I. PERSONAL DATA: Name: Mrs

I. PERSONAL DATA:

Name: Mrs. Suarez, Abundia Age: 92 years old
Address: San Antonio St. Inupacan Leyte Sex: Female
Date of birth: December 23, 1917 Place of birth: Inupacan Leyte
Civil status: Widowed Nationality: Filipino
Religion: Roman Catholic
Ed. Attainment: College Graduate Occupation: House Wife
Date of Admission: December 07, 2010 @ 10:30 pm
Chief complaint: LBM with intermittent fever and injury on the head
Initial diagnosis: – AGE with mild dehydration
– HPN stage II
Final diagnosis: Community Acquired Pneumonia
Attending Physician: Dr.
Source of info: Amalia I. Suarez (Daughter)
Reliability: 70% (seventy percent)

II. HEALTH HISTORY
According to the daughter of the patient 3 days prior to admission at Bethany Hospital, the patient experienced a passage of loose-watery stools, non-bloody, non-mucoid accompanied with an intermittent fever with mild cough. The manifestations start an hour after the patient ate an uncooked peanut. The patient used to take an oral antipyretic which is Biogesic every 4 hours during the onset of fever for relief and Flagyll, Bactrium and Hyanite for an aid of diarrhea. 1 day prior to admission, while the patient is going to the bathroom, she accidentally slipped and slammed her head, which eventually prompt her daughter to bring her to Hospital hence this admission and had been initially diagnosed with AGE, HPN, and Mild Aortic Stenosis leading to Concentric left ventricular hypertrophy with adequate systolic function and finally diagnosed with Community Acquired Pneumonia.

III. PAST HEALTH HISTORY
The patient’s daughter claimed that his mother suffered from childhood illnesses such as chicken pox, measles, cough/cold and fever and had taken some herbal medicine as a relief for cough/cold and sometimes Biogesic for fever management. The informant also talked about the admission of the patient to Bethany due to pneumonia, valvular heart disease and undergone surgery due to haemorrhoids. The patient has an allergy to hair colours and is hypertensive with no known complication as claimed by the daughter.

IV. FAMILY HISTORY
As what the informant remembered, the patient’s parents and ancestors has a history of hypertension and arthritis. (The informant was unable to recall the cause of death of her grandfather and grandmother).

V. FEEDING and PSYCHOSOCIAL HISTORY
The patient used to eat vegetables, fish, and meat. She favourably eat peanut more often. And drink Ensure milk without known allergies to any kind of food or fluids. Use clean Tap water for drinking. The patient do not puff a smoke and other drugs.

VI. GYNECOLOGIC HISTORY
The informant was unable to remember when was the menarche of the patient. Logically, the patient’s daughter estimated that her mother’s menopausal stage was at the age of 50’s.

REACTIONS AND EXPECTATIONS:
The informant expects that her mother will recover in a timely and efficient manner. “Maupay gud unta kun ma-upay dayon hiya para kami maka uli kay damu na it baraydan” as verbalized by the daughter.
Patterns of Functioning Clinical Inspection Other Sources
* Respiratory:

– Normal breathing pattern
– (+) history of colds/cough
– No asthma
– (+) history of pneumonia

* Circulatory:

– (+) hypertension
– No history of Dizziness or fainting spells
– (+) history of arrythmia

* Food & Fluid intake:

– Eats 3-4 times a day
– Drink ensure (milk)
* Regulatory Mechanism:

– Has a fever during admission

* Elimination:

– Meconium passed out at 24 hours of life
– Has constipation
– No relief measures taken at home
– RR: 18 as of December 12, 2010 with a normal rhythm
– (+) accessory muscle used
– (+) productive cough (whitish phlegm)
– (+) oxygen attached
– (+) nebulizer
– HR: 52 bpm as of December 12, 2010 with a normal rhythm
– BP: ***
– No cyanotic and skin discoloration
– No edema

– Mild anorexia
– Poor skin turgor
– Dry lips
– Temp: ***
– Dry skin
– No chills

– Swollen abdomen
– Yellow green mushy stools
– Constipation
– Enema used to expel stools

RADIOLOGIC FINDINGS

– Streaks of densities are seen in the lower lung field.
– The heart is not enlarged
– The rest of the visualized chest structured are unremarkable
IMPRESSION:
– Bibasal pneumonitis
– Fluid prescribed parenterally:
– HEMATOLOGY
WBC: 7.3×109/L
HEMOGLOBIN:
female: 94 (140-180 g/ L)
HEMATOCRIT:
female: 0.29 (0.37 – 0.48%)
LYMPHOCYTES: 0.11 (0.25 – 0.40)
NEUTROPHILS: 0.84

– CLINICAL CHEM.
Creatinine: 222.65
Sodium: 149.7
Potassium: 3.18
– FECALYSIS
Color: yellow green
Consistency: Mushy
Ova of Parasites: none
Pus cells: 0-2/hpf
RBC: 0-2/hpf
Occult blood: (+) trace Patterns of Functioning Clinical Inspection Other Sources

* Hygiene

– Family have no belief regarding to hygiene
– Clean apparently

* Exercise & Locomotion:

– Limited ROM
– House chores serves as the exercise.

* Rest & Sleep:

– (-) Difficulty of sleeping
– Side-lying position

* Communication:

– unable to speak at the time of admission

* Sensory:

– No epilepsy, convulsion etc.
– History of Hallucination as the effects of the medicine during admission

– The patient is clean
– Skin is partly dry

– No deformities
– Limited ROM
– The patient has enough rest
– Lacrimation (-)
– The patient responds to pain.
Pathophysiology of Pneumonia
Non-Modifiable Modifiable
– Age >70 years – Congestive heart disease
– COPD – Prolonged Immobility and dehydration

Streptococcus Pneumoniae

Invasion in the
Respiratory system
Defect in local pulmonary defenses
Activation of defense mechanism

Increase mucous production
Mucociliary transport is
depresses with the aging
process, dehydration etc
Productive cough

inflammatory cells pooling of lung secretions
activated
Crackles
mucus plugs

release of proteolytic deprivation of O2
enzymes
decrease surface area for O2 Tank
external respiration
CO2 retention

alters brochial and ciliary
clearance mechanism respiratory acidosis

stimulating production alveoli is filled with debris
of excess mucus by the WBC due to Tachypnea
inflammatory process
RECOVERY if treated Consolidation if not treated
DEATH Lung collapse
Nursing Diagnosis Scientific analysis Objectives Nursing Interventions Rationale Evaluation
Ineffective airway clearance r/t excessive viscous secretions in the bronchi as manifested by productive cough.

Subjective:
” nag i-inubo hiya na may plema” as vervalized by the patient’s daughter.

Objective:
– Productive cough
– Whitish Phlegm
– Pulse: 52 bpm
– RR: 18 cpm

Community acquired Pneumonia is an infection in the alveoli, distal airways, and interstitium of the lungs that occurs outside the hospital settings. And is characterized by fever, chills, cough (productive), or a chest pain. unexpelled mucous along the airways causes it to narrow.

Reference:
Straight A’s in Pathophysiology of Lippincott Williams & Wilkins page 83
After 8 hours of nursing interventions:
– The patient will maintain an adequate patent airway after he expectorates bronchial secretion.
– The client will improve and maintain an adequate airway clearance.

INDEPENDENT:

1.) Monitor respirations and note for breath sounds
.
2.) Suction airway as ordered by the physician.

3.) Increase the patient’s fluid intake to 2000 ml per day

1.) Presence may indicate accumulation of secretions and respiratory distress.

2.) To clear airway.

3.) Hydration can help liquify viscous secretions

Nursing Diagnosis Scientific analysis Objectives Nursing Interventions Rationale Evaluation
Ineffective breathing pattern r/t presence of abnormal breath sounds as evidenced by crackles
Objective:

– Productive cough
– Abnormal lung sound: Crackles
– Pulse: 52 bpm
– RR: 18 cpm

Community acquired Pneumonia is an infection in the alveoli, distal airways, and interstitium of the lungs that occurs outside the hospital settings. The production of phlegm or mucous produce a crackle sound due to the increased fluid in the alveoli and segmental spaces of the lung.
Reference:
Straight A’s in Pathophysiology of Lippincott Williams & Wilkins page 83

After 8 hours of nursing interventions:
The client will be able to breathe continuously and reduction of congestion and abnormal breath sounds.
INDEPENDENT:

1) Position the patient’s head in semi-fowler.

2) Provide bronchial tapping techniques.

3) Observe for increased dyspnea/tachypnea with onset of fever and change in sputum color, amount and character.
1) To maintain an open airway and facilitate maximum lung expansion.
2) To improve airflow and secretion clearance.
3) To identify infectious process and promote timely intervention.

Nursing Diagnosis Scientific analysis Objectives Nursing Interventions Rationale Evaluation
Impaired Gas exchange r/t ventilation perfusion imbalance as manifested by breathing pattern problems.

Objective:
– Oxygen tank attached
– Mild cyanotic of finger nails
– Pulse: 52 bpm
– RR: 18 cpm

Community acquired Pneumonia is an infection in the alveoli, distal airways, and interstitium of the lungs that occurs outside the hospital settings. Dyspnea, mucouid plug and tachypnea causes to decrease alveolar space for external respiration leading to decreased lung capacity and oxygen saturation.

Reference:
Straight A’s in Pathophysiology of Lippincott Williams & Wilkins page 83
After 8 hours of nursing interventions:
– The client will improve ventilation and adequate oxygenation.
INDEPENDENT:

1) Provide rest periods and limit activity to level of respiratory tolerance.
2) Change position every 2 hours or as needed.

3) Keep environment allergen-free.
1) Prevents fatigue and dyspnea.

2) To prevent bedsore and promote better lung compliance

3) To prevent possible entry of irritants, this will obstruct the airway.