Lyceum-St.

Cabrini College of Allied Medicine

School of Nursing

Maharlika Highway, Sto.Tomas, Batangas

Bronchitis
(A Case Study)

St. James Hospital

Date of Rotation: July 6-8, 2009

Presented to:

Billy John Luzung, R.N.

Presented by:

BSN 3-1

Group 4

Rumbines, Jinky C.

Sabonsolin, Isabelle

Saluta, Mark Angelo

Siervo, Haiyah Jestine

Suizo, Adrian

Tachibana, Cherryann

Tangco, Jennelyn

Tolentino, April May

1
 Table of Contents

I. Title Page…………………………………………………………………………………………………..1

II. Table of Contents………………………………………………………………………………………2

III. Introduction………………………………………………………………………………………………3

IV. Demographic Data……………………………………………………………………………………..4

V. Source of Reliability of Information…………………………………………………………..5

VI. Reason for Seeking Healthcare………………………………………………………………….5

VII. History of Present Illness…………………………………………………………………………..5

VIII. Past Medical History………………………………………………………………………………….5

IX. Family History…………………………………………………………………………………………….6

X. Review of System………………………………………………………………………………………..7

XI. Functional Assessment………………………………………………………………………………..8

XII. Anatomy and Physiology……………………………………………………………………………..9

XIII. Pathophysiology…………………………………………………………………………………………13

XIV. Laboratory………………………………………………………………………………………………….14

XV. Drug Study………………………………………………………………………………………………….16

XVI. Problem List………………………………………………………………………………………………..19

XVII. Nursing Care Plan……………………………………………………………………………………….20

XVIII. Progress Notes…………………………………………………………………………………………,,.28

XIX. References…………………………………………………………………………………………………..29

2
 I. Introduction

Nursing is the science of applying the art of care. As nursing students we are trained to provide

care and give a better way of living to our clients, sick or not. We chose the case of a client who was

diagnosed with Bronchitis.

Bronchitis is inflammation of the mucous membranes of the bronchi, the airways that carry

airflow from the trachea into the lungs. Bronchitis can be classified into two categories, acute and

chronic, each of which has unique etiologies, pathologies, and therapies.

Acute bronchitis is characterized by the development of a cough, with or without the production

of sputum, mucus that is expectorated (coughed up) from the respiratory tract. Acute bronchitis often

occurs during the course of an acute viral illness such as the common cold or influenza. Viruses cause

about 90% of cases of acute bronchitis while bacteria account for less than 10%.[1]

Bronchitis most commonly occurs after an upper respiratory infection such as the

common cold or a sinus infection. You may see symptoms such as fever with chills, muscle

aches, nasal congestion, and sore throat.

Cough is a common symptom of bronchitis. The cough may be dry or may produce

phlegm. Significant phlegm production suggests that the lower respiratory tract and the lung

itself may be infected, and you may have pneumonia.

The cough may last for more than two weeks. Continued forceful coughing may make

your chest and abdominal muscles sore. Coughing can be severe enough at times to injure the

chest wall or even cause you to pass out.

Wheezing may occur because of the inflammation of the airways. This may leave you

short of breath.

Knowing this, we’ve decided to study this case because we see it as an opportunity to

give one’s best to care for the client. We know that we will learn a plethora of knowledge from

this case and at the same time, give maximum effort of care we can give in our limited time of

rotation.

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 II. Demographic Data

A. Name : Mr. EAE

B. Age : 32 years old

C. Gender : Male

D. Civil Status : Married

E. Nationality : Filipino

F. Religion : Roman Catholic

G. Usual Source of Medical Help : Hospital

H. Address : St. Joseph Village 6. ,Cabuyao, Laguna

I. Date of Birth Aug. 4, 1976

J. Birth Place : Camarines Sur

K. Educational Background : Automotive (Vocational)

L. Occupation : Jeepney Driver

M. Usual Source of Income : From his and her wife's sallary

N. Attending Physician : Dr. Jose P. Santiago

O. Date of Admission : Jul. 4, 2009

P. Time of Admission : 8:00pm

Q. Room No. : 318 (A)

R. Chief Complaint : Fever

S. Admitting Diagnosis : URTI T/C Bronchitis

T. Name of Hospital : St. James Hospital- Sta. Rosa, Laguna

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III. Source of Reliability of Information

All information written and presented in this case were carefully collected and gathered

from St. James Hospital to be found in Sta. Rosa, Laguna. Information and data were gathered

from the client’s chart which includes medical records, laboratory examinations and medical

findings. Some information was also gathered from our assessment and from the client and his

wife.

IV. Reason for Seeking Healthcare

The client was brought to the hospital because of fever and chills.

V. History of Present Illness

The client experienced fever and chill the morning prior to admission. The client

performed self-medication, had taken Amoxicillin, Paracetamol and Alaxan. But the symptoms

of illness didn’t go off. The client together with his wife went to the hospital, Saturday evening.

The client experienced pain on the posterior side of his neck when coughing.

VI. Past Medical History

Mr. EAE has a history of asthma when he was still a child. Years ago, he experienced

headache and sleeping difficulty. Mr. EAE had been admitted to the hospital three times

because of three motorcycle accidents. He stated that he only acquired bruises and wounds

from the accidents.

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VII. Family History

Grandfather

Arthritis
Grandmother
Rheuma

Diabetes

HPN

Lung problem
HB HB Mothe
HB D r
M
RIP HB

(47)

Client 30 25 23 *A 21 1
*lung LP *S 5
problem

*A

*S

Son
Daughter
51/2 Asthma
4- cold, fever,
cough

*asthma

Legend:

Male

Female

A Alcoholic

S Smoker

6
VIII. Review of System

General  Comfortable
 Conscious
 Coherent
Skin  Dark brown
 Good turgor
 Presence of scars
Hair and Nails  Black
 Evenly distributed
 Nails: Normal
 Nail beds: pinkish
Head  Normocephalic
 Scalp: smooth
Eyes  Lids: symmetrical
 Conjunctiva: pink
 Pupil: equal
 Reactive to light accommodation
Ears  No hearing deficit
 Symmetrical
 External ears: normset
 Presence of light cerumen
Nose  Nasolabial fold: symmetrical
 Septum: Midline
 Mucous: pinkish
 Sinuses: not tender
Mouth  Lips: pinkish
 Tongue: midline
 Presence of dental caries
 Gums: pinkish to reddish
 Speech: grossly intact
 Teeth: incomplete
Pharynx  Uvula: midline
 Mucosa: pinkish
 Tonsils: pink and smooth
Neck  Trachea: midline
 Thyroid: non-palpable
Respiratory  Cough noted
 Lung expansion: symmetrical
 RR: 27
Cardiovascular  BP: 110/90
 PR: 75
Gastro Intestinal  Good appetite
 Regular defecation
Extremities  Limbs: symmetrical
 ROM: full, symmetrical
 Warmth: symmetrical
IX. Functional Assessment

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Health Perception and Health Maintenance

According to Mr. EAE, he had never been hospitalized before because if illness (except

for the 3 motor accidents he had experienced). He perceived himself as a healthy individual. He

smokes more than one pack a day, drinks 1 L of beer every night and eats street foods, he stated

that he always feel good when he do those things. As a jeepney driver, he is always exposed to

air pollution.

Self Esteem, Self- concepts, Self- Perception Pattern

Mr. EAE is a cheerful guy, his open and is always ready to answer questions. He is a

family-oriented man, he’s not fond of going out with his friends and drink alcohol, he prefer to

go home, drink beer alone and spend time with his family after work.

Exercise and Activity Pattern

Mr. EAE is a jeepney driver who works everyday. He wakes up every 6am, take a bath

and eats breakfast. At 7-11am, he drives the passenger’s jeepney, goes home at 11am and rest

for an hour. At 1-7pm, he drives again. At home, he likes to lie on the sofa, watches t.v., eats

foods brought from the street, drinks beer and bond with his wife and children.

Sleep and Rest Pattern

Mr. EAE goes home at 11am and rests at 12pm. He usually sleeps nine hours a day. He

sleeps at 9pm and wakes up at 6am.

Nutrition/Elimination

Mr. EAE has an unusual desire for food; He loves to eat four regular meals everyday and

eats snacks. He likes to eat junk foods, street foods, likes to smoke a lot and drink beer. He has

an allergy to shrimp. He defecates 2-3 times daily.

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 Coping Stress Management

Mr. EAE said that ho don’t experience stress at work, not with passengers, the noise, the

traffic and pollution. He said that sometimes his children’s activities and playfulness give him

stress. What he does is he talks with his children and force them to sleep.

Environment

Garbage were regularly collected by the garbage truck.

X. Anatomy and Physiology

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Breathing is so vital to life that it happens automatically. Each day, you breathe about 20,000

times, and by the time you're 70 years old, you'll have taken at least 600 million breaths.

All of this breathing couldn't happen without the respiratory system, which includes the nose,

throat, voice box, windpipe, and lungs.

At the top of the respiratory system, the nostrils (also called nares) act as the air intake, bringing

air into the nose, where it's warmed and humidified. Tiny hairs called cilia protect the nasal

passageways and other parts of the respiratory tract, filtering out dust and other particles that

enter the nose through the breathed air.

Air can also be taken in through the mouth. These two openings of the airway (the nasal cavity

and the mouth) meet at the pharynx, or throat, at the back of the nose and mouth. The pharynx

is part of the digestive system as well as the respiratory system because it carries both food and

air. At the bottom of the pharynx, this pathway divides in two, one for food (the esophagus,

which leads to the stomach) and the other for air. The epiglottis, a small flap of tissue, covers

the air-only passage when we swallow, keeping food and liquid from going into the lungs.

The larynx, or voice box, is the uppermost part of the air-only pipe. This short tube contains a

pair of vocal cords, which vibrate to make sounds. The trachea, or windpipe, extends downward

from the base of the larynx. It lies partly in the neck and partly in the chest cavity. The walls of

the trachea are strengthened by stiff rings of cartilage to keep it open. The trachea is also lined

with cilia, which sweep fluids and foreign particles out of the airway so that they stay out of the

lungs.

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At its bottom end, the trachea divides into left and right air tubes called bronchi, which connect

to the lungs. Within the lungs, the bronchi branch into smaller bronchi and even smaller tubes

called bronchioles. Bronchioles end in tiny air sacs called alveoli, where the exchange of oxygen

and carbon dioxide actually takes place. Each lung houses about 300-400 million alveoli. The

lungs also contain elastic tissues that allow them to inflate and deflate without losing shape and

are encased by a thin lining called the pleura. This network of alveoli, bronchioles, and bronchi is

known as the bronchial tree.

The chest cavity, or thorax, is the airtight box that houses the bronchial tree, lungs, heart, and

other structures. The top and sides of the thorax are formed by the ribs and attached muscles,

and the bottom is formed by a large muscle called the diaphragm. The chest walls form a

protective cage around the lungs and other contents of the chest cavity. Separating the chest

from the abdomen, the diaphragm plays a lead role in breathing. It moves downward when we

breathe in, enlarging the chest cavity and pulling air in through the nose or mouth. When we

breathe out, the diaphragm moves upward, forcing the chest cavity to get smaller and pushing

the gases in the lungs up and out of the nose and mouth.

The air we breathe is made up of several gases. Oxygen is the most important for keeping us

alive because body cells need it for energy and growth. Without oxygen, the body's cells would

die.

Carbon dioxide is the waste gas produced when carbon is combined with oxygen as part of the

energy-making processes of the body. The lungs and respiratory system allow oxygen in the air

to be taken into the body, while also enabling the body to get rid of carbon dioxide in the air

breathed out.

Respiration

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Respiration is the set of events that results in the exchange of oxygen from the environment and

carbon dioxide from the body's cells. The process of taking air into the lungs is inspiration, or

inhalation, and the process of breathing it out is expiration, or exhalation.

Air is inhaled through the mouth or through the nose. Cilia lining the nose and other parts of the

upper respiratory tract move back and forth, pushing foreign matter that comes in with air (like

dust) either toward the nostrils to be expelled or toward the pharynx. The pharynx passes the

foreign matter along to the stomach to eventually be eliminated by the body. As air is inhaled,

the mucous membranes of the nose and mouth warm and humidify the air before it enters the

lungs.

When you breathe in, the diaphragm moves downward toward the abdomen, and the rib

muscles pull the ribs upward and outward. In this way, the volume of the chest cavity is

increased. Air pressure in the chest cavity and lungs is reduced, and because gas flows from high

pressure to low, air from the environment flows through the nose or mouth into the lungs. In

exhalation, the diaphragm moves upward and the chest wall muscles relax, causing the chest

cavity to contract. Air pressure in the lungs rises, so air flows from the lungs and up and out of

respiratory system through the nose or mouth.

Every few seconds, with each inhalation, air fills a large portion of the millions of alveoli. In a

process called diffusion, oxygen moves from the alveoli to the blood through the capillaries (tiny

blood vessels) lining the alveolar walls. Once in the bloodstream, oxygen gets picked up by the

hemoglobin in red blood cells. This oxygen-rich blood then flows back to the heart, which pumps

it through the arteries to oxygen-hungry tissues throughout the body. In the tiny capillaries of

the body tissues, oxygen is freed from the hemoglobin and moves into the cells. Carbon dioxide,

which is produced during the process of diffusion, moves out of these cells into the capillaries,

where most of it is dissolved in the plasma of the blood. Blood rich in carbon dioxide then

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 returns to the heart via the veins. From the heart, this blood is pumped to the lungs, where

carbon dioxide passes into the alveoli to be exhaled.

XI. Pathophysiology

Predisposing Factors: Etiology Precipitating Factors:

XII.
 Age Respiratory synctial virus Smoking
 XIII.
Gender
Parainfluenza virus Exposure to air
 Family history of
asthma pollution
Corona virus

S. pneumonia, Haemophilus
influenza

Inflammation of bronchi

Irritation of the cells of the bronchial

lining tissue

Hyperemic and edematous mucous

membranes

Alpha antihypsin inhibited

Fever

fatigue

Air passages clogged by

debris

Diminish bronchial mucociliary function

Increased irritation

Increased mucus production

Difficulty of Breathing

Dry productive cough

13
Wheezes Dyspnea

Increased respiratory rate

XIV. Laboratory

Hematology

Composition and SI Unit Values Results Interpretation/Analysis

Hemoglobin: Male (120-150 gm/L ) 169 Above Normal

Female(110-140 gm/L) Possible dehydration

Hematocrit:Male (0.40 – 0.54) 0.49 Normal

Female (0.37 - 0.47)

RBC: Male (4.5 – 6 x 1012/L) 5.49 Normal

Female (4.5 – 5 x 1012/L)

Total WBC: (5 – 10 x 109/L) 6.3 Normal

Platelets (150 – 400) 219 Normal

Eosinophils (0.0 – 0.04) 0.03 Normal

Segmenters (0.50 – 0.70) 0.55 Normal

Lymphocytes (0.20 – 0.40) 0.31 Normal

Monocytes (0.0 - 0.50) 0.11 Normal

Microscopic Feces Examination

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Color: Yellowish brown

Consistency; soft to Semi-mucoid

Blood(gross) (-)

Mucus: (+)

Ova or Parasites: none found

Cells: WBC: 1-3/hpf

Others: E. hystolytica test (EIA): Negative

Bacteria: +

Routine Analysis

Gross

Color: Yellow

Trasparency: RBC: 0-3/hpf

Reaction: Acidic pus cells: 2-4/hpf

Specific Gravity: 1.020

Chemical

Albumin: ++ Crystals Aurates: ++

Sugar: Negative Mucus Threads: ++

15
XV. Drug Study

NAME INDICATION CONTRAINDICATION DOSAGE SIDE NURSING

EFFECT CONSIDERATION

BN

AMBROLEX Acute and chronic Early month of Retard cap adult and children >12 yr 1 Mild  Assess patient’s
disorders of the the pregnancy cap daily GI side fever or pain
GN: respiratory tract effects  Assess allergic
Tab Adult and children>12 yr old tid reactions
associated w/
AMBROXOL  Assess
pathologically thickened Syrup adult and children>12 yr 1tsp Hepatoxicity
HCL mucus and impaired tid  Monitor liver
mucus transport and rebal
2-6 yr old ½ tsp tid functions
 Advise patient
Paed syr children 6-12 yr bid-tid to avoid alcohol
 Teach patient to
2-6 yr tsp tid recognize signs
of overdose
1-2 yr ½ tsp bid (chronic)
 Teach
Infant drops children 13-24 month 1
patientthat
ml bid urine may
become dark
7-12 month 0.75 ml bid
brown.
<6 month 0.5 ml bid

NAME INDICATION CONTRAINDICATION DOSAGE SIDE EFFECT NUSING CONSIDERATION

16
 Moderate to severe
infection ,including
BN those of Hypersensitivity to Adults and Head ache  Monitor patient for life
cephalolosporins or children ages threatening adverse
ZINACEF,ZINNAT skin,bone,joints,urinary Hypertonia
or respiratory penicillins 12 and older effect,including
GN tract,gynecologic Seizures anaphylaxis,Steven’s
Carnitine deficiency 750 mg to 1.5g
infections,and John Syndrome
I.M or IV q8
CEFUROXIME
septicemia
Nausea and vomiting  Monitor neurologic
SODIUM hours for 5 -10
status,particularly for
days or 250 mg Diarrhea,abdominal
signs of impending
-500 mg P.O q pain
seizure
12 hours
Hyperglycemia  Monitor kidney and
Children ages 3 liver function
Toxic epidermal  Monitor temperature:
mos-12 years
necrolysis watch for signs and
50- symptoms of
Steven’s John
100mg/kg/day superinfection.
syndrome
I.V or I.M in
divided doses
q6 to 8 hours

NAME INDICATION CONTRAINDICATION DOSAGE SIDE EFFECT NURSING CONSIDERATION

Oral adults
325 mg to 650
Relief of mild mg as needed Drowsiness  Assess patient’s fever or pain: type of
17
GN: to moderate Hypersensitivity q4-6 hours, do Nausea pain,location,intensity,duration,tempera
pain not exceed ture
PARACETAMOL Intolerance to 4g/day Abdominal
 Assess allergic reaction:rash,utecaria
Treatment of tartrazine ,alcohol, pain
BN: Children:10-  Asses hepatotoxicity: dark urine,clay
fever table sugar, Hepatic
15 mg/kg dose colored stools,yellowish skin and schlera
saccharin seizure
ACETAMINOPHEN as needed q4  Monitor liver and renal dysfunction
-6 hours  Check input and output ratio:decreasing
Cyanosis
Suspension:6- output may indicate renal failure
Anemia
12 yrs 2-4 tsp
Rash
1-6 yrs 1-2 tsp
Convulsion
3mos- 1 yr ½-1
tsp 3x-4x/day Coma
Infant Delirium
drops:1-2 yrs followed by
1.2-1.8 ml6-12 vascular
mos 0.6- collapse.
1.2ml,0-6 mos
0.3-0.6 ml 3x- Death
4x a day.

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XVI. Problem List

Rank Problem Date Identified Date Resolved

1 Ineffective Airway Clearance July 6, 2009 July 8, 2009

2 Imbalanced Body Temperature July,6, 2009 July 8, 2009

3 Deficient Knowledge July 6, 2009 July 8, 2009

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XVII. Nursing Care Plan

ASSESSMENT NURSING PLANNING NURSING INTERVENTION RATIONALE EXPECTED

DIAGNOSIS OUTCOME

Subjective data: Ineffective airway After 8 hours of 1. Monitor vital >To have a baseline The client will be
clearance related to nursing intervention, signs. data. able to maintain
“May problema mucus secretion the client will be able 2. Establish Nurse- effective airway
‘pag umuubo ako, patient >for a comforting
to maintain airway clearance.
nahirapang huminga Interaction. and trusting
clearance.
pero konti lang”, as 3. Monitor relationship
respirations and
verbalized by the
breathe sounds. >indication of
client.
respiratory distress
“Mahigit isang kaha 4. Position head for (tachypnea, stridor,
ng sigarilyo ang appropriate for crackles, wheezes).
nabibili ko ko araw- condition- - semi-
araw, ang sarap kais fowler’s position. >to maintain open
5. Elevate head of airway.
lalo na ‘pag
bumabyahe”, as bed/change
position every 2
verbalized by the
hours.
client. >assist with the use
of respiratory devices
and treatments.
Objective data: >to enhance
>support reduction ventilation to
>productive cough or cessation of different lung
smoking. segment.
>position
20
 appropriately,
discourage use of oil-
based products >various therapies
may be required to
around nose.
maintain adequate
airways.

>to improve lung

function.

>to prevent vomiting

with aspiration into
lungs.

Nursing Intervention Progress Report

21
Problem: Ineffective Airway Clearance Date: July 6, 2009 Day: First day

Assessment: Subjective data:

“May problema ‘pag umuubo ako, nahirapang huminga pero konti lang”, as verbalized by the client.

“Mahigit isang kaha ng sigarilyo ang nabibili ko ko araw-araw, ang sarap kais lalo na ‘pag bumabyahe”, as verbalized by the client.

Objective data:

>productive cough

Intervention:

6. Monitor vital signs.

7. Establish Nurse-patient Interaction.
8. Monitor respirations and breathe sounds.

9. Position head for appropriate for condition- - semi-fowler’s position.

10. Elevate head of bed/change position every 2 hours.
>assist with the use of respiratory devices and treatments.

>support reduction or cessation of smoking.

>position appropriately, discourage use of oil-based products around nose.

Evaluation:

The client will be able to maintain effective airway clearance.

22
NURSING CARE PLAN

ASSESSMENT NURSING PLANNING NURSING RATIONALE EXPECTED OUTCOME

DIAGNOSIS INTERVENTION

Subjective data: Imbalance body After 8 hours of nursing 1. Monitor vital >To have a baseline The client will be
temperature intervention, the client signs. data. able to display
“Nilalagnat ako, related to will be able: decrease of
may trangkaso 2. Monitor >Hyperventilation
vigorous activity temperature from
yata”, as as manifested by 1. Display decrease respiration. may initially be 38°C to 37°C;
verbalized by the of temperature present, but
increased 3. Monitor maintain core
client. from 38°C to 37°C. ventilatory effort
temperature. 2. Maintain core temperature and temperature at
may eventually be
temperature at pulse. normal level;
normal level. impaired by seizures, demonstrate
Objective data: 3. demonstrate 4. Monitor hyper metabolic behaviors to
behaviors to laboratory studies. stage. monitor and
>Temperature – monitor and
>may indicate promote
38°C promote
presence of other normothermia.
normothermia.
>Blood Pressure 5. Promote surface illnesses or
– 110/90mmHg cooling by means evidences.
of undressing, cool
environment. >heat loss by
convection.
11. Cool sponge
bath

>heat loss by
evaporation and
conduction.
12. Maintain bed
23
 rest.

>to reduce metabolic

demands or oxygen
consumption.

Nursing Intervention Progress Report

24
Problem: Imbalanced boy temperature Date: July 6, 2009 Day: First day

Assessment:

Subjective data:

“Nilalagnat ako, may trangkaso yata”, as verbalized by the client.

Objective data:

>Temperature – 38°C

>Blood Pressure – 110/90mmHg

Intervention:

. Monitor vital signs.

2. Monitor respiration.

3. Monitor temperature and pulse.

4. Monitor laboratory studies.

5. Promote surface cooling by means of undressing, cool environment.

13. Cool sponge bath

Evaluation:

The client will be able to display decrease of temperature from 38°C to 37°C; maintain core temperature at normal level; demonstrate behaviors
to monitor and promote normothermia.

25
 ASSESSMENT NURSING PLANNING NURSING RATIONALE EXPECTED OUTCOME
DIAGNOSIS INTERVENTION

Subjective data: Deficient After 8 hours of nursing 1. Ascertain level of >To know if the The client will be
knowledge related intervention, the client knowledge. individual is able to participate
“Mahigit isang to incomplete will be able: Determine client’s physically, in the learning
kahanf sigarilyo at information about ability or readiness emotionally process; verbalize
isang litrong alak the effects of 1. Participate in the and barriers to capable. understanding of
(beer) ang nauubos learning process.
excessive alcohol learning. excessive alcohol
ko araw0araw”, as 2. Verbalize
consumption and understanding of consumption and
verbalized by the 2. Health Education
smoking excessive alcohol smoking; initiate
client. consumption and necessary lifestyle
>Differences
smoking. >For providing changes
between normal
3. Initiate necessary information and
lifestyle changes. and abnormal liver
for facilitating
4. >Effects of learning.
excessive
alcohol
consumption
and smoking.

Nursing Intervention Progress Report

26
Problem: Deficient Knowledge Date: July 6, 2009 Day: First day

Assessment:

Subjective data:

“Mahigit isang kahanf sigarilyo at isang litrong alak (beer) ang nauubos ko araw0araw”, as verbalized by the client.

Intervention

1. Ascertain level of knowledge. Determine client’s ability or readiness and barriers to learning.

2. Health Education

>Differences between normal and abnormal liver

>Effects of excessive alcohol consumption and smoking.

Evaluation:

The client will be able to participate in the learning process; verbalize understanding of excessive alcohol consumption and smoking; initiate
necessary lifestyle changes

27
XVIII. Progress Notes

7/6/09

 Received client lying on bed

 Weak
 Established NPI to have a comfortable and trusting relationship
 Performed interview of past and present history
 Frequent coughing
 Sleepy

7/7/09

 Received client lying on bed

 Regained strength
 Talkative
 Seldom coughs
 Maintained normal temperature

7/8/09

 Received client sitting on bed

 Cheerful and active
 Coherent
 Cough was productive
 Seldom coughs
 Client was discharged
 Maintained normal vital signs: temperature, pulse, respiration, blood pressure

XIX. References
28
PPD’s Nursing Drug Guide

Nurse’s Pocket Guide

Biology (Martinez; Julian; Nazareno; Sison)

Scribd.com

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