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Demographic Data

Date admitted: 10/31/2017

Name: Soriano, Lolita Punasen

Date of Birth: 05/10/1950 Birth Place: Bakun, Benguet Nationality: Filipino

Occupation: None Telephone no.: 09300921397

Age: 67 years old Sex: Female Marital Status: Married Religion: Anglican

Address: Timpugan, Gambang, Bakun, Benguet

Father’s Name: Cosilip Punasen

Mother’s Name: Rosalinda Punasen

Spouse Name: Vicente Soriano

Occupation: None Telephone no.: N/A
Address: Timpugan, Gambang, Bakun, Benguet

Chief Complaint
Difficulty In Breathing

History of Present Illness

10 days prior to admission patient started to experience sudden coughing episodes with white
yellowish non-blood tinged expectorated sputum with associated body weakness and easy fatigability as
manifested by shortness of breath upon ambulation, wherein she gets tired after only walking more
than 15 steps on a flat terrain, with no other associated signs and symptoms such as febrile episodes,
difficulty breathing, fast respiratory rate, chest indrawing, and chest pain, Patient did not take any
medications and did not seek for any consultation

6 days prior to admission patient still experiences coughing episodes and is now associated with
difficulty in breathing making them seek for consultation at atok district hospital where she was
managed as a case of pulmonary congestion with pneumonia, Dm type 2, non-obese, non-insulin

Patient was then referred to BGH-MC after 6 days of hospital days in atok district hopistal, for
further care and management.

History of Past Illness

Had no past medical hospitalizations, Childhood illnesses : History of pneumonia with completed
medications for 1 month, Had chicken pox at 12 years old, had no measles or mumps yet, has no
allergies and other diseases
Family History
There is no history of diabetes or asthma on both sides of the family but on the father side there
is a history of hypertension, (-) Arthritis, (-)Colon CA, (-)Rhinitis, (-)CVD, (-) CAD, (-)malignancy,

Social and Environment History

She and her husband has 7 children and 22 grandchildren, both of her parents are deceased,
they live in mountain trail and they are fund of planting, a lot of her children are college graduates and a
lot of her grandchildren are still studying and some are working.

Medical Diagnosis

Community Acquired Pneumonia – Mitral Regurgitation


According to Maslow’s hierarchy of needs,

physiological needs are the first in line and the
priority in the physiological needs is oxygen, and
ineffective airway clearance is first because this
fatal, anytime the airway could be obstructed
which could lead to the patient’s death, if not, if
this condition worsens it could render the patient
weak or it could alter the patients comfort,
Ineffective Airway Clearance related to presence
mobility, mental status, organs, cells and the brain,
of secretions in the tracheobronchial tree
they can either deteriorate or fail because they
secondary to pneumonia
won’t be receiving adequate oxygen and if this is
left untreated there are a lot of complications that
would arise such as pain (chest),lung conditions
such as emphysema, asthma, pneumonia,
atelectasis, DOB, SOB and could also be a factor for
heart diseases. So in short our system needs
oxygen to function well and this problem hinders
oxygen to flow in our body properly
According to Maslow’s hierarchy of needs,
physiological needs are the first in line and the
priority in the physiological needs is oxygen, the
complications are just like the ones ineffective
airway clearance it could alter the mental status,
comfort, it could render pain, confusion, irritability,
it could lead to organ cell and brain failure or
deterioration, and in this diagnosis the diffusion in
the alveoli and pulmonary capillaries are altered
so oxygen in our system is altered which could lead
to different complications in the body systems,
Impaired Gas Exchange related to thick or
such as cardiac problems, perfusion, oxygenation
excessive secretions in the tracheobronchial tree
problems and the patient might feel Confusion,
secondary to pneumonia
Cyanosis , Decreased carbon dioxide
Diaphoresis, Dyspnea, Elevated BP, Headache upon
awakening, Hypercapnea, Hypoxia, Hypoxemia,
Irritability, Nasal flaring, Pallor, Restlessness,
Somnolence, Tachycardia
Visual disturbances but ineffective airway
clearance is still more fatal because it could lead to
obstruction of airway which could kill the patient
immediately and also this diagnosis could result
from ineffective airway clearance so this diagnosis
is our 2nd priority.
This is an actual problem and this could alter the
patients comfort and movement this could also
increase ones blood pressure , temperature and
Pain related to Inflammatory Process other physiologic reactions, this could also add up
to the patients stress and resilience and when left
untreated a lot of complications would arise so this
is my 3rd nursing priority
Risk for decreased cardiac output related to This is still a potential problem but is an important
decreased oxygenation one because this includes the blood pumped by
the heart and if it is decreased then the different
body parts wouldn’t be getting the sufficient
volume of blood and transfer of oxygen so their
functions would be altered and hence make the
patient weaker and if the different body parts
becomes less functional then it could lead to
different complications and the patient won’t be
in her optimum level of performing tasks and be
less responsive to the health team and health care
management (medical and nursing)
This is still a potential problem, if this ever
happens then the patient would have less
nutrition, and with less nutrition the patient’s
response to the health care would be lesser and
Risk for imbalanced nutrition: less than body
the patients healing and recovery would be
requirements related to insulin deficiency
hindered without the sufficient and necessary
nutrition, because nutrition is one major
component of a patients recovery and the patients
intake might be insufficient for metabolic needs
This is still a potential problem but if this ever
happens the patients glucose level would be at
different levels which render the patient weak and
Risk for unstable blood glucose related to ongoing
less responsive to recovery, high levels of sugar in
disease process
the blood could also be a factor for hypertension
and other disease processes, and hypoglycaemia
could also alter the patients comfort and status.
This is still a potential problem but is important
because the patients safety is one of our priorities
but this is the 2nd to the last priority because the
problems above could all be the reason to the
Risk for Injury related to ongoing disease process patients injury, this is one of our priority nursing
diagnosis because the patient is at risk of injury at
any time because of her condition and the other
environmental factors and these could
compromise the patients’ health
This is the last priority because this is still a
potential problem and this could lead to
Risk for activity intolerance related to imbalance
Insufficient physiologic or physiological energy to
between oxygen supply and demand
endure or complete required or desired activity
which could help in the recovery of the patient