Saint Louis University

College of Nursing
Baguio City

Submitted By:

VALDEZ, Renart Lean S.

BSN III- C1

Submitted To:

Mr. Marvin Francisco, RN

SLU-CON, Faculty

Baguio Medical Center

06-26-10

Patient’s Profile
Name: Fernando Sison
Age: 55 year old
Gender: Male
Birthdate:
Birthplace: Benguet
Civil status: Married
Religion: Roman Catholic
Nationality: Filipino
Address: Camp 8, Baguio City
Occupation: Former security guard
Relationship: Married
Date admitted: 06-24-10
Time admitted: 09:45 am
Attending physician: Dr. Safarti

Health History

Chief Complaint: Headache and dizziness

Diagnosis: (none at the moment)

History of Present Illness: The condition started six years and diagnosed as hypertensive and diabetic
(DM II) and was prescribed a maintenance of unrecalled name of drug for hypertension and diamicron for
diabetes mellitus but the medications were not taken regularly. After the patient knew that he is
hypertensive and diabetic, lifestyle change were observed by eating less fatty foods and diet control for
being diabetic.
Few hours prior to admission the patient experienced headache and dizziness while watching
television. The patient took catapres and the symptoms were not relieved so they decided to go in the
hospital. Current medications were Norvasc, Digoxin, Metformin, Omeprazole, Vastarel.

Past Medical History: The patient is completely immunized. There were no allergies to foods and drugs.
There were no previous accidents or injuries occurred. This were the patient’s second hospitalization, the
first hospitalization was due to cataract and underwent EECE. There were maintenance drugs but was not
taken regularly. The patient is a cigarette smoker before but already stopped for many years now.

Family History: There were no hereditary disease in the father side but to the mother side there were
history of Diabetes mellitus, hypertension, heart disease, and arthritis. The mother is now with Diabetes
mellitus, hypertension, and arthritis.

Drugs

Metformin 500 mg 1 tab OD

Generic: Metformin
Brand: Glucophage
Classification: Antidiabetic, Biguanides
Indication: Managemengt to DM type II
Action: decrease hepatic glucose production and intestinal absorption of glucose and improves insulin
sensitivity (increase peripheral glucose uptake and use)
Adverse reactions: Anorexia, nausea, vomiting, diarrhea, metallic taste, wt loss, weakness, lassitude, skin
rash. Lactic acidosis, abdominal pain, hyperventilation, diminished consciousness.
Contraindication: hypersensitive to drug. Type I DM. Patient w/ acute or chronic alcoholism, or
conditions likely to predispose to lactic acidodis. Patient w/ impaired hepatic & renal function, CV
collapse, CHF, acute MI or other conditions leading to hypotension or hypoglycemia, DM complicated w/
acidosis, infection, gangrene or during surgery. Pregnancy & lactation.
Nursing Considerations:
 Asses renal function before therapy
 Give with meals
 Monitor patient’s glucose level regularly to evaluate effectiveness of therapy
  Watch out for any adverse reactions

Omeprazole 20 mg 1 tab OD
Generic: Omeprazole
Brand: Omeprex
Classification: Proton pump inhibitor
Indication:
Action: inhibits activity of acid pump and binds to hydrogen potassium adenosine tryphosphatase at
secretory surface of gastric parietal cells to block formation of gastric acid
Adverse reactions:
CNS: headache, dizziness
GI: nausea, diarrhea, constipation, flatulence, vomiting, diarrhea.
Skin: rash
Contraindication:
o Contraindicated in patients hypersensitive to drug
Nursing Considerations:
 Tell patient to swallow whole tablets or capsules wholeand not to open, crush or chew themFor
I.M. use, inject deep into a large muscle, such as the gluteus maximus or the side of the thigh.
 Give plenty of water
 Watch out for any adverse reactions

Digoxin 0.25mg 1 tab OD

Generic: Digoxin
Brand:
Classification: Inotropics
Indication: Atrial fibrillation
Action: inhibits sodium-potassium-activated adenosine triphosphatase, promoting movement of calcium
from extracellular to intracellular cytoplasm and strengthening myocardial contraction. Also acts on CNS
to enhance vagal tone, slowing conduction through the SA and AV nodes
Adverse reactions:
CNS: headache, fatigue, generalized muscle weakness, hallucinations, malaise
CV: arrhythmias
EENT: yellow-green halos, blurred vision, light flashes
GI: anorexia, nausea, vomiting, diarrhea
Contraindication:
o Contraindicated in patients hypersensitive to drug
o Digitalis toxicity
o Bradycardia
Nursing Considerations:
 Always check for heart rate if less than 60 bpm
 Encourage patient to eat rich in potassium foods
 Before giving get the vital signs as a baseline
 Give plenty of water
 Watch out for any adverse reactions

Vastarel 1 tab BID

Generic: Trimethazidine
Brand: Vastarel
Classification: Anti-anginal
Indication:
Action: Trimetazidine is a metabolic agent, a specific and selective inhibitor of an enzyme of the fatty
acid β-oxidation: The 3-ketoacyl CoA thiolase (3-KAT). This inhibition of β-oxidation allows a
recoupling of glycolysis and an increase in glucose oxidation for better energy production under ischemic
conditions.
By preserving the energy metabolism in cells exposed to hypoxia or ischaemia, trimetazidine prevents a
decrease in intracellular ATP levels, thereby ensuring the proper functioning of ionic pumps and
transmembranous sodium-potassium flow while maintaining cellular homeostasis.
Adverse reactions:
Rare cases of gastrointestinal disorders (nausea and vomiting).
Contraindication:
Hypersensitivity to any of the constituents of Vastarel MR.
Use in lactation: Vastarel MR is generally not recommended during breastfeeding
.Nursing Considerations:
 Assessed characteristics of angina including its duration
 Check vital signs before and after giving the drug
 Watch out for any adverse reactions

Laboratory Results

Clinical Chemistry (06-25-10)

Normal range Result
 LDL 65-175mg/dl 261.3- elevated
 Creatinine 44.2-5.72 mmol/l 61.88-normal
 FBS 3.85-5.72 mmol/l 8.4-elevated
 HDL 30-70 mg/dl 141.5-elevated
 Uric acid 0.20-0.43 mmol/l 0.20-normal
Implications:
Low-density lipoprotein (LDL) and High-density lipoprotein (HDL) are two of the five major groups
of lipoproteins, which in order of size, largest to smallest, are chylomicrons, VLDL, IDL, LDL and HDL,
that enable lipidslike cholesterol and triglycerides to be transported within the water-based bloodstream.
Medically, estimates of cholesterol content carried by LDL particles are used as part of a
cholesterol blood test; direct LDL measurements are also available. Since higher levels of LDL particles
can promote medical problems like cardiovascular disease, they are often called the bad
cholesterol particles.
High-density lipoprotein (HDL) is one of the five major groups of lipoproteins which, in order of sizes,
largest to smallest, are chylomicrons, VLDL, IDL, LDL and HDL, which
enablelipids like cholesterol and triglycerides to be transported within the water-based bloodstream. In
healthy individuals, about thirty percent of blood cholesterol is carried by HDL. HDL particles containing
cholesterol are termed HDL-C. It is often contrasted with low density or LDL cholesterol. HDL appears
to be able to remove cholesterol from atheroma withinarteries and transport it back to the liver for
excretion or re-utilization, which is the main reason why HDL-C is sometimes called "good cholesterol".
A high level of HDL-C does seem to protect against cardiovascular diseases, while low HDL cholesterol
levels (less than 40 mg/dL or about 1 mmol/L) increase the risk for heart disease.

Measuring serum creatinine is a simple test and it is the most commonly used indicator of renal function.
A rise in blood creatinine level is observed only with marked damage to functioning nephrons. Therefore,
this test is not suitable for detecting early-stage kidney disease. A better estimation of kidney function is
given by the creatinine clearance (CrCl) test.

Uric acid concentrations in blood plasma above and below the normal range are known, respectively,
as hyperuricemia and hypouricemia. Similarly, uric acid concentrations in urine above and below normal
are known as hyperuricosuria and hypouricosuria. Such abnormal concentrations of uric acid are not
medical conditions, but are associated with a variety of medical conditions.

Electrocardiogram (06-24-10)
 Atrial fibrillation
 Left anterior wall ischemia
Implications: This will show the status of the heart and to diagnose if there is an abnormality in the
cardiac rhythm of the patient.
Atrial fibrillation (AF or A-fib) is the most common cardiac arrhythmia (abnormal heart rhythm)
[1]
 and involves the two upper chambers (atria) of the heart. Its name comes from the fibrillating (i.e.,
quivering) of the heart muscles of the atria, instead of a coordinated contraction. It can often be identified
by taking a pulse and observing that the heartbeats don't occur at regular intervals. However, a stronger
indicator of AF is the absence of P waves on an electrocardiogram (ECG or EKG), which are normally
present when there is a coordinated atrial contraction at the beginning of each heart beat.
Cardiac ischemia may be asymptomatic or may cause chest pain, known as angina pectoris. It
occurs when the heart muscle, or myocardium, receives insufficient blood flow. This most frequently
results from atherosclerosis, which is the long-term accumulation of cholesterol-rich plaques in
the coronary arteries

Gordons’s Functional Health Patterns

Health Management
The patient is oriented to time, place and person and able to recall recent and remote memories.
The right eye is reactive to light with 2-3 mm pupil size; the left eye is post ECCE. The patient uses
reading glasses sometimes ‘with unrecalled grade. The general appearance is fair: with neat hair, trimmed
nails, and no foul odor but there were dark patches all over the body. The patient’s general health were
been rated as poor because of the underlying conditions. The patient’s health goal was to not develop
complications of Diabetes mellitus by controlling diet and doing exercises. There were no traditional
beliefs that may affect health or health care delivery system. There was neither routine physical exam nor
regular check-ups. The patient visits the doctor only if the patient feels unusual or there is persisting
symptoms. The patient does not follow to the medications prescribed to him as manifested by not taking
the maintenance drugs regularly. The patient is a cigarette smoker and an alcoholic drinker during his
bachelor days but now he already stopped it for many years. Their house has adequate lighting adequate
ventilation. There were adequate water supply and good toilet facility. The patient had slowed healing
process. The patient exercises on a regular basis (MWF). The patient does not taking any over the counter
drugs.

Nutritional Metabolic
The foods indicated in the three day recall diet were diningding, daing and sinigang coupled with
one-two cup of rice every meal. The typical daily fluid intake was 4-5 glasses only. The patient’s
knowledge on proper nutrition is that avoids fatty foods and should consist of vegetables and minimal
amount of meat. The patient likes and preferred foods with soup and dislikes fatty foods. The patient eats
in their dining area with the family members. There is no noticeable weight gain or weight loss. The
patient has good appetite. There were no eating discomforts during pre-hospitalization. The patient’s diet
restriction is that to avoid too much meat including fatty foods. The patient has a slowed healing process.
The patient has incomplete teeth.
During the hospitalization period the patient is on NGT and receiving Glucerna every six hours.
The patient can have fluids through spoons per orem providing that no coughing in between. The patient
wanted to remove the NGT and to be fed by mouth instead. The skin is warm to touch. The patient has
dark, irregular shape patches all over the body. No edema all over the body. Has moist white palpebral
conjunctiva and dried oral mucosa with whitish spots. The patient is receiving PNSS 1L x 12 hours.

Elimination
The patient’s elimination pattern was two times a day: one in the morning and the other in the
night and characterized as semi formed to formed and yellowish in color. Sometimes the patient
experiences constipation but there was no pain upon defecating. The patient urinates seven times: three
during the day and four during the night. The urine is color yellow with unapproximated amount. There
was no dysuria, excessive perspiration and foul odor noted.
During the hospitalization the patient was inserted and IFC and draining a straw colored urine,
aromatic, and approximately 30-50cc per hour. Since the patient was admitted there is no bowel
movement yet.

Activity
Before hospitalization.The patient’s usual activities in only confined in their home, watching
television. During Monday, Wednesday, and Friday the patient exercises for one to one and a half hour
doing carpentry works in their yard. The patient does not need any assistance in doing activities of daily
living.
During the hospitalization.The patient’s heart rate is 58 irregular beats per minute and he has an
atrial fibrillation. There is a regular weak distal pulse. The extremities were warm to touch with pale nail
beds but without clubbing of nails. There were 20 cycles per minute and it is regular, shallow, and labored
breathing with no adventitious breathsounds on both lung fields upon auscultation. There was limited
range of motion in the left arm. Muscle strength were 5/5 4/5
5/5 5/5
The Glassgow coma score is 15/15 and the blood pressure is 140/90. The patient needs assistance in
doing activities of daily living now. The patient is with O2 inhalation via nasal cannula at 3-5 LPM. He is
currently in a moderate high back rest position. The patient complains of difficulty of breathing due to the
inserted NGT. The patient practices active range of motion in bed.

Sleep/Rest
 The patient sleeps at ten in the evening and wakes up at seven in the morning completing a nine
hours of sleep but is he frequently wakes up just to urinate. The patient is satisfied and felt refreshed after
his sleep. He is just lying down in bed if he cannot sleep during the night. He takes naps during the
afternoon. The patient watches television for relaxation or just to lie down in bed.
During the hospitalization the patient is on moderate high back rest while sleeping throughout the
day.

Cognitive-perceptual
The patient is oriented to time, place and person and able to recall recent and remote memories.
The right eye is reactive to light with 2-3 mm pupil size; the left eye is post ECCE. The patient uses
reading glasses sometimes ‘with unrecalled grade. There is no problem in hearing. Can recall recent and
remote memories. The patient can read without difficulty and can text at right hand effectively. The
patient had slurred speech noted. The patient has chest pain characterized as crushing, originates at
anterior chest wall and radiates to upper back, rated as 8/10.

Self Concept
The patient is calm during the interview without any physiologic parameters change. The patient
is very cooperative in the therapeutic regimen and eager to manifest improvement in his condition. The
current admission is going to result in a body structure or function change for the patient because of the
weakness. The patient’s view of himself is positive. He is expressing his thoughts through words.

Role
The patient lives with the other family members and they are nuclear family. The relationship
within the family is harmonious. He is the father in the family and before he is the breadwinner of the
family but due to his illness he stopped working as a security guard. The patient has many close friends.
There is slurred speech noted and Ilocano is his native language.

Sexuality
There is no difficulty in expressing ones sexuality. The patient is in close relationship with his
wife and he is already satisfied to the number of their children. The patient appropriately as a male.

Coping
There is no observed overt signs of stress. The patient handled stress effectively by dealing with
it. If he is stressed the patient would rest either lie on bed or watch television. The patient only seeks
consultation if the symptoms persist and cannot tolerate it anymore.

Value-belief
The patient’s religion is Roman Catholic and there were no religious practices that might affect
the health of neither the child nor the health care delivery system. He gives importance to his health by
doing lifestyle change when he knew that he has a underlying condition.

Pathophysiology
Hypertension Atrial DM Smoking Genetics
fibrillation

Accumulation of LDL particles within the vessel wall

Chemical change

Stimulates endothelial cells to adhere to monocytes and T-cells

Endothelium produces chemical messengers

Signals the monocytes and T-cells to incorporate within internal layer

Maturation of monocytes into macrophages

Ingest critical mass of LDL particles (FOAM cells)

Additional growth of lesion

Larger Plaque

Rupture

Clot formation within the blood vessel

Interrupt blood flow to brain tissue supplies by the vessel

Hemorrhagic stroke

s/s
Dysarthria or facial muscle drooping
Transient weakness
Headache
Visual problems
Highblood pressure
Reference: Medical-surgical Nursing by Ignatavicius 5 th edition, 2006

List of identified prioritized problem

Nursing diagnosis Actual/Potentia Justification

 l
Acute pain related to tissue Actual This is the first priority because this is the patient’s
ischemia concern. Pain may cause elevation of the vital signs
including the blood pressure which is in close
monitoring.
Ineffective cerebral tissue Actual This is the second priority, according to the principle
perfusion related to of ABC, third in the rank is circulation. Brain is one of
interruption of blood flow the vital organs in the body and delay in the perfusion
may seriously damage it.
Risk for decreased cardiac Potential This is the third priority. According to the concept of
output related to myocardial ABC, third in the rank is circulation. Although this is a
ischemia potential problem this is the third priority because it
involves one of the major organ in the body and
alterations in the cardiac function other organism will
be affected too
Impaired physical mobility Actual This is the fourth priority according to the concept of
related to neuromuscular OFFTERAS, the first A stands for activity. Enhancing
weakness mobility has many beneficial effects like it increase
muscle strength which in return may already solve the
following prioritized problems. Mobilization also
promote peristalsis that may promote bowel
elimination.
Activity intolerance related to Actual This is the fifth priority according to the concept of
presence of ischemia OFFTERAS, the first A stands for activity. Enhancing
mobility has many beneficial effects like it increase
muscle strength which in return may already solve the
following prioritized problems. Mobilization also
promote peristalsis that may promote bowel
elimination.
Risk for impaired swallowing Potential This is the sixth priority according to the concept of
related to neuromuscular OFFTERAS, F stands for food. Nutrition is important
impairment to increase energy that should be utilize during the
metabolic processes and also during range of motion
exercise to improve circulation and muscle strength.
Risk imbalance nutrition: less Potential Seventh priority. According to the concept of
than body requirements OFFTERAS, F stands for food. Nutrition is important
related to altered ability to to increase energy that should be utilized during the
ingest nutrients metabolic processes and also during range of motion
exercise to improve circulation and muscle strength.
Impaired verbal Actual Eighth priority. Even it is an actual problem it is less
communication related to priority because delay in addressing this problem will
impaired cerebral circulation not lead to aggravation of the condition but improving
the verbal communication will alleviate anxiety and
facilitate learning about the condition
Knowledge deficit about Actual Ninth priority. Even it is an actual problem it is less
CVA related to lack of priority because delay in addressing this problem will
exposure not lead to aggravation of the condition. Patient
teaching is more on the last after the patient’s
condition is stabilized.
Interrupted family process Actual Tenth priority. Family is the patient’s support system
related to uncertainty about that’s why we include the family in the prioritized
outcomes problem. Improving the family process will also yield
in the patient’s positivism because of the strong
support system
NCP proper
Problem#2

S> “nahihilo at masakit ulo niya kaya namin dinala dito sa ospital” as verbalized by the significant others

O > with latest vital signs of CR=58 beats per minute, RR= 20 cycles per minute,regular labored shallow
breathing, and T= 36.7 OC via axilla and BP= 140/90 mmHg
 Muscle strength: 5/5 4/5
5/5 5/5
 Right eye reactive to light with 2-3 mm, left eye post ECCE
 With O2 inhalation via nasal cannula at 3-5LPM
 With Glasgow coma score of 15/15
 With pale nail beds
 With slurred speech noted
 With regular weak distal pulse

Nursing Diagnosis: Ineffective cerebral tissue perfusion related to interruption of blood flow

Explanation of the problem

The patient’s risk factors include HTN, DM, and atrial fibrillation. These factors greatly
contributed in the formation of atheroma or the foam cells. Foam cells are came from a series of process
before it became a large enough to be a blockage in the blood vessel. Blockage in the blood vessel going
to the brain causes neuromuscular affectation like alteration in the consciousness.

Goal and Objectives

Goal: After nursing interventions the patient should be able to have effective cerebral tissue
perfusion

LTO: After 3 days of nursing interventions the patient should be able to have effective cerebral
tissue perfusion as manifested by improvement of muscle strength, 5/5 all over

STO: After 8 hours of nursing interventions the patient would be able to maintained usual level of
consciousness appropriately
After 8 hours of nursing interventions the patient would be able to demonstrate stable vital signs
within normal ranges
NCP proper
Problem#1

S> “masakit yung dibdib ko”

 “characterized pain as crushing, 8/10, and originates at anterior chest wall and radiates at upper
back area

O > with latest vital signs of CR=58 beats per minute, RR= 20 cycles per minute,regular labored shallow
breathing, and T= 36.7 OC via axilla and BP= 140/90 mmHg
 Muscle strength: 5/5 4/5
5/5 5/5
 Right eye reactive to light with 2-3 mm, left eye post ECCE
 With O2 inhalation via nasal cannula at 3-5LPM
 With Glasgow coma score of 15/15
 With pale nail beds
 With slurred speech noted
 With regular weak distal pulse
 With grimaces noted and pointing to the affected part

Nursing Diagnosis: Acute pain related to tissue ischemia

Explanation of the problem

The patient’s risk factors include HTN, DM, and atrial fibrillation. These factors greatly
contributed in the formation of atheroma or the foam cells. Foam cells are came from a series of process
before it became a large enough to be a blockage in the blood vessel. Blockage in the vessel causes
vasocongestion that leads to pain and ineffective tissue perfusion

Goal and Objectives

Goal: after nursing interventions the patient should be able eradicate the pain

LTO: after eight hours of intervention the patient would be able to rate the pain from severe to
mild or from 8 to 4-5(from o-10, 10 being the highest), correctly

STO: after 5-10 minutes of nursing interventions the patient would be able to demonstrate deep
breathing exercise properly
after 5-10 minutes of nursing interventions the patient would be able to use of diversional
activities properly