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Maricar R. Trinidad
Celine S. Udani
BSN 135 Group 139
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2.O Immunizations
3.O Allergies
4.O Accidents
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5.O Hospitalization
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1.O Coping Patterns
2.O Interaction Patterns
3.O Cognitive Patterns
4.O Self-Concept
5.O Emotional Patterns
6.O Family Coping Patterns
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The World Health Organization defines psychological health as "a being of well-being in which
the individual realizes his or her own abilities, can cope with the normal stresses of life, can work
productively and fruitfully, and is able to make a contribution to his or her community͟. An example of
a wellness model includes one developed by Myers, Sweeney and Witmer. It includes five life tasksͶ
essence or spirituality, work and leisure, friendship, love and self-directionͶand twelve sub tasksͶ
sense of worth, sense of control, realistic beliefs, emotional awareness and coping, problem solving and
creativity, sense of humor, nutrition, exercise, self care, stress management, gender identity, and
cultural identityͶwhich are identified as characteristics of healthy functioning and a major component
of wellness. (wikipedia.com)
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Family is the source of strength of the patient in times of crisis. They support him emotionally
and financially. All kinds of consideration are given to him by his children, especially his wife, as they
took care of him.
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1.O Cultural Patterns
2.O Significant Relationships
3.O Recreation Patterns
4.O Environment
5.O Economic
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Being a part of a regional group of culture is called a subculture. Though they are smaller group, they
possess many of the values, beliefs and customs of the larger culture but have unique characteristics.
According to studies, Filipinos hereditary diseases include diabetes mellitus, Thalassemia, and G6PD
deficiency.
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OOis in a transition of accepting the shifting of generational roles. The family
needs to maintain own and couple functioning and interests in face of physiological decline; exploration
of new and familial and social role options. They also need to support for a more central role of middle
generation. They should also make a room for the wisdom and experience for elderly people, supporting
the older generation without over functioning for them. u
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Client has regional customs and beliefs. Hiscurrent health status has affected his daily activities.
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1.O Religious Beliefs and Practices
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Spiritual health is the connectedness with self, others, higher power, all life, nature and the
universe that transcends and empowers the self. Spiritual and religious beliefs can significantly affect
health behavior.
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The patient has religious beliefs and cultural values. These beliefs are influenced by the social
environment and also health behavior.
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General Appearance
1.O Skin color Pale Brown, light brown normal
Measurement
1.O Temperature 35.4 ʹ 37.4 C
2.O Pulse Rate 60 ʹ 100 cpm
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3.O Respiratory Rate 12 -20 breaths/ min Hypoxia and metabolic
4.O Blood Pressure S: 100-160 mmHg / acidosis are common
D: 60- 90 mmHg causes of tachypnea
Average: 130/80 (RR>20 breaths). The
5.O Weight increased respiratory
6.O Height rate is a compensatory
mechanism to provide
the body with more
oxygen and eliminate
excess hydrogen when
the body͛s metabolism
is increased.
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SKIN
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Skin color Light brown, darker on Skin is uniform whitish Normal
Uniformity of skin color areas exposed to light. pink or brown color,
Texture With warts scattered on depending on the
the face, chest and patient͛s race. Exposure
some on the abdomen. to sunlight can results in
increased pigmentation
of sun-exposed areas.
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Skin moisture Dry. Skin is dry with Normal.
Skin temperature Bilaterally equal warm minimum perspiration.
Skin turgor temperature and Moisture varies from
nontender. one body area to
another.
NAILS
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Fingernail plate shape smooth Convex curvature; angle Normal
Fingernail and toenail Pink. of nail plate about 160
texture Blanch test return to degrees
Fingernail and toe nail normal in 1 second. Smooth texture
bed color Convex curvature; angle Highly vascular and pink
Tissue surrounding nails of nail plate about 160 on light-skinned clients;
O degrees dark-skinned clients
Blanch test of the Smooth texture may have brown or
capillaryO Intact epidermis black pigmentation in
longitudinal streaks
Intact epidermis
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Prompt return of pink
or usual color (generally
less than 4 seconds)
SKULL AND FACE
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Skull size, shape, and Patient is Rounded Normal skull and face
symmetry normocephalic, (normocephalic and features.
Facial features proportion to the body. symmetrical, with
Facial movement frontal, parietal, amd
Symmetrical and occipital prominences);
bilaterally equal in parts smooth skull contour
Smooth, uniform
Skull nodules or masses No nodules, masses and consistency; absence of
and depressions depressions. nodules or masses
Slightly asymmetric
facial features;
palpebral fissures equal
in size; symmetric
nasolabial folds
Symmetric facial
movements.
EYES AND STRUCTURES
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Cornea Has whitish halo on the Pink, transparent Normal
Iris sides of the cornea. conjunctiva. Pupils
PERRLA Pupils constrict reactive to light and
Bulbar conjunctiva bilaterally direct and accommodation.
Palpebral conjunctiva indirect response, 3cm
O size in normal light,
Bulbar conjunctiva reactive to light and
Palpebral conjunctiva accommodation.
Iris is brown color.
Patency of both nasal Both nares are patent Both nares are patent Normal
cavities.
Presence of redness, No swelling and redness No swelling and redness Normal
swelling, growths, and present. present.
discharge.
Masses Nasal septum at the Nasal septum at the Normal
Nasal septum middle. middle.
THORAX
ABDOMEN
Skin integrity Symmetrical but No abdominal scars Normal
Contour and symmetry prominent. With present. O
Light palpation for areas tenderness, no masses,
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of tenderness or nodules found.
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No pain is felt upon
light palpation on the 4
quadrants of the
abdomen.
PERINEAL
Inspection Fluid retention on both No fluid present Abnormal
testicles and the penis.
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Hydrocele: A hydrocele
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is a collection of fluid in
the membrane that
covers the testis or
testes. A hydrocele may
be present at birth or
develop later in life. It is
most common after age
40. Usually the cause is
unknown. However, the
condition occasionally
results from a testicular
disorder (for example,
injury, epididymitis, or
cancer).
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27 September 2010 HEMATOLOGY
Hemoglobin 143 g/L 120 ʹ 140 g/L Increased Increased
hemoglobinmay be
caused by exposure
to high altitudes,
smoking,
dehydration, or
tumor.
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Hematocrit 0.42 0.37 ʹ 0.47 Normal
WBC count 14.9 x 109 /L 5.5 ʹ 11.0 x 109 /L Increased Indicates infection
Platelet Count 266 x 109 /L 150 ʹ 250 x 109 /L Increased Functions with WBC
to fight inflammation
and promote healing
process.
Segmenters 0.87 0.50 ʹ 0.70 Increased Neutrophils also
known as segmenters
are recruited to the
site of injury within
minutes following
trauma and are the
hallmark of acute
inflammation.
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Lymphocytes 0.08 0.20 ʹ 0.40 Decreased Decreased immune
Monocytes 0.05 0.01 ʹ 0.06 Normal response.
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Albumin +++ 0 Abnormal Proteinuria- may
Sugar NEGATIVE NEGATIVE Normal indicate
Ketones NEGATIVE NEGATIVE Normal glomerulonephritis or
Blood in urine NEGATIVE NEGATIVE Normal other decline in
Urobilinogen NEGATIVE NEGATIVE Normal kidney function.
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RBC 8-10 / hpf 0 Abnormal May be renal disease
Pus MANY /hpf 0 Abnormal Indicates bacterial
Epithelial MODERATE NEGATIVE Abnormal infection.
Mucus Threads MODERATE NEGATIVE Abnormal
Bacteria MODERATE NEGATIVE Abnormal u !!"
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28 September 2010 BLOOD CHEMISTRY
Potassium 4.92 mmol/L 3.5 ʹ 5.30 mmol/L Normal
Sodium 123.8 mmol/L 135 ʹ 148 mmol/L Hyponatremia Edematous disorders
Chloride 100.1 mmol/L 100 ʹ 112 mmol/L Normal resulting in sodium
deficits: CHF, liver
cirrhosis, nephrotic
syndrome, acute and
chronic renal failure,
psychogenic
polydipsia. u
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30 September 2010 Total Calcium 1.96 mmol/L 2.2 ʹ 2.55 mmol/L Decreased Fluid and electrolyte
imbalances especially
sodium also affects
calcium
concentration.
30 September 2010 IMMUNOLOGY 100 NG/ML 0.00 ʹ 4.00 NG/ML Increased Prostate-specific
PSA antigen (PSA) is a
protein produced by
the cells of the
prostate gland. PSA is
present in small
quantities in the
serum of men with
healthy prostates, but
is often elevated in
the presence of
prostate cancer
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2 October 2010 ABG
pH 7.215 7.35 ʹ 7.45 Acidosis Respiratory acidosis
PaCO2 103.9 mmHg 35 ʹ 45 mmHg Increased uncompensated is an
PaO2 79.9 mmHg 80 ʹ 100 mmHg Decreased indication that there
HCO3 42.0 meq/L 22 ʹ 26 meq/L Increased is a problem in the
TCO2 45.2 ml/dL 15 ʹ 20 ml/dL Increased released of CO2
BE 8.0 meq/L + 2 to ʹ 2 meq/L causing it to be
O2 Sat 92.8 % 95 ʹ 100 % Abnormal contained in the
FiO2 36.0 % blood. Metabolic
acidosis also follows
due to increase in
HCO3. This causes the
O2 Saturation to
decrease.
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Salbutamol Anti-asthmatic Treatment of acute Hypersensitivity to its Small increase in heart Special precaution on patient
and COPD prep. severe asthma and in content. rate, peripheral with hyperthyroidism, CV
Q1 2.5-5 mg
routine management vasodilation, fine tremor diseases
of chronic of skeletal muscle.
bronchospasm
unresponsive to
conventional therapy.
Budesomide Anti-asthmatic Prophylaxis and Primary treatment of Neck pain, cough, resp. WOF withdrawal symptoms
and COPD prep. management of status asthmaticus or infection during transfer from systemic
Q6
asthma other acute asthma corticosteroid therapy to
where in sensitive budesomide
measures are
required
Hydrocortisone Hormones Acute adrenocortical Latent, healed and Fluid electrolyte Special precaution on patient
insufficiency active TB imbalance, dermatologic with CHF, HPN, DM
Chloramphenico Anti-infective Diseases which does History of GI symptoms Take on an empty stomach ½
l not respond to other hypersensitivity or hour before meals
standard anti- toxic reaction
microbial agent
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Risk factors: Cigarette smoking, Advanced age (74 yrs old), Hx of asthma,
Chronic disease states such as Prostate Carcinoma stage II
Attachment to the
Infection
Impaired surfactant respiratory epithelium
production and lung
injury and repair
Fever
Inhaled into the alveolus
јWBC,
Impaired type 1 јSegmenters
alveolar cells Infect type II alveolar cells
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The patient acquired his pneumonia via the community where he is mostly exposed.
Contributing factors such as the surroundings or the environment the child lives in, her
age.
HOST
-O Age -9 monthsO
-O Sex ʹfemaleO
Nationality ʹ FilipinoO
Exposed to second hand smoke
History of asthmaO
ENVIRONMENT
AGENT
-O Streptococcus
pneumoniaO
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The patient became susceptible to pneumonia due to the following direct risk factors:
She͛s a 9-month old baby, history of asthma, and exposed to second hand smoke.
CAP is defined as pneumonia acquired outside of hospitals or long-term care facilities,
and HAP is pneumonia that develops 48 or more hours after patient admission to an
inpatient facility (e.g., hospital, long-term care facility, skilled nursing facility) or 48ʹ72
hours after patient intubation. Older adults are particularly susceptible to pneumonia
due to waning immunity and age-associated anatomical and physiological changes that
make the lungs more vulnerable to infection. Streptococcus pneumoniae is the most
common bacterial cause of pneumonia in older adults; other common causes include
Haemophilusinfluenzae, Staphylococcus aureus, Chlamydia pneumoniae, Legionella
pneumophila, and Klebsiellapneumoniae. Common viral pathogens that cause
pneumonia in older adults include influenza, parainfluenza, respiratory syncytial virus
(RSV), and possibly adenoviruses. Older adults with dysphagia often related to stroke,
dementia, and poor oral hygiene are also at risk for aspiration pneumonia, in which the
patient breathes in food, liquids, gastric contents, or exogenous chemicals, weakening
lung defenses and causing inflammatory changes that allow for bacterial overgrowth.
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http://www.smokehelp.org/html/second_hand_smoke.html)
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Children are also susceptible to pneumonia especially they are exposed to second-hand
smoke. Asthma not also makes the person susceptible but it also aggravates the
condition. Being a Filipino also contributes to his susceptibility because of cultural
aspects and way of life.
Nursing interventions should not only concentrate on the airway, breathing and
circulation of the patient but also on the possibility of spreading the disease and
preventing it from happening.
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Black, J. M., & Hawks, J. H. (2009).%&'()'
(. Manila, Philippines:
Saunders Elsevier.
Nisar, N., Guleria, R., Kumar, S., Chand Chawla, T., &RanjanBiswas, N.
(2007).Mycoplasma pneumoniae and its role in asthma.('
'
, 83(976), 100-104. Retrieved from CINAHL Plus with Full Text database.
Yoo, S., Cha, S., Shin, K., Lee, S., Kim, C., Park, J., et al. (2010). Bacterial pneumonia
following cytotoxic chemotherapy for lung cancer: clinical features, treatment
outcome and prognostic factors!&
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42(10), 734-740. Retrieved from CINAHL Plus with Full Text database
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