Republic of the Philippines

Bicol University Polangui Campus

Nursing Department
Polangui, Albay
S/Y 2020-2021

RLE Duty:
CASE STUDY

Submitted By:
Abundo, Esther Ellise P.
Espinol, Hazel Ann G.
Group 1

Submitted to:
Mr. John Perez
Clinical Instructor

Ms. Michaella Alcantara

Student Clinical Instructor

August 2021
 PATIENT INFORMATION

Name: Mr. X
Address: Barangay A, Municipality B
Age: 82
Gender: Male
Occupation: Retired Postman
Religious Affiliation: Roman Catholic
Nationality: Filipino
Marital Status: Widowed
Chief Complaint: Patient presented for preoperative cardiac evaluation prior to hip
replacement surgery
Date of Admission: August 20, 2020
Vital Signs:

Past Medical History

Patient has a history of hypertension. Is currently taking maintenance medication as
prescribed by his physician, ASA and Bisoprolol Fulmate.
 DRUG STUDY

Generic Dose/Route/Fr Mechanisms of Action Common Side Effects Nursing Responsibilities

Name equency

ASA (Aspirin) 1300mg/d PO Blocks pain impulses in CNS, GI: dyspepsia, heartburn, ● Assess for pain type,
to decrease inhibition of prostaglandin anorexia, nausea, location and
TIAs; synthesis, antipyretic action epigastric discomfort, pattern.
300-325mg/d results from vasodilation of potentiation of peptic ● Note for asthma
PO to reduce peripheral vessels; ulcer ● Monitor renal, LFTs
MI risk decreases platelet and CBC.
aggregation Allergic: Bronchospasm, ● Monitor vital signs.
asthma-like symptoms, ● Determine history of
anaphylaxis, skin rashes, peptic ulcers or
urticaria bleeding
tendencies.
Hematologic:
prolongation of bleeding
time, thrombocytopenia,
leucopenia

Other: thirst, fever,

dimness of vision

● Bisoprol Initially 5mg/d Decreases heart rate, CNS: headache, fatigue, ● Monitor BP, ECG,
ol PO, up to contractibility, and dizziness, depression, and pulse frequently
Fulmat 20mg/d PO excitability as well as a paresthesias, sleep during dosage
e may be membrane-stabilizing disturbances, memory adjustment period
needed effect, which leads to a loss, and disorientation
decrease in arrhythmias,
decreased cardiac CV: bradycardia, heart
workload, and decreased block, HF, hypotension,
oxygen consumption. and peripheral vascular
insufficiency
Pulmonary: Rhinitis,
bronchospasm, dyspnea
GI: GI upset, nausea,
vomiting, diarrhea, gastric
pain, colitis
GU: decreased libido,
impotence, dysuria,
Peyronie disease
Others: Decreased
exercise tolerance,
hypoglycemia or
hyperglycemia, liver
changes
and periodically
throughout therapy.
● Monitor intake and
output ratios and
daily weights. Assess
routinely for signs
and symptoms of HF
(dyspnea,
rales/crackles,
weight gain,
peripheral edema,
jugular venous
distention).
● Lab Test
Considerations: May
cause increased
BUN, serum
lipoprotein,
potassium,
triglyceride, and uric
acid levels.
● PO: Take apical
pulse before
administering. If 50
bpm or if arrhythmia
occurs, withhold
medication and
notify physician or
other health care
 professional.
● May be
administered
without regard to
meals.
● Advise patients to
change positions
slowly to minimize
orthostatic
hypotension
● Advise patient to
notify health care
professional if slow
pulse, difficulty
breathing,
wheezing, cold
hands and feet,
dizziness,
light-headedness,
confusion,
depression, rash,
fever, sore throat,
unusual bleeding, or
bruising occurs.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTIONS RATIONALE EVALUATION

Subjective Data: Ineffective SHORT TERM ● Assist with ● The danger After 8 hours of
" Nakakaramdam peripheral tissue GOAL: position of nursing
po ako ng sakit sa perfusion related changes. orthostatic intervention:
paa at balakang to perfusion After 8 hours of BP
pag naglalakad" abnormality in the nursing fluctuations Maintain optimal
as verbalized by distribution of intervention: can be tissue perfusion as
the patient. infarcted artery as reduced manifested by
evidenced by -The patient will by gently regular and
Objective Data: mild to moderate demonstrate moving the consistent pulse
● Pale skin anterior ischemic increased patient rhythm.
color of pattern involving perfusion with from a
lower the distal half of manifestation of supine to a
extremities the anterior regular pulse sitting/stan Skin is warm and
on segment characteristics. ding dry, indicating
elevation posture. optimal
● Coldness in -Recognize Patients alterations in skin
the lower reportable who are characteristics to
leg or foot changes in skin older are the affected
● Delayed characteristics to more extremity.
capillary the involved vulnerable
refill time of extremity that to pressure The Pt verbalizes
3 second indicate decreases understanding
● Low Blood decreased as a result about the
pressure perfusion. of posture necessary lifestyle
changes in changes. changes to
extremities -Determines minimize the
● Weak lifestyle ● Monitor These are signs of consequences of
peripheral modifications are peripheral arterial occlusion, ineffective tissue
pulses is needed to pulses. which can lead perfusion.
noted in increase tissue Check for to loss of a limb if
the perfusion. loss of not immediately
periphery pulses with reversed.
bluish,
purple, or
black
areas and
extreme
pain.

● Do not ● Leg
elevate elevation
legs above reduces
the level of arterial
the heart. blood flow
to the legs
in patients
with
arterial
insufficienc
y.
● Keep ● Keep
patient extremities
warm, and warm to
have sustain
patient vasodilatio
wear socks n and
and shoes blood flow
when in patients
mobile. with
Applying arterial
heat is not insufficienc
advised. y who
constantly
complain
of being
cold.
Ischemic
tissues are
easily
damaged
by heat.

● Encourage ● Improves
the patient blood flow
to walk to the
more extremities
often. by
promoting
 collateral
circulation.

● As ● Improved
tolerated, alveolar
place the gas
patient in a exchange
semi-Fowle is
rs to facilitated
high-Fowler by upright
's position. posture.

● Check for ● Sufficient

optimal fluid intake
fluid keeps filling
balance. pressures
stable and
maximizes
cardiac
output for
tissue
perfusion.

● Provide ● This
oxygen increases
therapy as the
 needed. efficiency
of blood
reaching
ischemic
tissues by
saturating
circulating
hemoglobi
n.

Subjective Data: Anxiety related to SHORT TERM ● Monitor ● To identify SHORT TERM
“Can something change in health GOAL: vital signs physical GOAL:
bad happen status as After 8 hours of responses After 8 hours of
during tomorrow's evidenced by nursing associated nursing
operation? I have increase in intervention: with both interventions, the
hypertension and respiratory rate, -the physical medical patient showed
I’m very nervous perspiration and appearance and and no signs of tension
about today’s scanning body language of emotional as observed in her
procedure and behavior the patient will conditions physical
tomorrow’s show signs of appearance and
operation.” improvement, body language.
without signs of ● Establish a She appeared to
Objective Data: tension or stress therapeuti ● Being be relaxed and
● Increase in -the patient will c supportive reported that
perspiratio appear relax and relationship and anxiety is reduced
n report that by approach to a manageable
● Voice anxiety is reduced conveying able level.
quivering to a manageable a non promotes
● Scanning level judgement nurse-patie
 behavior al and nt
● RR: 21 caring relationship
attitude. s. Reassure
the client
that he is
not alone.

● Encourage
the patient ● To provide
to express an outlet
her of
feelings, negative
while also emotions
reassuring and
him that concerns.
the doctors
will be
doing
everything
they could.

● Provide
accurate ● This helps
information the patient
about the identify
situation. what is
Teach reality
effective based. To
coping provide
techniques information
such as about
relaxation, possible
exercise, effective
meditation, coping
etc. strategies.