Professional Documents
Culture Documents
Client Identification
Name: Age/Gender:
Socio-economic Status
Health Assessment
a. History Taking
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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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
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
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
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
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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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
During hospitalization:
With his present condition, according to the
attendant he copes through taking adequate rest,
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Percussion -Dull
-Decreased diaphragmatic excursion
Auscultation -Bronchial breath sounds in periphery
-Decreased air entry
-Crepitations present
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:
Predisposing Factors:
Upper respiratory infection Surgery
Chronic illness Atelectasis
Cancer
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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:
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.
Classification: Penicillins
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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
Adverse Reactions: Acute liver failure, acute renal tubular necrosis and
hypoglycemia.
Planning
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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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