CASE PRESENTATION (Medical Ward)

I. Demographic Profile :Name: R.A.S. Sex: Female Age: 17 Civil Status: SingleBirthdate: July 2, 1997 Birthplace: Baguio CityAddress (1): 126 Hamada Subdivision, Baguio City Religion: Roman Catholic

Address (2): 09301888728 Nationality: FilipinoNext of kin: Rosemarie Salenga Relationship: MotherAdmitting Physician: Dr. Bartolo Date and time admitted: May 3, 2015/ 8:30 pm.

Attending Physician: Dr. Adrian Calera Room: 221-1, Medical wardChief Complaint: Generalized body pain

II. A. History of present illness

1 week prior to admission patient experience generalized body pain, rated as 3/10 but was tolerable. She just continued her maintenance medications, Methylprednisolone and Arcoxia which provided relief of the condition. No consults was done.

5 hours prior to admission, she was just resting when she suddenly felt pain in her whole body and noticed that her fingers were swollen. She rates the pain as 9/10 which is aggravated by movement. Her mother gave her maintenance medications but no relief was noted. Hence, she was brought in for consultation with a private physician and was advised admission.

B. Past Medical History

The mother claims that the patient had been diagnosed of rheumatic heart disease in her childhood years. In September 2014, the patient had dental extraction. The mother also claimed that she had a rheumatic heart fever and was given Salphen via IV. She was also admitted in BGH, at an unrecalled date for kidney problems secondary to her tonsillitis. The mother claims that she had an average of 3 incidence of tonsillitis in a month.On March 15, 2015, she was diagnosed of rheumatoid arthritis but she was negative for rheumatoid factor. She currently takes Arcoxia 120 mg OD and Methylprednisolone 16 mg OD for her maintenance medications. She also had been given Clenza 10 mg OD for 3 Days. The mother claimed that the patient is 100% compliant with her medications. No known allergies to food and drugs. No other history of surgery or trauma. The mother claimed the she have received complete immunization when she was a child.

C. Family History

There is no known maternal history of cerebrovascular disease. The patient had a history on both sides of coronary artery disease, diabetes mellitus and hypertension. There was no known history of pulmonary tuberculosis, cancer, dementia and depression.

D. Social and Environmental HistoryThe patient is a non-smoker, non-alcohol drinker, non-caffeinated beverage drinker. She lies an active

lifestyle until the beginning of March when she started to have problems with her boy. The family lives in a well-ventilated, non-congested, two-story house with 3 bedrooms and 6 occupants. She used to stay upstairs but now she was limited to the ground level due to her body pains. She is a 3rd year college student. The family’s drinking water comes from a water refilling stations and the water for domestic purposes comes from the Baguio water district. She doesn’t practice fad diets and any restrictions on her foods. They have 1 dog living in their backyard. The toilet is of manual flushed-type. Garbage is collected weekly.

Diagnostic/ Laboratory Results: X-ray: Hands: reveals swelling are note overlying the proximal interphalangeal joints and

metacarpophalangeal jointsChest: Mild Cardiomegaly

Doppler Ultrasound: Dilated left atrium with left atrial volume index of 29 cc/m3 Positive systemic erythemathosus (SLU)

LIST OF PRIORITIZATION:

PRIORITIZATION JUSTIFICATION1. Acute pain related to ongoing inflammatory

disease1.1 Impaired comfort

This is the first prioritized problem because this is what the patient complains about and it is an actual problem existing that may result to further complications if not resolved first. According to Maslow’s hierarchy of needs under physiologic needs rest is needed and should be met firs before moving to the level of hierarchy.

2. Ineffective peripheral tissue perfusion related to decreased blood flow

This is the second priority because according to the ABC’s of life circulation should be prioritized first and to prevent possible or further complications of decreased blood flow.

3. Activity Intolerance related to generalized body weakness/pain3.1. Fatigue related poor physical condition

3.2 Risk for fall3.3. Risk for injury

This is the third priority because this can be solved if the above problems will be solved. And also according to Maslow’s hierarchy of needs this falls under Safety which needs to be met before going to the next level of hierarchy. And I clustered the other 3 problems into this since they will have the same or similar nursing interventions and the risks will not occur if given appropriate interventions.

4. Risk for imbalanced body temperature related to infection/inflammation

This is my last prioritized problem since it is a potential problem that may arise if the above problems will not be resolved and also it can be corrected immediately with paracetamol or drug administration.

NCP 1

ASSESSMENT EXPLANATION OF PROBLEM

OBJECTIVES INTERVENTIONS

RATIONALE EVALUATION

S>”Medyo maputla nga po ung kamay ko”

O>capillary refill of 3-4 seconds, Doppler Ultrasound: dilated left atria with left atrial volume index of 29 cc/m3, X-ray: mild cardiomegaly, nail beds: pale, CR: 76 bpm regular BP: 110/70, with noticeable S1 and S2 auscultatory sound, urine output for the shift(7-3): 500 ml, yellowish clear, patient is awake,

Blood is a connective tissue composed of a liquid extracellular matrix called blood plasma that dissolves and suspends various cells and cell fragments. Blood transports oxygen from the lungs and nutrients from the gastrointestinal tract. The oxygen and nutrients subsequently diffuse from the blood into the interstitial fluid and then into

LTO> After 72 hours of nursing interventions the client will be able to

a.eradicate stressors that can help in reducing the workload of the heart such as stress management, therapeutic medication, balanced activity rest pattern

STO> : After 8 hours of nursing interventions the client will be able to:

a.understand

DXAuscultate apical pulse; assess heart rate, rhythm, and document dysrhythmia if telemetry available.

Tachycardia is usually present, even at rest, to compensate for decreased ventricular contractility. Premature atrial contractions (PACs), paroxysmal atrial tachycardia (PAT), PVCs, multifocal atrial tachycardia (MAT), and AF are common dysrhythmias associated with HF, although others may also occur. Note: Intractable ventricular dysrhythmias unresponsive to

LTO> Fully met if

a.eradicate stressors that can help in reducing the workload of the heart such as stress management, therapeutic medication, balanced activity rest pattern

Partially Met if a.lessen stressors that can help in reducing the workload of the heart such as stress management, therapeutic medication,

coherent, oriented to time, place, person

Nursing Diagnosis:Ineffective Peripheral Tissue Perfusion related to decreased blood flow

the body cells. Carbon dioxide and other wastes move in the reverse direction, from body cells to interstitial fluid to blood. Blood then transports the wastes to various organs—the lungs, kidneys, and skin—for elimination form the body. Circulating blood helps maintain homeostasis of all body fluids. Blood helps adjust body temperature through the heat absorbing and coolant properties of the water in blood plasma and its variable rate of flow through the

significant interventions

b.able to perform passive exercises

Note heart sounds.

Palpate peripheral pulses.

medication suggest ventricular aneurysm. wingate, 2007

S1 and S2 may be weak because of diminished pumping action.Gallop rhythms are common (S3 and S4), produced as blood flows into noncompliant, distended chambers. Murmurs may reflect valvular incompetence and stenosis. wingate, 2007

Decreased cardiac output may be reflected in diminished radial, popliteal, dorsalis pedis, and post-tibial pulses. Pulses

balanced activity rest pattern

Not met if a. No eradication of stressors which can reduce the workload of the heart

STO> Fully met if the a. patient was able to understand significant interventions

b.able to perform passive exercises

Partially met if

a. patient was able to

skin, where excess heat can be lost from the blood to the environment. In addition, blood osmotic pressure influences the water content of cells, mainly through interactions of dissolved ions and proteins. Blood can clot, which protects against its excessive loss from the cardiovascular system after an injury. In addition, its white blood cells protect against disease by carrying on phagocytosis. Several types of blood proteins including antibodies, interferons, and

Monitor BP.

Inspect skin for pallor and cyanosis.

may be fleeting or irregular to palpation, and pulsus alternans may be present.(Doenges, M.E.et.al.,2014)In early, moderate, or chronic HF, BP may be elevated because of increased SVR. In advanced HF, the body may no longerbe able to compensate, and profound or irreversible hypotension may occur. Note: Many clients with HF have consistently low systolic BP (80 to 100 mm Hg) due to their disease process and the medications

understand some part of the interventions

b.able to perform passive exercises

Not met if

a. patient was unable to understand some part of the interventions

b.unable to perform passive exercises

complement, help protect against disease in a variety of ways. However, conditions such as conditions such as amputation, cerebrovascular accident, stroke, crainiocerebral trauma, disk surgery, myocardial infarction, sepsis, thrombophebitis, deep vein thrombosis, upper gastrointestinal bleeding and atherosclerosis causes. Reduction in arterial blood flow that leads to deprived nutrition and oxygenation at the cellular level.

Check for calf tenderness; diminished pedal pulse; and swelling, local redness, or pallor of extremity.

Monitor urine output, noting decreasing output and dark or concentrated urine.

they take. Most tolerate this Bps without incident (Wingate, 2007).

Pallor is indicative of diminished peripheral perfusion secondary to inadequate cardiac output, vasoconstriction, and anemia.Cyanosis may develop in refractory HF. Dependent areas are often blue or mottled as venous congestion increases. (Doenges, M.E.et.al.,2014)

Decreases venous stasis and may reduce incidence of thrombus and

Decreased tissue perfusion can be transient with few or minimal consequences to the health of the patient. If the decreased perfusion is acute and protracted, it can have devastating effects on the patient. Diminished tissue perfusion, which is chronic in nature, invariably results in tissue or organ damage or death. Nursing management is directed at following: removing vasoconstricting factor(s), improving peripheral

Note changes in sensorium, for example, lethargy, confusion, disorientation, anxiety, and depression.

Provide quiet environment, explain medical and nursing management, help client avoid stressful situations, listen and respond to expressions of feelings or

embolus formation.(Doenges, M.E.et.al.,2014)

Kidneys respond to reduced cardiac output by retaining water and sodium. Urine output is usually decreased during the day because of fluid shifts into tissues but may be increased at night because fluid returns to circulation when client is recumbent.

May indicate inadequate cerebral perfusion secondary to

blood flow, reducing metabolic demands on the body, making the patient understand his/her disease process and its treatment, making the patient participate in self-care program, and preventing complications.

Reference: Doenges, M.E. et.al.(2010). Nurse’s Pocket Guide: Diagnoses, Prioritized interventions and rationale. F.A Davis Company. 12th Edition. Pp. 69-73.

fears.

Provide bedside commode. Have client avoid activities elicitinga vasovagal response, for instance, straining during defecation and holding breath during position changes.

Elevate legs, avoiding pressure under knee. Encourage active and passive exercises. Increase

decreased cardiac output.(Doenges, M.E.et.al.,2014)

Physical and psychological rest helps reduce stress, which can produce vasoconstriction, elevating BP and increasing heart rate and work.

(Doenges, M.E.et.al.,2014)

Commode use decreases work of getting to bathroom or struggling to use bedpan. Vasovagal maneuver causes vagal

ambulation and activity as tolerated.

EDX

Encourage rest, semi recumbent in bed or chair. Assist with physical care, as indicated.

stimulation followed by rebound tachycardia, which further compromises cardiac function and output.

Reduced cardiac output, venous pooling and stasis, and enforced bedrest increases risk of thrombophlebitis.

Physical rest should be maintained during acute or refractoryHF to improve efficiency of

cardiac contraction and to decrease myocardial oxygen consumption and workload.

NCP 2

ASSESSMENT BRIEF EXPLANATION OF

THE PROBLEM

Goals and Objectives

NURSING INTERVENTIONS

RATIONALE CRITERIA FOR EVALUATION/ EALUATION

S> “Nahihirapan pong maglakad, tsaka mabagal

Since my patient is diagnosed of having Rheumatic

LTO: After 72 hours of nursing interventions

Dx:1.Assessed functional level

>to be able to give the

After 72 hours of nursing interventions

po.”

O:- With functional level of 2.- Muscle strength of both left and right upper extremities: 3/5, both lower extremities: 4/5.-Needs assistance in doing ADL’S such as toileting or transferring from one place to another.

A :Activity intolerance related to generalized body weakness/pain3.1. Fatigue related poor

physical condition

3.2 Risk for fall3.3. Risk for

injury

heart disease which means it is caused by streptococcusinfection in which my patient has sensitivity to the antibodies that were formed in response to the invading bacteria. Since there is an increase production of antigen it circulates in her system attacking the valves of her heart causing inflammation. Which makes the heart difficult to pump blood.Becauseof decrease cardiac workload ,scarring of heart valves :mitral/aortic valve is damage which therefore decreases cardiac supply in different parts of her body ,in which she complain of body weakness .

the client will be able to

a. have a muscle strength of 5/5 in all extremeties with no pain and discomforts

a.Walk on her own without assistance.

c. Will not develop any fall and injury.

STO: After 8 hours of nursing interventions the client will be able to:

a.walk on her own with minimal assistance needed

b.Verbalize needs for assistance

c.Able to change position (from left to

of assistance

2.Assessed muscle strength

TX3. Gradually increase activity, allowing client to assist with positioning, transferring, and self-care as possible. Progress from sitting in bed to dangling, to chair sitting, to standing, to ambulation

4.Perform range-of-motion exercises if client is unable to tolerate activity.

appropriate assistance needed. (Doenges, M.E.et.al.,2014)

>to determine current status and needs associated with participation in needed/desired activities. Serves as a basis for determining the effectiveness of nursing interventions. (Doenges, M.E.et.al.,2014)

>Increasing activity helps to maintain muscle strength, tone, and endurance. Allowing the client to participate decreases the perception of the client as incapable and frail (Eliopoulous, 1998).

LTO: Fully met if: the client will be able to a.walk on her own without assistance

b.have a muscle strength of 5/5 in all extremeties with no pain and discomforts

c.Will not develop any complications such as fall and injury.

Partially met if: needs minimal assistance when ambulating,5/5 in all extremities with pain or discomforts

Not met if: Not able not walk or ambulateAnd did not have a muscle strength of 5/5 in all extremities.

STO :After 8

Activity intolerance according to NANDA, is an insufficient physiological or psychological energy to endure or complete required or desired daily activities.

Reference: Doenges, M.E. et.al.(2010). Nurse’s Pocket Guide: Diagnoses, Prioritized interventions and rationale. F.A Davis Company. 12th Edition. Pp. 69-73.

right or vice versa) frequently

5.Allow for periods of rest before and after planned exertion periods such as meals, baths, treatments, and physical activity.

6.Administer Colchicine a ordered

Ed:

>Inactivity rapidly contributes to muscle shortening and changes in periarticular and cartilaginous joint structure. These factors contribute to contracture and limitation of motion (Creditor, 1994).

>Rest periods decrease oxygen consumption (Prizant-Weston, Castiglia, 1992).

>The exact mechanism of action of colchicine in gout is not completely known, but it involves (1) a reduction in lactic acid production by leukocytes, which results in a decrease in

hours of nursing interventions the client will be able to:Fully met if: able to:

a. Have a muscle strength of 4/5 on both upper extremities

b. Verbalize needs for assistance

c. Able to change position (from left to right or vice versa) frequently

Partially met if:a. Ambulate

with minimal assistance

b. Still have a muscle strength of 3/5 on both upper extremities

c. Verbalize needs for

7.Encourage to ambulate and do exercise as tolerated

8. Instructed to call for SO for assistance when needed

uric acid deposition, and (2) a reduction inphagocytosis, with abatement of the inflammatory response.

>Both activity tolerance and health status improves with progressive and appropriate activity and exercise

>to prevent fall and injury, helps move from one place to another

assistanced. Able to

change position (from left to right or vice versa) frequently

Not met if:a. Can’t

Ambulate without assistance

b. Have a muscle strength of 3/5 on both upper extremities

c. Unable to verbalize needs for assistance

d. Unable to change position (from left to right or vice versa) frequently