Mini Case

Study

CESTINA, Rosemarie N.
 BIOGRAPHIC INFORMATION
NAME Jose Leolito R. Naga
SEX Male

ADDRESS San Jose Townhomes Subdivision brgy pasong camachile II, gen trias cavite

AGE 69 years old

MARITAL STATUS Married

RELIGION Roman Catholic

OCCUPATION Businessman

ALLERGIES none

SOCAL HISTORY Drinking alcohol. Not taking any medications

MEDICAL HISTORY Has hypertension

FAMILY HISTORY Father side has history of hypertension

 Gordon’s 11 Assessment Questions
Pattern

Pattern of Health The patient stated that he is fine but sometimes feel body pain.
Perception and Health He is often eating vegetables and fruits to improve his health and not allergic
Management to any food or medication. He also stated that he drinks alcohol but never
smokes. He has hypertension and does not have any regular check up.
Nutrional- Metabolic The patient stated that he eats 3 times a day and usually eats fish and
Pattern vegetables. The patient also consider himself as a healthy eater because as
much as possible he is avoiding oily foods. He drinks 7-8 glasses of water
everyday and he drinks alcohol if there is an occasion or feeling troubled and
he thinks he lost weight due to stress.
Elimination Pattern The patient stated that he defecates once daily with no signs of discomfort
and difficulty and it is color brown. He voids 3-4 times daily with no signs of
discomfort and difficulty and the color of urine is clear.

Pattern of Activity or The patient stated that he does not do any exercise because he is busy and
Exercise during his spare time he sings, listen to music or do some household chores
like washing the dishes. He also said that he does not do sports.
 Gordon’s 11 Assessment Questions
Pattern

Pattern of Sleep and Rest The patient stated that he usually wakes up at 6am and sleeps at 10pm. He
feels well rested and able to do his work. When sleeping he falls asleep
immediately and does not use any aids to fall asleep.

Cognitive- Spiritual The patient stated that he does not have any difficulty hearing. He uses a
Pattern reading glass to read any papers and does not have any eye routine exam.
He also mentioned that he does not have any diseases that can cause mental
or sensory functions.

Self- Perception- Self The patient stated that he feels good about his self but sometimes he felt like
Concept Pattern there is no hope, because of his children not finishing college and started their
own family and felt like there is something wrong with how he raise them.

Role- Relationship He stated that he is a father, a grandfather, a husband and a friend that lives
Pattern with his wife and grandchildren. For him family is the most important
relationship because they are the ones who will always care and support you.
 Gordon’s 11 Assessment Questions
Pattern

Sexuality – The patient stated that he does not have an active sexual life
Reproductive Pattern and that does not have any disease regarding his
reproductive system.
Pattern of Coping and The patient stated that his life has change because recently
Stress Tolerance he knew that his young grandchildren is having a baby. The
way for him to cope up with his problems is to talk to his
relatives or friends and drinks alcohol.
Pattern of Values and The patient stated that religion is important to him because
Beliefs he believes in God and that God can help him with his
problem and make him at ease. He is always reminding
himself about what his parents said and that is to always
believe in God.
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective Risk for After 8 hours of -Monitor blood - Changes in BP may
“paminsan decreased nursing pressure periodically. indicates changes in Goal Met
nararamdaman ko cardiac output intervention the patient status
na ang bilis ko related to patient will requiring prompt attention. After 8 hours of
mapagod tsaka -Auscultate heart -The presence of crackles nursing
increased maintain blood
nahihilo” as tones and breath and wheezes may intervention the
verbalized by the vascular pressure within sounds indicate pulmonary patient
patient. vasoconstriction normal range. congestion secondary to maintained
developing or chronic blood pressure
Objective heart failure. within normal
-Pale in color -Observe skin color, -The presence of pallor; range.
-Skin cool to touch moisture, temperature, cool, moist skin; and
-Irritability and capillary refill time delayed capillary refill time
- Capillary refill of may be due to peripheral
3 seconds vaso-constriction or reflect
-V/s taken as cardiac decompensation
follows: and decreased output
T- 36.5 -May indicate heart
P- 70 -Note dependent and failure, renal, or vascular
R- 20 general edema. impairment
Bp- 140-90 - Bed rest can help control
-Maintain activity your blood pressure and
restrictions (bed rest) may help keep your heart
and assist patient with from beating too fast.
self- care activities.
Assessment Diagnosis Planning Intervention Rationale Evaluation
Subjective Risk for After 8 hours of -Provide comfort -Raising the head of the
“paminsan decreased nursing measures, elevation of bed decreases the Goal Met
nararamdaman ko cardiac output intervention the head. amount of blood
na ang bilis ko related to patient will returning to the heart After 8 hours of
mapagod tsaka due to the effects of nursing
increased maintain blood
nahihilo” as -Monitor response to gravity. intervention the
verbalized by the vascular pressure within medications to control -to know the efficiency patient
patient. vasoconstriction normal range. blood pressure. of the medication maintained
-Administer medications -This medications blood pressure
Objective like diuretics, alpha and effectively decrease within normal
-Pale in color beta antagonists, blood pressure in range.
-Skin cool to touch calcium channel hypertensive patients,
-Irritability blockers, and and in adults with
- Capillary refill of vasodilators. hypertension reduce the
3 seconds risk of adverse
-V/s taken as cardiovascular
follows: outcomes.
T- 36.5 -Instruct and implement -Reducing sodium
P- 70 to patient dietary intake lowers blood
R- 20 restrictions in sodium, pressure in people with
Bp- 140-90 fat and cholesterol high and borderline high
blood pressure. 
 Dose, Frequency,
Name and Route, duration of Mechanism of Indications Contraindications Adverse Effects Nursing
Classification of administration study Responsibility
Drug

Generic name: Dose: Enalapril is an • Treatment of Hypersensitivity. • Dizziness (4- • Check for
Enalapril 5 mg. angiotensin hypertension History of 8%) allergy in
converting alone or in angioedema due to • Hypotension medications.
Brand name: Frequency: enzyme (ACE) combination previous treatment (0.9-6.7%) • Check WBCs
Enalaprilat, inhibitor. It works with other with ACE inhibitors; • Headache (2- regularly
OD
Epaned, Vasotec, by blocking a antihypertensiv bilateral renal 5%) because it can
and Vasotec IV. substance in the es, especially artery stenosis. • Chest pain cause
Route: Pregnancy
Oral body that causes thiazide-type (2%) neutropenia.
Classification: the blood vessels diuretics • Cough (1-2%) • Administer 1
Enalapril is in a to tighten. As a • Treatment of • Aortic stenosis • Rash (1.5%) hour before
class of result, enalapril acute and • Myocardial • Asthenia meals
medications relaxes the blood chronic CHF infraction • Nausea • Monitor blood
called angiotensin- vessels. This • Treatment of • Stroke • Vomiting pressure often
converting lowers blood asymptomatic • Hypertrophic • Hyperkalemia • Monitor weight
enzyme (ACE) pressure and left ventricular cardiomyopath and fluid status
inhibitors. It works increases the dysfunction y • Monitor renal
by decreasing supply of blood (LVD) • Collagen profile
certain chemicals and oxygen to the • Unlabeled use: vascular • Monitor CBC
that tighten the heart. Diabetic diseases frequently
blood vessels, so nephropathy • Renal artery
blood flows more stenosis
smoothly and the • Renal
heart can pump impairment
blood more
efficiently.
THANK
YOU!