INTRODUCTION

FINAL DX: MASSIVE PERICARDIAL EFFUSION WITH TAMPONADE SECONDARY TO TUBERCULOSIS PERICARDITIS.

MASSIVE PERICARDIAL EFFUSION WITH TAMPONADE

Pericardial effusion

Also called fluid around the heart, it is an abnormal accumulation of fluid between the heart and the pericardium, which is the sac
surrounding the heart. It is associated with many different medical conditions. Most pericardial effusions are not life threatening, unless it
is a massive pericardial effusions, in which can cause problems by impairing heart functions such as Cardiac Tamponade.

Cardiac Tamponade

It is a harmful result of pericardial effusion wherein the hearts ability to pump blood is impaired due to the compression of the heart. It is
an emergency medical condition resulting to the prevention of the refilling of the ventricles during diastole. This happens because the
fluid build-up in the pericardial sac exerts enough pressure on the heart. The effects are low stroke volume, low cardiac output and
eventually shock.

CLASSIFICATIONS

Massive pericardial effusions may contain more than 2 liters of pericardial fluid.

Small pericardial effusions may contain 100mL of pericardial fluid.

Chronic pericardial effusions pericardial effusions that lasts three months or longer.

transudative (congestive heart failure, myxoedema, nephrotic syndrome),

exsudative (tuberculosis, spread from empyema)

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 hemorrhagic (trauma, rupture of aneurysms, malignant effusion).

malignant (due to fluid accumulation caused by metastasis)

CAUSES

pericarditis- Inflammation of the pericardium

Bacterial infections, including tuberculosis
Injury to the pericardium or heart from a medical procedure
Heart attack (myocardial infarction)
Uremia (severe kidney failure)
Autoimmune disease (lupus, rheumatoid arthritis, and others)
Cancer

RISK FACTORS
Pericarditis (esp. if patient has HIV)
Cancer
Chest trauma/heart attack
Autoimmune disease

SIGNS AND SYMPTOMS

Pericardial Effusion
Chest pain (if caused by pericarditis)
Fever
Fatigue
Muscle aches
Shortness of breath
Nausea, vomiting, and diarrhea (if viral illness is present)

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Cardiac Tamponade

Becks Triad:
1. Hypotension due to decreased stroke volume
2. Jugular venous distention due to reduced venous return to the heart
3. Muffled heart sounds - due to the muffling effect of fluid surrounding the heart

DIAGNOSIS
Echocardiogram presents a cross-sectional slice of the heart where the excess fluid can be seen.
Physical examination abnormal sounds can be heard over the heart such as soft muffled sounds
Electrocardiogram (ECG) sees the hearts electrical activity which may suggest pericardial effusion
Chest X-ray film the hearts silhouette on a X-ray film may be enlarged, suggesting a pericardial effusion.
CT Scan if there is pericardial effusion, the image seen is of the heart surrounded by a halo of fluid.

MEDICAL MANAGEMENT
Treatment of pericardial effusion depends on its severity and its cause.

Treatment if due to pericarditis:

Nonsteroidal anti-inflammatory drugs (NSAIDs) such as Motrin, Aleve, and Indocin
Corticosteroids, such as prednisone and Solu-Medrol
Colchicine
Pericardiocentesis a needle is inserted through the chest into the pericardial effusion. A catheter is placed into the fluid, and the
pericardial effusion is suctioned out.
Pericardiectomy (pericardial window) - diagnostically and therapeutically used, with the latter involving the drainage of
accumulated pericardial fluid. The process involves the excision of a portion of the pericardium which allows the effusion to drain

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 continuously into the peritoneum or the chest. There are three ways to drain the fluid: small subxiphoid incision, thoracoscopically
or via thoracotomy. This prevents the reaccumulation of fluid.
CTT- a tube is inserted into the pleural space. It is used to drain or fluid form the chest.

LIFESTYLE MANAGEMENT
Blood pressure regulation
Strict compliance to medication
Developing a healthy lifestyle
Annual medical examinations (post treatment)
Avoid smoking
Avoid food that may raise blood pressure

SOURCES:
http://emedicine.medscape.com/article/1829679-overview
http://www.med.umich.edu/lrc/coursepages/m1/anatomy2010/html/clinicalcases/pericardial_effusion/pericardial_effusion.html
http://www.m.webmd.com/heart-disease/guide/pericardial-effusion

TUBERCULOUS PERICARDITIS

TUBERCULOUS
A disease caused by Mycobacterium tuberculosis.

PERICARDITIS

4
When the sac that encases the heart called the pericardium is inflamed, a condition called Pericarditis occurs. When it worsens, it can
become or be accompanied by pericardial effusion where excess fluid accumulates in the pericardial sac. Eventually, when the condition
worsens even more, cardiac tamponade occurs which is life-threatening when not treated early or properly.

TUBERCULOUS PERICARDITIS

One of the forms of pericarditis, it is usually called as pericardial effusion, constrictive pericarditis, or effusive-constrictive pericarditis.
According to data, in cases of HIV-infected people who have pericardial disease, TB pericarditis has a higher chance of occurring with TB
accounting for 96-100% of cases in this group. It is caused by Mycobacterium tuberculosis.

CAUSES
PERICARDITIS
Idiopathic unknown cause
Infection caused by a virus or bacteria (Mycobacterium tuberculosis)
Radiation radiation therapy may cause tuberculousis pericarditis
Trauma it may be caused by a myocardial infraction or a heart attack, a fault CPR or direct trauma to the chest
Drugs and toxins
Metabolic disorders kidney failure
Cancerous tumors when cancer metastisized in the heart especially in Hodgkin lymphoma.
Rheumatic diseases Most commonly, Systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis, and mixed
connective tissue are the causes. Others include systemic vasculitides and autoinflammatory diseases (ie, Familial Mediterranean
Fever).
Gastrointestinal diseases such as ulcerative colitis or Crohn's disease

RISK FACTORS
People with HIV (esp. those who have existing pericardial disease)
People who live in Subsaharan Africa
Radiation therapy
Cancerous tumors
Autoimmune diseases

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 Gastrointestinal diseases

MEDICAL MANAGEMENT
open pericardial window with biopsy diagnostically and therapeutically used, with the latter involving the drainage of
accumulated pericardial fluid. The process involves the excision of a portion of the pericardium which allows the effusion to drain
continuously into the peritoneum or the chest. There are three ways to drain the fluid: small subxiphoid incision, thoracoscopically
or via thoracotomy. This prevents the reaccumulation of fluid.

Antibiotics, pain-relieving medication.

Anti-inflammatory drugs (NSAIDs)
Corticosteroids
Standard 4-drug antituberculosis regimen for 6 months
Pericardiocentesis a needle is inserted through the chest, into the pericardial effusion. A catheter is placed into the fluid,
therefore sucking the pericardial effusion out of the chest.

LIFESTYLE MODIFICATIONS
Adequate rest must be given during the treatment period
Strict compliance to medications
Control blood pressure, blood cholesterol to keep the heart strong
Consult a dietitian to help with formulating a healthy diet
Avoid smoking
If with chronic pericarditis, patients may need to take nonsteroidal anti-inflammatory drugs or colchicine for several years, even
when they are feeling well.
Be physically active (after treatment as advised by physician)

Signs and symptoms

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 Chest pain
Dry cough
Fever
Fatigue
Anxiety
Breathing difficulty
Sweating
Chills
Rapid heart rate
Low blood pressure

Diagnosis

culturing to see either pericardial tissue or fluid is positive for Mycobacterium tuberculosis
histopathological examination sees granumolas and acid-fast bacilli (AFB)

SOURCES:
Mayosi BM, Burgess LJ, Doubell AF. Tuberculous pericarditis. Circulation. 2005
Reuter H, Burgess LJ, Doubell AF. Role of chest radiography in diagnosing patients with tuberculous pericarditis. Cardiovasc J S Afr.
2005.
Reuter H, Burgess LJ, Doubell AF. Epidemiology of pericardial effusions at a large academic hospital in South Africa. Epidemiol
Infect. 2005 Jun;133(3):393-9
Mayosi BM. (2002). "Interventions for treating tuberculous pericarditis". Cochrane Database of Systematic Reviews (4): CD000526.
http://emedicine.medscape.com/article/1829679-overview
http://www.rightdiagnosis.com/t/tuberculous_pericarditis/treatments.htm
http://circ.ahajournals.org/content/112/23/3608.full
http://www.uptodate.com/contents/pericarditis-beyond-the-basics

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 ANATOMY AND PHYSIOLOGY

Cardiovascular system
The cardiovascular system permits blood to circulate and transport nutrients (such as amino acids and electrolytes), oxygen, carbon
dioxide, hormones, and blood cells to and from the cells in the body to provide nourishment and help in fighting diseases, stabilize
temperature and pH, and maintain homeostasis. It is composed of the heart and the network of arteries, veins, and capillaries that
transport blood throughout the body.
1. HEART the hollow, cone-shaped muscular organ made up of involuntary striated muscles which pumps blood into the pulmonary
and systemic circulation. It is relatively small which is about the size of a clenched fist. It lies in the mediastinum (an anatomical
region in the thoracic cavity that extends from the sternum to the vertebral column, the first rib to the diaphragm and between the
lungs)

Apex: the pointed part of the heart which rests on the diaphragm and is directed anteriorly, inferiorly and to the left
Base: the uppermost, broad, posterior surface of the heart

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1.1 PERICARDIUM a triple-layered sac which surrounds and protects the heart

Has 2 main parts:

a. Fibrous Pericardium the superficial, outer layer which directly
attaches to the diaphragm. It is made of strong connective tissue. It
keeps the heart from overstretching or overfilling with blood and
holds the heart in place at the mediastinum.
b. Serous pericardium the deeper layer. It is a double-layered
membrane sandwiched between the fibrous pericardium and the
heart. It consists of:
Parietal Pericardium the outer layer of the serous
pericardium. It adheres to the inner surface of the fibrous
pericardium.
Visceral Pericardium the inner layer of the serous
pericardium. It is also called the epicardium and it is
considered part of the heart wall. It adheres tightly to the
surface of the heart.

Pericardial cavity the space between the parietal and visceral pericardium
Pericardial fluid occupies the pericardial cavity; the serous fluid produced by the epithelial cells of the serous pericardium which
prevents friction as the heart beats.

1.2 HEART WALL it is composed of three parts: (1) Epicardium which is covered in adipose tissue and contains blood vessels that
supply the myocardium; (2) Myocardium which forms the 95% of the heart wall that is made up cardiac muscle tissue and it is
responsible for the contraction of the heart; and (3) Endocardium which is made up of simple squamous epithelium to provide a
smooth lining for the cahambers of the heart and covers the valves of the heart.

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1.3 HEART CHAMBERS

a. Atrium (pl. Atria) composed of left and right atrium that is located superiorly to the ventricles
and serves as the receiving/collecting chambers of blood from veins
b. Ventricle (pl. Ventricles) composed of right and left ventricle located inferiorly to the atria
which serve as pumps that eject blood into the arteries

1.4 HEART VALVES

a. Atrioventricular valves - are located between each atrium and its corresponding ventricle. These
valves allow blood to flow from the atrium to the ventricle without allowing any blood to flow
backwards from the ventricle to the atrium. The two atrioventricular valves are the tricuspid valve
and the mitral valve.

b. Semilunar valves - are located in the arteries that carry blood from the ventricles to the rest of the body. The two semilunar
valves are called the pulmonary semilunar valve and the aortic semilunar valve.

2. BLOOD VESSELS

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 2.1 Arteries- made of a thick muscular layer to withstand higher blood pressure. They
carry blood from the heart to the capillaries.

2.2 Capillaries- form a vast network of very small vessels that enable the exchange of
materials between blood and the tissue cells. The term capillary bed refers to a
network of capillaries that supply blood to an organ.

2.3 Veins- return blood from the capillaries back to the heart. They are made up of a
relatively thin muscular layer and contain internal valves to keep the blood from ever flowing backwards. About 60% of the blood
volume is located in the veins at any given time.

3. BLOOD the only fluid connective tissue in the body. It is a type of connective tissue since it consists of cells and cell fragments
surrounded by a liquid matrix. It functionally connects the different body organ systems.

3.1 Blood Circulation - Deoxygenated blood from the body flows from the superior and inferior vena cava veins to the right atrium. This
blood is pumped to the right ventricle and then proceeds to the pulmonary trunk where it is oxygenated by the act of inhalation.
This newly oxygenated blood then flows through pulmonary veins to the left atrium and is pumped to the left ventricle to continue
to the aorta and the rest of the body. These are referred to as the pulmonary and systemic circuits.

a. Pulmonary Circuit - Assists deoxygenated blood from the right ventricle to the lungs and then assists newly oxygenated blood
from the lungs to the left atrium. (This is the flow of blood between the heart and lungs.)
b. Systemic Circuit - Assists oxygenated blood to all parts of the body (except the lungs) and then returns deoxygenated blood to
the right atrium. (This is the flow of blood from the heart to the rest of the body.)

Respiratory System

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The respiratory system consists of the nose, pharynx, trachea bronchi, bronchioles and lungs.
Its main purpose is for gas transport which allows oxygen from the air to enter the blood and
carbon dioxide to leave the blood and enter the air. It also helps in regulation of blood pH by
altering the blood CO2 levels. Other functions include voice production, olfaction and protection
by preventing microorganisms from entering into the body and removing them from
respiratory surfaces.
Respiration refers to the process of gas exchange between the atmosphere and the cells

1. LUNGS are spongy, cone-shaped organs in the thoracic cavity which are found on
both sides lateral to the heart and other structures in the mediastinum. They are
encircled and protected by the ribcage. They extend from the diaphragm to slightly
above the clavicles.

Parts of the lungs:

1.1 PLEURA a double-layered serous membrane that encloses and protects each lung.
It has two parts:
a. Parietal Pleura the outer layer attached to the wall of the thoracic cavity and
diaphragm
b. Visceral Pleura the inner layer directly attached to the lungs

Pleural cavity the narrow space between the 2 pleurae containing pleural fluid
secreted by the membranes
Pleural Fluid a slippery, lubricating serous fluid which prevents friction and keeps the pleurae together during breathing

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 1.2 BASE the broad inferior of the lungs which rests on the diaphragm

1.3 APEX the narrow superior portion of the lungs which is located just deep to the ribcage

1.4 CARDIAC NOTCH the indentation in the left lung where the heart lies

1.5 OBLIQUE FISSURE divides the left lung into the inferior and superior lobes

1.6 OBLIQUE & HORIZONTAL FISSURE divide the right lung into superior, middle and inferior lobes

1.7 HILUM (or hilus) an indentation on the medial surface of each lung where the primary bronchus and the pulmonary artery
and veins enter the lung

CLIENT IN CONTEXT PRESENT STATE INTERVENTIONS OUTCOME

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Patient G.L.M, 38 year old,
male, married, Roman Catholic,
Filipino, currently residing in
Bogo, Cebu was admitted to
CVGH on June 15, 2015 for the
first time due to dyspnea and
vomiting under the services of
Dr. Batoctoy from the Internal
Medicine department with the
case number and hospital
number of 15-69547 and
028757, respectively.
HISTORY OF PRESENT
ILLNESS
1 month PTA, the patient
noticed a difficulty in his
breathing with an
accompanying dry cough. He
also noticed a feeling of fullness
in his chest and abdomen which
he described as busug; no
other signs and symptoms were
noted and no pharmacologic
interventions were done. Client
claimed he was able to tolerate
the condition and continue his
ADLs. Patient tolerated
condition for 2 weeks, going
about his usual daily activities.
2 weeks PTA, patient shares
that s/s were still present and
that he had an episode of
vomiting. Patient verbalized,
Na-suka nako ang akong gi
PHYSICAL EXAMINATION
Day 1: June 25, 2015 ( 3:15
pm)
GENERAL APPEARANCE: Seen
patient on the bed awake,
lethargic, responsive, and
coherent with pericardial
window in the left side of his
chest and a CTT on his right
side, with the following vital
signs:
BP=100/70mmHg
PR=102bpm
RR=28cpm
Temperature=36.5C/axilla
SKIN: Dark brown, evenly
colored skin tone. Skin is dry
and warm. Skin is thin with
calluses noted on plantar
surface of both feet. Skin
pinches easily and immediately
return to its original position.
Skin is smooth without lesions.
With IV on his right hand and a
pericardial window in the left
side of his chest and a CTT on
his right side.
SCALP&HAIR: Hair is black,
clean, slightly oily, and smooth
and firm without parasites /lice
infestations noted. Scalp is
clean and dry. Even, prominent
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kaon. He then went for a
check-up in a hospital in Bogo
to seek consult, where he was
prescribed with Kremil-S (3x)
and Ranitidin (1x). His condition
improved in that he no longer
vomited and his breathing
improved.
6 days PTA, patient still noted a
dry cough and continuation of
difficulty in breathing, as well as
fullness in the chest. Patient
noticed that his appetite had
decreased and a small amount
of food intake would already
make him full. No medications
were taken as well. Condition
was tolerated without consult.
3 days PTA, client experienced
10 episodes of vomiting saliva
and previously ingested food,
amounting to about glass-
glass so approximately 60 mL to
120mL/ episode. Client
continued to feel bloated and
full and claimed to have
experienced excess salivation
and nausea. The client
continued to tolerate and
monitor condition. He shared
that he didnt take any
medication but did his best to
sleep, to relieve discomfort.
On the day of admission,
clients s/s continued. He
fine hair on arms, hands, thigh
and legs.
NAILS: Upper and lower
extremities has transparent nail
with pinkish nail beds. Nails are
round with 160 nail base. Hard,
immobile, smooth and firm nail
plate is firmly attached to nail
bed.
HEAD & FACE: Symmetric,
round, erect and in midline.
Hard and smooth without
lesions or lumps. Head is still
and upright without abnormal
facial movement.
Temporomandibular joint has no
swelling or tenderness, mouth
opens and closes fully.
EYES: Eyeballs are
symmetrically aligned in
sockets without protruding or
sinking. Eyebrows are the same
with hair color, symmetric and
evenly distributed. Lid margins
are moist and pink. Lashes are
short, evenly spaced and curled
outward. Bulbar conjunctiva is
clear, moist and smooth with
tiny vessels visible. Sclerae is
white. Palpebral conjunctivae
are pink, moist and free from
swelling and lesions. Cornea is
15
experienced nausea and
vomiting, fullness, fatigue,
dyspnea and body malaise. He
shared he was no longer able to
tolerate condition. Clients
family brought him to the same
hospital in Bogo, in which he
was referred to CVGH.
PAST HEALTH HISTORY
Client has no known drug or
food allergies. Client claimed
that he has not tried being
given anesthesia until the
Pericardial window surgery done
on June 23rd, 2015. No
difficulties were experienced
during and after administration.
The patient has not had any
previous hospitalizations. As a
child, the client experienced
chickenpox and convulsions
when he was 1 year old. The
childhood vaccines taken were
unrecalled. Heredofamilial
diseases includes hypertension
and stroke on his fathers side
and arthritis on his mothers
side. Added, his grandfather on
the maternal side of the family
has tuberculosis.
GORDONS FUNCTIONAL
HEALTH PATTERN
transparent, moist and without
opacities. Lens are clear. Pupils
are equally round and reactive
to light and accommodation
(PERRLA). Positive corneal light
reflex, reflections of light noted
at same spot on both eyes. Full
extraocular movements. Reads
student nurses nameplate
within 3 - 4 ft without difficulty.
Client and examiner report
seeing object at the same time
as it approaches from the
periphery and has an eye
grade of 20/ 20.
EARS: Equal in size bilaterally.
Pinna is in line with lateral
canthus of both eyes. External
ears are smooth without lesions,
color consistent with the facial
color and no discharges noted.
Small amount of moist, yellow
cerumen was noted on both
ears. Able to hear whispered
word house on right ear and
boy on left ear within 2 ft.
NOSE: Color consistent with the
rest of the face, smooth and
symmetric without tenderness
and discharges noted. Able to
sniff and blow through each
nostril while other is occluded.
Nasal mucosa is dark pink,
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I. Health Perception-Health
Management Pattern
Patient defines health as kung
maka-exercise, gaan ug lawas
ug maka buhat sa pang-adlaw
adlaw nga trabahu-un. He
rates his current state of health
as 5/10 due to his vomiting and
because of his current
hospitalization, with 1 as the
lowest and 10 as the highest.
The client expects that his
health rating will increase in the
near future because he expects
to improve and get better from
his current condition. When
asked what he understands
about his condition, client
verbalized, Naay tubig-tubig
akong dughan, wa ko ka sabot
sa akong gi-bati. Client is a
non-smoker and an occasional
drinker. He drinks 2 or 3 times a
year on special occasions like
fiestas and birthdays, and the
occasional times that he drinks
amounts to 1 liter of Red Horse
shared with family and friends.
Client does not use recreational
drugs and does use safety
devices like a seat belt and
helmet when needed. Client is
compliant with his current
treatment and does not practice
self-medication nor does he use
moist and free of exudates.
Nasal septum at midline, intact
and free of ulcers or
perforations. Clear frontal and
maxillary sinuses upon
transillumination and are non-
tender to palpation and
percussion.
MOUTH: Lips are pinkish, rough
and dry without lesions or
swelling. Gums are pink, moist
and firm with tight margins to
the teeth, no lesions, redness
and swelling noted. Buccal
mucosa is pinkish, smooth and
moist without lesions. Tongue is
moist, pinkish at midline
without lesions, nodules or
fasciculations, papillae present
on dorsal surface. Smooth, pink
and hard palate with firm
transverse rugae. Uvula is
pinkish, moist, hang freely in
midline without redness or
transudate. Tonsils are pink,
symmetric without exudates
and swelling. Gag reflex is
intact.
NECK: Symmetric with head
centered and without bulging
masses. Full range of motion,
smooth and contracted. Trachea
is in midline. Thyroid gland are
17
herbal medication. Client
claimed to not be taking any
maintenance medications.
Client had regular health check-
ups and complete physical
exams 1x-2x/ year when he
worked as a seaman from 1998-
2011. His last health check up
was May of 2014 and no
unusualities were noted. Client
and the clients mother is
unsure on whether or not he is
completely immunized, and is
unsure of which immunizations
he was given but he knows that
some of them were given by the
government.
Client currently works in sales
and marketing. He has a fixed
work shift everyday and works
about 10 hours every shift with
no days off as mentioned by his
wife. Client continually travels
in his occupation.
Client currently resides in Bogo
City, Cebu in a one story
detached housing unit. The area
is not congested, flood-prone, or
landslide-prone. The house and
lot is owned by the client. His
housing unit is comprised of
mixed materials. They have 2
doors that access the outside
and 7 windows. The house has
1 bedroom, a kitchen and a
positioned midline, smooth, firm
and non tender. Lymph nodes
are not palpable.
CHEST & LUNGS: Scapulae
symmetric & nonprotruding.
Anteroposterior is less than
transverse diameter. Sternum at
midline and straight. Ribs slope
downward with symmetric
intercostals spaces. Depth,
rhythm & quality of respiration
is fast, relaxed, effortless and
quiet use of accessory muscle.
No retractions and bulging
noted. Right side of the
patients thorax had stronger
vibrations compared to the left
side when he was asked to say
99. Chest expansion was .5
inches. Percussion tone is
resonance. Egophony soft and
muffled with distinguishable
letter E. Bronchophony is soft,
muffled and indistinct.
HEART & PERIPHERAL
VASCULATURE: Apical pulse at
fifth intercostals space, left
midclavicular line with a rate of
102 bpm. Rhythm is regular but
fast . S1 sound is distinct and
heard best at the apex (mitral
valve). S2 sound is distinct and
heard best on the base
(pulmonic & aortic valve). No
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bathroom. The crowding index extra heart sounds, murmurs
in 0.6. The toilet is a private and varicosities noted.
owned flush type with its CAPILLARY REFILL TIME: pink
drainage being closed. The tone returns immediately to
familys wastes are in a covered blanched nail beds when
trash can and is usually pressure is released.
collected by a garbage truck. Upper extremities (R)
Their source of water is MCWD, pinkish; <2 secs
through a piped system, and Upper extremities (L)
their drinking water is distilled. pinkish; <2 secs
Their electricity is provided Lower extremities (R)
through VECO. Medications, pinkish; <2secs
household chemicals, matches Lower extremities (L)
except knives and other sharps pinkish; <2 secs
are within reach of children. The PERIPHERAL PULSES:
family is able to afford a yaya Pulse
that is able to perform the (R) (L) Amplitude
typical household cleaning Temporal Scale
practices. The client has a 102 102 0 = Absent
private vehicle for +2 +2 +1 = Weak
transportation and their home is Carotid +2 = Normal
very close to the grocery and 102 102 +3 =
other health facilities as +2 +2 Increased
verbalized by the wife, Mga 5 Brachial +4 =
minutes away ra jud. Pwede ra 102 102 Bounding
ma lakaw. +2 +2
Client claims to be happy with Radial
his economic status and claims 102 102
that the money that he earns +3 +3
through his profits is adequate Popliteal
for food, water, housing, 102 102
clothing, medications and other +2 +2
health expenses. They do not Posterior
have medical insurance. tibialis 102
102 +2

19
(Genogram in Appendix)
II. Nutritional and Metabolic
Pattern
(24-hour diet recall in Appendix)
During meals, client usually
uses soy sauce and ketchup
amounting to 2 tablespoons per
meal. Client describes his
appetite as good because he
has the will to eat during every
meal. The client does not follow
a particular diet nor does he
pose any restrictions on his diet.
He prefers to eat beef and pork
for protein. He is very fond of
soup and claims to want to have
some form of soup every meal
time if possible. He prefers
utan bisaya for his soup. The
client generally eats home
cooked meals especially during
breakfast and dinner while
occasionally eating fast foods
for lunch when he is at work.
The client has no religious or
cultural beliefs that affects his
meal preparation. The client
claims to take a food
supplement called 24/7 Food
Supplement in order to
+2
Dorsalis
pedis
102 102
+2 +2
ABDOMEN: Rounded and
symmetric without bulges.
Striae not noted. Umbilicus is at
midline, depressed and without
bulging. Soft gurgles and clicks
heard all throughout the
quadrants of the abdomen.
Percussion tone is tympany.
RECTUM & GENITALIA:
Assessment not conducted
BACK & EXTREMITIES: Gait is
smooth with equal stride and
good base of support. Posture is
erect without exaggerated
curvature of cervical, thoracic
and lumbar spine. Spine is
straight. Client can perform full
range of motion of upper and
lower extremities. Upper and
lower extremities are
symmetric.
20
increase his appetite and to Muscle Scale:
enhance his health. Client does strength: 5 Full
not read food labels. The client 5/5 5/5 ROM
brushes his teeth twice a day against
but does not use floss or mouth gravity,
wash. He visits a dentist only full
when there are issues that 5/5 5/5 resistanc
e
come up and he cannot recall
4 Full
the date of his last visit. The
ROM
client does not have any dental against
or orthodontic appliances. The gravity,
client usually weighs 73kg. The some
client feels that he has lost resistanc
some weight during his e
hospitalization due to his taking 3 Full
of fluids for a number of days. ROM with
gravity
III. Elimination Pattern 2 Full
ROM with
The client usually defecates a
gravity
smooth, brownish, sausage-like
eliminate
stool once a day in the d (passive
afternoon, usually around 1 pm. motion)
The client hasnt experienced 1 Slight
constipation and has not Reaction
experienced any changes in his 0 No
elimination pattern. The client Reaction
usually voids 7 times a day
amounting to about 90 ml of
yellow, clear, odorless urine per NEUROLOGIC ASSESSMENT
elimination. Mental Status/ Cerebral
Function:
IV. Activity-Exercise Pattern Client is awake, responsive,
alert, and cooperative, appears

21
The client wakes up to eat
breakfast, takes a bath then
goes to work. He will either eat
fast food or a home cooked
meal for lunch during his work
break. He comes home to eat
dinner and takes the time to
watch TV before changing into
his sleepwear before he goes to
sleep. There is no difference to
his weekends in comparison to
the rest of his week and he
usually does the same
activities.
Before hospitalization, the
clients usual bedtime was
around 11 pm and would
usually wake up at about 6:30
am to get ready for work,
getting about 7 hours of sleep
every night. He does not take
any daytime naps. He claimed
to have felt rested when he
woke up during this time.
However, during hospitalization,
the client claims to sleep
around 10 pm and would wake
up at 6 am because his sleep is
usually disturbed as verbalized,
Nausab ra akong usual na oras
tingkatulog kay mag mata mata
man ko pirme gud sa kada taw
to be relaxed, and maintains
eye contact. Client states family
name Monterola when asked,
states naa ko sa hospital
when asked for the place and
states 3:30 pm when asked
for time. Client remembers the
date of his birthday as
September 5. Client listens
and can follow directions.
Motor/Cerebellar Functions
Client can perform rapid-
alternating movements. Client
was able to perform finger-
thumb test on the right and left
hand. Client was able to
perform heel-shin test. Client
can touch his nose with his right
and left hand. Client can stand
and ambulate without support
and assistance.
Sensory Function
Client can differentiate between
dull and sharp objects on both
arms as well as the cheeks.
Stereognosis : correctly
identifies object (clip).
Kinesthesia: correctly identifies
direction of movements on both
hands. Graphestesia: correctly
identifies numbers nine and
eight on both hands.
22
na mo musulod sa kwarto.
Client does not make use of any
assistive devices. Before
hospitalization and illness, the
client was fully independent in
his activities of daily living.
During hospitalization,
especially after his operation,
the client was somewhat
dependent upon his S.Os in
bathing, dressing, toileting and
transferring. Prior to
hospitalization, the client would
feel a shortness of breath and
abdominal pain while doing his
usual activities.
Client used to be part of a
formal exercise program when
he was still a seaman, for one
month in the gym. The client
used to mountain bike and
exercise before going to work.
In his spare time, the client likes
to watch TV and play basketball
for approximately 30 minutes.
VI. Cognitive-Perceptual
Pattern
G.M is able to read, write,
comprehend instructions, recall
long-term and short-term and
Cranial Nerve Testing
CN 1 (Olfactory): Correctly
identifies scent of orange peel
CN 2 (Optic): reads nameplate
at approximately 3-4 ft. on both
eyes
CN 3, 4 &6 (Oculomotor,
Trochlear, Abducens): full
extraoccular movements, (+)
PERRLA
CN 5 (Trigeminal): Corneal
reflex present; clenches teeth,
identifies dull and sharp
sensations on cheeks, forehead
and chin
CN 7 (Facial): Able to smile,
frown, wrinkle forehead, show
teeth, puff out cheeks, purses
lips, raise eyebrows & close
eyes against resistance.
CN 8 (Vestibulocochlear):
Whispered words heard within
2ft both ears.
CN 9 & 10
(Glossopharyngeal &
Vagus): Uvula & palate rise
symmetrically when client says
ah; gag reflex present;
swallows without difficulty.
CN 11 (Spinal Accessory):
Equal shoulder shrug against
resistance; turns head in both
directions against resistance.
CN 12 (Hypoglossal):
Protrudes tongue in midline,
23
make independent decisions. able to push tongue depressor
Client is able to speak and in left & right side of the mouth
understand Tagalog, Cebuano without difficulty
and English. He graduated
college and verbalized, Na DEEP TENDON REFLEXES:
ningkamut ko ug skwela para sa Biceps Grading
akong mga igsuon. Deep Tendon
(R) Reflexes
Client is satisfied with his +1 +4
current vision and does not (L) hyperactive,
currently use eyeglasses or +1 very brisk,
anyaids for his vision. He is also Triceps rhythmic
very satisfied with his ability to oscillations
(R) (clonus);
hear, taste and smell. He claims
+2 abnormal
that they have not changed at
(L) and
all. indicative of
+2
VII. Self-Perception- Self Brachioradial disorder
is +3 more
Concept Pattern
(R) +2 brisk or
G.M describes himself as dili ko (L) not active than
ganahan magpuyo nga way assessed normal, but
buhatun. Na anad ko sa barko due to ISA not
na daghan ug trabaho nga attached indicative of
Patellar disorder
nadala nako diri.a and apply
+2 normal,
nako sa akong business.
usual
Clients strength is that he is a response
hard worker and is a passionate (R) +2 +1
person. The wife describes the (L) +2 decreased,
husband as someone who does Achilles less active
not take a break from work. The (R) +2 than normal
client is satisfied with his (L) +2 0 - no
appearance and his major life response
accomplishment is that he got

24
to work in a boat and was able
to travel to different countries
and allowed him to help his
parents for the school tuition for
his siblings.
VIII. Role-Relationship
Pattern
(Client EcoMap in Appendix)
G.Ms family type is nuclear and
he is the provider for his family
and considers himself to be a
coordinator. He makes decisions
regarding child-rearing
practices and discipline, while
his wife is in charge of major
family practices, household
expenses, health matters, social
and household activities. These
decisions are usually made by
talking with one another. Their
current problem is in their
business because they were
forced to close It due to his
hospitalization. They have good
communication and the patient
is very satisfied with the life he
has and is very thankful. He is
the owner of his business and
he is expected to manage his
employees and corrects them if
something is wrong. He is not
currently part of any groups or
Day 2: June 26, 2015
(5:30pm)
GENERAL APPEARANCE:
General Survey: Seen patient
sitting on bed awake, alert,
responsive, and coherent and IV
on his right hand. His pericardial
window in the left side of his
chest and a CTT on his right
side have been removed. With
the following vital signs:
BP=100/60mmHg
PR=105bpm
RR=21cpm
Temperature=36.0C/axilla.
CHEST & LUNGS: Scapulae
symmetric & nonprotruding.
Anteroposterior is less than
transverse diameter. Sternum at
midline and straight. Ribs slope
downward with symmetric
intercostals spaces. Depth,
rhythm & quality of respiration
is fast, relaxed, effortless and
quiet use of accessory muscle.
No retractions and bulging
noted. Right side of the
patients thorax had stronger
vibrations compared to the left
side when he was asked to say
99. Chest expansion was .5
inches. Percussion tone is
resonance. Egophony soft and
muffled with distinguishable
25
organizations. letter E. Bronchophony is soft,
muffled and indistinct.
IX. Sexuality-Reproductive
Pattern HEART & PERIPHERAL
G.M is a heterosexual male and VASCULATURE: Apical pulse at
is currently sexually active. He fifth intercostals space, left
claims to have hit puberty at midclavicular line with a rate of
the age of 15. During this time 105 bpm. Rhythm is regular but
he experienced a deeper voice fast . S1 sound is distinct and
and changes in his body like heard best at the apex (mitral
getting taller and experiencing valve). S2 sound is distinct and
a widening of his shoulders. The heard best on the base
client claims that he was (pulmonic & aortic valve). No
circumcised when he was in extra heart sounds, murmurs
grade 4. The client was able to and varicosities noted.
screen for testicular and
prostate cancer as they were a PERIPHERAL PULSES:
part of his complete physical Pulse
exam on May 2014. No (R) (L) Amplitude
abnormal results were noted. Temporal Scale
105 105 0 = Absent
X. Coping-Stress Tolerance +2 +2 +1 = Weak
Pattern Carotid +2 =
Some of the stressors in the 105 105 Normal
clients life is his business. He +2 +2 +3 =
wants it to be successful and he Brachial Increased
worries about it sometimes. 105 105 +4 =
These stressors means a lot to +2 +2 Bounding
the patient as it is his livelihood Radial
and its how he gets his money 105 105
to provide for his family. Usually +2 +2
he just copes with these Popliteal
stressors by talking with his 105 105
wife and trying to balance his +2 +2
time between work and his Posterior

26
personal life. tibialis
105 105
XI. Value-Belief Pattern +2 +2
As the oldest of four children, Dorsalis
G.M learned to be responsible pedis
and hardworking. His goals is 105 105
for his child to have a good +2 +2
educations and to make his
business successful. He finds
Day 3: June 27, 2015 (8:05
that his source of hope,
am)
strength, comfort and peace is
General Survey: Seen patient
his family. He follows the Filipino
sitting on bed awake, alert,
culture and verbalized, Bisag
responsive, and coherent and
dili man ko tig simba kaayo,
his pericardial window in the left
dako ko ug pag tuo sa Ginoo
side of his chest , a CTT and IV
nya dako sdd ko ug kahadlok
on his right side have been
niya.
removed with the following vital
signs:
BP=120/60 mmHg
PR= 108 bpm
RR= 20 cpm
Temperature= 36.0C/axilla.

CHEST & LUNGS: Scapulae

symmetric & nonprotruding.
Anteroposterior is less than
transverse diameter. Sternum at
midline and straight. Ribs slope
downward with symmetric
intercostals spaces. Depth,
rhythm & quality of respiration
is fast, relaxed, effortless and
quiet use of accessory muscle.
No retractions and bulging
noted. Right side of the

27
patients thorax had stronger
vibrations compared to the left
side when he was asked to say
99. Chest expansion was .5
inches. Egophony soft and
muffled with distinguishable
letter E. Bronchophony is soft,
muffled and indistinct.

HEART & PERIPHERAL

VASCULATURE: Apical pulse at
fifth intercostals space, left
midclavicular line with a rate of
106 bpm. Rhythm is regular but
fast . S1 sound is distinct and
heard best at the apex (mitral
valve). S2 sound is distinct and
heard best on the base
(pulmonic & aortic valve). No
extra heart sounds, murmurs
and varicosities noted.

28
LABORATORY FINDINGS

1. Liver Function Test

Purpose: Liver function tests
help determine the health of
your liver by measuring levels
of proteins, enzymes, or
bilirubin in your blood

Resul 6/ / 6/15/
ts 15 15 Norm
al
Rang
e
HBA1 6.7 4.8-
C H 5.9%
(DCC
T/NG
SP)
HBA1 5.1 2.9-
C H 4.2%
(IFCC
)
CHOL 105.3 150.0
ESTE L -
ROL 200.0
mg/d
L

CREA 1.2 0.60-

TININ 0.80 1.50
E mg/d
L
ALT/S 34 79 H 5-40

29
 DRUG STUDY

PANTOPRAZOLE 40mg i tab OD ac BF / 40mg IVTT OD ac po

Classification: Proton pump inhibitor

Action: Blocks gastric acid secretion by inhibiting the hydrogen potassium adenosine triphosphatase, an enzyme system located at the
secretory surface of the gastric parietal cell thereby blocking the final step of acid production
Indication: Duodenal and gastric ulcer, reflux esophagitis and prevention of gastroduodenal ulcer induced by a need of continuous NSAID
treatment
Contraindication: Hypersensitivity, hepatic and renal failure, and pregnancy and lactating mother
Adverse Effect: Headache, diarrhea, dizziness, rashes, nausea, abdominal pain and constipation
Nursing Intervention:
- Inform the possible adverse effects
- Advise to avoid alcohol coffee and foods that may cause an increase in GI irritation such as chocolates, high fat
foods, junk foods and other processed foods
- Advise to report onset of black, tarry stools; diarrhea or abdominal pain promptly

LEVOFLOXACIN 500mg i tab OD po / 500mg IV infusion q 24H

Classification: Fluoroquinolone
Action: Bactericidal. Interferes with DNA by inhibiting DNA synase replication in susceptible gram-negative and gram-positive bacteria,
preventing cell reproduction.
Indication: Infection
Contraindication: Hypersensitivity, pregnancy and lactation, renal dysfunction
Adverse Effect: Nausea, headache, dizziness, palpitation, anemia, constipation, diarrhea, tendon rupture, hepatic failure
Nursing Intervention:

30
 - Advise to take full course of medication
- Assess for signs of infection
- Administer orally 1 hr before or 2 hrs after meals

METRONIDAZOLE 500mg i tab TID po / 500mg IV infusion q 8H

Classification: Antibacterial/antiprotozoal
Action: Bactericidal. Inhibit DNA synthesis causing cell death
Indication: Infections, Prophylaxis
Contraindication: Hypersensitivity, pregnancy and lactation
Adverse Effect: Vertigo, headache, nausea, vomiting, diarrhea, dark urine, rashes, dizziness, peripheral neuropathy
Nursing Intervention:
- Instruct to take drug with food or milk to avoid GI upset
- Inform that drug may turn urine into brown color
- Advise to take full course of medication

TRAMADOL 50mg slow IVTT q 8H x 3 doses

Classification: Opioid Analgsic
Action: Binds to mu-opioid receptors, causing inhibition of ascending pain pathways
Indication: Pain
Contraindication: Hypersensitivity, pregnancy and lactation, hepatic and renal failure
Adverse Effect: Sedation, dizziness, headache, constipation, nausea, vomiting, diarrhea, abdominal pain, pruritis, sweating, dry mouth
Nursing Intervention:
- Aseess type, location and intensity of pain
- Assess bowel function
- Advise to increase fluid intake to prevent dry mouth and constipation
- Assess previous analgesic history(this is not given to px dependent to opiods)

VITAMIN B i tab OD

Classification: Vitamins and minerals

Action: A coenzyme for cell replication, hematopoiesis and metabolic function
Indication: Vitamin B deficiency, pernicious anemia

31
Contraindication: Hypersensitivity
Adverse Effect: Peripheral vascular thrombosis, diarrhea, itching, urticaria, anaphylaxis
Nursing Intervention:
- Obtain sensitivity history before administration
- Administer with meals to increase absorption
- Avoid IV administration because faster systemic elimination will reduce effectiveness of vitamin
- Monitor for hypokalemia, as anemia correct itself

MYRIN P 4 tabs 1 hr before dinner or 2 hrs after dinner

Classification: Antituberculosis
Action: Inhibits RNA synthesis thus decreasing the tubercle bacilli replication
Indication: Initial treatment for TB
Contraindication: Hypersensitivity, alcoholism, optic neuritis, hepatic and renal failure, and pregnancy and lactating mother
Adverse Effect: Leukopenia, thrombocytopenia, anaphylactic reaction, anorexia, nausea, vomiting, headache, dizziness, rashes, fatigue,
visual disturbances
Nursing Intervention:
- Monitor input and output
- Inform patient to expect orange color of urine
- Instruct to report unusualities such as fatigue, anorexia, vomiting, jaundice

METFORMIN 500mg i tab BID po

Classification: Anti-diabetic, Biguanides

Action: Acts by decreasing hepatic glucose production and intestinal glucose absorption, and improves insulin sensitivity by increasing
peripheral glucose uptake and utilization
Indication: Diabetes Mellitus
Contraindication: Hypersensitivity, kidney disease, liver disease, metabolic acidosis, pregnancy and lactating mother
Adverse Effect: Abdominal bloating, diarrhea, nausea, vomiting, hypoglycemia, weakness, dizziness
Nursing Intervention:
- Instruct to take medication exactly as prescribed by doctor
- Instruct to take metformin with meal
- Encourage to avoid sweet foods

32
 - Encourage to store drug at room temperature
- Monitor capillary blood glucose
- Monitor s/s of hypoglycemia such as cold and clammy skin

LACTULOSE 20ml q HS po

Classification: Laxative/Hyperosmotic agent

Action: Hyperosmotic agent increases stool water content, softens stool, promotes peristalsis, and reduces blood ammonia concentration.
Indication: Constipation, prtal systemic encephalopathy
Contraindication: Hypersensitivity, px on low galactose diet, diabetes mellitus, pregnancy and lactation
Adverse Effect: Dehydration, diarrhea, abdominal cramping, abdominal distention, belching, flatulence, excessive bowel activity,
hypernatremia, hypokalemia
Nursing Intervention:
- Assess for abdominal distention, presence of bowel sounds and normal pattern of bowel function
- Assess color, consistency, and amount of stool
- Monitor serum electrolytes

CELECOXIB 200mg/cap BID po pc BF and supper

Classification: NSAID (non-steroidal anti-inflammatory drugs), Cyclooxygenase-2 (COX-2) inhibitor

Action: Inhibits enzyme COX-2 necessary for prostaglandin synthesis to produce anti-inflammatory, analgesics, and antipyretic effects.
Indication: Arthritis, pain
Contraindication: Hypersensitivity, pregnancy and lactation
Adverse Effect: Headache, dizziness, hypertension, sinusitis, diarrhea, abdominal pain, rashes, abdominal pain, constipation
Nursing Intervention:
- Assess pts history of allergic reaction to the drugs-
- Instruct patient to take drug with food or milk to avoid GI upset
- Teach patient to avoid aspirin and other NSAID during therapy
- Advise to report bloody stools, blood in vomit and s/s of liver damage

HRZE ii tabs BID pc BF and pc dinner

Classification: Antituberculosis

33
Action: Isoniazid kills tubercle bacilli by inhibiting the synthesis of mycolic acid which is the major component of the cell wall of
mycobacterium tuberculosis. Rifampicin inhibits DNA dependent RNA polymerase, leading to a suppression of RNA synthesis and cell
death. Pyrazinamide precise mechanism of action is unknown but the pyrazinoic acid of pyrazinamide disrupted membrane energetic and
inhibited membrane transport function in MTB. Ethambutol is a bacteriostatic against growing TB bacilli, it works by obstructing the
formation of cell wall.
Indication: Initial treatment of all forms tuberculosis
Contraindication: Hepatic and renal failure, hypersensitivity, optic neuritis, and pregnancy and lactating mother
Adverse Effect: Peripheral neuropathy, fluid discoloration, optic neuritis, hepatitis, fever, headache, dizziness, rashes, thrombocytopenia,
anaphylaxis
Nursing Intervention:
- Monitor input and output
- Monitor visual acuity
- instruct patient to expect orange discoloration of urine

SITAGLIPTIN + METFORMIN 50/500/tab OD pc dinner

Classification: Dipeptidyl peptidase 4 inhibitor; Biguanides

Action: Sitagliptin increases and prolongs incretin hormone activity which are inactivated by DPP 4 enzyme. Incretins increase insulin
release and synthesis from pancratic beta cells and reduce glucagon secretion; Metformin acts by decreasing hepatic glucose production
and intestinal glucose absorption, and improves insulin sensitivity by increasing peripheral glucose uptake and utilization
Indication: Diabetes Mellitus
Contraindication: Hypersensitivity, kidney disease, liver disease, metabolic acidosis, pregnancy and lactating mother
Adverse Effect: Abdominal bloating, diarrhea, nausea, vomiting, hypoglycemia, weakness, dizziness , anaphylaxis, renal failure
Nursing Intervention:
- Instruct to take medication exactly as prescribed by doctor
- Instruct to take metformin with meal
- Encourage to avoid sweet foods
- Encourage to store drug at room temperature
- Monitor capillary blood glucose
- Monitor s/s of hypoglycemia such as cold and clammy skin

METOCLOPRAMIDE i amp IVTT given

34
Classification: Antiemetic
Action: Blocks dopamine receptors in chemoreceptor trigger zone of CNS. It also makes the GI cells more sensitive to acetylcholine
leading to increases GI activity and rapid movement of food.
Indication: GERD, diabetic gastric stasis, treatment and prevention of postoperative nausea and vomiting
Contraindication: Hypersensitivity, pregnancy and lactation, GI obstruction
Adverse Effect: Drowsiness, fatigue, restlessness, sedation, headache, anxiety, depression, arrhythmias, constipation, extrapyramidal
reaction, hypertension/hypotnsion
Nursing Intervention:
- Obtain sensitivity history
- Monitor BP and extrapyramidal raction
- Educate about the possible side effects
- Instruct to avoid alcohol, sleep remedies to avoid possible serious sedation
FUROSEMIDE 40mg IVTT now

Classification: Loop Diuretic

Action: Inhibits reabsorption of sodium and chloride ions at proximal and distal renal tubules and loop of Henle thus increases renal
excretion of water, sodium, chloride, magnesium and calcium
Indication: Edema, renal failure, hypertension
Contraindication: Hypersensitivity, oliguria, anuria, fluid and electrolyte depletion, hepatic coma, pregnancy and lactation.
Adverse effect: Fluid and electrolyte imbalances, hypotension, dizziness, diarrhea, headache, hepatic dysfunction, dehydration,
photosensitivity
Nursing intervention:
- Closely monitor BP and vital signs
- Monitor I&O ratio and pattern.
- Administer orally with food to avoid GI upset
- Caution patient to change position slowly to minimize orthostatic hypotension

PROPOFOL 140mg + LIDOCAINE 2% 30mg + SUCCINYLCHOLINE

Classification: General anesthetics; Antiarrhythmics; Depolarizing neuromuscular blockers

Action: Propofol is a short acting hypnotic which causes global CNS depression. Lidocaine combines with fast Na channels and thereby
inhibits depolarization, resulting in decreasing myocardial excitability. Succinylcholine causes depolarization of neuromuscular junction by
mimicking the effect of acetylcholine but without being rapidly hydrolysed by acetylcholinesterase
Indication: Surgery, sedation, arrhythmias

35
Contraindication: Hypersensitivity, pregnancy and lactation
Adverse Effect: Hypotension, apnea, rashes, bradychardia, edema, paresthesia, headache, respiratory depressiom
Nursing Intervention:
- Monitor v/s especially BP and HR
- Inform possible side effects such as dizziness, hypotension, headache
- Instruct patient not to drive
- Advise not to take alcohol

PARECOXIB 40mg IVTT given

Classification: NSAID (non-steroidal anti-inflammatory drugs)

Action: Inhibits cyclooxygenase (COX) enzymes, which are involved in the synthesis of prostaglandins and thereby reduce pain and
inflammation.
Indication: Pain
Contraindication: hypersensitivity, renal or hepatic failure, pregnancy and lactation
Adverse effects: Dizziness, nausea, vomiting, back pain, changes in blood pressure, stomach upset, constipation, irritability
Nursing Considerations:
- Obtain history of sensitivity
- Inform patient the possible side effects of the medication
- Instruct patient to report any allergic reaction such as fever, redness, swelling and inflammation
- Monitor v/s especially the BP

36
 DISCHARGE PLAN

Health Teachings
Encouraged to do deep breathing exercise
Instructed to prioritize activities and establish balance between activity and rest to prevent fatigue
Encouraged to perform handwashing to prevent the transmission of microorganisms
Encouraged to eat foods rich in vitamins and minerals especially vitamin C to boost immune system.
Advised to seek medical attention for new and unexplained chest pain

Anticipatory Guidance
Instructed to immediately report any unusualities such as bleeding, fever, nausea, vomiting
Instructed to observe for signs of infection by the incision site such as redness, swelling, pus formation.
Instructed to visit physician for follow-up check-up

Spirituality
Encouraged to continue praying to God for strength and recovery
Encouraged to keep his faith and hope to God
Encouraged to ask for guidance to God
Encouraged to attend church every Sunday and on days of obligation
Encouraged to pray to God and be open to Him about any concerns because He will always be there to listen

37
 Advised to always trust in God and believe that He always has wonderful plans for each and everyone.
Advised to always be strong and optimistic in facing changes that he might encounter in life.

Medications
Instructed to take the full course of drug regimen.
Instructed to take take-home medications at the right time and the right dose.
Emphasized the importance of taking the full course of drug regimen.
Instructed to monitor for hypersensitivity such as fever, pain, or rashes.

Incision
Instructed to keep the incision site dry and clean at all times.
Instructed to change the dressing once a day or if it gets dirty or wet.
Instructed to only wash the suture line with mild soap and water.
Instructed to monitor the state of the incision site and report signs of infection such as redness, pain, swelling, or pus formation.

Nutrition
Encouraged to eat foods rich in vitamin A such as carrots, potatoes, pumpkin, cantaloupe and squash to help strengthen the
immune system
Instructed to avoid smoking and drinking alcohol
Advised to avoid food high in fats and cholesterol

Environment
Instructed to keep environment clean and safe
Advised to avoid crowded and polluted areas to prevent exposure to microorganism

38