Holyver Tabarnilla

BSN-II SEC.B

CASE PRESENTION

PATIENT NAME: KEN VILLANUEVA

AGE/SEX: 19 M

FATHER/SPOUSE NAME: LORDES VILLANUEVA

OCCUPATION: LIASON

WARD: PEDIA

HOSPITAL NO.24997

ADDRESS: 144 OSIEM MANGALDAN PANGASINAN

CIVIL STATUS: SINGLE

RELIGION: ROMAN CATHOLIC

DATE OF ADMISSION: 01/16/23

DATE OF DISCHARGE:

DIAGNOSIS: SEVERE RHD (BIPEDAL EDEMA)

SURGERY IF ANY: NONE

DATE OF SURGERY:NONE

DOCTOR IN CHARGE: NORMA M. CARRERA M.D

HISTORY OF ILLNESS

CHIEF OF COMPLAINTS:

BIPEDAL EDEMA, 2 WEEK AD. THE PATIENT HAD BIPEDAL EDEMA AND COUGH IVO. CONSULT HAS DONE
BUT INTAKE OF FLUID WAS LIMITED AT 850 ML/DAY. MAINTENANCE MEDICATIONS SUCH AS
FUROSEMIDES,METFROMIN,DIOSMIN,DAFLON,DIGOXIN. RESITENCE OF THE BIPEDAL EDEMA PROMTED
CONSULT AFTER ADMITTED.

PAST HISTORY:

RHD DIAGNOSED AT 2018 AND NOV.21 2022 APPROXIMATELY AMITTED AT R1MC

FAM HISTORY:

HYPERTENSION
LAB FINDINGS:

CHEST X-RAY

RT-PCR

CBC TYPING

S. ELECTROLYTES

RAT

PHYSICAL EXAMINATION:

SKIN:

WARM OF TOUCH,(-) POLLOR NOTED A LEER FEET

HEAD EENT:

AS,PDC,PERRLA

LYMPH NODES:

(-) CLAD

CHEST AND LUNGS:

SEE WITH CBS

CARDIOVASCULAR:

(+) MURMUR

BREAST:

NO DISCHARGE

ABDOMEN:

HOT SOFT NON TENDER

RECTUM:

INTACT RECTAL VAULT

GENETALIA:

GROSSLY MALE
 NORTHERN LUZON ADVENTIST COLLEGE
Artacho, Sison, Pangasinan
A SEVENTH-DAY ADVENTIST INSTITUTION
Accredited by ACSCU -AAI & IBE-AA
SCHOOL OF NURSING
Tel. No. 075 -632 -2290 http://www.nlac.edu.p h e-mail address: Info@nlac.edu.ph ; dean.nursing.nlac@gmail.com

Nursing Care Plan

Assessment Diagnosis Planning Interventions Rationale Evaluation

Subjective: Severe upon taking *Evaluate the *The condition of the goal met as
*sir namamanas rheumatic its skins overall skin may serve as the the pt. has been
po siya, kaya disease and recommende state condition starting point for encouraged to
hindi po siya bipedal edema d medicines including its prospective have ls/lf diet
makalakad the patient color texture and treatment options in and take
should able temperature the management and medications on
to *analyze the indentification of time the
Objective: stand and patients medical risk forimpaired skin intervention for
The patients walkon his history to integrity in the pt. is
foot are swollen own determine what edematous patients. effective.
because of the might be causing *health care providers
fluid trapped in the fluid can utilize this
body tissues. imbalance information to aid
*evaluate the themthrough the
patient for the decision making
presence of process or to actively
edema.check the manage their patients
ankles, .reviewing the patients
sacrum,and tibia medical historymay
for any signs of reveal increased fluid
pitting or sodium intake
*after pushing 1
finger in the affected
area and the
removing it
afterward one may
easily indetify edema
bythe depression left
behind . a measuring
tape can assess the
degree or extent of
edema in an
individual’s arm or
leg
 NORTHERN LUZON ADVENTIST COLLEGE
Artacho, Sison, Pangasinan
A SEVENTH-DAY ADVENTIST INSTITUTION
Accredited by ACSCU -AAI & IBE-AA
SCHOOL OF NURSING
Tel. No. 075 -632 -2290 http://www.nlac.edu.p h e-mail address: Info@nlac.edu.ph ; dean.nursing.nlac@gmail.com

DRUG STUDY
Name of Student: Holyver Tabarnilla Subject/Area of Exposure: R1MC/PEDIA WARD

Name of CI: Ervin Gelido,Rn

Name of Drug Classification Mechanism of Indication Contraindication Adverse Effect Nursing

Action
Responsibilities
Generic Name PLATELET- INHIBITING FOR THE HYPERSENSITIVITY MAY CAUSE IMPLEMENT
CILOSTASOL AGGREGATION PHOSPHODIESTERASE ALLEVATION OF HEMOSTATIC HEART THERAPEUTIC AND
INHIBITOR ACTIVITY AND SYMPTOMS OF DISORDERS PROBLEMS AMBULATION
SUPPRESSING Camp INTERMITTENT OR ACTIVE ACTIVITIES TO
Brand Name: INCREASE IN PLATELETS CLAUDICATION PATHOLOGIC AUGMENT THE
PLETAL AND BLOOD VESSELS -PAIN IN THE LEGS BLEEDING EFFECT OF DRUGS
LEADING TO THAT OCCURS THERAPYAND
Dosage: INHIBITION WITH WALKING PROMOTE
1 TAB 50MG OF PLATELETS AND DISSAPPERS INCREASED WALKING
AGGREGATION AND WITH REST DISTANCE
VASODILATION
Route

ORAL

Frequency:
BID
Having us in R1MC is one of the biggest pleasure of my life I get to learn different kind of cares our CI let
us explore many things like PICU and more rooms I get to know many patients and their love ones
praying for them to feel more better, it is an achievement for me, trusting us giving medications on
hands on like iv push and everything, we also have a quiz to see if we learned something, I hope that at
our next rotations we can do it again,our 3 days duty is far from enough because we get to learn a lot of
things, meet other SN’s from other schools and get to work with them, Thank You R1MC for having us
we are grateful for it!