Age: 74Civil Status: Single Birthday 04/8/1940Birthplace: Bauko Mountain ProvinceAddress: Crystal Cave Baguio cityNationality: FilipinoReligion: Roman CatholicDate of admission: 03 24 2015Admitting Physician: Dr,Sofia BlackDiagnosis:

2.Health History1.Chief Complaint Nahihirapan akong huminga at matagal na itong ubo ko

2. History of Present Illness: The patient was apparently well until 2 days PTA ,patient had a productive cough ,felt throughout the day,greenish ,non blood tinged ,thick with noted chest pains and 2 pillows orthopnea but no fever,no body weakness and joint pains.No medication and no consultation was done.The condition persisted until few hours PTA,patient was still couhing and with noted chest discomfort.Patient also complained of on and off knee pains,precipitated by movement and relieved by rest .These prompted patient for consultation. 3. History of Past IllnessA.Past History : The patient has a diagnosed history of PTB in 2007 with medications taken and Hepatitis B. The patient has no history of hypertension,Diabetes Mellitus ,bronchial asthma ,heart disease and stroke.The patient has no known food and drug allergies and no previous surgical interventions done.

B.Family History The patient has no family history of hypertension,diabetes mellitus ,heart disease ,stroke ,bronchial asthma ,PTB and cancer

C.Social and Environmental History the patient previously works as a private miner for 35 years.the patient is a smoker for 50 pack years and an occasional alcoholic beverage drinker .he is living in a well ventilated and non congested environment with his family.they have a good interpersonal relationship.Water is obtained from a nearest water refilling station.The water for domestic use is from water district.the patient has pets and stayed out the house.toilet is flushed type.. Generativity vs Stagnation Maturity (35-45 yrs old)

A person may experience midlife crisis between the ages of 35-45 years old, the deadline decade. This occurs when the individual recognizes that he has reached the halfway mark of life and according to Erik Erikson, the developmental task of the middle-aged adult is Generativity vs. Stagnation.As to our patient, who belongs to a middle age group and is suffering from a life-threatening condition, he had experienced this developmental crisis, which led him to be non-productive.Being non-productive led him to be stagnant after the occurrence and diagnosis of his disease which made him to be dependent with his family, he cant attend, function and be able to accomplish his responsibilities as a father, a husband and as part of the community.

PROBLEM PRIORITIZATIONLIST OF PRIORITIZED PROBLEMS1. 23. 4. 5. 6

PRIORITIZATION OF PROBLEMS:ProblemJustification

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Laboratory TestDiagnostic/ Laboratory ProceduresIndication orPurposeResultsNormal ValuesAnalysis and Interpretation of results

Complete Blood Count (CBC)

WBC count

-Measures the number of WBCs in a cubic mm of blood.-It is used to detect infection or inflammation and to monitor clients response to or adverse effects of chemotherapy or radiation therapy.

11.7 x 10g/L

5-10 x 10 g/L

The result is slightly above the normal range which may signify infection.

Lymphocytes

-To determine immune function, provides a gross measure in nutritional status.0.21

0.20 - 0.40

The result is within the normal range.

Eosinophils

-To fight infection and control mechanism associated with allergies and asthma. 0.01

0.01 - 0.06

The result is within the normal range.

Hemoglobin

-To evaluate the hemoglobin content (iron status and O2 carrying capacity) of erythrocytes by measuring the no. of grams of hemoglobin /dl of blood.107g/L

140 - 180 g/LThe result is below the normal range which indicates anemia.

Hematocrit- Measures the volume of RBCs in whole blood expressed as a percentage.- It is also a useful in the diagnosis of anemia, polycythemia, and abnormal hydration states.-Value is roughly three times the hemoglobin concentration.0.320.40 0.54The result is below the normal range which indicates anemia.

Diagnostic/ Laboratory ProceduresDate OrderedDate results INIndication orPurposeResultsNormal ValuesAnalysis and Interpretation of results

Random Blood Sugar 11/17/09

To measure blood glucose regardless of when you last ate.

145.3 mg/dl< 140 mg/dlThe result is above the normal range which indicates too little insulin/ diabetes mellitus.

Diagnostic/ Laboratory ProceduresDate OrderedDate results INIndication orPurposeResultsNormal ValuesAnalysis and Interpretation of results

Kidney Function Test

Createnine11/17/09

To monitor renal function, specifically the ability of the kidney to excrete waste products

3.7 mg/dl

0.4-1.4 mg/dl

Creatinine level is above the normal range which indicates kidney impairment.

Diagnostic/ Laboratory ProceduresDate OrderedDate results INIndication orPurposeResultsNormal ValuesAnalysis and Interpretation of results

Serum Electrolytes

Sodium (Na)

11/17/09

To reflect water balance.

135.2 mmol/L

137 145 mmol/L

The result is below the normal range which indicates that there is a relative increase in the amount of body water relative to sodium.

Potassium (K)

To evaluate fluid and electrolyte balances and identify renal dysfunction. Potassium is critical to neuromuscular function, specifically skeletal and cardiac muscle activity.3.6 mmol/L

3.6 5.0 mmol/L

The result is within the normal level which indicates normal osmotic pressure and cardiac and neuromuscular electrical conduction.

Chloride (Cl)

It reflects a change in the dilution or concentration of the ECF and does so in direct proportion to sodium concentration.97 mmol/L

96 110 mmol/LThe result is within the normal range which indicates normal balance of fluids.

Sources:Johnson, Joyce Young Medical- Surgical Nursing 10th Edition

Kluwer, Wolters Nursing 2008 Drug Handbook. Philippines: Lippincott Williams and Wilkins

Peckenpaugh, Nancy J. Nutrition Essentials and Diet Therapy. Singapore: W.b Sauders Company, 2007

Doenges, Marilynn E, et al. Nurses Pocket Guide. Philadelphia: F.A Davis Company

www. wikipedia. com

www.medlineplus.com