ACKNOWLEDGEMENT

We would like to extend our gratitude to the following people who help us and
believe in us to finish this group case study.
First, we would like to extend our gratitude to our Almighty God that gives us
life, knowledge, strength and wisdom in order for us to overcome challenges and
difficulties we encountered when we made this case study.
To our clinical instructor Mr. Hammed Leo Fabre RN,MN for her guidance and
giving us more knowledge in our field. And teaching us to become good nurse in the
future and to excel in our field.
To our Head nurses for their support in our duty. They are always there for us.
They have always a hand for help. They also support us and make sure that we will do
better in our duty.
To the staff of Northern Mindanao Medical Center OB ward, for allowing us to
experience different cases for us to grow and gain more knowledge.
To our client and her family for their support and willingness on answering our
questions.
To our groupmates for always there for us when we have problem.
And also to our family, friends and love ones who are our strengths and our
inspiration in making this group case study.

Introduction:

Angina Pectoris, Unstable

- Unstable angina occurs when the narrowing becomes so severe that not enough blood
gets through to keep the heart functioning normally, even at rest. The atherosclerotic
plaque may rupture in unstable angina, allowing blood clots to precipitate and further
decrease the lumen of the coronary vessel. This explains why an unstable angina
appears to be independent of activity. Sometimes the artery can become almost
completely blocked. It may occur unpredictably at rest which may be a serious indicator
of an impending heart attack
Clinical Manifestation
Angina itself is a symptom (or set of symptoms), not a disease. Any of the
following may signal angina:
An uncomfortable pressure, fullness, squeezing, or pain in the center of the

chest

It may also feel like tightness, burning, or a heavy weight.

The pain may spread to the shoulders, neck, or arms.

It may be located in the upper abdomen, back, or jaw.

The pain may be of any intensity from mild to severe.

Other symptoms may occur with an angina attack, as follows:

Shortness of breath

Lightheadedness

Fainting

Anxiety or nervousness

Sweating or cold, sweaty skin

Nausea

Rapid or irregular heart beat

Pallor (pale skin)

Feeling of impending doom

These symptoms are identical to the signs of an impending heart attack described by
the American Heart Association. It is not always easy to tell the difference between
angina and a heart attack, except angina only lasts a few minutes and heart attack pain
does not go away.

If you have never had symptoms like this before, sit down. If you are able, call

your healthcare provider, call 911, or go to the closest hospital emergency

department.
If you have had angina attacks before and this attack is similar to those, rest for

a few minutes. Take your sublingual nitroglycerin. Your angina should be totally
relieved in five minutes. If not, you may repeat the nitroglycerin dose and wait
another five minutes. A third dose may be tried but if you still have no relief, call 911
or go to the nearest hospital emergency department.

Diagnostic Examination
To diagnose angina, your doctor will start by doing a physical exam and asking about
your symptoms. You'll also be asked about any risk factors, including whether you have
a family history of heart disease.
There are several tests your doctor may order to help confirm whether you have angina:

Electrocardiogram (ECG or EKG). An electrocardiogram traces the electrical

signals that cause your heart to beat as they travel through your heart. Your doctor
can look for patterns among these heartbeats to see if the blood flow through your
heart has been slowed, interrupted or if you're having a heart attack.

Stress test. Sometimes angina is easier to diagnose when your heart is working
harder. During a stress test, you exercise by walking on a treadmill or pedaling a
stationary bicycle. While exercising, your blood pressure is monitored and your
ECG readings are watched. If you're unable to exercise, you may be given drugs
that cause your heart to work harder to simulate exercising.

Echocardiogram. An echocardiogram uses sound waves to produce images of

the heart. Your doctor can use these images to identify whether there are areas of
your heart muscle that have been damaged by poor blood flow a cause of
angina. An echocardiogram is sometimes given during a stress test.

Nuclear stress test. A nuclear stress test helps measure blood flow to your
heart muscle at rest and during stress. It is similar to a routine stress test, but
during a nuclear stress test, a radioactive substance is injected into your
bloodstream. This substance mixes with your blood and travels to your heart. A
special scanner which detects the radioactive material in your heart creates
images of your heart muscle. Inadequate blood flow to any part of your heart will
show up as a light spot on the images.

Chest X-ray. This test takes images of your heart and lungs. This is to look for
other conditions that might explain your symptoms and to see if you have an
enlarged heart.

Blood tests. Certain heart enzymes slowly leak out into your blood if your heart
has been damaged by a heart attack. Samples of your blood can be tested for the
presence of these enzymes.

Coronary angiography. Coronary angiography uses X-ray imaging to examine

the inside of your heart's blood vessels. It's part of a general group of procedures
known as cardiac catheterization. During coronary angiography, a type of dye
that's visible by X-ray machine is injected into the blood vessels of your heart. The
X-ray machine rapidly takes a series of images (angiograms), offering a detailed
look at your blood vessels.

Cardiac computerized tomography (CT) scan. In a cardiac CT scan, you lie on

a table inside a doughnut-shaped machine. An X-ray tube inside the machine
rotates around your body and collects images of your heart and chest, which can
show if any of your heart's arteries are narrowed or if your heart is enlarged

Causes
Stable angina occurs when the heart does not get the oxygen it needs to do the
work it is being asked to do. When you exercise, lift heavy items, or otherwise stress
your body, your heart works harder to accommodate the additional exertion.
Certain factors can impede your heart from receiving more oxygen, such as a narrowing
of the arteries (atherosclerosis). Your arteries can become narrow when plaque (a
substance made of fat, cholesterol, calcium, and other substances found in blood)
builds up inside them, usually due to high cholesterol. Blood clots can also block your
arteries and reduce the flow of oxygen-rich blood to the heart.

Risk Factors

being overweight

having a history of heart disease

having high cholesterol or blood pressure

being diabetic

smoking

not exercising enough

4

Additional risk factors can include any situation that requires your heart to need more
oxygen. Big meals, prolonged exposure to extreme hot or cold weather, vigorous
physical workouts, and emotional stress can also induce stable angina in some cases.
You can develop stable angina even if you do not have any of the signs of heart
disease, such as shortness of breath and pain, numbness, weakness, or coldness in
legs and arms. According to the National Institutes of Health, men are more likely to
develop stable angina than women

Epidemiology
Angina pectoris is of interest as a cause of disability and also because it is a marker for
potential severe manifestations of coronary heart disease such as cardiac infarction or
sudden death. However, the elucidation of its epidemiology is inherently difficult. It is not
specific for coronary heart disease. Because it is a symptom the diagnosis cannot be
validated. Clinical diagnosis is inconsistent. Standard questionnaires are more reliable
but these produce different results according to minor changes in circumstances and
wording. The variability of the disease means that incidence and prevalence measures
are closely related to the exact method of measurement. Risk factors for angina pectoris
are the same as those for coronary heart disease as a whole. The risk factors continue
to predict major coronary events even when angina pectoris has developed. The angina
revealed by population surveys is a much more mild, transient and less dangerous
disease than that reported in clinical case series. The implication for the latter is that the
results cannot be generalized unless the way in which cases are referred and selected
is known.

SIGNIFICANCE OF THE STUDY:

Nursing Education: The significance of this study to nursing education is to further
increase and expound knowledge of the students. It also helps to make a reliable and
holistic care plans to improve the quality of life of the client. The study hastens the
opportunity for the students to apply theoretical knowledge to actual health care
settings.
5

Nursing Practice: This study is significant to nursing practice to further improve the
skills and ability of the nursing students and enhances students capability to make
intelligent actions and decisions in the clinical area. This study also helps us to attain
our goal which is to provide quality care to our client to improve their quality of life.
Nursing Research:Through having this study, nursing students would be able to apply
their skills in research. Be able to apply systematic and scientific way of solving
problems and discover new ideas that would give answers to the patients situation. It
also a means of revision the kind of therapy we have and a means of discovering a new
technique or methods in dealing and caring of client with this kind of condition.

OBJECTIVES OF THE STUDY

General Objective:
The main objective of this case study is to be able to evaluate and have a firm
background on the health condition of the patient and her health needs associated with
chronic stable angina to achieve proper planning, management and intervention which
will be given to meet clients basic demands, alleviating further complications.
Additionally, this study also aims to offer knowledge and information, restore and
maintain patients health status utilizing a holistic approach of promoting and
rehabilitative process of nursing managements and nursing interventions.

Specific Objectives:
1 Develop an independent method, as well as a collaborative work method with the
medical health team.
2 Prioritize the health issues and concerns that we are presented with them and
respond to them appropriately with the proper nursing interventions.
3 Apply the core and fundamental systematic approach of the nursing profession in
promoting health to our client.
4 Assist the patient in developing a healthy self-concept of her, regardless of the
differences that may be considered as a hindrance or burden.
5 Aid the patient in accepting and adapting to the changes that may have been
made to her life, while doing our best to regain her normal condition.

Patients Profile
Patient x, a56-year-old, female, who was born on October 31, 1958, and residing at
Pueblo de Oro, Upper Carmen, Cagayan de Oro City. Her religion was Roman Catholic.
She is non-smoker, non-alcoholic drinker, and no allergies in any medication. She is
heavy in character. She was admitted at Capitol University Medical Centre under Dr.
Manuel Edmilao .The reason for her admission was chronic on and off chest pain
Medical Past History
Chronic chest pain on and off for 2 years
FAMILY HISTORY OF ILLNESS
History of Present Illness:
2 years prior to admission patient experienced chronic on and off chest pain that lasts
for minutes.
1 year prior to admission she had a check-up on manila- nuclear test done = normal
4 months she consulted a cardiologist reassurance done
3 months prior to admission she consulted a cardiologist anti ischemic drugs
continued
Still complained on and off chest discomfort
Nutritional and Lifestyle Pattern:
Patient x usually eats three large meals a day and eats snacks in the afternoon
with a good appetite. She is fond of eating fruits and vegetables. She also eats meat
such as beef and chicken. She also drinks 6-8 glasses of water a day. She has no
history of food and drug allergies. She is a non-smoker and doesnt drink alcohol
beverages. She usually sleeps around 8 PM and wakes up at 8 AM.
GENERAL SURVEY
During assessment, the patient appears conscious, lying on bed with an ongoing
IVF of NaCl. She is oriented to person, place and time and vital signs of T-36.1c,
PR-96bpm, RR-23 cpm BP-130/80 mmHg
INTEGUMENTARY
Skin color appears pale and poor skin turgor. Hair is naturally black, thin, firm in
texture and hair evenly distributed on the scalp. Capillary refill is assessed in 2
seconds. The Temperature is T-36.1c degrees Celsius.
HEAD
Head is symmetrical, rounded, normocephalic and in midline alignment,
EYES
Eyebrows are symmetrically aligned; equal movement with no presence of
flakes, scars, or lesions. Lids and periorbital region is edematous. Conjunctivas
of the eye are also pale. Pupil reaction to light and accommodation is
8

symmetrical.

Both

eyes

are

coordinated.

Peripheral

vision

is

normal.

EARS
The left and the right pinna are symmetrical and aligned with the outer cantus
of the eye with no discharges noted. The patient was able to hear normal
voice tones in both ears.
MOUTH
Lips are pale in color. Gums and mucosa are pale in color with no lesions or
ulcerations noted.
NECK
Can perform any range of motion without discomfort and with equal muscle
strength as the patient turns his head from left to right; up and down; and
circular motion. Trachea was located centrally in the midline of the neck.
CHEST AND LUNGS
Symmetrical in alignment; full and symmetric chest expansion, RR- 23 cpm.
CARDIOVASCULAR
the patients chest area is flat.
The point of maximal impulse was located at the fifth left intercostals spaces.
Heart rate is 96 beats per minute.
ABDOMEN
Abdomen round and soft. Bowel sounds x 4.Tenderness only in hypogastric
area due to menorrhagia.
GASTROINTESTINAL
have 2 episodes of non mucoid, non-blood streaked non foul smelling stools
MUSCULOSKELETAL
Patient x has still sufficient energy in completing desired required activities
but complains a painful sensation at her pelvic area.

Developmental Data
Sigmund Freuds Psychosexual development theory
In Freudian psychology, psychosexual development is a central element of
the psychoanalytic sexual drive theory, that human beings, from birth,
possess an instinctual libido (sexual energy) that develops in five stages.
Each stage the oral, the anal, the phallic, the latent, and the genital is
characterized by the erogenous zone that is the source of the libidinal
drive. Sigmund Freud proposed that if the child experienced sexual frustration
in

relation

to

any

psychosexual

developmental

stage,

s/he

would

experience anxiety that would persist into adulthood as a neurosis, a

functional mental disorder.

Stage

Age
Range

Erogenous zone

Consequences of psychologic fixation

Orally aggressive: chewing gum and the ends of

pencils, etc.
Orally Passive: smoking, eating, kissing, oral sexual
practices[4]
Oral stage fixation might result in a passive, gullible,
immature, manipulative personality.

Oral

Birth1
year

Anal

Anal retentive: Obsessively organized, or

Bowel and bladder eliminatio excessively neat
13 years
n
Anal expulsive: reckless, careless, defiant,
disorganized, coprophiliac

Phallic

Mouth

36 years Genitalia

Oedipus complex (in boys and girls); according to

Sigmund Freud.
Electra complex (in girls); according to Carl Jung.

Latenc
6puberty Dormant sexual feelings
y
Genital

Puberty
death

Sexual interests mature

Sexual unfulfillment if fixation occurs in this stage.

Frigidity, impotence, unsatisfactory relationships

10

ANATOMY AND PHYSIOLOGY

The heart is a muscular organ about the size of a fist, located just behind and
slightly left of the breastbone. The heart pumps blood through the network of
arteries and veins called the cardiovascular system.
The heart has four chambers:
The right atrium receives blood from the veins and pumps it to the right
ventricle.
The right ventricle receives blood from the right atrium and pumps it to the
lungs, where it is loaded with oxygen.
The left atrium receives oxygenated blood from the lungs and pumps it to
the left ventricle.
The left ventricle (the strongest chamber) pumps oxygen-rich blood to the
rest of the body. The left ventricles vigorous contractions create our blood
pressure.
The coronary arteries run along the surface of the heart and provide oxygen-rich
blood to the heart muscle. A web of nerve tissue also runs through the heart,
conducting the complex signals that govern contraction and relaxation.
Surrounding the heart is a sac called the pericardium.

11

PATHOPHYSIOLOGY
LEGENDS:

Predisposing Factor
Precipitating Factor

Etiology

Disease Process

Predisposing Factors:
Age- 56 years
oldHereditary- HPN,
DM
Gender- femaleHx of
Cholecystectomy
(NMMC; 1995)
Menopause (starts at
age 42 years old;
Menarche starts at
age 13 yrs.old.)
DM II (1999; usual
glucose level: 140-

Precipitating Factors:

Atherosclerotic
Plaque

HPN (37 yrs old; usual

BP 140/90; highest BP
is 200/110mmHg)>
Inc. serum Cholesterol
level: 231mg/dL>
Lack of
exercise/activity>
Obesity (BMI of 27
kg/m2, IBW: 48.96kg

Unstable Plaque
Stable Plaque
Thrombus Formation
Stable Angina
Incomplete occlusion

Unstable Angina

Myocardial Ischaemia
Electrical instability

Complete occlusion

Myocardial Infarction

Healing with scarring

leading to deterioration
to left ventricle

Repeated episodes

Ventricular Fibrillation
Chronic ischaemic heart
disease

Sudden Cardiac Death

Cardiac Failure

12

DIAGNOSTIC PROCEDURE AND LABORATORY RESULTS

The laboratory test and diagnostic procedures indicates a very significant finding necessary for the care and prevention of particular disease which
may occur in the clinical settings, here are the data as followed with interpretation.
COMPLETE BLOOD COUNT
The complete blood count (CBC) is one of the most commonly ordered blood tests. The complete blood count is the calculation of the cellular
(formed elements) of blood. These calculations are generally determined by special machines that analyze the different components of blood in less
than a minute
TEST
White blood cells
Red blood cells

RESULT
09-19-13 09-20-13
13.76
7.55
4.94 3.99

REFERENCE

INDICATION

5.0-10.0 10^3/uL
4.2-5.4 1066/uL

A blood test to measure the number of white blood cells.

The main function of the red blood cells is to transport oxygen

INTERPRETATION
09-19-13
09-20-13
Anemia
Normal
Normal
Anemia

from the lungs to the other tissues of the body and the other
function is to partly carry carbon dioxide, which is a waste
Hemoglobin

13.3

10.9

12.0-16.0 g/dL

product of metabolic activities in the body.

Essential chemical which carries oxygen from lungs to other

Normal

Anemia

parts of the body. It contains iron and performs the important

Hematocrit

40.7

33.0

37.0-47%

function of transporting oxygen via RBCs in blood.

Used to measure RBC number and volume. It is an integral Normal

MCV

82.4

82.7

82.0-98.0 fL

part of the evaluation of anemic patients.

Microtic cell volume, the test is an indicator for the size of the
RBCs or red blood cells. It helps to determine if there is risk for
certain anemias.
13

Normal

Anemia
Normal

MCH
MCHC
RDW-CV

26.9
32.7
13.9

27.3
33.0
13.8

27.0-31.0 pg
31.5-35.0 g/dL

This helps diagnose a cause of an anemia.

Measures of the concentration of haemoglobin in a given

Anemia
Normal

12.0-17.0%

volume of packed red blood cells.

A blood test, which calculates the variations in the size of the

Normal

Normal

Normal

Normal

Normal

Normal

PDW

12.1

12.5

9.0-16.0fL

red blood corpuscle.

A type of protein released by platelets of the blood that aid in

MPV

10.4

10.7

8.0-12.0 fL

the repair and regeneration of connective tissue.

This is a volume determined through a blood test that tells the

Normal
Normal

size of the platelets in your blood.

Differential Count
Lymphocyte

25.0

46.0

17.4-48.2%

They are specialized white blood cells, leukocytes, that

Normal

Normal

Neutrophil

67.9

42.9

43.4-76.2%

become active during an immune response of the body

Neutrophil granulocytes are a kind of white blod cells, forming

Normal

Anemia

Monocyte

5.5

6.5

4.5-10.5%

an essential part of the bodys defence system

A type of white blood cell and is part of the human bodys

Normal

Normal

Normal

Normal

immune system. Monocytes play multiple roles in immune

Eosinophil

1.4

4.2

1.0-3.0%

function.
Are white blood cells that are one of the immune system
components responsible for combating multicellular parasites
and certain infections in vertebrates.

14

Basophil

0.2

0.4

1.0-2.0%

Basophils appear in many specific kinds of inflammatory

Anemia

Anemia

reactions, particularly those that cause allergic symptoms.

Platelet

331

228

150-400 10^3uL

This is the number of cells that plug up holes in your blood

vessels and prevent bleeding.

URINALYSIS
15

Normal

Normal

The urinalysis is used as a screening and/or diagnostic tool it can help detect substances or cellular material in the urine associated with
different metabolic and kidney disorders. It is ordered widely and routinely to detect any abnormalities that require follow up. Often, substances such
as protein or glucose will begin to appear in the urine before patients are aware that they may have a problem. The urinalysis may be ordered at
intervals as rapid method to help monitor organ function, status, and response to treatment.
DATE
September 19, 2013
Yellow
Slightly hazy
--5.0
1.020
Trace
positive
2-3
---

Color
Clarity
Odor
Ph
Specific Gravity
Proteins
Glucose
Pus cells (WBC)
Mucus Threads

16

Interpretation: The results indicate that the patients urine has an infection.CLINICAL CHEMISTRY SECTION
DRUG
ORDER GLUCOSE
MECHANISM
(Generic
OF
UREA
name,brandna
ACTION
me,classificati
CREATININE
on,dosage,rout
e,
Frequency)

Generic
name

This medication
is
an
angiotensinSODIUM
converting
POTASSIUM
Ranipril
enzyme (ACE)
inhibitor,
used
or
in
Brand name alone
combination
with
Kardia
other
to
Classificatio medications
treat high blood
n
pressure. It is
also used to
ACE
reduce the risk of
inhibitor
heart attack and
stroke in patients
Dosage
at risk for these
5mg
problems and to
improve survival
Route
in patients with
P.O
heart failure after
a heart attack.
Frequency
BID

9-19-13
INDICATIONS
160.74
8.49
0.61

9-20-13
CONTRAINDI 104.67
ADVERSE EFFECTS
CATIONS
OF THE DRUG

This medication is
Contraindicate
an angiotensin- 9-19-13
d in patients
converting enzyme140.5
with
(ACE) inhibitor,
4.2hypersensitivity
used alone or in
, bilateral renal
combination with
artery stenosis
other medications to (narrowing of
treat high blood
the arteries
pressure. It is also
going to the
used to reduce the
kidney), or a
risk of heart attack
single kidney
and stroke in
with unilateral
patients at risk for
renal artery
these problems and stenosis, aortic
to improve survival
stenosis or
in patients with
outflow tract
heart failure after a
obstruction,
heart attack.
pregnancy and
breastfeeding.

NURSING
NORMAL RANGE
RESPONSIBILITIES/
60.00-110.00 mg/dl
PRECAUTIONS
4.60-23.40 mg/dl

UNIT
mg/dl
mg/dl
Mg/dl

0.68

0.60-1.20

Heart- Low blood pressure,

chest pain, loss of
9-20-13
consciousness.

It may cause dizziness, lightheadedness, or fainting;

Central Nervous System3.97

Dizziness.

these

Gastrointestinal- Nausea,
vomiting, diarrhea.
Genitourinary- Abnormal
kidney function.
Blood- Severe decrease in
white blood cells.
Metabolic- Increase in
potassium in blood.
Respiratory- Cough.
Miscellaneous- Severe
allergic reactions.

Other Precautions :
Dehydration,
excessive sweating,
vomiting, or diarrhea
may increase the risk
of low blood
pressure. So monitor
blood pressure
regularly.
17

135-148mmol/l
alcohol, hot weather, exercise,
or fever may increase
effects.

Get

3.5-5.3
mmol/l
slowly from

up

bed.

It may cause a serious side effect called angioedema

with symptoms of swelling of the hands, face, lips,
eyes, throat, or tongue; difficulty swallowing or
breathing;

or

hoarseness.

It may affect your blood sugar. Check blood sugar

levels

closely.

Monitor kidney function before and during treatment.

Regular monitoring of white blood cells in patients
with vascular collagen disorders is recommended.
Use with caution in patients with history of an allergic
reaction

which

included

swelling

of

the

face/lips/tongue/throat (angioedema). Before using

this medication, tell your doctor or pharmacist your
medical history, especially of: kidney disease, liver
disease, high blood levels of potassium, heart
problems,

severe

dehydration

(and

loss

of

electrolytes such as sodium), diabetes (poorly

controlled), strokes, blood vessel disease (e.g.,
collagen

vascular

scleroderma)

diseases
and

such

as

lupus,

children.

DRUG ORDER
(Generic
name,brandname,classi
fication,dosage,route,

MECHANISM OF

INDICATIONS

CONTRAINDIC
ATIONS

ACTION

Frequency)

18

ADVERSE EFFECTS

NURSING

OFTHE DRUG

RESPONSIBILITIES/
PRECAUTIONS

Generic name
Acetyl Salicylic
Acid
Brand name
Aspirin
Classification
ANALGESIC/NonSteroidal AntiInflammatory
Dosage
500mg
Route

Anticoagulants are used to prevent

clot extension and formation. They
do not dissolve clots. The
two types of anticoagulants in
common use are parenteral
heparins and oral warfarin. Therapy
is usually initiated with heparin or a
heparin-like agent because of rapid
onset of action, while
maintenance therapy consists of
warfarin. Warfarin takes several
days to produce therapeutic
anticoagulation. In serious or
severe thromboembolic events,
heparin therapy may be preceded
by thrombolytic therapy. Low doses
of heparin or heparin-like
compounds and fondaparinux
are mostly used to prevent deep
vein thrombosis after certain
surgical procedures and in similar
situations in which prolonged
bedrest increases the risk of
thromboembolism. Argatroban and
lepirudin are used as
anticoagulation in patients who
have developed thrombocytopenia
during
heparin therapy.

Prevention and
treatment of
thromboembolic
disorders including
deep vein
thrombosis,
pulmonary
embolism, and
atrial fibrillation
with embolization.
Also used in the
management of
myocardial
infarction (MI)
sequentially or in
combination with
thrombolytics
and/or antiplatelet
agents..

Frequency

Underlying
coagulation
disorders,
ulcer
disease,
malignancy
,
recent
surgery, or
active
bleeding

Conditions of
Excess Stomach Acid
SecretionLess Severe.
Feel Like Throwing
UpLess Severe.
HeartburnLess
Severe.
Irritation of the
Stomach or IntestinesLess
Severe.
Stomach
CrampsLess Severe.
Throwing UpLess
Severe

Caution patient to avoid activities

leading to injury, to use a soft
toothbrush and electric razor,
and to report any symptoms of
unusual bleeding or bruising to
health care professional
immediately.
Instruct patient not to take OTC
medications, especially those
containing aspirin, NSAIDs, or
alcohol, without advice of health
care professional.
Review foods high in vitamin K
(see Appendix M) with patients on
warfarin. Patient should
have consistent limited intake of
these foods, as vitamin K is the
antidote for warfarin and
greatly alternating intake of these
foods will cause PT levels to
fluctuate.
Emphasize the importance of
frequent lab tests to monitor
coagulation factors.
Instruct patient to carry
identification describing medication
regimen at all times and to inform
all health care professionals caring
for patient of anticoagulant therapy
before laboratory
tests, treatment, or
surgery.

Every 8hours

19

(DRUG

ORDER)

(Generic name, brand name,

classification ,dosage, route,

MECHANISM

OF

INDICATIONS

CONTRAINDICATION

ADVERSE EFFECTS

OF THE DRUG

ACTION

Frequency)

NURSING
RESPONSIBILITIES/
PRECAUTIONS

Generic Name :

Diazepam

probably by

management of:

- Cross-sensitivity with

1) dizziness

Brand Name

potentiating GABA, an

1) Anxiety

other benzodiazepines

2) drowsiness

to periodically throughout

Valium

inhibitory

2) Preoperative

may occurs

3) lethargy

therapy and frequently

Classification

neurotransmitter.

sedation

- Comatose patients

4) hangover

during IV therapy.

Antianxiety
agents,
anticonvulsants,
sedative/hyptonic
s, skeletal muscle
relaxants

- Produces skeletal

3) Conscious

- Pre-existing CNS

5) headache

- Assess IV site frequently

muscle relaxation by

sedation

depression

6) depression

during administration,

inhibiting spinal

- Provides light

- Uncontrolled severe

- EENT:

diazepam may cause

polysynaptic afferent

anesthesia and

painUse cautiously in:

1) blurred vision

phlebitis and venous

pathways.

anterograde

1) Hepatic dysfunction

- RESP:

thrombosis.

- Has anticonvul-sant

amnesia

2) Severe renal

1) respiratory

- Prolonged high-dose

properties due to

- Treatment of

impairment

depression

therapy may lead to

enhanced presynaptic

status epilepticus/

3) History of suicide

- CV:

psychological or physical

inhibi-tion.Therapeutic

uncontrolled

attempt or drug

1) hypotension

dependence. Restrict

effects:

seizures

dependence

- GI:

amount of drug available

(1) Relief of Anxiety

- Skeletal muscle

1) constipation

to patient. Observe

(2) Sedation

relaxant

2) diarrhea

depressed patients

(3) Amnesia

- Management of

3) nausea

closely for suicidal

the symptoms of

4) vomiting

tendencies.

Dosage
5 g tab
Route

Depress the CNS,

-Adjunct in the

Hypersensitivity

20

CNS:
Monitor BP, PR,RR prior

(4) Skeletal muscle

alcohol withdrawal

- DERM:

relaxant

1) rashes

(5) Decreased seizure

- LOCAL:

activity

1) pain (IM)
2) phlebitis (IV)
3) venous
thrombosis
- MISC:
1) physical &
psychological
depen-dence
2)tolerance

- Observe and record

intensity, duration and
location of seizure
activity. The initial dose
of diazepam offers
seizure control for 15-20
min after administration.
- IM injections are painful
and erratically absorbed.
If IM route is used, inject
deeply into deltoid
muscle for maximum
absorption.
- Caution patient to avoid
taking alcohol or other
CNS depressants
concurrently with this
medication.
- Effectiveness of therapy
can be demonstrated by
decrease anxiety level;

21

control of seizures;
decreased
tremulousness.

22

23

NURSING CARE PLAN

ASSESSMENT DATA
(Subjective and Objective

NURSING DIAGNOSIS

GOALS AND

NURSING INTERVENTIONS

Cues)

(Problem and Etiology)

OBJECTIVES

AND RATIONALE

24

EVALUATION

Subjective:

Acute pain

Long Term:

Give Aspirin 500mg to

Long Term:

relieve pain.
I always feel this abnormal
pain in my chest.
Objective:

Pain scale: 8/10

Facial expression
indicates slight

After 1 hour of nursing

Body weakness

Activity intolerance

hour

nursing

and pain behaviours :

be able demonstrate use

R:

of relaxation skills and

not be congruent with relaxation

diversional activities.

verbal reports or may be diversional activities.

Observations

interventions

of

interventions patient will

patient

was

may able to demonstrate use of

skills

and

only indicator present

Short Term:

when client is unable to Short Term:

verbalize.

discomfort

Observe nonverbal cues After

After

30

minutes

nursing

of

interventions

patient will be able to

Encourage

After 30 minutes of nursing

diversionalactivtities.

interventions

R: To distract attention able to

relieved.
and reduce tension

report pain is relieve.

Encourage

patient

report

adequate

rest periods.
R: to prevent fatigue.

NURSING CARE PLAN

ASSESSMENT DATA

EVALUATION
25

pain

was
is

(Subjective and Objective

NURSING DIAGNOSIS

GOALS AND

NURSING INTERVENTIONS

Cues)

(Problem and Etiology)

OBJECTIVES

AND RATIONALE

Subjective:
I felt weak all over my body
as verbalized by the patient.

Deficient fluid volume

After 8 hours of nursing

related to excessive blood

intervention, the

loss.

will be able to maintain

patient

and O

fluidvolume at a functional
level.

Objective:

Tranexamic After 8 hours of nursing

Acid 500mg every 8 intervention, the patient
hours to minimize was able to maintain fluid
Give

menstrual bleeding.

volume as evidenced by

Administer

I V accurate I and O.

Decreased hemoglobin

fluids,

as

and hematocrit count

indicated.

Maintain accurate I Goals met

Profuse menstruation

Used of 3-4 infant

to

diapers per day

intake

Pallor

Poor Skin turgor

Encourage patient
increase

Encourage patient
to

take

supplements.

NURSING CARE PLAN

26

fluid

iron

ASSESSMENT DATA

NURSING

(Subjective and Objective Cues)

EVALUATION

NURSING

GOALS AND

INTERVENTIONS AND

DIAGNOSIS

OBJECTIVES

RATIONALE

(Problem and
Etiology)

Subjective:

Impaired

mobility

hindiakomasyadonggumagalawngdahilsa

pain

sakit as verbalized by the patient.

physical After 1 hour of nursing

related

to interventions,

the

patient will be able to

Assist

with

activity/progressive

After 1 hour of nursing

ambulation

interventions, the patient

Encourage

and was be able to move

early within range of motion.

move within range of

facilitate

motion.

ambulation.

Objective:

Schedule

Pain scale: 8/10

with

Limited range of motion

periods

Slowed movement

day.

Reluctance to attempt movement

activities

adequate
during

rest
the

Determine degree of
Immobility in relation
to

previously

suggested scale.

27

28

DISCHARGE PLAN / HEALTH TEACHINGS

Medication:

Instruct the immediate family of the patient to keep track of all the home
medications that have given, and to be sure to administer at the proper times
with the right dosage as prescribed by the attending physician.

Exercise:

The patient is permitted to resume her former activities and responsibilities

completely once recovered from illness. Until then, bed rest is recommended.

Treatment:

Teach the family about the importance of making follow-up appointments.

Explain the importance of the medications prescribed by the physician, making

sure that the purpose of medication is fully comprehended by the client and her
family.

Instruct client and family to contact or see a physician if any serious side effects
are experienced.

Health teachings:

Keep a list of current medication and always include the amounts, and when,
how, and why you take them. Remember to always take the list or the pill bottles
to follow-up visits. Additionally, carry your medicine list with you in case of an
emergency.

Always take medicine as directed.

Patients must be properly informed of any and all side effects may occur, and
how to properly manage the side effects at first notice.

Outpatient:

Encourage patient and family members to consider regular check-ups as ordered

by the physician to ensure the continuing management and treatment.

Diet:

Inform family if there is specific diet ordered by the physician.

Spiritual:

Encourage client and family members to strengthen their relationship to God, to

maintain religious practices and beliefs.

Advice family members to provide emotional support to the client to help her
know that she will always have help during her most difficult times.
29

30

RELATED NURSING EXPERIENCE

Related Learning Experience subject is one of the most important subjects in the
field of Nursing. It is because in this subject, we are able to gain knowledge and skills in
the real hospital setting. Thus, it is in this subject matter that we will be able to perform
all the procedures that we acquired from school up to the real situation. Furthermore, it
serves as our foundation and training ground towards becoming a proficient nurse.
Our exposure at Northern Mindanao Medical Center, OB ward was the most
astonishing and in fact the most unforgettable moment that we will never forget for our
entire nursing profession. We were amazed by the learning experience. Our Clinical
instructor Mr. Hammed Leo Fabre served as a teacher who guided and assisted us on
what we were going to do prior to the care to our patients.
Having been exposed in a hospital area was not that easy because we were
dealing with the lives of the patients who were in need. It was in this rotation that we felt
that we were now moving on towards a more challenging event in our career. Our skills
have enhanced due to our day to day duties, we were introduced to new skills and
procedures and how to use and perform them. We learned how to become responsible
and effective nurses when it comes to giving quality care to our patients.
The experience that we had was fruitful because we were be able to acquire new
knowledge and skills that we need and it was very beneficial on our part because our
capabilities have reached its peak level. Lastly, it helped us mold into total persons, able
and willing to do all the best that we can in order to help without any doubts to those
who were in pain and ailing people.

31

BIBLIOGRAPHY
Books:

Maternal & Child Health Nursing, Care of the Child Bearing Family. Volume 1 &
2. 6th Edition. AdellePillitteri. (2010)

Nurses Pocket Guide. Diagnoses, Prioritize Interventions, and Rationales. 12 th

Edition. Marilynn E. Doenges, Mary Frances Moorhouse, Alice C. Murr. (2009)

2013 Lippincotts Pocket Drug Guide for Nurses. Amy M. Karch

Online Resources:
http://www.nlm.nih.gov/medlineplus/ency/article/000914.htm
http://labspace.open.ac.uk/mod/oucontent/view.php?id=450484&section=3.4
http://www.healthline.com/human-body-maps/uterus
http://en.wikipedia.org/wiki/Uterus
http://www.uterine-fibroids.org/myoma.html
http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001912/

32