Demographic Data

Name: Patient X
Address: Tondo Metro Manila
Age: 55 years old
Gender: Male
Civil Status: Married
Religion: Roman Catholic
Nationality: Filipino
Date of Admission: December 20, 2007
Time of Admission: 8:00 am
Chief complaint: productive cough for 3 months, fever, body weakness and dyspnea for 3
days PTA
Admitting Diagnosis: Dr. Jesper D. Bayaua MD
Final Diagnosis: Chronic bronchitis secondary to chronic smoking

Nursing History

I. History of Present Illness

The patient is known to be a chain smoker on their barangay. He usually
consumes 2 packs of cigarette (Champion) everyday for the past 6 years. On
this year, he usually experiences upper respiratory tract infection such as
colds and cough occurring at least 5-8 times a year. He usually treats this
condition using OTC drugs such as Neozep 1 tab TID and Robitussin 1 tbsp
TID and the condition subsides. Until 3 months prior to admission the
patient had experienced productive cough that persist for 3 months and not
relieve by his neozep and robitussin. He also experienced body weakness and
dyspnea 3 days PTA. Due to his condition he was rushed by his wife to
Quezon City memorial hospital. He was seen and examined by the physician
and CBC, urinalysis, ABG analysis, pulse oxymetry and chest X-ray was
ordered. After physical and medical examination he was diagnosed as having
chronic bronchitis.

II. Past Medical History

 The patient had experienced measles, chicken pox and diphtheria
during his childhood days and they are properly treated.
 The patient had experienced diarrhea, fever and headache usual
medication taken by the patient were paracetamol 1 tab q 4h, Imodium 1
tab TID and diatabs 1 tab, taken until symptoms are gone
 No other illnesses noted to the patient

III. Pedigree

Patient X Mother

Fioning Charing Mojo

IV. Genogram
 Lolo Lola Lolo Lola

Patient X Mother

Fioning Charing Mojo

= No genetic illness

= HPN

= Asthma

Daily Activity Pattern

Pattern of Before Hospitalization During Hospitalization Rationale

Functioning
1. Nutrition  The patient usually  The patient could  Adequate nutrition,
eats three times a not able to eat vitamins and
day with food well, he usually minerals are
preferences of consume ¼ of his necessary for the
meat, chicken and meal (lugaw) due to body to prevent
vegetables. Upon DOB. infection especially
meals, he usually on the respiratory
consumes 1 cup of tract
rice.  Dyspnea could able
to make the
 The patient weighs  Patient weight is patient resist food
55 kg (PTA) 54 kg intake for patient’s
 The patient usually  The patient drinks energy is directed
drinks 7-8 glasses 5-6 glasses of to increase O2
of water water (1,000 ml intake
only)
 Abdominal girth of  Abdominal girth is
28 inches (PTA) 27 inches
2. Elimination  The patient usually  The patient could  Bowel movement is
pattern defecates once a not able to move one vital
a. Fecal day with stool color her bowel for the assessment in
elimination of golden yellow past 3 days. order to monitor
and consistency is tissue perfusion on
formed GIT (Kozier, et al.,
 The patient does Fundamentals of
not feel any Nursing)
discomfort during  The patient could
defecation not able to move
his bowel for 3
days due to
decrease tissue
 oxygenation to
intestinal cell
caused by decrease
peristalsis and also
caused by dyspnea

b. Voiding  The patient usually  Patient urinates  Voiding pattern is

pattern urinates 6-7 times 700-800 ml/day essential in
a day with urine (usual intake of assessing fluid
characteristic of 2000-3000ml) balance in the body
amber color and and also in
clear urine. assessing renal
 The patient does tissue perfusion.
not experienced
any pain and
discomfort upon
urination.
3. Personal  The patient usually  The patient is  Personal hygiene
Hygiene takes a bath every cleansed and plays a role in
a. Bathing day and he usually bathed with a wet transmission of
shampoos his hair towel by his wife microorganisms
every day as well on the bed.

4. Rest and  The patient usually  The patient  Sleep disturbation

Sleep sleeps at around experienced sleep experienced by the
9pm and wakes up disturbance with patient was caused
at 5 am with total usual sleep span of by DOB
sleep span of 8 5-6 hours
hours
5. Exercise  The patient has no  The patient is  Exercise is an
regular exercise under CBR, passive essential part of
pattern his usual exercise, deep healthy lifestyle to
form of exercise is breathing and prevent illnesses
walking from their coughing exercise  CBR is necessary to
house to his office, and turning is the patient to
approximately 1 km initiated by the decrease O2
distance, every nurse demand on the
morning and body
afternoon  Turning, DBE and
coughing exercise
are necessary to
facilitate
mobilization and
expectoration of
bronchial secretion
6. Substance  The patient is  The patient is  The primary cause
abuse known to be chain instructed to stop of chronic
smoker, he usually smoking gradually bronchitis is the
consumes 2 packs (reduce 2-3 sticks chronic cigarette
of cigarette per day) smoking
everyday for 6  The patient takes  Smoking is so
years. About 4,380 the recommended difficult to stop
packs of cigarette drug regimen for once becomes
consumed for the the treatment of routine of one’s
 past 6 years his condition life, so we must
(Champion) encourage gradual
 The patient do not cessation of
use any smoking
illegal/prohibited
drugs
 The patient has no
supplemental
vitamins and
minerals

Sociocultural Pattern

A. Recreational pattern
The usual form of recreation of the patient was smoking for he verbalizes that he
feels relaxed everytime he smokes. Sometimes, the patient hangs out with his
friends after working, they usually go to KFC restaurant, they spent their time
chatting and smoking.

B. Environmental pattern
The patient lives in Tondo Manila besides the two rubber factory (about 5 meters
distance). They usually smell the unpleasant odor from the factory. Their house is
near the national highway where they were many buses and vehicles traveling. Their
toilet facility is clean and comfortable (with flush and drainage tank). Their water
supply is enough to supply their daily water need. Their drinking water is purified
water from Aqua Vida.

C. Economic pattern
The patient work as process server on Regional Trial Court of Metro Manila branch
II. He usually earns 6-7,000 a month. His wife is a public school teacher on Manuel
Roxas National High School with usual earning of 5-6 thousand per month. They
said that their income sometimes not enough to support their family.

Physiological Health Pattern

A. Coping Pattern
The patient views situations to his life positively. He believes that he will be cured
from his disease. He said that smoking is a one form of his stress reliever. Due to
hospital stay, he could not able to smoke inside the hospital and he was required by
his physician to stop smoking. He usually asks cigarette to his relatives, but advised
by her family to follow what his physician had advised.

B. Interactive Pattern
The patient has good relationship to his family and officemate. He usually makes
his officemate smile and laugh by his funny jokes every time he comes around their
office. He usually makes sure that ever Sunday his family celebrates mass as one
family.

C. Cognitive Pattern
The patient is an Information Technology graduate from University of Santo
Tomas. He verbalizes that he still can make decisions easily and decides for
himself despite his condition.
 Physical Examination

Date: December 21, 2007

Time: 8:00 am

I. General Appearance
Seen patient lying on bed, with HOB elevated at 30 o and with IVF of D5LR
at 600 ml regulated at 41 gtts/min. the patient is observed to be weak, pale,
has productive cough (expectoration of at least 6-8 times a day), and has
difficulty of breathing. Patient is under oxygen therapy regulated at 2LPM

II. Level of Consciousness

The patient is oriented to time, person and place and able to recall recent,
immediate and remote memory as evidence by, the patient could able to
recall his breakfast, his birthdate and able to repeat information given by
the examiner.

III. Anthropomimetric data

Patient’s height: 5 feet, 3 inches
Patient’s weight: 55 kg (PTA) and 54 kg (December 21, 2007)
Patient’s abdominal girth: 28 inches (PTA) and 27 inches (December 21,
2007)

IV. Vital signs

BP: 130/80
PR: 98 bpm
RR: 40 cpm
Temp: 38.0oC
 Body Part Method Used Findings Interpretation
Head Inspection No lesions, Normal
symmetrical to the
body
Skull Palpation Normocephalic Normal
Hair Inspection Black, equally Normal
distributed
EYES
Pupil Inspection PERRLA Normal
Sclera Inspection White Normal
Conjunctiva Inspection Both palpebral Due to ↓ tissue oxygenation
conjunctiva are pale secondary to inflammation
upon inspection of bronchi
Eyelashes Inspection Equally distributed Normal
Eyebrows Inspection Equally distributed Normal
Eyelids Inspections (+) dark circles below Due to sleep pattern
the lower eyelid disturbance caused by
dyspnea
EARS
Pinna Palpation Able to recoil Normal
Internal canal Inspection No discharge, with Normal
minimal cerumen
Nose Inspection (+) nasal flaring Body’s mechanism to
increase tissue oxygenation
Nasal septum Inspection Intact Normal
MOUTH
Lips Inspection  (+) purse lip  Body’s mechanism to
breathing increase tissue
oxygenation

 both upper and  Due to ↓ tissue

lower lips are pale oxygenation secondary
and dry to inflammation of the
bronchi

 (+) cyanosis around  Due to prolonged

the lips oxygen deprivation on
tissue caused by
inflammation of bronchi
Teeth Inspection (+) Tartar Due to chronic use of
cigarette
Gums Inspection (+) dark discoloration Due to chronic use of
on the gum line cigarette
Neck Inspection Symmetrical to the Normal
body

Palpation No palpable mass Normal

Chest Inspection  (+) rapid and
shallow breathing
(RR: 40 cpm)
 (+) Chest indrawing
 Chest size and  Barrel chest due to
 shape is longer and increased retained air
larger and on the lung causing
unsymmetrical than expansion of rib cage.
the abdominal size

Palpation  (+) fremitus upon  Due to accumulation of

speaking on left phlegm on the upper
and right lobe of lung lobe
the lung

Auscultation  (+) Rales/ crackles  Due to accumulation of

upon auscultation phlegm in the lower lung
of all over the left lobe
and right lobe of
lungs

Percussion  (+) hyperresonance  Due to accumulation of

upon percussion of air on the lung caused
both upper and by obstructed bronchi
lower of the right
and left lung lobe.
Abdomen Inspection  Abdominal size and  Normal
shape is
symmetrical to the
body
 Abdominal skin is  Due to decrease tissue
observed to be pale oxygenation caused by
inflammation of bronchi

Palpation  (-) tenderness all  Normal

over the quadrant
of abdomen
 (-) palpable mass,  Normal
nodules and lesions

Auscultation  (+) Borborygmi  Normal

sound

 bowel sound of 1  Due to decrease tissue

every minute oxygenation of GIT
caused by inflamed
bronchi

Percussion  (+) drum like sound  Normal

on epigastric area

 (+) flat sound upon  Normal

percossion of RUQ
of abdomen
Lower and Inspection  (+) nail clubbing  Due to prolonged
Upper (angle between nail oxygen deprivation
Extremities bed and root is
200o
 (+) pale skin  Due to decrease tissue
 oxygenation caused by
inflammation of the
bronchi

 (+) bluish  Due to prolonged O2

discoloration of nail deprivation on tissue
bed (cyanosis) caused by inflammation
of bronchi

Palpation  (+) Cold and clammy  Due to decrease tissue

skin oxygenation caused by
inflammation of the
bronchi

 Capillary of 3  Normal
seconds

Diagnostic Tests

1. Arterial Blood Gas Analysis

 Measurements of blood pH and of arterial oxygen and carbon dioxide
tensions are obtains when managing patients with respiratory problems and in
adjusting oxygen therapy as needed.
 Comprises of PaO2 and PaCO2
 PaO2 indicates degree of oxygenation of the blood and PaCO2 indicates the
adequacy of alveolar ventilation
 Radial artery, brachial artery and femoral artery is the common site for
withdrawal of blood specimen (10 ml)
 Avoid air on syringe and should be heparinized to prevent blood clot

2. Pulse Oximetry
 Non invasive method of continuously monitoring the oxygen saturation of
hemoglobin
 Although pulse oximetry does not replace arterial blood gas measurement, it
is an effective tool to monitor for subtle or sudden changes in oxygen
saturation
 A probe/sensor is attached to fingertip, forehead, earlobe, or bridge of the
nose. The sensor detects changes in oxygen saturation levels by monitoring
light signals
 Normal SaO2 is 95%-100%, 85% indicates tissues are not receiving enough
oxygen
Laboratory Results

I. CBC (December 20, 2007)

Parameters Normal Values Result Interpretation

RBC 5-7 mil/mm3 6 mil/mm3 Normal
WBC 5-10, 000/mm3 13,000/mm3 Leukocytosis due to
underlying bacterial
infection
Platelet 150-350, 000/mm3 300,000/mm3 Normal
Hct 32-42% 33 Normal
Hgb 8.1-11.2 mmol/L 9 mmol/L Normal
II. Urinalysis (December 20, 2007)

Parameters Normal Result Actual Result Interpretation

Color Yellow - straw Straw colored urine Normal
Specific Gravity 1.005 – 1.030 1.015 Normal
PH 5.0 – 8.0 7 Normal
Glucose Negative Negative Normal
Protein Negative Negative Normal

III. Blood Chemistry (December 20, 2007)

Normal Result Actual Result Interpretation

Serum albumin 35-50 g/L 35 g/L Normal

Serum protein 60-84 g/L 70 g/L

Normal

Serum K 3.5 – 5 mEq/L 4 mEq/L Normal

Serum Na 135-145 mEq/L 140 mEq/L Normal

IV. ABG analysis

Normal Value Result

PO2 80-100 mmHg 60 mmHg
PCO2 35-45 mmHg 55 mmHg
Impression:
 Respiratory acidosis
 Hypoxemia and hypercopnea

V. Pulse Oximetry

Normal Value Result Interpretation

Oxygen Saturation
Due to decrease
availability of oxygen
95-100% 83% caused by decrease O2
intake secondary to
inflammation of bronchi

VI. Pulmonary Function Test

Normal Value Result Interpretation
Residual Volume 1,200 ml 1,400 ml Due to increase air
remaining on the lungs
after maximum exhalation
caused by obstruction on
bronchi
Vital Capacity 4,600 ml 3,900 ml Due to decrease air
exhaled caused by
obstructed bronchi
Functional 2,300 ml 2,800 ml Due to increase air remains
Residual Capacity on lung after normal
expiration caused by
 obstruction on bronchi
Total Lung 5,800 ml 6,500 ml Due to increase air in the
Capacity lung after a maximum
expiration caused by
obstructed bronchi

Discharge Plan

Medication
 Mucolytic ( Ambroxol 1 tab BID)
 Ceftriaxone 500 mg PO q 12h
 Bronchodilator (Atropine Sulfate 12.5 mg IV q6)
 Hydrocortisone 50 mg IV OD

Exercise
 Instruct patient about DBE
 Instruct patient about coughing exercise
 Any tolerable exercise (Walking, jogging, aerobic, etc)

Health Teaching
 Instruct patient to avoid cigarette smoking gradually (at least2-3 sticks per
day) and provide health teaching regarding effect cigarette smoking to ones
health
 Instruct patient about the importance of adherence to medication
 Instruct patient about importance of follow up care

OPD
 For weekly check up
 For nebulization every other day

Diet
 Instruct patient to increase fluid intake (2-3 L/day)
 Diet as tolerated by the patient

Prepared By:

JESPER DOMINCIL-BAYAUA RN, RM

Clinical Instructor, College of Nursing

University Of La Salette

Health Assessment Summer 2011