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I.

INTRODUCTION

The case presentation provides the discussion, analysis, and application of the nursing
roles and responsibilities that are being observed and performed during the hospital
exposure in Vicente Sotto Memorial Medical Center, 6:00 A.M – 2P.M shift in the OB-
High Risk Area.This covers the study of the selected patient with the conditions of
Pulmonary congestion and Methicillin-resistant Staphylococcus Aureus Infection
(MRSA). The patient’s case provides a wide-range scope that allows the students to
study and interpret accordingly.

The primary complaint of the patient is Pulmonary Congestion. According to the latest
WHO data published in 2018, Pulmonary Congestion-related deaths in
the Philippines reached 26,151 or 4.23% of total deaths and has been known to cause
severe complications affecting thousands of people worldwide. Pulmonary Congestion
happens when there is an accumulation of fluid in a person’s lungs, resulting in impaired
gas exchange and arterial hypoxemia which causes extreme shortness of breath,
restlessness, hypertension, fatigue, and irregular palpitations. On the other hand, the
other condition of the patient is the Methicillin-resistant Staphylococcus Aureus Infection
(MRSA). MRSA cases in the Philippines increased in 31% (WHO, 2017). It causes
severe problems such as bloodstream infections, pneumonia and surgical site
infections. Despite new advances in drug development, drug-resistant infections are a
growing concern worldwide.

In relation to the patient’s status, both conditions are under a specialized therapeutic
regimen and have been monitored throughout the rotation and will be further discussed
by in this case presentation.

II. NURSING HEALTH HISTORY(Narrative Form)


Biographic Data

Patient L.L. born in and living in Kanamukan, Compostela City. A pure Filipino
aged 23, born on September 26, 1996. Delivered first baby via cesarean section.
G 1 T 1 P 1 A 0 L 1 M 0. Patient is currently single. Finished education to Grade
6 and then proceeded to work to support family. Patient does jogging and chores
around the house. Diet consists of vegetables, fish, softdrinks and occasionally
canned foods. Drinks 5 glasses of water a day and eat meals 3 time a day.
Patient sleeps 8 hours a day and has no sleeping related problems.

Chief Complaints

Pulmonary congestion
Patient is currently healthy. Previous Illnesses experienced include Chicken
Pox and measles. Client has also experienced fevers and coughs irregularly.
Patient has completed vaccinations of Hepa. B, OPV, BCG vaccine. Patient is
also hypertensive and has experienced mo previous hospitalization. Client had
menarche at age 12. Each menstruation lasts 3 days and has a 28 day cycle. G 1
T 1 P 0 L 1 M 0. Client does jogging and house chores regularly to keep in
shape. She also verbalized that before pregnancy she used to be more in shape
and more energetic when int comes to physical activities. . Client has a circle of
friends consisting of other mothers and neighbors which provide social support.
Client enjoys socializing with close friend and relatives. Maintains good
communication with distant family. Client is psychologically healthy and has no
previous history of psychological illness.

III. GORDON’S FUNCTIONAL HEALTH PATTERN and REVIEW OF SYSTEMS


- Must have data before and upon admission
- Summarize all the patterns at the end of table
GORDON’S BEFORE DURING
FUNCTIONAL
HEALTH PATTERN
1. Health Perception / The patient viewed health as The patient stated that she
Health Management a state in which she can will try her best to promote
perform her work daily and health and treat the initial
with the absence of illness. signs & symptoms of illnesses.

The patient consumed The patient statedthat in order


2. Nutritional - vegetables, soft drinks, dried to prevent the risk of having
Metabolic fish and sometimes eating diabetes, she don’t eat meat
snacks during midnight such andtake softdrinks; She also
as bread with juice and take medications for
stated that she does take maintenance.
medications.

The patient experienced The patient stated that she


3. Elimination problems on bowel will try her best to defecate
elimination. The defecation and void more often and drink
took about once for every 3 8-10 glasses of water every
days or once a week and day.
have never utilized any
suppositories for either
constipation or diarrhea. The
patient usually voided 2
times a day. She also stated
that she feels a little pain
when both on defecating and
voiding.
The patient stated that she The patient stated that during
4. Activity – Exercise can do a little household her pregnancy, she can’t able
chores and sometimes going to walk but she can able to
outside for walking and move just a little.
jogging.

The patient verbalized that The patient stated that she


5. Sleep – Rest her usual sleeping hours can rarely sleep and distracted
starts around 8-9pm and will due to the monitoring of the
generally achieved 7-8 hours health care team members
of sleep which she thought it and the visitation of her
provided her with ample rest significant others.
from her daily activities.

The patient stated that she The patient verbalized on her


6. Cognitive – has no altered memories nor lower extremities was getting
Perceptual can make a good decision worst and itchy and sore with
and no vision and hearing pus.
disturbances. She is able to
read and write properly. She
complained about her lower
extremities which it’s very
itchy and the evident of pus.
The patient stated that Patient verbalized that she
7. Self – Perception / whenever the fever strikes, accepted the reality even if
Self Concept she will seek medications and how they have a financial
sometimes, she drinks a soft problem and will try to lessen
drink. the soft drink intake.

The patient can speak bisaya The patient stated that she
8. Role - Relationship and maintained a good, open was provided comfort, love
communication and shares and care by her parents even
ideas when it comes in though the financing on her
decision-making. medications is not enough.

9. Sexually – The patient stated that they The patient verbalized that
Reproductive never used any protective she planned to use condoms
agents and have sex with her for safe sex.
partner, twice.
10. Coping / The patient stated that The patient stated that she
Stress everytime she get exhausted, won’t able to decrease her
Tolerance she will take a rest or drinks stress it is because of her
a soft drink. current condition and the
environment of the hospital.

11. Value - Belief The patient stated that her The patient verbalized that
religion is Roman she seldom went to church
Catholic.They always went to because of her current
Church every Sunday and condition.
prays every night.

IV. PHYSICAL ASSESSMENT (Head to Toe)andREVIEW OF SYSTEMS


PHYSICAL FINDINGS REVIEW OF SYSTEMS
ASSESSMENT
• The client’s skin • due to bacterial infection
SKIN doesn’t have any causes MRSA
discolorations;
evident of pus at
the left leg.
• Skin is moist.

 The client’s black


HAIR
hair with streaks of
brown and the
scalp is clean and
hair is coarse and
dry.

 The client’s head is


HEAD symmetric and well
rounded; no presence of
nodules and it is smooth
and has uniform consistency

 The client’s face has slight


FACE markings but no sign of
discoloration
 Symmetrical facial
movement and is noted

 The client is able to repeat


EARS phrases correctly in both
ears and negative result is
noted when Weber’s Test
was done

 The client’s pupils constricts


EYES when looking at near objects
and dilates at far object
 The pupils are equally
rounded and reactive to light
accommodation
 The client stated having
trouble reading without the
use of eyeglasses and only
can read when the reading
material is held away from
his eyes

 The client’s nose is


NOSE symmetrical and the air
moves freely as the client
breathes
 No discharges/flaring is
noted

 The client’s lips are pinkish


MOUTH and has the ability to purse
lips
 The uvula is positioned in
the midline of soft palates
 No abnormal growth is
observed

 The client’s neck muscles


NECK are equal in size; head
centered is noted and has
strong muscle tone
 It is coordinated smooth
movements with no
discomforts and head flexed
at 45 degree angle

 The client’s breast is


CHEST (Anterior / symmetrical and no masses
Posterior) felt on the chest wall
 The client’s abdomen is free
ABDOMEN of lesions; scattered fine
veins is noted and it is
evenly rounded

 The client has no lumps,  The client is currently weak


UPPER lesions or tumors is noted. due to caesarean surgery.
EXTREMITIES

 The client has healthy nails,  The client can’t move freely
LOWER symmetrical legs and feet because of MRSA at her left
EXTREMITIES but the left leg has evident leg.
of pus and bacterial
infections.

 The client stated that there


GENITALS are no lesions felt upon
palpation

V. SUMMARY OF MEDICATIONS/IV , BLOOD TRANSFUSIONS, TREATMENTS (ACTUAL;


According to date and specify date of discontinuation)

DRUGS :
1. Metronidazole is used to treat a wide variety of infections. It works by stopping the
growth of certain bacteria and parasites.
2. Amlodipine is for lowering high blood pressure helps prevent strokes, heart
attacks, and kidney problems.
3. Citirizenis used to relieve allergy symptoms such as watery eyes, runny nose,
itching eyes/nose, sneezing, hives, and itching.
4. Co-amoxiclav is given to treat bacterial infections. It is prescribed for sinus
infections, urine infections, skin infections, joint infections and some dental infections.
VI. ANATOMY AND PHYSIOLOGY (Review of the organ and its function, direct to the illness); but if
there is multiple organ involvement must also include.

RESPIRATORY SYSTEM

The organs of the respiratory system include the nose, pharynx, larynx, trachea, bronchi,
and their smaller branches, and the lungs.

Nose - Is the only externally visible part and primary organ of the respiratory system.

Nostrils - Two external openings of the nasal cavity in vertebrates that admit air to the
lungs and smells to the olfactory nerves.

The nasal cavity - It is large, air-filled space above and behind the nose in the middle of the
face.

Epiglottis - Sometimes referred to as the “guardian of the airways”, the epiglottis protects
the superior opening of the larynx.

Pharynx - Is the part of the throat behind the mouth and nasal cavity, and above the
esophagus

Larynx – The tubes going down to the stomach and the lungs.

The larynx - “Voice box” routes air and food into the proper channels and plays a role in
speech.

Trachea - Commonly known as the windpipe. The trachea begins just under the larynx
(voice box) and runs down behind the breastbone (sternum). The trachea then divides into
two smaller tubes called bronchi: one bronchus for each lung.
Primary bronchus - Represents the airway in the respiratory tract that conducts air into the
lungs. Bronchi will branch into smaller tubes that become bronchioles.

Bronchioles - Tubes in the lungs which branch off from the larger bronchi that enter each
lung, from the large and singular trachea which connects to the mouth.

Pleural cavity - Is the thin fluid-filled space between the two pulmonary pleurae (known as
visceral and parietal) of each lung.

Right and left lung - Are a pair of spongy, air-filled organs located on either side of the
chest (thorax).

Diaphragm - It contracts and flattens when you inhale. This creates a vacuum effect that
pulls air into the lungs.

INTEGUMENTARY SYSTEM

Epidermis - The upper or outer layer of the two main layers of cells that make up the skin.
The epidermis is mostly made up of flat, scale-like cells called squamous cells.

Dermis- The thick layer of living tissue below the epidermis which forms the true skin,
containing blood capillaries, nerve endings, sweat glands, hair follicles, and other
structures.

Subcutaneous tissue- Which is also known as the hypodermis is the innermost layer of skin.
It's made up of fat and connective tissues that house larger blood vessels and nerves, and
it acts as an insulator to help regulate body temperature.

Hair follicle- Is a hair by packing old cells together. Attached inside the top of the follicle
are sebaceous glands, which are tiny sebum-producing glands in almost all skin except on
the palms, lips and soles of the feet.
Hair shaft- It is made of a protein called keratin, compacted and fused together. It is made
of a protein called keratin, compacted and fused together.

Oil gland- Are usually attached to hair follicles and release a fatty substance, sebum, into
the follicular duct and thence to the surface of the skin.

Body tissue- Containing stored fat that serves as a source of energy; it also cushions and
insulates vital organs.

VII. SURGICAL MANAGEMENT

SURGICAL (INVASIVE OR IDEAL (Book) ACTUAL (Done or Not Done)


NON INVASIVE)
Cesarian Session and Cesarian session is a surgical A surgical procedure that
insertion of Intra-Uterine procedure that cut above helps the mother on
Device(IUD) mons pubis of the mother. It giving birth by giving a cut
well help the mother who to the lower abdomen
suffers from any diseases part of the mother.
that can affect her giving
birth to her baby. Insertion
of IUD will cover the cervix to
avoid from being in pregnant.

VIII. OUTLINE OF NURSING MANAGEMENT

GOAL Focus Nursing Interventions


Health Promotion Maintain current Provide information on how to eat more healthy
health status meals. Give a possible exercise plan to help client
maintain healthy body weight.
Disease Prevention Help prevent Provide health teaching on low sodium foods and
infection and meals that benefit hypertension. Give proper hygiene
complications and washing techniques to control infection.
due to
Hypertension

Curative Cure any Provide health teaching on proper diet and exercise,.
problems
resulting from
pregnancy.

Rehabilitation Recover from Give health teaching about how to recover from
Postpartum previous pregnancy. Give tips on what to eat for an
problems. effective recovery

IX. PATHOPHYSIOLOGY OF THE DISEASE

Non-modifiable factors: Modifiable factors:

 Genetics/Hereditary  High altitude exposure


 Patients with CHF  Illicit drug use or drug
 Leaking, Narrowed, or overdose
damaged heart valves  Near drowning

Pulmonary Congestion

Caused by excess fluid in the lungs

This fluid collects in the numerous


air sacs in the lungs

Making it difficult to breath

Wheezing Shortness of Swelling in the Irregular, rapid


breath when lower part of the heartbeat
physically body
active
Non-modifiable factors: Modifiable factors:

 Living in crowded or  Residing in a long-term care


unsanitary conditions facility
 Participating in contact
sports
 Being hospitalized

Methicillin-resistant Staphylococcus
aureus (MRSA) Infection

Caused by a type of staph bacteria

Bacteria that has become resistant


to many of the antibiotics used to
treat ordinary staph infections

Red, Swollen, Tender Wound that are slow to Boils or abscesses (pus
skin heal or show signs of filled areas)
infection
CEBU INSTITUTE OF TECHNOLOGY
UNIVERSITY
COLLEGE OF NURSING
N. Bacalso Avenue, Cebu City 6000, Philippines

Submitted by:
Dave Carl D. dela Cerna
Dave Arong
Gretel Abapo
BuenAlgono
Aela Montenegro
Christine Sumalinog
Jude Labajo
ErvieParinasan
Harvey Mata
BSN2 -Section N2 (Group 2)

Submitted to:

MarnellieObeso, RN, MAN


Clinical Instructor

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