Fa r E a s t e r n U n i v e r s i t y

Institute of Nursing
Summer term 2008

NURSING-PROCESS

In Partial Fulfillment
Of the
Requirements for NCM

Submitted by:
Kris-Ann Evert Manabat SN
BSN030

Submitted to:
Prof. Manolo R. Bilog II RN MAN
PERSONAL DATA

Name: JCN
Address: M. Delos Santos St., Sampaloc, Manila
Gender: Male
Age: 25 yrs. old
Birth date: January 14, 1983
Birthplace: PGH Manila
Civil Status: Single
Nationality: Filipino
Religion Orientation: Roman Catholic
Occupation: Call Center Agent

ADMISSION DATA

Chief Complaint:
Increase in production of cough and has difficulty of
breathing.

NURSING HISTORY

History of Present Illness

JCN is experiencing too much secretion and has difficulty in
breathing. He said at first he is not worried but due to
consecutive week of cough, he decided to have a check-up. He
doesn’t even stop smoking even if he is suffering cough. He said
that there are times he is suffering night sweat and fever. He had
partial loss of weight and sometimes loss his appetite. He is also
suffering fatigue.

Past Medical History

JCN has incomplete immunization, since he doesn’t
complete it until second of age. He told me that when he is a
child his mom buy drugs in a pharmacy whenever he is
experiencing fever, cough and colds. At the age of 13 he had
dengue fever that made him hospitalized for almost two weeks.
Family Medical History

Mother of Father
JCN of JCN
59 56
Asthma

JCN JBN
JMN
25 20
23
TB Syno

Occupational History
JCN is a graveyard shift call center agent. He drinks 3-4 cups
of coffee per day. He is a chain smoker, he smokes every time he
had free time and almost takes 20-25 sticks per day.

PATTERNS OF FUNCTIONING

Physiological Health
Coping Patterns
Due to the occupation of JCN he sleeps every morning and
wake up5-6 pm. He uses cigarette as a form of relaxation and to
manage stress, “naninigarilyo na lang ako kapag naiistress ako,
kasi nakakapaisip ako at nareerelax ako nito.” He prefer drinking
coffee, “gustong gusto ko ang kape, lalu na ang trabahi ako ay
panggabi. Umiinum lang ako ng kape para hindi dapuan ng
antok.”

Interaction Patterns
Every time he got home he just eat then go to sleep, and
when he wake up he just take a shower, eat then go to work. He
doesn’t interact too much, because he prefers to sleep than to
socialize.

Cognitive Patterns
JCN is a college graduate major in Mathematics. But due to
the unemployment problem in our country, he apply to be a call
center agent, in this way he help his mother and father to the
expenses of his brother and sister.

Self-concept
JCN verbalized “gusto ko kung sino ako, nagagwa ko ang
gusto ko at nakaktulong ako sa pamilya ko. Yan dapat ang
ginagawa ng mga lalake.” JCN is properly dressed but looks
haggard because of eye bugs.

Family Coping Patterns

“I live separately to my family, but still I help to the
expenses. When I get sick my mom visit me in my apartment.” He
said. JCN said that he maid the decision on his own since he live
separately.

Socio-Cultural Health
Significant Relationship
He said that his family has a good relationship, and he is
closed to both of his parents. He verbalized “kapag my problema
ako, kakausapin ko nalang yung mga kapatd ko. Sakanila ako
madalas naglalabas ng problema”. JCN have a girlfriend for 3
years and 6 months and said “ayos naman kami, madali lang
namin nanaayos ang problema. Open naman kasi kami eh. Nung
una ang madalas naming pinagaawayan ay ang paninigarilyo ko.
Pero hinayaan niya na ako, kasi sabi ko hindi ko na rin mapigilan
sarili ko, at dun na rin akonaglalabas ng sama ng loob o kaya
pagstress ako.”

Recreational Patterns
JCN is always sleep at day, that the reason why he is not
participating in any community activities. He said “matutulog
lang ako para makapagrelax o kung hindi naman maninigarilyo,
ayun ayos na.”

Environment
JCN’s Apartment is not well ventilated which is located in a
congested area. He said “madalas akong nahihirapang huminga,
iisa lang kasi ang bintana ko sa paratment ko”. He said that he is
not satisfied to the size and place but that’s the only apartment
he can afford for now.
ACTIVITIES of DAILY LIVING

ADL Before During Interpretation

Sickness Sickness
Nutrition He doesn’t eat Do not eat well Because of the
well, he eat increase in
twice a day. He secretion there
love too much is a loss of
coffee appetite
Exercise He doesn’t He doesn’t There will be a
practice practice increase in
exercise exercise difficulty of
breathing
Hygiene He has proper He has proper normal
hygiene hygiene
Sleep and Rest Doesn’t get Doesn’t get Because of his
enough sleep enough sleep job

PHYSICAL ASSESSMENT

General Appearance

Findings Interpretation/Analys
is
Height 5’10” His height is not
proportion to his
weight
Weight From59kg to 56kg He has weight loss
Posture/gait The client has a erect normal
posture, and his body
is straight and his
movements is
coordinated
Skin Color
Personal Clean and neat normal
Hygiene/Grooming
Body and breath He has bad breath The client smokes
Odor odor that causes bad
breath
Nutritional Status The client doesn’t abnormal
 have good nutrition,
he eat twice a day.
And take too much
coffee

Vital signs

Findings Interpretation/
Analysis
Temperature 37.1°C normal
Pulse rate 82beats/minute normal
Respiratory rate 23breaths/minute There is an
increased in the
respiratory rate
Blood pressure 100/70mm Hg normal

Head-to-toe Assessment

Body part Normal Actual Interpretation/ana

findings Findings lysis
Mouth 32 adult teeth 28 adult teeth Abnormal
Smooth, white Brown
shiny tooth discoloration
enamel of enamel
Pink gum Black gums
uniform pink Brown lips
color of lips
skin Varies from Pale skin abnormal
light to deep
brown ;from
ruby pink to
light pink from
yellow
overtones to
olive
No edema
When pinched
skin springs
back to
previous state
Moisture in
skin folds and
axillae
Other PA is normal and others are on the narrative.

PATHOPHYSIOLOGY (Schematic Diagram)

M. Tuberculae

Lungs Alveolist M. Tuberculae

Macrophages
Alveoli
(nuetrophils and WBC)

Inflammatory reaction Calcify

(Inflammation)

Increased in Secretion

Dormant Blood stream

Systematic infection of TB

LIST OF PRIORITIZED NURSING PROBLEM

Cues Nursing Diagnosis Reason For
Prioritization
Ineffective Airway Ineffective airway
S: Clearance related to clearance should be
He doesn’t even Smoking the first to prioritize
stop smoking even if based on the ABC’s
he is suffering cough where in Airway are
Sometimes loss his the first needed to
appetite. He is also prioritize before
suffering fatigue. breathing,
he is suffering night circulation and
sweat and fever other.
He is a chain
smoker, he smokes
every time he had
free time
“naninigarilyo na
lang ako kapag
naiistress ako, kasi
nakakapaisip ako at
nareerelax ako nito.”
“… pinagaawayan ay
ang paninigarilyo ko.
Pero hinayaan niya
na ako, kasi sabi ko
hindi ko na rin
mapigilan sarili ko,
at dun na rin
akonaglalabas ng
sama ng loob o kaya
pagstress ako.”
“matutulog lang ako
para makapagrelax o
kung hindi naman
maninigarilyo, ayun
ayos na.”
“madalas akong
nahihirapang
huminga, iisa lang
kasi ang bintana ko
sa paratment ko”.

O:
He had partial loss
of weight
Increase in
production of cough
and has difficulty of
breathing.
Almost takes 20-25
sticks of cigarette
per day.

28 adult teeth
Brown discoloration
of enamel
Black gums
Brown lips
Pale skin
23breaths/minute
S: Ineffective coping Ineffective coping is
“matutulog lang ako related to situational the least prioritize
para makapagrelax o crises since the airway is
kung hindi naman the first that should
maninigarilyo, ayun be prioritize, and the
ayos na.” problem doesn’t
“naninigarilyo na recognize by the
lang ako kapag client
naiistress ako, kasi
nakakapaisip ako at
nareerelax ako nito.”
“gustong gusto ko
ang kape, lalu na
ang trabahi ako ay
panggabi. Umiinum
lang ako ng kape
para hindi dapuan
ng antok.”
 NURSING CARE PLAN

Nursing Analysis Nursing Goal Nursing Intervention Rationale Evaluation

Diagnosis
/Cues
Ineffective Causes Long term Goal: Actions to achieve Performing Was the
Airway Immediate To maintain the adequate patient chest patient able to
Clearance : adequate, airway. physiotherap maintain
related Increase in patient airway. 1. Position the head hy will help airway
toSmoking Secretion midline with the patient patency?
Intermedia Short term Goal: flexion loosen and Yes_ No_ why?
S: te: 1. To maintain appropriate for mobilize
He doesn’t Increase in open airway in age/condition to secretion. Was the
even stop Infection at-rest or maintain open (Fundamental patient able to
smoking even Root/Prim compromised airway in at-rest s of Nursing identify
if he is ary: individual. or compromised by Taylor precipitating
suffering Predisposin individual. p1396) factors?
cough g Factors 2. To identify 2. Assist with When the Yes_ No_ why?
Sometimes related to causative/precipi appropriate cause is
loss his smoking tating factors. testing such as identified the Was the client
appetite. He pulmonary patient will able to identify
is also Analysis 3. To take function/ sleep be able to and
suffering Scientific: advantage of studies to identify assess the demonstrate
fatigue. When the gravity causative/precipit environment how to initiate
he is M.tubercula decreasing ating factors. and make appropriate
suffering e virus get pressure on the 3. Elevate head of adjustments. preventive
night sweat in to our diaphragm and the bed/change (Fundamental actions?
and fever body, it will enhancing position every 2 s of Nursing Yes_ No_ why?
He is a chain affect the drainage hours and prn to by Taylor
smoker, he lungs, the of/ventilation of take advantage of p.1392) Was the client
smokes every alveoli, then different lung gravity decreasing Postural able to
time he had their will be segments. pressure on the drainage, verbalize the
free time an diaphragm and gravity is important of
“naninigarilyo inflammator 4. To maintain enhancing used to drain allergen free
na lang ako y reaction, allergen free drainage the secretion environment?
kapag that causes environment. of/ventilation of from the Yes_ No_ why?
naiistress increase in different lung lungs.
ako, kasi secretion. segments. (Fundamental
nakakapaisip 4. Keep the s of Nursing
ako at Implicatio environment by Taylor
nareerelax n allergen free p.1397)
ako nito.” An according to A pollutant
“… increased in individual free
pinagaawaya secretion situation. environment
n ay ang may cause is particularly
paninigarilyo death important for
ko. Pero individuals
hinayaan niya with
na ako, kasi respiratory
sabi ko hindi problems.
ko na rin (Fundamental
mapigilan s of Nursing
sarili ko, at by Taylor p.
dun na rin 1392)
akonaglalaba
s ng sama ng
loob o kaya
pagstress
ako.”
“matutulog
lang ako para
makapagrelax
o kung hindi
naman
maninigarilyo
, ayun ayos
na.”
“madalas
akong
nahihirapang
huminga, iisa
lang kasi ang
bintana ko sa
paratment
ko”.

O:
He had partial
loss of weight
Increase in
production of
cough and
has difficulty
of breathing.
Almost takes
20-25 sticks
of cigarette
per day.

28 adult
teeth
Brown
discoloration
of enamel
Black gums
Brown lips
Pale skin
23breaths/mi
nute