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3h C Case Presentation.22
3h C Case Presentation.22
College of Nursing
Governor Pack Road, Baguio City, Philippines 2600
(+6374) 442-3316, 442-2564, 442-8219, 442-8256
E-mail: webmaster@bcf.edu.ph
Website: www.bcf.edu.ph
Submitted By:
Benito, Danny
Gesmundo, Lorraine
Limmang, Clarissa Marie
Maigi, Nicalin
Pagadian, Ia Rylyn
Paguirigan, Kryzza Leizel
Pangda, Jaceziel Kaye
Saavedra, Joy
Tucyapao, Irish P.
Villanueva, Jayson
(Date: DAY-MONTH-YEAR )
ABSTRACT
(250 – 300 words only not including title and author information)
TITLE: Approximately 10 -12 words identifying key components of your case report. When applicable,
include components such as primary reason for seeking care, clinical assessment, and/or main treatment. The
title should make it clear the presentation is a case report.
AUTHOR INFORMATION: Flashes Left under the Title. Names should be arranged alphabetically based on
FAMILY name, but FIRST name should be written first followed by FAMILY name (ex. April Anne B.
Bocato, Michael P. Nonog and Eugene Flor L. Ulpindo)
BACKGROUND: Briefly describe the background for the case. Introduce the issue that the case addresses.
Explain why the case is noteworthy and what it adds to current knowledge. This section helps answer the
question “Why should we care?” You may want to end the introduction with a sentence that states explicitly
why the case is being reported.
CASE DESCRIPTION: This section should be longest and most detailed part of the abstract. Relevant
information may include demographics, client’s main symptoms, or other reasons for seeking care, clinical
findings, clinical assessment, treatment plan, and health outcomes. Given the space limitations, include only
the information to the reason for presenting the case.
CONCLUSION: This section should state the main “take-home” lesson(s) from the case. If reporting
outcomes, remember that case reports do not typically demonstrate cause and effect. Be careful not to overstate
conclusion but instead describe the strengths and limitations of the case. You may want to add a sentence or
two about the implications of the case for practice for future research.
1
TABLE OF CONTENTS
I. Introduction..........................................................................................................................................3
II. Statement of Objectives.......................................................................................................................3
A. General Objectives...............................................................................................................................3
B. Specific Objectives...............................................................................................................................3
III. Patient’s Profile....................................................................................................................................3
IV. Chief Complaint...................................................................................................................................3
V. Present History of Illness.....................................................................................................................3
VI. Past History of Illness..........................................................................................................................4
VII. Family Health History.........................................................................................................................4
VIII. Developmental History........................................................................................................................4
IX. Social and Environmental History......................................................................................................4
X. Lifestyle and Health Practices.............................................................................................................5
XI. Health Assessment................................................................................................................................5
A. General Survey.....................................................................................................................................5
B. Head to Toe Assessment......................................................................................................................6
C. 13 Areas of Assessment........................................................................................................................7
XII. Diagnostics..............................................................................................................................................9
XIII. Comprehensive Pathophysiology........................................................................................................12
XIV. Treatment/Management......................................................................................................................13
A. Drugs.................................................................................................................................................13
B. IV Fluids...........................................................................................................................................13
C. Surgery..............................................................................................................................................13
XV. Nursing Care Plans..............................................................................................................................15
A. Prioritization of Problems..................................................................................................................15
a.1. List of Problems...........................................................................................................................15
a.2. Basis for Prioritization..................................................................................................................15
B. Nursing Care Plans............................................................................................................................16
NCP 1.........................................................................................................................................................16
NCP 2.........................................................................................................................................................16
NCP 3.........................................................................................................................................................16
NCP 4.........................................................................................................................................................16
NCP 5.........................................................................................................................................................16
C. Discharged Plan....................................................................................................................................17
XVI. Learning Insights.................................................................................................................................17
XVII. List of References.................................................................................................................................18
XVIII. Appendices...........................................................................................................................................19
Appendix A: Approval/ Request Letter......................................................................................................20
Appendix B: Interview Guides....................................................................................................................21
Appendix C: Others.....................................................................................................................................22
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Definition and discussion of SPECIFIED CASE and description and enumeration of common signs
and symptoms. (preferably from textbook)
INCLUDE also relevant STATISTICS (international, national and local statistics) about the CASE.
(could be internet source)
A complete obstruction to blood flow in a cornonary artery may result in a Myocardial Infarction
(MI), commonly called a heart attack. Infraction means the death of an area of tissue because of interrupted
blood supply. Because the heart tissue distal to the obstruction dies and is replaced by noncontractile scar
tissue, the heart muscle loses of its strength location of the infracted (dead) area, an infraction may disrupt the
conduction system of the heart and cause sudden death by triggering ventricular fibrillation. Treatment for
myocardial infarction may involve injection of thrombolytic (clot-dissolving) agent such as streptokinase or t-
PA, plus heparin (an anticoagulant), or performing coronary angioplasty or coronary artery bypass grafting.
Fortunately, heart muscle can remain alive in resting person if it receives as little as 10-15% of its normal
blood supply.(Tortora & Derrickson)
This case analysis aims to increase the understanding and knowledge of student
nurses on how to care for patients with Acute Mycardial Infarction; Urgency Hypertensive
effectively and efficiently.
B. Specific Objectives
Name : Patient X
Ethnic Background : Ibaloi
Civil Status : Married
Religion : Roman Catholic
Occupation : laborer
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IV. Chief Complaint
This presents the main complaint/s of the patient; the primary reason consultation was sought and
hence, admitted.
Patient X complains of chest pains and difficulty in breathing.
Narrative form. This is a brief account of when the patient’s condition started, how it developed, up
to the time of admission. Initial signs and symptoms are described in line with duration,
domain/localization, progression, character and how it has affected the physiological function of the patient.
Any interventions made by the patient to address the illness are to be described (e.g. home remedies,
medications, consultations) and whether these were effective or not. Elaboration of the chief complaint.
The patient’s condition started 3 days PTA, when the patient, while simply doing his homework, felt
a sudden sharp chest pain. Pain rate was with the severity of 8/10. It was not radiating to other parts of the
body but was accompanied by difficulty of breathing, weakness, shortness of breath, and sudden hacking
cough.
A few minutes after the said incident, the patient verbalized that all of the symptoms mentioned
slightly improved and was tolerable and only rest was promoted. No medications were taken nor were
consultations done during the incident. 2 days PTA, he was not feeling anything and verbalized that he was
alright until
One day PTA, the patient has the same manifestation but now the difficulty of breathing was so severe
that the patient decided to seek consult and subsequently admitted in this institution.
The patient had no history of accidents and or trauma, only minor illnesses, such as cough, colds and
fever and was remedied with over the counter medications such as Bioflu and water therapy with rest. The
patient however, was admitted last November 11, 2022 @ 4:05 PM at Benguet General Hospital and was
diagnosed to acute mycardial infarction: Hypertensive Urgency. He received medical interventions such as
medications for hypertension and for pain. The patient has unrecalled immunization status and with no history
of prolonged case of use of medications such as aspirin or NSAIDs. He also verbalized that he did not have
known allergies for foods or medications.
4
The patient is the last son out of the other 5 siblings, which are composed of 4 males and a female. He
is a 19 year old teenager with the task of developing his Identity according to Erik Erikson’s Developmental
theory. He has verbalized no problems with self-image and concept and reveals the desire to achieve his goals
in his studies especially in maintaining his place in the dean’s list and hopefully graduating with honors
or having a place in the Local Nursing Licensure examination. He also noted no difficulty in interacting with
people despite his silent nature. He tends to observe most of the time but also recognized a great number of
friends with whom he shared his childhood with. He also loves music. His passion is seen in his ability
to play the guitar with ease and is now learning how to play the piano.
As a student nurse, he is aware of the potential health threats associated with lifestyle related vices
like cancer for smoking and liver cirrhosis for alcoholic beverage drinking. He ensures that he receives
adequate nutrients by allowing himself to eat three complete meals in a day with snacks included
specially during his duty times. Food is prepared at home together with his cousins or is bought in fast-food
chains. He prefers pasta dishes and pizza. Fluid and electrolyte intake is a total of 2 – 3 liters a day coming
from fruit juices, carbonated beverages, water and milk. For maintenance he takes Vitamin C for supplement.
5
XI. Health Assessment
A. General Survey
This portion presents assessments performed as seen in the example below. The time that you FIRST handled
your patient. Include ht., wt., BMI, body built, posture and gait, hygiene and grooming, body and breath odor,
signs of distress, obvious signs, attitude, affect and mood, speech and thought process.
The patient was received awake, lying on bed with a moderate high back rest elevation. Patient with
ongoing IVF’s of D5LRS I L x 30 gtts per minute and a Tramadol drip (tramal) 300 mg in D5W 250 cc x 24
hours infusing well on the left arm and with oxygen inhalation at 2-3 LPM/ via the nasal cannula. He is
connected to three way bottle system chest drainage with the first bottle having 300cc bloody discharge.
Suction control is applied and there is bubbling noted in the third bottle.
Patient appears weak, needs assistance when assuming activities of daily living like toileting and
feeding or in changing positions. He wears a neat gown, hygiene is fair. Patient is conversant speech is well
formulated, oriented to the self and others around him, able to determine the time and date and is
aware that he stays in a private room for 3 days now.
Patient is an ectomorph. He verbalized that he is 5’6” tall and weighs 51 kilograms.
This portion presents assessments performed as seen in the example below. You can do FOCUS assessment
especially on the affected area (eg. CHF focus on Cardiac Assessment) and focus on abnormal findings.
1. Head Normocephalic, hair well distributed, oiliness and flaking noted no
areas of pain or tenderness during palpation.
2. Eyes Able to distinguish colors, with astigmatism, verbalized difficulty to
identify objects 6 feet away, wears corrective lenses, sclera is
anicteric, pupils are equally round, reactive to light and
accommodation, EOM is intact, able to follow penlight with gaze, no
detectable oscillations, mucous membranes are moist and light pink.
3. Ears Able to understand and hear spoken language correctly, with minimal
cerumen build – up in the ear canal, pearly sliver and intact tympanic
membrane.
4. Nose and sinuses Nose is patent, septum is located midline, no flaring noted, able to
distinguish the scent of alcohol and perfume, and no episodes of
epistaxis during the shift, and sinuses are not tender on palpation.
5. Mouth Complete set of adult teeth, pearly white in color, and no mal aligned
tooth, had braces for 1 year and a half year. No dental caries noted.
Oral mucosa is moist and pinkish, no lesions noted, tonsils are not
inflamed, Grade 1 bilaterally present, uvula is located midline.
6. Neck ROM intact, able to change direction of head slowly but with without
complaints of pain, carotid pulse are bilaterally symmetrical, full and
strong pulses, 2+, jugular vein is not distended, superficial cervical
lymph nodes are palpable but non tender. Thyroid is located midline,
no enlargement noted, trachea is located midline.
7. Chest Shape of the chest is elliptical, asymmetrical chest wall expansion
noted, with respiratory excursion best appreciated on the left side of
6
the thorax, decreased tactile fremitus in the right lung area, decreased
breath sounds in the right, no crackles, no wheeze, no stridor,
production of hollow drum like sounds in percussion of the right side
and resonant sound appreciated on the left. Patient with an Axillary
thoracotomy, dressing intact and dry, chest tube draining to a bloody
discharge 300 cc in amount. With limited movement on the right
shoulder. Patient verbalized, “mahina daw ung lungs ko, spontaneous
rupture of the bleb, kaya may pneumothorax ako” “Masakit tlaga ung
sugat, parang 8/10 din, pati ata sa loob masakit talaga, ditto lang
naman sya sa may incision, parang may tumutusok kaya binigyan nila
ako ng analgesic, ngayon, ayos ng konte pero may pain pa din at 6 na
cguro ung scale nya out of 10”. Patient is observed to guard area and
grimaces when a painful stimulus is felt. Diaphoresis noted, hands are
cool to touch. Maintains the supine position with head of bed elevated
to a moderate high back rest.
8. Cardiac Adynamic pericardium; normal rate, regular rhythm, PMI at 50 ICS
LMCL, no murmur noted, no visible pulsations in the precordium,
palpable apical pulse.
9. Breast/Chest Skin color is similar with the rest of the body, nipple is dark colored,
no discharges.
10. Abdomen Flat, with normoactive bowels sounds heard in all the quadrants, soft,
no direct tenderness or rebound tenderness upon palpation, tympanic,
no organomegaly.
11. Genitals Patient verbalized that he had been inserted with a catheter when he
was in the OR. No complaints of dysuria or urinary retention or
incontinence post operatively.
12. Musculoskeletal Muscle strength at the right side is 4/5 while the rest of extremities
are 5/5.
No visible tremors noted no complaints of pain.
13. Integumentary Skin…
C. 13 Areas of Assessment
This portion presents assessments performed as seen in the example below. Follow format on how to do your
13 areas of assessment. GORDON’S FUNCTIONAL HEALTH PATTERNS
1. Psychosocial and Psychological Status
3. Environmental Status
4. Sensor Status
a. Visual Status
b. Auditory
7
c. Olfactory Status
d. Gustatory Status
e. Tactile Status
5. Motor Status
6. Thermoregulatory Status
7. Respiratory Status
8. Circulatory Status
8
6 am 95 bpm
9. Nutritional Status
During episodes of airway obstruction, the patient’s capillary refill is 2-3 seconds.
However, when managed, he appears to be pinkish in color and with good skin turgor.
9
XII. Diagnostics
This shows all diagnostic procedures performed with the client. LANDSCAPE and Tabular form. Content of the table must follow the format below.
Diagnostic Date of
Description of the Procedure Significance/Purpose of the Procedure Findings & Implications
Procedure Procedure
Chest X-ray Chest radiography is the first It is used to determine the severity of the April 20, 2009 Follow-up study of the chest taken on the same day, SIP CIT
investigation performed to assess patient’s pneumothorax and to determine insertion reveals a relative partial reduction in the size of the
pneumothorax because it is simple, the progress of his medical and surgical previously noted right-sided pneumothorax. There is however
inexpensive, rapid, and noninvasive; management. no significant change in the extent and appearance of the
however, it is much less sensitive than massive atelectasis of the right lung field. A right sided CTT is
chest CT in detecting a small now seen.
pneumothorax, blebs, and bullae. April 22, 2009 Follow-up study of the chest since 6/20/2009 S/p Axillary
thoracotomy shows complete resolution of the pneumothorax on
the right with complete re-expansion of the right lung. A right
sided CTT is still seen in SITU. No other internal change of
note.
April 26, 2009 Follow-up study of the chest since 6/22/09 reveals the presence
of confluent hazy densities at the right paracardiac areas,
presenting a pneumonic process with consolidation. There is
now a homogenous opacity with meniscus level seen at the right
lower hemithorax obscuring the right hemi diaphragm and
costrophenic angle representing fluid.
April 26, 2009 Follow-up chest study since 6-26-2009 reveals minimal clearing
of the confluent hazy densities at the right paracardiac area.
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There is however, decrease in the volume of the previously
noted fluid in the right HEMITHORAX. A right sided CTT is
still seen in SITU.
For Blood Chemistry, Serum electrolytes, Urinalysis, Fecalysis and other lab test with quantitative results. SAMPLE not related with previous CASE.
Diagnostic procedure and Description of procedure Significance/ Purpose of the procedure Significant findings Nursing Implications
date done
Complete Blood Count A CBC may be ordered when a person has To determine general health status, Leucocyte (WBC) A low white blood cell count indicates that
Jan 3, 2015 any number of signs and symptoms that screen, diagnose, or monitor any one of a Normal Range: the patient has an infection.
may be related to disorders that affect variety of diseases and conditions that 5-10 x10^ 9/L
blood cells. When an individual has an affect blood cells, such as anemia, Result:
infection, inflammation, bruising, or infection, inflammation, bleeding 0.58- Low
bleeding, a doctor may order a CBC to disorder or cancer.
help diagnose the cause and/or determine
its severity.
Neutrophils Within the normal range.
Normal Range:
0.50-0.70
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Result:
0.31-Normal
Lymphocytes Indicates an acute bacterial infection.
Normal Range:
0.20-0.40
Result:
0.58- High
No result
Monocytes Within the normal range.
Normal Range:
0.00-0.07
Result:
0.03- Normal
Platelet count Indicates Thrombocytopenia.
Normal Range:
150,000-450,000
Result: 310,000 –low
Urinalysis A urinalysis…
Jan 3, 2015
Facalysis A fecalysis…
Jan 3, 2015
12
13
XIII. Comprehensive Pathophysiology
This is a diagrammatic presentation of the course of the disease with emphasis of information relevant to nursing
care. Predisposing factors (Modifiable), Precipitating factors (Non-modifiable), course of illness or condition, relevant
diagnostic findings, signs & symptoms, management and appropriate nursing diagnoses presented must be in line
with actual events that occurred with the patient.
PREDISPOSING FACTORS PRECIPITATING FACTORS
Exposure to 2nd hand Smoking & Pollution Height (tall person), Male, 19 years old
________________Bullae/Blebs Formation______________________
_______________Pneumothorax____________________
Activation of the receptors that monitor Tidal volume affected Changes in the thoracic pressure
lung volume
Distortion of movement of air
Sympathetic stimulation in and out of the lungs
Impairment of gas conduction Air trapping in the collapsed lung Ruptured bleb and lung collapse
in the lower respiratory airways activate inflammatory response
14
---------------------IMPAIRED GAS EXCHANGE-------------------
Pleural Effusion
Further restriction of lung expansion Collapse of alveoli Disequilibrium in pulmonary and pleural pressures
Stasis of pulmonary sections Decreased Hct and Hgb Tissue trauma and injury
---ACTIVITY INTOLERANCE---
15
XIV. Treatment/Management
This shows all treatments, including medical procedures, performed with the client. LANDSCAPE and tabular form. Content of the table must follow the format below. But for more COMPREHENSIVE
Nursing Implication, categorize your NURSING IMPLICATION as to Before, During and After giving the medication and each has Dx, Tx and EDx for DRUG STUDY.
A. Drugs
(Follow new Format for Drug Study)
DRUG STUDY 1: AMLODIPINE
DRUG NAME MECHANISM OF ACTION CONTRAINDICATIONS & ADVERSE EFFECTS NURSING RESPONSIBILITIES
INDICATIONS
Generic Name: Binds to dihydropyridine and Contraindications: CNS: Anxiety, dizziness, fatigue, BEFORE:
AMLODIPINE non-dihydropyridine cell Hypersensitivity to amlodipine headache, lethargy, light- Dx:
BESYLATE membrane receptor sites on or its components headedness, paresthesia, a. Verify doctor’s order.
myocardial and vascular somnolence, syncope, tremor b. Assess allergy to amlodipine or its components.
Brand Name: Norvasc smooth muscle cells and Indications: CV: Arrhythmias, chest pain,
inhibits influx of extracellular Indicated for the treatment of hypotension, palpitations, Tx:
Chemical Class: calcium ions across slow hypertension peripheral edema c. Prepare the medication at the right time and right dosage.
Dihydropyridine calcium channels. This EENT: Dry mouth, gingival
decreases intracellular calcium Drug to drug Interaction: hyperplasia, pharyngitis ENDO: EDx:
Therapeutic Class: level, inhibiting smooth-muscle beta blockers: Possibly Hot flashes d. Educated the patient and SO about the purpose and importance of the
Antianginal, cell contractions and relaxing excessive hypotension GI: Abdominal cramps, drug.
Antihypertensive coronary and vascular smooth cyclosporine: Possibly abdominal pain, anorexia, e. Educated SO on drug therapy to promote compliance.
muscles, decreasing peripheral constipation, diarrhea, dysphagia,
increased blood cyclosporine
Dosage: 5 mg vascular resistance, and elevated hepatic enzymes, DURING:
reducing systolic and diastolic levelsCYP3A4 inhibitors such esophagitis, flatulence, Dx:
Route: Oral blood pressure. Decreased as diltiazem, ketoconazole, indigestion, jaundice, nausea, f. Verify client’s identity.
peripheral vascular resistance itraconazole, and ritonavir: pancreatitis, vomiting g. Assess patient frequently for chest pain when starting or increasing the
also decreases myocardial Possible increased blood GU: Decreased libido, impotence, dose of amlodipine, because worsening of angina or an acute MI can
workload, oxygen demand, and amlodipine level urinary frequency occur.
possibly angina. Also, by MS: Myalgia
inhibiting coronary artery fentanyl: Increased risk of RESP: Dyspnea Tx:
muscle cell contractions and severe hypotension and SKIN: Dermatitis, flushing, rash h. Administer medication following the 10 rights of medication.
restoring blood flow, drug may Other: Weight loss i. Suggest taking amlodipine with food to reduce GI upset.
increased fluid volume
relieve Prinz metal’s angina. j. Assist patient when taking the medication.
16
requirements during surgery
EDx:
SOURCE: simvastatin: Increased k. Instruct SO to report persistent adverse effects such as dizziness,
Jones & Bartlett Learning exposure to simvastatin difficulty breathing, arm or leg swelling, and rash.
(2015). Nurse’s Drug
Handbook. Fourteenth AFTER:
Edition. Dx:
l. Monitor patient’s BP for postural changes.
m. Monitor drug effectiveness.
Tx:
n. Promote safety and comfort.
EDx:
o. Encourage the patient to verbalize feelings and concerns.
17
cord. Aspirin inhibits platelet postmyocardial infarction, vomiting, diarrhea, confusion, Dx:
aggregation by interfering with prophylaxis of MI, ischemic CNS depression, diaphoresis, f. Verify patient’s identity.
production of thromboxane A2, stroke, angina headache, hyperventilation, and g. Assess patient’s condition.
a substance that stimulates lassitude) with regular use of
platelet aggregation. Aspirin large doses Tx:
acts on the heat-regulating Drug to drug Interaction: h. Administer medication following the rights of giving medication.
center in the hypothalamus and ACE inhibitors: Decreased i. Suggest taking aspirin with food or after meals because it may cause GI
causes peripheral vasodilation, antihypertensive effect upset.
diaphoresis, and heat loss. activated charcoal: Decreased j. Assist patient when taking the medication.
aspirin absorption antacids,
EDx:
SOURCE: urine alkalinizers: Decreased k. Instruct patient not to cut, crush or chew the medication.
Jones & Bartlett Learning aspirin effectiveness
(2015). Nurse’s Drug anticoagulants: Increased risk AFTER:
Handbook. Fourteenth of bleeding; prolonged bleeding Dx:
Edition. time carbonic anhydrase l. Monitor patient for signs and symptoms.
inhibitors: Salicylism m. Monitor drug effectiveness.
corticosteroids: Increased
Tx:
excretion and decreased blood n. Promote safety and comfort.
level of aspirin heparin:
Increased risk of bleeding EDx:
o. Instruct patient and SO to notify the nurse if any symptoms of stomach
ibuprofen: Possibly reduced or intestinal bleeding occur such as black, tarry or bloody stools.
cardioprotective and stroke
preventive effects of aspirin
methotrexate: Increased blood
level and decreased excretion
of methotrexate, causing
toxicity nizatidine: Increased
blood aspirin level
18
enhanced effect of
sulfonylureas with large doses
of aspirin
20
LACTULOSE where it breaks down into lactic Hypersensitivity to lactulose or distention, diarrhea, flatulence Dx:
acid and small amounts of its components, low-galactose ENDO: Hyperglycemia a. Verify doctor’s order.
Brand Name: Duphalac formic and acetic acids, diet Other: Hypernatremia, b. Assess allergy to lactulose or its components.
acidifying fecal contents. hypokalemia, hypovolemia
Chemical Class: Synthetic Acidification leads to increased Indications: Tx:
disaccharide sugar osmotic pressure in the colon, Indicated for the treatment of c. Prepare the medication at the right time and right dosage.
which, in turn, increases stool constipation d. Don’t give concurrently with other laxatives.
Therapeutic Class: water content and softens stool.
Ammonia reducer, Also, lactulose makes intestinal Drug to drug Interaction: EDx:
Laxative contents more acidic than Anti-infectives: decreased e. Educated the patient and SO about the purpose and importance of the
blood. This prevents ammonia lactulose efficacy drug.
Dosage: 30 cc diffusion from intestine into f. Educated SO on drug therapy to promote compliance
blood, as occurs in hepatic Other laxatives: interference
Route: Oral encephalopathy. The trapped with response to lactulose (in DURING:
ammonia is converted into Dx:
patients with hepatic
ammonia ions and, by g. Verify patient’s identity.
lactulose’s cathartic effect, is encephalopathy h. Assess patient’s condition.
expelled in feces with other
nitrogenous wastes. Tx:
i. Check the solution appears pale yellow to yellow, viscous liquid.
Cloudiness, darkened solution does not indicate potency loss.
SOURCE:
Jones & Bartlett Learning
(2015). Nurse’s Drug EDx:
Handbook. Fourteenth j. Emphasize the importance of drinking adequate fluids and to report
Edition. signs and symptoms of dehydration.
AFTER:
Dx:
k. Monitor the patient's activity and vital signs.
l. Monitor for possible adverse effects of medication.
Tx:
m. Assess the patient and determine unusual changes.
n. Evaluate therapeutic response: decreased constipation, decreased blood
ammonia level, clearing of mental stat
21
EDx:
o. Immediately report to the physician, if unusual changes are noticed.
p. Not to use as a laxative long term, to use as prescribed.
23
Therapeutic Class: monophosphate (cGMP). An (S.L. form) EDx:
Antianginal, Vasodilator increased cGMP level may relax Indications: GI: Abdominal pain, diarrhea, e. Educated the patient and SO about the purpose and importance of the
vascular smooth muscle by Indicated for the treatment or indigestion, nausea, vomiting drug.
Dosage: 30 mg forcing calcium out of muscle prevention of angina pectoris GU: Dysuria, impotence, urinary f. Educated SO on drug therapy to promote compliance
cells, causing vasodilation. This frequency
Route: Oral improves cardiac output by Drug to drug Interaction: HEME: Hemolytic anemia DURING:
reducing mainly preload but also acetylcholine, MS: Arthralgia, muscle twitching Dx:
afterload. norepinephrine: Possibly RESP: Bronchitis, pneumonia, g. Verify patient’s identity.
decreased effectiveness of upper respiratory tract infection h. Assess patient’s condition.
SKIN: Diaphoresis, flushing, rash
these drugs
SOURCE: Tx:
Jones & Bartlett Learning i. Give drug 1 hour before or 2 hours after meals. Give with meals if
antihypertensives, calcium
(2015). Nurse’s Drug Handbook. patient experiences severe headaches or adverse GI reactions.
Fourteenth Edition. channel blockers, opioid
j. Administer medication as ordered.
analgesics, other
k. Assist patient when taking the medication.
vasodilators: Increased risk
of orthostatic hypotension EDx:
l. Caution patient not to crush or chew isosorbide E.R. capsules or tablets
aspirin: Increased blood level or S.L. tablets unless specifically ordered to do so by prescriber.
and pharmacologic action of m. Instruct patient to take drug before any situation or activity that might
isosorbide precipitate angina.
sildenafil, tadalafil,
vardenafil: Increased risk of AFTER:
hypotension and death Dx:
n. Monitor blood pressure often during isosorbide therapy, especially in
sympathomimetics: Increased elderly patients; drug may cause severe hypotension.
risk of hypotension, possibly o.
decreased therapeutic effects
of isosorbide Tx:
p. Know that patient may experience daily headaches from isosorbide’s
vasodilating effects. Give acetaminophen, as prescribed, to relieve pain.
q. Promote safety and comfort measures.
EDx:
24
r. Encouraged patient to verbalize feelings and concerns.
s. Instruct patient to notify prescriber about blurred vision, fainting,
increased angina attacks, rash, and severe or persistent headaches.
norepinephrine: Possibly
decreased arterial
response to norepinephrine
phenytoin, probenecid:
Possibly decreased
therapeutic effects of
furosemide
propranolol: Possibly
increased blood
propranolol level
antihypertensive effects of
furosemide
27
thiazide diuretics: Possibly
profound
tubocurarine: Antagonized
skeletal muscle relaxing
effect of tubocurarine
succinylcholine: Increased
action of
succinylcholine
B. IV Fluids
DURING:
28
nervousness, paresthesia, psychiatric Dx:
e. Monitor blood pressure and heart rate continually
disturbance, syncope, tremor, weakness during infusion and avoid too rapid or excessive
blood pressure drop during treatment. If there is
CV: Arrhythmias (bradycardia, concern of impending hypotension or tachycardia, the
infusion should be discontinued.
tachycardia), chest pain, exacerbation of
Tx:
angina (chronic therapy), heart failure, f. Administer nicardipine as ordered.
g. Check and regulate the drop rate.
hypotension, orthostatic hypotension,
EDx:
palpitations, peripheral edema
29
MS: Joint stiffness, muscle spasms
tract infection
urticaria
30
sodium chloride has a Joint pain, or d. Check and regulate the drop rate.
molecular weight of Shortness of breath. e. Change the IVF solution if needed.
approximately 58 grams
per mole, 58 grams of EDx:
sodium chloride equals
f. Instruct the patient not to move her hands frequently
1 mole. The where the IVF was attached.
concentration is 9 grams g. Educate the patient about the IVF solution.
h. Instruct to report if dislodged occurs.
per liter divided by 58
grams per mole, or 0.154
moles per liter, because DURING:
EDx:
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the IVF to avoid over infusion.
AFTER:
Dx:
Tx:
EDx:
C. Surgery
(if any)
32
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XV. Nursing Care Plans
A. Prioritization of Problems
This portion lists the health problems according to priority (No. 1 having the highest priority).
Health Problems are stated as Nursing Diagnoses using the Basic 3-Part Statement : PES Format
- Problem Statement + Etiology + Signs and Symptoms
-
- Ex: Self-Esteem Disturbance related to rejection by husband as manifested by hypersensitivity to
criticism, stating "I don't know if I can manage by myself", and rejecting positive feedback
- Variations to the PES format in order to make the problem statement more descriptive
(e.g. adding "Secondary to") is acceptable as long as the part following “secondary to” is a
disease process
(Ex: High-Risk for Impaired Skin Integrity related to decreased peripheral circulation secondary to
Diabetes)
Problems should comprise AT LEAST 3 Actual Problems and 2 Potential Problem ranked in order of
priority.
This portion presents the basis of how the health problems were prioritized. Prioritization should also be
discussed.
NURSING DIAGNOSES JUSTIFICATION
1. PES Format as stated in your Why is it number 1 out of your 5 problem, you can use nursing
list of problem theories or concepts.
2. PES Format as stated in your Why is it number 2 out of your 5 problem, you can use nursing
list of problem theories or concepts. Relate it with number 1 or 3.
3. PES Format as stated in your Why is it number 3 out of your 5 problem, you can use nursing
list of problem theories or concepts. Relate it with number 2 or 4.
4. PES Format as stated in your Why is it number 4 out of your 5 problem, you can use nursing
list of problem theories or concepts. Relate it with number 3 or 4.
5. PES Format as stated in your Why is it number 5 out of your 5 problem, you can use nursing
list of problem theories or concepts. Relate it with previous problems.
34
B. Nursing Care Plans
The Care Plans for the Nursing Diagnoses shall be presented here.
The format discussed during the Orientation shall be followed. (Follow new Format for NCP)
Subjective
Haan nak unay maka
kuti
Objective
Nursing Diagnosis
Activity intolerance
related to
35
NCP 3: PES Format as stated in your list of problem
36
C. Discharged Plan
Health Teaching
Diet/Nutrition 1. Aaaa
2. Bbbb
3. cccc
Activity 1. aaaa
2. bbb
3. cccc
4. DDD
Medication 1. Aaaa
2. Bbbb
Other 1. Aaaa
2. Bbbb
(Diet, Therapeutic regimens, Take home meds and Nursing education for the client)
D. MAIGI, Nicalin
Honestly, I am not part of the directly monitoring the patient but I was able to learn a
lot from our case by sharing my insights regarding…
E. PAGADIAN, Ia Rylyn
I was able to see the patient in our second day of duty and helped in the assessment,
so I learned to…
37
F. PAGUIRIGAN, Kryzza Leizel
I was able to see the patient in our second day of duty and helped in the assessment,
so I learned to…
G. PANGDA, Jaceziel
I was able to see the patient in our second day of duty and helped in the assessment,
so I learned to…
H. SAAVEDRA, Joy Anne
I was able to see the patient in our second day of duty and helped in the assessment,
so I learned to…
I. TUCYAPAO, Irish P.
I was able to see the patient in our second day of duty and helped in the assessment,
so I learned to…
J. VILLANUEVA, Jayson
I was able to see the patient in our second day of duty and helped in the assessment,
so I learned to…
38
XVII. List of References
This portion cites all books, journals and other references that were used as shown in the example
below. Use APA Format and as much as possible use updated book source.
39
XVIII. Appendices
40
Appendix A
Approval/Request Letter
41
Appendix B
Interview Guides
42
Appendix C
Others (just specify)
43