I. PATIENTS PROFILE: NAME: Ammagay, Jason Fud-Ar AGE: 37 yrs.

old SEX: Male BIRTHDATE: February 16, 1972 BIRTHPLACE: Tinglayan, Kalinga ADDRESS: Poblacion,Tinglayan, Kalinga CIVIL STATUS:single OCCUPATION: Carpenter RELIGION: Roman Catholic NATIONALITY: Filipino HIGHEST EDUCATIONAL ATTAINMENT: Grade IV DATE ADMITTED: Nov. 24, 2009 TIME ADMITTED: 8:15 pm CHIEF COMPLAINT UPON ADMISSION: Cough and Fever ADMITTING DIAGNOSIS: CAP-NR vs Parenchymal Disease Pulmonary mass vs Empyema ADMITTING PHYSICIAN: Dr. Aspiras ATTENDING PHYSICIAN: Dr. Manalo, Dr. Galasgas II. HEALTH HISTORY CHIEF COMPLAINT: Cough and fever HISTORY OF PRESENT ILLNESS: The present condition started about 3 months prior to admission when the patient started having cough which was productive with whitish and yellowish sputum, with associated fever and body weakness. The patient self-medicated with a number of antibiotics like Amoxicillin and Co-amoxiclav affording no relief. The condition of the patient progressed until about 1 week prior to admission, the symptoms were now with associated dyspnea. This prompted the pt. to seek for consultation at a local hospital where chest X-ray was done revealing the presence of Consolidation vs pleural effusion at the left lung with possible abscess formation. He was treated accordingly with Cefuroxime and Salbutamol nebulization. After 3 days of hospitalization, his condition improved and was discharged. However about 3 days PTA, the pt. again had episodes of cough but now blood streaked. There was also associated febrile episodes, loss of appetite, weight loss and difficulty of breathing. The persistence of the condition prompted the patient to seek for consultation with the same hospital where he was again admitted. He was then subsequently referred in this institution for further evaluation and management. PAST MEDICAL HISTORY: The patient denies any history of other medical illnesses like Hypertension, Diabetes Mellitus, Bronchial asthma, pulmonary tuberculosis and liver and kidney diseases. There were no previous operations. There are also no known allergies to food and drugs. FAMILY HISTORY: The patient claimed to have heredofamilial history of Hypertension but denies any family history of Diabetes Mellitus, Bronchial asthma, Pulmonary Tuberculosis, heart and kidney diseases.

COURSE OF CONFINEMENT: This is the case of Jason Fud-ar Ammagay, 37, male, who was admitted to surgical ward of SLU-HSH last Nov. 24, 2009 at 8:15 pm due to cough and fever. On the first day of admission, he underwent ECG, Sputum exam GSCS and Ultrasound at the left Hemithorax. They also infused D5 LRS 1L x 16 hrs at his left hand. Drugs given were as follows: 1. Clindamycin 300 mg IV every 6 hours Anti-infectives Action: Inhibits or interferes with bacterial protein synthesis by binding to the 50s ribosomal subunits of bacterial chromosome. Indication: Treatment of respiratory tract infection including bronchitis, pneumonia, siniusitis, pharyngitis, in skin and soft tissue infections. Contraindication: In patient with disturbances.Severe liver damage etc. pre-existing cardiac abnormality or electrolye

Adverse reaction: Nausea, diarrhea, gastrointestinal disturbances , abnormal pain / discomfort.

GORDONS FUNCTIONAL PATTERNS HEALTH PERCEPTION PATTERN: She perceives her health status and well-being as a stressor physically, emotionally and financially. She also thinks that adherence to preventive health practices is hard because of so many factor such us financial. NUTRITIONAL-METABOLIC PATTERN: The patient has no known allergy with any food and drugs. Before confinement, the patient eats rice, vegetables, fish and meat. Patient claims that her appetite and her eating habit are not affected with any associated dysphagia and or polyphagia. She also drinks at least 3 cups of water in a day and does not experience polydipsia. She also has no weight loss since her illness. ELIMINATION PATTERN: The patient normally urinates at least twice a day with no associated dysuria, hematuria, and incontinence. The patient also does bowel movement at least once a day, of stool soft in consistency with no difficulty doing it. Patient also does not manifest diaphoresis, and night sweats. ACTIVITY-EXERCISE PATTERN: The patient, according to her son is not so much active. She prefers staying inside the house and does minimal exercise like walking, etc. However, she does watching T.V. and frequently converses with neighbors and other relatives. Patient verbalized that certain factors such as body weakness and easy fatigability sometimes interferes with her desire to do things that she likes. SLEEP-REST PATTERN:

The patient sleeps also sleeps well regularly. She sleeps at least 6-7 hours in a day with no sleep disturbances and difficulties. Patient also claims to have adequate rest and relaxation in a day due to the fact that she has limited activities and strenuous activities. Patient does relaxation through watching T.V. in a sitting position, and sleeping. COGNITIVE-PERCEPTUAL PATTERN: The patient has adequate sensory modes. She has but a little difficulty visualizing letters of small size. However, she has no difficulty of hearing, pain sensation, and abnormal discharges. She also eats well with no pain in the mouth, soreness, bleeding gums, anorexia and is able to taste well. The patient has no problem in smelling with no obstruction and congestion in her nose. The patient can also discriminate different pain sensation. She is calm, coherent with no dizziness, confusion, headache and numbness. SELF-PERCEPTION PATTERN: The patient claims that she has a positive attitude about herself. She does not feel depressed even with her present condition and also does not feel anxious about her body image. She also claims that even with her illness, she does not feel useless to her family and that she feels a sense of worth to her family.

ROLE RELATIONSHIP PATTERN: The patient claims that she has a good relationship with her children and even with grandchildren. The patient also has good communication with the health team and cooperates well with interventions done. SEXUALITY/REPRODUCTIVE PATTERN: Patient does not feel dissatisfaction with her sexuality even if she already lost her husband. She also feels that she already is satisfied with the number of children that she has given birth. She also verbalized that she feels blessed as a woman because she has done so many great things. COPING-STRESS TOLERANCE PATTERN: Patient claims that she can handle stress well and can cope with it well. However in tough times, she often turns to her relatives especially her children to ask for support. She also prays when she feels she cannot control the situation anymore. VALUE BELIEF PATTERN: The patients family is Born Again Christian. They do not have any beliefs that affect their health but in terms of important decisions, they practice praying to ask for guidance. III. LIST OF PRIORITIZED PROBLEM AND DIAGNOSIS: 1) Ineffective breathing pattern r/t heart ailment.

2) Ineffective Airway Clearance r/t Bronchoconstriction.

4) Risk for ineffective myocardial perfusion r/t decreased oxygen supply to heart muscles 5) Risk for ineffective tissue perfusion (peripheral) r/t Interruption of blood flow.
6) Risk for activity intolerance r/t Presence of respiratory problem (dysrhythmia) 7) Acute pain r/t decreased oxygen to heart muscles.

8) Impaired Physical mobility r/t decreased muscle strength 9) Readiness for enhanced Religiosity r/t maintenance of prescribed medications.
10)

Readiness for enhanced therapeutic regimen r/t management of own health.

IV. PATHOPHYSIOLOGY OF THE DISEASE ENTITY:

Hypertension

Hyperlipidemia Mellitus

Cigarette smoking Diabetes

Stenosing Coronary Atherosclerosis

Intraluminal Thrombus overlying a ruptured Or fissured Plaque, CoronaryVasospasm, And platelet aggregation.

Narrowed or occluded coronary arteries Deprivation of blood-borne oxygen and nutrients to the Heart muscles. Pumping ability of the Heart is impaired. Blood supply is decreased or diminished Inability to meet the oxygen demand of the tissues. Dyspnea, adynamic precordium, chest pain

Coronary Artery Disease Impaired Myocardial Metabolism Ischemia Infarction or death of deprived myocardial tissue. Heart failure
V. NCP PROPER: Difficulty of Breathing

Subjective Data: > Nahihirapan akong huminga >with history of CAD >with chest pain and chest heaviness >weakness > rated pain as 8/10. Objective Data: > Vital signs: Bp= 110/60, T=37.1, PR=74, RR=23, > Use of accessory muscles when breathing >adynamic precordium, irregular rhythm >cool extremities >Clammy skin >Does not maintain eye contact when conversing .>Mottling >lethargy >nasal flaring Goals: LTO: After 3 days of nursing interventions the patient will be able to breathe without difficulty. STO: Within 8 hours of nursing interventions, the client will be able to: 1) Verbalize awareness of the disease process, causative factors, and treatment plan. 2) Demonstrate appropriate coping behaviors. 3) Demonstrate an increase in activity tolerance Explanation of the Problem: Dyspnea is defined as shortness of breath or labored breathing. It affects clients with cardiac and pulmonary disorders. It can develop in any form of heart disease, it

usually occurs with cardiac enlargement and other pathologic, cardiovascular, structural and physiological changes. Dyspnea develops when the left ventricle fails to function and the lungs become congested with fluid. Acute dypnea may occur with fever, exposure to high altitude, acute pulmonary edema, hyperventilation, anemia, pneumonia, pnuemothorax, pulmonary emboli, and airway obstruction. Chronic dyspnea also may occur in clients experiencing anxiety, depression, left ventricular heart failure , pulmonary disease, pleural effusion, asthma, obesity, poor physical fitness, and various psychosomatic conditions. Nursing Dx: Ineffective breathing pattern r/t heart ailment.

Dx:>Auscultate chest

To evaluate character of breath sounds. To determine degree of oxygenation, CO2 retention.

Goal fully met if patient will be able to breathe normally and without difficulty.

>Review lab. Data ABGs

>Assess for concomitant pain/discomfort. > Assess for possible causative factors r/t temporarily impaired arterial blood flow >Monitor quality of all pulses.

It may restrict /limit respiratory effort.

Goal partially met if patient will be able to manifest at least 2 of the 3 stated objectives above.

Early detection of cause facilitates prompt, effective treatment.

Goal not met if the pt. will not manifest any of the 3 stated objectives.

Assessment is needed for ongoing comparisons; loss of peripheral pulses must be reported or treated immediately.

>Assess pt.s description of pain

The discomfort of angina is often difficult for pts. To describe and many pts. Do not consider it to be pain.

>Determine changes any changes in mental status.

Hypoxia nad reduced cerebral perfusion are reflected in restlessness,

After 20 minutes of health teachings, the patient and the significant others will be able to: 1. Define Hypertension -Lecture with 2 minutes briefly visual aids what

Hypertens ion is. 2. Discuss signs and symptoms of Hypertens ion. 3. Introduce the STEP care approach for the managem ent of Hypertens ion.

Signs and Symptoms of Hypertension

-Lecture with visual aids

3 minutes

STEP Care Approach: I. Lifestyle Modification: -Exercise -Manage Stress -Cessation of Smoking -Loss of Excessive weight -Restriction of Sodium -Decrease Alcohol intake II. Continue Step I and add-one agent -diuretic or Ca channel blocker or ACE inhibitors or beta blocker III. Continue Step I and change or add another agent -beta-adrenergic blocker IV. Continue Step II and change or add another agent -direct vasodilating agents Diet Modifications and Food Selections for Hypertensive patients: 1. Low Calorie or Calorie Restricted Diet

-Lecture with visual aids

5 minutes

4. Discuss the Diet Modificati ons and Food Selections for Hypertens ive patients

-Lecture with visual aids

5 minutes

2. a. -

b. -

c. -

d. -

Not allowed: high fat foods, high carbohydr ates Sodium restricted Diet 200-250 mg Na Rice or oatmeal, jams, meat (4 exchange s/day), unsalted vegetable oil, low sodium milk Not allowed: butter, margarine , commerci al baled products 500 mg Na Ordinary evaporate d milk, food plan in 200 mg Na diet plus 2 exchange s of butter or margarine /day 1000 mg Na Food plan in 500 mg Na plus tsp of salt per day 20003000 mg Na Moderate use of salt

scuss DASH (Dietary Approach to Stop Hypertension ) and DASHSodium

in food preparatio n, selected canned and frozen foods - Not allowed: further addition of soy sauce, patis, salt or any other salty condiment s Foods recommended on DASH Diet and DASHSodium

-Lecture with visual aid

5 minutes