Last August 18, 2008, a group of students with eleven members were assigned toMrs. Aura Venus B. Ramos at Los Baños Doctor’s Hospital and Medical Center to completetheir affiliation and to gain lots of new knowledge, and develop their skills and passion on thefield of nursing.Each members of the group were required to submit an individual nursing case study.We have our orientation on the first day of duty and were told that being assigned on themain ward we must expect that each of us will have at least 2 patients everyday.What interests me to take Mr. RR’s case to be studied is that I handled him almost for the whole week of my duty. I think, I already established a good nurse-patient relationshipwith this patient and because of that it’ll be easier for me to ask information needed for mycase study.Another thing is that he’s always alone in his room. Nobody among the members of his family is there to take care of him and assist him while staying at the hospital. Throughtaking him as my case study, I can have the reason to stay longer with him and take care of him.And lastly, it is my first time to handle a patient with bronchopneumonia. This is mychance to gain new information related to geriatric nursing. I’m aiming to be a geriatric nurse,hoping to be suitable and deserving to be a nurse with the specialty of taking care of elderly,and I’m thankful that almost all my patient, even before, we’re old aged.Bronchopneumonia is a classification of Pneumonia according to its distribution of inflammation. Pneumonia is the leading cause of morbidity in the Philippines as of year 2004and the 5
leading cause of mortality in the Philippines as of year 2004 among male andfemale, and among all ages.
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I.PATIENT ASSESSMENT DATA BASEA.GENERAL DATA
1.Patient’s Name: K. I.2.Address: Sison, Pangasinan3.Age: 1 y/o & 1 mo.4.Sex: Female5.Birth Date: July 18, 20086.Rank in the Family: 1
child7.Nationality: Filipino8.Civil Status: Single (child)9.Date of Admission: August 30, 200910.Order of Admission:> Please admit order re service of Dr. Callanta> secure consent> I & O every shift & record> Monitor VS q 4° & record> DAT with SAP> Dx with CBC, CXR> IVF D
0.3 NaCl 500cc X 37-38 ugtts/min> Cefuroxime 250mg IVP q 8° ANST (-)> Pediatapp drops 1ml TID> Salbutamol + Ipratopium ½ neb q 6°> Paracetamol drops 100mg/ml 1ml q 4° prn for fever> E-zinc drops 1ml OD> refer accordingly11.Attending Physician: Dr. Callanta, MD
Cough and difficulty of breathing for one week, feverfor three days prior to admission
C.HISTORY OF PRESENT ILLNESS
One week prior to admission, K. O. had positive signsand symptoms of cough and yellowish phlegm followed withfever, three days before admission. Her mother knowing thatthese signs and symptoms were just the usual cough that herdaughter had, she gave her carbocisteine drops for her coughand paracetamol drops for her fever. However, she noticed nochanges so she decided to bring her to Pozorrubio MunicipalHospital. She was diagnosed of Pneumonia and because of theseverity of the condition, she was admitted. She was giveninitial medications and has had her for further observationsand laboratory exams.