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Pamantasan ng Lungsod ng Pasig
Alcalde Jose St., Kapasigan, Pasig City
COLLEGE OF NURSING
Case Presentation (Medicine Ward)
Submitted by:
Jhune Emmanuel S. Villegas
BSN III Nightingale
Submitted to:
Professor Elena Mabini
Introduction
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Congestive Heart failure
Inability of the heart to keep up with the demands on it and,
specifically, failure of the heart to pump blood with normal efficiency
may be due to failure of the right or left or both ventricles
This can include shortness of breath (dyspnea), cardiac asthma,
pooling of blood (stasis) in the systemic circulation or in the liver's
circulation, swelling (edema), cyanosis, and enlargement of the heart
as signs and symptoms
Hypertension
Generally defined as a persistent elevation of systolic a persistent elevation
of systolic blood pressure of 140mm of Hg or blood pressure of 140mm of Hg
or above and diastolic pressure of above and diastolic pressure of 90mm of
Hg or above.
Blood pressure is determined by the amount of blood your heart pumps and
the
amount of resistance to blood flow in your arteries. The more blood your
heart pumps
and the narrower your arteries, the higher your blood pressure.
Persistent hypertension is one of the risk factors for strokes, heart attacks,
heart failure and arterial aneurysm, and is a leading cause of chronic kidney
failure
Uncontrolled and prolonged elevation of blood pressure can lead to a variety
of changes in the myocardial structure, coronary vasculature, and conduction
system of the heart. These changes can lead to the development of left
ventricular hypertrophy, coronary artery disease, various conduction system
diseases, and systolic and diastolic dysfunction of the myocardium, which
manifest clinically as angina or myocardial infarction, cardiac arrhythmias,
and congestive heart failure. Thus, hypertensive cardiovascular disease is a
term applied generally to heart diseases, such as LVH, coronary artery
disease, cardiac arrhythmias, and CHF, caused by direct or indirect effects of
elevated BP. Although these diseases generally develop in response to
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chronically elevated BP, marked and acute elevation of BP can also lead to
accentuation of an underlying predisposition to any of the symptoms
traditionally associated with chronic hypertension
Community-Acquired Pneumonia
It occurs outside of hospitals and other health care settings. Most people get
CAP by breathing in germs (especially while sleeping) that live in the mouth,
nose, or throat.
It is the most common type of pneumonia. Most cases occur during the
winter. About 4 million people get this form of pneumonia each year. About 1
out of every 5 people who has CAP needs to be treated in a hospital.
most common causes of CAP differ depending on a person's age, but they
include Streptococcus pneumoniae, viruses, the atypical bacteria, andHaemophilus influenzae
Nursing Theory
THEORETICAL FRAMEWORK
NOLA PENDERS THEORY: HEALTH PROMOTION MODEL
The health promotion model is a competence- or approach-oriented model in which the
motivational source for behavior change is based in the individuals subjective value of the
changethat is, how our client perceives the benefits of changing the given health behavior.
The importance of an individuals unique personal factors or characteristics and
experiences will depend on the target behavior for health promotion. Prior related behavior
includes previous experience, knowledge, and skill in health-promoting actions.
Individuals who made a habit of a previous health-promoting behavior and received a
positive benefit as a result will engage in future health-promoting behaviors.
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In contrast, a person with a history of barriers to achieving the behavior remembers the
hurdles, which creates a negative effect.
Nurse can assist by focusing on the positive benefits of the behavior, teaching them howto overcome the hurdles and providing positive feedback for their successes.
Our interventions usually focus on factors that can be modified. We also focus on factors
that cannot be changed, such as family history. Like our client who has a family history of
hypertension, he may neglect self-care practices.
He may do this out of fear or just feeling that with his family history, it is inevitable that
he also had hypertension. Nurses should recognize this and direct more support and information
to this especially offer more hope for a cure.
Health-promoting behavior is directed toward attaining positive health outcomes for the
client. Health-promoting behaviors should result in improved health, enhanced functional ability,
and better quality of life at all stages of development.
To promote the health of our client, plan of activities is necessary for implementation. It
includes diet modification specifically Low Salt Low Fat Diet, deep breathing exercise for pain
management and coughing exercise,frequent positioning and elevation of bed for improvement
of ventilation.
As a nurse, one must reinforce clients personal and family health-promoting behaviors. And by
assisting them to develop and choose health-promoting options.
Next Anatomy and physiology dko mahanap eh
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Increased renal
absorption of sodium
and water Increase of Renin-
Angiotensin-
Aldosterone
activity (kidneys)
Dysfunction of Vascular
endothelium that leads to
decrease vasodilation
Increase sympathetic
nervous system
activity related toIncrease Fluid
volume
Hypertrophy
STRESS
Functional
Constrictions
Constriction
of veins
Increase
PreloadIncrease
Contractility
CARDIAC
OUTPUT
Increases Heart PERIPHERAL
RESISTANCE Increases
Ineffective Autoregulation
HYPERTENSION
Nephrons tend to
react on sympathetic
response of the bodyNormal Elastic Function of blood vessels
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Presence of Cardiovascular Disease
(Atherosclerosis of coronary arteries, cardiomayopathy valvular
disorders coronar arter disease
Hypertension
(Elevated Blood Pressure
Ventricular Overload
Decrease Ventricular Contraction
Stimulate release of epinephrine
and norepinephrine
Tachycardia
M ocardial H ertro h
Decrease Ventricular Filling
Stimulates Renin-Angiotensin-
Aldosterone System for sodium and
water retention
Decrease Renal Perfusion
Decrease CARDIAC OUTPUT
Increase Osmotic Pressure
Fluid Overload
EdemaInvading Organisms:
(Staphylococcus Pneumoniae)
Enters the small blood vessels in the
lungs(Capillaries)
Capillaries become leaky and protein
rich fluid seeps in the alveoliCause Oxygen Deprivation
Mucus production and leaky
capillaries may linge the mucus
with bloodAlveoli fill further with fluid and debris
Consolidation occurs
(Hollow air)
Solidification of spaces within the
lung due to quantities fluid debris
Infection of Alveolar walls and
Parenchyma of the lings
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Nursing Health History
Biographical Data
1. Patient X
2. Bayabas St., Napico, Manggahan, Pasig City
3. 49 years old
4. Male
5. Filipino
6. Married
7. Company worker
8. Roman Catholic
9. Office loan as source of health finances
Chief Complaint:
Client verbalizes, Nalulunod ako, Di ako makatulog. He stated that he was unable to sleep for three
consecutive days prior to admission because of shortness of breath. Presence of fever for three days and
cough with yellowish phlegm.
HEALTH HISTORY
A. History of Present Illness
Mr. B is known of having hypertension 5 years ago but not taking any maintenance drug. He was
admitted to ER last July 18, 2010 due to difficulty of breathing. He has cough with yellowish
phelgm and with (+) crackle and SCE.
B. Past History
Mr. B had childhood illnesses like chickepox, measles,mumps when he ws young. He has no
known allegies to food, drugs, animals, insects or environmental agents. He had a gunshot
accident before. He has previous hospitalization last 2000 due to peptic ulcer disease.
C. Past History of Illness
Mr. B stated that in his family, there was none of the diseasa conditions similar with other
patients of the hospitals. His family history was only about asthma with her wife and
hypertension from his dad. Her two chikdren also asthma, the eldest and youngest.
PAIN ASSESSMENT
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The client stated that prior to confinement he experiened some pain. It was pain during coughing under
the diaphram and upper abdomen. And when cough is prevented from doing so, it became more worst
pain. He rated it 7 out of 10 and to relieve the pain he usually position himself prone.
FUNCTIONAL HEALTH PATTERN
1. Health Perception and Health Management Pattern
According to Mr. B, he is feeling well even though he is not yet for discharge and they are still
waiting for more clarified reason of being healthily discharge. He said it is easy to follow the
instructions that his doctors and nurses may tell him. He thinks that his codition right now is
brought about by overworking and lack of proper food choices. He has stop smoking since 2000
after he was hospitalized of having peptic ulcer disease.
2. Nutrition and Metabolic Pattern
Mr. B said that before, his typical type of foods are galunggong and pinakbet but because he is
working, the typical foods he eats are chickens, porks, beef and oily foods. He also said thateating
too much fatty foods might be one of the reason why he became a CHF patient. He also loose
weight in 1 months , because before, he weighs 92 kilograms and now, its only 76.2 kilograms.
He has two decaying teeth but he doesnt want it to be removed for it is not aching anyway.
3. Elimination Pattern
Mr. B said that he has none of eliminating problems as well as urinating. He described it as
normal frequent urination.
4. Activity-Exercise Pattern
Perceived ability for:
Feeding 4 Grooming 4
Bathing 4 General Mobility 4
Toileting 5 Cooking 4
Bed mobility 5 Home Maintenance 4
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Dressing 5 Shopping 4
Mr. B.
5. Sleep- Rest Pattern
Mr. B said that there is difficulty for him to sleep due to cough he still have. He also said that he
takes siesta by 1pm to 6pm. And for him, to relieve the diffucultly hes in, he use to change
position from supine to sitting and to prone.
6. Cognitive-Perceptual Pattern
He has no colorblindness experiencing as well as hearing impairment. He also said that he learns
more easily when the topic is beng lactured to him and he take notes of those informations and
listens actively. Aside from that, Mr. B didnt say anything.
7. Self- Perception and Self- Concept Pattern
Mr. B, described himselfes Dati malakas ako, di naman ako nahahapo, ngayon lagi na ko
nahahapo. Para akong nalulunod,hinahingal agad ako.
The client states that he feels less capable of doing things he usually do. Especially those tasks
hes doing at work. He missed his job he said; he wants to be discharge early so that he can go
back to work and have the assignment in their working places.
8. Sexuality- Reproductive Pattern
Mr. B, admitted that he is sexually active only with his wife and they use contraceptives.
9. Role- Relationship Pattern
He descibed his role as a fullfiling one for he said, he was the only breadwinner of the family. But
now that he was in the hospital, he was uncapable to find job and give income to his family. Hestated,Kapag nakareover ako, babalik ako sa trabaho.
10. Stress- Tolerance Pattern
He said that his primary stressors are his daughters. Because if he ask for favors, his daughters
take some more time before dong it and he also said that his children were hardheaded and very
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noisy. But he always think that he was highblood so he usually rejects the emotion of being
angry. He want to calm down himself to prevent elevated blood pressure that he might have.
11. Value- Beliefs Pattern
He said that the most important things for him were enough income to support his childrens
studies as well as his family for everyday trials. His family were all Roman Catholics but they
usually listens to Ely Soriano. He said, it is important to have faith cause it is where he takes his
strength to go on and keep on struggling.The client believes that God will always be beside us.
He is a God-fearing person. And according to him, religion is very important.
Next P.E wala ako eh dko na mahanap
Tapos NCP dko din mahanap NCP nito eh
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ENERIC
NAME
BRAND
NAME
ACTION DRUG INTERACTION ADVERSE EFFECT NURSING CONSIDE
osemide
mg IV
then 40
V q 8-
heck
Lasix, Delone,
Detu
e
A "water pill"(diuretic) thatincreases the amountof urine you make,which causes yourbody to get rid ofexcess water.Lowering high bloodpressure helpsprevent strokes,heart attacks, andkidney problems.
It also reducesswelling/fluidretention (edema)and can help toimprove symptomssuch as troublebreathing.
blocking theabsorption of sodium,chloride, and waterfrom the filtered fluidin the kidney tubules,causing a profoundincrease in theoutput of urine(diuresis)
Congestive
heart failure,
liver disease,
or kidney
disease.
Hypertension
Drugs that can affecthearing/balance (e.g.,aminoglycoside antibioticssuch as gentamicin,tobramycin), amphotericinB, cholestyramine,cisplatin, colestipol,corticosteroids(e.g., prednisone), digoxin,lithium, nonsteroidal anti-inflammatorydrugs (NSAIDs suchas ibuprofen, indomethacin), large doses of aspirinand aspirin-like drugs
(salicylates), sucralfate.
Dizziness, light-headedness, headache,blurred vision, loss ofappetite, stomachupset, diarrhea,or constipation
serious symptomsof dehydration or mineralloss: muscle cramps orweakness, confusion,severe dizziness,drowsiness, unusual drymouth or thirst, nausea orvomiting, fast/irregularheartbeat, unusualdecrease in the amount ofurine, fainting, seizures
Before using thismedication ask fomedical history, esof: kidney disease,disease, untreatedimbalance (e.g., sopotassium), gout,
Avoid prolonged suexposure, tanning or sunlamps
Laboratory and/or tests (e.g., kidney liver function testsacid, cholesterol le
blood mineral leveas potassium,) shoperformed periodicmonitor your progcheck for side effe
Have your blood pchecked regularly taking this medica
oglyceri
ACLU L
6
Nitrostat,
Nitr
oqui
ck,
Nitr
olin
gual,
Nitr
o-
Dur,
Mini
tran,
Nitr
o-
Bid
and
Nitr
al
Patch
Preferentially dilatesblood vessels thatsupply the areas ofthe heart wherethere is not enoughoxygen therebydelivering oxygen tothe heart tissue thatneeds it most.
Used in themanagementof angina pectoris(heart pain).
congestive heart
failure associate
d
with myocardial
infarction (heartattack) and high
blood pressure
Some antidepressants;some anti-psychotics, quinidine (Quinaglute,Quinidex), procainamide(Pronestyl, Procan-SR,Procanbid), benzodiazepines suchas diazepam (Valium) oropiates(morphine)
Patients receivingnitroglycerin should beadvised to drink alcoholicbeverages with caution.
Sildenafil (Viagra), tadalafil(Cialis)and vardenafil (Levitra)exaggerate the bloodpressure lowering effectsof nitroglycerin
Ergot alkaloids can opposethe vasodilatory actions ofnitroglycerin and maycause angina.
Persistent,throbbing headache,flushing of the head andneck can occur withnitroglycerin therapy ascan an increase in heartrate or palpitations,dizziness or weakness.
Before using this med
tell your doctor your m
history especially of:
problems, head injury
surgery, glaucoma, thconditions, anemia, a
usage, allergies (espe
allergies to drugs or
adhesives).
Drug study
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LABORATORY RESULTS
Serum TestJuly 18, 2010
SERUM RESULTS NORMAL INDICATIONS
Glucose 6.11 mmol/L 4.16-6.11 mmol/L Normal range
HDL 0.6 mmol/L 1.0- 1.6 mmol/L considered acoronary heart
disease risk factorindependent of thelevel of totalcholesterol
LDL 4.00 mmol/L 0.00-3.36 mmol/L Associated with arterialartherosclerosis
Serum Test
July 18, 2010
SERUM RESULTS NORMAL INDICATIONS
Urea 3.4 mmol/L 3.2-7.1 mmol/L Normal range
Crea 72.0 mmol/L 58.0-110 mmol/L Normal range
Na 137.0 mmol/L 137.0- 145 mmol/L Cardiac failure,Diuretics abuse
K 3.5 mmol/L 3.6- 5.0 mmol/L Associated withcorticosteroids &
diuretics, drugs that maycause hypokalemia
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Course in the ward
PRESENT HISTORY:
3 days PTA,the patient has(+)Cough with
productive with yellowish phlegm;(+)Fever;
(+)Easy fatigability. Took self medications with
paracetamol, Cefalexin, Salbutamol,and
Guiafenessin
PAST HISTORY
The patient has(+)Previous Hospitalization (Year2000
QMMC with Dx: PUD; (+)HPN with (-)maintenace
medication;(-)DM, BA, PTB;(-)FDA ;previous cigarette
smoker D/C 2000,Alcoholic
Secure consentfor admission
EMERGENCY ROOM: 07-18-10(6:30am)Admitted a 49 y/o married male filipino client
CC: DIFFICULTY OF BREATHING
ASSESSMENT FINDINGS
Easy FatigabilityDOB (+)HPN (+) Fever(+) Crackles lower base with
occasional wheezes; SCE
Chest Pain
Given
Calcibloc prn
Given O2 at
4Lpm Via NCCombivent ml +
PNSS 2cc x 3 doses c
15 mins interval, thenq 2o
LABORATORIES:
CBC, APC, Na, K,
BUN, Creatinine,CXR-PA, HDL,LDL
Hooked to
PNSS 1Llx 12o
Results:
Urea: 3.4 mmol/L;Crea:72.0mmmol/L;
Na:137.0mmol(LO);K:3.5 mmol/L(LO)
MEDICATIONS:
Cefuroxime 1.5 g (-)ANST TIV
now then 250 mg TIV prn
Clarithrimycin 500mg if needed
then BID
Paracetamol 300g TIV
BP: 250/190 mmHg
P: 107 bpm
T: 38.5oC
RR: 32 breaths
NPO
Temporarily
Referral to Male Medicine Ward
WORKIND DIAGNOSIS:CAP MR, HAS CVD
MALE MEDICINE WARD 07-18-10(4pm)
Transfer via stretcher
Shift IVF to
D5W 500cc x
KVOon LSLF
Diet
Give Furosemide 40mg TIV now-
Check BP
Hold
Nebulization for15 mins, 60mg
tab PO now
On LSLF Diet Moderate HBRWith O2 2-3 Lpm via NC
With on going
IVF PNSS 1L x
KVO at fulllevel
SF 2DECHO with
DS-request , AU,
FBS, TC, TG, HDL,LDLT: 38. 9
oC
Paracetamol
1amp TIVPerform TSB by relativeT: 37.4oC
MALE MEDICINE WARD 07-19-10(6am)S/E by Dr. Duro
with orders carried
out Diet:LSLF with SAP
IVF: PNSS 1L
x KVO at900cc level
ADMITTING DIAGNOSIS:CHF 2o HPNCVD; CAP LR
Conscious &
Coherent at HBR
BP: 150/120RR: 36 breaths
T: 36.7oCCR: 108 bp
Medications:
Clarithromycin 500 mg/cap
Losartan 100mg/tabCefuroxime sodium 750mg TIVChest Pain Applied Nitroglycerinpatch
SF 2DECHO with
DS, UA, FBS, TC,HDL,LDL,
Continue O2support 3Lpm
via NC
Results:
LDL: 4.00mmol/L(HI)
HDL: 0.6mmol/L(LO)GLUCOSE:6.11mmol/L(HI)
A
A
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END OF DUTY
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EVALUATION
During the interview, nurse fined it hard to gather data that are necessary in their study. The
patient was 49years old but having difficulty speaking due to cough. Even though there was a barrier on
gathering information, the nurse was able to gather needed information because they had also interviewed
the clients wife and daughter.
The doctors orders were all put into action by the nurse in charge just like the order for a
2DECHO. Other than that, there were some other laboratory tests that were undertaken by the client for
further monitoring. There were many medications that were given to the client for different purposes like
Furosemide, Clarithromycin, Losartan, and others.
Overall, the nurse thought t all of the interventions made by all health care providers were
effective after the prescription to continue his medications. The nurse was able to implement necessaryinterventions like deep breathing exercise, coughing exercise as well as diet management for the client.
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