I.

INTRODUCTION

Rheumatic heart disease is a condition in which the heart valves are damaged by
rheumatic fever. Rheumatic fever begins with a strep throat from streptococcal infection.
Rheumatic fever is an inflammatory disease. It can affect many of the body's connective
tissues — especially those of the heart, joints, brain or skin. Anyone can get acute
rheumatic fever, but it usually occurs in children five to 15 years old. The rheumatic
heart disease that results can last for life.

Rheumatic heart disease is the most serious complication of rheumatic fever. Acute
rheumatic fever follows 0.3% of cases of group A beta-hemolytic streptococcal
pharyngitis in children. As many as 39% of patients with acute rheumatic fever may
develop varying degrees of pancarditis with associated valve insufficiency, heart failure,
pericarditis, and even death. With chronic rheumatic heart disease, patients develop
valve stenosis with varying degrees of regurgitation, atrial dilation, arrhythmias, and
ventricular dysfunction.

Acute rheumatic fever and rheumatic heart disease are thought to result from an
autoimmune response, but the exact pathogenesis remains unclear. While rheumatic
heart disease was the leading cause of death 100 years ago in people aged 5-20 years
in the United States, incidence of this disease has decreased in developed countries,
and the mortality rate has dropped to just above 0% since the 1960s. Worldwide,
rheumatic heart disease remains a major health problem. The mortality rate from this
disease remains 1-10%. A comprehensive resource provided by the World Health
Organization (WHO) addresses the diagnosis and treatment of this latter population.
Estimations worldwide are that 5-30 million children and young adults have chronic
rheumatic heart disease, and 90,000 patients die from this disease each year.

In the Philippines, about 2,389 Filipinos under all age groups die because of Chronic
Rheumatic Heart Disease each year and 873 of that are young Filipinos under 10-24
years old. (Philippine Health Statistics 2003, DOH) The Office of the Secretary under
the Department of Health released an administrative order no. 23-B on July 1 1996
entitled Addendum To Manual Of Operation of Rheumatic Fever/ Rheumatic Heart
Disease (RF/RHD); Guidelines on the Referral, Confirmation, Diagnosis, Registration
and Management of RF-RHD Cases. This guideline is the answer of Philippine
Government to address Rheumatic Heart Disease cases in the country.

The patient was also diagnosed witch Anemia secondary to blood loss after delivery
of a baby. Anemia is a condition in which a person’s blood has a lower than normal
number of red blood cells (RBCs), or the RBCs don’t have enough hemoglobin (HEE-
muh-glow-bin). Hemoglobin—an iron-rich protein that gives the red color to blood—
carries oxygen from the lungs to the rest of the body. In people with anemia, the blood
does not carry enough oxygen to the rest of the body. As a result, people with anemia
feel tired, along with other symptoms, because their bodies are not receiving enough
oxygen. In severe or prolonged cases of anemia, the lack of oxygen in the blood can
cause serious and sometimes fatal damage to the heart and other organs of the body.
here are more than 400 types of anemia, which are divided into 3 groupings; a.) Anemia
caused by blood loss, b.) Anemia caused by decreased or faulty red blood cell
production c.) Anemia caused by destruction of red blood cells.

Women and people with chronic diseases are at greater risk for anemia. Many types
of anemia can be mild, short-lived, and easily treated. Some forms of anemia can be
prevented with a healthy diet, and other forms can be treated with diet supplements.
Certain types of anemia may be severe, long-lasting, and life threatening if not
diagnosed and treated. People who have symptoms of anemia should see their doctor
to find out if they have the condition, its cause and severity, and how to treat it.

In the world, 17 out of 1000 population are suffering from anemia. (NHIS,) The most
common of Anemia is Iron deficiency anemia. Its prevalence is highest among young
children and women of childbearing age (particularly pregnant women).

In the Philippines, Anemia is the most prevalent, affecting almost one-third of the
Philippine population (table 5). Anemia prevalence is highest among infants 6 - 11 mos
old. Anemia prevalence among infants, preschool children, and school-age children was
higher or almost the same as the national prevalence in 1987, 1993 and 1998. Anemia
prevalence among children less than 6 years old also increased between 1993 and
1998, but 1998 levels were still lower than reported prevalence rates in 1987. ( NRI
National Nutrition Surveys; 1993, 1996 and 1998.)

The current Philippine Plan of Action for Nutrition gives priority to provision of
pharmaceutical iron supplements to pregnant women, infants, and preschoolers. The
next step is for the Department of Health to recommend a suitable iron supplement.
Fortification of rice and other food products with ferrous sulfate represents a potential
strategy in areas where anemia is widespread. Another approach is to reduce
consumption of iron absorption inhibitors and promote intake of absorption enhancers
such as vitamin C and heme iron. Parents can be taught to modify their infant's diet by
preparing complementary foods rich in iron and vitamin C, including purees of raw fruits
and cooked vegetables. The Filipino mass media are broadcasting messages promoting
foods rich in micronutrients. The basic goal of dietary modification and education
programs in the Philippines remains to persuade parents to feed their children well-
balanced meals. (Opportunities for Micronutrient Interventions [OMNI], 1995)

Another medical problem manifested by the patient is stroke. Stroke is the third
leading cause of death in the countries of the world and the No. 1 cause of adult disabil-
ity. 80% of strokes are preventable; you can prevent a stroke!

A stroke or "brain attack" occurs when a blood clot blocks an artery (a blood vessel that
carries blood from the heart to the body) or a blood vessel (a tube through which the
blood moves through the body) breaks, interrupting blood flow to an area of the brain.
When either of these things happen, brain cells begin to die and brain damage occurs.
When brain cells die during a stroke, abilities controlled by that area of the brain are
lost. These abilities include speech, movement and memory. How a stroke patient is
affected depends on where the stroke occurs in the brain and how much the brain is
damaged. Risk factors for stroke include advanced age, hypertension (high blood pres-
sure), previous stroke or transient ischemic attack (TIA), diabetes, high cholesterol, ci-
garette smoking, atrial fibrillation, estrogen-containing forms of hormonal contraception,
migraine with aura, and thrombophilia (a tendency to thrombosis), patent foramen ovale
and several rarer disorders. High blood pressure is the most important modifiable risk
factor of stroke.

The traditional definition of stroke, devised by the World Health Organization in the
1970s, is a "neurological deficit of cerebrovascular cause that persists beyond 24 hours
or is interrupted by death within 24 hours". This definition was supposed to reflect the
reversibility of tissue damage and was devised for the purpose, with the time frame of
24 hours being chosen arbitrarily. The 24-hour limit divides stroke from transient
ischemic attack, which is a related syndrome of stroke symptoms that resolve com-
pletely within 24 hours. With the availability of treatments that, when given early, can re-
duce stroke severity, many now prefer alternative concepts, such as brain attack and
acute ischemic cerebrovascular syndrome (modeled after heart attack and acute
coronary syndrome respectively), that reflect the urgency of stroke symptoms and the
need to act swiftly.

Stroke is occasionally treated with thrombolysis ("clot-buster"), but usually with

supportive care (physiotherapy and occupational therapy) and secondary prevention
with antiplatelet drugs (aspirin and often dipyridamole), blood pressure control, statins
and anticoagulation (in selected patients).

The Philippines has the highest death rate for hypertension in the region, second to
Indonesia in mortality for rheumatic heart dieases, fourth to Singapore for CAD, and
third to Japan for stroke (WHO 1990). Atherosclerotic diseases rank as first leading
death among Filipinos. Overall, deaths due to CVD comprise 25 percent of total deaths
in 1995 (PHS 1995). The rise of CVD deaths is due to hypertension, CAD and
cerebrovascular accidents, all of which have more than doubled during the period 1965-
90 (Facts and Figures, CVD in the Philippines). The prevalence of congenital heart dis-
ease at birth is 5 per 1,000 livebirths. It declines rapidly as many of the cases die. At
five years of age, the rate is about 1.5 per 1,000 and remains at 1.2 per 1,000 at age
eight and onwards.
 Another disease condition manifested by the patient was Nosocomial Pneumonia. A
working definition of nosocomial pneumonia (NP) is that of a new pulmonary infiltrate
that occurs after one week of hospitalization and that resembles a bacterial pneumonia
on the chest radiograph. Although most patients have fever and leukocytosis, these
findings are not uniformly present nor are they a requisite for the presumptive diagnosis
of NP. A patient with pneumonia may have the fever with of without chills, coughing
which may bring up yellow, green, rust of bloody phlegm, pain in the chest when
breathing or coughing shortness of breath, rapid and shallow breathing fatigue and
sweating and flushed color of skin loss of appetite or upset stomach. (DOH, 2003)

Some hospitalized patients develop pneumonia in less than 5 days, a condition

called early hospital-acquired pneumonia (HAP), which is better known as incubating
community-acquired pneumonia (CAP). Since NP is defined as occurring a week or
more after hospitalization, the early cases should not be regarded as NP but as CAP.
Both early HAP and CAP have the same etiology in that the main pathogens are
Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, although
atypical pathogens also may cause the conditions. (CDC, 2005)

NP is caused by different pathogens, the aerobic gram-negative bacilli (ie, excluding

H influenzae). Pseudomonas aeruginosa is not the most common cause of NP but is
the most important organism in terms of mortality and morbidity. Staphylococcus aureus
(ie, methicillin-susceptible S aureus [MSSA], methicillin-resistant S aureus [MRSA]) and
anaerobic organisms are not significant contributors to NP. (NLM, 2007)

Aerobic gram-negative bacilli cause all cases of NP, aerobic gram-negative

pathogens may be divided into 2 categories. The first category includes those
organisms causing necrotizing pneumonia with rapid cavitation, microabscess
formation, blood vessel invasion, and hemorrhage; typically, this is characteristic of P
aeruginosa. The second category consists of all other nonnecrotizing gram-negative
organisms responsible for NP that cause histologically indistinguishable nonnecrotizing
pneumonia. (NLM, 2007)
In the Philippines, the management of pneumonia is more focused on the childhood age
groups which is more prone and develops serious conditions rather than adults. The
health condition has improved in 16 of the 17 regions that applied the Integrated
Management of Childhood Illness (IMCI). IMCI is a strategy used in providing holistic
health care services among the under five-year-old children ranging from detailed
history taking, physical examination, diagnosis and treatment of diseases and
conditions. The promotion of IMCI through regular in-service and pre-service training of
frontline health personnel is supported by international and local funding agencies. The
IMCI strategy requires that appropriate drugs for pneumonia are available at the health
service outlets at any given time. DOH and PhilHealth-accredited clinics, health centers
and hospitals generally provide patients with the necessary drugs at low cost. However,
not all health facilities are able to carry out IMCI appropriately and consistently due to
shortage of drugs. This is due to the limited local sources of drugs or to failures in the
drug distribution system at the regional and local levels. (National Objectives for Health,
Philippines, 2005-2001, Department of Health)

Although the drugs necessary to treat pneumonia are available over the counter,
general consultations and treatment services for older children, adults and older
persons with pneumonia needs improvement to multiply the gains that have been
achieved in pneumonia control among age groups. (National Objectives for Health,
Philippines, 2005-2001, Department of Health)
A. Scope of the Study

The study focuses on an Intensive Care Unit patient, confined in Northern Mindanao

Medical Center, Cagayan de Oro City, having the final diagnosis of Stroke in the young,

rheumatic heart disease, moderate mitral regurgitation, moderate tricuspid regurgitation,

aortic regurgitation, acute pulmonary edema; resolved, nosocomial pneumonia;

resolved s/p intubation x2 weeks, s/p tracheostomy, anemia secondary to blood loss,

s/p postpartum home delivery (G2P2) (2002).

v Nature, causes, signs & symptoms, pathophysiology, nursing management,

interventions, and prognosis of the disease.

v Assessment of Ms. X’s personal background, health history, and history of

present illness.

v Involves the ideal and actual nursing management appropriate for Ms. X’s

condition, the drug study of the medications given, the health teachings and

referrals for her.

Limitation of the Study

v Limited only to the history of the patient which is comprised of the patient’s

profile, family and personal health history, chief complaint and history of present

illness.

v Information obtained from patient’s medical record, from the staff, during patient

assessment, and from the watcher.

 v The study is also limited on the laboratory results of the patient.

v The patient was only taken cared of for 3 days, starting from the 34th day of her

admission at Northern Mindanao Medical Center, Cagayan de Oro City and

ends with the 36th day of her admission.

v Other relevant information kept confidential same with her true identity to

protect her privacy.

B. Objective of the Study

This study aims to improve the present condition of the patient and is conducted

to gain a thorough understanding concerning the case of the patient. And to apply our

knowledge on nursing assessment, problem identification, nursing interventions and

evaluation that is related to the disease condition. Furthermore, by gathering the

subjective and objective regarding the case, it will allow us to have a proper and

appropriate nursing care towards the condition of an actual patient.

This study also aims to improve our skills in the clinical area, our interpersonal

relationships with other health care givers and to gain more confidence in ourselves

towards what is tasked to us.

C. Significance of the Study

The study will present the identification of Stroke, Rheumatic heart disease,

Nosocomial Pneumonia and Anemia to gain insight into the nature of Ms. X’s condition
in terms of its etiologic factors, treatment, and prevention. The method to be used will

provide comprehensive observation regarding her condition at the same time the

recognition of imparting knowledge, awareness to people and ways in preventing the

spread of the disease. This study can be considered beneficial to: (a) the family

concerned, helping them to be aware regarding Ms. X's condition, allowing them to

motivate the patient in complying with the medications as prescribed, and as to cope up

with the situation as well as to prevent the spread of the disease among other family

members; including on how to identify any symptoms that may occur, (b) nurses

handling similar cases, providing them additional information in formulating nursing care

plans, in such a way achieving efficiency in the treatment procedure – recovering

condition and health status improvement, (c) nursing students, in an attempt to provide

additional information with regard to the disease process, its treatment and prevention,

hopefully will result in decreasing the recurrence of the said disease at the same time

not focusing on the disease itself but will provide a chance to test their skills regarding

proper patient assessment in clinical settings, and (d) other researchers, providing them

a comparative study that will be useful in determining new nursing interventions with the

objectives of alleviating the patient’s condition, as well as to expand the information and

knowledge regarding the disease condition.

Moreover, the study will help the researchers in obtaining knowledge about the

treatment and regimens through implementations of nursing care directly to their

patients, aiming for health promotions and restorations.

 II. Health History

a. Developmental History

Growth and development both refer to dynamic processes. Continuous processes

are influence by maturational and genetic factors. Our patient’s growth and
development was assessed using the theories of Erikson and Freud.

Psychosocial Developmental Theory of Erikson

Erikson evisions life as a sequence of levels of achievement. He describes eight

stages of development where each stage signals a task that must be achieved. Our
patient belongs to the young adulthood where the central task is intimacy vs. isolation.
In this stage, the person begins to have intimate relationship with another person and
the ability to care for another person as well. The most important event in this stage is
commitment to work and relationships.
In line with our patient’s case, She has a live in partner, a three kids in which
her task is to care and guide with them as well. Unfortunately, she cannot be able to
come up with such task in which the kids are yearning for. because of the said
condition in which she is suffering right now.

Psychosexual Theory of Freud

According to Freud’s theory of psychosexual development, the personality

develops in five overlapping stages from birth to adulthood. This stage represents the
major portion of life and the basic task for the individual is the detachment from the
parents. In this stage, the focus is again genitals but this time the energy is expressed
with the adult sexuality.
 As what we have observed in our patient’s case, the foundation of love, sexual
acts and compassion with her partner was achieved as they indulged into a relationship
for almost three years from now.

B. Family Health History

Tracing the family history of Ms. X, it was found out that the patient’s father had
experienced a urinary tract infection at the age of 20. There were no medications
maintained but only lifestyle modifications were stressed out such as restrictions of
sodium, water therapy and regular exercises. Unhappily, at the age of 54, he died
suffering from the aforementioned illness.
On the other hand, her mother had goiter at the age of 25 and died due to
rupture of the aforesaid at the age of 48. Luckily, there were no known family histories of
hypertension, diabetes mellitus, asthma and arthritis.

C. Past Personal History

Ms. X is 23 years old and currently residing at Purok 10, Baloy, Tablon, Cagayan
de Oro City. She is the youngest in a brood of three of Mr. and Mrs. Z. Prenatal
checkups were done during her mother’s conceptions. Patient X was delivered at home
which was assisted by “hilot” with ungloved hand through Normal Spontaneous Vaginal
Delivery. The patient had completely received childhood immunizations like BCG, DPT,
OPV and measles. From birth up to 6 months, she was exclusively breastfed per
demand while having an eye-to-eye contact. At 6 months, she started to be fed with
porridge (lugaw), and at 1 year onward began to be fed with rice, vegetables and fish.
Ms. X’s had encountered chicken pox and measles when she was 5 years old but no
medical consultations done and medications taken. The patient had also experienced
common illnesses such as fever, colds, toothache and cough but no consultations done
instead it was managed by taking over-the-counter drugs (Paracetamol and Mefenamic
Acid). The patient doesn’t smokes and drinks any alcoholic beverages. So far, Ms. X
has no known food and drug allergies. At the age of 13, the patient had her first
menstruation. During her menses, it was found out that it is irregular but in moderate
amount of discharges. She has five-day duration of menses without experiencing
dysmenorrhea.
Last October 3, 2005, Ms. X delivered a lived baby boy through normal
spontaneous vaginal delivery, cephalic in labor at home helped out by a midwife. During
the delivery of the baby, incision was done and with perineal lacerations noted but
unfortunately it was not repaired by the midwife. During her conception, she actively
participates and cooperates with prenatal check-ups at Barangay Baloy Health Center.
The patient X underwent a surgical operation known as Tracheostomy last July
26, 2008. Blood transfusion was done after the operation accumulating 1 pack in the
operating room and 1 pack in the ward. Luckily, no certain blood reactions observed
during the blood transfusion.

D. History of Present Illness

One month (May 29, 2008) prior to admission, patient X (G2P2) delivered a baby
girl via normal spontaneous vaginal delivery, cephalic in labor at home assisted by a
midwife. One week prior to admission, patient is still having a vaginal spotting
associated with body malaise and headache. Patient took herbal medicine (kamote
tops) boiled and drank for three times a day but no relief of symptoms. However, due to
persistence of the above condition, prompted patient X to sought consultation, hence
this admission.
 III. A. PATIENT’S PROFILE

Patient’s Name:
Address:
Date of Birth:
Age:
Civil Status:
Gender:
Nationality:
Religion:
Educational
Attainment:
Height:
Weight:
Occupation:
Date of Admission:
Time of Admission:
Income:
Chief Complaint:
Attending Physician:
Allergies:
Baseline Vital Signs:
August 3, 2008 Temperature: 36.4 c
( Sunday) Pulse rate: 77 bpm
Respiratory rate: 26 cpm
Blood Pressure: 100/70 mmHg
O2 Sat: 98%
8 am: 12 noon:
August 4, 2008( Temperature: 36 c 36.5 c
Monday) Pulse rate: 85 bpm 85 bpm
Respiratory Rate: 24 cpm 31 cpm
Blood Pressure: 110/80 bpm 100/70 bpm
O2 Sat: 98% 99%
Temperature: 36.9 c
Pulse Rate: 86 beats per minute
August 5, 2008( Respiratory Rate: 27 cycles per minute
Tuesday) Blood Pressure: 110/70 mmHg
SIBLINGS

CHILDREN
 N

W E

Pontod
To Puerto

Coffee Pack Factory

Cagayan de Oro
City
Lapasan

Gusa
NFA, Baloy

Cugman
IV. Anatomy and Physiology

The Anatomy of the Heart

Your heart is located under the ribcage in the center of your chest between your right
and left lung. It’s shaped like an upside-down pear. Its muscular walls beat, or contract,
pumping blood continuously to all parts of your body.

The size of your heart can vary depending on your age, size, or the condition of your
heart. A normal, healthy, adult heart most often is the size of an average clenched adult
fist. Some diseases of the heart can cause it to become larger.

The Exterior of the Heart

Below is a picture of the outside of a normal, healthy, human heart.

The illustration shows the front surface of the heart, including the coronary arteries
and major blood vessels.
The heart is the muscle in the lower half of the picture. The heart has four chambers.
The right and left atria (AY-tree-uh) are shown in purple. The right and left ventricles
(VEN-trih-kuls) are shown in red.

Connected to the heart are some of the main blood vessels—arteries and veins
—that make up your blood circulatory system.

The ventricle on the right side of your heart pumps blood from the heart to your
lungs. When you breathe air in, oxygen passes from your lungs through blood vessels
where it’s added to your blood. Carbon dioxide, a waste product, is passed from your
blood through blood vessels to your lungs and is removed from your body when you
breathe air out.

The atrium on the left side of your heart receives oxygen-rich blood from the
lungs. The pumping action of your left ventricle sends this oxygen-rich blood through the
aorta (a main artery) to the rest of your body.

The Right Side of Your Heart

The superior and inferior vena cavae are in blue to the left of the muscle as you
look at the picture. These veins are the largest veins in your body. They carry used
(oxygen-poor) blood to the right atrium of your heart. “Used” blood has had its oxygen
removed and used by your body’s organs and tissues. The superior vena cava carries
used blood from the upper parts of your body, including your head, chest, arms, and
neck. The inferior vena cava carries used blood from the lower parts of your body.

The used blood from the vena cavae flows into your heart’s right atrium and then
on to the right ventricle. From the right ventricle, the used blood is pumped through the
pulmonary (PULL-mun-ary) arteries (in blue in the center of picture) to your lungs. Here,
through many small, thin blood vessels called capillaries, your blood picks up oxygen
needed by all the areas of your body.
 The oxygen-rich blood passes from your lungs back to your heart through the
pulmonary veins (in red to the left of the right atrium in the picture).

The Left Side of Your Heart

Oxygen-rich blood from your lungs passes through the pulmonary veins (in red to
the right of the left atrium in the picture). It enters the left atrium and is pumped into the
left ventricle. From the left ventricle, your blood is pumped to the rest of your body
through the aorta.

Like all of your organs, your heart needs blood rich with oxygen. This oxygen is
supplied through the coronary arteries as it’s pumped out of your heart’s left ventricle.
Your coronary arteries are located on your heart’s surface at the beginning of the aorta.
Your coronary arteries (shown in red in the drawing) carry oxygen-rich blood to all parts
of your heart.

Heart Interior
The illustration shows a cross-section of a healthy heart and its inside structures. The
blue arrow shows the direction in which low-oxygen blood flows from the body to the
lungs. The red arrow shows the direction in which oxygen-rich blood flows from the
lungs to the rest of the body.

The Septum

The right and left sides of your heart are divided by an internal wall of tissue
called the septum. The area of the septum that divides the two upper chambers (atria)
of your heart is called the atrial or interatrial septum. The area of the septum that divides
the two lower chambers (ventricles) of your heart is called the ventricular or
interventricular septum.

Heart Chambers

The picture shows the inside of your heart and how it’s divided into four
chambers. The two upper chambers of your heart are called atria. The atria receive and
collect blood. The two lower chambers of your heart are called ventricles. The ventricles
pump blood out of your heart into the circulatory system to other parts of your body.

Heart Valves

The picture shows your heart’s four valves. Shown counterclockwise in the
picture, the valves include the aortic (ay-OR-tik) valve, the tricuspid (tri-CUSS-pid)
valve, the pulmonary valve, and the mitral (MI-trul) valve.

Blood Flow

The arrows in the drawing show the direction that blood flows through your heart.
The light blue arrows show that blood enters the right atrium of your heart from the
superior and inferior vena cavae. From the right atrium, blood is pumped into the right
ventricle. From the right ventricle, blood is pumped to your lungs through the pulmonary
arteries.

The light red arrows show the oxygen-rich blood coming in from your lungs
through the pulmonary veins into your heart’s left atrium. From the left atrium, the blood
is pumped into the left ventricle, where it’s pumped to the rest of your body through the
aorta.

For the heart to function properly, your blood flows in only one direction. Your
heart’s valves make this possible. Both of your heart’s ventricles has an “in” (inlet) valve
from the atria and an “out” (outlet) valve leading to your arteries. Healthy valves open
and close in very exact coordination with the pumping action of your heart’s atria and
ventricles. Each valve has a set of flaps called leaflets or cusps, which seal or open the
valves. This allows pumped blood to pass through the chambers and into your arteries
without backing up or flowing backward.

The nervous system is a network of specialized nerve cells that conduct impulses from
or to areas of the body to the brain and spinal cord and within the brain. It is composed
of neurons and other specialized cells, like glial cells and neuroglia, that aid in the func-
tion of the neurons. Nerve cells are interconnected in complex arrangements and use
electrochemical signals to transmit impulses between cells, they respond to a great vari-
ety of stimuli and form neural circuits that regulate an organisms perception and behavi-
or. Nervous systems are found in many multicellular animals but differ greatly in com-
plexity between species.\ he human nervous system can be grouped into both with
gross anatomy, (which describes the parts that are large enough to be seen with the na-
ked eye,) and microanatomy, (which describes the system at a cellular level.) At gross
anatomy, the nervous system can be grouped in distinct organs, these being actually
stations which the neural pathways cross through. Thus, with a didactical purpose,
these organs, according to their ubication, can be divided in two parts: the central
nervous system (CNS) and the peripheral nervous system (PNS).[2]
Central nervous system

The central nervous system (CNS) represents the largest part of the nervous system,
including the brain and the spinal cord. The CNS is contained within the dorsal cavity,
with the brain within the cranial cavity, and the spinal cord in the spinal cavity. The CNS
is covered by the meninges. The brain is also protected by the skull, and the spinal cord
is also protected by the vertebrae. The nervous system can be connected into many
systems that can function together. The two systems are central nervous system (CNS)
and the peripheral nervous system (PNS).

Peripheral nervous system

The PNS consists of all the other nervous structures that do not lie in the CNS. The
large majority of what are commonly called nerves (which are actually axonal processes
of nerve cells) are considered to be PNS.

Microanatomy

The nervous system is, on a small scale, primarily made up of neurons. However, glial
cells also play a major role.

Neurons

Neurons are electrically excitable cells in the nervous system that process and transmit
information. Neurons are the core components of the brain, the vertebrate spinal cord,
the invertebrate ventral nerve cord, and the peripheral nerves. A number of different
types of neurons exist: sensory neurons respond to touch, sound, light and numerous
other stimuli effecting sensory organs and send signals to the spinal cord and brain, mo-
tor neurons receive signals from the brain and spinal cord and cause muscle contrac-
tions and effect glands, Interneurons connect neurons to other neurons with in the brain
and spinal cord.
Glial cells

Glial cells are non-neuronal cells that provide support and nutrition, maintain homeo-
stasis, form myelin, and participate in signal transmission in the nervous system. In the
human brain, glia are estimated to outnumber neurons by about 10 to 1.

Glial cells provide support and protection for neurons. They are thus known as the
"glue" of the nervous system. The four main functions of glial cells are to surround neur-
ons and hold them in place, to supply nutrients and oxygen to neurons, to insulate one
neuron from another, and to destroy pathogens and remove dead neurons.

Physiological division

A less anatomical but much more functional division of the human nervous system is
that classifying it according to the role that the different neural pathways play, regardless
whether these cross through the CNS or the PNS:

The somatic nervous system is responsible for coordinating the body's movements, and
also for receiving external stimuli. It is the system that regulates activities that are under
conscious control.

Of digestion, it regulates from the esophagus to the stomach, small intestine and colon.

In turn, these pathways can be divided according to the direction in which they conduct
stimuli:

• Afferent system by sensory neurons, which carry impulses from a receptor to the
CNS
• Efferent system by motor neurons, which carry impulses from the CNS to an ef-
fector
• Relay system by relay neurons (also called interneurons), which transmit im-
pulses between the sensory and motor neurones.

However, there are relay neurons in the CNS as well.

The junction between two neurones is called a synapse. There is a very narrow gap
(about 20nm in width) between the neurons - the synaptic cleft, where an action poten-
tial is transmitted from one neuron to a neighboring one. They do this by relaying the
message with the use of neurotransmitters which the next neuron then receives the
electrical signal, known as a nerve impulse. The nerve impulse is determined by the
neurotransmitter to then carry the message to its appropriate destination. These nerve
impulses are a change in ion balance in the nerve cell, which the central nervous sys-
tem can then interpret. The fact that the nervous system uses a mixture of electrical and
chemical signals makes it incredibly fast, which is necessary to acknowledge the pres-
ence of danger. For example, a hand touching a hot stove. If the nervous system was
only comprised of chemical signals, the body would not tell the arm to move fast enough
to escape dangerous burns. So the speed of the nervous system is a necessity for life.

Development

Some landmarks of embryonic neural development include the birth and differentiation
of neurons from stem cell precursors, the migration of immature neurons from their
birthplaces in the embryo to their final positions, outgrowth of axons from neurons and
guidance of the motile growth cone through the embryo towards postsynaptic partners,
the generation of synapses between these axons and their postsynaptic partners, and
finally the lifelong changes in synapses which are thought to underlie learning and
memory.

Importance

Many people have lost basic motor skills and other skills because of spinal cord injuries.
If this portion is damaged, the biggest nerve and the most important one get damaged.
This leads to paralysis or other permanent damage.
Abilities

The nervous system is able to make basic motor skills and other skills possible. The ba-
sic 5 senses of texture, taste, sight, smell, and hearing are powered by the nervous sys-
tem. If disabled, basic motor skills may be lost.

The Respiratory System

The respiratory system consists of the airways, the lungs, and the respiratory
muscles that mediate the movement of air into and out of the body. Within the alveolar
system of the lungs, molecules of oxygen and carbon dioxide are passively exchanged,
by diffusion, between the gaseous environment and the blood. Thus, the respiratory
system facilitates oxygenation of the blood with a concomitant removal of carbon
dioxide and other gaseous metabolic wastes from the circulation. The system also helps
to maintain the acid-base balance of the body through the efficient removal of carbon
dioxide from the blood.
Structure of the respiratory system

Upper airways

Nasal Cavity

The nasal cavity (or nasal fossa) is a large air-filled space above and behind the
nose in the middle of the face. The nasal cavity conditions the air to be received by the
areas of the respiratory tract and nose. Owing to the large surface area provided by the
conchae, the air passing through the nasal cavity is warmed or cooled to within 1
degree of body temperature. In addition, the air is humidified, and dust and other
particulate matter is removed by vibrissae, short, thick hairs, present in the vestibule.
The cilia of the respiratory epithelium move the particulate matter towards the pharynx
where it is swallowed.

Pharynx

The pharynx is the part of the neck and throat situated immediately posterior to
the mouth and nasal cavity, and cranial, or superior, to the esophagus, larynx, and
trachea.It is part of the digestive system and respiratory system of many
organisms.Because both food and air pass through the pharynx, a flap of connective
tissue called the epiglottis closes over the trachea when food is swallowed to prevent
choking or aspiration. In humans the pharynx is important in vocalization.

Larynx

The larynx (plural larynges), colloquially known as the voicebox, is an organ in

the neck of mammals involved in protection of the trachea and sound production. The
larynx houses the vocal folds, and is situated just below where the tract of the pharynx
splits into the trachea and the esophagus

Sound is generated in the larynx, and that is where pitch and volume are
manipulated. The strength of expiration from the lungs also contributes to loudness, and
is necessary for the vocal folds to produce speech. During swallowing, the backward
motion of the tongue forces the epiglottis over the laryngeal opening to prevent
swallowed material from entering the lungs; the larynx is also pulled upwards to assist
this process. Stimulation of the larynx by ingested matter produces a strong cough
reflex to protect the lungs.

Lower airways

Trachea
 The trachea extends from the larynx to the level of the 7th thoracic vertebrae,
where it divides 2 main bronchi, which is called the carina. It is a flexible, muscular 12-
cm long air passage with c shaped cartilaginous rings. Along with other regions of the
lower airways it is lined pseudo stratified columnar epithelium that contains goblet cells
and Celia. Because the Celia beat upward, they tend to carry foreign particles and
excessive mucus away from the lungs to the pharynx. The trachea (windpipe) divides
into two main bronchi the left and the right, at the level of the sternal angle.

Bronchi and Bronchioles

A bronchus is a caliber of airway in the respiratory tract that conducts air into the
lungs. No gas exchange takes place in this part of the lungs. . The right main bronchus
is wider, shorter, and more vertical than the left main bronchus. The right main bronchus
subdivides into three segmental bronchi while the left main bronchus divides into two.
The lobar bronchi divide into tertiary bronchi. Each of the segmental bronchi supplies a
bronchopulmonary segment. A bronchopulmonary segment is a division of a lung that is
separated from the rest of the lung by a connective tissue septum.
Lungs

The trachea divides into the two main bronchi that enter the roots of the lungs.
The bronchi continue to divide within the lung, and after multiple divisions, give rise to
bronchioles. The bronchial tree continues branching until it reaches the level of terminal
bronchioles, which lead to alveolar sacks. Alveolar sacs are made up of clusters of
alveoli, like individual grapes within a bunch. The individual alveoli are tightly wrapped in
blood vessels, and it is here that gas exchange actually occurs. Deoxygenated blood
from the heart is pumped through the pulmonary artery to the lungs, where oxygen
diffuses into blood and is exchanged for carbon dioxide in the hemoglobin of the
erythrocytes. The oxygen-rich blood returns to the heart via the pulmonary veins to be
pumped back into systemic circulation.

Human lungs are located in two cavities on either side of the heart. Though
similar in appearance, the two are not identical. Both are separated into lobes, with
three lobes on the right and two on the left. The lobes are further divided into lobules,
hexagonal divisions of the lungs that are the smallest subdivision visible to the naked
eye. The connective tissue that divides lobules is often blackened in smokers and city
dwellers. The medial border of the right lung is nearly vertical, while the left lung
contains a cardiac notch. The cardiac notch is a concave impression molded to
accommodate the shape of the heart. Lungs are to a certain extent 'overbuilt' and have
a tremendous reserve volume as compared to the oxygen exchange requirements when
at rest. This is the reason that individuals can smoke for years without having a
noticeable decrease in lung function while still or moving slowly; in situations like these
only a small portion of the lungs are actually perfused with blood for gas exchange. As
oxygen requirements increase due to exercise, a greater volume of the lungs is
perfused, allowing the body to match its CO2/O2 exchange requirements.

The Lungs

1. Trachea 5. Alveoli

2. Pulmonary artery 6. Cardiac notch

3. Pulmonary vein 7. Bronchioles

4. Alveolar duct 8. Tertiary bronchi

9. Secondary bronchi 11. Larynx

10. Primary bronchi

Alveoli

An alveolus is an anatomical structure that has the form of a hollow cavity.

Mainly found in the lung, the pulmonary alveoli are spherical outcroppings of the
respiratory bronchioles and are the primary sites of gas exchange with the blood.The
lungs contain about 300 million alveoli[2]., representing a total surface area of approx.
70-90 square meters (m2). Each alveolus is wrapped in a fine mesh of capillaries
covering about 70% of its area.The alveoli have radii of about 0.05 mm but increase to
around 0.1 mm during inhalation.The alveoli consist of an epithelial layer and
extracellular matrix surrounded by capillaries. In some alveolar walls there are pores
between alveoli. There are three major alveolar cell types in the alveolar wall.

• Type I cells that form the structure of an alveolar wall

• Type II cells that secrete surfactant to lower the surface tension of water and
allows the membrane to separate thereby increasing the capability to exchange
gases. Surfactant is continuously released by exocytosis. It forms an underlying
aqueous protein-containing hypophase and an overlying phospholipids film
composed primarily of dipalmitoyl phosphatidylcholine.

• Macrophages that destroy foreign material, such as bacteria.

Diaphragm

The Diaphragm is a dome-shaped musculofibrous septum which separates the

thoracic from the abdominal cavity, its convex upper surface forming the floor of the
former, and its concave under surface the roof of the latter. Its peripheral part consists of
muscular fibers which take origin from the circumference of the thoracic outlet and
converge to be inserted into a central tendon. The diaphragm is crucial for breathing
and respiration. During inhalation, the diaphragm contracts, thus enlarging the thoracic
cavity (the external intercostals muscles also participate in this enlargement). This
reduces intra-thoracic pressure: in other words, enlarging the cavity creates suction that
draws air into the lungs. When the diaphragm relaxes, air is exhaled by elastic recoil of
the lung and the tissues lining the thoracic cavity in conjunction with the abdominal
muscles which act as an antagonist paired with the diaphragm's contraction an
antagonist paired with the diaphragm's contraction.
 The Anatomy of the Blood

Blood facts

• Approximately 8% of an adult's body weight is made up of blood.

• Females have around 4-5 litres, while males have around 5-6 litres. This
difference is mainly due to the differences in body size between men and women.

• Its mean temperature is 38 degrees Celcius.

• It has a pH of 7.35-7.45, making it slightly basic (less than 7 is considered

acidic).

• Whole blood is about 4.5-5.5 times as viscous as water, indicating that it is more
resistant to flow than water. This viscosity is vital to the function of blood because
if blood flows too easily or with too much resistance, it can strain the heart and
lead to severe cardiovascular problems.

• Blood in the arteries is a brighter red than blood in the veins because of the
higher levels of oxygen found in the arteries.

• An artificial substitute for human blood has not been found.

Functions of blood
Blood has three main functions - Transport, Protection and Regulation

1. Transport of the following substances: Gases, namely oxygen (O2) and carbon
dioxide (CO2), between the lungs and rest of the body Nutrients from the
digestive tract and storage sites to the rest of the body Waste products to be
detoxified or removed by the liver and kidneys Hormones from the glands in
which they are produced to their target cells Heat to the skin so as to help
regulate body temperature
 2. Protection: Blood has several roles in inflammation Leukocytes, or white blood
cells, destroy invading microorganisms and cancer cells Antibodies and other
proteins destroy pathogenic substances Platelet factors initiate blood clotting and
help minimise blood loss

3. Regulation of: pH by interacting with acids and bases Water balance by

transferring water to and from tissues

Composition of blood
Blood is classified as a connective tissue and consists of two main components:

1. Plasma, which is a clear extracellular fluid

2. Formed elements, which are made up of the blood cells and platelets

The formed elements are so named because they are enclosed in a plasma membrane
and have a definite structure and shape. All formed elements are cells except for the
platelets, which tiny fragments of bone marrow cells. Formed elements are: throcytes,
also known as red blood cells (RBC) Platelets Leukocytes, also known as white blood
cells (WBC). Leukocytes are further classified into two subcategories called
granulocytes which consist of neutrophils, eosinophils and basophils; and agranulocytes
which consist of lymphocytes and monocytes. The formed elements can be separated
from plasma by centrifuge, where a blood sample is spun for a few minutes in a tube to
separate its components according to their densities. RBCs are denser than plasma,
and so become packed into the bottom of the tube to make up 45% of total volume. This
volume is known as the haematocrit. WBCs and platelets form a narrow cream-coloured
coat known as the buffy coat immediately above the RBCs. Finally, the plasma makes
up the top of the tube, which is a pale yellow colour and contains just under 55% of the
total volume.
Blood plasma - Composition and function
Blood plasma is a mixture of proteins, enzymes, nutrients, wastes, hormones and
gases. The specific composition and function of its components are as follows:

1. Proteins These are the most abundant substance in plasma by weight and play a
part in a variety of roles including clotting, defence and transport. Collectively,
they serve several functions:

1. They are an important reserve supply of amino acids for cell nutrition.
Cells called macrophages in the liver, gut, spleen, lungs and lymphatic
tissue can break down plasma proteins so as to release their amino acids.
These amino acids are used by other cells to synthesise new products.

2. Plasma proteins also serve as carriers for other molecules. Many types of
small molecules bind to specific plasma proteins and are transported from
the organs that absorb these proteins to other tissues for utilisation. The
 proteins also help to keep the blood slightly basic at a stable pH. They do
this by functioning as weak bases themselves to bind excess H+ ions. By
doing so, they remove excess H+ from the blood which keeps it slightly
basic.

3. The plasma proteins interact in specific ways to cause the blood to

coagulate, which is part of the body's response to injury to the blood
vessels (also known as vascular injury), and helps protect against the loss
of blood and invasion by foreign microorganisms and viruses.

4. Plasma proteins govern the distribution of water between the blood and
tissue fluid by producing what is known as a colloid osmotic pressure.

5. Albumins, which are the smallest and most abundant plasma proteins.
Reductions in plasma albumin content can result in a loss of fluid from the
blood and a gain of fluid in the interstitial space (space within the tissue),
which may occur in nutritional, liver and kidney disease. Albumin also
helps many substances dissolve in the plasma by binding to them, hence
playing an important role in plasma transport of substances such as drugs,
hormones and fatty acids.

6. Globulins, which can be subdivided into three classes from smallest to

largest in molecular weight into alpha, beta and gamma globulins. The
globulins include high density lipoproteins (HDL), an alpha-1 globulin, and
low density lipoproteins (LDL), a beta-1 globulin. HDL functions in lipid
transport carrying fats to cells for use in energy metabolism, membrane
reconstruction and hormone function. HDLs also appear to prevent
cholesterol from invading and settling in the walls of arteries. LDL carries
cholesterol and fats to tissues for use in manufacturing steroid hormones
and building cell membranes, but it also favours the deposition of
cholesterol in arterial walls and thus appears to play a role in disease of
the blood vessels and heart. HDL and LDL therefore play important parts
 in the regulation of cholesterol and hence have a large impact on
cardiovascular disease.

7. Fibrinogen, which is a soluble precursor of a sticky protein called fibrin,

which forms the framework of blood clot. Fibrin plays a key role in
coagulation of blood, which is discussed later in this article under
Platelets.

There are three major categories of plasma proteins, and each individual type of
proteins has its own specific properties and functions in addition to their overall
collective role:

2. Amino acids These are formed from the break down of tissue proteins or from the
digestion of digested proteins.

3. Nitrogenous waste Being toxic end products of the break down of substances in
the body, these are usually cleared from the bloodstream and are excreted by the
kidneys at a rate that balances their production.

4. Nutrients Those absorbed by the digestive tract are transported in the blood
plasma. These include glucose, amino acids, fats, cholesterol, phospholipids,
vitamins and minerals.

5. Gases Some oxygen and carbon dioxide are transported by plasma. Plasma also
contains a substantial amount of dissolved nitrogen.

6. Electrolytes The most abundant of these are sodium ions, which account for
more of the blood's osmolarity than any other solute.

Haemopoiesis
Haemopoiesis is the production of the formed elements of blood. Haemopoietic tissues
refer to the tissues that produce blood. The earliest haemopoietic tissue to develop is
the yolk sac, which also functions in the transfer of yolk nutrients of the embryo. In the
foetus, blood cells are produced by the bone marrow, liver, spleen and thymus. This
changes during and after birth. The liver stops producing blood cells around the time of
birth, while the spleen stops producing them soon after birth but continues to produce
lymphocytes for life. From infancy onwards, all formed elements are produced in the red
bone marrow. Lymphocytes are additionally produced in lymphoid tissues and organs
widely distributed in the body, including the thymus, tonsils, lymph nodes, spleen and
patches of lymphoid tissues in the intestine.

Erythropoesis
Erythropoiesis refers specifically to the production of erythrocytes or red blood cells
(RBCs). These are formed through the following sequence of cell transformations:

The proerythroblast has receptors for the hormone erythropoietin (EPO). Once EPO
receptors are in place, the cell is committed to exclusively producing RBCs. The
erythroblasts then multiply and synthesise haemoglobin (Hb), which is a red oxygen
transport protein. The nucleus from the erythroblasts is then discarded, giving rise to
cells named reticulocytes. The overall transformation from haemocytoblast to
reticulocytes involves a reduction in cell size, an increase in cell number, the synthesis
of haemoglobin, and the loss of the cell nucleus. These reticulocytes leave the bone
marrow and enter the bloodstream where they mature into erythrocytes when their
endoplasmic reticulum disappears.

Leukopoiesis
Leukopoiesis refers to the production of leukocytes (WBCs). It begins when some types
of haemocytoblasts differentiate into three types of committed cells:

1. B progenitors, which are destined to become B lymphocytes

2. T progenitors, which become T lymphocytes

 3. Granulocyte-macrophage colony-forming units, which become granulocytes and
monocytes

These cells have receptors for colony-stimulating factors (CSFs). Each CSF stimulates
a different WBC type to develop in response to specific needs. Mature lymphocytes and
macrophages secrete several types of CSFs in response to infections and other
immune challenges. The red bone marrow stores granulocytes and monocytes until
they are needed in the bloodstream. However, circulating leukocytes do not stay in the
blood for very long. Granulocytes circulate for 4-8 hours and then migrate into the
tissues where they live for another 4-5 days. Monocytes travel in the blood for 10-20
hours, then migrate into the tissues and transform into a variety of macrophages which
can live as long as a few years. Lymphocytes are responsible for long-tern immunity
and can survive from a few weeks to decades. They are continually recycled from blood
to tissue fluid to lymph and finally back to the blood.

Thrombopoiesis
Thrombopoiesis refers to the production of platelets in the blood, because platelets
used to be called thrombocytes. This starts when a haemocytoblast develops receptors
for the hormone thrombopoietin which is produced by the liver and kidneys. When these
receptors are in place, the haemocytoblast becomes a committed cell called a
megakaryoblast. This replicates its DNA, producing a large cell called a megakaryocyte,
which breaks up into tiny fragments that enter the bloodstream. About 25-40% of the
platelets are stored in the spleen and released as needed. The remainder circulate
freely in the blood are live for about 10 days.

Erythrocytes/Red Blood Cells (RBCs)

Red blood cells (RBCs), also known as erythrocytes, have two main functions:

1. To pick up oxygen from the lungs and deliver it to tissues elsewhere

2. To pick up carbon dioxide from other tissues and unload it in the lungs
An erythrocyte is a disc-shaped cell with a thick rim and a thin sunken centre. The
plasma membrane of a mature RBC has glycoproteins and glycolipids that determine a
person's blood type. On its inner surface are two proteins called spectrin and actin that
give the membrane resilience and durability. This allows the RBCs to stretch, bend and
fold as they squeeze through small blood vessels, and to spring back to their original
shape as they pass through larger vessels. RBCs are incapable of aerobic respiration,
preventing them from consuming the oxygen they transport because they lose nearly all
their inner cellular components during maturation. The inner cellular components lost
include their mitochondria, which normally provide energy to a cell, and their nucleus,
which contains the genetic material of the cell and enable it to repair itself. The lack of a
nucleus means that RBCs are unable to repair themselves. However, the resulting
biconcave shape is that the cell has a greater ratio of surface area to volume, enabling
O2 and CO2 to diffuse quickly to and from Hb. The cytoplasm of a RBC consists mainly
of a 33% solution of haemoglobin (Hb), which gives RBCs their red colour. Haemoglobin
carries most of the oxygen and some of the carbon dioxide transported by the blood.
Circulating erythrocytes live for about 120 days. As a RBC ages, its membrane grows
increasingly fragile. Without key organelles such as a nucleus or ribosomes, RBCs
cannot repair themselves. Many RBCs die in the spleen, where they become trapped in
narrow channels, broken up and destroyed. Haemolysis refers to the rupture of RBCs,
where haemoglobin is released leaving empty plasma membranes which are easily
digested by cells known as macrophages in the liver and spleen. The Hb is then further
broken down into its different components and either recycled in the body for further use
or disposed of.

White Blood Cells (WBC)

White blood cells (WBCs) are also known as leukocytes. They can be divided into
granulocytes and agranulocytes. The former have cytoplasms that contain organelles
that appear as coloured granules through light microscopy, hence their name.
Granulocytes consist of neutrophils, eosinophils and basophils. In contrast,
agranulocytes do not contain granules. They consist of lymphocytes and monocytes.

1. Granulocytes
 1. Neutrophils These contain very fine cytoplasmic granules that can be seen
under a light microscope. Neutrophils are also called polymorphonuclear
(PMN) because they have a variety of nuclear shapes. They play roles in
the destruction of bacteria and the release of chemicals that kill or inhibit
the growth of bacteria.

2. Eosinophils These have large granules and a prominent nucleus that is

divided into two lobes. They function in the destruction of allergens and
inflammatory chemicals, and release enzymes that disable parasites.

3. Basophils They have a pale nucleus that is usually hidden by granules.

They secrete histamine which increases tissue blood flow via dilating the
blood vessels, and also secrete heparin which is an anticoagulant that
promotes mobility of other WBCs by preventing clotting.

2. Agranulocytes

1. Lymphocytes These are usually classified as small, medium or large.

Medium and large lymphocytes are generally seen mainly in fibrous
connective tissue and only occasionally in the circulation bloodstream.
Lymphocytes function in destroying cancer cells, cells infected by viruses,
and foreign invading cells. In addition, they present antigens to activate
other cells of the immune system. They also coordinate the actions of
other immune cells, secrete antibodies and serve in immune memory.

2. Monocytes They are the largest of the formed elements. Their cytoplasm
tends to be abundant and relatively clear. They function in differentiating
into macrophages, which are large phagocytic cells, and digest
pathogens, dead neutrophils, and the debris of dead cells. Like
lymphocytes, they also present antigens to activate other immune cells.
Platelets
Platelets are small fragments of bone marrow cells and are therefore not really
classified as cells themselves. Platelets have the following functions:

1. Secrete vasoconstrictors which constrict blood vessels, causing vascular spasms

in broken blood vessels

2. Form temporary platelet plugs to stop bleeding

3. Secrete procoagulants (clotting factors) to promote blood clotting

4. Dissolve blood clots when they are no longer needed

5. Digest and destroy bacteria

6. Secrete chemicals that attract neutrophils and monocytes to sites of inflammation

7. Secrete growth factors to maintain the linings of blood vessels

VII. Medical Management
A. Medical Orders
Doctor’s Order
Date Order
7-31-08  For repeat CXR-pal ( semi
setting if able then secure
to please retrieve CXR
films
 Repeat CBC
 Please ff-up official 2d echo
result
 Planned Home care resid-
ent in-charges efforts highly
appreciated
 Thank you
 Family meeting was done
in the presence of pt. hus-
4pm
band jun and mother-in-law
Alice
 Jun will stand as primary
breadwinner and Alice the
caregiver
 The family perception as
the pt. condition were soli-
cited and confusion ques-
tion clarified
 Roles were identified as
previously noted
 Still facilitating financial as-
sistance for procurement of
suction machine
 Home care priorities were
also discussed
 Please ff-up pt. coordinate
with AP regarding FHCP
enrollment
 Thank you
8-01-08  Dr. Basaerg’s (Famed res-
ident) efforts highly appre-
ciated
Rationale
 For evaluation and
determination of
pt.’s condition.
 For prior determin-
ation of pt.’s condi-
tion
 For evaluation and
determination of
pt.’s condition.
 For home care of
pt. when dis-
charge
 Determination of
roles in the family
 For prior planning
of pt.’s condition
 Determination of
roles in the family
 For the pt.’s help
in finances
 For pt.’s continue
of care at home
 For pt.’s support at
finance
 For pt’s assistance
 For more evalu-
  Please repeat PTPA at 6am ation of pt.’s condi-
tomorrow tion
 For financial sup-
 Please remind husband of port
pt. PCSO  For financial
 Medical abstract form to fa- Support
cilitate financial assistance
in preparation for home
care  For continuity of
 Review of meds pt.’s treatment pro-
cess.
• to decrease
1. Propranalol tid as the ff. cardiac work-
• 40 mg at am dose load
• 10 mg
• 10 mg
• to decrease
2. Captopril 25 mg ¼ bid cardiac work-
load
• for cerebral in-
3. Citicoline drops 5cc bid sufficiency
• anti platelet
4. Aspirin 80 mg OD after
lunch • anti-infective
5. Mupirocin + petroleum jelly
as ordered • iron supple-
6. Ferrous Sulfate bid after ment
meals • appetite stimu-
7 Heraclene 3 mg bid
lant
8-2-08  SCIC to prep. Discharged  For preparation of
summary discharge
 To xerox lab flow sheet,  For pt.’s own re-
ecg, CXr result-(2 copies) cord for future
lates 2 result of PTR;Latest comparison
CBC, NA, K, creatinine
 For possible discharge  Pt. is ordered to
be discharge
 Will confirm with home care  For prior for home
properly care
 Cont. meds.  For continuity of
pt.’s treatment pro-
cess
 Cont. nursing care  For proper care of
pt.’s condition
8-4-08  For discharge once confer-  For prior dis-
 ence with Famed home charged
care resident is done
Generic Date Classificatio Dose/ May go for billing Specific
Mechanism  For computation
Contraindicati Side of Nursing
name Ordered n Frequecy of action Indication on paymenteffects Precaution
(Brand) Route
 SCIC to ff-up official result  For prior dis-
Petroleum 08-01-08 Emollients & BID over First it helps Softens dry charged
Contrindicated Burns, Tell patient
jelly Skin buttocks keep the skin, iin those Nasal and family to
Protectives and neck
 Homeoutside
meds to induced soothes patient
 with congestionof
For continuity watched and
areas (esp. world out - it chapped Acne-prone or or drynes, report any
pt.’s treatment pro-
those protects skin skin, minor greasy skin. Sex with signs od
reddish from the burns & cess. latex adverse
parts). 1.effects
Propanalol
of 10 mg tid
minor • to condoms,
decrease reaction.
weather and scrapes, cardiac work-
exposure. helps load
Second, it prevent
2.acts
Captopril 25 mg ¼ • to decrease
like a diaper rash.
bid to
sealant cardiac work-
help keep load
3.theCiticoline
inside drops 5cc • for cerebral in-
world
bid in - it
sufficiency
4.forms an
Aspirin 80 mg OD
occlusive • anti platelet
aftertolunch
barrier
5.theFerrous
natural Sulfate bid
afterloss
water meals
of • iron supple-
6.ourHeraclene
skin. So 3 mg bid ment
skin that is • appetite stimu-
dry and
lant
chapped is
 Cont.protected
good nursing care
from drying  For continuity of
 Resume elements,
coumadin 3.5 mg pt.’s care
enabling
OD skin-  For continuity of
softening treatment man-
moisture to agement
build up
naturally
from inside
the skin
itself.
8-05-08  Follow up CXR please And  For prior determin-
Cranial scan result with ation of pt.’s condi-
FAMED home care resid- tion
ent is done
 MGH- for billing  For pt.’s to be dis-
charge

B. Drug Study
Generic Date Classification Dose/ Mechanism Specific Contraindication Side
name Ordered Frequecy of action Indication effects
(Brand) Route
Mupirocin 08-01-08 Topical 80 mg OD Mupirocin is a Treatment for Containdicated Immun
ointment antibiotic after lunch novel infection in patients System
( sample ( 1p.m) antibiotic hypersensitive Disorde
brand name: produced to mupirocin or System
Bactroban through any of its allergic
fermentation constituents. reactio
by Skin an
Pseudomona Subcut
s fluorescens. Tissue
Mupirocin Disorde
inhibits Burning
isoleucyl localize
transfer-RNA the are
synthetase, applica
thereby Itching,
arresting erythem
bacterial stinging
protein drynes
synthesis. localize
the are
applica
cutane
sensitiz
reactio
Generic Date Classification Dose/ Mechanism Specific Contraindication Side
name Ordered Frequecy of action Indication effects
(Brand) Route

Citicoline 08-01-08 Cerebral 5 cc BID Citicoline is an CVA, in acute Containdicated Increas

drops activator. interneuronal recovery phase, in patients parasym
(Zynapse) communication in signs & hypersensitive effects,
enhancer. It symptoms of to drug and & discr
increases the cerebrovascular other related hypoten
neurotransmission insufficiency & drugs. effect
levels because it in cranial
favors the traumatism &
synthesis and their sequelae.
production speed
of dopamine in
the striatum,
acting then as a
dopaminergic
agonist thru the
inhibition of
tyrosine-
hydroxylase.

Generic Date Classification Dose/ Mechanism Specific Contraindication Side

name Ordered Frequecy of action Indication effects
(Brand) Route
Propanolol 08-01-08 Antianginals TID A nonselective Long term Contraindicated CNS:f
40 mg (8 beta blocker management in patients with Fever,
a.m) that reduces of cardiac bronchial heada
10 mg (1 cardiac oxygen arrhythmias. asthma, sinus Dizzin
p.m) demand by bradycardia, CV:
10 mg (6 blocking cardiogenic bradyc
p.m) catecholamine- shock, and hypote
induced overt and heart
increases in decompensated GI:
heart rate, heart failure abdom
blood (unless failure is cramp
pressure, and secondary to a consti
force of tachyarrhythmia diarrh
myocardial that can be nause
contraction. treated with Vomiti
Depresses propranolol. Skin: r
renin
secretions and
prevents
vasodilation of
cerebral
arteries.

Generic Date Classification Dose/ Mechanism Specific Contraindication Side

name (Brand) Ordered Frequecy of action Indication effects
Route
Warfarin 08-01-08 Anticoagulant 3.5 mg Inhibits Vitamin Prevention Contraindicated CNS:
(Coumadin) OD K- dependent and in patients heada
activation of treatment of hypersensitive fever
clothing factors venous to drug and in GI: an
II, VII, IX, and X, thrombo- those with Nause
formed in the Embolism. bleeding from vomitin
liver. the GI, GU, or diarrhe
respiratory tract, GU:
cerebrovascular hemat
hemorrhage. excess
menst
Avoid using in bleedin
patients with a Hemat
history of hemor
warfarin- Skin:
indused necros
necrosis; in rash.
unsupervised
patients with
semility,
alcoholism.
 Date Dosage
Generic Classifica- Mechanism Specific Contraindica- Adverse Effects Nursing
Ordere and
Name tion of Action Indication tion Precaution
d Route

Provide ele- To correct CNS:Nausea, -give on an

Ferrous 8-1-08 Anti-anemia 1 tab Contraindicated
mental iron, iron heat burn,anor- empty stom-
sulfate BID 2 in patients with exia,constipation, ach but
an essential deficiency
diarrhea (bet.meals).
Not indicated hours component anemia –
Drug can be
(ex. Brand after in the form- GI:epigastric given with
ation of pain, vomiting, some foods,
name: Feosol lunch -hemo-lytic
hemoglobin constipation, although ab-
anemia, (in black stools, sorption may
diarrhea, anorex- be de-
absence of iron
ia. creased.
deficiency)
- tell pt. to
-peptic
take tablets
ulceration, with juice or
water, but
-and in those
not milk or
receiving antacids.
repeated blood
- monitor pt.
transfusions. laboratory
results
-be aware
that IRON
preparation
cause dark
green or
block stool
 Date Dosage
Generic Classifica- Mechanism Specific Contraindica- Adverse Effects Nursing
Ordere and
Name tion of Action Indication tion Precaution
d Route

Inhibits For -CNS:Dizziness, - monitor pa-

Captopril 8-1-08 ACE inhibit- 25 mg ¼ Contraindicated
ACE, pre- hypertensio fainting, head- tient’s BP
Not indicated or: tab BID in patients ache, fatigue, and pulse
venting con- n
fever, nausea, rate fre-
(ex. Brand Anti-hyper- version of hypersensitive
vomiting, quently
name: Capo- tensive angiotensin to drug and
I to an- GI:abdominal - advise pt.
ten) other ACE
giotesnin pain, bed rest.
II, a potent inhibitor constipation,
vasocon- diarrhea, -monitor pa-
tient intake
strictor.
Hematology; and out
Less an- anemia,
giotensin II hyperkalemia, -monitor
decreases therapeutic
peripheral -RESP:dyspnea, effectiveness
arterial res- dry persistent
istance, de- nonproductive
cough.
creasing al-
dosterone -skin:
secretion, urticaria,pruritus
which re-
duces sodi-
um and wa-
ter retention
and lower
blood pres-
sure.
 Date Dosage
Generic Classifica- Mechanism Specific Contraindica- Adverse Effects Nursing
Ordere and
Name tion of Action Indication tion Precaution
d Route

Inhibits Use to -CNS:Dizziness,

Aspilit (aspir- 8-1-08 antiplatelet 80 mg -Contraindicate
platelet ag- reduce fainting, head- -administer
in) OD after d ache, fatigue, medication
gregation reoccurrenc
fever, with meal to
lunch thus redu- e of TIA in patients
abdominal pain prevent GI ir-
cing ability due to firin hypersensitive ritation
of blood clot platelet -GI:constipation,
to drug
emboli and diarrhea, nausea, - monitor pa-
risk of -GI ulceration, vomiting, tient’s BP
stoke and pulse
bleeding
Hematology: rate fre-
_vitamin K anemia, quently
-to relieve hyperkalemia,
pain of low deficiency
- assess pa-
to -RESP:dyspnea, tient for
moderate dry persistent signs drug
intensity nonproductive toxicity
cough.
- consult
-Skin:petechiae, physician be-
easy bruising fore using
and rash aspirin for
any fever ac-
-special senses; companied
hearing by rash, and
loos,tinnitus severe head-
ache

Date Dosage
Generic Classifica- Mechanism Specific Contraindica- Adverse Effects Nursing
Ordere and
Name tion of Action Indication tion Precaution
d Route

Increases - use to There is no

Dibencozide 8-1-08 Appetite 3 mg 1 -Contraindicate
the protein increase negative effect -assess for
(heraclene) stimulant cap BID d when taken in the effective-
efficiency appetite for
recommended ness of the
coefficient. faulty in patients
dosage. only drug
Manifested nutrition or hypersensitive increased in
by a marked patient with energy, strength - -monitor lab
to drug
increase of pernicious and muscle mass results espe-
appetite. anemia -GI ulceration, cially red
Thus facilit- blood cells
bleeding
count
ates utiliza- -low
tion of pro- energy, - it is more
tein dietary slow effective if
intake. Con- muscle drug would
tribute to the growth and be given with
formation energy milk
and repair
of the body
tissues and
stimulates
appetite.
VIII. Diagnostic Test and Laboratory Exam

RADIOLOGIC REPORT
July 30, 2008 Nursing
Results References
implications
Prothrombin Time
Protime Prolong protime
indicates deficiency
66.9 s 9.5-12sec.
of fibrinogen factors
XII
Control Low control
indicates impaired
13.1 s 14 sec. deficiency factors
VIII(antihemophiliac
factor)
Prothrombin Activity 19.5 %
Activated Partial Prolong APTT
Thromboplastin Time Prolonged 32-39sec. indicates necrosis
of the brain
July 26,2008
Prothrombin Time
Protime Prolong protime
indicates deficiency
21.8 s 9.5-12sec.
of fibrinogen factors
XII
Control Low control
indicates impaired
13.1 s 14sec. deficiency factors
VIII(antihemophiliac
factor)
INR 1.66 1.0 No therapy
July 20,2008
Prothrombin Time
Prolong protime
indicates deficiency
18.55 s 9.5-12sec.
of fibrinogen factors
XII
Control Low control
indicates impaired
in deficiency of
13.0 s 14sec.
factors
VIII(antihemophiliac
factor)
INR 1.42 1.0 No therapy
July 24, 2008

Impression:
1. Cardiomegaly- mitral form with waxing and waning pulmonary edema cannot
rule out an intercurrent pneumonia.
2. Tracheostomy tube in SITU
3. Pleural Effusion, right – Resolved

MICROBIOLOGY

July 16, 2008

Specimen: ETA
Direct Smear: Epithelian cells: few
Pus cells: moderate
Gram (-) rods: moderate

Organism isolated: Moderate heavy growth of Enterobacter spp.

ULTRASOUND

July 2, 2008

Diagnosis:

Minimal Ascites
Focal ileus
Normal ultrasound findings in the uterus and right ovary

BLOOD TYPING
July 16, 2008

Blood Type: A
Rh: Positive
HEMATOLOGY
July 16, 2008
Test Result Unit Reference Rationale

WHITE BLOOD 9,000 10^3/u 5,000-10,00 Within normal limit

CELLS L

RED BLOOD CELLS 3.85 10^6/u 4.20-5.40 Decreased results

L indicate anemia.

HEMATOCRIT 30.7 % 37.0-47.0 Decreased hematocrit

Indicates anemia
Decreased mean
MCV 79.9 cu um 84-96 cu um corpuscular volume
indicates microcytic
anemia
Decreased in mean
MCH 26.0 Cu um 28-33 corpuscular
hemoglobin indicates
microcytic anemia
Decreased mean
corpuscular
MCHC 32.6 % 33-35 hemoglobin
concentration
indicates severe
hypochromic anemia
Differential Count
Low lymphocyte count
Lymphocytes 14.3 % 17.4-48.2 indicates aplastic
anemia
Neutrophils 78.1 % 43.4-76.2 Increased neutrophils
indicates acute
infections
Monocytes 7.5 % 4.5-10.5 Within normal limit
Eosinophils 0.1 % 1.0-3.0 Decreased eosinophils
indicates stress
Basophil 0.0 % 0.0-2.0 Within normal limit
Platelet Count 557 Cu mm 150,00- Increased platelet
400,00 indicates malignancy
 HEMATOLOGY
July 26, 2008
Test Result Unit Reference Nursing implications

WHITE BLOOD 13,300 10^3/u 5,000-10,00 Increased WBC

CELLS L indicates infections
Decreased RBC
RED BLOOD CELLS 3.71 10^6/u 4.20-5.40 indicates anemia
L
Decreased
HEMOGLOBIN 10.1 G/dL 12.0-16.0 hemoglobin indicates
anemia
Decreased hematocrit
HEMATOCRIT 31.8 % 37.0-47.0 indicates anemia

MCV 85.7 cu um 84-96 cu um Within normal limit

Decreased in mean
MCH 27.2 Cu um 28-33 corpuscular
hemoglobin indicates
microcytic anemia
Decreased mean
corpuscular
MCHC 31.8 % 33-35 hemoglobin
concentration
indicates severe
hypochromic anemia
Differential Count
Low lymphocyte count
Lymphocytes 10.9 % 17.4-48.2 indicates aplastic
anemia
Increased neutrophils
Neutrophils 83.9 % 43.4-76.2 indicates acute
infections
Monocytes 4.8 % 4.5-10.5 Within normal limit
Decreased
Eosinophils 0.4 % 1.0-3.0 eosinophils indicates
stress
Basophil 0.0 % 0.0-2.0 Within normal limit
adequ Cu mm 150,00- Within normal limit
Platelet Count ate 400,00
 HEMATOLOGY
July 31, 2008
Test Result Unit Reference Nursing implications

WHITE BLOOD 8,500 10^3/u 5,000-10,00 Within normal limit

CELLS L
RED BLOOD CELLS 4.00 10^6/u 4.20-5.40 Decreased results
L indicate anemia
HEMOGLOBIN 10.3 G/dL 12.0-16.0 Decreased results
indicate anemia
Decreased results
HEMATOCRIT 33.3 % 37.0-47.0 indicate anemia
Decreased mean
MCV 83.3 cu um 84-96 cu um corpuscular volume
indicates microcytic
anemia
Decreased in mean
MCH 25.8 Cu um 28-33 corpuscular
hemoglobin indicates
microcytic anemia
Decreased mean
corpuscular
MCHC 30.9 % 33-35 hemoglobin
concentration
indicates severe
hypochromic anemia
Differential Count
Low lymphocyte count
Lymphocytes 13.6 % 17.4-48.2 indicates aplastic
anemia
Increased neutrophils
Neutrophils 80.1 % 43.4-76.2 indicates acute
infections
Monocytes 5.1 % 4.5-10.5 Within normal limit
Eosinophils 1.1 % 1.0-3.0 Within normal limit
Basophil 0.1 % 0.0-2.0 Within normal limit
150,00- Increased platelet
Platelet Count 493 Cu mm 400,00 indicates malignancy
VIII. Nursing Management

A. Ideal Nursing Care Plan

Problem 1

Nursing Diagnosis Interventions Rationale

Decrease Cardiac Independent

Output related to
altered myocardial - Administer supplemental - To assess degree of
contractility/inotropi oxygen as indicated to debilitation
c changes increase oxygen avail-
able to tissues

- Assist with or perform - To assess degree of

self-care activities for cli- debilitation
ent.

- Encourage relaxation - To promote venous re-

techniques to reduce turn.
anxiety

- Monitor intake/output - To maintain adequate

and calculate 24-hour nutrition and fluid bal-
fluid balance ance

Dependent:
- Administer drugs as - To promote therapeutic
ordered wellness
Problem 2

Nursing Diagnosis Interventions Rationale

Independent:
Activity Intolerance
related to - Encourage expression of - To assist client to deal
generalized feelings contributing with contributing
weakness to/resulting from condi- factors and manage
tion activities within indi-
vidual limits
- Promote comfort meas- - To assist client to deal
ures and provide for re- with contributing
lief of pain to enhance factors and manage
ability to participate in activities within indi-
activities vidual limits
- Assist client in learning - To promote wellness
and demonstrating ap- (teaching/discharge
propriate safety meas- considerations)
ures to prevent injuries
- Encourage client to
maintain positive atti- - To promote wellness
tude; suggest use of re- (teaching/discharge
laxation techniques, considerations)
such as
visualization/guided im-
agery as appropriate to
enhance sense of well-
being
- Provide/monitor re-
sponse to supplemental - To assist client to deal
oxygen & meds & with contributing
changes in treatment re- factors and manage
gimen activities within indi-
vidual limits
Problem 3

Nursing Diagnosis Interventions Rationale

Independent:
Ineffective tissue
perfusion related to - Monitor vital signs in- - To monitor vital signs
myocardial damage cludes BP, RR, PR and
(small infarcts, iron temperature
deposits, fibrosis)
- Encourage quiet, restful - To maximize tissue
atmosphere. perfusion

- Caution client to avoid - To maximize tissue

activities that increases perfusion
cardiac workload

- Monitor for signs of - To maximize tissue

bleeding during use of perfusion
fibrinolytic agents

Dependent:

- Administer medications - To promote therapeutic

as ordered wellness
Problem 4

Nursing Diagnosis Interventions Rationale

Independent:
Imbalanced Nutrition
less than body - Discuss eating habits, - To assess
requirement related including food prefer- causative/contributing
to failure to ences, intolerance/aver- factors
ingest/digest food or sions to appeal to clients
absorb nutrients likes/desires
necessary for
formation of RBC as - Encourage client to
evidence by weight choose foods that are - To establish nutritional
loss appealing to stimulate plan that meets indi-
appetite vidual needs

- Limit fiber/bulk if indic-

ated because it may - To establish nutritional
lead to early satiety plan that meets indi-
vidual needs
- Promote pleasant, relax-
ing environment, includ- - To establish nutritional
ing socialization when plan that meets indi-
possible to enhance in- vidual needs
take

- Emphasize importance
of well-balanced, nutri- - To promote wellness
tious intake.
Problem 5

Nursing Diagnosis Interventions Rationale

Independent:
Impaired gas
exchange related to - Monitor vital signs and - To assess causative
altered blood flow cardiac rhythm factors

- Elevate head of bed/po- - To correct/improve ex-

sition client appropri- isting deficiencies
ately, provide airway ad-
juncts and suction as in-
dicated to maintain air-
way

- Reinforce need for ad- - To promote wellness

equate rest, while en-
couraging activity within
client’s limitations

- Instruct the use of relax- - To promote wellness

ation, stress-reduction
techniques as appropri-
ate

Dependent:

- Administer medications - To promote therapeutic

as ordered wellness
Problem 6

Nursing Diagnosis Interventions Rationale

Independent:
Deficient knowledge
regarding - Provide information rel- - To assess client’s mo-
complications evant to the situation tivation
related to lack of
information - Provide positive rein- - To assess client’s mo-
forcement (encourages tivation
continuation of efforts)

- Discuss client’s percep-

tion of need. Relate in- - To establish priorities in
formation to client’s per- conjunction with client
sonal desires/needs and
values/beliefs

- Provide written informa- - To facilitate learning

tion/guidelines for client
to refer to as necessary.
Reinforces learning pro-
cess

- Provide an environment - To facilitate learning

that is conducive to
learning
 B. Nursing System Review Chart

Day 1

Date: August 3, 2008

Vital Signs:
Temp: 36.7 ºC Pulse: 68 bpm BP: 100/90mmHg Respiration: 30 cpm
Height: 5’0” Weight: 35 kg

Sunken
eyeballs
Tracheostomy
tubing

Generalized
body malaise
Bed sore

Cold clammy
skin

Poor muscle
tone
 Day 2
Date: August 4, 2008

Vital Signs:
Temp: 36.8 ºC Pulse: 65 bpm BP: 100/90mmHg Respiration: 25 cpm
Height: 5’0” Weight: 35 kg

Sunken
eyeballs
Tracheostomy
tubing

Generalized
body malaise

Bed sore
Cold clammy
skin

Poor muscle
tone
 Day 3
Date: August 5, 2008

Vital Signs:
Temp: 37.5 ºC Pulse: 70 bpm BP: 100/80mmHg Respiration: 27 cpm
Height: 5’0” Weight: 35 kg

Sunken
eyeballs

Tracheostomy
tubing

Generalized
body malaise
Bed sore
Cold clammy
skin

Poor muscle
tone
C. Actual Nursing Care Plan

CUES DIAGNOSIS OBJECTIVES INTERVENTION RATIONALE EVALUATION

Independent:

Objectives: Potential for At the end of 1. Observed color/ 1. Yellow/ green At the end of 24
infection 24 to 48 hours odor character- purulent odorous to 48 hours of
• Attached related to of nursing, isticsof sputum. sputum is indic- nursing
tracheos invasive intervention, Note drainage ate of infection; intervention,
tomy tube procedure- patient will be around tracheo- while thick, tena- patient was
• Long hospital tracheostomy protected from stomy tube. cious sputum protected from
–lization tube attached. possible 2. Reduced noso- suggests dehyd- possible potential
potential comial risk ex. ration. infection.
infection. Handwashing, 2. These factors
maintaining may be the
sterile suction simplest but are
technique. the most import-
ant keys ito pre-
3. Encouraged vention of hospit-
deep breathin, al-acquired-infec-
coughing and tion.
frequent position 3. Maximizes lung
changes. expansion and
4. Instructed Signi- mobilization of
ficant others and secretions to pre-
 patient in proper vent/reduce ac-
secretion dispos- cumulation of se-
al ex. Tissues cretions.
soiled tracheo- 4. Reduces trans-
stomy dressing. mission of fluid-
borne organisms.
Dependent:

5. Administer anti-
microbials as in- 5. One or more
dicated. may be used de-
pendent on iden-
tified pathogens
if infection does
occur.
CUES DIAGNOSIS OBJECTIVES INTERVENTION RATIONALE EVALUATION
 Independent:

Objectives: Altered At the end of 3 1. Monitored pa- 1. These symp- At the end of 3
Nutrition: less days to 1 tient’s general- toms are in- days to 1 week
• poor than body week nursing ized muscle wast- dicative of de- nursing
muscle requirements. intervention, ing. pletion of intervention,
tone patient will be 2. Documented oral muscle en- patient was able
• poor skin able to intake if/when ergy and can to increased
turgor increase body consumed. Offer reduce respir- body weight to a
• body mal- weight to a foods that patient atory muscle more desirable
aise more enjoys. function. weight within
• Sunken desirable 3. Providedsmall 2. Appetite is normal limits.
eyeballs weight within frequent feedings usually poor
normal limits. of soft/ easily di- and intake of
gested foods if essential nu-
able to swallow. trients may be
reduced. Of-
Dependent: fering favorite
foods can en-
4. Administer fluid hance oral in-
intake of atleast take.
2500 ml/ day 3. Prevents ex-
within cardiac tol- cessive fa-
erance. tigue,en-
5. Adjusted diet with hances intake
help of dietician and reduces
to meet respirat- risk of gastric
ory needs. distress.
4. Prevents de-
hydration that
can be ex-
acerbated by
increased in-
sensible
losses and re-
duces risk of
constipation.
 CUES DIAGNOSIS OBJECTIVES INTERVENTION RATIONALE EVALUATION

Independent:

Objectives: Activity At the end of 1. Adjusted activit- 1. Prevents over- At the end of 24
intolerance 24 hours ies as neces- exertion, al- hours nursing
• weak in ap- related to nursing sary, reducing lows for some intervention
pearance generalized intervention intensity level/ activity within patient was able
• limited range weakness. patient will be discontinuing patient ability. to remain free of
of motion able to remain activities as in- 2. Provides for preventable
• decreased free of dicated. sense of con- discomfort.
performance preventable 2. Encouraged pa- trol and feeling
• inability to discomfort. tient to do of accomplish-
maintain usu- whatever pos- ments.
al routines sible ex. Self 3. Enhances per-
care. formance
3. Stressed ne- while con-
cessities in of serving limited
allowing for fre- energy, pre-
quent rest peri- venting in-
ods. crease in level
4. Encouraged nu- of fatigue.
tritional intake/ 4. Necessary to
use of supple- meet energy
ments as ap- needs for
propriate. activity.
5. Increase oxy-
genation.
Evaluates
 eefctiveness in
Dependent: therapy.

5. Administer O2
at 2l/min to sus-
tain patient oxy-
genation, if ne-
cessary.

CUES DIAGNOSIS OBJECTIVES INTERVENTION RATIONALE EVALUATION

 Independent:

Objectives: Anxiety related At the end of 1. Noted narrowed 1. Narrowed focus At the end of 72
to change in 72 hours to 1 attentions. usually reflects hours to 1 week
• Feelings of health status week of 2. Identified pa- extreme fear/ of nursing,
helpless and nursing, tient’s/ significant panic. intervention,
-ness hospitalization. intervention, others percep- 2. Regardless of patient
• Facial ten- patient will be tion of the situ- the reality of the demonstrated
sion able to ation. situation, per- sense of health
• Fear on of demonstrate 3. Evaluated cop- ception affects illness
unspecific sense of health ing/ defense how each indi- awareness.
con-se- illness mechanisms be- viduals deals
quence awareness. ing used to deal with the illness.
with the per- 3. May be dealing
ceived. well with the situ-
4. Maintained fre- ation at the mo-
quent contact ment ex. Denial
with person/SO. and regression
Be available for may be helpful
listening and coping mechan-
talking as ism.
needed. 4. Establishes rap-
port, promotes
5. Stay with the pa- expression of
tient as indic- feelings and
ated. helps patient
deal with the ill-
ness.

5. Continuous sup-
port may help
patient regain in-
ternal focus of
control and re-
duce anxiety.
X. Progress Notes

First Day Assessment

August 3, 2008

General Objectives:

At the end of 5 days assessment and implementing nursing intervention the

group will be able to gather all data for the case analysis of the patient’s health condition

implement necessary nursing interventions and evaluate his daily progress.

Specific Objectives:

At the end of 5 hours, the group will be able to:

• Establish rapport and trust

• Systematically assess and obtain the baseline data of our patient

• Identify problem with regards to the patient condition

• Carryout necessary intervention for the identified problems

Evaluation:

On the first day of our assessment in Northern Mindanao Medical Center,

Intensive Care Unit, the group had established rapport with the patient and to her family.

The group explained our intention and purpose of this study, in a way that both the

patient and her Family would not misinterpret our action during the care and

assessment. The patient was lying down in the bed with Tracheostomy tube and had no

IV line. Bed sore was noted on her left side of her inguinal area. Vital Signs were taken

and recorded with the following result: BP: 100/90 mmHg, Temp: 36.7ºC, Pulse Rate:
68 bpm, Resp. Rate: 30 cpm. The patient was manifesting from dyspnea since his

Resp. Rate was 30 cpm. We positioned the patient in semi fowlers positioned and leave

comfortably.

After 5 hours, interaction with the patient performing intervention, the patient was

able relieved from dypsea with Resp. rate of 25 cpm.

Second Day of Care

August 4, 2008

Specific Objectives:

At the end of 8 hours, the group will be able to:

• Further assess the patient’s condition

• Perform necessary interventions for the identified problems

• Evaluate the patients response to the performed interventions

Evaluation:

On the second day, the vital signs were monitored and recorded with the

following results BP: 100/90 mmHg, Temp: 36.8 ºC, Pulse Rate: 65 bpm, Resp. Rate: 25

cpm. The patients O2 Saturation were monitored closely for every two hours. Vital

Signs, Intake and output were Monitored every four hours. The patient had difficulty in

coughing. Still bed sore was noted. We taught patient about range of motion and it’s

Importance. We position the patient In semi fowlers position.

After 8 hours, upon intervention done, patient was able was to perform Range Of

motion exercises and prevented bed sore by proper positioning and winkle free.
 Third Day of Care

July 22, 2008

Specific Objectives:

• Continue care of Patient

• Observe Patient’s health progress

• Perform necessary intervention for the identified problems

Evaluation:

On the third day of care, Vital signs were taken and recorded with the following

result: BP: 100/80 mmHg, Temp: 37.5 ºC, Pulse Rate: 70 bpm, Resp. Rate: 27 cpm. we

had established rapport to the patient, she was very cooperative, we turned the patient

side every two hours, we encourage patient to have deep breathing exercise and

coughing. We position patient in semi fowler’s position.

After 8 hours intervention the patients was able to expectorate phlegm. And bed

sore was prevented by Changing in position at Interval. We leave the patient

comfortably and winkle free.

X. A. Prognosis

Patient X is assessed with the following criteria to determine its prognosis

regarding his condition.

CRITERIA GOOD POOR REMARK

The patient is 23years old and thus still
has a strong disposition to survive.
Onset of illness / Unfortunately, there is a sudden
complications arising her condition in
which patient X is suffering right now.
Patient X’s case is a life-threatening
disorder but with immediate and proper
management, complications can be
prevented but since the patient lacks
Duration of illness / compliance with the medications due to
financial constraints, she has a poor
prognosis with this criteria because it will
take a long time for her to recover due to
the complications occuring her condition.
Precipitating / Patient X’s condition is deteriorating. This
factors triggers during her pregnancy period since
she wasn’t able to have a complete
prenataI. With this, she develops anemia
leading to severe blood loss. it is a
traumatic injury from which a lot of repair
is needed to be done because the heart is
 affected which is the vital organ for
pumping blood.
Patient X is cooperative enough upon
Attitude and
taking her prescribed medications. With
willingness to take
/ regards to the health teachings we’ve
medications and
imparted to her, she never refuses to
treatment
listen.
She has a good family support from her
parents. Her family are there taking care
of her and assists her with her needs as
Family support / well as encouraged her to get better soon.
Hers family really tried so hard to come up
with the necessary finances with regards
on her medications for her faster recovery.
The patient is not able to comply with all
the necessary medications as ordered by
the physician since they do not have an
Financial support /
adequate financial support. But still his
family tried their best to come up with the
medications though it was delayed.

Based on the result that the group had gathered, the group rated the patient a poor
prognosis as indicated with the six criterias given. Though patient X has a strong
disposition to survive, capabilities, and is determined to get well, but then her conditions
is deteriorating indeed and different organs are now affected. Certainly, this cannot be
abruptly cured.
B. Discharge Plan

Medication

- Encouraged patient to have strict adherence to the medication to attain

their therapeutic effects.

- Instructed patient and the family to strictly follow the orders for take home
medication such as its timing, dosage, and precautions upon discharge as
prescribed by the physician such as:

• Aspirin
• Captopril
• Citicholine
• Dibencozide
• Ferrous sulfate
• Propanolol
• Warfarin

Activity/Exercise

- Encouraged patient to have adequate rest and engaged only in light

activities.

- Encouraged patient to perform Active-Passive Range of Motion Exer-

cise to encourage normal muscle function everyday.

- Encouraged patient to avoid fatigue.

- Instructed the family members to let the patient turn to sides while on
bed to prevent bed sores.

Treatment

- Encouraged a responsible member of the family to serve as treatment

partner who will constantly remind about the timing of medications.
-
- Emphasized to the patient and the family members the importance of
proper personal hygiene.

- Instructed the family members of the patient to always listen to the

concerned that the patient to relieve her anxiety.
Diet

- Encouraged patient to eat foods that are rich in Iron like meat organs,
green leafy vegetables, fish, poultry products and meat to prevent anemia.

- Instructed patient to increase intake of foods that are rich in Vitamin C

like citrus fruits and juices and tomatoes to enhance Iron absorption.

- Encouraged patient to eat foods that are high in fibers like pineapple to
prevent constipation

Out-patient/Follow-Up

- Reminded patient and the family members to return to Dr.Watamama at

Northern Mindanao Medical Center Out Patient Department for follow up
check up 1 week prior to discharge.

- Encouraged patient to visit regularly to the nearest Health Center in their

barangay in Baloy Cagayan de Oro City.
XI. Evaluation and Recommendation

Since rheumatic fever is the cause of rheumatic heart disease, the best treatment
is to prevent rheumatic fever from occurring.we make sure in everyday vital signs that it
should be lowered in Temperature when we care for Patient X. Mupirocin ointmentPeni-
cillin and other antibiotics can usually treat strep throat (a streptococcus A bacterial in-
fection) and stop acute rheumatic fever from developing.Persons who have previously
contracted rheumatic fever are often given continuous (daily or monthly) antibiotic treat-
ments, possibly for life, to prevent future attacks of rheumatic fever and lower the risk of
heart damage. Antibiotic therapy has sharply reduced the incidence and mortality rate of
rheumatic fever/rheumatic heart disease. To reduce inflammation, aspirin, steroids, or
non-steroidal medications may be given. Warfarin (Coumadin).for prevention of
thrombo-embolism.Surgery may be necessary to repair or replace the damaged valve.
Throat cultures for group A beta hemolytic Streptococcus usually are negative by the
time symptoms of rheumatic fever or rheumatic heart disease appear. Citicoline drops
(Zynapse) for CVA, in acute recovery phase, in signs & symptoms of cerebrovascular.-
For Attempts should be made to isolate the organism before the initiation of antibiotic
therapy to help confirm a diagnosis of streptococcal pharyngitis and to allow typing of
the organism if it is isolated successfully. This test allows rapid detection of group A
streptococcal antigen and allows the diagnosis of streptococcal pharyngitis and the initi-
ation of antibiotic therapy while the patient is still in the physician's office. Since the rap-
id antigen detection test has a specificity of greater than 95% but a sensitivity of only
60-90%, a throat culture should be obtained in conjunction with this test. Acute phase
reactants: The C-reactive protein and erythrocyte sedimentation rate are elevated in
rheumatic fever due to the inflammatory nature of the disease. Both tests have a high
sensitivity but low specificity for rheumatic fever. They may be used to monitor the resol-
ution of inflammation, detect relapse when weaning aspirin, or identify the recurrence of
disease. Heart reactive antibodies: Tropomyosin is elevated in acute rheumatic fever.
Cardiomegaly, pulmonary congestion, and other findings consistent with heart failure
may be seen on chest x-ray. When the patient has fever and respiratory distress, the
chest x-ray helps differentiate heart failure from rheumatic pneumonia.Rapid detection
test for D8/17: This immunofluorescence technique for identifying the B cell marker
D8/17 is positive in 90% of patients with rheumatic fever. It may be useful for identifying
patients who are at risk for developing rheumatic fever.For non-pharmacologic interven-
tion,Evaluate /Document analgesia and assist in transitioning / altering drug regimen
based on individual needs.Encourage bed rest periods to avoid fatigue .Discuss impact
of pain to lifestyle/ independence and ways to maximize level of functioning. Identify
Specific signs and symptoms and changes in pain characteristics requiring medical fol-
low up.Perform Hemodynamic measurements as indicated (e.g. arterial CVP,pulmonary
and left atrial pressures.Assess the urine hourly or periodically;weight daily noting total
fluid balance.Elevate edematous extremeties and avoid restrictive clothing.Provide for
diet restrictions (e.g. low-sodium,bland, soft, low calorie/residue/fat diet with small feed-
ings. As indicated.Review the danger signs requiring immediate physician notification
(e.g. unrelieved or increased chest pain ,functional decline.dyspnea, edema).
XII. Documentation
XIII. Bibliography

Black, J. et al. (2005) Medical-Surgical Nursing.Clinical Management for Positive

Outcome (7th Edition). pp. 1844-1849

Doenges, M. et.al. Nurse’s Pocket Guide.Diagnoses, Interventions, Rationales (8th

Edition). F.A. Davis Company. pp.116-119, 403-405, 415-418,499-502

Doenges, M. et.al. Guidelines for Individualizing Client Care Across the Life Span (7th
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DOH.Public Health Nursing in the Philippines (2007). (10th Edition)...pp.240-250.

Goulg, B. (2006). Pathophysology for the Health Professionals (3rd Edition). pp.379-386.

Kozier, B. et al. (2004). Fundamentals of Nursing Concepts, Process, and Practice (7th
Edition). Addison Wesley pp.356-358

Marieb, E. (2004). Essential of Human Anatomy and Physiology (7th Edition). Pearson
Education South Asia PTE LTD. pp. 308-321

Mosby Pocket Dictionary of Medicine, Nursing and Allied Health (4th Edition).

Nettina, S. (2001). The Manual of Nursing Practice (7th Edition). Lippincott-Raven

Publishers. pp.272-309

Pillitteri, Adele. Maternal and Child Health Nursing, Care of the Childbearing &
Childrearing Family (4th Edition). Lippincott Williams & Wilkins. pp.782-785, 912

Porth, C. (2004) Pathophysiology-Concepts of Altered Health Status (6th Edition). pp.

615-619
Smeltzer, S. and Bare, B. (1992) Brunner and Suddarth’s Textbook of Medical-Surgical
Nursing (10th Edition). Lippincott Williams & Wilkins (Vol. 1&2). pp.520-542, 876-
877, 2214-2228

Sparks, et al. Nursing Diagnosis: Reference Manual (6th Edition). Lippincott Williams &
Wilkins.

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http://www.healthline.com/dictionary/essential