Case.presIII- final na tlga to!!!!

8/7/2019 Case.presIII- final na tlga to!!!!

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I. PERSONAL DATA

Name of the client:Felipe Domingo Acob Sr.

Address:37Ganagan, Bacarra Ilocos Norte

Hospital Number:101750

Sex:Male

Age:71

Date of Birth: October 23, 1938

Place of birth: Bacarra, Ilocos Norte

Civil Status: Married

Religion: Roman Catholic

Educational attainment: Elementary Graduate

Occupation: Farmer

Chief Complaint: Cough and difficulty of breathing

Admitting Diagnosis: Chronic Obstructive Pulmonary Disease in Acute exacerbation

Bronchitis, Pulmonary Tuberculosis Class IV

Date of admission:August19, 2010

Time of Admission: 11:55 pm

Admitting Physician:Decinna Quilala, M.D./ Emely T. Pumaras, M.D.

Attending Physician: Dr. Lijauco/ Dr. Rasos

Final Diagnosis: COPD exacerbation controlled Bronchitis resolved PTB class IV

Date of Discharge: August 24, 2010

Time of discharge: 4:30 PM


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III. FAMILY BACKGROUND

Name Sex Ag

e

Civil

Status

Relationshi

p to the

Patient

Educational

Attainment

Occupatio

n

Religio

n

Address

Felipe

Acob

Sr.

Male 71

y/o

Marrie

d

Patient Elementary

Graduate

None Catholi

c

37

Ganaga

n Doro,

Bacarra

Catalin

a Acob

Femal

e

65

y/o

Marrie

d

Wife High School

Graduate

None Catholi

c

37

Ganaga

n Doro,

Bacarra

Jose

Acob

Male 50

y/o

Marrie

d

Son College

Graduate

Office

Worker

Catholi

c

Milan,

Italy

Dolore

s Agas

Femal

e

48

y/o

Marrie

d

Daughter College

Graduate

Office

Worker

Catholi

c

Milan,

Italy

Felipe

Acob

Jr.

Male 47

y/o

Marrie

d

Son College

Graduate

Farmer Catholi

c

37

Ganaga

n Doro,

Bacarra

Norma

Galut

Femal

e

46

y/o

Marrie

d

Daughter College

Graduate

Office

Worker

Catholi

c

Milan,

Italy

Helen

Adina

Femal

e

44

y/o

Marrie

d

Daughter College

Graduate

Office

Worker

Catholi

c

Milan,

Italy

Julie

Acob

Male 24

y/o

Marrie

d

Son College

Undergraduat

e

Farmer Catholi

c

37

Ganaga

n Doro,

Bacarra


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Acob family is a nuclear type of family. They are living within the vicinity of the father,

thus, considered to be patrilocal type of family. The family is oriented with both the mother and

the fathers kin, thus, they are bilineal type of family. With regards to decision making, the

family is an egalitarian type of family where in both the father and mother makes the decision.

Mr. and Mrs. Acob participate in barangay activities such as Oplan Dalus. For other

activities such as fiestas and other assemblies they are not that active. The family have

misunderstanding sometimes like when Tata Felipe insists to work even though they tell him

not to work because of the fact that this may aggravate this condition (collecting fire woods)

but it is easily resolved When we argue about such things, my wife gives me a cold shoulder

but after an hour, she talks to me again like nothing happened, as added by Tata Felipe. Mr.

and Mrs. Acob are the only ones who are living in their family house since their children

already have their own families. The family has a good relationship and they communicate

properly. They communicate through phone calls and letters with their children abroad.

Reading magazines, listening radio, watching television, gardening and chatting to their

neighbours are their leisure time.

Mr. and Mrs. Acob dont have monthly allowance on their own since they do not have

job at present. Mrs Acob claimed that they depend on their children for their financial needs

since they are already old to work. Their children working abroad send them money every

month. They receive a total of 10,000 a month. Each of their children contributes Php. 2,500.

According to Mrs. Acob, she is the one who decides for the allocation of their monthly

allowance. The amount is allocated mainly for their needs and is broken down as follows; Php

3000 is allotted for food and groceries with toiletries, Php 500 each are allotted for

transportation and electricity, Php 1000 is for miscellaneous expenses such as sudden illness or

hospitalization, load and magazines, Php 180 is spend for drinking water and Php 1820 is their

savings. Php 1000 is also allocated for medicines like Dulcolax, Ventolin and their multivitamins.

According to Mrs. Acob, their monthly allowance is enough to meet their daily necessities for

living.


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FOOD (w/ groceries and toiletries)-3000

MEDICINES---------------------------- 3000

SAVINGS-------------------------------1820

MISCELLANEOUS---------------------1000

TRANSPORTATION-------------------500

ELECTRICITY--------------------------- 500

WATER(mineral water)-------------180

IV. HEALTHHISTORY

A. Family Health History

Nana Catalina, the wife of our patient revealed that the family had experienced having

coughs, colds, and fever during extreme temperatures, muscle aches, toothache, headache and

30%

30%

18%

10%

5%5%

2%

monthly budget

food

Medicines

savings

miscellaneous

electricity

transporatation

water


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stomach aches. Such minor discomforts are usually managed with over- the- counter drugs such

as Solmux 500 mg PC until the symptoms will subside for cough, Neozep 500 mg PC for colds,

Biogesic 500 mg PRN for fever, Mefenamic Acid 500 mg PRN for headache, Alaxan 500 mg PRN

for body pains, and Kremil-S 500 mg or Lomotil 2 mg both PRN for stomach ache; as claimed by

Nana Catalina. The family had experienced some infectious and communicable diseases such as

chicken pox, measles, mumps and sore eyes. They usually manage chickenpox thru bed rest

and by exposing the sick child to the smoke of burnt onions when lesions are healing. For

measles, they would let the member wear any black clothes for they believe that this will lessen

the itchiness and for mumps they would apply akot-akot mixed with vinegar on the affected

area. For other managements of diseases, he mentioned bed rest, adequate intake of nutritious

foods such as vegetables and enough sleep as their health habit practices.

They also utilize herbal medicines like oregano decoction, kutsay extract and guava

extract. They would use the oregano decoction for cough, kutsay extract for wounds and the

guava leaves for washing and cleansing wounds. As added by Tata Felipe, they do not usually

consult to the Bacarra health centre; instead, they go straight to tertiary hospital like MMMH &

MC whenever the condition of one family members health is severe or it worsens.

Mata Acob, grandmother of our client on paternal side had asthma but Nana Catalina

(wife of our client) do not know if she was diagnosed, who diagnosed her and what were the

managements done to her. As claimed by Nana Catalina, Mata Acob was a heavy smoker, and

she can consume 10 tobacco sticks a day. Nana Catalina added that she was the one who

taught our client to smoke when he was just grade 5. Apolinario Acob, husband of Mata Acob

died because of complications of old age. Apolinario Acob and Mata Acob were blessed with 12

children; unfortunately Nana Catalina can only remember 3 of them namely; Kolas Acob, Pilo

Acob, and Juan Acob. All of them already died because of complications of old age.

Santan, grandmother of our client on maternal side, died already because of

complications of old age. Santiago, husband of Santan died because of complications of old age.

They were blessed with 3 children, namely; Ferming, Dorothea and Crispin Domingo. They

already died because of complications of old age.


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Juan Acob and Dorothea Acob, parents of our client were blessed with 6 children.

Milagros Ancheta, 62 years old, Marta, 64 years old, residing now at Mindanao, Lory Bagaoisan

66 years old, residing at Hawaii, Susima Bagaoisan 70 years old, Maria Garcia died at the age of

69 years because of bone cancer but they cannot remember any informations regarding the

disease and Felipe Acob our patient who was diagnosed with COPD last August 19, 2010.

As for their immunizations, Nana Catalina is not sure if they received any and Tata

Felipe did not have any scar that would reveal that he have received his BCG vaccine. According

to Nana Catalina their children completed all their immunizations.

He stressed out that they do not believe in ghosts, bad spirits, witchcraft, and quack

doctor. But he stated that he often consults to manghihilot whenever there are sprains and

muscle aches and he claimed to be effective.

B. Past Health History

Tata Felipe already experienced having common illnesses such as cough, fever,

headache and toothache as claimed. These were managed through taking in over the counter

drugs such as Solmux for cough, Paracetamol for fever and headache and Mefenamic acid for

toothache.

Infectious diseases he encountered during his childhood were the following: measles,

chickenpox and mumps. No medical consultation done, instead they treated it by taking in

Paracetamol to relieve fever and they let the smoke of garlic and onions with a charcoal in a pot

to their body to relieve itchiness for chickenpox. When he had his mumps, his mother topically

applied akot-akot on the affected site. Tata Felipe did not undergo any minor or major

operations except for circumcision when he was in grade four.


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According to Tata Felipe, he had no allergies to food or to drugs. He prefers eating

vegetables and meat especially internal organs like liver. As claimed, He began smoking at a

very young age which actually at grade 5. His Lola taught him to try tobacco whenever he goes

home after school. He begun to consume 2-3 sticks a day at age of 13 and gradually increase to

8-10 sticks during high school years. As became older, he could already consume as much as 1

pack of cigarettes until his mid 40s. On the other hand, he also started drinking liquor such as

GSM Bilog and beer when he was 14 y/o consuming 2-3 bottles of each every week. He,

together with his friends drinks occasionally.

C. PRESENT HEALTHHISTORY

In the year 1972, when he was 42, he experienced and complaint difficulty of breathing

which prompted him to have a check up at their Health Center. He had undergone x-ray and

diagnosed with asthma. Tata Felipe can no longer remember the doctor who attended him but

he was given take home medications which he took in preventing his asthma attacks but he

doesnt remember the medications given to him.

Two months past, he was rushed to Ranada General Hospital when he suffered again

from difficulty of breathing. He was diagnosed to be an asthma case again and was given

Ventolin inhaler and other unrecalled medicines. As far on what his wife remembered, he was

confined for 3 days. When he suffers from the above symptoms or from asthma attacks, he no

longer sought consultation to any medical facility, instead, the family buys Ventolin inhaler to

relieve difficulty of breathing and Solmux for cough with their current prescription.


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In year 1990 of December, Nana Catalina decided to let her husband consult to Doctor

Reyes Clinic. She was alarmed seeing her husband expectorates phlegm, rusty in colour and

vicious when coughing and sweats mostly at night even in cold season. Nana Catalina knew

about Dr. Reyes since she read several articles written by the said doctor on Bannawag which

talks about asthma and other lung disorders. And so Tata Felipe together with his wife agreed

to go at Dr. Reyes Clinic in Ilocos Sur. Tata Felipe had a sputum examination, he was instructed

to collect 1 sputum specimen in the morning and 2 specimens were collected in the clinic. Dr.

Reyes also examined Mr. Acobs X-ray according to him. His sputum examination and X-ray

reveals that he was positive of pulmonary tuberculosis. As for treatment, he was prescribed to

take Rifampin, Pyrazinamide and Isoniazid pyridoxine for 6 months. When asked about the

dosages, they could no longer remember it. Dr. Reyes made a referral letter saying about Tata

Felipes condition to Bacarra Health Center so that those medicines would be given for free.

Tata Felipe revealed that he did not take the medication religiously for 6 months because

sometimes he would forget to take or, if we run out of medicines, sometimes we dont have

time to go and get from the health center and, we didnt continue it since Im feeling better

then as claimed. 1991 Tata Felipe went back to the Health Center for check-up after 6 months

and his examinations revealed that he is still positive of PTB, he was again given another 6

months treatment with an additional medication which is Ethambutol. According to Tata Felipe

he religiously took the medication until 6 months and when they went for another check-up for

evaluation, his PTB was already resolved. Tata Felipe was so happy and thankful

He continued to work as a farmer. But had asthma attacks especially during cold

seasons as well as when triggered by irritants such as dust, smoke and fumes as claimed. His


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asthma was not really that serious as he verbalized since medications can just relieved it

(Ventolin Inhaler, Solmux).

Because of his condition, his family advises him to quit smoking and drinking liquor.

It was also told by his doctor before that smoking can expose him to more severe disorders.

Tata Felipe didnt deny that once in while he still taste a bit after which but he emotionally

expressed that he made an effort to stop it for the sake of his children and to have a longer life

together with his family. Though it is difficult in his part; he successfully quitted such vices in a

gradual manner.

Upon waking up in the morning of August 17, 2010 he experienced sudden dryness and

itchiness of throat and finally ending up to productive cough. As his cough progresses,

shortness of breath had been developed it is hard for him to breath and he complaints of the

sound of rales he was experiencing as verbalized by Nana Catalina. He thought that this was

just brought by weather changes and exhaustion from doing house hold choirs such as cleaning

the backyard. At first, he does not sought consultation with the thought that he again had been

attacked by asthma. He had taken medicines previously prescribed by a private physician such

as Ventolin inhaler and Solmux. He gained temporary relief from those drugs. Nana Catalina

also added that his husband was sneezing caused maybe by frequently taking a bath just after a

perspiring work and weather changes so she bought Neozep Forte (500mg) as management of

cold which he took every 4 hours. However, as days pass by, his cough became recurrent and

persistent. On the evening of august 19, 2010, he suffered from difficulty of breathing and

severe coughing. He was immediately rushed to the Mariano Marcos Memorial Hospital and


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Medical Center at exactly 11:55 PM with an admitting diagnosis of COPD in acute exacerbation

bronchitis, PTB Class IV. He was admitted by Dr. Quilala and Dr. Pumaras.

V. DEVELOPMENTAL DATA

Ericksons Theory of Psychosocial Development

Ericksons Theory of Psychosocial Development

It is necessary to study the development of a person to be able to understand the responses

that are seen in the client in certain circumstances or situations. One theory that had been

devised to do such study is the Psychosocial or Emotional Development by Erik H. Erickson. He

believes that maturation of bodily functions is linked with expectations of society and culture inwhich the person lives. According to him, in each stages of a persons emotional development,

there are particular changes, which he called crisis that exists for a healthy development to

occur. When needs are met, a healthy or positive personality is developed and the individual

moves to the future stages with particular strength; but if not, an unhealthy outcome occurs

which will influence future relationships.

Erickson identified Ego Integrity versus Despair as the developmental stage to be

achieved during the Late Adulthood (60 years old and above) in which our client belongs. He

said that ego integrity suggest an acceptance of ones lifestyle and a belief the choices made

where the best that could be made at a particular time. Into our client, he accepts this stage by

showing a positive attitude instead of grumping feature when talking of his old age.

Despair, the opposite of ego integrity, implies that the older person feels dissatisfied

and disappointed with his or her life and if given another chance the person would live life

differently. It is being manifested by our client by longing for his drinking sessions and smoking

cigarettes.

In this span of age, the client is expected to feel good about his choices in life, and self

acceptance of the inevitable death and the acceptance that his ability to contribute to the

community is minimized. On the other hand, our client is not expected to wish life could turn


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out differently as with him now, to be angry of the aging bodies, and withdrawn from the

society.

Tata Felipe, 71 y/o is in his late adulthood stage with the central task of achieving Ego

Integrity vs. Despair. Tata Felipe feels good about his past life choices. He was able to form a

family and commit himself to his own responsibilities. And now that his children are all happily

married, still Tata Felipe never failed to be the good father to them. Towards his wife, Tata

Felipe has maintained same warmth or sweetness and a good relationship. They also quarrel at

times but the conflict does not last long because they would immediately settle it.

Tata Felipe belongs to certain organization in their barangay such as the Senior Citizen

Club, when he was still younger he would attend to Barangay Fiestas and Oplan Dalus. He alsostated that they won as the cleanest house in their barangay last 2008.

He is also regarded as a good neighbor and a good person because he knows how to

help others and he knows how to get along with them.

The negative indicators such as a persons feeling of dissatisfaction and disappointment

with his life and if given another chance the person would live life differently is not seen to our

client.

He said that he accepts the changes of his physical stature and that death is inevitable.

Analysis: Based from his accomplishments over the years, Tata Felipe could be said to be

manifesting the indicators of a positive resolution such as satisfaction with his life and the

decisions and acceptance of the inevitable death.

Havighursts Theory of Developmental Task

Havighursts theory of Developmental Tasks states that learning is essential to life and

that to understand growth and development; one must understand and accept the premise

that the human being continues to learn throughout life. Effective learning and achievement of


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tasks during one period leads to happiness and success with later task while failure leads to

unhappiness, disapproval by the society and difficulty with later tasks.

Tata Felipe belongs to Havighursts age group of Later Maturity wherein he is expected

to develop tasks like Accepting and adjusting to decrease physical strength and health Tata

Felipe already accepted and adjusted himself to his decreased physical strength and health. He

admitted that his activities now are no longer like his activities when he was still younger and

stronger. He also told us that these changes in strength and health are just normal to aging

people. Adjusting to retirement and lower income Tata Felipe long decided to stop doing

farming for he can no longer be productive with his work and his health can be worsen if he still

do strenuous activities. He has already retired and just stayed mostly in their home, and

enjoying the company of his wife. Even if he already retired from farming, he doesnt worry in

terms of financial terms for his children sends their income. Though his income is no longer like

of that when he was still farming, he already adjusted to a lower income and accepts it since he

and his wife also spends lesser now. Aging and inevitable death of age and spouse When we

asked Tata Felipe if he already accepted aging and death, he gladly told us that it is just a

normal part of living and that also includes death. As much as he wanted to return to his youth,

he also looks forward about the life that is to come after death. Establish Affiliation with Age

Group Despite of his age, he still maintained a relationship with the people, especially hisfriends who are at the same time belongs to his age group, they still have conversations yet it is

not as often as it was of the past since they no longer see each others often. Meet Social and

Civic Obligations, Even if Tata Felipe is now old, he makes sure that his social and civic

obligations are still met, such as exercising his right to vote. And during the 2010 National

Elections he voted and was delighted and accepted the new system of voting. He told us that

these are the things that he can never grow old with. Live in Satisfactory Physical Environment,

Being with his wife in their home, they maintain their physical environment with its cleanlinessand their community is also composed of a good environment. He was also satisfied with the

peacefulness of their community and his environment.


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Analysis:

Based from his accomplishments over the years, Tata Felipe could be said to have

achieved the expected tasks like practicing his rights to vote, satisfaction with his physical

environment and peacefulness of the community and acceptance of the inevitable death.

VI. Patterns of Functioning

Patterns of

Functioning

Before Illness During Illness

Before Hospitalization During Hospitalization

Eating The patient was

diagnosed of COPD on

August 19, 2010. Prior

to this, he claimed

that he eats three

times a day and have

snacks in between.

He usually eats his

breakfast between

6:00-6:30 AM, lunch

at 11:00-11:30 AM,

and dinner at 6:30-

Before hospital admission, he

usually eats the same foods

as that mentioned in before

illness as long as they are well

cooked and prepared such as

nilagang baka (1/2-1 bowl),

pancit (1 serving) and

sinabawang gulay with meat

(1 serving). He only can only

consume half of the food he

was eating before illness.

He eats his meal, 6:00-6:30

AM for breakfast, 11:00-

During his stay on hospital

he can consume all the

hospital rations served for

each meal which consist of

one serving for meat and

vegetable and one cup of

rice. He was on DAT diet. His

snacks usually consist of

fruits such as apples and

oranges.

He eats his meal around 6

AM for breakfast, 11:30-

12:30 PM at lunch and as


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7:00 in the evening.

He prefers to eat meat

especially nilagang

baka (1/2-1 bowl), he

also like pancit (1

serving) and

sinabawang gulay

with meat (1 serving).

He doesnt like to eat

foods that have bland

taste and no additives

and also raw foods

like kinilaw. He usually

consume 1- 1 1/2 cup

of rice each meal.

His snack usually

consists of native

delicacies like suman-

latik, banana cue, and

ginataan. According to

him he doesnt have

11:30 AM at lunch and 6:30-

7:00 for dinner.

His snack usually consists of

native delicacies like suman-

latik, banana cue, and

ginataan. According to him he

doesnt have any allergies to

food.

early as 5:30-6:00 PM for his

dinner.


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any allergies to food.

Analysis: There was a change on the eating pattern of the patient before illness and before

hospitalization due to difficulty of breathing. However when he was confined at the hospital,

his appetite increases as manifested by consuming all the rations served.

Patterns of

Functioning



Drinking He claimed that he

drinks upto 9 glasses

(250mL/glass) of

water per day. He also

like to drink alcoholic

beverages like gin

(bilog) which he

consume upto 2

bottles per week and

sometimes beer which

he can consumes 3

bottles in a week. He

doesnt like to drink

He already discontinued

drinking alcoholic beverages.

He can consume 2250 mL of

water in a day. He also drinks

1 glass of tea (320 ml)

whenever he feels

constipated. His total fluid

intake for 24 hours was

approximately 2,250- 2,570

ml.

During hospitalization, he only

drinks water with an amount of

600-1000 mL in a day.


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beverage that is

sweet. He also drinks

1 glass (320 ml) of tea

when he feels

constipated. He

doesnt have any

allergies to beverages.

All in all he can

consume

approximately 2,570-

2,850 ml/day.

Analysis: There was a change in the drinking pattern of the patient before illness and before

hospitalization since the patient discontinued drinking beer and gin, this is associated with the

presence of his ailment. There is also change during hospitalization due to decrease intake of

water because he is confined to bed.

Patterns of

Functioning



Bladder He voids 3-5 times a

day. Usually, he

Since Tata Felipe stop drinking

alcoholic beverages, his

He voids 2-3 times a day with

an approximate amount of


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Elimination urinates once in the

morning after he

wakes up, in the

afternoon and before

bedtime. He claimed

that his urine color

was yellowish to clear,

no foul odor,

bubbling, and the

duration during

voiding is not the

same.

bladder elimination is the

same as when they do not

have drinking session (3-5

times). His urine output is

approximately 1800-2000 ml/

day.

1200-1500 mL. Urine is

characterized as yellowish to

clear, no offensive odor.

Analysis: There was an alteration in bladder elimination as to frequency and amount before

illness to during illness attributed to the discontinuation of drinking alcoholic beverages.

However, during illness (before hospitalization) comparing during hospitalization, there was a

decrease in bladder elimination secondary to increase insensible losses due to the respiratory

tract.


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Patterns of

Functioning



Bowel

Elimination

Our client defecates

once a day. As to the

characteristics of his

feces, he describes it

as brownish in color,

aromatic, and its

consistency is soft. He

feels constipated

sometimes and

defecates early in the

morning around 3

AM.

He claimed that he defecates

the same before illness. As to

the characteristics of his

feces, he describes it as

brownish in color, aromatic,

and its consistency is soft. He

feels constipated sometimes

and defecates early in the

morning around 3 AM.

He claimed that he only

defecated on the day of

discharge. He doesnt use

Dulocolax anymore because

of the unavailability if the

drug. As to the characteristics

of his feces, he claimed that

its the same before illness

which is brownish in color,

and its consistency is hard.

Analysis: There was a change in the bowel elimination during illness (before hospitalization) to

during hospitalization due to the decrease activity and because he didnt use any Dulcolax.


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Patterns of

Functioning



Sleeping Our patient sleeps at

8:00-9:00 PM and

wakes up at 4:30-5:00

AM. He claimed that

his sleep was not

continuous and the

duration is 8 hours.

His bed time rituals

include watching TV

for 1-2 hours and

reading magazines

until he feels sleepy.

He also takes a nap

for 1-2 hours. All in all

he sleeps 9-10 hours

in a day. He utilizes 1

pillow on his head and

1 on his side. He also

applies gas and oil

He sleeps and wakes up the

same time at 8:00-9:00 PM

and wakes up at 4:30-5:00 AM

before hospitalization but he is

more frequently awakened

not like before illness. He

frequently awakes because of

profuse sweating. He still

applies gas and oil before

wearing sock at bedtime, he

uses 1 pillow on his head and

1 on his side and uses

mosquito net.

He sleeps at 10-11 PM and

wakes up around 5-7 AM. He

claimed that he is disturbed

during his sleep because of

the nurses routine. He uses 1

pillow on his head. He didnt

apply gas and oil before

bedtime. He also takes a nap

for 1-2 hours.


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before wearing socks

at bedtime and uses

mosquito net.

Analysis: There is a change in the sleeping pattern before hospitalization to during

hospitalization due to the new environment and nurses routine (vital sings taking and giving

medication).

Patterns of

Functioning



Bathing He takes a bath twice

a day, once in the

morning and before

he sleeps. He prefers

to use warm water.

He uses a pail of

water, Safeguard soap

and Sunsilk shampoo

and uses stone that

serve as body scrub

during bathing. He

He claimed that he do his

usual bathing the same

before illness such as using

herbal leaves, prefer warm

water, and utilize stone as

body scrub. He uses a pail of

water, Safeguard soap and

Sunsilk shampoo.

Sponge bath was rendered by

her wife once in the morning

and before his bedtime.

Sometimes his daughters do

her wifes activities.


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also uses herbal

decoction such as

lagundi and

sambong leaves

that he apply after

scrubbing for soothing

effect.

Analysis: There was a change in the in the bathing pattern of our patient during illness, before

hospitalization and during hospitalization due to the environment (dirty CR and its availability)

and presence of IV fluid prior to his confinement.

VII. LEVELS OF COMPETENCIES

PHYSICAL



Our clients daily routine

includes different kinds of

activities such as eating,

sleeping, bathing, feeding

their pets at home and

working at the farm. Even

The daily routine of our client

still includes eating, sleeping,

and bathing. But he cannot

do these without assistance

of his wife. By this time, he

can no longer also do feeding

Tata Felipe can no longer do

hes usual activities such as

eating, and bathing without

assistance of his wife. Because

Tata was easily being

exhausted when he does these


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though hes on the stage of

late adulthood, he can still

perform these things without

any assistance or any assistive

devices. He also performs

household chores like

washing the dishes and

cleaning their house. He does

these activities without being

exhausted.

their pets at home and

working at the farm because

of easy fatigability and the

presence of difficulty of

breathing.

things. He doesnt take a

whole bath during his 4 days of

confinement but nana Catalina

rendered him only Partial

Bath. He spend most of his

time on lying on bed, reading

magazines and chatting with

his wife and to those who

visits him.

Analysis: There was a change in the physical competency of our client because of the

discomforts such as difficulty of breathing and easy fatigability he is suffering.


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EMOTIONAL

Analysis: There was a change in the emotional competency of Tata Felipe because he became

irritable due to the presence of his illness.

SOCIAL





As claimed, Tata Felipe is a

cheerful one. However, nana

Catalina added that he is not

a type of person who is

expressive. As verbalized by

Nana Catalina, I just can

sense what my husband feels

even if he wont tell me.

When they quarrel, Nana

Catalina will just scold him

and Tata Felipe will stop

arguing.

According to Nana Catalina,

Tata Felipe is still cheerful.

Tata Felipe told us that he

can do anything he wanted

when he was at home which

is of his comfort. According to

him, when he doesnt feel

well, he tried to suppress it,

but nana Catalina can sense

his discomforts.

As we observed, Tata Felipe is

a cheerful person. But there

are times that he gets irritable.

He sometimes shouts to the

nurses. According to him,

when the nurses administer

medications in the night while

he is sleeping, he doesnt want

to be disturbed.


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Tata Felipe is a friendly type

of person. He has a good

relationship with his relatives

and other people in their

community. Whenever he has

nothing to do in their house,

he goes out and chats with

their neighbours. He is kind to

them and he knows how to

help them whenever they

have problems. He alsostated that he doesnt have

any enemies in their

community.

He maintains a good

relationship with other

people. He can still go out

from their house and chat

with their neighbours but

unlike before, he rarely does

it.

Even if tata Felipe have only

few people to interact with, he

still maintained his social

competency by having a

respecting relationship with

his room mate. He often has a

good conversation with the

people around him and his

fellow patient.

Analysis: There were changes in the social competency of our client since he still interact with

other people in a good manner.

MENTAL



Tata is a person who easily

understands of what is beingexplained to him. He is well

oriented about events, time,

place, person, and what is

happening around him. In

During the course of illness

he could still comprehend ofwhat is being explained and

being told to him. He can still

decide on things on his own.

Tata Felipe can still

comprehend what is beingexplained to him. He is still

well oriented about the time,

place, person and the things

happening about him. And


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terms of decision making on

such things like for the

welfare of their family, he can

decide on it.

during our interview, he

answers our questions

appropriately such as where

he lives and what date is their

anniversary.

Analysis: Tata Felipes mental capacity to comprehend and retain information and make

decisions did not change before and during illness. When we asked him questions, he

answers it appropriately and correctly.

SPIRITUAL



He rarely goes to church

because their house is too far

from their church. He has a

strong faith to God and

according to him,

eventhough i dont attend

the mass i never forget to

pray. He claimed that he

prays upon waking up in the

morning, before he eats his

meals and before he goes to

sleep.

Tata Felipes faith is still

strong. When we have asked

him if he still prays, he

claimed that he does. He

prays upon waking up in the

morning, before he eats his

meals and before he goes to

sleep. He affirmed that he

still believes in God despite

his illness.

Our clients faith was still the

strong as what he claimed it to

be. He told us that he always

pray to God when he wakes up

in the morning, before eating

his meals and before he will go

to sleep.

Analysis: There was no alteration in the spiritual competency of our client since his faith to God

remains before he got ill and during the course of his illness.


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VIII. PHYSICAL ASSESSMENT

General Appearance:

During the day of physical assessment, our client is wearing a yellow sando and a

white printed pajama. He is neat in appearance, with a brown complexion. His hair is well

combed. He has an IV fluid of D5NM inserted as venoclysis regulated at 27-28 gtts/min was

intact on his left basilic vein. He has a noticeable barrel chest. His body built is considered as an

ectomorph. He was cooperative during the assessment.

Height: 174 cm BMI: 20 kg/m2

Weight: 60 kg

Date of Assessment: August 20, 2010 Time of assessment: 3:00 PM

Vital Signs:

BP: 120/70mmHg, in sitting position, taken at right arm

PR: 81 bpm, regular in rhythm

Temperature: 36.5C per axilla

RR: 25 breaths per minute, regular in rhythm

Head:

- Normocephalic, round and proportional to the body- Hair is evenly distributed, with presence of white hair, thick, smooth and resilient- No discolorations, lesions or itchiness, no dandruff on the scalp- Facial features are found to be symmetric- No involuntary movements noted


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Eyes

- Almond shaped- Eyebrows are evenly distributed, thick and with few white hairs- Eyelashes are short, thin and evenly distributed- Eyelids are wrinkled- With noticeable eye bags- Pale conjunctiva, smooth, no lesions found- Cornea are opaque, moist and with reports of blurry vision on his left eye

Grade of eyeglass: 2.5

- Iris found to be round and black in color- PERRLA (Pupils Equally Round and Reactive to Light and Accommodation)- Has good ocular movement-able to move eyeballs from left to right, up and down

Ears

- Same color with the other parts of the body- In line with the outer canthus of the eye- Bean shaped, attached earlobe- With minimal cerumen- With a good hearing acuity- able to reiterate the words we uttered to him in a soft voice

Nose

- Same color with the face- No nasal discharges noted- High bridged nose- Pinkish nasal mucosa- With patent nares- No swelling observed around the nose


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Mouth and Throat

- Lips has symmetrical contour, pinkish in color but somewhat brownish at the edge- Lips are smooth and moist in appearance- Pinkish tongue- Able to move tongue left to right, up-down, in-out- Buccal mucosa is pinkish, smooth in appearance, with no lesions noted- Gums are pinkish, no lesions, no bleeding found and veins are slightly visible- No tooth is present at the upper part (he uses dentures)- Lower part has 5 teeth- yellowish and blackish in color and with carries- Hard palate appears bony and whitish while soft palate appears pinkish- Uvula positioned in the midline of the soft palate, pink in color- With visible veins on the buccal mucosa

Neck

- Same color with the other parts of the body- Skin is wrinkled and sagging- Trachea palpated in the midline- Has normal range of motion-able to flex and hyperextend- No engorgement of the neck vein

Chest

- Symmetrical- Has lighter color than the other parts of the body- Areola are round and black in color- Nipples are symmetrical in color- With a Barrel chest;

AP diameter: 17cm

Transverse diameter: 15cm


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- With normal lung expansion- With hyperresonant sound upon percussion- With a cardiac rate of 82 bpm- regular in rhythm- With abnormal breath sounds(wheezes) - lower lobe of the lungs- With a RR of 25 breaths per minute- regular in rhythm

Abdomen

- Lighter in color than the other parts of the body- Slightly protruberant- With normoactive bowel sound

RUQ- 7 LUQ- 8

RLQ- 8 LLQ- 8

- With tympanitic abdominal sound upon percussion

Upper Extremities

- Symmetrical in size and color- With hanging shoulders- Same color with the other parts of the body- No tenderness, lesions, deformities noted- With heart shape tattoo on the left forearm; about 2 inches in size- With sagging skin on the arm- With poor skin turgor- IV line inserted at left basilic vein- With a pulse rate of 81 bpm- regular in rhythm in both peripheral pulses- With good capillary refill of 2 seconds- With a good range of motion-able to adduct and abduct arms without restriction- With pinkish nailbeds- With short clean nails- With good muscle strength


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- Blood pressure taken at the right brachial artery: 120/70 mmHg

Lower Extremities

- Symmetrical in size and color- Same color with the other parts of the body- No tenderness, lesions, deformities noted- With good capillary refill of 2 seconds- With poor skin turgor- With a good range of motion-able to adduct and abduct legs without restriction- With pinkish nail beds- With short clean nails

IX. On- Going Appraisal

IX. On- Going Appraisal

August 21, 2010

1st

day appraisal

Tata Felipe was seen lying on bed in supine position with an IVF of D 5NM 1L @ 500 cc

level regulated to 27-28 gtts/min inserted at right basilic vein, infusing well. He complains of

back pain and wheezes every time he breathes. Tata Felipe has a productive cough with

yellowish sputum. He also reported having difficulty of getting sleep. The client was seen by

Dr. Lijauco with new orders made such as to continue meds (Salbutamol + Fluticasone 50


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mg/250 mg diskus inhalation BID, MV+Buclizine 1 cap OD and decrease Salbutamol +

Ipratroprium Neb to every 6 hours). Nebulization was done at 6 pm.

Tata Felipe is on DAT with strict aspiration precaution and was able to consume all of his

hospital rations served for breakfast, lunch and dinner. His vital signs were taken and

recorded as follows:

Body temperature (C) 36.2 36.6

Blood Pressure (mmHg) 110-120/70-80

Pulse Rate (beats/min) 80-88

Respiratory Rate (breaths/min) 22-28

Tata Felipe had partial bath this assisted by his wife.

His I and O for 24 hours monitoring were: for the 3-11 shift, his Clysis was 400 cc, oral

intake of 300 cc and output of 380 ml. For 11-7, his Clysis was 400 cc, oral intake of 200 cc

and output of 380 ml and for the 7-3 shift, his Clysis was 100 cc, oral intake of 300cc and

output of 400 ml.

Over all, his total Clysis was 900cc, oral intake of 800 cc and urine output of 1160 ml. he

urinated three times and did not defecate

August 22, 2010

2nd

day appraisal

Tata Felipe was seen sitting on the bedside with an IVF of D5NM 1L at 400cc

level regulated to 27-28 gtts/min. He is active in appearance. There were no back pains


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noted but he has still wheezes every time he breathes. He has still productive cough and

yellowish sputum and still with complains of difficulty in getting sleep. The client was seen

by Dr. Lijauco with new orders made such as to continue the meds (Budesonide every 12

hrs, N-acetylcysteine 200mg sachet in glass water BID , Salmeterol + Fluticasone 50

mg/250 mcg diskus inhalation BID, MV+Buchizine 1 cap OD, Salbutamol + Ipratropium Neb

every 6 hours, and Hydrocortisone 100 mg IV every 8 hours).

Tata Felipe is still on DAT with aspiration precaution and was able to consume all of his

hospital rations for breakfast, lunch and dinner.

His vital signs were taken and recorded as follows:

Body temperature (C) 36.2-36.8

Blood Pressure (mmHg) 120/70-80



Tata Felipe had a partial bath assisted by his wife. He was awake most of the time and

took two one-hour sleeps in the morning and afternoon.

His I and O for 24 hours monitoring were: for the 3-11 shift, his Clysis was 400 cc,

oral intake of 300 cc and output of 380 ml. For 11-7, his Clysis was 400 cc, oral intake of 200

cc and output of 380 ml and for the 7-3 shift, his Clysis was 100 cc, oral intake of 300cc and

output of 400 ml.




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August 23, 2010

3rd

day appraisal

Tata Felipe was seen lying on bed with an IVF of D5NMiL at 900 cc level regulated to

KVO. He is active in appearance and still complains of wheezes each time he breathes. Tata

Felipe has productive cough and with complaints of unable to sleep. The client was seen by

Dr. Rasos at 4:45 pm with new orders such as to facilitate spirometry but he refused, and

IVF to consume and shift to heplock.

Tata Felipe is still on DAT and was able to consume all of his hospital rations served for

breakfast and for lunch.



Blood Pressure (mmHg) 130- 110/70



He took a partial bath again with the help of his wife. He was awake most of the time

reading magazines and chatting to his wife and his roommate.

His I and O for 24 hours monitoring were: for the 3-11 shift, his clysis was 250 cc, oral

intake of 300 cc and output of 420 ml. For 11-7, his clysis was 200 cc, oral intake of 200 cc

and output of 380 ml and for the 7-3 shift, his clysis was 450 cc, oral intake of 250cc and

output of 400 ml.




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August 24, 2010

4th

day appraisal

Tata Felipe was seen sitting on bedside chair with heplock at right cephalic vein. He is

conversant and still with complains of wheezes but it is minimized compared to the

previous days. The client was seen by Dr. Lijauco at 1:30 pm with new orders made such as

MGH and prescribed with take home meds (Salmeterol + Fluticasone 50 mg per 250 mg

diskus inhalation BID, Salbutamol + Ipratroprium Nebule PRN if DOB, Levofloxacin 750 mg 1

tab OD for seven days) and for follow check up at OPD on September 2, 2010. Tata Felipe is

still on DAT and was able to consume all of his hospital rations for breakfast and for lunch.



Blood Pressure (mmHg) 130-110/90-70



He was able to take a full bath today but still with the assistance of his wife. He also

defecated once.

His I and O for 24 hours monitoring were: for the 7-3 shift he urinated and defecated

once, his oral intake was 450 cc. And total amount of urine was 380 cc. And at 4:30 pm he

already went home in good condition and disposition.

X. Medical Management

A. Diagnostic Procedures


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1. Complete Blood Count

DEFINITION

The CBC is used as a broad screening test to check for such disorders as anemia,

infection, and many other diseases. It is actually a panel of tests that examines different

parts of the blood and includes the following: Hemoglobin, Hematocrit, RBC indices, WBC,

and the differential count.

Purpose

Complete Blood Count (CBC) was done to our patient to determine significant changes

on the blood components brought about by the disease.

Date Requested: August 20, 2010

Date Performed: August 20, 2010

Requesting Physician: Mia Grace Lijauco, M.D.

RESULTS

EXAMINATIONS RESULT REFERENCE VALUE SIGNIFICANCE

Hemoglobin 140 140-175 g/L NORMAL

Hematocrit 0.41 0.41-0.50 NORMAL

RBC 4.560 4.5-5.9 x 10^12L NORMAL

MCV 89.00 80-100 fL NORMAL

MCH 30.70 27-32 pg NORMAL

MCHC 34.50 31-35 g/dL NORMAL

WBC 7.38 4.50-11.0 x 10^9/L NORMAL

Platelet 224 150-450 x 10^9/L NORMAL

DIFFERENTIAL COUNT

Segmenter 0.61 0.50-0.70 NORMAL

Lymphocyte 0.29 0.20-0.40 NORMAL


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Monocytes 0.08 0.02-0.08 NORMAL

Eosinophils 0.01 0.01-0.04 NORMAL

Basophils 0.01 0.00-0.01 NORMAL

Analysis

The result of the CBC was within normal range because our patient has good immune

system

Nursing Responsibilities Rationale

1. Verify doctors order To validate the existence of the procedure2. Reemphasize to the client about the

type of procedure and its purpose.

In order to establish rapport and gain

cooperation.

3. Explain to the client that a tinglingsensation maybe felt while collecting

the specimen.

In order for the client to know what to be felt

during the collection of specimen.

4. Refer to the doctor the results andattach to the patients chart

In order for the physician to evaluate the

results and perform the necessary

interventions.

2. Blood Chemistry

Purpose

Blood chemistry was done to our patient to determine significant changes on the

electrolyte components brought about by the disease.



Requesting Physician: Mia Grace Lijauco, M.D.


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RESULTS

EXAMINATION RESULT REFERENCE VALUE SIGNIFICANCE

Blood Urea Nitrogen 7.54 1.7-8.3 mmol/L NORMAL

Creatinine 66.25 44.2-150.3 mmol/L NORMAL

Sodium 142.00 136-150 mmol/L NORMAL

Potassium 4.20 3.4-5.3 mmol/L NORMAL

Chloride 102.00 96-106 mmol/L NORMAL

Analysis:

The result of the blood chemistry was within normal range and has no affectation on the

kidneys.


1. Verify doctors order To validate the existence of the procedure2. Reemphasize to the client about the


In order to establish rapport and gain

cooperation.

3. Explain to the client that a tinglingsensation maybe felt while collecting

the specimen.

In order for the client to know what to be felt

during the collection of specimen.

4. Refer to the doctor the results andattach to the patients chart



interventions.

3. Arterial Blood Gases

DEFINITION


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This test is used to evaluate oxygenation and acid/base status. This test assesses both

the ventilation and diffusion capacity of the lungs to assist in diagnosis and to give an objective

assessment of improvement or deterioration.

Purpose

This was done to our patient to identify an impending acid-base imbalances



Requesting Physician: Emely T. Pumaras, M.D.

Result

EXAMINATIONS RESULT REFERENCE VALUE SIGNIFICANCE

pH Arterial Blood 7.414 7.35-7.45 mmHg NORMAL

pCO2 35.2 3.5.0 -45.0 mmHg NORMAL

pO2 64.4 80.0 -105.0 mmol/L DECREASE

HCO3 22.0 22.0-26.0 mmol/L NORMAL

Base Excess -2.6 -2.00 3.00 % NORMAL

O2 Saturation 92.4 95% NORMAL

Analysis:

The abnormal low level of pO2 and O2 saturation results to hypoxemia is due to

impaired ventilation perfusion mismatch, narrowed airways secondary to the disease process

and decrease ventilation.


1. Verify doctors order To validate the existence of the procedure2. Reemphasize to the client about the To gain cooperation and compliance


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3. Inform the patient that arterial bloodsample collection is usually more

painful than regular venipuncture.

To be able to know by the patient what to be

felt during the collection of specimen.

4. Instruct the patient to sit with thearm hyper extended and wrist resting

on a small pillow

For proper collection of specimen from the

venipuncture site

5. Instruct the client to relax while bloodis being collected.

To void false positive results

5. Refer to the physician the result ofthe examination then attach to the

patients chart



interventions.

6. Administer oxygen as prescribed This is to address O2 saturation anddecreased pO2

7. Position patient in semi-fowlersposition

To loosen airways and facilitate

3. Acid-Fast Bacilli

DEFINITION

This test of various body fluids identifies tubercle bacilli in order to diagnose andmonitor the treatment of tuberculosis. Findings of acid-fast bacilli on microscopic examination

indicate possible tuberculosis and allow for timely initiation of anti-tuberculosis therapy.

Smears and cultures, primarily of sputum but also of other body specimens such a s urine, skin

biopsies, cerebrospinal fluids, gastric washing and blood are stained to detect acid-fast bacilli.


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Purpose

This procedure was done to our patient to confirm hi tuberculosis by determining the

causative agent involved and to determine the appropriate treatment.



Requesting Physician: Dr. Lijauco

Result

Gram Stain

Gram (+) cocci singly and short chain

Gram (-) bacilli many

WBC > 25/lpo

Fungal elements moderate

AFB Stain

(-) for fungal elements

Culture: x Aerobic x Anaerobic

Result:

Moderate growth of AmpC beta-lactamase producing Pseudomonas aeroginosa and

moderate growth ofCandida albicans

Susceptibility Test Result:

AmpC beta-lactamase producing pseudomonas aeroginosa (disk diffusion)

Susceptible to:

Amikacin

Cefepime

Ciprofloxacin

Gentamicin


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Imipenem

Levofloxacin

Meropenem

Tobramycin

Analysis

The presence of microorganisms (candida albicans and pseudomonas aeroginosa)

signifies that our client is suffering from tuberculosis


1. Verify doctors order To validate the existence of the procedure2. Reemphasize the purpose of such

diagnostic procedure.

To gain cooperation and compliance

3. Reemphasize to the patient thecorrect procedure of specimen

collection

In order for the client to become aware on

the correct procedure of gathering

specimen for accurate results

4. Encourage the client to increasefluid intake the night before

To loosen secretions and to expectorate

sputum and specimen easier

5. Refer to the doctor the result ofthe examination then attach to the

patients chart

So that the physician will see the result

and if abnormalities is present proper

management will be given

4. ELECTROCARDIOGRAPHY (ECG)

DEFINITION

The ECG is a diagnostic tool used in assessing the cardiovascular system. ECG is used to

measure the rate and regularity of heartbeats as well as the size and position of the chambers,


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the presence of any damage to the heart, and the effects of drugs or devices used to regulate

the heart (such as a pacemaker). It is a graphic recording of the electrical activity of the heart.

The ECG is obtained by placing disposable electrodes in standard positions on the skin of the

chest wall and extremities.

Purpose

This procedure was done to our patient to determine if there is an affectation in the

heart brought about by the disease.

Date Ordered: August 19, 2010


Requesting Physician: Mia Grace Lijauco M.D.

Result: Regular sinus rhythm, left axis deviation

Analysis: the left axis deviation may be possibly caused by the cardiac muscle enlargement due

to the increase workload of the heart to compensate for the ventilation perfusion.


1. Verify doctors order To validate the existence of the procedure2. Reemphasize to the patient and

significant other about the

procedure, including where it will

take place and its expected

duration

To alleviate anxiety and to gain

cooperation of the patient

3. Instruct patient to remove allmetals attached

To prevent any alteration in the result of

the ECG

4. Refer to the physician the ECG So that the physician will be able to


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result once available and then

attach it to the clients chart

determine the appropriate management

to be applied to the patient based on the

result

5. Report any abnormalities in the v/sand urine output to the physician

To make an immediate intervention to

prevent complication

B. Treatment

1. Intravenous Therapy

DEFINITION:

Intravenous Therapy is the giving of fluid substances into a vein. Intravenous Fluids aims

to maintain homeostatic functioning or maintain and replace body stores of water, electrolytes,

vitamins, minerals, proteins and calories in patients who cannot maintain an adequate intake

by the mouth; provide an avenue for the administration of IV medications and monitor central

venous pressure; restore acid-base balance and restore volume of blood components.

Purpose:

This was given to our client for rehydration and serves as an avenue for medications,

supplementary of nutrients and electrolytes.

IV Fluid Date Performed Requesting Physician

D5NM August 19, August 20, August

21, August 22

Dr. Lijauco

D5W August 20 Dr. Lijauco



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1. Verify doctors order to validate the presence of the procedure2. Reemphasize to the patient the

purpose of the therapy.

To gain the patients compliance and

cooperation.

3. Check the fluids and equipments tobe used for infusions for any

discoloration, cloudiness, presence of

particles, cracks of bottle, punctured

bottle, IV tubing and catheters

discoloration.

To identify possible indications of expiration or

contamination.

4. Clean the infusion site using cottonballs with alcohol.

To prevent infection.

5. Regulate IV Fluid to the desired flowrate.

In order to meet necessary fluid and

electrolyte needed by the body within the

specified length of infusion as well as to

prevent circulatory overload.

6. Check for the presence of signs ofinfiltrations such as coolness of the

area, absence of blood backflow,

leaking of solution, sluggish flow rate

and swelling at the IV site.

To assess for the patency of IV line and to

ensure proper infusion

7. Read the clysis at eye level. To ensure a more accurate measurement.8. Document the type of IV solution

infused, its volume, its desired flow

rate, the date and time it was infused

and consumed.

This would serve as a record or for legal

purposes.


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2. Nebulization

It provides a visible mist of water articles for the patient to inhale. This is used to liquefy

secretions, to warm and humidify air, relieve edema of airways and an avenue for medication purposes.

Purpose:

This was done to our patient to administer medications which will relieve mucosal edema thus

dilating airway thus facilitating ventilation.


1. Verify doctors order To validate the existence of the procedure2. Reemphasize the procedures to the

patient and significant others

To gain cooperation

3. Prepare and assemble the equipment.Check the electrical device before use

To ensure an effective nebulization

To prevent short circuit

4. Place the client in a semi-fowlersposition

For lung expansion for effective breathing

5. Place the prescribed dose ofmedication. Fill the nebulizer with

prepared medication

To ensure proper amount of medication is

given to the patient

6. Let the patent seal mouth on themouthpiece

To inhale the nebulizer vapor through the

mouth

7. Encourage the patient to breathe thenebulized vapor thru the mouthpiece

For maximum effect of the drug

8. Remain with the patient until all thesolution has been administered

To make sure that the patient consume all the

drug

9. May render bronchial clapping thenencourage patient to do deep

breathing and coughing exercise

To loosen the secretions thus easy to beexpectorate

10.Provide good oral hygiene after theprocedure

To remove the remaining mist of the drug

present in the mouth


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11.Wash and dry the nebulize equipment,tubing or mouthpiece and put in a

sealed plastic and into a proper place

To be ready for another use

12.Document the procedureappropriately

To record the improvement or any abnormal

finding

13. Increase oral fluid intake To synergize the effect of the therapy

C. Drug Study

GENERIC NAME:BUDESONIDE

BRAND NAME: Pulmicort Turbuhaler

CLASSIFICATION: Corticosteroid

DESIRED DOSAGE, ROUTE & FREQUENCY: two inhalations every 12 hours

DESIRED EFFECT: This drug is given to our patient to reduce inflammation in the bronchi.

MECHANISM OF ACTION:

Budesonide is an anti-inflammatory corticosteroid exhibits potent glucocorticoid

activity and weak minerolocorticoid activity. The exact mechanism of the cortiosteroids

isnt known, but they have a wide range of inhibitory activity against such cell types such

as mast cells and macrophages and mediators (such as leukotrienes) involved in allergic

and non-allergic inflammation.




1. Reemphasize to client the purpose,and effects of the drug



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2. Use cautiously, if at all, in patientswith active or quiescent TB of the

respiratory tract, ocular herpes

simplex, or untreated systemic fungal,

bacteria, viral, or parasitic infections

To avoid further complications.

3. Refer to physician if bronchospasmsoccur after using budesonide

To prevent further complications such as

bronchospasms

4. Watch for candida infections of thepharynx

For immediate treatment of the said

complication

5. Tell patient that budesonide inhalerisnt a bronchodilator and isntintended to treat episodes of asthma

For precautionary measures

6. Pulmicort Turbuhaler must be kept up-right(mouthpiece on top) during

loading

To provide correct dosage

7. instruct patient to place mouthpiecebetween lips and to inhale forcefully

and deeply

To obtain the desired effect of the drug faster

8. Tell the patient that he may not tastethe drug or sense it entering his lungs,

but it doesnt mean it isnt effective.

To make the patient aware on the possible

outcome of the drug given

9. Replace mouthpiece cover after useand always keep it clean and dry

To prevent the contamination from micro

organisms, thereby preventing the occurrence

of infection

10. Instruct the patient to carry or wearmedical identification indicating need

for supplementary corticosteroid

during periods of stress or an asthma

attack.

For identification purposes


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Generic name:N- Acetylcysteine

Classification: Mucolytic

Mode of action: This drug is a mucolytic that reduces the viscosity of pulmonary secretions by

splitting disulfide linkages between mucoprotein molecular complexes

Dosage, Route, Frequency: 200 mg / sachet in glass H20 BID

Desired Effect: This drug was given to our patient to improve airway flow and to provide a more

comfortable breathing.


Requesting Physician: Dr. Lijauco/Dr. Rasos


1. Reemphasize to client the purpose,and effects of the drug


2. Instruct patient or watcher thefrequency and dosage of the drug

To prevent toxicity

3. Administer cautiously to elderly ordebilitated patients with severe

respiratory insufficiency.

To avoid further problems since drug also

stimulates cardiac muscle.

4. Mix with juice Because drug smells strongly like sulfur soas to improve its palatability.

5. Monitor cough type andfrequency.

For more effective treatment.

6. Instruct client to report signs ofside effects of the medication

To prevent further complications


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GENERIC NAME: HYRDROCORTISONE

BRAND NAME: Sodium Succinate

CLASSIFICATION: Corticosteroids

DOSAGE, ROUTE AND FREQUENCY: 100 mg, IV every 8 hours

MECHANISM OF ACTION: Decreases inflammation by entering target cells and binding to

cytoplasmic receptors initiating many complex reactions thus resulting to blockage on the

release of histamine, bradykinine and serotonin.

DESIRED EFFECT: This drug is given to our patient to potentiate other drugs(Budesonide) to

reduce pulmonary inflammation.


Requesting Physician: Dr. Lijauco/Dr. Rasos


1. Reemphasize to client the purpose, andeffects of the drug


2. Do skin testing To determine any allergic reaction3. Check the patency of the IV line To make sure that it is in the vein4. Monitor I & O accurately Since one of the following signs is fluid

retention

5. Monitor BP Because this drug causesvasoconstriction effect thereby

increasing BP. Prompt monitoring of

side effects.

6. Weigh the patient daily with the sameclothing and weighing scale

To determine if he gained weight and

fluid retention


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7. Encourage patient to increase intake ofVitamin C and potassium rich foods

such as banana, cantaloupe, potato,

etc.

To increase body resistance and to

prevent the occurrence of hypokalemia

8. Increase fluid intake To loosen the secretions

Generic Name:Fluticasone-Salmeterol

Brand Name: Advair Diskus

Classification: Bronchodilators

Dosage, route, frequency: Fluticasone-Salmeterol 250mcg/50mcg Diskus Inhalation BID

Mechanism of Action:

It prevents the release of substances such as leukotrienes in the body that cause inflammation

and relaxing muscles in the airways to improve breathing.

Desired Effect:

This drug was given to our patient to dilate the bronchioles thereby facilitating normal

breathing pattern and air exchange

Date Prescribed: August 21, 2010

Requesting Physician: Dr. Quilala/Dr. Lijauco


1. Reemphasize to client the purpose ofthe drug

to gain cooperation

2. Tell the client to gargle and rinse mouthafter using this medication

to help prevent dryness, relieve throat irritation,

and to prevent mouth infections


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3. Inform the patient to report any unusualweakness, sudden weight loss, dizziness.

This is a side effect of the drug that needs

immediate treatment

4. Instruct the patient to carry a medical IDbracelet at anytime as noted

This would help identify that the patient need

for oral corticosteroids during times ofstress

5. Instruct the watcher or patient tostore the medication in a dry place

Drug content may be altered

6. Instruct the patient not to overdose This drug causes ototoxicity7. Increase oral fluid intake To loosen the cesretions

Generic Name: BUCLIZINE

Brand Name:

Classification: Antiemetic/Antihistamine

Dosage, Route, Frequency: 1 cap 50 mg oral OD

Mechanism of Action:

Vomiting (emesis) is essentially a protective mechanism for removing irritant or otherwiseharmful substances from the upper GI tract. Emesis or vomiting is controlled by the vomiting centre in

the medulla region of the brain, an important part of which is the chemotrigger zone (CTZ). The vomiting

centre possesses neurons which are rich in muscarinic cholinergic and histamine containing synapses.

These types of neurons are especially involved in transmission from the vestibular apparatus to the

vomiting centre. Motion sickness principally involves overstimulation of these pathways due to various

sensory stimuli. Hence the action of buclizine which acts to block the histamine receptors in the

vomiting centres and thus reduces activity along these pathways. Furthermore since buclizine possesses

anti-cholinergic properties as well, the muscarinic receptors are similarly blocked.

Desired effect:

This drug was given to our client to address nausea, vomiting and drowsiness.

Date ordered: August 21, 2010



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Nursing Intervention Rationale

1. Reemphasize to client the purpose andeffects of the drug


2. Advice the client to store the drug in dryplaces.

Heat or moisture may alter the content of the drug

3.

Advise patient to report any unusualweakness, sudden weight loss, dizziness. This maybe a side effect of the drug that requiresimmediate treatment

4. Should be taken with food. (Take within hr before meals.)

To avoid GI upset


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NURSING CARE PLAN

I. Nursing Diagnosis

Impaired Gas Exchange related to narrowed airway secondary to overproduction of

thick tenacious mucus secretion, hypertrophy and hyperplasia of mucus glands as manifested

by body weakness, presence of adventitious sounds (wheezes), productive cough, respiratory

rate of 28 bpm and a verbalization of marigatan nak nga mangirwar ti plemas ko anak ko.

Nursing Inference

The increase production and accumulation of thick tenacious mucus secretions, due to

the hypertrophy and hyperplasia of goblet cell,s causes obstruction in the airway. Obstruction

of the airway causes decrease in ventilation in the affected alveoli hence impairing gas

exchange.

Nursing Goal

After 30-60 minutes of rendering nursing interventions, the patient will have effective

gas exchange as manifested by absence of body weakness, absence of adventitious sounds and

absence of cough.

Nursing Intervention

1. Position the client in high Fowlers position.

To promote lung expansion.

2. Administer bronchodilator (salbutamol + ipratropium) as the ordered.

To relax the smooth muscle of tracheobronchial tree thereby increasing thelumen.

3. Administer oxygen inhalation 1-2 lpm.

To deliver oxygen adequate for tissue perfusion.


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4. Encourage the patient to drink plenty of water at least 3L/ day if it is not

contraindicated.

To loosen the secretions by decreasing its viscosity thus easier to expectorate.

5. Move patient side to side every two hours.

To promote postural drainage.

6.. Encourage deep, slow or pursed lip breathing.

To prevent airway collapse, dyspnea and work of breathing

7. Administer mucolytics (N-acetylcysteine)as ordered.

To liquefy or dissolve viscous mucus secretions thereby promoting easier

expectoration.

Nursing Evaluation

After 1 hourof rendering nursing intervention, the patient has an effective gas exchange

as manifested by absence of body weakness, absence of adventitious sounds, and absence of

cough.

II. Nursing Diagnosis

Ineffective airway clearance related to accumulation of secretions which are thick and

tenacious as manifested by an RR of 28 bpm rales and wheezes, productive cough and

verbalization of the client marigatan nak nga mangirwar toy plemas ko.

Nursing Inference

Due to hyperplasia of mucus glands, there will be increased production of

tracheobronchial secretions which interferes the flow of gases in the airway, thus ineffective

airway clearance occurs.


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Nursing Goal

After 30 minutes-1 hour of nursing intervention the client will be able to maintain

patent airway as would be manifested by absence of adventitious sound, and verbalization of

the client haanak unay marigatan nga umangesen ken nalakak mairwar ti plemas kon.


1. Position the client in high Fowlers position.

To promote lung expansion and promote postural drainage.

2. Encourage the patient to drink plenty of water at least 3L/ day as tolerated.

To loosen the secretions by decreasing its viscosity thus easier to expectorate

3. Encourage deep, slow or pursed lip breathing.

To prevent airway collapse, dyspnea and work of breathing

4. Administer mucolytics as ordered.

Breaks chemical bonds in the mucus, which are responsible for the increase

viscosity if such bonds are broken, mucus becomes easier to be expectorate.

5. Do postural drainage before meals and after nebulization

to help drain secretions

6. Administer oxygen inhalation 1-2 lpm

deliver oxygen adequate to meet the body cells needs.


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Nursing evaluation

After 1 hourof nursing intervention the client is able to maintain patent airway as manifested

by absence of adventitious sound, and verbalization of the client haanak unay marigatan nga

umangesen.

III.Nursing Diagnosis

Sleep pattern disturbances related to difficulty of breathing, and hospital settings and

routines as manifested by presence of eye bags, irritability, restlessness and a total sleep of 5

hours and verbalization of the client marigatanak nga mangala ti turog ko isu haanak unay

makatur-turog ken.

Nursing Inference

Due to change in the environment, difficulty of breathing and hospital settings and

routines, the client feels discomfort that may alter the usual or normal length of getting asleep

thus there is an alteration in the sleeping pattern of the client.

Nursing Goal

After of rendering nursing intervention, the clients sleep hour will be normalized as

manifested by absence of eyebags, sleep hour of 7-8 hours and verbalization of the client

hanak met marigatan mangala ti turog kon isu mayat met ti panagturog kon.


1. Provide comfort measures such as backrub.

To promote physical and mental relaxation.

2. Encourage patient not to have a nap during daytime.

To have a larger duration of being awake thus early getting sleep at night.


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3. Encourage patient to drink warm milk before going to bed.

It contains trypthopan which induces sleep.

4. Provide quiet environment conducive to sleep such as closing the door.

These measures promotes rest and sleep by decreasing stimulus

5. Encourage patient to turn off the light, but if not, provide cover to the eyes with the likes of

towellete/handkerchief.

By covering the eyes, light cant pass through thus increasing production of melatonin,

sleep inducing hormone.

6. Inform client of necessary care interruptions ahead of time.

Preparing the client for awakenings and planning to minimize awakenings, decrease

unnecessary stress and anxiety that may prevent subsequent sleep.

7. Implement measures as indicated to prevent frequent voiding at night, such as decreasing

fluid intake before bedtime.

These measures prevent the need to wake up for frequent voiding.

8. Administer bronchodilator and humidifiers as ordered

To prevent mucus membrane from drying and becoming irritated and to loosen

secretions for easier expectoration.

9. Encourage purse lip breathing .

It creates resistance to the air flowing out of the lungs, thereby prolonging exhalation

10. Encourage patient to assume semi fowlers while sleeping.

This posture permits full lung expansion.

11. Plan satisfying activities for the client during daytime.


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Satisfying daytime activities stimulate wakefulness and discourage daytime napping

which can disrupt circadian rhythms and night time sleep

12. Encourage the client to express concerns when unable to sleep.

To decrease anxiety thus promoting relaxation.

Nursing evaluation

After 2 days of rendering nursing intervention, the clients sleep hour have normalized

and decreased frequent awakenings as manifested by absence of eye bags, sleep hour of 7-8

hours and verbalization of the client hanak met marigatan mangala ti turog kon isu mayat met

ti panagturog kon.

IV. Nursing Diagnosis

Activity Intolerance related to body weakness secondary to decrease oxygen supply to

the different muscles of the body as manifested by easy fatigability and inability to bath

without assistance.

Nursing Inference

Oxygen is needed for the production of energy of the body. Once oxygen supply is

deprived, there will be poor production of body energy causing weakness. Since there is

weakness activity intolerance results.

Nursing Goal

After 1 to 2 days of rendering nursing interventions, the patient will be able to tolerate

activities as would be manifested by ability of the patient to do his usual mild routines in a long

period of time such as taking a bath without experiencing weakness and without assistance.


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Nursing Interventions

1. Encourage the patient to drink plenty of water, do bronchial clapping to the patient and

administer bronchodilator and mucolytic as order.

To improve airflow

2. Encourage the patient to have adequate rest.

To lessen the oxygen demand of body tissues and conserve energy

3. Instruct the watcher to assist the patient in doing his ADL

To reduce energy expenditure

4. Encourage passive exercise such as dangling and deep breathing exercises.

To maintain muscle strength

5. Avoid doing for the patient what the patient can do for him and avoid giving exercises to

which he cant do.

To increase self esteem of the patient

Nursing Evaluation

After 2 days of rendering nursing interventions, the patient is able to tolerate

activities as manifested by ability of the patient to perform his usual mild activities in longer

period such as taking a bath a bath without experiencing weakness and without assistance.

GENERAL EVALUATION

Tata Felipe, 71 years old,residing at Brgy. 37 Ganagan Doro, Bacarra, was admitted to

emergency room last August 19, 2010 at 11:55 in the evening with a chief complaint of cough

and difficulty of breathing. After thorough history taking and physical examination done by Dr.

Quilala and Dr. Pumaras, he was admitted to Mariano Marcos Memorial Hospital and Medical

Center (MMMH & MC). Tata Felipe had an admitting diagnosis of Chronic Obstructive


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Pulmonary Disease in Acute Exacerbation Bronchitis, PTB Class IV. After a continuous

management and examination, the final diagnosis was COPD exacerbation controlled Bronchitis

resolved PTB class IV.

Laboratory works were done such as Hematology, ECG, ABG and Acid Fast Bacili. Results

revealed some abnormalities such as decreased oxygen, has moderate of AmpC Beta-lactamase

producing Pseudomonas Aerogenosa and moderate growth of Candida albicans. Spirometry

was also ordered but the client refused because he said that he wants to perform the

procedure when he will have his check up.IV therapy such as D5NM and D5W were given and

medications such as Budesonide, N-acetylcystein, Hydrocortisone, and Fluticasone-Salmeterol

for nebulization to liquefy secretions.

After four days of nursing interaction, assessment, planning, and interventions, the

clients condition had improved in many ways.

The difficulty of breathing experienced by the client has been managed by proper

positioning, increasing its fluid intake as well as rest, comfort and conducive environment were

provided. Nutrition was also emphasized to increase strength and endurance for the body

weakness complained by the patient. Fortunately, the patient regained his strength. Body

weakness was no longer felt during the last days of confinement.

On August 24, 2010 the client was discharged in good condition and disposition. He was

given salmetrol + fluticasone 50 mg/250mg diskus inhalation twice a day,

salbutamol+ipatropium nebulization as needed if there is difficulty of breathing, and

levofloxacin 750 mg 1 tablet once a day for 7 days as his home medication and was ordered to

come back on September 2, 2010 for follow up check up.


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Mariano Marcos State University

COLLEGE OF HEALTH SCIENCES

Department of Nursing

Batac, Ilocos Norte

Chronic Obstructive Pulmonary

Disease in Acute exacerbation

Bronchitis, Pulmonary Tuberculosis

C

Case.presIII- final na tlga to!!!!

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