DEMOGRAPHIC DATA Name of the patient Age Address Gender Birth date Birth place Civil status Nationality

Religion Occupation Admission Date Admission Time Chief complaint : Mr. C.F. : 52 y.o : Burgos St. Sudlon Alang-alang, Mandaue City : Male : 9/22/55 : Mandaue City : Married : Filipino : Roman Catholic : None : 7/26/08 : 4:45 pm : 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 Alangalang, 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 kanun”, 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 WBC RBC Hgb Hct neutrophil Lymphocyt es Monophil Eosinophil Basophil Platelet FBS Creatinine 6.1/mm3 5.75x10(6) /mm3 120.2gm% 53 vol% 66% 31% 0% 3% 0% adequate 84.9 1.0 NORMAL VALUES 4.0 10x10(9)/L 4.76.1x10(12)/L SIGNIFICANCE – normal Normal

PATHOPHYSIOLOGY HEART Etilogic factor -autoimmune decreased contraction and filling Risk Factors -age 65 y.o above

Decrease amount of blood ejected from ventricle SNS stimulated to release epinephrine and norepinephrine Loss of beta-adrenergic receptor sites 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 -lightheadedness -fever GIT: -nausea and vomiting -enlarged liver -ascites CVS: -tachycardia -cardiac enlargement -anemia -increased jugular venous distension

-socio-economic -environmental -genetics -lifestyle -CAD -Cardiomyopathy -hypertension

GUT: -decrease urinary frequency during the day -nocturia Respi: -dypnea -orthopnea -bilateral crackles Skin: -pallor -edema

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

CLINICAL INSTRUCTOR

submitted to: Xenia mae p. vale

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