Presented to the faculty

of COLLEGE OF

NURSING

An Individual Case

Study

Admitting Diagnosis:
T/C Chronic Heart
Failure

Final Diagnosis:
Compensated Heart Failure, Acute Kidney Injury,Coronary Artery Disease

In Partial Fulfillment of the Requirements for

Care of Client with Problems in Nutrition and Gastro-Intestinal, Metabolism

and Endocrine, Percept (116 RLE)

Submitted by:

Submitted to:
Clinical Instructor

1
 TABLE OF CONTENTS

I. 3P’s - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 3-5
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II. BRIEF DESCRIPTION - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 6-13

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III. ANATOMY AND PHYSIOLOGY - - - - - - - - - - - - - - - - - - - - - - - - - - - 14-

-- 17

IV. PATHOPHYSIOLOGY - - - - -- - - - -- - - - - - - - -- - - - - - - - - - - - - - - - - 18-

--- 22

V. LABORATORY - - -- - - - - - -- - - - - - - - - - - - - - - - - - - - - - - - - - - -- 23-
--- 27

VI. PERSON ASSESSSMENT- - - - - - -- - - - - - -- - - - - - - - - - - - - - - - - - - 28-

-- 42

VII. DRUG ANALYSIS - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 43-

--- 60

VIII. COURSE IN THE WARD - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 61-

-- 65

IX. NURSING CARE PLAN - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 66-

-- 75

REFERENCES - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 76
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 CHAPTER I: 3P’s

A. PERSONAL PROFILE

Name Mr. S

Age 49 years old

Birthdate March 30, 1974

Birthplace Binalonan, Pangasinan

Address Bagahabag, Nueva Vizcaya

Marital Status Married

Occupation Teacher

Educational Attainment College Graduate

Religion Roman Catholic

Nationality Filipino

Primary Dialect Tagalog

Height 167 cm

Weight 92 kg

BMI 33 kg/m2 - Obese Class I

Chief Complaint Shortness of breath

Admitting Diagnosis T/C Chronic Heart Failure

Admission Date & Time March 09, 2024, 10:06pm

Attending Physician Dr. Dayag

Final Diagnosis Acute Decompensated Heart Failure, Acute Kidney

Injury, Nosocomial Pneumonia, Coronary Artery
Disease
Discharge Date & Time March 14, 2023, 7:00am

Significant Other:

Name Mrs. M

Age 47 years old

Birthdate May 30, 1975

Marital Status Married

Educational Attainment College Graduate

Occupation Teacher

Religion Roman Catholic

Relationship to the patient Wife

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A. HISTORY OF PRESENT ILLNESS

According to Mr. S, back in 2021, he was diagnosed with Hypertension II after

experiencing dizziness, blurred vision, and consistently high blood pressure
readings, which he takes valsartan for maintenance which the doctor orders to
take orally with 50mg/ tab twice a day.

In 2018, the patient mentioned that he was diagnosed with Acute Coronary
Syndrome. The patient stated that he doesn’t remember all the details during
this time of hospitalization. In the same year, he was hospitalized due to
difficulty breathing and a persistent cough, and it was then discovered that he
has Congestive Heart Failure. He recalls having procedures like an
electrocardiogram and a chest x-ray during that hospitalization.

On March 06, 2024, three days prior to confinement, the patient narrated
that he went out with his friends to basketball. They spent more time playing the
game than they often do, almost for three hours. At home, he began to feel
exhausted and had difficulty breathing, but he was able to manage it through
resting and doing breathing exercises.

Two days prior to confinement, the patient noticed swelling on both ankles
and feet; this worsens when the patient stands or sits for a long period. This
swelling gradually progressed up to the legs and eventually in the abdomen,
resulting in enlargement of the abdomen. Furthermore, the patient reported
occasional dry coughing which happens anytime of the day. As mentioned, he
also had episodic shortness of breath which he cannot tolerate flat in bed hence
he uses pillows to prop himself in bed.

Shortness of breath symptoms persisted for a few hours before confinement,

March 09, 2024, prompting the patient to decide to get medical attention. The
patient was brought to the Emergency Room of R2TMC with a chief complaint of
shortness of breath. As per agency policy, the patient has undergone rapid
antigen test which resulted negative for SARS-CoV-2. Chest x-ray was ordered
along with routine CBC and urinalysis. Initial medications were started as
ordered and heplock was hooked. Vital signs were obtained, the results are as
follows; T: 36.4, PR: 70, RR: 20, BP: 120/70, and O2 sat at 95%. Oxygen support
was hooked 1-2 LPM via nasal cannula as per physician’s order. The patient was
recommended to be on a low fat and low salt diet. Furthermore, the Chest x-ray
showed significant findings indicating enlargement of the heart. At 10:06pm, the
patient was admitted with an admitting diagnosis of T/C Chronic Heart Failure.

B. HISTORY OF PAST ILLNESS

Mr. S claims that in 2021, he got infected with coronavirus after being
exposed to one of his coworkers, resulting in fever, cough, and bodily aches and
pains. He had been quarantined for two weeks, and the RT-PCR test eventually
came back negative.

In February 05, 2023, the patient was brought again to R2TMC as he

experienced dry cough and difficulty breathing and a diagnosis of Community-
Acquired Pneumonia - Moderate Risk was made.

C. FAMILY HISTORY

Mr. S is married to his wife who works and teaches in a public school. He
resides with his household. He is a father of a son and a daughter. According to
the patient, both of his parents have a history of high blood pressure, in addition
to his mother’s side, some of their family has Diabetes Mellitus and Mr. S’ father
died because of a heart attack.

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D. LIFESTYLE HISTORY

Mr. S lives a comfortable life with his family allowing them to purchase anything
they need. He and his wife are both teachers. Aside from playing basketball with
his friends whenever he has free time, he doesn’t engage in any physical
activity. He also claims that this activity

5
greatly helps in the release of his stress and strain. In addition, he mentioned
that he has no vices at all. He used to drink coffee every day in the morning,
during his lunch break, and before going to bed, but after he was diagnosed with
hypertension, he immediately reduced his intake of coffee. He drinks 9 to 12
glasses or about 1L of water per day. He had three meals a day at the same time
but he said that he rarely ate “lutong bahay” dishes; instead, they frequently
dined at restaurants or fast-food chains. He admits that spending so much time
working- roughly 10 hours a day- on paper works and other duties make his
environment incredibly challenging for him and brings stress to his life. He
finished his dinner about 8:30 pm and went to bed at around 9:30 pm. He often
gets out of bed at around 5:30 in the morning to get ready for work.

E.SOCIOECONOMIC HISTORY

Mr. S didn't disclose the exact amount of his salary, but he did say that the
money he makes enough to support his family and pay for all of their
necessities. Earning between 30,000 – 40,000 PHP each month. From
kindergarten through college, they were able to enroll their children in private
schools. Furthermore, he narrated that both he and his wife worked, so when his
children were little they had a helper; but, after they were in high school and
capable of taking care of themselves, they were able to live without one.

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 II. BRIEF DESCRIPTION

Heart Failure
- It is the heart's failure to pump enough blood to supply the tissues' need for
nutrients and oxygen. Due to the frequent pulmonary or peripheral congestion
that many patients experience, heart failure was previously referred to as
congestive heart failure (CHF). Heart failure is a medical term that refers to a
myocardial condition where there is problem with the heart's ability to contract
(systolic dysfunction) or fill (diastolic dysfunction), which may or may not result
in pulmonary or systemic congestion.

Left-Sided Heart Failure

- The most common type of CHF is left-sided CHF. The left ventricle's inability to
efficiently pump blood into the aorta and the systemic circulation leads to
pulmonary congestion.
- The clinical manifestations of pulmonary congestion include dyspnea, cough,
pulmonary crackles, and low oxygen saturation levels.

Right-Sided Heart Failure

- This occurs because the right side of the heart cannot eject blood and cannot
accommodate all the blood that normally returns to it from the venous
circulation.

Biventricular Congestive Heart Failure

- This condition is a combination of both left- and right-sided heart failure. When
damage expands and impacts both sides of the heart, patients can experience
swelling and shortness of breath.

Systolic heart failure

- it occurs when the left ventricle is unable to contract with enough force to
circulate blood properly. As the left ventricle strains to perform, it can thin and
weaken, leading to backward blood flow, fluid buildup, and swelling.

Diastolic heart failure

- The less common type of CHF. It is characterized by a stiff and noncompliant
heart muscle, making it difficult for the ventricle to fill.

Epidemiology
- More than 5 million people in the United States have HF, and 550,000 new
cases are diagnosed each year (American Heart Association [AHA], 2007).
- According to World Health Organization, Cardiovascular diseases (CVDs) are
responsible for a third of death in the Philippines. According to the Philippine
Statistics Office (PSA), CVDs are part of the larger group of noncommunicable
diseases (NCDs), which account for 72% of deaths in the country in 2021.

Predisposing Factors:
- Age
- Alcohol
- Diabetes
- Genetic Predisposition
- History of Heart Failure

Precipitating Factors:
- Diet
- Hypertension
- Obesity

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Signs and symptoms
General
- Fatigue
- Decreased activity tolerance
- Edema
- Weight gain

Cardiovascular
- Third heart sound (S3)
- Apical impulse enlarged with left lateral displacement
- Pallor and cyanosis
- Jugular venous distention (JVD)

Respiratory
- Dyspnea
- Shortness of breath
- Pulmonary crackles that do not clear with cough
- Orthopnea
- Paroxysmal nocturnal dyspnea (PND)
- Dry Cough

Cerebrovascular
- Unexplained confusion or altered mental status
- Lightheadedness

Renal
- Oliguria and decreased frequency during the day
- Nocturia

Gastrointestinal
- Anorexia and nausea
- Enlarged liver
- Ascites
- Hepatojugular reflux

Cause:
- Myocardial dysfunction is most often caused by coronary artery disease,
cardiomyopathy, hypertension, or valvular disorders. Patients with diabetes
mellitus are also at high risk for HF.

Risk factors:
- Coronary artery disease
- Congenital heart disease
- Acute Coronary Syndrome
- Diabetes
- High blood pressure
- Obesity
- Smoking
- Eating foods high in fat, cholesterol, and sodium
- Not getting enough physical activity
- Excessive alcohol intake

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Classification of Heart Failure

Stage 1
- Stage I is considered “pre-heart failure.”
- High-risk individuals include patients with high blood pressure, diabetes,
hypertension, metabolic syndrome, and coronary artery disease.
- Patients in Stage I can typically manage their condition with lifestyle modifications.
- Patient is considered asymptomatic
- Usually no limitations of activities of daily living (ADLs)

Stage 2
- carries some noticeable symptoms.
- Patient reports no symptoms at rest but increased physical activity will cause symptoms
- Slight limitation on ADLs
- These symptoms may include—but are not limited to—heart palpitations,
shortness of breath, and fatigue.

Stage 3
- Patients have a known diagnosis of systolic heart failure.
- Shortness of breath, leg weakness, swelling of the lower body, fatigue, and
reduced ability to exercise are all notable signs of this advanced stage.
- These may include restricting salt intake, closely monitoring weight, and ending
the use of drugs that may inflame their condition.
- Marked limitation on ADL

Stage 4
- Patients have known systolic heart failure and advanced symptoms
- While at rest, patients still experience symptoms of breathlessness and fatigue,
and physical activity is likely not possible.
- they may also experience weight gain, swelling of the lower extremities, a dry
cough, and a bloated stomach.
- These include a balanced diet and exercise regimen where possible; abstaining
from drugs, smoking, and alcohol; and taking medications such as enzyme
inhibitors and beta- blockers.

Surgical Management

Coronary artery bypass

This surgery is most commonly referred to as simply
bypass surgery or CABG (pronounced "cabbage"). It is
often done in people who have chest pain (angina) and
coronary artery disease. Coronary artery disease is
when plaque has built up in the arteries. During the
surgery, the surgeon makes a bypass by grafting a
piece of a vein above and below the blocked area of a
coronary artery. This lets blood flow around the
blockage. The surgeon usually takes veins from a leg,
but
he or she may also use arteries from the chest or an arm. Sometimes, you may
need more than one bypass surgery to restore blood flow to all areas of the heart.

Heart Transplant
During a heart transplant, a patient’s heart is removed and replaced with a healthy
heart from a deceased donor. Heart transplants are used for patients with end-stage
heart failure whose condition cannot be treated effectively with medications or
other treatments.

9
Heart valve replacement surgery.
Heart failure can occur if one or more of these valves is not working properly.
Defective heart valves can be surgically repaired or replaced via open heart valve
replacement surgery or minimally invasive procedure. Increasingly, though, these
procedures are done using non- surgical techniques like TAVR.

Implantable medical devices. Doctors may surgically implant a mechanical device to

help the heart improve its ability to pump blood.

Cardiac resynchronization therapy (CRT)

- In some people with heart failure, the contraction of the ventricles is not
properly coordinated, which reduces the amount of blood the heart can pump.
CRT is used to resynchronize the ventricles. In this minimally invasive
procedure, a surgeon implants a small pacemaker (known as a biventricular
pacemaker) in the chest. Whenever the contraction of the ventricles is not
coordinated, the device delivers an electrical impulse to the ventricles to
resynchronize their contractions.
-
Implantable cardioverter-defibrillator (ICD)
- An irregular heart rate known as arrhythmia can cause heart failure. To treat
this condition, a surgeon may implant an ICD, a device that can sense abnormal
heartbeats and, in response, send an electrical impulse to the heart to correct
the heart’s rhythm. ICD implantation is done using a minimally invasive
procedure.
-
Ventricular assist device (VAD)
- VADs are battery-powered, mechanical pumps that help the ventricles pump
blood to the lungs and around the body. VADS are usually implanted via open-
heart surgery. The device is connected to the heart and blood vessels using
tubes, and a cable connects the device to a power supply and computerized
controller, which are carried outside the body through a hole in the abdomen.

All surgical procedures carry risks. Heart surgery risks include:

- Bleeding
- Infection
- Abnormal heartbeat (arrhythmia)
- Damage to other organs and tissues such as the lungs or kidneys during the procedure
- Stroke
- Heart attack
- Allergic reaction to anesthesia

Heart failure is a chronic condition that typically worsens over time. While
treatments, including surgery, usually cannot cure heart failure, they can reduce
symptoms, improve quality of life, and help people live longer lives.
A number of factors play a role in determining how well surgery will work for people
who have heart failure. A person’s age, overall health apart from heart failure, and
severity of heart failure all have an effect on the outcome.

Prevention:
Lifestyle changes, such as losing weight, cutting down on salt, and exercising
regularly, can improve your condition. Medications are also available to help your
heart better pump blood. Complementary and alternative therapies can be helpful,
too, when used along with standard medical treatment.

Carefully monitoring your health and helping to manage your condition makes a big
difference in managing heart failure. The results of one study found that healthy
lifestyle habits (normal body weight, not smoking, regular exercise, moderate
alcohol intake, and consumption of breakfast cereals, and fruits and vegetables)
1
0
were associated with a lower risk of heart failure. The highest risk was in men
adhering to none of the 6 lifestyle factors, and the lowest was among

1
1
men adhering to 4 or more healthy lifestyle factors. To do this, track your weight on
a daily basis. Weight gain can be a sign that you are retaining fluid and that the
pump function of your heart is getting worse. Make sure you weigh yourself at the
same time each day and on the same scale.

Other important measures include:

 Take your medications as directed. Carry a list of medications with you wherever you go.
 Cut down on salt. People with heart failure should consume no more than
2,000 mg of sodium per day.
 If you smoke, quit.
 Exercise and stay active.
 Lose weight if you are overweight.
 Get enough rest, including after exercise, eating, or other activities.
 Manage your stress and stay connected to others.
 Eat an antioxidant-rich diet.

Diagnostic Procedure:

Laboratory Description Nursing Consideration

Procedure

Electrocardiogram Also known as heart Before

ultrasonography is a
painless, noninvasive  Explain the procedure to the patient.
procedure that  Be mindful that there is no special
employs high- preparation needed.
frequency sound  Instruct patient to empty bladder.
waves to show the During
size, shape, and  Inform that a conductive gel is applied
motion of the heart's to the chest area.
internal structures.  Assist in positioning the patient on his
left side for better visualization of the
heart.
After
 Remove the conductive gel from the
skin of the patient.
 Inform patient that findings will be
discussed by the physician.
Chest X-Ray A chest x-ray is Before:
obtained to determine
the size, contour, and  Instruct the patient to remove all the
position of the heart. metallic objects
 Educate the patient regarding the
procedure and follow technician’s
instruction during the procedure.
During:
 Tell the patient that the x-ray technician
will stay behind while the film is being
developed.
After:
 Inform the client of the test results and
its indication.

1
ECG The ECG is a graphic Before:
representation of the
electrical currents of  Explain the procedure.
the heart.  Emphasize that no electrical current will
enter the body.
 Ask the client to remove any jewelry or
other objects that may interfere with the
test.
During
 Have the client lie supine in the center
of the bed with arms at his sides.
 Advise the patient to relax arms and
legs to minimize muscle trembling which
can cause electrical interference.
 Select flat, fleshy areas to place the limb
lead electrodes.
 Expose the patient’s chest. Put a pre-
gelled electrode at each electrode
position. Connect the lead wires to the
electrodes.
 Ask the patient to relax, not to talk, and
breathe normally while you record ECG.
Press the print button.
After
 Remove the electrodes and clean the
patient’s skin.
 After disconnecting the lead wires from
the electrode, clean and dry the
electrodes as per manufacturer
instructions.
 Assist the patient to a comfortable
position. Be sure that the bed is in a low
position.
Cardiac Stress Test This shows how the Before
heart works during a
(Physical) physical activity.  Explain the procedure to the client.
 NPO: 4 hours prior, no alcohol, caffeine
and beta-blockers as this may interfere
with test results.
During
 Monitor for two or more ECG leads for
heart rate, rhythm, and ischemic
changes; BP; skin temperature; physical
appearance; perceived exertion; and
symptoms, including chest pain,
dyspnea, dizziness, leg cramping, and
fatigue.
After
 Patient is monitored for 10-15 minutes.
Once stable, the patient may resume
their usual activities.

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Complete Blood To determine Before:
Count (CBC) presence and levels of
blood components  Check the identity of the patient and
that may indicate explain the procedure.
abnormality.  Inform and explain the procedure to the
client that there are feelings of slight
discomfort when the skin is punctured.
During:
 Instruct the patient to take a deep
breath as the fingers are being pricked.
After:
 Discuss the result to the patient and its
indications.

Urinalysis A test done to Before:

diagnose and treat a
variety of ailments,  Explain the procedure and educate the
such as urinary tract client regarding the test.
infections, renal  Instruct patient to give a sample
disease, and diabetes. urination using clean catch urine
sample
It is done by
evaluating the urine's During:
 Check the urine taking note of its
color, color, appearance, odor, volume, and
concentration, cloudiness
After:
and composition.
 Discuss the results and give
appropriate health teaching, then do the
documentation.
Blood Urea Nitrogen The BUN test Before:
(BUN) measures the level of
urea nitrogen in the  Educate the patient about the procedure.
blood. Kidneys  Explain to the patient that he may
eliminate urea experience slight discomfort from the
nitrogen, a waste tourniquet and the needle puncture.
product, from the During
blood.  Apply direct pressure to the
venipuncture site until bleeding stops.
After
 Discuss the results with the patient.

Creatinine Creatinine is a non- Before:

protein end product of
creatinine metabolism  Educate the patient about the procedure.
that appears in serum  Explain to the patient that he may
in amounts experience slight discomfort from the
proportional to the tourniquet and the needle puncture.
body’s muscle mass. During
The serum creatinine  Apply direct pressure to the
test provides a more venipuncture site until bleeding stops
sensitive measure of After
renal damage.
 Discuss the results with the patient.

1
Serum Electrolytes An electrolyte panel, Before:
commonly referred to
as a serum electrolyte  Educate the patient about the procedure.
test, is a blood  Explain to the patient that he may
examination that experience slight discomfort from the
measures the body’s tourniquet and the needle puncture.
major electrolytes. During
 Apply direct pressure to the
venipuncture site until bleeding stops.
After
 Discuss the results with the patient.

Medical Management
● The overall goals of management of HF are to relieve patient symptoms, to
improve functional status and quality of life, and to extend survival.
● Lifestyle recommendations include restriction of dietary sodium; avoidance of
excessive fluid intake, alcohol, and smoking; weight reduction when
indicated; and regular exercise.

Pharmacological Treatment
Angiotensin-Converting Enzyme Inhibitors
- Reduces afterload and preload, resulting in decreased cardiac effort through
vasodilation and diuresis. Thus relieving signs and symptoms and prevents
progression of HF.
Nursing Consideration: Observe for symptomatic hypotension, increased serum,
cough, worsening of renal function.

Angiotensin II Receptor Blockers

- ARBs block the effects of angiotensin II at its receptor; have similar
hemodynamic effects as of ACE inhibitors. Serves as an alternative for patients
who cannot tolerate ACE inhibitors because of cough.
Nursing Consideration: Observe for symptomatic hypotension, increased serum,
cough, worsening of renal function.

Hydralazine and Isosorbide Dinitrate

- Lowers systemic vascular resistance and left ventricular afterload. A
combination of hydralazine and isosorbide dinitrate may be another alternative
for patients who cannot take ACE inhibitors. Nitrates cause venous dilation,
which reduces the amount of blood return to the heart and lowers preload.
Hydralazine lowers systemic vascular resistance and left ventricular afterload.

Beta-blockers
- Reduces mortality and morbidity in HF by reducing the adverse effects from
constant stimulation of the sympathetic nervous system.
Nursing Consideration: Observe for decreased heart rate, hypotension, and fatigue.

Diuretics
- To eliminate excess extracellular fluid by increasing the rate of urine production
in patients with fluid overload.
Nursing Consideration: Observe for electrolyte, renal dysfunction, diuretic
resistance, and hypotension. Monitor I and O.

Digitalis
- Increases the force of myocardial contraction and slows conduction through the
atrioventricular node; improves contractility, increasing left ventricular output,
and enhances diuresis.
Nursing Consideration: Observe for decreased heart rate, symptomatic

1
Calcium Channel Blockers
- Causes vasodilation, reducing systemic vascular resistance.
Nursing Consideration: Observe for symptomatic hypotension, drowsiness, or dizziness.

Oxygen
- Oxygen may be necessary as HF progresses; need is based on the degree of
pulmonary congestion and resulting hypoxia.

1
 III. Anatomy and Physiology

Cardiovascular System
What is Circulatory system
The circulatory system or blood-vascular system are other names for the
cardiovascular system. It is made up of the heart, a muscle pump, and a closed
network of blood channels known as arteries, veins, and capillaries.
Heart
The heart is the main organ of the cardiovascular system, a network of blood
vessels that pumps blood throughout the body. It also works with other body
systems to control the heart rate and blood pressure. The heart is a hollow
mascular organ located in the center of the thorax, where it occupies the space
between the lungs and the rest of diagphram. It weighs approximately 300 g; the
weight and size of the heart are influenced by age, gender, body weight, extent of
physical exerxise and conditioning and heart disease.
Different parts of the heart
Heart walls
Heart walls have three layers
Endocardium: Inner layer.
Myocardium: Muscular middle layer.
Epicardium: Protective outer layer.
One layer of the pericardium is called the epicardium. A protective sac that
encircles the entire heart is called the pericardium. To lubricate your heart and
prevent it from rubbing against other organs, it creates fluid.
Heart chambers
Right atrium: The right atrium receives oxygen-poor blood from two major veins. The
upper body's blood is carried via the superior vena cava. Blood from the lower body
is brought up by the inferior vena cava. The blood is then pumped to the right
ventricle from the right atrium..
Right Ventricle: Through the pulmonary artery, the lower right chamber sends
oxygen-poor blood to the lungs. The blood is oxygenated again by the lungs.
Left atrium: After the lungs fill blood with oxygen, the pulmonary veins carry the
blood to the left atrium. This upper chamber pumps the blood to your left ventricle.
Left ventricle: The left ventricle is slightly larger than the right. It pumps oxygen-rich
blood to the rest of your body.

1
Heart Valves
Tricuspid valve: Door between your right atrium and right ventricle.
Mitral valve: Door between your left atrium and left ventricle
Aortic valve: Opens when blood flows out of your left ventricle to your aorta
Pulmonary valve: Opens when blood flows from your right ventricle to your pulmonary arteries
Blood vessels
Arteries: carry oxygen-rich blood from your heart to your body’s tissues. The
exception is your pulmonary arteries, which go to your lungs.
Veins: carry oxygen-poor blood back to your heart.
Capillaries: are small blood vessels where your body exchanges oxygen-rich and
oxygen-poor blood.

Blood Circulation
All of the body's cells receive nutrition and oxygen through the cardiovascular
system, which circulates blood. It is made up of the blood veins that run throughout
the body and the heart. Blood leaves the heart through the arteries and returns
through the veins.
When the heart slows down in between beats, blood circulation begins as blood
flows from both atria, the upper two chambers of the heart, into the ventricles, the
lower two chambers of the heart, which then enlarge. The next stage is referred to
as the ejection period, during which both ventricles pump blood into the major
arteries.
The left ventricle pumps blood that is rich in oxygen into the main artery (aorta) as
part of the systemic circulation. From the major artery, the blood passes through
bigger and smaller arteries before entering the capillary network. There, the blood
loses nutrition, oxygen, and other essential components while gaining carbon
dioxide and waste materials. The blood is gathered in veins and moves to the right
atrium and right ventricle while being depleted of oxygen.
The right ventricle sends low-oxygen blood into the pulmonary artery, which divides
into progressively smaller arteries and capillaries, starting the process of pulmonary
circulation. A delicate network of capillaries surrounds the pulmonary vesicles,
which are grape-shaped air sacs at the end of the airways. Here, fresh oxygen
enters the bloodstream and carbon dioxide from the blood is expelled into the
pulmonary vesicles. Carbon dioxide leaves our body as we exhale. The left atrium
and pulmonary veins carry oxygen-rich blood to the left ventricle.

1
Cardiac Electrophysiology
The myocardium contracts as a result of electrical impulses that are produced and
transmitted by the cardiac conduction system. In a typical situation, the conduction
system stimulates contraction of the ventricles after the atria. The ventricles can
fully fill up before ventricular ejection due to the timing of the atrial and ventricular
events, which maximizes cardiac output. Three physiologic characteristics of two
types of specialized electrical cells, the nodal cells and the Purkinje cells, provide
this synchronization:
 Automaticity: Ability to initiate an electrical impulse
 Excitability: ability to respond to an electrical impulse
 Conductivity: ability to transmit an electrical impulse from one cell to another
Both the sinoatrial (SA) node the primary pacemaker of the heart and the
atrioventricular (AV) node the secondary pacemaker of the heart is composed of
nodal cells. The SA node is located at the junction of the superior vena cava and the
right atrium. The SA node in a normal resting adult heart has an inherent firing rate
of 60 – 100 impulses per minute: however, the rate changes in response to the
metabolic demands of the body (Weber& Kelley, 2018).
The internodal pathways are specialized tracts that carry the electrical impulses
started by the SA node along the cardiac cells of the atria. The impulses stimulate
the atria electrically, which leads to atria contraction. The AV node, which is
situated in the right atrial wall next to the tricuspid valve, is where the impulses are
then carried after that. After a little delay, the AV node distributes the electrical
impulses to the ventricles after coordinating the incoming electrical impulses from
the atria.
The bundle of His, or the initial channel for the impulses, is a bundle of specialized
conducting tissue that separates into the right bundle branch and the left bundle
branch. to deliver impulses to the left ventricle, the heart's biggest chamber. The
left anterior and left posterior bundle branches are separated from the left bundle
branch. The Purkinje fibers, the terminal point in the conduction system, are
reached by impulses passing through the bundle branches. Purkinje cells make up
these fibers, which quickly conduct impulses through the thick ventricle walls. The
contraction of the ventricular myocardial cells is stimulated by this action.
The heart rate is determined by the myocardia cells with the fastest inherent firing
rate. Under normal circumstances, the SA node has the highest inherent rate 60-
100 impulses per minute, the AV node has the second highest inherent rate 40-60
and the ventricular pacemaker sites have the lowest inherent rate 30-40 impulses
per minute. If the SA node malfunction, the AV node generally takes over the
pacemaker function of the heart at its inherently lower rate. Should both the SA and
AV nodes fail in their pacemaker function, a pacemaker site in the ventricle will fire
at its inherent bradycardic rate of 30-40 impulses per minute.

1
Renin- Angiotensin- Aldosterone- System
A crucial regulator of blood volume, electrolyte balance, and systemic vascular
resistance is the renin-angiotensin-aldosterone system (RAAS). The RAAS is in
charge of acute and chronic modifications, whereas the baroreceptor reflex only
reacts in the short term to lowered arterial pressure. Renin, angiotensin II, and
aldosterone are thought to be the three main components of the RAAS .In reaction
to reduced renal blood pressure, salt transport to the distal convoluted tubule, and
beta-agonism, these three substances raise arterial pressure.
Organ system Involved
The renin-angiotensin-aldosterone system is ubiquitous with the involvement of
multiple organ systems, especially the kidneys, lungs, systemic vasculature, adrenal
cortex, and brain.
Mechanism
Prorenin is found in the juxtaglomerular (JG) cells that are found in the afferent
arterioles of the kidney. Renin is produced when JG cells that were previously
prorenin are activated. Proconvertase 1 and cathepsin B are two examples of the
enzymes that activate prorenin in the kidney. The granules of the JG cells are where
mature renin is kept.
Angiotensinogen
This molecule is primarily synthesized and constitutively secreted by the liver.
Renin cleaves the N-terminal of angiotensinogen and leads to the formation of
angiotensin I.
Angiotensin I
This peptide does not have any known biological activity.
Angiotensin-Converting Enzyme
Specifically in the pulmonary circulation, this enzyme is expressed on the plasma
membranes of vascular endothelial cells. The peptide angiotensin II is created by
breaking down the two amino acids from the C-terminal of angiotensin I.
Angiotensin II
ACE generates angiotensin II by cleaving the two amino acids at the C-terminal of
angiotensin I. Angiotensin II is the primary mediator of the physiologic effects of
RAAS, including blood pressure, volume regulation, and aldosterone secretion.
Aldosterone
The adrenal cortex's zona glomerulosa is where aldosterone is largely made.
Angiotensin II, ACTH, and extracellular potassium concentration are the primary
regulators of the synthesis and release of this hormone. Aldosterone binds to the
MR receptors on the main epithelial cells in the renal cortical collecting duct to exert
its effects on electrolyte and renal homeostasis. The main cells in the collecting
tubules have epithelial sodium channels on their apical membranes that allow
sodium to be reabsorbed. Aldosterone causes the apical membrane's ENaC channel
1
concentrations to increase, which increases salt reabsorption.

1
 IV. PATHOPHYSIOLOGY

Pituitary gland is PREDISPOSING FACTORS: PRECIPITATING FACTORS:

stimulated to ETIOLOGY:
secrete ACTH  Age  High fat diet
Unknown
 Genetic  Mental Stress
Predisposition

Hypothalamus Increased oxidative

produces stress TMAO is produced
Increase
CRH cholesterol and
Nitric Oxide Synthase is saturated fat
deactivated
TMAO
Atheros-clerosis accumulates in
Endothe-lial walls
Adrenal Gland Decrease NO
relseases stress
hormones Inflammation
(adrenalin and decrease
/Epinephrine, cortisol) EPC

Endothelial
cell
dysfunc-tion

Adrenergic binds with

receptors cardiomyo-
are cytes Endothelial
activated cell
dysfunction

1
 PKA is activated Narrow arteries
Vasoconstricti Renin is
on released @
juxtuglumelula Voltage Decreased blood
r cells in gated flow ( to heart and
(kidneys) channel in other body parts )
the
cardiomyocyt
RAAS is es open
activated Decreased
oxygen supply
Increase
calcium ions
entering the
cells

Glumerulus are damage Increased

oxygen
demand
Increased HR

Hypoxia Shortness Low SpO2

of breath
Damaged permeability Increased BP

Increase ventricular
afterload Respirator
y
Alkalosis
 hypertrophy Activated
collagen formation apocrine
Protein-uria gland
and fibroblast

Remodeling of diaphoresis
Presence of urine cast myocardium 2
 Thickening of cardiac Decreased LV compliance
muscle

Rapid degeneration of Increased

myocardium peripheral
vascular

Ventricular dilatation
Increased arterial
stiffness
Impaired systolic function Left ventricle is unable to
pump out blood

Atrial enlargement Stasis of blood in

left ventricle LV hypertrophy

\
Cardiomegally Increased filling pressure
and left atrial volume

Blood clots on the heart

lining Increased O2 and
nutrients demand

Tissue scarring
Weaker heart contractions
Low blood flow

Heart attack
2
 Weaker heart contractions

Left ventricle pumps

less blood to the
body

Blood back up to left Decrease cardiac output

ventricle

Blood back up to left Atrium Neurohormonal response

Blood back up to Lungs

SNS is activated Regulation of

RAAS
Blood back up to right
ventricle

Angiotensin II is Nocturia
Right side of the activated
heart is
damaged

Heart fails to pump ADH is relseased Aldosterone is

efficiently secreted

Hypernatremia Water
2 retention
( edema )
Prolonged nonspecific Blood builds up to
QT intraventricula the veins
interval r conduction
block
(widened QRS) Blood builds up
to the veins

Fluid is forced
to abdominal
cavity

Increased Increased
abdominal pressure in
girth abdominal cavity

Abdominal
Cramping

2
V. LABORATORY RESULTS
COVID-19 ANTIGEN RAPID TEST
Name: Mr. S Sex: M
Age: 48 y/o Date and Time: March 09, 2024, 9:58
PM
Examination Results
Specimen: NASOPHARYNGEAL SWAB NEGATIVE

IMMMUNOCHROMATOGRAPHIO TEST
Impression: SARS-CoV-2 (causative agent of COVID-19) viral RNA not detected.

CLINICAL CHEMISTRY
Name: Mr. S Sex:M
Age: 48 y/o Date and Time: March 09, 2024,10:15 PM
Test Result Values Results
Creatinin 2.14 0.7-1.3 Indication: INCREASED
e mg/dL Significance: It is done to see how well the kidneys are
working.
Implication: high levels of creatinine indicates kidney
disease or other condition that affects the kidney. It
commonly occurs in patients with heart failure
Impression: The patient have increased creatinine which implies problem with renal
function.

BLOOD CHEMISTRY
Name: Mr. S Sex:M
Age: 48 y/o Date and Time: March 09, 2024,10:15
PM
Test Result Values Results
Uric 8 3.5-7.2 Indication: INCREASED
Acid mg/dL Significance: Uric acid test is useful test as screening for
most of purine metabolic disorder. The importance of uric
acid measurement in plasma is highlighted. It indicates
gout, renal stones, nephritis, and cardiovascular diseases.
Implication: high levels of uric acid is associated with higher
risk of hypertension, diabetes, coronary heart disease, and
other cardiovascular diseases.
Impression: The have increase uri acid which may indicate higher of
patient cardiovascular d c risk
disease.

SERUM ELECTROLYTES
Name: Mr. S Sex:M
Age: 48 y/o Date and Time: March 09, 2024,10:14
PM
Test Result Values Results
Sodium (Na+) 138.1 135-145 NORMAL
mmol/L
Potassium (K) 4.96 3.5-5.5 mmol/L NORMAL
Chloride (Cl-) 101.2 97-107 mmol/L NORMAL
Impression: the patient has normal sodium, potassium, and chloride which implies
that she has no electrolyte imbalance.

BIO-CHEMICAL CARDIAC MARKER

Name: Mr. S Sex:M
Age: 48 y/o Date and Time: March 09, 2024,10:15
PM
Test Result Values Results

2
Troponin I 0.18 <0.30 ng/mL NORMAL
FLUOROSCENCE
IMMUNOASSAY
(FIA)
Impression: The patient has normal levels of troponin in blood

2
 URINALYSIS
Name: Mr. S Sex:M
Age: 48 y/o Date and Time: March 09, 2024,10:37
PM
Test Result (03- Result Values Results
12) (03-16)
Physical Examination
Color Yellow Yellow Pale NORMAL

yellow to

dark
amber
Transparency Clear Clear Clear NORMAL
Chemical Examination
Specific Gravity 1.020 1.020 1.005-1.030
pH Level 5.0 5.1 4.5-8.0 NORMAL
Protein 2+ 1+ Negative Indication: INCREASED
Significance: The presence
of protein in urine
indicates that kidneys are
not working well, and
protein can leak through
the kidney’s filter and
into the urine.
Implication: The patient
has presence of protein
in urine which can be a
sign of
kidney disease
Glucose - - - -
Ketone - - - -
Blood - - - -
Leukocyte - - - -
Esterase
Nitrite - - - -
Bilirubin - - - -
Urobilirobin 0.5 0.45 0.4-4.0 NORMAL
mg/d
Microscopic Examination
WBC 1-2 negative Negative NORMAL
or rare
RBC 2-4 negative negative Indication: INCREASED
Significance: The
presence of RBCs in
the urine is usually a
sign of
an underlying
health
issue, such as
infection or irritation of
the tissues in the
urinary tract
Implication: The patient
has presence of RBC in
urine which may be due
to kidney and urinary
tract problems such as
infection,
or stones.
Epithelial Cells Few few few NORMAL

2
Mucus Threads Moderate few Small- NORMAL
moderate
Amorphous Few few few NORMAL
Sediments
Bacteria Moderate none none Indication: INCREASED
Significance:
microorganisms

usually
enters the urethra and may
infect the bladder and can

2
 travel up to the ureters
and infect the kidneys.
Implication:
moderate
bacteria in urine
could
indicate urinary
tract
infection, or kidney
disease
Crystals - - - -
Casts (Hylaline) >10 0 0-1/lpf Indication: INCREASED
Significance: Presence
of hyaline casts in urine
can signify chronic renal
failure, chronic renal
disease,
congestive heart
failure, stress
or exercise Implication:
presence of
hyaline casts could
indicate
decreased urine flow
Impression: The patient has proteinuria which could be a sign of kidney disease.
The patient also has bacteria present in urine same as hyaline casts which could
indicate urinary tract infection.

HEMATOLOGY
Name: Mr. S Sex: M
Age: 48 y/o Date and Time: March 09, 2024,10:13
PM
Test Result Result Values Results
(03- (03-16)
12)
White Blood 9.57 8.5 4.0-10x109/L NORMAL
Cell
(WBC)
Neutrophil 71.0 68% 40%-70% Indication: INCREASED
Significance: A kind
of white blood
cells that
protects humans
from infections.
They make up about
40% to 60% of
body’s white blood
cells and are first to
appear on the scene
when there is most
likely,
bacterial
infection.
Implication: increased
neutrophils means
there is presence of
infection and
inflammation,

and
consequently is
associated to
2
 cardiovascular risk.
Lymphocytes 21.3 21 20%-50% NORMAL
Monocytes 7.7 7.5 3%-10% NORMAL
Red Blood Cell 5.12 5.12 3.80- NORMAL
(RBC) 5.80x1012/L
Hemoglobin 169 169 126-174 g/L NORMAL
Hematocrit 49 49 36.0%-52.0% NORMAL
MCV 96 94 80-94 fL Indication: INCREASED
Significance: It
measures the average
size and
volume of red blood
cells which
helps
determine etiology of
anemia. Low
MCV could
indicate microcytic
anemia,

2
 andhigh MCV could
indicate

macrocytic anemia.
Implication: increase in
MCV could indicate
macrocytic anemia
which can be
associated with
coronary disease,
heart failure,

myocardial
infarction, and stroke
MCH 33 32 26-33 pg NORMAL
MCHC 344 339 320-360 g/Dl NORMAL
Platelet Count 185 189 150- NORMAL
450x109/L
Impression: The patient has increased neutrophil which indicates infection and
inflammation. The patient also has increased MCV which means its RBC is larger
than normal size and
could indicate macrocytic anemia.

CHEST PA
Name: Mr. S Sex:M
Age: 48 y/o Date and Time: March 09, 2024,
Examinatio Findings Interpretatio Purpose
n n
CHEST PA - To examine
cardiomegal the lungs,
y chest
cavity, and
its
divisions as
well as the
vessels of the
heart. It is
also used to
aid diagnosing
-no active parenchymal opacities are seen a
-heart is enlarged range of
-pulmonary vascularity is within normal acute and
limits
-hemidiaphragms, sinuses, soft tissues chronic
and visualized osseous structures are conditions
intact involving
organs of the
thoracic
cavity.
Impression: The patient’s chest PA displays cardiomegaly which means the
patient has an
enlarged heart

ELECTROCARDIOGRAM (ECG)
Name: Mr. S Sex:M
Age: 48 y/o Date and Time: March 09, 2024,
Examinatio Findings Interpretatio Purpose
n n

2
ECG It records
the electrical
- left activity of
atrial the heart. It
enlargemen can
t also
- ventricul help
ar diagnose
arrhythmia certain
heart
conditions,
-sinus rhythm including
-nonspecific intraventricular conduction abnormal
block heart
- left atrial enlargement rhythms
and
coronary
heart
disease.

2
 -prolonged QT interval
Impression: The patient has left atrial enlargement and ventricular arrythmia

ARTERIAL BLOOD GAS TEST

Name: Mr. S Sex:M

Age: 48 y/o Date and Time: March 10, 2024; 3:53 AM

Test Results Values Pathophysiologic Basis

Ph 7.41 7.35- Indication: NORMAL

7.45 Significance: pH measures the balance of acid and
base in blood. If pH is lower than 7.35, blood is
considered acidic, and is higher than 7.45, it is
considered basic.
Implication: pH of blood is within normal range.
PaCO2 29.2 35-45 Indication: DECREASED
mmHg Significance: It shows how well the oxygen moves
from the lungs to the bloodstream. It measures the
amount of carbon dioxide present in the blood and
how well the carbon dioxide move out of the body.
Implication: low carbon dioxide in blood implies that
the body is removing too much carbon dioxide. It could
indicate ketoacidosis, diabetes, or Addison’s disease.
HCO3 18.0 22-26 Indication: DECREASED
mEq/L Significance: A byproduct of the body’s metabolism
which brings bicarbonate in lungs through blood and
will be exhaled as a carbon dioxide.
Implication: HCO3 of blood is decreased. It could
indicate diarrhea, kidney disease, and liver failure.
PaO2 461 21%- Indication: INCREASED
/ FiO2 100% Significance: It represents arterial oxygen pressure/
Note: It is frequently used to determine the severity of
Patient lung injury. It is also an indicator of oxygenation
is status and one diagnostic criteria for acute
respiratory disease.
on Implication: Patient have high PaO2/FiO2 which may
room indicate that patient have been overly supplied with
air oxygen.
FiO2:
21%
Impression: The patient has respiratory alkalosis, fully compensated. Patient
experienced difficulty of breathing and shortness of breath which is a symptoms of
respiratory alkalosis.

2
VI. PERSON ASSESSMENT

PSYCHOSOCIAL
Assessment Findings
Assessment PRE-ASSESSMENT POST-ASSESSMENT Pathophysiological
Basis
March 11, 2024 March 13, 2023
(7:00 Am) (7:00 am)
Family type Nuclear Family

Significant Mrs. M (Wife)

Others

Coping ● Emotion-Focused- he is involved in

Mechanism doing something that offers a
temporary distraction and returns to
the issue when he feels calmer.

Religion Roman Catholic

Primary Tagalog & Ilocano

Language

Primary Source of R2TMC, Bayombong Nueva Vizcaya

Healthcare

Financial With Philheath and from his own and

Resources wife salary and savings
Related to Illness

Occupation Teacher

2
Educational College Graduate College Graduate
Attainment

General ● The patient is ● The patient is

Appearance dressed suited dressed suited
for his age, for his age,
situation, and situation, and
weather. weather.
● Clean and neat, ● Clean and neat,
has no body has no body
odor, can odor, can
maintain eye maintain eye
contact contact
● Speak in normal ● Speak in normal
phase, phase,

with volume, with volume,

quantity, and quantity, and
quality as he quality as he
responds responds
to to
questions asked questions asked
● He also holds ● He also holds
his body upright his body upright
when standing when standing
and and
sitting, sitting,
where where
hands and hands and
shoulders are shoulders are
relaxed and relaxed and
held at his held at his
sides. sides.
Affect ● Broad Affect ●
Broad Affect
- The client -
The client
displays full displays full
range of range
emotional of
expressions emotional
that is expressions
appropriate with that is
the situation appropriate with
the situation
- He smiles and
responds
properly when
being asked
questions.
Level of Awake alert and Awake, alert
consciousness oriented to time, and oriented
person, and place. to time, person
and place

3
Orientation ● Can determine ● Can determine
the time, date, the time date,
and place to and place to
where he is as where he is as
of the moment. of the moment.

3
Memory
The patient The patient
memory is intact memory is intact

Immediate Memory: Immediate Memory:

The patient can The patient can
repeat the remember his last
sequence of words meal
uttered by the
nurse. Recent Memory:
Remembers the
Recent Memory:
day of admission
Remembers the
time of his last
meal
Remote Memory:

Remote Memory: Remembers the

year when he was
Remembers gifts he diagnosed with
receives on his last hypertension
birthday
Speech Speech organs are Speech organs are
normal as the normal as the
patient speaks patient speaks
clearly in moderate clearly in moderate
tone, clear, with tone, clear, with
moderate pace, moderate pace,
and and

culturally culturally
appropriate. appropriate.

Nonverbal ● The patient ● The patient

Behavior nods, and nods and
maintains eye smiles at the
contact during examiner.
assessment ● He can
and when maintain eye
answering the contact
questions whenever
there are
questions
asked.

3
 ELIMINATION

Stool ● Frequency: ● Frequency:

- once - once

● Pattern : ● Pattern :
-Everyday -Everyday

● Consistenc ● Consistenc
y and shape : y and shape :
- soft - soft

● Color: ● Color:
- dark - dark
brown brown
● Amount ● Amount
: minimal : minimal
● Odor : ● Odor :
foul odor foul odor
● No ● No
presence of presence of
parasites and parasites and
bowel bowel
diversions. diversions.

3
Urine ● Smell: ● Smell: The normal urine
- doesn’t have a - doesn’t have a output of an
strong strong individual is 1,200
smell (aromatic) smell (aromatic) to 1,500 mL every
24 hours. The
increase in urine
● Frequency: ● Frequency: output is caused by
- Once upon - usually urinates 8- the
admission 10 times a day
without pain diuretic
- usually urinates 8-
medications (
10 times a day
Furosemide
without pain
and Spironolactone
)
● Color: being administered
- Yellow amber to ● Color:
- Yellow amber to to patient .
light yellow
light yellow

Amount:
●
– 1,350 ml ●Amount :
- 1,200 ml

● Clarity:
-clear ● Clarity:
-clear

●Specifi
c gravity: Specifi
●
-1.020 c gravity:
- 1.020

Laborator
●
y Analysis: Laborator
●
-Presence of protein y Analysis:
- Normal

● No
presence of No
●
urinary presence of
diversions. urinary
diversions
Abdomen ● Bowe The patient stated
l of having increased
Bowe
● sounds: in abdominal girth
l -normoactive
sounds: upon admission to
-normoactive ER, but was
relieved during the
transfer to General
Ward.
● Contour ● Contour
-rounded -rounded
- with abdominal - with abdominal The rounded
girth of 42.5 girth of 42.5 contour on the
patient’s abdomen
is due to
● Auscultation: ● Auscultation: accumulation of
-15 -20
3
 fats. As male
Borborygmic Borborygmic ages, the
testosterone
levels

3
 sounds are heard in sounds are heard decreases causing
all quadrants in all quadrants a decline in muscle
mass and replaced
by new layers of
fats.

● Palpation: ● Palpation: ( Newsham, 2022)

- no visible masses, -no visible masses,
with visible with visible
pulsations, no pulsations, no
peristaltic rashes, peristaltic rashes,
without tenderness without
tenderness.

Toileting Ability
● The client ● The client
claims that he claims that he
doesn’t need doesn’t need
assistance when assistance when
attending to his attending to his
toileting needs. toileting needs.
As observed, As observed,
the patient the patient

can properly can properly

ambulate ambulate
independently. independently.

REST AND ACTIVITY

Current Activity The patient
Level is The patient
ambulatory. is
ambulatory.

3
ADLs ● Grooming: ● Grooming:
- the patient can
perform personal - the patient can
hygiene on his own perform personal
hygiene on his own
● Feeding:
- Can feed himself
● Feeding: without assistance
- Can feed himself
without assistance
● Ambulating

● Ambulating - He can stand

- He can stand and and walk
walk independently
independently.

● Toileting:
- the patient can
● Toileting: attend to his
- the patient can toileting needs
attend to his independently.
toileting needs
independently.
● Communicate
:

● Communicate -able to
: communicate and
use appropriate
-able to words
communicate and
use appropriate
words

Sleep ● Sleep History ● Sleep Pattern: kidney senses in

-the sleeps 10pm - the patient has low cardiac output
and wakes up 5 am improve his usal which reduced
bed time at 9 renal blood flow
pm to 5 am in and fluid retention.
the morning At night when lying
down, the fluid
● Duration : ● Duration
which has build up
- the patient sleeps - 7 to 8 hours of
during the day can
2 hrs in the sleep everyday
move back into the
afternoon and 7
bloodstream and
hours at night.
taken by the
● Quality : kidneys to that
- The patient’s
cause frequent
● Quality : sleep is easily
urination.
- The patient's awaken
sleep is interrupted
and easily awaken

3
Body Frame Endomorph Endomorph

Weight: 92 kg Weight: 92 kg
Height: 5’4 ft Height: 5’4 ft
BMI= 34.7 kg/ft BMI=34.7
(obesity) kg/ft
(obesity)

Posture The patient was The patient was

observed to have observed to have
an upright posture an upright posture
with parallel with parallel
alignment of the alignment of the
hips and shoulders hips and shoulders
Coordination ● Can perform ● Can
finger to nose
and alternate perform finger
tapping of the to nose and
hands test. alternate
tapping of the
hands test.
● The

patient's ● The
extremities patient's
show upper
well-coordinated extremities
movements show
as she well-
extends, raise coordinated
and flex her movements
hands and legs. and no
tremors
and repetitive
● Also, there are actions are seen
no tremors ● Also, there are
no tremors
and repetitive
actions seen. and repetitive
actions seen.
Gait ● Movements are ● Movements are
coordinated coordinated
● Normally walks
with ● Normally walks
with
arms
swinging freely arms
at the sides with swinging freely
the face and the at the sides with
head leading the face and the
the body. head leading
3
 the body.
Balance The patient can The patient can
walk with good walk with good
balance and does balance and does
not complain not complain
dizziness. dizziness.

3
Muscle ● Strength: ● Strength:
-Can perform daily - Can perform
activities daily activities
without
without assisstance assisstance

Medical Research
Medical Research Council
Council
Manual Muscle
Manual Muscle Testing Score:
Testing Score:
Upper
Upper
Extremities:5/5
Extremities:5/5
Lower
Lower Extremities
Extremities:5/5
5/5

Tone:
●
● Tone: -Muscles in upper
-Muscles in upper and lower
and lower extremities are firm
extremities are firm

Size:
●
● Size: -Muscle size are
-Muscle size are normal appropriate
normal appropriate to the client's body
to the client's body frame
frame

● With
● With contractures
contractures or shortening
or shortening -No contractures
-No contractures

● Fasciculatio
● Fasciculatio n or
n or tremors
tremors -No tremors
-No tremors

● Movements:
- No involuntary
● Movements: movements such

3
- No involuntary as twitching, or
movements such shaking
as twitching, or
shaking

3
Motor Function ● Fine: ● Fine:
- Can fold the - Can fold the
fingers and grasp a fingers and grasp a
ballpen ballpen

● Gross: ● Gross:
- Can flex and - Can flex and
extend extremities extend extremities

Range of motion ● Neck: ● Neck:

- Extension: 60° - Extension: 60°
- Flexion: 50° - Flexion: 50°

● Neck rotation ● Neck rotation

- Left: 80° - Left: 80°
- Right: 80° - Right: 80°

● Hip ● Hip
(flexion) Left (flexion) Left
- knee flexed: 100° - knee flexed: 100°
- knee - knee
extended: 100° extended: 100°
Right Right
- knee flexed: 100° - knee flexed: 100°
- knee - knee
extended: 100° extended: 100°

Knee (flexion) Knee (flexion)

- left: 150° - left: 150°
- right: 150° - right: 150°

● shoulder ● shoulder
(flexion- (flexion-
extensio extensio
n) n)
Left Left
- Extension: 50° - Extension: 50°
- Flexion: 150 - Flexion: 150

° Right ° Right
- Extension: 50° - Extension: 50°
- Flexion: 150 ° - Flexion: 150 °

3
 ● Elbo ● Elbo
w Left w Left
- Extension: 0° - Extension: 0°
- Flexion: - Flexion:
150° Right 150° Right
- Extension: 0° - Extension: 0°
- Flexion: 150° - Flexion: 150°

● Forearm ● Forearm
(Pronation- (Pronation-
Supination) Supination)
Left Left
- pronation: 80° - pronation: 80°
- Supination: - Supination:
80° Right 80° Right
- Pronation: 80° - Pronation: 80°
- Supination: 80° - Supination: 80°

Pain relief ● Sleep, rest ● Sleep, rest

measures and and
taking taking
of of
medicines. medicines.

Mobility and use ● Doesn’t use ● Doesn’t use

of assistive any assistive any assistive
device devices. devices.

SAFETY AND ENVIRONMENT

Allergies ● Doesn’t have ● Doesn’t have
any allergies any allergies

in medications, in medications,
food and food and
environment environment
Eyes/Vision ● Pupils equally ● Pupils equally
round react to round react to
light and light and
accommodation accommodation

Pupils constrict Pupils constrict

when when
looking at looking at
near near

3
objects, dilates objects, dilates
when when

3
 looking at far looking at far
objects, pupils objects, pupils
converged when a converged when a
near object is near object is
moved toward the moved toward the
nose. The 6 nose. The 6
cardinal eye cardinal eye
movements are movements are
assessed normal assessed normal
and coordinated and coordinated
( medial rectus, ( medial rectus,
superior superior

rectus, rectus,
superior oblique, superior oblique,
lateral rectus, lateral rectus,
inferior rectus, inferior rectus,

inferior oblique). inferior oblique).

Color ● Skin- ● Skin-

Light brown Light brown

● Nailbed ● Nailbeds
s- - pinkish
pinkish ● Lips-
● Lips-
moist and
moist and pinkish
pinkish
Capillary refill ● Returns to ● Returns to
normal in less normal in less
than 2 seconds than 2 seconds
● Pulse oximetry- ● Pulse oximetry-
98% SaO2 97% SaO2

Peripheral pulse ● 83 bpm (radial) ● 70 bpm (radial)

● Rhythm:
-regular, frequency
● Rhythm: of pulsation felt by
-regular, frequency
fingers follows an
of pulsation felt by
even tempo with
fingers follows an
equal
even tempo with
equal
interval between
interval between
● Volume:
-normal, detected
● Volume: readily, obliterated
-normal, detected
by strong pressure
readily, obliterated
by strong pressure

Blood Pressure ● 160/90 mmHg ● 150/80 mmHg High blood

● Site: upper arm- ● Site: upper arm- pressure is caused
uses brachial uses brachial by vasoconstriction
artery artery and increase in
4
pulse rate. Wide
pulse pressure can
also be observed
wich can be
caused
by
arteriosclerosis

4
 (Homan, et. al,
2022).
Arteriosclerosis is a
type of vascular
disease where the
blood vessels
carrying oxygen
away from the
heart

(arteries)
become damaged
from factors such
as high cholesterol,
high blood

pressure, diabetes
and certain genetic
influences.
Edema Absent Absent

Homan's sign ● Negative ● Negative

Hearing/hearing ● Doesn’t use ● Doesn’t use

aid hearing aid hearing aid

Hearing acuity: Hearing acuity:

● Response to ● Response to
normal voice tone- normal voice tone-
normal voice tones normal voice tones
audible audible
● Whispering- ● Whispering-
able to repeat able to repeat
whispered words whispered words
● Using ticking ● Using ticking
clock- able to hear clock- able to hear
ticking on one or ticking on one or
both ears both ears
● Using tuning ● Using tuning
fork- (Weber's test) fork- (Weber's test)
produce equal produce equal
sounds in both ears sounds in both ears
●

Skin integrity ● Has a good skin ● Has a good

turgor- skin turgor- upon
pinching the skin
upon pinching recoils
the skin recoils normally,
normally, discoloration and
discoloration varicosities are
and varicosities not
observed
Temperature ● 36.4 ● 36.3
degrees C degrees C
(axillary) (axillary)

4
 OXYGENATION
Activity ● Katz activities of ● Katz activities
Intolerance daily living of daily living
score= 6/6 score= 6/6
● The patient can ● The patient
perform can perform
ADLs ADLs

4
 alone alone

Airway ● No ● No secretions,
Clearance secretions, obstructions,
obstructions, polyps , mass,
polyps , tumor,
mass, deformity and
tumor, inflammation
deformity and observed in the
patient' mouth
inflammation and nose.
observed in
the
patient' mouth
and nose.
Respiration ● Rate: ● Rate:
- 17 breaths per - 18 breaths per
minute minute

● Rhythm:
● Rhythm: - Regular
- Regular

● Character:
● Character: - Depth is normal.
- Depth is normal.
The inspiration
The inspiration
volume and depth
volume and depth
of breast
of breast
movements
movements
are maintained,
are maintained,
with equal
with equal
expansion
expansion
and symmetry
and symmetry
Lung Sounds ● No presence of ● No presence of
crackles or crackles or
rales, wheezes, rales, wheezes,
rhonchi or rhonchi or
gurgles gurgles
● Normal vocal ● Normal vocal
fremitus fremitus
● Normal breath ● Normal breath
sounds sounds

NUTRITION

Diet Restrictions ● patient is ● patient is The patient has

restricted restricted manifested
with 1,500 with 1,500 peripheral edema
mL fluid mL fluid and fluid build- up
intake intake in abdominal cavity
● Low fat as a result of
and low
Congestive Heart
salt
Failure. Limiting
salt and oral fluid
intake would
4
prevent further
buil-up of fluids in
the body.

4
Fluid Intake ● Oral - 1,500mL ● Oral -
● 8-10 cups of 1,500mL
water per day ● 8-10 cups
of water per
day
Height ● Weight: 92 kg ● Weight: 92 kg
● Height: 5’4 ft ● Height: 5’4 ft.
And Weight

Tissue turgor/ ● Well- ● Well-

Skin Turgor hydrated. hydrated.
Goes back Goes back
less than 2 less than 2
seconds after seconds after
pinching pinching
Ability ● Chew ● Chew
- able to - able to
chew chew
● Swallow ● Swallow
- able to - able to
swallow swallow
● Tolerate food ● Tolerate food
-able to tolerate -able to tolerate
food food
● Feed Self ● Feed Self
- able to feed - able to feed
self self

4
 VI. DRUG STUDY
Name of Action Indication Contraindicati Side effect Adverse effect Nursing consideration
Medication on
FUROSEMIDE Inhibits - Edema Patients with: - Headaches CNS: - Monitor vital signs, and
sodium - Hyperten - Hypersen - Feeling sleepy, - Dizziness weight.
Brand and chloride si on si tive to tired, dizzy or - Headache - Monitor fluid intake and
reabsorption at drug "spaced out." - somnolence output and electrolyte,
name: Lasix the proximal - Hepati - Feeling or being - vertigo BUN, carbon dioxide levels
and distal c sick (nausea - seizures - Watch for signs of
cirrhosi or vomiting) - anxiety hypokalemia
Classifications: tubules and
s - Constipation - asthenia - Monitor uric acid level
loop diuretics ascending loop
- Activat - Dry mouth - CNS stimulation - Monitor patient who has
of Henle e SLE - Sweating - Confusion symptom of urine
Doctors order: - Low energy retention
- sleep disorder
Furosemide P.O - fever - Monitor hemoglobin
40mg/tab BID CV: levels, platelet and WBC
- orthostatic counts.
hypotensi
Date on
- thrombophlebitis
started: March EENT:
9, 2024 - visual
disturbances
- tinnitus
- yellow vision
Gl:
- constipation
- nausea
- vomiting
- abdominal pain
- anorexia
- diarrhea
GU.
- proteinuria
- urinary frequency

4
 - urine retention
Metabolic:
- dehydration
- weight loss
- weight loss.

Musculoskeletal:
- muscle spasm
KETOANALOGU transmitted by - Renal Allergy - Allergic reaction - increased - Assess electrolyte levels.
E + ESSENTAL taking insufficie and - Constipation - Assess allergy to the drug.
AMINO ACID nitrogen nc y hypersensitiv - Nausea calcium level - Assess vital signs.
from non- it y to - Headache - nausea - Monitor symptoms of
Brand name: essential amino any - Muscle weakness - vomiting hypercalcemia occurs like
Esensamin acids, thereby component - diarrhea muscle
- abdominal pain.
decreasing the of this
weakness, constipation.
Classifications: formation of drug.
- Monitor calcium levels.
Supplements urea by re-
using the Hypercalcem
Doctors order: amino group. ia due to any
Ketoanalogue The levels cause.
+
essential of Patients of
accumulating phenylketonu
amino acid P.O uremic toxins ri a.
2 tabs- are decreased.
60mg/tab TID Disturbed
amino
Date
acid
started: metabolism.
Maintenance.
Replaces - Prevent Patients with: - Headache CNS: - Monitor vital signs
POTASSIUM potassium hypokale - - Constipation - paresthesia and respiratory
CHLORIDE mi a - Weakness distress.
and maintains Hypersen od limbs - Monitor ECG and
4
si tive to electrolyte
drug

4
 potassium level - Renal - Tiredness - littleness imbalances
Brand name: impairme - Chills - confusion - Monitor renal function.
Kallum Durule nt - drowsiness - weakness of limbs - Monitor potassium level
- Teach patient not to worry
Classifications: CV: if there is presence of wax
Potassium Salt - post matrix in stool as it
indicates that drug is
infusion phlebitis already absorbed.
Doctors order:
- arrhythmias
Potassium
- cardiac arrest
chloride PO
Gl:
1tab BID
- nausea
- vomiting
Date - abdominal pain
- diarrhea
started: March
11, 2024 Respiratory:
- respiratory
paralysis
SALBUTAMOL Relaxes - Hypersensitiv - a dry mouth CNS: - Assess pulmonary function
bronchial, it y to drug - constipation - nervousness, at rest and during at work.
Brand name: uterine, and Bronchos - a cough - restlessness,
Ventolin p asm Cardiovascula - headaches - tremor, - Monitor signs of
vascular r disorder - feeling sick (nausea) - headache, paradoxical bronchospasm
Classification smooth with - difficulty - insomnia such as wheezing, cough,
reversible dyspnea, tightness in
s: Adrenergic muscle Hyperthyroidi
obstructiv swallowing (dysphagia) CV: chest and throat,
beta2- by sm
e airway - palpitations - chest pain especially at higher or
agonist - throat irritation excessive doses.
- palpitations,
stimulating Diabete - difficulty urinating - angina,
Doctors beta2 receptor s - Assess blood pressure
- arrhythmias,
order: mellitus periodically and compare
- hypertension.
Salbutamol to normal values.
inhaler Q8H GI narrowing GI:
- nausea - Monitor potassium level
Date

4
started: March
11, 2024

4
 - vomiting - Assess heart rate, ECG,
and heart sounds.

- Monitor and report signs

of CNS toxicity, including
nervousness, restlessness,
tremor, or hyperactivity.

ISOSORBIDE Thought to - Angina Hypersensitiv - headaches CNS: - Assess episodes of angina

MONONITRATE reduce cardiac pectori it y to drugs - feeling dizzy or weak - dizziness, pectoris at rest and during
oxygen s - feeling tired or sleepy - headache. exercise.
Brand demand by - Heart Methemoglobi - feeling sick (nausea)
decreasing diseas nemia - flushing CV: - Assess heart rate, ECG,
e - swelling in lower - hypotension, and heart sounds,
name: IMDUR preload
legs, ankles or feet - tachycardia, especially during exercise.
Blood
(oedema) - paradoxid
and
- bradycardia, - Assess dizziness and
Classifications: afterload. volume
- syncope. syncope that might affect
Nitrates Drug depletion gait, balance, and other
also may functional activities.
GI:
Doctors order: increase
- nausea,
ISMN PO - If used to treat CHF,
- vomiting.
30mg/tab blood flow assess signs and
through the Misc.: symptoms (dyspnea,
Date collateral - flushing, rales/crackles, peripheral
coronary edema, jugular venous
- tolerance.
started: vessels. distention, exercise
Maintenance. intolerance) to help
document whether drug
therapy is effective in
reducing these symptoms.

- Report signs of drug

tolerance during long-term
use, as indicated by
increased
episodes of angina or
4
 CHF

4
 symptoms.

- Instruct patient to
change position
slowly
VALSARTAN Blocks the - - Hypersen - Abdominal pain CNS: - Monitor signs of
binding si tivity to - Back pain - dizziness, angioedema, including
Brand Hyperten drugs - Diarrhea - fatigue, rashes, raised patches of
of angiotensin II si on - Angioede - Dizziness - headache. red or white skin (welts),
Name: Diovan to receptor ma - Fatigue CV: burning/itching skin,
- Renal - Headache - hypotension, swelling in the face, and
Classifications: sites in
- High blood potassium - edema. difficulty breathing.
ARBs vascular
or hepatic - Joint pain
smooth muscle disease - Low blood pressure EENT: - Assess blood pressure
Doctors order: and the adrenal periodically
- Nausea - rhinitis,
Valsartan P.O glands, which
- sinusitis,
50mg/tab OD inhibits the - Assess signs and
- pharyngitis.
pressor effects symptoms of CHF such as
of RAAS. dyspnea, rales/crackles,
GI:
Date peripheral edema, jugular
- abdominal pain,
venous distention,
- diarrhea
started: - nausea.
Maintenance. exercise intolerance.
GU:
- Assess peripheral edema
- impaired using girth
measurements, volume
renal function.
displacement, and
measurement of pitting
MS: edema.
- arthralgia
- back pain. - Watch for signs of
impaired renal function,
Misc.: including decreased urine
- angioedema output, cloudy urine, or
sudden weight gain due
to fluid retention.
4
 - Monitor signs of high
plasma

4
 potassium
levels
(hyperkalemia), including
bradycardia,

fatigue, weakness,
numbness, and tingling..

- Assess dizziness that might

affect gait, balance, and
other functional activities.
CALCIUM Calcium is - Hypocalc Cancer - upset stomach. GI: - Monitor calcium level
CARBONATE essential e mia patient with - vomiting - Constipation frequently.
for - Dietary bone - stomach pain - Monitor signs
Brand Name: nervous, suppleme metastases - belching or laxative effect, of
Calci-aid muscular, nt - constipation - acid rebound, hypercalcemia which
and - Hyperpho Ventricular - dry mouth - nausea, includes stupor, confusion,
s - increased urination - eructation, delirium, and coma.
Classifications: skeletal fibrillation
phatemia - loss of appetite - flatulence, - Monitor hemodynamics.
Calcium systems, helps
- metallic taste - vomiting, - Monitor
supplements maintain. cell Hypercalcemi
- fecal concretions.
a hypotension, bradycardia,
Doctors order: membranes, Metabolic: and arrhythmias.
Calcium aids Hypophosphat - Instruct pt on foods that
- Hypercalcemia
carbonate PO in emia with alkalosis, contain Vitamin D and
500mg/tab TID transmission of - metastat encourage adequate
x 6 doses nerve impulses Renal calculi ic intake.
and calcinosi - Monitor parathyroid
Date s, hormone.
muscle - hypercalciuria,
started: March contraction, - hypomagnesemia,
9, 2023 aids in blood - hypophosphatemi
a
formation and
CNS:
coagulation
- Mood and

mental changes.
4
 Urogenital:
- Polyuria,
- renal calculi.

4
CEFTAZIDIME Inhibits cell- Hypersensiti - severe stomach pain, CNS:
wall synthesis, - Pneumonia vit y to diarrhea that is watery - SEIZURES - Monitor signs
Brand Name: promoting - Lower drugs or bloody. of
Ceftazin osmotic respirato - pale or yellowed skin (HIGH DOSES pseudomembranous
instability; ry tract Hypersensiti - dark colored urine, IN colitis, including diarrhea,
Classifications: usually infection ve to - fever, or weakness PATIENTS abdominal pain, fever, pus
Antibiotics – bactericidal. - confusion, WITH or mucus in stools, and
penicillin
hallucinations, severe RENAL other severe or prolonged
Third weakness. IMPAIRMENT) Gi problems (nausea,
generation Prolonged - involuntary vomiting, heartburn).
- Encephalopathy
cephalosporins use can GI:
result in muscle movement. - PSEUDOMEMBRA - Monitor signs of allergic
Doctors order: superinfectio - seizure (black-out or NOUS COLITIS, reactions and anaphylaxis,
Ceftazidime n. convulsions); or - abdominal pain including
- a cold - diarrhea
1g IV Q8H History feeling, - nausea pulmonary symptoms
of discoloration, or skin - vomiting. (tightness in the throat
colitis, renal changes in your and chest, wheezing,
Date insufficiency fingers. Derm: cough dyspnea) or skin
- rashes reactions (rash, pruritus,
- pruritus urticaria).
started: March
12, 2023 - Urticaria
- Be alert for signs of
Hemat: encephalopathy, including
- Bleeding decreased alertness,
- blood dyscrasias lethargy, and
incoordination.
- hemolytic anemia

Local: - Monitor signs of blood

dyscrasias including
hemolytic anemia
(unusual weakness and
fatigue, dizziness,
jaundice, abdominal pain)
and thrombocytopenia
(bruising, nose bleeds,
bleeding gums, other
5
 unusual bleeding).

- Monitor injection site for

pain, swelling, and
irritation
HYDROCORTIS Decreases - Edematous Hypersensitivi - feeling dizzy, weak or CNS: - Monitor fluids and
t electrolytes

5
ONE inflammation, states y to drugs tired - seizures
mainly - headaches - Depression - Monitor weight and BP
Brand Name: GI - muscle ache - Euphoria
Hydrovex by - indigestion or feeling - Increase ICP - Monitor glucose and
stabilizing Condition sick (nausea) - Headache cholesterol level
Classifications: leukocyte - diarrhoea - Restlessness - Monitor signs
Corticosteroids lysosomal of
– membranes; EENT: hypersensitivity reactions
- Cataracts or anaphylaxis.
Glucocorticoids suppresses
- increase
immune
d - Assess any muscle or joint
Doctors order: response; intraocul pain.
Hydrocortisone stimulates ar
100mg IV Q12H bone pressure. - Assess muscle strength
x 6 doses marrow; periodically to determine
influences CV: degree of muscle wasting
protein, fat - hypertension. during long- term use.
Date and
carbohydrate GI: - Measure blood pressure
started: March metabolism. - Peptic ulceration periodically and compare
09, 2024 - Anorexia to normal.
- Nausea
Date - Vomiting - Assess peripheral edema
discontinued: using girth
March 13, measurements, volume
Metabolic: displacement, and
2024
- Decrease measurement of pitting
carbohydra edema.
te
ATORVASTATIN Inhibits - Coronar Hypersensitiv - diarrhea CNS: - Monitor ALT. AST and CK
HMG- y artery it y to drugs - heartburn - dizziness, levels
Brand CoA disease - gas - headache,
- Reduce Hepatic - joint pain - insomnia, - Assess any muscle pain,
Name: Lipitor reductase, an risk impairment - forgetfulness or - weakness. tenderness, or weakness,
Classifications: early step in memory loss EENT: especially if accompanied
of - confusion - rhinitis by fever, malaise, and
antilipemic cholesterol myocardial Renal failure dark- colored urine.
5
 – biosynthesis. infarction, Resp:
HMG- CoA stroke
reductase and
angina

5
inhibitors - Lipid - bronchitis
lowering - Monitor signs of
Doctors order: treatme CV: angioneurotic edema and
Atorvastatin nt. - chest pain other
P.O 40mg/tab - peripheral edema hypersensitivity reactions,
ODHS including rashes, raised
GI: patches of red or white
- abdominal cramps skin (welts),
- constipation burning/itching skin,
Date swelling in the face, and
- diarrhea,
- flatus, difficulty breathing.
started:
- heartburn,
Maintenance - Assess dizziness and
- altered taste,
- drug- weakness that might
induced affect gait, balance, and
hepatitis, other functional.
GU:
- erectile - Assess peripheral edema
dysfunction. using girth
Derm: measurements, volume
- rashes, displacement, and
measurement of pitting
- pruritus.
edema.
Misc:
- HYPERSENSITIVIT
Y REACTIONS, - Monitor chest pain or
symptoms of bronchitis
- INCLUDING
ANGIONEUROTIC (cough, production of
EDEMA. sputum, shortness of
breath, wheezing).
SPIRONOLACT Causes loss Hyperkalemia - diarrhea and belly CNS: - Monitor glucose, uric acid,
ONE of - Edema cramps - dizziness, BUN and potassium levels
sodium associate Addison's - nausea and vomiting - clumsiness, - Monitor signs of fluid,
Brand bicarbonate d with disease - hyperkalemia - headache. electrolyte, or acid-base
and congestiv (chronic imbalances,
Name: calcium e heart adrenal (high potassium level) CV: including
failure - leg cramps - arrhythmias. dizziness,
Aldactone while insufficiency)
cirrhosis, - headache
5
 saving and , - dizziness clumsiness,
Classification potassium and - drowsiness drowsiness,
s: Potassium- - itching
hydrogen headache,
ions by blurred vision, confusion,
hypotension, or
antagonizing
muscle

5
sparring aldosterone. nephrotic Conditions GI: cramps and weakness.
diuretics- syndrome associated - GI irritation.
aldostero . with - Assess dizziness and
ne hypertens hyperkalemi GU: clumsiness that might
i on a. - erectile affect gait, balance, and
Doctors order: dysfunction other functional activities.
Spironolactone Receiving - dysuria.
PO 25mg/tab other
OD potassium- Endo: - Assess heart rate, ECG,
- gynecomastia and heart sounds,
sparing especially during exercise.
Date agents
(in males),
- deepening of - Assess blood pressure
started: periodically and compare
voice,
Maintenance. to normal values to help
F and E: document
- hyperkalemia, antihypertensive effects.
- hyponatremia,
Hemat: - Assessing peripheral
- agranulocytosis. edema using girth
MS: measurements, volume
displacement, and
- muscle cramps.
measurement of pitting
Misc:
edema
- allergic reactions.
- Monitor signs of allergic
reactions,

including pulmonary
symptoms.
ISOSORBIDE Thought to - Angina Hypersensitiv - lightheadedness, CNS: - Assess episodes of angina
DINITRATE reduce cardiac pectori it y to drug - worsening chest pain, - dizziness, pectoris at rest and during
oxygen s - fast or slow heart rate, - headache. exercise.
ISDN demand by - Hear Methemoglobi - pounding heartbeats,
decreasing t nemia - fluttering in your chest, CV: - Assess heart rate, ECG,
failur - hives, - hypotension, and heart sounds,
Classifications: preload
e - difficulty breathing, and - tachycardia, especially during exercise.
5
Nitrates Blood volume - swelling of face, lips, - paradoxic
and
afterload.
Drug
also may

5
 increase depletion tongue, or throat - bradycardia,
Doctors order: - syncope. - Assess dizziness and
ISDN P.O 5mg blood flow syncope that might affect
Q15min x 3 through the GI: gait, balance, and other
doses collateral - nausea, functional activities.
coronary - vomiting.
vessels. - Assess
Date Misc:
- flushing, dyspnea, rales/crackles,
- tolerance. peripheral edema, jugular
started: March venous distention,
09, 2024
exercise intolerance to
help document whether
drug therapy is effective
in reducing these
symptoms.

- Report signs of drug

tolerance during long-term
use, as indicated by
increased episodes of
angina or CHF
symptoms.
SODIUM acts as - Metabolic - Edema - Aggravated - Assess the client’s fluid
BICARBONATE an - Flatulence congestive balance throughout the
alkalinizing Managem or respiratory - Gastric distention therapy. This assessment
Brand agent by e nt alkalosis - Metabolic alkalosis heart failure (CHF includes intake and
releasing Hypocalcemi - Hypernatremia - Cerebral output, daily weight,
of - Hypocalcemia hemorrha edema and lung sounds.
Name: Neut bicarbonate a Excessive
metabolic - Hypokalemia ge - Symptoms of fluid
ions. Following acidosis chloride loss
- Sodium and - Swelling (edema overload should be
Classifications: oral It is reported.
water - High blood
organic administration not retention sodium levels - Sigs of acidosis should be
carbonic acids of this recommende - Irritation at IV site - Low blood assessed such
medication, it d as an - Tetany calcium levels as
5
Doctors order: releases antidote - Low disorientation, headache,
Sodium bicarbonate following weakness, dyspnea, and
bicarbonate PO which is ingestion blood potassium hyperventilation.
capable of of levels - Assess for alkalosis
- Muscle by
strong
neutralizing mineral
spasms
gastric acid. acids. (associated with
low

5
650mg OD Patients calcium levels) monitoring the client for
- Metabolic alkalosis confusion,
Date on sodium - Belching
restricted - Bloating irritability, paresthesia,
started: March diet Renal - Excess fluid in tetany and altered
09, 2024 failure the lungs breathing pattern.
(pulmonary - Hypokalemia should also
Severe edema) be assessed by monitoring
abdominal - Hyperosmolality signs and symptoms such
pain - Intracranial as: weakness, fatigue, U
of acidosis wave on ECG,
unknown - Milk- arrhythmias, polyuria, and
cause alkali polydipsia.
especially syndrom - Monitor the client’s serum
e calcium, sodium,
if associated potassium, bicarbonate
with fever concentrations, serum
osmolarity, acid-base
balance and renal function
before and throughout
the
therapy.

5
BISOPROLOL Selectively - Hyperten Hypersensitiv - Headaches CNS: - Monitor serum
FUMARATE blocks cardiac si on it y to drug - Feeling dizzy or weak - fatigue, triglyceride, AST, ALT, uric
adrenoreceptor - Hear - Cold hands or feet - weakness, acid, creatinine, BUN,
Brand s reducing t Hepatic - Feeling or being - anxiety, potassium, glucose and
resting and failur sick (nausea - depression, phosphorus level.
e or vomiting) - dizziness, - Assess heart rate, ECG,
Name: Cardicor exercise HR, or renal
- Diarrhea - drowsiness, and heart sounds,
decreasing insufficiency
- Constipation - insomnia, especially during exercise.
Classifications: cardiac
- memory loss
Antihypertensiv Hyperthyroidi - Assess routinely for signs
- mental
e s – selectiveoutput, sm of CHF and pulmonary
beta blockers depressing status changes, edema, including
renin Anaphylactic - nervousness,
Doctors order: secretions, reaction - nightmares. dyspnea, rales/crackles,
Bisoprolol PO and weight gain, peripheral
5mg/ 1tab OD decreasing Bronchospas EENT: edema, and jugular
tonic ti c disease - blurred vision, venous distention.
sympathetic - stuffy nose.
Date outflow from - Assess blood pressure
started: (BP) periodically and
the vasomotor
compare to
centers in
the
brain.

5
Maintenance. Resp: normal values to help
- bronchospasm document
- wheezing. antihypertensive effects.

CV: - Assess symptoms of

- hypotension, bronchospasm.
- peripheral
vasoconstrictio - Monitor signs of peripheral
n. vasoconstriction, such as
extreme coldness in the
GI: hands and feet, cyanosis,
- constipation, and muscle cramping.
- diarrhea,
- liver - Be alert for signs of
hypoglycemia (weakness,
function malaise, irritability,
abnormalities, fatigue) or hyperglycemia
- nausea, (drowsiness, fruity breath,
- vomiting increased urination,
unusual thirst).
GU:
- urinary frequency. - Assess any back, joint, or
muscle pain to rule out
musculoskeletal
pathology.

- Assess dizziness and

drowsiness that might
affect gait, balance, and
other functional activities.

- Monitor excessive fatigue

or weakness.
COLCHICINE Exact - Serious - nausea GI: - Monitor AST, ALT, and CK
mechanism cardiovascular - vomiting - Diarrhea levels
Brand Name: o action is Preventio disease - diarrhea - Nausea - Monitor hemoglobin and
5
not fully n of

known; gout
flares

5
Colcrys thought to - Arthritis - stomach cramps or - Vomiting hematocrit
involve a - Pericarditis Renal pain - abdominal pain - Monitor and report signs
Classifications: reduction in - muscle pain or of agranulocytosis or any
antigout drugs lactic Hepati weakness GU: unusual weakness and
– Colchicum - numbness or tingling - anuria fatigue.
autumnale acid c in the fingers or toes. - hematuria
alkaloids - unusual bruising or - renal damage - Be alert for signs of kidney
produced
bleeding damage, including bloody
by GI Impairment
- sore throat, fever, Derm: urine (hematuria) and
Doctors order: leukocytes, decreased or absent urine
chills, and other signs - alopecia.
Colchicine P0 reducing uric Hematologic of infection output.
0.6mcg/tab OD acid deposits disorders - weakness or tiredness Hemat:
- paleness or grayness - Periodically assess
- AGRANULOCYTO
and of the lips, tongue, or patient's impairments
SIS
Date phagocytosis, palms (pain, range of motion),
- APLASTIC ANEMIA
thereby functional ability, and
- Leukopenia
started: Marh decreasing disability to help
- thrombocytopenia.
09, 2024 the determine if gout
inflammatory symptoms are reduced by
Local: drug therapy.
process - phlebitis at IV site.
- Be alert for signs of
Neuro: peripheral neuritis
- peripheral (numbness, tingling,
neuritis. decreased muscle
strength).

- Assess injection site

during and after IV
administration, and report
signs of phlebitis (local
pain, swelling,
inflammation).

5
CLOPIDROGEL Inhibits - Reduce Hypersensitiv  excessive tiredness - Monitor platelet count
rate of it y to drugs  headache CNS: - Be alert for signs of GI
Brand Name: the binding of MI and  dizziness bleeding signs or other
Plavix the P2Y12 stroke in Premature  nausea  depression, signs of bleeds.
patients  vomiting  Dizziness - Monitor signs of
component of interruption
 stomach pain  fatigue, thrombotic
Classifications: ADP to its
 diarrhea  headache. thrombocytopenic
platelet of therapy purpura,
receptor, such as purplish spots on
the

5
antiplatelet impeding ADP-  nosebleed skin,
drugs – mediated Increased EENT:
activation bleeding decreased consciousness,
platelet and  epistaxis.
aggregation subsequent from trauma fatigue,
Respiratory: weakness, shortness of
inhibitor platelet
breath on exertion, and
aggregation,  cough, tachycardia.
Doctors order: and irreversibly  dyspnea. - Assess blood pressure
Clopidogrel PO modifies periodically.
75mg/ 1tab OD the CV: - Assess peripheral edema
platelet ADP using girth
Date receptor  chest pain measurements, volume
 Edema, displacement, and
started:  hypertension. measurement of pitting
Maintenance. edema.
GI:
- Monitor excessive
coughing, chest pain, or
 GI bleeding
difficult, labored
 abdominal pain
breathing.
 Nausea
- Monitor signs
of
and vomiting
hypersensitivity reactions,
 Diarrhea
including
 Dyspepsia
pulmonary
symptoms (tightness in
the throat and chest,
wheezing, cough,
dyspnea) or skin reactions
(rash, pruritus, urticaria).
- Monitor and report signs
of neutropenia including
fever, sore throat, and
other signs of infection.
- Assess dizziness and
drowsiness that might
affect gait, balance, and
5
 other functional activities.
- Assess any back pain or
joint pain to rule out
musculoskeletal
pathology;
that is, try to determine if
pain

5
 is drug induced rather
than caused by
anatomic
or
biomechanical problems.
CETIRIZINE Antagonizes - Angioede Contraindicat - headaches CNS: Assess for
the effects m a. e d with - dry mouth - Somnolence possible
Brand - Relief allergy to - feeling sick (nausea) - sedation contraindications or cautions:
of - feeling dizzy CV: any history of allergy to
Name: histamine at H1 of nausea any - diarrhea - Palpitation antihistamines; pregnancy
and
Benadryl receptor sites; antihistamine - sore throat - edema and lactation; and prolonged
vomiting - sneezing or blocked
does not bind s, QT interval, which
associate and runny nose GI:
Classifications: to or d with hydroxyzine. are
antihistamine - Nausea contraindications to the use
motion
inactivate Narrow-angle - Diarrhea of the drug; and renal or
sickness.
Doctors order: - Abdominal
histamine. glaucoma hepatic impairment, which
Cetirizine PO requires cautious use of the
pain constipation
10mg PRN Stenosing Respiratory: drug.
peptic ulcer - Bronchospasm
- Pharyngitis Perform a physical
Symptomatic Other: examination to establish
Date prostatic - Fever baseline data for assessing
hypertrophy - Photosensitivity the effectiveness of the drug
started: March - Rash and the occurrence of any
09, 2024 Asthmatic - Myalgia adverse effects associated
attack - Arthralgia with the drug therapy.
- Angioedema
Bladder
Assess the skin color, texture,
neck and lesions to monitor for
obstruction anticholinergic effects or
allergy.
Pyloroduode
na l
obstruction Evaluate orientation, affect,
5
 and reflexes to monitor for
changes due to CNS effects.

Assess respirations and

adventitious sounds to
monitor

5
 drug effects.

Evaluate renal and liver

function tests to monitor for
factors that could affect the
metabolism or
excretion of the drug.
METOCLOPRA Stimulates - Preven Hypersensitiv - drowsiness CNS: - Monitor signs of
MIDE motility of t it y to drugs - excessive tiredness - drowsiness, neuroleptic malignant
upper GI nausea Impaired - weakness - extrapyrami
Brand and renal or - headache dal syndrome,
tract, vomitin - dizziness reactions, including
g - diarrhea - restlessness,
Name: increases hepatic
- Delayed - nausea - NEUROLEPTIC hyperthermia, diaphoresis,
Metozolv function
gastric - vomiting MALIGNANT
lower emptyin generalized
- breast enlargement SYNDROME,
esophageal g. Electrolyte or discharge muscle rigidity, altered
- anxiety,
Classifications: sphincter imbalance - missed menstrual - depression, mental status,
GI Stimulants period. - irritability, tachycardia, changes in
tone, Hyperuricemi - decreased sexual - tardive dyskinesia. blood pressure (BP), and
- dopamine and ability. CV: incontinence.
antagonist a SLE - frequent urination - arrhythmias - Assess motor function and
blocks - inability to - hypertension, be alert for
Doctors order: dopamine Diabete control - hypotension. extrapyramidal symptoms.
Metoclopramide receptors at urination GI: - Monitor the frequency,
IV 10mg s Gout - constipation, severity, and duration of
the
- diarrhea, GI problems (nausea,
chemoreceptor
- dry mouth, vomiting, heartburn,
Date trigger zone.
- nausea. hiccups) to help document
Endo: drug effectiveness.
started: March - Assess heart rate, ECG,
09, 2024 - gynecomastia.
and heart sounds,
especially during exercise.
Hemat:
- methemoglobine
- Assess BP and compare to
mi a,
normal values.
- neutropenia,
6
 - Monitor signs
of
agranulocytosis,
neutropenia, and
leukopenia (fever, sore
throat, signs of
infection) or
methemoglobinemia
(bluish coloring of the
skin, lips

6
 - leukopenia, fingernails;
- agranulocytosis.
headache; shortness of
breath; lack of energy).
- Monitor intake and output
and weight.
- Monitor glucose level.
- Monitor signs of
hypokalemia

6
COURSE IN THE WARD

Date and Time Focus Data/Action/Response Doctor’s Order

09 March 2024 Difficulty of D: In to ER a 49 years Please admit to NOC
10:06 pm breathing old male under the service
accompanied by his od Dr Dayag
wife with a chief
complaint of DOB Secure consent for
A: Chest x-ray done admission
and relayed
A: Advised for and management
Admission admission A: RAT
done (-); V/S taken Monitor V/S q4 then
and relayed; S/E; record
Informed AP Dr.
Dayag of A.; I&O every shift
Diagnostic done and
relayed; initial meds Diet:
as ordered started; Low fat and low salt
hooked to heplock;
other needs given; Diagnostics:
11:30 pm endorsed to ward CBC
Post admission NOD. ABG
care Serum electrolytes
D: Received from Biochemical
DEMS via wheelchair
with intact heplock; Cardiac Marker
awake; afebrile; with Creatinin
complaint of SOB and e
abdominal cramping Urinalysi
A: Assisted to bed s ECG
11:45 pm safely and COVID 19 RAT
comfortably
A: VS taken and Treatment:
recorded Heplock
A: Patient complaint
of shortness of Continue medication:
breathing and 1. Bisoprolol 5mg
diaphoresis. 1- tab OD
VS taken: 2. Valsartan 50mg
11:55 pm Temp: 36.4 1- tab OD
PR: 70 3. Spironolacton
RR: 20 e 25mg 1-tab
BP: OD
120/70 4. Atorvastatin
O2 sat: 95%
A: Informed AP 40mg 1-tab ODHS
and ROD for 5. Ketoanalogue 1-
assessment tab BID
A: S/E by ROD with 6. Clopidogrel 75mg
orders made and 1- tab OD
carried out 7. Colcichine 0.6mg
A: Hooked to O2 1- tab OD
support 1-2 LMP via 8. Imdur 30mg 1-
nasal cannula tab OD
A: Due meds given
A: Instructed SO to *Furosemide 40mg

6
report any untoward IV now q8
S/SX *Monitor closely
A: Needs and
calls attended
A: Safety ensured
A: Still with SOB
and DOB; on sitting
position;

6
 with O2 @ 2LPM via
nasal cannula
A: Refer to A; ISDN
5mg SL now then 3
doses given as
ordered
A: For transport to
ICU, ROD explained
to patient and SO,
but the pt and SO
refused. Refusal form
signed by
SO.
10 March 2024 D: AP ordered hook to
3:00 am high flow; explained
to patient but the
patient decided to
transfer to ICU
A: Informed AP;
carried out orders
A: Transfer to ICU for
continuity of care
3:44 am Trans in from dips D: Received patient
wheeled on
wheelchair; conscious

and conversant with

GCS 15/15 with O2
support via nasal
cannula. IV access on
right hand on heplock
A: Initial assessment
done; informed AP
with latest vital signs;
place comfortably on
4:23 am bed; monitored
closely
A: Furosemide 40 mg
given as ordered thru
messenger
A: Maintained on
sitting position on
5:00 am Morning care bed
A: VS and I and O
are monitored
A: Change gown and
5:40 am Doctor’s round beddings; discarded
soaked diaper after
weighing
7:00 am Handover A: Carried out new
orders
A: Attended all
3:00 pm Continuity of care needs; endorsed to
next shift.
A: Endorsed

D: Received patient
on bed on semi
6
fowlers position;
awake; GCS 15/15;
O2 support via NC; IV
access on R MCV
A: Maintained patient
on

6
 semi fowlers position
A: Monitored
patient’s V/S and
I&O
A: Advised patient
to report untoward
7:00 pm Continuity of care S/SX

D: Received patient on
bed on semi fowlers
position with O2
support via NC @ 1
LPM, with IV access on
R MCV, GCS 15/15
A: All due meds
given A: All needs
attended
A: Endorsed to next
shift
11 March 2024 Continuity of Care D: Patient on a
7:15 am moderate high back
rest with GCS 15/15
as assessed; with O2
support via NC @ 1
LPM but able to
tolerate room air;
free voiding via
urinal; with intact
heplock; able to
move all extremities
(-) chest pain A: V/S
taken and recorded;
due meds given as
ordered; monitored
7:51 am accordingly

D: Received an SMS
order from Dr. Dayag
A:
Trans Out
Transcribed
availability of
room
Trans In checked then
9:30 am reserved A: All needs
attended; endorsed
accordingly to DIPS-
NOD

D: In from ICU with

intact heplock; room
air; free voiding and
ambulatory
A: Transferred to bed
Continuity of Care comfortably;
11:00 am
meds attended;
monitored V/S;
6
instructed SO to
report for any
untoward S/SX

D: Patient on sitting
position in the bed
with heplock intact
A: V/S taken and
recorded
A: Pre-assessment
done

6
 A: Instructed pt and
SO to report any
untoward S/S

Continuity of Care D: Received

7:00 pm patient awake
sitting on chair; with
intact heplock; no
complaint of chest
pain A: Instructed
patient and SO to call
for assistance if they
need anything
A: Instructed to WOF
sudden chest pain
A: V/S taken
and recorded
A: All needs attended
12 March 2024 Continuity of Care D: Received patient
7:00 am with intact heplock
A: V/S taken and
recorded; WOF
untoward S/SX
A: Due meds given as
ordered
A: Calls and needs
attended

7:00 pm Continuity of Care D: Received patient

with intact and
patent heplock
A: V/S taken and
recorded; instructed
SO to report any
untoward S/SX
A: Due meds given as
ordered, calls and
needs attended

13 March 2024 Continuity of Care D: Received patient

7:00 am with patent heplock
A: Due meds
given, monitored
accordingly
A: V/S taken
and recorded
A: Calls and
needs attended
7:00 pm Continuity of Care
D: Received patient
on bed with intact
heplock A: V/S
taken and
recorded, WOF
untoward S/SX;
post assessment
done
A: Due meds given

6
as ordered
A: Calls and needs
attended

6
14 March 202 Discharge D: Received patient
7:00 am Planning on bed with no
complaints of pain.
A: Seen and
examined by Dr.
Dayag, with orders
made and carried
out, take home
medication, with may
go home order.
R: The patient and the
mother acceded to all
instructions, settled
their
bills, and went home

6
 NURSING CARE PLAN
ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION
ANALYSIS INTERVENTIONS
Subjective: Impaired Atheroscleros Short term goal: Independent Independent Short term goal:
gas is and
“Bigla nalang exchange endothelial After 6hrs of Note the presence of Can be related to GOAL MET
kase nag r/t dysfunction nursing conditions that can multiple factors:
cramps ineffective intervention the cause or be associated adult cardiac After 6hrs of
yung pt. will in some way with gas nursing intervention
airway the pt. will be able
tiyan ko clearance exchange problems. disorder,
tas  Demonstrate altered level to:
or Narrow improved
nahirapan breathing artery of  Demonstrate
naman ventilation consciousness,
pattern and improved
na and ventilation
akong adequate neuromuscular
oxygenation and
huminga kaya Decreased impairment of adequate
dali of breathing pattern
blood flow tissues by oxygenation
dali Note respiratory rate, This provides of
akong ABGs within depth, use ofinsights into the work tissues by
nagpatakbo accessory muscles, of breathing and ABGs within
sa client’s usual pursed- adequacy of alveolar
hospital” parameters lip breathing, and ventilation, and
Decreased and absence client’s usual
as oxygen areas ofpotential pulmonary parameters
verbalized of pallor/cyanosis, such or cardiac
supply symptoms and absence
as peripheral compromise of
by the pt. (nailbeds) versus symptoms
of respiratory central
distress (circumoral) or
Objective of respiratory
Increased general duskiness. distress
VITAL SIGNS oxygen  Participate Assess level of A decreased level of
demand in consciousness consciousness can
BP:160/90mmHg treatment be an  Participate
regimen and mentation in
within changes indirect treatment
O2-98% measurement regimen
the of within
6
 Difficulty level impaired
RR: 17rpm oxygenation, but it
the
of ability also impairs one’s
ability to protect the level

ABG: airway,
of ability
Long term goal: potentially
further Long term goal:

adversely affecting
oxygenation

6
Respiratory breathing Monitor vital signs and All vital signs are
Alkalosis After 3days cardiac rhythm impacted by GOAL MET
of nursing changes in
intervention the oxygenation After 3days of
pt. will nursing intervention
Evaluate pulse Determine
the pt. will be able
oximetry oxygenation and
to
levels of carbon
 Verbalize dioxide retention
understanding Elevate the head of  Verbalize
Elevation or upright
of understanding
the bed and position position facilitates
of
the client respiratory function
causative appropriately by gravity
factors causative
and factors
appropriate Encourage adequate This helps limit and
interventions rest and limit activities oxygen needs and appropriate
to within client consumption interventions
tolerance. Promote a
calm, restful
environment
Dependent: Dependent:
Reinforce the need for To decrease dyspnea
adequate rest, while and improve quality
encouraging activity of life
and exercise

Emphasize Improving stamina

and reducing the
the importance of work of breathing
nutrition
Review job Identify need for job
description modifications
and work activities
or vocational
rehabilitation

6
Collaborative Collaborative
Refer to To have better
respiratory health care
therapist and intervention
cardiologist

6
ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION
ANALYSIS INTERVENTIONS
Independent Independent
Subjective: Fatigue Physical Short term goal: Identify the Important Short term goal:
deconditioni presence information if
“Madalas ng After 3hrs of of fatigue is a result GOAL MET
r/t physical
na nursing physical of an underlying
deconditioning
akong mapagod intervention the condition After 3hrs of nursing
tuwing pt. will and/or intervention the pt.
psychological or disease will be able to:
nag naglalaro Diminished conditions process
ako ng cardiovascular  Participate Review Many medications  Participate
Basketbal, kaya function medication have the potential
limitado narin including in regimen/regim side effect in
ang paglalaro reduction of recommend en recommended
ko” as (CO, SV and treatment /another of treatment
verbalized by minimal O2 program. causing/exacerbating program.
the pt. consumption) drug use fatigue
 Identify  Identify basis
Objectives: basis of Assess To evaluate of fatigue and
fatigue and fluid status individual
HPT vital signs and
individual areas of
Obesity cardiopulmonary
areas control.
Compromise response to activity.
d oxygen Determine the Fatigue can be a
of control.
delivery presence/degr consequence
ee of
of, and/or
sleep exacerbated by,
Long term goal: Long term goal:
disturbances sleep deprivation
Fatigue Treat To reduce fatigue GOAL MET
After 3days
underlying caused by treatable
of conditions conditions. After 3days of
nursing where possible nursing
intervention intervention the
the pt. Establish This enhances the pt. will be able to:
7
 commitment  Report
will realistic activity improved
goals with the to promoting
client and optimal
 Report encourage
improve
d

7
 sense forward movement outcomes. sense
Plan interventions to To
of of energy.
allow
energy.  Perform
maximize
 Perform activities
individually participation.
activities of daily
adequate rest
of
periods. Schedule
living and
activities for periods
daily participate
when the client has
living in desired
the most energy
and activities
Dependent: Dependent:
participa at
Obtain To assist in
t e level of
client/SO evaluating the
in ability.
descriptions of impact on the
desired fatigue client’s life
activities
at level Collaborative Collaborative
of ability.

7
Refer to To improve stamina,
comprehensive strength, and muscle
rehabilitation tone and to enhance
sense of well-being
program, physical
and
occupational therapy
for programmed
daily exercises and
activities

7
ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION
ANALYSIS INTERVENTIONS
Independent Independent
Excessive
Subjective: Excessive Short term goal: Obtain Among children Short term goal:
workload
caloric intake and
-“Lagi akong After 2 hrs weight history, adolescents in
r/t regular
busy sa trabaho of nursing noting if client the United
consumption GOAL MET
ko kaya maaga intervention the has weight gain States. Being
of high
palang pt. will out of character overweight After 2 hrs of
fat Unable to
pumupunta na for self or family, during older nursing intervention
meal have healthy •Verbalize a
ako, late narin is or was obese childhood is the pt. will be able
AEB diet lifestyle realistic
ako umuuwi, ang child, or used to highly to:
history and self- concept be much more predictive of
nature din kase
lifestyle or body image physically active adult obesity, •Verbalize a
ng work ko is
status (congruent than is now especially if a realistic self-
hindi gaanong Increased mental parent is also concept or body
gumagamit ng availability and physical obese. image (congruent
physical of food picture of self). Assess risk and To
effort. presence of mental and
Madalas factors or determine physical
din treatments picture of self).
kaming nag Decreased conditions and
stre- physical Long term goal: associated with interventions
street food activity obesity Long term goal:
After 3months
at that may be
of nursing
nagrerestaurant indicated in
intervention addition to weight
dahil wala GOAL MET
the pt. will management.
kaming time mag Unable to
luto kaya naman release Assess Nutritional needs After 3months of
•Participate in
napaparami din converted are not nursing
development of,
ako sa pagkain” energy client’s knowledge of intervention the
and commit to,
as verbalized by own body weight always pt. will be able to:
a personal
and nutritional understood, being
the pt •Participate
needs, and overweight or
7
 Fat build up determine cultural having large body
in development
expectations size may not be
viewed of, and
Objectives: regarding size.
negatively
Height: 167cm
by individual
because it
is considered within
relationship to
family

7
Weight: 92kg weight loss eating patterns commit to, a
BMI: 33kg/m2 program or peer personal weight
and loss program

cultural •Demonstrate
Obesity •Demonstrate
influences appropriate
appropriate
Review Comparative changes in
changes
baseline and lifestyle
in daily activity and to and behaviors,
lifestyle regular exercise identify areas including eating
program for
and behaviors, modification.  Attain
including eating Calculate BMI Estimate
percentage desirable body
 Attain weight with
desirable optimal
of body fat
body maintenance
Dependent: Dependent: of
weight with health

optimal Assist client and Technology

maintenanc family in using offers
e of health technology applications
to that can assist
manage in monitoring
dietary intake
food and food
choices/track choices
intake
Engage client Approaches
and family in to the
structured weight treatment of
severely
loss obese
programs, individuals
may
as indicated include

7
 lifestyle
modifications,
physical activity
Collaborative: Collaborative:

7
Collaborate with Healthy eating
nutritionist in pattern limits intake
addressing/implementi of sodium, solid fats,
ng client’s specific added sugars, and
needs refined grains and
emphasizes nutrient-
dense foods and
beverages

7
ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION
ANALYSIS INTERVENTIONS
Independent Independent
Subjective: Disturbed Neurotransmitt Short term Establishing a Encourage the patient Short term goal:
sleep er imbalance goal: Sleep to establish a
“Hindi
pattern Routine consistent sleep-wake
ako
related to schedule, even on GOAL MET
masyado
Physical After 3days weekends, to regulate After 3days of
makatulog
variations of nursing their body's internal nursing
tuwing gabi
(medications intervention clock. Going to bed intervention the
kase madalas Affect
) the pt. will and waking up at the pt. will able to
akong
system in the same time each day
umihi,
brain can help reinforce the
siguro epekto Work Work with
including body's natural sleep-
din to ng healthcare provider
sleep wake cycle and
gamot na with to determine if
regulation improve overall sleep
iniinom ko healthcare adjusting the timing
quality.
ngayon” provider of medications
to Sleep problems can
as
determine if arise from internal
verbalized by Identify presence of and external factors can minimize the
adjusting the
pt. Impact on factors known to and may impact on sleep
timing of
circadian medications interfere with sleep,
Objectives: rhythm as can minimize including current require
body internal the impact on assessment over Long term goal:
clock is sleep. illness, hospitalization time to differentiate
Used of regulated by specific causes
diuretics and suprachiasmati Listen to reports of Helps clarify client’s
c nucleus of Long term goal: GOAL MET
sleep quality perception of sleep
the quantity and quality
other After 7 After 7 days
hypothalamus and response to
medications days of of nursing
inadequate sleep intervention the
(FUROSEMIDE, pt. will able to
VALSARTAN, nursing Incorporate To evaluate the type
ATORVASTATIN, interventio screening and
Medication
7
 affect the SCN information into etiology of
SPIRONOLACT n the pt. in- Adopt healthy
sleep
ONE) will lifestyle
disturbance and
to
 Adopt
health
y

7
 lifestyle depth sleep identify useful habits that support
habits diary or testing if treatment options. good sleep, such as
that needed maintaining
Disrupt the support
timing and good Perform To ascertain intensity
monitoring and a
synchronization sleep, and duration of
care activities consistent
of sleep wake such problems
cycles without
waking sleep schedule
as
maintai client whenever
ni ng possible.
a Dependent Dependent
Disturbances in consiste Enhanced Sleep-promoting
sleep patterns n t Restorative medications can
sleep Sleep. facilitate the
schedu attainment of deeper
and more
restorative
sleep, allowing
the patient
to experience
improved
cognitive
function,
mood
regulation, and
physical recovery.

Adequate sleep is
essential for the
body's repair
processes and overall
health maintenance
Collaborative Collaborative

7
Refer to physician or For specific
sleep specialist as interventions and/or
indicated
therapies, including
medications,
biofeedback

7
ASSESSMENT DIAGNOSIS SCIENTIFIC PLANNING NURSING RATIONALE EVALUATION
ANALYSIS INTERVENTIONS
Independent Independent
Subjective: Risk for Stimulation of Short term goal: Identify presence Can cause or Short term goal:
unstable vasomotor of associated exacerbate
center send Goal met
blood conditions
“Matagal na pressure impulses to After 4hrs blood pressure After 6hrs of
CNS instability
akong of nursing
r/t nursing Review current Use of certain intervention the pt.
may inconsistenc intervention medication regimen medications can will be able to:
hypertension, y with the pt. have direct effects
may binigay medication Acetylcholine will on blood pressure
narin si doc regimen released • Maintain blood
Note client reports of May indicate that
para sa pressure
headaches, blurred blood pressure is
maintenance • Maintain within
vision, chest pain, elevated
ko” as blood pressure weakness or numbness acceptable limits
verbalized by within
Constriction of in arms, legs, or face • Experience
the pt acceptable
blood vessels Note client reports of Which may indicate no
limits
thereby dizziness or fainting, that blood pressure cardiovascular
increasing blood • Experience blurred vision, nausea, is fluctuating or systemic
Objectives: pressure no shortness of breath, downward. complications
cardiovascular and thirst
or systemic
BP:160/90mmHg Recommend changing To enhance safety
complications Long term goal:
position from supine to and reduce
Adrenal medulla standing slowly and in gravitational blood
secretes stages, avoiding pooling in the lower
epinephrine Long term goal: Goal met
standing motionless or extremities
for long periods of After 3days of
time, or sitting with nursing
legs crossed intervention the pt.
Increased HR After 3days will
of
7
nursing
intervention
the

7
 pt. will Dependent Dependent • Verbalize
understanding of
Emphasize importance For monitoring
condition,
of regular and long- blood pressure
• Verbaliz therapeutic
Increased BP term medical follow- and
e understanding regimen,
up appointments disease/condition
of
trends, and to
condition, and preventive
provide for early
therapeutic measures
intervention to
regimen,
reduce risk • Initiate
and
of necessary
preventive
complications. lifestyle/behavioral
measures
Instruct client/SO in Exercise program, changes
• Initiat lifestyle modifications stress management
e based on identified techniques, not only
necessary risks reduce risk of blood
lifestyle/behavior pressure issues but
al changes also enhance
general wellbeing
Collaborative: Collaborative:
Refer for and Can restore
collaborate in hemodynamic
treatment/managemen stability or reduce
t of underlying risk of blood
condition pressure
fluctuations
Review current Use of certain
medication regimen medications can
have direct effects
on blood pressure

8
Identify presence Can cause or
of associated exacerbate
conditions
blood pressure
instability

8
x. References

Kishanrao, S. (2023). Congestive heart failure in Indian elders. Clinical

Cardiovascular Research, 2(1), 01–04. https://doi.org/10.58489/2836-5917/006
Kizior, R. J., & Hodgson, K. (2021). Saunders nursing drug handbook 2022 E-book.
Elsevier Health Sciences.