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“Acute Coronary Syndrome Non ST Elevation Myocardial Infarction, Hypertensive Cardiovascular Disease, Diabetes Mellitus Type 2, and Community Acquired Pneumonia” nsg asx

“Acute Coronary Syndrome Non ST Elevation Myocardial Infarction, Hypertensive Cardiovascular Disease, Diabetes Mellitus Type 2, and Community Acquired Pneumonia” nsg asx

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Published by: caloi on May 01, 2010
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05/12/2014

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II. NURSING ASSESSMENTA.PERSONAL HISTORY
Mr. Juan dela Cruz is a 68 years old male Filipino, Catholic, who was born onFebruary 8, 1941 at Mabalacat, Pampanga. He is 5’5 ft in height and 59.09 kg in weight.He is married and blessed with three children (two boys and a girl). He currently residesat Balibago, Angeles City with his family. He was a high school graduate in Mabalacat,Pampanga. He is a retired electrician. He was rushed on the emergency departmentof a private tertiary hospital in Angeles City, last November 25, 2009 (Wednesday) at9:00 pm with chief complaints of chest pain described as heartburn, dyspnea, coldclammy skin, pallor and dry mouth. Assessments of the sign and symptoms were doneand standards of care procedure were given at the emergency department. After seriesof initial laboratory and diagnostic exam the client was transferred to the Intensive CareUnit of the said institution with an admitting diagnosis of: Acute Coronary Syndrome,Non ST elevation Myocardial Infarction, Community Acquired Pneumonia, HypertensiveCardiovascular Disease (HCVD) and Diabetes Mellitus type 2. He stayed in theIntensive Care Unit for 4 days from November 25 to 28, 2009 and was transferred to aprivate room on the on the 28
th
day of November the patient was discharged lastDecember 3, 2009 with a final diagnosis of Acute Coronary Syndrome, Non STelevation Myocardial Infarction, Community Acquired Pneumonia, HypertensiveCardiovascular Disease (HCVD) and Diabetes Mellitus type 2.Mr. Juan dela Cruz He is a high school graduate in Mabalacat, Pampanga on theyear 1957. He started to work as an electrician when he was 20 years old approximatelyby the year 1961; he started as a helper of his uncle. He stops working as an electricianat the age of 50 years old approximately the year 1991. He got married on the age of 30by the year 1971. Presently, together with his wife, they are running a small sari-saristore built on the year. According to Mr. Juan Dela Cruz, they are earning an estimatedamount of PHP 3, 000 a month. With regards to the allocation of finances, Mr. & Mrs.Dela Cruz works together in order to solve the problems or what decision to be made.Some of their daily expenses are being paid off through the money being sent by his in-laws and cousins amounting to PHP 30,000 a month. They spend a total of Php.
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20,620.00/mo for their monthly expenses such as foods: 7,500.00, water bill:Php.800.00, electric bill: Php.3, 000.00, groceries: Php. 5, 000.00, gas tank: Php.1,650.00, medical Supplies: Php. 2,000.00, Soap: Php.120.00, laundry soap: Php.250.00, shampoo: Php. 200.00, toothpaste: Php. 100.00. Based from the breakdown of expenses, the money is enough to support the family’s needs and according to theNational Economic and Development Authority (NEDA), for a family not to beconsidered poor, each individual should be provided with at least Php 2,768.60 amonth. Dividing the sum of money among the 7 family members, each person is allottedwith Php 4,714.29 a month which indicates that the family is capable of providing for their needs adequately and thus classifying them as not poor.Mr.Juan dela Cruz used to wake up at around 4:00 am to have his breakfastsuch as coffee with pandesal, fried hotdog, egg and rice after which, he will open andclean the store. At 6:00 am, he will go to the market to buy groceries for their store. Andat 8:00 am, he would stay and sell at their store until 6:00 pm. He usually had his lunchtogether with his family at 12:00 pm they usually as adobo, sinigang, caldereta andpiritong isda at manok, he usually takes a bath at 6:00 pm. And at 7:00 pm, he takes hisdinner; watch television at around 8:00 – 10:00 pm and sleeps at around 10:00 pm.While during Sunday, the whole family will go to mall to have fun.The family of Mr. Juan dela Cruz is purely pampangeños. They could speakCapampangan, Tagalog and English. They have been residing in Angeles City for avery long time now. They are affiliated to the Roman Catholic Church and seldom go tochurch instead hear mass on television and according to them, they do not believe in
 pamahiin and albularyos
. They believe in images that would heal their sickness, wipinghandkerchief over it and pray for their health.The family gets their food from the market. They buy foods every other day andcook meals that is enough for a day to prevent left over foods. But if in case there wereleft-overs, they would store food in the refrigerator. The amount of food, however, is justexact for the family and sometimes they got their food supply in their sari-sari store. Thewife of Mr. dela Cruz is the one who prepares the food. Regular hand washing andproper food handling is being observed when preparing the food. They have a 2 gas
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range with stove and rice cooker for cooking. The entire household’s source of water issupplied by the Angeles Water Works, which is paid monthly. The family uses the samewater for laundry, bathing and house chores but for their drinking water and for cookingis form their water dispenser. The gallon is delivered by a Water Refilling Station near them and spending an amount of Php. 200.00/month while the electricity if provided bythe Angeles electric corporation. The family uses 2 toilet facilities that are carriage type.The toilet is generally clean. It has a shower, sink and a clothesline where they hangtowels and clothes during bathing. A trash can is also placed on one corner in whichthey throw used shampoo sachets, soap cartons, tissue and used napkins. Thedrainage system is closed. But generally water flows at the canal, especially whenever they do laundry. The family has reported zero cases of flood in their area, whichindicates an effective drainage system. The family observed segregation of garbage andit was collected by garbage collectors every week and being paid an amount of Php.80.00 per month. They make sure it is properly tied in order not to attract flies,rodents to invade and to avoid foul smell. The family’s means of communication isthrough telephone. Some members of the family have cellular phones used for textingand calling. They also have computer with internet connection for them to communicaterelatives form other countries. Their transportation needs are catered by a tricycle and jeepney which they own.
B.FAMILY HEALTH - ILLNESS HISTORY
When the researchers interviewed Mr. Juan Dela Cruz regarding his parents, hementioned that both of his parents died of heart attack, when asked about the reasonregarding the real cause of his parents heart attack, Mr. Dela Cruz cannot give theresearchers a concrete answer, as according to him he was just two years old when helost both of his parents. For the researchers to confirm the claim of Mr. Dela Cruz, theresearchers have interviewed his third sister when she visited him in the hospital.According to his sister, she mentioned that their mother died of heart attack when shewas giving birth to Mr. Dela Cruz due to severely increased high blood pressure duringthe delivery, wherein their mother refused a cesarean section as an alternative due tofinancial constraints. It was discussed to them that one of them either their mother or Mr. Dela Cruz will not survived, but their mother chose to save Mr. Dela Cruz. Two
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