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De La Salle - Health Sciences InstituteCollege of Nursing and School of Midwifery
Congressional Avenue, Pasong LawinDasmariñas City, Cavite
NursingCase
Presentation
BSN 31 Group 2
Aguda, Kimberly MarieBabasa, Cherry Mae I.
Caayao, Trixia LiezlDela Cruz, Jean Camille
Gicana, CharisseLacanilao, Keith Darrel
Medina, Gerald AmgeloOpiña, Janel Kate
Rabie, Anne SherinaSasoy, Alexies
CassandraUlarte, Wendelyn
August 16, 2010Nursing Case Study
Date of Admission: July 5, 2010
Admission Diagnosis: Community Acquired Pneumonia, Rheumatic Heart Disease
Final Diagnosis:
I. Health HistoryA. Demographic Data
1. Client’s Initial : E.R.A.2. Gender : Female3. Age : 39 years old4. Birthdate : July 22, 1971
Page 1 of 61
5. Birthplace : Apayao6. Marital Status : Married7. Nationality : Filipino8. Religion : Roman Catholic9. Address : Imus, Cavite10. Educational Background : College
graduate11. Occupation : employee12. Usual Source of Medical Care : hospital, clinic13. Date of Admission : July 5, 2010
B. Source and Reliability of Information Client herself who seems to be reliable to
provide personal information. The patient speaks clearly, conscious and coherent.
Patients husband who was competent and well-informed to provide concrete information about the client; she was able to speak clearly; conscious and coherent.
Patients chart was able to provide comprehensive and reliable information about the client. This serves as the tertiary source of information.
C. Reasons for Seeking Care or Chief Complaint “persistent cough for 4 days” “difficulty of breathing for 2 days” “chest pain”
D. History of Present Illness or Present Health
Patient ERA was apparently well until four days PTC, she experienced a non-productive, non-explosive cough. Other than that, no other symptoms were noted. She had self medicated with Solmux cap BID x 2 days with no consultation to a physician.
2 days PTC, the patient had expelled mucoid whitish phlegm and experienced mild DOB. She ignored the symptoms and still continues with her daily activities.
1 day PTC, the patient started to have minimally explosive cough with yellowish mucoid phlegm. She sought consultation at Our Lady of Pillar Medical Hospital and has been prescribed with Co-Amoxicillin 500 mg/cap TID and Carbocisteine 500 mg/cap TID. She both took only 2 times. The symptoms still persisted, which made her decide to seek consultation to DLSUMC.
Page 2 of 61
E. Past Medical History or Past Health
Client verbalized that she was diagnosed to have RHD when she was 13 years old, aside for some episodes of fever, headache and fever. She also verbalized that she had history of sore throat but she cannot recall when. Since then, she was prescribed to take Lanoxin. For her adult illnesses, she was diagnosed to have hypertension; her highest BP was 140/60 mmHg, but she was not given any maintenance medications. She stated that she cannot recall if she had any injuries or accidents. She was first confined at the hospital to her first pregnancy. She stated that she had her menarche at age 14. She has OB score of 333003. The client has unrecalled immunizations but she had taken all 5 doses of tetanus toxoid. She had her consultation to her doctor at Our Lady of Pillar Hospital last July 4, 2010, day prior to her admission to DLSUMC.
Page 3 of 61
F. Family History
The above diagram shows the patient’s family history. She can’t recall in what age her grandparents died, both mother’s and father’s
side. Her father is presently 68 years of age and with cardiac problems. Her mother is presenlty 63 years of age and she has hypertension. Her older brother and younger brother, who are 42 and 37 years of age respectively, are presently alive and well; she thinks that her 2 brothers did not inherit any diseases from their parents. Her younger sister, 35 years of age has hypertension. And the patient herself has been diagnosed with community-acquired pneumonia, rheumatic heart disease and hypertension.
G. Socio – Economic History
Family Member Occupation Monthly IncomeE.R.A. Financial analyst confidential
Income earner within the family includes the client herself. The client is working as a financial analyst in Makati. According to clients’ husband, they don’t find any difficulty in handling money but then there were times that they find it a problem when it is lacking. He also added that the monthly salary of clients’ daughter was enough and adequate to sustain their everyday living. They also don’t find any difficulty in purchasing their basic necessities since the salary was enough to sustain those things. She also states that their monthly income was enough in the payment of different bills, for the education of the clients’ grandchildren as well as for medical support whenever one member of the family got sick.
H. Psychosocial Assessment
In Erikson’s psychosocial development, patient E.R.A., who is 39 years of age, is in the middle adulthood stage (Generativity vs. Stagnation), which ranges from 35 to 55 or 65 years old. The client is able to perpetuate cultures and transmit values through the family by giving advices to her siblings and her child. She verbalized that she feels happy and contented if she could give help and care to her other family members, which indicates that she had done the task of generativity. She also verbalized that she is satisfied with what is happening with her life right now. She said that she focuses herself in the care for her family and help to the people around her. Her significant relationships during this stage revolve around the family, workplace and community.
I. Functional Assessment
1. Health-Perception-Health Management Pattern Patient E.R.A. perceives her condition as good as long as it
would cause integrity to her life. However, she does not perceive it as punishment from God but she hopes that in the future God will not take turns to let her know what she had done just to alleviate the pain that she is feeling. According to her, she does not have any activities to work with to improve her present condition what she is doing is that she make it to a point to have adequate rest if she is feeling not well. Moreover, she is into self medication, but sometimes when her condition gets worse, that’s the time
she seeks a doctor for consultation. As of now, as according to her, she is still of finding things that will add more happiness to her life. She admitted that she is still not contented of the things that she has now.
2. Nutritional – Metabolic Pattern Patient E.R.A. verbalized that she eats 3-4 times daily
included her snacks and small eating’s everyday. Because she eats 3-4 times a day, she supposes that she has a well – balanced diet. But she sometimes skips meals due to busy office work. She drinks at least four times in the morning and another four glasses in the evening to make sure that gets enough fluid and to avoid dehydration especially during hot days. Her skin is well hydrated in terms that it is moist and warm to touch. Her hair is well distributed and there are no presences of lumps or areas wherein there are no hair growth. She also verbalized that her meal everyday is almost always meat and fish. She prefers eating fish than vegetables.
3. Elimination Pattern Patient E.R.A. verbalized that she does not experience any
difficulty in urinating. According to her, the urine is more yellowish than normal, especially if she forgets to drink water. Bowel movement is regular; feces are brown in color.
4. Activity – Exercise Pattern Patient E.R.A. verbalized that she has not enough exercise
due to her busy office work. She said that she has enough energy for her work for the whole day. She perceives full self care for feeding, bathing, toileting, bed motility, dressing, grooming, general mobility, cooking, home maintenance and shopping. But still, she stated that she sometimes seek the help of her husband whenever she is not feeling well.
5. Sleep – Rest Pattern Patient E.R.A. perceives her sleeping pattern as well,
although she has no naps during the afternoon. She said she could have some naps if she is free during office break time. She sleeps at night at around 10 pm, and wakes up the next day at around 4 or 5 in the morning.
6. Self – Perception – Self Concept Pattern Client E.R.A. verbalized that there’s nothing unusual in her
appearance, just the same as before. She states that she is thankful for her appearance. She feels comfortable to what ever appearance she have.
7. Role Relationship Pattern
Patient E.R.A. is happily living with her family. Regarding to her relationship with the co-workers, all are cooperating and she strengthens it by attending in regular meeting and get-togethers. She said that whenever she has problems, she could consult her husband or her siblings.
8. Sexuality – Reproductive Pattern Client E.R.A. expressed her satisfaction regarding her
sexuality. They don’t use any contraceptive method. Her OB score is 333003. Her menarche started when she was 14 years old. She also experiences mild pre-menstrual pain.
9. Coping – Stress Tolerance Pattern According to the client, her only means of coping with stress
is by sleeping and relaxing at home. She thinks that her coping actions help to lessen the stress she is experiencing.
J. Review of Systems (July 7, 2010)
SYSTEM REVIEW OF SYSTEMS PHYSICAL EXAMINATION
General Client verbalized, “Ayos naman yung pakiramdam ko sa
ngayon, may konting ubo pa rin, tolerable naman yung sakit
ng dibdib ko. Di naman ako nakakaramdam ng ibang sakit
sa katawan ko, pero medyo pagod, siguro di rin kasi ako
sanay dito sa ospital.”
Received patient awake, lying on bed, conscious, coherent and oriented to time, place and person, with an IVF of PNSS 500 cc x 72º (1gtts/min) , inserted @ right metacarpal vein, intact and infusing well and without IV related complications; Maintains good eye contact, cooperative and expresses feelings appropriate to situation; The environment is conducive for the patient.
Ectomorpic body built Vital signs are the
following:
BP: 120/70 mmHg
Radial pulse: 71 bpm
RR: 39 cpm
T: 36.0ºC, afebrile
(+) restlessness
(+) weakness
(+) lips and palpebral conjunctiva paleness
(+) pallor
(+) fatigue
(+) use of accessory muscles when breathing
(+) chest indrawing (-) sweating (-) chills
(-) lethargy
Patient expels whitish mucoid phlegm (2.5ml)
Diet: Diet as Tolerated
Integument Client verbalized, “Hindi pa naman ako nagkakasakit sa
balat. Maalaga naman ako sa balat ko, lagi ako naglo-lotion,
hindi rin ako masyado nagbibilad sa ilalim ng araw.
Lagi nga ako nagamit ng payong e.”
SKIN:Inspection: Fair complexion (+) pallor (-) jaundice (-) cyanosis (-) ecchymosis (-) edema (-) bruises (-) pruritus Senile skin turgor (-) profuse non
odorous perspiration (-) lesions (-) Pendulous skinPalpation: (-) thin, dry, scaly
skin Good skin turgor:
returns immediately (1 sec)
HAIR: Hair is black in color. Shiny and equally
distributed. (-) alopecia (-) parasites (-) lesions on scalpNAILS: Nail bed pink in color Nails hard and round,
smooth in texture. Capillary refill
revealed after 2 seconds
Head Client verbalized, “Minsan lang naman sumasakit ulo ko.
Madalas lang mangati ang anit ko. Wala naman akong kuto. Maalaga talaga ako sa buhok,
kahit medyo manipis.”
Inspection: Round and
symmetrical skull and size is appropriate to the size of the body
(+) itchiness (+) dandruff (-) parasites (-) lesion (-) head injury scars Still and upright
facial featuresPalpation: Smooth and hard
skull (-) unusual lumps (-) masses (-) tenderness (-)
depressions/elevations on head
Eyes Client verbalized, “Malinaw pa naman ang paningin ko. Pero gumagamit ako ng salamin
kapag nagbabasa”
Inspection: Eyes are symmetrical
and equal in size. At the same level as
the pinna. Iris dark brown in
color. Eyelashes are
medium in length and equally
distributed; Pale palpebral conjunctiva
Scleras are white in color
Upper and lower lids close easily and meet completely
(+) convergence Eye movements are
smooth and symmetric throughout the six directions
(-) redness (+) use of reading
glasses (-) discharge in the
sclera (+) cornea is
transparent, smooth and moist
(-) opacity in both cornea
(+) PERRLA (Pupils equally round and reactive to light accommodation)
(+) moist and glossy eyeball
(-) excessive tearing (-) swelling (-) lesions or nodules
are apparent. (+) bilateral blinking
reflex (-) ectropion (-) myopia (-) ptosisPalpation: (-) unusual masses (-) tender eyelids (-) purulent discharge
Ears Client verbalized, “Wala naman ako nararamdamang masakit
sa tenga ko. Regular ako maglinis ng tenga.”
Inspection: Ears equal in size
and similar in appearance; symmetrical.
Pinna is aligned and parallel to outer
canthus of the eye; symmetrical and well formed
(-) swelling (-) thickening (-) unusual discharge (-) redness of the ear
lobePalpation: (+) firm pinna (-) lumps and masses (-) tenderness
Nose and Sinuses
Client verbalized, “Madalas lang ako magkasipon, pero bukod dun, wala na. Hindi
naman nasakit.”
Inspection: Client was able to
identify odors presented (alcohol and orange fruit)
Color same as the face
Symmetric, nose on midline, proportion with facial features with no swelling or lesions
(+) midline septum Smooth consistency Pink nasal mucosa (+) red glow of the
sinuses upon transillumination
(-) lesions (-) discharge (-) inflammation of
mucus membrane (-) edema (-) epistaxis (-) nasal flaringPalpation: (-) nodules and
masses (-) tenderness in the
sinus and nasal areaPercussion: (+) hollow tone on
sinuses
Mouth and Throat
Client verbalized, “Wala naman ako problema sa bibig ko, hindi
rin naman ako nahihirapan
Inspection: (+) pale lips Pinkish and moist
magsalita. Araw-araw akong nag sisipilyo.”
buccal mucosa Lips; smooth in
texture Frenulum in midline With rhinorrhea &
cough (+) hoarseness (-) ulcerations (-) lesions (-) oral thrush (-) gingivitis (+) tongue in midline (+) uvula in midline (+) gag reflex when
swallowing, revealed using tongue depressor
Tongue is pink, no swelling and lesions.
Tongue moves easily without tremor.
Neck Client verbalized, “Nagagalaw ko naman yung leeg ko ng
maayos, madalas lang mangalay dahil sa trabaho.”
Inspection: Same color as the
face Neck is symmetrical (-) lesions Full ROM on neck (-) superficial cervical
lymph node enlargement
Palpation: (-) enlargement and
masses (-) swelling (-) tenderness Thyroid in midline
position Non palpable cervical
nodes thyroid not palpableAuscultation:(-) bruits
Breast and Axilla
Client verbalized, “Wala naman masakit sa dibdib ko, wala din naman ako nakakapa na bukol.
Sa tingin ko pantay naman siya, hindi mabigat yung isa
kesa sa isa.”
Patient refused physical examination
Respiratory Client verbalized, “Nung una, medyo sumasakit, hirap din ng
konti huminga. Minsan naninikip, pero pagkainom naman ng gamot, ayos na.”
Inspection:
(+) tachypnea: RR:39 cpm
Equal chest symmetry
Scapula are symmetric & non-protruding
Sternum in midline and level with ribs
Shoulder & scapula are at equal horizontal position
Spinous processes appears straight
Ribs sloping downward
(+) tripod position and sometimes orthopneic
(+) shortness of breath
(+) difficulty of breathing
(+) use of accessory muscles when breathing
tenderness (+) productive cough
(whitish mucoid phlegm)
(+) mild chest indrawing
Palpation: (+) crepitus (+) fremitus (-) tenderness
Percussion:(+) dullness
Auscultation:
(+) crackles on both lungs fields
(-) stridor
(-) wheezes
Cardiac Client verbalized, “Sabi nung Inspection:
mga doktor dati, may sakit daw ako sa puso, pero may
pinapainom naman sakin na gamot.”
(-) jugular vein distention/bulging
BP = 120/80 mmHg (+) atheromatous
aorta based on X-Ray findings
Radial and apical pulse rates are identical = 71bpm
Apical pulse is weakPalpation: Apical pulse in mitral
areaAuscultation: Loudest sound at the
apex
Gastrointestinal
Client verbalized, “Wala naman nananakit sa tiyan ko. Minsan lang hindi natutunawan kaya
minsan nasakit.”Client verbalized, “Nakakakain
naman ako ng maayos”
Inspection: Abdomen flat and
rounded (-) discoloration of
the abdomen (+) stretch marks (-) jaundice (-) hematemesis (+) brownish soft
stool (+) passing of flatus (-) abdominal
distention (-) constipationAuscultation: 16 bowel sounds/min (-) bruitsPercussion: Tympanic sound over
four quadrant Dullness over the
liver Fluid wave test resultPalpation: Spleen & liver are
not palpable (-) masses (-) lesions (-) tenderness
Urinary Client verbalized, “Wala naman akong nararamdaman na
masakit pag naihi ako. Minsan
Inspection: Non odorous urine (-) abdominal pain
nagpipigil ako ng ihi, pero pag kailangan lang, yung sobrang busy lang. pero most of the
time, hindi talaga.”
Urine color: amber colored urine
Palpation: Kidneys are not
palpable (-) distended bladder (-) tenderness upon
palpation
Genitalia Client verbalized, “Wala naman ako nararamdaman, malinis
naman ako, regular ko namang hinuhugasan ang mga
pribadong parte ng katawan ko,”
Unable to perform examination, patient refused.
Peripheral Vascular
Client verbalized, “Wala naman ako nararamdaman, wala din
naman ako nakikitang kakaiba sa arms at legs ko. Pero
nanginginig minsan, dahil siguro sa pasma.”
Inspection: (-) lesions on arms
and legs (-) swelling in both
sides of arms and legs
(-) varicose veins (-) discoloration of
upper and lower extremities
(-) edemaPalpation: Radial pulse: 71 bpm (-) masses Regular weak radial
pulse swelling of legs Capillary refill: 2
secondsAuscultation: No unusual sounds
detected
Musculoskeletal
Client verbalized, “Pag sa trabaho, madalas ako nakatayo kaya minsan masakit yung sa binti ko, pero konting masahe lang ok na. Ganun din yung sa
likod ko.”
Inspection: Full ROM from head
to toe Movements are
coordinated and rhythmic
Mouth opens and closes smoothly
Jaw protrudes and retracts easily; has full resistance against applied force
Shoulders are symmetrically round, no swelling and deformities.
Elbows are symmetric
(+) body weakness & exertion upon movement
Neurologic Client verbalized, “Madali naman ako makatanda,
maayos ko naman nasasagot yung mga tinatanong sa kin.”
Patient is coherent and is oriented to people, places and time.Patient appears to be calm and restedPatient responds in moderate tone, clear and in moderate pace.Patient’s clothes are fit and appropriate for the situationPatient can recall past events especially prior to her illness. Patient is
cooperative and friendly, expresses feelings appropriate to the situation
Verbalizes positive healthy thoughts about future, family and self.
CN I: Correctly identifies scent presented (alcohol)
CNII: Full visual fields
CN III, IV, VI: eyelids move in a smooth and coordinated motion in all directions.
CN V: Temporal and masseter muscles contract bilaterally; eyelids blink bilaterally
CN VII: smiles, wrinkles, forehead, show teeth, moves eyebrows, closes eyes against any resistance. All movements are symmetrical.
CN VIII: Hears word correctly using voice whisper test.
CN IX, X: swallows without difficulty by drinking water
CN XI: trapezius muscles are symmetric
CN XII: tongue is smooth and mobilizes symmetrically
Hematologic Client verbalized, “Wala naman akong unusual bleeding. Hindi
rin ako madalas magsugat. Yung mga sugat ko, mabilis
naman gumaling.”
Inspection: (-) epistaxis (-)bleeding (-) excessive bruising (-) jaundice
K. Laboratory Studies and Diagnosis
PROCEDURE(DATE)
INDICATION NORMAL FINDINGS/ VALUES
ACTUAL FINDINGS NURSING RESPONSIBILITIES
Hematology(July 5)
To obtain small vials of blood for numerous tests involved
in diagnosing many conditions other than blood
diseases
Hgb:F: 123 – 150 g/LM: 140 -175 g/L
Hct:F: 0.36 – 0.45 g/LM: 0.41- 0.5 g/L
WBC:5,000 – 10,000/ mm3
Segmenters: 0.36 – 0.66
Lymphocytes: 0.22 – 0.40
Monocytes:0.04 – 0.08
PTT: 10 – 14 secs
Serum: 46-92 µmol/L
Hgb: 130 g/L
Hct: 0.40 g/L
WBC:12,400/ mm3
Segmenters: 0.83
Lymphocytes: 0.12
Monocytes: 0.05
PTT: 11.8 secs
Serum: 68 µmol/L
PRE
o Inform the patient of the necessity of the procedure.
o Inform the patient about the procedure.
INTRA
o Cleanse and dry puncture site.o Hold syringe or evacuation tube with
needle.o Gently invert the collection tubes
several times to blend sample. Do not shake.
POST
o Check patient and apply cotton to puncture site.
o Instruct to lie down and rest.
Na: 137-145 mmol/L
K: 3.5-5.10 mmol/L
Na: 142 mmol/L
K: 4.2 mmol/LASO titer(July 5)
A blood test to measure antibodies against
streptolysin O, a substance produced by Group A
Streptococcus bacteria
< 200 IU/ml < 200 IU/ml PRE
o Explain to the patient that the ASO test detects an immunologic response to certain bacteria(Streptococci)
o Inform the patient that he need not restrict food and fluids (although a fasting sample is preferred)
o Tell the patient that the test requires a blood sample.
o Explain who will perform the venipuncture and when.
o Explain to the patient that he may experience slight discomfort from the tourniquet and needle puncture.
o If the test is to be repeated at regular intervals to identify active and inactive states of rheumatic fever or to confirm acute glomerulonephritis, tell the patient that measuring changes in antibody levels helps determine the effectiveness of therapy.
o Check the patients history for drugs
that may suppress the streptococcal antibody responses.
o If such drugs must be continued, note this on the laboratory request.
INTRA
o Perform a venipuncture test and collect the sample in a 7 ml tube without additives.
o Apply direct pressure t the venipuncture site until bleeding stops.
ECG(July 5)
ECG permits to detect very many illnesses of the heart,
first of all the myocardial infarction. It is to help identify
primary conduction abnormalities, cardiac arrhythmias, cardiac
hypertrophy, myocardial ischemia and the site and
extent of myocardial infarction.To monitor recovery from
myocardial infarction.To evaluate the effectiveness of
cardiac medications (cardiac glycosides, vasodilator, and
antihypertensive)To assess pacemaker
Regular RhythmsP wave precedes every QRS complex with consistent PR interval is sinus rhythm.
No discernable P wave preceding each QRS but narrow regular QRS complexes is a nodal or junctional rhythm.
dilated left ventricle with good wall motion and contractility
dilated left atrium normal size right
atrium, right ventricle, main pulmonary artery and aortic root
thickened and calcified aortic valve cusps with restriction of motion
thickened arterior
PREo Explain to the patient that an ECG
evaluation evaluates the heart’s electrical activity.
o Tell the patient that he need not restrict food and fluids.
o Describe the test, including who will perform it, where it will take place and how long it will last.
o Tell the patient that electrodes will be attached to his arms, legs and chest and that the procedure is painless.
INTRA
performance. mitral valve leaflet without restriction of motion
structurally normal tricuspid valve and pulmonic valve
no intracardiac thrombus nor pericardial effusion noted
ECG mount: LVH, interolateral wall ischemia
o Place the patient in a supine position. If he can’t tolerate lying flat, help him to assume seme fowlers position.
o Help the patient expose his chest, both ankles and both wrists for electrode placement. If the patient is a woman provide a chest drape until the chest leads are applied.
o Turn on the machine and check the paper supply.
o Explain that during the test he’ll be asked to relax lie still and breathe normally.
o Advise the patient not to talk during the test because the sound of his voice may distort the ECG tracing.
POST
o Check the patient’s medication history for use of cardiac drugs and note the use of such drugs on the test request form.
CXR(July 5)
To evaluate the lungs, heart and chest wall; used to help diagnose symptoms such as shortness of breath, a bad or
persistent cough, chest pain or
A normal chest x ray will show normal structures for the age and medical history of the patient.
cardiomegaly with incipient pulmonary congestive changes and/or
PREo Explain too the patient that chest
radiography assesses chest anatomy.
o Tell the patient that he need not
injury, fever; to help diagnose or monitor treatment for
conditions
pneumonitis, both lower lobes
r/o the possibility of pericardial effusion wherein correlation with 2-D is suggested
restrict food and fluids.o Describe the test, including who will
perform it, where it will take place and how long it will last.
o Explain to the patient that he’ll be asked to take a deep breath and hold it momentarily while the film is being taken to provide a clear view of pulmonary structures.
INTRA
o The patient stands or sits in front of the machine so films can be taken posteroanterior and left lateral views.
o Place cardiac monitoring leadwires, IV tubing form central lines, pulmonary artery catheter lines and safety pins as far from the X-ray field as possible.
ECHOCARDIOGRAPHY
AND COLOR FLOW
DOPPLER REPORT(July 8)
Assess the heart’s function
Determine the presence of disease of the heart muscle,
valves and pericardium, heart tumors, and congenital
heart disease
M-Mode Exam, Left Ventricle
End-diastolic diameter
49±4 mm
Interpretation: technically
different study dilated left
ventricle with hypertrophied walls, mild global hypokinesia with
Evaluate the effectiveness of medical or surgical
treatments
Follow the progress of valve disease
End-sys tolic diameter
30±5 mm
Fibre fractional shortening
38±6 %
Interventricular septum thickness
9±1 mm
Septal systolic thickening
51±19 %
Postero-lateral wall thickness
8±1 mm
Wall systolic thickening
94±30 %
Hypertrophy index
0.34±0.05
depress left ventricular systolic function
dilated left atrium Normal right
atrium, right ventricle, main pulmonary artery and aortic root dimensions.
Thickened aortic valve cusps with calcifications along the cuspal margins, mild restriction of motion
anterior mitral valve leaflet is redundant. Middle scallop (A2) billowing into left atrium in systole, posterior mitral valve leaflet has mild restriction of motion. Mitral valve area of 2.02 cm2 by
Mass index
91±20 g/ m2
End-systolic meridional wall stress
56±17 103 dynes/cm2 Left Ventricular Ejection Fraction
Normal 55 – 65 % Mildly reduced 45 – 55 %35 – 45 %Moderately reduced < 35 %Severely reduced
Aortic Valve Stenosis
Mild < 20 mmHgModerate 20 – 50 mmHgSevere > 50 mmHg
Mitral Valve Stenosis
Mild < 6 mmHgModerate 6 – 16 mmHgSevere 16 mmHg
Wall Motion
Walls
planimetry. structurally,
normal tricuspid valve and pulmonic valve
No pericardial effusion and no intracavitary thrombus
Conclusion: Posteriorly
directed and eccentric mosaic color flow noted across mitral valve in systole
Mosaic color flow noted across aortic valve in diastole and across tricuspid valve in systole.
Aortic valve area of 1.9 cm2 by continuity equation; mean aortic valve gradient is equal
A AnteriorAL Antero-lateralSA Anterior septumI Infero-PosteriorSI Inferior septumPL Postero-Lateral
Asynergy Score0 Not visualized1 Normokinesis2 Hypokinesis3 Akinesis4 Diskinesis5 Aneurysm
Pericardial Effusion
Mild < 1 cm separation = 300 mlModerate 1-2 cm separation = 500 mlSevere > 2 cm separation > 700 ml
to 9.8mmHg, peak aortic valve gradient is equal to 22.6 mmHg, mitral valve area of 0.87 cm2 by pressure half time; mean pressure gradient is equal to 16.5 mmHg, peak pressure gradient is equal to 37.8 mmHg.
Prolonged deceleration time .
Pulmonary artery pressure of 44 mmHg by tricuspid regurgitant jet.
Conclusion: RHD Aortic
regurgitation, 3+ mild aortic
stenosis
anterior mitral valve prolapsed (A2)
severe mitral regurgitation
>mild mitral stenosis
moderate tricuspid regurgitation
eccentric left ventricular
Hypertrophy with mild global hypokinesia with depressed left ventricular systolic function.
dilated left atrium moderate
pulmonary hypertension
L. Other Assessment Tools
DATE TAKEN COMPREHENSIVE ACTUAL CONTENT/ LEGEND
ACTUAL RESULTS
June 25, 2010 Legend Functional Level Code
Feeding: 0Bathing: 2Toileting: 1Bed Motility: 0Dressing: 2Grooming: 0Gen. Mobility: 1Cooking: 4Home Maintenance: 4Shopping: 4
Level 0 Full self care
Level 1 Requires use of requirements or
device
Level 2 Requires assistance or supervision from another person or
device
Level 3 Requires assistance or supervision from another person or
device
Level 4 Is dependent and does not participate
M.Problem List
a) ACTUAL or Active
PROBLEM NO.
PROBLEM DATE IDENTIFIED
DATE RESOLVED/ REMARKS
1 Ineffective Airway Clearance
July 6, 2010 July 7, 2010/ patient was able
to effectively expel secretions
b) HIGH RISK or Potential
PROBLEM NO. PROBLEM DATE IDENTIFIED
1 Risk for Infection Transmission
July 7, 2010
Medical Diagnosis: RHD, CAP
Patient’s initials: E.R.A
NURSING CARE PLAN
CUESNURSING
DIAGNOSISLONG TERM SHORT TERM INTERVENTION RATIONALE EVALUATION
S
Client verbalized, “Naluluwa ko naman
Ineffective Airway Clearance related to excessive mucous
One month after the client’s discharge from the hospital, she
After 8 hours of giving nursing interventions, the patient will be able to
Independent: Establish
nurse-patient intervention
To gain trust and for the nurse to gain more information
Identify/demonstrate behaviors to achieve airway clearance.
yung plema pag naubo ako, pero konting konti lang.”
Client verbalized, “Pag nauubo ako, palaging may plema, tapos minsan after nun, nahihirapan ako huminga, pero sandali lang.”
O
(+) Shortness of breath
(+) difficulty of breathing
(+) frequent
production secondary to CAP
will be able to facilitate the maintenance of supply of oxygen to all body cells.
improve cough effort by reducing discomfort.
Assess rate and depth of respiration and monitor for signs of respiratory failure
Auscultate lung fields noting areas of decreased or absent airflow and anvetitious breath sounds
from the patient
Shallow respirations are frequently present because of the discomfort of moving chest wall.
Decreased airflow occurs in areas with consolidation of fluid. Bronchial breath sounds can also occur in consolidated areas. Crackles are heard in inspiration and
Display patent airway with breath sounds clearing; absence of dyspnea, cyanosis.
productive cough of whitish mucoid phlegm 2.5 cc in amount
Tachypnea (RR=39cpm)
(+) tripod position
(+) use of accessory muscles when breathing
Mild Chest indrawing
(+) shallow breathing
(+) crackles on both lung field at apex
Elevate head of bed and change position frequently.
Enourage patient to consume at least 3000 cc of fluids everyday. Offer warm than cold fluids.
expiration in response to fluid accumulation, thick secretions and airway obstruction.
It keeps the head elevated and promotes chest expansion and promotes mobilization and expectoration of secretions to keep the airway clear.
Fluids aid in the mobilization and expectoratio
Collaborative: Administer
medications as indicated
Assist in doing deep breathing exercises. Demonstrate or help the client in learning to
n of secretions. Warm liquids dilate the bronchioles.
Aids in reduction of bronchospasm and mobilization of secretions. Analgesics are given to improve cough effort by reducing discomfort, but should be used cautiously because they acn decrease cough effort or depress respiration.
Deep breathing
perform the activity. (ex. Pursed lip breathing)
Assist with/ monitor effects of nebulizer treatments. Perform treatment between meals.
Provide supplemental fluids (ex. IV fluids)
facilitates expansion of the lungs and smaller airways. Coughing is a natural self cleaning mechanism assisting the cilia to maintain patent airways.
Facilitates liquefaction and removal of secretions.
Fluids are required to replace losses (including insensible loss) and aid
in mobilization of secretions.
CUESNURSING
DIAGNOSISLONG TERM SHORT TERM INTERVENTION RATIONALE EVALUATION
S
The client verbalized “nahihirapan ako huminga, pero sandali lang.”
O
(+) use of accesory muscles when breathing
Tachypnea RR:39 bmp
(+)tripod or orthopneic
Alteration in comfort related to decreased oxygen supply secondary to CAP
One month after the client’s discharge from the hospital, she will be able to facilitate the maintenance of supply of oxygen to all body cells.
At the end of the shift the patient will verbalize comfort as man
Independent: Establish
nurse-patient intervention
Assess rate and depth of respiration and monitor for signs of respiratory failure
Position the client from lying to orthopneic position
To gain trust and for the nurse to gain more information from the patient
Shallow respirations are frequently present because of the discomfort of moving chest wall.
To promote respiration
The person will relate relief after a satisfactory health measure as evidenced by absence of disc
position (+)chest
indrawing (+)
weakness
Collaborative: Administer
medications as indicated
Assist in doing deep breathing exercises. Demonstrate or help the client in learning to
Aids in reduction of bronchospasm and mobilization of secretions. Analgesics are given to improve cough effort by reducing discomfort, but should be used cautiously because they acn decrease cough effort or depress respiration.
Deep breathing facilitates expansion of the lungs and smaller
perform the activity. (ex. Pursed lip breathing)
Assist with/ monitor effects of nebulizer treatments. Perform treatment between meals
airways. Coughing is a natural self cleaning mechanism assisting the cilia to maintain patent airways.
Facilitates liquefaction and removal of secretions.
CUESNURSING
DIAGNOSISLONG TERM SHORT TERM INTERVENTION RATIONALE EVALUATION
S
Client verbalized, “Medyo nanghihina ako, kaya di ako masyado nagalaw ng nagalaw.”
Client verbalized, “Nili-limit ko na lang yung pagalaw ko, pag nagalaw kasi ako ng nagalaw, parang ang bilis ko mapagod.”
O
(+)weakness (+)difficulty
of breathing Mild chest
pain
Activity intolerance related to mild chest pain secondary to RHD.
One month after the client’s discharge from the hospital, she will be able to promote optimal activity: sleep-rest exercise.
At the end of the shift, the pt. will be able to verbalize endurance in performing ADL.
Independent: Establish
nurse-patient intervention
Assess client’s ability to perform normal task/ADLs, noting reports of weakness, fatigue, and difficulty accomplishing task.
Note changes in balance/gait disturbance, muscle weakness.
To gain trust and for the nurse to gain more information from the patient
Influences choice of interventions/ needed assistance.
May inidcate neurologic changes associated with Vitamin B12 deficiency, affecting client’s safety/risk of
Report an increase in activity intolerance including ADLs.
Demonstarte a decrease in physiologic signs of intolerance like pulse, respiartion and BP remain within client’s normal range.
Display laboratory values like hemoglobin-hematocrit within acceptable range.
RR : 39cpm
Monitor BP, pulse, respiration during and after activity. Note adverse responses to increase levels of activity.
Recommend quiet atmosphere; bed rest if indicated. Stress need to monitor and limit visitors, phone calls, and repeated unplanned interruptions.
Elevate HOB as tolerated.
injury. Cardiopulmon
ary manifestations result from attempts by the heart and lungs to supply adequate amounts of oxygen to the tissues.
Enhances rest to lower body’s oxygen requirement, and reduces strain on the heart and lungs.
Enhances
Suggest client change position slowly, monitor for dizziness.
Assist client to prioritize ADLs/desired activities. Alternate rest periods with activity periods. Write out schedule for client to refer to.
Provide/recommend
lung expansion to maximize oxygenation for cellular uptake.
Postural hypotension or cerebral nypoxia may cause dizziness, fainting, and increase risk of injury.
Promotes adequate rest, maintains energy level, and alleviate strain on the cardiac and respiratory system.
Although help
assistance with activities/ambulation as necessary, allowing client to do as much as possible.
Plan activity progression with client, including activities that client views as essential. Increase activity levels as tolerated.
Identify/implement energy saving techniques; e.g., shower
may be necessary, self esteem is enhance when client does some things for self.
Promotes gradual return to normal activity level and improve muscle tone/stamina without undue fatigue. Increases self esteem and sense of control.
Encourages client to do as much as possible,
chair, sitting to perform tasks.
Instruct client to stop activity if palpitations, chest pain, shortness of breath, weakness, or dizziness occur.
Discuss importance of maintaining environmental temperature and body warmth as indicated.
while conserving limited energy and preventing fatigue.
Cellular ischemia potentiates risk of infarction and excessive cardiopulmonary strain/stress may lead to decompensation and failure.
Vasoconstriction decreases peripheral circulation, imppairing tissue perfusion. Client’s comfort/need
Collaborative: Monitor
laboratory status; e.g., Hb/Hct and RBC count, ABGs.
Provide supplemental oxygen as indicated.
Prepare for surgical intervention if indicated.
for warmth must be balance with need to avoid excessive heat with resultant vasodilation.
Identifies deficiencies in RBC components affecting oxygen transport and treatment needs/response to therapy.
Maximizing oxygen transport to tissues improves ability to function.
Surgery is usefeul to control
bleeding in patients who are anemic because of bleeding.
III. Anatomy and Physiology
CARDIOVASCULAR SYSTEM
A basic understanding of cardiac anatomy allows for correlation of physical exam finding with the unseen anatomy of the heart. The adult heart is about the size of a closed fist and sits in the thorax on the left side of the chest in front of the lungs. The heart is designed as a pump with four chambers - right atrium (RA), right ventricle (RV), left atrium (LA), and left ventricle (LV). The two atria are the smaller, upper chambers of the heart and the two ventricles are the larger, lower chambers of the heart. The heart is oriented in the chest rotated about 30 degrees to the left lateral side such the right ventricle is the most anterior structure of the heart. The left ventricle is generally about twice as thick as the right ventricle because it needs to generate enough force to push blood through the entire body while the right ventricle only needs to generate enough force to push blood through the lungs.
The heart also has four valves. The tricuspid valve is between the right atrium and right ventricles. The pulmonary valve is between the right ventricle and the pulmonary artery. The mitral valve is between the left atrium and the left ventricle and the aortic valve is between the left ventricle and the aorta. The valves, under normal conditions, insure that blood only flows in one direction in the heart.
In order to pump blood through the body, the heart is connecting to the vascular system of the body. This cardiovascular system is designed to transport oxygen and nutrients to the cells of the body and remove carbon dioxide and metabolic waste products from the body. The cardiovascular system is actually made up of two major circulatory systems, acting together. The
right side of the heart pumps blood to the lungs through the pulmonary artery (PA), pulmonary capillaries, and then returns blood to the left atrium through the pulmonary veins (PV). The left side of the heart pumps blood to the rest of the body through the aorta, arteries, arterioles, systemic capillaries, and then returns blood to the right atrium through the venules and great veins.
PHYSIOLOGY:1. Generating blood pressure. Contractions of the heart generate blood
pressure, which is required for blood flow through the blood vessels.2. Routing blood. The heart separates the pulmonary and systemic
circulation, which ensures the flow of oxygenated blood to tissues.3. Ensuring one-way blood flow. The valves of the heart ensure a one-way
flow of the blood through the heart and blood vessels.4. Regulating blood supply. Changes in the rate and force of heart
contraction match blood flow to the changing metabolic needs of the tissues during rest, exercise, and changes in the body position.
Source: Seeley, Stephens, Tate. 2007. Essentials of anatomy and physiology 6th edition. McGrawHill Education.
RESPIRATORY SYSTEM
The respiratory system is an intricate arrangement of spaces and passageways that conduct air from outside the body into the lungs and finally into the blood as well as expelling waste gasses. This system is responsible for the mechanical process called breathing, with the average adult breathing about 12 to 20 times per minute.
When engaged in strenuous activities, the rate and depth of breathing increases in order to handle the increased concentrations of carbon dioxide in the blood. Breathing is typically an involuntary process, but can be consciously stimulated or inhibited as in holding your breath.
ANATOMY:
Nostrils/Nasal Cavities During inhalation, air enters the nostrils and passes into the nasal cavities where foreign bodies are removed, the air is heated and moisturized before it is brought further into the body. It is this part of the body that houses our sense of smell.
Sinuses The sinuses are small cavities that are lined with mucous membrane within the bones of the skull.
Pharynx The pharynx, or throat carries foods and liquids into the digestive tract and also carries air into the respiratory tract.
Larynx The larynx or voice box is located between the pharynx and trachea. It is the location of the Adam's apple, which in reality is the thyroid gland and houses the vocal cords.
Trachea The trachea or windpipe is a tube that extends from the lower edge of the larynx to the upper part of the chest and conducts air between the larynx and the lungs.
Lungs The lungs are the organ in which the exchange of gasses takes place. The lungs are made up of extremely thin and delicate tissues. At the lungs, the bronchi subdivides, becoming progressively smaller as they branch through the lung tissue, until they reach the tiny air sacks of the lungs called the alveoli. It is at the alveoli that gasses enter and leave the blood stream.
Bronchi The trachea divides into two parts called the bronchi, which enter the lungs.
Bronchioles The bronchi subdivide creating a network of smaller branches, with the smallest one being the bronchioles. There are more than one million bronchioles in each lung.
Alveoli The alveoli are tiny air sacks that are enveloped in a network of capillaries. It is here that the air we breathe is diffused into the blood, and waste gasses are returned for elimination.
PHYSIOLOGY:
1. Gas exchange. The respiratory system allows oxygen from the air to enter the blood and carbon dioxide to leave the blood and enter the air. The cardiovascular system transports oxygen from the lungs to the cells of the body and carbon dioxide from the cells of the body to the lungs. Thus the respiratory and cardiovascular systems to work together to supply oxygen to all cells and to remove carbon dioxide. Without healthy respiratory and cardiovascular systems, the capacity to carry out normal activity is reduced, and without adequate respiratory and cardiovascular system functions, life itself is impossible.
2. Regulation of blood pH. The respiratory system can alter blood pH by changing blood carbon dioxide levels.
3. Voice production. Air movement past the vocal cords makes sound and speech possible.
4. Olfaction. The sensation of smell occurs when airborne molecules are drawn into nasal cavity.
5. Innate immunity. The respiratory system provides protection against some microorganisms by preventing their entry into the body and by removing them from respiratory surfaces.
Source: Seeley, Stephens, Tate. 2007. Essentials of anatomy and physiology 6th edition. McGrawHill Education.
Medical Diagnosis: RHD, CAP
Patient’s initial: E.R.A.
Non Modifiable Factors
Age (39 years old) Gender (Female) Race/Ethnicity Family History (DM, HPN)
Modifiable Factors
Environment (exposure to pollutants)
Lifestyle Diet Low socioeconomic status Untreated strep throat
infection
Inhalation of infectious particles and pathogenic microorganisms (streptococcus pneumoniae and streptococcus pyogenes)
Invasion of Group A hemolytic streptococci in the Upper respiratory
tract (nose, mouth and sinuses)
Invasion of streptococcus pneumoniae
Stick to local epithelial cells
Variety of enzymes liberated damage the tissue
Invasion to the upper respiratory tract (nose,
mouth, sinuses)
HematologyASO Titer
-cough and colds-mild fever-sneezing
Immune system response
Rheumatic fever
Invasion of lower respiratory tract (alveolar)
Cross reactive antibodies bind to cardiac tissues
Neutrophils, fluid and bacteria surrounding blood vessels fill the alveoli
Auto immune reactions releasing inflammatory cytokines (including TNF – alpha and IFN gamma)
Infiltration of streptococcal primed CD4 + T cells
Inflammatory process persists
O2 unable to reach bloodstream-causing interruption of normal O2
transportation
Rheumatic Heart Disease
Valvular lesions ( leaflet thickening, commissural fusion, and shortening and
thickening of the tendinuous cords)
Community Acquired Pneumonia
-Fever-Fatigue-Loss of appetite-Cough-headache-malaise-pallor-diaphoresis-sore throat
-Dyspnea-Nausea & Vomiting-Diarrhea
Chest X-Ray
-DOB-Productive cough-Fever-Loss of appetite-Chest pain-Wheezing breath sounds-Chills-Headaches-Fatigue
Hematology(Increased WBC)
(+) throat culture
ECG
Rheumatic Heart Disease is a condition of the heart in which it valves are damaged of rheumatic fever. When a susceptible person acquires a Group A beta hemolytic streptococcal infection, an autoimmune reaction may occur in the heart tissue, resulting in permanent deformities of heart valves or chordate tendinae. Involvement of the heart may be evident during acute rheumatic fever, or it may be discovered long after the acute disease has subsided.
It can be noted that in order to be diagnosed with Rheumatic Heart Disease, a patient must manifest the criteria or guidelines for diagnosis of RHD. In the case of patient ERA, she manifests or met 1 major and 3 minor which areas follow: Polyarthritis or migratory arthritis, arthralgias, presence of C-reactive protein and leukocytosis or increased in circulating WBC. Patient ERA also manifests symptoms such as chest discomforts and edema. Though patient does not have a history of rheumatic fever, laboratories revealed an elevation or rising streptococcal antibody titer.
There are precipitating factors that predisposes the client to have community acquired pneumonia. In the case of the patient, Due to inhalation of infectious particles and microorganisms such as Streptococcus pneumoniae, it resulted to invasion of these microorganisms to the upper respiratory tract, and then the body responds to this invasion having the patient manifests the early signs and symptoms. The microorganisms begin to invade the lower respiratory tract specifically in the alveoli. Due to the invasion in the alveoli, it triggers the immune system to send neutrophils, which are type of defensive WBC to the lungs. Neutrophils, fluid and bacteria surrounding blood vessels fill the alveoli. Thus, resulting to inflammation of the alveoli. Furthermore, because of the inflammation of the alveoli, the oxygen in the lungs is incapable to reach bloodstream-causing
Rheumatic Heart Disease
Community-Acquired Pneumonia
interruption of normal O2 transportation as a result the patient manifests persistence of signs and symptoms such as difficulty of breathing, fever, chill, cough and colds.
III. Medical-Surgical Management
1. Pharmacotherapeutics/ Medicines
GENERIC NAME (BRAND NAME)
CLASSIFICATION
INDICATIONDOSAGE AND FREQUENCY
NURSING RESPONSIBILITIES
ASA (Aspirin)Analgesic,
anticoagulant, antipyretic
For inflammatory conditions
to treat mild to moderate pain
to reduce fever or inflammation.
to treat or prevent heart attacks, strokes, and angina
80 mg/tab OD pc
Pre:
Check doctors order Asses patients
condition
Assess allergic reaction
Assess a recent history of stomach or intestinal bleeding
Take extra precaution when giving medication to children
Instruct patient not to chew, break, or open an enteric-coated or extended-release pill
Instruct the patient to swallow the pill whole.
Intra:
Instruct patient to take drug with meals
Monitor patients condition for signs and symptoms of bleeding, coughing up blood, severe nausea and vomiting
Post: Educate patient to
avoid taking ibuprofen if taking aspirin to prevent stroke or heart
attack
Educate patient to avoid drinking alcohol when taking aspirin.
Tell patient to report unusual side effects like difficulty breathing; swelling of your face, lips, tongue, or throat. Discontinue using aspirin and call your doctor.
Document.
Isosorbide Mononitrate (Imdur)Anti-anginal, nitrate,
vasodilator
Prevention and/ or
treatment for angina pectoris
to decrease the frequency and severity of
angina episodes
60 mg ½ tab OD hs PO
Pre:
Check doctors order Asses patients
condition
Assess allergic reaction
Intra:
Give sublingual preparation under the tongue or in the buccal pouch; discourage the patient from swallowing
Can be taken with empty stomach and with meals if severe
Post:
Tell patient that drug may cause dizziness, light headedness, headache, flushing of neck or face
Report blurred vision, persistent or severe headache, and rash, more frequent or more severe angina attacks, fainting.
Document
Digoxin (Lanoxin)Cardiac glycoside
used for mild to moderate congestive
heart failure for treating an
abnormal heart rhythm called atrial fibrillation.
0.25 mg/tab OD PO
Pre:
Check doctors order Asses patients
condition
Assess allergic reaction
Assess baseline ECG, cardiac auscultation, peripheral pulses
Check dosage
Intra:
Avoid giving the medication with food
Have emergency treatment ready in case of digoxin toxicity: lidocaine, phenytoin, atrophine, cardiac monitor.
Take pulse at the same time each day
Post: Tell pt. to report
slow or irregular pulse, rapid weight gain, loss of appetite, nausea and vomiting.
Document.
Cefuroxime (Ceftin)2nd generation cephalosporin
For the treatment of
many different types of bacterial
infections such as bronchitis,
sinusitis, tonsillitis, ear
infections, skin infections,
gonorrhea, and
Pre:
Perform ANST. Check results of
culture and sensitivity test.
Intra:
Give with meals.Post:
Watch out for
urinary tract infections.
750 mg IV q8º
hypersensitivity reaction.
Inform client that she may experience stomach upset or diarrhea.
Instruct client to report severe diarrhea, difficulty of breathing, fatigue and pain at injection site.
Document
Erdosteine (Ectrin)Cough and cold
preparations
Acute bronchitis,
chronic bronchitis & its exacerbations.
Resp disorders characterised by abnormal
bronchial secretions &
impaired mucus
transport.
300mg/cap BID PO
Pre:
Check doctor’s order
Assess for hypersensitivity to Erdosteine
Assess for pregnancy and lactation
Intra:
Can be taken with or without meals
Post:
Assess for possible side effects
Document
Levodropropizine
(Levopront)Cough and Cold
Preparation
Symptomatic treatment of
cough
10cc TID PO
Pre: Check doctor’s order
Assess for hypersensitivity to
Assess for pregnancy and lactation
Intra
Should be taken on an empty stomach. (Take between meals)
Post:
Tell the patient that the drug may cause Nausea, vomiting, heartburn, diarrhoea, fatigue, weakness, drowsiness, dizziness, headache, palpitations.
Document
Metoprolol (Lopressor)Antihypertensive, β1-selective adrenergic
blocker
For hypertension,
long-term treatment of
angina pectoris
50 mg/tab BID PO
Pre: Check doctors order assess patient
condition before therapy to monitor the effectively of the drug
assess heart failure obtain baseline renal
and liver status before therapy
assess for obstructive jaundice because the drug level may elevate due to the inability to excrete drug
Intra: Give food to
facilitate absorption Instruct the patient
to comply with dosage schedule even if feeling better
Tell the patient that drug may cause light-headedness, dizziness, fainting, and transient hypotension
Inform the client that excessive perspiration, dehydration, diarrhea may lead to fall in blood pressure
Post: Monitor for possible
drug induced adverse reactions
Monitor BP of the patient
Document
Enalapril(Vasotec)ACE
inhibitor,antihypertensive
Treatment of hypertension alone or with combination with other antihypertensive, especially thiazide types diuretics.
Treatment of acute and chronic heart failure
Treatment of asymptomatic left ventricular dysfunction
Pre:
Check doctors order Asses patients
condition
Assess allergic reaction
Assess for pregnancy especially during 2nd and 3rd trimesters can cause serious injury or death to the fetus
Intra:
Monitor patient on diuretic therapy for excessive hypotension afterthe1st few doses of enelapril
Monitor patient in any situation that may lead to a drop in BP secondary to reduced fluid volume because excessive hypotension may occur.
Monitor carefully because peak effect may not be seen for 4hours .
Do not administer second dose until Bp has been checked.
Assess allergic reaction
Post:
Tell the client not to stop taking the medication without consulting healthcare provider.
Tell the patient that this drug may cause GI upset, loss of appetite, change taste perception ,mouth sores, rash, fast heart rate, dizziness and light headedness.
Advice the patient to report mouth sores, fever, chills, swelling of the face,eyes,lips,tounge, feet and hands and irregular heart rate and difficulty of breathing
Document.
Spironolactone (Aldactone)
Potassium-sparing diuretic, aldosterone
antagonist
For essential hypertension,
usually in combination of
other drugs, prevention of hypokalemia
Short-term preoperative treatment of patients with
primary hyperaldostero
nism
25 mg/tab OD PO
Pre:
Check doctors order Asses patients
condition
Know patient’s history of hypersensitivity to drug.
Give daily doses early so that increase urination does not interfere with sleep.
Monitor BP
Intra :
Arrange for regular of serum electrolytes and
BUN Can be take with or
without food
Post:
Measure and record regular weight to monitor mobilization of edema fluid
Advise client to avoid foods rich in potassium
Tell the client that he may experience side effects like increase volume and frequency of urination, dizziness, confusion, drowsiness and increase stress.
Report weight change of more than 3poundsin 1 day, swelling ankles or fingers .
Monitor UO
Document
IV. Progress Notes
DAY 1 Received the patient lying on right lateral, sleeping; with O2
inhalation regulated at 1-2 lpm, with IVF of PNSS 1L x 16º, due at 1:50 pm with 300 more to infuse; diet of DAT; no available medical impression. Obtained v/s at 12 pm with T=36.5ºC, BP= 100/50 mmHg, RR=35 cpm and PR=60 bpm. The patient complained of chest pain aggravated with persistent cough with whitish mucoid secretions and difficulty of breathing. Had assessed for respiratory rate and depth. Had advised patient to elevate the head of bed and frequently change positions. Had assisted the patient in deep breathing exercises. Had
administered medications as indicated: antitussives and analgesics. At the end of the shift, the patient had verbalized that she could expectorate lung secretions effectively, and has relieved a little from her chest pain.
DAY 2 Received the patient sitting on bed, conscious, coherent and oriented to time, place and people; with O2 inhalation regulated at 1-2 lpm, with IVF of PNSS 500 cc x 72º, with diet of DAT. Obtained v/s T=36.0 ºC, 36.7ºC, BP= 120/70 mmHg, 100/50 mmHg, RR=39 cpm, 38 cpm and PR=71 bpm, 62 bpm, for 8 am and 12 pm, respectively. The patient had complained of persistent cough with whitish mucoid secretions but without chest pain. Had assisted the patient in deep breathing exercises. Had administered medications as indicated: antitussives and analgesics. At the end of the shift, the patient had decreased RR=35 cpm.
V. Discharge Health Teaching Plans
CONTENT STRATEGY
Compliance Compliance to the physician’s orders and medications can eventually lead to the betterment of the patient’s condition.
Health teaching
Medication Medications prescribed by her attending physician must be taken at due time. Take note that her aspirin, which is taken at 12 pm, must be taken after meals to facilitate absorption. Also take note that digoxin and metoprolol, which is taken at 8 am, could lower the BP of the patient and must notify the patient if the medication must be given or not.
Health teaching
Diet There is no diet restriction but still must be careful when eating to avoid aspiration.
Health teaching
Exercise Overexertion is not Health teaching
recommended; this may give way to difficulty in breathing.
VI. Summary of Client’s Status or Condition as of Last Day of Contact
Received the patient sitting on bed, conscious, coherent and oriented to time, place and people; with O2 inhalation regulated at 1-2 lpm, with IVF of PNSS 500 cc x 72º; diet of DAT; with medical impression of CAP and RHD. Obtained v/s T=36.0 ºC, 36.7ºC, BP= 120/70 mmHg, 100/50 mmHg, RR=39 cpm, 38 cpm and PR=71 bpm, 62 bpm, for 8 am and 12 pm, respectively. The patient had complained of persistent productive cough with whitish mucoid secretions but without chest pain. The patient looked tired and sleepy. She had also reported decreased appetite due to persistent cough. Had assisted the patient in deep breathing exercises. Had administered medications as indicated: antitussives and analgesics. At the end of the shift, the patient had decreased RR=35 cpm. She has been endorsed to be transferred to a private room in 3500.