Quezon Medical Mission Group Hospital and Health Services Cooperative Roeder Max R. Pangramuyen CI -Mrs. Melena V.

. Quintos Related Learning Experience BSN IV SLSU Group 7

CASE NARRATIVE August 04, 2013 is the first day of our exposure and actual handling of patient at QMMG HHSC. From August 04, 2013 August 06, 2013 I handle pt from room 238 A. The patient was Mr. Amador Santiago an 81 y/o male, born on May 1, 1932, Roman Catholic, widowed man, with chief complaint upon admission of pain/numbness on right upper extremities. He was admitted last July 30, 2013 under the service of Dr. Guinto with initial diagnosis of HTN stage II t/c CVA, and low salt low fat diet was ordered.

Upon assessment the patient looks slightly weak in appearance, conscious and coherent oriented to person, place and time with reports of numbness of lower extremities. The patient had increased blood pressure, with productive cough, whitish to yellowish in color, moderate in amount, crackles sound was heard on right lung field upon auscultation and reports of pain upon coughing. The patient due to old age had blurring of vision and hearing impairment. Although the diagnosis was CVA, aside from weakness, there is no marked impairment on patients extremities.

During history taking, the relative reveals that few years ago the patient underwent of surgery due to ulceration intestine. The patient was a drinker, smoker and fond of eating fatty and salty foods on his early years not until her wife died. The patient also had been hypertensive since middle age.

Different treatment was done and different medications had been administered to patient. The patient refused CT scan however medications for CVA were given. Citicoline 500 mg 1 cap TID which acts as brain stimulant was given; ASA 80 mg/tab 1tab OD p/c was given after meals for its Non opiod analgesic, antipyretic and to prevent thrombosis due to CVA and prevent further attacks; Clexane 0.4ml subqutaneous q12 an anticoagulant which deactivates thrombin and prevent coagulation of blood. Fecalysis was ordered to observe for signs of bleeding; it shows
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Quezon Medical Mission Group Hospital and Health Services Cooperative on the fecalysis result that there was residue of occult blood. Careful monitoring of changes in pts level of consciousness was done.

On x-ray result on July 31, 2013 it reveals that the patient have pneumonia right, cardiomegaly, and atheromatous aorta. Since that the patient had pneumonia, had productive cough and pain upon coughing, the following medications had been administered. Acetylcysteine 60mg 1 tad OD which is dissolved in glass of water was given which act as mucolytic that makes the secretions less viscous; Sinecod Forte 1tab TID was given to suppress cough; Doxofyline 400 mg tab BID, Prednisone 20mg P.O. BID a corticosteroid, both act as bronchodilator. Atrovent q6 was given by respiratory therapist was also given and act as bronchodilator. Zenith 1tab 500mg OD act as anti-infective and bacteriostatic was given to fully eliminate causes of formation of mucus secretions. Deep breathing, coughing was demonstrated to patient for full lung expansion and expels respiratory secretions. Pt was placed on semi fowlers position and head of bed elevated for optimal breathing, back tapping and rubbing was also provided. Pt was encouraged to keep back dry at all times and to increase oral fluid intake but only at least 1l/ day to avoid fluid overload and increase in blood pressure.

Lipid profile results were as follows: cholesterol 166.33mg/dl, triglyceride 101.16mg/dl, HDL 42.44mg/dl and LDL 103.7 mg/dl. CPK-MB result was 9.50 and Trop1 as positive both indicators of heart damaged (related to cardiomegaly and atheromatous aorta). Medications for hypertension and angina were given. Transdermal patch 50mg ACW OD an antianginal (nitroglycerine) and ISMN 30mg 1 tab OD in AM, both reduces oxygen demand by decreasing left ventricular end diastolic pressure and also increases flow through the collateral artery vessels. Amlodipine of 5mg P.O. BID an anti angina inhibits calcium ion influx thus decreasing oxygen demand and also dilates coronary arteries and arterioles and also given for hypertension. Losartan 50mg 1tab OD pm and Catapres 75mg/tab 1tab SL PRN for BP >140/90 was given for hypertension. Clopidogrel hinders platelet aggregation was given to reduce thrombotic events in pt with atherosclerosis documented by recent CVA. Nursing interventions was done such as Monitoring BP and observed for complaints of blurring of vision and
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Quezon Medical Mission Group Hospital and Health Services Cooperative dizziness, placing client on semi fowlers position to decrease cardiac overload, encouraged to limit oral fluid intake up to 1L/day to minimize or limit increase of blood volume, instructed on low salt low fat diet, instructed to limit or avoid strenuous activities and provided quiet environment, and adequate rest and sleep.

CBC indicates altered tissue perfusion with result of Hgb 100mg/dl, Hct 0.30, RBC 3.4 10^12, and WBC 4.6 10^g/L. Patient was encouraged to do deep breathing exercises and lip pursed breathing, to increase food rich in iron and vitamin C, to perform ROM exercises and to avoid strenuous activities. IVF was regulated on prescribed rate.

SGOT result was 50u/l, which indicates impaired liver function. The patient was administered with Lactulose 20ml ODHS PRN to eliminate feces and to possibly to eliminate ammonia.

FBS show normal result of 100.11mg/dl and Blood uric acid 7.4mg/dl which is slightly elevated. Pt. was encouraged to avoid foods containing large amount of sugar such as soft drinks and chocolates and limit carbohydrates intake; as well as foods rich in uric acid such as organ meat and limit intake of nuts and beans.

Other laboratory results were BUN 4.0 mmol/L which is within normal limits and

Crea 1.7mg/dl which is risk for impaired renal function. The pt was currently on low salt low fat diet and instructed on regular urine elimination and to prevent urine stasis.

On August 05, 2013 final diagnoses were: ACS NSTEMI, CAP moderate risk, COPD acute exacerbation, TIA, HTN stage II, and the patient was ordered may go home, health teachings was given and instructed of take home medications. August 06, 2013 the patient was finally discharged @ 1:30pm in good condition.

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