I.

PERSONAL DATA

Name of the client: Felipe Domingo Acob Sr.

Address: 37 Ganagan, Bacarra Ilocos Norte
Hospital Number: 101750
Sex: Male
Age: 71
Date of Birth: October 23, 1938
Place of birth: Bacarra, Ilocos Norte
Civil Status: Married
Religion: Roman Catholic
Educational attainment: Elementary Graduate
Occupation: Farmer
Chief Complaint: Cough and difficulty of breathing
Admitting Diagnosis: Chronic Obstructive Pulmonary Disease in Acute exacerbation
Bronchitis, Pulmonary Tuberculosis Class IV
Date of admission: August 19, 2010
Time of Admission: 11:55 pm
Admitting Physician: Decinna Quilala, M.D./ Emely T. Pumaras, M.D.
Attending Physician: Dr. Lijauco/ Dr. Rasos
Final Diagnosis: COPD exacerbation controlled Bronchitis resolved PTB class IV
Date of Discharge: August 24, 2010
Time of discharge: 4:30 PM

1
III. FAMILY BACKGROUND

Name Sex Ag Civil Relationshi Educational Occupatio Religio Address

e Status p to the Attainment n n

Patient
Felipe Male 71 Marrie Patient Elementary None Catholi 37
Acob y/o d Graduate c Ganaga
Sr. n Doro,
Bacarra
Catalin Femal 65 Marrie Wife High School None Catholi 37
a Acob e y/o d Graduate c Ganaga
n Doro,
Bacarra
Jose Male 50 Marrie Son College Office Catholi Milan,
Acob y/o d Graduate Worker c Italy
Dolore Femal 48 Marrie Daughter College Office Catholi Milan,
s Agas e y/o d Graduate Worker c Italy
Felipe Male 47 Marrie Son College Farmer Catholi 37
Acob y/o d Graduate c Ganaga
Jr. n Doro,
Bacarra
Norma Femal 46 Marrie Daughter College Office Catholi Milan,
Galut e y/o d Graduate Worker c Italy
Helen Femal 44 Marrie Daughter College Office Catholi Milan,
Adina e y/o d Graduate Worker c Italy
Julie Male 24 Marrie Son College Farmer Catholi 37
Acob y/o d Undergraduat c Ganaga
e n Doro,
Bacarra

Acob family is a nuclear type of family. They are living within the vicinity of the father,
thus, considered to be patrilocal type of family. The family is oriented with both the mother and
2
the father’s kin, thus, they are bilineal type of family. With regards to decision making, the
family is an egalitarian type of family where in both the father and mother makes the decision.

Mr. and Mrs. Acob participate in barangay activities such as Oplan Dalus. For other
activities such as fiestas and other assemblies they are not that active. The family have
misunderstanding sometimes like when Tata Felipe insists to work even though they tell him
not to work because of the fact that this may aggravate this condition (collecting fire woods)
but it is easily resolved “When we argue about such things, my wife gives me a cold shoulder
but after an hour, she talks to me again like nothing happened”, as added by Tata Felipe. Mr.
and Mrs. Acob are the only ones who are living in their family house since their children
already have their own families. The family has a good relationship and they communicate
properly. They communicate through phone calls and letters with their children abroad.
Reading magazines, listening radio, watching television, gardening and chatting to their
neighbours are their leisure time.

Mr. and Mrs. Acob don’t have monthly allowance on their own since they do not have
job at present. Mrs Acob claimed that they depend on their children for their financial needs
since they are already old to work. Their children working abroad send them money every
month. They receive a total of 10,000 a month. Each of their children contributes Php. 2,500.
According to Mrs. Acob, she is the one who decides for the allocation of their monthly
allowance. The amount is allocated mainly for their needs and is broken down as follows; Php
3000 is allotted for food and groceries with toiletries, Php 500 each are allotted for
transportation and electricity, Php 1000 is for miscellaneous expenses such as sudden illness or
hospitalization, load and magazines, Php 180 is spend for drinking water and Php 1820 is their
savings. Php 1000 is also allocated for medicines like Dulcolax, Ventolin and their multivitamins.
According to Mrs. Acob, their monthly allowance is enough to meet their daily necessities for
living.

3
 FOOD (w/ groceries and toiletries)-3000

MEDICINES---------------------------- 3000

SAVINGS-------------------------------1820

MISCELLANEOUS---------------------1000

TRANSPORTATION-------------------500

ELECTRICITY---------------------------500

WATER(mineral water)-------------180

monthly budget
2%
5%
5%
30% food
10% Medicines
savings
miscellaneous
electricity
transporatation
18% water

30%

IV. HEALTH HISTORY

A. Family Health History

Nana Catalina, the wife of our patient revealed that the family had experienced having
coughs, colds, and fever during extreme temperatures, muscle aches, toothache, headache and
stomach aches. Such minor discomforts are usually managed with over- the- counter drugs such

4
as Solmux 500 mg PC until the symptoms will subside for cough, Neozep 500 mg PC for colds,
Biogesic 500 mg PRN for fever, Mefenamic Acid 500 mg PRN for headache, Alaxan 500 mg PRN
for body pains, and Kremil-S 500 mg or Lomotil 2 mg both PRN for stomach ache; as claimed by
Nana Catalina. The family had experienced some infectious and communicable diseases such as
chicken pox, measles, mumps and sore eyes. They usually manage chickenpox thru bed rest
and by exposing the sick child to the smoke of burnt onions when lesions are healing. For
measles, they would let the member wear any black clothes for they believe that this will lessen
the itchiness and for mumps they would apply “akot-akot” mixed with vinegar on the affected
area. For other managements of diseases, he mentioned bed rest, adequate intake of nutritious
foods such as vegetables and enough sleep as their health habit practices.

They also utilize herbal medicines like oregano decoction, kutsay extract and guava
extract. They would use the oregano decoction for cough, kutsay extract for wounds and the
guava leaves for washing and cleansing wounds. As added by Tata Felipe, they do not usually
consult to the Bacarra health centre; instead, they go straight to tertiary hospital like MMMH &
MC whenever the condition of one family member’s health is severe or it worsens.

Mata Acob, grandmother of our client on paternal side had asthma but Nana Catalina
(wife of our client) do not know if she was diagnosed, who diagnosed her and what were the
managements done to her. As claimed by Nana Catalina, Mata Acob was a heavy smoker, and
she can consume 10 tobacco sticks a day. Nana Catalina added that she was the one who
taught our client to smoke when he was just grade 5. Apolinario Acob, husband of Mata Acob
died because of complications of old age. Apolinario Acob and Mata Acob were blessed with 12
children; unfortunately Nana Catalina can only remember 3 of them namely; Kolas Acob, Pilo
Acob, and Juan Acob. All of them already died because of complications of old age.

Santan, grandmother of our client on maternal side, died already because of

complications of old age. Santiago, husband of Santan died because of complications of old age.
They were blessed with 3 children, namely; Ferming, Dorothea and Crispin Domingo. They
already died because of complications of old age.

5
 Juan Acob and Dorothea Acob, parents of our client were blessed with 6 children.
Milagros Ancheta, 62 years old, Marta, 64 years old, residing now at Mindanao, Lory Bagaoisan
66 years old, residing at Hawaii, Susima Bagaoisan 70 years old, Maria Garcia died at the age of
69 years because of bone cancer but they cannot remember any informations regarding the
disease and Felipe Acob our patient who was diagnosed with COPD last August 19, 2010.

As for their immunizations, Nana Catalina is not sure if they received any and Tata
Felipe did not have any scar that would reveal that he have received his BCG vaccine. According
to Nana Catalina their children completed all their immunizations.

He stressed out that they do not believe in ghosts, bad spirits, witchcraft, and quack
doctor. But he stated that he often consults to ”manghihilot” whenever there are sprains and
muscle aches and he claimed to be effective.

B. Past Health History

Tata Felipe already experienced having common illnesses such as cough, fever,

headache and toothache as claimed. These were managed through taking in over the counter

drugs such as Solmux for cough, Paracetamol for fever and headache and Mefenamic acid for

toothache.

Infectious diseases he encountered during his childhood were the following: measles,

chickenpox and mumps. No medical consultation done, instead they treated it by taking in

Paracetamol to relieve fever and they let the smoke of garlic and onions with a charcoal in a pot

to their body to relieve itchiness for chickenpox. When he had his mumps, his mother topically

applied “akot-akot” on the affected site. Tata Felipe did not undergo any minor or major

operations except for circumcision when he was in grade four.

6
 According to Tata Felipe, he had no allergies to food or to drugs. He prefers eating

vegetables and meat especially internal organs like liver. As claimed, He began smoking at a

very young age which actually at grade 5. His Lola taught him to try tobacco whenever he goes

home after school. He begun to consume 2-3 sticks a day at age of 13 and gradually increase to

8-10 sticks during high school years. As became older, he could already consume as much as 1

pack of cigarettes until his mid 40’s. On the other hand, he also started drinking liquor such as

GSM Bilog and beer when he was 14 y/o consuming 2-3 bottles of each every week. He,

together with his friends drinks occasionally.

C. PRESENT HEALTH HISTORY

In the year 1972, when he was 42, he experienced and complaint difficulty of breathing

which prompted him to have a check up at their Health Center. He had undergone x-ray and

diagnosed with asthma. Tata Felipe can no longer remember the doctor who attended him but

he was given take home medications which he took in preventing his asthma attacks but he

doesn’t remember the medications given to him.

Two months past, he was rushed to Ranada General Hospital when he suffered again

from difficulty of breathing. He was diagnosed to be an asthma case again and was given

Ventolin inhaler and other unrecalled medicines. As far on what his wife remembered, he was

confined for 3 days. When he suffers from the above symptoms or from asthma attacks, he no

longer sought consultation to any medical facility, instead, the family buys Ventolin inhaler to

relieve difficulty of breathing and Solmux for cough with their current prescription.

7
 In year 1990 of December, Nana Catalina decided to let her husband consult to Doctor

Reyes Clinic. She was alarmed seeing her husband expectorates phlegm, rusty in colour and

vicious when coughing and sweats mostly at night even in cold season. Nana Catalina knew

about Dr. Reyes since she read several articles written by the said doctor on Bannawag which

talks about asthma and other lung disorders. And so Tata Felipe together with his wife agreed

to go at Dr. Reyes Clinic in Ilocos Sur. Tata Felipe had a sputum examination, he was instructed

to collect 1 sputum specimen in the morning and 2 specimens were collected in the clinic. Dr.

Reyes also examined Mr. Acob’s X-ray according to him. His sputum examination and X-ray

reveals that he was positive of pulmonary tuberculosis. As for treatment, he was prescribed to

take Rifampin, Pyrazinamide and Isoniazid pyridoxine for 6 months. When asked about the

dosages, they could no longer remember it. Dr. Reyes made a referral letter saying about Tata

Felipe’s condition to Bacarra Health Center so that those medicines would be given for free.

Tata Felipe revealed that he did not take the medication religiously for 6 months because

sometimes he would forget to take or, “if we run out of medicines, sometimes we don’t have

time to go and get from the health center and, we didn’t continue it since I’m feeling better

then” as claimed. 1991 Tata Felipe went back to the Health Center for check-up after 6 months

and his examinations revealed that he is still positive of PTB, he was again given another 6

months treatment with an additional medication which is Ethambutol. According to Tata Felipe

he religiously took the medication until 6 months and when they went for another check-up for

evaluation, his PTB was already resolved. Tata Felipe was so happy and thankful

He continued to work as a farmer. But had asthma attacks especially during cold

seasons as well as when triggered by irritants such as dust, smoke and fumes as claimed. His

8
asthma was not really that serious as he verbalized since medications can just relieved it

(Ventolin Inhaler, Solmux).

Because of his condition, his family advises him to quit smoking and drinking liquor.

It was also told by his doctor before that smoking can expose him to more severe disorders.

Tata Felipe didn’t deny that once in while he still taste a bit after which but he emotionally

expressed that he made an effort to stop it for the sake of his children and to have a longer life

together with his family. Though it is difficult in his part; he successfully quitted such vices in a

gradual manner.

Upon waking up in the morning of August 17, 2010 he experienced sudden dryness and

itchiness of throat and finally ending up to productive cough. As his cough progresses,

shortness of breath had been developed “it is hard for him to breath and he complaints of the

sound of rales he was experiencing” as verbalized by Nana Catalina. He thought that this was

just brought by weather changes and exhaustion from doing house hold choirs such as cleaning

the backyard. At first, he does not sought consultation with the thought that he again had been

attacked by asthma. He had taken medicines previously prescribed by a private physician such

as Ventolin inhaler and Solmux. He gained temporary relief from those drugs. Nana Catalina

also added that his husband was sneezing caused maybe by frequently taking a bath just after a

perspiring work and weather changes so she bought Neozep Forte (500mg) as management of

cold which he took every 4 hours. However, as days pass by, his cough became recurrent and

persistent. On the evening of august 19, 2010, he suffered from difficulty of breathing and

severe coughing. He was immediately rushed to the Mariano Marcos Memorial Hospital and

9
Medical Center at exactly 11:55 PM with an admitting diagnosis of COPD in acute exacerbation

bronchitis, PTB Class IV. He was admitted by Dr. Quilala and Dr. Pumaras.

V. DEVELOPMENTAL DATA

Erickson’s Theory of Psychosocial Development

Erickson’s Theory of Psychosocial Development

It is necessary to study the development of a person to be able to understand the responses
that are seen in the client in certain circumstances or situations. One theory that had been
devised to do such study is the Psychosocial or Emotional Development by Erik H. Erickson. He
believes that maturation of bodily functions is linked with expectations of society and culture in
which the person lives. According to him, in each stages of a person’s emotional development,
there are particular changes, which he called crisis that exists for a healthy development to
occur. When needs are met, a healthy or positive personality is developed and the individual
moves to the future stages with particular strength; but if not, an unhealthy outcome occurs
which will influence future relationships.

Erickson identified Ego Integrity versus Despair as the developmental stage to be

achieved during the Late Adulthood (60 years old and above) in which our client belongs. He
said that ego integrity suggest an acceptance of one’s lifestyle and a belief the choices made
where the best that could be made at a particular time. Into our client, he accepts this stage by
showing a positive attitude instead of grumping feature when talking of his old age.

Despair, the opposite of ego integrity, implies that the older person feels dissatisfied
and disappointed with his or her life and if given another chance the person would live life
differently. It is being manifested by our client by longing for his drinking sessions and smoking
cigarettes.

In this span of age, the client is expected to feel good about his choices in life, and self
acceptance of the inevitable death and the acceptance that his ability to contribute to the
community is minimized. On the other hand, our client is not expected to wish life could turn

10
out differently as with him now, to be angry of the aging bodies, and withdrawn from the
society.

Tata Felipe, 71 y/o is in his late adulthood stage with the central task of achieving Ego
Integrity vs. Despair. Tata Felipe feels good about his past life choices. He was able to form a
family and commit himself to his own responsibilities. And now that his children are all happily
married, still Tata Felipe never failed to be the good father to them. Towards his wife, Tata
Felipe has maintained same warmth or sweetness and a good relationship. They also quarrel at
times but the conflict does not last long because they would immediately settle it.

Tata Felipe belongs to certain organization in their barangay such as the Senior Citizen
Club, when he was still younger he would attend to Barangay Fiestas and Oplan Dalus. He also
stated that they won as the cleanest house in their barangay last 2008.

He is also regarded as a good neighbor and a good person because he knows how to
help others and he knows how to get along with them.

The negative indicators such as a person’s feeling of dissatisfaction and disappointment

with his life and if given another chance the person would live life differently is not seen to our
client.

He said that he accepts the changes of his physical stature and that death is inevitable.

Analysis: Based from his accomplishments over the years, Tata Felipe could be said to be
manifesting the indicators of a positive resolution such as satisfaction with his life and the
decisions and acceptance of the inevitable death.

Havighurst’s Theory of Developmental Task

Havighurst’s theory of Developmental Tasks states that learning is essential to life and
that to understand growth and development; one must understand and accept the premise
that the human being continues to learn throughout life. Effective learning and achievement of

11
tasks during one period leads to happiness and success with later task while failure leads to
unhappiness, disapproval by the society and difficulty with later tasks.
Tata Felipe belongs to Havighurst’s age group of Later Maturity wherein he is expected
to develop tasks like Accepting and adjusting to decrease physical strength and health Tata
Felipe already accepted and adjusted himself to his decreased physical strength and health. He
admitted that his activities now are no longer like his activities when he was still younger and
stronger. He also told us that these changes in strength and health are just normal to aging
people. Adjusting to retirement and lower income Tata Felipe long decided to stop doing
farming for he can no longer be productive with his work and his health can be worsen if he still
do strenuous activities. He has already retired and just stayed mostly in their home, and
enjoying the company of his wife. Even if he already retired from farming, he doesn’t worry in
terms of financial terms for his children sends their income. Though his income is no longer like
of that when he was still farming, he already adjusted to a lower income and accepts it since he
and his wife also spends lesser now. Aging and inevitable death of age and spouse When we
asked Tata Felipe if he already accepted aging and death, he gladly told us that it is just a
normal part of living and that also includes death. As much as he wanted to return to his youth,
he also looks forward about the life that is to come after death. Establish Affiliation with Age
Group Despite of his age, he still maintained a relationship with the people, especially his
friends who are at the same time belongs to his age group, they still have conversations yet it is
not as often as it was of the past since they no longer see each other’s often. Meet Social and
Civic Obligations, Even if Tata Felipe is now old, he makes sure that his social and civic
obligations are still met, such as exercising his right to vote. And during the 2010 National
Elections he voted and was delighted and accepted the new system of voting. He told us that
these are the things that he can never grow old with. Live in Satisfactory Physical Environment,
Being with his wife in their home, they maintain their physical environment with its cleanliness
and their community is also composed of a good environment. He was also satisfied with the
peacefulness of their community and his environment.

12
 Analysis:

Based from his accomplishments over the years, Tata Felipe could be said to have
achieved the expected tasks like practicing his rights to vote, satisfaction with his physical
environment and peacefulness of the community and acceptance of the inevitable death.

VI. Patterns of Functioning

Patterns of Before Illness During Illness

Functioning Before Hospitalization During Hospitalization

Eating The patient was Before hospital admission, he During his stay on hospital

diagnosed of COPD on usually eats the same foods he can consume all the

August 19, 2010. Prior as that mentioned in before hospital rations served for

to this, he claimed illness as long as they are well each meal which consist of

that he eats three cooked and prepared such as one serving for meat and

times a day and have nilagang baka (1/2-1 bowl), vegetable and one cup of

snacks in between. pancit (1 serving) and rice. He was on DAT diet. His

sinabawang gulay with meat snacks usually consist of

He usually eats his
(1 serving). He only can only fruits such as apples and
breakfast between
consume half of the food he oranges.
6:00-6:30 AM, lunch
was eating before illness.
at 11:00-11:30 AM, He eats his meal around 6

and dinner at 6:30- He eats his meal, 6:00-6:30 AM for breakfast, 11:30-

7:00 in the evening. AM for breakfast, 11:00- 12:30 PM at lunch and as

13
He prefers to eat 11:30 AM at lunch and 6:30- early as 5:30-6:00 PM for his

meat especially 7:00 for dinner. dinner.

nilagang baka (1/2-1

His snack usually consists of
bowl), he also like
native delicacies like suman-
pancit (1 serving) and
latik, banana cue, and
sinabawang gulay
ginataan. According to him he
with meat (1 serving).
doesn’t have any allergies to
He doesn’t like to eat
food.
foods that have bland

taste and no additives

and also raw foods

like kinilaw. He usually

consume 1- 1 1/2 cup

of rice each meal.

His snack usually

consists of native

delicacies like suman-

latik, banana cue, and

ginataan. According to

him he doesn’t have

any allergies to food.

14
 Analysis: There was a change on the eating pattern of the patient before illness and before

hospitalization due to difficulty of breathing. However when he was confined at the hospital, his

appetite increases as manifested by consuming all the rations served.

Patterns of Before Illness During Illness

Functioning Before Hospitalization During Hospitalization

Drinking He claimed that he He already discontinued During hospitalization, he only

drinks upto 9 glasses drinking alcoholic beverages. drinks water with an amount of

(250mL/glass) of He can consume 2250 mL of 600-1000 mL in a day.

water per day. He also water in a day. He also drinks

like to drink alcoholic 1 glass of tea (320 ml)

beverages like gin whenever he feels

(bilog) which he constipated. His total fluid

consume upto 2 intake for 24 hours was

bottles per week and approximately 2,250- 2,570

sometimes beer which ml.

he can consumes 3

bottles in a week. He

doesn’t like to drink

beverage that is

sweet. He also drinks

1 glass (320 ml) of tea

15
 when he feels

constipated. He

doesn’t have any

allergies to beverages.

All in all he can

consume

approximately 2,570-

2,850 ml/day.

Analysis: There was a change in the drinking pattern of the patient before illness and before

hospitalization since the patient discontinued drinking beer and gin, this is associated with the

presence of his ailment. There is also change during hospitalization due to decrease intake of

water because he is confined to bed.

Patterns of Before Illness During Illness

Functioning Before Hospitalization During Hospitalization

Bladder He voids 3-5 times a Since Tata Felipe stop drinking He voids 2-3 times a day with

Elimination day. Usually, he alcoholic beverages, his an approximate amount of

urinates once in the bladder elimination is the 1200-1500 mL. Urine is

morning after he same as when they do not characterized as yellowish to

wakes up, in the have drinking session (3-5 clear, no offensive odor.

afternoon and before times). His urine output is

16
 bedtime. He claimed approximately 1800-2000 ml/

that his urine color day.

was yellowish to clear,

no foul odor,

bubbling, and the

duration during

voiding is not the

same.

Analysis: There was an alteration in bladder elimination as to frequency and amount before

illness to during illness attributed to the discontinuation of drinking alcoholic beverages.

However, during illness (before hospitalization) comparing during hospitalization, there was a

decrease in bladder elimination secondary to increase insensible losses due to the respiratory

tract.

Patterns of Before Illness During Illness

Functioning Before Hospitalization During Hospitalization

Bowel Our client defecates He claimed that he defecates He claimed that he only

Elimination once a day. As to the the same before illness. As to defecated on the day of

17
 characteristics of his the characteristics of his discharge. He doesn’t use

feces, he describes it feces, he describes it as Dulocolax anymore because

as brownish in color, brownish in color, aromatic, of the unavailability if the

aromatic, and its and its consistency is soft. He drug. As to the characteristics

consistency is soft. He feels constipated sometimes of his feces, he claimed that

feels constipated and defecates early in the it’s the same before illness

sometimes and morning around 3 AM. which is brownish in color,

defecates early in the and its consistency is hard.

morning around 3

AM.

Analysis: There was a change in the bowel elimination during illness (before hospitalization) to

during hospitalization due to the decrease activity and because he didn’t use any Dulcolax.

Patterns of Before Illness During Illness

Functioning Before Hospitalization During Hospitalization

Sleeping Our patient sleeps at He sleeps and wakes up the He sleeps at 10-11 PM and

8:00-9:00 PM and same time at 8:00-9:00 PM wakes up around 5-7 AM. He

wakes up at 4:30-5:00 and wakes up at 4:30-5:00 AM claimed that he is disturbed

18
AM. He claimed that before hospitalization but he is during his sleep because of

his sleep was not more frequently awakened the nurse’s routine. He uses 1

continuous and the not like before illness. He pillow on his head. He didn’t

duration is 8 hours. frequently awakes because of apply gas and oil before

His bed time rituals profuse sweating. He still bedtime. He also takes a nap

include watching TV applies gas and oil before for 1-2 hours.

for 1-2 hours and wearing sock at bedtime, he

reading magazines uses 1 pillow on his head and

until he feels sleepy. 1 on his side and uses

He also takes a nap mosquito net.

for 1-2 hours. All in all

he sleeps 9-10 hours

in a day. He utilizes 1

pillow on his head and

1 on his side. He also

applies gas and oil

before wearing socks

at bedtime and uses

mosquito net.

19
 Analysis: There is a change in the sleeping pattern before hospitalization to during

hospitalization due to the new environment and nurse’s routine (vital sing’s taking and giving

medication).

Patterns of Before Illness During Illness

Functioning Before Hospitalization During Hospitalization

Bathing He takes a bath twice He claimed that he do his Sponge bath was rendered by

a day, once in the usual bathing the same her wife once in the morning

morning and before before illness such as using and before his bedtime.

he sleeps. He prefers herbal leaves, prefer warm Sometimes his daughters do

to use warm water. water, and utilize stone as her wife’s activities.

He uses a pail of body scrub. He uses a pail of

water, Safeguard soap water, Safeguard soap and

and Sunsilk shampoo Sunsilk shampoo.

and uses stone that

serve as body scrub

during bathing. He

also uses herbal

decoction such as

“lagundi” and

“sambong” leaves

that he apply after

20
 scrubbing for soothing

effect.

Analysis: There was a change in the in the bathing pattern of our patient during illness, before

hospitalization and during hospitalization due to the environment (dirty CR and it’s availability)

and presence of IV fluid prior to his confinement.

VII. LEVELS OF COMPETENCIES

PHYSICAL

Before Illness During Illness

Before Hospitalization During Hospitalization
Our client’s daily routine The daily routine of our client Tata Felipe can no longer do
includes different kinds of still includes eating, sleeping, he’s usual activities such as
activities such as eating, and bathing. But he cannot eating, and bathing without
sleeping, bathing, feeding do these without assistance assistance of his wife. Because
their pets at home and of his wife. By this time, he Tata was easily being
working at the farm. Even can no longer also do feeding exhausted when he does these
though he’s on the stage of their pets at home and things. He doesn’t take a
late adulthood, he can still working at the farm because whole bath during his 4 days of
perform these things without of easy fatigability and the confinement but nana Catalina
any assistance or any assistive presence of difficulty of rendered him only Partial
devices. He also performs breathing. Bath. He spend most of his
household chores like time on lying on bed, reading
washing the dishes and magazines and chatting with
cleaning their house. He does his wife and to those who

21
 these activities without being visits him.
exhausted.

Analysis: There was a change in the physical competency of our client because of the
discomforts such as difficulty of breathing and easy fatigability he is suffering.

Before Illness During Illness

Before Hospitalization During Hospitalization
As claimed, Tata Felipe is a According to Nana Catalina, As we observed, Tata Felipe is

cheerful one. However, nana Tata Felipe is still cheerful. a cheerful person. But there

Catalina added that he is not Tata Felipe told us that he are times that he gets irritable.

a type of person who is can do anything he wanted He sometimes shouts to the

expressive. As verbalized by when he was at home which nurses. According to him,

Nana Catalina, “I just can is of his comfort. According to when the nurses administer

sense what my husband feels him, when he doesn’t feel medications in the night while

even if he won’t tell me”. well, he tried to suppress it, he is sleeping, he doesn’t want

When they quarrel, Nana but nana Catalina can sense to be disturbed.

Catalina will just scold him his discomforts.

and Tata Felipe will stop

arguing.
EMOTIONAL

Analysis: There was a change in the emotional competency of Tata Felipe because he became
irritable due to the presence of his illness.

22
SOCIAL

Before Illness During Illness

Before Hospitalization During Hospitalization
Tata Felipe is a friendly type He maintains a good Even if tata Felipe have only
of person. He has a good relationship with other few people to interact with, he
relationship with his relatives people. He can still go out still maintained his social
and other people in their from their house and chat competency by having a
community. Whenever he has with their neighbours but respecting relationship with
nothing to do in their house, unlike before, he rarely does his room mate. He often has a
he goes out and chats with it. good conversation with the
their neighbours. He is kind to people around him and his
them and he knows how to fellow patient.
help them whenever they
have problems. He also
stated that he doesn’t have
any enemies in their
community.

Analysis: There were changes in the social competency of our client since he still interact with
other people in a good manner.

MENTAL

Before Illness During Illness

Before Hospitalization During Hospitalization
Tata is a person who easily During the course of illness Tata Felipe can still
understands of what is being he could still comprehend of comprehend what is being
explained to him. He is well what is being explained and explained to him. He is still
oriented about events, time, being told to him. He can still well oriented about the time,
place, person, and what is decide on things on his own. place, person and the things

23
 happening around him. In happening about him. And
terms of decision making on during our interview, he
such things like for the answers our questions
welfare of their family, he can appropriately such as where
decide on it. he lives and what date is their
anniversary.

Analysis: Tata Felipe’s mental capacity to comprehend and retain information and make
decisions did not change before and during illness. When we asked him questions, he
answers it appropriately and correctly.

SPIRITUAL

Before Illness During Illness

Before Hospitalization During Hospitalization
He rarely goes to church Tata Felipe’s faith is still Our client’s faith was still the
because their house is too far strong. When we have asked strong as what he claimed it to
from their church. He has a him if he still prays, he be. He told us that he always
strong faith to God and claimed that he does. He pray to God when he wakes up
according to him, prays upon waking up in the in the morning, before eating
“eventhough i don’t attend morning, before he eats his his meals and before he will go
the mass i never forget to meals and before he goes to to sleep.
pray”. He claimed that he sleep. He affirmed that he
prays upon waking up in the still believes in God despite
morning, before he eats his his illness.
meals and before he goes to
sleep.

Analysis: There was no alteration in the spiritual competency of our client since his faith to God
remains before he got ill and during the course of his illness.

24
VIII. PHYSICAL ASSESSMENT

General Appearance:

During the day of physical assessment, our client is wearing a yellow sando and a
white printed pajama. He is neat in appearance, with a brown complexion. His hair is well
combed. He has an IV fluid of D5NM inserted as venoclysis regulated at 27-28 gtts/min was
intact on his left basilic vein. He has a noticeable barrel chest. His body built is considered as an
ectomorph. He was cooperative during the assessment.

Height: 174 cm BMI: 20 kg/m2

Weight: 60 kg

Date of Assessment: August 20, 2010 Time of assessment: 3:00 PM

Vital Signs:

BP: 120/70mmHg, in sitting position, taken at right arm

PR: 81 bpm, regular in rhythm

Temperature: 36.5˚C per axilla

RR: 25 breaths per minute, regular in rhythm

Head:

- Normocephalic, round and proportional to the body

- Hair is evenly distributed, with presence of white hair, thick, smooth and resilient
- No discolorations, lesions or itchiness, no dandruff on the scalp
- Facial features are found to be symmetric
- No involuntary movements noted

25
Eyes

- Almond shaped
- Eyebrows are evenly distributed, thick and with few white hairs
- Eyelashes are short, thin and evenly distributed
- Eyelids are wrinkled
- With noticeable eye bags
- Pale conjunctiva, smooth, no lesions found
- Cornea are opaque, moist and with reports of blurry vision on his left eye
Grade of eyeglass: 2.5
- Iris found to be round and black in color
- PERRLA (Pupils Equally Round and Reactive to Light and Accommodation)
- Has good ocular movement-able to move eyeballs from left to right, up and down

Ears

- Same color with the other parts of the body

- In line with the outer canthus of the eye
- Bean shaped, attached earlobe
- With minimal cerumen
- With a good hearing acuity- able to reiterate the words we uttered to him in a soft voice

Nose

- Same color with the face

- No nasal discharges noted
- High bridged nose
- Pinkish nasal mucosa
- With patent nares
- No swelling observed around the nose

26
Mouth and Throat

- Lips has symmetrical contour, pinkish in color but somewhat brownish at the edge
- Lips are smooth and moist in appearance
- Pinkish tongue
- Able to move tongue left to right, up-down, in-out
- Buccal mucosa is pinkish, smooth in appearance, with no lesions noted
- Gums are pinkish, no lesions, no bleeding found and veins are slightly visible
- No tooth is present at the upper part (he uses dentures)
- Lower part has 5 teeth- yellowish and blackish in color and with carries
- Hard palate appears bony and whitish while soft palate appears pinkish
- Uvula positioned in the midline of the soft palate, pink in color
- With visible veins on the buccal mucosa

Neck

- Same color with the other parts of the body

- Skin is wrinkled and sagging
- Trachea palpated in the midline
- Has normal range of motion-able to flex and hyperextend
- No engorgement of the neck vein

Chest

- Symmetrical
- Has lighter color than the other parts of the body
- Areola are round and black in color
- Nipples are symmetrical in color
- With a Barrel chest;
AP diameter: 17cm
Transverse diameter: 15cm

27
 - With normal lung expansion
- With hyperresonant sound upon percussion
- With a cardiac rate of 82 bpm- regular in rhythm
- With abnormal breath sounds(wheezes) - lower lobe of the lungs
- With a RR of 25 breaths per minute- regular in rhythm

Abdomen

- Lighter in color than the other parts of the body

- Slightly protruberant
- With normoactive bowel sound
RUQ- 7 LUQ- 8
RLQ- 8 LLQ- 8
- With tympanitic abdominal sound upon percussion

Upper Extremities
- Symmetrical in size and color
- With hanging shoulders
- Same color with the other parts of the body
- No tenderness, lesions, deformities noted
- With heart shape tattoo on the left forearm; about 2 inches in size
- With sagging skin on the arm
- With poor skin turgor
- IV line inserted at left basilic vein
- With a pulse rate of 81 bpm- regular in rhythm in both peripheral pulses
- With good capillary refill of 2 seconds
- With a good range of motion-able to adduct and abduct arms without restriction
- With pinkish nailbeds
- With short clean nails
- With good muscle strength

28
 - Blood pressure taken at the right brachial artery
: 120/70 mmHg

Lower Extremities

- Symmetrical in size and color

- Same color with the other parts of the body
- No tenderness, lesions, deformities noted
- With good capillary refill of 2 seconds
- With poor skin turgor
- With a good range of motion-able to adduct and abduct legs without restriction
- With pinkish nail beds
- With short clean nails

IX. On- Going Appraisal

IX. On- Going Appraisal

August 21, 2010

1st day appraisal

Tata Felipe was seen lying on bed in supine position with an IVF of D5NM 1L @ 500 cc
level regulated to 27-28 gtts/min inserted at right basilic vein, infusing well. He complains of
back pain and wheezes every time he breathes. Tata Felipe has a productive cough with
yellowish sputum. He also reported having difficulty of getting sleep. The client was seen by
Dr. Lijauco with new orders made such as to continue meds (Salbutamol + Fluticasone 50

29
mg/250 mg diskus inhalation BID, MV+Buclizine 1 cap OD and decrease Salbutamol +
Ipratroprium Neb to every 6 hours). Nebulization was done at 6 pm.

Tata Felipe is on DAT with strict aspiration precaution and was able to consume all of his
hospital rations served for breakfast, lunch and dinner. His vital signs were taken and
recorded as follows:

Body temperature (°C) 36.2 – 36.6

Blood Pressure (mmHg) 110-120/70-80

Pulse Rate (beats/min) 80-88

Respiratory Rate (breaths/min) 22-28

Tata Felipe had partial bath this assisted by his wife.

His I and O for 24 hours monitoring were: for the 3-11 shift, his Clysis was 400 cc, oral
intake of 300 cc and output of 380 ml. For 11-7, his Clysis was 400 cc, oral intake of 200 cc
and output of 380 ml and for the 7-3 shift, his Clysis was 100 cc, oral intake of 300cc and
output of 400 ml.

Over all, his total Clysis was 900cc, oral intake of 800 cc and urine output of 1160 ml. he
urinated three times and did not defecate

August 22, 2010

2nd day appraisal

Tata Felipe was seen sitting on the bedside with an IVF of D5NM 1L at 400cc level
regulated to 27-28 gtts/min. He is active in appearance. There were no back pains noted but
he has still wheezes every time he breathes. He has still productive cough and yellowish

30
sputum and still with complains of difficulty in getting sleep. The client was seen by Dr.
Lijauco with new orders made such as to continue the meds (Budesonide every 12 hrs, N-
acetylcysteine 200mg sachet in ½ glass water BID , Salmeterol + Fluticasone 50 mg/250 mcg
diskus inhalation BID, MV+Buchizine 1 cap OD, Salbutamol + Ipratropium Neb every 6 hours,
and Hydrocortisone 100 mg IV every 8 hours).

Tata Felipe is still on DAT with aspiration precaution and was able to consume all of his
hospital rations for breakfast, lunch and dinner.

His vital signs were taken and recorded as follows:

Body temperature (°C) 36.2-36.8

Blood Pressure (mmHg) 120/70-80

Pulse Rate (beats/min) 80-88

Respiratory Rate (breaths/min) 24-28

Tata Felipe had a partial bath assisted by his wife. He was awake most of the time and
took two one-hour sleeps in the morning and afternoon.

His I and O for 24 hours monitoring were: for the 3-11 shift, his Clysis was 400 cc,
oral intake of 300 cc and output of 380 ml. For 11-7, his Clysis was 400 cc, oral intake of 200
cc and output of 380 ml and for the 7-3 shift, his Clysis was 100 cc, oral intake of 300cc and
output of 400 ml.

Over all, his total Clysis was 900cc, oral intake of 800 cc and urine output of 1160 ml. he
urinated three times and did not defecate

August 23, 2010

31
3rd day appraisal

Tata Felipe was seen lying on bed with an IVF of D5NMiL at 900 cc level regulated to
KVO. He is active in appearance and still complains of wheezes each time he breathes. Tata
Felipe has productive cough and with complaints of unable to sleep. The client was seen by
Dr. Rasos at 4:45 pm with new orders such as to facilitate spirometry but he refused, and
IVF to consume and shift to heplock.

Tata Felipe is still on DAT and was able to consume all of his hospital rations served for
breakfast and for lunch.

His vital signs were taken and recorded as follows:

Body temperature (°C) 36.1-36.5

Blood Pressure (mmHg) 130- 110/70

Pulse Rate (beats/min) 60-88

Respiratory Rate (breaths/min) 22-25

He took a partial bath again with the help of his wife. He was awake most of the time
reading magazines and chatting to his wife and his roommate.

His I and O for 24 hours monitoring were: for the 3-11 shift, his clysis was 250 cc, oral
intake of 300 cc and output of 420 ml. For 11-7, his clysis was 200 cc, oral intake of 200 cc
and output of 380 ml and for the 7-3 shift, his clysis was 450 cc, oral intake of 250cc and
output of 400 ml.

Over all, his total Clysis was 900cc, oral intake of 750 cc and urine output of 1200 ml. he
urinated three times and did not defecate

August 24, 2010

4 th day appraisal

32
 Tata Felipe was seen sitting on bedside chair with heplock at right cephalic vein. He is
conversant and still with complains of wheezes but it is minimized compared to the
previous days. The client was seen by Dr. Lijauco at 1:30 pm with new orders made such as
MGH and prescribed with take home meds (Salmeterol + Fluticasone 50 mg per 250 mg
diskus inhalation BID, Salbutamol + Ipratroprium Nebule PRN if DOB, Levofloxacin 750 mg 1
tab OD for seven days) and for follow check up at OPD on September 2, 2010. Tata Felipe is
still on DAT and was able to consume all of his hospital rations for breakfast and for lunch.

His vital signs were taken and recorded as follows:

Body temperature (°C) 36.3-36.7

Blood Pressure (mmHg) 130-110/90-70

Pulse Rate (beats/min) 80-72

Respiratory Rate (breaths/min) 24-28

He was able to take a full bath today but still with the assistance of his wife. He also
defecated once.

His I and O for 24 hours monitoring were: for the 7-3 shift he urinated and defecated
once, his oral intake was 450 cc. And total amount of urine was 380 cc. And at 4:30 pm he
already went home in good condition and disposition.

X. Medical Management

A. Diagnostic Procedures

1. Complete Blood Count

DEFINITION

33
 The CBC is used as a broad screening test to check for such disorders as anemia,
infection, and many other diseases. It is actually a panel of tests that examines different
parts of the blood and includes the following: Hemoglobin, Hematocrit, RBC indices, WBC,
and the differential count.

Purpose
Complete Blood Count (CBC) was done to our patient to determine significant changes
on the blood components brought about by the disease.

Date Requested: August 20, 2010

Date Performed: August 20, 2010
Requesting Physician: Mia Grace Lijauco, M.D.

RESULTS
EXAMINATIONS RESULT REFERENCE VALUE SIGNIFICANCE
Hemoglobin 140 140-175 g/L NORMAL
Hematocrit 0.41 0.41-0.50 NORMAL
RBC 4.560 4.5-5.9 x 10^12L NORMAL
MCV 89.00 80-100 fL NORMAL
MCH 30.70 27-32 pg NORMAL
MCHC 34.50 31-35 g/dL NORMAL
WBC 7.38 4.50-11.0 x 10^9/L NORMAL
Platelet 224 150-450 x 10^9/L NORMAL
DIFFERENTIAL COUNT
Segmenter 0.61 0.50-0.70 NORMAL
Lymphocyte 0.29 0.20-0.40 NORMAL
Monocytes 0.08 0.02-0.08 NORMAL
Eosinophils 0.01 0.01-0.04 NORMAL
Basophils 0.01 0.00-0.01 NORMAL

Analysis
The result of the CBC was within normal range because our patient has good immune
system

34
 Nursing Responsibilities Rationale
1. Verify doctor’s order To validate the existence of the procedure
2. Reemphasize to the client about the In order to establish rapport and gain
type of procedure and its purpose. cooperation.
3. Explain to the client that a tingling In order for the client to know what to be felt
sensation maybe felt while collecting during the collection of specimen.
the specimen.
4. Refer to the doctor the results and In order for the physician to evaluate the
attach to the patients chart results and perform the necessary
interventions.

2. Blood Chemistry

Purpose
Blood chemistry was done to our patient to determine significant changes on the
electrolyte components brought about by the disease.

Date Requested: August 20, 2010

Date Performed: August 20, 2010
Requesting Physician: Mia Grace Lijauco, M.D.

RESULTS
EXAMINATION RESULT REFERENCE VALUE SIGNIFICANCE
Blood Urea Nitrogen 7.54 1.7-8.3 mmol/L NORMAL
Creatinine 66.25 44.2-150.3 mmol/L NORMAL
Sodium 142.00 136-150 mmol/L NORMAL
Potassium 4.20 3.4-5.3 mmol/L NORMAL
Chloride 102.00 96-106 mmol/L NORMAL

Analysis:

35
 The result of the blood chemistry was within normal range and has no affectation on the
kidneys.

Nursing Responsibilities Rationale

1. Verify doctor’s order To validate the existence of the procedure
2. Reemphasize to the client about the In order to establish rapport and gain
type of procedure and its purpose. cooperation.
3. Explain to the client that a tingling In order for the client to know what to be felt
sensation maybe felt while collecting during the collection of specimen.
the specimen.
4. Refer to the doctor the results and In order for the physician to evaluate the
attach to the patients chart results and perform the necessary
interventions.

3. Arterial Blood Gases

DEFINITION

This test is used to evaluate oxygenation and acid/base status. This test assesses both
the ventilation and diffusion capacity of the lungs to assist in diagnosis and to give an objective
assessment of improvement or deterioration.

Purpose
This was done to our patient to identify an impending acid-base imbalances

Date Requested: August 22, 2010

Date Performed: August 23, 2010
Requesting Physician: Emely T. Pumaras, M.D.

Result

EXAMINATIONS RESULT REFERENCE VALUE SIGNIFICANCE

36
 pH Arterial Blood 7.414 7.35-7.45 mmHg NORMAL
pCO2 35.2 3.5.0 -45.0 mmHg NORMAL
pO2 64.4 80.0 -105.0 mmol/L DECREASE
HCO3 22.0 22.0-26.0 mmol/L NORMAL
Base Excess -2.6 -2.00 – 3.00 % NORMAL
O2 Saturation 92.4 95% NORMAL

Analysis:

The abnormal low level of pO2 and O2 saturation results to hypoxemia is due to
impaired ventilation perfusion mismatch, narrowed airways secondary to the disease process
and decrease ventilation.

Nursing Responsibilities Rationale

1. Verify doctor’s order To validate the existence of the procedure
2. Reemphasize to the client about the To gain cooperation and compliance
type of procedure and its purpose.
3. Inform the patient that arterial blood To be able to know by the patient what to be
sample collection is usually more felt during the collection of specimen.
painful than regular venipuncture.
4. Instruct the patient to sit with the For proper collection of specimen from the
arm hyper extended and wrist resting venipuncture site
on a small pillow

5. Instruct the client to relax while blood To void false positive results
is being collected.

5. Refer to the physician the result of In order for the physician to evaluate the
the examination then attach to the results and perform the necessary
patients chart interventions.
6. Administer oxygen as prescribed This is to address O2 saturation and
decreased pO2
7. Position patient in semi-fowler’s To loosen airways and facilitate
position

37
3. Acid-Fast Bacilli

DEFINITION

This test of various body fluids identifies tubercle bacilli in order to diagnose and
monitor the treatment of tuberculosis. Findings of acid-fast bacilli on microscopic examination
indicate possible tuberculosis and allow for timely initiation of anti-tuberculosis therapy.
Smears and cultures, primarily of sputum but also of other body specimens such a s urine, skin
biopsies, cerebrospinal fluids, gastric washing and blood are stained to detect acid-fast bacilli.

Purpose
This procedure was done to our patient to confirm hi tuberculosis by determining the
causative agent involved and to determine the appropriate treatment.

Date Requested: August 19, 2010

Date Performed: August 20, 2010
Requesting Physician: Dr. Lijauco

Result
Gram Stain
Gram (+) cocci singly and short chain
Gram (-) bacilli many
WBC > 25/lpo
Fungal elements – moderate
AFB Stain
(-) for fungal elements

Culture: x Aerobic x Anaerobic

Result:

38
 Moderate growth of AmpC beta-lactamase producing Pseudomonas aeroginosa and
moderate growth of Candida albicans

Susceptibility Test Result:

AmpC beta-lactamase producing pseudomonas aeroginosa (disk diffusion)
Susceptible to:
Amikacin
Cefepime
Ciprofloxacin
Gentamicin
Imipenem
Levofloxacin
Meropenem
Tobramycin
Analysis

The presence of microorganisms (candida albicans and pseudomonas aeroginosa)

signifies that our client is suffering from tuberculosis

Nursing Responsibilities Rationale

1. Verify doctor’s order To validate the existence of the procedure

2. Reemphasize the purpose of such To gain cooperation and compliance

diagnostic procedure.

3. Reemphasize to the patient the In order for the client to become aware on
correct procedure of specimen the correct procedure of gathering
collection specimen for accurate results

4. Encourage the client to increase To loosen secretions and to expectorate

fluid intake the night before sputum and specimen easier

5. Refer to the doctor the result of So that the physician will see the result
the examination then attach to the and if abnormalities is present proper

39
 patients chart management will be given

4. ELECTROCARDIOGRAPHY (ECG)

DEFINITION

The ECG is a diagnostic tool used in assessing the cardiovascular system. ECG is used to
measure the rate and regularity of heartbeats as well as the size and position of the chambers,
the presence of any damage to the heart, and the effects of drugs or devices used to regulate
the heart (such as a pacemaker). It is a graphic recording of the electrical activity of the heart.
The ECG is obtained by placing disposable electrodes in standard positions on the skin of the
chest wall and extremities.

Purpose

This procedure was done to our patient to determine if there is an affectation in the
heart brought about by the disease.

Date Ordered: August 19, 2010

Date Performed: August 20, 2010

Requesting Physician: Mia Grace Lijauco M.D.

Result: Regular sinus rhythm, left axis deviation

Analysis: the left axis deviation may be possibly caused by the cardiac muscle enlargement due
to the increase workload of the heart to compensate for the ventilation perfusion.

Nursing Responsibilities Rationale

1. Verify doctors order To validate the existence of the procedure

2. Reemphasize to the patient and To alleviate anxiety and to gain

significant other about the cooperation of the patient
procedure, including where it will

40
 take place and its expected
duration

3. Instruct patient to remove all To prevent any alteration in the result of

metals attached the ECG

4. Refer to the physician the ECG So that the physician will be able to
result once available and then determine the appropriate management
attach it to the client’s chart to be applied to the patient based on the
result

5. Report any abnormalities in the v/s To make an immediate intervention to

and urine output to the physician prevent complication

B. Treatment

1. Intravenous Therapy

DEFINITION:

Intravenous Therapy is the giving of fluid substances into a vein. Intravenous Fluids aims
to maintain homeostatic functioning or maintain and replace body stores of water, electrolytes,
vitamins, minerals, proteins and calories in patients who cannot maintain an adequate intake
by the mouth; provide an avenue for the administration of IV medications and monitor central
venous pressure; restore acid-base balance and restore volume of blood components.

Purpose:

This was given to our client for rehydration and serves as an avenue for medications,
supplementary of nutrients and electrolytes.

IV Fluid Date Performed Requesting Physician

D5NM August 19, August 20, August Dr. Lijauco
21, August 22

41
D5W August 20 Dr. Lijauco

Nursing Responsibilities Rationale

1. Verify doctors order to validate the presence of the procedure
2. Reemphasize to the patient the To gain the patient’s compliance and
purpose of the therapy. cooperation.

3. Check the fluids and equipments to To identify possible indications of expiration or

be used for infusions for any contamination.
discoloration, cloudiness, presence of
particles, cracks of bottle, punctured
bottle, IV tubing and catheters
discoloration.

4. Clean the infusion site using cotton To prevent infection.

balls with alcohol.
5. Regulate IV Fluid to the desired flow In order to meet necessary fluid and
rate. electrolyte needed by the body within the
specified length of infusion as well as to
prevent circulatory overload.
6. Check for the presence of signs of To assess for the patency of IV line and to
infiltrations such as coolness of the ensure proper infusion
area, absence of blood backflow,
leaking of solution, sluggish flow rate
and swelling at the IV site.
7. Read the clysis at eye level. To ensure a more accurate measurement.
8. Document the type of IV solution This would serve as a record or for legal
infused, its volume, its desired flow purposes.
rate, the date and time it was infused
and consumed.

42
2. Nebulization

It provides a visible mist of water articles for the patient to inhale. This is used to liquefy
secretions, to warm and humidify air, relieve edema of airways and an avenue for medication purposes.

Purpose:

This was done to our patient to administer medications which will relieve mucosal edema thus
dilating airway thus facilitating ventilation.

Nursing Responsibilities Rationale

1. Verify doctors order To validate the existence of the procedure

2. Reemphasize the procedures to the To gain cooperation

patient and significant others

3. Prepare and assemble the equipment. To ensure an effective nebulization

Check the electrical device before use
To prevent short circuit

4. Place the client in a semi-fowler’s For lung expansion for effective breathing
position

5. Place the prescribed dose of To ensure proper amount of medication is

medication. Fill the nebulizer with given to the patient
prepared medication

6. Let the patent seal mouth on the To inhale the nebulizer vapor through the
mouthpiece mouth

7. Encourage the patient to breathe the For maximum effect of the drug
nebulized vapor thru the mouthpiece

8. Remain with the patient until all the To make sure that the patient consume all the
solution has been administered drug

9. May render bronchial clapping then To loosen the secretions thus easy to be
encourage patient to do deep expectorate
breathing and coughing exercise

10. Provide good oral hygiene after the To remove the remaining mist of the drug
procedure present in the mouth

43
 11. Wash and dry the nebulize equipment, To be ready for another use
tubing or mouthpiece and put in a
sealed plastic and into a proper place

12. Document the procedure To record the improvement or any abnormal

appropriately finding

13. Increase oral fluid intake To synergize the effect of the therapy

C. Drug Study

GENERIC NAME: BUDESONIDE

BRAND NAME: Pulmicort Turbuhaler

CLASSIFICATION: Corticosteroid

DESIRED DOSAGE, ROUTE & FREQUENCY: two inhalations every 12 hours

DESIRED EFFECT: This drug is given to our patient to reduce inflammation in the bronchi.

MECHANISM OF ACTION:

Budesonide is an anti-inflammatory corticosteroid exhibits potent glucocorticoid

activity and weak minerolocorticoid activity. The exact mechanism of the cortiosteroids
isn’t known, but they have a wide range of inhibitory activity against such cell types such
as mast cells and macrophages and mediators (such as leukotrienes) involved in allergic
and non-allergic inflammation.
Date Ordered: August 20, 2010
Requesting Physician: Dr. Lijauco
Nursing Responsibilities Rationale
1. Reemphasize to client the purpose, To gain cooperation and compliance
and effects of the drug
2. Use cautiously, if at all, in patients To avoid further complications.

44
 with active or quiescent TB of the
respiratory tract, ocular herpes
simplex, or untreated systemic fungal,
bacteria, viral, or parasitic infections
3. Refer to physician if bronchospasms To prevent further complications such as
occur after using budesonide bronchospasms
4. Watch for candida infections of the For immediate treatment of the said
pharynx complication
5. Tell patient that budesonide inhaler For precautionary measures
isn’t a bronchodilator and isn’t
intended to treat episodes of asthma
6. Pulmicort Turbuhaler must be kept up- To provide correct dosage
right(mouthpiece on top) during
loading
7. instruct patient to place mouthpiece To obtain the desired effect of the drug faster
between lips and to inhale forcefully
and deeply
8. Tell the patient that he may not taste To make the patient aware on the possible
the drug or sense it entering his lungs, outcome of the drug given
but it doesn’t mean it isn’t effective.
9. Replace mouthpiece cover after use To prevent the contamination from micro
and always keep it clean and dry organisms, thereby preventing the occurrence
of infection
10. Instruct the patient to carry or wear For identification purposes
medical identification indicating need
for supplementary corticosteroid
during periods of stress or an asthma
attack.

Generic name: N- Acetylcysteine

Classification: Mucolytic

45
Mode of action: This drug is a mucolytic that reduces the viscosity of pulmonary secretions by
splitting disulfide linkages between mucoprotein molecular complexes

Dosage, Route, Frequency: 200 mg / sachet in ½ glass H20 BID

Desired Effect: This drug was given to our patient to improve airway flow and to provide a more
comfortable breathing.
Date Ordered: August 19, 2010
Requesting Physician: Dr. Lijauco/Dr. Rasos

Nursing Responsibilities Rationale

1. Reemphasize to client the purpose, To gain cooperation and compliance
and effects of the drug
2. Instruct patient or watcher the To prevent toxicity
frequency and dosage of the drug
3. Administer cautiously to elderly or To avoid further problems since drug also
debilitated patients with severe stimulates cardiac muscle.
respiratory insufficiency.
4. Mix with juice Because drug smells strongly like sulfur so
as to improve its palatability.
5. Monitor cough type and For more effective treatment.
frequency.
6. Instruct client to report signs of To prevent further complications
side effects of the medication

GENERIC NAME: HYRDROCORTISONE

BRAND NAME: Sodium Succinate

CLASSIFICATION: Corticosteroids

DOSAGE, ROUTE AND FREQUENCY: 100 mg, IV every 8 hours

46
MECHANISM OF ACTION: Decreases inflammation by entering target cells and binding to
cytoplasmic receptors initiating many complex reactions thus resulting to blockage on the
release of histamine, bradykinine and serotonin.

DESIRED EFFECT: This drug is given to our patient to potentiate other drugs(Budesonide) to
reduce pulmonary inflammation.

Date Ordered: August 20, 2010

Requesting Physician: Dr. Lijauco/Dr. Rasos
Nursing Responsibilities Rationale
1. Reemphasize to client the purpose, and To gain cooperation and compliance
effects of the drug
2. Do skin testing To determine any allergic reaction
3. Check the patency of the IV line To make sure that it is in the vein

4. Monitor I & O accurately Since one of the following signs is fluid

retention
5. Monitor BP Because this drug causes
vasoconstriction effect thereby
increasing BP. Prompt monitoring of
side effects.
6. Weigh the patient daily with the same To determine if he gained weight and
clothing and weighing scale fluid retention

7. Encourage patient to increase intake of To increase body resistance and to

Vitamin C and potassium rich foods prevent the occurrence of hypokalemia
such as banana, cantaloupe, potato,
etc.
8. Increase fluid intake To loosen the secretions

Generic Name: Fluticasone-Salmeterol

Brand Name: Advair Diskus

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Classification: Bronchodilators

Dosage, route, frequency: Fluticasone-Salmeterol 250mcg/50mcg Diskus Inhalation BID

Mechanism of Action:
 It prevents the release of substances such as leukotrienes in the body that cause inflammation
and relaxing muscles in the airways to improve breathing.
Desired Effect:
This drug was given to our patient to dilate the bronchioles thereby facilitating normal
breathing pattern and air exchange

Date Prescribed: August 21, 2010

Requesting Physician: Dr. Quilala/Dr. Lijauco
Nursing Responsibilities Rationale

1. Reemphasize to client the purpose of to gain cooperation

the drug

2. Tell the client to gargle and rinse mouth to help prevent dryness, relieve throat irritation,
after using this medication and to prevent mouth infections

3. Inform the patient to report any unusual This is a side effect of the drug that needs
weakness, sudden weight loss, dizziness. immediate treatment

4. Instruct the patient to carry a medical ID This would help identify that the patient need
bracelet at anytime as noted for oral corticosteroids during times of stress

5. Instruct the watcher or patient to Drug content may be altered

store the medication in a dry place

6. Instruct the patient not to overdose This drug causes ototoxicity

7. Increase oral fluid intake To loosen the cesretions

Generic Name: BUCLIZINE

Brand Name:

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Classification: Antiemetic/Antihistamine

Dosage, Route, Frequency: 1 cap 50 mg oral OD

Mechanism of Action:

Vomiting (emesis) is essentially a protective mechanism for removing irritant or otherwise

harmful substances from the upper GI tract. Emesis or vomiting is controlled by the vomiting centre in
the medulla region of the brain, an important part of which is the chemotrigger zone (CTZ). The vomiting
centre possesses neurons which are rich in muscarinic cholinergic and histamine containing synapses.
These types of neurons are especially involved in transmission from the vestibular apparatus to the
vomiting centre. Motion sickness principally involves overstimulation of these pathways due to various
sensory stimuli. Hence the action of buclizine which acts to block the histamine receptors in the
vomiting centres and thus reduces activity along these pathways. Furthermore since buclizine possesses
anti-cholinergic properties as well, the muscarinic receptors are similarly blocked.

Desired effect:

This drug was given to our client to address nausea, vomiting and drowsiness.

Date ordered: August 21, 2010

Requesting Physician: Dr. Lijauco

Nursing Intervention Rationale

1. Reemphasize to client the purpose and
effects of the drug
2. Advice the client to store the drug in dry
places.
3. Advise patient to report any unusual
weakness, sudden weight loss, dizziness.
To gain cooperation and compliance
Heat or moisture may alter the content of the drug
This maybe a side effect of the drug that requires
immediate treatment

4. Should be taken with food. (Take within ½ To avoid GI upset

hr before meals.)

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NURSING CARE PLAN

I. Nursing Diagnosis

Impaired Gas Exchange related to narrowed airway secondary to overproduction of

thick tenacious mucus secretion, hypertrophy and hyperplasia of mucus glands as manifested
by body weakness, presence of adventitious sounds (wheezes), productive cough, respiratory
rate of 28 bpm and a verbalization of “marigatan nak nga mangirwar ti plemas ko anak ko”.

Nursing Inference

The increase production and accumulation of thick tenacious mucus secretions, due to
the hypertrophy and hyperplasia of goblet cell,s causes obstruction in the airway. Obstruction
of the airway causes decrease in ventilation in the affected alveoli hence impairing gas
exchange.

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Nursing Goal

After 30-60 minutes of rendering nursing interventions, the patient will have effective
gas exchange as manifested by absence of body weakness, absence of adventitious sounds and
absence of cough.

Nursing Intervention

1. Position the client in high Fowler’s position.

To promote lung expansion.

2. Administer bronchodilator (salbutamol + ipratropium) as the ordered.

To relax the smooth muscle of tracheobronchial tree thereby increasing the

lumen.

3. Administer oxygen inhalation 1-2 lpm.

To deliver oxygen adequate for tissue perfusion.

4. Encourage the patient to drink plenty of water at least 3L/ day if it is not
contraindicated.

To loosen the secretions by decreasing its viscosity thus easier to expectorate.

5. Move patient side to side every two hours.

To promote postural drainage.

6.. Encourage deep, slow or pursed – lip breathing.

To prevent airway collapse, dyspnea and work of breathing

7. Administer mucolytics (N-acetylcysteine)as ordered.

To liquefy or dissolve viscous mucus secretions thereby promoting easier

expectoration.

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Nursing Evaluation

After 1 hour of rendering nursing intervention, the patient has an effective gas exchange
as manifested by absence of body weakness, absence of adventitious sounds, and absence of
cough.

II. Nursing Diagnosis

Ineffective airway clearance related to accumulation of secretions which are thick and
tenacious as manifested by an RR of 28 bpm rales and wheezes, productive cough and
verbalization of the client “marigatan nak nga mangirwar toy plemas ko”.

Nursing Inference

Due to hyperplasia of mucus glands, there will be increased production of

tracheobronchial secretions which interferes the flow of gases in the airway, thus ineffective
airway clearance occurs.

Nursing Goal

After 30 minutes-1 hour of nursing intervention the client will be able to maintain
patent airway as would be manifested by absence of adventitious sound, and verbalization of
the client “haanak unay marigatan nga umangesen ken nalakak mairwar ti plemas kon”.

Nursing Intervention

1. Position the client in high Fowler’s position.

To promote lung expansion and promote postural drainage.

2. Encourage the patient to drink plenty of water at least 3L/ day as tolerated.

To loosen the secretions by decreasing its viscosity thus easier to expectorate

3. Encourage deep, slow or pursed – lip breathing.

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 To prevent airway collapse, dyspnea and work of breathing

4. Administer mucolytics as ordered.

Breaks chemical bonds in the mucus, which are responsible for the increase
viscosity if such bonds are broken, mucus becomes easier to be expectorate.

5. Do postural drainage before meals and after nebulization

to help drain secretions

6. Administer oxygen inhalation 1-2 lpm

deliver oxygen adequate to meet the body cell’s needs.

Nursing evaluation

After 1 hour of nursing intervention the client is able to maintain patent airway as manifested
by absence of adventitious sound, and verbalization of the client “haanak unay marigatan nga
umangesen”.

III.Nursing Diagnosis

Sleep pattern disturbances related to difficulty of breathing, and hospital settings and
routines as manifested by presence of eye bags, irritability, restlessness and a total sleep of 5
hours and verbalization of the client “marigatanak nga mangala ti turog ko isu haanak unay
makatur-turog ken”.

Nursing Inference

53
 Due to change in the environment, difficulty of breathing and hospital settings and
routines, the client feels discomfort that may alter the usual or normal length of getting asleep
thus there is an alteration in the sleeping pattern of the client.

Nursing Goal

After of rendering nursing intervention, the client’s sleep hour will be normalized as
manifested by absence of eyebags, sleep hour of 7-8 hours and verbalization of the client
“hanak met marigatan mangala ti turog kon isu mayat met ti panagturog kon”.

Nursing Intervention

1. Provide comfort measures such as backrub.

To promote physical and mental relaxation.

2. Encourage patient not to have a nap during daytime.

To have a larger duration of being awake thus early getting sleep at night.

3. Encourage patient to drink warm milk before going to bed.

It contains trypthopan which induces sleep.

4. Provide quiet environment conducive to sleep such as closing the door.

These measures promotes rest and sleep by decreasing stimulus

5. Encourage patient to turn off the light, but if not, provide cover to the eyes with the likes of
towellete/handkerchief.

By covering the eyes, light can’t pass through thus increasing production of melatonin,
sleep inducing hormone.

6. Inform client of necessary care interruptions ahead of time.

Preparing the client for awakenings and planning to minimize awakenings, decrease
unnecessary stress and anxiety that may prevent subsequent sleep.
54
7. Implement measures as indicated to prevent frequent voiding at night, such as decreasing
fluid intake before bedtime.

These measures prevent the need to wake up for frequent voiding.

8. Administer bronchodilator and humidifiers as ordered

To prevent mucus membrane from drying and becoming irritated and to loosen
secretions for easier expectoration.

9. Encourage purse lip breathing .

It creates resistance to the air flowing out of the lungs, thereby prolonging exhalation

10. Encourage patient to assume semi – fowlers while sleeping.

This posture permits full lung expansion.

11. Plan satisfying activities for the client during daytime.

Satisfying daytime activities stimulate wakefulness and discourage daytime napping

which can disrupt circadian rhythms and night time sleep

12. Encourage the client to express concerns when unable to sleep.

To decrease anxiety thus promoting relaxation.

Nursing evaluation

After 2 days of rendering nursing intervention, the client’s sleep hour have normalized
and decreased frequent awakenings as manifested by absence of eye bags, sleep hour of 7-8
hours and verbalization of the client “hanak met marigatan mangala ti turog kon isu mayat met
ti panagturog kon”.

IV. Nursing Diagnosis

55
 Activity Intolerance related to body weakness secondary to decrease oxygen supply to
the different muscles of the body as manifested by easy fatigability and inability to bath without
assistance.

Nursing Inference

Oxygen is needed for the production of energy of the body. Once oxygen supply is
deprived, there will be poor production of body energy causing weakness. Since there is
weakness activity intolerance results.

Nursing Goal

After 1 to 2 days of rendering nursing interventions, the patient will be able to tolerate
activities as would be manifested by ability of the patient to do his usual mild routines in a long
period of time such as taking a bath without experiencing weakness and without assistance.

Nursing Interventions

1. Encourage the patient to drink plenty of water, do bronchial clapping to the patient and
administer bronchodilator and mucolytic as order.

To improve airflow

2. Encourage the patient to have adequate rest.

To lessen the oxygen demand of body tissues and conserve energy

3. Instruct the watcher to assist the patient in doing his ADL

To reduce energy expenditure

4. Encourage passive exercise such as dangling and deep breathing exercises.

To maintain muscle strength

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5. Avoid doing for the patient what the patient can do for him and avoid giving exercises to
which he can’t do.

To increase self – esteem of the patient

Nursing Evaluation

After 2 days of rendering nursing interventions, the patient is able to tolerate

activities as manifested by ability of the patient to perform his usual mild activities in longer
period such as taking a bath a bath without experiencing weakness and without assistance.

GENERAL EVALUATION

Tata Felipe, 71 years old,residing at Brgy. 37 Ganagan Doro, Bacarra, was admitted to
emergency room last August 19, 2010 at 11:55 in the evening with a chief complaint of cough
and difficulty of breathing. After thorough history taking and physical examination done by Dr.
Quilala and Dr. Pumaras, he was admitted to Mariano Marcos Memorial Hospital and Medical
Center (MMMH & MC). Tata Felipe had an admitting diagnosis of Chronic Obstructive
Pulmonary Disease in Acute Exacerbation Bronchitis, PTB Class IV. After a continuous
management and examination, the final diagnosis was COPD exacerbation controlled Bronchitis
resolved PTB class IV.

Laboratory works were done such as Hematology, ECG, ABG and Acid Fast Bacili. Results
revealed some abnormalities such as decreased oxygen, has moderate of AmpC Beta-lactamase
producing Pseudomonas Aerogenosa and moderate growth of Candida albicans. Spirometry
was also ordered but the client refused because he said that he wants to perform the
procedure when he will have his check up. IV therapy such as D5NM and D5W were given and
medications such as Budesonide, N-acetylcystein, Hydrocortisone, and Fluticasone-Salmeterol
for nebulization to liquefy secretions.

After four days of nursing interaction, assessment, planning, and interventions, the
client’s condition had improved in many ways.

57
 The difficulty of breathing experienced by the client has been managed by proper
positioning, increasing its fluid intake as well as rest, comfort and conducive environment were
provided. Nutrition was also emphasized to increase strength and endurance for the body
weakness complained by the patient. Fortunately, the patient regained his strength. Body
weakness was no longer felt during the last days of confinement.

On August 24, 2010 the client was discharged in good condition and disposition. He was
given salmetrol + fluticasone 50 mg/250mg diskus inhalation twice a day,
salbutamol+ipatropium nebulization as needed if there is difficulty of breathing, and
levofloxacin 750 mg 1 tablet once a day for 7 days as his home medication and was ordered to
come back on September 2, 2010 for follow up check up.

58
 Mariano Marcos State University
COLLEGE OF HEALTH SCIENCES
Department of Nursing
Batac, Ilocos Norte

Chronic Obstructive Pulmonary

Disease in Acute exacerbation
Bronchitis, Pulmonary Tuberculosis
Class IV

Submitted to:
Panelist

Submitted by:
Agulay, Reinier Gardner
Andres, Robin Jay
Bagaoisan, Gladys Pearl
Balalio, Lervie Jane
Banao, Winchelle
Baptista, Levi
Baxa, Berghine Joy Abigail
Bolosan, Lea-Joy
Calzado, V
Coma, Danah Lorraine
Corpuz, Princess Tessa
(BSN III-F, Group 1)

October 14, 2010

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