De La Salle - Health Sciences Institute College of Nursing and School of Midwifery Congressional Avenue, Pasong Lawin Dasmariñas City

, Cavite

Nursing Case Presentation
BSN 31 Group 2

Aguda, Kimberly Marie Babasa, Cherry Mae I. Caayao, Trixia Liezl Dela Cruz, Jean Camille Gicana, Charisse Lacanilao, Keith Darrel

Medina, Gerald Amgelo Opiña, Janel Kate Rabie, Anne Sherina Sasoy, Alexies Cassandra Ularte, Wendelyn

August 16, 2010 Nursing Case Study
Date of Admission: July 5, 2010 Admission Diagnosis: Community Acquired Pneumonia,

Rheumatic Heart Disease
Final Diagnosis:

I.

Health History A. Demographic Data 1. Client’s Initial 2. Gender 3. Age 4. Birthdate

: E.R.A. : Female : 39 years old : July 22, 1971
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5. Birthplace 6. Marital Status 7. Nationality 8. Religion 9. Address 10. Educational Background graduate 11. Occupation 12. Usual Source of Medical Care 13. Date of Admission

: Apayao : Married : Filipino : Roman Catholic : Imus, Cavite : College : employee : hospital, clinic : July 5, 2010

B. Source and Reliability of Information • Client herself who seems to be reliable to provide personal information. The patient speaks clearly, conscious and coherent. • Patients husband who was competent and well-informed to provide concrete information about the client; she was able to speak clearly; conscious and coherent. • Patients chart was able to provide comprehensive and reliable information about the client. This serves as the tertiary source of information.

C. Reasons for Seeking Care or Chief Complaint • “persistent cough for 4 days” • “difficulty of breathing for 2 days” • “chest pain” D. History of Present Illness or Present Health Patient ERA was apparently well until four days PTC, she experienced a non-productive, non-explosive cough. Other than that, no other symptoms were noted. She had self medicated with Solmux cap BID x 2 days with no consultation to a physician. 2 days PTC, the patient had expelled mucoid whitish phlegm and experienced mild DOB. She ignored the symptoms and still continues with her daily activities. 1 day PTC, the patient started to have minimally explosive cough with yellowish mucoid phlegm. She sought consultation at Our Lady of Pillar Medical Hospital and has been prescribed with Co-Amoxicillin 500 mg/cap TID and Carbocisteine 500 mg/cap TID. She both took only 2 times. The symptoms still persisted, which made her decide to seek consultation to DLSUMC.
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E. Past Medical History or Past Health Client verbalized that she was diagnosed to have RHD when she was 13 years old, aside for some episodes of fever, headache and fever. She also verbalized that she had history of sore throat but she cannot recall when. Since then, she was prescribed to take Lanoxin. For her adult illnesses, she was diagnosed to have hypertension; her highest BP was 140/60 mmHg, but she was not given any maintenance medications. She stated that she cannot recall if she had any injuries or accidents. She was first confined at the hospital to her first pregnancy. She stated that she had her menarche at age 14. She has OB score of 333003. The client has unrecalled immunizations but she had taken all 5 doses of tetanus toxoid. She had her consultation to her doctor at Our Lady of Pillar Hospital last July 4, 2010, day prior to her admission to DLSUMC.

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And the patient herself has been diagnosed with community-acquired pneumonia. Her mother is presenlty 63 years of age and she has hypertension. rheumatic heart disease and hypertension. . She can’t recall in what age her grandparents died. 35 years of age has hypertension. who are 42 and 37 years of age respectively.F. are presently alive and well. she thinks that her 2 brothers did not inherit any diseases from their parents. Her father is presently 68 years of age and with cardiac problems. Her younger sister. both mother’s and father’s side. Family History The above diagram shows the patient’s family history. Her older brother and younger brother.

H. Socio – Economic History Family Member E. Moreover.R.G. who is 39 years of age. she does not have any activities to work with to improve her present condition what she is doing is that she make it to a point to have adequate rest if she is feeling not well.. Her significant relationships during this stage revolve around the family. The client is able to perpetuate cultures and transmit values through the family by giving advices to her siblings and her child. they don’t find any difficulty in handling money but then there were times that they find it a problem when it is lacking.A. They also don’t find any difficulty in purchasing their basic necessities since the salary was enough to sustain those things. but sometimes when her condition gets worse. which ranges from 35 to 55 or 65 years old.R. Psychosocial Assessment In Erikson’s psychosocial development. According to clients’ husband. that’s the time . Stagnation). She said that she focuses herself in the care for her family and help to the people around her. for the education of the clients’ grandchildren as well as for medical support whenever one member of the family got sick. perceives her condition as good as long as it would cause integrity to her life.A. Functional Assessment 1. she does not perceive it as punishment from God but she hopes that in the future God will not take turns to let her know what she had done just to alleviate the pain that she is feeling. she is into self medication. The client is working as a financial analyst in Makati. Occupation Financial analyst Monthly Income confidential Income earner within the family includes the client herself. He also added that the monthly salary of clients’ daughter was enough and adequate to sustain their everyday living. However. Health-Perception-Health Management Pattern  Patient E. which indicates that she had done the task of generativity.A.R. According to her. She also verbalized that she is satisfied with what is happening with her life right now. patient E. She also states that their monthly income was enough in the payment of different bills. She verbalized that she feels happy and contented if she could give help and care to her other family members. workplace and community. I. is in the middle adulthood stage (Generativity vs.

She states that she is thankful for her appearance. Her hair is well distributed and there are no presences of lumps or areas wherein there are no hair growth. verbalized that she eats 3-4 times daily included her snacks and small eating’s everyday. Her skin is well hydrated in terms that it is moist and warm to touch. Elimination Pattern  Patient E. general mobility. But still. cooking. Role Relationship Pattern . She prefers eating fish than vegetables.she seeks a doctor for consultation. She also verbalized that her meal everyday is almost always meat and fish.A.R. She admitted that she is still not contented of the things that she has now. feces are brown in color.R. although she has no naps during the afternoon. dressing. She sleeps at night at around 10 pm.R. especially if she forgets to drink water. Because she eats 3-4 times a day. Sleep – Rest Pattern  Patient E. toileting. 5. Activity – Exercise Pattern  Patient E. 4. home maintenance and shopping. verbalized that she does not experience any difficulty in urinating. verbalized that she has not enough exercise due to her busy office work. grooming. She said that she has enough energy for her work for the whole day.A. just the same as before. as according to her. 3. As of now. perceives her sleeping pattern as well. She feels comfortable to what ever appearance she have.R. 2. she stated that she sometimes seek the help of her husband whenever she is not feeling well. Self – Perception – Self Concept Pattern  Client E. 6. 7. According to her. She drinks at least four times in the morning and another four glasses in the evening to make sure that gets enough fluid and to avoid dehydration especially during hot days. verbalized that there’s nothing unusual in her appearance.A.A. bed motility. she is still of finding things that will add more happiness to her life.A. But she sometimes skips meals due to busy office work. She perceives full self care for feeding. and wakes up the next day at around 4 or 5 in the morning.R. She said she could have some naps if she is free during office break time. bathing. Bowel movement is regular. Nutritional – Metabolic Pattern  Patient E. the urine is more yellowish than normal. she supposes that she has a well – balanced diet.

8. siguro di rin kasi ako sanay dito sa ospital. She thinks that her coping actions help to lessen the stress she is experiencing. Sexuality – Reproductive Pattern  Client E. tolerable naman yung sakit ng dibdib ko. conscious. she could consult her husband or her siblings. 9. Di naman ako nakakaramdam ng ibang sakit sa katawan ko. Review of Systems (July 7. her only means of coping with stress is by sleeping and relaxing at home.  Ectomorpic body built  Vital signs are the following: SYSTEM General . 2010) REVIEW OF SYSTEMS Client verbalized.R. pero medyo pagod. J. is happily living with her family. She also experiences mild pre-menstrual pain. cooperative and expresses feelings appropriate to situation. Her OB score is 333003. expressed her satisfaction regarding her sexuality. may konting ubo pa rin. Maintains good eye contact.A.R. with an IVF of PNSS 500 cc x 72º (1gtts/min) . coherent and oriented to time. “Ayos naman yung pakiramdam ko sa ngayon. She said that whenever she has problems. They don’t use any contraceptive method. Regarding to her relationship with the co-workers. all are cooperating and she strengthens it by attending in regular meeting and gettogethers. inserted @ right metacarpal vein. Patient E. place and person.” PHYSICAL EXAMINATION  Received patient awake. The environment is conducive for the patient. Coping – Stress Tolerance Pattern  According to the client.A. lying on bed. intact and infusing well and without IV related complications. Her menarche started when she was 14 years old.

Maalaga naman ako sa balat ko.BP: 120/70 mmHg Radial pulse: 71 bpm RR: 39 cpm T: 36. “Hindi pa naman ako nagkakasakit sa balat. afebrile  (+) restlessness  (+) weakness  (+) lips and palpebral conjunctiva paleness  (+) pallor  (+) fatigue  (+) use of accessory muscles when breathing  (+) chest indrawing  (-) sweating  (-) chills  (-) lethargy  Patient expels whitish mucoid phlegm (2. hindi rin ako masyado nagbibilad sa ilalim ng araw.” SKIN: Inspection:  Fair complexion  (+) pallor  (-) jaundice  (-) cyanosis  (-) ecchymosis  (-) edema  (-) bruises  (-) pruritus  Senile skin turgor  (-) profuse non odorous perspiration  (-) lesions .0ºC. lagi ako naglo-lotion. Lagi nga ako nagamit ng payong e.5ml)  Diet: Diet as Tolerated Integument Client verbalized.

” Eyes Client verbalized. kahit medyo manipis. smooth in texture. scaly skin  Good skin turgor: returns immediately (1 sec) HAIR:  Hair is black in color. “Minsan lang naman sumasakit ulo ko. Wala naman akong kuto. Maalaga talaga ako sa buhok. “Malinaw pa  (-) Pendulous skin Palpation:  (-) thin.  Shiny and equally distributed. Madalas lang mangati ang anit ko. dry.Head Client verbalized.  (-) alopecia  (-) parasites  (-) lesions on scalp NAILS:  Nail bed pink in color  Nails hard and round.  Capillary refill revealed after 2 seconds Inspection:  Round and symmetrical skull and size is appropriate to the size of the body  (+) itchiness  (+) dandruff  (-) parasites  (-) lesion  (-) head injury scars  Still and upright facial features Palpation:  Smooth and hard skull  (-) unusual lumps  (-) masses  (-) tenderness  (-) depressions/elevation s on head Inspection: .

 Eyelashes are medium in length and equally distributed.  (+) bilateral blinking reflex .  At the same level as the pinna. Pero gumagamit ako ng salamin kapag nagbabasa”  Eyes are symmetrical and equal in size. smooth and moist  (-) opacity in both cornea  (+) PERRLA (Pupils equally round and reactive to light accommodation)  (+) moist and glossy eyeball  (-) excessive tearing  (-) swelling  (-) lesions or nodules are apparent.naman ang paningin ko. Pale palpebral conjunctiva  Scleras are white in color  Upper and lower lids close easily and meet completely  (+) convergence  Eye movements are smooth and symmetric throughout the six directions  (-) redness  (+) use of reading glasses  (-) discharge in the sclera  (+) cornea is transparent.  Iris dark brown in color.

“Madalas Inspection: lang ako magkasipon. proportion with facial features with no swelling or lesions  (+) midline septum  Smooth consistency  Pink nasal mucosa  (+) red glow of the sinuses upon . pero  Client was able to bukod dun. Regular ako and similar in maglinis ng tenga. wala na. “Wala naman Inspection: ako nararamdamang masakit  Ears equal in size sa tenga ko. symmetrical. Hindi identify odors naman nasakit.  Pinna is aligned and parallel to outer canthus of the eye.” appearance. nose on midline.” presented (alcohol and orange fruit)  Color same as the face  Symmetric. symmetrical and well formed  (-) swelling  (-) thickening  (-) unusual discharge  (-) redness of the ear lobe Palpation:  (+) firm pinna  (-) lumps and masses  (-) tenderness Client verbalized.Ears Nose and Sinuses  (-) ectropion  (-) myopia  (-) ptosis Palpation:  (-) unusual masses  (-) tender eyelids  (-) purulent discharge Client verbalized.

smooth in texture  Frenulum in midline  With rhinorrhea & cough  (+) hoarseness  (-) ulcerations  (-) lesions  (-) oral thrush  (-) gingivitis  (+) tongue in midline  (+) uvula in midline  (+) gag reflex when swallowing. no swelling and lesions. “Wala naman Inspection: ako problema sa bibig ko. “Nagagalaw Inspection: ko naman yung leeg ko ng  Same color as the maayos. madalas lang face .  Tongue moves easily without tremor. hindi  (+) pale lips rin naman ako nahihirapan  Pinkish and moist magsalita. Client verbalized. revealed using tongue depressor  Tongue is pink.Mouth and Throat Neck transillumination  (-) lesions  (-) discharge  (-) inflammation of mucus membrane  (-) edema  (-) epistaxis  (-) nasal flaring Palpation:  (-) nodules and masses  (-) tenderness in the sinus and nasal area Percussion:  (+) hollow tone on sinuses Client verbalized. Araw-araw akong buccal mucosa nag sisipilyo.”  Lips.

” Client verbalized. wala din physical examination naman ako nakakapa na bukol. hindi mabigat yung isa kesa sa isa. Inspection: medyo sumasakit. Minsan RR:39 cpm naninikip. pero pagkainom  Equal chest naman ng gamot. hirap din ng  (+) tachypnea: konti huminga. “Nung una. Sa tingin ko pantay naman siya. ayos na.” symmetry  Scapula are symmetric & nonprotruding  Sternum in midline and level with ribs  Shoulder & scapula are at equal horizontal position  Spinous processes appears straight  Ribs sloping downward  (+) tripod position and sometimes orthopneic  (+) shortness of mangalay dahil sa trabaho.” .Breast and Axilla Respiratory  Neck is symmetrical  (-) lesions  Full ROM on neck  (-) superficial cervical lymph node enlargement Palpation:  (-) enlargement and masses  (-) swelling  (-) tenderness  Thyroid in midline position  Non palpable cervical nodes  thyroid not palpable Auscultation: (-) bruits Client verbalized. “Wala naman  Patient refused masakit sa dibdib ko.

“Sabi nung Inspection: mga doktor dati. pero may distention/bulging pinapainom naman sakin na  BP = 120/80 gamot. may sakit daw  (-) jugular vein ako sa puso. Minsan  Abdomen flat and Gastrointestin al .” mmHg  (+) atheromatous aorta based on X-Ray findings  Radial and apical pulse rates are identical = 71bpm  Apical pulse is weak Palpation:  Apical pulse in mitral area Auscultation:  Loudest sound at the apex Client verbalized. “Wala naman Inspection: nananakit sa tiyan ko.breath  (+) difficulty of breathing  (+) use of accessory muscles when breathing  tenderness  (+) productive cough (whitish mucoid phlegm)  (+) mild chest indrawing Palpation:  (+) crepitus  (+) fremitus  (-) tenderness Percussion: (+) dullness Auscultation:  (+) crackles on both lungs fields  (-) stridor  (-) wheezes Cardiac Client verbalized.

” Client verbalized.”  Kidneys are not palpable  (-) distended bladder  (-) tenderness upon palpation Client verbalized. “Wala naman  Unable to perform ako nararamdaman. hindi talaga. “Wala naman Inspection: akong nararamdaman na  Non odorous urine masakit pag naihi ako. hinuhugasan ang mga pribadong parte ng katawan lang hindi natutunawan kaya minsan nasakit. “Nakakakain naman ako ng maayos” . regular ko namang refused. malinis examination. Minsan  (-) abdominal pain nagpipigil ako ng ihi. patient naman ako.Urinary Genitalia rounded  (-) discoloration of the abdomen  (+) stretch marks  (-) jaundice  (-) hematemesis  (+) brownish soft stool  (+) passing of flatus  (-) abdominal distention  (-) constipation Auscultation:  16 bowel sounds/min  (-) bruits Percussion:  Tympanic sound over four quadrant  Dullness over the liver  Fluid wave test result Palpation:  Spleen & liver are not palpable  (-) masses  (-) lesions  (-) tenderness Client verbalized. pero pag  Urine color: amber kailangan lang. pero most of the Palpation: time. yung sobrang colored urine busy lang.

“Wala naman Inspection: ako nararamdaman. “Madali Patient is coherent and is naman ako makatanda.  Elbows are symmetric  (+) body weakness & exertion upon movement Client verbalized. Ganun din yung sa coordinated and likod ko. “Pag sa Inspection: trabaho. . maayos ko naman nasasagot places and time.” legs  (-) varicose veins  (-) discoloration of upper and lower extremities  (-) edema Palpation:  Radial pulse: 71 bpm  (-) masses  Regular weak radial pulse  swelling of legs  Capillary refill: 2 seconds Auscultation:  No unusual sounds detected Client verbalized.Peripheral Vascular Musculoskelet al Neurologic ko. dahil sides of arms and siguro sa pasma.” Client verbalized. no swelling and deformities.” rhythmic  Mouth opens and closes smoothly  Jaw protrudes and retracts easily. oriented to people. has full resistance against applied force  Shoulders are symmetrically round. wala din  (-) lesions on arms naman ako nakikitang kakaiba and legs sa arms at legs ko. madalas ako nakatayo  Full ROM from kaya minsan masakit yung sa head to toe binti ko. Pero  (-) swelling in both nanginginig minsan. pero konting masahe  Movements are lang ok na.

show teeth. Patient’s clothes are fit and appropriate for the situation Patient can recall past events especially prior to her illness. expresses feelings appropriate to the situation Verbalizes positive healthy thoughts about future. CN IX. CN V: Temporal and masseter muscles contract bilaterally. All movements are symmetrical. family and self.” Patient appears to be calm and rested Patient responds in moderate tone. VI: eyelids move in a smooth and coordinated motion in all directions. eyelids blink bilaterally CN VII: smiles. X: swallows . Patient is cooperative and friendly.yung mga tinatanong sa kin. closes eyes against any resistance. CN I: Correctly identifies scent presented (alcohol) CNII: Full visual fields CN III. forehead. CN VIII: Hears word correctly using voice whisper test. moves eyebrows. clear and in moderate pace. IV. wrinkles.

“Wala naman Inspection: akong unusual bleeding.without difficulty by drinking water CN XI: trapezius muscles are symmetric CN XII: tongue is smooth and mobilizes symmetrically Client verbalized. mabilis  (-) excessive naman gumaling. Hindi  (-) epistaxis rin ako madalas magsugat.” bruising  (-) jaundice Hematologic .  (-)bleeding Yung mga sugat ko.

o Instruct to lie down and rest.04 – 0. o Gently invert the collection tubes several times to blend sample.05 o Check patient and apply cotton to puncture site.5 g/L WBC: 5. POST Monocytes: 0.12 o Cleanse and dry puncture site.83 Lymphocytes: 0.0.000 – 10. Laboratory Studies and Diagnosis PROCEDURE (DATE) INDICATION NORMAL FINDINGS/ VALUES ACTUAL FINDINGS NURSING RESPONSIBILITIES Hematology (July 5) To obtain small vials of blood for numerous tests involved in diagnosing many conditions other than blood diseases Hgb: F: 123 – 150 g/L M: 140 -175 g/L Hct: F: 0.08 Monocytes: 0.45 g/L M: 0.66 Lymphocytes: 0.22 – 0. Do not shake.36 – 0.36 – 0. o Inform the patient about the procedure.40 g/L WBC: 12.400/ mm3 Segmenters: 0. INTRA Hct: 0.8 secs Serum: 68 µmol/L . o Hold syringe or evacuation tube with needle.41.K. PTT: 10 – 14 secs Serum: 46-92 µmol/L PTT: 11.40 Hgb: 130 g/L PRE o Inform the patient of the necessity of the procedure.000/ mm3 Segmenters: 0.

a substance produced by Group A Streptococcus bacteria PRE o Explain to the patient that the ASO test detects an immunologic response to certain bacteria(Streptococci) o Inform the patient that he need not restrict food and fluids (although a fasting sample is preferred) o Tell the patient that the test requires a blood sample. tell the patient that measuring changes in antibody levels helps determine the effectiveness of therapy. o If the test is to be repeated at regular intervals to identify active and inactive states of rheumatic fever or to confirm acute glomerulonephritis.Na: 137-145 mmol/L K: 3.2 mmol/L < 200 IU/ml ASO titer (July 5) A blood test to measure antibodies against streptolysin O. o Explain to the patient that he may experience slight discomfort from the tourniquet and needle puncture. o Check the patients history for .5-5.10 mmol/L < 200 IU/ml Na: 142 mmol/L K: 4. o Explain who will perform the venipuncture and when.

where it will take place and how long it will last. INTRA o Perform a venipuncture test and collect the sample in a 7 ml tube without additives. including who will perform it. myocardial ischemia and the site and extent of myocardial infarction. o If such drugs must be continued. INTRA ECG (July 5) ECG permits to detect very many illnesses of the heart.  dilated left ventricle with good wall motion and contractility  dilated left atrium  normal size right atrium. vasodilator. PRE o Explain to the patient that an ECG evaluation evaluates the heart’s electrical activity. main pulmonary artery and aortic root  thickened and calcified aortic valve cusps with restriction of motion . first of all the myocardial infarction. To evaluate the effectiveness of cardiac medications (cardiac glycosides. It is to help identify primary conduction abnormalities. To monitor recovery from myocardial infarction. note this on the laboratory request. cardiac arrhythmias. cardiac hypertrophy. o Tell the patient that electrodes will be attached to his arms. o Tell the patient that he need not restrict food and fluids.drugs that may suppress the streptococcal antibody responses. No discernable P wave preceding each QRS but narrow regular QRS complexes is a nodal or junctional rhythm. and antihypertensive) Regular Rhythms P wave precedes every QRS complex with consistent PR interval is sinus rhythm. right ventricle. o Apply direct pressure t the venipuncture site until bleeding stops. legs and chest and that the procedure is painless. o Describe the test.

used to help diagnose symptoms such as shortness of breath. POST o Check the patient’s medication history for use of cardiac drugs and note the use of such drugs on the test request form. interolateral wall ischemia o Place the patient in a supine position. heart and chest wall. o Advise the patient not to talk during the test because the sound of his voice may distort the ECG tracing.To assess pacemaker performance. If he can’t tolerate lying flat. o Explain that during the test he’ll be asked to relax lie still and breathe normally. o Turn on the machine and check the paper supply. help him to assume seme fowlers position. If the patient is a woman provide a chest drape until the chest leads are applied. both ankles and both wrists for electrode placement. o Help the patient expose his chest. a bad or A normal chest x ray will show normal structures for the age and medical history of  cardiomegaly with incipient pulmonary congestive . PRE o Explain too the patient that chest radiography assesses chest CXR (July 5) To evaluate the lungs.  thickened arterior mitral valve leaflet without restriction of motion  structurally normal tricuspid valve and pulmonic valve  no intracardiac thrombus nor pericardial effusion noted  ECG mount: LVH.

chest pain or injury. changes and/or pneumonitis. ECHOCARDI OGRAPHY AND COLOR FLOW DOPPLER REPORT Assess the heart’s function Determine the presence of disease of the heart muscle. o Tell the patient that he need not restrict food and fluids. including who will perform it. o Explain to the patient that he’ll be asked to take a deep breath and hold it momentarily while the film is being taken to provide a clear view of pulmonary structures. to help diagnose or monitor treatment for conditions the patient. INTRA o The patient stands or sits in front of the machine so films can be taken posteroanterior and left lateral views. valves and pericardium. where it will take place and how long it will last. Left Ventricle End-diastolic diameter 49±4 mm Interpretation:  technically different study  dilated left ventricle with hypertrophied . o Describe the test. o Place cardiac monitoring leadwires. fever. and congenital M-Mode Exam.persistent cough. both lower lobes  r/o the possibility of pericardial effusion wherein correlation with 2D is suggested anatomy. pulmonary artery catheter lines and safety pins as far from the X-ray field as possible. IV tubing form central lines. heart tumors.

main pulmonary artery and aortic root dimensions.  Thickened aortic valve cusps with calcifications along the cuspal margins.(July 8) heart disease Evaluate the effectiveness of medical or surgical treatments Follow the progress of valve disease End-sys tolic diameter 30±5 mm Fibre fractional shortening 38±6 % Interventricular septum thickness 9±1 mm Septal systolic thickening 51±19 % Postero-lateral wall thickness 8±1 mm Wall systolic thickening 94±30 % Hypertrophy index walls. posterior mitral valve leaflet has mild restriction of . mild restriction of motion  anterior mitral valve leaflet is redundant. mild global hypokinesia with depress left ventricular systolic function  dilated left atrium  Normal right atrium. right ventricle. Middle scallop (A2) billowing into left atrium in systole.

34±0.0. normal tricuspid valve and pulmonic valve  No pericardial effusion and no intracavitary thrombus Conclusion:  Posteriorly directed and eccentric mosaic color flow noted across mitral valve in systole  Mosaic color flow noted across aortic valve in diastole and across tricuspid valve in systole.9 cm2 .  structurally.05 Mass index 91±20 g/ m2 End-systolic meridional wall stress 56±17 103 dynes/cm2 Left Ventricular Ejection Fraction Normal 55 – 65 % Mildly reduced 45 – 55 %35 – 45 % Moderately reduced < 35 % Severely reduced Aortic Valve Stenosis Mild < 20 mmHg Moderate 20 – 50 mmHg Severe > 50 mmHg Mitral Valve Stenosis Mild < 6 mmHg Moderate 6 – 16 mmHg Severe 16 mmHg motion. Mitral valve area of 2.02 cm2 by planimetry.  Aortic valve area of 1.

peak aortic valve gradient is equal to 22.Wall Motion Walls A Anterior AL Antero-lateral SA Anterior septum I Infero-Posterior SI Inferior septum PL Postero-Lateral Asynergy Score 0 Not visualized 1 Normokinesis 2 Hypokinesis 3 Akinesis 4 Diskinesis 5 Aneurysm Pericardial Effusion Mild < 1 cm separation = 300 ml Moderate 1-2 cm separation = 500 ml Severe > 2 cm separation > 700 ml by continuity equation.8mmHg. peak pressure gradient is equal to 37.87 cm2 by pressure half time.  Pulmonary artery pressure of 44 mmHg by tricuspid regurgitant jet.6 mmHg.  Prolonged deceleration time . mean aortic valve gradient is equal to 9. Conclusion:  RHD .5 mmHg. mean pressure gradient is equal to 16. mitral valve area of 0.8 mmHg.

 Aortic regurgitation. 3+  mild aortic stenosis  anterior mitral valve prolapsed (A2)  severe mitral regurgitation  >mild mitral stenosis  moderate tricuspid regurgitation  eccentric left ventricular  Hypertrophy with mild global hypokinesia with depressed left ventricular systolic function.  dilated left atrium  moderate pulmonary hypertension .

2010/ patient was able to effectively expel secretions b) HIGH RISK or Potential PROBLEM NO. 2010 Ineffective Airway Clearance DATE RESOLVED/ REMARKS July 7. Problem List a) PROBLE M NO. Mobility: 1 Cooking: 4 Home Maintenance: 4 Shopping: 4 M. 2010 . Other Assessment Tools DATE TAKEN June 25. PROBLEM 1 Risk for Infection Transmission DATE IDENTIFIED July 7.L. 2010 COMPREHENSIVE ACTUAL CONTENT/ LEGEND Legend Functional Level Code Level 0 Full self care Level 1 Requires use of requirements or device Level 2 Requires assistance or supervision from another person or device Level 3 Requires assistance or supervision from another person or device Level 4 Is dependent and does not participate ACTUAL RESULTS Feeding: 0 Bathing: 2 Toileting: 1 Bed Motility: 0 Dressing: 2 Grooming: 0 Gen. 1 ACTUAL or Active PROBLEM DATE IDENTIFIED July 6.

the patient INTERVENTION Independent:  Establish nurse-patient intervention RATIONALE EVALUATION  Identify/demo nstrate behaviors to achieve airway  To gain trust and for the nurse to gain more . CAP NURSING CARE PLAN CUES S  Clien t verbalized.Medical Diagnosis: Patient’s initials: E.A RHD.R. “Naluluwa ko naman NURSING DIAGNOSIS  Ineffective Airway Clearance related to excessive LONG TERM  One month after the client’s discharge from the SHORT TERM  After 8 hours of giving nursing interventions.

Crackles are heard in inspiration clearance. nahihirapan ako huminga. “Pag nauubo ako.  Display patent airway with breath sounds clearing. Bronchial breath sounds can also occur in consolidated areas. .”  Clien t verbalized. palaging may plema.  Decreased airflow occurs in areas with consolidation of fluid. pero konting konti lang. will be able to improve cough effort by reducing discomfort.yung plema pag naubo ako. cyanosis. she will be able to facilitate the maintenance of supply of oxygen to all body cells. pero sandali lang. tapos minsan after nun. absence of dyspnea.” O  (+) Shortness of breath  (+) difficulty of breathing  (+) frequent mucous production secondary to CAP hospital.  Assess rate and depth of respiration and monitor for signs of respiratory failure  Auscultate lung fields noting areas of decreased or absent airflow and anvetitious breath sounds information from the patient  Shallow respirations are frequently present because of the discomfort of moving chest wall.

 Fluids aid in the mobilization and .productive cough of whitish mucoid phlegm 2.  Enourage patient to consume at least 3000 cc of fluids everyday. thick secretions and airway obstruction. and expiration in response to fluid accumulation . Offer warm than cold fluids.  It keeps the head elevated and promotes chest expansion and promotes mobilization and expectoratio n of secretions to keep the airway clear.5 cc in amount  Tachypnea (RR=39cpm)  (+) tripod position  (+) use of accessory muscles when breathing  Mild Chest indrawing  (+) shallow breathing  (+) crackles on both lung field at apex  Elevate head of bed and change position frequently.

 Deep  Assist in doing deep breathing exercises.Collaborative:  Administer medications as indicated expectoratio n of secretions.  Aids in reduction of bronchospas m and mobilization of secretions. Demonstrate or help the . Warm liquids dilate the bronchioles. but should be used cautiously because they acn decrease cough effort or depress respiration. Analgesics are given to improve cough effort by reducing discomfort.

IV fluids) breathing facilitates expansion of the lungs and smaller airways.client in learning to perform the activity.  Facilitates liquefaction and removal of secretions. Pursed lip breathing)  Assist with/ monitor effects of nebulizer treatments.  Provide supplemental fluids (ex. Coughing is a natural self cleaning mechanism assisting the cilia to maintain patent airways. (ex. Perform treatment between meals.  Fluids are required to replace losses (including insensible .

NURSING DIAGNOSIS  Alteration in comfort related to decreased oxygen supply secondary to CAP CUES S  The client verbalized “nahihirapa n ako huminga.” O  (+) use of accesory muscles when breathing  Tachypnea RR:39 bmp  (+)tripod LONG TERM  One month after the client’s discharge from the hospital.  To promote respiration . pero sandali lang. SHORT TERM  At the end of the shift the patient will verbalize comfort as man INTERVENTION Independent:  Establish nurse-patient intervention RATIONALE EVALUATION  The person will relate relief after a satisfactory health measure as evidenced by absence of disc  Assess rate and depth of respiration and monitor for signs of respiratory failure  Position the client from lying to  To gain trust and for the nurse to gain more information from the patient  Shallow respirations are frequently present because of the discomfort of moving chest wall. she will be able to facilitate the maintenanc e of supply of oxygen to all body cells.loss) and aid in mobilization of secretions.

or orthopneic position  (+)chest indrawing  (+) weakness orthopneic position Collaborative:  Administer medications as indicated  Assist in doing deep breathing exercises. Analgesics are given to improve cough effort by reducing discomfort.  Deep breathing facilitates expansion of the lungs and . Demonstrate or help the  Aids in reduction of bronchospas m and mobilization of secretions. but should be used cautiously because they acn decrease cough effort or depress respiration.

client in learning to perform the activity. Pursed lip breathing)  Assist with/ monitor effects of nebulizer treatments.  Facilitates liquefaction and removal of secretions. (ex. . Perform treatment between meals smaller airways. Coughing is a natural self cleaning mechanism assisting the cilia to maintain patent airways.

will be able to verbalize endurance in performing ADL. and difficulty accomplishin g task. respiartion and BP remain within client’s normal range. muscle weakness.  To gain trust and for the nurse to gain more information from the patient  Influences choice of interventions/ needed assistance. LONG TERM One month after the client’s discharge from the hospital. “Medyo nanghihina ako.  Display laboratory values like hemoglobinhematocrit within acceptable range.CUES S  Client verbalized.  Demonstart e a decrease in physiologic signs of intolerance like pulse. kaya di ako masyado nagalaw ng nagalaw. she will be able to promote optimal activity: sleeprest exercise. “Nili-limit ko na lang yung pagalaw ko. parang ang bilis ko mapagod. noting reports of weakness. the pt. SHORT TERM At the end of the shift.  Note changes in balance/gait disturbance.”  Client verbalized. .” O  (+)weakne ss NURSING DIAGNOSIS Activity intolerance related to mild chest pain secondary to RHD.  Assess client’s ability to perform normal task/ADLs. pag nagalaw kasi ako ng nagalaw.  May inidcate neurologic changes associated with Vitamin B12 deficiency. fatigue. INTERVENTION Independent:  Establish nurse-patient intervention RATIONALE EVALUATION  Report an increase in activity intolerance including ADLs.

respiration during and after activity. pulse. and repeated unplanned interruptions. bed rest if indicated. phone calls.  Elevate affecting client’s safety/risk of injury. Stress need to monitor and limit visitors.  Cardiopul monary manifestation s result from attempts by the heart and lungs to supply adequate amounts of oxygen to the tissues. . (+)difficult y of breathing  Mild chest pain  RR : 39cpm  Monitor BP.  Enhances rest to lower body’s oxygen requirement. and reduces strain on the heart and lungs. Note adverse responses to increase levels of activity.  Recomme nd quiet atmosphere.

HOB as tolerated.

 Suggest client change position slowly, monitor for dizziness.

 Assist client to prioritize ADLs/desired activities. Alternate rest periods with activity periods. Write out schedule for client to refer to.

 Enhances lung expansion to maximize oxygenation for cellular uptake.  Postural hypotension or cerebral nypoxia may cause dizziness, fainting, and increase risk of injury.  Promotes adequate rest, maintains energy level, and alleviate strain on the cardiac and respiratory system.

 Provide/re

commend assistance with activities/amb ulation as necessary, allowing client to do as much as possible.  Plan activity progression with client, including activities that client views as essential. Increase activity levels as tolerated.

Although help may be necessary, self esteem is enhance when client does some things for self.

 Identify/im plement energy saving

Promotes gradual return to normal activity level and improve muscle tone/stamina without undue fatigue. Increases self esteem and sense of control.  Encourage s client to do as much as possible, while

techniques; e.g., shower chair, sitting to perform tasks.  Instruct client to stop activity if palpitations, chest pain, shortness of breath, weakness, or dizziness occur.

 Discuss importance of maintaining environmenta l temperature and body warmth as indicated.

conserving limited energy and preventing fatigue.  Cellular ischemia potentiates risk of infarction and excessive cardiopulmon ary strain/stress may lead to decompensati on and failure.  Vasoconstr iction decreases peripheral circulation, imppairing tissue perfusion. Client’s comfort/need for warmth

e.  Identifies deficiencies in RBC components affecting oxygen transport and treatment needs/respons e to therapy. Hb/Hct and RBC count.  Prepare for surgical intervention if indicated. ABGs..  Maximizin g oxygen transport to tissues improves ability to function.g.  Provide supplemental oxygen as indicated.Collaborative:  Monitor laboratory status.  Surgery is usefeul to control bleeding in . must be balance with need to avoid excessive heat with resultant vasodilation.

.patients who are anemic because of bleeding.

III. and left ventricle (LV). under normal conditions. Anatomy and Physiology CARDIOVASCULAR SYSTEM A basic understanding of cardiac anatomy allows for correlation of physical exam finding with the unseen anatomy of the heart. The left ventricle is generally about twice as thick as the right ventricle because it needs to generate enough force to push blood through the entire body while the right ventricle only needs to generate enough force to push blood through the lungs. left atrium (LA). The adult heart is about the size of a closed fist and sits in the thorax on the left side of the chest in front of the lungs. acting together. The tricuspid valve is between the right atrium and right ventricles. The valves. insure that blood only flows in one direction in the heart. the heart is connecting to the vascular system of the body. arteries. PHYSIOLOGY: . arterioles. and then returns blood to the left atrium through the pulmonary veins (PV). upper chambers of the heart and the two ventricles are the larger. systemic capillaries. The heart also has four valves. and then returns blood to the right atrium through the venules and great veins. The mitral valve is between the left atrium and the left ventricle and the aortic valve is between the left ventricle and the aorta. The two atria are the smaller. The right side of the heart pumps blood to the lungs through the pulmonary artery (PA).right atrium (RA). pulmonary capillaries. The pulmonary valve is between the right ventricle and the pulmonary artery. The heart is designed as a pump with four chambers . The left side of the heart pumps blood to the rest of the body through the aorta. lower chambers of the heart. The heart is oriented in the chest rotated about 30 degrees to the left lateral side such the right ventricle is the most anterior structure of the heart. The cardiovascular system is actually made up of two major circulatory systems. In order to pump blood through the body. This cardiovascular system is designed to transport oxygen and nutrients to the cells of the body and remove carbon dioxide and metabolic waste products from the body. right ventricle (RV).

Essentials of anatomy and physiology 6th edition. When engaged in strenuous activities. the air is heated and moisturized before it is brought further into the body. Routing blood. Generating blood pressure. It is this part of the body that houses our sense of smell. with the average adult breathing about 12 to 20 times per minute. The valves of the heart ensure a one-way flow of the blood through the heart and blood vessels. It is the . Source: Seeley. 2007. 4. ANATOMY: Nostrils/Nasal Cavities During inhalation. This system is responsible for the mechanical process called breathing. which is required for blood flow through the blood vessels. The heart separates the pulmonary and systemic circulation. Sinuses The sinuses are small cavities that are lined with mucous membrane within the bones of the skull. RESPIRATORY SYSTEM The respiratory system is an intricate arrangement of spaces and passageways that conduct air from outside the body into the lungs and finally into the blood as well as expelling waste gasses. air enters the nostrils and passes into the nasal cavities where foreign bodies are removed. the rate and depth of breathing increases in order to handle the increased concentrations of carbon dioxide in the blood. Regulating blood supply. Pharynx The pharynx. and changes in the body position. 3. which ensures the flow of oxygenated blood to tissues. Ensuring one-way blood flow. Changes in the rate and force of heart contraction match blood flow to the changing metabolic needs of the tissues during rest. but can be consciously stimulated or inhibited as in holding your breath. Tate. Stephens. 2. or throat carries foods and liquids into the digestive tract and also carries air into the respiratory tract. McGrawHill Education. Larynx The larynx or voice box is located between the pharynx and trachea. exercise.1. Breathing is typically an involuntary process. Contractions of the heart generate blood pressure.

2. Air movement past the vocal cords makes sound and speech possible. The respiratory system provides protection against some microorganisms by preventing their entry into the body and by removing them from respiratory surfaces. which enter the lungs. the capacity to carry out normal activity is reduced.location of the Adam's apple. Bronchi The trachea divides into two parts called the bronchi. The respiratory system allows oxygen from the air to enter the blood and carbon dioxide to leave the blood and enter the air. Without healthy respiratory and cardiovascular systems. 5. 3. The cardiovascular system transports oxygen from the lungs to the cells of the body and carbon dioxide from the cells of the body to the lungs. and waste gasses are returned for elimination. The sensation of smell occurs when airborne molecules are drawn into nasal cavity. and without adequate respiratory and cardiovascular system functions. Innate immunity. It is here that the air we breathe is diffused into the blood. At the lungs. life itself is impossible. Bronchioles The bronchi subdivide creating a network of smaller branches. becoming progressively smaller as they branch through the lung tissue. Regulation of blood pH. Lungs The lungs are the organ in which the exchange of gasses takes place. which in reality is the thyroid gland and houses the vocal cords. Voice production. 4. Thus the respiratory and cardiovascular systems to work together to supply oxygen to all cells and to remove carbon dioxide. Alveoli The alveoli are tiny air sacks that are enveloped in a network of capillaries. Gas exchange. It is at the alveoli that gasses enter and leave the blood stream. PHYSIOLOGY: 1. Olfaction. Trachea The trachea or windpipe is a tube that extends from the lower edge of the larynx to the upper part of the chest and conducts air between the larynx and the lungs. with the smallest one being the bronchioles. until they reach the tiny air sacks of the lungs called the alveoli. The respiratory system can alter blood pH by changing blood carbon dioxide levels. . There are more than one million bronchioles in each lung. The lungs are made up of extremely thin and delicate tissues. the bronchi subdivides.

Stephens. . McGrawHill Education. Essentials of anatomy and physiology 6th edition. 2007. Tate.Source: Seeley.

Medical Diagnosis: RHD.R.A. CAP Patient’s initial: E. .

sinuses) (+) throat culture Variety of enzymes Immune system response liberated damage the tissue -cough and colds -mild fever -sneezing -Fever -Fatigue -Loss of appetite -Cough -headache -malaise -pallor diaphoresi s . mouth. mouth and sinuses) Stick to local epithelial cells Hematolog y ASO Titer Invasion of streptococcus pneumoniae Invasion to the upper respiratory tract (nose. HPN) Inhalation of infectious particles and pathogenic microorganisms (streptococcus pneumoniae and streptococcus pyogenes) Invasion of Group A hemolytic streptococci in the Upper respiratory tract (nose.Modifiable Factors  Environment Non Modifiable Factors  Age (39 years old)  Gender (Female) (exposure to pollutants)  Lifestyle  Diet  Low socioeconomic  Race/Ethnicity  Family History (DM.

Rheumatic fever Neutrophils. fluid and bacteria surrounding blood vessels fill the alveoli Cross reactive antibodies bind to cardiac tissues Invasion of lower respiratory tract (alveolar) Hematology (Increased WBC) Infiltration of streptococcal primed CD4 + T cells -Dyspnea -Nausea & Vomiting -Diarrhea Auto immune reactions releasing inflammatory cytokines (including TNF – alpha and IFN gamma) ECG Inflammatory process persists Chest XRay Valvular lesions ( leaflet thickening. commissural fusion. and shortening and thickening of the tendinuous cords) O2 unable to reach bloodstream-causing interruption of normal O2 transportation -DOB -Productive cough -Fever -Loss of appetite -Chest pain -Wheezing breath sounds -Chills -Headaches -Fatigue Rheumatic Heart Disease Community Acquired Pneumonia .

resulting to inflammation of the alveoli. resulting in permanent deformities of heart valves or chordate tendinae. There are precipitating factors that predisposes the client to have community acquired pneumonia. and then the body responds to this invasion having the patient manifests the early signs and symptoms. chill. The microorganisms begin to invade the lower respiratory tract specifically in the alveoli. fluid and bacteria surrounding blood vessels fill the alveoli. Furthermore. . laboratories revealed an elevation or rising streptococcal antibody titer. an autoimmune reaction may occur in the heart tissue. Due to the invasion in the alveoli. because of the inflammation of the alveoli. a patient must manifest the criteria or guidelines for diagnosis of RHD. Involvement of the heart may be evident during acute rheumatic fever. Neutrophils. When a susceptible person acquires a Group A beta hemolytic streptococcal infection. arthralgias. or it may be discovered long after the acute disease has subsided. presence of C-reactive protein and leukocytosis or increased in circulating WBC.Rheumatic Heart Disease CommunityAcquired Pneumonia Rheumatic Heart Disease is a condition of the heart in which it valves are damaged of rheumatic fever. which are type of defensive WBC to the lungs. it resulted to invasion of these microorganisms to the upper respiratory tract. It can be noted that in order to be diagnosed with Rheumatic Heart Disease. Patient ERA also manifests symptoms such as chest discomforts and edema. Though patient does not have a history of rheumatic fever. In the case of patient ERA. she manifests or met 1 major and 3 minor which areas follow: Polyarthritis or migratory arthritis. the oxygen in the lungs is incapable to reach bloodstream-causing interruption of normal O2 transportation as a result the patient manifests persistence of signs and symptoms such as difficulty of breathing. fever. cough and colds. In the case of the patient. it triggers the immune system to send neutrophils. Thus. Due to inhalation of infectious particles and microorganisms such as Streptococcus pneumoniae.

.

strokes.Medical-Surgical Management 1. or open an entericcoated or extendedrelease pill Instruct the patient to swallow the pill whole. to treat or prevent heart attacks.III. Pharmacotherapeutics/ Medicines GENERIC NAME (BRAND NAME) CLASSIFICATION ASA (Aspirin) Analgesic. and angina NURSING RESPONSIBILITIES Pre: • • Check doctors order Asses patients condition Assess allergic reaction Assess a recent history of stomach or intestinal bleeding Take extra precaution when giving medication to children Instruct patient not to chew. break. • • • • • 80 mg/tab OD pc • Intra: • Instruct patient to take drug with meals Monitor patients condition for signs and symptoms of bleeding. severe nausea and vomiting • Post: • Educate patient to avoid taking ibuprofen if taking aspirin to prevent stroke or heart attack Educate patient to avoid drinking • . antipyretic INDICATION DOSAGE AND FREQUENCY • For inflammatory conditions • • to treat mild to moderate pain to reduce fever or inflammation. anticoagulant. coughing up blood.

headache. Pre: • • • Check doctors order Asses patients condition Assess allergic reaction Intra: • Give sublingual preparation under the tongue or in the buccal pouch. fainting. • Tell patient to report unusual side effects like difficulty breathing.alcohol when taking aspirin. persistent or severe headache. lips. tongue. Isosorbide Mononitrate (Imdur) Anti-anginal. vasodilator Prevention and/ or treatment for angina pectoris • to decrease the frequency and severity of angina episodes • • Document. light headedness. swelling of your face. Discontinue using aspirin and call your doctor. flushing of neck or face Report blurred vision. and rash. more frequent or more severe angina attacks. discourage the patient from swallowing Can be taken with empty stomach and with meals if severe 60 mg ½ tab OD hs PO • Post: • Tell patient that drug may cause dizziness. or throat. • Digoxin (Lanoxin) Cardiac glycoside • used for mild to moderate congestive • Document Pre: • Check doctors order . nitrate.

Intra: • Give with meals. gonorrhea. nausea and vomiting. cardiac auscultation. Instruct client to report severe diarrhea. Post: • Watch out for hypersensitivity reaction. rapid weight gain. skin infections. phenytoin. Take pulse at the same time each day • Post: • Tell pt. tonsillitis. loss of appetite. and urinary tract infections. peripheral pulses Check dosage Intra: • • Avoid giving the medication with food Have emergency treatment ready in case of digoxin toxicity: lidocaine. difficulty of • • • 750 mg IV q8º • . • • • 0. Pre: Perform ANST. Inform client that she may experience stomach upset or diarrhea. to report slow or irregular pulse.25 mg/tab OD PO • Asses patients condition Assess allergic reaction Assess baseline ECG. Cefuroxime (Ceftin) 2nd generation cephalosporin • For the treatment of many different types of bacterial infections such as bronchitis. Check results of culture and sensitivity test. cardiac monitor. ear infections. sinusitis. atrophine.• heart failure for treating an abnormal heart rhythm called atrial fibrillation. • Document.

weakness. 300mg/cap BID PO • Intra: • Can be taken with or without meals Post: • • Assess for possible side effects Document Levodropropizine • (Levopront) Cough and Cold Preparation Symptomatic treatment of cough 10cc TID PO Pre: • Check doctor’s order • • Intra • Should be taken on an empty stomach. palpitations. dizziness.breathing. fatigue and pain at injection site. heartburn. fatigue. chronic bronchitis & its exacerbations. drowsiness. • Document Pre: • • Check doctor’s order Assess for hypersensitivity to Erdosteine Assess for pregnancy and lactation Erdosteine (Ectrin) Cough and cold preparations • • Acute bronchitis. headache. (Take between meals) Assess for hypersensitivity to Assess for pregnancy and lactation Post: • Tell the patient that the drug may cause Nausea. . Resp disorders characterised by abnormal bronchial secretions & impaired mucus transport. vomiting. diarrhoea.

long-term treatment of angina pectoris 50 mg/tab BID PO Pre: • Check doctors order • assess patient condition before therapy to monitor the effectively of the drug • assess heart failure • obtain baseline renal and liver status before therapy • assess for obstructive jaundice because the drug level may elevate due to the inability to excrete drug Intra: • Give food to facilitate absorption • Instruct the patient to comply with dosage schedule even if feeling better • Tell the patient that drug may cause light-headedness.• Document Metoprolol (Lopressor) Antihypertensive. dehydration. fainting. β1selective adrenergic blocker • For hypertension. dizziness.antihyperten • Treatment of hypertension alone or with combination Pre: • • Check doctors order Asses patients . diarrhea may lead to fall in blood pressure • Post: • Monitor for possible drug induced adverse reactions Monitor BP of the patient Document • • Enalapril(Vasotec) ACE inhibitor. and transient hypotension Inform the client that excessive perspiration.

Do not administer second dose until Bp has been checked. Treatment of acute and chronic heart failure Treatment of asymptomatic left ventricular dysfunction • condition Assess allergic reaction Assess for pregnancy especially during 2nd and 3rd trimesters can cause serious injury or death to the fetus • Intra: • Monitor patient on diuretic therapy for excessive hypotension afterthe1st few doses of enelapril Monitor patient in any situation that may lead to a drop in BP secondary to reduced fluid volume because excessive hypotension may occur. Tell the patient that this drug may cause GI upset. change taste perception . fast heart rate. Assess allergic reaction • • • • Post: • Tell the client not to stop taking the medication without consulting healthcare provider. rash. Monitor carefully because peak effect may not be seen for 4hours .sive • • with other antihypertensi ve.mouth sores. loss of appetite. dizziness and light headedness. especially thiazide types diuretics. Advice the patient to • • .

tounge . fever. chills. aldosterone antagonist • For essential hypertension.eyes.lips. Spironolactone (Aldactone) Potassium-sparing diuretic. Monitor BP 25 mg/tab OD PO • Intra: • Arrange for regular of serum electrolytes and BUN Can be take with or without food • Post: • Measure and record regular weight to monitor mobilization of edema fluid Advise client to avoid foods rich in potassium Tell the client that he may experience side effects like increase volume and frequency of • • . prevention of hypokalemia • Short-term preoperative treatment of patients with primary hyperaldostero nism • Give daily doses early so that increase urination does not interfere with sleep. Pre: • • • Check doctors order Asses patients condition Know patient’s history of hypersensitivity to drug.report mouth sores. feet and hands and irregular heart rate and difficulty of breathing • Document. swelling of the face. usually in combination of other drugs.

BP= 100/50 mmHg. Monitor UO Document DAY 2 Received the patient lying on right lateral. due at 1:50 pm with 300 more to infuse. drowsiness and increase stress. with O2 inhalation regulated at 1-2 lpm. the patient had decreased RR=35 cpm. RR=35 cpm and PR=60 bpm.5ºC. Had assisted the patient in deep breathing exercises. swelling ankles or fingers . Obtained v/s at 12 pm with T=36. conscious. Had assessed for respiratory rate and depth. RR=39 cpm. Discharge Health Teaching Plans CONTENT Compliance to the physician’s orders and medications can eventually lead to the betterment of the patient’s condition. confusion. Received the patient sitting on bed. At the end of the shift. and has relieved a little from her chest pain. Had advised patient to elevate the head of bed and frequently change positions. dizziness. Had administered medications as indicated: antitussives and analgesics. diet of DAT. Obtained v/s T=36. respectively. Had assisted the patient in deep breathing exercises. with IVF of PNSS 500 cc x 72º. Report weight change of more than 3poundsin 1 day. for 8 am and 12 pm. sleeping. with O2 inhalation regulated at 1-2 lpm. DAY 1 Progress Notes urination. The patient complained of chest pain aggravated with persistent cough with whitish mucoid secretions and difficulty of breathing. 62 bpm. the patient had verbalized that she could expectorate lung secretions effectively. 100/50 mmHg. Compliance . no available medical impression. The patient had complained of persistent cough with whitish mucoid secretions but without chest pain. 38 cpm and PR=71 bpm. STRATEGY Health teaching V. Had administered medications as indicated: antitussives and analgesics. BP= 120/70 mmHg. place and people. with IVF of PNSS 1L x 16º.0 ºC. coherent and oriented to time.7ºC. with diet of DAT.• • • IV. At the end of the shift. 36.

62 bpm. conscious. the patient had decreased RR=35 cpm.0 ºC. diet of DAT. She had also reported decreased appetite due to persistent cough.Medication Diet Exercise Medications prescribed by her attending physician must be taken at due time. for 8 am and 12 pm. Take note that her aspirin. coherent and oriented to time. Health teaching Health teaching Health teaching VI. with O2 inhalation regulated at 1-2 lpm. 36. which is taken at 8 am. place and people. could lower the BP of the patient and must notify the patient if the medication must be given or not.7ºC. Also take note that digoxin and metoprolol. Had assisted the patient in deep breathing exercises. respectively. . At the end of the shift. which is taken at 12 pm. must be taken after meals to facilitate absorption. 100/50 mmHg. Overexertion is not recommended. BP= 120/70 mmHg. Summary of Client’s Status or Condition as of Last Day of Contact Received the patient sitting on bed. 38 cpm and PR=71 bpm. this may give way to difficulty in breathing. Had administered medications as indicated: antitussives and analgesics. The patient looked tired and sleepy. with medical impression of CAP and RHD. Obtained v/s T=36. with IVF of PNSS 500 cc x 72º. There is no diet restriction but still must be careful when eating to avoid aspiration. RR=39 cpm. The patient had complained of persistent productive cough with whitish mucoid secretions but without chest pain. She has been endorsed to be transferred to a private room in 3500.