A Case Study
Chronic Obstructive Pulmonary Disease
In Partial Fulfillment of the Requirements for the degree
Master of Arts in Nursing
Major in Medical-Surgical Nursing
Prof. Regie B. Tumala
Aiceledne M. Else
Age: 3 years & 8 months
Date of birth: May 2, 2005
Existing Diagnosis: Acute Glomerulonephritis, Post infection Past Medical History:
Mother claimed that it’s DR’s 3rd hospitalization: first, was last 2008 for a diagnosis of Dengue; second was last February 16, 2009 for a kidney infection and presently for his condition of Acute Glomerulonephritis.
* Hepatitis B – 3x (complete)
* DPT – 3x (complete)
* BCG – complete
* OPV – complete
* Measles- complete
Habits and Lifestyles:
Personal Habits: Takes a bath daily, brushes his teeth once a day after breakfast, and likes to bite his nails.
Diet: Eats three times a day with dried fish and rice as the main course. He also likes to eat pork if available as claimed by mother. He loves to eat junk foods and softdrinks often.
Sleep/rest patterns: Sleeps 8-10 hours a day.
Recreation/hobbies: Plays with his friends and cousins, often watches TV
Patient lives with her grandmother and mother as a single parent. He regularly plays with her cousins who live in the same place. He stays indoors most of the time being cared for by mother or grandmother.
History of Present Illness:
Patient was admitted last February 16, 2009 due to a kidney infection and discharged on February 21, 2009 with home medications of Cotrimoxazole and Phenoxymethyl and Multivitamins. Mother claimed she forgot how often the medicines were given. 1 day PTA had low grade fever with edema on face. Mother noticed the edema but took the child’s condition for granted thinking that it was just an allergic reaction to some foods he might have eaten. He was made to take paracetamol. Several hours PTA, had high grade fever and puffiness of the face and both lower extremities. The patient’s condition was then associated with a tea-colored urine, thus, mother decided to seek medical consultation.
FAMILY HISTORY WITH GENOGRAM:
The patient has a familial history of hypertension and heart disease. + ER
GORDON’S FUCTIONAL HEALTH PATTERN with remarks:
HEALTH PERCEPTION- HEALTH MANAGEMENT PATTERN
Mr. R.M. defined health or being healthy as “ being in the best overall condition a person can be”. With his disease condition his food is prepared for him mainly consisting of rice, fish or meat and vegetables in small portions because he gets tired easily even from eating. He takes bronchodilators and anti-hypertensive medications for his blood pressure, he also has an oxygen tank near him at all times. Although diagnosed with COPD and hospitalized twice for the condition, he still smokes a few sticks a day. Asked why he continues with this habit, he verbalized “naa na man ni, nya maglisod na man ko undang. Tiguwang na bitaw ko, mamatay lang gihapon ko sooner or later”. Remark: Risk for infection related to chronic disease and insufficient knowledge
NUTRITIONAL- METABOLIC PATTERN
The patient eats 3 times a day prepared for him. He eats rice, sea foods or meat and vegetable but only in small quantities because he tires easily even in this basic activity. He also asks for fruits and fruit juices from time to time. When he gets hungry between meals he is served with sandwiches or arozcaldo, but only eats a few bites or spoons. He does not like to eat junk foods or soft drinks. He does like to drink coffee and water throughout the day. Although he has been eating as much as he could, he is still losing weight. Remark: Imbalanced...
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