Functional Health Pattern A. Health perception and Health Management Client has been a smoker for 60 pack years.

He stopped smoking 30 years ago. He is also a strong alcoholic beverage drinker but stopped being one at about 35 years ago. A. Metabolic Pattern B. Elimination Pattern PROGRESS NOTES: Since my patient, Mr. Tuazon, was transform to pay ward, I was assigned to new patient. 7 AM We received endorsements from the night-shift nurses. 7 AM I obtained baseline vital signs of the client after introducing myself to him and informing him that I would be his nurse for today. I then performed a quick but through assessment of the diet. 7:25 AM Afterwards, the nurse noted moderate find accumulation at the medicinal ventilator tubings. The nurse then proceeded to drain these tubings and noticed that the client tolerated the removal of water via disconnecting the tubes. He was not on distress after that. 7:30AM The client complained of pain at R-Leg with VAS:7. The nurse then encouraged deep breathing to distract the client and referred it to RORS doing rounds. After wards, the clients VAS was at 5. 8 AM Because the client does not have NGT, all oral needs were not given. My buddy nurse was informed of this already. I also performed oral care to the client using bactidol to prevent infection. I also nebulized the client. The oral care was brought about the nurses auscultation findings of rhonchi on both lung fields. Before I did oral core, I suctioned the clients secretions. The secretions were minimal and nutrition. 8:20 AM The nurse performed passive ROM exercise with the patient. The patient was compliant to exercise regimen. 8:30 AM

The nurse noted increases on the clients antiembolic stockings. She also noticed that the clients feet were contracted. As intervention, the nurse fixed these overseas and positioned the clients legs for maximum contract. 8:40 AM The nurse took the time to explore the mech vent settings of the client as well as to plot missing details on the monitoring sheet. 9:00 AM The nurse noted moderate accumulated fluid in the client tubings. The nurse then drained the tubings. Client was able to tolerate short period of time the mech vent tubings were not connected to each other well. 9:15 AM Client was noted to be shivering while asleep so the nurse kept him thermoregulated by covering him with a blanket and turning off his fan. His temperature while shivering 360 c became 36.20 c and his shivering ceased after about a minute. Nurse noted almost empty PNSS (below 100 cc). The nurse then changed clients IVP to PNSS IT x 30cc/hour. This was also documented on the monitoring sheet. 09:30 AM Fellow-on-duty adjusted clients mech vent settings to: Trigger- 2 PS -15

PEEP- 5 Fi02 - 30% Mode SPONT The nurse monitored the clients oxygen saturation ,RR, breathing pattern as well as other signs of cardio-respiratory distress to see if patients tolerates the new mech vent settings well. The nurse noted that the client was negative for signs of cardio-respiratory distress. His 0202 was at 100% and his RR was 19 bpm. His breathing pattern is eupnic and effortless. 09:45 AM Clients complained of DOB. The nurse noted that the client was breathing deeply and rapidly with RR of 20-28 bpm. The nurse auscultated for breath sounds and found that they are clear.

My buddy nurse was informed of this and we referred him to DR. Hernandez. The patient was seen by DR. Hernandez. The nurse also stayed by the patients side and encouraged him to relax and perform deep breathing. Afterwards, the clients breathing resumed to empheic and stage T RR of 19 bpm. 10:00 AM The client was asleep so the nurse took opportunity to check for orders. There she found that the doctors prescribed tramadol 50 gm IVprn for pain. The nurse anticipated that the client need it anytime soon so she informed her buddy nurse about it and whether the medication will available anytime soon. Her buddy nurse then told her that it may availed from CENICU pharmacy so the nurse went there to obtain the drug. NHH A biological profile Name: Ernesto Mendoza Adress: Batangas Sex: Male Age: 80 Birthday: 7/31/31 Chief complaint: Difficulty of breathing, generalized weakness Reason for admission Management of difficulty of breathing and generalized weakness Admitting Diagnosis ARF S/H HAP, HCU Din,CHF S/T HPN nephrosclerosis Present medical history 2 months prior to admission, the patient started have caugh productive of witish to yellowish phtegm that is associated with undocumented fever. He consulted a doctor and he was prescribed with unrecalled meds with no relief of his symptoms

1 month prior to admission, the patient started to experience difficulty in swallowing solids associated with generalized weakness, anorexia, and weight loss. 15 days prior to admission, there was a noted persistence of symptoms which prompted the client to consult to a local hospital where he was observed overnight then sent home. No improvement was noted. 12 days prior to admission , the patient was re admitted at the same hospital. The patient was treated as a case of CAP. He was also given Ceftriazone, NGT insertion was attempted several times but was unsuccessful. His relatives opted to transfer him to another hospital. 8 days prior to admission, the client was transformed to manila doctors hospital and was received with BV -140/100 mmttg, HR-160s, RR-42. Because of this, the client was intubated as a case of ARF S/T CAP, COPD. Discharge diagnosis ARF, S/F HAP, CORD, ITE,HCVD,CHF T/C esophageal mass, azotemia S/F n. infection to DHN on top of CKD. Family History of Illness According to chart the clients family is positive for hypertension history. Functionient is on diaper. He is on foley catheler that drains to urine bag. Activity- Exercise The client communicated that he is weaker now compared to his former days. Level of self care Eating 3 Bathing- 4 Grooming -3 Elimination 3 Housecloves 4 Sleep- rest Client sleep an average of 10-12 hours a day. He takes frequent ways every now and then of about 15-30 minutes in duration Connitive- perceptual Client expressed extreme pain on his r-leg. Because of this he does not move his right leg as small movement exacerbates the pain. Self- perception and Self- concept The client finds it frustrating that he is not able to do activities. That he previously could do alone. Because of this, the client finds himself easily irritated. He also dependent on his family and nurses for relief of his frustrations. Role- relationship

C.

D.

E.

F.

G.

The client used to work as a former government employee. As of now, it is his children own funds for his hospitalization. He does not live with them as they now have lives of their own. His companion in the province (batangas) is their caretaker of the house. This is also why his children have limited knowledge of how their fathers condition progressed. H. Sexuality- reproductive The client is a married male and he was claramcised. I. Coping/ Stress- tolerance As of now, the client was support from his family when they are visiting in ICU. One of the greatest changes in his life is his loss of certain familiar functions due recent illness. He is dependent on the staff and his nurse(own) for solution of problems. J. Value-belief The client is a roman catholic. Physical Assesment Vital signs F - 36- 2 BP -130/70

PR 38-106 RR 21

GCS -E4VTM6 VAS -7 @R-Leg

General Survey Cautions,(-) cardio-respiratory distress Looks according to age, cachexic, appears, edematous Skin (+) pallor, (+) milky, nonfoul smelling discharge at R-fore arm fair turgor, rough, warm, dry skin. Head Normocepphalic Fine hair, clean scalp (-) masses Eyes Symmetricallids, pole conjunctira Amicteric sctera, equal pupil size: 3mm Brisk reaction to light, uniform accomudation, uniform coverage Ears Normoset,(-) Discharge, I symmetrical gross hearing Mouth Pale lips, tongue and midline Teeth totally missing Pinkish gums, pinkish mucosa Nose Symmetrical nasolabial fold Septum and middle

Both nostrils patent Nontender sinses Neck Trachea at midline Nonpalpable lymph nodes Nonpalpable thyroids Heart/ Arnterior Chest Flat periodical area PMI @5th LCS, apical beat @4th, ICS. LMCL 51>52 @ Base, 51> 52 @ apex Distinct but irregular heart sounds Posterior Chest 1:1 I/E ratio Eupnea T occasional use of accessory muscles 1:2 APL ratio Decreased breath sounds at L-lung fields Occational rhonchi Abdomen Globular, (-) lesions Normoactive Bowel sounds: 6/min. Tymponitic to precussion (-) muscle guarding ,(-) tenderness Extremities Peripheral pules not assessed d/t periplepaledima Peripheral edema, grade 1 pitting Pale nailbeds, capillary refill tim= 2 sec Muscle size equal Others PNSS @L-cephalic vein x 30cc/hr T side drip of kabiven 1400 kcal/1920cc +18 units Hum R SAI X 24 H, recieved at 1100 cc Heplock @R-metacarpalvien,(-) erythema, (-) tenderness ,(-) warmth LABS AND DIAGNOSTIC ECG-to identify disturbances, conduction abnormalities and electrolyle imbalances Atrial fibrilliation T occasional PVCS AFIB- possible causes are RHD, HYPERTENSION, MI, CAD,HF, cardiomyopathy and periorditis -other causes: CORD, Increased sympathetic response PVC- Possible causes are electrolyle imbalance, myocarrdid isdemia -possibly asymptomatic - seen in older patients often