Final Na Final Na Final Na Ms

ASIA PACIFIC COLLEGE OF ADVANCED STUDIES
A.H. Banzon St., Ibayo, Balanga City, Bataan

COLLEGE OF NURSING AND ALLIED HEALTH SCIENCES
CORONARY ARTERY DISEASE IN CONGESTIVE HEART FAILURE;

ACUTE RESPIRATORY FAILURE SECONDARY TO (1) ACUTE
PULMONARY CONGESTION (2) PNEUMONIA HIGH RISK;
CHRONIC KIDNEY DISEASE
A Case Study Presented to the

College of Nursing and Allied Health Sciences
In Partial Fulfillment of the Requirements for the

Care of Clients with Problems and Oxygenation, Fluid and Electrolytes,
Infectious, Inflammatory and Immunologic Response, Cellular Aberrations, Acute and Chronic
PRESENTED BY:
Casimiro, Ma. Erika G.
Dappay, Queenrich A.
Falla, Jamayca T.
Fernandez, Maura Fredeeliz A.
Galanida, Kate Marie R.
Gaquit, Aileen Joy B.
Ilaya, MJ Kenneth M.
Leonardo, Giewel Jane V.
Matula, Tisha L.
Monton, Jamaile C.
Santos, Gian Lawrence C.
NOVEMBER 2023
TABLE OF CONTENTS
TITLE PAGE………………………………………………………………………………………………i
TABLE OF
CONTENTS………………………………………………………………………………….ii
Introduction………………………………………………………………………………………………..1
Biographic Data…………………………………………………………………………………………..
Nursing History…………………………………………………………………………………………..
Activities of Daily Living………………………………………………………………………………...
Nutrition………………………………………………………………………………………….
Elimination………………………………………………………………………………………
Activity and Exercise……………………………………………………………………………
Hygiene………………………………………………………………………………….………..
Substance Use……………………………………………………………………………………
Sleep and Rest……………………………………………………………………………………
Sexuality……………………………………………………………………...…………………..
Anatomy and Physiology…………………………………………………………………………………
Pathophysiology………………………………………………………………………………………….
Patterns of Functioning…………………………………………………………………………………..
Coping Pattern…………………………………………………………………………………...
Interaction Pattern………………………………………………………………………………
Cognitive Pattern………………………………………………………………………………..
Self Concept……………………………………………………………………………………..
Emotional Pattern………………………………………………………………………………
Sexuality…………………………………………………………………………………………
Cultural Pattern…………………………………………………………………………………
Significant Pattern………………………………………………………………………………
Recreational Pattern…………………………………………………………………………….
Environmental Pattern………………………………………………………………………….
Economic Pattern………………………………………………………………………………..
Religious Belief…………………………………………………………………………..………
Values and Valuing………………………………………………………………………………
Physical Assessment……………………………………………………………………………………...
Course in the Ward……………………………………………………………………………………….
Diagnostic Examinations……………………………………………………………………………….
Drug Study………………………………………………………………………………………………
Nursing Care Plan………………………………………………………………………………………
Discharge Planning……………………………………………………………………………………..
GENERAL
PATHOPHYSIOLOGY
BIOGRAPHIC
DATA
BIOGRAPHIC DATA
PERSONAL DATA
Patient B
Name :
: 68 years old
Age
: Male
Gender
: March 03, 1955
Birthday
: Roman Catholic
Religion
: Married
Marital Status
: Balanga City, Bataan
Address
: Filipino
Nationality
: Elementary Graduate
Education Level
: 70kg
Weight
: 177cm
Height
CLINICAL DATA
Chief Complaint : Difficulty of Breathing

Onset - September 25, 2023 at 11:03 PM
Location - Chest
Duration - Occasionally, 3 mins after coughing
Characteristics - Tightening in the chest, difficulty breathing
Manifestation - Difficulty in breathing
Aggravating - Coughing
Relieving - Taking medication; Rest
Treatment - Budecort + Trimetazidine + Salbutamol Nebule
Date of Admission : September 26, 2023, 12:32 AM
Admitting Diagnosis : Congestive Heart Failure
Attending Physician : Orlando Rivera Bugarin, MD
Roda Bautista Payumo, MD
Ward : Intensive Care Unit
General Ward
Final Diagnosis : Coronary Artery Disease in Congestive Heart Failure;
Acute Respiratory Failure secondary to (1) Acute Pulmonary
Congestion (2) Pneumonia High Risk; Chronic Kidney Disease
NURSING HISTORY
A. History of Present Illness

On September 25, 2023 at 10:58 PM
Patient started to experienced Difficulty of Breathing
Patient took his medications: Budecort, Trimetazidine, Salbutamol Nebule
Oxygen supply was given to the patient
Difficulty of breathing was still present
Patient starts to have tachypnea and cold, clammy skin
On September 25, 2023 at 11:43 PM
Patient was rushed into the Emergency Room
Vital signs were taken:

BP: 160/100 T: 36 RR:30 PR:115 O2Sat: 99%
Oxygen therapy was given to the Patient on the Emergency Room
Arterial Blood Gas examination was performed to the Patient:

Metabolic Acidosis
On September 26, 2023 at 12:32 AM
Patient was admitted with complained Difficulty of breathing
B. Past Health History

Childhood Illness
● The patient had chicken pox, and measles as his childhood illness.
Immunizations
● The patient cannot recall whether he received a complete immunization.
Allergies
● No known drug allergies. No known environmental, food, or seasonal allergies.
Accidents
● None
Hospitalization
● 2014, Patient was diagnosed with Hypertension

● 2015, Patient was diagnosed with Type II Diabetes Mellitus
● 2016, Patient was diagnosed with Transient Ischemic Attack
● 2017, Patient was admitted and was diagnosed with Mild Stroke: Left and Right
● 2018, Patient was admitted and was diagnosed with Congestive Heart Failure
● 2022, Patient was admitted and was diagnosed with Ischemic Stroke on the left
side of the Brain
● June 2023, Patient was admitted and was diagnosed with Ischemic Stroke
● August 2023, Patient was admitted and was diagnosed with Pulmonary
Congestion
● September 26, 2023, Patient was admitted to the Intensive Care Unit
Surgical History : None

Medication : Budecort; Pantoprazole; Rosuvastatin;
Clopidogrel; Furosemide; Ismodin;
Trimetazidine; Isordil; Insulin Glargine;
Nebivolol; Glycoair; Phenobarbital; Focale;
Dopezil
Foreign and Domestic Travel : None
C. Family Health History

Mother : N/A
Father : N/A
Siblings : N/A
Children : N/A
Grandparents : N/A
Present Health History

On September 26, 2023, a 68 year old male patient was rushed into the emergency room
with a chief complaint of difficulty breathing and was referred to Dr. Bugarin. After assessment
the patient was transferred to the Intensive care unit. Intubation, NGT, and IFC was ordered, an
IVF PNSS 1L was given to the patient upon admission. Upon admission, the patient was also
ordered to take diagnostic examinations including complete blood count with platelet including
chest x-ray. Patient was also advised nothing per orem except medications. On the same day, Dr,
Bugarin ordered the patient to be hooked to a mechanical ventilation, administered Isoket drip in
Solucet 10mg by 10 ugtts/minute, and to continue the patient’s medications. Patient was referred
to Dra. Tumulak for pulmonary co-management. On September 26, 2023 at 2:30am, Dra.
Tumulak telephoned an order to administer Procalcitonin Stat, at 3:31am patient’s blood pressure
was 180/90, Dra Tumulak ordered Nicardipine Stat. On the same day, Dr. Bugarin ordered to
repeat Potassium, Creatinine, and Complete Blood Count diagnostics on the next day. Mechanical
ventilation was shifted into positive airway pressure.
On September 27, 2023 at 6:04AM, the patient was ordered to start feeding 1800kcal
which is divided into 6 equal feedings and to re-insert NGT. On September 28, 2023, Dra.
Tumulak ordered to hold the next feeding and to start Ipratropium+Salbutamol Nebule 1hub stat.
On the same day, an Chest X-ray was performed, the patient had whitish to yellowish secretions,
NT was extubated. On September 29, 2023 at 12:45am, Dra. Tumulak ordered the patient to have
a soft diet trial STAT and was ordered to be transferred to a regular ward room. On the same day,
patient was ordered for complete bed rest without bathroom privileges, vital signs were recorded
every 2 hours for monitoring, the same IVF to follow PNSS 1L at KVO.
On September 30, 2023, the patient was ordered to repeat Chest X-Ray in the morning.
Dr. Bugarin was informed regarding the hematuria and ordered the patient to have bladder
training. On the same day, IFC were ordered to be removed. On October 1, 2023, vital signs were
stable. On October 2, 2023, the patient was advised for discharge.
ACTIVITIES
OF
DAILY
LIVING
ACTIVITIES OF DAILY LIVING
ADL Before Analysis During Analysis Nursing

Hospitalizatio Hospitalizatio Diagnosis
n n
Nutrition “Ayos naman Knowledge “ Nakakain Hospitalization Risk for

ang pagkain about the naman na siya Imbalanced
niya. diet that the ngayong Nutrition:
Kumakain patient’s umaga ng Less Than
naman siya ng need lugaw. Lugaw Patient’s Body
umaga, palang kasi present Requirements
tanghali,at naka soft diet Condition
gabi. Alam ko siya .”as
naman na ang Normal verbalized by
mga tamang the patient’s
ipakain wife
sakanya hindi
ko na din siya
pinapakain ng
mga bawal. Sa
mga may
sabaw na ulam
niya tinatakal
nalang din
namin pati ang
pag-inom niya
ng tubig, dahil
limitado na
ang tubig na
pwede niyang
inumin.”as
verbalized by
the patient’s
wife
Weight: 70kg Weight: 70kg
Height: 177cm Height: 177cm
( Overweight) ( Overweight)
SEPTEMBER 23,2023 SEPTEMBER 24,2023
DAY1 DAY2
BEFORE HOSPITALIZATION
FOODS & PREPARATIO CALORIE FOODS & PREPARATIO CALORIE

BEVERAGE N / BRAND/ EQUIVALEN BEVERAGE N / BRAND/ EQUIVALEN
S AMOUNT T S AMOUNT T
CONSUMED CONSUMED
BREAKFAST: 403 kcal BREAKFAST:597 kcal
Wheat Bread 2 Wheat Bread 247 kcal Pancit canton 1 plate pancit 350 kcal
canton
Boiled Egg 2 Boiled Egg 156 kcal Wheat Bread 2 Wheat Bread 247 kcal
Water 100 ml 0 kcal Water 100 ml 0 kcal
LUNCH: 366 kcal LUNCH: 347 kcal
Pesang isda 1 small bowl of 160 kcal Sinigang na 1 small bowl of 141 kcal
Pesang isda Bangus sinigang na bangus
Rice 1 cup of rice 206 kcal Rice 1 cup of rice 206 kcal
AFTERNOON SNACK: 280 kcal AFTERNOON SNACK:240 kcal
Fita crackers 2 pack of fita 280 kcal Sky flakes 2 pack of sky flakes 240 kcal
biscuit
DINNER: 366 kcal DINNER: 347 kcal
Pesang isda 1 bowl of 160 kcal Sinigang na 1 bowl of sinigang 141 kcal
Pesang isda Bangus na bangus
Rice 1 cup of rice 206 kcal Rice 1 cup of rice 206 kcal
Total: 1,415 Calories Total:1,531 calories
Water intake: 1,010 ml Water intake: 1,010 ml
SEPTEMBER 25,2023
DAY 3
BREAKFAST:156 kcal
Lugaw 1 bowl of lugaw 175 calories
Egg 1 boiled egg 78 kcal
LUNCH: 447 kcal
Bulanglang 1 bowl of bulanglang 241 kcal
Rice 1 cup of rice 206 kcal
SNACK: 280 kcal
Fita crackers 2 packs of fita biscuit 280 kcal
DINNER: 447 kcal
Bulanglang 1 bowl of bulanglang 241 kcal
Rice 1 cup of rice 206 kcal
Total: 1,330 calories
Water intake: 1,025 ml

SEPTEMBER 29,2023 SEPTEMBER 30,2023
DAY1 DAY2
DURING HOSPITALIZATION
FOODS & PREPARATIO CALORIE FOODS & PREPARATIO CALORIE

BEVERAGE N / BRAND/ EQUIVALEN BEVERAGE N / BRAND/ EQUIVALEN
S AMOUNT T S AMOUNT T
CONSUMED CONSUMED
BREAKFAST: 175 kcal BREAKFAST: 258 kcal
Lugaw 1 bowl of 175 kcal Oatmeal 1 bowl of 259 kcal

lugaw oatmeal with
banana
LUNCH: 349kcal LUNCH: 117 kcal
Mushroom 1 bowl of 349 kcal Chicken soup 1 bowl of 117 kcal

soup mushroom chicken soup
soup
DINNER:175 kcal DINNER: 117 kcal
Lugaw 1 bowl of 175 kcal Lugaw 1 bowl of 175 kcal

lugaw lugaw
Total: 699 calories Total: 551 calories
Water intake: 880 ml Water intake: 960 ml
OCTOBER 01,2023
DAY 3
BREAKFAST:175 kcal
LUNCH: 259 kcal
Oatmeal with banana 1 bowl of oatmeal with banana 259 kcal
DINNER: 175 kcal

Total: 609 calories

Water intake: 880 ml
ADL Before Analysis During Analysis Nursing

Hospitalization hospitalization Diagnosis
Elimination Defecation Defecation: Defecation: Defecation: Risk for

Impaired
“ Sa pagdumi Decreased “.Nakatae na Decreased fluid Bowel
niya fluid intake rin naman siya intake Elimination
nahihirapan ngayon sa related to
siya dahil diaper niya isa dehydration.
umaabot ang beses
tatlong araw Dehydration palamang” Dehydration
bago siya
makadumi” as verbalized by
the patient’s
as verbalized by Constipated wife Constipated
the patient’s (lumpy and (lumpy and
wife sausage-like) Stool output: sausage-like)
Mild 1x Mild
Constipation Constipation
Urination URINATION Functional

URINATION
urinary
Stroke “Naka- catheter T2 DM incontinence
URINATION:
siya ngayon,
related to
“ Sa pagihi tuwing nag
neuromuscula
naman rorotation ang
Affecting Increased r limitation
nakakaihi mga nurse
naman siya the Pons kinukuha nila Glucose level
( right sided
palagi pero yung ihi.”
weakness)
walang control
hindi niya as verbalized by
Urinary the patient’s Damaged
kayang pigilan
Incontinence wife blood vessels in
dire-diretso
the kidneys
kaya madalas
naabutan siya Characteristic:C
ng ihi sa higaan loudy
o upuan” appearance Urine Output:
Altered
Urine Output: Kidney filtration ICU
as verbalized by
the patient’s
ICU 1-6am:
wife
1170ml
September Build up glucose
26,2023 in the urine 7-6pm:
1-3 90ML 1240ml
3-5 90ML 7-6am: 870ml

Cloudy
5-7 110 WARD
ML
Appearance 7-2pm:
7-9 125 720ml
ML
3-10pm:
9-11 100
730ml
ML
11-1 120 11-6am:

ML 800ml
1-3 90ML
7-
3-5 120 2pm:1,070ml
ML
3-
5-7 100 10pm:620ml
ML
7-9 110
ML
9-11 110
ML
1,165
ML
September 27,
2023
12-2 90ML
2-4 110
ML
4-6 90ML
6-8 90ML
8-10 115
ML
10-12 100
ML
12-2 90ML
2-4 80ML
4-6 110
ML
6-8 90ML
8-10 120
ML
10-12 110
ML
1,195
ML
September
28,2023
12-2 100
ML
2-4 100
ML
4-6 100
ML
6-8 130
ML
8-10 95ML
10-12 90ML
12-2 90ML
2-4 85ML
4-6 90ML
6-8 80ML
8-10 90ML
10-12 110
ML
1.160
ML
WARD
September
29,2023
Activity and “ Nanonood Unable to “ Ayan Patient’s present Impaired

Exercise lang siya palagi perform naabutan niyo condition during physical
dahil nga sa physical nanonood lang hospitalization mobility
sitwasyon niya activities siya, yan lang related to
bawal siyang pinagkakaaba- muscle
mapagod“ lahan niya dahil weakness and
nga bawal na decreased
din siya range of
mapagod. Kung motion
“ Madalas din Lack of hindi nanonood secondary to
nakikipaglaro exercise nakikinig ng stroke
siya sa mga apo mga musics.”
niya at
nakikipagkwen- as verbalized by
tuhan “ as the patient’s
verbalized by wife
the patient’s
wife
Hygiene “ Ako na ang Unable to “ Ngayong nasa Patient’s present Self-care

nagpapaligo perform hospital kami condition during deficit:
sakanya self-care pinupunas- hospitalization bathing/
madalas hapon punasan ko hygiene
na ang ligo niya siya, dahil (related to
mga bandang mahihirapan impaired
alas dos o alas Self- care kami kung motor or
tres” deficit papaliguan sensory
namin siya function,
dito.” as cognitive
verbalized by impairment)
“ Sa the patient’s
pagsisipilyo wife
naman minsan
nakakalimutan
na namin.
Madalas kasi
siyang
iritable.”
“ Sa paglilinis
naman ng tenga
niya isang beses
lang sa isang
linggo o minsan
lumalagpas pa”
“ Sa kuko
naman niya
pag napapansin
kong mahaba
na o madumi
doon ko siya
ginugupitan”as
verbalized by
the patient’s
wife
“ Sa sobrang Unable to “ Hindi ko alam Knowledge

dami niyang give the ang mga deficit about the Ineffective
Substance gamot medicine on iniinom niya drugs Health
Use lumalagpas na time in the ngayon, dahil Maintenance
kami minsan sa patient mga nurse Related to
oras bago naman ang Deficient
mapainom nagpapainom knowledge
sakanya. Ang sakanya.”as about
mga gamot ay Medication verbalized by medications
Budecort, errors the patient’s
Pantoprazole, wife
Rosuvastatin,
Clopidogrel,
Furosemide,
Ismodin,
Trimetazidine,
Isordil, Insulin
Glargine,
Nebivolol,
Glycoair,
Phenobarbital,
Focale,
Dopezoil”
as verbalized
by the patient’s
wife
Sleep and “ Sa gabi Uncomfortab “ Hindi siya Uncomfortable Risk for

Rest nakakatulog le position masyadong environment impaired
siya ng 11 pm nakakatulog, physical
pero nagigising dahil hindi mobility
din siya agad naman siya related to
ng alas dos o kumportable Disturbed weakness,
alas tres hindi dito sa hospital. sleeping pattern paralysis, or
kasi siya Disturbed Nagigising- loss of
kumportable sa sleeping gising siya hindi sensation,
pagtulog gusto pattern rin kasi siya affecting the
palipat-lipat” kumportable” ability to find
as verbalized by a comfortable
Sa hapon the patient’s sleep
naman wife position.
natutulog siya
ng alas dos
diretso na yun
hanggang alas
kwatro o alas
singko.”as
verbalized by
the patient’s
wife
Sexuality “ Ay Showing “ Ayan Patient’s present

and napakalambing love and care naglalambing condition during
Reproductio ng taong yan for each siya kaninang hospitalization Normal
n palagi akong other umaga
niyayakap at pagkagising
hinahalikan. niya. Kahit
Pag umaga nga masama ang
may kausap Presence of pakiramdam
lang ako sa love malambing
labas akala mo parin” as
iniwan ko na verbalized by
siya.” as the patient’s

verbalized by wife
the patient’s
wife
ANATOMY
AND
PHYSIOLOGY
Body Part/ System Function Alteration
Right Coronary Artery Characteristics of the Right Endothelial Dysfunction

Coronary Artery (RCA):
Origin and Course: The right Formation of Atherosclerotic
coronary artery is one of the two Plaque
main coronary arteries that
supply blood to the heart Plaque Rupture or Erosion
muscle. It typically arises from
the right aortic sinus, which is
one of the three sinuses located Thrombosis Formation
at the base of the aorta.
Obstruction in blood flow
● supplies blood to your
right atrium and right CAD
ventricle (where
deoxygenated blood
goes before heading to
the lungs)
● supplying blood to the
back of the
interventricular septum
and certain components
of the heart's conduction
system.
Lungs Characteristics of the Lungs: CHF

Organ Structure: The lungs are
paired, spongy organs located in decreased tissue Oxygenation
the thoracic cavity of the chest.
pulmonary edema
Divided into Lobes: The right
lung has three lobes, while the
left lung has two lobes. The Impaired gas exchange
lobes are further divided into
smaller units called lobules. weakened immune defense
Surrounded by Pleura: The Increased susceptibility to

lungs are covered by a double- infection
layered membrane called the
pleura, which helps reduce Pulmonary pneumonia
friction during breathing.
The main function is to:

● supply oxygen to all
body organs
● to release carbon
dioxide.
● regulation of ph
● Filtering and
humidifying air
Kidneys Characteristics of the Kidneys: Damage to Renal Blood Vessels

Organ Location: The kidneys
are bean-shaped organs located Glomerular Injury
on each side of the spine, below
the ribcage, in the back of the Fibrosis
abdomen.
Internal Structure: Each kidney Reduced Filtration

is divided into an outer renal

cortex and an inner renal Acute Renal Injury
medulla. The functional units
are called nephrons.
Blood Supply: The kidneys

receive a significant amount of
blood, with renal arteries
bringing in oxygenated blood
for filtration and renal veins
carrying filtered blood away.
The main function of the

kidneys is to:
● filter waste products and
excess substances from
the blood to produce
urine
● regulate the body's fluid
balance
● Waste Excretion
● Blood Pressure
Regulation
● produce a hormone
Pancreas Characteristics of Pancreas Genetic/Lifestyle

Location: The pancreas is a
glandular organ located behind Insulin resistance
the stomach, extending
horizontally across the Beta cell dysfunction
abdomen.
Dual Function: The pancreas has hyperglycemia

both endocrine and exocrine
functions. The endocrine
component consists of hormone-
producing cells located in the
islets of Langerhans, while the
exocrine component consists of
acinar cells that produce
digestive enzymes.
Endocrine function:
● It produces the
hormones insulin and
glucagon.
● Produce additional
hormones like
somatostatin or
pancreatic polypeptide
which have roles in
regulating digestion or
appetite respectively
Exocrine Function:
● responsible for
producing digestive
enzymes mentioned
before being released
through pancreatic ducts
into intestines
Brain Characteristics of the Brain: Atherosclerosis

Highly Complex Structure: The
brain is an intricately structured Hypertension
organ composed of
approximately 86 billion Endothelial Dysfunction
neurons, which are specialized
cells that transmit information.
Divided into Hemispheres: The Inflammation
brain is divided into two
hemispheres (left and right) that Hemodynamic Stress
are connected by the corpus
callosum, facilitating Ischemic Stroke
communication between them.
Protected by the Skull: The
brain is encased in the skull,
providing protection from
external trauma.
Functions of the Brain:
● Cognitive Functions
● Motor Functions
● Sensory Processing
● Emotional Regulation
● Memory storage and
retrieval
● Autonomic function
SPECIFIC
PATHOPHYSIOLOGY
PATTERNS
OF FUNCTIONING
PATTERNS OF FUNCTIONING
Psychological Health Assessment Interpretation Relevant Theory Analysis
Coping Pattern Adaptation Model BEFORE:
BEFORE: (Sister Calista Roy)

BEFORE: Stressors
“Noong Bata-bata pa siya ang stress reliever nya
The patient's main stress reliever or Adaptation model explains how
iyung paninigarilyo, nakaka tatlong kaha siya kapag
sobrang stress niya pero kapag hindi naman mga coping mechanism is mainly using individuals and groups adapt to change. Nicotine
isang kaha lamang sa isang araw. nicotine products and talking to his It is a useful tool for understanding products
Bago siya ma-ospital Mahilig din siya makipag close friends. how people cope with stress, illness,
kwentuhan sa mga kaibigan at kapitbahay namin and other challenges. Adaptation
kapag may problema siya. Marami siyang kaibigan models are used in a variety of fields, Present of
doon. Pero noong namatay ang isang anak namin, including nursing, social work, companion
talagang nag damdam siya.” DURING:
psychology, and education
The patient exhibits good coping
DURING: strategies despite the numerous obstacles Even with the constant challenges Death of famil
he encounters. He receives assistance and environmental changes the
“May mga oras na iritable siya at magagalitin lalo and encouragement from his close circle patient demonstrates a continuous
IMPAIRED
na kapag maraming nurse, walang makain at of support such as friends and family. adaptation to the event unfolding in
COPING
mainom sa loob at pati narin kapag iniisip niya ang his journey.
mga babayaran sa ospital. RELATED T
Sobrang lungkot niya noong nasugod siya sa ospital DEATH OF

at napasok sa ICU ayaw niyang mag stay don, HIS
nagwawala siya minsan at inaalis ang mga naka DAUGHTER
lagay sakaniya, siguro takot siya lalu pa’t
kamamatay lang ng anak namin noong nakaraang
November 18,2022. Ang pampakalma at pampagaan
niya ng loob ang mga apo namin. ‘Yung mga anak at GRIEVING
kapatid niya madalas din dumalaw at makipag
kwentuhan.
DURING:
Pati ang panonood ng T.V gumagaan din ang
pakiramdam niya, lalu na iyung balita na di-distract
ang isip niya kapag nakikipag kwentuhan siya sakin Present of
tungkol sa mga usapin sa bansa. Nawawala din
stressors
iyong stress niya kapag kinakausap niya sa cellphone
ang mga kaibigan niya kapag kinakamusta siya saka
ang kalagayan niya. Pero sa loob ng ospital more on
panonood lang talaga ng TV saka pakikipag Support
kwentuhan ang nakapag-papasaya sakaniya. Pero network from
kahit pinakita niya na ok siya, alam ko na hindi. brothers, sister
Minsan nakikita ko siya umiiyak tuwing gabi, ayaw and friends
niyang ipakita iyung bigat ng loob na
nararamdaman niya sa akin at mga apo niya. Alam
ko hindi niya hinahayaang lamunin siya ng
Problems self
kalungkutan kaya kahit anong problema ang
dumating, tinatawanan lang niya ito. contained
Ganun paman patuloy siyang lumalaban para sa IMPAIRED

amin at sa lahat ng taong nagmamahal sakaniya” COPING
-As Verbalized by his wife.

Interaction Pattern
BEFORE: Interpersonal relation theory
BEFORE:
“ Kahit noon pa naman mahilig siya makipag Before hospitalization the patient shows ( Hildegard Peplau) BEFORE:
interact at makipag usap. Kaya nga marami siyang and demonstrates a good interaction
kaibigan sa lugar namin. Saka close din siya sa mga pattern with his family and community. an interpersonal relation (or Good interaction
kapatid at mga kamag anak namin. Pati ung mga interpersonal relationship) describes a friends and comm
anak at apo niya. Dati nga siyang may pwesto sa social association, connection, or
barangay eh “ affiliation between two or more
-As Verbalized by his wife. persons. It overlaps significantly with Good
the concept of social relations, which relationship
are the fundamental unit of analysis with family
DURING: within the social sciences.
DURING:
“ Hindi siya cooperative sa lahat ng oras.kailangan ko .
Connection
muna siyang pilitin at kausapin. Nakikipag cooperate
with the
lang siya kapag maganda ang nurse. Pero may mga oras In relation with the theory the patient is
But during hospitalization the patient barangay
nakikipag biruan siya sa mga nurse at doctor kapag not cooperative with the health
interaction with the health providers
maganda ang gising niya.. providers thus the wife needs to be
seems lacking in cooperation. The
involve so health intervention can be
Samay pamilya namin active siya, lagi nga siyang patient is picky with the health provider GOOD
delivered.
dinadalaw ng mga kapatid, anak, at apo niya. Hindi to assist him, causing a slow and trouble INTERACTIO
matatapos ang araw ng wala siyang bisita. Kaya parang in delivery of care. The patient still -N PATTERN
wala din kami sa ospital kasi lagi niyang nakakausap ung retains his active interaction with his
mga anak at apo niya. Malapit talaga ang loob niya sa family.
NORMAL
mga kapamilya namin kasi hindi naman sila lagi pupunta
dito kung hindi diba?
Kaya mas lumalakas ang loob niyang labanan ang sakit DURING:
siya dahil sa mga tao na nagmamahal sa kanya.”

Hospitalization
Stress
Poor cooperation
professionals
Cause a trouble fo
health treatmen
Stress disturbs
interaction wit
healthcare provid
IMPAIRED
INTERACTIO
PATTERN
INEFFECTIV
E HEALTH
MANAGEME
NT
Cognitive Pattern
Conservation Model
BEFORE: BEFORE: (Myra Estrin Levine in the 1960s).

“ magaling siya sa math, siya ang nagtuturo sa mga
anak namin saka iyong nagbibilang ng pera at Base of the subjective ques.The patient
nagbibigay ng sukli sa mga customer namin. Siya din exhibits a good cognition. The theory is based on the belief that
iyung tagabuhat ng mga paninda namin at taga ayos BEFORE:
nursing is the process of conserving
ng mga gamit sa pwesto namin sa palengke”
the integrity of the individual. Levine NORMAL
-As Verbalized by his wife. identified four

conservation principles:
DURING:
DURING:
“Kahit naman noong hindi pa siya na o-ospital at kahit Conservation of energy: This involves hospitalization
may edad na klaro padin ang pandinig niya, panlasa, DURING:
balancing the individual's energy
ung pang amoy nga niya napaka talas eh at medyo
The patient's cognitive pattern is input and output to prevent fatigue.
sensitive sa pabango, kahit ang pandama niya wala
impressive, especially considering their Retain:
namang problema.’ung paglakad lang niya ang affected
age and situation. He demonstrates good
kasi nga na stroke siya, tapos medyo malabo din pala
cognitive skills, including memory. The Conservation of structural integrity:
ang mata niya. Kaya ngalang hindi siya ganun kabilis
identified a problem that is related to This involves maintaining or restoring
nakapag adjust sa nangyari sa kanya, kaya hirap ang Perception, sme
cognition is locomotion related to stroke
mga nurse, madalas siyang umangal. the individual's physical structure. taste, and hearin
and vision. retention

Conservation of personal integrity:
iyung memorya niya klaro,. Kahit hindi siya nakatapos This involves preserving and
sa pag-aaral proud na proud kami diyan kasi napaka
promoting the individual's sense of
talas ng memorya niya lalu na sa math.” Stroke
self-worth and identity.
Conservation of social integrity: This Impaired mobil

involves supporting the individual's
interactions and relationships with
others. IMPAIRED
COGNITIVE
FUNCTION
The patient manages to conserve his
mental skills even with the constant
challenges he’s facing. INEFFECTIV
E ROLE
PERFORMA
NCE
Self-Concept Pattern
BEFORE: BEFORE:
PSYCHOSOCIAL
“ Siya iyong masasabi kong matatag na haligi ng tahanan DEVELOPMENT BEFORE:
mula noon hanggang ngayon. Kasi kung hindi dahil sa
(ERIK ERIKSON)
sipag at tiyaga niya hindi kami aahon at mapag aaral ang The patient's self-concept regarding their
mga anak namin. role as a man and a father is NORMAL
exceptionally positive and impactful. Theory outlines 8 stages of
Bilib na bilib ako sa kanya noon kasi ang taas ng They have a strong sense of identity and development that individuals go
confidence niya, at kahit medyo wala kaming pera noon take great pride in their gender and through throughout their lives. The
eight stages of ego integrity vs
despair, occur during late adulthood

hindi siya sumuko sa buhay parental roles. They exhibit confidence, typically from the age 65 onwards. DURING:
assertiveness, and a clear understanding
Ang mga anak namin lumaki ng ayos, disiplina at may of their responsibilities and duties. The Positive view from
takot sa magulang. Pati iyong mga kapatid niya ni re- patient shows a deep commitment to family
respeto siya” being involved in their family's lives, In the last stages of Erikson theory
actively participating in parenting and the patient falls in despair, as he
providing emotional and financial feels despair and regret because of Hospitalizatio
support. the things he can't do anymore. The
DURING:
patient may feel bitterness, and a
DURING: sense of emptiness. Deficient
“Hindi na niya nagagampanan lahat ng tungkulin na
dapat ginagawa niya. Siguro ito rin iyong isang rason bathing or
During hospitalization the patient
kung bakit umiiyak siya minsan kapag gabi.Pero kahit hygiene
showed impairment in self concept. He’s
ganun pa man nagpapasalamat ako sa Diyos dahil unable to do the things he used to do.
kasama pa namin siya. Kung wala siya ay siguro hindi Patients unable to perform self hygiene Impaired
kami makakaahon sa hirap at mapag papatapos sa pag- and show a decrease in body mass mobility due t
aaral iyong mga anak namin. leading to self pity. But the patient's stroke
family didn't change the way they saw
Lalaking lalaki siya sa paningin namin ng mga anak niya
him.
at hindi lang siya pundasyon ng pamilya namin siya din
bubong na handang sumalo ng lahat ng problema. Decrease body
mass
Kaso nito ngang na-ospital siya hindi na siya makaligo at
makapag lakad lakad, medyu pumayat siya at
ikinalulungkot niya iyun, pahid pahid nalang siya. Pero Self pity
ang sabi nya naman sa oras na makalabas siya
magbabawi siya ng katawan ang laki din kasi ng binaba
Impaired self
ng timbang niya, 55 kilos nalang siya ngayun.
concept
Simula nong pabalik-balik kami ng ospital, Panay din
siyang nag so-sorry kasi palagay nya daw naging pahirap
RISK FOR
siya sa akin at mga anak niya. ”
. COMPROMI
-SED HUMA
DIGNITY

Emotional Pattern
BEFORE: BEFORE: Neuman’s System Model
“Kahit naman bago pa siya ma-ospital masaya na talaga Based on the subjective assessment the ( Betty Neuman) BEFORE:
siya saka friendly. Pati noong bago palang kaming patient shows a positive emotional
asawa. Panay siya masaya at hindi mo siya makikitang pattern and normal emotional pattern. It is a holistic and system-based NORMAL
nalulungkot, pwera nalang kapag sinusubok at may approach to nursing that focuses on
challenges na ibinibigay sa amin ang mundo gaya ng the client's response to actual or
pagkamatay ng anak namin.” potential environmental stressors. The
theory is based on the following DURING:
-As Verbalized by her wife. assumptions:
Sadness due t
DURING: ● Individuals are open systems hospitalization
that are constantly interacting
“Hindi na siya, masyadong malungkot sa ospital hindi with their environment.
kagaya ni yung mga unang araw na talagang tahimik DURING:
● The environment is all the Fear due to
siya at mapili sa nurse dahil kasama na niya kami.. internal and external forces that death of their
surround the client daughter
Pero hindi maiiwasan na matakot at nalulungkot siya
During hospitalization the patient shows ● Stressors are any forces that
pati kami dahil nga kamamatay lang ng anak namin
the following emotion including; fear disrupt the client's stability.
noong nakaraang november. May mga hindi inaasahan Sudden outrag
due to the death of his daughter , distress ● The client has lines of
magagalit siya. Gaya na lang kapag maraming bayarin,
because of the events happening in his resistance that protect them
walang pagkain saka inumin sa kwarto. Tapos yung nasa
life , and loneliness because he’s alone from stressors. *
ICU siya, kasi nga diba bawal pumasok doon, talagang Distress and
in ICU. The patient showed decrease ● The client has a normal line of
lungkot na lungkot siya tapos natakot din siya noon kasi fear in ICU
loneliness because of his family support defense, which is their usual
nga namatay yung katabi niyang pasyente. Pero hindi
level of health and well-being.*
niya hinayaan na kainin siya ng lungkot, paglabas niya
● The client has a flexible line of
sa ICU medyo naging ok ang mood niya. Nakatulong din
defense, which is their ability

siguro iyong mga bisita namin, ung mga kaibigan, apo, to adapt to stressors. * IMPAIRED
anak saka mga kapatid niya.. ● The goal of nursing is to help EMOTIONAL
clients maintain their stability PATTERN
and reduce their reaction to
stressors
Pero hindi pa rin talaga maiiwasan ang mga oras na
maiyak siya, lalo na kapag iniisip niya ‘ung mga RISK FOR
nangyayari sa buhay niya.”. LONELINES
The patient has a number of stressors
-As Verbalized by her wife. during hospitalization, he’s able to
adapt mainly because of his family
which cherish and love him, he is able
to adapt be it slow because of them.
Sexuality Pattern
BEFORE: BEFORE: The Theory of Nursing as Caring: BEFORE:
A Model for Transforming Practice
“Lalaking lalaki siya sa mata ko, ang layo nga ng
pinanggalingan niyan. Galing pa siyang Bulacan, (Anne Boykin and Savina
nagtago sa balanga kasi napaka babaero. Pero nung The patient demonstrates a fitting role Schoenhofer) GOOD FATHER
nagkakilala kami tumino na siya. Napaka lambing din as a husband, father, grandfather and HIS CHILDREN
niyang asawa kahit na nga matanda na kami, hindi siyabrother.He is solid and dedicated to the It is a unitary and transformative model
nagbago” role as a man. Unmoving and a fighter that focuses on the relationship between
for his loved ones. the nurse and the person receiving care.
Ginagampanan din niya ang papel niya bilang mabuting GOOD HUSBAN
asawa, mapagmahal sa mga anak at responsableng kuya The theory is based on the following
sa mga kapatid niya kahit na malalaki na sila” assumptions:
-As Verbalized by her wife. RELIABLE ROLE

● Humans are unitary beings, MODEL
DURING: meaning that they are whole
and indivisible.
● Caring is the central focus of

“ Ngayong nasa ospital na siya, hindi na niya DURING: nursing practice.
nagagampanan ang obligasyon niya bilang ama at ● Caring is a human-to-human
asawa. Hindi na siya makakapag trabaho at nakakaligo Based on the assessment the patient will relationship that is intentional, IMMOVABLE RO
mag isa saka nakaka dumi at ihi kasi nga stroke siya, not be able to fulfill his role as a husband authentic, and nurturing. IN THE FAMILY
Hindi narin siya nakaka-ligo at nakakadumi mag isa. and even self hygiene because of his ● Caring transforms both the
Kaya lagi kong sinasabi sa kanya na magpalakas siya at condition. nurse and the person receiving
labanan ang sakit niya. care.
FULFILLMENT O
Pero kahit nasa ospital kami, malambing parin siya GENDER ROLE
saakin. Hindi narin kami nag se-sex kasi nga matanda
na kami, kaya halik halik at at yakap yakap.
Based on the assumption of theory the
patient is not invisible as he is truly NORMAL
loved by his friends and family and
Pero kahit ganyan ang nangyari sa kanya, patuloy because of that he is well cared for.
siyang lumalabas para sa akin, sa mga anak niya at mga Physically because of the nurses and
apo” DURING:
emotionally because the people that
love and support him. Human to human
relationship helps him become strong
while facing challenges. HOSPITALIZ
Stroke
Impaired
mobility
Self-care defic
ALTERED
SEXUALITY
PATTERN
SEDENTARY
LIFE STYLE
Socio Cultural Pattern Assessment Interpretation Relevant Theory Analysis
Cultural Pattern
BEFORE: Patient demonstrating good cultural TRANSCULTURAL DIVERSIT
patterns with one's family involves NURSING THEORY WITH HIS W
“Kahit tubong bulacan siya, wala naman kaming recognizing and embracing the values
pinagtatalunan na pamahiin, wala naman din daw kasing and traditions of one's culture, (Madeleine Leininger)
pagkakaiba ng kultura ng bataan at bulacan. Kapag may maintaining strong connections and
fiesta naghahanda kami, kapag may may birthday, pasko relationships with family members, Transcultural nursing theory is a POSITIVE V
at lalu na bagong taon. Hindi buo ang bagong taon namin and treating them with love, respect, nursing theory that focuses on IN CULTU
ng walang paputok at bibingka. and support. the relationship between culture DIFFERENC
and health.
Mas naniniwala din kami sa doctor kesa sa mga albularyo
The theory is based on the
Mapagbigay din kami sa mga kapitbahay namin kaya nga following assumptions: POSITIV
madami kaming naging kaibigan sa lugar namin eh.” CULTURA
● Culture is a learned and PATTER
-As Verbalized by her wife. transmitted system of
values, beliefs, and
practices that guide and
influence human
behavior, including
health-related
behaviors.*
● Culture is dynamic and
constantly evolving.*
● Culture is essential to
human health and well-
being. *
● Nurses play a vital role
in providing culturally
competent care to
patients and their

families.
The patient and his family share

a similar cultural belief. Making
a good relationship and not
having a disagreement about
their cultural differences.
Significant Pattern
BEFORE: BEFORE; FAMILY CENTERED
CARE THEORY
“Noon at ngayon pamilya pa rin ang pinaka importante sa Based on the assessment the patient is BEFORE
kanya. Napaka maalahanin niya lalu na sa mga apo niya significant to his whole family. His (Rodenick Navalta Agtarap)
whole family respects him and the
patient expresses his love and joy for his After the iterative process of Familial lov
grandchildren . the synthesis process. The
Mataas ang respeto ng mga kapatid niya sa kanya” development assumptions of
the family centered care Familial
. theory were: family is the importanc
DURING: primary source of strength of
every patient at the various
“Kahit naman no’ong na-ospital siya wala naman pinag settings. NORMAL
bago ang panananaw namin sakaniya. Iyun nga nga lang DURING:
medyo malungkot siya kasi hindi na kami makapag
hanapbuhay sa palengke. Pero lagi ko naman din sinasabi DURING
The patient gains strength
sa kanya na magpagaling ka muna.Lagi siyang nag so-
from his family to continue
sorry dahil sa kanya hindi na kami makapag hanapbuhay. The patient effectively demonstrates Sadness due
fighting until he overcomes
his significance to his family even hospitalizat
Lagi din pumapasok sa isip nya na kapag namatay siya these challenges. The patient
after hospitalization, showing them
has a good relationship with
paano na iyong mga kapatid, anak, apo at laluna ako. that he is still capable, valuable, and his friends, family, children
Pero lagi ko nagpapaalala sa kanya na malalagpasan niya loved. He may do this by actively and wife. Fear of dea
ito participating in family activities and
conversations, expressing his opinions
and feelings, and engaging in Challenge
meaningful interactions with family
Pero buti nalang lagi dumadalaw ang mga kapatid, apo, at members.. Overall, the patient's
anak niya. Nagkakaroon siya ng oras at nalilibang dahil actions and words convey his worth Presence o
sa mga apo niya, humihingi ‘din ng payo ang mga kapatid and importance to his family, even love and
niya sa kanya kapag nag uusap sila, mabuti nalang talaga during a challenging time. support fro
mahal na mahal siya ng pamilya namin, kasi kung hindi at family
wala siyang dalaw, siguro hindi magiging ayos ang mental
health at maapektuhan ang pagpapagaling. Pamilya lang
talaga ang sandigan niya” Strength

Enhance
coping
Able to figh
challenge
NORMAL
Recreational Pattern
Health Promotion Model
BEFORE:
BEFORE: (Nola Pender)
“ Iyung kasiyahan niya noon, pakikipagkwentuhan sa
mga kapitbahay namin, paninigarilyo saka pag i-inom The patient recreation mainly consists The HPM is based on the BEFORE
noong mabata-bata pa siya. Saka shempre pam-babae of using nicotine products, drinking following assumptions:
alcohol and socializing with his Socializati
Saka sempre pakikipag harutan sa akin saka friends. ● People are motivated to
pakikipaglaro sa mga apo niya. ” engage in health-
-As Verbalized by his wife. promoting behaviors in Alcohol an
order to achieve and cigarette
maintain a high level of
DURING: well-being. *
● People's cognitions and DESTRUC
“Panonood lang naman ng TV at pakikipagkwentuhan sa affect (i.e., thoughts and TIVE
cellphone at sa mga bisita namin ang nakakapagpasaya sa feelings) about health- RECREAT
kanya. Lalu na ang pakikipag kasatan niya sa mga apo. DURING: promoting behaviors ONAL
Hindi namin din kami magaling gumamit ng cellphone.” influence their PATTERN
The patient's recreational pattern motivation to engage in
-As Verbalized by his wife. consists mainly of watching television those behaviors.*
and engaging in phone conversations ● People's prior behaviors INEFFEC
with friends. While these activities can and experiences with -IVE
provide entertainment and social health-promoting RECREAT
connection. Be it limited based on the behaviors also influence IONAL
analysis, these recreational pattern their motivation to PATTERN
seems effective. ● engage in those
behaviors.*
● People's personal DURING
characteristics and
experiences, such as their Limited
demographics, recreation
knowledge, skills, and
attitudes, also influence
their motivation to
engage in health-
promoting behaviors.
TV, visitors
friends
Recreational activity is also part

of health promoting behavior.
Playing an
Relaxation influences people in
socializing
health promoting behavior. The
with his wi
patient's recreational activity, be
and
it limited, helps him fight
grandchildr
loneliness that hinders health
-n
promoting behavior.
LIMITED B
GOOD
RECREATI
AL PATTE
NORMAL
Environmental Pattern
BEFORE: BEFORE: Environmental Theory
“ Safe namin sa lugar na tinitirhan namin. Madali din The patient environment is considered (Florence Nightingale)
makahanap ng ospital kasi nga sobrang lapit lang namin safe and free from danger. According
sa ospital. Noong nag collapse nga siya naisugod namin to an assessment they live near a Nightingale believed that the
siya sa ospital agad agad. hospital facility. environment had a significant BEFORE
impact on the patient's health
and well-being. She identified Safe hom
five factors that were essential environme
Wala naman din kaming nababalitaang nag dru-drugs, for a healthy environment:
saksakan, saka barilan sa lugar namin “ fresh air, pure water, sufficient
food, efficient drainage, and Health
cleanliness. facilities ar
near
DURING: DURING:
According to theory the

“Safe naman sa ospital at medyo komportable, malinis din No presenc
environment is also essential
pero mas komportable padin sa bahay. of dangerou
According to subjective assessment, in health care and healing. The
activity
the patient showed slight distress patient showed mild distress
Palipat lipat kami ng ospital kasi nga ung ibang ospital
because of frequent environmental and not cooperation
kulang ng gamit. Pero ung mga room namin komportabel
changes. The patient was in distress sometimes causing hindered NORMAL
naman lahat at maayos
when he was admitted to ICU because care and slow treatment
Nung na ICU siya, hindi daw siya komportable kase bawal of isolation and fear.
tumayo tas namatay payung katabi niya, nag wala din siya
doon kasi nga takot siya at baka na schock nadin sa
DURING
pangyayari, dagdag mopa yung namatay na katabi niya”
Safe hospi
-As Verbalized by his wife
Frequent
environmen
change du
to treatmen
availability
Distres from
ICU
ALTERED
ENVIRON
MENTAL
PATTERN
Economic Pattern
BEFORE AND AFTER: Self-Transcendence Theory
BEFORE:
“ Iyung buhay namin noon ay talagang napakahirap, (Pamela Reed)
wala kaming sariling bahay, nakikitira lang kami sa
bahay ng magulang ko. Wala kaming matinong trabaho The patient shows financial It is a developmental theory BEFORE
noon, pero buti nalang talaga naisipan ko na magtinda development and improvement over that explains how individuals
ng kakanin sa palengke. Kami yung pinaka unang the years as evidenced by managing can grow and expand their
nagbebenta ng kakanin sa palengke. Dahil doon his child to go abroad. This indicates sense of self beyond their own
nakapag patapos kami ng pag aaral ng mga anak Lower cla
that the patient and his wife show a needs and concerns to connect
namin.
good partnership for them to develop with something larger than
and surpass their past economic level themselves. This can be done
and situation. The patient's financial through intrapersonal, Not able to
status could be considered as middle interpersonal, transpersonal,
avail hous
DURING: lower class. and temporal transcendence.
“ Kung ikukumpara mo ang buhay namin noon at ngayon. ● Intrapersonal

Present of
Talagang mas umalwan na kami. Napag tapos namin transcendence involves
job
iyong mga anak namin sa college, nakapag pundar kami expanding one's sense of
sasakyan at napaayos namin ang bahay.Iyung isa nga self through self-
naming anak nasa abroad na eh. Nababayaran din namin awareness, introspection,
Collaborati
lahat ng bills na dumating. Eto ngang sa ospital nakaka and personal growth. *
1million na kami pero tuloy pa rin ang laban. Kahit nasa ● Interpersonal
ospital kami, nakkaka kain padin kami ng tama at wasto sa transcendence involves Able to ava
oras. expanding one's sense of collage
self through relationships
Nakakailang balik at pasok na kami sa ospital pero awa with others, such as
ng diyos nakakabayad naman kami lagi sa tulong nadin ng family, friends, and GOOD
government financial assistance niya saka ung bigay ng community members. ECONOM
mga anak namin” ● Transpersonal CAL
transcendence involves DEVELOP
expanding one's sense of MENT
self through connection
with a higher power,
nature, or a larger DURING
CHILD C: MONTHLY PADALA 30,000 purpose. *
● Temporal transcendence STARTS FR
involves expanding one's LOWER CL
sense of self through
connection to the past,
FOOD DURING HOSPITAL: 20,000 present, and future.
PARTNERS
As the theory suggests, the AND
patient's family is able to pay HARDWOR
HOSPITAL FEE; 1,000,000 the bills in the hospital using
ELECTRIC BILL: 3000

WATER BILL: 1000 intrapersonal transcendence,
using their own self to expand
and to prosper. Interpersonal TRANSITIO
with the help of their family. TO:
Transpersonal with the help of
government and temporal
transcendence with help from
patient friends. MIDDLE CL
ABLE TO P
BILLS ON T
ABLE TO
AFFORD
COLLEGE F
THEIR
CHILDRE
GOOD
ECONOM
PATTER
NORMAL
Socio Cultural Pattern Assessment Interpretation Relevant Theory Analysis
Religious Belief Pattern Theory of Carative Caring

BEFORE: LIMITED TO NON
BEFORE: ATTENDEE OF MA
“Kahit noon hindi kami paladasal at pala simba pero Based on the assessment. Patient (Katie Erikkson)
namimili kami ng mga poon at rosario para sa is catholic but not religious.
proteksyon ng bahay namin” is a holistic and patient-centered
theory that focuses on the CATHOLIC
importance of love, mercy, and
compassion in nursing care.
PRESENT OF
DURING: The theory is based on the
ROSARY AND SA
following assumptions:
Hindi naman kami paladasal na tao, pero minsan IN THEIR HOME
sinasamahan niya akong magdasal at lagi ko din siyang
● Humans are created in the
ipina pagdasal
image of God and are
Sa bahay may santo din kami at mga rosaryo. Matagal na therefore worthy of love ATTEND MASS ON
kaming Katoliko kaya nga lang sa mga nangyari nga and respect. IN SPECIAL
samin, madalang nalang kaming makapag simba.Pero ● Suffering is a part of the HOLIDAY
kapag may mga espesyal na okasyon gaya ng pasko ay human condition, and it
can be transformative.
nagsisimba kami. ● Nurses have a moral
responsibility to care for
-As Verbalized by his wife. the suffering with love and PRAYER DURIN
compassion. HOSPITALIZATIO
● Caritative caring is a
relational process that
involves both the nurse
and the patient. PATIENT IS NO
● Caritative caring ACTIVE RELIGIO
promotes healing and
wholeness.
As the theory suggests, humans

are created in the image of God
and are therefore worthy of love.
Even if the patient is not that
religious as the theory suggested
he is worthy of healing, protection
and free from suffering.
Values and Valuing

BEFORE: BEFORE AND AFTER: Theory of Carative Caring PATIENT IS NOT
Pattern
ACTIVE CATHOLI
“ Hindi talaga kami pala dasal at pala simba na tao, (Katie Erikkson)
napaka dalang namin mag simba. Mas pinagkukunan niya
ng lakas ng loob iyong pamilya namin. Pero ngayon na- Based on the assessment the
is a holistic and patient-centered
ospital na siya may mga oras at araw na na-nagdadasal patient is not religious. He gets GET HIS COURA
theory that focuses on the
kami ng asawa ko” his courage and motivation to FROM FAMILY
importance of love, mercy, and
fight his condition through his
family.
compassion in nursing care. NORMAL
DURING: The theory is based on the

following assumptions:
“Pero minsan susubukin ka talaga ng buhay, iyun nga
namatay ang isa naming anak tapos ngayon eto ● Humans are created in the
nagkasakit siya. image of God and are
therefore worthy of love
Pero dahil dito mag tumatag ang samahan namin at mas and respect.
naramdaman niya na marami pala ang nagmamahal sa ● Suffering is a part of the
kanya” human condition, and it
can be transformative.
● Nurses have a moral
responsibility to care for
the suffering with love and
compassion.
● Caritative caring is a
relational process that
involves both the nurse
and the patient.
● Caritative caring
promotes healing and
wholeness.\
Based on the assessment the

patient indicated as not an active
catholic, but even so as theory
suggested everyone is from the
image of god and therefore
worthy. The patient indicated that
he has more value in his family,
and it means that love is within

him.
PHYSICAL
ASSESSMENT
RED - SEVERE
GREEN- MILD
A. General Assessment
Actual Findings
Parts Normal Findings Initial Assessment Final Assessment Analysis/Nsg Dx
September 30, October 6, 2023

2023
Posture/Gait Bilateral/equal Fowler Position Poor walking CAD

100% normal coordination
Strength; normal Atherosclerosis
full
movement;against Weakness and Weakness and Transient Ischemic
gravity and stiffness of muscle stiffness of muscle Attack
against full on the right side of on the right side of
resistance. the body. the body. Paralysis of one side of
the body
Has upright
posture Impaired physical
and steady gait mobility
with opposing
arm swing;
walks unaided,
maintaining
balance.
Personal Clean/neat Body Odor Body Odor Pulmonary Congestion

Hygiene No body odor (3- Distinct) (4- weak)
Breath odor. Breath Odor Breath Odor Difficulty of breathing
(3- Distinct) (4- weak)
Odor Intensity Has a removable Has a removable Bed Rest
1- Extremely dentures dentures
Strong Inability to perform self
2- Strong Lengthy dirty nails Lengthy nails care practices
3-Distinct
4- Weak Activity Intolerance
Self-Care Deficit
Verbal Behavior Understandable, Understandable, Understandable, NORMAL

moderate pace; moderate pace and moderate pace and
clear tone and exhibits thought exhibits thought
inflection;exhibits association association
thought
association
Vital Signs
a. Pulse Rate 60-100 bpm 63 bpm 73 bpm NORMAL
b. Respiration Rate 12-20 cpm 18 cpm 19 cpm NORMAL

c.Blood Pressure 90/120 - 60/80 110/80 mmHg 100/70 mmHg NORMAL
mmHg
d.Temperature 36.5 - 37.5 °C 36.2 °C 36 °C NORMAL
e. Pain 0/10
(Using the NORMAL
Numeric Pain
Rating
Scale)
Body Built
a. Height 5 feet 7 inches (170 cm) NORMAL
b. Weight Ideal Body 75 kg (165 lbs.) CHF

Weight of a 5’7
Male Destruction of heart valve
133-163 lbs. Unable to pump blood well
Accumulation of fluid
Excess Fluid Volume
c. BMI Ideal: 18.5 – Overweight CHF

24.90 25.9
Overweight: 25 - Destruction of heart valve
29.9
Obese: 30 over Unable to pump blood well
Accumulation of fluid
Excess Fluid Volume
B. INTEGUMENTARY SYSTEM
Actual Findings
Parts Technique Normal Analysis
Used Finding Initial Final
Assessment Assessment
Inspection Varies from Brown skin tone Brown skin NORMAL

Skin Color light to deep tone
brown; from
ruddy pink to
light pink; from
yellow
overtones to
olive.
Uniformity of Inspection Generally Uniform in Uniform in NORMAL

skin color uniform except color color
in areas exposed
to the sun.
Skin turgor Palpation When pinched, Skin moves Skin moves Aging
skin springs back slowly back slowly
back to its (3 seconds) (3 seconds) Skin loses elasticity
previous state.
Less than 2 secs Poor skin turgor
Impaired Skin
Integrity
Temperature Palpation Uniform; within Warm to touch Warm to touch NORMAL

normal range
Temperature: Temperature:
36.2 °C 36 °C
Edema Palpation No edema Edema Edema CHF

Inspection (feet) (feet)
Pitting Destruction of heart
Edema 2+ 4mm deep 2+ 4mm deep valve
Grade: pit. A few pit. A few
seconds to seconds to Unable to pump
1+ 2 mm rebound rebound blood well
depression,
barely Accumulation of
detectable. fluid
Immediate
rebound. Excess Fluid Volume
2+ 4mm deep
pit. A few
seconds to
rebound
3+ 6 mm deep
pit. 10-12
seconds to
rebound.
4+ 8 mm very
deep pit. 20
seconds to
rebound.
Hair Inspection Evenly Bald Bald Aging

Palpation Distributed,
covering the Decreased
whole scalp Has white hair Has white hair melanocytes and
melanin
Maybe thick or Presence of Presence of Lack of pigment in

thin, coarse or mustache and mustache and the hair
smooth. beard beard
Risk for Altered Body
Neither brittle Image
nor dry. Evenly Evenly
There is no distributed leg distributed leg
infestation hair hair
observed.
Has a variable
amount of body
hair.
Nails Inspection The nail has a Delayed return Delayed return CAD
light pink color of pink or usual of pink or usual
color color Decreased
myocardial
Smooth Texture Capillary refill Capillary refill contractility
time time
Intact epidermis 3 seconds 3 seconds Decreased cardiac
output
Prompt return of
pink or usual Decrease oxygen
color delivery to the tissues
Prolonged capillary
refill time
Ineffective Tissue
Perfusion
C. CEPHALOCAUDAL ASSESSMENT
ACTUAL FINDINGS
TECHNIQU NORMAL
PARTS E USED FINDINGS INITIAL FINAL ANALYSIS/
ASSESSMENT ASSESSMENT NSG DX
Head Inspection Rounded Rounded Rounded NORMAL

Skull Palpation (normocephalic
ic and symmetric, Smooth skull Smooth skull
with frontal, contour contour
parietal and
occipital Absence of Absence of
prominences); nodules or nodules or
smooth skull masses masses
contour
Absence of
nodules or
masses
Facial Features Inspection Symmetric facial Slightly Slightly CAD

features; palpebral asymmetric asymmetric
fissures equal in facial features. facial features. Atherosclerosis
size;asymmetric
nasolabial folds Transient
Palpebral Palpebral Ischemic Attack
fissures equal in fissures equal in
size size Paralysis of one
side of the body
Slightly Slightly
symmetric symmetric Slightly
nasolabial folds nasolabial folds asymmetric facial
features and
nasolabial folds
Disturbed Body
Image
Facial Inspection and Symmetrical Asymmetrical Asymmetrical CAD

Movements palpation facial movement facial movement facial movement
Atherosclerosis
Drooping of
right corner of Drooping of right Transient
mouth corner of mouth Ischemic Attack
Paralysis of one
Can raise or Can raise or side of the body
lower both lower both
eyebrows, close eyebrows, close Drooping of right
the eyes and the eyes and corner of mouth
smile smile
Disturbed Body
Image
Eyes and Vision
Eyebrows Inspection Hair evenly Hair evenly Hair evenly NORMAL

distributed; skin distributed and distributed and
intact skin is intact skin is intact
Eyebrow The client can The client can

symmetrically raise and lower raise and lower
aligned;equal the eyebrows the eyebrows
movement
Eyelids Inspection Skin intact;no Swelling Swelling CHF

discharge;no
discoloration Destruction of
heart valve
Lids close Lids close Lids close
symmetrically symmetrically symmetrically Unable to pump
blood well
Approximately 15
to 20 involuntary Accumulation of
blinks per minute; 15 involuntary 18 involuntary fluid
bilateral blinking blinks per blinks per minute
minute Excess Fluid
When lids open, Volume
no visible sclera
above corneas, Ptosis (right Ptosis (right eye) CAD
and upper and eye)
lower borders of Atherosclerosis
cornea are slightly
covered. Transient
Ischemic Attack
Paralysis of one
side of the body
Drooping of right
eyelid
Disturbed Body
Image
Bulbar Inspection Transparent; Sclera appears Sclera appears NORMAL

Conjunctiva capillaries white white
sometimes
evident; sclera
appears white
(darker or
yellowish and
with small brown
macules in dark
skinned clients)
Palpebral Inspection Shiny, smooth and Pale Palpebral Pale Palpebral CAD
Conjunctiva pink or red Conjunctiva Conjunctiva
Decreased
myocardial
contractility
Decreased cardiac
output
Poor circulation
Decrease oxygen
delivery to the
tissues
Ineffective Tissue
Perfusion
Cornea Inspection Transparent, shiny Details of the Details of the iris NORMAL
and smooth;details iris are visible are visible
of the iris are
visible
In older people, a
thin grayish white Arcus Senilis is Arcus Senilis is
ring around the evident evident
margin called
arcus senilis, may
be evident
Pupils Inspection Equal in Equal in size; Equal in size; NORMAL

size;normally 3 to 3 mm in 3 mm in
7mm in diameter diameter diameter
Constrict when
light is directed to Both pupil Both pupil
the eye constrict and constrict and
dilate dilate
Pupils dilate when

looking at distant PERRLA PERRLA (pupils
objects and (pupils equally equally round
constrict when round and react and react to light
looking at nearer to light and and
objects. accommodation) accommodation)
CN3 and CN4 Inspection Illuminated pupil Both pupil Both pupil NORMAL
constricts(direct constricts constricts
response)
Equal response Equal response
Nonilluminated
pupil constricts
(consensual
response)
CN2 Inspection 20/20 near and far Mild vision loss Mild vision loss Type II DM
vision is
determined using High blood sugar
visual acuity tests.
Damages blood
vessels in the
retina
Diabetic
retinopathy
Mild vision loss
Disturbed sensory
perception:
Vision
Age
When looking Visual field Visual field
straight ahead, the smaller than smaller than Obstructed
client can see normal (due to normal (due to Trabecular
objects in the glaucoma) glaucoma) network
periphery.
Gradual
diminishing of
aqueous humor
outflow
Compression of
blood flow to the
retinal cells
Loss of peripheral
vision
Glaucoma
Disturbed sensory
perception:
Vision
Ears
Ears Auricles Inspection The auricles are The patient´s The patient´s NORMAL
Palpation symmetrical and auricles are auricles are
have the same symmetrical, symmetrical,
color as his facial and firm. firm, and have
skin. The auricles the same color
are aligned with as his face
the outer canthus
of the eye.
When palpating
for the texture, the No tenderness No tenderness
auricles are and pinna and pinna recoils
mobile, firm and recoils after it is after it is being
not tender. being folded folded
External Ear Inspection The canal is skin- No lesions; has No lesions; has NORMAL
Canal colored and has contains hair contains hair
small hairs. follicle follicle
Yellowish- brown Brownish Brownish earwax

earwax may be earwax is is present
present. present
The eardrum is a Eardrum is gray Eardrum is gray

light-gray color or in color in color
a shiny pearly-
white.
Light reflect off Light reflect off
Light should the eardrum the eardrum
reflect off the
eardrum surface.
Tympanic Inspection Pearly gray color, Pearly gray in Pearly gray in NORMAL
membrane / semi- transparent color color
Eardrum
Gross Hearing Inspection Normally the Both left and Both left and NORMAL
Acuity Test client can identify right ears are right ears are
the sound and at able to able to
what side it was distinguish distinguish sound
heard sound
Nose
External Inspection Symmetrical, Symmetrical Symmetrical CHF

structure Palpation no masses,
tender and no Presence of Poor blood
flaring oxygen cannula circulation
(+) flaring (+)) flaring Lack of oxygen in

(+) discharge (-) masses blood
(-) masses (-) tenderness
(-) tenderness (-) discharge Impaired Gas
Exchange
Patency Inspection Air moves freely Presence of Dyspnea CHF

as the client oxygen cannula
breathes through 2L/min Poor blood
the nares circulation
Lack of oxygen in
blood
Impaired Gas
Exchange
Nasal cavities Inspection Mucosa is pink Mucosa is red Mucosa is CHF

and has no lesions in color pinkish in color
Poor blood
Presence of circulation
oxygen cannula
2L/min Lack of oxygen in
blood
(+) watery (-) discharge
discharge Impaired Gas
Exchange
Nasal Septum Inspection Nasal Septum is in Intact and free Intact and free of NORMAL
the midline and no of ulcers or ulcers or
perforation perforation perforation
Midline Midline
Facial sinuses Palpation Sinuses is not The patient´s The patient´s NORMAL
tender upon frontal and frontal and
palpation maxillary maxillary sinuses
sinuses are not are not tender
tender when when palpated.
palpated.
CN1 Inspection Can identify Can accurately Can accurately NORMAL

different smell in distinguish the distinguish the
each side smell of the smell of the
materials used. materials used.
(vicks inhaler) (vicks inhaler)
Mouth
Lips Inspection Symmetrical in Asymmetrical; Asymmetrical; CHF

appearance, Drooping in the Drooping in the
uniform pink in right corner of right corner of Poor blood
color, soft, moist, the lips the lips circulation
smooth in texture,
and able to purse Pallor lips Pallor lips Lack of oxygen in
lips. blood
Able to purse Able to purse
lips lips Discoloration of
lips
Impaired Gas
Exchange
Teeth Inspection Teeth should be Has no teeth Has no teeth Cigarette

clean, no decay, Smoking
white with no
loose, missing, Periodontal
chipped or broken disease
teeth.
Receding gums
Adults should
have a total of 32 Jawbone
teeth. deterioration
Teeth loss
Impaired
Dentition
Gums Inspection Gums color Dark Dark CHF

is pinkish discoloration of discoloration of
and no gums gums Poor blood
presence of circulation
lesions and (-) gum bleeding (-) gum bleeding
sore (-) lesion (-) lesion Lack of oxygen in
(+)Moist (+)Moist blood
Discoloration of
lips
Impaired Gas
Exchange
Dentures Inspection No dentures Has upper and Has upper and Cigarette
lower dentures lower dentures Smoking
Periodontal
disease
Receding gums
Jawbone
deterioration
Teeth loss
Impaired
Dentition
Tongue Inspection Moist, slightly Has thin whitish Has thin whitish NORMAL
rough, thin coating coating
whitish coating
smooth, no
lesions)
Able to move the Able to move Able to move the

tongue freely and the tongue tongue freely
with strength. freely
(-) lesion (-) lesion
Palate Inspection Soft palate is light Soft palate is Soft palate is NORMAL
pink and smooth smooth smooth
Hard palate is Hard palate Hard palate

lighter pink and irregular in irregular in
more irregular texture texture
texture
Uvula Inspection Positioned in the Positioned Positioned NORMAL

midline, pinkish to midline midline
red in color, no
swelling or lesion (-) swelling (-) swelling
noted and able to
move upward and
backwards when
ask to say “ah”
Oropharynx Inspection Pink and smooth Smooth Smooth posterior NORMAL

posterior wall posterior wall wall
Tonsils Inspection Pink in color, Visible Visible NORMAL

visible but not
enlarged (-) swelling (-) swelling
Neck
Observe head Inspection The neck Straight Straight Pulmonary

movement muscles are Congestion
equal in size. No visible mass No visible mass
The client is or lumps or lumps Difficulty of
showed breathing
coordinated,
smooth, head Lack of physical
movement Limited range of Able to move movement
with no motion head
discomfort Muscle weakness
(+) Oxygen
cannula Limited Range of
Motion
Impaired physical
mobility
Sternocleidomas Inspection Head flexes 45°. Semi fowler’s Pulmonary

toid muscle position Congestion
Limited range of Able to flex at Difficulty of

motion 45° breathing
Lack of physical
movement
Muscle weakness
Limited Range of
Motion
Impaired physical
mobility
Trapezius Inspection and Head Semi fowler’s Able to Pulmonary

muscle Palpation hyperextends 60°. position hyperextend at Congestion
60°
Limited range of Difficulty of
motion breathing
Head Lac of physical

hyperextends movement
less than 60°
Muscle weakness
Limited Range of
Motion
Impaired physical
mobility
Muscle strength Inspection and Equal in strength Unequal Unequal strength CAD
palpation on each side. strength
Atherosclerosis
Transient
Ischemic Attack
Paralysis of one
side of the body
Impaired physical
mobility
Lymph nodes Inspection and Not palpable Not palpable Not palpable NORMAL
palpation
Trachea Palpation Trachea is Trachea is Trachea is NORMAL

palpable palpable palpable
Positioned in the Positioned in the Positioned in the

midline midline. midline.
Thyroid gland Inspection and Not visible on Not visible on Not visible on NORMAL
palpation inspection and inspection inspection
gland ascends
during swallowing
but is not visible
UPPER EXTREMITIES
Skin and Nails Inspection The skin of upper Uniform in Uniform in color CAD
Palpation extremities is color
uniform in Decreased
color except in Warm to touch Warm to touch myocardial
areas exposed to contractility
the sun Temperature: Temperature:
36.2 °C 36.2 °C Decreased cardiac
Skin’s output
temperature is
within normal Poor circulation
Nails are intact Nails are intact
Has a good with the with the Decrease oxygen
skin turgor epidermis epidermis delivery to the
tissues
Nails are clean Ineffective Tissue

and pink in Capillary refill Capillary refill is Perfusion
color with a is 3 seconds 3 seconds
convex curve
and is intact
with the
epidermis Poor skin turgor Poor skin turgor Age
(3 seconds) (3 seconds)
Skin loses
flexibility
Poor skin turgor
Impaired Skin
Integrity
Bones Inspection There is no (-) deformities (-)deformities NORMAL

Palpation presence of (-) tenderness (-) tenderness
bone (-) swelling (-) swelling
deformities,
tenderness
and swelling
Muscle strength Inspection and Smooth, Limited Limited CAD
and tone palpation coordinated movements movements
movements and Atherosclerosis
equal strength on
each body side Muscle strength Muscle strength Transient
Grade on right Grade on right Ischemic Attack
The tone there is arms arms
the right amount (0)complete (0) complete Paralysis of one
of tension inside paralysis paralysis side of the body
the muscle at rest
Muscle strength Muscle strength Impaired Physical
Muscle strength of left arms of left arms Mobility
grading range (3) movement (4) movement
from 0 to 5 being against gravity against at least
(5) muscle is with but not some resistance
full strength and resistance supplied
(0) complete
paralysis
Bicep/Triceps Inspection and Equal strength on Strength is not Strength is not CAD
palpation each body side equal equal
and is able to Atherosclerosis
resist force
Muscle strength Muscle strength Transient
Grade on right Grade on right Ischemic Attack
arms arms
(0)complete (0)complete Paralysis of one
paralysis paralysis side of the body
Impaired Physical
Mobility
Muscle strength Muscle strength
of left arms of left arms
(3) movement (4) movement
against gravity against at least
but not some resistance
resistance supplied
Wrist and finger Inspection Wrists are Fingers are Fingers are NORMAL
Palpation symmetrical complete and complete and
symmetrical to symmetrical to
Fingers are the other the other
symmetrical,
complete (-) deformities (-) deformities
(-) swelling (-) swelling
No deformities, (-) lesion (-) lesion
lesion or abrasion
on wrist and
finger
Joint Inspection and There were Right arm was Right arm was CAD
Palpation no swelling, unable to unable to
tenderness perform flexion perform Atherosclerosis
and joints and extension, flexion and
moves pronation and extension, Transient
smoothly supination pronation and Ischemic Attack
supination
Paralysis of one
(-) swelling (-) swelling side of the body
(-) tenderness (-) tenderness
(-) crepitation (-) crepitation Impaired Physical
Mobility
Range of motion Inspection Varies to some Left upper Left upper CAD
degree in extremities extremities
accordance with (3) active (3) active Atherosclerosis
person’s movement movement
genetic makeup against gravity against gravity Transient
and degree of but not against but not against Ischemic Attack
physical activity resistance resistance
Paralysis of one
Right upper Right upper side of the body
extremities extremities
(0)complete (0)complete Impaired Physical
paralysis paralysis Mobility
Brachial and Varies to some A normal pulse The patient’s The patient’s NORMAL
radial pulses degree can be felt with brachial and brachial and
moderate pressure radial pulses are radial pulses are
and the pressure is palpable and palpable and
equal with each normal pulses in normal pulses in
beat. each beat for 1 each beat for 1
full minute full minute
Sensation Inspection and The client can Client’s left Client’s left CAD
palpation identify the upper extremity upper extremity
difference was able to feel was able to feel Atherosclerosis
between light and sensation. sensation.
deep touch Able to identify Able to identify Transient
between light to between light to Ischemic Attack
The client can deep touch and deep touch and
able to soft to sharp soft to sharp Paralysis of one
discriminate sensation sensation side of the body
“sharp” and “dull”
sensations Impaired physical
Client’s right Client’s right mobility
upper extremity upper extremity
wasn’t able to wasn’t able to Risk for Injury
feel sensation feel sensation
Phalen’s Sign Inspection and Patient wrist Left hand of the Left hand of the CAD
Palpation manually and hold client feel client feel
together for one tingling in tingling in Atherosclerosis
minute. thumb, index thumb, index
finger and finger and Transient
Patient middle half of middle half of Ischemic Attack
should feel elicit the ring finger the ring finger
tingling in thumb, Paralysis of one
index finger and side of the body
middle Right hand was Right hand was
half of the ring unable to feel unable to feel Impaired physical
finger. any sensation any sensation mobility
Risk for Injury
Test Tinel’s Sign Inspection and No tingling No tingling or No tingling or NORMAL

Palpation or shocking shocking shocking
sensation sensation sensation
experienced experienced experienced
with the test
for Tinel’s
sign
Deep Tendon Reflexes
Tricep Inspection, Elbow extends, Left Tricep Left Tricep CAD

Percussion and triceps contracts Reflex is 2+ Reflex is 2+
Palpation range from 1+ to (normal) (normal) Atherosclerosis
3+
Right Tricep Right Tricep Transient
Reflex is 0 Reflex is 0 Ischemic Attack
(not normal) (not normal)
Paralysis of one
side of the body
Impaired physical
mobility
Risk for Injury
Biceps Inspection, Bicep muscles is Left Bicep Left Bicep CAD

Percussion and seen or felt ranges Reflex is 2+ Reflex is 2+
Palpation from 1 + to 3 + (normal) (normal) Atherosclerosis
Right Bicep Right Bicep Transient

Reflex is 0 Reflex is 0 Ischemic Attack
(not normal) (not normal)
Paralysis of one
side of the body
Impaired physical
mobility
Risk for Injury
Brachioradialis Inspection, Forearm flexes Left Left CAD

Percussion and and supinates Brachioradialis Brachioradialis
Palpation ranges from 1 + to Reflex is 2+ Reflex is 2+ Atherosclerosis
3+ (normal) (normal)
Transient
Right Right Ischemic Attack
Brachioradialis Brachioradialis
Reflex is 0 Reflex is 0 Paralysis of one
(not normal) (not normal) side of the body
Impaired physical
mobility
Risk for Injury
CHEST
Posterior Inspection and Anteroposterior to Bilaterally Bilaterally NORMAL

Thorax Palpation transverse symmetrical symmetrical
diameter in ration
of 1:2
Spine vertically Spine vertically
Thorax symmetric aligned aligned
Spine Vertically
aligned
Spinal column is
straight
Right and left

shoulders and hips
are at the same
height
Respiratory Inspection The 2-to-3-inch Symmetric Symmetric NORMAL

Excursion Palpation symmetrical thorax thorax expansion
thoracic expansion expansion
thumbs move When a client
apart equal When a client takes a deep
distance in both takes a deep breath, the thumb
direction breath, the of the assessor
thumb of the separates for
assessor about 2 cm.
separates for
about 2 cm.
Thorax for vocal Palpation Bilateral Increase vocal Increase vocal Pneumonia
(tactile fremitus) symmetry of vocal fremitus fremitus
fremitus. Fremitus Compression of
is heard most lung tissue
clearly at the apex
of the lung Increase fremitus
Activity
intolerance related
to impaired
respiratory
function
Anterior Thorax Inspection The symmetrical Symmetrical Symmetrical NORMAL

Expansion thumbs Expansion Expansion
move thumbs move thumbs move
apart equal apart equal apart equal
distance in both distance in both distance in both
directions directions. directions.
HEART
Tricuspid Area Auscultation S1 is louder than Holosystolic Holosystolic Congestive Heart

S2 murmurs murmurs Failure
Blood flows
abnormally over
the heart valve
Murmur
Ineffective Tissue
Perfusion
Aortic Area Auscultation S2 is louder than murmurs murmurs Congestive Heart

S1. No heart Failure
murmurs
Blood flows
abnormally over
the heart valve
Murmur
Ineffective Tissue
Perfusion
Carotid Arteries Inspection Symmetric pulse Pulsations are Pulsations are NORMAL
Palpation volumes full symmetrical symmetrical
pulsations,
thrusting quality, Have similar Have similar
quality remains characteristics characteristics as
same when client as the radial the radial artery.
breaths, turns, artery.
head, and changes
from sitting to
supine position
elastic arterial
wall, no sound
heard on
auscultation
Jugular Veins Inspection Veins not visible Not visible Not visible NORMAL
Palpation indicating the
right side of heart
is functioning
normally.
Peripheral Palpation Symmetric pulse Decreased,weak Decreased,weak, CAD

Pulses volume ;full , pulsation pulsation
pulsation Aterosclerosis
Narrowing of
blood vessels
Slow blood
circulation
Decreased
Cardiac Output
Peripheral veins Inspection, In dependent Not distended Not distended NORMAL

Auscultation position presence
and Palpation of distension and
nodular bulges at
calves.
When limbs are

elevated, veins
collapse
Symmetric in
size.
Capillary refill Inspection and Immediate return Capillary refill Capillary refill CAD
test palpation of color (less time time
than 2 seconds) 3 seconds 3 seconds Decreased
myocardial
contractility
Decreased cardiac
output
Decrease oxygen
delivery to the
tissues
prolonged
capillary refill
time
Ineffective tissue
perfusion
BREAST
Size, Symmetry, Inspection, Rounded unequal in unequal in NORMAL

Contour or Palpation shape size size
Shape slightly
unequal in generally generally
size symmetric symmetric
generally
symmetric & No tenderness No tenderness
no
tenderness
Skin Inspection, and Skin uniform in Uniform in color Uniform in color NORMAL
Palpation color (similar
to the skin of Wrinkled skin
the abdomen if Wrinkled skin
not tanned).
Areola Inspection, and Rounded or Dark brown color Dark brown color NORMAL
Palpation oval.
Color
depending on
race.
Nipples Inspection, and Symmetrical Rounded and Rounded and NORMAL

Palpation Size symmetrical in size symmetrical in
size
No discharge Dark brown in Dark brown in

color color
ABDOMEN
Skin Inspection Color is Skin color is Skin color is Age

Palpation uniform. uniform uniform
Collagen
Contour may be Contour is rounded Contour is breakdown
flat, rounded or rounded
scaphoid. Skin wrinkling
(-) stretchmarks (-) stretchmarks
No presence of (-) lesion (-) lesion Impaired skin
lesions, (+) distention (+) distention Integrity
tenderness and (+) wrinkled (+) wrinkled
distension. abdominal skin abdominal skin
Abdominal Inspection and Symmetric Symmetrical Symmetrical NORMAL

movements palpation movement respiration respiration
associated with caused by movement movement
respiratory or respiration.
peristalsis
Vascular pattern Auscultation No visible No visible venous No visible NORMAL

venous pattern. patterns venous patterns
Bowel Sound Auscultation Bowel sound Hypoactive active Hypoactive Reduced

consists of sound (1/min) active sound digestive
clicks and (1/min) system function
gurgles 5-30
per minute. Reduction in
the volume and
An occasional frequency of
borborygmus noises emitted
(loud prolonged from the gut
gurgle) may be
heard. Hypoactive
bowel sound
Altered bowel
elimination
Constipation
Vascular sound Auscultation Absence of No bruit No bruit NORMAL

bruit.
Peritoneal Auscultation Absence of Absence of friction Absence of NORMAL

Friction Rubs friction rub. rub. friction rub.
Urinary Bladder Palpation Not palpable. The client’s bladder The client’s NORMAL
Not distended is not palpable bladder is not
palpable
MUSCULOSKELETAL
Muscle Inspection Equal size of Equal in size Equal in size NORMAL

both sides of the
body.
Muscle strength Palpation Equal strength Both sides are not Both sides are not CAD
on each body equal in strength equal in strength
side. Atherosclerosis
Transient
Ischemic
Attack
Paralysis of one
side of the body
Impaired
physical
mobility
Bones Inspection No deformities. No deformities. No deformities. NORMAL
Joints Inspection No swelling, no Unable to move Unable to move CAD

Palpation tenderness or right arm due to right arm due to
nodules. hemiplegia hemiplegia Atherosclerosis
Left arm Able to Left arm Able to Transient
perform palm perform palm Ischemic
pronation and pronation and Attack
supination, supination,
opposition and opposition and Paralysis of one
reposition reposition side of the body
without difficulty without difficulty
Impaired
physical
(-) swelling (-) swelling mobility
(-) tenderness (-) tenderness
(-) crepitation (-) crepitation
LOWER EXTREMITIES
Skin and nails Inspection The skin of Uniform in color Uniform in color CAD
Palpation lower
extremities is Warm to touch Warm to touch Decreased
uniform in color myocardial
except in areas Temperature: Temperature: contractility
exposed to the 36.2 °C 36.2 °C
sun. Decreased
cardiac output
Skin’s Nails are intact with Nails are intact
temperature is the epidermis with the Poor circulation
within normal. epidermis
Decrease
oxygen
Capillary refill is Capillary refill is delivery to the
3 seconds 3 seconds tissues
Nails are
pinkish in color. Ineffective
Smooth and tissue perfusion
intact with the
epidermis.
Age
Poor skin turgor Poor skin turgor
Skin loses
Capillary refill flexibility
time is usually
less than 2 Poor skin
seconds. turgor
Has a good skin Impaired Skin

turgor. Integrity
Bones Inspection and No presence of No presence of No presence of NORMAL

Palpation bone bone deformities, bone deformities,
deformities, tenderness and tenderness and
tenderness and swelling. swelling.
swelling.
Muscle strength Inspection Able to resist Limited movements Limited CAD

and tone Palpation applied pressure movements
symmetrically. Atherosclerosis
Symmetric Muscle strength Muscle strength Transient

muscle tone. Grade on right leg Grade on right Ischemic
(0)complete leg Attack
paralysis (0)complete
paralysis Paralysis of one
side of the body
Impaired
physical
Muscle strength of Muscle strength mobility
left leg of left leg
(3)movement (4) movement
against gravity but against at least
not resistance some resistance
supplied
Hip muscle Inspection Equal strength Unequal strength Unequal strength CAD
Palpation on each body
side. Atherosclerosis
Right lower Right lower Transient

extremities extremities Ischemic
(0)complete (0)complete Attack
paralysis paralysis
Paralysis of one
side of the body
Left lower Left lower Impaired

extremities extremities physical
(3) active (3) active mobility
movement against movement
gravity but not against gravity
against resistance but not against
resistance
Hip abduction Inspection Equal strength Unequal strength Unequal strength CAD
side. Right lower Right lower Atherosclerosis
(0)complete (0)complete Transient
paralysis paralysis Ischemic
Attack
Left lower Left lower Paralysis of one

extremities extremities side of the body
(3) active (3) active
movement against movement Impaired
gravity but not against gravity physical
against resistance but not against mobility
resistance
Hip adduction Inspection Equal strength Unequal strength Unequal strength CAD
side. Right lower Right lower Atherosclerosis
(0)complete (0)complete Transient
paralysis paralysis Ischemic
Attack
Paralysis of one
Left lower Left lower side of the body
(3) active (3) active Impaired
movement against movement physical
gravity but not against gravity mobility
resistance
Hamstring Inspection Equal strength Unable to do Unable to do CAD

Palpation on each body popliteal angle test popliteal angle
side. at 45° test at 45° Atherosclerosis
Transient
Ischemic
Attack
Paralysis of one
side of the body
Impaired
physical
mobility
Muscle of the Inspection Equal strength Right lower Right lower CAD
ankles and feet Palpation on each body extremities extremities
side. (0)complete (0)complete Atherosclerosis
paralysis paralysis
Transient
Ischemic
Attack
Left lower Left lower Paralysis of one

extremities extremities side of the body
(3) active (3) active
movement against movement Impaired
gravity but not against gravity physical
against resistance but not against mobility
resistance
Joint Inspection Equal strength Right leg was Right leg was CAD
Palpation on each body unable to perform unable to perform
side. eversion and eversion and Atherosclerosis
inversion inversion
Able to move Transient
smoothly. Ischemic
Left leg able to Attack
perform eversion
and inversion Paralysis of one
side of the body
Impaired
(-) swelling (-) swelling physical
(-) tenderness (-) tenderness mobility
(-) crepitation (-) crepitation
Range of motion, Inspection The range of Right lower Right lower

popliteal, Palpation motion are 160 extremities extremities CAD
posterior tibial, degrees of (0)complete (0)complete
and dorsalis flexion 180 paralysis paralysis Atherosclerosis
pedis pulse degrees of
extension 90 Transient
degrees of Left lower Left lower Ischemic
pronation and extremities extremities Attack
supination. (3) active (3) active
movement against movement Paralysis of one
gravity but not against gravity side of the body
resistance Impaired
physical
mobility
Sensation Inspection The client can Client’s right lower Client’s right CAD
Palpation identify light extremity wasn’t lower extremity
and deep touch able to feel wasn’t able to Atherosclerosis
sensation feel sensation
The client is Transient
able to Client’s left lower Client’s left Ischemic
discriminate extremity was able lower extremity Attack
between to feel sensation was able to feel
“sharp” and sensation Paralysis of one
“dull” side of the body
sensations
Able to identify Able to identify Impaired
between light to between light to physical
deep touch and soft deep touch and mobility
to sharp sensation soft to sharp
sensation
COURSE IN
THE WARD
COURSE IN THE WARD
DATE MANAGEMENT INDICATION
September 26, 2023 Patient has admitted to ICU

(12:32 am) Due to present Condition
BP: 160/100 (coronary artery disease in congestive

heart failure; acute respiratory failure
T: 36 secondary to (1) acute pulmonary
congestion (2) pneumonia high risk;
RR: 30 chronic kidney disease)
PR: 115
O2 Sat: 99% For management and evaluation of the

patient’s condition.
Weight: 75kg
Height: 5’7
September 26, 2023 Secure consent for admission to the

(12:35 am) management Rights of the patient when required for
medical care
Rights for information and legal

purposes
Secure Consent
September 26, 2023 Secure consent for intubation

(12:35 am) Rights of the patient when required for
medical care

purposes
Secure Consent
(12:40 am) NGT and IFC intubation.

Secure consent Rights of the patient when required for
medical care

purposes
Secure Consent
NPO except by meds

decrease the risk of vomiting or bringing
up food into the throat
food could get into the lungs and affect

the breathing
Causing damage to the lungs.
Nothing by mouth except meds
To avoid aspiration
(12:45 am) IVF PNSS 1L x 24

Extracellular fluid replacement
Treatment of metabolic acidosis
September 26, 2023 CBC with Platelet

(12:55 am) Measure the number of RBC, WBC,
PLT.
Diagnostics
help detect complication of the heart
Serum Potassium
Possible alterations of the fluid and
electrolytes of the patient
To monitor abnormal potassium levels.

Serum Magnesium
to monitor abnormal minerals; calcium,
potassium, phosphorus
to measure the amount of the mineral

magnesium in the blood
Alb
due to acute renal failure
To monitor the function of kidney
PT PTT
To monitor blood clotting
To measure how much blood can make

clot
BUN
Due to Acute Renal Failure
Measure the amount of urea nitrogen in

the blood.
To monitor if kidney works properly
Crea
To measure the creatinine in the blood
For proper management
Ast
Blood test to check for liver damage
Alt
To measure the health of the liver
HCT
Coronary Artery Disease
cc: Difficulty of breathing
red blood cell carry oxygen to the body
Measures the percentage of red blood

cell in the blood
Trop I
Due to Congestive heart failure
Chest pain
trisha walang diff of breath
To monitor if heart attack has occurred
Basis for proper medical management
ABG
cc: shortness of breath
Measures the acidity and level of

oxygen and carbon dioxide in the blood
from an artery.
To determine the lungs capability to

move oxygen into the blood and remove
carbon dioxide from the blood.
12L ECG
Due to present Condition
(Congestive heart failure)
To evaluate electrical conduction of the

heart
CXR AP post intubation

To illustrate the position of the
endotracheal tube
to ensure proper tube positioning
RAT
To detect covid 19 virus
Prior to admission
UA
(Chronic Kidney Disease)
To detect and manage urinary tract

infection, kidney disease, and diabetes.
September 26, 2023 Hook to mechanical ventilation at ICU

(1:25 am) Difficulty of breathing
To alleviate difficulty of breathing
September 26, 2023 Continue own medication

(1:27 am) Continue the prescribe maintenance
Dr. Bugarin as attending medication of the patient
physician
(Cardio)
to improve patients health by the use of

pharmacological treatment
September 26, 2023 Isoket drip in soluset 10mg by 10

(1:30 am) ugtts/min Shortness of breath
Dr. Bugarin as attending
physician
(Cardio)
To manage heart problems of the patient
To prevent angina pectoris
(1:37 am) Furosemide 40mg TID now

Due to Pulmonary Edema
Inhibits the reabsorption of sodium and

chloride from the loop of Henle and
distal renal tube
Increases renal excretion of water,

sodium, chloride, magnesium,
potassium, and calcium.
Promote diuresis
to treat pulmonary edema
(1:38 am) Hydrocortisone 200mg TID then

100mg q8 TID 3 doses cc: Difficulty of breathing
inhibiting the release of secretagogue

from macrophages
Used for calming down body’s immune

response
reduce mucos secretion
airway clearance
(1:38 am) Salbutamol + ipratropium neb x 3

doses cc: Difficulty of breathing
q15 Now then q8
Inhibit acetylcholine
relaxing the muscles in the airway
Airway clearance
Monitor VS q1 and record

Need for close observation and frequent
monitoring
For baseline data and information
To monitor deviation of normal values
Monitor input and output q shift and

record Assess the condition of patient intake
and output
To evaluate and monitor the fluid and

electrolyte imbalance until unstable
To prevent circulatory overload and

complications
CBG TID pre-meals

Increased Glucose level
(Result: 181)
Monitor accurate blood sugar level
for further monitoring and proper

management
September 26, 2023 Refer to

(1:45 am)) Dr. Tumulak for consult Need close observation
Refer to For pulmo co management
Dr. Tumulak for consult
(Pulmo)
For accurate documentation and

management
For further assessment and treatment
Inform attending physician admitted to

ICU Need close observation
For continuity of care
Please recall all laboratories and plates

Need close observation
Refer accordingly
September 26, 2023 Referred to Dr. Tumulak

For accurate documentation and

management
Continue previous orders

continuity of care
for proper and effective management
Diagnostics: ABG 30 minutes post-mechanical

(1:58 am) ventilation Proper monitoring of oxygen level
To provide valuable information about

the adequacy of oxygenation, ventilation
to monitor if the patient’s oxygen

improved
ETA GSCS
Difficulty of breathing
to eliminate secretions in patients with

artificial airways
Therapeutics: Omeprazole 40mg TIV now

(2:03 am) Then OD prn Inhibit proton pump activity by binding
to hydrogen-potassium adenosine
triphosphate
to suppress gastric acid secretions
(2:27 am) Mechanical ventilation:

Due to difficulty of breathing
400 TV
50 peak flow
Fi02 100%
Once ABG post-intubation is done To promote proper oxygenation to the
May titrate Fio2 by 10% per hour patient
Until 40% is readed. Up O2 sat at
least 96%
Provide patient normal oxygen level
Please relay all labs

Refer accordingly
September 26, 2023 Give dioxidine 75meq subcutaneous

(2:28 am) now x2 doses antibacterial drugs
BP: 180/100
To treat suppurative infection

Titrate Isoket drip at 150gtts/min
Due to congestive heart failure
To avoid congestions
September 26,2023 For procalcitonin now

(2:30 am) Due to Sepsis
Telephone order by Dra. Tumulak
To distinguish bacterial infection from

other causes of infection or inflammation
September 26, 2023 Give Nicardipine 1mg IV now

(3:31 am) due to Congestive heart failure
Note- BP: 180/90 mmHg Telephone order by Dra. Tumulak
lowers blood pressure by relaxing blood

vessels
Manage heart problems of the patient
September 26, 2023 Give Ceftriaxone 2mg IV OD ANST

(4:37am ) inhibition of bacterial cell wall synthesis
Viber order by Dra. Tumulak
binding to penicillin-binding proteins
leading to cell lysis or cell death
To treat bacterial infection
September 26, 2023 Give NaHCO3 50meqs SIVP now

(5:07 am) To increase plasma bicarbonate levels
Viber order by Dra. Tumulak
Raises solution pH
Decreasing metabolic acidosis
Normalize acid-base balance
Give in slow IV push
To minimize fluctuations in cerebral

hemodynamic
September 26, 2023 Continue patient’s medications, NPO

(5:17am) except meds via NGT NPO except meds
to prevent aspiration
Continue patient’s medications
To have effective nursing and medical

and pharmacological management
(5:23 am) HOLD, shift pantoprazole (antaxid)

40mg tab to Omeprazole 40mg IV OD Pantoprazole is contraindicated to other
prescribe medicines
shift omeprazole for wider

pharmacological intervention
(5:25 am) Shift furosemide 20mg tab OD to

Furosemide 40mg IVF q12 Increased Pulmonary Edema
Telephone order by dr. Bugarin

distal renal tube
Increase renal excretion of water,

sodium, chloride, magnesium,

potassium, and calcium
Reduced the severity of medically

diagnosed calculi symptoms
Promote diuresis
To treat pulmonary edema
September 26, 2023 Isoket drip to consume

(6:40pm) for effective management
Viber order by dr. Bugarin
September, 26, 2023 Discontinue motilium

(7:30 am) Patient relieved from nausea and
vomiting
Medication no longer require for

treatment
(8:09 am) Increase Apixaban to 5mg to 1 tab

anticoagulant
to promote increase blood flow
(11:00 am) Repeat K, Crea, CBC tomorrow

morning For proper monitoring and ensure
stability
For proper management and treatment
September 26, 2023 Same IVF to follow

6:47pm For effective medical management
IVF PNSS 1LxKVO

(6: 50 pm) Isordil 5mg/tab 1 tab SL TID change
to ERN due to Coronary artery Disease and
Congestive Heart Failure
To prevent chest pain
Thank you so much for this referral
Daily follow up of ETA GSCS

Difficulty of breathing
to eliminate secretions in patients with

artificial airways
(7:00 pm) Shift Mechanical ventilation to

continuous positive airway pressure 5 Continuity of care
pulmonary stenosis 12- done
To promote proper oxygenation
(9:00 pm) May down titrate pressure support by 2

per hour until 6 is reached Patient no longer need high titrate
pressure support
Patient’s respiration improved
(11:00 pm) Decrease Fi02 to 30%-done

patient no longer need high pressure
Patient’s respiration’s improved
(11:12 pm) Watch out for dub, desaturation, cardio

respiratory distress signs Due to critical case of the patient
If patient shows abnormalities in general

health conditions
Need for strict monitoring and treatment
Please relay labs tomorrow

For accurate baseline
For proper medical management
(11:45 pm) Repeat CXR portable

For accurate baseline and proper
management
to monitor if the NG tube is in proper

position
September 27, 2023 Give Kalium Durules TID

(7:04am) Due to low potassium level
(Result: 3.36)
to treat low amount of potassium in the

blood
(7:15 am) Start of feeding 1800 kcal divided into

BP: 130/90 6 equal feedings Meal plan of the patient
To restrict and control patient’s daily

caloric intake
For adequate nutrition needed by the

patient
(7:34 am) Re insert NGT

Patient cant tolerate soft diet
September 27, 2023 D2-3 Ceftriaxone

WBC: 16.15 -- 16.67
NEU: 89 – 35
CREA: 285.8
HBG: 122 – 3.36
inhibition of bacterial cell wall synthesis

Whitish to yellowish
secretions
Bibasal crackles
Chest pain/DOB binding to penicillin-binding proteins
leading to lysis and cell death
(7:41 am) Budesonide Neb Q8

Due to shortness of breath
To control or prevent shortness of breath
(7:41 am) Hydrocortisone 100mg/IV now and

another at 8am CC: Difficulty of breathing
Corticosteroid
Calming down body’s immune response
Airway Clearance
(7:45 am) Shift to t piece Fio2 30%

SF 4LPM at 8am if patient will continuity of care
continue to be stable
Patient’s oxygen level became stable
(8:07 am) Please viber CXR in AM

(8:46 am) ABG 2 hours after hooking to Tpiece

to monitor if T Piece alleviate patient’s
oxygen and carbon dioxide level
To provide valuable information about

the adequacy of oxygenation, ventilation
(9:00 am) Watch out for DUB. Desaturations,

signs of cardio respiratory distress Due to critical case of the patient

health conditions
September 27, 2023 Give clonidine 75 mcg tab SL

(11:24pm) Same IVF to follow Due to high blood pressure
Bp at 11pm- 160/80
Centrally acting alpha-agonist

hypotensive agents
Decrease heart rate
Relaxes blood vessels
Blood flow easily to the body
To treat high blood pressure form 160/80

to its normal range
September 28,2023 Hytrin 2mg/tab 1 tab now then OD HS

(8:00 am) Relaxing blood vessels
140/90
Monitor chest for DUB
HR: 86
02 sat 99% Decrease the amount of work the heart
has to do
Treats high blood pressure

September 28, 2023 Hold next due feeding
1:03 pm Viber order by Dra. Tumulak Improved condition
Note: last of feeding via NGT at

12nn
termination of NGT feeding
preparation to return to pre

hospitalization diet and minimize
infection
September 28, 2023 Nebulize the ipratropium+salbutamol 1

1:59pm hub now Due to shortness of breath
Viber order by Dr. Tumulak
inhibits acetylcholine
Relaxing the muscle in the airway
airway clearance
September 28, 2023 D3-4 ceftriaxone

(2:57 pm) Due to Sepsis
Tolerated Tpiece
Whitish to light yellowish To kill or prevent bacterial growth

secretions
02 sat 99% @TPC
Chest Xray significant clearing

of congestions
NGT extubated
(6:17 pm) to practice patient eating without NGT
No longer need for medical management
(6:30 am) 02 at 2LPM NC

Due to difficulty of breathing
to improved oxygenation to myocardial

tissues and help lungs for adequate
oxygenation of the body
Awaiting official ETA GSCS results
Baseline
for proper medical management
(7:15 pm) Fluimucil 600mg/tab in ¼ glass H2O

OD Expectorant
Breaking up the congestions, thins and

loosen phlegm from the airways
To relieve symptoms such as tightness of

chest, shortness of breath, wheezing and
coughing.
(10:45 pm) Refer for DOB, Desaturations, cardio

respiratory distress Due to critical case of the patient

health conditions
(10:49 pm) May have trial of sips of water in AM

if well practicing water tolerance
September 29, 2023 Give soft diet trial for now

(12:45am) Dysphagia
Viber order by dra. Tumulak
Cannot tolerate normal food intake

September 29, 2023 Furosemide to 40mg IU OD
(8:09 am) Inhibits the reabsorption of sodium and
chloride from the
loop of Henle and distal renal tube

sodium, chloride, magnesium, potassium
and calcium
Promote diuresis
Treat high blood pressure and edema
(9:06 am) NA objection to transfer to regular

room patient no longer require to stay in ICU
September. 29, 2023 CBR without BRP

(9:38am) Required bed rest for proper medical
management
Restriction of usage of bathroom for

safety purposes
VS Q2
Baseline
For accurate diagnosis, treatment and

prediction of outcome of the patient
(1:15 pm) Monitor input and output in cc
To assess the condition of patient intake
and output
To evaluate and monitor the fluid and

electrolyte imbalance until unstable
To prevent circulatory overload and

complications
(5:04 pm) Please update me for any signs and

symptoms To identify abnormalities in general
condition
Text ordered by dr. Bugarin
for proper medical management
September 29, 2023 Same IVF to follow at KVO

(11:09pm) For continuity of care
proper medical treatment
September 29, 2023 D4-5 Ceftriaxone

(11:12 pm) Due to Sepsis
O2 sat 97-98%
Whitish phlegm To kill or prevent bacterial growth

Cough
Crackles bases
Tolerated soft diet

(11:15 pm) Please follow up sputum/ ETA GSCS

results Due to present Condition
For proper diagnosis, treatment and

(11:27 pm) For CBCPC, K, Crea in AM and
please relay Baseline

needed
For proper diagnosis, treatment and

May resume glycoair 50mcg cap/ 1cap

OD via inhaler (12nn) Bronchodilator
To relieve symptoms and reduce

exacerbation with COPD
(11:37 pm) May have LSLF renal diet SAP at all

times To prevent increase oxygen demand
To lessen the patient body’s tendency to

retain fluid
To prevent further increase in blood

pressure
To prevent metabolic acidosis and

maintain sodium level
To maintain patient nutritional status
(11:56 pm) Refer for recurrence of chest

pains/DOB, Desaturations To manage the chest pain
for continuity of care

September 30, 2023 D5-6 ceftriaxone
Laboratories not yet done
noted ETA results

Cough
Phlegm
To kill or prevent bacterial growth
crackles
Patient relative inquiring if they

can go home tomorrow
(10:11 am) Levofloxacin 750mg/tab once every

other day or q48hours Due to Sepsis
Stopping the growth
of bacteria
To treat variety of bacterial infection
(11:22 am) Shift 02 ts pm bases

For continuity of treatment
Need for adequate oxygen level
(7:34 pm) Please relay 02 sat at 9pm and 9:30pm

To assess reduced function of respiratory
system
For adequate oxygenation
(8:45 pm) Please relay laboratory results

Baseline
for accurate medical management

(11:07 pm) For repeat CXR in AM (Portable
setting) atherosclerosis
Need for further assessment and

evaluation
(11:25 pm) Refer for DOB, desaturations

Due to critical case of the patient
To assess if the patient experience

abnormalities in general health
conditions
(11:33 pm) Suggest bladder training if ok with dr.

Bugarin To assess id the patient can control
bladder
Prior to removal of IFC
(11:42 pm) Kindly inform dr. Bugarin regarding

hematuria Continuity of care
September 30, 2023 Okay with bladder training

11:59pm
Text by dr. Bugarin
September 30, 2023 May remove IFC

(7:14 am) No longer require for medical
management
To induced normal voiding
(8:01 am) May not reinsert IV

no longer require for medical
management
Prior to discharge
October 1, 2023 Change omeprazole IV to oral
(9:15 am) 40mg/tab Changed to oral medication
Stable vital signs
To provide medication at home
To relieve the pain
(9:15 am) Change furosemide IV to Oral

40mg/tab 1 tab BID Inhibits the reabsorption of sodium and
distal renal tube

and calcium
Promote diuresis
Change to oral medication
To provide medication at home
October 02, 2023 Discontinue ceftriaxone

(9:47 am) No longer require antibiotics
Chest X-ray new infiltrates

Regression of congestions
treatment for sepsis no longer require
(3:07 pm) May go home pulmo wise

No longer require inpatient treatment
To facilitate a transition in care

Take home medications: Levofloxacin 750mg/BID once every
(4:36 pm) other day (after dinner) until October 6 Prevent from the growth of bacteria
only
To treat variety of bacterial infection
Fluimucil 600mg/tb in ¼ glases H20

until October 4 only Expectorant
Breaking up the congestions, thins and

loosen phlegm from the airways
To relieve symptoms such as tightness of

chest, shortness of breath, wheezing and
coughing.
Glycoair TID/50mg/cap 1cap via

inhale OD Bronchodilator
To relieve symptoms and reduce

exacerbation with COPD
Pulmodual neb TID x 5days then as

needed for difficulty of breathing Relaxing muscles around airways
To treat airway obstruction
Please give them copies of worksup

done (including sputums) To provide the information regarding
their health
May use as reference

Follow up after 2 weeks
Text 09093392708/09092004787 for Ensure that the recommended course of
appointment treatment is followed
To increase the likelihood of a positive

management outcome
For further monitoring, management,

and evaluation of the patient’s condition
Additional home medications: Budecort 200mg turbuhaler BID,

gargle after use to provide medication at home
To prevent wheezing and shortness of

breath
May go home
No longer require inpatient treatment
To facilitate a transition in care
Apixaban 5mg tab ½ tab BID

Anticoagulant (blood thinner)
Decrease the thickness of the blood
Reduce the risk of stroke and systemic

embolism
Entresto 50 mg/tab
Relaxes blood vessels, improves blood
flow, and reduces stress on the heart
Treatment of patient with heart failure
Reduce ejection fraction to lower the risk

of cardiovascular death
Rosuvastatin 100mg tab

Lower bad cholesterol and fats
Raise good cholesterol in the blood
Helps reduced the amount of cholesterol

made by the liver
Dopezil 10mg tab OD

Treatment of vascular dementia
Clopidogrel 15mg tab BID

Blood thinner medication
Stop platelets from clumping up together

and forming blood clots
Helps prevent heart attacks and strokes
Trimetazidine 15mg Tab BID

Helps to maintain the energy metabolism
of heart muscle, protecting them from
the effects of reduced oxygen supply
Prevent and treat symptoms of angina

Glyxambi 10mg/5mg tab OD
Helps lower blood sugar
Improved blood sugar in patient with

T2DM
Ismodin 30mg tab OD

Due to congestive heart failure
To prevent angina and treatment of

coronary heart disease and congestive
heart failure
Isordil 50mg tab prn

Relaxes and widens blood vessels
therefore blood can easily flow to the
heart
Prevent angina in patient with CHF
Furosemide 40 mg tab BID

distal renal tube

and calcium
Promote diuresis

Follow up after 1 week
To ensure that the recommended course
Telephone order by dr. Bugarin of treatment is followed
To increase the likelihood of a positive

management outcome
For further monitoring, management,

and evaluation of the patient’s condition
DIAGNOSTIC
EXAMINATION
ARTERIAL BLOOD GAS
September 25,2023 FI02: 10 LMP Via Facemask

1:53PM Site: Right Radial Artery
Seq #: 17521
REFERENCE RESULT ANALYSIS

RANGE
CHF
pH 7.35-7.45 7.086
Decreased Atrial and Pulmonary
Pressure
Decreases regulatory substances

pCO2 35-45 mmHg 53.3
Decreased Plasma Volume
Reduced renal flow
HCO3 22-26 mEq/L 15.7 Altered kidney excretion
Accumulation of Acid
Decreased pH and HCO3 level
Metabolic Acidosis
pO2 80-100 mmHg 101.1 Respiratory dysfunction

(Pulmonary Congestion)
Aberration in the respiratory system

equilibrium
Increased elimination of Carbon

dioxide from the body
Reduces alveolar pressure of carbon

dioxide
Higher oxygen levels.
O2 Sat. 97% 95.9 NORMAL

SEROLOGY
September 26,2023
12.02AM COVID -19 RAPID ANTIGEN TEST
QUANTITY 0.00 mIU/mL
REFERENCE RANGE 0.00 – 0.039 mIU/mL
INTERPRETATION NEGATIVE (-)
CULTURE AND SENSITIVITY TESTING RESULT
Specimen ETA: M2309019
Date of Collection September 26,2023
Organism Isolated MODERATE GROWTH OF STREPTOCOCCUS AGALACTIAE
Antimicrobial Susceptibility Testing
SENSITIVE TO INTERMEDIATE TO RESISTANT TO
Chloramphenicol Clindamycin Erythromycin

Meropenem Levofloxacin
Tetracycline Vancomycin
GRAM STAIN RESULT
Specimen ETA: M2309019
Date Received September 26,2023 / 11.06AM
Result:
WBC/LPF MODERATE
EPITHELIAL CELLS/LPF RARE
ORGANISM/OIF GRAM POSITIVE COCCI IN PAIRS: FEW
GRAM NEGATIVE BACILLI: FEW
CLINICAL CHEMISTRY
DATE TYPES OF NORMAL RESULT ANALYSIS

EXAMINATION VALUES
September 26,2023 Bacterial infection

12.32AM
Pneumonia
PROCALCITONIN 0.0 – 0.5 0.10
Inflammation
Tissue Damage
Sepsis
ALT/SGPT 0 - 50 27 NORMAL
AST/SGOT 14 - 50 31 NORMAL
URINALYSIS RESULT
DATE TYPES OF RESULT ANALYSIS

EXAMINATION
September 26,2023
01.50AM PHYSICAL EXAMINATION
COLOR LIGHT YELLOW NORMAL
T2 DM
Increased Glucose level

Appearance SLIGHTLY HAZY
Damaged blood vessels in the
kidneys
Kidney Damaged
Altered Kidney filtration
Build up glucose in the urine
Cloudy Appearance
Reaction/PH 6.0 NORMAL
Specific Gravity 1.010 NORMAL

MICROSCOPIC EXAMINATION
CHF
Pus Cells 18-22/hpf Reduced blood flow to the kidneys
Kidney damaged
Presence of infection
Inflammation
Accumulation of Pus
Pyuria
T2 DM
RBC 11-12/hpf Kidney damaged
Pyelonephritis
Altered kidney filtration
Infection in the kidney
Presence of Kidney Stones
Impact of stone on lining cells of the

Urinary Tract
Destruction of lining cells

in the Urinary Tract
Blood leaks into the Urine
Hematuria
CHEMICAL EXAMINATION
Kidney problem
Protein + Altered kidney function
Altered Filtration
Clogged Kidneys
Accumulation of waste
Proteinuria
Type II Diabetes Mellitus
Sugar ++++ Kidney damaged
Altered kidney function
Altered filtration
Glycosuria
Ketone NEGATIVE NORMAL

Pathogens invade Urinary tract
Leucocytes ++ Inflammation in Urinary tract
Urinary tract Infection
Leukocyturia
Nitrite NEGATIVE NORMAL

Urobilinogen NEGATIVE NORMAL
Bilirubin NEGATIVE NORMAL
T2 DM
Kidney damaged
Blood + Pyelonephritis
Altered kidney filtration
Infection in the kidney
Presence of Kidney Stones
Impact of stone on lining cells of the

Urinary Tract
Destruction of lining cells

in the Urinary Tract
Blood leaks into the Urine
Hematuria
HEMATOLOGY
DATE LABORATORY NORMAL ACTUAL ANALYSIS

RESULT RESULT

12.41AM
WBC 4.00 – 10.00 16.67 Pneumonia
(White Blood Cells)
Inflammation
Inflammatory response
Increased WBC level

Hematocrit 0.37 – 0.54 0.43 NORMAL
Hemoglobin 120 - 160 142 NORMAL
Disruption of body’s
Immune system
Segmenters 0.500 – 0.700 0.35 Bacterial infections
Compromised ability to
fight off infections.
Decreased Neutrophils
Bacterial Infections
Tissue Trauma
Lymphocytes 0.200 – 0.400 0.53 Inflammatory response
Increased blood flow

into Lymph nodes
Increased T
Lymphocytes influx
Increased Lymphocyte
Level
Monocytes 0.030 – 0.120 0.05 NORMAL
Body detects harmful

pathogens
Eosinophils 0.005 – 0.050 0.06
Presence of bacteria
Immune system
releases eosinophils
Eosinophilia
Elevated eosinophil
level
Basophils 0.000 – 0.010 0.01 NORMAL
Platelet count 150 - 450 308 NORMAL

ARTERIAL BLOOD GAS
September 26,2023
01.50AM FI02: 100% AC MODE
Site: Right Radial Artery
Seq #: 17522

RANGE
CHF
pH 7.35-7.45 7.250
Pressure
Decreases regulatory substances

pCO2 35-45 mmHg 34.8
Reduced renal flow
Altered kidney excretion

HCO3 22-26 mEq/L 14.9
Metabolic Acidosis
Respiratory dysfunction
(Pulmonary Congestion)
pO2 80-100 mmHg 252.2
Aberration in the respiratory system
equilibrium

Reduces alveolar pressure of carbon

dioxide
O2 Sat. 97% 99.5 NORMAL

CLINICAL CHEMISTRY
TYPE OF NORMAL ACTUAL ANALYSIS

September 26,2023 EXAMINATION RESULT RESULT
12.41AM
Albumin 35 - 50 45 NORMAL
Dehydration
Decreased fluid volume

Blood Urea 3.2 - 7.1 10.61
Nitrogen Impaired kidney function
Water retention
Kidney retains water
Lead to concentrated urine and

elevated urea nitrogen.
HF
Creatinine 71 - 133 272.9 Decreased Blood Flow
Congestion
Increased Pressure
Blood congestion in the kidneys
Kidney Damaged
Renal Dysfunction
Altered Filtration
Accumulation of Creatinine
Elevated Creatinine level
Hemoglucotest 60 - 130 181 Impaired glucose

metabolism
Fails to produce enough

insulin in the body
Presence of glucose
in the blood
Elevated HemaGlucose
Ionized calcium 1.13 - 1.32 1.17 NORMAL
Serum Sodium 135 - 148 138.6 NORMAL
Serum Potassium 3.5 - 5.1 3.74 NORMAL
Serum Magnesium 1.6 - 2.3 2.30 NORMAL
Troponin I ES 0.0-0.120 0.062 NORMAL
HEMATOLOGY
DATE LABORATORY NORMAL ACTUAL ANALYSIS

RESULT RESULT

05:44AM
WBC 4.00 – 10.00 16.15 Pneumonia
(White Blood Cells)
Inflammation
Inflammatory
response
Increased WBC level
Hematocrit 0.37 – 0.54 0.37 NORMAL
Hemoglobin 120 - 160 122 NORMAL
Bacterial infection
Segmenters 0.500 – 0.700 0.89 Bone marrow

increases production
of neutrophils
Ongoing bacterial
infection
Increased Segmenters
Bacterial Infections
Lymphocytes 0.200 – 0.400 0. 06 Tissue Trauma
Inflammatory
response
Increased blood flow

into Lymph nodes
Increased T
Lymphocytes influx
Increased
Lymphocyte Level
Monocytes 0.030 – 0.120 0.03 NORMAL
Eosinophils 0.005 – 0.050 0.02 Corticosteroids
Activation of body’s
stress response
Weakened immune
system
Reduced eosinophils
production
Basophils 0.000 – 0.010 0.00 NORMAL
Platelet count 150 - 450 271 NORMAL
CLINICAL CHEMISTRY
TYPE OF NORMAL ACTUAL ANALYSIS

September 27,2023 EXAMINATION RESULT RESULT
05:44AM
HF
Creatinine 71 - 133 285.8 Decreased Blood Flow

Congestion
Increased Pressure
Blood congestion in the kidneys
Kidney Damaged
Renal Dysfunction
Altered Filtration
Accumulation of Creatinine
Elevated Creatinine level
Hemoglucotest 60 - 130 192 Impaired glucose metabolism
Fails to produce enough insulin

in the body
Presence of glucose in the blood
Elevated Hemaglucose
Serum Potassium 3.5 - 5.1 3.36 NORMAL
X-RAY
September 28,2023
10.10AM
Procedure:
CHEST AP SITTING PORTABLE (ADULT)
Findings:
COMPARISON: 09/26/2023
The endotracheal tube is observed in place.

There is an interval regression of the bilateral lung opacities ascribed to pulmonary
edema.
Correlate clinically and with laboratory parameters. Please follow-up accordingly.
Heart is magnified.
Atheromatous aorta.
No other significant findings of note.
ARTERIAL BLOOD GAS

September 28,2023 FI02: 30% VIA MV

10.46AM Site: Right Radial Artery
Seq #: 17530

RANGE
CHF
pH 7.35-7.45 7.37
Pressure
29.2 Decreases regulatory substances

pCO2 35-45 mmHg
Reduced renal flow

HCO3 22-26 mEq/L 16.6
Altered kidney excretion
Metabolic Acidosis
Respiratory dysfunction
pO2 80-100 mmHg 110.9 (Pulmonary Congestion)
Aberration in the respiratory

system equilibrium

Reduces alveolar pressure of

carbon dioxide
O2 Sat. 97% 98.0% NORMAL

DRUG STUDY
DRUG STUDY: OMEPRAZOLE

Drug Name Mechanism of Action Indication Contraindication Side Effect Nursing Considerations
Generic Name: inhibits proton pump To treat excess stomach Contraindicated in patients Headache Independent
Omeprazole activity by binding to acid caused by other with hypersensitivity to the ● Assess respiratory
hydrogen- potassium medications drug status, including
Brand Name: adenosine triphosphatase respiratory rate and
Prilosec rhythm; note
to suppress gastric acid evidence of cough,
Classification: secretion hoarseness, and
proton-pump inhibitors epistaxis, to
monitor for
Dosage: potential adverse
40 mg effects of the
drugs.
Date Ordered: ● Monitor other CNS
September 26, 2023 side effects
(drowsiness,
Route: IV fatigue, weakness,
headache), and
Frequency: OD report severe or
prolonged effects.
● Monitor any chest
pain and attempt to
determine if pain is
drug induced or
caused by
cardiovascular
dysfunction.
Dependent
● Advise patient to
notify doctor
immediately if
they have
abdominal pain or
diarrhea.
Health Teaching:
● Take this
medication by
mouth as
prescribed usually
30 minutes before
meals and at
bedtime.
● Tell the patient that
he may get dizzy
or drowsy with this
drug, tell him not
to sit or stand
quickly.
DRUG STUDY: IPRATROPIUM BROMIDE/ ALBUTEROL

Generic Name: Ipratropium inhibit acetylcholine To treat air flow blockage Contraindicated in patients Headache Independent
bromide/albuterol with hypersensitivity to the ● Assess respiratory
work by relaxing the drug status of patients.
Brand Name: muscles in the airways ● Monitor patient’s
DuoNeb oxygen saturation.
the relaxation causes the ● Assess the patient's
Classification: airways to open up and the heart rate.
Bronchodilators bronchial tubes to widen ● Assess the patient's
blood pressure.
Dosage:
Ipratropium bromide- 0.5 mg Dependent
Albuterol- 3 mg ● Be alert for signs
of allergic
Date Ordered: reactions,
September , 26, 2023 including
pulmonary
Route: symptoms
Inhale by mouth (tightness in the
throat and chest,
Frequency: q6 wheezing, cough,
dyspnea) or skin
reactions (rash,
pruritus, urticaria).
Notify physician or
nursing staff
immediately if
these reactions
occur.
Health Teaching:
● Patients should
remain compliant
with the
medication dosing
regimen.
● Individuals should
contact their
healthcare provider
if they experience
ongoing shortness
of breath
unrelieved with
medication
therapy.
● If using an inhaler,
the patient should
be sure to prime
the inhaler prior to
administering the
dose of
medication.
● The medication
can cause an
unusual taste in the
mouth, so patients
should rinse their
mouth with water
after each use.
DRUG STUDY: HYDROCORTISONE
Generic Name: inhibiting the release of To reduce pulmonary Contraindicated in patients Headache Independent
Hydrocortisone secretagogue from inflammation in severe with hypersensitivity to the ● Monitor patient’s
macrophages pneumonia, preventing drug weight, bp, and
Brand Name: respiratory failure electrolyte levels.
Alphosyl calming down your body's ● Patient with
immune response diabetes may need
Classification: increased insulin;
corticosteroids reduce the mucus secretion monitor glucose
level.
Dosage:
100 mg Dependent
● Monitor intake and
Date Ordered: output ratios.
September 26, 2023 Observe patient for
peripheral edema,
Route: steady weight gain,
IV rales/crackles, or
dyspnea. Notify
Frequency: q8 health care
professionals
should these occur.
Health Teaching:
● Corticosteroids
cause
immunosuppressio
n and may mask
symptoms of
infection. Instruct
patient to avoid
people with known
contagious
illnesses and to
report possible
infections
immediately.
● Review side
effects with
patient. Instruct
patient to inform
health care
professionals
promptly if severe
abdominal pain or
tarry stools occur.
Patient should also
report unusual
swelling, weight
gain, tiredness,
bone pain,
bruising, non
healing sores,
visual
disturbances, or
behavior changes.
DRUG STUDY: FUROSEMIDE

Generic Name: inhibit a transport system To treat high blood Contraindicated in patients Headache Independent
Furosemide that moves sodium pressure (hypertension), with hypersensitivity to the ● Monitor electrolyte
heart failure and a build up drug levels, particularly
Brand Name: this means you have less of fluid in the body potassium, sodium,
Lasix fluid in your tissues which (edema). and magnesium.
helps get rid of swelling ● Regularly monitor
Classification: (edema) blood pressure,
loop diuretics heart rate, and
you will also have less respiratory rate.
Dosage: fluid in your blood, which Furosemide’s
40 mg helps reduce blood primary action is to
pressure reduce fluid
Date Ordered: volume, leading to
September 26, 2023 potential changes
in blood pressure
Route: IV and heart rate.
● Assess renal
Frequency: q12 function through
laboratory tests,
such as serum
creatinine and
estimated
glomerular
filtration rate
(eGFR).
Dependent
● Emphasize the
need to follow any
dietary
modifications,
such as a low-
sodium diet, as
prescribed.
Health Teaching:
● Explain to the
patient why
furosemide has
been prescribed to
them. Describe its
role as a diuretic
medication that
helps eliminate
excess fluid from
the body, reducing
symptoms such as
edema or shortness
of breath.
● Provide clear
instructions on
how to take
furosemide,
including the
recommended
dosage, frequency,
and timing.
DRUG STUDY: CEFTRIAXONE

Generic Name: inhibition of bacterial cell To treat bacterial infections Contraindicated in patients Headache Independent
Ceftriaxone wall synthesis in many different parts of with hypersensitivity to the ● Asses BUN and
the body drug creatinine levels in
Brand Name: binding to penicillin- clients with renal
Rocephin binding proteins impairment.
● Monitor VS, I&O,
Classification: leading to cell lysis and bleeding.
cephalosporin antibiotics death ● If client is diabetic
monitor glucose
Dosage: levels.
2g Dependent
● Watch for seizures;
Date Ordered: notify physician
September 26, 2023 immediately if
patient develops or
Route: IV increases seizure
activity.
Frequency: OD
Health Teaching:
● Tell the patient to
report adverse
reactions promptly.
● Instruct patient to
report discomfort
at IV insertion site.
● If patient with
diabetes is
receiving home
care and is testing
urine for glucose,
tell patient patient
drug may affect
results of cupric
sulfate tests and to
use an enzymatic
tes instead.
● Tell patient to
notify prescriber
about loose stools
or diarrhea.
DRUG STUDY: APIXABAN

Generic Name: it makes your blood flow To help prevent strokes or Contraindicated in patients Headache Independent
Apixaban through your veins move blood clots in people who with hypersensitivity to the ● Assess patient for
easily have atrial fibrillation drug symptoms of
Brand Name: stroke, DVT, PE,
Eliquis which means your blood is bleeding, or
less likely to make blood peripheral vascular
Classification: clots disease
factor Xa inhibitors periodically during
therapy.
Dosage: ● Obtain baseline
5mg status for complete
blood count and
Date Ordered: clotting studies to
September 26, 2023 determine any
potential adverse
Route: PO effects
● Conduct thorough
Frequency: BID physical
assessment before
beginning drug
therapy to establish
baseline status,
determine
effectivity of
therapy, and
evaluate potential
adverse effects.
Dependent
notify health care
professional of
medication
regimen prior to
treatment.
Health Teaching:
● Warn patient not to
discontinue drug
with-out talking to
prescriber, because
of risk of clot
formation and
stroke.
● Tell patient to
report all adverse
reactions, caution
patient that
bruising or
bleeding may
occur more easily.
report unsual
bleeding.
take apixaban as
directed. Take
missed doses as
soon as
remembered on the
same day and
resume twice daily
administration; do
not double doses.
DRUG STUDY: DOMPERIDONE

Generic Name: blocks dopamine receptors To treat nausea and Contraindicated in patients Headache Independent
Domperidone in the gut and in the part of vomiting, including when with hypersensitivity to the ● Assess for nausea,
the brain linked to it is caused by headaches drug vomiting,
Brand Name: vomiting abdominal
Motilium distention, and
the chemoreceptor trigger bowel sounds
Classification: zone, located just outside before and after
dopamine antagonists the blood brain barrier administration.
● Monitor BP
Dosage: results in increased (sitting, standing,
10 mg esophageal and gastric lying down) and
peristalsis, such that food pulse before and
Date Ordered: moves more quickly periodically during
September 26, 2023 through the stomach and therapy.
into the intestine ● Monitor signs of
Route: PO abdominal
discomfort such as
Frequency: TID epigastric pain or
abdominal
fullness.
Dependent
● Instruct the patient
to take as directed.
Health Teaching:
● Take this
medication by
mouth as
prescribed usually
30 minutes before
meals and at
bedtime.
● Do not increase
your dose or take
this more.
● Tell the patient that
he may get dizzy
or drowsy with this
drug, tell him not
to sit or stand
quickly.
DRUG STUDY: SACUBITRIL/ VALSARTAN

Generic Name: relaxes blood vessels To treat patients with Contraindicated in patients Headache Independent
Sacubitril / Valsartan chronic heart failure with hypersensitivity to the ● Assess blood
improves blood flow drug pressure
Brand Name: periodically and
Entresto reduces stress on the heart compare it to
normal values.
Classification: ● Assess signs and
it helps to improve your
angiotensin receptor symptoms of CHF
heart's ability to pump
neprilysin inhibitor (ARNI) (dyspnea,
blood to the body
rales/crackles,
Dosage: peripheral edema,
50mg jugular venous
distention, exercise
Date Ordered: intolerance) to help
September 26, 2023 document whether
drug therapy is
Route: PO effective in
reducing these
Frequency: BID symptoms.
Dependent
● Assess dizziness
that might affect
gait, balance, and
other functional
activities. Report
balance problems
and functional
limitations to the
physician, and
caution the patient
and
family/caregivers
to guard against
falls and trauma.
Health Teaching:
● Implement aerobic
exercise and
cardiac
conditioning
programs to
augment drug
therapy and
maintain or
improve
cardiovascular
pump function in
patients with heart
failure and other
cardiac conditions.
● Use caution during
aerobic exercise
and other forms of
therapeutic
exercise in patients
recovering from
myocardial
infarction. Assess
exercise tolerance
frequently (blood
pressure, heart
rate).
DRUG STUDY: NEBIVOLOL

Generic Name: affecting the response to To treat hypertension Contraindicated in patients Headache Independent
Nebivolol nerve impulses in certain with hypersensitivity to the ● Assess blood
parts of the body, like the drug pressure
Brand Name: heart periodically and
Nebil compare to normal
heart beats slower values to help
Classification: document
beta blockers decreases the blood antihypertensive
pressure effects.
Dosage: ● Assess dizziness
5 mg that might affect
the amount of blood and
gait, balance, and
oxygen is increased to the
Date Ordered: other functional
heart
September 26, 2023 activities.
● Monitor excessive
Route: PO fatigue or
weakness. Beta
Frequency: OD blockers often
cause some degree
of fatigue and
weakness, but any
sudden or severe
change in muscle
strength or energy
levels should be
reported.
Dependent
● Report balance
problems and
functional
limitations to the
physician, and
caution the patient
and
family/caregivers
to guard against
falls and trauma
Health Teaching:
● Remind patients to
take medication as
directed to control
hypertension even
if they are
asymptomatic.
● Counsel patients
about additional
interventions to
help control blood
pressure such as
regular exercise,
weight loss,
sodium restriction,
stress reduction,
moderation of
alcohol
consumption, and
smoking cessation.
DRUG STUDY: KETOPROFEN

Generic Name: inhibition cylooxygenase-2 To treat pain caused by Contraindicated in patients Headache Independent
Ketoprofen (COX-2), an enzyme inflammation with hypersensitivity to the ● Assess the patient's
involved in prostaglandin drug pain level and
Brand Name: synthesis range of motion
Ketocid prior to and
via the arachidonic acid following
Classification: pathway administration of
non-steroidal anti- ketoprofen.
inflammatory drugs this results in decreased ● Monitor the patient
(NSAIDs) levels of prostaglandins for signs and
that mediate pain and symptoms of GI
Dosage: inflammation upset, such as
200 mg nausea, vomiting,
diarrhea, and
Date Ordered: abdominal pain.
September 26, 2023 ● Monitor the
patient's
Route: PO cardiovascular
status and renal
Frequency: TID function,
especially in
patients with risk
factors for these
conditions.
Dependent
● Monitor the patient
for signs and
symptoms of
bleeding, such as
black, tarry stools,
hematemesis, and
melena.
Health Teaching:
● Educate the patient
about the potential
side effects of
ketoprofen and
what to do if they
experience any
side effects.
● Advise the patient
to take ketoprofen
with food to reduce
the risk of GI upset
to avoid taking
ketoprofen with
other NSAIDs or
aspirin, as this can
increase the risk of
bleeding.
DRUG STUDY: ROSUVASTATIN

Generic Name: blocking an enzyme that is To prevent heart disease, Contraindicated in patients Headache Independent
Rosuvastatin needed by the body to including heart attacks and with hypersensitivity to the ● Monitor CV status,
make cholesterol strokes. drug especially with a
Brand Name: known history of
Lustatin stopping the liver from hypertension or
making cholesterol heart disease.
Classification: ● Assess any joint
HMG-CoA reductase this reduces the amount of pain or muscle
inhibitors (statins) cholesterol in the blood pain, tenderness, or
weakness,
Dosage: especially if
10mg accompanied by
fever, malaise, and
Date Ordered: dark-colored urine.
September 26, 2023 ● Advise patient that
these symptoms
Route: PO may represent
drug-induced
Frequency: OD HS myopathy, and that
myopathy can
progress to severe
muscle damage
(rhabdomyolysis).
Dependent
● Report any
unexplained
musculoskeletal
symptoms to the
physician
immediately, and
suspend exercise
and gait training
until these
symptoms can be
evaluated.
Health Teaching:
● Counsel patients
about additional
interventions to
help control lipid
disorders and
improve
cardiovascular
health, including
dietary
modification,
regular exercise,
moderation of
alcohol
consumption, and
smoking cessation.
● Instruct patient and
family/caregivers
to report other
troublesome side
effects such as
severe or
prolonged skin
rash or GI
problems such as
nausea,
constipation, and
abdominal pain.
DRUG STUDY: INSULIN GLARGINE

Generic Name: replacing the insulin that is To lower blood sugar Contraindicated in patients Headache Independent
Insulin glargine normally produced by the levels in patients with type with hypersensitivity to the ● Monitor blood
body 2 diabetes mellitus drug glucose levels
Brand Name: during dosage
Toujeo move sugar from the blood changes, which
into other body tissues may predispose
Classification: where it is used for energy patient to
long-acting insulins hypoglycemia or
stops the liver from hyperglycemia.
Dosage: producing more sugar ● Monitor patient for
26 units worsening
glycemic control
Date Ordered: or failure to
September 26, 2023 achieve targeted
glycemic control,
Route: SQ significant
injection-site
Frequency: OD reactions, or
allergic reactions,
as they may
indicate antibody
formation.
Consider
alternative
antidiabetic
therapy.
Dependent
● Always check
insulin label before
giving drug, as
accidental mix-ups
among insulin
products have been
reported.
Health Teaching:
● Inform patient that
serious
hypersensitivity
reactions,
including
anaphylaxis, have
been reported.
Instruct the patient
to stop drug and
immediately seek
medical attention
for signs and
symptoms of
hypersensitivity
reactions.
● Inform patient of
risk of worsening
renal function,
which may require
dialysis.
● Instruct patient on
self-management
procedures,
including glucose
monitoring and
management of
hypoglycemia and
hyperglycemia.
DRUG STUDY: TAMSULOSIN HYDROCHLORIDE

Generic Name: inhibits alpha adrenergic To help increase the flow Contraindicated in patients Headache Independent
Tamsulosin Hydrochloride receptors of urine with hypersensitivity to the ● Monitor patients
drug for decreased BP.
Brand Name: relaxing the muscles in Drug may cause
Tamzor your bladder and prostate orthostatic
hypotension and
Classification: this helps improve the flow syncope, especially
alpha blockers of your urine with the first dose.
● To minimize
Dosage: orthostatic
400 mcg hypotension,
advise patient to
Date Ordered: move slowly when
September 26, 2023 assuming a more
upright position.
Route: PO Dependent
Frequency: OD that might affect
gait, balance, and
other functional
activities. Report
balance problems
and functional
limitations to the
physician, and
caution the patient
and
family/caregivers
to guard against
falls and trauma.
Health Teaching:
● Instruct patient not
to crush, chew, or
open capsules.
● Advise patient that
drug may cause
sudden drop in BP,
especially after
first dose or when
changing doses.
Tell the patient to
rise slowly from a
chair or bed when
starting therapy
and to avoid
situations in which
injury could occur
as a result of
fainting.
take drug about 30
minutes after the
same meal each
day.
DRUG STUDY: DONEPEZIL

Generic Name: slows the breakdown of a To improved functional Contraindicated in patients Headache Independent
Donepezil chemical called recovery in the immediate with hypersensitivity to the ● Monitor patient for
acetylcholine in the brain post-stroke period drug evidence of active
Brand Name: or occult GI
Aricept sends messages between bleeding.
nerve cells and the brain ● Monitor
Classification: cardiovascular
cholinesterase inhibitors improves communication status.
between nerve cells in the ● Monitor carefully
Dosage: brain patients with a
10 mg history of asthma
or obstructive
Date Ordered: pulmonary disease.
September 26, 2023
Dependent
Route: PO ● When
administering
Frequency: OD donepezil, nurses
should be sure to
administer with
food in order to
minimize GI upset.
Health Teaching:
● Tell the caregiver
to give drug just
before patient’s
bedtime.
● Tell the patient and
caregiver not to
break or crush
tablets.
avoid OTC cold or
sleep remedies
because of risk of
increased anti-
cholinergic effects.
DRUG STUDY: CLOPIDOGREL

Generic Name: reduces the ability of the To prevent platelets (a type Contraindicated in patients Headache Independent
Clopidogrel platelets to stick together of blood cell) from with hypersensitivity to the ● Assess blood
collecting and forming drug pressure
Brand Name: reduces the risk of clots clots that may cause a heart periodically and
Plavix forming attack or stroke compare it to
normal values.
Classification: this protects you from ● Be alert for signs
antiplatelet medications having a stroke or heart of GI bleeding
attack signs (abdominal
Dosage: pain, vomiting
75 mg blood, blood in
stools, black/tarry
Date Ordered: stools) or other
September 26, 2023 signs of bleeds
(bleeding gums,
Route: PO nosebleeds,
unusual bruising,
Frequency: OD hematuria; fall in
hematocrit or
blood pressure).
● Monitor signs of
thrombotic
thrombocytopenic
purpura, such as
purplish spots on
the skin, decreased
consciousness,
fatigue, weakness,
shortness of breath
on exertion, and
tachycardia.
Dependent
hypersensitivity
reactions,
including
pulmonary
symptoms
(tightness in the
throat and chest,
wheezing, cough,
dyspnea) or skin
reactions (rash,
Notify physician or
nursing staff
immediately if
these reactions
occur.
Health Teaching:
notify prescriber if
unusual bleeding
or bruising occurs.
inform all health
care providers,
including dentists,
before undergoing
procedures or
starting new drug
therapy, about
taking drug.
● Inform patient that
drug may be taken
with-out regard to
meals
DRUG STUDY: TRIMETAZIDINE

Generic Name: it helps metabolize fatty To prevent and treat the Contraindicated in patients Headache Independent
Trimetazidine acids, which helps your symptoms of angina with hypersensitivity to the ● Assess the patient's
body use oxygen drug vital signs and
Brand Name: cardiac status
Vastarel allows for more blood flow regularly.
to your heart ● Monitor the patient
Classification: for signs and
coronary vasodilator limits quick changes in symptoms of side
your blood pressure effects, such as
Dosage: headache,
35 mg dizziness, nausea,
this can help lessen chest
diarrhea, tremors,
pain from blocked blood
Date Ordered: stiffness, and
vessels
September 26, 2023 slowness of
movement.
Route: PO ● Review the
patient's
Frequency: BID medication list
with them to
identify any
potential
interactions with
trimetazidine.
Dependent
● Encourage the
patient to report
any side effects
they experience to
their doctor.
Health Teaching:
to take
trimetazidine
exactly as
prescribed by their
doctor and to avoid
taking more or less
of it than
prescribed.
● Instruct the patient
to take
trimetazidine with
food to reduce the
risk of stomach
upset.
to avoid alcohol
while taking
trimetazidine, as
this can increase
the risk of side
effects.
DRUG STUDY: EMPAGLIFLOZIN/ LINAGLIPTIN

Generic Name: increasing the removal of To lower blood sugar Contraindicated in patients Headache Independent
Empagliflozin / Linagliptin sugar by your kidneys levels in patients with type with hypersensitivity to the ● Assess the patient's
2 diabetes mellitus drug blood sugar levels
Brand Name: increasing levels of natural regularly.
Glyxambi substances called incretins ● Monitor patients
for signs and
Classification: incretins help to control symptoms of
a combination of an blood sugar by increasing dehydration, such
inhibitor of the sodium- insulin release as thirst, decreased
glucose co-transporter urination, fatigue,
(SGLT2) and an inhibitor and confusion.
of the dipeptidyl peptidase- ● Be aware of the
4 (DPP-4) enzyme potential for
hypoglycemia (low
Dosage: blood sugar),
10mg/5mg especially in
patients who are
Date Ordered: taking other
September 26, 2023 diabetes
medications.
Route: PO
Dependent
Frequency: OD ● Instruct the patient
to monitor their
blood sugar levels
regularly and to
report any low
blood sugar levels
to their doctor
immediately.
Health Teaching:
about what
Glyxambi is used
for, how to take it,
and what to expect
in terms of side
effects.
● Counsel patients to
avoid alcohol
while taking
Glyxambi.
about the
importance of
staying hydrated.
112
DRUG STUDY: ISOSORBIDE MONONITRATE

Generic Name: widening blood vessels To prevent angina and Contraindicated in patients Headache Independent
Isosorbide Mononitrate (veins and arteries) treatment of coronary heart with hypersensitivity to the ● Assess heart rate,
disease and congestive drug ECG, and heart
Brand Name: increases the blood supply heart failure sounds,
Ismodin to your heart ● If used to treat
CHF, assess signs
Classification: which gets more oxygen to and symptoms
nitrate class your heart muscles (dyspnea,
rales/crackles,
Dosage: peripheral edema,
reduces chest pain
30 mg jugular venous
distention, exercise
Date Ordered: intolerance) to help
September 26, 2023 document whether
drug therapy is
Route: PO effective in
reducing these
Frequency: OD symptoms.
● Report signs of
drug tolerance
during long-term
use, as indicated
by increased
episodes of angina
or CHF symptoms.
Dependent
and syncope that
might affect gait,
balance, and other
functional
activities. Report
balance problems
and functional
limitations to the
physician, and
caution the patient
and
family/caregivers
to guard against
falls and trauma.
Health Teaching:
● Educate patients
about the
importance of
adhering to their
medication
regimen.
Isosorbide
mononitrate is
most effective
when taken on a
regular basis.
Educate patients
about the
importance of
taking their
medication even
when they are
feeling well.
● Be aware of the
potential for drug
interactions.
Isosorbide
mononitrate can
interact with a
number of other
medications,
including
antihypertensives,
antidepressants,
and other
vasodilators.
Review the
patient's
medication list
carefully and
educate the patient
about any potential
drug interactions.
DRUG STUDY: ISOSORBIDE DINITRATE
Generic Name: relaxing the blood vessels To prevent and treatment Contraindicated in patients Headache Independent
Isosorbide dinitrate of angina pectoris due to with hypersensitivity to the ● Monitor BP,HR,
increasing the supply of coronary artery disease drug and intensity and
Brand Name: blood and oxygen to the duration of drug
Isordil heart response.
● Drug may cause
Classification: reducing its workload headache,
nitrate class especially at the
beginning of
prevents angina attacks
Dosage: therapy. Dosage
from occurring
5 mg may be reduced
temporarily, but
Date Ordered: tolerance usually
September 26, 2023 develops.Treat
headache with
Route: PO aspirin or
acetaminophen.
Frequency: PRN ● Assess for
orthostatic
hypotension.
Dependent
● Take drug as
prescribed and to
keep accessible at
all times.
Health Teaching:
● Advise patient on
isosorbide dinitrate
to take oral tablet
on an empty
stomach either 30
minutes before 1 to
2 hours after meals
and to swallow
oral tablets whole.
change to an
upright position
slowly, to climb
stairs carefully,
and to lie down at
first sign of
dizziness.
● Caution patient to
avoid alcohol
because it may
worsen low BP
effects
DRUG STUDY: POTASSIUM CHLORIDE
Drug Name Mechanism of Indication Contraindication Side Effect Nursing Considerations
Action
Generic Name: replacing lost To prevent or to treat Contraindicated in patients with Headache Independent
Potassium Chloride potassium low blood levels of hypersensitivity to the drug ● Assess the patient's
potassium serum potassium level
Brand Name: increased potassium before administering
Kalium Durules levels in blood potassium chloride.
Potassium chloride
Classification: increased should not be
electrolyte extracellular administered if the
supplement potassium levels patient has
hyperkalemia (high
Dosage: potassium level).
750 mg ● Monitor the patient's
vital signs, cardiac
Date Ordered: rhythm, and respiratory
September 27, 2023 rate closely while
administering
Route: PO potassium chloride.
Potassium chloride can
Frequency: TID cause cardiac
dysrhythmias and
respiratory arrest,
especially if it is
administered too
quickly or in too high
of a dose.
● Monitor the patient's
fluid intake and output.
Hyperkalemia can
occur if the patient is
dehydrated or if they
have kidney failure.
Dependent
● Teach the patient about
the signs and
symptoms of
hyperkalemia, and
instruct them to notify
their healthcare
provider immediately
if they experience any
of these symptoms.
Health Teaching:
● Tell the patient to take
with or after meals
with a full glass of
water to lessen GI
distress.
● Advise the patient to
eat a diet that is rich in
potassium-rich foods,
such as bananas,
oranges, and potatoes.
DRUG STUDY: BUDESONIDE

Generic Name: preventing inflammation To control and prevent Contraindicated in patients Headache Independent
Budesonide (swelling) symptoms (wheezing and with hypersensitivity to the ● Assess the patient's
shortness of breath) caused drug respiratory status
Brand Name: open up narrowed by ongoing lung disease before
Rhinocort breathing passages administering
budesonide
Classification: calming down your inhalation.
corticosteroid class immune system Budesonide
inhalation should
Dosage: not be
0.5 mg/ 2mL administered to
patients with
Date Ordered: severe
September 27, 2023 bronchospasm or
respiratory
Route: Inhalation distress.
● Assess muscle
Frequency: q8 strength
periodically during
longterm use.
Although
inhalation reduces
the risk of systemic
musculoskeletal
damage, some
degree of
weakness and bone
loss may still occur
during prolonged,
extensive use.
● Monitor the patient
for any adverse
effects after
administering
budesonide
inhalation.
Budesonide
inhalation is
generally well-
tolerated, but it can
cause side effects
such as oral thrush,
hoarseness, and
cough.
Dependent
● Observe for
paradoxical
bronchospasm
(cough, wheezing,
dyspnea),
especially at higher
or excessive doses.
If condition occurs,
advise patient to
withhold
medication and
notify physician
immediately.
Health Teaching:
● Counsel patient on
proper use of
inhalation
techniques
(nebulizer, powder
inhalers, nasal
sprays); observe
administration
whenever possible
to ensure proper
technique.
about the
importance of
adhering to their
medication
regimen and the
risks of adverse
effects.
Budesonide
inhalers and nasal
sprays are most
effective when
taken on a regular
basis.
DRUG STUDY: TERAZOSIN
Generic Name: relaxing blood vessels To treat high blood Contraindicated in patients Headache Independent
Terazosin pressure with hypersensitivity to the ● Assess the patient's
blood passes through them drug blood pressure and
Brand Name: more easily heart rate before
Hytrin and after
decreases blood pressure administering
Classification: terazosin.
Alpha-blockers Terazosin can
cause a sudden
Dosage: drop in blood
2mg pressure,
especially when
Date Ordered: first started
September 28, 2023 therapy.
Route: PO about the signs and
symptoms of
Frequency: OD HS orthostatic
hypotension.
Orthostatic
hypotension is a
common side
effect of terazosin
that occurs when
the patient stands
up quickly.
● Be aware of the
potential for drug
interactions.
Terazosin can
interact with a
number of other
medications,
including
antihypertensives,
antidepressants,
and other
vasodilators.
Dependent
● To inform their
healthcare provider
of all other
medications they
are taking,
including over-the-
counter
medications and
herbal
supplements.
Health Teaching:
● Tell the patient not
to stop drug
suddenly but to
notify prescribe if
adverse reactions
occur.
● Warn patient to
avoid hazardous
activities that
require mental
alertness, such as
driving or
operating heavy
machinery, for 12
hours after first
dose.
DRUG STUDY: ACETYLCYSTEINE
Generic Name: breaks up the mucus in the To helps get rid of sticky Contraindicated in patients Headache Independent
Acetylcysteine respiratory tract and thick mucus that is with hypersensitivity to the ● Monitor signs of
obstructing the airway, drug bronchospasm and
Brand Name: reduces its viscosity resulting in coughing respiratory
Fluimucil irritation, including
making it easier to cough wheezing, cough,
Classification: up and clear from the lungs dyspnea, increased
mucolytic agents secretions, and
tightness in the
Dosage: chest and throat.
600 mg Report excessive
or prolonged
Date Ordered: respiratory
September 28, 2023 problems to the
physician.
Route: PO ● When used as a
mucolytic, assess
Frequency: OD the quantity and
consistency of
sputum to help
document whether
this drug is
successful in
reducing the
viscosity of
respiratory
secretions.
angioedema,
including rashes,
raised patches of
red or white skin
(welts),
burning/itching
skin, swelling in
the face, and
difficulty
breathing.
Dependent
● Monitor other
signs of allergic
reactions and
anaphylaxis,Signs
include pulmonary
symptoms
(tightness in the
throat and chest,
wheezing, cough,
dyspnea) and skin
reactions (rash,
Notify physician or
nursing staff
immediately if
these reactions
occur.
Health Teaching:
● Warn patient that
drug may have a
foul taste or smell
that may be
distressing.
● For maximum
effect, instruct the
patient to cough to
clear the airway.
DRUG STUDY: INDACATEROL/ GLYCOPYRRONIUM BROMIDE

Generic Name: activating targets called To relax the muscles in the Contraindicated in patients Headache Independent
Indacaterol / beta-2 receptors in the lungs and widening the with hypersensitivity to the ● Assess lung
Glycopyrronium bromide muscle cells airways (bronchi) drug sounds, pulse, and
BP before
Brand Name: relaxes the muscle around administration and
Glycoair Breezhaler the airways during peak of
into the lungs medication.
Classification: ● Monitor
Bronchodilators helps to keep the airways pulmonary
open function tests
Dosage: before initiating
50 mcg and periodically
during therapy to
Date Ordered: determine
September 29, 2023 effectiveness.
● Note the amount,
Route: Inhalation color, and
character of
Frequency: OD sputum produced.
Dependent
● Tell your doctor
right away if you
have a rash,
itching,
hoarseness, trouble
breathing, trouble
swallowing, or any
swelling of your
hands, face, or
mouth after using
this medicine.
Health Teaching:
notify prescriber of
worsening
symptoms,
decreased
effectiveness of
drug, or the need
for more frequent
use of a short-
acting inhaler.
● Instruct patient on
proper
administration,
use, storage of the
Breezhaler device
and capsules.
Remind patient to
use only the
Breezhaler device
and no other
inhaler to
administer the
medication.
NURSING CARE
PLAN
Ineffective tissue perfusion related to impaired of O2 across capillary membrane as evidenced by weak, capillary refill less than 3 second
Assessment Nursing Diagnosis Nursing Analysis Goal and Objective Intervention Rationale Evaluation
Subjective: Ineffective tissue Due to decreased After 8 hours of nursing Independent: Independent: Goal met. After 8 hours
perfusion related to cardiac output intervention, the client • Established Rapport • To gain client trust of nursing intervention,
“ Kinakapos kasi ako impaired of O2 across will demonstrate and cooperation the client manifested
ng hininga” as capillary membrane as increased perfusion regular and consistent
verbalized by the evidenced by weak, Decreased preload and with manifestation of • To establish baseline pulse rhythm.
patient capillary refill 3 second stroke volume regular pulse • Monitored and data
characteristics. recorded vital signs
Objective: • Monitored and • To determine fluid

• Alert, awake and Decreased blood recorded intake and Volume relative to
responsive pumped out from the output oxygen transportation
• capillary refill 3 blood and circulation
second
• weakness
• Vital Sign
T: 36.6 Decreased in stroke • Quiet atmosphere
PR: 65 volume • Advised restful, quiet conducive to rest
RR: 18 atmosphere alleviates stress which
Bp: 110/80 aids the heart in proper
function
Decrease perfusion
throughout the body
• Activities that requires

• Cautioned to avoid too much workload
activities that increase leads to heart stress
the heart work load
Dependent:
Dependent: • These medication
•Administered Kalium promote proper
Durule and erdosteine circulation and
as ordered transportation of O2
Ineffective Breathing Pattern related to Acute Pulmonary Congestion evidenced by dyspnea
Subjective: Ineffective Breathing Precipitating factors Long Term: Independent: Independent: Long Term:
Pattern related to Acute After 2 days of nursing Partially met
“Nahihirapan akong Pulmonary Congestion intervention, the patient • Established rapport • To gain client trust After 2 days of nursing
huminga” as verbalized evidenced by dyspnea Passes to the pharynx, will be able to: and cooperation intervention, the patient
by the patient. larynx, and trachea • Establish a normal/ will be able to:
effective respiratory • Monitored and • To establish baseline •Established a normal/
Objective: pattern as evidenced by recorded vital sign data effective respiratory
• Dyspnea absence of sign and pattern as evidenced by
• Observed physical Microorganisms enters symptoms of hypoxia. • Assess respiratory rate •Respiratory rate and absence of sign and
discomfort and affects lung and depth by listening rhythm changes are symptoms of hypoxia
• Use of accessory Short term: to lung sounds. early warning signs of
muscle After 8 hours of nursing impending respiratory Short Term:
• CPAP Oxygen 12 Bacteria infects the lung intervention, the patient difficulties • After 8 hours of
will be able to: nursing intervention,
• Verbalize awareness • These signify an the patient will be able
Inflammatory response of causative factors increase in work of to;
initiated • Demonstrate breathing • Verbalize awareness
appropriate coping of causative factors
behaviors like proper
breathing and coughing • Note muscles used for • Demonstrate
Cavity extends to
breathing • This is for good lung appropriate coping
bronchus
(sternocleidomastoid, excursion and chest behaviors like proper
diaphragmatic) and expansion breathing and coughing
retractions/ flaring of
Narrowing of air nostrils • This provides
passages adequate oxygenation
• Position client with to prevent patient from
proper body alignment ( desaturation
Difficulty breathing semi Fowler’s position)
• This prevents dyspnea
resulting from fatigue
• Ensure that oxygen • These promote deep
delivery system is inspiration
applied to the patient,

the appropriate amount
of oxygen is delivered
• These facilitate
adequate clearance of
secretions
• Pace and schedule

activities providing
adequate rest periods
• Encourage sustained
deep breaths by
emphasizing slow
inhalation, holding end
inspiration
• Teach client
appropriate deep
breathing and coughing
techniques
Dependent:
• Administer Dependent:
medication as indicated • This provides support
and sense of ease and
comfort to the patient
Collaborative:
• Administer oxygen at Collaborative:
lowest concentration • For management of
indicated underlying pulmonary
condition and
respiratory
• Refer the client to

dieticians and or
support groups. • For proper counseling
and intake of caloric
needs
Impaired gas exchange related to ventilation perfusion imbalance evidence by restless
Subjective: Impaired gas exchange Perfusion of the After 8 hours of nursing Independent: Independent: Partially when the
related to ventilation myocardium is often intervention the patient patient was able to
“Masakit ang dibdib perfusion imbalance will be able to: • Established rapport • To gain client trust demonstrate improved
ko, nahihirapan akong evidence by restless. •Demonstrate improved and cooperation ventilation and
huminga.” as Impaired with left ventilation and adequate oxygenation.
verbalized by the ventricular failure adequate oxygenation. • Monitored and • To establish baseline
patient Cardiac hypertrophy recorded vital signs data • Was able to
• Participate in a participate in a
Objective: treatment regimen • Elevated head of the • To maintain airway treatment regimen
Patient is restless. Rate, ( breathing exercises, bed / position client ( breathing exercises,
Blood ejected from the
rhythm and depth of effective coughing, use appropriately, provide effective coughing, use
left ventricle diminishes
breathing is abnormal. of oxygen) within level airway adjunct and • Promotes optimal of oxygen) within level
of ability/ situation. suction as indicated chest expansion and of ability/ situation.
Vital sign: drainage of secretion.
Bp: 110/80 Hypostatic pressure • Verbalize •Encouraged frequent • Was able to verbalize
PR: 65 builds in the pulmonary understanding of deep breathing / • Reveals presence of understanding of
T: 36.6 venous system causative factors and coughing exercises. pulmonary congestion / causative factors and
RR: 18 appropriate collection of secretion, appropriate
intervention. •Auscultated breath indicating need for intervention.
Result in fluid – filled sounds noting crackles, further intervention.
alveoli and pulmonary wheezes
congestion.
Dependent: Dependent:
• Administer • This provides support
medication as and a sense of ease and
prescribed. comfort to the patient.
Collaborative: Collaborative:
• Assisted with • To improve
procedure as respiratory function/
individually indicated oxygen carrying

capacity.
Ineffective Breathing Pattern related to Acute Pulmonary Congestion evidenced by dyspnea
Subjective: Ineffective Breathing Precipitating factors Long Term: Independent: Independent: Long Term:
Pattern related to Acute After 2 days of nursing After 2 days of nursing
“Nahihirapan akong Pulmonary Congestion intervention, the patient intervention, the patient
huminga” as verbalized evidenced by dyspnea Passes to the pharynx, will be able to: • Establish rapport •To gain client’s trust, will be able to:
by the patient. larynx, and trachea • Establish a normal/ and cooperation •Established a normal/
effective respiratory effective respiratory
Objective: pattern as evidenced by • Monitor and record • To establish baseline pattern as evidenced by
• Dyspnea absence of sign and vital signs data absence of sign and
• Observed physical Microorganisms enters symptoms of hypoxia. symptoms of hypoxia
discomfort and affects lung • Assess respiratory rate •Respiratory rate and
• Use of accessory Short term: and depth by listening rhythm changes are Short Term:
muscle After 8 hours of nursing to lung sounds early warning signs of • After 8 hours of
• CPAP Oxygen 12 Bacteria infects the lung intervention, the patient impending respiratory nursing intervention,
will be able to: difficulties the patient will be able
• Verbalize awareness to;
Inflammatory response of causative factors • Verbalize awareness
initiated • Demonstrate of causative factors
appropriate coping
behaviors like proper • Demonstrate
breathing and coughing appropriate coping
Cavity extends to
• Note muscles used for • These signify an behaviors like proper
bronchus
breathing increase in work of breathing and coughing
(sternocleidomastoid, breathing
diaphragmatic) and
Narrowing of air retractions/ flaring of
passages nostrils
• Position client with • This is for good lung

Difficulty breathing proper body alignment ( excursion and chest
semi Fowler’s position) expansion
• This provides
• Ensure that oxygen adequate oxygenation
delivery system is to prevent patient from

applied to the patient, desaturation
the appropriate amount
of oxygen is delivered
• This prevents dyspnea

• Pace and schedule resulting from fatigue
activities providing
adequate rest periods
• These promote deep
• Encourage sustained inspiration
deep breaths by
emphasizing slow
inhalation, holding end
inspiration
• These facilitate
• Teach client adequate clearance of
appropriate deep secretions
breathing and coughing
techniques
Dependent:
Dependent: • This provides support
• Administer and sense of ease and
medication as indicated comfort to the patient
Collaborative:
Collaborative: • For management of
• Administer oxygen at underlying pulmonary
lowest concentration condition and
indicated respiratory
• For proper counseling

and intake of caloric
• Refer the client to needs
dieticians and or
support groups.
Impaired gas exchange related to ventilation perfusion imbalance evidence by restless
Subjective: Impaired gas exchange Perfusion of the After 8 hours of nursing Independent: Independent: Goal met when patient
related to ventilation myocardium is often intervention the patient was able to demonstrate
“Masakit ang dibdib perfusion imbalance will be able to: • Establish rapport • To gain client’s trust, improved ventilation
ko, nahihirapan akong evidence by restless. •Demonstrate improved and cooperation and adequate
huminga.” as Impaired with left ventilation and oxygenation.
verbalized by the ventricular failure adequate oxygenation. • Monitor and record • To establish baseline
patient Cardiac hypertrophy vital signs data • Was able to
• Participate in a participate in a
Objective: treatment regimen treatment regimen
Patient is restless. Rate, ( breathing exercises, • Elevated head of the • To maintain airway ( breathing exercises,
Blood ejected from the
rhythm and depth of effective coughing, use bed / position client effective coughing, use
left ventricle diminishes
breathing is abnormal. of oxygen) within level appropriately, provide of oxygen) within level
of ability/ situation. airway adjunct and of ability/ situation.
Vital sign: suction as indicated.
Bp: 110/80 Hypostatic pressure • Verbalize • Was able to verbalize
PR: 65 builds in the pulmonary understanding of •Encouraged frequent • Promotes optimal understanding of
T: 36.6 venous system causative factors and deep breathing / chest expansion and causative factors and
RR: 18 appropriate coughing exercises. drainage of secretion. appropriate
intervention. intervention.
Result in fluid – filled •Auscultated breath • Reveals presence of
alveoli and pulmonary sounds noting crackles, pulmonary congestion /
congestion. wheezes collection of secretion,
indicating need for
further intervention.
Dependent: Dependent:
• Administer • This provides support
medication as and a sense of ease and
prescribed. comfort to the patient.
Collaborative: Collaborative:
• Assisted with • To improve
procedure as respiratory function/
individually indicated oxygen carrying
capacity.
DISCHARGE
PLAN
ADMITTING DIAGNOSIS:Congestive Heart Failure

FINAL DIAGNOSIS: CAD in CHF; Acute Respiratory Failure Secondary to (1)Acute Pulmonary
Congestion (2) Pneumonia high risk
DATE OF ADMISSION: September 26, 2023, 12:32 AM
DATE OF DISCHARGE: October 02, 2023, 12:26PM
Category Discharge plan
M - Medication ● Levofloxacin 750 mg/tab

Health teaching
○ Inumin ito isang beses sa isang araw tuwing 8 ng gabi
pagkatapos ng hapunan
○ Inumin ang gamot isang beses sa isang araw pagkatapos ng
susunod na araw
○ Inumin ito simula Oktubre 3, 2023, hanggang Oktubre 6,
2023
○ Ang Levofloxacin ay maaaring inumin na mayroon o
walang kasabay na pagkain
○ Ang tableta ay lunukin ng buo, huwag durugin o hatiin
○ Ang Levofloxacin ay para maiwasan ang insidente ng mga
impeksyon
● Fluimucil - 600 mg/tab

Health teaching
○ I-instruct ang pasyente na inumin ang Fluimucil sa ¼ baso
ng tubig isang beses sa isang araw tuwing 8 ng umaga
○ Inumin ito simula Oktubre 3, 2023, hanggang Oktubre 4,
2023
○ Inumin ito ng may laman ang tiyan
● Glycoair - 50mg/cap
Health teaching
○ Gumamit ng Glyco Air 1 cap sa pamamagitan ng inhaler
isang beses sa loob ng isang araw tuwing 10 ng umaga
○ Ito ay isang bronchodilator at ito ay ginagamit upang
mapawi ang mga sintomas at mabawasan ang exacerbation
na may COPD
● Pulmodual Neb 50mg/ cap

Health teaching
○ Gumamit nito 3 beses sa loob isang araw, simula 8am,
12pm at 4pm
○ Gamitin kada 4 na oras ang pagitan
○ I-instruct ang pasyente na ipagpatuloy ito sa loob ng 5 araw
○ Use the content of the ampule immediately after opening
since the Pulmodual solution contains no preservatives
○ I-instruct ang pasyente na gumamit ng Pulmodual solution
sa biglaang pag hirap sa paghinga
● Budecort - 200mg
Health teaching
○ I-instruct ang pasyente na gumamit ng turbuhaler dalawang
beses sa isang araw tuwing 8am at 12pm
○ Turuan ang pasyente na langhapin ang budecort sa
pamamagitan ng face mask o mouthpiece
○ Magmumog tuwing pagkatapos gamitin
○ Dapat iwasan ng pasyente ang regular na pagkonsumo ng
grapefruits at grapefruit juice upang maiwasan ang hindi
nararapat na pagtaas sa mga antas ng plasma budesonide at
systemic effect.
○ Ang Budecort ay isang Nasal Decongestants at Iba pang

Paghahanda sa Ilong, Respiratory corticosteroids at ito ay
ginagamit upang maiwasan ang paghinga at pangangapos
ng hininga
● Apixaban - 5 mg/tab
Health teaching
○ Inumin ang Apixaban ½ tablet dalawang beses sa isang
araw tuwing 10 umaga at 8 ng gabi
○ Inumin kada 8 na oras ang pagitan
○ Uminom ng Apixaban na mayroon o walang pagkain ang
tiyan
○ Turuan ang pasyente na mag-ulat ng hindi pangkaraniwang
pagdurugo
○ Ang pagkuha ng mga napalampas na dosis sa sandaling
maalala sa parehong araw at ipagpatuloy ang dalawang
beses araw-araw na pangangasiwa; huwag magdoble ng
dosis
○ Iwasan ang mga aktibidad na maaaring mag pataas ng iyong
panganib ng pagdurugo o pinsala. Gumamit ng karagdagang
pangangalaga habang nag-aahit o nagsisipilyo ng iyong
ngipin.
○ Ang Apixaban ay maaaring gawing mas madali para sa iyo
na dumugo, kahit na mula sa isang maliit na pinsala.
Humingi ng medikal na atensyon kung mayroon kang
pagdurugo na hindi titigil.
○ Turuan ang pasyente na huwag ihinto ang gamot nang hindi
nakikipag-usap sa nagrereseta dahil sa panganib ng pagbuo
ng clot at stroke
○ Ang Apixaban ay isang Factor Xa inhibitor at ginagamit ito
upang maiwasan ang panganib ng stroke at systemic
embolism.
● Entresto - 50mg/tab
Health teaching
○ Inumin ang Entresto dalawang beses sa isang araw tuwing
10 ng umaga at 8 ng gabi
○ Inumin ang gamot na mayroon o walang pagkain ang tiyan
○ Iulat kaagad sa iyong doktor ang anumang mga palatandaan
o sintomas ng angioedema (pamamaga ng mukha o
lalamunan, kahirapan sa paghinga)
○ Kung napalampas mo ang isang dosis, dalhin ito sa
sandaling maalala mo. Kung malapit na ito sa iyong
susunod na dosis, huwag kunin ang napalampas na dosis.
Kunin ang susunod na dosis sa iyong regular na oras.
○ Ang Entresto ay isang Angiotensin Receptor Neprilysin
Inhibitor (ARNI) at ginagamit ito upang gamutin ang
pasyenteng may talamak na pagpalya ng puso
● Rosuvastatin - 100mg/tab
Health teaching
○ Inumin ang Rosuvastatin ayon sa direksyon ng iyong doktor
○ Inumin ang Rosuvastatin isang beses sa isang araw tuwing
9am
○ Uminom ng Rosuvastatin na mayroon o walang pagkain sa
tiyan.Dalhin kasama ng pagkain kung ito ay nagdudulot ng
sakit sa tiyan
○ Lunukin nang buo ang Rosuvastatin. Huwag ngumunguya,
basagin, o durugin
○ Panatilihin ang isang karaniwang diyeta na nagpapababa ng
kolesterol
○ Atasan ang pasyente at pamilya/tagapag-alaga na mag-ulat

ng iba pang nakakabagabag na epekto tulad ng malubha o
matagal na pantal sa balat o mga problema sa GI tulad ng
pagduduwal, paninigas ng dumi, at pananakit ng tiyan
○ Ang Rosuvastatin ay HMG-CoA reductase inhibitors
(statins) at ginagamit ito upang makatulong na mabawasan
ang dami ng kolesterol at mabawasan ang panganib ng
atake sa puso at stroke
● Donepezil - 10mg/tab
Health teaching
○ Inumin ang gamot na ito isang beses tuwing 10pm
○ Inumin ito bago matulog
○ Maaaring inumin ng wala o mayroon laman ang tiyan
○ Ang tableta ay lunukin ng buo, huwag durugin o hatiin
○ Instruct the patient to allow the tablet to dissolve on the
tongue, then swallow with a sip of water.
○ Donepezil is a Cholinesterase inhibitors and it is used to
treat vascular dementia
● Clopidogrel - 15mg/tab
Health teaching
○ Inumin ang gamot na ito dalawang beses sa isang araw
tuwing 8am at 12pm
○ Inumin kada 4 na oras ang pagitan
○ Uminom ng Clopidogrel na mayroon o walang pagkain ang
tiyan
○ Uminom ng Clopidogrel sa parehong oras ng araw upang
gumana ng epektibo.
○ Turuan ang pasyente na kumuha ng Clopidogrel kung
napalampas nila ang isang dosis sa sandaling maalala nila.
○ Turuan ang pasyente na huwag uminom ng Clopidogrel
kung malapit na ang kanilang susunod na dosis, laktawan
ang napalampas na dosis at bumalik sa kanilang normal na
iskedyul ng dosis.
○ HUWAG magdoble ng dosis.
○ Ang Clopidogrel ay isang antiplatelet na gamot at
tumutulong sa pamamagitan ng pagpigil sa pamumuo ng
dugo at pinoprotektahan ang pasyente mula sa atake sa puso
o stroke.
● Trimetazidine - 15mg/tab
Health teaching
○ Inumin ang gamot na ito isang beses sa isang araw tuwing
8am
○ Inumin ito kasama ng pagkain o kaagad pagkatapos kumain
○ Inumin ito sa parehong oras bawat araw
○ Huwag hatiin, ngumunguya, o durugin ang tableta
○ Regular na inumin ang Trimetazidine para maging epektibo
○ Turuan ang pasyente na kumuha ng Trimetazidine kung
napalampas nila ang isang dosis sa sandaling maalala nila
○ Huwag uminom ng Trimetazidine kung malapit na ang
kanilang susunod na dosis, laktawan ang napalampas na
dosis at bumalik sa kanilang normal na iskedyul ng dosing.
○ HUWAG magdoble ng dosis sa anumang pagkakataon
○ Ito ay isang coronary vasodilator at ginagamit upang
gamutin ang mga kondisyon ng puso tulad ng angina
pectoris, pagpalya ng puso, at peripheral artery disease
(PAD)
● Glyxambi - 10mg/5mg/tab
Health Teaching
○ Inumin ang Glyxambi isang beses sa loob ng isang araw
tuwing 10am
○ Turuan ang pasyente na inumin ito sa parehong oras bawat
araw
○ Uminom ng Glyxambi na mayroon o walang pagkain sa
tiyan
○ Lunukin ang mga tablet nang buo sa tubig
○ Huwag nguyain, durugin, o hatiin ang Glyxambi
○ Umiwas sa alkohol habang umiinom ng Glyxambi
○ Glyxambi isang kumbinasyon ng isang inhibitor ng sodium-
glucose co-transporter (SGLT2) at isang inhibitor ng
dipeptidyl peptidase-4 (DPP-4) enzyme at ito ay ginagamit
upang makatulong na kontrolin ang mga antas ng asukal sa
dugo sa mga nasa hustong gulang na may type 2 diabetes
mellitus
● Ismodin - 30mg/tab
Health Teaching
○ Uminom ng Ismodin isang beses tuwing 8 ng umaga
○ Inumin ang gamot na ito nang may pagkain o walang
pagkain sa tiyan
○ Lunukin nang buo sa pamamagitan ng pagsipsip ng tubig
○ Ipaalala sa pasyente at pamilya na huwag nguyain o durugin
ang gamot
○ Ang Ismodin ay isang antianginal na gamot/organic nitrate
vasodilator at ginagamit ito para maiwasan ang angina at
paggamot ng coronary heart disease at congestive heart
failure
● Isordil - 50mg/tab
Health Teaching
○ Uminom ng Isordil sa parehong oras bawat araw
○ Inumin ang gamot na ito nang walang laman ang tiyan,
hindi bababa sa 30 minuto bago o 2 oras pagkatapos
kumain. Huwag dalhin kasama ng pagkain.
○ Uminom ng gamot sa mga regular na pagitan. Huwag
uminom ng iyong gamot nang mas madalas kaysa sa
itinuro.
○ Turuan ang pasyente na ilagay ang tableta sa ilalim ng
kanilang dila at hayaan itong matunaw nang dahan-dahan.
Huwag nguyain o lunukin ang gamot.
○ Iwasan ang pagtayo ng mahabang panahon
○ Ang Isordil ay isang antianginal na gamot at ito ay
ginagamit upang maiwasan ang angina pectoris dahil sa
coronary artery disease
● Furosemide- 40mg/tab
Health Teaching
○ Inumin ang gamot na ito dalawang beses sa isang araw,
simula 8am at 12pm
○ Inumin kada 4 oras ang pagitan
○ Turuan ang pasyente at pamilya na baguhin ang posisyon
ng dahan-dahan upang maiwasan ang pagkahilo
○ Ang Furosemide ay isang Loop Diuretics at ito ay
ginagamit upang makatulong sa paggamot sa fluid retention
(edema) at pamamaga na sanhi ng congestive heart failure
E - Exercise ● Deep Breathing Exercise

Instructions:
○ Umupo nang kumportable sa isang tuwid na posisyon,
alinman sa isang upuan o sa gilid ng kama

○ Huminga ng mabagal at malalim sa pamamagitan ng ilong
na parang umaamoy ng isang bulaklak. Palawakin ang
iyong lower rib cage, at hayaang ang iyong tyan na
sumulong
○ I-hold ang paghinga sa loob ng tatlo hanggang limang
segundo
○ Dahan dahang ibuga ang hangin na parang umiihip ng
kandila
○ Ulitin ang cycle na ito ng paglanghap, pagcontrol, at
pagbuga ng dahan dahan ng 5-10 beses, ilang beses sa isang
araw
○ Seated shoulder Press
Instructions:
○ Umupo nang tuwid sa isang upuan na nakalapat ang iyong
mga paa sa sahig.
○ Hawakan ang isang pares o isang solong magaan na
dumbbell o may timbang na mga bagay sa taas ng balikat,
ang mga palad ay nakaharap sa harap.
○ Pindutin ang bigat nang direkta sa itaas, ganap na iunat ang
iyong mga braso nang hindi nakakandado ang mga siko.
○ Ibaba ang mga timbang pabalik sa antas ng balikat.
○ Ulitin ito ng 10-12 na pag-uulit
● Leg Presses Exercise
Instructions:
○ Umupo sa isang matibay na upuan at ilagay ang iyong mga
paa nang patag sa lupa.
○ Dahan-dahang iunat ang isang binti palabas, ituwid ang
tuhod, at pagkatapos ay ibaba ito pabalik.
○ Ulitin ang paggalaw na ito para sa 10-12 na pag uulit bawat
binti.
● Seated Marching Exercise
Instructions:
○ Umupo sa isang upuan na may magandang suporta sa likod
at magmartsa sa puwesto, iangat ang isang tuhod pataas
patungo sa dibdib at pagkatapos ay ibababa ito pabalik.
○ Ulitin ang paggalaw na ito sa loob ng 30 segundo hanggang
1 minuto.
● Seated Arm Curls
Instructions:
○ Iunat ang iyong mga braso sa mga gilid sa antas ng balikat.
○ Gumawa ng maliliit na paggalaw ng bilog gamit ang iyong
mga braso, unti-unting pinalaki ang laki ng mga bilog.
○ Pagkatapos ng ilang pag-ikot, baliktarin ang direksyon ng
mga bilog.
○ Ulitin ito ng 10-12 na pag-ikot sa bawat direksyon
○ Gawin ito ng isa o tatlong beses kada araw
Health Teaching
● Hikayatin ang pasyente na unahin ang pahinga at bigyan ng
oras ang kanilang katawan na mapahinga. Kabilang dito ang
pagkakaroon ng sapat na tulog sa gabi at pagkuha ng
maiikling pahinga upang makapagpahinga sa loob ng isang
araw
● Payuhan ang pasyente na iwasan ang anumang aktibidad na
nangangailangan ng labis na pisikal na pagga, tulad ng
mabibigat na pagbubuhat, matinding ehersisyo, o mabibigat
na gawain.
● Paalalahanan ang pasyente na humingi ng tulong kung
kinakailangan. Wife,mga anak at iba pang miyembro ng
pamilya na maaaring magbigay ng tulong sa mga aktibidad
na nangangailangan ng labis na paggalaw
T - Treatment ● I-instruct ang pasyente na inumin ang lahat ng mga gamot

sa tamang oras at kung ilang tableta ito upang mapadali ang
mabilis na paggaling
● I-instruct ang pasyente na sundin ang medikal na paggamot
● I-instruct ang pasyente na inumin ang inireseta sa tamang
oras at huwag laktawan o doblehin ang dosis kapag ito ay
napalampas.
● I-instruct ang pasyente at kanyang pamilya nairegular
nasubaybayan ang pag inom at pagkain ng wastong mga
pagkain
H - Health teaching Proper Good Hygiene:

● Bathing and Showering
○ Payuhan ang mga miyembro ng pamilya na tulungan ang
pasyente sa regular na pagligo o pagligo.
○ Hikayatin ang paggamit ng banayad, hindi nakakairita na
mga sabon at maligamgam na tubig upang maiwasan ang
pagkatuyo at pangangati ng balat
○ Paalalahanan sila na dahan-dahang tapikin ang tuyong balat
sa halip na kuskusin nang husto
○ Payuha ang mga miyembro ng pamilya na tulungan ang
pasyente na mapanatili ang malinis at maayos na buhok.
○ Ang regular na paghuhugas ng buhok gamit ang malambot
na shampoo ay makakatulong na maiwasan ang mga isyu sa
anit at magkaroon ng pangkalahatang kalinisan
○ Payuhan ang mga miyembro ng pamilya na tiyakin na ang
damit at mga sapin,kumot at punda ng pasyente ay
pinananatiling malinis at regular na pinapalitan
● Hand Hygiene and Nail Care
○ Bigyang-diin ang kahalagahan ng wastong pamamaraan ng
paghuhugas ng kamay para sa parehong mga miyembro ng
pasyente at pamilya.
○ Maghugas ng kamay gamit ang sabon at tubig bago at
pagkatapos ng anumang direktang kontak sa pasyente o sa
kanyang mga personal na gamit.
○ Regular na pagputol at paglilinis ng mga kuko upang
maiwasan ang akumulasyon ng mga dumi at mga potensyal
na impeksyon.
○ Paalalahanan ang mga miyembro ng pamilya na putulin ang
mga kuko ng diretso at iwasan ang paggupit ng masyadong
malapit sa balat upang maiwasan ang pinsala sa balat o
magtamo ng sugat
● Oral Care / Denture Cleaning
○ Hikayatin ang mga miyembro ng pamilya na tulungan ang
pasyente sa pagpapanatili ng regular na oral hygiene routine
kahit na may pustiso. Kabilang dito ang pagsipilyo ng mga
gilagid, dila, at anumang natural na ngipin ng pasyente na
maaaring naroroon gamit ang soft-bristle toothbrush at
fluoride toothpaste.
○ Atasan ang pasyente o ang mga miyembro ng pamilya na
tanggalin ang mga pustiso para sa paglilinis.
○ Linisin ito ng hindi bababa sa dalawang beses sa isang araw
lalo na pagkatapos kumain
○ Payuhan silang hawakan ang mga pustiso sa ibabaw ng
lababo o palanggana na nilagyan ng tuwalya o tubig upang
maiwasan ang pagkasira kung aksidenteng mahulog.
○ Hikayatin ang pasyente na magsipilyo ng mga pustiso araw-
araw gamit ang isang soft-bristle toothbrush at mild denture
cleaner o non-abrasive toothpaste na espesyal na idinisenyo
para sa mga pustiso.
○ Paalalahanan ang pasyente at pamilya na iwasan ang
paggamit ng mga abrasive substance o matitigas na brush

na maaaring kumamot sa ibabaw ng pustiso
○ Turuan ang pasyente at mga miyembro ng pamilya na
ibabad ang mga pustiso sa isang panlinis ng pustiso o
pinaghalong suka at tubig sa loob ng ilang minuto bawat
araw upang makatulong na alisin ang mga mantsa at
bakterya
○ Ingatan sila laban sa paggamit ng mainit na tubig, dahil
maaari itong maging sanhi ng pag-warping o pagbaluktot ng
mga pustiso
● Foot Hygiene
○ Turuan ang mga miyembro ng pamilya na tulungan ang
pasyente na hugasan at patuyuing mabuti ang kanilang mga
paa, mas bigyang pansin ang mga puwang sa pagitan ng
mga daliri ng paa.
○ Regular na inspeksyon ng mga paa para sa anumang mga
palatandaan ng pamumula, pamamaga, o sugat lalo na kung
ang pasyente ay may diabetes.
Dietary Restrictions
● Turuan ang pasyente sa pagkontrol sa bahagi, pagbabasa ng
mga label ng pagkain, at paggawa ng masustansyang mga
pagpipilian sa pagkain
● Makipag-collaborate sa isang dietitian para bumuo ng isang
heart-healthy diet plan na mababa sa saturated at trans fats,
sodium, at cholesterol.
Promoting physical activity
● Pagbibigay ng kamalayan tungkol sa kahalagahan ng mga
kasanayan sa pamamahala sa sarili na maaaring mabawasan
ang panganib na ma-ospital
● Bigyang-diin ang kahalagahan ng regular, moderate-
intensity exercise at magbigay ng gabay sa unti-unting
pagtaas ng mga antas ng aktibidad.
Bladder Training
● Hikayatin ang pasyente na subaybayan ang intake at output
● Makakatulong ito na matukoy ang mga pattern at gabayan
ang iyong plano sa pagsasanay sa pantog
● Hikayatin ang pasyente na iwasan ang labis na pag inom ng
tubig sa loob ng maikling panahon, lalo na bago ang oras ng
pagtulog
● Para mabawasan ang dalas ng pag-ihi sa gabi
O - OPD Follow-up ● I-instruct ang pamilya at ang pasyente na sundin ang

kanyang follow-up appointment.
● Sundin ang follow-up check-up ayon sa tagubilin ng nurse
staff o ng doktor.
Iskedyul para sa check-up:

○ Oktubre 16, 2023; Lunes sa ICMC Balanga, Bataan
○ Oktubre 23, 2023; Lunes sa ICMC Balanga, Bataan
○ Payuhan ang pasyente at pamilya na sundin ang
iskedyul para sa check-up at mag-ulat kung lumala
ang mga kondisyon sa doktor o gumawa ng
appointment upang masuri kaagad.
D - Diet ● Uminom ng isang litro ng tubig kada araw

FOODS TO EAT:
● Mataas sa omega 3 fatty acid, isda tulad ng salmon,
mackerel, at trout
● Makukulay na prutas at gulay tulad ng berries, madahong
gulay, citrus fruit, at lalo na ang kamatis
Mga pagkain na dapat iwasan:

● Iwasan ang caffeine at alkohol tulad ng mga softdrinks,tsaa,
at kape, na maaaring mag-sanhi nh dehydration, at
abdominal discomfort o pananakit ng tiyan lalo na ang
pagtaas ng acid sa tiyan
● Iwasan ang trans at saturated fats, tulad ng mga taba na
matatagpuan sa mantikilya, margarine, salad dressing , at
mga pritong pagkain.
● Iwasan ang maalat,maanghang at cholesterol, pati na rin ang
mga simpleng carbs
S - Sexuality/Sprituality ● Mag-alok ng mga paraan upang matulungan ang pasyente

na i-relax ang kanyang isip, tulad ng malalim na paghinga
na pagmumuni-muni o pagmuni-muni, yoga, at iba pa.
● Hikayatin ang pasyente na unahin ang kanyang sariling
kalusugan at gawin ang mga aktibidad na kinagigiliwan nila
tulad ng pagbabasa, pakikinig sa musika, o paggugol ng
oras sa kanyang mga mahal sa buhay
● Hikayatin ang pamilya na makinig at makipag-usap sa
pasyente tungkol sa kanyang mga iniisip, at mga alalahanin
● Himukin ang pasyente na magkaroon ng koneksyon sa
DIYOS. Magagawa ito sa pamamagitan ng pagdarasal at
pagbabasa ng mga relihiyosong teksto.
● Turuan ang pasyente tungkol sa mga normal na pagbabago
na nangyayari sa sekswal na kalusugan habang tumatanda
ang mga lalaki. Tugunan ang mga alalahanin gaya ng
erectile dysfunction, pagbaba ng libido, o mga pagbabago
sa sexual function, at pisikal na limitasyon.
● Hikayatin ang paggalugad ng iba pang anyo ng
pagpapalagayang-loob sa kabila ng pakikipagtalik.
Magmungkahi ng mga aktibidad tulad ng pagyakap,
paghawak ng mga kamay, paghalik, o paggawa ng mga
sekswal na masahe bilang mga paraan upang mapanatili at
mahusay ang pagiging malapit sa isa’t isa. Ipaalala sa kanila
na ang pagpapalagayang-loob ay maaaring magkaroon ng
iba't ibang anyo at maaari pa ring maging kasiya-siya at
kasiya-siya
CURRICULUM
VITAE
CASIMIRO, MA. ERIKA G.

Bagong SIlang, Balanga City, Bataan

0962 132 9144
ekhacasimiro@gmail.com
_____________________________________________________________________________________
PERSONAL DATA
Age :
Sex :
Birthdate :
Birthplace :
Civil Status :
Nationality :
Religion :
_____________________________________________________________________________________
EDUCATIONAL BACKGROUND
Tertiary : Asia Pacific College of Advanced Studies
Bachelor of Science in Nursing
Ibayo, Balanga City, Bataan
2021 up to present
Secondary : Tomas Del Rosario College

San Jose, Balanga City, Bataan
2015 - 2021
Primary : Tomas Del Rosario College

San Jose, Balanga City, Bataan
2012 - 2015
DAPPAY, QUEENRICH A.
Wawa, Abucay, Bataan
0945 280 4352

dappayqueenrich@gmail.com
_____________________________________________________________________________________
PERSONAL DATA
Age : 20 years old
Sex : Female
Birthdate : October 15, 2002
Birthplace : Balanga City
Civil Status : Single
Nationality : Filipino
Religion : Roman Catholic
_____________________________________________________________________________________

A.H Banzo Ibayo, City of Balanga, Bataan
2021 up to present
Secondary : International School of Asia the Pacific

Bulanao, Tabuk City, Kalinga
2019-2021
Bonifacio Camatcho National High School
Calaylayan, Abucay, Bataan
2015-2019
Elementary : Abucay North Elementary School

Laon, Abucay, Bataan
2008 - 2015
FALLA, JAMAYCA T.
Waling-Waling St., Sisiman, Mariveles, Bataan
0950 855 4142

fallajamayca1283@gmail.com
_____________________________________________________________________________________
PERSONAL DATA
Age : 20 years old
Sex : Female
Birthdate : January 28, 2003
Birthplace : Infanta, Pangasinan
_____________________________________________________________________________________

Balanga City, Bataan
2021 up to present
Secondary : LMI Integrated, Formation and Education Inc.

Mariveles, Bataan
2019-2021
Elementary : Sisiman Elementary School

Sisiman, Mariveles, Bataan
2008 - 2015
FERNANDEZ, MAURE FREDEELIZ A.

Tuyo, Balanga City, Bataan
0998 542 1801
07fernandezmaura@gmail.com
_____________________________________________________________________________________
PERSONAL DATA
Age : 40 years old
Sex : Female
Birthdate : April 07, 1983
Birthplace : Quezon City
_____________________________________________________________________________________

Balanga, Bataan
2021 up to present
Philippine Women’s University
2 year course HRM

2004-2006
Secondary : Tomas Del Rosario College

1996 - 2000
Tertiary : Balanga Elementary School
GALANIDA, KATE MARIE R.

Capunitan, Orion, Bataan
0906 466 2921
katemariegalanida@gmail.com
_____________________________________________________________________________________
PERSONAL DATA
Age : 27 years old
Sex : Female
Birthdate : August 14, 1996
Birthplace : Orion, Bataam
Religion : Born Again
_____________________________________________________________________________________

2021 up to present
Philippine Women's University CDCEC Bataan
Bachelor of Science in Hotel and Restaurant Management
San Jose, Balanga, Bataan
2013-2017
Secondary : Jose Rizal Institute Arellano

Orion, Bataan
2009-2013
Elementary : Capunitan Elementary School

Capunitan, Orion, Bataan
2002-2009
GAQUIT, AILEEN JOY B.

Sitio Panibatuhan, Poblacion, Morong, Bataan
0910 364 8401
aileenjoygaquit@gmail.com
_____________________________________________________________________________________
PERSONAL DATA
Age : 23 years old
Sex : Female
Birthdate : April 27, 2000
Birthplace : Morong, Bataan
_____________________________________________________________________________________

A.H Banzon St. Ibayo Balanga City, Bataan
2021 - Present
Secondary : Morong National High School

Hilltop,Sabang, Morong, Bataan
2015- 2019
Elementary : Panibatuhan Elementary School

Sitio Panibatuhan, Poblacion, Morong,Bataan
2008-2015
ILAYA, MJ KENNETH M.
Camacho, Balanga City, Bataan
0968 369 2105
KennethIlaya22@gmail.com
_____________________________________________________________________________________
PERSONAL DATA
Age : 20 years old
Sex : Male
Birthdate : July
Birthplace :
Civil Status :
Nationality :
Religion :

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ASIA PACIFIC COLLEGE OF ADVANCED STUDIES

A.H. Banzon St., Ibayo, Balanga City, Bataan

CORONARY ARTERY DISEASE IN CONGESTIVE HEART FAILURE;

A Case Study Presented to the

In Partial Fulfillment of the Requirements for the

Chief Complaint : Difficulty of Breathing

A. History of Present Illness

On September 25, 2023 at 10:58 PM

Patient started to experienced Difficulty of Breathing

Patient took his medications: Budecort, Trimetazidine, Salbutamol Nebule

Oxygen supply was given to the patient

Difficulty of breathing was still present

Patient starts to have tachypnea and cold, clammy skin

On September 25, 2023 at 11:43 PM

Patient was rushed into the Emergency Room

Vital signs were taken:

Oxygen therapy was given to the Patient on the Emergency Room

Arterial Blood Gas examination was performed to the Patient:

On September 26, 2023 at 12:32 AM

Patient was admitted with complained Difficulty of breathing

B. Past Health History

● 2014, Patient was diagnosed with Hypertension

Surgical History : None

C. Family Health History

Present Health History

ACTIVITIES OF DAILY LIVING

ADL Before Analysis During Analysis Nursing

Nutrition “Ayos naman Knowledge “ Nakakain Hospitalization Risk for

Weight: 70kg Weight: 70kg

Height: 177cm Height: 177cm

SEPTEMBER 23,2023 SEPTEMBER 24,2023

FOODS & PREPARATIO CALORIE FOODS & PREPARATIO CALORIE

BREAKFAST: 403 kcal BREAKFAST:597 kcal

Water 100 ml 0 kcal Water 100 ml 0 kcal

LUNCH: 366 kcal LUNCH: 347 kcal

Water 100 ml 0 kcal Water 100 ml 0 kcal

AFTERNOON SNACK: 280 kcal AFTERNOON SNACK:240 kcal

Water 50 ml 0 kcal Water 50 ml 0 kcal

DINNER: 366 kcal DINNER: 347 kcal

Water 100 ml 0 kcal Water 100 ml 0 kcal

Total: 1,415 Calories Total:1,531 calories

Water intake: 1,010 ml Water intake: 1,010 ml

Lugaw 1 bowl of lugaw 175 calories

Egg 1 boiled egg 78 kcal

LUNCH: 447 kcal

Bulanglang 1 bowl of bulanglang 241 kcal

Rice 1 cup of rice 206 kcal

SNACK: 280 kcal

Fita crackers 2 packs of fita biscuit 280 kcal

DINNER: 447 kcal

Bulanglang 1 bowl of bulanglang 241 kcal

Rice 1 cup of rice 206 kcal

Total: 1,330 calories

Water intake: 1,025 ml

SEPTEMBER 29,2023 SEPTEMBER 30,2023

FOODS & PREPARATIO CALORIE FOODS & PREPARATIO CALORIE

BREAKFAST: 175 kcal BREAKFAST: 258 kcal

Lugaw 1 bowl of 175 kcal Oatmeal 1 bowl of 259 kcal

LUNCH: 349kcal LUNCH: 117 kcal

Mushroom 1 bowl of 349 kcal Chicken soup 1 bowl of 117 kcal

DINNER:175 kcal DINNER: 117 kcal

Lugaw 1 bowl of 175 kcal Lugaw 1 bowl of 175 kcal

Total: 699 calories Total: 551 calories