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I. Introduction

Cardiovascular diseases were the most common cause of death in

the world. Base on the latest statistics, the number of people diagnose

with heart failure, which means the heart is too weak to pump blood

throughout the body is projected to rise by 46% by 2030, resulting in

more than 8 million people adults with heart failure. In the Philippine,

cardiovascular diseases are the most common causes of mortality.

According to the Department of Health (2009), about77,060 in a

100,000 population have died in the Philippines due to diseases of the

heart. The aging of the population and emerging pandemic of

cardiovascular disease in the developing nations of the world signal a

rise in the incidence and prevalence of the heart failure globally and

magnify the importance of its prevention. The prevention of the heart

failure is a urgent public health need with national and global

implications.

It is estimated that 10 percent of the global population is suffering

from chronic kidney disease (CKD). Mortality due to CKD is

increasing, it rose between 2005 and 2015 by 32% to 12 million

deaths worldwide. In 2015, Latin America had the highest CKD death

rates in the world, and in Mexico more than half of patients who

develop kidney failure did so as a result of diabetes. An additional

concern is emerging epidemics of death due to unexplained CKD in

younger adults in Central America, as well as in India and Sri Lanka.

(Horspool, 2015). In the Philippines, the numbers are just as

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disturbing. In 2013, there were only 10,000 Filipinos developing

kidney problems annually, but it has since jumped to 14,000 at

present. The DOH has since estimated an increase in the number of

kidney disease cases between 10 to 15 percent a year. While it does

not rank the highest among the top causes of death and diseases in

the country, it brings with it one of the heaviest functional and

financial burdens on an individual. According to the Philippine

Council for Health Research and Development, many Filipinos damage

their kidneys because of diabetes and hypertension.

The proponents were appointed to conduct a study on the health

problems of Ms. Maria Lily, 43 years old. He was choosen among all

the patients because of his current condition. She was diagnosed with

congestive heart failure, and chronic kidney disease.

The purpose of this study is to know the problems of the prospect

client and apply nursing process such as health teachings to the

client under the students care. In order to complete the study, the

proponents conducted a complete health history and physical,

analysis data from assessment, diagnosis problems, plan actions to

resolve problems, implement plan, evaluate progress of the plan,

makes conclusions for the result of the study being done.

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A. Rationale

Heart failure, sometimes known as congestive heart failure,

occurs when your heart muscle doesn't pump blood as well as it

should. Certain conditions, such as narrowed arteries in your heart

(coronary artery disease) or high blood pressure, gradually leave your

heart too weak or stiff to fill and pump efficiently. If you have heart

failure, your outlook depends on the cause and the severity, your

overall health, and other factors such as your age. Complications can

include: Kidney damage or failure. Heart failure can reduce the blood

flow to your kidneys, which can eventually cause kidney failure if left

untreated. This disease cause from lifestyle factors of the client such

as using tobacco, eating habits and drinking alcohol.

The proponent assessed the present condition of the client and

determine the health threat and health deficits that affects the said

prospect client. From initial to follow up assessment that was

conducted on the length of two weeks, the proponents made a

thorough assessment to get the complete data of the clients health

problem. Then, nursing interventions where performed to find

solutions or to minimize the risk of the client, and to provide health

teachings that can help the client in managing the current condition,

prevent worsening of the clients condition and to achieve optimal

health that is needed for the client. Then, nursing interventions where

performed to find solutions to minimize the health risk, and to provide

health teachings that may help the client in preventing further

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complications to happen if medical attention will be met and to

emphasize the benefits of promoting optimal health. Nonetheless,

further observation and research are still going on to minimize if not

eradicate the problems being identified. This study was conducted at a

secondary hospital in Maramag, Bukidnon. The proponents chose to

conduct their case study to the said client. The prospect client was

choosen by the help of clinical instructor. The proponents conduct

their study to the said prospect because they know that they can

gather more details and information for their case study to manage

help, to reduce risk of the prospect clients condition. The purpose of

this study is to know the problems of the prospect client and apply

nursing process such as health teachings to the client under the

students care. In order to complete the study, the proponents

conducted a complete health history and physical, analysis data from

assessment, diagnosis problems, plan actions to resolve problems,

implement plan, evaluate progress of the plan, makes conclusions for

the result of the study being done.

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B. Objectives

At the end of clinical exposure at a secondary hospital in

Maramag, Bukidnon, the proponents will be able to the care for a

client with problems in the cardiovascular system and endocrine

system, applying the concept, of nursing care and management.

Specifically the proponents are expected to do the following:

1. Gain thorough understanding about the disease process, and

the clinical manifestations of the client in response to the

disease condition.

2. Relate the medical diagnosis to the actual signs and symptoms

experienced by the client.

3. Develop a teaching plan and nursing intervention to alleviate

the client symptoms.

4. Implement the nursing care plan in caring for the client.

5. Evaluate clients improve to the treatment and nursing

interventions.
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C. Scope and Limitation

This research is conducted as a case study. The data here in is

specific only to the client assess in a secondary hospital in Maramag,

Bukidnon. Serial assessments were conducted for three occurrences

only and such will not warrant for an accurate results or impart of the

nursing intervention made by the proponents. Some of the diagnostic

and clinical records were not abstracted in it entirely because of time

and logistic constraints.

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II. Theoretical Framework

Figure II.1

The first theory we used was Florence Nightingales

Environmental theory she defined Nursing as the act of utilizing the
environment of the patient to assist him in his recovery. She linked
health with five environmental factors; pure or fresh air, pure water,
efficient drainage, cleanliness and light, especially the sunlight. This
theory was applied in order to assess the following environmental
factors that needs to be improved to minimize the possibility of
worsening the patients condition. Nightingale said that a healthy
environment is essential for healing. Since our chosen patient has a
poor immunity which makes him prone to diseases and infections and
this things are usually acquired from the environment. We focused on
altering the patients environment in order to help her attain optimum
state of wellness.

Our role in a patient's recovery is to alter the environment in

order to gradually create the optimal conditions for the patient's body
to heal itself. This would mean minimal noise and in other cases could
mean a specific diet. All of these areas can be manipulated to help the
patient meet her health goals and get healthy. Thus, the goal of the
nursing field is to provide assistance for patients in maintaining her
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vital capacity, satisfying her needs. Therefore, Nightingale shows that

nursing is a healing practice, in which the patient is placed in the best
condition for the action of nature

The environment paradigm in Nightingale's model is

understandably the most important aspect. Her observations taught
her that unsanitary environments contribute greatly to ill health, and
that the environment can be altered in order to improve conditions for

a patient and allow healing to occur.

Figure II.2

Another theory used was the theory of Virginia Henderson

where she define nursing to assist the individual in the performance of
those activities contributing to health and its recovery that he would
perform unaided if he had the necessary strength, will or knowledge.
The following are some of the components of Basic Nursing Care that
is needed for us to understand and help our chosen patient and its
family to gain independence specially of obtaining the following;
Breathe normally, Eat and drink adequately, Eliminate body wastes,
Sleep and rest, Select suitable clothes, Maintain body temperature,
Keep body clean and well groomed, Avoid dangers in environment and
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avoid injuring others. And these aspects are important in attaining the
optimum level of wellness.

Assessment is one of the part of the nursing process which is

very crucial and important. It involves collection, verification,
organization, interpretation of data collected during the process. We
used Marjory Gordons functional health pattern to provide a more
comprehensive nursing assessment to the patient. This type of
assessment tool helps or provides more specific information that we
need to plan and render or implement our prioritized nursing care. It
enables nursing individual to make a standardized and systematic
approach to data collection. This assessment tool is very specific and
views every person holistically and helps us to assess thoroughly.

The Gordons functional health pattern covers everything. First

it focuses on the persons perceived level of health and well-being. It
also identifies the actual or potential problems related to safety and
health management. It also covers the pattern of food and fluid
consumption relative to metabolic needs and identifies the actual or
potential problems related to fluid balance, tissue integrity and host
defenses as well as problems in the gastrointestinal system which is
really significant to our case. Elimination pattern that identifies
problems in excreting the wastes in the body. It also assesses the
activity level, exercise program, and leisure activities. Sleeping
pattern is also assessed and problems are identified. It also assesses
the ability of an individual to understand and follow directions, retain
information, make decisions, and solve problems. It also assesses the
perception of ones self, the relationship of an individual towards
his/her family, its sexuality and reproductive pattern if its
appropriate to age and situation. Assessing the values and beliefs of
an individual is also important in order to know how to deal with the
patients situation.

We also used some development theories that helps as provide a

framework for the psychosocial profile. Identifying the patients
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developmental stage will help to determine the relationship between

patients health status and his growth and development. First is
Sigmund Freuds psychosexual theory which is one of the best known,
but also one of the most controversial. Freud believed that personality
develops through a series of childhood stages during which the
pleasure seeking energies of the id become focused on certain
erogenous areas. This psychosexual energy, or libido was described as
the driving force behind behavior. These psychosexual stages are
completed successfully, the result is a healthy personality. If one of
this specific stage are not attained problems may occurred that cause
fixation. Until this conflict are not resolved the individual may get
stuck on the specific stage.

Hendersons concept of nursing is widely accepted in nursing

practice today. Her theory and 14 components are relatively simple,
logical, and can be applied to individuals of all ages. Hendersons
Needs Theory can be applied to nursing practice as a way for nurses
to set goals based on Hendersons 14 components. Meeting the goal of
achieving the 14 needs of the client can be a great basis to further
improve ones performance towards nursing care.
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Figure II.3

Next theory is Dorothea Orems Self-Care Deficit Theory, the

Self-Care Deficit Theory developed as a result of Dorothea E.
Orem working toward her goal of improving the quality of nursing in
general hospitals in her state. The model interrelates concepts in such
a way as to create a different way of looking at a particular
phenomenon. The theory is relatively simple, but generalizable to
apply to a wide variety of patients. It can be used by nurses to guide
and improve practice, but it must be consistent with other validated
theories, laws and principles. This theory focuses on the performance
or practice of activities that individuals initiate and perform on their
own behalf to maintain life, health and well-being.

Moreover, this theory signifies that all patients want to care for
themselves, and they are able to recover more quickly and holistically
by performing their own self-care as much as theyre able. This theory
is particularly used in rehabilitation and primary care or other
settings in which patients are encouraged to be independent.

Though this theory greatly influences every patients

independence, the definition of self-care cannot be directly applied to
those who needs complete care or assistance with self-care activities
such as the infants and the aged.
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III. Assessment Data

D. Physical Assessment

a. General Survey:

The patient appears older than actual age. During assessment

the patient is cooperative, responsive, conscious, calm and joyful. The
patient had a lack of subcutaneous fat with prominent bones, edema
in both extremities, pale and dry lips, prominent eye bags, kyphosis,
imbalanced movement upon walking, tremors in the hand, distended
neck veins, fatigue, weakness, blurred vision, oliguria, nocturia,
tachycardia, tachypnea, dyspnea, hypertension, back and chest pain
with pain scale of 6/10 and guarding behaviour.

b. Integumentary

Upon inspection evenly colored of skin tones without unusual or

prominent discoloration. Skin is intact, and there are no reddened
areas. I- Rounded and smooth skull contour, symmetric facial
features and symmetric facial movements. Hair evenly distributed in
the eyes, eyebrows symmetrical aligned. Auricle aligned with outer
cantus of eye. Pale lips, dry skin, poor hygiene, edema in both
extremities, scaly skin and no lesions are noted. Nails are not clean,
pink tones seen, 180-degree angle, thickened nails and nails are
rough and firm. Symmetrical scalp and head. It is smooth and firm.
Head size and shape is normocephalic, no lesions are visible and the
face is symmetric with no abnormal movements noted. Able to hear
ticking on a right ear at a distance of one inch and was able to hear
the ticking on the left ear at the same distance. Neck is symmetric,
with head centered and with distended neck veins. The patient
experienced blurry vision. Ears are equal in size bilaterally, the
auricle aligns with the corner of each eye and within 10-degree angle.
Have dental caries, missing teeth and no lesions or masses present.
Upon palpation the patient skin is rough, flaky, dry skin, thin skin,
warm to touch, skin rebounds and does not remain indented when
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pressure is released, no lesions palpated. Skin is warm to touch

bilaterally. Hair is natural in color with white-colored hair, scalp is
clean and dry, and hair is smooth and firm. Nails are rough and firm,
nail plate is attached to nail bed, and there is slow capillary nail bed
refill of 3 seconds. There is no swelling or enlargement and tenderness
in the throat, face, ears and head is noted. Percussion is not possible.
No bruit sound noted in the thyroid area upon auscultation.

In the 2nd day assessment the patient had slightly moist skin,
hygiene is fair, scaly skin, nails are clean, pink tones seen, 180-degree
angle, thickened nails and nails are rough and firm. Distended neck
veins. The patient do not have blurry vision but is near sighted. Have
dental caries. Upon palpation skin is rough, slightly moist skin,
normal skin turgor, and normal capillary refill. No Bruit sound noted
in the thyroid area.

c. Respiratory

Upon inspection Diaphragm and the external intercostal

muscles do most of the work of breathing. Spinous processes appear
straight, and thorax appears symmetric, ribs and bones are visible.
Nasal flaring is seen with the use of accessory muscle upon breathing,
dyspnea, shortness of breathing, cough, tachypnea RR= 35cpm, rapid
shallow breathing and scapulae are symmetric and non-protruding.
Equal chest expansion. Upon palpation clients reports no tenderness,
pain, or unusual sensations. Theres a full and symmetric expansion
and the thumbs separate 2-3 cm during deep inspiration when
assessing for the respiratory excursion. Upon percussion elicits flat
tones over the scapula. Resonance tone elicited over lung tissue. Rales
is noted upon auscultation.

On the on-going assessment there were no nasal flaring is

noted, slightly using accessory muscle, no dyspnea is noted due to the
supplied oxygen at place, rapid shallow breathing, RR= 25 cpm,
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occasional cough is noted. There were no significant changes from the

baseline up to present.

d. Cardiovascular

Upon inspection distended jugular veins is noted, no blowing or

swishing sounds heard and grade 2+ pitting edema in both extremities
and chest pain. Upon palpation pulses are equal strength bilaterally,
weak pulses, tachycardia /HR= 128 bpm, toes, feet, and legs are
equally warm bilaterally, no lesion and tenderness noted. Slow
capillary nail bed refill that returns 3 seconds. No bruit sound heard.

In the 2nd level of assessment the patient still on distended jugular

veins, grade 1+ pitting bipedal edema and mild chest pain with the
pain scale of 4/10. The heart rate was in normal range, HR= 89 bpm.
Normal capillary refill.

e. Gastrointestinal

Upon inspection normal paler, with white striae, fine veins

observable and no rashes or lesions is noted. Umbilicus is centrally
located and pinkish in color. Abdomen is rounded, symmetrical, no
movement or slight peristalsis visualized over aorta. Stool is brown in
color, hard and impacted. Nausea, vomiting, anorexia, and weight
loss. Upon palpation the patient had a generalized tympany over
bowel, no pain and tenderness, no masses upon palpation. Upon
percussion tympany over the stomach and dullness especially over the
liver and spleen. No increase in abdominal girth, no fluid wave
transmitted, and level of dullness does not change. No bruit, no
venous hums, and no friction rub upon auscultation.

In the on-going assessment the patient vomited once with 50

mL level, stool is soft and yellow in color. There were no significant
changes noted.
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f. Urinary System

Upon inspection labia is equal in size, free of lesions, smooth, loose

skin and pink in color. Urinary meatus is small, slit like, anterior to
vaginal orifice and in midline. Yellow-orange urine, nocturia and
oliguria is noted. The patient is in Catheter. Upon palpation No pain,
tenderness, masses is noted. No bulging, no swelling, vaginal wall is
smooth without tenderness. Cervix feels firm and soft like the tip of
the nose.

In the on-going assessment the patients urine is yellowish in color.

Oliguria with 150 mL urine output. There were no significant changes
from the baseline data up to the present.

g. Musculoskeletal

Upon inspection the patient is thin. Toes Client able to do flexion,

extension, abduction and adduction, external rotation, and internal
rotation but limited to weigh heavy objects. Wrist and elbows are
symmetric, without redness and swelling. They are not tender and free
of nodules. Kyphosis, posture is stooped, limited ROM with pain and
SOB, uneven weight bearing is evident, back pain, there is no visible
bony overgrowth, swelling, redness, or joint is non-tender. Shoulder,
elbow, hand, and fingers are bilaterally symmetrical. Foot and ankle
have edema and decrease in ROM. Easy fatigability and weakness.
Upon palpation decrease muscle strength, the clients mouth opens
and closes smoothly, jaw protrudes and retracts easily, bony
landmarks are bilaterally symmetrical and equal, warm and no
tender.

In the on-going assessment the patient is very thin in appearance,

kyphosis, less SOB, unbalanced gait, less pain in chest and back with
pain scale of 4/10, edema in foot and leg is grade 1+ pitting bipedal
edema, limited ROM, easy fatigability, resolved with sleep and rest. No
other unusualities noted.
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h. Neurologic

Upon inspection the patient was alert and awake with eyes open
and looking at examiner; client responds appropriately with soft and
low-tone voice, tremors in the hand and has a slow movement. Wear
dirty clothes, large shirt, dirty nails, foul odors, good eye contact,
smiles/frowns appropriately, expresses dissatisfaction with self,
expressed thoughts are jumbled, confusing, indecisive, inconsistent
information given, is unable to follow through with directives,
inaccurate answer to question asked, expresses incomplete thoughts,
unable to recall any past events, does not know to how to write, aware
of self, others, place, time; had address, identifies similarity in bees
and birds, and has a long attention span. Identifies scent correctly
with each nostril, eyelids blink bilaterally, identifies light touch, dull,
and sharp sensation, muscles contract bilaterally, diminished taste,
gag reflex present, symmetrical rise of soft palate and uvula and
unsteady gait. Tongue movements is symmetric, smooth, and bilateral
strength is apparent. Client touches each finger to the thumb with
tremors. Client cannot rapidly turns palms up and down. Able to
identify hot and cold water.

In the on-going assessment the changes noted from the baseline

data are the patients hygiene improved having less bad body odor.
During assessment the patient was in O2 cannula, responsive, calm
and conscious. There were no changes noted from the baseline data.

i. Reproductive System

Upon inspection the patient was negative on sexually transmitted

infection, reported negative on pain upon urination, no any genital
problem, and no any discharges noted. Free of nodules and masses
upon palpation.

There were no significant changes from baseline data up to the

present.
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E. Family History (Genogram)

Maria Lily is a 47-year old female, alive and well. He had an eldest
brother but was deceased due to chronic kidney disease by the age of
78. Her second sibling female, suffered toxic goiter for 10 years died at
the age of 60 years old. Her third and fourth siblings male and female
are living well with the age of 54 and 50 years old respectively.

His father was deceased due to stroke. His uncles, on his fathers
side, were also deceased by the age of 80 due to hypertension. His
mother was deceased due to CVA by the age of 62. His uncle, on his
mothers side, was deceased due to hypertension. Maria Lily doesnt
remember his grandparents on his both mother and fathers side.
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F. Growth and Development

Maria Lily is under Sigmund Freuds stage of Genital. She is 47

years old and is in the adulthood stage. She has passed the fantasy of

being directed towards own body, she has directed outward toward a

genuine love relationship focused on heterosexual genital sex. The

patient has a live in partner and 9 siblings.

She is also under Erik Eriksons stage of Middle Adulthood (35-50

years old) which is Generativity versus Stagnation. She is not that

productive due to lifestyle of alcoholism and smoking. She is currently

a housewife. She is starting to leave a legacy. Thus, the patient is not

in the state of stagnation but is in generativity.

Jean Piagets Formal Operational falls under Marias stage. She

reached this stage of intellectual development wherein she is able to

logically use symbols related to life concepts. But because of lack of

education, she academically doesnt know a lot of things. She cant

even decide on what to do.

Kholbergs Level III Post conventional Morality which is Stage 5

Social Contact and Individual Rights falls under the clients stage. She

is not that disciplined and responsible citizen due to vices and does

not cooperate in social activities.

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G. Gordons Functional health pattern

a. Health Perception- Health Management

29 days up to date (December 20, 2017) the patients reason for

seeking health care is grade 2+ bipedal pitting edema, back and chest

pain, hemoptysis, and dyspnea. The rate of the health of the patient is

poor. . She had difficulty of coping up in her illness because she is

careless about her health as she keeps on eating high salt food, high

fat food, drinking alcohol and smokes even she was carrying a chronic

illness. She has inability to move due to the weight and pain of her leg

that affects her activity in daily living. Upon movement she has

shortness of breathing even in walking short distances. She drinks

alcohol 4-6 glasses a week. She has been smoking for almost 35 years

starting 12 years of age and stopped 3 months ago ( September,

2017). She used 3 sticks per day. She had no history of accidents and

surgery. She had an incomplete immunization. She rarely visits a

doctor to have a check-up and seek for medical assistance. When sick,

goes to manghihilot or just waits for the sickness to heal.

30 days up to date the patient is suffering dyspnea, chest and back

pain, and grade 2+ pitting bipedal edema. The rate of the health of the

patient is fair. She was on low salt, low fat and soft diet and it was

properly managed and followed. She is currently supplied by oxygen

through face mask connected into oxygen tank to provide enough

oxygenation to resolved problem in dyspnea. She was hesitant to

ambulate because of the attached IV and catheter. She thinks that it

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will be unattached and the IV will be dislodged. She experienced SOB

upon movement short distances.

31 days up to date the patient is suffering less dyspnea, less chest

and back pain, and grade 1+ pitting bipedal edema. She can breathe

by herself but have a scheduled O2 inhalation through nasal cannula.

She can eat by herself and can move slightly in short distances having

less SOB. The rate of the health of the patient is fair. She was able to

swallow food without difficulty, eat properly with proper adherence to

the prescribed diet.

b. . Nutritional- Metabolic Pattern

29 days up to date the patient eats rice, cow meat, vegetables,

dried fish, fish and coconut. She is eating 3 times day but sometimes

she only eats once a day. The patient loss weight 67kg to 40 kg.

Height is 411. BMI is 17.8= Underweight. She drinks 1-3 glass per

day. She had loss of appetite because she cannot taste the food well

and had a feeling of fullness (anorexia), nausea and vomiting. She had

difficulty of swallowing because she felt that her throat was obstructed

upon swallowing. She had scaly and dry skin. No lesions presence.

She had dry and pale lips. She had dental cavities and had an

incomplete set of teeth. No dentures used.

30 days up to date the patient eats rice, vegetables and meat.

She is on low salt, low fat diet. She ate 3 times a day. She has loss of
 21

appetite and cannot taste the food well. She vomited for about 50 mL.

She has less difficulty swallowing. She had dry and scaly skin. She

maintains her weight = 40 kg. She drinks 4 glass of water.

31 days up to date the patient breakfasts are rice and fish. The

patients lunch are rice, spaghetti, and beef steak. The patients

dinners are rice, sinabawang isda and pinakbet. She can swallow the

food properly. She drinks 5-7 glass. She was able to eat whole share of

meal with good appetite as the patient can slightly taste the food.\

c. Elimination Pattern

29 days up to date the patient defecates once a day. It is a little

hard, yellowish in color, no blood and pain is noted. No laxatives

used. The patient is using catheter .Urine is reddish in color. It has

100 mL urine output. No pain, lesions, masses in the abdomen and

rectum is noted.

30 days up to date the patient does not defecate during the

shift. She was on catheter with yellow-colored urine. She had 150 mL

urine output for 12 hours.

31 days up to date the patient defecates once in the morning

having soft stool, no blood present and no pain upon defecation. The

patient was on catheter having yellowish-colored urine. She had 200

mL urine output for 12 hours. No pain, lesions, masses in the

abdomen and rectum is noted.

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d. Activity- Exercise Pattern

29 days up to date the patient energy is not sufficient for

desired activities. She walks seldom in short distances. She is

sleeping, resting, watching television, and talking to her husband in

her leisure time. Before the occurrence of disease, the patient went to

their farm to weed, cooked and does the household chores. The

patients hygiene is poor, she had a bad odor, and she has untidy

appearance and requires assistance to bathe and toileting. She can

feed and dress herself. The patience gait and balance is not properly

managed. She can pick up a light objects but unable to carry heavy

objects. She had an episode of dyspnea and chest pain. Walking is the

only exercise she had been doing. She is a housekeeper and the

illness affects greatly her capability to do activities.

30 days up to date the patient energy is slightly sufficient for

desired activities. She was able to walk with less SOB. She doesnt

want to walk because she have catheter and IV attached and she feel

nuisance about it. The patient requires assistance to significant others

to walk, bathe and toileting. She keeps staying on her bed but able to

sit. The patients hygiene is fair, she has untidy appearance. She had

an unbalanced gait.

31 days up to date the patients energy is slightly sufficient for

desired activities. She can walk in short distances with less dyspnea.
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The patient gait is not properly balanced and posture is stooped or

kyphosis. She was able to walk around the room.

e. Sleep-Rest Pattern

29 days up to date the patient sleeps 9pm in the evening and

wakes up 5am in the morning. She had an interrupted sleep due to

nocturnal, coughing and noise in the surroundings. Sometimes she

takes a nap during noon time for about 1-2 hours. No medication to

promote sleep. She has a long attention span.

30 days up to date the patient sleeps 11pm in the evening and

wakes up 5am. She had an interrupted sleep due to the noise. She is

able to take a nap during afternoon for about 30 minutes to 1 hour.

No medication to promote sleep.

31 days up to date the patient sleeps 10pm in the evening and

wakes up 5 am in the morning. She had an interrupted sleep due to

the noise.

f. Cognitive-Perceptual Pattern

29 days up to date the patient perceived her illness as Beriberi

and hoping to be treated in the hospital. She has a low-tone voice.

She lacks the ability in expressing herself and gave inconsistent

information. She had a hard time to recollect or recall past events,

relatives/family names and important matters that concern her life.

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She is indecisive and slow learner. Able to hear ticking of the clock

and resulted positive in tick tock test. She has no difficulty of hearing

and able to hear whisper. She has changes in memory and is forgetful.

Pain in the Medio-lateral in the thoracic area that radiates in the left

shoulder to the back. The patient experience chest pain and back

pain. She endures the pain and tries to resist it until it is gone.

Patient appears calm, responsive, cooperative and weak and very thin

in appearance. She doesnt able to grasp ideas and questions instantly

and do not answer questions accurately. She has a hand tremor.

Attention span is longer.

30 days up to date pain scale of pain in chest and back pain is

4/10.

No further changes.

31 days up to date the patient voice is in normal tone that the

listener was able to hear clearly.

g. Self-PerceptionSelf Concept Pattern

29 days up to date the patient describes herself as a sick

person, a person that needs treatment, thin in appearance, old,

talkative, and friendly. She can weed, eat sugarcane, energetic and

can do a lot of things before the occurrence of disease. She missed

doing the activity and understands the limitation she had. She will

become angry when her children are hard-headed. She maintains eye
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contact. Low- tone voice and speech is good. Body Posture is stooped.

Gait is not good.

30 days up to date the patient perceived that she is well. She

thinks that she is okay because she doesnt have oxygen attached to

her. Mas okay naman ko kaysa gahapon kay wala naman koy

oxygen as verbalized by the patient. She is slightly bored to the

hospital. Low-tone voice but is enough to be heard. Body posture is

stooped. Gait is unbalanced.

31 days up to date the patient verbalizes that okay naman

akong paminaw gamay nalang nga sakit-sakit akong ginabati pero

kaya raman. She perceived that she is okay.

h. Roles-Relationship Pattern.

29 days up to date the patient is married. She is a mother of a 9

children. As a mother and a wife, she had a great responsibility to

take good care of her loved ones but it is affected by her illness. Her

husband died but she found her new partner. She lives with her live-

in partner and her brother. Her children send money to sustain the

needs of the patient. She is friendly and is close to their neighbors in

their barangay.

30 days up to date the patient was accompanied by her live-in

partner. She is now executing the role as a patient where she needs to

drink medication on time and follow the health care providers

 26

command. She is not that sociable because she only talks to her

husband.

31 days up to date the patient was with her live-in partner and

brother. She was blessed and happy because she was accompanied.

i. Sexuality-Reproductive Pattern

29 days up to date the patient menstrual period is 15 years old.

Last Menstrual period is 40 years old. Gravida 9 Para 9. In her new

live-in partner, the patient is not satisfied because the patients live-in

partner is sterile. They are unable to produce child. No significant

changes.

j. Coping-Stress Tolerance Pattern

29 days up to date the Patients Big Crisis in her life is her

illness and when all her children didnt live with her. Her live-in

partner is the most helpful in taking things over. He is the one who

will find a ways and solution in every problem they encounter. She

will pray to God for guidance and help.

30 days up to date the patients crisis in her life is her illness

and her financial status. Though, her children sends money to sustain

the needs of their mother but it is not enough because the patient

seldom received money from them. Her live-in partner is the most
 27

helpful in taking things over. He is the one who will find solutions in

every problem they encounter.

31 days up to date the patient stated no crisis. She thinks that

she is well. She had money to spend and saved.

k. Values-Beliefs Pattern

29 days up to date the patient wants to be treated and be back

from normal self. She does not want to dream big. She just wants to

eat 3 times a day and to go to mass every Sunday and to avoid

drinking alcoholic beverages.

30 days up to date the patient wants to go home. She feels

bored.

31 days up to date the patient is satisfied because she has

money to spend and better food to eat. But sometimes, she feels

uncomfortable because of the rooms humidity.

 28

l. Review of Systems

a. Integumentary System

Pale lips, dry and scaly skin, poor hygiene, edema in both

extremities with grade 2+ pitting, scaly skin and no lesions are

noted. Nails are not clean, pink tones seen, 180-degree angle,

thickened nails and nails are rough and firm. Distended neck

veins noted. The patient experienced blurry vision. Have dental

caries, missing teeth and no lesions or masses present. Upon

palpation the patient skin is rough, flaky, dry skin, thin skin,

warm to touch, skin rebounds and does not remain indented

when pressure is released. There is slow capillary nail bed refill

of 3 seconds. The patient has difficulty in swallowing, or

dysphagia. She also has prominent eye bags and near-

sightedness.

b. Cardiovascular and Peripheral System

The patient has distended neck veins, tachycardia with

heart rate of 128bpm, back and chest pain, 180-degree nail bed,

slow capillary refill of 3 seconds and weak pulse.

c. Respiratory System

Nasal flaring is seen with the use of accessory muscle upon

breathing, dyspnea, shortness of breathing, cough, tachypnea RR=

 29

35cpm, rapid shallow breathing and scapulae are symmetric and

non-protruding.

d. Gastrointestinal System

The client had experience nausea, vomiting, anorexia and

weight loss as verbalized by the significant others. She has a

weight of 40kgs which is low for age and an underweight BMI of

17.8.

e. Urinary System

She experienced oliguria and nocturia. There were then

no other anomalies.

f. Musculoskeletal System

Client observed to have insufficient muscle tone, tremors,

unstable gait, kyphosis, fatigue, weakness and limited to weigh

heavy object.

g. Neurological System

The client was observed as having confusion, unable to

follow through directives, inaccurate answer and unable to

recall past events.

 30

h. Reproductive System

The client has no history of undescended testicle, or

hernia. The client has no history of anus or rectum disease

condition.
 31

IV. Doctors Order

Date and Doctors Order Rationale

time
October Please admit To diagnosis the diseases
31, 2017 and underlying
9 pm complications of the
patient.
Secure Consent To give treatment to the
patient legally. Securing
consent will ensure that
the patient understand
her condition.
v/s q 4h To monitor if there is
abnormal fluctuation in
the normal range of the
patients vital signs.
I & 0 q shift Monitoring input and
output will determine if
the intake is equal to the
substance excreted by
the patients body. This
is to know if there is
kidney failure.
Patient Bipedal edema, The patient diagnosis for
dyspnea, cap excess fluid volume in
her extremities and
difficulty of breathing
due to Community
Acquired Pneumonia.
Diet, NPO temporarily The patient experienced
vomiting upon
admission. To prevent
further vomiting it is
needed to have NPO
laboratory test temporarily.
Laboratory tests are one
of the basis to diagnose
CBC certain diseases.
CBC is to indicate if
there are abnormalities
UA in the blood components.
Urinalysis is to indicate
if there is abnormalities
Na+K in the patients urine.
Checking the Sodium
and potassium levels of
the body to determine if
 32

there are electrolytes

imbalances.
Serum creatinine To determine if
creatinine levels are low,
or high and any
alterations in the
creatinine levels are
indication for kidney
failure.
Chest XR PA Chest X-ray is a
diagnostic test to be able
to see if there are
abnormalities noted in
the Posterior Anterior
chest area.
ECG ECG is to determine the
abnormalities in the
defibrillator and the
pacemakers of the heart.
SGPT SGPT is an enzyme that
is normally present in
liver and heart cells.
SGPT is released into
blood when the liver or
heart is damaged.
Increase
RBS To know the level of the
glucose in the blood
level.
IVF PNSS iL @ KVO To provide hydration to
(Micro set ) the patient and to
replace the fluid and
electrolytes losses in the
body
SD Dobutamine drip Dobutamine was
(D5W 200cc + iiL caps administered to
dobutamine) 10 cc/hr increased cardiac
output, blood pressure
and heart rate, as well as
decreased peripheral
vascular resistance.
02 inhalation @ 4- To provide adequate
6L/min via nasal oxygen saturation
cannula throughout the
circulation of the body.
And to treat the dyspnea
and shortness of
breathing of the patient.
moderate high back rest Moderate high back rest
 33

is a position to maintain
a proper airway
breathing of the patient.
chest physiotherapy Chest physiotherapy is
to promote a proper
breathing therapy to the
patient.
Refer for any vomiting Refer the patient if
vomiting persist to
properly intervene the
fluid loss of the patient
Refer to any IM on call Refer to specialist to
provide a special
treatment or a more
accurate assessment to
BP 15 100/60, Give the patient.
Furide 40mg 1oading
dose then 20mgs q 8h

Increase dobutamine Dobutamine was

drip @ 30cc/hr 10 units administered to
per hour q 8hs to increased cardiac
achieve BP of >90/60 output, blood pressure
w/ digoxinof 50cc/hr and heart rate, as well as
decreased peripheral
vascular resistance.
If BP is still Norepinephrine
<90/60mmhg, start Stimulate nervous
Norepinephrine drip system by combining
(8mg Norepinephrine + with either alpha-
100cc D5W ) @ 10cc/hr, adrenergic or beta-
@50cc/hr 10 units w/ adrenergic receptors. It
Moxan of30cc/hr is increased cardiac
output, blood pressure
and heart rate, as well as
decreased peripheral
vascular resistance.
ceftriazone 2 gms IV OD Inhibits cell-wall
ANST synthesis, promoting
osmotic instability;
usually bactericidal. It is
to kill the bacteria
present in the patients
body. To lower the WBC
in the body.
Amlodipine 150cc IV Inhibits synthesis of
bulus now prostaglandins by
10pm cyclooxygenase; inhibits
 34

Aspirin 80mg OD PO 1st platelet aggregation; has

dose ms antipyretic and analgesic
November activity. It is indicated to
1, 2017 lessen the pain felt by
12:45am the patient.
S.0 appraisal of patient To be able the significant
8Am condition others to know the
condition of the client.
3pm To ICU Transferring the patient
to Intensive care unit, to
monitor closely the
patients condition.
Insert FBC To measure the urine
output of the patient.
NPO except meds NPO to prevent episodes
of vomiting.
Digoxin 0.25mg IVTT Inhibit the sodium-
now then OD potassium activation of
adenosine triphosphate,
which regulates the
amount ofsodium and
potassium inside the
cell.
Promote movement of
calcium from
extracellular to
intracellular cytoplasm
and strengthens
myocardial contractility.
Act on the central
nervous system to
enhance the vagal tone,
slowing contractility
through the SA and AV
nodes. it is to normalize
the patient BP, HR, and
to treat the edema of the
patient.
Ketoanaloque tab TID The plasma kinetics of
PO
amino acids under their
integration in metabolic
pathways is will
establish. It is indicated
to be able to excrete
urine and treat the
 35

oliguric condition of the

patient.
5:15pm for FBS, Lipid profile, To know the if there are
ABG
any alterations on
November fasting blood sugar, fat
2, 2017 distribution, and the
3:15pm acid-base balance of the
patient.
Refer the patient to
Refer intervene closely the
patient abnormal
conditions.
Omeprazole 40mg IVTT Block gastric acid
now then OD secretion by inhibiting
acid pump in gastric
parietal cells.
Furosemide to 20mg Loop diuretic; inhibits
IVTT q 8hrs
reabsorption of sodium
an chloride ions at
proximal and distal renal
tubules and loop of
Henle; by interfering with
chloride-binding
cotransport system,
causes increases in
November water, calcium,
3, 2017 magnesium, sodium and
3:20pm chloride.
continue other meds To treat the patients
condition
To check the patients
for 2D-echo w/ poppler
once stable heart condition upon
doing the 2D echo test
May have soft diet To easily digest the food
intake
Refer Refer the patient to
intervene closely the
patient abnormal
conditions.
D/c Norepinephrine drip Discontinue the
once consumed Norepinephrine because
the patient BP is at
normal range
 36

D/c Dobutamine drip Discontinue the

once consumed, Dobutamine because the
provided BP is >90/60 patient HR is at normal
range
Shift Digoxin IV to Inhibit the sodium-
Digoxin ) 0.25mg tab, 1 potassium activation of
tab OD adenosine triphosphate,
which regulates the
amount ofsodium and
potassium inside the
cell.
Shift Furosemide IV to Loop diuretic; inhibits
Furosemide 40mg tab, 1 reabsorption of sodium
tab OD an chloride ions at
proximal and distal renal
tubules and loop of
Henle; by interfering with
chloride-binding
cotransport system,
causes increases in
water, calcium,
magnesium, sodium and
November chloride.
4, 2017
Decrease mucus
3:20pm Acetylcysteine 600mg
tab, 1 tab in glass viscosity by breaking or
H20 OD altering the chemical
bonds of glycoprotein
complexes in mucus
Shift Omeprazole IV to Block gastric acid
Omeprazole 40mg cap, 1 secretion by inhibiting
cap OD
acid pump in gastric
parietal cells
refer Refer the patient to
intervene closely the
patient abnormal
conditions.
D/c Norepinephrine drip BP and HR are within
once consumed
normal limits
November
6, 2017
9:35
Up titrate Dobutamine Stimulate nervous
if BP is <80/60 system by combining
 37

with either alpha-

adrenergic or beta-
adrenergic receptors.
Broad-spectrum,
Tevofloxacin 500mg 1
tab OD systemic antibacterial
action; active against a
wide range of organisms.
Refer Refer the patient to
intervene closely the
patient abnormal
conditions.
November Repeat S-creatinine, To check if there are
7, 2017 CBC abnormalities in the
2:10pm blood components and
creatinine level of the
body
Digoxin 0.25mg tab to Inhibit the sodium-
tab OD
potassium activation of
adenosine triphosphate,
which regulates the
amount ofsodium and
potassium inside the
cell.
for possible trans-out
To transfer the patient
tomorrow
refer back to ward
Refer the patient to
intervene closely the
patient abnormal
conditions.
Trans-out to Cardio To transfer the patient
Ward
back to ward
Summary of meds Loop diuretic; inhibits
1. Furosemide 40mg tab, reabsorption of sodium
tab OD an chloride ions at
proximal and distal renal
tubules and loop of
Henle; by interfering with
chloride-binding
cotransport system,
causes increases in
water, calcium,
magnesium, sodium and
chloride.
 38

2. spironolactone 25 mg Antagonizes aldosterone

tab, 1 tab OD in the distal tubules,
increasing sodium and
water secretion.
3. Aspirin 80mg tab, 1 tab Inhibits synthesis of
OD p.c. lunch prostaglandins by
cyclooxygenase; inhibits
platelet aggregation; has
antipyretic and analgesic
activity
Inhibits cell-wall
4. Ceftriaxone 2gms IV OD
synthesis, promoting
osmotic instability;
usually bactericidal
5. Levofloxacin 500 mg Broad-spectrum,
tab, 1 tab OD systemic antibacterial
action; active against a
wide range of organisms.
6. Acetylcysteine 600mg
tab, 1 tab in glass Decrease mucus
H20 OD viscosity by breaking or
altering the chemical
bonds of glycoprotein
complexes in mucus.
Histamine H1-receptor
7. Cetirizine 10mg tab, 1
9pm tab oD at HS antagonist; competes
with histamine on
November effector cells in the
8, 2017 gastrointestinal tract,
10am blood vessels and
respiratory tract
Still for 2D echo w/ poppler
To check the patients
heart condition upon
doing the 2D echo test
Refer for BP <80/60mmhg To intervene closely the
Blood pressure of the
patient
O2 to prn To administer oxygen
enough to sustain the
November
9, 2017 Refer body needs.
3pm Refer the patient to
intervene closely the
5pm patient abnormal
conditions.
 39

IVFTF PNSS 2L @ KVO rate To provide hydration to

the patient and to
replace the fluid and
electrolytes losses in the
body
November Still for 2D-echo Doppler To treat the conditions
10, 2017 Continue Medictions To provide hydration to
12:40pm IVFTF PNSS 1L @ SR the patient and to
replace the fluid and
electrolytes losses in the
body
November Refer the patient to
11, 2017 Refer
intervene closely the
11:35am
patient abnormal
conditions
Dobutamine drip (D5W Stimulate nervous
250cc + 1 amp system by combining
Dobutamine) @ 10cc/hr with either alpha-
adrenergic or beta-
adrenergic receptors.
Continue Medications
To treat the patient
conditions
IVFTF PNSS 1L @ SR
To provide hydration to
November
the patient and to
12, 2017
10am replace the fluid and
electrolytes losses in the
body
IVFTF PNSS 1l @ SR To provide hydration to
the patient and to
replace the fluid and
electrolytes losses in the
body
TF Dobutamine drip with Stimulate nervous
November SR (as previously ordered system by combining
13, 2017
with either alpha-
11 am
adrenergic or beta-
adrenergic receptors.
Continue Other meds To treat the patient
conditions
Resume dobutamine drip @ Stimulate nervous
10cc/hr system by combining
with either alpha-
adrenergic or beta-
adrenergic receptors.
 40

Limit Oral Fluid Intake to To lessen the edema of

1L/day the patient.
Continue other meds To treat the patient
conditions
IVFTF PNSS iL @ SR To provide hydration to
the patient and to
replace the fluid and
electrolytes losses in the
November body
14, 2017 Still for 2D-echo with To check the hearts
9am droppler condition of the patient
Refer Refer the patient to
intervene closely the
patient abnormal
conditions.
Inhibits cell-wall
Ceftriaxone to CONIDIME
synthesis, promoting
osmotic instability;
usually bactericidal
Discontinue levofloxacin Broad-spectrum,
systemic antibacterial
action; active against a
wide range of organisms.
WBC within normal
November
range
15, 2017
10am IVFTF PNSS iL @ SR To provide hydration to
the patient and to
replace the fluid and
electrolytes losses in the
body
Facilitate 2D echo with To check the hearts
Doppler condition of the patient
To treat the patient
Continue medications conditions
To provide hydration to
November IVFTF PNSS iL @ SR the patient and to
16, 2017 replace the fluid and
electrolytes losses in the
body
Continue medications
To treat the patient
conditions
IVFTF PNSS iL @ SR To provide hydration to
the patient and to
replace the fluid and
electrolytes losses in the

ECG 12 lead
O2 via mask @ 8Lpm
Repeat creatinine
Give Ketorolac 3omg IVTT
now
Continue Meds
IVFTF D5NSS 1L @ SR
Continue medications
IVFTF PNSS iL @ SR
Refer
41
body
ECG is to determine the
abnormalities in the
defibrillator and the
pacemakers of the heart.
To provide adequate
oxygen saturation
throughout the
circulation of the body.
And to treat the dyspnea
and shortness of
breathing of the patient.
To determine if
creatinine levels are low,
or high and any
alterations in the
creatinine levels are
indication for kidney
failure.
Inhibits synthesis of
prostaglandins in body
tissues by inhibiting at
least 2 cyclo oxygenase
(COX) isoenzymes, COX-
1 an COX-2.
To treat the patient
conditions
To provide hydration to
the patient and to
replace the fluid and
electrolytes losses in the
body
To treat the patient
conditions
To provide hydration to
the patient and to
replace the fluid and
electrolytes losses in the
body
Refer the patient to
intervene closely the
patient abnormal
conditions
 42

V. Diagnostic and Laboratory Test

 43

VI. Anatomy and Physiology

a. Cardiovascular System

To understand what occurs in heart failure, it is useful to be familiar with

the anatomy of the heart and how it works. The heart is composed of two

independent pumping systems, one on the right side, and the other on the left.

Each has two chambers, an atrium and a ventricle. The ventricles are the major

pumps in the heart.

The external structures of the heart include the ventricles, atria, arteries,

and veins. Arteries carry blood away from the heart while veins carry blood into the

heart. The vessels colored blue indicate the transport of blood with relatively low

content of oxygen and high content of carbon dioxide. The vessels colored red

indicate the transport of blood with relatively high content of oxygen and low content

of carbon dioxide.

The Right Side of the Heart

The right system receives blood from the veins of the whole body. This

is "used" blood, which is poor in oxygen and rich in carbon dioxide. The right atrium

is the first chamber that receives blood. The chamber expands as its muscles relax

to fill with blood that has returned from the body. The blood enters a second

muscular chamber called the right ventricle. The right ventricle is one of the heart's
 44

two major pumps. Its function is to pump the blood into the lungs. The lungs

restore oxygen to the blood and exchange it with carbon dioxide, which is exhaled

The Left Side of the Heart

The left system receives blood from the lungs. This blood is now oxygen rich.

The oxygen-rich blood returns through veins coming from the lungs (pulmonary

veins) to the heart. It is received from the lungs in the left atrium, the first chamber

on the left side. Here, it moves to the left ventricle, a powerful muscular chamber

that pumps the blood back out to the body. The left ventricle is the strongest of the

heart's pumps. Its thicker muscles need to perform contractions powerful enough to

force the blood to all parts of the body. This strong contraction

produces systolic blood pressure. The lower number (diastolic blood pressure)

is measured when the left ventricle relaxes to refill with blood between beats. Blood

leaves the heart through the ascending aorta, the major artery that feeds blood to

the entire body.

The Valves

Valves are muscular flaps that open and close so blood will flow in the right

direction. There are four valves in the heart:

The tricuspid regulates blood flow between the right atrium and the rightventricle.

The pulmonary valve opens to allow blood to flow from the right ventricle to the

lungs.

The mitral valve regulates blood flow between the left atrium and the leftventricle.

The aortic valve allows blood to flow from the left ventricle to the ascending aorta.

The Heart's Electrical System

The heartbeats are triggered and regulated by the conducting system, a network

of specialized muscle cells that form an independent electrical system in the heartm

uscles. These cells are connected by channels that pass chemically caused electrical

impulses.
 45

b. Urinary System

The kidneys are the primary organs of the urinary system invertebrates. The

kidneys filter the blood, remove the wastes, and excrete the wastes in the urine.

About 1,300 milliliters of blood flow through the kidneys each minute (about 400

gallons a day).From this blood the Malphigian corpuscles (see below) extract about

170 liters of filtrate a day. As this fluid passes down the uriniferous tubules it is

almost all reabsorbed. Only about 1.5liters are left in the tubules to carry away the

waste products. The whole blood supply passes through the kidneys every

5minutes, ensuring that waste materials don't build up. The renal artery carries

blood to the kidney, while the renal vein carries blood, now with much lower

concentrations of urea and mineral ions, away from the kidney. The urine formed

passes down the ureter to the bladder.