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I. DEMOGRAPHIC DATA
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II. HEALTH HISTORY
Family History
The patient claims to have heredofamilial disease of HPN and asthma.
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and urinary frequency, with no associated signs and symptoms of headache, vomiting, or dizziness. Laboratory
work done include CBC and urinalysis, revealing normal results. The patient did not suffer from any illness
durignt the course of pregnancy except for UTI late in the pregnancy where she was given Cefalexin 500mg to
be taken 2x a day. Quickening was felt at 14 weeks AOG. Ultrasound was first done in a local hospital at 20
AOG, which revealed a live singleton intrauterine fetus. There were no reported exposures to viral
exanthematous diseases such as measles and chicken pox, radiation and toxic chemicals during the entire
duration of pregnancy.
Menstrual History
The patient had her menarche at 16 years old, 4 days duration, consuming 3 fully soaked pads/day,
dysmenorrheal. Subsequent menses were irregular at 28-33 day interval for 5 days, consuming 508 fully
soaked pads/day
1) URINALYSIS
Physical Examination
Color: light yellow
Reaction: acidic
Appearance: turbid
Specific Gravity: 1. 010
Pus Cells: many/hpf
Rbc: 0-3/hpf
Mucus Threads: occasional
Epithelial Cells: many
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Chemical Examination
Albumin: negative
Sugar: negative
Microscopic Examination
Crystals- negative
Casts- negative
Bacteria- many
Amorphous Urates –few
Yeast Cell- negative
2) Hematologic test
WBC 11.1 10e 9/L
19.5 % L
70.8 % N
7.62 % M
1.45 % E
RBC 5.68 10 e12/L
HGB 117.9/L
HCT .382 L/l
MCV 67.3 fL
MCH 20.6 pg
MCHC305 g/l
Platelet: Adequate
Comments: Mild anisocytosis
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GORDON’S FUNCTIONAL PATTERN
B. NUTRITIONAL-METABOLIC PATTERN
Her height is 5’2’ and her weight is 51 kg. She does not experience being nauseated. The usual
content of her meal before hospitalization was mostly rice with vegetable because she was allergic to
chicken and when she married her husband she stopped eating pork because her husband is a muslim. She
usually drinks 5-8 glasses of water, she occasionally drinks soft drinks. She is smoking about 2-3 sticks per
day and drinks liquor occasionally with friends but when she knew she was pregnant she stopped smoking
and drinking. She has no difficulty in swallowing. There is presence of dental caries. She is taking in
vitamins.
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C. ELIMINATION PATTERN
Before hospitalization, the usual amount of her urine is about 200 ml every voiding. She is able to
control her urine. Her urine output at present ranges from 100-200 ml in eight hours. Before hospitalization,
she usually eliminate once a day. She has no difficulty in passing stool. But now she eliminates once in 3
day period.
D. ACTIVITY-EXERCISE PATTERN
Her form of exercise is through walking. She claims that she walks everyday going to work. She
usually cleans their house and does household chores before she was hospitalized.
E. SLEEP-REST PATTERN
She sleeps for 8-10 hours from 10:00 pm until 6-7 am. She had no difficulty in sleeping and has no
interruption when sleeping. She doesn’t use sleeping aids in order to sleep. She usually takes a nap for
about 30-1 hour in the afternoon. During hospitalization her sleep is interrupted because of pain on her
perineal area and was interrupted by the staff nurse and student nurse for monitoring.
F. COGNITIVE-PERCEPTUAL PATTERN
She does not use reading glasses. Her eyes are symmetrical. Her eyebrows are equally distributed
with no scaling and dryness noted. Her ears have the same color with the face and proportionate with head
and face. There are no lumps and lesions noted. Her nose is symmetrical with no deformities and lesions.
There are no discharges and no difficulty in breathing noted.
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She can distinguish odors. Her mouth closes symmetrically. Dryness of the mouth is noted. She has
yellowish teeth. She is able to distinguish taste. She responds to pain stimulus. She is oriented to time,
person and place. She is responsive. She has no difficulty in speaking and speaks spontaneously.
H. ROLE-RELATIONSHIP PATTERN
She and her husband is living together. She has no children. Her first child supposedly was aborted.
They have friends outside which is their support system. They find joy in going out with other people.
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J. COPING-STRESS TOLERANCE PATTERN
She usually talks about immediate problems with her friends. But when it comes to handling
stressors, she usually talks with her husband because she believes that they have the same stressors and
the same coping mechanisms. They eat food a lot and then talk about their problem while they are eating.
K. VALUE-BELIEF PATTERN
Patient is a member of the muslim. According to her, there are prohibited foods such as pork. She
expresses now a positive vibe with her religion.
PROBLEMS JUSTIFICATION
ACTUAL PROBLEMS:
This is the first problem because this is the one which takes most of the attention of
the patient we need to solve this problem first so that other nursing interventions
Acute pain
will be accepted by the patient. If we prioritize what she does not feel important she
will not cooperate properly
Maintaining skin integrity is also important so that potential and actual problems will
Impaired skin integrity related to
not occur. Solving this problem will help to solve other impending problems such as
episiotomy
infection, bed sores.
RISK PROBLEM:
This is the third problem because if this is will occur the pain of the patient will
Risk for infection
persist more.
Self care deficit: bathing According to Maslow’s Hierarchy of Needs, another physiologic need is self-care
maintenance. Since the patient has musculoskeletal impairment and cannot
perform her ADLs well due to her condition, her self-care such as bathing is not
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properly met, this problem should also be taken into consideration in order to
prevent further complications such as increase risk for infection and development
of low self esteem.
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LIST OF PROBLEMS:
ACTUAL problems:
1. Decreased cardiac output related to altered contractility secondary to cardiomegaly and myocardial infarction.
2. Impaired cardiac tissue perfusion related to decreased blood flow secondary to myocardial infarction
3. Impaired peripheral tissue perfusion related to mild tricuspid regurgitation secondary to Myocardial infarction.
4. Impaired skin integrity related to allergic reaction secondary to prolonged diaper use
5. Acute pain related to fractured right femur.
6. Impaired physical mobility related to physical restraint secondary to right femur fracture
7. Impaired transfer mobility related to fractured right femur
8. Sensory deficit: vision related to ongoing disease process secondary to diabetes mellitus
9. Disturbed thought process related to side effects of drugs.
10. Self care deficits:bathing related to physical immobility secondary to fractured right femur
11. Impaired role performance related to prolonged hospitalization.
POTENTIAL problems
1. Risk for urinary elimination related to prolonged bed rest
2. Risk for impaired skin integrity related to physical immobilization secondary to fractured right femur
3. Risk for infection related to decreased wound healing secondary to diabetes mellitus
4. Risk for unstable blood glucose related to decreased insulin secretions.
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NCP PROPER
Objective:
with edema on the left hand and on the lower part of the left foot
vital signs: T=36.0, P=60 bpm, R=20 cpm, BP=160/80 mmHg
with capillary refill of 1-2 seconds
with good skin turgor of 1-2 seconds
with visible pulsation of the jugular vein
Chest X-ray as of September 9,2009 revealed Pneumonia right paracardiac, mild cardiomegaly
Bradycardic at times
Echocardiogram andDoppler sound results:
Non-obstructive hypertrophic cardiomyopathy with segmental wall motion abnormality suggestive of Coronary Artery
o
Disease with adequate systolic function
o Dilated left atrium
o Aortic sclerosis
o Mitral sclerosis
o Mild tricuspid regurgitation
o Normal pulmonary artery pressure with pulmonic regurgitation
X-ray results:
o Pulmonary congestion and edema
o True or apparent cardiomegaly
o Atherosclerosis aortic knob
Goals:
Long Term Goal: After 3 days of nursing intervention, the patient will be able to maintain hemodynamic stability.
Short Term Goal: After 8 hours of nursing intervention the patient will:
a. not have any life-threatening dysrhythmias or complications
b. reduce myocardial workload
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c. maintain current cardiac status
Assessment: Decreased Cardiac Output related to altered contractility secondary to tricuspid regurgitation and
myocardial infarction
Several factors have been affecting the occurrence of Hypertension. Lifestyle and age are few of them. Patient
lived in Italy from 1988 to 1996. She always ate Italian foods such as pasta, short breads, and sweets. She doesn’t have
enough exercise. She stays most of the time at home. Because of this, carbohydrates are stored in the form of fat and
lead to the formation of Diabetes Mellitus. This can be a risk in the formation of plaque in the peripheral blood vessels in
the aorta which leads to Atherosclerosis. Narrowing of the blood vessels limits distribution of blood and oxygen in the
different parts of the body. Decreased oxygen in the heart muscles leads to myocardial infarction. The infracted heart
muscle affects the ability to pump blood efficiently, thus, resulting to decreased cardiac output.
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decrease oxygen flowing to the STO:
Evaluate quality peripheral vessels causing Goal fully met if: the patient
and equality of cyanosis. will be able to meet the
pulses, as three short term objectives
indicated. Decreased cardiac output
Auscultate blood results in diminished Goal partially met if the
pressure . weak/thready pulses. patient will be able to meet
Compare both Irregularities suggest 1-2 out of the three
artms and dysrhythmias, which may objectives.
obtain lying, require further evaluation/
sitting and monitoring. Goal unmet if the patient
standing Hypotension may occur related will not able to meet any of
pressures when to ventricular dysfunction, the three short term
able. hypoperfusion of the objectives.
myocardium, and vagal
Auscultate heart stimulation. However,
sounds hypertension is also a common
phenomenon, possibly related to
pain, anxiety, catecholamine
release, and /or preexisting
vascular problems. Orthostatic
hypotension may be associated
with complications of infarct.
Tx S3 is usually associated with
Promote rest HF, but it may also be noted
appropriately with the mitral insufficiency
(regurgitation) and left
Provide small/ ventricular overload that can
easily digested accompany severe infarction.
meals. Limit S4 may be associated with
caffeine intake like myocardial ischemia, ventricular
chocolate and stiffening, and pulmonary or
coffee. systemic hypertension.
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Maintain Optimal
fluid balance Overexertion increases oxygen
consumption and demand and
Place pt. In semi to can compromise myocardial
high-fowlers function.
position to reduce Large meals may increase
preload and myocardial workload and cause
ventricular filling. vagal stimulation, resulting in
Provide quiet and bradycardia/ ectopic beats.
calm environment. Caffeine is a direct cardiac
stimulant that can increase heart
rate.
Decreased cardiac output
Edx results impaired kidney
Explain symptoms perfusion, sodium/water
and interventions retention and reduced urine
for decreased output.
cardiac output 30 degrees angle of bed will
related to etiology. promote venous return
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myocardial workload.
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NCP PROPER II
Subjective:
“Malabo na paningin ko kaya gumagamit na ako ng salamin”
“Nagkaroon siya ng myocardial infarction noong October last year(2008) ”, as verbalized by the significant other.
Objective:
vital signs: T=36.0 oC, P=60 bpm, R=20 cpm, BP=160/80 mmHg
with capillary refill of 1-2 seconds
with good skin turgor of 1-2 seconds
with visible pulsation of the jugular vein
with edema on the left hand and on the lower part of the left foot
with dizziness noted
with crackles on both lung fields noted
Chest X-ray as of September 9,2009 revealed Pneumonia right paracardiac, mild cardiomegaly
Bradycardic at times
Assessment: Impaired cardiac tissue perfusion related to decrease blood flow secondary to myocardial infarction
Goals
LTO: After 3 days of nursing intervention, the patient would have vital signs within the normal range.
STO: After 8 hours of nursing intervention, the patient will be able to:
a. Enumerate 5 factors that contribute to the development of hypertension.
b. Enumerate 5 behaviors that can improve circulation properly.
c. Demonstrate understanding of the importance of compliance to therapeutic regimen.
Oxygen is very important in every cellular process and without it the cells or tissues may die (ischemia) or if not
damaged. Thus, if there is a problem (such as in hypertension) in blood flow, oxygen transport and exchange then some
body areas can not be nourished with enough oxygen. The brain can be a usual part where anoxia or ischemia may
happen because it has small blood vessels. The lack of oxygen on the brain may result to various neuromuscular
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impairments or affectations and if the ischemic episode is not addressed immediately it may lead to comatose or even
death. Brain is considered as the “central government” in the human body, it regulates and controls all bodily functions.
Functions necessary to maintain breathing, circulation, movement or basically to maintain “life”. Therefore, it is important
that cerebral perfusion be maintained or improved as much as possible to ensure vital body processes to continue and to
prevent life-threatening conditions. Hypertension may compromise the blood flow to the brain, especially if the blood
pressure is too high it may alter the delivery of blood to certain parts of the body. This is especially true to the brain since
it has small blood vessels and that the cells in the brain are very sensitive to decreased oxygen supply.
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distress, however sudden slightly elevated.
continued dyspnea may Will be able to
Monitor intake, note indicate thrombo-embolic enumerate 3 factors that
changes in urine pulmonary complications contribute to the
output. development of
hypertension.
Decrease intake or
Will be able to
persistent nausea may
enumerate 3 behaviors
result in reduce improve circulation
circulating volume which properly
negatively affects Will be able to
Tx: perfusion and organ demonstrate
Place patient in semi- function understanding of the
fowler to high fowler’s importance of
position compliance to
therapeutic regimen but
Fowler’s position is with slight deviation.
the position of choice for
people who have difficulty
Not met if:
breathing and for some
Would not have vital
people with heart
signs within normal
problems. When the range.
client is in this position, Will be able to
gravity pulls the enumerate 1-2 factors
Provide calm, restful diaphragm downward, that contribute to the
surroundings, minimize allowing greater chest development of
environmental activity expansion and lung hypertension.
or noise ventilation (Kozier,2008). Will not be able to
30 degrees angle of bed enumerate behaviors
Schedule rest and will promote venous improve circulation
activities return and good properly
circulation Will not be able to
demonstrate
understanding of the
Rest reduces stress
importance of
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and tension that affects compliance to
blood pressure and the therapeutic regimen.
course of hypertension. .
Assist in position
changes
Overexertion
increases oxygen
consumption and demand
and can compromise
myocardial function. It
protects from over
fatigue, reduces oxygen
demand or degree of
Ensure safety by hypoxia and reduces
preventing falls through sympathetic stimulation.
maintaining side rails
Movement includes
all the activities promoted
by the muscular system,
such as propelling
ourselves from one place
to another. Mobility
administer medication improve circulation,
as ordered (antiHPN prevent venous stasis,
and antivertigo) and promote optimal
respiratory function
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one of the effective
methods of preventing
falls but must be used
depending on the
condition of the patient.
Depending on the
antihypertensive drugs
some decreases blood
pressure thru decreasing
heart contractility,
decreasing peripheral
Ed: vascular resistance and
Health educate on decreases sympathetic
Myocardial Infarction stimulation. On the other
as to: hand, antivertigo relieves
a. causes dizziness thru acting on
b. signs and symptoms the histamine receptors.
c. management These receptors are
d. complications found in blood vessel
walls, including those in
Advise significant the ear. By activating
others to always stay at these receptors, a
the bedside as much process is started which
as possible results in the widening of
blood vessels. This
improves circulation,
reducing the pressure in
Reinforce the the ear. It helps in
importance of relieving the inner ear
cooperation with pressure and by reducing
treatment regimen the frequency and
severity of nausea and
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vertigo attacks. It also
reduces ringing in the
ears (tinnitus) thus
helping to restore normal
hearing.
Advise to report for
signs and symptoms of
increasing BP (e.g Health education on
nape pain, blurring of patient promotes their
vision, headache) and involvement in the care
signs and symptoms of management. In addition,
hypotension it promotes compliance
(palpitation,weakness, from the patient and
decreased LOC) significant others since
they know now something
about the health
condition.
Lack of cooperation is
a common reason for
failure of antihypertensive
therapy. Effective therapy
reduces the incidence of
stroke, heart failure, renal
impairment, and possibly
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MI.
Early recognition
allows for timely
evaluation and
intervention to prevent
life-threatening
conditions.
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