NAME: Patient XYZ AGE: 67 GENDER: Male

CIVIL STATUS: Married RELIGION: Roman Catholic BIRTHDAY: 11/19/1950

BIRTH PLACE: Tagudin, Ilocos Sur NATIONALITY: Filipino
ADDRESS: San Antonio, Agoo, La Union
OCCUPATION: Retired Police Officer PHIC: No CASE: Medicine
DATE & TIME ADMITTED: 08/07/2018 (10:37 PM)
CHIEF COMPLAINT: Cough, fever and other associated symptoms

HISTORY OF PRESENT ILLNESS:

2 days prior to admission, patient had cough characterized as productive with
yellowish phlegm and occurs throughout the day. Associated fever, chills, generalized body
weakness and loss of appetite noted. No difficulty of breathing, nausea, vomiting, abdominal
pain, diarrhea, bleeding episodes. No medications were taken. No consult was done.
1 day prior to admission, there was persistence of productive cough with associated
fever, chills, generalized body weakness and loss of appetite. Patient consulted a private
hospital and had a complete blood count done revealing a platelet count of 146. Patient
was prescribed with Cefuroxime 500mg BID and Acetylcysteine 600mg. Patient took in the
ordered medications but offered no relief.
Few hours prior to admission, patient went back to the private hospital to repeat a
complete blood count, which then revealed platelet count of 125. Patient was prescribed
with multivitamins + Buclizine HCl and 2 tablets of Inosince Acedoben Dimepranol. Cough
worsened still with fever, chills, generalized body weakness, loss of appetite and this time with
increased bowel movement. Persistence of symptoms together with the low platelet count
prompted the patient to seek consult from this institution. Hence, current admission.

PAST MEDICAL HISTORY:

Patient had no history of childhood illnesses such as measles, chickenpox or mumps.
Patient was hospitalized in 1994 due to a vehicular accident and undergone bracing of his
fractured right lower leg. Patient is a diagnosed hypertensive for 10 years and is maintained
on Atenolol 50mg 1 tab OD, Losartan 50mg 1 tab OD, and Amlodipine 10mg 1 tab OD.
Patient was diagnosed of Diabeted Mellitus since 2017. Patient was diagnosed with lung
cancer in 2017 and underwent 5 cycles of chemotherapy at SLU-HSH from August 2017 to
November 2017. Patient shifted to oral chemotherapy (Erlotinib 1 tab OD) in December 2017.
Patient also takes in Tamsulosin 400mg 1 tab OD.
Patient has no known allergies to any food or drug.

FAMILY HISTORY:
Patient has no family history of hypertension, stroke, heart disease, Diabetes Mellitus,
coronary artery disease, bronchial asthma, and cancer in both maternal and paternal side.
Patient has a brother who is a hypertensive and a sister diagnosed with breast cancer.

SOCIAL AND ENVIRONMENTAL HISTORY:

Patient is a college undergraduate and a retired policeman. Patient is a non-smoker
and an occasional alcoholic beverage drinker. Patient lives together with his wife, son and
daughter-in-law. Patient’s wife had a 3-day history of productive cough prior to patient’s
symptoms. The house is well ventilated. Patient’s diet consists mainly of vegetables and fish.
Drinking water is bought from the refilling station. Garbage is segregated and collected every
day. Patient has no history of recent travel.
PRIORITIZATION OF NURSING PROBLEMS
NURSING DIAGNOSIS
1. Ineffective airway
clearance related to
retained secretions in the
bronchotracheal tree 2°
pneumonia
Classification: Actual Problem
2. Ineffective tissue perfusion
related to altered blood
pressure outside of
acceptable parameters
Classification: Actual Problem
3. Hyperthermia related to
inflammatory process
Classification: Actual Problem
4. Diarrhea related to
infectious process
Classification: Actual Problem
JUSTIFICATION
Airway must be given the first attention as based on the
rule of ABC, which stands for Airway, Breathing and
Circulation. Addressing the problem will give patent
airway to the client. Oxygenation is a vital need for every
cell, if there is any problem related to it, it could easily
affect the functioning of the individual. Retained
secretions can cause blockage of airway, which will
further cause difficulty of breathing (Berman, et al, 2016).
Circulation is the 2nd prioritized problem. Circulation
needs to be addressed since decrease in circulation may
result in failure to nourish tissues at capillary level.
Insufficient arterial blood flow causes decreased nutrition
and oxygenation at the cellular level. When diminished
tissue perfusion becomes chronic, it can result in tissue or
organ damage or death.
This is the 3rd priority because the increase in the body
temperature is just in response to the disease
experienced by the body. However, many complications
may arise if it was left untreated. Hyperthermia may result
to fluid loss, hemodynamic alterations, serum enzyme
abnormalities and other symptoms of variable severity. It
can also cause neurologic symptoms including nausea,
confusion, disorientation, apathy, delirium, stupor or
coma (Progress in Brain Research, page153).
Diarrhea is addressed last since according to
Henderson’s Nursing Need Theory, an individual achieves
wholeness by maintaining physiological and emotional
balance and the physiological components include eat
and drink adequately together with elimination of body
wastes. The problem is prioritized last because based on
Maslow’s Hierarchy of Needs, Self-Actualization or
wholeness is achieved only after the other needs are met