Rheumatic Heart Disease_cs

I.

INTRODUCTION

Rheumatic heart disease is a condition in which the heart valves are damaged by rheumatic fever. Rheumatic fever begins with a strep throat from streptococcal infection. Rheumatic fever is an inflammatory disease. It can affect many of the body's connective tissues — especially those of the heart, joints, brain or skin. Anyone can get acute rheumatic fever, but it usually occurs in children five to 15 years old. The rheumatic heart disease that results can last for life. Rheumatic heart disease is the most serious complication of rheumatic fever. Acute rheumatic fever follows 0.3% of cases of group A beta-hemolytic streptococcal pharyngitis in children. As many as 39% of patients with acute rheumatic fever may develop varying degrees of pancarditis with associated valve insufficiency, heart failure, pericarditis, and even death. With chronic rheumatic heart disease, patients develop valve stenosis with varying degrees of regurgitation, atrial dilation, arrhythmias, and ventricular dysfunction. Acute rheumatic fever and rheumatic heart disease are thought to result from an autoimmune response, but the exact pathogenesis remains unclear. While rheumatic heart disease was the leading cause of death 100 years ago in people aged 5-20 years in the United States, incidence of this disease has decreased in developed countries, and the mortality rate has dropped to just above 0% since the 1960s. Worldwide, rheumatic heart disease remains a major health problem. The mortality rate from this disease remains 1-10%. A comprehensive resource provided by the World Health Organization (WHO) addresses the diagnosis and treatment of this latter population. Estimations worldwide are that 5-30 million children and young adults have chronic rheumatic heart disease, and 90,000 patients die from this disease each year. In the Philippines, about 2,389 Filipinos under all age groups die because of Chronic Rheumatic Heart Disease each year and 873 of that are young Filipinos under 10-24 years old. (Philippine Health Statistics 2003, DOH) The Office of the Secretary under the Department of Health released an administrative order no. 23-B on July 1 1996

entitled Addendum To Manual Of Operation of Rheumatic Fever/ Rheumatic Heart Disease (RF/RHD); Guidelines on the Referral, Confirmation, Diagnosis, Registration and Management of RF-RHD Cases. This guideline is the answer of Philippine Government to address Rheumatic Heart Disease cases in the country. The patient was also diagnosed witch Anemia secondary to blood loss after delivery of a baby. Anemia is a condition in which a person’s blood has a lower than normal number of red blood cells (RBCs), or the RBCs don’t have enough hemoglobin (HEEmuh-glow-bin). Hemoglobin—an iron-rich protein that gives the red color to blood— carries oxygen from the lungs to the rest of the body. In people with anemia, the blood does not carry enough oxygen to the rest of the body. As a result, people with anemia feel tired, along with other symptoms, because their bodies are not receiving enough oxygen. In severe or prolonged cases of anemia, the lack of oxygen in the blood can cause serious and sometimes fatal damage to the heart and other organs of the body. here are more than 400 types of anemia, which are divided into 3 groupings; a.) Anemia caused by blood loss, b.) Anemia caused by decreased or faulty red blood cell production c.) Anemia caused by destruction of red blood cells. Women and people with chronic diseases are at greater risk for anemia. Many types of anemia can be mild, short-lived, and easily treated. Some forms of anemia can be prevented with a healthy diet, and other forms can be treated with diet supplements. Certain types of anemia may be severe, long-lasting, and life threatening if not diagnosed and treated. People who have symptoms of anemia should see their doctor to find out if they have the condition, its cause and severity, and how to treat it. In the world, 17 out of 1000 population are suffering from anemia. (NHIS,) The most common of Anemia is Iron deficiency anemia. Its prevalence is highest among young children and women of childbearing age (particularly pregnant women). In the Philippines, Anemia is the most prevalent, affecting almost one-third of the Philippine population (table 5). Anemia prevalence is highest among infants 6 - 11 mos old. Anemia prevalence among infants, preschool children, and school-age children was

higher or almost the same as the national prevalence in 1987, 1993 and 1998. Anemia prevalence among children less than 6 years old also increased between 1993 and 1998, but 1998 levels were still lower than reported prevalence rates in 1987. ( NRI National Nutrition Surveys; 1993, 1996 and 1998.) The current Philippine Plan of Action for Nutrition gives priority to provision of pharmaceutical iron supplements to pregnant women, infants, and preschoolers. The next step is for the Department of Health to recommend a suitable iron supplement. Fortification of rice and other food products with ferrous sulfate represents a potential strategy in areas where anemia is widespread. Another approach is to reduce consumption of iron absorption inhibitors and promote intake of absorption enhancers such as vitamin C and heme iron. Parents can be taught to modify their infant's diet by preparing complementary foods rich in iron and vitamin C, including purees of raw fruits and cooked vegetables. The Filipino mass media are broadcasting messages promoting foods rich in micronutrients. The basic goal of dietary modification and education programs in the Philippines remains to persuade parents to feed their children wellbalanced meals. (Opportunities for Micronutrient Interventions [OMNI], 1995) Another medical problem manifested by the patient is stroke. Stroke is the third leading cause of death in the countries of the world and the No. 1 cause of adult disability. 80% of strokes are preventable; you can prevent a stroke! A stroke or "brain attack" occurs when a blood clot blocks an artery (a blood vessel that carries blood from the heart to the body) or a blood vessel (a tube through which the blood moves through the body) breaks, interrupting blood flow to an area of the brain. When either of these things happen, brain cells begin to die and brain damage occurs. When brain cells die during a stroke, abilities controlled by that area of the brain are lost. These abilities include speech, movement and memory. How a stroke patient is affected depends on where the stroke occurs in the brain and how much the brain is damaged. Risk factors for stroke include advanced age, hypertension (high blood pressure), previous stroke or transient ischemic attack (TIA), diabetes, high cholesterol, cigarette smoking, atrial fibrillation, estrogen-containing forms of hormonal contraception,

migraine with aura, and thrombophilia (a tendency to thrombosis), patent foramen ovale and several rarer disorders. High blood pressure is the most important modifiable risk factor of stroke. The traditional definition of stroke, devised by the World Health Organization in the 1970s, is a "neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours". This definition was supposed to reflect the reversibility of tissue damage and was devised for the purpose, with the time frame of 24 hours being chosen arbitrarily. The 24-hour limit divides stroke from transient ischemic attack, which is a related syndrome of stroke symptoms that resolve completely within 24 hours. With the availability of treatments that, when given early, can reduce stroke severity, many now prefer alternative concepts, such as brain attack and acute ischemic cerebrovascular syndrome (modeled after heart attack and acute coronary syndrome respectively), that reflect the urgency of stroke symptoms and the need to act swiftly. Stroke is occasionally treated with thrombolysis ("clot-buster"), but usually with supportive care (physiotherapy and occupational therapy) and secondary prevention with antiplatelet drugs (aspirin and often dipyridamole), blood pressure control, statins and anticoagulation (in selected patients). The Philippines has the highest death rate for hypertension in the region, second to Indonesia in mortality for rheumatic heart dieases, fourth to Singapore for CAD, and third to Japan for stroke (WHO 1990). Atherosclerotic diseases rank as first leading death among Filipinos. Overall, deaths due to CVD comprise 25 percent of total deaths in 1995 (PHS 1995). The rise of CVD deaths is due to hypertension, CAD and cerebrovascular accidents, all of which have more than doubled during the period 196590 (Facts and Figures, CVD in the Philippines). The prevalence of congenital heart disease at birth is 5 per 1,000 livebirths. It declines rapidly as many of the cases die. At five years of age, the rate is about 1.5 per 1,000 and remains at 1.2 per 1,000 at age eight and onwards.

Another disease condition manifested by the patient was Nosocomial Pneumonia. A working definition of nosocomial pneumonia (NP) is that of a new pulmonary infiltrate that occurs after one week of hospitalization and that resembles a bacterial pneumonia on the chest radiograph. Although most patients have fever and leukocytosis, these findings are not uniformly present nor are they a requisite for the presumptive diagnosis of NP. A patient with pneumonia may have the fever with of without chills, coughing which may bring up yellow, green, rust of bloody phlegm, pain in the chest when breathing or coughing shortness of breath, rapid and shallow breathing fatigue and sweating and flushed color of skin loss of appetite or upset stomach. (DOH, 2003) Some hospitalized patients develop pneumonia in less than 5 days, a condition called early hospital-acquired pneumonia (HAP), which is better known as incubating community-acquired pneumonia (CAP). Since NP is defined as occurring a week or more after hospitalization, the early cases should not be regarded as NP but as CAP. Both early HAP and CAP have the same etiology in that the main pathogens are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, although atypical pathogens also may cause the conditions. (CDC, 2005) NP is caused by different pathogens, the aerobic gram-negative bacilli (ie, excluding H influenzae). Pseudomonas aeruginosa is not the most common cause of NP but is the most important organism in terms of mortality and morbidity. Staphylococcus aureus (ie, methicillin-susceptible S aureus [MSSA], methicillin-resistant S aureus [MRSA]) and anaerobic organisms are not significant contributors to NP. (NLM, 2007) Aerobic gram-negative bacilli cause all cases of NP, aerobic gram-negative pathogens may be divided into 2 categories. The first category includes those organisms causing necrotizing pneumonia with rapid cavitation, microabscess formation, blood vessel invasion, and hemorrhage; typically, this is characteristic of P aeruginosa. The second category consists of all other nonnecrotizing gram-negative organisms responsible for NP that cause histologically indistinguishable nonnecrotizing pneumonia. (NLM, 2007)

In the Philippines, the management of pneumonia is more focused on the childhood age groups which is more prone and develops serious conditions rather than adults. The health condition has improved in 16 of the 17 regions that applied the Integrated Management of Childhood Illness (IMCI). IMCI is a strategy used in providing holistic health care services among the under five-year-old children ranging from detailed history taking, physical examination, diagnosis and treatment of diseases and conditions. The promotion of IMCI through regular in-service and pre-service training of frontline health personnel is supported by international and local funding agencies. The IMCI strategy requires that appropriate drugs for pneumonia are available at the health service outlets at any given time. DOH and PhilHealth-accredited clinics, health centers and hospitals generally provide patients with the necessary drugs at low cost. However, not all health facilities are able to carry out IMCI appropriately and consistently due to shortage of drugs. This is due to the limited local sources of drugs or to failures in the drug distribution system at the regional and local levels. (National Objectives for Health, Philippines, 2005-2001, Department of Health) Although the drugs necessary to treat pneumonia are available over the counter, general consultations and treatment services for older children, adults and older persons with pneumonia needs improvement to multiply the gains that have been achieved in pneumonia control among age groups. (National Objectives for Health, Philippines, 2005-2001, Department of Health)

A. Scope of the Study The study focuses on an Intensive Care Unit patient, confined in Northern Mindanao Medical Center, Cagayan de Oro City, having the final diagnosis of Stroke in the young, rheumatic heart disease, moderate mitral regurgitation, moderate tricuspid regurgitation, aortic regurgitation, acute pulmonary edema; resolved, nosocomial pneumonia; resolved s/p intubation x2 weeks, s/p tracheostomy, anemia secondary to blood loss, s/p postpartum home delivery (G2P2) (2002).

v Nature, causes, signs & symptoms, pathophysiology, nursing management, interventions, and prognosis of the disease. v Assessment of Ms. X’s personal background, health history, and history of present illness. v Involves the ideal and actual nursing management appropriate for Ms. X’s condition, the drug study of the medications given, the health teachings and referrals for her.

Limitation of the Study v Limited only to the history of the patient which is comprised of the patient’s profile, family and personal health history, chief complaint and history of present illness. v Information obtained from patient’s medical record, from the staff, during patient assessment, and from the watcher.

v The study is also limited on the laboratory results of the patient. v The patient was only taken cared of for 3 days, starting from the 34th day of her admission at Northern Mindanao Medical Center, Cagayan de Oro City and ends with the 36th day of her admission. v Other relevant information kept confidential same with her true identity to protect her privacy.

B. Objective of the Study This study aims to improve the present condition of the patient and is conducted to gain a thorough understanding concerning the case of the patient. And to apply our knowledge on nursing assessment, problem identification, nursing interventions and evaluation that is related to the disease condition. Furthermore, by gathering the subjective and objective regarding the case, it will allow us to have a proper and appropriate nursing care towards the condition of an actual patient. This study also aims to improve our skills in the clinical area, our interpersonal relationships with other health care givers and to gain more confidence in ourselves towards what is tasked to us.

C. Significance of the Study The study will present the identification of Stroke, Rheumatic heart disease, Nosocomial Pneumonia and Anemia to gain insight into the nature of Ms. X’s condition

in terms of its etiologic factors, treatment, and prevention. The method to be used will provide comprehensive observation regarding her condition at the same time the recognition of imparting knowledge, awareness to people and ways in preventing the spread of the disease. This study can be considered beneficial to: (a) the family concerned, helping them to be aware regarding Ms. X's condition, allowing them to motivate the patient in complying with the medications as prescribed, and as to cope up with the situation as well as to prevent the spread of the disease among other family members; including on how to identify any symptoms that may occur, (b) nurses handling similar cases, providing them additional information in formulating nursing care plans, in such a way achieving efficiency in the treatment procedure – recovering condition and health status improvement, (c) nursing students, in an attempt to provide additional information with regard to the disease process, its treatment and prevention, hopefully will result in decreasing the recurrence of the said disease at the same time not focusing on the disease itself but will provide a chance to test their skills regarding proper patient assessment in clinical settings, and (d) other researchers, providing them a comparative study that will be useful in determining new nursing interventions with the objectives of alleviating the patient’s condition, as well as to expand the information and knowledge regarding the disease condition. Moreover, the study will help the researchers in obtaining knowledge about the treatment and regimens through implementations of nursing care directly to their patients, aiming for health promotions and restorations.

II.

Health History

a. Developmental History Growth and development both refer to dynamic processes. Continuous processes are influence by maturational and genetic factors. Our patient’s growth and development was assessed using the theories of Erikson and Freud. Psychosocial Developmental Theory of Erikson Erikson evisions life as a sequence of levels of achievement. He describes eight stages of development where each stage signals a task that must be achieved. Our patient belongs to the young adulthood where the central task is intimacy vs. isolation. In this stage, the person begins to have intimate relationship with another person and the ability to care for another person as well. The most important event in this stage is commitment to work and relationships. In line with our patient’s case, She has a live in partner, a three kids in which her task is to care and guide with them as well. Unfortunately, she cannot be able to come up with such task in which the kids are yearning for.

because of the said

condition in which she is suffering right now.

Psychosexual Theory of Freud According to Freud’s theory of psychosexual development, the personality develops in five overlapping stages from birth to adulthood. This stage represents the major portion of life and the basic task for the individual is the detachment from the parents. In this stage, the focus is again genitals but this time the energy is expressed with the adult sexuality.

As what we have observed in our patient’s case, the foundation of love, sexual acts and compassion with her partner was achieved as they indulged into a relationship for almost three years from now. B. Family Health History Tracing the family history of Ms. X, it was found out that the patient’s father had experienced a urinary tract infection at the age of 20. There were no medications maintained but only lifestyle modifications were stressed out such as restrictions of sodium, water therapy and regular exercises. Unhappily, at the age of 54, he died suffering from the aforementioned illness. On the other hand, her mother had goiter at the age of 25 and died due to rupture of the aforesaid at the age of 48. Luckily, there were no known family histories of hypertension, diabetes mellitus, asthma and arthritis. C. Past Personal History

Ms. X is 23 years old and currently residing at Purok 10, Baloy, Tablon, Cagayan de Oro City. She is the youngest in a brood of three of Mr. and Mrs. Z. Prenatal checkups were done during her mother’s conceptions. Patient X was delivered at home which was assisted by “hilot” with ungloved hand through Normal Spontaneous Vaginal Delivery. The patient had completely received childhood immunizations like BCG, DPT, OPV and measles. From birth up to 6 months, she was exclusively breastfed per demand while having an eye-to-eye contact. At 6 months, she started to be fed with porridge (lugaw), and at 1 year onward began to be fed with rice, vegetables and fish. Ms. X’s had encountered chicken pox and measles when she was 5 years old but no medical consultations done and medications taken. The patient had also experienced common illnesses such as fever, colds, toothache and cough but no consultations done instead it was managed by taking over-the-counter drugs (Paracetamol and Mefenamic Acid). The patient doesn’t smokes and drinks any alcoholic beverages. So far, Ms. X has no known food and drug allergies. At the age of 13, the patient had her first menstruation. During her menses, it was found out that it is irregular but in moderate

amount of discharges. She has five-day duration of menses without experiencing dysmenorrhea. Last October 3, 2005, Ms. X delivered a lived baby boy through normal spontaneous vaginal delivery, cephalic in labor at home helped out by a midwife. During the delivery of the baby, incision was done and with perineal lacerations noted but unfortunately it was not repaired by the midwife. During her conception, she actively participates and cooperates with prenatal check-ups at Barangay Baloy Health Center. The patient X underwent a surgical operation known as Tracheostomy last July 26, 2008. Blood transfusion was done after the operation accumulating 1 pack in the operating room and 1 pack in the ward. Luckily, no certain blood reactions observed during the blood transfusion. D. History of Present Illness One month (May 29, 2008) prior to admission, patient X (G2P2) delivered a baby girl via normal spontaneous vaginal delivery, cephalic in labor at home assisted by a midwife. One week prior to admission, patient is still having a vaginal spotting associated with body malaise and headache. Patient took herbal medicine (kamote tops) boiled and drank for three times a day but no relief of symptoms. However, due to persistence of the above condition, prompted patient X to sought consultation, hence this admission.

III.

A. PATIENT’S PROFILE

Patient’s Name: Address: Date of Birth: Age: Civil Status: Gender: Nationality: Religion: Educational Attainment: Height: Weight: Occupation: Date of Admission: Time of Admission: Income: Chief Complaint: Attending Physician: Allergies: Baseline Vital Signs: August 3, 2008

Temperature:

( Sunday)

Pulse rate:

36.4 c 77 bpm

Respiratory rate: 26 cpm Blood Pressure: O2 Sat:

100/70 mmHg 98% 8 am:

August 4, 2008(

Temperature:

Monday)

Pulse rate:

36 c 85 bpm

Respiratory Rate: 24 cpm Blood Pressure: O2 Sat: Temperature: Pulse Rate:

110/80 bpm

12 noon: 36.5 c 85 bpm 31 cpm 100/70 bpm

98% 36.9 c 86 beats per minute

August 5, 2008(

Respiratory Rate: 27 cycles per minute

Tuesday)

Blood Pressure:

110/70 mmHg

99%

SIBLINGS

CHILDREN

N W

E S

Pontod

To Puerto

Coffee Pack Factory Cagayan de Oro City

Lapasan

Gusa NFA, Baloy Cugman

IV. Anatomy and Physiology The Anatomy of the Heart Your heart is located under the ribcage in the center of your chest between your right and left lung. It’s shaped like an upside-down pear. Its muscular walls beat, or contract, pumping blood continuously to all parts of your body. The size of your heart can vary depending on your age, size, or the condition of your heart. A normal, healthy, adult heart most often is the size of an average clenched adult fist. Some diseases of the heart can cause it to become larger. The Exterior of the Heart Below is a picture of the outside of a normal, healthy, human heart.

The illustration shows the front surface of the heart, including the coronary arteries and major blood vessels.

The heart is the muscle in the lower half of the picture. The heart has four chambers. The right and left atria (AY-tree-uh) are shown in purple. The right and left ventricles (VEN-trih-kuls) are shown in red. Connected to the heart are some of the main blood vessels—arteries and veins —that make up your blood circulatory system. The ventricle on the right side of your heart pumps blood from the heart to your lungs. When you breathe air in, oxygen passes from your lungs through blood vessels where it’s added to your blood. Carbon dioxide, a waste product, is passed from your blood through blood vessels to your lungs and is removed from your body when you breathe air out. The atrium on the left side of your heart receives oxygen-rich blood from the lungs. The pumping action of your left ventricle sends this oxygen-rich blood through the aorta (a main artery) to the rest of your body. The Right Side of Your Heart The superior and inferior vena cavae are in blue to the left of the muscle as you look at the picture. These veins are the largest veins in your body. They carry used (oxygen-poor) blood to the right atrium of your heart. “Used” blood has had its oxygen removed and used by your body’s organs and tissues. The superior vena cava carries used blood from the upper parts of your body, including your head, chest, arms, and neck. The inferior vena cava carries used blood from the lower parts of your body. The used blood from the vena cavae flows into your heart’s right atrium and then on to the right ventricle. From the right ventricle, the used blood is pumped through the pulmonary (PULL-mun-ary) arteries (in blue in the center of picture) to your lungs. Here, through many small, thin blood vessels called capillaries, your blood picks up oxygen needed by all the areas of your body.

The oxygen-rich blood passes from your lungs back to your heart through the pulmonary veins (in red to the left of the right atrium in the picture). The Left Side of Your Heart Oxygen-rich blood from your lungs passes through the pulmonary veins (in red to the right of the left atrium in the picture). It enters the left atrium and is pumped into the left ventricle. From the left ventricle, your blood is pumped to the rest of your body through the aorta. Like all of your organs, your heart needs blood rich with oxygen. This oxygen is supplied through the coronary arteries as it’s pumped out of your heart’s left ventricle. Your coronary arteries are located on your heart’s surface at the beginning of the aorta. Your coronary arteries (shown in red in the drawing) carry oxygen-rich blood to all parts of your heart. Heart Interior

The illustration shows a cross-section of a healthy heart and its inside structures. The blue arrow shows the direction in which low-oxygen blood flows from the body to the lungs. The red arrow shows the direction in which oxygen-rich blood flows from the lungs to the rest of the body. The Septum The right and left sides of your heart are divided by an internal wall of tissue called the septum. The area of the septum that divides the two upper chambers (atria) of your heart is called the atrial or interatrial septum. The area of the septum that divides the two lower chambers (ventricles) of your heart is called the ventricular or interventricular septum.

Heart Chambers The picture shows the inside of your heart and how it’s divided into four chambers. The two upper chambers of your heart are called atria. The atria receive and collect blood. The two lower chambers of your heart are called ventricles. The ventricles pump blood out of your heart into the circulatory system to other parts of your body. Heart Valves The picture shows your heart’s four valves. Shown counterclockwise in the picture, the valves include the aortic (ay-OR-tik) valve, the tricuspid (tri-CUSS-pid) valve, the pulmonary valve, and the mitral (MI-trul) valve. Blood Flow The arrows in the drawing show the direction that blood flows through your heart. The light blue arrows show that blood enters the right atrium of your heart from the superior and inferior vena cavae. From the right atrium, blood is pumped into the right

ventricle. From the right ventricle, blood is pumped to your lungs through the pulmonary arteries. The light red arrows show the oxygen-rich blood coming in from your lungs through the pulmonary veins into your heart’s left atrium. From the left atrium, the blood is pumped into the left ventricle, where it’s pumped to the rest of your body through the aorta. For the heart to function properly, your blood flows in only one direction. Your heart’s valves make this possible. Both of your heart’s ventricles has an “in” (inlet) valve from the atria and an “out” (outlet) valve leading to your arteries. Healthy valves open and close in very exact coordination with the pumping action of your heart’s atria and ventricles. Each valve has a set of flaps called leaflets or cusps, which seal or open the valves. This allows pumped blood to pass through the chambers and into your arteries without backing up or flowing backward.

The nervous system is a network of specialized nerve cells that conduct impulses from or to areas of the body to the brain and spinal cord and within the brain. It is composed of neurons and other specialized cells, like glial cells and neuroglia, that aid in the function of the neurons. Nerve cells are interconnected in complex arrangements and use electrochemical signals to transmit impulses between cells, they respond to a great variety of stimuli and form neural circuits that regulate an organisms perception and behavior. Nervous systems are found in many multicellular animals but differ greatly in complexity between species.\ he human nervous system can be grouped into both with gross anatomy, (which describes the parts that are large enough to be seen with the naked eye,) and microanatomy, (which describes the system at a cellular level.) At gross anatomy, the nervous system can be grouped in distinct organs, these being actually stations which the neural pathways cross through. Thus, with a didactical purpose, these organs, according to their ubication, can be divided in two parts: the central nervous system (CNS) and the peripheral nervous system (PNS).[2]

Central nervous system The central nervous system (CNS) represents the largest part of the nervous system, including the brain and the spinal cord. The CNS is contained within the dorsal cavity, with the brain within the cranial cavity, and the spinal cord in the spinal cavity. The CNS is covered by the meninges. The brain is also protected by the skull, and the spinal cord is also protected by the vertebrae. The nervous system can be connected into many systems that can function together. The two systems are central nervous system (CNS) and the peripheral nervous system (PNS). Peripheral nervous system The PNS consists of all the other nervous structures that do not lie in the CNS. The large majority of what are commonly called nerves (which are actually axonal processes of nerve cells) are considered to be PNS. Microanatomy The nervous system is, on a small scale, primarily made up of neurons. However, glial cells also play a major role. Neurons Neurons are electrically excitable cells in the nervous system that process and transmit information. Neurons are the core components of the brain, the vertebrate spinal cord, the invertebrate ventral nerve cord, and the peripheral nerves. A number of different types of neurons exist: sensory neurons respond to touch, sound, light and numerous other stimuli effecting sensory organs and send signals to the spinal cord and brain, motor neurons receive signals from the brain and spinal cord and cause muscle contractions and effect glands, Interneurons connect neurons to other neurons with in the brain and spinal cord.

Glial cells Glial cells are non-neuronal cells that provide support and nutrition, maintain homeostasis, form myelin, and participate in signal transmission in the nervous system. In the human brain, glia are estimated to outnumber neurons by about 10 to 1. Glial cells provide support and protection for neurons. They are thus known as the "glue" of the nervous system. The four main functions of glial cells are to surround neurons and hold them in place, to supply nutrients and oxygen to neurons, to insulate one neuron from another, and to destroy pathogens and remove dead neurons. Physiological division A less anatomical but much more functional division of the human nervous system is that classifying it according to the role that the different neural pathways play, regardless whether these cross through the CNS or the PNS: The somatic nervous system is responsible for coordinating the body's movements, and also for receiving external stimuli. It is the system that regulates activities that are under conscious control. Of digestion, it regulates from the esophagus to the stomach, small intestine and colon. In turn, these pathways can be divided according to the direction in which they conduct stimuli: •

Afferent system by sensory neurons, which carry impulses from a receptor to the CNS

•

Efferent system by motor neurons, which carry impulses from the CNS to an effector

•

Relay system by relay neurons (also called interneurons), which transmit impulses between the sensory and motor neurones.

However, there are relay neurons in the CNS as well.

The junction between two neurones is called a synapse. There is a very narrow gap (about 20nm in width) between the neurons - the synaptic cleft, where an action potential is transmitted from one neuron to a neighboring one. They do this by relaying the message with the use of neurotransmitters which the next neuron then receives the electrical signal, known as a nerve impulse. The nerve impulse is determined by the neurotransmitter to then carry the message to its appropriate destination. These nerve impulses are a change in ion balance in the nerve cell, which the central nervous system can then interpret. The fact that the nervous system uses a mixture of electrical and chemical signals makes it incredibly fast, which is necessary to acknowledge the presence of danger. For example, a hand touching a hot stove. If the nervous system was only comprised of chemical signals, the body would not tell the arm to move fast enough to escape dangerous burns. So the speed of the nervous system is a necessity for life. Development Some landmarks of embryonic neural development include the birth and differentiation of neurons from stem cell precursors, the migration of immature neurons from their birthplaces in the embryo to their final positions, outgrowth of axons from neurons and guidance of the motile growth cone through the embryo towards postsynaptic partners, the generation of synapses between these axons and their postsynaptic partners, and finally the lifelong changes in synapses which are thought to underlie learning and memory. Importance Many people have lost basic motor skills and other skills because of spinal cord injuries. If this portion is damaged, the biggest nerve and the most important one get damaged. This leads to paralysis or other permanent damage.

Abilities The nervous system is able to make basic motor skills and other skills possible. The basic 5 senses of texture, taste, sight, smell, and hearing are powered by the nervous system. If disabled, basic motor skills may be lost.

The Respiratory System The respiratory system consists of the airways, the lungs, and the respiratory muscles that mediate the movement of air into and out of the body. Within the alveolar system of the lungs, molecules of oxygen and carbon dioxide are passively exchanged, by diffusion, between the gaseous environment and the blood. Thus, the respiratory system facilitates oxygenation of the blood with a concomitant removal of carbon dioxide and other gaseous metabolic wastes from the circulation. The system also helps to maintain the acid-base balance of the body through the efficient removal of carbon dioxide from the blood.

Structure of the respiratory system Upper airways Nasal Cavity The nasal cavity (or nasal fossa) is a large air-filled space above and behind the nose in the middle of the face. The nasal cavity conditions the air to be received by the areas of the respiratory tract and nose. Owing to the large surface area provided by the conchae, the air passing through the nasal cavity is warmed or cooled to within 1 degree of body temperature. In addition, the air is humidified, and dust and other

particulate matter is removed by vibrissae, short, thick hairs, present in the vestibule. The cilia of the respiratory epithelium move the particulate matter towards the pharynx where it is swallowed. Pharynx The pharynx is the part of the neck and throat situated immediately posterior to the mouth and nasal cavity, and cranial, or superior, to the esophagus, larynx, and trachea.It is part of the digestive system and respiratory system of many organisms.Because both food and air pass through the pharynx, a flap of connective tissue called the epiglottis closes over the trachea when food is swallowed to prevent choking or aspiration. In humans the pharynx is important in vocalization. Larynx The larynx (plural larynges), colloquially known as the voicebox, is an organ in the neck of mammals involved in protection of the trachea and sound production. The larynx houses the vocal folds, and is situated just below where the tract of the pharynx splits into the trachea and the esophagus Sound is generated in the larynx, and that is where pitch and volume are manipulated. The strength of expiration from the lungs also contributes to loudness, and is necessary for the vocal folds to produce speech. During swallowing, the backward motion of the tongue forces the epiglottis over the laryngeal opening to prevent swallowed material from entering the lungs; the larynx is also pulled upwards to assist this process. Stimulation of the larynx by ingested matter produces a strong cough reflex to protect the lungs.

Lower airways Trachea

The trachea extends from the larynx to the level of the 7th thoracic vertebrae, where it divides 2 main bronchi, which is called the carina. It is a flexible, muscular 12cm long air passage with c shaped cartilaginous rings. Along with other regions of the lower airways it is lined pseudo stratified columnar epithelium that contains goblet cells and Celia. Because the Celia beat upward, they tend to carry foreign particles and excessive mucus away from the lungs to the pharynx. The trachea (windpipe) divides into two main bronchi the left and the right, at the level of the sternal angle.

Bronchi and Bronchioles A bronchus is a caliber of airway in the respiratory tract that conducts air into the lungs. No gas exchange takes place in this part of the lungs. . The right main bronchus is wider, shorter, and more vertical than the left main bronchus. The right main bronchus subdivides into three segmental bronchi while the left main bronchus divides into two. The lobar bronchi divide into tertiary bronchi. Each of the segmental bronchi supplies a bronchopulmonary segment. A bronchopulmonary segment is a division of a lung that is separated from the rest of the lung by a connective tissue septum.

Lungs The trachea divides into the two main bronchi that enter the roots of the lungs. The bronchi continue to divide within the lung, and after multiple divisions, give rise to bronchioles. The bronchial tree continues branching until it reaches the level of terminal bronchioles, which lead to alveolar sacks. Alveolar sacs are made up of clusters of alveoli, like individual grapes within a bunch. The individual alveoli are tightly wrapped in blood vessels, and it is here that gas exchange actually occurs. Deoxygenated blood from the heart is pumped through the pulmonary artery to the lungs, where oxygen diffuses into blood and is exchanged for carbon dioxide in the hemoglobin of the erythrocytes. The oxygen-rich blood returns to the heart via the pulmonary veins to be pumped back into systemic circulation. Human lungs are located in two cavities on either side of the heart. Though similar in appearance, the two are not identical. Both are separated into lobes, with three lobes on the right and two on the left. The lobes are further divided into lobules, hexagonal divisions of the lungs that are the smallest subdivision visible to the naked

eye. The connective tissue that divides lobules is often blackened in smokers and city dwellers. The medial border of the right lung is nearly vertical, while the left lung contains a cardiac notch. The cardiac notch is a concave impression molded to accommodate the shape of the heart. Lungs are to a certain extent 'overbuilt' and have a tremendous reserve volume as compared to the oxygen exchange requirements when at rest. This is the reason that individuals can smoke for years without having a noticeable decrease in lung function while still or moving slowly; in situations like these only a small portion of the lungs are actually perfused with blood for gas exchange. As oxygen requirements increase due to exercise, a greater volume of the lungs is perfused, allowing the body to match its CO2/O2 exchange requirements. The Lungs

1. Trachea

5. Alveoli

2. Pulmonary artery

6. Cardiac notch

3. Pulmonary vein

7. Bronchioles

4. Alveolar duct

8. Tertiary bronchi

9. Secondary bronchi

11. Larynx

10. Primary bronchi

Alveoli An alveolus is an anatomical structure that has the form of a hollow cavity. Mainly found in the lung, the pulmonary alveoli are spherical outcroppings of the respiratory bronchioles and are the primary sites of gas exchange with the blood.The lungs contain about 300 million alveoli[2]., representing a total surface area of approx. 70-90 square meters (m2). Each alveolus is wrapped in a fine mesh of capillaries covering about 70% of its area.The alveoli have radii of about 0.05 mm but increase to around 0.1 mm during inhalation.The alveoli consist of an epithelial layer and extracellular matrix surrounded by capillaries. In some alveolar walls there are pores between alveoli. There are three major alveolar cell types in the alveolar wall.

•

Type I cells that form the structure of an alveolar wall

•

Type II cells that secrete surfactant to lower the surface tension of water and allows the membrane to separate thereby increasing the capability to exchange gases. Surfactant is continuously released by exocytosis. It forms an underlying aqueous protein-containing hypophase and an overlying phospholipids film composed primarily of dipalmitoyl phosphatidylcholine.

•

Macrophages that destroy foreign material, such as bacteria.

Diaphragm The Diaphragm is a dome-shaped musculofibrous septum which separates the thoracic from the abdominal cavity, its convex upper surface forming the floor of the former, and its concave under surface the roof of the latter. Its peripheral part consists of muscular fibers which take origin from the circumference of the thoracic outlet and converge to be inserted into a central tendon. The diaphragm is crucial for breathing and respiration. During inhalation, the diaphragm contracts, thus enlarging the thoracic cavity (the external intercostals muscles also participate in this enlargement). This reduces intra-thoracic pressure: in other words, enlarging the cavity creates suction that draws air into the lungs. When the diaphragm relaxes, air is exhaled by elastic recoil of the lung and the tissues lining the thoracic cavity in conjunction with the abdominal muscles which act as an antagonist paired with the diaphragm's contraction an antagonist paired with the diaphragm's contraction.

The Anatomy of the Blood Blood facts •

Approximately 8% of an adult's body weight is made up of blood.

•

Females have around 4-5 litres, while males have around 5-6 litres. This difference is mainly due to the differences in body size between men and women.

•

Its mean temperature is 38 degrees Celcius.

•

It has a pH of 7.35-7.45, making it slightly basic (less than 7 is considered acidic).

•

Whole blood is about 4.5-5.5 times as viscous as water, indicating that it is more resistant to flow than water. This viscosity is vital to the function of blood because if blood flows too easily or with too much resistance, it can strain the heart and lead to severe cardiovascular problems.

•

Blood in the arteries is a brighter red than blood in the veins because of the higher levels of oxygen found in the arteries.

•

An artificial substitute for human blood has not been found.

Functions of blood Blood has three main functions - Transport, Protection and Regulation 1. Transport of the following substances: Gases, namely oxygen (O2) and carbon dioxide (CO2), between the lungs and rest of the body Nutrients from the digestive tract and storage sites to the rest of the body Waste products to be detoxified or removed by the liver and kidneys Hormones from the glands in which they are produced to their target cells Heat to the skin so as to help regulate body temperature

2. Protection: Blood has several roles in inflammation Leukocytes, or white blood cells, destroy invading microorganisms and cancer cells Antibodies and other proteins destroy pathogenic substances Platelet factors initiate blood clotting and help minimise blood loss 3. Regulation of: pH by interacting with acids and bases Water balance by transferring water to and from tissues Composition of blood Blood is classified as a connective tissue and consists of two main components: 1. Plasma, which is a clear extracellular fluid 2. Formed elements, which are made up of the blood cells and platelets The formed elements are so named because they are enclosed in a plasma membrane and have a definite structure and shape. All formed elements are cells except for the platelets, which tiny fragments of bone marrow cells. Formed elements are: throcytes, also known as red blood cells (RBC) Platelets Leukocytes, also known as white blood cells (WBC). Leukocytes are further classified into two subcategories called granulocytes which consist of neutrophils, eosinophils and basophils; and agranulocytes which consist of lymphocytes and monocytes. The formed elements can be separated from plasma by centrifuge, where a blood sample is spun for a few minutes in a tube to separate its components according to their densities. RBCs are denser than plasma, and so become packed into the bottom of the tube to make up 45% of total volume. This volume is known as the haematocrit. WBCs and platelets form a narrow cream-coloured coat known as the buffy coat immediately above the RBCs. Finally, the plasma makes up the top of the tube, which is a pale yellow colour and contains just under 55% of the total volume.

Blood plasma - Composition and function Blood plasma is a mixture of proteins, enzymes, nutrients, wastes, hormones and gases. The specific composition and function of its components are as follows: 1. Proteins These are the most abundant substance in plasma by weight and play a part in a variety of roles including clotting, defence and transport. Collectively, they serve several functions: 1. They are an important reserve supply of amino acids for cell nutrition. Cells called macrophages in the liver, gut, spleen, lungs and lymphatic tissue can break down plasma proteins so as to release their amino acids. These amino acids are used by other cells to synthesise new products. 2. Plasma proteins also serve as carriers for other molecules. Many types of small molecules bind to specific plasma proteins and are transported from the organs that absorb these proteins to other tissues for utilisation. The

proteins also help to keep the blood slightly basic at a stable pH. They do this by functioning as weak bases themselves to bind excess H+ ions. By doing so, they remove excess H+ from the blood which keeps it slightly basic. 3. The plasma proteins interact in specific ways to cause the blood to coagulate, which is part of the body's response to injury to the blood vessels (also known as vascular injury), and helps protect against the loss of blood and invasion by foreign microorganisms and viruses. 4. Plasma proteins govern the distribution of water between the blood and tissue fluid by producing what is known as a colloid osmotic pressure. 5. Albumins, which are the smallest and most abundant plasma proteins. Reductions in plasma albumin content can result in a loss of fluid from the blood and a gain of fluid in the interstitial space (space within the tissue), which may occur in nutritional, liver and kidney disease. Albumin also helps many substances dissolve in the plasma by binding to them, hence playing an important role in plasma transport of substances such as drugs, hormones and fatty acids. 6. Globulins, which can be subdivided into three classes from smallest to largest in molecular weight into alpha, beta and gamma globulins. The globulins include high density lipoproteins (HDL), an alpha-1 globulin, and low density lipoproteins (LDL), a beta-1 globulin. HDL functions in lipid transport carrying fats to cells for use in energy metabolism, membrane reconstruction and hormone function. HDLs also appear to prevent cholesterol from invading and settling in the walls of arteries. LDL carries cholesterol and fats to tissues for use in manufacturing steroid hormones and building cell membranes, but it also favours the deposition of cholesterol in arterial walls and thus appears to play a role in disease of the blood vessels and heart. HDL and LDL therefore play important parts

in the regulation of cholesterol and hence have a large impact on cardiovascular disease. 7. Fibrinogen, which is a soluble precursor of a sticky protein called fibrin, which forms the framework of blood clot. Fibrin plays a key role in coagulation of blood, which is discussed later in this article under Platelets. There are three major categories of plasma proteins, and each individual type of proteins has its own specific properties and functions in addition to their overall collective role: 2. Amino acids These are formed from the break down of tissue proteins or from the digestion of digested proteins. 3. Nitrogenous waste Being toxic end products of the break down of substances in the body, these are usually cleared from the bloodstream and are excreted by the kidneys at a rate that balances their production. 4. Nutrients Those absorbed by the digestive tract are transported in the blood plasma. These include glucose, amino acids, fats, cholesterol, phospholipids, vitamins and minerals. 5. Gases Some oxygen and carbon dioxide are transported by plasma. Plasma also contains a substantial amount of dissolved nitrogen. 6. Electrolytes The most abundant of these are sodium ions, which account for more of the blood's osmolarity than any other solute. Haemopoiesis Haemopoiesis is the production of the formed elements of blood. Haemopoietic tissues refer to the tissues that produce blood. The earliest haemopoietic tissue to develop is the yolk sac, which also functions in the transfer of yolk nutrients of the embryo. In the foetus, blood cells are produced by the bone marrow, liver, spleen and thymus. This

changes during and after birth. The liver stops producing blood cells around the time of birth, while the spleen stops producing them soon after birth but continues to produce lymphocytes for life. From infancy onwards, all formed elements are produced in the red bone marrow. Lymphocytes are additionally produced in lymphoid tissues and organs widely distributed in the body, including the thymus, tonsils, lymph nodes, spleen and patches of lymphoid tissues in the intestine. Erythropoesis Erythropoiesis refers specifically to the production of erythrocytes or red blood cells (RBCs). These are formed through the following sequence of cell transformations:

The proerythroblast has receptors for the hormone erythropoietin (EPO). Once EPO receptors are in place, the cell is committed to exclusively producing RBCs. The erythroblasts then multiply and synthesise haemoglobin (Hb), which is a red oxygen transport protein. The nucleus from the erythroblasts is then discarded, giving rise to cells named reticulocytes. The overall transformation from haemocytoblast to reticulocytes involves a reduction in cell size, an increase in cell number, the synthesis of haemoglobin, and the loss of the cell nucleus. These reticulocytes leave the bone marrow and enter the bloodstream where they mature into erythrocytes when their endoplasmic reticulum disappears. Leukopoiesis Leukopoiesis refers to the production of leukocytes (WBCs). It begins when some types of haemocytoblasts differentiate into three types of committed cells: 1. B progenitors, which are destined to become B lymphocytes 2. T progenitors, which become T lymphocytes

3. Granulocyte-macrophage colony-forming units, which become granulocytes and monocytes These cells have receptors for colony-stimulating factors (CSFs). Each CSF stimulates a different WBC type to develop in response to specific needs. Mature lymphocytes and macrophages secrete several types of CSFs in response to infections and other immune challenges. The red bone marrow stores granulocytes and monocytes until they are needed in the bloodstream. However, circulating leukocytes do not stay in the blood for very long. Granulocytes circulate for 4-8 hours and then migrate into the tissues where they live for another 4-5 days. Monocytes travel in the blood for 10-20 hours, then migrate into the tissues and transform into a variety of macrophages which can live as long as a few years. Lymphocytes are responsible for long-tern immunity and can survive from a few weeks to decades. They are continually recycled from blood to tissue fluid to lymph and finally back to the blood. Thrombopoiesis Thrombopoiesis refers to the production of platelets in the blood, because platelets used to be called thrombocytes. This starts when a haemocytoblast develops receptors for the hormone thrombopoietin which is produced by the liver and kidneys. When these receptors are in place, the haemocytoblast becomes a committed cell called a megakaryoblast. This replicates its DNA, producing a large cell called a megakaryocyte, which breaks up into tiny fragments that enter the bloodstream. About 25-40% of the platelets are stored in the spleen and released as needed. The remainder circulate freely in the blood are live for about 10 days. Erythrocytes/Red Blood Cells (RBCs) Red blood cells (RBCs), also known as erythrocytes, have two main functions: 1. To pick up oxygen from the lungs and deliver it to tissues elsewhere 2. To pick up carbon dioxide from other tissues and unload it in the lungs

An erythrocyte is a disc-shaped cell with a thick rim and a thin sunken centre. The plasma membrane of a mature RBC has glycoproteins and glycolipids that determine a person's blood type. On its inner surface are two proteins called spectrin and actin that give the membrane resilience and durability. This allows the RBCs to stretch, bend and fold as they squeeze through small blood vessels, and to spring back to their original shape as they pass through larger vessels. RBCs are incapable of aerobic respiration, preventing them from consuming the oxygen they transport because they lose nearly all their inner cellular components during maturation. The inner cellular components lost include their mitochondria, which normally provide energy to a cell, and their nucleus, which contains the genetic material of the cell and enable it to repair itself. The lack of a nucleus means that RBCs are unable to repair themselves. However, the resulting biconcave shape is that the cell has a greater ratio of surface area to volume, enabling O2 and CO2 to diffuse quickly to and from Hb. The cytoplasm of a RBC consists mainly of a 33% solution of haemoglobin (Hb), which gives RBCs their red colour. Haemoglobin carries most of the oxygen and some of the carbon dioxide transported by the blood. Circulating erythrocytes live for about 120 days. As a RBC ages, its membrane grows increasingly fragile. Without key organelles such as a nucleus or ribosomes, RBCs cannot repair themselves. Many RBCs die in the spleen, where they become trapped in narrow channels, broken up and destroyed. Haemolysis refers to the rupture of RBCs, where haemoglobin is released leaving empty plasma membranes which are easily digested by cells known as macrophages in the liver and spleen. The Hb is then further broken down into its different components and either recycled in the body for further use or disposed of. White Blood Cells (WBC) White blood cells (WBCs) are also known as leukocytes. They can be divided into granulocytes and agranulocytes. The former have cytoplasms that contain organelles that appear as coloured granules through light microscopy, hence their name. Granulocytes

consist

of

neutrophils,

eosinophils

and

basophils.

In

contrast,

agranulocytes do not contain granules. They consist of lymphocytes and monocytes. 1. Granulocytes

1. Neutrophils These contain very fine cytoplasmic granules that can be seen under a light microscope. Neutrophils are also called polymorphonuclear (PMN) because they have a variety of nuclear shapes. They play roles in the destruction of bacteria and the release of chemicals that kill or inhibit the growth of bacteria. 2. Eosinophils These have large granules and a prominent nucleus that is divided into two lobes. They function in the destruction of allergens and inflammatory chemicals, and release enzymes that disable parasites. 3. Basophils They have a pale nucleus that is usually hidden by granules. They secrete histamine which increases tissue blood flow via dilating the blood vessels, and also secrete heparin which is an anticoagulant that promotes mobility of other WBCs by preventing clotting. 2. Agranulocytes 1. Lymphocytes These are usually classified as small, medium or large. Medium and large lymphocytes are generally seen mainly in fibrous connective tissue and only occasionally in the circulation bloodstream. Lymphocytes function in destroying cancer cells, cells infected by viruses, and foreign invading cells. In addition, they present antigens to activate other cells of the immune system. They also coordinate the actions of other immune cells, secrete antibodies and serve in immune memory. 2. Monocytes They are the largest of the formed elements. Their cytoplasm tends to be abundant and relatively clear. They function in differentiating into macrophages, which are large phagocytic cells, and digest pathogens, dead neutrophils, and the debris of dead cells. Like lymphocytes, they also present antigens to activate other immune cells.

Platelets Platelets are small fragments of bone marrow cells and are therefore not really classified as cells themselves. Platelets have the following functions: 1. Secrete vasoconstrictors which constrict blood vessels, causing vascular spasms in broken blood vessels 2. Form temporary platelet plugs to stop bleeding 3. Secrete procoagulants (clotting factors) to promote blood clotting 4. Dissolve blood clots when they are no longer needed 5. Digest and destroy bacteria 6. Secrete chemicals that attract neutrophils and monocytes to sites of inflammation 7. Secrete growth factors to maintain the linings of blood vessels

VII. Medical Management A. Medical Orders Doctor’s Order Date 7-31-08

4pm

8-01-08

Order Rationale  For repeat CXR-pal ( semi  For evaluation and setting if able then secure determination of to please retrieve CXR pt.’s condition. films  Repeat CBC  For prior determination of pt.’s condition  Please ff-up official 2d echo  For evaluation and result determination of pt.’s condition.  Planned Home care resident in-charges efforts highly appreciated  Thank you  For home care of  Family meeting was done pt. when disin the presence of pt. huscharge band jun and mother-in-law  Determination of Alice roles in the family  Jun will stand as primary breadwinner and Alice the caregiver  For prior planning  The family perception as of pt.’s condition the pt. condition were solicited and confusion question clarified  Determination of  Roles were identified as roles in the family previously noted  Still facilitating financial as For the pt.’s help sistance for procurement of in finances suction machine  For pt.’s continue  Home care priorities were of care at home also discussed  For pt.’s support at  Please ff-up pt. coordinate finance with AP regarding FHCP enrollment  Thank you  Dr. Basaerg’s (Famed res For pt’s assistance ident) efforts highly appreciated  For more evalu-

 Please repeat PTPA at 6am tomorrow  Please remind husband of pt. PCSO  Medical abstract form to facilitate financial assistance in preparation for home care  Review of meds 1. Propranalol tid as the ff. • 40 mg at am dose • 10 mg • 10 mg

ation of pt.’s condition  For financial support  For financial Support  For continuity of pt.’s treatment process. • to decrease cardiac workload •

•

to decrease cardiac workload for cerebral insufficiency anti platelet

•

anti-infective

2. Captopril 25 mg ¼ bid • 3. Citicoline drops 5cc bid 4. Aspirin 80 mg OD after lunch 5. Mupirocin + petroleum jelly as ordered 6. Ferrous Sulfate bid after meals 7 Heraclene 3 mg bid 8-2-08

 SCIC to prep. Discharged summary  To xerox lab flow sheet, ecg, CXr result-(2 copies) lates 2 result of PTR;Latest CBC, NA, K, creatinine  For possible discharge  Will confirm with home care properly  Cont. meds.  Cont. nursing care

8-4-08

 For discharge once confer-

•

iron supplement • appetite stimulant  For preparation of discharge  For pt.’s own record for future comparison  Pt. is ordered to be discharge  For prior for home care  For continuity of pt.’s treatment process  For proper care of pt.’s condition  For prior dis-

Generic name (Brand)

Date Ordered

Petroleum jelly

08-01-08

Classificatio n

ence with Famed home care resident is done Dose/ May go Mechanism for billing Specific Frequecy Route

of action

Indication

 SCIC to ff-up official result

Emollients & Skin Protectives

8-05-08

B. Drug Study

BID over First it helps Softens dry buttocks keep the skin, and neck soothes  Homeoutside meds to induced areas (esp. world out - it chapped those protects skin skin, minor reddish from the burns & 1.effects Propanalol 10 mg tid parts). of minor weather and scrapes, exposure. helps Second, it prevent 2.acts Captopril 25 mg ¼ like a diaper rash. bid to sealant help keep inside 3.theCiticoline drops 5cc world in it bid an 4.forms Aspirin 80 mg OD occlusive aftertolunch barrier 5.theFerrous natural Sulfate bid water of afterloss meals skin. So 3 mg bid 6.ourHeraclene skin that is dry and chapped is  Cont.protected good nursing care from drying elements,  Resume coumadin 3.5 mg enabling OD skinsoftening moisture to build up naturally from inside the skin itself.

 Follow up CXR please And Cranial scan result with FAMED home care resident is done  MGH- for billing

charged Contraindicati Side  For computation on paymenteffects

of Nursing

Precaution

 For prior discharged Contrindicated Burns, Tell patient iin those Nasal patient congestionof  with For continuity Acne-prone or or drynes, pt.’s treatment progreasy skin. Sex with cess. latex • to condoms, decrease

• • • • •

cardiac workload to decrease cardiac workload for cerebral insufficiency anti platelet iron supplement appetite stimulant

 For continuity of pt.’s care  For continuity of treatment management

 For prior determination of pt.’s condition  For pt.’s to be discharge

and family to watched and report any signs od adverse reaction.

Generic name (Brand)

Date Ordered

Classification

Dose/ Frequecy Route

Mechanism of action

Specific Indication

Contraindication

Side effects

Mupirocin ointment ( sample brand name: Bactroban

08-01-08

Topical antibiotic

80 mg OD after lunch ( 1p.m)

Mupirocin is a novel antibiotic produced through fermentation by Pseudomona s fluorescens. Mupirocin inhibits isoleucyl transfer-RNA synthetase, thereby arresting bacterial protein synthesis.

Treatment for infection

Containdicated in patients hypersensitive to mupirocin or any of its constituents.

Immun System Disorde System allergic reactio Skin an Subcut Tissue Disorde Burning localize the are applica Itching, erythem stinging drynes localize the are applica cutane sensitiz reactio

Generic name (Brand)

Date Ordered

Classification

Dose/ Frequecy Route

Mechanism of action

Specific Indication

Contraindication

Side effects

Citicoline drops (Zynapse)

08-01-08

Cerebral activator.

5 cc BID

Citicoline is an interneuronal communication enhancer. It increases the neurotransmission levels because it favors the synthesis and production speed of dopamine in the striatum, acting then as a dopaminergic agonist thru the inhibition of tyrosinehydroxylase.

CVA, in acute recovery phase, in signs & symptoms of cerebrovascular insufficiency & in cranial traumatism & their sequelae.

Containdicated in patients hypersensitive to drug and other related drugs.

Increas parasym effects, & discr hypoten effect

Generic name (Brand)

Date Ordered

Classification

Dose/ Frequecy Route

Mechanism of action

Specific Indication

Contraindication

Side effects

Propanolol

08-01-08

Generic name (Brand)

Date Ordered

Antianginals

Classification

TID 40 mg (8 a.m) 10 mg (1 p.m) 10 mg (6 p.m)

Dose/ Frequecy Route

A nonselective beta blocker that reduces cardiac oxygen demand by blocking catecholamineinduced increases in heart rate, blood pressure, and force of myocardial contraction. Depresses renin secretions and prevents vasodilation of cerebral arteries.

Mechanism of action

Long term management of cardiac arrhythmias.

Contraindicated in patients with bronchial asthma, sinus bradycardia, cardiogenic shock, and overt and decompensated heart failure (unless failure is secondary to a tachyarrhythmia that can be treated with propranolol.

CNS:f Fever, heada Dizzin CV: bradyc hypote heart GI: abdom cramp consti diarrh nause Vomiti Skin: r

Specific Indication

Contraindication

Side effects

Warfarin (Coumadin)

08-01-08

Anticoagulant

3.5 mg OD

Inhibits Vitamin K- dependent activation of clothing factors II, VII, IX, and X, formed in the liver.

Prevention and treatment of venous thromboEmbolism.

Contraindicated in patients hypersensitive to drug and in those with bleeding from the GI, GU, or respiratory tract, cerebrovascular hemorrhage. Avoid using in patients with a history of warfarinindused necrosis; in unsupervised patients with semility, alcoholism.

CNS: heada fever GI: an Nause vomitin diarrhe GU: hemat excess menst bleedin Hemat hemor Skin: necros rash.

Generic Name

Ferrous

Date Ordere d

8-1-08

Classification

Anti-anemia

Dosage and Route

1 tab

sulfate

BID 2

Not indicated

hours

(ex. Brand

after

name: Feosol

lunch

Mechanism

Specific

Contraindica-

of Action

Indication

tion

Provide elemental iron, an essential component in the formation of hemoglobin

To correct iron deficiency anemia

Contraindicated in patients with – -hemo-lytic anemia, (in absence of iron

Adverse Effects

Nursing Precaution

CNS:Nausea, heat burn,anorexia,constipation, diarrhea GI:epigastric pain, vomiting, constipation, black stools, diarrhea, anorexia.

-give on an empty stomach but (bet.meals). Drug can be given with some foods, although absorption may be decreased.

deficiency) -peptic ulceration, -and in those receiving repeated blood transfusions.

- tell pt. to take tablets with juice or water, but not milk or antacids. - monitor pt. laboratory results -be aware that IRON preparation cause dark green or block stool

Generic Name

Captopril

Date Ordere

Classification

d

and Route

ACE inhibit-

25 mg ¼

Not indicated

or:

tab BID

(ex. Brand

Anti-hyper-

name: Capo-

tensive

ten)

8-1-08

Dosage

Mechanism

Specific

Contraindica-

of Action

Indication

tion

Inhibits ACE, preventing conversion of angiotensin I to angiotesnin II, a potent vasoconstrictor. Less angiotensin II decreases peripheral arterial resistance, decreasing aldosterone secretion, which reduces sodium and water retention and lower blood pressure.

For hypertensio n

Contraindicated in patients hypersensitive

Adverse Effects

Nursing Precaution

-CNS:Dizziness, fainting, headache, fatigue, fever, nausea, vomiting,

- monitor patient’s BP and pulse rate frequently

GI:abdominal pain, constipation, diarrhea,

- advise pt. bed rest.

to drug and other ACE inhibitor

Hematology; anemia, hyperkalemia, -RESP:dyspnea, dry persistent nonproductive cough. -skin: urticaria,pruritus

-monitor patient intake and out -monitor therapeutic effectiveness

Generic Name

Aspilit (aspir-

Date Ordere d

8-1-08

Classification

antiplatelet

in)

Dosage and Route

80 mg OD after lunch

Mechanism

Specific

Contraindica-

of Action

Indication

tion

Inhibits platelet aggregation thus reducing ability of blood clot

Use to reduce reoccurrenc e of TIA due to firin platelet emboli and risk of stoke

-Contraindicate

-to relieve pain of low to moderate intensity

d in patients

Adverse Effects

Precaution

-CNS:Dizziness, fainting, headache, fatigue, fever, abdominal pain

hypersensitive to drug -GI ulceration, bleeding _vitamin K deficiency

-GI:constipation, diarrhea, nausea, vomiting, Hematology: anemia, hyperkalemia, -RESP:dyspnea, dry persistent nonproductive cough. -Skin:petechiae, easy bruising and rash -special senses; hearing loos,tinnitus

Generic Name

Dibencozide (heraclene)

Date Ordere d

8-1-08

Classification

Dosage and Route

Appetite

3 mg 1

stimulant

cap BID

Mechanism

Specific

Contraindica-

of Action

Indication

tion

Increases the protein efficiency coefficient. Manifested by a marked increase of appetite. Thus facilitates utilization of protein dietary intake. Contribute to the formation and repair of the body tissues and stimulates appetite.

- use to increase appetite for faulty nutrition or patient with pernicious anemia

-Contraindicate d in patients hypersensitive to drug -GI ulceration, bleeding

-low energy, slow muscle growth and energy

Nursing

Adverse Effects

-administer medication with meal to prevent GI irritation - monitor patient’s BP and pulse rate frequently - assess patient for signs drug toxicity - consult physician before using aspirin for any fever accompanied by rash, and severe headache

Nursing Precaution

There is no negative effect when taken in recommended dosage. only increased in energy, strength and muscle mass

-assess for the effectiveness of the drug - -monitor lab results especially red blood cells count - it is more effective if drug would be given with milk

VIII. Diagnostic Test and Laboratory Exam

July 30, 2008

RADIOLOGIC REPORT Results References

Prothrombin Time Protime 66.9 s

9.5-12sec.

13.1 s

14 sec.

Control

Prothrombin Activity Activated Partial Thromboplastin Time

Prolonged

32-39sec.

21.8 s

9.5-12sec.

13.1 s

14sec.

1.66

1.0

Control

18.55 s

9.5-12sec.

13.0 s

14sec.

1.42

1.0

Control

INR

Prolong protime indicates deficiency of fibrinogen factors XII Low control indicates impaired deficiency factors VIII(antihemophiliac factor)

19.5 %

July 26,2008 Prothrombin Time Protime

INR July 20,2008 Prothrombin Time

Nursing implications

Prolong APTT indicates necrosis of the brain

Prolong protime indicates deficiency of fibrinogen factors XII Low control indicates impaired deficiency factors VIII(antihemophiliac factor) No therapy Prolong protime indicates deficiency of fibrinogen factors XII Low control indicates impaired in deficiency of factors VIII(antihemophiliac factor) No therapy

July 24, 2008 Impression: 1. Cardiomegaly- mitral form with waxing and waning pulmonary edema cannot rule out an intercurrent pneumonia. 2. Tracheostomy tube in SITU 3. Pleural Effusion, right – Resolved

MICROBIOLOGY July 16, 2008 Specimen: Direct Smear:

ETA Epithelian cells: Pus cells: Gram (-) rods:

few moderate moderate

Organism isolated: Moderate heavy growth of Enterobacter spp.

ULTRASOUND July 2, 2008 Diagnosis: Minimal Ascites Focal ileus Normal ultrasound findings in the uterus and right ovary

BLOOD TYPING July 16, 2008 Blood Type: Rh:

A Positive HEMATOLOGY

July 16, 2008 Test

Result

Unit

Reference

Rationale

WHITE BLOOD CELLS

9,000

10^3/u L

5,000-10,00

Within normal limit

RED BLOOD CELLS

3.85

10^6/u L

4.20-5.40

Decreased results indicate anemia.

HEMATOCRIT

30.7

%

37.0-47.0

MCV

79.9

cu um

MCH

26.0

Cu um

MCHC

32.6

%

Lymphocytes

14.3

%

17.4-48.2

Neutrophils

78.1

%

43.4-76.2

Monocytes

7.5

%

4.5-10.5

Eosinophils

0.1

%

1.0-3.0

Basophil

0.0

%

0.0-2.0

Decreased eosinophils indicates stress Within normal limit

Platelet Count

557

Cu mm

150,00400,00

Increased platelet indicates malignancy

Decreased hematocrit Indicates anemia Decreased mean 84-96 cu um corpuscular volume indicates microcytic anemia Decreased in mean 28-33 corpuscular hemoglobin indicates microcytic anemia Decreased mean corpuscular 33-35 hemoglobin concentration indicates severe hypochromic anemia

Differential Count Low lymphocyte count indicates aplastic anemia Increased neutrophils indicates acute infections Within normal limit

HEMATOLOGY July 26, 2008 Test WHITE BLOOD CELLS RED BLOOD CELLS

Result

Unit

Reference

Nursing implications

13,300

10^3/u L

5,000-10,00

3.71

10^6/u L

4.20-5.40

Increased WBC indicates infections Decreased RBC indicates anemia

HEMOGLOBIN

10.1

G/dL

12.0-16.0

HEMATOCRIT

31.8

%

37.0-47.0

MCV

85.7

cu um

Decreased hemoglobin indicates anemia Decreased hematocrit indicates anemia

84-96 cu um Within normal limit

MCH

27.2

Cu um

28-33

MCHC

31.8

%

33-35

Decreased in mean corpuscular hemoglobin indicates microcytic anemia Decreased mean corpuscular hemoglobin concentration indicates severe hypochromic anemia

Differential Count Lymphocytes

10.9

%

17.4-48.2

Neutrophils

83.9

%

43.4-76.2

Monocytes

4.8

%

4.5-10.5

Eosinophils

0.4

%

1.0-3.0

Basophil

0.0

%

0.0-2.0

adequ ate

Cu mm

150,00400,00

Platelet Count

Low lymphocyte count indicates aplastic anemia Increased neutrophils indicates acute infections Within normal limit Decreased eosinophils indicates stress Within normal limit Within normal limit

HEMATOLOGY July 31, 2008 Test

Result

Unit

Reference

Nursing implications

WHITE BLOOD CELLS RED BLOOD CELLS

8,500

5,000-10,00

Within normal limit

HEMOGLOBIN

10.3

10^3/u L 10^6/u L G/dL

HEMATOCRIT

33.3

%

MCV

83.3

cu um

MCH

25.8

Cu um

MCHC

30.9

%

13.6

%

4.00

4.20-5.40

Decreased results indicate anemia 12.0-16.0 Decreased results indicate anemia Decreased results 37.0-47.0 indicate anemia Decreased mean 84-96 cu um corpuscular volume indicates microcytic anemia Decreased in mean 28-33 corpuscular hemoglobin indicates microcytic anemia Decreased mean corpuscular 33-35 hemoglobin concentration indicates severe hypochromic anemia

Differential Count Lymphocytes

17.4-48.2

Low lymphocyte count indicates aplastic anemia

Neutrophils

80.1

%

43.4-76.2

Monocytes

5.1

%

4.5-10.5

Increased neutrophils indicates acute infections Within normal limit

Eosinophils

1.1

%

1.0-3.0

Within normal limit

Basophil

0.1

%

0.0-2.0

Within normal limit

Cu mm

150,00400,00

Increased platelet indicates malignancy

Platelet Count

493

VIII. Nursing Management A. Ideal Nursing Care Plan Problem 1 Nursing Diagnosis Decrease Cardiac Output related to altered myocardial contractility/inotropi c changes

Interventions

Rationale

Independent -

Administer supplemental oxygen as indicated to increase oxygen available to tissues

-

To assess degree of debilitation

-

Assist with or perform self-care activities for client.

-

To assess degree of debilitation

-

Encourage relaxation techniques to reduce anxiety

-

To promote venous return.

-

Monitor intake/output and calculate 24-hour fluid balance

-

To maintain adequate nutrition and fluid balance

-

To promote therapeutic wellness

Dependent: - Administer drugs as ordered

Problem 2 Nursing Diagnosis

Interventions

Rationale

Independent: Activity Intolerance related to generalized weakness

-

Encourage expression of feelings contributing to/resulting from condition

-

-

Promote comfort measures and provide for relief of pain to enhance ability to participate in activities Assist client in learning and demonstrating appropriate safety measures to prevent injuries Encourage client to maintain positive attitude; suggest use of relaxation techniques, such as visualization/guided imagery as appropriate to enhance sense of wellbeing Provide/monitor response to supplemental oxygen & meds & changes in treatment regimen

-

-

-

-

-

To assist client to deal with contributing factors and manage activities within individual limits To assist client to deal with contributing factors and manage activities within individual limits To promote wellness (teaching/discharge considerations)

-

To promote wellness (teaching/discharge considerations)

-

To assist client to deal with contributing factors and manage activities within individual limits

Problem 3 Nursing Diagnosis

Interventions

Rationale

Independent: Ineffective tissue perfusion related to myocardial damage (small infarcts, iron deposits, fibrosis)

-

Monitor vital signs includes BP, RR, PR and temperature

-

To monitor vital signs

-

Encourage quiet, restful atmosphere.

-

To maximize tissue perfusion

-

Caution client to avoid activities that increases cardiac workload

-

To maximize tissue perfusion

-

Monitor for signs of bleeding during use of fibrinolytic agents

-

To maximize tissue perfusion

-

To promote therapeutic wellness

Dependent: -

Administer medications as ordered

Problem 4 Nursing Diagnosis

Interventions

Rationale

Independent: Imbalanced Nutrition less than body requirement related to failure to ingest/digest food or absorb nutrients necessary for formation of RBC as evidence by weight loss

-

Discuss eating habits, including food preferences, intolerance/aversions to appeal to clients likes/desires

-

Encourage client to choose foods that are appealing to stimulate appetite

-

-

-

Limit fiber/bulk if indicated because it may lead to early satiety Promote pleasant, relaxing environment, including socialization when possible to enhance intake Emphasize importance of well-balanced, nutritious intake.

-

To assess causative/contributing factors

-

To establish nutritional plan that meets individual needs

-

To establish nutritional plan that meets individual needs

-

To establish nutritional plan that meets individual needs

-

To promote wellness

Problem 5 Nursing Diagnosis

Interventions

Rationale

Independent: Impaired gas exchange related to altered blood flow

-

Monitor vital signs and cardiac rhythm

-

To assess causative factors

-

Elevate head of bed/position client appropriately, provide airway adjuncts and suction as indicated to maintain airway

-

To correct/improve existing deficiencies

-

Reinforce need for adequate rest, while encouraging activity within client’s limitations

-

To promote wellness

-

Instruct the use of relaxation, stress-reduction techniques as appropriate

-

To promote wellness

-

To promote therapeutic wellness

Dependent: -

Administer medications as ordered

Problem 6 Nursing Diagnosis

Interventions

Rationale

Independent: Deficient knowledge regarding complications related to lack of information

-

Provide information relevant to the situation

-

To assess client’s motivation

-

Provide positive reinforcement (encourages continuation of efforts)

-

To assess client’s motivation

-

Discuss client’s perception of need. Relate information to client’s personal desires/needs and values/beliefs

-

To establish priorities in conjunction with client

-

Provide written information/guidelines for client to refer to as necessary. Reinforces learning process

-

To facilitate learning

-

Provide an environment that is conducive to learning

-

To facilitate learning

B. Nursing System Review Chart Day 1 Date: August 3, 2008 Vital Signs: Temp: 36.7 ºC Pulse: 68 bpm BP: 100/90mmHg Respiration: 30 cpm Height: 5’0” Weight: 35 kg

Tracheostomy tubing

Sunken eyeballs

Generalized body malaise Bed sore Cold clammy skin Poor muscle tone

Day 2 Date: August 4, 2008 Vital Signs: Temp: 36.8 ºC Pulse: 65 bpm BP: 100/90mmHg Respiration: 25 cpm Height: 5’0” Weight: 35 kg

Tracheostomy tubing

Sunken eyeballs

Generalized body malaise Bed sore Cold clammy skin Poor muscle tone

Day 3 Date: August 5, 2008 Vital Signs: Temp: 37.5 ºC Pulse: 70 bpm BP: 100/80mmHg Respiration: 27 cpm Height: 5’0” Weight: 35 kg

Sunken eyeballs Tracheostomy tubing

Generalized body malaise Bed sore Cold clammy skin Poor muscle tone

C. Actual Nursing Care Plan

CUES

DIAGNOSIS

OBJECTIVES

INTERVENTION

RATIONALE

EVALUATION

Independent: Objectives: •

•

Potential for infection related to Attached invasive tracheos proceduretomy tube Long hospital tracheostomy tube attached. –lization

At the end of 24 to 48 hours of nursing, intervention, patient will be protected from possible potential infection.

1. Observed color/ odor characteristicsof sputum. Note drainage around tracheostomy tube. 2. Reduced nosocomial risk ex. Handwashing, maintaining sterile suction technique. 3. Encouraged deep breathin, coughing and frequent position changes. 4. Instructed Significant others and

1. Yellow/ green purulent odorous sputum is indicate of infection; while thick, tenacious sputum suggests dehydration. 2. These factors may be the simplest but are the most important keys ito prevention of hospital-acquired-infection. 3. Maximizes lung expansion and mobilization of secretions to pre-

At the end of 24 to 48 hours of nursing intervention, patient was protected from possible potential infection.

patient in proper secretion disposal ex. Tissues soiled tracheostomy dressing.

vent/reduce accumulation of secretions. 4. Reduces transmission of fluidborne organisms.

Dependent: 5. Administer antimicrobials as indicated.

5. One or more may be used dependent on identified pathogens if infection does occur.

CUES

DIAGNOSIS

OBJECTIVES

INTERVENTION

RATIONALE

EVALUATION

Independent: Objectives: •

• • •

poor muscle tone poor skin turgor body malaise Sunken eyeballs

Altered Nutrition: less than body requirements.

At the end of 3 days to 1 week nursing intervention, patient will be able to increase body weight to a more desirable weight within normal limits.

1. Monitored patient’s generalized muscle wasting. 2. Documented oral intake if/when consumed. Offer foods that patient enjoys. 3. Providedsmall frequent feedings of soft/ easily digested foods if able to swallow. Dependent: 4. Administer fluid intake of atleast 2500 ml/ day within cardiac tolerance. 5. Adjusted diet with help of dietician to meet respiratory needs.

1. These symptoms are indicative of depletion of muscle energy and can reduce respiratory muscle function. 2. Appetite is usually poor and intake of essential nutrients may be reduced. Offering favorite foods can enhance oral intake. 3. Prevents excessive fatigue,enhances intake and reduces risk of gastric distress. 4. Prevents dehydration that can be exacerbated by

At the end of 3 days to 1 week nursing intervention, patient was able to increased body weight to a more desirable weight within normal limits.

increased insensible losses and reduces risk of constipation.

CUES

DIAGNOSIS

OBJECTIVES

INTERVENTION

RATIONALE

EVALUATION

Independent: Objectives: • • • •

weak in appearance limited range of motion decreased performance inability to maintain usual routines

Activity intolerance related to generalized weakness.

At the end of 24 hours nursing intervention patient will be able to remain free of preventable discomfort.

1. Adjusted activities as necessary, reducing intensity level/ discontinuing activities as indicated. 2. Encouraged patient to do whatever possible ex. Self care. 3. Stressed necessities in of allowing for frequent rest periods. 4. Encouraged nutritional intake/ use of supplements as appropriate.

1. Prevents overexertion, allows for some activity within patient ability. 2. Provides for sense of control and feeling of accomplishments. 3. Enhances performance while conserving limited energy, preventing increase in level of fatigue. 4. Necessary to meet energy needs for activity. 5. Increase oxygenation. Evaluates

At the end of 24 hours nursing intervention patient was able to remain free of preventable discomfort.

Dependent:

eefctiveness in therapy.

5. Administer O2 at 2l/min to sustain patient oxygenation, if necessary.

CUES

DIAGNOSIS

OBJECTIVES

INTERVENTION

RATIONALE

EVALUATION

Independent: Objectives: •

• •

Feelings of helpless -ness Facial tension Fear on of unspecific con-sequence

Anxiety related to change in health status and hospitalization.

At the end of 72 hours to 1 week of nursing, intervention, patient will be able to demonstrate sense of health illness awareness.

1. Noted narrowed attentions. 2. Identified patient’s/ significant others perception of the situation. 3. Evaluated coping/ defense mechanisms being used to deal with the perceived. 4. Maintained frequent contact with person/SO. Be available for listening and talking as needed. 5. Stay with the patient as indicated.

1. Narrowed focus usually reflects extreme fear/ panic. 2. Regardless of the reality of the situation, perception affects how each individuals deals with the illness. 3. May be dealing well with the situation at the moment ex. Denial and regression may be helpful coping mechanism. 4. Establishes rapport, promotes expression of feelings and helps patient deal with the illness. 5. Continuous support may help patient regain in-

At the end of 72 hours to 1 week of nursing, intervention, patient demonstrated sense of health illness awareness.

ternal focus of control and reduce anxiety.

X. Progress Notes First Day Assessment August 3, 2008 General Objectives: At the end of 5 days assessment and implementing nursing intervention the group will be able to gather all data for the case analysis of the patient’s health condition implement necessary nursing interventions and evaluate his daily progress. Specific Objectives: At the end of 5 hours, the group will be able to: •

Establish rapport and trust

•

Systematically assess and obtain the baseline data of our patient

•

Identify problem with regards to the patient condition

•

Carryout necessary intervention for the identified problems

Evaluation: On the first day of our assessment in Northern Mindanao Medical Center, Intensive Care Unit, the group had established rapport with the patient and to her family. The group explained our intention and purpose of this study, in a way that both the patient and her Family would not misinterpret our action during the care and assessment. The patient was lying down in the bed with Tracheostomy tube and had no IV line. Bed sore was noted on her left side of her inguinal area. Vital Signs were taken and recorded with the following result: BP: 100/90 mmHg, Temp: 36.7ºC, Pulse Rate:

68 bpm, Resp. Rate: 30 cpm. The patient was manifesting from dyspnea since his Resp. Rate was 30 cpm. We positioned the patient in semi fowlers positioned and leave comfortably. After 5 hours, interaction with the patient performing intervention, the patient was able relieved from dypsea with Resp. rate of 25 cpm.

Second Day of Care August 4, 2008 Specific Objectives: At the end of 8 hours, the group will be able to: •

Further assess the patient’s condition

•

Perform necessary interventions for the identified problems

•

Evaluate the patients response to the performed interventions

Evaluation: On the second day, the vital signs were monitored and recorded with the following results BP: 100/90 mmHg, Temp: 36.8 ºC, Pulse Rate: 65 bpm, Resp. Rate: 25 cpm. The patients O2 Saturation were monitored closely for every two hours. Vital Signs, Intake and output were Monitored every four hours. The patient had difficulty in coughing. Still bed sore was noted. We taught patient about range of motion and it’s Importance. We position the patient In semi fowlers position. After 8 hours, upon intervention done, patient was able was to perform Range Of motion exercises and prevented bed sore by proper positioning and winkle free.

Third Day of Care July 22, 2008 Specific Objectives: •

Continue care of Patient

•

Observe Patient’s health progress

•

Perform necessary intervention for the identified problems

Evaluation: On the third day of care, Vital signs were taken and recorded with the following result: BP: 100/80 mmHg, Temp: 37.5 ºC, Pulse Rate: 70 bpm, Resp. Rate: 27 cpm. we had established rapport to the patient, she was very cooperative, we turned the patient side every two hours, we encourage patient to have deep breathing exercise and coughing. We position patient in semi fowler’s position. After 8 hours intervention the patients was able to expectorate phlegm. And bed sore was prevented by Changing in position at Interval. We leave the patient comfortably and winkle free.

X. A. Prognosis Patient X is assessed with the following criteria to determine its prognosis regarding his condition. CRITERIA

Onset of illness

GOOD POOR

/

REMARK The patient is 23years old and thus still has a strong disposition

to survive.

Unfortunately,

a

there

is

sudden

complications arising her condition in which patient X is suffering right now. Patient X’s case is a life-threatening disorder but with immediate and proper management,

complications

can

be

prevented but since the patient lacks Duration of illness

/

compliance with the medications due to financial constraints, she has a poor prognosis with this criteria because it will take a long time for her to recover due to

Precipitating factors

/

the complications occuring her condition. Patient X’s condition is deteriorating. This triggers during her pregnancy period since she wasn’t able to have a complete prenataI. With this, she develops anemia leading to severe blood loss. it is a traumatic injury from which a lot of repair is needed to be done because the heart is

affected which is the vital organ for pumping blood. Patient X is cooperative enough upon

Attitude and willingness to take medications and

taking her prescribed medications. With /

regards to the health teachings we’ve imparted to her, she never refuses to

treatment

listen. She has a good family support from her parents. Her family are there taking care of her and assists her with her needs as

Family support

/

well as encouraged her to get better soon. Hers family really tried so hard to come up with the necessary finances with regards on her medications for her faster recovery. The patient is not able to comply with all the necessary medications as ordered by

Financial support

/

the physician since they do not have an adequate financial support. But still his family tried their best to come up with the medications though it was delayed.

Based on the result that the group had gathered, the group rated the patient a poor prognosis as indicated with the six criterias given. Though patient X

has a strong

disposition to survive, capabilities, and is determined to get well, but then her conditions is deteriorating indeed and different organs are now affected. Certainly, this cannot be abruptly cured.

B. Discharge Plan Medication Encouraged patient to have strict adherence to the medication to attain their therapeutic effects. -

Instructed patient and the family to strictly follow the orders for take home medication such as its timing, dosage, and precautions upon discharge as prescribed by the physician such as: • • • • • • •

Aspirin Captopril Citicholine Dibencozide Ferrous sulfate Propanolol Warfarin

Activity/Exercise Encouraged patient to have adequate rest and engaged only in light activities. Encouraged patient to perform Active-Passive Range of Motion cise to encourage normal muscle function everyday. -

Exer-

Encouraged patient to avoid fatigue.

Instructed the family members to let the patient turn to sides while on bed to prevent bed sores. Treatment -

Encouraged a responsible member of the family to serve as treatment partner who will constantly remind about the timing of medications. Emphasized to the patient and the family members the importance of proper personal hygiene.

Instructed the family members of the patient to always listen to the concerned that the patient to relieve her anxiety.

Diet Encouraged patient to eat foods that are rich in Iron like meat organs, green leafy vegetables, fish, poultry products and meat to prevent anemia. Instructed patient to increase intake of foods that are rich in Vitamin C like citrus fruits and juices and tomatoes to enhance Iron absorption. Encouraged patient to eat foods that are high in fibers like pineapple to prevent constipation

Out-patient/Follow-Up Reminded patient and the family members to return to Dr.Watamama at Northern Mindanao Medical Center Out Patient Department for follow up check up 1 week prior to discharge. Encouraged patient to visit regularly to the nearest Health Center in their barangay in Baloy Cagayan de Oro City.

XI. Evaluation and Recommendation Since rheumatic fever is the cause of rheumatic heart disease, the best treatment is to prevent rheumatic fever from occurring.we make sure in everyday vital signs that it should be lowered in Temperature when we care for Patient X. Mupirocin ointmentPenicillin and other antibiotics can usually treat strep throat (a streptococcus A bacterial infection) and stop acute rheumatic fever from developing.Persons who have previously contracted rheumatic fever are often given continuous (daily or monthly) antibiotic treatments, possibly for life, to prevent future attacks of rheumatic fever and lower the risk of heart damage. Antibiotic therapy has sharply reduced the incidence and mortality rate of rheumatic fever/rheumatic heart disease. To reduce inflammation, aspirin, steroids, or non-steroidal medications may be given. Warfarin (Coumadin).for prevention of thrombo-embolism.Surgery may be necessary to repair or replace the damaged valve. Throat cultures for group A beta hemolytic Streptococcus usually are negative by the time symptoms of rheumatic fever or rheumatic heart disease appear. Citicoline drops (Zynapse) for CVA, in acute recovery phase, in signs & symptoms of cerebrovascular.For Attempts should be made to isolate the organism before the initiation of antibiotic therapy to help confirm a diagnosis of streptococcal pharyngitis and to allow typing of the organism if it is isolated successfully. This test allows rapid detection of group A streptococcal antigen and allows the diagnosis of streptococcal pharyngitis and the initiation of antibiotic therapy while the patient is still in the physician's office. Since the rapid antigen detection test has a specificity of greater than 95% but a sensitivity of only 60-90%, a throat culture should be obtained in conjunction with this test. Acute phase reactants: The C-reactive protein and erythrocyte sedimentation rate are elevated in rheumatic fever due to the inflammatory nature of the disease. Both tests have a high sensitivity but low specificity for rheumatic fever. They may be used to monitor the resolution of inflammation, detect relapse when weaning aspirin, or identify the recurrence of disease. Heart reactive antibodies: Tropomyosin is elevated in acute rheumatic fever. Cardiomegaly, pulmonary congestion, and other findings consistent with heart failure may be seen on chest x-ray. When the patient has fever and respiratory distress, the

chest x-ray helps differentiate heart failure from rheumatic pneumonia.Rapid detection test for D8/17: This immunofluorescence technique for identifying the B cell marker D8/17 is positive in 90% of patients with rheumatic fever. It may be useful for identifying patients who are at risk for developing rheumatic fever.For non-pharmacologic intervention,Evaluate /Document analgesia and assist in transitioning / altering drug regimen based on individual needs.Encourage bed rest periods to avoid fatigue .Discuss impact of pain to lifestyle/ independence and ways to maximize level of functioning. Identify Specific signs and symptoms and changes in pain characteristics requiring medical follow up.Perform Hemodynamic measurements as indicated (e.g. arterial CVP,pulmonary and left atrial pressures.Assess the urine hourly or periodically;weight daily noting total fluid balance.Elevate edematous extremeties and avoid restrictive clothing.Provide for diet restrictions (e.g. low-sodium,bland, soft, low calorie/residue/fat diet with small feedings. As indicated.Review the danger signs requiring immediate physician notification (e.g. unrelieved or increased chest pain ,functional decline.dyspnea, edema).

XII. Documentation

XIII. Bibliography Black, J. et al. (2005) Medical-Surgical Nursing.Clinical Management for Positive Outcome (7th Edition). pp. 1844-1849 Doenges, M. et.al. Nurse’s Pocket Guide.Diagnoses, Interventions, Rationales (8th Edition). F.A. Davis Company. pp.116-119, 403-405, 415-418,499-502 Doenges, M. et.al. Guidelines for Individualizing Client Care Across the Life Span (7th Edition). pp. 128-140, 184-186 DOH.Public Health Nursing in the Philippines (2007). (10th Edition)...pp.240-250. Goulg, B. (2006). Pathophysology for the Health Professionals (3rd Edition). pp.379-386. Kozier, B. et al. (2004). Fundamentals of Nursing Concepts, Process, and Practice (7th Edition). Addison Wesley pp.356-358 Marieb, E. (2004). Essential of Human Anatomy and Physiology (7th Edition). Pearson Education South Asia PTE LTD. pp. 308-321 Mosby Pocket Dictionary of Medicine, Nursing and Allied Health (4th Edition). Nettina, S. (2001). The Manual of Nursing Practice (7th Edition). Lippincott-Raven Publishers. pp.272-309 Pillitteri, Adele. Maternal and Child Health Nursing, Care of the Childbearing & Childrearing Family (4th Edition). Lippincott Williams & Wilkins. pp.782-785, 912 Porth, C. (2004) Pathophysiology-Concepts of Altered Health Status (6th Edition). pp. 615-619

Smeltzer, S. and Bare, B. (1992) Brunner and Suddarth’s Textbook of Medical-Surgical Nursing (10th Edition). Lippincott Williams & Wilkins (Vol. 1&2). pp.520-542, 876877, 2214-2228 Sparks, et al. Nursing Diagnosis: Reference Manual (6th Edition). Lippincott Williams & Wilkins. Webliography http://www.medflix.com. http://www.doh.gov.ph. http://www.labtestoutline.org/understanding/analytes/cbc/test/html. http://www.medicinenet.com/complete_blood_count/article.htm. http://www.nlm.nih.gov/medlineplus/ency/article/003725/html http://www.pennhealth.com/ency/article/003624.htm http://www.ucsfhealth.org/adult/adam/data/003624.html http://www.who.int/tb/en/ http://www.teleflexmedical.com/ucd/normal_anatomy_physiology.php http://www.webmd.com/a-to-z-guides/pneumonia-topic-overview http://www.healthline.com/dictionary/essential