De La Salle - Health Sciences Institute

College of Nursing and School of Midwifery

Congressional Avenue, Pasong Lawin
Dasmariñas City, Cavite

Nursing
Case
Presentation

BSN 31 Group 2

Aguda, Kimberly Marie Medina, Gerald Amgelo

Babasa, Cherry Mae I. Opiña, Janel Kate
Caayao, Trixia Liezl Rabie, Anne Sherina
Dela Cruz, Jean Camille Sasoy, Alexies
Gicana, Charisse Cassandra
Lacanilao, Keith Darrel Ularte, Wendelyn

August 16, 2010

Nursing Case Study
Date of Admission: July 5, 2010

Admission Diagnosis: Community Acquired Pneumonia,

Rheumatic Heart Disease

Final Diagnosis:

I. Health History
A. Demographic Data
1. Client’s Initial : E.R.A.
2. Gender : Female
3. Age : 39 years old
4. Birthdate : July 22, 1971

Page 1 of 61
 5. Birthplace : Apayao
6. Marital Status : Married
7. Nationality : Filipino
8. Religion : Roman Catholic
9. Address : Imus, Cavite
10. Educational Background : College
graduate
11. Occupation : employee
12. Usual Source of Medical Care : hospital, clinic
13. Date of Admission : July 5, 2010

B. Source and Reliability of Information

• Client herself who seems to be reliable to
provide personal information. The patient
speaks clearly, conscious and coherent.
• Patients husband who was competent and
well-informed to provide concrete information
about the client; she was able to speak
clearly; conscious and coherent.
• Patients chart was able to provide
comprehensive and reliable information about
the client. This serves as the tertiary source
of information.

C. Reasons for Seeking Care or Chief Complaint

• “persistent cough for 4 days”
• “difficulty of breathing for 2 days”
• “chest pain”

D. History of Present Illness or Present Health

Patient ERA was apparently well until four days

PTC, she experienced a non-productive, non-explosive
cough. Other than that, no other symptoms were
noted. She had self medicated with Solmux cap BID x
2 days with no consultation to a physician.
2 days PTC, the patient had expelled mucoid
whitish phlegm and experienced mild DOB. She
ignored the symptoms and still continues with her
daily activities.
1 day PTC, the patient started to have minimally
explosive cough with yellowish mucoid phlegm. She
sought consultation at Our Lady of Pillar Medical
Hospital and has been prescribed with Co-Amoxicillin
500 mg/cap TID and Carbocisteine 500 mg/cap TID.
She both took only 2 times. The symptoms still
persisted, which made her decide to seek consultation
to DLSUMC.

Page 2 of 61
E. Past Medical History or Past Health

Client verbalized that she was diagnosed to have

RHD when she was 13 years old, aside for some
episodes of fever, headache and fever. She also
verbalized that she had history of sore throat but she
cannot recall when. Since then, she was prescribed to
take Lanoxin. For her adult illnesses, she was
diagnosed to have hypertension; her highest BP was
140/60 mmHg, but she was not given any
maintenance medications. She stated that she cannot
recall if she had any injuries or accidents. She was first
confined at the hospital to her first pregnancy. She
stated that she had her menarche at age 14. She has
OB score of 333003. The client has unrecalled
immunizations but she had taken all 5 doses of
tetanus toxoid. She had her consultation to her doctor
at Our Lady of Pillar Hospital last July 4, 2010, day
prior to her admission to DLSUMC.

Page 3 of 61
F. Family History

The above diagram

shows the patient’s
family history. She
can’t recall in what
age her grandparents died, both mother’s and father’s side.
Her father is presently 68 years of age and with cardiac problems. Her mother is presenlty 63 years of age and she has
hypertension. Her older brother and younger brother, who are 42 and 37 years of age respectively, are presently alive and
well; she thinks that her 2 brothers did not inherit any diseases from their parents. Her younger sister, 35 years of age has
hypertension. And the patient herself has been diagnosed with community-acquired pneumonia, rheumatic heart disease
and hypertension.
G. Socio – Economic History

Family Member Occupation Monthly Income

E.R.A. Financial analyst confidential

Income earner within the family includes the client herself. The
client is working as a financial analyst in Makati. According to clients’
husband, they don’t find any difficulty in handling money but then
there were times that they find it a problem when it is lacking. He also
added that the monthly salary of clients’ daughter was enough and
adequate to sustain their everyday living. They also don’t find any
difficulty in purchasing their basic necessities since the salary was
enough to sustain those things. She also states that their monthly
income was enough in the payment of different bills, for the education
of the clients’ grandchildren as well as for medical support whenever
one member of the family got sick.

H. Psychosocial Assessment

In Erikson’s psychosocial development, patient E.R.A., who is 39

years of age, is in the middle adulthood stage (Generativity vs.
Stagnation), which ranges from 35 to 55 or 65 years old. The client is
able to perpetuate cultures and transmit values through the family by
giving advices to her siblings and her child. She verbalized that she
feels happy and contented if she could give help and care to her other
family members, which indicates that she had done the task of
generativity. She also verbalized that she is satisfied with what is
happening with her life right now. She said that she focuses herself in
the care for her family and help to the people around her. Her
significant relationships during this stage revolve around the family,
workplace and community.

I. Functional Assessment

1. Health-Perception-Health Management Pattern

 Patient E.R.A. perceives her condition as good as long as it
would cause integrity to her life. However, she does not
perceive it as punishment from God but she hopes that in
the future God will not take turns to let her know what she
had done just to alleviate the pain that she is feeling.
According to her, she does not have any activities to work
with to improve her present condition what she is doing is
that she make it to a point to have adequate rest if she is
feeling not well. Moreover, she is into self medication, but
sometimes when her condition gets worse, that’s the time
 she seeks a doctor for consultation. As of now, as according
to her, she is still of finding things that will add more
happiness to her life. She admitted that she is still not
contented of the things that she has now.

2. Nutritional – Metabolic Pattern

 Patient E.R.A. verbalized that she eats 3-4 times daily
included her snacks and small eating’s everyday. Because
she eats 3-4 times a day, she supposes that she has a well –
balanced diet. But she sometimes skips meals due to busy
office work. She drinks at least four times in the morning and
another four glasses in the evening to make sure that gets
enough fluid and to avoid dehydration especially during hot
days. Her skin is well hydrated in terms that it is moist and
warm to touch. Her hair is well distributed and there are no
presences of lumps or areas wherein there are no hair
growth. She also verbalized that her meal everyday is almost
always meat and fish. She prefers eating fish than
vegetables.

3. Elimination Pattern
 Patient E.R.A. verbalized that she does not experience any
difficulty in urinating. According to her, the urine is more
yellowish than normal, especially if she forgets to drink
water. Bowel movement is regular; feces are brown in color.

4. Activity – Exercise Pattern

 Patient E.R.A. verbalized that she has not enough exercise
due to her busy office work. She said that she has enough
energy for her work for the whole day. She perceives full self
care for feeding, bathing, toileting, bed motility, dressing,
grooming, general mobility, cooking, home maintenance and
shopping. But still, she stated that she sometimes seek the
help of her husband whenever she is not feeling well.

5. Sleep – Rest Pattern

 Patient E.R.A. perceives her sleeping pattern as well,
although she has no naps during the afternoon. She said she
could have some naps if she is free during office break time.
She sleeps at night at around 10 pm, and wakes up the next
day at around 4 or 5 in the morning.

6. Self – Perception – Self Concept Pattern

 Client E.R.A. verbalized that there’s nothing unusual in her
appearance, just the same as before. She states that she is
thankful for her appearance. She feels comfortable to what
ever appearance she have.

7. Role Relationship Pattern

  Patient E.R.A. is happily living with her family. Regarding to
her relationship with the co-workers, all are cooperating and
she strengthens it by attending in regular meeting and get-
togethers. She said that whenever she has problems, she
could consult her husband or her siblings.

8. Sexuality – Reproductive Pattern

 Client E.R.A. expressed her satisfaction regarding her
sexuality. They don’t use any contraceptive method. Her OB
score is 333003. Her menarche started when she was 14
years old. She also experiences mild pre-menstrual pain.

9. Coping – Stress Tolerance Pattern

 According to the client, her only means of coping with stress
is by sleeping and relaxing at home. She thinks that her
coping actions help to lessen the stress she is experiencing.

J. Review of Systems (July 7, 2010)

SYSTEM REVIEW OF SYSTEMS PHYSICAL

General Client verbalized, “Ayos naman
yung pakiramdam ko sa
ngayon, may konting ubo pa
rin, tolerable naman yung sakit
ng dibdib ko. Di naman ako
nakakaramdam ng ibang sakit
sa katawan ko, pero medyo
pagod, siguro di rin kasi ako
sanay dito sa ospital.”
EXAMINATION
 Received patient
awake, lying on bed,
conscious, coherent
and oriented to time,
place and person,
with an IVF of PNSS
500 cc x 72º
(1gtts/min) , inserted
@ right metacarpal
vein, intact and
infusing well and
without IV related
complications;
Maintains good eye
contact, cooperative
and expresses
feelings appropriate
to situation; The
environment is
conducive for the
patient.
 Ectomorpic body
built
 Vital signs are the
following:
 BP: 120/70 mmHg

Radial pulse: 71
bpm

RR: 39 cpm

T: 36.0ºC, afebrile

 (+) restlessness

 (+) weakness

 (+) lips and

palpebral conjunctiva
paleness

 (+) pallor

 (+) fatigue

 (+) use of accessory

muscles when
breathing
 (+) chest
indrawing
 (-) sweating
 (-) chills

 (-) lethargy

 Patient expels
whitish mucoid
phlegm (2.5ml)

 Diet: Diet as
Tolerated

Integument Client verbalized, “Hindi pa SKIN:

naman ako nagkakasakit sa Inspection:
balat. Maalaga naman ako sa  Fair complexion
balat ko, lagi ako naglo-lotion,  (+) pallor
hindi rin ako masyado  (-) jaundice
nagbibilad sa ilalim ng araw.  (-) cyanosis
Lagi nga ako nagamit ng
 (-) ecchymosis
payong e.”
 (-) edema
 (-) bruises
 (-) pruritus
 Senile skin turgor
 (-) profuse non
odorous perspiration
 (-) lesions
  (-) Pendulous skin
Palpation:
 (-) thin, dry, scaly
skin
 Good skin turgor:
returns immediately
(1 sec)
HAIR:
 Hair is black in
color.
 Shiny and equally
distributed.
 (-) alopecia
 (-) parasites
 (-) lesions on scalp
NAILS:
 Nail bed pink in
color
 Nails hard and
round, smooth in
texture.
 Capillary refill
revealed after 2
seconds
Head Client verbalized, “Minsan lang Inspection:
naman sumasakit ulo ko.  Round and
Madalas lang mangati ang anit symmetrical skull and
ko. Wala naman akong kuto. size is appropriate to
Maalaga talaga ako sa buhok, the size of the body
kahit medyo manipis.”  (+) itchiness
 (+) dandruff
 (-) parasites
 (-) lesion
 (-) head injury
scars
 Still and upright
facial features
Palpation:
 Smooth and hard
skull
 (-) unusual lumps
 (-) masses
 (-) tenderness
 (-)
depressions/elevation
s on head
Eyes Client verbalized, “Malinaw pa Inspection:
naman ang paningin ko. Pero  Eyes are
gumagamit ako ng salamin symmetrical and
kapag nagbabasa” equal in size.
 At the same level
as the pinna.
 Iris dark brown in
color.
 Eyelashes are
medium in length
and equally
distributed; Pale
palpebral conjunctiva
 Scleras are white
in color
 Upper and lower
lids close easily and
meet completely
 (+) convergence
 Eye movements
are smooth and
symmetric
throughout the six
directions
 (-) redness
 (+) use of reading
glasses
 (-) discharge in the
sclera
 (+) cornea is
transparent, smooth
and moist
 (-) opacity in both
cornea
 (+) PERRLA (Pupils
equally round and
reactive to light
accommodation)
 (+) moist and
glossy eyeball
 (-) excessive
tearing
 (-) swelling
 (-) lesions or
nodules are
apparent.
 (+) bilateral
blinking reflex

Palpation:
Ears Client verbalized, “Wala naman Inspection:
ako nararamdamang masakit
sa tenga ko. Regular ako
maglinis ng tenga.”
Palpation:
Nose and Client verbalized, “Madalas Inspection:
Sinuses lang ako magkasipon, pero
bukod dun, wala na. Hindi
naman nasakit.”
 (-) ectropion
 (-) myopia
 (-) ptosis
 (-) unusual masses
 (-) tender eyelids
 (-) purulent
discharge
 Ears equal in size
and similar in
appearance;
symmetrical.
 Pinna is aligned
and parallel to outer
canthus of the eye;
symmetrical and well
formed
 (-) swelling
 (-) thickening
 (-) unusual
discharge
 (-) redness of the
ear lobe
 (+) firm pinna
 (-) lumps and
masses
 (-) tenderness
 Client was able to
identify odors
presented (alcohol
and orange fruit)
 Color same as the
face
 Symmetric, nose
on midline,
proportion with facial
features with no
swelling or lesions
 (+) midline septum
 Smooth
consistency
 Pink nasal mucosa
 (+) red glow of the
sinuses upon
 transillumination
 (-) lesions
 (-) discharge
 (-) inflammation of
mucus membrane
 (-) edema
 (-) epistaxis
 (-) nasal flaring
Palpation:
 (-) nodules and
masses
 (-) tenderness in
the sinus and nasal
area
Percussion:
 (+) hollow tone on
sinuses
Mouth and Client verbalized, “Wala naman Inspection:
Throat ako problema sa bibig ko, hindi  (+) pale lips
rin naman ako nahihirapan  Pinkish and moist
magsalita. Araw-araw akong buccal mucosa
nag sisipilyo.”  Lips; smooth in
texture
 Frenulum in
midline
 With rhinorrhea &
cough
 (+) hoarseness
 (-) ulcerations
 (-) lesions
 (-) oral thrush
 (-) gingivitis
 (+) tongue in
midline
 (+) uvula in
midline
 (+) gag reflex
when swallowing,
revealed using
tongue depressor
 Tongue is pink, no
swelling and lesions.
 Tongue moves
easily without tremor.
Neck Client verbalized, “Nagagalaw Inspection:
ko naman yung leeg ko ng  Same color as the
maayos, madalas lang face
 mangalay dahil sa trabaho.”  Neck is
symmetrical
 (-) lesions
 Full ROM on neck
 (-) superficial
cervical lymph node
enlargement
Palpation:
 (-) enlargement
and masses
 (-) swelling
 (-) tenderness
 Thyroid in midline
position
 Non palpable
cervical nodes
 thyroid not
palpable
Auscultation:
(-) bruits
Breast and Client verbalized, “Wala naman  Patient refused
Axilla masakit sa dibdib ko, wala din physical examination
naman ako nakakapa na bukol.
Sa tingin ko pantay naman
siya, hindi mabigat yung isa
kesa sa isa.”
Respiratory Client verbalized, “Nung una, Inspection:
medyo sumasakit, hirap din ng
konti huminga. Minsan  (+) tachypnea:
naninikip, pero pagkainom RR:39 cpm
naman ng gamot, ayos na.”  Equal chest
symmetry
 Scapula are
symmetric & non-
protruding
 Sternum in midline
and level with ribs
 Shoulder & scapula
are at equal
horizontal position
 Spinous processes
appears straight
 Ribs sloping
downward
 (+) tripod position
and sometimes
orthopneic
 (+) shortness of
 breath
 (+) difficulty of
breathing
 (+) use of
accessory muscles
when breathing
 tenderness
 (+) productive
cough (whitish
mucoid phlegm)
 (+) mild chest
indrawing
Palpation:
 (+) crepitus
 (+) fremitus
 (-) tenderness
Percussion:
(+) dullness

Auscultation:

 (+) crackles on
both lungs fields

 (-) stridor

 (-) wheezes

Cardiac Client verbalized, “Sabi nung Inspection:

mga doktor dati, may sakit daw  (-) jugular vein
ako sa puso, pero may distention/bulging
pinapainom naman sakin na  BP = 120/80
gamot.” mmHg
 (+) atheromatous
aorta based on X-Ray
findings
 Radial and apical
pulse rates are
identical = 71bpm
 Apical pulse is
weak
Palpation:
 Apical pulse in
mitral area
Auscultation:
 Loudest sound at
the apex
Gastrointestin Client verbalized, “Wala naman Inspection:
al nananakit sa tiyan ko. Minsan  Abdomen flat and
 lang hindi natutunawan kaya rounded
minsan nasakit.”  (-) discoloration of
Client verbalized, “Nakakakain the abdomen
naman ako ng maayos”  (+) stretch marks
 (-) jaundice
 (-) hematemesis
 (+) brownish soft
stool
 (+) passing of
flatus
 (-) abdominal
distention
 (-) constipation
Auscultation:
 16 bowel
sounds/min
 (-) bruits
Percussion:
 Tympanic sound
over four quadrant
 Dullness over the
liver
 Fluid wave test
result
Palpation:
 Spleen & liver are
not palpable
 (-) masses
 (-) lesions
 (-) tenderness
Urinary Client verbalized, “Wala naman Inspection:
akong nararamdaman na  Non odorous urine
masakit pag naihi ako. Minsan  (-) abdominal pain
nagpipigil ako ng ihi, pero pag  Urine color: amber
kailangan lang, yung sobrang colored urine
busy lang. pero most of the Palpation:
time, hindi talaga.”  Kidneys are not
palpable
 (-) distended
bladder
 (-) tenderness
upon palpation
Genitalia Client verbalized, “Wala naman  Unable to perform
ako nararamdaman, malinis examination, patient
naman ako, regular ko namang refused.
hinuhugasan ang mga
pribadong parte ng katawan
 ko,”
Peripheral Client verbalized, “Wala naman Inspection:
Vascular ako nararamdaman, wala din
naman ako nakikitang kakaiba
sa arms at legs ko. Pero
nanginginig minsan, dahil
siguro sa pasma.”
Musculoskelet Client verbalized, “Pag sa Inspection:
al trabaho, madalas ako nakatayo
kaya minsan masakit yung sa
binti ko, pero konting masahe
lang ok na. Ganun din yung sa
likod ko.”
Neurologic Client verbalized, “Madali Patient is coherent and is
naman ako makatanda,
maayos ko naman nasasagot
 (-) lesions on arms
and legs
 (-) swelling in both
sides of arms and
legs
 (-) varicose veins
 (-) discoloration of
upper and lower
extremities
 (-) edema
Palpation:
 Radial pulse: 71
bpm
 (-) masses
 Regular weak
radial pulse
 swelling of legs
 Capillary refill: 2
seconds
Auscultation:
 No unusual sounds
detected
 Full ROM from
head to toe
 Movements are
coordinated and
rhythmic
 Mouth opens and
closes smoothly
 Jaw protrudes and
retracts easily; has
full resistance
against applied force
 Shoulders are
symmetrically round,
no swelling and
deformities.
 Elbows are
symmetric
 (+) body weakness
& exertion upon
movement
oriented to people,
places and time.
yung mga tinatanong sa kin.” Patient appears to be
calm and rested
Patient responds in
moderate tone, clear and
in moderate pace.
Patient’s clothes are fit
and appropriate for the
situation
Patient can recall past
events especially prior to
her illness.
Patient is
cooperative and
friendly, expresses
feelings appropriate
to the situation
Verbalizes positive
healthy thoughts
about future, family
and self.

CN I: Correctly identifies
scent presented (alcohol)

CNII: Full visual fields

CN III, IV, VI: eyelids

move in a smooth and
coordinated motion in all
directions.

CN V: Temporal and
masseter muscles
contract bilaterally;
eyelids blink bilaterally

CN VII: smiles, wrinkles,

forehead, show teeth,
moves eyebrows, closes
eyes against any
resistance. All
movements are
symmetrical.

CN VIII: Hears word

correctly using voice
whisper test.

CN IX, X: swallows
 without difficulty by
drinking water

CN XI: trapezius muscles

are symmetric

CN XII: tongue is smooth

and mobilizes
symmetrically
Hematologic Client verbalized, “Wala naman Inspection:
akong unusual bleeding. Hindi  (-) epistaxis
rin ako madalas magsugat.  (-)bleeding
Yung mga sugat ko, mabilis  (-) excessive
naman gumaling.” bruising
 (-) jaundice
 K. Laboratory Studies and Diagnosis

PROCEDURE INDICATION NORMAL FINDINGS/ ACTUAL FINDINGS NURSING RESPONSIBILITIES

(DATE) VALUES
Hematology To obtain small vials of blood Hgb: Hgb: 130 g/L PRE
(July 5) for numerous tests involved F: 123 – 150 g/L
o Inform the patient of the necessity
in diagnosing many M: 140 -175 g/L
conditions other than blood of the procedure.
diseases Hct: Hct: 0.40 g/L o Inform the patient about the
F: 0.36 – 0.45 g/L procedure.
M: 0.41- 0.5 g/L
INTRA
WBC: WBC: o Cleanse and dry puncture site.
5,000 – 10,000/ mm3 12,400/ mm3
o Hold syringe or evacuation tube
with needle.
Segmenters: 0.36 – Segmenters: 0.83
o Gently invert the collection tubes
0.66
several times to blend sample. Do
not shake.
Lymphocytes: 0.22 – Lymphocytes: 0.12
0.40
POST

o Check patient and apply cotton to

Monocytes: Monocytes: puncture site.
0.04 – 0.08 0.05 o Instruct to lie down and rest.

PTT: 10 – 14 secs PTT: 11.8 secs

Serum: 46-92 µmol/L Serum: 68 µmol/L

 Na: 137-145 mmol/L Na: 142 mmol/L

K: 3.5-5.10 mmol/L K: 4.2 mmol/L

ASO titer A blood test to measure < 200 IU/ml < 200 IU/ml PRE
(July 5) antibodies against
o Explain to the patient that the
streptolysin O, a substance
produced by Group A ASO test detects an immunologic
Streptococcus bacteria response to certain
bacteria(Streptococci)
o Inform the patient that he need
not restrict food and fluids (although
a fasting sample is preferred)
o Tell the patient that the test
requires a blood sample.
o Explain who will perform the
venipuncture and when.
o Explain to the patient that he may
experience slight discomfort from
the tourniquet and needle puncture.
o If the test is to be repeated at
regular intervals to identify active
and inactive states of rheumatic
fever or to confirm acute
glomerulonephritis, tell the patient
that measuring changes in antibody
levels helps determine the
effectiveness of therapy.
o Check the patients history for

ECG ECG permits to detect very
(July 5) many illnesses of the heart,
first of all the myocardial
infarction. It is to help identify
primary conduction
abnormalities, cardiac
arrhythmias, cardiac
hypertrophy, myocardial
ischemia and the site and
extent of myocardial infarction.
To monitor recovery from
myocardial infarction.
To evaluate the effectiveness of
cardiac medications (cardiac
glycosides, vasodilator, and
antihypertensive)
drugs that may suppress the
streptococcal antibody responses.
o If such drugs must be continued,
note this on the laboratory request.
INTRA
o Perform a venipuncture test and
collect the sample in a 7 ml tube
without additives.
o Apply direct pressure t the
venipuncture site until bleeding
stops.
Regular Rhythms  dilated left PRE
P wave precedes every ventricle with o Explain to the patient that an ECG
QRS complex with
good wall motion evaluation evaluates the heart’s
consistent PR interval
is sinus rhythm. and contractility electrical activity.
 dilated left o Tell the patient that he need not
No discernable P wave atrium restrict food and fluids.
preceding each QRS o Describe the test, including who
 normal size
but narrow regular
right atrium, right will perform it, where it will take
QRS complexes is a
ventricle, main place and how long it will last.
nodal or junctional
pulmonary artery o Tell the patient that electrodes will
rhythm.
and aortic root be attached to his arms, legs and
 thickened and chest and that the procedure is
calcified aortic painless.
valve cusps with
restriction of INTRA
motion
 To assess pacemaker  thickened o Place the patient in a supine
performance. arterior mitral position. If he can’t tolerate lying
valve leaflet flat, help him to assume seme
without restriction fowlers position.
of motion o Help the patient expose his chest,
 structurally both ankles and both wrists for
normal tricuspid electrode placement. If the patient is
valve and a woman provide a chest drape until
pulmonic valve the chest leads are applied.
 no intracardiac o Turn on the machine and check
thrombus nor the paper supply.
pericardial o Explain that during the test he’ll
effusion noted be asked to relax lie still and breathe
 ECG mount: normally.
LVH, interolateral o Advise the patient not to talk
wall ischemia during the test because the sound of
his voice may distort the ECG
tracing.

POST

o Check the patient’s medication

history for use of cardiac drugs and
note the use of such drugs on the
test request form.
CXR To evaluate the lungs, heart A normal chest x ray  cardiomegaly PRE
(July 5) and chest wall; used to help will show normal with incipient
diagnose symptoms such as structures for the age o Explain too the patient that chest
pulmonary
shortness of breath, a bad or and medical history of radiography assesses chest
congestive
 persistent cough, chest pain or
injury, fever; to help diagnose
or monitor treatment for
conditions
the patient. changes and/or anatomy.
pneumonitis, both o Tell the patient that he need not
lower lobes restrict food and fluids.
 r/o the o Describe the test, including who
possibility of will perform it, where it will take
pericardial place and how long it will last.
effusion wherein o Explain to the patient that he’ll be
correlation with 2- asked to take a deep breath and
D is suggested hold it momentarily while the film is
being taken to provide a clear view
of pulmonary structures.

INTRA

o The patient stands or sits in front

of the machine so films can be taken
posteroanterior and left lateral
views.
o Place cardiac monitoring
leadwires, IV tubing form central
lines, pulmonary artery catheter
lines and safety pins as far from the
X-ray field as possible.
ECHOCARDI Assess the heart’s function M-Mode Exam, Left Interpretation:
OGRAPHY Ventricle  technically
AND COLOR Determine the presence of different study
End-diastolic diameter
FLOW disease of the heart muscle,  dilated left
DOPPLER valves and pericardium, 49±4 mm ventricle with
REPORT heart tumors, and congenital hypertrophied
(July 8) walls, mild global
heart disease hypokinesia with
End-sys tolic diameter depress left
Evaluate the effectiveness of ventricular
30±5 mm
medical or surgical systolic function
treatments Fibre fractional  dilated left
shortening atrium
Follow the progress of valve  Normal right
38±6 %
disease atrium, right
Interventricular ventricle, main
septum thickness pulmonary artery
9±1 mm and aortic root
dimensions.
Septal systolic  Thickened
thickening
aortic valve cusps
51±19 % with calcifications
along the cuspal
Postero-lateral
margins, mild
wall thickness
restriction of
8±1 mm motion
 anterior mitral
valve leaflet is
Wall systolic redundant. Middle
thickening scallop (A2)
billowing into left
94±30 %
atrium in systole,
Hypertrophy index posterior mitral
valve leaflet has
mild restriction of
0.34±0.05 motion. Mitral
valve area of 2.02
Mass index
cm2 by
91±20 g/ m2 planimetry.
 structurally,
End-systolic meridional
normal tricuspid
wall stress
valve and
56±17 103 dynes/cm2 pulmonic valve
Left Ventricular  No pericardial
Ejection Fraction effusion and no
Normal 55 – 65 % intracavitary
Mildly reduced 45 – 55 thrombus
%35 – 45 %
Moderately Conclusion:
reduced < 35 %  Posteriorly
Severely reduced directed and
Aortic Valve Stenosis eccentric mosaic
color flow noted
Mild < 20 mmHg across mitral
Moderate 20 – 50 valve in systole
mmHg
 Mosaic color
Severe > 50 mmHg
flow noted across
Mitral Valve Stenosis aortic valve in
diastole and
Mild < 6 mmHg
across tricuspid
Moderate 6 – 16
mmHg valve in systole.
Severe 16 mmHg  Aortic valve
area of 1.9 cm2
Wall Motion by continuity
equation; mean
Walls
aortic valve
A Anterior
AL Antero-lateral gradient is equal
SA Anterior septum to 9.8mmHg,
I Infero-Posterior peak aortic valve
SI Inferior septum gradient is equal
PL Postero-Lateral to 22.6 mmHg,
mitral valve area
Asynergy Score
of 0.87 cm2 by
0 Not visualized
1 Normokinesis pressure half
2 Hypokinesis time; mean
3 Akinesis pressure gradient
4 Diskinesis is equal to 16.5
5 Aneurysm mmHg, peak
pressure gradient
Pericardial Effusion
is equal to 37.8
Mild < 1 cm mmHg.
separation = 300 ml  Prolonged
Moderate 1-2 cm deceleration
separation = 500 ml time .
Severe > 2 cm
 Pulmonary
separation > 700 ml
artery pressure of
44 mmHg by
tricuspid
regurgitant jet.

Conclusion:
 RHD
 Aortic
regurgitation, 3+
 mild aortic
stenosis
 anterior mitral
valve prolapsed
(A2)
 severe mitral
regurgitation
 >mild mitral
stenosis
 moderate
tricuspid
regurgitation
 eccentric left
ventricular
 Hypertrophy
with mild global
hypokinesia with
depressed left
ventricular
systolic function.
 dilated left
atrium
 moderate
pulmonary
hypertension
 L. Other Assessment Tools

DATE TAKEN COMPREHENSIVE ACTUAL ACTUAL RESULTS

CONTENT/ LEGEND
June 25, 2010 Legend Functional Level Feeding: 0
Code Bathing: 2
Level 0 Full self care Toileting: 1
Level 1 Requires use of Bed Motility: 0
requirements or device Dressing: 2
Level 2 Requires assistance or Grooming: 0
supervision from Gen. Mobility: 1
another person or Cooking: 4
device Home Maintenance:
Level 3 Requires assistance or 4
supervision from Shopping: 4
another person or
device
Level 4 Is dependent and does
not participate

M. Problem List

a) ACTUAL or Active
PROBLE PROBLEM DATE DATE
M NO. IDENTIFIED RESOLVED/
REMARKS
1 Ineffective Airway July 6, 2010 July 7, 2010/
Clearance patient was able
to effectively
expel secretions

b) HIGH RISK or Potential

PROBLEM NO. PROBLEM DATE IDENTIFIED
1 Risk for Infection July 7, 2010
Transmission
 Medical Diagnosis: RHD, CAP

Patient’s initials: E.R.A

NURSING CARE PLAN

NURSING
CUES LONG TERM SHORT TERM INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

S  Ineffective  One month  After 8 Independent:  Identify/demo

Airway after the hours of  Establish  To gain nstrate
 Clien
Clearance client’s giving nursing nurse-patient trust and for behaviors to
t verbalized,
related to discharge interventions, intervention the nurse to achieve
“Naluluwa
excessive from the the patient gain more airway
ko naman
 yung plema mucous hospital, she will be able to information clearance.
pag naubo production will be able to improve from the  Display patent
ako, pero secondary to facilitate the cough effort patient airway with
konting CAP maintenance by reducing  Assess  Shallow breath sounds
konti lang.” of supply of discomfort. rate and respirations clearing;
oxygen to all depth of are absence of
 Clien body cells. respiration frequently dyspnea,
t verbalized,
and monitor present cyanosis.
“Pag
for signs of because of
nauubo ako,
respiratory the
palaging
failure discomfort of
may plema,
moving chest
tapos
 Auscultate wall.
minsan after
lung fields  Decreased
nun,
noting areas airflow
nahihirapan
of decreased occurs in
ako
or absent areas with
huminga,
airflow and consolidation
pero sandali
anvetitious of fluid.
lang.”
breath Bronchial
O sounds breath
 (+) sounds can
Shortness of also occur in
breath consolidated
areas.
 (+) difficulty
Crackles are
of breathing
heard in
 (+) frequent inspiration
 productive and
cough of expiration in
whitish response to
mucoid fluid
phlegm 2.5 cc accumulation
in amount , thick
 Elevate secretions
 Tachypnea and airway
head of bed
(RR=39cpm) obstruction.
and change
 (+) tripod position  It keeps
position frequently. the head
 (+) use of elevated and
accessory promotes
muscles chest
when expansion
breathing and
promotes
 Mild Chest mobilization
indrawing and
 (+) shallow  Enourage expectoratio
breathing patient to n of
consume at secretions to
 (+) crackles
least 3000 cc keep the
on both lung
of fluids airway clear.
field at apex
everyday.  Fluids aid
Offer warm in the
than cold mobilization
fluids. and
 expectoratio
n of
Collaborative: secretions.
 Administer Warm liquids
medications dilate the
as indicated bronchioles.

 Aids in
reduction of
bronchospas
m and
mobilization
of secretions.
Analgesics
are given to
improve
cough effort
by reducing
discomfort,
but should be
used
cautiously
 Assist in because they
doing deep acn decrease
breathing cough effort
exercises. or depress
Demonstrate respiration.
or help the  Deep
client in breathing
learning to facilitates
perform the expansion of
activity. (ex. the lungs and
Pursed lip smaller
breathing) airways.
Coughing is a
natural self
cleaning
 Assist mechanism
with/ monitor assisting the
effects of cilia to
nebulizer maintain
treatments. patent
Perform airways.
treatment  Facilitates
between liquefaction
meals. and removal
 Provide of secretions.
supplemental
fluids (ex. IV
fluids)
 Fluids are
required to
replace
losses
(including
insensible
 loss) and aid
in
mobilization
of secretions.

NURSING
CUES LONG TERM SHORT TERM INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

S  Alteration in  One month  At the end Independent:  The person

comfort after the of the shift  Establish  To gain will relate
 The client
related to client’s the patient nurse-patient trust and for relief after a
verbalized
decreased discharge will intervention the nurse to satisfactory
“nahihirapa
oxygen from the verbalize gain more health
n ako
supply hospital, comfort as information measure as
huminga,
secondary she will be man from the evidenced by
pero sandali
to CAP able to patient absence of
lang.”
facilitate the  Assess  Shallow disc
O maintenanc rate and respirations
 (+) use of e of supply depth of are
accesory of oxygen to respiration frequently
muscles all body and monitor present
when cells. for signs of because of
breathing respiratory the
failure discomfort of
 Tachypnea
moving chest
RR:39
 Position wall.
bmp
the client  To promote
 (+)tripod from lying to respiration
 or orthopneic
orthopneic position
position Collaborative:
 Administer  Aids in
 (+)chest
medications reduction of
indrawing
as indicated bronchospas
 (+) m and
weakness mobilization
of secretions.
Analgesics
are given to
improve
cough effort
by reducing
discomfort,
but should be
used
cautiously
because they
acn decrease
cough effort
or depress
 Assist in respiration.
doing deep  Deep
breathing breathing
exercises. facilitates
Demonstrate expansion of
or help the the lungs and
client in smaller
learning to airways.
perform the Coughing is a
activity. (ex. natural self
Pursed lip cleaning
breathing) mechanism
assisting the
cilia to
maintain
 Assist patent
with/ monitor airways.
effects of  Facilitates
nebulizer liquefaction
treatments. and removal
Perform of secretions.
treatment
between
meals
 NURSING
CUES LONG TERM SHORT TERM INTERVENTION RATIONALE EVALUATION
DIAGNOSIS

S Activity One month after At the end of the Independent:  Report an

intolerance the client’s shift, the pt. will  Establish  To gain increase in
 Client related to mild discharge from be able to nurse-patient trust and for activity
verbalized, chest pain the hospital, she verbalize intervention the nurse to intolerance
“Medyo secondary to will be able to endurance in gain more including
nanghihina RHD. promote optimal performing ADL. information ADLs.
ako, kaya di activity: sleep- from the  Demonstart
ako masyado rest exercise. patient e a decrease
nagalaw ng
 Assess  Influences in physiologic
nagalaw.”
client’s ability choice of signs of
 Client to perform interventions/ intolerance
verbalized, normal needed like pulse,
“Nili-limit ko task/ADLs, assistance. respiartion
na lang yung noting reports and BP remain
pagalaw ko, of weakness, within client’s
pag nagalaw fatigue, and normal range.
kasi ako ng difficulty  Display
nagalaw, accomplishin laboratory
parang ang g task.  May values like
bilis ko  Note inidcate hemoglobin-
mapagod.” changes in neurologic hematocrit
balance/gait changes within
disturbance, associated acceptable
O
muscle with Vitamin range.
 (+)weakne weakness. B12
ss deficiency,
 affecting
 (+)difficult
client’s
y of
safety/risk of
breathing
 Monitor injury.
 Mild chest BP, pulse,  Cardiopul
pain respiration monary
 RR : during and manifestation
39cpm after activity. s result from
Note adverse attempts by
responses to the heart and
increase lungs to
levels of supply
activity. adequate
amounts of
 Recomme oxygen to the
nd quiet tissues.
atmosphere;  Enhances
bed rest if rest to lower
indicated. body’s oxygen
Stress need requirement,
to monitor and reduces
and limit strain on the
visitors, heart and
phone calls, lungs.
and repeated
unplanned
interruptions.
 Elevate
HOB as
tolerated.  Enhances
lung
expansion to
maximize
 Suggest oxygenation
client change for cellular
position uptake.
slowly,  Postural
monitor for hypotension
dizziness. or cerebral
nypoxia may
cause
dizziness,
fainting, and
increase risk
 Assist of injury.
client to  Promotes
prioritize adequate
ADLs/desired rest,
activities. maintains
Alternate rest energy level,
periods with and alleviate
activity strain on the
periods. Write cardiac and
out schedule respiratory
for client to system.
refer to.
 Provide/re
commend  Although
assistance help may be
with necessary,
activities/amb self esteem is
ulation as enhance
necessary, when client
allowing does some
client to do as things for self.
much as
possible.  Promotes
 Plan gradual return
activity to normal
progression activity level
with client, and improve
including muscle
activities that tone/stamina
client views without undue
as essential. fatigue.
Increase Increases self
activity levels esteem and
as tolerated. sense of
control.
 Encourage
s client to do
 Identify/im as much as
plement possible,
energy saving while
techniques; conserving
e.g., shower limited energy
chair, sitting and
to perform preventing
tasks. fatigue.
 Cellular
 Instruct ischemia
client to stop potentiates
activity if risk of
palpitations, infarction and
chest pain, excessive
shortness of cardiopulmon
breath, ary
weakness, or strain/stress
dizziness may lead to
occur. decompensati
on and failure.
 Vasoconstr
 Discuss iction
importance of decreases
maintaining peripheral
environmenta circulation,
l temperature imppairing
and body tissue
warmth as perfusion.
indicated. Client’s
comfort/need
for warmth
 must be
balance with
need to avoid
Collaborative: excessive
 Monitor heat with
laboratory resultant
status; e.g., vasodilation.
Hb/Hct and  Identifies
RBC count, deficiencies in
ABGs. RBC
components
affecting
oxygen
 Provide transport and
supplemental treatment
oxygen as needs/respons
indicated. e to therapy.
 Maximizin
g oxygen
 Prepare for transport to
surgical tissues
intervention if improves
indicated. ability to
function.
 Surgery is
usefeul to
control
bleeding in
patients who
are anemic
because of
bleeding.
 III. Anatomy and Physiology

CARDIOVASCULAR SYSTEM
A basic understanding of
cardiac anatomy allows for
correlation of physical exam finding
with the unseen anatomy of the
heart. The adult heart is about the
size of a closed fist and sits in the
thorax on the left side of the chest in
front of the lungs. The heart is
designed as a pump with four
chambers - right atrium (RA), right
ventricle (RV), left atrium (LA), and
left ventricle (LV). The two atria are the smaller, upper chambers of the
heart and the two ventricles are the larger, lower chambers of the heart. The
heart is oriented in the chest rotated about 30 degrees to the left lateral side
such the right ventricle is the most anterior structure of the heart. The left
ventricle is generally about twice as thick as the right ventricle because it
needs to generate enough force to push blood through the entire body while
the right ventricle only needs to generate enough force to push blood
through the lungs.

The heart also has four valves. The tricuspid valve is between the
right atrium and right ventricles. The pulmonary valve is between the right
ventricle and the pulmonary artery. The mitral valve is between the left
atrium and the left ventricle and the aortic valve is between the left ventricle
and the aorta. The valves, under normal conditions, insure that blood only
flows in one direction in the heart.

In order to pump blood

through the body, the heart is
connecting to the vascular
system of the body. This
cardiovascular system is
designed to transport oxygen and
nutrients to the cells of the body
and remove carbon dioxide and
metabolic waste products from
the body. The cardiovascular
system is actually made up of
two major circulatory systems,
acting together. The right side of
the heart pumps blood to the lungs through the pulmonary artery (PA),
pulmonary capillaries, and then returns blood to the left atrium through the
pulmonary veins (PV). The left side of the heart pumps blood to the rest of
the body through the aorta, arteries, arterioles, systemic capillaries, and then
returns blood to the right atrium through the venules and great veins.

PHYSIOLOGY:
 1. Generating blood pressure. Contractions of the heart generate blood
pressure, which is required for blood flow through the blood vessels.
2. Routing blood. The heart separates the pulmonary and systemic
circulation, which ensures the flow of oxygenated blood to tissues.
3. Ensuring one-way blood flow. The valves of the heart ensure a one-way
flow of the blood through the heart and blood vessels.
4. Regulating blood supply. Changes in the rate and force of heart
contraction match blood flow to the changing metabolic needs of the
tissues during rest, exercise, and changes in the body position.

Source: Seeley, Stephens, Tate. 2007. Essentials of anatomy and

physiology 6th edition. McGrawHill Education.

RESPIRATORY SYSTEM

The respiratory system is an intricate arrangement of spaces and

passageways that conduct air
from outside the body into the
lungs and finally into the blood
as well as expelling waste
gasses. This system is
responsible for the mechanical
process called breathing, with
the average adult breathing
about 12 to 20 times per
minute.

When engaged in
strenuous activities, the rate
and depth of breathing
increases in order to handle the increased concentrations of carbon dioxide
in the blood. Breathing is typically an involuntary process, but can be
consciously stimulated or inhibited as in holding your breath.

ANATOMY:

Nostrils/Nasal Cavities
During inhalation, air enters the nostrils and passes into the nasal cavities
where foreign bodies are removed, the air is heated and moisturized before it
is brought further into the body. It is this part of the body that houses our
sense of smell.

Sinuses
The sinuses are small cavities that are lined with mucous membrane within
the bones of the skull.

Pharynx
The pharynx, or throat carries foods and liquids into the digestive tract and
also carries air into the respiratory tract.

Larynx
The larynx or voice box is located between the pharynx and trachea. It is the
location of the Adam's apple, which in reality is the thyroid gland and houses
the vocal cords.

Trachea
The trachea or windpipe is a tube that extends from the lower edge of the
larynx to the upper part of the chest and conducts air between the larynx
and the lungs.

Lungs
The lungs are the organ in which the exchange of gasses takes place. The
lungs are made up of extremely thin and delicate tissues. At the lungs, the
bronchi subdivides, becoming progressively smaller as they branch through
the lung tissue, until they reach the tiny air sacks of the lungs called the
alveoli. It is at the alveoli that gasses enter and leave the blood stream.

Bronchi
The trachea divides into two parts called the bronchi, which enter the lungs.

Bronchioles
The bronchi subdivide creating a network of smaller branches, with the
smallest one being the bronchioles. There are more than one million
bronchioles in each lung.

Alveoli
The alveoli are tiny air sacks that are enveloped in a network of capillaries. It
is here that the air we breathe is diffused into the blood, and waste gasses
are returned for elimination.

PHYSIOLOGY:

1. Gas exchange. The respiratory system allows oxygen from the air to
enter the blood and carbon dioxide to leave the blood and enter the air.
The cardiovascular system transports oxygen from the lungs to the
cells of the body and carbon dioxide from the cells of the body to the
lungs. Thus the respiratory and cardiovascular systems to work
together to supply oxygen to all cells and to remove carbon dioxide.
Without healthy respiratory and cardiovascular systems, the capacity
to carry out normal activity is reduced, and without adequate
respiratory and cardiovascular system functions, life itself is impossible.
2. Regulation of blood pH. The respiratory system can alter blood pH by
changing blood carbon dioxide levels.
3. Voice production. Air movement past the vocal cords makes sound and
speech possible.
4. Olfaction. The sensation of smell occurs when airborne molecules are
drawn into nasal cavity.
5. Innate immunity. The respiratory system provides protection against
some microorganisms by preventing their entry into the body and by
removing them from respiratory surfaces.
Source: Seeley, Stephens, Tate. 2007. Essentials of anatomy and
physiology 6th edition. McGrawHill Education.
Medical Diagnosis: RHD, CAP

Patient’s initial: E.R.A.

 Modifiable Factors Non Modifiable Factors

 Environment  Age (39 years old)

(exposure to  Gender (Female)
pollutants)  Race/Ethnicity
 Family History (DM,
 Lifestyle HPN)

 Diet

 Low socioeconomic

Inhalation of infectious particles and

pathogenic microorganisms
(streptococcus pneumoniae and
streptococcus pyogenes)

Hematolog Invasion of Group A hemolytic

Invasion of
y streptococci in the Upper
streptococcus
ASO Titer respiratory tract (nose, mouth
pneumoniae
and sinuses)

Stick to local epithelial Invasion to the upper

cells respiratory tract -cough
(nose, mouth, and colds
-Fever
sinuses) -mild fever -Fatigue
Variety of enzymes -sneezing -Loss of
Immune appetite
liberated damage thesystem response
-Cough
(+) throat tissue -headache
culture -malaise
-pallor
-
diaphoresi
s
 Rheumatic fever Neutrophils, fluid and bacteria surrounding blood
vessels fill the alveoli

Cross reactive antibodies Invasion of lower respiratory

bind to cardiac tissues Hematology
tract (alveolar)
(Increased WBC)

Infiltration of streptococcal primed

CD4 + T cells

-Dyspnea
Auto immune reactions releasing inflammatory -Nausea
cytokines (including TNF – alpha and IFN gamma) &
Vomiting
-Diarrhea

ECG Inflammatory process

persists Chest X-
-DOB
Ray -Productive
cough
Valvular lesions ( leaflet thickening, O2 unable to reach -Fever
-Loss of
commissural fusion, and shortening bloodstream-causing appetite
and thickening of the tendinuous interruption of normal O2 -Chest pain
cords) transportation -Wheezing
breath
sounds
-Chills
-Headaches
-Fatigue
Rheumatic Heart Disease Community Acquired Pneumonia
 Rheumatic Heart Community-
Disease Acquired Pneumonia

Rheumatic Heart Disease is a condition of the heart in which it valves are damaged of rheumatic fever. When a susceptible
person acquires a Group A beta hemolytic streptococcal infection, an autoimmune reaction may occur in the heart tissue, resulting
in permanent deformities of heart valves or chordate tendinae. Involvement of the heart may be evident during acute rheumatic
fever, or it may be discovered long after the acute disease has subsided.

It can be noted that in order to be diagnosed with Rheumatic Heart Disease, a patient must manifest the criteria or
guidelines for diagnosis of RHD. In the case of patient ERA, she manifests or met 1 major and 3 minor which areas follow:
Polyarthritis or migratory arthritis, arthralgias, presence of C-reactive protein and leukocytosis or increased in circulating WBC.
Patient ERA also manifests symptoms such as chest discomforts and edema. Though patient does not have a history of rheumatic
fever, laboratories revealed an elevation or rising streptococcal antibody titer.

There are precipitating factors that predisposes the client to have community acquired pneumonia. In the case of the
patient, Due to inhalation of infectious particles and microorganisms such as Streptococcus pneumoniae, it resulted to invasion of
these microorganisms to the upper respiratory tract, and then the body responds to this invasion having the patient manifests the
early signs and symptoms. The microorganisms begin to invade the lower respiratory tract specifically in the alveoli. Due to the
invasion in the alveoli, it triggers the immune system to send neutrophils, which are type of defensive WBC to the lungs.
Neutrophils, fluid and bacteria surrounding blood vessels fill the alveoli. Thus, resulting to inflammation of the alveoli. Furthermore,
because of the inflammation of the alveoli, the oxygen in the lungs is incapable to reach bloodstream-causing interruption of
normal O2 transportation as a result the patient manifests persistence of signs and symptoms such as difficulty of breathing, fever,
chill, cough and colds.
III.Medical-Surgical Management

1. Pharmacotherapeutics/ Medicines

GENERIC NAME INDICATION NURSING

(BRAND NAME) DOSAGE AND RESPONSIBILITIES
CLASSIFICATION FREQUENCY
ASA (Aspirin) • For Pre:
Analgesic, inflammatory
anticoagulant, conditions • Check doctors order
antipyretic • Asses patients
• to treat mild to condition
moderate pain
• Assess allergic
• to reduce reaction
fever or • Assess a recent
inflammation. history of stomach or
intestinal bleeding
• to treat or • Take extra
prevent heart precaution when
attacks, giving medication to
strokes, and children
angina • Instruct patient not
to chew, break, or
open an enteric-
80 mg/tab OD pc coated or extended-
release pill
• Instruct the patient
to swallow the pill
whole.

Intra:

• Instruct patient to
take drug with meals

• Monitor patients
condition for signs
and symptoms of
bleeding, coughing
up blood, severe
nausea and vomiting

Post:
• Educate patient to
avoid taking
ibuprofen if taking
aspirin to prevent
stroke or heart
attack

• Educate patient to
avoid drinking
 alcohol when taking
aspirin.

• Tell patient to report

unusual side effects
like difficulty
breathing; swelling of
your face, lips,
tongue, or throat.
Discontinue using
aspirin and call your
doctor.

• Document.
Isosorbide •
Prevention Pre:
Mononitrate (Imdur) and/ or
Anti-anginal, nitrate, treatment for • Check doctors order
vasodilator angina • Asses patients
pectoris condition
• to decrease • Assess allergic
the frequency reaction
and severity of
angina Intra:
episodes
• Give sublingual
60 mg ½ tab OD hs preparation under
PO the tongue or in the
buccal pouch;
discourage the
patient from
swallowing
• Can be taken with
empty stomach and
with meals if severe

Post:

• Tell patient that drug

may cause dizziness,
light headedness,
headache, flushing of
neck or face
• Report blurred vision,
persistent or severe
headache, and rash,
more frequent or
more severe angina
attacks, fainting.

• Document
Digoxin (Lanoxin) • used for mild Pre:
Cardiac glycoside to moderate
congestive • Check doctors order
 heart failure • Asses patients
• for treating an condition
abnormal • Assess allergic
heart rhythm reaction
called atrial • Assess baseline ECG,
fibrillation. cardiac auscultation,
peripheral pulses
0.25 mg/tab OD PO • Check dosage

Intra:

• Avoid giving the

medication with food
• Have emergency
treatment ready in
case of digoxin
toxicity: lidocaine,
phenytoin, atrophine,
cardiac monitor.
• Take pulse at the
same time each day

Post:
• Tell pt. to report
slow or irregular
pulse, rapid weight
gain, loss of
appetite, nausea
and vomiting.
• Document.

Cefuroxime (Ceftin) • For the Pre:

2nd generation treatment of
cephalosporin many different • Perform ANST.
types of • Check results of
bacterial culture and
infections such sensitivity test.
as bronchitis, Intra:
sinusitis,
tonsillitis, ear • Give with meals.
infections, skin Post:
infections,
gonorrhea, and • Watch out for
urinary tract hypersensitivity
infections. reaction.
• Inform client that she
750 mg IV q8º may experience
stomach upset or
diarrhea.
• Instruct client to
report severe
diarrhea, difficulty of
 breathing, fatigue
and pain at injection
site.

• Document
Erdosteine (Ectrin) • Acute Pre:
Cough and cold bronchitis,
preparations chronic • Check doctor’s order
bronchitis & its
• Assess for
exacerbations.
hypersensitivity to
• Resp disorders Erdosteine
characterised
by abnormal • Assess for pregnancy
bronchial and lactation
secretions &
impaired Intra:
mucus
transport. • Can be taken with or
without meals
300mg/cap BID
PO Post:

• Assess for possible

side effects

• Document

Levodropropizine • Symptomatic
treatment of
(Levopront) cough
Pre:
Cough and Cold
• Check doctor’s order
Preparation 10cc TID PO
• Assess for
hypersensitivity to

• Assess for pregnancy

and lactation

Intra

• Should be taken on
an empty stomach.
(Take between meals)

Post:

• Tell the patient that

the drug may cause
Nausea, vomiting,
heartburn, diarrhoea,
fatigue, weakness,
drowsiness, dizziness,
headache,
palpitations.
 • Document

Metoprolol (Lopressor) • For Pre:

Antihypertensive, β1- hypertension, • Check doctors order
selective adrenergic long-term • assess patient
blocker treatment of condition before
angina pectoris therapy to monitor
the effectively of the
50 mg/tab BID PO drug
• assess heart failure
• obtain baseline renal
and liver status
before therapy
• assess for
obstructive jaundice
because the drug
level may elevate
due to the inability to
excrete drug
Intra:
• Give food to facilitate
absorption
• Instruct the patient
to comply with
dosage schedule
even if feeling better

• Tell the patient that

drug may cause
light-headedness,
dizziness, fainting,
and transient
hypotension

• Inform the client that

excessive
perspiration,
dehydration,
diarrhea may lead to
fall in blood pressure

Post:
• Monitor for possible
drug induced
adverse reactions
• Monitor BP of the
patient
• Document

Enalapril(Vasotec) • Treatment of Pre:

ACE hypertension
inhibitor,antihyperten alone or with • Check doctors order
combination • Asses patients
sive with other condition
antihypertensi • Assess allergic
ve, especially reaction
thiazide types • Assess for pregnancy
diuretics. especially during 2nd
• Treatment of and 3rd trimesters
acute and can cause serious
chronic heart injury or death to the
failure fetus
• Treatment of
asymptomatic Intra:
left ventricular
dysfunction • Monitor patient on
diuretic therapy for
excessive
hypotension
afterthe1st few
doses of enelapril
• Monitor patient in
any situation that
may lead to a drop in
BP secondary to
reduced fluid volume
because excessive
hypotension may
occur.
• Monitor carefully
because peak effect
may not be seen for
4hours .
• Do not administer
second dose until Bp
has been checked.
• Assess allergic
reaction

Post:

• Tell the client not to

stop taking the
medication without
consulting healthcare
provider.
• Tell the patient that
this drug may cause
GI upset, loss of
appetite, change
taste perception
,mouth sores, rash,
fast heart rate,
dizziness and light
headedness.
• Advice the patient to
 report mouth sores,
fever, chills, swelling
of the
face,eyes,lips,tounge
, feet and hands and
irregular heart rate
and difficulty of
breathing

• Document.
Spironolactone • For essential Pre:
(Aldactone) hypertension,
Potassium-sparing usually in • Check doctors order
diuretic, aldosterone combination of • Asses patients
antagonist other drugs, condition
prevention of • Know patient’s
hypokalemia history of
• Short-term hypersensitivity to
preoperative drug.
treatment of • Give daily doses
patients with early so that
primary
increase urination
hyperaldostero
does not interfere
nism
with sleep.
• Monitor BP
25 mg/tab OD PO

Intra:

• Arrange for regular

of serum
electrolytes and
BUN
• Can be take with or
without food

Post:

• Measure and
record regular
weight to monitor
mobilization of
edema fluid
• Advise client to
avoid foods rich in
potassium
• Tell the client that
he may experience
side effects like
increase volume
and frequency of
 urination, dizziness,
confusion,
drowsiness and
increase stress.
• Report weight
change of more
than 3poundsin 1
day, swelling
ankles or fingers .
• Monitor UO

• Document

IV. Progress Notes

DAY 1 Received the patient lying on right lateral, sleeping; with O2

inhalation regulated at 1-2 lpm, with IVF of PNSS 1L x 16º, due at
1:50 pm with 300 more to infuse; diet of DAT; no available medical
impression. Obtained v/s at 12 pm with T=36.5ºC, BP= 100/50
mmHg, RR=35 cpm and PR=60 bpm. The patient complained of
chest pain aggravated with persistent cough with whitish mucoid
secretions and difficulty of breathing. Had assessed for respiratory
rate and depth. Had advised patient to elevate the head of bed
and frequently change positions. Had assisted the patient in deep
breathing exercises. Had administered medications as indicated:
antitussives and analgesics. At the end of the shift, the patient had
verbalized that she could expectorate lung secretions effectively,
and has relieved a little from her chest pain.
DAY 2 Received the patient sitting on bed, conscious, coherent and
oriented to time, place and people; with O2 inhalation regulated at
1-2 lpm, with IVF of PNSS 500 cc x 72º, with diet of DAT. Obtained
v/s T=36.0 ºC, 36.7ºC, BP= 120/70 mmHg, 100/50 mmHg, RR=39
cpm, 38 cpm and PR=71 bpm, 62 bpm, for 8 am and 12 pm,
respectively. The patient had complained of persistent cough with
whitish mucoid secretions but without chest pain. Had assisted the
patient in deep breathing exercises. Had administered medications
as indicated: antitussives and analgesics. At the end of the shift,
the patient had decreased RR=35 cpm.

V. Discharge Health Teaching Plans

CONTENT STRATEGY
Compliance Compliance to the Health teaching
physician’s orders and
medications can
eventually lead to the
betterment of the
patient’s condition.
 Medication Medications Health teaching
prescribed by her
attending physician
must be taken at due
time. Take note that
her aspirin, which is
taken at 12 pm, must
be taken after meals
to facilitate
absorption. Also take
note that digoxin and
metoprolol, which is
taken at 8 am, could
lower the BP of the
patient and must
notify the patient if
the medication must
be given or not.
Diet There is no diet Health teaching
restriction but still
must be careful when
eating to avoid
aspiration.
Exercise Overexertion is not Health teaching
recommended; this
may give way to
difficulty in breathing.

VI. Summary of Client’s Status or Condition as of Last Day of

Contact

Received the patient sitting on bed, conscious, coherent and oriented to

time, place and people; with O2 inhalation regulated at 1-2 lpm, with IVF of
PNSS 500 cc x 72º; diet of DAT; with medical impression of CAP and RHD.
Obtained v/s T=36.0 ºC, 36.7ºC, BP= 120/70 mmHg, 100/50 mmHg, RR=39
cpm, 38 cpm and PR=71 bpm, 62 bpm, for 8 am and 12 pm, respectively.
The patient had complained of persistent productive cough with whitish
mucoid secretions but without chest pain. The patient looked tired and
sleepy. She had also reported decreased appetite due to persistent cough.
Had assisted the patient in deep breathing exercises. Had administered
medications as indicated: antitussives and analgesics. At the end of the shift,
the patient had decreased RR=35 cpm. She has been endorsed to be
transferred to a private room in 3500.