I. ASSESSMENT a. General Data Patient’s Initials:

I. ASSESSMENT

A. General Data

Patient’s Initials: C.L. Sex: MaleAddress: Paranaque CityAge: 74 years old Civil status: Married# of Days in this Hospital: 6 days Occupation: Retired Production

SupervisorDate of Birth: January 27, 1934 Place of Birth: ManilaDate of Admission: January 11, 2009; 2300 H Order of Admission: Via

StretcherInformant: C.L. (Patient) Date of History: January 17, 2009

B. Chief Complaint:

Pressing Pain localized on the substernal part of the chest with a scale of

7/10, 10 being the worst pain, precipitated by physical exertion which is driving. The

chest pain is accompanied by difficulty of breathing of 30 minutes duration before

admission.

C. History of Present Illness:

Four years prior to confinement, the patient was diagnosed of Type II

Diabetes Mellitus and Hypertension simultaneously in his hospitalization during that

year. He was then prescribed with the following medications: Metformin and Inderal.

Adherence to a diet of low fat and low salt was also advised by his physician.

Two years prior to confinement, January 2007, the patient underwent an

operation in which 2 digits of his left foot were amputated due to gangrene

formation secondary to Diabetes Mellitus. During discharge, he was prescribed with

an insulin injection of once a day before dinner.

3 months prior to confinement, October 2008, the patient was admitted to

the Asian Hospital due to chest pain. He was subsequently diagnosed of Acute

Myocardial Infarction secondary to Coronary Artery Disease. At the same, he was

also diagnosed of Congestive Heart Failure with Pulmonary Congestion. He was

recommended by his doctor for a Coronary Angioplasty which he refused to undergo

because of financial constraints. After seven days of confinement, he was

discharged with medication prescriptions of the following:

Amlodipine 10 mg x 1 tablet OD-AM Furosemide 40 mg x 1 tablet OD-AM

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Spironolactone 25 mg x ½ tablet OD-AM Isosorbide Mononitrate 60 mg x ½ tablet BID Clopidogrel 25 mg x 1 tab OD-AM Aspirin 80 mg x 1 tab OD-After Lunch Carvedilol 25 mg x ½ tab BID Ketosteril 600 mg x 1 tab TID Simvastatin 40 mg x ½ tab OD-HS Telmisartan 80 mg x 1 tab OD-PM Betahistine 1 tab PRN x 3 days Insulin – Novomix 18 u before breakfast; 22 u before supper Iberet 500 mg x 1 tab OD-AM Isordil 5 mg 1 tab PRN SL for Chest Pain

In addition, he was advised to strictly adhere to his low salt and low fat diet. From

then on, the patient continued to experience episodes of chest pain of at least twice

every month which he managed by taking Isordil as prescribed. These episodes

were usually precipitated by physical exertion such as driving and walking.

12 hours prior to admission, the patient and his wife attended their Sunday

church activity which lasted for 2 hours. He drove for 1 ½ hour from Manila to

Paranaque. When they reached their house, he rested for 3 hours. Afterwards, they

prepared to attend a party held in Manila. The event ended at around 10:00 in the

evening. He started to feel difficulty of breathing and mild chest pain of 3/10

intensity. Since his wife doesn’t know how to drive, he was left with no choice but to

endure the pain while driving.

Thirty minutes prior to admission, while the patient was still driving, he took

Isordil 5 mg due to worsening of pain (scale of 7/10). The patient also persisted.

These symptoms prompted him to seek consultation to the nearest hospital

available. Upon arrival to Medical Center Paranaque, the patient suddenly collapsed

on the Emergency Room Floor; hence, admission.

D. Past History

1. Childhood Illness: Patient was unable to recall.

2. Adult Illness: Type 2 Diabetes Mellitus (2005); Hypertension (2005);

Myocardial Infarction (2008); Congestive Heart Failure (2008); Coronary

Artery Disease (2008)

3. Immunization: Patient was unable to recall.

4. Previous Hospitalization: Medical Center Paranaque due to HPN and

DM (2005); Medical Center Paranaque due to gangrenous toes (January

2007); Asian Hospital due to Myocardial Infarction (2008)

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5. Operations: Amputation of the first and second digit of the left foot

(Medical Center Paranaque; January 2007)

6. Injuries: None.

7. Medications Taken Prior to Confinement:

October 2008:

Amlodipine 10 mg x 1 tablet OD-AM

Furosemide 40 mg x 1 tablet OD-AM

Spirinolactone 25 mg x ½ tablet OD-AM

Isosorbide Mononitrate 60 mg x ½ tablet BID

Clopidogrel 25 mg x 1 tab OD-AM

Aspirin 80 mg x 1 tab OD-After Lunch

Carvedilol 25 mg x ½ tab BID

Ketosteril 600 mg x 1 tab TID

Simvastatin 40 mg x ½ tab OD-HS

Telmisartan 80 mg x 1 tab OD-PM

Betahistine 1 tab PRN x 3 days

Insulin – Novomix 18 u before breakfast; 22 u before supper

Iberet 500 mg x 1 tab OD-AM

Isordil 5 mg 1 tab PRN SL for Chest Pain

8. Allergies: No Allergies to any substances on food and drugs.

E. Gordon’s Eleven Functional Health Patterns

1. Health Perception- Health Management Pattern

The patient used to have a positive perception of his health status until

he was diagnosed to have Type II Diabetes Mellitus and Hypertension in

2005. According to the patient, he never absents himself from work because

his body is always in good condition and he seldom gets sick. The patient

actually expected that he would have Diabetes because of the fact that both

of his parents died due to the said condition. In addition to that, the deaths of

his three siblings were related to the complications of Diabetes that they

have developed. The patient verbalized that he understands the strong

familial tendency of Diabetes. His hypertension, on the other hand, has been

caused by his lifestyle which includes a diet high in fat and salt content

coupled with his vice of smoking 2 packs of cigarette everyday which started

when he was still 15 years old and continued until he was 45. When the

patient was discharged from the hospital, he was advised to make lifestyle

modifications particularly on his diet. However, he was not able to adhere to

a diet restricted in Salt, Fat and Carbohydrate content. He explained the main

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reason for this; he believes that he should not limit himself when it comes to

enjoying life, for when the time comes that he is already dead, he can no

longer eat his favorite foods. He was also prescribed with Metformin and

Inderal. The patient is very consistent when it comes to medication regimen.

He unfailingly takes these drugs everyday, as prescribed. He monitors his

Capillary Blood Sugar every other day. He even drinked the herbal tea

Charantia to help improve his condition but he eventually stopped drinking it

because he has noted no change with himself. Moreover, he was advised to

have regular check up with his doctor but he was not able to follow this as he

goes to his doctor only if there is something wrong with regards to the

physical aspect of his health. The patient recalled that the usual readings of

his blood pressure were mostly high, he remembered the highest reading in

particular which is 170/100 mmHg during one of his check up. In 2007, the

patient underwent amputation of the 1st and 2nd digit of his left foot.

According to him, he was not informed of the importance of foot care when

he was diagnosed of Diabetes. He even added that he did not know that he

will experience decreased sensation on his foot. As a result he did not initiate

measures to be more careful with the shoes he is wearing or be more

cautious to avoid being wounded. His doctor prescribed a daily single dose

insulin injection for him. He consistently receives insulin everyday. His son is

the one administering the insulin because the patient is afraid to inject the

needle of the syringe to his abdomen. In 2008, the patient was admitted at

the Asian Hospital and was diagnosed to have experienced Acute Myocardial

Infarction due to Coronary Artery Disease. He was also found to have

Congestive Heart Failure. According to the patient, his lungs were already

congested with fluid, as explained by his doctor. The same doctor

recommended that the patient undergo Coronary Angioplasty, however he

refused the procedure because he does not want to leave financial burden to

his family when he dies. Besides, he believes that death is inevitable so

spending much to delay it is not a wise decision. The patient continued with

his inconsistency to his diet, he still eats the prohibited foods without

moderation. But he takes the new prescribed medications for him without any

interruptions.

Presently, the patient is admitted to the hospital because of complains

of difficulty of breathing and chest pain. He now perceives his health to be

unstable. He elaborated this word by saying that he can die because of his

condition any moment now. However, the patient still holds his beliefs when

it comes to eating. He still does not have any plans of following his diet

religiously. He still does not want to undergo Coronary Angioplasty. But he

said he will continue with his medication regimen.

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2. Nutritional- Metabolic Pattern

When the patient was diagnosed to have Diabetes, he was ordered to

follow a diet Restricted in carbohydrates. He enumerated the foods and

drinks that he was not allowed to consume liberally, and these are cakes, ice

cream, fruits, sodas, chocolates, even rice and other sugar containing

desserts such as his favorite leche flan. Because he already expected that he

will have Diabetes, it was not a surprise to him that these restrictions that

some of his family members have experienced will also apply to him.

However, even at the very beginning, he does not want to control himself too

much with the food that he wants to eat. He still eats cake and his favorite

leche flan, he still drinks soda. In addition to the Diabetic Diet that he has to

follow, he was also ordered to have a Low Salt- Low Fat diet after being

diagnosed of Hypertension and eventually Coronary Artery Disease and

Congestive Heart Failure. His wife is the one preparing their meals at home

and they usually argue when she prepares dishes that is bland because of not

adding salt and other seasonings. He complains when his wife serves Milk

Fish, because he already wants to throw up even at the mere sight of the said

fish that he is asked to eat most of the time. The patient is not fond of eating

vegetables. He is not contented with the matchbox size meat that he is

allowed to eat, so he consumes more than this amount. As for his fluid

intake, he is able to drink approximately 1500 ml of water everyday.

However, after his hospitalization in 2008, he was placed on a fluid restriction

of 1000 ml per day and he follows this by measuring his intake for the whole

day. He does not usually drink coffee.

Presently, the patient is about to be discharged from the hospital

where he stayed for 6 days. During his entire confinement, he was under a

LSLF- DM diet. He said that the dietary department serves food that does not

have any taste. He further complained that his tray sometimes includes foods

that are not allowed for him such as meat, fruits, and soft drinks. As a result,

he just eats these foods. His intake and output was monitored strictly during

his hospital stay, making sure that he does not exceed a liter of water a day.

The patient does not have difficulty with his fluid restriction. He verbalized

that once he goes home, he would probably continue eating the foods that

are prohibited.

3. Elimination Pattern

Before hospitalization, the patient does not have any problem with

defecation and urination. He considers his defecation pattern of once every

other day as normal. Its characteristics include formed to hard consistency,

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moderate amount and brownish color. There are times that he has to strain

to be able to pass stool. He perceives that the reason for this is he does not

eat much vegetable. He is able to urinate 8 to 10 times during the day which

amounts to approximately more than 2500 cc. During night time, he has to

wake around two to three time to urinate which adds around 500 ml to his

total urine output for the day. According to the patient, he started to have

increased urine output when he was diagnosed of Diabetes Mellitus in 2005.

He does not usually experience problem controlling the urge to urinate and

defecate. He even added that he does not experience any sensation of pain

when he voids.

During hospitalization, the patient experienced constipation. The

patient understands that this is due to his decreased activity because of his

ordered confinement to bed. He is advised not strain and so he was

prescribed with Lactulose 30 cc to be taken during bedtime. After taking the

said medication, the patient was able to pass stool without difficulty. The

patient was catheterized during his confinement to the hospital. It drains to

yellowish urine with an average amount of 1900 per day. The patient said

that it is very uncomfortable to have a catheter that is why he asked his

doctor to have it removed after a few days. He underwent bladder training

before the removal of the catheter. He experienced extreme pain when the

tube was removed. The patient believes that his urethra was injured that is

why he is having painful urination since then. But he explained that the pain

is gradually becoming less intense.

4. Activity- Exercise Pattern

The patient used to live an active lifestyle. As a Production Supervisor

in a well known company where he worked for roughly 40 years, most of his

time is being spent standing, monitoring the performance of the other

employees. The patient remembered that when he was still a high school

student, he is very fond of playing basketball, and he still plays basketball

during the sport fests of their office when he was still working. When he

retired from work in the year 1994, he spent most of his time in their house.

He has chickens and banana tree in the backyard that he is taking care of. He

usually walks around the subdivision in the morning. When inside the house,

he would usually spend his spare time watching television. His wife is the one

taking care of all the household chores that is why he gets to rest when he

wants. When two of the digits on his left foot were amputated in 2007, he

initially had to stay on bed because he could not walk through the pain. After

a few weeks, he eventually got used to walking with two of his toes missing

and no significant change was noted with his activity. It was after his

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hospitalization in 2008, that he started to experience a gradual decline in his

energy level and in his ability to perform his usual daily activities. He

described that he gets easily fatigued after walking for even just short

distances. He is also extra careful not to get excessively tired because he

might experience difficulty of breathing and chest pain.

During hospitalization, the patient is advised to limit his level of

activity. He complied with this order. On the day of discharge, the patient is

already able to walk around the hallway but is still experiencing fatigue after

a few steps.

5. Sleep- Rest Pattern

Before being hospitalized the patient does not have any difficulties

regarding his sleeping routine. When he goes to bed, he is able to initiate

sleep without any problem. He usually goes to sleep at around 9 in the

evening and wakes at around 5 in the morning. Although he has to get up to

urinate at night, he said that he does not usually experience difficulty getting

back to sleep. With approximately 7 hours of sleep, the patient said that he

usually feels well rested. In addition, to that the patient also said that his wife

and him are sleeping on separate rooms for almost 15 years now. For the

reason that his wife is snoring and he gets disturbed. Moreover, when his wife

listens to radio, he cannot go to sleep. In the afternoon, the patient takes a

nap for about an hour.

In the hospital, the patient felt deprived of sleep. Particularly when the

patient was bladder training, he became very cautious in monitoring whether

he already feels the urge to urinate. This occurred even when the patient is

already supposed to be sleeping at night. But the patient said that he is able

to take several naps during the day.

6. Cognitive-Perception Pattern

Before the patient was admitted to the hospital, he already had problem with

his vision. He reports that his left eye see things more blurry than his right eye.

He believes that it is because of him being diabetic that he develop vision

problem. He had with him 4 eye glasses but admits that he never wore them

for a long time now. This is because he noticed that there was no improvement

in his visual acuity. For this reason, he doesn’t anymore read small printed

materials such as news papers. He said that he prefer to watch television than

to read newspaper where he can’t even see a word due to its small print. The

patient also reported that he had problem hearing especially with his left ear,

though he is able to hear a person talking in moderate voice. Even with

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auditory problem, the patient still denies use of any hearing devices. He also

report ringing sensation inside his left ear. He even added that there are

instances that when he stand coming from a sitting or lying position, he would

feel dizzy as if his environment where circling him. Due to this reason, there

have been couple of times where he lost his balance, lucky, no accidents had

yet occurred. The patient said that due to his age, his memory is not anymore

sharp as compared before. He was still able to recall important dates and

events in his life; however, he admits that he had difficulty recalling

insignificant experiences. He said he learn quickly and was able to absorb

things really fast. He learns things easily through demonstrations and said that

he is a visual learner. The patient denies problem with communicating to other

people and said that he can speak English eloquently. He said that he had a

short attention span especially in matters that are not so important and off of

his interest. He is capable of making decision for himself and his family. When

faced with difficult problem and situations, consultation with his wife before

giving final decision is what he do to lessen possible conflict. Whenever patient

is in pain, he would always try to control the pain using his mind first, and if not

tolerable anymore, medications and consultation with the doctors will be his

last resort.

Presently, the patient still report vision and auditory problems. He is still not

using his eyeglasses and is not interested of having his eyes checked by a

doctor. He is still able to make decision especially with regards to his care and

medical treatment.

7. Self-Perception Self-Concept Pattern

The patient, despite of being a diabetic and knowing the possible

complication that may arise from the condition, remain optimistic. He never

loses hope and believes that problems come with solutions. He said that he is

contented with his life now and how his life been formed but verbalizes that if

given a chance, his life would be much happier if he never commit the

mistakes that ruin the life of his first wife and the children from his mistress.

He said that as a father, he never fail to provide his children with financial

support but fail when it comes to the emotional support and the

insurmountable happiness that comes with a complete family. He said that he

feels good about himself but he would feel better if he would be able to

reconcile with his eldest son because they have been in bad terms for a long

time now since the eldest son had believed that they were the first family, only

to find out that they are not. He believes that every thing happens for a reason

and being a man doesn’t exempt him from committing human mistakes.

Though, he verbalizes not being happy with the situation with his son,

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regretting things he had done in the past will not do good, either. The patient

perceives himself to be a family oriented person. He had strong convictions

and believes in his advocacy. Due to this reason, he is not easily influenced. He

knows himself and said that he can control his emotions well. He said that he is

a very relaxed and calm person and is not easily distracted over simple things.

He cope up with stressful events quite well.

Presently, the patient feels not good about himself because his health had

never been better, since he started to be hospitalized in 2005. However, the

patient remains to be optimistic and hopeful. He believes that it is not healthy

to think about his problems right now because it would only stress him out and

can possibly make his condition worse. He is not easily distracted and annoyed

with simple things. He is relaxed most of the time and described himself as an

assertive type of person but when it comes to medical treatment, he is just

passive about it especially when matters concerning money are involved.

8. Roles-Relationship Pattern

The patient lives in a simple house with his second wife and his 19- year- old

son with his mistress. The patient does not verbalize problems with his wife

and his youngest son but reports having a problem with his eldest. The patient

and his eldest son in his mistress had been in bad terms for a long time now

since the day the eldest son found out that they are not the first family of the

patient, and that is way back 1984. This is the only problem that the patient

admits he had difficulty in handling. As a husband, he has this perception that

he has not been so good to his previous wives except to his present wife. He

had his first wife but the wife can never bore a child because she had a

condition called “baby uterus”. And because of the patient’s desire to have

children, he looked for someone who could give him that desire. He then

submitted himself into an illicit affair where he had 3 kids with his mistress.

Both his legal wife and his mistress died of cancer. He even verbalizes how he

wished he had accepted the fact that his first wife cannot give him children and

must have been loyal to her. How he wished he had not ruin the life of this two

woman. He said that his being a father is the only thing he is proud of himself.

He had been financially supporting his 3 children and had been a responsible

father to them. However, he was not in good terms with his eldest for quite a

long time now. Up to now, they are still not in good terms, and it frustrates

him. As a friend, the patient said he is very supportive and loyal. He helps a

friend in need without expecting anything in return. He is friendly with his

neighbours and very sociable to them. He even had a habit of giving his

neighbours bananas whenever the banana tree would bear its fruits. As a

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citizen of the country, the patient believes that he is a good and responsible

one. He abides with the rules of the country.

Presently, the patient was still in bad terms with his eldest son.

Because of his current state of health, the patient believes that he is not

productive to his family like before. He also thinks that because of his recent

and frequent hospitalization, the money that should be allotted to important

things have been unwisely allotted to his care, and he feels not good about it.

At present, his wife and his youngest son took care of him in the hospital and

attend to his need. He said that his family had been very supportive and

generous in taking care of him. He had his pension with him and he had an

apartment which he let others rent and he uses it as a source of his income.

However, the patient admits that every centavos coming from them was only

spent in his medications. Right now, the patient thinks that he can’t support

the financial needs of his family.

9. Sexuality – Reproductive Pattern

The patient and his wife has not been sleeping in the same bed since 1994.

The reason for this is because his wife had a habit of listening to the radio before

sleeping and is snoring loudly to the extent that he will wake up in the middle of the

night. The patient said that he had a very satisfying sexual activity with his first 2

partner. Never did he nor his partner use any form of contraceptive because it is his

desire to have children. The patient also said that he do sexual activity not only for

the reason of pleasure but more because he wanted to have children. Though, he is

contented with his first wife in terms of copulation, he never had a very satisfying

relationship with her because he cannot accept that his wife could never give him

kids. This is the reason why he sorted for a way where he could satisfy his

frustration, this is where he had an illicit affair with his mistress. The patient never

undergoes nor is interested with any reproductive examination or consultation. He

said that he feels good about his reproductive health and that there is nothing to

worry about. Patient denies having a sexual activity with his present partner since

1994. The patient admits not being expressive with his feelings but loves his wife so

much. The patient and his wife is in good terms ever since.

Presently, the patient and his wife are still in good terms. He said that he

makes him love his wife more because of how thoughtful his wife is and how good

she had taken care of him for the past few years. He also said that he had no more

interest in any sexual activity because he thinks that he is old enough for that. He is

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still admit not being affectionate with his wife but verbalizes that she loves her very

much.

10. Coping Stress Tolerance pattern

For a long time, the patient being in bad terms with his eldest son have been

the ultimate stressor for him. He said that he loves his children so much that any

matter which involves his children stresses him. Furthermore, for the past few

years, the gradual decline of his health and complications that are arising due to his

disease condition stresses him that much. Though, compliant with the treatment

regimen, financial matters involving his care is one of his biggest problems. His

perceived inability to support his family of their need is one of the causes of his

frustrations. He said that he can cope up well on difficult situation provided that

solutions are visible. He also said that, since he believe that problems comes with

solutions, problems should not be worried too much especially that he had an

unstable health, and worrying too much would do no good for him. When face with

problems, patient would like to solve the problem first and if still unresolved despite

of the strategies he had taken on, that’s the only time he would talk to his wife to

settle things. Relaxing, in the form of listening to soft, instrumental music also help

him in time of stressful events. He said that he never consider using medication or

alcohol during stressful time. Natural way is still the best way for him. When face

with difficulties and problems in life, the patient said that solving things one by one

is most helpful and are most of the time, successful.

Presently, the patient’s recent hospitalization had been a great stressor for

him. The financial matter concerning his care frustrates him. Since he was advised

by the doctor to undergo angioplasty, the patient said that he decided not to

undergo such procedure because he doesn’t want to invest something big on it. He

said that he would just comply with the medications he was prescribed and thinks

that it is enough already to prevent complications from occurring.

11. Values Belief Pattern

Religion is very important to the patient and when difficulties arises, his faith

is His only source of strength. Being a protestant, he said that he is an active

member of his religion. He said that he is a religious person. He attends mass every

Sunday and Christian holidays and he participates in church activities. Despite of

the things he experienced with his life, the patient said that he knows that God

wants everything to happen and that he had a purpose for doing so. He said that he

is a man of integrity and honesty. He works hard and the values of fair-play,

perseverance and dedication are the things he holds on into his character and the

things he wants his children to learn from him. He said that generally, he did get the

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things he wants in life. But his being contented with what life present to him made

him want no more. His children are his treasures. He loves his children so much that

he wants nothing but success and blessing to them. He said that he had one

important plan for the future and that is to be reconciled with his eldest son. He said

that when that’s happened, he can die peacefully without regrets.

Presently, the patient verbalizes that the sole source of his strength is his

faith in the Lord and his children. He had given all his trust on Him and had offered

his life to whatever His plans. Despite of his present conditions, patient remains

hopeful and optimistic. He even said that nothing will happen and there is nothing

to worry about. One of his most important plans are to reconciled with his eldest

son and completely adhere to his treatment regimen so that possible complication

will least occur.

F. Family Assessment

Name Relation Age Sex Occupation Educational Attainment

L.C. Patient 74 y/o Male Retired College Graduate

R.C. Wife 70 y/o Female Housewife High School Graduate

M.C. Son 19 y/o Male Student High School Graduate

I.G. Employee 23 y/o Female House Helper High School Graduate

G. Heredo- Familial Illness

1. Maternal: Diabetes Mellitus, Hypertension 2. Paternal: Diabetes Mellitus, Kidney disease

H. Developmental History

Theory/ Theorist

Age TaskPatient Description

Psychosocial theory

Eric Erikson

74 years old

Integrity VS. Despair

The patient is more on despair. Though, the fact that he was able to support his family, send his children to college and provide them with all their basic needs which is for him his greatest dream, he still seem to regret all those mistakes he had done to his family, especially to his eldest son (they’re still not in good terms until now). There was also a part of the patient that suggests him to have achieved integrity which is his verbalization of contentment and satisfaction to life and was even ready (according to

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him) to face death itself.

He has a very good relationship with his neighbours and relatives. He believes that he has been a good father to his children but not a perfect husband to his wife.

The patient was able to adapt to changes in lifestyle as he ages and still was independent in performing his ADLs such as eating, toileting, bathing and ambulating.

Psychosexual theory

Sigmund Freud

74 years old

Genital stage The patient has fathered 3 children (all boys). He was able to build his own family and raise them on his own while providing all their basic

needs and sending them to school at the same time.

Although there is already no sexual activity between his wife for a long

time now, their intimacy shows their strong tie with each other and love

seems to endure after years. Even if both of them are not expressive with

their feelings with each other, the patient said that he appreciates how his wife takes care of him. For him, that’s one way of showing how they

love each other.

Cognitive theory

Jean Piaget

74 years old

Formal operational

phase

The patient experiences gradual decline in his cognitive function.

He has hearing difficulties and vision problems which were then validated

during the interview. He used to wear reading glasses before but he stopped when he noticed it doesn’t

help his vision even a bit. He doesn’t use any hearing aids. According to

him, he experiences memory changes; he’s sometimes having a

hard time recalling things.

The patient respects the decision and opinions of others because he believes that each is entitled to his

own opinion.

Moral theoryLawrence Kohlberg

74 years old

Level III- Post conventional

Stage6 Universal

ethical principle orientations.

According to the patient, before making a major decision he first

outweighs the benefits and disadvantages of his decision. He

based his decision on his own evaluation and standard of what is

right.

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The patient believes what you do to other people is what other people

will do to you.

Furthermore, he is not the type of person who simply complies with the

rules of majority, if he thinks it is unnecessary.

Spiritual theoryJames Fowler

74 years old

Universalizing The patient is a religious person. He never missed a single church activity every Sundays (that is

before his confinement).

Even when his children were still young and staying with him, they

used to attend the mass every Sunday which then serves as their

family bonding moments.

Despite of the things he experienced with his life, the patient said that he knows that God wants everything to happen and that he had a purpose for doing so. He said that he is a man of integrity and honesty. He works hard and the values of fair-play, perseverance and dedication are the things he holds on into his character and the things he wants

his children to learn from him

I. Physical Examination

Date: January 15, 2009

Time: 0800 H

Height : 168 cm

Actual Weight: 65 kg

Ideal Body Weight: 61 kg

Vital Signs

Temp: 36.4 ºC

PR: 68 beats per minute

HR: 70 beats per minute

RR: 22 breaths per minute

BP: 130/80 mmHg

Regional Examination

A. Skin:

I:

Fair colored skin

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Superficial blood vessels are visible in hands and feet

Absence of lesions

P:

Dry skin

Warm to touch

Poor skin turgor

B. Nails:

I:

Transparent, well-rounded and convex

Fingernails are clean and short

Blackened toenails

Cuticles of the fingernails are intact without inflammation

Fingernail beds are pale

P:

Smooth fingernails

Rough toenails

Firmly attached to nail bed

Capillary refill= 5 seconds

C. Head and Face:

I:

Normocephalic and positioned on the midline

Proportion to gross body structure

Facial expressions are symmetrical

Presence of white hair

P:

Absence of deformities, lumps or masses

Absence of tenderness

D. Eyes:

I:

Eyes are parallel to each other

Eyebrows are greyish and symmetrical

Eyelid’s color same as skin

Eyelashes are evenly distributed and curved outward

Pinkish conjunctiva

Anicteric sclera

Corneas are shiny and smooth

Pupils are equally round and reactive to light and accommodation

15

Blinking in response to bright light

Blinking in response to quick movement of an object toward eyes

Able to blink when wisped with cotton

Blinking is symmetrical

Normal convergence and extraocular movements

Able to see things in the periphery

Near visual acuity: can hardly read printed materials with or without

eyeglasses

P:

Absence of tenderness and drainage from lacrimal apparatus

E. Ears:

I:

Bean shaped

At the level of outer canthus of the eyes

Absence of discharges and lesions

P:

Firm and smooth

Absence of tenderness

Tests:

Rinne’s Test: air conducted sound was heard twice as long as bone

conducted sound

Weber’s Test: able to hear sounds on both ears; louder on right ear

Patient can easily hear whispers on right ear

Patient has difficulty hearing whispers on left ear

F. Nose:

I:

Nose is same color as skin

Nasal mucosa is pinkish and moist

P:

Patent nares

Absence of masses and tenderness

G. Mouth and Pharynx:

I:

Lips are pale and dry

Oral mucosa is pinkish and dry

Absence of teeth

Tongue is pale with papillae present and is placed at midline

16

H. Neck:

I:

Symmetric

Proportion to gross body structure

Absence of neck vein engorgement

P:

Absence of tenderness, masses and deformities

Lymph nodes are not palpable

I. Spine

I:

Located at the midline

With slight curved kyphosis

P:

Absence of tenderness, masses or lumps

J. Thorax and Lungs

I:

Chest contour is symmetrical

Absence of bulging or active movement within the intercostals spaces

during expiration

Absence of retraction during inspiration

With exertional dyspnea

Accessory muscles were used during breathing

RR: 22 breaths per minutes

P:

Absence of lumps and masses

Chest Excursion: Symmetrical

Tactile Fremitus: Symmetrical; vibrations are heard strongest on top

Pe:

Dull sounds are noted

A:

Presence of fine bi-basal crackles

K. Heart/Cardiovascular

I:

Absence of visible pulsations

P:

17

Absence of jugular vein distention

Weak radial pulses

Weak dorsalis pedis pulses

Absence of heaves, lifts, or thrill

A:

PMI is located at the 5th intercostals space left midaxillary line

Presence of S1 and S2

Absence of murmurs

L. Breast:

I:

Breasts are symmetric

Areola is light brown

Nipples are everted

Absence of dimpling and retraction

P:

Absence masses or lumps

Absence of discharge in nipples

M. Abdomen:

I:

Abdomen is round and symmetric

The color is the same as neighboring skin

Umbilicus is concave positioned and at midline

Absence of scars and lesions

Absence of visible peristalsis or pulsations

A:

Bowel sounds: 23 bowel sounds per minute

Pe:

Tympany heard over the stomach

Pa:

Soft

Absence of masses

Absence of organomegaly

N. Extremities

I:

Arms:

Symmetrical

Absence of swelling and venous enlargement

18

Legs:

Symmetrical

Absence of swelling and venous enlargement

Presence of scar on the right leg

P:

Able to perform active and passive range of motion of the upper and lower

extremities

Absence of masses or nodules over the joints

Able to resist applied force on arms, hands, legs, and feet

Absence of edema

O. Genitals

With foley catheter connected to urine bag draining yellowish colored

urine

Absence of swelling and redness of scrotal area

P. Rectum and Anus

Not performed.

Q. Neurologic Exam:

Appearance and Behavior:

Awake and alert

Understand questions and responds appropriately

Able to walk around

Looks relaxed

Kyphotic posture

Dressed appropriately, has good hygiene

Has appropriate facial expression

Speech and Language:

Able to express feelings well

Speech was in moderate rate

Talks in a moderate tone voice

Able to speak clearly and distinctly

Mood:

Has appropriate mood depending on the situation

Thought and Perception:

Able to converse coherently with relevant and organized information

19

Cognitive Functions:

Oriented to time, place, self and other people

Has good attention span

Able to recall remote memory as evidenced by ability to remember past

events in his life

Able to recall recent memory

Cranial Nerve Assessment:

Cranial Nerve I (Olfactory) - Able to detect smell of perfume

Cranial Nerve II (Optic) - Unable to read printed materials

Cranial Nerve III, IV, VI (Oculomotor, Trchlear, and Abducens) - Pupils

are reactive to light and accommodation. Able to follow six directions of gaze.

Cranial Nerve V (Trigeminal) - Able to clench jaw; Able to detect painful

stimuli applied to his face; Eyes blinked when wisped with cotton.

Cranial Nerve VII (Facial) - Able to show different facial expressions

Cranial Nerve VIII (Acoustic) - Positive for lateralization of sounds. Air

conduction lasted longer than bone conduction on both ears.

Cranial Nerve IX and X (Glossopharyngeal and Vagus)- Presence of gag

reflex

Cranial Nerve XI (Spinal Accessory) - Able to shrug shoulders

Cranial Nerve XII (Hypoglossal) - Has good articulation. Tongue is

symmetrical, located on the midline, and able to move freely

Sensory System:

Able to determine painful stimuli

Able to detect light touch

Has difficulty detecting sensation of vibration

Two -point discrimination: 45 mm

Reflexes:

Biceps Reflex- 2+ average, normal

Triceps Refles- 2+ average, normal

Abdominal reflex- 2+ average, normal

Knee Reflex- 2+ average, normal

Plantar Response- plantar flexion of toes

II. Personal/ Social History

1. Lifestyle: The patient used to have an active lifestyle until he started to

experience a gradual decline in his health. Presently, he gets easily fatigued

20

after walking several steps, that is why he usually limits his activity to sitting

and walking a few steps around the house.

2. Vices: The patient started smoking 2 packs of cigarette per day when he was

15 years old. He stooped smoking when he was 45 years old. The patient said

that he is not an alcohol drinker and that he only drinks during parties which

happen rarely. He also added that he did not engage in abuse of prohibited

drugs.

3. Travel: The patient did not have any travel previously.

4. Sports: Presently, the patient does not have any sports. He verbalized that

he is already old for these.

5. Educational Attainment: The patient was able to graduate from college.

6. Social affiliation: The patient is a member of the counsel of elders in their

church.

7. Order in the family: The patient is the father in the family.

8. Patient’s Usual Day Like: The patient usually wakes at around 5 in the

morning. After his wife has finished preparing breakfast, they will eat

together. Afterwards, he will visit his chickens at the backyard and take a

short walk within the yard. He then stays inside the house for the rest of the

day watching television and taking nap in the afternoon. After dinner, he will

again watch television with his wife and son. At around 9 in the evening, he

goes to bed and eventually falls asleep.

III. Environmental History

The patient lives in a subdivision located in Paranaque. The houses there

are built with adequate spaces in between. There are trees and plants all over the

place. Garbage cans are placed on some corners of the subdivision. Water and

electrical supply are available in the community. There is a market, school, park,

store and other food establishments just outside the subdivision. A guard house is

located at the entrance to their village. There are no flies and other insects at their

place. According to the patient, the garbage is being collected every day.

The yard outside the patient’s house has plants and trees. There is a

garage where the patient’s car is parked. The patient’s bungalow type house is well

21

maintained. There are no scattered rags on the floor. His room is located near the

living room, dining area and the bathroom.

22

23

24

V. Laboratory Study

LABORATORY NORMAL VALUE

RESULT1/11/09

RESULT1/13/09

RESULT 1/14/09

INTERPRETATION/ SIGNIFICANCE

WBC 4.5 – 11 x

10^9/L

13.3 9.10 8.2 INCREASED to NORMAL; This was taken to assess if the patient

might be suffering from an infection, inflammation or tissue necrosis.

Any emotional or physical trauma or stress might lead to an increase

in WBC. An initial increase in the patient’s WBC might be because he

has experienced physical stress before he was admitted to the

hospital. The rest of the result doesn’t show that the patient might

have infection or inflammation.

LYMPH 0.25 –0.40 x

10^9/L

.24 .24 .27 DECREASED to NORMAL; This test was taken together with WBC to

assess if there are any presence of infection or inflammation in the

patient. Even though the results in the first 2 test were low, it doesn’t

necessarily mean that the patient has an infection or inflammation

since the WBC is normal.

HGB 140 – 170 g/l 100 88 105 DECREASED; Hgb is the indirect reflection of RBC numbers. A

decrease in the patient’s level of Hgb is due to the decreased number

of the patient’s RBC. Taken into consideration a decrease in the urine

output of the patient, a decrease level of Hgb in all test might suggest

that the patient might have kidney disease. Erythropoietin which is a

strong stimulant of RBC production is produced in the kidney. Since

the kidney of the patient is damaged, there is a decrease production of

erythropoietin resulting in a decreased RBC production thus resulting

25

in a decrease Hgb. The patient’s Hgb has increased but still below the

normal level on January 14, 2009 because 1 unit of pack RBC was

transfused to him last January 13, 2009 at 10 in the evening.

RBC 4.50 – 6.5 x

10^12/L

3.48 3.06 3.69 DECREASED; decreased level of RBC might suggest that the patient

has a kidney disease. Erythropoietin is made in the kidney and is a

strong stimulant of RBC production. Since the patient’s kidneys are

damaged, there is a decrease production of erythropoietin therefore

the number of RBC is diminishing. The level of RBC in the patient’s

body has increased but still below the normal level on January 14,

2009 because the patient was transfused with 1 ‘u’ of pack RBC last

January 13, 2009.

HCT 40 – 54 % 31% 27% 32% DECREASED; Hct is the indirect measurement of the RBC number and

volume. A decreased level of the patient’s Hct can be due to the

decrease level of RBC secondary to diabetic nephropathy and chronic

kidney disease. Decline in the level of Hct is related to the decrease

production of erythropoietin, due to the damage in the kidneys, which

plays an important factor in RBC production.

PLATELETS 200 – 400 Adequat

e

Adequat

e

Adequat

e

NORMAL; This test was taken to assess if there are any abnormality

in the amount or number of platelets that can lead to thrombus

formation that might cause tissue infarction.

SEGMENTERS .55 -.65 .80 .87 .80 INCREASED; Increase level of segmenters might be because there is

an organ in the patient’s body that is damage such as his heart or the

kidneys. Taking into consideration the abnormal results of BUN and

CREA, his kidney might be damaged.

26

LABORATORY NORMAL VALUE

RESULT1/11/09

RESULT1/12/09

RESULT1/13/09

RESULT1/16/09


Hba1c 4.2% - 6.2% ---- 9.43% ---- ---- INCREASE; increase level of Hba1c is due to the fact that

the patient was diagnosed of diabetes mellitus for 3 years.

Measuring glycosylated hemoglobin assesses the

effectiveness of therapy since this test is proportional to

average blood glucose concentration over the previous four

weeks to three months. Poorly controlled glucose might

lead to the development of kidney and heart disease.

BUN 7.98 - 20

mg/dl

96.33 100.45 59.38 57.98 INCREASED; The patient’s BUN level is increased because

of the patient’s diabetic nephropathy and chronic kidney

disease. BUN reflects the excretory function of the kidneys.

Since in diabetic nephropathy or in any kidney disease, the

kidneys are damaged, there is an inadequate excretion of

nitrogenous products causing an increase in the level of

urea nitrogen in the blood. Since the patient has a

significant increase in BUN, he is said to be azotemic.

CREATININE 0.6 - 1.3

mg/dl

3.98 3.07 3.92 2.22 INCREASED; An increased in the creatinine of the patient

is also due to his diabetic nephropathy and chronic kidney

disease. The creatinine, as BUN is excreted entirely by the

kidneys and therefore is directly proportional to renal

excretory function. Since the kidneys of the patient are

damaged and unable to perform its function normally, it

27

will not be able to excrete the creatinine which is the

catabolic product of creatine phosphate, an important

substance used in skeletal muscle contraction thus it will

lead to an increase serum creatinine level.

SODIUM 135 - 145

mmol/L

138 139 ---- ---- NORMAL; This was taken since this test can help assessed

the fluid balance of the patient. An abnormality in the

result might suggest that the patient might have fluid

retention or dehydration..

POTASSIUM 3.80 - 5.60

mmol/L

7.6 6 4.4 4 INCREASED TO NORMAL; The result of potassium was

increased due to the presence of diabetic nephropathy

since the kidneys are the primary regulator of potassium

balance. One of the reasons why the potassium level of the

patient normalized is due to the administration of Lasix drip

240 mg in 90cc D5W x 10cc/hour which was ordered by the

physician on January 12, 2009 since the patient was unable

to produce a normal urine output. One of the effects of this

drug is to excrete potassium in urine.

CK -MB 0 - 24 U/L 15 ---- ---- ---- NORMAL; CK-MB is an isoenzyme which has a high

concentration in the cardiac muscle. If the myocardium or

the cardiac muscle is damaged, it will release a large

amount of CK-MB in the bloodstream. This test was taken

to assess if the patient might be suffering of myocardial

infarction since he has CAD and had suffered MI last 2008.

TROPONIN Negative Negative ---- ---- ---- NORMAL; Troponin is a protein found in the cardiac

28

muscles and it regulates the myocardium contractile

process. This test was taken since this is a critical marker

of myocardium damage. The patient might be suffering

from myocardial infarction since he has CAD and had

suffered MI last 2008.

LABORATORY(Urinalysis)

NORMAL VALUE

RESULT(Jan. 12,

2009)


COLOR Yellow Dark Yellow The patient’s color of urine is dark yellow since there is presence of RBC in his

urine due to kidney damage.

TRANSPARENCY Clear Cloudy Cloudy urine of the patient is due to the presence of RBC,.

REACTION 4.5 – 8 6.0 NORMAL; This was assessed since pH indicates the acid base balance. The urine

pH reflects the work of the kidneys to maintain normal pH homeostasis. This test is

important to assess to determine the function of the kidney as regulator of pH.

SPEC. GRAVITY 1.005 – 1.025 1.002 DECREASED;. Specific gravity is used to evaluate the concentrating and excretory

power of the patient’s kidneys. A decrease in the level of specific gravity signifies

that the kidneys are not able to concentrate the urine. The result suggests that the

kidneys of the patient might be damage since if the kidneys are not properly

functioning such as in renal failure, the kidney loses its ability to concentrate urine

through water reabsorption.

ALBUMIN negative +2 INCREASED; Proteins are sensitive indicator of kidney function. Normally, protein

29

is not present in the urine because the spaces in the normal glomerular filtrate

membrane are too small to allow its passage. Since there is a presence of protein in

the patient’s urine, it might suggest that his kidneys might be damaged secondary

to diabetes mellitus.

GLUCOSE Negative INCREASED; This test serves as an additional to the evaluation of the patient’s

kidney function. Presence of glucose in the urine might suggest an additional role in

determining if the kidney of the patient is entirely damaged. Glycosuria can be the

result of damaged to the patient’s renal tubule secondary to diabetes mellitus

LEUKOCYTES 0 - 4/ hpf 2/ hpf NORMAL; This test was taken to assess if the patient might have infection.

RBC <2/ hpf 3-4/ hpf There is a presence of blood in the patient’s urine (hematuria). The result

suggests that his kidneys especially his glomerulus might be damaged causing an

increased permeability of the glomerular wall resulting in the migration of

erythrocytes through the damage cell wall.

BACTERIA Negative Few The presence of bacteria indicates might indicate presence of infection.

30

Electrocardiography ECG #79213 January 11, 2009

RATE: 75 / min

RHYTHM: Sinus

INTERVAL: PR - 0.20 QRS - 0.08 QT - 0.38

INTERPRETATION: Old antero septal wall MI

High Lateral wall ischemia

CHEST AP, SEMI UPRIGHT January 11, 2009

FINDINGS:

The cardiac shadow is enlarged with accentuation of pulmonary vascularity.

Hazed density observed in the right hilar - perihilar areas.

Cardiomegaly with pulmonary congestion / interstial edema and pneumonitis.

Other chest structures are unremarkable.

2D ECHOCARDIOGRAPHY RESULT January 12, 2009

31

Echocardiographic Information

Dimension Measureme

nt

Normal Dimension Measureme

nt

Normal

LV (ed) 5.6 4.5-5 cm LVEDV 152

LV (es) 4.1 LVESV 74

IVS (ed) .9 .8- 1.1 SV 78 cc

IVS (es) .9 CO 3978 cc

LPVW (ed) 1.1 .8- 1.1 EF 51% 55- 57%

LVPW (es) 1.3 FS 27% 29- 42%

Aorta 3.6 3- 3.5 VCF .5- 1.5

LA (ap

diam)

4.1 3- 3.5 LV mass 213

MPA 2.2 RA 3.9 3.5- 4 cm

LVET 280 RV 3.7 2.2- 4 cm

EPSS 1.1 < 1 cm MV Annulus 2.8

LVOT 2.2 TV Annulus 2.5

INTERPRETATION: Dilated left ventricles with hypokinesia of the interventricular septum and

thinned out from mid to apex. There is also hypokinesia of the anterior and anterolateral left ventricular free wall from mid to apex.

Dilated left atrium. Normal size right ventricle, right atrium, main pulmonary artery and aortic root dimension.

Structurally normal mitral valve, tricuspid valve and pulmonary valve. No pericardial effusion, no thrombus.

DOPPLER STUDY; Aortic Regurgitation - trivial Mitral Regurgitation - mild Tricuspid Regurgitation - trivial Reversed transmitral in flow velocities Pulmonary artery pressure is 49 mmHg by pulmonary acceleration time.

CONCLUSION:1. Dilated left ventricle dimension with multisegmental wall motion

abnormality suggestive of CAD with systolic and diastolic dysfunction.2. Dilated left atrium.3. Aortic annular calcification.4. Aortic sclerosis with trivial aortic regurgitation.5. Mild mitral regurgitation.6. Trivial tricuspid regurgitation.7. Mild pulmonary hypertension

32

33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

49

VII- A. Nursing Care Plans

1. Decreased cardiac output related to altered myocardial contractility

2. Activity Intolerance related to fatigue and exertional dyspnea.

3. Constipation related to decreased peristalsis secondary to decreased level of activity.

4. Sleep pattern disturbance related to routine hospital procedures during night shift.

5. Ineffective Management of Therapeutic Regimen related to conflict between personal beliefs and the prescribed therapeutic regimen.

Date: January 15, 2008 (Thursday) 8:00 am

Data/Cues Nursing Diagnosis

Rationale Goals and Objectives

Nursing Intervention Rationale Evaluation

Subjective:“ Maglakad lang ako mula kama hanggang CR, napapagod at hinihingal na agad ako”, as verbalized by the patient.

Objective:PE- Weak and decreased peripheral pulse

- Pale nail beds

- Capillary refill of 5 seconds

- Exertional

Decreased cardiac output related to altered myocardialcontractility

Coronary atherosclerosis is an abnormal accumulation of lipid and fibrous tissue within the coronary artery, progressively narrowing the lumen of the vessel. As the lumen narrows, resistance to flow increases and myocardial blood flow is compromised that deprives cardiac muscle cells of oxygen needed for their

After 2 hours of nursing intervention, the client will be able to:

Goal: Display an

improvement of his cardiac output.

Expected Outcomes:

o Vital signs within acceptable limits.

o Strong peripheral

Independent

Monitor vital signs (e.g. heart rate, BP).

Auscultate heart sounds.

Decreased cardiac output may be reflected in diminished peripheral pulses. It is due to inadequate blood flow to the peripheral pulses.

Pallor is indicative of diminished peripheral perfusion secondary to inadequate cardiac output. Cold, clammy skin is secondary to compensatory increase in sympathetic nervous system stimulation and low cardiac output.

Changes in sensorium

After 2 hours of nursing intervention, the goal was partially met as evidenced by the following:

Vital Signs:

PR= 70 beats per minuteHR= 72 beats per minuteRR= 20 breaths per minuteBP= 120/80 mm Hg

- Weak and decreased peripheral pulse

50

Tachycardia may be linked with a drop in cardiac output which is secondary to decreased stroke volume. Changes may also occur in blood pressure (hypotension or hypertension) because of cardiac response.

S3, or S4 can occur with cardiac decompensation or some medications. S1 and S2 may be weak because of diminished pumping action.

dyspnea

- Vital Signs:PR= 68 beats per minuteHR= 70 beats per minuteRR= 22 breaths per minuteBP= 120/80 mm HgTemp: 36.4

- Pulse deficit of 2 beats

Laboratory Findings:

- Color flow Doppler study result: Abnormal color flow display noted across the mitral valve and tricuspid valve during systole and across the mitral valve and aortic valve during diastole.

- Cardiac output of 3.98 L/min

survival. If the decrease in blood supply is great enough, of long duration, or both, irreversible damage and death of myocardial cells, or MI result. Overtime, irreversibly damaged myocardium undergoes degeneration and is replaced by scar tissue, causing various degrees of myocardial dysfunction. Significant myocardial damage may result in persistently low cardiac output, and the heart cannot support the body’s need for blood.

Source:

pulses

o Capilliary Refill of less than 3 sec.

o Regular cardiac rhythm.

o Reports decreased severity of exertional dyspnea.

o Participates in self-care activities without feeling exhaustion.

Palpate peripheral pulses.

Inspect skin color and temperature.

Note changes in sensorium (lethargy, confusion, disorientation, anxiety, and depression).

Assess for chest pain.

Maintain adequate ventilation and perfusion, as in the following:

o Place in semi- to- high fowler’s position.

may

Decreased cardiac output may be reflected in diminished peripheral pulses. It is due to inadequate blood flow to the peripheral pulses.

Pallor is indicative of diminished peripheral perfusion secondary to inadequate cardiac output. Cold, clammy skin is secondary to compensatory increase in sympathetic nervous system stimulation and low cardiac output.

Indicate inadequate cerebral perfusion secondary to decreased cardiac output.

The most common manifestation of myocardial ischemia is acute onset of chest pain. This allows for prompt intervention.

This position reduces

- Pale nail beds

- Capillary refill of 5 seconds

- Able to perform self care activities such as combing hair, feeding, and changing of clothes.

51

1. Brunner & Suddarth’s Textbook of Medical- Surgical Nursing 11th Edition by: Suzanne C. Smeltzer et al. page 860

Maintain physical and emotional rest as in the following:

o Restrict activity.

o Provide quiet and relaxed environment.

o Organize nursing and medical care.

o Provides for adequate rest periods. Assists in performing self-care activities.

o Have patient avoid activities eliciting a vasovagal response such as straining

preload and ventricular filling by minimizing the degree of stretch on the cardiac muscle fibers.

Physical rest should be maintained to reduce oxygen demands by improving efficiency of cardiac contraction and to decrease myocardial oxygen demand or consumption and workload. Psychological rest helps reduce emotional stress, which can produce vasoconstriction, elevating BP and increasing heart rate or load

This allows rest periods and optimal use of patient’s limited energy resources.

Physical rest improves efficiency of cardiac contraction and to decrease myocardial oxygen demand/ consumption and workload.

52

during defecation, holding breath during position changes.

o Encourage immediate reports of pain for prompt administration of medication as indicated.

Collaborative:

Administer Digoxin (Lanoxin) 0.25 mg ½ tab PO every other day

Vasovagal maneuver (Valsalva maneuver) causes vagal stimulation followed by rebound tachycardia, which further compromises cardiac function or output.

- Timely intervention can reduce oxygen consumption and myocardial workload and may prevent or minimize cardiac complications

Digoxin increases contractility of the myocardium by inhibiting ATP and sodium- potassium exchange activity. The altered ionic distribution across the membrane results in an augmented calcium ion influx, thus increasing the availability of calcium at the time of excitation- contraction coupling.

Source/s:1. Nursing Care Plans (6th ed)

53

Marilyn DoengesPage 63-642. Delmar’s Critical Care (Nursing Care Plans, Sheree Comer,2nd edition. Page 31-33

Date: January 15, 2008 (Thursday) 3:00 pm

Data/Cues Nursing Diagnosis

Rationale Goals and Objectives

Nursing Intervention Rationale Evaluation

Subjective: “Hindi ko na kayang maglakad ng mahaba- haba kaya dito na lang ako sa kama”, as verbalized by the patient.

Objective:

Patient always stays on bed and seldom walks.

Patient requires aaistance in activities such as toileting, and getting out of the bed.

Activity Intolerance related to fatigue and exertional dyspnea.

Activity intolerance is defined as insufficient physiological energy to endure or complete required or desired daily activities. Most activity intolerance is related to generalize weakness secondary to acute or chronic illness and phase. During activity, where oxygen demands are paramount, the compensatory mechanism of

After 8 hours of nursing intervention:

Goal: Client will

perform ADLs within capabilities

Expected Outcomes:

o Client exhibits normal heart rate and blood pressure, as well as absence of shortness of breath, weakness and fatigue

Independent

Assess the patient’s cardiopulmonary status and stability for exercise before activity using the following measures.

Observe and document response to activity. Report any of the following:o Rapid pulse (20 to 30

beats/min over resting rate or 120 beats/min)

o Palpitations/noticeable change in heart rhythm

o Significant increase in systolic BP (greater than 20 mm Hg)

o Significant decrease in systolic BP (greater than 10 mm Hg)

o Dyspnea, labored breathing, wheezing

o Weakness, fatigue

Cardiopulmonary status determines the patient’s ability to tolerate activities.

Close monitoring serves as a guide for optimal progression of activityDuring exercise, intense increase in metabolism in active skeletal muscles acts directly on the muscle arterioles to relax them and to allow adequate oxygen and other nutrients needed to sustain muscle contraction. This serves as a signal that the patient cannot tolerate the activity and therefore, must stop.

After 8 hours of nursing intervention, goal was met as evidenced by the following:

Client’s heart rate and blood pressure were within normal limits.

No shortness of breath, weakness and fatigue were exhibited by the client.

Client enumerated and used energy-conservation techniques.

Patient was able to perform Self Care Activities such as

54

Exertional Dyspnea

- Vital Signs:PR= 68 beats per minuteHR= 70 beats per minuteRR= 22 breaths per minuteBP= 120/80 mm HgTemp: 36.4

the heart which is t increase the heart rate is unable to meet the demands of the body, causing easy fatigability.

Source:Nursing Care Plans, Nursing Diagnosis and Inrevention,6th edition, Gulanick/MyersTextbook of Medical Surgical Nursing, 11th edition

o Client verbalizes and uses energy-conservation techniques

o Light-headedness, dizziness, pallor , diaphoresis

o Chest discomfort

Encourage adequate rest period, especially before meals, other ADLs, exercise sessions, and ambulation

Assist with ADLs as indicated; however avoid doing for patients what they can do for themselves.

Intervention:

Encourage active ROM exercises(ind).

Teach the patient and caregivers to recognize signs of physical overactivity

Teach energy conservation techniques, such as the following:

Rest between activities provides time for energy conservation and recovery.

Caregivers need to balance providing assistance with facilitating progressive endurance that will ultimately enhance the patient’s activity tolerance and self-esteem.

Exercise maintains muscle strength and joint ROM. Limiting movement reduces blood flow, typically resulting in stiff, painful joints, and this pain contributes to the spiral of inactivity and ROM loss.

This promotes awareness of when to reduce activity

These reduce oxygen

dressing, feeding, grooming and getting to bedside commode without exhaustion.

55

Sitting to do tasks

Changing position often

Working at an even pace

Teach ROM and strengthening exercises

consumption, allowing more prolonged activity

Standing requires more work. Good posture, sitting or standing, balances the weight of your head and limbs on the bony framework so that the force of gravity helps keep joint position.

This distributes work to different muscles to avoid fatigue

This allows enough time so not all wok is completed in a short period.

Exercise promotes increased venous return, and maintains/increases muscle strength and endurance.

Sources: Cardiovascular

and Pulmonary Physical Therapy Evidence and Practice, 4th edition, Felter/Dean

Physical Rehabilitation, O’Sullivan, Schmitz

56

Textbook of Medical Physiology, Guyton and Hall

Essentials of Anatomy and Physiology, 7th edition, Marieb

January 15, 2008 (Thursday) 7:00 am

Cues/ Needs Nursing Diagnosis

Rationale Planning Nursing Intervention

Rationale Evaluation

Subjective:

“Nurse, bigyan niyo na ko ng suppository dahil kasing tigas na ng bato yung dumi ko, nahihirapan na ako”, as verbalized by the patient.

Objective:

- Bowel Sounds of 6/ min

Constipation related to decreased peristalsis secondary to decreased level of activity.

The patient has been on bed rest for four days now. This position promotes decrease in peristaltic movement in the Gastrointestinal Tract. Thus, decreasing gastric emptying time and prolongs absorption of fluid from the food making the formed stool harder.

After 8 hours of nursing intervention, the patient will be able to have a bowel movement.

Expected Outcomes:

Patient will not experience straining during defecation.

Patient will pass a soft formed

Independent:

Encourage patient to consume foods that are soft in consistency. May include noodles and porridge in diet.

Encourage adequate fluid intake within restriction.

Encourage ambulation, as tolerated.

Soft Diet aids in the digestion process producing soft formed stool.

Fluids soften the consistency of the stool decreasing the risk for being constipated.

Ambulation promotes peristalsis and Bowel Movement.

After 8 hours of nursing intervention, the goal was met. The patient was able to move his bowel at around 3:00 pm that day.

- Patient experienced straining when she tried to defecate.

- Patient was not able pass a soft formed stool.

57

- Patient has been confined on bed for 4 days now.

- Patient has not had Bowel Movement since January 12, 2009.

- Patient is with contraptions which include: Foley cathether, Peripheral IV line and O2 via nasal cannula on PRN basis

Source: Holloway, Nancy, 2003. Medical- Surgical Care Planning. 4th Edition. Pp 347.

stool on moderate amount.

Provide privacy to the patient when the urge to defecate is felt.

Dependent:

Administer laxative Lactulose (Duphalac) 30 cc OD at bedtime.

Privacy promotes ease of defecation.

The metabolites of lactulose draw water into the bowel, causing a cathartic effect through osmotic action.

Source:Gulanick, Meg., 2007. Nursing Care Plans. Nursing Diagnosis and Intervention. 6th Edition.

Date: January 15, 2008 (Thursday) 11:00 pm


Rationale Planning Interventions Rationale Evaluation

Subjective Data:“Hindi ako gaanong makatulog kasi kahit gabi merong pumapasok dito sa kwarto”as verbalized by the patient.

Objective Data:

Sleep pattern disturbance related to routine hospital procedures during night shift.

Proper sleep and rest are important to good health as good nutrition and adequate exercise. Without proper amounts of rest and sleep, the ability to concentrate, make judgments, and participate in daily activities

After 24 hours of nursing interventions, the client was able to:

Goal:Achieve optimal amounts of sleep.

Expected Outcome:- Looks well rested

-Verbalization of feeling rested

-Verbalization of improved sleep

Independent Interventions:-Maintain environment conducive to sleep or rest like quiet environment and comfortable temperature

-Assist in observing any previous bedtime ritual

-Provide nursing aids such as back rub or comfortable position

-Organize nursing care

-To promote sleep and rest

-To promote relaxation

-These promote sleep and relaxation through

-To promote minimal

After 24 hours of nursing interventions, the goal was MET as evidenced by:

-Well-rested appearance

-Verbalized that he was able to rest well during the night

-Verbalized that he was able to sleep longer hours

58

http://en.wikipedia.org/wiki/Osmotic

-Restlessness observed during night shift

-Frequent yawning

-Irritability

-Fatigued appearance

decreases and irritability increases.

Our patient has been on his fourth day of hospitalization. According to him, routine hospital procedure especially during the night shift prevents him form having an uninterrupted sleep.

*Source:Fundamentals of Nursing by Patricia A. Potter and Anne Griffin Perry page 1199.

pattern and eliminate nonessential nursing activities

-Attempt to allow for sleep cycle of at least 90 min

-Establish semblance of “normal daily” routine with periods of activity, rest

-Provide soporifics such as milk and avoidance of stimulants such as caffeinated beverages before sleep

-Discourage daytime naps unless deemed necessary or part of usual pattern

- Limit fluids 2 to 4 hours before bedtime

interruption in sleep/rest

-Experimental studies have indicated that 60-90 min are needed to complete one sleep cycle and the completion of an entire cycle is necessary to benefit from sleep

-Adherence previously established patterns/routines minimizes energy required for adaptation and disruption in biological rhythms

- These help promote sleep during the night

-Napping can disrupt normal sleep pattern

-To reduce need for voiding during night

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Dependent Intervention:- Administer Zolpidem (Stilnox) 10mg ½ tab

-Carry out doctor’s order of no vital signs monitoring when the patient is asleep.

- This drug is indicated for short-term management of insomnia. It interacts with GABA – benzodiazepine channel chloride complex and binds itself with GABA-A receptor complex on the alpha subunit, which is known as the benzodiazepine (BZ) type 1 or omega receptor. Then it will modulate the actions of GABA. Upon modulation, sedation occurs. Thus sleep is induced.

- Preventing disturbance and stimulation during sleeping hours promotes restful sleep.

*Source:Nursing Care Plans

60

3rd Edition by Meg Gulanick et al. pages 63-62

Date: January 17, 2008; 3:00 pm


Rationale Planning Nursing Interventions

Rationale Evaluation

Subjective Data:“Lahat naman tayo mamatay, kapag hindi ko kinain ‘yung mga gusto ko ngayong nabubuhay pa ako, hindi ko na ‘yon makakain sa langit”, as verbalized by the

Ineffective Management of Therapeutic Regimen related to conflict between personal beliefs and the prescribed therapeutic regimen.

The patient has this belief that death is unavoidable and one should enjoy life without too much restriction for when one dies he can no longer enjoy these things. This belief

After 8 hours of nursing intervention, the patient will verbalize readiness to modify present management of therapeutic regimen.

Assess the patient’s readiness and ability to learn.

Assess what the patient already

The patient must be motivated to learn, have the capability to learn the content, and be free of distractions from learning such as pain and emotional distress.

The patient may have some knowledge about his disease conditions and

After 8 hours of nursing intervention, the goal was not met. The patient still insisted on not following his prescribed diet.

Expected Outcomes:

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patient.

Objective Data:-Patient shows no interest in learning more about the disease.

-Patient asks no question on how to improve his condition.

of the patient conflicts with his compliance to the therapeutic regimen he is prescribed to follow. He does not adhere to his Low Salt Low Fat- Diabetic Diet because following this will contradict his belief. This conflict results to patient having ineffective management of his therapeutic regimen.

Source:Rodger’s, Shielda R. Medical- Surgical Nursing Care Plans. Pp 967- 970

Expected Outcomes:

-Patient will ask questions regarding the disease process and how to manage his condition effectively.

knows.

Stress the importance of adhering to the prescribed Diet for the patient.

Enumerate the foods that are restricted for consumption by the patient and the rationale for such restrictions.

Provide food selections and alternatives for those restricted foods for the patient.

Discuss with the patient the complications that may arise from his condition when effective management is not practiced.

Encourage patient to have regular Appointments with the health care provider.

teaching should begin with what the patient already knows.

Reinforcing the appropriate Diet may encourage patient’s compliance to therapeutic regimen.

Understanding the negative effects of consuming the restricted foods may enhance compliance.

To provide patient with choices of food that he can consume to prevent the usual food he is consuming from becoming less appealing.

Understanding the risks of not following the prescribed treatment regimen may enhance compliance to therapeutic regimen.

Regular follow up is required to monitor blood sugar and progress towards control and self

-Patient shows resistance when being taught about effective management of his condition.

-patient did not ask questions on how to improve his present condition.

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management, as well as for early detection of complications.

Source:Rodger, Shielda R. Medical- Surgical Nursing Care Plans. Pp 967- 970

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VII- B. On Going Appraisal

On January 15, 2009 at 0600H, the patient was received awake lying on bed with

O2 at 2Lpm via nasal cannula as ordered. The patient was with IVF of PNSS1L X KVO at

300cc level. With foley catheter to urine bag, clamped for bladder training. Patient was on

DM diet of 1,800kcal/day, 40g protein without fruits and juices. On CBG monitoring three

times a day pre-meals. On fluid restriction of 800cc/day. The patient reported urge to

urinate and complained of pain at the genital area. CBG reading was 145 mg/dl.

At 0700H, the patient complained of difficulty of moving his bowel. It was his third

day without bowel movement. AP was informed and order was made to give the HS dose

of Duphalac 30 cc stat.

At 0800H, vital signs were taken and recorded, no abnormalities noted. Plavix

75mg/tab, Pantoprazole 40mg, Dilatrend 25mg 1/2tab, Amlodipine 5mg 1tab, Aprior 20mg

were given.

At 1015H, standing order of HR 6units SQ before breakfast was discontinued as

ordered. With orders to give HR pre-meals with new sliding scale of:

CBG < 150 – none

150 – 200 – 4 units

201 – 250 – 6 units

> 250 – 8 units

To continue HN 15 units SQ before breakfast and 10 units SQ at 10pm daily as ordered.

At 1030H, foley catheter was removed as ordered and O2 on PRN basis

At 1130H, CBG reading was 227 mg/dl, 6 units of HR SQ was given per sliding scale.

At 1200H, VS taken and recorded with BP of 130/80.

At 1400H, pain felt at the genital area was decreased as reported by the patient.

Urine output was 250 cc the whole shift. IVF of PNSS1L x KVO was at 50cc level.

At 1530H, IV line was removed as ordered.

At 1600H, VS were taken and recorded, no abnormalities noted.

At 1730H, CBG reading of 277 mg/dl, 8 units of HR SQ was given.

At 1810H, the patient has crackles on auscultation, 12am dose of Lasix 40mg 1tab

was put on hold as ordered. With new orders to limit total fluid intake to 1.0 – 1.2L/day and

for repeat BUN, Creatinine, Potassium tomorrow morning.

At 2000H, VS were checked and recorded with no abnormalities noted

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At 2200H, patient had urine output of 330cc the whole shift. CBG reading was 185,

HN 10 units was given subcutaneously as ordered.

At 2300H, the patient complained of difficulty falling asleep. Stilnox 10mg ½ tab

was given.

At 2400H, the vital signs were not monitored because the patient was seen asleep

on bed.

On January 16, 2009 at 0400H, the patient was able to void freely

At 0530H, CBG was 110 mg/dl.

At 0600H, urine output was 420cc with one bowel movement the whole night shift.

Patient was received flat on bed. Out on pass was allowed by the doctor and with orders

for possible discharge tomorrow. The patient reported three times bowel movement with

loose, watery stool. Lactulose was discontinued as ordered.

At 0800H, VS were checked and recorded, no abnormalities noted. Amlodipine 5mg

½ tab OD, Sangobion 1tab TID and Ketoteril 2tabs BID were given. Creatinine was noted,

2.2 mg/dl.

At 1130H, CBG was 229 mg/dl, 6 units of HR SQ was given.

At 1200H, no abnormalities noted regarding the vital signs of the patient.

At 1400H, patient’s urine output the whole shift was 1250cc with reports of 2x

bowel movement.

At 1600H, VS taken and recorded, no abnormalities.

At 1640H, the patient reported to have no objection for discharge. Patient was given

prescription for home medications of:

1. HN 15 units + HR 6units SQ before breakfast daily

2. HN 10 units + HR 6 units before supper daily, if CBG < 100 mg/dl, give HN

only, hold HR

3. CBG monitoring at home twice a day, before breakfast and supper daily.

4. for OPD follow-up after one week with CBG monitoring records at home.

At 1730H, CBG reading was 216 mg/dl, HR 6 units SQ was given per sliding scale.

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At 2000H, no abnormalities noted on vital signs.

At 2200H, urine output of 420cc and no bowel movement during the whole shift.

On January 17, 2009 at 0530H, VS were taken and recorded with BP of 130/70.

CBG reading was 105 mg/dl with no complaints made during the entire night shift. Urine

output of 300 cc/ shift with no bowel movement.

At 0600H, patient was received awake on bed and was advised on protein and

water restriction.

At 0800H, vital signs taken and recorded, BP of 130/90. Patient was given additional

prescription of home medications: Sangobion 1cap TID and Ketosteril 2caps BID. For

follow-up after 2 weeks with BUN, Crea, K and Urinalysis.

At 1130H, CBG was 220 mg/dl, patient was given 6 units of HR subcutaneously per

sliding scale.

At 1200H, VS taken and recorded with BP of 130/90

At 1400H, urine output was noted 450cc the whole shift with no bowel movement.

At 1530H, the patient was discharged, ambulatory, with home meds and OPD

follow-up instructions.

VII- C. Discharge Plan

1. Medications

Advised patient to take her home medications

HN 15 U + HR 6U SQ before breakfast daily

HN 10 U + HR 6U SQ before super daily if CBC < 100, give HN only. Hold HR

Aprion 20 mg/ tab 2x a day

Clopidogrel 25 mg/ tab 2x a day

Lanoxin 0.25 mg ½ tab every other day

Cardipres 25 mg/ tab AM

Sangobion 3x a day

Ketosteril 2 caps 2x a day

2. Exercise

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May do light exercises if symptoms subsides (walking, stretching). Stop exercise if the

patient feels chest pain, dizziness, difficulty of breathing.

3. Treatment

CBG monitoring at home. BID before breakfast and supper daily

4. Health Teachings

Instruct the patient to take all your medications as prescribed by your doctor

Instruct the patient to keep a list of the medications with patient at all times

If the patient has questions or concerns, call the doctor. Do not stop or change the

dose of any of the medications with out first talking to the doctor.

Instruct the patient not take any medications-including vitamins, Over-the-counter

medications or herbal remedies-with out first talking with the doctor.

Instruct the patient to weigh himself every morning after going to bathroom. Use same

scale and weigh himself in the same type of clothing each day.

For Congestive Heart Failure

Plan rest periods during the day to allow heart to regain strength for next activities.

Advised the patient to immediately stop whatever he is doing if he feels tired,

experience chest pain or have shortness of breath

Instruct patient to put his feet up every few hours to avoid swelling.

Instruct patient to avoid smoking to have enough rest at night.

For Diabetes Mellitus:

Teach patient specific directions for obtaining an adequate blood sample and

what to do with the numbers that they receive.

The patient needs to be reminded to record the blood glucose values on a log

sheet with the date and time and any associated signs and symptoms that

he/she is experiencing at the time the specimen was obtained.

Teach the patient about self-administration of insulin or oral agents as

prescribed, and the importance of taking medications exactly as prescribed, in

the appropriate dose Patients should be provided with a list of signs and

symptoms of hypoglycemia and hyperglycemia and actions to take in each

situation.

The patient should also be educated on the importance of smoking cessation,

cholesterol and lipid management, blood pressure monitoring and management

of other disease processes.

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Encourage client and family about regular exercise. Regular exercise can

improve the functioning of the cardiovascular system, improve strength and

flexibility, improve lipid levels, improve glycemic control, help decrease weight,

and improve quality of life and self-esteem.

5. OPD Follow Up

Follow-up after 1 week (January 24, 2009) with CBG results from home

Follow-up after 2 weeks with BUN, (January 31, 2009) Creatinine, Hematocrit, Urinalysis

results

6. Diet

Instruct patient to adhere to a diet restricted on Salt, Fat, Protein, and Carbohydrates.

Advise patient to follow a fluid restriction of up to 1.2 L/ day

Limit the amount of Sodium (salt) in the diet to less than 2,000 mg each day.

.>Instruct patient not to add salt while cooking or at the table

>Instruct patient to avoid processed foods like luncheon meats and canned sopis

>Check food labels for Sodium content

>Instruct patient to consult the doctor or a dietitian before using any salt substation

>Instruct the patient to consult the doctor about how much liquid the patient can drink

each day.

Instruct the patient to eat balanced diet that is low in fat

> All types of added fats, such as butter, margarine, mayonnaise, sour

cream and salad dressings, are reduced or eliminated.

> Foods high in fat, such as fried foods, snack foods, cheeses and red meat,

should be replaced with lower-fat versions or eaten in smaller portions.

Instruct patient to adhere to a Diabetic diet

> Eat more starches such as bread, cereal, and starchy vegetables. Aim for six

servings a day or more. For example, have cold cereal with nonfat milk or a bagel with

a teaspoon of jelly for breakfast. Another starch-adding strategy is to add cooked black

beans, corn or garbanzo beans to salads or casseroles.

> Eat five fruits and vegetables every day. Have a piece of fruit or two as a

snack, or add vegetables to chili, stir-fried dishes or stews. The patient can also pack

raw vegetables for lunch or snacks.

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> Eat sugars and sweets in moderation. Include patient’s favorite sweets in his

diet once or twice a week at most. Split a dessert to satisfy his sweet tooth while

reducing the sugar, fat and calories.

Instuct patient to adhere to a Protein- Restricted Diet

Fruits and most vegetables have little or no protein. There are some exceptions to this like peas,

beans (both can be rather high) and some starchy vegetables (like potatoes and corn which are in

the medium range).

Teach Patient to avoid eating organ meats

7. Signs/Symptoms

Call the doctor the immediately if the patient experiences the following:

For Congestive Heart Failure:

Sudden weight gain(3-5 movies in 1-4 days)\

Swollen feet, ankles, legs, abdomen

Shortness of breath which may occur with activity ( may become continuous and

may cause to make up breathless @ night)

Difficulty sleeping

Frequent dry, hacking, cough, especially when lying down

Extreme fatigue or a constant feeling of tiredness

Decrease in how often or how much the patient urinate

For Diabetes Mellitus:

Early signs of hyperglycemia in diabetes include:

Increased thirst

Headaches

Difficulty concentrating

Blurred vision

Frequent urination

Fatigue (weak, tired feeling)

Weight loss

Blood glucose more than 180 mg/dL

Prolonged hyperglycemia in diabetes may result in:

Vaginal and skin infections

Slow-healing cuts and sores

Decreased vision

Nerve damage causing painful cold or insensitive feet, loss of hair on the lower

extremities, and/or erectile dysfunction

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Stomach and intestinal problems such as chronic constipation or diarrhea

Hypoglycemia causes symptoms such as

hunger

shakiness

nervousness

sweating

dizziness or light-headedness

sleepiness

confusion

difficulty speaking

anxiety

weakness

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I. ASSESSMENT a. General Data Patient’s Initials:

Documents

x tablet od

tab prn x

x tab bid

x tab odhs

x tablet bid

tab odpm

tab tid

tab prn sl