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Health Assessment and Care Plan

Data of patient:

Name: Mr N
Age: 64 years old Sex: Male
Race: Caucasian Status: married
Religion: Buddhis Eduction: Master Degree
Address: Hat Yai Job : Lecturer
Date of approach: 31th October 2014
Bed Number: 10

Data collection

Health history
Chief complaint:
- Chest Paint in left chest

History of Present illness:

Clients 64 years, the patient felt pain in the chest left after jogging, before the patient
say never sick like this, then he brought the family to come to the Hospital
Shongklanagarin on October 31, 2014, the pain felt like a knife being stabbed, the
patient said the pain scale 3 of scale of 1-10, and sometimes pain occurs suddenly or
gradually, no history of the disease in the past and suffered from other diseases
according to him. at home he can enjoy as normal

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Functional Health Pattern Assessment

First the client was explained about the purpose and procedure and the verbal consent
was obtained from the client. Then data was collected in the form of question answer
systematically as per Gordon’s 11 functional health patterns assessment.

1. Health perception-health management pattern

Subjective data:
The client is made comfortable and inquired about the health perception he said, "In my
opinion, we can do for the health of our normal activities without any difficulty. I eat a
healthy diet and exercise to be healthy; I was actively jogging 2-3 times per week. In
past I have been in the hospital for examination and is always followed by prescription.
When I became ill, I would go to the hospital.

Objective data:
Client face looks tired but him always smiling

2. Nutritional-metabolic pattern
Subjective data:
Client says at home he eats a lot but here's appetite remains

Objective data:

- Skin: Skins are flexible, have dry skin at both of leg, both of leg have rash.
- Hair: short white and black hair, hair not dry doesn’t have dandruff.
- Nail: short and clean, Capillary refill less than 2 seconds.
- Eye: conjunctiva is pink, the whole sclera is white, don’t have cataract in the eye.
- Mouth: do not have dry lips.
-Abdomen: symmetry, soft, not tender, don’t have tumor, bowel sound 7-8/min.
-Lymph node: not large.
-Thyroid: not large.
- BMI = 75kg / (1,65 x 1,65)
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BMI = 27,55 → Obesities (normal range=18.5-22.9)

3. Elimination pattern
Subjective data:

- Client said, “I do not have problem about void. I void 4-5 times /day about 3-4
times in the morning and 1-2 times in the night. No pain or blood"
- Client said, “I have normal frequency of defecation. I defecate 1 time/day
without pain or blood.”
Objective data:
- Abdomen: soft, Bowel sound 7-8 /min.

4. Activity-exercise pattern
Subjective data:
Client said, ‘I am energetic and I do my daily routine by myself. For exercise, I do
jogging near my home 2-3 times per week and skip 15 minutes every day. I spend my
free time reading book because i special lecturer in Hat Yai University. I also go to play
badminton with my friends
Objective data:

- Respiratory system: Respiratory rate 20/m

- Cardiovascular system: HR 115 /min, normal rhythm, S1S2 normal no murmur, BP
124/84 mmHg.
Both legs and hands can find pulse, warm hand and foot
- Muscle strong: Both leg and both hand 5+
- Well groomed and hygiene was maintained.

5. Sleep-rest pattern
Subjective data:
The client says, "I usually sleep from 10 pm and get up at 5 in the morning. I do
not have any problem after I sleep. Sometimes I slept in the afternoon to rest."

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Objective data:
- Looks fresh.

6. Cognitive-perceptual pattern
Subjective data:
The client said, "I could clearly see and hear properly. Sometimes I use glass to read the
book. But I do not have much problem with seeing".
The client said, "I do not have a problem or a change in my memory. I make important
decisions alone and I have no problems in doing so".
Objective data:
- The client is well oriented to time, place and person.
- He easily hears while we whisper to him on both ears.
- He can easily read newspaper.
- No sensory deficits.
- Good attention and concentration during interview
- Fully conscious

7. Self-perception-self-concept pattern
Subjective data:
The client said, ‘‘I like the way I am. I am happy with how I look. I rarely get angry. I
don’t get angry with others but with family sometimes for prevent my family problem.
Sometimes I get annoyed by not understanding the language. I am not scared if i death. I
am also scared of disappointing other people, my family. I don’t want to lose my hope at
any situation. I believe in hope.’’
Objective data:
- He has good eye contact with us and was relaxed.
- His face looks happy and cheerful when he talks about his appearance.
- Hopeful and positive about life

8. Role-relationship pattern
Subjective data:

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Client said, ‘there are 2 members in my family: me and my older brothers. But I
stayed with my wife in hat yai as my school was there. So I spend a lot of time with my
family I love them a lot. There aren’t any problems within my family. As I am a Lecturer,
I responsibility not only to my family but to my student also.’

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Fig: Mr N’s Family Genogram

When the client was asked about the health belief in family, he said, ‘All of my
family members mostly believe in doctor. If I get ill, I will go to hospital first.’
Everything is going smoothly here. I talk with my family and friends every day.’

Objective data:
- The client looked contained and satisfied

9. Sexuality-reproductive pattern
Subjective data:

Client said, “Now I am 64 years old and have 2 children.”

Objective data:
- Appropriate sexual expression.

10. Coping-stress-tolerance pattern

Subjective data:

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When we asked him questions related to stress and coping, she responded, "I have not
experienced a major crisis in my life but I believe that I can handle it if it is in the future
as I have learned to be independent. It also depends on the nature of issues but
especially I want to meet people and share the problem. When I am stressed I usually
talk to my close friends and ask for advice. I am over 40 years of experience is enough to
overcome the existing problems.
Objective data:
- He is excited while talking about ways to handle stress
- He seemed very happy while talking about his career and family.
- He has good eye contact while having communication.
11. Value-belief pattern
Subjective data:
The client said, "I usually get what I want out of life. I have lived this life, the days of old I
just wanted to spend my life with family.
Regarding questions related to religion, the client replied, "I am a Buddhist I believe in
the religion and guide me and show me the right way when I'm in trouble."
Objective data:
- He is confident while talking about the religion and also smiles at times.
- He has eye contact during communication.

Sign and symptoms during taking care of the patient

Good consciousness, no dyspnea, Vs.: BT 37 C, PR 64, RR 20 min BP 124/84, HEET:no
pale conjunctiva, anicteric sclera, no carotid bruit, Heart: no JVP engorgements, normal
S1 S2 no murmur
Lungs: clear equal both lungs, no adventitious sounds, Abdomen: soft not tender,
Marked (data 31 October 2014) hypoactive bowel sound, soft, generalize mild tender,
no palpable mass, liver span 10 cm, splenic dullness negative fluid thrill positive and
shifting dullness positive but no pitting edema.
RT: groin, no hematoma, no bleeding per site
EXT: dorsalis pedis pulse 2+ both sides, no edema, warmth full and regular pulse all
extremities. Patient gives cooperation during interview and answers all of the questions
and Look moody.

Laboratory and investigation

Hematology: 03/11/2014
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Results Normal range

WBC 5.62 4.5 – 10.0 x 10 ^ 3 / uL
Hb 13.5 13.0 – 18.0 g / dL
Hct 41.1 40 – 54%
RBC 5.23 4.5 – 6.3 x 10 ^ 6 / uL
MCV (L) 78.6 83.0 – 97.0 fl
MCH 25.8 31.0 – 35.0 g/dl
(L)
PLT 209 150 – 450 x 10^ 3/UL
RDW 13.6 11.0 – 16.0%
PMN 65.1 40-70%
MCHC 32.8 31.0 – 35.0 g / dL
Eos 4.4 1 - 6%
Sample naff blood
Test result (ref.units)
Glu_FB (H)130 (70-110 mg%)

Electrocardiography:31/10/2014
interpreted: NSTEMI patients the ST segment is not elevated, and instead other patterns
are seen. Characteristics of NSTEMI ECGs are ST depression and T inversion.

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no JVP engorgement, normal S1 S2 no murmur

Order for one day Order for continuation
31/10/56 31/11/56
- blood PRC Iv fluid
NNS inj 1000ml
Iv fluid mix
NSS inj 100ml
- ASA 1x1
- Enoxaparin injection 1x1

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NURSING CARE PLAN

Nursing Diagnosis Objective/Goal Intervention Rationale Evaluation criteria and

patients outcome

1st Health problem/ Risk
for Health problem
Chest pain related to
abnormal myocardial
contraction
Subjective data:
- Client said chest pain in
left chest
Objective data
Objective 1. Teach the client for
Within 1 × 24 applying distraction and
hours, pain will relaxation technique
be reduced or 2. Observe 12 lead ECG
adapted. recording during pain,
as prescribed for
Result criteria determining the extent
1. Reduction in of infarction
pain intensity 3. Adjust the position and
1. Distraction can help patients turn their Evaluation criteria
attention to something that he likes and
1. S: Client said pain
can reduce pain example watching tv,
reduction
playing games etc.
2. O: Pain scale 1
Relaxation can Helps reduce pain.
3. A: the problem is
2. ECG during pain is useful in
resolved
diagnosing the extent of myocardial
4 P: continue
infarction or angina infarction.
intervention
3. Physical rest can reduce cardiac

- Pain scale : 3 (Mild) 2. Reduced pain rest of the client in a oxygen consumption. Fear and

(Hayward scale 1- 3 Mild,
4-6 Medium, 7 - 9 severe,
10 Uncontrol)
- T 37 C, PR 64, RR 20
/min BP 124/84
due to lack of comfortable position to anxiety can cause stress; resulted Patients outcome
convenient instruct the client to sit trigger endogenous catecholamines,
Pain reduction/ pain
3. Patient will down, raise a head in which can lead to increased activity
control
demonstrate the pillow, or lying of the heart. With the increase in
activities and down. pain threshold epinephrine will
behaviors that 4. Give appropriate decrease and will increase the
activity of the heart

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Nursing Diagnosis Objective/Goal Intervention Rationale Evaluation criteria and

patients outcome

will prevent prescription drug 4. Drug therapy is a defense tops to

the recurrence therapy and continuous keep the heart tissue, and the effects
of pain. evaluation of the of the drug is very dangerous and the
returned to the patient's response. response of patients must to be
level before the 5. Teach the patient how observed.
pain to distinguish between 5. In some case, the chest pain may be
angina pain and signs more serious than stable angina. The
and symptoms of patient needs to understand the
myocardial infarction. differences in order to seek
emergency care in a timely fashion.

2nd Health problem/ Risk Objective 1. Observe for skin 1. Clients on anticoagulant Evaluation criteria
for Health problem Within 3 × 24 necrosis, changes in Therapy remains at risk for
1. S: The client
Risk of bleeding related hours, Laboraty blue or purple mottling developing emboli resulting in CVA
demonstrates an
to adverse effects of value normal of the feet that or PE.
understanding of the
anticoagulant therapy blanches with pressure 2. Bleeding is a sign of anticoagulant
drug’s action by
Subjective data: Result criteria or fades when the legs overdose
accurately describing
- Client said chest pain 1. Experience a are elevated 3. Increase in heart rate accompanied
decrease in drug side effects and

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Nursing Diagnosis Objective/Goal Intervention Rationale Evaluation criteria and

patients outcome

Objective data blood 2. Monitor for signs of by low blood pressure or subnormal precautions.
- PR 64 coagulation as bleeding: flulike temperature may signal bleeding. 2. O: The client’s
- BP 124/84 evidenced by symptoms, excessive 4. Heparin may cause significant laboratory values
laboratory
laboratory bruising, pallor, elevations of aspartate exhibit a decrease in
values
MCV (L) 78.6 83.0 – 97.0 fl epistaxis, hemoptysis, aminotransferase (AST) and alanine blood coagulation
2. Demonstrate
MCH (L) 25.8 31.0 – 35.0 hematemesis, transaminase (ALT), because the 3. A: the problem is
an
g/dl menorrhagia, drug is metabolized by the liver resolved
understanding
PLT 209 150 – 450 x 10^ hematuria, melena, 4 P: continue
of the drug’s
3/UL action by frank intervention
Therapy accurately Rectal bleeding or
describing excessive bleeding from
Patients outcome
- ASA 1x1 drug side wounds or in the mouth.
- Enoxaparin injection 1x1 effects and 3. Monitor vital signs. Laboratory values back
precautions 4. Monitor laboratory to normal/ bleeding
values: aPTT and PTT control
for therapeutic values

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Reference

Carpenito-Moyet, L.J. (2010).Nursing diagnosis: Application to clinical practice (13th ed.)

Philadelphia, PA: Lippincott Williams & Wilkins.
Gordon, M. (2011). Manual of nursing diagnosis. Sudbury, MA: Jones and Barlett
Publishers.

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Kholid Rosyidi MN

Kholid Rosyidi Muhammad Nur is an author and motivator, he Graduated

from bachelor of Nursing, Muhammadiyah University of Surabaya. He
has published seven books of nursing and three ebooks motivation and
he works as a lecturer in Prodi III of Nursing, Bondowoso University and
UBI Banyuwangi, now he continued his studies at the Faculty of nursing,
Prince of Songkla University Thailand

Health Assessment and Care Plan