MEDICAL COLLEGES OF NORTHERN PHILIPPINES

Alimannao Hills, Peñablanca, Cagayan

Telefax No. (078) 304-1010 Website: www.mcnpisap.com
E-mail Address: adminoffice@mcnp.edu.ph

CASE STUDY
∙ NURSING HEALTH HISTORY
Name: L.C
Age: 67
Address: Atulu, Iguig, Cagayan
Date of Birth: December 13, 1953
Religious Affiliation: Roman Catholic
Civil Status: Married
Occupation: Pottery making
Dialect: Iloko, Ytawes, Ybanang, Filipino
CC: Difficulty of breathing
Date and Time of Admission: December 1, 2021 at 10:50 am
Admitting physician: Dr. Quinto
Admitting diagnosis: Hypertensive Cardiovascular Disease, Cardiomegaly and
Congestive Heart Failure, Stage IV

∙ Present Health History

- On September 2021, patient LC was diagnosed with Congestive Heart Failure and was
admitted on the same day of consultation
- After discharge, patient kept on experiencing DOB, easy fatigability, occasional cough and
edema.
- One month prior to admission, patient LC experienced intermittent DOB associated with
generalized edema. No consultation of follow-up check-ups done
- On December 1, the symptoms persisted and worsened thus prompting her admission. She
was then given a diagnosis of HCVD, Cardiomegaly and CHF Stage IV.

Significant information:
✔ Patient LC rated her current health status as 4/10
✔ (+) bowel difficulty of breathing
✔ Decreased rate of activities since hospitalization but can still do her ADLs
✔ Poor quality of sleep since hospitalization
✔ Skin texture is smooth
✔ Skin turgor: snaps back after 7-10 seconds
✔ Edema on lower legs
✔ Skin color: slightly cyanotic
✔ CRT is 4 seconds
Laboratory Results:
Date: December 1, 2021
Procedure: CBC
 Category Result Reference Analysis Nursing
Range Responsibilities

Hemoglobin 120 g/L 120-160

Concentration

Hematocrit 0.413 0.380-0.470

Erythrocyte 4.30 x 10-12 /L 4.50-6.00

Thrombocyte 179 x 10/L 150-400

MCV 96.1 fL 80-100

MCH 31.0 26-32

WBC 4.91 4.5-11

Neutrophils 87.5 35-65

Lymphocyte 6.6 20-40

Clinical chemistry
Date: December 1, 2021
Category Result Reference Analysis Nursing
Range Responsibilities

Sodium 131.8 135-145

Potassium 3.3 3.5-5.4

COURSE IN THE WARD

Date and Time Doctor’s Order Rationale

December 1, 2021 - Admit to medical ward

10:00 am under my service
- Secure consent for
admission and management -
Diet: 1600 Kcal, 70% CHO,
15% CHON, 15% Fat, Na
2gm/day, limit OFI
- Diagnostics: CBC with
APC - FBS, Lipid Profile
- Na+, K+
- Creatinine
- CXR PA/ Lateral
 - 12 Lead ECG
- 2D Echo with Doppler
- Therapeutics: D5W 500 cc X
KVO (microset)
- Furosemide 40 mg IV now
then every 6 hours with
strict BP precaution
- Spironolactone 25mg tablet
OD with strict BP precaution -
ISMN 30 mg tab ODHS

- Clopidogrel 75 mg/ tablet

ODPC
- ASA 50 mg tab ODPC
- Captopril 25 mg tab 1/4t tab
BID
- Lactulose 30 cc ODHS -
Atorvastatin 40 mg tab
ODHS
- O2 inhalation @ 3LPM via
NC
- Maintain on MHBR
- VS every 1 hour and record
- Insert IFC connect to Urine
bag
- Monitor I&O q shift and
record
- Refer

December 1, 2021 - Continue present

2:10 pm management and
medications
Grade 4 pitting edema - IVF TF D5W 500 cc X
KVO - VS q hour
- Refer

December 2, 2021 - Increase spironolactone to

Bipedal edema grade III BID
- Continue medications
- IVF TF: D5W 500 cc X
KVO - I&O q shift and
record - Refer

December 3, 2021 - Start Dopamine drip: 500 cc

Palpatory 100 - D5W + 4 amps dobutamine
x 20 ugtts/min to titrate
 every hour with increment
and decrement of 5
ugtts/min to maintain SBP >
100 mmHg
- Hold spironolactone and
Captopril
- Continue meds
- IVF TF: D5W 500 cc X
KVO - VS q hour
- CBR without BRP
- Refer
- Deck to ICU

BED 2:
Situation: Henry Taguinod is an 80-year-old male who was admitted last night with an acute
exacerbation of COPD. He was brought in to the Emergency Department at 10PM and was
admitted to our acute care unit at 11:30PM
Date of admission: December 5, 2021

Background: Mr. Taguinod has a history of COPD, coronary artery disease, and he has a
hearing deficit. He was very short of breath last night and called his physician, who told him to
go the ED. A neighbor brought him in, and his family followed shortly after. His daughter-in-law
Andeng is a nurse, and his wife Ertha came in with her. Andeng is concerned about their ability
to care for themselves. She feels Henry may be depressed. She says he is not eating well and
has lost interest in activities he previously enjoyed, like doing crossword puzzles and following
his favorite football team. She also said that Ertha has memory loss and is often confused.
Ertha and Andeng went home after Mr. Taguinod was settled in his room. He had an albuterol
treatment by respiratory therapy an hour and a half ago, and they should be back in about 30
minutes.

Assessment: Admission oxygen saturation was 82% on room air. He is now at 88% on 2 liters
of oxygen by nasal cannula. Pulse is 112, respiratory rate: 28, blood pressure 134/88. IV of
lactated ringers infusing at 50 mL/hour in right arm. He is alert and oriented, denies pain. He did
not sleep well and seems very tired. His AM labs were just drawn. He is very worried about his
wife who he says depends on him.
Date/Time:

Bedrest, BRP with assist

Regular, low fat diet

Intake & output

 Respiratory treatment:

Albuterol nebulizer treatment 2.5 mg and ipratropium bromide 0.5 mg in 3 cc NS q

20 minutes x 3, followed by albuterol 2.5 mg and ipratropium bromide 0.5 mg in 3
cc NS q 2 hours

(decrease frequency as tolerated)

Oxygen: per nasal cannula to maintain SaO2 at or above 90%.

Labs: CBC, BMP, BNP, (brain natriuretic peptide), ABGs stat then daily

IV: Lactated ringers @ 50 ml/hour

Prednisone 40 mg daily x 10 days

Fluticasone propionate 250 mcg & salmeterol 50 mcg oral inhaler q 12 hours

Albuterol 2 puffs as needed for acute onset of shortness of breath

Lisinopril 12.5 mg po daily

Metoprolol tartrate 50 mg po daily

Acetylsalicylic acid 81 mg po daily

Rosuvastatin calcium 20 mg every evening

Montelukast sodium 10 mg every evening

Katherine Angoluan, MDfrdcv

Date: DECEMBER 5, 2021

Time: 10:00 6 PM

Temperature: 36.5 36.8

Heart 110 112

Rate/Pulse:

Respirations: 30 26
 Blood 140/90 134/88
Pressure

O2 Saturation: 82% 88%

Laboratory Data
Complete Blood Count Result Reference Range

WBC (White Blood Count) 11.8 6.0-11.0 K/uL

RBC (Red Blood Count) 4.7 4.5-5.9 M/uL

HGB (Hemoglobin) 10 12.0-15.6 g/dL (F)

13.0-18.0 g/dL (M)

HCT (Hematocrit) 40% 36-46 % (F)

40-52 % (M)

PLT (Platelets) 225 150-450 K/uL

Basic Metabolic Panel Result Reference Range

Sodium 137 135-145 mmol/L

Potassium 4.0 3.5-5 mmol/L

Carbon dioxide 45 35-45 mm hg

Calcium 2.2 2-2.6 mmol/L

Chloride 96 95-105 mEq/L

Glucose 109 65-110 mg/dL

Bun 2.5 1.2-3 mmol/L

Creatinine 1.2 0.8-1.3 mg/dL

Arterial Blood Gases Result Reference Range

PH 7.34 7.35-7.45

PCO2 50 35-45 mmHg

PO2 88 75-100 mmHg

 HCO3 27 22-26 mEq/L

Personal Profile:
Name: Maureen Wroble
Age: 28
Sex: Female
Marital Status: Single
Occupation: Online Seller
Address: Tuao, Cagayan
Educational Attainment: College graduate
Nationality: Filipino/German
Religious Affiliation: Roman Catholic
Date of Birth: December 17, 1988
Place of Birth: Penablanca, Cagayan
Date and Time of admission: December 5,
2021
Admitting Physician: Dr. Steffi Aberas

A. Chief Complaint

Patient Lourdes, a 28 year old female, was brought by her sibling for
consultationat the hospital on December 5, 2021 due to complaint of body
weakness.

B. Admitting Diagnosis

Anemia of Chronic Disease probably secondary to:

1) Blood dyscrasia
2) Chronic Gastrointestinal blood loss

C. History of Present Illness

3 weeks prior to admission, the patient complained of dizziness without
associated easy fatigability, loss of consciousness, and chest pain. She also
noted of epigastric pain with burning sensations that is relieved by food intake.
No weight loss was noted. No consultation was done prior to admission. Few
hours prior to admission, the patient complained of dizziness which is not
tolerable, easy fatigability and pallor. She decided to seek consultation at the
hospital, and was admitted.
LABORATORY RESULTS:
PROCEDURE RESULT REFERENCE
RANGE

December 5, Hemoglobin: 85 Hemoglobin:

2021 M: 136-180 g/L
Complete F: 126-160 g/L
Bloo Hematocrit: 0.25 Hematocrit:
dCount M: 0.04-0.54
F: 0.37-0.47
RBC Count: 2.7 RBC Count:
M: 4.4-6.3 10^12 /L

F: 4.0- 5.1 10 ^9/L

WBC Count: 4.4
WBC Count: 5.0-10.0x/L
Neutrophils: 0.50-
Neutrophils: 0.42
0.70
Lymphocytes: 0.43
Lymphocytes: 0.20-
Monocytes: 0.13
0.40
Eosinophils: 0.02
Monocytes: 0.0-
0.07
Platelet Count: 154
Eosinophils: 0.0-
ABO:B
0.05
Rh: Positive
Basophils: 0.0-0.01
Platelet Count: 150-400x10/

PROCEDURE DESCRIPTION RESULT

 December 5, Imaging method using Impression:
2021 high-frequency sound 1. Mild
Ultrasound waves to diagnose Splenomegaly 2.
whether masses are Sonographically
solid or fluid-filled. normal
liver,gallbladder,
pancreas,kidneys
and urinary

bladder.

COURSE IN THE WARD:

Date/ Time Doctor’s Order

December 5, 2021 ∙ Pls admit to ROC under my service

(+) body weakness ∙ Secure consent for admission and
management
∙ NPO initially
∙ I&O q shift and record
∙ TPR q shift and record
∙ Dx: CBC, Utz
∙ Therapeutics:
- Start PNSS 1L x 8 hours
- FeSO4 + FA 1 tab BID
- Omeprazole 40g/cap OD ac
breakfast
- Start ampicillin-sulbactam 1.5 g IV
q6 hrs x 7 days
 - Paracetamol 500 mg tab q4 prn
for fever
∙ Monitor for untoward signs and
symptoms
∙ Refer

December 6, 2021 ∙ Secure consent for blood typing and

cross-matching
Hgb: 85 ∙ Secure consent for BT
∙ Transfuse 2 PRBC 250 ml x 4-6 hrs
∙ Refer

Date: DECEMBER 5, 2021

Time: 10:00 6 PM

Temperature: 37.5 37.8

Heart 115 100

Rate/Pulse:

Respirations: 22 25

Blood 110/80 110/70

Pressure

O2 Saturation: 85% 88%

Kardex
Mauree
n Femal
NAME: Wroble GENDER e BED #2
CIVIL
STATUS: Single AGE 28 y/o ALLERGIES: None
RELIGION Roman OCCUPATIO Online
: Catholic N Seller BIRTHDAY: December 17, 1998
Tuao,
ADDRESS Cagaya DATE OF December 5,
: n ADMISSION 2021 CLASSIFICATION: PHIC
NURSING LABORATORY/DIAGNOST
ASSESSMENT SPECIAL ENDORSEMENT IC PROCEDURES
10:00 PM

Temperature:
- 37.5
Heart Rate/Pulse:
-80
Respirations:
-18
Blood Pressure
-110/80 Waiting for blood to arrive
Prep for BT
Monitor for untoward signs and symptoms
Physical  Transfuse 2 PRBC 250 ml x 4-6 hrs
Assessment
(+)pallor
CHIEF COMPLAINT

Blood typing and cross-

matching (OR)
body weakness
DIET MEDICATIONS ONGOING IVF
REMARKS

FeSO4 + FA 1 tab
BID

Bland Diet Started / 6PM

Omeprazole
40g/cap OD ac
breakfast
PHYSICIAN TBA @7AM
- Start ampicillin-
sulbactam 1.5 g IV
q6 hrs x 7 days

Started / 4PM
- Paracetamol 500
mg tab q4 prn for
fever Started / 3:30PM
Dr. Steffi Aberas PNSS 1L X 8hrs (Remaining
DIAGNOSIS : 375ml )
Anemia of Chronic IVF TO FOLLOW
Disease probably PNSS 1L X 8hrs
secondary to:
1) Blood dyscrasia
2) Chronic
Gastrointestinal
TPR

PATIENT’S MAUREEN AGE: 28 C.S: SINGLE BED#: 3

NAME: WROBLE

DATE/TIME BLOOD TEMPERATURE PULSE RATE RESPIRATORY

PRESSURE

DECEMBER,
2021

10:00 am 90/70 37.5 115 22

12:00 pm 93/70 37.8 112 25

2: 00 pm 94/70 37.7 100 23

4:00 pm 95/70 37.6 99 22

6: 00 pm 100/80 37.6 89 20

8: 00 pm 105/80 37.5 85 18

10: 00 pm 110/80 37.5 89 18

Doctor’s Order
Patient’s Name: Age: 28 Gender: Cs: Single Bed #: 2
y/o Female
Maureen Wroble

DATE AND TIME PROGRESS NOTES DOCTOR’S ORDER

· Pls admit to ROC under my

12/5/2021 3 weeks PTC, service ∙ Secure consent for
admission and management
10 am (+) Dizziness
· NPO initially
(+) Epigastric pain c · I&O q shift and record
burning sensation · TPR q shift and record
· Dx: CBC, Utz
· Therapeutics:
- Start PNSS 1L x 8 hours
2 hours PTC,
(+) body - FeSO4 + FA 1 tab BID
weakness (+) Dizziness not - Omeprazole 40g/cap OD ac
tolerable breakfast
- Start ampicillin-sulbactam 1.5 g IV
(+) Easy fatigability
q6 hrs x 7 days
(+) pallor - Paracetamol 500 mg tab q4 prn for
fever
(+) consult done - Monitor for untoward signs and
symptoms

BP: 110/80

Temp: 37.5

HR 155

RR: 22

O2 SAT: 85%

Dx:

Anemia of Chronic
Disease probably
 secondary to:

1. Blood Dyscrasia

2. Chronic
Gastrointestinal blood
Loss

· Secure consent for blood typing and

12/06/2021 Hgb: 85 cross-matching
· Secure consent for BT
· Transfuse 2 PRBC 250 ml x 4-6
hrs

Medication Sheet

DATE OF MEDICAT DOSAGE ROUTE FREQUE DATE OF TIME OF INITIALS

ORDER ION NCY ADMINIS ADMINIS
TRATION TRATION

12/05/21 FeSO4 + PO 1 TAB 12/05/21 6:00 PM G4

FA BID

12/06/21 OMEPRA 40 MG PO 1 cap OD TBA TBA/7:00 G4

ZOLE ac AM
breakfast

12/05/21 AMPICILL 1.5 G IV Every 6 12/05/21 4:00 PM G4

IN - hrs for 7
SULBAC days
TAM
PRN and STAT

DATE OF MEDICAT DOSAGE ROUTE FREQUE DATE OF TIME OF INITIALS

ORDER ION NCY ADMINIS ADMINIS
TRATION TRATION

12/05/21 PARACE 500 MG PO 1 tab 12/05/21 3:00 PM G4

TAMOL every 4
hours as
needed
for fever

I&O

INTAKE OUTPUT

DATE/SHIF ORA IVF OTHER TOTA URINE EMESI DRAIN OTHE TOTA
T L L S S R L

12-05-21 / 3 750m 1000m 1.5 ml 1,751. 200 ml 200 ml

to 11 pm l l ampicilli 5 ml
n-
sulbacta
m

Individual Output:

https://drive.google.com/drive/folders/19gHR-
WFKiW2Excdc3wx3FYbA6eLRwu6jFlaaKx8TzZei8fscLSzcVEhzadcDlRY7RdUkujbx