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Virgen Milagrosa University Foundation

Martin P. Posadas Ave. San Carlos City, Pangasinan
College of Nursing

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Presented to:
Mrs. Jocelyn Ona,MSN,RN

Prepared by:

Cornel, Joan
Cristobal, Raymund
Cudal, Ma. Charisse Joy E.
(BSN III-G)
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Name: Mr. P.M.R
Age: 68 years old
Sex: Male
Date of birth: November 19, 1942
Place of birth: Quezon Province
Civil status: married
Nationality: Filipino
Religion: Roman Catholic
Occupation: Construction Worker
Date of Admission: June 6, 2010
Chief complaint: Melena
Initial diagnosis: Community Acquired Pneumonia
Final diagnosis: Community Acquired Pneumonia
Admitting physician: Dr. Don B. Maldo


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(+) Smoker (+) Cough x 2 weeks (+) Smoker

(+) Alcohol Drinker (+) Body Malaise x 1 week (+) Alcohol Drinker
( -) Asthma (+) Epigastric Pain ( -) Asthma
( -) Hypertension (+) Hypertension
(+) Diabetes Mellitus ( -) DM
( -) PTB ( -) PTB
(+) Pneumonia ( -) Pneumonia
( -) Heart Disease ( -) heart disease

Social and demographic factors:

üc Urban Residence
üc ow Socio-economic Status
üc Construction worker
Educational attainment:
üc High School Graduate

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Our client according to Erick Ericksonǯs stage of development is under the stage of
middle adulthood wherein he must develop generativity, but when he failed to do so, he
might be experiencing stagnation or being self-absorbed. The significant task is to
perpetuate culture and transmit values of the culture through the family and working to
establish a stable environment. In this stage the client often fears inactivity and
meaninglessness.
With regards to Freudǯs psychoanalytic theory, wherein the clientǯs feeling about
his situation is under the conscious mind, this includes everything that we are aware of.
This is the aspect of his mental processing that he can think and talk about rationally. A
part of this includes our memory, which is not always part of consciousness but can be
retrieved easily at any time and brought into our awareness. Freud called this ordinary
memory the preconscious. For his internal feelings which he canǯt fully verbalize is mostly
of the contents of the unconscious or unpleasant, such as feelings of pain, anxiety, or
conflict. According to Freud, the unconscious continues to influence our behaviour and
experience, even though we are unaware of these underlying influences.
The clientǯs cognitive or the ability to think logically is based on Piagetǯs Theory of
cognitive development, this stage brings cognition to its final form. This client n no
longer requires concrete objects to make rational judgements. At his point, he is capable
of hypothetical and deductive reasoning.
The clientǯs Moral development is in accordance to Kohlbergǯs moral development, this is
what he calls the stage of Universal Principles or the Stage 5, the client must be working
toward a conception of the good society. Stage 5 then, talk about "morality" and "rights"
that take some priority over particular laws. At stage 5, people are making more of an
independent effort to think out what any society ought to value. Client is trying to
determine logically what a society ought to be like.

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History of Past Illness:

According to the patient two months prior to admission at San azaro Hospital, he
was experiencing an on and off cough accompanied by body malaise and fever, which he
aided by taking Paracetamol and Ibuprofen. He used to visit a local hospital for a check
up, he was prescribed due medications which he later discontinued every time he felts
good and relieved. He is negative to hypertension, pulmonary tuberculosis, and asthma.
He is a chain smoker and a heavy drinker.

History of Present Illness:

One week prior to admission, the patient has undocumented fever, accompanied by
body malaise, headache and vague epigastric pain. He was brought to the San azaro
Hospital on June 6, 2010 with the chief complaint of a black tarry stool which was
diagnosed by the physician as Melena. He had taken Cefixime 200 mg twice a day,
iprofloxacin 500 mg twice a day, Omeprazole 20 mg once a day, Cemetridin 400 mg
thrice and Paracetamol.
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Head (-) wounds normal
(+) dry hair
(+) normocephalic
Ears (-) umps/lesion normal
Eyes (+) Pupillary reflex normal
(+) pupils equal
(-) periorbital edema
(-) yellowish discoloration
Nose (-) Discharge noted normal
Mouth (+) Dry lips Poor oral hygiene
(+) foul smell
(+)tartar
Face (-) Edema normal
(-) scars
Neck (-) Palpable mass normal
(-) lumps
Shoulder (+) symmetry Normal
(+) muscle mass noted
Chest (-) palpable mass normal
skin (-) jaundice Normal
(+) dry skin Poor hygiene
Abdomen (-) scars Normal
(+) tenderness
(+) normal bowel sounds
(+) active motion
arms (+) muscle mass noted normal
(-) palpable mass
legs (-) superficial lumps normal
Bowel elimination (+) black tarry stool Upper gastrointestinal
Bleeding(melena)
Bladder elimination (+) yellow colored urine normal

 
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HEMOGOBIN 6.32 g/dl Male:14-17g/dl Anemia, recent,
Female:12-15g/dl hemorrhage
Hematocrit 18.93% Male:40-50% Hemodilution(fluid
Female:37-47% overload)
White blood cell 10.52x10g/l 5x10g/l infection
Red blood cell 2.05 g/l 4.7-8.1g/l Pulmonary disorder,
anemia
Platelet count 58,000 150,000-400,000 Rebound thrombocytosis

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Color Amber Normal
Transparency Slightly turbid
Ketones ( -) Normal
Blood ( -) Normal
Protein 1+
Nitrite ( -) Normal
eukocytes ( -) Normal
Glucose ( -) Normal
pH Acidic Acidic
Specific gravity 1.015 Normal(1.010-1.025)
Amorphous substance Few












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Subjective: *Ineffective airway *The patient will *Monitor *Presence *The clientǯs
>feeling of clearance
r/t maintain an respirations may indicate airway
breathlessness excessive viscous adequate patent and note for accumulation became
>dyspnea secretions in the airway after he breath
of secretions patent and
bronchi as expectorates sounds. and reduced
Objective: manifested by bronchial respiratory viscosity of
>body malaise productive cough. secretion. distress. secretions.
>productive >The client will

cough demonstrate >Suction *To clear
>rusty colored behavior to airway as airway.
sputum improve and ordered by
>adventitious maintain an the physician.
breath sounds adequate airway >Increase the >Hydration
>difficulty of clearance. patientǯs fluid can help
breathing intake to 2000 liquify viscous
ml per day. secretions
V/S: >Ineffective
BP:100/60 breathing pattern >The client will
mmHg r/t presence of demonstrate >The
Temp: 36.4 0C abnormal breath reduction of >
Position the >To maintain patientǯs
PR:100bpm sounds as congestion and patientǯs head an open difficulty of
RR:29bpm evidenced by abnormal breath in semi- airway and breathing was
crackles and sounds. fowlerǯs. facilitate relieved by
stridors. maximum positioning
>Provide lung and doing
bronchial expansion. back tapping
tapping >To improve techniques.
techniques. airflow and
secretion
>Observe for clearance.
increased >To identify
>The client will dyspnea with infectious
>Impaired Gas improve onset of fever process and
exchange r/t ventilation and and change in promote
ventilation adequate sputum color, timely >The clientǯs
perfusion oxygenation. amount and intervention. ventilation
imbalance as character. and
manifested by >Encourage oxygenation
breathing pattern >The client will deep became more
problems. comply with breathing and >To promote effective after
medication coughing optimal chest the
regimen. exercises. expansion and interventions
maximize done.
breathing
>The client will effort.
understand the >Discourage
possible use of oil- >To prevent
complications of based vomiting with
the disease products aspiration to
process and will around the the lungs. >The client
initiate nose. demonstrated
preventive ways on how
actions. >Prevents to prevent
fatigue and further
>Provide rest dyspnea. complications
periods and of the
limit activity disease.
to level of >To prevent
respiratory bedsore.
tolerance.
>Change >To prevent
position every further
2 hours or as decline in
needed. lung function
>Encourage and prevent
cessation of further
smoking. complications.
>To report
changes in
color and
>Provide amount in the
information event that
about the medical
necessity of intervention
expectorating may be
secretion needed to
rather than treat
swallowing it. infection.
>To prevent
spread of
>Explain the disease.
 importance of
covering nose
when >To prevent
coughing or possible entry
sneezing. of irritants,
>Keep this will
environment obstruct the
allergen-free. airway.
>To limit level
of anxiety.
>Maintain
calm attitude
when dealing
with the
client.