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Fa r Ea s te r n Un i ve r s i t yIn s t i t u te o f Nu r s i n g

S u mmer t e r m 2008

NURSING-PROCESS

In Partial FulfillmentOf the

Requirements for NCM

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PERSONAL DATA

Name: JCN

Address: M. Delos Santos St., Sampaloc, Manila

Gender: Male

Age: 25 yrs. old

Birth date: January 14, 1983

Birthplace: PGH Manila

Civil Status: Single

Nationality: Filipino

Religion Orientation: Roman Catholic

Occupation: Call Center Agent

ADMISSION DATA

Chief Complaint:Increase in production of cough and has difficulty of

breathing.

NURSING HISTORY

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Family Medical History

Occupational HistoryJCN is a graveyard shift call center agent. He drinks 3-4 cupsof coffee per day. He is a chain smoker, he smokes every time hehad free time and almost takes 20-25 sticks per day.

Mother of

JCN59

Asthma

JMN23

Fatherof JCN

56

JBN20

Syno

JCN25

TB

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doesnt interact too much, because he prefers to sleep than tosocialize.

Cognitive PatternsJCN is a college graduate major in Mathematics. But due to

the unemployment problem in our country, he apply to be a callcenter agent, in this way he help his mother and father to theexpenses of his brother and sister.

Self-conceptJCN verbalized gusto ko kung sino ako, nagagwa ko ang

gusto ko at nakaktulong ako sa pamilya ko. Yan dapat angginagawa ng mga lalake. JCN is properly dressed but lookshaggard because of eye bugs.

Family Coping PatternsI live separately to my family, but still I help to the

expenses. When I get sick my mom visit me in my apartment. Hesaid. JCN said that he maid the decision on his own since he liveseparately.

Socio-Cultural HealthSignificant Relationship

He said that his family has a good relationship, and he isclosed to both of his parents. He verbalized kapag my problema

ako, kakausapin ko nalang yung mga kapatd ko. Sakanila akomadalas naglalabas ng problema. JCN have a girlfriend for 3years and 6 months and said ayos naman kami, madali langnamin nanaayos ang problema Open naman kasi kami eh Nung

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ACTIVITIES of DAILY LIVING

ADL BeforeSickness

DuringSickness

Interpretation

Nutrition He doesnt eatwell, he eattwice a day. Helove too muchcoffee

Do not eat well Because of theincrease insecretion thereis a loss ofappetite

Exercise He doesntpracticeexercise

He doesntpracticeexercise

There will be aincrease indifficulty ofbreathing

Hygiene He has properhygiene

He has properhygiene

normal

Sleep and Rest Doesnt getenough sleep Doesnt getenough sleep Because of hisjob

PHYSICAL ASSESSMENT

General Appearance

Findings Interpretation/Analysis

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have good nutrition,he eat twice a day.

And take too muchcoffee

Vital signs

Findings Interpretation/Analysis

Temperature 37.1C normalPulse rate 82beats/minute normalRespiratory rate 23breaths/minute There is an

increased in therespiratory rate

Blood pressure 100/70mm Hg normal

Head-to-toe Assessment

Body part Normalfindings

ActualFindings

Interpretation/analysis

Mouth 32 adult teethSmooth, whiteshiny tooth

enamelPink gumuniform pinkcolor of lips

28 adult teethBrowndiscoloration

of enamelBlack gumsBrown lips

Abnormal

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Other PA is normal and others are on the narrative.

PATHOPHYSIOLOGY (Schematic Diagram)

M. Tuberculae

Lungs Alveolist M. Tuberculae

Increased in Secretion

Inflammatory reaction

(Inflammation)

Alveoli

Blood stream

Calcify

Macrophages

(nuetrophils and WBC)

Dormant

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He doesnt evenstop smoking even if

he is suffering coughSometimes loss hisappetite. He is alsosuffering fatigue.he is suffering nightsweat and feverHe is a chainsmoker, he smokesevery time he hadfree timenaninigarilyo nalang ako kapagnaiistress ako, kasinakakapaisip ako atnareerelax ako nito.

pinagaawayan ayang paninigarilyo ko.Pero hinayaan niyana ako, kasi sabi kohindi ko na rinmapigilan sarili ko,at dun na rinakonaglalabas ng

sama ng loob o kayapagstress ako.matutulog lang akopara makapagrelax o

Smoking the first to prioritizebased on the ABCs

where in Airway arethe first needed toprioritize beforebreathing,circulation andother.

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sticks of cigaretteper day.

28 adult teethBrown discolorationof enamelBlack gumsBrown lipsPale skin23breaths/minute

S:matutulog lang akopara makapagrelax okung hindi namanmaninigarilyo, ayunayos na.naninigarilyo na

lang ako kapagnaiistress ako, kasinakakapaisip ako atnareerelax ako nito.gustong gusto koang kape, lalu naang trabahi ako aypanggabi. Umiinum

lang ako ng kapepara hindi dapuanng antok.

Ineffective copingrelated to situationalcrises

Ineffective coping isthe least prioritizesince the airway isthe first that shouldbe prioritize, and theproblem doesntrecognize by the

client

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NURSING CARE PLAN

Nursing

Diagnosis/Cues

Analysis Nursing Goal Nursing Intervention Rationale Evaluation

IneffectiveAirwayClearancerelatedtoSmoking

S:He doesnt

even stopsmoking evenif he issufferingcoughSometimesloss hisappetite. Heis alsosuffering

fatigue.he issufferingnight sweatand feverHe is a chainsmoker, he

CausesImmediate:Increase inSecretionIntermediate:Increase in

InfectionRoot/Primary:Predisposing Factorsrelated tosmoking

AnalysisScientific:

When theM.tuberculae virus getin to ourbody, it willaffect thelungs, the

Long term Goal:To maintainadequate,patient airway.

Short term Goal:1. To maintainopen airway in

at-rest orcompromisedindividual.

2. To identifycausative/precipitating factors.

3. To takeadvantage of

gravitydecreasingpressure on thediaphragm andenhancingdrainageof/ventilation of

Actions to achievethe adequate patientairway.1. Position the head

midline withflexionappropriate forage/condition to

maintain openairway in at-restor compromisedindividual.

2. Assist withappropriatetesting such aspulmonaryfunction/ sleepstudies to identify

causative/precipitating factors.

3. Elevate head ofthe bed/changeposition every 2hours and prn totake advantage of

Performingchestphysiotheraphy will helpthe patientloosen andmobilizesecretion.

(Fundamentals of Nursingby Taylorp1396)When thecause isidentified thepatient willbe able toassess the

environmentand makeadjustments.(Fundamentals of Nursingby Taylorp.1392)

Was thepatient able tomaintainairwaypatency?Yes_ No_ why?

Was the

patient able toidentifyprecipitatingfactors?Yes_ No_ why?

Was the clientable to identifyanddemonstrate

how to initiateappropriatepreventiveactions?Yes_ No_ why?

Was the client

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smokes everytime he hadfree time

naninigarilyona lang akokapagnaiistressako, kasinakakapaisipako atnareerelaxako nito.

pinagaawayan ay angpaninigarilyoko. Perohinayaan niyana ako, kasisabi ko hindiko na rinmapigilansarili ko, at

dun na rinakonaglalabas ng sama ngloob o kayapagstressako.matutulog

alveoli, thentheir will bean

inflammatory reaction,that causesincrease insecretion.

ImplicationAnincreased in

secretionmay causedeath

different lungsegments.

4. To maintainallergen freeenvironment.

gravity decreasingpressure on thediaphragm and

enhancingdrainageof/ventilation ofdifferent lungsegments.

4. Keep theenvironmentallergen freeaccording toindividual

situation.

Posturaldrainage,gravity is

used to drainthe secretionfrom thelungs.(Fundamentals of Nursingby Taylorp.1397)A pollutantfree

environmentis particularlyimportant forindividualswithrespiratoryproblems.(Fundamentals of Nursingby Taylor p.

1392)

able toverbalize theimportant of

allergen freeenvironment?Yes_ No_ why?

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lang ako paramakapagrelaxo kung hindi

namanmaninigarilyo, ayun ayosna.madalasakongnahihirapanghuminga, iisalang kasi angbintana ko sa

paratmentko.

O:He had partialloss of weightIncrease inproduction ofcough andhas difficulty

of breathing.Almost takes20-25 sticksof cigaretteper day.

28 adult

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teethBrowndiscoloration

of enamelBlack gumsBrown lipsPale skin23breaths/minute

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