Lyceum-St.

Cabrini College of Allied Medicine

School of Nursing
Maharlika Highway, Sto.Tomas, Batangas

Bronchitis
(A Case Study)

St. James Hospital

Date of Rotation: July 6-8, 2009

Presented to:
Billy John Luzung, R.N.
Presented by:
BSN 3-1
Group 4
Rumbines, Jinky C.
Sabonsolin, Isabelle
Saluta, Mark Angelo
Siervo, Haiyah Jestine
Suizo, Adrian
Tachibana, Cherryann
Tangco, Jennelyn
Tolentino, April May

Table of Contents

I.

Title
Page
..1

II.

Table of
Contents2

III.

Introduction

IV.

3
Demographic

V.

Data..4
Source of Reliability of

VI.

Information..5
Reason for Seeking

VII.

Healthcare.5
History of Present

VIII.

Illness..5
Past Medical

IX.

History.5
Family
History.

X.

6
Review of

XI.

System..7
Functional

XII.

Assessment..8
Anatomy and

XIII.

Physiology..9
Pathophysiology

XIV.

13
Laboratory
.14

XV.

Drug
Study

XVI.

.16
Problem
List..1

XVII.

9
Nursing Care

XVIII.

Plan.20
Progress

XIX.

Notes,,.28
References
..29

I.

Introduction
Nursing is the science of applying the art of care. As nursing students we are

trained to provide care and give a better way of living to our clients, sick or not. We
chose the case of a client who was diagnosed with Bronchitis.
Bronchitis is inflammation of the mucous membranes of the bronchi, the
airways that carry airflow from the trachea into the lungs. Bronchitis can be
classified into two categories, acute and chronic, each of which has unique
etiologies, pathologies, and therapies.
Acute bronchitis is characterized by the development of a cough, with or
without the production of sputum, mucus that is expectorated (coughed up) from
the respiratory tract. Acute bronchitis often occurs during the course of an acute
viral illness such as the common cold or influenza. Viruses cause about 90% of
cases of acute bronchitis while bacteria account for less than 10%.[1]

Bronchitis most commonly occurs after an upper respiratory infection such as the
common cold or a sinus infection. You may see symptoms such as fever with chills, muscle
aches, nasal congestion, and sore throat.
Cough is a common symptom of bronchitis. The cough may be dry or may produce
phlegm. Significant phlegm production suggests that the lower respiratory tract and the lung
itself may be infected, and you may have pneumonia.
The cough may last for more than two weeks. Continued forceful coughing may make
your chest and abdominal muscles sore. Coughing can be severe enough at times to injure the
chest wall or even cause you to pass out.
Wheezing may occur because of the inflammation of the airways. This may leave you
short of breath.
Knowing this, weve decided to study this case because we see it as an opportunity to
give ones best to care for the client. We know that we will learn a plethora of knowledge from
this case and at the same time, give maximum effort of care we can give in our limited time of
rotation.

II.

Demographic Data

A. Name

Mr. EAE

B. Age

32 years old

C. Gender

Male

D. Civil Status

Married

E. Nationality

Filipino

F. Religion

Roman Catholic

G. Usual Source of Medical

Help

Hospital

H. Address

St. Joseph Village 6. ,Cabuyao,

Laguna

I. Date of Birth

Aug. 4, 1976
J. Birth Place

Camarines Sur

K. Educational Background

Automotive (Vocational)

L. Occupation

Jeepney Driver

M. Usual Source of Income

From his and her wife's sallary

N. Attending Physician

Dr. Jose P. Santiago

O. Date of Admission

Jul. 4, 2009

P. Time of Admission

8:00pm

Q. Room No.

318 (A)

R. Chief Complaint

Fever

S. Admitting Diagnosis

URTI T/C Bronchitis

T. Name of Hospital

III.

St. James Hospital- Sta. Rosa, Laguna

Source of Reliability of Information

All information written and presented in this case were carefully
collected and gathered from St. James Hospital to be found in Sta. Rosa,
Laguna. Information and data were gathered from the clients chart which
includes medical records, laboratory examinations and medical findings.
Some information was also gathered from our assessment and from the client
and his wife.

IV.

Reason for Seeking Healthcare

The client was brought to the hospital because of fever and chills.

V.

History of Present Illness

The client experienced fever and chill the morning prior to admission.
The client performed self-medication, had taken Amoxicillin, Paracetamol and
Alaxan. But the symptoms of illness didnt go off. The client together with his
wife went to the hospital, Saturday evening. The client experienced pain on
the posterior side of his neck when coughing.

VI.

Past Medical History

Mr. EAE has a history of asthma when he was still a child. Years ago, he
experienced headache and sleeping difficulty. Mr. EAE had been admitted to
the hospital three times because of three motorcycle accidents. He stated
that he only acquired bruises and wounds from the accidents.

VII.

Family History

Grandfather
Arthritis
Grandmot
her

Rheuma
Diabetes
HPN
Lung problem

HB

H
B

HB

Moth
er

D
M

RIP

HB

(47)

Client
*lung
problem

30
LP

25

23

*A
*S

2
1

1
5

*A
*S

Son
51/2
Asthma

Daughter
4- cold, fever,
cough

*asthma

Legend:
Male

Femal
e

A
S

VIII.

Alcoholic
Smoker

Review of System

General

Skin

Hair and Nails

Head
Eyes

Ears

Nose

Mouth

Pharynx

Neck
Respiratory

Cardiovascular
Gastro Intestinal
Extremities

IX.

Comfortable
Conscious
Coherent
Dark brown
Good turgor
Presence of scars
Black
Evenly distributed
Nails: Normal
Nail beds: pinkish
Normocephalic
Scalp: smooth
Lids: symmetrical
Conjunctiva: pink
Pupil: equal
Reactive to light accommodation
No hearing deficit
Symmetrical
External ears: normset
Presence of light cerumen
Nasolabial fold: symmetrical
Septum: Midline
Mucous: pinkish
Sinuses: not tender
Lips: pinkish
Tongue: midline
Presence of dental caries
Gums: pinkish to reddish
Speech: grossly intact
Teeth: incomplete
Uvula: midline
Mucosa: pinkish
Tonsils: pink and smooth
Trachea: midline
Thyroid: non-palpable
Cough noted
Lung expansion: symmetrical
RR: 27
BP: 110/90
PR: 75
Good appetite
Regular defecation
Limbs: symmetrical
ROM: full, symmetrical
Warmth: symmetrical

Functional Assessment
Health Perception and Health Maintenance

According to Mr. EAE, he had never been hospitalized before because if

illness (except for the 3 motor accidents he had experienced). He perceived
himself as a healthy individual. He smokes more than one pack a day, drinks
1 L of beer every night and eats street foods, he stated that he always feel
good when he do those things. As a jeepney driver, he is always exposed to
air pollution.

Self Esteem, Self- concepts, Self- Perception Pattern

Mr. EAE is a cheerful guy, his open and is always ready to answer
questions. He is a family-oriented man, hes not fond of going out with his
friends and drink alcohol, he prefer to go home, drink beer alone and spend
time with his family after work.

Exercise and Activity Pattern

Mr. EAE is a jeepney driver who works everyday. He wakes up every
6am, take a bath and eats breakfast. At 7-11am, he drives the passengers
jeepney, goes home at 11am and rest for an hour. At 1-7pm, he drives again.
At home, he likes to lie on the sofa, watches t.v., eats foods brought from the
street, drinks beer and bond with his wife and children.

Sleep and Rest Pattern

Mr. EAE goes home at 11am and rests at 12pm. He usually sleeps nine
hours a day. He sleeps at 9pm and wakes up at 6am.
Nutrition/Elimination
Mr. EAE has an unusual desire for food; He loves to eat four regular
meals everyday and eats snacks. He likes to eat junk foods, street foods, likes
to smoke a lot and drink beer. He has an allergy to shrimp. He defecates 2-3
times daily.

Coping Stress Management

Mr. EAE said that ho dont experience stress at work, not with
passengers, the noise, the traffic and pollution. He said that sometimes his
childrens activities and playfulness give him stress. What he does is he talks
with his children and force them to sleep.

Environment
Garbage were regularly collected by the garbage truck.

X.

Anatomy and Physiology

10

Breathing is so vital to life that it happens automatically. Each day, you

breathe about 20,000 times, and by the time you're 70 years old, you'll have
taken at least 600 million breaths.

All of this breathing couldn't happen without the respiratory system, which
includes the nose, throat, voice box, windpipe, and lungs.

At the top of the respiratory system, the nostrils (also called nares) act as the
air intake, bringing air into the nose, where it's warmed and humidified. Tiny
hairs called cilia protect the nasal passageways and other parts of the
respiratory tract, filtering out dust and other particles that enter the nose
through the breathed air.

Air can also be taken in through the mouth. These two openings of the airway
(the nasal cavity and the mouth) meet at the pharynx, or throat, at the back
of the nose and mouth. The pharynx is part of the digestive system as well as
the respiratory system because it carries both food and air. At the bottom of
the pharynx, this pathway divides in two, one for food (the esophagus, which
leads to the stomach) and the other for air. The epiglottis, a small flap of
tissue, covers the air-only passage when we swallow, keeping food and liquid
from going into the lungs.

The larynx, or voice box, is the uppermost part of the air-only pipe. This short
tube contains a pair of vocal cords, which vibrate to make sounds. The
trachea, or windpipe, extends downward from the base of the larynx. It lies
partly in the neck and partly in the chest cavity. The walls of the trachea are
strengthened by stiff rings of cartilage to keep it open. The trachea is also

11

lined with cilia, which sweep fluids and foreign particles out of the airway so
that they stay out of the lungs.

At its bottom end, the trachea divides into left and right air tubes called
bronchi, which connect to the lungs. Within the lungs, the bronchi branch into
smaller bronchi and even smaller tubes called bronchioles. Bronchioles end in
tiny air sacs called alveoli, where the exchange of oxygen and carbon dioxide
actually takes place. Each lung houses about 300-400 million alveoli. The
lungs also contain elastic tissues that allow them to inflate and deflate
without losing shape and are encased by a thin lining called the pleura. This
network of alveoli, bronchioles, and bronchi is known as the bronchial tree.

The chest cavity, or thorax, is the airtight box that houses the bronchial tree,
lungs, heart, and other structures. The top and sides of the thorax are formed
by the ribs and attached muscles, and the bottom is formed by a large
muscle called the diaphragm. The chest walls form a protective cage around
the lungs and other contents of the chest cavity. Separating the chest from
the abdomen, the diaphragm plays a lead role in breathing. It moves
downward when we breathe in, enlarging the chest cavity and pulling air in
through the nose or mouth. When we breathe out, the diaphragm moves
upward, forcing the chest cavity to get smaller and pushing the gases in the
lungs up and out of the nose and mouth.

The air we breathe is made up of several gases. Oxygen is the most

important for keeping us alive because body cells need it for energy and
growth. Without oxygen, the body's cells would die.

Carbon dioxide is the waste gas produced when carbon is combined with
oxygen as part of the energy-making processes of the body. The lungs and

12

respiratory system allow oxygen in the air to be taken into the body, while
also enabling the body to get rid of carbon dioxide in the air breathed out.

Respiration
Respiration is the set of events that results in the exchange of oxygen from
the environment and carbon dioxide from the body's cells. The process of
taking air into the lungs is inspiration, or inhalation, and the process of
breathing it out is expiration, or exhalation.

Air is inhaled through the mouth or through the nose. Cilia lining the nose and
other parts of the upper respiratory tract move back and forth, pushing
foreign matter that comes in with air (like dust) either toward the nostrils to
be expelled or toward the pharynx. The pharynx passes the foreign matter
along to the stomach to eventually be eliminated by the body. As air is
inhaled, the mucous membranes of the nose and mouth warm and humidify
the air before it enters the lungs.

When you breathe in, the diaphragm moves downward toward the abdomen,
and the rib muscles pull the ribs upward and outward. In this way, the volume
of the chest cavity is increased. Air pressure in the chest cavity and lungs is
reduced, and because gas flows from high pressure to low, air from the
environment flows through the nose or mouth into the lungs. In exhalation,
the diaphragm moves upward and the chest wall muscles relax, causing the
chest cavity to contract. Air pressure in the lungs rises, so air flows from the
lungs and up and out of respiratory system through the nose or mouth.

Every few seconds, with each inhalation, air fills a large portion of the millions
of alveoli. In a process called diffusion, oxygen moves from the alveoli to the

13

blood through the capillaries (tiny blood vessels) lining the alveolar walls.
Once in the bloodstream, oxygen gets picked up by the hemoglobin in red
blood cells. This oxygen-rich blood then flows back to the heart, which pumps
it through the arteries to oxygen-hungry tissues throughout the body. In the
tiny capillaries of the body tissues, oxygen is freed from the hemoglobin and
moves into the cells. Carbon dioxide, which is produced during the process of
diffusion, moves outEtiology
of these cells into the capillaries, where
most of Factors:
it is
Precipitating
dissolved in the plasma of the
blood. Blood
rich in carbon dioxide then
returns
Respiratory
synctial
Smoking
virus
to the heart via the veins. From the heart, this blood is pumped toExposure
the lungs,
to
Parainfluenza virus
air pollution
where carbon dioxide passes into the alveoli to be exhaled.
Corona virus
S. pneumonia,
Haemophilus influenza
XI.

Pathophysiology

Predisposing Factors:
XII.
Age
XIII.
Gender
Family history
of asthma

Inflammation of bronchi
Irritation of the cells of the
bronchial lining tissue
Hyperemic and edematous
mucous membranes
Alpha antihypsin inhibited
Fever
fatigue
Air passages
clogged by debris

Diminish bronchial mucociliary

function

Increased irritation
Increased mucus production

Difficulty of Breathing
Dry productive cough
Wheezes

Dyspnea

Increased respiratory rate

14

XIV.

Laboratory
Hematology

Composition and SI Unit Values

Interpretation/Analysis

Results

Hemoglobin:

169

Above Normal

0.49

Normal

5.49

Normal

6.3

Normal

Male (120-150 gm/L )

Female(110-140 gm/L)Possible dehydration

Hematocrit:

Male (0.40 0.54)

Female

(0.37 - 0.47)

Male (4.5 6 x 1012/L)

RBC:

Female

Total WBC:

Platelets

(4.5 5 x 1012/L)

(5 10 x 109/L)

(150 400)

219

Normal

Eosinophils

(0.0 0.04)

0.03

Normal

Segmenters

(0.50 0.70)

0.55

Normal

Lymphocytes

(0.20 0.40)

0.31

Normal

Monocytes

(0.0 - 0.50)

0.11

Normal

15

Microscopic Feces Examination

Color:

Yellowish brown

Consistency;

soft to Semi-mucoid

Blood(gross) (-)
Mucus: (+)
Ova or Parasites: none found
Cells: WBC: 1-3/hpf

Others: E. hystolytica test (EIA): Negative

Bacteria: +

Routine Analysis

Gross
Color:

Yellow

Trasparency:
Reaction:

RBC: 0-3/hpf
Acidic

pus cells: 2-4/hpf

Specific Gravity:1.020

Chemical
Albumin:

++

Crystals Aurates: ++

Sugar:

Negative

Mucus Threads: ++

16

XV.

Drug Study

NAME

INDICATION

CONTRAINDICATI
ON

DOSAGE

SIDE
EFFE
CT

Acute and chronic

disorders of the the
respiratory tract
associated w/
pathologically
thickened mucus
and impaired
mucus transport

Early month of
pregnancy

Retard cap adult and children

>12 yr 1 cap daily

Mild
GI
side
effect
s

NURSING
CONSIDERATION

BN
AMBROLEX
GN:
AMBROXOL
HCL

Tab Adult and children>12 yr

old tid
Syrup adult and children>12
yr 1tsp tid
2-6 yr old tsp tid

Paed syr children 6-12 yr bidtid

2-6 yr tsp tid

1-2 yr tsp bid

Infant drops children 13-24
month 1 ml bid
7-12 month 0.75 ml bid
<6 month 0.5 ml bid

Assess
patients
fever or pain
Assess
allergic
reactions
Assess
Hepatoxicity
Monitor liver
and rebal
functions
Advise
patient to
avoid alcohol
Teach patient
to recognize
signs of
overdose
(chronic)
Teach
patientthat
urine may
become dark
brown.

17

NAME

BN
ZINACEF,ZIN
NAT
GN
CEFUROXIME
SODIUM

INDICATION
Moderate to
severe infection
,including those of
skin,bone,joints,uri
nary or respiratory
tract,gynecologic
infections,and
septicemia

CONTRAINDICAT
ION

DOSAGE

Hypersensitivity
to
cephalolosporin
s or penicillins

Adults and
Head ache
children
ages 12 and Hypertonia
older
Seizures

Carnitine
deficiency

750 mg to
1.5g I.M or
IV q8 hours
for 5 -10
days or 250
mg -500 mg
P.O q 12
hours
Children
ages 3 mos12 years

SIDE EFFECT

Nausea and
vomiting

NUSING CONSIDERATION

Diarrhea,abdomi
nal pain
Hyperglycemia
Toxic epidermal
necrolysis
Stevens John
syndrome

Monitor patient for

life threatening
adverse
effect,including
anaphylaxis,Steven
s John Syndrome
Monitor neurologic
status,particularly
for signs of
impending seizure
Monitor kidney and
liver function
Monitor
temperature: watch
for signs and
symptoms of
superinfection.

50100mg/kg/d
ay I.V or I.M
in divided
doses q6 to
8 hours

18

NAME

GN:

INDICATIO
N

BN:

Relief of
mild to
moderate
pain

ACETAMINOPH
EN

Treatment
of fever

PARACETAMOL

CONTRAINDICAT
ION

Hypersensitivity
Intolerance to
tartrazine
,alcohol, table
sugar, saccharin

DOSAGE
Oral adults
325 mg to
650 mg as
needed
q4-6 hours,
do not
exceed
4g/day
Children:10
-15 mg/kg
dose as
needed q4
-6 hours
Suspension
:6-12 yrs 24 tsp
1-6 yrs 1-2
tsp
3mos- 1 yr
-1 tsp 3x4x/day
Infant
drops:1-2
yrs 1.2-1.8
ml6-12 mos
0.61.2ml,0-6
mos 0.3-0.6
ml 3x-4x a

SIDE
EFFECT

Drowsines
s

NURSING CONSIDERATION

Nausea
Abdominal
pain

Hepatic
seizure

Cyanosis

Anemia
Rash
Convulsio
n

Assess patients fever or pain:

type of
pain,location,intensity,duration,t
emperature
Assess allergic
reaction:rash,utecaria
Asses hepatotoxicity: dark
urine,clay colored
stools,yellowish skin and schlera
Monitor liver and renal
dysfunction
Check input and output
ratio:decreasing output may
indicate renal failure

Coma
Delirium
followed
by
vascular
collapse.
Death

19

day.

20

XVI.
Rank

Problem List
Problem

Date Identified

Date Resolved

Ineffective Airway Clearance

July 6, 2009

July 8, 2009

Imbalanced Body Temperature

July,6, 2009

July 8, 2009

Deficient Knowledge

July 6, 2009

July 8, 2009

21

XVII.

Nursing Care Plan

ASSESSMENT

Subjective
data:
May problema
pag umuubo
ako, nahirapang
huminga pero
konti lang, as
verbalized by the
client.
Mahigit isang
kaha ng sigarilyo
ang nabibili ko ko
araw-araw, ang
sarap kais lalo na
pag
bumabyahe, as
verbalized by the

NURSING
DIAGNOSIS

PLANNING

Ineffective
airway clearance
related to mucus
secretion

After 8 hours of
nursing
intervention, the
client will be able
to maintain
airway clearance.

NURSING
INTERVENTION

1. Monitor vital
signs.
2. Establish
Nurse-patient
Interaction.
3. Monitor
respirations
and breathe
sounds.
4. Position head
for
appropriate
for condition- semifowlers
position.
5. Elevate head
of
bed/change
position every

RATIONALE

>To have a
baseline data.
>for a
comforting and
trusting
relationship

EXPECTED
OUTCOME

The client will be

able to maintain
effective airway
clearance.

>indication of
respiratory
distress
(tachypnea,
stridor, crackles,
wheezes).
>to maintain
open airway.

22

client.

Objective data:
>productive
cough

2 hours.
>assist with the
use of
respiratory
devices and
treatments.
>support
reduction or
cessation of
smoking.
>position
appropriately,
discourage use
of oil-based
products around
nose.

>to enhance
ventilation to
different lung
segment.

>various
therapies may
be required to
maintain
adequate
airways.
>to improve
lung function.

>to prevent
vomiting with
aspiration into
lungs.

23

Nursing Intervention Progress Report

Problem: Ineffective Airway Clearance

Date: July 6, 2009

Day: First day

Assessment: Subjective data:

May problema pag umuubo ako, nahirapang huminga pero konti lang, as verbalized by the client.
Mahigit isang kaha ng sigarilyo ang nabibili ko ko araw-araw, ang sarap kais lalo na pag bumabyahe, as
verbalized by the client.
Objective data:
>productive cough
Intervention:
6. Monitor vital signs.
7. Establish Nurse-patient Interaction.
8. Monitor respirations and breathe sounds.
9. Position head for appropriate for condition- - semi-fowlers position.
10.Elevate head of bed/change position every 2 hours.
>assist with the use of respiratory devices and treatments.
>support reduction or cessation of smoking.
24

>position appropriately, discourage use of oil-based products around nose.

Evaluation:
The client will be able to maintain effective airway clearance.

25

NURSING CARE PLAN

ASSESSMENT

Subjective
data:
Nilalagnat
ako, may
trangkaso
yata, as
verbalized by
the client.

Objective
data:
>Temperature
38C
>Blood
Pressure
110/90mmHg

NURSING
DIAGNOSIS

PLANNING

Imbalance
body
temperature
related to
vigorous
activity as
manifested by
increased
temperature.

After 8 hours of
nursing intervention,
the client will be
able:
1. Display
decrease of
temperature
from 38C to
37C.
2. Maintain core
temperature
at normal
level.
3. demonstrate
behaviors to
monitor and
promote
normothermia.

NURSING
INTERVENTION

RATIONALE

1. Monitor vital
signs.

>To have a
baseline data.

2. Monitor
respiration.

>Hyperventilatio
n may initially be
present, but
ventilatory effort
may eventually
be impaired by
seizures, hyper
metabolic stage.

3. Monitor
temperature
and pulse.
4. Monitor
laboratory
studies.

5. Promote
surface cooling
by means of
undressing,
cool
environment.
11.Cool sponge
bath

>may indicate
presence of other
illnesses or
evidences.

EXPECTED
OUTCOME

The client will

be able to
display
decrease of
temperature
from 38C to
37C; maintain
core
temperature at
normal level;
demonstrate
behaviors to
monitor and
promote
normothermia.

>heat loss by
convection.

>heat loss by
evaporation and
conduction.

26

12.Maintain
bed rest.

>to reduce
metabolic
demands or
oxygen
consumption.

Nursing Intervention Progress Report

Problem: Imbalanced boy temperature

Date: July 6, 2009

Day: First day

27

Assessment:
Subjective data:
Nilalagnat ako, may trangkaso yata, as verbalized by the client.
Objective data:
>Temperature 38C
>Blood Pressure 110/90mmHg
Intervention:
. Monitor vital signs.
2. Monitor respiration.
3. Monitor temperature and pulse.
4. Monitor laboratory studies.
5. Promote surface cooling by means of undressing, cool environment.
13.Cool sponge bath
Evaluation:
The client will be able to display decrease of temperature from 38C to 37C; maintain core temperature at normal
level; demonstrate behaviors to monitor and promote normothermia.

28

ASSESSMENT

Subjective
data:
Mahigit
isang kahanf
sigarilyo at
isang litrong
alak (beer) ang
nauubos ko
araw0araw, as
verbalized by
the client.

NURSING
DIAGNOSIS

Deficient
knowledge
related to
incomplete
information
about the
effects of
excessive
alcohol
consumption
and smoking

PLANNING

After 8 hours of
nursing intervention,
the client will be
able:
1. Participate in
the learning
process.
2. Verbalize
understandin
g of excessive
alcohol
consumption
and smoking.
3. Initiate
necessary
lifestyle
changes.

NURSING
INTERVENTION

RATIONALE

1. Ascertain
level of
knowledge.
Determine
clients ability
or readiness
and barriers to
learning.

>To know if the

individual is
physically,
emotionally
capable.

2. Health
Education

>For providing
information
and for
facilitating
learning.

>Differences
between normal
and abnormal
liver

EXPECTED
OUTCOME

The client will

be able to
participate in
the learning
process;
verbalize
understanding
of excessive
alcohol
consumption
and smoking;
initiate
necessary
lifestyle
changes

4. >Effects of
excessive
alcohol
consumption
and
smoking.

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Nursing Intervention Progress Report

Problem: Deficient Knowledge

Date: July 6, 2009

Day: First day

Assessment:
Subjective data:
Mahigit isang kahanf sigarilyo at isang litrong alak (beer) ang nauubos ko araw0araw, as verbalized by the
client.
Intervention
1. Ascertain level of knowledge. Determine clients ability or readiness and barriers to learning.
2. Health Education
>Differences between normal and abnormal liver
>Effects of excessive alcohol consumption and smoking.
Evaluation:
The client will be able to participate in the learning process; verbalize understanding of excessive alcohol
consumption and smoking; initiate necessary lifestyle changes

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XVIII.

Progress Notes

7/6/09

Received client lying on bed

Weak
Established NPI to have a comfortable and trusting relationship
Performed interview of past and present history
Frequent coughing
Sleepy

7/7/09

Received client lying on bed

Regained strength
Talkative
Seldom coughs
Maintained normal temperature

7/8/09

XIX.

Received client sitting on bed

Cheerful and active
Coherent
Cough was productive
Seldom coughs
Client was discharged
Maintained normal vital signs: temperature, pulse, respiration, blood pressure

References
PPDs Nursing Drug Guide
Nurses Pocket Guide
Biology (Martinez; Julian; Nazareno; Sison)
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