Department of Health

Quirino Memorial Medical Center

Project 4,Quezon City

Professional Nurses Training Program

MEDICAL EXTENSION

I. Biographic Data
Name: Mr. DDU
Sex: Male
Address: Pasig City
Age: 58 years old
Religious Affiliation: Roman Catholic
Civil Status: Married
Room #: Medicine Extension
Chief Complaint: Difficulty of breathing and chest pain
Medical Diagnosis: COPD in Acute Exacerbation,
Principal Diagnosis: COPD not in Exacerbation
Date of Admission: March 15, 2010

II. Nursing History

A. Past Health History

1. Childhood Illness
The past illnesses of the patient include colds, cough, fever, measles, mumps and chicken pox.

2. Immunizations
According to the patient, He said that he completed his basic immunizations when he was a child.

3. Allergies
According to the patient, he has no allergy to any foods, drugs and other things but he claims that his skin
is sensitive and turns red easily when scratch.

4. Accidents
He never experienced any accident.

5. Hospitalization
According to the patient, this was his second time to be hospitalized. His first hospitalization was in QMMC
last year.

6. Medications Used Before Hospitalization

He is not taking any medication.
 7. Foreign (when, Length of stay)
He has not been in other countries.

B. History of Present Illness

According to him, this was his second time to be hospitalized. His previous hospitalization was also
because of difficulty of breathing and cough problems. According to the client two weeks prior to
admission, he had cough but non-productive associated with shortness of breath, no consultation done and
medication given. Few hours prior to admission difficulty of breathing progress hence, the patient seeks
medical attention.

C. Family History
The patient’s

GENOGRAM

Legend:

- Female

- Male

- Dead
 III. Patterns of Functioning
IV.
A. Psychological Health

1. Coping Patterns
The patient stated that whenever they have problems, they talk about it in the family. He verbalized,
“nilalayasan ko ang asawa ko kapag nagagalit na siya sakin andami kasi sinasabi ang parati naming pinagaaway
eh ang pag yoyosi ko, pero pagbalik ko naman nagbabati na kami, normal lang sa pamilya ang
nagkakaproblema”.

Interpretation:
 The patient overcome stagnation and realizes to have commitment to her family. He tries to understand his
wife first and let her calm down. He learns to accommodate her anxiety by solving problems with his family. His
source of strength is also them to help him overcome problems.

Analysis:
Stress can have physical, emotional, intellectual, social, and spiritual consequences. Usually the effects are
mixed, because stress affects the whole person. Physically, stress can threaten a person’s physiologic
homeostasis. Emotionally, stress can produce negative or non-constructive feelings about the self. Intellectually,
stress can influence a person’s perceptual and problem-solving abilities. Socially, stress can alter a person’s
relationship with others. Spiritually, stress can challenge one’s beliefs and values. Many illnesses have been
linked to stress. (Fundamentals of Nursing by Kozier, p.1014)

2. Interaction Patterns
According to the patient, they have an open communication in the family. They resolve problems easily
because they talk about it together. He said that he has a good relationship with his co-workers in the terminal
of tricycles. ”

Interpretation:
The patient has positive interaction patterns and has a healthy interpersonal relationship with the people
around him, likewise being able to adapt to the changes around him.

Analysis:
A positive self-concept is essential to a person’s mental and physical health. Individuals with a positive
self-concept are better able to develop and maintain interpersonal relationships and resist psychological and
physical illness. An individual possessing a strong self-concept should be better able to accept or adapt to
changes that may occur over the life span. How one views oneself affects one’s interaction with others.
(Fundamentals of Nursing by Kozier, p.957)

3. Cognitive Patterns
During the interview, he was cooperative and able to answer our questions. He sometimes asked to repeat
some questions; nevertheless, he responds appropriately. The client is also oriented with regards to time, date,
place and person while doing this assessment.

Interpretation:
 The client is cooperative but have some problems regarding his senses (visual, auditory, gustatory,
olfactory, tactile), can cope with his pain, aware of what is happening, oriented with the date, time and where he
is.

Analysis:
Full consciousness- alert; oriented to time, place, person: understands verbal and written words no problems
regarding the five sense( visual, auditory, gustatory, olfactory, tactile) (Fundamentals of Nursing by Kozier,
p.940)

Awareness is the ability to perceive environmental stimuli and body reactions and to respond appropriately
through thought and action. The normal , alert person can assimilate many kinds of information at one time.
(Fundamentals of Nursing by Kozier, p.940)

All individual’s senses are essential for growth, development, and survival. Sensory stimuli give meaning
to events in the environment. Any alterations in the people’s sensory functions can affect their ability to function
within the environment. (Fundamentals of Nursing by Kozier, p.939)

Memory and problem solving are maintained through middle adulthood (40-65 years old) Learning
continous and can be enhanced by increasing motivation t this time in life. (Fundamentals of Nursing by Kozier,
p.400)

The person may learn to cope with the pain through cognitive and behavioral activities, such as diversions,
imaginary, and excessive sleeping. (Fundamentals of Nursing by Kozier, p.1137)

4. Self-Concept
The patient said, “hindi na ako makapagsalita ng matagal kasi hinihingal ako at nakakapagod ang trabaho
ko”. He rated his health 5, 0 as the lowest and 10 as the highest. When asked his perception of a healthy person,
he verbalized, “hindi nagkakasakit at nanghihina, malakas kumain, at malakas sa trabaho”.

Interpretation:
The patient is aware of his health condition. And according to him, he sees his self as an unhealthy individual
that needs appropriate treatment.

Analysis:
A positive self-concept is essential to a person’s mental and physical health. Individuals with a positive
self-concept are better able to develop and maintain interpersonal relationships and resist psychologic and
physical illness. An individual possessing a strong self-concept should be better able to accept or adapt to
changes that may occur over the life span. How one views oneself affects one’s interaction with others.
(Fundamentals of Nursing by Kozier, p.957)

5. Emotional Patterns
The patient stated that he does not easily get angry. According to him “pag may problema dinadaan ko na
lang sa inom. Whenever problem arises, he usually keeps it. According to his wife, he is a kind and hard-working
husband.

Interpretation:
The patient has positive outlook in life promoting good relationship with others and healthy emotional aspect
of life.

Analysis:
According to Erick Erikson, one of the psychosocial developments of adulthood adults is emotional
generativity versus emotional stagnation. This task concerns the ability to become productive such as being able
to shift emotional investment from one person to another and one task to another.
(Fundament of Nursing, by Kozier et al. p. 399)

6. Sexuality
The patient verbalized, “maayos naman ang pagsasama namin ng asawa ko”, “hindi naman uso ang family
planning noon”. As the head of the family, he makes sure that he provides all the needs of his family.

Interpretation:
The client has a positive sexual self-concept enabling him to form intimate relationships with other people.

Analysis:
A positive sexual concept enables people to form intimate relationships throughout life. A negative sexual
self-concept may impede the formation of relationships. How a person feels about her or his body is related to
one’s sexuality. People who feel good about their bodies are likely to be comfortable with and enjoy sexual
activity. People who have a poor body image may respond negatively to sexual arousal. . (Fundamentals of
Nursing by Kozier, p.973)

7. Family Coping Patterns

 He stated that everyone in the family is free to suggest solutions. According to the patient, whenever they
have problems the couple talks about it. They also tell it to their children. They help one another in solving
problems

Interpretation:
The patient is able to conform his feelings and with his family and is able to assume different roles that is
assigned to him, all of which are indications of a healthy relationship with each member of his family.

Analysis:
Each person usually has several roles, such as husband; parent, brother, son, employee, friend, church
member. Some roles are assumed for only limited periods, such as client, student and ill person. To act
appropriately, people need to know who they are in relation to others and what society expects for the positions
they hold. Failure to master a role creates frustration and feelings of inadequacy, often with consequent lower
self-esteem. (Fundamentals of Nursing by Kozier, p.960)

B. Socio-cultural Patterns

1. Cultural Patterns
The patient said that they celebrate Christmas and New Year all together. According to the patient, it is
important to strengthen their relationship with each other.

Interpretation:
There is a great possibility that her children will develop the same practice. They are family-oriented.

Analysis:
Culture is a non-physical trait such as values, beliefs, attitude and customs that are shared by a group of
people that are passed on one generation to the next. Culture and social interaction also influence how a person
perceives experiences and copes with health and illness. Each culture has ideas about health and this are often
transmitted from one parent to children.
(Fundament of Nursing, by Kozier et al. p. 179)

2. Significant Relationships
According to the patient, he has a good relationship with his family. They are open to one another. They have
a harmonious relationship. His wife said that he is a good father to their children. He always reminds them of
righteousness.
 Interpretation:
The patient has a healthy interpersonal relationship with the environment and the people around him,
likewise being able to adapt to the changes around him.

Analysis:
Each person usually has several roles, such as husband; parent, brother, son, employee, friend, church
member. Some roles are assumed for only limited periods, such as client, student and ill person. To act
appropriately, people need to know who they are in relation to others and what society expects for the positions
they hold. Failure to master a role creates frustration and feelings of inadequacy, often with consequent lower
self-esteem. (Fundamentals of Nursing by Kozier, p.960)

3. Recreation Patterns
The patient stated that they do not go out for recreational activities since their family income is only enough
for their needs. The patient verbalized, “minsan sinasama ko ang pamilya ko kapag may kainan sa mga kakilala
nila”.

Interpretation:
Recreational activity is not prioritized by the family.

Analysis:
Recreation is a way of relaxation. It is often considered as behavior and activities over which people have
control. It is usually performed with the significant others to build a strong relationship.
(Fundamentals of Nursing by Kozier, p.177)

4. Environment
The client verbalized, “malapit sa hi-way ang bahay namin at malapit sa terminal”, “nakatira pamilya ko sa
isang bahay”. They stated that their area is congested.

Interpretation:
Their place is accident prone since they are living near a hi-way. Nevertheless, their place can be considered
suitable and is conducive to health. There is also an advantage because they are near the market where he
works.

Analysis:
 Information is elicited about the type of housing in which the person lives, its location, the level of safety and
comfort within the home and neighborhood, and the presence of environmental hazards.

5. Economic
The patient was a tricycle driver. His wife verbalized, “lagi siyang nasa kalsada”. According to the patient,
their family income is 200php per day. He said that it is not usually enough for their daily needs. “pero sanay na
eh”. Health is not usually prioritized by the family

Interpretation:
The family’s income is not enough to support all their needs especially medical assistance.

Analysis:
Economic status is an indication of a person’s place in the society. Information about how the client is paying
for medical care (including what kind of medical and hospitalization and coverage has) and whether the client’s
illness presents financial concerns.
(Fundamentals of Nursing by Kozier, p.264)

C. Spiritual Patterns

1. Religious Beliefs and Practices

The patient is a Roman Catholic. But he does not go to the church because it is far from their house. He just
prays by himself. Since the patient’s family is Roman Catholic, there is no religion factor that may interfere to
health.

Interpretation:
The client does not have problem in terms of his religious beliefs and practices. He is not really active with
his spiritual responsibilities.

Analysis:
Spiritual health or spiritual well- being manifested by a feeling of being generally alive, purposeful, and
fulfilled.
Religion - organized System of beliefs and Practices A way of spiritual expression that provides guidance for
believers in responding to life's questions and challenges (Fundament of Nursing, by Kozier et al. p. 996)

2. Values and Valuing

He stated that he gives importance on teaching his children kindness, respect, love and good manners.
Each family member is important for them.
 Interpretation:
The patient does not have problem in terms of his value. They have close family ties, they are family-
oriented and have been developed a strong relationship which it can lead to their progress. His family does not
have any practices that may affect the health of any family members.

Analysis:
Values in a family may influence a particular health problem.
(Fundament o Nursing, by Kozier et al. p. 71)

IV. Activities Of Daily Living

ADL Before During Interpretation and Analysis

Hospitalizati Hospitalization
on
1. Nutrition According to The patient ANALYSIS:
the patient, he verbalized “tubig Nutrients are the organic and
eats 3 times a lang madalas, inorganic chemicals found in foods
day, he tapos iyon required for proper body functioning:
verbalized binibigay nilang 1. Water
“kung ano pagkain dito”. 2. Carbohydrates
lang meron sa 3. Proteins
binibilhan 4. Fats
namin”. He 5. Vitamins
always 6. Minerals
smokes (Fundamentals of Nursing, 2nd
afterwards. edition; Josie Quiambao-Udan,
pg.239-240)

When the body’s fluid balance

is low, blood flow through kidneys is
reduced therefore, the kidneys are
less effective in removing wastes
from the body. Effect on low fluid
intake on urinary elimination is
 infrequent emptying of the bladder.
This increase the incidence of urinary
tract infections. (Fundamentals of
Nursing by Atkinson pp.602)

INTERPRETATION:
The client eats variety of food.
These nutrients are needed by our
body to meet our daily requirement
to be able to function normally.
2. Elimination He said that The patient ANALYSIS:
he defecates verbalized “parang
once a day hindi na masyado A person’s urinary and fecal habits
and urinates 2 ang hirap kasi depend on social Culture, personal
times a day. dito.” habits and physical abilities. Personal
habits regarding urination and
defecation are affected by social
property of leaving to urinate and
defecate, the availability of a private
clean facility, and initial toilet
training. Urinary eliminations is
essential to health, and voiding can
be postponed for only so long before
the urge normally becomes too great
to control.

Characteristic of Normal Feces

Brown
Formed, soft, semisolid, moist
Cylindrical
Aromatic
(Fundamental of Nursing, by kozier et
al. pg.1227)

Characteristic of normal Urine

1,200 – 1,500 ml
 Straw, amber, transparent
Faint aromatic
(Fundamental of Nursing, by kozier et
al. pg.1264)

The normal frequency of

urination/day ranges from 4-6
times/day. The amount of urine
excreted each day can vary from as
much as 25L when water is extremely
high, to as little as 400ml when there
is a need to conserve water. ( Vander
et al., 1980 )

INTERPRETATION:
The client has regular bowel
movement. Although he doesn’t
frequently urinate The client does not
have excessive perspiration.

3. Exercise He stated that The patient ANALYSIS:

he do not verbalized “lakad Regular exercise not only keeps your
exercise, but lakad lang”. weight down; it also relieves stress
considers and makes you look and feel good.
unlike when (Philippines Health Guide, p.73)
he was still
young. He Exercises maintain or increase
stated that muscle strength.
“palagi kasi Physical activity is a stressor to the
akong pagod body in the sense that it produces
kaya di ko na changes and utilizes energy.
magawa ang (Atkinson, Lesley D., Fundamentals
dati kong of Nursing, pp. 700 and 719)
ginagawa
noong bata pa General exercise promotes both
ako”. physical and emotional health. In
 general, health guidelines
recommend exercise at least three
times a week for 30 to 45 minutes.
People who manage their time
effectively usually experience less
stress because they feel more in
control of their circumstances. For
example, working mothers may need
to consider delegating tasks to family
members or hiring part-time help.
(Kozier, Barbara, Fundamentals of
Nursing, 7th Edition, pp. 1023)

INTERPRETATION:
The patient needs to have a regular
exercise for him to become more
active and healthy. It also helps
relieve stress.

4. Hygiene He said that The patient ANALYSIS:

he takes a verbalized “minsan Bathing minimizes skin dryness in
bath hindi na, elders, avoid excessive use of soap.
everyday. nakakatamad eh”. The ideal time to moisture the skin is
immediately after bathing. Bathing
removes accumulated oil,
perspiration, dead skin cells and
some bacteria. It also promotes
stimulation of circulation and sense of
well-being.
(Kozier, Barbara, Fundamentals of
Nursing, 7th Edition, p. 698)

INTERPRETATION:
In her current condition, he was
unable to perform proper hygienic
measures.
5. Substance The client The patient ANALYSIS:
Abuse frequently verbalized “hindi Some people use mood altering
drinks liquor eh bawal dito sa substances in attempt to cope with
and he ospital”. He added life challenges. Some people may
smokes 10 “pag uwi ko na respond to personal illnesses to
sticks of lang”. decrease pain. Typically people who
cigarette per abuse substances are unable o
day (Philip identify and implement adoptive
brand) for 25 behaviors and use illegally obtained
years. drugs prescribed or over the counter
medications and alcohol alone in an
effective attempt to cope with
pressures, stains and burdens of life.
(Medical-Surgical Nursing by Suzanne
C. Smeltzer, et. al., 10th edition,
p.107)
INTERPRETATION:
He smokes 10 sticks per day for 25
years, cigarettes contents nicotine a
substance that can constricts blood
vessels.
6. Sleep and He sleeps at The patient ANALYSIS:
Rest 10pm and verbalized “halos The older adults sleep about 6
wakes up at hindi na makatulog hours a night.
3am. He laging may (Fundamentals of Nursing by
seldom takes gumigising sa akin Kozier, et.al, p.1117)
naps. He dito”.
verbalized Fatigue also affects a person’s
“nonood pa ng sleep pattern. The more tired the
tv sa gabi eh”. person is, the shorter the first period
of paradoxical (REM) sleep. As the
person rest, the REM periods become
longer. (Fundamentals of Nursing by
Kozier, p.1118)
 Fatigue is characterized by the
inability to perform physical tasks at
one's usual pace or strength, and by
a slowing of the thinking processes
that may involve failure of memory.
The same is true of hearing. A
prolonged noise that is heard
continuously becomes less intense
due to fatigue of the processes of the
inner ear. Continued mental exertion,
as in a protracted working over of a
problem, causes the condition known
as mental fatigue. (Microsoft ®
Encarta ® Premium Suite 2005. ©
1993-2004 Microsoft Corporation.)

The skin around the eye is very

delicate and transparent. Dark circles
appear when the blood vessels that
are close to the surface show
through. Under-eye bags occur when
the muscles that enclose the upper
and lower eyelids lose elasticity,
which can result in the underlying fat
to bulge out. Fatigue can contribute
to the formation of dark circles and
under-eye bags
(http://www.murad.com/lightenandbri
ghten/darkcirclesundereyebags.html)

Fatigue may be the result of

one or more environmental causes
such as inadequate rest, and home
stressors
(http://www.healthatoz.com/healthat
oz/Atoz/common/standard/transform.j
 sp?
requestURI=/healthatoz/Atoz/ency/fat
igue.jsp)

INTERPRETATION:
The patient should have rested for
about 6 hours to promote her normal
sleeping pattern and to relieve from
fatigue.
7. Sexual The couple The patient Analysis:
Activity does not verbalized “sympre A positive sexual concept
perform any lalaki ako, may enables people to form intimate
family anak na nga ako”. relationships throughout life. A
planning. The negative sexual self-concept may
couple still impede the formation of
sleeps relationships. How a person feels
together but about her or his body is related to
has a good one’s sexuality. People who feel good
relationship about their bodies are likely to be
with his wife. comfortable with and enjoy sexual
activity. People who have a poor body
image may respond negatively to
sexual arousal. . (Fundamentals of
Nursing by Kozier, p.973)

Interpretation:
The client has a positive sexual self-
concept enabling him to form
intimate relationships with other
people.

X. Prioritized List of Nursing Problem

PROBLEMS IDENTIFIED
 



PRIORITIZED PROBLEMS

RANK NURSING PROBLEMS IDENTIFIED JUSTIFICATION

1 Ineffective Airway Clearance r/t secretions in the It is a potential problem
If the problem will be solved other health
bronchi as evidence by problems that can arise will be prevented.
The problem can be easily modifiable because
adventitious sounds the caregiver’s resources are easily available.
2 Impaired Gas Exchange r/t hypoxia as It is an actual problem.
evidence by 4-5secs capillary refill The problem can be easily modifiable because
the caregiver’s resources are easily available.
3 It is an actual problem.
The problem can be easily modifiable because
the caregiver’s resources are easily available.