III.

Scope and Limitations

This case study is done by fourth year level nursing students of Xavier
University - College of Nursing enrolled in the second semester of School Year 2015 to
2016. We were exposed for our clinical exposure for three weeks in the Intensive Care
Unit of Maria Reyna Xavier University Hospital Incorporated, from June 21, 2014 to
July 1, 2015.
The case focused mainly on a 58-year-old patient with the diagnoses of
Hypovolemic Shock secondary to Upper Gastrointestinal Bleeding secondary to BPUD
secondary to immediate aspirin use, Cardiac Dysrhythmia- Ventricular Tachycardia
secondary to Ischemia secondary top severe anemia, Hypertensive Cardiocascular
Disease, Left Ventricular Hypertrophy, Acute Coronary Syndrome, Non ST-segment
elevation Myocardial Infarction, Chronic Heart Failure Class IV, Sepsis secondary to
Diabetic Foot (L) and Hospital Acquired Pneumonia, Chronic Kidney Disease secondary
to Diabetic Nephropathy, Diabetes Mellitus Type 2, IR, Non-obese, Peripheral Arterial
Occlusive Disease, S/P AKA (June 2015), S/P Blood Transfusion with the chief
complaint of difficulty of breathing. The patient was admitted on June blah, 2015. He
was under the student nurses care for four days, on February 1 to 3 and February 8 to
10, 2015, and he was also assessed on the dates July chuchuchu.
For this case study, we were only allowed to perform limited nursing procedures
with the guidance and supervision of our clinical instructor, Mrs. Leny V. Baguio, RN.
The procedures that were carried out were nasogastric tube feeding, oral care,
intravenous follow-up and termination, mechanical ventilation (???), suctioning, moving

and lifting, neurologic vital signs and vital signs taking, intake and output monitoring,
bedside care and administration of medications per nasogastric tube.
This case study covers the health condition of the patient, assessment, the
nursing care plans that were applied, and the anatomy and physiology of the
cardiovascular system, circulatory system and neurologic system, pathophysiology and
relevant drug study in relation to the patients present condition for the better
understanding of the whole scenario. An appendix that comprised the doctors order,
nurses notes, Glasgow Coma Scale, vital signs, intake and output monitoring and
informed consent were also incorporated for supplemental information. The drugs and
medications discussed in this study are limited to those prescribed by the physician to
the patient. A discharge plan is also incorporated in this case study.
However, this study is limited only to the data gathered by the proponents
through the information from the client, the doctor and through his chart with the
respective exposure hours. And the concepts that were covered in this study were
grounded on the topics of Nursing Care Management 105.1 of the school year 20152016, as well as the topics and cases that were formerly handled in Nursing Care
Management 105.1, Medical-Surgical Nursing of the previous school year.