ACKNOWLEDGEMENT

We would like to extend our gratitude to the following people who help us and
believe in us to finish this group case study.
First, we would like to extend our gratitude to our Almighty God that gives us
life, knowledge, strength and wisdom in order for us to overcome challenges and
difficulties we encountered when we made this case study.
To our clinical instructor Mr. Hammed Leo Fabre RN,MN for her guidance and
giving us more knowledge in our field. And teaching us to become good nurse in the
future and to excel in our field.
To our Head nurses for their support in our duty. They are always there for us.
They have always a hand for help. They also support us and make sure that we will do
better in our duty.
To the staff of Northern Mindanao Medical Center OB ward, for allowing us to
experience different cases for us to grow and gain more knowledge.
To our client and her family for their support and willingness on answering our
questions.
To our groupmates for always there for us when we have problem.
And also to our family, friends and love ones who are our strengths and our
inspiration in making this group case study.

1
 Introduction:
 
Angina Pectoris, Unstable
- Unstable angina occurs when the narrowing becomes so severe that not enough blood
gets through to keep the heart functioning normally, even at rest. The atherosclerotic
plaque may rupture in unstable angina, allowing blood clots to precipitate and further
decrease the lumen of the coronary vessel. This explains why an unstable angina
appears to be independent of activity. Sometimes the artery can become almost
completely blocked. It may occur unpredictably at rest which may be a serious indicator
of an impending heart attack

Clinical Manifestation

  Angina itself is a symptom (or set of symptoms), not a disease. Any of the
following may signal angina:

 An uncomfortable pressure, fullness, squeezing, or pain in the center of the

chest
 It may also feel like tightness, burning, or a heavy weight.
 The pain may spread to the shoulders, neck, or arms.
 It may be located in the upper abdomen, back, or jaw.
 The pain may be of any intensity from mild to severe.

Other symptoms may occur with an angina attack, as follows:

 Shortness of breath
 Lightheadedness
 Fainting
 Anxiety or nervousness
 Sweating or cold, sweaty skin
 Nausea
 Rapid or irregular heart beat
 Pallor (pale skin)
 Feeling of impending doom

These symptoms are identical to the signs of an impending heart attack described by
the American Heart Association. It is not always easy to tell the difference between
angina and a heart attack, except angina only lasts a few minutes and heart attack pain
does not go away.

 If you have never had symptoms like this before, sit down. If you are able, call
your healthcare provider, call 911, or go to the closest hospital emergency
department.
 If you have had angina attacks before and this attack is similar to those, rest for
a few minutes. Take your sublingual nitroglycerin. Your angina should be totally
relieved in five minutes. If not, you may repeat the nitroglycerin dose and wait
another five minutes. A third dose may be tried but if you still have no relief, call 911
or go to the nearest hospital emergency department.

2
Diagnostic Examination
To diagnose angina, your doctor will start by doing a physical exam and asking about
your symptoms. You'll also be asked about any risk factors, including whether you have
a family history of heart disease.

There are several tests your doctor may order to help confirm whether you have angina:

 Electrocardiogram (ECG or EKG). An electrocardiogram traces the electrical

signals that cause your heart to beat as they travel through your heart. Your
doctor can look for patterns among these heartbeats to see if the blood flow
through your heart has been slowed, interrupted or if you're having a heart attack.

 Stress test. Sometimes angina is easier to diagnose when your heart is working

harder. During a stress test, you exercise by walking on a treadmill or pedaling a
stationary bicycle. While exercising, your blood pressure is monitored and your
ECG readings are watched. If you're unable to exercise, you may be given drugs
that cause your heart to work harder to simulate exercising.

 Echocardiogram. An echocardiogram uses sound waves to produce images of

the heart. Your doctor can use these images to identify whether there are areas of
your heart muscle that have been damaged by poor blood flow — a cause of
angina. An echocardiogram is sometimes given during a stress test.

 Nuclear stress test. A nuclear stress test helps measure blood flow to your
heart muscle at rest and during stress. It is similar to a routine stress test, but
during a nuclear stress test, a radioactive substance is injected into your
bloodstream. This substance mixes with your blood and travels to your heart. A
special scanner — which detects the radioactive material in your heart — creates
images of your heart muscle. Inadequate blood flow to any part of your heart will
show up as a light spot on the images.

 Chest X-ray. This test takes images of your heart and lungs. This is to look for
other conditions that might explain your symptoms and to see if you have an
enlarged heart.

 Blood tests. Certain heart enzymes slowly leak out into your blood if your heart
has been damaged by a heart attack. Samples of your blood can be tested for the
presence of these enzymes.

 Coronary angiography. Coronary angiography uses X-ray imaging to examine

the inside of your heart's blood vessels. It's part of a general group of procedures

3
 known as cardiac catheterization. During coronary angiography, a type of dye
that's visible by X-ray machine is injected into the blood vessels of your heart. The
X-ray machine rapidly takes a series of images (angiograms), offering a detailed
look at your blood vessels.

 Cardiac computerized tomography (CT) scan. In a cardiac CT scan, you lie on

a table inside a doughnut-shaped machine. An X-ray tube inside the machine
rotates around your body and collects images of your heart and chest, which can

show if any of your heart's arteries are narrowed or if your heart is enlarged .

Causes

Stable angina occurs when the heart does not get the oxygen it needs to do the
work it is being asked to do. When you exercise, lift heavy items, or otherwise stress
your body, your heart works harder to accommodate the additional exertion.

Certain factors can impede your heart from receiving more oxygen, such as a narrowing
of the arteries (atherosclerosis). Your arteries can become narrow when plaque (a
substance made of fat, cholesterol, calcium, and other substances found in blood)
builds up inside them, usually due to high cholesterol. Blood clots can also block your
arteries and reduce the flow of oxygen-rich blood to the heart.

Risk Factors

 being overweight
 having a history of heart disease
 having high cholesterol or blood pressure
 being diabetic
 smoking
 not exercising enough
Additional risk factors can include any situation that requires your heart to need more
oxygen. Big meals, prolonged exposure to extreme hot or cold weather, vigorous
physical workouts, and emotional stress can also induce stable angina in some cases.

You can develop stable angina even if you do not have any of the signs of heart
disease, such as shortness of breath and pain, numbness, weakness, or coldness in
legs and arms. According to the National Institutes of Health, men are more likely to
develop stable angina than women

4
Epidemiology

Angina pectoris is of interest as a cause of disability and also because it is a marker for
potential severe manifestations of coronary heart disease such as cardiac infarction or
sudden death. However, the elucidation of its epidemiology is inherently difficult. It is not
specific for coronary heart disease. Because it is a symptom the diagnosis cannot be
validated. Clinical diagnosis is inconsistent. Standard questionnaires are more reliable
but these produce different results according to minor changes in circumstances and
wording. The variability of the disease means that incidence and prevalence measures
are closely related to the exact method of measurement. Risk factors for angina pectoris
are the same as those for coronary heart disease as a whole. The risk factors continue
to predict major coronary events even when angina pectoris has developed. The angina
revealed by population surveys is a much more mild, transient and less dangerous
disease than that reported in clinical case series. The implication for the latter is that the
results cannot be generalized unless the way in which cases are referred and selected
is known.

SIGNIFICANCE OF THE STUDY:

Nursing Education: The significance of this study to nursing education is to further

increase and expound knowledge of the students. It also helps to make a reliable and
holistic care plans to improve the quality of life of the client. The study hastens the
opportunity for the students to apply theoretical knowledge to actual health care
settings.

Nursing Practice: This study is significant to nursing practice to further improve the
skills and ability of the nursing students and enhances student’s capability to make
intelligent actions and decisions in the clinical area. This study also helps us to attain
our goal which is “to provide quality care to our client to improve their quality of life.”

Nursing Research:Through having this study, nursing students would be able to apply
their skills in research. Be able to apply systematic and scientific way of solving
problems and discover new ideas that would give answers to the patient’s situation. It
also a means of revision the kind of therapy we have and a means of discovering a new
technique or methods in dealing and caring of client with this kind of condition.
5
6
OBJECTIVES OF THE STUDY

General Objective:
The main objective of this case study is to be able to evaluate and have a firm
background on the health condition of the patient and her health needs associated with
chronic stable angina to achieve proper planning, management and intervention which
will be given to meet client’s basic demands, alleviating further complications.
Additionally, this study also aims to offer knowledge and information, restore and
maintain patient’s health status utilizing a holistic approach of promoting and
rehabilitative process of nursing managements and nursing interventions.

Specific Objectives:
1. Develop an independent method, as well as a collaborative work method with the
medical health team.
2. Prioritize the health issues and concerns that we are presented with them and
respond to them appropriately with the proper nursing interventions.
3. Apply the core and fundamental systematic approach of the nursing profession in
promoting health to our client.
4. Assist the patient in developing a healthy self-concept of her, regardless of the
differences that may be considered as a hindrance or burden.
5. Aid the patient in accepting and adapting to the changes that may have been
made to her life, while doing our best to regain her normal condition.

7
Patient’s Profile
Patient x, a56-year-old, female, who was born on October 31, 1958, and residing at
Pueblo de Oro, Upper Carmen, Cagayan de Oro City. Her religion was Roman Catholic.
She is non-smoker, non-alcoholic drinker, and no allergies in any medication. She is
heavy in character. She was admitted at Capitol University Medical Centre under Dr.
Manuel Edmilao .The reason for her admission was chronic on and off chest pain
Medical Past History
Chronic chest pain on and off for 2 years
FAMILY HISTORY OF ILLNESS

History of Present Illness:

2 years prior to admission patient experienced chronic on and off chest pain that lasts
for minutes.
1 year prior to admission she had a check-up on manila- nuclear test done = normal
4 months she consulted a cardiologist – reassurance done
3 months prior to admission she consulted a cardiologist – anti ischemic drugs
continued
Still complained on and off chest discomfort
Nutritional and Lifestyle Pattern:
Patient x usually eats three large meals a day and eats snacks in the afternoon
with a good appetite. She is fond of eating fruits and vegetables. She also eats meat
such as beef and chicken. She also drinks 6-8 glasses of water a day. She has no
history of food and drug allergies. She is a non-smoker and doesn’t drink alcohol
beverages. She usually sleeps around 8 PM and wakes up at 8 AM.
 GENERAL SURVEY

 During assessment, the patient appears conscious, lying on bed with an ongoing
IVF of NaCl. She is oriented to person, place and time and vital signs of T-36.1⁰c,
PR-96bpm, RR-23 cpm BP-130/80 mmHg

 INTEGUMENTARY

 Skin color appears pale and poor skin turgor. Hair is naturally black, thin, firm in
texture and hair evenly distributed on the scalp. Capillary refill is assessed in 2
seconds. The Temperature is T-36.1⁰c degrees Celsius.

 HEAD

 Head is symmetrical, rounded, normocephalic and in midline alignment,

 EYES
Eyebrows are symmetrically aligned; equal movement with no presence of
flakes, scars, or lesions. Lids and periorbital region is edematous. Conjunctivas
of the eye are also pale. Pupil reaction to light and accommodation is

8
 symmetrical. Both eyes are coordinated. Peripheral vision is normal.

 EARS
The left and the right pinna are symmetrical and aligned with the outer cantus
of the eye with no discharges noted. The patient was able to hear normal
voice tones in both ears.
 MOUTH
Lips are pale in color. Gums and mucosa are pale in color with no lesions or
ulcerations noted.
 NECK
Can perform any range of motion without discomfort and with equal muscle
strength as the patient turns his head from left to right; up and down; and
circular motion. Trachea was located centrally in the midline of the neck.
 CHEST AND LUNGS
Symmetrical in alignment; full and symmetric chest expansion, RR- 23 cpm.
 CARDIOVASCULAR
the patient’s chest area is flat.
The point of maximal impulse was located at the fifth left intercostals spaces.
Heart rate is 96 beats per minute.
 ABDOMEN
Abdomen round and soft.  Bowel sounds x 4.Tenderness only in hypogastric
area due to menorrhagia.
 GASTROINTESTINAL
have 2 episodes of non mucoid, non-blood streaked non foul smelling stools
 MUSCULOSKELETAL
Patient x has still sufficient energy in completing desired required activities
but complains a painful sensation at her pelvic area.

Developmental Data

Sigmund Freud’s Psychosexual development theory

In Freudian psychology, psychosexual development is a central element of

the psychoanalytic sexual drive theory, that human beings, from birth,
possess an instinctual libido (sexual energy) that develops in five stages.
Each stage – the oral, the anal, the phallic, the latent, and the genital – is
characterized by the erogenous zone that is the source of the libidinal
drive. Sigmund Freud proposed that if the child experienced sexual frustration
in relation to any psychosexual developmental stage, s/he would
experience anxiety that would persist into adulthood as a neurosis, a
functional mental disorder.

9
 Age
Stage Erogenous zone Consequences of psychologic fixation
Range

Orally aggressive: chewing gum and the ends of

pencils, etc.
Birth–1 Orally Passive: smoking, eating, kissing, oral sexual
Oral Mouth
year practices[4]
Oral stage fixation might result in a passive, gullible,
immature, manipulative personality.

Anal retentive: Obsessively organized, or excessively

Bowel and bladder eliminatio neat
Anal 1–3 years
n Anal expulsive: reckless, careless, defiant,
disorganized, coprophiliac

Oedipus complex (in boys and girls); according to

Phallic 3–6 years Genitalia Sigmund Freud.

Electra complex (in girls); according to Carl Jung.

Latenc
6–puberty Dormant sexual feelings Sexual unfulfillment if fixation occurs in this stage.
y
Puberty–
Genital Sexual interests mature Frigidity, impotence, unsatisfactory relationships
death

10
 ANATOMY AND PHYSIOLOGY

The heart is a muscular organ about the size of a fist, located just behind and
slightly left of the breastbone. The heart pumps blood through the network of
arteries and veins called the cardiovascular system.
The heart has four chambers:

 The right atrium receives blood from the veins and pumps it to the right
ventricle.
 The right ventricle receives blood from the right atrium and pumps it to the
lungs, where it is loaded with oxygen.
 The left atrium receives oxygenated blood from the lungs and pumps it to
the left ventricle.
 The left ventricle (the strongest chamber) pumps oxygen-rich blood to the
rest of the body. The left ventricle’s vigorous contractions create our blood
pressure.

The coronary arteries run along the surface of the heart and provide oxygen-rich
blood to the heart muscle. A web of nerve tissue also runs through the heart,
conducting the complex signals that govern contraction and relaxation.
Surrounding the heart is a sac called the pericardium.

11
 PATHOPHYSIOLOGY
LEGENDS:

Predisposing Factor

Precipitating Factor Etiology

Disease Process

Predisposing Factors:
 Age- 56 years Precipitating Factors:
 HPN (37 yrs old; usual
oldHereditary- HPN, DM
BP 140/90; highest BP
 Gender- femaleHx of
is 200/110mmHg)>
Cholecystectomy (NMMC;
 Inc. serum Cholesterol
1995)
level: 231mg/dL>
 Menopause (starts at age
 Lack of
42 years old; Menarche
exercise/activity>
starts at age 13 yrs.old.) Atherosclerotic  Obesity (BMI of 27
 DM II (1999; usual glucose Plaque
kg/m2, IBW: 48.96kg
level: 140-160mg/dL;
highest level: 300mg/dL

Unstable Plaque

Stable Plaque

Thrombus Formation

Stable Angina
Incomplete occlusion Complete occlusion

Unstable Angina Myocardial Infarction

Myocardial Ischaemia
Electrical instability Healing with scarring
leading to deterioration Repeated episodes
. to left ventricle
Ventricular Fibrillation

Chronic ischaemic heart

Sudden Cardiac Death disease

Cardiac Failure

12
 DIAGNOSTIC PROCEDURE AND LABORATORY RESULTS

The laboratory test and diagnostic procedures indicates a very significant finding necessary for the care and prevention of particular disease which
may occur in the clinical settings, here are the data as followed with interpretation.

COMPLETE BLOOD COUNT

The complete blood count (CBC) is one of the most commonly ordered blood tests. The complete blood count is the calculation of the cellular
(formed elements) of blood. These calculations are generally determined by special machines that analyze the different components of blood in less
than a minute
TEST RESULT REFERENCE INDICATION INTERPRETATION
09-19-13 09-20-13 09-19-13 09-20-13
White blood cells 13.76 7.55 5.0-10.0 A blood test to measure the number of white blood cells. Anemia Normal
10^3/uL
Red blood cells 4.94 3.99 4.2-5.4 1066/uL The main function of the red blood cells is to transport Normal Anemia
oxygen from the lungs to the other tissues of the body and
the other function is to partly carry carbon dioxide, which is
a waste product of metabolic activities in the body.
Hemoglobin 13.3 10.9 12.0-16.0 g/dL Essential chemical which carries oxygen from lungs to Normal Anemia
other parts of the body. It contains iron and performs the
important function of transporting oxygen via RBC’s in
blood.
Hematocrit 40.7 33.0 37.0-47% Used to measure RBC number and volume. It is an Normal Anemia
integral part of the evaluation of anemic patients.
MCV 82.4 82.7 82.0-98.0 fL Microtic cell volume, the test is an indicator for the size of Normal Normal

13
 the RBC’s or red blood cells. It helps to determine if there
is risk for certain anemias.
MCH 26.9 27.3 27.0-31.0 pg This helps diagnose a cause of an anemia. Anemia Normal
MCHC 32.7 33.0 31.5-35.0 g/dL Measures of the concentration of haemoglobin in a given Normal Normal
volume of packed red blood cells.
RDW-CV 13.9 13.8 12.0-17.0% A blood test, which calculates the variations in the size of Normal Normal
the red blood corpuscle.
PDW 12.1 12.5 9.0-16.0fL A type of protein released by platelets of the blood that aid Normal Normal
in the repair and regeneration of connective tissue.
MPV 10.4 10.7 8.0-12.0 fL This is a volume determined through a blood test that tells Normal Normal
the size of the platelets in your blood.
Differential Count
Lymphocyte 25.0 46.0 17.4-48.2% They are specialized white blood cells, leukocytes, that Normal Normal
become active during an immune response of the body
Neutrophil 67.9 42.9 43.4-76.2% Neutrophil granulocytes are a kind of white blod cells, Normal Anemia
forming an essential part of the body’s defence system
Monocyte 5.5 6.5 4.5-10.5% A type of white blood cell and is part of the human body’s Normal Normal
immune system. Monocytes play multiple roles in immune
function.
Eosinophil 1.4 4.2 1.0-3.0% Are white blood cells that are one of the immune system Normal Normal
components responsible for combating multicellular
parasites and certain infections in vertebrates.

14
Basophil 0.2 0.4 1.0-2.0% Basophils appear in many specific kinds of inflammatory Anemia Anemia
reactions, particularly those that cause allergic symptoms.

Platelet 331 228 150-400 This is the number of cells that plug up holes in your blood Normal Normal
10^3uL vessels and prevent bleeding.

URINALYSIS

15
 The urinalysis is used as a screening and/or diagnostic tool it can help detect substances or cellular material in the urine associated with
different metabolic and kidney disorders. It is ordered widely and routinely to detect any abnormalities that require follow up. Often, substances such
as protein or glucose will begin to appear in the urine before patients are aware that they may have a problem. The urinalysis may be ordered at
intervals as rapid method to help monitor organ function, status, and response to treatment.

DATE
September 19, 2013
Color Yellow
Clarity Slightly hazy
Odor ---
Ph 5.0
Specific Gravity 1.020
Proteins Trace
Glucose positive
Pus cells (WBC) 2-3
Mucus Threads ---

Interpretation: The results indicate that the patient’s urine has an infection.

16
 CLINICAL CHEMISTRY SECTION

9-19-13 9-20-13 UNIT NORMAL RANGE

GLUCOSE 160.74 104.67 mg/dl 60.00-110.00 mg/dl
UREA 8.49 mg/dl 4.60-23.40 mg/dl
CREATININE 0.61 0.68 Mg/dl 0.60-1.20

9-19-13 9-20-13
SODIUM 140.5 135-148mmol/l
POTASSIUM 4.2 3.97 3.5-5.3 mmol/l

DRUG ORDER
(Generic name,brandname,classification,dosage,route,
Frequency)

MECHANISM OF
ACTION

INDICATIONS

CONTRAINDICATIONS

ADVERSE EFFECTS
OF THE DRUG
NURSING
RESPONSIBILITIES/
PRECAUTIONS
Generic name
17
Ranipril

Brand name
Kardia

Classification

ACE inhibitor

Dosage
5mg

Route
P.O

Frequency
BID
 This medication is an angiotensin-converting enzyme (ACE) inhibitor, used alone or in combination with other medications to treat high blood
pressure. It is also used to reduce the risk of heart attack and stroke in patients at risk for these problems and to improve survival in patients with
heart failure after a heart attack.  

This medication is an angiotensin-converting enzyme (ACE) inhibitor, used alone or in combination with other medications to treat high blood
pressure. It is also used to reduce the risk of heart attack and stroke in patients at risk for these problems and to improve survival in patients with
heart failure after a heart attack.  

Contraindicated in patients with hypersensitivity, bilateral renal artery stenosis (narrowing of the arteries going to the kidney), or a single kidney with
unilateral renal artery stenosis, aortic stenosis or outflow tract obstruction, pregnancy and breastfeeding.

Heart- Low blood pressure, chest pain, loss of consciousness.

  Central Nervous System- Dizziness. 

18
  Gastrointestinal- Nausea, vomiting, diarrhea. 

  Genitourinary- Abnormal kidney function. 

  Blood- Severe decrease in white blood cells. 

  Metabolic- Increase in potassium in blood. 

  Respiratory- Cough. 

  Miscellaneous- Severe allergic reactions. 

Other Precautions : 
 Dehydration, excessive sweating, vomiting, or diarrhea may increase the risk of low blood pressure. So monitor blood pressure regularly. 

It may cause dizziness, lightheadedness, or fainting; alcohol, hot weather, exercise, or fever may increase these effects. Get up slowly from bed.
It may cause a serious side effect called angioedema with symptoms of swelling of the hands, face, lips, eyes, throat, or tongue; difficulty swallowing or breathing; or hoarseness.
It may affect your blood sugar. Check blood sugar levels closely.
Monitor kidney function before and during treatment.
Regular monitoring of white blood cells in patients with vascular collagen disorders is recommended.
Use with caution in patients with history of an allergic reaction which included swelling of the face/lips/tongue/throat (angioedema). Before using this medication, tell your doctor or
pharmacist your medical history, especially of: kidney disease, liver disease, high blood levels of potassium, heart problems, severe dehydration (and loss of electrolytes such as
sodium), diabetes (poorly controlled), strokes, blood vessel disease (e.g., collagen vascular diseases such as lupus, scleroderma) and children. 

19
 DRUG ORDER ADVERSE EFFECTS NURSING
(Generic MECHANISM OF OFTHE DRUG RESPONSIBILITIES/
name,brandname,classi
INDICATIONS CONTRAINDIC
ACTION ATIONS PRECAUTIONS
fication,dosage,route,
Frequency)
Generic name Anticoagulants are used to prevent Prevention and  Underlying Conditions of Caution patient to avoid activities
clot extension and formation. They treatment of coagulation Excess Stomach Acid leading to injury, to use a soft
Acetyl Salicylic do not dissolve clots. The disorders, toothbrush and electric razor,
two types of anticoagulants in
thromboembolic SecretionLess Severe. and to report any symptoms of
 ulcer
Acid common use are parenteral disorders including disease, Feel Like Throwing unusual bleeding or bruising to
heparins and oral warfarin. Therapy deep vein  malignancy UpLess Severe. health care professional
is usually initiated with heparin or a thrombosis, , immediately.
heparin-like agent because of rapid  HeartburnLess ● Instruct patient not to take OTC
Brand name pulmonary recent
onset of action, while surgery, or Severe. medications, especially those
embolism, and
Aspirin maintenance therapy consists of
 active Irritation of the
containing aspirin, NSAIDs, or
warfarin. Warfarin takes several atrial fibrillation alcohol, without advice of health
with embolization. bleeding Stomach or IntestinesLess
days to produce therapeutic care professional.
anticoagulation. In serious or Also used in the Severe. ● Review foods high in vitamin K
Classification severe thromboembolic events, (see Appendix M) with patients on
management of Stomach
heparin therapy may be preceded warfarin. Patient should
ANALGESIC/Non- by thrombolytic therapy. Low doses
myocardial CrampsLess Severe. have consistent limited intake of
of heparin or heparin-like infarction (MI) Throwing UpLess these foods, as vitamin K is the
Steroidal Anti-
compounds and fondaparinux sequentially or in Severe antidote for warfarin and
Inflammatory are mostly used to prevent deep combination with greatly alternating intake of these
vein thrombosis after certain thrombolytics foods will cause PT levels to
surgical procedures and in similar fluctuate.
situations in which prolonged
and/or antiplatelet ● Emphasize the importance of
Dosage bedrest increases the risk of agents.. frequent lab tests to monitor
thromboembolism. Argatroban and coagulation factors.
500mg lepirudin are used as ● Instruct patient to carry
anticoagulation in patients who identification describing medication
have developed thrombocytopenia regimen at all times and to inform
Route during all health care professionals caring
heparin therapy. for patient of anticoagulant therapy
before laboratory
 tests, treatment, or surgery.
Frequency
Every 8hours

20
(DRUG ORDER)
NURSING
(Generic name, brand CONTRAINDICATIO ADVERSE EFFECTS
name, classification MECHANISM OF INDICATIONS RESPONSIBILITIES/
NS OF THE DRUG
,dosage, route, ACTION PRECAUTIONS
Frequency)
Generic Name : - Depress the CNS, probably -Adjunct in the  Hypersensitivity  CNS:  Monitor BP, PR,RR prior to
Diazepam by potentiating GABA, an management of: - Cross-sensitivity with 1) dizziness periodically throughout therapy
Brand Name inhibitory neurotransmitter. 1) Anxiety other benzodiazepines 2) drowsiness and frequently during IV
Valium 2) Preoperative may occurs 3) lethargy
- Produces skeletal muscle therapy.
Classification sedation - Comatose patients 4) hangover
relaxation by inhibiting - Assess IV site frequently
Antianxiety 3) Conscious sedation - Pre-existing CNS 5) headache
agents, spinal polysynaptic afferent during administration,
anticonvulsants, - Provides light depression 6) depression
pathways. diazepam may cause phlebitis
sedative/hyptonic - Uncontrolled severe
- Has anticonvul-sant anesthesia and - EENT: and venous thrombosis.
s, skeletal muscle
relaxants  anterograde amnesia painUse cautiously in: 1) blurred vision
properties due to enhanced - Prolonged high-dose therapy
1) Hepatic dysfunction
presynaptic inhibi- - Treatment of status - RESP: may lead to psychological or
Dosage 2) Severe renal
tion.Therapeutic effects: epilepticus/ 1) respiratory physical dependence. Restrict
5 g tab impairment
(1) Relief of Anxiety uncontrolled seizures depression amount of drug available to
Route 3) History of suicide
(2) Sedation - Skeletal muscle - CV: patient. Observe depressed
attempt or drug
(3) Amnesia relaxant 1) hypotension patients closely for suicidal
dependence
(4) Skeletal muscle relaxant - Management of the - GI: tendencies.
(5) Decreased seizure symptoms of alcohol 1) constipation - Observe and record intensity,
activity withdrawal 2) diarrhea duration and location of seizure

21
 3) nausea activity. The initial dose of
4) vomiting diazepam offers seizure control
- DERM: for 15-20 min after
1) rashes administration.
- LOCAL: - IM injections are painful and
1) pain (IM) erratically absorbed. If IM route
2) phlebitis (IV) is used, inject deeply into
3) venous thrombosis deltoid muscle for maximum
- MISC: absorption.
1) physical & - Caution patient to avoid
psychological depen- taking alcohol or other CNS
dence depressants concurrently with
2)tolerance this medication.
- Effectiveness of therapy can
be demonstrated by decrease
anxiety level; control of
seizures; decreased
tremulousness.

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 NURSING CARE PLAN

ASSESSMENT DATA
(Subjective and Objective NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS EVALUATION
Cues) (Problem and Etiology) OBJECTIVES AND RATIONALE

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Subjective: Acute pain Long Term:  Give Aspirin 500mg to Long Term:
relieve pain.
I always feel this abnormal After 1 hour of nursing  Observe nonverbal After 1 hour of nursing
pain in my chest. interventions patient will cues and pain interventions patient was
be able demonstrate use behaviours : able to demonstrate use of
Objective: of relaxation skills and R: Observations may relaxation skills and
 Pain scale: 8/10 diversional activities. not be congruent with diversional activities.
 Facial expression verbal reports or may
indicates slight Short Term: be only indicator Short Term:
discomfort present when client is
 Body weakness After 30 minutes of unable to verbalize. After 30 minutes of nursing

 Activity intolerance nursing interventions  Encourage interventions patient was

patient will be able to diversionalactivtities. able to report pain is
report pain is relieve. R: To distract attention relieved.
and reduce tension
 Encourage adequate
rest periods.
R: to prevent fatigue.

NURSING CARE PLAN

ASSESSMENT DATA EVALUATION

25
 (Subjective and Objective NURSING DIAGNOSIS GOALS AND NURSING INTERVENTIONS
Cues) (Problem and Etiology) OBJECTIVES AND RATIONALE

Subjective: Deficient fluid volume After 8 hours of nursing  Maintain accurate I Goals met
related to excessive blood intervention, the patient and O
“I felt weak all over my body” loss. will be able to maintain  Give Tranexamic After 8 hours of nursing
as verbalized by the patient. fluidvolume at a functional Acid 500mg every 8 intervention, the patient
level. hours to minimize was able to maintain fluid
Objective: menstrual bleeding. volume as evidenced by
 Administer I V accurate I and O.
 Decreased hemoglobin fluids, as
and hematocrit count indicated.
 Profuse menstruation  Encourage patient
 Used of 3-4 infant to increase fluid
diapers per day intake
 Pallor  Encourage patient
 Poor Skin turgor to take iron
supplements.

NURSING CARE PLAN

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 ASSESSMENT DATA NURSING EVALUATION
(Subjective and Objective Cues) NURSING GOALS AND INTERVENTIONS AND
DIAGNOSIS OBJECTIVES RATIONALE
(Problem and
Etiology)
 Assist with
Subjective: Impaired physical After 1 hour of nursing activity/progressive After 1 hour of nursing
“ mobility related to interventions, the ambulation interventions, the patient
hindiakomasyadonggumagalawngdahilsa pain patient will be able to  Encourage and was be able to move
sakit “as verbalized by the patient. move within range of facilitate early within range of motion.
motion. ambulation.
Objective:  Schedule activities
 Pain scale: 8/10 with adequate rest
 Limited range of motion periods during the
 Slowed movement day.
 Reluctance to attempt movement  Determine degree of
Immobility in relation
to previously
suggested scale.

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28
DISCHARGE PLAN / HEALTH TEACHINGS
Medication:
 Instruct the immediate family of the patient to keep track of all the home
medications that have given, and to be sure to administer at the proper times
with the right dosage as prescribed by the attending physician.

Exercise:
 The patient is permitted to resume her former activities and responsibilities
completely once recovered from illness. Until then, bed rest is recommended.

Treatment:
 Teach the family about the importance of making follow-up appointments.
 Explain the importance of the medications prescribed by the physician, making
sure that the purpose of medication is fully comprehended by the client and her
family.
 Instruct client and family to contact or see a physician if any serious side effects
are experienced.

Health teachings:
 Keep a list of current medication and always include the amounts, and when,
how, and why you take them. Remember to always take the list or the pill bottles
to follow-up visits. Additionally, carry your medicine list with you in case of an
emergency.
 Always take medicine as directed.
 Patients must be properly informed of any and all side effects may occur, and
how to properly manage the side effects at first notice.

Outpatient:
 Encourage patient and family members to consider regular check-ups as ordered
by the physician to ensure the continuing management and treatment.

Diet:
 Inform family if there is specific diet ordered by the physician.

Spiritual:
 Encourage client and family members to strengthen their relationship to God, to
maintain religious practices and beliefs.
 Advice family members to provide emotional support to the client to help her
know that she will always have help during her most difficult times.

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 RELATED NURSING EXPERIENCE

Related Learning Experience subject is one of the most important subjects in the
field of Nursing. It is because in this subject, we are able to gain knowledge and skills in
the real hospital setting. Thus, it is in this subject matter that we will be able to perform
all the procedures that we acquired from school up to the real situation. Furthermore, it
serves as our foundation and training ground towards becoming a proficient nurse.
Our exposure at Northern Mindanao Medical Center, OB ward was the most
astonishing and in fact the most unforgettable moment that we will never forget for our
entire nursing profession. We were amazed by the learning experience. Our Clinical
instructor Mr. Hammed Leo Fabre served as a teacher who guided and assisted us on
what we were going to do prior to the care to our patients.
Having been exposed in a hospital area was not that easy because we were
dealing with the lives of the patients who were in need. It was in this rotation that we felt
that we were now moving on towards a more challenging event in our career. Our skills
have enhanced due to our day to day duties, we were introduced to new skills and
procedures and how to use and perform them. We learned how to become responsible
and effective nurses when it comes to giving quality care to our patients.
The experience that we had was fruitful because we were be able to acquire new
knowledge and skills that we need and it was very beneficial on our part because our
capabilities have reached its peak level. Lastly, it helped us mold into total persons, able
and willing to do all the best that we can in order to help without any doubts to those
who were in pain and ailing people.

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 BIBLIOGRAPHY

Books:
 Maternal & Child Health Nursing, Care of the Child Bearing Family. Volume 1 &
2. 6th Edition. AdellePillitteri. (2010)
 Nurse’s Pocket Guide. Diagnoses, Prioritize Interventions, and Rationales. 12 th
Edition. Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr. (2009)
 2013 Lippincott’s Pocket Drug Guide for Nurses. Amy M. Karch

Online Resources:
http://www.nlm.nih.gov/medlineplus/ency/article/000914.htm
http://labspace.open.ac.uk/mod/oucontent/view.php?id=450484&section=3.4
http://www.healthline.com/human-body-maps/uterus
http://en.wikipedia.org/wiki/Uterus
http://www.uterine-fibroids.org/myoma.html
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001912/

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