Manila Tytana Colleges President Diosdado Macapagal Boulevard, Metropolitan Park, Pasay City

NURSING PROCESS CARDIOVASCULAR DISEASE BLEED THALAMIC

Submitted by: Ongaco. Aliera Sofia F.

Clinical instructor: Mrs. Auria Tianco 2011

Manila Tytana Colleges Pres. Diosdado Macapagal Blvd., Metropolitan Park, Pasay City

Nursing Process

I. Assessment A. General Data

Patients Initial: J. R. G. Address: Bocaue, Laguna Age: 52 years old Sex: M wheelchair Date of Birth: 03/31/1959 hospital:4days Civil Status: Married Occupation: Seaman Informant: C.G. Date of Admission: 06/29/11 Order of Admission: using No. of days in the

B. Chief Complaints
The clients chief complaint was right sided weakness.

C. History of Present Illness

Two weeks prior to confinement, JRG was admitted in china because of sudden right sided weakness and numbness, with slurring of speech. The patient subsequently underwent CT scan resulting to cardiovascular disease bleed thalamic. 1 day prior to admission, the patient was repatriated to the Philippines hence admitted.

D. Past history
1. Childhood illnesses: Chicken pox 2. Adult illnesses: Hypertension 3. Immunization: none 4. Previous immunization: none 5. Operation: none 6. Injuries: none 7. Medications taken prior to confinement: Centrum 8. Allergies: penicillin

E. System Reviews Gordons Eleven Functional Areas

1.) Health Perception Health Management

Prior to admission, the clients general health has been well and fine. He rated himself 9 out 10. He considers his body healthy, because he does not smoke exercises regularly when he is off board and only drinks occasionally. He believes that health is wealth and eating vegetables are the most important practice. During admission, the patient follows the orders of his physician with discipline. He rated himself 5 out of 10 because of his health condition. He still practices good hygiene even if he is in the hospital. 2.) Nutritional Metabolic Pattern

The patient usually eats three to four times a day. He consumes 2 cups of rice, one serving of viand or two. He usually drinks water instead of juices and soft drinks. The patient has a good appetite; he eats any type of food but he mostly has an appetite for meat. He drinks 6 8 glasses of water in one day. the patient takes Centrum as his food supplement. He weighs 75 kg. There are no problems in eating, or difficulties and discomfort in swallowing. The client doesnt wear dentures. He doesnt have any lesions at all. During admission, the patients food is usually prepared by the cafeteria. Where he stated that, the food that is served for him is actually on a low sodium diet. He didnt gain nor loss weight.
Breakfast Day1 wednesday June 29, 2011 1 serving of fried fish and 2 cups of rice water 300 ml Day2 Thursday June 30,2011 1 serving of fish fillet and 1 cup of rice water 250 Day3 friday July 1,2011 I seving of piniyahang manok and 2 cups of rice water 3000ml Lunch 1 serving of chopseuy and 2.5 cups of rice water 200 ml 1 serving of barbecued chicken and 2 cups of rice water 300 1 serving of Adobong manok and 2cup of rice water 350ml (none) (none) Snack 1 piece of avcado And water 250ml dinner 1 serving of chicken adobo and 1 cup rice water 250 ml 1 serving of pork mechado and half cup rice water 200ml 1 serving of chpseuy and 1 cup of rice water 100ml

3. Elimination Pattern Before admission, the patient has a regular bowel movement. Usually he defecates once a day in the morning without any discomfort. He urinates 4 to 6 times a day without any discomfort depending on the fluid intake. During admission the patient experiences constipation. But he does not have any discomforts in urinating. No excessive sweating and no body odor.

4. Activity and Exercise Pattern The patient always exercises in the morning when he is off board. He engages himself in jogging. He jogs 20-30 minutes a day regularly. He was quite satisfied with his exercise. He is a seaman for more than 15 years. During his spare time he enjoys watching television and reading the newspapers. During admission, the patient only watches television since he cannot move his right part of the body. On therapy, he is encouraged to do ROM with the help of the nurse.
Wednesday Thursday friday

5:30AM------------Wakes up

6:00AM-----------wakes up

6:00AM --- wakes up

6:30 7:30AM----Eats breakfast

6:00 7:00AM-- Eats breakfast while watching a movie

6:00 7:00AM -- Eats breakfast while playing

7:30 - 8:00AM---- Bathe 7:00 7:30AM bathe 8:00 12:00PM---takes his ROM therapy 7:00 7:30AM bathe 7:30 11:00AM - takes his ROM therapy

12:001:00PM----Eats lunch chatting with his wife

7:30 -11:30AM - takes his ROM therapy

11:30-12:00PM eats lunch 1:00 3:00PM---bonds with his friend and family

11:00 2:00PM -- Eats lunch with wife

12:00 3:00PM --- watch tv 3:00-6:00- naps 2:00 6:00PM watch tv

3:00 television

6;00PM---watch 6:00 7:00PM ----- eats dinner 6:00 630PM eats dinner

6:00 7:00PM---eats dinner with his family

7:00 9:00PM ----bond with family and friends 9:00 12:00AM ----- watch tv 12:00AM -------------sleeps 1:00- disturbed: wakes up 1:30- sleep again Pulse Rate: 87beats/min

6:30 7:00PM bathe

7:00 11:30PM---watch tv 11:30PM-sleeps 3:00AM disturbed: wakes up 3:30- sleep again

7:00 11:00PM watch tv 11:00PM sleep

Pulse Rate: 87 beats/min Respiratory 19breaths/min Blood Pressure: 140/90 Temp: 36.3 Rate:

Pulse Rate: 89beats/min Respiratory Rate: 19breaths/min Blood Pressure: 140/90mmhg

Respiratory Rate: 20 breaths/min Blood Pressure: 140/90 Temp: 36

5. Sleep and Rest Pattern Before admission, the patient usually sleeps 5 to 6 hours a day. He regularly sleeps at 12 am to 5 or 6 am in the morning. The patient doesnt have any sleep disturbances and feels refreshed and satisfied with his sleep. During admission, the patient experiences sleep disturbances because he is not used to sleep in hospitals. Because hospitals makes him uncomfortable. The patient takes naps in the afternoon when he failed to have complete sleep at night.
Wedneday 11:30PM sleeps Thursday 1200PM sleeps friday 12:00AM sleeps

3:00AM disturbed

1:00AM disturbed

(no disturbances)

6:00AM wakes up

600AM wakes up

6:00AM wakes up

6. Cognitive Perceptual Pattern The patient has no difficulty in reading and writing. He is able to hear well and clear. The patient has no visual problems; the patient can easily learn things by focusing and by having discipline.

During admission, knowing that he is right handed, the patient has a hard time mobilizing his right hand for writing.

7. Self Perception - Self Concept Pattern The patient describes himself as a productive and responsible father. In relation to other people like his wife and child, he maintains a good and open relationship. He stated that tatay ako kaya kelangan ko maging responsible para masustentuhan ko ang pangangailangan nila (family). During admission, the patient feels anxious because of his current condition. Since he is the provider, he feels down whenever he remembers his condition and but there are times that he keeps on thinking how to manage their budget 8. Roles Relationship Pattern The client is currently living with his wife and child. He also stated that he lost 2 children because of an illness and in an accident. He has a good relationship with her family members at home. He also stated that they bond every Sunday. The family has no financial problems. 9. Sexuality Reproductive Pattern alam ko matanda na kame, pero inlove padin kami sa isat isa. As verbalized by the patient. The patient has no problems in his sexuality. They dont use any contraceptives. 10. Coping Stress Tolerance Pattern Whenever the patient is stressed he always views it challenging n a positive side. He uses guided imagery for relaxation and talks it out with his wife to lessen the trouble. Until now, he gets his strength from his wife and child. 11.Values Beliefs Pattern The clients religion is Roman Catholic. he believes that a person should have a direct relationship with God. But seldom goes to church, but he maintains a personal relationship with god through prayers. Until now, he would always believe in God no matter what.

F. Family Assessment

Name

Relation

Age

Sex

Occupatio n None Student

Educational Attainment Elementary Graduate High school Undergradua te

C.G. A.G. (decease d) K.G. (decease d) R.G.

Wife Daughter

50 14

F F

Son

24

Employee

College graduate

Daughter

14

Student

High school Undergradua te

G. Heredo Familial Illness

Maternal: hypertension Paternal: none

H. Developemental History

Theorist

Age

Task
During adulthood, we continue to build our lives, focusing on our career and family. Those who are successful during this phase will feel that they are contributing to the world by being active in their home and community. Those who fail to attain this skill will feel unproductive and uninvolved in the world.

Patients Description The client stated that he works overseas to provide his familys needs.

Erik Erikson (Generativity vs.

(Middle Adulthood, 40 to 65 years)

Stagnation
)

Theorist

Age

Task Energy is directed toward full sexual maturity and function and development of skills needed to cope with the environment

Patients Description The client verbalized that when you get older sexual attraction decreases and we focus more on our priority and our jobs to sustain the family.

Sigmund Freud (Genital Stage)

Puberty onwards

Theorist

Age

Task The representations in the mind of a set of perceptions, ideas, and / or actions, which go together.

Patients Description The client said that he has his own interpretation of what is right and wrong.

Jean Piaget (Schema/ Scheme) Puberty onwards

Theorist

Age

Task Kohlbergs final level of moral reasoning is based upon universal ethical principles and abstract reasoning. At this stage, people follow internalized principles of justice, even if they conflict with laws and rules. Task
When one has acquired concrete operational thought

Patients Description
The client stated that he has a strong faith in God. Because for the patient, every decision should be with morality. For the good of oneself and for the others.

Lawrence Kohlberg (Post Conventional)

Middle-age or older adult

Theorist

Age

Patients Description
According to the client he believed in God. And also he believes in

James Fowler (Mythical Literal Faith)

Puberty onwards

he/she begins to separate what things are real and what is make-believed. One takes on the stories, beliefs and observances of the group to which they belong. This gives rise to a more linear, narrative construction of meaning and coherent.

superstitions. He has his own critical thinking on things that are real and arent not.

I. Physical Examination
Height: 56 ft Weight: 75 kg Vital Signs
Temperature: 35.3 C BP:140/90 mmhg PR: 86 RR: 20

Regional Examination

A. Skin I: Has fair complexion No presence of discoloration, jaundice, cyanosis Presence of scar mark from previous injury P:
Has smooth, saggy and warm skin

B. Nails I: Presence of pinkish nail bed, transparent, well rounded P: No presence of clubbing
Good capillary refill, returns to usual nail color after 3 seconds

C. Head and Face I: Symmetrical Oval in shape

Facial hair is evenly distributed; has wrinkles

P: No presence of mass
No tenderness

Right side part of face is slightly immovable

D. Eyes Well-aligned
Pinkish pale conjunctiva

Pupil are equal, round and reactive to light For accommodation: accommodative pupils constricts at near objects dilates at far.

E. Ears I: Auricles are level with each other No presence of lesions For hearing acuity: good hearing acuity For Webers Test: equal lateralization of sound

F. Nose I. Smooth, symmetrical Same color as the face Proportional to the face No presence of flaring nostrils P. Equal patency of nares No presence of tenderness G. Mouth and Pharynx I.
Lips are pale in color, symmetrical, moist and smooth

No presence of ulcers
Gums are light pink in color, no presence of swelling

Teeth are well-aligned Uvula are pinkish

Tongue pinkish in color and slightly asymmetrical

 No inflammation and bleeding H. Neck I: Symmetrical, proportional to gross body structure P: No presence of masses or scars Trachea is positioned midline of neck I. Spine I: Symmetrical, no scoliosis J. Thorax / Lungs I: Uniform skin color, skin is intact P: No presence of tenderness/ masses Equal lung expansion Equal Tactile Fremitus vibrations A.
No crackle sounds can be heard

K. Heart I: Uniform in color, skin is intact, no scars or any lesions P: No presence of thrills/ vibrations

A: Normal heart rate No murmurs L. Breast I: same color with the body
small areola, averted

P: No presence of lumps and tenderness M. Abdomen I: Abdomen is symmetrical No presence of visible peristaltic waves P: Warm and moist No presence of tenderness N. Extremities I: Shoulders are symmetrical No limitation in movement P: No presence of tenderness No presence of masses/ lumps Presence of slight numbness on the right part of extremities

O: Genitals I: No inflammation P: Rectum and Anus I: No hemorrhoids

Q: Neurological Glasgow coma scale = 15E4V5M6

II. - Optic (Pupil 2-3mm RTL) - To check if the pupil is illuminated or non-illuminated. Illuminated- direct response Non-illuminated- indirect response

III, IV, VI. -EOM, (full & equal) -To check if both eyes are coordinated, if they move in unison and if misalignment is present.

V. -V1, V2, V3 (intact) To check for the: - Upper 1st Branch - Ophthalmic Eye, eyebrow, forehead and frontal portion of the scalp.

- Middle - 2nd Branch - Maxillary Upper lip, upper teeth, upper gum, cheek, lower eyelid and side of nose. - Lower - 3rd Branch - Mandibular Lower lip, lower teeth, lower gum and side of the tongue. VII.Facial (positive facial asymmetry) To check if he/she can do different facial expression and to check if they can identify.

VIII.-

Auditory (No hearing loss) To know if the patient can hear spoken words.

IX, X-

Glossopharyngeal and Vagus Check if they can swallow, to check the ability of tongue to move, taste To assess for the clients speech.

XI.-

Accessory (shoulder shrugs) L>R Check if the shoulder shrugs, head movement

XII.

Hypoglossal (tongue at midline, can move up and down) Check if the tongue can protrude, moves tongue up and down

II. Personal / Social History

Habits: enjoys watching television, watching TV. Vices: occasionally drinking Lifestyle: the patient has an active lifestyle. He always jogs in the morning if hes not on duty and consumes more on seafood and red meat.

Social Affiliation: Senior Citizen

Travel: traveled in china

Educational Attainment: High school graduate

III. Environmental History

The client lives in a subdivision in Bocaue, Laguna. They own a 4 story house with enough space for the family with good ventilation. Their place is safe as said by his wife. They are 2 miles away from the road. They buy mineral water for drinking and has legal electric connection.

V. Pathophysiology
A. Theoretical based

TI
Microemboli is released from a thrombus Small spasms in arterioles Temporary interruption of blood flow (temporary perfusion)

Temporary deprivation of brain cells of oxygen (temporary ischemia) Obstructing clot is dissolved by Reverses before endogenous infarction fibrinogen

References: Pathophysiology(Concepts of Altered Health States), Carol Mattson Porth: Advanced Pathophysiology, Maureen Groer Handbook of Pathophysiology, Joan P. Frizzell

B. Client-based

predisposing factors: risk factors: -age (above 40) -atherosclerosis -lifestyle -stress -vices(smoking) -smoking

TI
Microemboli is released from a thrombus

Small spasms in arterioles Temporary interruption of blood flow (temporary perfusion)

Obstructing clot is dissolved by endogenous fibrinogen

system

Reverses before infarction

VI. Laboratory Results/ Findings

Specimen: SERUM

SI unit
TEST Fbs RESULT 5.2 NORMAL VALUES 3.90-5.55 mmol/L 0.00-5.20 1.4 0.9 LO 2.6 0.00-2.26 1.00-1.60 0.00-3.90

CONVENTIONAL UNIT
RESULT 93.69 158.30 123.89 34.75 LO 100.39 38.61-61.78 0.00-150.58 NORMAL VALUE 70.30-100.00mg/dl 0.000.00-

Cholesterol 4.1 200.77mg/dl Triglycerides 200.00mg/dl HDL LDL

INTERPRETATION:

Examination head CT- scan results CT- scans of the head Multiple non contract axial CT images of the head were obtained and compared of the study done in another faculty on 18 June 2011. There is interval decrease in the amount of hyper dense collar seen in the Left capsulo gengliona region with minimal sensory perilesional edema now measuring about 1.3x1.0x1.3cm (LWF) with an estimated volume of 1cc from previous 5e computed volume 5cc. the rest of the brains parenchyma membrane no infarcts seen. The grey white matter interfere is normal There is no extra axial fluid collection or bleed The sulci, sylvian fissures and basal cistems are not unusual. The ventricles are normal in size, shape and position. The midline structures are undisplaced. The sella turcica and pineal region are unremarkable The orbits included paranasal sinuses, petromastoids and bony calvarium are not unusual. IMPLICATIONS: interval decrease in anterior if the prematurely noted small hemorrhagic collection in the left capsulogenglionic region. INTERPRETATION:

COAGULATION AND HEMOSTASIS SPECIMEN: PLASMA EXAMINATION PROTIME Prothrombin time-PT Prothrombin time-control Prothrombin time-acetant Prothrombin time-INR APTT Activated partial thromboplastin-PT Activated partial thromboplastin-control 30.7 27.9 22.60-35sec 22.60-35sec 12.0 8.59 0.93 11.1 10.00-14.00sec 10.00-14.00sec 70.00-130% RESULT NORMAL VALUE

INTERPRETATION:

Specimen: serum SI UNIT

TEST BUN RESULT 5.0 NORMAL VALUE 3.20-7.10mmol/L 58-220umol/L 21-72u/L 3.60-5mmol/L

COVENTIONAL UNIT
RESULT 14.07 0.77 NORMAL VALUE 8.96-19.89mg/dl 0.60-1.24mg/dl

Createnine 68 AIT/SGPT Sodium 30 3.7

INTERPRETATION:

SPECIMEN: BLOOD

Laboratory Hemoglobin

Normal value 140-175g/L 157

Result

Significance Low; decreased in oxygen circulating in the blood Low; decreased in hemoglobin normal

Hematocrit RBC count

0.42-0.50 4.50-5.90x1012/L

0.47 5.85

WBC count

4.00-10.5x1012g/L

8.85

normal

Basophil Eosinophil Stab Neutrophil Lymphocyte Monocyte Platelets RDW MCV

0.00-0.01 0.01-0.04 0.02-0.05 0.36-0.66 0.24-0.44 0.02-0.12 150.0045090x1012/L 12.00-17.00% 80.00-96.00 TL

---------0.02 ---------0.72 0.21 0.05 211 13.1% 79.7

------------------normal normal normal

normal normal

MCH

27.50-33.20 pg

26.8

Low; decreased in folic acid/ Vit B12; Low with iron deficiency normal

MCHL

33.40-35.50 g/dL

33.7

2-D Echo cardiogram report

Left ventricle End diastolic diameter (<50) End systolic diameter Septal thickness (diast) (8-11) 34mm 21mm 18mm (syst) Amplitude (3-8) Thickening (>30%) 22mm 6mm 22%

PW thickness (diast) 16mm (8-11) (Systolic) Amplitude (3-8) Thickening (> 30%) End diastolic vol. 47.43mm End systolic vol. 14.40mm Stroke volume 33.03m/beat Heart rate 81bpm Cardiac output 2.67L/min Ejection fract 69% (55-77) Fraction shortening (28-42) Vcf 1.39circ/sec EPSS (<10) LVET Left atrium R-L diameter (30-35) Others -

20mm 5mm 25 %

Right Ventricle End diastolic diameter (240) Wall thickness (<7) Others MITRAL VALVE Leaflets Valve area (4.6) Calcification Subvulvar involvement Commissures TRICUSPID VALVE Leaflets AORTIC VALVE Leaflets PULMONIC VALVE Leaflets AORTA Diameter Leaflet separation PULMONARY ARTERY Diameter PERICARDIUM Calcification Effusions

34mm 5mm

cm^2

46 20 37 -

38%

6mm 0.274

31mm

CARDIAC DOPPLER REPORT

Mitral valve Diastolic velo (cm/msec) E velo A velo E/A ratio Systolic velo(cm/msec) 0.72/2.08 1.24/6.19 tricuspid valve 0.60/1.43 0.55/1.20

Gradient(mmhg) Previous halftime Area (Dht)(cm^2)by planning Regurgitation Aortic valve valve Systolic velo (cm/msec) 1.07/4.55 0.94/4 Diastolic velo (cm/msec) 1.17/5 Valve Area (cm.2) Aortic valve gradient Regurgitation Pulmonary artery pressure (1)by acceleration time (2)by TRJ gradient pulmonary

INTERPRETATION: 2 dimensional cardiogram Left ventricle- concentrically hypertrophied with anteroseptal hypertrophy with adequate wall motor and contractility. Estimated ejection fraction is 69%. Left atrium, right atrium and right ventricle are normal. Mitral valve, aortic valve, tricuspid valve and pulmonic valve are structurally normal. Aortic root is dilated. Main pulmonary artery is normal. No pericardial abnormality noted. Color flow and spectral Doppler: Reversal transmitral EA flow ratio. Aortic regurgitation 1+ mild tricuspid regurgitation pulmonic regurgitation Conclusion: Concentric left ventricle hypertrophy of anterosptal hypertrophy and Doppler evidence of impaired diastolic relaxation but with preserved ejection fraction dilated aortic root. Aortic regurgitation 1+ mild tricuspid regurgitation pulmonic regurgitation

Right

PSV CCA ICA ECA IC/CC Vert.

Left

EDV --0.13 ----0.19 EDV --0.18 ----0.24

0.90 0.54 1.56 0.60 0.75 PSV

CCA ICA ECA IC/CC Vert.

Comments: Right CCA: Right ICA: normal

0.85 0.63 0.97 0.74 0.80

calcified plaques on the anterior and posterior

walls of the bulb. Right ECA: normal

Right vertebral: ante grade flow

Left CCA: Left ECA: Left ICA:

normal normal calcified plaques on the anterior and posterior walls of the valve.

VII. Drug Study

DRUGS INDICATIONS ACTION
SIDE EFFECTS/ADV ERSE REACTIONS NURSING CONSIDERATION S

PATIENT TEACHINGS

Date Ordered: 09/02/09 Generic Name: Citicoline Brand Name: Zynapse Classificati on: Dosage:

CVA in acute and recovery phase. Symptoms and signs of cerebral insufficiency i.e., dizziness, headache, poor concentratio n, memory loss, disorientatio n, etc. Recent cranial trauma and their sequelae. Parkinson disease.

Citicoline is a derivative of choline and cytidine involved in the biosynthe sis of lecithin. It is claimed to increase blood flow and oxygen consumpti on in the brain.

Shock, hypersensiti vity, hypotension, insomnia, excitement. Stimulates parasympat hetic action and fleeting and discreet hypotensor effect.

- Evaluate patient medical history - Assess patient condition - Monitor blood pressure, pulse and heart rate - Assess allergic reaction like gastrointesti nal disturbances

- Teach patient to gain benefits and not to miss any dose - Instruct patients to take only the prescribed medicines - Advice patient to consult the physician if problem occurs during medication - Caution in pregnancy and lactation

DRUGS

INDICATIONS

ACTION

SIDE EFFECTS/ADVE RSE REACTIONS

NURSING CONSIDERATIONS

PATIENT TEACHINGS

Date ordered: 09/02/09 Generic name: Lansofrazol e Brand name: Prevacid Classification: Gastrointes tinal drug Dosage & Route: 30 mg; oral Frequency: OD

* Treatment of duodenal ulcer and gastric ulcer

* Classified as gastric acid pump inhibitor since it blocks the final step of acid productio n

* Infrequently rash, anemia, constipation, dry mouth, diarrhea, headache, insomnia, sleepiness, and dizziness

* Assess patients condition before treatment and reassess regularly thereafter to monitor drugs effectiveness. * Assess patients and familys knowledge of drug therapy. * Instruct patient to take drug before meal and not to crush/ chew drug.

*Explain how to mix drug with other liquids to patients having difficulty in swallowing.

DRUGS

INDICAT IONS

ACTION

SIDE EFFECTS/ADVE RSE REACTIONS

NURSING CONSIDERATION S

PATIENT TEACHINGS

Date ordered: 09/02/09 Generic name: Sulbacta m sodium Brand name: Unasyn Classificati on: Antiinfective Dosage & Route: 750 mg; oral Frequency : BID

Skin and soft tissue infectio ns; bone and joint infectio ns

Sulbacta m is used to treat infections caused by bacteria resistant to betalacta m antibiotics . Sulbacta m blocks the enzyme which breaks down ampicillin and thereby allows ampicillin to attack and kill the bacteria

GI disturbances, phlebitis, skin rashes, itching, blood disorders anaphylaxis, superinfection

* Assess for laboratory results, adverse reactions and therapeutic effectiveness.

* Explain to patient reason for hospitalization during the course of therapy. * Inform pa tient of potential adverse reactions and encourage to report any problems.

DRUGS

INDICATIONS

ACTION

SIDE EFFECTS/ADVER SE REACTIONS

NURSING CONSIDERATION S

PATIENT TEACHINGS

Date ordered: 09/02/09 Generic name: Clopidogre l Brand name: Plavix Classificatio n: Cardiovasc ular drug Dosage & Route: 75 mg; oral Frequency: OD

* Reduction of atheroscleroti c events (myocardial infarction stroke and vascular death) in patients with atheroscleros is documented by recent stroke. Treatment of patients suffering from non- ST segment elevation acute coronary syndrome.

* Blocks ADP receptors which prevent fibrinogen binding at that site and thereby reduce the possibility of platelet aggregati on

. GI bleeding, GI * Monitor signs disturbances, of bleeding, bruising hemoglobin ad purpura, hematocrit hematuria, eye periodically. bleeding, diarrhea & * Instruct rash patient to take drugs as directed by the physician

* Advise patient to report any unusual bleeding to physician that it may take longer than usual to stop bleeding.

DRUGS

INDICATION

ACTION

SIDE EFFECT *Headache, Asthenia , Insomnia, Muscle cramps, G.I. Disturbanc

NURSING CONSIDERATIO N *Assess for muscle pain

PATIENT TEACHING S *Advise patient report adverse reaction

Date ordered: 09/02/09

*Hypercholesterole mia adjunct to diet to reduce elevated total cholesterol.

Generic Name: Atorvastatin

*Lowers cholester ol and lipoprotei ns levels

*Assess patients and family knowledge on drug therapy

*Advise patient to stay out of

Brand Name: Lipitor

es, Myotitis, Myopathy

*Monitor cholesterol

the sun

Classification: Cardiovascul ar Drug

Dose and Route: 40mg; oral

*Inform patient that compliance Is needed for positive results to occur; dont double the dose treatment may take several years

Frequency: HS

DRUGS Date ordered: 09/02/09 Generic Name: Lactulose Brand Name: Duphalac Classificatio n: Gastrointe stinal Drug Dosage and Route: 30cc; oral Frequency: OD

INDICATION *Treatment of hepatic encephalopat hy; constipation salmonellosis

ACTION *Causes an influx of fluids in the intestina l tract by increasin g the osmotic pressure within the intestina l lumen

SIDE EFFECT *Abdomin al discomfort associated with flatulence and intestinal cramps. Nausea, vomiting, diarrhea on prolonged used

NURSING CONSIDERATION

PATIENT TEACHINGS *Advice the patient to dilute drug with juice or water / take with food to improve taste

*Monitor fluid and electrolyte status; urine output, input and output ratio to identify fluid loss

*Inform patient *Assess of possible sign patients and symptoms condition before and need to therapy and notify the reassess physician regularly immediately thereafter to monitor drugs effectiveness

DRUG Date ordered: 09/03/09 Generic Name: Celecoxib Brand Name: Celebrex Classification: Analgesics, muscle relaxants uricosurics Dosage: 200mg; oral

INDICATION

ACTION *Inhibits prostaglan din synthesis by selectively inhibiting cyclooxyge nase 2

SIDE EFFECT *Constipat ion, dysphagia esophagiti s, gastritis, dry mouth, tooth disorders, vomiting, aggravate d hypertensi on; headache, dizziness, fever, hit flashes, fatigue, pain

NURSING CONSIDERATION

PATIENT TEACHINGS *Teach patient that drug must be continued for prescribed time and be effective

*Acute/chr onic use in the treatment of the sign and symptoms of rheumatoid arthritis

*Assess for appropriatenes s of the therapy for pain; inflammation of joints.

*Check ROM

*Relieves pain and inflammati on

*Monitor blood counts during therapy

*Instruct patient to report bleeding, bruising, cramping, fatigue and malaise

Frequency: BID

DRUG

INDICATION

ACTION

SIDE EFFECT *Rashes and renal damage and large doses cause profuse diarrhea

NURSING CONSIDERAT ION *Assess for toxicity; weakness, abdominal pain

PATIENT TEACHING S *Teach patient to take drug as prescribe and ordered

Date ordered: 09/04/09 Generic Name: Colchicine Brand Name: Colchicine Classification : Analgesics, muscle relaxants, uricosurics

*Symptomat ic treatment of acute attacks of gouty arthritis

*Although Colchicine is not an analgesic reduction of inflammati on result to pain relief

*Assess for sign and symptoms: wheezing, facial swelling

Instruct patient to report any pain

*Assess patients underlying condition

Dosage and Route: 500mg; oral

Frequency: TID

VIII. List of Priority Problem 1. Ineffective Airway Clearance 2. Acute Pain 3. Impaired Physical Mobility 4. Sleep Deprivation 5. High risk for impaired verbal communication

Cues / Needs

Nursing Diagnosis .

Rationale

Goals & Objective s . After 2 days of nursing intervent ion, the patient will be able to expector ate/ clear secretion s readily and demonstrate absence/r eduction of congestio n with breath sounds clear, respiratio ns noiseless .

Interventio n

Rational e

Evaluatio n

. Inability to clear secretion s or obstructi ons from the respirato ry tract to maintain a clear airway

S: Nahihirapan ako huminga. As verbalized by the patient

O: -cough -with presence of phlegm -crackles is heard

Ineffectiv e airway clearance related to presence of whitish to yellowish secretions as manifeste d by cough and presence of crackles

*Monitor RR and breath sounds

*Indicative of respiratory distress or accumulati on of secretion * to take advantage of gravity decreasing pressure on the diaphragm & enhancing drainage/v entilation to different lung segment *to decrease cough

*Elevate head of bed/chang e position every 2 hours and if needed

After 2 days of nursing intervention , Goal was partially met as evidenced by reduced secretions, patients respiration is noiseless.

*Give expectoran ts as ordered *Increase fluid intake

*Hydration can help liquefy viscous secretions & improve secretion clearance *to ascertain status and note progress *to prevent fatigue

*Auscultat e breath sounds

*Encourage adequate rest periods

Cues / Needs

Nursing Diagnos is

Rational e

Goals &
Objective s

Interventi on

Ration ale
.

Evaluation

S: Masaki tang tuhod ko, di ko magalaw. As verbalized by the patient

O: -observed evidence of pain Pain scale: 7/10 -facial grimace -BP 150/80

Acute pain related to arthritis as manifes ted by observe d evidenc e of pain 7/10

Unpleasa nt sensory and emotiona l experien ce arising from actual/ potential tissue damage/ describe d in terms of such damage (Internati onal Associati on for the study of Pain)

After 2 days of nursing intervent ion, the patient will be able to report pain is relieved or controlle d

*Obtain clients assessment of pain to include location, characteristi c, onset/durati on

*to rule out worseni ng of underlyi ng conditio n/develo pment of complica tions

After 2 days of nursing intervention, Goal was met as evidenced by verbalization of relieved pain.

*Use pain rating scale

*Monitor skin color/ temp and VS

*are usually altered in acute pain

*Provide comfort measures, quiet environment

*to promote non pharmac ological pain manage ment

*Administer analgesics

*to maintain accept able level of pain

*Encourage adequate rest periods

* to prevent fatigue

Cues / Needs

Nursing Diagnosis

Rational e

Goals &
Objective s

Interventio n

Rationale

Evaluatio n

. S: di ako makagalaw ng maayos As verbalized by the patient Impaired physical mobility related to pain, neuromu scular impairme nt as manifest ed by pain scale of 7/10 and slowed movemen t Limitation in independe nt,purpose ful physical movement of the body or of one or more extremities After 2 days of nursing intervent ion the client will be able to verbalize understa nding of the situation and individua l treatmen t regimen and safety measures and demonstr ate techniqu es/behavi ors that enable resumpti on of activities *Observe movement when client is unaware of observation

. *to note incongrue ncies with reports of abilities After 2days of nursing intervention , Goal was partially met

O: -limited range of motion -slowed action

*Note emotional/be havioral responses to problems of immobility

*feeling of frustratio n/powerle ss may impede attainmen t of goals

*Encourage adequate rest periods

*to prevent fatigue

*support affected body parts/joints using pillow/rolls

*to maintain position of function and reduce risk of pressure ulcers

Cues / Needs

Nursing Diagnosis

Rational e

Goals & Objective s

Interventio n
.

Rational e
. *provides comparativ e baseline

Evaluatio n

S: Di ako makatulog kaagad As verbalized by the patient

Sleep deprivatio n related to prolonged discomfor t/pain

Prolong ed periods of time without sleep

O: restlessnes s -slowed reaction -irritability

After 2 days of nursing intervent ion the client will be able to verbalize understa nding of sleep disorder and report improve ment in sleep/res t pattern

*Determine the clients usual pattern and expectation

After 2 days of nursing intervention , Goal was met.

*Observe for physical signs of fatigue(yaw ning, irritability, restlessnes s)

*Provide calm, quiet environmen t

Cues / Nursing Needs Diagnosis

Rationale

Goals & Intervention Objective s

Rational e

Evaluatio n

. High risk for impaired verbal communicat ion related to decrease in circulation to brain Decrease d, delayed or absent ability to receive process, transmit, and or use a system of symptom After 3days of nursing interventio n, the patient will be able to: -participate in therapeutic communicat ion(reflecti ng, restating, activelistening) -establish method of communicat ion in which needs can be expressed. *Review history for neurological conditions

. *that could affect speech such as TIA *convey s interest & concern After 2 days of nursing intervention , Goal was partially met.

O: -slurred/ slowed speech

*Establish relationship with the client, listening carefully and attending to clients verbal/ nonverbal expression

*Use confrontation skills when appropriate within an established nurse-client relationship

*to clarify discrepa ncies between verbal & nonverbal cues

Cues / Needs

Nursing Diagnosis

Rationale

Goals & Objective s

Intervention

Rational e
. *to promote soft stool and stimulate bowel activity

Evaluatio n

. S: Di pa ako nakakadu mi. As verbalized by the patient Risk for constipati on related to insufficien t physical activity At risk for a decrease in normal frequenc y of defecatio n accompa nied by difficult or incomplet e passage of stool and/or passage of excessive ly hard, dry stool After 2 days of nursing interventi on the client will be able to maintain usual pattern of bowel functionin g *Promote adequate fluid intake, including water and high-fiber fruit juices; also suggest drinking warm fluids

After 2 days of nursing intervention, Goal was not met

*Review medication

*for impact on/effects of changes in bowel function

*Instruct/en courage a diet of balanced diet and fiber supplements

*to improve consistenc y of stool and facilitate passage through colon

*Administer stool softener as ordered

XI. Discharge Plan

Medication

Lipitor (to lower the cholesterol / HS) Celecoxib (for rheumatoid arthritis)

Exercise
Teach the patient to have Range of Motion exercise regularly and maintained it.

Treatment
Follow maintenance medications, abide follow-up check ups, do the physicians advice.

Health Education
Teach the client the importance of maintaining the medications, exercise and diet. Also, give them advice to follow the treatment the doctors ordered. Addition to that, give them encouragement that they will get well soon.

OPD Follow-up

Follow up check up after 1 week to see the progress on the patient

Diet
Maintain Low sodium, Low fat diet. Avoid foods that is high in salt and foods that are fatty.

Signs and Symptoms

If patient experience any pain, loss of consciousness, dizziness, and fever. Consult Physician immediately.