d.

Discharge Planning

A. General Condition

The patient was wearing a white shirt and maong pants. He manifests good
grooming and he appears neat. He shows increased strength and a relieved
condition. He is able to tolerate activities minimally as he experiences fatigue in
simple performance of ADLs.

B. METHOD

M> Advised to take home medications on time as prescribed such as::

• Mixtard 22 ”u” SC am, 12 “u” pm

• Clopidogrel 75mg/tab OD

• Captopril 75mg 1/2 tab OD

• Cordarone 200 mg TID for 2 days then BID

• Atorvastatin 40 mg OD

• Vastarel MR BID

• Imdur 60mg ½ tab BID

• Recormon 5,000 “u” to be given by Dr. Cunan on December 10, 2009

E> the patient is encouraged to have mild physical activity if tolerated.

T> None

H> the patient is advised to prevent emotional stress, avoid fatty, salty and sweet foods.
Compliance to the home management planning is encouraged. Patient was advised to
have some to take his blood pressure at home to monitor elevation on blood pressure
which may precipitate another heart attack.

O> patient is advised to go back on December 10, 2009 for follow check up with Dr.
Cunan.

D> the patient was encouraged to have a low salt, low fat diet.

159
 e. Follow – up Home Visits

Home Visit (December 22, 2009 - Tuesday)

Upon the assessment and interaction of the health care team with the patient, the
patient verbalized easy fatigability in doing even his activities of daily living, especially
during walking and taking bath. There is also visible weakness in long hours of
standing. The pt. manifested pale palpebral conjunctiva, cold clammy skin, good skin
turgor, dry skin, capillary refill of < 3 sec, with no edema, but with crackles on right lung
field.

T= 36ºC

RR= 21 cpm

PR= 65 bpm

BP= 130/80 mmHg

Health teachings were given such as to sit instead of standing during activities or
shower to conserve energy and to ask for assistance when doing extreme range of
motions. Upon interview, the patient revealed that there are some modifications and
changes on his medications:

• Lasix 40mg ½ tab OD M-W-F

• Aldactone 25mg/tab 1 tab OD

• Losartan 50 mg 1 tab OD

• Clopidogrel (Platexan) 1 tab OD

• Amiodarone 500mg 1tab OD

• Lanoxin 0.25mg ½ tab M-W-F

• Imdur 300mg ½ tab od

• Atorvastatin 40mg OD
160
 • Mixtard 27/14

Home Visit (December 26, 2009 - Saturday)

Upon the assessment and interaction of the nursing students with the patient, the
patient verbalized easy fatigability in doing even his activities of daily living, especially
during walking and after taking bath. There is also visible weakness in long hours of
standing. The patient verbalized that he cannot perform his past daily regimens like
going jogging and exercising. The pt. manifested pale palpebral conjunctiva, cold
clammy skin, good skin turgor, dry skin, capillary refill of < 3 sec, with no edema.

T= 36ºC

RR= 20 cpm

PR= 70 bpm

BP= 130/80 mmHg

Health teachings were given such as to sit instead of standing during activities or
shower to conserve energy and to ask for assistance when doing extreme range of
motions.

Home Visit (December 28, 2009 - Monday)

Throughout the home visits, it was been noted by the researchers that the home
management plan are being followed strictly by the patient. Same with the previous
home visits the patient is still complaining of easy fatigability even with simple activities.

T= 36.8ºC

RR= 16 cpm

PR= 77 bpm

BP= 120/80 mmHg

161