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PATIENTS INITIAL DATABASE

Patient: 3109A Age: 57 y/o Birthday: November 06, 1956 Civil status: Separated Nationality: Filipino Religion: Roman Catholic Admission Date: March 11, 2014 Admission Time: 10:55pm Medical Diagnosis: Secondary Spontaneous Pneumothorax Prob. Sec. to COPD

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II. NURSING HISTORY Patient 3019A was born in cephalic presentation @ 39 weeks AOG. According to him, he had a complete immunization & had no serious illnesses during childhood. He had common cough and colds & fever which were commonly treated with paracetamol, nasal decongestants, antitussives and mucolytics which offered relief to the patient. He was a smoker, he smoked 39 years x 1 pack per day = 39 pack years. He only stopped recently when he began experiencing SOB and chest pain. He was also an occasional alcohol drinker, he drinks when there are special occasions like birthdays, weddings, and other social events. He can consume up to 5 bottles of 500mL beer. Patient was a cableman, and is separated from his wife. He usually eat three times a day & seldom eats snacks, and doesnt like to eat vegetables. According to him his family had no history of any hereditary diseases or other serious illnesses. III. PAST MEDICAL HISTORY Two (2) years prior to admission, patient experienced cough lasting to three (3) years, he sought consultation at local hospital. Undergone chest x-ray, sputum analysis, and tuberculin test which showed he was (+) for Pulmonary Tuberculosis. He has undergone anti-kochs treatment for two months at hospital. After two months, he requested HAMA and wasnt able to continue treatment. No other serious illness was recorded as claimed.

IV. PRESENT MEDICAL HISTORY Two (2) months prior to admission, patient experienced fatigue easily with periods of chest pain precipitated by deep breathing, and walking on the grounds associated with shortness of breath, prompting consultation @ Mt. Carmel Hospital at Lucena where chest x-ray showed Pneumothorax R . CTT was inserted at R anterior chest wall. CTT was assessed, positive from bubbles confirming bronchopleural fistula, undergone treatment. When lungs were free from air, patient was discharged. After two (2) weeks, symptoms reoccurred. Hence, this admission.

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V. PHYSICAL ASSESSMENT Head > The head of the client is rounded; normocephalic; 57 cm in diameter and symmetrical. Hair is black in color with portions of white hair, dull in appearance and oily in texture. In skull, no nodules or masses and depressions when palpated. The face of the client appeared smooth and has uniform consistency and with no presence of nodules or masses. Eyes > Eyebrows is evenly distributed. The clients eyebrows are symmetrically aligned and showed equal movement when asked to raise and lower eyebrows. > Eyelashes appeared to be equally distributed and curled slightly outward. >The sclera appeared whitish to yellowish. > The conjunctiva appeared moist and pink. >Cornea is transparent, smooth and shiny and the details of the iris are visible. The client blinks when the cornea was touched. >The pupils of the eyes are black and equal in size, 3mm in shine of bright light and 7mm if light is absent. Pupils equally round respond to light accommodation, illuminated and non-illuminated pupils constricts. Pupils constrict when looking at near object and dilate at far object. Pupils converge when is moved towards the nose. >When assessing the peripheral visual field, the client can see objects in the periphery when looking straight ahead. >When testing for the extraocular muscle, both eyes have conjugated eye movement >The client is able to read with the aid of reading glasses. Ears >The Auricles are symmetrical and has the same color with his facial skin. >The auricles are aligned with the outer canthus of eye. >When palpating for the texture, the auricles are mobile, firm and not tender. >The pinna recoils when folded. >(+) for Rombergs test, patient slightly loss his balance when eyes were closed. >(+) for Rinne and Webers test, patient reporting the sound heard equally in both sides. >Patient heard equally loud in both ears with no one ear hearing the sound louder than the other. >Earwax noted on inspection Nose >The nose appeared symmetric, straight and uniform in color. >There was no presence of discharge or flaring. When lightly palpated, there were no tenderness and lesions >Nostrils are functional, able to identify three (3) odors, perfume, calamansi and coffee. Mouth>The lips of the client are pale in color and dry. >Teeth and Gums, tooth enamels is whitish to yellowish, cavities noted.
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>The buccal mucosa of the client appeared as uniformly pink; moist, soft, glistening and with elastic texture. >The tongue of the client is centrally positioned. It is pink in color, moist and slightly rough. Presence of white coating, able to identify tastes, sugar-sweet, salt-salty, bittergourd-bitter, calamansi-sour >The smooth palates are light pink and smooth while the hard palate has a more irregular texture. >The uvula of the client is positioned in the midline of the soft palate. >(-) for any airway obstruction. Neck>(+) from lesions wounds scars and pimples at nape. >With mass at left side of the neck, non-movable, not painful to approximately 2cm in diameter. >(-) for any problems that may cause airway obstruction. >The neck muscles are equal in size. The client showed coordinated, smooth head movement with no discomfort. >The lymph nodes of the client are not palpable. >The trachea is placed in the midline of the neck. >The thyroid gland is not visible on inspection and the glands ascend during swallowing but are not visible. Chest and Lungs >Inspection: The chest wall is intact with no tenderness and masses. No lesions and masses noted. Chest is symmetrical in shape, anterior-posterior diameter is normal. >Percussion: Resonant sound noted on percussion @ left chest wall and on right chest wall. > Palpation: Theres a full and symmetric expansion and the thumbs separate 2-3 cm during excursion. >Auscultation: Fine rales noted on auscultation @ both left and right upper lungs. Abdomen: >Inspection: Abdomen is flat, uniform in color, and there are no wound scars, birthmarks noted (flat moles), umbilicus is clean and malodorous. >Auscultation: Normoactive bowel sounds noted on auscultation, 12 per minute on all four (4) quadrants of the abdomen. >Percussion: Tympanic sounds noted on percussion at all four quadrants of his abdomen. >Palpation: No masses noted on palpation, bladder is slightly distended because of urine.

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Genito-Urinary: >Penis is (+) for erection, no warts, masses and discharges noted. >No lesions noted >Able to urinate freely without pain or any discomfort. Skin & Extremities: Inspection: Skin appears to dry, brown in color, with good skin turgor, wound scars and keloids noted on both upper and lower extremities. Nails are slightly pale. Palpation: Nails have delayed capillary refill of 2 seconds. Skin is slightly cold and clammy. General Condition: > Patient is on O2 therapy of 2L/m via nasal cannula with episodes of SOB when talking. > Patient has CTT to (-) 18cm H20 pressure to 3 bottles. > Patient is weak with moderate anorexia. Current weight of 65kg, and height of 511 BMI of 19.9 which is normal.

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VI.

GORDONS FUNCTIONAL HEALTH PATTERNS AND NEEDS A. Perceptions & Expectations of Illnesses/Hospitalizations Before onset of signs & symptoms, patient perceives self as healthy. He doesnt bother having common cough & colds & expects it to get better even without medication or proper treatment. When he started experiencing chest pain and difficulty of breathing when walking, he asked for medical advice. When he was diagnoses with PTB, he tried to be more aware of his health but still became non-compliant to PTB therapy. When he was hospitalized recently, he perceived himself as an unhealthy person and expects the worst out of his condition, he thinks that if he doesnt stay at the hospital for all treatment, he might die. He is also refusing to go home even if the doctor orders it, this is for the reason that he think he couldnt make it to live normally with a CTT and that his home is far away from the LCP so it would be difficult for him to travel for follow-up checkups as mentioned. He tries to be amenable to all his treatment but he does not fully trust his doctors order of having him go home. Analysis: Patients is experiencing misunderstanding about his present condition. Nursing Diagnosis: Knowledge deficit r/t present condition B. Specific Basic Needs 1. Comfort/rest needs Before onset of s/s patient sleeps 6-7 hours per day. He usually sleeps @ around 10:00pm. He takes nap in the afternoon is he is not busy at work. When signs and symptoms occurred, his sleep pattern was changed; he couldnt sleep well because of what he is feeling. During hospitalization, his sleep routine was completely disrupted because he couldnt sleep straight due to the difficulties that he is feeling. He often sleeps but its hes half awake as claimed. Analysis: The patients sleep pattern is disrupted. His comfort and rest needs isnt met adequately. Nursing Diagnosis: Disturbed sleep pattern 2. Safety needs Since the patient is weak and unable to function as dynamic as before hospitalization, there are risks that are being faced by the patient, In terms of fall, the patient is in moderate risk because he is weak and is always in the bed, so side rails must always be up so as to avoid falling, for the aspiration risk, the patient is in moderate risk because he experience DOB even when
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talking, so when he eats, he easily tires off, making him at risk of getting aspirated. The patient requires assistance in sitting and standing, he seldom stands up, because he is uncomfortable due to his CTT. He also uses reading glasses in order to see what he reads. Analysis: The patient isnt able to perform well his activities of daily living independently and his safety isnt secured due to some risks that he is experiencing. Nursing Diagnosis: Impaired physical mobility 3. Fluids and Nutritional Needs Before Hospitalization: Meal Breakfast Food Taken Rice Fried Egg Coffee Rice Fried Chicken Chicken Soup Royal Amount 2 cups 1pc. 1 cup 2 cups 2 pieces 1 cup 1 glass kCal 432 kCal 196 kCal 1 kCal 629 kCal

TOTAL kCal Lunch

432 kCal 492 kCal 87 kCal 38 kCal TOTAL kCal 1049 kCal Dinner Rice 1 cup 216 kCal Fried Chicken 1 piece 246 kCal Chicken Soup 1 cup 87 kCal Royal 2 glasses 76 kCal TOTAL kCal 625 kCal TOTAL kCal for 24 hours: 2,303 kCal

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During Hospitalization Meal Breakfast Food Taken Loaf Bread Large Boiled Egg 1 Large Banana Orange Juice Amount 1 slice 1pc. 1 pc. 1 glass kCal 66 kCal 77 kCal 121 kCal 45 kCal 309 kCal 216 kCal 161 kCal 38 kCal 415 kCal

Total kCal Lunch

Rice 1 cup Afritadang Manok cup Royal 1 glass

TOTAL kCal Dinner Rice Beef Steak Large Banana Water

TOTAL kCal

1 cup 216 kCal 1 piece 138 kCal 1 cup 121 kCal 1 glasses 0 kCal 475 kCal

TOTAL kCal for 24 hours: 1,199 kCal Body Weight: 65kg or 143lbs. Body Height: 511 BMI: 19.9 = Normal Recommended Energy Intake For Male Filipinos ages 50-64 who has moderate work is 2,170 kCal/day. Patient 3109A has a 24 hour kCal intake of 2,303 kCal which is more than the recommended, but when he was hospitalized his 24 hour kCal intake was only 1,199 kCal which is almost half of the recommended 24 hour kCal intake. Analysis: Before hospitalization, clients nutritional needs are being met adequately, when he was hospitalized, his intake decreased, he started to have moderate anorexia. This made his total kCal per 24 hour inadequate for the normal RDI of his age and gender. Nursing Diagnosis: Risk for nutritional imbalance: less than body requirements r/t loss of appetite secondary to physiological condition 4. Elimination Before hospitalization, patient defecates 2-3 times per two days to approximately 30cc per defecation, firm and brownish in color. He urinates
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almost 5 to 10 times per day depending on his meal and activities; he urinates to approximately 65 cc per urination, clear to yellowish in color. Total urine output per day 650 cc. During hospitalization his elimination pattern started to change, it was deteriorating. According to him, he was able to defecate once since he was admitted. His urinary elimination changed as well, its color became yellowish to orange and its transparency became cloudy. During hospitalization he urinates 10 to 15 times per day to approximately 100cc per urination. His total urine output per day is 1000cc whereas the normal urine output per day is 720cc per day. Analysis: The patients elimination pattern was altered during hospitalization, his urine output is more than the normal ones might be because he is experiencing anorexia and always drink fluids instead. Nursing Diagnosis: Risk for fluid volume deficit r/t increase urine output 5. Oxygenation Before onset of signs and symptoms, patient was an active smoker who smoked 39 pack years. Before he just experienced common cough and colds then it persisted to shortness of breath, difficulty of breathing up to hospitalization. According to the patient he has a high exposure to pollutants such as smog, vehicular gasses, and nicotine, this is due to his work which is a cableman wherein he often works at street sides, and since he is a smoker, he has a high exposure to nicotine. According to him, he has no exposure to other chemicals and radiations. During hospitalization, he had undergone a test wherein his oxygenation was assessed. On his Arterial Blood Gas Analysis, ABG results were as follows: FC102 3%; pH 7.554 PCO2 - 37.1 mmHg; TCO2 34.2; PO2 78.6 mmHg; BE 10.7; HCO3 33.1 meq/L; %SAT 94% Analysis: Since the patient is has a high exposure to nicotine, this became a contributing factor to his present condition. The interpretation of his ABG result is Metabolic Alkalosis with Moderate Hypoxemia which indicates that the patient is having problems in the diffusion stage of oxygenation in his lungs. Nursing Diagnosis: Impaired gas exchange

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6. Others A. Sexuality Patient perceives himself as a straight man, he doesnt have problems with his sexuality and he is comfortable with his gender. Recently, the patient is sexually inactive as claimed because he is separated from his wife. Analysis: The patient has no problems with sexuality and theres no significant relationship between the patients sexuality and his problem with oxygenation. B. Allergies According to the patient he has no allergies to food or medications. Analysis: (-) from all forms of allergies. C. Before onset of signs and symptoms, patient is able to communicate without difficulties. During onset of signs and symptoms, difficulty in speaking began to develop because he experience SOB at the same time. When he was hospitalized, he still experiences SOB when talking a lot. Analysis: Patients communication was altered due to SOB. Nursing Diagnosis: Impaired verbal communication

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