Professional Documents
Culture Documents
I. Vital Information
Name: M. C.
Age: 72 yrs. Old
Sex: Female
Address: Nasagud, Lanot Roxas City
Civil Status: Married
Religion: Roman Catholic
Date and Time Admitted: Jan 14, 2009 @ 2:10 p.m.
Ward: Immaculate Heart of Mary ward Room # 217
Chief Complaints: DOB
Impression/Diagnosis: Pneumonia, Bibasal Asthma, DM
Attending Physician: Dr. A. & Dr. B.
A. Nursing History
4. Patterns of Functioning:
a. Breathing Patterns: RR- 36 BPM, (+) bibasal
crackles, (+) wheezing, (+) rhonchi
b. Circulation: BP- 170/100 mmHg, PR- 120 BPM,
CR- 123 BPM
c. Sleeping Patterns: sleeps in lateral position, with 2
pillows.
d. Drinking Patterns: Daily Intake of 120 cc per 8
hrs. Usually drinks juice and water.
e. Eating Patterns: Eats vegetables, fruits, rice, meat
and fish.
f. Elimination Pattern:
i. Bowel Movement: Every other day
ii. Urination: Twice per 8 hrs.
g. Personal Hygiene: Takes a bath every day.
h. Recreation and Exercise: Sits on bed every 2 hrs,
Passive ROM every 8 hrs.
B. Clinical Inspection:
1. Vital Signs:
2. Height: N/A
Weight: N/A
4. General Appraisal:
a. Speech- Coherent
b. Language- Hiligaynon
c. Hearing- Hears and listen well
d. Mental Status- Conscious, response to questions in
manner, mostly quiet.
e. Emotional Status-Worry about their financial
problems.
C. Laboratory Data:
1. Chemistry
Name of Significance of
Result Normal Values
Examination Abnormal Result
Having a low level
of blood creatinine
indicates nothing
Creatinine LO 48.3 umol/L 62.0-106.0 more than an
efficient and
effective pair of
kidneys.
Low sodium levels
Sodium LO 127.3 mmol/L 137.0- 145.0 may indicate
Hyponatremia.
Potassium 4.18 mmol/L 3.50-5.10
2. X-Ray Result
Impression:
Atheromatous Aorta
Levoscoliosis, thoracic spine
Pulmonary Emphysema
Bibasal Pneumonia
PTB w/ Residual Calcified Granulomas, both upper
lobes
4. Fecalysis
Color: Greenish-brown
Consistency: Soft
Bacteria: Many
5. Urinalysis
Color: Yellow
Transparency: Slightly Hazy
Reaction: pH 5.0
Sp. Gravity: 1.030
Protein: ++
Glucose: Negative
Amorph. U/P: Few
RBC/hpf: 0-3
WBC/hpf: 2-5
Epith. Cells: Squamous- Moderate
Bacteria: Moderate
D. Drug Study
Name of
Generic Side Contra- Nsg.
Drug w/ Action Indication
Name Effect Indications Responsibilities
Dosage
Tergece Cephalos- Anti- Lungs, Mild Hyper- Watch out for
f 100 phorins Bacterial skin, soft rashes, sensitive to hyper-sensitivity
mg. 1 tissue, fever, drugs, with reactions,
Cap Penicillin bones, abdominal renal or Monitor renal
BID joints, pain, hepatic function study,
urinary diarrhea, impairment, Monitor Intake
and dyspepsia, history of and Output
respiratory glossitis, GI disease,
tracts, nausea, or allery to
blood, tenesmus, penicillins
abdomen, and
and heart vomiting
infections
E. Textbook Discussion
Definition:
Bacteria typically enter the lung when airborne droplets are inhaled, but
can also reach the lung through the bloodstream when there is an infection in another part
of the body. Many bacteria live in parts of the upper respiratory tract, such as the nose,
mouth and sinuses, and can easily be inhaled into the alveoli. Once inside, bacteria may
invade the spaces between cells and between alveoli through connecting pores. This
invasion triggers the immune system to send neutrophils, a type of defensive white blood
cell, to the lungs. The neutrophils engulf and kill the offending organisms, and also
release cytokines, causing a general activation of the immune system. This leads to the
fever, chills, and fatigue common in bacterial and fungal pneumonia. The neutrophils,
bacteria, and fluid from surrounding blood vessels fill the alveoli and interrupt normal
oxygen transportation.
Bacteria often travel from an infected lung into the bloodstream, causing
serious or even fatal illness such as septic shock, with low blood pressure and damage to
multiple parts of the body including the brain, kidneys, and heart. Bacteria can also travel
to the area between the lungs and the chest wall (the pleural cavity) causing a
complication called an empyema.
Management:
Most cases of pneumonia can be treated without hospitalization. Typically,
oral antibiotics, rest, fluids, and home care are sufficient for complete resolution.
However, people with pneumonia who are having trouble breathing, people with other
medical problems, and the elderly may need more advanced treatment. If the symptoms
get worse, the pneumonia does not improve with home treatment, or complications occur,
the person will often have to be hospitalized.
Prevention:
5. Bronchodilators
relaxes bronchial
and uterine smooth
muscle by acting on
Beta2-adrenergic
receptors.
Subjective: Activity Intolerance After Nsg. 1. Provide positive 1. Helps to Goal Met. After
(Level IV) related Interventions, the atmosphere, while minimize frustration Nsg. Interventions,
“Nabudlayan ako to dyspnea and pt. will be able to acknowledging and re-channel the pt was able to
mag ginhawa kag abnormal vital signs report measurable difficulty of the energy. report measurable
maluya akon increase in activity situation for the increase in activity
kalawasan” as tolerance. client. 2. To enhance tolerance. Pt. was
verbalized by the pt. ability to participate able to sit on bed,
2. Promote comfort in activities. and walk slowly
Objective: measures and with assistance.
provide for relief
BP: 170/100 mmHg and pain.
CR: 123 BPM
RR: 36 BPM
Temp: 38.4 C
(+) body malaise
(+) facial grimace
Subjective: Acute Pain related After Nsg. 1. Provide comfort 1. To promote non-
to persistent cough Interventions, the pt measures (e.g. pharmacological
“Masakit na akon as evidenced by will be able to touch, pain management
dughan sang inubo” reports of report pain is repositioning)
as verbalized by the discomfort. relieved/controlled. 2. To distract
pt. 2. Encourage attention and reduce
diversional tension.
Objective: activities (watching
T.V., listening to 3. Analgesics blocks
(+) loss of appetite pain impulses,
(+) facial grimace
BP: 170/100 mmHg radio) probably inhibiting
Temp: 38.4 C prostaglandin or
RR: 36 BPM 3. Administer pain receptor
CR: 123 BPM analgesics as sensitizers.
Verbal report of ordered.
pain: 9 in pain scale