Nursing Assessment

I.Nursing Assessment

A. Personal Data

Name : Mr. LP
Address: G. Robles Maybangkal Street, Morong, Rizal
Age: 61 years old
Birth date :March 30, 1948
Religion: Roman Catholic
Civil Status: Married
Nationality: Filipino
Occupation: Former Farmer
Admitted on: June 21, 2009
Time: 9:10 p.m.
Admitting Diagnosis: COPD in exacerbation, Plural Effusion, Pneumonia, t/c Electrolyteimbalance
Chief Complaint: D.O.B. (Difficulty of Breathing)

B. History of Past illness
Patient has undergone, thoracentesis last June 15 at Queen Mary Help of Christians hospital prior to that admission he was diagnose with plural effusion, thoracentesis was perform and after 5days of admission he was discharge home.

C. History of Present Illness
After the patient was discharge home around 8:50pm (June 15, 2009) after 3 days at home heexperienced DOB and he was rush to the hospital accompanied by his wife and cousins.-COPD-Questionable Pneumonia-Electrolyte Imbalance

D. Family History
According to patients wife they can not recall any illness in the family of his husband exceptfrom asthma.

E. Patient’s Concept of Health Illness and Hospitalization
He didn’t expect that this would happen to him, doctors doesn’t have any idea of the source of his illness but the patient says, that it might be from the work, he thought that it would just be a simple cough due to tiring day but it lasted for about a month and he needs to be admitted andundergone some procedures.

Parts of the Respiratory System

Structurally, the respiratory system consists of two parts:
1. Upper Respiratory Tract
2. Lower Respiratory Tract

Functionally, the respiratory system consists of two parts:
1. The conducting portion
2. The respiratory portion

Respiratory Tract
The respiratory tract is the path of air from the nose to the lungs. It is divided into two sections:

Upper Respiratory Tract
Lower Respiratory Tract

Upper respiratory tract
1. Nose
2. Pharynx (throat)
3. Associated structures

Lower Respiratory Tract
1. Larynx (voice box)
2. Trachea (windpipe)
3. Bronchi
4. Lungs


Upper respiratory tract


The nose, whether “pug” or “ski-jump” in shape, is the only externally visible part of the respiratory system. During breathing, air enters the nose by passing through the external nares, or nostrils. The interior of the nose consists of the nasal cavity, divided by a midline nasalmucoseptum. The olfactory receptors for the sense of smell are located in the mucosa in the slitlike superior part of the nasal cavity, just beneath the ethmoid bone.

The pharynx is a muscular passageway about 13 cm long that vaguely resembles a short lengthof red garden hose. Commonly called the throat, the pharynx serves as a common passagewayfor food and air.Air enters the superior potion, the nasopharynx, from the nasal cavity and then descendsthrough the oropharynx and laryngopharynx to enter the larynx-below.

Lower Respiratory Tract
The larynx, routes air and food into the proper channels and plays a role in speech. The largest of the hyaline cartilages is the shield shape thyroid cartilage, which protrudes anteriorly and iscommonly called the Adams’s apple.

Air entering the trachea or windpipe from the larynx travels down its length (10-12 cm, or about4 inches) to the level of the fifth thoracic vertebra, which is approximately midchest. The tracheais lined with a ciliated mucosa.
Primary Bronchi
The division of the trachea forms the right and left primary bronchi. The right primary bronchusis wider, shorter, and straighter than the left. By the time incoming air reaches the bronchi, it iswarm, cleansed of most impurities, and well humidified.
The paired lungs are fairly large organs. They occupy the entire thoracic cavity except for themost central area, the mediastinum, which houses the heart, the great blood vessels, bronchi,esophagus, and other organs. The surface of each lung is covered with a visceral serosa called the pulmonary,or visceral, pleura, and the walls if the thoracic cavity is lined by the parietal pleura.
Alveoli (site of gas exchange)
An alveolus (plural: alveoli, from Latin alveus, “little cavity”), is an anatomical structure that hasthe form of a hollow cavity. In the lung, the pulmonary alveoli are spherical outcroppings of therespiratory bronchioles and are the primary sites of gas exchangewith the blood. The lungs contain about 300 million alveoli, representing a total surface area of 70-90 square metres, eachwrapped in a fine mesh of capillaries. It has a radii of about 0.1 mm and wall thicknesses of about 0.2 µm. It consists of an epithelial layer and extracellular matrix surrounded bycapillaries. In some alveolar walls there are pores between alveoli. There are three major alveolar cell types in the alveolar wall (pneumocytes): Type I cells that form the structure of an