I.

PERSONAL DATA:

Name: Mrs. Suarez, Abundia Age: 92 years old

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

II. HEALTH HISTORY

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

III. PAST HEALTH HISTORY

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

IV. FAMILY HISTORY

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

V. FEEDING and PSYCHOSOCIAL HISTORY

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

VI. GYNECOLOGIC HISTORY

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

REACTIONS AND EXPECTATIONS:

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

 Respiratory:
RADIOLOGIC FINDINGS
- Normal breathing - RR: 18 as of December
pattern 12, 2010 with a normal - Streaks of densities are seen in the
- (+) history of rhythm lower lung field.
colds/cough - (+) accessory muscle used - The heart is not enlarged
- No asthma - (+) productive cough - The rest of the visualized chest
- (+) history of (whitish phlegm) structured are unremarkable
pneumonia - (+) oxygen attached IMPRESSION:
- (+) nebulizer - Bibasal pneumonitis

 Circulatory:

- (+) hypertension - HR: 52 bpm as of - Fluid prescribed parenterally:

- No history of December 12, 2010 with a
Dizziness or fainting normal rhythm
spells - BP: *** - HEMATOLOGY
- (+) history of - No cyanotic and skin WBC: 7.3x109/L
arrythmia discoloration HEMOGLOBIN:
- No edema female: 94 (140-180 g/ L)
HEMATOCRIT:
female: 0.29 (0.37 – 0.48%)
LYMPHOCYTES: 0.11 (0.25 –
0.40)
NEUTROPHILS: 0.84

- CLINICAL CHEM.
Creatinine: 222.65
Sodium: 149.7
Potassium: 3.18

 Food & Fluid intake:

- Mild anorexia
- Eats 3-4 times a day - Poor skin turgor
- Drink ensure (milk) - Dry lips

 Regulatory
Mechanism:
- Temp: ***
- Has a fever during - Dry skin
admission - No chills

 Elimination:

- Meconium passed out - Swollen abdomen - FECALYSIS

at 24 hours of life - Yellow green mushy Color: yellow green
- Has constipation stools Consistency: Mushy
- No relief measures - Constipation Ova of Parasites: none
taken at home - Enema used to expel Pus cells: 0-2/hpf
stools RBC: 0-2/hpf
Occult blood: (+) trace
Patterns of Functioning Clinical Inspection Other Sources

 Hygiene

- Family have no belief - The patient is clean

regarding to hygiene - Skin is partly dry
- Clean apparently

 Exercise &
Locomotion:

- Limited ROM
- House chores serves as - No deformities
the exercise. - Limited ROM

 Rest & Sleep:

- (-) Difficulty of
sleeping - The patient has enough
- Side-lying position rest

 Communication:

- unable to speak at the

time of admission

 Sensory:

- No epilepsy, - Lacrimation (-)

convulsion etc. - The patient responds to
- History of pain.
Hallucination as the
effects of the medicine
during admission
 Pathophysiology of Pneumonia

Non-Modifiable Modifiable
- Age >70 years - Congestive heart disease
- Sedentary Lifestyle
- Smoking

Streptococcus Pneumoniae

Invasion in the
Respiratory system

Defect in local pulmonary defenses

Activation of defense mechanism

Increase mucous production

Mucociliary transport is
depresses with the aging
process, dehydration etc

Productive cough

inflammatory cells pooling of lung secretions

activated
Crackles
mucus plugs

release of proteolytic deprivation of O2

enzymes
decrease surface area for
external respiration

alters brochial and ciliary

clearance mechanism

stimulating production alveoli is filled with debris

of excess mucus by the WBC due to Tachypnea
inflammatory process
Nursing Diagnosis Scientific analysis Objectives Nursing Interventions Rationale Evaluation

Ineffective airway Community acquired After 8 hours of INDEPENDENT:

clearance r/t excessive Pneumonia is an infection in nursing interventions: 1.) Presence may indicate
viscous secretions in the the alveoli, distal airways, and 1.) Monitor respirations and accumulation of secretions
bronchi as manifested by interstitium of the lungs that - The patient will note for breath sounds and respiratory distress.
productive cough. occurs outside the hospital maintain an adequate
settings. And is characterized .
patent airway after he
Subjective: by fever, chills, cough
expectorates bronchial 2.) Suction airway as ordered
“ nag i-inubo hiya na may (productive), or a chest pain. 2.) To clear airway.
plema” as vervalized by unexpelled mucous along the secretion. by the physician.
the patient’s daughter. airways causes it to narrow.
- The client will
Objective: improve and maintain 3.) Hydration can help
- Productive cough an adequate airway 3.) Increase the patient’s fluid liquify viscous secretions
- Whitish Phlegm clearance. intake to 2000 ml per day
- Pulse: 52 bpm
Reference:
- RR: 18 cpm
Straight A’s in
Pathophysiology of Lippincott
Williams & Wilkins page 83
Nursing Diagnosis Scientific analysis Objectives Nursing Interventions Rationale Evaluation

Ineffective breathing Community acquired After 8 hours of INDEPENDENT:

pattern r/t presence of Pneumonia is an infection in nursing interventions:
abnormal breath the alveoli, distal airways, and 1) Position the patient’s 1) To maintain an
sounds as evidenced interstitium of the lungs that The client will be able head in semi-fowler. open airway and
occurs outside the hospital to breathe continuously facilitate maximum
by crackles
settings. The production of and reduction of lung expansion.
Objective: phlegm or mucous produce a congestion and
crackle sound due to the abnormal breath 2) Provide bronchial
2) To improve airflow
- Productive increased fluid in the alveoli sounds. tapping techniques.
and secretion
cough and segmental spaces of the
lung. clearance.
- Abnormal
lung sound: 3) Observe for increased 3) To identify
Crackles infectious process
- Pulse: 52 bpm
dyspnea/tachypnea
with onset of fever and and promote timely
change in sputum intervention.
- RR: 18 cpm
color, amount and
Reference: character.
Straight A’s in
Pathophysiology of Lippincott
Williams & Wilkins page 83
Nursing Diagnosis Scientific analysis Objectives Nursing Interventions Rationale Evaluation

Impaired Gas Community acquired After 8 hours of INDEPENDENT:

exchange r/t Pneumonia is an infection in nursing interventions:
ventilation perfusion the alveoli, distal airways, and 1) Provide rest periods 1) Prevents fatigue
imbalance as interstitium of the lungs that - The client will and limit activity to and dyspnea.
manifested by occurs outside the hospital improve level of respiratory
breathing pattern settings. Dyspnea, mucouid ventilation and tolerance.
problems. plug and tachypnea causes to
adequate 2) To prevent bedsore
decrease alveolar space for 2) Change position every
Objective: external respiration leading to oxygenation. and promote better
2 hours or as needed.
- Oxygen tank decreased lung capacity and lung compliance
attached oxygen saturation.
- Mild cyanotic
of finger nails 3) Keep environment
- Pulse: 52 bpm allergen-free. 3) To prevent possible
entry of irritants,
- RR: 18 cpm this will obstruct
Reference: the airway.
Straight A’s in
Pathophysiology of Lippincott
Williams & Wilkins page 83