I.

Nursing Assessment
This chapter covers the different nursing assessment documented, they reflect the condition of Lola Tere.

A. Personal History

1. Demographic Data
Lola Tere is 69 years old born on June 17, 1941 who is currently a widow and religiously affiliated with the Roman Catholic Church. She is
a full blooded Filipino citizen.
She currently resides in a four-roomed concrete house located at Sitio Calibutbut. She lives together with her three siblings. She is fourth
among her 12 siblings.
Lola Tere was admitted last January 21, 2010 in a district hospital in Angeles City with a chief complaint of difficulty of breathing and
bipedal edema. She had an admitting diagnosis of Congestive Heart Failure (CHF), Community Acquired Pneumonia (CAP) and Ischemic Heart
Disease (IHD), with Atrioventricular block (AV Block), and Pulmonary Congestion.

2. Socio-Economic and Cultural Factors

Lola Tere is currently unemployed. She graduated from elementary in one of the schools in Bacolor. She then started working at the
age of 22 years old as a cook in Camp Olivas for 6 years. According to Mommy Tere, she earns about 3,000 to 5,000 pesos per month. At the age
of 29, she went to Manila and studied Culinary Arts for a year and came back to Angeles by the year 1978.

When she has reached the age of 49, she decided to stop working and would want to just rest.
Currently, their source of living comes from her younger siblings. They were given money for food and other needs. This is tantamount
to 1,000 to 1,500 pesos a day. Income and Expenses (Occupation)

B. Family Health-Illness History

C. History of Past Illness (disease/ailments not relevant to patient’s present condition)

According to Lola Tere she occasionally acquires fever, but she most of the times complains of coughs and colds. She manages these
problems with cough medicines. She said that she acquired chicken pox and measles at the age of five.
In the year 2002, she was hospitalized in a district hospital in Angeles City due to complaints of DOB and was diagnosed of pneumonia.
She stayed in the hospital for a week.
She also underwent laser treatment last 2006 for her cataract which developed in her right eye.
A year ago, she experienced hyperacidity and didn’t consult a doctor about it. She is taking an antacid once a day for almost half a year.

D. History of Present Illness (diseases/ailments relevant to patient’s condition)

Five days prior to admission, Lola Tere experienced difficulty of breathing and chest pain while doing her household chores. She was able
to manage these by resting and lightly massaging her chest to decrease the pain.
Three days prior to admission, chest pain occurred again and she decided to call her younger brother and told him that she wants to be
admitted in a hospital due to her frequent difficulty of breathing.
On January 21, 2010, Lola Tere was admitted to a district hospital in Angeles City with a chief complaint of DOB and chest pain. The
doctors and nurses attended to her and she was diagnosed as a case of congestive heart failure (CHF), community acquired pneumonia (CAP),
ischemic heart disease (IHD), atrioventricular block (AV Block), and pulmonary congestion.
http://www2.doh.gov.ph/data_stat/html/mortality.htm
http://journals.lww.com/
http://www.springerlink.com/content/qj54767271250916/fulltext.pdf?page=1
http://www.medscape.com/viewarticle/555392_2
http://www.flexyx.com/C/Ceftin.html
http://www.druglib.com/activeingredient/azithromycin/
http://www.drugs.com/mtm/mefenamic-acid.html
http://www.aic.cuhk.edu.hk/web8/corticosteroids.htm

II. NURSING ASSESMENT

PERSONAL HISTORY

The client is pertained to via the name “Stu” for the rest of the discussion within this written case study for anonymity.

Stu is a 50 year old male and will turn 51 on Janurary 20. He is married and resides at Carpa, Baliuag, Bulacan although he was born in Misamis
Oriental. He is religiously affiliated as a Roman Catholic and earns a living as a construction worker specifically as a “bako” operator. He lives with
her wife and 4 children.
In the socio-economic aspect, Stu and his family can be considered poor. According to NEDA if the income of the family divided by the number of
family members in a household falls below 2,768.60, the household is categorized as poor. In the case of Stu, who earns roughly Php 12,000 per
month (12,000/6=2,000), one can say that they are poor using this parameter.

Now pertaining to the environmental aspect of the subject, the description of their living vicinity can be discussed. In general, the patient and his
family is situated in a rural type of environment. Their house is made of concrete. The total living space is roughly 6 by 4 meters as estimated by the
client.

The drinking water facility of the client comes from NAWASA. Food storage is via food covering. Waste disposal is via weekly collection of sacked
trash. The cooking facility is frequently via LPG but sometimes “uling” and “de-gatong” are also utilized.

Three days prior to admission, Stu complained about chest pains and periods of on and off cough. He is also a known asthmatic since his childhood
days.

Persistence of the above mentioned symptoms is evident until the patient is rushed to a tertiary institution within Guagua, Pampanga. The
admission date is August 6, 2009 at around 10:15 AM. After the initial physical examination and assessment, Stu was given the admitting diagnosis
of: Acute Coronary Syndrome with Unstable Angina with Bronchial Asthma.

HISTORY OF PAST ILLNESS

The history of past illness of the client refers to all the former diseases that Stu has contracted but has no direct link to the occurrence of the
diagnosed condition. Upon interview, the client revealed his past illnesses.

Hemorrhoids was one of those verbalized by the client. These are characterized by the inflammation of the veins of the rectum. The complication
was managed however by surgery or hemorrhoidectomy. Such management was initiated 3 months after the manifestation of the condition. The
onset of hemorrhoids meanwhile was noted by the client to have occurred 3 years ago.

Siniusitis is the inflammation of the sinuses that may be a result of bacterial, viral or fungal infection. This condition was properly diagnosed in a
tertiary institution. Its occurrence was usually coupled with headache. Management initialed for such condition included taking of oral pain
relieving drugs. Such condition started manifesting to the client about 5 years ago as of date of admission.

Although coughs and colds and fevers are not actual disease conditions but rather signs and symptoms of other underlying conditions, these were
cited by the client as included in his past illnesses. Stu’s management of such conditions include taking over-the-counter medicines, Tepid sponge
bath, and adequate bed rest.

HISTORY OF PRESENT ILLNESS

The discussion in this part of the report includes all the disease conditions that have significant correlation to the incidence of the diagnosed illness
of the client.

Among of which includes occurrence of increased cholesterol levels in the blood or Hyperlipidemia. Management for such condition was prescribed
intake of appropriate oral medicines. However, Stu neglected the intake of such drugs. He also noted that such condition has been persisting for
about 4 years hence.
The increased level of cholesterol is considered as a present illness of the client since it directly contributes to the diagnosis of the client. The
cholesterol promotes formation of thrombus that may initiate narrowing due to its deposition within the coronary arteries.

The patient also is a known Asthmatic. Stu has been asthmatic since he was a child. The condition subsided for quite sometime but has reappeared
within the adolescent days of the patient. The management, which is nebulization, for such condition was religiously followed by the client as
evidenced by the client’s purchase of his own nebulization machine.

The Bronchial Asthma exacerbates the diagnosed condition of the client because narrowing of the air passages causes impaired breathing. This in
turn, contributes to the poor oxygenation of tissues.

Angina and periods of headaches are also reported by the client. These are manifestations of other underlying symptoms. The management for
angina and headache is rest, as noted by the client.