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De La Salle - Health Sciences Institute College of Nursing and School of Midwifery Congressional Avenue, Pasong Lawin Dasmariñas City, Cavite Nursing Case Presentation BSN 31 Group 2 Aguda, Kimberly Marie Babasa, Cherry Mae I. Caayao, Trixia Liezl Dela Cruz, Jean Camille Gicana, Charisse Lacanilao, Keith Darrel Medina, Gerald Amgelo Opiña, Janel Kate Rabie, Anne Sherina Sasoy, Alexies Cassandra Ularte, Wendelyn August 16, 2010 Nursing Case Study Date of Admission: July 5, 2010 Page 1 of 76

CASE PRE - RHD+CAP[1]

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Page 1: CASE PRE - RHD+CAP[1]

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

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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.

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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.

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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.

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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

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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

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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

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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:

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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

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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

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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

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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

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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:

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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

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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

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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

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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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

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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

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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.

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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.

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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

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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

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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

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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

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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

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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

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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.

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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

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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

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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,

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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

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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

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bleeding in patients who are anemic because of bleeding.

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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.

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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.

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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.

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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.

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Medical Diagnosis: RHD, CAP

Patient’s initial: E.R.A.

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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

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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

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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

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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.

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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

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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.

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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

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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)

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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

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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:

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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

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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

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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

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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.