OBJECTIVES Nurse-Centered Objectives: To be familiarize with the role of the nurse in having a patient with hypertension.

ion. Acquire knowledge and skills that can be use in the future as nurse. To practice some procedures related to the condition of the patient. To enhance our skills as a student nurse.

Patient-Centered Objectives: The patient will able to gain trust to the student nurse providing care to the patient. The patient will able to feel comfortable while interacting with the student nurse. The patient will able to improve her condition. The patient will able to cooperate in the management of her condition. The patient will able to practice proper hygiene. The patient will able to learn how to accept her condition. The patient will able to acquire knowledge about the possible complication and treatment to her condition.

2. FAMILY HISTORY OF HEALTH AND ILLNESS GRAND FATHER (Deceased) Cause of death: Heart attack GRAND FATHER (Deceased) Cause of death: heart attack GRAND MOTHER (Deceased) Cause of death: PTB

GRAND MOTHER (Deceased) Cause of death: HTN

MOTHER (Deceased) Cause of death: HTN

FATHER (Deceased) Cause of death: Due to accident

SISTER 49 y/o (Alive)

PATIENT 56 y/o

SISTER 42 y/o (Alive)

II. PATIENT BASED

HYPERTENSION
Genetic
AGE 52

SEX FEMALE

INCREASED CHOLESTEROL INTAKE

INCRAESED SODIUM INTAKE

8. PATHOPHYSIOLOGY I. Book Based

HYPERTENSION
Decreased arterial blood flow RISK FACTORS Family History Advancing Age Cigarette Smoking Obesity Heavy alcohol consumption Gender (Men <50 years, Women >50 years) Black Race High dietary sodium intake Low dietary intake of Potassium, Calcium and Magnesium Glucose Increased sodium and water in arterial walls

Kidney will produced RENIN

Converted to ANGIOTENSIN I

ANGIOTENSIN II

ALDOSTERONE

Sodium Retention

Renal retentions of sodium and water

Increased plasma and ECF volume

Increased cardiac output

Auto-regulation and remodeling of arterial walls Increased peripheral resistance Structural thickening of resistance vessels

Blood pressure elevation

13 AREAS OF ASSESSMENT I. SOCIAL STATUS Mrs. Bulatao, is a 56 years old female, born on December 30, 1953 at San Clemente Tarlac City. She is a Roman Catholic. She together with her husband and three daughters are recently residing at Brgy. Managuenan Camiling Tarlac. She was then a teacher in Malacampa High School for about 10 years. Her husband Mr. Romeo is the one who takes charged of their small farm, which serves as their primary source of income. Her hospitalization was supported by her husband and daughters as well. They have three daughters; two of their daughters were already married. According to her daughter, Mrs. Bulatao is a loving mother and she always support her family even at times of difficulties, and that is why they will not leave her at point of her life where her health is in the jeopardy. Standard: (Kozier, Erb, Berman, Snyder (2004). Fundamentals of Nursing (7th ed.)). Age ranging from 40-65 years belongs to the middle- age adults who have been called the years of stability and consolidation. Analysis: Mrs. Bulatao, 56 years old belongs to this age. This is the turning point in her life which involves changes in commitments and her concepts of service, love, and compassion to others gain prominence. However, they are experiencing regarding financial matters because their income is not enough to sustain their needs. Base from the standard and acquired data, friendship, warmth and understanding must be fairly adopted to improve social status. II. MENTAL STATUS Level of Consciousness Upon calling the patient name, we noticed that she was awake and conscious but whenever we ask about her condition, she was very emotional and was not able to respond appropriately. Standard: (Weber, 2006) The client must be alert and awake with eyes open and looking at the examiner and responds appropriately. Analysis: The manner shows by the patient was not normal because she was not able to respond appropriately but shows awareness.

Appearance and Movement As we observed Mrs. Bulatao, her right hand and foot was pale and she cant flexed and extend it. She experienced mild stroke when she was 42 yeas old. She cant do anything without the assistant of her daughters. Not well-groomed, her skin and nails were unclean and untrimmed. There was also a time that whenever she remember the day that she had no severe illnesses, she suddenly cry and show discomfort. Standard: (Weber, 2006) The client must be relaxed with shoulders back and both felt stable, smooth, coordinated movement. Clothes fit and appropriate for occasion and weather. Skin and nails are clean and trimmed. And has a good eye contact, smiles/ frowns appropriately. Analysis: She wasnt able to move her right upper and lower extremities. As verbalized by her while crying, Ayoko ng ganito. And because of the pain inside her, she sometimes get out of concentration talking to us and show discomfort. Orientation Well oriented about her condition, despite the fact that she cannot accept it. The patient knows that she is in the hospital and who are with her in the room. Standard: (Weber, 2006) Aware of self, others, place, time and address. Analysis: The patient was well oriented with the place and others around her. Speech As we talk to her, we noticed that she cant speak well; she understands Tagalog and Ilokano dialects. She speaks soft and sometimes repeats her answers to us. Standard: (Weber, 2006) Speech should be clear and moderate in pace. Analysis: Mrs. Bulatao speech was not normal that is why she cant express her self and having a hard time talking to other people.

Intellectual Functioning She can listen but cannot respond appropriately, she responds at a snails pace. She cannot express her thoughts, just like when we asked her, Ano po ang balak niyo, kapag nakauwi na po kayo?, she answered as with Hindi ko alam with sad face. Standard: (Weber, 2006) Respond appropriately to topics discussed. Express full and free- flowing thoughts during interview and listens and respond with full thoughts. Analysis: Based on the standard, Mrs. Bulataos intellectual function was not normal because she cant able to express her thoughts and cannot answer appropriately to our questions. III. EMOTIONAL STATUS As we enter the room and have a conversation with our patient, we have observed that Mrs. Bulatao was disturbed and sad. She cant answer our questions without her daughter. But after we have asked about her condition at the moment, we have noticed that she is not eased in giving the details pertaining to her health. Sometimes she stops responding to the question and cry. She is also cold when we ask her about the reactions of her friends, relatives and family members on her present condition. Standard: (Kozier, Erb, Berman, Snyder (2004). Fundamentals of Nursing (7th ed.)). My patient belongs to middle-aged adults and these groups are often called The Sandwich Generation. They find themselves caring for children and grandchildren and often caring for aging at the same time. Analysis: With our patient, she is undergoing in an event of an emotional stress and depression. She was the one who has been taking cared of, by her children and husband, instead of her guiding and talking care of them. Coping may be described as dealing with problems and situations like these successfully. But Mrs. Bulatao has a very hard time coping in this situation of a big changed in her physical appearance, life style and also shifting to another role. Coping strategies vary among individuals and are often related to the individuals perception of the stressful event and of course, the support of the family members. The family should support, love and accept her in whatever the patient is now today.

IV. SENSORY PERCEPTION Visual Acuity Mrs. Bulatao is able to recognize her environment proceeding to our presence and can identify objects 2-3 meters. She knows who are in her room and where she is. Sense of Taste The patient is able to distinguish the taste of the Sunkist she ate. She can also differentiate sweet, sour, bitter and salty taste upon presenting the different kinds of food to her. Auditory Acuity She is able to hear loud and moderate for about 1-2 feet words but cannot hear soft words; she wasnt able to answer appropriately the questions without the help of her daughter that was being asked to her upon the interview. Sense of smell About the ability to smell, she can identify the Sunkist by bringing her to her face and smell it. Pain Perception The patient daughter verbalized, Namamaga ang mga sugat niya. Standard: (Kozier, Erb, Berman, Snyder (2004). Fundamentals of Nursing (7th ed.)). An individuals senses are essential for growth, development, and survival. Sensory stimuli give meaning to events in the environment. Any alterations in an individuals sensory function can affect the ability to function within the environment. Analysis: The patient was able to sense the stimuli in her environment. Based from the book, senses of the patient was normal but not about the pain, auditory and smell. It interfere the physical and psychological function of the patient. It irritates the patient and may lead to discomfort, restlessness and impaired responses. V. MOTOR STABILITY Mrs. Bulatao can sit; she cannot perform activity without the assistance of her daughter. She can perform slightly neck flexion and extension. Her left arm can perform normal forward flexion and hyperextension but her right arm cannot perform normal forward normal flexion. Her left elbow can perform normal extension, pronation and supination. Her right elbow cannot perform normal pronation and supination with the assistant of her daughter. She can raise her left hand about 15 inches from her waist without complaint except her right hand. Her left leg can flexed

and extend with toes flexed and extend without complaint. But her right leg, cannot be flexed nor extend because of history of mild stroke. Standard: (Nurse Guide 4th ed. Marillynn E. Doenges) Normal motor stability is the ability to move within the physical environment without complaint of pain or discomfort. Analysis: The patients movements are controlled, slow and limited because of stroke. The patient cannot perform maximum range of motion especially on her right hand and foot. She was capable of moving her body joints but not her right hand and foot. VI. BODY TEMPERATURE After 7 minutes of taking her temperature by using an axillary thermometer at the right axilla, the temperature reading was: Admission Date July 21, 2011 10:20 AM Second Day July 22, 2011 2:00 AM 36.9 OC 6:00 AM 37. 1 OC 10:00 AM 36.8 OC 2:00 PM 37 OC 6:00 PM 37 OC 10:00 PM 36.5 OC Third Day July 23, 2011 2:00 AM 36.5 OC 6:00 AM 36. 8 OC 10:00 AM 36.6 OC 2:00 PM 36.4 OC 6:00 PM 36. 6 OC 10:00 PM 36.5 OC Fourth Day July 24, 2011 2:00 AM 36.6 OC 6:00 AM 36. 5 OC 10:00 AM 36.3 OC 2:00 PM 36.8 OC 6:00 PM 36. 8 OC 10:00 PM 36.7 OC Fifth Day July 25,2011 2:00 AM 36.6 OC 6:00 AM 36. 5 OC

2:00 PM 37.7 OC 6:00 PM 37. 8 OC 10:00 PM 37.4 OC

Standard: (Kozier, Erb, Berman, Snyder (2004). Fundamentals of Nursing (7th ed.)). The standard temperature is 36.5C-37.5C of a person with the standard of 5-10 minutes on the axillary part. The patients temperature was below the normal.

VII. RESPIRATORY STATUS The respiratory rate of the patient upon assessment was: Admission Date July 21, 2011 10:20 AM Second Day July 22, 2011 2:00 AM 23 bpm 6:00 AM 20 bpm 10:00 AM 18 bpm 2:00 PM 23 bpm 6:00 PM 21 bpm 10:00 PM 23 bpm Third Day July 23, 2011 2:00 AM 25 bpm 6:00 AM 22 bpm 10:00 AM 25 bpm 2:00 PM 23 bpm 6:00 PM 21 bpm 10:00 PM 21 bpm Fourth Day July 24, 2011 2:00 AM 20 bpm 6:00 AM 19 bpm 10:00 AM 21 bpm 2:00 PM 21 bpm 6:00 PM 23 bpm 10:00 PM 23 bpm Fifth Day July 25,2011 2:00 AM 23 bpm 6:00 AM 23 bpm

2:00 PM 28 bpm 6:00 PM 30 bpm 10:00 PM 20 bpm

Standard: (Daniels (2004). Nursing Fundamentals) Normal respirations are characterized by a rate rangng from 12-20 breaths per minute. Also, normal breath sounds can be classified into three types, like the vesicular breath sounds which is soft- intensity, low-pitched and gentle sighing sounds. Another is the broncho- vesicular, which is moderate- intensity and moderate- pitched blowing sounds. While bronchial breath sound which is characterized by high-pitched, loud and harsh sound. It is also stated in this reference that in testing for vocal (tactile) fremitus, the vibration should be felt in both chest wall upon palpating it while patient is speaking. There should also be a downward and upward movement of diaphragm and the elevation and depression of the ribs upon inspiration and expiration. Analysis: Mrs. Bulataos respiratory rate was beyond normal on admission day at 2: 00 PM and 6:00 PM and also on the third day at 2:00 AM and 10: AM. She has rapid breathing that makes his breathing pattern irregular. It was noticed because of the pain, restless, and uncomfortable feeling she was experiencing. Her breath sounds was characterized as vesicular which is soft- intensity and low-pitched. Upon inhalation, Mrs. Bulatao chest is expanded, and on exhalation, her chest is contracted which is normal and ideal.

VIII. CIRCULATORY STATUS The patients pulse rate was: Admission Date July 21, 2011 10:20 AM Second Day July 22, 2011 2:00 AM 75 bpm 6:00 AM 78 bpm 10:00 AM 68 bpm 2:00 PM 63 bpm 6:00 PM 61 bpm 10:00 PM 63 bpm Second Day July 22, 2011 2:00 AM 150/100mmHg 6:00 AM 140/100mmHg 10:00 AM 180/120mmHg 2:00 PM 140/100mmHg 6:00 PM 160/100mmHg 10:00 PM 120/80mmHg Third Day July 23, 2011 2:00 AM 62 bpm 6:00 AM 63 bpm 10:00 AM 65 bpm 2:00 PM 70 bpm 6:00 PM 76 bpm 10:00 PM 71 bpm Third Day July 23, 2011 2:00 AM 140/80mmHg 6:00 AM 160/100mmHg 10:00 AM 150/100mmHg 2:00 PM 140/100mmHg 6:00 PM 170/100mmHg 10:00 PM 160/90mmHg Fourth Day July 24, 2011 2:00 AM 72 bpm 6:00 AM 74 bpm 10:00 AM 75 bpm 2:00 PM 73 bpm 6:00 PM 72 bpm 10:00 PM 75 bpm Fourth Day July 24, 2011 2:00 AM 160/100mmHg 6:00 AM 160/100mmHg 10:00 AM 140/90mmHg 2:00 PM 160/100mmHg 6:00 PM 140/100mmHg 10:00 PM 120/80mmHg Fifth Day July 25,2011 2:00 AM 78 bpm 6:00 AM 80 bpm

2:00 PM 88 bpm 6:00 PM 91 bpm 10:00 PM 74 bpm Admission Date July 21, 2011 11:00 AM 200/110mmHg

Fifth Day July 25,2011 2:00 AM 140/80mmHg 6:00 AM 140/90mmHg

2:00 PM 170/90mmHg 6:00 PM 160/80mmHg 10:00 PM 150/90mmHg

Standard: (Kozier, Erb, Berman, Snyder (2004). Fundamentals of Nursing (7th ed.)). The standard pulse rate for an adult person is ranging from 60- 80 counts per minute. The standard blood pressure is 120/80 mmHg. And the standard Allens test is ranging from 1-3 seconds when returning to original color. Conjunctiva should be pinkish and moist. And the palms should turn pink promptly upon compression. The standard values of laboratory results are the ff: Glucose 70-110 mg/dL, Creatinine

for male: 0.9-1.5 mg.dL and female: 0.7-1.37 mg/dL, Cholesterol for male: 119-200 mg/dL and female: 115-200 mg/dL. Analysis: The pulse rate of the patient was beyond the normal range as compared to the standard data. Her blood pressure was above the normal range. Her capillary refill does not return to its original color when pinched as well as the palms of the patient. Her conjunctiva was also pale and less moist. She had impaired circulation. IX. NUTRITIONAL STATUS Prior to admission, does have specific type of diet. The patient is given food contains low fat and low salt, moderate protein and variety of carbohydrates such as vegetable (green leafy). She took her breakfast at 6:00 am, her lunch at 12:00 noon and dinner at 6:00 pm. She eats her meals on time. The patient consumes 5-7 glasses of water each day. She doesnt have any foods allergy. The patient skin and conjunctiva are pale. She cant move to maximum range that she is mostly on bed. In that she cannot perform any exercise Patients height is 52 and her weight is 70 kg. She does not take any vitamins or herbal supplements. She refuses of vices such as smoking and alcohol intake. She also refuses of problems in eating, chewing and swallowing. She does not complain of having stomach irritability when taking her medications. Standard: (Kozier, Erb, Berman, Snyder (2004). Fundamentals of Nursing (7th ed.)). Standard intake of fluid must be 8-10 glasses daily. The patient is considered overweight and must continue to eat healthy and balanced diet with special attention to protein, carbohydrates and limiting cholesterol intake. Overweight is considered as one of the factors for diseases such as diabetes and cardiovascular disease. Treatment begins with diet control, exercise, and weight reduction, although over time this treatment may not be adequate. Analysis: The family should formulate a diet plan that regulates blood sugar levels so that they do not rise too swiftly after a meal. A recommended meal is usually low in fat (30 percent or less of total calories), provides moderate protein (10 to 20 percent of total calories), and contains a variety of carbohydrates, such as beans, vegetables, and grains. Regular exercise will helpeven ten minutes of exercise a day can be effective. Diet control and exercise may also play a role in weight reduction.

In determining degree of obesity by body mass index: BMI WEIGHT CLASSIFICATION 25.0-29.9 OVERWEIGHT (PRE-DOSE) 30.0-34.9 CLASS I OBESITY 35.0-39.9 CLASS II OBESITY >40 CLASS III OBESITY Normal BMI values in age group: Age Group BMI (kg/m2) (years) 19-24 19-24 25-34 20-25 35-44 21-26 45-54 22-27 55-65 23-28 >65 24-29 X. ELIMINATION STATUS The patient voids 3-5 times a day with clear yellow color of urine. She refuses of current problem with dysuria, hematuria, polyuria, resistancy, incontinence or nocturia. She defecates once a day with yellowish in brown in color, soft, not so moist and formed stool. She refuses of difficulty of neither voiding nor defecating. Standard: (Kozier, Erb, Berman, Snyder (2004). Fundamentals of Nursing (7th ed.)). The amount and frequency of defecation and urination are highly individual. Normal feces are brown and formed but soft and moist. Factors like food and fluid intake, medications and surgery can interfere or affect the elimination status. The excretory function diminishes with age but not significantly below normal levels unless a disease process intervenes. Analysis: The patients fluid intake is slightly low which reflects to low number of urination each day. Her defecation was normal that she defecates without difficulty and once a day. Her stools characteristic is normal in color and not so moist. The patient should maintain a good voiding and defecating and should increase fluid intake. XI. REPRODUCTIVE STATUS She does not have any previous or present sexually transmitted disease. She said that she and her husband did not use any form of contraceptives. She does not undergo any birth control procedures such as tubal ligation.

Standard: (Kozier, Erb, Berman, Snyder (2004). Fundamentals of Nursing (7th ed.)). The climacteric (andropause) refers to the change of life in men, when sexual activity decreases. In men there is no change comparable to the menopause in women. The change is not as dramatic as in the female, changes are more gradual. Most experts say there is not a true climacteric in the male, but that the decline in male sexual desire is related to the decline in physical strength and aging of all body tissues. Analysis: According to her, since she was diagnosed in her second hospitalization with mild stroke, their sexual activity of her husband stop already. She also said that she was already menopause. XII. STATE OF REST AND SLEEP According to the daughter of the patient, one week prior to her admission in the hospital, she cannot sleep well because of the environment. However, in her admission days in the hospital there are times that she cannot sleep for an hour because of the administration of the medicines. Standard: (Kozier, Erb, Berman, Snyder (2004). Fundamentals of Nursing (7th ed.)). Middle-aged adults generally maintain the sleep pattern established at a younger age. They usually sleep 6-8 hours per night. The numbers of arousal from sleep increases. Analysis: Rest and sleep are essential for health. People who are ill frequently require more rest and sleep than usual. Rest restores her energy, allowing her to have an improvement in her functioning. Providing a restful environment for the patient is an important and an important function for nurses. XIII. STATE OF SKIN APPENDAGES Upon of our assessment, the color of the skin of Mrs. Bulatao is brown. There are presence of lesions and have an IV abrasion related to IV insertion on his left hand. Her skin is not that fair because oh her age. Lower extremities are cold to touch, pale and had altered moisture. Rough not uniform; palms and soles are thicker than any areas. Mild resilience of skin (spring back to its previous state after being pinched). Standard: (Nurse Guide 4th ed. Marillynn E. Doenges)

Skin appendages should be free from itching, pain, numbness, lesions, wounds, masses, and proper moisture and free from any alterations. Analysis: The main concern of the patient is her right upper and lower extremities due to pain and she cannot move it. The appearance of the skin and skin integrity are influenced by internal factors such as genetics, age and the underlying health of the individual as well as external factors such as activity. In people with impaired circulation like my patient, she has skin on the legs that appears shiny and may damages easily. Poor nutrition alone also can interfere with the appropriate and function of normal skin.

II. NURSING PROCESS A. ASSESSMENT 1. PERSONAL DATA Demographic data Name Age Gender Civil Status Role Position in the family Birth date Birth place Address Religion Nationality Occupation Education Date Admitted Time Admitted Place Admitted Final Diagnosis Physician Ward Health Care Financing Environmental Status Standard: Most adult are risk for having a complications because they were aging as a part of it. Meanwhile, at this age, adults must avoid inhaling smoke because they are risk of having lung problems because of their lung immunity response to any harmful environment. They must provide proper ventilation, nutrition especially calcium intake and rest. Analysis: The patients daughter told us that their house is made up of concrete and wood, and it is safe to live in, they told us that their house is suitable for them, they have house appliances needed on their daily living. They have their own garbage cans and plastics, their source of water is from a deep-well and they placed their water on a container with cover. The youngest of the patients daughter make sure that she swept their surroundings to prevent the occurrence of mosquitoes and flies. : : : : : : : : : : : : : : : : : : : Carmelita J. Bulatao 56 years old Female Married Mother December 30, 1953 San Clemente, Tarlac City Brgy. Managuenan, Camiling Tarlac Catholic Filipino Housewife (Teacher before) College Graduate July 21, 2011 10:20 A.M Tarlac Provincial Hospital Essential Hypertension Dr. Abriso Female Ward Mr. Federico Bulatao (husband) Mrs. Mary Grace Bulatao Esteban (daughter)

Lifestyle Standard: People who are presently working focuses for a mid-planning for retirement. At age of adulthood, people normally, especially women prefer to do household chores as their diversional activities for those who are not working. Analysis: Mrs. Carmelitas daughter stated that her mother usually do household chores before she got mild stroke that she loves eating foods high in cholesterol and sodium. After getting mild stroke, Mrs. Bulatao got so emotional that she just stays at her room and often cries because she cannot accept the condition that she is suffering now.

3. HISTORY OF PAST ILLNESS At the age of 38 the patient usually experience headaches, dizziness, and chest pain and she was hospitalized at Camiling District Hospital and diagnosed Hypertension after 4 years basically at age of 42 patient experienced headaches, dizziness, body malaise and severe chest pain, and she was hospitalized and diagnosed mild stroke. The patient doesnt have any allergies to drugs, animals or food. The patient was not able to recover totally to her condition. Patient has medicines for maintenance (Nifedifine, Amlodefine) and takes (biogesic, paracetamol, antibiotic, and mefenamic acid). 4. HISTORY OF PRESENT ILLNESS One day prior to admission the patient experienced body malaise, headache, and severe chest pain, her symptoms are gradual (for the reason that she was hospitalized before because of hypertension) severe pain was felt by the patient thats why they brought her to Camiling District Hospital.

III. CONCLUSION We BSN IV-D, after doing this case study were able to: Be familiarized with the role of the nurse in caring a patient with hypertension. Acquired knowledge and skills that can be use in the future as nurse. Practiced some procedure related to the condition of the patient Enhanced our skills as a student nurses and the patient was able to gain trust. Gained trust to the student nurse providing care to the patient. Felt comfortable while interacting with the student nurse. Improved her condition. Cooperated in the management of her condition. Practiced proper hygiene. Learned how to accept her condition. Acquired knowledge about the possible complication and treatment to her condition.

B. PLANNING Nursing Care Plan

ASSESSMENT NURSING DIAGNOSIS Impaired tissue integrity r/t impaired physical mobility as evidence by pressure sore. SCIENTIFIC EXPLANATION Damage or destroyed tissue; mechanical (pressure, integumentary or subcutaneous, shear, friction, surgery). PLANNING Within 4-5 hours of nursing intervention the patient and family will be able to gain knowledge about the prevention of wounds INTERVENTION v/s taken and recorded R: serve as a baseline data positioned patient in comfortable position R: can help alleviate the pain experienced by the patient cleaned wounds of the patient R: can help to prevent the occurrence of bacteria turned patient side to side every q2h R: to prevent bedsores taught the significant others the EVALUATION

S:

O: pale weak in appearance irritable and restless limited movements (+) wounds on the right upper and lower extremities (Reddish in color, moist, and around 5 cm in size). (+) bedsore found in elbow and pelvic part. With minimal redness on parts where bone is permanent. Withdraw

extremities during palpation on the areas.

importance of turning the patient side to side R: for the significant others to be able to do such intervention even without the assistant of the nurse avoid touching areas where the redness is present R: Touching the areas induces pain that result in withdrawal of extremities NURSING DIAGNOSIS Infection r/t inadequate primary defenses as evidenced by swelling on the upper and lower extremities. SCIENTIFIC EXPLANATION Due to environmental factors, patient may acquire stimuli that can cause infections or development of infection. PLANNING Within 4-5 hours of nursing intervention the patient and family will be able to know how to care a patient with wounds. INTERVENTION positioned the patient comfortably in bed R: Can alleviate the pain experienced by the patient cleaned the EVALUATION

ASESSMENT S: Namamaga yung mga sugat niya as verbalized by the daughter of the patient. O: Pale weak in

appearance with facial grimace irritable and restless untidy (+) wounds on the right upper and lower extremities (reddish in color, moist, and around 5 cm in size)

wounds of the patient R: to prevent the occurrence of bacteria that can lead to infection taught the significant others on how to clean wounds R: for the significant others to be able to do such intervention even without the assistant of the nurse instructe d the significant others to wash hand first before and after cleaning the wounds R: To prevent spread of microorganisms

ASSESSMENT S: Lagi siyang umiiyak as verbalized by the daughter of the patient. O: teary eyes With emotional expressions With right sided weakness With minimal movement Lethargic With facial grimaces With slurred speech Pale and weak in appearance

NURSING DIAGNOSIS Impaired adjustment r/t disability or health status requiring change in lifestyle.

SCIENTIFIC EXPLANATION Inability to modify lifestyle/ behavior in a manner consistent with a change in health status.

PLANNING Within 1-3 hours of continuous and proper nursing intervention, the patient will increase sense of well being and feeling rested.

INTERVENTION Encouraged adequate rest period R: To gain strength and conserve energy Encouraged expression of feelings contributing R: Can help to relieve tension experienced. Changed position every 2 hours. R: To prevent bedsores. Taught the patient the importance of having complete rest. R: To gain energy needed in daily living Encourage family to support their mother with her

EVALUATION

condition R: Tighten the family relationship

ASSESSMENT S: Minsa nahihirapan siyang huminga as verbalized by the daughter of the patient O: pale irritable use of accessory muscle in breathing as evidenced by increased RR30 bpm chest retraction noted dyspneic

NURSING DIAGNOSIS Impaired gas exchanged r/t imbalanced between oxygen supply/demand as evidenced by chest retraction.

SCIENTIFIC EXPLANATION Excess or deficit in oxygen and/or carbon-dioxide elimination at the alveoli-capillary membrane.

PLANNING Within 4-6 hours of nursing intervention the patient will manifest less difficulty in breathing.

INTERVENTION positioned patient in a left lateral on bed R: can promote proper oxygenation provided proper ventilation R: for comfort advised significant others to limit visitors R: to promote proper gas exchange within the room kept back dry R: to prevent further complications Encouraged adequate rest periods. R: to gain strength and

EVALUATION

conserve energy Refrain from asking the patient from her condition. R: To avoid patient from crying when she remember her condition Offer diversional activities( like listening to music and watching TV) R: To divert feelings to other things to lessen emotional responses

ASSESSMENT S: Hindi niya magalaw ang katawan niya as verbalized by the daughter of the patient. O: Lethargic Inability to move right upper/lower extremities weak in appearance with right sided body weakness with minimal movement with facial grimaces with slurred speech vital signs taken and recorded

NURSING DIAGNOSIS Impaired physical mobility r/t neuromuscular impairment as evidence by right sided body weakness.

SCIENTIFIC EXPLANATION Limitation in independent, purposeful physical movement of the body or of one or more extremities.

PLANNING Within 1-3 hours of continuous and proper nursing intervention, patient will gain knowledge on management of her condition and will exhibit signs of improvement.

INTERVENTION Monitored vital signs R: For baseline data Encouraged deep breathing exercise. R: For proper gas exchange. Passive ROM done R: To maintain joint flexion and extension mobility. Provided safety measures. R: Protection of patient from self harm or in the environment. Provided quiet environment. R: For the better sleep pattern of the patient

EVALUATION

2. Nursing Management (SOAPIE/R)

DATE SUBJECTIVE CUES Hindi niya magalaw ang katawan niya as verbalized by the daughter of the patient. OBJECTIVE CUES Lethargic Inability to move right upper/lower extremities weak in appearance with right sided body weakness with minimal movement with facial grimaces with slurred speech teary eyes With emotional expressions With right sided weakness With minimal movement With facial grimaces With slurred speech ASSESSMENT Impaired physical mobility r/t neuromuscular impairment as evidence by right sided body weakness. IMPLEMENTATION/ INTERVENTION Within 1-3 hours Monitored vital of continuous signs and proper Encouraged nursing deep breathing intervention, exercise. patient will gain Passive ROM knowledge on done management of Provided safety her condition measures. and will exhibit Provided quiet signs of environment. improvement. PLAN EVALUATION After 1-3 hours of continues and proper nursing intervention, patient gained knowledge on management of her condition and exhibit signs of improvement as evidenced by eagerness to move.

July 21,2011 July 25, 2011

Lagi siyang umiiyak as verbalized by the daughter of the patient. July 22- 23, 2011

Impaired adjustment r/t disability or health status requiring change in lifestyle.

Within 1-3 hours of continuous and proper nursing intervention, the patient will increase sense of well being and feeling rested.

Encouraged adequate rest period Encouraged expression of feelings contributing Changed position every 2 hours. Taught the patient the importance of having complete rest. Encourage family

After 1-3 hours of continuous and proper nursing intervention, the patient increased sense of well being and feeling rested as evidenced by continuous sleep, undisturbed.

July 21- 25, 2011

Pale and weak in appearance weak in appearance irritable and restless limited movements (+) wounds on the right upper and lower extremities (Reddish in color, moist, and around 5 cm in size). (+) bedsore found in elbow and pelvic part. With minimal redness on parts where bone is permanent. Withdraw extremities during palpation on the areas.

Impaired tissue integrity r/t impaired physical mobility.

Within 4-5 hours of continuous nursing intervention the patient and family will be able to gain knowledge about the prevention of wounds.

to support their mother with her condition v/s taken and recorded positioned patient in comfortable position cleaned wounds of the patient turned patient side to side every q2h taught the significant others the importance of turning the patient side to side avoid touching areas where the redness is present

After 4-5 hours of continuous nursing intervention the patient and family had gained knowledge about the management of wounds. The daughter of the patient was seen positioning her mother in a left lateral in bed every 2 hours.

July 24, 2011

Nahihirapan siyang huminga as verbalized by the daughter of the patient.

pale irritable (+) difficulty of breathing use of accessory muscle in breathing increased RR for several days

Impaired gas exchange r/t imbalanced between oxygen supply/demand as evidenced by chest retraction.

Within 4-6 hours of continues nursing intervention the patient will manifest less difficulty in breathing.

positioned patient in a left lateral on bed provided proper ventilation advised significant others to limit visitors kept back dry Encouraged adequate rest periods. positioned the patient comfortably in bed cleaned the wounds of the patient taught the significant others on how to clean wounds instructed the significant others to wash hand first before and after cleaning the wounds

After 4-6 hours of continuous nursing intervention the patient had manifest less difficulty of breathing. Latest RR-22.

Namamaga yung mga sugat niya as verbalized by the daughter of the patient. July 21, 2011

Pale weak in appearance with facial grimace irritable and restless untidy (+) wounds on the right upper and lower extremities (reddish in color, moist, and around 5 cm in size)

Infection r/t inadequate primary defenses as evidenced by swelling on the upper and lower extremities.

Within 4-5 hours of nursing intervention the patient and family will be able to know how to care a patient with wounds.

After 4-5 hours of nursing intervention the patient and family know how to manage and gave care to a patient with wounds as evidenced by the daughter of the patient seen cleaning the wounds of her mother with proper medication instructed.

D. EVALUATION 1. Patients Daily Program in the Hospital ADMISSION SECOND DATE THIRD DATE DAILY PROGRAM DATE July 21, 2011 July 22, 2011 July 23, 2011 Nursing Problems 1. Impaired physical MODERATE MODERATE MODERATE
mobility 2. Disability in health status requiring change in lifestyle. 3. Impaired tissue integrity 4. Impaired gas exchanged 5. Infection

FOURTH DATE July 24, 2011 MODERATE 2AM BP 160/100 CR 72 bpm RR 20 bpm T 36.6 OC 6AM BP 160/100 CR 74 bpm RR 19 bpm T 36.5 OC 10AM BP 140/90 CR 75 bpm RR 21 bpm T 36.3 OC

DISCHARGE DATE July 25, 2011 2AM BP 140/80 CR 78 bpm RR 23 bpm T 36.6 OC 6AM BP 140/90 CR 80 bpm RR 23bpm T 36.5 OC

MILD MODERATE MILD MODERATE 11:00 AM BP-200/110

MILD MILD 2AM BP 150/100 CR 75 bpm RR 23 bpm T 36.9 OC 6AM BP 140/100 CR 78 bpm RR 20 bpm T 37.1 OC 10AM BP 180/120 CR 58 bpm RR 18 bpm T 36.8 OC

2AM BP 140/80 CR 62 bpm RR 25 bpm T 36.5 OC 6AM BP 160/100 CR 63 bpm RR 22 bpm T 36.8 OC 10AM BP 150/100 CR 65 bpm RR 25 bpm T 36.6 OC

Vital Signs

Diagnostic and Laboratory Procedures Drugs Diet

2PM BP 170/90 CR 88 bpm RR 28 bpm T 37.7 OC 6PM BP 160/80 CR 91 bpm RR 30 bpm T 37.8 OC 10PM BP 150/90 CR 74 bpm RR 20 bpm T 37.4 OC Blood Chemistry and Hematology Ranitidine Enalapril Furosemide

2PM BP 140/100 CR 63 bpm RR 23 bpm T 37 OC 6PM BP 160/100 CR 61 bpm RR 21 bpm T 37 OC 10PM BP 120/80 CR 63 bpm RR 23 bpm T 36.5 OC N/A Ranitidine Enalapril Furosemide Piracetam

2PM BP 140/100 CR 70 bpm RR 23 bpm T 36.4 OC 6PM BP 170/100 CR 76 bpm RR 21 bpm T 36.6 OC 10PM BP 160/90 CR 71 bpm RR 21 bpm T 36.5 OC N/A

2PM BP 160/100 CR 73 bpm RR 21 bpm T 36.8 OC 6PM BP 140/100 CR 72 bpm RR 23 bpm T 36.8 OC 10PM BP 130/80 CR 75 bpm RR 23 bpm T 36.7 OC N/A

N/A Enalapril Ranitidine Nifedipine

Ranitidine Ranitidine Enalapril Enalapril Furosemide Nifedipine Piracetam Nifedipine LOW SALT AND LOW FAT DIET