DE LA SALLE HEALTH SCIENCES INSTITUTE

Dasmarias City, Cavite

College of Nursing and School of Midwifery

NURSING CASE STUDY UMC-3600

Submitted by: Julius C. Bustamante, SN13 BSN 3-3 November 2011

Submitted to: Mrs. Shirley Terencio, R.N., M.A.P. (Clinical Instructor)

I.

HEALTH HISTORY A. DEMOGRAPHIC DATA 1. Clients initial:R.S.G. 2. Gender: Male 3. Age: 56 y/o 4. Birthdate:February 6, 1955 5. Birthplace: Pasay City, Philippines 6. Marital status: Married 7. Race and Nationality: Filipino, Asian 8. Religion: Roman Catholic 9. Address: Golden City, Imus, Cavite 10. Telephone Number:N/A 11. Occupation: OFW 12. Usual Source of medical care: DLSUMC 13. Diagnosis: Transient Ischemic Attack, Hypertension B. SOURCE AND RELIABILITY OF INFORMATION y The patient himself who is awake, conscious, coherent, and communicative y Patients spouse who is communicative and seems reliable y Patients chart from the Nurses station C. REASONS FOR SEEKING CARE OR CHIEF COMPLAINTS y Blurring of vision y Headache y Elevated blood pressure D. HISTORY OF PRESENT ILLNESS OR PRESENT HEALTH 13 hours prior to admission, felt pain at the right flank. He also had difficulty in urination but theres still no sign of nausea and vomiting. 6 hours prior to admission, difficulty in urination and flank pain disappeared. No signs of fever were seen. Patient started to experience headache and blurring of vision, more on the right eye. His blood pressure also rose to 130/90 mmHg that made them decide to consult a physician in the hospital.

E. PAST MEDICAL HISTORY OR PAST HEALTH y Pediatric/childhood/adult illnesses The patient did not experience any serious illness or disease when he was a child. He was 30 years old when he started to have high blood pressure that still persist until the day of admission. He also experienced the same case during the year 2009. y Injuries or accidents The patient did not experience any types of injuries and accidents before. y Hospitalization The first time the patient got hospitalized was during the year 2009. After that, he was not again confined to any hospital until the day of admission. y Operation The patient underwent angioplasty last 2009. Aside from that, there is no other surgery that was done to him y Immunization Patient had completed all the vaccinations needed since he was given birth. y Allergies The patient has no known allergy to any foods or environmental allergens. y Medications The patient before his admission to the hospital was already taking medications as maintenance for his blood pressure. Aside from that, no other medications was taken even supplementary drugs.

F. FAMILY HISTORY MATERNAL PATERNAL

Cancer, 90

CVA, 89

CVA, 65

CVA, 84

62, DM 2

35, W&A 33, W&A 60, Cancer

31, W&A 59, Cardiac Dse 23, W&A

21, W&A 56, HPN

54, W&A

LEGEND:

53, W&A

Patient

Deceased

Male

Female

Synthesis: The above diagram shows the family tree of patient RSG. Together with the diagram are the ages and diseases that the patients family has. And also, the diagram show the relatives of the patient and about on how they are connected and interrelated. As we can see, the patients family has diseases and disorders that may have been inherited by their descendants. These include heart diseases such as hypertension and cerebrovascular accident, cancer, and diabetes mellitus. No other inheritable disorders from other vital organs of the body were traced. This diagram is shown to see the possible ways why the patient got his disease. Aside from lifestyle, genetics is one of the biggest influences in inheritance of diseases. In the case of the patient, he might have inherited the disease from his parents. Not only him, but also, we can see that some of his siblings had inherited those diseases too.

G. SOCIO-ECONOMIC The family is a nuclear type of family so they are just earning to support and fulfill the needs of their own family. As they all live at the same house except for the eldest child who has been working abroad for years, they are sharing the earning they have. These earning or income comes from the job that the patient and some of his children has. As the patient said, their income is just enough to sustain their everyday needs. They only have one child left studying and so they are now able to save money not like when almost all of their children were still studying. H. DEVELOPMENTAL HISTORY The patient, age 56, is under the stage of middle adulthood with accordance to Erik Ericksons developmental theory. In this stage of development, adults need to create or nurture things that will outlast them, often by having children or creating a positive change that benefits other people. Success leads to feelings of usefulness and accomplishment, while failure results in shallow involvement in the world The patient manifested a well-developed personality. At his age, he already filled his duties not only to himself but also for others. He already has his children and fulfills their needs as a good father. He also had done works that also help others so he consider himself as a great help to the society where he lives in. he is contented with what he has done because he know to himself that he has already made lots of accomplishments.

I. REVIEW OF SYSTEM AND PHYSICAL EXAMINATION 1. R.O.S. and P.E. SYSTEM 1. General R.O.S. P.E.  Awake, conscious, slight coherent  Temp= 36.0 oC maayos naman ako, tingin ko makakaya ko na mag-adjust pag nakalabas na ako ng ospital..  RR= 19 cpm  PR= 62 bpm  BP = 120/80 mmHg  (+) mild general weakness  (+) ambulatory 2. Integument Skin  Skin is dark, dry, medyo namumuti na yung buhok ko dahil sa katandaan.. ..may pilat ako sa dibdib dahil naoperahan ako noong 2009 sa puso.. smooth and evenly fair  Good skin turgor  Warm to touch  (-) skin lesions  (-) abnormal discoloration]  (+) scar at the chest Hair  Hair is black, long, and fine with some white discolorations  (+) Normal hair

distribution  (-) lice and dandruff

Nails  Fingernails are clean  Round, hard nails with partial whiteness on the nail beds  (-) nail clubbing  Capillary refill <3 seconds 3. Head  Head is round and organs are symmetrically hindi na naman sumasakit ulo ko, hindi tulad noong bago pa lang ako maconfine.. distributed  (-) lesions on the scalp  Proportional to body  temporomandibuilar joint felt bilaterally within  (-) involuntary facial movements  (-) abnormal masses found all over the face 4. Eyes  Symmetrical and simultaneous blinking  (+) blurring of right Malabo yung kanan kong eyes

mata, simula lang ito nung inatake ako.. pero mas maayos na ngayon kesa dati..

 round and equal iris  (-) protrusions  (-) inflammation  (-) unusual discharges  (-) discoloration of sclera

5. Ears

 Ears are soft and symmetrical  Ears are aligned with okay pa naman pang dinig ko.. the outer cantus of the eyes  (+) recoils when folded  (+) firm cartilages  (-) discharges on external ear  (+) small amount of cerumen in the ear canal without foul odor  (-) tenderness and abnormal masses  (-) lesions and abrasions  (+) pierce on both sides

6. Nose and Sinuses

 Located at the midline of the face  Symmetrical in Dito lang naman ako sa ospital sinipon pero di naman ganun kalala.. shape  Pink and moist mucosa with no lesions

 (+) nasal secretion: clear, slightly thick, small amount  (-) tenderness and masses upon palpation 7. Mouth and throat  Lips are slightly dry  Lips are pinkish in color nagtu-toothbrush naman ako at inaalagaan kong mabuti mga ngipin ko..  (-) lesions and inflammation  Pharyngeal tonsils not inflamed  (-) bad breath  (-) tenderness and masses upon palpation  (-) mouth ulcers or stomatitis 8. Neck  (+) ROM  Smooth, firm, nontendered thyroid wala naman masakit sa leeg ko.. maayos ko naigagalaw..  (-) lymph node enlargements  (-) abnormal prominence of bones 9. Breast and Axilla  (-) axillary lymph nodes enlargement  (-) abnormal wala naman ako secretions

nakakapa na bukol o anumang masakit dito 10. Respiratory

 (-) skin damage or abrasions  Chest expands symmetrically while breathing

kahapon lang din ako inubo, ditto lang din sa ospital, di naman ako nahihirapan huminga..

 RR 19 cpm  PR 62 bpm  Effortless respiration  (+) productive cough  (-) unusual breath sounds

11. Cardiac  PR 62 bpm  BP 130/90 mmHg pangalawang beses ko na to inatake.. una nung 2009 nung inoperahanb ako.. 30-40 taon gulang ako nung nagsimula akong mahigh-blood 12. Gastrointestinal  Stomach is round and distended  (-) protrusion of the maayos naman sikmura ko saka tyan, walang masakit o kakaibang umbilicus  (-) rashes  (-) mass and  (+) hypertension  (-) distension of jugular vein  (-) edematus  (-) bruit upon auscultation

pakiramdam.. 13. Urinary nakakaihi na ulit ako ng maayos, hindi tulad nung bago ako maconfine, masakit kapag umiihi ako.. 14. Genitalia 15. Peripheral vascular wala akong napapansin na ugat na malaking lumalabas.. 16. Musculoskeletal N/A

tenderness  Urine is slightly clear and yellowish in color  (-) dysuria

 No P.E.  (-) any abnormalities of blood vessels  (-) edematus on any extremeties  (-) paresthesia  Patient can stand erect  (+) ROM and muscle strength of upper and

malakas pa naman ako, minsan lang inaatake ako ng rayuma dito sa may baywang lalo na kapag malamig..

lower muscle  Muscle is proportionally and equally distributed  (-) muscle pain and weakness  (+) oriented to place

17. Neurologic tingin ko naman eh maayos pa pag-iisip ko at nakakagalaw ako ng maayos.. 18. Hematologic wala ako napapansin na mga biglaang pag-

and person  (+) conscious, coherent and communicative  (-) unusual bleeding  (-) bruising

dudugo at basta bastang pamamasa sa katawan ko.. 19. Endocrine Wala pa naman ako nakikitang sakit sa lapay ko..

 (-) rashes

 (+) heat and cold tolerance

2. Laboratory Studies/Diagnostics Date Indication Normal values Actual findings 11/05/2011 Hgb Monitor of the 140-175 g/L 153 Blood components of Chemistry the blood to Hct check for 0.36-0.45 0.46 infection, deficiency, loss WBC of electrolytes, 5-10 x 109/L 9.1 etc..

Differential count: Segmenters 0.36 0.66 Lymphocytes 0.22 0.40

0.68

0.27

Eosinophils 0.01-0.04 Monocytes 0.04-0.08 Others:

Nursing responsibilities y Explain to the patient the rationale and the interpretation of the result of the exam. y Monitor vital signs and signs and symptoms relating to increase or decrease in RBC. y Maintain adequate hydration. y Assist with medical interventions. y Instruct the client to eat foods rich in iron like liver, green veggies, etc. y Instruct patient to prevent to the exposure of chemical elements like lead to avoid ingestion and poisoning.

11/08/2011 Check for UTI Urinalysis

RBC morphology: normocytic, normochronic Platelets: adequate Basophils: 0.01 Color Characteristic Specific gravity Ph Albumin Sugar WBC RBC Epithelial cells

Yellow Clear 1.020 5.0 negative +1 1-3/hpf 10-15/hpf Rare

y Explain to the patient the rationale and the interpretation of the result of the exam. y Maintain adequate hydration y Assist with medical interventions y Monitor UO

11/05/11 PTT To check clotting time of the blood Time: 12.7 secs % acivity: 123.3 % 10-14 secs

70-120%

INR: 0.83

=/< 1.15

Patient Preparation y Explain to the patient that the test determines whether blood clots normally. y Notify the laboratory and physician of drugs the patient is taking that may affect test results; it may be necessary to restrict them. y Tell the patient that the test requires a blood sample. y Explain who will perform the venipuncture and

when. y Explain to the patient that he may feel slight discomfort from the tourniquet and the needle puncture. y Inform the patient that he need not to restrict food and fluids. Nursing Interventions y Apply pressure to the venipuncture site until bleeding has stopped. y If a hematoma develops at the venipuncture site, apply direct pressure. If the hematoma is large, monitor pulses distal to the phlebotomy site. y Tell the patient that he may resume any medication that was discontinued before the test is ordered.

3. Other assessment tools Date taken Comprehensive actual content/Legend --J. FUNCTIONAL ASSESSMENT

Actual result --

1. Health perception/Health management pattern The patient seems to be healthy but not that well because he find difficulty in performing activities because he was told by his physician to limit his activities to avoid fatigue. He said that he cannot say that he is fully recovered because there is already damage in his body. All he can do is to maximize his life with the things that he accomplishes that is not beyond the limit of what his body can do. 2. Self-esteem, self-concept/self-perception pattern The patient has enough self-esteem according to him. He is confident of what he has, what he is, and what he can do. He sees himself as a productive individual that makes sense not only for himself but also to other people around him. 3. Activity/exercise pattern The patient used to have regular exercise when he was home due to past experience last 2009. It was advised to him to do so. But when he was admitted to the hospital, due to limited activities allowed for him to do, he cannot find any way to physically exercise himself. But as he have said, he will try to regain his usual habit of regular exercise whenever he come back home. 4. Sleep/rest pattern Since before, he did not experience any difficulty or problem in sleeping. He gets enough sleep whenever he wants to. He can sleep with 1 or two pillows only, without experiencing difficulty in breathing. 5. Nutrition/elimination The patient together with his family was able to take enough nutrients needed by their body. w\they eat lots of healthy food that he knows can bring something good to their body. He could also urinate and defecate regularly without experiencing any difficulties. 6. Sexuality/reproductive The patient, as he said, is satisfied with his sexuality. He knows that he is contented of what he can do as a good husband to her wife. The same as her wife that is giving him enough of what they want. He knows that he does not have reproductive problems because they already bore children. 7. Interpersonal relationships/resources The patient is obviously strong bonded with his family. He was able to communicate effectively with them. They do not have any family issues that could affect the whole family. 8. Coping and stress management/tolerance pattern

Whenever the patient is stressed, sleeping and listening to music is the only solution used to manage these stressors. 9. Environmental hazards The patient together with his family is living in a subdivision and a home where there is good security. Good enough that they can maintain safety. He said that even there are factories nearby that could affect their health, they are still confident that they are not reached by the chemicals that could bring danger. II. PROBLEM LIST A. ACTUAL OR ACTIVE Problem No. Problem 1 Activity Intolerance

Date identified November 08, 2011

Date resolved November 08, 2011

B. HIGH RISK OR POTENTIAL Problem No. Problem 1 Risk for constipation related to decreased peristalsis secondary to decreased physical activities.

Date Identified November 08, 2011

III. Cues

NURSING CARE PLAN Nursing Background Long diagnosis knowledge term A1. Activity Intolerance related to deconditioni ng effects of bed rest and physical immobility. Due to deconditioni ng effects of complete bed rest ordered by the patients physician, he was limited to several activities that can only be tolerated by him to avoid fatigue. A week after discharge, the patient will be able to perform and tolerate more activities than what he just can do during stay at the to hospital. After a week, the patient will be able to retain and maintain regular bowel movement pattern.

Short term Intervention

Rationale

Evalua tion

S: Masakit ulo ko kanina pero nawala na naman nung pinainom ako ng gamot O: y Received pt sitting beside the bed, currently eating. Awake, conscious, coherent, and communicative. With IVF of #16 PNSS 1L to run for 24 hours, regulated and infusing well at right metacarpal vein. y Diagnosed with TIA, HPN y on diet of LSLF y (-) headache y (-) dizziness y On CBR y (-) BM for 2 days

Within the 8 hours shift, the patient will be able to perform and tolerate activities that are within his limitation. Within the shift, the patient will be able to defecate for at least once.

y NPI established

y For the patient to be comfortable while communicating with the nurse y To attain baseline information about the patient y To determine if patient is getting enough hydration

y Monitored v/s q4

y Monitored

I&O

A2. Risk for constipation related to decreased peristalsis secondary to decreased physical activities.

Due decreased physical activities, peristaltic movement of the GIT was also decreased that could cause stasis of the food taken by pt.

y Reinforced LSLF diet

y To avoid problems that may predispose client to further danger in his health y To avoid client getting tired and fatigue that could cause him hypertension. y To have baseline

y Reinforced complete bed rest

y v/s taken q4, @8am: y T 36.0 oC y PR 62 bpm y RR 19 cpm y BP 120/80 mmHg

y Assessed patients recent bowel movement pattern

information if ever the patient is already having constipation.

y Aided in performing limited ROM exercises, self care activities, and ADL

y To provide physical activities and prevent risk for constipation

y Advised the client to report signs of: 1.dizziness 2. headache 3. palpitations

y To provide further intervention to be resolved, and to prevent further complication.

IV.

ANATOMY AND PHYSIOLOGY

The systems involved in giving part to the development of TIA are the circulatory system and the nervous system. The circulatory system is a network that carries blood throughout the body. The human circulatory system supplies the cells of the body with the food and oxygen they need to survive. At the same time, it carries carbon dioxide and other wastes away from the cells. The circulatory system also helps regulate the temperature of the body and carries substances that protect the body from disease. In addition, the system transports chemical substances called hormones, which help regulate the activities of various parts of the body. One of the parts of the circulatory system is the heart. It is a hollow, muscular organ that pumps blood. It consists of two pumps that lie side by side. These pumps relax when taking in blood and contract as they send out blood. The left side of the heart is a stronger pump than the right side. The stronger pump receives blood from the lungs and sends it to cells throughout the body. The weaker pump receives blood from the cells throughout the body and sends the blood to the lungs.

Another of the parts of the circulatory system are the blood vessels. They form a complicated system of connecting tubes throughout the body. There are three major types of these vessels. Arteries carry blood from the heart. Veins return blood to the heart. Capillaries are extremely tiny vessels that connect the arteries and the veins. The blood consists chiefly of liquid called plasma, and three kinds of solid particles known as formed elements. Plasma is made up mostly of water, but it also contains proteins, minerals, and other substances. The three types of formed elements are called red blood cells, white blood cells, and platelets. Red blood cells carry oxygen and carbon dioxide throughout the body. White blood cells help protect the body from disease. Platelets release substances that enable blood to clot. Platelets thus aid in preventing the loss of blood from injured vessels. The nervous system is a very complex system in the body. It has many, many parts. The nervous system is divided into two main systems, the central nervous system (CNS) and the peripheral nervous system. The spinal cord and the brain make up the CNS. Its main job is to get the information from the body and send out instructions. The peripheral nervous system is made up of all of the nerves and the wiring. This system sends the messages from the brain to the rest of the body.

One of the parts of the CNS is the brain. It keeps the body in order. It helps to control all of the body systems and organs, keeping them working like they should. The brain also allows us to think, feel, remember and imagine. In general, the brain is what makes us behave as human beings. The brain communicates with the rest of the body through the spinal cord and the nerves. They tell the brain what is going on in the body at all times. This system also gives instructions to all parts of the body about what to do and when to do it. There are five main senses - touch, smell, taste, hearing and sight. These are the external sensory system, because they tell you about the world outside your body. Your senses tell you what is happening in the outside world. Your body's sense organs constantly send signals about what is happening outside and inside it to your control center - the brain. The cerebrum is part of the forebrain. The cerebral cortex is the outer layer of the cerebrum. Certain areas of the cerebral cortex are involved with certain functions. Sensory areas such as touch, smell, taste, hearing and sight receive messages from the skin, nose, mouth, ears and eyes. We feel, taste, hear and see when these messages are received by the sensory parts of the brain. The second main part of the nervous system is the peripheral nervous system. The nervous system is made up of nerve cells or neurons that are "wired" together throughout the body, somewhat like communication system. Neurons carry messages in the form of electrical impulses. The messages move from one neuron to another to keep the body functioning. Neurons have a limited ability to repair themselves. Unlike other body tissues, nerve cells cannot also be repaired if damaged due to injury or disease.

V.

PATHOPHYSIOLOGY

TRANSIENT ISCHEMIC ATTACK Definition: The definition of TIA continues to evolve. Traditionally, TIA has been defined as the presence of neurologic symptoms of vascular etiology in one area of the brain lasting less than 24 hours. Implicit in this definition is neuronal injury that is not permanent in nature. However, there are several problems with this definition. It is now clear through newer diagnostic modalities such as diffusionweighted magnetic resonance imaging (MRI) that this time- and symptom-based definition can be clinically misleading. It assumes a complete correlation between the resolution of symptoms and normalization of tissue reperfusion, which often underestimates the potential tissue damage detected by diffusion-weighted MRI. Nearly 50% of patients who meet the classic definition of TIA have in fact suffered subclinical strokes with detectable cerebrovascular infarction. Symptoms:  Blurred vision in both eyes, brief blindness, or double vision Parietal and temporal lobe strokes may interrupt visual fibers of the optic tract and route to the occipital cortex and impair visual acuity.  Difficulty speaking It is caused by cranial nerve dysfunction from a stroke in vertebrobasilar artery or its branches. It may result from the weakness or paralysis of the muscles of the lips, tongue, and larynx or form loss of sensation.  Weakness, sometimes on only one side of the body The deficit is usually caused by a stroke in the anterior or middle cerebral artery, leading to infarction of motor strip of the frontal cortex.  Vertigo (a whirling or spinning feeling), headache, confusion They occur due to decreasing oxygen level or total oxygen deprivation.  Loss of consciousness It occurs due to impaired Oxygen absorption, altering or disturbing brain cell metabolism and functioning.  Chest pain Anything that compresses a nerve root (like a disc or multiple discs) due to cardiac ischemia will hurt. Synthesis: As noted, patient RSG had almost all of the predisposing and precipitating factors that might have been the reason why he experienced such illness. These are old age, personal hypertension, sedentary lifestyle, and as well as genetic factors that he inherit from his parents. The patient was also known to be smoker and alcohol beverage drinker. As for the symptoms, patient felt the headache,

dizziness, weakness, and blurring of eyes just before he was admitted to the hospital. Good thing is that it was only mild stroke and the patient did not lose his consciousness because if ever he did, he might have experienced greater injury that can be caused by accidental fall. Until the time of interview, the patients vision of the right eye is still impaired. It is indicated for him to consult an ophthalmologist to see if the problem is directly to the eyes or maybe possibly from the optic nerves.

VI.

MEDICAL SURGICAL MANAGEMENT 1. PROCEDURE Procedure/Date -

Indication/Analysis -

Nursing Responsibilities -

2. PHARMACOTHERAPEUTICS/MEDICINES Generic Indication, dosage, name, brand frequency name, classification, stock Citicoline BRAND NAME Somazine amp DOSAGE 125 mg/mL 12 inj/day. 250 mg/mL 1 inj/day increases the neurotransmission levels because it favors the synthesis and production speed of dopamine in the striatum, acting then as dopominergic agonist through the inhibition of tyrosine hydroxilase. PO 1000mg/cap OD Paracetamol Biogesic Antipyretic Fever, Relief of mild to moderate pain like headaches, muscular aches and pain, toothache, colds, earache, fever due

Nursing responsibilities

y Somazine must not be administered along with medicaments containing meclophenoxate Administer PO medications with meals to minimize gastric irritation. y It should not be crushed or chewed.

y If to be given as analgesia, assess onset, type, location, duration of pain. y Can be given without regards to meals.

650mg tablet

to tonsillectomy, inoculations, and vaccinations. 650 mg PRN x Pain

y Tablets can be crushed. y Assess temperature directly before and 1 hour after giving medication. y If respirations are <12/min (<20/min in children), withhold the medication and contact the physician. y Evaluate for therapeutic response: relief of pain, stiffness, swelling; increasing in joint mobility; reduced joint tenderness; improve grip strength. y Therapeutic blood serum level: 10-30 mcg/mL; toxic serum level: >200 mcg/mL.

LACTULOSE BRAND NAME duphalac DOSAGE Infants: 5 ml Children: 1-6 y/o- 510ml 7-14y/o- 15ml 15-45y/o- 1530ml. Dose given in 3 days

Constipation, salmonellosis. Treatment of hepatic encephalopathy 30cc ODHS

y Assess condition before therapy and reassess regularly thereafter to monitor drugs effectiveness y Monitor pt for any adverse GI reactions, nausea,vomiting,diarrhe a, y Assess for adverse reactions y for pt. with hepatic encelopathy: regularly assess mental condition y monitor I & O y monitor for Inc. glucose level in diabetic pts y tablet may be crashed or swallowed whole y instruct pt to take with meals

metropolol BRAND NAME Neobloc

Hypertension, chronic angina pectoris

DOSAGE Adult : 50mg BID or 100 mg OD

y inform the pt that drug only controls but does not cure the disorder y tell the pt. not to discontinue drug abruptly can worsen angina

Simvastatin 40mg/tab 1 tab OD at hs

Adjunct to diet in the treatment of elevated total cholestrol and LDL cholesterol with primary hypercholesterolemia (types IIa and IIb) in those unresponsive to dietary restriction of saturated fat and cholesterol and other nonpharmacologic 20mg ODHS

y Assess nutrition: fat, protein, carbohydrates y Monitor bowel pattern daily y Monitor triglycerides, cholesterol baseline throughout treatment

Mannitol

Raised intracranial pressure 75cc Q8

y Take care to avoid extravasation. Observe injection site for signs of inflammation or edema y check for signs of fluid and electrolyte imbalance y measure I&O accurately and record to achieve proper fluid balance y monitor vital signs closely. Report significant changes in BP and signs of CHF y assess cough: type, frequency, character y advice medical consultation for persistent cough of more than 7 days y advice pt. to avoid

Generic Name: Erdosteine Brand Name: Ectrin

Treatment of acute bronchitis, chronic bronchitis and its exacerbations. Respiratory disorders characterized by abnormal bronchial secretions and impaired

Classification: Mucolytics Dosage: 300 mg 1 tab bid

mucus transport. 300 mg BID

smoking y suggest sugarless lozenges to decrease throat irritation and cough

VII.

PROGRESS NOTES Day 1 y The patient is ambulatory y He was feeling mild general weakness y She felt no pain at all y She is slightly irritable due to fear of nurses y Patient was crying y The patient was not able to take food, only breastmilk y The patient has fever y The patient is ambulatory y She was still feeling mild general weakness y Irritability of the patient was decreased not like the day before y Patient was not crying anymore y The patient still was not able to take food, only breastmilk y Fever alleviated

Day 2

VIII.

SUMMARY OF CLIENTS STATUS OR CONDITION AS OF LAST DAY OF CONTACT

Date: August 19, 2011 The patient seems to be still slightly sick. Presence of cough and colds still persist. The patient was able to communicate with the nurse assigned to her not like the first day. She was not still able to take any meal aside from breast milk. Crackles were still present. The patient seems to like sleeping more than playing. She still cry when she

see a nurse in white uniform try to take her vital signs. Medications are continued and oral fluid intake was increased to eliminate sticky lung secretions.