FM-CON-1023
Revision No. 00
VIRGEN MILAGROSA COLLEGE OF
Effectivity Date: Nov.5, 2018
UNIVERSITY FOUNDATION NURSING
Name of Student: Angela Mae M. Ribu
Year and Section: BSN 3-F
GENERAL INFORMATION OF PATIENT:
Name: Eulagia Barabot Coxia
Admission Date: August 24, 2023
Admission Time: 9:45 am
Admitting Physician: Doctor Model Palisoc
Chief complaint: Fever and coughing out blood
Final Diagnosis: Pneumonia
FM-CON-1023
Revision No. 00
VIRGEN MILAGROSA COLLEGE OF
Effectivity Date: Nov.5, 2018
UNIVERSITY FOUNDATION NURSING
Pathophysiology (10 Points)
Precipitating Factor:
Stress brought by the death of a
loved one
Altered lifestyle: not eating, Serum Electrolytes: Signs of Dehydration
isolated, bed ridden High level of Sodium
Low Level of Potassium
Weakening of the Immune Elevated Creatinine
Function Elevated BUN
CBC Indicates:
Elevated WBC Indicates Kidney
Susceptibility to Infection Urinalysis Indicates:
Damage
Turbidity
Inflammation of the lungs Fever
Does not produce enough
erythropoietin that
stimulates production of
RBC
Ruptured Blood Vessels in the
Lungs
Hemoptysis
Anemia
Pneumonia
Low Oxygen Saturation
CBC Result:
Chest XRay Suggests: Low levels of
Pneumonia t/o PTB Impaired Gas Exchange hematocrit and RBC
FM-CON-1023
Revision No. 00
VIRGEN MILAGROSA COLLEGE OF
Effectivity Date: Nov.5, 2018
UNIVERSITY FOUNDATION NURSING
II. DEVELOPMENTAL DATA (based on Erik Erickson’s Life and Development) (15 Points)
Definition of the Theory
From infancy to adulthood, Erik Erikson argued that personality develops via eight stages of psychosocial
development in a set order. The person goes through a psychological crisis at each step, which may or may not have an
impact on how their personality develops. The theory holds that after each stage is successfully completed, a healthy
personality and the attainment of basic virtues result. Basic virtues are defining qualities that the ego can draw upon to get
through later crises. A lessened capacity to complete subsequent stages and, consequently, a more unhealthy personality
and sense of self, might arise from failing to complete a stage. However, these phases can be effectively resolved in the
future. In this case, patient Coxia is under the stage of Integrity vs. Despair base on her age which is 85 years old. This
stage is taking stock of one's life in hindsight. One might either experience integrity by concluding that one has led a life that
was well-lived or despair by reflecting on past decisions and wasted possibilities.
Connection of Theory to the Problem
In the situation of the patient, she's in the point of despair. The patient loses her hope since her husband died.
She's not eating and start to lose her weight to the point that she cannot help herself anymore and also become isolated
and bed ridden.
Nursing Management and Intervention
Spend some time talking and listening to the patient. Patients who are feeling hopeless could think no one is
interested in how they are feeling. Assure the patient that you are willing to assist and are available. Before the patient will
open up and communicate what is making them feel hopeless, a rapport may need to be established.
III. HEALTH HISTORY
A. FAMILY HISTORY (5 Points)
Both Parents : hypertension, heart problem
Mother : coronary heart disease
Father : Lung problem
B. PAST MEDICAL HISTORY: (5 Points)
July 2022: elevated blood pressure and increase blood sugar
C. PRESENT ILLNESS: (5 Points)
Fever (2days)
Medication Taken: 500 mg Paracetamol Tab every 4 hours
Coughing out blood
IV. MEDICAL TREATMENT AND MANAGEMENT INCLUDING DIAGNOSTIC PROCEDURES AND ITS
INTERPRETATION TO NURSING.
Laboratory result:
1. Chest Xray august 25,2023
a. Impression: pneumonia t/o PTB, atherosclerotic aorta, degenerative osseous changes
b. Nursing Interpretation: The patient is likely to have pneumonia with the possibility of pulmonary
tuberculosis. There are also possibility for Atherosclerosis Aorta and age related changes that occur in the
bones.
2. Serum electrolytes:
a. Na: 152.1
b. K: 3.2
c. C: 115.3
d. Nursing Interpretation:
i. Sodium levels are high which is also called hypernatremia
ii. Potassium level is low which indicates hypokalemia
iii. Chloride level is also elevated which indicates hyperchloremia.
FM-CON-1023
Revision No. 00
VIRGEN MILAGROSA COLLEGE OF
Effectivity Date: Nov.5, 2018
UNIVERSITY FOUNDATION NURSING
3. Urinalysis Result
a. Color: pale yellow,
b. Transparency: turbid
c. Reaction: acidic
d. Specific gravity:1.020
e. Urates: few
f. Epithelial cell: moderate
g. Bacteria: few,
h. RBC: TNTC
i. WBC:4-6
j. Nursing Interpretation:
i. The urine is turbid which can be caused by bacteria, mucus or other substances.
ii. RBC is too numerous to count which indicates that there are many RBC in the urine.
iii. WBC level is slightly elevated which can indicate an infection.
4. CBC Result
a. Hematocrit:0.36.
b. Hemoglobin:114.
c. RBC:3.8.
d. WBC:12.0,
e. Platelet count:411
f. Nursing Interpretation:
i. Hematocrit is in below the normal range which can indicate anemia
ii. Hemoglobin level is also below the normal range
iii. RBC is below the normal range which is consistent to the low hematocrit and hemoglobin
iv. WBC is slightly elevated
5. Creatinine and BUN Result
a. Creatinine:87.8
b. BUN:3.5
c. Nursing Interpretation:
i. High level of creatinine which may indicate kidney damage
ii. High level of BUN can also indicate kidney damage
V: DRUG STUDY (INCLUDE GENERIC NAME, ACTIONS, SE, AND CONTRAINDICATION (Use separate sheet/s if not
enough)
Generic Name Mechanism of Action Indication Side Effect Nursing
(2 Points) (2 Points) (2 Points) (2 Points) Responsibilities
(2 Points)
Paracetamol May block pain Mild to moderate pain Cyanosis, anemia, Assess for
impulses peripherally or fever, arthralgia, neutropenia, temperature for
that occur in dental pain, jaundice, fever
response to inhibition dysmenorrhea, pancytopenia, CNS Assess for pain
of prostaglandin headache, myalgia, stimulation, delirium Monitor for Side
synthesis; does not osteoarthritis followed by vascular effects
possess anti- collapse, seizures,
inflammatory coma
properties; antipyretic
action results from
inhibition of
prostaglandins in the
CNS (hypothalamic
heat-regulating
center)
Tranexamic acid A synthetic derivative Hereditary Severe Be alert for
of lysine that exerts angioedema and gastrointestinal bleeding gums,
FM-CON-1023
Revision No. 00
VIRGEN MILAGROSA COLLEGE OF
Effectivity Date: Nov.5, 2018
UNIVERSITY FOUNDATION NURSING
antifibrinolytic effects other instances of symptoms, nose, or other
by blocking lysine significant bleeding in hypotension, unusual bleeding
binding sites on the context of thromboembolism, or bruising
plasminogen hyperfibrinolysis visual imoairment, Monitor
molecules, inhibiting convulsions, mental increased blood
the interaction of status change, rash coagulation or
plasminogen with symptoms of
formed plasmin and pulmonary
fibrin embolism
Assess blood
pressure
Assess for
dizziness that
might affect gait
and balance
Kenzolin It works by interfering Bacterial infection Upset stomach, Monitor for
with the formation of vomiting, unpleasant/ bleeding
bacterial cell walls by abnormal taste, manifestations
preventing the diarrhea, headache, Watch for
bacteria from vital constipation, seizures
cross-links within insomnia, rash, Monitor for signs
their cell walls bruising or bleeding of
pseudomembran
ous colitis
Assess for
muscle aches
and joint pain
that may be
caused by serum
sickness
Budesonide Neb Prevents Rhinitis; prophylaxis Headache, rash, otitis Assess
inflammation by for asthma; media, dysphonia, pulmonary
depressing migration Crohn’s disease, epistaxis, pharyngitis, function
of polymorphonu ulcerative colitis, rhinitis, sinusitis, observe for
clear leukocytes and nasal polyps dyspepsia, paradoxical
fibroblasts, reversal gastroentiritis bronchospasm
of increased capillary monitor for signs
permeability, and of adrenal
lysosomal supression
stabilization; does not
sup
press hypothalamus
or pituitary function
Amlodipine Inhibits calcium ion Chronic stable Headache, fatigue, assess cardiac
influx across cell angina pectoris, dizziness, status: blood
membrane during hypertension, variant Somnolence, pressure, pulse,
cardiac angina (Prinzmetal’s Peripheral edema, respirations
depolarization; angina) bradycardia, assess for chest
produces relaxation hypotension, angina, pain: intensity,
of coronary vascular edema, palpitations, location, and
smooth muscle, Nausea, abdominal duration
peripheral vascular pain, anorexia,
smooth muscle; gingival hyperplasia,
dilates coronary dyspepsia, Rash,
vascular arteries; pruritus
increases myocardial
O2 delivery in
patients with
FM-CON-1023
Revision No. 00
VIRGEN MILAGROSA COLLEGE OF
Effectivity Date: Nov.5, 2018
UNIVERSITY FOUNDATION NURSING
vasospastic angina
Berodual Neb Berodual contains For Symptoms of tachycardia, Assess
two active COPD with reversible palpitation, tremor, pulmonary
bronchodilating bronchospasm such hypertension, function at rest
ingredients: as bronchial asthma hypotension, and during
ipratropium bromide, widening of the pulse exercise
exhibiting an pressure, anginal Monitor for signs
anticholinergic effect pain, arrhythmias, of paradoxical
and fenoterol and flushing. bronchospasm
hydrobromide a beta- Be alert for
adrenergic agent. allergic reactions
Assess blood
pressure
periodically
Levophed Strong beta1- and Acute hypotension, dizziness, weakness, monitor BP
alpha-adrenergic cardiac arrest, sepsis headache, slow heart continuously if
effects and moderate and septic shock rate, breathing possible or every
beta2 effects, which difficulty, or redness
couple of
increase cardiac and swelling at the
output and heart rate, injection site.pain or minutes.
decrease renal burning where the double check all
perfusion and PVR, injection is given, concentrations
and cause variable sudden numbness/ with additional
BP effects weakness/cold nurse.
feeling in your body, may result in
blue lips or
rebound
fingernails, urinating
less than usual or not hypotension due
at all, trouble to tissue
breathing,dangerousl ischemia when
y high blood discontinued.
pressure (severe monitor EKG and
headache, blurred CVP.
vision, buzzing in
if patient is
your ears, anxiety,
confusion, chest awake instruct
pain, shortness of them to report
breath, irregular headaches,
heartbeats, seizure) dizziness, or
chest pain.
FM-CON-1023
Revision No. 00
VIRGEN MILAGROSA COLLEGE OF
Effectivity Date: Nov.5, 2018
UNIVERSITY FOUNDATION NURSING
VI: NURSING INTERVENTIONS AND RATIONALE (Use separate sheet/s if not enough)
Assessment Diagnosis Planning Intervention Evaluation
(6 Points) (6 Points) (6 Points) (6 Points) (6 Points)
Objective Data: Impaired gas Within 1 hour of Assess Patients oxygen
exchange related to nursing respiration for saturation has
HR: 56 bpm altered oxygen- interventions, the rate and quality, increased from 90%
carrying capacity of patient will as well as use to 95%.
RR: 25
blood secondary to demonstrate of accessory
O2 Sat: 90% anemia as improved gas muscles
evidenced by low exchange as
Positive rales rbc, low hematocrit, evidenced by Monitor vital
on both lungs and oxygen oxygen saturation signs for
saturation of 90%. greater than 90% oxygen
saturation and
changes in
heart rate,
blood pressure,
or cardiac
rhythm -
Change the
patient’s
position every
two hours.
Educate the
patient in how
to perform
therapeutic
breathing and
coughing
techniques
VII: NURSING IMPLICATIONS
A. NURSING PRACTICE (2 Points)
- Following the case presentation, the study will prepare the nurses for success by providing them with a deep
understanding of the characteristics of the illness in terms of the risk factors, signs and symptoms, and management,
enabling them to handle patients and implement the necessary nursing interventions in accordance with the patient's
situation.
B. NURSING EDUCATION (2 Points)
- Using case scenarios like this can help students develop and improve their critical thinking and problem-solving skills in
studying for various illnesses and make them more knowledgeable when it comes to assessing their patients in the future.
Case studies can engage students in applying what they have learned to be able to apply it in actual situations.
C. NURSING RESEARCH (2 Points)
- The nursing research would benefit from using this case study as a source of data, for example, to monitor the people in
the community with this problem. This material would share crucial details on the early identification and prevention of the
medical state, raise awareness of the sickness and the need for treatment.
FM-CON-1023
Revision No. 00
VIRGEN MILAGROSA COLLEGE OF
Effectivity Date: Nov.5, 2018
UNIVERSITY FOUNDATION NURSING
VIII: REFERRAL AND FOLLOW UP (IF ANY): (4 Points)
(There is nothing indicated)
Submitted by:
ANGELA MAE M. RIBU
Signature over printed name of student
Submitted to:
Brando Rayray Jr.
Clinical Instructor
