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PERSONAL DATA
Name: 301-A, R.A

Age: 61 years old

Sex: Male

Address: #57 Lakeview Drive Street. Bagong Ilog, Pasig City

Civil Status: Married

Educational Attainment: High School Graduate

Occupation: Utility Worker (janitor)

Religion: Roman Catholic

Nationality: Filipino

Date and Time Admitted: April 08, 2014 @ 3.16 P.M

Medical Diagnosis: Pleural Effusion (R)

Chief Complaints: Difficulty of Breathing, Cough

Informant: Patient









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NURSING MEDICAL HISTORY
Patient RA was delivered normally at full term in cephalic presentation. According to him, he
had a complete immunization. No serious illness during childhood, but he had common cough
and colds, fever and diarrhea, commonly treated with Paracetamol. He also uses herbal
medicines such as oregano and calamansi, and was relieved from cough and colds. He was a
smoker for 10 years, usually 10 sticks of cigarette a day, and consumed a total of 100 sticks. He
was also an occasional drinker of alcohol beverages, can consume up to 4 bottles of 500 ml beer.
He usually eats 3x a day and eats snacks. He likes eating vegetables and meats, has no known
allergy to foods. Has a family history of hypertension and asthma. Prior to admission, patient
was working on a textile factory and was assigned to finishing process for 6 years, plywood
factory and was assigned to hot press area for 10 years, noodles factory and was assigned to
packaging for 6 months, toothpaste factory and was assigned to packaging for 6 months, and his
current work was a utility worker on a mall.

PAST MEDICAL HISTORY
Patient RA had mild stroke last June 22, 2013. Confined for 3 days at Mary Immaculate hospital
and subsequently discharged in apparently improve condition. Had completed home medications
and was relieved.

PRESENT MEDICAL HISTORY
Last March 21, 2014, patient RA experienced cough, colds and difficulty of breathing. Consulted
a private physician and was prescribed solmux and antibiotics which afforded no relief. As per
advised by private attending physician, had chest x-ray which revealed pleural effusion.
Subsequently sought consultation at Rizal Medical Center outpatient department, where he was
given analgesics (tramadol), nebulization (combivent), antibiotics (cefuroxime and levofloxacin),
mucolytic (NAC) and butamirate citrate which provided temporary relief. Recurrence and
severity of signs and symptoms also with severe DOB prompted consultation at Lung Center of
the Philippines. Hence, this admission.





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PHYSICAL ASSESSMENT
A. HEENT
HEAD: Normocephalic at 56 cm, with white hair approximately 4-6 inches in length. Scalp is
smooth with (-) dandruff, (-) pediculosis capitis, no bumps, masses or trauma noted; upon
inspection and palpation; able to raise eyebrows; close both eyes to resistance; smile, frown; able
to turn head against resistance, able to extend the head
EYES: Symmetrical in size and shape; in normal position; eyebrows and eyelids intact; lashes
are present on upper and lower lids; evenly distributed and turned outward; (-) swelling lacrimal
gland; pupils equally round and reactive to light (brisk); (+) eye movement; with papillary sizes
of 3mm in diameter on both eye, no lumps or lesions noted.
EARS: Ears are functional and symmetrical; odorous earwax was noted upon inspection and no
inflammation; (-) to Rombergs test, able to maintain balanced while standing; (+) to Rinnes and
Webers Test, but sometimes he cant hear clearly due to increased in age.
NOSE: Nostrils are symmetrical, straight and uniform in color; there was no presence of nasal
discharge or flaring; no tenderness and lesions upon palpation; able to identified three odors such
as alcohol, cologne and coffee; with 02 therapy at 3L per minute, via nasal cannula;
MOUTH: Teeth is incomplete with (+) cavities; no dentures; no retraction of gums, pinkish in
color; lips are pale, dry in texture and symmetrical; able to purse lips when asked to whistle; able
to stuck out tongue; chewing/mastication and movement of jaw noted; able to say AH;
NECK: Neck muscles are equal in size; showed coordinate, smooth head movement with no
discomfort; lymph nodes are not palpable; trachea is placed in midline of the neck; thyroid gland
is not visible upon inspection, glands ascend during swallowing but not visible;
CHEST AND LUNGS:
Inspection: Symmetrical lung expansion; tachypneic with RR-28/min; no use of accessory
muscles noted; with rapid labored breathing pattern;
Percussion: Dullness at right lung field;
Palpation: Chest wall is intact with no tenderness and masses; with tactile fremitus at upper lobes
of both lung fields;
Auscultation: Ronchi sound at central airways;


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ABDOMEN:
Inspection: Umbilicus located at midline; color conforms to the rest of the body;
Auscultation: Normoactive bowel sounds at 15-20 seconds interval;
Percussion: Dull sound on RUQ, LUQ, RLQ, LLQ
Palpation: Uniform temperature on abdominal surface; soft to touch; (-) tenderness; (-) mass or
lumps noted
GENITO-URINARY:
Inspection: With pubic hair; (-) discharge; (-) warts noted
Palpation: (-) mass or lesions noted;
Urinates 8-10 times a day into dark yellow colored urine, approximately 300cc each urination;
defecates 1-2 times a day into soft, brown in colored stool, approximately 40cc per defecation;
SKIN AND EXTREMETIES: White complexion; pallor noted; (-) rashes; muscle strength
grading of 4/5 upper extremities and lower extremities; cyanotic fingernails and toe nails;
cyanotic palm; clammy feet; soft and cyanotic soles;
GENERAL CONDITION: Moderately pale with slight to moderate dyspnea on exertion with
occasional cough without any secretions. All in all, patient presents a problem in diffusion.











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GORDONS FUNCTIONAL HEALTH NEEDS
A. Perceptions and Expectations of Illness/hospitalization.
The patient is anxious about his condition and does not know the cause behind pleural
fluid on his right lung. His family knows that the prognosis of his condition is good and
they are very hopeful that patients condition will be better. Patient expects that he can go
home as early as possible after surgery. And he knows that nurses and physicians are very
competent about his condition.

Analysis: The patient is worried about his condition and his prognosis.
Nursing Diagnosis: Anxiety r/t physiologic condition

B. Comfort/Rest Needs
Before he usually sleeps for about 7-8 hours, going to bed at 9 in the evening and wakes
up around 4 to 5 am. He usually takes a bath in the morning. When he was hospitalized,
he couldnt sleep for a long time anymore, he has to wake up every now and then and
always feel sleepy.

Analysis: The patients sleep was altered due to his condition. He has inadequate rest and
comfort.
Nursing Diagnosis: Disturbed sleep pattern.

C. Safety Needs
Prior to hospitalization, he can do activities of daily living independently. Can go to work
and performed his task well. He is at risk for injury due to exposure to machineries.
During hospitalization, he is at risk for injury because he feels weak and restless, cannot
go to comfort room without supervision. And he is at risk for aspiration when he
experienced difficulty of breathing and coughing.

Analysis: He cannot perform activities of daily living independently and safety for
aspiration is needed when he experienced difficulty of breathing and coughing.
Nursing Diagnosis:
Risk for injury.
Risk for aspiration.






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D. Fluids and Nutrition

Before hospitalization

Meal Food Taken Amount kCal
Breakfast



Total kCal
Rice
Fried fish
Coffee

1 cup
1 pc.
1 cup
216kCal
103kCal
106kCal
Lunch



Total kCal
Rice
Sinigang na isda
Water
2 cups
2 cups
2 glasses
432kCal
103kCal
0
Dinner



Total kCal
Rice
Fried fish
Water
2 cups
2 pc.
2 glasses
432kCal
103kCal
0

Total kCal for 24 hours: 960 kCal

After hospitalization
Meal Food Taken Amount kCal
Breakfast


Total kCal
Rice
Fried Egg
Water
1 cup
1 pc
2 glasses
216kCal
196kCal
0
Lunch


Total kCal
Rice
Tinola
Water
1 cup
2 cups
3 glasses
216kCal
492kCal
0
Dinner


Total kCal
Rice
Fried Chicken
Water
1 cup
1 pc
3 glasses
216kCal
246kCal
0

Total kCal in 24hours: 1582 kCal

Body Weight: 70
Body Height: 510

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BMI: 22.1 Normal
Prior to admission, patient has a 24 hour kCal intake of 960 kCal, when he was
hospitalized his 24 hour kCal intake was 1582. Has a normal body mass index of 22.1 as
evidence of his weight and height.


Analysis: Normal body mass index. Has inadequate nutrition, because the normal is
2170kCal per day and his intake is 1582kCal per day.
Nursing Diagnosis: Imbalanced nutrition less than body requirements.

E. Elimination
Prior to hospitalization, patient urinates every two hours with yellowish color
approximately 500-700cc and defecates two to three times a day with soft brownish in
color approximately 30-40cc. During hospitalization, he urinates 8-10 times a day into
dark yellow colored urine, approximately 300cc each urination and defecates 1-2 times a
day into soft, brown in colored stool, approximately 40cc per defecation. His intake has
IVF with 270 cc and H20 with 240 cc total of, 510 cc. And output of 3,000.

Analysis: The patients output is not equal with his intake.
Nursing Diagnosis: Risk for urinary incontinence.

F. Oxygen
Client always experienced chest pain and difficulty of breathing. Smoker for 10 years and
can consumed 10 sticks of cigarette a day. He was also exposed to fumer, chemicals,
radiation and pollutants at work. During hospitalization client is tachypneic with RR of
28 per minute. He was given 02 inhalation at 3L per minute via nasal cannula due to
difficulty of breathing, and SPO2 of 93%. With a medical diagnosis of Pleural Effusion
on right lung.

Analysis: The patients oxygenation was altered due to pleural fluid on his right lung.
Has a problem in diffusion.
Nursing Diagnosis: Impaired gaseous exchange.

G. Sexuality
The patient perceives himself as a man. He has no problem with his gender and accepts it
wholly and functions properly. Prior to admission, he was sexually active. When he was
hospitalized, he became sexually inactive.

Analysis: The patient is sexually inactive due to increase in age and his condition. There
was no relation about patients sexuality and oxygenation.

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H. Allergies
No known allergies to food and drugs.

Analysis: (-) from all forms of allergies

I. Communication
The client is responsive, alert and cooperative during conversations and able to follow all
instructions that are given to him. He knows what and when to take his medications and
his routines for the day.

Analysis: Patient has a good communication and receptive.