Intensive

Case Study

Nursing Health History

II Biographic Data
 Name: Erlinda Ayala Etcubañas
Age/sex: 71 y/o, Female
Birth date: March 20, 1937
Birth place: Pagbilao, Quezon
Address: Venus, Bukal, Pagbilao, Quezon
Nationality: Filipino
Civil status: Married (widow)
Religion: Roman Catholic
Occupation: housekeeper
Source of Medical Care: Phil Health

III Chief Complaint

C/C: recurrent headache

Diagnosis: Hypertensive Arteriosclerotic Cardiovascular
Disease
Date Admitted: September 04, 2008
Physician: Dra. Canela, co-mgnt with Dr. Alincastre
Source of data: ( / ) patient ( / ) Relatives ( )
Others

IIII History of Present Illness

P- Two days prior to admission, the patient experiences

headache; this is recurrent. They checked her blood pressure
resulting to 140/90 and she has taken her maintenance
medication, ____________. On the day of admission at about
1:30am, the pt complaint again of headache accompanied by
vomiting. That morning too, the patient had two episodes of
convulsions. They immediately brought the patient to the
hospital, Mt. Carmel Diocesan Gen. Hospital.

Q- The headache is accompanied by vomiting and seizures, too.

The pain is a stabbing pain.

R- The pain radiates to the patient’s nape and lower back.

S- With the scale of 1 to 5 whereas 1 is the lowest and 5 is the

highest, the
patient chose 5 for his headache.

T- The headache started 2days PTA. The seizure started few

hours PTA.

I V I Past History

 Illnesses- The patient has been operated before due to

cholelithiasis.

 Hospitalizations- According to the relative, she has been

hospitalized when she was operated at MCDGH. She was
frequently hospitalized before due to simple health problems
such as fever, abdominal pain and vomiting.

 Allergies- the patient do not have any allergies on foods,

animals and drugs.
  Medications-

VI Family History of Illness

Mother
HPN and Asthma
Kidney Stone, CVA
Father
Patient
HASCVD

V II Lifestyle

 Diet – The patient has been fond of eating fatty foods, as well as
salty foods and often times, wanted meat. But since she has
been experienced problems with his health, and upon the advice
of her doctor, she slowly limits her intake of these foods but only
at minimal level. She consumed 1 1/2 rice in a meal and since
they have a mini-store, she has been eating junk foods or chips a
lot.
 Sleep/Rest Pattern- Before, she usually sleep 6-8 hours a day
with naps during afternoon, but according to her daughter, these
past few years, sleeping at night was hard on his part maybe due
to aging. They even requested to have sleeping pills for her.
 ADL – she performs his ADL independently and does not need
assistance upon eating, dressing, grooming and toileting. At
home, she is watching after their store and she helps in
household chores, too.
 Exercises- the client has no regular exercise.
 Hobbies/Recreation- She loves to watch television and read
newspaper while staying in their store. Like the usual scenario,
she loves to have chitchat with her colleagues.
 Habits-

VI, Review of System

Respiratory

Cardiovascular

GIT

GUT

VII. Social Data

 Family / friends relationship – the patient is married to
___________ who already passed away year 2002, with eight
children (_ sons,__ daughters) in which all have their own family
except for one, Ofelia, which is staying with her at home and
supporting her needs to, since her mini-store can’t support all
her needs. From time to time, her sons and daughters visit her
and they see to it that they have a reunion once a month or
more if possible since all have their works. She always has
chitchat with her friends.
 Neighborhood Condition- She lives in Pagbilao, Quezon since
her birth and didn’t experience to go to other places for any
reason. Her house is a concrete one and very spacious since her
one daughter is the only one with her and their maid. With her
71 years of age, she hasn’t fight with her neighbors.
 Occupation – She hasn’t work all throughout her existence. She
just put up a store as a means of living since her husband is the
one working before.

VI. Psychological Data

The patient is conscious but does not spoke that much but
only yes or no and if she would like me to do something for her.
She is cooperative in procedures I’m doing and she is responsive
manifested in her nonverbal cues. She looks sad and barely
smiles. She was anxious with her condition and would not like to
talk about it.
Present Mental Status: Alert
Present Behavior: Cooperative

VII. Patterns of Health Care

She was always brought to hospital whenever she has any
untoward feelings.

Physical Examination
Head
Round and symmetrical
With white hair evenly distributed throughout the scalp
No dandruff and lice
No lesions
No mass palpated
Eyes
Symmetrical
Pupils equally round and reactive to light accommodation, 2-3 mm
With pale conjunctiva
With eye bags
No discharges noted
Ears
External ears symmetrical
Upper pinna of the ear in line with outer cantus of ayes
No ear tags
No discharges noted
Nose
Nasal septum centrally located and intact
No flaring of alae nase upon breathing
No discharges noted
No nasal fracture
With NGT
Sinus
No inflammation of sinus

Mouth
Lips brownish in color
With incomplete set of teeteh
Tongue pinkish in color with whitish spots and moves freely and
centrally located
Uvula centrally located
No seen lesions
No halitosis
Throat
With no inflammation of tonsils, reddish in color
With untolerated swallowing of foods
Neck
With fair complexion
Centrally located
No masses, tenderness
No deformities palpated
With strong carotid pulse, no jugular vein distention
Moves bilateral 90o without resistance
Chest
I-with fair complexion
No lesions/ scars
Symmetrical
With slightly sag breast
P-no masses
No tenderness upon palpation
P-resonance sound heard upon percussion
A-heart sounds are regular, no unusual beats noted with HR= 84
beats/min
Back (Lungs)
 I-with fair complexion
No lesions/ scars
Symmetrical
With slight use of accessory muscle upon breathing
With slight effort upon breathing
P-no tenderness/pain upon palpation
P-resonance sound heard upon percussion
A- With normal sound heard on right lung upon auscultation, with
fine rales heard on left lung, RR- 24 breaths / minute at regular rate
and rhythm
Abdomen
I- With fair complexion
With slightly globular abdomen
Umbilicus centrally located
With good healing wound (secondary to cholecystectomy) on the
RUQ, with no signs of infection
A- Hypoactive bowel sound at LUQ and RUQ (3 bowel sound/min)
Π− Tymphanic sound heard upon percussion
Skin dry and warm
No mass palpated
No positive rebound tenderness on areas other than the incision
site
Upper extremities
With fair complexion
With few lentigo senilus or brown spots
With unkempt and not well-clipped nails
Skin warm to touch
With poor skin turgor
With good capillary refill
Brachial and radial pulse palpable
With equal grip of both hands, purposeful movement
GIT
The patient usually defecates once or twice a day before. But
since she has been hospitalized, she didn’t have any bowel
movement. The patient experiences constipation.
GUT
The patient has no pain upon urination. He urinates to a
yellowish in color urine and moderate in amount as manifested by a
fully soaked diaper. Within my 8 hours of shifts, the patient urinates
2-3 times in range varying every day. The bladder is not distended
upon physical examination. The patient has known history of UTI.
Lower Extremities
Symmetrical
With dry skin
Skin warm to touch
With unkempt toe
With difficulty in ambulation
General Impression:
The patient is conscious and coherent, oriented to time, person and
place, and responds appropriately but talks limited and more on
nonverbal cues. The patient is not able to do ADL without assistance
from significant others since she has been hospitalized. The patient
can’t do grooming, cleaning and changing clothes and needs help
from s.o. or student nurse. She participates well in the procedures
and follows instructions. She is not ambulatory and not able to
verbalize feelings and thought accordingly.
Vital Signs:
T- 37.2o c
PR- 84 beats/min
RR- 24 breaths/min
BP- 160/90mmHg

Disease Entity
 Nursing Care Plan
Assessment Nursing Planning Intervention Rationale Evaluation
Diagnosis

O> -guarding Alteration in At the end of the  Comprehensive  For baseline data At the end of the
behavior comfort related to shift, the patient’s assessment of pain shift, the patient’s
- slight facial headache headache will be as to location, headache was
grimace secondary to cough lessen or minimized severity and onset.  To know if there lessened and
-frequent as manifested by:  Vital signs are alterations minimized as
touching • verbalization monitoring because of pain manifested by:
of head while of “ Hindi na  To provide • verbalization of “
coughing masyadong  Instruct pt to comfort Hindi na
-covering towel masakit ang ulo deep breathing and masyadong
in ko.” coughing exercise  To provide masakit ang ulo
head • less or no  Assist in comfort ko.”
touching of the assuming  To distract • less or no
S> “sumasakit ang head upon comfortable touching of the
attention on pain
ulo ko kapag coughing position head upon
umuubo ako” • seen coughing
 Provide
socializing with divertional activities  To prevent • seen socializing
s.o such as NPI and with s.o
fatigue and
• no facial socialization with • no facial grimace
facilitate relaxation.
grimace S.O. • no guarding
 If nursing
• no guarding behavior
 Provide adequate intervention is no
behavior
periods of rest/ longer effective
sleep

 Administer drug
as ordered
 Problem Objective Intervention Rationale Evaluation

Ineffective airway Within the shift, pt will be  Assess respiratory  Changes may indicate Within the shift, pt
clearance related to able to demonstrate rate changes in respiratory demonstrated behaviors to
presence of mucous behaviors to improve pattern improve airway clearance
secretions secondary airway clearance as  Auscultate lung fields,  To note abnormal breath as manifested by:
to productive cough manifested by: noting adventitious sounds and as baseline • deep breathing
as manifested by: • deep breathing breath sounds data exercise,
exercise,  Bronchial tapping • expectorate
S> “nahihirapan • expectorate  Health teaching to the  To remove secretions secretions
akong huminga secretions SO regarding:  To provide knowledge to • coughing effectively
minsan pag dere- • coughing SO how to mage condition • breath without effort
• Position change
deretso ang ubo, effectively and use of accessory
frequently • Promoting chest
parang barado ng • breath without • muscle
Increase fluid intake expansion and
plema” effort and use of expectoration of secretions
accessory muscle • Keep pt back dry • It aids in expectoration of
O> -slight use of
secretions
accessory muscle
upon breathing  Elevate head of bed • To prevent progression of
- with effort upon cough
breathing  Encourage deep-slow  oxygen delivery may be
-repeated breathing as needed improve in upright position
touching of plastic to  Properly regulate IVF  Breathing exercises to
expel phlegm  Assist pt with deep decrease airway collapse
-RR= 24 breathing and  For hydration
breaths/min coughing exercise  Facilitates expansion of
 Promote sleep and lungs, cough is self
rest cleaning mechanism
 To regain energy
  Teach pt., family  To prevent spread of
proper disposal of infections
used plastics and
tissues
 Provide calm restful  External stimuli may
environment inhibit pt’s ability to rest
and relax.

DRUG STUDY
Generic Brand Classificati Action Nursing Responsibility
Name Name on
Sultamicillin Unasyn Antibiotics Treatment of upper and -Assess pt with a history of
tosylate lower respiratory track hypersensitivity/allergy to drug
infections -Instruct pt to report pain or signs of irritation
-Review to pt/family the expected benefits and
possible side effects
-Bear on mind the rights in administering
medications
Ambroxol HCl Mucosolvan Cough and Cold It is an expectoration - Bear on mind the rights in administering
Remedy improver and mucolytic medications
agent used in the treatment -Give the medication with plenty of water to
of acute and chronic liquefy secretions
disorders characterized by - Monitor cardiac rate
the production of excess or - To be given after meal
thick mucus. It works to - Monitor for signs of allergic reactions such as
decrease mucus viscosity by skin rash
altering its structure.
Lacidipine Lacipil Calcium Treatment of hypertension -Monitor BP and pulse during initial administration
Antagonists either alone or in to detect excessive hypotensive response and
combination with other increased heart rate due to peripheral
 antihypertensive agents vasodilation.
-Review to pt/family the expected benefits and
possible side effects
-Bear on mind the rights in administering
medications

Eperisone HCl Myonal Muscle Spastic paralysis in -Review to patient side effects such as dizziness,
Relaxants cerebrovascular diseases, vertigo and headache
tension-type headaches -Monitor vital signs and blood pressure
-Instruct pt to move slowly from lying to sitting or
standing positions.
-Instruct patient to report skin changes
-Bear on mind the rights in administering
medications
Butamirate Sinecod Forte Cough and Cold Cough of any etiology -Take the dose with meals or light snack to
Citrate Remedies prevent irritation
-Instruct pt to swallow the medicine whole,
without chewing or trying to crush.
-Instruct patient to report development of any
unexpected sign or symptom
-Review to pt/family the expected benefits and
possible side effects
-Bear on mind the rights in administering
medications

Benzydamine Difflam Throat For sore throat -Instruct patient to let the medicine stay in mouth
HCl Preparations and not to swallow right away
-Review to pt/family the expected benefits and
possible side effects
-Bear on mind the rights in administering
medications
Olmesartan Olmetec Angiotensin II Treatment of Essential -Monitor BP and pulse during initial administration
mexodomil Antagonist hypertension to detect excessive hypotensive response and
increased heart rate due to peripheral
vasodilation.
 -Review to pt/family the expected benefits and
possible side effects
-Bear on mind the rights in administering
medications
-Instruct patient to report development of any
unexpected sign or symptom
Ethambutol, Myrin P Forte Anti- Initial phase treatment and -Encourage pt. to drink each dose with a full glass
Rifampicin, tuberculous re-treatment of all forms of to lessen gastric irritation
Pyrazinamide Agent TB in category I & II patients -Instruct patient to report worsening of GI
caused by susceptible symptoms
strains of myobacteria. -Inspect pt for signs of allergic response
-Teach pt that urine may turn to red when urine
comes in contact with the drug
Telmisartan Micardis Angiotensin II Treatment of essential -Monitor blood pressure and pulse
Antagonists hypertension -Monitor blood pressure when the patient is in
It inhibits the angiotensin sitting, lying and standing position
converting enzyme -Inform patient of the desired effects of drug
prescribed, side effects and toxicity
-Instruct patient to a low salt low fat diet.
-Bear on mind the rights in administering
medications
 Laboratory Analysis

Urinalysis (Random Urine)

Color: Yellow
 Color is affected by concentration of urine. Usually clear to yellow. As
a general rule, the more yellow, the more concentrated. Bright yellow
urine may be secondary to medicine intake of my patient, too.
Transparency: Clear
 The normal urine is clear.
Protein: Negative
 A protein should not be found in the urine. Protein in the urine can be
a symptom of kidney stones, inflammation of the kidneys,
degenerative kidney disease, or multiple tumors. My patient is free of
these illnesses.
Sugar: Negative
 When glucose exceeds this number, sugar overflows into the urine.
Glucose should not be found in the urine normally. People with
normal kidneys and normal glucose metabolism do not have glucose
in their urine. Since my patient is negative in sugar, he doesn’t have
DM.
Ph: 6.0
 This is a demonstration of how the kidneys regulate excretion of
nonvolatile acids produced by normal metabolic processes. A normal
pH is 7. A pH < 7 indicates acidic urine and > 7 indicates alkaline
urine. My pt has slightly acidic urine.
Specific Gravity: 1.015
 This is the density of the urine. This is an indication of the relative
proportions of dissolved solid components to the total volume of the
specimen and reflects the relative degree of concentration or dilution
of the specimen. A normal specific gravity is between 1.005-1.025.
This is a direct reflection of the concentration ability of the kidneys
and fluid status.
Pus: 0-1
 The presence of pus in urine indicates infection but 0-1 pus is normal
and very little which can be solved by water therapy.
RBC: 0-3
 Red blood cells in the urine can be due to vigorous exercise or
exposure to toxic chemicals. Bloody urine can also be a sign of
bleeding in the genitourinary tract as a result of systemic bleeding
disorders and bacterial infections.
Epithelial Cells: +
 Epithelial cells from the skin surface or from the outer urethra can
appear in urine. Their significance is that they represent possible
contamination of the specimen with skin flora.
Complete Blood Count

Result Reference
RBC 4.1 4.5-5.5
WBC 6.1 5.0-10.0
Differential Count
Segmenters 0.57 0.55-0.65
Lymphocyte 0.43 0.25-0.35
MCV 85 82-92
MCH 27 27-32
MCHC 32 32-36
Hemoglobin 11.5 13.5-18.0
Hematocrit 0.35 0.40-0.48
Platelet 263 150-400

Red Blood Cell

 The primary function of the red blood cells, or erythrocytes, is to
carry oxygen from the lungs to body tissues and to transfer carbon
dioxide from the tissues to the lungs. Anemia is a general term that
refers to a decrease in red blood cells. But several results to be in
related to each other should be performed to diagnose this. A person
with a significantly low RBC count can have symptoms of fatigue,
shortness of breath, and appear pale in color.
Since my patient has difficulty of breathing, it is related to his
decrease number of RBC as it indicates that not enough oxygen is being
delivered to our system, particularly in the lung tissues. This decreased
number of RBC is a factor that triggers his difficulty of breathing.

Lymphocyte
 It indicates a viral infection. Lymphocytosis is seen in infectious
mononucleosis such as viral hepatitis, cytomegalovirus infection, other
viral infections, pertussis, toxoplasmosis, brucellosis, TB and syphilis.
Lymphocytes play an important and integral role in the body's defenses.
My patient has a history of Pulmonary Tuberculosis and right now,
being examined still with the presence of this. His lymphocyte count
increases due to his viral or infectious disease, TB. His lymphocyte count
increases as it is trying to kill infected cells and to protect body and
prevent dissemination of infected cells.

Hemoglobin
 Hemoglobin is comprised of an iron containing pigment (heme) and a
protein (globulin). Oxygen transfer is accomplished via the hemoglobin
contained in red blood cells. The oxygen-combining ability of the blood
is in direct proportion to the hemoglobin concentration, rather than the
numbers of red blood cells, because some cells contain more
hemoglobin than others
Because hemoglobin is a component of all red blood cells, the
conditions that cause a low RBC, also produce a low hemoglobin level.
My patient’s RBC count is low which causes hemoglobin count to be low,
too, as hemoglobin is in RBC.

Hematocrit
  A decrease in hematocrit is always seen with a decrease in the
hemoglobin. These two values are linked to one another. The hematocrit
determines the percentage of red blood cells in the plasma. A decrease
in the number or size of red cells also decreases the amount of space
they occupy, resulting in a lower hematocrit.
Since the RBC and hemoglobin of my patient decrease, hematocrit
automatically decreases, too.

CHEST X-RAY
Homogenous opacity in left upper lobe
Hazy densities in right upper lobe and left base
Blunted left costophrenic sinus
Heart is not enlarged
Rest of the chest structure unremarkable

Impression:

-Primary consideration is Koch’s Pneumonia, Bilateral

 Tuberculosis is a common and deadly infectious disease caused by
mycobacteria, mainly Mycobacterium tuberculosis. Tuberculosis most
commonly attacks the lungs.
My patient has a history of Pulmonary Tuberculosis which means that
the TB directly attacks his lungs.

-Pleural reaction or effusion, left

 A “pleural reaction” is either an inflammation of the pleura or an
increased accumulation of pleural fluid. A pleural reaction is actually a
symptom that can result from several disorders. The most common one,
particularly when there is pain present, is pneumonia. The pneumonia
may be caused by either a bacteria or a virus, and the cause determines
what treatment may be of benefit. A pleural reaction can also result from
infection of the pleura. TB is the most common organism that does this,
but there are other less frequently encountered bacterial, fungal and viral
ones, too.
My patient has history of TB that’s why there’s a pleural effusion
specifically in his left lung/lobe.

SPUTUM Acid-Fast Bacillus (for 3 consecutive days)

First Result: None seen

 A negative or none seen in AFB sputum indicates a possibility of

negative TB but since it’s just the first result and the other two have
not yet being taken, there’s still a chance that my patient still has
PTB. For the PTB to be ruled out, these three consecutive days
Sputum AFB should all be negative.