I.

PATIENT ASSESMENT DATA BASE

A. General Data
1. Patients Name: Mr.A.L
2. Address: Moncada Tarlac
3. Age: 44 yrs. old
4. Sex: M
5. Birth Date: 04/23/1970
6. Rank in the family: 3rd child
7. Nationality: Filipino
8. Religion: Catholic
9. Civil Status: Single

B. Date of Admission: 09-25-2014

Order of Admission:
Upon Admission
Please admit to medical ward
Secure consent for admission & management
TPR every shift & record
Low salt, low fat diet
Diagnostic Test:
o CBC
o U/A
o BUN
o CREA
o SERUM
o CXN PA
o 2D ECHO
IVF: D5W 1L KVO
MEDICATIONS:
o Furosemide 40mg IVP now then q6 with BP precaution
o ISMN 30mg/tab 1 tab OD @PM with BP precaution
o Trimetazidine
o Atorvastatin 40/tab OD @ HS
o Captopril tab 1 tab BID
o Lactulose 30cc OD @ HS
o Digoxin 0.25 mg/tab 1 tab OD
o Spironolactone 25mg/tab 1 tab BID
 for IFC insertion aseptically secure consent
O2 inhalation 2-3 lpm via nasal cannula
Moderate high back rest
Complete bed rest without bathroom privileges
Monitor v/s every hour
Monitor I & O every hour & record refer if I & O <30cc/hr
Monitor O2 SAT every hour
Weigh patient daily & record
WOF: chest pain, dyspnea
Notify
Refer accordingly
Attending Physician:
Dr. Quebral, Mares Polene
Chief Complaint:
Difficulty of Breathing

History of Present Illness:

2 weeks prior to admission, patient experienced difficulty of breathing accompanied with easy fatigability .
no consult was done. No meds taken. Few hours prior to admission, patient experienced difficulty of breathing. Sought consult in
our institution, hence admitted.

C. Eclectic Assessment Model:

I. Current Health Status
A. Biophysical Health
1. Mental Status
a. Appearance and Behavior
The patient wears a cotton white sando & shorts and slippers that is appropriate for the environment. The
patient has black short hair with no dandruff & lice. He has good hygiene, with white complete teeth. The skin is
brown with slight scratch, and itchiness. Well trimmed nails and neat. He has a neat, fixed clothing. The patient
cant able to walk steadily without support. While having interview with the patients father, the patient is awake and
respond to my question by moving his head.

b. Speech and Language

The patient has a low volume of speech and cannot speak well because he has headache.
c.Mood
The patient cannot work properly, as verbalized by the father.
 d. Thought processes, thought content, and perceptions

The patient cannot speak and speak well he has DOB.

e. Cognitive Functions
The client is oriented to place , person, & time. He cannot speak well.

2. Daily Activity Patterns

a. Nutritional

The patients family has a simple life. Having a meal three times a day is a big blessing for them.
Eating in the dining area with his family everyday with the 3 basic food groups as a healthy food. They dont go in
the restaurant because of financial problem. He dont take daily vitamins, iron, minerals. He has decreased in
appetite. His skin is brown smooth, has scratches. No dandruff, lice and has black short hair. With well trimmed
nails, white teeth.

Three Day Recall:

Breakfast Lunch Dinner

Fried Fish, rice Chicken, Rice Mongo, egg, rice
Water Gelatin water
Water
Paksiw nabangus, rice Cannot recall Rice, vegetable
Water water

Bread and coffee Rice, pritong tilapia Rice, adobong babo

water water

b. Elimination

The patients elimination pattern, he urinates 3 times and defecates 2 times a day. His bowel is
brown and semi formed
 c. Exercise

The client has no exercise but instead he was drinking alcohol, using drugs and he was a smoker
when he is within the house he was just sleeping or sitting after he eats then same way as routine everyday.

d. Hygiene

The patient take a bath 2 times a day in the morning and afternoon. He prefer to bath using tabo
and timba. After taking a bath he brushes his teeth (3x a day) but he dont visit dentist because of financial
problem, then he uses cologne

e. Substance Use

The client smokes 1 pack a day and according to his sister, he was aware that it is bad to his
health and his condition but he neglects it. He was drinking alcohol 5 bottles of alcohol. He was drinking hard
liquors and beer with his friends then they were using drugs after they get drunk.
Upon observation the patient is eyes are sore, cannot sleep easily and psychologically disturbed.

f. Sleep and Rest

According to his sister he sleeps 6 hours and he does not take naps .Watching TV helps him to
sleep and he wakes up sometimes during at night. Upon observation no facial expression, no verbal language, he
was only responding at nodding. He was flat on bed.

g. Sexual Activity

The patient has no sexual activities because he is single, and never been involved in a
relationship.

3. Past Biophysical Health

a. Restorative Intervention

The patient consulted a doctor last July 25, 2014 but was not admitted. He was just admitted last
September 25 2014
 b. Allergies

He has no allergies to any food and medication. Upon observation his eyes is ballag. No
presence of sniffing and need to blow nose. His condition of skin has scratch on it.

c. Immunization

Cannot recall as verbalized by the sister

d. Growth and Development

The growth and development is not the same as for other children at his age because children
now uses gadgets compared to them when he was a child according to his sister.
 DIAGRAM of Heredo-Familial Illness

FATHER SIDE MOTHER SIDE

C.L SR. Z.DV R.A E.A

(+) (+) (+)

C.L SR R.L SR (+) W.M B.L SR (+) V.A D.A G.A Y.A M.A
(lung cancer) (ulcer)

P.T C.N A.L R.L D.L SR. G.B S.M C.L C.P

(goiter) (pt) (CHF)

 a. Foreign Travel
The client has not yet travel out of this country or to malaria-endemic area.

b. Family Health History

In patients family his uncle died because of lung cancer & ulcer. His elder sister has goiter, and
our patient A.L has CHF.

Psychological Health

1. Coping Patterns

According to his sister, his family is the people mean a lot to him, he was talking to his mother and father
on regular basis. The patient is with his family father, mother and father. Usually the patient expresses his feelings
to his father. When he has problems like not feeling well, angry he just approach his father and expresses his
feelings.
FAMILY ASSESSMENT
NAME RELATIONSHIP AGE SEX OCCUPATION EDUC.ATTAINMENT
P.T Sis 48 F H.W ELEMENTARY
GRADUATE
C.N Sis 46 F H.W ELEMENTARY
GRADUATE
A.L Pt 44 M NONE ELEMENTARY
GRADUATE
R.L Bro 42 M COOK ELEMENTARY
GRADUATE
D.L.SR Bro 40 M FARMER ELEMENTARY
GRADUATE
G.B Sis 36 F H.W ELEMENTARY
GRADUATE
S.M Sis 33 F H.W ELEMENTARY
GRADUATE
C.L Sis 30 F H.W ELEMENTARY
GRADUATE
C.P Sis 29 F H.W ELEMENTARY
GRADUATE
C.L SR Father 74 M FARMER ELEMENTARY
GRADUATE
A.L mother 67 F H.W ELEMENTARY
GRADUATE
 3. Cognitive Patterns

His attainment is elementary level because of financial problems. He can read and has no difficulty in school or
learning new things. He does not know his IQ

4. Self-Concept

His highest weight is 73kgs. He feels bad about his weight and appearance. He does not have any physical
alterations in his body and it is accepted by the people around him and by himself. He sees himself equal to others. He is
raised as a Catholic and with good moral values. He is comfortable to his religion. He always expresses his thoughts
directly and verbally.

5. Emotional Patterns

He always feels happy. He seldom changes his mood and he does not express it. His relationship with others
does not affect his mood. He is very satisfied to his usual mood and to his behavior.
.
6. Sexuality

He expresses himself as a man through making friends with the same sex. He enjoys being a man by going
outside during nighttime and not being controlled by his parents. He does not have any problems regarding what others
want him to do. He always goes outside with his peers during nighttime. He does not have occupation yet.

7. Family Coping Patterns

According to his sister, his father is the one who makes decision in their family. When one member of the family
disagrees, they make another plan that everybody agrees.

B. Sociocultural Health
1. Cultural Patterns

He was taught to say po and opo to people older than him and he finds it very important. There are no
gatherings in their family.
He is more close to his father and tells his problem to him according to his sister. In his condition right
now, his family is still supportive to him and even understands him regarding his condition.
 2. Significant Relationships

The people who are significant to him are his family. He feels closest to his father because he always tells
his problems. There is no major conflict in their family. He first goes to his father when he needs help. If someone in their
family is sick they take care of each other.

3. Recreation Patterns

The patient plays with his nephews and niece. He usually smokes for his leisure.

4. Environment
The patient and his family stay in a simple place. They are comfortable where they live now and have an
enough space to live with.

5. Economic
The patients sister states that their income is adequate to meet their basic needs for housing and food.
They also have health insurance like phil health so this contributes to lessen the amount to be paid in the hospital.

D. Spiritual Health
1. Religious Beliefs and Practices

The patient is a Roman Catholic until he grew up.

2. Values and Valuing

The important things in his life are food and water. The most important is food. He likes to eat always.
II. Physical Assessment

Actual
Physiologic Cues Normal Analysis
Findings
0-2 years 36.4C to 38 C
3-10 years 36.1 to 37.8 C
11-65 years 35.9 to 37.6 C Patient is
Temperature 36.7
>65 years 35.8 to 37.5 C afebrile

SITE: https://www.google.com.ph/search?q=ranges+of+normal+temperature+by+age
Adult 60-100 beats per minute
Children age 1 to 8 years 80 to 100
Infants age 1 to 12 months 100-120 Patient is
Pulse Neonates age 1 to 28 days 120 to 160 116 experiencing
tachycardia
SITE: http://prohealthsys.com/site/resources/assessment/physical-assessment/vital-
signs/vital_signs_table/
Adult 12-20 breaths per minute
Children age 1 to 8 years 15 to 30
Infants age 1 to 12 months 25 to 50 Patient is
Respiration Neonates age 1 to 28 days 40 to 60 27 experiencing
tachypnea
SITE: http://prohealthsys.com/site/resources/assessment/physical-assessment/vital-
signs/vital_signs_table/
Adult 90 to 140 mmHg
Children age 1 to 8 years 80 to 110 mmHg
Infants age 1 to 12 months 70 to 95 mmHg
Patient is
Blood Pressure Neonates age 1 to 28 days <60 mmHg 200/150
hypertensive
SITE: http://prohealthsys.com/site/resources/assessment/physical-assessment/vital-
signs/vital_signs_table/
For adult males 163.5 cm (5' 4.3") for adult females, 151.8 cm (4' 11.8") Patients
height is
Height http://www.chacha.com/question/what-is-the-average-weight-for-a-filipino-person 165 cm (55)
above
normal
Weight The average weight for Filipino adults is relatively low at 121 pounds for those aged 20 to 132 lbs (60 Patients
39, 122 pounds for those aged 40 to 59, and 109 pounds for those aged 60 and over. kgs) weight is
above
 http://www.chacha.com/question/what-is-the-average-weight-for-a-filipino-person
normal

Below 18.5 underweight

18.5 to 24.9 normal
25.0 to 29.9 overweight
BMI 22.0 Normal
30.0 and above obese

SITE:http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/index.html?
Body Parts Technique Normal/ Standard Actual Findings Analysis
Head Inspection Symmetrical, rounded normocephalic head His head is
positioned at midline and erect with no lumps symmetrical,
rounded
normocephalic head
positioned at midline Normal
and erect with no
lumps
Palpation
Nonpalpable lymph nodes or small, round, soft,
There is
mobile, non tender lymph nodes
nonpalpable lymph
nodes or small,
round, soft, mobile,
non tender lymph
Percussion nodes
Auscultation Not applicable
not applicable

REFERENCE: Lippincott Williams & Wilkins Nursing

Procedures & Protocols
Skull Inspection
Generally round, with prominences in the frontal His skull is generally
and occipital area. (Normocephalic). round with
No tenderness noted upon palpation. prominences in the Normal
frontal and occipital
area.
 Palpation
(Normocephalic).

Percussion
Auscultation No tenderness
Not applicable
REFERENCE:http://www.rnpedia.com/home/notes/fun noted upon palpation
damentals-of-nursing-notes/head-to-toe-assessment

Scalp/Hair Inspection His scalp/ hair there

Lighter in color than the complexion. No scars is no scars no lice
noted. Free from lice, nits and dandruff. nits and dandruff. and
lighter in color than
the complexion

His hair is thick Normal

Can be black, brown or burgundy depending on
smooth black and
the race. Evenly distributed covers the whole
evenly distributed
scalp (No evidences of Alopecia) Maybe thick or
covers the whole
Palpation thin, coarse or smooth. Neither brittle nor dry
scalp and no
No lesions should be noted. No tenderness or evidences of alopecia
masses on palpation. Can be moist or oily.

Percussion
Not applicable
Auscultation
Not applicable
 REFERENCE:http://www.rnpedia.com/home/notes/fun
damentals-of-nursing-notes/head-to-toe-assessment

Face Inspection The patients

Shape maybe oval or rounded. Face is face is oval and
symmetrical. No involuntary muscle movements. symmetrical. No
Normal
Can move facial muscles at will. involuntary muscle
Palpation movement. And can
move facial muscles
Percussion Intact cranial nerve V and VII. at will
Auscultation
Not applicable

REFERENCE:
http://www.rnpedia.com/home/notes/fundamentals-of-
nursing-notes/head-to-toe-assessment

Eyes/ Vision Inspection His eyes is evenly

Evenly placed and inline with each other. None placed and inline with
each other. None Normal
protruding. Equal palpebral fissure
protruding and equal
palpebral fissure

Palpation

Percussion Non palpable

auscultation

Not applicable

REFERENCE:http://www.rnpedia.com/home/notes/fun
damentals-of-nursing-notes/head-to-toe-assessment
Eyeball, eyelashes, Inspection Bright, clear, symmetrical eyes free of nystagmus; He has bright, clear
eyelids eyelids close completely; no lesions, scaling, or symmetrical eyes free Normal
inflammation from nystagmus;
eyelids close
completely; no
lesions, scaling, or
inflammation

Palpation
Percussion Not applicable
Auscultation

REFERENCE: Lippincott Williams & Wilkins Nursing

Procedures & Protocols

Eyebrows Inspection Hair is evenly distributed. The clients eyebrows His eyebrows,
are symmetrically aligned and showed equal Hair is evenly
movement when asked to raise and lower distributed.
eyebrows Symmetrically Normal
aligned and showed
equal movement
when asked
Palpation
Percussion Not applicable
Auscultation

REFERENCE:http://www.rnpedia.com/home/notes/fun
 damentals-of-nursing-notes/head-to-toe-assessment

Sclera Appeared white His sclera

Inspection appeared white

Palpation Normal
Percussion Not applicable
auscultation
REFERENCE:http://www.rnpedia.com/home/notes/fun
damentals-of-nursing-notes/head-to-toe-assessment

Cornea/ Iris Patents cornea is

Inspection Cornea is transparent, smooth and shiny and the transparent, smooth
details of the iris are visible. The client blinks when the and shiny and the
cornea was touched. details of the iris are
visible. The client
client blinks when Normal
the cornea was
touched
Palpation Not applicable
Percussion
auscultation
REFERENCE:http://www.rnpedia.com/home/notes/fun
damentals-of-nursing-notes/head-to-toe-assessment

Conjunctiva The palpebral conjunctiva appeared shiny, The patients

Inspection smooth and pink conjunctiva appeared
to be shiny, smooth
REFERENCE:http://www.rnpedia.com/home/notes/ Normal
and pink
fundamentals-of-nursing-notes/head-to-toe-
assessment
Visual accommodation Not Assessed
Visual field When looking straight ahead, the client can see
Visual acuity objects at the periphery which is done by having the
client sit directly facing the student nurse at a distance
of 2-3 feet. The right eye is covered with a card and
asked to look directly at the student nurses nose.
 Hold penlight in the periphery and ask the client when
the moving object is spotted
Able to identify letter/read in the newsprints at a
distance of fourteen inches. She was able to read the
newsprint at a distance of 8 inches

Inspection His ear lobes are bean

The ear lobes are bean shaped, parallel, and shaped, parallel and
symmetrical. The upper connection of the ear lobe symmetrical. Skin is
is parallel with the outer canthus of the eye. Skin same in color as in the
is same in color as in the complexion. No lesions complexion and no Normal
noted on inspection. lesions noted

Palpation

The auricles are has a firm cartilage

His auricles are has a
Percussion
auscultation firm cartilage
Not applicable

REFERENCE:http://www.rnpedia.com/home/notes/fun
damentals-of-nursing-notes/head-to-toe-assessment

Hearing Acuity Whispered Whispered voice heard at distance of 1 to 2 (30- The patient cannot
voice test or 61 cm); watch-tick heard at a distance of 5 (13 hear voice at Not normal
watch-tick test cm) distance of 1 to 2
on one ear at (30-61 cm)
a time Cannot hear any Patient has a
voice hearing loss

REFERENCE: Lippincott Williams & Wilkins Nursing

Procedures & Protocols
 Nose Palpation No bumps, lesions, edema or tenderness Patients nose has no
edema or tenderness normal
lesions, & bumps
REFERENCE: Lippincott Williams & Wilkins Nursing
Procedures & Protocols
Internal Nares Inspection The nasal mucosa is pinkish to red in color. Not Assessed
Palpation (Increased redness turbinates are typical of allergy).
No tenderness noted on palpation of the paranasal
sinuses

Septum Inspection Nasal septum in the mid line and not perforated
Mouth/lips Inspection The lips and
With visible margin. Symmetrical in mouth of the patient is Normal
appearance and movement. Pinkish in color & no with visible margin
edema symmetrical in
appearance &
movement, pinkish in
color & no edema

REFERENCE:http://www.rnpedia.com/home/notes/
fundamentals-of-nursing-notes/head-to-toe-
assessment

Gums Inspection The patients gums

Pinkish in color. No gum bleeding& no has no bleeding & no Normal
receding gums receding gums and
pinkish in color
REFERENCE:http://www.rnpedia.com/home/notes/fun
damentals-of-nursing-notes/head-to-toe-assessment
Temporo- mandibular joint Palpate the Smooth joint movement without pain; correct The temporo-
temporo- approximation mandibular joint can
madibular be move without pain Normal
joints as the with a correct
patient opens approximation
and closes the REFERENCE: Lippincott Williams & Wilkins Nursing
jaws Procedures & Protocols

Teeth Inspection His teeth is

White to yellowish in color. With or without white in color without
dental carries and no Normal
dental carries and/or dental fillings .With or without
malocclusions.No halitosis halitosis

REFERENCE:http://www.rnpedia.com/home/n
otes/fundamentals-of-nursing-notes/head-to-toe
assessment
Tongue Inspection Pink, slightly rough tongue with a midline Patients tongue is
depression pinkish in color with
slightly rough tongue Normal
with a midline
depression

REFERENCE: Lippincott Williams & Wilkins Nursing

Procedures & Protocols

Hard & soft palate Inspection Pink to light red palates with symmetrical lines His hard & soft palate
has a pink to light red Normal
in color with
symmetrical lines
REFERENCE: Lippincott Williams & Wilkins Nursing
 Procedures & Protocols

Uvula Inspection Positioned in the mid line

Pinkish to red in color
Tonsils Inspection Pink and smooth; no discharge
Of normal size or not visible
Not Assessed
Lippincott Williams &Wilkins, Assessment 3rd Ed., p.
137
Frenulum Not assessed Not assessed
Buccal Mucosa Inspection The buccal mucosa of the client appeared as
Palpation uniformly pink; moist, soft, glistening and with elastic
texture.
Neck Inspection His neck is straight no
Palpation The neck is straight. No visible mass or visible lumps or
mass, symmetrical Normal
lumps. Symmetrical, no jugular venous distension
(suggestive of cardiac congestion). and no jugular venous
distension
REFERENCE: Lippincott Williams & Wilkins Nursing
Procedures & Protocols

Anterior Thorax Inspection The chest wall is intact with no tenderness and Not Assessed
masses. Theres a full and symmetric expansion and
the thumbs separate 2-3 cm during deep inspiration
when assessing for the respiratory excursion. The
client manifested quiet, rhythmic and effortless
respirations
Posterior Thorax Palpation The spine is vertically aligned
Heart Palpation No, palpable pulsation over the aortic, pulmonic, and Not Assessed
mitral valves.
Apical pulsation can be felt on palpation
Breast Inspection The overlying the breast should be even.
May or may not be completely symmetrical at rest.
The areola is rounded or oval, with same color, (Color
 varies form light pink to dark brown depending on
race)
Abdomen Inspection No venous engorgement.
Upper Extremities

Shoulders, elbow, Inspection Smooth, freely movable joints with no swelling The patients Normal
wrist & hand shoulders, elbow,
wrist & hand is
smooth, freely
Palpation movable joints with no
Warm, moist skin with bilaterally even temperature
swelling, warm, moist
skin with bilaterally
REFERENCE: Lippincott Williams & Wilkins Nursing even temperature
Procedures & Protocols

Lower Extremities

Knee, ankle & Inspection Even skin color; symmetrical hair and nail growth; There is edema on
foot no lesions, varicosities, or edema; bilaterally equal right and left foot of
muscle mass the patient Pitting edema
due to CHF

REFERENCE:http://www.rnpedia.com/home/notes/fun
damentals-of-nursing-notes/head-to-toe-assessment

SENSORY FUNCTION
Pain
Light Touch
One-and-two Not Assessed
point
discrimination
MOTOR FUNCTION

Finger-to-nose-
test
Alternating Not Assessed
supination and
pronation of
hands and hands
Fingers to thumb Fingers to Not Assessed
thumb Can able to perform these movement and the
responses are equal bilaterally
BALANCE
Heel-toe-walking Heel-toe- Maintains a heel toe walking along a straight line
walking Not Assessed

REFERENCE: http://nurseslabs.com/nursing-
assessment-cheat-sheet/
Romberg Test Romberg Test Steady stance with minimal weaving Not Assessed
Walking gait Steady gait, good balance and no signs of muscle Not Assessed
weakness or pain in any style of walking

REFERENCE: Lippincott Williams & Wilkins Nursing

Procedures & Protocols

REFLEXES
Triceps reflex Place your Normal reflex reaction
fingers over Not Assessed
the triceps
tendon area
and tap them
with a reflex
hammer REFERENCE: Lippincott Williams & Wilkins Nursing
Procedures & Protocols
Biceps
 Plantar reflex
Not Assessed
Patellar/knee Using the Normal reflex reaction
reflex reflex hammer Not Assessed

REFERENCE: Lippincott Williams & Wilkins Nursing

Procedures & Protocols

CRANIAL NERVE
FUNCTION
CN I (Olfactory) Letting the Odor normally detectable @ distance of ~10cm The patient can
patient smell smell the thing that I Normal
something let him smell (cotton
(cotton with REFERENCE: Lippincott Williams & Wilkins Nursing with alcohol)
alcohol) Procedures & Protocols

CN II (Optic) Using the Examination not

snellen chart
done
CN III Diagnostic Examination not
(Oculomotor) Position Overall responses of the pupils: PERRLA done
CN IV (Pupil,Equal,Round,React to Light and
Test
(Trochlear) Accommodation)
CN VI
(Abducens) REFERENCE: Health Assessment and Physical
Examination ----Josie Quiambao-Udan RN,MAN

CN VII (Facial) Observation Facial symmetry Examination not

for movement done
and facial
symmetry
 CN VIII o Whispered o The patient repeats each word correctly
(Auditory) Voice Test
o Weber Test o The patient should hear the tone by bone
conduction through the skull and it should sound
equally loud in both ears
o Rinne Test o Is documented as positive Rinne Test or
AC>BC

REFERENCE: Health Assessment and Physical

Examination ----Josie Quiambao-Udan RN,MAN
CN IX Inspection Uvula and soft palate rise in midline and Examination not
(Glossopharyngeal) tonsillar pillars move medially when patient done
says ah
Leasia Monahan, A Practical guide to Health
Assessment 2nd Ed.,p.417

VI. Laboratory Result and Diagnostic Examination

Type of Diagnostic Examination: BLOOD CHEMISTRY

Date: 09-26-14

Examination Result Normal Values Significance

BUN 40.040 2.9-8.2 mmol/L Normal
Reference: internet
google
CREATININE 627.04 53-106mol/L Normal
Reference: internet
google
SODIUM 126.2 136-142 mmol/L Normal
 Reference: internet
google
POTASSIUM 5.86 3.8-5.0 mmol/L Normal
Reference: internet
google
CHLORIDE 85.3 95-103meeq/L Normal
Reference: internet
google
RBS 116 45.0-130.0mg Normal
Reference: internet
google

Type of Diagnostic Examination: HEMATOLOGY REPORT

Date: 09-25-14

Examination Result Normal Significance

Values
WBC 9.28 3.70-10.1 Normal
Reference
: internet
google
NEU 7.22 1.63-6.96 Normal
Reference
: internet
google
LYM 1.32 1.09-2.99 Normal
Reference
: internet
google
MONO .648 .240-.790 Normal
Reference
: internet
google
BASO .075 0.00-.080 Normal
Reference
: internet
google
RBC 3.18 3.60-4.69 Normal

Reference
: internet
google
HGB 88.9 108-142
Reference
: internet
google
HCT .297 .377-.537
Reference
: internet
google
 DEVELOPMENTAL HISTORY
Theorist Age/Sex Stage Norms/Standard Patients Description
The final stage of The patient develop this
psychosexual development kind of development, but
Freud ADULT Genital Stage (puberty on) begins at the start of doesnt get involve in
puberty when sexual urges sexual activities because
are once again awakened. of the abnormality he has

Young adults need to form

intimate, loving
relationships with other
people. Success leads to
strong relationships, while
Erikson ADULT Intimacy vs. Isolation
failure results in loneliness
and isolation.
The patient doesnt
involved in relationships
with opposite sex
sometimes that results in
isolation. But does have
friends to be with.

Maslow hierarchy of needs five- Biological and The patient meets this
stage model Physiological needs - air, basic need, for his daily
food, drink, shelter, living
warmth, sex, sleep.

2. Safety needs -
protection from elements,
security, order, law,
At any age. stability, freedom from fear.

3. Love and belongingness

needs - friendship,
intimacy, affection and
 love, - from work group,
family, friends, romantic
relationships.

4. Esteem needs -
achievement, mastery,
independence, status,
dominance, prestige, self-
respect, respect from
others.

5. Self-Actualization needs
- realizing personal
potential, self-fulfillment,
seeking personal growth
and peak experiences.

Adolescence and intelligence is

adulthood demonstrated through the
logical use of symbols The patient cannot think
related to abstract logically because of his
Piaget Formal operational stage
concepts. Early in the abnormality. And cannot
period there is a return to make his own decision.
egocentric thought.

Kohlberg Significant Others, The patient knows how to

Acceptance of the rules follow rules and regulation
Beginning in middle and standards of one's and knows the
 school, up to middle age group.
punishments done.

stage begins when oldest The patient still stays with

- Families launching young child leaves home and his parents. Because of his
Duvall Stage 6
adults ends when youngest child abnormality he cannot live
leaves home by his own

III. Introduction
Heart failure the inability or failure of the heart to adequately meet the needs of organs and tissues for oxygen and nutrients. This
decrease in cardiac output, the amount of blood that the heart pumps, is not adequate to circulate the blood returning to the heart from the
body and lungs, causing fluid (mainly water) to leak from capillary blood vessels. This leads to the symptoms that may include shortness
of breath, weakness, and swelling

IV. Anatomy & Physiology of the Circulatory System

The heart itself is made up of 4 chambers, 2 atria and 2 ventricles. De-oxygenated blood returns to the right side of the heart via
the venous circulation. It is pumped into the right ventricle and then to the lungs where carbon dioxide is released and oxygen is absorbed.
The oxygenated blood then travels back to the left side of the heart into the left atria, then into the left ventricle from where it is pumped
into the aorta and arterial circulation.
.

The pressure created in the arteries by the

contraction of the left ventricle is the systolic blood
pressure. Once the left ventricle has fully
contracted it begins to relax and refill with blood
from the left atria. The pressure in the arteries falls
whilst the ventricle refills. This is the diastolic
blood pressure

Nursing
Assessment Planning Intervention Rationale Evaluation
Diagnosis
Patienthas
Subjective: Excessive After 1 hour of nursing 1. Establish rapport 1. To gain patients trust and demonstrated
Fluid volume r/t interventions, the cooperation adequate fluid
Objective: sodium and patient will balance :clearing
water retention demonstrate adequate 2. Monitor and record 2. To obtain baseline data breath sounds and
Patient VS
secondary to fluid balance as decreasing edema.
manifested: 3. To determine what
CHF. manifested by clearing
Edema on 3. Assess patients approach to use in treatment
breath sounds, and
extremities general condition
decreasing edema
Crackles,
after 3 days. 4. Body weight is a sensitive
heard on both
lung fields 4. Weigh patient daily indicator of fluid balance and
RR = and compare to an increase indicates fluid
30bpm previous weights. volume excess.
BP =
5. May include increased
180/110 5. Follow low-sodium
PR = 119 fluids or sodium intake, or
diet and/or fluid compromised regulatory
Weight =
 60kg restriction mechanisms.

6. Treatment focuses on
6. Assess the need for diuresis of excess fluid.
an indwelling urinary
catheter.
7. This helps reduce
extracellular volume.
7. Institute/instruct
patient regarding fluid
restrictions as
8. Enhances excretion of
appropriate.
sodium, chloride,potassium
8. Administer diuretics by direct action at
as prescribed ascendinglimb of loop of
Henle. Therapeutic
Effect:Produces diuresis,
lowers B/P.

Nursing
Assessment Planning Intervention Rationale Evaluation
Diagnosis
Subjective: Activity After 2 hours of After 2 hours of
intolerance r/t nursing interventions, 1. Establish Rapport 1. To gain clients nursing
Objective: imbalance O2 the patient will report participation and interventions, the
supply measurable increase cooperation in the nurse patient reported
Patient
in activity intolerance: patient interaction measurable increase
manifested:
RR to normal level in activity
2. Monitor and record
<20, PR to normal 2. To obtain baseline data intolerance: RR to
1. generalized Vital Signs
weakness level <100, increased normal level <20, PR
2. limited range ROM, absence of to normal level <100,
of motion as weakness 3. Adjust clients daily 3. To prevent strain and increased ROM,
observed activities and reduce overexertion absence of
3. abnormal intensity of level. weakness
pulse rate Discontinue activities
(PR that cause undesired
=119bpm) psychological
4. (+) DOB changes
4. to relax the body
(30bpm)
4. Encourage patient to
have adequate bed
rest and sleep 5. to provide relaxation

5. Provide the patient

with a calm and quiet
environment 6. to sustain motivation of
client
6. Give client
information that
provides evidence of
daily or weekly 7. to promote easy breathing
progress
8. to maintain an open
7. Assist the client in a
airway
semi-fowlers position

8. Elevate the head of

the bed
VIII. List of Identified Problems According To Priority

I. Impaired gas exchange related to accumulation of fluid in the alveoli

II. Activity intolerance r/t imbalance O2 supply
III. Excessive Fluid volume r/t sodium and water retention secondary to CHF.
Nursing
Assessment Planning Intervention Rationale Evaluation
Diagnosis
Subjective: Impaired gas After 30 minutes of The patient has been
exchange nursing 1. Monitor and record vital 1. To obtain baseline able to demonstrate
Nahihirapan related to interventions, the signs data improvement in gas
akong huminga accumulation of patient will be able to exchange a decrease in
fluid in the demonstrate respiratory rate to normal
Objective:
alveoli improvement in gas
2. To promote
Patient exchange a
2. Elevate head of bed and maximal inspiration,
manifested: decrease in
encourage frequent position enhance
presence respiratory rate to
changes. expectoration of
of rales, normal.
secretions in order to
crackles upon improve ventilation
auscultation
RR= 30 3. Keep back dry.
3. To avoid coughing
bpm
4. Promote adequate rest
4. Rest will prevent
periods
weakness and
decrease oxygen
demands for
metabolic demands
5. Change position q 2 hrs.
5. To promote
drainage of secretions
6. Suction secretions PRN
6. To clear airway
when secretions are
blocking the airway.
7. Administer oxygen therapy
as ordered. 7. O2 therapy is
indicated to increase
 oxygen saturation

TRIMETAZIDINE, ATORVASTATIN LACTIULOSE SPIRONOLACTONE

Generic Name: Atorvastatin

Brand Name: Lipitor
Drug Classification: Anti-hyperlipidemic
Dosage:
Indications:
Mechanism of Actions Side Effects Contraindications Adverse Reactions Nursing Considerations

Inhibits HMG-CoA Active hepatic Potential for cataracts, Question for possibility of pregnancy
reductase, the disease, photosensitivity, before initiating therapy (Pregnancy
enzyme lactation, myalgia, Category)
that catalyzes the pregnancy, rhabdomyolysis Assess baseline lab results:
early step in unexplained cholesterol,
cholesterol synthesis elevated triglycerides, hepatic function
hepatic tests. Obtain dietary history.
function test
results Monitor for headache. Assess for
rash, pruritus, malaise. Monitor
cholesterol, triglyceride
lab values for therapeutic response.
Monitor hepatic function tests, CPK.

Follow special diet (important part of

treatment).
 Periodic lab tests are essential
part of therapy. Do not take other
medications without consulting
physician.
Report dark urine, muscle fatigue,
bone pain.
Avoid excessive alcohol intake,
large quantities of grapefruit juice.

Generic Name: Lactulose

Brand Name: Acilac
Drug Classification: Hyperosmotic laxative, ammonia detoxicant
Dosage:
Indications: Prevention, treatment of portal-systemic encephalopathy (including hepatic precoma, coma); treatment of chronic constipation.
Mechanism of Actions Side Effects Contraindications Adverse Reactions Nursing Considerations

Prevents reabsorption Abdominal Use in pts Diarrhea Encourage adequate fluid

of ammonia, cramping, requiring a indicates intake. Assess
producing flatulence, low-galactose overdose. bowel sounds for peristalsis.
increased thirst,
osmotic effect diet. Long-term Monitor
abdominal daily pattern of bowel
use may result
discomfort
in laxative activity, stool consistency;
dependence, record time of evacuation.
chronic Assess
constipation, for abdominal disturbances.
loss of normal Monitor
bowel function. serum electrolytes in pts
exposed to
prolonged, frequent,
excessive use of
medication.
Generic Name: Spironolactone
Brand Name: Aldactone
Drug Classification: Potassium- sparing diuretic, antihypertensive, antihypokalemic
Dosage:
Indications: Management of edema associated with severe CHF, cirrhosis, nephrotic syndrome
Mechanism of Actions Side Effects Contraindications Adverse Reactions Nursing Considerations
Interferes with sodium Hyperkalemia (in Acute renal Severe Weigh pt; initiate strict I&O. Evaluate
reabsorption by pts with renal insufficiency, hyperkalemia hydration
competitively inhibiting insufficiency, anuria, may produce status by assessing mucous
those taking
action of aldosterone hyperkalemia. arrhythmias, membranes,
in distal tubule, potassium
bradycardia, skin turgor. Obtain baseline serum
supplements),
promoting sodium dehydration, EKG changes electrolytes, renal/hepatic function,
and water excretion, (tented T
hyponatremia, urinalysis. Assess for edema; note
increasing potassium lethargy. waves, location,extent. Check baseline vital
retention. widening QRS signs,note pulse rate/regularity.
complex,
ST segment
Monitor serum electrolyte values, esp.
depression).
for increased potassium, BUN,
creatinine.
Monitor B/P. Monitor for
hyponatremia:
mental confusion, thirst, cold/clammy
skin, drowsiness, dry mouth. Monitor
forhyperkalemia: colic, diarrhea,
muscle twitching followed by
weakness/paralysis,
arrhythmias. Obtain daily weight. Note
changes in edema, skin turgor.
X. Ongoing Appraisal

Day 1 ( 09-27-14)

Received a 44 year old patient lying on bed

With ongoing IVF D5Water in his left metacarpal running at 10-15 gtts/min
DAT
Afebrile
With vital sign:
o BP:180/110
o RR:30
o PR:119
o TEMP:37C

DAY 2 (08-01-14)

Awake patient
With ongoing IVF D5Water in his left metacarpal running at 10-15 gtts/min

With a vital signs:
o BP: 200/150
o RR: 28
o PR:115
o TEMP: 36.3C
XI. Discharge Planning

Medications:
1. Teach patient and her family or significant others the proper dosage and the right time to take the medication.

2. Emphasize to the patient the importance of obediently taking the prescribed medications and the disadvantages or complications that
may arise if these are not taken properly.

3. Inform and discuss the possible side effects and reactions that these drugs might produce and seek medical attention immediately is these arise

Exercise:
1. Tell client to refrain from straining activities

2. Deep breathing exercise

3. Minor activities that promotes gas exchange and lung expansion

Treatment:
Complete bed rest

Health Teachings:
1. Encourage patient to have a sufficient rest and sleep to maintain internal equilibrium

2. Understanding what to do with side effects of the medications

OPD follow up:

clinic appointments schedules