200704112 grand-case-study-final

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I. INTRODUCTION:
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Basically the purpose of this study is to relay a realistic information to the readers providing
complete experience based data that would hopefully assess our knowledge in research making.
In the course of making this study we strongly suggest that student nurses should begin his/her
experience from the student nurse’s first encounter with the patient subject to the study. This
would aid a student to deliver accurate information for his/her study. We would also like to
suggest having an intensive bed side cares for as to the role performance which is necessary
though in some settings the same observably being compromised.
Fungi, parasites, and viruses. This is the most common cause of death here in the
Philippines. In ranked third among the causes morbidity and fourth the causes of death in 2000.
There was an increase in the morbidity trend for pneumonia from 1990 to 1996. This may be due
to improved case finding and reporting with the intensification of the program to control acute

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respiratory infections during this period. The morbidity trend decreased slightly from 1997 to
2000 but the number of cases remained high at 829 cases per 100,000 populations in 2000. On
the other hand, there is a decreasing trend of mortality from pneumonia in the general population
from 1990 to 2000 despite the high number of cases per year. The mortality rate from pneumonia
decreased from 64.7 deaths per 100,000 population in 1990 to 42.7 deaths per 100,000
population in 2000.
Pneumonia is the most common cause of death from infectious disease in the
United States. Together they account for nearly 60,000 deaths annually and ranked as the 8th
leading cause of death in the United States (MINING, HERON, MURPHY, et al., 2007). CAP
occurs either in the community setting or within the first 48 hours after hospitalization as
Institutionalization. The need for hospitalization for CAP depends on the severity of PHN. The
causative agents for CAP that requires hospitalization are most frequently S. Pneumoniae, H.
influenziae, Legionella, Pseudonomas aureiginosa, and other gram-negative rods. The specific
etiology agents is identified in about 50% of causes. It is estimated that more than 915, 000
episodes of CAP occur in adults 65 years old of age and older each year in the United States
(MENDELL, WUNDERINIC, ANZUETO, et. al., 2007)
S. pneumonia (pneumococcus) is the most common cause of CAP in people younger than
60 years of age without co-morbidity and in those 60 years and older with co-morbidity.
S. pneumonia, gram-positive organism that resides naturally in Upper respiratory tract,
colonizes the upper respiratory tract and can cause disseminated. Invasive infection, PHN and
other Lower respiratory tract infection, and upper respiratory tract infection, such as otitis media
and rhinosinusitis. It may occur as a lobar or bronchopneumonic in patient of any age and mat
follow a recent respiratory illness. (M.S.N 12th edition, Brunner’s and Suddarth’s)
(pneumococcal) pneumonia usually has a sudden onset of chills, rapidly rising fever (38.5°C
to 40.5 °C), and pleuritic chest pain that is aggravated by deep breathing and coughing. The
patient is severely ill, with marked tachypnea (25-45 bpm), accompanied by other signs of

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respiratory distress. Signs and symptoms of pneumonia may also depend on a patient’s
condition. Such as the following:
 People 65 years of age and older.
 Immunocompetent people who are at increased risk for illness and death associated with
pneumococcal disease because of chronic illness (eg, cardiovascular disease, pulmonary
disease, diabetes mellitus, chronic liver cirrhosis)
These complications are encountered chiefly in patients who have received no specific
treatment or inadequate or delayed treatment. These complications are also encountered when
the infecting organisms resistant to therapy, when a co-morbid disease complicates the
pneumonia or when the patient is immunocompromised. Patients may require endotracheal
intubations and mechanical ventilation. Heart failure, cardiac dysrhythmias, pericarditis and
myocarditis also are complications of pneumonia that may lead to shock.
II. OBJECTIVES
GENERAL OBJECTIVE:
 To be knowledgeable about the nature of our Case, management and treatment to be able
to render effective nursing care to the client.
SPECIFIC OBJECTIVES:
 To know the etiology, risk factors and manifestations of the disease process
 to determine client-based pathophysiology of undifferentiated
 to learn the basic principle of medical management of COPD

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 to detect possible complications of the disease process
 to use the nursing process to identify nursing problems from the client and provide the
appropriate nursing care plan
 to formulate health teachings for disease prevention and health maintenance
III. THEORETICAL FRAMEWORK
The case of Mrs. C.F. is being correlated to Florence Nightingale’s Environmental
Theory. This theory explains that external factors influence the health of a patient. She believed
that healthy surroundings were necessary for proper nursing care. Pure air, pure water, efficient
drainage, cleanliness and light are the five essential components of environmental health. For the
attainment of these essential components, man must use their power to control and modify the
environment.
The patient describes their area as congested and houses are built right next to the other.
Their house has small space that minimizes ventilation and natural light that enters the house. It’s

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also located few meters away from the national road causing them to constantly inhale polluted
air from passing vehicles. They also have no electrical supply that adds up to the compensation
of proper ventilation. The patient adds that they can’t maintain the cleanliness of their
surroundings because of the constant dirt coming from their neighbors. These clearly reveal that
3 of the 5 essential components are being compromised and may be one of the cause of the
patient’s present condition. Modification of the environment is an effective strategy on patient’s
treatment and rehabilitation.
IV. NURSING HISTORY:
Source of information: Patient herself, including her son, 19 years old.
A. Biographical Data
Patient name : Patient C.F.
Address : Lacson St., Sampaloc Manila
Date of Birth : May 15, 1964
Birth Place : Masbate City
Age : 47 years old
Sex : Female

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Occupation : “labandera”
Nationality : Filipino
Marital Status : Widowed
Religion : Roman Catholic
Source of health assistance: health center; Ospital ng Sampaloc
Chief Complaints: “nahihirapan akong huminga”, as verbalized by the patient
(Difficulty of Breathing)
B. Reasonfor seeking health care:
“ Nung una po nahihirapan syang huminga pero sabi nya ok na daw sya after 30
minutes pero isang oras pagkatapos nya maglaba, nakita ko nalang siya na nakahiga na sa
sahig at sobrang hirap nang huminga kaya dinala ko na sya dito sa Ospital.” As
verbalized by her son.
Patient C.F. is a 47 years old female. Born on May 15, 1964 in Masbate City. She
is widowed with 2 children of 19 and 11 years old. She lives in Lacson St., Sampaloc
Manila.
She experienced cough and cold, fever, and body weakness most of the time and
took over the counter drugs like neozep, biogesic, mefenamic acid, strepsil and bioflu for
medication. Or sometimes she just ignored it. If she has time, she goes to the health
center for consultation and check-up.
C. History of present illness:
1 year prior to admission patient C.F claims that she is healthy. She claims that
sometimes she experienced difficulty of breathing and easy fatigability but she just
ignored it thinking that it has something to do with her whole day doing the household
chores. She just took rest and have a nap for relief.
6 months prior to admission, she experienced difficulty of breathing accompanied
with body weakness, and dizziness. She then decided to go to Ospital ng Sampaloc for

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consultation and check-up. She was given nebulization. After the three doses of
nebulization, she was advised to go home after experiencing relief from her difficulty of
breathing. She was also advised to undergo Chest X-ray and CBC but unfortunately, she
didn’t comply due to her reason that it’s just a waste of time to wait.
3 months prior to admission, still with the above symptoms, so they decided again
to Ospital ng Sampaloc for consultation and check-up. This time, she complied to
undergo Chest X-ray and CBC. Chest X-ray result reveals that she has pneumonia and
hemoglobin level slightly decreased from normal as she claims. The doctor prescribed
her ferrous sulfate once a day and unrecalled antibiotics. Due to financial constraints, she
was not able to take religiously those said medications.
3 weeks prior to admission, still with the above symptoms accompanied with
productive cough which she claims that it is greenish in color. But no consultations or
check-up done.
3 days prior to admission while doing laundry, she felt sudden difficulty of
breathing and got worse that leads her to rushed to Ospital ng Sampaloc. At the
emergency room, she was hooked with oxygen at 3 Lpm/NC and nebulization with
salbutamol. Her situation got worsen so she was then advised for admission and
confinement.
D. Past Health History:
1. Medical History – no previous hospitalization
2. Surgical History – no surgical or operations done
3. Medications – ferrous sulfate, and unrecalled antibiotics, but poor compliance
4. Allergies- chemical inhalants such as “zonrox”, “rugby”, and “vulcaseal’’. No
allergies to drugs, foods and animals.
5. Injuries and accidents – none
6. Special needs – none
7. Childhood illness and immunization – can’t recall except for tetanus toxoid

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E. Family Health History:
Legend: asthmatic hypertensive
mother
father
brother
sister hypertensive pneumonia
patient
F. Social History:
a. alcohol use – she denies that she’s not drinking any alcoholic beverages
b. drug use – none
c. tobacco use – non-smoker
d. sexual practice – not mentioned
e. travel history – none
f. work environment- poor ventilation
g. physical environment – they’re living in a small space, made of light materials.
h. home environment – congested, they live in a crowded place with poor ventilation
and sanitation, they have one common CR described as pail system; they don’t have
electrical connection, and they don’t have a conducive sleeping space using only
plastic mat; their source of water supply is NAWASA; they don’t usually boil their
water prior to drinking.
i. Psychosocial environment – they live near in a public market and accessible to
recreational areas and public utility vehicles.
j. Hobbies and leisure – she plays BINGO as a form of her relaxation
k. Stress – financial constraints is her primary reason of stress
l. Education – she is an elementary graduate at Geronimo Elementary School.

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m. Economic status religion ethnic background – she is a laundry woman earning P150
per day (depending to the number of costumers), but able to eat three times a day. She
is a Roman Catholic and no ethnic background affiliation.
n. Roles and relationship – she is a mother of two, a widow for seven years, with good
personal relationship to her neighbors and her family. She is a law abiding citizen and
able to exercise her right to vote every election.
V. IMMUNIZATION/EXPOSURE TO COMMUNICABLE DISEASES
She doesn’t recall any immunizations except for TT 1.
She recall that she experienced chicken pox
VI. ALLERGIES – she has allergy to chemicals/agents such as “zonrox”, “rugby”, and
“vulcaseal’’. No allergies to drugs, foods and animals.
VII. HOME MEDICATION/ALTERNATIVE MEDICINES – she usually takes paracetamol
for fever, mefenamic acid for headache, neozep for colds. She doesn’t have history of
taking any alternative medications and she doesn’t believe in “herbolaryos” or quack
doctors.
VIII. PSYCHOSOCIAL HISTORY
a. Alcohol use – she denies that she’s not drinking any alcoholic beverages
b. Drug use –
c. Caffeine use- she drinks coffee 3 cups everyday, sometimes mixed with milk powder.
IX. OBSTETRICAL HISTORY
Menarche – 13 years olds
G2P2

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X. GORDONS HEALTH PATTERN:
GORDON’S
FUNCTIONAL
HEALTH
PATTERN
BEFORE
HOSPITALIZATION
DURING
HOSPITALIZATION
ANALYSIS
Health Perception
Pattern
Patient C.F. described
herself sick because she
feels weak and she
doesn’t know why. She
wanted to visit the center
but she doesn’t find time.
She even felt worse
during her stay in the
hospital. She couldn’t do
her daily routine. She
wanted to feel better and
eventually healed from
her sickness and go
home to take care of her
children.
Due to knowledge
deficit because she
is an elementary
graduate.
Nutritional and
Metabolic Pattern
She eats 3 times a day.
Commonly she eats fish
and vegetables. She eat
In the hospital she eat
everything they served
but in a little amount
Loss of appetite is
due to decrease
taste sensation.

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meat twice a week
because she doesn’t like
too much meat like
chicken and pork. She
could drink 2 glasses of
water about 500 to 600ml
daily.
because she doesn’t have
appetite or loss her
appetite all the time. She
drinks not more than
500ml daily.
Elimination Pattern She doesn’t have any
problem in urinating. She
urinate 4 0r 5 times daily
without any difficulty
with slightly yellowish
color. She defecates twice
daily, one in the morning
and in the evening
without any difficulty
with brown color with
soft to hard consistency
or it’s depend on the food
she eats.
Now, she urinates 2 to 3
times daily without any
difficulty with yellowish
color with a very
minimal amount. She
defecate once a day or
sometimes none with a
soft consistency.
Due to decrease
amount of food
and fluids intake.
Activity-Exercise
Pattern
She could still perform
her daily living. She
clean the house, wash her
clothes and her children,
cooking food, and doing
the household chores was
her way of exercising and
also stretching and
walking around the house
for 20 to 30 minutes
daily.
She couldn’t do
everything that she was
doing before. She felt
very weak and couldn’t
even move too much
because of the IVF and
the oxygen. Moving and
talking a little started her
to cough and start to feel
the difficulty of
breathing.
Due to generalize
body weakness is
a sign of
pneumonia.
Sleep and Rest
Pattern
She has the normal 6 to 8
hours of sleep daily. She
sleeps 9 in the evening
and woke up 4 in the
morning. Sometime she
could still nap in the
afternoon by 2 to 4 in the
afternoon.
She couldn’t get her 6 to
8 hours sleep daily
because of her present
condition. Difficulty of
breathing made her
restless. She wanted to
sleep but she couldn’t get
it.
Restless and
difficulty of
breathing are the
sign and
symptoms of
patient with
respiratory
problem.
Cognitive
Perceptual Pattern
She doesn’t have any
problem in term of her
cognitive abilities. She
still has a good memory.
She doesn’t wear
eyeglasses or hearing aid.
She is always restless
and irritated because of
her present condition.
Restlessness and
irritability are sign
of pneumonia
Self Perception-
Self Concept
Pattern
She doesn’t always feel
fine especially when she
has coughed that last 1 ½
week with a mild
headache every time she
experienced it. It limits
her daily activities.
She felt very weak and
her conditions worsen
everyday she stays in the
hospital. She felt scare of
the situation.
Anxiety is due to
her condition and
a long stay in the
hospital.
Role-Relationship
Pattern
She’s living with his
children and has a good
relationship with them.
She became more closer
to them after her husband
She is more close to her
family now because of
her condition.
Her present
condition made
the family more
closer.

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died. She also has good
relationship with her
neighbors and relatives.
Sexual
Reproductive
Pattern
When her husband died 7
years ago she never
thought of having a
second husband and has a
sexual activity. She
dedicated her life to her
children and never
thought about that.
Now, she couldn’t
imagine herself with
another man except her
son especially with her
present condition.
No problem on her
sexual
reproductive
pattern.
Coping Stress
Tolerance
She always seeks her
siblings’ advice and help
every time she has
problem. She just cries
and thinks of the best
way to resolve all the
stress she has when her
siblings are not available
to help her.
Praying, crying and
talking to her sibling are
her ways to lessen her
stress because of her
condition.
These are the
natural ways on
how she cope
from her stress.
Value Belief
Pattern:
She is a Roman Catholic.
She wasn’t very religious
person and she doesn’t
remember the last time
she visited the church to
ask for God help.
When she recover from
her disease and discharge
from the hospital she
promise that the first
thing she will do is to
visit the Black Nazarene
in Quiapo and always
attend the mass every
Sunday and will devote
her life in serving Him.
Her present
condition changed
her beliefs.
XI. PHYSICAL ASSESSMENT:
General Appearance:
 The patient is sitting on the bed on high back rest. She is conscious and coherent, oriented
to time, place and person. She is appropriately dressed with no body odor. She has
oxygen via nasal cannula at a flow rate of 3Lpm. She has 0.9% NaCl IV fluid regulated at
KVO rate at left hand (cephalic vein). She appears weak, with accompanying shortness of
breath.
Vital Signs:
BP: 100/70 Weight: 90 kg
T: 36.5 Height: 5 ft.
RR: 28
PR: 90

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BODY PARTS ACTUAL FINDINGS ANALYSIS NURSING
ALERT
SKULL -Rounded (normocephalic and
symmetrical, with frontal,
parietal, and occipital
prominences); smooth skull
contour
- no presence of nosules,
masses and depressions
No deviations found
HAIR - excessive dryness; sparse
dandruff visible
-evenly distributed and covers
the whole scalp
-abnormal, excessive dry
hair could indicate
malnutrition and can
attract nits.
-advise patient to
practice proper
hygiene to prevent
further hair
problems
SKIN -appears pale
-with even skin tone
-no lesions and abrasions noted
Cyanosis is a sign of
decreased oxygen level in
the blood (hypoxemia) due
to increased fluid in the
pleural space
FACE -symmetric and palpebral
fissure equal in size, nasolabial
folds are symmetrical
No deviations found
EYES -pupil equally rounded reactive
to light and accommodation
-Able to follow movement -
symmetrically in all direction
-white sclera
pink conjunctiva
-Symmetrical eyes
-No drainage upon palpation of
the nasolacrimal duct
No deviations found
EARS -Symmetrical
-Tympanic membrane are
pearly, grey, and translucent
with no bulging and
retraction
No deviations found
NOSE -both nares are patent
-symmetric and straight
-nasal septum, intact and
midline
-no tenderness or lesions
No deviations found
MOUTH -Lips appear cyanotic, -cyanosis is an indication -

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-has 27 adult teeth, yellowish
and has halitosis
of decreased oxygen level
in the body.
No deviations found
-abnormal, incomplete
number of teeth is due to
having history of poor oral
hygiene.
-most unpleasant breath
known to arise from
proteins trapped in the
mouth which are
processed by oral bacteria.
-teach client about
proper oral
hygiene to prevent
further oral
infections
LYMPH NODES -not palpable -no deviations
THORAX
Anterior -difficulty of breathing
-medium-pitched, thudlike
sound is heard on percussion
-unequal chest expansion is
observed on palpation
-has crackles sounds on the
upper and lower thorax
-abnormal labored
breathing is a common
manifestation affecting
clients with cardiac and
pulmonary disorders. Its is
related to obstructed
airways. It is also related
to the decreased size of the
lungs due to PTB
-it is also the most
common symptom of a
pleural effusion. As the
effusion grows larger with
more fluid, the harder it is
for the lung to expand and
the more difficult it is for
the patient to breathe.
-abnormal, dullness may
characterize areas of
increased density such as
pleural effusion
-unequal chest expansion
is seen in patients with
severe atelectasis,
pneumonia, chest trauma,
pleural effusion or
pneumothorax.
-abnormal crackles are
audible when there is s
sudden opening of the
-administer
oxygen as ordered
by the doctor to
support
oxygenation
-minimize
physical activity
to decrease
oxygen demand
-
-changing of
positions at bed
every 30 mins will
minimize mucus
stasis for easy
expectoration.
-nebulization
must be done as
prescribed

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Posterior
-spine vertically aligned
-skin intact, uniform
temperature; no tenderness;
no masses
-uses accessory muscles to
assist breathing
-diminished breath sounds are
auscultated at the apex of the
lungs
small airways that contain
fluid. It is usually heard
during inspiration; may
indicate pnuemonia
No deviations found
-trapezius or shoulder
muscles are used to
facilitate inspiration in
cases of acute and chronic
airway obstruction
-diminished or absent
breath sounds often
indicate that little or no air
is moving in or out of the
lung area being
auscultated. It may also
indicate abnormalities of
the pleural space such as
pleural effusion.
CARDIOVASCULAR -has full and rapid pulsations; No deviations found
ABDOMEN -uniform color and has no
blemish; has a concave
abdomen; symmetric colour;
-abdominal movements note
when inhaling
-has no vessels visible
No deviations found

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MUSCOSKELETAL
Muscle strength
Right arm
Left arm
Right leg
Left leg
-weak muscle tone; weak
muscle strength
- +4 active motion
against some resistance
- +4 active motion
- With IV fluids inserted
specifically at the
cephalic vein
- +4 active motion
- +4 active motion
-no edema, no pain when
moved
-nails are
-abnormal, possibly
related to the amount of
food she is eating; due to
decrease oxygen supply to
the body causing easy
fatigability.
-abnormal
-abnormal
-abnormal
-abnormal
No deviations found
-minimize
physical activity
to prevent over
fatigue
-place patient’s
needs within
reach to reduce
exertion of energy
-raise side railes
to prevent injury

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XII. ANATOMY AND PHYSIOLOGY
THE RESPIRATORY SYSTEM
The human respiratory system consists of the lungs and tubes associated with the lungs. It
is located in thethorax or chest. The thorax is surrounded by the ribs. The diaphragm forms the
base of the thorax.
Contractions of the diaphragm and the intercostals muscle change the size of the thorax and,
thus, cause air to move in and out of the lungs.
The main job of the respiratory system is to get oxygen into the body and get waste gases
out of the body. It is the function of the respiratory system to transport gases to and from the
circulatory system.
The Nose or Nasal Cavity
As air passes through the nasal cavities it is warmed and humidified, so that air that
reaches the lungs is warmed and moist. The Nasal airways are lined with cilia and kept moist by
mucous secretions. The combination of cilia and mucous helps to filter out solid particles from
the air an Warm and moisten the air, which prevents damage to the delicate tissues that form the
Respiratory System. The moisture in the nose helps to heat and humidify the air, increasing the
amount of water vapour the air entering the lungs contains. This helps to keep the air entering the
nose from drying out the lungs and other parts of our respiratory system. When air enters the
respiratory system through the mouth, much less filtering is done. It is generally better to take in
air through the nose.
To review: he nose does the following:
1. Filters the air by the hairs and mucous in the nose
2. Moistens the air
3. Warms the air

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The Pharynx
The pharynx is also called the throat. As we saw in the digestive system,
the epiglottis closes off the tracheawhen we swallow. Below the epiglottis is the larynx or voice
box. This contains 2 vocal cords, which vibrate when air passes by them. With our tongue and
lips we convert these vibrations into speech. The area at the top of the trachea, which contains
the larynx, is called the glottis.
The Trachea
The trachea or windpipe is made of muscle and elastic fibres with rings of cartilage. The
cartilage prevents the tubes of the trachea from collapsing. The trachea is divided
or branched into bronchi and then into smallerbronchioles. The bronchioles branch off
into alveoli. The alveoli will be discussed later.

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These tubes are lined with mucous-secreting cells and tiny hairs called cilia. The mucous
traps bacteria, dust and viruses. The cilia beat and create an upward current. This moves the
mucous up and into the oesophagus. Here it goes to the stomach. When we clear our throats we
force the mucous away from our vocal cords. This is often called coughing. It is used to get rid
of irritants and excess mucous from our respiratory system.

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The Lungs
The lungs are spongy structure where the exchange of gases takes place. Each lung is surrounded
by a pair of pleural membranes. Between the membranes is pleural fluid, which reduces friction
while breathing. The bronchi are divided into about a million bronchioles. The ends of the
bronchioles are hollow air sacs called alveoli. There are over 700 million alveoli in the lungs.
This greatly increases the surface area through which gas exchange occurs. Surrounding the
alveoli are capillaries. The lungs give up their oxygen to the capillaries through the alveoli.
Likewise, carbon dioxide is taken from the capillaries and into the alveoli.

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Gas Exchange
Body cells use the inhaled oxygen gotten from the alveoli of the lungs. In turn, they
produce carbon dioxide and water, which is taken to the alveoli and then exhaled. These
exchanges occur as a result of diffusion. In each case the materials move from an area of high
concentration to an area of lower concentration.
The alveoli are well suited for the important job they have. There are about 300,000,000
alveoli per lung! That means there is a great surface area for gas exchange. Also, the walls of the
alveoli as well as the capillaries are very thin so that the gases can diffuse readily.
When the blood picks up the diffused gases the gases are carried to their destinations. Most
of the oxygen is carried by the haemoglobin in the red blood cells with only a small % dissolved
in the plasma. Carbon dioxide and water are carried in the plasma of the blood.
The following chart compares the content of air before as it is inhaled (Inspired Air) and as it is
exhaled (Expired Air).
Inspired and Expired Air Comparison
Gas + %
Inspired
Air
Expired
Air
Alteration
Nitrogen 78% 76% No real change.
Oxygen 20.8% 15.3% Reduced by about a quarter
Carbon
Dioxide
0.04% 4.2%
Increased by about a hundred and
five times
Water
Vapour
1.2% 6.1% Increased about five times
Note: a lot of water is lost from the body each day due to breathing.

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The Mechanism of Breathing
Inspiration or inhalation is said to be an active process because it involves muscle
contraction. The diaphragm andintercostal muscles contract. The contracting diaphragm flattens
and stretches the elastic lungs downward. The contracting intercostals pull the ribcage up and out
causing the elastic lungs to stretch. The expanding lungs cause the air inside to expand (a gas
will always fill its container). The expansion of air causes a drop in air pressure in the lungs. The
air in the lungs is at a lower pressure than the air outside. Air flows from higher to lower pressure
so air flows into the lungs from outside.
Expiration or exhalation is said to be a passive process because it does not involve
muscle contraction. The diaphragm and the intercostal muscles relax. The deforming force on the
elastic lungs has been removed. The lungs recoil elastically reducing their volume – a passive
process. The volume of air in the lungs decreases causing an increase in the air pressure. The air
in the lungs is at a higher pressure than the air outside. Air flows from higher to lower pressure
so the air flows out of the lungs. The elastic recoil of the lungs pulls up the adhering diaphragm
and drags in the adhering ribcage.
Breathing is normally under unconscious control. We don’t have to think about
breathing. Exercise increases the rate of breathing. The brain detects a large increase in carbon

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dioxide and increases the rate of breathing. Now, exhalation, which is normally passive, becomes
active. Other times when we control our breathing rate is in speaking, singing, or swimming.
Breathing is always controlled by the brain’s detection of carbon dioxide in the blood.
When carbon dioxide is in the blood the pH of the blood is slightly lowered. The brain detects
this slight drop and sends impulses to the diaphragm and intercostal muscles. Thus, our breathing
mechanism is controlled by rising levels of carbon dioxide, not low levels of oxygen. Just as the
level of carbon dioxide controls the stomata opening in leaves it also controls our breathing.
Breathing Disorders
Asthma is a breathing disorder. Its symptoms include coughing, wheezing, tightness of
chest and breathlessness. It is caused by an allergic reaction to materials in the environment such
as pollen, cigarette smoke, house dust and pet dander. More recently scientists have found a link
between stress and anxiety with the onset of asthma.
Asthma is a chronic ailment in which inflammation of the airways, or bronchi, affects the
way air enters and leaves the lungs, thereby disrupting breathing. When allergens or irritants
come into contact with the inflamed airways, the already sensitive airways tighten and narrow,
making it difficult for the person to breathe. Progressively severe symptoms can lead to an
asthma attack. In asthma attacks, the overproduction of mucus lining the airways further narrows
the airways, limiting oxygen intake and making it more difficult to breathe.

24
To prevent asthma the allergen must be identified and avoided. Also, in the case of stress,
the stress must be alleviated.
The treatment of asthma is usually by Inhalers. These devices (sometimes called 'puffers')
contain a gas that will propel the correct dose of medication when the top is pressed down. This
is inhaled into the airways. There are two basic categories of inhaler medicines that are used for
asthma: relievers - which treat the symptoms and preventers - which can prevent the symptoms.

27
XIV. LABORATORY/DIAGNOSTIC EXAMINATIONS:
Fuentes, Clarinda
47 yrs old
HEMATOLOGY RESULTS
January 29, 2012
Tests Normal Value Found Value Interpretation
Hemoglobin F: 12-14g/dl 10.2 Below normal: An
indication of pleural
effusion and PTB.
Hematocrit F: 0.37-0.47 0.31 Below normal: An
indication of
inadequate
hydration.
WBC count 4.8-10.8x10 8.0 Normal.
Segmenters 60-70% 77 Increased: Indicates
that the body’s
immune response is
activated and
compensating in the
body.
Lymphocytes 30-40% 23 Decreased: Indicates
that the body's
resistance to fight
infection has been

28
substantially lost.
Monocytes 2-8%
Platelet count 130-400x10 280 Normal.
January 23, 2012
effusion and PTB..
indication of
inadequate
hydration.
that the body’s
immune response is
activated and
compensating in the
body.
that the body's
resistance to fight
infection has been

29
substantially lost.
Monocytes 2-8%
Platelet count 130-400x10
January 9, 2012
effusion and PTB.
indication of
inadequate
hydration.
that the body’s
immune response is
activated and
compensating in the
body.
that the body's
resistance to fight
infection has been

30
substantially lost.
Monocytes 2-8%
December 31, 2011
indication of
pleural effusion and
PTB.
indication of
inadequate
hydration.
that the body’s
immune response is
activated and
compensating in the
body.
that the body's
resistance to fight

31
infection has been
substantially lost.
Monocytes 2-8%
December 28, 2011
effusion, PTB
indication of
inadequate
hydration.
WBC count 4.8-10.8x10 10 Normal.
that the body’s
immune response is
activated and
compensating in the
body.
that the body's
resistance to fight

32
infection has been
substantially lost.
Monocytes 2-8%
December 30, 2011
effusion and PTB.
indication of
inadequate
hydration.
Segmenters 60-70% 66 Normal.
Lymphocytes 30-40% 34 Normal.
Monocytes 2-8%
Platelet count 130-400x10
Analysis:

33
Complete blood count is the calculation of the cellular formed components of the blood.
Its major portion includes the measurement of red blood cells, white blood cells, and platelet
concentration in the blood.
Based on Mrs. C.F’s hematology test, hemoglobin as well as the hematocrit level was
below normal which merely indicates a possible iron deficiency anemia and nutritional
deficiency due to muscle waste, fatigue and having loss of appetite. An increase of segmenters
indicates that there is a presence of infection. Elevation of segmenters indicates presence of
infection; means that many band (immature) cells are present as the body fights infection. A low
lymphocyte count indicates that the body’s resistance to fight infection has been substantially
lost and one becomes more susceptible to certain types of infection.
URINALYSIS
January 3, 2012
Tests Found Value Analysis
MACROSCOPIC
Color Yellowish Normal.
Transparency Slightly turbid
MICROSCOPIC
Pus cell 5-8/hpf
Red cell 3-5/hpf
Epithelial cell Many
Mucus thread Few

34
December 9, 2011
Tests Found Value Analysis
MACROSCOPIC
Color Yellowish Normal.
Transparency Slightly turbid
MICROSCOPIC
Pus cell 0-2/hpf
Red cell 0-2/hpf
Epithelial cell Many
Mucus thread Few
Clinical Chemistry
Date: January 3, 2012
Tests Normal Value Found Value Analysis
Bun 2.49-6.42umol/L 3.33 Normal.
Creatinine 53.04-106.08
umol/L
94.72 Normal.
Sodium 135-14 umol/L 136.5 Normal.
Potassium 2.5-5.5 umol/L 3.69 Normal.
Gram Stain

35
Date: 1-27-12
Specimen Pleural Fluid
Pus Cells Rare
Epithelial Cell Occasional
Results No organisms found
CHEST X-RAY
Date: 1-31-12
RIGHT CHEST:
There is pleural effusion with an approximate volume of 290cc seen in the posterior costal
sulcus. No loculations seen at this time.
IMPRESSION: PROGRESSIVE PTB VS. PNEUMONIA
NURSING ANALYSIS:
Pleural effusion accumulates due to imbalance in hydrostatic or oncotic pressure.
Date: 1-30-12
Follow up when compared to the one done 1/17/12 shows no significant interval changed.
NURSING ANALYSIS:

36
Date: 12-29-11
CXR PA:
There is almost complete specification of the right lung.
Reticulonodular densities seen in the left lung.
Heart size cannot be assess.
Left hemidiaphragm and sulcus intact.
Bony thorax are unremarkable.
IMPRESSION:
PTB EXTENSIVE, BILATERAL VS. MASSIVE PLEURAL EFFFUSION RIGHT.
OVER WHELMING PNUEMONIA , BILATERAL.
NURSING ANALYSIS:
CXR PA:
Follow-up new shows total specification of the right lung while the left lung shows
further increase in infiltrates.
Date: 12-17-12
CHEST PA:
Follow up film when compared to the one done Jan. 6, 2012 shows no significant interval
changed.

37
NURSING ANALYSIS:

38
XVII. DISCHARGED PLANNING
Discharge Planning
Medication
Medication includes:
 FeSo4 500mg/ tab BID
 Combivent nib 1Mb q6
 Ceftazidine 500mg TIV q8
Environment
 Teaching breathing retaining exercise to increase diaphragmatic excursion and reduce
work of breathing
 Teaching relaxation techniques to reduce anxiety with dyspnea
 Augment the patient’s ability to cough effectively by spiriting the patient’s chest
manually
Treatment/Therapy
 Follow strict compliance to treatment regimen given to improve condition especially
medications, diet, and lifestyle
 Encourage significant others to assist the patient in performing of breathing exercises to
promote lung expansion and clearing.
 Encourage to provide adequate rest and sleep for the patient.
Health Teaching
 Health teachings regarding the importance of proper hygiene and hand washing, food and
water preparation, intake of adequate vitamins especially vitamin C-rich foods to
strengthen the immune response and increasing of oral fluid intake should be conveyed.
 Encourage family members to provide adequate support and care to the patient
 Teach relative/care provider to recognize signs and symptoms of the disease to prevent its
progression and to manage it
 Recommend that they consult the physician if the patient is in a respiratory distress
 To decrease your pain; when coughing. Hold a pillow over your chest where pain is.

39
 Quit smoking. Do not smoke and do not allow others to smoke around you. Smoking
increases your risk of lung infections such as pneumonia. Smoking also makes it harder
for you to get better after having a lung problem. Talk to your care giver if you need help
in quitting smoking.
 Exercise your lungs. The discomfort of pleural effusion may cause you to avoid breathing
as deeply as you should. Coughing and deep breathing can help prevent a new or
worsening lun infection. Take a deep breath and hold the breath as long as you can then
push the air out of the lungs with a deep strong cough. Take 10 deep breaths in a row
every hour that you are awake. Remember to follow each deep breath with a cough.
Outpatient follow-up
 Confirms and advise them to keep all scheduled physician appointment or checkup to see
how well the treatment is working. The physician might change the medications of the
patient for better treatment
 Inform family that follow-up appointment provides an opportunity for the evaluation of
the patient recuperation and identify recurrent or new care needs
 Notify family that follow-up reinforces patient teaching initiated in the hospital in
recognizing and managing the different danger signs of illness
Diet/Nutrition
 Diet which is prescribed should be followed. To include fruits and vegetables in the diet
is significant.
 Ensure adequate protein intake such as milk, eggs, oral nutritional supplements, chicken,
and fish if other treatments not tolerated
 Increase fluid intake; avoid drinks with caffeine and alcohol content
 Eat less salty, oily, spicy, and sweet foods.
Spiritual
 Respect the spiritual coping of the patient during illness
 Encourage patient’s family members to seek council with their spiritual leader

200704112 grand-case-study-final

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