Father Saturnino Urios University

Nursing Program
Butuan City

AN INDIVIDUAL
CASE STUDY
(Date of Exposure)

______________________________________
Level III Student Nurse

_________________________
Supervising Clinical Instructor
 INTRODUCTION

Congestive heart failure (CHF) is a chronic progressive condition that affects the pumping
power of the heart muscle, heart failure does not mean that the heart has stopped or is about to
stop working, heart failure means the heart isn’t just able to pump blood as well as it should
(Balingit,
2021). As a result, it can’t keep up with the body’s demand, and blood returns to the heart faster
than it can be pumped out thus it becomes congested, or backed up. This pumping problem
means that there’s not enough oxygen-rich blood that can get to the body’s other organs. When
the heart has less pumping power, it can damage the organs and nutrients won’t be able to meet
the body's needs as mentioned by the (National Heart, lung and Blood institute). The term
"congestive heart failure" is often used, as one of the common symptoms which is congestion, or
build-up of fluid in a person's tissues and veins in the lungs or other parts of the body (Beckerman,
2020). In the early stage of congestive heart failure, there will not be many changes in a person’s
body but as the condition progress there would be gradual changes that would be experienced by
the person. Symptoms to be noticed first includes fatigue, swelling in your ankles, feet and leg,
weight gain, increased need to urinate especially at night. Some signs and symptoms indicating
that the condition gets worse includes experiencing irregular heartbeat, bloated stomach and
shortness of breath indicating pulmonary edema, lastly symptoms indicating severe heart
condition are chest pain, rapid breathing, cyanosis and fainting (Beckerman, 2020).
According to the American Heart Association, risk factors for congestive heart failure are age,
ethnicity, gender, family history and genetics, people with diabetes, being obese and having
sedentary lifestyle. Diagnosis of congestive heart failure is achieved through a comprehensive
assessment of the heart muscle, including evaluation of its pumping action and thickness of its
walls, the test that are done in order to confirm CHF are (1) Electrocardiogram (ECG/EKG), (2)
Echochardiogram (3) Computed Tomography scan (CTscan) (4) Magnetic Resonance Imaging
(MRI) (5) Positron Emission Tomography (PET) scan and (6) Biopsy or catheterization of the
heart and arteries (Colluci, 2020). Regarding its treatment, according to (Jones, 2020) the types of
medications typically prescribed includes vasodilators, diuretics, aldosterone inhibitors, ACE
inhibitors, digitalis glycosides, anticoagulants or antiplatelet, beta-blockers and tranquilizers.
Surgery may sometimes prevent further damage to the heart and improve the heart's function,
some of the procedures done are Coronary artery bypass grafting surgery, heart valve surgery,
Implantable left ventricular assist device (LVAD) and heart transplant.
Complications of heart failure depend on the severity of the heart disease. If heart failure
becomes severe, several dire complications can result this includes (1) pulmonary complications
due to patient’s breathing which is compromised by the heart failure itself (2) stroke partly
because of the blood flow and blood clots that form in the heart which can travel to the brain and
cause the death of brain tissue (3) organ failure as reduced cardiac pumping action can rob
various organs of their needed blood supply, and organ malfunction can occur. In addition to the
neurological deficits often seen in people with heart failure, kidney failure can occur, and severe
gastrointestinal
disorders are common. Lastly is, (4) sudden death, caused by cardiac arrhythmias as stated by
(Forgoros, 2021). In a person with heart failure, any of these issues can lead to considerably
worse long-term disability or death. If you have heart failure, one of the major considerations is
to pay attention to changes in your symptoms to ensure that you and your healthcare practitioner
are aware of any potential changes in your cardiac status.
As reported by the World Health Organization (WHO), Heart failure (HF) is a global
pandemic affecting at least 26 million people worldwide and is increasing in prevalence,
cardiovascular diseases (CVDs) are the leading cause of death globally, taking an estimated 17.9
million lives each year, an estimated 17.9 million people died from CVDs in 2019, representing
32% of all global deaths, of these deaths, 85% were due to heart attack and stroke. Despite two
surges of the COVID-19 pandemic battering the Philippines, coronary heart disease remains the
top leading cause of death among Filipinos from January 2021 to September 2021, according to
the Philippine Statistics Authority (PSA) and in 2019 as stated by the Department of Health,
Butuan city had the highest number of deaths by heart diseases in the Philippines' CARAGA
region, accounting for 500 out of
2.66 thousand deaths across the region.
We, the group 3 level 4 nursing students were exposed to the Medical Surgical Ward at
Manuel J. Santos Hospital and we chose this case because we would like to have more
understanding specifically with patient’s having congestive heart failure, and also we would like
to trace the progress of our patient’s condition after the interventions that was done to her,
considering as well that it is also the leading cause of death globally so we wanted to gain more
knowledge at the same time spread awareness with regards to its cause, treatment and
management to other people.
 Definition of terms
 ACE inhibitors- Angiotensin-converting enzyme (ACE) inhibitors are medications that
help relax the veins and arteries to lower blood pressure
 Aldosterone inhibitors- are diuretics or “water pills.” They may also be called
aldosterone receptor blockers. These drugs treat high blood pressure and heart failure.
They do it by helping your kidneys produce more urine. The more you pee, the more
excess salt and water you flush out of your body
 Anticoagulants or antiplatelet- are medicines that help prevent blood clots. They're
given to people at a high risk of getting clots, to reduce their chances of developing serious
conditions such as strokes and heart attacks
 Beta-blockers- also known as beta-adrenergic blocking agents, are medications that
reduce blood pressure.
 Biopsy- a medical test commonly performed by a surgeon, interventional radiologist, or
an interventional cardiologist. The process involves extraction of sample cells or tissues
for examination to determine the presence or extent of a disease.
 Computed tomography scan- is a medical imaging technique used in radiology to
obtain detailed internal images of the body noninvasively for diagnostic purposes.
 Cyanosis- refers to a bluish-purple hue to the skin. It is most easily seen where the skin is
thin, such as the lips, mouth, earlobes and fingernails. Cyanosis indicates there may be
decreased oxygen attached to red blood cells in the bloodstream.
 Digitalis glycosides- Cardiac glycosides are a class of organic compounds that increase
the output force of the heart and decrease its rate of contractions by inhibiting the cellular
sodium- potassium ATPase pump.
 Diuretics- also called water pills, are medications designed to increase the amount of
water and salt expelled from the body as urine
 Echocardiogram- is a scan used to look at the heart and nearby blood vessels. It's a type
of ultrasound scan, which means a small probe is used to send out high-frequency sound
waves that create echoes when they bounce off different parts of the body.
 Electrocardiogram- is the process of producing an electrocardiogram, a recording of the
heart's electrical activity. It is an electrogram of the heart which is a graph of voltage
versus time of the electrical activity of the heart using electrodes placed on the skin.
 Implantable left ventricular assist device- A left ventricular assist device (LVAD)
is implanted in your chest. It helps pump blood from the lower left heart chamber (left
ventricle) to the rest of your body. A control unit and battery pack are worn outside your
body and are connected to the LVAD through a small opening (port) in your skin.
 Magnetic resonance imaging- a medical imaging technique used in radiology to form
pictures of the anatomy and the physiological processes of the body. MRI scanners use
 strong magnetic fields, magnetic field gradients, and radio waves to generate images of
the organs in the body.
 Positron emission tomography- is a functional imaging technique that uses radioactive
substances known as radiotracers to visualize and measure changes in metabolic
processes, and in other physiological activities including blood flow, regional chemical
composition, and absorption.
 Pulmonary edema- is a condition caused by excess fluid in the lungs. This fluid collects
in the numerous air sacs in the lungs, making it difficult to breathe. In most cases, heart
problems cause pulmonary edema
 Tranquilizers- are drugs that is used to reduce anxiety, fear, tension, agitation, and
related states of mental disturbance
 Vasodilators- are medications that open (dilate) blood vessels. They affect the muscles in
the walls of the arteries and veins, preventing the muscles from tightening and the walls
from narrowing.
 NURSING HEALTH HISTORY

History-taking is an essential part of assessment and planning for the actions to be taken to
ensure the delivery of safe and quality patient care, and effective clinical decision making (Ohm,
[Link]., 2013). This also allows for the nurse to look at other areas apart from the physiological,
and allows for a more wholesome approach to understanding and providing nursing care.
Nursing health history encompasses not only biographical and medical data/history, but also that
psychosocial and lifestyle-related information, which may prove to be helpful in determining
both present or possible illnesses and risk factors, and in the prioritization of later-identified
problems.
The nursing health history herein will encompass both the client’s history prior to admission,
and health history according to Gordon’s 11 Functional Health Patterns. The utilization of
Gordon's Functional Health Patterns will aid in investigating the health-related behaviors our
client usually engages in and also in determining the development of care and appropriate
treatment to be rendered.

The gathered information about the patient were all from the patient's record and
verbalization of the identified persona. By means of gathering data from the patient herself, the
group applied ethical principles in nursing such as confidentiality as it helps to build and develop
trust between the student nurses and the client. To preserve the client’s privacy and
confidentiality, the student nurses, therefore, withhold the real name of the subject. Thus, the
student nurses hereby call the client under the pseudonym of Patient X.

On the second day of our exposure, we were able to choose a befitting client for our Grand
Patient Analytic Report Presentation with a diagnosis of Congestive Heart Failure Secondary to
Ischemic Cardiomyopathy; Diabetes Mellitus Type 2; Hypokalemia; and Hypertensive
Cardiovascular Disease. The initial physical assessment and history taking were conducted last
April 18, 2022, and were completed on April 20, 2022.

Demographic Profile

Patient X, is a 50-year-old woman, of Filipino descent, a widow, and has no children. She
weighs 55 kilos and stands 4 feet and 11 inches, Seventh Day Adventist by faith, born on July 22,
1971. She is a college graduate and is currently residing in Princess Subdivision, San Vicente,
Butuan City, Agusan del Norte. Furthermore, Patient X lives with her parents and is currently
unemployed since 2018, she is dependent on her financial needs. Currently, her niece and
siblings are financing most of her medications and other expenses. Prior to her first admission in
2018, she worked as a bookseller outside the church and at the same time walking around the city
advertising and selling their books. Furthermore, she claimed that her income was not enough
considering her medications and other expenses. Due to her illness and condition, she decided to
stop selling books as her work gets her moving fast and strenuously enough to burn off much of
her energy.
 Family History
According to Patient X, both of her parents are hypertensive. Her father suffered from
coronary artery disease and also has Alzheimer’s Disease. Moreover, two of her brothers are also
hypertensive and diabetic.

Past Health History

Patient X claims that she seldom gets sick when she was younger, stating, “dili man ko dali
masakit tong bata pako kung masakit man gane ko sauna dali rajud ko maayo”. Furthermore,
she stated that her childhood diet was nutritious since vegetables and fruits were included in
every meal. Due to her religious views, Patient X was not immunized against COVID-19. In
terms of her childhood immunization, she said that she had certain immunizations when
she was younger but couldn't recall what specific vaccines. Patient X is a non-smoker, however,
she had a history of drinking in her younger years but eventually stopped at the age of 25.
According to Patient X, this was her third hospitalization. The first one was in the year 2018
month of October in Maternity Hospital, she was experiencing shortness of breath, swelling of
the abdomen, legs, ankles, and feet, stating “nag hupong kaayo akong tiil ug paa ato, lain akong
tiyan sakit sab wala ko makasabot, grabe nako ka hangak”. She was then diagnosed with
Congestive Heart Failure and Hypertension with a total length stay in the hospital for nine days.
She was instructed to modify her diet, however, despite her diagnosis, she would still eat
whatever her cravings are. She was given maintenance medications such as Losartan for her
hypertension, Ismodin to prevent angina (chest pain), Lanoxin, and Aspirin. The second
admission was in the year 2020 month of March she was brought in Butuan Doctors Hospital
due to difficulty of sleeping and shortness of breath, stating “hangak kaayo ko ato wala koy
tulog duha ka semana, pagdala sa ER gipislit nila akong heart grabe kaayo kasakit”. She was
hospitalized for five days and the same home medications were advised to take. This year, her
current hospitalization, she was admitted on April 6, 2022, due to difficulty sleeping. She has an
admitting diagnosis of Hypertension, Insomnia and Congestive Heart Failure secondary to
Ischemic changes. Moreover, the patient has no known drug or food allergies. During these
times, even though she was concerned about her health, she wouldn’t seek medical attention
right away not unless someone would offer to pay for her hospital expenses.

Furthermore, during her first admission in 2018, Patient X’s mobility was slightly affected
which made her slow, stating, "sugod adtong first nako nga admission sge nako hangakon pero
di man jud mapugngan magtrabaho man ghapon kos balay kay wamay muatiman, mag hinay
hinay lang ko ug mu pause rako kung hangakon unya balik dayon trabaho". After her first
admission, she was advised to contact her physician if symptoms persisted and exacerbated.
When she’s at home she constantly complains of chest pain, swelling of the feet, shortness of
breath, and a sudden bloating of the abdomen. However, every time she had these onset of
symptoms she chose to not take it seriously and opted to self-medicate due to financial problems.
 History of Present Illness

One month prior to admission, the patient had difficulty breathing associated with episodes
of shortness of breath, dryness of mouth, and epigastric discomfort. A month after the onset of
symptoms, prior to hospitalization, she believed that there was something wrong as she felt
much worse than she had before. However, she couldn’t do anything as she doesn’t have the
money to seek health care professionals, stating, “1 month ko ga antos maam, wako kasabot,
mag tuyok tuyok ko sa balay kay djud ko katulog tapos grabe ang hangak. Nihangyo jud ako
mama paadmit pero unsaon ta man wa man jud kwarta di masigo”. On the day of the admission,
after a while of recurrent and progression of symptoms, her niece decided to consult with the
attending physician, thus prompting them for admission. At exactly 10:55 PM, Patient X is in
for admission due to difficulty sleeping. Based on the patient’s chart, upon admission, Patient X
arrived conscious, awake, and alert, she obeys commands; and is oriented to person, place, and
time. Furthermore, during the assessment of the student nurses, specifically on the first day, the
patient reported chest pain on a scale of 5/10 and abdominal pain on a scale of 6/10. Additionally,
the patient manifested signs of dyspnea, abdominal and chest discomfort that comes and goes,
and abdominal distention was also noted.

Course of Treatment

On April 6, 2022, at 10:55 PM, Patient X was admitted to Manuel J Santos Hospital and
came in from the emergency room with a chief complaint of difficulty sleeping. She was placed
in bed with presenting symptoms of shortness of breath and angina (chest pain). She underwent a
series of assessments and has an admitting diagnosis of Hypertension, Insomnia, and Congestive
Heart Failure secondary to Ischemic changes. With initial vital signs as follows: temperature
-
36.5°C, pulse rate - 108 bpm, respiratory rate - 22 cpm, blood pressure -150/100 mmHg, and 02
sat - 93%. Patient X has a final diagnosis of Congestive Heart Failure secondary to Ischemic
Cardiomyopathy; Diabetes Mellitus Type 2; Hypokalemia; and Hypertensive Cardiovascular
Disease.

Seen and examined by Dr. H with orders carried out by the staff nurse:

Date Doctors Order

➢ Diet: Full low salt
➢ VS q 4 hours
➢ I & O q shift
➢ O2 inhalation at 2L/min
➢ Start IVF with PNSS 1L 20 cc/hr
➢ Labs:
CBC
HGT
Chest X-ray PA view
RT PCR Creatinine
April 6, 2022 Electrolyte Panel C
(Admitting Orders)
 Urinalysis
Lipid Panel
FBS
BUA
SGPT in AM
Prothrombin Time
➢ Medications
Losartan 50 mg 1 tab OD
Aspilet EC 80 mg, OD PO
Lanoxin 1 tab OD
Ismodin 60 mg 1/2 tab OD
Spironolactone (Aldactone)
25 mg 1 tab OD
Benadryl 25 mg 1 cap (Hold
for BP 90/60

April 7, 2022 ➢ Cefuroxime 750 mg IVTT ANST

then 750 mg IVTT q 8 hrs

➢ Furosemide 20 mg now
➢ Trimetazidine (Vestar) 25 mg 1 tab
April 8, 2022 BID
➢ Nebulized now
➢ 2D Echo Scan

➢ Continue O2 inhalation @ 2L/min

➢ Shift cefuroxime 750 mg to to
April 10, 2022 cefuroxime 500 mg 1tab BID

➢ Start Ganaton 1 tab TID pre meals

➢ Discontinue 02
April 12, 2022 ➢ Discontinue present IVF
➢ Possible discharge tomorrow if with
no other acute cardiac problems
➢ Gliclazide (Glubitor) 30 mg 1 tab
OD
➢ Kalium Durule 1 tab TID first dose
now
➢ Ultrasound of the whole abdomen
tomorrow
➢ Lanoxin 0.25 mg IVTT now

➢ Give furosemide 20 mg IVTT q 6

hrs x 4 doses. Hold for BP 90/60
April 13, 2022 ➢ Decrease O2 inhalation to 1L/min
➢ Pantoprazole with domperidone 1
cap now then 1 cap OD
➢ Continue IVF @ 10 cc/hr
➢ Discontinue Ganaton and aspilets
EC
➢ Ivabradine 5 mg 1 tab OD
 ➢ Clopidogrel (PLATZ) 75 mg 1 tab
OD

➢ Continue medications
➢ Limit total P.O fluids to 800 ml/day
➢ IVF rate @ 10 cc/hr
April 16, 2022 ➢ For possible discharge on Monday
➢ Biogesic 500 mg 1 tab q 4 hrs. PRN
for headache or fever

➢ MGH
➢ Give Levocin 500 mg 1 tab OD, 1
April 18, 2022 dose now
➢ Home meds to be given

GORDON’S 11 FUNCTIONAL HEALTH PATTERN

1. Health Perception- Health Management Pattern

When it comes to health practices, Patient X frequently self-medicates and relies on over-
the- counter medications and natural remedies for acute ailments like fever, cough, and colds.
The most common medicine she used to treat fever is paracetamol. Whenever she doesn’t feel
good, she takes anything that has no certified therapeutic claim and is not recommended by her
doctor. She takes herbal and nutritional supplements including barley, sambong, guava leaves,
and calamansi, which she believes have aided her condition, stating “bisan unsa nalang akong
imnon ma’am nga gina recommend ug ginahatag saako para lang jud maayo ko, gaan sad ako
paminaw ug mo inom ko, ganahan jud ko ani kay natural lang ba daghan pod benefits”.

Patient X claims that while she feels her illness should be addressed by health professionals,
she also claims that during acute illnesses, she frequently seeks "manghilotay", stating
“magpahilot jud ko ma’am basta naa koy bation saakong lawas kay bati nako basta mahilot ko
kay ma arang arang akong paminaw”. Furthermore, she has been very adherent with her
medications since her hospitalization in 2018, stating, “sukad na admit ko atong 2018 pirme ko
naay tambal ug sige nako gina follow ang pag inom as prescribed ni doc”. She was instructed to
modify her diet in the year 2018, however, despite her diagnosis, she continued with her bad
eating habits and would still eat whatever her cravings are including sweets, junk foods, fast
foods, and processed foods, stating, “sa sugod ni follow jud ko kay shempre hadlok bya pero
after a month sakong hospitalization nibalik ra sad kog kaon sa mga bawal walay control hantod
atong wa pako
na admit dri”. Furthermore, there are also times when she forgets to relax and overworks herself.
She also refuses to get vaccinated against COVID-19 due to her religious views.
When asked about her perceptions regarding her current condition, Patient X says that she
acquired her illness from her family as she believes that genes likely play some huge role in her
current illness. Furthermore, aside from poor diet, she considers stress-related work and
overworking herself as one of the reasons that triggered her current condition, stating “kabalo ko
maam isa akong food ani nga gina eat ang rason kay grabe nako ka unhealthy. Didto sab nag
sugod nga naglisod kog ginhawa katong bagyong odette nag sige sya ug nigara jud akong
hangak, sige pod nuon kog alsa ug bisag unsa nga bug at, sigeg kaws ug tubig balik balik alsa
grabe nga lihok trabaho balay walay undang ni grabe jud sya maong nakabantay ko pag hago ko
mu trigger sha saakong gibati”. She further stated, ”inhale exhale jud ako ginabuhat basta
hangakon, maynalang aron makalma ko”. Moreover, this time, patient X is well aware of the
constraints imposed by her condition. She was able to point out knowledge of her
disease, her current situation, and its implications.

2. Nutritional- Metabolic Pattern

Patient X stands 4’11 and weighs around 55 kg and has a body mass index of 24.4 which is
classified as normal weight according to the World Health Organization (WHO). Prior to
hospitalization, Patient X is not a picky eater, but she does consume things that aren't healthy for
her. During her first doctor's visit in 2018, she was encouraged to change her diet, but she
continues to eat meals that are contrary to her recommended diet. When asked about her typical
food intake, she eats sweets everyday due to her cravings, she consumes almost 2 plates of rice
every meal, she also eats any kinds of fruits and vegetables but she’s more on meat, processed
foods, fast foods, and junk foods, stating “dili jud na mawala ang sweets kada adlaw mu kaon
jud ko, pala rice sad ko nga tao grabe ka unhealthy saakong ginakaon di jud nako ma pugngan
kabalo ko dili maayo pero lami jud ang mga bawal”. Furthermore, Patient X drinks 3 liters of
water every day, doesn’t drink soft drinks, and drinks milk instead of coffee, stating “kusog
kaayo ko moinom ug tubig ug dili jud ko gainom ug softdrinks kay dko hilig ana''.

Upon admission, she verbalized, "wala may nausab sa akong appetite before and during ko
na hospital gana man akong kaon, ang kalahi lang sukad tong nia ko dri wa nako ga kaon ug
mga bawal kung unsay ration nila mao rajud na akong ginakaon kay naningkamot najud kog
likay sa mga di maayo kan on ug nakaya ra nako". Moreover, Patient X’s attending physician
limits her fluid intake to 800 ml/day.

3. Elimination Pattern

Both before and during hospitalization, Patient X stated that she has no problem urinating
and defecating, stating “okay raman akong pag libang ug ihi wala koy nakita nga problema”.
She
claimed she doesn’t need any assistance when going to the bathroom. She usually urinates 4-5
times a day and defecates once a day. She also said that she has no history of having urinary
tract infections. Additionally, when the student nurses asked for the observation of her urine and
stool, she stated that her urine was yellow in color and had no foul odor, and for the observation
of her stool, she said that it was not watery or loose.

4. Activity Exercise Pattern

Prior to hospitalization, she lives an active lifestyle. Her activities of daily living includes
cleaning the house, doing the laundry, cooking, running an errands, etc., stating “lihok kaayo ko
sa balay kay aron makatabang ko kay nanay ug tatay alangag diko mu lihok wa na gane tay
mahatag kwarta pabigat pajud, mu pause rakog hangakon ko unya balik dayon trabaho”
Furthermore, she has problems with regards to breathing and when asked about her exercise
regimen, she walks at home for 15 minutes everyday, stating “mag lakaw-lakaw ko sa balay
mga
15 mins kada adlaw”. During hospitalization, she verbalized, “karon nga dia ko sa hospital sge
rajud kog ga higda ug ingkod maong mas mabati nako akong sakit kay wakoy mabuhat dri, mag
lain pod usahay akong tiyan ug dughan lami ra ikahigda pirme”. Furthermore, as observed upon
assessment she is able to do tasks on her own without any assistance.

5. Sleep- Rest Pattern

Patient X claimed that in the year 2018 she already has problems with sleeping but worsens a
month prior to her current hospitalization, she has trouble in both falling and staying asleep,
stating “isa ka bulan ko nag antos aning tulog nako, grabe ka lisod e tulog tungod kay hangak
mag sge kog hangos”. During this time, sleeping is one of her major problems and she doesn’t
take any kind of sleeping medication nor drink prior to sleeping.

When asked about her sleeping pattern during confinement, she stated that she still doesn’t
have enough rest and usually sleeps for a maximum of 1 hour, stating “lisod jud kaayo e tulog
tungod sa hangak, usahay mag sakit ako dughan, mag lain akong tiyan di ko kasabot. Inig gabie
diko katug pagka kadlawon najud ko makapiyong pero isa ka oras rasab.” Furthermore, she
claimed she’s been taking Benadryl if she finds it hard falling asleep, stating “pag moinom kog
benadryl arang arang kay makatug dayon ko pero mubo ra ghapon akong tulog naa ra sa 2 ka
oras kay dali rako madistorbo di na dayon ko katug balik”. During the mornings of sleepless
nights, Patient X reported feelings of fatigue as she stated, "kada buntag mabati nako ang ka
luya mag try kog nap maka idlip ko mga 10 mins ra pod.”

6. Cognitive Perceptual Pattern

Patient X is oriented to time, place, and circumstances and she was able to respond
appropriately to the questions given. During the interview, there was no evidence of difficulty in
forming sentences. She also claimed that she was able to hear and understand everything as she
was able to follow the flow of the conversation with ease. She appears to show no signs of long-
term memory loss through a thorough past health history and was able to recall and elaborate
events from the past. However, there are times where she forget things that just happened
recently, stating “dala saakong edad usahay maka limot ko kung nainom na ba nako akong
tambal, na anhian naba ko ug nurse, or kung asa nako nabutang ang isa ka butang”.
Furthermore, Patient X failed to recall what she ate the day before and failed to completely
recall the three words mentioned before the start of the interview in which the student nurse
asked her to memorize them. Moreover, when asked about her vision she claimed that she
started wearing glasses in the year
2016 which was also her last eye check-up. According to her, she can see distant objects clearly,
but objects nearby are blurry, stating “mag glasses jud ko kada magbasa ko ug bible, makaklaro
man ko sa layo kung walay antipara pero kung duol kay hanap na”.

7. Self – Perception – Self – Concept Pattern

Patient X describes herself as a brave woman who can conquer any problem that is thrown
at her, stating “nagpaka strong ko para sakong parents”. Furthermore, she also sees herself as a
laid- back individual who makes acquaintances easily. She said that she has never been in a fight
and that she is capable of gently resolving conflicts with others, stating “dali rako makaamigo
dili sad ko tipo nga masuko sa laing tao ug malain man gane ko ako jud dayon na sulbaron”.

Patient X expresses that if she had followed her doctor's recommendations regarding eating
limitations, she would not be in this situation, stating “pangka tulo nani nako nga admit, karon
pa ko daghag na realize, kung di palang ko gahig ulo wa siguro ko miabot ani nga point
nagkagrabe man jud akong gibati compared sauna nako nga hospitalizations, karon pasad ko
kabalo nga diabetic diay ko.” Additionally, she somewhat feels useless and considers herself a
burden to her family as she can’t do anything due to her illness. Furthermore, Patient X aspires to
be financially secure and self-sufficient, stating “gusto ko manarbaho na aron ma sustentohan
na nako akong self, lisod kaayo ning nag salig ratas lain tao wa sab koy mabuahat, wala jud
income tungod aning sakit”. Moreover, she volunteers mentoring and teaching children on the
contents of the bible and shares her knowledge about it. Thus, she sees herself as a person with
the purpose of spreading the word of God and that she is proud of it and considers it as her
achievement.

8. Role Relationship Pattern

Patient X is unemployed and has no other source of income. She lives with her parents and
considers her relationship with them on good terms. Her niece and siblings covers all
of her expenses, such as food, medication, and other necessities. Furthermore, she claimed that
her siblings are supportive and have a strong relationship with each other. She mentioned that
they always offer assistance when it comes to hospital finances and that they also communicate
with each other online. However, she still considers and views herself a burden to her family
especially
to her parents, stating “mag sakit jud akong buot mag huna huna nga akoy gi atiman nila imbis
silay atimanonon kay mga oldies na, makita nako nga pabigat ko labi na sila poy ga bayad
sakong mga expenses diri grabe na kaulaw”. Furthermore, she also socializes with other people
and has no problem with communication, her churchmates were also involved and
encouraged her to comply with the treatments.

9. Sexuality Pattern
Patient X, is a widow for 5 years and has no children. When asked about her sexual lifestyle,
she claimed to have no current sexual partner for the last 5 years. Furthermore, she refused to
talk about why they haven’t had any children.

10. Coping - Stress Tolerance Pattern

Patient X considers her condition as a major stressful event in her life. She already has
accepted her situation and relies solely on medical management and prayers. Despite the
difficulties she faced, she maintained and portrayed a positive outlook in life, as per patient’s
statement “step by step lang jud ta ma’am, eventually malamposan rani nako di man ko biya an
sa Ginoo ug diko niya tagaan ug problema nga di nako makaya”. Furthermore, she was able to
cope with the stress because of her niece and siblings who keeps track on her health condition
and treatment by frequently calling and checking on her. Patient X also added that praying to
God and reading the bible was one of the biggest reasons why she was able to cope with the
weight of the situation.

11. Value Belief Pattern

Patient X is Seventh-Day Adventist by faith and prior to admission, she goes to church every
Saturday. She has expressed strong faith in God and has repeatedly mentioned “Ginoo”
throughout the conversation. She believes that there is power in prayer as she stated, "guol
gamay ampo dako ko ma’am, ang Ginoo ray nahibalo sa tanan. Buhaton lang nko akong part dri
ug ang Ginoo na ang bahala nako”. Furthermore, the patient has no value-belief conflicts related
to health and stated, “mo comply man jud ko kung unsay e ingon ni doc basta saakong
kaayohan”. Since her confinement, she only joins virtual services conducted by their church so
that she doesn’t miss worshiping God.
 Developmental Stage (Erik Erikson's 8 Stages of Development)
Erik Erikson's developmental theory posits 8 sequential stages of individual human
development that are influenced by biological, psychological, and social factors throughout the
lifespan (Orenstein, 2020) Erikson's theory focused on the socio-cultural aspect of development
through an individual's life. The different stages result in either a positive or negative impact on
an individual's relationship with others.
According to Erik Erikson's theory of psychosocial development, Patient X belongs to the
stage known as Generativity vs. Stagnation. This stage of development happens between 40-65
years of age. Patient X belongs to the Generativity Stage because she has developed
relationships with her family and other people and communicates with them. She also
participates in the discussion and likes to be involved in improving her health. Patient X is
taking responsibility for her health and is honest about her emotions in order to connect with
others. Furthermore, through generativity, she developed a sense of being a part of the bigger
picture. She has successfully achieved this stage wherein she became successful in many
aspects and is proud of the accomplishment she has in her life despite the circumstances.
 PHYSICAL ASSESSMENT

Physical Assessment is an organized, systemic process of collecting objective data based on health history and head-to-toe examination. The physical
assessment is the first step in the nursing process. It provides the foundation of nursing care planning in which the nurse’s observations play an integral part in the
assessment, intervention, and evaluation phases. The initial physical assessment was conducted last April 18, 2022 and was completed on April 20, 2022 when the
patient was on her 12th day of confinement at Manuel J. Santos Hospital, Medical-Surgical Ward. The examiner made the best efforts of obtaining as much
information throughout the interview.

General Survey
Patient X, a 50-year-old woman who appears in her stated chronological stage, her body type is endomorph and her overall appearance was neat, dressed
appropriately, clean and well-groomed. She was pleasant and cooperative during the assessment. The patient stands 4’11 feet, weighs 55 kg and has a body mass
index of 24.4 which is classified as normal weight according to the World Health Organization (WHO).
On the first day of assessment, April 18, 2022, patient was received lying on bed, alert, awake and coherent with ongoing IVF PNSS 1L at 10 cc/hour
hooked at right metacarpal vein; site dry and intact without swelling noted. The overall appearance was neat, dressed appropriately, clean and well-groomed. She
was pleasant and cooperative during the assessment.
On the second day of assessment, April 19, 2022, patient was received lying on bed, alert, awake and coherent with ongoing IVF PNSS at KVO hooked at
right metacarpal vein; site dry and intact without swelling noted. The overall appearance was neat, dressed appropriately, clean and well-groomed. She was
pleasant and cooperative during the assessment. She speaks softly and was able to follow the flow of the conversation with ease.
On the last day of assessment, April 20, 2022, the patient was received lying on bed, alert, awake and coherent without IVF. The overall appearance was
neat, dressed appropriately, clean and well-groomed. She was pleasant and cooperative during the entire assessment.

Date Body Temperature Pulse Rate Respiratory Rate Blood Pressure Oxygen Saturation
April 18, 2022 36.5 °C 97 bpm 21 cpm 110/80 mmHg 98 %
April 19, 2022 36.5 °C 101 bpm 22 cpm 110/80 mmHg 98 %
April 20, 2022 36.5 °C 101 bpm 21 cpm 110/80 mmHg 98%
Pain
Date Pain Scale (Chest) Pain Scale (Abdominal)
April 18, 2022 5/10 6/10
April 19, 2022 3/10 3/10
April 20, 2022 3/10 3/10

During the interview on the first day of assessment, April 18, 2022, the patient reported non-radiating chest pain on a pain rating of 5/10 and abdominal pain
on a pain scale of 6/10. On the second and third days of examination, April 19 and 20, 2022, she reported chest and abdominal discomfort that comes and goes
both on a pain scale of 3/10. The following were nonverbal cues observed on the first day of assessment:
 Guarding
 Grimacing
 Grasping of blankets
 Reluctance to move

Below is a table that outlines the results of the head-to-toe assessment.

Legend:
Black – Normal findings
Red – Abnormal findings
Area April 18, 2022 April 19, 2022 April 20, 2022
Skin Inspection: Inspection: Inspection:
- Brown skin complexion and uniform in color - Brown skin complexion and uniform in color - Brown skin complexion and uniform in color
- No lesions noted - No lesions noted - No lesions noted
Palpation: Palpation: Palpation:
- Skin is warm to touch with good turgor <2 - Skin is warm to touch with good turgor <2 - Skin is warm to touch with good turgor <2
seconds seconds seconds
Scalp and Hair Inspection: Inspection: Inspection:
- Hair color is black, smooth and silky and - Hair color is black, smooth and silky and - Hair color is black, smooth and silky and
evenly distributed all over the scalp evenly distributed all over the scalp evenly distributed all over the scalp
- Scalp is lighter in color than the complexion - Scalp is lighter in color than the complexion - Scalp is lighter in color than the complexion
- Free from lice, nits, and dandruff - Free from lice, nits, and dandruff - Free from lice, nits, and dandruff
- No scaling and lesions noted - No scaling and lesions noted - No scaling and lesions noted
Palpation: Palpation: Palpation:
- No tenderness or masses noted - No tenderness or masses noted - No tenderness or masses noted
-Gray and white haired, showing -Gray and white haired, showing -Gray and white haired, showing
characteristics of age, smooth and silky and characteristics of age, smooth and silky and characteristics of age, smooth and silky and
evenly distributed all over the scalp evenly distributed all over the scalp evenly distributed all over the scalp
- Scalp is lighter in color than the complexion - Scalp is lighter in color than the complexion - Scalp is lighter in color than the complexion
- Free from lice, nits, and dandruff - Free from lice, nits, and dandruff - Free from lice, nits, and dandruff
- No scaling and lesions noted - No scaling and lesions noted - No scaling and lesions noted
Head Inspection: Inspection: Inspection:
- Generally round, smooth and firm with - Generally round, smooth and firm with - Generally round, smooth and firm with
prominences in the frontal and occipital area. prominences in the frontal and occipital area. prominences in the frontal and occipital area.
- No cephalic deviation was observed - No cephalic deviation was observed - No cephalic deviation was observed
- Palpebral fissure is equal in both eyes - Palpebral fissure is equal in both eyes - Palpebral fissure is equal in both eyes
Palpation: Palpation: Palpation:
- No presence of nodules, tenderness and - No presence of nodules, tenderness and - No presence of nodules, tenderness and
masses noted masses noted masses noted
Eyes and Visual Inspection: Inspection: Inspection:
acuity - Eyebrows are evenly distributed and - Eyebrows are evenly distributed and - Eyebrows are evenly distributed and
symmetrically aligned; equal movement symmetrically aligned; equal movement symmetrically aligned; equal movement
- Eyelashes are equally distributed and curled - Eyelashes are equally distributed and curled - Eyelashes are equally distributed and curled
outward outward outward
- Eyelids skin intact, no discharge, no - Eyelids skin intact, no discharge, no - Eyelids skin intact, no discharge, no
discoloration and lids close symmetrically discoloration and lids close symmetrically discoloration and lids close symmetrically
- Sclera appears white and free of any lesions - Sclera appears white and free of any lesions - Sclera appears white and free of any lesions
- Pale appearance of the palpebral conjunctiva - Pale appearance of the palpebral conjunctiva - Pale appearance of the palpebral conjunctiva
- Pupils are equal, round, reactive to light and - Pupils are equal, round, reactive to light and - Pupils are equal, round, reactive to light and
accommodation (PERRLA) accommodation (PERRLA) accommodation (PERRLA)
 - Both eyes are coordinated, move in unison - Both eyes are coordinated, move in unison - Both eyes are coordinated, move in unison
and with parallel alignment and with parallel alignment and with parallel alignment
- No nystagmus and any shift in fixation was - No nystagmus and any shift in fixation was - No nystagmus and any shift in fixation was
noted noted noted
- Patient reports she has blurry vision - Patient reports she has blurry vision - Patient reports she has blurry vision
- Patient wears reading glasses - Patient wears reading glasses - Patient wears reading glasses
Palpation: Palpation: Palpation:
- No masses and tenderness noted over the - No masses and tenderness noted over the - No masses and tenderness noted over the
lacrimal and nasolacrimal gland lacrimal and nasolacrimal gland lacrimal and nasolacrimal gland
Ears Inspection: Inspection: Inspection:
- The auricles were aligned with outer - The auricles were aligned with outer - The auricles were aligned with outer
canthus canthus canthus
of each eye of each eye of each eye
- Pinna is aligned with the outer canthus - Pinna is aligned with the outer canthus - Pinna is aligned with the outer canthus
- Normal voice tone is audible for the patient; - Normal voice tone is audible for the patient; - Normal voice tone is audible for the patient;
does not have to request the student nurse to does not have to request the student nurse to does not have to request the student nurse to
repeat words or statements repeat words or statements repeat words or statements
Palpation: Palpation: Palpation:
- The auricles were firm and pinna recoils - The auricles were firm and pinna recoils - The auricles were firm and pinna recoils
after being folded within 2 seconds without after being folded within 2 seconds without after being folded within 2 seconds without
pain noted pain noted pain noted
- Auricles are mobile, firm - Auricles are mobile, firm - Auricles are mobile, firm
- No areas of tenderness on the auricles and - No areas of tenderness on the auricles and - No areas of tenderness on the auricles and
Nose mastoid process noted
Inspection: mastoid process noted
Inspection: mastoid process noted
Inspection:
- Skin color is the same in color as in the - Skin color is the same in color as in the - Skin color is the same in color as in the
complexion complexion complexion
- No lesions, discharges or flaring noted - No lesions, discharges or flaring noted - No lesions, discharges or flaring noted
- Both nares are patent - Both nares are patent - Both nares are patent
- Nasal mucosa is pinkish in color - Nasal mucosa is pinkish in color - Nasal mucosa is pinkish in color
Palpation: Palpation: Palpation:
- No tenderness of the paranasal sinuses noted - No tenderness of the paranasal sinuses noted - No tenderness of the paranasal sinuses noted
Mouth and Inspection: Inspection: Inspection:
Oropharynx - Dental caries noted on left lower 1st molar - Dental caries noted on left lower 1st molar - Dental caries noted on left lower 1st molar
 - Buccal mucosa appears pinkish in color - Buccal mucosa appears pinkish in color - Buccal mucosa appears pinkish in color
- No gum bleeding - No gum bleeding - No gum bleeding
- Tongue is centrally positioned, moist, no - Tongue is centrally positioned, moist, no - Tongue is centrally positioned, moist, no
whitish coats noted whitish coats noted whitish coats noted
- Able to move the tongue freely and with - Able to move the tongue freely and with - Able to move the tongue freely and with
strength strength strength
- No nodules, lumps and excoriated areas - No nodules, lumps and excoriated areas - No nodules, lumps and excoriated areas
noted noted noted
Palpation: Palpation: Palpation:
- No masses or nodules were felt upon moving - No masses or nodules were felt upon moving - No masses or nodules were felt upon moving
her tongue her tongue her tongue
- No reddened or edematous area noted - No reddened or edematous area noted - No reddened or edematous area noted
Neck Inspection: Inspection: Inspection:
- Trachea is in midline position - Trachea is in midline position - Trachea is in midline position
Palpation: Palpation: Palpation:
- No visible or palpable lumps or masses - No visible or palpable lumps or masses - No visible or palpable lumps or masses
upon palpation upon palpation upon palpation
Thorax and Lungs Inspection: Inspection: Inspection:
- Asymmetrical chest expansion view - Asymmetrical chest expansion view - Asymmetrical chest expansion view
- Showing signs of dyspnea - Showing signs of dyspnea Palpation:
Palpation: Palpation: - Symmetric thorax expansion
- Symmetric thorax expansion - Symmetric thorax expansion Auscultation:
Auscultation: Auscultation: - No rales heard over the lung bases breath
- Rales heard over the lung bases breath - Rales heard over the lung bases breath sounds
sounds noted sounds noted - Diminished breath sounds were noted
- Diminished breath sounds were noted - Diminished breath sounds were noted
Heart Palpation: Palpation: Palpation:
- Apical pulsation can be felt on palpation - Apical pulsation can be felt on palpation - Apical pulsation can be felt on palpation
- Bounding pulsations were noted - Bounding pulsations were noted - Bounding pulsations were noted
Auscultation: Auscultation: Auscultation:
- Gallop sound were noted - Gallop sound were noted - Gallop sound were noted
Breast Inspection: Inspection: Inspection:
 - Breasts were even with the chest wall, - Breasts were even with the chest wall, - Breasts were even with the chest wall,
smooth, and bilaterally round just like the smooth, and bilaterally round just like the smooth, and bilaterally round just like the
areola. areola. areola.
- Nipples were everted and smooth with no - Nipples were everted and smooth with no - Nipples were everted and smooth with no
discharges. discharges. discharges.
Palpation: Palpation: Palpation:
- No lumps, bumps, masses and tenderness - No lumps, bumps, masses and tenderness - No lumps, bumps, masses and tenderness
noted. noted. noted.
Upper Extremities Inspection: Inspection: Inspection:
- Capillary refill was <2 seconds on both sides - Capillary refill was <2 seconds on both sides - Capillary refill was <2 seconds on both sides
- No muscle atrophy noted - No muscle atrophy noted - No muscle atrophy noted
Palpation: Palpation: Palpation:
- Pulsations were full and symmetric in - Pulsations were full and symmetric in - Pulsations were full and symmetric in
volume on both sides volume on both sides volume on both sides
Abdomen Inspection: IInspection: Inspection:
- Unblemished skin and uniform in color - Unblemished skin and uniform in color - Unblemished skin and uniform in color
- No rashes, lesions, discoloration - No rashes, lesions, discoloration - No rashes, lesions, discoloration
- The aorta is midline without bruit or visible - The aorta is midline without bruit or visible - The aorta is midline without bruit or visible
pulsation pulsation pulsation
- Abdominal distention were noted (36.5 - Abdominal distention were noted (36 - Abdominal distention were noted (35.5
inches) inches) inches)
Auscultation: Auscultation: Auscultation:
-Bowel sounds are high-pitched, gurgling -Bowel sounds are high-pitched, gurgling -Bowel sounds are high-pitched, gurgling
noises that occur approximately every 5 – 15 noises that occur approximately every 5 – 15 noises that occur approximately every 5 – 15
seconds seconds seconds
Percussion: Percussion: Percussion:
- Tympanitic dull abdomen over the stomach, - Tympanitic dull abdomen over the stomach, - Tympanitic dull abdomen over the stomach,
epigastric area epigastric area epigastric area
Palpation: Palpation: Palpation:
- Superficial & deep palpation without - Superficial & deep palpation without - Superficial & deep palpation without
organomegaly or masses; no direct or rebound organomegaly or masses; no direct or rebound organomegaly or masses; no direct or rebound
tenderness tenderness tenderness
Lower Inspection: Inspection: Inspection:
Extremities - No asymmetry or muscle atrophy - No asymmetry or muscle atrophy - No asymmetry or muscle atrophy
- Full range of motion (ROM) of all joints - Full range of motion (ROM) of all joints - Full range of motion (ROM) of all joints
- No edema, or superficial varicosities noted - No edema, or superficial varicosities noted - No edema, or superficial varicosities noted
- Inguinal lymph nodes not enlarged - Inguinal lymph nodes not enlarged - Inguinal lymph nodes not enlarged
Palpation: Palpation: Palpation:
- Normal skin temperature - Normal skin temperature - Normal skin temperature
- All distal pulses (or: femoral, popliteal, PT, - All distal pulses (or: femoral, popliteal, PT, - All distal pulses (or: femoral, popliteal, PT,
and DP pulses) intact, full, and equal; no and DP pulses) intact, full, and equal; no and DP pulses) intact, full, and equal; no
bruits over femoral artery bruits over femoral artery bruits over femoral artery
Musculoskeletal Inspection: Inspection: Inspection:
- Symmetric muscles on both side - Symmetric muscles on both side - Symmetric muscles on both side
- No contractures noted - No contractures noted - No contractures noted
Reproductive The client refused to do the examination. The client refused to do the examination. The client refused to do the examination.
 ANATOMY AND PHYSIOLOGY

This section discuss the normal functions of the body systems involved in the disease
process of the patient specifically those that are affected in a congestive heart failure and type 2
diabetes mellitus. These systems are cardiovascular system and endocrine system, focusing
mainly on the organ pancreas.

CARDIOVASCULAR SYSTEM

The cardiovascular system also known as the circulatory system functions to transport
nutrients and oxygen-rich blood to all parts of the body and to carry deoxygenated blood back to
the lungs. It consists of the heart and a closed system of vessels called arteries, veins, and
capillaries. Blood contained in the circulatory system is pumped by the heart around a closed
circle or circuit of vessels as it passes again and again through the various circulations of the
body.

The Heart Wall and Its Layers

The heart is a muscular organ located

in the mediastinum. It works as a pump,
delivering blood to the body and receiving it
in exchange for transmission to the
pulmonary circuit for gas exchange.

The heart muscle has three layers

namely the epicardium, myocardium and
endocardium. The first layer of the heart is the
epicardium or the visceral layer, it is the
outermost layer of the heart and is also known
as a part of the heart wall. The second layer is
the myocardium which consists of thick
bundles of cardiac muscle twisted and whirled
into ring like arrangements and is the layer
responsible for the contractions. Lastly the
endocardium which is the innermost layer of the heart. It is a thin, glistening sheet of
endothelium that lines the heart chambers.

The Chambers of the Heart

The heart has four chambers that serve as

two sides of a two-chamber circuit (atrium and
ventricle); the left side chambers supply systemic
circulation, while the right side chambers supply
pulmonary circulation. The heart is divided by a
septa or partitions into right and left halves, and
each half is subdivided into two chambers. The
atrioventricular valve (AV valve) divides the
chambers on either side. The mitral (bicuspid)
valve divides the left-sided chambers, whereas
the tricuspid valve separates the right-sided
chambers.
 The atrium receive blood from various parts of the body and pass it into the ventricles.
The ventricles, in turn, pump blood to the lungs and to the remainder of the body.

The right atrium, or right superior portion of the heart, is a thin-walled chamber receiving
blood from all tissues except the lungs. Three veins empty into the right atrium, the superior and
inferior venae cavae, bringing blood from the upper and lower portions of the body, respectively,
and the coronary sinus, draining blood from the heart itself. Blood flows from the right atrium to
the right ventricle. The right ventricle, the right inferior portion of the heart, is the chamber from
which the pulmonary artery carries blood to the lungs.

The left atrium, the left superior portion of the heart, is slightly smaller than the right
atrium and has a thicker wall. The left atrium receives the four pulmonary veins, which bring
oxygenated blood from the lungs. Blood flows from the left atrium into the left ventricle. The
left ventricle, the left inferior portion of the heart, has walls three times as thick as those of the
right ventricle. Blood is forced from this chamber through the aorta to all parts of the body
except the lungs.

The Blood Circulation Through the Heart

The right and left sides of the

heart work together in achieving a
smooth flowing blood circulation.

Blood enters the heart through

two large veins, the inferior and
superior vena cava, emptying oxygen-
poor blood from the body into the
right atrium of the heart. As the
atrium contracts, blood flows from the
right atrium to the right ventricle
through the open tricuspid valve.
When the ventricle is full, the
tricuspid valve shuts to prevent blood
from flowing backward into the atria
while the ventricle contracts. As the
ventricle contracts, blood leaves the
heart through the pulmonic valve, into
the pulmonary artery and to the lungs
where it is oxygenated. The
pulmonary vein empties oxygen-rich blood from the lungs into the left atrium of the heart. As the
atrium contracts, blood flows from the left atrium into the left ventricle through the open mitral
valve. When the ventricle is full, the mitral valve shuts. This prevents blood from flowing
backward into the atrium while the ventricle contracts. As the ventricle contracts, blood leaves
the heart through the aortic valve, into the aorta and to the body.
 THE ENDOCRINE SYSTEM

The endocrine system is a complex

network of glands and organs that regulates
the body's hormones. Hormones manage and
coordinate the body's metabolism, energy
level, reproduction, growth and development,
injury, stress, and mood responses. One of the
organ involved in the endocrine system is the
pancreas which is the organ responsible for the
production of the hormone involved in case a
type 2 diabetes mellitus happens. This
discussion would focus mainly on the organ
pancreas.
Pancreas

The pancreas is an elongated,

tapered organ located across the back of
the belly, behind the stomach. The right
side of the organ called the head is the
widest part of the organ and lies in the
curve of the duodenum, the first division
of the small intestine. The tapered left
side extends slightly upward called the
body of the pancreas and ends near the
spleen called the tail. Although it is
primarily an exocrine gland, secreting a
variety of digestive enzymes, the
pancreas has an endocrine function.
Its pancreatic islet clusters of cells
formerly known as the islets of Langerhan secrete the hormones glucagon, insulin, somatostatin,
and pancreatic polypeptide (PP).

The pancreatic exocrine function involves the acinar cells secreting digestive enzymes
that are transported into the small intestine by the pancreatic duct. Its endocrine function
involves the secretion of insulin (produced by beta cells) and glucagon (produced by alpha cells)
within the pancreatic islets. These two hormones regulate the rate of glucose metabolism in the
body.

Cells and Secretions of the Pancreatic Islets

The pancreatic islets each contain four varieties of cells namely the alpha cell, beta cell,
delta cell, and PP cell.

The alpha cell produces the hormone glucagon and makes up approximately 20 percent of
each islet. Glucagon plays an important role in blood glucose regulation; low blood glucose
levels stimulate its release.
 The beta cell produces the hormone insulin and
makes up approximately 75 percent of each islet.
Elevated blood glucose levels stimulate the release of
insulin.

The delta cell accounts for four percent of the

islet cells and secretes the peptide hormone
somatostatin. An inhibiting hormone, pancreatic
somatostatin inhibits the release of both glucagon and
insulin.

The PP cell accounts for about one percent of islet cells and secretes the pancreatic
polypeptide hormone. It is thought to play a role in appetite, as well as in the regulation of
pancreatic exocrine and endocrine secretions. Pancreatic polypeptide released following a meal
may reduce further food consumption; however, it is also released in response to fasting.

Regulation of Blood Glucose Levels by Insulin

Glucose is required for cellular respiration and is the preferred fuel for all body cells. The
body derives glucose from the breakdown of the carbohydrate-containing foods and drinks
people consume. Glucose not immediately taken up by cells for fuel can be stored by the liver
and muscles as glycogen, or converted to triglycerides and stored in the adipose tissue.
Hormones regulate both the storage and the utilization of glucose as required. Receptors located
in the pancreas sense blood glucose levels, and subsequently the pancreatic cells secrete
glucagon or insulin to maintain normal levels.

Insulin

The primary function of insulin is to facilitate the uptake of glucose into body cells. Red
blood cells, as well as cells of the brain, liver, kidneys, and the lining of the small intestine, do
not have insulin receptors on their cell membranes and do not require insulin for glucose uptake.
Although all other body cells do require insulin if they are to take glucose from the bloodstream,
skeletal muscle cells and adipose cells are the primary targets of insulin.

The presence of food in the intestine triggers the release of gastrointestinal tract
hormones such as glucose-dependent insulinotropic peptide. This is in turn the initial trigger for
insulin production and secretion by the beta cells of the pancreas. Once nutrient absorption
occurs, the resulting surge in blood glucose levels further stimulates insulin secretion.
Precisely how insulin facilitates glucose uptake is not entirely clear. However, insulin
appears to activate a tyrosine kinase receptor, triggering the phosphorylation of many substrates
within the cell. These multiple biochemical reactions converge to support the movement of
intracellular vesicles containing facilitative glucose transporters to the cell membrane. Insulin
triggers the rapid movement of a pool of glucose transporter vesicles to the cell membrane,
where they fuse and expose the glucose transporters to the extracellular fluid. The transporters
then move glucose by facilitated diffusion into the cell interior.
Insulin also reduces blood glucose levels by stimulating glycolysis, the metabolism of
glucose for generation of ATP. Moreover, it stimulates the liver to convert excess glucose into
glycogen for storage, and it inhibits enzymes involved in glycogenolysis and gluconeogenesis.
Finally, insulin promotes triglyceride and protein synthesis. The secretion of insulin is regulated
through a negative feedback mechanism. As blood glucose levels decrease, further insulin release
is inhibited.
 LABORATORY RESULTS
Legend: RED values indicate abnormalities.

COMPLETE Result Normal Value Remarks Interpretation

BLOOD
COUNT
04/06/22
Hemoglobin 149 117-140 ↑  A high hgb count is
associated with high
hgb levels which
means that you hgb
has an increased
oxygen-carrying
capacity than normal.
It may indicate: lung
problems, heart
disease,
ploycythemia vera.
Hematocrit 0.43 0.34-0.44 N
WBC 14.5 5.0-10.0 N
Differential
Count
Segments 0.78 0.37-0.72 ↑  High levels of
segmets indicates
that there is infection
and your body is
more susceptible to
infection.
Lymphocytes 0.15 0.72-0.50 ↓  Sever or chronic low
counts can indicate a
possible infection.
 Low lymphocyte
blood levels indicate
your body is dealing
with an infection or
other inflammatory
condition.
Band 0.00 0.20-0.05 ↓  Low band counts
could be at risk of
infections
developing.
Eosinphil 0.01 0.00-0.06 N
Monocyte 0.05 0.08-0.14 ↓  Having low levels of
monocytes may
mean your body is
more susceptible to
infection.

Basophil 0.01 0-0.01 N

Platelet Count 244 150-390 N

RED values indicate abnormalities.

 URINALYSIS
4/6/22
Microscopic Examination
Color Yellow
Transparency Slightly Cloudy
pH 6.0
Specific Gravity 1.015
Chemical
Glucose ++
Protein ++
Microscopic
RBC 0-2
Pus Cells >50
Epithelial Cells Few
Amorphous Materials Few
Bacteria Mod

HEMATOLOGY Result Normal Value Interpretation

4/6/22
INR 1.10 0.80 – 1.20 N

ELECTROLYTE Result Normal Value Interpretation

PANEL C
04/07/22
Potassium 3.24 3.5-5.5mmol/ml N
Sodium 135.2 135-145mmol/L N
Chloride 96.6 96.0–10.0mmol/L N

CHEMISTRY Result Normal Value Remarks Interpretation

SECTION
4/7/22
BUA (Blood 3.1 2.4 – 5.7 N
Uric Acid)
Creatinine 0.84 0.51-0.95 mg/dL N
ALT Serum 51 10 – 35 u/L ↑ High leves of
Glutamate ALT in blood
Pyruvate/SGPT can be due to
damage or
injury to the
cells in liver.

LIPID Result Normal Value Remarks

PROFILE
4/7/22
Examination
Cholesterol 111 0.00-200.00 N
mg/dl
 Triglyceride 110 0.00-201.58 N
mg/dl
HDL 18 35-60 mg/dl ↓  Low levels of
HDL is risk
factor for
cardiovascular
problems
including
serious
conditions like
heart disease
and stroke,
Low levels
occur due to
genetic factors;
Type 2
diabetes.
LDL 71 0.00-130.01 N
mg/dl
VLDL 22 2-30 mg/dl N

CHEMISTRY Result Normal Value Remarks Interpretation

SECTION
4/7/22
FBS 270 mg/dl 74.55-100.00 ↑  High
mg/dl fasting
blood
sugar
levels
point to
insulin
resistance
or
diabetes

ECG (4/6/22)
Interpretation: Sinus Tachycardia with inferior way myocardia Ischemic with poor R wave
progression from V1-V6 (Probable anterolateral wall myocardial Infarction)

Chest PA (4/6/22)
Interpretation:
- No active lung parenchymal infiltrates seen.
- Heart is moderately enlarged with left ventricular predominance.
- Aorta is tortuous and calcified.
- Diaphragm and costophrenic sulci are intact.
- Included spine shows degenerative changes.
Impression:
1. Incoperative LV cardiomegaly, as described (Suggest 2D Echocarmography)
2. Atheromatous Aorta.
3. Mild Thoracic Spondycosis.
Whole Abdomen Sonogram (4/13/22)
1. Prominent liver with mild to moderate fat infiltration and mild venous congestion as
described.
2. Minimal Ascites
3. Normal size bladder with diffusely thickened wall as described likely due to congestion
ascites.
4. Normal size anteverted uterus with several small leiomyotous growth described. The
endometrium is hyperechoic and unthickened.
5. Unremarkable sonogram of pancreas, spleen, both kidneys, urinary bladder and both
adrexal areas.
6. Non-dilated biliary tree.
 DRUG STUDY

Name of drug Classification Mechanism of actions Indications Contraindications Side effects Nursing
Considerations
Losartan Cardiovascular Blocks the Hypertension Hypersensitivity to Dizziness, Monitor bp at drug trough
agent; angiotensin ii vasoconstrictor and losartan, pregnancy, insomnia, (prior to a scheduled
receptor antagonist; aldosterone-secreting lactation. headache. Gi: dose). Monitor drug
antihypertensive effects of angiotensin II diarrhea,
effectiveness, especially in
by selectively blocking dyspepsia.
the binding of Musculoskeletal: african-americans when
angiotensin II to the muscle cramps, losartan is used as
AT1 receptor found in myalgia, back or monotherapy.
many tissues. leg pain. Inadequate response may
be improved by splitting
the daily dose into twice-
daily dose.
Lab tests: monitor cbc,
electrolytes, liver &
kidney function with long-
term therapy.
Aldactone Electrolytic and Steroidal compound and Clinical conditions Anuria, acute renal Lethargy, mental Check blood pressure
water balance agent; specific pharmacologic
associated with insufficiency; confusion, fatigue before initiation of therapy
potassium-sparing antagonist of
diuretic aldosterone. augmented progressing (with rapid and at regular intervals
Presumably acts by
aldosterone impairment of kidney weight loss), throughout therapy.
competing with
aldosterone for cellular production, as in function, headache, Lab tests: monitor serum
receptor sites in distal
essential hyperkalemia; drowsiness electrolytes (sodium and
renal tubule. Promotes
sodium and chloride hypertension, pregnancy, lactation. potassium) especially
excretion without
refractory edema during early therapy;
concomitant loss of
potassium. Diuretic due to chf, hepatic
effect reportedly not
 associated with cirrhosis, nephrotic monitor digoxin level
hyperuricemia or
syndrome, and when used concurrently.
hyperglycemia. Activity
depends on presence of idiopathic edema. Assess for signs of fluid
endogenous or
exogenous aldosterone. May be used to and electrolyte imbalance,
potentiate actions of and signs of digoxin
other diuretics and toxicity.
antihypertensive Monitor daily i&o and
agents or for its check for edema. Report
potassium-sparing lack of diuretic response
effect. Also used for or development of edema;
treatment of both may indicate
primary tolerance to drug.
aldosteronism.
Ganaton Gastroprokinetics; Inhibit dopamine and Prescribed for Contraindicated in Diarrhea, Caution needed for
proton-pump acetylcholine esterase
dyspepsia and other patients with constipation, pregnant women and
inhibitor enzyme and have a
gastrokinetic effect. gastrointestinal gastrointestinal headache, elderly people.
conditions. Eg. bleeding, obstruction, abdominal pain,
Sensation of and hypersensitivity. irritated feeling Ganaton tablet should not
bloating, early and dizziness. be used by children below
satiety, upper 16 years of age.
abdominal pain or
discomfort,
 anorexia, heartburn, It may cause dizziness, do
nausea and not drive a car or operate
vomiting. machinery while taking
this medication.

Cefuroxime Antiinfective; This inhibits third and Infections caused by Hypersensitivity to Diarrhea, nausea, Monitor for manifestations
antibiotic; second- final stage of bacterial
susceptible cephalosporins and antibiotic- of hypersensitivity
generation cell wall synthesis, thus
cephalosporin killing the bacterium. organisms in the related antibiotics; associated discontinue drug and
Partial cross-
lower respiratory pregnancy [Link] report their appearance
allergenicity between
other beta-lactam tract, urinary tract, serum creatinine promptly.
antibiotics and
skin, and skin and bun, Monitor i&o rates and
cephalosporins has been
reported. structures; also used decreased pattern: especially
for treatment of creatinine important in severely ill
meningitis, clearance. patients receiving high
gonorrhea, and otitis doses. Report any
media and for significant changes.
perioperative Determine history of
prophylaxis hypersensitivity reactions
to cephalosporins,
penicillins, and history of
allergies, particularly to
drugs, before therapy is
initiated.
Lab tests: perform culture
and sensitivity tests before
initiation of therapy and
periodically during
therapy if indicated.
Therapy may be instituted
pending test results.
Monitor periodically bun
and creatinine clearance.
Lanoxin Cardiovascular Widely used cardiac Rapid digitalization Digitalis Fatigue, muscle Vital signs
agent; cardiac glycoside of digitalis
and for maintenance hypersensitivity, weakness, Intake and output
glycoside; lanata. Acts by
antiarrhythmic increasing the force and therapy in chf, atrial ventricular headache, facial Take apical pulse for 1 full
velocity of myocardial
systolic contraction fibrillation, atrial fibrillation, neuralgia, mental min, noting rate, rhythm,
(positive inotropic flutter, paroxysmal ventricular depression, and quality before
effect). It also decreases
conduction velocity atrial tachycardia. tachycardia unless nausea, vomiting, administering drug.
through the diarrhea
due to chf. Full Withold medication and
atrioventricular node.
Action is more prompt digitalizing dose not notify physician if apical
and less prolonged than
that of digitalis and given if patient has pulse falls below ordered
digitoxin. received digoxin parameters (60/min in

Increases the during previous week adults).

contractility of the heart or if slowly excreted Lab tests: baseline and
muscle (positive
inotropic effect). cardiotonic glycoside periodic serum digoxin,
has been given during potassium, magnesium,
previous 2 wk. and calcium.
Isosorbide Cardiovascular Isosorbide mononitrate Prevention of Hypersensitivity to Restlessness Monitor cardiac status,
mononitrate agent; nitrate is a long-acting
the angina. nitrates; severe Anxiety frequency and severity of
Brand: ismodin vasodilator metabolite of
coronary vasodilator Not indicated for anemia; closed-angle Dizziness angina, and bp.
isosorbide dinitrate. It
decreases preload as acute attacks. glaucoma, postural Tinnitus Assess for and report
measured by pulmonary hypotension, head Blurred vision possible s&s of toxicity,
capillary wedge
pressure (pcwp), and trauma, cerebral Tremors including orthostatic
left ventricular end hemorrhage Slow/fast heart hypotension, syncope,
volume and diastolic
pressure (lvedv), with a (increases intracranial rate and low dizziness, palpitations,
consequent reduction in
myocardial oxygen pressure). Safe use blood pressure light-headedness, severe
consumption. during pregnancy) for headache, blurred vision,
It is a potent vasodilator sustained form or and difficulty breathing.
with antianginal and lactation is not Lab tests: monitor serum
antiischemic effects.
established. electrolytes periodically.
Diphenhydramine Antihistamine; h1- H1-receptor antagonist Temporary Hypersensitivity to Headache Monitor cardiovascular
Brand: benadyl receptor antagonist and antihistamine with
symptomatic relief antihistamines of Dizziness status especially with pre-
significant
anticholinergic activity. of various allergic similar structure; Anorexia existing cardiovascular
It inhibits involuntary
conditions and to lower respiratory Diarrhea disease.
muscle movements and
various bodily treat or prevent tract symptoms Nausea and Monitor for adverse
functions.
motion sickness, (including acute vomitting effects especially in
vertigo, and asthma); narrow- children and the older
reactions to blood or angle glaucoma; adult.
plasma in prostatic hypertrophy
 susceptible patients. Supervise ambulation and
Also used in use side-rails as necessary.
anaphylaxis as Drowsiness is most
adjunct to prominent during the first
epinephrine and few days of therapy
other standard
measures after acute
symptoms have
been controlled.
Trimetazidine Fatty acid oxidation Inhibit β-oxidation of For the symptomatic Contraindicated in Pain that may also Monitor bp, rr, pr prior to
inhibitors free fatty acid that
treatment of stable patients with occur in your periodically throughout
normalizes metabolic
disturbances in low- angina pectoris in parkinson disease, upper back, both therapy
flow ischemia.
patients parkinsonian arms, neck, or ear notify prescribing signs of
The drug allows for
more blood flow to the inadequately symptoms, tremors, lobes. heart failure
heart and limits quick
controlled restless leg Chest pain that
changes in your blood
pressure. This can help syndrome, and other spreads to your
lessen chest pain from
related movement arms, shoulders,
blocked blood vessels.
disorders. jaw, neck, or
[Link] of
breath. Weakness.
Tiredness
Potassium Electrolytic and Principal intracellular To prevent and treat Severe renal Nausea, vomiting, Monitor i&o ratio and
chloride water balance agent; cation; essential for
potassium deficit impairment; severe diarrhea, pattern in patients
Kalium durules replacement maintenance of
solution intracellular isotonicity, secondary to hemolytic reactions; abdominal receiving the parenteral
transmission of nerve
impulses, contraction of diuretic or untreated addison's distension, drug. If oliguria occurs,
cardiac, skeletal, and corticosteroid disease; crush irritability, stop infusion promptly and
smooth muscles,
maintenance of normal therapy syndrome; early listlessness, notify physician.
kidney function, and for
postoperative paresthesias of Lab test: frequent serum
enzyme activity. Plays a
prominent role in both oliguria; adynamic extremities, electrolytes are warranted.
formation and
correction of ileus; acute muscle weakness Monitor for and report
imbalances in acid–base dehydration; heat signs of gi ulceration
metabolism.
cramps, (esophageal or epigastric
hyperkalemia, pain or hematemesis).
Monitor patients receiving
parenteral potassium
closely with cardiac
monitor. Irregular
heartbeat is usually the
earliest clinical indication
of hyperkalemia.
Aspirin Central nervous Major actions appear to To relieve pain of History of Dizziness, Monitor for loss of
Brand: aspilet system agent; be associated primarily
low to moderate hypersensitivity to confusion, tolerance to aspirin.
analgesic, salicylate; with inhibiting the
antipyretic; formation of intensity. Also for salicylates including [Link] Lab tests: more frequent
antiplatelet prostaglandins involved
in the production of various methyl salicylate (oil a, vomiting, fasting blood glucose
inflammation, pain, and inflammatory of wintergreen); diarrhea, levels with diabetes.
fever.
conditions, such as sensitivity to other anorexia, Monitor for salicylate
acute rheumatic nsaids; patients with heartburn, toxicity. In adults, a
fever, systemic "aspirin triad" stomach pain sensation of fullness in the
lupus, rheumatoid (aspirin sensitivity, ears, tinnitus, and
arthritis, nasal polyps, decreased or muffled
osteoarthritis, asthma); chronic hearing are the most
bursitis, and calcific rhinitis; chronic frequent symptoms
tendonitis, and to urticaria; history of gi associated with chronic
reduce fever in ulceration, bleeding, salicylate overdosage.
selected febrile or other problems
conditions.
Gliclazide Sulfonylurea class Act by stimulating β Prescribed for type Hypersensitivity to Anxiousness. Caution should be
of insulin cells of the pancreas to
2 diabetes gliclazide, Blurred vision. exercised in patients with
secretagogues release insulin.
Sulfonylureas increase sulfonylureas or Cold sweats. history of liver, kidney
both basal insulin
sulphonamides. Type Confusion. problems, any allergy,
secretion and meal-
stimulated insulin 1 diabetes, diabetic Difficulty during pregnancy and
release.
pre-coma and coma, concentrating. breastfeeding.
 diabetic keto- Drowsiness. Monitor bloodsugar level
acidosis. Fast heart rate. regularly while taking this
Headache. medication.

Clopidogrel Blood formers, Inhibits platelet Secondary Hypersensitivity to Chest pain, Carefully monitor for and
coagulators, and aggregation by
prevention of mi, clopidogrel; edema, immediately report s&s of
anticoagulants; selectively preventing
antiplatelet agent the binding of adenosine stroke, and vascular intracranial hypertension, gi bleeding, especially
diphosphate to its
platelet receptor. It is an death in patients hemorrhage, peptic thrombocytic when coadministered with
analog of ticlopidine. with recent mi, ulcer, or any other purpura. nsaids, aspirin, heparin, or
The drug's effect on the
adenosine diphosphate stroke, unstable active pathologic warfarin.
receptor of a platelet is bleeding; pregnancy
angina or Lab tests: periodic platelet
irreversible.
established count and lipid profile.
peripheral arterial Evaluate patients with
disease. unexplained fever or
infection for
myelotoxicity.
Ivabradine Hyperpolarization- Ivabradine is a heart- Indicated to reduce Decompensated heart Blurred vision. Tell patients to report
activated cyclic rate-lowering agent that
the risk of failure. Chest pain or significant decreas- es in
nucleotide-gated acts by selectively and
(hcn) channel specifically inhibiting hospitalization for Blood pressure less discomfort. heart rate or signs and
blockers. the cardiac pacemaker
worsening hf in than 90/50. Fast or irregular symp- toms such as
current (if), a mixed
sodium-potassium patients with stable, Conduction heartbeat. dizziness, fatigue, or
inward current that
symptomatic abnormalities, e.g., hypotension, as well as
controls the
spontaneous diastolic
 depolarization in the chronic hf with a sick sinus syndrome, Lightheadedness, symptoms of atrial
sinoatrial (sa) node and
hence regulates the left ventricular sinoatrial block, or dizziness, or fibrillation such as
heart [Link] the heart ejection fraction third-degree av block, fainting. palpitations or shortness of
can
pump more blood unless a pacemaker Pounding in the breath.
through the body each determines the heart ears. instruct patients to take
time it beats
rate. Slow or irregular each dose with food.
Severe liver heartbeat.
impairment. Unusual
tiredness.
Furosemide Electrolytic and Rapid-acting potent Treatment of edema History of Hypotension, Monitor for s&s of
water balance agent; sulfonamide "loop"
associated with chf, hypersensitivity to dizziness with hypokalemia
loop diuretic diuretic and
antihypertensive with cirrhosis of liver, furosemide or excessive Monitor bp during periods
pharmacologic effects
and kidney disease, sulfonamides; dieresis, of diuresis and through
and uses almost
identical to those of including nephrotic increasing oliguria, hypovolemia, period of dosage
ethacrynic acid. Exact
syndrome. May be anuria, fluid and dehydration, adjustment.
mode of action not
clearly defined; used for electrolyte depletion hyponatremia, Lab tests: obtain frequent
decreases renal vascular
management of states; hepatic coma; nausea, vomiting, blood count, serum and
resistance and may
increase renal blood hypertension, alone pregnancy oral and gastric urine electrolytes, co2,
flow.
or in combination burning bun, blood sugar, and uric
with other acid values
antihypertensive Monitor i&o ratio and
agents, and for pattern.
 treatment of
hypercalcemia.

Paracetamol Central nervous Produces analgesia by Fever reduction. Hypersensitivity to Anorexia, nausea, Monitor for s&s of:
Brand: biogesic system agent; unknown mechanism,
Temporary relief of acetaminophen or vomiting, hepatotoxicity, even with
nonnarcotic perhaps by action on
analgesic, peripheral nervous mild to moderate phenacetin; use with dizziness, moderate acetaminophen
antipyretic system. Reduces fever
by direct action on pain. Generally as alcohol. lethargy, doses, especially in
hypothalamus heat- substitute for aspirin diaphoresis individuals with poor
regulating center with
consequent peripheral nutrition or who have
vasodilation, sweating,
ingested alcohol
and dissipation of heat.
Do not take other
medications (e.g., cold
preparations) containing
acetaminophen without
medical advice
 PROBLEM PRIORITIZATION

Priority Number Identified Nursing Problem Date Identified

1 Acute Pain r/t decreased myocardial blood flow April 18, 2022
2 Ineffective Breathing Pattern r/t pulmonary congestion secondary to April 18, 2022
Congestive Heart Failure
3 Decreased Cardiac Output r/t altered afterload and contractility of the April 18, 2022
heart secondary to Congestive Heart Failure
4 Ineffective Tissue Perfusion r/t chronic venous insufficiency April 18, 2022
5 Excess Fluid Volume r/t/ compromised regulatory mechanism April 18, 2022
secondary to Congestive Heart Failure
6 Imbalanced Nutrition: More Than Body Requirements r/t poor dietary April 18, 2022
habits
7 Activity Intolerance r/t imbalance between oxygen supply and demand April 18, 2022
8 Fatigue r/t physiological disease process April 18, 2022
9 Insomnia r/t physical discomfort April 18, 2022
10 Powerlessness April 18, 2022
11 Risk for Impaired Gas Exchange April 18, 2022
 NURSING CARE PLAN NO. 1
Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Evaluation
Subjective cue: Acute Pain related to Short Term Goal: Independent Nursing Short Term Goal:
P - Upon doing activities decreased myocardial Interventions:
of daily living blood flow Within 2 hours of After 2 hours of nursing
Q - Squeezing nursing interventions, 1. Assess patient pain for - To identify intensity, interventions, the patient
R - Chest; non-radiating the patient will report intensity using a pain precipitating factors, describes satisfactory
S - 5/10 on pain scale pain is relieved or rating scale, location, and and location to assist in pain control at the level
rating controlled at the level 4 precipitating factors. accurate diagnosis. of 4 out of 10.
T - Steady in nature out of 10.
2. Monitor vital signs, - Tachycardia and Goal met.
Objective cues: Long Term Goal: especially pulse and blood elevated blood pressure
- Guarding pressure, every 5 minutes usually occur with Long Term Goal:
- Grimacing Within 2 days of until pain subsides. angina and reflect
- Grasping of blankets nursing interventions compensatory After 2 days of nursing
the patient will be able mechanisms secondary interventions the patient
- Reluctance to move
to demonstrate to sympathetic nervous has demonstrated
- Restlessness activities and behaviors system stimulation. activities and behaviors
that will prevent the that prevent the
recurrence of pain. 3. Establish a quiet and - A quiet environment recurrence of pain
restful environment. reduces the energy control such as taking
demands on the patient. pain medications in a
timely manner, and
4. Provide relaxation - Anginal pain is often practicing focused
techniques and diversional precipitated by breathing.
activities such as emotional stress that
distraction, focused can be relieved by non- Goal met.
breathing, visualization, pharmacologic
and guided imagery). measures such as
relaxation.

5. Encourage adequate rest - To prevent fatigue

periods. that can impair ability
 to manage or cope with
pain.

6. Teach the patient how to - In some cases, chest

distinguish between angina pain may be more
pain and signs and serious than stable
symptoms of myocardial angina. The patient
infarction. needs to understand the
differences to seek
emergency care in a
timely fashion.

7. Evaluate the patient’s - It is essential to assist

response to pain and patients to express as
management strategies. factually as possible
the effect of pain relief
measures.
Inconsistencies
between behavior or
appearance and what
the patient says about
pain relief may reflect
other methods the
patient is using to cope
with the pain rather
than pain relief itself.

Dependent Nursing
Interventions:

8. Provide optimal pain - NSAIDs such as

relief by administering Aspirin and Ibuprofen
work in peripheral
prescribed pain relief tissues. Some block the
medication. synthesis of
prostaglandins, which
stimulate nociceptors.
They are effective in
managing mild to
moderate pain. All
NSAIDs have anti-
inflammatory (except
for acetaminophen),
analgesic, and
antipyretic effects.
They work by
inhibiting the enzyme
cyclooxygenase
(COX), a chemical
activated during tissue
damage, resulting in
decreased synthesis of
prostaglandins; Nitrates
may be given to relax
the blood vessels.
Other medications that
help treat angina
include anti-cholesterol
drugs (e.g. statins), beta
blockers, and calcium
channel blockers.

- The patient’s
effectiveness of pain
9. Evaluate the
medications must be
effectiveness of pain relief
evaluated individually
medication as ordered and
observe for any signs and since they are absorbed
symptoms of side effects. and metabolized
differently.

Collaborative Nursing
Intervention:

10. Discuss with SO(s) - Family members/SOs

ways in which they can may provide assistance
assist the patient with pain by transporting the
management. patient to prevent
walking long distances,
or by taking on the
patient’s strenuous
chores, supporting
timely pain control,
encouraging eating
nutritious meals to
enhance wellness, and
providing gentle
massage to reduce
muscle tension.
 NURSING CARE PLAN NO. 2
Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Evaluation
Subjective cue: Ineffective Breathing Short Term Goal: Independent Nursing Short Term Goal:
“Didto sab nag sugod Pattern related to Interventions:
lisod kog ginhawa pulmonary congestion Within 4 hours of After 4 hours of nursing
hangakon ... nakabantay secondary to Congestive nursing interventions, 1. Assess the patient’s vital - The average rate of interventions, the patient
ko pag hago ko mu Heart Failure the patient will be able signs and characteristics of respiration for adults is was not able to carry out
trigger sha saakong to carry out ADLs, respirations at least every 4 10 to 20 breaths per ADLs, breathing pattern
gibati” as verbalized by breathing pattern hours. minute. It is important remained unstable
the patient. remains within to take action when evidenced by shortness
established limits. there is an alteration in of breath. Goal
Objective cues: breathing patterns to
- Difficulty of breathing Long Term Goal: detect early signs of not met. Long
- Asymmetric chest compromise on the
expansion Within 2 days of respiratory system. Term Goal:
- Crackles (rales) and nursing interventions
gallop heard upon the patient will be able 2. Auscultate breath - This is to evaluate the After 2 days of nursing
auscultation to demonstrate sounds at least every 4 presence/characteristics interventions, the patient
maximum lung hours. of breath sounds and was able to demonstrate
expansion with secretions. maximum lung
adequate ventilation. expansion with adequate
3. Elevate the head of the - To promote ventilation.
bed and/or have the patient physiological and
sit up in a chair or assume psychological ease of Goal met.
a tripod position, as maximal inspiration;
appropriate. the sitting position
permits maximum lung
excursion and chest
expansion.

4. Encourage sustained - These techniques

deep breaths. Techniques promote deep
include (1) using inspiration, which
demonstration: increases oxygenation
highlighting slow and prevents
inhalation, holding end atelectasis. Controlled
inspiration for a few breathing methods may
seconds, and passive also aid slow
exhalation; (2) utilizing respirations in
incentive spirometer and tachypneic patients.
(3) requiring the patient to Prolonged expiration
yawn. prevents air trapping.

5. Encourage - This method relaxes

diaphragmatic breathing. muscles and increases
the patient’s oxygen
level.

6. Encourage frequent rest - To limit fatigue and

periods and teach the maximize respiratory
patient to pace activity. effort; extra activity
can worsen shortness
of breath. Ensure the
patient rests between
strenuous activities.

7. Encourage small - This prevents

frequent meals. crowding of the
diaphragm.

Dependent Nursing
Interventions:

8. Administer - To increase the

supplemental oxygen, as oxygen level and
prescribed. Discontinue if achieve an SpO2 value
 SpO2 level is above the within the target range
target range, or as ordered at least 96%.
by the physician.

9. Administer the - Bronchodilators: To

prescribed bronchodilators, dilate or relax the
steroids, or combination muscles on the airways.
inhalers/nebulizers, as
prescribed. Steroids: To reduce the
inflammation in the
lungs.

Inhalers or nebulizers –
To facilitate relaxation
of the airway.

10. Help the patient with - This conserves energy

ADLs, as necessary. and avoids
overexertion and
fatigue.

Collaborative Nursing
Intervention:

11. Refer the patient for - Exercise promotes the

evaluation of exercise conditioning of
potential and development respiratory muscles and
of an individualized the patient’s sense of
exercise program. well-being.
 NURSING CARE PLAN NO. 3
Assessment Nursing Diagnosis Planning Nursing Interventions Rationale Evaluation
Subjective cue: Decreased Cardiac Short Term Goal: Independent Nursing Short Term Goal:
“Dali ragud ko Output r/t altered Interventions:
hangakon, bisag gamay afterload and Within 4 hours of After 4 hours of nursing
ra akong buhaton” as contractility of the nursing interventions, 1. Monitor Vital signs/ - Provides baseline data interventions, the patient
verbalized by the heart secondary to the patient will be able Hemodynamic parameters. for comparison to follow has demonstrated
patient. Congestive Heart to demonstrate adequate Noting V/S changes in trends and evaluate adequate cardiac output
Failure cardiac output. response to activity or response to interventions. as evidenced by BP of
Objective cues: procedures. 110/80, RR of 21 cpm,
- Diagnosis of Long Term Goal: and O2 sat of 98%.
Congestive heart failure 2. Assess for reports of - Fatigued and exertional
- Restlessness Within 2 days of fatigued and reduced dyspnea are common Goal met.
- Pale conjunctiva nursing interventions activity tolerance. problems with low
- Crackles (rales) and the patient will be able cardiac output. Close Long Term Goal:
gallop heard upon to participate in monitoring of the
auscultation activities that reduce patient’s response serves After 2 days of nursing
the workload of the as a guide for optimal interventions, the patient
heart. progression of activity. has participated in
activities that reduce the
3. Auscultate heart sounds - If the patient develops workload of the heart as
and breath sounds. pulmonary edema, there evidenced by utilizing
will be coarse crackles stress management/
on inspiration and severe relaxation skills and
dyspnea. S3 indicates avoiding activities that
reduced left ventricular may stimulate Valsalva
ejection and is a class response.
sign of left ventricular
failure. S4 occurs with Goal met.
reduced compliance of
the left ventricle, which
impairs diastolic filling.
4. Encourage changing - To reduce risk for
positions slowly, dangling orthostatic hypotension.
legs before standing.

5. Decrease stimuli; provide - To promote adequate

quiet environment rest and maximize rest
periods.

6. Instruct client to - These maneuver can

avoid/limit activities that put extra strain on the
may stimulate a Valsalva cardiac muscles
response. impeding blood flow.

7. Instruct patient about - To provide non-

stress management pharmacological
techniques and relaxation management to the
techniques. patient.

8. Constantly review signs - Early detection of

of impending failure/shock, changes in these
noting decreased cognition parameters promotes
and impending low blood timely intervention to
pressure. limit degree of cardiac
dysfunction.

Dependent Nursing
Interventions:

9. Administer supplemental - To increase the oxygen

oxygen, as prescribed. level and achieve an
Discontinue if SpO2 level is SpO2 value within the
above the target range, or as target range at least 96%.
ordered by the physician.
10. Administer medications - Vasodilators treat heart
as prescribed (vasodilator failure by increasing
therapy, angiotensin- cardiac output and
converting enzyme (ACE) reducing ventricular
inhibitors, Beta blockers, as workload. ACE
prescribed, noting side inhibitors lowers blood
effects and toxicity. pressure. Beta blockers
reduce blood pressure.
Knowing what side
effects or adverse effects
that may occur equips
the nurse to look out for
possible problems and
the appropriate
interventions to do
thereafter.

Collaborative Nursing
Intervention:

11. Associate patient to - A thoroughly

heart failure or cardiac monitored exercise
rehabilitation programs for program can improve
education, evaluation, and both functional
guided support. capacities and left
ventricular function.
Cardiac rehabilitation
can improve quality of
life and functional
capacity.
 DISCHARGE PLAN
Discharge planning is an interdisciplinary approach to continuity of care and a process
that a patient need for a smooth move from one level of care to another.

Medication:

- Instruct the patient to have strict compliance with regards to the medication to attain
therapeutic effects and emphasize the importance of taking home medications
appropriately

● Losartan 50mg 1 tab once a day

● Ismodin 60mg 1/2 tab once a day
● lanoxin 1 tab once a day
● Aspirin 50mg once a day
- Instructed to take the following home medications at the right time, with the right dose,
frequency, and route.

- Educate the patient and significant others about the importance of following medication
and dietary regimens so that the patient’s condition can remain stable and avoid further
complications

- Encourage the patient to call her healthcare provider if she thinks her medicine is not
helping her or if she experienced any side effects

Environment:

- Advise the patient and significant others to provide a well-ventilated and well-
lighted environment conducive for the recovery and healthy living of the patient.

- Encourage the patient to avoid staying in polluted areas such as near factories, lots of
vehicles, areas where people smoke, and etc.

- Encourage the patient and significant others to also provide a room free from noises and
loud sounds

- Encourage the patient to avoid areas with crowded people and hot temperatures

Treatment:

- Remind and instruct the patient to have a follow up clinical check up at her physician’s
clinic.

- Advise the patient to see her healthcare provider every month for a long term check-up.

Health Teaching:

- Instruct the patient and significant others to monitor blood pressure and blood sugar of
the patient frequently

- Advise the patient and significant others to avoid stressful situations such as problems
encountered at home as much as possible. Instead, practice healthy coping techniques
such as muscle relaxation and deep breathing exercises.

- Encourage patient to rest 8-10hours a day

 - Encourage the patient to change position frequently when lying in bed and elevating feet
when sitting as tolerated.

- Encourage active passive exercises such as walking, lifting leg up, arm extensions, etc.

- Emphasize to avoid strenuous activities such as doing laundry, carrying heavy objects,
and etc .

- Instruct significant others to assist the patient in activities she cannot perform to avoid
further complications.

- Instruct the patient to record weight daily. Weighing at the same time of the day in the
same kind of clothes. Ideally, weighing first thing in the morning after emptying the
bladder has the most accurate results

- Encourage patient to rest 8-10hours a day

Observable signs and symptoms:

- Advise to consult the physician if the following symptoms are observed:

● Sudden weight gain (more than 2 pounds in 1 day or 5 pounds in 1 week, or

whatever weight gain you were told to report by your doctor). Clues to weight
gain include checking ankles for swelling, or noticing short of breath when lying
down.

● Trouble breathing not related to being active

● New or increased swelling of legs or ankles

● Swelling or pain in the abdomen

● Breathing trouble at night (waking up short of breath, needing more pillows to

breathe)

- Advise the patient to go to the nearest health facility if the following occurs:

● Severe shortness of breath, such that the patient can't catch her breath even while
resting

● Severe chest pain that does not resolve with rest or nitroglycerin

● Pink, foamy mucus with cough and shortness of breath

● An ongoing rapid or irregular heartbeat

● Passing out or fainting

● Stroke symptoms such as sudden numbness or weakness on one side of the face,
arm, or leg or sudden confusion, trouble speaking or vision changes

Diet

- Instruct the patient to follow a heart healthy diet that most benefits for both diabetes and
heart health foods high in fiber and healthy fats. These includes:

● Fresh fruits and vegetables such as bananas, avocadoes, oranges, green leafy
vegetables (e.g. malunggay, pechay, cabbage, lettuce, kangkong), peas, tomatoes.
 ● Whole grains, such as whole-grain bread and whole-grain cereal

● Legumes such as beans, batao, patani which are high in soluble fiber

● Walnuts, almonds which are packed with protein, and these particular nuts are
also high in omega-3 fatty acids and unsaturated fats, which can help lower
bad cholesterol. But since nuts are high in calories, emphasize to eat only in
small portions.

● Fatty or oily fish such as salmon, sardines, and tuna which are high in omega-3
fatty acids, a type of unsaturated fatty acid that can help reduce inflammation in
the body.

- Advise to grill meats rather than frying as grilling reduces fat contents.

- Emphasize to avoid foods with added sugars, such as baked goods, sodas, and other
drinks with added sugars

- Emphasize to limit salt as directed by the physician by doing the following:

● Limit canned, dried, packaged and fast foods

● Do not add salt to food

● Season foods with only herbs instead of salt

● Limit fluids to 6 to 9 cups (1.5 to 2 liters) a day. Drinking too much can make
heart failure worse

● When eating out, ask that meals have no added salt

● Choose foods low in salt such as eggs, oatmeal, yogurt

● Read food labels before buying packaged foods. Picking sodium content less than
350 mg for each serving. If salt or sodium is listed in the first five ingredients, it is
too high in sodium

Spirituality:

- Encourage the patient to pray, asking for guidance and healing for the restoration of
health.

- Emphasize the importance of attending church as tolerated or attending through an online

platform.

- Encourage the patient in talking with significant others to express her feelings.
 LEARNING OUTCOMES
Within the four days exposure of medical-surgical in the clinical area of Manuel J Santos
Hospital, the Group 3 student nurses were able to acquire knowledge, apply skills and appreciate
the eleven core competencies such as Safe and Quality Nursing Care, Management of Resources
and environment; Health Education; Legal Responsibility; Ethico/Moral Responsibility;
Personal and Professional Development; Quality Improvement; Research; Record Management;
Communication; and Collaboration and teamwork.

The student nurses were able to establish Safe and Quality nursing care through doing
rounds, assessments, identifying nursing diagnosis, implementing nursing interventions, and
giving due medications following the 10 rights of medication administration to ensure safe and
quality care. With that, Health education was also a part of it through doing health teachings of
the side effects and indications of each medication before administering to a patient. Not only in
that manner, but also educating the patients regarding their conditions. Also, through giving
them information before performing procedures as part of nursing interventions. In management
of resources, it was also observed through proper disposal of waste, segregating from infectious,
sharps, non-biodegradable, and etc. We were able to use our resourcefulness in terms of
modification such as using and cutting empty IV bottles in measuring urine for I and O.
Meanwhile, research was also utilized in caring for patients. This was observed through utilizing
evidence based findings and applying it through FDAR, individual case studies and PAR
presentations. Researching relevant articles regarding our patient’s condition helped us acquire
more knowledge in the management of diseases. All that was not possible without
Communication, Collaboration and teamwork within the clinical area. Through endorsements,
communicating with staff nurses, and the other health care team, this ensures appropriate
referrals and provision of holistic nursing care. Therapeutic communication also played a vital
role in caring for patients as this helped us establish rapport with our patient making it easier to
perform interventions promoting social growth and development. Moreover, we also learned the
importance of Record management and Legal Responsibility through securing right
documentation; ensuring data recorded and reflected were done with true honesty and by not
committing errors with knowledge that it is a legal document. With all that being said, we made
sure that as student nurses it is also our responsibility to be honest with patients and colleagues.
We maintained self-integrity and high personal moral standards through recalling the principles
of Ethico/moral responsibility. We ensured to render nursing care consistent with the patient’s
bill of rights: (i.e. confidentiality of information, privacy, etc.); adhering to the Code of Ethics
for Nurses and abiding by its provision. Lastly, through doing self-evaluation, this has
enlightened us with the actions we can improve. The competency of Personal and Professional
Development as well as Quality Improvement was observed and appreciated all throughout the
span of our care. Clinical problems were identified through demonstration of knowledge;
detecting variations of vital signs; setting daily objectives and evaluating our performance,
making room for improvement.

All in all, it was a great experience of rendering care to patients. It allowed us to be more
efficient and prepare us student nurses of the challenges that will arrive as we become competent
nurses someday. Being a student nurse was never easy, however, amidst all these circumstances,
this will not stop us from learning and becoming the best nurses we aspire to be.
 REFERENCES
Books:
Ohm, F., Vogel, D., Sehner, S., Wijnen-Meijer, M., & Harendza, S. (2013). Details
acquired from medical history and patients’ experience of empathy–two sides of the same coin.
BMC medical education, 13(1), 67.
Kannel WB, Belanger AJ. Epidemiology of heart failure. Am Heart J. 1991;121(3 pt
1):951–7.
Jones & Barlett (n.d.). Anatomy and Physiology of the Cardiovascular System. Retrieved
from 99069_ch05_6101.pdf

Doenges, M. E., Moorhouse, M.F., & Murr, A. C. (2010). Nurse's Pocket Guide.
Diagnosed, Prioritized Interventions, and Rationales. Philadelphia, Pennsylvania: F.A. Davis
Company

Published Sites:
Fairview Health Services (2019). Discharge Instructions for Heart Failure. Retrieved 26
March from [Link]
Education/Articles/English/d/i/s/c/h/Discharge_Instructions_for_Heart_Failure_86317

Mcleod, S. (2018). Erik Erikson’s Stages of Psychosocial Development. Simply

Psychology. Retrieved April 27, 2022 from
[Link] [Link]?
fbclid=IwAR3biNWOXcZnnK_Mi7hBuoC-
m6BOSsKZ4PYeFxf3HKMzT7QM4hlrzQccG2o#:~:text=Initiative%20versus%20guilt%20is%
20the,years%20in%20a%20child's%20life
Medscape (2022) Heart Failure Clinical Presentation. Retrieved April 23, 2022 from,

Kaiser Foundation Health Plan (2022) History and Physical Exam for Heart Failure.
Retrieved April 23, 2022 from, [Link]

John Hopkins Medicine (2022). The Pancreas. Retrieved from

[Link]
pancreas#:~:text=Anatomy%20of%20the%20pancreas,division%20of%20the%20small%20intes
tine.

Kohli P. (2021 July 29). What to know about the cardiovascular system. Retrieved from
[Link]

Belleza M. (2021 Feb 11). Cardiovascular System Anatomy and Physiology. Retrieved
from [Link]

Buddiga [Link] (2014 Aug 20). Cardiovascular System Anatomy. Retrieved from
[Link]/article/1958510-overview#a2

Brittanica (n.d.) The heart. Retrieved from[Link]

cardiovascular-system/Blood-supply-to-the-heart

U.S. Department of Health and Human Services. (n.d.). Diabetes, heart disease, &amp;
stroke. National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved April 27,
2022, from [Link]
problems/heart-disease-stroke

Mayo Foundation for Medical Education and Research. (2020, December 2). High
hemoglobin count causes. Mayo Clinic. Retrieved April 27, 2022, from
[Link]
 Tello, A. the A. V., Tello, V., &amp; *, N. (2021, January 20). High Alanine
Aminotransferase (ALT) causes &amp; health effects. SelfDecode Labs. Retrieved April 27,
2022, from [Link]

Journals:
Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guideline on lifestyle management
to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart
Association Task Force on practice guidelines. J Am Coll Cardiol. 2014;63(25 Pt B):2960-2984.
PMID: 2423992 [Link]/24239922/.
Mann DL. Management of heart failure patients with reduced ejection fraction. In: Zipes
DP, Libby P, Bonow RO, Mann DL, Tomaselli GF, Braunwald E, eds. Braunwald's Heart
Disease: A Textbook of Cardiovascular Medicine. 11th ed. Philadelphia, PA: Elsevier;
2019:chap 25.
Parakh, N., Karthikeyan, G., & Bhargava, B. (2015). Creating healthy heart environment.
The Indian journal of medical research, 142(3), 235–237. [Link]
5916.166526
Yancy CW, Jessup M, Bozkurt B, et al. 2017 ACC/AHA/HFSA focused update of the
2013
ACCF/ AHA guideline for the management of heart failure: a report of the American College of
Cardiology/American Heart Association Task Force on Clinical Practice Guidelines and the
Heart Failure Society of America. Circulation. 2017;136(6):e137-e161. PMID: 28455343
[Link]/28455343/.
Zile MR, Litwin SE. Heart failure with a preserved ejection fraction. In: Zipes DP, Libby
P, Bonow RO, Mann DL, Tomaselli GF, Braunwald E, eds. Braunwald's Heart Disease: A
Textbook of Cardiovascular Medicine. 11th ed. Philadelphia, PA: Elsevier; 2019:chap 26.
Malone, J., Liu, S., Vaillant, G., Rentz, D., and Waldinger, R. (2016). Midlife Eriksonian
psychosocial development: Setting the stage for late-life cognitive and emotional health. Dev
Psychol. 52(3):496-508. doi:10.1037/a0039875

Middlekauff HR, Stevenson WG, Stevenson LW. (2002) Prognostic significance of atrial
fibrillation in advanced heart failure. A study of 390 patients. Circulation. 2002;84:40–8.

Wenger NK, Abelman WH, Roberts WC. (2000) Cardiomyopathy and specific heart
muscle disease. In: Hurst JW, ed. The heart, arteries and veins. 7th ed. New York: McGraw-Hill,
2000;1278–1347.

Open Stax College (n.d.). The Endocrine Pancreas. Retrieved from [Link]
[Link]/anatomyandphysiology/chapter/the-endocrine-pancreas/