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OOctober 7, 1951
O Tanauan City, Batangas
 59 years old
Male
 Married
: Roman Catholic

: Filipino
47kg
 157 cm
  
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 as
verbalized by the patient.

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Mr. SRL experiences shortness of breath.
 

  
 

 
Mr. SRL woke up in the middle of the night
complaining of persistent cough. He couldn¶t sleep well
because of this. Later on, he complained of shortness of
breath that became intolerable. He was sent to
emergency room in DMMC hospital last January 5 at
around 4:18 in the morning. His physical examination
revealed that he appeared in acute distress and was
tachycardic. Upon auscultation, he has wheezing and
fine crackles. Five days prior to admission, Mr. SRL has
noted to have productive cough associated with whitish
thick phlegm but has no fever. He also experienced
increasing shortness of breath.


 
 

Mr. SRL has history of asthma that was diagnosed when
he was 2 years old. He was also diagnosed with
hypertension a year ago and had PTB that was given
uncompleted treatment. Mr. SRL was hospitalized
recently in DMMC because of asthma last November
2010. His first confinement due to asthma is said to be
caused by exposing and allowing his sweaty back area
to dry with cold air without wiping it. It was also
mentioned that his activity of cutting fire woods and
exposing himself to wood smoke when he is cooking
also triggered his asthma. He has no known allergy and
his immunization status is unrecalled.
 [ 
Cause of Death Cause of Death
Hypertension
Old age 88 y.o
82 y.o

è
 
è
 Hypertension

Male Tuberculosis

Female Patient

Asthma Deceased

  



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1. Ineffective airway clearance related to bronchoconstriction
and increased mucus production as manifested by presence of
crackles upon auscultation, wheezing, productive cough and
difficulty of breathing.
2Impaired gas exchange related to ventilation perfusion
imbalance as manifested by difficulty of breathing, increased
heart and respiratory rate.
3. Fatigue related to physical exertion to maintain adequate
ventilation as manifested by the use of accessory muscles in
breathing.
#0.1
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1. Risk for activity intolerance related to decreased oxygenation.
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  '1 11!.20

/ 2

!0
2'1.20

O N RIC NAM : Skin: Stomatitis
Acetyl-csyteine Oeneralized urticaria
CNS: Nausea and vomiting
BRAND NAM : Mild fever
Fluimucil Metabolic: other OI
symptoms,
Circulation: hypotension
2 Respiratory: wheezing, âAssess patient¶s history of
Treatment of respiratory dyspnea underlying condition
affection characterized by cough: type, frequency,
thick and viscous and character.
hypersecretion:acute and â Assess patient¶s
chronic bronchitis and its respiration and pulmonary
exacerbation secretion.
â Caution on patient¶s with
respiratory insufficiency
and history of
bronchospasm.
 '
  '1 11!.20

/ 2

!0
2'1.20

O N RIC NAM : Respiratory: Pulmonary âAssess patient¶s fro sign
Cefixime Interstitial emphysema or and symptoms of infection
interstitital pneumonia before and during
BRAND NAM : treatment:fever.
Tergecef
âMonitor electrolytes.
2 âAssess for possible
superinfection:
Bronchitis,
change in cough or
bronchiectasiswith
sputum.
infection,
secondary infection of
chronic respiratory tract
CNS: Shock
diseases,
pneumonia
 '
  '1 11!.20

/ 2

!0
2'1.20

O N RIC NAM : CNS: Depression âAssess patient¶s condition
Hydrocortisone Mood change before starting therapy and
Headache reassess regularly.
BRAND NAM : Weakness
Solu-Cortef Skin: Flushing âAssess for sign of
Sweating infection especially fever.
Circulation: Hypertension âMonitor patient¶s weight,
2 Tachycardia Blood pressure and
Treatment of primary or
electrolyte.
secondary adrenal cortex
insufficiency rheumatic
disorder collagen diseases,
dermatologic disease,
allergic state, allergic and
inflammatory ophthalmic
processes,
respiratory diseases
 '
  '1 11!.20

/ 2

!0
2'1.20

O N RIC NAM : Assess patient¶s condition
Prednisone before therapy and
regularly thereafter to
BRAND NAM : monitor drug effectiveness.
Pred20
Circulation: Hypertension Obtain baseline weight,
Others:Fluid and blood pressure and
lectrolyte disturbances electrolytes level and
2 monitor periodically
Allergic and inflammation
during therapy.
condition in bronchial
asthma
Monitor patient¶s stress
level to determine need for
dose adjustment.

Skin: Fungal Infection

ð
 
 
edication
>Prednisone 10 mg 2 times a day to be taken for 7 days
>Ansimar 400 mg ½ tablet 2 times a day
>Flumucil 600 mg 1 tablet 2 times a day to be dissolve in ¼
glass of water
>Montemax 10 mg 1 tablet a day for 2 weeks
>Regeron plus once a da
>Levox 500 mg once a day for 7 days
> ssentials forte 2 times a day after medications.
1xercise

The patient has advised to limit activities that

may contribute to excessive sweating.

.reatment

The patient was instructed to follow all the

doctors advised with regarding to his
medication for fast recovery
 ealth Teaching
The patient has instructed to:
>Avoid consuming milk, eggs, seafoods, chiken, eggplant, and
pineapple.
>Limit intake of sodium to >2g/ day, cholesterol to < 200
mg/day, fat to
20% of total calorie
>Avoid cigarette smoking
>Avoid exposing to wood smoke, chemicals and air pollution.
> at a healthy balanced diet everyday
>Increase fluid intake
>Avoid activities that causes fatigue
>Have enough sleep and rest periods
>Avoid being stressed as much as possible
0n follow Up
The patient has instructed to visit his
physician for any compliance and for check
up after discharge.
'iet
The patient has instructed to:
>Avoid consuming milk, eggs, seafoods,
chiken, eggplant, and pineapple.
>Limit intake of sodium to >2g/ day,
cholesterol to < 200 mg/day, fat to
20% of Total calories.
    
O3
Smeltzer, C.S. and Bare, B.O. (2008) O


 
 
 

 Baltimore,
Md: Lippincott Williams & Wilkins.
Marieb, .N. (2004) 





Singapore, Pearson ducation Inc.
Reyes, L.N and Layug, M. .M (2009)
 
   


! 

"#!$Quezon City, C&
publishing, Inc.
2
http://www.ecarma.net/asthma.html(Retreived:January 9,
2011/9:50 pm)
http://www.webmd.com/asthma/guide/bronchial
asthma(Retreived:January 9,2010/8:45 pm)
http://www.nlm.nih.gov/medlineplus/ency/article/000092.ht
(Retreived:January 9, 2011/7:00 pm)