TABLE OF CONTENTS I. Objectives of the Case II. Introduction A. Definition of the Case B. Etiology C. Incidence D.

General Signs and Symptoms E. Theoretical Framework III. Patients Profile A. Patient Data B. Nursing History 1. Chief Complaint 2. Present History 3. Past History 4. Personal and Social History 5 Obstetric History 6. Developmental History 7. Feeding History 8. Immunization History 9. Gordons Functional Health Patterns 10. Review of Systems and Physical Examination IV. Anatomy and Physiology V. Pathophysiology VI. Drug Study VII. Laboratory Examination Values VIII. Course in the ward IX. Nursing Care Plan X. Discharge Planning (M.E.T.H.O.D.S.) XI. Implications on A. Nursing Research B. Nursing Education C. Nursing Practice

I.

OBJECTIVES OF THE STUDY

GENERAL OBJECTIVES: To develop knowledge, skills, and attitude in rendering appropriate nursing care utilizing the nursing process as a framework of care.

SPECIFIC OBJECTIVES: Student-Nurse Centered: To identify actual problems in line with the patients condition. To develop plan of care and competency in implementing nursing interventions. To establish interpersonal relationship with the patient and the members of the health care team. Client Centered: To prevent and manage potential complications that may occur. To collaborate with the members of the health care team in providing care to the patient. To give the patient an opportunity to express fear or anxiety during the treatment regimen.

II.

INTRODUCTION

A. DESCRIPTION OF THE CASE This is a case of a 52 years old female from Quezon City. She was admitted in FEUNRMF Medical Center with a diagnosis of Hypertensive Cardiovascular Disease, Coronary Artery Disease, Non-ST Elevation Myocardial Infarction: Killips I, type 2 Diabetes Mellitus. Type 2 diabetes mellitus consists of an array of dysfunctions characterized by hyperglycemia and resulting from the combination of resistance to insulin action, inadequate insulin secretion, and excessive or inappropriate glucagon secretion. Poorly controlled type 2 diabetes is associated with an array of microvascular, macrovascular, and neuropathic complications. Microvascular complications of diabetes include retinal, renal, and possibly neuropathic disease. Macrovascular complications include coronary artery and peripheral vascular disease. Diabetic neuropathy affects autonomic and peripheral nerves. It usually takes some time for the problem of high blood pressure to eventually lead to hypertensive cardiovascular disease and therefore high blood pressure is often called the silent killer. Eventually hypertensive cardiovascular disease can also lead to congestive heart failure. Some symptoms of hypertension and the eventual congestive heart failure include arrhythmias, shortness of breath, weakness and fatigue, swelling in lower extremities and greater frequency of urination during the night. Hypertensive cardiovascular disease may also result in ischemic heart condition and in this case there might be chest pain, sweating and dizziness, nausea and shortness of breath. Hypertrophic cardiomyopathy could also be a result of hypertensive heart disease. Hypertensive cardiovascular disease also known as hypertensive heart disease occurs due to the complication of hypertension or high blood pressure. In this condition the workload of the heart is increased manifold and with time this causes the heart muscles to thicken. The heart continues pumping blood against this increased pressure and over a period of time the left ventricle of the heart enlarges and this in turn causes the blood pumped by heart to reduce. If proper treatment is not taken at this stage then symptoms of congestive heart failure may be observed. CAD happens when the arteries that supply blood to heart muscle become hardened and narrowed. This is due to the build - up of cholesterol and other material, called plaque, on their inner walls. This build - up is called atherosclerosis. As it grows, less blood can flow through the

arteries. As a result, the heart muscle can't get the blood or oxygen it needs. This can lead to chest pain (angina) or a heart attack. Most heart attacks happen when a blood clot suddenly cuts off the hearts' blood supply, causing permanent heart damage. Over time, CAD can also weaken the heart muscle and contribute to heart failure and arrhythmias. Heart failure means the heart can't pump blood well to the rest of the body. Arrhythmias are changes in the normal beating rhythm of the heart. Myocardial infarction (MI) or acute myocardial infarction (AMI), commonly known as a heart attack is the interruption of blood supply to a part of the heart, causing heart cells to die. This is most commonly due to blockage of a coronary artery following the rupture of a atherosclerotic plaque, which is an unstable collection of fatty acids and white blood cells in the wall of an artery. The resulting ischemia due to restriction in blood supply and oxygen shortage, if left untreated for a sufficient period of time, can cause damage or death (infarction) of heart muscle tissue The onset of MI is characterized by a crushing, viselike chest pain that may radiate to the left arm, neck, jaw, or epigastrium and sometimes stimulates the sensation of acute indigestion or a gallbladder attack. The patient usually becomes ashen, clammy, short of breath, nauseated, faint, and anxious and often feels that death is imminent. Typical signs are tachycardia, a barely palpable pulse, low blood pressure, mildly elevated temperature, cardiac arrhythmia, and elevation of the S-T segment and Q wave on the electrocardiogram. Laboratory studies usually show an increased sedimentation rate, leukocytosis, and elevated serum levels of creatine kinase and its isoenzyme MB, lactic dehydrogenase and its isoenzymes, and glutamic-oxaloacetic transaminase. Potential complications in MI are pulmonary or systemic embolism, pulmonary edema, acute congestive heart failure, shock, ventricular tachycardia, ventricular fibrillation, and cardiac arrest.

After experiencing myocardial infarction a patient is categorized using Killip Classification. Killip classification Cardiology a system used to stratify the severity of left ventricular dysfunction and determine clinical status of patients post MI. In this case the patient was categorized under Killip I. Where in: Killip class I includes individuals with no clinical signs of heart failure. Killip class II includes individuals with rales or crackles in the lungs, an S3, and elevated jugular venous pressure. Killip class III describes individuals with frank acute pulmonary edema.

Killip class IV describes individuals in cardiogenic shock or hypotension (measured as systolic blood pressure lower than 90 mmHg), and evidence of peripheral vasoconstriction (oliguria, cyanosis or sweating).

Patients health after myocardial infarction depends in the patient and the seriousness of the heart damage. The patient Prognosis is significantly worsened if mechanical complications such as papillary muscle or myocardial free wall rupture occur. Morbidity and mortality from myocardial infarction has improved over the years due to better treatment. Devotedly taking maintenance medication is important to sustain the patients life condition.

B. ETIOLOGY According to United Kingdom Prospective Diabetes Study Group, patients with type 2 diabetes mellitus have a twofold to threefold increased incidence of diseases related to atheroma, and those who present in their 40s and 50s have a twofold increased total mortality. Risk factors for development of coronary artery disease in the general population may not apply once diabetes has developed. Obesity and raised insulin concentrations provide an increased risk for cardiovascular disease. Once diabetes has developed, hypertension, increased concentrations of low density lipoprotein or decreased concentrations of high density lipoprotein cholesterol and hyperglycaemia measured at baseline are greater risk factors for coronary artery disease than these precipitating factors.

C. SIGNS AND SYMPTOMS Coronary artery disease produces symptoms and complications according to the location and degree of narrowing of the arterial lumen, thrombus formation, and obstruction of blood flow to the myocardium. This impediment to blood flow is usually progressive, causing an inadequate blood supply that deprives the cardiac muscle cells of oxygen needed for their survival. The condition is known as ischemia. The most common manifestation of myocardial ischemia is the onset of chest pain. However, according to Kannel, 1986, the classic epidemiologic study of the people in Framingham, Massachusetts showed that nearly 15% of men and women who had coronary events, which included unstable angina, MIs, or sudden cardiac death events, were totally asymptomatic prior to the coronary event. In addition, patients who are older or have a history of diabetes may report symptoms such as shortness of breath. Also, many women have been found to have a typical symptoms,

including dyspnea, nausea and weakness (Canto, Goldberg,Hand, et al., 2007). Furthermore, prodromal symptoms may occur like angina a few hours to days before the acute episode. D. INCIDENCE Based on the WHO study, the Philippines is projected to have an estimated number of 7.8 million cases by 2030 and eventually may rank ninth in the list of countries with the highest estimated cases worldwide. In addition, according to the report from the International Institute of Diabetes from Australia, More than 65 percent of diabetics will die of some form of heart disease or stroke.

E. THEORETICAL FRAMEWORK Theory of Ida Jean Orlando (The Nursing Process Theory) She is known of her ideas about the nursing process. She believes that a nurse reacts on the verbal as well as non verbal cues that the patient manifests in order to alleviate her sufferings. There is an automatic reaction which consists of perception, thought, or feeling. The patient may not be verbalizing her plea, but when a nurse perceives that the patient is need, she must attend to the behaviours that suggest discomfort in the patient. Then after perceiving that the patient is need, the nurse will then confirm it with the patient, identifies the problem, and deliberative actions will be taken. In line with our case, the patient manifested a guarding behaviour and irritation which gave us an idea that she is in pain and discomfort. As a nurse, we had an assessment for us to further understand her condition so that we can give appropriate nursing interventions to alleviate her suffering.

Theory of Myra Estrine Levine: The Conservation Model Levine defined nursing as supportive and therapeutic interventions. She based the nursing actions on four principles: Conservation of energy is basic to the natural, universal law of conservation. Since the patient has a coronary problems, energy conservation is encouraged through the limitation of activities .It is important that, even, at rest energy costs are incurred through the activities necessary to support living. Also, within nursing practice, measurement of vital signs serves as a measurement for energy parameters. Conservation of structural integrity focuses on the healing process (Levine, 1989). As nurses who support structural integrity, we gave efforts to limit the injury to the patient and thus limiting further complications to her condition through proper positioning, range of motion exercises, modifying the activities within her capabilities and as well as health teachings on proper diet. Conservation of personal integrity focuses on a sense of self- that intensely private, always unique and secret knowledge that we use to define ourselves (Levine, 1996). According to Levine, a person can share mere fragments of her private self with others. In relation to our patient, she was confined on her room of choice so that privacy will be maintained. In this study, her personal identifiers were also kept confidential.

Conservation of social integrity involves a definition of self that goes beyond the individual and includes holiness of each person. According to Levine, ones identity is connected to family, friends, community, workplace, school, culture, ethnicity, religion,vocation, education, and socioeconomic status. With regards to our patient, she has a good interaction with her family, friends, and social contact.

III.

PATIENTS PROFILE:

A.BIOGRAPHICAL DATA: NAME: DAD AGE: 52 y/o DATE OF BIRTH: August 24, 1960 GENDER: Female ADDRESS: H-20 F.Marcos St., Wiltor Heights, Pasong Tamo, Quezon City Race: Filipino Marital Status: Married Occupation: Business woman Religous Orientation: Catholic Health Care Financing and Usual Source of Medical Care: source of income DATE OF ADMISSION: September 8, 2012, ICU ADMITTING DIAGNOSIS: HCVD,CAD,NSTEMI KI,Type 2 DM ADMITTING INSTITUTION: FEU-NRMF

B. NURSING HISTORY 1. CHIEF COMPLAINT: Ang sakit sakit ng dibdib ko dito sa bandang kaliwa,parang sinasaksak ako, pati ang leeg at balikat ko sumasakit din (my chest is very painful here at the left sideit seems that I am stabbed, my neck and my shoulder are also aching) 2. HISTORY OF PRESENT ILLNESS: The patient illness started two weeks prior to admission when patient experienced chest pain on left parasternal area with a pain scale of 7-8/10, squeezing in character, radiating to neck and shoulder area aggravated by work and relieved by rest. There are no other associated signs and symptoms such as difficulty of breathing, abdominal pain, loss of consciousness, fever and cough. Patient took omeprazole 40mg/tab OD. No consultation done. 3 days PTC patient again had episode of chest pain nor accompanied by difficulty of breathing. No other associated signs and symptoms. Patient decides to seek consult at East Avenue Medical Center where she was given Omeprazole IV. There was noted relief of symptoms. One day PTC patient again experienced chest pain not relieved by rest and accompanied by difficulty of breathing. She was rushed to OCW General Hospital. She was given Lansoprazole 30mg/tab and AlmOH which did not afford relief of symptoms. She was advised to seek consult at FEU-NRMF Medical Center, hence was subsequently admitted.

3. PAST MEDICAL HISTORY: Patient experienced childhood diseases such as measles and chicken pox. No known allergies were noted. She was hospitalized on 2005 at East Avenue Medical Center due to chest pain unrelieved by rest and was diagnose to have type 2 diabetes mellitus and hypertension. Since then, she takes maintenance drugs which includes Lozartan and Metformin.

4. FEEDING HISTORY: Seven years ago, patient stated that she ate whatever food she wanted. She also claimed that she ate a whole roll chocolate cake together with her son on her birthday 2 years ago. She consumes almost 1 L of carbonated beverages every day. But, since she was diagnosed of diabetes and hypertension on 2005, she made modifications on her diet but admitted that there are times that she is tempted to eat that is beyond her restrictions.

5. PERSONAL AND SOCIAL HISTORY: Patient started to consume alcohol at 12 years old when she had her menarche. She drinks a shot or approximately 30 ml. of gin every time she experiences pain and discomfort. At the age of 16, she consumes at 12-24 bottles of beer occasionally. Patient ceased to drink alcoholic beverages when she was diagnosed to have type 2 DM and HPN on 2005. She does not smoke and use prohibited drugs. Patient is married for 31 years and has 5 children with 4 daughters and a son. She stated that she has a good relationship with her family and even though her 4 daughters are not living with them, they still communicate with each other through cell phone and internet. Her friends and social contacts frequently visit her. They adopted a 15 y/o girl but patient said that the girl gave her so much stress because the girl had so much trouble in school and got pregnant last year. She thinks that the situation aggravated her condition.

6. FAMILY HISTORY OF ILLNESS: Her mother died of cardiac arrest at the age of 82 y/o while her father has diabetes mellitus and died at the age of 86 following myocardial infarction. She has 3 brothers and a sister. She and her eldest brother have hypertension and diabetes mellitus.

7. GORDONS FUNCTIONAL HEALTH PATTERN I. Health and Health Management Pattern

Patient used to treat herself with OTC drugs and sometimes with the use of alternative medicines. She does her everyday routines even if she feels sick or not. She decides to seek for professional help when the condition does not relieved through her treatment and

aggravates. When she was diagnosed to have type 2 DM and hypertension 7 years ago, she adheres to doctors prescribed medications and take it religiously. Often times, when she feels chest pain, she mistakenly acknowledges it as dyspepsia because it is sometimes accompanied by nausea and vomiting and treat herself with the use of antacid like Gaviscon.

II.

Nutritional and Metabolic Pattern

She eats 6 times a day with snacks between major meals usually includes 1-2 cups of rice and her usual viand includes 2-4 servings of vegetables and 1-2 servings of meat products.She consumes 16-24 glasses of water a day and sometimes drinks at least 1-2 glasses of carbonated beverages or juices. III. Elimination Pattern

The patient defecates every morning without pain and difficulty with solid, formed, and yellowish to brownish stools. She urinates 8-10 times a day with ease. She also noticed that her urine became yellowish and sometimes cloudy and had a fruity scent. IV. Activity-Exercise Pattern

The patient wanted to do any activities as long as she can. She does her duties as a mother and wife in the morning. Even though they have a helper, she still does some household chores. If she is able to walk even for a distance, she will do it because for her, this is her way of doing physical exercise. If she is sick, she does not want to stay on bed for a long time and do her usual routines. On the other hand, she believes that these activities also aggravate her condition. V. Sleep-Rest Pattern

The patient usually sleeps at 8-9 pm and wakes up at 3 am. She normally has an average of 7-8 hours of sleep. She also takes an afternoon nap 30 minutes after she had her lunch and wakes up at 3 pm. She sleeps with her head higher than her feet VI. Cognitive-Perceptual Pattern

Patient does not wear eyeglasses and does not have difficulty in hearing. She is alert and coherent and without memory lapses. She attained a college degree in commerce major in accountancy. She is able to at least describe her condition.

VII.

Self-Perception and Self-Concept Pattern

When the patients condition aggravated, she accepted that she might die. During her hospitalization, she was thankful that the hospital admitted her even though she does not have available money for hospitalization and her significant other is helping their family in money matters. She views the problems as a challenge for her to fight and defeat. She keeps in mind that she can overcome whatever problems come to her with Gods help. VIII. Role Relationship Pattern The patient is the mother of 5 children with 4 daughters and a son. She has a good relationship with her husband and children. She also has a good interaction with her friends. On the other hand, she stated that she adopted a 15 years old girl and support her in her studies but the girl had troubles in school and got pregnant. The patient recognized this as a stressful situation which worsened her condition. IX. Sexuality Reproductive Pattern

The patient had her menarche when she was 12 years old and got married at 20 years old; with an OB history of 55(5005). She had her menopause at the age of 48 years old. Presently, she and her husband are not sexually active but have a good relationship with each other. X. Coping Stress Tolerance Pattern

Whenever the patient feels stressed, she faces her problems with head held up. She said that she does not want anyone to belittle her no matter what the reason of their misunderstanding is. She also used to walk outside to clear her mind whenever she experiences stress. Often times, when she had problems, she used to go to her best friend. XI. Value-Belief Pattern

Patient DAD is a Catholic but participates more in Born Again Christian Churchs religious activity. She stated that when she was young, she laughs at the Born Agains activity because they use to sing and dance frequently but when her friend convince her to attend a bible rading in Born Again, she cried and felt that God was wit

8. PHYSICAL ASSESSMENT FINDINGS The client has a big body GENERAL APPEARNCE built. Appeared weak and restless. Signs of distress are present. No obvious deformity NUTRITIONAL ASSESSMENT Height- 160 cm Weight- 82 kgs. BMI- 32.03 (>30 Obese)

CLINICAL SIGNIFICANCE Needs to be carefully assessed via the history and physical examination

VITAL SIGNS

SKIN, NAILS, AND HAIR

According to American Association of Diabetes Educators, obesity is involved in the pathological process that culminates in the development of type 2 diabetes, and is a severely aggravating factor in the disease itself, as well as a serious risk factor for the cardiovascular disorders that frequently affect persons with diabetes. Axillary temp-35.8C Decreased temperature and Respiratory rate- 26 cpm peripheral pulse are due to Pulse rate (radial pulse)- 62 shunting of blood from the bpm peripheries to vital organs. BP- 140/90 Increased RR,, and BP was caused by the compensatory response of the body to cardiovascular dysfunction. Skin is brown in color with Decreased peripheral tissue noted pallor on the extremities perfusion and with slight dryness. Cool and clammy. With poor skin turgor. With bluish nailbeds. Capillary refill time is 4 secs. No noted edema. No significant findings

Hair is thin, slightly dry, and No significant findings evenly distributed.

HEAD,NECK REGIONAL LYMPHATICS

AND Head is normocephalic. Facial No significant findings features are symmetrical. Scalp is intact. Without noted enlargement, mass, and

EYES

lesions. No facial edema. Without palpable lymph nodes. Eyebrows are evenly No significant findings. distributed and are symmetrically aligned. Eyelids close symmetrically. Does not use eyeglasses. Bulbar conjunctiva is transparent while palpebral conjunctiva is shiny,smooth, and pale in color. Sclera is white without lesion. No noted discharge. Peripheral vision, extraocular movement and visual acuity are not assessed due to clients condition. Stated that she experiences vasoconstriction of the retina blurring of vision. and decreased cerebral perfusion alters the patients vision.

EARS

Presence of respiratory distress to compensate for hypoxia Due to decreased tissue MOUTH AND THROAT perfusion. Accumulation of lactic acid as CHEST a result of anaerobic respiration due to hypoxia, and increased pumping of the heart Dyspnea on exertion noted. Increased oxygen demand and LUNGS Without crackles upon decreased oxygen supply auscultation. Caused by rapid ventricular HEART AND S3 sound noted. filling PERIPHERAL Pt. experienced palpitations Increased heart rate VASCULATURE NOSE

Auricles are uniform in color with the skin without redness, tenderness, lesions, and masses. With no noted discharge. Pt. is able to hear on both ears soft voices 3 feet away from her. Nasal flaring is noted. With no noted tenderness and discharge. Pale and slightly dry oral mucosa. Experienced squeezing chest pain radiating to the left arm and with the pain scale of 7-8 out of 10.

No significant findings.

MENTAL STATUS

ABDOMEN

Peripheral pulse is decreased and weak. Capillary refill time is 4 secs. Altered level of consciousness. With dizziness noted. Flabby and without tenderness, lesions, and discolorations.

Decreased peripheral tissue perfusion Decreased cerebral perfusion

Increased fat deposits

With hypoactive bowel sounds Decreased bowel motility With no noted organomegaly. No significant findings. GENITOURINARY NOT ASSESSED

IV.

ANATOMY AND PHYSIOLOGY

Every cell in the human body needs energy in order to function. The b o d y s primary energy source is glucose, a simple sugar resulting from the digestion of foods containing carbohydrates (sugars and starches). Glucose from the digested food circulates in the blood as a ready energy source for any cells that need it. Insulin is a hormone or chemical produced by cells in the pancreas, an organ located behind the stomach. Insulin bonds to a receptor site on the outside of cell and acts like a key to open a doorway into t h e cell through which glucose can enter. S o m e o f t h e g l u c o s e c a n b e c o n v e r t e d t o concentrated energy sources like glycogen or fatty acids and saved for later use. When t h e r e i s n o t e n o u g h i n s u l i n p r o d u c e d o r w h e n t h e d o o r w a y n o l o n g e r r e c o g n i z e s t h e insulin key, glucose stays in the blood rather entering the cells. Anatomy of the pancreas: The pancreas is an elongated, tapered organ located across th e b a c k o f t h e abdomen, behind the stomach. The right side of the organ (called the head) is the widest part of the organ and lies in the curve of the duodenum (the first section of the small intestine). The tapered left side extends slightly upward (called the body of the pancreas)and ends near the spleen (called the tail).The pancreas is made up of two types of tissue: Exocrine tissue The exocrine tissue secretes digestive enzymes. These enzymes are secreted into a network of ducts that join the main pancreatic duct, which runs the length of the pancreas. Endocrine tissue The endocrine tissue, which consists of the islets of Langerhans, secretes hormones into the bloodstream.

Functions of the pancreas: The pancreas has digestive and hormonal functions: The enzymes secreted by the exocrine tissue in the pancreas help break down carbohydrates, fats, proteins, and acids in the duodenum. These enzymes travel down the pancreatic duct into the bile duct in an inactive form. When they enter the duodenum, they are activated. The exocrine tissue also secretes bicarbonate to neutralize stomach acid in the duodenum. The hormones secreted by the endocrine tissue in the pancreas are insulin and glucagon (which regulate the level of glucose in the blood), and somatostatin (which prevents the release of the other two hormones

Anatomy of kidney
The kidneys play key roles in body function, not only by filtering the blood and getting rid of waste products, but also by balancing levels of electrolytes in the body, controlling blood pressure, and stimulating the production of red blood cells. The kidneys are located in the abdomen toward the back, normally one of each side of the spine. They get their blood supply through the renal arteries directly from the aorta and send blood back to the heart via the renal veins to the vena cava. (The term renal" is derived from the Latin name for kidney.) The kidneys have the ability to monitor the amount of body fluid, the concentrations of electrolytes like sodium and potassium, and the acid-base balance of the body. They filter waste products of body metabolism, like urea from protein metabolism and uric acid from DNA breakdown. Two waste products in the blood can be measured: blood urea nitrogen(BUN) and creatinine (Cr).Kidneys are also the source of erythropoietin in the body, a hormone that stimulates the bone marrow to make red blood cells. Special cells in the kidney monitor the oxygen concentration in blood. If oxygen levels fall, erythropoietin levels rise and the body starts to manufacture more red blood cells.

ANATOMY & PHYSIOLOGY for hypertension Central Nervous System Medulla Oblongata; relays motor and sensory impulses between other parts of the brain and the spinal cord. Reticular formation (also in pons, midbrain, and diencephalon) functions in consciousness and arousal. Vital centers regulate heartbeat, breathing (together with pons) and blood vessel diameter. Hypothalamus; controls and integrates activities of the autonomic nervous system and pituitary gland. Regulates emotional and behavioral patterns and circadian rhythms. Controls body temperature and regulates eating and drinking behavior. Helps maintain the waking state and establishes patterns of sleep. Produces the hormones oxytocin and antidiuretic hormone. Cardiovascular System Baroreceptor, pressure-sensitive sensory receptors, is located in the aorta, internal carotid arteries, and other large arteries in the neck and chest. They send impulses to the cardiovascular center in the medulla oblongata to help regulate blood pressure. The two most important baroreceptor reflexes are the carotid sinus reflex and the aortic reflex. Chemoreceptors, sensory receptors that monitor the chemical composition of blood, are located close to the baroreceptors of the carotid sinus and the arch of the aorta in small structures called carotid bodies and aortic bodies, respectively. These chemoreceptors detect changes in blood level of O2, CO2, and H+. Renal System Renin-Angiotensin-Aldosterone system. When blood volume falls or blood flow to the kidneys decreases, juxtaglomerular cells in the kidneys secrete renin into the bloodstream. In sequence, renin and angiotensin converting enzyme (ACE) act on their substrates to produce the active hormone angiotensin II, which raises blood pressure in two ways. First, angiotensin II is a potent vasoconstrictor; it raises blood pressure by increasing systemic vascular resistance. Second, it stimulates secretion of aldosterone, which increases reabsorption of sodium ions and water by the kidneys. The water reabsorption increases total blood volume, which increases blood pressure. Antidiuretic hormone. ADH is produced by the hypothalamus and released from the posterior pituitary in response to dehydration or decreased blood volume. Among other actions, ADH causes vasoconstriction, which increases blood pressure. Atrial Natriuretic Peptide. Released by cells in the atria of the heart, ANP lowers blood pressure by causing vasodilation and by promoting the loss of salt and water in the urine, which reduces blood volume.

V. PATHOPHYSIOLOGY

VI. DRUG STUDY

VII.
Laboratory Exam Glucose (FBS) CBG

LABORATORY EXAMS
Normal Values 70-100mg/dl 70-180 mg/dl Clinical Clinical Significance Manifestation Elevated levels are -Polyuria found with DM -Polydipsia Elevated levels are -Polyphagia -dry mouth found with DM -fatigue -dry skin -dizziness upon standing -increased BP Nursing Interventions Before Test: Instruct client to withhold food for 12hrs before a fasting test During Test: Adhere to standard precautions After Test: Apply pressure to venipuncture site. Explain that some bruising, discomfort and swelling may appear on the site and that warm compress can alleviate this Monitor signs of infection

Result 150 mg/dl 297 mg/dl

Lipid Profile: Total Cholesterol 8.38mm ol/L

Triglycerides

2.49 mmol/L

HDL LDL

1.46 mmol/L 6.42 Mmol/L

VLDL

0.50 mmol/L

- increased BP -increased fat Before Test: F- 0.00-5.17 Elevated levels are deposits Explain the test procedure mmol/L with patients with -increased and the purpose of the test. DM, obesity and a weight Assess the client's diet with high knowledge of the test. cholesterol and fats Instruct client to withhold F-0.00-1.69 Elevated levels are food for 12hrs before test mmol/L with patients with and abstain alcohol DM, obesity and a consumption for 24hrs diet with high before test cholesterol and fats During Test: 1.04N Adhere to standard 1.55mmol/L precautions 2.49-3.96 Elevated levels are After Test: mmol/L with patients with Apply pressure to DM, obesity and a venipuncture site. diet with high Explain that some cholesterol and fats bruising, discomfort and 0Elevated levels are swelling may appear on 0.34mmol/L with patients with the site and that warm DM, obesity and a compress can alleviate this diet with high Monitor signs of infection cholesterol and fats Interpret test results and observe for signs of cardiac disease Instruct a dietary changes such as weight loss, low salt diet and exercise

program

Cardiac marker: Troponin I 0.050 mg/ml F0.000- Elevated level are 0.023 mg/ml found with MI, chronic muscle disease and muscle trauma --Chest pain -Dyspnea -indicates myocardial infarction No special preparations needed. Refer immediately if there is elevated level.

Hematology: Hematocrit WBC Count Hemoglobin MCV MCH MCHC Platelet Urinalysis: Glucosuria +3 negative Elevated levels are Yellowish found with DM ,frothy smelled urine 0.37 8.74x10
9/L

F- 0.37-0.42 5-10 x109/L 12-14 g/dl 80-100 fl 27-33 pg 32-38% 160-380 x10/L N N N N N N N N N N N N N N

No special preparations needed. Just advise the patient to do her usual routines before test.

13.20 g/dl 83.9 fl 30.3 pg. 36.1% 200

Instruct the patient to take midstream urine as sample Advise to increase fluid inatke

VIII. COURSE IN THE WARD September 11, 2012 (7am-3pm)

Received patient awake on bed, conscious and coherent accompanied by her husband and son. Patient does not have IVF or oxygen connected to her. Morning care done. She verbalized that she was not defecated since the date of admission. Advised patient to eat high fiber foods like fruits and green and leafy vegetables, and to increase fluid intake to 1-2 liters as tolerated. Administered prescribed medications. Assisted to defecate at the bed side commode. Vital signs monitored and recorded every four hours. Intake and output measured and recorded. Needs attended. Kept safe and comfortable. September 12, 2012 (7am- 3pm)

Received patient awake on bed, conscious and coherent accompanied by her friends. Patient do not have contraptions. Vital signs taken and recorded. Intake and output measured and recorded. Administered prescribed medications. Patient is for discharge today. Instructions for discharge given. Needs attended. Kept safe and comfortable.

IX. NURSING CARE PLANS

X. DATE 10/12/12

DISCHARGE PLANNING

M >Instructed the client to take medication as follows: Psirdopril- 8 mg orally once a day. aspirin- 160 mg per day carvedilol-6.25 mG/tab, tab,two times a day, hold if heart rate 60 bpm ISMN (Isosorbide Mononitrate) - 60 mG,one and a half tab once a day clopidogrel- 75 mG/tab, one tab once a day atorvastatin-80 mG/tab, one tab once a day at hours of sleep janumet- 50mg/tab 1 tab once a day before lunch E >Instructed the patient to have a regular exercise program start with brisk, 5 minutes walk per day and increase slowly to 30 minutes per day. T H >Health Teachings Instructed to the patient: Have a regular Blood Pressure check-up. Control or Reduce weight. Increase aerobic activity to 30-45 minutes as tolerated. O > follow-up check-up after 1 week at MAB room 514 to Dr. Alex Ang office hrs: Mon. Wed. Sat. 10A-12N D > Advised patient on Low fat, Low salt, High fiber Diet and DM diet. S >Advised to continue or maintain her relationship with God.

XI.

NURSING IMPLICATIONS Nursing Research

This case study aims to make a significant contribution in raising the awareness of the people, especially those in the health care profession by making them more sensitive to the unique needs of the patient with the mentioned disease and in guiding the patients significant others experiencing the same situation. In addition, this also serves as a data source for future researches.

Nursing Education This paper would like to emphasize further study on the said disease by making recommendations on how different institutions will provide care to those patients with the same condition. As well as, knowing the complications associated with the disease. This can also be used by the educators as a tool for imparting knowledge to the students.

Nursing Practice This study should provide other health care professionals in providing a better, more holistic model in constructing an individualistic care plan that will suit the clients need and that would minimize further complications. Also, the issues about incompetence in handling cases similarly to the case stated in this study will be answered, as health care providers will be able to be more knowledgeable on the prevention and ways to manage the said condition for the patient who suffers from the said disease.

XII.

BIBLIOGRAPHY

Brunner & Suddarth. Text Book of Medical-Surgical Nursing(12th ed.). Wolters Kluwer Press. Ignativicius and Workman.Patient Centered Collaborative Care Approach to MedicalSurgical Nursing(6th ed.)C&E Publishing Inc. Spratto, G.R. and Woods, A.L. Delmars Nurses Drug Hand Book 2010 ed. Delmar Cengage Learning. http://globalnation.inquirer.net/cebudailynews/opinion/view/20080728-151202/Diabeteswarning http://www.ncbi.nlm.nih.gov/pmc/articles/PMC28484/