OBJECTIVES

This study is made so that readers of the case study and research will gain enough knowledge and understand HCVD, CASHD, NIF (its cause, manifestations, treatment and preventions) which will lead to reaching out to the awareness of every individual who may have this kind of disease and to the members of the health care team and to teach them the proper ways on how to effectively care to patients suffering from this problem. Specific Objectives: To determine the patients Nursing Health History of the Patient To identify the Gordons Typology of the functional health patterns of the patient To know the review of systems of the patient To assess the physical condition of the patient in a cephalocaudal manner noting her general physique and patterns of functioning To know the anatomy and physiology of the system that is affected by the condition of the patient To identify the disease process of the patient To know the analysis, and interpretation of the laboratory findings of the patient To identify the medical, surgical, and nursing management done to the patient To determine the action, side/ adverse effects, and contraindications of the drug administered to the patient To provide a discharge plan for the patient To formulate an effective Nursing Care Plan for the patient.

NURSING HEALTH HISTORY

The nursing health history has a percentage reliability of information based on the following: 90 % of the information was taken from the client which has a GCS of 15, and is conscious, coherent and responsive. 5% of the info is also taken from the patients daughter which is her significant other, and the other 5 % of the information rendered here is taken from the patients chart. A. Biographical Data Patients Name: Patient CA Age: 68y/o Sex: Female Address: Tondo, Manila Date of Birth: October 11, 1944 Nationality: Filipino Significant Others: Daughter Occupation: Sari - Sari store owner Religion: Roman Catholic Parents Name: Deceased B. Chief Complain Difficulty Of Breathing C. History of Present Illness 2 hours prior to admission, the patient experienced difficulty of breathing. D. Past Medical History. 1. Past Illness >According to the patient, she didnt have any past illnesses.

Allergies >The patient stated that she hasnt experienced any allergic reactions regarding with food, medicines and environmental factors. 2. Previous Surgery The patient has not undergone any previous surgery. 3. Accidents The patient stated that she did not encounter any accident prior to her confinement. E. Family History

Figure 1. Genogram of Patient CA

F. Lifestyle Personal Habits: The patient stated that shes only doing mild household chores. She cited examples of her daily activities like cleaning the house, washing her clothes and cooking her food. Other than that, her daughter takes charge of everything in their house. She also does ballroom dancing at home. Diet The patient is placed on low salt low fat diet. The patient is also on fluid restriction of strictly 1 Liter/day. Sleep/Rest Pattern The patient stated that she has a disturbance in her sleeping pattern. Her hours of sleep vary. She also stated that she has unpredictable rhythm in terms of sleep. She cited examples like sometimes, she sleeps at 10:00 PM and wakes at 4:00 AM. Sometimes, she added, she sleeps at 12:00 AM and wakes up at 5:00 AM. Average hours of sleep of the patient was reduced from 8 hours to 5 to 6 hours. The patient also stated that she wakes up at the middle of the night because shes irritable and cant get a good night sleep. Activities of Daily Living: At 5:00 in the morning as soon as the patient wakes up, she takes a bath; she prepares breakfast and then takes a rest. At 2:00 in the afternoon, she frequently washes her clothes. Watching T.V. serves as her resting habit. At her leisure time, she does ballroom dancing indoors. She also takes charge of her sari-sari store. Recreation/ Hobbies: The patients hobbies are managing their Sari Sari Store and Ballroom Dancing.

G. Social Data Family Relationship/friendship: The patients family comprises of her 3 daughters. 1 of them is OFW and she is residing with her another daughter. Educational History: The patient has no formal education. She can only understand numbers. She said, she cant read nor write. Economic Status of the Family: The patient stated that her family is above the poverty line (Daily earning of 329.00Php). The familys daily income is 426.00Php (monthly income is 11,076Php) and is only enough for them to meet immediate needs. 40% of their income is allotted for their food which corresponds to a monetary value of Php4,430.40, another 25% for their bills which corresponds to a monetary value of Php2,769.00 , and 15% for their medications and health needs which corresponds to a monetary value of Php1,661.40 . The remaining 20% goes to other necessities which corresponds to a monetary value of Php2,215.20 . Home and Neighbor Status: The patient stated that they dont hire helpers for their household. They seek help from their neighbors in the times of emergency situations or state of calamity. Coping Pattern: The patient stated that whenever things went wrong, she just prays and everything will soon be okay. She has positive outlook towards life and she also stated that she is optimistic.

Communication Pattern: The patient considers communication as her way of being okay. The patient stated that she can communicate properly with the members of the family.

GORDONS TYPOLOGY
PATTERN HEALTH PERCEPTION PATTERN BEFORE HOSPITALIZATION The patient stated that health is a need for every individual; her health is good because she doesnt have any illness before she was admitted. She has no difficulty in accessing health care facilities.. DURING ANALYSIS HOSPITALIZATION The patient stated Patient cannot that she cannot function consider herself as normally like healthy like before but her before and was health values idle sometimes. increased. But still, the patient has increased valuing in terms of her health. Shes taking all her prescribed medications.

NUTRITIONALMETABOLIC PATTERN

Patient stated that she has a good appetite and eats thrice a day. She usually eats vegetables but ost the time she prefers to eat meat, especially beef which is considered red meat. Also, the patient said that she often eats sardines because its her favorite food and drinks 8 glasses of water per day. She also takes her snack somewhere between 3pm.

Patient stated that she is able to eat small frequent meals a day due to decrease in appetite because of her illness. Her fluid intake is restricted to 1 L per day. She is also placed on a low salt low fat diet.

An individuals health status greatly affects eating habits and nutritional status (Fundamentals of Nursing by Kozier p. 1178) Patients nutritional health status has been changed due to her confinement and her diet.

ELIMINATION PATTERN

The patient stated that she defecates every day and urinates approximately 8 times a day

During her hospital stay, the patient said that she defecates every other day and urinates approximately 5 times a day

There was a change in the frequency of the stool and the urine.

ACTIVITY/ EXERCISE PATTERN

SLEEP/REST PATTERN

Patient prefers The patient stated ballroom dancing in that her activity and their house and doing exercise pattern was household chores decreased due to her such as cooking, hospitalization. The cleaning the house physician on duty and managing her sari ordered the patient sari store as her to be in CBR. exercise and activity pattern The patient has The patient stated normal cycles of that she has a sleep. She sleeps 8 hours a day and takes disturbance in her a nap at 2 to 3 pm. sleeping pattern. Her hours of sleep vary. She also stated that she has unpredictable rhythm in terms of sleep. She cited examples like sometimes, she sleeps at 10:00 PM and wakes at 4:00 AM. Sometimes, she added, she sleeps at 12:00 AM and wakes

During patients confinement, there is quite changes in her activities and has quite restrictions for her actions.

Illness that causes physical distress can result in sleep problems. People who are ill require more sleep than normal and the normal rhythm and wakefulness is often disturbed. (Fundamentals of Nursing, 7th Ed by Barbara Kozier, et al, p. 1117).

up at 5:00 AM. Her average hours of sleep was reduced to 5 to 6 hours. The patient also stated she wakes in the middle of the night because shes irritable and cant get a good night sleep COGNITIVEPERCEPTUAL PATTERN Patient stated that she does not have any formal education. According to her, she can only read numbers and she cannot read written letters or words . Patient stated that though she cannot read nor write, she still can understand her condition because the physician explained everything to her in a manner she could understand. She cited examples like when the physician explained everything in Filipino, and translating the disease in Filipino terms. There is a slight change in the level of her thinking with regards to her disease.

SELF PERCEPTION/ SELF-CONCEPT PATTERN

The client stated that she views herself as functional. She cited examples like doing household chores, and earning a living through her sari sari store as a proof that she is not a burden in their family. She stated that she do what she wants, she is confident and optimistic. Patients husband as she stated had already passed away but she said that both of them had a good relationship with each other. She also stated that she is living with one of her daughters and they do not have quarrels at home. The patient claimed that her reproductive pattern when the time that her husband is still alive is good, though she refuses to talk about things much deeper. She also stated that shes already menopause.

She stated that her self-concept is altered. Sometimes, she said, she thinks that she is a burden to her daughter because she is hospitalized and can only do minimal tasks.

Events or situations may change the level of the self concept over time. Illness and trauma can also affect the selfconcept. (Fundamentals of Nursing 7th Ed by Barbara Kozier p. 959 & 962)

ROLERELATIONSHIP PATTERN

The patient stated that she had a really close relationship with her daughter right now because she is the only one taking care of her in patients hospital stay.

The patient is more dependent to her daughter during hospitalization.

SEXUALITY/ REPRODUCTIVE PATTERN

The patient does not have an active sexual life.

Sexuality and reproductive patterns are affected by the changes that takes place in a persons body or in a persons life

COPING/STRESS TOLERANCE PATTERN

In times of stress or problems, she usually tackles it with her daughter According to her she does not take seriously light problems because she is optimistic and has a positive outlook in life. When everything went wrong, she just pray and she believes that everything will soon be okay

No change

VALUE/BELIEF PATTERN

The patient stated that she is a Roman Catholic. She said that she believes that God will help her to solve her problems. She usually goes to church every Sunday and she does not believe in Hilot and Albularyos.

Patient stated that her belief to God remained the same though the frequency of attending mass decreased

According to Folkman and Lazaruz, coping is the cognitive and behavioral effort to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person(Fundame ntals Of Nursing by Kozier P. 1020) After what happened, patient is still seeking for medical assistance. Religious effort is still a part of patient s life.

PHYSICAL ASSESSMENT
VITAL SIGNS BT: 36.6 oC

BP: 140/100mmHg PR: 87 bpm

RR: 40 cpm

GENERAL STATUS Patient CA is 68 years old, female. Upon seeing, patient CA experiences DOB and pain in the chest area. She assumes a (+) Levine sign upon observation. Has a slight facial grimace. After an hour, patient CA had a relief. Upon interview of the patient, she is conscious, coherent and responsive. She responds appropriately to the questions being asked to her and cooperates throughout the physical assessment SKIN Patient CAs skin as inspected has a brown color.Lesions are noted. Irritations in skin and redness were not present. Patients skin also has good skin turgor when pinched in the forehead. No edema was present on the four extremities upon inspection and palpation HAIR Upon inspection, the patient has thin and oily hair, black in color with a touch of white. It is evenly distributed with presence of dandruff. Nits and lice was not present upon inspection NAILS The patient has normal nail curvature. Tissues surrounding nails are intact. Upon performance of blanch test, nails displayed a capillary refill of 4 seconds. SKULL AND HEAD The patient has rounded and symmetrical skull contour when palpated. Facial features are symmetrical and there are no lesions present in the said area. There were no nodules/masses and tenderness felt when palpated. EYES The patients eyebrows are symmetrically aligned, with evenly distributed hair. The eyelids are intact having no discharge or discoloration. Upon inspection, both bulbar and palpebral conjunctivas are normal. Pupils are equally round and reactive to light. Swelling of eyes is not present upon inspection. Whitish discoloration of the side of pupils was present. Blurring of vision was also claimed by patient CA.

EARS The patients ears are equal in size, symmetry and color with the facial skin. The pinna is in the level of outer canthus of the eye and recoiled after it was folded. Little amount of cerumen were found inside the ear of patient. CA. There are no other unusual discharge and lesions noted. No tenderness is felt by the patient upon palpation in the mastoid process NOSE The patients nose is symmetrical in shape, size and color. Nasal flaring was absent when patient CA breaths. There was no discharge and lesions noted. Both nares are patent. Nasal septum is intact and in between the nasal chambers. Upon palpation of the nose, there is no tenderness of the frontal and maxillary sinuses. Nasal patency was not that good LIPS, MUCOSA, TEETH AND GUMS The patients lips are symmetrical and quite dry. Her dentures are all false teeth. Upon inspection in the oral cavity, no lesions were seen. Thrushes were not observed in both sides of the cheeks and in gums. Upon palpation of the tongue using a tongue depressor, gag reflex was present NECK The patients neck muscles are symmetrical in size and color. It is positioned at the middle. Lymph nodes are not palpable. Head can move normally and smoothly without discomfort. Upon palpation of the neck, tenderness was not present. The thyroid gland also is in the middle and it moves down as the patient swallows. BREAST The patients breast is saggy in shape, slightly unequal in size but generally symmetric, uniform in color. Areola is round and bilaterally the same, color is brown with no masses or lesion. Nipples are round, everted downward. Upon palpation of the axillary, nodules was not present CHEST The patients has symmetrical chest. Spine is vertically aligned, straight, with the right and left shoulders are at the same height. Neither tenderness nor masses were present on the chest wall. When palpated, the patients chest demonstrated loud bilateral symmetry of vocal fremitus. Wheezing and stridor sounds are not heard, though crackles are heard upon auscultation. There is full symmetric chest expansion. The respiratory rate during the interview was 22 beats per minute. CARDIOVASCULAR: Upon inspection, the patients aortic and pulmonic areas have no pulsations. Jugular vein distention is not present. Limbs are not tender and in symmetric in size. Edema was present. Heart Rate during the interview was 87bpm

ABDOMEN Upon inspection, the patients abdomen is loose and uniform in color. The patients abdominal contour is symmetric. Symmetrical abdominal movements caused by respiration were noted. When palpated, tenderness was not present. Liver when palpated was not enlarged REPRODUCTIVE Patient CA reported dysuria or difficulty in urinating. No lesions were noted in the genital area and infestations were not also present when patient is asked. Other unusual discharges are not present MUSCULOSKELETAL Extremities of patient CA were symmetrical with weak muscle tone. Muscle weakness was observed by the patient as she cannot shrug her shoulders as force was exerted on it. Upon inspection, movements of muscle and bones are slow while she was moving her extremities. Weakness of the neck muscle was also observed as she cannot apply an opposing force against the hand on her face NEUROLOGIC The patient has a slouch posture and unsteady gait, walks with assistance and does maintain a little balance while standing. Patient CA was able to discriminate sharp and dull sensations and is able to discriminate hot and cold sensations. For CN I (Olfactory Nerve), she has confusion in identifying the scent of soy sauce while eyes are closed, she got to identify the scent of other objects correctly. For CN II (Optic Nerve), she was able to read written numbers in a notebook easily but she cannot read letters and words. She said she really dont know how to read them. For CN III (Oculomotor Nerve), her pupils constrict when lighted by a penlight and dilates when light is removed. For CN IV (Trochlear Nerve), eyes are coordinated and moved in unison. For CN V (Trigeminal Nerve), she blinks when the cornea is touched and is able to clenched teeth. For CN VI (Abducens Nerve), eyeball moves laterally. For cranial nerve VII (Facial Nerve), she was able to smile, raise the eyebrows, frown, puff out cheeks and close his eyes tightly. For CN VIII (Auditory Nerve), she has positive in Romberg test and positive in Webers test. For CN IX and CN X (Glossopharyngeal and Vagus Nerves), she was able to move her tongue from side to

side and up and down. For CN XI (Accessory Nerve), she has difficulty both in shrugging her shoulders against the resistance of my hands and turning her head to the opposite side of the hand resisting her head. For CN XII (Hypoglossal Nerve), she was able to protrude tongue at midline, and then move it side to side.

MEDICAL MANAGEMENT
1. On total parenteral nutrition.

Patient is on TPN because additional intake of food and water will cause blood volume of patient increase taking the heart congestion much severe.
2. On a low salt low fat diet

Where sodium goes, water follows which means that a increase intake of salty food stimulates our eagerness to drink more water wherein additional intake of water will increase blood volume therefore, increasing the rate of contractility making the blood pressure high. Increase fat intake, plays an important role in putting the heart at risk of cardiovascular diseases.
3.

Infusion of D5W, 500mL x KVO, 10 gtts/min

D5W indicated for parenteral maintenance of routine daily fluid and electrolyte requirements with minimal carbohydrate calories from dextrose.
4. Administration of O2 therapy via nasal cannula 2L/min.

O2 therapy is given to clients who have difficulty ventilating all areas of their lungs or clients with heart failure. Nasal cannula is used because it is relatively comfortable, does not interfere with the clients ability to eat or talk and is well tolerated by the client. 5. With Heplock on the right arm A hep lock is a small tube that a medical professional inserts into the arm or other site on a patient's body. The tube has a catheter on one end. The medical care provider administers medication or fluids in an efficient manner through the catheter lock, which works by keeping a vein accessible for administration of medication or fluids. 6. Limit OFI to 1L per day Additional intake of water will increase blood volume therefore, increasing the rate of contractility making the blood pressure high. Increase fat intake, plays an important role in putting the heart at risk of cardiovascular diseases.