I. ASSESSMENT A. General Data Patient’s Initials: C.L.

Address: Paranaque City Age: 74 years old # of Days in this Hospital: 6 days Sex: Male

Civil status: Married Occupation: Retired Production Supervisor Date of Birth: January 27, 1934 Place of Birth: Manila Date of Admission: January 11, 2009; 2300 H Order of Admission: Via Stretcher Informant: 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 Furosemide 10 mg x 1 tablet OD-AM 40 mg x 1 tablet OD-AM

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Spironolactone Isosorbide Mononitrate Clopidogrel Aspirin Carvedilol Ketosteril Simvastatin Telmisartan Betahistine Insulin – Novomix Iberet Isordil

25 mg x ½ tablet OD-AM 60 mg x ½ tablet BID 25 mg x 1 tab OD-AM 80 mg x 1 tab OD-After Lunch 25 mg x ½ tab BID 600 mg x 1 tab TID 40 mg x ½ tab OD-HS 80 mg x 1 tab OD-PM 1 tab PRN x 3 days 18 u before breakfast; 22 u before supper 500 mg x 1 tab OD-AM 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 Furosemide Spirinolactone Isosorbide Mononitrate Clopidogrel Aspirin Carvedilol Ketosteril Simvastatin Telmisartan Betahistine Insulin – Novomix Iberet Isordil 10 mg x 1 tablet OD-AM 40 mg x 1 tablet OD-AM 25 mg x ½ tablet OD-AM 60 mg x ½ tablet BID 25 mg x 1 tab OD-AM 80 mg x 1 tab OD-After Lunch 25 mg x ½ tab BID 600 mg x 1 tab TID 40 mg x ½ tab OD-HS 80 mg x 1 tab OD-PM 1 tab PRN x 3 days 18 u before breakfast; 22 u before supper 500 mg x 1 tab OD-AM 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

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

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

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

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

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Though, he verbalizes not being happy with the situation with his son, 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 L.C. R.C. M.C. I.G. Relation Patient Wife Son Employee Age 74 y/o 70 y/o 19 y/o 23 y/o Sex Male Female Male Female Occupation Retired Housewife Student House Helper Educational Attainment College Graduate High School Graduate High School Graduate High School Graduate

G. Heredo- Familial Illness 1. Maternal: Diabetes Mellitus, Hypertension 2. Paternal: Diabetes Mellitus, Kidney disease

H. Developmental History Theory/ Theorist Psychosocial theory Eric Erikson Age 74 years old Task Integrity VS. Despair Patient Description 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 him) to face death itself.

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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 theory Lawrence 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. The patient believes what you do to

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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 theory James 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 fairplay, 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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• • P: • • • B. Nails: I:

Superficial blood vessels are visible in hands and feet Absence of lesions Dry skin Warm to touch Poor skin turgor

• • • • • P: • • • •

Transparent, well-rounded and convex Fingernails are clean and short Blackened toenails Cuticles of the fingernails are intact without inflammation Fingernail beds are pale

Smooth fingernails Rough toenails Firmly attached to nail bed Capillary refill= 5 seconds

C. Head and Face: I: • • • • P: • • 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 Absence of deformities, lumps or masses Absence of tenderness Normocephalic and positioned on the midline Proportion to gross body structure Facial expressions are symmetrical Presence of white hair

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• • • • • • • • • P: • E. Ears: I: • • • P: • • Tests: • • • • F. Nose: I: • • P: • •

Corneas are shiny and smooth Pupils are equally round and reactive to light and accommodation 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 Absence of tenderness and drainage from lacrimal apparatus

Bean shaped At the level of outer canthus of the eyes Absence of discharges and lesions Firm and smooth Absence of tenderness

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

Nose is same color as skin Nasal mucosa is pinkish and moist Patent nares Absence of masses and tenderness

G. Mouth and Pharynx: I:

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• • • • H. Neck: I: • • • P: • • I. Spine I: • • P: •

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

Symmetric Proportion to gross body structure Absence of neck vein engorgement Absence of tenderness, masses and deformities Lymph nodes are not palpable

Located at the midline With slight curved kyphosis Absence of tenderness, masses or lumps

J. Thorax and Lungs I: • • • • • • P: • • Absence of lumps and masses Chest Excursion: Symmetrical Tactile Fremitus: Symmetrical; vibrations are heard strongest on top 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


Pe: • A:

Dull sounds are noted

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Presence of fine bi-basal crackles

K. Heart/Cardiovascular I: • P: • • • • A: Absence of jugular vein distention Weak radial pulses Weak dorsalis pedis pulses Absence of heaves, lifts, or thrill Absence of visible pulsations


• •

PMI is located at the 5th intercostals space left midaxillary line Presence of S1 and S2 Absence of murmurs

L. Breast: I: • • • • P: • • Absence masses or lumps Absence of discharge in nipples Breasts are symmetric Areola is light brown Nipples are everted Absence of dimpling and retraction

M. Abdomen: I: • • • • • A: • Pe: • Pa: • Soft Tympany heard over the stomach Bowel sounds: 23 bowel sounds per minute 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

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• •

Absence of masses Absence of organomegaly

N. Extremities I: Arms: • • • • • 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 Symmetrical Absence of swelling and venous enlargement Symmetrical Absence of swelling and venous enlargement Presence of scar on the right leg

Legs:

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

19

• • •

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

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

20

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 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.

21

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 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 WBC NORMAL VALUE 4.5 – 11 x 10^9/L RESULT 1/11/09 13.3 RESULT 1/13/09 9.10 RESULT 1/14/09 8.2 INTERPRETATION/ SIGNIFICANCE 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 LYMPH 0.25 –0.40 x 10^9/L .24 .24 .27 have infection or inflammation. 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 HGB 140 – 170 g/l 100 88 105 since the WBC is normal. 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 in a decrease Hgb. The patient’s Hgb has increased but still below the

25

normal level on January 14, 2009 because 1 unit of pack RBC was RBC 4.50 – 6.5 x 10^12/L 3.48 3.06 3.69 transfused to him last January 13, 2009 at 10 in the evening. 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 HCT 40 – 54 % 31% 27% 32% January 13, 2009. 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 PLATELETS 200 – 400 Adequat e SEGMENTERS .55 -.65 .80 Adequat e .87 Adequat e .80 plays an important factor in RBC production. 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. 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. LABORATORY NORMAL VALUE RESULT 1/11/09 RESULT 1/12/09 RESULT 1/13/09 RESULT 1/16/09 INTERPRETATION/ SIGNIFICANCE

26

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. 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. 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 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.

BUN

7.98 - 20 mg/dl

96.33

100.45

59.38

57.98

CREATININE

0.6 - 1.3 mg/dl

3.98

3.07

3.92

2.22

27

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.. 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. 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. NORMAL; Troponin is a protein found in the cardiac 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.

POTASSIUM

3.80 - 5.60 mmol/L

7.6

6

4.4

4

CK -MB

0 - 24 U/L

15

----

----

----

TROPONIN

Negative

Negative

----

----

----

28

29

LABORATOR Y (Urinalysis) COLOR TRANSPARE NCY REACTION

NORMAL VALUE Yellow Clear 4.5 – 8

RESULT (Jan. 12, 2009) Dark Yellow Cloudy 6.0

INTERPRETATION/ SIGNIFICANCE

The patient’s color of urine is dark yellow since there is presence of RBC in his urine due to kidney damage. Cloudy urine of the patient is due to the presence of RBC,. 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. 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. INCREASED; Proteins are sensitive indicator of kidney function. Normally, protein 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. 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 NORMAL; This test was taken to assess if the patient might have infection. 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. The presence of bacteria indicates might indicate presence of infection. January 11, 2009

SPEC. GRAVITY

1.005 – 1.025

1.002

ALBUMIN

negative

+2

GLUCOSE

Negative

LEUKOCYTE S RBC

0 - 4/ hpf <2/ hpf

2/ hpf 3-4/ hpf

BACTERIA

Negative

Few

Electrocardiography ECG #79213

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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 FINDINGS:

January 11, 2009

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

Echocardiographic Information

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Dimension LV (ed) LV (es) IVS (ed) IVS (es) LPVW (ed) LVPW (es) Aorta LA (ap diam) MPA LVET EPSS LVOT

Measureme nt 5.6 4.1 .9 .9 1.1 1.3 3.6 4.1 2.2 280 1.1 2.2

Normal 4.5-5 cm .8- 1.1 .8- 1.1 3- 3.5 3- 3.5

Dimension LVEDV LVESV SV CO EF FS VCF LV mass RA RV MV Annulus TV Annulus

Measureme nt 152 74 78 cc 3978 cc 51% 27% 213 3.9 3.7 2.8 2.5

Normal

55- 57% 29- 42% .5- 1.5

3.5- 4 cm 2.2- 4 cm

< 1 cm

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

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33

34

35

36

37

38

39

40

41

42

43

44

45

46

47

48

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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 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 Nursing Diagnosis Decreased cardiac output related to altered myocardial contractility Rationale 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 Goals and Objectives 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. Strong peripheral • Auscultate heart sounds. Nursing Intervention Independent • Monitor vital signs (e.g. heart rate, BP). Tachycardia may be linked with a drop in Decreased cardiac output cardiac output which is may be reflected in secondary to decreased diminished peripheral stroke volume. Changes pulses. It is due in blood may also occur to inadequate blood flow to pressure (hypotension or the peripheral pulses. of hypertension) because cardiac response. Pallor is indicative of diminishedcan occur with S3, or S4 peripheral perfusion secondary to cardiac decompensation inadequate cardiac or some medications. S1 output. Cold,be weak skin and S2 may clammy is secondary to because of diminished compensatory increase in pumping action. sympathetic nervous system stimulation and low cardiac output. Changes in sensorium Rationale Evaluation After 2 hours of nursing intervention, the goal was partially met as evidenced by the following: Vital Signs: PR= 70 beats per minute HR= 72 beats per minute RR= 20 breaths per minute BP= 120/80 mm Hg - Weak and decreased peripheral pulse

o

50

dyspnea - Vital Signs: PR= 68 beats per minute HR= 70 beats per minute RR= 22 breaths per minute BP= 120/80 mm Hg Temp: 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.

pulses o Capilliary Refill of less than 3 sec. Regular cardiac rhythm. Reports decreased severity of exertional dyspnea. Participates in self-care activities without feeling exhaustion. • Palpate peripheral pulses.

may - Pale nail beds 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. - Capillary refill of 5 seconds - Able to perform self care activities such as combing hair, feeding, and changing of clothes.

o

Inspect skin color and temperature.

o

o

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 semito- high fowler’s

Source:

This position reduces

51

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

position.

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

Maintain physical and emotional rest as in the following: o Restrict activity. 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.

o

Provide quiet and relaxed environment.

o

Organize nursing and medical care.

o

o

Provides for adequate rest periods. Assists in performing self-care Physical rest improves efficiency of cardiac activities. contraction and to decrease myocardial oxygen demand/ Have patient avoid activities eliciting a consumption and vasovagal response workload.

52

such as straining during defecation, holding breath during position changes. o Encourage immediate reports of pain for prompt administration of medication as indicated.

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

Collaborative: Administer Digoxin (Lanoxin) 0.25 mg ½ tab

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

PO every other day
Digoxin increases contractility of the myocardium by inhibiting ATP and sodiumpotassium 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 excitationcontraction coupling. Source/s: 1. Nursing Care Plans (6th ed)

53

Marilyn Doenges Page 63-64 2. Delmar’s Critical Care (Nursing Care Plans, Sheree Comer,2nd edition. Page 31-33 Date: January 15, 2008 (Thursday) 3:00 pm Data/Cues 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. Nursing Diagnosis Activity Intolerance related to fatigue and exertional dyspnea. Rationale 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 Goals and Objectives 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 Nursing Intervention 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. Rationale Evaluation 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 energyconservation techniques. Patient was able to perform Self Care Activities such as

Close monitoring serves as a guide for optimal progression of activity During 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.

54

Exertional Dyspnea - Vital Signs: PR= 68 beats per minute HR= 70 beats per minute RR= 22 breaths per minute BP= 120/80 mm Hg Temp: 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/Myers Textbook of Medical Surgical Nursing, 11th edition

o

Client verbalizes and uses energyconservation techniques

o o

Light-headedness, dizziness, pallor , diaphoresis Chest discomfort

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

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:

55

Sitting to do tasks

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

Changing position often

Working at an even pace

Teach ROM and strengthening exercises

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 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 - Patient has been Nursing Diagnosis Constipation related to decreased peristalsis secondary to decreased level of activity. Rationale 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. Planning 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 Nursing Intervention 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. Rationale Evaluation 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.

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.

57

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. MedicalSurgical 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 Cues/ Needs Subjective Data: “Hindi ako gaanong makatulog kasi kahit gabi merong pumapasok dito sa kwarto”as verbalized by the patient. Objective Data: Nursing Diagnosis Sleep pattern disturbance related to routine hospital procedures during night shift. Rationale 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 Planning 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 Interventions 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 Rationale Evaluation After 24 hours of nursing interventions, the goal was MET as evidenced by: -Well-rested appearance -To promote relaxation -These promote sleep and relaxation through -To promote minimal -Verbalized that he was able to rest well during the night -Verbalized that he was able to sleep longer hours

-To promote sleep and rest

58

-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.

pattern

and eliminate nonessential nursing activities -Attempt to allow for sleep cycle of at least 90 min

interruption in sleep/rest -Experimental studies have indicated that 6090 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

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

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

-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

-Napping can disrupt normal sleep pattern -To reduce need for voiding during night

59

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

- This drug is indicated for short-term management of insomnia. It

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

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 Cues/ Needs 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 Nursing Diagnosis Ineffective Management of Therapeutic Regimen related to conflict between personal beliefs and the prescribed therapeutic regimen. Rationale 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 Planning After 8 hours of nursing intervention, the patient will verbalize readiness to modify present management of therapeutic regimen. Nursing Interventions Assess the patient’s readiness and ability to learn. Rationale 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 Evaluation After 8 hours of nursing intervention, the goal was not met. The patient still insisted on not following his prescribed diet. Expected Outcomes:

Assess what the patient already

61

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 FatDiabetic 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. MedicalSurgical Nursing Care Plans. Pp 967- 970

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

knows.

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.

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.

-Patient shows resistance when being taught about effective management of his condition. -patient did not ask questions on how to improve his present condition.

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

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management, as well as for early detection of complications. Source: Rodger, Shielda R. MedicalSurgical 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.

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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.

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.

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> 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. > 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 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

may cause to make up breathless @ night)

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

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• • •

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 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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