DEMOGRAPHIC DATA

Name of the patient : Mr. C.F.

Age : 52 y.o
Address : Burgos St. Sudlon Alang-alang, Mandaue City
Gender : Male
Birth date : 9/22/55
Birth place : Mandaue City
Civil status : Married
Nationality : Filipino
Religion : Roman Catholic
Occupation : None
Admission Date : 7/26/08
Admission Time : 4:45 pm
Chief complaint : difficulty in breathing
CLIENT ASSESSMENT

I. Chief complaint:
“Naghangak kog kalit atong pagsabado” as verbalized by the patient.

II. Current Health Status:

A case of Mr. C.F., 52 years old, a resident of Burgos St. Sudlon Alang-
alang, Mandaue City, admitted for the first time at Mandaue City Hospital
last July 26, 2008 4:45 pm due to difficulty in breathing.
Prior to admission, while the patient was sitting at home, all of a
sudden, he had difficulty in breathing with chest discomfort which sought
for admission in Mandaue City Hospital.

III. Past Medical History:

Mr. C.F. cannot recall the immunizations given to her. He had
tuberculosis in the year 1983 as verbalized. He cannot recall the
medications given to him when he had such illness. If ever the patient has
fever and cough, he would take over-the-counter drugs such as biogesic or
solmux for remedies.

IV. Psychosocial History:

Mr. C.F. was born on September 22, 1955 at Mandaue City, Cebu. He is
a resident of Burgos St. Sudlon Alang-alang, Mandaue City. She is a Roman
Catholic and usually attends Sunday mass. The patient is unemployed and
admits that he drinks beer and smokes occasionally. In Erik Erikson’s
Psychosocial Theory of Development, Mr. C.F. belongs to the Generativity
versus Stagnation task where a positive outcome indicates that there is
creativity, productivity and concern for others. On the other hand, a
negative outcome indicates that there is self-indulgence, self-concern, lack
of interests and commitments.

GORDON’S FUNCTIONAL HEALTH PATTERN

I. Health Perception and Health Management Pattern

Prior to admission:
Mr. C.F. defined health as walay bationg sakit sa kalawasan”. He
maintains a healthy body by eating at least three times a day and taking a
bath daily. Whenever he is tired, he just takes a nap to recover his
strength. Recently, he is not taking any vitamin supplements. During mild
illnesses, like fever and cough, he would not go directly to the hospital for a
check up. Instead the patient goes to the barangay health center for
consultation to seek advice and was instructed to use OTC drugs like
paracetamol.

Upon admission:
Patient can no longer maintain proper hygiene as evidenced by
unchanged clothing, unkempt hair, uncut dirty nails, and haven’t took a
bath since admission. The patient is weak that she cannot perform well
activities of daily living due to his condition. The patient has productive
cough which also makes him weaker.

Remarks: Self care deficit related to generalized weakness.

Ineffective airway clearance related to excessive secretions.
II. Nutrition and Metabolic Pattern

Prior to admission:
“Magpa-init raman ko bsta pamahaw, puto ug sikwati lng akong kan-
un”, as verbalized by the patient. In lunch, patient usually takes a cup of
rice with either pork or chicken while in dinner, the patient eats a cup of rice
and usually paired with chicken. Mr. C.F. usually has a good appetite but he
does not prefer to eat vegetables. The patient usually drinks water at least
5 to 6 glasses of water. He does not have any vitamins or supplements and
he admits that he drinks occasionally.

Upon admission:
Mr. C.F. cannot finish his meals served in the hospital. During
breakfast, a cup of rice and pork is served, and then during lunch and
dinner, a cup of rice with pork and vegetables is served. Patient states that
he has lost his appetite to eat which results in taking less food. He drinks
plenty of water, about 7 to 9 glasses of water a day. He states that he feels
dehydrated every time.

Remarks: Altered eating pattern related to loss of appetite.

III. Elimination Pattern

Prior to admission:
The patient usually defecates at least once a day and urinates at least
2 to 3 times a day with a pale yellow urine, and having an amount of at
least half a cup. Mr. C.F. does not have any difficulty in defecating nor in
urinating.
Upon admission:
The patient urinates 5 to 6 times a day yellowish in color, of about a
cup in amount. He states that he was not able to defecate since admission
and he haven’t felt so. The patient usually urinates in a bedpan because he
is restricted to go to the comfort room.

Remarks: Constipation related to recent environmental changes secondary

to hospitalization.

IV. Activity - Exercise Pattern

Prior to admission:
Mr. C.F. wakes up at 5 a.m. and fixes immediately his bed and folds
his blanket. After fixing his bed, he walks around their place as a form of
exercise. He does some minor household chores like washing dishes and
sweeping the floor. He spends most of his time watching television at home.

Upon admission:
Mr. C.F. can’t perform anymore his usual activity at home because he
is exhausted easily. He usually needs assistance in order to do his activities
of daily living. The patient is actually in complete bed rest without toilet
privilege.

Remarks: Fatigue related to insufficient supply of blood into the extremities

secondary to CHF.
V. Sleep – Rest Pattern

Prior to admission:
The patient usually sleeps at 7 p.m. and wakes up at 5 a.m. having 10
hours of sleep. He sleeps with two pillows and a blanket. He usually sleeps
in supine position. He usually wakes up at night to urinate but goes to sleep
easily.

Upon admission:
Though Mr. C.F. used to spend most of the day lying in bed, he can’t
sleep well because he is uncomfortable with the new environment and
states that it is very hot inside the room. He states that he is irritated
because of his continuous coughing which disturbs his rest. And having pain
in the chest.

Remarks: Disturbed sleeping pattern related to environmental changes

secondary to hospitalization.
Alteration in comfort: moderate pain related to physiologic
disturbances.

VI. Cognitive and Perceptual Pattern

Prior to admission:
The patient can comprehend and follow instructions and can answer
some questions being asked. He sometimes can’t recall important events in
his life or any unusualities like the medications taken when he had
tuberculosis.
Upon admission:
There are no changes in the comprehension level of the patient. She
feels very worried about his current condition.

Remarks: Moderate anxiety related to situational crisis.

VII. Self – Perception and Self – Concept Pattern

Prior to admission:
The patient describes himself as a simple person. He makes sure that
her grandchildren will be able to finish school. Aside from his family, he also
values health. Health for him has a great impact in performing activities of
daily living that is why he said that he should do everything he can for
health.

Upon admission:
Mr. C.F. still values health. He wanted to be discharged as soon as
possible. The patient said that he feels so weak that he cannot do what is
most expected for him. He feels that instead of her being a father helping
his children, it’s the other way around.

Remarks: Risk for situational self-esteem related to functional impairment

secondary to decreased health status.
VIII. Role and Relationship Pattern

Prior to admission:
The patient’s children have their own families already. To survive each
day’s meals and expenses, he depends on his youngest son who supports
his daily needs. In return, he watches over his grandchildren for them while
they are at work. As to his role in the community, Mr. C.F. is active and
participative in barangay meetings.

Upon admission:
The patient was dependent on his son as evidenced by complying his
needs of his daily living. he needs assistance in moving in bed and as well
as during urination. He claimed that does not want to bother other people’s
lives because of his condition.

Remarks: Interrupted family process related to situational transition

secondary to hospitalization.

IX. Sexuality – Reproductive Pattern

Prior to admission:
Mr. C.F. claimed that he was married at an early age. With regards to
family planning method, they don’t use any contraceptive form because
both of them wanted to have natural complete family.

Upon admission:
At his stage, patient is not affectionate anymore and is hypoactive
towards sexual matters due to his health status and age.
X. Coping Stress – Tolerance Pattern

Prior to admission:
Mr. C.F. perceives stress as a result from too much exhaustion due to
work. Since the patient does not have any work, he still admits that he feels
stressed. In order to cope with stress, she used to watch television or listen
to radio.

Upon admission:
The patient feels irritable because of some headache that he usually
experiences. He considers his hospitalization as the most stressful
experience and is still on the process of coping it.

Remarks: Ineffective coping related to situational crisis.

XI. Value – Belief Pattern

Prior to admission:
Mr. C.F. claimed that he is a religious person. He usually goes to
church during Sundays and prefers to attend in the morning. The church is
a walking distance from their home and goes to church along with
neighbors. When it comes to decision – making, the patient stated that she
always like her decisions to be followed.
REVIEW OF SYSTEM

General survey:
Seen patient sitting on bed with IVF #6 of D5 0.3 NaCl 1L at 30
gtts/min infusing well at the right arm.
Patient is responsive with tired gestures, noted with body weakness upon
movement, verbalized difficulty in breathing.

Skin: upon inspection, patient’s skin is quite pale with nails uncut. No
unusualities in patients extremities.
Cardiovascular: patient has strong palpation and with a pulse rate of 79
bpm. Patient’s blood pressure is 150/100.

PRIORITY NURSING DIAGNOSIS

Alteration in comfort: moderate pain related to physiologic disturbances.

Disturbed sleeping pattern related to environmental changes secondary
to hospitalization.
Constipation related to recent environmental changes secondary to
hospitalization.
Ineffective airway clearance related to excessive secretions.
Fatigue related to insufficient supply of blood into the extremities
secondary to CHF.
LABORATORY RESULTS

Complete Blood Count

RESULTS NORMAL SIGNIFICANCE
VALUES
WBC 6.1/mm3 4.0 – normal
10x10(9)/L
RBC 5.75x10(6) 4.7- Normal
/mm3 6.1x10(12)/L
Hgb 120.2gm%
Hct 53 vol%
neutrophil 66%
Lymphocyt 31%
es
Monophil 0%
Eosinophil 3%
Basophil 0%
Platelet adequate
FBS 84.9
Creatinine 1.0

PATHOPHYSIOLOGY

HEART

Etilogic factor Risk Factors

-autoimmune decreased contraction and filling -age 65 y.o above
 -socio-economic
Decrease amount of blood ejected from ventricle -environmental
-genetics
SNS stimulated to release epinephrine and norepinephrine -lifestyle
-CAD
Loss of beta-adrenergic receptor sites -Cardiomyopathy
-hypertension
Damage to the heart muscle cells

Sympathetic stimulation and renal perfusion decreases

Release of rennin by the kidney

Increase stress on ventricular wall

Increase heart workload

Decreased contractility of myofibrile

Ventricular dilation

Ventricular hypertophy increase in capillary blood supply

Myocardial ischemia

Manifestations:

CNS:
-dizziness GUT:
-lightheadedness -decrease urinary frequency during the day
-fever -nocturia

GIT: Respi:
-nausea and vomiting -dypnea
-enlarged liver -orthopnea
-ascites -bilateral crackles

CVS: Skin:
-tachycardia -pallor
-cardiac enlargement -edema
-anemia
-increased jugular venous distension
 RLE 104

MANDAUE CITY HOSPITAL

WARD
2 – 10 SHIFT

CASE STUDY OF A PATIENT WITH

Congestive heart failure

Submitted by:
John richie N. Delos Santos
Bsn-iv grp 13 submitted to:
Xenia mae p. vale
CLINICAL INSTRUCTOR