Documente Academic
Documente Profesional
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College of nursing
Submitted to:
Sir Rey Ronald V. Solde, RN MN
Submitted by:
Daniel John P. Torres
BSN 4
October 8, 2015
Introduction
This case study is about Patient SJ, a 91 year old woman, who was
referred at Northern Mindanao Medical Center because no one will take good
care of her. She had a diagnosis of Coronary Artery disease moderate; old
Myocardial
Infarction,
arrhythmia-AF
(Atrial
Fibrillation),
Hypertensive
Cardiovascular disease. Patient SJ, is a former nun. At the age of 33 (1964) she
joined Congregation of Daughter of St. Theresa in Balingasag Mis. Or. At the year
1972 she suffered a heart attack, and was brought to Lourdes Hospital in Quezon
City. She was admitted for 2 months and was advised by the priest to leave the
convent due to medical condition. For 8 years she stayed in Caloocan with sister
for 8 years and went back to Camiguin. She lived with her father and her sister;
Asuncion De la Rosa along with her husband and children. At the year 2010, her
sister died of leukemia, her family could no longer look after her needs. Her
niece, Erlinda took care of her till 2012. By the year 2012, Sr. Marian L. Tagupa
visited Nanay Sofia in her home and offered her to stay at Northern Mindanao
Medical Center.
According to WebMD (2014) the heart is mainly made of special
muscle (myocardium). The heart pumps blood into arteries (blood vessels) which
take the blood to every part of the body. Like any other muscle, the heart muscle
needs a good blood supply. The coronary arteries take blood to the heart muscle.
The main coronary arteries branch off from the aorta (the large artery which takes
oxygen-rich blood from the heart chambers to the body.) The main coronary
arteries divide into smaller branches which take blood to all parts of the heart
muscle.
Coronary artery disease, also called coronary heart disease, or simply,
heart disease, is the No. 1 killer in America, affecting more than 13 million
Americans. Heart disease is a result of plaque buildup in the arteries, which
blocks blood flow and heightens the risk for heart attack and stroke. From a
young age, cholesterol-laden plaque can start to deposit in the blood vessel
walls. As a person gets older, the plaque burden builds up, inflaming the blood
vessel walls and raising the risk of blood clots and heart attack. The plaques
release chemicals that promote the process of healing but make the inner walls
of the blood vessel sticky. Then, other substances, such as inflammatory cells,
lipoproteins, and calcium that travel in your bloodstream start sticking to the
inside of the vessel walls. Eventually, a narrowed coronary artery may develop
new blood vessels that go around the blockage to get blood to the heart.
However, during times of increased exertion or stress, the new arteries may not
be able to supply enough oxygen-rich blood to the heart muscle. In some cases,
a blood clot may totally block the blood supply to the heart muscle, causing heart
attack. If a blood vessel to the brain is blocked, usually from a blood clot, an
ischemic stroke can result. If a blood vessel within the brain bursts, most likely as
a result of uncontrolled hypertension (high blood pressure), a hemorrhagic stroke
can result.
In myocardial infarction (heart attack), a coronary artery or one of its
smaller branches is suddenly blocked. The part of the heart muscle supplied by
this artery loses its blood (and oxygen) supply if the vessel is blocked. This part
of the heart muscle is at risk of dying unless the blockage is quickly removed.
When a part of the heart muscle is damaged it is said to be infarcted. The term
myocardial infarction (MI) means damaged heart muscle. If main coronary
arteries are blocked, a large part of the heart muscle is affected. If a smaller
branch artery is blocked, a smaller amount of heart muscle is affected. After an
MI, if part of the heart muscle has died, it is replaced by scar tissue over the next
few weeks. Normally you will be advised to take regular medication for the rest of
your life. Normally, normally be advised to take the antiplatelet medicine
clopidogrel or ticagrelor in addition to aspirin. However, this is usually only
advised for a number of weeks or months, depending on the type and severity of
your MI.
I.
Objectives
General objectives:
At the end of 4 hours of exposure at Northern Mindanao Medical Center, I will be
able to:
Apply the concepts, terms and theories regarding elderly care to the
assigned patient. Utilize the knowledge acquired from the 4 walls of the
classroom to distinguish the appropriate nursing interventions. Conduct a
comprehensive interview to the assigned patient in a proper environmental
setting. Apply the skills from previous clinical experiences to provide the patient
with holistic nursing care.
of Northern Mindanao Medical Center to promote the elderly patients health and
well-being. Maintain the proper student nurse attitude all throughout the
exposure.
Specific objectives:
At the end of 4 hours of exposure at St. Josephs Home for the aged, the student
nurses will:
A.
B.
C.
D.
E.
F.
G.
attitude
Establish collaborative relationship with colleagues and other members of the
health team for the health plan
II.
CLIENT PROFILE
Name: Jagape, Sofia C.
Nickname: Sofia
Age:91 y.o
Gender: Female
Address:Mainit, CatarmanCamiguin
Birthplace:Mainit, CatarmanCamiguin
III.
ASSESSMENT PARAMETERS
I. Demographics
Name:Jagape, Sofia C.
Age:91y.o
At the age of 41, she suffered a heart attack, brought to Lourdes Hospital.
Admitted for 2 months, and was advised to leave the convent due to medical
condition.
Had heart attack 3x on her stay at Northern Mindanao Medical Center. The
last heart attack she experienced was on May 2013.
Food and drug allergies: No known food and drug allergies
Family Medical History: (+) Cancer; Her sister died because of Leukemia.
(+) Hypertension; Paternal
II. Functional Pattern
A. Nutritional/Metabolic Pattern
Meal Pattern: Appetite is fair and patient exhibits changes in the amount of meal.
The patient verbalized Ginagmay ra akong kina-on ug dapat nay sabaw kay
tungod sa akong sakit sa heart.
Weight Loss/Gain:There are no significant changes in weight.
Feeding: Per Orem and able to eat independently.
B. Elimination Pattern
Bladder: Patient doesnt experience difficulty in urinating, thus voids within her
own pattern.
Bowel: Usually defecates once a day but it solely depends on the food intake of
the client. The patient verbalizes Inig buntag, gakalibang jud ko.
Character: Yellowish
(I) Bathing
(I) Toileting
(I) Dressing
(D) Ambulation
Respiratory rate (as of September 21, 2015) is 17cpm. Respirations are quiet
and regular. Slightly pale nail beds and lips noted. Breath sounds in both lung
fields are clear. No cough noted.
C. Cardiovascular Assessment
The patient verbalized usahay naa koy mabatian na sakit sakong dughan
dapit pero mutumar rako sakong tambal. Haya rapud manghupong akong tiil ug
magsakit ako dughan kung mukaon ko ug fatty foods. Dali rapud ko mahangos
tungod sa akong sakit sa kasing-kasing the patient added. With regular apical
pulse and BP of 110/60mmHg by September 21, 2014 9AM. No edema noted.
D. Peripheral-Vascular Assessment
Both upper extremities are pink, warm and movable within the normal range
of motion. Peripheral pulses are palpable. There is weakness on the lower
extremities and that there are limited ROM. No peripheral edema noted. No
complaints of numbness or any calf tenderness.
E. Genitourinary Assessment
The patient voids without discomfort and voids within own pattern. There are
no usual vaginal irritation and discharge noted.
F. Musculoskeletal Assessment
The patient verbalized maka bati ko ug kasakit sakong likod usahay.
Absence of joint swelling and tenderness, no evidence of inflammation,
weakness on both knees noted. The patient is able to flex all joints.
G. Integumentary Assessment
The patient verbalized kaluoy sa diyos wala sad koy samad-samad sakong
lawas. Patients skin is within her norm, it is warm, dry, and intact.
H. Psychological/Psychosocial
The patient verbalized that she is happy and satisfied with her life. She always
pray and have many friends.
ECG
CBC
Urinalysis
Blood Chemistry
IV.
CERAE/REFLECTION PAPER
Daniel John P. Torres
Reflection Paper:
When the chart of the patient assigned to us was given, I got amazed when I
read that my patient is 91 years old. People rarely reach such age. And I got more
amazed when I personally meet our patient and converse with her, because her
memory is still intact that she can remember everything that happened from the past
events of her life. Upon assessment I didnt just gathered the relevant datas needed
for our care plan, but I also gain lessons in life from her and especially in spiritual
aspects of life. It just shows that she still hasnt forgotten her former duty which is a
nun.
On the other hand, as what I have observed to nanay Sofia, she has difficulty
in hearing. She tends to let me repeat my questions and/or answer differently. As a
health care provider, what I did was I speak in a soft loud tone, slowly and clearly.
I admire how optimistic and satisfied nanay Sofia is. When she was asked
about feeling as of the moment, she said she feels happy to where she is right now.
She feels like she found a new family in the hospital.
I think what nanay Sofia need right now is a health care provider that will
assist her physically and emotionally; and most especially in reminder her to take her
medications for her medical condition. Aside from her health condition, she reports no
other concerns to her situation. She seem to be happy and contented. Someday,
when I grow old, I would want to be like her; happy and contented like she lived her
life without regret.
V.
patients
who are diagnosed with MI are given regular medications for life to prevent
recurrence and exacerbation of disease condition. Considering the age of the
patient, she needs a health care provider that would constantly remind her to take
her medications. Once diagnosed, the patient should fully comply with the
regimen given by the healthcare team. They should follow the medications
prescribed, diet, exercise and rest.
Diet of thepatient with MI should consist of the following: Protein, which
plays an essential role in protecting the body, for it produces antibodies to fight
infection. Drinking enough fluids is essential to keep the client hydrated. The
recommended fluid intake for MI patients is 2 to 3 liters of caffeine-free liquids per
day. Water is essential to the body. It helps prevent constipation. Drinking plain
water may be your best source of fluid. Are also good sources. Milk is a good
source of fluid. It has the added benefit of providing many healthy nutrients. And
also patient should be reminded that she should take light meals with water so
that MI attack would not trigger.
Student nurses and other health care personnel should have thorough
assessments so that early diagnosis could be made and recommended therapy
could be given. Health care personnel should be careful about the diet given to
the patient and should ensure that the food provided is in connection with the
prescribed diet of the physician/dietician.
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