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Client Identification

Name: Age/Gender:

C/O with Contact No.: Local Address:

Date & Time of Admission: Permanent Address:

Ward and Bed No.: Hospital Reg. No.:

Socio-economic Status

Marital Status: No. of Children:

Level of Education: Occupation:

Type of House: Total Income (Annually):

Health Assessment

a. History Taking

Chief Complaints: Irritability and Difficulty of Breathing (DOB)

History of Present Illness: Five days prior to admission, the patient had a stroke and was
confined at CVMC and few hours prior to admission the patient
was irritable and had a difficulty of breathing.

History of Past Illness: The patient had completed his immunization when he was a child.
He experiences cough and cold in the past. According to his
attendant, the patient had a hypertension.

Family Health History: Patient has a family history of hypertension and heart disease but
not on respiratory problems such as bronchitis, asthma or
pneumonia.
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Gordon’s 11 Functional Pattern

Functional Pattern Problems Diagnosed


1. Health Perception – Health Management
Pattern

Before Hospitalization: No problems.


According to the attendant, the patient views health
as very important to human. One cannot function
that well with the absence of it. Once health is
absent, other aspects such as emotional, spiritual and
social are affected. They always consult a doctor for
any health problems. The attendant also reports that
he also takes over-the-counter drugs for simple
illnesses such as fever

During hospitalization:
The attendant said that the patient perceived his self
as weak and wasn’t able to do his daily activities. He
manages his condition by complying with the entire
doctor’s order and taking adequate rest. He reported
no allergies to any foods and medications. At
present, he manages his condition by complying with
the entire doctor’s order and taking adequate rest.
2. Nutritional – Metabolic Pattern

Before hospitalization: No problems.


According to the attendant, the patient eats 3 times a
day with snacks in between. He prefers to eat more
on meat than vegetables. He drinks at least 7-9
glasses of water approximately 200 ml/glass
throughout the day. He usually eats crackers, biscuits
and bread for his snacks with tea. He had no
difficulty in swallowing.

During hospitalization:
Patient’s diet was on NG feed at 400ml of feed every
four hours. He drinks about 200ml/glass throughout
the day via NG tube.
3. Elimination Pattern

Before Hospitalization: No problems.


According to the attendant, the patient had no
problem with urination and defecation. The Patient
urinates at least 3-5 times a day depending on the
urge he feels. The attendant describes the patient
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urine as light yellow in color. He defecates 1-2 times


a day before starting his day in the morning and
sometimes in the evening before going to bed. He
describes his stool with brown color.

During hospitalization:
According to the attendant, the patient urinates
smoothly without difficulty. The attendant describes
patient’s urine as light yellow. He defecates once a
day with brown in color.
4. Activity – Exercise Pattern

Before Hospitalization: Impaired physical mobility related to


According to the attendant, patient had no difficulty musculoskeletal impairment as evidenced
doing his daily chores such as gardening, fixing their by inability to move purposefully within
house and watching his grandchildren. Five days physical environment.
prior to admission, he can no longer do his activities
of daily living because of his condition even with High risk for impaired skin integrity
assistance. related to immobility.

During hospitalization:
“Lam lay shom bay jo metsu bay,” as verbalized by
the attendant. The attendant reports that he needs
assistance in every movement he does.
5. Sleep – Rest Pattern

Before hospitalization: Disturbed sleep pattern related to stasis


He sleeps about 6-7 hours at night and sometimes 5- of secretions.
6 hours. After lunch, he takes about an hour or less
for his naps. Five days prior to admission, the patient
had difficulty in sleeping because he got irritated
with the presence of his NG tube.

During hospitalization:
The attendant reported difficulty in sleeping.
“Layshom bay nay metsu bay,” as verbalized by the
attendant. The attendant also reported that the patient
wakes up because he was hungry or got irritated by
the presence of his NG tube. He sleeps about 2-4
hours at night and about 2-5 hours during daytime.
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Functional Pattern Possible Problems


6. Cognitive Perceptual

The patient has no cognitive problem. He is oriented Difficulty speaking due to post stroke.
to time, place, and persons. He can see and hear
clearly but he has difficulty speaking due to post High risk for Sensory/Perceptual
stroke. He is able to understand and follow the Alterations (Tactile) r/t post stroke.
instructions given by the nurses and doctors.
7. Role – Relationship Pattern

According to the attendant, the patient has no No problems.


problem with regards to his relationship with his
family and the people of the community. The
attendant also added that they treat him nicely. He is
married and had 4 children all have finished college.
8. Self- perception/Self-concept Pattern

According to the patient, he never thought of losing No problems.


hope about his condition, he always thought positive
that someday he can recover in whatever illness that
he felt. He did not think of him less because of his
condition. When he was hospitalized he accepts this
with his whole heart and did not have any doubt or
fear upon it.
9. Sexual – Reproduction Pattern

Patient has no sexual function problem noted. He No problems.


and his wife copulated for quite some time. He
cannot remember how frequent they’ve done this.
After the incident, they never engaged into sexual
activities. They don’t have any children after his
condition. He is not using any form of contraceptive
measures.
10. Coping – Stress Management Pattern

Before hospitalization: No problems.


According to the attendant, the patient whenever
problem occur he always seek his children’s pieces
of advice. The attendant reports that the patient prays
regularly to relieve his worries and to ask for
guidance. He takes a rest to alleviate whatever stress
he feels.

During hospitalization:
With his present condition, according to the
attendant he copes through taking adequate rest,
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following all the doctor’s instructions and adhering


with the regiments given. He always asks his
attendant to position him comfortably and regular
care for his comfort. The presence of NG tube
sometimes makes him restless and irritable. He
regularly prays to relieve his worries regarding his
condition.
11. Value – Belief

The patient is a Buddhist. According to the attendant No problems.


he believes that God will be the one who will help
him to all his problem especially about his condition
and the Lord has a purpose why he is experiencing
the illness he had.

b.1. Physical Examination (General Head to Toe Examination)

Area Assessed Method Used Normal Findings Actual Findings Evaluation


SKIN
- Color Inspection Deep brown Brown Normal
- Texture Inspection/Palpation Smooth Smooth Normal
-Temperature Palpation Normally warm Normal skin Normal
temperature
- Moisture Palpation Moist to dry Moist to dry Normal
HAIR
- Distribution Inspection Evenly distributed Evenly distributed Normal
- Texture Palpation Silky; resilient Silky Normal
- Color Inspection Black Black with white Due to aging
hair
NAILS
- Color of the Inspection Pink transparent Pink transparent Normal
nail-bed
- Capillary refill Palpation Delayed(2-3 sec) Delayed (2-3 sec) Normal
time
- Shape Palpation Convex Convex Normal
HEAD
- Shape Inspection Regular Regular Normal
EYES
- Hair Inspection Evenly distributed Evenly distributed Normal
distribution
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Area Assessed Method Used Normal Findings Actual Findings Evaluation


PUPILS
- Color Inspection Black Black Normal
- Shape Inspection Round and regular Round and regular Normal
- Ocular Inspection Both eyes move Both eyes move Normal
movement parallel with each parallel with each
other in directions other in directions
of gaze
EARS
- Symmetry Inspection Auricles are at Auricles are at Normal
and position level of each other level of each other
EXTERNAL
AUDITORY
CANAL
- Hearing Inspection Hears equally in Hears equally in Normal
both ears both ears
NOSE
- Symmetry Inspection Symmetrical Symmetrical Normal
- Color Inspection Same color as the Same color as the Normal
face and skin face and skin
LIPS AND
MOUTH
- Symmetry Inspection Symmetrical Symmetrical Normal
- Color (lips) Inspection Pink Pale Due to
decreased
oxygen
- Moisture Inspection Moist Dry Due to cold
environment
NECK
- Symmetry Palpation Symmetrical Symmetrical Normal
- Alignment Inspection Symmetrical Symmetrical Normal
of the trachea
THORAX
- Chest contour Inspection Symmetrical Symmetrical Normal
- Clavicle Inspection Prominent Prominent Normal
- Chest wall Inspection/Auscultat Absence of Crackles breath Due to
ion crackles upon sound upon presence of
auscultation auscultation secretions on
the
bronchioles
ABDOMEN
- General Auscultation Flat Flat Normal
contour
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Area Assessed Method Used Normal Findings Actual Findings Evaluation


UPPER
EXTREMITIES
- Skin color Inspection Light to deep Brown Normal
brown
- Size (arms) Inspection Equal Size Equal Size Normal
-Symmetry Inspection Symmetrical Symmetrical Normal
- ROM Inspection (+)ROM upon (-) ROM at the Due to
Movement with no right side of the numbness
pain body and
weakness at
the right side
LOWER
EXTREMITIES
- Skin color Inspection Light to deep Light to deep Normal
brown brown
- Size (legs) Inspection Equal Size Equal Size Normal
- Symmetry Inspection Symmetrical Symmetrical Normal
- ROM Inspection (+)ROM upon (-) ROM at the d/t numbness
movement right side of the and
with no pain body weakness at
the right side
of the body
NEUROLOGIC
-Level of Interview Can follow simple Can follow simple Normal
consciousness instructions and instructions and
commands commands
CEREBELLAR
FUNCTION
-Muscle tone Inspection Maintain stability Cannot Due to past
in posture Maintain posture stroke
-Speech Inspection Clear and well Slurred speech Due to past
pronounced stroke

b.2. Physical Examination (Systemic Examination of Respiratory System)

Method Used Positive Findings


Inspection -Restricted chest movement on the affected side
-Ill looking
-Diaphoresis
-Chills/rigors
-Respiratory distress cough
Palpation -Decreased chest expansion or asymmetry
-Lymphadenopathy
-Tactile fremitus
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Percussion -Dull
-Decreased diaphragmatic excursion
Auscultation -Bronchial breath sounds in periphery
-Decreased air entry
-Crepitations present

Medical Diagnosis with Definition

Pneumonia
Pneumonia is an acute infection of the lung’s terminal alveolar spaces and/or the interstitial
tissues which results in gas exchange problems. It is a common illness which occurs in all age
groups, and is a leading cause of death among the elderly and people who are chronically and
terminally ill. The source of infection is difficult to identify. It is rank as the sixth most common
cause of death.

General Pathophysiology:
In pneumonia’s early stages, pulmonary vessels dilate and erythrocytes spread into the alveoli
and cause a reddish liver-like appearance in the lung consolidation area. Polymorphonuclear
cells then enter the alveolar spaces and the consolidation increases to a gray hepatilization. The
leukocytes trap bacteria against the alveolar wall or other leukocytes so that more organisms are
found in the increasing margins of the consolidation. The macrophage reaction occurs when
mononuclear cell advance into the alveoli and phagocytise the exudates debris.

Causes:
Pneumonia can result from a variety of causes including infection with bacteria, virus, fungi or
parasites. Pneumonia may also occur from chemical or physical injury of the lungs. The
causative organism gains entry by aspiration of cropharyngeal or gastric contents affected by the
way of bloodstream or directly with surgery or trauma, this reasons causes pneumonia to spread
or to be transferred to one person to another if not properly treated with right medical attention.

Having a long-term, or chronic, disease like asthma, heart disease, cancer, or diabetes also makes
you more likely to get pneumonia symptoms:

 Sudden onset of shaking chills


 Fever
 Purulent sputum
 Pleuritic chest pain worsened with respiration or coughing
 Tachycardia
 Tachypnea
 Use of accessory muscles

Predisposing Factors:
 Upper respiratory infection  Surgery
 Chronic illness  Atelectasis
 Cancer
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 Chronic obstructive pulmonary  Smoking


disease  Alcoholism
 Asthma  Immunosuppressive therapy
 Cystic fibrosis  Aspiration
 Bronchiectasis  Sickle cell disease
 Influenza  Head injury or coma
 Malnutrition

Diagnosis:
Diagnosis may be assisted with the observation of sputum characteristics, with bacterial
pneumonia having mucopurulent sputum, viral and mycoplasmic pneumonia having more watery
secretions, pneumococcal pneumonia having rust-colored sputum, and klebsiellal pneumonia
noting dark red mucoid secretions.

Treatment:
Most cases of pneumonia can be treated without hospitalization, typically, oral antibiotics, rest,
fluids, and home cares are sufficient for complete resolution. However, people with pneumonia
who are having trouble breathing, people with other medical problems, and the elderly may need
advanced treatment. If the symptoms get worse, the pneumonia does not improve with home
treatment, or complications occurs, the person will often have to be hospitalized

Drug Study:

1. Name of the Drug: Aspirin

Classification: Anticoagulants, Antiplatelets and Fibrinolytics


(Thrombolytics)

Drug Action: Aspirin works to prevent heart attacks and strokes by


reducing the production of thromboxane, a chemical that
makes platelets sticky. When aspirin works as it should,
platelets make less thromboxane and are less likely to form
a blood clot that could block an artery.

Adverse Reaction: Dyspepsia, GI bleeding, ulceration, tinnitus, acute


anaphylaxis & hyperpnoea.

Nurses’ Responsibilities: Assess monitoring clotting factors, bleeding time, liver and
renal function tests for ling term therapy. Monitor for signs
& symptoms of drug allergy. If aspirin has a vinegar-like
odour, then the use of that drug should not be given.

2. Name of the Drug: Amoxicillin

Classification: Penicillins
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Drug Action: It is similar to penicillin in its bacterial action against


susceptible bacteria during the stage of active
multiplication. It acts through the inhibition of cell wall
biosynthesis that leads to the death of the bacteria.

Adverse Reactions: Nausea, Diarrhoea

Nurses’ Responsibilities: Monitor for signs & symptoms of a rash (usually occurring
within a few days after start of drug) suggestive of a
hypersensitivity reaction. If it occurs, look for other signs
of hypersensitivity (fever, wheezing, generalized itching,
dyspnoea), and report to physician immediately. Report
onset of generalized, erythematous, maculopapular rash
(ampicillin rash) to physician.
3. Name of the Drug: Paracetamol

Classification: Analgesics, Antipyretics, & NSAIDs

Drug Action: It is thought to reduce the intensity of pain signals to the


brain. It may also prevent the release of substances called
prostaglandins that increase pain and body temperature.

Adverse Reactions: Acute liver failure, acute renal tubular necrosis and
hypoglycemia.

Nurses’ Responsibilities: Assess patient’s fever or pain. Assess allergic reactions if


any from the drug prescribed to the patient. Teach patient
to recognize signs and symptoms of chronic overdose:
bleeding, bruising, fever, sore throat.

Planning

Possible nursing diagnoses made:

 High risk for impaired skin integrity related to immobility.


 Ineffective airway clearance related to stasis of secretions in the bronchi
 High risk for aspiration r/t depressed gag reflex.
 Impaired physical mobility related to musculoskeletal impairment as evidenced by
inability to move purposefully within physical environment.
 Disturbed sleep pattern related to stasis of secretions.
 Difficulty in speaking due to post stroke.
 High risk for sensory/perceptual alterations (tactile) related to post stroke.
 Constipation related to insufficient physical activity
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Nursing goals and expected outcomes:

 The patient will be able to achieve optimal amounts of sleep as evidence by rested
appearance, verbalization of feeling rested, and improvement in sleep pattern.
 The patient will be able to demonstrate behaviors to prevent skin break down.
 The patient will be able to experience no aspiration as evidenced by noiseless aspirations
and clear breath sounds.
 The patient’s skin will remain free of injuries, including pressure ulcers.
 The patient will be able to maintain airway potency and expectorate/clear secretions
readily.
 The patient will be able to increase strength of affected and/or compensatory body parts.
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Nursing Care Plan

Assessment Diagnosis Goals/Expected Intervention Rationale Evaluation


Outcomes
Subjective data: -Ineffective -At the end of 1 -Elevated head of -To take Goal met: At
“Kho lay shom airway clearance hour, the patient the bed/ changed advantage of the end of 1
bay bu len related to stasis will be able to position every 2 gravity hour, the
metsu bay,” as of secretions in maintain airway hours. decreasing patient was
verbalized by the bronchi. potency and -Performed back pressure on the able to
the attendant. expectorate/clear tapping. diaphragm. maintain
secretions readily. -Encouraged -To mobilize airway
Objective data: increase fluid secretions. potency and
-crackles intake via NGT. -To help expectorate/
-RR: 34 cpm -Performed chest liquefy clear
-use of physiotherapy. secretions. secretions
accessory -Provided -To loosen readily.
muscles supplemental secretions.
humidification -To ascertain
(nebulizer). status and note
-Monitored vital progress.
signs. -To assess
changes and
note
complications.

Assessment Diagnosis Goals/Expected Intervention Rationale Evaluation


Outcomes
Subjective data: -Impaired -At the end of the -Encourage and -To promote Goal met: At
“Lam layshom physical shift, the patient facilitate early optimal range the end of the
bay jo metsu mobility related will be able to ambulation and of motion. shift, the
bay. La zhen ga to increase strength of other ADL when -To promote patient was
chi bay ro charo musculoskeletal affected and/or possible. safe convinced of
go bay,” as impairment as compensatory body -Assist with each environment. the nursing
verbalized by evidenced by parts. initial change: -To prevent cares that the
the attendant. inability to dangling, sitting in foot drop patient was
move chair, and and/or assigned for
Objective data: purposefully ambulation. excessive impaired
-limited range of within physical -Keep side rails up plantar flexion physical
motion environment. and bed in low or tightness. mobility and
-decreased position. -To promote was happy to
reaction time -Maintain limbs in increased receive the
-reluctance to functional venous return, assigned
attempt alignment. prevent interventions.
movement -Support feet in stiffness, and
-functional level dorsiflexed position maintain
classification= 4 and use bed cradle. muscle
-Perform strength and
passive/active endurance.
assistive ROM
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exercises to all -To drain


extremities. bronchial tree.
-Turn patient to -To prevent
prone or semi- build up of
prone position once secretions.
daily unless -To optimize
contraindicated. hydration
-Encourage status and
coughing and deep prevent
breathing exercises. hardening of
-Use suction as stool.
needed.
-Encourage liquid
intake of 2000-
3000 ml/day unless
contraindicated.

Assessment Diagnosis Goals/Expected Intervention Rationale Evaluation


Outcomes
Subjective data: -Disturbed -At the end of the -Elevated head of -To take Goal met: At
“Nga layshom sleep pattern shift, the patient will the bed/ change advantage of the end of the
bay nay metsu related to be able to achieve position every 2 gravity shift the
bay kap kap,” as stasis of optimal amounts of hours. decreasing patient was
verbalized by secretions. sleep as evidence by -Suction secretion pressure on the able to
the patient in rested appearance, diaphragm. achieved
PRN.
slurred speech. verbalization of -To remove optimal
feeling rested, and -Provide nursing accumulated amounts of
Objective data: improvement in sleep aid: back rub secretions sleep as
-dark circles pattern. bedtime care, pain -To promote evidence by
under eyes relief, rest and rested
-restlessness comfortable relaxation. appearance
-expressionless position, and -To promote and
face relaxation completion of verbalization
-frequent technique. one complete of feeling
yawning -Attempt to allow cycle and rested.
for sleep cycles of completion of
an entire cycle
at least 90mins.
is necessary to
-Discourage pattern
benefit from
of daytime naps
sleep.
unless necessary or
-Napping can
part of usual
disrupt normal
pattern.
sleep pattern.
-Limit fluids before
-To reduce
bedtime.
need for
voiding during
night.
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Health Education

 Take your medication exactly as directed. Don't skip doses. Continue taking your
antibiotics as directed until they are all gone - even if you start to feel better. This will
prevent the pneumonia from reoccurring.
 Drink at least 8 glasses of water daily, unless directed otherwise. This helps to loosen and
thin secretions so that you can cough themup.
 Use a cool-mist humidifier in your bedroom. Be sure to clean the humidifier daily.
 Coughing up mucus is normal. Don't use medications to suppress your cough unless your
cough is dry, painful, or interferes with your sleep.
 You may use an expectorant if ordered by your doctor.
 Warm compresses or a heating pad on the lowest setting can be used to relieve chest
discomfort. Use the compress several times a day for 15 to 20minutes at a time. (To
prevent injuring your skin, be sure the temperature of the compress or heating pad is
warm, not hot.)
 Get plenty of rest until your fever, shortness of breath, and chest pain goes away.
 Plan to get a flu shot every year.
 Ask your doctor about pneumonia vaccinations.
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References

Seaback, W. W. (2006). Nursing process: concepts and application. Canada: Thomson Delmar

Learning.

Faculty of Nursing and Public Health. (2014). Nursing practical manual: nursing procedures

checklist and guidelines. Thimphu: Druk Printers.

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