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PATIENT’S PROFILE

Name: H. M.

Address: Cabagan, Isabela

Age: 65 y/o

Gender: Male

Civil Status: Married

Religion: Roman Catholic

Nationality: Filipino

Date and time of Admission: April 23, 2007 @ 3:00 pm

Attending Physician: Dr. C. Cinco and Dr. Ramos

Chief complaint: Blurring of vision

Clinical Diagnosis: Hypertension


NURSING HISTORY OF ILLNESS

HISTORY OF PAST ILLNESS

 Patient H.M. doesn’t remember if he had any childhood immunization because


during their time they were not aware about this thing which is a very important
to an individual concerning to our health. .According to the patient, he
experienced childhood illness such as chickenpox and mumps. He doesn’t have
allergy to any foods and drugs. He has good appetite and is able to do activities
like fixing furniture and cooking foods. He is aware that he has high blood
pressure so he take Vascoride as his maintenance. He doesn’t have any previous
hospitalization.

PRESENT HEALTH HISTORY

 Six day prior to admission, the patient has sudden onset of blurring of vision and
he walked differently. Few hours prior to admission, they consulted at CVMC
with high blood pressure. According to the SO, patient H.M. doesn’t want to
confine at CVMC but the physician insisted that he must be admitted so they
brought him to Saint Paul Hospital.

FAMILY HEALTH HISTORY

 According to the patient, they have a family history of hypertension. Almost all
her children acquired it.
GORDON’S 11 FUNCTIONAL HEALTH ASSESSMENT PATTERN

1. Health Perception/ Health Management Pattern

 The patient perceives health as a wealth and a gift from God that must be used
properly because life is too short. He perceives his health as not in good state
because she still experience sensory dysfunction (blurring of vision). He doesn’t
go for check-up even in their nearest clinic. According to him, he just buy
medicine at the drugstore when his illness is unbearable. At this moment, he
manages his health by taking his meds, undergoing hospitalization and by resting.

2. Nutritional/ Metabolic Pattern

Before Hospitalization
 He eats three times a day with adequate amount and no food preferences. He is
fond of eating pork. He also eats her snacks at 9 o’clock in the morning and 3
o’clock in the afternoon. He drinks 8-10 glasses of water a day. He consumed 4
cups of coffee per day.
During Hospitalization
 His appetite has decreased because of his condition and to the hospital
environment. He eats three times a day but in small amount. He easily gets hungry
and is fund of having meat as his food preference.

3. Elimination Pattern

Before Hospitalization
 He urinates 4 to 5 times a day, in moderate amount and has yellow colored urine.
He has no difficulty in urinating. He moves his bowel regularly. He
doesn’t have any blood in the stool. He describe his stool as color light brown and
is semiformed.
During Hospitalization
 He has difficulty in defecating but he frequently voids of about 5 to 6 a day.

4. Activity/ Exercise Pattern

Before Hospitalization
 At this time he doesn’t already but before his work is carpentering. Sometimes he
still apply this in their house by fixing furniture. He is the one who cook for their
meal. He considers walking as his form of exercise.
During Hospitalization
 He just stays at his bed. He still needs assistance in walking and even going to CR
to urinate. He can’t perform on his own ADL’s like taking a bath alone and
grooming his self.

5. Sleep/ Rest Pattern

Before Hospitalization
 He sleeps 8 hours a day. She usually sleeps at 8 pm and wakes up at 6 am. He also
take his every afternoon. He watches television while he is resting.
During Hospitalization
 His sleep hour has increased. He sleeps at 8pm and wakes up at 6 am. Every time
he lay down, he easily gets asleep. And he always feel dizzy.
6. Cognitive/ Perceptual Pattern

Before Hospitalization
 He can do whatever is instructed to him. He can also hear whisper voice. He
doesn’t use eyeglasses.
During Hospitalization
 The patient is oriented to time, place and person. He is responsive but fatigued.
He responds appropriately to verbal and physical stimuli. His recent and remote
memory is not intact. He had understand the health teachings I shared to him.

7. Self-Perception/ Self-Concept Pattern

 He views his self as a kind, industrious, patient and peace loving person. He
expresses worry about his condition and concern for his family but states no
difficulty in dealing with his condition.

8. Role-Relationship Pattern

 His family is intact and close with each other. Conflicts arise between them but
they manage to resolve them easily. He has a good relationship with his sons and
daughters including his in laws, friends, neighbors and relatives.

9. Sexual-Reproductive Pattern

 She lives with his wife only because all his siblings have already their own
family. He has 5 children.

10. Coping Stress/ Tolerance Pattern

 According to him, he seeks his daughter’s advice whenever he has problems. He


is very anxious of his condition. He copes with his condition by taking enough
rest and sleep and by following his doctor’s orders.

11. Value-Belief Pattern

 He is a Roman Catholic. He sometimes attends mass religiously and he use to


pray before going to sleep. He doesn’t believe in any superstitions but he respects
these beliefs. He perceives God as the center of their lives and the source of
strength whenever he is not in the state of good health.
LABORATORY RESULTS

HEMATOLOGY TEST

February 13, 2006

Normal Value Results Analysis

WBC 5-1010 g/L 15.8 Increased; may


indicate infection
RBC 4.2-5.4 x 106L 5.51 Normal

Hgb 12.0-16.0 g/dl 15.8 Normal

Hct 37%-47% 48.6% Increased: may


indicate excess
erythrocyte in the
body or
polycytemia.

DIFFERENTIAL
COUNT

Lymphocyte 20-40% 14% Decreased: due to


immunodeficiency
Monocyte 2%-8% 5%
Normal
NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation


Subjective: Decreased cardiac At the end of the shift,  Monitored and  To establish baseline Goal partially met. The
“Nahihilo at nanghihina output r/t altered stroke the patient’s cardiac recorded v/s. data. patient was able to attain
ako” as verbalized by volume. output will become cardiac output of 60,
the patient. adequate.  Assessed radial pulse  To monitor for thus, cardiac output is
every hour and arrhythmias; impending adequate.
Objective: reported any cardiac arrest.
- CR= 55 bpm deviations from the
- restlessness baseline

 Reduced stressful  To help decrease


elements, such as arrhythmias.
excessive noise in the
patient’s environment.

 Encouraged the patient  To avoid valsalvas


to increase fluid intake maneuver during
and dietary fiber defecation, which can
increase heart rate and
blood pressure, and
decrease cardiac output.

 Changed patient’s  To promote comfort and


position frequently. avoid tachycardia.

 Provided dietary  To reduce risk of cardiac


restrictions. disease.
 Due medication such  It is a drug indicated for
as metoprolol given. hypertension.
NURSING CARE PLAN

Assessment Planning Intervention Rationale


Diagnosis Evaluation
Subjective: At the end of 3 hours,  Assessed response  To identify causative
“Nanghihina ako at Activity Intolerance the patient will be able to to activity factors Goal partially met.
madaling mapagod kya r/t general weakness. report measurable including pre/post The pt. verbalized
maghapon lang akong increase in energy and v/s. measurable increase
nakahiga”,as verbalized by will participate in  To assist pt. to deal in energy but was not
the patient. necessary desired  Provided pt. with with manage factors able to perform the
activities. positive that contribute to desired activities.
Objective: atmosphere. fatigue
 BP=160/100
 PR=55 bpm  Encouraged pt.’s  To provide pt. with a
participation in sense of control
planning of
activities.

 Assisted pt in  To improve mobility.


carrying out self-
care activities.

 Encouraged pt to  To enhance
carry out ADLs. motivation

 Placed pt on a  To maintain body


position of alignment
comfort.
NURSING CARE PLAN

Assessment Diagnosis Planning Intervention Rationale Evaluation


Subjective: Knowledge deficit r/t At the end of 1 hour,  Ascertained what  To reduce potential for Goal met. The patient was
“Paborito ko kasi ang lack of motivation. the patient will be able patient knows non-compliance of able to express desire to
karneng baboy kaya yun ang to express desire to medical regimen change behavior.
gusto kong ulamin namin change behavior.
araw-araw”  Provided explanations  To reduce potential for
and in formations in non-compliance of
Objective: clear and simple medical regimen.
 Inadequate performance of language
test.
 Encouraged pt to  To determine what patient
express feelings. need to know and
building own known
information leads to
successful learning.

 Offered praise when  To help clarify


patient attempts new information and evaluate
behavior. patient’s comprehension.

 Instructed patient and  To motivate patient to


family regarding low- learn more.
sodium, low fat, low
cholesterol diet.

 Instruct patient in  To assist in reducing


isotonic exercises like blood pressure.
walking.
 Made self-available  To help promote weight
to answer questions and loss while reducing BP.
correct misconceptions  To enhance the
for patient. effectiveness of what he’s
learning
 Have pt. incorporate  To practice new skills.
learned skills.
PATHOPHYSIOLOGY
(Hypertension)
Predisposing Factors Precipitating Factors
 Genetic factors  Lifestyle
 Family history  Stress
 Obesity

Aging process

Strain on arterial wall

Loss of elasticity

Increased collagen and calcification of arterial media

Atherosclerosis in intima
Narrowing of blood vessel lumen

Stiffness of aortic and peripheral arteries


Constriction of arterioles

Cardiovascular Neurologic Renal

Increased TPR, CO Decreased baroreceptor sensitivity Sympathetic stimulation

Impaired myocardial O2 Chronic hypertension Angiotensin/aldosterone release


Increased workload on heart Decreased renal blood flow
Increased myocardial O2 consumption Decreased renal oxygenation

Dyspnea on exertion Changes in CSF pressures Ischemia of renal tissues


Ventricular hypertrophy Decrease in cerebral perfusion Renin /aldosterone secretion
Chest pain Decreased in cerebral Oxygen supply Increased BP

Cardiac decompensation memory impairment Nocturia


Coronary artery disease Dull headache in a.m. Na/water retention
MI Vertigo, tremors Increased blood volume
Cardiac failure Decreased GFR

Cerebral edema

Retinal hemorrhage, blurred vision, cerebral hemorrhage, CVA Azotemia, Renal failure
Submitted to:
Ms. Gladys Mae
Pagunuran
Clinical Instructor