HOLY NAME UNIVERSITY

College of Health Sciences

Department of Nursing
Tagbilaran City, Bohol

HNU Vision
A Catholic institution trailblazing excellence in educating servant leaders.
HNU Mission
We commit ourselves to the:
1. Faithful witnessing to the Word
2. Pursuit of the highest standard of innovative instruction, research and community service.
3. Formation of committed professionals guided by the principle of prophetic dialogue.
HNU Goals
We aim to:
1. Make HNU a model Basic Ecclesial Community.
2. Perform the Institution’s trilogy of functions with excellence and scholarship.
3. Engage actively in the apostolate of Communication, Bible, Mission Animation, and
Justice, Peace and Integrity of Creation.

Course Code: NCM 112

Course Title: Care of Clients with Problems in Oxygenation, Fluids and Electrolytes, Infectious,
Inflammatory and Immunologic Response, Cellular Aberrations, Acute and Chronic

Placement: Level III - SY 2020-2021, 1st Semester

No. of Hours: 51hrs
Date of Skills Laboratory Exposure: Oct. 26 to 31, 2020

OBJECTIVES/OUTCOMES:
At the end of the 51hrs Related Learning Experience, you are expected to
1. Perform a holistic assessment of a client using appropriate assessment tool based on a
case scenario provided,
2. Formulate a plan of care to address the needs/ problems based on priorities,
3. Implement safe and quality interventions to address the identified needs or problems, and
4. Evaluate the client status and outcomes of care
5. Demonstrate properly on how to perform Chest Physiotherapy
Based on the scenario given, make the following requirements using the given template:
( all requirements/ outputs will be graded with rubrics)
1. Health Assessment
2. Nursing Care Plan with 1 priority problem in every scenario -
3. Drug Study
4. Health Teaching Plan

Evaluation Criteria:
Health Assessment ------------------------------------------ 10%
NCP ------------------------------------------ 20%

Drug Study ------------------------------------------ 10%

Health Teaching Plan ------------------------------------------ 10%
CPT Video Recording ------------------------------------------ 50%
TOTAL = 100%

Case Scenario 1
Mr KJ 57 years old, married with 3 children, a regular employee in a private firm presents to the
Emergency Department with fever and difficulty of breathing. Patient reports 3 days of sleepless
nights due to history of Shortness of breathing, sore throat, malaise, and low-grade fever. Patient
recently developed productive cough. Prior to admission, his temperature increased to 39.6
degrees centigrade at which point his family decided to bring the patient to the hospital.
He presents with yellow sputum, myalgias, right sided chest pain that is worse with deep
breathing. No known drug allergy, with complete immunization, undergone appendectomy at
the age 18, non-smoker but drinks 2 beers/night, “sometimes more on weekends”. He denies use
of illicit drugs. He works as furniture dealer, divorced and dating currently. His mother died of
Myocardial infarction at the age 75 and his father is still alive, age 86 but has colon cancer.
Review of Systems (ROS) reveals: (+) Dyspnea, diaphoresis, subjective fever, myalgia, no GI
complaints, no chills, no headache, no blurred vision, no lightheadedness, no palpitations, no
numbness/motor weakness, no abdominal pain, no urinary symptoms. Claims no contact with
sick people, no recent hospitalizations, nor history of similar symptoms in the past.
Vital signs upon admission: HR 112, BP 130/75, RR 24 Temperature 39.0 degree centigrade, O2
Sat (Room Air) 92% and weighs 72 kilos.
Generally, nontoxic appearing but increased work of breathing and splinting with deep
inspiration noted. He is alert and oriented to person, place and time, pupils are equally responsive
and reactive to light with extra ocular muscles intact but conjunctiva is pale with non-icteric
sclera. Bilateral chest with crackles, and decreased breath sounds when auscultated, abdomen is
soft non-tender and not distended with (+) bowel sounds. Skin has no rashes, warm to touch, and
cap refill <2 seconds. No rashes on extremities and no edema noted.
STAT Laboratories were ordered; Chest X-ray, ABG, CBC, U/A, Blood C/S, sputum C/S. IVF
of D5 NSS 1 Liter started at 30gtts/min, supplemental O2 administered at 5L/min and on close
monitoring. Patient was nebulized with Salbutamol +ipratropium 1 neb every 15 minutes times 3
doses and was given Paracetamol 300 mg IVTT. Ceftriaxone 1 gm was then started ANST
through IV. After 2 doses of Ceftriaxone, patient develops a reaction to antibiotic.
Patient was diagnosed with Community Acquired Pneumonia, High Risk, Anaphylactic
Reaction.
In this Skills Laboratory, you will be given 2 case scenarios where you base all your data to fill
in the assessment form. Then, you are going to analyse which assessment findings be given the
highest priority and formulate your nursing diagnosis. With your nursing diagnosis, you make a
nursing care plan and a drug study using the templates provided. In evaluating the outcomes of
care, you may do it hypothetically. Good luck.

Case Scenario 2
Mrs. B. F, 34 years old, female, married, from Catigbian, Bohol presents to the emergency
department with 10 episodes of vomiting following abdominal pain. She was just completed six
cycle of Chemotherapy for 2 days now and from there, no food intake, only sips of water. The
patient experienced muscle weakness and cramping and later on it worsen the symptoms. Patient
was complaining of severe muscle weakness, unable to walk and with projectile vomiting thus
prompted admission. The nurse assessed her fluid state and noted that her skin was flushed and
warm with dryness, poor skin turgor, delayed capillary refill time. The doctor inspect her
abdomen as flat with normal bowel sounds and no abdominal tenderness noted upon palpation.
She claimed that her urination ranges from 2 -3 times per day for the past 2 days with small
amount, concentrated urine. On the day of admission, she had not defecated yet but usually, she
defecated daily and described her stool as brownish or depending on the colors of the food
intake.
Patient stated that she was admitted last February 2015 at GCGMH for a mass she felt at her
right breast. Physical exam revealed a large mass in the upper outer quadrant of the right breast
and a second fixed palpable mass in the axillary region. Patient was referred for a guided needle
biopsy of the abnormal mammographic area. The patient has had no bleeding or discharge from
the nipple. There is a strong family history of breast cancer in her family sister died of breast
cancer. The patient has no symptoms of fever but does experience night sweats.
Patient completed a regimen of doxorubicin and cyclophosphamide followed by paclitaxel. An
MRI of the breast showed the breast tumor now has a maximum dimension of 1.2cm and the
axillary mass is no longer present. The patient was referred for a partial mastectomy and axillary
node dissection. Following surgery she completed her regimen of chemotherapy.
Ultrasound result last 2/15/15- Breast US: an ill-defined hypoechoic speculated nodule is
identified measuring 3.4 x 4.3 x 2.2cm spiculated mass in the 11 o’clock right breast with
involvement of the pectoralis minor. A 3cm mass in the axillary region most likely represents
matted lymph node metastasis. A stereotactic biopsy of the breast nodule and of the axillary mass
were performed to evaluate for potential malignancy.
Pathology Report dated 2/15/15-Stereotactic Core Biopsy of breast mass-Invasive ductal
carcinoma with comedo features, ER/PR negative (less than 1%), HER/2 negative 1+ by IHC.
Nottingham Bloom Richardson score: 5. Biopsy of axillary mass result: Invasive Carcinoma
Mrs. B.F is a housewife with 4 children. She was born catholic and teaches her children a good
values and strong faith in God. At present, the source of income comes from her husband
working as a Computer Technician at a company. She attained a High school degree having the
knowledge and ability to read and write. As for her interests, she entertains herself by reading
and cleaning, this would certainly alleviate her stress. She also enjoyed doing household chores
and taking care of her family. She seems to have a good outlook on life. She deals well with her
watchers and seem to have a good relationship them. Because of her illness, she was worried
about their financial stability.
The patient’s pupils are equally rounded with 3mm in size, both reactive to light. There is no
reduced accommodation to light changes when a light is directed to the eyes. She does not have
difficulties seeing far away objects and recognizing people. She has no difficulties hearing soft
voices upon seeing her conversing with her watcher in a whispering manner. The nasal mucosa is
intact, smooth, and moist pink upon inspection. She was able to discriminate foul odor, as noted
when she complained about the bad smell of the comfort room. She also perceived coldness as
she asked the nurse why the thermometer is cold. She stated that lately she was not comfortable
sleeping, there are episodes where she sleeps only for 4 hours due to pain in her right breast. She
tried to listen to music to promote sleep.
The patient was pregnant for four times and delivered four healthy children via Normal
Spontaneous Delivery. During her pregnancy, she has a regular pre-natal check-up every month.
She has a normal menstrual cycle (ranging from 3 to 4 days every month). There is no history of
abortion and reproductive abnormalities.
Patient was conversant and oriented to date time, place, and people and her present condition.
There were no observed mood swings and emotional changes. Her positive attitude was
consistent throughout. She answers questions and follows instructions appropriately. She is
fluent in Cebuano and Tagalog only but able to understand English. Attentive and cooperative in
the nursing and medical management given to her.
Exam: Vital Signs
T= 37.0 ℃
P = 124bpm
R= 24bpm
BP= 90/50mmHg
Oxygen saturation 97% in room air, Weight 51 kg., pain scale of 5 out of 10.

Started IVF of Plain NSS 1 Liter fast drip of 300 ml. and regulated at 30gtts/minute. Hgb Hct,
Blood typing and a chemistry panel is drawn at the same time. After receiving lab result, the
doctor ordered another line to start @ right arm with Plain NSS iL + 20 meq KCL to run for
10gtts. The medications ordered for the patient are the following:
1. Ranitidine 50 mg now then every 8hrs IVTT
2. Metoclopramide 20mg IVTT now
3. Tramadol 50mg IVTT every 8hrs prn for pain.

Operative Procedure: Partial mastectomy and axillary node dissection.

Final Diagnosis: Right breast, partial mastectomy: invasive comedocarcinoma with severe
hypokalemia.

LABORATORY RESULTS:
Result Reference
Value
Hemoglobin 78 120-160l/l
Hematocrit 0.23 0.3 7 - 0.4 7 l / l
WBC Count 21.1 5.0 - 10.0 x 10 g/L
Neutrophils 0.84 0.5 - 0.70
Lymphocytes 0.15 0.20 – 0.40
Midcell 0.03 – 0.09
Eosinophil 0.10 0.01 – 0.07
Monocyte 0.00 – 0.07
Band 1.00 0.00 – 0.05
Total 1.00
RBC 4.0 - 5.50
Platelet Count Markedly increased 150 – 400 x g/l
Blood Type “O”
Rh “Positive”
 RESULT REFERENCE VALUE

Sodium 149 135 – 145 mEq/L

Potassium 3.0 3.5 – 5.0 mmol/L

Chloride 102 97-107 mEq/L
Calcium 94 8.6 – 10.2 mEq/L
 CHEST PHYSIOTHERAPY

Instructions for Chest Physiotherapy video recording:

1. Kindly view the video indicated below as your reference. (Link and downloaded file provided)
Video file name: Postural drainage, percussion, vibration technique
Video Link : https://www.youtube.com/watch?v=vxFUPdFc1eM
2. You need to make your own video, showing how to perform Chest Physiotherapy.
3. Utilize the things that you have in your house.
4. Explain in a detailed manner the steps as you act it out in the video.
5. Strictly follow the contents written in the checklist.
6. During the video presentation, please do not look or read the checklist. Practice first before
making the final output for your video.
8. Upload the file in the google classroom, it should not be more than 5 minutes.
9. Deadline of submission will be on December 4, 2020 @ 11:59 PM.

Note:
Attached here is the copy of the checklist for your guide.
 Holy Name University
College of Health Sciences
Department of Nursing
Tagbilaran City

Procedure in Performing Percussion, Vibration and Postural Drainage.

PROCEDURE
1. Help the patient assume the appropriate position based on the lung field that requires
drainage.
a. Apical areas of the upper lobes:
 Have patient sit at the edge of the bed.
 Place a pillow at the base of the spine for support, if needed. If patient unable to sit at
edge of the bed, place him in high Fowler’s position.
b. Posterior section of the upper lobes:
 Position the patient in a supine position with the pillow under his hips and knees
flexed.
 Have the patient rotate slightly away from the side that requires drainage.

c. Middle or lower lobes:

 Place the bed in Trendelenburg’s position.
 Position the patient in Sim’s position.
 To drain the left lung, position the patient on his right side.
 For the right lung, position the patient on his left lung.

d. Posterior lower lobes:

 Keeping the bed flat, assist the patient in prone position with the pillow under his
stomach.
2. Have the patient remain in the desired position for 10 to 15 minutes.
3. Perform percussion over the affected lung area while the patient is in the desired drainage
position:
a. Promote relaxation by instructing the patient to breathe deeply and slowly.
b. Cover the area to be percussed with a towel or the patient’s gown.
c. Avoid clapping over the bony prominences, female breast or tender areas.
d. Cup the hands with fingers flexed and thumbs pressed against the index fingers.
e. Place cupped hands over the lung area requiring drainage.
Percuss the area for 1 to 3 minutes by alternately striking cupped hands rhythmically
against the patient.
4. Perform vibration while the patient remains in the desired drainage position:
a. Place one hand flat over the surface area of the lung that requires vibration.
Place the other hand on top of the first hand and position at the right angle.
b. Instruct the patient to inhale slowly and deeply into the nose and exhale into the mouth.
c. As the patient exhales, press the fingers and palms firmly against the patient’s chest wall
 and gently vibrates with the hands over the lung area.
d. Continue performing vibrations for 3 exhalations.
5. After performing postural drainage, percussion and vibration, allow the patient to sit up.
Have him cough at the end of a deep inspiration. Suction the patient if he is unable to
expectorate secretions.
6. If the sputum specimen is needed, collect it in a specimen container.
7. Repeat step 1 to 5 for each lung field that requires treatment.