I.

TABLE OF CONTENTS

Introduction..2
Nursing Assessment.2
Patients Profile. 2
Patients History.2
Assessment tool..3
Pathophysiology5
List of Prioritized Nursing Problems7
Nursing Care Plans...9
Acute pain.. 9
Decreased cardiac output..11
Ineffective tissue perfusion...13
Anxiety..15
Reference.17

Comprehensive Case Analysis | 1

II.

INTRODUCTION

This is the case of Mrs. B with a clinical condition that involves the renal and cardiovascular systems, two
systems which are closely interrelated. These topics interest me the most due to dynamic changes that can occur
because of how one impaired system can affect the functions of the other system, which eventually progresses to a
more critical stage if not given prompt medical and nursing interventions. These clinical conditions also require the
nurse to be more critical and alert in observing life-threatening manifestations in a glimpse of an eye, thus
promotes the enhancement of skills in critical care. I have only handled the patient for 3 days, January 3-5, 2013,
where the prevalent manifestation she had was chest pains and hypertension. Although she has a kidney problem,
obvious manifestations like oliguria, ascites and edema were not present during assessment; however, she
manifests personality changes at times due to increased circulating metabolic wastes in the blood. Concepts
involved in this case analysis include the relationship of the cardiovascular functions and the kidney functions, the
complications that entail them, and the nursing interventions that should be provided to the patient which include
cardiovascular care like monitoring for vital signs, specifically the blood pressure and pulse rate, monitoring for
signs and symptoms if impending myocardial infarction, and monitoring for peripheral tissue perfusion and its
effects to the neurologic system. For the renal system, strict fluid and electrolyte balance must be monitored

III.

NURSING ASSESSMENT

Patients Profile
Demographic data
NAME: Mrs. B
GENDER: Female
AGE: 60 y/o
RELIGION: Roman Catholic
BIRTHDAY: May 2, 1952
CIVIL STATUS: Married
OCUPATION: Businesswoman in a contraction company subcontractor
Admission Details
DATE ADMITTED: December 31, 2012
TIME ADMITTED: 7:10 A,M
ROOM: Medical ward, 205A
CHIEF COMPLAINS: Epigastric pain and bloatedness
IMPRESSION DIAGNOSIS: Acid related disorder rule out acute coronary syndrome, chronic kidney disease stage V
secondary to hypertensive nephrosclerosis, coronary artery disease, chronic stable angina rule out community acquired
pneumonia, hypertension, hyperuricemia
A. History of Present Illness
Four days prior to consultation, patient felt bloatedness and epigastric pain rated as 8/10, non-radiating.
It was with associated dyspnea, restlessness, irritability and difficulty sleeping. There were no associated
vomiting, fever, and LBM. The patient was maintained on Pantoprazole and TUMS due to acid related
disorder, although claims that she was not relieved by these medications. Persistence of epigastric pain
prompted consultation, hence admission.
1. Past Medical History
10 years ago, she was diagnosed with hypertension and takes unrecalled maintenance
medications. According to her, she was repeatedly admitted in thei and other institutions due
to
hypertension.
2 years ago, the patient was diagnosed with chronic kidney disease stage V, and was advised to
undergo dialysis, but patient refused.
2 weeks prior to admission, patient was admitted in this institution due to dyspnea, epigastric pain and
right flank pain. Patients condition improved with a diagnosis of chronic kidney disease stage V,
hypertension, anemia and acid related disorder, with home medications of Twynsta, Metoprolol and
Clopidogrel. The patient has no known food or drug allergies.
2. Socio-cultural history
The patient lives in a non-congested neighborhood with her family. She does not drink alcoholic
beverages, and she was a smoker, with 1 pack year. She works as a businesswoman in a subcontraction
firm and is managing her employees.
3. Heredofamilial history
Comprehensive Case Analysis | 2

The patient has a family history of hypertension on both paternal and maternal side and bronchial
asthma on paternal side. The patient has no renal disease, PTB, DM, and cancer history.
B. ASSESSMENT: MS TOOL
ACTIVITY/REST
The patient is a businesswoman in a contraction firm. She usually spends leisure time by watching and
talking to her relatives. Upon assessment, she has a stooped posture, and was able to walk with a normal gait,
but with slowed movements and phasing. Her activity level is sedentary because at work as well as at home,
she often sits down. She has a normal muscle tone and strength, but her anginal episodes impose immobility,
weakness and breathlessness. Due to her hospitalization, she developed a feeling of dissatisfaction and a
feeling of cannot concentrate due to inability to manage her job as a businesswoman. Her usual hours of sleep
range from 7-8 hours, but due to her chest pains, it was decreased to 4-5 hours. Medications to facilitate sleep
include Alprazolam. Every after getting up to void, she complains of chest pains, mild dizziness, and blood
pressure elevation of 160/90, tremors are also observed in both hands while having anginal episodes. Care
concerns include activity intolerance and risk for injury
CARDIOVASCULAR ASSESSMENT & PAIN/ DISCOMFORT
Upon the rotational period, she mostly complained of chest pain/heaviness with a rate that ranges from
7/10 to 8/10, which also radiates at the scapular and nape area. Physical exertion and low-lying position
aggravates her condition, while medications like antianginal, specifically Isordil, and analgesics like Ketorolac,
Tramadol and Norgesic relieve the pain felt by the patient. Cardiovascular assessment also includes report of
palpitations during the second day of the care provided. During anginal episodes, apical pulse increased up to
103bpm. BP revealed 160/100 and respiratory rate was 20cpm. Peripheral tissue perfusion include capillary
refill of 2s, and pale nail beds and conjunctiva. Peripheral pulses revealed a pulse rate of 82bpm, moderate (+2)
with skip beats. Diagnostic tests include an X-ray as of December 31, 2012 that revealed a mild cardiomegaly
probably multichamber, and an atherosclerotic aortic knob. A 12 lead ECG was also done upon admission with
results of sinus bradycardia to consider old anteroseptal wall infarction, prominent U waves, and left atrial
abnormality; however, 12 lead ECG as of January 4 and 5, 2013 revealed premature ventricular contractions
with bigeminys. Trop I has a normal result of .168 ng/mL but CK-MB has an increased result of 26.4 u/L.
Medical diagnoses are coronary artery disease, Chronic stable angina rule out community acquired pneumonia
and hypertension. Medications given for the carsiovascular system include Antihypertensives (Amvasc,
Twynsta, Metoprolol, Clonidine) Antianginal/Anti ischemia (Isordil/Isoket, Trimetazidine, Nitroglycerine)
Anticoagulant (Clopidogrel) Analgesics (Tramadol, Ketorolac, Norgesic Forte, Ketoprofen/Fastum Gel), and
Antiarrhythmias (Amiodarone). Care concerns are acute pain, decreased cardiac output, ineffective
myocardial tissue perfusion, ineffective peripheral tissue perfusion, disturbed sleep pattern, and activity
intolerance.
GASTROINTESTINAL TRACT/ FOOD & FLUID/ INTEGUMENTARY
The patients usual food intake is 100% but upon hospitalization, it decreased to 50-75%, and takes in
2-3 snacks per day. Her prescribed diet was Full, low cholesterol diet. She usually takes in more than 1 liter of
fluids per day, including caffeine and sodas. Her bowel movement during her hospitalization reached to 3-4
times per day. The patients history upon admission revealed epigastric pain and bloatedness, but upon the time
of assessments, the patient never complained of epigastric pain and bloatedness; however, she vomited twice
during the first day and the second day, characterized as previously ingested food and whitish secretions,
respectively. She verbalized that intake of certain medications, like Lactulose and Maalox, causes increased
borborygmi which is succeeded by vomiting. Her lips are cracked and dry, with dry ashen gray skin and good
turgor, mucous membranes are moderately moist. Diagnostic tests include 12 Lead ECG, which revealed sinus
bradycardia to consider old anteroseptal wall infarction, prominent U waves, and left atrial abnormality. This
diagnostic test was conducted to determine if the pain originates directly from the gastrointestinal tract or just a
radiating pain from an underlying heart condition. With a diagnosis of acid related disorder, the patient is given
Itopride HCl, Hyoscine N-Butylbromide, Lactulose, Maalox, Pantoprazole, and Calcium Carbonate. Due to the
vomiting episodes; care concerns include Risk for aspiration and risk for fluid volume deficit.
GENITOURINARY TRACT/ RENAL SYSTEM
Due to her chronic hypertension, the kidneys are also affected, leading to a diagnosis of Chronic
Kidney Disease (CKD) stage V. The patient did not manifest any excess fluid volume symptoms like edema
and ascites, however, during the last day of my rotation, the patient manifested a puffy eyelids which could be
caused by excessive fluid volume due to inability of the kidneys to retain albumin, or may be due to lack of
sleep. She also did not manifest oliguria, where urine output for one day was more than 1ooomL. She also did
not manifest any flank pain during the entire shifts of handling her. Her complexion was ashen gray, which is a
symptom of CKD. Diagnostic tests include BUN and Crea which revealed 129.2mg/dL and 1015umol/L,
respectively. This was done to determine the ability of the kidneys to excrete waste products from the body.
Another test done was serum electrolytes particularly that of serum sodium= 128mmol/L and serum
Potassium= 3.49mmol/L, done to determine presence of electrolyte imbalance brought about by the kidney
Comprehensive Case Analysis | 3

problem. CBC also revealed a low hematocrit level of 0.304 and a low hemoglobin level of 101, indicative of
anemia due to decreased erythropoietin production. Lastly, urinalysis revealed turbid urine, a specific gravity of
1.010, and a positive Albumin in the urine (++) or otherwise known as Albuminuria. Because of the impaired
functionality of the kidneys, metabolic wastes accumulate in the body, particularly in the blood stream. Uric
acid is one of the wastes which accumulate in the blood stream, a manifestation otherwise known as
Hyperuricemia. This hyperuricemia makes the client at risk for mental status and personality changes;
Allopurinol therefore was given to facilitate excretion of excessive uric acid in the blood. Medications given
for her CKD include diuretics (Lasix) and Sodium bicarbonate. Iron and folic acid was given to prevent
anemia. Care concerns include electrolyte imbalance, ineffective renal tissue perfusion, risk for acute
confusion, risk for injury, and risk for infection. Due to lack of knowledge regarding dialysis, another
concern is deficient knowledge.
NEUROLOGIC ASSESSMENT
The patient claimed once of a tingling sensation all over her body accompanied by diaphoresis, during
one of her anginal episodes. The patient is oriented to person, time, place and situation. She is also alert,
conversant, and follows commands; but restless during anginal episode attacks. Her Glasgow coma scale has a
total of 15. All cranial nerves are intact and has no significant findings.
RESPIRATION
Respiratory rate is 20-21cpm, regular and deep. The patient experiences dyspnea related to an
underlying cardiovascular problem. She is relieved by rest and oxygenation at 1-2LPM per nasal cannula. She
was a past smoker with 1 pack year.
PSYCHOSOCIAL ASSESSMENT
This patient verbalized that her hospitalization worries her because she cannot perform her job as a
businesswoman. She constantly thinks about it which causes increased blood pressure and chest pains, which
alters her sleeping pattern. Aside from that, the patient, on the last day of assessment, verbalized that she
refuses to undergo dialysis despite her condition because her notion of undergoing dialysis hastens a persons
death, and it increases her anxiety. However, upon explanation that dialysis would only be the last and best
treatment available, the patient then verbally agreed to undergo dialysis. Care concerns therefore include
Ineffective role performance, mild anxiety, fear, sleep pattern disturbance, and deficient knowledge.

Comprehensive Case Analysis | 4

IV.

PATHOPHYSIOLOGY OF CORONARY ARTERY DISEASE AND

CHRONIC KIDNEY DISEASE

PREDISPOSINGFACTORS:

PRECIPITATING FACTORS:

Age: 60 y/o
Gender: Female
Family history: HPN on both
paternal and maternal side

Cigarette contains nicotine (along with

caffeine in coffee and sodas)

Lifestyle: sedentary
Stress from work
Past smoker: 1 pack year
Diet: fat; caffeine
intake

age=fat; accumulation of
lipids in the intima
(atherosclerosis)

Potent vasoconstrictor

Narrowing of blood vessels

Vasoconstriction
Total peripheral resistance
Decreased perfusion to other
organs, especially the kidneys

Blood pressure= 160/100

Risk for injury

Narrowing of preglomerular
arteries and arterioles

Renal tissues, especially

the glomeruli, hardens

RAAS is stimulated

Progressive glomerular
sclerosis
Hypertensive
nephrosclerosis

Myocardium compensates by
contracting harder and faster

Myocardium is overworked

Perfusion occurs during

diastole/relaxation
Therefore, contraction

X-ray as of 12.31.12 revealed

Further BP elevation

perfusion to tissues
Ineffective Cardiac tissue
perfusion

glomerular blood flow

Dizziness, nape pain

Mild cardiomegaly probably

multichamber
Atherosclerotic aortic knob

Thickening/ enlargement of
cardiac muscles

Relaxation period
O2 supply to coronary
arteries

Inability to contract
effectively
Decreased cardiac output

Ischemia
Ineffective Cardiac tissue
perfusion

Easy fatigability
Angina
Activity intolerance
Acute pain

Disturbed sleep
pattern
Legends:
Nursing Diagnoses

ECG as of 12.31.12 revealed:

Sinus bradycardia t/c old
anteroseptal wall infarction
Prominent U waves
Left atrial abnormality

Lab results

Comprehensive Case Analysis | 5

Chronic Kidney Disease Stage V

glomerular filtration
capacity

Inability to regulate fluid

and electrolytes

metabolic wastes in the

blood

As of 12.31.12
Serum Na: 128mmol/L
Serum K: 3.9mmol/L

uric acid
Electrolyte
imbalance

Inability to hold
bicarbonates/ act as buffer
system

ABG as of 12.31.12
Ph: 7.37
pCO2: 28.4
paO2: 77.2
HCO3: 18

Erythropoietin
production

RBC production

CBG as of 12.31.12
Hct: 0.304
Hgb: 101

Hyperuricemia
Metabolic acidosis
Anemia

As of 12.31.12
BUN: 129.2 mg/dL
Crea: 1015 umol/L
Urinalysis as of 12.31.12 revealed:
Specific grav.: 1.010
Albumin: positive (++)

CHON
excretion

Ig production (made
up of protein)

Risk for acute

confusion

Aside from Acid Related

Disorder, the body
compensates by
eliminating HCl acid
through vomiting

Pale conjunctiva and

nail beds
Capillary refill of 2s

Ineffective peripheral
tissue perfusion
Risk for fluid volume
deficit

humoral response

Risk for infection

Legends:

Nursing diagnoses
Lab results

REFERENCES
BARE et al. (2012), Brunner and Suddarths Textbook of
Medical-Surgical Nursing10th edition, Volume 2
CORWIN, E. (2008), Handbook of Pathophysiology 3rd
Edition
McCANN (2007), Straight As in Fluid and Electrolytes

V.

LIST OF PRIORITIZED NURSING DIAGNOSES

Comprehensive Case Analysis | 6

NURSING PROBLEMS ACCORDING TO

PRIORITY

RATIONALE

Acute pain related to anaerobic metabolism in

myocardium secondary to decreased oxygen supply

This is an actual problem that needs to be addressed

first, because when a person is in pain, the patient tends to
have a narrowed focus. This now leads to having a
decreased compliance to medical and nursing
interventions, because the focus of the client is on
relieving pain. Addressing this will improve the patients
compliance and cooperation to address the underlying
problem causing this actual problem.

Decreased cardiac output related to increased total

peripheral resistance secondary to hypertension

This actual problem is actually the underlying cause

of acute pain, so this was prioritized next. This falls under
physiologic need according to Maslows hierarchy
because the blood carries the oxygen which will be
needed by all the cells in the body. By addressing this, the
succeeding problems may also be resolved eventually.

Ineffective cardiac tissue perfusion related to blockage

of coronary arteries secondary to atherosclerosis;
Ineffective renal tissue perfusion related to narrowing of
preglomerular arteries secondary to chronic hypertension

These two actual problems are of the same category,

ineffective tissue perfusion. With decreased blood flow to
the heart, the kidneys are also deprived of Oxygen which
in turn allows it to respond to the lack of blood supply
through stimulating the RAAS. RAAS, in turn, further
increases the blood pressure and further decreases the
blood being supplied by the heart. This cycle continues
and promotes further damage; therefore, both problems
should be addressed simultaneously, to prevent
complications.

Anxiety related to uncertainty of own prognosis

This actual problem falls under safety and security.

This psychosocial care concern should be addressed and
watched out for, because anxiety can cause physical
effects like increased blood pressure and even chest pains.

Ineffective peripheral tissue perfusion related to

decreased hematocrit and hemoglobin levels secondary to
decreased erythropoietin production

This actual problem, though falls under the same

category as the preceding problem, is prioritized next
because it still involves oxygenation. This problem was
excluded from the preceding tissue-perfusion-related
group of problem, since this is just a result of preceding
nursing diagnoses (except anxiety). Correcting the cardiac
and tissue perfusion may eventually give way to the
resolution of this. Besides, this problem implies a diferent
set of nursing interventions from the other two perfusion
problem.

Risk for aspiration related to presence of vomiting

episodes

Despite being a potential problem, this is prioritized

over the other actual problems because the patient may
suffer from an immediate respiratory arrest due to
aspiration that may happen anytime the patient vomits;
and this involves airway, still a physiologic priority
according to Maslows and Hendersons 14 basic needs.
Life-threatening situations may happen if this risk
problem is not prevented or addressed.

Comprehensive Case Analysis | 7

NURSING PROBLEMS ACCORDING TO

PRIORITY

RATIONALE

Electrolyte imbalance related to inability of the

kidneys to regulate fluids and electrolytes secondary to
Chronic Kidney Disease

According to Maslows hierarchy, this actual problem

involves another physiologic need which is electrolytes.
This problem should be addressed next because
electrolyte imbalances can cause multisystem affectations
like neuromuscular symptoms such as seizures and muscle
weakness, cardiovascular effects like hypotension or
hypertension, and even arrhythmias which can be fatal to
the patient and may cause irreversible damages to the
body system.

Disturbed sleep pattern related to anginal episodes

occurring at night time

Sleep and rest is another physiologic need under

Maslows hierarchy. It is necessary to address this
problem because sleep or rest may be the patients source
of energy needed for faster recovery. Disruption of sleep
may deplete ones energy and even affects mental status,
and even compliance to medical and nursing regimen.

Activity intolerance related to easy fatigability

secondary to ischemic episodes

All the preceding nursing diagnoses may affect the

patients ability to participate in activities of daily living.
This actual problem falls under safety and security,
according to Maslows hierarchy. Addressing this problem
may prevent occurrence of injuries brought about by
inability to assist one in performing activities of daily
living. By addressing this, nurses can help the patient
achieve a sense of well-being for accomplishing activities
within her level of performance, thus increasing the
patients compliance and cooperation in solving other
identified problems.

Risk for acute confusion related to high metabolic

wastes in the blood secondary to hyperuricemia

Due to an increased BUN, creatine and uric acid levels

in the patients blood, the patient is at risk for personality
changes and even loss of consciousness. This now
predisposes the patient to injuries brought about by falls
and sudden loss of consciousness; therefore, the patient
should be watched out for this potential problem to
prevent further complications.

Risk for injury related to presence of dizziness

secondary to hypertension

This potential problem falls under safety and security

of Maslows hierarchy which should be prevented to
prevent serious injuries or falls.

Risk for infection related to decreased humoral

response secondary to albuminuria

Due to albuminuria, the patients immunoglobulins,

which are made up of proteins are decreased in
production, thereby decreasing the humoral response of
the patient to opportunistic bacteria that she might acquire
during her course of hospitalization.

Comprehensive Case Analysis | 8

VI. NURSING CARE PLANS

Problem #: Chest pains
Nursing Diagnosis: Acute pain related to anaerobic metabolism in myocardium secondary to decreased oxygen supply
Goals:
STO: After 3-4 hours, the patient will be able to manifest: decreased pain intensity from severe to mild or none, decreased pain rating from 7/10 to 3/10 and below; demonstrate: use
of relaxation skills like guided imagery and deep breathing exercises, use of diversional activities like conversing or listening to music, verbalization on how to prevent angina like limiting
physical exertion and through stress management, verbalization on how to relieve or control pain like DBE, sitting up and medication compliance
LTO: After a month, the patient will be able to prevent, relieve or control pain brought about by the decreased Oxygen supply. The patient will be able to manage and prevent chest
pains
PROBLEM CUES

EXPLANATION OF THE
PROBLEM

S> Gumagrabe yung sakit netong

dibdib ko; complains of chest
heaviness rated as 7/10, radiating to
left scapular area, aggravated by
physical exertion, intermittent and
relieved by antianginal medications
and high fowlers position.

Chest pain results from lack of

oxygen supply to the myocardium,
which still stimulates anaerobic
metabolism. This metabolism only
happens with the lack of oxygen, and
results to the production of lactic
acid, which irritates the myocardium
and the nerves in it, sending pain
perceptions to the brain, thus a
nursing diagnosis of ACUTE PAIN.

O> 12 Lead ECG as of 12.31.12

revealed
sinus
wall
infarction;prominent U waves; left
atrial abnormality; Trop I= .
168ng/ml, CK-MB 26.4 u/L as of
12/31/12. With BP of 150/90, PR:
82;
grimaces
noted
upon
movements and speech; holds left
chest and massages it at times when
pain surges; assumes high back rest
most of the time; narrowed focus
noted, reduced interaction with
people; diaphoresis on forehead and
antero-posterior chest noted

Reference:

INTERVENTIONS

RATIONALE

Assess pain location and characteristics.

Pain assessment is important in determining the pain origin

and so as to address immediately the underlying cause.

Monitor increasing pain intensity/

severity and to where it radiates.

The angina can further lead to myocardial infarction if not

watched out for.

Maintain on O2 inhalation at 1-2LPM

It increases O2 supply and prevents anaerobic metabolism.

Demonstrate DBE

DBE increases the O2 entering the airways.

Maintain on high fowlers position

It facilitates better lung expansion, which increases O2

supply
Heat promotes vasodilation, allowing more O2 to the heart.

BARE et al. (2012), Brunner and

Suddarths
Textbook of Medical- Apply hot water bag on affected area
Surgical Nursing10th edition, Volume 2

Administer anti-anginal medications:

Isordil, Nitroglycerine, Trimetazidine,
and analgesics like Tramadol and
Ketorolac

Promotes vasodilation which allows more blood to the

arteries supplying the heart itself. Analgesics inhibit
prostaglandin synthesis causing decreased pain.

Encourage to limit physical exertion, and

These interventions decrease O2 demand which may help

Comprehensive Case Analysis | 9

provide adequate rest periods

Instructed on a low chol., low Na diet

like DASH diet

prevent angina
Diet containing cholesterol and caffeine increases
vasoconstriction which compromises blood supply, causing
anginal episodes.

Evaluation:
Goal unmet

VII. JUSTIFICATION
The goal was unmet because Mrs. Bs pain was recurrent due to poor stress management and non-compliance to some medications like pain relievers. Her condition
also worsened which prompted intensive critical care.

VIII. MODIFICATIONS AND RECOMMENDATIONS

The chest pain was actually one of the manifestations of increased metabolic wastes in the blood. Since the patient, refused dialysis, the metabolic wastes accumulated.
This could have been prevented if both patient and family members were corrected of the wrong notion that hemodialysis worsens the condition and hastens death. I
recommend to include the significant others in the explanation of all medical and nursing interventions and ensure that they comprehend it properly. Any explanation of
medical and nursing interventions should also be done when the patient is in a calm and oriented state.

Comprehensive Case Analysis | 10

Problem #: Chronic Hypertension

Nursing Diagnosis: Decreased cardiac output related to increased total peripheral resistance secondary to hypertension
Goals:
STO: After 24 hours of nursing interventions and health teachings, the patient will be able to manifest: maintained normal BP; normal ECG findings, capillary refill of 1-2s and
pinkish mucosal membranes; skin will be warm to touch; demonstrate: management of hypertension like: proper diet regimen like DASH; low chol, low sodium diet; stress management and
decreased caffeine intake
LTO: After 3 days and beyond, the patient will be able to manage her hypertension.
PROBLEM CUES
S> Tumataas na palagi tong BP ko
complains of angina
O> Patient was diagnosed with hypertension
10 years ago; with BP of 150/90-160/100;
PR= 82bpm; 12 Lead ECG as of 12.31.12
revealed sinus wall infarction;prominent U
waves; left atrial abnormality; Chest X-ray as
of 12.31.12 revealed midl cardiomegaly
probably multichamber, atherosclerotic aortic
knob; ECG as of 01.03.12 revealed Premature
ventricular contractions; capillary refill of 2s;
with pale nail beds and conjunctiva; with cool
and clammy skin

EXPLANATION OF THE PROBLEM

Due to increased blood pressure, there is
vasoconstriction that results to decreased
filling of ventricles, which when contracts
supplies lesser amount of blood to the system,
thus a nursing problem of DECREASED
CARDIAC OUTPUT
Reference:
BARE et al. (2012), Brunner and Suddarths
Textbook of
Medical-Surgical Nursing10th
edition, Volume 2

INTERVENTIONS

RATIONALE

Monitor and record vital signs,

especially BP

An increase in BP should be referred

to provide immediate interventions to
prevent complications like
myocardial infarction

Monitor intake and output

quantitatively

Output like urine is also indicative of

a decreased cardiac output and
perfusion to the kidneys

Maintain on O2 inhalation

This saturates circulating

hemoglobin and increases the
effectiveness of blood that is
reaching the ischemic tissues.

Provide adequate rest periods by

clustering nursing interventions

Maintain on high fowlers position

Frequent physical exertion elevates

BP and increases O2 demand, making
patient at risk for complication

This promotes optimal lung

ventilation and perfusion. The
patient will experience optimal
lung expansion in upright
Comprehensive Case Analysis | 11

position.
Do passive range-of-motion (ROM)
exercises to unaffected extremity
every 2 to 4 hours
Administer antihypertensives:
Twynsta, Amvasc, Metoprolol and
anti coagulants: Clopidogrel; and
antianginal: nitroglycerine

Instructed to avoid high sodium diet

like ketchup and high preservativecontaining foods like bacon, and
canned goods; and to limit caffeine
intake like coffee and soda
Encouraged to manage stress through
DBE and relaxational and diversional
activities like waching tv.

Exercise prevents venous stasis.

Promotes vasodilation and prevents

blood clot formation, and promotes
myocardial perfusion, respectively

Diet regulation prevents

vasoconstriction thereby preventing
good perfusion, thus, it should be
managed

Decreased stress, prevents the patient

from being at risk to having increased
BP.
Evaluation: Goal unmet

I.

JUSTIFICATION
The goal was unmet because the patients BP remained increased for 3 days upon assessment due to inability to manage stressors like business problems and
hospitalization concerns. The patient wasnt also compliant to some medications and medical interventions like 12 Lead ECG.

II.

MODIFICATIONS AND RECOMMENDATIONS

Comprehensive Case Analysis | 12

This was a result of incomprehension due to the experienced manifestations like chest pains and narrowed focus during explanations. Therefore, recommendations
include proper health teaching and explanation of all interventions to promote patients compliance to both medical and nursing interventions. Nurses should also be assertive
in providing nursing interventions.

Problem #: Coronary artery disease, Chronic Kidney Disease

Nursing Diagnoses: Ineffective cardiac tissue perfusion related to blockage of coronary arteries secondary to atherosclerosis; Ineffective renal tissue perfusion related to narrowing of
preglomerular arteries secondary to chronic hypertension
Goals:
STO: Within 48 hours of nursing interventions, the patient will be able to manifest optimal tissue perfusion like a) capillary refill of 1-2s b) warm to touch skin c) decreased anginal
episodes d) normal BP
LTO: The patient will be able to maintain optimal tissue perfusion to vital organs within the course of confinement until discharge.
PROBLEM CUES
EXPLANATION OF THE
INTERVENTIONS
RATIONALE
PROBLEM
S> Sabin i Doc pangit daw yung
kidney ko kaya tumataas BP ko
tsaka sumasakit dibdib ko
O> > Patient was diagnosed with
hypertension 10 years ago and
with CKD 2 years ago; with BP of
150/90-160/100; PR= 82bpm, +2,
with skip beats; 12 Lead ECG as
of 12.31.12 revealed sinus wall
infarction;prominent U waves;
left atrial abnormality; Chest Xray as of 12.31.12 revealed mild
cardiomegaly
probably
multichamber,
atherosclerotic
aortic knob; ECG as of 01.03.12
revealed Premature ventricular
contractions ;
BUN= 129.2

Due to her chronic hypertension and

CKD stage V, the perfusion to vital
organs is compromised, causing
decreased nutrition and oxygenation at
the cellular level. Thus, a nursing
problem of INEFFECTIVE TISSUE
PERFUSION
Reference:
BARE et al. (2012), Brunner and
Suddarths
Textbook of MedicalSurgical Nursing10th edition, Volume 2

Monitor and record vital signs, especially BP

An increase in BP should be referred to provide

immediate interventions to prevent
complications like myocardial infarction

Monitor intake and output quantitatively

Output like urine is also indicative of a

decreased cardiac output and perfusion to the
kidneys

Assess for possible causative factors

related to temporarily impaired arterial
blood flow.

Early detection of cause facilitates prompt,

effective treatment.
It increases O2 availability for cardiac function

Maintain O2 inhalation

Provide adequate rest periods by clustering

nursing interventions

Frequent physical exertion elevates BP and

increases O2 demand, making patient at risk for
complication

Comprehensive Case Analysis | 13

mg/dL, Crea: 1015 umol/L; with

anginal episodes; capillary refill
of 2s; with pale nail beds and
conjunctiva; with cool and
clammy skin

Administer antihypertensives: Twynsta,

Amvasc, Metoprolol and anti coagulants:
Clopidogrel;
Applying NSAID gel on nape area for nape
pains
Instructed to avoid high sodium diet like
ketchup and high preservative-containing
foods like bacon, and canned goods; and to
limit caffeine intake like coffee and soda

Promotes vasodilation and prevents blood clot

formation, respectively
Provides relief, thus also decreases the patients
BP.
Diet regulation prevents vasoconstriction and
fluid overload brought about by the components
of food.

Decreased stress, prevents the patient from

being at risk to having increased BP.

Encouraged to manage stress through DBE

and relaxational and diversional activities
like waching tv.
Evaluation: Goal partially met

I.

JUSTIFICATION
Goal is partially met since during the time of evaluation, the patients condition improved and manifested good cardiac perfusion, although it was not continuously
improving. At times, the patient still manifests decreased cardiac and renal perfusion.

II.

MODIFICATIONS AND RECOMMENDATIONS

Since the cause of this nursing problem is increased metabolic waste, hemodialysis should be properly explained to the patient, and her vital signs and condition
however, should be stabilized first before undergoing any surgical procedure and hemodialysis. Before undergoing hemodialysis, supportive care should be provided to
alleviate suffering of patients due to the increased metabolic wastes and atherosclerosis.

Comprehensive Case Analysis | 14

Problem TP: Anxiety related to role dysfunction and uncertainty of prognosis

Nursing Diagnosis: Anxiety related to uncertainty of prognosis
Goals: Patient will be able to manage her anxiety
STO: The patient will be able to recognize signs of anxiety, after an hour to two of nursing interventions.
LTO: After 3 days, patient will be able to Patient will be able to manage her anxiety by demonstrating positive coping mechanisms like verbalization of the thoughts that cause her
anxiety.
PROBLEM CUES

EXPLANATION OF THE
PROBLEM

S> Panpanunutek gamin diay

nabatik nga trabaho mi ;
Hindi ba ako mamamatay agad
kung
magdialysis
ako?;
complains of palpitations after
overthinking of her problems;
complains of lack of sleep at
night

Anxiety is probably present at

some level in every individuals
life, but the degree and the
frequency with which it manifests
differs broadly. The patient let a
job behind which she constantly
thinks about, causing her to
manifest symptoms of anxiety.

O>
With vital signs of
BP=160/100, PR= 82bpm, RR=
22;
restlessness
noted;
trembling of hands noted;
diaphoresis noted on forehead
and back area; moaning
episodes noted at times; has
difficulty
concentrating;
decreased interaction with
people noted; stares blankly at
times

INTERVENTIONS

RATIONALE

Assess patients level of anxiety

Assess the manifestations of her anxiety.

This allows for appropriate

interventions for the type of
anxiety. Mild anxiety enhances
the patients awareness and ability
to identify and solve problems.

REFERENCE:
GULANICK et al., (2007)
Nursing Care
Plans:
Nursing
Diagnosis
and
Intervention.

Determine how patient copes with anxiety.

To recognize if the patient is
having anxiety and to provide
appropriate nursing interventions.
Acknowledge awareness of patients anxiety

This assessment helps determine

the effectiveness of coping
strategies currently used by
patient.
Maintain a calm manner while interacting with patient.
Establish a working relationship with the patient through
continuity of care. An ongoing relationship establishes a basis
for comfort in communicating anxious feelings.

Because a cause for anxiety cannot

always be identified, the patient may feel
as though the feelings being experienced

Comprehensive Case Analysis | 15

are counterfeit. Acknowledgment of the

patients feelings validates the feelings
and communicates acceptance of those
feelings.

Use simple language and brief statements when instructing patient

about self-care measures or about diagnostic and surgical
procedures.

Reduce sensory stimuli by maintaining a quiet environment; keep

"threatening" equipment out of sight.

Encourage patient to seek assistance from an understanding

significant other or from the health care provider when anxious
feelings become difficult.

The patients feeling of stability

increases in a calm and
nonthreatening atmosphere.

When experiencing moderate to

severe anxiety, patients may be
unable to comprehend anything more
than simple, clear, and brief
instructions.
Anxiety may escalate with excessive
conversation, noise, and equipment
around the patient. This may be
evident in both hospital and home
environments.

The presence of significant others

reinforces feelings of security for the
patient.

Comprehensive Case Analysis | 16

Evaluation: Goal partially met

VI. JUSTIFICATION
Goal was partially met because the patient was able to recognize the signs of anxiety; however, she wasnt able to manage the stressors causing her anxiety.

VII. MODIFICATIONS AND RECOMMENDATIONS

The significant others must also be informed that the patient experiences anxiety and that they should be of support to prevent occurrence of this nursing problem. The
significant others must also be informed of the manifestations and the appropriate interventions for every level of anxiety, whenever Mrs. B experiences anxiety, for them to
help the patient manage the anxiety.

VIII. REFERENCES
BARE et al. (2012), Brunner and Suddarths Textbook of Medical-Surgical Nursing10 th edition, Volume 2
CORWIN, E. (2008), Handbook of Pathophysiology 3rd Edition
DOENGES, et al. (2010) Nurses Pocket Guide 12th Edition
GULANICK et al., (2007) Nursing Care

Plans:

Nursing Diagnosis and Intervention.

McCANN (2007), Straight As in Fluid and Electrolytes

Comprehensive Case Analysis | 17

Comprehensive Case Analysis | 18