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UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS

MINANTE UNO, CAUAYAN CITY, ISABELA

A Case Study
Of
HYPERTENSION EMERGENCY,
HYPERTENSIVE
CARDIOVASCULAR DISEASE
(In partial fulfillment in NCM-101 Related Learning Experience)

Submitted by:

MANUEL, Kristine Nelly M.

GROUP 2 of BSN 3A

Submitted to:

MS. VERLYN F. PEREZ, RN, MSN

Clinical Instructor
UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS
MINANTE UNO, CAUAYAN CITY, ISABELA

INTRODUCTION

A hypertensive emergency is severe hypertension (high blood pressure) with acute


impairment of an organ system (especially the central nervous system, cardiovascular system
and/or the renal system) and the possibility of irreversible organ-damage. In case of a
hypertensive emergency, the blood pressure should be lowered aggressively over minutes to
hours with an antihypertensive agent.

Several classes of antihypertensive agents are recommended and the choice for the
antihypertensive agent depends on the cause for the hypertensive crisis, the severity of elevated
blood pressure and the patient's usual blood pressure before the hypertensive crisis. In most
cases, the administration of an intravenoussodium nitroprussideinjection which has an almost
immediate antihypertensive effect is suitable but in many cases not readily available. In less
urgent cases, oral agents like captopril, clonidine, labetalol, prazosin, which all have a delayed
onset of action by several minutes compared to sodium nitroprusside, can also be used.

It is also important that the blood pressure is lowered not too abruptly, but smoothly. The
initial goal in hypertensive emergencies is to reduce the pressure by no more than 25% (within
minutes to 1 or 2 hours) and then toward a level of 160/100 mm Hg within 2–6 hours. Excessive
reductions in pressure may precipitate coronary, cerebral, or renal ischemia.The diagnosis of a
hypertensive emergency is not only based on the absolute level of blood pressure, but also on the
individual regular level of blood pressure before the hypertensive crisis. Individuals with a
history of chronic hypertension may not tolerate a "normal" blood pressure.

DEMOGRAPHIC PROFILE

PATIENT’S NAME: Patient D

AGE: 49

SEX: Male

ADDRESS:Taguinod St. Linao Norte, Tuguegarao City

CIVIL STATUS: Married

OCCUPATION: Tricycle Driver

RELIGION: Roman Catholic

DATE AND TIME OF ADMISSION: March 07, 2010 at 10:00 in the morning

ADMITTING DIAGNOSIS: Hypertension Emergency HCVD

PRINCIPAL DIAGNOSIS: Hypertension Emergency Epistaxis 2°

ATTENDING PHYSICIAN: Dr. Robin Zingapan


UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS
MINANTE UNO, CAUAYAN CITY, ISABELA

NURSING HISTORY

Present Health History

On March 07, 2010, Patient D was admitted at Tuguegarao City People’s General
Hospital with chief complaint of epistaxis, dizziness, (+) HPN and body weakness. He was
diagnosed with Hypertension Emergency, Hypertensive Cardiovascular Disease (HCVD) with
the initial vital signs of BP-180/110mmHg, CR-86bpm, RR-18cpm, T-37°C.

He undergone with different laboratories like Complete Blood Count with Actual Platelet
Count (CBC with APC), Blood Chemistry such as Sodium (Na), Potassium (K), Fasting Blood
Sugar (FBS), Total Cholesterol, Triglycerides, HDL and LDL.

Past Health History

On December 2007, he was admitted to People’s Emergency Hospital because of sudden


stomachache. According to him, maybe it is cause of its drinking alcohol. He was stayed here for
two days.

On January 4, 2008, he was diagnosed with gallstone at Divine Mercy Wellness Inc., the
physician told him that it is curable by medicines. He was admitted because of the upper right
quadrant pain that radiates at the back.

On March 2009, Patient D was diagnosed with hypertension, gallstone and at the same
time Cardiomegaly in Cagayan Valley Medical Center. He was rushed from Emergency Room
and directly admitted at Intensive Care Unit (ICU) for three days.

He was in and out of the hospital for almost three times.

He also experienced only mild health problems like cough and colds, headache and fever.
When he experienced those, he buys medication like Paracetamol, Neozep and other over-the-
counter (OTC) products in the Pharmacy but sometimes, he prefers to take a rest.

Family History

According to Patient D, He inherited both of the disease he’s parent died. His mother
died with a gallstone and his father died with hypertension. They also had genetic disease of
Cardiomegaly (the enlargement of the heart). Aside from these diseases, no one in their family
had Cancer, Diabetes, and Respiratory disease.

Medical History

He was not yet undergone with any operation. According to him, he’s gallstone can cure
with medications so he may not be able to undergone any surgery.

Personal and Social History

He lives in Barangay taguinod St. Linao Norte, Tuguegarao City, where in he is a tricycle
driver and Barangay chief tanod. In the morning, he is a tricycle driver and when he had duty in
the evening he is a Barangay chief tanod. But most of the time, he is a tricycle driver.
UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS
MINANTE UNO, CAUAYAN CITY, ISABELA
According to him, he has four beautiful daughter and one adopted son. His elder daughter
is now a professional teacher, his second daughter is now on the Singapore because he is a HRM
Student who happened had their On the-Job-Training (OJT) in one of the prestigious Hotel and
Restaurant in Singapore. His third daughter is a second year College and also his adopted son,
his last daughter is in third year high school.

He is very friendly with good relationship with his neighbor. He went to Church every
Sunday and when he likes to go to Church even though it is not Sunday. He also had vices such
as drinking alcohol and smoking but he stopped it for one year. Then after a year, he began again
to drinks and smokes.

He was circumcised at the age of 14. He, then, get married at the age of 19 years old.

Gordon’s Eleven Functional Patterns

1. Health- Perception- Health Management Pattern

 Before Hospitalization:
According to him, being healthy is can partake all necessities including
worked. It is a good source of being healthy because he can do everything
he can without any obstruction.
 During Hospitalization:
According to him, it is very difficult for him to be confined because he
cannot do his daily activities like feeding its pig, doing household every
noon and being a tricycle driver.

2. Nutrition-Metabolic Pattern

 Before hospitalization:
He usually eats three times a day with snacks in between. He usually eats
vegetables, meats and poultry products. He usually consumes 2 cups of rice and 1
cup of vegetables and other meat. He consumes 8-10 glasses of water a day and
drinks 1-2 carbonated drinks occasionally.

 During Hospitalization:
He was advised to eat low fat, low salt diet. He eats the food given by the
hospital. He eats three times a day. He usually eats sausage and drink
carbonated drinks as source of intake. But mostly, the intake of his oral
fluid decreases.

3. Sleep-Rest Pattern

 Before Hospitalization:
His usual sleeping pattern is 5-6 hours from 9:00-3:00 AM. If there is a
chance to take naps, he usually takes naps after eating. Sometimes, he
sleeps from 12:00 midnight to 3:00 because of his duty as a chief tanod.

 During Hospitalization:
He was not able to sleep well in the ward because of interruption when
taking his blood pressure. It is also being interrupted brought by difficulty
of breathing due to his nasal pack that blocks the way of breathing.
UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS
MINANTE UNO, CAUAYAN CITY, ISABELA

4. Elimination Pattern

 Before Hospitalization:
The patient was able to void from 4-5 times a day with a yellowish color
and able to defecate 2-3 times with a yellow stool.

 During Hospitalization:
He urinates ranging from 2-3 times a day with color yellow. He defecates
1-2 times with a dark stool.

5. Activity-Exercise Pattern

 Before Hospitalization:
The patient day to day activity is to take good care and feeding his pigs.
He does also other household chores during afternoon and he cooked for
his family. As a form of exercise, he uses dumbbells and push-ups.

 After Hospitalization:
The patient’s daily activities as well as his exercise become altered
because of his condition. He just standing, lying on bed, sitting on the
chair and make some chitchat to other patients.

6. Cognitive-Perceptual Pattern

 As General:
He can read and write. He uses tagalong and Itawis as his primary dialect.
He is the most dominant who make decision-making but sometimes, he
also asks his wife regarding with his decision.

7. Self-Perception-Self-Concept Pattern

 Before Hospitalization:
He believed that he will recover in just matter of weeks. He believed that
he will regain again his strength. He is type of person who is very
determined and he always thinks of his family. He cares for others and
very helpful to its Barangay.

 During Hospitalization:
The patient wants to recover fast to back in his normal life. According to
him, he missed already his daughters and neighborhood. He misses the
things he used to do before he was admitted.

8. Role-Relationship Pattern

 Before Hospitalization:
The patient can able to comprehend and speaks Tagalog and Itawis to
other people. He is also a good father even though he was only reached
second year highschool. He is good father because, he never let her
daughters suffer but instead he does his best to send them in school.

 During Hospitalization:
Even though his in the hospital, he didn’t forget his role as a father. He
always checks the conditions through texting and calling them in their cell
phones and makes some updates with his wife. He also show courage and
determination to cooperate with the interventions implemented for
promoting wellness.
UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS
MINANTE UNO, CAUAYAN CITY, ISABELA

9. Sexuality-Reproductive Pattern

 As general:
According to him, he shows his love and affection to his wife by showing
that he loves her, by helping his wife with household chores. He also show
his love to his daughters by giving what they need, also with his adopted
son.

10.Coping Stress Tolerance Management

 Before Hospitalization:
According to him,for him tocope up with those problems they encountered
in their marriage life, he pray for guidance and get his strength to his
family.

 During Hospitalization:
He got strength from his family in recovering. He also makes chitchat
from his student nurse and fellow patients in the ward to divert his
attention from his problems and anxiety.

11.Value-Belief System

 Before Hospitalization:
He believed with witch doctors and other creatures that create illness.
They believed in “atang” and other form of rituals. According to him,
“Wala naming mawawalakungmaniniwalaako”. He went to church every
Sunday and when he wants to.

 During Hospitalization:
He prays for his fast recovery. He also believed that he must quit in
pursuing his vices and start to follow his diet which is low fat, low salt diet
to prevent any further complications.
UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS
MINANTE UNO, CAUAYAN CITY, ISABELA

PHYSICAL ASSESSMENT

General Appearance: the patient is sitting on chair conscious, coherent. He is not too tall or
too short. He is chubby with good posture. He is slightly weak looking, with IV line inserted at
his right arm and with dry nasal pack.

Date and Time Started:March 09, 2010 at exactly 9:20 AM

Date and Time Ended:March 09, 2010 at exactly 10:30 AM

Vital Signs:BP-130/90 mmHg T-36.2°C PR- 50 bpm RR-20cpm

ACTUAL NORMAL
BODY PARTS TECHNIQUE ANALYSIS
FINDINGS FINDINGS

Skull Inspection Proportion to Proportional to the size Normal


the size of the of the body, round,
body; with prominences in
symmetrical the frontal area
anteriorly and the
occipital area
posteriorly,
symmetrical in all
planes, gently curved.

Palpation No areas of No areas of tenderness Normal


tenderness

Scalp Inspection Yellowish, White, clean, free from Normal


dandruff, scars, nits and
lesions

Palpation No nodules free from massesand Normal


and masses. lumps; no areas of
tenderness

Hair Inspection Black, evenly Black evenly normal


distributed distributed and covers
the whole scalp, thick,
shiny, free from split
ends.

Palpation Fine Course or fine Normal

Face Inspection Oval shaped, Oblong or oval or Normal


free from square or heart-shaped,
wrinkles symmetrical, facial
UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS
MINANTE UNO, CAUAYAN CITY, ISABELA
expression that is
dependent on the mood
or true feelings, smooth
and free from wrinkles,
no involuntary muscle
movements.

Parallel and evenly


place symmetrical,
Eyes Inspection Parallel, black non-protruding, with normal
scant amount of
secretions

Black, symmetrical,
thick, can raise lower
Black evenly eyebrows
distributed, can symmetrically and
Eyebrows Inspection Normal
raise lower without difficulty,
eyebrows. evenly distributed and
parallel with each
other.

Eyelashes Inspection Black, evenly Black, evenly Normal


distributed distributed

White and
Sclera Inspection White and clear Normal
clear

Proportional to the size


Proportional to
of the eye, round,
Iris Inspection the size of the Normal
black/brown, and
eye
symmetrical.

From pinpoint to Normal


almost the size of the
Constricts as iris, round, symmetrical
Pupils Inspection
the light passes constrict with
increasing light and
accommodation.

Eye Movement Inspection Able to move Able to move eyes in Normal


eyes in full full range of motion or
range of able to move in a
motion direction.

Ears Inspection Parallel, bean- Parallel, symmetrical, Normal


shaped proportional to the size
of the head, bean-
shaped, helix is in line
with the outer canthus
of the eye, skin is the
same color as the
surrounding area,
UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS
MINANTE UNO, CAUAYAN CITY, ISABELA
clean.

Palpation Firm cartilage Firm Cartilage Normal

With presence Pinkish, clean, with


Ear canal Inspection of cerumen and scant amount of Normal
a few cilia cerumen and a few cilia

Midline, symmetrical Due to nasal


Nose Inspection Not patent
and patent packed

Lips Inspection Dry lips, black Pinkish, symmetrical,


Due to mouth
in color lip margin well
breathe and
defined, smooth and
smoking
moist

Pinkish, smooth, moist,


No swelling, Due to
Gums Inspection no swelling, no
dark in color smoking
retraction, no discharge

Teeth Inspection Incomplete 32 permanent teeth,


teeth, not well well align, free from
align, with carries or filling,
presence of halitosis. Due to poor
steel at the oral hygiene
middle tooth.

Absence of
halitosis

Tongue Inspection Medium, Large, Medium, red or


moist, can’t pink, slightly rough on Due to nasal
raise up the top, smooth along packed
tongue lateral margins, moist, attached.
shiny, freely movable.

Pinkish and Pinkish, moist and


Cheeks Inspection Normal
moist smooth

Tonsils Inspection Non-inflamed Pinkish, non-inflamed Normal

Inspection Proportional to the size Normal


Symmetrical
and of the head,
Neck
proportional to symmetrical and
the size of the straight
head
UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS
MINANTE UNO, CAUAYAN CITY, ISABELA

No palpable lumps,
masses, tenderness
Palpation No palpable Normal
masses, lumps Adam’s apple are
and tenderness palpable

Freely
Range of motion movable Freely movable without
Inspection Normal
of neck without difficulty
difficulty

Arms Inspection Dark brown Skin color varies, Normal


with fine hair symmetrical, fine hair
evenly distributed,
Presence of
presence of visible
visible veins
veins
Presence of
Warm, dry and elastic,
scars in right
no areas of tenderness.
arm
Muscle appears equal
with good muscle tone

No areas of tenderness

No areas of Normal
Palpation
tenderness

Nails Inspection short andclean. Nails are transparent, Normal


smooth, and convex
with pink nail beds and
white translucent tips

1-2 second
Palpation Normal
capillary refill
UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS
MINANTE UNO, CAUAYAN CITY, ISABELA

Dark brown, Presence of


Inspection Skin color varies, skin
presence of varicose
Legs is smooth, fine hair are veins is due
varicose veins
evenly distributed, to tricycle
absence of varicose driver
veins, muscles andchief
symmetrical, length tanod.
symmetrical.

Muscle Muscles appear equal,


Palpation
appears equal warm and with good Normal
muscle tone.

Rough foot, Five toes in each foot;


Toes Inspection presence of Rough foot
sole and dorsal surface
cracks, with is smooth; with pink
long toenails. nail beds and white
translucent tips.

1-2 second of Normal


palpation Comes back 1-2 second
capillary refill.

Inspection Symmetrical The chest is contour is Normal


symmetrical and the
chest is twice as wide
Thorax and as deep. The spine is
Lungs straight. Posteriorly,
the ribs tend to slope
(anterior and across and down. The
posterior) ribs are prominent in a
thin person. There is no
bulging or retraction of
the ICS during
breathing.

The chest wall moves


symmetrically during
respiration.

Palpation No masses No lumps, masses, Normal


areas of tenderness
UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS
MINANTE UNO, CAUAYAN CITY, ISABELA

Percussion Resonance Percussion note varies Normal


with the thickness of
the chest wall.

Auscultation Presence of Bronchovesicular Due to


wheezes sounds excessive
secretions.
RR- 23cpm
UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS
MINANTE UNO, CAUAYAN CITY, ISABELA

No pulsations
Heart Inspection and No pulsations, No pulsations Normal
Palpation in apical area
pulsations No pulsations
visible and
Pulsations visible and
Aortic valve palpable.
palpable
Pulmonic area Abdominal aortic
Tricuspid area pulsations visible and
palpable.
Apical area

Epigastric area

The two heart sounds


PR- 92bpm Normal
auscultation are audible in all areas
but loudest at apical
area

Cardiac rate ranges


from 60-100bpm

Abdomen Inspection Flubby Skin is unblemished, Normal


no scars, color is
uniform, flat, rounded
or scaphoid,
UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS
MINANTE UNO, CAUAYAN CITY, ISABELA
symmetrical
movements caused by
respiration, aortic
pulsations at epigastric
area visible in thin
persons, umbilicus is
flat or concave,
positioned midway
between the xiphoid
process and the
symphysis pubis, color
is the same as the
surrounding skin.

Auscultation presence of There are clicks and normal


borborygmi, gurgles, the frequency
of which has been
estimated at from 5-34
per minute.

Percussion Tympany predominates


because of the presence
of air in the stomach
and intestines.
Percussion is dull at the
liver’s lower boarder.

Palpation no masses and Soft abdomen, no Normal


tenderness. tenderness, no muscle
guarding, no lumps, or
masses, no
organomegaly.

Liver’s edge feels firm


and non-tender.
UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS
MINANTE UNO, CAUAYAN CITY, ISABELA

LABORATORY

HEMATOLOGY March 07, 2010

Examinations Result Reference Analysis


WBC 5.2 3.5-10.0 Normal
RBC 4.79 3.8-5.8 Normal
HGB 12.4 11.0-16.5 Normal
HCT 36.0 35-50 Normal
PLT 195 150-390 Normal
Differential Count Normal
LYM 30.3 17-48 Normal
MON 5.0 2.0-6.0 Normal
GRA 64.7 43-76 Normal
TOTAL 100 Normal

BLOOD CHEMISTRY March 07, 2010

Examination Result Reference Value Analysis


Na 134 135-155 Decrease. Due to
hyponatremia, the too
much loss of sodium
in the body.
K 4.4 3.60-5.50 Normal

BLOOD CHEMISTRY March 08, 2010

Examination Result Reference Value Analysis


Glucose: Fasting 5.41 3.89-5.83 Normal
Total Cholesterol 5.11 Up to 5.20 Normal
HDL 0.64 Up to 1.56 Normal
LDL 4.26 Less than 3.90 Increase. Due to
increase bad
cholesterol in the
body that may leads to
serious heart problem
like arterioschlerosis,
stroke.
Triglycerides 1.01 Up to 1.70 Increase. Due to
presence of excessive
fat in the body that
may lead to heart
attack.

FECALYSIS March 13, 2010

Physical Character: Watery


Color: Yellow Brown
Bacteria ##
WBC 6-8
RBC 2-4
Fat Globules ∕
Yeast Cells ∕
Parasite/Ova E. Histolytica Cyst Seen
Amoeba: E. Histolytica Cyst Seen
UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS
MINANTE UNO, CAUAYAN CITY, ISABELA

ANATOMY AND PHYSIOLOGY

9. Right Atrium
10. Right Ventricle
1. Right Coronary
11. Left Atrium
2. Left Anterior Descending
12. Left Ventricle
3. Left Circumflex
13. Papillary Muscles
4. Superior Vena Cava
14. Chordae Tendineae
5. Inferior Vena Cava
15. Tricuspid Valve
6. Aorta
16. Mitral Valve
7. Pulmonary Artery
17. Pulmonary Valve
8. Pulmonary Vein
Aortic Valve (Not
pictured)

The heart is the muscular organ of the circulatory system that constantly pumps blood throughout
the body. Approximately the size of a clenched fist, the heart is composed of cardiac muscle
tissue that is very strong and able to contract and relax rhythmically throughout a person's
lifetime.

The heart has four separate compartments or


chambers. The upper chamber on each side of
the heart, which is called an atrium, receives and
collects the blood coming to the heart. The atrium
then delivers blood to the powerful lower
chamber, called a ventricle, which pumps blood
away from the heart through powerful, rhythmic
contractions.The human heart is actually two
pumps in one. The right side receives oxygen-
poor blood from the various regions of the body
and delivers it to the lungs. In the lungs, oxygen
is absorbed in the blood. The left side of the
heartreceives the oxygen-rich blood from the
lungs and delivers it to the rest of the body.
UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS
MINANTE UNO, CAUAYAN CITY, ISABELA
The Sinoatrial Node (often called the SA node or sinus node)
serves as the natural pacemaker for the heart. Nestled in the
upper area of the right atrium, it sends the electrical impulse that
triggers each heartbeat.

The impulse spreads through the atria, prompting the cardiac


muscle tissue to contract in a coordinated wave-like manner.The
impulse that originates from the sinoatrial node strikes the
Atrioventricular node (or AV node) which is situated in the
lower portion of the right atrium.

The atrioventricular node in turn


sends an impulse through the
nerve network to the ventricles,
initiating the same wave-like
contraction of the ventricles.The
electrical network serving the
ventricles leaves the atrioventricular node through the Right and
Left Bundle Branches. These nerve fibers send impulses that
cause the cardiac muscle tissue to contract

1. Sinoatrial node (SA node)


2. Atrioventricular node (AV node)
3. Common AV Bundle

Right & Left Bundle Branches

Systole

The contraction of the cardiac muscle tissue in the ventricles is called systole. When the
ventricles contract, they force the blood from their chambers into the arteries leaving the heart.
The left ventricle empties into the aorta and the right ventricle into the pulmonary artery. The
increased pressure due to the contraction of the ventricles is called systolic pressure.

Diastole
The relaxation of the cardiac muscle tissue in the ventricles is called diastole. When the ventricles
relax, they make room to accept the blood from the atria. The decreased pressure due to the
relaxation of the ventricles is called diastolic pressure.

Electrical Conduction System

The heart is composed primarily of muscle tissue. A network of nerve fibers coordinates the
contraction and relaxation of the cardiac muscle tissue to obtain an efficient, wave-like pumping
action of the heart.
UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS
MINANTE UNO, CAUAYAN CITY, ISABELA

PATHOPHYSIOLOGY

Predisposing Factors Precipitating Factors


(Non-modifiable) (Modifiable)
1. Age – 49 years old 1. Diet
2. Sex – Male 2. Lifestyle
3. Race – Filipino

Idiopathy

Stress Geriatric Considerations

Cell membrane alteration


Overactivity of the
Symphatetic Nervous Renin – angiotension
System excess
Accumulation of
atherosclerotic plaque

Increase contractility
Fragmentation of arterial
Functional /BV
elastins
Constriction
Increase Cardiac output

Collagen deposits

Peripheral resistance
Elasticity of BV

Increase BP

Nose bleed
Nape pain dizziness
UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS
MINANTE UNO, CAUAYAN CITY, ISABELA

COURSE IN THE WARD

DATE/TIME DOCTOR’S ORDER RATIONALE NURSING


RESPONSIBILITIES
March 07, 2010 Please admit to Male -initiates initial care -Facilitated transfer
Ward from ER to Male
9:50 AM Ward.
Secure consent for -For legal basis of - Assessed the patient
admission and continuous care and level of consciousness
management management. before letting him sign
the consent
Low salt, low fat diet -To control the health -Instructed the patient
condition of the to avoid salty and fatty
patient foods
Vital signs every 4 -To obtain baseline -Monitored every shift
hours data to know the condition
of the patient
Diagnostics: -To determine Facilitated laboratories
whether there is exams.
CBC with APC, NaK, abnormalities within.
FBS, Total Cholesterol,
triglycerides,HDL,LDL
Treatment: -To help maintain -Regulated IVF to 8-10
fluid and electrolytes gtts/min
IVF: D5W ½ L x KVO in the body and
replace what was lost
TF: D5W ½ L x KVO
Meds:

Clonidine drip: 90cc of -To lower blood -Assure the ten rights
D5W + 1amp of pressure of administering
clonidine in solucet to medicine
run at 15ugtts/min,
increment 5ugtts/min
every 1 hour if
BP≥140/90.
Amlodipine 10mg/tab, -Management of -meds given once a
1 tab OD (Hold if BP ≤ hypertension, angina day
120/80) pectoris.
High back Rest -to prevent aspiration -Maintained on high
of blood. bask rest
I&O every 4 hour
Refer -For immediate -Report any un
report. towards signs and
symptoms.
Refer to ENT for nasal -To identify the -Facilitated referral to
problem problem within the ENT.
nasal part
1:40 pm For nasal packing -To prevent from -Facilitated nasal
bleeding. packing;dry
UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS
MINANTE UNO, CAUAYAN CITY, ISABELA
ENT Notes ----- ----
Thank you for referring acknowledging ----
Partial seen and -To identify the -Facilitated partial
examined problem at the nose examination of the
nose
Anterior nasal packing -For prevention of -Facilitated nasal
dry bleeding packing
Secure consent please For legal purposes Assessed the patient
level of consciousness
before letting him sign
the consent
Start on sultamicillin For upper and lower Sultamicillin started.
750mg tablet TID PO respiratory tract
infections, UTI and
pyelonephritis; skin
and soft tissue and
gonococcal
infections.
Will follow up patient For follow up check Facilitated follow up
up check up
Refer accordingly For immediate report Report it immediately
March 08, 2010 Continue Management For continuous care Continue therapeutic
and management management
TF: D5W ½ L x KVO -To help maintain -Regulated IVF to 8-10
fluid and electrolytes gtts/min
in the body and
replace what was lost
March 09, 2010 IVFTF: D5W ½ L x -To help maintain -Regulated IVF to 8-10
KVO fluid and electrolytes gtts/min
in the body and
replace what was lost
Clonidine drip to -To lower blood -Clonidine drip
consume pressure consumed.
Give captopril 25mg -To lower blood -Meds given as needed
SL prn for SBP ≥140 pressure as needed
March 10, 2010 IVFTF: D5W 1L x -To help maintain -Regulated IVF to 8-10
8:00am KVO fluid and electrolytes gtts/min
in the body and
replace what was lost
Tranexamic Acid -For hemorrhage or -Meds given 2x a day
500mg 1 cap BID risk of hemorrhage in
increase fibrinolysis
or fibrogenolysis.
Possible discharge -Readiness for -Promoted wellness.
tomorrow if OK with enhance therapeutic
Dr. Reyes regimen
management.
March 11, 2010 IVFTF: D5W 1L x -To help maintain -Regulated IVF to 8-10
KVO fluid and electrolytes gtts/min
8:00 Am in the body and
replace what was lost
Cont. meds For continuous care Continue therapeutic
and management management
For nasal cautery For removal of nasal Facilitated the nasal
tomorrow @ 1PM packing under local cautery
under L.A. bedside anesthesia
UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS
MINANTE UNO, CAUAYAN CITY, ISABELA
Refer accordingly -For immediate -Report any un
report. towards signs and
symptoms.
March 12, 2010 S/P: chemical cautery -for removal of nasal -Facilitated chemical
packing. cautery of nasal septi
vessels.
MGH if ok with other -Readiness for -Promoted wellness.
AP enhance therapeutic
regimen
management.
Home meds: -For upper and lower -Instructed patient to
respiratory tract continue all home
Sultamicillin 750mg infections, UTI and meds.
for TID PO pyelonephritis; skin
and soft tissue and
gonococcal
infections.
Follow up @ -For follow up check -Instructed patient to
CITIMEDIC on up come back on Monday
Monday, March 15, follow up check up at
2010 @ 11am citimedic
Refer accordingly -For immediate -Report any un
report. towards signs and
symptoms.
3:30pm Home meds: -Management of -Instructed patient to
hypertension, angina continue all home
Amlodipine 10mg OD pectoris. meds.

March 13, 2010 MGH -Readiness for -Promoted wellness.


enhance therapeutic
regimen
management.
THM: Amlodipine -Management of -Instructed patient to
10mg OD hypertension, angina continue all home
pectoris. meds.

TCB: after 1 week -For follow up check -Instructed patient to


up come back after 1week
follow up check up at
OPD
Defer MGH -Some problems are -Discontinuation of the
identified order
For fecalysis anytime -For fecalysis -Facilitated laboratory
exams.
Metronidazole 500mg -antibiotic -due meds given
1 tab, 1 tab TID
refer -For immediate -Report any un
report. towards signs and
symptoms.
March 14, 2010 Continue management For continuous care Continue therapeutic
and management management
TF: PLRS 1L x 8 hours -To help maintain -Regulated IVF to 30-
fluid and electrolytes 31 gtts/min
in the body and
UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS
MINANTE UNO, CAUAYAN CITY, ISABELA
replace what was lost
4:40pm TF: PLRS 1L x 8 hours -To help maintain -Regulated IVF to 30-
3 cycles fluid and electrolytes 31gtts/min
in the body and
replace what was lost
March 15, 2010 MGH -Readiness for -Promoted wellness.
enhance therapeutic
regimen
management.
Metronidazole 500mg -antibiotic Instructed patient to
TID x 5 days continue all home
meds.
Amlodipine 10mg OD Management of Instructed patient to
hypertension, angina continue all home
pectoris. meds.

Follow up checked up For follow up check Instructed patient to


1 week up come back after 1
week follow up check
up at OPD
UNIVERSITY OF PERPETUAL HELP SYTEM-ISABELA CAMPUS
MINANTE UNO, CAUAYAN CITY, ISABELA

DISCHARGE CARE PLAN

MEDICATION Advised to take and continue all oral meds at


home for maintenance.

HOME MEDS:

-Amlodipine 10 mg OD

-Metronidazole 500mg TID PO x 5 days


EXERCISE Encourage patient to perform light exercises
such as deep breathing and walking.
TREATMENT Advised patient to avoid or limit vices like
smoking and drinking alcohol
HYGIENE Good proper hygiene such as daily bathing,
washing of hands before and after eating
emphasized.
OPD-FOLLOW UP Advised patient to come back for follow up
check up on Friday, March 19, 2010, 9:00 AM
at OPD
DIET Advised patient to avoid or lessen salty and
fatty foods.
SPIRITUAL/ SEXUAL Encouraged patient to attend Sunday mass and
pray at night together with his family for
spiritual guidance.

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