TABLE OF CONTENTS

CHAPTER TITLE PAGE

I. Patient’s Profile……………………………………………………………1

II. Chief Complaints…………………………………………………………...1

III. History of Present Illness…………………………………………………..1

IV. Past Medical History…………………………………………………….. 1

V. Social and Environmental History…………………………..2

VI. Family History………………………………………………………………2

VII. Physical Examination……………………………………………………....2

VIII. Diagnostics…………………………………………………………………..4

IX. Medical Diagnosis.………………………………………………………....10

X. Comprehensive Pathophysiology…………………………………………11

XI. Treatment and Management……………………………………………..13

XII. Nursing Diagnosis ………………………………………………………....21

XIII. Discharge Plan…………………………………………………………..…37

XIV. Conclusions and Recommendations…………………………………..….38

XV. List of References…………………………………………………….…...38

XVI. Appendices………………………………………………………………….39

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I. PATIENT’S PROFILE

Name: Mr. A. R.

Age: 73

Sex: Male

Civil Status: Married

Religion: Roman Catholic

Address: Brgy. Manlocboc Aguilar, Pangasinan

Occupation: Farmer

II. CHIEF COMPLAINTS

The patient was experiencing Difficulty of Breathing (DOB) characterized by a heavy object on top of
his left chest with a scale of 7 over 10 as 10 being the highest. .

III. HISTORY OF PRESENT ILLNESS

Present condition started one hour prior to admission, patient is watching news at their home and
experienced sudden difficulty of breathing, as verbalize by the significant others and the patient stated
this “ kasla adda naka patong ditoy barukong ko su nga marigatan nak a aganges” to the S.O. And he adds
that the client has a history of asthma and they think that it was the cause of difficulty of breathing.
Before it was mild and can relieve through rest but this time it was the time the client was not able to
tolerate the complaint so the family immediately refer it to the hospital.

IV. PAST MEDICAL HISTORY

The client is 73 years old, he suffers from asthma, and had his check ups only when severe
asthma attacks and was prescribed a medicine such as ventolin and salbutamol at the very young age but
despite of his condition he began to smoke five (5) sticks/day at the age of 20 and the S.O. claims that the
client used to drink occasionally. He loves to eat fatty foods and drink coffee 2 cups a day and doesn’t
follow any special diet.
Year 2007 when the client first confined at a primary hospital in their town Aguilar, Mr. A. R.
was admitted and confined for more than a week because of difficulty in breathing and increased blood
pressure. They were advised to undergo ECG and Chest X-ray in Dagupan Doctors Villaflor Memorial
Hospital. The result was seen and interpreted by the cardiologist and was found out that Mr. A. R. has
enlargement of the heart. From then on, Mr. A.R visits his cardiologist twice a month and takes his
medicines as maintenance for his BP and heart religiously.

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V. SOCIAL AND ENVIRONMENTAL HISTORY

The client is a farmer, he started to work in their own rice field at the age of 18 and stop tending
their rice field at the age of 50. Basing from Erickson’s developmental tasks theory, he is on late
adulthood. .According to the S.O. the client drinks occasionally and began to smoke five (5) sticks/day at
the age of 20.
Their house is well ventilated and was sited along the national road although it is expose to
smokes from vehicles which triggers his asthma.

VI. FAMILY HISTORY

The patient’s father was deceased by natural death. The mother was deceased with a history of
asthma and hypertension. They had 6 siblings; our patient was the 4th child. The first and second child
was deceased with an illness of hypertension. The 3rd and 5th child have no known illness inherited from
the parents and the last child is suffering from asthma. According to the S.O., other relatives from the
mother side are asthmatic and hypertensive and some relatives were past away with the same health
problem.

VII. PHYSICAL EXAMINATION

1. GENERAL SURVEY
The client is weak in appearance, with an ongoing IVF of D5NM 1L, conscious, was not able
to speak due to tracheostomy, needs assistance in moving, with a mechanical ventilator and with
NGT inserted at the right nostril. He can response to pain through withdrawing his left foot.

2. HEAD, EYES, EARS, NOSE, THROAT

a. HEAD
The client’s head is symmetrical and no fracture observed.
b. EYES
The client can’t able to open his left eyelid; his right pupil is dilated and reactive to light
at 2-3 mm. No tender mass upon palpation, lacrimal discharges were absent. Patient can only see
object place on his right and in front of him.
c. EARS
Ears are symmetrical, smooth in texture and are in the same color. No discharges were
noted. Patient responds to slow and loud instruction. Sense of hearing bilaterally is tested thru
watch ticking into the ear and hearing is intact as a result.
d. NOSE
Olfactory status was not properly assessed since test of each nostril separately was not
possible due to the presence of nasogastric tube on client right nostril. Small lesion noted around
the site where NGT was inserted.
e. THROAT
The throat was not proper assessed since the client has underlying tracheostomy.

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3. RESPIRATORY SYSTEM
Client breathes thru the help of mechanical ventilator on this following set up: FiO2:
30% TV: 450 BUR: 12 PF: 40
Rales or crackling sound is heard on inspiration upon auscultation on the left lung field. Oral
mucosa and lips are pale, no clubbing of finger nails noted. Thick yellowish, tenacious secretion
is evident upon suctioning. ABG study reveals: Metabolic Alkalosis Compensated - Ph = 7.5
PCO2 = 41.1 PO2 = 64.3 HCO3 = 32.2 B.E = 9.3 TCO2
= 33.5 O2Sat. = 84.1

4. CARDIOVASCULAR SYSTEM
The patients blood pressure ranges from 120/60 up to 160/60 mmHg at the left arm while
on lying position. Heart beat is irregular during periods of exertion and anxiety. ECG tracing
reveals occasional PVC and tachycardia. Heart murmurs are audible. Extremities are warm to
touch and peripheral pulses are present and palpable. Hemoglobin and hematocrit values are
relatively low. Jugular vein distention is present and all pulses are weak upon palpation.

5. GASTROINTESTINAL SYSTEM
The client’s mean of feeding is through NGT due to the presence of tracheostomy,
enlargement of the abdomen noted.

6. GENITO-URINARY SYSTEM
The client eliminates via diaper and condom catheter. His urine output ranges from 500-
1000ml for 8hrs and has bowel movement twice a day with semi-solid and tarry stool. No bladder
distention upon assessment at the hypogastric region.

7. MASCULO- SKELETAL SYSTEM

The client is on complete bed rest without bathroom privileges and need assistance in
moving. Tingling sensation was noted upon asking the client to squeeze an examiner’s hands and
push his feet against a resistance. Client is not able to perform flexion, extension, abduction and
adduction independently because when he was instructed to stretch his upper and lower
extremities to and fro he was not able to do it by himself, thus he needs support in doing such.

8. INTEGUMENTARY SYSTEM
The client is slightly cyanotic in nail beds, with pale oral mucosa and palpebral
conjunctiva. Skin is dry and warm to touch. No lesion cracks and bruises noted. The client has a
short, dry gray hair. No dandruff and parasites observed. Nails are clean and well trimmed.

9. NERVOUS SYSTEM
Orientation of three areas (time, place and date) was limited due to his condition. Verbal
response is finite but thru gestures, facial expression as his way of interaction it was known that

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 he is aware where he is, understand simple to complex instruction, able to write and read. It is
evident that intellectual development is appropriate on his age.
During the interview and assessment using GCS, client obtained a score of GCS 9 which
means client is lethargic. (EO: 4 V:1 M:4)

VIII. DIAGNOSTIC

DATE August 12,2009

DIAGNOSTIC Chest AP
PROCEDURE
DESCRIPTION X rays are a form of radiation that can penetrate the body and produce an image
on an x-ray film. Another name for x ray is radiograph.

Consist of two views, the frontal view (referred to as posterioranterior or PA)

and the lateral (side) view. It is preferred that the patient stand for this exam,
particularly when studying collection of fluid in the lungs.

PURPOSE Used to evaluate organs and structures within the chest for symptoms of
diseases. Chest x-ray include views of the lungs, heart, small portion of the GIT,
thyroid gland and the bones of the chest
IMPLICATIONS OF o There is a confluent density in the right peracardiac area and in the
THE FINDINGS right middle lung field.
- Indicates abnormal accumulation of fluid in the pericardiac area
and right middle lung which is to be consider as pneumonia.
o There is an irregular foreign body in the left midhemithorax.
- It may be an artifact or a bullet fragment.
o The heart is moderately enlarged. Aorta is atheromatous.
- There’s a fatty deposits on the inner walls of the aorta. This
narrows the passageway, and can become mineralized and
hardened.
- An enlarged heart may be caused by a thickening of the heart
muscle because of increased workload.
o Blunted right costophrenic sulcus.
- It may be due to minimal pleural effusion.

DATE August 15,2009

DIAGNOSTIC Chest AP
PROCEDURE
DESCRIPTION X rays are a form of radiation that can penetrate the body and produce an
image on an x-ray film. Another name for x ray is radiograph.

Consist of two views, the frontal view (referred to as posterioranterior or

PA) and the lateral (side) view. It is preferred that the patient stand for this
exam, particularly when studying collection of fluid in the lungs.

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 PURPOSE Used to evaluate organs and structures within the chest for symptoms of
diseases. Chest x-ray include views of the lungs, heart, small portion of the GIT,
thyroid gland and the bones of the chest area.
IMPLICATIONS OF o Follow-up examination after 3 days shows significant clearing of the
THE FINDINGS pneumonia in the right lung.
- Infiltrate has been cleared.
o The heart is enlarged to the same degree with LAE and LVE. There is
no pulmonary congestion.
- An enlarged heart may be caused by a thickening of the heart
muscle because of increased workload.

DATE August 17,2009

DIAGNOSTIC Chest AP
PROCEDURE
DESCRIPTION X rays are a form of radiation that can penetrate the body and produce an
image on an x-ray film. Another name for x ray is radiograph.

Consist of two views, the frontal view (referred to as posterioranterior or

PA) and the lateral (side) view. It is preferred that the patient stand for this
exam, particularly when studying collection of fluid in the lungs.
PURPOSE Used to evaluate organs and structures within the chest for symptoms of
diseases. Chest x-ray include views of the lungs, heart, small portion of the GIT,
thyroid gland and the bones of the chest area.
IMPLICATIONS OF o Follow-up examination 2 days after the last study shows essentially the
THE FINDINGS same findings. The cardiac shadow is enlarged with apparent flask-
shaped configuration.
- May be due to the presence of pericardial effusion is now considered.
o The lungs are hypoventilated. (Peak Flow increased to 30% on August 18,
2009).
- Due to reduced lung function. The body's carbon dioxide level
rises, which results in too little oxygen in the blood.

DATE Aug.25, 2009

DIAGNOSTIC Chest AP
PROCEDURE
DESCRIPTION X rays are a form of radiation that can penetrate the body and produce an
image on an x-ray film. Another name for x ray is radiograph.

Consist of two views, the frontal view (referred to as posterioranterior or

PA) and the lateral (side) view. It is preferred that the patient stand for this
exam, particularly when studying collection of fluid in the lungs.
PURPOSE Used to evaluate organs and structures within the chest for symptoms of
diseases. Chest x-ray include views of the lungs, heart, small portion of the GIT,

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 thyroid gland and the bones of the chest area.
IMPLICATIONS OF o Follow-up study since 17 August shows minimal haziness of the right
THE FINDINGS perihilar region wherein pneumonitis cannot be excluded. Clinical
correlation is recommended.
- Haziness likely represents layering of pleural effusion.
o An endotracheal tube is still seen with its tip at the level of T3-T4.
- To ensure proper placement of the ET tube.
o There is cardiomegaly. Aorta is minimally tortuous and calcified.
- An enlarged heart may be caused by a thickening of the heart
muscle because of increased workload.
- The aorta has an irregular shape, contorted, and can affect blood
flow coming out of the heart and to the body tissues.
- Aorta is stiff due to calcium deposits in the artery wall which is
known as atherosclerosis. Aortic calcification is more common in
older patients and those with cardiovascular disease and high
cholesterol.
o Right hemidiaphragm appears elevated.
- May be due to atelectasis (lung collapse).
o The right costophrenic sulcus is blunt.
- To rule out minimal right pleural fluid and/or thickening.
o An opaque foreign body is noted in the left lower hemithorax
superimposed on the left cardiac shadow to be correlated clinically
- Presence of foreign body in the left lower hemithorax.

DATE Sept. 1, 2009

DIAGNOSTIC Chest AP
PROCEDURE
DESCRIPTION X rays are a form of radiation that can penetrate the body and produce an
image on an x-ray film. Another name for x ray is radiograph.

Consist of two views, the frontal view (referred to as posterioranterior or

PA) and the lateral (side) view. It is preferred that the patient stand for this
exam, particularly when studying collection of fluid in the lungs.

PURPOSE Used to evaluate organs and structures within the chest for symptoms of
diseases. Chest x-ray include views of the lungs, heart, small portion of the GIT,
thyroid gland and the bones of the chest area.

IMPLICATIONS OF o Follow-up examination since August 25, 2009 now shows a tracheostomy
THE FINDINGS tube in place of the ET.
o Linear strands in the left lung base.

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 - May be due to subsegmental atelectasis.
o The heart shadow is enlarged. Aorta is atheromatous.
- There’s a fatty deposits on the inner walls of the aorta. This
narrows the passageway, and can become mineralized and
hardened.
- An enlarged heart may be caused by a thickening of the heart
muscle because of increased workload.
o There is a bulge in the right hilar area.
- May be due to prominent pulmonary artery.
o Elevated diaphragm. Minimal pleural effusion in the right is not ruled-
out.
- Still there’s an excess fluid accumulation in the pleural cavity.

DATE Aug.19, 2009

DIAGNOSTIC 2D ECHO
PROCEDURE
DESCRIPTION
Based on detection of echoes produce by a beam of ultrasound passes
transmitted in to the heart.
PURPOSE Used for imaging the living heart
IMPLICATIONS OF o Eccentric left ventricular hypertrophy with multi segmental wall
THE FINDINGS motion.
- Abnormality consistent with coronary artery disease with post
myocardial infarction with depressed systolic function (EF 30-
35%).
o Dilated left atrium.
- Dilated left atrium may be due to mitral regurgitation.
o Aortic sclerosis with mild aortic regurgitation.
- There’s a calcification and thickening of an aortic valve in the
absence of obstruction of ventricular outflow but the valve doesn't
close properly, and blood can leak backward through it.
o Mild mitral regurgitation.
o Left ventricular thrombus noted.
- Left ventricular thrombus is the complications of myocardial
infarction (MI). Left ventricular thrombus is the major source
of embolic stroke after ST segment elevation myocardial
infarction.

DATE Aug.22-Sept.1, 2009

DIAGNOSTIC CBC
PROCEDURE
DESCRIPTION
Is a series of test used to evaluate the composition and concentration of the

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 cellular components of blood.
PURPOSE As a preoperative test to ensure both adequate oxygen carrying capacity and
hemostasis.
IMPLICATIONS OF WBC:
THE FINDINGS The WBC was relatively high due to pneumonia, as shown by the
graph; there was a slight drop on August 27 probably as result of
aggressive antibiotic regimen implemented on the patient. Apparently due
to long-term use of Mechanical Ventilator and the insertion of ET tube,
VAP was considered as the cause of the steady rise of WBC.
- A high count indicates not a specific disease by itself but indicates
infection, systemic illness, inflammation, allergy and leukemia, too
much of mental stress also increases the count of the white blood cells
in the body. Also, once the count of white blood cell is on the higher
side, the risk of cardiovascular mortality also increases.
RBC:
- Low RBC counts are indicative of anemia and anemia can have many
causes, with our patient causes includes vitamin and iron deficiencies
and acute bleeding. Replacement of this component (RBC) is necessary
to increase the oxygen carrying capacity of blood.
HEMOGLOBIN:
- A low hemoglobin count indicates a low red blood cell count referred to
as anemia. Hemoglobin levels can be resurrected by following a
balanced diet.
HEMATOCRIT:
- A low hematocrit is referred to as being anemic. An anemic person has
fewer or smaller than normal red blood cells. A low hematocrit,
combined with other abnormal blood tests, confirms the diagnosis.

DATE Aug.12-Sept 2, 2009

DIAGNOSTIC Serum electrolytes
PROCEDURE
DESCRIPTION
Are positively and negatively charged molecules called ions, that are found
within the body cell and extracellular fluids including blood plasma.These ions
are measured to assess renal, endocrine and acid base function.
PURPOSE To measure the concentration of electrolytes are needed for both the diagnosis
and management of renal endocrine acid base balance and many concentration.
IMPLICATIONS OF Sodium:
THE FINDINGS - Low blood sodium (hyponatremia) occurs when you have an
abnormally low amount of sodium in your blood or when you have an
excess of water in your blood. Low blood sodium is common in older
adults, especially those who are hospitalized or living in long term care
facilities

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 Chloride:
- Hypochloremia is decreased serum chloride level and is usually related
to excess losses of chloride ion through the GI tract, kidneys, or
sweating. Hypochloremic clients are at risk for alkalosis and may
experience muscle twiyching,tremors or tetany.
- If you are dehydrated, your chloride level is increased and. if you are
overhydrated, your chloride level is decreased
Potassium:
Hyperkalemia
- Is a potassium excess or a serum potassium level greater than 5.3
meq/L. Hyperkalemia is less common than hypokalemia and rarely
occurs in clients with normal renal function. It is however, more
dangerous than hypokalemia and can lead to cardiac arrest.
Hypokalemia
- Is a potassium deficit or a serum potassium level of less than 3.4 meq/L.

DATE Aug. 23 and Sept 24, 2009

DIAGNOSTIC BUN
PROCEDURE
DESCRIPTION
Measure amount of nitrogen in the blood that comes from the waste product
urea.
PURPOSE It is done to see how well the kidneys are working.
IMPLICATIONS OF - A BUN test is done to see how well your kidneys are working. If your
THE FINDINGS kidneys are not able to remove urea from the blood normally, your
BUN level rises.
- Heart failure, dehydration, or a diet high in protein can also make your
BUN level higher.

DATE Aug.20 -Sept.1, 2009

DIAGNOSTIC Creatinine
PROCEDURE
DESCRIPTION
Important compound produced by the body, it combines with phosphorus to
make high energy phosphate compared in the body
PURPOSE Use to diagnose impaired kidney function and to determine renal damage
IMPLICATIONS OF - High creatinine occurs with sudden (acute) kidney failure, which may
THE FINDINGS be caused by conditions such as shock or severe dehydration.
- As the kidneys become impaired for any reason, the creatinine level in
the blood will rise due to poor clearance by the kidneys. Abnormally
high levels of creatinine thus warn of possible malfunction or failure of
the kidneys.

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IX. MEDICAL DIAGNOSIS

CONGESTIVE HEART FAILURE SECONDARY TO CORONARY ARTERY

DISEASE- MYOCARDIAL INFARCTION

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X. Comprehensive Pathophysiology
ETIOLOGY OF CONGES HEART FAILURE
SECONDARY to CORONARY ARTERY DISEASE-MYOCARDIAL INFARCTION
Risk Factors: and RELATED COMPLICATIONS (ACUTE RENAL FAILURE)
Hypercholesterolemi
Men (>45 years old)
Women (>55 years old) heart damage old myocardial infarction
Cigarette smoking ventricular overload
Alcoholism ↓ ventricular contraction
Diabetes mellitus
Obesity Coronary Artery
Physical inability Disease
↑ sodium intake ↓ myocardial contractility
Hereditary ↑ cardiac workload
Predisposing Factors: ↓ diastolic filling
Hypertension
CAD

↑ left atrial pressure

rupture of chordae tendeneae LEFT-SIDED HEART FAILURE

mitral valve regurgitation

aortic valve regurgitation/stenosis

Blood dams back into ↓ stroke volume enlargement of the chambers

the pulmonary capillary bed of the heart

Pressure of blood into ↓ tissue perfusion

the pulmonary capillary altered normal
bed increases ( dyspnea ) electrical pathway

Pulmonary Edema
Signs and Symptoms: Hyperventilation, headache, cyanosis,
Dyspnea ↑ cellular
dizziness, Fatigue, drowsiness, ↓ blood flow to Palpitations, tachycardia, irregular
PULMONARY
paroxysmal EDEMA
nocturnal hypoxiaparesthesias, tingling
unconsciousness, the kidneys ARRHYTHMIAS
heartbeat, anxiety, weakness,
orthopnea dizziness, lightheadedness, fainting
rales / crackles / wheezes Tingling or nearly fainting, sweating,
moist cough shortness of breath, chest pain
blood-tinged frothy sputum
dizziness
syncope
fatigue
weakness
anorexia prolonged renal ischemia
clubbing fingers
pulses alternans ACUTE TUBULAR NECROSIS/ACUTE RENAL FAILURE
S3 and S4 heart sounds
l

Failure of kidneys inability of the ↓ excretion of ↓ Na reabsorption

to produce kidneys to nitrogenous in tubules
Fatigue , weakness, fainting,
erythropoietin metabolize wastes
breathlessness, palpitations, dizziness, Vit. D , pulses weak,
Hypotension
↑ pulmonary vascular headache, tinnitus, difficulty
Anemia sleeping, Diarrhea, abdominal pain,
resistance difficulty concentrating, pale hypocalcemia uremia water
Nausea/vomiting, muscle
retention complexion, tachycardia
spasms, anxiety

RIGHT SIDED HEART

FAILURE
edema/ascites

↑ RV contraction

Azotemia Stomatitis and GI renal encephalopathy accumulation

bleeding of wastes
↑ force of RV on skin
contraction
CNS changes

↑ RV oxygen demand coffee-ground NGT aspirate lethargy pruritus

↑ RV blood backflows
↓ force of RV ↑ residual blood of from RV to RA
RV Hypoxia contraction the RV at the time preload 11
of diastole
 Peripheral edema

Signs and Symptoms:

↑ RA pressure
liver congestion, ascites,
weakness, weight gain
due to retention of fluid
↑ RA preload

↑ fluid moves into the blood backflows from

interstitial space RA to systemic
due to retention of ↑ venous pressure circulation
fluid JVD
(07/23/08

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XI. TREATMENT AND MANAGEMENT

a. Drug study

TRADE AND GENERIC CLASSIFICATION MECHANISM OF SIDE EFFECTS NURSING INTERVENTIONS

NAME ACTION

Trade Name: diuretics A potent loop diuretic CNS: vertigo, headache,
Furoscan that inhibits sodium dizziness, weakness,
and chloride restlessness.
reabsorbtion at the CV: orthostatic hypotension
Generic name: proximal and distal GI: abdominal discomfort and
Furosemide tubules and the pain, diarrhea, anorexia, nausea,
ascending loop of constipation, pancreatitis
Henle. HEMATOLOGIC: anemia,
METABOLIC: dehydration,
hypokalemia, fluid and
electrolyte imbalance, including
dilutional hyponatremia,
hypocalcemia, and
hypomagnesemia,hyperglycemia
and impaired
glucose tolerance
• Monitor fluid intake and output
and electrolyte, BUN, and
carbon dioxide frequently.
• Watch for signs of
hypokalemia, such as muscle
weakness and cramps.
• Monitor elderly patients, who
are especially susceptible to
excessive diuresis, because
circulatory collapse and
thrombo-embolic complication
are possible.

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 14

TRADE AND CLASSIFICATION MECHANISM OF SIDE EFFECTS NURSING

GENERIC NAME ACTION INTERVENTIONS

Trade Name: Anti-arrythmic Inhibits sodium CNS: Fatigue, generalized • Before giving loading dose ,
Lanoxin potassium –activated muscle weakness, agitation, obtain base line data (heart rate
adenosine hallucination, headache, malaise, and rhythm, blood pressure,
triphosphatase, dizziness, vertigo, stupor, and electrolytes) and ask
Generic name: thereby promoting paresthesia. patient about use of cardiac
Digoxin movement of calcium CV: arrhythmias glycocides within the previous
from extra cellular to EENT: blurred vision, light 2 to 3 weeks.
intra cellular flashes, photophobia, diplopia • Before giving drug , take
cytoplasm and streng GI: anorexia, nausea, vomiting, apical-radial pulse for 1 minute.
thening myocardial diarrhea. Record and notify the
contraction. Also acts prescriber of significant
on CNS to enhance (sudden increase or decrease in
vagal tone, slowing pulse rate, pulse deficit,
conduction through irregular beats and particularly,
the SA Node to AV regularization of a previously
nodes and providing irregular rhythm). If this occur,
an anti arrhythmic check blood pressure and
effect. obtain a 12 lead ECG.
• Toxic effects on the heart
maybe life-threatening and
require immediate attention.

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TRADE AND GENERIC CLASSIFICATION MECHANISM OF SIDE EFECTS NURSING

NAME ACTION INTERVENTIONS

Trade Name: Adrenergic Directly stimulates CNS: Headache • Monitor potassium level
Dobutrex beta1 receptors of CV: Increase heart rate, carefully. Take corrective
200mg/250ml heart to increase hypertension, pvc’s , angina. action before hypocalemia
myocardial Palpitation. hypotension occurs.
contractility and GI: nausea/ vomiting • Monitor digoxin level.
Generic name: stroke volume. At Respiratory: shortness of Therapeutic level ranges from
Dobutamine therapeutic dosages, breath, asthmatic episodes 0.8-2 mg per ml. obtain blood
hydrochloride drug decreases for digoxin level at least 6-8
peripheral vascular hrs after last oral dose,
resistance (afterload), preferably just before next
reduces ventricular scheduled dose.
filling
pressure( preload),
and may facilitate
AV node conduction .

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 16

TRADE NAME AND CLASSIFICATION

GENERIC NAME MECHANISM OF SIDE EFFECTS NURSING INTERVENTIONS
ACTION

Trade Name: Anti-arrythmic A class IB anti CNS: ligthheadedness, • Give IM injections in the
lLgnonex arrhythmic that confusion, tremor, lethargy, deltoid muscle only.
decreases the restlessness, anxiety, seizures. • Monitor isoenzymes when using
Generic Name: depodalization, CV: Hypotension, IM drug for suspected M.I.
Lidocaine hydrochloride automaticity, and bradycardia, new or worsen lidocaine will show a sevenfold
excitability in the cardiac arrythmias, cardiac increase in C and K level. Such an
ventricles during the arrest. increase originates in the skeletal
diastolic phase by GI: vomiting muscle, not the heart.
direct action on the Respiratory: Respiratory • Monitor drug level. Therapeutic
tissues, especially the depression and arrest. levels are 2-5 mcg per ml.
purkinje network. • Monitor patient’s response,
especially blood pressure and
electrolytes, BUN, and creatinine
levels .notify prescriber promptly
if abnormalities develop.
• If arrhythmias worsen or ECG
changes (for example, QRS
complex widens or P.R interval
substantially prolongs), stop
infusion and notify physician.

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 17

TRADE NAME CLASSIFICATION MECHANISM OF SIDE EFFECTS NURSING INTERVENTIONS

AND GENERIC ACTION
NAME

Trade Name: Aminoglyciside Inhibits protein CNS: seizure, dizziness,
Xylocaine synthesis by binding headache, encelopathy,
directly to the 30S confusion
Generic Name: ribosomal subunit. CV: hypotension
Gentamicine sulfate Usually bactericidal. GU: nephrotoxicity, possible
increase in urinary excretion
of casts.
Respiratory: apnea
GI: vomiting, nausea
Hematologic: leucopenia,
thrombocytopenia,
agranulocytosis
Musculoskeletal: muscle
twitching, myasthenia
gravis-like syndrome
• Obtain specimen for culture and
sensitivity test before giving first dose
period. Therapy may begin while
awaiting results.
• Evaluate patient’s hearing before and
during therapy. Notify physician if
patient complains of tinnitus, vertigo, or
hearing lost.
• Weigh patient and review renal
function studies before therapy begins.
• Obtain blood for peak gentamicin
level one hour after IM injection for 30
minutes after IV infusion finishes; for
trough levels, draw blood just before
next dose. Don’t collect blood in a
heparinized tube; heparin is
incompatible with amino glycosides

• Monitor renal function: urine output,

specific gravity, urinalysis, BUN and
creatinine clearance. Report to
prescriber evidence of declining renal
function.

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 18

TRADE NAME AND CLASSIFICATION MECHANISM OF SIDE EFFECTS NURSING INTERVENTIONS

GENERIC NAME ACTION

Trade name: antihypertensive Unknown. A selective CNS: fatigue, dizziness, • Always check patient’s
Toprol beta blocker that headache, depression apical pulse rate when before
selectively blocks CV: hypotension, bradycardia, giving drug. If it’s slower than
Generic name: beta1- adrenergic heart failure, AV block 60bpm. Withhold drug and call
Metoprolol succinate receptors; decreases Respiratory: dyspnea physician immediately.
cardiac output, GI: diarrhea, nausea • Monitor blood pressure
peripheral resistance, frequently; metropolol masks
and cardiac oxygen common signs and symptoms
consumption; and of shock.
depresses rennin
secretion.

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b. IV Fluids

COMPONENT CLASSIFICATION EFFECTS/ USES SIGNIFICANCE

o Used to supply water and calories to
D5W ISOTONIC the body
o Adult I.V. solution to keep vein open
o Vehicle for mixing medications for
I.V. delivery for all age groups.
o May be a primary adult I.V. fluid for
medical emergencies
o Provides calories for some metabolic
needs.
o Supplies body water for hydration
o Spares body protein by providing
carbohydrate for metabolism.
o Capable of producing diuresis depending
on clinical state of the patient.

COMPONENT CLASSIFICATION EFFECTS/ USES SIGNIFICANCE

o For long-term parenteral nutrition in o For replacement of acute extracellular
D5NM ISOTONIC acute and chronic renal insufficiency fluid losses without disturbing normal
and in haemofiltration and peritoneal electrolyte relationships.
and haemodialysis.
o Provides water and electrolytes with
carbohydrate calories for replacement
of acute extracellular fluid losses
without disturbing normal electrolyte
relationships

19
 20

COMPONENT CLASSIFICATION EFFECTS/ USES SIGNIFICANCE

o Is used in emergency care to treat o Primary carbohydrate fuel used in the
Dextrose D 50% HYPERTONIC hypoglycemia and to manage coma of body.
unknown origin.

COMPONENT CLASSIFICATIO EFFECTS/ USES SIGNIFICANCE

N
o Used to replace fluids in dehydration
PNSS contains 154 mEq/L ISOTONIC o Used frequently in intravenous drips
of Na+ and Cl−. (IVs) for patients who cannot take
fluids orally and have developed or
are in danger of developing
dehydration or hypovolemia
o Used to replace fluids in dehydration,
go with blood transfusions,
hyponatremia, and burn victims, it is
isotonic,( same osmolarity as our body
fluids
o Replacement & maintenance of fluid &
electrolytes.
o Restores the blood volume rapidly.
o The first fluid used when hypovolemia is
severe enough to threaten the adequacy of
blood circulation and has long been
believed to be the safest fluid to give
quickly in large volumes.

20
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XII. NURSING DIAGNOSIS

ACTUAL PROBLEM 1: IMPAIRED GAS EXCHANGE RELATED TO VENTILATION PERFUSION IMBALANCE AS MANIFESTED BY INCREASE IN CARDIAC RATE
AND RESPIRATION, RESTLESSNESS, AND SHORTNESS OF BREATH.

ASESSSMENT EXPLANATION PLANNING NSG. RATIONALE EVALUATION

OF THE INTERVENTION
PROBLEM
OBJECTIVE: The rise in STO: INDEPENDENT  STO met.
pulmonary, venous
 Increased and capillary After 24 hrs of  Auscultated breath  Reveals presence of pulmonary  Ventilation and
cardiac rate pressure nursing sounds noting crackles, congestion/ collection of oxygenation is
(PR- 160 bpm) precipitates intervention, the wheezes. secretions indicating need for adequate for
movement of fluid patient’s further intervention. individual needs.
from the capillaries symptoms of
 Restlessness/ in to the respiratory  Assessed respiratory  Hypoventilation (pleuritic pain/  Patient
changes in interstitium and distress will be rate, depth and ease; use abdominal distention), pleural demonstrates
mentation alveolar spaces. lessened of accessory muscles. effusion/ alveolar edema, and ease of breathing
Excessive incomplete airway clearance
 Shortness of interstitial fluid (general weakness/ fatigue and
breath accumulation pain) impair gas exchange,
prevents the resulting in respiratory
 Increased exchange of gas insufficiency/ distress.
respiratory rate back and forth Manifestations are dependent on
(RR=32per min) between alveoli degree of lung involvement and
and blood. underlying pulmonary general
health status.

 Instructed patient in  Clears airway and facilitates

effective deep breathing. oxygen delivery.

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 22

Encourage frequent
position changes.
NURSING
DIAGNOSIS:

IMPAIRED GAS  Maintained bed rest in  Reduces oxygen consumption/

EXCHANGE Semi-Fowler’s position. demands and promotes maximal
RELATED TO lung inflation.
VENTILATION
PERFUSION  Observed color of skin, Cyanosis of nailbeds may
IMBALANCE AS mucus membranes, indicate vasoconstriction or body
MANIFESTED BY nailbeds, noting presence response to fever/ chills.
INCREASE IN of peripheral (nailbeds)
CARDIAC RATE cyanosis.
AND
RESPIRATION,  Assessed mental  Restlessness, irritaion,
RESTLESSNESS, status. confusion may reflect
AND SHORTNESS hypoxemia/ decreased cerebral
OF BREATH. oxygenation.

 Tachycardia is usually present

>Monitored heart rate/ as a result of fever/ dehydration
rhythm. but may represent a response to
hypoxemia.

 Monitored body  High fever (common in

temperature, as pneumonia) greatly increases
indicated. Provided metabolic demands and oxygen
comfort measures to consumption, and alters
reduce fever and chills, oxyhemoglobin curve reducing
e.g.,addition/ removal of cellular oxygenation.
bed covers/ blankets,
comfortable room
temperature, tepid or cool
water sponges.

22
 23

 Maintained bed rest.  Prevents over exhaustion and

reduces oxygen consumption/
demands and energy needs to
facilitate resolution of infection.

 Elevated head and  These measures promote

encourage frequent maximal inspiration, enhance
position changes and expectoration of secretions to
deep breathing. improve ventilation.

 Assessed level of  Anxiety is a manifestation of

anxiety, stayed with psychologic concerns as well as
patient. physiologic response to hypoxia.
Providing reassurance,
enhancing sense of security can
reduce the psychologic
component, thereby decreasing
oxygen demand and adverse
physiologic response

 Observed for  Shock and pulmonary edema

deterioration in condition, are the most common causes of
noting decrease in BP, death in pneumonia and require
copious amount of pink/ immediate medical intervention.
bloody secretion, pallor,
cyanosis, change in level
of consciousness, severe
DOB, restlessness.

COLLABORATIVE

 Monitored serial ABGs.  May show severe hypoxemia

during acute pulmonary edema
or reveal compensatory changes

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in chronic CHF.

 Administered  Increases alveolar oxygen

supplemental oxygen as concentration and may enhance
indicated. arterial oxygenation to correct/
reduce tissue hypoxemia.

 Administered
medications as indicated.
- Diuretics  Reduces alveolar congestion,
enhancing gas exchange.
- Bronchodilators
 Increases oxygen delivery by
dilating small airways and exerts
mild diuretic effect to aid in
reducing pulmonary congestion.

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ACTUAL PROBLEM 2: DECREASED CARDIAC OUTPUT RELATED TO ALTERED HEART RATE/RHYTHM AS EVIDENCED BY INCREASED HEART
RATE/DYSRRYTHMIAS, CHANGES IN BLOOD PRESSURE, EXTRA HEART SOUNDS AND DECREASED URINE OUTPUT.

25
 ASSESSMENT EXPLANATION OF
THE PROBLEM
OBJECTIVE: When failure first begins,
the left ventricle fails to
 Increased heart eject its full quota of
rate (PR- 160 blood. At this point, the
bpm) compensatory
mechanisms of
 Decreased urine sympathetic nervous
output system activation
200 cc/ day (tachycardia, dilation and
hypertrophy) occur. When
 Diminished this mechanism fail, the
peripheral pulses amount of blood
remaining in the left
Cool skin, ventricle t the end of
excessive diastole increases this
sweating increase in residual blood
in turn decreases the
breathes better ventricles capacity to
when in upright receive blood from the
position, crackles left atrium. The left
noted atrium having to work
harder to eject blood
jugular vein dilates and hypertrophies.
distension, edema It is unable to receive the
full amount of incoming
blood from the pulmonary
NURSING vein and left atrial
DIAGNOSIS: pressure increases. The
workload of the
DECREASED myocardium greatly
CARDIAC OUTPUT increases with abnormal
RELATED TO “loading” of the
ALTERED HEART ventricles. While an
RATE/RHYTHM AS increase in preload
EVIDENCED BY usually precipitates an
INCREASED increase in myocardial
HEART RATE / contractility (Starling’s
DYSRRYTHMIAS, law), filling pressures may
CHANGES IN rise beyond the
BLOOD capabilities of the
normally compliant heart.
26 PRESSURE,
EXTRA HEART Suddenly or overtime,
SOUNDS AND this expansion in preload
DECREASED lessens the force and
URINE OUTPUT. efficiency of ventricular
PLANNING NSG. RATIONALE EVALUATION
INTERVENTION
26
STO: INDEPENDENT
After 24 hrs. of
nursing  Assessed, monitored  Tachycardia is usually The goal met
intervention, the and recorded heart present even at rest to since the vital
pt. will be able to rate and rhythm. compensate for decreased LV signs of the client
display vital contractility. PVCs, PACs, and is within normal
signs within AF are common dysrrythmias range, absence
acceptable limits, associated with CHF, although of irregular heart
absence of others may also occur. rhythm or
irregular heart controlled and
rhythm or  Palpated peripheral  Decreased cardiac output episodes of DOB
controlled pulses. may be reflected in diminished
episodes of DOB. radial, popliteal, dorsalis pedis
and posttibial pulses. Pulses
may be fleeting or irregular to
palpation, and pulsus alternans
(strong beat alternating with
weak beat) may be present.
 Monitored blood  In early, moderate or chronic
pressure. CHF, BP may be elevated due
to increased SVR. In advanced
CHF, the body may no longer
be able to compensate and
profound/ irreversible
hypotension may occur.
 Inspected skin for  Indicative of diminished
pallor, cyanosis, and peripheral perfusion secondary
excessive sweating. to decreased /inadequate
cardiac output. Cyanosis may
develop in refractory CHF.
Dependent areas are often blue
or mottled as venous
congestion increases.
 Monitored urine  Kidneys respond to reduce
output, noted cardiac output by retaining
fluctuations of/ water and sodium.
decreasing output and
dark/ concentrated
urine
 Assessed level of  May indicate inadequate
consciousness. cerebral perfusion secondary to
 27

27
 28

ACTUAL PROBLEM No. 3 : EXCESS FLUID VOLUME RELATED TO COMPROMISED REGULATORY MECHANISM AND SODIUM RETENTION AS MANIFESTED
BY DECREASE URINE OUTPUT, EDEMA, JUGULAR VEIN DISTENTION AND INCREASED BLOOD PRESSURE

ASSESSMENT EXPLANATION PLANNING NSG. RATIONALE EVALUATION

OF THE INTERVENTION
PROBLEM
OBJECTIVE: As cardiac output falls, INDEPENDENT
decrease renal blood STO: STO met since the
 Decreased urine flow causes oliguria. If After 24 hrs of  Monitored urine output,  Urine output may be patients’:
output renal artery pressure nursing noting amount and color. scanty and concentrated.
(200 cc/ day) falls, lowered intervention, the
glomerular filtration patient will  Monitored/ calculated 24-  Diuretic therapy may serum electrolytes
increases retention of demonstrate hour intake and output result in sudden/ are within normal
 Edema, jugular sodium and water. In stabilized fluid balance. excessive fluid loss limits.
vein distention response to a volume with (hypovolemia) even
continued production balanced intake though edema/ ascitis  Peripheral pulses are
 Increased blood in renal blood flow, the and output, breath remains. palpable.
pressure rennin- angiogenesis- sounds clearing,
(BP=160/90) aldosteron mechanism vital signs within  Maintained bed rest in  Recumbency increases  Peripheral edema
activates. The adrenal acceptable range, semi-Fowler’s position. glomerular filtration and not present
Respiratory cortex released edema reduced. decreases production of
distress, abnormal aldosteron, promotes ADH, thereby enhancing  Skin appears
breath sounds further retention of diuresis. hydrated.
sodium and water by
 breathes well the renal tubule this  Assessed for distended  Excessive fluid
when in upright results in an neck and peripheral retention may be
position expansion in blood vessels. Inspected manifested by venous
volume of up to 30% dependent body areas for engorgement and edema
and edema. As the edema with/without pitting; formation. Peripheral

28
 29

sodium concentration noted presence of edema begins in feet/

NURSING in the extracellular generalized body edema ankles (or dependent
DIAGNOSIS: fluid increases, the (anasarca). areas), and ascends as
osmotic pressure of failure worsens. Pitting
EXCESS FLUID the plasma also edema is generally
VOLUME RELATED increases. The obvious only after
TO COMPROMISED hypothalamus retention of at least 10 lb
REGULATORY response to the higher of fluid.
MECHANISM AND osmotic pressure by
SODIUM RETENTION releasing ADH from  Edema formation,
AS MANIFESTED BY posterior pituitary.  Changed position slowed circulation,
DECREASE URINE This promotes renal frequently. Elevated feet. altered nutritional intake
OUTPUT, EDEMA, tubular reabsorption of Inspected skin surface, and prolonged
JUGULAR VEIN water kept dry and provided immobility/ bed rest are
DISTENTION AND padding as indicated. cumulative stressors
INCREASED BLOOD affecting skin integrity
PRESSURE which require close
supervision and
preventive interventions.

 Fluid volume excess

 Auscultated breath
sounds, noting decreased
and/or adventitious sounds,
e.g., crackles, wheezes.
often leads to pulmonary
congestion. Symptoms of
pulmonary edema may
reflect left acute heart
failure.

 Investigated sudden  May indicate

extreme DOB air hunger,
sitting straight up,
sensation of suffocation,
feelings of panic.
development of
complications
(pulmonary edema/
embolus) and differs
from othopnea and
paroxysmal nocturnal
dyspnea in that it

29

 Monitored blood
pressure.
 Provided small, frequent
easily digestible meals.
 Noted increased lethargy,
hypotension, muscle
cramping.
COLLABORATIVE
Administered medications
as indicated:
- Diuretics
30
30
develops much more
rapidly and requires
immediate intervention.
Hypertension suggests
fluid volume excess and
may reflect developing/
increasing pulmonary
congestion, heart failure.
 Reduced gastric
motility can adversely
affect digestion and
absorption. Small
frequent meals may
enhance digestion/
prevent abdominal
discomfort.
 Signs of potassium
and sodium deficits that
may occur due to fluid
shifts and diuretic
therapy.
 Increases rate of urine
flow and may inhibit
reabsorption of sodium/
chloride in the renal
tubules.
 31

 Potassium wasting is a
- Potassium supplements common side effect of
diuretic therapy which
can adversely affect
cardiac function.

 Reduces total body

 Maintained fluid/ sodium water/ prevents fluid re-
restrictions as indicated. accumulation.

Reveals changes
 Monitored chest x-ray. indicative of increased/
resolution of pulmonary
congestion.

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POTENTIAL PROBLEM NO. 1: RISK FOR IMPAIRED SKIN INTEGRITY RELATED TO PROLONGED PHYSICAL IMMOBILIZATION.

ASSESSMENT EXPLANATION PLANNING NSG. INTERVENTION RATIONALE EVALUATION

OF THE
PROBLEM
OBJECTIVE: Immobility STO: INDEPENDENT STO:
 Bed ridden impedes
 With limited circulation and After 8 hours of  Assess skin daily. Note  Establishes baseline After 8 hours of
mobility diminishes the nursing color, turgor, circulation and with which changes in nursing interventions,
 Weak in intervention, the sensation. Describe lesion status can be compared, goal met if the client
supply of
appearance patient will and observed changes. and appropriate demonstrate behaviors
nutrients to demonstrate interventions instituted. or techniques to
 Need
assistance specific areas, as behaviors or prevent skin
when moving a result skin techniques to  Maintain good skin  Maintaining clean, dry breakdown and
breakdown and prevent skin hygiene, e.g. wash skin provides a barrier to ulceration.
formation of breakdown and thoroughly, pat dry infection. Patting skin dry
NURSING pressure ulcers ulceration. carefully, and massage with instead of rubbing reduces
DIAGNOSIS: can occur. The lotion or appropriate cream risk of dermal trauma to
skin can atrophy as indicated. dry/ fragile skin. LTO:
RISK FOR IMPAIRED as a result of Massaging increases
SKIN INTEGRITY LTO: circulation to the skin and After 2- 3 days of
prolonged
RELATED TO promotes comfort. nursing interventions,
immobility. Shifts After 2-3 days of LTO met if the patient
PROLONGED
PHYSICAL
in body fluids nursing  Reposition frequently.  Reduces stress on will display no
IMMOBILIZATION. between the fluid intervention, the Protect bony prominences pressure points and ulceration and
compartments patient will prevent with pillows. possibility of ulceration/ maintains skin
can affect the the occurrence of decubiti. integrity.
consistency and skin ulcers.
health of the  Massage bony surfaces  Increase circulation to
dermis and especially that patient is all skin areas limiting
subcutaneous sedentary in bed. tissue ischemia/ effects of
tissues in the cellular hypoxia.

32

dependent parts
of the body,  Assist with active or
eventually passive range of motion
causing a gradual exercises.
loss in skin
Maintain clean, dry,
elasticity.
wrinkle-free linen.
 Cleanse perianal area.
Remove stool with water
and soap and mineral oil.
Avoid use of toilet paper.
Apply protective creams,
e.g. zinc oxide.
COLLABORATIVE
 Use protective devices,
e.g., egg-crate, heel/elbow
protectors, and pillows as
indicated.
33
33
 Promotes circulation;
prevents stasis.
 Skin friction caused by
wet or wrinkled sheets
leads to irritation and
potentiates infection.
 Prevents maceration
caused by diarrhea and
keeps perianal lesions dry.
Note: Use of toilet paper
may abrade lesions.
 Avoids skin breakdown
by preventing/ reducing
pressure against skin
surfaces.
 34

POTENTIAL PROBLEM NO. 2: RISK FOR ASPIRATION RELATED TO PRESENCE OF TRACHEOSTOMY.

ASSESSMENT Explanation of PLANNING NSG. INTERVENTION RATIONALE EVALUATION

the problem

OBJECTIVES: Client was not able STO: Independent: STO:

to swallow and so  Auscultate lung sounds  To determine
 impaired tracheostomy was After 8 hours of frequently presence of Goal met if after 8
swallowing done. Client is at nursing intervention, secretions/silent hours of nursing
 presence of risk of aspiration the client will aspiration intervention, the client
tracheostomy due to the presence experience no will experience no
 aggressiveness of tracheostomy aspiration as  Observe for neck and  Client with neck aspiration as
to lie down after because there’s a evidenced by facial edema opening, tracheal/ evidenced by noiseless
NGT feeding possibility for entry noiseless bronchial injury is at respirations; clear
of gastrointestinal respirations; clear particular risk for airway breath sounds, clear,
secretions, breath sounds, obstruction and inability odorless secretions
NURSING oropharyngeal clear, odorless to handle secretions.
DIAGNOSIS: secretions, or solids secretions LTO:
or fluids into  A decreased level of
RISK FOR tracheobronchial LTO:  Monitor level of consciousness is a prime Goal met if after 24
ASPIRATION passages. consciousness risk factor for aspiration. hours of nursing
RELATED TO After 24 hours of intervention, patient’s
PRESENCE OF nursing intervention,  Avoid keeping client  Supine positioning and risk of aspiration is
TRACHEOSTOMY patient’s risk of supine or flat when on enteral feedings have decreased
aspiration is mechanical ventilation been shown to be
decreased as a (especially when also independent risk factors
result of ongoing receiving enteral feedings). for the development of
assessment and aspiration pneumonia
daily intervention.
 Assess for residual food
 Pockets of food can be
in mouth after eating
easily aspirated at a later
time.

34
 35

 Ascertain that feeding

tube is in correct position.  Prevents overfeeding
Measure residuals at and risk of aspiration
appropriate period

35
 37

XIII. DISCHARGE PLAN

CRITERIA HEALTH TEACHINGS

a. Diet • Limit the amount of sodium (salt) in your diet to less than
2,000 mg. each day
o Don’t add salt while you’re cooking or at the table .
o Avoid processed foods like lunch meats and canned
soups .
o Check food labels for sodium content.
o Talk with your doctor or a dietitian before using salt
substitutes.
o Ask your doctor how much liquid you can drink each
day. You may have to limit the amount of liquids
you drink.
o Eat a balanced diet that is low in fats and cholesterol.

b. Activities • Weigh yourself every morning after you go to the bathroom.

Use the same scale and weigh yourself in the same type of
clothing each day.
• Plan rest periods during the day to allow your heart to regain
strength for the next activity.
• Once your symptoms begin to go away, start light exercise —
walking or chair exercises to help strengthen muscles. (Do
not exercise when you have severe symptoms).
• If you feel tired, have chest pain or are short of breath,
immediately stop what you are doing and rest.
• Put your feet up every few hours to avoid swelling in your legs
and ankles.
• Get enough rest at night.
• Do not smoke!

c. Medications • Take all your medications as prescribed by your doctor.

• Keep a list of your medications with you at all times.

If you have questions or concerns, call your doctor

o Do not stop or change the dose of any of your
medications without first talking with your doctor.
o Do not take any new medications — including
vitamins, over-the-counter medications or herbal
remedies — without first talking with your doctor.

XIV. Conclusions and Recommendations:

37
 38

The case is focused on the importance of precipitating factors that could lead to

complicated diseases.

The group recommends that during any health teachings, they should emphasize

on the importance of seeking medical advice when feeling not good. With these,

complicated diseases should be minimized or prevented as well.

Furthermore, the group would like to emphasis to these nurses that proper health

teaching to the client with the same situation and those similar needs. Health teachings

are very important for the patient and his significant others for them to understand and

realize that cooperation is very important in the prevention of disease and improvement

of his status

XV. List of References

1. Books
a.) Pathophysiology by Catherine Paradiso (2nd edition)
b.) Medical surgical nursing by Luckmann and Sorensen ( 3rd edition)
c.) Understanding Pathophysiology by Sue E. Huether and Kathryn L. McCance
(2nd edition)
d.) Nurse’s Pocket Guide by Doenges (11th edition)
e.) Drug hand book by Lippincott
f.) Anatomy and Physiology by Tortora
g.) Anatomy and Physiology by Seeley, et al.
h.) Fundamentals of Nursing by Kozier,

2. Websites
a. http://www.bannerhealth.com/NR/rdonlyres/8AF826C6-6BCD-4246-8DB8-
8919D3E3CCDC/18039/DischargeCHF.pdf
b. http://www.imedix.com/congestive_heart_failure

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XVI. APPENDICES

A) Interview Guide

University of the Cordilleras

College of Nursing

CASE PRESENTATION FORMAT

SY 2009-2010

I. General Profile/Information-name, age, sex, marital status occupation, address,

religion

II. Chief Complaint/s- main complaint of the patient why s/he seek consultation and
hence, admitted.
III. History of present illness (seek the interviewer guide)

a. Complaint/s
b. Duration
c. Domain/ localization
d. Progression
e. Character
f. Relation to physiological function- what is the effect of posture? Are
symptoms worse when the patient is walking/ lying?

Note: Interview guide (Holloway,2004) to expound the HPI

. 1. Statement of the general health before illness. “ how have you been feeling
before the problem started?”
2. Date of onset. “When did this start?”
3. Characteristics at onset. “what was this like when this started?”
4. Severity of symptoms. “how would you rate the pain on a scale of 1-10, with 1
being the worst?”
5. Course since onset. “How often does the attack or the pain occur?” ( once only,
daily, intermittently, continuously) and “ and have the symptoms changed since
the first attack?”
6. Associated s/s. “ Have you noticed any other changes in your health or the way
you feel?”
7. Aggravating or relieving factors. “ Is there anything that seems to make you
feel better or worse?” Do you feel better or worse at certain times of the day?”
8. Effect on activities. “Has this stop you from going to work or kept you awake?”

39
 40

9. Treatments tried and results. “ have you ever taken any medications or tried any
treatments?” If so, “what happened when you took the medication or after the
treatment?”

In addition it is helpful to ask :

• “What do you think caused this problem?” The patient may actually know the
cause but hesitate to reveal it for numerous reasons; for example, s/he may
have feelings of guilt regarding the cause of illness.

• “Is anyone else in the household sick?”

IV. Past medical history ( Narrative form)

V. Social and environmental history (Narrative form)
VI. Family history (Narrative form)
VII. Physical examination
VIII. Diagnostics
IX. Medical diagnosis- final or principal diagnosis
X. Comprehensive Pathophysiology and Management
XI. Treatment and Management
XII. Nursing Diagnosis
XIII. Discharge Plan
XIV. Conclusions and Recommendations
XV. List of References
XVI. Appendices

40