ER2015CP

7/25/2019 ER2015CP

1/87

ACKNOWLEDGEMENT

The group would like to acknowledge the following for providing and the

support to the success of the case presentation, and all of this would have not

been possible without them:

Firstly to the almighty father, who gave his unconditional love and support

to the success the group have obtained in life and with his help the group can

provide help towards the recovery of the client. He has watched over the group

and provided the values of a quality student nurse and has guided each in

becoming the person they are today.

Secondly to the dear parents, who provided the financial needs and has

worked hard for the sake of giving a bright future for the group. The people who

had a big participation in providing the philosophies and the beliefs in life thus

giving the group an individualistic beliefs that will reach the hearts of the clients.

Thirdly the client, who had tolerated the group for bothering him even

when in times he is in pain still he has provided the group the necessary

information needed for the case presentation. lso, allowing the group to help in

the recovery of the client.

Fourthly to the clinical instructors, who had to con!ure effort and patience

in teaching the group how to provide care to the clients. They had to give a lot of

their time and thought to provide all their knowledge and e"perience to the group

and to make the group a student nurse that would we worth of their time and

effort.

1

7/25/2019 ER2015CP

2/87

Fifthly to the health constitution, S#$%, for providing the group an area or

related learning e"perience in the hospital especially for giving the group a real

e"posure of how the world practically works. They have given the group

knowledge how to handle situations much like of the other countries that would

someday be helpful to the group especially for those who dream to work abroad.

&astly to the school, who made ways to provide for the group, learnings

and knowledge that would help the group for their futures.

2

7/25/2019 ER2015CP

3/87

INTRODUCTION

'heumatic heart disease ('H)* is the most common acquired heart

disease in children in many countries of the world, especially in developing

countries. The global burden of disease caused by rheumatic fever currently falls

disproportionately on children living in the developing world, especially where

poverty is widespread.

'H) is a chronic heart condition caused by rheumatic fever that can be

prevented and controlled. 'heumatic fever is caused by a preceding group

streptococcal (strep* infection. Treating strep throat with antibiotics can prevent

rheumatic fever. $oreover, regular antibiotics (usually monthly in!ections* can

prevent patients with rheumatic fever from contracting further strep infections and

causing progression of valve damage.

The risk of 'H) is greater with repeated episodes of 'F. +hile 'F

usually occurs between and - years of age, it can also occasionally occur in

adulthood with /0 of adults make up the cases. The condition affects both

se"es equally, though girls and women tend to have more severe symptoms

(+orld Heart Federation*.

1n the #hilippines, 'heumatic Heart )isease is one of the top ranking

cause of mortality and morbidity when it pertains to acquired cardiovascular

disease specially among schoolchildren (age 2- years old*. )espite the

concerted efforts of 3overnment and 4o2 3overnment 5rgani6ations to screen

and treat diagnosed cases of cute 'heumatic Fever, the recurrence rate is high

3

7/25/2019 ER2015CP

4/87

and the dismal progression to multivalvular involvement remains unchanged

through several decades (#hilippine Foundation for the #revention and %ontrol of

'heumatic Fever7'heumatic Heart )isease, /-*.

)uring the group8s clinical e"perience in the 9mergency 'oom

)epartment at Southern #hilippines $edical %enter, along with their clinical

instructor, they chose patient because they wanted to apply the things that they

have learned in their lectures and to also know more about the condition of the

patient and how to properly take care of the patient. s student nurses, they will

be able to use the information they have in order to take better care of patients

that they may encounter in the future that may have the same condition and to

properly give interventions their patients need.

4

7/25/2019 ER2015CP

5/87

OBJECTIVES

3eneral 5b!ective:

+ithin days of duty in the emergency room of Southern #hilippine

$edical %enter, the proponent will be able to give safe and effective nursing

care, use the knowledge that has been imparted to the proponent from the

academe, and that the proponent would be able to choose a patient and conduct

a comprehensive case study of the patient8s condition.

Specific 5b!ectives:

%ognitive

o To be able to define the complete diagnosis of the patient

o To identify the developmental data of the patient

o To conduct a cephalocaudal assessment of the patient

o To be able to trace the signs, symptoms, etiology and

pathophysiology of the condition of the patient

o To present a comprehensive prognosiso To be able to create efficient nursing care plan based on actual

high2risk health needso )iscuss the implications of the laboratory results of the patient as

well as the surgical procedure doneo To review and discuss the human anatomy and physiology of the

respiratory system.o To present a genogram that could trace any disease that could be

hereditary to the patient which might contribute to her present

condition

#sychomotor

5

7/25/2019 ER2015CP

6/87

o To select a patient, conduct an interview and record data for the

case studyo To apply the different and related nursing theories that are

appropriate to the present health condition of the patiento To present drug studies and discuss the different medications given

to the patient and why they were indicated for the patiento To record the patient8s data, family background, health history and

present health condition

ffective

o To establish a good rapport with the patient to gain their trust and

cooperation;o pproach the patient and the significant others in a non2!udgmental

manner;o #rovide a compassionate and caring approach to the patient and

significant others;o To provide health teachings to the client to achieve optimum

wellness as well as other relevant discharge orders.

PATIENTS DATA

BIOGRAPHICAL:

#atient8s name: #atient

ddress: %entral ,

7/25/2019 ER2015CP

7/87

9ducational ttainment: High School 3raduate

5ccupation: 4one

, /- D :>- #$

Eital Signs pon dmission:

#': -> bpm

'': >/ cpm

o%

dmitting #hysician: )r. 'achel nn +.

7/25/2019 ER2015CP

8/87

8

7/25/2019 ER2015CP

9/87

Genogra

9

K56 y.o.

J78 y.o.

C19 y.o.

E46 y.o.

I48 y.o.

L

A24 y.o.

B23 y.o.

M

G43 y.o.

H40 y.o.

F45 y.o.

D18 y.o.

LegendM!"e # Fe$!"e #

De%e!&ed #

'ne($on)! #

Hy*e+,en&)on # -HD #

K)dney *+o"e$& #'!,)en, #

He!+, d)&o+de+ #

D)!e,e& Me""),(& #

7/25/2019 ER2015CP

10/87

PRESENT HEALTH HISTOR!

ccording to the mother, last Culy =, a Saturday, patient e"perienced

pain on her throat and they had a check2up at a clinic in Toril. They were told that

patient has tonsillitis and were given a prescription to buy antibiotics, which

was %larithromycin. 5n Culy , a $onday, patient was said to have difficulty

breathing and her skin was starting to turning yellow in color. They went to have

another check2up at a clinic in Toril and were advised to go to Southern

#hilippines $edical %enter.

#atient was admitted last Culy ->, /- at :>- #$ at Southern

#hilippines $edical %enter for consultation when the symptoms of difficulty of

breathing and !aundice were noted.

PAST HEALTH HISTOR!

ccording to mother 3, patient only e"perienced fever, cough, and colds

when she was young. She was complete in having her immuni6ations when she

was young. She also e"periences migraine which started when she was on the

fourth grade in elementary. She had her mumps when she was already years

old. She was also a child who doesn8t get sick most of the time. +henever they

get sick they would go to a former clinic in Toril, named @ue!ada %linic and the

new clinic in Toril named )r. 3allos8 %linic or Anagapahilot lang meB, as verbali6ed

by mother 3. #atient was hospitali6ed once when she gave birth to her son last

$ay -G, /-> at Southern #hilippines $edical %enter where she had undergone

a normal spontaneous vaginal delivery.

10

7/25/2019 ER2015CP

11/87

&ast Culy =, she went to )r. 3allos8 %linic in Toril for complaint of difficulty

of breathing wherein she was prescribed to take %larithromycin.

FAMIL! HEALTH HISTOR!

#atient was the eldest child of mother 3 and father 1. ccording to

mother 3, her family has life threatening conditions such as diabetes mellitus,

pneumonia, heart disorder, kidney problems and hypertension. 5ne of patient 8s

siblings already has diabetes mellitus. $other 3 does not know about father 18s

side as they had separated when their children were still young but says that

father 1 uses illegal drugs when they were still together.

SOCIAL HISTOR!

#atient does not smoke and drink. She would only stay at home to take

care of her child. She does not stay with her partner since they are not married

yet and lives with her mother and other siblings with her son.

7/25/2019 ER2015CP

12/87

would also eat vegetables such as malunggay when there are no other food to

eat. They eat fruits when they have the money to buy some. She also doesn8t

have any allergy on any particular food.

MEDICATION RECONCILIATION

$edicine s of $edication ccording to #atient8s nderstanding

%larithromycin ccording to patient , this is an antibiotic to help fight of

bacteria.

#aracetamol ccording to patient , this is to help relieve fever.

Flana" ccording to patient , this is to be relieved from pain.

7/25/2019 ER2015CP

13/87

P"age#$ S#age$ o% Cogn"#"&e De&e'o(en#

The #iaget stages of development is a blueprint that describes the stages of

normal intellectual development, from infancy through adulthood. This includes

thought, !udgment, and knowledge. The stages were named

after psychologist and developmental biologist Cean #iaget, who recorded the

intellectual development and abilities of infants, children, and teens.

Stage )escription 'esult Custification

The Formal

5perational

Stage

(dolescence

through

adulthood*

The final stage of

#iagetIs theory

involves an

increase in logic,

the ability to use

deductive

reasoning, and an

understanding of

abstract ideas.

%H19E9) The patient has

increased in logic, the

ability to use deductive

reasoning, and

understanding abstract

ideas. Custified when

patient was asked;

A4gano diay ka na

hospitalJB #atientanswered A3iadto ko sa

akong bana diri kay

nang hupong na akong

tiil ug nag lisod nako ug

hinga.B

Er") Er")$on$ P$*+,o$o+"a' De&e'o(en# T,eor*

13

7/25/2019 ER2015CP

14/87

9rikson8s psychosocial theory of development considers the impact of e"ternal

factors, parents and society on personality development from childhood to

adulthood. ccording to 9rikson8s theory, every person must pass through a

series of eight interrelated stages over the entire life cycle.


Koung

dulthood (-?

to =/ years*

1ntimacy vs. 1solation

5nce people have

established their identities,

they are ready to make long2

term commitments to others.

They become capable of

forming intimate, reciprocal

relationships and willingly

make the sacrifices and

compromises that such

relationships require. 1f

people cannot form these

intimate relationships22a

sense of isolation may result.

14T1$%

K

The patient has

a husband that

also brought her

in the hospital.

A$aayo man ang

relasyon nako sa

akong bana

mamB as

verbali6ed by the

patient.

14

7/25/2019 ER2015CP

15/87

Ha&"g,-r$#$ De&e'o(en#a' Ta$)$

'obert Havighurst developmental task is a theory that e"plains and emphasi6es

that education is fundamental and that it continues all through life span. 1t states

that growth and development occurs in si" stages that include middle childhood,

adolescent, early childhood, middle age and late maturity.

15

7/25/2019 ER2015CP

16/87

16


9arly

dulthood (-?

L >/ years

old*

-.Selecting a mate

.&earning to live with

marriage partner

>.Starting family

=.'earing children

.$anaging home

.3etting started in

occupation

G.Taking on civic

responsibility

M. Finding congenial social

group.

%H19E9)The patient has a

partner but they

are not married

yet and did not

live together.

They have one

son. Her

husband is a

!eepney driver.

ccording to the

patient, they did

not !oin any

social groups.

7/25/2019 ER2015CP

17/87

ANATOM! AND PH!SIOLOG!

T,e Hear#

17

7/25/2019 ER2015CP

18/87

The heart itself is made up of = chambers, atria and ventricles. )e2

o"ygenated blood returns to the right side of the heart via the venous circulation.

1t is pumped into the right ventricle and then to the lungs where carbon dio"ide is

released and o"ygen is absorbed. The o"ygenated blood then travels back to the

left side of the heart into the left atria, then into the left ventricle from where it is

pumped into the aorta and arterial circulation.

The pressure created in the arteries by the contraction of the left ventricle is the

systolic blood pressure. 5nce the left ventricle has fully contracted it begins to

rela" and refill with blood from the left atria. The pressure in the arteries falls

whilst the ventricle refills. T,"$ "$ #,e ."a$#o'"+ /'oo. (re$$-re0

The atrio2ventricular septum completely separates the sides of the heart.

nless there is a septal defect, the sides of the heart never directly

communicate.

7/25/2019 ER2015CP

19/87

However #,e +,a/er$ #,e$e'&e$ 1or) #oge#,er . The atria contract

simultaneously, and the ventricles contract simultaneously.

Car."a+ Con.-+#"on S*$#e

3oing back to the analogy of the central heating system, the pump, pipes and

radiators are of no use unless connected to a power supply. The pump needs

electricity to work. The human heart has a similar need for a power source and

also uses electricity. Thankfully we donIt need to plug ourselves in to the mains,

the heart is able to create itIs own electrical impulses and control the route the

impulses take via a specialised conduction pathway.

This pathway is made up of elements:

- The sino2atrial (S* node

The atrio2ventricular (E* node

> The bundle of His

= The left and right bundle branches

The #urkin!e fibres

19

7/25/2019 ER2015CP

20/87

The S node is the natural pacemaker of the heart. Kou may have heard of

permanent pacemakers (##$s* and temporary pacing wires (T#+s* which are

used when the S node has ceased to function properly.

The S node releases electrical stimuli at a regular rate, the rate is dictated by

the needs of the body. 9ach stimulus passes through the myocardial cells of the

atria creating a wave of contraction which spreads rapidly through both atria.

s an analogy, imagine a picture made up of dominoes. One domino is pushed

over causing a wave of collapsing dominoes spreading out across the picture

until all dominoes are down.

The heart is made up of around half a billion cells, 1n the picture above you can

see the difference in muscle mass of the various chambers. The ma!ority of the

cells make up the ventricular walls. The rapidity of atrial contraction is such that

20

7/25/2019 ER2015CP

21/87

around -// million myocardial cells contract in less than one third of a second.

So fast that it appears instantaneous.

The electrical stimulus from the S node eventually reaches the E node and is

delayed briefly so that the contracting atria have enough time to pump all the

blood into the ventricles. 5nce the atria are empty of blood the valves between

the atria and ventricles close. t this point the atria begin to refill and the

electrical stimulus passes through the E node and rd section to this

process. The S node and E node contain only one stimulus. Therefore every

time the nodes release a stimulus they must recharge before they can do it

again.

21

7/25/2019 ER2015CP

22/87

Imagine you are washing your car and have a bucket of water to rinse off the

soap. You throw the bucket of water over the car but find you need another one.

The bucket does not magically refill. You have to pause to fill it.

1n the case of the heart, the S node recharges whilst the atria are refilling, and

the E node recharges when the ventricles are refilling. 1n this way there is no

need for a pause in heart function. gain, this process takes less than one third

of a second.

The times given for the > different stages are based on a heart rate of / bpm ,

or - beat per second.

The term used for the release (discharge* of an electrical stimulus is

NdepolarisationN, and the term for recharging is NrepolarisationN.

So, the > stages of a single heart beat are:

- trial depolarisation

Eentricular depolarisation

> trial and ventricular repolarisation.

s the atria repolarise during ventricular contraction, there is no wave

representing atrial repolarisation as it is buried in the @'S.

22

7/25/2019 ER2015CP

23/87

Re&"e1 o% S*$#e$ 2ROS3

S)"n: +arm to touch. #ositive !aundice and bipedal edema. 4egative for

lesions, wounds, ulcers, tumors, masses, bruises7ecchymoses, change in

moles, itching, acne, diaper rash, burns, temperature changes, hair growth7loss.

E*e$: #ositive for icterus. 4o use of glasses, contacts. 4egative for pain,

e"cessive tearing, itching7pruritis, discharge, swelling, double vision, blurred

vision, intolerance to light; history of eye infections, cataracts, or glaucoma,

strabismus, blindness.

Ear$: 4o hearing impairments. 4egative for use of aids, ear pain,

ringing7tinnitus, wa"7cerumen, h" of ear infections, otitis media.

No$e4 S"n-$e$4 Mo-#,4 T,roa#: 4egative for nose bleeds7epista"is, sinus

infections, sore throats, tonsillitis, voice changes, hoarseness, difficulty chewing

or swallowing, sores in mouth, dentures, cleft lip7palate, mouth

breathing7snoring.

Ne+): 4egative for enlarged lymph nodes, pain, stiffness, limited '5$.

Brea$#$: 4egative for lumps, masses, thickening, pain, discomfort, nipple

discharge, lesions, rashes, sores, history of breast disease, surgery,

7/25/2019 ER2015CP

24/87

and result of last mammogram.

Re$("ra#or*: #ositive for S5< and tachypnea. 4egative for cough but sputum

production is present, bloody sputum (hemoptysis*, whee6ing. #ositive for

crackles. 4o history of %5#), T< or lung cancer, asthma, use of home

o"ygen7equipment, smoking7chewing tobacco history, cystic fibrosis, pneumonia,

bronchitis, choking episodes, apnea7sleep apnea.

Hear#: #ositive for 'H), &HH and &E), tachycardia. 4egative for angina,

palpitations, orthopnea, para"ysmal nocturnal dyspnea, fainting, syncope,

pacemaker, history of murmurs7defects, $1, %HF, HT4. se of prophylactic

antibiotics.

Per"(,era' Va$+-'ar: #ositive for bipedal edema. 4egative for leg pain with

walking, numbness, tingling, changes in skin color, history of phlebitis, varicose

veins, HT4.

Ga$#ro"n#e$#"na': 4ormal bowel habits (freq, color, amt, consistency*,

abdominal enlargement. 4o recent changes in bowel habits, use of therapies

(la"atives, stool softeners, diet, suppositories, enemas, other*4OE (spitting up*,

hemoptysis, belching, flatulence, abdominal pain, abd distention, heartburn,

indigestion, loose stool, diarrhea, constipation encoporesis, bloody stools,

ostomies, ulcers, cirrhosis, gallbladder h", !aundice liver problems, hernia.

24

7/25/2019 ER2015CP

25/87

Ur"nar*: 4egative for any loss of control, difficulty starting stream, pain,

burning7dysuria, hematuria, frequency, urgency, oliguria, polyuria, nocturia,

T1Is,

7/25/2019 ER2015CP

26/87

Men#a' S#a#-$: 9motional illness or difficulty with thinking, memory problems,

history of psychiatric illness such as an"iety, depression, schi6ophrenia.

26

7/25/2019 ER2015CP

27/87

PH!SICAL ASSESSMENT

Genera' S-r&e*

'eceived patient sitting on bed awake with significant others at bedside

with heplock. #atient was with foley catheter. Her body structure was thin and

looks weak. Hair is unkempt. 5bserved difficulty in breathing and !aundice all

over the skin including the sclera on both eyes. M.o%

#' -> bpm

'' ? cpm

7/25/2019 ER2015CP

28/87

unkempt but distributed evenly. 4o dandruff was observed. Fingernails were

short and clean. 4ails had a conve" curvature of about -/ degrees angle, and

capillary refill returned in less than seconds. 4ail beds were pale. 4ail te"ture

was smooth. %uticles were also smooth and no detachment of nail plate.

E*e$ A$$e$$en#

%ornea is transparent, smooth and moist with no opacities. Sclera on both

eyes are yellowish. 1rises were round and flat. #upils were black in color and

equal in si6e, constricts when penlight was e"posed to it and had a measurement

of mm. %on!unctiva was pinkish with a few capillaries evident. 9yebrows are

symmetrically aligned. 9yelashes appeared to be equally distributed and curled

slightly outward. 9yelids had no presence of any discharges and no discoloration

noted. #atient was not wearing any reading devices.

No$e A$$e$$en#

4ose was positioned midline on face, straight and uniform in color.

7/25/2019 ER2015CP

29/87

&ips were pale and moist without lesions. Tongue was pale with white

spots present and located centrally in mouth. 4o lesions and bleeding noted.

3ums were pale and no swelling was noted. The uvula was positioned in the

midline of the soft palate.

Ear$ A$$e$$en#

9ars are equal in si6e bilaterally. 9"ternal ear was noted without any

bleeding, lesions or masses. Hearing function was normal on both ears as he

was able to answer accurately when he was asked a question. uricles were

smooth and symmetrical without discoloration. Small amount of dry yellowish

cerumen present on both internal ears. 4o tenderness noted. The pinna recoils

when folded. There is no pain or tenderness on the palpation of the auricles and

mastoid process.

Ne+) an. T,roa# A$$e$$en#

The muscles of the neck are symmetrical with the head at a central

position. The patient is able to move head through a full range of motion without

complaint of discomfort or noticeable limitation. The lymph nodes were not

palpable. The trachea is placed in the midline of the neck. Thyroid was not

enlarged and can8t easily be palpated. 4o edema. $oves smoothly with no

crepitus. 4o deviations noted. 4o pain or tenderness on palpation and !aw

movement.

29

7/25/2019 ER2015CP

30/87

T,ora5 an. L-ng A$$e$$en#

The chest wall is intact with no tenderness and masses. Thora" e"pands

upon inspiration and rela"es upon e"piration. %rackles are heard upon

auscultation. Sputum is present. 5bserved fast deep respirations.

7/25/2019 ER2015CP

31/87

tenderness. Coints were able to move smoothly. Showed body weakness through

slow movements. 9nable to move upper and lower e"tremities without

discomfort. Fle"ion and e"tension of feet and hands were demonstrated.

dduction and abduction of arms were demonstrated.

31

7/25/2019 ER2015CP

32/87

PATHOPH!SIOLOG!

32

7/25/2019 ER2015CP

33/87

33

7/25/2019 ER2015CP

34/87

34

7/25/2019 ER2015CP

35/87

DOCTORS ORDER

Da#ean.

T"e:

Or.er$ Ra#"ona'e Rear)$

G7->7-:>/pm #lease admit pt. underyellow skin to 1%&>

Secure consent to care

1EF2Heplock

Soft diet with Strict

aspiration precaution

)iagnostic test:

%

7/25/2019 ER2015CP

36/87

) echo

Hbsag and nti H%E

%P'2#&

'5$

- .mg tabletone 5)2 -st

dose now 9ssentiale

forte onetablet q.i.d

E7S q=

175 q shift

Hook to cardiac monitor

time, used tocheck for bleedingproblems.and standardi6ing

the results ofprothrombin timetests.

to assess the

function of theheartstructures(muscle, valves, pumpingchambers*.

To detect whether

acute signs and

symptoms aredue to HEinfection, fordiagnosticpurposes.

To spot

abnormalities ordiseases of theairways, bloodvessels, bones,heart, and lungs.

For management

of thehypertension,fluid retention(edema*, and toprovide theaffected liver withessentialphospholipids.

For proper

monitoring,management,and referral.

For proper

)one

)one

)one

5rdered

$onitored

Transferred

36

7/25/2019 ER2015CP

37/87

Transfer to %1monitoring ,management,and evaluation

G7->7-?:-pm

3ive 4a - vial -:-H%5> To correct

electrolyte

imbalances.

dministered

G7->7---pm

Shift Eit. Q amp 1E & amp

now then qM lbumin /0 1E at

furosemide -/mg 1E

For S) of whole abdomen

#ls. facilitate %P'

To prevent and

treat bleeding. For proper

manegment(albumin andfurosemideadministeredtogether form acomple" thatcarries the

furosemide to thekidney for uptakeby renal tubularcells.*(liverproblems*

to e"amine

organs in theabdomenincluding theliver, gallbladder,spleen, pancreas,

and kidneys for evaluation

dministered

)one

Facilitated

G7-=7-=:-Gam

Soft diet with S#

$aintain heplock

)" secure the:

)echo

S) of +hole

bdomen

%ont. present meds

ES q hourly with 5 Sat

To ease difficulty

in chewing and7orswallowing and toprevent thepatient for aspiration.

dministration of

meds.

For proper

evaluation7diagnosis andmanagement.

For proper

monitoring,

)one

)one

Secured

%ontinued$onitored'eferred

37

7/25/2019 ER2015CP

38/87

175 q shift

'efer

(*

(* sore throat2

clarythromycin

(2* bipedal edemaand dyspnea

(* orthopnea and

pallor

(* basal crackles

(* bipedal edema

grade

management,and referral.

G7-=7-M:/?

am

S) of whole abdomen

7/25/2019 ER2015CP

39/87

G7-=7--:-pm->/7M/(*

dsypnea(*

!aundice " -wk

)": for )echo and Sputum

3S%S

Start ceftria"one gm 1ETT

5) #5ST2error

Start %larithromycin -// mg

tab #ad " days

1ncrease bicoprolol to mg

tab 5)

dd meds:- Spironolactone /mg

tab 5) %aptopril mg R tab

'efer accordingly

to assess the

function of theheartstructures(muscle, valves, pumping

chambers* and todetect themicroorganismcausingpneumonia andother respiratoryinfections .

to treat or prevent

infections that areproven or strongly

suspected to becaused bysusceptiblebacteria(withsecured 3S%Sresults*.

To treat bacterial

infections.

$anagement of

hypertension and

fluid2electrolyteimbalances7fluidretension.

For proper

monitoring,

management,

and referral.

)one

dministered

dministered

dministered

%ontinueddmitted'eferred

39

7/25/2019 ER2015CP

40/87

DIAGNOSTIC TESTS

rterial 7- /:=

'eleased: G7->7- /:>=

Mea$-re.#e$#

Re$-'#$ Un"#$ Lo16H"g,

Ana'*7er Ra#"ona'e C'"n"+a'In."+a#"on$

pHD >G G.=/M (2* #H5P This test isdone tomeasure theblood phbalance and

o"ygen andcarbon dio"idelevels. Thishelpsunderstandhow well thelungs andkidneysfunction.1dentifyingimbalances in

your pH andblood gaslevels canprovide anearly warningabout how yourbody ishandlingillness.

lkalosis4ormal :&owernumbersmean more

acidity;highernumbersmean morealkalinity.

#%5D >G -.- mmHg

(2* #H5P p%5 (partialpressure of

carbon dio"ide*reflects the theamount of carbon dio"idegas dissolvedin the blood.

)ecreasedp%5 is

caused by: Hyperventilat

ion

Hypo"ia

n"iety

#ulmonary

embolism

40

7/25/2019 ER2015CP

41/87

#5D>G G.= mmHg

(2* #H5P #5 (partialpressure of o"ygen*reflects theamount of

o"ygen gasdissolved inthe blood. 1tprimarilymeasures theeffectivenessof the lungs inpulling o"ygeninto the bloodstream fromthe

atmosphere.

)ecreased

Ca'+-'a#e.#e$#$

Re$-'#$ Un"#$ Nor a'Range

Ana'*7er Ra#"ona'e C'"n"+a'In."+a#"on$

H%5> ->. mmol7&

2

#H5P +hen an acid2baseimbalance isidentified,bicarbonate(as part of the

electrolytepanel* andblood gasesmay beordered toevaluate theseverity of theimbalance,determinewhether it isprimarily

respiratory(due to animbalancebetween theamount of o"ygen comingin and %5being

)ecreased:cidosis

41

7/25/2019 ER2015CP

42/87

released* ormetabolic (dueto increased ordecreasedamounts of

bicarbonate inthe blood* innature, andmonitor itstreatment untilthe acid2basebalance isrestored.

1nterpretation: Fully %ompensated 'espiratory lkalosis

/G7->7-- /M:-? #$

'eleased: /G7->7- --:->pm

Serology and 1mmunology

Test 'esult 'eference 'ange %linical 1ndication

nti2HE -gm /.-=/

nonreactive

-./ %T25FF E&9

-./

4onreactive2 4on2

reactive or anegative Hepatitis

antibody test resul

means that a person

does not have

Hepatitis .

H

7/25/2019 ER2015CP

43/87

4ursing 'esponsibilities:

9"plain that this test is done to detect suspected blood disorders

particularly hepatitis infections(hepa ,

7/25/2019 ER2015CP

44/87

of red blood

cells.

'.G= " -/7ul =.2.-/ This test can

indicate if there

is a problem

with red blood

cell production

and7or lifespan

Lo1: )ecrease

in '

7/25/2019 ER2015CP

45/87

gangrene.

)ifferential %ount

TEST RESULT6UNITS Nora'

Va'-e$

RATIONALE CLINICAL

INDICATIONS

4eutrophil G= 0 .//2

G.//

4eutrophils are

a type of white

blood cell

(+ &ymphocytesaccumulate

when there is

chronic in!ury or

irritation.

4ormal

$onocyte ./ 0 2-/ Type of

granular

leukocyte

(white blood

cell* that

functions in the

ingestion ofbacteria and

other foreign

particles.

4ormal

9usinophil & 0 2-/ 9osinophils,

normally about

-2>0 of the

&ow :

45

7/25/2019 ER2015CP

46/87

total white

blood cell

count, are

believed to

function in

allergicresponses and

in resisting

some parasitic.

7/25/2019 ER2015CP

47/87

9"plain to the patient that he may feel a slight discomfort from the needle

puncture and the tourniquet. %ollecting the sample only takes a few minutes however if the patient is

being treated for an infection, the test will be repeated several times to

monitor the patient8s progress. 9nsure subdermal bleeding has stopped before removing pressure.

1f hematoma develops at the venipuncture site, apply warm soaks. 1f

hematoma is large, monitor pulse distal to the venipuncture site.

/G7->7- M:-?#$

'eleased /G7->7- --:-> pm

TEST RESULT6UNITS Nora'

Va'-e$

RATIONALE CLINICAL

INDICATIONS

#T #atient H -?.M sec --.M2-.- #rothrombin

time (#T* is a

blood test that

measures how

long it takes

blood to clot. 1t

can be used to

check for

bleeding

problems and it

is also used to

check what

medicine to

prevent blood

clot is working.

High: number

higher than average

means it takes blood

longer than usual to

clot; may be due to:

&iver

problems

1nadequate

levels of

proteins

(factors* tha

cause blood

to clot Eitamin Q

deficiency

%ongenital

factor

47

7/25/2019 ER2015CP

48/87

deficiency

#resence o

coagulation

factor

inhibitors

#T 1nr -. 4ot taking

blood

thinners:

/.M to -.

1f taking

warfarin:

./2>./

#T test, also

called an 14'

(1nternational

4ormali6ed

'atio* test.

sing this

system,

treatment with

blood thinning

medicine

(anticoagulant

therapy* will be

the same.

High: slow blood

clotting time.

#T 0

ctivity

=>.> 0

7/25/2019 ER2015CP

49/87

#T control -/. sec ?.?2-. 4ormal


9"plain the importance, function, and procedure of the test.

1nform patient that there is no restriction in food or fluids.

9"plain to the patient that he may feel a slight discomfort from the needle

puncture.

%linical %hemistry: /G7->7- M:-?#$

'eleased: G7->7- --:/>pm

TEST RESULT6

UNITS

Nora'

Va'-e$

RATIONALE CLINICAL

INDICATIONS

Sodium ->M.

mmol7&

->.//2

-==.//

The serum test for

sodium levels

evaluates fluid and

electrolyte balance

as well as renal or

adrenal disorders.

Sodium, ma!or

e"tracellular cation,

affects body water

distribution,

maintains osmoticpressure of

e"tracellular fluid

and helps promote

neuromuscular

function; it also

maintains acid2

base balance.

4ormal

S3#T >>.? 7& -=./2>./ an initial screening

for liver disease.

4ormal

lbumin & -M.M

g7&

>.//2

/.//

n albumin test is

often used as part

of a test known as

a liver panel, which

tests your blood for

albumin, creatinine,

blood urea

nitrogen, and

&ow: &ower2

than2normal

levels of serum

albumin may

be a sign of:

Qidney

49

7/25/2019 ER2015CP

50/87

prealbumin.

Kour physician will

likely order an

albumin test if he

or she suspects

you may have acondition that

affects your liver

function

diseases

&iver

disease

(for

e"ample

,hepatitis,

or

cirrhosis

that

make

cause

ascites*

Total

7/25/2019 ER2015CP

51/87

or kidney

cancer can

raise

levels.

serious

infection thathas spread

through the

body (sepsis*

can also raise

levels.

%reatinine .-/

mmol7&

-.G/2M./ The creatinine

blood test

measures the level

of creatinine in the

blood. This test is

done to see how

well your kidneys

work

4ormal

3lucose2 '

7/25/2019 ER2015CP

52/87

evaluate changes

in potassium levels

and is helpful in

diagnosing

disorders of acid2

base and waterbalance and

neuromuscular

disorders in the

body.


Tell the patient or the significant other that the test requires a blood

sample. 9"plain who will perform the venipuncture.

9"plain to the patient or to the significant other(s* that he or she may

e"perience discomfort from the tourniquet and needle puncture. 1nform the patient or significant other that he7she need not restrict food

and fluids.

DRUG STUD!

52

7/25/2019 ER2015CP

53/87

3eneric 4ame: Eitamin Q

7/25/2019 ER2015CP

54/87

Taste alterations

4ursing 'esponsibilities: - ssess client for any signs of hypersensitivity. 9ducate client that adverse reactions to the drug

may occur.

> %arefully regulate 1EF with vitamin Q. 'apid 1Eadministration may cause potentially fatalanaphyla"is

= #rotect the medication from light; agent is rapidlydegraded

$onitor patient constantly. Severe reactions,including fatalities, have occurred during andimmediately after 1E in!ection (see )E9'S99FF9%TS*.

&ab tests:

7/25/2019 ER2015CP

55/87

3eneric 4ame: #iperacillin ta6obactam

7/25/2019 ER2015CP

56/87

1ndications: Treatment of moderate to severe appendicitis

uncomplicated and complicated skin and skin structure

infections, endometritis, pelvic inflammatory disease, or

nosocomial or community2acquired pneumonia caused

by piperacillin2resistant, piperacillin7ta6obactam2

susceptible, beta2lactamase2producing bacteria.

Side effects: %onstipation; diarrhea; headache; indigestion; nausea

pain, swelling, or redness at the in!ection site; trouble

sleeping; vomiting.

dverse effects: %4S: Headache, insomnia, fever. 31: )iarrhea

constipation, nausea, vomiting, dyspepsia

pseudomembranous colitis. Skin: 'ash, pruritus

hypersensitivity reactions.4ursing

%onsideration:ssessment O )rug 9ffects

5btain history of hypersensitivity to penicillins

cephalosporins, or other drugs prior to administration.

&ab tests: %OS prior to first dose of the drug; start drug

pending results. $onitor hematologic status with prolongedtherapy (Hct and Hgb, %/ min after

initiation of the infusion for signs of hypersensitivity (seeppendi" F*.

#atient O Family 9ducation

'eport rash, itching, or other signs of hypersensitivity

immediately.

'eport loose stools or diarrhea as these may indicate

pseudomembranous colitis.

56

7/25/2019 ER2015CP

57/87

3eneric 4ame: %larithromycin

7/25/2019 ER2015CP

58/87

combination.

1ndications: Treatment of '1s caused

by Streptococcus pyogenes, S. pneumoniae

Treatment of &'1s caused

by Mycoplasma pneumoniae, S. pneumoniae,aemophilus influen!ae, Mora"ella catarrhalis

Treatment of active duodenal ulcer with H. pylori

in combination with proton pump inhibitor

Treatment of acute otitis media, acute ma"illary

sinusitis due to H. influen6ae, $. cararrhalis, S.

pneumoniae

Treatment of mild to moderate community2

acquired pneumonia in adults (9' tablets*

Side effects: Stomach cramping, discomfort, diarrhea; fatigue,

headache (medication may be ordered*; additional

infections in the mouth or vagina (consult with

care provider for treatment*.

dverse effects: )i66iness, headache, vertigo, somnolence,

fatigue, )iarrhea, abdominal pain, nausea,

dyspepsia, flatulence, vomiting, melena,pseudomembranous colitis, Superinfections,

increased #T, decreased +

7/25/2019 ER2015CP

59/87

serum levels and assess for SOS of drug to"icity.

Pa#"en# 8 Fa"'* E.-+a#"on

%omplete prescribed course of therapy.

'eport rash or other signs of hypersensitivity

immediately.

%ulture infection before therapy.

)o not cut or crush, and ensure that patient does

not chew 9' tablets.

$onitor patient for anticipated response.

'eport loose stools or diarrhea even after completionof drug therapy.

3eneric 4ame: Spironolactone

7/25/2019 ER2015CP

60/87

ions.

)osage, 'oute

and Frequency:

#5: /mg tab 5)

%ontraindication

:

nuria, hyperkalemia, acute or progressive renal

insufficiency. ddison8s disease.

)rug

interactions:

%ombinations of spironolactone and acidifying doses of

ammonium chloride may produce systemic acidosis; use

these combinations with caution. )iuretic effect of

spironolactone may be antagoni6ed by aspirin and other

S&1%K&T9S. )igo"in should be monitored for decreased

effect of %')1% 3&K%5S1)9. Hyperkalemia may result

with #5TSS1$ S##&9$94TS, %9 14H1

7/25/2019 ER2015CP

61/87

upset, drowsiness, headache, hyponatremia;

tachycardia, hypotension, oliguria, hyperkalemia;

confusion, weakness, paresthesia, hirsutism,

mental disturbances, menstrual irregularities, loss

of libido and impotence.

4ursing

%onsideration:

ssessment

H"$#or*:llergy to spironolactone; hyperkalemia;

renal disease; pregnancy, lactation

P,*$"+a':Skin color, lesions, edema; orientation,

refle"es, muscle strength; #, baseline 9%3,

7/25/2019 ER2015CP

62/87

+eigh patient under standard conditions before

therapy begins and daily throughout therapy. +eightis a useful inde" of need for dosage ad!ustment. Forpatients with ascites, physician may want

measurements of abdominal girth.

5bserve for and report immediately the onset of

mental changes, lethargy, or stupor in patients withliver disease.

dverse reactions are generally reversible with

discontinuation of drug. 3ynecomastia appears to berelated to dosage level and duration of therapy; itmay persist in some after drug is stopped.

3949'1% 4$9: &

7/25/2019 ER2015CP

63/87

chills, fever, increased salivation, nausea, vomiting,uticaria, tachycardia.

)E9'S9 9FF9%TS: Fluid overload may occur, marked by increased

7/25/2019 ER2015CP

64/87

T,e Se'%9Care De%"+"# N-r$"ng T,eor*

#orothea $. Orem

5rem developed the Self2%are )eficit Theory of 4ursing, which is composed of

three interrelated theories: (-* the theory of self2care, (* the self2care deficit

theory, and (>* the theory of nursing systems.

The theory of self2care includes self2care, which is the practice of activities that

an individual initiates and performs on his or her own behalf to maintain life,

health, and well2being; self2care agency, which is a human ability that is Nthe

ability for engaging in self2care,N conditioned by age, developmental state, life

e"perience, socio2cultural orientation, health, and available resources;

therapeutic self2care demand, which is the total self2care actions to be performed

over a specific duration to meet self2care requisites by using valid methods and

related sets of operations and actions.

niversal self2care requisites are associated with life processes, as well as the

maintenance of the integrity of human structure and functioning. 5rem identifies

these requisites, also called activities of daily living, or )&s, as:

- the maintenance of sufficient intake of air, food, and water

provision of care associated with the elimination process

> a balance between activities and rest, as well as between solitude and

social interaction

64

7/25/2019 ER2015CP

65/87

= the prevention of ha6ards to human life and well2being

the promotion of human functioning

The second part of the theory, self2care deficit, specifies when nursing is needed.

ccording to 5rem, nursing is required when an adult is incapable or limited in

the provision of continuous, effective self2care. The theory identifies five methods

of helping: acting for and doing for others; guiding others; supporting another;

providing an environment promoting personal development in relation to meet

future demands; and teaching another.

)evelopmental self2care requisites are associated with developmental

processes. They are generally derived from a condition or associated with an

event.

Health deviation self2care is required in conditions of illness, in!ury, or disease.

These include:

- Seeking and securing appropriate medical assistance

9ffectively carrying out medically prescribed measures

= $odifying self2concepts to accept onseself as being in a particular state of

health and in specific forms of health care

&earning to live with the effects of pathologic conditions.

65

7/25/2019 ER2015CP

66/87

The theory of nursing systems describes how the patientIs self2care needs will be

met by the nurse, the patient, or by both. 5rem identifies three classifications of

nursing system to meet the self2care requisites of the patient: wholly

compensatory system, partly compensatory system, and supportive2educative

system.

#eople are distinct individuals. 4ursing is a form of action. 1t is an interaction

between two or more people. #eople should be self2reliant, and responsible for

their care, as well as others in their family who need care. Successfully meeting

universal and development self2care requisites is an important component of

primary care prevention and ill health. personIs knowledge of potential health

problems is needed for promoting self2care behaviors. Self2care and dependent

care are behaviors learned within a socio2cultural conte"t.

Care4 C-re4 Core N-r$"ng T,eor*

%ydia $loise all

1t contains three independent but interconnected circles: the core, the care, and

the cure.

The core is the patient receiving nursing care. The core has goals

set by himself or herself rather than by any other person, and

behaves according to his or her feelings and values.

66

7/25/2019 ER2015CP

67/87

The cure is the attention given to patients by medical professionals.

Hall e"plains in the model that the cure circle is shared by the nurse

with other health professionals, such as physicians or physical

therapists. These are the interventions or actions geared toward

treating the patient for whatever illness or disease he or she is

suffering from.

The care circle addresses the role of nurses, and is focused on

performing the task of nurturing patients. This means the NmotherlyN

care provided by nurses, which may include comfort measures,

patient instruction, and helping the patient meet his or her needs

when help is needed.

1n all the circles of the model, the nurse is present. The focus of the nurseIs role

is on the care circle. This is where she acts as a professional in order to help the

patient meet his or her needs and attain a sense of balance.

N-r$"ng Pro+e$$ T,eor*

Ida &ean Orlando

The nurse uses the standard nursing process in 5rlandoIs 4ursing #rocess

)iscipline Theory, which follows' assessment, diagnosis, planning,

implementation, and evaluation.The theory focuses on the interaction between

67

7/25/2019 ER2015CP

68/87

the nurse and patient, perception validation, and the use of the nursing process

to produce positive outcomes or patient improvement. 5rlandoIs key focus was

the definition of the function of nursing. The model provides a framework for

nursing, but the use of her theory does not e"clude nurses from using other

nursing theories while caring for patients.

The ma!or dimensions of the model e"plain that the role of the nurse is to find out

and meet the patientIs immediate needs for help. The patientIs presenting

behavior might be a cry for help. However, the help the patient needs may not be

what it appears to be.

7/25/2019 ER2015CP

69/87

Culy -=, /-G2>pm shift-/://$

Sub!ctive:A$aglisodgihapon ko ughinga mamB asverbali6ed.

5b!ective:/ 5bserved

dyspnea/ Skin is pale/ 5bserved

tachycardia/ 5bserved

abnormalbreathing

/ v7s:

temp2 >M.#'2 ->''2 ?. $obehaviorstatus

restlessnconfusiolate stalethargy.%hangesand menbe earimpaired($isasi, 1n late stbecomessomnolecomatos///*.

=. $onitosaturatiousing p4ote blo

69

7/25/2019 ER2015CP

70/87

as n o"yge?/0 (n-//0* pressure

M/ (norindicateso"ygena

. 5bserin skin; ecolor of tmucous %entral tongue mucosa

serious ha medic#eriphere"tremitinot (%arpent

. 1f clidyspneicclient respirato

touch ondemonstrespiratiomaking ethe communcalm, fashion.

n"iety cdyspneaclient todyspneic(3ift, $-??;

U #': ?U M. %

S&99#2'9ST

#TT9'4

Sleep#attern)isturbancer7t )ifficultyof

7/25/2019 ER2015CP

74/87

$onconmen': '

an"somcommanhyphyp

G 9vaeffemedcan': 1

hoscarepatifollomedschrequin thhouchasch

chadaymayprob

M ussou':#cracwhethe airwwhicor ee"is

? #laca hipos': t

74

7/25/2019 ER2015CP

75/87

e"p-/ 1nst

largbefo': F

neethe -- )em

pursand':breaincrintedecresp

incrvoluimpsatu(

5b!ective:

ES as

follows:o T: >M.o%

o

#': ->bpmo '': ?

cpmo . L>G.o%.

b Have a coolskin whentouched.

- 9stablish r': #romotecooperatio

$onitor vit': 4otesand chacondition.

> $onitor tq-o.': 1n regularly changes

75

7/25/2019 ER2015CP

76/87

to touch $9T

both lowere"tremities

'1T15

4&2$9T

)iscourage eating too much or too less than the required intake.

= )iscourage the intake of !unk foods and softdrinks.

1nstruct to include fresh fruits and vegetables on his diet.

'9%5$$94)T154S

%ritical care nursing is a comple" and challenging nurse specialty to which many

registered nurses ('4s* aspire. lso known as 1% nurses, critical care nurses

use their advanced skills to care for patients who are critically ill and at high risk

for life2threatening health problems. 1n this case, it is important for the nurse to be

knowledgeable and to be a critical thinker, for it plays a vital role in the recovery

of the their patient. 4urses in this role will assess needs, plan, implement and

evaluate evidence2based nursing care in a fast paced and will work

collaboratively with other members of the health and social care team.

85

7/25/2019 ER2015CP

86/87

s future nurses of the teneo de )avao niversity, the proponents emphasi6e

the continuity of care for the promotion of health of their clients. These

recommendations are made to deliver the best nursing care to their client to

address their needs and so that they could live a better and healthy life.

#atient and Friends:

The patient should be participative to every program promoted by the health

sectors. She should not let any common diseases or any sickness for granted.

For she will never know what it may lead to, it would not be severe on the first

few days but it will eventually progress and complicate an individual8s health.

Family and friends support7influence plays a very significant role in the recovery

and coping of the patient. They should always be there for the patient in all

aspects, mainly in emotional, social, and spiritual and should not forget that they

are included in the care of the patient .They are the ones who should encourage

the patient to be strong and to chose the best care as possible.

4urse 9ducation:

The student nurses should be able to furnish health teachings to their patients for

it also plays a significant role in the continuity of care, promotion, prevention and

even inputs to their patients. They should be responsible in their chosen

endeavor by being client2centered instead of their personal benefits. They should

put every patient in the area as their foremost priority.

86

7/25/2019 ER2015CP

87/87

4ursing #ractice:

4ursing professionals and student nurses should collaborate in the care of their

patients. They should be able to provide the best care to their clients so that the

clients would be able to recover from their health condition and also to avoid

further complications from occurring. They should understand any patient8s

condition, the nature of the illness and should know the health seeking behavior

of the client. The principle of putting their clients first before anything else is

something that they must practice every time they render care.

lso, valuing the rights and confidentiality of the patient, friends, and family

should be practiced in any situations, regardless of the background, status of the

said people.

4ursing 'esearch:

Student nurses should always be updated and involved on new trends,

management and researches about the care of patients having 'heumatic Heart

)isease. lso, The sources7references that the nursing professionals7nursing

students used should also be considered and validated. 1t should be evidenced

based and with scientific rationales7e"planation.

Documents

ER2015CP