INTRODUCTION

13 AREAS OF ASSESSMENT
Medical History: Has history of high blood pressure and high cholesterol. Sedentary lifestyle. Heavy
smoker. Absence of all other major illnesses noted.
Family History: No siblings. Father is a heavy smoker and has had two strokes in the past three
years. Mother suffers from obesity. Grandparents died of old age and not of a major illness. No other
major illness noted.
Social History: No heavy drinking. Smokes 2-3 packs of light cigarettes daily. Sedentary lifestyle.
Lives in apartment alone. Works full time as sales executive for Sears Department Store.
Physical assessment: High blood pressure of 130/95. High cholesterol. Overweight (height is 5,11 @
275lbs. Pulse is 95bpm. Temperature is 98.8 C. Respiratory rate is 18. Patient is somewhat confused
and suffers from blurred vision, slurred speech and loss of balance.

Physical Examination
Use of the Stethoscope. The most important diagnostic tool for pneumonia is the
stethoscope. Sounds in the chest that may indicate pneumonia include:
Rales, a bubbling or crackling sound. Rales on one side of the chest or that are
heard while the patient is lying down strongly suggest pneumonia.
Rhonchi, abnormal rumblings indicating that there is sputum in the large
airways.
A dull thud. The physician will use a test called percussion, in which the chest
is tapped lightly. A dull thud, instead of a hollow drum-like sound, indicates
certain conditions that suggest pneumonia. These conditions include
consolidation (in which the lung becomes firm and inelastic) and pleural
effusion (fluid build-up in the space between the lungs and the lining around it).
Patient lives in an extended type of family; her fathers mother is residing in
thefamilys
house

Example of a Complete History and Physical Write-up

Patient Name:

Unit No:
Location:
Informant: patient, who is reliable, and old CPMC chart.
Chief Complaint: This is the 3
rd
CPMC admission for this 83 year old woman with a long history of
hypertension who presented with the chief complaint of substernal toothache like
chest pain of 12 hours
duration.
History of Present Illness: Ms J. K. is an 83 year old retired nurse with a long history
of hypertension that
was previously well controlled on diuretic therapy. She was first admitted to CPMC
in 1995 when she
presented with a complaint of intermittent midsternal chest pain.
electrocardiogram at that time

Her

showed first degree atrioventricular block, and a chest X-ray showed mild pulmonary
congestion, with
cardiomegaly.
Myocardial infarction
electrocardiographic and cardiac enzyme

was

ruled

out

by

the

lack

of

abnormalities. Patient was discharged after a brief stay on a regimen of enalapril, and
lasix, and digoxin,
for presumed congestive heart failure. Since then she has been followed closely by her
cardiologist.
Aside from hypertension and her postmenopausal state, the patient denies other
coronary artery disease risk
factors, such as diabetes, cigarette smoking, hypercholesterolemia or family history
for heart disease. Since

her previous admission, she describes a stable two pillow orthopnea, dyspnea on
exertion after walking two
blocks, and a mild chronic ankle edema which is worse on prolonged standing. She
denies syncope,
paroxysmal nocturnal dyspnea, or recent chest pains.
She was well until 11pm on the night prior to admission when she noted the onset of
aching pain under
her breast bone while sitting, watching television.
heavy and toothache

The pain was described as

like. It was not noted to radiate, nor increase with exertion. She denied nausea,
vomiting, diaphoresis,
palpitations, dizziness, or loss of consciousness. She took 2 tablespoon of antacid
without relief, but did
manage to fall sleep. In the morning she awoke free of pain, however upon walking
to the bathroom, the
pain returned with increased severity. At this time she called her daughter, who gave
her an aspirin and
brought her immediately to the emergency room.
presentation showed sinus

Her electrocardiogram on

tachycardia at 110, with marked ST elevation in leads I, AVL, V4-V6 and occasional
ventricular
paroxysmal contractions.
cardiac medications, and

Patient immediately received thrombolytic therapy and

was transferred to the intensive care unit.

Current Regimen
Digoxin 0.125mg once daily
Enalapril 20mg twice daily

Lasix 40mg once every other day

Kcl 20mg once daily
Tylenol 2 tabs twice daily as needed for arthritis
Past Health
General: Relatively good
Infectious Diseases: Usual childhood illnesses. No history of rheumatic fever.
Immunizations: Flu vaccine yearly. Pneumovax 1996
Allergic to Penicillin-developed a diffuse rash after an injection 20 years ago.
Transfusions: 4 units received in 1980 for GI hemorrhage, transfusion complicated
by Hepatitis B infection.
Hospitalizations, Operations, Injuries:
1) Normal childbirth 48 years ago
2) 1980 Gastrointestinal hemorrhage, see below
3) 9/1995 chest pain- see history of present illness

Family Medical history:

No hereditary disease can be attributed from her family. However, relatives from his
father side like uncle and cousins encountered illnesses such as hypertension. Other
than the latter, no hereditary diseases from both of his parents are within the patients
knowledge
Social History
As we know client runs a small business as a door-to-door sweets. Being a business
owner, client knows how to mingle and interact with her customers. In consideration
the clients social environment are also good with her relative and neighbors.

REASON FOR CONSULTATION: Congestive heart failure.

HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old gentleman presented
through the emergency room. Symptoms are of shortness of breath, fatigue, and tiredness.
Main complaints are right-sided and abdominal pain. Initial blood test in the emergency
room showed elevated BNP suggestive of congestive heart failure. Given history and his
multiple risk factors and workup recently, which has been as mentioned below, the patient
was admitted for further evaluation. Incidentally, his x-ray confirms pneumonia.
CORONARY RISK FACTORS: History of hypertension, no history of diabetes mellitus,
active smoker, cholesterol elevated, questionable history of coronary artery disease, and
family history is positive.
FAMILY HISTORY: Positive for coronary artery disease.
PAST SURGICAL HISTORY: The patient denies any major surgeries.
MEDICATIONS: Aspirin, Coumadin adjusted dose, digoxin, isosorbide mononitrate 120 mg
daily, Lasix, potassium supplementation, gemfibrozil 600 mg b.i.d., and metoprolol 100 mg
b.i.d.
ALLERGIES: None reported.
PERSONAL HISTORY: Married, active smoker, does not consume alcohol. No history of
recreational drug use.
PAST MEDICAL HISTORY: Hypertension, hyperlipidemia, smoking history, coronary artery
disease, cardiomyopathy, COPD, and presentation as above. The patient is on
anticoagulation on Coumadin, the patient does not recall the reason.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: Weakness, fatigue, and tiredness.
HEENT: History of blurry vision and hearing impaired. No glaucoma.
CARDIOVASCULAR: Shortness of breath, congestive heart failure, and arrhythmia. Prior
history of chest pain.
RESPIRATORY: Bronchitis and pneumonia. No valley fever.
GASTROINTESTINAL: No nausea, vomiting, hematemesis, melena, or abdominal pain.
UROLOGICAL: No frequency or urgency.

MUSCULOSKELETAL: No arthritis or muscle weakness.

SKIN: Non-significant.
NEUROLOGICAL: No TIA. No CVA or seizure disorder.
ENDOCRINE: Non-significant.
HEMATOLOGICAL: Non-significant.
PSYCHOLOGICAL: Anxiety. No depression.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse of 60, blood pressure of 129/73, afebrile, and respiratory rate 16 per
minute.
HEENT: Atraumatic and normocephalic.
NECK: Supple. Neck veins flat.
LUNGS: Air entry bilaterally decreased in the basilar areas with scattered rales, especially
right side greater than left lung.
HEART: PMI displaced. S1 and S2, regular. Systolic murmur.
ABDOMEN: Soft and nontender.
EXTREMITIES: Trace edema of the ankle. Pulses are feebly palpable. Clubbing plus. No
cyanosis.
CNS: Grossly intact.
MUSCULOSKELETAL: Arthritic changes.
PSYCHOLOGICAL: Normal affect.
LABORATORY AND DIAGNOSTIC DATA: EKG shows sinus bradycardia, intraventricular
conduction defect. Nonspecific ST-T changes.
Laboratories noted with H&H 10/32 and white count of 7. INR 1.8. BUN and creatinine
within normal limits. Cardiac enzyme profile first set 0.04, BNP of 10,000.
Nuclear myocardial perfusion scan with adenosine in the office done about a couple of weeks
ago shows ejection fraction of 39% with inferior reversible defect.
IMPRESSION: The patient is a 75-year-old gentleman admitted for:
1. Pneumonia, chest x-ray confirms the same with shortness of breath.
2. Ischemic cardiomyopathy with abnormal stress test, inferior defect, ejection fraction 39%
with elevated BNP, possibly secondary to underlying infection versus decompensated
congestive heart failure.
3. Smoking history, hypertension, and hyperlipidemia.
4. Anticoagulation with Coumadin.
RECOMMENDATIONS:
From cardiac standpoint, the patient will be aggressively treated for pneumonia. Once the
pneumonia is resolved and fever is under control, consideration will be given for cardiac

workup. All the questions were discussed in this regard. The patient understood aggressive
plan of care.

Read
more: http://www.umm.edu/patiented/articles/how_pneumonia_diagnosed_000064_6.
htm#ixzz26jeZWTqW
Soapie
1.

Antral gastritis

Subjective

>

habang kumakain ako ng are-kare ay biglang

nangasim ang tiyan ko, parang may asido sa dibdib
ko na tumaas patungong lalamunan ko at halos
ikasunog nito
akala ko mamatay na ako

Reports of pain

Objective
>

V/S take as follows:

Temperature :
38.5
Pulse Rate:
73 bpm
Respiratory Rate: 24 bpm
BP
120/80 mm Hq

Assessment

>

episgastric Pain

Planning

>
>
>
>

Promote comfort
Monitor vital signs
Monitor urine discharge
Assess pain, noting location, intensity (scale of 0 to
10). Characteristics and duration
Promotes muscle relaxation
Prevent complication
Advise him on his diet
Help patient deal with psychosocial concerns
Promote information on BPH and possible
complications
Reinforce importance of medical follow-up for at least
6 months to 1 year, including rectal examination and
urinalysis

>
>
>
>
>
>

Intervention

>

After the intervention, the patient will have the

courage to again see the doctor and have him
physically checked.

>
>

Advised the patient to avoid spicy food

Advised him about the need to maintain a high fluid
intake, to ensure adequate urine output.
Explained to him about BPH in simple terms
Urged the patient to seek medical care and report any
difficulties with urination to the physician immediately.
Advised the patient to go to the hospital and have
further diagnostic exams

>
>
>
Evaluation

>
>
>

Pain/discomfort relieved
Complications prevented/minimized
Patient promised that he will go to the hospital and
have himself be checked up
GENERAL EVALUATION

As we go on with our hospital duty, we are able to encountered patients

withdifferent cases that we are able to care for, as we conduct our assessment,
intervieww i t h t h e p a t i e n t , w e h a v e t o c h o o s e
o n e o f t h i s p a t i e n t f o r o u r c a s e s t u d y. B e i n g exposed to the hospital ward at
Polymedic General Hospital, as a nursing student it isour duty to give care to the ill
patients. We have encountered many interesting casesthat would surely enhance
our knowledge and skills, and Acute Bronchitis is one of those diseases
Being expose to the hospital ward and implement nursing care to tho
s e i l l patients. There are many cases I have had encountered during the duty one of which isthe
acute bronchitis. Sense we are all future health care providers; somehow I was ableto identify nursing
diagnosis and implement possible effective nursing care.This study will serve as a reference
material in rendering competent care to myclient especially those with similar situation.
Through this, I will be able to develop myknowledge as well as my skills and attitudes in
applying the prescribed procedure toimprove the health status of the patient.This study
will act as a baseline as well as a guide for a good, accurate andcomprehensive
research paper dealing with issues commonly experienced by patient inthe hospital setting.
This may aid the researchers to widen the scope of the study in relation to more or
less similar cases

After conducting this case study, we were able to appreciate more the essence of utilizing the nursing
process in the care and management of our patient. It was indeed a tough job on conducting this
study, yet, it gave us a big impact regarding ow useful it is in our chosen profession. Nursing really
demands a tender loving care attitude. It demands patience and is calling that cannot be merely taken
for granted.
Moreover, this case study taught us to stand on our own by not depending on others just to make this.
This provide us, the studenst, a big learning regarding onhow well we take care of our patients in the
real clinical setting. Most of all, thi s study teaches the students to provide clients care more efficiently
and competitively to achieve an effective and quality nursing care.

Good adherence to health care teachings provided to our client and parents
became the reason of meeting our family centered objectives.
Before any nursing intervention, we made it a point that we were able tounderstand the disease
itself and its proper management. Rendering healtht e a c h i n g i s o n e o f t h e
i m p o r t a n t t o o l s t o h e l p p r o m o t e t h e h e a l t h o f t h e patient. We
established a trusting relationship with the parents especially the mother which
enable us to provide efficient nursing care. A good nurse-patient interaction plays a
vital role in meeting the objectives. This is metthrough creating an
environment of trust in listening to the mother of
thep a t i e n t c o n c e r n a n d b e i n g a v a i l a b l e t o c l i e n t s s i d e . T h i s e n a b l e s
u s t o established rapport and respect needed before the mother of the patient willbe willing to take
part in the learning process.We the student discussed about the disease of the
patient to themother and how it is acquired. Maybe, caused by their environment,
lifestylea n d a l s o h e r e d i t a r y. To p r e v e n t s u c h d i s e a s e , t h e p a r e n t s o r
t h e f a m i l y should clean their surroundings and before handling the baby they must
dohandwashing to prevent spread of microorganism. Most important thing
isfor them to give vitamin C to protect her immune system and the importanceof completing all the
immunizations provided by the Department of
Healthe s p e c i a l l y t h e D P T v a c c i n e w h i c h h e l p s t h e c h i l d t o p r e v e
n t i n h a v i n g pneumonia.Certain health teaching was discussed to the mother
like theimportance of adhering therapeutic management regimens like taking
themedications and knowing its advantages or benefits and the effects
andadhering to proper hygiene like cleaning the breast with water before
thebaby will suck and washing the hands before handling the baby. We
alsoimparted to them knowing the potential complications and how to
initiatea p p r o p r i a t e p r e v e n t i v e o r c o r r e c t i v e a c t i o n . L a s t l y

w e w e r e a b l e t o encourage the patients mother on the proper posit

i o n i n g w h i l e b r e a s t feeding or when propping up the baby in order to
increase its intake andprevent aspirations and to help immobilizing secretions. The
patient is stillconfine in the 3B- pedia at Lorma Medical Center.

ACKNOWLEDGEMENT

I wish to thank my groupmate who assisted me in the tiresome work of giving their
comments, observations and criticisms for the improvement of the text.
To our family who encouraged us and for many days tolerated our complete
preoccupation with the making of this paper, we lovingly dedicate this humble opus.

SOAPIE

SS
Ang una gyud nga Gi-TB sa amoa kay akong bana tapos wala ko nakabalobahin ana nga sakit. As
verbalized by the patient.
OO

Lack of information

Expressing feelings of concerns

AA
Knowledge deficit related to unfamiliarity with disease process and newtreatment methods.
PP
At the end of 2 hours client will be able to verbalize understanding of disease process and treatment
regimen.
II
Independent:
1.
The client and significant others were taught for the following:2.Emphasized the importance of
good nutrition. To help him motivatesto take action and to strengthen the immune system to
preventcomplication.3.Encouraged client and significant others to verbalized concerns,
andanswers questions factually. Provide opportunity to correctmisconceptions and alleviate anxiety.
4.

Emphasized the importance of maintaining high-protein,carbohydrate and adequate fluid intake.

Meeting metabolic needs
34

helps minimize fatigue and promote recovery5.Provided a position of comfort and a quite
environment for the clientduring interaction/discussion. This allows patient to concentrate onwhat
is being discussed.
EE
At the end of 2 hours, client was able to verbalized understanding of
thedisease process, treatment regimen, and preventive measures to reducethe risk of