CLIENT PRESENTATION

This is a case of a 76 y/o male client who was admitted with a complain of difficulty of breathing.
The client has five (5) children but lives with neither of them. Client was a chain smoker during his teens
but stopped at the age of 56. He has no history of drinking alcohol or has been taking illegal drugs. Client
eats a mixture of food but mostly fatty foods. He was hospitalized twice and was diagnosed with
Hypertension at the age of 50. Clients father also had hypertension. Widower
5 days prior to admission, client went to private clinic for consultation for having a difficulty of breathing
was given Aspirin but did not provide relief.

On July 22,2014, client was admitted to the Emergency Room with a chief complain of Difficulty of
Breathing. Client was conscious, coherent, and alert. Upon receiving, initial vital signs were: T: 36.2 PR:
57(bradycardia) RR: 23(tachypnea) BP:180/60 O2: 95% CBG: 124. Client was then given Oxygen via

nasal cannula @ 2-3 Lpm and was placed on Cardiac Monitoring to monitor cardiac activities,
SPO2 monitoring to keep watch of the oxygen levels in the body, a 12 lead ECG to detect
which part of the heart is not functioning properly and to determine the type of cardiac
emergency. He was also given Isoket 20mg + 90ml D5W anti anginal, nitrate, vasodilator,
relaxes vascular smooth muscle with a resultant decrease in venous return and decrease in
arterial BP, which reduces left ventricular workload and decreases myocardial oxygen
consumption and Nicardipine 10mg + 90ml D5W - Calcium channel blocker, It relaxes your
blood vessels so your heart does not have to pump as hard. It also increases the supply of blood

and oxygen to the heart to control chest pain (angina). The patient was placed on a fowlers
position to facilitate maximum lung expansion to promote ventilation.
He was seen by cardiologist: Ryan D. Andal M.D. on same day and prescribed: Furosemide (Lasix) -

Loop diuretic, reduces BP in hypertensive, inhibits reabsorption of Na and chloride and Sodium
bicarbonate - gastrointestinal agent; antacid; fluid and electrolyte balance agent - rapidly neutralizes
gastric acid or systemic acidosis ABG. He ordered for a CBC, BUN, Crea and Electrolytes - may
show elevated lipid (fats) levels that indicate atherosclerosis and an elevated CPK (creatine
phosphokinase) level. CPK is an enzyme released into the blood when heart tissue dies. Testing CPK
blood levels in the emergency room and during the next 6 to 24 hours can determine with some certainty
whether heart attack has occurred, Urinalysis - may reveal diabetes mellitus or renal disease, both of
which are associated with atherosclerosis and Chest X-ray- may show an enlarged heart or other
structural signs of possible heart failure.