i.

INTRODUCTION
Acute myocardial infarction (AMI or MI), commonly known as a heart attack, is a
disease state that occurs when the blood supply to a part of the heart is interrupted. The
resulting ischemia or oxygen shortage causes damage and potential death of heart
tissue. It is a medical emergency, and the leading cause of death for both men and
women all over the world. Important risk factors are a previous history of vascular
disease such as atherosclerotic coronary heart disease and/or angina, a previous heart
attack or stroke, any previous episodes of abnormal heart rhythms or syncope, older
age—especially men over 40 and women over 50, smoking, excessive alcohol
consumption, the abuse of certain illicit drugs, high triglyceride levels, high LDL ("Low-
density lipoprotein") and low HDL ("High density lipoprotein"), diabetes, high blood
pressure, obesity, and chronically high levels of stress in certain persons.
Heart diseases constitute the second most common cause of death. Coronary
heart disease death rates have shown consistent declines over the past 15 years, with
men having almost twice the death rates of women. The difference in rates has
remained constant over the years. In 2008, the age-standardized death rate for men
was 105 per 100 000 resident population, compared with 56 for women. The incidence
of acute myocardial infarction events among adults has generally decreased since
1990. The incidence rate for men is about twice that for women; in 2007, the age-
standardized incidence rate for men was 179 per 100 000 resident population,
compared with 79 for women.

Myocardial infarction is a leading cause of morbidity and mortality in the United States.
Approximately 1.3 million cases of nonfatal MI are reported each year, for an annual incidence
rate of approximately 600 cases per 100,000 people. The proportion of patients diagnosed with
NSTEMI compared with STEMI has progressively increased. MI continues to be a significant
problem in industrialized countries and is becoming an increasingly significant problem in
developing countries.

This is a case of patient FT, 89 years old, male, Roman Catholic, from Talakag,
Bukidnon; admitted at MRH on Feb. 3, 2010 with chief complaints of facial asymmetry
associated with slurring of speech and chest pain. His previous diagnosis from last

1
hospitalization includes CAD, AF with RVR (AF with CVR); CHF Class IV (Clan I, Stage
C); Stress Hyperglycemia; and BPH.

In organizing patient care, the group utilized Primary Nursing, also known as
relationship-based nursing. The group viewed themselves as the primary nurses. They
were the ones who assessed and established the nursing care plans which were then
clearly communicated to the student nurses directly assigned to the patient when the
group was not present. Feedback was then sought from them with regards to the
evaluation and progress of the client’s condition.

Charge
Physician Health care
Nurse
Organization
Resources
Clinical
Instructor

Primary
Student
Nurse

Associate
Staff Nurse Staff Nurse
Level 3
Student
Nurse

A. GENERAL OBJECTIVES:
This case presentation seeks to enhance the students’ knowledge with
regards to the patient’s general health and disease condition, its pathophysiology,
possible complications, treatment plan and medical regimen. This also seeks to
assimilate the student’s skills through application of several nursing interventions and
medical management. Furthermore, this case presentation intends to improve the
students’ attitude by conveying open-mindedness and utilizing therapeutic
communication all throughout the activity.

2
B. SPECIFIC OBJECTIVES:
The student nurses aim to achieve the following objectives in 1 hour of case
presentation:
1. Accurately present a thorough general health assessment of the client which
includes physical assessment and family history taking.
2. Effectively discuss and elaborate actual signs and symptoms of disease exhibited
by the client
3. Thoroughly discuss, explain, and elaborate the nature of the disease process
4. Efficiently provide appropriate and proper nursing diagnosis in line with the client’s
medical condition
5. Skillfully formulate nursing care plans for the different problems identified
6. Appropriately provide nursing interventions according to the standards of nursing
practice
7. Effectively apply the learned concepts and theories of disease
8. Efficiently appraise the effectiveness and efficacy of nursing interventions
rendered to the client
9. Impart the outcome of the rendered nursing interventions
10. Convey the significance of client’s response to the rendered nursing interventions
11. Correctly provide concise and concrete information to the audience with regards to
the patient’s disease condition.
12. Appropriately provide appropriate environment for learning for the audience

C. SCOPE AND LIMITATION

The data presented in this case was primarily obtained from student nurse-
patient interaction as well as with the significant other who partly served as informant.
Further information is based on the patient’s chart. The student nurses were only able to
render care to the patient during the assessment on February 4, 7, and 10, 2010 since
the former’s clinical exposure at MRH already ended during that period. Additionally,
subsequent assessments after the 3rd visit were not done because the patient was then
discharged. The Nursing Care Plans presented herein were implemented at a very
limited time but were endorsed and continued by the student nurse assigned to the
patient. Nevertheless, the evaluation bears the nursing outcome observed upon
assessing the patient

3
II. ASSESSMENT

COLLEGE OF NURSING
Xavier University
Ateneo de Cagayan

LEVEL IV
NURSING HISTORY and ASSESSMENT RECORD

Dates of Assessment:
February 4, 2010 – first assessment day
February 7, 2010 – second assessment day
February 10, 2010 – third assessment day

I. PATIENT’S PROFILE
Name of Patient: FT Age: 89 y.o.
Admitting Diagnosis: CVD, coronary infarct, HPN2,HCVD, CD, AF with CVR
Latest Diagnosis: Myocardial infarction, chronic obstructive pulmonary disease, benign
prostatic hyperplasia
Religion: Roman Catholic
Name of Attending Physician: Dr. Elbis Nacua Civil Status:
Married
Date and Time of Admission: Feb. 3, 2010; 7:15 AM
Language/Dialect Spoken: Cebuano

February 4, 2010
Temperature 36.4 oC Pulse 92 bpm Respiration 26 cpm
Blood Pressure 120/70 mmHg
February 7, 2010
Temperature 37 oC Pulse 85 bpm Respiration 24 cpm
Blood Pressure 110/70 mmHg
February 10, 2010
Temperature 36.6 oC Pulse 76 bpm Respiration 23 cpm

4
Blood Pressure 130/70 mmHg

Height: 5’4” Weight 55 kls.

CHIEF COMPLAINT/REASON FOR HOSPITALIZATION: Weakness; facial asymmetry
and slurring of speech
HISTORY OF PRESENT ILLNESS: Patient FT, 89 years old, male, Roman Catholic,
from Talakag, Bukidnon; admitted at MRH on Feb. 3, 2010 with chief complaints of
facial asymmetry associated with slurring of speech and chest pain.
Last January 16, 2010, the patient experienced pain on the nape, dyspnea and
verbalized to his daughter, “naglain ako ginhawa” which alarmed the SO to seek
medical assistance at MRH and was then admitted. He was then discharged on Jan.
23, 2010, with discharge diagnoses of CAD, AF with RVR (AF with CVR); CHF Class IV
(Clan I, Stage C); Stress Hyperglycemia; and BPH. Patient discharged with home
medications: Digoxin 0.7g/tab OD before lunch, Metoprolol 50mg ½ tab BID, Rovustatin
10 mg/tab OD, Losartan 50mg tab OD AC BF, Spiriva rotacup thru inhaler OD,
Allopurinol 100 mg 1tab OD and Avodart 1tab OD. Patient discharged with foley
catheter, such apparatus taken with good compliance.
The patient recovered well after the hospitalization he was able to continue
activities without dyspnea and fatigue. He was able to move freely in the house, perform
ADLs and did not manifest any symptoms of his illness, but SO verbalized persisting
coughs a week prior to admission. On the evening of Feb. 2, 2010, the patient slept
early. 3 hours PTA at around 4:00 am, the patient was found restless and moaning in
bed. Upon observation by the daughter, she noticed that the patient’s face was already
asymmetrical, accompanied with shortness of breath and slurring of speech. The patient
was also observed clutching his chest and grimacing in pain. The situation above
prompted the family to bring the patient to the hospital (MRH). Thus lead to the patient’s
admission.
FOOD AND DRUG ALLERGIES: Pls. specify: no known food and drug allergy
PAST MAJOR ILLNESS, OPERATIONS, AND HOSPITALIZATIONS
ILLNESS/HOSPITALIZATION DATE
Admitted for CAD, AF with RVR (AF with Jan. 2010

5
 CVR); CHF Class IV (Clan I, Stage C);
Stress Hyperglycemia; and BPH at MRH
Hypertension 2005

Family Medical History

(X) Heart disease: Paternal side (-) Renal Disease
(X) Hypertension: Both maternal and paternal side (-) Cancer
(X) Stroke: Maternal side (-) Substance
Abuse
(-) Lung Disease ( ) Others
Others:
_______________________________________________________________
II. FUNCTIONAL PATTERN
A. NUTRITION/METABOLIC PATTERN
Meal Pattern: Patient normally eats three times a day (breakfast, lunch and dinner).
Reports of patient’s fondness of eating fatty food (e.g. humba, chicharon).
Appetite: ( ) Good ( X ) Fair ( ) Poor
Changes in Eating Habits? ( ) No ( X ) Yes
Appetite Changes? ( ) No ( X ) Yes
Weight loss/gain: 55kls-50kls Special Diet: low salt, low fat, diabetic diet

TEETH:
Comments/Nursing Problem Identified:
February 4, 2010 - Patient is on NGT feeding of 1,600 kcal/feeding.
February 7, 2010 – Patient is still on NGT feeding.
February 10, 2010 – Patient is on soft diet.
“Lugaw ra gyud iya pwede kaonon kay galisod pa siya ug tulon. Mukaon man pod siya
pero gamay ra kay murag wala man siya gana. Mao man sab ang ingon sa doctor na
lugaw lang sa ang ipakaon sa iya. “ – as verbalized by the SO.

B. ELIMINATION PATTERN
BLADDER (X) No difficulty ( ) Dysuria ( ) Oliguria

6
 ( ) Incontinence ( ) Nocturia ( ) Anuria
( ) UTI ( ) Stones
Comments/Nursing Problem Identified:
February 4, 2010 – Patient is with foley bag catheter.
“Dili man namo mabantayan kung galisod ba siya og ihi o dili kay gi catheter man siya.
Daghan biya pod iyang ihi kay dali ra man mapuno ang kanang sudlanan usahay.” – as
verbalized by the SO.
Urine output: 2, 700 cc (in 24 hours)
February 7, 2010 – “Mao ra man gihapon, naka catheter ra gihapon siya.” – as
verbalized by the SO.
Urine output: 2, 250 cc (in 24 hours)
February 10, 2010 – Patient is still with Foley bag catheter.
Urine output: 480 cc (in 6-2 Shift)

BOWEL
February 4, 2010 ( ) No difficulty (X) Constipation
February 7, 2010 ( ) Constipation
February 10, 2010 ( ) Constipation
( ) Incontinence ( ) Ileostomy
(X) Laxative aids (specify: Lactulose (ordered Feb. 3, 2010)
Comments/Nursing Problem Identified:
February 4, 2010 – “Pila na kaadlaw wala siya kalibang. Pero naa man siya tambal
kalibang na man pud siya.” As verbalized by SO
February 7, 2010 – “Nakalibang man siya. Humok tungod sa iyang tambal” – as
verbalized by the SO.
February 10, 2010 – “Makalibang na siya adalw.” – as verbalized by the SO.

C. SLEEP/REST PATTERN
( X ) No difficulty ( ) Yes
Use of sleeping aids: ( ) No (X) Yes
Comments/Nursing Problem Identified:

7
“Diretso-diretso man iyang tulog. Sa iya sa kapoy sa iyang sakit mao tingali diretso-
diretso iyang tulog.” As verbalized by SO
Activities of Daily Living (I = Independent, A = With Assistance, D =
Dependent)
Eating (D) Bathing (D) Dressing (D)
Grooming (D) Toileting (D) Ambulating (D)

ACTIVITY LEVEL ( ) Active (X) Sedentary

Comments/Nursing Problem Identified:
February 4, 2010 – “Kadtong wala pa siya nagsakit, maglihok-lihok man pod siya sa
balay.” “Karon dili man niya kaayo malihok iya kamot kay luya.” “Karon kay magghigda
ug matulog ra gyud siya..”– as verbalized by the SO. The patient is very dependent to
his SO due to his condition.
February 7, 2010 – “Karon na naa siya sa hospital, maghigda ra gyud na siya kay luya
man gud pod siya.” – as verbalized by the SO.
“Kami man gyud ga ilis ug gapakaon niya kay maglisod man siya ug lihok-lihok.” – as
verbalized by the SO.
February 10, 2010 –“Makaya-kaya naman niya nga maglihok-lihok nga siya ra. Pero
amo ra gihapon siya i-assist kay basin ma-unsa bah.” –as verbalized by the SO.

E. COGNITIVE PERCEPTION PATTERN

Glasses ( ) No (X) Yes Contact Lens ( ) Yes
( ) Right
( )
Left
Hearing Aids (X) No ( ) Yes Prosthesis ( ) Yes ( )
Right
( ) Right ( ) Left ( )
Left
Comments/Nursing Problem Identified:

8
“Makakita pa man pod siya gamay pero kung magbasa siya kay gagamit siya ug
antipara. Karon naa siya sa hospital kay dili man niya ginagamit iyang antipara.
Makadungog pa man pod na siya.” – as verbalized by the SO.

F. BEHAVIOR PATTERN (COPING/VALUES)

BEHAVIOR (X) Relaxed ( ) Mildly Anxious
( ) Moderately anxious ( ) Very anxious
Psychiatric History: none

SUBSTANCE ABUSE (If yes, pls. indicate frequency/# of packs/glasses per day)
Tobacco (X) No ( ) Yes _____________________________
Drugs (X) No ( ) Yes _____________________________
Alcohol ( ) No ( X ) Yes approximately twice a week______
Cigarette/Cigar/Pipe (X) No ( ) Yes
_____________________________
Comments/Nursing Problem Identified: “Dili man na siya ga sigarilyo, ga inom siya
usahay ra pod dayon ginagmay ra pod.” – as verbalized by the SO.
G. PAIN

February 4, 2010
( ) No (X) Yes (describe) crushing pain on the chest with a pain scale of 3/5, 5
being the highest
Present Pain Management: relaxation technique, deep breathing exercises, Dolcet 1 tab
TID; movement stopped, rest provided along with diversional activities

9
February 7, 2010
( ) No (X) Yes (describe) crushing pain on the chest with a pain scale of 2/5, 5
being the highest
Present Pain Management: relaxation technique, deep breathing exercises, Dolcet 1 tab
TID
February 10, 2010
(X) No ( ) Yes (describe)
Present Pain Management:
_________________________________________________________________
Comments/Nursing Problem Identified:
February 4, 2010 - sighing with no intent to move unless absolutely necessary;
very slow movement with facial grimace; shortness of breath upon pain
onset with facial grimace and sighing
“Murag gi-kumot. 3/5.” Replied the client when asked by the SN regarding
the description of pain and the pain rate scale.
“Muingon na siya na sakit iyahang dughan. Sauna ga reklamo naman siya
nga musakit iyang dughan labaw na kanang mahago siya.” – as verbalized
by the SO.
February 7, 2010 – “Gasakit man gihapon iya dughan usahay.” – as verbalized by the
SO.
February 10, 2010 - “Kaluoy sa Ginoo wala na siya ga-reklamo of sakit sa
iyang dughan” –as verbalized by SO.

H. SEXUALITY/REPRODUCTION PATTERN
Date of last menstrual period (LMP): N/A
Date of Last Pap Smear: N/A
Is the patient pregnant? ( ) No ( ) Unsure ( ) Yes, no of weeks _____________
Breast (cyst, lump, discharge) ( ) No ( ) Yes

10
Testicular/prostate problem: ( ) NA ( ) No (X) Yes

Birth Control: (X) NA ( ) No

( ) Yes (describe) ______________________________
Comments/Nursing Problem Identified: Patient is diagnosed with benign prostatic
hyperplasia.
I. ROLE RELATIONSHIP PATTERN
Occupation: none
With whom does patient live? Family (one son, one daughter and 2 grandchildren)
Anticipating to return home? (X) Yes ( ) No (specify the reason)
________________________
Person(s) available to assist at home: children
Comments/Nursing Problem Identified: The patient is taken care of by his children.
“Wala man gyud lain makatabang ug makabantay ni papa mao na kami ra gyud
magbantay.” – as verbalized by the SO.

III. PHYSICAL ASSESSMENT

(Indicate subjective and objective cues for abnormalities noted)

A. NEUROLOGICAL ASSESSMENT
Alert and oriented to person, place and time?
Subjective
February 4, 2010
“Gahapon, dili na siya kabalo kung aha siya. Unya murag ga-tanga ra siya
pirminti. Naa pud usahay na dili siya kaila sa amo matulog lang dayun siya
balik.”, as verbalized by the SO.
February 7, 2010
“Makaila naman siya. Katulgon na siya pero dili na kaayo pareha sa una.
Murag wala lang siya kabalo sa oras ug adlaw kay naa siya diri sa hospital”,
as verbalized by the SO.

11
February 10, 2010
“ Naa ko ospital karun. Mga alas kwatro naman tingale sa hapon” as
verbalized by the client.

Objective
February 4, 2010
GCS score: eyes – 4, verbal – 4, motor – 4 =12 moderate brain injury,
conscious and coherent but drowsy. Not oriented to person, place and time.
February 7, 2010
GCS score: eyes – 4, verbal – 4, motor – 5 = 13 minor brain injury, There is
difficulty remembering persons, place and time but patient is able to
recognize close members of the family.
February 10, 2010
GCS score: eyes – 4, verbal – 4, motor – 6 = 14 minor brain injury. The
patient can recognize close members of the family, is oriented and is able to
respond to questions although slurring of speech is still present.
Pupils equally round & reactive to light?
No paresthesia (weakness) or paralysis of extremities?
Subjective
February 4, 2010
“Luya na iyang tuo nga side sa lawas.”, as verbalized by the SO.
February 7, 2010
“Kami ra gyud magilis ug pakaon niya kay maglisod siya ug lihok-lihok.”, as verbalized
by the SO.
February 10, 2010
“Medyo okay naman siya. Pero luya ra gihapon daw iyang tuo.” As verbalized
by SO.
Objective
February 4, 2010 – R: weakness on upper and lower extremities present, Grade 1: no
active range of motion & No muscle resistance; L: normal ROM, Grade 3: full active
range of motion & No muscle resistance

12
February 7, 2010 – with complaints of generalized body weakness, R: Grade 2:
Reduced active range of motion & No muscle resistance; L: Grade 4: full active range of
motion & reduced muscle resistance
February 10, 2010 – still with complaints of generalized weakness, R: Grade
4: full active range of motion & Reduced muscle resistance; L: Grade 4: full
active range of motion & Reduced muscle resistance
No difficulty in speech or swallowing noted?
Subjective
February 4, 2010 “Maglisod man siya ug istorya dili kaayo mi kasabot.”, as
verbalized by the SO. “Sa tubo ra man ginapaagi iyang pagkaon, dili mi
maka ingon na maglisod siya ug tulon.” – as verbalized by the SO.
February 7, 2010 “Maglisod man gihapon siya ug istorya.”, as verbalized by the SO.
“Gaapason niya iyang ginhawa kung magsturya siya.” As verbalized by SO.
February 10, 2010 ““Lugaw ra gyud iya pwede kaonon kay galisod pa siya ug tulon.
Mukaon man pod siya pero gamay ra kay murag wala man siya gana. Mao man sab
ang ingon sa doctor na lugaw lang sa ang ipakaon sa iya. “ – as verbalized by the SO
“Makasturya siya pero dili kaayo ingon ana ka klaro.”.

Objective
February 4, 2010
Slurred speech noted
Difficulty in expressing thoughts verbally and use of facial or body
expression due to condition.
February 7, 2010
There is difficulty swallowing thus patient is still on NGT feeding.
February 10, 2010
There is difficulty uttering words.
Difficulty in expressing thoughts verbally and use of facial or body
expression due to condition.
There is improved swallowing. Patient is on soft diet.

13
B. RESPIRATORY ASSESSMENT
Resp. 12 to 22 breath/minute at rest?
Subjective
February 4, 2010
“Gi oxygen man siya kay maglisod siya ug ginhawa. Gi ubo man gud siya.”, as
verbalized by the SO.
“Naay plema iyang ubo, medyo white na sticky.”, as verbalized by the daughter.
February 7, 2010
“Galisod gyud siya ug ginhawa tungod sa iyang ubo.”, as verbalized by the SO.
“Nakaluwa siya ug dugo ganina buntag.”, as verbalized by the SO.
February 10, 2010
“Medyo arangan na iya pamati kay wala naman pod siya gi oxygen pero naa gihapon
siya’y ubo.”, as verbalized by the SO.
Objective
February 4, 2010
RR=26 cpm, shallow breathing, use of accessory muscles
February 7, 2010
RR= 24 cpm, shallow breathing
February 10, 2010
RR= 23 cpm, normal breathing

Respirations quiet & regular?

Breath sounds in both lung fields are clear?
Objective
Rales and ronchi present at both lung fields upon auscultation.
Positive for lung congestion based upon chest x-ray result, productive cough
noted.
Nail beds and lips pink.
Objective
Nail beds and lips are pale.

C. CARDIOVASCULAR ASSESSMENT
Regular apical pulse. Heart rate 60 to 100 beats/minute?
Objective
February 4, 2010
HR= 92 bpm, regular rhythm
February 7, 2010
HR= 85 bpm, regular rhythm
Dilated aorta based upon chest x-ray result.
February 10, 2010
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HR = 76 bpm, regular rhythm
No complaints of chest pain?
Subjective
“Gareklamo man siya nga sakit iyang dughan usahay.”, as verbalized by the SO.
“Musakit iyang dughan usahay. Sauna ga reklamo naman siya nga musakit
iyang dughan labaw na kanang mahago siya.” – as verbalized by the SO.
Objective
Sighing with no intent to move unless absolutely necessary; very slow
movement with facial grimace; shortness of breath upon pain onset
associated with facial grimace and sighing
No Edema?
None noted

D. PERIPHERAL-VASCULAR ASSESSMENT
Extremities are pink, warm and movable within normal ROM?
Subjective
Pale extremities and cold.
Upper and lower extremities movable within ROM with assistance but there
weakness on the right side of the body.
Peripheral pulses palpable. No edema. No complaints of numbness
or calf tenderness?
Objective
February 4, 2010: Capillary refill: 4 sec
February 5, 2010: Oxygen Saturation =93%
February 7, 2010: Capillary refill: 2 sec
February 10, 2010: Capillary refill: 2 sec
E. GENITOURINARY ASSESSMENT
Voiding without discomfort or difficulty?
Urine clear, frequency within own pattern?
Subjective

15
“Dili man namo mabantayan kung galisod ba siya og ihi o dili kay gi catheter man siya.
Daghan biya pod iyang ihi kay dali ra man mapuno ang kanang sudlanan usahay.” – as
verbalized by the SO.

Objective
February 4, 2010 -The patient is with foley bag catheter.
Urine output: 2, 700 cc (in 24 hours)
February 7, 2010 – “Mao ra man gihapon, naka catheter ra gihapon siya.” – as
verbalized by the SO.
Urine output: 2, 250 cc (in 24 hours)
February 10, 2010 – Patient is still with foley bag catheter.
No unusual penile irritation/discharge noted?
No unusual penile discharges.

F. MUSCOLUSKELETAL ASSESSMENT
Absence of joint swelling and tenderness, no evidence of
inflammation?
Normal ROM of all joints?
Subjective
“Kinahanglan gyud namo siya tabangan kung mulihok kay luya man gyud
siya.”, verbalized by the SO.

No muscle weakness?
Objective
Generalized body weakness noted.
No complaints of back pain?
No complaints of backpain

G. INTEGUMENTARY ASSESSMENT
Skin color within patient’s norm, skin warm, dry & intact?

16
Objective
Skin is cold, pale and saggy.
Pale mucous membranes.
Scalp condition: oily.
Decubiti/burns present? ( ) Yes ( X ) No

Medications Indications
Topamax To prevent migraine headache
Dolcet Moderate to severe pain.
Keppra adjunctive therapy in the treatment of
partial onset seizures in adults
Coumadine Myocardial Infarction
Piperacillin + Tazobactam Moderate to severe nosocomial pneumonia
Combivent To prevent bronchospasm in people with
chronic obstructive pulmonary disease
(COPD) who are also using other
medicines to control their condition
Sucralfate Short term treatment of duodenal ulcer.
Fluimocil For acute & chronic resp tract affections w/
abundant mucus secretions
Metoprolol Myocardial Infarcion
Citicoline drops Used to treat cerebrovascular disease
Perindopril Used to treat high blood pressure Essential
hypertension.), and reduction of risk of
cardiac events in patients with a history of
myocardial infarction
Warfarin (coumadin) Used to prevent heart attacks, strokes, and
blood clots in veins and arteries.
Digoxin Used in treating an abnormal heart rhythm
Rosuvastatin Used to treat high cholesterol
Tiotropium Bromide (Spiriva Rotacap) Used in treatment of bronchial spasms
(wheezing) associated with chronic
obstructive pulmonary disease.
Allopurinol It reduces the production of uric acid in
your body
Dutasteride (Avodart) Avodart is used to treat benign prostatic
hyperplasia (BPH) in men with an enlarged
prostate.
LACTULOSE Used to treat constipation

17
Body Map:
February 4, 2010 – first assessment day
1. Nasogastric Tube on left nostril
2. O2 cannula
3. IV on left arm
4. COPD
5. BPH
6. Myocardial infarction
7. Foley catheter

February 7, 2010 – second assessment day

1. Nasogastric Tube on left nostril
2. O2 cannula
3. IV on left arm
4. COPD
5. BPH
6. Myocardial infarction
7. Foley catheter

February 10, 2010 – second assessment day

18
 1. COPD
2. BPH
3. Myocardial infarction
4. Foley catheter

LABORATORY RESULTS

COAGULATION
PROTHROMBIN TIME
Normal Value: 11-15 seconds
(2-3-10) (2-7-10) (2-10-10)
Prothrombin Time: 14.6 seconds 14.5 seconds 16.3 seconds
Control: 13.9 seconds 13.9 seconds 14.4 seconds
Percent Activity : 70.6 % 71.2 % 62. 3
%
INR: 1.45 1.44 1.66
Ratio: 1.05 1.04 1.13
Interpretation: Slightly increased prothrombin time; Indicates that the patient has some
abnormal amounts of clotting factors VII and X. Increased clotting factors is due to
damage in the endothelial tissue of the heart.

ACTIVATED PARTIAL THROMBOPLASTIN TIME

Normal Value: 25 to 35 seconds
APTT : 27.7 seconds
Control : 29.8 seconds
Ratio: 0.60
Interpretation: Normal

BLOOD SUGAR MONITORING RECORD

Normal Value: 70-125 mg/dl

19
HGT Results:
2-3-10 (8:40 am) : 93 mg/dl
2-3-10 (12 nn): 92 mg/dl
2-3-10 (6 pm): 91 mg/dl
2.4.10 (12 am): 94 mg/dl
2.4.10 (6 am): 124 mg/dl

2-10-10 (11pm): 107 mg/dl

Interpretation: Normal

CLINICAL CHEMISTRY

(2-5-10) (2-7-10) (2-9-10) Normal Values:

Sodium : 129 135 134 135-145 mmol/L
Potassium : 4.2 4.7 4.3 3.6-5.1 mmol/L
Creatinine : - 1.2 1.0 0.8-1.5 mg/dl
Urea Nitrogen : - - 16 9-20 mg/dl
ALT : - 49 - 21-72 U/L
Interpretation: slight decreased of sodium is of little clinical value

URINALYSIS (2-4-10)
Color : Yellow
Transparency : Turbid
Specific Gravity : 1.000
pH : 7.5
Sugar : Negative
Protein : Track
Microscopic Findings
RBC : Loaded/ hpf
Pus Cells : 0-1/ hpf
Epithelial Cells : Rare
Bacteria : Few
Interpretation: there is a presence of hematuria; possible bacterial infection

BLOOD CHEMISTRY
Parameters Result Normal Values
COMPLETE BLOOD COUNT
Total WBC 6.0 17.0 5.4 3.0-10.0 x 109/liter
Total RBC 3.70 4.9 4.09 2.60-5.30 x 1012/liter
Hemoglobin 12.6 14.2 13.9 12.70-16.70mmol/L
Hematocrit 35.5 35.5 39.1 40.0-49.70%
MCV 95.4 94.3 95.6 70.0-97.0 fl
MCH 34.1 33.3 34.0 28.0-34.0 pg
MCHC 35.7 35.3 35.5 32-36%

20
Platelet Count 124 109 145 150.0-390.0 x
109/liter
DIFFERENTIAL COUNT
Neutrophils 69.2 84.9 58.9 27.00-72.00 %
Lymphocytes 20.6 10.9 30.5 20.00-50.00 %
Monocytes 6.5 9.7 8.2 8.00-14.00 %
Eosinophils 1.2 0.3 1.7 0.00-6.00 %
Basophils 0.5 0.2 0.7 0.0-1.0 %
RDW-CV 14.3 14.4 14.5 11.50-14.50 %

Interpretation:
Increased WBC,shows the body’s effort to transport cells and substances nvolved in
immune reactions
Decreased Hematocrit,indicates ineffective transport of oxygen and carbon dioxide.
Decreased Platelet Count suggests ineffective clotting at breaks in blood vessels.
Increased Neutrophil is due to the necrotic of tissue present from MI. Neutrophils are
the major components in phagocytosis.
Decreased Lymphocytes, indicates severity of illness due to the body’s lack of
production of principal agents for the body’s immune response.
Decreased Monocyte levels can indicate bone marrow injury or failure

X-RAY REPORT
(2-4-10)
Heart is enlarged with CT ratio of .78. The aorta is atheromatous and sclerotic. Minimal
haziness in the right base. Rest of the lungfields are clear. Hemi diaphragms and sulci
are intact.
Impression:
Cardiomegaly LV and LA form. Atheromatous thoracic aorta. Consider Pneumonia, right
base
(2-5-10)
No significant change of the densities in right base (edema and/or pneumonia)
Cardiomegaly LV form
Atherosclerosis thoracic aorta
Rest of findings unchanged

CT SCAN REPORT

21
(2-1-10)
Plain CT Scan of the brain with serial arial views disclose the following findings.
> There are punctuate hypodensities in the peri ventricular white matter. There is a 2.2
cm hypodense focus in the left mid peri ventricular white matter.
> Ventricles are not dilated.
> Midline structures are intact.
> There is prominence of the sulci and cisterns.
> The middle cerebral arteries are calcified.
> Cerebellum, brain stem, petro mastoids, sinuses, orbits, and sellar areas are
unremarkable.
Impression:
Consider small vessel ischemic changes both peri ventricular white matter..
Consider an infarct, left mid peri ventricular white matter likely old.
Mild cerebro cerebellar atrophy.
Arteriosclerosis of the middle cerebral arteries.

ECG (2-3-10)
Interpretation:
ST segment depression and T-wave inversion – indicates pattern of ischemia
Q wave present – tissue necrosis
Atrial fibrillation present
S3 and S4 present

22
ECG RESULTS

III.

23
ANATOMY AND PHYSIOLOGY

The Heart
The heart is a hollow, muscular organ located in the center of the thorax, where it
occupies the space between the lungs (mediastinum) and rests on the diaphragm. It
weighs approximately 300 g (10.6 oz), although heart weight and size are influenced by
age, gender, body weight, extent of physical exercise and conditioning, and heart
disease. The hearts consists of three distict layers of tissue: endocardium (inner most
layer), myocardium (middle layer) consists of muscle fibers and is the actual contracting
muscle of the heart, and the epicardium (which covers the outer surface of the heart).
The heart pumps blood to the tissues, supplying them with oxygen and other nutrients.
The heart also consists of four chambers: two upper collecting chambers (atria) and two
lower pumpung chambers (ventricles). The right atrium recieves deoxygenated blood
from the body. The blood moves to the right ventricle, which pumps it to the lungs
against low resistance. The left atrium recieves oxygenated blood from the lungs. The
blood flows into the left ventricle (the heart's largest, most muscular chamber), which
pumps it against high resistance into the systemic circulation. The pumping action of the
heart is accomplished by the rhythmic contraction and relaxation of its muscular wall.
During systole (contraction of the muscle), the chambers of the heart become smaller
as the blood is ejected. During diastole (relaxation of the muscle), the heart chambers
fill with blood in preparation for the subsequent ejection. A normal resting adult heart
beats approximately 60 to 80 times per minute. Each ventricle ejects approximately 70
mL of blood per beat and has an output of approximately 5 L per minute.

Respiratory Tract
The respiratory system is an organ system which is used for gas exchange. the
respiratory system generally includes tubes, such as the bronchi, used to carry air to the
lungs, where gas exchange takes place. A diaphragm pulls air in and pushes it out.
The respiratory system can be conveniently subdivided into a conducting zone
and a respiratory zone. The conducting zone starts with the nares (nostrils) of the nose,
which open into the nasopharynx (nasal cavity), which in fact opens into the oropharynx
(behind the oral cavity). The oropharynx leads to the larynx (voicebox), which contains

24
the vocal cords, and connects to the trachea (wind pipe) which leads down to the
thoracic cavity (chest) where it divides into the right and left "main stem" bronchi, which
continue to divide up to 16 more times into even smaller bronchioles. The bronchioles
lead to the respiratory zone of the lungs which consists of respiratory bronchioles,
alveolar ducts and the alveoli, the multi-lobulated sacs in which most of the gas
exchange occurs. Ventilation of the lungs is carried out by the muscles of respiration.
Inhalation is initiated by the diaphragm and supported by the external intercostal
muscles. During vigorous inhalation (at rates exceeding 35 breaths per minute), or in
approis filtered, warmed, and humidified as it flows to the lungs.aching respiratory
failure, accessory muscles of respiration are recruited for support. These consist of
sternocleidomastoidAir moves through the body in the following order: Nostrils, Nasal
cavity, Oropharynx Larynx (voice box), Trachea (wind pipe), Thoracic cavity (chest),
Bronchi (right and left), Alveoli (site of gas exchange). The major function of the
respiratory system is gas exchange. Respiration consists of a mechanical cycle of
inhalation and exhalation, with gaseous exchange occurring in between.
Inhalation is driven primarily by the diaphragm. When the diaphragm contracts,
the ribcage expands and the contents of the abdomen are moved downward. This
results in a larger thoracic volume, which in turn causes a decrease in intrathoracic
pressure. As the pressure in the chest falls, air moves into the conducting zone. Here,
the air is filtered, warmed, and humidified as it flows to the lungs.
Exhalation, on the other hand, is typically a passive process. The lungs have a
natural elasticity; as they recoil from the stretch of inhalation, air flows back out until the
pressures in the chest and the atmosphere reach equilibrium.
During forced inhalation, as when taking a deep breath, the external intercostal
muscles and accessory muscles further expand the thoracic cavity.
During forced exhalation, as when blowing out a candle, expiratory muscles
including the abdominal muscles and internal intercostal muscles, generate abdominal
and thoracic pressure, which forces air out of the lungs.
Upon inhalation, gas exchange occurs at the alveoli, the tiny sacs which are the
basic functional component of the lungs. The alveolar walls are extremely thin (approx.
0.2 micrometres), and are permeable to gases. The alveoli are lined with pulmonary

25
capillaries, the walls of which are also thin enough to permit gas exchange. All gases
diffuse from the alveolar air to the blood in the pulmonary capillaries, as carbon dioxide
diffuses in the opposite direction, from capillary blood to alveolar air. At this point, the
pulmonary blood is oxygen-rich, and the lungs are holding carbon dioxide. Exhalation
follows, thereby ridding the body of the carbon dioxide and completing the cycle of
respiration.

Prostate gland
The prostate sits in front of and below the bladder and is wrapped around the
urethra. That's why prostate problems (e.g. enlargement, infection, inflammation, etc.)
may interfere with a man's ability to urinate and/or to have sex. The prostate happens to
be where it is because it is needed for ejaculation, and the ejaculate passes through the
same urethra as the urine does.
The prostate gland's primary job is to add special fluid to the sperm before it is
ejaculated out from the penis. Sperm is produced in the testicles. From the testicles it
moves up into the epididymis, where it matures, then into the two small, muscular tubes
called the vas deferens, which coil up and around the bladder to the seminal vesicles.
During ejaculation, the seminal vesicles and the prostate gland contract and
expel contents into the prostatic portion of the urethra and then down this route it
washes out toward the tip of the penis. The two ejaculatory ducts pass through the
prostate and open into the prostatic urethra.
One of the prostate's main duties is to add to the seminal fluid nutrients and other
substances which mix with, nourish, protect, and carry sperm out of the penis upon
ejaculation. The prostate also helps to push the semen containing sperm with sufficient
power out of a man's body on its way to fertilizing a woman's egg. The prostate
functions as a gland and contains muscle fibers which contract and relax.

26
IV. PATHOPHYSIOLOGY

A. Narrative

Coronary Artery Disease (CAD) is a disease characterized by the accumulation of

plaque within the layers of the coronary arteries. The plaques progressively enlarge,
thicken and calcify, causing a critical narrowing (75% occlusion) of the coronary artery
lumen, resulting in a decrease in coronary blood flow and an inadequate supply of
oxygen to the heart muscle. The most widely accepted cause of CAD is atherosclerosis.
Angina pectoris caused by inadequate blood flow is the most common manifestation of
CAD. Nonmodifiable risk factors includes: age (risk increases with age), male sex
(women typically suffer from heart disease 10 years later than men due to
postmenopausal decrease in cardiac-protective estrogen), and family history. Modifiable
risk factors include: elevated lipid levels, hypertension, obesity, sedentary lifestyle and
stress. Myocardial Infarction (MI) refers to a dynamic process by which one or more
regions of the heart to experience a severe and prolonged decrease in oxygen supply
because of insufficient coronary blood flow; subsequently, necrosis or death to the
myocardial tissue occurs. The onset of MI may be sudden or gradual, and the
progression of the event to completion takes approximately 3 to 6 hours. MI is one
manifestation of Acute Coronary Syndromes. Sever CAD (greater than 70% narrowing
of the artery) precipitates thrombus formation. The first step in thrombus formation
involves plaque rupture. Platelets adhere to the damaged area. Activation of the
exposed platelets causes expression of glycoprotein IIb/IIIa receptors that bind
fibrinogen. Further platelet aggregation and adhesion occurs, enlarging the thrombus
and occluding the artery. Heart Failure is a clinical syndrome that results from the
progressive process of remodeling, in which mechanical and biochemical forces alter
the size, shape and function of the ventricle’s ability to pump enough oxygenated blood
to meet the metabolic demands of the body. Cardiac compensatory mechanisms
(increases in heart rate, vasoconstriction, heart enlargement) occur to assist the
struggling heart. These mechanisms are able to compensate for the hearts inability to
pump effectively and maintain sufficient blood flow to organs and tissue at rest.
Physiologic stressors increase the workload of the heart and may cause these
mechanisms to fail and precipitate the clinical syndrome associated with a failing heart
(elevated ventricular/atrial pressures, sodium and water retention, decreased cardiac
output and circulatory and pulmonary congestion. These compensatory mechanisms
may hasten the onset of failure because they increase afterload and cardiac work. In
Diastolic failure, a stiff myocardium impairs the ability of the left ventricle to fill up with
blood. This causes and increases pressure in the left atrium and pulmonary vasculature
causing the pulmonary signs of heart failure. With the pulmonary signs of heart failure,
the patient’s mucus secretion and fluid accumulation in the lungs causes obstruction in
the airways. With this, elasticity of lung fibers are lost. There is impaired expiratory
flowrate, increased air trapping which can cause airway collapse. The collapse of the
alveoli or the airways there is decreased surface for gas exchange. This causes COPD.

With the patient’s old age and imbalance in hormones (e.g. androgens) hypertrophy
of the nodules and capsules in the prostate occurs. The hypertrophy obstructs urine
flow. Acute retention may occur together with othe lower urinary tract infections
27
B. Schematic

28
V. Medical Management
A. General Management
IDEAL MEDICAL MANAGEMENT
I. Laboratory Test
1. Complete Blood Count
2. Arterial Blood Gases
3. Computerized Tomography (CT)
Scan
4. Pulmonary Functions Tests (PFTs)
5. Pulse Oximetry
6. Sputum Culture
Rationale
A complete blood count (CBC) will alert the doctor to
an infection as well as telling him, among other things,
how much hemoglobin is present in your blood.
Hemoglobin is the iron-containing pigment in your
blood that carries the oxygen from your lungs to the
rest of your body.
In COPD, the amount of air that you breathe into and
out of your lungs is impaired. Arterial blood gases
(ABGs) measure the oxygen and carbon dioxide
levels in your blood and determine your body's pH
and sodium bicarbonate levels. ABGs are important in
forming a diagnosis of COPD as well as in adjusting
oxygen therapy.
Although a CT is not required for making a diagnosis
of COPD, the doctor may order it when it’s indicated
(infection is not resolving, change of symptoms,
consideration for surgery etc.) While a chest X-ray
shows larger areas of density in the lungs, a CT scan
is more definitive, showing fine details that a chest X-
ray does not. Sometimes, prior to a CT scan, material
called contrast is injected into the vein. This allows
your doctor to see the abnormalities in your lungs
more clearly.
PFTs are used to evaluate lung function and
determine the extent of the damage within your lungs.
The most common PFT is spirometry.
A noninvasive method, pulse oximetry measures how
well your tissues are being supplied with oxygen. A
probe or sensor is normally attached to the finger,
forehead, earlobe or bridge of the nose.
Pulse oximetry can be continuous or intermittent. A
measurement of 95% to 100% is considered normal.
Sputum or mucus from your lungs can be obtained by
coughing it up or suctioning. Your sputum specimen
will be evaluated in a laboratory and will provide your
doctor with a guide in both the diagnosis and
treatment of your lung disease.
29

7. Lung Diffusion Studies
8. Chest x-ray
9. Echocardiography
10. Coronary angiography
11. Myocardial perfusion imaging new ST segment elevation; new Q waves; any ST
scintigraphy using SPECT
12. Electrocardiography (ECG)
13. Digital Rectal Examination (DRE)
14. Prostate-Specific Antigen (PSA)
Blood Test
Measuring the diffusing capacity of the lungs for
carbon monoxide (DLCO), tells the doctor how well
the air that you breathe travels from your lungs to
your blood. Abnormal results mean that your lungs do
not have the ability to move gases in and out of the
lungs properly. Other pulmonary function tests may
also be done as an adjunct to DLCO.
To assess heart size and presence or absence of
heart failure and pulmonary edema. May also assist in
differential diagnosis.
The doctor will perform an initial chest X-ray when
trying to reach a diagnosis of COPD, and then
throughout your treatment to monitor your progress.
is helpful if the diagnosis is in question, can define the
extent of the infarction and can identify complications,
such as acute mitral regurgitation, left ventricular
rupture or pericardial effusion
Defines the patient's coronary anatomy and the extent
of the disease. Whether all patients with acute
myocardial infarction should ideally undergo cardiac
catheterization is controversial and present
consensus is for angiography only if indicated by
recurrent chest pain or significant ischemia shown by
exercise ECG or perfusion imaging. Patients with
cardiogenic shock, intractable angina despite
medications or severe pulmonary congestion should
undergo cardiac catheterization immediately.
Performed before hospital discharge to assess the
extent of residual ischemia if the patient has not
already undergone cardiac catheterization and
angiography.
Features that increase the likelihood of infarction are:
segment elevation; new conduction defect. Other
features of ischemia are ST segment depression and
T wave inversion.
This examination is usually the first test done. The
doctor inserts a gloved finger into the rectum and
feels the part of the prostate next to the rectum. This
examination gives the doctor a general idea of the
size and condition of the gland.
To rule out cancer as a cause of urinary symptoms,
the doctor may recommend a PSA blood test. PSA, a
protein produced by prostate cells, is frequently
30
 present at elevated levels in the blood of men who
have prostate cancer.

If there is a suspicion of prostate cancer, the doctor

15. Rectal Ultrasound and Prostate
Biopsy
may recommend a test with rectal ultrasound. In this
procedure, a probe inserted in the rectum directs
sound waves at the prostate. The echo patterns of the
sound waves form an image of the prostate gland on
a display screen. To determine whether an abnormal-
looking area is indeed a tumor, the doctor can use the
probe and the ultrasound images to guide a biopsy
needle to the suspected tumor. The needle collects a
few pieces of prostate tissue for examination with a
microscope.

In this examination, the doctor inserts a small tube

16. Cystoscopy through the opening of the urethra in the penis. This
procedure is done after a solution numbs the inside of
the penis so all sensation is lost. The tube, called a
cystoscope, contains a lens and a light system that
help the doctor see the inside of the urethra and the
bladder. This test allows the doctor to determine the
size of the gland and identify the location and degree
of the obstruction

The doctor may ask the patient to urinate into a

17. Urine Flow Study special device that measures how quickly the urine is
flowing. A reduced flow often suggests BPH.

II. Medications Patients who have COPD are often prescribed

1. Bronchodilators medications called bronchodilators. Bronchodilators
work by relaxing and expanding the smooth muscle of
the airways, making it easier to breath.

f you have COPD, your doctor may have prescribed

2. Glucocorticoids glucocorticoids, or steroids, as part of your COPD
treatment plan. This drug is liquefy the mucus in your
lungs which reduce the swelling in your breathing
tubes.

People with COPD are more prone to bacterial lung

3. Antibiotics infections than most. And, if you have a bacterial lung
infection, then chances are your doctor will have
prescribed you an antibiotic.

Supplemental oxygen is a very helpful treatment that

4. Oxygen Therapy enables many patients with severe COPD lead a
more normal and productive life.

Flu shots not only help prevent the flu, they can help

31
5. Flu Vaccine
6. Pneumonia Vaccine
7. Antiplatelet agent
o Clopidogrel
o Warfarin (INR 2-
3)
8. Beta blockers
9.Angiotensin-converting
inhibitors: Heparin infusion
10.Prophylaxis against
thromboembolism
11.Cholesterol lowering agents:
12.Heparin infusion
COPD patients fight off potential exacerbations of
symptoms, which are periods of time when your
COPD may worsen.
People with COPD are at greater risk for developing
pneumococcal pneumonia, a serious lung infection
that kills 1 out of every 20 people who get it. And,
even if you have already had a pneumonia vaccine,
the Centers for Disease Control recommend that
certain high-risk groups have a second dose.
Aspirin reduces mortality, non-fatal reinfarction, non-
fatal stroke and vascular death and the survival
benefit is maintained for at least four years.
When started within hours of infarction, beta blockers
reduce mortality, non-fatal cardiac arrest and non-
fatal reinfarction. Unless contraindicated, the usual
regime is to give intravenously on admission and then
continue orally, titrate upwards to the maximum
tolerated dose.
Reduce mortality whether or not patients have clinical
heart failure or left ventricular dysfunction. They also
enzyme reduce the risk of non-fatal heart failure. Titrate dose
upwards to the maximum tolerated or target dose.
Measure renal function, U+E and blood pressure
before starting an ACE inhibitor (or ARB) and again
within 1-2 weeks.1
If not already receiving heparin by infusion, then
patients should be given regular subcutaneous
heparin until fully mobile
Ideally initiate therapy with a statin as soon as
possible on all patients with evidence of CVD unless
contraindicated - after discussing risks and benefits
with the patient, taking into account comorbidities and
life expectancy.
Is used as an adjunctive agent in patients receiving
alteplase but not with streptokinase. Heparin is also
indicated in patients undergoing primary angioplasty
32
13. Alpha-adrenergic blockers

• terazosin (Hytrin) in 1993

• doxazosin (Cardura) in 1995
• tamsulosin (Flomax) in 1997
• alfuzosin (Uroxatral) in 2003
Relaxes the smooth muscle of the prostate and
bladder neck to improve urine flow and to reduce
14. Anti-androgen agents bladder outlet obstruction.

Prevent conversion of testosterone to

dihydrotestosterone to decrease glandular cell activity
• Finasteride (Proscar) and the size of prostate.

Inhibit production of the hormone DHT which is

involved with prostate enlargement.

Is regarded as superior to fibrinolysis in the

III. Surgical Management management of acute myocardial infarction and is
• Primary percutaneous becoming increasingly available for initial patient care.
transluminal coronary
angioplasty (PTCA) Following myocardial infarction reduces death, non-
fatal MI and stroke compared to thrombolytic
reperfusion. However up to 50% of patients
• Balloon angioplasty experience restenosis and 3% to 5% recurrent
myocardial infarction.

Are particularly indicated in patients with large

infarcts, anterior infarction, cardiogenic shock, those
who do not fit the criteria for thrombolytic therapy,
• Cardiac angiography when thrombolysis is contraindicated or has failed
and angioplasty and have persistent ischaemia.

Surgery is indicated in patients in whom angioplasty

fails and in patients who develop mechanical
complications such as a ventricular septal defect, left
• Coronary artery bypass ventricular rupture, or a papillary muscle rupture.

All patients should be offered a cardiological

assessment to consider whether coronary
revascularisation is appropriate.
• Coronary
revascularisation
This operation can improve shortness of breath and
quality of life. This is also to improving dyspnea by
removing areas of major lung damage from
emphysema.
• Lung volume reduction surgery,
(LVRS)
In this type of surgery, no external incision is needed.

33

• Transurethral Surgery
• Open Surgery
• Laser Surgery
• Photoselective Vaporization of
the Prostate (PVP)
• Interstitial Laser Coagulation
IV. General Management
A. Diet
1. Monitor Your Body Weight
2. Drink Plenty of Fluids
After giving anesthesia, the surgeon reaches the
prostate by inserting an instrument through the
urethra.
In the few cases when a transurethral procedure
cannot be used, open surgery, which requires an
external incision, may be used. Open surgery is often
done when the gland is greatly enlarged, when there
are complicating factors, or when the bladder has
been damaged and needs to be repaired. The
location of the enlargement within the gland and the
patient's general health help the surgeon decide
which of the three open procedures to use.
laser energy destroys prostate tissue and causes
shrinkage. As with TURP, laser surgery requires
anesthesia and a hospital stay. One advantage of
laser surgery over TURP is that laser surgery causes
little blood loss. Laser surgery also allows for a
quicker recovery time.
PVP uses a high-energy laser to destroy prostate
tissue and seal the treated area.
Unlike other laser procedures, interstitial laser
coagulation places the tip of the fiberoptic probe
directly into the prostate tissue to destroy it.
Weighing yourself at least once a week will help you
keep your weight under control. If you are taking
diuretics or steroids, however, your doctor may
recommend daily weigh-ins. If you have a weight gain
or loss of 2 pounds in one day or 5 pounds in one
week, you should contact your doctor.
Unless your doctor tells you otherwise, you should
drink 6 to 8, eight-ounce glasses of non-caffeinated
beverages daily. This helps to keep your mucus thin,
making it easier for your body to cough it up. Some
people find it easier to fill a container full of their daily
fluid requirement in the morning and spread it out
during the day. If you try this method, it is best to slow
down your intake of fluids towards evening so you are
not up all night urinating.
Eating too much salt causes your body to retain fluid.
Too much fluid can make breathing more difficult. To
34

3. Decrease Sodium Intake
4. Avoid Overeating and Foods that
Cause Gas
5. Eat Smaller, More Frequent Meals
that Are High in Calories
6. Include Enough Fiber in Your Diet
B. Exercise
4 Types of Exercises for COPD
1. Stretching exercises
2. Aerobic exercises
reduce sodium intake, don't add salt when you cook
and make sure you read all food labels. If the sodium
content in food is greater than 300 milligrams of
sodium per serving, don't eat it. If you are thinking of
using salt substitutes, make sure you check with your
doctor first, as some ingredients in them may be just
as harmful as salt.
When you overeat, your stomach can feel bloated
making breathing more difficult. Carbonated
beverages or gas-producing foods such as beans,
cauliflower or cabbage can also cause bloating.
Eliminating these types of beverages and foods will
ultimately allow for easier breathing.
If you are underweight, eating smaller, more frequent
meals that are higher in calories can help you meet
your caloric needs more efficiently. This can also help
you feel less full making it easier to breathe. Avoid
low-fat or low-calorie food products. Supplement your
meals with high-calorie snacks like pudding or
crackers with peanut butter.
High fiber foods such as vegetables, dried legumes,
bran, whole grains, rice, cereals, pasta and fresh fruit
aid in digestion by helping your food move more
easily through your digestive tract. Your daily fiber
requirement should be between 20 to 35 grams of
fiber each day.
These four types of exercises can help you if you
have COPD. How much you focus on each type of
exercise may depend upon the COPD exercise
program your health care providers suggests for you.
lengthen your muscles, increasing your flexibility.
Stretching can also help prepare your muscles for
other types of exercise, decreasing your chance of
injury.
Use large muscle groups to move at a steady,
rhythmic pace. This type of exercise works your heart
and lungs, improving their endurance by working your
respiratory muscles. This helps your body use oxygen
more efficiently and, with time, can improve your
breathing. Walking and using a stationary bike are
two good choices of aerobic exercise if you have
COPD.
Involve tightening muscles repeatedly to the point of
35
 fatigue. When you do this for the upper body, it can
help increase the strength of your breathing muscles.

3. Strengthening exercises Helps you strengthen breathing muscles, get more

oxygen, and breathe with less effort. Here are two
examples of breathing exercises you can begin doing
for five to 10 minutes, three to four times a day.

4. Breathing exercises for COPD Use pursed-lip breathing while exercising. If you
experience shortness of breath, first try slowing your
rate of breathing and focus on breathing out through
Pursed lip breathing: pursed lips.
1. Relax your neck and shoulder
muscles.
2. Breathe in for two seconds
through your nose, keeping your
mouth closed.
3. Breathe out for four seconds
through pursed lips. If this is too
long for you, simply breathe out First developed to assist women with childbirth, are
twice as long as you breathe in. also useful for men in helping to prevent urine
leakage. They strengthen the muscles of the pelvic
Diaphragmatic breathing: floor that both support the bladder and close the
1. Lie on your back with knees sphincter.
bent. You can put a pillow under
your knees for support.
2. Place one hand on your belly
below your rib cage. Place the
other hand on your chest.
3. Inhale deeply through your nose
for a count of 3. (Your belly and
lower ribs should rise, but your
chest should remain still.)
4. Tighten your stomach muscles
and exhale for a count of 6
through slightly puckered lips.
For BPH patients
• Kegel Exercises

• Don't do any heavy lifting.

• Avoid straining when having a
bowel movement.
• Don't drive or operate Smoking is the underlying cause of the majority of
machinery. cases of emphysema and chronic bronchitis. Anyone
C. Lifestyle who smokes should stop, and, although quitting
1. Smoking smoking will not reverse the symptoms of COPD, it
may help preserve the remaining lung function.

Exposure to other respiratory irritants, such as air

pollution, dust, toxic gases, and fumes, may
aggravate COPD and should be avoided when

36
2. Exposure possible.

D. Supplements Helps break down mucus. For that reason, inhaled

Some vitamins are useful for COPD
patients
1. NAC (N-acetyl cysteine)
NAC is used in hospitals to treat bronchitis. NAC may
also protect lung tissue through its antioxidant activity.
Oral NAC, 200 mg taken three times per day, is also
effective and improved symptoms in people with
bronchitis in double-blind research. Results may take
six months. NAC does not appear to be effective for
people with COPD who are taking inhaled steroid
medications.

Has been given to people with chronic lung disease in

trials investigating how the body responds to exercise.
In these double-blind trials, 2 grams of L-carnitine,
2. L-carnitine taken twice daily for two to four weeks, led to positive
changes in breathing response to exercise.

Is a type of palm tree, also known as the dwarf palm.

Its primary medicinal value is in the oily compounds
found in its berries. Most dietary supplements are
For BPH patients composed of an extract or powder derived from the
Saw palmetto berries. Saw palmetto is believed to inhibit the actions
of testosterone on the prostate that causes prostate
enlargement.

Is of interest because it accumulates in the prostate,

regardless of whether it is a normal prostate or one
enlarged from benign prostate hyperplasia. It may
have some protective properties against prostate
Zinc cancer.

is an evergreen tree native to Africa. Numerous

clinical trials in over six hundred patients have
demonstrated pygeum extract to be effective in
reducing the symptoms and clinical signs of BPH,
especially in early cases. However, in a double-blind
Pygeum africanum
study that compared the pygeum extract with the
extract of saw palmetto, the saw palmetto extract
produced a greater reduction of symptoms and was
better tolerated. There may be circumstances in
which pygeum is more effective than saw palmetto
and as the two extracts have somewhat overlapping
mechanisms of actions, they can be used in
combination. The typical dosage of pygeum extract is
50-100 mg twice per day.

An extract of flower pollen, has been used in Europe

to treat BPH for more than thirty-five years and its

37
 effects have been confirmed in double-blind clinical
studies. The overall success rate of Cernilton in
patients with BPH is about seventy percent. The
typical dosage of is 63-126 mg two to three times per
Cernilton day.

38
39
 B. Drug Study

Name of Date Dose/ Mechanism of Specific Side Effects/

Classification Contraindication Nursing Responsibilities
Drug Ordered Frequency Action Indication Adverse Effects
Citicoline 02-09-10 CNS Stimulant 2cc TID Citicoline Used to Contraindicated Headache, dry  May be taken with or
drops increases blood treat to any allergies cough, nausea, without food. (Take w/
flow and O2 cerebrova (especially drug Unusual or between meals.)
consumption in scular allergies), kidney weakness, back  Best taken on an
the brain. It is disease. problems, liver pain, diarrhea, empty stomach at the
also involved in problems, heart or cramps, chest same time each day.
the biosynthesis blood vessel pain, one-sided  To avoid dizziness
of lecithin. diseases, history arm or leg and lightheadedness
of angioedema, weakness, vision when rising from a
diabetes. changes,tingling seated or lying
of the hands or position, get up
feet, fever, slowly.
persistent sore  Limit your intake of
throat, dizziness, alcohol
fainting, unusual  Use caution when
change in amount exercising or during
of urine, hot weather as these
yellowing of the can aggravate
eyes or skin, dark dizziness and
urine, stomach/ lightheadedness.
abdominal pain,
 Follow all directions
persistent fatigue,
exactly and take the
persistent nausea,
medication as
directed.
 Do not stop taking this
drug without
consulting your
doctor. Some
conditions may
become worse when
the drug is abruptly
stopped.
Perindopri 02-09-10 angiotensin- 5m ½ tab Block the action Used to Contraindicated in Cough, fatigue,  Check BP before
l converting OD per BF of a chemical in treat high patients known to asthenia, giving the medication
enzyme (ACE) the body called blood be hypersensitive headache, and do not give the

40
inhibitors angiotensin pressure to this product or disturbances of medication if pulse is
converting Essential to any other ACE mood and/or below 60bpm.
enzyme (ACE). hypertensi inhibitor. It is also sleep, taste  Comes as a tablet to
Normally ACE on.), and contraindicated in impairment, take by mouth. It is
produces reduction patients with a epigastric usually taken once or
another of risk of history of discomfort, twice a day. Follow the
chemical, cardiac angioedema. nausea, directions on your
angiotensin. events in abdominal pain, prescription.
Angiotensin has patients and rash,  Perindopril controls
two actions: with a dizziness, high blood pressure
history of diarrhea, but does not cure it.
• Firstly it myocardia Continue to take
acts on l infarction perindopril even if you
blood feel well. Do not stop
vessels taking perindopril
to make without talking to your
them doctor.
narrow  Talk to your doctor
• Secondl before using salt
y it acts substitutes containing
on the potassium. If your
kidney doctor prescribes a
to low-salt or low-sodium
produce diet, follow these
less directions carefully
urine

As perindopril
stops the
production of
angiotensin,
these actions
are reversed.
Therefore more
urine is
produced by the
kidneys, which
results in less
fluid in the
blood vessels.

41
 The blood
vessels also
widen. The
overall effect of
this is a drop in
blood pressure
and a decrease
in the workload
of the heart.
Warfarin 02-09-10 anticoagulant 2.5mg It reduces the Used to Contraindicated in Bleeding and  May be taken with
(coumadin (blood 1/2tab OD formation of prevent any localized or necrosis or without food.
) thinner) blood clots. It heart general physical (gangrene) of the  Frequent blood
works by attacks, condition or skin. Bleeding can tests are performed to
blocking the strokes, personal occur in any measure blood
synthesis of and blood circumstance in organ or tissue. clotting time (protime)
certain clotting clots in which the hazard Bleeding around during Coumadin
factors. Without veins and of hemorrhage the brain can treatment.
these clotting arteries. might be greater cause severe  Since it is
factors, blood than the potential headache and metabolized by the
clots are unable clinical benefits of paralysis. liver and excreted by
to form. anticoagulation. Bleeding in the the kidneys, caution is
joints can cause needed in giving this
joint pain and drug to patients with
swelling. Bleeding liver and kidney
in the stomach or dysfunction.
intestines can  Instruct the
cause weakness, patient to seek
fainting spells, immediate medical
black tarry stools, care if symptoms of
vomiting of blood, overdose will
or coffee ground manifest, these
material. Bleeding includes: bleeding
in the kidneys can gums, bruising,
cause back pain nosebleeds, heavy
and blood in menstrual bleeding,
urine, purple, and prolonged
painful toes, rash, bleeding from cuts.
hair loss,
bloating, diarrhea,

42
and jaundice.

43
 02-09-10 Digitalis 25mg ½ Increases the Used in Contraindicated Extra beats,  People of Asian descent
Digoxin glycoside tab force of treating an to Digitalis anorexia, nausea may absorb
contraction of abnormal toxicity, and vomiting, rosuvastatin at a higher
the muscle of heart ventricular confusion, rate than other people.
the heart by rhythm tachycardia/fibrill dizziness, Make sure your doctor
inhibiting the ation, obstructive drowsiness, knows if you are Asian.
activity of an cardiomyopathy. restlessness, You may need a lower
enzyme Arrhythmias due nervousness, than normal starting
(ATPase) that to accessory agitation and dose.
controls pathways (e.g. amnesia, visual  Take digoxin exactly as
movement of Wolff-Parkinson- disturbances, prescribed by your
calcium, sodium White syndrome). gynaecomastia, doctor. Do not take it in
and potassium larger amounts or for
into heart Special longer than
muscle. Calcium Precautions on recommended.
controls the Cardiac  May be taken with or
force of dysrhythmias, without food.
contraction. hypokalaemia,  Take it with full glass of
Inhibiting hypertension, water.
ATPase IHD,  Take the medication at
increases hypercalcaemia, the same time of the
calcium in heart hypomagnesaemi day.
muscle and a,
 Do not stop taking
therefore electroconversion
digoxin without first
increases the , chronic cor
talking to your doctor.
force of heart pulmonale, aortic
Stopping suddenly may
contractions. valve disease,
make your condition
Digoxin also acute myocarditis,
worse.
slows electrical congestive
 Store digoxin at room
conduction cardiomyopathies
temperature away from
between the , constrictive
moisture and heat.
atria and the pericarditis, heart
ventricles of the block, renal
heart and is impairment,
useful in abnormalities in
treating thyroid function
abnormally
rapid atrial
rhythms such
as atrial
fibrillation, atrial
44
Rosuvasta 02-09-10 cholesterol- 10mg 1tab Blocks the Used to Do not take this Muscle pain,  Take this
tin lowering OD production of treat high medication if you tenderness, or medication exactly as
medication cholesterol (a cholestero are allergic to weakness with it was prescribed for
type of fat) in l. rosuvastatin, if fever or flu you. Do not take the
the body. It you have liver symptoms and medication in larger
works by disease. dark colored amounts, or take it for
reducing levels urine;urinating longer than
of "bad" more or less than recommended by your
cholesterol Special usual, or not at doctor.
(low-density precaution on all; nausea,  You may take the
lipoprotein, or patients with stomach pain, low medicine with or
LDL) and kidney disease; fever, loss of without food. Take
triglycerides in underactive appetite, dark rosuvastatin at the
the blood, while thyroid; muscle urine, clay- same time each day.
increasing disorder; epilepsy colored stools,  It is best to take
levels of "good" or other seizure jaundice this drug in the
cholesterol disorder; an (yellowing of the evening.
(high-density electrolyte skin or  Take this medication
lipoprotein, or imbalance (such eyes);chest pain; with a full glass of
HDL). as high or low or swelling in water.
potassium levels your hands or  Avoid drinking
in your blood); a feet. alcohol while taking
severe infection this medication.
or illness. Alcohol can increase
triglyceride levels, and
may also damage your
liver while you are
taking rosuvastatin.
 Call your doctor at
once if you have
unexplained muscle
pain or tenderness,
muscle weakness,
fever or flu symptoms,
and dark colored
urine.
 Rosuvastatin is
only part of a
complete program of

45
 treatment that also
includes diet,
exercise, and weight
control. Follow your
diet, medication, and
exercise routines very
closely.
 Do not stop using
rosuvastatin without
first talking to your
doctor.
 Store rosuvastatin
at room temperature
away from moisture
and heat.
Tranexami 02-07-10 antifibrinolytic 500mg, Tranexamic acid short-term Do not use Nausea, vomiting,  Take this medication
c acid agent PRN is a man-made control of Tranexamic diarrhea might exactly as prescribed
form of an bleeding Acid if: you occur. If these by your doctor. Do not
amino acid are allergic persist or worsen, take it in larger
(protein) called to any notify your doctor amounts or for longer
lysine. It works ingredient promptly. Very than recommended.
by blocking the in unlikely but report  To be sure this
breakdown of Tranexamic promptly: vision medication is not
blood clots, Acid, you changes, causing harmful
which prevents have blood dizziness. If you effects, your vision
bleeding. clots, notice other may need to be
bleeding effects not listed checked while you are
within the above, contact using tranexamic acid.
brain, or your doctor or  Store this medication
eye pharmacist. at room temperature
problems Diarrhea; away from moisture
(retinal giddiness; and heat.
disease), nausea; vomiting.
you are Severe allergic
colorblind, reactions (rash;
you are hives; difficulty
using factor breathing;
IX complex tightness in the
concentrate chest; swelling of
s or anti- the mouth, face,

46
 inhibitor lips, or tongue);
coagulant calf pain,
concentrate swelling, or
s. tenderness;
changes in vision
(disturbance of
color, sharpness,
or field of vision);
chest pain;
decreased
urination; one-
sided weakness;
pain, swelling, or
redness at the
injection site;
severe headache;
shortness of
breath; speech
problems.
Tiotropiu 02-03-10 Muscarinic 1 cap OD Opens the Used in Titropium is Dry mouth, dry  Spiriva capsules
m receptor respiratory tract treatment contraindicated in throat, increased are packaged as a
Bromide antagonist and makes of Hypersensitivity. heart rate, blurred blister card containing
(Spiriva breathing bronchial Spiriva should not vision, glaucoma, two strips. Each strip
Rotacap) easier. spasms be used for the urinary difficulty, has three capsules.
Tiotropium acts (wheezing) initial treatment of urinary retention, When removing a
on the lungs, associated acute episodes of narrow-angle capsule from the
where it blocks with bronchospasm. glaucoma, blister card, peel back
muscarinic chronic prostatic only the foil that is
receptors on the obstructiv hyperplasia or covering the capsule
muscle e bladder-neck you are about to use.
surrounding the pulmonary obstruction and The capsule's
airways. The disease. constipation. effectiveness may be
natural chemical reduced if it is not
in the body the used immediately after
Acetylcholine the foil is opened. If
normally acts you accidentally
on these remove the foil
receptors, covering any of the
causing the other capsules, you
muscle in the must throw them

47
airways to away.
constrict and
the airways to
narrow.
Tiotropium
blocks the
muscarinc
receptors in the
lungs and
therefore stops
the action of
acetylcholine on
them. This
allows the
muscle around
the airways to
relax and the
airways to open.

48
 02-03-10 xanthine 100mg ½ Reduces the It reduces Contraindicated Diarrhea, nausea,  Take each dose
Allopurino oxidase tab OD PO production of the to allergic to any rash and itching, with a full glass of
l inhibitor uric acid in your productio these drugs, or if and drowsiness, water. To reduce your
body. Uric acid n of uric you have: kidney skin rash. risk of kidney stones
buildup can lead acid in disease; liver forming, drink 8 to 10
to gout or your body. disease; diabetes; full glasses of fluid
kidney stones. congestive heart every day, unless your
failure; high blood doctor tells you
pressure otherwise.
 Avoid drinking
alcohol. It can make
your condition worse.
 Allopurinol can
cause side effects that
may impair your
thinking or reactions.
Be careful if you drive
or do anything that
requires you to be
awake and alert.
 Allopurinol can
lower the blood cells
that help your body
fight infections. This
can make it easier for
you to bleed from an
injury or get sick from
being around others
who are ill, so
advised patient to
boost immune system
by taking vitamin s
supplements and
eating nutritious food.
 Allopurinol should
be discontinued
immediately at the
first appearance of
rash, painful urination,
blood in the urine, eye
irritation, or swelling
49
Dutasterid 02-03-10 1tab OD Avodart Avodart is Contraindicated Decreased libido  Take 1 capsule
e PO prevents the used to to clinically (sex drive); once a day.
(Avodart) conversion of treat significant decreased  Do not chew,
testosterone to benign hypersensitivity amount of semen crush, or open an
dihydrotestoster prostatic (e.g., serious skin released during Avodart capsule. The
one (DHT) in the hyperplasi reactions, sex; impotence capsule should be
body. DHT is a (BPH) in angioedema) to (trouble getting or swallowed whole.
involved in the men with AVODART or keeping an
 Dutasteride can
development of an other 5α- erection); or
irritate your lips,
benign prostatic enlarged reductase breast tenderness
mouth, or throat if the
hyperplasia prostate. inhibitors. or enlargement.
capsule has been
(BPH).
broken or opened
Dutasteride
before you swallows
helps improve
it. It may take up to 6
urinary flow and
months of using this
may also reduce
medicine before your
your need for
symptoms improve.
prostate surgery
For best results, keep
later on.
using the medication
as directed.
 Can be taken with
or without meals.
 Take this
medicine with a full
glass of water.
 Do not stop taking
Avodart without
talking to your doctor.
 To be sure this
medication is helping
your condition, your
prostate will need to
be checked on a
regular basis.
 Store Avodart at
room temperature
away from moisture
and heat. Avodart
capsules may become

50
 soft and leaky, or they
may stick together if
they get too hot. Do
not use any capsule
that is cracked or
leaking.
LACTULO 02-03-10 laxative 20cc OD Lactulose is a Used to This medication Gas, belching or  This medication is
SE synthetic sugar treat contains stomach cramps, taken by mouth. To
used to treat constipati galactose and diarrhea, nausea, improve the taste, the
constipation. It on. lactose. Be sure vomiting. dose may be mixed in
is broken down to tell your doctor a glass of fruit juice,
in the colon into if you have water or milk.
products that diabetes. And if  Take this
pull water out you are having medication as
from the body surgery or tests prescribed. Take this
and into the on your colon or medication exactly as
colon. This rectum, tell the prescribed by your
water softens doctor that you doctor. Do not take it
stools. are taking in larger amounts or
Lactulose is lactulose. for longer than
also used to recommended.
reduce the  The liquid form of
amount of lactulose may become
ammonia in the slightly darken in
blood of color, but this is a
patients with harmless effect.
liver disease. It However, do not use
works by the medicine if it
drawing becomes very dark, or
ammonia from if it gets thicker or
the blood into thinner in texture.
the colon where  Instruct the
it is removed patient that it may take
from the body. up to 48 hours before
you have a bowel
movement after taking
lactulose.

 Store lactulose at

51
 room temperature
away from moisture
and heat.

Topamax 2/3/10 Anticonvulsan 25mg ½ May block a To prevent Hypersensitivity Dizziness,  Tell pt. to drink plenty of
t tab BID sodium channel, migraine to drug Nervousness, fluids during therapy to
Sulfamate PO potentiate the headache Chest pain, minimize risk of forming
substituted activity of GABA Palpitations, kidney stones.
monosacchari and inhibit Anorexia, Muscle
de kainate’s ability Weakness.  Inform patient that drug
to activate an can be taken without
amino acid regard to food.
receptor.

Dolcet 2/3/10 Analgesic 1 tab TID Inhibits Moderate Acute intoxication CNS & GI  Assess for level of pain
prostaglandin to severe w/ alcohol, disturbances. relief and administer
synthesis pain. Nausea, dose as needed but not
reducing Hypersensitivity dizziness, to exceed the
sensitivity of somnolence. recommended total
pain receptors Asthenia, fatigue, daily dose.
hot flushes,  Discontinue drug and
constipation, notify physician if S/Sx
diarrhea, of hypersensitivity
flatulence, occur.
dry mouth,  Take drug with food to
pruritus, avoid GI disturbances.
increased
sweating, tinnitus.
Keppra 2/3/10 Anticonvulsan 500mg/tab May act by adjunctive Hypersensitivity Headache,  Drug can be taken with
t 1tab TID inhibiting therapy in to drug emotional lability, or without food
Pyrrolidine simultaneous the vertigo,  Warn patient to use
derivative neuronal firing treatment Immunocompromi leukopenia, extra care when sitting
that leads to of partial sed patients neutropenia, up or standing up to
seizure activity onset anorexia avoid falling
seizures in
adults
Piperaci 2/3/10 Anti infectives 4.5g IVTT Inhibits cell wall Moderate Hypersensitivity Headache,  Ask patient about
llin + q 8h synthesis to severe to drug seizure, fever, allergic reactions pror to
Tazoba during bacterial nosocomi hypertension, med administration

52
 ctam multiplication al Caution to pts. abdominal pain,  Monitor
pneumoni with bleeding dyspnea hematologic and
a tendencies coagulation parameters
 Tell patient to
report adverse reactions
promptly

Combiv 2/3/10 bronchodilato 1/2neb Reduces To prevent Hypersensitivity Headache, Chest  Auscultate breath
ent r +1cc bronchospasm bronchosp to drug Pain, Dyspnea, sounds before and after
combinations NSS q through two asm in Coughing, nebulization
6h distinctly people Bronchospasm,  Monitor HR and
different with Palpitations RR
mechanisms, chronic  Do chest and back
anticholinergic obstructiv tapping after
(parasympathol e nebulization
ytic) and pulmonary
sympathomimet disease
ic. (COPD)
Simultaneous who are
administration also using
of both an other
anticholinergic medicines
and a beta2- to control
sympathomimet their
ic is designed to condition.
benefit the
patient by
producing, a
greater
bronchodilator
effect than when
either drug is
utilized alone at
its
recommended
dosage.
Sucralfate 2/3/10 Anti ulcer 1 tab q6h An antiulcer that Short term Allergy to Constipation, Dry  Take medication
NGT forms an ulcer- treatment sucralfate mouth, Backach, on an empty stomach
adherent of Diarrhea,
complex with duodenal Dizziness,  Monitor pattern of

53
 proteinaceous ulcer. Nausea, Rash, bowel activity and stool
exudates such Abdomina, consistency
as albumin, at discomfort.  Increase fluid
ulcer site. Also intake as indicated.
forms a viscous,
adhesive barrier  Monitor for
on the surface hypersensitivity
of intact reactions.
mucosa of the
stomach or
duodenum.
Protects
damaged
mucosa from
further
destruction by
absorbing
gastric acid,
pepsin and bile
salts.

Fluimocil 2/3/10 Cough and 600mg/ta N-acetylcysteine For acute Hypersensitivit nausea,  Dilute with normal
cold b 1 tab in (NAC) is the N- & chronic y to any of the headache, saline solution or sterile
preparations 100cc acetyl derivative resp tract ingredients. tinnitus, water for injection
, H2O q of the naturally affections stomatitis,  Inform patient that
Mucolytic 12h NGT occurring amino w/ Caution in chills, fever, nebulization may
acid l-cysteine. abundant asthma bronchospasm produce an initial
NAC has an mucus patients. disagreeable solution
intense secretions Occasional cases but will soon disappear
fluidifying . of nausea and
action, through dyspepsia
its free
sulfhydryl Rare cases of
group, on the urticaria
mucoid or
mucopurulent
secretions by
cleaving the
intra- and
intermolecular

54
 disulfide bonds
in glycoprotein
aggregates.

Metoprolol 2/3/10 Beta-Blocker 50mg ½ Competetively Myocardia Hypersens Heartfailure,  Monitor HR prior
tab BID blocks beta- l Infarcion itivity to heartblock & to administration of
adrenergic drug bronchospasm, drug
receptors in the fatigue &  Hold drug if
heart and Bronchos coldness of HR<60 bpm
juxtaglomerular pasm or extremities,  Give drug with
apparatus, asthma bradycrdia, CHF food to facilitate
decreasing the pneumonitits, absorption
influence of the History of depression,  Instruct patient to
sympathetic obstructiv hallucination,GI swallow tablet whole; do
nervous system e airway retroperitoneal not crush or chew
of these tissues disease fibrosis,
and the sclerosing
excitability of Sinus pentoritis
the heart, bradycardi
decreasing a or partial
cardiac output heartblock
and the release & CHF
of rennin, and
lowering BP;
acts in the CNS
to reduce
sympathetic
outflow and
vasoconstrictor
tone

Digoxin 02-07- Digitalis 25 mg ½ Increases the Used in Contraindicated Extra beats,  People of Asian
10- Glycoside tab force of treating an to Digitalis anorexia, nausea descent may absorb
disconti contraction of abnormal toxicity, and vomiting, rosuvastatin at a
nued on the muscle of heart ventricular confusion, higher rate than other
02-09-10 the heart by rhythm tachycardia/fibrill dizziness, people. Make sure
inhibiting the ation, obstructive drowsiness, your doctor knows if
activity of an cardiomyopathy. restlessness, you are Asian. You
enzyme Arrhythmias due nervousness, may need a lower than
(ATPase) that to accessory agitation and normal starting dose.

55
 controls pathways (e.g. amnesia, visual  Take digoxin
movement of Wolff-Parkinson- disturbances, exactly as prescribed
calcium, sodium White syndrome). gynaecomastia, by your doctor. Do not
and potassium take it in larger
into heart Special amounts or for longer
muscle. Calcium Precautions on than recommended.
controls the Cardiac  May be taken with
force of dysrhythmias, or without food.
contraction. hypokalaemia,  Take it with full
Inhibiting hypertension, glass of water.
ATPase IHD,  Take the
increases hypercalcaemia, medication at the
calcium in heart hypomagnesaemi same time of the day.
muscle and a,  Do not stop taking
therefore electroconversion digoxin without first
increases the , chronic cor talking to your doctor.
force of heart pulmonale, aortic Stopping suddenly
contractions. valve disease, may make your
Digoxin also acute myocarditis, condition worse.
slows electrical congestive
 Store digoxin at
conduction cardiomyopathies
room temperature
between the , constrictive
away from moisture.
atria and the pericarditis, heart
ventricles of the block, renal
heart and is impairment,
useful in abnormalities in
treating thyroid function
abnormally
rapid atrial
rhythms such
as atrial
fibrillation, atrial
flutter, and atrial
tachycardia.
captopril 02-08-10 angiotensin 25mg ¼ Angiotensin II is used for Contraindicated dry, persistent  Take this
- converting tab q12h a very potent treating to allergic to it; or cough, abdominal medication by mouth,
disconti enzyme (ACE) chemical that high blood to other ACE pain, usually two to three
nued inhibitors causes the pressure inhibitors (e.g., constipation, times a day; or as
muscles benazepril, diarrhea, rash, directed by your
surrounding lisinopril); or if dizziness, fatigue, doctor.

56
blood vessels to you have any headache, loss of  Take this drug on
contract, other allergies taste, loss of an empty stomach,
thereby (including appetite, nausea, one hour before a
narrowing the allergies to bee or vomiting, fainting meal.
vessels. The wasp stings, or and numbness or  Use this
narrowing of the exposure to tingling in the medication regularly
vessels certain hands or feet. in order to get the
increases the membranes used most benefit from it.
pressure within for blood  Remember to use
the vessels filtering). it at the same time(s)
causing high each day.
blood pressure Special  Do not take
(hypertension). precaution on potassium
Angiotensin II is patients with supplements or salt
formed from specially of: substitutes containing
angiotensin I in kidney disease, potassium without
the blood by the liver disease, high talking to your doctor
enzyme blood levels of or pharmacist first.
angiotensin potassium, heart
converting problems, severe
enzyme or ACE. dehydration (and
ACE inhibitors loss of
are medications electrolytes such
that slow as sodium),
(inhibit) the diabetes (poorly
activity of the controlled),
enzyme ACE strokes, blood
and decrease vessel disease
the production (e.g., collagen
of angiotensin vascular diseases
II. As a result, such as lupus,
blood vessels scleroderma).
enlarge or
dilate, and
blood pressure
is reduced. The
lower blood
pressure makes
it easier for the
heart to pump

57
 blood and can
improve the
function of a
failing heart.
NaCl 02-07- NaCl 1 tab TID Treatment of Preventio Cautious to Peripheral  Check and limit
10- supplement deficiencies of n or patient with edemas, sodium intake to
disconti sodium and treatment congestive heart pulmonary decrease adverse
nued on chloride ions. of failure, severe edema. effect reaction.
02-09-10 deficiencie renal  Checks signs of
s of insufficiency, and edema and seek
sodium in clinical states medical advice if it is
and in which there is manifesting.
chloride sodium retention
ions (e.g., with edema.
caused by
excessive
diuresis or
excessive
salt
restriction
).

VI. NURSING MANAGEMENT

Nursing Care Plan #1

58
 Cues Nursing Dx Objectives Intervention Rationale Evaluation
Subjective: Ineffective Short term: Independent:
“Gi oxygen man airway At the end of 2Nursing
hours ofCare
1.Plan #2 patient
Remind -Hydration helps Short term:
siya kay maglisod clearance nursing intervention the to drink fluids per decrease the
siya ug ginhawa. related to patient will be able to : cardiac tolerance. viscosity of At the end of 2
Gi ubo man gud copious a. have the ability to Provide warm or secretions hours, the patient:
siya.”, as bronchial effectively cough up hot drinks instead facilitating a. effectively
verbalized by the secretions secretions of cold fluids expectoration. expectorated
SO. secondary to b. demonstrate secretions.
“Naay plema chronic behaviors to 2. Assist the b. maintained
iyang ubo, medyo obstructive improve or maintain patient in airway patency
white na sticky.”, pulmonary clear airway coughing, huffing, - Deep breathing c. demonstrated
as verbalized by disease as c. demonstrate and breathing and diaphragmatic improved
the daughter. evidenced by improved oxygen efforts to make breathing allow for oxygen
presence of exchange, them more greater lung exchange as
Objective: productive reduction with productive expansion and evidenced by
-productive cough cough breath sounds and ventilation as well reduction of
with copious respirations as a more effective breath sounds
bronchial noiseless cough and noiseless
secretions d. verbalize 3. Assist with respirations
understanding of cupping and -Cupping and d. verbalized
- dyspnea cause & therapeutic clapping activities clapping loosen understanding
management q4h while awake. secretions and of cause &
- respiratory rate: regimen Teach the family assist therapeutic
26 cpm (as of these procedures. expectoration. management
2/4/10) Long term: regimen
24 cpm (as of 4. Assist the
2/7/10) At the end of 16 hours patient with -Teaching the
23 cpm (as of of nursing intervention, clearing secretions family allows them Long term
2/10/10) the patient will be able from mouth or to participate in objectives were not
to: nose by: care under met.
- abnormal breath a. maintain airway -Providing tissues supervision and
sounds (Rales and free of secretions -Using gentle promotes
ronchi present at b. show evidence of suctioning if continuation of the
both lung fields clear lung sound necessary procedure after
upon and eupnea discharge.
auscultation) c. demonstrate
absence of Collaborative:
-changes in congestion with 1. Administer
respiratory depth breathing, absence medications such -This aids the
shallow(as of 2/4 of cyanosis, ABG/ as antibiotics as patient in
and 2/7) pulse oximetry ordered. Noting recovering from
results within effectiveness and the disease
-Positive for lung clients norms. side effect process and 59
congestion based d. Demonstrate eliminate signs and
upon chest x-ray behaviors to symptoms
result maintain clear
airway.
 Cues Nursing Diagnosis Objectives Interventions Rationale Evaluation
Subjective: Impaired Gas Short Term: Independent:
Exchange related By the end of 4 1. Maintain -This provides for Short and long
“Galisod gyud siya to alveolar- hours of nursing oxygen adequate tissue term goals were
ug ginhawa tungod capillary interventions, the administration oxygenation. fully met as
sa iyang ubo.”, as membrane client and his SOs device as Hypoxia stimulates evidenced by:
verbalized by the changes secondary must be able to: ordered, the drive to
SO. to chronic attempting to breathe in the a. A decrease in
obstructive a. Verbalize maintain O2 chronic CO2 the RR and PR of
“Gahapon, dili na pulmonary disease understanding of Saturation at container patient. the client after
siya kabalo kung causative factors 90% or greater. When applying O2, interventions.
aha siya. Unya and appropriate Avoid high close monitoring is
murag ga-tanga ra interventions concentration imperative to b. An increase in
siya pirminti. Naa of O2 in prevent unsafe the oxygen
pud usahay na dili b. Participate in patients with increases in the saturation of the
siya kaila sa amo. treatment regimen COPD unless patient’s PaO2 client.
Magkabali0bali na within level of ordered. which could result
among ngalan. ability in apnea. c. Client already
Kung musturya pud has alert and
siya, dili lang c. Demonstrate an -This prevents the responsive
kaayo klaro”, as improvement in 2. Position the abdominal mentation but still
verbalized by the ventilation and patient with contents from with slurring of
SO. adequate gas proper body crowding the lungs speech.
exchange. alignment for and preventing
Objective: optimal their full
Long term: respiratory expansion.
-February 4, 2010 By the end of 16 excursion (if
RR=26 cpm, hours, patient must tolerated, head
shallow breathing maintain optimal of bed at 45°.) -When the patient
PR: 99 bpm gas exchange as is positioned on the
evidenced by 3. Position patient side, the good side
-February 7, 2010 arterial blood to facilitate down.
RR= 24 cpm, gases and oxygen ventilation-
shallow breathing saturation within perfusion
the patient’s usual matching when
-February 10, 2010 range, alert and a side-lying -Even simple
RR= 23 cpm, responsive position is activities during
normal breathing mentation or no used. bed rest can cause
further reduction in fatigue and
-productive cough mental status, and 4. Pace activities increase O2
no signs of and schedule demand, resulting
-Oxygen respiratory rest periods to in dyspnea.
Saturation: 93% distress. prevent fatigue.
(with Oxygen Assist with -This facilitates
inhalation) ADLs. secretion
-pale skin movement and
drainage.
5. Change 60
position every 2 -This reduces
hours. alveolar collapse

6. Encourage
 Nursing Care Plan #3
Cues Nursing Dx Objectives Intervention Rationale Evaluation
Subjective: Ineffective Short-term: Independent: The Short term
cardiopulmon 1. Elevate head of -This is to reduce goal was met for
“Gi oxygen man siya ary tissue At the end of 30 bed. oxygen patient was able
kay maglisod siya ug perfusion minutes nursing consumption & to perform
ginhawa.”, as related to interventions, patient promotes maximal passive ROM
verbalized by the SO. imbalance will be able to lung function. exercises and
between demonstrate 2. Encourage passive positioning as
“Gasakit man myocardial techniques to improve leg exercise, -This is to ways to improve
gihapon iya dughan oxygen circulation such as avoidance of isometric enhance venous circulation.
usahay.”, as demand and passive ROM exercises exercises. return, reduce
verbalized by the SO. supply and positioning venous stasis and
reduce risk of The Long term
Long-term: thrombophlebitis; goal was not
Objective: however, met.
At the end of 16 hours isometric
-radiating pain on the nursing interventions, exercises can
chest with a pain patient will be able to adversely affect
scale level of: demonstrate 3. Prevent straining at cardiac output by
3/5 (as of 2/4/10) improved stools. increasing
2/5 (as of 2/7/10) cardiopulmonary myocardial work
tissue perfusion as and consumption.
-dyspnea evidenced by absence 4. Reposition
of dyspnea and frequently. - This avoids an
-use of accessory respiratory distress increase cardiac
muscles overload.

-capillary refill: 4 -This prevents

seconds 5. Provide adequate skin breakdown
rest. and pulmonary
-Blood-tinged sputum complications
associated with
-prescence of atrial Dependent: bed rest.
fibrillation and S3& 1. Administer
S4 based on ECG supplemental oxygen -to conserve
result (1-2LPM)as indicated energy and lower
oxygen demand.
-Pulmonary

61
congestion - This increases
amount of oxygen
available for
myocardial
uptake, reducing
ischemia and
dysrhythmias

Nursing Care Plan #4

62
 Cues Nursing Objectives Interventions Rationale Evaluation
Diagnosis
Subjective: Acute chest Short Term: Independent: At the end of 30
pain related At the end of 30 1. Assist the -A semi-fowler’s is minutes of nursing
“Murag gi-kumot. to reduced minutes the patient patient to a usually most interventions, patient
3/5.” Replied the coronary will be able to: comfortable comfortable. was able to
client when asked blood flow a. Report that position. Restricted activity experience relief from
by the SN resulting to pain/discomfort is Maintain bed reduces oxygen pain as evidenced by
regarding the myocardial alleviated or rest, at least demands of the heart. a decrease in the Pain
description of pain ischemia controlled, as during periods Scale Rate: 2/5, with 5
and the pain rate evidenced by a of pain. as the most painful
scale. decrease in pain 2. Provide -Techniques are used - Short term goal was
rating the scale. comfort to bring about a state fully met 02/10/10
“Muingon na siya measures, quiet of physical and mental At the end of 8 hours
na sakit iyahang b. Display a relaxed environment awareness and of nursing
dughan. Sauna ga appearance and be and calm tranquillity. The goal of interventions patient
reklamo naman able to sleep/rest activities these techniques is to was able to
siya nga musakit comfortably and reduce tension, demonstrate use of
iyang dughan engage in desired subsequently, relaxation skills to
labaw na kanang activities she can 3. Encourage reducing pain. help alleviate pain.
mahago siya.” – as tolerate. use of
verbalized by the relaxation -This heightens one’s Long term goal was
SO. c. Demonstrates techniques, concentration upon fully met: 02/10/10
ability to cope with such as focused nonpainful stimuli to
Objective: partially relieved pain. breathing and decrease one’s
(e.g., deep breathing imagery. awareness and
-sighing with no exercises and position 4. Eliminate experience of pain.
intent to move changes) additional
unless absolutely stressors or -Patient may
necessary d. Demonstrate use of sources of experience an
relaxation skills and discomfort exaggeration in pain
-very slow diversional activities when possible. or a decreased ability
movement with as indicated for to tolerate painful
facial grimace individual situation 5. Provide rest stimuli if
and verbalize non- periods to environmental,
- shortness of pharmacologic facilitate intrapsychic,
breath upon pain methods that provide comfort, sleep intrapersonal factors
onset with facial relief. and relaxation. are further stressing
grimace and Dependent: him.
sighing Long Term: 1.Administers
At the end of four analgesics as -Patient’s experience
days, client will ordered of pain may become
remain free from pain exaggerated due to
as evidenced by no fatigue.
reports of pain, and 63
normal vital signs.

-Analgesics are given

to alleviate pain.
 Nursing Care Plan #5
Cues Nursing Diagnosis Objectives Interventions Rationale Evaluation
Subjective: Ineffective cerebral Short Term: Independent: Goals partially met.
February 4, 2010 tissue perfusion
“Gahapon, dili na related to By the end of 4 1. Maintain -This ensures Client and his SO
siya kabalo kung interruption of hours of nursing optimal adequate perfusion were able to
aha siya. Unya blood flow as interventions, cardiac to the brain. participate in the
murag ga-tanga ra evidenced by patient and SOs output. treatment regimen.
siya pirminti. Naa slurring of speech, will be able to: -Increased
pud usahay na dili right-sided 2. Avoid intracranial Client already has
siya kaila sa amo. weakness and a. Verbalize measures pressures will responsive
Magkabali-bali na decreased understanding of that may further reduce mentation but his
among ngalan. mentation causative factors of trigger cerebral blood slurring of speech
Pero karun, okay such problem and increase ICP flow. is still present.
naman. Kung appropriate (ex.
musturya lang, dili interventions Straining,
pa kaayo klaro”, as needed to be done. strenuous
verbalized by the coughing, -Decreased blood
SO. b. Participate in positioning flow may result in
treatment regimen. with neck in changes in the
“Medyo luya na flexion, head LOC.
iyang tuo nga side Long Term: flat)
sa lawas.”, as
verbalized by the By then end of 16 3. Reorient to
SO. hours, client must environment -These facilitate
be able to obtain as needed. perfusion when
optimal perfusion obstruction to
to vital organs, as blood flow exists or
Objective: evidenced by alert Dependent: when perfusion has
-Slurring of speech level of dropped to such a
-Decreased consciousness, 1. Administer dangerous level
mentation clearer and more anti- that ischemic
-Right-sided understandable coagulants, damage would be
weakness speech and thrombolyti inevitable without
-GCS Score gradual recovery of cs and anti- treatment. Anti-
2/4/10=12 his right-sided convulsants convulsants reduce
(moderate brain weakness. as risk of seizures
injury) prescribed. which may result
2/7/10=13(minor from cerebral

64
brain injury) edema or ischemia.
2/10/10=14(mild
brain injury)
-arteriosclerosis of
the middle-cerebral
arteries (CT scan
result)

Nursing Care Plan #6

Cues Nursing Dx Objectives Intervention Rational Evaluation
Subjective: Activity Short term: Independent:
“Kapoy kaayo ako Intolerance At the end of 30 After 30 minutes,
panlawas” as related to minutes of nursing 1. Assess -Assessing the patient:
verbalized by the generalized interventions, the cardiopulmonary cardiopulmonary a. identified the
patient weakness patient will be able to: response to physical notes progression factors that
activity, including or accelerating affected her
February 7, 2010 a. Identify negative vital signs before, degree of fatigue. activities of
– “Karon na naa factors affecting activity during and after daily living.
siya sa hospital, tolerance. activity. -Adjust activities to b. used identified
maghigda ra gyud prevent techniques to
na siya kay luya b. Verbalize 2. Reduce intensity overexertion. enhance
man gud pod understanding of level or discontinue activity
siya.” – as techniques to enhance activities that tolerance.
verbalized by the activity tolerance. cause undesired
SO. physiological -Assisting the
“Kami man gyud changes. patient with ADL’s Long Term:
ga ilis ug Long term: allows for
gapakaon niya 3. Assist with ADL’s conservation of After 16 hours, the
kay maglisod man At the end of 24 hours as indicated; energy. patient
siya ug lihok- of nursing intervention however, avoid a. particated
lihok.” – as the patient will be able doing for patients willingly in
verbalized by the to: what they can do necessary or
SO. for themselves. -Exercise maintains desired
a. Participate willingly muscle strength activities.
February 10, 2010 in necessary activities. 4. Encourage and joint ROM. b. reported
–“Makaya-kaya active ROM increase in

65
naman niya nga b. Report measurable exercises; if further activity
maglihok-lihok increase in activity reconditioning is tolerance
nga siya ra. Pero tolerance. needed, confer
amo ra gihapon with rehabilitation
siya i-assist kay c.Demonstrate a personnel. -Providing
basin ma-unsa decrease in physiologic oxygenation
bah.” –as signs of intolerance (PR, reduces fatigue
verbalized by the RR, and BP within Dependent: and anxiety for
SO. patient’s normal range). 1. Administer O2 patient.
“Kinahanglan inhalation as
gyud namo siya prescribed.
tabangan kung
mulihok kay luya
man gyud siya.”,
verbalized by the
SO.

Objective:
-generalized body
weakness noted.
- seeks help in
ADL
-ECG reflecting
atrial fibrillation
with pattern of
ischemia and
tissue necrosis
Nursing Care Plan #7
Cues Nursing Diagnosis Objectives Intervention Rationale Evaluation
Subjective: Impaired physical Short Term: Independent: Goals met as
mobility related to At the end of 30 1. Assist patient -This is to promote evidenced by:
February 7, 2010 – decreased minutes of nursing reposition self on a proper circulation
“Kami man gyud muscular control intervention the regular schedule as and prevent a. Patient able to
ga ilis ug gapakaon and function as patient will be able dictated by formation of verbalize
niya kay maglisod evidence by to : individual situation. skin/decubitus improvement of
man siya ug lihok- generalized ulcer. condtion.
lihok.” – as weakness a. verbalize 2. Inspect skin
verbalized by the understanding odf regularly -This prevents skin b. Motor control on
SO. situation, individual particularly over breakdown and all upper and lowe

66
 treatment and bony prominences. decubitus ulcer extremities would
regimen and safety Gently massage development. return to normal as
Objective: measures. any reddened preferred by the
areas as patient.
-Scale for b. Demonstrate necessary.
measuring RIGHT techniques and -This helps c. No signs and
hand muscle score: behaviors that 3. Perform passive maintain/enhance symptoms of
enable resumption ROM exercises of maximum paralysis.
2/4/10= grade1( no of activities upper and lower neuromuscular
active range of participate in ADLs extremities. control and
motion and and desired function.
palpable muscle activities.
contraction only) 4. Encourage - This enhances
2/7/10=grade2( re Long Term: participation in self self concept and
duced active range At the end of 32 care and other sense of
of motion and no hours of Nursing activities. independence.
muscle resistance) intervention the
2/10/10=grade4 patient will be able 5. Provide safety -This prevents
(full active range of to: measure such as injury from falling.
motion and normal raising the side
muscle resistance) a. Maintain position rails as indicated
of function and skin by individual
integrity as situation.
evidenced by
absence of Dependent: -This permits
contractures, foot maximal
drop, decubitus 1. Administer effort/involvement
and the likes. medications prior in activity.
to activities as
b. Maintain or needed for pain. -
increase strength
and function of 2. Administer
affected and laxative as
compensatory part. ordered.

Nursing Care Plan #8

67
Cues Nursing Diagnosis Objectives Intervention Rationale Evaluation

68
Subjective: Imbalanced Short Term: Independent: At the end of 20
“Lugaw ra gyud iya Nutrition: Less than At the end of 10 minutes of nursing
pwede kaonon kay body requirements minutes of nursing 1.Discuss with the - Success rates are interventions, the
galisod pa siya ug related to inability interventions, the significant others higher when the patient was able to:
tulon. Mukaon man to ingest adequate patient will be able the need of having family incorporates
pod siya pero nutrients to: right diet for the a healthy eating a. Receive
gamay ra kay secondary to patient and plan. adequate and
murag wala man dysphagia as a. Receive introduce the food desired amount of
siya gana. Mao evidenced by adequate and pyramid. calories per feeding
man sab ang ingon weight loss of 5 kg desired amount of - This promotes
sa doctor na lugaw calories per 2.Place patient in comfort during Long Term:
lang sa ang feeding moderate high feeding and allow At the end of 8
ipakaon sa iya. “ – back rest during flow of food by hours of nursing
as verbalized by Long Term: feeding. gravity. interventions,
the SO. At the end of patient was able to:
hours of nursing
interventions, 3.Check the tube’s - This ensures a. Receive
patient will be able patency before correct tube adequate amount
Objective: to: feeding (auscultate placement in the of caloric
for bubbling sound stomach. requirement per 8
-Weight loss- 55kg- a. Receive using stethoscope hours in relation to
50kg adequate amount just above the patient’s status
of caloric stomach area)
-With NGT requirement per 8
hours in relation to 4.Flush 30 cc of - This is to rinse
-Weakness of patient’s status water before and tubing, provide
muscle after feeding. fluid source to
required for maintain adequate
mastication related hydration and to
to right-sided ensure that all
weakness feeding goes into
Dependent: the stomach.
-Dysphagia
1. Administer OF
-Pale and dry 1600 kcal in 4 -To meet
mucous divided feedings nutritional
membranes via NGT. demands of the
patient per day.
-Dry lips

69
 Nursing Care Plan #9
Cues Nursing Diagnosis Objectives Intervention Rationale Evaluation
Impaired Verbal Short term: Independent: The Short term
Subjective: Communication After an hour of 1.Provide -Provide objectives were
related to loss of nursing alternative communication partially met
February 4,2010 facial or oral intervention the methods of needs or desires because was still
“ Maglisod man ni muscle control as patient will be able communication like based on individual having a hard time
siya ug storya. Dili evidenced by to demonstrate pictures or visual situation or with his speaking
kayo mi kasabot”, slurring of speech improved ability to cues, gestures or underlying deficits. ability although he
as verbalized by express self demonstration already managed
SO. -This is helpful in to use non-verbal
2. Anticipate and decreasing cues
February 7,2010 Long Term: provide for patients frustration when
“Gaapason niya After 8 hours of needs dependent on The Long term
iyang ginhawa nursing others and unable objectives were
kung magstorya intervention the to communicate fully met. Patient
siya.”, as patient will be able desires. was able to show
verbalized by SO. to: decreased
3. Talk directly to -It reduces frustration and
February 10,2010 a. Have decreased the patient, confusion and communicates well
“Makastorya na frustration and speaking slowly anxiety at having using non verbal
siya ug tarong pero isolation with and clearly. Use to process and mode of
dili kayo klaro.”, as communication. yes or no questions respond to large communication.
verbalized by SO to begin with. amount of
b. Establish information at one
method of time
communication in 4. Speak in normal
which needs can tones and avoid -Patient is not
be expressed talking too fast. necessarily hearing
Give patient time impaired and
Objective: an ample time to raising voice may
respond. irritate or anger
-right-sided the patient.
weakness 5. Encourage

70
 family members to -It is important for
-Facial asymmetry persist effort to family members to
communicate with continue talking to
-Slurred speech the patient. the patient to
reduce patient
-with difficulty in isolation, promote
pronouncing words establishment of
effective
communication
and maintain sense
of connectedness
or bonding with the
family

Nursing Care Plan #10

Cues Nursing Dx Objectives Intervention Rational Evaluation
Risk Factors: Risk for Short term: Independent: Short term goal
infection 1. Help patient - Hand washing were met because
-age: 89 years old At the end of 30 wash hands before prevents spread of the patient and his
-inadequate minutes of Nursing and after meals pathogens to other SO were able to
secondary defenses intervention, the after using objects and food. verbalize
-chronic disease patient will be able bathroom, bedpan understanding of
-malnutrition to: or urinal. individual risk
-presence of - To help prevent factors and identify
indwelling catheter a. Verbalize 2. Help the patient venous stasis and interventions to
-invasive procedures understanding of turn to sides every skin breakdown prevent risk of
-insufficient individual risk two hours. Provide infection
knowledge to avoid factors skin care,
exposure to particularly over
pathogens b. Identify bony prominences. Long term goal was
interventions to - This helps met since patient
prevent risk of 3. Ensure adequate stabilize weight, was able to
infection nutrition intake. improves muscle promote safe
Note: A risk diagnosis Offer high protein tone and mass, environment and
is not evidenced by Long term: supplements such aids in wound did not show any
signs and symptoms, egg white. healing. Also signs of infection.
and the problem has At the end of one serves to minimize
not occurred and week of Nursing edema.

71
nursing interventions intervention, the 4. Arrange
are directed at patient will be able protective isolation - These measures
prevention to: for compromised prevent patient
immune function. pathogens in the
a. Demonstrate Monitor flow and environment and
techniques and numbers of protect from skin
lifestyle changes to visitors. breakdown.
promote safe
environment 5. Teach patients
about good hand - These measures
b. Show no signs of washing technique, allow patient to
infection such as factors increase participate in care
fever infection risk, and help patient
infection sign and modify lifestyle to
symptoms. maintain optimum
health level.
Dependent:
1. Administer
prophylactic - To prevent
antibiotics as infection caused by
ordered. pathogen.

72
VII. DISCHARGE PLANNING

Medications  Encourage strict medication compliance and to take medications as

directed to attain therapeutic effects.
 Instruct patient and significant others to keep a list of medications
with their respective dosage and frequency of intake to prevent
medication errors and their purpose.
• Digoxin 0.7g/tab OD before lunch
• Metoprolol 50mg ½ tab BID
• Rosuvastatin 10mg/tab OD
• Losartan 50mg tab OD, AC, BF
• Spiriva rotacup thru inhaler OD
• Allopurinol 100mg 1 tab OD
• Avodart 1 tab OD

 Inform patient regarding side effects of medication to allay patient

anxiety if said side affects manifest.
 Encourage patient to discuss with health care provider concerns
regarding medications.

Exercise  Teach patient and his significant others to do passive and active
range of motion with slow progressions in frequency.
 Adequate rest periods must be given in between exercises to
prevent straining.
 Always bear in mind that one has to start on easy-to-do exercises
first and must rest frequently, building up strength is essential as
one goes on until hard exercises are tolerated.
 Moderate exercise such as walking should be encouraged.

 Instruct patient’s SO to seek medical advice and immediately treat

Treatment
infections of the upper respiratory system, and oral cavity.

Health Teachings  Provide patient and relative written and verbal information
regarding the following:
1. Explain the indications of the prescribed medications, their
actions, dosages, contraindications and side effects.
2. Immediate notification of physician for presence of adverse

73
 reactions in medicines and home care complications.
3. Contacting the healthcare provider when signs of recurrence
or complications of the disease appear, especially shortness of
breath and chest tightness.
4. Seek medical advice from healthcare provider for immediate
treatment of upper respiratory system, and oral cavity
infections.
5. Compliance to follow up examinations.
6. Providing support. The patient and family need assistance,
explanation, and support every time patient requires treatment
to prevent serious complications and improve condition.
7. Indicate enough bed rest to reduce exertion and to avoid all
strenuous activities that has not been approved by the
physician.

Outpatient Follow-up  Assert importance of follow up visits to physician.

 Advise patient and family to report to the physician if any
recurrence or severity of symptoms, any adverse effects of the
medication, and any development of complication.
 Patients should be encouraged to keep a record of their daily
weights. An action plan should be developed so that if the patient
experiences unexplained weight gain of greater than 3 pounds
since their last clinical evaluation the patient can take action (call
physician or take additional medication).
 Promote the use of the community’s available resources such as
carrying out regular visits to the nearest health center for continuing
monitoring of client’s over all status.
 If there are things that are unclear, advise patient and SO to refer
concerns to physician.

74
 1. Alcohol use should be discouraged.
2. Depending on the health care provider a diet that is
Diet
low in sodium content, about 2 grams per day is
recommended.
3. It is advisable that cholesterol intake be limited
4. Sources of fiber are to be added to the diet to aid in
digestion.
5. Protein intake is recommended but must not be from
fatty sources. Fish, chicken and beans are good
sources of protein so long as it is not contraindicated
by the patient’s physician.
6. Intake of vitamin supplements and other sources of
minerals are recommended.
7. Excessive fluid intake should be discouraged, but fluid
restriction is rarely indicated.

Spiritual Care
 Encourage significant others to contact the family pastor
to provide spiritual guidance.
 Participating in religious ceremonies together can be a
form of family bonding and can strengthen the family
internally.
 Encourage patient to verbalize anxieties to spiritual guide
(i.e. pastor, priest) to relieve pent up frustrations.
 Ask the significant others to constantly remind patient that
the disease is not a form of punishment from God and that
it is not the patients fault for getting the disease in the first
place.

VIII. PROGNOSIS
75
 GOOD POOR
CRITERIA ANALYSIS/IMPLICATION
PROGNOSIS PROGNOSIS

Onset of The patient’s severe manifestations occurred

/
Illness very late to be able to be treated.

Duration of There was a late detection of the disease of the

Illness patient, thus contributes to a late prevention.
/
The old age of the patient, his gender, family
history of having heart disease, stroke and
/ hypertension, sedentary lifestyle, and his diet that
Precipitating is rich in cholesterol and fats predisposes him
and and puts him at risk for acquiring such disease.
Predisposing Such factors manifested by the patient cannot
Factors already be altered and prevented. But
manifestations showed by the patient may be
improved through the medication regimen
prescribed and provided by the healthcare team.
Attitude & The patient’s admission and adherence to
Willingness to medication treatment may somehow show that
take / patient is very willing to take treatment in order
Treatment for him to recover from the disease.

It is very important to note that prognosis for patients having such diseases vary greatly
depending on a person’s health, the extent of the damage, the treatment given and the patient’s
adherence to it, and most importantly, the early detection of the disease. Most of the prognosis
in the chart exhibited poor prognosis especially that the patient manifest important factors that
may lead to life-threatening complications. Patient is responsive to the treatment given as
evidenced by diminished symptoms of the disease which also suggest a good prognosis for the
patient. But still, long term prognosis may suggest that the client’s problem may not lead to a full
recovery of the patient as such that the patient is already in the late stage of treating the
disease.
IX. CONCLUSION

76
 At the end of this case study we were able to attain goals that we have set from the start
of this study. Through the gathered data we were able to formulate nursing care plans that we
were able to apply to our patient. By studying on the patient’s prescribed medication we were
able to understand its effects which could aid in his recovery. A review on the affected anatomy
and physiology of the body enabled us to create interventions that could alleviate pain and any
discomforts from the patient, if not completely prevent it. With the help of the patient’s family,
we were able to explore part of the patient’s personality and this information was used on the
formulation of the interventions.
Today it is but promising to note that the number of heart related diseases affecting aged
people are increasing. Myocardial Infarction is the interruption of blood supply to part of the
heart, causing some heart cells to die.There are a lot of factors which may lead to the
development of such disease one of the most noticeable factor is poor or unhealthy lifestyle
which the patient practiced for many years. Chronic Obstructive Pulmonary Disease refers to
chronic bronchitis and emphysema, a pair of two commonly co-existing diseases of the lungs in
which the airways become narrowed.This leads to a limitation of the flow of air to and from the
lungs causing shortness of breath. This is caused by noxious particles or gas, most commonly
from tobacco smoking, which triggers an abnormal inflammatory response in the lung.
The patients condition was greatly aggravated because of the many complications of
congested heart failure. It is but evident that the patients condition was worsening due to the
prevalence of other manifestations thereof. It is therefore important for the patient to strictly
follow the doctors orders specially on the medication regimen and the diet for palliative
treatment since the patients condition cant be cured mainly because of his old age. Measures
show focus on how to prevent the deterioration of the patients condition. Therefore it is most
important to include the family in the plans of care for the patient.

XI. RECOMMENDATION

77
 The recommendations made by the proponents for this grand case presentation are
necessary for a patient who is diagnosed with Benign Prostatic Hyperplasia; Myocardial
Infarction; and Chronic Obstructive Pulmonary Disorder. Although the data presented are
factual and relevant, the paper’s aspect is limited to the patient’s case and the data gathered.
The recommendations will serve as a guided care for the well being of the patient. These
involve the patient, her significant others and the health care providers.
Recommendations made for the patient are as follows: First, cooperation in his
treatment therapy is needed. He should continue to report any abnormalities she will experience
or manifest that could be a sign of a more serious problem. Second, the patient should be able
to adhere well with the medication regimen as prescribed. Third, the patient must be set to
follow dietary guidelines for metabolic needs and his daily nutritional requirement. Fourth, he
should be able to establish in his mind a positive outlook regarding her condition. Fifth, spiritual
health should also be strengthened with his condition since it is important for his holistic care
and in maintaining a healthy status.
For the significant others, it is encouraged that they continue to provide comfort and care
measures to the patient throughout the disease process. Their presence is also an important
factor for the emotional and mental stability of the patient. They can convince and supervise the
patient in the adherence to the treatment regimen and providing the daily needs of the patient
either with personal necessities or adequate rest.
For the health care providers, they should be able to provide quality health care to the
patient by being equipped with knowledge and skills necessary for the appropriate interventions
needed by the patient and also by being sensitive to the needs and being observant to possible
manifestations of the patient. Constant monitoring is also very important as to the critical status
of the patient.
For us, since availability of time and length of duty is limited, further care and
interventions was not done to the patient. The sources of data used were also based only on the
patient’s chart, assessment tools and textbooks. Thus, ample time to do further research and
interaction of the patient is recommended.

XI. BIBLIOGRAPHY

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Book sources:
• Black, Joyce M. Hawks, Jane Hokanson. Medical-Surgical Nursing Clinical Management
for Positive Outcomes. 8th Ed. Philippines. Saunder-Elsevier, Inc.,2008

• Brunner , Suddarth . Textbook of Medical-Surgical Nursing volume 1 & 2. 11th edition,

Lippincott Williams and Wilkins, 2007

• Doenges, Marilynn E et al. Nurse’s Pocket Guide Diagnosis, Prioritized Interventions &
Rationales. 10th edition, F.A. Davis Company, 2006

• Karch, Amy M. Focus on Nursing Pharmacology. 3rd edition, Lippincott Williams and
Wilkins, 2006

• Kindersley, Dorling. British Medical Association’s New Guide to Medicines and Drugs.
Great Britain: Dorling Kindersley.6th Ed. 2004

• Kozier, B., Erb, G., and Berman, A. Fundamentals of Nursing: Concepts, Process and
Practice. 6th edition, Upper Saddle River, NJ: Prentice-Hall Inc., 2000

• Turgeon, M. (2005). Instrumentation in hematology. Clinical Hematology: Theory and

Procedures 4th ed. Copyright © 2005 Lippincott Williams & Wilkins 351 West Camden
Street Baltimore, MD 21201 pp. 507-508

• Wilson, Billie Ann, et. al. Prentice Hall’s Drug guide. New Jersey: Pearson Education,
Inc., 2004.

Internet sources:
”Management of Chronic Obstructive Pulmonary Disease.” NHLEP.
<http://www.nlhep.org.ugcopd.about.com>

http://www.mayfieldclinic.com/IM-AnatCardio.htm
http:www.drugs.com/mmx/tranexamic-acid.htm
http:www.umm.edu.search.index.htm
http://medterms.com/script/main.art.asp?articlekey=9349s

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