READINGS

GOUTY ARTHRITIS

Gouty arthritis is an intense pain in a joint, most often the big toe, but sometimes other

joints, including knees, ankles, elbows, thumbs, or fingers. Attacks of gout can be unexpected and

excruciatingly painful. With prompt treatment, the pain and inflammation usually disappear after

a few days, but they may recur at any time.

Gout is actually a form of arthritis. It is the body's reaction to irritating crystal deposits in

the joints. The pain can be intense, but treatment usually works very well. Mild cases may be

controlled by diet alone. Recurring attacks of gout may require long-term medication to prevent

damage to bone and cartilage and deterioration of the kidneys. Chronic gout sufferers may feel

tiny, hard lumps accumulating over time in the soft flesh of areas such as the hands, elbows, feet,

or earlobes. These deposits, called tophi, are concentrations of uric acid crystals and can cause

pain and stiffness over time. If similar deposits form in the kidneys, they can lead to painful and

potentially dangerous kidney stones.

TYPES

Asymptomatic hyperuricemia is the period prior to the first gout attack. There are no symptoms,
but blood uric acid levels are high and crystals are forming in the joint.

Acute gout, or gout attack, happens when something (such as a night of drinking) causes uric
acid levels to spike or jostles the crystals that have formed in a joint, triggering the attack. The
resulting inflammation and pain usually strike at night and intensify over the next eight to 12 hours.
The symptoms ease after a few days and likely go away in a week to 10 days.

Interval gout is the time between attacks. Although there’s no pain, the gout isn’t gone. Low-
level inflammation may be damaging joints.

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Chronic gout develops in people with gout whose uric acid levels remain high over a number of
years. Attacks become more frequent and the pain may not go away as it used to. Joint damage
may occur, which can lead to a loss of mobility.

MANIFESTATIONS

● Intense joint pain. Usually affects the large joint of the big toe. Other commonly

affected joints include the ankles, knees, elbows, wrists and fingers. The pain is

likely to be most severe within the first 4 to 12 hours after it begins.

● Lingering discomfort. After the most severe pain subsides, some joint discomfort

may last from a few days to a few weeks. Later attacks are likely to last longer and

affect more joints.

● Inflammation and redness. The affected joint or joints become swollen, tender,

warm and red.

● Limited range of motion. Inability to move joints normally.

RISK FACTORS

Age and sex. Gout occurs more often in men, primarily because women tend to have lower uric

acid levels. After menopause, however, women's uric acid levels approach those of men. Men are

also more likely to develop gout earlier ,usually between the ages of 30 and 50 .Whereas women

generally develop signs and symptoms after menopause.

Diet. Eating a diet rich in meat and seafood and drinking beverages sweetened with fruit sugar

(fructose) increase levels of uric acid, which increase your risk of gout. Alcohol consumption,

especially of beer, also increases the risk of gout.

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Obesity. If overweight, the body produces more uric acid and the kidneys have a more difficult

time eliminating uric acid.

Recent surgery or trauma. Experiencing recent surgery or trauma has been associated with an

increased risk of developing a gout attack.

Medical conditions. Certain diseases and conditions increase the risk of gout. These include

untreated high blood pressure and chronic conditions such as diabetes, metabolic syndrome, and

heart and kidney diseases.

Certain medications. The use of thiazide diuretics are commonly used to treat hypertension and

low-dose aspirin also can increase uric acid levels. So can the use of anti-rejection drugs prescribed

for people who have undergone an organ transplant.

COMPLICATIONS

People with gout can develop more-severe conditions, such as:

● Recurrent gout. Some people may never experience gout signs and symptoms again.
Others may experience gout several times each year. Medications may help prevent
gout attacks in people with recurrent gout. If left untreated, gout can cause erosion
and destruction of a joint.
● Advanced gout. Untreated gout may cause deposits of urate crystals to form under
the skin in nodules called tophi. Tophi can develop in several areas such as fingers,
hands, feet, elbows or Achilles tendons along the backs of your ankles. Tophi usually
aren't painful, but they can become swollen and tender during gout attacks.
● Kidney stones. Urate crystals may collect in the urinary tract of people with gout,
causing kidney stones.

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DIAGNOSTIC EXAMS

Tests to help diagnose gout may include:

1. Joint fluid test. A needle is used to draw fluid from affected joints. Urate crystals
may be visible when the fluid is examined under a microscope.
2. Blood test. It is to measure the levels of uric acid and creatinine in the blood.
3. X-ray imaging. Joint X-rays can be helpful to rule out other causes of joint
inflammation.
4. Dual energy CT scan. This type of imaging can detect the presence of urate crystals
in a joint, even when it is not acutely inflamed. This test is not used routinely in
clinical practice due to the expense and is not widely available.

PREVENTION

1. Drink plenty of fluids. Stay well-hydrated, including plenty of water. Limit how many

sweetened beverages especially those sweetened with high-fructose corn syrup.

2. Limit or avoid alcohol. Talk with the doctor about whether any amount or type of alcohol

is safe.. Recent evidence suggests that beer may be particularly likely to increase the risk

of gout symptoms, especially in men.

3. Get protein from low-fat dairy products. Low-fat dairy products may actually have a

protective effect against gout.

4. Limit intake of meat, fish and poultry. A small amount may be tolerable, but pay close

attention to what types and how much.

5. Maintain a desirable body weight. Choose portions that allow the body to maintain a

healthy weight. Losing weight may decrease uric acid levels in the body. But avoid fasting

or rapid weight loss, since doing so may temporarily raise uric acid levels.

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MEDICAL MANAGEMENT

● Nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs include over-the-

counter options such as ibuprofen and naproxen sodium , as well as more-powerful
prescription NSAIDs such as indomethacin or celecoxib.
NSAIDs carry risks of stomach pain, bleeding and ulcers.
● Colchicine. A type of pain reliever that effectively reduces gout pain. The drug's
effectiveness may be offset, however, by side effects such as nausea, vomiting and
diarrhea, especially if taken in large doses.
● Corticosteroids. Corticosteroid medications, such as the drug prednisone, may
control gout inflammation and pain. Corticosteroids may be in pill form, or they can
be injected into the joint. Corticosteroids are generally used only in people with gout
who can't take either NSAIDs or colchicine. Side effects of corticosteroids may
include mood changes, increased blood sugar levels and elevated blood pressure.

PREVENTIVE MEASURES

● Exercise and eat a balanced diet to control weight.

● Increase oral fluid intake
● Stay away from sugary drinks.
● Avoid excessive alcohol use, especially beer.
● Eat less meat, especially liver and sweetbreads, and seafood.

HYPERTENSION STAGE 2

Stage 2 hypertension represents a classification of hypertension development that comes

after the advancement of Stage 1 hypertension. By definition, high blood pressure refers to the

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long-term medical condition in which the blood pressure in the arteries is persistently elevated.

Hypertension Stage 2 is defined as high blood pressure with a systolic reading of greater or equal

to 160 mmHg, also have a diastolic blood pressure reading of greater or equal to 100mmHg.

TYPES

PRIMARY HYPERTENSION

Primary hypertension has no clear cause and is thought to be linked to genetics, poor diet,

lack of exercise and obesity. Approximately 90-95% of adults with hypertension have primary

hypertension. It is also no identifiable cause.

SECONDARY HYPERTENSION

Secondary hypertension tends to appear suddenly and cause higher blood pressure than

does primary hypertension. It can be caused by conditions that affect the kidneys, arteries, heart

an endocrine system.

RISK FACTORS

● Age. The risk of high blood pressure increases by age. High blood pressure is more
common in men. Women are more likely to develop high blood pressure after age 65.
● Race. High blood pressure is particularly common among people of African heritage,
often developing at an earlier age than it does in whites. Serious complications, such

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 as stroke, heart attack and kidney failure, also are more common in people of African
heritage.
● Family history. High blood pressure tends to run in families.
● Being overweight or obese. The heavier the weight the more the blood needs to
supply oxygen and nutrients to the tissues. As the volume of blood circulated through
blood vessels increases, so does the pressure on artery walls.
● Not being physically active. People who are inactive tend to have higher heart rates.
The higher the heart rate, the harder the heart must work with each contraction and
the stronger the force on the arteries.
● Using tobacco. Not only does smoking or chewing tobacco immediately raise blood
pressure temporarily, but the chemicals in tobacco can damage the lining of the artery
walls. This can cause the arteries to narrow and increase your risk of heart disease.
Secondhand smoke also can increase your heart disease risk.
● Too much salt (sodium) in your diet. Too much sodium in the diet can cause the
body to retain fluid, which increases blood pressure.
● Too little potassium in diet. Potassium helps balance the amount of sodium in the
cells.
● Drinking too much alcohol. Heavy drinking can damage the heart. Having more
than one drink a day for women and more than two drinks a day for men may affect
blood pressure.
● Stress. High levels of stress can lead to a temporary increase in blood pressure.
● Certain chronic conditions. Certain chronic conditions also may increase risk of
high blood pressure, such as kidney disease, diabetes and sleep apnea.

MANIFESTATIONS

● Drowsiness

● Visual disturbances-interfere with the visual sight

● Tinnitus-ringing or buzzing in ears

● Dizziness-spinning sensation

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 ● Shortness of breath/chest pain-difficulty of breathing

● Increased urination frequency-cause by diseases affecting the urinary tract

● Pale skin-completion or pallor

DIAGNOSTIC TEST

·To measure blood pressure, the doctor or a specialist will place an inflatable arm cuff

around the arm and measure blood pressure using a pressure-measuring gauge.

A blood pressure reading, given in millimeters of mercury (mm Hg), has two numbers. The

first, or upper, number measures the pressure in your arteries when your heart beats (systolic

pressure). The second, or lower, number measures the pressure in your arteries between beats

(diastolic pressure).

Blood pressure measurements fall into four general categories:

● Normal blood pressure. Your blood pressure is normal if it is below 120/80 mm Hg.
● Elevated blood pressure. Elevated blood pressure is a systolic pressure ranging from
120 to 129 mm Hg and a diastolic pressure below 80 mm Hg. Elevated blood pressure
tends to get worse over time unless steps are taken to control blood pressure.
● Stage 1 hypertension. Stage 1 hypertension is a systolic pressure ranging from 130
to 139 mm Hg or a diastolic pressure ranging from 80 to 89 mm Hg.
● Stage 2 hypertension. More severe hypertension, stage 2 hypertension is a systolic
pressure of 140 mm Hg or higher or a diastolic pressure of 90 mm Hg or higher.

MEDICAL MANAGEMENT

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 ● Diuretics. Work by ridding off the body excess water and salt. This drug by design

involuntarily elevates the rate of urination in patients. It follows that frequent rest and room

visits are common.

● Ace Inhibitor. They are hypertension medications designed to treat hypertension and

congestive heart failure, renal disease and systemic sclerosis (degenerative changes on the

skin). The primary action of ACE is to block the conversion of Angiotensin 1 to

Angiotensin 2.

● Calcium Channel Blockers. They are designed to disrupt the calcium conduction of what

are known as calcium channels. They blocked the voltage gated calcium channels in blood

vessels. This affects muscle contraction by causing less contraction therefore increasing

arterial diameter. This in turn causes a drop in blood pressure by relaxing and widening

blood vessels.

● Angiotensin II Receptor Blockers. Angiotensin 2 receptor antagonist antagonises

angiotensin 2 receptors on blood vessels from preventing them from binding. This causes

blood vessels to enlarge. The angiotensin II is a chemical that causes muscles about blood

vessels to contract with the net effect of narrowing blood vessels.

● Beta Blockers. They block the effect of a specific type of adrenaline thereby reducing

heart rate and also dilating blood vessels in turn reducing blood pressure.

NURSING MANAGEMENT

● Healthy Diet. Dietary Approaches to Stop Hypertension diet (DASH), which emphasizes

fruits, vegetables, whole grains, poultry, fish and low fat dairy foods. Get plenty of

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 potassium, which can help prevent and control high blood pressure. A lower sodium level

1,500mg per day is appropriate for people 51 years of age or older and individuals of any

age who are black or who have hypertension.

● Encouraged to increase physical activity. Regular physical activity can help lower blood

pressure, manage stress, reduce the risk of several health problems and keep weight under

control.

● Instruct patient and watcher to monitor blood pressure at home. It can help keep

closer tabs on the blood pressure, show if medication is working, an even alert the doctor

to potential complications.

URINARY TRACT INFECTION

A urinary tract infection (UTI) is an infection in any part of the urinary system kidneys,

ureters, bladder and urethra. Most infections involve the lower urinary tract — the bladder and the

urethra.

TYPES OF UTIs

1. Cystitis (bladder): Urge to urinate a lot, or pain when urinating. It might also have lower

belly pain and cloudy or bloody urine.

2. Pyelonephritis (kidneys): This can cause fever, chills, nausea, vomiting, and pain in your

upper back or side.

3. Urethritis (urethra): This can cause a discharge and burning when urinating.

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MANIFESTATIONS

● A burning feeling when peeing.

● A frequent or intense urge to pee.

● Cloudy, dark, bloody, or strange-smelling pee.

● Fatigue

● Fever or chills (a sign that the infection may have reached the kidneys)

● Pain or pressure in your back or lower abdomen

CAUSES

UTIs are a key reason why doctors tell women to wipe from front to back after using the

bathroom. The urethra, the tube that takes urine from the bladder to the outside of the body is close

to the anus. Bacteria from the large intestine, such as E. coli, can sometimes get out of the anus

and into the urethra. From there, they can travel up to the bladder and, if the infection isn't treated,

can continue to infect the kidneys.

RISK FACTORS

● Gender. Women have shorter urethras than men. That makes it easier for bacteria to get to

their bladders.

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 ● Urinary tract abnormalities. Babies born with urinary tract abnormalities that don't allow

urine to leave the body normally or cause urine to back up in the urethra have an increased

risk of UTIs.

● Blockages in the urinary tract. Kidney stones or an enlarged prostate can trap urine in

the bladder and increase the risk of UTIs.

● A suppressed immune system. Diabetes and other diseases that impair the immune system

— the body's defense against germs — can increase the risk of UTIs.

● Catheter use. People who can't urinate on their own and use a tube (catheter) to urinate

have an increased risk of UTIs. This may include people who are hospitalized, people with

neurological problems that make it difficult to control their ability to urinate and people

who are paralyzed.

● A recent urinary procedure. Urinary surgery or an exam of the urinary tract that involves

medical instruments can both increase risk of developing a urinary tract infection.

NURSING MANAGEMENT

● Drink plenty of liquids.. Drinking water helps dilute the urine and urinate more frequently

allowing bacteria to be flushed from the urinary tract before an infection can begin.

● Wipe from front to back. Doing so after urinating and after a bowel movement helps

prevent bacteria in the anal region from spreading to the vagina and urethra.

● Avoid potentially irritating feminine products. Using deodorant sprays or other

feminine products such as douches and powders, in the genital area can irritate the urethra.

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II. ANATOMY AND PHYSIOLOGY

JOINTS

A joint, also called an articulation, is any place where

adjacent bones or bone and cartilage come together to form a
connection. Joints are classified both structurally and
functionally. Structural classifications of joints take into
account whether the adjacent bones are strongly anchored to
each other by fibrous connective tissue or cartilage, or whether
the adjacent bones articulate with each other within a fluid-
filled space called a joint cavity. Functional classifications
describe the degree of movement available between the bones,
ranging from immobile, to slightly mobile, to freely moveable
joints. The amount of movement available at a particular joint of the body is related to the
functional requirements for that joint. Thus immobile or slightly moveable joints serve to protect
internal organs, give stability to the body, and allow for limited body movement. In contrast, freely
moveable joints allow for much more extensive movements of the body and limbs.

STRUCTURAL CLASSIFICATION OF JOINTS

The structural classification of joints is based on whether the articulating surfaces of the
adjacent bones are directly connected by fibrous connective tissue or cartilage, or whether the
articulating surfaces contact each other within a fluid-filled joint cavity.

These differences serve to divide the joints of the body into three structural classifications.

Fibrous joint . It is where the adjacent bones are united by fibrous connective tissue.

Cartilaginous joint. The bones are joined by hyaline cartilage or fibrocartilage.

Synovial joint. The articulating surfaces of the bones are not directly connected, but
instead come into contact with each other within a joint cavity that is filled with a lubricating fluid.

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Synovial joints allow for free movement between the bones and are the most common joints of the
body.

FUNCTIONAL CLASSIFICATION OF THE JOINTS

The functional classification of joints is determined by the amount of mobility found

between the adjacent bones. Joints are thus functionally classified as a synarthrosis or immobile
joint, an amphiarthrosis or slightly movable joint, or as a diarthrosis, which is a freely movable
joint. Depending on their location, fibrous joints may be functionally classified as a synarthrosis
or an amphiarthrosis . Cartilaginous joints are also functionally classified as either a synarthrosis
or an amphiarthrosis joint. All synovial joints are functionally classified as a diarthrosis joint.

Gout is caused by too much uric acid in the bloodstream and accumulation of urate crystals
in tissues of the body. Uric acid crystal deposits in the joint cause inflammation of the joint leading
to pain, redness, heat, and swelling.

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CIRCULATORY SYSTEM

The cardiovascular system can be thought of

as the transport system of the body. This system has
three main components: the heart, the blood vessel
and the blood itself. The heart is the system’s pump
and the blood vessels are like the delivery routes.
Blood can be thought of as a fluid which contains
the oxygen and nutrients the body needs and carries
the wastes which need to be removed.

Each time the heart beats, blood is pumped

through the arteries and veins, the blood vessels of the circulatory system. Arterial blood pressure
is created by the force exerted by the blood against the artery walls, as they carry blood around the
body.

PARTS OF THE CIRCULATORY SYSTEM

Circulatory system is made up of three main parts: blood, which carries substances such as
nutrients, oxygen and waste products around the body; blood vessels, a network of tubes that carry
the blood; and the heart, a muscular organ, located in the centre of the chest, whose job is to pump
blood throughout the circulatory system.

BLOOD

It is made of a pale yellow fluid, called plasma that contains red and white blood cells, and
platelets. The red blood cells contain hemoglobin, a chemical that can combine with oxygen.

BLOOD VESSELS

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 The tubes through which blood travels, with different jobs. Blood flows away from the
heart through strong, thick-walled vessels, called arteries, which branch into networks of tiny, thin-
walled tubes, called capillaries. Oxygen and other substances can easily diffuse out of the
capillaries into the cells of tissues and organs, where they are needed, while carbon dioxide and
waste products can easily diffuse back into the bloodstream, for disposal. The capillaries
eventually join up again to form veins, which are the tubes that transport blood back to the heart.

HEART

Is divided into four chambers. The two upper chambers are the atria and the two lower
chambers are the ventricles. As the heart pumps, one way valves between the chambers keep the
blood flowing in a specific direction. Blood passes through your heart twice as it makes a complete
tour of the body. Starting from the heart, it is pumped from the right ventricle to the lungs, where
it picks up oxygen. It then returns to the left atrium, flows into the left ventricle, and is pumped
out of there to the rest of the body. With this done, the blood returns to the right atrium, flows into
the right ventricle, and the cycle starts again.

High blood pressure, or hypertension, has been called the "silent killer"because it often has
no warning signs or symptoms, and many people do not even know they have it. Over time, the
constant pressure overload causes accumulating damage that eventually becomes more than the
circulatory system can handle, often leading to serious health problems.

URINARY SYSTEM

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 The urinary system's function is to filter blood

and create urine as a waste by-product. The organs of the

urinary system include the kidneys, renal pelvis, ureters,

bladder and urethra.The body takes nutrients from food

and converts them to energy. After the body has taken

the food components that it needs, waste products are left

behind in the bowel and in the blood.

The kidney and urinary systems help the body to

eliminate liquid waste called urea, and to keep chemicals, such as potassium and sodium, and water

in balance. Urea is produced when foods containing protein, such as meat, poultry, and certain

vegetables, are broken down in the body. Urea is carried in the bloodstream to the kidneys, where

it is removed along with water and other wastes in the form of urine.

PARTS AND FUNCTIONS

● Two kidneys. This pair of purplish-brown organs located below the ribs toward the

middle of the back. The kidneys remove urea from the blood through tiny filtering units

called nephrons. Each nephron consists of a ball formed of small blood capillaries, called

a glomerulus, and a small tube called a renal tubule. Urea, together with water and other

waste substances, forms the urine as it passes through the nephrons and down the renal

tubules of the kidney.

● Two ureters. These narrow tubes carry urine from the kidneys to the bladder. Muscles in

the ureter walls continually tighten and relax forcing urine downward, away from the

kidneys. If urine backs up, or is allowed to stand still, a kidney infection can develop.

About every 10 to 15 seconds, small amounts of urine are emptied into the bladder from

the ureters.

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 ● Bladder. This triangle-shaped, hollow organ located in the lower abdomen. It is held in

place by ligaments that are attached to other organs and the pelvic bones. The bladder's

walls relax and expand to store urine, and contract and flatten to empty urine through the

urethra. The typical healthy adult bladder can store up to two cups of urine for two to five

hours.

● Two sphincter muscles. These circular muscles help keep urine from leaking by closing

tightly like a rubber band around the opening of the bladder.

● Nerves in the bladder. The nerves alert a person when it is time to urinate, or empty the

bladder.

● Urethra. This tube allows urine to pass outside the body. The brain signals the bladder

muscles to tighten, which squeezes urine out of the bladder. At the same time, the brain

signals the sphincter muscles to relax to let urine exit the bladder through the urethra.

When all the signals occur in the correct order, normal urination occurs.

Urinary tract infections typically occur when bacteria enter the urinary tract

through the urethra and begin to multiply in the bladder. When that happens, bacteria

may take hold and grow into a full-blown infection in the urinary tract.

III. PERTINENT DATA

Name Tito Raffy

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 Age 58 years old

Sex Male

Address Lapaz East, Laoag City Ilocos Norte

Date of Birth June 10, 1961

Place of Birth Laoag City

Civil Status Married

Educational Attainment Highschool graduate

Occupation Baranggay Official

Hospital Number 46422

Chief Complaint Right sided body weakness and joint pain

Date and Time of Admission November 09, 2019 4:01PM

CVD infarct, HPN urgency, Gouty Arthritis, Urinary

Admitting Diagnosis
Tract Infection

Attending Physician Marian Grace Mati Formoso M.D.

Date and Time of Discharge November 14, 2019, 3:05 pm

Final Diagnosis Acute Gouty Arthritis, HPN II, Urinary Tract Infection

IV. FAMILY HEALTH HISTORY

Tito Raffy’s father died due to a stroke at the age of 72 in the year 1999 while his mother

died with the same illness at the age of 89 last 2013. He also claims that his parents are both

hypertensive and that his mother had a chronic asthma.

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 Tito Raffy has 11 siblings he is the second oldest among them. His older brother and his

3rd younger sister have chronic asthma and are currently taking maintenance drug salbutamol

nebul. While the 5th sibling among them is also hypertensive with a maintenance drug of

amlodipine. Meanwhile the rest of his siblings are alive and well. He is married to Mrs. X, 56 years

old housewife. They have 6 children age ranging from 27-38 years old. Their second and third

children are currently working at New Zealand as an installer, their 5th child is a tricycle driver

while the 6th is working as a merchandiser.

Tito Raffy. worked at the bank for 19 years as a security guard but had a forced retirement

due to his illness. He is now a barangay official and he works from Sunday to Saturday but has a

flexible schedule.

They are currently living at a bungalow cemented house with proper ventilations and good

environment. According to Tito Raffy, they are fond of eating vegetables, seafood, chicken and

seldom eat pork.

Whenever their family experience common illnesses such as cold, cough and fever they

usually go to the pharmacy to get medicine. Tito Raffy. remembered some medications such as

Paracetamol (Biogesic) 500mg for fever, Neozep 500mg for cold, Loperamide for stomach ache

and Tuseran Forte 1 cap 3x a day for cough, they drink a lot of water as their common intervention.

Aside from having the aforementioned diseases, the family also experienced childhood

illnesses such as chickenpox, measles and mumps. In managing Mumps, as verbalized by the

patient “Itapal tapal mi nukwa jay akot akot” they apply the “akot-akot” , and mix the soil with

vinegar and apply it to the affected area. He believes that it can cool the area. The management

was effective. Meanwhile in measles he verbalized “agusar kami ti nangisit nukwa” however he

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doesn’t know the rationale of this belief. In managing chickenpox, as verbalized by the patient

“mang mangan kami ti ado nga itlog ken agdigosak tay napaburekan nga tay bulong ti bayabas”

until the chickenpox subsided and they believed that eggs facilitates the eruption of the pustules.

Tito Raffy and Mrs X claimed their children did not receive immunizations during their time

because it was not fully implemented.

PAST HEALTH HISTORY

Tito Raffy was born through a Normal Spontaneous Delivery at their home and attended

by a traditional birth attendant on June 10,1961. He had experienced common illnesses such as

fever, colds and cough. For fever he takes Paracetamol (Biogesic) 500mg taken orally every 4

hours until temperature subsides.He managed colds by taking Neozep 500mg and drinking a lot of

water, while cough was managed by Tuseran forte 1 cap three times a day. Meanwhile for stomach

ache they use Loperamide 2mg twice a day 2 cap for loading dose then 1 cap every bowel

movement.

During Tito Raffy’s childhood, he can recall his childhood illnesses like mumps, measles

and chickenpox but he can’t recall what exact age when he had these illnesses. In managing

mumps, he applies “akot-akot” , and mix the soil with vinegar and apply it to the affected area. He

believes that it can cool the area. In chickenpox, as verbalized by the patient “mang mangan kami

ti ado nga itlog ken agdigosak tay napaburekan nga tay bulong ti bayabas” until the chickenpox

subsided and the management was effective. Meanwhile in measles he verbalized “agbado nak ti

nangisit nukwa ” however he doesn’t know the rationale of this belief.

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 Tito Raffy. started smoking cigarettes when he was in highschool and can consume 2 packs

per day. He can also drink 1 “bilog” of GIN in one sitting but when he is with his friends they can

consume 2-3 bottles of emperador light.

In year 1990’s he met a vehicular accident and sustained bruised, he was treated at the

Emergency Room of GRAMH. In 2003 he was diagnosed with arthritis. He claimed that he

only goes for a check up if he feels pain and managed it by drinking medicines such as celecoxib

200 mg or mefenamic acid 500 mg as needed only. He also had a stabbing accident while drinking

alcohol and was rushed again and treated at the Emergency Room of GRAMH, In 2016 he had

an appendectomy at Laoag City General Hospital and verbalized “Inikkat dat apdokon ejay

pinagininom ko gamin idi ngem nanipod idi na opera nak insardeng kon ngem gapo ta idi naudi

nga election ket ado met ti agayab a karubba naisubsubli manen a”.Then last year he was again

admitted at GRAMH and due to LBM.

Tito Raffy. usually sought consultation directly at the hospital and claimed that they do not

believe in “albularyo”(quack doctor). He also claimed he does not have any allergies to

medications and food.

PRESENT HEALTH HISTORY

Prior to admission Tito Raffy. consulted at GRAMH and was attended by unrecalled

physician due to swollen right pinky finger and was given Celecoxiv to relieve pain. However,

pain persist accompanied by right sided weakness. He was bedridden for a week, unable to move

his legs due to severe pain. He was rushed at Governor Roque Ablan Memorial Hospital on

November 09, 2019 with a chief complaint of right sided body weakness and joint pain.

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 Seen and examined by Dr. Maria Grace F. Mati-Formoso with an admitting diagnosis of

CVD infarct, Hypertension urgency;Gouty Arthritis;UTI.

V. PHYSICAL ASSESSMENT

Date of Assessment : November 10, 2019

General Appearance

Tito Raffy was seen lying in bed awake and aware of self and environment, weak and pale
in appearance, with an IVF of PNSS 1 liter at 450 cc level regulated to 28 gtts/min hooked at the
left hand, infusing well. With complaint of weakness at the right side of his body, joint pain and
Body malaise. He is 79 kg. 5 feet 7 inches in height.

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 HEAD ● Rounded in shape normocephalic and

symmetrical

● No nodules or masses noted upon

palpated

SCALP ● Lighter in color than the complexion

● With minimal dandruff

● Oily

● Free from lice

FACE ● Appeared smooth and has uniform

consistency

● With no presence of nodules or

masses.

EYEBROWS ● Hair is evenly distributed

● Eyebrows are symmetrically

aligned and showed equal movement

when asked to raise and lower

eyebrows.

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EYELASHES ● Appeared to be equally distributed

● Curled slightly outward

EYELIDS ● No presence of discharges and

discoloration

● Involuntary blinks approximately

15-20 times per minute

EYES ● Bulbar conjunctiva appeared

transparent

● With white sclera

● Palpebral conjunctiva appeared pale

● The client was able to read the print

bond paper held at a distance of

approximately 12 inches away

● The pupils of the eyes are black

● pupils equally round respond to light

accommodation

EARS ● When palpating the texture the

auricles are mobile firm and not

tender

● The pinna recoils when folded

25
 ● During the assessment of pen tick

test client was able to hear ticking in

both ears

NOSE AND SINUSES ● Symmetrical, uniform in color

● No presence of discharges or flaring

● There were no tenderness and lesion

MOUTH ● The lips of the client is , moist,

slightly symmetrical

● Presence of flakey skin around the

lips

● Pinkish buccal mucosa

● The tongue is centrally positioned,

pink in color moist and rough

● The uvula is positioned in the

midline no inflammation or pus

noted during the assessment

TEETH ● With incomplete teeth ( no 1st

premolar upper right teeth and no

2nd premolar left lower teeth)

● With discoloration of the enamel

26
 NECK ● The neck muscle is equally in size

● The lymph nodes are not palpable

● Showed coordinated movement with

no discomfort

● Thyroid gland is not visible

THORAX ● Chest wall is intact no masses or

tenderness noted

● The client manifest crackles and

wheezing sound

ABDOMEN ● Unblemished skin and uniform in

color

● Has symmetric in contour

● There were scars at the right side

due to stabbing

27
 UPPER EXTREMITIES ● Radial pulse is 76 beats/min

● Slightly can’t flex both arms

● Reduce range in motion

● With dirty nails

● Nail beds is pale in color

● Capillary refill return 4-5 sec

● Can do passive assistive ROM

LOWER EXTREMITIES ● Both legs can't flex

● With Joint and muscle pain

● Can do passive ROM

● Swollen of both feet

● Right sided weakness

VI. PATHOPHYSIOLOGY

28
29
VII. DEVELOPMENTAL TASK DATA

The Developmental Tasks Theory, it was Robert J. Havighurst who elaborated on this

theory in the most systematic and extensive manner. Havighurst’s main assertion is that

development is continuous throughout the entire lifespan, occurring in stages, where an individual

moves from one stage to the next by means of successful resolution of problems or performance

of developmental tasks. These tasks are typically encountered by most people in a culture where

the individual belongs. When people successfully accomplish and master these developmental

tasks, they feel pride and satisfaction, and consequently earn the approval of their community or

society. Conversely, when people fail to accomplish a developmental task, they’re often unhappy

30
and are not accorded the desired approval by society, resulting in the subsequent experience of

difficulty when faced with succeeding developmental tasks. Havighurst’s Developmental Tasks

Theory suggests that we are active learners who continually interact with a similarly active social

environment.

In the client’s case, he is 58 years old. This makes him belong to middle age group whose age

ranges from 30 to 60 years old. Below are the task to be achieved in this stage.

Developmental Achieved or Not

Analysis
task Achieved

1. Achieving adult Achieved Tito Raffy is much aware of the activities

civic and social or meetings in their barangay especially

responsibilities that he is a barangay official. He

participates and help with the preparations

of the activities.

31
2. Establishing Achieved Tito Raffy has a stable life and the money

and maintaining he earns and received from his children is

an economic enough for their daily living as verbalized

standard of living. by the patiet“usto lang met tay ma

swelsweldok a pang gastos idjay balay mi

ken adda met digijay annak ko nga

agipaoit wenu umay mangted nukwa nu

kasapulan”

3. Assisting Achieved Tito Raffy assisted and guided all of his

teenage children to children in their teenage years and now

become they are all responsible adults and have

responsible and their own life.

happy adults.

4. Developing Achieved Tito Raffy works every day at 7 am to 9

adult leisure time pm but has a lot of free time within the

activities. day. He usually watch television or go

fishing at their river. As verbalized by the

patient “nu haan nga sumro digitoy sakit

ti tumeng ko ket innak nukwa agkalap nu

awan duty’k ditoy baranggay”

32
 5. Relating oneself Achieved Tito Raffy and his wife maintains a good

to one’s spouse as relationship. Though they argue

a person. sometimes but they still manage to settle

it, and as verbalized by the patient “agap-

apa latta a panggep ti inom a ngem mayat

to metlang”

6. Accepting and Achieved Tito Raffy accepts the changes that

adjusting to happened in his body. and stated, “isu

physiologic ngarod nanipod idi nagikkat nak ta banko

changes in middle ket ng baranggay official nak lattan ta

age atleast makatulungak pelat pamilyak uray

kastoy iti kondisyon ko”

7. Adjusting to Achieved Tito Raffy took care of his old parents

aging parents when they were still alive and adjusted to

their needs.

Analysis:

The patient was able to achieve all of the developmental task of middle age.

33
VIII. PATTERNS OF FUNCTIONING

A. EATING PATTERN

Before Hospitalization During Hospitalization Analysis

Tito Raffy eats (3) times a day. He Tito Raffy eats (3) times a day. He There is no alteration

usually eats 1 skyfakes during eats pandesal with cheese during in eating pattern.

breakfast. During lunch, he usually breakfast. He usually eats half of

consumes 1 cup of rice and the hospital ratio which consist of

prepares 1 serving of vegetables 1 cup of rice, 3-5 slices of meat

and fish. For dinner, he usually eats (cube size) and 1 serving of

1 cup of rice with half serving of vegetables.

lean meat.

B. DRINKING PATTERN

34
Before Hospitalization During Hospitalization Analysis

Tito Raffy usually drinks 3 cups of Tito Raffy now drinks 8-10 glasses There is no alteration

coffee a day (235-240 ml/cup) . He of water (2000-2500 ml) per day. in the drinking

drinks 8-10 glasses of water He also drinks 1 cup of coffee pattern.

(approximately 2000-2500 ml) per (235-240ml) every breakfast. He

day. Sometimes he drinks ¼ of an does not drink alcohol anymore.

8 oz coke (237ml) mixed with

water for snack. He is also fond of

drinking gin with his friends. Total:

Total: Approximately 2000ml - 2500ml

Approximately 2500ml- 3000ml

C. SLEEPING PATTERN

Before Hospitalization During Hospitalization Analysis

Tito Raffy goes to bed around Tito Raffy sleeps at around There is an

9:00pm and wakes up around 10:00pm and wakes up at around alteration in

4:30am-5:30am uninterrupted. He 4:30am with interruptions because sleeping pattern

occasionally takes a nap around of the vital signs monitoring and

1:00-2:00 pm for about 15-20 noisy environment. He takes a nap

minutes. The patient sleeps an of 15-20 minutes during the day.

35
average of 7- 8 hours a day. The patient sleeps an average of 6-

7 hours.

D. BLADDER PATTERN

Before Hospitalization During Hospitalization Analysis

Tito Raffy usually urinates 5-6 He urinates 5-6 times a day, few and There is no change

times a day in large volumes with an sometimes large volume in bladder pattern.

approximate amount of (1500- approximately (1500-2000ml).

2000ml/day).

E. BOWEL PATTERN

Before Hospitalization During Hospitalization Analysis

Tito Raffy usually defecates twice a Tito Raffy usually defecates once There is a change in

day. One is when he wakes up in the a day. Usually in the morning bowel pattern.

morning and usually after lunch. It when he wakes up and usually

has a semi formed stool which is after lunch. The consistency of

brownish in color and aromatic stool is semi formed.

36
odor.

F. BATHING PATTERN

Before Hospitalization During Hospitalization Analysis

He takes a full bath twice a day He doesn’t take a bath but There is a change in bathing

around 6:00 in the morning for 10- instead his wife does tepid pattern before

15 minutes before going to his sponge bath to him twice a hospitalization, the client

work and full bath in the evening. day, one in the morning takes a full bath in the

and before going to bed. morning and full bath in the

evening while during

hospitalization the patient

only does tepid sponge bath

due to pain of lower

extremities and inability to

move alone.

37
IX. LEVELS OF COMPETENCY

A. PHYSICAL

Before Hospitalization During Hospitalization Analysis

Tito Raffy is capable of Tito Raffy can’t perform his There was a decline in his

performing his activities of activities of daily living physical competency due

daily living, such as eating, without assistance. Tito to his condition; his daily

taking a bath and changing his Raffy is unable to stand or sit activities were

clothes freely without alone. He has difficulty diminished.

assistance. He was physically fit moving due to body

to work. weakness and pain.

B. SOCIAL

Before Hospitalization During Hospitalization Analysis

38
 Tito Raffy. has a good Tito Raffy. still communicate There is no significant

interpersonal relationship with with his family and have a change in socializing

his family. He was able to pleasant relationship with with other people

socialize well with his friends, them despite his current because he still able to

co workers and people from his condition. He also interacts communicate well

barangay. with the doctors, nurses, with others.

student nurses and other

patients. He also verbalized

“mayat ta makatulungak pela

kenyayo nga studyante uray

kastoy ti kondisyon ko”

B. EMOTIONAL

Before Hospitalization During Hospitalization Analysis

39
 Tito Raffy. is very expressive in Tito Raffy. is still capable of There is no significant

showing his feelings to his expressing his feelings change in his

family and loved ones. despite what happened. emotional aspect and

During our interview, he can still express his

expresses what he feels about emotions and interacts

his condition. with others.

C. MENTAL

Before Hospitalization During Hospitalization Analysis

Tito Raffy. claimed that he has a Tito Raffy. is well oriented There is no alteration

good decision making skills when even with his condition. He in the mental

it comes to family matters but also can recall happenings and competency of Tito

with the help of his wife. family members. He can also Raffy because he can

respond to questions that were still make sound

being asked. judgement and is

aware to

predicament.

D. SPIRITUAL

40
 Before Hospitalization During Hospitalization Analysis

Tito Raffy is a member of His faith still remains strong. There is no change

Aglipayan Church but he seldom spiritual aspects.

goes to church.

X. ONGOING APPRAISAL

Day 1 Day 2 Day 3 Day 4 Day 5

(November (November (November (November (November
10) 11) 12) 13) 22- Home
Visit)

Intravenous PNSS PNSS PNSS PNSS

fluid

PNSS ✓ ✓ ✓ ✓

Diet Low salt, Low salt, Low salt, low Low salt,
low fat low fat fat low fat

Medications

1. Citicholine ✓ ✓ ✓ ✓
1gm IV q8

2. Peracitan 1gm ✓ ✓ ✓ ✓
3d mps IV q8

3. Vit B IV OD ✓ ✓ ✓ ✓

4. Omeprazole ✓ ✓ ✓ ✓
40 mg IV OD

5. Losartan 50mg ✓ ✓ ✓ ✓
1 tab BID

41
 6. Ketorolac IV ✓
q12

BP: 130/80 BP: 130/90 BP: 140/80 BP: 120/80 BP: 120/80
Vital Signs PR: 80 PR: 90 PR: 85 PR: 86 PR: 84
RR: 20 RR: 23 RR: 20 RR: 20 RR: 20
Temp: 36.5 Temp: 38.9 Temp: 36.5 Temp: 36.4 Temp: 36.9
o o o o o
C C C C C

First Appraisal: November 10, 2019 (9:30 AM)

This was the first day of appraisal. Tito Raffy was seen sitting on bed, awake, weak in

appearance but conversant. Tito Raffy has an IVF of PNSS 1L @ full level, regulated to 30

gtts/min, inserted on his left dorsum, infusing well. The patient complained of body malaise and

pain in lower extremities with a pain scale of 6/10 Advised to take medications ordered religiously

and stick to the prescribed diet.

Vital signs: BP 130/80 mmHg; PR 80 cpm; RR 20 bpm; and body temperature 36.5 oC.

Low salt low fat diet.

Second Appraisal: November 11, 2019 (3:00 PM)

This was the second day of appraisal, Tito Raffy was seen lying on bed, awake and

conversant, with an IVF of PNSS 1L @ 300 cc level regulated 30 gtts per minute, inserted at left

dorsum; infusing well. Febrile, still with body malaise and pain at lower extremities with a pain

scale of 4/10. He is on a low salt, low fat diet and consumed half of the hospital ration for lunch.

Previous health teachings re-emphasized.

42
 Vital signs: BP 130/90 mmHg; PR 90 cpm; RR 23 bpm; and body temperature 38.9 oC.

Low salt low fat diet.

Third Appraisal: November 12, 2019 (4:00 AM)

Our 3rd day of appraisal, Tito Raffy was seen sitting on bed weak, with an IVF of PNSS

1L @ 700 cc level regulated 30 gtts per minute, inserted at left dorsum; infusing well. Encouraged

patient to avoid high purine foods.

Vital signs: BP 140/80 mmHg; PR 85 cpm; RR 20 bpm; and body temperature 36.5 oC.

Low salt low fat diet.

Fourth Appraisal: November 13, 2019 (4:00 PM)

At 4:00 PM, Tito Raffy was seen sitting on bed awake and conversant, with an IVF of

PNSS 1L @ 100 cc level regulated 21 gtts per minute, inserted at left dorsum; infusing well. Doctor

ordered may go home. Previous health teachings re-emphasized.

Vital signs: BP 120/80 mmHg; PR 86 cpm; RR 20 bpm; and body temperature 36.4 oC.

Low salt, low fat diet.

Fifth Appraisal: November 14, 2019 (10:30 AM)

At 10:30 in the morning we went to their house at, La Paz Ilocos Norte. It was located near

the elementary school. Tito Raffy was inside their house, he was fair in appearance, wearing a

white shirt and short. Tito Raffy looked a lot better and felt a lot better after being discharged. He

was already able to do ADL without assistance. He verbalized “Maymayat ti riknak tattan.

Napigpigsa akon.” Previous health teachings were re-emphasized, and also emphasized the

importance of eating fruits and vegetables and taking medications religiously.

43
 Vital signs: BP 120/80 mmHg; PR 84 cpm; RR 20 bpm; and body temperature 36.9 oC.

XI. LABORATORY AND DIAGNOSTIC PROCEDURES

1. HEMATOLOGY

Date Ordered: 11-09-2019

Purpose: This test was done to the client to see the overall condition of the patient’s blood

component to determine deviations from the normal values and be able to determine appropriate

interventions.

Component Reference Value Found Value Significance

WBC 4.00 – 10.00 16.53 x10^9/L HIGH

Neu% 50.0 – 70.0 80.2 % HIGH

Lym% 20.0 – 40.0 9.9 % LOW

Mon% 0.0 – 7.0 9.1 % HIGH

Eos% 0.0 – 7.0 0.5 % Normal

Bas% 0.0 – 1.0 0.3 % Normal

44
 RBC 4.69-6.13 5.76 x10^12/L Normal

Hgb 120 – 160 112 g/L LOW

HCT 40.0 – 54.0 38.9 % LOW

MCV 80.0 – 100.0 67.5 fL LOW

MCH 27.0 – 34.0 19.4 LOW

MCHC 320 – 360 288 g/L LOW

RDW-CV 11.0 – 16.0 14.5 % Normal

RDW-SD 35.0 – 56.0 37.9 fL Normal

PLT 150 – 400 353 x10^9/L Normal

MPV 6.5 – 12.0 7.3 fL Normal

PDW 9.0 – 17.0 15.5 Normal

PCT 1.08-2.82 2.58% Normal

Analysis:

The result of the CBC shows that the WBC, neutrophils and monocytes are elevated are while

lymphocytes is low, this means that there is a presence of infection. Meanwhile the low Hgb,

MCH and MCHC is precipitated by the lack or inadequate sleep of the patient due to the severe

joint pain and fatigue.

45
2. CLINICAL PATHOLOGY

Date Ordered: 11-10-2019

Purpose: Supports the diagnosis of disease using laboratory testing of blood and other bodily

fluids, tissues and microscopic evaluation of individual cells.

TEST FULL NAME RESULT FLAG Reference

TG Triglycerides 1.64 mmol/L Normal <=2.30
T.CHLOE Cholesterol 4.26 mmol/L Normal <=5.20
VLDL Very Low Density Lipoprotein 0.7 mmol/L Normal

AST AST/SGOT 33.4 U/L Normal <=35.0

ALT/SGPT SGPT/ALT 33.3 U/L Normal <=45.0
CREA Creatinine 101.9 umol/L Normal 72.0-127.0
BUA Uric Acid 541.1 umol/L High 214=488

Analysis

The results show hyperuricemia which is caused by many factors such as high purine foods

like fish, beans alcohol etc. Tito Raffy is fond of drinking alcohol and eating fish.. Thus,

explaining high levels of uric acid.

46
3. BLOOD ELECTROLYTES

Date Ordered: 11-09-2019

TEST RESULTS REFERENCE

Sodium 132.0 135-148 mmol/L

Potassium 4.75 3.5-5.3 mmol/L

Chloride 98-107 mmol/L

Calcium 1.13-10.32

Analysis

The blood electrolytes are normal

4. URINALYSIS

Date Ordered: 11/10/2019

PHYSICAL EXAMINATION CHEMICAL EXAMINATION

Color: DARK YELLOW Glucose: (-) Blood: Negative
Character: TURBID Leukocytes:(-) Ketone: Negative
Reaction: 6.0 Nitrate: Negative Bilirubin: Negative
Specific Gravity: 1.030 Protein: (-) Urobilinogen: Negative

MICROSCOPIC EXAMINATION

47
 Pus Cells: 15-20 / HPF Amorphous Urates: Rare Crystals:
Blood Cells: 2-4/HPF Amorphous Phosphates:
Epithelial Cells: Few Bacteria: Rare Casts:
Mucus Threads: Rare Others:
Pregnancy Test:

Analysis:

Tito Raffy’s urine character is turbid, also known as foamy or cloudy urine. Turbid urine

is mainly caused by disorders of the urinary tract which includes the kidneys, ureters, bladder and

the urethra. Urine specific gravity is high, indicates very concentrated urine which may be caused

by a urinary tract infection.

The normal range of pus cells in the urine is 0-5. Since the urinalysis suggests pus cells of

15-20/HPF it is suggestive of urinary tract infection(UTI).

5. CT SCAN

Cranial CT Scan - Plain

Multiple axial tomographic section of the cranium with contrast media were obtained
The CT image reveal no acute intracranial hemorrhage or major vascular territory
infarct
The cortical sulci and lateral fissure are normal
The ventricles are S1 S1 & position
The midline structures are not displaced
Pineal gland & choroid plexus calcification as seen
Intimal calcification seen at the internal carotid arteries
The sella and posterior fossa including, decreased brain stem, cerebellum,
cerebellopontine angles and basal arteries are unremarkable
No extra axial fluid collection noted
Bilateral maxillary sinus disease demonstrated
The rest of the paranasal sinuses, mastoid process and orbits are normal visualized
The calvarium is intact

48
 The extracalvarial soft tissue is unremarkable

Impression:

No evidence of acute intracranial, hemorrhage, or major vascular territory infarct at

this time

6. ECG

HR 100 bpm

PR 120 ms

Q,R,S 193 ms

QT,QTZ 380/491 ms

P,QRS,TAXES 217, 268, 62

RV5/SV1 1.10-0.57 mV

RV5+SV1 1.67 mV

Dx Result

Sinus tachycardia

Ventricular conduction; block

XII. MEDICAL AND NURSING MANAGEMENT

A. INTRAVENOUS FLUID

49
 The administration of fluid through the vein is the most common means by which water,

electrolytes, nutrients and some drugs may be given when oral intake is not possible or must be

supplemented. Intravenous Fluid is also used as a route for parenteral medication. Compared with

other routes of administration, the intravenous route is the fastest way to deliver fluids and

medications throughout the body.

Purpose: This is given to the patient as a means of supportive therapy for his condition and as a

passageway of administration of parenteral medication. It is also to convert further imbalance of

fluids and electrolytes.

PNSS (0.9% Sodium Chloride) 1L x 12 hours

Date Ordered: November 09, 2019

Time: pm

Classification: Isotonic

Nursing Responsibilities:

1. Verify doctor’s order to prevent error

2. Make an IV tag and observe 10 R’s when administering IV medication.

3. Check and regulate the rate of infusion to prevent embolism.

4. Explain the procedure to the patient to gain trust and cooperation.

5. Do not administer unless solution is clear and container is undamaged.

6. Monitor for signs of infection such as redness and swelling to prevent further

complications.

50
B. DIET

LOW SALT LOW FAT

Purpose: This diet encourages to reduce the sodium and fat in the diet and eat a variety of foods

rich in nutrients that help lower blood pressure, such as potassium, calcium and magnesium. Diets

high in fruits and vegetables with low-fat dairy foods, reduced saturated and total fat as well as

low-sodium are important in the initial management of hypertension, urinary tract infection and

gouty arthritis.

Nursing Responsibilities:

1. Explain to the patient the purpose of the diet to gain cooperation.

2. Monitor the client’s adherence to the diet prescribed

3. Provide a comprehensive list of the foods and drinks that the client may or may not take in

consideration to the prescribed diet.

XIII. DRUG STUDY

Date Ordered: November 9, 2019

Generic Name: Losartan

Brand Name: Cozaar

Dosage/Route/Frequency: 50 mg 1 tab Oral BID

51
Classification: Antihypertensive-angiotensin II receptor blocker

Mechanism of Action: Inhibits vasoconstrictive and aldosterone-secreting action of angiotensin

II by blocking angiotensin on the surface of vascular smooth muscles and other tissue cells

Desired Effect: This drug is given to lower blood pressure.

Nursing Interventions:

1. Monitor BP frequently

● Rationale: To evaluate drugs effectiveness

2. Administer Losartan as ordered.

● Rationale: To prevent errors and to maximize the effectiveness of the drug

3. Advise the patient to take the drug with food

● Rationale: To prevent GI upset

4. Instruct the client to change position slowly

● Rationale: To prevent orthostatic hypotension and side effects of the drug are CNS

disturbances such as headache and dizziness

5. Advise the client to report any hypersensitivity reaction

● Rationale: To prevent further complications.

6. Watch for the side effect of the drug:

● Headache - Encourage bed rest

● Constipation - Advice to increase fluid intake

● Nausea - Give ice chips and crackers

Date Ordered: November 9, 2019

52
Generic Name: N/A

Brand Name: Vitamin B

Dosage/Route/Frequency: 1 amp IV OD

Classification: Vitamins and minerals

Mechanism of Action: A coenzyme that stimulates metabolic function and is needed for cell

replication, hematopoiesis, and nucleoprotein and myelin synthesis

Desired Effect: This drug is used by the patient to prevent vitamin B12 deficiency

Nursing Interventions:

1. Perform skin testing before initiating drug therapy.

● Rationale: If allergy occur including rash, dyspnea it should be discontinued.

2. Protect Vitamin B12 from light. Don't refrigerate or freeze.

● Rationale: It may alter the effect of the drug

3. Monitor for the side effects of the drug.

● Rationale: To prevent further complications

Date Ordered: November 09,2019

Generic Name: Omeprazole

Brand Name: Prilosec

Dosage/Route/Frequency: 40 mg, IV OD

Classification: Proton pump inhibitor

Mechanism of Action: Selective and irreversible proton inhibitor, it suppresses stomach acid

secretion by specific inhibition of the H+/K+-ATpase system found at the secretory surface of

gastric acid secretion

53
Desired Effect: This drug is used to decrease the amount of acid the stomach makes.

Nursing Interventions:

1. Check the chart and identify patient before giving the medication

Rationale: To avoid errors in administering medication

2. Caution patient to limit activities requiring alertness until response to medication is known.

Rationale: To avoid drowsiness and dizziness

3. Watch out for side effects:

Constipation - Encourage to eat more fiber and especially soluble

Headache - Promote rest

Dizziness - Advise gradual ambulation

Date Ordered: November 09, 2019

Generic Name: Ketorolac

Brand Name: Toradol

Dosage/Route/Frequency: IV q12

Classification: Antipyretic

Mechanism of Action: Works by blocking your body's production of certain natural substances

that cause inflammation. This effect helps to decrease swelling, pain, or fever.

Desired Effect: This drug decreased pain.

Nursing Interventions:

1. Check doctor’s order.

54
Rationale: To be able to administer the drug with the right dosage, route and frequency. To avoid

errors.

2. Assess the patient before administering the drug.

Rationale: To ensure the patient is receiving the correct medication for the correct reason. Be

diligent in all medication calculations.

3. Monitor urine output .

Rationale: Discontinuation of drug will return urine output to pre-treatment level.

4. Correct hypovolemia prior to administration of the drug.

Rationale: Because the drug inhibits the normal clotting function.

5. Monitor for bleeding including GI pain and diarrhea.

Rationale: Drug decreases platelet aggregation and thus may prolong bleeding time.

Brand Name: Nootropil

Generic Name: Piracetam

Classification: Neuromuscular Agent

Dosage, Route, Frequency: 6g OD oral

Mechanism of Action: This drug acts selectively upon telencephalon by improving its associative

function. It increases the energy output of the brain cells and activates its neurophysiological

potentialities, especially in deficit conditions. Nootropil is virtually nontoxic and has no

stimulating, sedative or neurovegetative activities.

Desired Effect: This drug reduces platelet aggregation as well as fibrinogen concentration, and

thus is contraindicated to patients suffering from cerebral haemorrhage.

55
Nsg. Responsibilities:

1. Check doctor’s order.

Rationale: To be able to administer the drug with the right dosage, route and frequency. To avoid

errors.

2.Monitor weight daily.

Rationale: Because this drug increase weight.

4. Monitor signs and symptoms. (myoclonic seizure symptoms)

Rationale: Because this drug impaired the ability to write and eat.

5. Monitor urine output.

Rationale: Because this drug caused renal impairment.

6. Document the procedure done.

Rationale: For legal purposes.

Brand Name: Cholinerv

Generic Name: Citicholine

Classification: Neurotropic

Dosage,Route,Frequency: 1gm, IV, q8hrs.

56
Mechanism of Action: Citicoline consumption promotes brain metabolism by restoring

phospholipid content in the brain and regulation of neuronal membrane excitability. It also

influences the mitochondria or energy factories of the brain cells and found to improve memory

function.

Desired Effect: This drug stimulates the synthesis and increase in the content of brain

phospholipids.

Nsg. Responsibilities:

1.Check doctor's order and follow the 10R's in drug administration.

Rationale: To be able to administer the drug with the right dosage, route and frequency. To avoid

errors.

2. This drug should not be taken in the afternoon or night.

Rationale: Because this drug can cause difficulty sleeping.

3.Monitor for adverse effects;instruct patient to report immediately if he/she develops chest

tightness, tingling in mouth and throat, headache, diarrhea and blurring of vision.

Rationale: To prevent further complications.

4..Monitor blood pressure, pulse rate and heart rate.

Rationale: Assessment requires in administering this drug to ensure the patient’s safety.

5. Note if there are signs of slurred speech.

57
Rationale: To determine if there is an improvement in speaking.

6. .Document the procedure done.

Rationale:For legal purpose

XIV. NURSING CARE PLAN

Nursing Goal

Activity Intolerance related to generalized weakness inability to perform activity as

manifested by discomfort.

Nursing Inference

Activity is the condition in which things are happening or being done. Weakness restricts

an individual from doing their occupation, task, or responsibilities.

Planning

After 8 hours of effective nursing intervention the patient will be able to do ADL’s alone and

to participate in self- care activities.

Intervention Rationale

58
 1. Monitor vital sign esp. BP ● To help determine patients current

health status and evaluate the

effectiveness of nursing intervention

rendered

2. Assess ability to perform ADL ● To determine the capacity of patient

in doing ADL’s

3. Assess physical mobility status ● To know if there is any changes on

patient condition specifically on

physical aspect

4. Assist patient to do ADL’s ● To minimize fatigue and evaluate his

capabilities in doing such

5. Assist to do active range of motion ● To maximize full strength

exercise like flexing both

extremities

6. Promote rest and comfort ● To conserve energy

7. Emphasize importance of frequent ● To promote circulation

ambulation

Evaluation

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 Goal was partially met because after 8 hours of effective nursing intervention, the patient is

able to do ADL but with assistance and participate in self - care activities.

Nursing Diagnosis

Acute pain related to motor and sensory damage as evidenced by inability to stand alone

and verbalization of “jak pay makatakder kinasakit nan”

Nursing Inference

Pain is physical suffering or discomfort caused by illness or injury.

Planning

After 8 hours of effective nursing intervention the patient will be able to verbalize

acceptable level of pain relief and ability to engage in desired activities

Intervention Rationale

1. Assess for signs and symptoms of ● Patient with chronic pain may not

associated with chronic pain as exhibit physiologic changes and

fatigue, decrease in appetite, behaviors associated with acute pain

anxiety, irritability, restlessness.

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 2. Assess the patient's perception of ● Patient chronic pain have a long

the effectiveness of the method history of using many

used for pain relief in the past pharmacological and

nonpharmacological methods to

control pain

3. Assess the patients expectations ● The patient with chronic pain may

about the pain relief. not expect complete absence of pain,

but satisfied with decreased severity

of pain

4. Assess the patient's ability to ● Fatigue, anxiety, associated with

accomplish activities of daily chronic pain and can limit the

living person's ability to complete self –

care activities

Evaluation

After 8 hours of effective nursing intervention the patient was able to verbalize acceptable level

of pain relief and ability to engage in desired activities.

Nursing Diagnosis

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 Decreased cardiac output related to elevated blood pressure as manifested by restlessness.

Inference

When cardiac output decreases, tissue perfusion adversely affected,any disease process that

produces a reduction in stroke volume or alteration has a direct effect on cardiac output.

Planning

After 6 hours of effective nursing intervention the client will have no elevation of blood

pressure above normal limits and will maintain acceptable blood pressure limit.

Intervention Rationale

1. Monitor BP every hour ● Changes in benp my indicates

changes requiring prompt attention

2. Encourage patient to decrease ● Caffeine is a stimulant and may

intake of caffeine or cola adversely affect cardiac

3. Observe skin color, capillary ● Peripheral vasoconstriction may

refill time and diaphoresis result in pale , cool clammy skin,

with prolonged capillary refill.

Evaluation

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After 6 hours of effective nursing interventions the client blood pressure is in above normal limit

and will maintain acceptable blood pressure limit.

Nursing Diagnosis

Anxiety related to situational crisis as verbalization by the patient “ mayat ta makatulong

nak py bago ak matay”

Inference

Anxiety is the feeling of discomfort and apprehension in response to the disturbance of the

usual concept or pattern situation or environment.

Planning

After 3-4 hours of effective nursing interventions the patient will be able to discuss feelings

of dread, anxiety, and so forth and reduce own anxiety level.

Intervention Rationale

1. Maintain a calm, non threatening ● Anxiety is contagious and may be

manner while working with the transferred from health care provider

client. to client or vice versa. Client

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 develops feeling of security in

presence of calm staff person.

2.Promote expression of feelings and ● Unexpressed feelings may create

fears. internal turmoil. Verbalization of

concerns reduces tension, verifies

level of coping and facilitates

dealing with feelings.

3. Explain purpose of tests and ● Reduces anxiety attribute to fear of

procedures. unknown diagnosis and prognosis.

4. Encourage family and friends to ● Reassures patient that role in the

treat patient the same. family has not been altered.

Evaluation

After 3 hours of effective nursing interventions the patient was able to discuss feelings of dread,

anxiety and reduce his own anxiety level.

Nursing Diagnosis

Deficient knowledge related to lack of information about illness as manifested by

lifestyle and verbalization of “jak met ammo nga madi ti aginom kenyak”

Inference

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 Absence or deficiency of cognitive information related to the disease. Knowledge plays an
influential and significant part of a patient’s life and recovery.

Planning

After 45 minutes to 1 hour of nursing interventions, the patient will be able to verbalize
correctly how and when to take his medications.

Nursing Interventions

Intervention Rationale

1. Educate the patient and family ● Increases awareness of the

members on the treatment importance of completing the
regimen that the patient will prescribed treatment.
undergo.

2. Describe a therapeutic ● This will let the patient gain trust

relationship between and among from the nurse and will boost
the patient and significant others. confidence in the completion of the
treatment.

3. Include the patient in planning the ● It will motivate the patient to plan
proper treatment for him. achievable goals regarding the
treatment

4. Motivate client by providing ● To help client acquire relevant

information relaxant to the information especially in the
situation. treatment regimen.

Evaluation

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After 1 hour of successful nursing interventions, patient was able to verbalize correctly how and
when to take his medications. The goal was met.

XV. GENERAL EVALUATION

Tito Raffy, 58 years of age residing at Lapaz East, Laoag City Ilocos Norte. He was

admitted at Governor Roque B. Ablan Sr. Memorial Hospital last November 09, 2019 at 4:01 PM

with a chief complaint of right sided body weakness and pain in lower extremities. After history

taking and physical examination done by Dr. Marian Grace Mati Formoso. He was admitted to

the hospital.

Tito Raffy had an admitting diagnosis of CVD infarct, HPN urgency, Gouty Arthritis,

Urinary Tract Infection and the same final diagnosis, after a continuous management and

examination.

After 5 days of hospitalization, his condition improved from therapeutic care and

compliance to medications. There is a gradual relief of pain in his lower extremities.

After 5 days of nursing intervention our client's condition had improved, He was

discharged on November 14, 2019 at 3:05 PM went home with proper instruction and health

teachings imparted to client and relatives.

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