FAR EASTERN UNIVERSITY

Institute of Nursing

INITIAL DATABASE
I. Biographic Data
Name: EPM Occupation: PUJ Driver

Address: 67 Gumamela St. Roxas District, Quezon City

Age: 38

Gender: M Religious Affiliation:

Roman Catholic

Marital Status: Married

Room and Bed#: SW-1

Chief Complaint: Chest pain

Provisional Diagnosis: Stable Angina

Attending Physician: Dr. Lim

II. Past Health History

According to the patient, he has complete immunizations and has
no allergies noted. One accident he mentioned was when he fell from a
carabao when he was 6 and then got run over by the araro. Fortunately,
he only inflicted minor injuries in a part of his abdomen but didn’t go to
the hospital afterwards. When asked of his childhood illnesses, he only
verbalized having chicken pox when he was already 18 and that he
didn’t go to the hospital then. Instead, he took unprescribed antipyretic
for fever and added that it was effective. Other than that, he mentioned
having fever, coryza and diarrhea when he was young which occurs
about 2 times a month in which he also took unprescribed medicine and
was treated.

EPM has no previous hospitalization except for this one. Last year,
the patient experienced extreme chest pain for the first time and was
only brought to the clinic. He was given an SL medicine to lower his
 blood pressure and was treated. Also, he has no foreign travel for this
year as of yet.

Interpretation: There are no risk factors that are significant in clients past history
except for the 1st chest pain he experience last year, this could have been a sign of
alteration to his circulation.

Analyis: The health history identifies risk factors and strengths in the patient’s
physical and psychosocial status. This information does will lead in making
interventions to meet the patient’s needs and facilitates his or her recovery.
(Fundamentals of Nursing, 5th Edition by Taylor et al, p. 78)

III. History of Present Illness

EPM verbalized having an all-nighter the previous night. At 9-
11pm, the patient drove his cousin’s friend to the airport. Afterwards,
from 1-2am, he then drove his mother-in-law to the airport. When he
got home, he felt a throbbing pain in the left side of his chest radiating
to the jaw to the left arm which he rated as 7 and then afterwards he
collapsed and became unconscious afterwards. His family provided
intervention for awhile and let him rest. When he became conscious,
he was then taken to Dr. Fe Del Mundo Hospital Emergency. According
to the client, he thought he was okay because the pain that he felt was
not tantamount to the pain that he felt previously by that time and he
insisted that he will drive himself to the hospital was admitted to SW-1.
The patient’s wife verbalized that “napagod siguro ng sobra kagabi
kaya nagkaganyan.” When asked, how long the pain did occur; the
client stated that it almost lasted for about 20 to 30 minutes.
According to the client, this was the second time that he experienced
that kind of pain. He stated that perhaps his driving provoked his chest
pain.

IV. Family History of Illness

FP, OP,
90 82
?
?
JM, JM, KM, EM,
50 SO, LM, 70 41 38
46 70
 LEGEND

male female

patient

? unknown deceased heart disease Diabetes old age

As seen above, the patient and all of his siblings have

hypertension which they must have inherited from their father whom
he doesn’t know who his grandparents from that side were. “Sa
malayo kasi sila nakatira”, he reasoned.

Interpretation: As seen in the figure above, the patient and all of his siblings have
hypertension which they must have inherited from their father. It can also be
observed that the patient’s grandparent has history of heart disease.

Analysis: Hypertension and heart disease can be inherited by the patient from his
parents and grandparents. Hypertension may contribute to the severity of the
client’s condition that was diagnosed with stable angina pectoris. Hypertension
increases the risk of coronary heart disease due to changes in work load of the
heart which may cause hypertrophy which may contribute to heart failure.
Hypertension can also cause endothelial damage to blood vessels, which may
stimulate the development of atherosclerosis.

a. Environment
Their house is owned by his aunt who lives nearby. The house
stands along the road but they do not find it noisy or polluted since not
 many a vehicle pass there. The only problem is the piggery near them
which is very smelly and its owner opposes to get it transferred that’s
why they can’t get rid of it. It has no damaging effects to them though.
Also, they don’t segregate their trash but sweeps and clean every day.

The patient described his home adequate for his family. It is not
crowded, well-ventilated and has no mosquitoes even if they do not
have screens on their windows. Appliances they own are TV, stereo
and electric fan but do not have a refrigerator nowadays ever since it
broke so they buy food every now and then.

Interpretation: The client do not own their house, they find it clean and not noisy
and is well ventilated. They had a problem with the piggery near their house
because of the smell it causes. They do not segregate their garbage but they
dispose it to keep their house clean.

Analysis: Piggery causes unpleasant smell due to waste coming from pigs. In line
with this, there are still risks of spread of infections due to waste products and
insects that may breed near the piggery. Unpleasant smell of air may causes or
increase anxiety or stress to the patient or the family member which may affects
the health condition of the patient. Stress causes neurohormonal response (e.g:
epinephrine and norepinephrine). This hormones can cause increase in heart
contraction, heart rate and stimulates vasoconstriction which may increase blood
pressure (Fubdamentals of Nursing, Kozier et. al, 7th edition). Since the patient is
has hypertension, the environment of the patient may affect his health condition in
relation to stress.

b. Economic
The client stated to have financial adequacy but sometimes,
encounters problems at times like now so they go to Philhealth for
help. Their income comes from his driving salary and his wife’s salary
who works as a sales lady at Ever Commonwealth. Sometimes, the
patient gets extra income when someone buys his chicken. They
prioritize their budget on the kids’ schooling and others come next.

V. Patterns of Functioning
a. Health Perception and Health Management
The patient rates his health to be 9 out of 10 since his
hospitalization only happened by chance. His definition of healthy
person is one who eats and exercises a lot. He bathes once a day,
trims his nails once a week, brushes his teeth three times a day, wears
 slippers at home, washes his hands before and after eating, after using
the comfort room and whenever he thinks his hands are dirty.

With regards to health practices, he said, “Nagpapacheck naman

ako sa doktor kaso kapag naisipan ko lang kahit na may sakit ako o
wala. Unang-una ko rin pinupuntahan ang health center na malapit sa
amin.” He doesn’t drink vitamins. He mentioned drinking alcohol and
smokes at times but believes that he is not a smoker. He knows the
bad effects of this but still does it.

Interpretation: The patients take good care of his hygiene based in the activities
he do. He rates his health 9 out of 10 which could indicate that the patient is
confident with his health status even he has a health problem. The client first
consults in the health center and sometimes do checkups with doctor when he
wants to. The client drinks alcohol and also smokes even though he knows the
consequence of it.

Analysis: The client drinks alcohol at times which may affects his health condition.
Alcohol in excessive intake affects oxygenation because it’s a respiratory
depressant (Fundamentals of Nursing, Kozier et. al, 7th edition). It has properties
which increases blood pressure and heart rate and can contribute to development
of hypertension. Also alcoholism can damage heart muscles and may lead to cardio
myopathy and Liver diseases.

b. Nutrition
The patient weighs 71 kg and stands 175cm making his BMI
23.18kg/cm² which is according to PHN is at risk. His built is muscular,
not fat. He mentioned having a large appetite and admits that he eats
a lot. His favorite food is lechon and rice and seems to be not fond of
bread. When at work, he eats at turo-turo alone and drinks about 2 L of
water in a day of drive. At home, even though his wife cooks
vegetables, fruits, seafoods and meat, he likes to eat oily foods more.
He also is known to be an alcoholic and added jokingly that red horse
is his vitamins. His TEA is 2700 kcal/ day. His 1-day food recall is as
follows:
 Meal Day 1 Day 2 Day 3
Breakfast 1 cup of coffee 1 cup of coffee 3 pcs longganisa
1 fried egg (60 3 pcs of tuyo ( 45 (75 Kcal)
Kcal) Kcal) 4 cups of rice
3 slices of tucino 4 cups of rice (640 Kcal)
( 45 Kcal) (640 Kcal)
4 cups of rice 1 pc fried chicken
(640 Kcal) ( 491 Kcal)

Lunch 1 serving of pork 3 cups of rice 1 serving of kare-

sinigang (480 Kcal) kare (103
(170 Kcal) 1 fried egg (60 Kcal)
3 cups of rice Kcal) 3 cups of rice
(480 Kcal) (480 Kcal)
1 pc banana (40
Kcal)
3 glass of water

Merienda 3 pcs of hopia 2 slices of 1 pc

( 95 Kcal) watermelon cheeseburge
(280 Kcal) r ( 318 Kcal)
1 glass of buko
juice (180 Kcal)

Dinner 1 serving of 1 serving of 1 serving of pork

adobo (175 pinakbet (32 lechon (273
Kcal) Kcal) Kcal)
3 cups of rice 3 cups of rice 3 cups of rice
(480 Kcal) (480 Kcal) (480 Kcal)
2 glass of water

Total Kcal per 2725 Kcal 2578 Kcal 3149 Kcal

day

Total energy allowance= 67.5(DBW) x 40(physical activity-

moderate) = 2700 Kcal
Interpretation: The client is considered as over weight for having a BMI of 23.18,
the normal BMI ranges from 18-22. As observed with the types of food that the
client eat on his three day diet recall are oily foods and most are meat and rice. The
client is known to be alcoholic.

Analysis: Being overweight or obese is a risk for the client’s health, the intake of
fatty foods increase the risk for elevation of serum lipid levels and the development
of coronary heart disease or clogging of veins due to fat content in blood this may
also influence the increase of possibility to increase Blood pressure thus causing
hypertension. Additionally, being overweight or obese increased the work load
demand on the heart which increases oxygen demand. (Fundamentals of Nursing,
Kozier et. al, 8th edition pg 1409). Alcohol in excessive intake affects oxygenation
because it’s a respiratory depressant (Fundamentals of Nursing, Kozier et. al, 7th
edition). It has properties which increases blood pressure and heart rate and can
contribute to development of hypertension. Also alcoholism can damage heart
muscles and may lead to cardiomyopathy and Liver diseases. (Fundamentals of
Nursing, Kozier et. al, 8th edition pg.1441)

c. Elimination
The client verbalized that he defecates once a day every
morning with brown color and dry hard consistency. He verbalized that
he has no difficulty and discomfort in defecating not until he was in the
hospital he has not yet defecated. According to him his bowel practices
include handwashing of hands after defecating. He is not taking
medication to achieve proper elimination.
He usually urinates 5-6 times at 2 litres a day. He stated that the
color is yellowish with aromatic odor. He is not experiencing any pain
and discomfort in urinating. . He also stated that he does not hold his
urge to void. He stated that he usually urinates whenever he drinks
fluids. The client has no body odor and do not perspire excessively.
Interpretation: The patient maintains his hygienic practices during defecation and
urinating. There are changes in the elimination pattern of the patient in term of
defecation. The client does not hold his urge to void and he frequently urinates in a
day.

Analysis: Defecation is affected by the amount of food intake of the patient and as
well as the type of food he eats. Also activity of the patient affects defecating
because movement promotes peristalsis which promotes bowel movement.
Urination also depends on the amount of water intake of a person

d. Activity and Rest

The patient starts his day by waking up at 4:45 am feeling
satisfied despite being a light sleeper but sleeps continuously when
really tired. He then eat his breakfast, take a bath and change to his
working clothes. After that, he now drives to Morayta to work. He eats
lunch at about 12 noon and sometimes, takes a nap when he has no
drive that lasts for half an hour to an hour. At 6pm, he goes home, eats
dinner with the whole family, watches TV, looks over his chickens and
once a week, drinks with friends and finally sleeps at 9. He mentioned
not having any rituals before going to bed which he shares with his
wife.

Before, EPM mentioned to go to gym everyday for lifts. Now, he

just goes to the gym when he has the time and lasts just half the time
 compared before and verbalized that it is not enough. He added to feel
a decrease in his muscle strength about 3 years ago.

Interpretation: The patient before being hospitalized was an active person having
regular exercise as he goes to the gym and with moderate level of activity. He had
almost continuous 8 hours of sleep

Analysis: Physical exercise increases the heart rate and hence the supply of
oxygen in the body, with regular and vigorous exercise, heart muscles become
more powerful and efficient. The activity of the client may help the prevention of
coronary heart disease before he experience angina but as he experience right now,
the exercise that he has done is not that enough to control it, because there is still a
need to control diet with exercise and some medication. In his present condition,
there is a limitation of movement due to angina pectoris which was stable.

d. Self Perception – Self Concept

When asked to describe himself, he said “Di ko madescribe,
basta kuntento ako sa sarili ko.” He mentioned that there were
changes felt in his body and the desire to do something because
before according to him he had his exercise 20 minutes a day but now
he can only do it 10 minutes a day. In addition to this he also
mentioned that there were no changes he felt for himself when he got
ill. He said, “Tsamba lang na nagkasakit ako.” According to him, his
goal is to let his children finish their studies. “Sikap ang kailangan ko
para mapag-aral ko sila.” He said.
Interpretation: The client has still positive perception of his self and still
determined to achieve his goals in life

Analysis: having a positive perception of self is a si

e. Role-Relationship
The patient said, “Ako ang nasusunod sa pamilya ko.” According
to him, he is the head in his family. His family constitutes his wife and
children and they also live together in one house. In addition to this he
mentioned that during his free days, he goes out with his family like
going to the mall and he doesn’t have any conflict with them. He
added that his family is the closest to him whom he considers as his
significant people in his life. When asked about how he expresses his
feelings to others he said, “Pinapabayaan ko lang pag galit ako. Ayoko
na kasi ng mahabang awayan pa.” One thing that would make him
angry would be when one of his chickens dies. As observed, he
interacts with his family and relatives who stays with him in the
hospital. In addition to this he had mentioned that he is a friendly
person.
Interpretation: the family of the patient is a patricentric family where in he as the
father makes decisions for the family. It can be obnserced that the [atient has good
relationship with his family.

Analysis: Family influences on health care because health is defined uniquely by

each clients culture the nurse must assess the family’s health definition and beliefs.
Family is often major caregivers of their relatives. Lack of social support from family
or significant others result in psychological ad spiritual isolation, which negatively
impacts a person’s physiological state. (Rick Daniels. Nursing Fundamentals Caring
and Clinical Decision Making 2004 page 849-851)

f. Sexuality and Reproductive Pattern

The client expresses himself according to him by wearing clothes
that are for men and so are his gestures. He said that health condition
right now did not change the way he expresses himself. When asked of
his sexual activity he said that he is satisfied and he does this once a
week with his wife only. He mentioned that he is not using any
contraceptives right now. “Nagpatuli ako noong grade six pa lang
ako”, he stated. He also stated that he does not perform TSE because
he does not know how to do it.
Interpretation: The patient sees himself as a man like figure, he is sexually active
but do not perform testicular self examination due to not knowing how to do it.

Analysis: At any time in life, physical, psychological and social problems may a
profound effect on a person’s expression of sexuality. This should be taken into
account when it involves a person’s health or the delivery of care. A person doesn’t
only express sexuality through sexual activity but also through their clothes,
grooming, activities and roles in life. (Objectives for Care: Specifying Standards for
Clinical Nursing, 2nd edition by Wolf page 62)

g. Cognitive-Perceptual Pattern
The client is a college graduate. Considering his learning, the
client stated that he has no difficulty learning thing by any means. He
added “Sa ngayong nagkakaedad na nagiging makakalimutin na rin.”
The client also said, “Nababasa ko lang binabasa ko kung malapit. Pero
wala naman akong problema sa pandinig. ‘Di rin ako gumagamit ng
salamin habang nagbabasa.” According to the client, he handles his
problem well because he accepts it and tries his best to solve it with
the aid of his family. Even though the client is sick his relation towards
others doesn’t change at all. He is still friendly. As observed, he is
responsive and was able to answer back the questions correctly. He is
not wearing any glasses or hearing aid to correct his vision and
hearing.

Interpretation: The client does have problem in learning new things. The client is
confident enough with her answers and thoughts in life.
Analysis: Coping mechanism can be viewed as an active method of problem
solving developed to meet life’s challenges. Cooperative or friendly, expressive
feelings appropriate to the situation, verbalizes positive things regarding others and
the future expresses positive coping mechanism. (Fundamentals of Nursing, 7th by:
kozier et. al, page 193)

h. Value-Belief Pattern
When asked about the things important to client’s life, he said,
“Pamilya ko talaga ang una sa lahat lalo na ang mga anak ko.
Malaking parte ng kita ko napupunta sa pag-aaral nila.” With regards
to religion, he said “Di ako nagsisimba lingo-linggo kasi muslim ako.”
He was also laughing while saying it. His wife added that he only goes
to church during weddings, wakes and baptisms. With regards to his
relation to society, he said “Di ako nagiging pabigat dito, wala namang
times.” When asked what does he feel now with regard to his situation,
“namumrublema ako kasi baka maging tuloy tuloy na sakit na ito. Pero hindi
naman gaano kasi ngayon lang naman nangyare sakin to.”

Interpretation: The patient is family oriented and focuses to the benefit of his
family. In terms of religion, he is not that active in terms of participating religious
routine activities except in important event or special events.

Analysis: Culture may be defined as a shared system of beliefs, values, and

behavioral expectations that provides social structure for daily living. Culture
defines roles and interactions with others as well as with families and communities.
And is a parent in the attitudes and institutions unique to particular group. Culture
includes the beliefs, habits, likes and dislikes and customs and rituals learned from
ones family (Fundamentals of Nursing, 5th Edition by: Carol Taylor, Carol Lillis, &
Priscilla LeMone, pp. 40, 791). The patient is not that attached to values and beliefs
of his culture around but more focused on his family and his good relation to the
ociety.
VI. Activities of Daily Living
Activities of Before During Interpretation
Daily Living Hospitalization Hospitalization and Analysis
Nutrition When at work, During
he eats at turo- hospitalization, the
turo alone and patient eats foods
drinks about 2 L that are less salty
such as sopas,
of water in a day
chopsuey, lychee
of drive. At home,
and the like. Before
even though his he can finish the
wife cooks whole food
vegetables, fruits, prepared but now,
seafoods and he can only finish
meat, he likes to 75% of the food
eat oily foods prepared. He
more. He also is verbalized,
known to be an “walang lasa ung
pagkain.”
alcoholic and
added jokingly
that red horse is
his vitamins.

Elimination The client The client

verbalized that mentioned that
he defecates during
once a day every hospitalization, he
morning with does not defecate
brown color and immediately in the
dry hard morning but he
consistency. He does not have any
verbalized that problem in
he has no urination. He
difficulty and describes his urine
discomfort in
yellowish with
defecating. He is
not taking aromatic odor
medication to and he does not
achieve proper feel any pain and
elimination. discomfort.
He usually
urinates 5-6
times at 2 litres a
day. He stated
that the color is
yellowish with
aromatic odor. He
is not
experiencing any
pain and
discomfort in
urinating. He
also stated that
VII. Areas of Growth and Development
a. Anthropometric Measurements

Anthropometric
Measurement Normal Findings Actual Findings Analysis -
Interpretat
ion
157.8 - 171.9 cm (5’2” – 5’7”) 5’2” Normal
Height (cm)
Weight (kg) 45.8 – 62.1 kg (100.8 – 136.6 lbs) 59 kg Normal

BMI • Underweight = <18.5 23.69 Normal

• Normal weight = 18.5-24.9
• Overweight = 25-29.9

• Obesity = BMI of 30 or
greater
b. Vital Signs
 Vital signs Normal Actual Findings Analysis
Finding -Interpretati
s on
Temperature 36.5 -37.5 °C 35.4°C Not Normal

Pulse Rate 80 bpm (60- 102bpm Not Normal

(Averages and 100)
Ranges)

Respiratory Rate 16 Bpm (15-20) 30bpm Not Normal

(Averages
and Ranges)

Blood Pressure 120/80 mmHg 110/50mmHg Not Normal

(mmHg)

C. Physical Assessment
 Body Part Normal Actual Findings Analysis - Interpretation
Findings
Body built Proportionate Large body built for Normal
height and and varies his age.
weight in with lifestyle Proportionate and
relation to the varies with lifestyle
client’s age,
health and
lifestyle.
Client’s posture Relaxed, erect Client is relaxed in Not Normal
and gait, posture; posture
standing,
Coordinated
sitting, and
movement
walking.
Client’s overall Clean and neat Unkempt Not Normal
hygiene and
grooming

Body breath No body odor No body odor or Normal

and odor or minor body minor body odor
odor relative to relative to work or
work or exercise;
exercise;
No breath odor
No breath odor

Signs of No distress No distress noted Not Normal

distress, in noted
posture of facial
expression
Signs of health Healthy Generally, the patient Not Normal
or illness appearance show restricted
health condition due
to illness
Client’s attitude Cooperative Cooperative Normal
Client’s Appropriate to Appropriate to Normal
affect/mood; situation situation
Appropriatenes
s of client’s
response
Quantity and Understandabl The client shows Normal
quality of e, moderate understandable,
speech pace; exhibits moderate pace of
thought speech; exhibits
association thought association
Relevance and Logical The client talks in Normal
organization of sequence; logical sequence;
thoughts makes sense; makes sense; has
has sense or sense or reality
reality

Parts Normal Findings Actual Findings Analysis -

Interpretation
Skin o Varies from light to deep Color: dark brown Normal
brown; from ruddy pink to
Uniform in different areas
light pink; from yellow
of the body; areas
overtones to olive.
exposed to sun is darker
Generally uniform except in
in color
areas exposed to the sun;
areas lighter pigmentation
in dark-skinned people

• No edema No edema Normal

• Freckles, some birthmarks, No freckles present. Normal

some flat and raised nevi; There are some birth mark
no abrasions or other on the back. No abrasions
VIII. Diagnostic and Laboratory Procedures

Laboratory Results Interpretation &

procedure Analysis

Chest X-Ray Visualized lungs are

clear
Heart, diaphragm and
bony thorax are stable

Hemoglobin: 14.8g/dl
Hematocrit: 42.2
RBC Count: 4.92
MCV: 85.8
MCH: 30.1
MCHC: 35.1
Platelets: 211
WBC Count: 9.24
Complete blood Eosinophil: 2
count Neutrophil: 84
Lymphocyte: 10
Monocyte: 4
Prothrombin time: 11.6
APTT: 34.1

BUN, Crea, Na, K BUN: 5.49

Creatinine: 33.03
Sodium: 140
Potassium: 4.0

Color: Light yellow

Urinalysis Transparency: Hazy
Specific gravity: 1.010
Glucose: negative
Albumin: Negative

ECG
IX. Drug Study
 Classifica Mechanism Contraindicati Adverse
Drug Indication Nursing Considerations
tion of action ons effects
Proton Decreases the Used to treat Hypersensitivit Rash, itching, • Instruct patient to take
Generic pump y to any swelling, severe each dose on an empty
amount of symptoms of
Name inhibitor component of dizziness, stomach, at least 1 h
acid produced gastroesophage
: (PPI) the drug trouble before eating.
in the al reflux disease
omepr breathing • Instruct patient to
stomach. (GERD) and
azole, swallow capsules whole
other conditions and not to open, crush,
omepr
caused by or chew the capsule.
azole/s
excess stomach • Advise patient having
odium
acid. It is also difficulty swallowing the
bicarb capsule to open it and
used to promote
onate gently mix the pellets
healing of
erosive with 1 Tbsp of cool or
Brand cold applesauce and
nam esophagitis
then immediately
e: (damage to your swallow the mixture
Prilos esophagus without chewing.
ec, caused by Remind patient not to
Zege stomach acid). crush or chew the pellets
and not to prepare the
rid pellet/applesauce
mixture ahead of time or
Dosage: store for future use.
20 mg cap . • Remind patient that
BID omeprazole is to be
taken every day and not
as needed or only when
symptoms are present.
• Advise patient that this
drug may take 1 to 4
days for full effect to be
seen.
• Inform patient that
antacids may be taken
concurrently with
omeprazole.
• Instruct patient to report
any of the following to
health care provider:
bloody or coffee ground–
like vomit; black, tarry
X. Pathophysiology
XI. Ecologic Model
XII. Problem Identification
Identified Problems
 Decreased Cardiac Output
related to altered stroke
volume
 Acute Pain related to
biological injuring agents
 Impaired Dentition related
to dietary habits
 Mild anxiety related to
threat to health status
 Disturbed sensory
perception specifically
visual related to altered
Cues
O> ECG readings: ST depression and
T wave inversion
BP: 130/90 mmhg
Pulse rate: 102 bpm
S> When he got home, he felt a
throbbing pain in the left side of his
chest radiating to the jaw to the left
arm which he rated as 7.
When asked, how long the pain did
occur; the client stated that it almost
lasted for about 20 to 30 minutes.
O> ECG readings: ST depression and
T wave inversion
BP: 130/90 mmHg
RR: 102 bpm
S> At home, even though his wife
cooks vegetables, fruits, seafoods
and meat, he likes to eat oily foods
more. He also is known to be an
alcoholic and added jokingly that red
horse is his vitamins.
He mentioned drinking alcohol and
smokes at times but believes that he
is not a smoker.
O> Teeth is yellowish in color with
dental carries on the 2nd molar of the
upper and lower teeth
S> “medyo natatakot kasi baka
magtuloy tuloy na sakit na ito. Tsaka
baka makaapekto ito sa trabaho
ko.”rublema ako kasi baka maging
tuloy tuloy na sakit na ito.”
S> The client also said, “Nababasa
ko lang binabasa ko kung malapit.”
He is not wearing any glasses or
 status of sense organs hearing aid to correct his vision and
hearing.

O> Visual Acuity: Able to read

newsprint but holds the newspaper
very near
Squints while reading the newspaper

XIII. Problem Prioritization

Rank Problem Justification
Acute Pain related to Nursing intervention to

1
biological injuring agents be performed will focus
on management of pain
to ensure client
comfort. If pain is
managed, client will be
able to respond to
further interventions
easier.

Mild anxiety related to In Maslow’s hierarchy of

threat to health status needs, this is under the
physiologic needs. The
problem is easily

2
modifiable by letting
the client voice out his
anxieties and thoughts
with regards to his
illness. Health teaching
and proper information
dissemination can also
help lessen the anxiety
the client is feeling.
Other problems will be
solved with ease if the
client’s anxiety is
lessened.

Decreased Cardiac Although according to

Output related to altered Nursing’s ABC,
stroke volume circulation is checked
third, it is ranked third
because it is not easily
 modifiable via nursing

3
interventions. Nursing
interventions will
primarily focus on
therapeutic
interventions. As to
Maslow’s hierarchy of
needs, this is part of
the physiologic needs
which is at the base of
the hierarchy.

Disturbed sensory In Maslow’s hierarchy of

4
perception specifically needs, this is under the
visual related to altered physiologic needs, and
is only moderately
status of sense organs
modifiable through
health teaching and
making the client see
the long term benefits if
he gets his eyes
checked.

Impaired Dentition This problem is a health

5
related to dietary habits deficit that is
moderately modifiable
via health teaching.
Difficulties may arise
since the client is
already used to his
practices.

XIV. Nursing Care Plan

XV. Discharge Plan

METHODS
• Instruct the patient to take-in the prescribed
medications religiously.
Medications • Emphasize that Nitrites must always be kept at hand
since the patient may experience anginal attacks
 even at rest.
• Teach the client the proper storage of his drugs since
improper handling may decrease the potency of the
medications.

• Encourage deep breathing exercises.

• Advised the client to avoid stressful situations and
Exercise/Econ strenous activities to avoid exacerbations of anginal
omic Factor attacks.
• Advise patient to have relaxation techniques and
brief rest periods daily as a preventive measure.
• Remind client to never perform Valsalva maneuver
(straining).

• Several diagnostic tests such as ECG, and Stress test,

Treatment and cardiac catheterization may be performed in the
course of the disease.
• Multiple drug therapy may still be prescribed by the
physician as this could prevent other health problems
from aggravating.
• Treatment modalities such as PTCA and CABG should
be discussed with the patient and his relatives.

• Consult physician for medical advice when chest pain

persists.
• Instruct patient to quit smoking, and avoid intake of
Health alcohol.
Teaching • Encourage patient to follow prescribed medication for
treatment to avoid the possibility of angina pectoris
progressing to myocardial infarction.
• Also, encourage client to gradually lose weight, as
this may help lower blood pressure.

Out patient • Always have a regular check up by the patient’s

Follow-up health provider.
• Inform that the client should be rushed immediately
to the ER when chest pain persists and radiates to
other body parts.
 • Always drink a lot of water.
Diet • Also eat fruits and vegetables and increase fiber
intake.
• Advise the client to avoid alcohol intake, and cease
smoking,

• Spiritual health affects the wellness of an individual

Spiritual/Sex greatly.
ual Activities • Prayers and
• Strengthen relationship with Lord by showing love
and respect to the people around you.