OBJECTIVES

This study is made so that readers of the case study and research will gain
enough knowledge and understand HCVD, CASHD, NIF (its cause, manifestations,
treatment and preventions) which will lead to reaching out to the awareness of every
individual who may have this kind of disease and to the members of the health care
team and to teach them the proper ways on how to effectively care to patients
suffering from this problem.

Specific Objectives:

 To determine the patient’s Nursing Health History of the Patient

 To identify the Gordon’s Typology of the functional health patterns of
the patient
 To know the review of systems of the patient
 To assess the physical condition of the patient in a cephalocaudal
manner noting her general physique and patterns of functioning
 To know the anatomy and physiology of the system that is affected by
the condition of the patient
 To identify the disease process of the patient
 To know the analysis, and interpretation of the laboratory findings of
the patient
 To identify the medical, surgical, and nursing management done to the
patient
 To determine the action, side/ adverse effects, and contraindications of
the drug administered to the patient
 To provide a discharge plan for the patient
 To formulate an effective Nursing Care Plan for the patient.
 NURSING HEALTH HISTORY
The nursing health history has a percentage reliability of information based on the
following: 90 % of the information was taken from the client which has a GCS of 15,
and is conscious, coherent and responsive. 5% of the info is also taken from the
patient’s daughter which is her significant other, and the other 5 % of the information
rendered here is taken from the patient’s chart.

A. Biographical Data
Patient’s Name: Patient CA
Age: 68y/o
Sex: Female
Address: Tondo, Manila
Date of Birth: October 11, 1944
Nationality: Filipino
Significant Others: Daughter
Occupation: Sari - Sari store owner
Religion: Roman Catholic
Parent’s Name: Deceased

B. Chief Complain
Difficulty Of Breathing

C. History of Present Illness

2 hours prior to admission, the patient experienced difficulty of breathing.

D. Past Medical History.

1. Past Illness
>According to the patient, she didn’t have any past illnesses.
 Allergies
>The patient stated that she hasn’t experienced any allergic reactions
regarding with food, medicines and environmental factors.

2. Previous Surgery
The patient has not undergone any previous surgery.

3. Accidents
The patient stated that she did not encounter any accident prior to her
confinement.

E. Family History

Figure 1. Genogram of Patient CA

F. Lifestyle
Personal Habits:
The patient stated that she’s only doing mild household chores. She
cited examples of her daily activities like cleaning the house, washing her
clothes and cooking her food. Other than that, her daughter takes charge of
everything in their house. She also does ballroom dancing at home.

Diet
The patient is placed on low salt low fat diet. The patient is also on
fluid restriction of strictly 1 Liter/day.

Sleep/Rest Pattern
The patient stated that she has a disturbance in her sleeping pattern.
Her hours of sleep vary. She also stated that she has unpredictable rhythm in
terms of sleep. She cited examples like sometimes, she sleeps at 10:00 PM and
wakes at 4:00 AM. Sometimes, she added, she sleeps at 12:00 AM and wakes up
at 5:00 AM. Average hours of sleep of the patient was reduced from 8 hours to
5 to 6 hours. The patient also stated that she wakes up at the middle of the
night because she’s irritable and can’t get a good night sleep.

Activities of Daily Living:

At 5:00 in the morning as soon as the patient wakes up, she takes a
bath; she prepares breakfast and then takes a rest. At 2:00 in the afternoon,
she frequently washes her clothes. Watching T.V. serves as her resting habit.
At her leisure time, she does ballroom dancing indoors. She also takes charge
of her sari-sari store.

Recreation/ Hobbies:
The patient’s hobbies are managing their Sari – Sari Store and Ballroom
Dancing.
G. Social Data
Family Relationship/friendship:
The patient’s family comprises of her 3 daughters. 1 of them is OFW and
she is residing with her another daughter.

Educational History:
The patient has no formal education. She can only understand numbers.
She said, she can’t read nor write.

Economic Status of the Family:

The patient stated that her family is above the poverty line (Daily
earning of 329.00Php). The family’s daily income is 426.00Php (monthly income
is 11,076Php) and is only enough for them to meet immediate needs. 40% of
their income is allotted for their food which corresponds to a monetary value
of Php4,430.40, another 25% for their bills which corresponds to a monetary
value of Php2,769.00 , and 15% for their medications and health needs which
corresponds to a monetary value of Php1,661.40 . The remaining 20% goes to
other necessities which corresponds to a monetary value of Php2,215.20 .

Home and Neighbor Status:

The patient stated that they don’t hire helpers for their household.
They seek help from their neighbors in the times of emergency situations or
state of calamity.

Coping Pattern:
The patient stated that whenever things went wrong, she just prays and
everything will soon be okay. She has positive outlook towards life and she also
stated that she is optimistic.
Communication Pattern:
The patient considers communication as her way of being okay. The
patient stated that she can communicate properly with the members of the
family.
 GORDON’S TY POLOGY
PATTERN BEFORE DURING ANALYSIS
HOSPITALIZATION HOSPITALIZATION
HEALTH The patient stated The patient stated Patient cannot
PERCEPTION that health is a need that she cannot function
PATTERN for every individual; consider herself as normally like
her health is good healthy like before but her
because she doesn’t before and was health values
have any illness idle sometimes. increased.
before she was But still, the
admitted. She has no patient has
difficulty in accessing increased valuing
health care in terms of her
facilities.. health. She’s
taking all her
prescribed
medications.

NUTRITIONAL- Patient stated that Patient stated that An individual’s

METABOLIC she has a good she is able to eat health status
PATTERN appetite and eats small frequent meals greatly affects
thrice a day. She a day due to eating habits and
usually eats decrease in appetite nutritional status
vegetables but ost because of her (Fundamentals of
the time she prefers illness. Her fluid Nursing by Kozier
to eat meat, intake is restricted p. 1178) Patient’s
especially beef which to 1 L per day. She is nutritional health
is considered red also placed on a low status has been
meat. Also, the salt low fat diet. changed due to
patient said that she her confinement
often eats sardines and her diet.
because it’s her
favorite food and
drinks 8 glasses of
water per day. She
also takes her snack
somewhere between
3pm.
ELIMINATION The patient stated During her There was a
PATTERN that she defecates hospital stay, the change in the
every day and patient said that frequency of
urinates she defecates the stool and
approximately 8 every other day the urine.
times a day and urinates
approximately 5
times a day

ACTIVITY/ Patient prefers The patient stated During patient’s

EXERCISE ballroom dancing in that her activity and confinement,
PATTERN their house and doing exercise pattern was there is quite
household chores decreased due to her changes in her
such as cooking, hospitalization. The activities and has
cleaning the house physician on duty quite restrictions
and managing her sari ordered the patient for her actions.
sari store as her to be in CBR.
exercise and activity
pattern
SLEEP/REST The patient has The patient stated “Illness that
PATTERN normal cycles of causes physical
that she has a
sleep. She sleeps 8 distress can
hours a day and takes disturbance in her result in sleep
a nap at 2 to 3 pm. problems. People
sleeping pattern. Her
who are ill
hours of sleep vary. require more
sleep than normal
She also stated that
and the normal
she has rhythm and
wakefulness is
unpredictable
often disturbed.”
rhythm in terms of (Fundamentals of
Nursing, 7th Ed by
sleep. She cited
Barbara Kozier,
examples like et al, p. 1117).
sometimes, she
sleeps at 10:00 PM
and wakes at 4:00
AM. Sometimes, she
added, she sleeps at
12:00 AM and wakes
 up at 5:00 AM. Her
average hours of
sleep was reduced to
5 to 6 hours. The
patient also stated
she wakes in the
middle of the night
because she’s
irritable and can’t
get a good night
sleep
.
COGNITIVE- Patient stated that Patient stated that There is a slight
PERCEPTUAL she does not have any though she cannot change in the
PATTERN formal education. read nor write, she level of her
According to her, she still can understand thinking with
can only read her condition regards to her
numbers and she because the disease.
cannot read written physician explained
letters or words everything to her in
a manner she could
understand. She
cited examples like
when the physician
explained everything
in Filipino, and
translating the
disease in Filipino
terms.
 SELF The client stated that She stated that her “Events or
PERCEPTION/ she views herself as self-concept is situations may
SELF-CONCEPT functional. She cited altered. Sometimes, change the level
PATTERN examples like doing she said, she thinks of the self
household chores, that she is a burden concept over
and earning a living to her daughter time. Illness and
through her sari sari because she is trauma can also
store as a proof that hospitalized and can affect the self-
she is not a burden in only do minimal concept.”
their family. She tasks. (Fundamentals of
stated that she do Nursing 7th Ed by
what she wants, she Barbara Kozier p.
is confident and 959 & 962)
optimistic.

ROLE- Patient’s husband as The patient stated The patient is

RELATIONSHIP she stated had that she had a really more dependent
PATTERN already passed away close relationship to her daughter
but she said that both with her daughter during
of them had a good right now because hospitalization.
relationship with she is the only one
each other. She also taking care of her in
stated that she is patient’s hospital
living with one of her stay.
daughters and they
do not have quarrels
at home.

SEXUALITY/ The patient claimed The patient does not Sexuality and
REPRODUCTIVE that her reproductive have an active reproductive
PATTERN pattern when the sexual life. patterns are
time that her affected by the
husband is still alive changes that
is good, though she takes place in a
refuses to talk about person’s body or
things much deeper. in a person’s life
She also stated that
she’s already
menopause.
COPING/STRESS In times of stress or No change According to
TOLERANCE problems, she usually Folkman and
PATTERN tackles it with her Lazaruz, coping is
daughter According to “the cognitive
her she does not take and
seriously light behavioral effort
problems because she to manage
is optimistic and has specific external
a positive outlook in and/or internal
life. When everything demands that are
went wrong, she just appraised as
pray and she believes taxing or
that everything will exceeding the
soon be okay resources of the
person”(Fundame
ntals Of Nursing
by Kozier P.
1020)
VALUE/BELIEF The patient stated Patient stated that After what
PATTERN that she is a Roman her belief to God happened,
Catholic. She said remained the same patient is still
that she believes that though the seeking for
God will help her to frequency of medical
solve her problems. attending mass assistance.
She usually goes to decreased Religious effort is
church every Sunday still a part of
and she does not patient s life.
believe in Hilot and
Albularyos.
 PHY SICAL ASSESSMENT

VITAL SIGNS
BT: 36.6 oC BP: 140/100mmHg PR: 87 bpm RR: 40 cpm

GENERAL STATUS
Patient CA is 68 years old, female. Upon seeing, patient CA experiences DOB
and pain in the chest area. She assumes a (+) Levine sign upon observation. Has a
slight facial grimace. After an hour, patient CA had a relief. Upon interview of the
patient, she is conscious, coherent and responsive. She responds appropriately to the
questions being asked to her and cooperates throughout the physical assessment

SKIN
Patient CA’s skin as inspected has a brown color.Lesions are noted. Irritations
in skin and redness were not present. Patient’s skin also has good skin turgor when
pinched in the forehead. No edema was present on the four extremities upon
inspection and palpation

HAIR
Upon inspection, the patient has thin and oily hair, black in color with a touch
of white. It is evenly distributed with presence of dandruff. Nits and lice was not
present upon inspection

NAILS
The patient has normal nail curvature. Tissues surrounding nails are intact.
Upon performance of blanch test, nails displayed a capillary refill of 4 seconds.

SKULL AND HEAD

The patient has rounded and symmetrical skull contour when palpated. Facial
features are symmetrical and there are no lesions present in the said area. There
were no nodules/masses and tenderness felt when palpated.

EYES
The patient’s eyebrows are symmetrically aligned, with evenly distributed hair.
The eyelids are intact having no discharge or discoloration. Upon inspection, both
bulbar and palpebral conjunctivas are normal. Pupils are equally round and reactive
to light. Swelling of eyes is not present upon inspection. Whitish discoloration of the
side of pupils was present. Blurring of vision was also claimed by patient CA.
EARS
The patient’s ears are equal in size, symmetry and color with the facial skin.
The pinna is in the level of outer canthus of the eye and recoiled after it was folded.
Little amount of cerumen were found inside the ear of patient. CA. There are no
other unusual discharge and lesions noted. No tenderness is felt by the patient upon
palpation in the mastoid process

NOSE
The patient’s nose is symmetrical in shape, size and color. Nasal flaring was
absent when patient CA breaths. There was no discharge and lesions noted. Both
nares are patent. Nasal septum is intact and in between the nasal chambers. Upon
palpation of the nose, there is no tenderness of the frontal and maxillary sinuses.
Nasal patency was not that good

LIPS, MUCOSA, TEETH AND GUMS

The patient’s lips are symmetrical and quite dry. Her dentures are all false
teeth. Upon inspection in the oral cavity, no lesions were seen. Thrushes were not
observed in both sides of the cheeks and in gums. Upon palpation of the tongue using
a tongue depressor, gag reflex was present

NECK
The patient’s neck muscles are symmetrical in size and color. It is positioned at
the middle. Lymph nodes are not palpable. Head can move normally and smoothly
without discomfort. Upon palpation of the neck, tenderness was not present. The
thyroid gland also is in the middle and it moves down as the patient swallows.

BREAST
The patient’s breast is saggy in shape, slightly unequal in size but generally
symmetric, uniform in color. Areola is round and bilaterally the same, color is brown
with no masses or lesion. Nipples are round, everted downward. Upon palpation of
the axillary, nodules was not present

CHEST
The patient’s has symmetrical chest. Spine is vertically aligned, straight, with
the right and left shoulders are at the same height. Neither tenderness nor masses
were present on the chest wall. When palpated, the patient’s chest demonstrated
loud bilateral symmetry of vocal fremitus. Wheezing and stridor sounds are not heard,
though crackles are heard upon auscultation. There is full symmetric chest expansion.
The respiratory rate during the interview was 22 beats per minute.

CARDIOVASCULAR:
Upon inspection, the patient’s aortic and pulmonic areas have no pulsations.
Jugular vein distention is not present. Limbs are not tender and in symmetric in size.
Edema was present. Heart Rate during the interview was 87bpm
ABDOMEN
Upon inspection, the patient’s abdomen is loose and uniform in color. The
patient’s abdominal contour is symmetric. Symmetrical abdominal movements caused
by respiration were noted. When palpated, tenderness was not present. Liver when
palpated was not enlarged

REPRODUCTIVE
Patient CA reported dysuria or difficulty in urinating. No lesions were noted in
the genital area and infestations were not also present when patient is asked. Other
unusual discharges are not present

MUSCULOSKELETAL
Extremities of patient CA were symmetrical with weak muscle tone. Muscle
weakness was observed by the patient as she cannot shrug her shoulders as force was
exerted on it. Upon inspection, movements of muscle and bones are slow while she
was moving her extremities. Weakness of the neck muscle was also observed as she
cannot apply an opposing force against the hand on her face

NEUROLOGIC
The patient has a slouch posture and unsteady gait, walks with assistance and does
maintain a little balance while standing. Patient CA was able to discriminate sharp
and dull sensations and is able to discriminate hot and cold sensations.
For CN I (Olfactory Nerve), she has confusion in identifying the scent of soy
sauce while eyes are closed, she got to identify the scent of other objects correctly.
For CN II (Optic Nerve), she was able to read written numbers in a notebook easily but
she cannot read letters and words. She said she really don’t know how to read them.
For CN III (Oculomotor Nerve), her pupils constrict when lighted by a penlight and
dilates when light is removed. For CN IV (Trochlear Nerve), eyes are coordinated and
moved in unison. For CN V (Trigeminal Nerve), she blinks when the cornea is touched
and is able to clenched teeth. For CN VI (Abducens Nerve), eyeball moves laterally.
For cranial nerve VII (Facial Nerve), she was able to smile, raise the eyebrows, frown,
puff out cheeks and close his eyes tightly. For CN VIII (Auditory Nerve), she has
positive in Romberg test and positive in Weber’s test. For CN IX and CN X
(Glossopharyngeal and Vagus Nerves), she was able to move her tongue from side to
side and up and down. For CN XI (Accessory Nerve), she has difficulty both in
shrugging her shoulders against the resistance of my hands and turning her head to
the opposite side of the hand resisting her head. For CN XII (Hypoglossal Nerve), she
was able to protrude tongue at midline, and then move it side to side.
 MEDICAL MANAGEMENT

1. On total parenteral nutrition.

Patient is on TPN because additional intake of food and water will cause blood
volume of patient increase taking the heart congestion much severe.

2. On a low salt low fat diet

Where sodium goes, water follows which means that a increase intake of salty
food stimulates our eagerness to drink more water wherein additional intake of water
will increase blood volume therefore, increasing the rate of contractility making the
blood pressure high. Increase fat intake, plays an important role in putting the heart
at risk of cardiovascular diseases.

3. Infusion of D5W, 500mL x KVO, 10 gtts/min

D5W indicated for parenteral maintenance of routine daily fluid and electrolyte
requirements with minimal carbohydrate calories from dextrose.

4. Administration of O2 therapy via nasal cannula 2L/min.

O2 therapy is given to clients who have difficulty ventilating all areas of their lungs
or clients with heart failure. Nasal cannula is used because it is relatively
comfortable, does not interfere with the client’s ability to eat or talk and is well
tolerated by the client.

5. With Heplock on the right arm

A hep lock is a small tube that a medical professional inserts into the arm or other
site on a patient's body. The tube has a catheter on one end. The medical care
provider administers medication or fluids in an efficient manner through the catheter
lock, which works by keeping a vein accessible for administration of medication or
fluids.

6. Limit OFI to 1L per day

Additional intake of water will increase blood volume therefore, increasing the
rate of contractility making the blood pressure high. Increase fat intake, plays an
important role in putting the heart at risk of cardiovascular diseases.

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