Cardiovascular Disease

A case study

Submitted by:

Delos Santos, Judith

Dela Torre, James
Dela Cruz, Michelle
Elacion, Marijie
Elizalde, April
Lim, Michelle

Submitted to:

Mr. Candelario, RN
 Case Abstract

This is a case of a 66 years old patient with a history of Diabetes Mellitus and
Hypertension. He has been taking Diamicron and Calciblock but uncompliant to his
medication. Until one day prior to admission, the patient experienced sudden onset of
right-sided body weakness associated with slurring of speech and elevated blood
pressure. He was immediately brought to Ospital ng Muntinlupa by his relatives and was
diagnosed of CVD infarct. Due to his serious condition, the doctor advised him for
admission in the said institution.

Learning Objectives:

At the end of the rotation, the student nurse was able to:

1. Describe the pathophysiology, clinical manifestation and treatment of CVD

infarct.
2. Formulate nursing diagnosis that address the needs of a patient with CVD
3. Plan and implement nursing interventions as a framework for care of a patient
with CVD
4. Evaluate outcomes for effectiveness and achievement of nursing care
Biographical data

Name: Mr. CVD

Age: 66
Gender: Male
Civil Status: Married
Address: Cupang, Muntinlupa
Date of Birth: February 26, 1944
Place of Birth: Sta. Cruz, Laguna
Educational Attainment: College graduate
Occupation: Philippine navy
Religion: Born Again Christian
Dialect/Language Spoken: English, Tagalog
Health Insurance: Phil Health
Admitting Diagnosis: CVD infarct

Nursing History

Major Concern: right- sided body weakness, slurred speech and elevated blood pressure
History of Major Concern:
One day PTA, the patient was experiencing right- sided body weakness,
slurring of speech and elevating blood pressure but the patient was not complaining of
headache, dizziness, and nausea and vomiting and chest pain

Current Health Status

I. Physiologic Mood

A. Activity

Frequency and regularity of exercise: twice a week

Duration of physical exercise: 1-2 hours
Are there any limitations in activity: yes
Is there any complaint of fatigue: yes
Length of time since last exercise: 3 hours

B. Rest

Usual no. Of hours of sleep and rest at night: 5-6 hours

At daytime: 2 hours
No. Of hours of sleep and rest to feel rested: 2 hours
Any change in sleep/rest pattern: none Specify: none

C. Nutritional Metabolic Pattern:

 Food Preference: leafy vegetables, meats and fruits
Food Restrictions: fatty foods like pork, beef, and chicken, junk foods
and simple sugars like cakes, pastries
Volume/Type of fluid per day: 1-1.5 L
Source of drinking water supply: distilled water
Frequency of taking meals at home: 3-4 times/day
At restaurant: once/month
Any change in diet: yes Specify: diabetic diet
Any change in appetite: yes Specify: increased appetite
Medications used: diamecron, ?????????/

D. Elimination Pattern:

a. Bladder
Frequency and amount of urination per day: 10-12 x a day
Color and odor of urine: light yellow, odorless
Any discomfort in urination: none

b. Bowel
Frequency of bowel elimination/day: once/day
Consistency and color of stools: semi- formed, brownish
Any changes in bowel elimination: none

E. Fluid and Electrolytes:

Skin turgor: poor skin turgor

Condition of mucous membrane: pale
Edema: lower extremities both feet
K, Ca, Na supplements: none

F. Oxygenation and Circulation

Do you smoke? No
No. Of cigarettes/day: None
Presence of cough: positive
History of Asthma, PTB, in the family: None
History of Heart Diseases, HPN? Hypertension
Chest pain (location, frequency, duration, and type of pain): none
Shortness of breath/difficulty of breathing: none
Coldness of extremities: yes
Usual or known blood pressure: 140/90

G. Senses
Any difficulty/disturbance in:

Sight: blurred vision

 Hearing: none
Touch: none
Taste: none
Smell: none
How long have you had the difficulty? Since I was in college during my
training in Philippine navy
How do you manage it: using my reading glass
How has this affected your lifestyle? It was really difficult for him
especially during training

H. Skin Integrity

Pigmentation: brownish
Temperature: 36.9 degree Celsius warm( ) cold( ⁄ )
Character:
Smooth (⁄ ) Rough(× ) Soft(⁄ ) Dry(× )

Perspiration and odor problems: None

Use of any beauty aids: Johnson Baby Powder

I. Endocrine Function
Do you have a history of: Diabetes (⁄ ) Thyroid problem ( )

J. Neurological Function:

Level of consciousness: awake, conscious

Orientation: unable to speak clearly/slurring of speech but well oriented to
place time and person
Gait: unable to stand due to affected right- sided part of the body
Changes in facial, mouth, and neck function: with facial asymmetry
Pupil Reactivity: Sluggish
Sense of pain and light touch: perceives pain
Deep tendon reflex:

Self Concept Mode:

I. Personal Self:
How do you describe yourself: simple, gentleman but sometimes strict
father
Your moods: swing mood but most of the time has good mood

What do you like about yourself? Brave and responsible husband and
father
What do you want to change in yourself? Easily mad

What is preventing you? I, myself

 Are there changes in the way you feel about yourself or your body?

Since illnesses started, yes I felt bad and mad always maybe because of my
condition being useless and incapable of doing anything

II. Physical Self:

What is your highest weight? 75 kgs. Lowest weight? 58 kgs,
How do you feel about yourself and your appearance? Happy and contented
so far. Not a big deal for me
Any physical changes on your body? Yes I gained too much weight
Was it difficult to accept the changes? No
How have these changes affected your relationship with others? Nothings
gonna change when it comes to relationship. They were all supportive and
sincere about my conditions.

III. Personal Values:

What do you consider as the most valuable/important in your life? God and
my family

With what and who do you find a source of strength or meaning? God
Almighty

Is religion important to you? Yes very important

Why? Its inspires and strengthens me spiritually

Does illnesses/hospitalization interfere your religion practices? No, I

always keep on praying and believing the power of God

IV. Role Function Mode

Type of family Structure: Nuclear family
How many members in the family? 8 members
Who is the breadwinner? I and my wife my eldest daughter at the same time
Who makes the decisions for the family? My wife and I
How does the family feel about the illness/hospitalization? They are all
worried about my condition
Family expectations: very loving, caring family
Expectation of yourself? Medical treatment compliance
Expectations from attending physicians: effective medical services-oriented
Expectation from the nurse: taking good care of me

V. Interdependence Mode
Frequency of interaction in the family: everyday
Duration of interaction: 6 hours
Frequency of interaction outside family: 6 hours
 Do you belong to the social group? Yes, Philippine Navy Association
Close friend? A lot of friend
What do you do when you are tense or under stress? Eat and relax
How do you make decisions? Alone or with assistance
With whom? With my wife
How does your family cope in time of crisis? Through prayers
Any big change in your life last year? Yes
What were the changes? When my eldest daughter gave birth to my first
grandson. How great feeling it is to become a lolo

Physical Examination:

Date Performed: 2/22/2010 No. Of hospital Days: 3

I. Measurements
1.1 Weight 80 kgs Height: 5’6’’
I.2 Vital signs
T= 36.2°C PR= 67 RR= 21 BP=150/110
I.3 When Applicable:
Head Circumference: 58 cm
Chest circumference: 98 cm
Abdominal circumference: 88 cm

II. Regional Examinations

2.1 Hair: Distribution: equal appearance: hygiene: good
Density of growth: normal
2.2 Skin: Color: pale Abnormalities: moist and cold
2.3 Head: Size: symmetrical/equal Shape: round
2.4 Face: Symmetry: asymmetrical Facial Musculature:
2.5 Eyes: Color(optic disk and conjuctiva): pale Visual Acuity:
Pupil Response: decreased papillary response
Accomodation:
2.6 Ears: Symmetry: equal Discharges or Growth: some earwax
no discharges
Hearing Ability: normal
2.7: Nose: Condition of mucosa: pale Discharges and growth: none
2.8 Mouth and pharynx:
Lips: pink, moist,and smooth
Tongue and Mucous membrane: pink, moist, and free of swelling
and lesions
Teeth: looseness/presence of cavity: have dental restoration
Mucous membrane: color: pale
Gums: color: pink and smooth
2.9 Neck: Symmetry: equal Growth: none
Lymph Nodes: none
2.10 Chest walls (anterior and Posterior):
Symmetry: equal Shape: have downward equal shape at the rib
cage
Respiratory movements: smooth and even
Breath sounds: crackles
2.11 Breast and Axillary:
Symmetry: even Retraction: none
Discharge: none Lymph Nodes: none
Growth: none
2.12 Heart:
Rhythm: normal Sounds: normal
Intensity: normal Murmur: none
Extra sounds: none
2.13 Abdomen:
General contour: symmetric Tenderness: negative
Bowel sounds: normal Abdominal sounds: tympanic
2.14 Genitals
Growth: none Discharges: none
2.15 Anus and rectum: normal
2.16 Extremities
Strength: right sided body weaknesses
ROM:
Upper extremities
Right: no movement
Left: normal, full and active
Lower extremities
Right: no movement
Left: move strong and lift
GLASCOW COMA SCALE

Date performed: 2/22/2010

Time performed: 10:00 am

Level of Consciousness

Eyes Response: 4 (spontaneous)

Motor Response: 6 (obey command)
Verbal Response: 2 (incomprehensible sounds)

Pupils

Right:
Size: 2-3 mm
Reaction: sluggish
Left:
Size: 2-3mm
Reaction: sluggish
Extremities:
Upper:
Right: 1 (no movement)
Left: 5 (normal)
Lower:
Right: 1 (no movement)
Left: 4 (move strong lift and hold)