Don Mariano Marcos Memorial State University

South La Union Campus

COLLEGE OF COMMUNITY HEALTH AND ALLIED MEDICAL SCIENCES
Agoo, La Union
Tel. 072.682.0663/[Link]
Embracing World Class Standards NURSING DEPARTMENT Care to learn, Learn to care

Name: DIANNE D, VILLANUEVA Program and Course: BSN IV

CASE 3
TASK 1:
Use a safe work practices to protect yourself and limit the spread of infection
 Ensure health care worker hydrated
 Tie hair back
 Remove jewelries
 Check PPE in a correct size is available
 Keep hands away from face and PPE being worn
 Limit surfaces touched in the patient environment
 Always clean hands

PROPER DONNING OF PPE

1
Hand Hygiene

2
Put on the long-sleeved fluid
repellent disposable gown – fasten
neck ties and waist ties.

3
Respirator
This must be the respirator that you have been fit
tested to use. Where googles or safety spectacles
are to be worn with the respirator, these must be
worn during the fit test to ensure compatibility.
Position the upper straps on the crown of your
head, above the ears and the lower strap at the
nape of the neck. Ensure that the respirator is flat
against your cheeks. With both hands mould the
nose piece from the bridge of the nose firmly
pressing down both sides of the nose with your
fingers until you have a good facial fit. If a good fit
cannot be achieved DO NOT PROCEED. Perform a fit check. The technique for this will
differ between different makes of respirator. Instructions for the correct technique are
provided by manufacturers and should be followed for fit checking.

4
Eye Protection
Place over face and eyes and adjust the headband to fit.

5
Gloves
Select according to hand size. Ensure cuff of coverall is covered by the cuff of the glove.
TASK 2:
GENERAL APPEARANCE
 The patient is conscious, but disoriented to date and place.
 Patient was diaphoretic, weak and pale looking.
 Patient is in increasing restless.
 The patient’s vital signs are 02sat-90%, rr-23cpm, and BP-140/90mmhg.
 The patient has no obvious physical deformities or abnormalities.
 Physically, the patient’s nutritional status and body built/stature is appropriate to his age.
 The patient physically looks clean and neat.

CEPHALOCAUDAL PHYSICAL ASSESSMENT

 SKIN
The client’s skin is uniform in color, unblemished and no presence of any foul odor. He has a
good skin turgor. There is a noted beginning cyanosis on fingernails on hands.
 HEAD AND FACE
The head of the client is rounded, normocephalic and symmetrical. There are no nodules or
masses and depressions when palpated. The hair of the client is thick, silky hair is evenly
distributed and has a variable amount of body hair. There are also no signs of infection and
infestation observed. The patient has symmetric facial movements.
 EYE
The patient’s eyebrows have evenly distributed hair, symmetrically aligned, and has equal
movement. The conjunctiva is transparent, capillaries sometimes evident, and sclera appears
white and clear. The cornea is transparent, shiny and smooth, details of iris are visible. The iris is
brown, flat and round. The patient’s visual acuity is normal with spontaneous eye opening, both
pupils at 2 mm equally reactive to light.
 EAR
The auricles are symmetrical and has the same color with his facial skin. The auricles are aligned
with the outer canthus of eye. When palpating for the texture, the auricles are mobile, firm and
not tender. The pinna recoils when folded.
 NOSE
The patient has no tenderness on sinuses. The patient has nasal flaring with the use of
sternocleidomastoid muscle during inspiration with slight jugular vein distention. No bone and
cartilage deviation noted on palpation.
 MOUTH AND THROAT
The patient’s buccal mucosa is uniformly pink in color, moist, smooth, soft, glistening and elastic
in texture, and has no lesions. Teeth are white to yellowish in color, gums are pink, moist, firm,
has no retraction and bleeding of gums. Tongue is pink, has thin whitish color. Uvula is
positioned in the midline of soft palate. The tonsils are pink in color, and have no discharges.
 NECK
The neck muscles are equal in size. The trachea is on central placement in the midline of the
neck, spaces are equal on both sides. The thyroid gland is not visible in inspection, gland ascends
during swallowing, no masses palpated.
 LUNGS / CHEST
Patient has equal chest expansion on both fields, with no bruising or redness on both chest
walls. Upon palpation, there is no noted nodules, areas of tenderness or deformity in the chest.
Upon percussion, there is normal chest vibrations with equal diaphragmatic excursions. On
auscultation, patient has unequal breath sounds, there is decreased breath sounds on the right
lung parenchyma more on basal region, (+) basal crackles on right lung and wheezing on both
lung fields.
 HEART
The patient’s heart has no palpable pulsation over the aortic, pulmonic, and mitral valves, no
noted abnormal heaves, and thrills felt over the apex, and no abnormal heart sounds is heard
like murmurs.
 ABDOMEN
The patient’s abdomen skin color is uniform, no lesions, have scar, flat, rounded, no tenderness
noted, with smooth and consistent tension, and has no muscle guarding.
 UPPER EXTREMITIES
 Both extremities are equal in size, have the same contour with prominences of joints, no
involuntary movements, no edema, color is even, temperature is warm and even, has equal
contraction and even, can perform complete range of motion, no crepitus noted on joints, and
can counter act gravity and resistance on ROM.
 LOWER EXTREMITIES
Both extremities are equal in size, have the same contour with prominences of joints, no
involuntary movements, no edema, color is even, temperature is warm and even, has equal
contraction and even, can perform complete range of motion, no crepitus noted on joints, and
can counter act gravity and resistance on ROM.
 MUSCULOSKELETAL
The patient’s muscles are bilaterally symmetric, has no contractures and tremors, normal
muscle tension, adequate strength of the muscle. The bones are uniform in structure, no
deformities, tenderness or edema. Joints are not tender, has smooth movement and no
nodules.

TASK 3:

Date/Shift/Time FOCUS D-DATA A-ACTION R-RESPONSE SIGNATURE

12/01/20 Ineffective breathing pattern D> Admitted patient in RICU-COVID
7-3 related to COPD as ICU with secured consent for
manifested by nasal flaring, admission. Informed AMD, hooked to
pale and weak looking, cardiac monitor, hooked to nasal
cyanotic nailbeds, shallow cannula @2LPM with onset IVF of
breathing and RR of 22 cpm PNSS 1L strictly KVO rate. Patient was
diaphoretic, weak and pale looking.
Patient follows command, but
disoriented to date and place. Patient
has with spontaneous eye opening,
both pupils at 2mm equally reactive to
light. Beginning cyanosis on fingernails
on hands noted. Patient has nasal
flaring with the use of
sternocleidomastoid muscle during
inspiration with slight jugular vein
distention upon inspection. No cough
noted. Has equal chest expansion on
both fields, with no bruising or redness
on both chest walls. No noted nodules,
areas of tenderness or deformity in
the chest upon palpation. Normal
chest vibrations with equal
diaphragmatic excursions upon
percussion. Has unequal breath
sounds, decreased breath sounds on
the right lung parenchyma more on
basal region, (+) basal crackles on right
lung and wheezing on both lung fields
upon palpation. Vital signs taken: T-
37.8⁰C, cr-130(sinus rhythm), rr-
22cpm, 02sat-80%, bp-160/100mmhg.
A>Monitored vital signs. Auscultated
breath sounds noting crackles,
wheezes and rhonci. Elevated head of
the bed for about 30 degrees.
Assessed for concomitant pain or
discomfort. Encouraged position of
comfort. Encouraged deep breathing
exercise. Encouraged use of adjuncts
such as incentive spirometer. Kept
environmental pollution to a
minimum. Monitored respiratory
patterns including rate, depth and
effort. Gave supplemental oxygen as
order and prescribed respiratory
medications. Obtained blood specimen
for arterial blood gas.
R>The patient exhibits less difficulty of
breathing.

DIANNE D. VILLANUEVA
SN DMMMSU