Case 1 - GDM

Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY

Cabanatuan City
COLLEGE OF NURSING
In Partial Fulfillment of the Requirement for the
Clinical Duty
CASE ANALYSIS
Submitted By:
Ariola, Mary Kathleen M
Atienza, Jan Rae B.
De Leon, Bernadeth C.
SN’23
Submitted To:
QWERTYUIQWERTYU
Clinical Instructor
CHAPTER I
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COLLEGE OF NURSING
General Objective
To be able to provide student nurses and other Health Care professionals with an
overview of the patient’s condition, possible complications, treatment plan, and medical &
nursing intervention.
Specific Objectives
Specifically, this case analysis aims to:
 Present a thorough general assessment of the client which includes physical assessment
and family history
 Understand the pathophysiology and etiology of the case being presented.
 Identify the factors that contributed in the development of the diagnosis.
 Efficiently provide appropriate and proper nursing diagnosis in line with the client’s
medical condition and skillfully formulate nursing care plans for the problems identified.
 Appropriately apply nursing interventions necessary for the patient’s condition in
reference with the learned theories and concepts of the disease.

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Introduction
Pregnancy related low back pain (LBP) is a common complaint among pregnant women.
It can potentially have a negative impact on their quality of life (Katonis et al, 2011). Various
explanations on the pathophysiology leading to LBP in the antenatal period have been advocated,
these includes possible weight gain coupled with the weight of the baby, posture changes to
accommodate the weight, and hormonal changes that loosen up the ligaments.
While LBP wouldn’t be a major concern during pregnancy, respiratory diseases on the
other hand may pose a potential threat during pregnancy. According to John Hopkins Medicine,
people who smoke increases their risk of lung diseases such as chronic and acute bronchitis,
emphysema, and asthma.
The airways in a person with asthma are very sensitive and can react to many things, or
"triggers." Coming into contact with these triggers often produces asthma symptoms. Tobacco
smoke is a powerful asthma trigger. Furthermore, cigarette smoking is the number one risk factor
for developing chronic bronchitis because smoking damages the bronchial tree which makes it
easier for viruses and bacteria to cause infection.
During pregnancy, respiratory diseases such as asthma significantly increases the risk of
preeclampsia based on the 2017 research done by J. Stokholm, A. Sevelsted, U. Anderson, and
H. Bisgaard. This problem may lead to the increase the risk of restricted fetal growth, premature
birth, and the need of C-section during delivery.

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Patient’s Data
Name of Patient: X
Sex: Female
Blood Type: O+
Date of Admission: August 24, 2020
Demographic Profile
Address: Acropolis North, Sumacab, Cabanatuan City

Birth date: February 14, 2004
Place of Birth: Cabanatuan City
Educational Level: Highschool Level
Occupation: Student
Significant others or support persons: Parents
Age: 16-year-old
Religion: Roman Catholic
Marital Status: Married
Siblings: None
Family History
Mother
Age: 33
Illnesses: Asthma, Hypertension
Father
Age: Deceased at 35, now 38
Illnesses: Died to Lung Cancer
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History of Past Illness
Problems at birth: None

Childhood Illnesses: Asthma
Immunizations to date: Polio, Chickenpox, Diphtheria, Tetanus, Measles, Mumps, and Rubella
Adult Illnesses: Asthma
Surgeries: Abdominal Surgery for Ectopic Pregnancy
Accidents: None
Allergies: None
Admitting History
Date of Service: July 16, 2018

Cause of Admission: Ectopic Pregnancy
Status of Present Illness
Patient’s chief complaint since August 22, 2020 was a recurring Lumbo-sacral pain,
exacerbated by physical activities and alleviated through pain medications. Using a pain scale of
1(barely noticeable) to 10 (worst pain), patient described the pain as 8 and enough to keep her
awake through the night.
On August 24, 2020, after admission, patient began having deep coughs that can often
bring about discolored sputum, along with the difficulty of breathing. Patient displayed elevated
Pulse Rate, Respiratory Rate, and Blood Pressure. Furthermore, Complete Blood Count of the
patient revealed elevated WBC count, particularly Neutrophils, which indicates a high possibility
of bacterial infection and was later revealed as an acute bronchitis after a chest x-ray.
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PHYSICAL ASSESSMENT
Head to Toe Physical Assessment
BODY PARTS NORMAL FINDINGS ACTUAL FINDINGS RESULT
SKULL Rounded The head of the client No abnormalities

(normocephalic and is rounded;
symmetric, with frontal, normocephalic and
parietal, and occipital symmetrical.
prominences); smooth
skull contour There are no nodules No abnormalities
or masses and
depressions when
palpated.
Evenly distributed hair

HAIR & SCALP Evenly distributed
Thick hair hair.
No abnormalities
With short, black and
Silky, resilient hair shiny hair.
No infection or No presence of No abnormalities

infestation infestation.
Amount of body hair is

variable
Symmetric or slightly
FACE asymmetric facial The face of the client
features; palpebral appeared smooth and
fissures equal in size; has uniform No abnormalities
symmetric nasolabial consistency.
fold
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No abnormalities
No edema No presence of
nodules or masses.
External Features The client’s eyebrows

Hair evenly distributed; are symmetrically No abnormalities
skin intact Eyebrows aligned and showed
symmetrically aligned; equal movement
equal movement when asked to raise
and lower eyebrows.
Equally distributed;
EYES curled slightly outward
Eyelashes appeared to
Skin intact; no be equally distributed No abnormalities
discharge; no and curled slightly
discoloration outward.
Lids close There are no presence

symmetrically of discharges, lids
Approximately 15 to 20 close symmetrically
involuntary blinks per with involuntary
minute; bilateral blinks approximately
blinking When lids 15-20 times per
open, no visible sclera minute. No abnormalities
above corneas, and
upper and lower borders
of cornea are slightly The Bulbar
covered conjunctiva appeared
yellowish color due to
Transparent; capillaries smoking with few
sometimes evident; capillaries evident. No abnormalities
sclera appears white
(darker or yellowish and
with small brown The sclera appeared
macules in dark-skinned white
clients)
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Transparent, shiny, and

smooth; details of the
iris are visible In older The palpebral
people, a thin, grayish conjunctiva appeared
white ring around the shiny, smooth and No abnormalities
margin, called arcus pink
senilis, may be evident
Black in color; equal in There is no edema or

size; normally 3 to 7 tearing of the lacrimal
mm in diameter; round, gland
smooth border, iris flat
and round
Cornea is transparent, No abnormalities
When looking straight smooth and shiny and
ahead, client can see the details of the iris
objects in the periphery are visible. The client
blinks when the
Temporally, peripheral cornea was touched.
objects can be seen at
right angles (90°) to the No abnormalities
central point of vision. The pupils of the eyes
The upward field of are black and equal in
vision is normally 50°, size
because the orbital ridge
is in the way. The
The client can see
downward field of
objects in the
vision is normally 70°, No abnormalities
periphery when
because the cheekbone
looking straight
is in the way. The nasal
ahead.
field of vision is
normally 50° away from
the central point of
vision because the nose
is in the way
Extraocular Muscle
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Tests
Both eyes coordinated, Both eyes of the
move in unison, with client coordinately No abnormalities
parallel alignment moved in unison with
parallel alignment.
Light falls No abnormalities
symmetrically (e.g., at Patient was able to
“6 o’clock” on both read the newsprint at
pupils) a distance of 8 inches
Uncovered eye does not

move
Able to read newsprint
20/20 vision on Snellen-

type chart
Auricles
Color same as facial
skin.
Symmetrical Client’s color of the
Auricle aligned with auricles is same as
outer canthus of eye, facial skin,
about 10°, from vertical symmetrical, auricle No abnormalities
is aligned with the
Mobile, firm, and not outer canthus of the
tender; pinna recoils eye, mobile, firm,
after it is folded non-tender, and pinna
Gross Hearing Acuity recoils after it is
EARS Tests being folded.
Normal voice tones
audible Able to hear ticking
on right ear at a
Able to repeat the distance of one inch No abnormalities
phrases correctly in both and was able to hear
ears the ticking on the left
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ear at the same

Sound is heard in both distance.
ears or is localized at the
center of the head
(Weber negative)
Lips And Buccal Client’s lips are

Mucosa symmetrical has dark
brown color lips,
Uniform pink color brownish gums and With abnormalities
(darker, e.g., bluish hue, gum stains and able
in Mediterranean groups to purse lips.
MOUTH and darkskinned clients)
Soft, moist, smooth
texture Symmetry of
contour Ability to purse With dental caries,
lips yellow-stained teeth With abnormalities
and decayed lower
Teeth And Gums molars
Pink gums (bluish or

brown patches in dark- Moves when asked to
skinned clients) Moist, move without No abnormalities
firm texture to gums difficulty and without
tenderness upon
No retraction of gums palpation.
Tongue/Floor Of The
Mouth
Central position Pink Central position, pink

color (some brown but with whitish
pigmentation on tongue coating which is No abnormalities
borders in dark-skinned normal, with veins
clients); moist; slightly prominent in the floor
rough; thin whitish of the mouth
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coating Smooth, lateral

margins; no lesions
Raised papillae (taste
buds)
Tongue moves freely;
no tenderness
Smooth tongue base Client’s uvula

with prominent veins positioned midline of
soft plate No abnormalities
Palates And Uvula
Light pink, smooth, soft Client’s gag reflex is

palate Lighter pink hard present which is
palate, more irregular elicited through the No abnormalities
texture use of a tongue
depressor
Positioned in midline of
soft palate, rises during
vocalization
Muscles equal in size; The neck muscles are

head centered equal in size. The No abnormalities
Coordinated, smooth client showed
movements with no coordinated, smooth
discomfort head movement with
no discomfort.
Lymph Nodes The lymph nodes of

NECK Not palpable the client are not No abnormalities
palpable.
Trachea
Central placement in The trachea is placed
midline of neck; in the midline of the No abnormalities
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spaces are equal on both neck.

sides
The thyroid gland is

Thyroid Gland not visible on
Not visible on inspection and the No abnormalities
inspection glands ascend during
swallowing but are
not visible.
Symmetric chest shape The chest wall is

Normal chest shape, intact with no
with no visible tenderness and No abnormalities
deformities, such as a masses. There’s a full
chest barrel kyphosis, or and symmetric
scoliosis expansion and the
No muscle retractions thumbs separate 2-3
CHEST when breathing cm during deep
Quiet, unlabored inspiration when
respirations assessing for the
A regular respiratory respiratory excursion.
rhythm, with expiration
taking about twice as
long as inspiration The client manifested With abnormalities
A respiratory rate of 12- slightly shallow,
20 in an adult quick and labored
respirations.
A respiratory rate of
of 28cpm
Posterior Thorax and Hoover's sign,

Anterior Thorax presenting as
THORAX/LUNGS paradoxical With abnormalities
Anteroposterior to indrawing of lower
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transverse diameter in intercostal spaces, is
ratio of 1:2 evident
Thorax symmetric
Spinal column is straight,
right and left Coarse crackles with
shoulders and hips are at
inspiration
same height. Wheezing breath With abnormalities
Skin Intact, uniform
temperature sounds.
Client experiencing
Quiet, rhythmic, and “air hunger” or
effortless respirations dyspnea.
Full and symmetric
thorax expansion
Unblemished skin Unblemished skin No abnormalities

Uniform color
Flat, rounded (convex),
or scaphoid
(concave)
ABDOMEN No evidence of The fundus shape of
No abnormalities
enlargement of liver or the client is normal to
Spleen the gestation weeks.
Audible bowel sounds
Both extremities are

equal in size. Have the
The extremities are
same contour with
EXTREMITIES symmetrical in size
prominences of joints.
and length.
No involuntary
movements.
No edema, Color is No abnormalities
even.
Temperature is warm
and even. Has equal
contraction and even. Without scars on both
Can perform complete extremities.
range of motion.
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No crepitus must be
noted on joints.
Compressing nerve
Can counteract gravity With abnormalities
roots causing Lower
and resistance on ROM
back pain
SKIN Skin is uniform in color,

unblemished and no Client’s skin color is With abnormalities
presence of any foul yellowish and dry due
odor. Good skin turgor to smoking.
and skin’s temperature
is within normal limit.
Pubic skin intact, no

lesions Membranes ruptured
Skin of vulva area and leaking clear
slightly darker than the fluid, Fetal baseline is With abnormalities
GENITAL AREA rest 150 with minimal
of the body variability and
Labia round, full, and moderate variable
relatively symmetric in decelerations.
adult females, No
enlargement or
tenderness
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COLLEGE OF NURSING
CHAPTER II
Case Discussion and Presentation
Chemical dependence is defined as the physical and physiological dependence on a substance
such as alcohol, tobacco or drugs that are either legal or illicit. During pregnancy, smoking and
drinking should be prohibited because the fetus itself experiences the same systematic effects as
the mother. The fetus doesn’t have the capability to metabolize the drugs efficiently so it may
result to the risk of having medical complications. For pregnant women, there is also a high risk
of having spontaneous abortion, infants with low birth weight and length, abruptio placentae,
placenta previa, premature rupture of membranes, and perinatal mortality.
Bronchitis are known as the transient airway inflammation confine to the respiratory mucosa
of the central airways and clinically characterized by cough and sputum production. Having
inflammation in our airways causes the difficulty of breathing and infection in the mucous
membrane causes to develop an extra mucous which hindering the bronchi to purify themselves.
During pregnancy, the pregnant woman is usually susceptible to different common illness due
the changes in their immunity so catching a cold or flu may cause a longer effect on them. Acute
bronchitis is most common among pregnant women and is caused by the viruses and bacteria. In
terms of symptoms, cough is recognized as the cardinal symptom observed, but there are other
symptoms such as sputum production, dyspnoea, wheezing, rhonchi, chest pain, fever,
hoarseness and malaise. Smoking during pregnancy can also trigger bronchitis to occur due to
the smoke that it releases. Once the smoke from the cigarette is inhaled it can worsen the
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inflammation of the bronchioles, which can harm the baby and cause a respiratory tract
conditions and congenital effects.
As we can depict from the scenario that the patient is experiencing signs that she will go into
labor or will have an early term pregnancy. The on and off lumbo sacral pain or back pain,
contractions and the rupture of the membrane are the early symptoms. Although contractions for
the pregnant woman is normal, the painful contractions that are closer than five minutes apart
and last more than an hour is a probable sign. The rupture of the membranes that causes the
leakage of the amniotic fluid also serve as a sign of onset labor within the next 24 hours. Early
term pregnancy occurs if the baby is born between 37 weeks to 38 weeks and 6 days. It can be
considered dangerous, especially for the baby, but if the mother has other complications and
problems it simply outweighs the risk it may cost.
The occurrence of preeclampsia or the increase of blood pressure causes the early delivery of
the client. According to some experts, preeclampsia occurs due to poor nutrition or high body fat,
lack of blood flow from the uterus and through genes. The substance abuse of the patient causes
her to have a preeclampsia. Having a blood pressure of 140/90 mmHg is considered abnormal in
pregnancy so the doctor in charge does the order of delivering the baby soon.
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Anatomy and Physiology
The respiratory system is divided into tro parts: upper respiratory tract and lower
respiratory tract. The upper respiratory tract is consists of nose, pharynx, adenoids, tonsils,
epiglottis, larynx and trachea. While, the lower respiratory tract includes: bronchi, bronchioles,
alveolar ducts and alveoli. With the exception of the right and left main-stem bronchi, all lower
airway structures are contained within the lungs. The right is divided into three lobes (upper,
middle and lower) and the left lung is divided into two lobes (upper and lower). The structures of
the chest wall (ribs, pleura, muscles of respiration) are essential to respiration.
Nose – It is the primary upper respiratory organ in which air enters into and exits from the body.
Nasal Cavity- It is a large, air-filled space in the skull above and behind the nose in the middle
of the face. As we inhale, the air flows through the nasal cavity, it becomes warmed and
humidified. Cila and the mucus helps in trapping
foreign particles in the air before they go deeper
into the respiratory tract. Also, it contains
chemoreceptors that are needed for the sense of
smell and that contribute importantly to the sense
of taste.
Pharynx - A tube-like structure that connects the

nasal cavity and the back of the mouth to other
structures lower in the throat including the larynx.
It contains three parts: the nasopharynx (connects
the upper part of the throat with the nasal cavity),
oropharynx (positioned between the top of the
epiglottis and soft palate) and laryngopharynx
(located below the epiglottis).
Larynx – It is also known as the voice box. It

connects the pharynx and trachea and helps to conduct air through the respiratory tract. A very
important function of the larynx is protecting the trachea from aspirated food. When swallowing
occurs, the backward motion of the tongue forces a flap called the epiglottis to close over the
entrance to the larynx. This prevents swallowed material from entering the larynx and moving
deeper into the respiratory tract. If swallowed material does start to enter the larynx, it irritates
the larynx and stimulates a strong cough reflex. This generally expels the material out of the
larynx and into the throat.
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Trachea (Windpipe) - It is the widest passageway in the respiratory tract. It is about 2.5 cm (1
in.) wide and 10-15 cm (4-6 in.) long. The trachea connects the larynx to the lungs for the
passage of air through the respiratory tract.
Bronchi and Bronchioles - There are two main bronchial tubes, or bronchi, called the right and
left bronchi. The bronchi carry air between the trachea and lungs. Each bronchus branches into
smaller, secondary bronchi; and secondary bronchi branch into still smaller tertiary bronchi. The
smallest bronchi branch into very small tubules called bronchioles. The tiniest bronchioles end in
alveolar ducts, which terminate in clusters of minuscule air sacs called alveoli into the lungs.
Lungs – The largest organs of the respiratory tract which is spongy, pinkish organ looks like two
upside-down cones in your chest. The right lung is made up of three lobes. The left lung has only
two lobes to make room for your heart. It is responsible for removing carbon dioxide from the
blood and adding oxygen to it. It is located on either side of the breastbone in the chest activity
and are divided into five sections of lobes. The lungs are covered by a thin tissue called pleura
which secrete a fluid that allows the lungs to move freely within the pleural cavity. This is
necessary so the lungs can expand and contract during breathing.
Physiology of Gas Exchange
Each brand of the bronchial tree eventually sub-divides to form very narrow terminal
bronchioles, which terminate the alveoli. There are many millions of alveoli in each lung, and
these are the areas responsible for gaseous
exchange, presenting a massive surface area
for exchange to occur over.
Each alveolus is very closely

associated with a network of capillaries
containing deoxygenated blood from the
pulmonary artery. The capillary and alveolar
walls are very thin, allowing rapid exchange
of gases by passive difusion along
concentration gradients. CO2 moves out of the
alveolus as the continuous flow of blood
through the capilaries prevents saturation of the blood with O2 and allows maximal transfer
across the membrane.
The lung can be conseptualized as a collection of 300 million bubbles (alveoli), each 0.3
mm in diameter. The alveolar surface is composed of two kinds of cells: Type I and Type II.
Type I cells provide structure and type II cells secrete surfactant.
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Surfactant lowers surface tension in the alveoli, thereby reducing the amount of pressure
needed to inflate the alveoli and decreasing the tendency of the alveoli collapse. This sigh
stretches the alveoli and causes surfactant to be secreted by type II cells.
Functions
The respiratory system is responsible for gaseous exchange that involves the transfer of
oxygen and carbon dioxde between the atmosphere
and the blood.
The respiratory system assists in gas exchange and

performs other functions:
1. Gas Exchange. The respiratory system allows

oxygen from the air to enter the blood and for
carbon dioxide to leave the blood and enter the
air.
2. Regulation of the Blood pH. It can alter the
blood pH by changing blood carbon dioxide
levels.
3. Voice Production. Air movement past the
vocal cords which makes the sound and speech
possible.
4. Olfaction. The sensation of smell occurs when
airborne molecules are drawn into the nasal
cavity.
5. Innate Immunity. It provides protection against some microorganisms by preventing
their entry into the body and by removing them from the respiratory surfaces.
OVERVIEW OF THE DISEASE
The respiratory system plays a vital role in terms of exchanging gases in the body wherein it
brings oxygen to the lungs and disposes carbon dioxide. The air enters the body via mouth or
nose through breathing process. Then, it moves down towards the lungs through the airway. The
airway leads to the chest, where it splits into two – the bronchioli. Each of the bronchioli split
into smaller tubes until they reach the nodes in the lungs. If the bronchioli are blocked, less
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oxygen reaches the lungs, resulting in respiratory problems. The lining of the bronchiole has a
number of glands which secrete mucus.
Brochitis is characterised by an increase in mucus production and damaged cilia in the
bronchi. As a result, the bronchi become clogged with mucus, which continues to stimulate the
airway’s irritant receptors, producing a cough. This chronic irritation causes inflammation and
the bronchial wall thickens, causing airway obstruction.
The lack of functioning cilia makes mucus clearance difficult and as a result, mucus
collects and blocks the smaller
airways. Secondary infections then
occur, causing yet more irritation
and infl ammation. As more and
more airways become blocked,
external respiration is reduced and
less oxygen is transferred into the
bloodstream. The pathophysiological processes behind increased mucus production and cilia
dysfunction are thought to involve an inflammatory response to the constant bombardment by
cigarette smoke (MacNee, 2006).

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Pathophysiology
The pathophysiology of asthma based on the Medical-Surgical Nursing Assessment and
Management of Clinical Problems by Lewis Heitkemper Dirksen.

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ASTHMA
Hypertension (Preeclampsia)
Dyspnea
Constant cough
Tightness in the chest
Heartburn
Getting Flu
Severe rhinitis
Hyperexpansion of the thorax
Expiratory wheezing
Nasal polyps
Figure 1.
The figure Atopic dermatitis or eczema shows the
pathophysiologal of Bronchitis
Clinical Manifestations
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Table 1. This table shows the clinical manifestation of asthma and hypertension during
pregnancy.
Medical Management
In clients with Acute Bronchitis, immediate intervention may be necessary, because
continuing and progressive dyspnea leads to increased anxiety, aggravating the situation. If the
causative agent for the Bronchitis are bacteria, antibiotics will be used.
Drug classes that may be used to treat chronic bronchitis/COPD include:
 Antibiotics to treat worsening coughs, breathlessness, and mucus production
caused by infections.
 Anti-inflammatory drugs, such as corticosteroids (also called steroids), to reduce
swelling and mucus output. Steroids can have many different types of side effects,
including swelling in feet and hands, mood changes, increased appetite and
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weight gain, trouble sleeping, and more serious ones such as diabetes, higher risk
of infections, osteoporosis, and cataracts.
 Bronchodilators to keep muscles around the airways relaxed so that airways stay
open. There are long-acting and short-acting bronchodilators. Short-acting
products are often called rescue drugs because they act quickly, but wear off in a
couple of hours.
 Combination drugs that contain a mix of steroids and long- or short-acting
bronchodilators
Nursing Management
The immediate care of clients with asthma depend on the severity of the symptoms.
 Encourage mobilization of secretion through ambulation, coughing, and deep breathing.

 Ensure adequate fluid intake to liquefy secretions and prevent dehydration caused by
fever and tachypnea.
 Encourage rest, avoidance of bronchial irritant, and a good diet to facilitate recovery.
 Instruct the patient to complete the full course of prescribed antibiotics and explain the
effect of meals on drug absorption.
 Caution the patient on using over-the-counter cough suppressants, antihistamines, and
decongestants, which may cause drying and retention of secretions. However, cough
preparations containing the mucolytic guaifenesin may be appropriate.
 Advise the patient that a dry cough may persist after bronchitis because of irritation of
airways. Suggest avoiding dry environments and using a humidifier at bedside.
Encourage smoking cessation.
 Teach the patient to recognize and immediately report early signs and symptoms of acute
bronchitis.
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Chapter III
Laboratory Results
Name of Patient: XXXX Date:

Address: Sumacab, Cabanatuan City Laboratory/Hematology I
INVESTIGATION FINDINGS UNIT BIOLOGICAL METHOD
REFERENCE
COMPLETE BLOOD
COUNT – HE
AUTOMATED
RBC INDICES: ANALYZER
WITH 5 PART
HAEMOGLOBIN L 10.9 gm/dl 12.00-15.50
RBC COUNT H 5.52 million/cm 3.9-5.03 DIFFERENCE
HAEMATOCRIT/PCV L 34 % 35.00-45.00
MCH L 19.8 pg 27-33
MCHC 32.1 g/dl 32-36
MCV L 61.7 fL 79-99
RDW H 15.7 % 11.9-15.5
TOTAL WBC COUNT:
TOTAL WBC COUNT H 14500 /cumm 3500-10500
WBC DIFFERENTIAL
COUNT:
NEUTROPHILS H 10919 /cumm 1800-7000
Absolute count
NEUTROPHILS: 75.3 %
LYMPHOCYTES 2436 /cumm 900-2900
Absolute Count
LYMPOCTES: 16.8 %
MONOCYTES 711 /cumm 300-900
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Absolute Count
MONOCYTES: 4.9 %
EOSINOPHILS 406 /cumm 50-500
Absolute Count
EOSINOPHILS: 2.8 %
BASOPHILS Absolute 29 /cumm 0-300
Count
BASOPHILS: 0.2 %
IMMATURE % 0.00-0.5
GRANULOCYTES
PLATELET COUNT 202000 /cumm 150000-450000
MPV 9.1 fL 6.5-12
COMMENTS
REMARK
Chest x-ray confirming acute bronchitis

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DRUG STUDY
NAME ACTION INDICATIO CONTRAINDI ADVERSE NURSING

N CATION EFFECT CONSIDERATIO
N
Generic Name: Bactericida It is effective Contraindicated CV Determine history

l agent that for the in Phlebitis of hypersensitivity
Cefuroxime hypersensitive Thrombophleb reactions to
acts by treatment of
to drug. itis cephalosporins,
1.5 g, ANST inhibition penicillinase-
penicillin’s and
Brand Name: of bacterial producing Cefuroxime is GI history of allergies
Zinacef cell wall Neisseria contraindicated Pseudomembra particularly to drugs
synthesis, gonorrhea in patients with neous colitis, before therapy is
known allergy nausea, initiated. Note
promoting (PPNG).
to the anorexia, reason for therapy,
osmotic Effectively cephalosporin
instability. treats bone vomiting, baseline
group of diarrhea assessments. Assess
and joint antibiotics for anemia, renal
infections,
Use with Hematologic dysfunction reduce
bronchitis, dose with impaired
caution in
meningitis, Transient renal function.
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gonorrhea, breast-feeding Inform patient need

otitis media, women and in neutropenia, and importance of
pharyngitis/to patients with eosinophilia, drug to him/her.
nsilitis, history of renal haemolytic,
anemia, Culture infection,
sinusitis, sufficiency. thrombocytopen and arrange for
lower ia sensitivity tests
respiratory before and during
tract Skin therapy if expected
infections, response is not
skin and soft Rash,pruritis, seen. Monitor BUN
urticaria, pain, and creatinine
tissue
sterile abscess, clearance.
infections, temperature
urinary tract elevation, Do skin-test before
infections and induration, administering the
is used for tissue sloughing drug
surgical
prophylaxis, Urogenital Inspect IV Injection
Increased sites for sign of
reducing or
serum cretonne phlebitis
eliminating
infection. and BUN,
Monitor for
decreased manifestations of
creatinine hypersensitivity.
clearance. Discontinue drug
and report their
appearance
promptly.
Monitor I & O rates

and pattern:
Especially
important in
severely ill patients
receiving high
doses. Report any
significant changes.
Tell the client to

report loose stools
or diarrhea
promptly. Avoid
Cabanatuan City
COLLEGE OF NURSING
alcohol while
taking this drug to
avoid severe
reaction.
May experience
these side effects:
Stomach upset or
diarrhea.
Report severe
diarrhea, difficulty
breathing, unusual
tiredness or fatigue,
pain at injection
site.
Generic Name: Inhibits Relief of Hypersensitivit CNS: dizziness, Drug compatibility

acetylcholi smooth y to drug anaphylactic should be
HYOSCINE- ne at muscle spasm contents reactions, monitored closely
BUTYLBROMI in patients requiring
receptor of the anaphylactic
DE Tachycardia adjunctive therapy
site in gastrointestina shock,
(HNBB) automatic l and increased ICP, Avoid driving &
2 amps, ANST nervous genitourinary disorientation, operating
system, systems. restlessness, machinery after
BrandName: parenteral
which irritability,
Buscopan administration &
controls dizziness,
Avoid strict heat.
secretions, drowsiness,
free acids headache, Raise side rails as a
in the confusion, precaution, some
stomach, hallucination, patient become
blocks delirium, temporarily excited
central impaired or disoriented and
muscular memory some develop
amnesia or become
receptors CV:
Cabanatuan City
COLLEGE OF NURSING
which hypotension,
decreases tachycardia, drowsy.
involuntary palpitations,
movements flushing Reorient your client
that tolerance may
. GI: Dry mouth, develop when
constipation, therapy is
nausea, prolonged.
epigastric
distress Atropine-like
DERM: toxicity may cause
dose related adverse
flushing,
reactions.
dyshidrotic Individual tolerance
GU: Urinary varies greatly
retention,
urinary Overdose may
hesitancy cause curare-like
Resp: dyspnea, effects, such as
respiratory
bronchial
paralysis. Keep
plugging, emergency
depressed equipment
respiration available.
EENT:
mydriasis,
dilated pupils,
blurred vision,
photophobia,
increased
intraocular
pressure,
difficulty of
swallowing.
Cabanatuan City
COLLEGE OF NURSING
CHAPTER VI
Evaluation
 Client is a 16-year-old, Filipino, born on February 14, 2004 in Acropolis North,

Sumacab, Cabanatuan City
 Was admitted August 24, 2020 @8AM due to on and off Lumbo Sacral Pain 2 days prior
to admission
 Smokes 11/2 packs of cigarettes per day and drinks moderately.
 Began prenatal care late during the pregnancy and has been inconsistent with
appointments.
 Has a history of respiratory problem in the family
 Had to abort last July 16, 2018 due to ectopic pregnancy
 Her WBC is 14,500/mm3 with this differential: bands, 0%, neutrophils, 75.3%.
 Latest Vital Signs: Temp – 37c, PR- 110bpm, RR- 28cpm, BP- 130/90mmHg, FHT-
142bpm, IE - 6cm
Cabanatuan City
COLLEGE OF NURSING
Findings
 There are abnormalities in the mouth, extremities, chest, lungs, skin, and genital areas.
 Patient has a family history of respiratory problems. Furthermore, risk factors such as
smoking and drinking were also present.
 The pathophysiology and etiology of acute bronchitis of the patient were explored: may
have been due to risk factors (asthma) and/or acquired factors (smoking).
 Diagnosis were formulated after a series of assessment: Ineffective breathing pattern and
Ineffective airway clearance.
 Health teaching about the risk of smoking & drinking, and as well as the importance of
taking prescribed medications, scheduling activities, and breathing & relaxation
techniques were applied.
Cabanatuan City
COLLEGE OF NURSING
RECOMMENDATIONS
The client must be able to recover health and prevent further complications as possible.
This, in turn, will consider having a healthier status – be it physically, emotionally, mentally, and
spiritually. For the patient, recommendations would include but not limited to the following:
Medication
 Antibiotics to treat worsening coughs, breathlessness, and mucus production caused by

infections.
 Anti-inflammatory drugs, such as corticosteroids (also called steroids), to reduce swelling
and mucus output.
 Bronchodilators (inhaled medicines that help open the airways).
 Combination drugs that contain a mix of steroids and long- or short-acting

bronchodilators.
Treatment
 Stop smoking.
 Get plenty of rest and drink plenty of fluids. It may help to disappear more quickly.
 Sleeping near a humidifier or sitting in a steamy bathroom.
Exercise
 Advice the client to do breathing and relaxation techniques and to do passive to active
ROM exercises to help the client return to activities of daily living.
 Avoid lifting and stressful activities.
Health Teaching
 Instruct the client and the family about the risks of smoking and drinking to the health of
client and neonate, the need to take medications as prescribed and check with the
physician before taking any new medication.
Cabanatuan City
COLLEGE OF NURSING
 Remind the client to express any discomfort in order for the health care provider to carry
out certain measures.
 Advise the client to establish direct open communication with her partner and health care
practitioner to link care needs.
OPD Checkup
Instruct the patient to comply with the prescribed medication.
 Remind the client about the follow-up visits and succeeding visits prescribed by the
health care provider.
Spirituality
Interpreting and understanding the diversity of religious and spiritual needs of the client.

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Republic of the Philippines

NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY

In Partial Fulfillment of the Requirement for the

Ariola, Mary Kathleen M

Atienza, Jan Rae B.

Specifically, this case analysis aims to:

and family history

 Understand the pathophysiology and etiology of the case being presented.

 Identify the factors that contributed in the development of the diagnosis.

 Appropriately apply nursing interventions necessary for the patient’s condition in

reference with the learned theories and concepts of the disease.

emphysema, and asthma.

easier for viruses and bacteria to cause infection.

birth, and the need of C-section during delivery.

Address: Acropolis North, Sumacab, Cabanatuan City

Problems at birth: None

Date of Service: July 16, 2018

Status of Present Illness

Head to Toe Physical Assessment

BODY PARTS NORMAL FINDINGS ACTUAL FINDINGS RESULT

SKULL Rounded The head of the client No abnormalities

Evenly distributed hair

No infection or No presence of No abnormalities

Amount of body hair is

External Features The client’s eyebrows

Lids close There are no presence

Transparent, shiny, and

Black in color; equal in There is no edema or

Uncovered eye does not

Able to read newsprint

20/20 vision on Snellen-

ear at the same

Lips And Buccal Client’s lips are

Pink gums (bluish or

Central position Pink Central position, pink

coating Smooth, lateral

Smooth tongue base Client’s uvula

Light pink, smooth, soft Client’s gag reflex is

Muscles equal in size; The neck muscles are

Lymph Nodes The lymph nodes of

spaces are equal on both neck.

The thyroid gland is

Symmetric chest shape The chest wall is

Posterior Thorax and Hoover's sign,

Unblemished skin Unblemished skin No abnormalities

Both extremities are

SKIN Skin is uniform in color,

Pubic skin intact, no

Case Discussion and Presentation

Chemical dependence is defined as the physical and physiological dependence on a substance

placenta previa, premature rupture of membranes, and perinatal mortality.

conditions and congenital effects.

problems it simply outweighs the risk it may cost.

Pharynx - A tube-like structure that connects the

Larynx – It is also known as the voice box. It

Physiology of Gas Exchange

Each alveolus is very closely

The respiratory system assists in gas exchange and