Case - Presentation Pneumo

FIRST CITY PROVIDENTIAL COLLEGE
Barangay Narra, Francisco Homes Subd., City of San Jose del

Monte, Bulacan
Tel (044) 815 6814 Fax (044) 815 7137 email:
[email protected]
Case Presentation Outline

TANGPAP, MERCY A.
BSN-4
Demographics
a. Patient’s Profile
Name: Teresita Clamor
Age: 74 year old
Weight:115 pounds
Religion: Roman Catholic
Address: Dela Costa, Valenzuela City
b. Chief Complaint: Productive cough, Difficulty of breathing
Date of Admission: 12/29/2022
c. History of Present Illness
3 weeks PTA – (+) cough
(+) nasal congestion, whitish phlegm

(+) nasal discharge
(+) difficulty of breathing
(+) vomiting, 1 episode
(-) edema
d. Past Illness
(-) asthma
(+) allergies
(+) acute stroke
e. Family History
PMHx: (+) asthma (mother)
f. Activities of Daily Living
Sleeping mostly at night and during afternoon
Usually wakes up early in the morning (5AM)
BM (1-2 times a day)
Urinates in her diaper (more than 7 times a day)
g. Review of Systems
Neuromuscular: weakness of muscles
Integumentary: (-) cyanosis
(+) coarse crackles, (+) wheezes,
Key findings
74 year old female Patient with a history of hypertensive. PTA,

admitted with a three week history of cough productive bringing up
with whitish phlegm accompanied with difficulty of breathing
generalized body weakness, poor appetite, and. PTA went to Feu for a
check-up, and they conducted Chest X-ray, but the findings were
normal. They gave zykast for a week, but the cough did not disappear,
so they decided to go to TALA for admission, test are done and was
diagnose with Acute Respiratory Type I secondary to hypertensive
cardio pulmonary disease CM CHF NYAHA IIC vital signs are as follows:
blood pressure 130/90, apical heart rate 112/minute and regular,
respiratory rate 24/minute and somewhat labored, temperature 36.4
C. Examination of the Both lungs are resonant by percussion with one
exception: the right mid-anterior and right mid-lateral lung fields are
dull. Auscultation reveals bilateral diminished vesicular breath sounds.
Bronchial breath sounds, rhonchi and late inspiratory crackles (are
heard) in the area of the right mid-anterior and right mid-lateral lung
fields. The remainder of the lung fields is clear. Percussion and
auscultation of the heart reveals no significant abnormality.
Background
Mrs. Teresita is a senior citizen Female patient, Filipino, Roman

catholic, upper-middle class 74 years of age. The patient is a
nonsmoker. She is widow with 1 daughter, who is 27 years old. She
presented to the hospital
complaining of Difficulty of breathing and cough. She has previous
history of Acute Stroke last 2018, the daughter stated that her mother
is usually hypertensive and has breast cancer. She is a retired public
teacher. Her husband died last October 2019. Her daughter and her
niece are the only ones still residing at home.. Her Father and Mother
is already diseased. She has 2 siblings. Got admitted last December
29, 2022.
Formulation
The patient complaints of increasing shortness of breath, the daughter
stated that the first time she noticed her mother had some difficulty
catching her breath was when her mother carry heavy loads up and
down a flight of stairs daily and her shortness of breath began to make
this very difficult. From that time on she avoids activities that cause
her to physically exert herself.
Interventions and Plans
I need to address health teaching with the patient including the

patient deficit knowledge, risk for dehydration, unbalanced nutrition,
acute pain, activity intolerance, risk for infection, impaired gas
exchange, and last but not least, ineffective airway clearance. Airway
management always needs to be addressed initially. Ineffective airway
clearance is the first nursing diagnosis that would need to be
addressed in Mrs. Clamor’s hospitalization. The airway, when COPD is
present could be compromised due to the presence of secretions. The
breathing
pattern would be affected.
 Assess respiratory symptoms. Symptoms of fever, chills, or

night sweats in a patient should be reported immediately as
these can be signs of bacterial pneumonia.
 Assess clinical manifestations. Respiratory assessment
should further identify clinical manifestations such as pleuritic
pain, bradycardia, tachypnea, and fatigue, use of accessory
muscles for breathing, coughing
 Physical assessment. Assess the changes in temperature and
pulse; amount, odor, and color of secretions; frequency and
severity of cough; degree of tachypnea or shortness of breath;
and changes in the chest x-ray findings.
 Assessment in elderly patients. Assess elderly patients for
altered mental status, dehydration, unusual behavior, excessive
fatigue, and concomitant heart failure
Reason for Presentation
I was able to see the importance of recognizing the affect of all co-
morbidities of the patient. For each disease process there is an effect
on other systems, and each of these effects must be taken into
account when treating the patient.
When teaching this patient I also was learning the things needed to
help in achieving a healthier lifestyle for this patient. This helped me
develop a knowledge base that I can build upon. Since this patient was
not receptive to instruction, I had to find ways to get him to comply
with his orders. I learned to depend on others on my team to help get
the job done.

Case - Presentation Pneumo

Uploaded by

Copyright:

Available Formats

Case - Presentation Pneumo

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Case - Presentation Pneumo

Uploaded by

Copyright:

Available Formats

FIRST CITY PROVIDENTIAL COLLEGE

Barangay Narra, Francisco Homes Subd., City of San Jose del

Case Presentation Outline

Name: Teresita Clamor

Age: 74 year old

Religion: Roman Catholic

Address: Dela Costa, Valenzuela City

b. Chief Complaint: Productive cough, Difficulty of breathing

Date of Admission: 12/29/2022

c. History of Present Illness

3 weeks PTA – (+) cough

(+) nasal congestion, whitish phlegm

PMHx: (+) asthma (mother)

f. Activities of Daily Living

Sleeping mostly at night and during afternoon

Usually wakes up early in the morning (5AM)

BM (1-2 times a day)

Urinates in her diaper (more than 7 times a day)

Neuromuscular: weakness of muscles

Integumentary: (-) cyanosis

(+) coarse crackles, (+) wheezes,

74 year old female Patient with a history of hypertensive. PTA,

Mrs. Teresita is a senior citizen Female patient, Filipino, Roman

Interventions and Plans

I need to address health teaching with the patient including the

 Assess respiratory symptoms. Symptoms of fever, chills, or

Reason for Presentation

You might also like