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SAINT LOUIS UNIVERSITY

School of Nursing

A CASE PRESENTATION

SUBMITTED BY:

Harckom, Kyle Kevin


Lazo, Nickha Pauline
Macabontoc, Lavenia
Pascual, Patricia Marie
Samonte, Joy
Solis, Genette

SUBMITTED TO:

Kathleen Gail Guevarra


November 24, 2016
A) Biographical Information
1. Name: Jose Monteclaro Jr.
2. Address: Crystal cave baguio City
3. Birthdate: June 12, 1961
Place: Isabela
Age: 55
4. Gender: Male
5. Nationality: Filipino
6. Marital status: Married
7. Religion: Roman Catholic
8. Occupation: Retired Store Supervisor
9. Educational status: College graduate
10. PHIC:
11. Admitting Diagnosis: CAP-MR

B. Health history:
a) History of Pressent Illness:
Three days prior to admission patient had undocumented fever, headache on
the frontal area, throbbing 6-7/10, non-radiating, loss of appetite, body weakness and
myalgia with no associated nausea, vomiting dizziness, bleeding episodes, ours and
abdominal pain. Patient took paracetamol (biogesic) with offered temporary relief of
fever. No consult done. Few hours prior to admission, patient had undocumented fever,
loss of appetite, frontal headache, throbbing 7/10, radiating to the temporal area, myalgia,
and body weakness with no nausea, vomiting, bleeding episodes, abdominal pain and
dizziness. Consult was done in this institution and patient was subsequently admitted.
b) Past Medical History:
Patient underwent surgical procedure due to a fractured right ring finger
several years ago. He is not allergic to any food and medication.The patient is known
hypertensive for more than 3 years already and is on Losartan 50 mg once a
day,Rosuvastatin 10 mg/tab OD,but stopped taking Amlodipine 5mg/tab OD.He also has
diabetes mellitus and is taking Metformin 1 gram once a day.Patient has bronchial asthma
but has no maintenance medication and last exacerbation is unrecalled by the patient.
c)Heredofamilial History.
There is maternal history of hypertension,DM,and bronchial asthma.No
family history of CVD,CAD,and Malignancy.
d) Social & Environmental History:
Patient was previously a smoker years back but cannot recall how many
years back, he also mentioned drinking beer regularly every night consuming a minimum
of two bottles.He Lives in a 2-storey concrete house in a non-congested area with 6
rooms and 4 occupants.Water for domestic purposes comes from the Water District and
drinking water comes from a refilling station and garbage was collected per schedule.
e)Feeding History:
He eats vegetables, meat, beef, chicken etc. He eats more than 3 times a
day at most.
f)Obstetric History:
Not Applicable
g)Prenatal History:
Not Applicable

A CASE PRESENTATION
This is the case of Patient Jose Monteclaro Jr. who came to Saint Louis
University Hospital of the Sacred Heart with complaints of undocumented fever, loss of appetite,
frontal headache, throbbing 7/10, radiating to the temporal area, myalgia, and body weakness
with no nausea, vomiting, bleeding episodes, abdominal pain and dizziness. He took paracetamol
prior to admission. Consult was done in this institution and patient was subsequently admitted.
Past medical history reveals patient underwent surgical procedure due to a fractured right ring
finger several years ago. He is not allergic to any food and medication. The patient is known
hypertensive for more than 3 years already and is on Losartan 50 mg once a day, Rosovastatin 10
mg/tab OD, but stopped taking Amlodipine 5mg/tab OD. He also has diabetes mellitus and is
taking Metformin 1 gram once a day. Patient has bronchial asthma but has no maintenance
medication and last exacerbation is unrecalled by the patient. Has a family history of
hypertension DM, and bronchial asthma. Patient was previously a smoker years back but cannot
recall how many years back, he also mentioned drinking beer regularly every night consuming a
minimum of two bottles. He Lives in a 2-storey concrete house in a non-congested area with 6
rooms and 4 occupants. Water for domestic purposes comes from the Water District and drinking
water comes from a refilling station and garbage was collected per schedule. His diet consists of
vegetables with beef, chicken or pork and rice but plate consists mostly of meat and rice and only
with a small percentage of vegetables. He eats on average of 3 times a day. He iterated that he
walks to the market and back home daily in the morning as his form of exercise but is easily
exhausted. Pinagpapawisan naman ako ehh kaya parang yun na yung exercise ko, yun lang kaya
ko medyo matanda na .Patient mentioned normally having one bowel movement a day unless
with diarrhea or constipation which can alter the number of passing of stools a day. Patient
urinates a minimum of 6 times a day frequently every interval, with a light yellow color and has
an odorous smell.

Diagnostic results reveal a CBG 130 mg/ DL, Blood pressure 130/80, serum osmolality test.

C. PATHOPHYSIOLOGY
D. PRIORITIZATION:
Nursing Diagnosis Rationale
1. Decreased cardiac output related to This is highly prioritized because it is an
vasoconstriction actual problem and according to Maslows
hierarchy of needs physiological needs is the
most prioritized. The inability of the heart to
produce adequate volume of blood to supply
the body may be fatal to the body if not
properly given immediate attention. Blood is
necessary to deliver oxygen for the entire
body, thus adequacy of cardiac output is
important.
2. Ineffective peripheral perfusion This is another actual problem needing
related to failure of the ventricles to immediate attention because this may lead to
maintain cardiac output inadequate supply of oxygen to the rest of the
body. Inadequacy may lead to hypoxia which
is fatal to the patient because it may lead to
cell death. Oxygen is a physiology need by
the body which is top most prioritized in
Maslows
3. Acute pain This is another progressing problem because
when there is presence of pain the client will
have the tendency to be distracted by it and
there is a tendency to not comply to any
therapeutic regimen. This falls under
physiologic needs according to Maslows
hierarchy of needs.
4. Activity Intolerance related to Under Maslows hierarchy of needs, is the
decreased systematic circulation second prioritization which is safety. Activity
intolerance may be dangerous for the patient
because it may accompany risk for falls.
Activities of daily life is part of human life
that contributes to homeostasis. ADLs
accompanied by danger the person might feel
powerless and incomplete.
5. Knowledge deficit: Proper nutritional Nutrition is important to our bodies because it
intake related to lack of information this is one factor that contributes to the
stabilization of homeostasis of the body. The
food we ingest is one of the sources of the
major electrolytes in the body like sodium,
potassium, calcium and others. This falls
under Self-actualization in Maslows
hierarchy of needs
6. Risk for Fluid and electrolyte Fluid and electrolytes regulated the
imbalance related to dehydration homeostasis of the body. The imbalanced of
fluid and electrolytes in the body alter body
functions such as contractility of the heart,
acid base balance and others. This falls under
physiologic needs in Maslows hierarchy of
needs
7. Risk for Impaired Skin Integrity Under Maslows hierarchy of needs this
problem under physiologic needs because as
we know the skin is the first line of our
bodys defense from pathogens and infection.
When our skin integrity is impaired there is a
higher risk for infection, this can also
contribute to risk for bleeding and other
complications.