99997548 case-study

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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 patient’s Nursing Health History of the Patient
 To identify the Gordon’s 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.

NNUURRSSIINNGG HHEEAALLTTHH HHIISSTTOORRYY
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
patient’s daughter which is her significant other, and the other 5 % of the information
rendered here is taken from the patient’s chart.
A. BiographicalData
Patient’s 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
Parent’s 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 didn’t have any past illnesses.

Allergies
>The patient stated that she hasn’t 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 she’s 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 she’s irritable and can’t 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 patient’s hobbies are managing their Sari – Sari Store and Ballroom
Dancing.

G. SocialData
Family Relationship/friendship:
The patient’s 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 can’t 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 family’s 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 don’t 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.

GGOORRDDOONN’’SS TTYYPPOOLLOOGGYY
PATTERN BEFORE
HOSPITALIZATION
DURING
HOSPITALIZATION
ANALYSIS
HEALTH
PERCEPTION
PATTERN
The patient stated
that health is a need
for every individual;
her health is good
because she doesn’t
have any illness
before she was
admitted. She has no
difficulty in accessing
health care
facilities..
The patient stated
that she cannot
consider herself as
healthy like
before and was
idle sometimes.
But still, the
patient has
increased valuing
in terms of her
health. She’s
taking all her
prescribed
medications.
Patient cannot
function
normally like
before but her
health values
increased.
NUTRITIONAL-
METABOLIC
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 it’s 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 individual’s
health status
greatly affects
eating habits and
nutritional status
(Fundamentals of
Nursing by Kozier
p. 1178) Patient’s
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
Patient prefers
ballroom dancing in
their house and doing
household chores
such as cooking,
cleaning the house
and managing her sari
sari store as her
exercise and activity
pattern
The patient stated
that her activity and
exercise pattern was
decreased due to her
hospitalization. The
physician on duty
ordered the patient
to be in CBR.
During patient’s
confinement,
there is quite
changes in her
activities and has
quite restrictions
for her actions.
SLEEP/REST
PATTERN
The patient has
normal cycles of
sleep. She sleeps 8
hours a day and takes
a nap at 2 to 3 pm.
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
“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 she’s
irritable and can’t
get a good night
sleep
.
COGNITIVE-
PERCEPTUAL
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.
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 self-
concept.”
(Fundamentals of
Nursing 7th Ed by
Barbara Kozier p.
959 & 962)
ROLE-
RELATIONSHIP
PATTERN
Patient’s 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 stated
that she had a really
close relationship
with her daughter
right now because
she is the only one
taking care of her in
patient’s hospital
stay.
The patient is
more dependent
to her daughter
during
hospitalization.
SEXUALITY/
REPRODUCTIVE
PATTERN
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
she’s already
menopause.
The patient does not
have an active
sexual life.
Sexuality and
reproductive
patterns are
affected by the
changes that
takes place in a
person’s body or
in a person’s 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 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)
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
After what
happened,
patient is still
seeking for
medical
assistance.
Religious effort is
still a part of
patient s life.

PPHHYYSSIICCAALL AASSSSEESSSSMMEENNTT
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 CA’s skin as inspected has a brown color.Lesions are noted. Irritations
in skin and redness were not present. Patient’s 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 patient’s 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 patient’s 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 patient’s 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 patient’s 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 patient’s 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 patient’s 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 patient’s 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 patient’s 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 patient’s 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 patient’s abdomen is loose and uniform in color. The
patient’s 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 don’t 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 Weber’s 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.

MMEEDDIICCAALL MMAANNAAGGEEMMEENNTT
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 whereinadditional 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 givento 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 client’s 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.
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99997548 case-study