ACKNOWLEDGEMENT

The group would like to acknowledge the following for providing and the
support to the success of the case presentation, and all of this would have not
been possible without them:
Firstly to the almighty father, who gave his unconditional love and support
to the success the group have obtained in life and with his help the group can
provide help towards the recovery of the client. He has watched over the group
and provided the values of a quality student nurse and has guided each in
becoming the person they are today.
Secondly to the dear parents, who provided the financial needs and has
worked hard for the sake of giving a bright future for the group. The people who
had a big participation in providing the philosophies and the beliefs in life thus
giving the group an individualistic beliefs that will reach the hearts of the clients.
Thirdly the client, who had tolerated the group for bothering him even
when in times he is in pain still he has provided the group the necessary
information needed for the case presentation. Also, allowing the group to help in
the recovery of the client.
Fourthly to the clinical instructors, who had to conjure effort and patience
in teaching the group how to provide care to the clients. They had to give a lot of
their time and thought to provide all their knowledge and experience to the group
and to make the group a student nurse that would we worth of their time and
effort.

Fifthly to the health constitution, SPMC, for providing the group an area or
related learning experience in the hospital especially for giving the group a real
exposure of how the world practically works. They have given the group
knowledge how to handle situations much like of the other countries that would
someday be helpful to the group especially for those who dream to work abroad.
Lastly to the school, who made ways to provide for the group, learnings
and knowledge that would help the group for their futures.

INTRODUCTION

Rheumatic heart disease (RHD) is the most common acquired heart

disease in children in many countries of the world, especially in developing
countries. The global burden of disease caused by rheumatic fever currently falls
disproportionately on children living in the developing world, especially where
poverty is widespread.
RHD is a chronic heart condition caused by rheumatic fever that can be
prevented and controlled. Rheumatic fever is caused by a preceding group A
streptococcal (strep) infection. Treating strep throat with antibiotics can prevent
rheumatic fever. Moreover, regular antibiotics (usually monthly injections) can
prevent patients with rheumatic fever from contracting further strep infections and
causing progression of valve damage.
The risk of RHD is greater with repeated episodes of ARF. While ARF
usually occurs between 5 and 15 years of age, it can also occasionally occur in
adulthood with 20% of adults make up the cases. The condition affects both
sexes equally, though girls and women tend to have more severe symptoms
(World Heart Federation).
In the Philippines, Rheumatic Heart Disease is one of the top ranking
cause of mortality and morbidity when it pertains to acquired cardiovascular
disease specially among schoolchildren (age 5-15 years old). Despite the
concerted efforts of Government and No- Government Organizations to screen
and treat diagnosed cases of Acute Rheumatic Fever, the recurrence rate is high

and the dismal progression to multivalvular involvement remains unchanged

through several decades (Philippine Foundation for the Prevention and Control of
Rheumatic Fever/Rheumatic Heart Disease, 2012).
During the groups clinical experience in the Emergency Room
Department at Southern Philippines Medical Center, along with their clinical
instructor, they chose patient A because they wanted to apply the things that they
have learned in their lectures and to also know more about the condition of the
patient and how to properly take care of the patient. As student nurses, they will
be able to use the information they have in order to take better care of patients
that they may encounter in the future that may have the same condition and to
properly give interventions their patients need.

OBJECTIVES

General Objective:
Within 6 days of duty in the emergency room of Southern Philippine
Medical Center, the proponent will be able to give safe and effective nursing
care, use the knowledge that has been imparted to the proponent from the
academe, and that the proponent would be able to choose a patient and conduct
a comprehensive case study of the patients condition.

Specific Objectives:

Cognitive
o To be able to define the complete diagnosis of the patient
o To identify the developmental data of the patient
o To conduct a cephalocaudal assessment of the patient
o To be able to trace the signs, symptoms, etiology and
pathophysiology of the condition of the patient
o To present a comprehensive prognosis
o To be able to create efficient nursing care plan based on actual
high-risk health needs
o Discuss the implications of the laboratory results of the patient as
well as the surgical procedure done
o To review and discuss the human anatomy and physiology of the
respiratory system.
o To present a genogram that could trace any disease that could be
hereditary to the patient which might contribute to her present
condition

Psychomotor

o To select a patient, conduct an interview and record data for the

case study
o To apply the different and related nursing theories that are
appropriate to the present health condition of the patient
o To present drug studies and discuss the different medications given
to the patient and why they were indicated for the patient
o To record the patients data, family background, health history and
present health condition

Affective
o To establish a good rapport with the patient to gain their trust and
cooperation;
o Approach the patient and the significant others in a non-judgmental
manner;
o Provide a compassionate and caring approach to the patient and
significant others;
o To provide health teachings to the client to achieve optimum
wellness as well as other relevant discharge orders.
PATIENTS DATA

BIOGRAPHICAL:
Patients name: Patient A
Address: Central 2, Binugao, Toril, Davao City
Age: 24 y.o.
Sex: Female
Date of Birth: August 31, 1990
Race/Ethnic Background: Filipino/Cebuano, Davaoeno
Civil Status: Single
Religion: Roman Catholic
6

Educational Attainment: High School Graduate

Occupation: None
Birthplace: Quejada Clinic, Toril, Davao City

REASON FOR SEEKING HEALTHCARE:

Sign/s (Objective): Grimace and skin turning yellowish noted.
Symptom/s (Subjective): Naglisud kog hinga verbalized by the patient.
Chief Complaint (Onset): Difficulty of breathing
Date and Time of Admission: July 13, 2015 @ 5:31 PM
Vital Signs Upon Admission:
PR: 132 bpm
RR: 30 cpm
BP: 172/116 mmHg
T: 36oC
Admitting Physician: Dr. Rachel Ann W. Benilla
Admitting Diagnosis: RHD (+) LHH (+) LVD sinus tachycardia FC IV R/O
cholestatic jaundice 2o to Clarithromycin intake
Institution/Health Facility: Southern Philippines Medical Center

Genogram
J
78 y.o.

E
46 y.o.

F
45 y.o.

A
24 y.o.

K
56 y.o.

G
43 y.o.

B
23 y.o.

H
40 y.o.

C
19 y.o.

I
48 y.o.

D
18 y.o.

Legend:
Male

Female

Deceased
Pneumonia
Hypertension

RHD

Kidney
problems
Patient

Heart disorder
Diabetes Mellitus
9

PRESENT HEALTH HISTORY

According to the mother, last July 4, a Saturday, patient A experienced
pain on her throat and they had a check-up at a clinic in Toril. They were told that
patient A has tonsillitis and were given a prescription to buy antibiotics, which
was Clarithromycin. On July 6, a Monday, patient A was said to have difficulty
breathing and her skin was starting to turning yellow in color. They went to have
another check-up at a clinic in Toril and were advised to go to Southern
Philippines Medical Center.
Patient A was admitted last July 13, 2015 at 5:31 PM at Southern
Philippines Medical Center for consultation when the symptoms of difficulty of
breathing and jaundice were noted.

PAST HEALTH HISTORY

According to mother G, patient A only experienced fever, cough, and colds
when she was young. She was complete in having her immunizations when she
was young. She also experiences migraine which started when she was on the
fourth grade in elementary. She had her mumps when she was already 22 years
old. She was also a child who doesnt get sick most of the time. Whenever they
get sick they would go to a former clinic in Toril, named Quejada Clinic and the
new clinic in Toril named Dr. Gallos Clinic or nagapahilot lang me, as verbalized
by mother G. Patient A was hospitalized once when she gave birth to her son last
May 17, 2013 at Southern Philippines Medical Center where she had undergone
a normal spontaneous vaginal delivery.

10

Last July 4, she went to Dr. Gallos Clinic in Toril for complaint of difficulty
of breathing wherein she was prescribed to take Clarithromycin.

FAMILY HEALTH HISTORY

Patient A was the eldest child of mother G and father I. According to
mother G, her family has life threatening conditions such as diabetes mellitus,
pneumonia, heart disorder, kidney problems and hypertension. One of patient As
siblings already has diabetes mellitus. Mother G does not know about father Is
side as they had separated when their children were still young but says that
father I uses illegal drugs when they were still together.

SOCIAL HISTORY
Patient A does not smoke and drink. She would only stay at home to take
care of her child. She does not stay with her partner since they are not married
yet and lives with her mother and other siblings with her son. But her partner
would often visit them when he brings money to help in raising their child.
Patient A is also not involved in organizations in their community. She has
a good relationship with their neighbors as they would talk with one another
during their free time.

DIET HISTORY
According to mother G, patient A likes to eat junk food especially those
that are salty. She is also fond of drinking soft drinks suck as Coca Cola. She

11

would also eat vegetables such as malunggay when there are no other food to
eat. They eat fruits when they have the money to buy some. She also doesnt
have any allergy on any particular food.

MEDICATION RECONCILIATION
Medicine
Clarithromycin

Us of Medication According to Patients Understanding

According to patient A, this is an antibiotic to help fight of

Paracetamol
Flanax
B-complex

bacteria.
According to patient A, this is to help relieve fever.
According to patient A, this is to be relieved from pain.
According to patient A, this serves as vitamins for the
body.

DEVELOPMENTAL DATA

12

Piagets Stages of Cognitive Development

The Piaget stages of development is a blueprint that describes the stages of
normal intellectual development, from infancy through adulthood. This includes
thought,

judgment,

and

knowledge.

The

stages

were

named

after psychologist and developmental biologist Jean Piaget, who recorded the
intellectual development and abilities of infants, children, and teens.

Stage
The

Result
Description
Formal The final stage of ACHIEVED

Justification
The
patient

has

Operational

Piaget's

theory

increased in logic, the

Stage

involves

an

ability to use deductive

(Adolescence

increase in logic,

reasoning,

through

the ability to use

understanding abstract

adulthood)

deductive

ideas. Justified when

reasoning, and an

patient

was

understanding

Ngano

diay

of

abstract ideas.

hospital?

and

asked;
ka

na

Patient

answered Giadto ko sa
akong bana diri kay
nang hupong na akong
tiil ug nag lisod nako ug
hinga.

Erik Eriksons Psychosocial Development Theory

13

Eriksons psychosocial theory of development considers the impact of external

factors, parents and society on personality development from childhood to
adulthood. According to Eriksons theory, every person must pass through a
series of eight interrelated stages over the entire life cycle.

Stage
Young

Description
Intimacy vs. Isolation

Adulthood (19
to 40 years)

Result
INTIMAC

Justification
The patient has

a husband that

Once people have

also brought her

established their identities,

in the hospital.

they are ready to make long-

Maayo man ang

term commitments to others.

relasyon nako sa

They become capable of

akong

bana

forming intimate, reciprocal

mam

as

relationships and willingly

verbalized by the

make the sacrifices and

patient.

compromises that such

relationships require. If
people cannot form these
intimate relationships--a
sense of isolation may result.

14

Havighursts Developmental Tasks

Robert Havighurst developmental task is a theory that explains and emphasizes
that education is fundamental and that it continues all through life span. It states
that growth and development occurs in six stages that include middle childhood,
adolescent, early childhood, middle age and late maturity.

15

Stage

Description

Result

Justification
The patient has a

Early

1.Selecting a mate

ACHIEVED
partner but they

Adulthood (19
2.Learning

30

to

live

with

are not married

years
yet and did not

marriage partner
old)

live
3.Starting family

They have one

son.

4.Rearing children
5.Managing home
6.Getting

started

in

Her

husband

is

jeepney

driver.

According to the
patient, they did

occupation

not
7.Taking

together.

on

civic

join

any

social groups.

responsibility
8. Finding congenial social
group.

16

ANATOMY AND PHYSIOLOGY

The Heart

17

The heart itself is made up of 4 chambers, 2 atria and 2 ventricles. Deoxygenated blood returns to the right side of the heart via the venous circulation.
It is pumped into the right ventricle and then to the lungs where carbon dioxide is
released and oxygen is absorbed. The oxygenated blood then travels back to the
left side of the heart into the left atria, then into the left ventricle from where it is
pumped into the aorta and arterial circulation.

The pressure created in the arteries by the contraction of the left ventricle is the
systolic blood pressure. Once the left ventricle has fully contracted it begins to
relax and refill with blood from the left atria. The pressure in the arteries falls
whilst the ventricle refills. This is the diastolic blood pressure.
The atrio-ventricular septum completely separates the 2 sides of the heart.
Unless there is a septal defect, the 2 sides of the heart never directly
communicate. Blood travels from right side to left side via the lungs only.

18

However the chambers themselves work together . The 2 atria contract

simultaneously, and the 2 ventricles contract simultaneously.
Cardiac Conduction System
Going back to the analogy of the central heating system, the pump, pipes and
radiators are of no use unless connected to a power supply. The pump needs
electricity to work. The human heart has a similar need for a power source and
also uses electricity. Thankfully we don't need to plug ourselves in to the mains,
the heart is able to create it's own electrical impulses and control the route the
impulses take via a specialised conduction pathway.
This pathway is made up of 5 elements:
1 The sino-atrial (SA) node
2 The atrio-ventricular (AV) node
3 The bundle of His
4 The left and right bundle branches
5 The Purkinje fibres

19

The SA node is the natural pacemaker of the heart. You may have heard of
permanent pacemakers (PPMs) and temporary pacing wires (TPWs) which are
used when the SA node has ceased to function properly.
The SA node releases electrical stimuli at a regular rate, the rate is dictated by
the needs of the body. Each stimulus passes through the myocardial cells of the
atria creating a wave of contraction which spreads rapidly through both atria.
As an analogy, imagine a picture made up of dominoes. One domino is pushed
over causing a wave of collapsing dominoes spreading out across the picture
until all dominoes are down.
The heart is made up of around half a billion cells, In the picture above you can
see the difference in muscle mass of the various chambers. The majority of the
cells make up the ventricular walls. The rapidity of atrial contraction is such that

20

around 100 million myocardial cells contract in less than one third of a second.
So fast that it appears instantaneous.
The electrical stimulus from the SA node eventually reaches the AV node and is
delayed briefly so that the contracting atria have enough time to pump all the
blood into the ventricles. Once the atria are empty of blood the valves between
the atria and ventricles close. At this point the atria begin to refill and the
electrical stimulus passes through the AV node and Bundle of His into the Bundle
branches and Purkinje fibres.
Imagine the bundle branches as motorways, if you like, with the Purkinje fibres
as A and B roads that spread widely across the ventricles . In this way all the
cells in the ventricles receive an electrical stimulus causing them to contract.
Using the same domino analogy, around 400 million myocardial cells that make
up the ventricles contract in less than one third of a second. As the ventricles
contract, the right ventricle pumps blood to the lungs where carbon dioxide is
released and oxygen is absorbed, whilst the left ventricle pumps blood into the
aorta from where it passes into the coronary and arterial circulation.
At this point the ventricles are empty, the atria are full and the valves between
them are closed. The SA node is about to release another electrical stimulus and
the process is about to repeat itself. However, there is a 3rd section to this
process. The SA node and AV node contain only one stimulus. Therefore every
time the nodes release a stimulus they must recharge before they can do it
again.

21

Imagine you are washing your car and have a bucket of water to rinse off the
soap. You throw the bucket of water over the car but find you need another one.
The bucket does not magically refill. You have to pause to fill it.
In the case of the heart, the SA node recharges whilst the atria are refilling, and
the AV node recharges when the ventricles are refilling. In this way there is no
need for a pause in heart function. Again, this process takes less than one third
of a second.
The times given for the 3 different stages are based on a heart rate of 60 bpm ,
or 1 beat per second.
The term used for the release (discharge) of an electrical stimulus is
"depolarisation", and the term for recharging is "repolarisation".
So, the 3 stages of a single heart beat are:
1 Atrial depolarisation
2 Ventricular depolarisation
3 Atrial and ventricular repolarisation.
As the atria repolarise during ventricular contraction, there is no wave
representing atrial repolarisation as it is buried in the QRS.

22

Review of Systems (ROS)

Skin:

Warm to touch. Positive jaundice and bipedal edema. Negative for

lesions, wounds, ulcers, tumors, masses, bruises/ecchymoses, change in

moles, itching, acne, diaper rash, burns, temperature changes, hair growth/loss.

Eyes:

Positive for icterus. No use of glasses, contacts. Negative for pain,

excessive tearing, itching/pruritis, discharge, swelling, double vision, blurred

vision, intolerance to light; history of eye infections, cataracts, or glaucoma,
strabismus, blindness.

Ears:

No hearing impairments. Negative for use of aids, ear pain,

ringing/tinnitus, wax/cerumen, hx of ear infections, otitis media.

Nose, Sinuses, Mouth, Throat:

Negative for nose bleeds/epistaxis, sinus

infections, sore throats, tonsillitis, voice changes, hoarseness, difficulty chewing

or

swallowing,

sores

in

mouth,

dentures,

cleft

lip/palate,

mouth

breathing/snoring.

Neck: Negative for enlarged lymph nodes, pain, stiffness, limited ROM.

Breasts:

Negative for lumps, masses, thickening, pain, discomfort, nipple

discharge, lesions, rashes, sores, history of breast disease, surgery, BSE, date

23

and result of last mammogram.

Respiratory: Positive for SOB and tachypnea. Negative for cough but sputum
production is present, bloody sputum (hemoptysis), wheezing. Positive for
crackles. No history of COPD, TB or lung cancer, asthma, use of home
oxygen/equipment, smoking/chewing tobacco history, cystic fibrosis, pneumonia,
bronchitis, choking episodes, apnea/sleep apnea.

Heart:

Positive for RHD, LHH and LVD, tachycardia. Negative for angina,

palpitations, orthopnea, paraxysmal nocturnal dyspnea, fainting, syncope,

pacemaker, history of murmurs/defects, MI, CHF, HTN. Use of prophylactic
antibiotics.

Peripheral Vascular: Positive for bipedal edema. Negative for leg pain with
walking, numbness, tingling, changes in skin color, history of phlebitis, varicose
veins, HTN.

Gastrointestinal:

Normal bowel habits (freq, color, amt, consistency),

abdominal enlargement. No recent changes in bowel habits, use of therapies

(laxatives, stool softeners, diet, suppositories, enemas, other) N&V (spitting up),
hemoptysis, belching, flatulence, abdominal pain, abd distention, heartburn,
indigestion, loose stool, diarrhea, constipation encoporesis, bloody stools,
ostomies, ulcers, cirrhosis, gallbladder hx, jaundice liver problems, hernia.

24

Urinary: Negative for any loss of control, difficulty starting stream, pain,
burning/dysuria, hematuria, frequency, urgency, oliguria, polyuria, nocturia,
UTI's, BPH, kidney disease, (peds-hx of toilet training).

Hematolymphatic: Negative for any bleeding problems, bruises/ecchymoses,

petechiae, lymph node swelling, excessive fatigue, blood transfusions, cancer,
HIV, healing problems, hemophilia, blood disorders: anemia, hyperlipidemia, &
high cholesterol.

Endocrine:

Negative for any unexplained wt changes, changes in hair,

heat/cold intolerances, polyuria, polydipsia, polyphagia, thyroid hx, diabetes

mellitus hx, adrenal disorders.

Musculoskeletal: Negative for any muscle cramping, spasm, pain; joint pain,
swelling, redness, deformity, grating/ crepitation, arthritis; scoliosis, hip
dislocation, club foot; Gait; Special equip (cane, walker, W/C); fractures, sprains,
amputations, webbing, current motor development (gross motor skills).

Neurological:

Fainting/syncope, dizziness/vertigo, balance difficulties/ataxia,

tics, tremors, spasms, muscle weakness/paresis, paralysis, memory problems,

hallucinations, phobias, disorientation, headaches, strokes, seizures, epilespy,
difficulties with speech or speaking, cerebral palsey, muscular dystrophy.

25

Mental Status: Emotional illness or difficulty with thinking, memory problems,

history of psychiatric illness such as anxiety, depression, schizophrenia.

26

PHYSICAL ASSESSMENT

General Survey
Received patient sitting on bed awake with significant others at bedside
with heplock. Patient was with foley catheter. Her body structure was thin and
looks weak. Hair is unkempt. Observed difficulty in breathing and jaundice all
over the skin including the sclera on both eyes. Bipedal edema was present.
Patient was oriented to time and place. Patients mood was cooperative and
displayed enthusiasm.

Vital Signs
Temperature
PR
RR
BP

38.5 o C
132 bpm
69 cpm
140/70 mmHg

Head Assessment
Head was symmetrically rounded, hard and smooth. There were no
lesions or bumps noted. Shape of face is oval. Temporal arteries were not
palpable and there were no tenderness noted.

Skin, Hair and Nails Assessment

Skin was smooth and warm to touch. Observed jaundice all over the body.
Hair was black, wavy, and shiny and length was up to the shoulders. It was

27

unkempt but distributed evenly. No dandruff was observed. Fingernails were

short and clean. Nails had a convex curvature of about 160 degrees angle, and
capillary refill returned in less than 2 seconds. Nail beds were pale. Nail texture
was smooth. Cuticles were also smooth and no detachment of nail plate.

Eyes Assessment
Cornea is transparent, smooth and moist with no opacities. Sclera on both
eyes are yellowish. Irises were round and flat. Pupils were black in color and
equal in size, constricts when penlight was exposed to it and had a measurement
of 2 mm. Conjunctiva was pinkish with a few capillaries evident. Eyebrows are
symmetrically aligned. Eyelashes appeared to be equally distributed and curled
slightly outward. Eyelids had no presence of any discharges and no discoloration
noted. Patient was not wearing any reading devices.

Nose Assessment
Nose was positioned midline on face, straight and uniform in color. Both
nostrils were patent when patient covered the left nare and was able to breathe
to the right and vice versa. When palpated lightly, there were no tenderness and
lesions noted. No purulent drainage noted. Nasal septum was positioned
centrally with no lesions or deviations along the inner nasal mucosa. No bone
and cartilage deviation noted on palpation, no tenderness noted on palpation. No
tenderness noted on palpation of the paranasal sinuses.
Mouth Assessment

28

Lips were pale and moist without lesions. Tongue was pale with white
spots present and located centrally in mouth. No lesions and bleeding noted.
Gums were pale and no swelling was noted. The uvula was positioned in the
midline of the soft palate.

Ears Assessment
Ears are equal in size bilaterally. External ear was noted without any
bleeding, lesions or masses. Hearing function was normal on both ears as he
was able to answer accurately when he was asked a question. Auricles were
smooth and symmetrical without discoloration. Small amount of dry yellowish
cerumen present on both internal ears. No tenderness noted. The pinna recoils
when folded. There is no pain or tenderness on the palpation of the auricles and
mastoid process.

Neck and Throat Assessment

The muscles of the neck are symmetrical with the head at a central
position. The patient is able to move head through a full range of motion without
complaint of discomfort or noticeable limitation. The lymph nodes were not
palpable. The trachea is placed in the midline of the neck. Thyroid was not
enlarged and cant easily be palpated. No edema. Moves smoothly with no
crepitus. No deviations noted. No pain or tenderness on palpation and jaw
movement.

29

Thorax and Lung Assessment

The chest wall is intact with no tenderness and masses. Thorax expands
upon inspiration and relaxes upon expiration. Crackles are heard upon
auscultation. Sputum is present. Observed fast deep respirations. Breathing
pattern is not smooth. Her respiratory rate is 69 cpm..

Heart and Peripheral Vasculature Assessment

There were no visible pulsations. Patient was tachycardia with irregular
rate and rhythm without any murmurs. Heart sounds were normal in cardiac
landmarks. Apical pulse was 132 bpm. Nidako daw akong heart ana ang doctor
as verbalized by the patient.

Abdomen Assessment
Surface is uniform in color of the skin. Observed jaundice. No rashes or
lesions are present. Has a symmetric contour and is smooth. Navel is normally in
the midline. There are abdominal sounds noted with 18 counts in 5 minutes. The
abdomen rises with inhalation and falls with expiration. Right upper quadrant is
enlarged.

Musculoskeletal Assessment
Muscles feel firm and smooth with no, masses or tenderness noted.
Bipedal edema were noted on both lower extremities. Arms and legs
symmetrically aligned. There were no presence of bone deformities, and

30

tenderness. Joints were able to move smoothly. Showed body weakness through
slow movements. Enable to move upper and lower extremities without
discomfort. Flexion and extension of feet and hands were demonstrated.
Adduction and abduction of arms were demonstrated.

31

PATHOPHYSIOLOGY

32

33

34

DOCTORS ORDER
Date
and
Time:
7/13/15
5:30pm

Orders

Rationale

Please admit pt. under

yellow skin to ICU2L3
Secure consent to care

IVF-Heplock
Soft
diet
with
aspiration precaution

Strict

Diagnostic test:
CBC

PTT

Serum Na, Crea, Ca,

Mg,
APT
phen.,
TM,DM, IB, Albumin

PT/INR

Remarks

For
proper Admitted
monitoring
,
management,
and evaluation
Serves
as Secured
protection
for
patients health
and welfare and
also
for
the
health care team.
Administration of Done
meds.
To ease difficulty Done
in chewing and/or
swallowing and to
prevent
the
patient
for
aspiration.
to
evaluate Done
overall health and
detect a wide
range
of
disorders.
To measure the Done
blood
clotting
time, used to
check
for
bleeding
problems.
Done
To detect and
measure
abnormalities,
fluid
and
electrolyte
imbalances,
kidney function
Done
To measure the
blood
clotting
35

2D echo

Hbsag and Anti HCV

CXR-PAL

ROM
1 2.5mg tablet
one OD- 1st
dose
now
Bisoprolol
2 Furosemide
40g IV now
then 20mg q8
3 Essentiale
forte
one
tablet q.i.d
V/S q4
I/O q shift
Hook to cardiac monitor

time, used to
check
for
bleeding
problems.
and standardizing
the results of
prothrombin time
tests.
to assess the Done
function of the
heart
structures(muscle
, valves, pumping
chambers).
To detect whether Done
acute signs and
symptoms
are
due
to
HV
infection,
for
diagnostic
purposes.
To
spot
abnormalities or Done
diseases of the
airways,
blood
vessels, bones,
heart, and lungs.
For management Ordered
of
the
hypertension,
fluid
retention
(edema), and to
provide
the
affected liver with
essential
phospholipids.

For
proper Monitored
monitoring,
management,
and referral.
For

proper Transferred
36

 Transfer to CIU

monitoring
,
management,
and evaluation
To
correct
electrolyte
imbalances.
To prevent and
treat bleeding.
For
proper
manegment
(albumin
and
furosemide
administered
together form a
complex
that
carries
the
furosemide to the
kidney for uptake
by renal tubular
cells.)(liver
problems)
to
examine
organs in the
abdomen
including
the
liver, gallbladder,
spleen, pancreas,
and kidneys
for evaluation
To ease difficulty
in chewing and/or
swallowing and to
prevent
the
patient
for
aspiration.
Administration of
meds.

7/13/15
9:15pm

Give Na 1 vial 1:1HCO3

7/13/15
11pm

Shift Vit. K amp IV L amp

now then q8
Albumin
20%
IV
at
furosemide 10mg IV

For USD of whole abdomen

Pls. facilitate CXR

Soft diet with SAP

Maintain heplock

Dx secure the:
2Decho
USD
of
Abdomen

For
proper Secured
evaluation/diagno
sis
and
management.

7/14/15
4:17
am

Whole

Cont. present meds

VS q hourly with O2 Sat

Administered
Administered

Done

Facilitated
Done

Done

For
proper Continued
Monitored
monitoring,
Referred
37

 I/O q shift
Refer
(+)
(+)
sore
throatclarythromycin
(-) bipedal edema
and dyspnea
(+) orthopnea and 5
pallor
(+) basal crackles
(+) bipedal edema
grade 2
7/14/15
8:09
am

USD of whole abdomen

Blood GSCS x 2 sitesextract PRN

With
combination
antibiotic

of

UA

Urine GSCS

Piperacillin + tazobactam
4.5 gm q8

management,
and referral.

to
examine
organs in the
abdomen
including
the
liver, gallbladder,
spleen, pancreas,
and kidneys
To identify the
cause
of
a
bacterial infection
(positive
or
negative
bacteria).
treatment
of
present
infections
to diagnose a
urinary
tract
infection
(UTI)
and to detect the
bacteria/microorg
anism causing it.

treatment of
infections caused
by
susceptible
organisms.

Done

Done

Done
Done

Ordered

38

7/14/15
1:15
pm
130/80
(+)
dsypne
a
(+)
jaundic
e x 1wk

Dx: for 2Decho and Sputum

GSCS

Start ceftriaxone 2gm IVTT

OD APOST-error

Start Clarithromycin 100 mg

tab Pad x 5days
Increase bicoprolol to 5mg
tab OD
Add meds:
1 Spironolactone 50mg
tab OD
2 Captopril 25mg tab
BID
Cont. other meds
Admit to CP. Pneumonia IVI
3
Refer accordingly

to assess the Done

function of the
heart
structures(muscle
, valves, pumping
chambers) and to
detect
the
microorganism
causing
pneumonia and
other respiratory
infections .
to treat or prevent Administered
infections that are
proven
or
strongly
suspected to be
caused
by
susceptible
bacteria(with
secured
GSCS
results).
To treat bacterial Administered
infections.
Management of Administered
hypertension and
fluid-electrolyte
imbalances/fluid
retension.
Continued
proper Admitted
Referred

For
monitoring,
management,
and referral.

39

DIAGNOSTIC TESTS
Arterial Blood Gas: 7/13/15 20:24
Released: 7/13/15 20:34

Measured
test
pH@ 37

Results

Units

7.408

PCO2@ 37 21.1

mmH
g

Low/
High
(-)

Analyzer
PHOX

(-)

PHOX

Rationale
This test is
done
to
measure
the
blood
ph
balance
and
oxygen
and
carbon dioxide
levels.
This
helps
understand
how well the
lungs
and
kidneys
function.
Identifying
imbalances in
your pH and
blood
gas
levels
can
provide
an
early warning
about how your
body
is
handling
illness.
pCO2 (partial
pressure
of
carbon dioxide)
reflects the the
amount
of
carbon dioxide
gas dissolved
in the blood.

Clinical
Indications
Alkalosis
Normal
:
Lower
numbers
mean more
acidity;
higher
numbers
mean more
alkalinity.

Decreased
pCO2
is
caused by:
Hyperventilat
ion
Hypoxia
Anxiety
Pulmonary
embolism
40

PO2@37

72.4

mmH
g

(-)

PHOX

Calculated
tests

Results

Units

Analyzer

HCO3

13.5

mmol/
L

Nor
mal
Ran
ge
2226

PHOX

PO2
(partial Decreased
pressure
of
oxygen)
reflects
the
amount
of
oxygen
gas
dissolved
in
the blood. It
primarily
measures the
effectiveness
of the lungs in
pulling oxygen
into the blood
stream
from
the
atmosphere.
Rationale
Clinical
Indications
When an acid- Decreased:
base
Acidosis
imbalance
is
identified,
bicarbonate
(as part of the
electrolyte
panel)
and
blood
gases
may
be
ordered
to
evaluate
the
severity of the
imbalance,
determine
whether it is
primarily
respiratory
(due to an
imbalance
between
the
amount
of
oxygen coming
in and CO2
being
41

released)
or
metabolic (due
to increased or
decreased
amounts
of
bicarbonate in
the blood) in
nature,
and
monitor
its
treatment until
the acid-base
balance
is
restored.
Interpretation: Fully Compensated Respiratory Alkalosis

07/13/115 08:19 PM
Released: 07/13/15 11:13pm
Serology and Immunology
Test
Anti-HAV 1gm

Result
0.140
nonreactive

HBsAG Quali.

Nonreactive

Anti-HCV

nonreactive

Reference Range
Clinical Indication
<1.0 CUT-OFF VALUE Nonreactive- A Non1.0
reactive
or
a
negative Hepatitis A
antibody test result
means that a person
does
not
have
Hepatitis A.
<1.0 CUT-OFF VALUE Nonreactive no
1.0
hepatitis B infection.
<1.0 CUT-OFF VALUE Nonreactive- A Non1.0
reactive
or
a
negative Hepatitis C
antibody test result
means that a person
does
not
have
Hepatitis C.

42

Nursing Responsibilities:
Explain that this test is done to detect suspected blood disorders
particularly hepatitis infections(hepa A,B,C)
Inform patient that there is no restriction in food or fluids.
Explain to the patient that he may feel a slight discomfort from the needle
puncture and the tourniquet.
Hematology
TEST
CBC+PLT
Hemoglobin

RESULT/UNITS
L 92.0 g/L

Normal
Values
115.0-155.0

RATIONALE
To

INDICATIONS
for Low: Low Hb

check

anemia.
test

CLINICAL

The concentration

may

be may

indicate

used to screen anemia,

for,
or

recent

diagnose, hemorrhage, or
monitor

number

a fluid

retention,

of causing

conditions and hemodilution

diseases

that

affect red blood

cells

Hematocrit

L 0.31 %

0.36-0.48

(RBCs)

and/or

the

amount

of

hemoglobin

in

blood.
A blood

test Low :A
Low
in
that measures count
hematocrit may
the percentage
result in having
of the volume Anemia.
of whole blood
that is made up
43

of
RBC count

L 3.74 x 10^6/ul

4.26-6.10

red

blood

cells.
This test can Low: Decrease
indicate if there in
is

RBC

count

problem may be due to

with red blood the result of red

cell production cell
and/or lifespan

loss

by

bleeding

or

hemolysis,
failure of marrow
production,

or

may be due to
secondary
dilution

factors

(intravenous
WBC count

H 17.53 x 10^3/ul

5.0-10.0

Part

of

fluids)
the High:

An

complete blood elevated

WBC

count, the white count commonly

blood cell out signals infection,
(WBC)
reports

count such

an

the abscess,

number
white

as

of meningitis,
cells appendicitis,

or

found in whole tonsillitis. A high

blood. This can count may also
help determine result
infection
inflammation

from

or leukemia
tissue
due

and

necrosis
to

burns,

myocardial
infarction,
44

or

gangrene.

Differential Count
TEST

RESULT/UNITS

Normal

Neutrophil

74 %

Values
55.0075.00

Lymphocytes

20 %

20-35

Monocyte

6.0 %

2-10

Eusinophil

L%

2-10

RATIONALE

CLINICAL

INDICATIONS
Neutrophils are Normal
a type of white
blood
cell
(WBC).
This
test is used to
evaluate
and
manage
immune, blood,
and
cancer
disorders,
including
suspected
neutropenia.
Lymphocytes
Normal
accumulate
when there is
chronic injury or
irritation.
Type
of Normal
granular
leukocyte
(white
blood
cell)
that
functions in the
ingestion
of
bacteria
and
other
foreign
particles.
Eosinophils,
Low :
normally about
1-3% of the
45

Basophil

Platelet count

400 x 10^3/uL

150-400

MCV:
83.10 fl
Mean
Corpuscular
Volume
MCH:
L 24.6 pg
Mean
Corpuscular
Hemoglobin

79.4094.80

MCHC:
Mean
Corpuscular
Hemoglobin
Concentration

32.2035.50

L 29.6 g/Dl

25.6032.20

total
white
blood
cell
count,
are
believed
to
function
in
allergic
responses and
in
resisting
some parasitic.
Increase
in
number during
healing phase
of inflammation.
A platelet count Normal
is
used
to
detect a low or
high number of
platelets in the
blood.
MCV- estimates Normal
the
average
size of RBC.
MCH
Low:
measure
the
content
of
hemoglobin in
RBC.
MCHC
Low:
measure
the
entire
blood
volume
hemoglobin in
RBC.

Blood Type: AB +
Nursing Responsibilities:
Explain that this test is done to detect suspected blood disorders or to
determine infection or inflammation.
Inform patient that there is no restriction in food or fluids.
46

 Explain to the patient that he may feel a slight discomfort from the needle
puncture and the tourniquet.
Collecting the sample only takes a few minutes however if the patient is
being treated for an infection, the test will be repeated several times to
monitor the patients progress.
Ensure subdermal bleeding has stopped before removing pressure.
If hematoma develops at the venipuncture site, apply warm soaks. If
hematoma is large, monitor pulse distal to the venipuncture site.

07/13/15 8:19PM
Released 07/13/15 11:13 pm
TEST
PT Patient

RESULT/UNITS
H 19.8 sec

Normal
Values
11.8-15.1

RATIONALE

CLINICAL
INDICATIONS
High:
A
number

Prothrombin

time (PT) is a higher than average

blood test that means it takes blood
measures
long

it

how longer than usual to

takes clot; may be due to:

blood to clot. It

Liver

problems
Inadequate

can be used to
check

for

bleeding

levels

problems and it

proteins

is also used to

(factors) that

check

cause

medicine
prevent

what
to
blood

clot is working.

of

blood

to clot
Vitamin

deficiency
Congenital
factor

47

deficiency
Presence of
coagulation
factor
inhibitors

PT Inr

1.65

Not

taking PT

test,

also High:

slow

blood

called an INR clotting time.

thinners:

(International

0.8 to 1.2

Normalized

If

taking Ratio)

warfarin:

Using

2.0-3.0

system,

test.
this

treatment
blood

with

thinning

medicine
(anticoagulant
therapy) will be
PT
Activity

% 43.3 %

the same.
Blood that takes
too long to clot
in a PT test may
be a sign of
hereditary
deficiency
(bleeding
disorders), liver
disease, vitamin
K

deficiency,

blood

thinning

medication,
therapy

using

warfarin
48

blood

PT control 10.5 sec

Nursing Responsibilities:

9.9-12.5

Normal

Explain the importance, function, and procedure of the test.

Inform patient that there is no restriction in food or fluids.
Explain to the patient that he may feel a slight discomfort from the needle
puncture.

Clinical Chemistry: 07/13/15 8:19PM

Released: 7/13/15 11:03pm
TEST

RESULT/

Normal

Sodium

UNITS
138.5
mmol/L

Values
136.00144.00

SGPT

33.9 U/L

14.0-63.0

Albumin

L 18.82 35.00g/L
50.00

RATIONALE
The serum test for
sodium
levels
evaluates fluid and
electrolyte balance
as well as renal or
adrenal disorders.
Sodium,
major
extracellular cation,
affects body water
distribution,
maintains osmotic
pressure
of
extracellular fluid
and helps promote
neuromuscular
function; it also
maintains
acidbase balance.
an initial screening
for liver disease.
An albumin test is
often used as part
of a test known as
a liver panel, which
tests your blood for
albumin, creatinine,
blood
urea
nitrogen,
and

CLINICAL
INDICATIONS
Normal

Normal
Low:
Lowerthan-normal
levels of serum
albumin
may
be a sign of:

Kidney

49

prealbumin.
Your physician will
likely
order
an
albumin test if he
or she suspects
you may have a
condition
that
affects your liver
function

Total Bilirubin

H 189.24 5.1-20.5
mmol/L

A bilirubin
test
measures
the
amount of bilirubin
in a blood sample.

Alkaline
Phosphatase

H 235.41 38.0-126.0
U/L

A test measures
the amount of the
enzyme ALP in the
blood. Check for
liver disease or
damage to the liver

diseases
Liver
disease
(for
example
,
hepatitis,
or
cirrhosis
that
make
cause
ascites)

High:
Higher
than
normal
levels of direct
or
indirect
bilirubin
may
indicate
different types
of
liver
problems.
Higher bilirubin
may indicate an
increased rate
of destruction
of
RBCs
(hemolysis).
High: Very high
levels of ALP
can be caused
by
liver
problems, such
as
hepatitis,
blockage of the
bile
ducts
(obstructive
jaundice),
gallstones,
cirrhosis, Heart
failure,
heart
attack,
mononucleosis,
50

Creatinine

5.10
mmol/L

1.70-8.60

Glucose- RBS

5.6
mmol/L

4.10-6.60

Indirect
Bilirubin

H
68.1 3.40-11.90
mmol/L

Potassium

4.1
mmol/L

3.6-5.1

or
kidney
cancer
can
raise
ALP
levels.
A
serious
infection
that
has
spread
through
the
body (sepsis)
can also raise
ALP levels.
The
creatinine Normal
blood
test
measures the level
of creatinine in the
blood. This test is
done to see how
well your kidneys
work
A blood glucose Normal
test measures the
amount of a sugar
called glucose in a
sample of your
blood.
A bilirubin
test High: Increased
measures
the level: skin and
amount of bilirubin whites of the
in a blood sample. eyes
may
Bilirubin
is
a appear yellow
brownish
yellow (jaundice).
substance found in
bile. It is produced
when
the
liver
breaks down old
red blood cells.
Bilirubin is then
removed from the
body through the
stool (feces) and
gives
stool
its
normal color.
The serum test for Normal
potassium
level
51

evaluate changes
in potassium levels
and is helpful in
diagnosing
disorders of acidbase and water
balance
and
neuromuscular
disorders in the
body.
Nursing Responsibilities:
Tell the patient or the significant other that the test requires a blood
sample.
Explain who will perform the venipuncture.
Explain to the patient or to the significant other(s) that he or she may
experience discomfort from the tourniquet and needle puncture.
Inform the patient or significant other that he/she need not restrict food
and fluids.

DRUG STUDY
52

Generic Name:

Vitamin K

Brand Name:
Classifications:
Dosage:
Mechanism of Action:

Phytonadione
Vitamins and minerals
Injection: 10mg
Promotes hepatic synthesis of clotting factors II, VII, IX, X
(exact mechanism is unknown)
anticoagulant-induced prothrombin deficiency caused by
coumarin or indanedione derivatives;
prophylaxis and therapy of hemorrhagic disease of the
newborn;
hypoprothrombinemia due to antibacterial therapy;
hypoprothrombinemia secondary to factors limiting
absorption or synthesis of vitamin K, e.g., obstructive
jaundice, biliary fistula, sprue, ulcerative colitis, celiac
disease, intestinal resection, cystic fibrosis of the pancreas,
and regional enteritis;
other drug-induced hypoprothrombinemia where it is
definitely shown that the result is due to interference with
vitamin K metabolism, e.g., salicylates.
Hypersensitivity to any component of this medication.
Temporary resistance to prothrombin-depressing
anticoagulants may result, especially when larger doses of
phytonadione are used. If relatively large doses have been
employed, it may be necessary when reinstituting
anticoagulant therapy to use somewhat larger doses of the
prothrombin- depressing anticoagulant, or to use one which
acts on a different principle, such as heparin sodium.
Anaphylaxis with too-rapid IV administration (has
resulted in death)
Dyspnea
Cyanosis
Erythematous skin eruptions
Pruritus
Scleroderma-like lesions
Flushing
Hyperbilirubinemia (in premature neonates)
Hypotension
Injection site reactions

Indications:

Contraindications:
Drug Interactions:

Adverse Reaction:

53


Nursing Responsibilities:

Taste alterations

1 Assess client for any signs of hypersensitivity.

2 Educate client that adverse reactions to the drug
may occur.
3 Carefully regulate IVF with vitamin K. Rapid IV
administration may cause potentially fatal
anaphylaxis
4 Protect the medication from light; agent is rapidly
degraded
5 Monitor patient constantly. Severe reactions,
including fatalities, have occurred during and
immediately after IV injection (see ADVERSE
EFFECTS).
6 Lab tests: Baseline and frequent PT/INR.
7 Frequency, dose, and therapy duration are guided
by PT/INR clinical response.
8 Monitor therpeutic effectiveness which is indicated
by shortened PT, INR, bleeding, and clotting times,
as well as decreased hemorrhagic tendencies.
9 Be aware that patients on large doses may develop
temporary resistance to coumarin-type
anticoagulants. If oral anticoagulant is reinstituted,
larger than former doses may be needed. Some
patients may require change to heparin.
10 Educate patient/family maintain consistency in diet
and avoid significant increases in daily intake of
vitamin Krich foods when drug regimen is
stabilized. Know sources rich in vitamin K:
Asparagus, broccoli, cabbage, lettuce, turnip
greens, pork or beef liver, green tea, spinach,
watercress, and tomatoes.

54

Generic Name:

Piperacillin + tazobactam

Brand Name:

Zosyn

Classification:

ANTIINFECTIVE;
BETA-LACTAM
ANTIBIOTIC;
ANTIPSEUDOMONAL PENICILLIN

Action:

Antibacterial combination product consisting of the

semisynthetic piperacillin and the beta-lactamase

inhibitor tazobactam. Tazobactam component does not
decrease the activity of the piperacillin component
against susceptible organisms.
Therapeutic Effects
Tazobactam is an inhibitor of a wide variety of bacterial

Dosage,

betalactamases. It has little antibacterial activity itself;

however, in combination with piperacillin, it extends the
spectrum of bacteria that are susceptible to piperacillin.
Two-drug combination has antibiotic activity against an
extremely broad spectrum of gram-positive, gramnegative, and anaerobic bacteria.
Route 4.5 gm q8 Injection

and Frequency:
Contraindication:

Drug interactions:

Hypersensitivity to piperacillin, tazobactam, penicillins,

cephalosporins, or beta-lactamase inhibitors such as
clavulanic acid and sulbactam.
May increase risk of bleeding with ANTICOAGULANTS;
probenecid decreases elimination of piperacillin.
55

Indications:

Side effects:

Adverse effects:

Treatment

uncomplicated and complicated skin and skin structure

infections, endometritis, pelvic inflammatory disease, or
nosocomial or community-acquired pneumonia caused
by
piperacillin-resistant,
piperacillin/tazobactamsusceptible, beta-lactamase-producing bacteria.
Constipation; diarrhea; headache; indigestion; nausea;

pain, swelling, or redness at the injection site; trouble

sleeping; vomiting.
CNS: Headache, insomnia, fever. GI: Diarrhea,

of

moderate

to

severe

appendicitis,

constipation,
nausea,
vomiting,
dyspepsia,
pseudomembranous colitis. Skin: Rash, pruritus,
hypersensitivity reactions.
Nursing
Assessment & Drug Effects
Consideration:

Obtain
history
of
hypersensitivity
to
penicillins,
cephalosporins, or other drugs prior to administration.

Lab tests: C&S prior to first dose of the drug; start drug
pending results. Monitor hematologic status with prolonged
therapy (Hct and Hgb, CBC with differential and platelet
count).

Monitor patient carefully during the first 30 min after

initiation of the infusion for signs of hypersensitivity (see
Appendix F).

Patient & Family Education

Report rash, itching, or other signs of hypersensitivity

immediately.

Report loose stools or diarrhea as these may indicate

pseudomembranous colitis.

56

Generic Name:

Clarithromycin

Brand Name:

Biaxin
Biaxin XL

Classification:

Macrolide antibiotic

Action:

A semisynthetic macrolide antibiotic that binds to

the 50S ribosomal subunit of susceptible bacterial
organisms and thus inhibits protein synthesis of
the bacteria.

Therapeutic Effects

Dosage,

Inhibits protein synthesis in susceptible bacteria,

causing cell death.

Route PO: 100 mg tab Pad x 5days

and Frequency:
Contraindication

:
Drug

interactions:

Contraindicated

with

hypersensitivity

to

clarithromycin, erythromycin, or any macrolide

antibiotic.
Increased
serum
levels
and
effects
of
carbamazepine, theophylline, lovastatin, phenytoin

Interaction with Food:

Food

clarithromycin but does not alter effectiveness

Decreased metabolism and risk of toxic effects if

decreases

combined

with

the

rate

grapefruit

of

absorption

juice;

avoid

of

this
57

combination.
Treatment

Indications:

of

URIs

caused

by Streptococcus pyogenes, S. pneumoniae

Treatment
of
LRIs
caused

by Mycoplasma pneumoniae,
S. pneumoniae,
Haemophilus influenzae, Moraxella catarrhalis
Treatment of active duodenal ulcer with H. pylori

in combination with proton pump inhibitor

Treatment of acute otitis media, acute maxillary
sinusitis due to H. influenzae, M. cararrhalis, S.
pneumoniae

Treatment of mild to moderate communityacquired pneumonia in adults (ER tablets)

Side effects:

Adverse effects:

Stomach cramping, discomfort, diarrhea; fatigue,

headache (medication may be ordered); additional

infections in the mouth or vagina (consult with
care provider for treatment).
Dizziness, headache, vertigo, somnolence,
fatigue, Diarrhea, abdominal pain, nausea,
dyspepsia,
flatulence,
vomiting,
melena,
pseudomembranous
colitis,
Superinfections,
increased PT, decreased WBC

Nursing
Assessment & Drug Effects
Consideration:

Inquire about previous hypersensitivity to other

macrolides (e.g., erythromycin) before treatment.

Withhold drug and notify physician, if hypersensitivity

occurs (e.g., rash, urticaria).

Monitor for and report loose stools or diarrhea, since

pseudomembranous colitis must be ruled out.

When clarithromycin is given concurrently with

anticoagulants, digoxin, or theophylline, blood levels
of these drugs may be elevated. Monitor appropriate
58

serum levels and assess for S&S of drug toxicity.

Patient & Family Education

Complete prescribed course of therapy.

Report rash or other signs of hypersensitivity

immediately.

Generic Name:

Culture infection before therapy.

Do not cut or crush, and ensure that patient does

not chew ER tablets.

Monitor patient for anticipated response.

Report loose stools or diarrhea even after completion

of drug therapy.

Spironolactone

Brand Name:

Aldactone
Novospiroton (CAN)

Classification:

Potassium-sparing diuretic
Aldosterone antagonist

Action:

Spironolactone acts on the distal renal tubules as

a competitive antagonist of aldosterone. It
increases the excretion of sodium chloride and
water while conserving potassium and hydrogen
59

ions.
Dosage,

Route PO: 50mg tab OD

and Frequency:
Contraindication

Anuria, hyperkalemia, acute or progressive renal

insufficiency. Addisons disease.

:
Drug

Combinations of spironolactone and acidifying doses of

interactions:

ammonium chloride may produce systemic acidosis; use

these

combinations

with

caution.

Diuretic

effect

of

spironolactone may be antagonized by aspirin and other

SALICYLATES. Digoxin should be monitored for decreased
effect of CARDIAC GLYCOSIDE. Hyperkalemia may result
with POTASSIUM SUPPLEMENTS, ACE INHIBITORS,
ARBS, heparin may decrease lithium clearance resulting in
increased tenacity; may alter anticoagulant response in
warfarin.
Indications:

Food: Salt substitutes may increase risk of hyperkalemia.

Diagnosis
and
maintenance
of
primary

hyperaldosteronism
Adjunctive therapy in edema associated with CHF,

nephrotic syndrome, hepatic cirrhosis when other

therapies are inadequate or inappropriate
Treatment of hypokalemia or prevention of

hypokalemia in patients who would be at high risk

if hypokalemia occurred: Digitalized patients,
patients with cardiac arrhythmias
Essential hypertension, usually in combination
with other drugs

Adverse effects:

Fluid or electrolyte imbalance, gynecomastia, GI

60

upset, drowsiness, headache, hyponatremia;

tachycardia, hypotension, oliguria, hyperkalemia;
confusion, weakness, paresthesia, hirsutism,
mental disturbances, menstrual irregularities, loss
of libido and impotence.
Nursing

Assessment

Consideration:

History: Allergy to spironolactone; hyperkalemia;

renal disease; pregnancy, lactation

Physical: Skin color, lesions, edema; orientation,
reflexes, muscle strength; P, baseline ECG, BP;
R, pattern, adventitious sounds; liver evaluation,
bowel sounds; urinary output patterns, menstrual
cycle; CBC, serum electrolytes, renal function
tests, urinalysis

Interventions

Give daily doses early so that increased urination

does not interfere with sleep.

Measure and record regular weight to monitor

mobilization of edema fluid.

Avoid giving food rich in potassium.

Check blood pressure before initiation of therapy and

at regular intervals throughout therapy.

Lab tests: Monitor serum electrolytes (sodium and

potassium) especially during early therapy; monitor
digoxin level when used concurrently.

Assess for signs of fluid and electrolyte imbalance,

and signs of digoxin toxicity.

Monitor daily I&O and check for edema. Report lack

of diuretic response or development of edema; both
may indicate tolerance to drug.

61

Weigh patient under standard conditions before

therapy begins and daily throughout therapy. Weight
is a useful index of need for dosage adjustment. For
patients with ascites, physician may want
measurements of abdominal girth.

Observe for and report immediately the onset of

mental changes, lethargy, or stupor in patients with
liver disease.

Adverse reactions are generally reversible with

discontinuation of drug. Gynecomastia appears to be
related to dosage level and duration of therapy; it
may persist in some after drug is stopped.

GENERIC NAME:

ALBUMIN

BRAND NAME:
ACTION:

Albuminar-5, Albuminar-25, Albutein, Buminate

Blood volume expander.
Therapeutic effect: provides temporary increase in blood
volume, reduces hemoconcentration and blood viscosity.
Plasma protein fraction.
Blood derivative.
Albumin 1 amp via heplock
5% should be used in hypovolemic or intravascularly
depleted pts.
25% should be used in pts. In whom fluid and sosium
intake must be minimized.
Heart failure, severe anemia.
Drug: none significant
Herbal: none significant
Food: none known
Lab values: may increase serum alkaline phosphatase.
Occasional: hypotension
Rare: high dose in repeated therapy: altered vital signs,

CLASSIFICATION:
DOSAGE AND ROUTE:
INDICATION:

CONTRAINDICATION:
DRUG INTERACTION:

SIDE EFFECTS:

62

ADVERSE EFFECTS:

NURSING
RESPONSIBILITIES:

chills, fever, increased salivation, nausea, vomiting,

uticaria, tachycardia.
Fluid overload may occur, marked by increased BP,
distended neck veins. Pulmonary edema may occur,
evidenced by labored respirations, dyspnea, rales,
wheezing, coughing. Neurologic change that may occur
include headache, weakness, blurred vision, isolated
muscle twitching.
Baseline Assessment:
Obtain B/P, pulse, respirations immediately before
administration.
Adequate hydration required before albumin is
administered.
Intervention
Monitor B/P for hypotension/hypertension.
Monitor Hgb, Hct, urine specific gravity.
Assess frequently for evidence of fluid overload,
pulmonary edema.
Check skin for flushing, uticaria.
Monitor I and O ratio.
Assess for therapeutic response.

NURSING THEORIES
63

The Self-Care Deficit Nursing Theory

Dorothea E. Orem

Orem developed the Self-Care Deficit Theory of Nursing, which is composed of

three interrelated theories: (1) the theory of self-care, (2) the self-care deficit
theory, and (3) the theory of nursing systems.

The theory of self-care includes self-care, which is the practice of activities that
an individual initiates and performs on his or her own behalf to maintain life,
health, and well-being; self-care agency, which is a human ability that is "the
ability for engaging in self-care," conditioned by age, developmental state, life
experience,

socio-cultural

orientation,

health,

and

available

resources;

therapeutic self-care demand, which is the total self-care actions to be performed

over a specific duration to meet self-care requisites by using valid methods and
related sets of operations and actions.

Universal self-care requisites are associated with life processes, as well as the
maintenance of the integrity of human structure and functioning. Orem identifies
these requisites, also called activities of daily living, or ADLs, as:
1 the maintenance of sufficient intake of air, food, and water
2 provision of care associated with the elimination process
3 a balance between activities and rest, as well as between solitude and
social interaction
64

4 the prevention of hazards to human life and well-being

5 the promotion of human functioning
The second part of the theory, self-care deficit, specifies when nursing is needed.
According to Orem, nursing is required when an adult is incapable or limited in
the provision of continuous, effective self-care. The theory identifies five methods
of helping: acting for and doing for others; guiding others; supporting another;
providing an environment promoting personal development in relation to meet
future demands; and teaching another.

Developmental self-care requisites are associated with developmental

processes. They are generally derived from a condition or associated with an
event.

Health deviation self-care is required in conditions of illness, injury, or disease.

These include:
1 Seeking and securing appropriate medical assistance
2 Being aware of and attending to the effects and results of pathologic
conditions
3 Effectively carrying out medically prescribed measures
4 Modifying self-concepts to accept onseself as being in a particular state of
health and in specific forms of health care
5 Learning to live with the effects of pathologic conditions.

65

The theory of nursing systems describes how the patient's self-care needs will be
met by the nurse, the patient, or by both. Orem identifies three classifications of
nursing system to meet the self-care requisites of the patient: wholly
compensatory system, partly compensatory system, and supportive-educative
system.
People are distinct individuals. Nursing is a form of action. It is an interaction
between two or more people. People should be self-reliant, and responsible for
their care, as well as others in their family who need care. Successfully meeting
universal and development self-care requisites is an important component of
primary care prevention and ill health. A person's knowledge of potential health
problems is needed for promoting self-care behaviors. Self-care and dependent
care are behaviors learned within a socio-cultural context.

Care, Cure, Core Nursing Theory

Lydia Eloise Hall

It contains three independent but interconnected circles: the core, the care, and
the cure.

The core is the patient receiving nursing care. The core has goals
set by himself or herself rather than by any other person, and
behaves according to his or her feelings and values.

66

The cure is the attention given to patients by medical professionals.

Hall explains in the model that the cure circle is shared by the nurse
with other health professionals, such as physicians or physical
therapists. These are the interventions or actions geared toward
treating the patient for whatever illness or disease he or she is
suffering from.

The care circle addresses the role of nurses, and is focused on

performing the task of nurturing patients. This means the "motherly"
care provided by nurses, which may include comfort measures,
patient instruction, and helping the patient meet his or her needs
when help is needed.

In all the circles of the model, the nurse is present. The focus of the nurse's role
is on the care circle. This is where she acts as a professional in order to help the
patient meet his or her needs and attain a sense of balance.

Nursing Process Theory

Ida Jean Orlando

The nurse uses the standard nursing process in Orlando's Nursing Process
Discipline

Theory,

which

follows:

assessment,

diagnosis,

planning,

implementation, and evaluation. The theory focuses on the interaction between

67

the nurse and patient, perception validation, and the use of the nursing process
to produce positive outcomes or patient improvement. Orlando's key focus was
the definition of the function of nursing. The model provides a framework for
nursing, but the use of her theory does not exclude nurses from using other
nursing theories while caring for patients.

The major dimensions of the model explain that the role of the nurse is to find out
and meet the patient's immediate needs for help. The patient's presenting
behavior might be a cry for help. However, the help the patient needs may not be
what it appears to be. Because of this, nurses have to use their own perception,
thoughts about perception, or the feeling engendered from their thoughts to
explore the meaning of the patient's behavior. This process helps nurses find out
the nature of the patient's distress and provide the help he or she needs.

Date and time

Cues

Need

Nursing
diagnosis

Objective
care

of Nursing interve

68

July 14, 2015

7-3pm shift
10:00AM

Subjctive:
A
Maglisod
C
gihapon ko ug T
hinga mam as I
verbalized.
V
I
Objective:
T
- Observed
Y
dyspnea
- Skin is pale E
X
- Observed
tachycardia E
R
- Observed
C
abnormal
I
breathing
S
- v/s:
temp- 38.5 E
PR- 132
P
RR- 69
BP- 140/70 A
T
T
- ABG
E
results:
pO2
R
N
72
mmHg
pCO2
21.1
mmHg

Impaired gas At the end of

exchange
our 8 hour shift
related
to the client will
ventilation
be able to:
perfusion
a Demonstrate
imbalance
s improved
ventilation
Rationale:
and
The
adequate
relationship
oxygenation
between
as
ventilation
evidenced
(airflow) and
by
blood
perfusion
gases within
(blood flow)
client's
affects the
normal
efficiency of the
parameters
gas exchange. b Maintains
Normally there
clear
lung
is a balance
fields
and
between
remains free
ventilation and
of signs of
perfusion.
respiratory
However,
distress
certain
c Verbalizes
conditions can
understandi
offset this
ng of oxygen
balance,
and
other
resulting in
therapeutic
impaired gas
interventions
exchange.
Altered blood
flow from a
pulmonary
embolus or
decreased
cardiac output
or shock can
cause
ventilation
without
perfusion.
(Copyright
2012 Mosby ,
an imprint
of Elsevier Inc.

1. Monitor res
rate, depth, and
including
us
accessory
m
nasal
flaring,
abnormal
b
patterns.
Increased
res
rate, use of ac
muscles, nasal
abdominal
br
and a look of p
the client's eyes
seen
with
h

2. Auscultate
sounds as o
Presence of c
and wheezes m
the nurse to an
obstruction, whi
lead to or exa
existing
h

3.
Monitor
behavior and
status for on
restlessness, a
confusion, and
late stages)
lethargy.
Changes in b
and mental sta
be early sig
impaired gas ex
(Misasi, Keyes,
In late stages th
becomes
le
somnolent, an
comatose
(P
2000).

4. Monitor
saturation contin
using pulse o
Note blood gas
69

as
ava
An oxygen satur
<90% (normal:
100%) or a
pressure of ox
<80 (normal: 80
indicates
sig
oxygenation pro

5. Observe for c
in skin; especia
color of tongue a
mucous
mem
Central cyano
tongue
and
mucosa is indic
serious hypoxia
a medical eme
Peripheral cyan
extremities may
not
be
(Carpenter,

6. If client is
dyspneic, coac
client
to
respiratory rate
touch on the s
demonstrating
respirations
making eye cont
the
client,
communicating
calm,
su
fashion.
Anxiety can exa
dyspnea, caus
client to enter
dyspneic panic
(Gift, Moore, S
1992; Bruera
2000). The
presence, reass
and help in co
the client's b
can be very be
70

(Truesdell,

7. Demonstrat
encourage the
use
pu
breathing.
Pursed-lip
b
results in increa
of intercostal m
decreased res
rate, increased
volume, and im
oxygen
sa
levels (Breslin,
Pursed-lip
b
can result in in
exercise perfo
(Casciarai et al
and it empow
client to selfdyspnic
inc
(Truesdell,

8. Position clie
head of bed elev
a semi-Fowler's
as
to
Semi-Fowler's
allows increase
expansion beca
abdominal conte
not crowding the

9. Administer hu
oxygen
appropriate
(e.g., nasal can
face
mask
physician's
watch for on
hypoventilation
evidenced by in
somnolence
initiating or inc
oxygen therapy.

71

A client with
lung disease clie
need a hypoxic
breathe
and
hypoventilate
oxygen therapy.

10. Help clien

breathe and
controlled
co
Have
client
deeply, hold bre
several second
cough two to
times with mou
while tightenin
upper
ab
muscles as to
This technique c
increase
clearance and d
cough
s
Controlled
c
uses the diaphr
muscles, maki
cough more
and effective

72

Date
and
Time:
7/14/15
10:00
am

Cues:

Need Nursing
:
Diagnosis:

Subjective:

Maglisod ko og tulog
kay nag-lisod ko og
ginhawa, gamay ra
kayo akong tulog,
as verbalized by the
patient.
Objectives:
Dyspnic
Labored
breathing
Tachycardic
Irritable
Weakness
noted
With
O2
attached via
face mask
1-2 hours of
sleep
Vital Signs:

RR: 132

PR: 69

BP:140/70

Temp: 38.5 C

S
L
E
E
P
R
E
S
T
P
A
T
T
E
R
N

Sleep
Pattern
Disturbance
r/t Difficulty
of Breathing

Objective of care:

Within the eight

hour shift the
patient achieves
optimal amounts
of sleep as
R: difficulty evidenced by:
breathing
result
in
a rested
reduced
appearanc
blood
e
oxygen
levels,
causing
fatigue,
b verbalizatio
sleep
n of feeling
problems
rested
and leading
to adverse
health
conditions.
c improveme
(http://sleep
nt in sleep
foundation.
pattern.
org/ )

Nursing interventio

1 Monitor Vita

R:
baseline
information
comparison
changes.

2 Monitor an
regulate the
flow, and th
placement
mask.
R: To impro
ventilation a
enhance sl

3 Provide qui
environmen
R: To prom
environmen
conducive t

4 Obtain feed
from SO re
usual bedti
rituals/routi
R: To deter
usual sleep
patterns &
comparativ
baseline
5

73

Recomme
morning na
required
R: Napping
the afternoo
disrupt norm
sleep patte

6 Monitor lev
consciousn
mental stat
R: Restless
anxiety,con
somnolenc
common
manifestati
hypoxia an
hypoxemia
7 Evaluate tim
effects of
medication
can disrupt
R: In both t
hospital an
care setting
patients ma
following
medication
schedules t
require awa
in the early
hours. Atten
changes in
schedule o
changes to
day medica
may solve t
problem.
8 Auscultate
sounds as
R:Presence
crackles an
wheezes m
the nurse to
airway obst
which may
or exacerba
existing hyp

9 Place the p
a high fowle
position
R: to prom
74

expansion
10 Instruct to
large fluid
before bedt
R: For patie
need to vo
the night.
11 Demonstra
pursed lip b
and encour
R:
P
breathing r
increased
intercostal
decreased
respiratory
increased
volume,
improved
saturation
(Breslin, 19

Date &
Cues
Time
July
Objective:
14,
VS
as
2015
follows:
10 AM o T: 38.5oC
73
o PR: 132
bpm
o RR:
69
cpm
o BP:
140/70
mmHg
Skin warm

Need
N
U
T
R
I
T
I
O
N
A
L
-

Nursing
Objective of Care
Nursing Interventio
Diagnosis
Hyperthermia r/t After 8 hours of 1 Establish rapport.
inflammation of providing nursing
R: Promotes trust
the heart valves. interventions, the
cooperation.
patient will be 2 Monitor vital signs
R: Inflammation able to:
R: Notes prog
is an immune a Have a normal
and
changes
response;
a
temperature
condition.
response to an
within 36.5 3 Monitor tempera
infection,
an
37.5oC.
q1o.
irritation, or an b Have a cool
R:
In
order
injury. Immune
skin
when
regularly
ch
cells are called
touched.
changes
in
75

to touch

M
E
T
A
B
O
L
I
C

to
the
site
through
the
blood
stream.
The
blood
vessels near the
site
become
miraculously
permeable and
the site becomes
warm and red
due
to
the
increased blood
flow
(International
Wellness
Directory)

P
A
T
T
E
R
N

Date &
Cues
Time
July
Objective:
14,
Bipedal
2015
edema

Need

on

N
U
T

temperature.
Note presence
absence of swea
as body attempts
increase heat loss
evaporation.
R: Evaporation
decreased
environmental fac
of high humidity
high
am
temperature as
as
b
factors producing
of ability to sweat.
Provide tepid spo
bath.
R: Enhances
loss by evapora
and conduction.
Promote
lo
clothing.
R: Enhances
loss.
Promote bed rest.
R:
To
red
metabolic
demands/oxygen
consumption.
Encourage
increase oral
intake.
R:
To
sup
circulating
vol
and tissue perfusio

Nursing Diagnosis

Objective of
Nursing
Care
Interventio
Ineffective
tissue After 8 hours of 1 Establish
perfusion r/t decreased providing
rapport.
metabolism
primarily nursing
76

10 AM
73

both
lower
extremities

R
I
T
I
O
N
A
L
M
E
T
A
B
O
L
I
C
P
A
T
T
E
R
N

due to vasoconstriction interventions,

R: To gain
of peripheral blood the patient will
and
vessels.
be able to:
a Have no edema
cooperatio
R: The volume of blood
present.
2 Monitor
increases
due
to b Eat low salt and
vasoconstriction which
low fat foods
patients
leads
to
edema
such
as
signs.
(http://courses.was
vegetables,
hington.edu/con
fish and fruits.
R: To o
j/heart/valve.htm).
patients

baseline da

3 Assess the
of edema.
R:

To

baseline
and

dete

the severi

the conditio

4 Monitor I &

R: To dete

if the inta
equal

to

output. Th

determinin
there is sti
retention.

5 Advise a r
and

atmospher
R:

atmospher

conductive
rest
77

alle

stress

aids the he
proper

functioning
6 Caution to
activities
increase
hearts
load.

R: Activitie
require

much work
leads to
stress.

7 Encourage

ambulation
often
possible.

R: To pro

venous ret

8 Instruct p

to elevate

when sittin

R: To pro
venous

reduce ede

9 Encourage

low salt lo
diet

such

eating

vegetables
78

and fruits.
R:

To

re

occurrence

fluid retent

10 Instruct clie
comply

medication
regimen.
R:

Comp

with medic
regimen
essential
clients

he

and recove

Date and
Time:
07/14/201
5
10:00am

Cues:

Need:

Nursing Diagnosis

Objective of care

Subjective: Dili ko
kalihok-lihok kay
maglisod ko og
ginhawa.
Objective:
Vital signs of :
RR:
69cpm
PR:
69cpm
BP:
140/70
mmHg
Temp:
38.5 C

A
C
T
I
V
I
T
Y
E
X
E
R
C
I
S
E

Activity intolerance

Within the eight hour

shift the patient will be
able aschieve
measurable increase
in activity tolerance as
evidenced by :

Attached to O2
via facial mask.
Dyspnic,/labore
d breathing
tachycardic

P
A
T
T
E

related to
imbalance
between oxygen
supply and
demand.

reduced
fatigue and
weakness and
by vital signs
within
acceptable
limits during
activity.
Participate in
desired
activities; meet
own self-care
needs.
Patient no
longer dyspnic
and
79

Nursing In
1

Ch
be
im
ac
if
re
va
di
bl

R: O
hypoten
with acti
medi
(vasodila
(di
compro
pump
2

Do
ca
re
ac

 Diaphoretic
Weakness
Fatigue

R
N

tachycardic.

ta
dy
dy
di
pa

R:
myo
inab
strok
activi
imme
heart
dem
a
w
3

As
ca
(tr
m

R: F
ef
med

tran
seda
stre
also
and p
4

De
pu
br

R: to
5

Ev
ac
ac
in

R
incr
dec
rat

80

Pr
as
se
as
In
ac
wi

R: M
perso
w
myoc
exc
7

Im
ca
re
pr

R: S
imp
functi
if car
is n
Grad
ac
exces
workl
c
8

M
sig

R: pr
in
co

Resp

meet
fx s
assis
9

M
re
ox
th
th

10 Es
81

en

envir
the e
on

11 .Eleva

R: Elev
chest e
oxy

DISCHARGE PLANNING

These are the formulated plans for the patient after discharge using the
METHOD approach.

MEDICATION
1 Instruct the patient and primary care providers, the importance of strict
and religious compliance of the prescribed medications by his physician.
2 Discuss all take home medications to the patient and significant others;
the generic name, dosage, timing, and action/ indication as well.
3 Discuss the possible side effects of taking the drugs.
82

4 Instruct the patient that when adverse reactions occur and if there are
unusualities, seek and consult his physician immediately.
5 Encourage taking drug with food if not contraindicated, or take medication
one hour before or two hours after meals.
6 Remind the patient and family members to check the medicine before
taking, especially its expiration date.
7 Stress that self-medication should not be done.

EXERCISE
1 Encourage patient to exercise such as walking, and do light activities with
relatives and friends in order not to isolate himself.
2 When feeling well, continue usual activities unless the physician instructs
otherwise.
3 Instruct the patient not to stress herself while doing physical exercises and
to rest in between activities.
4 Instruct patient to always be careful and take precautions, to avoid getting
hurt; and keep away from sharp objects that may cause injury.
5 Discuss with him the importance of balancing rest and exercise and to
obtain sufficient rest and sleep.

TREATMENT
1 Instruct patient to comply with take home medications.

83

2 Discuss the importance of routine submission of self for check-up with his
doctor.
3 Encourage adequate time for resting and sleeping.
4 Encourage eating appropriate and healthy foods.
HYGIENE
1 Discuss to the patient the importance of proper hygiene such as a bath
everyday, proper grooming, oral hygiene and the essence of frequent
hand washing.
2 Instruct and emphasize to the patient and to his family to wash hands
before and after eating and after using the toilet.
3 Practice a good oral hygiene because some drugs may cause sores in
the mouth.

OUT PATIENT ORDERS

1 Instruct patient to follow and do the formulated discharge plan religiously.
2 Advice patient to have his follow-up appointment with his physician even
already discharged, to monitor health state.
3 Explain the purpose of why the treatment should be continued at home.

DIET
1 Instruct patient to have and maintain well balanced diet or follow the
ordered diet.
2 Encourage eating three times a day and neither skip nor miss meals.

84

3 Discourage eating too much or too less than the required intake.
4 Discourage the intake of junk foods and softdrinks.
5 Instruct to include fresh fruits and vegetables on his diet.

RECOMMENDATIONS
Critical care nursing is a complex and challenging nurse specialty to which many
registered nurses (RNs) aspire. Also known as ICU nurses, critical care nurses
use their advanced skills to care for patients who are critically ill and at high risk
for life-threatening health problems. In this case, it is important for the nurse to be
knowledgeable and to be a critical thinker, for it plays a vital role in the recovery
of the their patient. Nurses in this role will assess needs, plan, implement and
evaluate evidence-based nursing care in a fast paced and will work
collaboratively with other members of the health and social care team.

85

As future nurses of the Ateneo de Davao University, the proponents emphasize

the continuity of care for the promotion of health of their clients. These
recommendations are made to deliver the best nursing care to their client to
address their needs and so that they could live a better and healthy life.
Patient and Friends:
The patient should be participative to every program promoted by the health
sectors. She should not let any common diseases or any sickness for granted.
For she will never know what it may lead to, it would not be severe on the first
few days but it will eventually progress and complicate an individuals health.
Family and friends support/influence plays a very significant role in the recovery
and coping of the patient. They should always be there for the patient in all
aspects, mainly in emotional, social, and spiritual and should not forget that they
are included in the care of the patient .They are the ones who should encourage
the patient to be strong and to chose the best care as possible.
Nurse Education:
The student nurses should be able to furnish health teachings to their patients for
it also plays a significant role in the continuity of care, promotion, prevention and
even inputs to their patients. They should be responsible in their chosen
endeavor by being client-centered instead of their personal benefits. They should
put every patient in the area as their foremost priority.

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Nursing Practice:
Nursing professionals and student nurses should collaborate in the care of their
patients. They should be able to provide the best care to their clients so that the
clients would be able to recover from their health condition and also to avoid
further complications from occurring. They should understand any patients
condition, the nature of the illness and should know the health seeking behavior
of the client. The principle of putting their clients first before anything else is
something that they must practice every time they render care.
Also, valuing the rights and confidentiality of the patient, friends, and family
should be practiced in any situations, regardless of the background, status of the
said people.

Nursing Research:
Student nurses should always be updated and involved on new trends,
management and researches about the care of patients having Rheumatic Heart
Disease. Also, The sources/references that the nursing professionals/nursing
students used should also be considered and validated. It should be evidenced
based and with scientific rationales/explanation.

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