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Name: Mrs. Suarez, Abundia Age: 92 years old
Address: San Antonio St. Inupacan Leyte Sex: Female
Date of birth: December 23, 1917 Place of birth: Inupacan Leyte
Civil status: Widowed Nationality: Filipino
Religion: Roman Catholic
Ed. Attainment: College Graduate Occupation: House Wife
Date of Admission: December 07, 2010 @ 10:30 pm
Chief complaint: LBM with intermittent fever and injury on the head
Initial diagnosis: - AGE with mild dehydration
' HPN stage II
Final diagnosis: Community Acquired Pneumonia
Attending Physician: Dr.
Source of info: Amalia I. Suarez (Daughter)
Reliability: 70% (seventy percent)

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According to the daughter of the patient 3 days prior to admission at Bethany Hospital, the patient
experienced a passage of loose-watery stools, non-bloody, non-mucoid accompanied with an intermittent fever
with mild cough. The manifestations start an hour after the patient ate an uncooked peanut. The patient used to
take an oral antipyretic which is Biogesic every 4 hours during the onset of fever for relief and Flagyll,
Bactrium and Hyanite for an aid of diarrhea. 1 day prior to admission, while the patient is going to the
bathroom, she accidentally slipped and slammed her head, which eventually prompt her daughter to bring her to
Hospital hence this admission and had been initially diagnosed with AGE, HPN, and Mild Aortic Stenosis
leading to Concentric left ventricular hypertrophy with adequate systolic function and finally diagnosed with
Community Acquired Pneumonia.

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The patient¶s daughter claimed that his mother suffered from childhood illnesses such as chicken pox,
measles, cough/cold and fever and had taken some herbal medicine as a relief for cough/cold and sometimes
Biogesic for fever management. The informant also talked about the admission of the patient to Bethany due to
pneumonia, valvular heart disease and undergone surgery due to haemorrhoids. The patient has an allergy to
hair colours and is hypertensive with no known complication as claimed by the daughter.




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As what the informant remembered, the patient¶s parents and ancestors has a history of hypertension and
arthritis. (The informant was unable to recall the cause of death of her grandfather and grandmother).



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The patient used to eat vegetables, fish, and meat. She favourably eat peanut more often. And drink
Ensure milk without known allergies to any kind of food or fluids. Use clean Tap water for drinking. The
patient do not puff a smoke and other drugs.

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The informant was unable to remember when was the menarche of the patient. Logically, the patient¶s
daughter estimated that her mother¶s menopausal stage was at the age of 50¶s.

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The informant expects that her mother will recover in a timely and efficient manner. ³Maupay gud unta
kun ma-upay dayon hiya para kami maka uli kay damu na it baraydan´ as verbalized by the daughter.






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' Normal breathing ' RR: 18 as of December

pattern 12, 2010 with a normal ' Streaks of densities are seen in the
' (+) history of rhythm lower lung field.
colds/cough ' (+) accessory muscle used ' The heart is not enlarged
' No asthma ' (+) productive cough ' The rest of the visualized chest
' (+) history of (whitish phlegm) structured are unremarkable
pneumonia ' (+) oxygen attached cc

' (+) nebulizer ' Bibasal pneumonitis

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' (+) hypertension ' HR: 52 bpm as of ' " 
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' No history of December 12, 2010 with a
Dizziness or fainting normal rhythm
spells ' BP: *** '  

' (+) history of ' No cyanotic and skin WBC: 7.3x109/L
arrythmia discoloration HEMOGLOBIN:
' No edema female: 94 (140-180 g/ L)
HEMATOCRIT:
female: 0.29 (0.37 ± 0.48%)
LrMPHOCrTES: 0.11 (0.25 ±
0.40)
NEUTROPHILS: 0.84

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Creatinine: 222.65
Sodium: 149.7
Potassium: 3.18

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' Mild anorexia
' Eats 3-4 times a day
' Poor skin turgor
' Drink ensure (milk) ' Dry lips

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' Temp: ***
' Has a fever during ' Dry skin
admission ' No chills

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' Meconium passed out ' Swollen abdomen
at 24 hours of life ' rellow green mushy
' Has constipation stools
' No relief measures ' Constipation
taken at home ' Enema used to expel
stools
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Color: yellow green
Consistency: Mushy
Ova of Parasites: none
Pus cells: 0-2/hpf
RBC: 0-2/hpf
Occult blood: (+) trace
 

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' Family have no belief ' The patient is clean
regarding to hygiene ' Skin is partly dry
' Clean apparently

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' Limited ROM

' House chores serves as ' No deformities
the exercise. ' Limited ROM

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' (-) Difficulty of

sleeping ' The patient has enough
' Side-lying position rest

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' unable to speak at the
time of admission



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' No epilepsy, ' Lacrimation (-)
convulsion etc.
' The patient responds to
' History of pain.
Hallucination as the
effects of the medicine
during admission







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' Age >70 years - Congestive heart disease

' COPD - Prolonged Immobility and dehydration






 



Invasion in the
Respiratory system

Defect in local pulmonary defenses

Activation of defense mechanism

Increase mucous production

Mucociliary transport is
depresses with the aging
process, dehydration etc

Productive cough

inflammatory cells pooling of lung secretions

activated
Crackles
mucus plugs

release of proteolytic deprivation of O2

enzymes
decrease surface area for O2 Tank
external respiration
CO2 retention

alters brochial and ciliary

clearance mechanism respiratory acidosis

stimulating production alveoli is filled with debris

of excess mucus by the WBC due to Tachypnea
inflammatory process

RECOVERr if treated Consolidation if not treated

DEATH Lung collapse


Nursing Diagnosis Scientific analysis Objectives Nursing Interventions Rationale Evaluation

Ineffective airway Community acquired After 8 hours of c




clearance
r/t excessive Pneumonia is an infection in nursing interventions: 1.) Presence may indicate
viscous secretions in the the alveoli, distal airways, and 1.) Monitor respirations and accumulation of secretions
bronchi as manifested by interstitium of the lungs that - The patient will note for breath
sounds and respiratory distress.
productive cough. occurs outside the hospital maintain an adequate
settings. And is characterized .

patent airway after he
), -
by fever, chills, cough
expectorates bronchial 2.) Suction airway as ordered
³ nag i-inubo hiya na may (productive), or a chest pain. 2.)
To clear airway.
plema´ as vervalized by unexpelled mucous along the secretion. by the physician.
the patient¶s daughter. airways causes it to narrow.
- The client will
), -
improve and maintain 3.) Hydration can help
- Productive cough an adequate airway 3.) Increase the patient¶s fluid liquify viscous secretions
- Whitish Phlegm clearance. intake to 2000 ml per day
- Pulse: 52 bpm


- RR: 18 cpm

 


Pathophysiology of Lippincott
Williams & Wilkins page 83
 

 

 



  
  

 
    
Ineffective breathing Community acquired After 8 hours of c



pattern r/t presence of Pneumonia is an infection in
abnormal breath the alveoli, distal airways, and
sounds as evidenced interstitium of the lungs that
occurs outside the hospital
by crackles
settings. The production of
nursing interventions:
The client will be able
to breathe continuously
and reduction of
 
1) Position the patient¶s
head in semi-fowler.
1) To maintain an
open airway and
facilitate maximum
lung expansion.
), -
phlegm or mucous produce a congestion and
crackle sound due to the abnormal breath 2) Provide bronchial

2) To improve airflow
- Productive increased fluid in the alveoli sounds. tapping techniques.
and secretion
cough and segmental spaces of the 
clearance.
- Abnormal lung.
lung sound: 
3) Observe for increased 3) To identify
Crackles infectious process
- Pulse: 52 bpm
dyspnea/tachypnea
with onset of fever and and promote timely
change in sputum intervention.
- RR: 18 cpm
color, amount and 

character.







Pathophysiology of Lippincott
Williams & Wilkins page 83


 

 
   
       
  
     
Impaired Gas Community acquired After 8 hours of c



exchange r/t Pneumonia is an infection in nursing interventions:  
ventilation perfusion the alveoli, distal airways, and 1) Provide rest periods 1) Prevents fatigue
imbalance as interstitium of the lungs that - The client will and limit activity to and dyspnea.
manifested by occurs outside the hospital improve level of respiratory
breathing pattern settings. Dyspnea, mucouid ventilation and tolerance.
problems. plug and tachypnea causes to
adequate 2) To prevent bedsore
decrease alveolar space for 2) Change position every
), -
external respiration leading to oxygenation. and promote better
2 hours or as needed.
- Oxygen tank decreased lung capacity and lung compliance

attached
oxygen saturation.

- Mild cyanotic
of finger nails
3) Keep environment
- Pulse: 52 bpm allergen-free. ð  To prevent possible
entry of irritants,
- RR: 18 cpm  this will obstruct

the airway‘


 



 Pathophysiology of Lippincott
Williams & Wilkins page 83