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Final Med Ward
Final Med Ward
NURSING ASSESSMENT I
PATIENT’S NAME: PATIENT X ADDRESS: RAGAYAN, POONA BAYABAO (GATA), LANAO DEL SUR AGE: 59yrs old
SEX: FEMALE RELIGION: ISLAM CIVIL STATUS: WIDOW OCCUPATION: NONE
1. Tobacco X X X
2. Alcohol X X X
A. CHIEF OF COMPLAINTS:
“Margn a kapakaginaw akn saman aya ka pitaro rakn pn o doctor a pagilay rakn na and kon pn oto a asthma akn” as verbalized by patient
B. HISTORY OF PRESENT ILLNESS (HPI) {onset, character, intensity, duration, aggravation, and alleviation, associated symptoms, previous treatment and results, social and vocational
responsibilities, affected diagnoses}.
This is a case of a 59-year-old female from Ragayan, Poona Bayabao (Gata), Lanao del sur. According to her, May 21 st of 2023 when the patient caught a cold associated
with a persistent cough, she thought that it is just a normal cold that can be treated in a just few days by drinking lots of water and using an Over the counter drugs such as Biogesic or Paracetamol
unfortunately her cold and cough has worsen to the point that she experienced shorter of breathing. On May 28 th, prior to admission the patient had shortness of breathing. On May 30 th, the patient
cannot tolerate the pain that she experiencing that make her think that it is the last day of her life, exactly 9:12 in the evening they arrived in Emergency room at Amai pakpak medical center and
Immediately they assessed her vital signs her Respiratory rate is quit abnormal because it is 44cpm and Oxygen Saturation of 89%, doctors first suspect her that she has covid since she have most
common symptoms but after they swab her, and the result came out negative after further laboratories and examinations they confirmed it that the patient has a Bronchial Asthma Acute Exacerbation.
A. HISTORY OF PAST ILLNESS (previous hospitalization, injuries, procedures, infectious disease, immunization/health maintenance, major illnesses, allergies, medications, habits,
birth and developmental history, nutrition- for pedia)
The patient has been hospitalized due to hypertension and no report of injuries. The patient has never undergone for any minor or major surgery and reported that she experienced
chicken fox and measles during her childhood days, and she also added that she had completed her immunization. The patient has a health maintenance for her hypertension and no reports
any major illness, no allergies, taking OTC drugs as needed and losartan every morning, she likes cleaning around the house and loves to stroll around not for just fun but to have an
exercise as well, she is G8P7.
Acquired Diseases:
Hypercholesterolemia X
Kidney Disease X
Tuberculosis X
Alcoholism X
Drug Addiction X
Hepatitis A X
B X
C X
Others (pls. specify)
FAMILY HISTORY GENOGRAM
Patient
Daughter
Son
Husband (Deceased)
“Margn a kapakaginaw akn saman aya ka pitaro rakn pn o doctor a pagilay rakn na and kon pn oto a asthma akn” as verbalized by patient
2. Hospital Environment
“Mapiya mambo ka pkatabangan iran so madakl a kikinanglan na pakalibre tapn sa bayad ogaid na aya say abo sakit na so mga kakaba a mangaito a na didn kada” as verbalized by the
patient.
C. SUMMARY OF INTERACTION
The Patient is cooperative and has an understanding to everything. She entertains the student nurse and answers every question you ask. She was always smiling when you were
talking to her. She never get tired or irritated while you were asking personal questions perhaps she will answer you very detailed.
PHYSICAL EXAMINATION
Name: Patient X Date: June 02,2023
Chief of Complaints: Difficulty of breathing Height: 144 cm Weight: 50 kg
Vital signs: T: 36.4℃ RR:23cpm PR:67bpm O2Sat:95% BP:130/90mmHg Pain score:6/10 BMI: 23.6 kg/m2
Received patient sitting at the bed with on-going IVF of patient on right metacarpal. Patient is alert, conscious, and
oriented to time, place and people surrounding. Patient is cooperative and enjoy the company of the student nurses
GENERAL especially when you were asking a questions personal or not she will answer it clearly and detailed, patient is well
groomed, nails was clean cut, hair is combed properly and tucked in.
Head: Head is normochepalic and has no lesions, lumps, or masses. Hair has a visible gray in some part but not
completely gray
HEENT Eyes: Eyebrows are symmetric and black in color, but few are turning in white. Eyelashes are evenly distributed. Eyelids
are swollen. No presence of discharges is noted.
Ears: Ears are symmetric. There is no presence of tenderness, lesions, and discharges.
Nose: nasal flaring is noted and a nasal discharge.
Throat: No presence of swelling and masses.
INTEGUMENTARY Senile turgor is noted due to aging, patient has no lesion or masses in the body and no discoloration.
Pulse rate is 67 bpm with blood pressure of 130/90 mmHg. Chest expansion is equal. Patient has no history of any cardiovascular
CARDIOVASCULAR
problem.
RESPIRATORY Respiratory rate of patient is 23 cpm and saturation of oxygen at 95% via room air. No oxygen therapy is used. Wheezes at right
lung field and crackles is heard as Auscultated. Patient also has a persistent cough
GASTROINTESTINAL Patient has a complete incisor, canine and premolars but she only have 6 molars, mouth appear healthy and moist, no abdominal
pain, no loss in appetite, has normal sound of bowel movement and can defecate without using any kind laxative.
NEUROLOGICAL Sense Smelling and touching is functioning well, Vision is no longer 20/20, no sign of cataract, PERRLA, hearing is intact as
well. Patient is Alert and conscious around her surrounding
MUSCULOSKELETAL Deterioration of vertebral support and body weakness is noted due to aging but can walk, sit and eat without assistance.
Menarche starts on 15 years age and the patient is G8P7, Menopause at the age of 50 years old, no history of any cervical
REPRODUCTIVE diseases.
EXCRETORY The patient verbalized that she voids 3 to 6 times a day, and no burning is felt in every void and no foul odor is smelled.
NURSING ASSESSMENT II
DAY 1 DAY 2
1.ACTIVITIES- REST The patient was usually doing a house The patient shows body weakness, The patient shows body weakness, The patient shows body weakness
hold chores and stroll around, and rest and tiredness. She spends most of and tiredness. She spends most of but can walk from bed to comfort
a. Activities after luhor prayer for an hour and sleep the time in bed. And sleeps all the the time in bed. And sleeps all the room. She rests most of the time and
b. Rest every 9:30pm and wake up 4:00am time due to tiredness and Shortness time due to tiredness and shortness sleeps every 8:00pm to 4:00am.
2.NUTRITIONAL- The patient has no diet restrictions. The patient loses her appetite, she The patient has no appetite, but she The patient has no diet restrictions.
METABOLIC She eats three times a day and drinks always depends on IVF most of the doesn’t have any restriction in food, She eats three times a day and
a. Typical intake (food, 5-7glasses of water a day. She was not time. Weight gradually loss and but she usually eats soft food such drinks 4 to 5 glasses of water a day.
fluid)
taking any vitamins but takes some received medication through IVTT, as porridge, weight is the same She received medication through
b. Diet OTC drugs like Paracetamol as except for his maintenance losartan when she was admitted, and she IVTT, except for his maintenance
c. Diet restrictions needed. The patient has a maintenance and the other prescribed received medication through IVTT, losartan and the other prescribed
d. Weight of losartan for her hypertension. Azithromycin received it through PO and nib Azithromycin received it through
e. Medications/supplement oral and she also received it through oral and she also received it through
food nebulizer. nebulizer.
3. ELIMINATION Frequent urination color is yellow. Patient voids 3 a day and urination Patient voids 3 a day and urination Patient voids 3 a day and urination
a. Urine (frequency, color, Usually voids 3 to 6 times a day and color are yellow. Since her color are yellow. Since her color are yellow. Since her
transparency) defecates once every day characterized admission no burn felt or foul smell. admission no burn felt or foul smell. admission no burn felt or foul smell.
with a stool color of brown and intact Also reported that she defecates Also reported that she defecates Also reported that she defecates
stool form. No burning felt or foul every other day since her admission. every other day since her admission. every other day since her admission.
smell
b. Bowel (frequency, color,
consistency)
4. EGO INTEGRITY Patient is content in her life, whenever The patient shows tiredness and The patient shows tiredness and Patient’s believe that only Allah
a. Perception of self she feels lonely or have a problem that body weakness. She just seeking body weakness. She just seeking knows when she will get back at
b. Coping Mechanism she faced, she is praying much more Allah’s mercy and guidance. Her Allah’s mercy and guidance. Her home and she prays a lot to ease the
and ask Allah’s guidance. Her family family supports her and is always by family supports her and is always pain she feel, her family is the
c. Support System
support her especially her daughters her side, especially his by her side, especially his primary support and she doesn’t get
d. Mood/Affect
and sons, she is not moody and doesn’t granddaughter who always stays by granddaughter who always stays by irritated in hospital instead she was
get angry or irritated in small things her side ever since admission. her side ever since admission. thankful that the doctor and nurses
instead she smiles a lot. helping her.
5. NEURO-SENSORY Patient has no history of any mental Patient has no history of any mental Patient has no history of any mental Patient has no history of any mental
a. Mental state illness and disorders. The patient is illness and disorders. The patient is illness and disorders. The patient is illness and disorders. The patient is
conscious, coherent, and oriented to conscious, coherent, and oriented to conscious, coherent, and oriented to conscious, coherent, and oriented to
time, date, place, and persons. time, date, place, and persons. time, date, place, and persons. time, date, place, and persons.
b. Condition of five senses:
(sight, hearing, smell, The patient’s five senses are intact.
taste,
Patient's sense of light, smell, Patient's sense of light, smell, The patient’s five senses are intact.
touch)
hearing, and touch function well. hearing, and touch function well.
6. OXYGENATION Vital signs are not taken and no history T=36.2°C T=36.4°C T=35.6°C
a. Vital signs of respiratory problem.
P= 90 bpm P= 65 bpm P= 92 bpm
Temperature
R=44 cpm R= 23 cpm R= 22 cpm
Respiratory rate
BP= 140/90 mmHg BP= 130/90 mmHg BP= 130/80 mmHg
Heart rate
Blood pressure
b. Lung sounds Patient’s experienced shortness of Patient’s experienced shortness of Patient’s experienced shortness of
c. History of Respiratory breathing, Wheezing and Crackles breathing, Wheezing and Crackles breathing, Wheezing and Crackles
Problems are noted. Patient is suspect of are noted. are noted
COVID.
7. PAIN-COMFORT The patient feels shortness of Patient having trouble breathing The Patient still feel shortness of The Patient still feel shortness of
a. Pain (location, onset, breathing, fever, and productive cough radiating at the back and pain feels breathing but the pain is no longer breathing but the pain is no longer
character, intensity, 3 days prior to admission. No comfort like someone’s choking her that felt like before, with pain score of felt like before, with pain score of
duration, reported. makes her difficult to breath
associated symptoms, properly. 6/10. 4/10.
aggravation)
The patient received oxygen therapy The patient was nebulized. The patient was nebulized.
b. Comfort
measures/Alleviation stat to alleviate the pain and make
her breath properly.
c. Medications
8. HYGIENE AND Patient takes a bath thrice a week. She Patient can't take bath as usual to Patient can't take bath as usual to Patient can't take bath but received
ACTIVITIES usually does household chores and routine process. The patient can't do routine process. The patient can't do tepid sponge bath. She can sit, eat,
OF DAILY LIVING strolls around the neighborhood. usual ADLs and shows tiredness usual ADLs and shows tiredness and walk without assistance.
and body weakness. and body weakness.
9. SEXUALITY Menarche starts on 15 years age and Menarche starts on 15 years age and Menarche starts on 15 years age and Menarche starts on 15 years age and
the patient is G8P7, Menopause at the the patient is G8P7, Menopause at the patient is G8P7, Menopause at the patient is G8P7, Menopause at
a. female (menarche, age of 50 years old, patient is widow the age of 50 years old, patient is the age of 50 years old, patient is the age of 50 years old, patient is
menstrual and no history of cervical disease. widow and no history of cervical widow and no history of cervical widow and no history of cervical
cycle, civil status, number disease. disease. disease.
of
children, reproductive
status)
b. male (circumcision, civil
status, number of children)
SUMMARY OF INTRAVENOUS FLUID
DATE/TIME STARTED INTRAVENOUS FLUID AND VOLUME DROP RATE NUMBER OF HOURS DATE/TIME CONSUMED
05-30-2023 – 9:18pm PNSS 1L 80cc/hr 8hrs 05-31-2023 – 5:18am
DRUG STUDY
The treatment of choice for Bronchial Asthma Acute Exacerbation is to administer the following drugs:
Bronchodilators (beta-2 agonists and anticholinergics)
Epinephrine
Ipratropium
Systemic Corticosteroids
Antibiotics
Nebulizer treatment relaxes the breathing muscles and permits air to flow more easily in and out of the lungs. It also helps to loosen mucous in the lungs. Both of these benefits
of nebulizer treatment help to decrease and prevent wheezing, shortness of breath, coughing, and tightness in the chest.
Hospitalization generally is required if patients have not returned to their baseline within 4 hours of aggressive emergency department treatment. Criteria for hospitalization
vary, but definite indications are:
Failure to improve
Worsening fatigue
Relapse after repeated beta-2 agonist therapy
Significant decrease in PaO2 (to < 50 mm Hg)
Significant increase in PaCO2 (to > 40 mm Hg)
A significant increase in PaCO2 indicates progression to respiratory failure.
Noninvasive positive pressure ventilation (NIPPV) may be needed in patients whose condition continues to deteriorate despite aggressive treatment, to alleviate the work
of breathing.
Endotracheal intubation and mechanical ventilation allow the provision of sedation to further alleviate the work of breathing, but the routine use of neuromuscular
blocking agents should be avoided because of possible interactions with corticosteroids that can cause prolonged neuromuscular weakness.
Bronchial thermoplasty is a minimally invasive treatment for severe asthma. It's a way to open airways. The procedure uses gentle heat to shrink the smooth muscles in lungs -- the
ones that tighten during asthma attacks and make it hard to breathe.
Actual Management
NURSING MANAGEMENT
IDEAL ACTUAL
Obtain health history
Assess the vital signs every 2 to 4 hours.
Physical examination
Prescribed medications were administered to the patient in accordance to the
Administration of IV fluid and medications (Oral, intramuscular, or intravenous
doctor’s instruction. These include:
antibiotics)
Teach the patient how to cough, deep breathe, and use an incentive spirometer - Losartan 100mg 1tab OD
- Lactulose 30cc
Encourage mobilization of secretion through ambulation, coughing, and deep - Erythromycin 500mg 1tab OD
breathing. - Budesonide neb 1doss q12
- Salbutamol + Ipratropium q8
Ensure adequate fluid intake to liquefy secretions and prevent dehydration caused - N-acetylcysteine 600mg BID q12
by fever and tachypnea.
Assist the patient to assume a position of comfort elevate the head of the bed, and
Instruct the patient to complete the full course of prescribed antibiotics and have the patient lean on an overbed table or sit on the edge of the bed
explain the effect of meals on drug absorption. Demonstrate effective coughing and deep-breathing exercise
Encourage rest, avoidance of bronchial irritant, and a good diet to facilitate Relive pain by encouraging bed rest and relaxation.
recovery.
Intake and Output (I&O) was also monitored
Encourage deep slow or pursed lip breathing as individually tolerated or Encouraged to drink plenty of water
indicated. Patient was advised to increase fluid intake and to drink clean, drinking water.
In every session of care, student nurse on duty communicated with the patient in a
calming voice and answers all questions asked by the patient and S.O in a delicate
way.
Patient is kept monitored for any unusualities.
Continuity of Care is ensured in every endorsement.
Dependent
Give medication, as To minimize symptoms
ordered. and provide well-being
Subjective Ineffective Short Term Goal: Take the vital signs of the For baseline date After 40 minutes of nursing
“Di ako pakaginawa Breathing Patter After 40 minutes of patient intervention, the patient was able to
piya-piya related to nursing intervention, To ensure the comfort of the patient perform deep breathing exercise
watakulay”, as inflammation and the patient will be Perform bed care
verbalized by the swelling to the able to perform deep
patient lungs as evidenced breathing exercise To ensure that supply of oxygen is
by dyspnea Check the placement of the being properly breathe by the patient
“I can’t properly Long Term Goal: cannula and state of oxygen
breathe my dear After 8 hours of flow rate
child”, as verbalized nursing intervention, Respiratory rate is a fundamental vital After 8 hours of nursing
by the patient the patient will be Note the rate and depth of the sign that sensitive to different intervention, the patient was be able
able to display small respiration for 1 minute pathological conditions to display small improvements that
Objective: improvements that showed an effective breathing
The vital signs were will show an Auscultate the lung fields. Wheezing is a common finding with pattern as evidenced by a
taken as follows: effective breathing asthma as the airways are constricted respiratory rate and rhythm within
T: 37.3 pattern as evidenced from inflammation. normal limits
P: 70 bpm by a respiratory rate Monitor ABG
RR: 28 cpm and rhythm within Respiratory acidosis occurs from
O2: 90% normal limits severe asthma and can develop into,
BP: 130/70mmHg respiratory failure prolonged.
-Application of O2 Avoid overfeeding
therapy noted Abdominal distention can interfere
-Dyspnea noted with breathing
-Facial Grimace Instruct on peak flow meters
noted Peak flow meters can be used daily to
-Discomfort noted monitor how well air is moving in and
-BM+ Teach and encourage the patient out of the lungs
-U/O= 500ml to do deep breathing and
relaxation technique Promotes more effective breathing and
airway management
-Application of O2 therapy Determine the past illness that might To determine the other factors that
noted contributed in her current condition contributes to her condition thus,
-Dyspnea noted accurate nursing intervention will be
-Facial Grimace noted executed
-Discomfort noted
-BM+ Note the rate and depth of the respiration Respiratory rate is a fundamental vital
-U/O= 500ml for 1 minute sign that sensitive to different
pathological conditions
Auscultate the lung fields. Wheezing is a common finding with
asthma as the airways are constricted
from inflammation
Teach and encourage the patient to do Promotes more effective breathing and
deep breathing and relaxation technique airway management
DISCHARGE PLAN
NAME: Patient X DATE OF DISCHARGE: June 2023
CONDITION UPON DISCHARGE Nature: Home per request ( ) Discharge against medical advice ( )
Give adequate instruction about the importance of following medication and dietary regimens.
Medications for Maintenance:
1. MEDICATIONS 1.Salbutamol 4 mg, TID, Inhalation
2.Prednisone 40 mg, OD, PO
3.Ciclesonide 160 mcg, BID, PO
4. Salmeterol + Fluticasone 250/10 mcg MDI 2 puffs BID q12
Exercise as your provider recommends. Some people have coughing or wheezing only during or after
physical activity. This is called exercise-induced asthma. Even though exercise may trigger an asthma
2. EXERCISE attack, exercise is still important. Some ways to prevent an asthma attack during exercise include:
Start with a long, slow warm-up to the activity.
It may be necessary to use a rescue inhaler before you start exercise.
Always have a rescue inhaler with you during exercise.
Promote rest and pursed lip breathing exercise.
Do active range of motion with slow progressions infrequency and provide assistance if needed.
Mediterranean diet, one based on eating plenty of healthy fats (like olive oil), fish, whole grains, and
fruit, fits the bill
3. DIET Stay hydrated. Staying hydrated with plenty of fluids such as water, juice, and tea can help alleviate
asthma symptoms.
Avoid sulfites. Sulfites can trigger asthma symptoms in some people. Used as a preservative, sulfites can
be found in wine, dried fruits, pickles, fresh and frozen shrimp, and some other foods.
Teach patient and family about asthma (chronic inflammatory).
Teach patient and family about the purpose and action of medications.
4. HEALTH TEACHING Teach the patient and family about the triggers to avoid and how to do so.
Teach the patient and family about proper inhalation technique.
Instruct patient and family about peak-flow monitoring.
5. SCHEDULE FOR THE NEXT VISIT Follow-up check-up:
June 13, 2023, at APMC