Liceo de Cagayan UniversityCollege of nursing

In Partial Fulfillment for the Requirementsof the Subject Elective II

Submitted to:

Sir Rey Ronald V. Solde, RN MN

Submitted by:

Daniel John P. Torres

BSN 4October 8, 2015Introduction

This case study is about Patient SJ, a 91 year old woman, who was referred at Northern Mindanao Medical Center because no one will take good care of her. She had a diagnosis of Coronary Artery disease moderate; old Myocardial Infarction, arrhythmia-AF (Atrial Fibrillation), Hypertensive Cardiovascular disease. Patient SJ, is a former nun. At the age of 33 (1964) she joined Congregation of Daughter of St. Theresa in Balingasag Mis. Or. At the year 1972 she suffered a heart attack, and was brought to Lourdes Hospital in Quezon City. She was admitted for 2 months and was advised by the priest to leave the convent due to medical condition. For 8 years she stayed in Caloocan with sister for 8 years and went back to Camiguin. She lived with her father and her sister; Asuncion De la Rosa along with her husband and children. At the year 2010, her sister died of leukemia, her family could no longer look after her needs. Her niece, Erlinda took care of her till 2012. By the year 2012, Sr. Marian L. Tagupa visited Nanay Sofia in her home and offered her to stay at Northern Mindanao Medical Center.According to WebMD (2014) the heart is mainly made of special muscle (myocardium). The heart pumps blood into arteries (blood vessels) which take the blood to every part of the body. Like any other muscle, theheartmuscle needs a good blood supply. The coronary arteries take blood to the heart muscle. The main coronary arteries branch off from the aorta (the large artery which takes oxygen-rich blood from the heart chambers to the body.) The main coronary arteries divide into smaller branches which take blood to all parts of the heart muscle.Coronary artery disease, also called coronaryheart disease, or simply, heart disease, is the No. 1 killer in America, affecting more than 13 million Americans. Heart disease is a result of plaque buildup in the arteries, which blocks blood flow and heightens the risk for heart attack and stroke. From a young age, cholesterol-laden plaque can start to deposit in the blood vessel walls. As a person gets older, the plaque burden builds up, inflaming the blood vessel walls and raising the risk of blood clots and heart attack. The plaques release chemicals that promote the process of healing but make the inner walls of the blood vessel sticky. Then, other substances, such as inflammatory cells, lipoproteins, and calcium that travel in your bloodstream start sticking to the inside of thevessel walls.Eventually, a narrowed coronary artery may develop new blood vessels that go around the blockage to get blood to the heart. However, during times of increased exertion or stress, the new arteries may not be able to supply enough oxygen-rich blood to the heart muscle. In some cases, a blood clot may totally block the blood supply to the heart muscle, causing heart attack. If a blood vessel to the brain is blocked, usually from a blood clot, an ischemic stroke can result. If a blood vessel within the brain bursts, most likely as a result of uncontrolled hypertension (high blood pressure), a hemorrhagic stroke can result.In myocardial infarction (heart attack), a coronary artery or one of its smaller branches is suddenly blocked. The part of the heart muscle supplied by this artery loses its blood (and oxygen) supply if the vessel is blocked. This part of the heart muscle is at risk of dying unless the blockage is quickly removed. When a part of the heart muscle is damaged it is said to be infarcted. The term myocardial infarction (MI) means damaged heart muscle.If main coronary arteries are blocked, a large part of the heart muscle is affected. If a smaller branch artery is blocked, a smaller amount of heart muscle is affected. After an MI, if part of the heart muscle has died, it is replaced by scar tissue over the next few weeks. Normally you will be advised to take regular medication for the rest of your life. Normally, normally be advised to take the antiplatelet medicine clopidogrel or ticagrelor in addition to aspirin. However, this is usually only advised for a number of weeks or months, depending on the type and severity of your MI.

I. Objectives

General objectives:At the end of 4 hours of exposure at Northern Mindanao Medical Center, I will be able to:Apply the concepts, terms and theories regarding elderly care to the assigned patient. Utilize the knowledge acquired from the 4 walls of the classroom to distinguish the appropriate nursing interventions. Conduct a comprehensive interview to the assigned patient in a proper environmental setting. Apply the skills from previous clinical experiences to provide the patient with holistic nursing care. Identify 3 major problems at Northern Mindanao Medical Center that need correction and intervention. Work alongside the staff of Northern Mindanao Medical Center to promote the elderly patients health and well-being. Maintain the proper student nurse attitude all throughout the exposure. Specific objectives:At the end of 4 hours of exposure at St. Josephs Home for the aged, the student nurses will:A. Conduct an interview and assessment with their assigned elderly patientB. Promote wholeness and well-being including safety and comfort of patientC. Set priorities in nursing care based on patients' needD. Formulate a plan of care in collaboration with patients and other members of the health teamE. Implement planned nursing care to achieve identified outcomesF. Project a professional image of the nurse and maintain the appropriate attitudeG. Establish collaborative relationship with colleagues and other members of the health team for the health plan

II. CLIENT PROFILEName: Jagape, Sofia C.Nickname: SofiaAge:91 y.oGender: FemaleCivil Status: SingleDate of Birth: July 8, 1924Address:Mainit, CatarmanCamiguinBirthplace:Mainit, CatarmanCamiguinReligion: Roman CatholicDate of Admission: Sept 14, 2015Reasons for Referral: No one will take good care of her.

History of the situation: Nanay Sofia is a former nun.At the age of 33 (1964) she joined Congregation of Daughter of St. Theresa in BalingasagMis. Or. At the year 1972 she suffered a heart attack, brought to Lourdes Hospital in Quezon City. She was admitted for 2 months and was advised by the priest to leave the convent due to medical condition. For 8 years she stayed in Caloocan with sister for 8 years and went back to Camiguin. She lived with her father and her sister; Asuncion De la Rosa along with her husband and children. At the year 2010, her sister died of leukemia, her family could no longer look after her needs. Her niece, Erlinda took care of her till 2012. By the year 2012, Sr. Marian L. Tagupa visited Nanay Sofia in her home and offered her to stay at Northern Mindanao Medical Center. Hence her admission.

Source of Information: Sr. Marian L. Tagupa Sr. Sofia Jagape (the patient herself)

III. ASSESSMENT PARAMETERSI. DemographicsName:Jagape, Sofia C.Date of Birth:July 8, 1924Age:91y.oGender: FemaleDiagnosis:Coronary Artery disease moderate; old Myocardial Infarction, arrhythmia-AF (Atrial Fibrillation), Hypertensive Cardiovascular disease Attending Physician:Dr. Hedy L. CorunaLanguage spoken: CebuanoInformant:Jagape, SofiaDate of Admission:Sept 14, 2015

History of Present Illness: At the age of 41, she suffered a heart attack, brought to Lourdes Hospital. Admitted for 2 months, and was advised to leave the convent due to medical condition. Had heart attack 3x on her stay at Northern Mindanao Medical Center. The last heart attack she experienced was on May 2013.Food and drug allergies: No known food and drug allergiesFamily Medical History: (+) Cancer; Her sister died because of Leukemia. (+) Hypertension; PaternalII. Functional PatternA. Nutritional/Metabolic PatternMeal Pattern: Appetite is fair and patient exhibits changes in the amount of meal. The patient verbalized Ginagmay ra akong kina-on ug dapat nay sabaw kay tungod sa akong sakit sa heart.Weight Loss/Gain:There are no significant changes in weight.Feeding: Per Orem and able to eat independently.

B. Elimination PatternBladder: Patient doesnt experience difficulty in urinating, thus voids within her own pattern.Bowel: Usually defecates once a day but it solely depends on the food intake of the client. The patient verbalizes Inig buntag, gakalibang jud ko.Character: YellowishFrequency: Once a dayAmount: Moderate in amount. Usually 50-80 cc

C. Sleep/Rest PatternSleep Difficulty: Patient verbalized sleeping difficulty such as always awakening in the middle of the night. Presence of eyebags and weakness noted.Use of Sleeping Aids: The patient verbalized Sayo man mi matulog pero dili straight akong tulog, gamata-mata jud ko.D. Activity/Exercise (D= Dependent)Activities of Daily Living: (I) Eating(I) Bathing(I) Dressing(I) Grooming(I) Toileting(D) AmbulationActivity level: Sedentary lifestyleE. Cognitive Perception PatternsPatient verbalized Galisod jud kog basa, kailangan najud kog antipara, the patient dont use hearing aids and prosthesis. She ambulates with the help of cane.F. Behavior Pattern (Coping/Values)Behavior: Patient is relaxed and responds to our question attentively.Psychiatric History: NoneSubstance Abuse: The patient has no history of substance abuse.G. PainThe patient verbalized ang akong tuhod kay gasakit ug ga-poy-poy sa pamati. Usahay musakit akong tuhod kung mukaon ko ug monggos. Mag sakit pud akong dughan usahay, pero dili pareha sauna na grabe ang sakit.Pain is noted on her chest and knees with a pain scale of 5/10.H. SexualityMenopausal period/age: Cant be determined.Patient doesnt perform self Breast examination and is already sexually inactive.I. Role Relationship PatternOccupation:Former Nun With whom does the Patient Live: . Sr. Marian L. TagupaAnticipating to return home: No, because no one will be taking good care of the patient. The patient verbalized malipay nako sako friends diri, I will be missing them.

PHYSICAL ASSESSMENT

A. Neurological AssessmentPatient is oriented to self, place; person and time. Weakness/paresthesia noted on her both knees. Has no difficulty in speech or swallowing.

B. Respiratory AssessmentRespiratory rate (as of September 21, 2015) is 17cpm. Respirations are quiet and regular. Slightly pale nail beds and lips noted. Breath sounds in both lung fields are clear. No cough noted.

C. Cardiovascular AssessmentThe patient verbalized usahay naa koy mabatian na sakit sakong dughan dapit pero mutumar rako sakong tambal. Haya rapud manghupong akong tiil ug magsakit ako dughan kung mukaon ko ug fatty foods. Dali rapud ko mahangos tungod sa akong sakit sa kasing-kasing the patient added. With regular apical pulse and BP of 110/60mmHg by September 21, 2014 9AM. No edema noted.

D. Peripheral-Vascular AssessmentBoth upper extremities are pink, warm and movable within the normal range of motion. Peripheral pulses are palpable. There is weakness on the lower extremities and that there are limited ROM. No peripheral edema noted. No complaints of numbness or any calf tenderness.

E. Genitourinary AssessmentThe patient voids without discomfort and voids within own pattern. There are no usual vaginal irritation and discharge noted.

F. Musculoskeletal AssessmentThe patient verbalized maka bati ko ug kasakit sakong likod usahay. Absence of joint swelling and tenderness, no evidence of inflammation, weakness on both knees noted. The patient is able to flex all joints.

G. Integumentary AssessmentThe patient verbalized kaluoy sa diyos wala sad koy samad-samad sakong lawas. Patients skin is within her norm, it is warm, dry, and intact.

H. Psychological/PsychosocialThe patient verbalized that she is happy and satisfied with her life. She always pray and have many friends.

Priority Nursing Problems Identified1. Ineffective breathing pattern2. Chronic pain3. Disturbed sensory perception: Visual4. Risk for injury/falls5. Activity intolerance6. Disturbed Sleeping Pattern

Medications: Multivitamins + Iron 1 tab OD PO Ventolin 2mg TID, via inhalation Losartan 50mg 1 tab OD PO Meloxicam (Mobic) 15mg 1tab OD PO Trimetazidine 35mg 1tab OD PO Salbutamol 2mg 1tab BID via inhalation

Procedures done ECG CBC Urinalysis Blood Chemistry

IV. CERAE/REFLECTION PAPERDaniel John P. TorresReflection Paper:When the chart of the patient assigned to us was given, I got amazed when I read that my patient is 91 years old. People rarely reach such age. And I got more amazed when I personally meet our patient and converse with her, because her memory is still intact that she can remember everything that happened from the past events of her life. Upon assessment I didnt just gathered the relevant datas needed for our care plan, but I also gain lessons in life from her and especially in spiritual aspects of life. It just shows that she still hasnt forgotten her former duty which is a nun. On the other hand, as what I have observed to nanay Sofia, she has difficulty in hearing. She tends to let me repeat my questions and/or answer differently. As a health care provider, what I did was I speak in a soft loud tone, slowly and clearly.I admire how optimistic and satisfied nanay Sofia is. When she was asked about feeling as of the moment, she said she feels happy to where she is right now. She feels like she found a new family in the hospital. I think what nanay Sofia need right now is a health care provider that will assist her physically and emotionally; and most especially in reminder her to take her medications for her medical condition. Aside from her health condition, she reports no other concerns to her situation. She seem to be happy and contented. Someday, when I grow old, I would want to be like her; happy and contented like she lived her life without regret.

V. Recommendation and EvaluationMyocardial Infarction means damage on the heart muscle. patients who are diagnosed with MI are given regular medications for life to prevent recurrence and exacerbation of disease condition. Considering the age of the patient, she needs a health care provider that would constantly remind her to take her medications. Once diagnosed, the patient should fully comply with the regimen given by the healthcare team. They should follow the medications prescribed, diet, exercise and rest. Diet of thepatient with MI should consist of the following: Protein, which plays an essential role in protecting the body, for it produces antibodies to fight infection. Drinking enough fluids is essential to keep the client hydrated. The recommended fluid intake for MI patients is 2 to 3 liters of caffeine-free liquids per day. Water is essential to the body. It helps prevent constipation. Drinking plain water may be your best source of fluid. Are also good sources. Milk is a good source of fluid. It has the added benefit of providing many healthy nutrients. And also patient should be reminded that she should take light meals with water so that MI attack would not trigger. Student nurses and other health care personnel should have thorough assessments so that early diagnosis could be made and recommended therapy could be given. Health care personnel should be careful about the diet given to the patient and should ensure that the food provided is in connection with the prescribed diet of the physician/dietician.

Bibliography

ONLINE: 11 Key Area of Responsibility in Nursing - Scribd. (n.d.). Retrieved September 16, 2014.

Zafari, A. (2014) Myocardial Infaction. Medscape Reference. Retrieved from: http://emedicine.medscape.com/article/155919-overview

BOOKS: Doenges, M., &Moorhouse, M. (2002).Nurse's pocket guide diagnoses, interventions, and rationales(8th ed.). Philadelphia: F.A. Davis.

Karch, A. (2009).2009 Lippincott's nursing drug guide. Philadelphia: Lippincott Williams &Wilkens.

Brunner, L. (2008).Brunner &Suddarth's textbook of medical-surgical nursing(11th ed.). Philadelphia: Lippincott Williams & Wilkins.

Kozier, B, &Erb, G. (2008). Kozier&Erb's Fundamentals of Nursing. Singapore: Pearson Education South Asia Pte Ltd.