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I. 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 O
2
therapy of 2L/m via nasal cannula with episodes of
SOB when talking.
> Patient has CTT to (-) 18cm H
2
0 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.






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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
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:













TOTAL kCal for 24 hours: 2,303 kCal
Meal Food Taken Amount kCal
Breakfast

TOTAL kCal
Rice
Fried Egg
Coffee
2 cups
1pc.
1 cup
432 kCal
196 kCal
1 kCal
629 kCal
Lunch


TOTAL kCal
Rice
Fried Chicken
Chicken Soup
Royal

2 cups
2 pieces
1 cup
1 glass

432 kCal
492 kCal
87 kCal
38 kCal
1049 kCal
Dinner


TOTAL kCal
Rice
Fried Chicken
Chicken Soup
Royal
1 cup
1 piece
1 cup
2 glasses

216 kCal
246 kCal
87 kCal
76 kCal
625 kCal