Copd Final G

i.
INTRODUCTION
Acute myocardial infarction (AMI or MI), commonly known as a heart attack, is a
disease state that occurs when the blood supply to a part of the heart is interrupted. The
resulting ischemia or oxygen shortage causes damage and potential death of heart
tissue. It is a medical emergency, and the leading cause of death for both men and
women all over the world. Important risk factors are a previous history of vascular
disease such as atherosclerotic coronary heart disease and/or angina, a previous heart
attack or stroke, any previous episodes of abnormal heart rhythms or syncope, older
ageespecially men over 40 and women over 50, smoking, excessive alcohol
consumption, the abuse of certain illicit drugs, high triglyceride levels, high LDL ("Lowdensity lipoprotein") and low HDL ("High density lipoprotein"), diabetes, high blood
pressure, obesity, and chronically high levels of stress in certain persons.
Heart diseases constitute the second most common cause of death. Coronary
heart disease death rates have shown consistent declines over the past 15 years, with
men having almost twice the death rates of women. The difference in rates has
remained constant over the years. In 2008, the age-standardized death rate for men
was 105 per 100 000 resident population, compared with 56 for women. The incidence
of acute myocardial infarction events among adults has generally decreased since
1990. The incidence rate for men is about twice that for women; in 2007, the agestandardized incidence rate for men was 179 per 100 000 resident population,
compared with 79 for women.
Myocardial infarction is a leading cause of morbidity and mortality in the United States.
Approximately 1.3 million cases of nonfatal MI are reported each year, for an annual incidence
rate of approximately 600 cases per 100,000 people. The proportion of patients diagnosed with
NSTEMI compared with STEMI has progressively increased. MI continues to be a significant
problem in industrialized countries and is becoming an increasingly significant problem in
developing countries.
This is a case of patient FT, 89 years old, male, Roman Catholic, from Talakag,
Bukidnon; admitted at MRH on July 21, 2014 with chief complaints of difficulty
breathing, chest pain. His previous diagnosis from last hospitalization includes
hypertension.
In organizing patient care, the group utilized Primary Nursing, also known as
relationship-based nursing. The group viewed themselves as the primary nurses. They
were the ones who assessed and established the nursing care plans which were then
clearly communicated to the student nurses directly assigned to the patient when the
group was not present. Feedback was then sought from them with regards to the
evaluation and progress of the clients condition.
Physician
Charge
Nurse
Health care
Organization
Resources
Clinical
Instructor
Primary
Student
Nurse
Staff Nurse
Associate
Level 3
Student
Nurse
Staff Nurse
A. GENERAL OBJECTIVES:
This case presentation seeks to enhance the students knowledge with
regards to the patients general health and disease condition, its pathophysiology,
possible complications, treatment plan and medical regimen. This also seeks to
assimilate the nurse skills through application of several nursing interventions and
medical management. Furthermore, this case presentation intends to improve the nurse
attitude by conveying open-mindedness and utilizing therapeutic communication all
throughout the activity.
B. SPECIFIC OBJECTIVES:
The nurse aim to achieve the following objectives in 1 hour of case presentation:
1. Accurately present a thorough general health assessment of the client which
includes physical assessment and family history taking.
2. Effectively discuss and elaborate actual signs and symptoms of disease exhibited
by the client
3. Thoroughly discuss, explain, and elaborate the nature of the disease process
4. Efficiently provide appropriate and proper nursing diagnosis in line with the clients
medical condition
5. Skillfully formulate nursing care plans for the different problems identified
6. Appropriately provide nursing interventions according to the standards of nursing
practice
7. Effectively apply the learned concepts and theories of disease
8. Efficiently appraise the effectiveness and efficacy of nursing interventions
rendered to the client
9. Impart the outcome of the rendered nursing interventions
10. Convey the significance of clients response to the rendered nursing interventions
11. Correctly provide concise and concrete information to the audience with regards to
the patients disease condition.
12. Appropriately provide appropriate environment for learning for the audience
C. SCOPE AND LIMITATION
The data presented in this case was primarily obtained from nurse-patient
interaction as well as with the significant other who partly served as informant. Further
information is based on the patients chart. The nurse were only able to render care to
the patient during the assessment on July 21, 22, and 23, 2014 since the formers
clinical exposure at MRH already ended during that period. Additionally, subsequent
assessments after the 3rd visit were not done because the patient was then discharged.
The Nursing Care Plans presented herein were implemented at a very limited time but
were endorsed and continued by the student nurse assigned to the patient.
Nevertheless, the evaluation bears the nursing outcome observed upon assessing the
patient
II. ASSESSMENT
COLLEGE OF NURSING
Xavier University
Ateneo de Cagayan
LEVEL IV
NURSING HISTORY and ASSESSMENT RECORD
Dates of Assessment:
February 4, 2010 first assessment day
February 7, 2010 second assessment day
February 10, 2010 third assessment day
I. PATIENTS PROFILE
Name of Patient: FT
Age: 89 y.o.
Admitting Diagnosis: COPD Acute exacerbation

Latest Diagnosis: PTB III
Religion: Roman Catholic
Name of Attending Physician: Dr. Capatoy
Civil Status:
Married
Date and Time of Admission: July 21, 2014; 7:15 AM
Language/Dialect Spoken: Cebuano
July 21, 2014
Temperature 36.4 oC
Pulse 92 bpm
Respiration 34 cpm
Blood Pressure 120/70 mmHg

July 22, 2014
Temperature 37 oC
Pulse 85 bpm
Respiration 30 cpm

July 23, 2014
Temperature 36.6 oC
Pulse 76 bpm
Respiration 24 cpm

4
Height: 54
Weight 55 kls.
CHIEF COMPLAINT/REASON FOR HOSPITALIZATION: Weakness; facial asymmetry

and slurring of speech
HISTORY OF PRESENT ILLNESS: Patient FT, 89 years old, male, Roman Catholic,
from Talakag, Bukidnon; admitted at MRH on July 21, 2014 at 7:15 am with chief
complaints of facial asymmetry associated with slurring of speech and chest pain.
Last January 16, 2010, the patient experienced pain on the nape, dyspnea and
verbalized to his daughter, naglain ako ginhawa which alarmed the SO to seek
medical assistance at MRH and was then admitted. He was then discharged on Jan.
23, 2010, with discharge diagnoses of CAD, AF with RVR (AF with CVR); CHF Class IV
(Clan I, Stage C); Stress Hyperglycemia; and BPH. Patient discharged with home
medications: Digoxin 0.7g/tab OD before lunch, Metoprolol 50mg tab BID, Rovustatin
10 mg/tab OD, Losartan 50mg tab OD AC BF, Spiriva rotacup thru inhaler OD,
Allopurinol 100 mg 1tab OD and Avodart 1tab OD.
Patient discharged with foley
catheter, such apparatus taken with good compliance.

The patient recovered well after the hospitalization he was able to continue
activities without dyspnea and fatigue. He was able to move freely in the house, perform
ADLs and did not manifest any symptoms of his illness, but SO verbalized persisting
coughs a week prior to admission. On the evening of Feb. 2, 2010, the patient slept
early. 3 hours PTA at around 4:00 am, the patient was found restless and moaning in
bed. Upon observation by the daughter, she noticed that the patients face was already
asymmetrical, accompanied with shortness of breath and slurring of speech. The patient
was also observed clutching his chest and grimacing in pain. The situation above
prompted the family to bring the patient to the hospital (MRH). Thus lead to the patients
admission.
FOOD AND DRUG ALLERGIES: Pls. specify: no known food and drug allergy
PAST MAJOR ILLNESS, OPERATIONS, AND HOSPITALIZATIONS
ILLNESS/HOSPITALIZATION
Admitted for CAD, AF with RVR (AF with
DATE
Jan. 2010
CVR); CHF Class IV (Clan I, Stage C);

5
Stress Hyperglycemia; and BPH at MRH

Hypertension
2005
Family Medical History

(X) Heart disease: Paternal side
(-) Renal Disease
(X) Hypertension: Both maternal and paternal side
(-) Cancer
(X) Stroke: Maternal side
(-) Substance
(-) Lung Disease
( ) Others
Abuse
Others:
_______________________________________________________________
II. FUNCTIONAL PATTERN
A. NUTRITION/METABOLIC PATTERN
Meal Pattern: Patient normally eats three times a day (breakfast, lunch and dinner).
Reports of patients fondness of eating fatty food (e.g. humba, chicharon).
Appetite:
( ) Good
( X ) Fair
( ) Poor
Changes in Eating Habits?
( ) No
( X ) Yes
Appetite Changes?
( ) No
( X ) Yes
Weight loss/gain: 55kls-50kls
Special Diet: Hypoallergenic Diet
TEETH:
Comments/Nursing Problem Identified:
July 21, 2014- Patient is on hypoallergenic diet
July 22, 2014 Patient is still hypoallergenic diet
July 23, 2014 Patient is on DAT but hypoallergenic diet
Dili jud sya pwede makakaon ug konrta sir kay mo kalit lang sya ka hangak inig human
niya kaon, mao mamili nalag mi ug pagkaon na pwede sa iyaha as verbalized by the
SO.
B. ELIMINATION PATTERN
BLADDER
(X) No difficulty
( ) Dysuria
( ) Oliguria
6
( ) Incontinence
( ) Nocturia
( ) UTI
( ) Stones
( ) Anuria

February 4, 2010 Patient is with foley bag catheter.
Dili man namo mabantayan kung galisod ba siya og ihi o dili kay gi catheter man siya.
Daghan biya pod iyang ihi kay dali ra man mapuno ang kanang sudlanan usahay. as
verbalized by the SO.
Urine output: 2, 700 cc (in 24 hours)
February 7, 2010 Mao ra man gihapon, naka catheter ra gihapon siya. as
February 10, 2010 Patient is still with Foley bag catheter.
Urine output: 480 cc (in 6-2 Shift)
BOWEL
July 21, 2014
( X ) No difficulty
July 22, 2014
( ) Constipation
July 23, 2014
( ) Constipation
( ) Incontinence
( ) Constipation
( ) Ileostomy
( ) Laxative aids
February 4, 2010 Pila na kaadlaw wala siya kalibang. Pero naa man siya tambal
kalibang na man pud siya. As verbalized by SO
February 7, 2010 Nakalibang man siya. Humok tungod sa iyang tambal as
February 10, 2010 Makalibang na siya adalw. as verbalized by the SO.
C. SLEEP/REST PATTERN
( X ) No difficulty
( ) Yes
Use of sleeping aids: ( ) No
(X) Yes

7
Diretso-diretso man iyang tulog. Sa iya sa kapoy sa iyang sakit mao tingali diretsodiretso iyang tulog. As verbalized by SO
Activities of Daily Living
(I = Independent, A = With Assistance, D =
Dependent)
Eating (D)
Bathing (D)
Grooming (D)
ACTIVITY LEVEL
Toileting (D)
(
) Active
Dressing (D)
Ambulating (D)
(X) Sedentary

February 4, 2010 Kadtong wala pa siya nagsakit, maglihok-lihok man pod siya sa
balay. Karon dili man niya kaayo malihok iya kamot kay luya. Karon kay magghigda
ug matulog ra gyud siya.. as verbalized by the SO. The patient is very dependent to
his SO due to his condition.
February 7, 2010 Karon na naa siya sa hospital, maghigda ra gyud na siya kay luya
man gud pod siya. as verbalized by the SO.
Kami man gyud ga ilis ug gapakaon niya kay maglisod man siya ug lihok-lihok. as
February 10, 2010 Makaya-kaya naman niya nga maglihok-lihok nga siya ra. Pero
amo ra gihapon siya i-assist kay basin ma-unsa bah. as verbalized by the SO.
E. COGNITIVE PERCEPTION PATTERN
Glasses
( ) No
(X) Yes
Contact Lens
( ) Yes
( ) Right
( )
Left
Hearing Aids (X) No
( ) Yes
Prosthesis
( ) Yes
( )
Right
( ) Right ( ) Left
( )
Left
Makakita pa man pod siya gamay pero kung magbasa siya kay gagamit siya ug
antipara. Karon naa siya sa hospital kay dili man niya ginagamit iyang antipara.
Makadungog pa man pod na siya. as verbalized by the SO.
F. BEHAVIOR PATTERN (COPING/VALUES)
BEHAVIOR
(X) Relaxed
) Mildly Anxious
) Very anxious
) Moderately anxious
Psychiatric History: none

SUBSTANCE ABUSE (If yes, pls. indicate frequency/# of packs/glasses per day)
Tobacco
(X) No
Drugs
(X) No
Alcohol
Cigarette/Cigar/Pipe
) Yes _____________________________
(
) No
) Yes _____________________________
( X ) Yes approximately twice a week______
(X) No
) Yes
_____________________________
Comments/Nursing Problem Identified: Dili man na siya ga sigarilyo, ga inom siya
usahay ra pod dayon ginagmay ra pod. as verbalized by the SO.
G. PAIN
February 4, 2010
(
) No
(X) Yes (describe) crushing pain on the chest with a pain scale of 3/5, 5
being the highest

Present Pain Management: relaxation technique, deep breathing exercises, Dolcet 1 tab
TID; movement stopped, rest provided along with diversional activities
February 7, 2010
(
) No
(X) Yes (describe) crushing pain on the chest with a pain scale of 2/5, 5
being the highest

Present Pain Management: relaxation technique, deep breathing exercises, Dolcet 1 tab
TID
February 10, 2010
(X) No
( ) Yes (describe)
Present Pain Management:

_________________________________________________________________
February 4, 2010 - sighing with no intent to move unless absolutely necessary;
very slow movement with facial grimace; shortness of breath upon pain
onset with facial grimace and sighing
Murag gi-kumot. 3/5. Replied the client when asked by the SN regarding
the description of pain and the pain rate scale.
Muingon na siya na sakit iyahang dughan. Sauna ga reklamo naman siya
nga musakit iyang dughan labaw na kanang mahago siya. as verbalized
by the SO.
February 7, 2010 Gasakit man gihapon iya dughan usahay. as verbalized by the
SO.
February 10, 2010 - Kaluoy sa Ginoo wala na siya ga-reklamo of sakit sa
iyang dughan as verbalized by SO.
H. SEXUALITY/REPRODUCTION PATTERN
Date of last menstrual period (LMP): N/A
Date of Last Pap Smear: N/A
Is the patient pregnant? (
) No (
) Unsure (
) Yes, no of weeks _____________
Breast (cyst, lump, discharge)
) No
) Yes
Testicular/prostate problem:
) NA
) No
(X) Yes
10
Birth Control:
(X) NA
(
) No
) Yes (describe) ______________________________
Comments/Nursing Problem Identified: Patient is diagnosed with benign prostatic

hyperplasia.
I. ROLE RELATIONSHIP PATTERN
Occupation: none
With whom does patient live? Family (one son, one daughter and 2 grandchildren)
Anticipating to return home?
(X) Yes
) No (specify the reason)
________________________
Person(s) available to assist at home: children
Comments/Nursing Problem Identified: The patient is taken care of by his children.
Wala man gyud lain makatabang ug makabantay ni papa mao na kami ra gyud
magbantay. as verbalized by the SO.
III. PHYSICAL ASSESSMENT
(Indicate subjective and objective cues for abnormalities noted)
A. NEUROLOGICAL ASSESSMENT
Alert and oriented to person, place and time?
Subjective
February 4, 2010
Gahapon, dili na siya kabalo kung aha siya. Unya murag ga-tanga ra siya
pirminti. Naa pud usahay na dili siya kaila sa amo matulog lang dayun siya
balik., as verbalized by the SO.
February 7, 2010
Makaila naman siya. Katulgon na siya pero dili na kaayo pareha sa una.
Murag wala lang siya kabalo sa oras ug adlaw kay naa siya diri sa hospital,
as verbalized by the SO.
February 10, 2010
11
Naa ko ospital karun. Mga alas kwatro naman tingale sa hapon as

verbalized by the client.
Objective
February 4, 2010
GCS score: eyes 4, verbal 4, motor 4 =12 moderate brain injury,
conscious and coherent but drowsy. Not oriented to person, place and time.
February 7, 2010
GCS score: eyes 4, verbal 4, motor 5 = 13 minor brain injury, There is
difficulty remembering persons, place and time but patient is able to
recognize close members of the family.
February 10, 2010
GCS score: eyes 4, verbal 4, motor 6 = 14 minor brain injury. The
patient can recognize close members of the family, is oriented and is able to
respond to questions although slurring of speech is still present.
Pupils equally round & reactive to light?
No paresthesia (weakness) or paralysis of extremities?
Subjective
February 4, 2010
Luya na iyang tuo nga side sa lawas., as verbalized by the SO.
February 7, 2010
Kami ra gyud magilis ug pakaon niya kay maglisod siya ug lihok-lihok., as verbalized
by the SO.
February 10, 2010
Medyo okay naman siya. Pero luya ra gihapon daw iyang tuo. As verbalized
by SO.
Objective
February 4, 2010 R: weakness on upper and lower extremities present, Grade 1 : no
active range of motion & No muscle resistance; L: normal ROM, Grade 3: full active
range of motion & No muscle resistance
12
February 7, 2010 with complaints of generalized body weakness, R: Grade 2:

Reduced active range of motion & No muscle resistance; L: Grade 4: full active range of
motion & reduced muscle resistance
February 10, 2010 still with complaints of generalized weakness, R: Grade
4: full active range of motion & Reduced muscle resistance; L: Grade 4: full
active range of motion & Reduced muscle resistance
No difficulty in speech or swallowing noted?
Subjective
February 4, 2010 Maglisod man siya ug istorya dili kaayo mi kasabot., as
verbalized by the SO. Sa tubo ra man ginapaagi iyang pagkaon, dili mi maka
ingon na maglisod siya ug tulon. as verbalized by the SO.
February 7, 2010 Maglisod man gihapon siya ug istorya., as verbalized by the SO.
Gaapason niya iyang ginhawa kung magsturya siya. As verbalized by SO.
February 10, 2010 Lugaw ra gyud iya pwede kaonon kay galisod pa siya ug tulon.
Mukaon man pod siya pero gamay ra kay murag wala man siya gana. Mao man sab
ang ingon sa doctor na lugaw lang sa ang ipakaon sa iya. as verbalized by the SO
Makasturya siya pero dili kaayo ingon ana ka klaro..
Objective
February 4, 2010
Slurred speech noted
Difficulty in expressing thoughts verbally and use of facial or body expression
due to condition.
February 7, 2010
There is difficulty swallowing thus patient is still on NGT feeding.
February 10, 2010
There is difficulty uttering words.
Difficulty in expressing thoughts verbally and use of facial or body expression
due to condition.
There is improved swallowing. Patient is on soft diet.
13
B. RESPIRATORY ASSESSMENT
Resp. 12 to 22 breath/minute at rest?
Subjective
February 4, 2010
Gi oxygen man siya kay maglisod siya ug ginhawa. Gi ubo man gud siya., as
Naay plema iyang ubo, medyo white na sticky., as verbalized by the daughter.
February 7, 2010
Galisod gyud siya ug ginhawa tungod sa iyang ubo., as verbalized by the SO.
Nakaluwa siya ug dugo ganina buntag., as verbalized by the SO.
February 10, 2010
Medyo arangan na iya pamati kay wala naman pod siya gi oxygen pero naa gihapon
siyay ubo., as verbalized by the SO.
Objective
February 4, 2010
RR=26 cpm, shallow breathing, use of accessory muscles
February 7, 2010
RR= 24 cpm, shallow breathing
February 10, 2010
RR= 23 cpm, normal breathing
Respirations quiet & regular?
Breath sounds in both lung fields are clear?
Objective
Rales and ronchi present at both lung fields upon auscultation.
Positive for lung congestion based upon chest x-ray result, productive cough
noted.
Nail beds and lips pink.
Objective
Nail beds and lips are pale.
C. CARDIOVASCULAR ASSESSMENT
Regular apical pulse. Heart rate 60 to 100 beats/minute?
Objective
February 4, 2010
HR= 92 bpm, regular rhythm
February 7, 2010
HR= 85 bpm, regular rhythm
Dilated aorta based upon chest x-ray result.
February 10, 2010
14
HR = 76 bpm, regular rhythm

No complaints of chest pain?
Subjective
Gareklamo man siya nga sakit iyang dughan usahay., as verbalized by the SO.
Musakit iyang dughan usahay. Sauna ga reklamo naman siya nga musakit
iyang dughan labaw na kanang mahago siya. as verbalized by the SO.
Objective
Sighing with no intent to move unless absolutely necessary; very slow
movement with facial grimace; shortness of breath upon pain onset
associated with facial grimace and sighing
No Edema?
None noted
D. PERIPHERAL-VASCULAR ASSESSMENT
Extremities are pink, warm and movable within normal ROM?
Subjective
Pale extremities and cold.
Upper and lower extremities movable within ROM with assistance but there
weakness on the right side of the body.
Peripheral pulses palpable. No edema. No complaints of numbness
or calf tenderness?
Objective
February 4, 2010: Capillary refill: 4 sec
February 5, 2010: Oxygen Saturation =93%
E. GENITOURINARY ASSESSMENT
Voiding without discomfort or difficulty?
Urine clear, frequency within own pattern?
Subjective
15
Dili man namo mabantayan kung galisod ba siya og ihi o dili kay gi catheter man siya.
Daghan biya pod iyang ihi kay dali ra man mapuno ang kanang sudlanan usahay. as
Objective
February 4, 2010 -The patient is with foley bag catheter.
February 7, 2010 Mao ra man gihapon, naka catheter ra gihapon siya. as
February 10, 2010 Patient is still with foley bag catheter.
No unusual penile irritation/discharge noted?
No unusual penile discharges.
F. MUSCOLUSKELETAL ASSESSMENT
Absence of joint swelling and tenderness, no evidence of
inflammation?
Normal ROM of all joints?
Subjective
Kinahanglan gyud namo siya tabangan kung mulihok kay luya man gyud
siya., verbalized by the SO.
No muscle weakness?
Objective
Generalized body weakness noted.
No complaints of back pain?
No complaints of backpain
G. INTEGUMENTARY ASSESSMENT
Skin color within patients norm, skin warm, dry & intact?
16
Objective
Skin is cold, pale and saggy.
Pale mucous membranes.
Scalp condition: oily.
Decubiti/burns present?
) Yes
Medications
Topamax
Dolcet
Keppra
Coumadine
Piperacillin + Tazobactam
Combivent
Sucralfate
Fluimocil
Metoprolol
Citicoline drops
Perindopril
Warfarin (coumadin)
Digoxin
Rosuvastatin
Tiotropium Bromide (Spiriva Rotacap)
Allopurinol
Dutasteride (Avodart)
LACTULOSE
( X ) No
Indications
To prevent migraine headache
Moderate to severe pain.
adjunctive therapy in the treatment of
partial onset seizures in adults
Myocardial Infarction
Moderate to severe nosocomial
pneumonia
To prevent bronchospasm in people with
chronic obstructive pulmonary disease
(COPD) who are also using other
medicines to control their condition
Short term treatment of duodenal ulcer.
For acute & chronic resp tract affections w/
abundant mucus secretions
Myocardial Infarcion
Used to treat cerebrovascular disease
Used to treat high blood pressure Essential
hypertension.), and reduction of risk of
cardiac events in patients with a history of
myocardial infarction
Used to prevent heart attacks, strokes, and
blood clots in veins and arteries.
Used in treating an abnormal heart rhythm
Used to treat high cholesterol
Used in treatment of bronchial spasms
(wheezing) associated with chronic
obstructive pulmonary disease.
It reduces the production of uric acid in
your body
Avodart is used to treat benign prostatic
hyperplasia (BPH) in men with an enlarged
prostate.
Used to treat constipation
17
Body Map:
February 4, 2010 first assessment day
1. Nasogastric Tube on left nostril
2. O2 cannula
3. IV on left arm
4. COPD
5. BPH
6. Myocardial infarction
7. Foley catheter

1. Nasogastric Tube on left nostril
2. O2 cannula
3. IV on left arm
4. COPD
5. BPH
7. Foley catheter

18
1. COPD
2. BPH
4. Foley catheter
LABORATORY RESULTS
COAGULATION
PROTHROMBIN TIME
Normal Value: 11-15 seconds
(2-3-10)
(2-7-10)
(2-10-10)
Prothrombin Time: 14.6 seconds
14.5 seconds
16.3 seconds
Control:
13.9 seconds
13.9 seconds
14.4 seconds
Percent Activity
:
70.6 %
71.2 %
62. 3
%
INR:
1.45
1.44
1.66
Ratio:
1.05
1.04
1.13
Interpretation: Slightly increased prothrombin time; Indicates that the patient has some
abnormal amounts of clotting factors VII and X. Increased clotting factors is due to
damage in the endothelial tissue of the heart.
ACTIVATED PARTIAL THROMBOPLASTIN TIME
Normal Value: 25 to 35 seconds
APTT : 27.7 seconds
Control
: 29.8 seconds
Ratio: 0.60
Interpretation: Normal
BLOOD SUGAR MONITORING RECORD

Normal Value: 70-125 mg/dl
19
HGT Results:
2-3-10 (8:40 am) : 93 mg/dl
2-3-10 (12 nn): 92 mg/dl
2-3-10 (6 pm): 91 mg/dl
2.4.10 (12 am): 94 mg/dl
2.4.10 (6 am): 124 mg/dl
2-10-10 (11pm): 107 mg/dl
Interpretation: Normal
CLINICAL CHEMISTRY
(2-5-10)
(2-7-10)
(2-9-10)
Normal Values:
Sodium
: 129
135
134
135-145 mmol/L
Potassium : 4.2
4.7
4.3
3.6-5.1 mmol/L
Creatinine : 1.2
1.0
0.8-1.5 mg/dl
Urea Nitrogen
: 16
9-20 mg/dl
ALT
: 49
21-72 U/L
Interpretation: slight decreased of sodium is of little clinical value
URINALYSIS (2-4-10)
Color
: Yellow
Transparency
: Turbid
Specific Gravity
: 1.000
pH
: 7.5
Sugar
: Negative
Protein
: Track
Microscopic Findings
RBC
: Loaded/ hpf
Pus Cells
: 0-1/ hpf
Epithelial Cells
: Rare
Bacteria
: Few
Interpretation: there is a presence of hematuria; possible bacterial infection
BLOOD CHEMISTRY
Parameters
COMPLETE BLOOD COUNT
Total WBC
Total RBC
Hemoglobin
Hematocrit
MCV
MCH
MCHC
Result
6.0
3.70
12.6
35.5
95.4
34.1
17.0
4.9
14.2
35.5
94.3
33.3
35.7
Normal Values
5.4
4.09
13.9
39.1
95.6
34.0
35.3
35.5
3.0-10.0 x 109/liter
2.60-5.30 x 1012/liter
12.70-16.70mmol/L
40.0-49.70%
70.0-97.0 fl
28.0-34.0 pg
32-36%
20
Platelet Count
109/liter
DIFFERENTIAL COUNT
Neutrophils
Lymphocytes
Monocytes
Eosinophils
Basophils
RDW-CV
69.2
20.6
6.5
1.2
0.5
14.3
124
109
84.9
10.9
9.7
0.3
0.2
14.4
58.9
30.5
8.2
1.7
0.7
14.5
145
150.0-390.0 x
27.00-72.00 %
20.00-50.00 %
8.00-14.00 %
0.00-6.00 %
0.0-1.0 %
11.50-14.50 %
Interpretation:
Increased WBC,shows the bodys effort to transport cells and substances nvolved in
immune reactions
Decreased Hematocrit,indicates ineffective transport of oxygen and carbon dioxide.
Decreased Platelet Count suggests ineffective clotting at breaks in blood vessels.
Increased Neutrophil is due to the necrotic of tissue present from MI. Neutrophils are
the major components in phagocytosis.
Decreased Lymphocytes, indicates severity of illness due to the bodys lack of
production of principal agents for the bodys immune response.
Decreased Monocyte levels can indicate bone marrow injury or failure
X-RAY REPORT
(2-4-10)
Heart is enlarged with CT ratio of .78. The aorta is atheromatous and sclerotic. Minimal
haziness in the right base. Rest of the lungfields are clear. Hemi diaphragms and sulci
are intact.
Impression:
Cardiomegaly LV and LA form. Atheromatous thoracic aorta. Consider Pneumonia, right
base
(2-5-10)
No significant change of the densities in right base (edema and/or pneumonia)
Cardiomegaly LV form
Atherosclerosis thoracic aorta
Rest of findings unchanged
CT SCAN REPORT
21
(2-1-10)
Plain CT Scan of the brain with serial arial views disclose the following findings.
> There are punctuate hypodensities in the peri ventricular white matter. There is a 2.2
cm hypodense focus in the left mid peri ventricular white matter.
> Ventricles are not dilated.
> Midline structures are intact.
> There is prominence of the sulci and cisterns.
> The middle cerebral arteries are calcified.
> Cerebellum, brain stem, petro mastoids, sinuses, orbits, and sellar areas are
unremarkable.
Impression:
Consider small vessel ischemic changes both peri ventricular white matter..
Consider an infarct, left mid peri ventricular white matter likely old.
Mild cerebro cerebellar atrophy.
Arteriosclerosis of the middle cerebral arteries.
ECG (2-3-10)
Interpretation:
ST segment depression and T-wave inversion indicates pattern of ischemia
Q wave present tissue necrosis
Atrial fibrillation present
S3 and S4 present
22
ECG RESULTS
III.
23
ANATOMY AND PHYSIOLOGY

The Heart
The heart is a hollow, muscular organ located in the center of the thorax, where it
occupies the space between the lungs (mediastinum) and rests on the diaphragm. It
weighs approximately 300 g (10.6 oz), although heart weight and size are influenced by
age, gender, body weight, extent of physical exercise and conditioning, and heart
disease. The hearts consists of three distict layers of tissue: endocardium (inner most
layer), myocardium (middle layer) consists of muscle fibers and is the actual contracting
muscle of the heart, and the epicardium (which covers the outer surface of the heart).
The heart pumps blood to the tissues, supplying them with oxygen and other nutrients.
The heart also consists of four chambers: two upper collecting chambers (atria) and two
lower pumpung chambers (ventricles). The right atrium recieves deoxygenated blood
from the body. The blood moves to the right ventricle, which pumps it to the lungs
against low resistance. The left atrium recieves oxygenated blood from the lungs. The
blood flows into the left ventricle (the heart's largest, most muscular chamber), which
pumps it against high resistance into the systemic circulation. The pumping action of the
heart is accomplished by the rhythmic contraction and relaxation of its muscular wall.
During systole (contraction of the muscle), the chambers of the heart become smaller
as the blood is ejected. During diastole (relaxation of the muscle), the heart chambers
fill with blood in preparation for the subsequent ejection. A normal resting adult heart
beats approximately 60 to 80 times per minute. Each ventricle ejects approximately 70
mL of blood per beat and has an output of approximately 5 L per minute.
Respiratory Tract
The respiratory system is an organ system which is used for gas exchange. the
respiratory system generally includes tubes, such as the bronchi, used to carry air to the
lungs, where gas exchange takes place. A diaphragm pulls air in and pushes it out.
The respiratory system can be conveniently subdivided into a conducting zone
and a respiratory zone. The conducting zone starts with the nares (nostrils) of the nose,
which open into the nasopharynx (nasal cavity), which in fact opens into the oropharynx
(behind the oral cavity). The oropharynx leads to the larynx (voicebox), which contains
24
the vocal cords, and connects to the trachea (wind pipe) which leads down to the
thoracic cavity (chest) where it divides into the right and left "main stem" bronchi, which
continue to divide up to 16 more times into even smaller bronchioles. The bronchioles
lead to the respiratory zone of the lungs which consists of respiratory bronchioles,
alveolar ducts and the alveoli, the multi-lobulated sacs in which most of the gas
exchange occurs. Ventilation of the lungs is carried out by the muscles of respiration.
Inhalation is initiated by the diaphragm and supported by the external intercostal
muscles. During vigorous inhalation (at rates exceeding 35 breaths per minute), or in
approis filtered, warmed, and humidified as it flows to the lungs.aching respiratory
failure, accessory muscles of respiration are recruited for support. These consist of
sternocleidomastoidAir moves through the body in the following order: Nostrils, Nasal
cavity, Oropharynx Larynx (voice box), Trachea (wind pipe), Thoracic cavity (chest),
Bronchi (right and left), Alveoli (site of gas exchange). The major function of the
respiratory system is gas exchange. Respiration consists of a mechanical cycle of
inhalation and exhalation, with gaseous exchange occurring in between.
Inhalation is driven primarily by the diaphragm. When the diaphragm contracts,
the ribcage expands and the contents of the abdomen are moved downward. This
results in a larger thoracic volume, which in turn causes a decrease in intrathoracic
pressure. As the pressure in the chest falls, air moves into the conducting zone. Here,
the air is filtered, warmed, and humidified as it flows to the lungs.
Exhalation, on the other hand, is typically a passive process. The lungs have a
natural elasticity; as they recoil from the stretch of inhalation, air flows back out until the
pressures in the chest and the atmosphere reach equilibrium.
During forced inhalation, as when taking a deep breath, the external intercostal
muscles and accessory muscles further expand the thoracic cavity.
During forced exhalation, as when blowing out a candle, expiratory muscles
including the abdominal muscles and internal intercostal muscles, generate abdominal
and thoracic pressure, which forces air out of the lungs.
Upon inhalation, gas exchange occurs at the alveoli, the tiny sacs which are the
basic functional component of the lungs. The alveolar walls are extremely thin (approx.
0.2 micrometres), and are permeable to gases. The alveoli are lined with pulmonary
25
capillaries, the walls of which are also thin enough to permit gas exchange. All gases
diffuse from the alveolar air to the blood in the pulmonary capillaries, as carbon dioxide
diffuses in the opposite direction, from capillary blood to alveolar air. At this point, the
pulmonary blood is oxygen-rich, and the lungs are holding carbon dioxide. Exhalation
follows, thereby ridding the body of the carbon dioxide and completing the cycle of
respiration.
Prostate gland
The prostate sits in front of and below the bladder and is wrapped around the
urethra. That's why prostate problems (e.g. enlargement, infection, inflammation, etc.)
may interfere with a man's ability to urinate and/or to have sex. The prostate happens to
be where it is because it is needed for ejaculation, and the ejaculate passes through the
same urethra as the urine does.
The prostate gland's primary job is to add special fluid to the sperm before it is
ejaculated out from the penis. Sperm is produced in the testicles. From the testicles it
moves up into the epididymis, where it matures, then into the two small, muscular tubes
called the vas deferens, which coil up and around the bladder to the seminal vesicles.
During ejaculation, the seminal vesicles and the prostate gland contract and
expel contents into the prostatic portion of the urethra and then down this route it
washes out toward the tip of the penis. The two ejaculatory ducts pass through the
prostate and open into the prostatic urethra.
One of the prostate's main duties is to add to the seminal fluid nutrients and other
substances which mix with, nourish, protect, and carry sperm out of the penis upon
ejaculation. The prostate also helps to push the semen containing sperm with sufficient
power out of a man's body on its way to fertilizing a woman's egg. The prostate
functions as a gland and contains muscle fibers which contract and relax.
26
IV. PATHOPHYSIOLOGY
A. Narrative
Coronary Artery Disease (CAD) is a disease characterized by the accumulation of
plaque within the layers of the coronary arteries. The plaques progressively enlarge,
thicken and calcify, causing a critical narrowing (75% occlusion) of the coronary artery
lumen, resulting in a decrease in coronary blood flow and an inadequate supply of
oxygen to the heart muscle. The most widely accepted cause of CAD is atherosclerosis.
Angina pectoris caused by inadequate blood flow is the most common manifestation of
CAD. Nonmodifiable risk factors includes: age (risk increases with age), male sex
(women typically suffer from heart disease 10 years later than men due to
postmenopausal decrease in cardiac-protective estrogen), and family history. Modifiable
risk factors include: elevated lipid levels, hypertension, obesity, sedentary lifestyle and
stress. Myocardial Infarction (MI) refers to a dynamic process by which one or more
regions of the heart to experience a severe and prolonged decrease in oxygen supply
because of insufficient coronary blood flow; subsequently, necrosis or death to the
myocardial tissue occurs. The onset of MI may be sudden or gradual, and the
progression of the event to completion takes approximately 3 to 6 hours. MI is one
manifestation of Acute Coronary Syndromes. Sever CAD (greater than 70% narrowing
of the artery) precipitates thrombus formation. The first step in thrombus formation
involves plaque rupture. Platelets adhere to the damaged area. Activation of the
exposed platelets causes expression of glycoprotein IIb/IIIa receptors that bind
fibrinogen. Further platelet aggregation and adhesion occurs, enlarging the thrombus
and occluding the artery. Heart Failure is a clinical syndrome that results from the
progressive process of remodeling, in which mechanical and biochemical forces alter
the size, shape and function of the ventricles ability to pump enough oxygenated blood
to meet the metabolic demands of the body. Cardiac compensatory mechanisms
(increases in heart rate, vasoconstriction, heart enlargement) occur to assist the
struggling heart. These mechanisms are able to compensate for the hearts inability to
pump effectively and maintain sufficient blood flow to organs and tissue at rest.
Physiologic stressors increase the workload of the heart and may cause these
mechanisms to fail and precipitate the clinical syndrome associated with a failing heart
(elevated ventricular/atrial pressures, sodium and water retention, decreased cardiac
output and circulatory and pulmonary congestion. These compensatory mechanisms
may hasten the onset of failure because they increase afterload and cardiac work. In
Diastolic failure, a stiff myocardium impairs the ability of the left ventricle to fill up with
blood. This causes and increases pressure in the left atrium and pulmonary vasculature
causing the pulmonary signs of heart failure. With the pulmonary signs of heart failure,
the patients mucus secretion and fluid accumulation in the lungs causes obstruction in
the airways. With this, elasticity of lung fibers are lost. There is impaired expiratory
flowrate, increased air trapping which can cause airway collapse. The collapse of the
alveoli or the airways there is decreased surface for gas exchange. This causes COPD.
With the patients old age and imbalance in hormones (e.g. androgens) hypertrophy
of the nodules and capsules in the prostate occurs. The hypertrophy obstructs urine
flow. Acute retention may occur together with othe lower urinary tract infections
27
B. Schematic
28
V. Medical Management
A. General Management
IDEAL MEDICAL MANAGEMENT
Rationale
I. Laboratory Test
1. Complete Blood Count
A complete blood count (CBC) will alert the doctor

to an infection as well as telling him, among other
things, how much hemoglobin is present in your
blood. Hemoglobin is the iron-containing pigment
in your blood that carries the oxygen from your
lungs to the rest of your body.
2. Arterial Blood Gases
In COPD, the amount of air that you breathe into

and out of your lungs is impaired. Arterial blood
gases (ABGs) measure the oxygen and carbon
dioxide levels in your blood and determine your
body's pH and sodium bicarbonate levels. ABGs
are important in forming a diagnosis of COPD as
well as in adjusting oxygen therapy.
3. Computerized Tomography (CT) Scan
Although a CT is not required for making a

diagnosis of COPD, the doctor may order it when
its indicated (infection is not resolving, change of
symptoms, consideration for surgery etc.) While a
chest X-ray shows larger areas of density in the
lungs, a CT scan is more definitive, showing fine
details that a chest X-ray does not. Sometimes,
prior to a CT scan, material called contrast is
injected into the vein. This allows your doctor to
see the abnormalities in your lungs more clearly.
4. Pulmonary Functions Tests (PFTs)
PFTs are used to evaluate lung function and

determine the extent of the damage within your
lungs. The most common PFT is spirometry.
A noninvasive method, pulse oximetry measures
how well your tissues are being supplied with
oxygen. A probe or sensor is normally attached to
the finger, forehead, earlobe or bridge of the nose.
5. Pulse Oximetry
Pulse oximetry can be continuous or intermittent.

A measurement of 95% to 100% is considered
normal.
6. Sputum Culture
Sputum or mucus from your lungs can be
obtained by coughing it up or suctioning. Your
sputum specimen will be evaluated in a laboratory
and will provide your doctor with a guide in both
the diagnosis and treatment of your lung disease.
29
7. Lung Diffusion Studies

Measuring the diffusing capacity of the lungs for
carbon monoxide (DLCO), tells the doctor how
well the air that you breathe travels from your
lungs to your blood. Abnormal results mean that
your lungs do not have the ability to move gases
in and out of the lungs properly. Other pulmonary
function tests may also be done as an adjunct to
DLCO.
To assess heart size and presence or absence of
heart failure and pulmonary edema. May also
assist in differential diagnosis.
8. Chest x-ray
The doctor will perform an initial chest X-ray when

trying to reach a diagnosis of COPD, and then
throughout your treatment to monitor your
progress.
is helpful if the diagnosis is in question, can define
the extent of the infarction and can identify
complications, such as acute mitral regurgitation,
left ventricular rupture or pericardial effusion
9. Echocardiography
Defines the patient's coronary anatomy and the

extent of the disease. Whether all patients with
acute myocardial infarction should ideally undergo
cardiac catheterization is controversial and
present consensus is for angiography only if
indicated by recurrent chest pain or significant
ischemia shown by exercise ECG or perfusion
imaging. Patients with cardiogenic shock,
intractable angina despite medications or severe
pulmonary congestion should undergo cardiac
catheterization immediately.
10. Coronary angiography
11.
Myocardial
perfusion
scintigraphy using SPECT
imaging
Performed before hospital discharge to assess the

extent of residual ischemia if the patient has not
already undergone cardiac catheterization and
angiography.
12. Electrocardiography (ECG)

13. Digital Rectal Examination (DRE)
14. Prostate-Specific Antigen (PSA)

Blood Test
Features that increase the likelihood of infarction

are: new ST segment elevation; new Q waves;
any ST segment elevation; new conduction defect.
Other features of ischemia are ST segment
depression and T wave inversion.
This examination is usually the first test done. The
doctor inserts a gloved finger into the rectum and
feels the part of the prostate next to the rectum.
This examination gives the doctor a general idea
of the size and condition of the gland.
30
15. Rectal Ultrasound and Prostate

Biopsy
16. Cystoscopy
17. Urine Flow Study
II. Medications
1. Bronchodilators
To rule out cancer as a cause of urinary

symptoms, the doctor may recommend a PSA
blood test. PSA, a protein produced by prostate
cells, is frequently present at elevated levels in the
blood of men who have prostate cancer.
If there is a suspicion of prostate cancer, the
doctor may recommend a test with rectal
ultrasound. In this procedure, a probe inserted in
the rectum directs sound waves at the prostate.
The echo patterns of the sound waves form an
image of the prostate gland on a display screen.
To determine whether an abnormal-looking area is
indeed a tumor, the doctor can use the probe and
the ultrasound images to guide a biopsy needle to
the suspected tumor. The needle collects a few
pieces of prostate tissue for examination with a
microscope.
In this examination, the doctor inserts a small tube
through the opening of the urethra in the penis.
This procedure is done after a solution numbs the
inside of the penis so all sensation is lost. The
tube, called a cystoscope, contains a lens and a
light system that help the doctor see the inside of
the urethra and the bladder. This test allows the
doctor to determine the size of the gland and
identify the location and degree of the obstruction
The doctor may ask the patient to urinate into a
special device that measures how quickly the
urine is flowing. A reduced flow often suggests
BPH.
2. Glucocorticoids
Patients who have COPD are often prescribed
medications called bronchodilators.
Bronchodilators work by relaxing and expanding
the smooth muscle of the airways, making it
easier to breath.
3. Antibiotics
4. Oxygen Therapy
f you have COPD, your doctor may have

prescribed glucocorticoids, or steroids, as part of
your COPD treatment plan. This drug is liquefy the
mucus in your lungs which reduce the swelling in
your breathing tubes.
5. Flu Vaccine
People with COPD are more prone to bacterial

lung infections than most. And, if you have a
bacterial lung infection, then chances are your
31
doctor will have prescribed you an antibiotic.

Supplemental oxygen is a very helpful treatment
that enables many patients with severe COPD
lead a more normal and productive life.
6. Pneumonia Vaccine
Flu shots not only help prevent the flu, they can
help COPD patients fight off potential
exacerbations of symptoms, which are periods of
time when your COPD may worsen.
7. Antiplatelet agent
o
Clopidogrel
o
Warfarin (INR 2-3)
People with COPD are at greater risk for

developing pneumococcal pneumonia, a serious
lung infection that kills 1 out of every 20 people
who get it. And, even if you have already had a
pneumonia vaccine, the Centers for Disease
Control recommend that certain high-risk groups
have a second dose.
8. Beta blockers
9.Angiotensin-converting
inhibitors: Heparin infusion
Aspirin reduces mortality, non-fatal reinfarction,

non-fatal stroke and vascular death and the
survival benefit is maintained for at least four
enzyme years.
10.Prophylaxis against thromboembolism

11.Cholesterol lowering agents:
12.Heparin infusion
When started within hours of infarction, beta

blockers reduce mortality, non-fatal cardiac arrest
and non-fatal reinfarction. Unless contraindicated,
the usual regime is to give intravenously on
admission and then continue orally, titrate
upwards to the maximum tolerated dose.
Reduce mortality whether or not patients have
clinical heart failure or left ventricular dysfunction.
They also reduce the risk of non-fatal heart failure.
Titrate dose upwards to the maximum tolerated or
target dose. Measure renal function, U+E and
blood pressure before starting an ACE inhibitor (or
ARB) and again within 1-2 weeks.1
If not already receiving heparin by infusion, then

patients should be given regular subcutaneous
heparin until fully mobile
13. Alpha-adrenergic blockers
Ideally initiate therapy with a statin as soon as

possible on all patients with evidence of CVD
unless contraindicated - after discussing risks and
32
terazosin (Hytrin) in 1993

doxazosin (Cardura) in 1995
tamsulosin (Flomax) in 1997
alfuzosin (Uroxatral) in 2003
14. Anti-androgen agents
benefits with the patient, taking into account

comorbidities and life expectancy.
Is used as an adjunctive agent in patients
receiving alteplase but not with streptokinase.
Heparin is also indicated in patients undergoing
primary angioplasty
Finasteride (Proscar)
Relaxes the smooth muscle of the prostate and

bladder neck to improve urine flow and to reduce
bladder outlet obstruction.
III. Surgical Management
Primary percutaneous transluminal

coronary angioplasty (PTCA)
Prevent conversion of testosterone to
dihydrotestosterone to decrease glandular cell
activity and the size of prostate.
Balloon angioplasty
Inhibit production of the hormone DHT which is
involved with prostate enlargement.
Cardiac
angioplasty
angiography
Coronary artery bypass
Coronary revascularisation
Lung volume reduction surgery,

(LVRS)
Is regarded as superior to fibrinolysis in the

and management of acute myocardial infarction and is
becoming increasingly available for initial patient
care.
Following myocardial infarction reduces death,
non-fatal MI and stroke compared to thrombolytic
reperfusion. However up to 50% of patients
experience restenosis and 3% to 5% recurrent
myocardial infarction.
Are particularly indicated in patients with large
infarcts, anterior infarction, cardiogenic shock,
those who do not fit the criteria for thrombolytic
therapy, when thrombolysis is contraindicated or
has failed and have persistent ischaemia.
Surgery is indicated in patients in whom
angioplasty fails and in patients who develop
mechanical complications such as a ventricular
septal defect, left ventricular rupture, or a papillary
muscle rupture.
33
Transurethral Surgery
All patients should be offered a cardiological

assessment to consider whether coronary
revascularisation is appropriate.
Open Surgery
This operation can improve shortness of breath

and quality of life. This is also to improving
dyspnea by removing areas of major lung damage
from emphysema.
Laser Surgery
Photoselective Vaporization of the

Prostate (PVP)
Interstitial Laser Coagulation
IV. General Management

A. Diet
1. Monitor Your Body Weight
In this type of surgery, no external incision is

needed. After giving anesthesia, the surgeon
reaches the prostate by inserting an instrument
through the urethra.
In the few cases when a transurethral procedure
cannot be used, open surgery, which requires an
external incision, may be used. Open surgery is
often done when the gland is greatly enlarged,
when there are complicating factors, or when the
bladder has been damaged and needs to be
repaired. The location of the enlargement within
the gland and the patient's general health help the
surgeon decide which of the three open
procedures to use.
laser energy destroys prostate tissue and causes
shrinkage. As with TURP, laser surgery requires
anesthesia and a hospital stay. One advantage of
laser surgery over TURP is that laser surgery
causes little blood loss. Laser surgery also allows
for a quicker recovery time.
PVP uses a high-energy laser to destroy prostate
tissue and seal the treated area.
2. Drink Plenty of Fluids
3. Decrease Sodium Intake
Unlike other laser procedures, interstitial laser

coagulation places the tip of the fiberoptic probe
directly into the prostate tissue to destroy it.
Weighing yourself at least once a week will help

you keep your weight under control. If you are
taking diuretics or steroids, however, your doctor
may recommend daily weigh-ins. If you have a
weight gain or loss of 2 pounds in one day or 5
pounds in one week, you should contact your
34
doctor.
4. Avoid Overeating and Foods that

Cause Gas
5. Eat Smaller, More Frequent Meals that

Are High in Calories
6. Include Enough Fiber in Your Diet
Unless your doctor tells you otherwise, you should

drink 6 to 8, eight-ounce glasses of noncaffeinated beverages daily. This helps to keep
your mucus thin, making it easier for your body to
cough it up. Some people find it easier to fill a
container full of their daily fluid requirement in the
morning and spread it out during the day. If you try
this method, it is best to slow down your intake of
fluids towards evening so you are not up all night
urinating.
Eating too much salt causes your body to retain
fluid. Too much fluid can make breathing more
difficult. To reduce sodium intake, don't add salt
when you cook and make sure you read all food
labels. If the sodium content in food is greater
than 300 milligrams of sodium per serving, don't
eat it. If you are thinking of using salt substitutes,
make sure you check with your doctor first, as
some ingredients in them may be just as harmful
as salt.
When you overeat, your stomach can feel bloated
making breathing more difficult. Carbonated
beverages or gas-producing foods such as beans,
cauliflower or cabbage can also cause bloating.
Eliminating these types of beverages and foods
will ultimately allow for easier breathing.
B. Exercise
4 Types of Exercises for COPD
1. Stretching exercises
2. Aerobic exercises
3. Strengthening exercises
If you are underweight, eating smaller, more

frequent meals that are higher in calories can help
you meet your caloric needs more efficiently. This
can also help you feel less full making it easier to
breathe. Avoid low-fat or low-calorie food
products. Supplement your meals with highcalorie snacks like pudding or crackers with
peanut butter.
High fiber foods such as vegetables, dried
legumes, bran, whole grains, rice, cereals, pasta
and fresh fruit aid in digestion by helping your food
move more easily through your digestive tract.
Your daily fiber requirement should be between 20
to 35 grams of fiber each day.
These four types of exercises can help you if you
have COPD. How much you focus on each type of
35
exercise may depend upon the COPD exercise

program your health care providers suggests for
you.
4. Breathing exercises for COPD
Pursed lip breathing:
1. Relax your neck and shoulder
muscles.
2. Breathe in for two seconds through
your nose, keeping your mouth
closed.
3. Breathe out for four seconds
through pursed lips. If this is too
long for you, simply breathe out
twice as long as you breathe in.
Diaphragmatic breathing:
1. Lie on your back with knees bent.
You can put a pillow under your
knees for support.
2. Place one hand on your belly below
your rib cage. Place the other hand
on your chest.
3. Inhale deeply through your nose for
a count of 3. (Your belly and lower
ribs should rise, but your chest
should remain still.)
4. Tighten your stomach muscles and
exhale for a count of 6 through
slightly puckered lips.
For BPH patients
Kegel Exercises
lengthen your muscles, increasing your flexibility.

Stretching can also help prepare your muscles for
other types of exercise, decreasing your chance of
injury.
Use large muscle groups to move at a steady,
rhythmic pace. This type of exercise works your
heart and lungs, improving their endurance by
working your respiratory muscles. This helps your
body use oxygen more efficiently and, with time,
can improve your breathing. Walking and using a
stationary bike are two good choices of aerobic
exercise if you have COPD.
Involve tightening muscles repeatedly to the point
of fatigue. When you do this for the upper body, it
can help increase the strength of your breathing
muscles.
Helps you strengthen breathing muscles, get more
oxygen, and breathe with less effort. Here are two
examples of breathing exercises you can begin
doing for five to 10 minutes, three to four times a
day.
Use pursed-lip breathing while exercising. If you
experience shortness of breath, first try slowing
your rate of breathing and focus on breathing out
through pursed lips.
Don't do any heavy lifting.

Avoid straining when having a
bowel movement.
Don't drive or operate machinery.
C. Lifestyle
1. Smoking
First developed to assist women with childbirth,

are also useful for men in helping to prevent urine
leakage. They strengthen the muscles of the
pelvic floor that both support the bladder and
close the sphincter.
2. Exposure
36
D. Supplements
Some vitamins are useful for COPD
patients
1. NAC (N-acetyl cysteine)
2. L-carnitine
For BPH patients

Saw palmetto
Zinc
Pygeum africanum
Smoking is the underlying cause of the majority of

cases of emphysema and chronic bronchitis.
Anyone who smokes should stop, and, although
quitting smoking will not reverse the symptoms of
COPD, it may help preserve the remaining lung
function.
Exposure to other respiratory irritants, such as air
pollution, dust, toxic gases, and fumes, may
aggravate COPD and should be avoided when
possible.
Helps break down mucus. For that reason, inhaled

NAC is used in hospitals to treat bronchitis. NAC
may also protect lung tissue through its
antioxidant activity. Oral NAC, 200 mg taken three
times per day, is also effective and improved
symptoms in people with bronchitis in double-blind
research. Results may take six months. NAC does
not appear to be effective for people with COPD
who are taking inhaled steroid medications.
Has been given to people with chronic lung
disease in trials investigating how the body
responds to exercise. In these double-blind trials,
2 grams of L-carnitine, taken twice daily for two to
four weeks, led to positive changes in breathing
response to exercise.
Is a type of palm tree, also known as the dwarf
palm. Its primary medicinal value is in the oily
compounds found in its berries. Most dietary
supplements are composed of an extract or
powder derived from the berries. Saw palmetto is
believed to inhibit the actions of testosterone on
the prostate that causes prostate enlargement.
Is of interest because it accumulates in the
37
Cernilton
prostate, regardless of whether it is a normal

prostate or one enlarged from benign prostate
hyperplasia. It may have some protective
properties against prostate cancer.
is an evergreen tree native to Africa. Numerous
clinical trials in over six hundred patients have
demonstrated pygeum extract to be effective in
reducing the symptoms and clinical signs of BPH,
especially in early cases. However, in a doubleblind study that compared the pygeum extract with
the extract of saw palmetto, the saw palmetto
extract produced a greater reduction of symptoms
and was better tolerated. There may be
circumstances in which pygeum is more effective
than saw palmetto and as the two extracts have
somewhat overlapping mechanisms of actions,
they can be used in combination. The typical
dosage of pygeum extract is 50-100 mg twice per
day.
An extract of flower pollen, has been used in
Europe to treat BPH for more than thirty-five years
and its effects have been confirmed in doubleblind clinical studies. The overall success rate of
Cernilton in patients with BPH is about seventy
percent. The typical dosage of is 63-126 mg two
to three times per day.
38
39
B. Drug Study
Name of
Drug
Citicoline
drops
Date
Ordered
02-09-10
Perindopri
l
02-09-10
Classification
CNS Stimulant
angiotensinconverting
enzyme (ACE)
inhibitors
Dose/
Frequency
2cc TID
Mechanism of
Action
Citicoline
increases blood
flow and O2
consumption in
the brain. It is
also involved in
the biosynthesis
of lecithin.
Specific
Indication
Used to
treat
cerebrova
scular
disease.
5m tab
OD per BF
Block the action

of a chemical in
the body called
angiotensin
Used to
treat high
blood
pressure
Contraindication
Contraindicated
to any allergies
(especially drug
allergies), kidney
problems, liver
problems, heart or
blood vessel
diseases, history
of angioedema,
diabetes.
Contraindicated in
patients known to
be hypersensitive
to this product or
Side Effects/
Adverse Effects
Headache, dry
cough, nausea,
Unusual
weakness, back
pain, diarrhea,
cramps, chest
pain, one-sided
arm or leg
weakness, vision
changes,tingling
of the hands or
feet, fever,
persistent sore
throat, dizziness,
fainting, unusual
change in amount
of urine,
yellowing of the
eyes or skin, dark
urine, stomach/
abdominal pain,
persistent fatigue,
persistent nausea,
Cough, fatigue,
asthenia,
headache,
disturbances of
Nursing Responsibilities
May be taken with or
without food. (Take w/
or between meals.)
Best taken on an
empty stomach at the
same time each day.
To avoid dizziness and
lightheadedness when
rising from a seated or
lying position, get up
slowly.
Limit your intake of
alcohol
Use caution when
exercising or during
hot weather as these
can aggravate
dizziness and
lightheadedness.
Follow all directions
exactly and take the
medication as
directed.
Do not stop taking this
drug without
consulting your
doctor. Some
conditions may
become worse when
the drug is abruptly
stopped.
Check BP before
giving the medication
and do not give the
medication if pulse is
40
converting
enzyme (ACE).
Normally ACE
produces
another
chemical,
angiotensin.
Angiotensin has
two actions:
Firstly it
acts on
blood
vessels
to make
them
narrow
Secondl
y it acts
on the
kidney
to
produce
less
urine
As perindopril
stops the
production of
angiotensin,
these actions
are reversed.
Therefore more
urine is
produced by the
kidneys, which
results in less
fluid in the
blood vessels.
The blood
vessels also
widen. The
Essential
hypertensi
on.), and
reduction
of risk of
cardiac
events in
patients
with a
history of
myocardia
l infarction
to any other ACE

inhibitor. It is also
contraindicated in
patients with a
history of
angioedema.
mood and/or
sleep, taste
impairment,
epigastric
discomfort,
nausea,
abdominal pain,
and rash,
dizziness,
diarrhea,
below 60bpm.
Comes as a tablet to
take by mouth. It is
usually taken once or
twice a day. Follow the
directions on your
prescription.
Perindopril controls
high blood pressure
but does not cure it.
Continue to take
perindopril even if you
feel well. Do not stop
taking perindopril
without talking to your
doctor.
Talk to your doctor
before using salt
substitutes containing
potassium. If your
doctor prescribes a
low-salt or low-sodium
diet, follow these
directions carefully
41
Warfarin
(coumadin
)
02-09-10
anticoagulant
(blood
thinner)
2.5mg
1/2tab OD
overall effect of
this is a drop in
blood pressure
and a decrease
in the workload
of the heart.
It reduces the
formation of
blood clots. It
works by
blocking the
synthesis of
certain clotting
factors. Without
these clotting
factors, blood
clots are unable
to form.
Used to
prevent
heart
attacks,
strokes,
and blood
clots in
veins and
arteries.
Contraindicated in
any localized or
general physical
condition or
personal
circumstance in
which the hazard
of hemorrhage
might be greater
than the potential
clinical benefits of
anticoagulation.
Bleeding and
necrosis
(gangrene) of the
skin. Bleeding can
occur in any
organ or tissue.
Bleeding around
the brain can
cause severe
headache and
paralysis.
Bleeding in the
joints can cause
joint pain and
swelling. Bleeding
in the stomach or
intestines can
cause weakness,
fainting spells,
black tarry stools,
vomiting of blood,
or coffee ground
material. Bleeding
in the kidneys can
cause back pain
and blood in
urine, purple,
painful toes, rash,
hair loss,
bloating, diarrhea,
and jaundice.
May be taken with

or without food.
Frequent blood
tests are performed to
measure blood
clotting time (protime)
during Coumadin
treatment.
Since it is
metabolized by the
liver and excreted by
the kidneys, caution is
needed in giving this
drug to patients with
liver and kidney
dysfunction.
Instruct the
patient to seek
immediate medical
care if symptoms of
overdose will
manifest, these
includes: bleeding
gums, bruising,
nosebleeds, heavy
menstrual bleeding,
and prolonged
bleeding from cuts.
42
02-09-10
Digoxin
Digitalis
glycoside
25mg
tab
Increases the
force of
contraction of
the muscle of
the heart by
inhibiting the
activity of an
enzyme
(ATPase) that
controls
movement of
calcium, sodium
and potassium
into heart
muscle. Calcium
controls the
force of
contraction.
Inhibiting
ATPase
increases
calcium in heart
muscle and
therefore
increases the
force of heart
contractions.
Digoxin also
slows electrical
conduction
between the
atria and the
ventricles of the
heart and is
useful in
treating
abnormally
rapid atrial
rhythms such
as atrial
Used in
treating an
abnormal
heart
rhythm
Contraindicated
to Digitalis
toxicity,
ventricular
tachycardia/fibrill
ation, obstructive
cardiomyopathy.
Arrhythmias due
to accessory
pathways (e.g.
Wolff-ParkinsonWhite syndrome).
Special
Precautions on
Cardiac
dysrhythmias,
hypokalaemia,
hypertension,
IHD,
hypercalcaemia,
hypomagnesaemi
a,
electroconversion
, chronic cor
pulmonale, aortic
valve disease,
acute myocarditis,
congestive
cardiomyopathies
, constrictive
pericarditis, heart
block, renal
impairment,
abnormalities in
thyroid function
Extra beats,
anorexia, nausea
and vomiting,
confusion,
dizziness,
drowsiness,
restlessness,
nervousness,
agitation and
amnesia, visual
disturbances,
gynaecomastia,
People of Asian descent

may absorb
rosuvastatin at a higher
rate than other people.
Make sure your doctor
knows if you are Asian.
You may need a lower
than normal starting
dose.
Take digoxin exactly as
prescribed by your
doctor. Do not take it in
larger amounts or for
longer than
recommended.
May be taken with or
without food.
Take it with full glass of
water.
Take the medication at
the same time of the
day.
Do not stop taking
digoxin without first
talking to your doctor.
Stopping suddenly may
make your condition
worse.
Store digoxin at room
temperature away from
moisture and heat.
43
Rosuvasta
tin
02-09-10
cholesterollowering
medication
10mg 1tab
OD
fibrillation, atrial
flutter, and atrial
tachycardia.
Blocks the
production of
cholesterol (a
type of fat) in
the body. It
works by
reducing levels
of "bad"
cholesterol
(low-density
lipoprotein, or
LDL) and
triglycerides in
the blood, while
increasing
levels of "good"
cholesterol
(high-density
lipoprotein, or
HDL).
Used to
treat high
cholestero
l.
Do not take this

medication if you
are allergic to
rosuvastatin, if
you have liver
disease.
Special
precaution on
patients with
kidney disease;
underactive
thyroid; muscle
disorder; epilepsy
or other seizure
disorder; an
electrolyte
imbalance (such
as high or low
potassium levels
in your blood); a
severe infection
or illness.
Muscle pain,
tenderness, or
weakness with
fever or flu
symptoms and
dark colored
urine;urinating
more or less than
usual, or not at
all; nausea,
stomach pain, low
fever, loss of
appetite, dark
urine, claycolored stools,
jaundice
(yellowing of the
skin or
eyes);chest pain;
or swelling in
your hands or
feet.
Take this
medication exactly as
it was prescribed for
you. Do not take the
medication in larger
amounts, or take it for
longer than
recommended by your
doctor.
You may take the

medicine with or
without food. Take
rosuvastatin at the
same time each day.
It is best to take
this drug in the
evening.
Take this medication
with a full glass of
water.
Avoid drinking
alcohol while taking
this medication.
Alcohol can increase
triglyceride levels, and
may also damage your
liver while you are
taking rosuvastatin.
Call your doctor at

once if you have
unexplained muscle
pain or tenderness,
muscle weakness,
fever or flu symptoms,
and dark colored
44
Tranexami
c acid
02-07-10
antifibrinolytic
agent
500mg,
PRN
Tranexamic acid
is a man-made
form of an
amino acid
(protein) called
lysine. It works
by blocking the
breakdown of
blood clots,
which prevents
bleeding.
short-term
control of
bleeding
Do not use
Tranexamic
Acid if: you
are allergic
to any
ingredient
in
Tranexamic
Acid, you
have blood
clots,
bleeding
within the
brain, or
eye
problems
(retinal
disease),
you are
colorblind,
you are
Nausea, vomiting,
diarrhea might
occur. If these
persist or worsen,
notify your doctor
promptly. Very
unlikely but report
promptly: vision
changes,
dizziness. If you
notice other
effects not listed
above, contact
your doctor or
pharmacist.
Diarrhea;
giddiness;
nausea; vomiting.
Severe allergic
reactions (rash;
hives; difficulty
urine.
Rosuvastatin is
only part of a
complete program of
treatment that also
includes diet,
exercise, and weight
control. Follow your
diet, medication, and
exercise routines very
closely.
Do not stop using
rosuvastatin without
first talking to your
doctor.
Store rosuvastatin
at room temperature
away from moisture
and heat.
Take this medication
exactly as prescribed
by your doctor. Do not
take it in larger
amounts or for longer
than recommended.
To be sure this
medication is not
causing harmful
effects, your vision
may need to be
checked while you are
using tranexamic acid.
Store this medication
at room temperature
away from moisture
and heat.
45
using factor
IX complex
concentrate
s or antiinhibitor
coagulant
concentrate
s.
Tiotropium
Bromide
(Spiriva
Rotacap)
02-03-10
Muscarinic
receptor
antagonist
1 cap OD
Opens the
respiratory tract
and makes
breathing
easier.
Tiotropium acts
on the lungs,
where it blocks
muscarinic
receptors on the
muscle
surrounding the
airways. The
natural chemical
in the body the
Acetylcholine
normally acts
Used in
treatment
of
bronchial
spasms
(wheezing)
associated
with
chronic
obstructiv
e
pulmonary
disease.
Titropium is
contraindicated in
Hypersensitivity.
Spiriva should not
be used for the
initial treatment of
acute episodes of
bronchospasm.
breathing;
tightness in the
chest; swelling of
the mouth, face,
lips, or tongue);
calf pain,
swelling, or
tenderness;
changes in vision
(disturbance of
color, sharpness,
or field of vision);
chest pain;
decreased
urination; onesided weakness;
pain, swelling, or
redness at the
injection site;
severe headache;
shortness of
breath; speech
problems.
Dry mouth, dry
throat, increased
heart rate, blurred
vision, glaucoma,
urinary difficulty,
urinary retention,
narrow-angle
glaucoma,
prostatic
hyperplasia or
bladder-neck
obstruction and
constipation.
Spiriva capsules
are packaged as a
blister card containing
two strips. Each strip
has three capsules.
When removing a
capsule from the
blister card, peel back
only the foil that is
covering the capsule
you are about to use.
The capsule's
effectiveness may be
reduced if it is not
used immediately after
the foil is opened. If
46
on these
receptors,
causing the
muscle in the
airways to
constrict and
the airways to
narrow.
Tiotropium
blocks the
muscarinc
receptors in the
lungs and
therefore stops
the action of
acetylcholine on
them. This
allows the
muscle around
the airways to
relax and the
airways to open.
you accidentally
remove the foil
covering any of the
other capsules, you
must throw them
away.
47
02-03-10
Allopurino
l
xanthine
oxidase
inhibitor
100mg
tab OD PO
Reduces the
production of
uric acid in your
body. Uric acid
buildup can lead
to gout or
kidney stones.
It reduces
the
productio
n of uric
acid in
your body.
Contraindicated
to allergic to any
these drugs, or if
you have: kidney
disease; liver
disease; diabetes;
congestive heart
failure; high blood
pressure
Diarrhea, nausea,
rash and itching,
and drowsiness,
skin rash.
Take each dose

water. To reduce your
risk of kidney stones
forming, drink 8 to 10
full glasses of fluid
every day, unless your
doctor tells you
otherwise.
Avoid drinking
alcohol. It can make
your condition worse.
Allopurinol can
cause side effects that
may impair your
thinking or reactions.
Be careful if you drive
or do anything that
requires you to be
awake and alert.
Allopurinol can
lower the blood cells
that help your body
fight infections. This
can make it easier for
you to bleed from an
injury or get sick from
being around others
who are ill, so
advised patient to
boost immune system
by taking vitamin s
supplements and
eating nutritious food.
Allopurinol should
be discontinued
immediately at the
first appearance of
rash, painful urination,
blood in the urine, eye
48
Dutasterid
e
(Avodart)
02-03-10
1tab OD
PO
Avodart
prevents the
conversion of
testosterone to
dihydrotestoster
one (DHT) in the
body. DHT is
involved in the
development of
benign prostatic
hyperplasia
(BPH).
Dutasteride
helps improve
urinary flow and
may also reduce
your need for
prostate surgery
later on.
Avodart is
used to
treat
benign
prostatic
hyperplasi
a (BPH) in
men with
an
enlarged
prostate.
Contraindicated
to clinically
significant
hypersensitivity
(e.g., serious skin
reactions,
angioedema) to
AVODART or
other 5reductase
inhibitors.
Decreased libido
(sex drive);
decreased
amount of semen
released during
sex; impotence
(trouble getting or
keeping an
erection); or
breast tenderness
or enlargement.
irritation, or swelling
of the mouth or lips,
because these can be
a signs of an
impending severe
allergic reaction that
can be fatal.
Take 1 capsule
once a day.
Do not chew,
crush, or open an
Avodart capsule. The
capsule should be
swallowed whole.
Dutasteride can
irritate your lips,
mouth, or throat if the
capsule has been
broken or opened
before you swallows
it. It may take up to 6
months of using this
medicine before your
symptoms improve.
For best results, keep
using the medication
as directed.
Can be taken with
or without meals.
Take this medicine
water.
Do not stop taking
Avodart without
To be sure this
medication is helping
your condition, your
49
LACTULO
SE
02-03-10
laxative
20cc OD
Lactulose is a
synthetic sugar
used to treat
constipation. It
is broken down
in the colon into
products that
pull water out
from the body
and into the
colon. This
water softens
stools.
Lactulose is
also used to
reduce the
amount of
ammonia in the
blood of
patients with
liver disease. It
works by
drawing
ammonia from
the blood into
the colon where
Used to
treat
constipati
on.
This medication
contains
galactose and
lactose. Be sure
to tell your doctor
if you have
diabetes. And if
you are having
surgery or tests
on your colon or
rectum, tell the
doctor that you
are taking
lactulose.
Gas, belching or
stomach cramps,
diarrhea, nausea,
vomiting.
prostate will need to

be checked on a
regular basis.
Store Avodart at
room temperature
away from moisture
and heat. Avodart
capsules may become
soft and leaky, or they
may stick together if
they get too hot. Do
not use any capsule
that is cracked or
leaking.
This medication is
taken by mouth. To
improve the taste, the
dose may be mixed in
a glass of fruit juice,
water or milk.
Take this
medication as
prescribed. Take this
medication exactly as
prescribed by your
doctor. Do not take it
in larger amounts or
for longer than
recommended.
The liquid form of
lactulose may become
slightly darken in
color, but this is a
harmless effect.
However, do not use
the medicine if it
becomes very dark, or
if it gets thicker or
thinner in texture.
50
it is removed
from the body.
Topamax
Dolcet
Keppra
2/3/10
2/3/10
2/3/10
Anticonvulsan
t
Sulfamate
substituted
monosacchari
de
25mg
tab BID
PO
Analgesic
1 tab TID
Anticonvulsan
t
500mg/tab
1tab TID
May block a
sodium channel,
potentiate the
activity of GABA
and inhibit
kainates ability
to activate an
amino acid
receptor.
Inhibits
prostaglandin
synthesis
reducing
sensitivity of
pain receptors
May act by
inhibiting
To prevent
migraine
headache
Moderate
to severe
pain.
Hypersensitivity
to drug
Acute intoxication
w/ alcohol,
Hypersensitivity
adjunctive
therapy in
Hypersensitivity
to drug
Instruct the
patient that it may take
up to 48 hours before
you have a bowel
movement after taking
lactulose.
Store lactulose at
room temperature
away from moisture
and heat.
Dizziness,
Nervousness,
Chest pain,
Palpitations,
Anorexia, Muscle
Weakness.
Tell pt. to drink plenty of

fluids during therapy to
minimize risk of forming
kidney stones.
CNS & GI
disturbances.
Nausea,
dizziness,
somnolence.
Asthenia, fatigue,
hot flushes,
constipation,
diarrhea,
flatulence,
dry mouth,
pruritus,
increased
sweating, tinnitus.
Headache,
emotional lability,
Assess for level of pain

relief and administer
dose as needed but not
to exceed the
recommended total
daily dose.
Discontinue drug and
notify physician if S/Sx
of hypersensitivity
occur.
Take drug with food to
avoid GI disturbances.
Inform patient that drug

can be taken without
regard to food.
Drug can be taken with

or without food
51
Pyrrolidine
derivative
Piperaci
llin +
Tazobac
tam
2/3/10
Combiv
ent
2/3/10
Anti infectives
bronchodilato
r
combinations
simultaneous
neuronal firing
that leads to
seizure activity
4.5g IVTT
q 8h
1/2neb
+1cc
NSS q
6h
Inhibits cell wall

synthesis
during bacterial
multiplication
Reduces
bronchospasm
through two
distinctly
different
mechanisms,
anticholinergic
(parasympathol
ytic) and
sympathomimet
ic.
Simultaneous
administration
of both an
anticholinergic
and a beta2sympathomimet
ic is designed to
benefit the
patient by
producing, a
greater
bronchodilator
effect than when
the
treatment
of partial
onset
seizures in
adults
Moderate
to severe
nosocomi
al
pneumoni
a
To prevent
bronchosp
asm in
people
with
chronic
obstructiv
e
pulmonary
disease
(COPD)
who are
also using
other
medicines
to control
their
condition.
Immunocompromi
sed patients
Hypersensitivity
to drug
Caution to pts.
with bleeding
tendencies
Hypersensitivity
to drug
vertigo,
leukopenia,
neutropenia,
anorexia
Warn patient to use

extra care when sitting
up or standing up to
avoid falling
Headache,
seizure, fever,
hypertension,
abdominal pain,
dyspnea
Headache, Chest
Pain, Dyspnea,
Coughing,
Bronchospasm,
Palpitations
Ask patient about

allergic reactions pror to
med administration
Monitor
hematologic and
coagulation parameters
Tell patient to
report adverse reactions
promptly
Auscultate breath
sounds before and after
nebulization
Monitor HR and
RR
Do chest and back

tapping after
nebulization
52
Sucralfate
Fluimocil
2/3/10
2/3/10
Anti ulcer
Cough and
cold
preparations
,
Mucolytic
1 tab q6h
NGT
600mg/ta
b 1 tab in
100cc
H2O q
12h NGT
either drug is
utilized alone at
its
recommended
dosage.
An antiulcer that
forms an ulceradherent
complex with
proteinaceous
exudates such
as albumin, at
ulcer site. Also
forms a viscous,
adhesive barrier
on the surface
of intact
mucosa of the
stomach or
duodenum.
Protects
damaged
mucosa from
further
destruction by
absorbing
gastric acid,
pepsin and bile
salts.
N-acetylcysteine
(NAC) is the Nacetyl derivative
of the naturally
occurring amino
acid l-cysteine.
NAC has an
intense
fluidifying
action, through
Short term
treatment
of
duodenal
ulcer.
Allergy to
sucralfate
Constipation, Dry
mouth, Backach,
Diarrhea,
Dizziness,
Nausea, Rash,
Abdomina,
discomfort.
Monitor pattern of
bowel activity and stool
consistency
Increase fluid
intake as indicated.
For acute
& chronic
resp tract
affections
w/
abundant
mucus
secretions
.
Hypersensitivit
y to any of the
ingredients.
Caution in
asthma
patients.
nausea,
headache,
tinnitus,
stomatitis,
chills, fever,
bronchospasm
Occasional cases
of nausea and
dyspepsia
Take medication
on an empty stomach
Monitor for
hypersensitivity
reactions.
Dilute with normal

saline solution or sterile
water for injection
Inform patient that

nebulization may
produce an initial
disagreeable solution
but will soon disappear
53
its free
sulfhydryl
group, on the
mucoid or
mucopurulent
secretions by
cleaving the
intra- and
intermolecular
disulfide bonds
in glycoprotein
aggregates.
Metoprolol
2/3/10
Beta-Blocker
50mg
tab BID
Competetively
blocks betaadrenergic
receptors in the
heart and
juxtaglomerular
apparatus,
decreasing the
influence of the
sympathetic
nervous system
of these tissues
and the
excitability of
the heart,
decreasing
cardiac output
and the release
of rennin, and
lowering BP;
acts in the CNS
to reduce
sympathetic
outflow and
vasoconstrictor
tone
Rare cases of
urticaria
Myocardia
l Infarcion
Hypersens
itivity to
drug
Bronchos
pasm or
asthma
History of
obstructiv
e airway
disease
Sinus
bradycardi
a or partial
heartblock
& CHF
Heartfailure,
heartblock &
bronchospasm,
fatigue &
coldness of
extremities,
bradycrdia, CHF
pneumonitits,
depression,
hallucination,GI
retroperitoneal
fibrosis,
sclerosing
pentoritis
Monitor HR prior
to administration of
drug
Hold drug if
HR<60 bpm
Give drug with

food to facilitate
absorption
Instruct patient to
swallow tablet whole; do
not crush or chew
54
Digoxin
02-0710disconti
nued on
02-09-10
Digitalis
Glycoside
25 mg
tab
Increases the
force of
contraction of
the muscle of
the heart by
inhibiting the
activity of an
enzyme
(ATPase) that
controls
movement of
calcium, sodium
and potassium
into heart
muscle. Calcium
controls the
force of
contraction.
Inhibiting
ATPase
increases
calcium in heart
muscle and
therefore
increases the
force of heart
contractions.
Digoxin also
slows electrical
conduction
between the
atria and the
ventricles of the
heart and is
useful in
treating
abnormally
rapid atrial
rhythms such
as atrial
Used in
treating an
abnormal
heart
rhythm
Contraindicated
to Digitalis
toxicity,
ventricular
tachycardia/fibrill
ation, obstructive
cardiomyopathy.
Arrhythmias due
to accessory
pathways (e.g.
Wolff-ParkinsonWhite syndrome).
Special
Precautions on
Cardiac
dysrhythmias,
hypokalaemia,
hypertension,
IHD,
hypercalcaemia,
hypomagnesaemi
a,
electroconversion
, chronic cor
pulmonale, aortic
valve disease,
acute myocarditis,
congestive
cardiomyopathies
, constrictive
pericarditis, heart
block, renal
impairment,
abnormalities in
thyroid function
Extra beats,
anorexia, nausea
and vomiting,
confusion,
dizziness,
drowsiness,
restlessness,
nervousness,
agitation and
amnesia, visual
disturbances,
gynaecomastia,
People of Asian
descent may absorb
rosuvastatin at a
higher rate than other
people. Make sure
your doctor knows if
you are Asian. You
may need a lower than
normal starting dose.
Take digoxin
exactly as prescribed
by your doctor. Do not
take it in larger
amounts or for longer
than recommended.
May be taken with
or without food.
Take it with full
glass of water.
Take the
medication at the
same time of the day.
Do not stop taking
digoxin without first
Stopping suddenly
may make your
condition worse.
Store digoxin at
room temperature
away from moisture.
55
captopril
02-08-10
disconti
nued
angiotensin
converting
enzyme (ACE)
inhibitors
25mg
tab q12h
fibrillation, atrial
flutter, and atrial
tachycardia.
Angiotensin II is
a very potent
chemical that
causes the
muscles
surrounding
blood vessels to
contract,
thereby
narrowing the
vessels. The
narrowing of the
vessels
increases the
pressure within
the vessels
causing high
blood pressure
(hypertension).
Angiotensin II is
formed from
angiotensin I in
the blood by the
enzyme
angiotensin
converting
enzyme or ACE.
ACE inhibitors
are medications
that slow
(inhibit) the
activity of the
enzyme ACE
and decrease
the production
of angiotensin
II. As a result,
used for
treating
high blood
pressure
Contraindicated
to allergic to it; or
to other ACE
inhibitors (e.g.,
benazepril,
lisinopril); or if
you have any
other allergies
(including
allergies to bee or
wasp stings, or
exposure to
certain
membranes used
for blood
filtering).
Special
precaution on
patients with
specially of:
kidney disease,
liver disease, high
blood levels of
potassium, heart
problems, severe
dehydration (and
loss of
electrolytes such
as sodium),
diabetes (poorly
controlled),
strokes, blood
vessel disease
(e.g., collagen
vascular diseases
such as lupus,
dry, persistent
cough, abdominal
pain,
constipation,
diarrhea, rash,
dizziness, fatigue,
headache, loss of
taste, loss of
appetite, nausea,
vomiting, fainting
and numbness or
tingling in the
hands or feet.
Take this
medication by mouth,
usually two to three
times a day; or as
directed by your
doctor.
Take this drug on
an empty stomach,
one hour before a
meal.
Use this
medication regularly
in order to get the
most benefit from it.
Remember to use
it at the same time(s)
each day.
Do not take
potassium
supplements or salt
substitutes containing
potassium without
talking to your doctor
or pharmacist first.
56
NaCl
02-0710disconti
nued on
02-09-10
NaCl
supplement
1 tab TID
blood vessels
enlarge or
dilate, and
blood pressure
is reduced. The
lower blood
pressure makes
it easier for the
heart to pump
blood and can
improve the
function of a
failing heart.
Treatment of
deficiencies of
sodium and
chloride ions.
scleroderma).
Prevention
or
treatment
of
deficiencie
s of
sodium
and
chloride
ions (e.g.,
caused by
excessive
diuresis or
excessive
salt
restriction
).
Cautious to
patient with
congestive heart
failure, severe
renal
insufficiency, and
in clinical states
in which there is
sodium retention
with edema.
Peripheral
edemas,
pulmonary
edema.
Check and limit

sodium intake to
decrease adverse
effect reaction.
Checks signs of
edema and seek
medical advice if it is
manifesting.
57
VI. NURSING MANAGEMENT

Cues
Subjective:
Gi oxygen man siya kay
maglisod siya ug
ginhawa. Gi ubo man
gud siya., as verbalized
by the SO.
Naay plema iyang ubo,
medyo white na sticky.,
as verbalized by the
daughter.
Objective:
-productive cough with
copious bronchial
secretions
- dyspnea
- respiratory rate:
26 cpm (as of 2/4/10)
24 cpm (as of 2/7/10)
23 cpm (as of 2/10/10)
- abnormal breath
sounds (Rales and ronchi
present at both lung
fields upon auscultation)
-changes in respiratory
Nursing Dx
Ineffective airway
clearance related to
copious bronchial
secretions secondary
to chronic obstructive
pulmonary disease as
evidenced by
presence of
productive cough
Nursing Care Plan #1

Objectives
Intervention
Short term:
Independent:
At the end of 2 hours of nursing
1. Remind patient to drink
intervention the patient will be
fluids per cardiac
able to :
tolerance. Provide warm or
a. have the ability to effectively hot drinks instead of cold
cough up secretions
fluids
b. demonstrate behaviors to
improve or maintain clear
2. Assist the patient in
airway
coughing, huffing, and
c. demonstrate improved
breathing efforts to make
oxygen exchange, reduction them more productive
with breath sounds and
respirations noiseless
d. verbalize understanding of
cause & therapeutic
3. Assist with cupping and
management regimen
clapping activities q4h
while awake. Teach the
Long term:
family these procedures.
intervention, the patient will be
able to:
a. maintain airway free of
secretions
b. show evidence of clear lung
sound and eupnea
c. demonstrate absence of
congestion with breathing,
absence of cyanosis, ABG/
Rationale
-Hydration helps decrease
the viscosity of secretions
facilitating expectoration.
- Deep breathing and

diaphragmatic breathing
allow for greater lung
expansion and ventilation
as well as a more effective
cough
-Cupping and clapping
loosen secretions and
assist expectoration.
4. Assist the patient with

clearing secretions from
mouth or nose by:
-Providing tissues
-Using gentle suctioning if
necessary
-Teaching the family allows

them to participate in care
under supervision and
promotes continuation of
the procedure after
discharge.
Collaborative:
1. Administer medications
-This aids the patient in
Evaluation
Short term:
At the end of 2 hours, the
patient:
a. effectively
expectorated
secretions.
b. maintained airway
patency
c. demonstrated
improved oxygen
exchange as
evidenced by
reduction of breath
sounds and noiseless
respirations
d. verbalized
understanding of
cause & therapeutic
management regimen
Long term objectives were
not met.
58
depth
shallow(as of 2/4 and
2/7)
pulse oximetry results within

clients norms.
d. Demonstrate behaviors to
maintain clear airway.
such as antibiotics as
ordered. Noting
effectiveness and side
effect
recovering from the

disease process and
eliminate signs and
symptoms
-Positive for lung

congestion based upon
chest x-ray result
Cues
Subjective:
Galisod gyud siya ug
ginhawa tungod sa iyang
ubo., as verbalized by the
SO.
Gahapon, dili na siya
kabalo kung aha siya.
Unya murag ga-tanga ra
siya pirminti. Naa pud
usahay na dili siya kaila sa
amo. Magkabali0bali na
among ngalan. Kung
musturya pud siya, dili lang
kaayo klaro, as verbalized
by the SO.
Nursing Diagnosis
Impaired Gas Exchange
related to alveolar-capillary
membrane changes
secondary to chronic
obstructive pulmonary
disease
Objectives
Short Term:
By the end of 4 hours of
nursing interventions, the
client and his SOs must be
able to:
a. Verbalize understanding
of causative factors and
appropriate interventions
b. Participate in treatment
regimen within level of
ability
c. Demonstrate an
improvement in ventilation
and adequate gas
exchange.
Interventions
Independent:
1. Maintain oxygen
administration device
as ordered,
attempting to maintain
O2 Saturation at 90%
or greater.
Avoid high
concentration of O2 in
patients with COPD
unless ordered.
Long term:
By the end of 16 hours,
patient must maintain
Evaluation
-This provides for

adequate tissue
oxygenation. Hypoxia
stimulates the drive to
breathe in the chronic CO2
container patient. When
applying O2, close
monitoring is imperative to
prevent unsafe increases
in the patients PaO2
which could result in
apnea.
Short and long term goals

were fully met as
evidenced by:
2.
Position the patient

with proper body
alignment for optimal
respiratory excursion
(if tolerated, head of
bed at 45.)
-This prevents the

abdominal contents from
crowding the lungs and
preventing their full
expansion.
3.
Position patient to
-When the patient is
Objective:
-February 4, 2010
RR=26 cpm, shallow
Rationale
a. A decrease in the RR
and PR of the client after
interventions.
b. An increase in the
oxygen saturation of the
client.
c. Client already has alert
and responsive mentation
but still with slurring of
speech.
59
breathing
PR: 99 bpm
optimal gas exchange as

evidenced by arterial blood
gases and oxygen
saturation within the
patients usual range, alert
and responsive mentation
or no further reduction in
mental status, and no
signs of respiratory
distress.
facilitate ventilationperfusion matching

when a side-lying
position is used.
positioned on the side, the

good side down.
4.
Pace activities and

schedule rest periods
to prevent fatigue.
Assist with ADLs.
-Even simple activities

during bed rest can cause
fatigue and increase O2
demand, resulting in
dyspnea.
-productive cough
5.
Change position
every 2 hours.
-This facilitates secretion

movement and drainage.
-Oxygen Saturation: 93%

(with Oxygen inhalation)
-pale skin
6.
Encourage deep
breathing.
-This reduces alveolar

collapse
-February 7, 2010
RR= 24 cpm, shallow
breathing
-February 10, 2010
RR= 23 cpm, normal
breathing

Cues
Subjective:
Gi oxygen man siya kay
maglisod siya ug ginhawa.,
as verbalized by the SO.
Gasakit man gihapon iya
dughan usahay., as
Nursing Dx
Ineffective
cardiopulmonary
tissue perfusion
related to imbalance
between myocardial
oxygen demand
and supply
Objectives
Short-term:
At the end of 30 minutes
nursing interventions, patient
will be able to demonstrate
techniques to improve
circulation such as passive
ROM exercises and
positioning
Intervention
Independent:
1. Elevate head of bed.
2. Encourage passive leg

exercise, avoidance of
isometric exercises.
Long-term:
Objective:
-radiating pain on the chest
with a pain scale level of:
3/5 (as of 2/4/10)
2/5 (as of 2/7/10)
-dyspnea
-use of accessory muscles
At the end of 16 hours nursing

interventions, patient will be
able to demonstrate improved
cardiopulmonary tissue
perfusion as evidenced by
absence of dyspnea and
respiratory distress
Rationale
-This is to reduce oxygen
consumption & promotes
maximal lung function.
-This is to enhance
venous return, reduce
venous stasis and reduce
risk of thrombophlebitis;
however, isometric
exercises can adversely
affect cardiac output by
increasing myocardial
work and consumption.
3. Prevent straining at stools.
- This avoids an increase

cardiac overload.
4. Reposition frequently.
-This prevents skin

breakdown and
pulmonary complications
Evaluation
The Short term goal
was met for patient
was able to perform
passive ROM
exercises and
positioning as ways to
improve circulation.
The Long term goal
was not met.
60
associated with bed rest.

-capillary refill: 4 seconds
5. Provide adequate rest.
-Blood-tinged sputum
Dependent:
1. Administer supplemental
oxygen (1-2LPM)as indicated
-prescence of atrial fibrillation

and S3& S4 based on ECG
result
-Pulmonary congestion
-to conserve energy and

lower oxygen demand.
- This increases amount
of oxygen available for
myocardial uptake,
reducing ischemia and
dysrhythmias

Cues
Subjective:
Murag gi-kumot. 3/5.
Replied the client when
asked by the SN regarding
the description of pain and
the pain rate scale.
Muingon na siya na sakit
iyahang dughan. Sauna ga
reklamo naman siya nga
musakit iyang dughan
labaw na kanang mahago
siya. as verbalized by
the SO.
Objective:
-sighing with no intent to
move unless absolutely
necessary
Nursing Diagnosis
Acute chest pain
related to reduced
coronary blood
flow resulting to
myocardial
ischemia
Objectives
Short Term:
At the end of 30 minutes the
patient will be able to:
a. Report that pain/discomfort
is alleviated or controlled, as
evidenced by a decrease in
pain rating the scale.
b. Display a relaxed
appearance and be able to
sleep/rest comfortably and
engage in desired activities
she can tolerate.
c. Demonstrates ability to cope
with partially relieved pain.
(e.g., deep breathing exercises
and position changes)
d. Demonstrate use of
relaxation skills and
Interventions
Independent:
1. Assist the patient to
a comfortable
position. Maintain bed
rest, at least during
periods of pain.
2. Provide comfort
measures, quiet
environment and calm
activities
3. Encourage use of
relaxation techniques,
such as focused
breathing and
imagery.
4. Eliminate additional
stressors or sources
of discomfort when
possible.
Rationale
-A semi-fowlers is usually most
comfortable. Restricted activity
reduces oxygen demands of
the heart.
-Techniques are used to bring
about a state of physical and
mental awareness and
tranquillity. The goal of these
techniques is to reduce tension,
subsequently, reducing pain.
-This heightens ones
concentration upon nonpainful
stimuli to decrease ones
awareness and experience of
pain.
Evaluation
At the end of 30 minutes of
nursing interventions, patient
was able to experience relief
from pain as evidenced by a
decrease in the Pain Scale
Rate: 2/5, with 5 as the most
painful
- Short term goal was fully met
02/10/10
At the end of 8 hours of
nursing interventions patient
was able to demonstrate use of
relaxation skills to help
alleviate pain.
Long term goal was fully met:
02/10/10
-Patient may experience an
61
-very slow movement with

facial grimace
- shortness of breath upon
pain onset with facial
grimace and sighing
diversional activities as
indicated for individual
situation and verbalize nonpharmacologic methods that
provide relief.
Long Term:
At the end of four days,
client will remain free from
pain as evidenced by no
reports of pain, and normal
vital signs.
5. Provide rest
periods to facilitate
comfort, sleep and
relaxation.
Dependent:
1.Administers
analgesics as ordered
exaggeration in pain or a
decreased ability to tolerate
painful stimuli if environmental,
intrapsychic, intrapersonal
factors are further stressing
him.
-Patients experience of pain
may become exaggerated due
to fatigue.
-Analgesics are given to

alleviate pain.
Cues
Subjective:
February 4, 2010
Gahapon, dili na siya
kabalo kung aha siya.
Unya murag ga-tanga ra
siya pirminti. Naa pud
usahay na dili siya kaila sa
amo. Magkabali-bali na
among ngalan. Pero karun,
okay naman. Kung
musturya lang, dili pa
kaayo klaro, as verbalized
by the SO.
Medyo luya na iyang tuo
nga side sa lawas., as
Nursing Diagnosis
Ineffective cerebral tissue
perfusion related to
interruption of blood flow
as evidenced by slurring of
speech, right-sided
weakness and decreased
mentation

Objectives
Interventions
Short Term:
Independent:
By the end of 4 hours of
nursing interventions,
patient and SOs will be
able to:
a. Verbalize understanding
of causative factors of
such problem and
appropriate interventions
needed to be done.
Rationale
1. Maintain optimal
cardiac output.
-This ensures adequate

perfusion to the brain.
2. Avoid measures that

may trigger increase ICP
(ex. Straining, strenuous
coughing, positioning with
neck in flexion, head flat)
-Increased intracranial
pressures will further
reduce cerebral blood flow.
3. Reorient to
environment as needed.
-Decreased blood flow

may result in changes in
the LOC.
b. Participate in treatment
regimen.
Evaluation
Goals partially met.
Client and his SO were
able to participate in the
treatment regimen.
Client already has
responsive mentation but
his slurring of speech is
still present.
Dependent:
Long Term:
1.
By then end of 16 hours,
client must be able to
Administer anticoagulants,
thrombolytics
-These facilitate perfusion

when obstruction to blood
flow exists or when
62
Objective:
-Slurring of speech
-Decreased mentation
-Right-sided weakness
-GCS Score
2/4/10=12 (moderate brain
injury)
2/7/10=13(minor brain
injury)
2/10/10=14(mild brain
injury)
-arteriosclerosis of the
middle-cerebral arteries
(CT scan result)
Cues
Subjective:
Kapoy kaayo ako
panlawas as verbalized
by the patient
February 7, 2010
Karon na naa siya sa
hospital, maghigda ra
gyud na siya kay luya
man gud pod siya. as
Kami man gyud ga ilis
ug gapakaon niya kay
maglisod man siya ug
lihok-lihok. as
February 10, 2010
Makaya-kaya naman
niya nga maglihok-lihok
obtain optimal perfusion to

vital organs, as evidenced
by alert level of
consciousness, clearer
and more understandable
speech and gradual
recovery of his right-sided
weakness.
Nursing Dx
Activity Intolerance
related to generalized
weakness
and anticonvulsants as
prescribed.

Intervention
Short term:
Independent:
nursing interventions, the patient 1. Assess cardiopulmonary
will be able to:
response to physical activity,
including vital signs before,
a. Identify negative factors
during and after activity.
affecting activity tolerance.
2. Reduce intensity level or
b. Verbalize understanding of
discontinue activities that
techniques to enhance activity
cause undesired
tolerance.
physiological changes.
Objectives
Long term:
intervention the patient will be
able to:
a. Participate willingly in
perfusion has dropped to

such a dangerous level
that ischemic damage
would be inevitable without
treatment. Anti-convulsants
reduce risk of seizures
which may result from
cerebral edema or
ischemia.
Rational
-Assessing
cardiopulmonary notes
progression or accelerating
degree of fatigue.
-Adjust activities to prevent
overexertion.
3. Assist with ADLs as

indicated; however, avoid
doing for patients what
they can do for
themselves.
-Assisting the patient with

ADLs allows for
conservation of energy.
4. Encourage active ROM

exercises; if further
-Exercise maintains
muscle strength and joint
Evaluation
After 30 minutes, the
patient:
a. identified the factors
that affected her
activities of daily
living.
b. used identified
techniques to enhance
activity tolerance.
Long Term:
After 16 hours, the patient
a. particated willingly in
necessary or desired
activities.
b. reported increase in
activity tolerance
63
nga siya ra. Pero amo ra

gihapon siya i-assist kay
basin ma-unsa bah. as
Kinahanglan gyud namo
siya tabangan kung
mulihok kay luya man
gyud siya., verbalized by
the SO.
necessary activities.
b. Report measurable increase in
activity tolerance.
c.Demonstrate a decrease in
physiologic signs of intolerance
(PR, RR, and BP within patients
normal range).
reconditioning is needed,
confer with rehabilitation
personnel.
Dependent:
1. Administer O2 inhalation
as prescribed.
ROM.
-Providing oxygenation
reduces fatigue and
anxiety for patient.
Objective:
-generalized body
weakness noted.
- seeks help in ADL
-ECG reflecting atrial
fibrillation with pattern of
ischemia and tissue
necrosis
Cues
Subjective:
February 7, 2010 Kami
man gyud ga ilis ug
gapakaon niya kay
maglisod man siya ug
lihok-lihok. as verbalized
by the SO.
Objective:
-Scale for measuring
RIGHT hand muscle score:
2/4/10= grade1( no active
range of motion and
palpable muscle
contraction only)
2/7/10=grade2( reduced
Nursing Diagnosis
Impaired physical mobility
related to decreased
muscular control and
function as evidence by
generalized weakness

Objectives
Intervention
Short Term:
Independent:
At the end of 30 minutes of 1. Assist patient reposition
nursing intervention the
self on a regular schedule
patient will be able to :
as dictated by individual
situation.
a. verbalize understanding
odf situation, individual
2. Inspect skin regularly
treatment and regimen and particularly over bony
safety measures.
prominences. Gently
massage any reddened
b. Demonstrate techniques areas as necessary.
and behaviors that enable
resumption of activities
3. Perform passive ROM
participate in ADLs and
exercises of upper and
desired activities.
lower extremities.
Long Term:
Nursing intervention the
4. Encourage participation
in self care and other
activities.
Rationale
-This is to promote proper
circulation and prevent
formation of skin/decubitus
ulcer.
-This prevents skin
breakdown and decubitus
ulcer development.
-This helps
maintain/enhance
maximum neuromuscular
control and function.
Evaluation
Goals met as evidenced
by:
a. Patient able to verbalize
improvement of condtion.
b. Motor control on all
upper and lowe extremities
would return to normal as
preferred by the patient.
c. No signs and symptoms
of paralysis.
- This enhances self

concept and sense of
independence.
64
active range of motion and

no muscle resistance)
2/10/10=grade4 (full active
range of motion and
normal muscle resistance)
a. Maintain position of
function and skin integrity
as evidenced by absence
of contractures, foot drop,
decubitus and the likes.
5. Provide safety measure

such as raising the side
rails as indicated by
individual situation.
-This prevents injury from

falling.
Dependent:
b. Maintain or increase
strength and function of
affected and compensatory
part.
Cues
Subjective:
Lugaw ra gyud iya pwede
kaonon kay galisod pa siya
ug tulon. Mukaon man pod
siya pero gamay ra kay
murag wala man siya
gana. Mao man sab ang
ingon sa doctor na lugaw
lang sa ang ipakaon sa
iya. as verbalized by
the SO.
Objective:
-Weight loss- 55kg-50kg
Nursing Diagnosis
Imbalanced Nutrition: Less
than body requirements
related to inability to ingest
adequate nutrients
secondary to dysphagia as
evidenced by weight loss
of 5 kg
1. Administer medications
prior to activities as
needed for pain.
-This permits maximal

effort/involvement in
activity.
2. Administer laxative as
ordered.

Objectives
Intervention
Short Term:
Independent:
1.Discuss
with
the
significant others the need
of having right diet for the
a. Receive adequate and
patient and introduce the
desired amount of calories food pyramid.
per feeding
2.Place
patient
in
Long Term:
moderate high back rest
At the end of hours of
during feeding.
3.Check the tubes patency
a. Receive adequate
before feeding (auscultate
amount of caloric
for bubbling sound using
requirement per 8 hours in stethoscope just above the
relation to patients status
stomach area)
Rationale
- Success rates are higher
when the family
incorporates a healthy
eating plan.
Evaluation
patient was able to:
a. Receive adequate and
desired amount of calories
per feeding
- This promotes comfort

during feeding and allow
flow of food by gravity.
Long Term:
patient was able to:
- This ensures correct tube

placement in the stomach.
a. Receive adequate
amount of caloric
requirement per 8 hours in
relation to patients status
-With NGT
65
4.Flush 30 cc of water
before and after feeding.
-Weakness of muscle
required for mastication
related to right-sided
weakness
-Dysphagia
Dependent:
-Pale and dry mucous

membranes
1. Administer OF 1600 kcal

in 4 divided feedings via
NGT.
- This is to rinse tubing,

provide fluid source to
maintain adequate
hydration and to ensure
that all feeding goes into
the stomach.
-To meet nutritional
demands of the patient per
day.
-Dry lips
Cues
Subjective:
February 4,2010
Maglisod man ni siya ug
storya. Dili kayo mi
kasabot, as verbalized by
SO.
February 7,2010
Gaapason niya iyang
ginhawa kung magstorya
siya., as verbalized by
SO.
February 10,2010
Makastorya na siya ug
tarong pero dili kayo
klaro., as verbalized by
Nursing Diagnosis
Impaired Verbal
Communication related to
loss of facial or oral muscle
control as evidenced by
slurring of speech

Objectives
Intervention
Short term:
Independent:
After an hour of nursing
1.Provide alternative
intervention the patient will methods of communication
be able to demonstrate
like pictures or visual cues,
improved ability to express gestures or demonstration
self
2. Anticipate and provide
for patients needs
Long Term:
After 8 hours of nursing
intervention the patient will
be able to:
3. Talk directly to the
a. Have decreased
patient, speaking slowly
frustration and isolation
and clearly. Use yes or no
with communication.
questions to begin with.
b. Establish method of
communication in which
4. Speak in normal tones
Rationale
-Provide communication
needs or desires based on
individual situation or
underlying deficits.
-This is helpful in
decreasing frustration
when dependent on others
and unable to
communicate desires.
-It reduces confusion and
anxiety at having to
process and respond to
large amount of
information at one time
Evaluation
The Short term objectives
were partially met because
was still having a hard time
with his speaking ability
although he already
managed to use nonverbal cues
The Long term objectives
were fully met. Patient was
able to show decreased
frustration and
communicates well using
non verbal mode of
communication.
-Patient is not necessarily
66
SO
needs can be expressed
Objective:
and avoid talking too fast.

Give patient time an ample
time to respond.
hearing impaired and

raising voice may irritate or
anger the patient.
5. Encourage family
members to persist effort
to communicate with the
patient.
-It is important for family

members to continue
talking to the patient to
reduce patient isolation,
promote establishment of
effective communication
and maintain sense of
connectedness or bonding
with the family
-right-sided weakness
-Facial asymmetry
-Slurred speech
-with difficulty in
pronouncing words
Cues
Risk Factors:
-age: 89 years old
-inadequate secondary
defenses
-chronic disease
-malnutrition
-presence of indwelling
catheter
-invasive procedures
-insufficient knowledge to
avoid exposure to pathogens
Nursing Dx
Risk for infection

Objectives
Intervention
Short term:
Independent:
1. Help patient wash hands
before and after meals
Nursing intervention, the
after using bathroom,
bedpan or urinal.
a. Verbalize understanding of
individual risk factors
b. Identify interventions to
prevent risk of infection
Long term:
Note: A risk diagnosis is not

evidenced by signs and
symptoms, and the problem
has not occurred and nursing
interventions are directed at
At the end of one week of

Nursing intervention, the
a. Demonstrate techniques
and lifestyle changes to
Rational
- Hand washing prevents
spread of pathogens to
other objects and food.
2. Help the patient turn to

sides every two hours.
Provide skin care,
particularly over bony
prominences.
- To help prevent venous

stasis and skin breakdown
3. Ensure adequate
nutrition intake. Offer high
protein supplements such
egg white.
- This helps stabilize

weight, improves muscle
tone and mass, aids in
wound healing. Also
serves to minimize edema.
4. Arrange protective
isolation for compromised
- These measures prevent

patient pathogens in the
Evaluation
Short term goal were met
because the patient and
his SO were able to
verbalize understanding of
individual risk factors and
identify interventions to
prevent risk of infection
Long term goal was met
since patient was able to
promote safe environment
and did not show any signs
of infection.
67
prevention
promote safe environment

b. Show no signs of infection
such as fever
immune function. Monitor

flow and numbers of
visitors.
environment and protect

from skin breakdown.
5. Teach patients about

good hand washing
technique, factors increase
infection risk, infection sign
and symptoms.
- These measures allow

patient to participate in
care and help patient
modify lifestyle to maintain
optimum health level.
Dependent:
1. Administer prophylactic
antibiotics as ordered.
- To prevent infection
caused by pathogen.
68
VII. DISCHARGE PLANNING
Medications
Encourage strict medication compliance and to take medications as

directed to attain therapeutic effects.
Instruct patient and significant others to keep a list of medications
with their respective dosage and frequency of intake to prevent
medication errors and their purpose.
Digoxin 0.7g/tab OD before lunch

Metoprolol 50mg tab BID
Rosuvastatin 10mg/tab OD
Losartan 50mg tab OD, AC, BF
Spiriva rotacup thru inhaler OD
Allopurinol 100mg 1 tab OD
Avodart 1 tab OD
Inform patient regarding side effects of medication to allay patient

anxiety if said side affects manifest.
Encourage patient to discuss with health care provider concerns
regarding medications.
Exercise
Teach patient and his significant others to do passive and active

range of motion with slow progressions in frequency.
Adequate rest periods must be given in between exercises to
prevent straining.
Always bear in mind that one has to start on easy-to-do exercises
first and must rest frequently, building up strength is essential as
one goes on until hard exercises are tolerated.
Moderate exercise such as walking should be encouraged.
Instruct patients SO to seek medical advice and immediately treat
Treatment
Health Teachings
infections of the upper respiratory system, and oral cavity.

Provide patient and relative written and verbal information
regarding the following:
1. Explain the indications of the prescribed medications, their
actions, dosages, contraindications and side effects.
69
2. Immediate notification of physician for presence of adverse

reactions in medicines and home care complications.
3. Contacting the healthcare provider when signs of recurrence
or complications of the disease appear, especially shortness of
breath and chest tightness.
4. Seek medical advice from healthcare provider for immediate
treatment of upper respiratory system, and oral cavity
infections.
5. Compliance to follow up examinations.
6. Providing support. The patient and family need assistance,
explanation, and support every time patient requires treatment
to prevent serious complications and improve condition.
7. Indicate enough bed rest to reduce exertion and to avoid all
strenuous activities that has not been approved by the
physician.
Outpatient Follow-up
Assert importance of follow up visits to physician.

Advise patient and family to report to the physician if any
recurrence or severity of symptoms, any adverse effects of the
medication, and any development of complication.
Patients should be encouraged to keep a record of their daily
weights. An action plan should be developed so that if the patient
experiences unexplained weight gain of greater than 3 pounds
since their last clinical evaluation the patient can take action (call
physician or take additional medication).
Promote the use of the communitys available resources such as
carrying out regular visits to the nearest health center for continuing
monitoring of clients over all status.
If there are things that are unclear, advise patient and SO to refer
concerns to physician.
70
1. Alcohol use should be discouraged.

Diet
2. Depending on the health care provider a diet that is

low in sodium content, about 2 grams per day is
recommended.
3. It is advisable that cholesterol intake be limited
4. Sources of fiber are to be added to the diet to aid in
digestion.
5. Protein intake is recommended but must not be from
fatty sources. Fish, chicken and beans are good
sources of protein so long as it is not contraindicated
by the patients physician.
6. Intake of vitamin supplements and other sources of
minerals are recommended.
7. Excessive fluid intake should be discouraged, but fluid
restriction is rarely indicated.
Spiritual Care
Encourage significant others to contact the family pastor

to provide spiritual guidance.
Participating in religious ceremonies together can be a
form of family bonding and can strengthen the family
internally.
Encourage patient to verbalize anxieties to spiritual guide
(i.e. pastor, priest) to relieve pent up frustrations.
Ask the significant others to constantly remind patient that
the disease is not a form of punishment from God and that
it is not the patients fault for getting the disease in the first
place.
VIII. PROGNOSIS
71
CRITERIA
GOOD
POOR
PROGNOSIS
PROGNOSIS
Onset of
ANALYSIS/IMPLICATION
The patients severe manifestations occurred

/
Illness
Duration of
very late to be able to be treated.

There was a late detection of the disease of the
patient, thus contributes to a late prevention.
Illness
/
The old age of the patient, his gender, family
history of having heart disease, stroke and
/
Precipitating
hypertension, sedentary lifestyle, and his diet that

is rich in cholesterol and fats predisposes him
and
and puts him at risk for acquiring such disease.
Predisposing
Such factors manifested by the patient cannot
Factors
already be altered and prevented. But

manifestations showed by the patient may be
improved through the medication regimen
Attitude &
prescribed and provided by the healthcare team.

The patients admission and adherence to
Willingness to
medication treatment may somehow show that
take
Treatment
patient is very willing to take treatment in order

for him to recover from the disease.
It is very important to note that prognosis for patients having such diseases vary greatly
depending on a persons health, the extent of the damage, the treatment given and the patients
adherence to it, and most importantly, the early detection of the disease. Most of the prognosis
in the chart exhibited poor prognosis especially that the patient manifest important factors that
may lead to life-threatening complications. Patient is responsive to the treatment given as
evidenced by diminished symptoms of the disease which also suggest a good prognosis for the
patient. But still, long term prognosis may suggest that the clients problem may not lead to a full
recovery of the patient as such that the patient is already in the late stage of treating the
disease.
IX. CONCLUSION
72
At the end of this case study we were able to attain goals that we have set from the start
of this study. Through the gathered data we were able to formulate nursing care plans that we
were able to apply to our patient. By studying on the patients prescribed medication we were
able to understand its effects which could aid in his recovery. A review on the affected anatomy
and physiology of the body enabled us to create interventions that could alleviate pain and any
discomforts from the patient, if not completely prevent it. With the help of the patients family,
we were able to explore part of the patients personality and this information was used on the
formulation of the interventions.
Today it is but promising to note that the number of heart related diseases affecting aged
people are increasing. Myocardial Infarction is the interruption of blood supply to part of the
heart, causing some heart cells to die.There are a lot of factors which may lead to the
development of such disease one of the most noticeable factor is poor or unhealthy lifestyle
which the patient practiced for many years. Chronic Obstructive Pulmonary Disease refers to
chronic bronchitis and emphysema, a pair of two commonly co-existing diseases of the lungs in
which the airways become narrowed.This leads to a limitation of the flow of air to and from the
lungs causing shortness of breath. This is caused by noxious particles or gas, most commonly
from tobacco smoking, which triggers an abnormal inflammatory response in the lung.
The patients condition was greatly aggravated because of the many complications of
congested heart failure. It is but evident that the patients condition was worsening due to the
prevalence of other manifestations thereof. It is therefore important for the patient to strictly
follow the doctors orders specially on the medication regimen and the diet for palliative
treatment since the patients condition cant be cured mainly because of his old age. Measures
show focus on how to prevent the deterioration of the patients condition. Therefore it is most
important to include the family in the plans of care for the patient.
XI. RECOMMENDATION
73
The recommendations made by the proponents for this grand case presentation are
necessary for a patient who is diagnosed with Benign Prostatic Hyperplasia; Myocardial
Infarction; and Chronic Obstructive Pulmonary Disorder. Although the data presented are factual
and relevant, the papers aspect is limited to the patients case and the data gathered. The
recommendations will serve as a guided care for the well being of the patient. These involve the
patient, her significant others and the health care providers.
Recommendations made for the patient are as follows: First, cooperation in his
treatment therapy is needed. He should continue to report any abnormalities she will experience
or manifest that could be a sign of a more serious problem. Second, the patient should be able
to adhere well with the medication regimen as prescribed. Third, the patient must be set to
follow dietary guidelines for metabolic needs and his daily nutritional requirement. Fourth, he
should be able to establish in his mind a positive outlook regarding her condition. Fifth, spiritual
health should also be strengthened with his condition since it is important for his holistic care
and in maintaining a healthy status.
For the significant others, it is encouraged that they continue to provide comfort and care
measures to the patient throughout the disease process. Their presence is also an important
factor for the emotional and mental stability of the patient. They can convince and supervise the
patient in the adherence to the treatment regimen and providing the daily needs of the patient
either with personal necessities or adequate rest.
For the health care providers, they should be able to provide quality health care to the
patient by being equipped with knowledge and skills necessary for the appropriate interventions
needed by the patient and also by being sensitive to the needs and being observant to possible
manifestations of the patient. Constant monitoring is also very important as to the critical status
of the patient.
For us, since availability of time and length of duty is limited, further care and
interventions was not done to the patient. The sources of data used were also based only on the
patients chart, assessment tools and textbooks. Thus, ample time to do further research and
interaction of the patient is recommended.
XI. BIBLIOGRAPHY
74
Book sources:
Black, Joyce M. Hawks, Jane Hokanson. Medical-Surgical Nursing Clinical Management

for Positive Outcomes. 8th Ed. Philippines. Saunder-Elsevier, Inc.,2008
Brunner , Suddarth . Textbook of Medical-Surgical Nursing volume 1 & 2. 11th edition,

Lippincott Williams and Wilkins, 2007
Doenges, Marilynn E et al. Nurses Pocket Guide Diagnosis, Prioritized Interventions &
Rationales. 10th edition, F.A. Davis Company, 2006
Karch, Amy M. Focus on Nursing Pharmacology. 3rd edition, Lippincott Williams and
Wilkins, 2006
Kindersley, Dorling. British Medical Associations New Guide to Medicines and Drugs.
Great Britain: Dorling Kindersley.6th Ed. 2004
Kozier, B., Erb, G., and Berman, A. Fundamentals of Nursing: Concepts, Process and
Practice. 6th edition, Upper Saddle River, NJ: Prentice-Hall Inc., 2000
Turgeon, M. (2005). Instrumentation in hematology. Clinical Hematology: Theory and

Procedures 4th ed. Copyright 2005 Lippincott Williams & Wilkins 351 West Camden
Street Baltimore, MD 21201 pp. 507-508
Wilson, Billie Ann, et. al. Prentice Halls Drug guide. New Jersey: Pearson Education,
Inc., 2004.
Internet sources:
Management
of
Chronic
Obstructive
<http://www.nlhep.org.ugcopd.about.com>
Pulmonary
Disease.
NHLEP.
http://www.mayfieldclinic.com/IM-AnatCardio.htm
http:www.drugs.com/mmx/tranexamic-acid.htm
http:www.umm.edu.search.index.htm
http://medterms.com/script/main.art.asp?articlekey=9349s
75
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i.

Admitting Diagnosis: COPD Acute exacerbation

Blood Pressure 120/70 mmHg

Blood Pressure 110/70 mmHg

Blood Pressure 130/70 mmHg

CHIEF COMPLAINT/REASON FOR HOSPITALIZATION: Weakness; facial asymmetry

Patient discharged with foley

catheter, such apparatus taken with good compliance.

CVR); CHF Class IV (Clan I, Stage C);

Stress Hyperglycemia; and BPH at MRH

Family Medical History

(-) Renal Disease

(X) Hypertension: Both maternal and paternal side

(X) Stroke: Maternal side

(-) Lung Disease

Changes in Eating Habits?

Weight loss/gain: 55kls-50kls

Special Diet: Hypoallergenic Diet

Comments/Nursing Problem Identified:

July 22, 2014

July 23, 2014

Use of sleeping aids: ( ) No

Comments/Nursing Problem Identified:

(I = Independent, A = With Assistance, D =

Comments/Nursing Problem Identified:

Psychiatric History: none

( X ) Yes approximately twice a week______

being the highest

being the highest

Present Pain Management:

) Yes, no of weeks _____________

Breast (cyst, lump, discharge)

) Yes (describe) ______________________________

Comments/Nursing Problem Identified: Patient is diagnosed with benign prostatic

) No (specify the reason)

Naa ko ospital karun. Mga alas kwatro naman tingale sa hapon as

February 7, 2010 with complaints of generalized body weakness, R: Grade 2:

HR = 76 bpm, regular rhythm

February 7, 2010 second assessment day

February 10, 2010 second assessment day

BLOOD SUGAR MONITORING RECORD

ANATOMY AND PHYSIOLOGY

A complete blood count (CBC) will alert the doctor

2. Arterial Blood Gases

In COPD, the amount of air that you breathe into

3. Computerized Tomography (CT) Scan

Although a CT is not required for making a

4. Pulmonary Functions Tests (PFTs)

PFTs are used to evaluate lung function and

Pulse oximetry can be continuous or intermittent.

7. Lung Diffusion Studies

The doctor will perform an initial chest X-ray when

Defines the patient's coronary anatomy and the

10. Coronary angiography

Performed before hospital discharge to assess the

12. Electrocardiography (ECG)

14. Prostate-Specific Antigen (PSA)

Features that increase the likelihood of infarction

15. Rectal Ultrasound and Prostate

17. Urine Flow Study

To rule out cancer as a cause of urinary

f you have COPD, your doctor may have

People with COPD are more prone to bacterial