ALVAREZ, RONILYN A.

BSN III-B2

BGHMC 7-3 MED 5 November 17-19, 2016

A. BIOGRAPHICAL INFORMATION
Name: Marciana Paraan
Age: 79y/o
Gender: Female
Religion: Roman Catholic
Birthdate: April 15, 1937
Birthplace: Taba-ao, Kapangan, Benguet
Address: Taba-ao, Kapangan, Benguet
Chief complaint: dizziness, weakness of left lower extremity
Diagnosis: Hypertensive urgency
B. HEALTH HISTORY
1. HISTORY OF PRESENT ILLNESS
- One day prior to admission, patient experienced dizziness with no associated
symptoms of chest pain, body weakness or chest heaviness. Few hours prior to
admission, patient had dizziness with associated right upper and lower extremity, with
loss of consciousness. Consult done at a nearby hospital and managed as a case of
CVD, and Hypertension. Clonidine drip was started, Mannitol 200 ml IV bolus was given.
Patient was then referred to the institution for further management.
2. PAST MEDICAL HISTORY
- Patient had heart failure but was not admitted to a tertiary care unit, with unrecalled
date and unrecalled medications and was apparently non-adherent to therapeutic
regimen once the patient was feeling better. With gallstones but did not have surgical
management and treated with unrecalled medications and did not adhere to
therapeutic regimen because of claimed absence of signs and symptoms. No surgical
operations done. No history of any trauma or any past hospitalizations. Unrecalled
childhood diseases and no known allergies to foods or drugs.
3. HEREDOFAMILIAL HISTORY
- No known history of hypertension on paternal and maternal side. No known history of
diabetes, cardiovascular diseases, asthma, cancer, stroke, and congenital diseases on
both sides of the family.
4. PERSONAL/SOCIAL HISTORY
- Patients has no history of any substance abuse, tobacco/cigarette smoking or excessive
alcohol use.
5. ENVIRONMENT
- Patient lives in a 2 storey house, non-congested neighborhood in a concrete and wood
house, well-ventilated rooms, living with 5-8 family members. Garbage is collected
every week. Toilet is indoor, open-sealed.
6. GYNECOLOGIC HISTORY
- Unrecalled age at first menstruation period and menopausal age
7. OBSTETRIC HISTORY
- With an OB score of: G5P5 (5-0-0-5)

C. PHYSICAL ASSESSMENT

D. NURSING DIAGNOSES PRIORITIZATION

ALVAREZ, RONILYN A.
PROBLEMS

BSN III-B2

BGHMC 7-3 MED 5 November 17-19, 2016

THEORIES USED

JUSTIFICATIONS

1. Ineffective tissue
perfusion related to
elevated blood
pressure secondary to
Hypertensive Urgency

ABC ( Airway,
Breathing,
Circulation) CIRCULATION

This is the most prioritized problem because

according to the ABC Theory, Circulation is
prioritized which is preceded by Airway and
Breathing. Blood circulation is one of the most
important functions in the body. It supplies
oxygen to the brain and other organs. Its what
makes our bodies work.

2. Acute pain related

to possible biological
injuring agents

Maslow's Hierarchy of
Needs - The need
for comfort
(Physiological
need)

This is the 2nd prioritized problem because

individuals in pain will not be concerned about
other basic human needs until pain is relieved.

3. Risk for Activity

Intolerance related to
deconditioned status

Maslow's Hierarchy of
Needs - The need to
move
(Physiological
need)

This is the 3rd prioritized problem because

according to Maslows Hierarchy of Needs,
Activity should be satisfied in the physiological
needs but placed third because it is only a risk
problem.

4. Ineffective health
maintenance related
to impaired ability to
make appropriate
judgments

Maslow's Hierarchy of
Needs - Safety need
for protection
(Safety and
Security needs)

This is the 4th prioritized problem because

according to Maslows Hierarchy of Needs,
Safety and Security needs should be satisfied
second. Ineffective health maintenance is a
safety need for protection and is an actual
problem

5. Risk for Injury

related to advancing
age and history of
falls

Maslow's Hierarchy of
Needs - Anticipated
safety need for
protection (Safety
and Security
needs)

This is the 5th prioritized problem because

according to Maslows Hierarchy of Needs, an
individual should be from any kind of threat to
safety. It is placed fifth because it should be
satisfied only preceded by physiological needs
and is only a risk problem.