan Sr. Memorial Hospital

A. General Appearance:

Patient Ly was wearing a plain white sleeveless and a ¾ pants, lying on her bed with an IVF of
D5LRS @ 900 cc level regulated to 33- 34 gtts/ min. Patent and infusing well, weak in appearance,
coherent, conversant but was not able to handle long conversation. She also followed command upon
assessing the whisper voice test and eyes test. She is also oriented to time and date as well as the
people surrounds her.

B. VITAL SIGNS

Blood Pressure: 160/ 90 mmHg

 Body Temperature: 36.7 ℃

Pulse Rate: 112 bpm

Respiratory Rate: 24 cpm

Cardiac Rate: 112 bpm

C. BODY MASS INDEX/IBW/ Kcal per day

Anthropometric Measurement

Weight: 45 kg

Height: 150 cm = 1.50m

a. BODY MASS INDEX

Formula:

BMI= Weight (kg)

Height (m)2

Solution:

BMI ₌ 45 kg

(1.50m)2

BMI ₌ 45 kg
 2.25

BMI ₌ 20 kg (Normal)

b. IDEAL BODY WEIGHT

IDW = Ht. (m2) x 21 kg (Female)

IDW = 2.25 (m2) x 21 kg

IDW = 47.25 kg

c. kcal/day

kcal/day = IBW x Activity Level

kcal/day = 47.25 x 30 (Hospitalized)

kcal/day = 1,417. 50 kcal/day

II. HEAD-TO-TOE ASSESSMENT

HEAD

 Normocephalic

 Hair is black in color with small portion of gray color

 Scalp is clean, dry, and lighter complexion

 No presence of dandruff and lice

 No presence of tenderness, lesions, and nodules noted during palpation

FACE

 With symmetrical shape of the face

  Skin color is brown

 With no masses, lesions upon palpation

 Able to smile, frown, show teeth, raise eyebrows and tightly close eyes

EYES

 Visual Acuity: OD= OS=

 Both eyelids are free from lesions, redness and swelling

 Bulbar conjunctiva and palpebral conjunctiva of both eyes are pale pink

 Sclera is white

 Iris is brown coated with semi white cloudy

 No swelling of lacrimal gland

 Pupils are equally round and reactive to light and accommodation

 No involuntary movement upon testing

EARS

 With no tenderness of the pinna, consistency of the cartilage and swelling noted during
palpation

 No lesions noted on both ears

 No discharges found

 Able to hear whisper words on the both ears

NOSE

 Nasal structure are smooth and symmetric

 Nasal flaring

 Nostrils are patent

 Frontal and maxillary sinuses are not tender

 No tenderness felt during palpation

MOUTH

 Lips are slightly gray in color

 Uvula hangs freely at the middle

 Tongue color is slightly pink

 Tongue is in the midline

 Molar and Pre-molar teeth are missing both side up and down

NECK

 Neck is at the midline and without a bulging masses

 Trachea is at the midline

 No swelling, tenderness, and no enlargement of the lymph nodes noted

CHEST

OSTERIOR THORAX

 No tenderness and masses noted upon palpation

 With wheezes heard upon auscultation

 With fremitus after saying “99” and “33”

ANTERIOR THORAX

 With wheezes heard upon auscultation

 No tenderness and masses noted upon palpation

 Symmetry, free from lesions

 Sternum is positioned to midline

 No bulging of intercostal spaces noted

 DOB was evidence, expiratory wheezes. With irregular rhythm with an abnormal depth
at rate of 24 bpm.

BREASTS AND AXILLAE

  Lymph nodes have no swelling upon palpation

 Axilla are non- tender

 With white scar on the left part

 With 3 stitches at level of breast upward

SPINE

 Spine is in the midline

ABDOMEN

 Umbilicus is at the midline and inverted

 Abdomen is lighter that the general complexion

UPPER EXTREMITIES

 Finger nails is short and has a pale nail beds

 Capillary refill with a > 2 seconds duration

 Right and Left arms are symmetrical

 Has an IV line at her right hand at radial vein without any signs of inflammation

 Wrist are symmetric without any redness and swelling

 With a pulse rate of 112 bpm

 Without clubbing of fingers

LOWER EXTREMITIES

 Toe nails is short and has a pale nail beds

 Capillary refill with > 2 seconds duration

 Nail normally grow at a constant rate

 With no masses, tenderness, swelling noted upon palpation

  Right and Left feet are both symmetrical

XII: APPRAISAL

Day 1: November 28, 2018

This is the second day of the patient in hospital. The patient is awake sitting on bed in upright
position with on IVF fluid of PNSS 1 L @ 850 cc level at her right hand. We observed that the patient was
coughing with thick and dark yellow phlegm. She was weak, pale in appearance and raising her shoulder
when she breaths but the patient denies this condition as she verbalized “mabalin nak agawidden kasi
lummag-an ti panaganges kun.” Wheezes was also heard when we auscultated her back.

Dr. Pumaras seen and examined the patient twice. At 8:00 am she ordered cefuroxime 750 mg
IV q 8° and IVF PNSS 1 L to run for 12 hours for 2 cycle. At 11:30 am the doctor ordered Potassium
chloride 1 tab TID. Patient diet was DAT.

She urinated twice and not yet defecated.

Vital Signs 9:00 am

Blood Pressure: 130/70 mm HG

Pulse Rate: 76 bpm

Respiration Rate: 24 bpm

Temperature: 36.2 °C

Date 2: November 29, 2018

The patient was sleeping on bed in left lateral position with on IVF of PNSS @ 650 cc level at her
right hand. She appeared fair and observed frequent coughing with think and dark yellow phlegm which
she spited in a white tissue paper. Guarding her chest when coughing was noted. The patient also
complained of dizziness and drowsiness this maybe possibly due to patient frequent awakening at night
when coughing and nebulization.

Dr. Pumaras examined the patient at 11:40 am and ordered to decreased hydrocortisone to
10mg q 12°, decreased nebulization q 8° and IVF PNSS 1 L to run for 24°.

She drinks fluid frequently with 10-12 glasses a day, urinated trice and not defecated.
 Vital Signs 9:00 am

Blood Pressure: 140/80 mm HG

Pulse Rate: 82 bpm

Respiration Rate: 21 bpm

Temperature: 36.2 °C

Day 3: November 30, 2018

On this day, she was sitting on bed in upright position, fair in appearance and conversant. The
patient seen coughing with loose yellow phlegm. Wheezes are no longer heard when we auscultated her
back. Dr. Pumaras visited and examined her at 8:30 am. Doctor ordered her to go home. At 1:00 pm the
patient was discharged and given a home medication such as: NaC 60 mg in ½ glass of water OD,
Montelukast 10mg OD, Clarithromycin 500mg BID for 5 days, Cefuroxime 500 mg BID for 5 days and
Multivitamins Buclazine OD.

Vital Signs 9:00 am

Blood Pressure: 130/80 mm HG

Pulse Rate: 72 bpm

Respiration Rate: 20 bpm

Temperature: 36 °C

Home Visit

Day 4: December 1, 2018

The patient was standing sweating and tired. She just finished wash clothes when we visited the
patient. She still coughing with thick and yellow phlegm. Here are the vital signs taken.

Vital Signs 9:00 am

Blood Pressure: 120/80 mm HG

 Pulse Rate: 72 bpm

Respiration Rate: 20 bpm

Temperature: 36.2 °C

APPRAISAL TABLE

Day 1 Day 2 Day 3 Day 4

November 28, November 29, November 30, 2018 Home Visit

2018 2018
December 1, 2018

General Had a Fair in appearance Fair in appearance, Sweating, look tired

Condition productive and observed conversant and still and seldom cough
cough with frequent coughing coughing with loose with loose light yellow
think and dark with thick dark yellow phlegm. phlegm are noted.
yellow phlegm, yellow phlegm. Wheezes is no longer
weak and pale Complain of chest heard.
in appearance pain when
and observed coughing with
raising her guarding
shoulder girdle behavior.
when she
breaths.
Wheezes is
heard when
auscultated.
Unable to
manage long
conversation.

Diet DAT DAT DAT DAT

Vital Signs Time: 9 AM Time: 9 AM Time: 9 AM Time: 9 AM

 BP: BP:140/80 mm HG BP:130/80 mm HG BP:120/80 mm HG

130/70 mm HG PR: 82 bpm PR: 72 bpm PR: 72 bpm

PR: 76 bpm RR: 21 bpm RR: 20 bpm RR: 21 bpm

RR: 24 bpm T: 36.2 °C T: 36.0 °C T: 36.2 °C

T: 36.2 °C

IV Fluids *PNSS 1L to *IVF to follows

run for 12° for PNSS 1 L to run for
2 cycle 24 °

Medication *Cefuroxime * Hydrocortisone Take home meds:

750 mg IV q 8° 10 mg q 12°
*NaC 60 mg in ½ glass
*Potassium * Nebulization q of water OD
Chloride 1 tab 8°
*Montelukast 10 mg
PO TID
PO OD

* Clarithromycin
500mg PO BID for 5
days

* Cefuroxime 500 mg
PO BID for 5 days

*Multi Vitamins
Buclizine PO OD

XIII. LABORATORY AND DIGNOSTIC PROCEDURES

a. CHEST X- RAY / CHEST RADIOGRAPH

Date ordered: November 27, 2018 @ 6:25 am

Date processed: November 27, 2018 @ 8:30 am

Attending Physician: Dr. Emely Torralba Pumaras

Radiologic technologist: Edwin Samonte

Brief Description:

An X-ray is an imaging test that uses small amount of radiation to produce pictures of the
organs, tissues and bones of the body. When focused on the chest, it can help spot abnormalities or
diseases of the airways, blood vessels, bones, heart and lungs. Chest X-rays can also determine fluid in
lungs or air surrounding the lungs.

Indication:

This test is done to the patient to determine abnormalities of the lung airways.

Purpose:

The important purpose of chest X-ray is to examine the lungs of our patient. One of the steps in
evaluating a patient with symptoms such as shortness of breathing, difficulty of breathing, cough or
wheezing is to take a radiograph of the chest. This provides information about how well the lungs
inflate, whether there is any abnormal material present within the lungs and if fluid has collected
around the lungs. Information from this study can support making diagnosis such as pneumonia, asthma
and chronic obstructive pulmonary disease (COPD).

Procedure:

The X-ray occurs in a special room with a movable X-ray camera attached to a large metal arm.
The patient will stand next to a “plate”. This plate may contain X-ray film or special sensor that record
the images on a computer. The X-ray technician will instruct the patient how to stand and will record
both front and side views of the chest. The patient will need to hold her breath so that her chest stays
completely still.

Procedure time:

The procedure will take around 15-20 minutes.

Result:
 There are interstitial opacities in the right lower lung field

The pulmonary vascularity is not dilated

The heart is not enlarged

The aorta is calcific

The trachea is midline

The hemidiaphragms and costophrenic angles are intact

The visualized osseous structures and soft tissue are unremarkable

Impression:

Pneumonia is considered

Atherosclerotic aorta

Nursing Responsibilities:

Responsibilities Rationale

Before:

Verify doctors order To ensure the correct procedure to be done

Explain the procedure To reduce anxiety of the patient and for her to
know why is the test being done to her

During:

Assist the patient during the procedure To provide support and needs of the patient

After:

Refer immediately the results to the physician For the doctor to give further orders after
analyzing the result

b. SAMPLE TYPE SERUM

Date ordered: November 27, 2018 @ 6:25 am

Date processed: November 27, 2018 @ 11:25 am

Attending physician: Dr. Alejandro Leano

Test: FBS & CREA

Brief Description:

Fasting Blood Sugar Test (FBS)

Fasting blood sugar provides vital clues about how the body is managing

Blood Sugar - The concentration of glucose in the blood. Glucose, a type of simple sugar, body’s main
source of energy. Body converts the carbohydrates we eat into glucose.

Creatinine Test (CREA)

Creatinine blood test measures the level of creatinine in the blood.

Creatinine - Creatinine is a waste product that comes from the normal wear and tear on

Muscles of the body.

Indication:

FBS test

To determine if the patient’s blood glucose level is within a healthy range, to screen for and
diagnose diabetes and prediabetes and to monitor for high blood glucose (hyperglycemia) or low blood
glucose (hypoglycemia).

Creatinine test

If kidneys aren't functioning properly, an increased level of creatinine may accumulate in blood.
Creatinine test indicate whether kidneys are working properly. A serum creatinine test measures the
level of creatinine in blood and provides an estimate of how well your kidneys filter (glomerular filtration
rate).

Purpose:
FBS test

People who have diabetes do have higher rates of having asthma. These patients do tend to
have a hard time maintaining their blood glucose levels and keeping their asthma under control. People
who have diabetes that is not under control or is poorly maintained, are the ones who are at a higher
risk of developing asthma, because their lung functioning seems to be weaker than those that have
diabetes that is properly controlled or maintained. On the reverse side, people who suffer from asthma
are at a higher risk of developing diabetes and need to be careful.

Creatinine test

Patients with bronchial asthma may have increased risk of developing chronic kidney disease.
The use of steroids or non-steroidal drugs in the treatment of asthma may attenuate this risk.

Sample required: A blood sample drawn from a vein in arm or a drop of blood from a skin prick.

Procedure:

FBS Test

It is recommended that the patient fast (nothing to eat or drink except water) for at least 8
hours before having a blood glucose test. A blood sample is obtained by inserting a needle into a vein in
the arm or a drop of blood is taken by pricking a finger with a small, pointed lancet (fingerstick). When
finished drawing blood, the healthcare provider removes the needle and places a bandage over the
puncture site. Pressure will be applied to the puncture site for a few minutes to prevent bruising.

Creatinine test

A creatinine blood test doesn’t require much preparation. Fasting isn’t necessary. You can and
should eat and drink the same as you do normally to get an accurate result. First, pull up the patient’s
sleeves so that her arm is exposed. Sterilize the injection site with an antiseptic and then tie a band
around her arm. This makes the veins swell with blood, allowing them to find a vein more easily.

Insert a needle into vein to collect blood. In most cases, a vein on the inside of the elbow is used. Patient
feel a slight prick when the needle is inserted, but the test itself isn’t painful. After removal of the
needle, put a bandage over the puncture wound.
 Procedure time:

The procedure usually takes less than five minutes.

Result:

Test Name Result Units Reference

FBS Glucose 8.88 mmol/L 3.50 -5.50

CREA Creatinine 65.0 mmol/L 58.0 – 96.0

Normal Blood Sugars

*A normal fasting (no food for eight hours) blood sugar level is between 70 and 99 mg/dL or 3.50 -5.50
mmol/L.

*A normal blood sugar level two hours after eating is less than 140 mg/dL or >7.8 mmol/L.

mmol/L – Millimoles per Liter

mg/L - Milligrams per Deciliter

Analysis:

The blood sugar level is 8.88 mmo/L or 158 mg/dl which is above normal range this indicate
that the patient is hyperglycemic and might indicate pre-diabetes while her creatinine level is in within
normal range which means that her kidneys are functioning properly.

Nursing responsibilities:

Responsibilities Rationale

Before:

Check the doctor’s order To verify what examination to be done to the

patient

Inform the patient the reasons why this procedure To reduce anxiety of the patient and for her to
was ordered, how the specimen is to be collected know why the test is being done at her. To gain
and the stinging sensation to be felt. cooperation as well.

Fill up the laboratory request properly and forward To inform the medical technologist on what
it to the laboratory. procedure is to be done to the client.

During:

Assist the patient during the collection of blood To provide support and other needs to the
and be sure to wear gloves. patient and to avoid cross-contamination of
bacteria or other microorganism.

Place the collected blood into a sterile, specimen To prevent contamination of the specimen.
bottle.

Cover all the specimen tightly, label properly with To avoid contamination and loss of specimen.
identifying data, test, time started and time of
completion and send immediately to the
laboratory.

Facilitate proper hand washing To prevent spread of microorganisms.

After:

Upon arrival of the laboratory result, refer it In order for the physician to determine and
immediately to the attending physician and then address any abnormal results and for further
attach it to the patient’s chart. actions needed.

Carry out doctor’s order with regards to the To address and correct any abnormal findings.
management for abnormal results.

Document the procedure For legal purposes.

c. BLOOD ELECTROLYTES

Date ordered: November 27, 2018 @ 6:25am

Date processed: November 27, 2018 @ 11:26am

Pathologist: Modesty M. Alenjandro Leano

Medical Technologist: Remedios C. Plasido

Brief Description:

Electrolyte test can help determine whether there's an electrolyte imbalance in the body. Electrolytes
are present in the human body, and the balance of the electrolytes in our bodies is essential for normal
function of our cells and our organs.
Indication:

Electrolyte tests are commonly ordered at regular intervals to monitor treatment of certain
conditions, including high blood pressure (hypertension), heart failure, lung diseases, and liver and
kidney disease.

Purpose:

To detect a problem with our patient body’s electrolyte balance. Electrolytes play a vital role in
maintaining blood volume, which impacts blood pressure. Two important electrolytes, sodium and
potassium, work together to balance fluid level. Potassium ions enter cells, while the majority of sodium
ions remain in the fluid surrounding our cells. Because both attract water, this helps balance the level of
fluid in and out of cells. An imbalance in sodium or potassium can increase blood volume, which causes
blood pressure to increase, or decrease blood volume, causing low blood pressure. Low blood pressure
decreases the flow of oxygen to our cells, which can cause shortness of breath. High blood pressure
causes the heart to work harder, which requires more oxygen, causing to feel shortness of breath.

Procedure:

A health care professional will take a blood sample from a vein in patient’s arm, using a small
needle. After the needle is inserted, a small amount of blood will be collected into a test tube or vial.
When finished drawing blood, the healthcare provider removes the needle and places a bandage over
the puncture site. Pressure will be applied to the puncture site for a few minutes to prevent bruising.

Procedure time:

The procedure usually takes less than five minutes.

Sample required:

A blood sample drawn from a vein in arm.

Result:
Examination Result Units Reference Range

Sodium 140.7 mmol/L 135-148 mmol/L

Potassium 3.50 mmol/L 3.5 – 5.3 mmol/L

Analysis:

Sodium and potassium level are within normal range. There were no electrolyte imbalances
finding in the patient’s body.

Nursing responsibilities:

Responsibilities Rationale

Before:

Check the doctor’s order To verify what examination to be done to the

patient

Inform the patient the reasons why this procedure To reduce anxiety of the patient and for her to
was ordered, how the specimen is to be collected know why the test is being done at her. To gain
and the stinging sensation to be felt. cooperation as well.

Fill up the laboratory request properly and forward To inform the medical technologist on what
it to the laboratory. procedure is to be done to the client.

During:

Assist the patient during the collection of blood To provide support and other needs to the patient
and be sure to wear gloves. and to avoid cross-contamination of bacteria or
other microorganism.

Place the collected blood into a sterile, specimen To prevent contamination of the specimen.
bottle.

Cover all the specimen tightly, label properly with To avoid contamination and loss of specimen.
identifying data, test, time started and time of
completion and send immediately to the
laboratory.

Facilitate proper hand washing To prevent spread of microorganisms.

After:

Upon arrival of the laboratory result, refer it In order for the physician to determine and
immediately to the attending physician and then address any abnormal results and for further
attach it to the patient’s chart. actions needed.

Carry out doctor’s order with regards to the To address and correct any abnormal findings.
management for abnormal results.

Document the procedure For legal purposes.

d. HEMATOLOGY

Date ordered: November 27, 2018 @ 6:25am

Date processed: November 27, 2018 @ 9:19am

Medical technologist: Remedios Pacido

Pathologist: Modesty A. Leano

Test: Complete Blood Count

Brief description:

Hematology - Branch of medicine concerned with the study of the cause, prognosis, treatment, and
prevention of diseases related to blood.

Complete Blood Count (CBC) – Is a series of test used to evaluate and concentration of the cellular
components of blood. The items commonly evaluated include hemoglobin, hematocrit, red blood cells,
white blood cells, differentials, platelets and microscopic examination or stained blood smear.

Blood – A body fluid that delivers necessary substances such as nutrients and oxygen to the cells and
transports metabolic waste products away from those same cells.
 Indication:

This test is done to our patient to determine significant changes on the different blood
components.

Purpose:

To determine our patient’s general health status; to screen for, diagnose, or monitor any one of
a variety of diseases and conditions that affect blood cells, such as anemia, infection, inflammation,
bleeding disorder or cancer.

Procedure:

A health care professional will take a blood sample from a vein in patient’s arm, using a small
needle. After the needle is inserted, a small amount of blood will be collected into a test tube or vial.
When finished drawing blood, the healthcare provider removes the needle and places a bandage over
the puncture site. Pressure will be applied to the puncture site for a few minutes to prevent bruising.

Procedure time:

The procedure usually takes less than five minutes.

Sample required: A blood sample drawn from a vein in our patient’s arm.

Result:

Parameter Result Unit Normal range

MCV 99.0 fL 80.0 -100.0

MCH 30.8 pg 27.0 – 34.0

MCHC 311 g/L 320 - 360

RDW-CV 11.9 % 11.0 – 16.0

RDW -SP 45.9 fL 35.0 – 56.0

PLT 292 *10^9L 150 - 400

MPV 7.1 fL 6.5 – 12.0

PDW 16.0 % 9.0 – 17.0

PCT 0.207 % 0.108 - 0282

Analysis:

There were no abnormal findings.

Nursing responsibilities:

Responsibilities Rationale

Before:

Check the doctor’s order To verify what examination to be done to the

patient

Inform the patient the reasons why this procedure To reduce anxiety of the patient and for her to
was ordered, how the specimen is to be collected know why the test is being done at her. To gain
and the stinging sensation to be felt. cooperation as well.

Fill up the laboratory request properly and forward To inform the medical technologist on what
it to the laboratory. procedure is to be done to the client.

During:

Assist the patient during the collection of blood To provide support and other needs to the patient
and be sure to wear gloves. and to avoid cross-contamination of bacteria or
other microorganism.

Place the collected blood into a sterile, specimen To prevent contamination of the specimen.
bottle.

Cover all the specimen tightly, label properly with To avoid contamination and loss of specimen.
identifying data, test, time started and time of
completion and send immediately to the
laboratory.

Facilitate proper hand washing To prevent spread of microorganisms.

After:

Upon arrival of the laboratory result, refer it In order for the physician to determine and
immediately to the attending physician and then address any abnormal results and for further
attach it to the patient’s chart. actions needed.

Carry out doctor’s order with regards to the To address and correct any abnormal findings.
management for abnormal results.

Document the procedure For legal purposes.

e. ELECTROCARDIOGRAPHY

Date ordered: November 27, 2018 @ 6:25am

Date processed: November 27, 2018 @ 8:39am

Brief description:

Electrocardiogram (ECG or EKG) - Is a diagnostic tool that is routinely used to assess the electrical and
muscular functions of the heart.

Electrocardiography – It is the process of recording the electrical activity of the heart over a period of
time using electrodes placed over the skin. These electrodes detect the tiny electrical changes on the
skin that arise from the heart muscle’s electro physiologic pattern of depolarizing and repolarizing
during each heartbeat. It is very commonly performed to detect any cardiac problems.

There are three main components to an ECG: the P wave, which represents the depolarization of the
atria; the QRS complex, which represents the depolarization of the ventricles; and the T wave, which
represents the repolarization of the ventricles. It can also be further broken down into the following:

O is the origin or datum point preceding the cycle

P is the atrial systole contraction pulse

Q is a downward deflection immediately preceding the ventricular contraction

R is the peak of the ventricular contraction

S is the downward deflection immediately after the ventricular contraction

T is the recovery of the ventricles

U is the successor of the T wave but it is small and not always observed
Indication and purpose:

This was done to our patient to monitor electrical act, impulse formation and conduction in her
heart since our patience experienced symptoms that may suggest a heart problem.

Procedure:

An ECG/EKG is quick, painless and harmless. After the patient changed into a gown, a

Technician attaches 12 to 15 soft electrodes with a gel to her chest, arms, and legs. The technician may
have to shave small areas to ensure the electrodes stick properly to her skin. Each electrode is about the
size of a quarter. These electrodes are attached to electrical leads (wires), which are then attached to
the ECG machine. During the test, the patient need to lie still, while the machine records her heart’s
electrical activity and places the information on a graph.

Procedure time:

The entire procedure takes about 10 minutes.

Result:

Result Normal Range

HR 101bpm 60 -100 bpm

PR 123 ms 120 – 200 milliseconds

QRS 100 ms 80 – 100 milliseconds

QT/QTC 286/371 ms ≤440

P/QRS/T AXES 252/74/76 deg <120 / ≤100 / -30 to +90 degrees.

RV5/SV1 2.40 / 0.66 mv

RV5 + JV1 3.06 mv

Analysis:

There are no abnormal findings in the patient‘s electrocardiogram.

Nursing responsibilities:

Responsibilities Rationale

Before

Verify doctors order To confirm the intervention to be done and

prevent clinical error.

Inform the patient the reasons why this To gain cooperation and in order for the
procedure was ordered. patient to have an idea about the purpose of
this procedure.

Fill up the laboratory request properly and To inform the medical technologist what
forward it to the laboratory. procedure is to be done to the client.

During

Position the client comfortably. For clearer visualization

Areas on the arms, legs, and chest where To provide a clean, smooth surface to attach
electrodes will be placed are clean and possibly the electrode discs.
shaved.

After

Upon arrival of the result, attach it to the chart So that the physician will be able to determine
of the patient or refer it to the physician. the appropriate management to be applied to
the patient

Carry out doctor’s order with regards to the To address and correct the abnormal results
management for abnormal results

Document the procedure For legal purposes

f. URINALYSIS

Date ordered: November 27, 2018 @ 6:25am

Date processed: November 28, 2018

Pathologist: Modesty M. Alenjandro Leano

Medical Technologist: Remedios C. Plasido

Brief description:

A urinalysis is a test of urine. It can help to detect problems that may be shown by the patient’s
urine. Many illnesses and disorders affect how the body removes waste and toxins. The organs involved
in this are lungs, kidneys, urinary tract, skin, and bladder. Problems with any of these can affect the
appearance, concentration, and content of the urine.

Indication:

This test is done to our patient to diagnose disease or to screen for health problems.

Purpose:

Used to look for abnormalities such as an excess amount of protein, blood, pus, bacteria or
sugar. A urine test can help detect a variety of kidney and urinary tract disorders, including chronic
kidney disease, diabetes, bladder infections and kidney stones. A trace of one type of protein, albumin in
urine (albuminuria) is an early sign of chronic kidney disease. Persistent amounts of albumin and other
proteins in the urine (proteinuria) indicate kidney damage. The presence of albumin is also a risk factor
for cardiovascular events.

Procedure:

A urine sample is collected in an unused disposable plastic cup with a tight-fitting lid. A randomly
voided sample is suitable for routine urinalysis, although the urine that is first voided in the morning is
preferable because it is the most concentrated. The best sample for analysis is collected in a sterile
container after the external genitalia have been cleansed using the midstream void (clean-catch)
method.

Result:

Physical Examination Chemical Examination

Color : Light yellow Glucose: Negative Blood:

Microscopic Examination
Character: Turbid Leukocytes: Negative Ketone: (-)
Pus cells: 3-4 Amorphous Urates: Moderate Crustals:
Reaction: 6.0 Nitrate: Negative Bilirubin: (-)

Specific gravity: 1.015 Protein: Negative Urobilinogen: (-)

 Red Blood Cells: 10-12/hpf Amorphous Phosphates:

Epithelial cells: Few Bacteria: Casts:

Mucus Threads: Moderate Others:

Pregnancy test

Normal results and analysis:

Physical Examination

Color : Light Normal urine is yellowish in color, ranging from pale to deep amber. The
yellow patient’s urine color is light yellow which mean normal. An unusual urine
color can be a sign of disease.

Character: Turbid Healthy urine is clear, having a cloudy or turbid urine of our patient is not
unusual. It might be a sign of an underlying health condition. Unhealthy
urine can be cloudy or turbid, hazy, or milky looking. This can occur for a
number of different reasons, including sexually transmitted diseases,
dehydration, infections, or diseases that affect other body systems along
with the urinary tract.

Reaction: 6.0 A neutral pH is 7.0. The higher the number, the more basic (alkaline) it is.
The lower the number, the more acidic your urine is. The average urine
sample tests at about 6.0.

Normal pH for urine ranges from 4.5 to 8.0. The patient’s urine pH level is
within normal range.

Specific gravity: The normal range of urine specific gravity is 1.002 to 1.030. Abnormal
1.015 specific gravity results could indicate:

 excess substances in the blood

  kidney disease (high or low specific gravity can indicate an inability
of the kidney tubules to function correctly)

 infection, such as a urinary tract infection

 brain injuries, which can cause a person to develop diabetes

insipidus.

The patient urine specific gravity is within normal range.

Chemical Examination

Glucose: Negative The normal amount of glucose in urine is 0 to 0.8 mmol/L

(millimoles per liter). A higher measurement could be a sign
of a health problem. Diabetes is the most common cause of
elevated glucose levels. There is negative result of glucose in
our patient’s urine.

Leukocytes: Negative Only very low levels of leukocytes, if any, are normally found
in the urine, high leukocyte content in the urine may
indicate an infection or other underlying inflammatory
medical problems. Infections or obstruction in the urinary
tract or bladder may cause to have an increased amount of
leukocytes in the urine.

The patient’s leukocytes result is negative. This means that

there is no infection or any inflammatory medical problems.

Nitrate: Negative Normal urine contains chemicals called nitrates. If bacteria

enter the urinary tract, nitrates can turn into different,
similarly named chemicals called nitrites. Nitrites in urine
may be a sign of a urinary tract infection (UTI).

There is negative result of nitrate in our patient’s urine

which means that, our patient don’t have UTI.
Protein: Negative Normal values are 0 to 20 mg/dL.

Persistently high levels of protein in urine may be a sign of

kidney disease.

Ketone: Negative Any amount of ketones detected in the urine could be a sign
of diabetes and requires follow-up testing.

Ketones are not present in our patient’s urine.

Bilirubin: Negative Bilirubin is a product of red blood cell breakdown. Normally,

bilirubin is carried in the blood and passes into the liver,
where it's removed and becomes part of bile. Bilirubin in the
urine may indicate liver damage or disease.

There is no bilirubin present in our patient’s urine.

Urobilinogen: Negative Urobilinogen in urine can indicate a liver disease such as

hepatitis or cirrhosis.

There is no indication of liver diseases.

Microscopic Examination

Pus cells: 3-4 The normal range of pus cells in the urine is 0-5. Presence of pus cells in
urine is a definite indication of some type of infection. Pus in urine
signifies that the body is fighting an infection in the lower or upper
urinary tract. The pus cells present in our patient’s urine is within normal
range. There is no indication of infection.

Red Blood Cells: 10- A normal result is 4 red blood cells per high power field (RBC/HPF) or less
12/hpf when the sample is examined under a microscope. Our patient’s RBC
result is above normal range. A higher than normal number of RBCs in
the urine may be due to:

Kidney and other urinary tract problems, such as infection, tumor, or

stones

Kidney injury

Prostate problems

Bladder or kidney cancer

 Epithelial cells: Few It's normal to have one to five squamous epithelial cells per high power
field (HPF) in the urine. Having a moderate number or many cells may
indicate: a yeast or urinary tract infection (UTI) kidney or liver disease.

Our patient has only few epithelial cells, this means that there is no
indication of UTI and kidney or liver diseases.

Mucus Threads: A small amount of mucus in the urine is normal. An excess amount may
Moderate indicate a urinary tract infection (UTI) or other medical condition.

There is moderate amount of mucus in patient’s urine which is

considered normal.

Nursing responsibilities:

Responsibilities Rationale

Before:

Check the doctor’s order To verify what examination to be done to

the patient

Inform the patient the reasons why this procedure To reduce anxiety of the patient and for her
was ordered, how the specimen is to be collected. to know why is the test being done to her.

Fill up the laboratory request properly and forward To inform the medical technologist what
it to the laboratory. procedure is to be done to the patient.

During:

Place the collected urine into a sterile, specimen To prevent contamination of the specimen.
bottle.

Cover all the specimen tightly, label properly with To avoid contamination and loss of
identifying data, test, time started and time of specimen.
completion and send immediately to the
laboratory.

Advise patient to facilitate proper hand washing. To prevent spread of microorganisms.

After:

Upon arrival of the laboratory result, refer it In order for the physician to determine and
 immediately to the attending physician and then address any abnormal results and for
attach it to the patient’s chart. further actions needed.

Carry out doctor’s order with regards to the To address and correct any abnormal
management for abnormal results. findings.

Document the procedure For legal purposes.

g. BLOOD CHEMISTRY

Date ordered: November 27, 2018 @ 6:25am

Date processed: November 28, 2018

Pathologist: Arlene Francisco-Castro

Medical Technologist: Czarina Baptista

Brief description:

Blood chemistry testing is defined simply as identifying the numerous chemical substances
found in the blood. The analysis of these substances will provide clues to the functioning of the major
body systems.

Indication and purpose:

This test is done to our patient to determine how well her certain organs are working and can
help find abnormalities.

Blood chemistry tests can be done to:

 learn information about your general health

 check how certain organs are working, such as the kidneys, liver and thyroid

 check the body’s electrolyte balance

 help diagnose diseases and conditions

 provide the levels of chemicals (a baseline) to compare with future blood chemistry tests

 check how a treatment is affecting certain organs

 monitor cancer or another condition (as a part of follow-up)

Procedure:

Blood is usually taken from a vein in the arm. An elastic band (a tourniquet) is wrapped around
your upper arm to apply pressure to the area and make the veins easier to see. You may be asked to
make a fist so the veins stand out more. The skin is cleaned and disinfected. A needle is inserted into the
vein and a small amount of blood is removed. You may feel a prick or stinging sensation.

The blood is collected in a tube and labelled with your name and other identifying information.
Sometimes more than one tube of blood is collected. The tourniquet is removed and the needle is
withdrawn. You may feel mild discomfort when the needle is withdrawn. Pressure is applied to the area
where the needle was inserted until bleeding stops. A small bandage may be put on the area.

Procedure time:

The procedure usually takes less than five minutes.

Sample required: A blood sample drawn from a vein in our patient’s arm.

Result:

Test Result Reference Range

HBA1C 6.3 % <6.5 %

Analysis:

Hemoglobin A1c, often abbreviated HbA1c, is a form of hemoglobin (a blood pigment that
carries oxygen) that is bound to glucose. Blood HbA1c levels are reflective of how well diabetes is
controlled. The normal range for level for hemoglobin A1c is less than 6.5 %, this means that our
patient’s HbA1C level is within normal range. This indicate great blood sugar controlled.
Nursing responsibilities:

Responsibilities Rationale

Before:

Check the doctor’s order To verify what examination to be done to the

patient

Inform the patient the reasons why this procedure To reduce anxiety of the patient and for her to
was ordered, how the specimen is to be collected know why is the test being done to her. To gain
and the stinging sensation to be felt. cooperation as well.

Fill up the laboratory request properly and forward To inform the medical technologist what
it to the laboratory. procedure is to be done to the client.

During:

Assist the patient during the collection of blood To provide support and other needs to the patient
and be sure to wear gloves. and to avoid cross-contamination of bacteria or
other microorganism.

Place the collected blood into a sterile, specimen To prevent contamination of the specimen.
bottle.

Cover all the specimen tightly, label properly with To avoid contamination and loss of specimen.
identifying data, test, time started and time of
completion and send immediately to the
laboratory.

Facilitate proper hand washing To prevent spread of microorganisms.

After:

Upon arrival of the laboratory result, refer it In order for the physician to determine and
immediately to the attending physician and then address any abnormal results and for further
attach it to the patient’s chart. actions needed.

Carry out doctor’s order with regards to the To address and correct any abnormal findings.
management for abnormal results.

Document the procedure For legal purposes.

XIV. MEDICAL MANANGEMENT

A. Diet

DAT - DIET AS TOLERATED

 Definition

This food preparation provides complete nutrients, carbohydrates, protein, fats, vitamins, and
minerals on their normal proportions. It is characterized as the food preference of the patient that is a
routine and is usual.

Purpose

This is indicated to the patient to provide good and adequate nutrition to gain strength, to have
greater resistance against infection and support the body for anticipated situations and needs necessary
for the condition.

B. INTRAVENOUS THERAPY

a. PNSS IVF

Generic Name: PNSS

Classification: Isotonic Intravenous Solution

Dosage/Route/Frequency: 1L/IV/12 hours

Mechanism of action: Sterile, nonpyogenic solution fluid and electrolytes replenishment

Purpose:

Used to maintain fluid intake and reestablish water volume because these fluids stays in the
vascular compartment, therefore it expands the vascular volume.

Nursing Responsibilities Rationale

1. Check the doctor’s order To avoid mistake and confirm IVF ordered by the
physician

2. Explain the procedure and the purposes To decrease her anxiety and gain cooperation
of infusion to the patient

3. Proper hand washing before IVF To maintain asepsis and to prevent the spread of
insertion microorganism

4. Use peripheral vein on the temporal To keep needle from being dislodge.
region.
 5. Check the patency of the IV fluid To avoid possible complications such as
infusion. infiltration.

6. Place the time of infusion started and

the regulation.

b. D5LR IVF

Generic Name: D5LR

Classification: Hypertonic Solution

Dosage/route/Frequency: 1L/IV/12hours

Mechanism of action: The electrolyte composition approaches that the principal ions of normal plasma.

Purpose:

It is useful for daily maintenance of body fluid and nutritional and for rehydration.

Nursing responsibilities Rationale

Observe for the correct regulations To prevent water retention

Assess IV tubing for kinking To maintain the patency of the infusion

Monitor glucose level carefully

Check order to verify solution, rate and frequency To prevent cardiac arrest

Monitor Fluid intake and output To prevent Dehydration

c. D5NSS IVF

Generic Name: D5NSS

Classification: Hypertonic Solution

Dosage/Route/Frequency: 1L/IV/12 hours

 Mechanism of action: Provide water electrolytes for maintenance of daily fluid and electrolytes
requirement, plus minimal carbohydrates calories.

Nursing responsibilities Rationale

Observe aseptic technique when handling IVF To prevent infection.

and during insertion.

Check doctor’s order. To determine the proper IV solution for the

proper patient.

Regulate IV flow properly. To maintain proper hydration

XV. DRUG STUDY

Date and Time Odered: 11/27/18

Generic Name: Omeprazole

Brand Name: Omebloc

Classification: Proton Pump Inhibitor

Dosage, Frequency and route: 40mg/tab, OD, Oral

Mechanism of action: Inhibits hydrogen – potassium adenosine triphosphate (H+/K+ ATP pump), an
enzyme on the surface of gastric parietal cells.

Desired Effect: Suppresses gastric acid secretion relieving gastrointestinal distress and promoting ulcer

Adverse Effect: CNS: dizziness, drowsiness, fatigue and headache

CV: Chest pain

GI: abdominal pain

Nursing Responsibilities Rationale

1. Check doctor’s order and follow the 10Rs in To prevent error or mistakes.
drug administration.

2. Give omeprazole before meals, preferably in the The drug is absorbed better on a empty stomach.
morning for once daily dosing.

3. Instruct patient to take medicine at the same To maintain the potency of the drug
each day.

4. Inform the patient the action, use, and the So that the patient is aware of what she is taking in
reason of taking drug. and to gain cooperation during the drug therapy.

5. Monitor for adverse effects such as drowsiness, To determine and immediately address adverse
fatigue, chest pain, and abdominal pain. effects that may possibly occur to the patient
during therapy.

Generic Name: Acetylcysteine

Brand Name: Ac-lyte

Classification: Mucolytic agent

Dosage, Frequency and Route: 200mg, TID, ½ glass of water powder for oral suspension

Mechanism of Action: Mucolytic splits linkage of mucoproteins, reducing viscosity of pulmonary

secretions. Acetaminophen toxicity: Hepatoprotective by restoring heptic glutathione and enhancing
nontoxic conjugation of acetaminophen.

Desired Effect: Facilitates removal of pulmonary secretions by coughing, postural drainage, mechanical
means. Protects against acetaminophen over dose induced hepatotoxicity.

Nursing Responsibilities Rationale

1. Verify the Physician’s Order To confirm the procedure to be done to the

patient

2. Instruct patient to follow direction exactly To prevent lessen liver damaged

3. Explain the importance of using drug directed To get maximum benefit from your medication

4.Report difficulty with clearing the airway or any To notify abnormal findings
other respiratory distress

Generic Name: Montelukast Sodium + Levocetirizine Dihydrochloride

Brand Name: Monti Plus

Physiologic Classification: Antiasthmatic

Pharmacologic Classification: Leukotriene receptor antagonist

Dosage, Frequency and Route: 10mg, OD HS, Oral

Mechanism of Action: Binds to cysteinyl leukotriene receptors, inhibiting effects of leukotrienes on

bronchial smooth muscle.

Desired Effect: Decreases bronchoconstriction, vascular permeability, mucosal edema, mucus

production.

Side Effects: Frequent: Headache

Occasional: Influenza

Rare: abdominal pain, cough, dyspepsia, dizziness, fatigue, dental pain

Nursing Responsibilities Rationale

1. Check the physician order To Obtain baseline data

2. Observe the rights in giving medication To prevent toxicities

3. Monitor the adverse effect To prevent complication

Generic Name: Cefuroxime

Brand Name:

Classification: second generation, cephalosporin

Dosage, Frequency and Route: 750mg, every 8 hours, IV

 Mechanism of Action: Bactericidal inhibits synthesis of bacterial cell wall, causing cell death. Used to
treat a variety of bacterial infections. It may also use to prevent infection from certain surgeries. It works
by stopping the growth of bacteria

Desired Effect: Bactericidal

Nursing Responsibilities Rationale

1. Report the onset of loose stool To reduce the development of drug resistant
bacteria

2. Absorption of cefuroxime is enhanced by food To investigate the effect of food and of contrast
the absorption

3. Notify prescriber about rashes or super To obtain culture and sensitivity report
infection

4. Do a skin test To determine if the patient has a hypersensitivity

of cefuroxime

Generic Name: Clarithromycin

Brand Name: Clistanex Forte

Dose/Route/Frequency: 500mg/Oral/BID PC (after meal)

Physiologic Classification: Antibiotic

Pharmacologic Classification: Macrolide

Mechanism of Action: Binds to ribosomal receptor sites of susceptible organisms, inhibiting CHON
synthesis of bacterial cell wall.

Desired Effect: Bacteriostatic; may be bacteria with high doses or very susceptible microorganisms

Indication: Treatment of susceptible infection: CAP

Contraindication: Hypersensitivity to clarithromycin, other macrolide antibiotics

Side Effects: Occasional: Diarrhea, nausea, altered taste, abdominal pain

Rare: headache, dyspepsia

 Adverse Effects: Antibiotic- associated colitis. Other super –infections (abdominal cramps, severe water
diarrhea, and fever) may result from other bacterial balance in GI tract. Hepatoxicity, thrombocytopenia
occur rarely.

Nursing Responsibilities Rationale

1. Avoid IORs in administering medication To avoid medication error

2. Assess for allergy To avoid anaphylactic shock

3. Asses for other contraindications To avoid complications

4. Instruct the patient to report if she experience To give proper Interventions

severe diarrhea and abdominal cramps

5. Monitor vital signs and after medication To indicate patients physiologic state and to
determine which treatment protocols to follow,
to ;provide critical information needed to make
like- saving decisions and to confirm feedback on
treatments performed

Date and Time Ordered:

Generic Name: Multivitamins Buclizine

Classification: Multivitamins

Dosage/Route/Frequency: 1 tab/PO/OD

Mechanism of Action: Dietary supplement for the treatment and prevention of the vitamin deficiencies,
necessary for the normal growth and development

Desired Effect:

Nursing Responsibilities Rationale

1.Advice the patient avoid alcohol Intolerance It decrease the effectiveness of the drugs

2. Use exactly as directed on the level To prevent cause of toxicity

3. Eat Nutritious food For more effectiveness of the drugs

4. Eat before taking the drug For more absorption of the drugs

Generic Name: Cefuroxime Axetil

Brand Name: Rucef

Dose/Route/Frequency: 500mg/film coated tab PO/BID

Classification: Antibiotic

Mechanism of Action: Bactericidal inhibits synthesis of bacterial cell wall, causing cell death. Used to
treat a variety of bacterial infections. It may also use to prevent infection from certain surgeries. It works
by stopping the growth of bacteria

Desired Effect: Bactericidal

Nursing Responsibilities Raationale

1. Before initiating therapy obtain history To determine previous use of and Reaction

2. Give oral form with food. To decrease GI disress and enhance absorption

3. Assess patient for any signs and symptoms To assess for possible hypersensitivity
of allergic response to drug. reaction.

4. Report onset of loose stools To reduce the development of drug resistant

bacteria.

5.Instruct patient report signs of To prevent complication

hypersensitivity
 Generic Name: Salbutamol Sulfate+Ipratropium Bromide

Brand Name: Salresp -1

Dose/Route/Frequency: every 6 hours

Classification: Bronchodilator

Mechanism of Action: Blocks action of acetylcholine at parasympathetic sites in bronchial smooth

muscle.

Desired Effect: Causes bronchodilation, inhibits nasal secretion.

Nursing Responsibilities Rationale

1. Advice patient not to exceed the prescribe To prevent toxicity

dose

2. Instruct on proper use of Inhaler To ensure the patient receiving the correct dose
of medication

3. Rinsing mouth with water immediately after It may prevent mouth throat dryness
inhalation

Generic Name: Potassium Chloride

Brand Name: K-lyte

Dose/Route/Frequency: 600mg/ oral/ TID

Classification: Electrolyte
 Mechanism of Action: Necessary for multiple cellular metabolic processes. Primary action is intracellular

Desired Effect: Required for nerve impulse conduction, contraction of cardiac, skeletal, smooth muscle,
maintains normal renal function, acid base balance

Nursing Responsibilities Rationale

1. Monitor I & O ratio pattern in patient receiving If oliguria occurs stop infusion promptly and
parenteral drugs notify physician

2. Be alert for potassium indication To prevent the patient asymptomatic

3. Patient should be advised to read the labels To prevent excess potassium intake

4. Emphasize the importance of regular follow-up To monitor level progress

exam

Generic Name: Salbutamol

Brand Name: Hivent

Dose/Route/Frequency:

Classification: Anticholinergic

CLINICAL: Bronchodilator

Mechanism of Action: Blocks action of acetylcholine at parasympathetic sites in bronchial smooth

muscle.

Desired Effect: Causes bronchodilation, inhibits nasal secretion.

Nursing Responsibilities Rationale

1. Assess the vital signs before drug To obtain baseline data

administration

2. Listen to lung sound To notify physician or healthcare provider of

abnormal findings

3. Monitor pulmonary function test before To determine effectiveness of medication

initiating therapy

4. Monitor for chest pain arrhythmias, heart To consult for parameter of pulse
rate>110 bpm

Generic Name: Hydrocortisone

Brand Name:

Dose/Route/Frequency: 10mg/IV/every 8 hours

Classification: Adrenal corticosteroid

Mechanism of Action: Inhibits accumulation of inflammatory cells at inflammation sites, phagocytosis,

lysosomal enzyme release, synthesis and or release of mediators of inflammation. Reverses increased
capillary permeability.

Desired Effect: Prevents or suppresses cell mediated immune reactions. Decreases or prevents tissue
response to inflammatory process.

Nursing Responsibilities Rationale

1. Monitor for consistency, color and amount of To monitor in an intensive

stool

2. Assess affected skin before and daily therapy To notify health care professional if symptoms of
infection

3. Monitor weight blood pressure, glucose and To obtain baseline data

electrolytes

4. Monitor input/output ration To prevent fluid overload

XVII. NURSING CARE PLAN

1. INEFFECTIVE AIRWAY CLEARANCE

a. Nursing Diagnosis:

P: Ineffective Breathing Pattern

E: related to presence of secretion

S:

Objective
 - coughing with thick and dark yellow sputum

- nasal flaring

- difficulty of breathing

- elevation of both shoulder girdle when breathing

Subjective

- significant other’s verbalize ‘Marigatan ngata pelang nga aganges kasi agngatu ngatu
met pelang ta abaga nu kasta nga umanges’

b. Nursing Inference:

Presence of secretions in the bronchi will result into a blockage of air that will enter the body
and thus producing insufficient air needed by the body. And inability to maintain clear airway. This
obstruction is further heightened by bronchospasm due to the contraction of the smooth muscles in the
bronchi. This is caused by parasympathetic stimulation of the muscarinic2receptors as well as by
chemical mediators released in response to the presence of allergen.

c. Planning

After 2 hours of rendering proper nursing interventions, the patient respiration will improve and
difficulty of breathing will be relieved.

d. Nursing Intervention

Independent Rationale

1. Assess rate and depth of respirations and chest To establish baseline data and monitor changes
movement.

2. Auscultate lung fields, noting areas of To determine possible bronchospasm or

decreased or absent obstruction.

Air flow and adventitious breath sounds such as

wheezes.

3. Elevate head of bed; change position Keeping the head elevated lowers diaphragm,
frequently promoting chest expansion, aeration of lung
 segments, and mobilization and expectoration of
secretions to keep the airway clear.

4. Provide health teaching regarding coughing To facilitate in the expulsion of mucus

and deep breathing exercise

5. Encourage the patient to increase fluid intake To facilitate mucus secretion

to at least 3000 ml per day.
To liquefy secretion

Dependent Rationale

1. Administer mucolytic and bronchodilators as Aids in reduction of bronchospasm and

ordered by the doctor mobilization of secretions.

e. Nursing Evaluation

After 2 hours of rendering proper nursing interventions, the patient respiration already
improved and difficulty of breathing was relieved.

2. ACUTE CHEST PAIN

a. Nursing Diagnosis:

P: Acute Chest Pain

E: related to persistent coughing

S:

Objective

- frequent coughing of thick dark yellow sputum

- guarding the chest when coughing

- restless

Subjective

The patient verbalized “Nasakit detoy barukung ko nu aguyek nak”

b. Nursing Inference
 An inflammation or irritation of the lining of the lungs and chest is likely causes a sharp pain
when breathing and coughing. The most common causes of chest pain are bacterial or viral infections.

c. Nursing Goal

After 4 hours of nursing intervention the patient will verbalized relief of pain and demonstrate
relaxed manner.

d. Nursing Intervention

Independent Rationale

1. Determine pain characteristics and investigate Chest pain, usually present to some degree
changes in character, location, and intensity of with pneumonia, may also herald the onset of
pain. complications of pneumonia, such as
pericarditis and endocarditis

2. Provide comfort measures, such as back rubs, Nonanalgesic measures administered with a
change of position and conversation. gentle touch can lessen discomfort and
augment therapeutic effects of analgesics.

3. Encourage use of relaxation and deep breathing Deep breathing facilitates maximum
exercises. expansion of the lungs and small airways.
Involvement of the patient in pain control
measures also promotes independence and
enhances sense of well-being.

4. Instruct and assist client in chest-splinting Aids in control of chest discomfort while
techniques during coughing episodes. enhancing effectiveness of cough effort.

5. Offer frequent oral hygiene. Mouth breathing and oxygen therapy can
irritate and dry out mucous membranes,
potentiating general discomfort.

6. Encourage patient to drink warm fluids at least Warm fluids aid in mobilization and
3000 ml per day. expectoration of secretion.

Dependent Rationale

1. Administer mucolytic agent as prescribe by the Aids in the mobilization of secretions thereby
doctor enhancing ease when coughing

2. Administer antibiotic as ordered To kill bacteria and viruses causing infection

e. Nursing Evaluation

After 4 hours of nursing intervention the patient verbalized relief of pain and demonstrated
relaxed manner.

3. ACTIVITY INTOLERANCE

a. Nursing Diagnosis:

P: Activity Intolerance

E: related to exhaustion associated with interruption in usual sleep pattern because of

discomfort, excessive coughing, and dyspnea

S:

Objective

-dyspnea

- drowsy

- restless

- fatigue

- lethargic

- dizziness

-V/S:

BP:

RR:

Subjective

The patient verbalized ‘Madik pelang kayat ti agkuti kuti kasi maulawak”

b. Nursing Inference

Sleep conserve energy without enough sleep the body have insufficient physiologic or
physiological energy to endure or complete required or desired activity.
c. Nursing Goal

After 24 to 48 hours of rendering proper nursing intervention, the patient will able to report and
demonstrate a measurable increase in tolerance to activity with absence of dizziness, restlessness,
drowsiness and vital signs are within acceptable range.

d. Nursing Intervention

Independent Rationale

1. Evaluate client’s response to activity. Note To establishes client’s capabilities and needs and
reports of dyspnea, increased weakness and facilitates choice of interventions
fatigue, and changes in vital signs during and
after activities.

2. Encourage use of stress management and Reduces stress and excess stimulation promotes
diversional activities such as listening to relaxing rest.
music.

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

Dependent Rationale

1. Administer multivitamin Buclizine as ordered To prevent dizziness

by the physician

e. Nursing Evaluation

After 24 to 48 hours of rendering proper nursing intervention, the patient will able to report and
demonstrate a measurable increase in tolerance to activity with absence of dizziness restlessness,
drowsiness and vital signs are within acceptable range.

XVII. GENERAL EVALUATION

Patient Ly is a 68 years old married and a mother of six children. She was considered as bread
winner of the family and her occupation makes her expose to different smokes, bacteria and expose to
different types of people. The patient first hospitalization was on 1986 due to coughing and difficulty of
breathing. The second hospitalization of the patient regarding the same complain in her first
hospitalization was on the morning of November 27, 2018. Patient Ly was admitted at 6:30 am with an
admitting diagnosis of Bronchial asthma in acute exacerbation.

During the patient hospitalization, she undergo some diagnostic and laboratory. The laboratory
test were X-ray and EKG. The o laboratory tests were FBS and Creatinine, Blood Electrolytes and CBC.
Pharmaceutical medications was also given and administered to her to treat her condition. The diet of
the patient was DAT.

Nursing care was rendered to the patient in associated to her principal diagnosis which is
community acquired pneumonia. The Nursing diagnosis that was implemented to the patient to improve
her breathing pattern, promote mobility and control pain are ineffective airway clearance, chest pain
and activity intolerance.

On November 28 the patient was discharged with taken home medicine which we abled to
explain her the right time, dosage, and the route of all of her take home medicine. We also explained to
her the important of finishing the entire course of her medicine particularly those antibiotics in order to
kill all the possible pathogen in the body that was contributed to her hospitalization. The take home
medicine ordered were NaC 60 mg in ½ glass of water OD, Montelukast 10 mg PO OD, Clarithromycin
500mg PO BID for 5 days, Cefuroxime 500 mg PO BID for 5 days and Multi Vitamins Buclizine PO OD. The
patient fallow check-up was last December 7, 2018.