I.

ASSESSMENT

A. General Data

Patient’s Initials: C.L. Sex: Male

Address: Paranaque City
Age: 74 years old Civil status: Married
# of Days in this Hospital: 6 days Occupation: Retired Production
Supervisor
Date of Birth: January 27, 1934 Place of Birth: Manila
Date of Admission: January 11, 2009; 2300 H Order of Admission: Via
Stretcher
Informant: C.L. (Patient) Date of History: January 17, 2009

B. Chief Complaint:

Pressing Pain localized on the substernal part of the chest with a scale of
7/10, 10 being the worst pain, precipitated by physical exertion which is driving. The
chest pain is accompanied by difficulty of breathing of 30 minutes duration before
admission.

C. History of Present Illness:

Four years prior to confinement, the patient was diagnosed of Type II

Diabetes Mellitus and Hypertension simultaneously in his hospitalization during that
year. He was then prescribed with the following medications: Metformin and Inderal.
Adherence to a diet of low fat and low salt was also advised by his physician.

Two years prior to confinement, January 2007, the patient underwent an

operation in which 2 digits of his left foot were amputated due to gangrene
formation secondary to Diabetes Mellitus. During discharge, he was prescribed with
an insulin injection of once a day before dinner.

3 months prior to confinement, October 2008, the patient was admitted to

the Asian Hospital due to chest pain. He was subsequently diagnosed of Acute
Myocardial Infarction secondary to Coronary Artery Disease. At the same, he was
also diagnosed of Congestive Heart Failure with Pulmonary Congestion. He was
recommended by his doctor for a Coronary Angioplasty which he refused to undergo
because of financial constraints. After seven days of confinement, he was
discharged with medication prescriptions of the following:

• Amlodipine 10 mg x 1 tablet OD-AM

• Furosemide 40 mg x 1 tablet OD-AM

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 • Spironolactone 25 mg x ½ tablet OD-AM
• Isosorbide Mononitrate 60 mg x ½ tablet BID
• Clopidogrel 25 mg x 1 tab OD-AM
• Aspirin 80 mg x 1 tab OD-After Lunch
• Carvedilol 25 mg x ½ tab BID
• Ketosteril 600 mg x 1 tab TID
• Simvastatin 40 mg x ½ tab OD-HS
• Telmisartan 80 mg x 1 tab OD-PM
• Betahistine 1 tab PRN x 3 days
• Insulin – Novomix 18 u before breakfast; 22 u before supper
• Iberet 500 mg x 1 tab OD-AM
• Isordil 5 mg 1 tab PRN SL for Chest Pain

In addition, he was advised to strictly adhere to his low salt and low fat diet. From
then on, the patient continued to experience episodes of chest pain of at least twice
every month which he managed by taking Isordil as prescribed. These episodes
were usually precipitated by physical exertion such as driving and walking.

12 hours prior to admission, the patient and his wife attended their Sunday
church activity which lasted for 2 hours. He drove for 1 ½ hour from Manila to
Paranaque. When they reached their house, he rested for 3 hours. Afterwards, they
prepared to attend a party held in Manila. The event ended at around 10:00 in the
evening. He started to feel difficulty of breathing and mild chest pain of 3/10
intensity. Since his wife doesn’t know how to drive, he was left with no choice but to
endure the pain while driving.

Thirty minutes prior to admission, while the patient was still driving, he took
Isordil 5 mg due to worsening of pain (scale of 7/10). The patient also persisted.
These symptoms prompted him to seek consultation to the nearest hospital
available. Upon arrival to Medical Center Paranaque, the patient suddenly collapsed
on the Emergency Room Floor; hence, admission.

D. Past History

1. Childhood Illness: Patient was unable to recall.

2. Adult Illness: Type 2 Diabetes Mellitus (2005); Hypertension (2005);
Myocardial Infarction (2008); Congestive Heart Failure (2008); Coronary
Artery Disease (2008)
3. Immunization: Patient was unable to recall.
4. Previous Hospitalization: Medical Center Paranaque due to HPN and
DM (2005); Medical Center Paranaque due to gangrenous toes (January
2007); Asian Hospital due to Myocardial Infarction (2008)

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 5. Operations: Amputation of the first and second digit of the left foot
(Medical Center Paranaque; January 2007)
6. Injuries: None.
7. Medications Taken Prior to Confinement:
October 2008:
• Amlodipine 10 mg x 1 tablet OD-AM
• Furosemide 40 mg x 1 tablet OD-AM
• Spirinolactone 25 mg x ½ tablet OD-AM
• Isosorbide Mononitrate 60 mg x ½ tablet BID
• Clopidogrel 25 mg x 1 tab OD-AM
• Aspirin 80 mg x 1 tab OD-After Lunch
• Carvedilol 25 mg x ½ tab BID
• Ketosteril 600 mg x 1 tab TID
• Simvastatin 40 mg x ½ tab OD-HS
• Telmisartan 80 mg x 1 tab OD-PM
• Betahistine 1 tab PRN x 3 days
• Insulin – Novomix 18 u before breakfast; 22 u before supper
• Iberet 500 mg x 1 tab OD-AM
• Isordil 5 mg 1 tab PRN SL for Chest Pain

8. Allergies: No Allergies to any substances on food and drugs.

E. Gordon’s Eleven Functional Health Patterns

1. Health Perception- Health Management Pattern

The patient used to have a positive perception of his health status until
he was diagnosed to have Type II Diabetes Mellitus and Hypertension in
2005. According to the patient, he never absents himself from work because
his body is always in good condition and he seldom gets sick. The patient
actually expected that he would have Diabetes because of the fact that both
of his parents died due to the said condition. In addition to that, the deaths of
his three siblings were related to the complications of Diabetes that they
have developed. The patient verbalized that he understands the strong
familial tendency of Diabetes. His hypertension, on the other hand, has been
caused by his lifestyle which includes a diet high in fat and salt content
coupled with his vice of smoking 2 packs of cigarette everyday which started
when he was still 15 years old and continued until he was 45. When the
patient was discharged from the hospital, he was advised to make lifestyle
modifications particularly on his diet. However, he was not able to adhere to

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a diet restricted in Salt, Fat and Carbohydrate content. He explained the main
reason for this; he believes that he should not limit himself when it comes to
enjoying life, for when the time comes that he is already dead, he can no
longer eat his favorite foods. He was also prescribed with Metformin and
Inderal. The patient is very consistent when it comes to medication regimen.
He unfailingly takes these drugs everyday, as prescribed. He monitors his
Capillary Blood Sugar every other day. He even drinked the herbal tea
Charantia to help improve his condition but he eventually stopped drinking it
because he has noted no change with himself. Moreover, he was advised to
have regular check up with his doctor but he was not able to follow this as he
goes to his doctor only if there is something wrong with regards to the
physical aspect of his health. The patient recalled that the usual readings of
his blood pressure were mostly high, he remembered the highest reading in
particular which is 170/100 mmHg during one of his check up. In 2007, the
patient underwent amputation of the 1st and 2nd digit of his left foot.
According to him, he was not informed of the importance of foot care when
he was diagnosed of Diabetes. He even added that he did not know that he
will experience decreased sensation on his foot. As a result he did not initiate
measures to be more careful with the shoes he is wearing or be more
cautious to avoid being wounded. His doctor prescribed a daily single dose
insulin injection for him. He consistently receives insulin everyday. His son is
the one administering the insulin because the patient is afraid to inject the
needle of the syringe to his abdomen. In 2008, the patient was admitted at
the Asian Hospital and was diagnosed to have experienced Acute Myocardial
Infarction due to Coronary Artery Disease. He was also found to have
Congestive Heart Failure. According to the patient, his lungs were already
congested with fluid, as explained by his doctor. The same doctor
recommended that the patient undergo Coronary Angioplasty, however he
refused the procedure because he does not want to leave financial burden to
his family when he dies. Besides, he believes that death is inevitable so
spending much to delay it is not a wise decision. The patient continued with
his inconsistency to his diet, he still eats the prohibited foods without
moderation. But he takes the new prescribed medications for him without any
interruptions.
Presently, the patient is admitted to the hospital because of complains
of difficulty of breathing and chest pain. He now perceives his health to be
unstable. He elaborated this word by saying that he can die because of his
condition any moment now. However, the patient still holds his beliefs when
it comes to eating. He still does not have any plans of following his diet
religiously. He still does not want to undergo Coronary Angioplasty. But he
said he will continue with his medication regimen.

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2. Nutritional- Metabolic Pattern

When the patient was diagnosed to have Diabetes, he was ordered to

follow a diet Restricted in carbohydrates. He enumerated the foods and
drinks that he was not allowed to consume liberally, and these are cakes, ice
cream, fruits, sodas, chocolates, even rice and other sugar containing
desserts such as his favorite leche flan. Because he already expected that he
will have Diabetes, it was not a surprise to him that these restrictions that
some of his family members have experienced will also apply to him.
However, even at the very beginning, he does not want to control himself too
much with the food that he wants to eat. He still eats cake and his favorite
leche flan, he still drinks soda. In addition to the Diabetic Diet that he has to
follow, he was also ordered to have a Low Salt- Low Fat diet after being
diagnosed of Hypertension and eventually Coronary Artery Disease and
Congestive Heart Failure. His wife is the one preparing their meals at home
and they usually argue when she prepares dishes that is bland because of not
adding salt and other seasonings. He complains when his wife serves Milk
Fish, because he already wants to throw up even at the mere sight of the said
fish that he is asked to eat most of the time. The patient is not fond of eating
vegetables. He is not contented with the matchbox size meat that he is
allowed to eat, so he consumes more than this amount. As for his fluid
intake, he is able to drink approximately 1500 ml of water everyday.
However, after his hospitalization in 2008, he was placed on a fluid restriction
of 1000 ml per day and he follows this by measuring his intake for the whole
day. He does not usually drink coffee.
Presently, the patient is about to be discharged from the hospital
where he stayed for 6 days. During his entire confinement, he was under a
LSLF- DM diet. He said that the dietary department serves food that does not
have any taste. He further complained that his tray sometimes includes foods
that are not allowed for him such as meat, fruits, and soft drinks. As a result,
he just eats these foods. His intake and output was monitored strictly during
his hospital stay, making sure that he does not exceed a liter of water a day.
The patient does not have difficulty with his fluid restriction. He verbalized
that once he goes home, he would probably continue eating the foods that
are prohibited.

3. Elimination Pattern

Before hospitalization, the patient does not have any problem with
defecation and urination. He considers his defecation pattern of once every

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 other day as normal. Its characteristics include formed to hard consistency,
moderate amount and brownish color. There are times that he has to strain
to be able to pass stool. He perceives that the reason for this is he does not
eat much vegetable. He is able to urinate 8 to 10 times during the day which
amounts to approximately more than 2500 cc. During night time, he has to
wake around two to three time to urinate which adds around 500 ml to his
total urine output for the day. According to the patient, he started to have
increased urine output when he was diagnosed of Diabetes Mellitus in 2005.
He does not usually experience problem controlling the urge to urinate and
defecate. He even added that he does not experience any sensation of pain
when he voids.
During hospitalization, the patient experienced constipation. The
patient understands that this is due to his decreased activity because of his
ordered confinement to bed. He is advised not strain and so he was
prescribed with Lactulose 30 cc to be taken during bedtime. After taking the
said medication, the patient was able to pass stool without difficulty. The
patient was catheterized during his confinement to the hospital. It drains to
yellowish urine with an average amount of 1900 per day. The patient said
that it is very uncomfortable to have a catheter that is why he asked his
doctor to have it removed after a few days. He underwent bladder training
before the removal of the catheter. He experienced extreme pain when the
tube was removed. The patient believes that his urethra was injured that is
why he is having painful urination since then. But he explained that the pain
is gradually becoming less intense.

4. Activity- Exercise Pattern

The patient used to live an active lifestyle. As a Production Supervisor

in a well known company where he worked for roughly 40 years, most of his
time is being spent standing, monitoring the performance of the other
employees. The patient remembered that when he was still a high school
student, he is very fond of playing basketball, and he still plays basketball
during the sport fests of their office when he was still working. When he
retired from work in the year 1994, he spent most of his time in their house.
He has chickens and banana tree in the backyard that he is taking care of. He
usually walks around the subdivision in the morning. When inside the house,
he would usually spend his spare time watching television. His wife is the one
taking care of all the household chores that is why he gets to rest when he
wants. When two of the digits on his left foot were amputated in 2007, he
initially had to stay on bed because he could not walk through the pain. After
a few weeks, he eventually got used to walking with two of his toes missing

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 and no significant change was noted with his activity. It was after his
hospitalization in 2008, that he started to experience a gradual decline in his
energy level and in his ability to perform his usual daily activities. He
described that he gets easily fatigued after walking for even just short
distances. He is also extra careful not to get excessively tired because he
might experience difficulty of breathing and chest pain.
During hospitalization, the patient is advised to limit his level of
activity. He complied with this order. On the day of discharge, the patient is
already able to walk around the hallway but is still experiencing fatigue after
a few steps.

5. Sleep- Rest Pattern

Before being hospitalized the patient does not have any difficulties
regarding his sleeping routine. When he goes to bed, he is able to initiate
sleep without any problem. He usually goes to sleep at around 9 in the
evening and wakes at around 5 in the morning. Although he has to get up to
urinate at night, he said that he does not usually experience difficulty getting
back to sleep. With approximately 7 hours of sleep, the patient said that he
usually feels well rested. In addition, to that the patient also said that his wife
and him are sleeping on separate rooms for almost 15 years now. For the
reason that his wife is snoring and he gets disturbed. Moreover, when his wife
listens to radio, he cannot go to sleep. In the afternoon, the patient takes a
nap for about an hour.
In the hospital, the patient felt deprived of sleep. Particularly when the
patient was bladder training, he became very cautious in monitoring whether
he already feels the urge to urinate. This occurred even when the patient is
already supposed to be sleeping at night. But the patient said that he is able
to take several naps during the day.

6. Cognitive-Perception Pattern

Before the patient was admitted to the hospital, he already had problem with
his vision. He reports that his left eye see things more blurry than his right eye.
He believes that it is because of him being diabetic that he develop vision
problem. He had with him 4 eye glasses but admits that he never wore them
for a long time now. This is because he noticed that there was no improvement
in his visual acuity. For this reason, he doesn’t anymore read small printed
materials such as news papers. He said that he prefer to watch television than
to read newspaper where he can’t even see a word due to its small print. The
patient also reported that he had problem hearing especially with his left ear,

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 though he is able to hear a person talking in moderate voice. Even with
auditory problem, the patient still denies use of any hearing devices. He also
report ringing sensation inside his left ear. He even added that there are
instances that when he stand coming from a sitting or lying position, he would
feel dizzy as if his environment where circling him. Due to this reason, there
have been couple of times where he lost his balance, lucky, no accidents had
yet occurred. The patient said that due to his age, his memory is not anymore
sharp as compared before. He was still able to recall important dates and
events in his life; however, he admits that he had difficulty recalling
insignificant experiences. He said he learn quickly and was able to absorb
things really fast. He learns things easily through demonstrations and said that
he is a visual learner. The patient denies problem with communicating to other
people and said that he can speak English eloquently. He said that he had a
short attention span especially in matters that are not so important and off of
his interest. He is capable of making decision for himself and his family. When
faced with difficult problem and situations, consultation with his wife before
giving final decision is what he do to lessen possible conflict. Whenever patient
is in pain, he would always try to control the pain using his mind first, and if not
tolerable anymore, medications and consultation with the doctors will be his
last resort.
Presently, the patient still report vision and auditory problems. He is still not
using his eyeglasses and is not interested of having his eyes checked by a
doctor. He is still able to make decision especially with regards to his care and
medical treatment.

7. Self-Perception Self-Concept Pattern

The patient, despite of being a diabetic and knowing the possible

complication that may arise from the condition, remain optimistic. He never
loses hope and believes that problems come with solutions. He said that he is
contented with his life now and how his life been formed but verbalizes that if
given a chance, his life would be much happier if he never commit the
mistakes that ruin the life of his first wife and the children from his mistress.
He said that as a father, he never fail to provide his children with financial
support but fail when it comes to the emotional support and the
insurmountable happiness that comes with a complete family. He said that he
feels good about himself but he would feel better if he would be able to
reconcile with his eldest son because they have been in bad terms for a long
time now since the eldest son had believed that they were the first family, only
to find out that they are not. He believes that every thing happens for a reason
and being a man doesn’t exempt him from committing human mistakes.

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 Though, he verbalizes not being happy with the situation with his son,
regretting things he had done in the past will not do good, either. The patient
perceives himself to be a family oriented person. He had strong convictions
and believes in his advocacy. Due to this reason, he is not easily influenced. He
knows himself and said that he can control his emotions well. He said that he is
a very relaxed and calm person and is not easily distracted over simple things.
He cope up with stressful events quite well.
Presently, the patient feels not good about himself because his health had
never been better, since he started to be hospitalized in 2005. However, the
patient remains to be optimistic and hopeful. He believes that it is not healthy
to think about his problems right now because it would only stress him out and
can possibly make his condition worse. He is not easily distracted and annoyed
with simple things. He is relaxed most of the time and described himself as an
assertive type of person but when it comes to medical treatment, he is just
passive about it especially when matters concerning money are involved.

8. Roles-Relationship Pattern

The patient lives in a simple house with his second wife and his 19- year- old
son with his mistress. The patient does not verbalize problems with his wife
and his youngest son but reports having a problem with his eldest. The patient
and his eldest son in his mistress had been in bad terms for a long time now
since the day the eldest son found out that they are not the first family of the
patient, and that is way back 1984. This is the only problem that the patient
admits he had difficulty in handling. As a husband, he has this perception that
he has not been so good to his previous wives except to his present wife. He
had his first wife but the wife can never bore a child because she had a
condition called “baby uterus”. And because of the patient’s desire to have
children, he looked for someone who could give him that desire. He then
submitted himself into an illicit affair where he had 3 kids with his mistress.
Both his legal wife and his mistress died of cancer. He even verbalizes how he
wished he had accepted the fact that his first wife cannot give him children and
must have been loyal to her. How he wished he had not ruin the life of this two
woman. He said that his being a father is the only thing he is proud of himself.
He had been financially supporting his 3 children and had been a responsible
father to them. However, he was not in good terms with his eldest for quite a
long time now. Up to now, they are still not in good terms, and it frustrates
him. As a friend, the patient said he is very supportive and loyal. He helps a
friend in need without expecting anything in return. He is friendly with his
neighbours and very sociable to them. He even had a habit of giving his
neighbours bananas whenever the banana tree would bear its fruits. As a

9
 citizen of the country, the patient believes that he is a good and responsible
one. He abides with the rules of the country.
Presently, the patient was still in bad terms with his eldest son.
Because of his current state of health, the patient believes that he is not
productive to his family like before. He also thinks that because of his recent
and frequent hospitalization, the money that should be allotted to important
things have been unwisely allotted to his care, and he feels not good about it.
At present, his wife and his youngest son took care of him in the hospital and
attend to his need. He said that his family had been very supportive and
generous in taking care of him. He had his pension with him and he had an
apartment which he let others rent and he uses it as a source of his income.
However, the patient admits that every centavos coming from them was only
spent in his medications. Right now, the patient thinks that he can’t support
the financial needs of his family.

9. Sexuality – Reproductive Pattern

The patient and his wife has not been sleeping in the same bed since 1994.
The reason for this is because his wife had a habit of listening to the radio before
sleeping and is snoring loudly to the extent that he will wake up in the middle of the
night. The patient said that he had a very satisfying sexual activity with his first 2
partner. Never did he nor his partner use any form of contraceptive because it is his
desire to have children. The patient also said that he do sexual activity not only for
the reason of pleasure but more because he wanted to have children. Though, he is
contented with his first wife in terms of copulation, he never had a very satisfying
relationship with her because he cannot accept that his wife could never give him
kids. This is the reason why he sorted for a way where he could satisfy his
frustration, this is where he had an illicit affair with his mistress. The patient never
undergoes nor is interested with any reproductive examination or consultation. He
said that he feels good about his reproductive health and that there is nothing to
worry about. Patient denies having a sexual activity with his present partner since
1994. The patient admits not being expressive with his feelings but loves his wife so
much. The patient and his wife is in good terms ever since.
Presently, the patient and his wife are still in good terms. He said that he
makes him love his wife more because of how thoughtful his wife is and how good
she had taken care of him for the past few years. He also said that he had no more
interest in any sexual activity because he thinks that he is old enough for that. He is

10
still admit not being affectionate with his wife but verbalizes that she loves her very
much.

10. Coping Stress Tolerance pattern

For a long time, the patient being in bad terms with his eldest son have been
the ultimate stressor for him. He said that he loves his children so much that any
matter which involves his children stresses him. Furthermore, for the past few
years, the gradual decline of his health and complications that are arising due to his
disease condition stresses him that much. Though, compliant with the treatment
regimen, financial matters involving his care is one of his biggest problems. His
perceived inability to support his family of their need is one of the causes of his
frustrations. He said that he can cope up well on difficult situation provided that
solutions are visible. He also said that, since he believe that problems comes with
solutions, problems should not be worried too much especially that he had an
unstable health, and worrying too much would do no good for him. When face with
problems, patient would like to solve the problem first and if still unresolved despite
of the strategies he had taken on, that’s the only time he would talk to his wife to
settle things. Relaxing, in the form of listening to soft, instrumental music also help
him in time of stressful events. He said that he never consider using medication or
alcohol during stressful time. Natural way is still the best way for him. When face
with difficulties and problems in life, the patient said that solving things one by one
is most helpful and are most of the time, successful.
Presently, the patient’s recent hospitalization had been a great stressor for
him. The financial matter concerning his care frustrates him. Since he was advised
by the doctor to undergo angioplasty, the patient said that he decided not to
undergo such procedure because he doesn’t want to invest something big on it. He
said that he would just comply with the medications he was prescribed and thinks
that it is enough already to prevent complications from occurring.

11. Values Belief Pattern

Religion is very important to the patient and when difficulties arises, his faith
is His only source of strength. Being a protestant, he said that he is an active
member of his religion. He said that he is a religious person. He attends mass every
Sunday and Christian holidays and he participates in church activities. Despite of
the things he experienced with his life, the patient said that he knows that God
wants everything to happen and that he had a purpose for doing so. He said that he
is a man of integrity and honesty. He works hard and the values of fair-play,
perseverance and dedication are the things he holds on into his character and the
things he wants his children to learn from him. He said that generally, he did get the

11
things he wants in life. But his being contented with what life present to him made
him want no more. His children are his treasures. He loves his children so much that
he wants nothing but success and blessing to them. He said that he had one
important plan for the future and that is to be reconciled with his eldest son. He said
that when that’s happened, he can die peacefully without regrets.

Presently, the patient verbalizes that the sole source of his strength is his
faith in the Lord and his children. He had given all his trust on Him and had offered
his life to whatever His plans. Despite of his present conditions, patient remains
hopeful and optimistic. He even said that nothing will happen and there is nothing
to worry about. One of his most important plans are to reconciled with his eldest
son and completely adhere to his treatment regimen so that possible complication
will least occur.

F. Family Assessment

Name Relation Age Sex Occupation Educational Attainment

L.C. Patient 74 y/o Male Retired College Graduate
R.C. Wife 70 y/o Female Housewife High School Graduate
M.C. Son 19 y/o Male Student High School Graduate
I.G. Employee 23 y/o Female House Helper High School Graduate

G. Heredo- Familial Illness

1. Maternal: Diabetes Mellitus, Hypertension

2. Paternal: Diabetes Mellitus, Kidney disease

H. Developmental History

Theory/ Age Task

Patient Description
Theorist

Psychosocial 74 years Integrity VS. The patient is more on despair.

theory old Despair Though, the fact that he was able to
Eric Erikson support his family, send his children
to college and provide them with all
their basic needs which is for him his
greatest dream, he still seem to
regret all those mistakes he had
done to his family, especially to his
eldest son (they’re still not in good
terms until now).

There was also a part of the patient

that suggests him to have achieved
integrity which is his verbalization of
contentment and satisfaction to life
and was even ready (according to
him) to face death itself.

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 He has a very good relationship with
his neighbours and relatives. He
believes that he has been a good
father to his children but not a
perfect husband to his wife.

The patient was able to adapt to

changes in lifestyle as he ages and
still was independent in performing
his ADLs such as eating, toileting,
bathing and ambulating.

Psychosexual 74 years Genital stage The patient has fathered 3 children

theory old (all boys). He was able to build his
Sigmund Freud own family and raise them on his
own while providing all their basic
needs and sending them to school at
the same time.

Although there is already no sexual

activity between his wife for a long
time now, their intimacy shows their
strong tie with each other and love
seems to endure after years. Even if
both of them are not expressive with
their feelings with each other, the
patient said that he appreciates how
his wife takes care of him. For him,
that’s one way of showing how they
love each other.

Cognitive 74 years Formal The patient experiences gradual

theory old operational decline in his cognitive function.
Jean Piaget phase
He has hearing difficulties and vision
problems which were then validated
during the interview. He used to
wear reading glasses before but he
stopped when he noticed it doesn’t
help his vision even a bit. He doesn’t
use any hearing aids. According to
him, he experiences memory
changes; he’s sometimes having a
hard time recalling things.

The patient respects the decision

and opinions of others because he
believes that each is entitled to his
own opinion.

Moral theory 74 years Level III- Post According to the patient, before
Lawrence old conventional making a major decision he first
Kohlberg outweighs the benefits and
Stage6 disadvantages of his decision. He
Universal based his decision on his own
ethical principle evaluation and standard of what is
orientations. right.

The patient believes what you do to

13
 other people is what other people
will do to you.

Furthermore, he is not the type of

person who simply complies with the
rules of majority, if he thinks it is
unnecessary.

Spiritual theory 74 years Universalizing The patient is a religious person. He

James Fowler old never missed a single church activity
every Sundays (that is before his
confinement).

Even when his children were still

young and staying with him, they
used to attend the mass every
Sunday which then serves as their
family bonding moments.

Despite of the things he experienced

with his life, the patient said that he
knows that God wants everything to
happen and that he had a purpose
for doing so. He said that he is a
man of integrity and honesty. He
works hard and the values of fair-
play, perseverance and dedication
are the things he holds on into his
character and the things he wants
his children to learn from him

I. Physical Examination
Date: January 15, 2009
Time: 0800 H

Height : 168 cm
Actual Weight: 65 kg
Ideal Body Weight: 61 kg

Vital Signs
Temp: 36.4 ºC
PR: 68 beats per minute
HR: 70 beats per minute
RR: 22 breaths per minute
BP: 130/80 mmHg

Regional Examination
A. Skin:
I:
• Fair colored skin

14
 • Superficial blood vessels are visible in hands and feet
• Absence of lesions
P:
• Dry skin
• Warm to touch
• Poor skin turgor

B. Nails:
I:
• Transparent, well-rounded and convex
• Fingernails are clean and short
• Blackened toenails
• Cuticles of the fingernails are intact without inflammation
• Fingernail beds are pale
P:
• Smooth fingernails
• Rough toenails
• Firmly attached to nail bed
• Capillary refill= 5 seconds

C. Head and Face:

I:
• Normocephalic and positioned on the midline
• Proportion to gross body structure
• Facial expressions are symmetrical
• Presence of white hair
P:
• Absence of deformities, lumps or masses
• Absence of tenderness

D. Eyes:
I:
• Eyes are parallel to each other
• Eyebrows are greyish and symmetrical
• Eyelid’s color same as skin
• Eyelashes are evenly distributed and curved outward
• Pinkish conjunctiva
• Anicteric sclera

15
 • Corneas are shiny and smooth
• Pupils are equally round and reactive to light and accommodation
• Blinking in response to bright light
• Blinking in response to quick movement of an object toward eyes
• Able to blink when wisped with cotton
• Blinking is symmetrical
• Normal convergence and extraocular movements
• Able to see things in the periphery
• Near visual acuity: can hardly read printed materials with or without
eyeglasses
P:
• Absence of tenderness and drainage from lacrimal apparatus

E. Ears:
I:
• Bean shaped
• At the level of outer canthus of the eyes
• Absence of discharges and lesions
P:
• Firm and smooth
• Absence of tenderness

Tests:
• Rinne’s Test: air conducted sound was heard twice as long as bone
conducted sound
• Weber’s Test: able to hear sounds on both ears; louder on right ear
• Patient can easily hear whispers on right ear
• Patient has difficulty hearing whispers on left ear

F. Nose:
I:
• Nose is same color as skin
• Nasal mucosa is pinkish and moist
P:
• Patent nares
• Absence of masses and tenderness

G. Mouth and Pharynx:

I:

16
 • Lips are pale and dry
• Oral mucosa is pinkish and dry
• Absence of teeth
• Tongue is pale with papillae present and is placed at midline

H. Neck:
I:
• Symmetric
• Proportion to gross body structure
• Absence of neck vein engorgement
P:
• Absence of tenderness, masses and deformities
• Lymph nodes are not palpable

I. Spine
I:
• Located at the midline
• With slight curved kyphosis
P:
• Absence of tenderness, masses or lumps

J. Thorax and Lungs

I:
• Chest contour is symmetrical
• Absence of bulging or active movement within the intercostals spaces
during expiration
• Absence of retraction during inspiration
• With exertional dyspnea
• Accessory muscles were used during breathing
• RR: 22 breaths per minutes
P:
• Absence of lumps and masses
• Chest Excursion: Symmetrical
• Tactile Fremitus: Symmetrical; vibrations are heard strongest on top
Pe:
• Dull sounds are noted
A:

17
 • Presence of fine bi-basal crackles

K. Heart/Cardiovascular
I:
• Absence of visible pulsations
P:
• Absence of jugular vein distention
• Weak radial pulses
• Weak dorsalis pedis pulses
• Absence of heaves, lifts, or thrill
A:
• PMI is located at the 5th intercostals space left midaxillary line
• Presence of S1 and S2
• Absence of murmurs

L. Breast:
I:
• Breasts are symmetric
• Areola is light brown
• Nipples are everted
• Absence of dimpling and retraction
P:
• Absence masses or lumps
• Absence of discharge in nipples

M. Abdomen:
I:
• Abdomen is round and symmetric
• The color is the same as neighboring skin
• Umbilicus is concave positioned and at midline
• Absence of scars and lesions
• Absence of visible peristalsis or pulsations
A:
• Bowel sounds: 23 bowel sounds per minute

Pe:
• Tympany heard over the stomach

Pa:
• Soft

18
 • Absence of masses
• Absence of organomegaly

N. Extremities
I:
Arms:
• Symmetrical
• Absence of swelling and venous enlargement
Legs:
• Symmetrical
• Absence of swelling and venous enlargement
• Presence of scar on the right leg
P:
• Able to perform active and passive range of motion of the upper and lower
extremities
• Absence of masses or nodules over the joints
• Able to resist applied force on arms, hands, legs, and feet
• Absence of edema

O. Genitals
• With foley catheter connected to urine bag draining yellowish colored urine
• Absence of swelling and redness of scrotal area

P. Rectum and Anus

Not performed.

Q. Neurologic Exam:
Appearance and Behavior:
• Awake and alert
• Understand questions and responds appropriately
• Able to walk around
• Looks relaxed
• Kyphotic posture
• Dressed appropriately, has good hygiene
• Has appropriate facial expression

Speech and Language:

• Able to express feelings well

19
 • Speech was in moderate rate
• Talks in a moderate tone voice
• Able to speak clearly and distinctly

Mood:
• Has appropriate mood depending on the situation

Thought and Perception:

• Able to converse coherently with relevant and organized information

Cognitive Functions:
• Oriented to time, place, self and other people
• Has good attention span
• Able to recall remote memory as evidenced by ability to remember past
events in his life
• Able to recall recent memory

Cranial Nerve Assessment:

• Cranial Nerve I (Olfactory) - Able to detect smell of perfume

• Cranial Nerve II (Optic) - Unable to read printed materials

• Cranial Nerve III, IV, VI (Oculomotor, Trchlear, and Abducens) - Pupils

are reactive to light and accommodation. Able to follow six directions of gaze.
• Cranial Nerve V (Trigeminal) - Able to clench jaw; Able to detect painful
stimuli applied to his face; Eyes blinked when wisped with cotton.
• Cranial Nerve VII (Facial) - Able to show different facial expressions

• Cranial Nerve VIII (Acoustic) - Positive for lateralization of sounds. Air

conduction lasted longer than bone conduction on both ears.
• Cranial Nerve IX and X (Glossopharyngeal and Vagus)- Presence of gag
reflex
• Cranial Nerve XI (Spinal Accessory) - Able to shrug shoulders

• Cranial Nerve XII (Hypoglossal) - Has good articulation. Tongue is

symmetrical, located on the midline, and able to move freely

Sensory System:
• Able to determine painful stimuli
• Able to detect light touch
• Has difficulty detecting sensation of vibration
• Two -point discrimination: 45 mm

20
Reflexes:
• Biceps Reflex- 2+ average, normal
• Triceps Refles- 2+ average, normal
• Abdominal reflex- 2+ average, normal
• Knee Reflex- 2+ average, normal
• Plantar Response- plantar flexion of toes

II. Personal/ Social History

1. Lifestyle: The patient used to have an active lifestyle until he started to

experience a gradual decline in his health. Presently, he gets easily fatigued
after walking several steps, that is why he usually limits his activity to sitting
and walking a few steps around the house.

2. Vices: The patient started smoking 2 packs of cigarette per day when he was
15 years old. He stooped smoking when he was 45 years old. The patient said
that he is not an alcohol drinker and that he only drinks during parties which
happen rarely. He also added that he did not engage in abuse of prohibited
drugs.

3. Travel: The patient did not have any travel previously.

4. Sports: Presently, the patient does not have any sports. He verbalized that
he is already old for these.

5. Educational Attainment: The patient was able to graduate from college.

6. Social affiliation: The patient is a member of the counsel of elders in their

church.

7. Order in the family: The patient is the father in the family.

8. Patient’s Usual Day Like: The patient usually wakes at around 5 in the
morning. After his wife has finished preparing breakfast, they will eat
together. Afterwards, he will visit his chickens at the backyard and take a
short walk within the yard. He then stays inside the house for the rest of the
day watching television and taking nap in the afternoon. After dinner, he will
again watch television with his wife and son. At around 9 in the evening, he
goes to bed and eventually falls asleep.

21
III. Environmental History

The patient lives in a subdivision located in Paranaque. The houses there

are built with adequate spaces in between. There are trees and plants all over the
place. Garbage cans are placed on some corners of the subdivision. Water and
electrical supply are available in the community. There is a market, school, park,
store and other food establishments just outside the subdivision. A guard house is
located at the entrance to their village. There are no flies and other insects at their
place. According to the patient, the garbage is being collected every day.
The yard outside the patient’s house has plants and trees. There is a
garage where the patient’s car is parked. The patient’s bungalow type house is well
maintained. There are no scattered rags on the floor. His room is located near the
living room, dining area and the bathroom.

22
23
24
V. Laboratory Study

LABORATORY NORMAL RESULT RESULT RESULT INTERPRETATION/ SIGNIFICANCE

VALUE 1/11/09 1/13/09 1/14/09

WBC 4.5 – 11 x 13.3 9.10 8.2 INCREASED to NORMAL; This was taken to assess if the patient
10^9/L might be suffering from an infection, inflammation or tissue necrosis.
Any emotional or physical trauma or stress might lead to an increase
in WBC. An initial increase in the patient’s WBC might be because he
has experienced physical stress before he was admitted to the
hospital. The rest of the result doesn’t show that the patient might
have infection or inflammation.
LYMPH 0.25 –0.40 x .24 .24 .27 DECREASED to NORMAL; This test was taken together with WBC to
10^9/L assess if there are any presence of infection or inflammation in the
patient. Even though the results in the first 2 test were low, it doesn’t
necessarily mean that the patient has an infection or inflammation
since the WBC is normal.
HGB 140 – 170 g/l 100 88 105 DECREASED; Hgb is the indirect reflection of RBC numbers. A
decrease in the patient’s level of Hgb is due to the decreased number
of the patient’s RBC. Taken into consideration a decrease in the urine
output of the patient, a decrease level of Hgb in all test might suggest
that the patient might have kidney disease. Erythropoietin which is a
strong stimulant of RBC production is produced in the kidney. Since
the kidney of the patient is damaged, there is a decrease production of
erythropoietin resulting in a decreased RBC production thus resulting
in a decrease Hgb. The patient’s Hgb has increased but still below the

25
 normal level on January 14, 2009 because 1 unit of pack RBC was
transfused to him last January 13, 2009 at 10 in the evening.
RBC 4.50 – 6.5 x 3.48 3.06 3.69 DECREASED; decreased level of RBC might suggest that the patient
10^12/L has a kidney disease. Erythropoietin is made in the kidney and is a
strong stimulant of RBC production. Since the patient’s kidneys are
damaged, there is a decrease production of erythropoietin therefore
the number of RBC is diminishing. The level of RBC in the patient’s
body has increased but still below the normal level on January 14,
2009 because the patient was transfused with 1 ‘u’ of pack RBC last
January 13, 2009.
HCT 40 – 54 % 31% 27% 32% DECREASED; Hct is the indirect measurement of the RBC number and
volume. A decreased level of the patient’s Hct can be due to the
decrease level of RBC secondary to diabetic nephropathy and chronic
kidney disease. Decline in the level of Hct is related to the decrease
production of erythropoietin, due to the damage in the kidneys, which
plays an important factor in RBC production.
PLATELETS 200 – 400 Adequat Adequat Adequat NORMAL; This test was taken to assess if there are any abnormality
e e e in the amount or number of platelets that can lead to thrombus
formation that might cause tissue infarction.
SEGMENTERS .55 -.65 .80 .87 .80 INCREASED; Increase level of segmenters might be because there is
an organ in the patient’s body that is damage such as his heart or the
kidneys. Taking into consideration the abnormal results of BUN and
CREA, his kidney might be damaged.

LABORATORY NORMAL RESULT RESULT RESULT RESULT INTERPRETATION/ SIGNIFICANCE

VALUE 1/11/09 1/12/09 1/13/09 1/16/09

26
 Hba1c 4.2% - 6.2% ---- 9.43% ---- ---- INCREASE; increase level of Hba1c is due to the fact that
the patient was diagnosed of diabetes mellitus for 3 years.
Measuring glycosylated hemoglobin assesses the
effectiveness of therapy since this test is proportional to
average blood glucose concentration over the previous four
weeks to three months. Poorly controlled glucose might
lead to the development of kidney and heart disease.
BUN 7.98 - 20 96.33 100.45 59.38 57.98 INCREASED; The patient’s BUN level is increased because
mg/dl of the patient’s diabetic nephropathy and chronic kidney
disease. BUN reflects the excretory function of the kidneys.
Since in diabetic nephropathy or in any kidney disease, the
kidneys are damaged, there is an inadequate excretion of
nitrogenous products causing an increase in the level of
urea nitrogen in the blood. Since the patient has a
significant increase in BUN, he is said to be azotemic.
CREATININE 0.6 - 1.3 3.98 3.07 3.92 2.22 INCREASED; An increased in the creatinine of the patient
mg/dl is also due to his diabetic nephropathy and chronic kidney
disease. The creatinine, as BUN is excreted entirely by the
kidneys and therefore is directly proportional to renal
excretory function. Since the kidneys of the patient are
damaged and unable to perform its function normally, it
will not be able to excrete the creatinine which is the
catabolic product of creatine phosphate, an important
substance used in skeletal muscle contraction thus it will
lead to an increase serum creatinine level.

27
 SODIUM 135 - 145 138 139 ---- ---- NORMAL; This was taken since this test can help assessed
mmol/L the fluid balance of the patient. An abnormality in the
result might suggest that the patient might have fluid
retention or dehydration..
POTASSIUM 3.80 - 5.60 7.6 6 4.4 4 INCREASED TO NORMAL; The result of potassium was
mmol/L increased due to the presence of diabetic nephropathy
since the kidneys are the primary regulator of potassium
balance. One of the reasons why the potassium level of the
patient normalized is due to the administration of Lasix drip
240 mg in 90cc D5W x 10cc/hour which was ordered by the
physician on January 12, 2009 since the patient was unable
to produce a normal urine output. One of the effects of this
drug is to excrete potassium in urine.
CK -MB 0 - 24 U/L 15 ---- ---- ---- NORMAL; CK-MB is an isoenzyme which has a high
concentration in the cardiac muscle. If the myocardium or
the cardiac muscle is damaged, it will release a large
amount of CK-MB in the bloodstream. This test was taken
to assess if the patient might be suffering of myocardial
infarction since he has CAD and had suffered MI last 2008.
TROPONIN Negative Negative ---- ---- ---- NORMAL; Troponin is a protein found in the cardiac
muscles and it regulates the myocardium contractile
process. This test was taken since this is a critical marker
of myocardium damage. The patient might be suffering
from myocardial infarction since he has CAD and had
suffered MI last 2008.

28
29
LABORATOR NORMAL RESULT INTERPRETATION/ SIGNIFICANCE
Y VALUE (Jan. 12,
(Urinalysis) 2009)

COLOR Yellow Dark The patient’s color of urine is dark yellow since there is
Yellow presence of RBC in his urine due to kidney damage.
TRANSPARE Clear Cloudy Cloudy urine of the patient is due to the presence of RBC,.
NCY
REACTION 4.5 – 8 6.0 NORMAL; This was assessed since pH indicates the acid base
balance. The urine pH reflects the work of the kidneys to
maintain normal pH homeostasis. This test is important to
assess to determine the function of the kidney as regulator of
pH.
SPEC. 1.005 – 1.002 DECREASED;. Specific gravity is used to evaluate the
GRAVITY 1.025 concentrating and excretory power of the patient’s kidneys. A
decrease in the level of specific gravity signifies that the kidneys
are not able to concentrate the urine. The result suggests that
the kidneys of the patient might be damage since if the kidneys
are not properly functioning such as in renal failure, the kidney
loses its ability to concentrate urine through water reabsorption.
ALBUMIN negative +2 INCREASED; Proteins are sensitive indicator of kidney function.
Normally, protein is not present in the urine because the spaces
in the normal glomerular filtrate membrane are too small to
allow its passage. Since there is a presence of protein in the
patient’s urine, it might suggest that his kidneys might be
damaged secondary to diabetes mellitus.
GLUCOSE Negative INCREASED; This test serves as an additional to the evaluation
of the patient’s kidney function. Presence of glucose in the urine
might suggest an additional role in determining if the kidney of
the patient is entirely damaged. Glycosuria can be the result of
damaged to the patient’s renal tubule secondary to diabetes
mellitus
LEUKOCYTE 0 - 4/ hpf 2/ hpf NORMAL; This test was taken to assess if the patient might
S have infection.
RBC <2/ hpf 3-4/ hpf There is a presence of blood in the patient’s urine
(hematuria). The result suggests that his kidneys especially his
glomerulus might be damaged causing an increased
permeability of the glomerular wall resulting in the migration of
erythrocytes through the damage cell wall.
BACTERIA Negative Few The presence of bacteria indicates might indicate presence of
infection.
Electrocardiography ECG #79213 January 11, 2009

30
RATE: 75 / min
RHYTHM: Sinus
INTERVAL: PR - 0.20 QRS - 0.08 QT - 0.38
INTERPRETATION: Old antero septal wall MI
High Lateral wall ischemia

CHEST AP, SEMI UPRIGHT January 11, 2009

FINDINGS:
The cardiac shadow is enlarged with accentuation of pulmonary vascularity.
Hazed density observed in the right hilar - perihilar areas.
Cardiomegaly with pulmonary congestion / interstial edema and pneumonitis.
Other chest structures are unremarkable.

2D ECHOCARDIOGRAPHY RESULT January 12, 2009

Echocardiographic Information

31
Dimension Measureme Normal Dimension Measureme Normal
nt nt
LV (ed) 5.6 4.5-5 cm LVEDV 152
LV (es) 4.1 LVESV 74
IVS (ed) .9 .8- 1.1 SV 78 cc
IVS (es) .9 CO 3978 cc
LPVW (ed) 1.1 .8- 1.1 EF 51% 55- 57%
LVPW (es) 1.3 FS 27% 29- 42%
Aorta 3.6 3- 3.5 VCF .5- 1.5
LA (ap 4.1 3- 3.5 LV mass 213
diam)
MPA 2.2 RA 3.9 3.5- 4 cm
LVET 280 RV 3.7 2.2- 4 cm
EPSS 1.1 < 1 cm MV Annulus 2.8
LVOT 2.2 TV Annulus 2.5

INTERPRETATION:
• Dilated left ventricles with hypokinesia of the interventricular septum and
thinned out from mid to apex. There is also hypokinesia of the anterior
and anterolateral left ventricular free wall from mid to apex.
• Dilated left atrium. Normal size right ventricle, right atrium, main
pulmonary artery and aortic root dimension.
• Structurally normal mitral valve, tricuspid valve and pulmonary valve.
• No pericardial effusion, no thrombus.

DOPPLER STUDY;
• Aortic Regurgitation - trivial
• Mitral Regurgitation - mild
• Tricuspid Regurgitation - trivial
• Reversed transmitral in flow velocities
• Pulmonary artery pressure is 49 mmHg by pulmonary acceleration time.

CONCLUSION:
1. Dilated left ventricle dimension with multisegmental wall motion
abnormality suggestive of CAD with systolic and diastolic dysfunction.
2. Dilated left atrium.
3. Aortic annular calcification.
4. Aortic sclerosis with trivial aortic regurgitation.
5. Mild mitral regurgitation.
6. Trivial tricuspid regurgitation.
7. Mild pulmonary hypertension

32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
VII- A. Nursing Care Plans

1. Decreased cardiac output related to altered myocardial contractility

2. Activity Intolerance related to fatigue and exertional dyspnea.
3. Constipation related to decreased peristalsis secondary to decreased level of activity.
4. Sleep pattern disturbance related to routine hospital procedures during night shift.
5. Ineffective Management of Therapeutic Regimen related to conflict between personal beliefs and the prescribed therapeutic regimen.

Date: January 15, 2008 (Thursday) 8:00 am

Data/Cues Nursing Rationale Goals and Nursing Intervention Rationale Evaluation

Diagnosis Objectives

Subjective: Decreased Coronary After 2 hours of Independent After 2 hours of

“ Maglakad cardiac output atherosclerosis nursing Tachycardia may be nursing
lang ako mula related to is an abnormal intervention, the • Monitor vital signs (e.g. linked with a drop in intervention, the
kama hanggang altered accumulation of client will be able heart rate, BP). Decreased
cardiac output cardiac
whichoutput
is goal was partially
CR, napapagod myocardial lipid and fibrous to: may be reflected
secondary in
to decreased met as
at hinihingal na contractility tissue within diminished
stroke volume. peripheral
Changes evidenced by the
agad ako”, as the coronary Goal: pulses. It is
may also occur due in
to blood following:
verbalized by artery, • Display an inadequate blood
pressure (hypotension flow to
or
the patient. progressively improvement the peripheral pulses.
hypertension) because of Vital Signs:
narrowing the of his cardiac cardiac response.
Objective: lumen of the output. Pallor is indicative of PR= 70 beats per
PE vessel. As the • Auscultate heart diminished
S3, or S4 can peripheral
occur with minute
- Weak and lumen narrows, Expected sounds. perfusion secondary
cardiac decompensation to HR= 72 beats
decreased resistance to Outcomes: inadequate cardiac
or some medications. S1 per minute
peripheral pulse flow increases output.
and S2 Cold,
may be clammy
weak skin RR= 20 breaths
and myocardial o Vital signs is secondary to
because of diminished per minute
- Pale nail beds blood flow is within compensatory
pumping action. increase in BP= 120/80 mm
compromised acceptable sympathetic nervous Hg
- Capillary refill that deprives limits. system stimulation and
of 5 seconds cardiac muscle low cardiac output. - Weak and
cells of oxygen o Strong decreased
- Exertional needed for their peripheral Changes in sensorium peripheral pulse
50
dyspnea survival. If the pulses may
decrease in • Palpate peripheral - Pale nail beds
- Vital Signs: blood supply is o Capilliary pulses. Decreased cardiac output
PR= 68 beats great enough, Refill of less may be reflected in - Capillary refill
per minute of long than 3 sec. diminished peripheral of 5 seconds
HR= 70 beats duration, or pulses. It is due to
per minute both, o Regular inadequate blood flow to - Able to perform
RR= 22 breaths irreversible cardiac the peripheral pulses. self care
per minute damage and rhythm. • Inspect skin color and activities such as
BP= 120/80 death of temperature. Pallor is indicative of combing hair,
mm Hg myocardial o Reports diminished peripheral feeding, and
Temp: 36.4 cells, or MI decreased perfusion secondary to changing of
result. severity of inadequate cardiac clothes.
- Pulse deficit of Overtime, exertional output. Cold, clammy skin
2 beats irreversibly dyspnea. is secondary to
damaged compensatory increase in
Laboratory myocardium o Participates in sympathetic nervous
Findings: undergoes self-care system stimulation and
degeneration activities • Note changes in low cardiac output.
- Color flow and is replaced without sensorium (lethargy,
Doppler study by scar tissue, feeling confusion, Indicate inadequate
result: causing various exhaustion. disorientation, anxiety, cerebral perfusion
Abnormal color degrees of and depression). secondary to decreased
flow display myocardial cardiac output.
noted across dysfunction.
the mitral valve Significant • Assess for chest pain.
and tricuspid myocardial The most common
valve during damage may manifestation of
systole and result in myocardial ischemia is
across the persistently low acute onset of chest pain.
mitral valve cardiac output, This allows for prompt
and aortic valve and the heart intervention.
• Maintain adequate
during diastole. cannot support
ventilation and
the body’s need
perfusion, as in the
- Cardiac output for blood.
following:
of 3.98 L/min
o Place in semi-
to- high fowler’s
Source: This position reduces
51
1. Brunner & position. preload and ventricular
Suddarth’s filling by minimizing the
Textbook of degree of stretch on the
Medical- cardiac muscle fibers.
Surgical • Maintain physical and
Nursing 11th emotional rest as in
Edition by: the following:
Suzanne C.
Smeltzer et al. o Restrict activity.
page 860 Physical rest should be
maintained to reduce
oxygen demands by
improving efficiency of
cardiac contraction and to
decrease myocardial
oxygen demand or
consumption and
o Provide quiet and workload.
relaxed
environment. Psychological rest helps
reduce emotional stress,
which can produce
vasoconstriction,
elevating BP and
increasing heart rate or
o Organize nursing load
and medical care.
This allows rest periods
and optimal use of
o Provides for patient’s limited energy
adequate rest resources.
periods. Assists in
performing self-care Physical rest improves
activities. efficiency of cardiac
contraction and to
decrease myocardial
o Have patient avoid oxygen demand/
activities eliciting a consumption and
vasovagal response workload.
52
 such as straining
during defecation, Vasovagal maneuver
holding breath (Valsalva maneuver)
during position causes vagal stimulation
changes. followed by rebound
tachycardia, which
further compromises
o Encourage cardiac function or
immediate reports output.
of pain for prompt
administration of
medication as
indicated. - Timely intervention can
reduce oxygen
Collaborative: consumption and
myocardial workload and
Administer Digoxin may prevent or minimize
(Lanoxin) 0.25 mg ½ tab cardiac complications
PO every other day

Digoxin increases
contractility of the
myocardium by inhibiting
ATP and sodium-
potassium exchange
activity. The altered ionic
distribution across the
membrane results in an
augmented calcium ion
influx, thus increasing the
availability of calcium at
the time of excitation-
contraction coupling.

Source/s:
1. Nursing Care Plans (6th
ed)
53
 Marilyn Doenges
Page 63-64
2. Delmar’s Critical Care
(Nursing Care Plans,
Sheree Comer,2nd edition.
Page 31-33

Date: January 15, 2008 (Thursday) 3:00 pm

Data/Cues Nursing Rationale Goals and Nursing Intervention Rationale Evaluation

Diagnosis Objectives

Subjective: Activity Activity After 8 hours of Independent After 8 hours of

“Hindi ko na Intolerance intolerance is nursing nursing
kayang related to defined as intervention: • Assess the patient’s Cardiopulmonary status intervention, goal
maglakad ng fatigue and insufficient cardiopulmonary status determines the patient’s was met as
mahaba- haba exertional physiological Goal: and stability for exercise ability to tolerate evidenced by the
kaya dito na dyspnea. energy to • Client will before activity using the activities. following:
lang ako sa endure or perform ADLs following measures.
kama”, as complete within Client’s heart rate
verbalized by required or capabilities • Observe and document and blood pressure
the patient. desired daily response to activity. Report Close monitoring serves were within normal
activities. Most Expected any of the following: as a guide for optimal limits.
activity Outcomes: o Rapid pulse (20 to 30 progression of activity
Objective: intolerance is beats/min over resting During exercise, intense No shortness of
related to o Client exhibits rate or 120 beats/min) increase in metabolism breath, weakness
Patient always generalize normal heart o Palpitations/noticeable in active skeletal and fatigue were
stays on bed weakness rate and change in heart rhythm muscles acts directly on exhibited by the
and seldom secondary to blood o Significant increase in the muscle arterioles to client.
walks. acute or pressure, as systolic BP (greater relax them and to allow
chronic illness well as than 20 mm Hg) adequate oxygen and Client enumerated
Patient and phase. absence of o Significant decrease in other nutrients needed and used energy-
requires During activity, shortness of systolic BP (greater to sustain muscle conservation
aaistance in where oxygen breath, than 10 mm Hg) contraction. This serves techniques.
activities such demands are weakness and o Dyspnea, labored as a signal that the
as toileting, paramount, the fatigue patient cannot tolerate Patient was able to
breathing, wheezing
and getting out compensatory the activity and perform Self Care
o Weakness, fatigue
of the bed. mechanism of therefore, must stop. Activities such as
54
 the heart which o Client o Light-headedness, dressing, feeding,
Exertional is t increase the verbalizes dizziness, pallor , grooming and
Dyspnea heart rate is and uses diaphoresis getting to bedside
unable to meet energy- o Chest discomfort commode without
- Vital Signs: the demands of conservation exhaustion.
PR= 68 beats the body, techniques Encourage adequate rest
per minute causing easy period, especially before
HR= 70 beats fatigability. meals, other ADLs, exercise Rest between activities
per minute sessions, and ambulation provides time for energy
RR= 22 breaths Source: conservation and
per minute Nursing Care Assist with ADLs as indicated; recovery.
BP= 120/80 Plans, Nursing however avoid doing for
mm Hg Diagnosis and patients what they can do for
Temp: 36.4 Inrevention,6th themselves. Caregivers need to
edition, balance providing
Gulanick/Myers assistance with
Textbook of facilitating progressive
Medical endurance that will
Surgical Intervention: ultimately enhance the
Nursing, 11th patient’s activity
edition Encourage active ROM tolerance and self-
exercises(ind). esteem.

Teach the patient and
caregivers to recognize signs
of physical overactivity
Teach energy conservation
techniques, such as the
following:
Exercise maintains
muscle strength and joint
ROM. Limiting
movement reduces blood
flow, typically resulting in
stiff, painful joints, and
this pain contributes to
the spiral of inactivity
and ROM loss.
This promotes awareness
of when to reduce
activity

These reduce oxygen

55
Sitting to do tasks
Changing position often
Working at an even pace
Teach ROM and strengthening
exercises
consumption, allowing
more prolonged activity
Standing requires more
work. Good posture,
sitting or standing,
balances the weight of
your head and limbs on
the bony framework so
that the force of gravity
helps keep joint position.
This distributes work to
different muscles to
avoid fatigue
This allows enough time
so not all wok is
completed in a short
period.
Exercise promotes
increased venous return,
and maintains/increases
muscle strength and
endurance.
Sources:
• Cardiovascular
and Pulmonary
Physical Therapy
Evidence and
Practice, 4th
edition,
Felter/Dean
• Physical
Rehabilitation,
O’Sullivan,
Schmitz
56
 • Textbook of
Medical
Physiology,
Guyton and Hall
• Essentials of
Anatomy and
Physiology, 7th
edition, Marieb

January 15, 2008 (Thursday) 7:00 am

Cues/ Needs Nursing Rationale Planning Nursing Rationale Evaluation

Diagnosis Intervention
Subjective: Constipation The patient has After 8 hours of Independent: After 8 hours of
related to been on bed rest nursing nursing
“Nurse, bigyan decreased for four days now. intervention, the Encourage patient to Soft Diet aids in the intervention, the
niyo na ko ng peristalsis This position patient will be consume foods that digestion process goal was met. The
suppository dahil secondary to promotes able to have a are soft in producing soft formed patient was able to
kasing tigas na ng decreased level decrease in bowel consistency. May stool. move his bowel at
bato yung dumi of activity. peristaltic movement. include noodles and around 3:00 pm
ko, nahihirapan movement in the porridge in diet. that day.
na ako”, as Gastrointestinal Expected
verbalized by the Tract. Thus, Outcomes: Encourage adequate Fluids soften the - Patient
patient. decreasing gastric fluid intake within consistency of the stool experienced
emptying time and Patient will not restriction. decreasing the risk for straining when she
Objective: prolongs experience being constipated. tried to defecate.
absorption of fluid straining during
- Bowel Sounds of from the food defecation. Encourage - Patient was not
6/ min making the formed ambulation, as Ambulation promotes able pass a soft
stool harder. Patient will pass tolerated. peristalsis and Bowel formed stool.
- Patient has been a soft formed Movement.
57
confined on bed stool on
for 4 days now. moderate Provide privacy to the Privacy promotes ease of
Source: amount. patient when the defecation.
- Patient has not Holloway, Nancy, urge to defecate is
had Bowel 2003. Medical- felt.
Movement since Surgical Care
January 12, 2009. Planning. 4th Dependent:
Edition. Pp 347. The metabolites of
- Patient is with Administer laxative lactulose draw water into
contraptions Lactulose (Duphalac) the bowel, causing a
which include: 30 cc OD at bedtime. cathartic effect through
Foley cathether, osmotic action.
Peripheral IV line
and O2 via nasal
cannula on PRN Source:
basis Gulanick, Meg., 2007.
Nursing Care Plans.
Nursing Diagnosis and
Intervention. 6th Edition.
Date: January 15, 2008 (Thursday) 11:00 pm

Cues/ Needs Nursing Rationale Planning Interventions Rationale Evaluation

Diagnosis
Subjective Sleep pattern Proper sleep After 24 hours of Independent After 24 hours of
Data: disturbance and rest are nursing interventions, Interventions: nursing interventions,
“Hindi ako related to important to the client was able to: -Maintain environment -To promote sleep the goal was MET as
gaanong routine hospital good health as conducive to sleep or rest and rest evidenced by:
makatulog kasi procedures good nutrition Goal: like quiet environment
kahit gabi during night and adequate Achieve optimal and comfortable -Well-rested
merong shift. exercise. amounts of sleep. temperature appearance
pumapasok Without proper -To promote
dito sa amounts of rest Expected Outcome: -Assist in observing any relaxation -Verbalized that he was
kwarto”as and sleep, the - Looks well rested previous bedtime ritual able to rest well during
verbalized by ability to -These promote the night
the patient. concentrate, -Verbalization of -Provide nursing aids such sleep and
make feeling rested as back rub or relaxation through -Verbalized that he was
Objective judgments, and comfortable position able to sleep longer
Data: participate in -Verbalization of -To promote hours
daily activities improved sleep -Organize nursing care minimal
58
-Restlessness decreases and pattern and eliminate interruption in
observed irritability nonessential nursing sleep/rest
during night increases. activities
shift -Experimental
Our patient has -Attempt to allow for studies have
-Frequent been on his sleep cycle of at least 90 indicated that 60-
yawning fourth day of min 90 min are needed
hospitalization. to complete one
-Irritability According to sleep cycle and the
him, routine completion of an
-Fatigued hospital entire cycle is
appearance procedure necessary to
especially benefit from sleep
during the
night shift -Adherence
prevents him previously
form having an -Establish semblance of established
uninterrupted “normal daily” routine patterns/routines
sleep. with periods of activity, minimizes energy
rest required for
adaptation and
disruption in
biological rhythms
*Source:
Fundamentals - These help
of Nursing by promote sleep
Patricia A. during the night
Potter and -Provide soporifics such as
Anne Griffin milk and avoidance of
Perry page stimulants such as
1199. caffeinated beverages -Napping can
before sleep disrupt normal
sleep pattern
-Discourage daytime naps
unless deemed necessary
or part of usual pattern -To reduce need for
voiding during
- Limit fluids 2 to 4 hours night
before bedtime
59
Dependent - This drug is
Intervention: indicated for
- Administer Zolpidem short-term
(Stilnox) 10mg ½ tab management of
insomnia. It
interacts with
GABA –
benzodiazepine
channel chloride
complex and binds
itself with GABA-A
receptor complex
on the alpha
subunit, which is
known as the
benzodiazepine
(BZ) type 1 or
omega receptor.
Then it will
modulate the
actions of GABA.
Upon modulation,
sedation occurs.
-Carry out doctor’s order Thus sleep is
of no vital signs induced.
monitoring when the
patient is asleep. - Preventing
disturbance and
stimulation during
sleeping hours
promotes restful
sleep.

*Source:
Nursing Care Plans

60
 3rd Edition by Meg
Gulanick et al.
pages 63-62

Date: January 17, 2008; 3:00 pm

Cues/ Needs Nursing Rationale Planning Nursing Rationale Evaluation

Diagnosis Interventions
Subjective Data: Ineffective The patient has After 8 hours of Assess the The patient must be After 8 hours of
“Lahat naman Management of this belief that nursing patient’s motivated to learn, have nursing
tayo mamatay, Therapeutic death is intervention, the readiness and the capability to learn the intervention, the
kapag hindi ko Regimen related unavoidable and patient will ability to learn. content, and be free of goal was not met.
kinain ‘yung mga to conflict one should enjoy verbalize distractions from learning The patient still
gusto ko ngayong between personal life without too readiness to such as pain and emotional insisted on not
nabubuhay pa beliefs and the much restriction modify present distress. following his
ako, hindi ko na prescribed for when one dies management of prescribed diet.
‘yon makakain sa therapeutic he can no longer therapeutic The patient may have some
langit”, as regimen. enjoy these regimen. Assess what the knowledge about his Expected
verbalized by the things. This belief patient already disease conditions and Outcomes:
61
patient. of the patient Expected knows. teaching should begin with
conflicts with his Outcomes: what the patient already -Patient shows
Objective Data: compliance to the knows. resistance when
-Patient shows no therapeutic -Patient will ask being taught
interest in regimen he is questions Stress the Reinforcing the appropriate about effective
learning more prescribed to regarding the importance of Diet may encourage management of
about the disease. follow. He does disease process adhering to the patient’s compliance to his condition.
not adhere to his and how to prescribed Diet for therapeutic regimen.
-Patient asks no Low Salt Low Fat- manage his the patient. -patient did not
question on how Diabetic Diet condition ask questions on
to improve his because following effectively. Enumerate the Understanding the negative how to improve
condition. this will contradict foods that are effects of consuming the his present
his belief. This restricted for restricted foods may condition.
conflict results to consumption by enhance compliance.
patient having the patient and
ineffective the rationale for
management of such restrictions.
his therapeutic
regimen. Provide food To provide patient with
selections and choices of food that he can
alternatives for consume to prevent the
Source: those restricted usual food he is consuming
Rodger’s, Shielda foods for the from becoming less
R. Medical- patient. appealing.
Surgical Nursing
Care Plans. Pp Discuss with the
967- 970 patient the Understanding the risks of
complications that not following the prescribed
may arise from his treatment regimen may
condition when enhance compliance to
effective therapeutic regimen.
management is
not practiced.

Encourage patient
to have regular Regular follow up is
Appointments required to monitor blood
with the health sugar and progress towards
care provider. control and self
62
management, as well as for
early detection of
complications.

Source:
Rodger, Shielda R. Medical-
Surgical Nursing Care
Plans. Pp 967- 970

63
VII- B. On Going Appraisal
On January 15, 2009 at 0600H, the patient was received awake lying on bed with
O2 at 2Lpm via nasal cannula as ordered. The patient was with IVF of PNSS1L X KVO at
300cc level. With foley catheter to urine bag, clamped for bladder training. Patient was on
DM diet of 1,800kcal/day, 40g protein without fruits and juices. On CBG monitoring three
times a day pre-meals. On fluid restriction of 800cc/day. The patient reported urge to
urinate and complained of pain at the genital area. CBG reading was 145 mg/dl.
At 0700H, the patient complained of difficulty of moving his bowel. It was his third
day without bowel movement. AP was informed and order was made to give the HS dose
of Duphalac 30 cc stat.
At 0800H, vital signs were taken and recorded, no abnormalities noted. Plavix
75mg/tab, Pantoprazole 40mg, Dilatrend 25mg 1/2tab, Amlodipine 5mg 1tab, Aprior 20mg
were given.

At 1015H, standing order of HR 6units SQ before breakfast was discontinued as

ordered. With orders to give HR pre-meals with new sliding scale of:
CBG < 150 – none
150 – 200 – 4 units
201 – 250 – 6 units
> 250 – 8 units
To continue HN 15 units SQ before breakfast and 10 units SQ at 10pm daily as ordered.

At 1030H, foley catheter was removed as ordered and O2 on PRN basis

At 1130H, CBG reading was 227 mg/dl, 6 units of HR SQ was given per sliding scale.

At 1200H, VS taken and recorded with BP of 130/80.

At 1400H, pain felt at the genital area was decreased as reported by the patient.
Urine output was 250 cc the whole shift. IVF of PNSS1L x KVO was at 50cc level.

At 1530H, IV line was removed as ordered.

At 1600H, VS were taken and recorded, no abnormalities noted.

At 1730H, CBG reading of 277 mg/dl, 8 units of HR SQ was given.

At 1810H, the patient has crackles on auscultation, 12am dose of Lasix 40mg 1tab
was put on hold as ordered. With new orders to limit total fluid intake to 1.0 – 1.2L/day and
for repeat BUN, Creatinine, Potassium tomorrow morning.

At 2000H, VS were checked and recorded with no abnormalities noted

64
 At 2200H, patient had urine output of 330cc the whole shift. CBG reading was 185,
HN 10 units was given subcutaneously as ordered.

At 2300H, the patient complained of difficulty falling asleep. Stilnox 10mg ½ tab
was given.

At 2400H, the vital signs were not monitored because the patient was seen asleep
on bed.

On January 16, 2009 at 0400H, the patient was able to void freely

At 0530H, CBG was 110 mg/dl.

At 0600H, urine output was 420cc with one bowel movement the whole night shift.
Patient was received flat on bed. Out on pass was allowed by the doctor and with orders
for possible discharge tomorrow. The patient reported three times bowel movement with
loose, watery stool. Lactulose was discontinued as ordered.

At 0800H, VS were checked and recorded, no abnormalities noted. Amlodipine 5mg

½ tab OD, Sangobion 1tab TID and Ketoteril 2tabs BID were given. Creatinine was noted,
2.2 mg/dl.

At 1130H, CBG was 229 mg/dl, 6 units of HR SQ was given.

At 1200H, no abnormalities noted regarding the vital signs of the patient.

At 1400H, patient’s urine output the whole shift was 1250cc with reports of 2x
bowel movement.

At 1600H, VS taken and recorded, no abnormalities.

At 1640H, the patient reported to have no objection for discharge. Patient was given
prescription for home medications of:
1. HN 15 units + HR 6units SQ before breakfast daily
2. HN 10 units + HR 6 units before supper daily, if CBG < 100 mg/dl, give HN
only, hold HR
3. CBG monitoring at home twice a day, before breakfast and supper daily.
4. for OPD follow-up after one week with CBG monitoring records at home.

At 1730H, CBG reading was 216 mg/dl, HR 6 units SQ was given per sliding scale.

65
 At 2000H, no abnormalities noted on vital signs.

At 2200H, urine output of 420cc and no bowel movement during the whole shift.

On January 17, 2009 at 0530H, VS were taken and recorded with BP of 130/70.
CBG reading was 105 mg/dl with no complaints made during the entire night shift. Urine
output of 300 cc/ shift with no bowel movement.

At 0600H, patient was received awake on bed and was advised on protein and
water restriction.

At 0800H, vital signs taken and recorded, BP of 130/90. Patient was given additional
prescription of home medications: Sangobion 1cap TID and Ketosteril 2caps BID. For
follow-up after 2 weeks with BUN, Crea, K and Urinalysis.

At 1130H, CBG was 220 mg/dl, patient was given 6 units of HR subcutaneously per
sliding scale.

At 1200H, VS taken and recorded with BP of 130/90

At 1400H, urine output was noted 450cc the whole shift with no bowel movement.

At 1530H, the patient was discharged, ambulatory, with home meds and OPD
follow-up instructions.

VII- C. Discharge Plan

1. Medications
Advised patient to take her home medications
• HN 15 U + HR 6U SQ before breakfast daily
• HN 10 U + HR 6U SQ before super daily if CBC < 100, give HN only. Hold HR
• Aprion 20 mg/ tab 2x a day
• Clopidogrel 25 mg/ tab 2x a day
• Lanoxin 0.25 mg ½ tab every other day
• Cardipres 25 mg/ tab AM
• Sangobion 3x a day
• Ketosteril 2 caps 2x a day

2. Exercise

66
• May do light exercises if symptoms subsides (walking, stretching). Stop exercise if the
patient feels chest pain, dizziness, difficulty of breathing.

3. Treatment
• CBG monitoring at home. BID before breakfast and supper daily

4. Health Teachings

• Instruct the patient to take all your medications as prescribed by your doctor
• Instruct the patient to keep a list of the medications with patient at all times
• If the patient has questions or concerns, call the doctor. Do not stop or change the
dose of any of the medications with out first talking to the doctor.
• Instruct the patient not take any medications-including vitamins, Over-the-counter
medications or herbal remedies-with out first talking with the doctor.
• Instruct the patient to weigh himself every morning after going to bathroom. Use same
scale and weigh himself in the same type of clothing each day.

For Congestive Heart Failure

• Plan rest periods during the day to allow heart to regain strength for next activities.
• Advised the patient to immediately stop whatever he is doing if he feels tired,
experience chest pain or have shortness of breath
• Instruct patient to put his feet up every few hours to avoid swelling.
• Instruct patient to avoid smoking to have enough rest at night.

For Diabetes Mellitus:

• Teach patient specific directions for obtaining an adequate blood sample and
what to do with the numbers that they receive.
• The patient needs to be reminded to record the blood glucose values on a log
sheet with the date and time and any associated signs and symptoms that
he/she is experiencing at the time the specimen was obtained.

• Teach the patient about self-administration of insulin or oral agents as

prescribed, and the importance of taking medications exactly as prescribed, in
the appropriate dose Patients should be provided with a list of signs and
symptoms of hypoglycemia and hyperglycemia and actions to take in each
situation.

67
• The patient should also be educated on the importance of smoking cessation,
cholesterol and lipid management, blood pressure monitoring and management
of other disease processes.

• Encourage client and family about regular exercise. Regular exercise can
improve the functioning of the cardiovascular system, improve strength and
flexibility, improve lipid levels, improve glycemic control, help decrease weight,
and improve quality of life and self-esteem.

5. OPD Follow Up

• Follow-up after 1 week (January 24, 2009) with CBG results from home
• Follow-up after 2 weeks with BUN, (January 31, 2009) Creatinine, Hematocrit, Urinalysis
results

6. Diet
Instruct patient to adhere to a diet restricted on Salt, Fat, Protein, and Carbohydrates.

• Advise patient to follow a fluid restriction of up to 1.2 L/ day

• Limit the amount of Sodium (salt) in the diet to less than 2,000 mg each day.
.>Instruct patient not to add salt while cooking or at the table
>Instruct patient to avoid processed foods like luncheon meats and canned sopis
>Check food labels for Sodium content
>Instruct patient to consult the doctor or a dietitian before using any salt substation
>Instruct the patient to consult the doctor about how much liquid the patient can drink
each day.

• Instruct the patient to eat balanced diet that is low in fat

> All types of added fats, such as butter, margarine, mayonnaise, sour
cream and salad dressings, are reduced or eliminated.
> Foods high in fat, such as fried foods, snack foods, cheeses and red meat,
should be replaced with lower-fat versions or eaten in smaller portions.

• Instruct patient to adhere to a Diabetic diet

> Eat more starches such as bread, cereal, and starchy vegetables. Aim for six
servings a day or more. For example, have cold cereal with nonfat milk or a bagel with
a teaspoon of jelly for breakfast. Another starch-adding strategy is to add cooked black
beans, corn or garbanzo beans to salads or casseroles.

68
 > Eat five fruits and vegetables every day. Have a piece of fruit or two as a
snack, or add vegetables to chili, stir-fried dishes or stews. The patient can also pack
raw vegetables for lunch or snacks.
> Eat sugars and sweets in moderation. Include patient’s favorite sweets in his
diet once or twice a week at most. Split a dessert to satisfy his sweet tooth while
reducing the sugar, fat and calories.

• Instuct patient to adhere to a Protein- Restricted Diet

 Fruits and most vegetables have little or no protein. There are some exceptions to this like peas,
beans (both can be rather high) and some starchy vegetables (like potatoes and corn which are in
the medium range).
 Teach Patient to avoid eating organ meats

7. Signs/Symptoms

Call the doctor the immediately if the patient experiences the following:

For Congestive Heart Failure:

• Sudden weight gain(3-5 movies in 1-4 days)\
• Swollen feet, ankles, legs, abdomen
• Shortness of breath which may occur with activity ( may become continuous and
may cause to make up breathless @ night)
• Difficulty sleeping
• Frequent dry, hacking, cough, especially when lying down
• Extreme fatigue or a constant feeling of tiredness
• Decrease in how often or how much the patient urinate

For Diabetes Mellitus:

Early signs of hyperglycemia in diabetes include:
• Increased thirst
• Headaches
• Difficulty concentrating
• Blurred vision
• Frequent urination
• Fatigue (weak, tired feeling)
• Weight loss
• Blood glucose more than 180 mg/dL

Prolonged hyperglycemia in diabetes may result in:

• Vaginal and skin infections

69
 • Slow-healing cuts and sores
• Decreased vision
• Nerve damage causing painful cold or insensitive feet, loss of hair on the lower
extremities, and/or erectile dysfunction
• Stomach and intestinal problems such as chronic constipation or diarrhea

Hypoglycemia causes symptoms such as

• hunger
• shakiness
• nervousness
• sweating
• dizziness or light-headedness
• sleepiness
• confusion
• difficulty speaking
• anxiety
• weakness

70