OBJECTIVES

A. General Objective After analyzing and gathering clients information, we will be able to gain knowledge, develop skills and attitude in rendering proper care and management for patients having coronary artery disease, pulmonary congestion, and pneumonia with asthmatic component. B. Specific Objectives Given the opportunity to render care for client, we will be able to: 1. 2. 3. 4. 5. 6. Understand what the disease process is. Distinguish its clinical manifestations, epidemiology and predisposing factors. Discuss the anatomy and physiology of the disease. Outline the pathophysiology of the disease condition. Create a good therapeutic nurse-patient relationship. Determine the health status of the patient through a. History of the present illness b. History of past illness c. Family health history d. Physical examination e. Genogram Analyze laboratory test performed and correlate it on clients present condition. Evaluate the effectiveness of nursing care plan and medical treatment. Check the prognosis and formulate a suitable discharge plan for the client.

7. 8. 9.

INTRODUCTION
The heart is the one of the most important organs in our body. As the heart beats, it pumps blood to different parts of our body. The human heart beats approximately 80,000 to 100,000 a day and pumps 2 gallons of blood. It is made up of muscle which allows the heart to beat constantly. A healthy heart supplies enough blood in the circulation. If disease or injury weakens the heart, the body organs will not receive adequate blood supply needed to support normal functions. There are several conditions affecting the heart like coronary artery disease, congestive heart failure, congenital heart disease and heart attack. Based on the health indicators of the Department of Health, diseases of the heart has been the leading cause of death among Filipinos for six consecutive years. (2000-2005) There is several types of heart disease but the most common is coronary artery disease.

OVERVIEW OF THE DISEASE What is Coronary Artery Disease? Coronary Artery disease is the narrowing of the coronary arteries caused by atherosclerosis. It is sometimes called as hardening of arteries, is the buildup of fatty deposits in the walls of the arteries. These fatty deposits restrict the blood flow to the heart. If there is restriction in the blood flow, the heart will be deprived of oxygen and nutrients it needs to function properly. This can cause chest pain. How does Coronary Artery disease develop? Coronary Artery Disease starts at very young age. Even before teen years, blood vessel walls may start to show fatty streak. As we get older, the fat builds up, causing injury to blood vessel wall. This injury will release inflammatory substance that can promote healing and make the blood vessel wall sticky. The fat and other combined substances form plaque. Inside the arteries, plaque may develop into different sizes. Some plaque deposits are soft on the inside and hard on the outside with hard fibrous cap covering. If the hard surface cracks, fatty deposit is exposed. Platelet come to the area and blood clot accumulate on the injured blood vessel wall. This causes the artery to narrow even more. When plaques narrow the artery, it cannot supply enough oxygen-rich blood to meet organs needs and cramping of muscles occur. This is called ischemia. Ischemia is more likely to occur when the heart demands extra oxygen. This is most common during exercise, stress, excitement or exposure to cold. When the ischemia is relieved in less than 10 minutes or at rest, the patient may have stable coronary artery disease.

Symptoms of Coronary Artery Disease The most common symptom of coronary artery disease is chest pain described as discomfort, heaviness, numbness or tightness. It is usually felt in the chest but may also be felt in the left shoulder, arms, neck or jaw. Other symptoms include shortness of breath, palpitations, dizziness, nausea, weakness, sweating. How to diagnose Coronary Artery Disease? Doctors diagnose it by taking clients medical history and performing physical exam. Blood test, ECG, exercise stress test and cardiac catherization may be required for appropriate diagnosis. Risk Factors for Coronary Artery Disease 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Male Gender Advanced Age Family history of heart disease Cigarette smoking and exposure to tobacco smoke High blood cholesterol and triglycerides Overweight Physical Inactivity Uncontrolled Diabetes Diet high in saturated fat Uncontrolled Anger or stress Drinking too much alcohol

Treatment for Coronary Artery Disease 1. Reduce the risk factors. This involves lifestyle changes. If you smoke, you should quit. Control your blood pressure. Low cholesterol, low salt foods are recommended. Manage your blood sugar 2. 3. Increase exercise and physical activity. Medications. If lifestyle medications are not enough, medications will be a great help.

4. Surgery: Common procedures to treat CAD include balloon angioplasty (PTCA), stent placement and coronary artery bypass surgery. These procedures increase blood supply to the heart, but they do not cure the disease. It will still need to decrease the risk factors to prevent future complications.

PATIENTS DATA
Name Address Age Sex Marital Status Ward Religious Affiliation Date of Birth Race Occupation Admitting Doctor Usual Source of Medical Care Chief Complaint History of Present Illness One month prior to admission she experienced on and off cough so she decided to ask health care professionals in their near barangay center. She was given carbocisteine, sinecod and multi vitamins with iron. But one day prior to admission, the patient consulted a private doctor because of the same reason. She was prescribed with mucobron forte, chloramphenicol and isorbide, but she told us that these medicines aggravate the symptoms, with a verbalization of iniisip ko nga na baka sa mga gamot na ininom ko kaya lumala ung nararamdaman ko. Bigla na lang ako nahirapan huminga at nanghina. She also told us that shell just drink cold water to lessen the feeling of DOB. Then few hours prior to admission, when she was sleeping, she experienced mild amount of DOB which aggravates after an hour. Then they decided to ask for immediate consultation in CMRMDH and was advised and agreed to be admitted. During the time of her confinement she was diagnosed of having CAD, Pulmonary congestion, pneumonia with asthmatic component. According to the client it was her first time to experience the manifestation of the said disease. And every time she feels ill or not feeling well, she asks for immediate consult in their barangay health center. As she claimed ngayon lang naman ako nagkaganito eh. Tsaka pag may nararamdaman akong kakaiba eh nagpupunta na ako agad sa center. : : : : : : : : : L. DL Abiawin, Infanta Quezon : 72 y/o : Female Married : Aircon Ward Roman Catholic March 4, 1938 : Filipino Sari-sari store owner Dra. Delos Reyes Health Center Severe DOB

Past Health History The client stated the she cant remember if she had complete immunization, but she goes to their near center every time it gives free immunization. She verbalized hindi ko alam kung kumpleto ako at kung ano yung mga binibigay sa akin basta pumupunta lang ako sa center namin pag mayroong mga libreng bakuna, yung nga lang di ko na tanda kung ano yung mga yun. She denies of having allergy to any food or drug. But she claimed that she had chicken pox, mumps, and measles. She also told us that whenever she gets sick like common colds, cough and fever she will just take over the counter drugs as her initial

treatment like medicol, paracetamol and even herbal meds like lagundi, malungay at sambong, but seeks consult if symptoms are not relieve with these medications. She was confined first in our institution just for one day due to epigastric pain. But she cant remember what year it was. Then in 2003, again in CMRMDH, she was confined and stayed for 11 days because of hypertension and she was given maintenance of amlodipine. Then in 2005, she had an operation at her left eye because of cataract in UDMC, which was followed by her right eye in 2006, here in CMRMDH. She verbalizes naoperahan ako dati sa mata dahil sa katarata yung una sa kaliwa sa UDMC noong 2005 tapos nung nakaraang taon sa kanan naman dito na sa ospital. Nagkaroon kasi ng medical mission noon she also had a motor accident when she was young and had a right knee injury. Family Health History Our client was the 8th child of their parents. She told us that her parents died because of old age. Her father had asthma but died because of old age at the age of 98, while her mother at the age of 97. They were 12 but her 3 siblings died because of different reasons. First was her eldest sister, she died at the age of 86 because of heart attack. Then her brother who suffered colon cancer died at 71 and last was her 10th brother who had lung problem and died at the age of 40s. Aside from those disease mentioned, no other disease are experienced by her and her family.

GENOGRAM

Parts examined General Survey Height Weight

Actual findings 54 or 64 inches 55 kg. or 121 lbs. BMI = 22.9

Normal findings The ratio of height and weight is an assessment of overall health, hydration status, and nutrition. (p. 572 Fundamentals of Nursing 5th edition by Taylor et. al) Normal BMI ranges from 20.0 24.9 (p. 100 ABCs of Nutrition and Diet Therapy by Dellova et. al) According to page 531 of Koziers Fundamentals of Nursing, 7th Edition, a persons body built should be proportionate and that it varies with lifestyle. According to page 531 of Koziers Fundamentals of Nursing, 7th Edition, a persons posture and gait should be relaxed, erect, and coordinated. According to page 531 of Koziers Fundamentals of Nursing, 7th Edition, one should have no body odor or minor body odor relative to work or exercise, and no breath odor. According to page 531 of Koziers Fundamentals of Nursing, 7th Edition, there should be no distress noted. According to page 531 of Koziers Fundamentals of Nursing, 7th Edition, one should normally have a healthy appearance, with no signs of pallor, weakness, and obvious illness.

Interpretation Normal

Body Built

The clients body built is proportionate to her body.

Normal

Posture and Gait

The client can stand straight. Body movement is coordinated.

Normal

Body and Breath Odor

She has breath odor

Signs of Distress

She has respiratory distress is showing signs of difficulty of breathing and restlessness. The patient is slightly pale in appearance. She is weak and is obviously ill. She complains of easy fatigability.

Disease or injury may reduce a persons ability to perform hygiene measures or motivation to follow hygiene habits. (p. 1109 Fundamentals of Nursing 5th edition by Taylor et. al) A person who has a disease or is ill manifests signs of distress. Pallor or paleness of the skin, often results from inadequate amount of circulating blood or hemoglobin, causing inadequate oxygenation of the body tissues. (p. 573 Fundamentals of Nursing 5th edition by Taylor et. al)

Signs of Health or Illness

REVIEW OF SYSTEMS
Integumentary System Wala naman akong allergy sa gamot at pagkain. Musculoskeletal System Kaya ko naman umupo at tumayo kaya lang pinagsabihan ako ng doctor na huwag magkikikilos at dahil na rin dito sa nasakit sa akin. Cardio-Pulmonary System Nakakatulong itong oxygen na mabawasan ang hirap ko sa paghinga at ayoko nang magkikilos rin dahil sumasakit minsan ang dibdib ko. Buti nga at gumaganda na ang pakiramdam ko ngayon. The patient rated her pain at the scale of 4-5 out of 10.

GORDONS FUNCTIONAL HEALTH PROCESS

A.

Psychological Health

According to the client, whenever she has a problem, she goes out in the backyard and does the garden for a day or more. According to her significant other, she easily gets weak when doing simple chores. She finished 2nd year high school and thought of going to college but never had the chance. She said she can understand and knows some words in English and speak Filipino language. She strongly said that she has a good relationship with her neighbors.

Analysis:
An individuals affect (mood or feeling tone) can affect thinking ability. Several situations would arouse several feelings like when people are deprived of something (money, love, food) they feel sad or anxious & when people satisfy a need, they feel happy. Moreover, happiness of a person may reflect a tendency toward optimism rather than overall satisfaction with life. Happy people emphasize the positive in what they see & remember. Sadness on the other hand is a feeling of displeasure which can be triggered by real or imagined wrongs. Like for an example. Experience, arouse relatively strong emotions.

The ability to expand ones personal and social involvement is critical to this stage of development. Middle aged adults should be able to see beyond their needs and accomplishment on the needs of the society. Dissatisfaction with ones place and achievement often leads to self absorption and stagnation. (Fundamentals of Nursing,6th ed. Potter and Perry. pp.161) Changes in the cognitive function in the middle adults are rare except with the illness or trauma. The middle adult can learn new skills and information. Some middle adults enter educational or vocational programs to prepare themselves for entering the job market or changing job. (Fundamentals of Nursing,6th ed. Potter and Perry. pp.228) . . . feelings and attitudes about sex vary widely: the sexual experience is unique to each individual, but sexual physiology (i.e. how the body responds to sexual arousal) has common features. (Maternal and Child Health Nursing 5th edition by Adele Pillitteri Vol. 1 page 93)

B.

Socio-Cultural Patterns

She said she does believe in almost all of the known superstitious beliefs. The only thing that she truly believes is when you sweep the floor at night because it may give you bad luck. She lives with her significant other for more than half of her life. She is fond of watching television and gardening. She is also satisfied with the environment she has at home. She earns P 300 500/day from her sari-sari store and ulingan.

Analysis:
Every individual needs a source of recreation to alleviate stress. (Psychiatric Nursing by Beck. page 87) The environment of the community in which an individual lives and works might have both helpful and harmful effects on health. (Fundamentals of Nursing 5th edition by Taylor, Lillis, Lemone page 34) The environment has many influences on health and illness. Housing, sanitation, climate, and pollution of air, food, and water are elements in the environmental dimension. Health practices and beliefs are strongly influenced by a persons economic level, lifestyle, family and culture. The culture in which a person belongs influences the persons patterns of living and values about health and illness; such patterns are often unalterable. (Fundamentals of Nursing 5th edition by Taylor, Lillis, Lemone page 66)

C.

Spiritual Patterns

The clients religion is Roman Catholic. She cannot remember her last visit to the church. She is contented with her religion and conforms to the beliefs and practices of her religion like going to church every Sunday and praying.

Analysis:
Spirituality is a concept that is unique to each individual, dependent upon persons culture, development, life experiences, beliefs and ideas about life. As people mature, they often turn inward to enduring values and to a concept of a supreme being or higher meaning that has been sustaining and meaningful. A healthy spirituality in adults is one that gives peace and acceptance of the self and that is often based on lifelong relationship with a supreme being. (Fundamentals of Nursing 6th ed. by Potter and Perry page 546) People nurture or enhance their spirituality in many ways. Some focus on development of the inner self or world; other focus on the expression of their spiritual energy with others or the outer world. (Fundamentals of Nursing 7th edition by Kozier et. al. page 996) Most middle adults are less rigid in their beliefs and have increased faith in a Supreme Being as well as trust in spiritual strength. (Fundamentals of Nursing 5th edition by Taylor, Lillis, Lemone page 422)

D. ADL

Activities of Daily Living Before Hospitalization The client eats well. She is fond of eating cooked fish and vegetables. During Hospitalization The patient is unable to eat well. She has lack of appetite during hospitalization. The client can eat anything that she can tolerate except those that are high in fat and sodium. Interpretation and Analysis I: The patients appetite is affected because of her illness. A: Poor diet can have an injurious impact on health, causing deficiency diseases (Fundamental of Nursing seventh edition by Kozier page 83) Diet as tolerated (DAT) is ordered when the clients appetite, ability to eat and tolerance to certain foods may change. (Fundamentals of Nursing 7th edition y Kozier, page 1202) I: The clients elimination pattern is somewhat affected due to her illness and physical condition Frequency of Bowel Elimination and urination:

1. Nutrition

2. Elimination

The patient defecates once a day and urinates 5 times a day. The color of her stool is brown. Her urine is

The clients elimination is different now compared before she is hospitalized. As she claimed kaunti lang ang

yellowish in color. She doesnt feel any discomfort or pain when defecating and urinating.

ihi ko ngayon kesa dati.

The frequency of elimination is highly individual varying from several times per day. The amount eliminated also varies from person to person. Presence of Discomforts and ability to control: normally absent (Fundamentals of Nursing 7th edition y Kozier, page 1250) Various factors can affect bowel elimination. Interference with the normal functioning of elimination from the intestines can occur in health as well as during illness. Elimination can be affected by a persons developmental stage, daily patterns, the amount and quality of fluid or food intake, the level of activity, lifestyle, emotional status, pathologic processes, medications and procedures, such as diagnostic tests and surgery. (Fundamentals o Nursing 5th edition by carol Taylor et. al. page 1340 ) I: There is a decrease in functional status of the client due to hospitalization and illness. A: Functional status is determined by the ability to perform activities of daily living (ADLs)eating, dressing, bathing, ambulating, and toileting and instrumental ADLs

3. Exercise

The client does not exercise but performs physical activities like walking and gardening.

Due to her hospitalization and illness, her activities are limited. She is in a complete bed rest.

(IADLs) shopping for groceries, meal preparation, housework, laundry, getting to places beyond walking distance, managing medications, managing finances, and using a telephone. Functional declinethe inability to perform usual activities of daily living due to weakness, reduced muscle strength, and reduced exercise capacity. During hospitalization, the patient often experiences reduced mobility and activity levels. Functional decline, including changes in physical status and mobility, has been identified as the leading complication of hospitalization for the middle-aged patients. Bed rest results in a reduction of exercise capacity due to several physiologic changes that occur, including reductions in maximal stroke volume, cardiac output, and oxygen uptake. (www.ahrq.gov/qual/nurse shdbk/docs/KleinpellR_RF DHE.pdf) Regular exercise promotes both physical and emotional health. Physiologic benefits include increased cardiopulmonary function and weight control. Psychological benefits include relief of tension, a feeling of well being and

4. Hygiene

relaxation. (Fundamentals of Nursing 7th edition by Kozier page 114) She takes a The client was I: The clients hygienic bath once a day not able to take a practices are affected sometimes bath during her mainly because of twice a day. The stay in the hospitalization and degree patient brushes hospital. of functioning. her teeth when she wakes up A: Disease or injury may and before reduce a persons ability to going to bed. perform hygienic measures or motivation to follow usual hygiene habits . . . illness may also create a demand for new or modified hygienic measures. (Fundamentals o Nursing 5th edition by carol Taylor et. al. page 1009) Personal hygiene affects an individuals comfort, safety and well-being. Well people are capable of meeting their own hygiene needs. Ill or physically challenged people may require various level of assistance. (Fundamentals of Nursing,6th ed. Potter and Perry. pp.1003) I: The client has an altered sleeping pattern because of illness and physical condition A: Illness, a physiologic and psychological stressor, influences sleep. Certain illnesses are more closely related to sleep disturbances. (Fundamentals o Nursing 5th edition by carol Taylor et. al. page 965)

5. Sleep and Rest

The client has difficulty falling asleep and maintaining sleep pattern.

The client still has difficulty falling asleep and maintaining sleep pattern because of her illness.

ANATOMY AND PHYSIOLOGY

HEART GENERATION OF BLOOD PRESSURE. Contraction of the heart generate blood pressure, which is responsible for blood movements through blood vessels.

ROUTING BLOOD. The separate pulmonary and systemic circulations, which ensures the flow of oxygenated blood to tissues.

ENSURING ONE WAY OF BLOOD. The valves of the heart ensures the one-way flow of the blood through the heart and blood vessels.

REGULATING BLOOD SUPPLIES. Changes in the heart rate and force of heart contractions match blood delivery to the changing metabolic need of the tissues, such as during rest, exercise and changing position. PERICARDIUM- Outermost layer of the heart. Function is to protect the heart from friction. It allows the heart to move easily during contraction. EPICARDIUM- Covers surface of the heart. MYOCARDIUM- middle layer of the heart. Muscular layer. ENDOCARDIUM- Thin, inner membranous layer lining the chambers of the heart. PAPILLARY MUSCLES- arise from myocardial and endocardial surface of the ventricles and attach to the cordae tendinae. CHORDAE TENDINAE- Prevent eversion during systole. RIGHT AND LEFT ATRIUM- two chambers. Function as receiving chambers. RIGHT AND LEFT VENTRICLES- two thicked walled chambers. Major responsibility for forcing blood out of the heart. ATRIOVENTRICULAR VALVES: MITRAL (LEFT) AND TRICUSPID VALVE (RIGHT)permit unidirectional flow from specific atrium to specific ventricle during ventricular diastole. Prevent reflux flow during ventricular systole. Valve leaflets open during

ventricular diastole and close during ventricular systole. Closure produces first heart sound. (S1). SEMILUNAR VALVES: PULMONARY AND AORTIC VALVE- permit unidirectional flow from specific atrium to specific ventricle during ventricular SYSTOLE. Prevent reflux flow during ventricular DIASTOLE. Valve open when ventricles contract and close during ventricular diastole . valve closures produces second heart sounds. CORNARY ARTERIES- branch off at the base of the aorta and supply blood to the myocardium and the conduction system. CORONARY VEINS- superficial vessels that return blood from myocardium back to the right atrium via the coronary sinus. PURKENJI FIBERS- transmit impulses to the ventricles and provide for depolarization after ventricular contraction. SINOATRIAL NODE (SA)- Pacemaker of the heart of the heart. Initiates cardiac impulse.

The lungs expand upon inhalation, or inspiration, and fill with air. They then return to their resting volume and push air out upon exhalation, or expiration. These two movements make up the process of breathing, or respiration. The respiratory system contains several structures. When you breathe, the lungs facilitate this process: 1. Air comes in through the mouth and/or nose, and travels down through the trachea, or "windpipe." This air travels down the trachea into two bronchi, one leading to each lung. The bronchi then subdivide into smaller tubes called bronchioles. The air finally fills the alveoli, which are the small air sacs at the ends of the bronchioles. 2. In the alveoli, the lungs facilitate the exchange of oxygen and carbon dioxide to and from the blood. Adult lungs have hundreds of alveoli, which increase the lungs' surface area and speed this process. Oxygen travels across the membranes of the alveoli and into the blood in the tiny capillaries surrounding them. 3. Oxygen molecules bind to hemoglobin in the blood and are carried throughout the body. This oxygenated blood can then be pumped to the body by the heart. 4. The blood also carries the waste product carbon dioxide back to the lungs, where it is transferred into the alveoli in the lungs to be expelled through exhalation. Smoking can damage the alveoli and make breathing labor intensive, resulting in emphysema or lung cancer. Types of Respiration Two types of respiration exist:
Quiet respiration happens when the body is at rest. During quiet respiration,

the diaphragm contracts and pulls down, lowering the pressure in the lungs and causing air to enter the lungs through the mouth and nose to equalize the pressure. When the diaphragm relaxes, it moves back up, pushing air back out of the lungs. The lungs and chest walls also return to their resting positions. This also reduces the size of the chest cavity and helps to push air out of the lungs.

 Active respiration occurs when the body is active and requires higher levels

of oxygen to the blood than when resting. During active respiration, the muscles around the ribs raise and push out the ribs and sternum, which increases thoracic volume, helping the lungs take in more air. During exhalation, the intercostals force the ribs to contract, and the abdominal muscles contract, forcing the diaphragm to rise. Both these movements make the thoracic cavity contract, and help push air out of the lungs. The Lungs' Protections

Several lung parts and functions act as protective mechanisms to keep out irritants and foreign particles. The hairs and mucus in the nose prevent foreign particles from entering the respiratory system. The breathing tubes in the lungs secrete mucus, which also helps protect the lungs from foreign particles. This mucus is naturally pushed up toward the epiglottis, where is passed into the esophagus and swallowed. Coughing up any of this mucus is usually an indication of a respiratory infection, or a condition such as bronchitis or chronic obstructive pulmonary disease (COPD). Irritants can also cause bronchospasm, in which the muscles around the bronchial tubes constrict in order to keep out irritants. Asthma involves inflammation and constriction of the bronchial tubes, and is often triggered by environmental irritants. Bronchial constriction causes breathing difficulties.

PATHOPHYSIOLOGY

CAD, Pulmonary Congestion, Pneumonia with Asthmatic Component

Precipitating factor Diet Smoking Obesity Sedentary lifestyle Others C-reactive protein (from Predisposing factor HPN,DM Insulin resistance History (women- 55 above, Male-45

Accumulation to artery Plaque formation Decreased blood enter to heart

Blood becomes viscous Artery becomes injured

Decreased oxygen going to the heart tissue

Arrhythmia Can cause

CHF (left sided heart failure) Myocardial Infarction
Obstruction of the arteries (aorta)

Angina

Shortness of Breath

Causing backflow of blood Back to LV then to Fluid leak to the lung vein Back to pulmonary parenchyma and to the then to the lungs alveoli (stiffen the lungs)

Causing pulmonary congestion Severe hypoxia Dyspnea, tiredness, easy fatigability Decreased urine output Decreased pulses, tachycardia

Asthma

Intrinsic Factor/Extrinsic Factor Histamine, bradykinin, prostaglandin, serotonin

Bronchospasm
PNEUMONIA

Bronchoconstriction

Irritants (inhalation)

Inflammation of the lung tissue

Edema of mucus membrane Hyper secretion of mucus

Narrowing of airway Diaphoresis, restless, cold clammy skin, tachypnea, dyspnea, wheezing, retraction, nasal flaring

Increase work of breathing

Exhaustion

Retention of CO2

hypoxia

Respiratory acidosis

DIAGNOSTIC STUDIES AND LABORATORY RESULTS A. Diagnostic Studies

ELECTROCARDIOGRAPHIC REPORT Date: 01-15-11 Rhythm: sinus Rate: Auricular: 50/min Ventricular: 50/min Axis: 0o PR Interval: 0.165 QRS: 0.085 QT interval: 0.485 INTERPRETATION: Sinus Bradycardia Lateral wall ischemia

DIAGNOSTIC IMAGING REPORT

Date: 01-05-11

Chest (PA) view: There are streaky densities at the right lung base. The heart is enlarged. Aorta is tortuous. The cp sulci, diaphragm and bony thorax are unremarkable. Impression: Basal Pnuemonitis, right Cardiomegaly Tortuous Aorta

B.

Laboratory tests

Requested by: Dr. Formaran Date Requested: 1/17/2011 BLOOD CHEMISTRY Examination BUA Creatinine Cholesterol LDL S.I. Result 381 (high) 99 (high) 8.46 (high) 6.8 (high) S.I. Reference Value Male- 204-420 mmol/L Female- 144-342 mmol/L Male- 59-104 umol/L Female- 45-84 umol/L < 5.17 mmol/L < 2.6 mmol/L

Date Requested: 11/22/2011

BLOOD CHEMISTRY Examination BUA Creatinine Cholesterol HDL LDL S.I. Result 356 (high) 115 (high) 8.96 (high) 1.0 (low) 7.0 (high) HEMATOLOGY Result 11.3 (low) 0.34 (low) 78.3 (low) 26.4 (low) 0.09 (low) 4.5 (low) 18.7 (high) S.I. Reference Value Male- 204-420 mmol/L Female- 144-342 mmol/L Male- 59-104 umol/L Female- 45-84 umol/L < 5.17 mmol/L >1.0 mmol/L < 2.6 mmol/L

Test HGB HCT MCV MCH PCT MPV PDW

Reference Values 12.0-16.0 g/dL 0.36-0.46 80-100fl/L 27.0-32.0 pg/L 0.10-1.00% 5.0-10.0 fl 12-18%

URINALYSIS It is a group of chemical and microscopic tests. They detect the byproducts of normal and abnormal metabolism, cells, cellular fragments, and bacteria in urine.

Date Ordered 01-17-11

Urinalysis Color Transparency

Result yellow hazy

Clinical Significance/Meaning of the Results Pale yellow or colorless urine indicates a dilute urine where lots of water is being excreted. Urine clarity refers to how clear the urine is. Usually, laboratories report the clarity of the urine using one of the following terms: clear, slightly cloudy, cloudy, or turbid. "Normal" urine can be clear or cloudy. The glomerular filtrate of blood plasma is usually acidified by renal tubules and collecting ducts from a pH of 7.4 to about 6 in the final urine. However, depending on the acid-base status, urinary pH may range from as low as 4.5 to as high as 8.0. Specific gravity between 1.002 and 1.035 on a random sample should be considered normal if kidney function is normal. Since the sp.gravity of the glomerular filtrate in Bowmans space ranges from 1.007 to 1.010, any measurements below this range indicates hydration and any measurements above this range indicates a relative dehydration.

Reaction/pH

6.0

Specific Gravity

1.020

Protein RBC

+4 5-10

The small number of RBCs normally present in urine usually result in a "negative" test.However, when the number of RBCs increases, they are detected as a "positive" test result. Normally in men and women, a few epithelial cells from the bladder or from the external urethra can be found in the urine sediment. In health, the urinary tract is sterile; there will be no microorganisms seen in the urine sediment. Microorganisms are usually reported as "none," "few," "moderate," or "many" present per high power field (HPF).

Epithelial cells Bacteria

Few moderate

DRUG STUDY

Generic Name

Mechanisms of Action These medications block the transport of calcium into the smooth muscle cells lining the coronary arteries and other arteries of the body. Since calcium is important in muscle contraction, blocking calcium transport relaxes artery muscles and dilates coronary arteries and other arteries of the body. By relaxing coronary arteries, amlodipine is useful in preventing chest pain (angina) resulting from coronary artery spasm. Relaxing the muscles lining the arteries of the rest of the body lowers the blood pressure, which reduces the burden on the heart as it pumps blood to the body. Reducing heart burden lessens the heart muscle's demand for oxygen, and further helps to prevent angina in patients with coronary artery disease.

Dose/Frequ ency/ Route (as ordered by the physician)

Nursing Considerations

Indications

Amlodipine (Calcium Channel Blocker)

5 mg once a day

1. Monitor BP and Cardiac status 2. Give once a day without regard to meal 3. Advise patient to avoid hazardous activities until stabilized on drug.

Hypertension Angina (Chest pain)

Prevents bacteria from growing by interfering with their ability to make proteins. Due to the differences in the way proteins are made in bacteria and humans, the macrolide antibiotics do not interfere with production of proteins in humans. It is an unusual antibiotic in that it stays in the body for quite a while (has a long half-life), allowing for once a day dosing and for shorter treatment courses for most infections.

Azithromycin ( Antibiotics)

500 mg once a day for 7 days

1. Monitor allergy before treatment, reaction of each medication. 2. Provide adequate intake of fluids. 3. Teach patient complete dosage regimen.

Upper respiratory tract infections: pharyngitis/tonsillitis, sinusitis, otitis media Lower respiratory tract infections: bronchitis, acute exacerbation of chronic bronchitis, community acquired pneumonia of mild severity. Sexually transmitted diseases: uncomplicated urethritis, uncomplicated cervicitis due to Neisseria gonorrhoeae or Chlamydia trachomatis. Chancroid (genital ulcer disease in men). Skin and soft tissue infections: erysipelas, impetigo, secondary pyoderma, erythema

Decreased Cardiac Output

Assessment S= O= >restlessness >increased bp > cold clammy skin >decreased peripheral pulses Nursing diagnosis Scientific explanation Planning Short term: Nursing interventions > assess patients condition Rationale Expected outcome

Decreased Cad causes narrowing cardiac output r/tof blood vessels. This increased condition leads to vascular intense pressure resistance exerted on the walls of the blood vessels. The bodys

After 2-3 hours of nursing intervention > monitor and record vital signs > the patient will verbalize understanding > encourage patient to of disease process. verbalize concerns > encourage patient to change position every two hours with assistance

> to determine possible Goal partially met. problems Short term: > for baseline data The patient verbalized > to make client express his feelings Understanding of disease process. > to improve venous return > to reduce stress Long term: The patient participated in activities to decrease the hearts workload

Compensatory mechanism is to increase the work load >have decreased BP at of the heart and thus least 150/100 to 130/90 the patient has decreased cardiac Long term: output.

> to divert attention and > encourage patient to After two days of nursing help patient lessen do relaxation techniques interventions the patient experienced pain and will participate in anxiety activities to decrease in > encourage patient to the hearts workload engage in divertional > to prevent further activities such as complications of the chatting with family and disease friends. > reinforced low salt and low fat diet

Ineffective Tissue Perfusion

Assessment S> O> the patient manifested the following: >shortness of breath >easy fatigability > slightly pale in appearance > cold and clammy skin > decrease urine output >RR: 34 cpm >Hgb: 11.3 g/dL

Nursing diagnosis Scientific explanation Ineffective tissue perfusion r/t decrease oxygen carrying capacity of blood

Objectives

Nursing interventions

Rationale

Expected outcome

The oxygen content of Short term: >assess pt.s condition. >to have baseline data. Short term: arterial blood is almost The patient After 3 hours of ni, >monitor and record >to have baseline data and demonstrated all bound to hgb. In the pt. Will be able to v/s. this are usually altered in the behavior changes to anemia, the oxygen demonstrate behavior condition. content will therefore improve her changes to improve fall in proportion to the circulation. >note color and circulation like reduction in hgb temperature of the skin.>cool, pale skin is indicative relaxation techniques concentration, even of decrease peripheral tissue Goal Partially met. through the po2 is The patient is still perfusion. >monitor peripheral normal. The normal complaining of easy Long term: pulse. compensatory to fatigability and (+) >decrease pulse is indicative pallor. restore oxygen delivery of decreased tissue perfusion is an increase in cardiacAfter 2 days of ni, the >provide a warmth patient will improve from vasoconstriction of the Long term: output. environment. circulation such as vessels. negative complaints The patient shall be >encourage passive of fatigue and >a warm environment free from fatigue and shortness of breath rom. promotes vasodilation which shortness of breath and as evidenced by decreases preload and and improve Hgb improved Hgb count >monitor urine output. promotes tissue perfusion. level. >monitor Hgb count as >rom helps decreases Goal unmet. ordered. venous pooling and promotes tissue perfusion. >decreased tissue perfusion to the kidneys may result in oliguria.

Acute Pain

Assessment S> sumasakit minsan ang dibdib ko. O> restlessness > pain scale of 45/10 > chest pain > (+) facial grimaces > v/s change; RR-34 bpm > ECG reading sinus bradycardia, lateral wall ischemia

Nursing diagnosis Acute pain related to presence of lateral wall ischemia

Scientific explanation

Objectives

Nursing interventions

Rationale

Expected outcome Short term: >the pt. verbalized her understanding about her condition and able to understand the health teachings given to her. Goal Met. Long term: >the patient is relieved from pain and complication. Goal Unmet.

Coronary artery disease Short term: >assess pt.s condition. >to have baseline data. (CAD) is caused by a narrowing of the arteries After 3 hours of nursing >monitor and record v/s. >to have baseline data and this are usually that supply the heart intervention, the pt. Will muscle with blood. verbalize understanding >assess pains location and altered in the condition. When the arteries of her condition and intensity/severity arising narrow, blood flow is health teachings will be with. >to have baseline data reduced. The reduced given to provide comfort for planning and blood flow causes the and relieve of pain. interventions. >provide comfort measures heart muscle to receive like stretching of linens and Long term less oxygen then it assisting in position. >to provide nonneeds to function pharmacological properly. When After 2 days of nursing Pain management. ischemia occurs > provide diversional intervention, the pt. Will patients typically demonstrate behavior of activities like having >to divert pt.s attention. develop angina or chest being relieved from pain conversation w/ the pt. pain originating from the and will be free from the heart. It has been >to prevent fatigue. complications of the >stress to pt the described as chest pain condition. importance of providing or discomfort that has a adequate rest period. >to reduce pain. squeezing or pressurelike quality, usually felt >administer meds as behind the breastbone ordered. (sternum), but sometimes felt in the shoulders, arms, neck, > transderm patch ACW jaws, or back. OD, as ordered

Impaired Gas Exchange

Assessment S> Nahihirapan ako huminga at madali mahapo as vebalized O> with oxygen inhalation per nasal cannula >tachypnea >restless >pale in appearance >RR- 34 cpm >crackles and wheezing >ECG reading sinus bradycardia, lateral wall ischemia

Nursing diagnosis

Scientific explanation

Objectives Short term:

Interventions > monitor and record vital signs

Rationale > for baseline data

Outcomes Short term: The patient is was able to participate well in her treatment regimen. Goal met.

Impaired Gas Excess or deficit in Exchange oxygenation and/or r/t carbon dioxide ventilation perfusion elimination at the imbalance as alveoli-capillary evidence by RR 34 membrane cpm

After 2 hours of nursing interventions and health > elevate head of bed or >to maintain airway, teachings, the patient will position the client for maximum lung be able to participate in appropriately expansion treatment regimen Long term: After 2-4 days of nursing interventions, the patient will be able to improve ventilation and adequate oxygenation. > auscultate breath sounds, note areas of decrease/adventitious sounds

The patient manages to breath with ease due to > encourage frequent improve ventilation and position changes and oxygenation as >promotes chest deep breathing/coughing evidenced by weaning expansion and exercises off from oxygen drainage of secretions inhalation >keep environment >to reduce irritant in allergen or pollutant free airways >provide oxygen inhalation and nebulization as ordered. Goal met

>to note any abnormal findings

Long term:

Ineffective Airway Clearance Assessment Nursing diagnosis Scientific explanation Objectives Interventions Rationale Outcomes

Subjective: hirap ako sa paghinga as verbalized by the patient Objective: >(+) cough >Dyspneic >Abnormal breath sounds (crackles and wheezing) >depth of respiration >restless >unable o perform ADL >changes in respiratory rate ( 34 CPM) >(+) shortness of breath >slightly pale > cold and clammy skin

CAD( coronary Ineffective artery disease)airway resulting to L clearance sided heart related to failure- backflow edema of the blood to formation the lungsto the lungs pulmonary as congestion manifested ineffective airway by clearance (DOB) abnormal breath sounds (crackles and wheezing)

DISCHARGE OUTCOME: The client will be free from DOB and display patent airway.

INDEPENDENT >tachypnea and Goal met >assess rate / asymmetric chest depth of respiration movement are and chest frequently present coz The client is free from DOB and movement of discomfort/ fluid in display patent lungs airway as evidenced >monitor for signs >when pneumonia is by Short term goal: of respiratory severe, it require After 8 hours of failure endotracheal tubing rendering nursing >monitor vital >baseline data >performed deep interventions the signs. Auscultate decrease airflows breathing exercise. client will be able breath sounds. occurs in areas >expectorated to: consolidated w/ fluids secretions >perform deep >promoting lung >demonstrate breathing exercise. >elevate head of expansion. Mobilization dreduction of >expectorate the bed and change and expectoration of congestion w/ secretions position frequently secretions to keep the breathe sounds >demonstrate airway clear. clear reduction of >deep breathing >identified potential congestion w/ facilitates maximum complications and breathe sounds >assist to frequent lung expansion, how to initiate clear deep breathing splinting reduces chest appropriate >identify potential exercise. Help discomfort. Coughing is preventive actions complications and client to perform natural self cleaning >verbalized how to initiate activity eg. mechanism. understanding of appropriate Splinting chest and >aid in mobilization andcause and preventive actions effective coughing expectoration of therapeutic. >verbalized while in upright secretions. management understanding of position. regimen. cause and >offer warm water therapeutic. rather than cold >facilitate liquification management water and removal of regimen. secretions. Schedules COLLBORATIVE between meals and oral >assist / monitor intake decrease of effects of nebulizer vomiting w/ coughing treatments and and expectorations. other respiratory >help to breath and physio therapy eg. aids in mobilization of Percussion, postural secretions drainage, perform treatments

between meals and limit fluids. >provide supplemental fluids eg. IV, humidified oxygen

PROGNOSIS
Mrs. De Leon requested to go home because she is already feeling better she said. She is able to breathe at ease without support of oxygen inhalation during the second day of hospitalization. Prescribed medications were taken within the duration of confinement. She showed her willingness in improving her lifestyle as she verbalized, hindi na nga ako mahilig sa karne at yung matataba, syempre pag matanda na ay hindi na nga dapat nakain ng mga ganay on lagi. Gulay laang kami madalas at saka isda, iba-iba ang luto. Mrs. De Leon is a sari-sari store owner and she sells repacked charcoal. Particles of charcoal can also cause harm to health. She verbalized yun nga pa lang uling daw ay nakakasama din, at yun daw ay kahit na may mask ay nalusot yung alikabok. Kaya magtatakip nalaang ako ng basang panyo para dun dumikit yung alikabok. On the third day her attending physician (Dra. de los Reyes), decided to prescribe home medications upon seeing her improved condition. She was discharged at 11:30 in the morning accompanied by her relatives. We saw Mrs. De Leon when she had her follow up check up last March 4, 2011. March 6, 2011 at 12:05 in the morning, Mrs. De Leon was confined once again because of her illness. She looks very weak, with difficulty of breathing and easy fatigability. March 8 at around 2:00pm she passed away.

DISCHARGE PLAN

M-edication

The patient should drink all medicines prescribed by the doctor and should consume it at the time provided for the whole period of medication. She was advised to take home medications which are; Azithromycin 50mg tab once a day to complete three days since admission, Clopidogrel once a day, and Isobar three times a day. E-xercise

Advise patient to have her regular exercise like doing household chores and

walking. T-reatment H-ygiene It was emphasized to the patient of having a good hygiene. It plays an important role in a persons body because it promotes comfort and can lessen her susceptibility to infection. O-utpatient orders/follow ups The patient was advised to comply with her treatment regimen for good outcome.

Tell patient to go for a regular check up, especially when she experiences complications or other reactions. D-iet

Advise patient to avoid foods like rich in sodium and high in cholesterol that might trigger high blood pressure. Patient was advised to eat nutritious foods like vegetables, fruits and protein rich foods.