CASE

PRESENTATION
(Medical Ward)
I.

Demographic Profile :
Name: R.A.S.
Sex: Female
Age: 17
Civil Status: Single
Birthdate: July 2, 1997
Birthplace: Baguio City
Address (1): 126 Hamada Subdivision, Baguio City
Religion: Roman Catholic

II.

Address (2): 09301888728

Next of kin: Rosemarie Salenga
Admitting Physician: Dr. Bartolo

Nationality: Filipino
Relationship: Mother
Date and time admitted: May 3, 2015/ 8:30 pm.

Attending Physician: Dr. Adrian Calera

Chief Complaint: Generalized body pain

Room: 221-1, Medical ward

A. History of present illness

1 week prior to admission patient experience generalized body pain, rated as 3/10 but was tolerable.
She just continued her maintenance medications, Methylprednisolone and Arcoxia which provided relief of the
condition. No consults was done.
5 hours prior to admission, she was just resting when she suddenly felt pain in her whole body and
noticed that her fingers were swollen. She rates the pain as 9/10 which is aggravated by movement. Her
mother gave her maintenance medications but no relief was noted. Hence, she was brought in for
consultation with a private physician and was advised admission.

B. Past Medical History

The mother claims that the patient had been diagnosed of rheumatic heart disease in her childhood
years. In September 2014, the patient had dental extraction. The mother also claimed that she had a rheumatic
heart fever and was given Salphen via IV. She was also admitted in BGH, at an unrecalled date for kidney problems
secondary to her tonsillitis. The mother claims that she had an average of 3 incidence of tonsillitis in a month.On
March 15, 2015, she was diagnosed of rheumatoid arthritis but she was negative for rheumatoid factor. She
currently takes Arcoxia 120 mg OD and Methylprednisolone 16 mg OD for her maintenance medications. She also
had been given Clenza 10 mg OD for 3 Days. The mother claimed that the patient is 100% compliant with her
medications. No known allergies to food and drugs. No other history of surgery or trauma. The mother claimed the
she have received complete immunization when she was a child.
C. Family History
There is no known maternal history of cerebrovascular disease. The patient had a history on both sides
of coronary artery disease, diabetes mellitus and hypertension. There was no known history of pulmonary
tuberculosis, cancer, dementia and depression.

D. Social and Environmental History

The patient is a non-smoker, non-alcohol drinker, non-caffeinated beverage drinker. She lies an active
lifestyle until the beginning of March when she started to have problems with her boy. The family lives in a wellventilated, non-congested, two-story house with 3 bedrooms and 6 occupants. She used to stay upstairs but now
she was limited to the ground level due to her body pains. She is a 3 rd year college student. The familys drinking
water comes from a water refilling stations and the water for domestic purposes comes from the Baguio water
district. She doesnt practice fad diets and any restrictions on her foods. They have 1 dog living in their backyard.
The toilet is of manual flushed-type. Garbage is collected weekly.
Diagnostic/ Laboratory Results:
X-ray: Hands: reveals swelling are note overlying the proximal interphalangeal joints and
metacarpophalangeal joints
Chest: Mild Cardiomegaly
Doppler Ultrasound: Dilated left atrium with left atrial volume index of 29 cc/m3
Positive systemic erythemathosus (SLU)

LIST OF PRIORITIZATION:

PRIORITIZATION
1. Acute pain related to ongoing inflammatory
disease
1.1 Impaired comfort

JUSTIFICATION
This is the first prioritized problem because this is what
the patient complains about and it is an actual problem
existing that may result to further complications if not
resolved first. According to Maslows hierarchy of needs
under physiologic needs rest is needed and should be
met firs before moving to the level of hierarchy.

2. Ineffective peripheral tissue perfusion related to

decreased blood flow

This is the second priority because according to the

ABCs of life circulation should be prioritized first and to
prevent possible or further complications of decreased
blood flow.

3. Activity Intolerance related to generalized body

weakness/pain
3.1. Fatigue related poor physical condition
3.2 Risk for fall
3.3. Risk for injury

This is the third priority because this can be solved if the

above problems will be solved. And also according to
Maslows hierarchy of needs this falls under Safety which
needs to be met before going to the next level of
hierarchy. And I clustered the other 3 problems into this
since they will have the same or similar nursing
interventions and the risks will not occur if given
appropriate interventions.

4. Risk for imbalanced body temperature related to

infection/inflammation

This is my last prioritized problem since it is a potential

problem that may arise if the above problems will not be
resolved and also it can be corrected immediately with
paracetamol or drug administration.

NCP 1

ASSESSMENT

EXPLANATION
OF PROBLEM
S>Medyo
Blood is a
maputla nga po connective
ung kamay ko
tissue
composed of a
O>capillary
liquid
refill of 3-4
extracellular
seconds,
matrix called
Doppler
blood plasma
Ultrasound:
that dissolves
dilated left atria and suspends
with left atrial
various cells
volume index of and cell
29 cc/m3, X-ray: fragments.
mild
Blood transports
cardiomegaly,
oxygen from the
nail beds: pale, lungs and
CR: 76 bpm
nutrients from
regular BP:
the
110/70, with
gastrointestinal
noticeable S1
tract. The
and S2
oxygen and
auscultatory
nutrients
sound, urine
subsequently
output for the
diffuse from the
shift(7-3): 500
blood into the
ml, yellowish
interstitial fluid
clear, patient is and then into
awake,
the body cells.

OBJECTIVES

INTERVENTIO
NS
LTO> After 72
DX
hours of nursing Auscultate
interventions
apical pulse;
the client will
assess heart
be able to
rate, rhythm,
and document
a.eradicate
dysrhythmia if
stressors that
telemetry
can help in
available.
reducing the
workload of the
heart such as
stress
management,
therapeutic
medication,
balanced
activity rest
pattern
STO> : After 8

hours of nursing
interventions the
client will be able
to:

a.understand
significant

RATIONALE
Tachycardia is
usually present,
even at rest, to
compensate for
decreased
ventricular
contractility.
Premature atrial
contractions
(PACs),
paroxysmal
atrial
tachycardia
(PAT), PVCs,
multifocal atrial
tachycardia
(MAT), and AF
are common
dysrhythmias
associated with
HF, although
others may also
occur. Note:
Intractable
ventricular
dysrhythmias
unresponsive to

EVALUATION
LTO>
Fully met if
a.eradicate
stressors that
can help in
reducing the
workload of the
heart such as
stress
management,
therapeutic
medication,
balanced
activity rest
pattern
Partially Met if
a.lessen
stressors that
can help in
reducing the
workload of the
heart such as
stress
management,
therapeutic
medication,

coherent,
oriented to
time, place,
person
Nursing
Diagnosis:
Ineffective
Peripheral
Tissue Perfusion
related to
decreased
blood flow

Carbon dioxide
and other
wastes move in
the reverse
direction, from
body cells to
interstitial fluid
to blood. Blood
then transports
the wastes to
various organs
the lungs,
kidneys, and
skinfor
elimination form
the body.
Circulating
blood helps
maintain
homeostasis of
all body fluids.
Blood helps
adjust body
temperature
through the
heat absorbing
and coolant
properties of
the water in
blood plasma
and its variable
rate of flow
through the
skin, where

interventions
b.able to
perform passive
exercises

Note heart
sounds.

Palpate
peripheral
pulses.

medication
suggest
ventricular
aneurysm.
wingate, 2007
S1 and S2 may
be weak
because of
diminished
pumping action.
Gallop rhythms
are common (S3
and S4),
produced as
blood flows into
noncompliant,
distended
chambers.
Murmurs may
reflect valvular
incompetence
and stenosis.
wingate, 2007
Decreased
cardiac output
may be
reflected in
diminished
radial, popliteal,
dorsalis pedis,
and post-tibial
pulses. Pulses

balanced
activity rest
pattern

Not met if
a. No
eradication of
stressors which
can reduce the
workload of the
heart
STO>
Fully met if the
a. patient was
able to
understand
significant
interventions
b.able to
perform passive
exercises
Partially met if
a. patient was
able to
understand

excess heat can

be lost from the
blood to the
environment. In
addition, blood
osmotic
pressure
influences the
water content of
cells, mainly
through
interactions of
dissolved ions
and proteins.
Blood can clot,
which protects
against its
excessive loss
from the
cardiovascular
system after an
injury. In
addition, its
white blood
cells protect
against disease
by carrying on
phagocytosis.
Several types of
blood proteins
including
antibodies,
interferons, and
complement,

Monitor BP.

Inspect skin for

pallor and
cyanosis.

may be fleeting
or irregular to
palpation, and
pulsus alternans
may be present.
(Doenges,
M.E.et.al.,2014)
In early,
moderate, or
chronic HF, BP
may be
elevated
because of
increased SVR.
In advanced HF,
the body may
no longer
be able to
compensate,
and profound or
irreversible
hypotension
may occur.
Note: Many
clients with HF
have
consistently low
systolic BP (80
to 100 mm Hg)
due to their
disease process
and the
medications
they take. Most

some part of
the
interventions
b.able to
perform passive
exercises

Not met if
a. patient was
unable to
understand
some part of
the
interventions
b.unable to
perform passive
exercises

help protect
against disease
in a variety of
ways. However,
conditions such
as conditions
such as
amputation,
cerebrovascular
accident,
stroke,
crainiocerebral
trauma, disk
surgery,
myocardial
infarction,
sepsis,
thrombophebitis
, deep vein
thrombosis,
upper
gastrointestinal
bleeding and
atherosclerosis
causes.
Reduction in
arterial blood
flow that leads
to deprived
nutrition and
oxygenation at
the cellular
level.
Decreased

tolerate this Bps

without incident
(Wingate,
2007).
Pallor is
indicative of
diminished
peripheral
perfusion
secondary to
inadequate
cardiac output,
vasoconstriction
Check for calf
, and anemia.
tenderness;
Cyanosis may
diminished
develop in
pedal pulse;
refractory HF.
and swelling,
Dependent
local redness, or areas are often
pallor of
blue or mottled
extremity.
as venous
congestion
increases.
(Doenges,
M.E.et.al.,2014)
Monitor urine
output, noting
decreasing
output and dark
or concentrated
urine.

Decreases
venous stasis
and may reduce
incidence of
thrombus and
embolus
formation.

tissue perfusion
can be transient
with few or
minimal
consequences
to the health of
the patient. If
the decreased
perfusion is
acute and
protracted, it
can have
devastating
effects on the
patient.
Diminished
tissue
perfusion, which
is chronic in
nature,
invariably
results in tissue
or organ
damage or
death. Nursing
management is
directed at
following:
removing
vasoconstricting
factor(s),
improving
peripheral blood
flow, reducing

(Doenges,
M.E.et.al.,2014)

Note changes in
sensorium, for
example,
lethargy,
confusion,
disorientation,
anxiety, and
depression.

Provide quiet
environment,
explain medical
and nursing
management,
help client
avoid stressful
situations, listen
and respond to
expressions of
feelings or
fears.

Kidneys respond
to reduced
cardiac output
by retaining
water and
sodium. Urine
output is usually
decreased
during the day
because of fluid
shifts into
tissues but may
be increased at
night because
fluid returns to
circulation when
client is
recumbent.
May indicate
inadequate
cerebral
perfusion
secondary to
decreased
cardiac output.
(Doenges,

metabolic
demands on the
body, making
the patient
understand
his/her disease
process and its
treatment,
making the
patient
participate in
self-care
program, and
preventing
complications.

Reference:
Doenges, M.E.
et.al.(2010).
Nurses Pocket
Guide:
Diagnoses,
Prioritized
interventions and
rationale. F.A
Davis Company.
12th Edition. Pp.
69-73.

M.E.et.al.,2014)

Provide bedside
commode. Have
client avoid
activities
eliciting
a vasovagal
response, for
instance,
straining during
defecation and
holding breath
during position
changes.

Elevate legs,
avoiding
pressure under
knee.
Encourage
active and
passive
exercises.
Increase
ambulation and

Physical and
psychological
rest helps
reduce stress,
which can
produce
vasoconstriction
, elevating BP
and increasing
heart rate and
work.
(Doenges,
M.E.et.al.,2014)

Commode use
decreases work
of getting to
bathroom or
struggling to
use bedpan.
Vasovagal
maneuver
causes vagal
stimulation
followed by
rebound

activity as
tolerated.

tachycardia,
which further
compromises
cardiac function
and output.

EDX

Reduced cardiac
output, venous
pooling and
stasis, and
enforced
bedrest
increases risk of
thrombophlebiti
s.

Encourage rest,
semi recumbent
in bed or chair.
Assist with
physical care,
as indicated.

Physical rest
should be
maintained
during acute or
refractory
HF to improve
efficiency of
cardiac
contraction and
to decrease

myocardial
oxygen
consumption
and workload.

NCP 2
ASSESSMENT
S> Nahihirapan
pong maglakad,
tsaka mabagal
po.
O:- With

BRIEF
EXPLANATION OF
THE PROBLEM
Since my patient
is diagnosed of
having Rheumatic
heart disease
which means it is
caused by

Goals and
Objectives
LTO: After 72
hours of nursing
interventions the
client will be
able to

NURSING
INTERVENTIONS
Dx:
1.Assessed
functional level
of assistance

RATIONALE

>to be able to
give the
appropriate
assistance
needed.

CRITERIA FOR
EVALUATION/
EALUATION
After 72 hours of
nursing
interventions
LTO:
Fully met if:
the client will be

functional level
of 2.
- Muscle strength
of both left and
right upper
extremities: 3/5,
both lower
extremities: 4/5.
-Needs
assistance in
doing ADLS such
as toileting or
transferring from
one place to
another.
A :Activity
intolerance
related to
generalized
body
weakness/pai
n
3.1. Fatigue
related poor
physical
condition
3.2 Risk for fall
3.3. Risk for
injury

streptococcusinfe
ction in which my
patient has
sensitivity to the
antibodies that
were formed in
response to the
invading bacteria.
Since there is an
increase
production of
antigen it
circulates in her
system attacking
the valves of her
heart causing
inflammation.
Which makes the
heart difficult to
pump
blood.Becauseof
decrease cardiac
workload ,scarring
of heart valves
:mitral/aortic
valve is damage
which therefore
decreases cardiac
supply in different
parts of her
body ,in which
she complain of
body weakness .
Activity
intolerance
according to

a. have a muscle
strength of 5/5
in all
extremeties with
no pain and
discomforts

(Doenges,
M.E.et.al.,2014)
2.Assessed
muscle strength

a.Walk on her
own without
assistance.
c. Will not
develop any fall
and injury.
STO: After 8
hours of nursing
interventions the
client will be
able to:
a.walk on her
own with
minimal
assistance
needed
b.Verbalize
needs for
assistance
c.Able to
change
position (from
left to right or
vice versa)
frequently

TX
3. Gradually
increase activity,
allowing client to
assist with
positioning,
transferring, and
self-care as
possible.
Progress from
sitting in bed to
dangling, to chair
sitting, to
standing, to
ambulation
4.Perform rangeof-motion exercis
es if client is
unable to
tolerate activity.

>to determine
current status
and needs
associated with
participation in
needed/desired
activities. Serves
as a basis for
determining the
effectiveness of
nursing
interventions.
(Doenges,
M.E.et.al.,2014)
>Increasing
activity helps to
maintain muscle
strength, tone,
and endurance.
Allowing the
client to
participate
decreases the
perception of the
client as
incapable and
frail (Eliopoulous,
1998).
>Inactivity
rapidly
contributes to

able to
a.walk on her
own without
assistance
b.have a muscle
strength of 5/5 in
all extremeties
with no pain and
discomforts
c.Will not develop
any
complications
such as fall and
injury.
Partially met if:
needs minimal
assistance when
ambulating,5/5 in
all extremities
with pain or
discomforts
Not met if: Not
able not walk or
ambulate
And did not have
a muscle
strength of 5/5 in
all extremities.
STO :After 8
hours of nursing
interventions the
client will be able

NANDA, is an
insufficient
physiological or
psychological
energy to endure
or complete
required or
desired daily
activities.
Reference:
Doenges, M.E.
et.al.(2010).
Nurses Pocket
Guide: Diagnoses,
Prioritized
interventions and
rationale. F.A
Davis Company.
12th Edition. Pp.
69-73.

5.Allow for
periods of
rest before and
after planned
exertion periods
such as meals,
baths,
treatments, and
physical activity.

muscle
shortening and
changes in
periarticular and
cartilaginous
joint structure.
These factors
contribute to
contracture and
limitation of
motion (Creditor,
1994).

6.Administer
Colchicine a
ordered

>Rest periods
decrease oxygen
consumption
(Prizant-Weston,
Castiglia, 1992).

Ed:
7.Encourage to
ambulate and do
exercise as

>The exact
mechanism of
action
of colchicine in go
ut is not
completely
known, but it
involves (1) a
reduction in lactic
acid production
by leukocytes,
which results in a
decrease in
uric acid
deposition, and
(2) a reduction

to:
Fully met if: able
to:
a. Have a
muscle
strength of
4/5 on
both upper
extremities
b. Verbalize
needs for
assistance
c. Able to
change
position
(from left
to right or
vice versa)
frequently
Partially met if:
a. Ambulate
with
minimal
assistance
b. Still have a
muscle
strength of
3/5 on
both upper
extremities
c. Verbalize
needs for
assistance
d. Able to
change
position
(from left

tolerated

8. Instructed to
call for SO for
assistance when
needed

inphagocytosis,
with abatement o
f
the inflammatory
response.
>Both activity
tolerance and
health status
improves with
progressive and
appropriate
activity and
exercise
>to prevent fall
and injury, helps
move from one
place to another

to right or
vice versa)
frequently
Not met if:
a. Cant
Ambulate
without
assistance
b. Have a
muscle
strength of
3/5 on
both upper
extremities
c. Unable to
verbalize
needs for
assistance
d. Unable to
change
position (from
left to right or
vice versa)
frequently