Table of Contents

Content Page

Table of Contents i
List of Tables ii
List of Figures iv
Acknowledgement v
I. Introduction 1
A. Rationale 2
B. Objectives 3
C. Scope and Limitation 3
II. Theoretical Framework 4
III. Assessment Data 7
A. Biographical Data 7
B. Reason for Seeking Healthcare/Chief Complaint 7
C. History of Present Illness 7
D. Past Health History 8
E. Family History (Genogram) 9
F. Growth and Development 10
G. Psychosocial Profile (Gordon’s Functional Pattern) 11
H. Review of Systems 15
I. Physical Assessment 17
IV. Doctor’s Order 22
V. Diagnostic Test and Laboratory Test 48
VI. Anatomy and Physiology 52
VII. Pathophysiology (Schematic Diagram) 54
VIII. Pharmacologic Management 59
IX. Nursing Management 73
X. Discharge Plan 90
XI. References 91
XII. Appendices 92
A. Vital Signs Monitoring 92
B. Intake and Output Records 123

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 List of Tables
Tables Title Page

Table G.1 Gordon’s Functional Health Pattern 11

Table I.1 Physical Assessment 17
Table IV.1 Doctor’s Order 22
Table V.1 Chemistry Result (11-01-17) 48
Table V.2 Hematology Result (11-01-17) 48
Table V.3 Chemistry Result (11-01-17) 48
Table V.4 Chemistry Result (11-02-17) 49
Table V.5 Urinalysis Result (11-04-17) 49
Table V.6 Hematology Result (11-06-17) 50
Table V.7 Chemistry Result (11-07-17) 50
Table V.8 Chemistry Result (11-21-17) 50
Table V.9 Hematology Result (11-25-17) 50
Table V.10 Chemistry Result (11-25-17) 51
Table V.11 Ultrasound Report (11-20-17) 51
Table V.12 Radiologic Report (11-08-17) 51
Table V.13 Radiologic Report (11-19-17) 51
Table V.14 Electrocardiogram (11-15-17) 51
Table VIII.1 Drug Study (Ketorolac) 59
Table VIII.2 Drug Study (Dobutamine) 60
Table VIII.3 Drug Study (Aspirin) 61
Table VIII.4 Drug Study (Digoxin) 62
Table VIII.5 Drug Study (Omeprazole) 63
Table VIII.6 Drug Study (Furosemide) 64
Table VIII.7 Drug Study (Norepinephrine) 65
Table VIII.8 Drug Study (Cetirizine) 66
Table VIII.9 Drug Study (Acetylcysteine) 67
Table VIII.10 Drug Study (Levofloxacin) 68
Table VIII.11 Drug Study (Spironolactone) 69
Table VIII.12 Drug Study (Ceftriaxone) 70
Table VIII.13 Drug Study (Ketoanalogue) 71

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Table VIII.14 Drug Study (Amiodarone) 72
Table IX.1 Actual NCP Acute Pain 75
Table IX.2 Actual NCP Decreased Cardiac Output 77
Table IX.3 Actual NCP Ineffective Tissue Perfusion 79
Table IX.4 Actual NCP Impaired Gas Exchange 81
Table IX.5 Actual NCP Imbalance Nutrition 83
Table IX.6 Actual NCP Fluid Volume Excess 85
Table IX.7 Actual NCP Activity Intolerance 86
Table IX.8 Actual NCP Disturbed Thought Process 88
Table X.1 Discharge Plan 90

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 List of Figures
Figures Title Page

Figure II.1 Nightingale’s Framework 4

Figure II.2 Orem’s Framework 5
Figure E.1 Genogram 9
Figure H.1 Review of Systems 16
Figure VI.1 Anatomy of the Heart 52
Figure VI.2 Anatomy of the Kidney 53
Figure VII.1 Schematic Diagram 54

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 Acknowledgement

We the Student nurses would like to extend our sincere thanks and gratitude to
the following people who have contributed and supported us on the fulfilment of our
clinical case study.
To Mrs. Pilar V. Domagsang RN, MAN, Dean of College of Nursing, for allowing
us to have this clinical exposure and case presentation.
To Mr. Karl Jay G. Guinitaran RN, MSCPH, and Mr. Al Duane B. Ungab RN,
MAN our clinical adviser who provided insight and expertise that greatly assisted the
research, for the patience and time they extended in checking the manuscript and for
sharing suggestions and constructive criticisms and for guiding us during the clinical
exposure, which meant so much for the completion.
To the family of Maria Lily respondents of this study for being approachable and
cooperative and for spending their time in answering all the question being asked.
We would also like to show gratitude to the Bardon and Lepon family for sharing
their support during the making of our family case presentation. To our beloved family for
their unending moral, spiritual, and financial support.
And most of all, we would like to extend wholeheartedly the gratitude and praise
to ever loving and merciful God for touching and bringing together those people who
literally shared their abundant resource, skills, time and effort for the completion of this
family case study.