Liceo de Cagayan University

College of nursing

In Partial Fulfillment for the Requirements

of the Subject Elective II

Submitted to:
Sir Rey Ronald V. Solde, RN MN

Submitted by:
Daniel John P. Torres

BSN 4
October 8, 2015

Introduction
This case study is about Patient SJ, a 91 year old woman, who was
referred at Northern Mindanao Medical Center because no one will take good
care of her. She had a diagnosis of Coronary Artery disease moderate; old
Myocardial

Infarction,

arrhythmia-AF

(Atrial

Fibrillation),

Hypertensive

Cardiovascular disease. Patient SJ, is a former nun. At the age of 33 (1964) she
joined Congregation of Daughter of St. Theresa in Balingasag Mis. Or. At the year
1972 she suffered a heart attack, and was brought to Lourdes Hospital in Quezon
City. She was admitted for 2 months and was advised by the priest to leave the
convent due to medical condition. For 8 years she stayed in Caloocan with sister
for 8 years and went back to Camiguin. She lived with her father and her sister;
Asuncion De la Rosa along with her husband and children. At the year 2010, her
sister died of leukemia, her family could no longer look after her needs. Her
niece, Erlinda took care of her till 2012. By the year 2012, Sr. Marian L. Tagupa
visited Nanay Sofia in her home and offered her to stay at Northern Mindanao
Medical Center.
According to WebMD (2014) the heart is mainly made of special
muscle (myocardium). The heart pumps blood into arteries (blood vessels) which
take the blood to every part of the body. Like any other muscle, the heart muscle
needs a good blood supply. The coronary arteries take blood to the heart muscle.
The main coronary arteries branch off from the aorta (the large artery which takes
oxygen-rich blood from the heart chambers to the body.) The main coronary
arteries divide into smaller branches which take blood to all parts of the heart
muscle.
Coronary artery disease, also called coronary heart disease, or simply,
heart disease, is the No. 1 killer in America, affecting more than 13 million
Americans. Heart disease is a result of plaque buildup in the arteries, which
blocks blood flow and heightens the risk for heart attack and stroke. From a
young age, cholesterol-laden plaque can start to deposit in the blood vessel
walls. As a person gets older, the plaque burden builds up, inflaming the blood
vessel walls and raising the risk of blood clots and heart attack. The plaques
release chemicals that promote the process of healing but make the inner walls
of the blood vessel sticky. Then, other substances, such as inflammatory cells,
lipoproteins, and calcium that travel in your bloodstream start sticking to the

inside of the vessel walls. Eventually, a narrowed coronary artery may develop
new blood vessels that go around the blockage to get blood to the heart.
However, during times of increased exertion or stress, the new arteries may not
be able to supply enough oxygen-rich blood to the heart muscle. In some cases,
a blood clot may totally block the blood supply to the heart muscle, causing heart
attack. If a blood vessel to the brain is blocked, usually from a blood clot, an
ischemic stroke can result. If a blood vessel within the brain bursts, most likely as
a result of uncontrolled hypertension (high blood pressure), a hemorrhagic stroke
can result.
In myocardial infarction (heart attack), a coronary artery or one of its
smaller branches is suddenly blocked. The part of the heart muscle supplied by
this artery loses its blood (and oxygen) supply if the vessel is blocked. This part
of the heart muscle is at risk of dying unless the blockage is quickly removed.
When a part of the heart muscle is damaged it is said to be infarcted. The term
myocardial infarction (MI) means damaged heart muscle. If main coronary
arteries are blocked, a large part of the heart muscle is affected. If a smaller
branch artery is blocked, a smaller amount of heart muscle is affected. After an
MI, if part of the heart muscle has died, it is replaced by scar tissue over the next
few weeks. Normally you will be advised to take regular medication for the rest of
your life. Normally, normally be advised to take the antiplatelet medicine
clopidogrel or ticagrelor in addition to aspirin. However, this is usually only
advised for a number of weeks or months, depending on the type and severity of
your MI.

I.

Objectives
General objectives:
At the end of 4 hours of exposure at Northern Mindanao Medical Center, I will be
able to:
Apply the concepts, terms and theories regarding elderly care to the
assigned patient. Utilize the knowledge acquired from the 4 walls of the
classroom to distinguish the appropriate nursing interventions. Conduct a
comprehensive interview to the assigned patient in a proper environmental
setting. Apply the skills from previous clinical experiences to provide the patient
with holistic nursing care.

Identify 3 major problems at Northern Mindanao

Medical Center that need correction and intervention.

Work alongside the staff

of Northern Mindanao Medical Center to promote the elderly patients health and
well-being. Maintain the proper student nurse attitude all throughout the
exposure.
Specific objectives:
At the end of 4 hours of exposure at St. Josephs Home for the aged, the student
nurses will:
A.
B.
C.
D.

Conduct an interview and assessment with their assigned elderly patient

Promote wholeness and well-being including safety and comfort of patient
Set priorities in nursing care based on patients' need
Formulate a plan of care in collaboration with patients and other members of

E.
F.

the health team

Implement planned nursing care to achieve identified outcomes
Project a professional image of the nurse and maintain the appropriate

G.

attitude
Establish collaborative relationship with colleagues and other members of the
health team for the health plan

II.

CLIENT PROFILE
Name: Jagape, Sofia C.

Nickname: Sofia

Age:91 y.o

Gender: Female

Civil Status: Single

Date of Birth: July 8, 1924

Address:Mainit, CatarmanCamiguin

Birthplace:Mainit, CatarmanCamiguin

Religion: Roman Catholic

Date of Admission: Sept 14, 2015

Reasons for Referral: No one will take good care of her.
History of the situation:
Nanay Sofia is a former nun.At the age of 33 (1964) she joined Congregation
of Daughter of St. Theresa in BalingasagMis. Or. At the year 1972 she suffered a
heart attack, brought to Lourdes Hospital in Quezon City. She was admitted for 2
months and was advised by the priest to leave the convent due to medical
condition. For 8 years she stayed in Caloocan with sister for 8 years and went
back to Camiguin. She lived with her father and her sister; Asuncion De la Rosa
along with her husband and children. At the year 2010, her sister died of
leukemia, her family could no longer look after her needs. Her niece, Erlinda took
care of her till 2012. By the year 2012, Sr. Marian L. Tagupa visited Nanay Sofia
in her home and offered her to stay at Northern Mindanao Medical Center. Hence
her admission.
Source of Information:

III.

Sr. Marian L. Tagupa

Sr. Sofia Jagape (the patient herself)

ASSESSMENT PARAMETERS
I. Demographics
Name:Jagape, Sofia C.
Age:91y.o

Date of Birth:July 8, 1924

Gender: Female

Diagnosis:Coronary Artery disease moderate; old Myocardial Infarction,

arrhythmia-AF (Atrial Fibrillation), Hypertensive Cardiovascular disease
Attending Physician:Dr. Hedy L. Coruna Language spoken: Cebuano
Informant:Jagape, Sofia

Date of Admission:Sept 14, 2015

History of Present Illness:

At the age of 41, she suffered a heart attack, brought to Lourdes Hospital.
Admitted for 2 months, and was advised to leave the convent due to medical

condition.
Had heart attack 3x on her stay at Northern Mindanao Medical Center. The
last heart attack she experienced was on May 2013.
Food and drug allergies: No known food and drug allergies
Family Medical History: (+) Cancer; Her sister died because of Leukemia.
(+) Hypertension; Paternal
II. Functional Pattern
A. Nutritional/Metabolic Pattern
Meal Pattern: Appetite is fair and patient exhibits changes in the amount of meal.
The patient verbalized Ginagmay ra akong kina-on ug dapat nay sabaw kay
tungod sa akong sakit sa heart.
Weight Loss/Gain:There are no significant changes in weight.
Feeding: Per Orem and able to eat independently.
B. Elimination Pattern
Bladder: Patient doesnt experience difficulty in urinating, thus voids within her
own pattern.
Bowel: Usually defecates once a day but it solely depends on the food intake of
the client. The patient verbalizes Inig buntag, gakalibang jud ko.
Character: Yellowish

Frequency: Once a day

Amount: Moderate in amount. Usually 50-80 cc

C. Sleep/Rest Pattern
Sleep Difficulty: Patient verbalized sleeping difficulty such as always awakening
in the middle of the night. Presence of eyebags and weakness noted.
Use of Sleeping Aids: The patient verbalized Sayo man mi matulog pero dili
straight akong tulog, gamata-mata jud ko.
D. Activity/Exercise (D= Dependent)
Activities of Daily Living:
(I) Eating
(I) Grooming

(I) Bathing
(I) Toileting

(I) Dressing
(D) Ambulation

Activity level: Sedentary lifestyle

E. Cognitive Perception Patterns
Patient verbalized Galisod jud kog basa, kailangan najud kog antipara, the
patient dont use hearing aids and prosthesis. She ambulates with the help of
cane.
F. Behavior Pattern (Coping/Values)
Behavior: Patient is relaxed and responds to our question attentively.
Psychiatric History: None
Substance Abuse: The patient has no history of substance abuse.
G. Pain
The patient verbalized ang akong tuhod kay gasakit ug ga-poy-poy sa
pamati. Usahay musakit akong tuhod kung mukaon ko ug monggos. Mag sakit
pud akong dughan usahay, pero dili pareha sauna na grabe ang sakit.Pain is
noted on her chest and knees with a pain scale of 5/10.
H. Sexuality
Menopausal period/age: Cant be determined.
Patient doesnt perform self Breast examination and is already sexually inactive.
I. Role Relationship Pattern
Occupation:Former Nun

With whom does the Patient Live: . Sr. Marian L. Tagupa

Anticipating to return home: No, because no one will be taking good care of
the patient. The patient verbalized malipay nako sako friends diri, I will be
missing them.
PHYSICAL ASSESSMENT
A. Neurological Assessment
Patient is oriented to self, place; person and time. Weakness/paresthesia
noted on her both knees. Has no difficulty in speech or swallowing.
B. Respiratory Assessment

Respiratory rate (as of September 21, 2015) is 17cpm. Respirations are quiet
and regular. Slightly pale nail beds and lips noted. Breath sounds in both lung
fields are clear. No cough noted.
C. Cardiovascular Assessment
The patient verbalized usahay naa koy mabatian na sakit sakong dughan
dapit pero mutumar rako sakong tambal. Haya rapud manghupong akong tiil ug
magsakit ako dughan kung mukaon ko ug fatty foods. Dali rapud ko mahangos
tungod sa akong sakit sa kasing-kasing the patient added. With regular apical
pulse and BP of 110/60mmHg by September 21, 2014 9AM. No edema noted.
D. Peripheral-Vascular Assessment
Both upper extremities are pink, warm and movable within the normal range
of motion. Peripheral pulses are palpable. There is weakness on the lower
extremities and that there are limited ROM. No peripheral edema noted. No
complaints of numbness or any calf tenderness.

E. Genitourinary Assessment
The patient voids without discomfort and voids within own pattern. There are
no usual vaginal irritation and discharge noted.
F. Musculoskeletal Assessment
The patient verbalized maka bati ko ug kasakit sakong likod usahay.
Absence of joint swelling and tenderness, no evidence of inflammation,
weakness on both knees noted. The patient is able to flex all joints.

G. Integumentary Assessment
The patient verbalized kaluoy sa diyos wala sad koy samad-samad sakong
lawas. Patients skin is within her norm, it is warm, dry, and intact.

H. Psychological/Psychosocial
The patient verbalized that she is happy and satisfied with her life. She always
pray and have many friends.

Priority Nursing Problems Identified

1.
2.
3.
4.
5.
6.

Ineffective breathing pattern

Chronic pain
Disturbed sensory perception: Visual
Risk for injury/falls
Activity intolerance
Disturbed Sleeping Pattern
Medications:

Multivitamins + Iron 1 tab OD PO

Ventolin 2mg TID, via inhalation
Losartan 50mg 1 tab OD PO
Meloxicam (Mobic) 15mg 1tab OD PO
Trimetazidine 35mg 1tab OD PO
Salbutamol 2mg 1tab BID via inhalation
Procedures done

ECG
CBC
Urinalysis
Blood Chemistry

IV.

CERAE/REFLECTION PAPER
Daniel John P. Torres
Reflection Paper:
When the chart of the patient assigned to us was given, I got amazed when I
read that my patient is 91 years old. People rarely reach such age. And I got more
amazed when I personally meet our patient and converse with her, because her
memory is still intact that she can remember everything that happened from the past
events of her life. Upon assessment I didnt just gathered the relevant datas needed
for our care plan, but I also gain lessons in life from her and especially in spiritual
aspects of life. It just shows that she still hasnt forgotten her former duty which is a
nun.
On the other hand, as what I have observed to nanay Sofia, she has difficulty
in hearing. She tends to let me repeat my questions and/or answer differently. As a
health care provider, what I did was I speak in a soft loud tone, slowly and clearly.
I admire how optimistic and satisfied nanay Sofia is. When she was asked
about feeling as of the moment, she said she feels happy to where she is right now.
She feels like she found a new family in the hospital.
I think what nanay Sofia need right now is a health care provider that will
assist her physically and emotionally; and most especially in reminder her to take her
medications for her medical condition. Aside from her health condition, she reports no
other concerns to her situation. She seem to be happy and contented. Someday,
when I grow old, I would want to be like her; happy and contented like she lived her
life without regret.

V.

Recommendation and Evaluation

Myocardial Infarction means damage on the heart muscle.

patients

who are diagnosed with MI are given regular medications for life to prevent
recurrence and exacerbation of disease condition. Considering the age of the
patient, she needs a health care provider that would constantly remind her to take
her medications. Once diagnosed, the patient should fully comply with the
regimen given by the healthcare team. They should follow the medications
prescribed, diet, exercise and rest.
Diet of thepatient with MI should consist of the following: Protein, which
plays an essential role in protecting the body, for it produces antibodies to fight
infection. Drinking enough fluids is essential to keep the client hydrated. The
recommended fluid intake for MI patients is 2 to 3 liters of caffeine-free liquids per
day. Water is essential to the body. It helps prevent constipation. Drinking plain
water may be your best source of fluid. Are also good sources. Milk is a good
source of fluid. It has the added benefit of providing many healthy nutrients. And
also patient should be reminded that she should take light meals with water so
that MI attack would not trigger.
Student nurses and other health care personnel should have thorough
assessments so that early diagnosis could be made and recommended therapy
could be given. Health care personnel should be careful about the diet given to
the patient and should ensure that the food provided is in connection with the
prescribed diet of the physician/dietician.

Bibliography
ONLINE:

11 Key Area of Responsibility in Nursing - Scribd. (n.d.). Retrieved

September 16, 2014.

Zafari, A. (2014) Myocardial Infaction. Medscape Reference. Retrieved

from: http://emedicine.medscape.com/article/155919-overview

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